Other Medical Problems

21.1 Overtraining (Staleness)

Phy Sportsmed 2003;31:25; Phy Sportsmed 2001;29:35; Med Sci Sports Exerc 1997;30:1173; Med Sci Sports Exerc 1998;30:1146; Sports Med 1998;30:1140; Sports Med 2000;32:317; Sports Med 1996;21:80; Sports Med 1998;26:1; Sports Med 1998;26:177; Sports Med 1999;27:73; J Sport Sci 1997;15:341

Cause: Excessive training and competition without adequate recovery.

Epidem: Affects 5-15% of elite athletes at any one time.

Pathophys:

Definitions:

Overreaching-acute phase of increased training load w short-term deterioration in performance (usually <2 wk).
Overtraining-maladaptive response to an extended period of training overload w inability to recover within 2-wk rest period.

Multiple hypotheses:

Chronic glycogen depletion: chronic nutritional deficiency leading to chronic glycogen depletion and increased oxidation of branched chain amino acids and a change in the BCAA: free try ratio and ultimately central fatigue (Med Sci Sports Exerc 1998;30:1146).
Autonomic imbalance: increased sympathetic activity from stress and overloaded target organs and increased catabolism
leading to decreased sympathetic intrinsic activity (Med Sci Sports Exerc 1998;30:1140).
Central fatigue hypothesis: peripheral fatigue and nutrient depletion leading to the consumption of BCAA with subsequent change in the BCAA: free try ratio; with elevated CNS free try leading to elevated CNS 5HT and central fatigue (Med Sci Sports Exerc 1997;30:1173).
Glutamine hypothesis (immune dysfunction): overload training leading to depressed glutamine production from muscle tissue; glutamine deficiency, as well as acute exercise stress on the immune system create immunologic open window, leading to repeated minor infections and systemic stress (Sports Med 1998;26:177).
Cytokine hypothesis: incomplete recovery of locally damaged tissues with overload causing a local inflammatory response to become systemic with elevated pro-inflammatory cytokines IL-1β, TNF-α, and IL-6 (Med Sci Sports Exerc 2000;32:317; Med Sci Sports Exerc 2004;36:794).

Fatigue

Physiologic fatigue:

Insufficient sleep, nutritional disorder, jet lag, pregnancy, excessive competition, overreaching.

Pathologic fatigue:

Medical disorders, mood disorders, chronic fatigue syndrome, overtraining.

Sx: Fatigue; decreased performance; overuse injuries (musculoskeletal manifestation of overtraining); sleep disturbance; mood disorder.

Si: Elevated resting HR (usually >10 BPM over baseline) (Clin J Sp Med 2000;10:279); decreased LBM; depressed mood on various evaluation tools; otherwise essentially normal exam.

Crs: Depends on duration and severity of symptoms and the athletes and coaches management.

Cmplc: Early retirement, poor performance during key periods (Olympics, etc), injury.

Diff Dx:

Infectious disease: infectious mono, Lymes, pneumonia, CMV, other viral inf (see 20.1 and 20.2).
Metabolic disorders: anemia, diabetes, hypo- or hyperthyroid.
Substance abuse: ETOH, cocaine, marijuana, stimulants.
Mood disorder: depression, BPD, other.
Cancer: lymphoma, leukemia, other.
Pregnancy.

Lab: W initial visit consider CBC, ESR, Chem 20, TSH, ferritin, serum β-HCG, monospot; at f/u consider urine drug screen or other labs based on history and examination.

Rx:

Rest (initially for 2 wk); if recovered, then resume more balanced training.
More significant symptoms may require longer periods of rest from training and competition.
Upon return to activity need more balanced training (periodization) w periods of relative rest and cross training to avoid monotony and overuse w careful attention to sleep, nutrition, hydration, social support, and stretching.

Return to Activity: Monitor overall recovery process and listen to the body’s signals (mood, myalgias, sense of well-being).

21.2 Exertional Rhabdomyolysis

Arch IM 1976;136:692; Mil Med 1996;161:564; Am Fam Phys 2002;65:907; Am Fam Phys 1995;52:502; Phy Sportsmed 2004;32:15; Phy Sportsmed 2002;30:37

Cause: Muscle breakdown from severe, exhaustive exercise.

Epidem:

Many reports associated with mass training or mass participation, as in military training or police training of recruits.
Risk factors of high ambient temp and high humidity, poor conditioning, dehydration, compromised nutritional state, hypoxia, sickle cell disease or trait, medication use (aspirin, phenothiazines, anticholinergics), drugs (cocaine, alcohol), renal insufficiency, recent viral illness, or prior heat injury.
Recent reports of exertional rhabdomyolysis associated with creatine supplementation (J Am Board Fam Prac 2000;13:134).

Pathophys: Severe muscle breakdown with release of toxins and electrolytes leading to hypernatremia, hyperkalemia, hyperuricemia, lactic acidosis, and secondary oliguric renal failure.

Sx: H/o exhaustive exercise session (often eccentric type); delayed onset muscle soreness with local swelling; dark urine.

Si: Significant local compartment soft tissue swelling; pain with passive motion of muscles; decreased urine output; may have signs of multiorgan failure or even collapse.

Crs: Variable depending on extend of muscle damage and comorbid disease.

Cmplc: Renal failure (more associated with CPKs >16,000 (Am Fam Phys 2002;65:907), multiorgan failure, acute compartment syndrome, ARDS, DIC.

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