THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO. 3 - MARCH 2001

XFL Raises Unique Sports Medicine Issues

The XFL is being touted as a rougher, tougher, and more entertaining brand of professional football. And that might lead some observers to predict "extreme" sports medicine scenarios.

More Injuries?

Those close to the medical action, however, say that despite the gladiator-style hype, the XFL is just as concerned with player welfare as are other professional leagues. Lawrence J. Lemak, MD, medical director for the XFL and an orthopedic surgeon at Alabama Sports Medicine in Birmingham, says he was involved with drawing up league rules. "Rule changes were not made to make the players more injury prone," he says. "They're not trying to set up an injury clinic."

Departures from National Football League rules were designed to make the XFL games faster and more exciting, such as doing away with kicking extra points after touchdowns (teams can run or pass for a 1-point conversion) and with fair catches on punts (but there is a 5-yard halo rule). "There was a lot of thought behind the rules," Lemak says.

That doesn't mean the physicians on the sidelines won't be busy, he says. "Football at all levels is a pretty tough game."

When asked, Lemak says he doesn't expect a rash of injuries related to players being out of shape or rusty with their football skills. "These aren't guys sitting around on barstools wanting to play football. They're mainly seasoned players from NFL Europe, Canadian football, and arena football who have been playing professionally at a high level," he says.

A Different Sports Medicine Model

The XFL differs from most other professional sports leagues in that the teams are not locally owned and that players work for one corporation rather than through their individual teams. As such, Lemak says medical care is centralized through a unique contract with HealthSouth Corp, a nationwide provider of ambulatory surgery, diagnostic imaging, and rehabilitation services. A similar centralized sports medicine system is present in Major League Soccer and NFL Europe, both of which Lemak also serves as medical director.

"In the XFL there is a global fee per injury, and this is done in hopes of controlling costs in sports medicine," he says. "Medical costs are a huge burden to teams. The high cost of medical care is one reason why minor league teams struggle financially."

However, like the traditional sports medicine model, a regular team of physicians will follow the team at home and on the road. Tracy Ray, MD, a family practice physician and sports medicine fellowship director at Alabama Sports Medicine, is one of three primary care physicians who will cover the XFL's Birmingham Bolts. "I think this will end up being much more football than professional wrestling, and it will be a pretty good brand of football."

Is Ray impressed by the XFL's media glitz? "I tell my fellows that it's a lot like handling a workers' comp case," he jokes.

Cameo Roles for the Medical Team

XFL telecasts focus in part on participants who are usually in the background, such as fans and cheerleaders. Will the physicians be expected to ham it up for the camera? Lemak quips: "No....the physicians work will be very serious and they won't be dating the cheerleaders." (Vince McMahon, World Wrestling Federation chairperson and cocreator of the XFL, has been widely reported as having encouraged players and cheerleaders to fraternize in order to promote soap-opera drama for the game telecasts (1).)

However, viewers will note that medical aspects of the game will be highlighted. "If players are hurt, the fans will know," Lemak says. "There will be a lot of information and exposure to what the physicians are doing. We'll let people observe this without violating patient-physician confidentiality."

A more visible role for the sports medicine team might even offer viewers an educational message about injuries and treatment in the future, he says. "But we have to go slow and develop this."

Lisa Schnirring
Minneapolis

REFERENCE

1. Starr M, Gordon D: Not your father's NFL. Newsweek 2001;137(5):56-57

New Treatment for Plantar Fasciitis

A new outpatient treatment is available for patients who have plantar fasciitis. In October 2000, the US Food and Drug Administration (FDA) approved an extracorporeal shock wave (ESW) device (OssaTron, HealthTronics Inc, Marietta, Georgia) for chronic proximal plantar fasciitis that has not responded to 6 months of conventional treatment.

The patient's heel is placed against a water-filled dome that houses a spark plug. A single ESW treatment delivers 1,000 to 1,500 shocks at 18,000 volts over 30 minutes. The treatment is painful and requires local anesthesia or a heel block and ear protection from the sound made by the device.

The FDA approval was based on a placebo-controlled clinical trial of 320 patients who had not responded to standard plantar fasciitis treatments. Treatment was considered successful in 47% of the study group and 30% of the placebo group; on average, pain was reduced by 89%.

The FDA is requiring further study to evaluate adverse effects. Misdirected ESW may result in damage to large blood vessels and major nerves. In a clinical study of the device, a small number of patients (0.6%) sustained plantar fascia tears. ESW treatment is contraindicated for children, pregnant women, and patients who have a history of bleeding problems or who are on medications that interfere with clotting.

After treatment, patients are asked to curtail stressful activity (such as running, jogging, heavy housework, or yard work) for 4 weeks and are advised that they may not experience pain relief for up to 6 weeks following treatment. At 12-month follow-up, some patients report a significant (up to 99%) reduction in pain and no limitation of activities.

Anthony Galea, MD, a sports medicine physician and director of sports medicine at Lifemark Health, based in Toronto, says ESW treatment (also known as orthotripsy) has been used in Canada and Europe over the past few years for plantar fasciitis, epicondylitis, calcific tendinitis, and stress fractures. Galea estimates that he's used ESW to treat about 160 patients with chronic plantar fasciitis and estimates that he's had about an 80% success rate. He says his center's success rate is higher than that of the FDA study because he prescreens patients: To qualify for treatment, the plantar fascia must be thicker than 4 mm as measured on ultrasound. Galea says it's thought that the therapeutic effect of ESW treatment occurs when tiny bubbles invade and explode into tissues, causing microtrauma followed by rehealing.

Lloyd Nesbitt, DPM, a podiatrist in private practice in Toronto, says ESW treatment appears to be useful in the treatment of chronic plantar fasciitis. "In about 95% of cases there are biomechanical imbalances that you can usually correct with conventional treatments such as taping, orthotics, ice, physical therapy and massage" he says. "But there is a place for it [ESW treatment] in the clinical setting."

The machines are currently in use in 16 states and Toronto. The device is also being evaluated as a treatment for nonunion fractures.

Lisa Schnirring; Patricia D. Mees
Minneapolis

Field Notes

Mouth Guard Momentum Moves Beyond Playing Field
In an effort to prevent more facial injuries among children, the American Dental Association (ADA) is suggesting that mouth guards be worn, even for recreational activities. The group hopes to make mouth guard use in young people as common as helmets during biking or protective pads during activities such as in-line skating.

"Parents just need to remember to 'slip and slide' when it comes to protecting their children from head injuries," says Matthew Messina, DDS, ADA consumer adviser. "Slipping on a helmet and padding, and sliding in a mouth guard will significantly reduce a child's risk of mouth trauma. Even in noncontact sports, such as gymnastics, mouth guards help protect children from injury."

The three basic types of mouth guards available are custom-made, ready-made or stock, and the so-called "boil and bite." The most effective mouth guard should be resilient, tear-resistant, and comfortable, and when properly fitted, will not restrict speech or breathing.

Could You Recognize Resistance Overtraining?
Resistance exercise is increasingly prescribed for general fitness, rehabilitation, or improved athletic performance. The appropriate combination of training volume and intensity is often elusive, and physicians have little guidance on how to identify and treat resistance overtraining. A recent statement from the American College of Sports Medicine offers several useful tips for practitioners.

Data on resistance exercise overtraining are limited when compared with the data for endurance exercise overtraining; however, it appears that symptoms of overtraining for both activities are similar. Though the testosterone/cortisol ratio is not altered by resistance overtraining, such activity does elevate catecholamine levels, which suggests sympathetic overtraining syndrome.

Overreaching occurs when athletes exceed their capabilities and fail to incorporate enough recovery time into their programs, thus experiencing a short-term performance decrement that improves with a few days of adequate rest. Overtraining is more serious and usually results from excessive training volume and high-intensity workouts performed for a prolonged period. Exhaustion sets in and performance suffers. The time required for recovery is directly proportional to the extent of overtraining.

Some of the warning signs of overtraining include:

• Decreased muscle strength, endurance, training tolerance, or motor coordination;
• Increased recovery requirements, muscle soreness, or joint pain;
• Altered resting heart rate, blood pressure, and respiration patterns;
• Chronic fatigue, sleep and eating disorders, headaches, gastrointestinal distress, or menstrual disruptions;
• Depression, apathy, inability to concentrate, or decreased self-esteem or self-efficacy;
• Decreased rate of healing, increased occurrence of illnesses, and impaired immune function; and
• Hypothalmic dysfunction, increased serum cortisol, decreased muscle glycogen, decreased free testosterone, and decreased serum hemoglobin.

Suggestions for preventing or treating overtraining include:

• Decrease training volume when increasing training intensity or vice versa;
• Add one or more recovery days to each training week;
• Avoid performing every set of every exercise to failure at every session with no variation;
• Select exercises to avoid overuse of certain muscles or joints;
• Avoid excessive use of eccentric muscle actions; and
• Take into account the cumulative stresses from other forms of exercise such as cardiovascular training or sport-specific training.

Reckless Skiing Judged Homicide
A Colorado skier was recently sentenced to 90 days in jail for negligent homicide involving a 1997 fatal collision on a Vail, Colorado, ski hill, according to a February 1 article in The Denver Post.

The case drew national attention because sports-related homicide convictions are rare and because two high-profile ski fatalities in recent years (Sonny Bono and Michael Kennedy) have heightened concerns about reckless skiing. The man convicted in the Colorado incident reportedly skied down an intermediate run, uncontrolled and at high speed, and struck a Denver man who died of a skull fracture. The case was thrown out of two lower courts before the Colorado Supreme Court ordered it to trial.

Collisions between snow-sport participants account for about 3% of all ski injuries.