Undergraduate perspective on Sports & Exercise Medicine – a BJSM blog series

By Sean Carmody (@seancarmody1)

“Too often in sport, doctors are men and they don’t understand”

That was the opinion of Paula Radcliffe last January in reference to the effects of menstruation on athletic performance. Clearly a challenge had been laid down to Sport and Exercise Medicine (SEM) as a discipline to deliver better care, that pays attention to sex and gender, to female athletes. With that in mind, the recent BASEM Spring Conference on the theme of The Female Athlete was particularly timely. Key themes and sub-topics from the conference are highlighted below.

The Relative-Energy Deficiency in Sport – Professor Sundgot-Borgen

• The Female Athlete Triad doesn’t account for effects of reduced energy availability among male athletes.
• Relative Energy Deficiency in Sport (RED-S) recognises the importance of energy availability for optimal health and performance but presents a more comprehensive approach than the triad’s limited triangular view.
• Risk factors for developing relative energy deficiency include; restrictive eating, injuries and illness, specialisation, decline in performance level, casual misinformed comments by coaches on physical appearance.
• Risk of developing RED-S can be minimised by: educational programs for athletes and coaches, re-emphasising weight as a performance parameter, avoid critical comments about body shape, increase athlete awareness of effect of optimal energy intake on performance, open communication to encourage discussion around eating problems.
• Further research is required to examine energy deficiency among male athletes and Paralympians.

See also: IOC Consensus Statement on Relative Energy Deficiency in Sport.

Bone Health in Athletes – Dr Julia Newton

• Bone is a biological machine and adapts to load and function.
• 7% of maternal bone is lost to the fetus during pregnancy.
• The adolescent period is key- bone mass increases by 25-40% in puberty.
• Factors which can affect the attainment of peak bone mass include; exercise, endogenous hormone profile, energy deficiency associated amenorrhoea, timing of puberty, smoking, teenage pregnancy, anorexia, exogenous hormones whilst still accruing bone.
• Factors which lead to bone loss include; low oestrogen or testosterone, increasing age, corticosteroids, decreased weight or muscle mass, smoking and alcohol.
• There is a 2-4 fold increased risk of stress fractures in amenorrhoeic athletes.
• Vitamin D deficiency is an independent risk factor for stress fractures.
• Treatment options for low bone mineral density include; calcium and vitamin D supplements, impact exercise, addressing contributory lifestyle factors.

Ballet: The Vitamin D and Bone Mineral Density Story – Professor Matthew Wyon

• Ballet dancers undertake rigorous training; 38 hours per week at least.
• They are considered prime candidates for developing the female athlete triad.
• The research examining the prevalence of low BMD among ballet dancers is limited, however initial studies suggest 40% have low bone mineral density.
• The average ballet career ends at 24, so it is important to keep long term health of the athlete in mind.
• Ballet dancers are commonly deficient in Vitamin D. They train and perform indoors, have restricted diet practices and do not commonly supplement.
• Diet has poor effect in restoring Vitamin D levels apart from a few exceptions (eg oily fish).
• There is a potential link between vitamin D deficiency and increased incidence of injury.

To Bleed or not to Bleed – Mr Michael Dooley

• A sports gynaecologist concerns themselves with the effects of the menstrual cycle on performance, amenorrhoea and relative energy deficiency in sport, contraception and infertility.
• The percentage of women participating in the Olympics has increased from 11.5% in 1960 to 44.5% in 2012, meaning that understanding the effects of the menstrual cycle on performance is a relatively new issue.
• Women have won gold medals, and broken world records at all stages of the menstrual cycle.
• Swimmers have demonstrated a premenstrual worsening of performance with improvement during the menstrual cycle.
• ACL rupture is 4-8 times higher in women, and appears to occur more often in the ovulatory phase of the cycle.
• Amenorrhoea leads to an increased risk of stress fractures.
• Athlete quote; “Having a carefully prepared plan to manipulate my cycle to avoid competition has helped my mental preparation, performance and enjoyment”.

Gymnastics – Dr Chris Tomlinson

• Gymnastics is a weight-dependent sport demanding intensive training regimes.
• Gymnastics involves young, skeletally immature athletes who are at risk of overuse and traumatic injuries.
• Common injuries in gymnastics include shoulder impingement, osteochondral defects in the elbow, lumbar spine stress fractures, and ACL rupture.
• Physicians take a twice-yearly menstrual history from gymnasts, and a once yearly SCAT score as a baseline, DEXA scan twice annually to examine body composition.
• Daily weighing in gyms is common and can lead to public shaming. 20% of gymnasts show evidence of an eating disorder.
• Weighing should be carried out in a private setting (eg in a clinical consultation room away from coaches and other athletes).
• Retiring gymnasts should be equipped with the skills to cope, and the appropriate social support structures should be put in place.

The Female Elite Athlete: A practical approach to the medical issues – Dr Anita Biswas

• Common problems among female athletes include stress fractures, ACL rupture, low energy availability and mental health issues.
• All support staff should be aware of issues surrounding training load and menstrual cycle.
• The EIS Vitamin D strategy includes: screening for deficiency and supplementing accordingly.
• Faddy diets such as carbohydrate restriction are often practiced by female athletes.
• The EIS carry out annual medical screening including questions around menstruation and eating habits.
• Information sharing between sports will improve athlete care.

Sean Carmody is a final year medical student at the Hull York Medical School. He tweets regularly on subjects relating to sports medicine and performance @seancarmody1.

Dr. Liam West BSc (Hons) MBBCh PGCert SEM (@Liam_West) is a graduate of Cardiff Medical School and now works as a junior doctor at the John Radcliffe Hospital, Oxford. In addition to his role as an associate editor for BJSM he also coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

If you would like to contribute to the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series please email LIAMWESTSEM@HOTMAIL.CO.UK for further information.