Deep Venous Thromboembolism in a Triathlete

Venous thromboembolism among physically active young adult females

Background

Young adult females are at risk of venous thromboembolism (VTE) due to various acquired and transient factors. In recent years, a growing number of females have engaged in strenuous physical activity, but its role as a risk factor for VTE is uncertain.

Objectives

To determine the incidence of VTE in young adult females engaged in strenuous physical activity.

Methods

A large national cohort of female individuals enlisted in the Israeli Defense Forces between 2012 and 2019 was analyzed. The study group consisted of participants undergoing strenuous physical training during their military service, while the control group maintained regular activity levels. We compared the incidence of VTE between the groups and adjusted for potential risk factors using a multivariate Cox analysis.

Results

The cohort included 160,718 female individuals aged 18 to 21years, of whom 11,745 engaged in strenuous physical activity and 148,973 served as controls. During a mean follow-up of 1.7 years, VTE occurred in 5 individuals (0.04%) in the strenuous activity group and 47 individuals (0.03%) in the control group. The incidence per 10,000 person-years was 2.41 (95% CI, 0.78-5.62) for the strenuous activity group and 1.82 (95% CI, 1.34-2.42) for the controls. Strenuous activity did not increase the risk for VTE in univariate or multivariate regression, with a hazard ratio (HR) of 1.27 (95% CI, 0.49-4.22). Use of oral contraceptives was the only significant risk factor, demonstrating dose effect; HR 1.95 (95% CI, 1.06-3.57) for low dose and HR 3.62 (95% CI, 1.40-9.37) for medium estrogen dose contraceptives.

Conclusion

Strenuous physical activity did not increase the risk for VTE among a large cohort of young adult female individuals.

Musculoskeletal health considerations for the transgender athlete

BACKGROUND

In addition to the familiar sports-related injuries and conditions experienced by cisgender athletes, transgender athletes may also face unique challenges to maintaining their musculoskeletal health. Encouraging sports medicine professionals to become familiar with accepted nomenclature and terminology related to transgender athletes will enable open communication on the field, in the athletic training facility, and office.

OBJECTIVE

Understanding contemporary medical and surgical gender-affirming treatments and the unique ways in which the musculoskeletal system might be affected by each - such as impairments in bone health, changes in ligamentous function and the potential increased risk for deep venous thromboembolism - is essential for provision of optimal musculoskeletal care to transgender athletes. Knowledge of the existing participation policies for transgender athletes is also key for enabling sports medicine professionals to effectively counsel athletes about the need for specialized protective equipment. Additionally, this knowledge is important for appropriately managing therapeutic use exemptions in the competitive sports setting.

CONCLUSION

This article provides an overview of the current accepted nomenclature, common gender-affirming medical and surgical treatments, unique musculoskeletal health considerations, and participation policies for transgender athletes.

Sport and Venous Thromboembolism

BACKGROUND

The occurrence of venous thromboembolisms (VTE) in association with sporting activity has been described but not yet systematically explored. The aim of this study was to determine the sites at which VTE occur in athletes, the accompanying features, and the special features of the symptoms and diagnosis, so that physicians can take the findings into consideration.

METHODS

A search of the literature in the databases PubMed, Web of Science, and Cochrane in accordance with the PRISMA criteria, together with a search of Google Scholar up to 29 February 2020.

RESULTS

No observational studies were identified. A total of 154 case descriptions were evaluated: 89 on upper-extremity deep vein thrombosis (DVT), 53 on lower-extremity DVT, and 12 on pulmonary embolisms with no evidence of thrombosis. Ninety-five percent of the upper-extremity DVT involved the region of the subclavian/axillary vein. Thoracic outlet syndrome (38%), hereditary thrombophilia/a family history of VTE (16%), intensive training (12%), and the use of oral contraceptives (7%) were identified as accompanying features. The upper-extremity DVT occurred mainly in male strength athletes and ball sports players. The lower-extremity DVT were located in the lower leg/knee (30%), the thigh (19 %), or occurred in combination in the lower leg-to-pelvis region (30 %). The features accompanying lower-extremity DVT were hereditary thrombophilia/a family history of VTE (30%), trauma (25%), immobilization (21%), and the use of oral contraceptives (11%). The lower-extremity DVT were found in endurance sports and ball sports. The symptoms may be obscured by sport-specific symptoms/trauma, and diagnosis is often delayed. Early D-dimer determination is useful and is complemented by diagnostic imaging.

CONCLUSION

VTE are found in association with sports. The background factors, the sites of VTE, the types of sports involved, and the accompanying features are all important to know. The symptoms may be obscured, and it may be difficult to reach the correct diagnosis. The possible presence of DVT must be borne in mind.

Management of venous thromboembolism in athletes

Venous thromboembolism (VTE) is a common condition with high associated morbidity and mortality. Athletes have unique VTE risk factors compared with the general population, and may have a higher than anticipated risk of thrombosis. Anticoagulant treatment poses additional challenges in athletes, as these individuals usually wish to return to sporting activities without delay. In addition, those athletes who engage in contact sports may have bleeding complications with extended anticoagulation. In this paper, we discuss VTE risk factors in athletes, the impact of exertion on haemostasis, measures which could be adopted to mitigate VTE risks in these highly active individuals and options to deal with bleeding risks from anticoagulation during injury-prone sporting activities.

Amateur Endurance Athletes: At Higher Risk of Suffering Dural Arteriovenous Fistulas? Report of 3 Cases

BACKGROUND

The present study aims to draw attention to the fact that endurance sport could be a risk factor for dural arteriovenous fistula (DAVF) development. DAVFs have been correlated with acquired dural venous sinus anomalies owing to trauma, infection, neoplasia, or other classic risk thrombogenic factors. Here we report 3 cases of intracranial DAVF in young healthy patients who had no known thrombogenic risk factors other than amateur intensive sports practice.

CASE DESCRIPTION

Three young healthy individuals not fitting into the classical clinical picture of a DAVF patient presented to our institution. One was a 40-year-old man with an acute subdural hematoma secondary to an ethmoidal DAVF. Another 41-year-old man presented with a cerebellar hematoma due to a tentorial DAVF. A third 41-year-old man presented with numbness of his right arm in relationship to a superior sagittal sinus DAVF. None of them had a relevant medical history. All the usual thrombogenic risk factors for DAVF development were ruled out. Interestingly, the 3 patients had outstanding training and practice routines for endurance sports.

CONCLUSIONS

Dehydration, microfractures, muscular contractures, low heart rate, long distance travel, and high altitudes are all well documented thrombogenic risk factors affecting endurance sports amateur athletes and might represent a plausible mechanism for the development of DAVF. Despite its limitations, to our knowledge, this is the first work suggesting a possible link between such sport practice and DAVF development. Further prospective research from larger dedicated vascular centers might shed further light on this hypothetic but intriguing link.

An unusual case of upper limb ischemia in a marathon runner

Acute limb ischemia in young adults warrants thorough investigation to determine the underlying cause. Here, we present a case of acute upper limb ischemia in a marathon runner secondary to paradoxical embolism. The patient had associated deep venous thrombosis of the lower limb with multiple pulmonary emboli and patent foramen ovale. This case report emphasizes the under-recognition of intense endurance exercise as a risk factor for venous thromboembolism and highlights the potentially debilitating embolic sequelae of venous thromboembolism in patients with patent foramen ovale.

Effects of Sports Compression Socks on Performance, Physiological, and Hematological Alterations After Long-Haul Air Travel in Elite Female Volleyballers

Broatch, JR, Bishop, DJ, Zadow, EK, and Halson, S. Effects of sports compression socks on performance, physiological, and hematological alterations after long-haul air travel in elite female volleyballers. J Strength Cond Res 33(2): 492-501, 2019-The purpose of this investigation was to assess the merit of sports compression socks in minimizing travel-induced performance, physiological, and hematological alterations in elite female volleyball athletes. Twelve elite female volleyballers (age, 25 ± 2 years) traveled from Canberra (Australia) to Manila (Philippines), and were assigned to 1 of 2 conditions; compression socks (COMP, n = 6) worn during travel or a passive control (CON, n = 6). Dependent measures included countermovement jump (CMJ) performance, subjective ratings of well-being, cardiovascular function, calf girth, and markers of blood clotting, collected before (-24 hours, CMJ; -12 hours, all measures), during (+6.5 and +9 hours, subjective ratings and cardiovascular function), and after (+12 hours, all measures except CMJ; +24 hours and +48 hours, CMJ) travel. When compared with CON, small-to-large effects were observed for COMP to improve heart rate (+9 hours), oxygen saturation (+6.5 hours and +9 hours), alertness (+6.5 hours), fatigue (+6.5 hours), muscle soreness (+6.5 hours and +9 hours), and overall health (+6.5 hours) during travel. After travel, small-to-moderate effects were observed for COMP to improve systolic blood pressure (+12 hours), right calf girth (+12 hours), CMJ height (+24 hours), mean velocity (+24 hours), and relative power (+48 hours), compared with CON. COMP had no effect on the markers of blood clotting. This study suggests that compression socks are beneficial in combating the stressors imposed by long-haul travel in elite athletes, and may have merit for individuals frequenting long-haul travel or competing soon after flying.

Overview of venous pathology related to repetitive vascular trauma in athletes

BACKGROUND

Athletes are generally young, high-functioning individuals. Pathology in this cohort is associated with a decrease in function and consequently has major implications on quality of life. Venous disorders can be attributed to a combination of vascular compression with a high burden of activity.

OBJECTIVE

This article promotes increased awareness of these uncommon conditions specific to the athlete by summarizing pathophysiology, clinical features, investigation, and treatment protocols for use in clinical practice. Prognostic outcomes of these management regimens are also discussed, allowing for clinicians to counsel these high-functioning individuals appropriately. With the aim of providing an overview of sport-related venous pathology, a literature review was undertaken identifying articles that were independently reviewed by the authors.

RESULTS

Lower limb venous thrombosis has been identified in young, high-functioning athletes attributed to both compression-related venous trauma, associated with repetitive movements resulting in intimal damage, and blunt trauma. The diagnosis and treatment follow the same protocols as for the general population. Of note, early ambulation is advocated, with an aim to return to premorbid (noncontact) function within 6 weeks. Athletes performing high-intensity repetitive upper limb movement, such as baseball players, are predisposed to upper limb deep venous thrombosis (DVT). Diagnosis follows the same protocols as for lower extremity DVT; however, the optimal treatment strategy remains debated. Current guidelines advocate the use of anticoagulation alone. A specific subset of primary upper limb DVT is effort thrombosis, where there is compression at the level of the thoracic outlet. Thrombolysis with first rib resection is indicated in the acute setting within 14 days. In cases of complete occlusion, surgical decompression with venous reconstruction may be required. Popliteal vein entrapment syndrome is also discussed. This entity has been identified as an overuse injury associated with popliteal vein compression. Duplex ultrasound examination is indicated as a first-line investigation, with conservative noninvasive options considered as an initial management strategy. Chronic venous insufficiency or persistent symptoms may require subsequent surgical decompression.

CONCLUSIONS

Key conditions including upper extremity and lower extremity venous thrombosis, venous aneurysms, Paget-Schroetter syndrome (effort thrombosis), and popliteal vein entrapment syndrome are discussed. Further studies evaluating long-term outcomes on morbidity for current treatment regimens in upper extremity DVT, effort thrombosis, venous thoracic outlet syndrome, and popliteal venous entrapment syndrome are required.

Differential Diagnosis in a Patient Presenting With Both Systemic and Neuromusculoskeletal Pathology: Resident's Case Problem

Study Design Resident's case problem. Background Patients presenting with multiple symptomatic areas pose a diagnostic challenge for the physical therapist. Though musculoskeletal and nonmusculoskeletal symptoms typically present separately, they can occur simultaneously and mimic each other. Consequently, the ability to differentiate between musculoskeletal and nonmusculoskeletal symptoms is an important skill for physical therapists. The purpose of this resident's case problem was to describe the clinical-reasoning process leading to medical and physical therapy management of a patient presenting with upper and lower back pain, bilateral radiating arm and leg pain, and abdominal pain. Diagnosis The patient was a 30-year-old woman referred to physical therapy for upper and lower back pain. A detailed history and thorough examination revealed that the patient had signs and symptoms consistent with a possible abdominal aortic aneurysm. She was referred for medical management and was diagnosed with symptomatic cholelithiasis. She subsequently had a cholecystectomy, which ultimately resolved her abdominal pain and reduced her pain in other areas significantly. Although many of her symptoms resolved postoperatively, her pain in other areas remained and was potentially musculoskeletal in origin. Following re-evaluation and 3 physical therapy treatments over a 2-month period, she was relatively symptom free at discharge and had achieved all functional rehabilitation goals. Discussion This resident's case problem provides an opportunity to discuss the differential diagnosis, clinical reasoning, and outcome of a patient who presented with both systemic and neuromusculoskeletal pathology. Level of Evidence Differential diagnosis, level 5. J Orthop Sports Phys Ther 2018;48(6):496-503. Epub 6 Feb 2018. doi:10.2519/jospt.2018.7652.

Compression Socks Worn During Flight and Hemostatic Balance in Boston Marathon Runners on Oral Contraceptives

OBJECTIVE

To investigate the effect of oral contraceptive (OC) use and compression socks on hemostatic activation in women flying cross-country to and from a marathon.

DESIGN

Prospective study.

SETTING

2015 Boston Marathon.

PARTICIPANTS

Women were divided into non-OC using (CONTROL; n = 12), OC-using (OC; n = 15), and OC-using plus compression sock (OC + SOCK; n = 14) groups.

INTERVENTION

Women in OC + SOCK wore compression socks during flights to and from the marathon.

MAIN OUTCOME MEASURES

Venous blood samples were collected within 24 hours of arriving in Boston (EXPO), immediately after the marathon (RUN), and within 24 hours after a return flight home (Post-Flight) for analysis of thrombin-antithrombin complex (TAT), d-dimer, and tissue plasminogen activator (t-PA).

RESULTS

TAT did not increase with exercise (P = 0.48) and was not affected by group (P = 0.08) or the interaction between these 2 factors (P = 0.80). Group, time, and their interaction were significant for d-dimer (all P < 0.05) such that d-dimer increased with acute exercise to a greater extent (Δ d-dimer from expo to postrace = 909.5 ± 1021.9 ng/mL) in the OC + SOCK group relative to OC (Δ d-dimer = 240.0 ± 178.5 ng/mL; P = 0.02) and CONTROL (Δ d-dimer = 230.3 ± 120.3 ng/mL; P = 0.02). There was a significant effect of time, group, and the interaction on t-PA (all P < 0.01) such that t-PA increased with acute exercise to a greater extent (Δ t-PA from expo to postrace = 19.6 ± 10.0 ng/mL) in the CONTROL group relative to OC (Δ t-PA = 4.0 ± 1.8 ng/mL; P < 0.01) and OC + SOCK (Δ t-PA = 3.3 ± 1.2 ng/mL; P < 0.01).

CONCLUSIONS

Female runners using OCs did not exhibit disproportionately increased coagulation. The use of compression socks in women on OCs, surprisingly, resulted in a greater increase in d-dimer after exercise.

Interaction of a genetic risk score with physical activity, physical inactivity, and body mass index in relation to venous thromboembolism risk

INTRODUCTION

Venous thromboembolism (VTE) is highly heritable. Physical activity, physical inactivity and body mass index (BMI) are also risk factors, but evidence of interaction between genetic and environmental risk factors is limited.

METHODS

Data on 2,134 VTE cases and 3,890 matched controls were obtained from the Nurses' Health Study (NHS), Nurses' Health Study II (NHS II), and Health Professionals Follow-up Study (HPFS). We calculated a weighted genetic risk score (wGRS) using 16 single nucleotide polymorphisms associated with VTE risk in published genome-wide association studies (GWAS). Data on three risk factors, physical activity (metabolic equivalent [MET] hours per week), physical inactivity (sitting hours per week) and BMI, were obtained from biennial questionnaires. VTE cases were incident since cohort inception; controls were matched to cases on age, cohort, and genotype array. Using conditional logistic regression, we assessed joint effects and interaction effects on both additive and multiplicative scales. We also ran models using continuous wGRS stratified by risk-factor categories.

RESULTS

We observed a supra-additive interaction between wGRS and BMI. Having both high wGRS and high BMI was associated with a 3.4-fold greater risk of VTE (relative excess risk due to interaction = 0.69, p = 0.046). However, we did not find evidence for a multiplicative interaction with BMI. No interactions were observed for physical activity or inactivity.

CONCLUSION

We found a synergetic effect between a genetic risk score and high BMI on the risk of VTE. Intervention efforts lowering BMI to decrease VTE risk may have particularly large beneficial effects among individuals with high genetic risk.

Performance of wells score to predict deep vein thrombosis and pulmonary embolism in endurance athletes

INTRODUCTION

There are an increasing number of reports describing deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in otherwise healthy endurance athletes. The Wells score is the most commonly used clinical prediction rule to diagnose DVT/PE in clinical populations. However, the Wells score may have limited utility for recognition of DVT/PE in athletes, contributing to missed or delayed diagnosis.

OBJECTIVE

We performed an analysis of the ability of the Wells score to identify DVT/PE events in athletes through a review of published case reports.

METHODS

A systematic search of the literature yielded 11 case reports.

RESULTS

The Wells score had a 100% failure rate in identifying athletes with DVT (0/6) and PE (0/5), resulting in a delayed diagnosis for DVT of 20 ± 14 days. Retrospectively removing 'differential diagnosis' from the clinical prediction rule for DVT changed the Wells score median from 0 (range: -1 to 0) to 2 (range: 1 to 2); the threshold for predicting DVT as 'likely'. There were limited clinical characteristics captured in the Wells score for PE that were applicable to athletes, highlighting the need for reappraisal. Although the Wells score failed to accurately triage athletes with known DVT and/or PE, the addition of a D-dimer value (mean: 1566 ± 758ng/dL) to the Wells score correctly identified 9/9 athletes.

CONCLUSIONS

The Wells score had a 100% failure rate for triaging athletes with known DVT/PE. When performed, D-dimer adequately facilitated the additional diagnostic testing required for a timely diagnosis of DVT/PE in athletes. Improving awareness of an atypical presentation of thrombotic events in athletes may reduce the widespread underestimation of DVT/PE among athletes and facilitate the additional testing required for a timely diagnosis.

Special Circumstances and Populations

Venous thromboembolism is a condition that includes both deep venous thrombosis and pulmonary embolism. Venous thromboembolism disease can result because of a combination of risk factors, including patient-related, treatment-related, and, more specifically, cancer-related factors. It is not disease-specific or a population-specific disorder, but it is more prevalent in certain specialty populations. This article will cover those specialty populations including cancer, pregnancy, and athletes.

Athletes and blood clots: individualized, intermittent anticoagulation management

Essentials Athletes on anticoagulants are typically prohibited from participation in contact sports. Short-acting anticoagulants allow for reconsideration of this precedent. An individualized pharmacokinetic/pharmacodynamics study can aid patient-specific management. Many challenges and unresolved issues exist regarding such tailored intermittent dosing.

SUMMARY

Athletes with venous thromboembolism (VTE) are typically prohibited from participating in contact sports during anticoagulation therapy, but such mandatory removal from competition can cause psychological and financial detriments for athletes and overlooks patient autonomy. The precedent of compulsory removal developed when options for anticoagulation therapy were more limited, but medical advances now allow for rethinking of the management of athletes with VTE. We propose a novel therapeutic approach to the treatment of athletes who participate in contact sports and require anticoagulation. A personalized pharmacokinetic/pharmacodynamics study of a direct oral anticoagulant can be performed for an athlete, which can inform the timing of medication dosing. Managed carefully, this can allow athletic participation when plasma drug concentration is minimal (minimizing bleeding risk) and prompt resumption of treatment after the risk of bleeding sufficiently normalizes (maximizing therapeutic time).

Upper extremity deep vein thrombosis in a triathlete: Again intense endurance exercise as a thrombogenic risk

Triathlon followers increase each year and long-distance events have seen major growth worldwide. In the cycling phase, athletes must maintain an aerodynamic posture on the bike for long periods of time. We report a case of a 38-year-old triathlete with symptoms of an axillary vein thrombosis 48h after a long triathlon competition. After 3days of hospitalization with a treatment consisted on enoxaparin anticoagulant and acenocumarol, the patient was discharged with instructions to continue treatment under home hospitalization with acetaminophen. Four weeks after the process, the patient was asymptomatic and the diameter of his arm was near normality. Due to the growing popularity of events based on endurance exercise, it is necessary more research to determine the etiopathogeny of deep venous thrombosis in athletes.

Venous Thromboembolism in Physically Active People: Considerations for Risk Assessment, Mainstream Awareness and Future Research

The global healthcare burden of venous thromboembolism (VTE) and associated comorbidities (e.g., obesity, heart disease and cancer) is significant. Physical activity-especially cardiovascular exercise-is popularly acclaimed for gold-standard prevention. Paradoxically, intensive training can expose athletes to several potentially thrombogenic risk factors (e.g., heat stress, dehydration, blood vessel injury and inflammation). However, awareness regarding the risk of VTE in physically active people is generally lacking. Given that the overall incidence of asymptomatic and/or occult blood clots that resolve spontaneously is uncharted, and because symptoms and sequelae are not always 'textbook', triage evaluation and diagnosis of VTE at large can be challenging. Front-line clinical evaluations, including the major Wells scoring criteria, are (versus the total number of possible factors and diagnoses) comparably reductionist, and the point at which a minor risk might be considered significant in one person-but not in another-is subjective. Considering the popular associations between VTE and inactivity, athletes might be at greater risk of a missed diagnosis quite simply because their cardiovascular conditioning presents as the polar opposite to standard assessment criteria. Undoubtedly, risk factors for VTE associated with exercise are not unique to cardiovascular training or athletes, but the extent to which they might increase the chances of blood clot precipitation in certain participants warrants attention. A multi-agency approach, including research to inform mainstream understanding and awareness about risk factors for VTE in patient groups across age, comorbidity and activity spectra, is required. In this article, the potential for pre-participatory thrombophilia screening, haemostatic monitoring and personalized prophylactic guidelines is discussed.

The effect of compression socks worn during a marathon on hemostatic balance

INTRODUCTION

Marathon running evokes parallel increases in markers of coagulation and fibrinolysis (i.e. hemostatic activation) immediately following strenuous, endurance exercise such that hemostatic balance is maintained. However, other factors incident to marathon running (i.e. dehydration, travel) may disproportionately activate the coagulatory system, increasing blood clot risk after an endurance event in otherwise healthy individuals. We investigated the effect of compression socks on exercise-induced hemostatic activation and balance in endurance athletes running the 2013 Hartford Marathon.

METHODS

Adults (n = 20) were divided into compression sock (SOCK; n = 10) and control (CONTROL; n = 10) groups. Age, anthropometrics, vital signs, training mileage and finishing time were collected. Venous blood samples were collected 1 day before, immediately after and 1 day following the marathon for analysis of coagulatory (i.e. thrombin-antithrombin complex [TAT] and D-dimer) and fibrinolytic (i.e. tissue plasminogen activator [t-PA]) factors.

RESULTS

Plasma D-dimer, TAT and t-PA did not differ between groups at baseline (p > 0.16). There were no significant group · time interactions (all p ≥ 0.17), however, average t-PA was lower in SOCK (8.9 ± 0.7 ng/mL) than CONTROL (11.2 ± 0.7 ng/mL) (p = 0.04). Average TAT also tended to be lower in SOCK (2.8 ± 0.2 µg/L) than CONTROL (3.4 ± 0.2 µg/L) (p = 0.07).

CONCLUSIONS

Our results suggest that overall hemostatic activation (both coagulation and fibrinolysis) following a marathon tended to be lower with compression socks. Thus, compression socks do not adversely influence markers of hemostasis, appear safe for overall use in runners and may reduce exercise-associated hemostatic activation in individuals at risk for deep vein thrombosis.

An update on the Boston Marathon as a research laboratory

PURPOSE/METHODS

The Boston Athletic Association's annual marathon, also referred to as BAA in this article, continues to be a source of subjects for exercise and endurance performance research. We performed a systematic literature review of BAA studies published in the 7 years since our prior report.

RESULTS

We identified 20 articles published from January 2008 to February 2015. Nine were related to cardiology; six were related to exercise physiology; four were related to metabolism; and one was related to marathon qualifying times. As in our prior, report cardiovascular studies remained the dominant topic, but with risk factors for atherosclerosis and thrombosis as the present focus.

CONCLUSION

Cardiac issues remain the largest subject area for BAA studies, but with more emphasis on the effect of prolonged exercise on atherosclerotic and thrombotic risk factors. This shift is associated with an increase in marathon participation by older, recreational runners at increased risk of cardiac complications due to exercise.

Protective effect of compression socks in a marathon runner with a genetic predisposition to thrombophilia due to Factor V Leiden

INTRODUCTION

The present case study is an analysis of the effect of compression socks on hemostatic activation following a marathon in a female endurance athlete found to be heterozygous for the coagulation factor V (F5 1691 G>A [Arg>Gln rs6025/560]) risk allele that predisposes one to a genetically inherited disorder of blood clotting, Factor V Leiden.

METHODS

Markers for coagulation and fibrinolysis were obtained 24 h prior to (PRE), immediately after (FINISH) and 24 h after (POST) completion of two marathons: the first in which the runner was not wearing compression socks, and the second in which the runner wore compression socks throughout the race.

RESULTS

Compression socks worn during a marathon appeared to lower the overall impact on hemostasis as well as clot formation in this particular athlete as evidenced by lower t-PA (-56%), TAT (-63%) and D-dimer (-30%).

CONCLUSIONS

Hemostatic activation may be lower with the use of compression socks, and thus may be effective for preserving hemostasis in endurance athletes at risk.

The impact of triathlon training and racing on athletes' general health

Although the sport of triathlon provides an opportunity to research the effect of multi-disciplinary exercise on health across the lifespan, much remains to be done. The literature has failed to consistently or adequately report subject age group, sex, ability level, and/or event-distance specialization. The demands of training and racing are relatively unquantified. Multiple definitions and reporting methods for injury and illness have been implemented. In general, risk factors for maladaptation have not been well-described. The data thus far collected indicate that the sport of triathlon is relatively safe for the well-prepared, well-supplied athlete. Most injuries 'causing cessation or reduction of training or seeking of medical aid' are not serious. However, as the extent to which they recur may be high and is undocumented, injury outcome is unclear. The sudden death rate for competition is 1.5 (0.9-2.5) [mostly swim-related] occurrences for every 100,000 participations. The sudden death rate is unknown for training, although stroke risk may be increased, in the long-term, in genetically susceptible athletes. During heavy training and up to 5 days post-competition, host protection against pathogens may also be compromised. The incidence of illness seems low, but its outcome is unclear. More prospective investigation of the immunological, oxidative stress-related and cardiovascular effects of triathlon training and competition is warranted. Training diaries may prove to be a promising method of monitoring negative adaptation and its potential risk factors. More longitudinal, medical-tent-based studies of the aetiology and treatment demands of race-related injury and illness are needed.

Fatalities in high school and college football players

BACKGROUND

Fatalities in football are rare but tragic events.

PURPOSE

The purpose was to describe the causes of fatalities in high school and college football players and potentially provide preventive strategies.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

We reviewed the 243 football fatalities reported to the National Center for Catastrophic Sports Injury Research from July 1990 through June 2010.

RESULTS

Football fatalities averaged 12.2 per year, or 1 per 100,000 participants. There were 164 indirect (systemic) fatalities (average, 8.2 annually [or 0.7 per 100,000 participants]) and 79 direct (traumatic) fatalities (average, 4.0 annually [or 0.3 per 100,000 participants]). Indirect fatalities were 2.1 times more common than direct fatalities. The risk of a fatality in college compared with high school football players was 2.8 (95% CI, 0.7-8.2) times higher for all fatalities, 3.6 (95% CI, 2.5-5.3) times higher for indirect events, 1.4 (95% CI, 0.6-3.0) times higher for direct injuries, 3.8 (95% CI, 1.8-8.3) times higher for heat illness, and 66 (95% CI, 14.4-308) times higher for sickle cell trait (SCT) fatalities. Most indirect events occurred in practice sessions; preseason practices and intense conditioning sessions were vulnerable periods for athletes to develop heat illness or SCT fatalities, respectively. In contrast, most brain fatalities occurred during games. The odds of a fatality during the second decade, compared with the first decade of the study, were 9.7 (95% CI, 1.2-75.9) for SCT, 1.5 (95% CI, 0.8-2.9) for heat illness, 1.1 (95% CI, 0.8-1.7) for cardiac fatalities, and 0.7 (95% CI, 0.4-1.2) for brain fatalities. The most common causes of fatalities were cardiac failure (n = 100, 41.2%), brain injury (n = 62, 25.5%), heat illness (n = 38, 15.6%), SCT (n = 11, 4.5%), asthma and commotio cordis (n = 7 each, 2.9% each), embolism/blood clot (n = 5, 2.1%), cervical fracture (n = 4, 1.7%), and intra-abdominal injury, infection, and lightning (n = 3, 1.2% each).

CONCLUSION

High school and college football have approximately 12 fatalities annually with indirect systemic causes being twice as common as direct blunt trauma. The most common causes are cardiac failure, brain injury, and heat illness. The incidence of fatalities is much higher at the college level for most injuries other than brain injuries, which were only slightly more common at the college level. The risk of SCT, heat-related, and cardiac deaths increased during the second decade of the study, indicating these conditions require a greater emphasis on diagnosis, treatment, and prevention.

Factor V leiden thrombophilia in a female collegiate soccer athlete: a case report

OBJECTIVE

To raise awareness among health care providers caring for an active population to an uncommon genetic mutation that increases the risk for a potentially fatal venous thromboembolism.

BACKGROUND

A 19-year-old previously healthy female collegiate soccer athlete complained of coughing and progressively decreased exercise tolerance, which were attributed to a recent illness and lack of sleep. Later that evening, she complained of dyspnea and pleuritic pain and was referred to the emergency department. Bilateral pulmonary emboli were identified with computed tomography, and a hypercoagulable panel revealed that the patient was heterozygous for the factor V Leiden mutation.

DIFFERENTIAL DIAGNOSIS

Pneumonia, pneumothorax, pericarditis, pleuritis, gastroesophageal reflux disease, pulmonary embolism.

TREATMENT

Intravenous heparin therapy was initiated immediately in the emergency department. This was followed by inpatient anticoagulant therapy for 5 days and outpatient anticoagulant therapy for an additional 12 months. During this time, the patient was unable to participate in soccer drills or return to competition and was limited to conditioning activities due to the risk of increased bleeding time.

UNIQUENESS

Documented cases of pulmonary embolism in a young athletic population are rare and are usually associated with genetic risk factors. Factor V Leiden is a relatively uncommon genetic mutation that dramatically increases the risk for venous thromboembolism. Although the fatality rate in this population is low, fatality is preventable if the condition is recognized early and managed properly.

CONCLUSIONS

Athletes should be encouraged to communicate with their athletic trainers regarding any changes in health status or medication usage. When an athlete presents with nonspecific symptoms such as dyspnea and chest pain, athletic trainers should consider the possibility of pulmonary embolism. A high degree of suspicion results in early diagnosis and treatment and may prevent a fatal event.

Ultrasound in sports medicine: relevance of emerging techniques to clinical care of athletes

The applications of ultrasound in managing the clinical care of athletes have been expanding over the past decade. This review provides an analysis of the research that has been published regarding the use of ultrasound in athletes and focuses on how these emerging techniques can impact the clinical management of athletes by sports medicine physicians. Electronic database literature searches were performed using the subject terms 'ultrasound' and 'athletes' from the years 2003 to 2012. The following databases were searched: PubMed, Web of Science, Cochrane Library, CINAHL, and SPORTDiscus™. The search produced 617 articles in total, with a predominance of articles focused on cardiac and musculoskeletal ultrasound. 266 of the studies involved application of ultrasound in evaluating the cardiovascular properties of athletes, and 151 studies involved musculoskeletal ultrasound. Other applications of ultrasound included abdominal, vascular, bone density and volume status. New techniques in echocardiography have made significant contributions to the understanding of the physiological changes that occur in the athlete's heart in response to the haemodynamic stress associated with different types of activity. The likely application of these techniques will be in managing athletes with hypertrophic cardiomyopathy, and the techniques are near ready for application into clinical practice. These techniques are highly specialized, however, and will require referral to dedicated laboratories to influence the clinical management of athletes. Investigation of aortic root pathology and pulmonary vascular haemodynamics are also emerging, but will require additional studies with larger numbers and outcomes analysis to validate their clinical utility. Some of these techniques are relatively simple, and thus hold the potential to enter clinical management in a point-of-care fashion. Musculoskeletal ultrasound has demonstrated a number of diagnostic and therapeutic techniques applicable to pathology of the shoulder, elbow, wrist, hand, hip, knee and ankle. These techniques have been applied mainly to the management of impingement syndromes, tendinopathies and arthritis. Many of these techniques have been validated and have entered clinical practice, while more recently developed techniques (such as dynamic ultrasound and platelet-rich plasma injections) will require further research to verify efficacy. Research in musculoskeletal ultrasound has also been helpful in identifying risk factors for injury and, thus, serving as a focus for developing interventions. Research in abdominal ultrasound has investigated the potential role of ultrasound imaging in assessing splenomegaly in athletes with mononucleosis, in an attempt to inform decisions and policies regarding return to play. Future research will have to demonstrate a reduction in adverse events in order to justify the application of such a technique into policy. The role of ultrasound in assessing groin pain and abdominal pain in ultraendurance athletes has also been investigated, providing promising areas of focus for the development of treatment interventions and physical therapy. Finally, preliminary research has also identified the role of ultrasound in addressing vascular disease, bone density and volume status in athletes. The potential applications of ultrasound in athletes are broad, and continuing research, including larger outcome studies, will be required to establish the clinical utility of these techniques in the care of athletes.

Effect of air travel on exercise-induced coagulatory and fibrinolytic activation in marathon runners

OBJECTIVE

Air travel and exercise change hemostatic parameters. This study investigated the effect of air travel on exercise-induced coagulation and fibrinolysis in endurance athletes.

DESIGN

A prospective longitudinal study.

SETTING

The 114th Boston Marathon (April 19, 2010).

PARTICIPANTS

Forty-one adults were divided into travel (T: 23 participants, living >4-hour plane flight from Boston) and nontravel (C: 18 participants, living <2-hour car trip from Boston) groups.

INDEPENDENT VARIABLES

Age, anthropometrics, vital signs, training mileage, and finishing time were collected.

MAIN OUTCOME MEASURES

Subjects provided venous blood samples the day before (PRE), immediately after (FINISH), and the day following the marathon after returning home (POST). Blood was analyzed for thrombin-antithrombin complex (TAT), tissue plasminogen activator (t-PA), hematocrit (Hct), and the presence of Factor V Leiden R506Q mutation.

RESULTS

Thrombin-antithrombin complex increased more in T subjects in PRE to FINISH samples (5.0 ± 4.0 to 12.9 ± 15.6 μg/L) than in C subjects (4.0 ± 1.2 to 6.1 ± 1.2 μg/L; P = 0.02 for comparison). The t-PA increased in both the T (5.4 ± 2.3 to 25.1 ± 12.2 ng/mL) and C (5.6 ± 2.0 to 27.7 ± 11.3 ng/mL) groups in PRE to FINISH samples, and this response did not differ between groups (P = 0.23 for comparison). Both groups exhibited similar t-PA and TAT values at POST that were not different than PRE (all P > 0.35). Age was related to the FINISH TAT values in T (r = 0.19; P = 0.04) but not in C (r = 0.03; P = 0.53) subjects.

CONCLUSIONS

Results suggest that the combination of air travel and marathon running induces an acute hypercoaguable state; this hemostatic imbalance is exaggerated with increasing age.