The athletic polydrug abuse phenomenon. A case report

Bilateral Quadriceps Rupture in an Elite Weight Lifter: A Case Report and Review of Literature

Simultaneous bilateral quadriceps tendon ruptures (QTR) are rare injuries in sportspersons; weightlifting, involving sudden eccentric contraction of the bilateral quadriceps, has the potential to cause this injury. We present a case of an elite weightlifter with bilateral quadriceps tear occurring during the "jerk" part of clean and jerk phase of weightlifting; single stage bilateral end to end repair was done, followed by 3 weeks of cast immobilisation. He then underwent a supervised rehabilitation protocol, leading to graduated strengthening of the muscles. He went back to competitive sport after 2 years and participated in a national championship after 5 years. Detailed questioning revealed a history of anabolic steroid use in the early phase of his career; a literature review showed only seven cases of this injury pattern in weightlifting/bodybuilding sports, and five of these seven had a definitive history of anabolic steroid use. Bilateral QTR may be a pointer to predisposing factors like use of steroids, which should be diligently identified. Good outcomes are possible after early surgical repair and rehabilitation, with high rates of return to sports.

Tendon Remodeling in Response to Resistance Training, Anabolic Androgenic Steroids and Aging

Exercise training (ET), anabolic androgenic steroids (AAS), and aging are potential factors that affect tendon homeostasis, particularly extracellular matrix (ECM) remodeling. The goal of this review is to aggregate findings regarding the effects of resistance training (RT), AAS, and aging on tendon homeostasis. Data were gathered from our studies regarding the impact of RT, AAS, and aging on the calcaneal tendon (CT) of rats. We demonstrated a series of detrimental effects of AAS and aging on functional and biomechanical parameters, including the volume density of blood vessel cells, adipose tissue cells, tendon calcification, collagen content, the regulation of the major proteins related to the metabolic/development processes of tendons, and ECM remodeling. Conversely, RT seems to mitigate age-related tendon dysfunction. Our results suggest that AAS combined with high-intensity RT exert harmful effects on ECM remodeling, and also instigate molecular and biomechanical adaptations in the CT. Moreover, we provide further information regarding the harmful effects of AAS on tendons at a transcriptional level, and demonstrate the beneficial effects of RT against the age-induced tendon adaptations of rats. Our studies might contribute in terms of clinical approaches in favor of the benefits of ET against tendinopathy conditions, and provide a warning on the harmful effects of the misuse of AAS on tendon development.

Narrative review of injuries in powerlifting with special reference to their association to the squat, bench press and deadlift

Pain and injuries are considered a common problem among elite athletes and recreational lifters performing the squat, bench press and deadlift. Since all three lifts engage multiple joints and expose the lifters’ bodies to high physical demands often several times a week, it has been suggested that their injuries might be related to the excessively heavy loads, the large range of motion during the exercises, insufficient resting times between training sessions and/or faulty lifting technique. However, no previous article has summarised what is known about specific injuries and the injury aetiology associated with the three lifts. Thus, the aim of this narrative review was to summarise what is known about the relationships between the powerlifting exercises and the specific injuries or movement impairments that are common among lifters and recreationally active individuals.

Sex Hormones and Tendon

The risk of overuse and traumatic tendon and ligament injuries differ between women and men. Part of this gender difference in injury risk is probably explained by sex hormonal differences which are specifically distinct during the sexual maturation in the teenage years and during young adulthood. The effects of the separate sex hormones are not fully elucidated. However, in women, the presence of estrogen in contrast to very low estrogen levels may be beneficial during regular loading of the tissue or during recovering after an injury, as estrogen can enhance tendon collagen synthesis rate. Yet, in active young female athletes, physiological high concentration of estrogen may enhance the risk of injuries due to reduced fibrillar crosslinking and enhanced joint laxity. In men, testosterone can enhance tendon stiffness due to an enhanced tendon collagen turnover and collagen content, but testosterone has also been linked to a reduced responsiveness to relaxin. The present chapter will focus on sex difference in tendon injury risk, tendon morphology and tendon collagen turnover, but also on the specific effects of estrogen and androgens.

Ruptured Tendons in Anabolic-Androgenic Steroid Users: A Cross-Sectional Cohort Study

BACKGROUND

Accumulating case reports have described tendon rupture in men who use anabolic-androgenic steroids (AAS). However, no controlled study has assessed the history of tendon rupture in a large cohort of AAS users and comparison nonusers.

HYPOTHESIS

Men reporting long-term AAS abuse would report an elevated lifetime incidence of tendon rupture compared with non-AAS-using bodybuilders.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Medical histories were obtained from 142 experienced male bodybuilders aged 35 to 55 years recruited in the course of 2 studies. Of these men, 88 reported at least 2 years of cumulative lifetime AAS use, and 54 reported no history of AAS use. In men reporting a history of tendon rupture, the circumstances of the injury, prodromal symptoms, concomitant drug or alcohol use, and details of current and lifetime AAS use (if applicable) were recorded. Surgical records were obtained for most participants.

RESULTS

Nineteen (22%) of the AAS users, but only 3 (6%) of the nonusers, reported at least 1 lifetime tendon rupture. The hazard ratio for a first ruptured tendon in AAS users versus nonusers was 9.0 (95% CI, 2.5-32.3; P < .001). Several men reported 2 or more independent lifetime tendon ruptures. Interestingly, upper-body tendon ruptures occurred exclusively in the AAS group (15 [17%] AAS users vs 0 nonusers; risk difference, 0.17 [95% CI, 0.09-0.25]; P < .001 [hazard ratio not estimable]), whereas there was no significant difference between users and nonusers in risk for lower-body ruptures (6 [7%] AAS users, 3 [6%] nonusers; hazard ratio, 3.1 [95% CI, 0.7-13.8]; P = .13). Of 31 individual tendon ruptures assessed, only 6 (19%) occurred while weightlifting, with the majority occurring during other sports activities. Eight (26%) ruptures followed prodromal symptoms of nonspecific pain in the region. Virtually all ruptures were treated surgically, with complete or near-complete ultimate restoration of function.

CONCLUSION

AAS abusers, compared with otherwise similar bodybuilders, showed a markedly increased risk of tendon ruptures, particularly upper-body tendon rupture.

The effect of local use of nandrolone decanoate on rotator cuff repair in rabbits

OBJECTIVE

There is still controversy about the effect of anabolic steroid on connective tissue. This study examines the hypothesis that the local use of nandrolone decanoate, an anabolic steroid on rotator cuff, facilitates the healing process when used in combination with surgical repair.

METHODS

Forty-eight male rabbits were divided in four groups with anabolic steroids (Nandrolone Decanoate 10 mg/kg) and immobilization as variables. The groups were the following: first group, nonsteroid use-immobilization (NSI); second group, nonsteroid use-nonimmobilization (NSNI); third group, steroid use-immobilization (SI); fourth group steroid use-nonimmobilization (SNI). Every rabbit underwent a rotator cuff incision and reconstruction. Fifteen days later the tendons were sent for biomechanical and histological evaluation.

RESULTS

Groups that did not receive anabolic steroids showed better healing and more tendon strength in comparison to groups that received anabolic steroids. Microscopic examination of specimens from the groups without the use of anabolic steroid showed extensive fibroblastic activity whereas the specimens from those groups with anabolic steroid use showed focal fibroblastic reaction and inflammation. Immobilization provided better results in the groups with anabolic steroid use but it did not influence healing in groups without steroids.

CONCLUSIONS

The effect of local nandrolone decanoate use on a rotator cuff tear is detrimental, acting as a healing inhibitor.

Doping and musculoskeletal system: short-term and long-lasting effects of doping agents

Doping is a problem that has plagued the world of competition and sports for ages. Even before the dawn of Olympic history in ancient Greece, competitors have looked for artificial means to improve athletic performance. Since ancient times, athletes have attempted to gain an unfair competitive advantage through the use of doping substances. A Prohibited List of doping substances and methods banned in sports is published yearly by the World Anti-Doping Agency. Among the substances included are steroidal and peptide hormones and their modulators, stimulants, glucocorticosteroids, β₂-agonists, diuretics and masking agents, narcotics, and cannabinoids. Blood doping, tampering, infusions, and gene doping are examples of prohibited methods indicated on the List. Apart from the unethical aspect of doping, as it abrogates fair-play's principle, it is extremely important to consider the hazards it presents to the health and well-being of athletes. The referred negative effects for the athlete's health have to do, on the one hand, by the high doses of the performance-enhancing agents and on the other hand, by the relentless, superhuman strict training that the elite or amateur athletes put their muscles, bones, and joints. The purpose of this article is to highlight the early and the long-lasting consequences of the doping abuse on bone and muscle metabolism.

Self-reported anabolic-androgenic steroids use and musculoskeletal injuries: findings from the center for the study of retired athletes health survey of retired NFL players

OBJECTIVE

The relationship between musculoskeletal injuries and anabolic-androgenic steroids is not well understood. The purpose of our study was to investigate the association between self-reported anabolic-androgenic steroids use and the prevalence of musculoskeletal injuries in a unique group of retired professional football players.

DESIGN

A general health questionnaire was completed by 2552 retired professional football players. Survey data were collected between May 2001 and April 2003. Results of self-reported musculoskeletal injuries were compared with the use of anabolic-androgenic steroids using frequency distributions and chi2 analyses.

RESULTS

Of the retired players, 9.1% reported using anabolic-androgenic steroids during their professional career. A total of 16.3% of all offensive line and 14.8% of all defensive line players reported using anabolic-androgenic steroids. Self-reported anabolic-androgenic steroids use was significantly associated (P < 0.05) with the following self-reported, medically diagnosed, joint and cartilaginous injuries in comparison with the nonanabolic-androgenic steroids users: disc herniations, knee ligamentous/meniscal injury, elbow injuries, neck stinger/burner, spine injury, and foot/toe/ankle injuries. There was no association between anabolic-androgenic steroids use and reported muscle/tendon injuries.

CONCLUSIONS

Our findings demonstrate that an association may exist between anabolic-androgenic steroids use and the prevalence of reported musculoskeletal injury sustained during a professional football career, particularly ligamentous/joint-related injuries. There may also be an associated predisposition to selected types of injuries in anabolic-androgenic steroids users.

Nandrolone decanoate and load increase remodeling and strength in human supraspinatus bioartificial tendons

BACKGROUND

To date, no studies document the effect of anabolic steroids on rotator cuff tendons.

STUDY DESIGN

Controlled laboratory study.

HYPOTHESIS

Anabolic steroids enhance remodeling and improve the biomechanical properties of bioartificially engineered human supraspinatus tendons.

METHODS

Bioartificial tendons were treated with either nandrolone decanoate (nonload, steroid, n = 18), loading (load, nonsteroid, n = 18), or both (load, steroid, n = 18). A control group received no treatment (nonload, nonsteroid [NLNS], n = 18). Bioartificial tendons' remodeling was assessed by daily scanning, cytoskeletal organization by staining, matrix metalloproteinase-3 levels by ELISA assay, and biomechanical properties by load-to-failure testing.

RESULTS

The load, steroid group showed the greatest remodeling and the best organized actin cytoskeleton. Matrix metallo-proteinase-3 levels in the load, steroid group were greater than those of the nonload, nonsteroid group (P <.05). Ultimate stress and ultimate strain in the load, steroid group were greater than those of the nonload, nonsteroid and nonload, steroid groups (P <.05). The strain energy density in the load, steroid group was greater when compared to other groups (P <.05).

CONCLUSIONS

Nandrolone decanoate and load acted synergistically to increase matrix remodeling and biomechanical properties of bioartificial tendons.

CLINICAL RELEVANCE

Data suggest anabolic steroids may enhance production of bioartificial tendons and rotator cuff tendon healing in vitro. More research is necessary before such clinical use is recommended.

Ultrastructural analysis of ruptured tendon from anabolic steroid users

Tendon rupture has been linked with anabolic steroid abuse on the basis of a small number of published case reports. Although experimental data from animal models suggest steroids alter the biomechanical properties of tendon, ultrastructural evidence to support this theory is lacking. Indeed, microscopic analysis of human tendon from steroid users has not previously been reported. In this study, specimens of ruptured human tendon from four patients were biopsied during surgical repair. Two of the subjects were anabolic steroid users, and two subjects were used as nonsteroid-user controls. Ruptured tendon from both groups was examined using electron microscopy. No differences in collagen fibril ultrastructure were seen. We conclude that anabolic steroids did not induce ultrastructural collagen changes that might predispose to tendon rupture in humans.

Spontaneous rupture of the anterior cruciate ligament after anabolic steroids

Anabolic steroids remain popular among body builders and power athletes despite numerous warning about their side effects. A case of spontaneous rupture of the anterior cruciate ligament is reported in a bodybuilder taking steroids. While there are many published reports of tendon rupture associated with steroid intake, the authors could find no report relating to ligament disruption.

The effects of anabolic steroids on rat tendon. An ultrastructural, biomechanical, and biochemical analysis

Forty-eight male rats were randomly separated into four groups: a control group, a group treated with anabolic steroids, a group treated with daily exercise, and a group treated with both steroids and exercise. At 6 weeks, biomechanical, ultrastructural, and biochemical testing was performed on the Achilles tendons of half of the rats in each group. The remaining rats continued in the experimental protocol, but steroid administration was discontinued. Similar testing was then performed on the remaining rats at 12 weeks. Testing showed anabolic steroids produced a stiffer tendon that absorbs less energy and fails with less elongation; tendon strength was unaffected. Effects were entirely reversible on discontinuation of the steroids. Light microscopic analysis revealed no changes in the appearance of the fibrils. No change in fibril diameter or shape was noted on electron microscopic analysis. Biochemical testing revealed no change in qualitative immunofluorescence staining with Type III collagen or fibronectin. Abuse of anabolic steroids is a widespread problem among competitive athletes; consequently, complications after their use are seen with increasing frequency. Knowledge of the effects of these drugs on tendon and the musculotendinous unit may prove helpful in counseling athletes who use anabolic steroids.

Experimental changes in mineral content of juvenile mouse femora

Juvenile laboratory mice were exposed to hypergravity (8 g), burrowing exercise, swimming to exhaustion, an anabolic steroid, and swimming and an anabolic steroid for 30 days to determine the variability of skeletal mineralization during growth. Changes in mineralization were correlated with changes in bending strength. Experimental mouse femora were loaded to failure in a cantilever beam configuration to determine bending strength, and ashed to determine total mineral content. Between experimental groups, mineral content ranged from 66.0 to 71.2% with the greatest change from the control being a 4.7% decrease in mineralization in the male swimming exercise group (P less than 0.001). Within two age-matched experiments, the first showed that the group with the greatest decrease in mineralization also had the greatest reduction in bending strength (P less than 0.001). The second age-matched experiment showed that the group with the greatest reduction in mineralization had bending strength greatly reduced (P less than 0.001). However, in this experiment, the weakest femora were in the anabolic steroid group that did not have the mineral content reduced. We conclude that (1) mineralization of juvenile mouse femora is extremely variable given varied conditions of exercise or loading; (2) mineralization of normal bone is decreased more often and to a greater extent than increased from normal exercise controls; (3) the decrease in mineralization seen here can decrease bending strength; and (4) the decrease in mineralization seen was not caused by a decrease in a mechanical loading but was probably due to a corticosterone-mediated psychological stress response.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of the oral and maxillofacial surgery patient on anabolic steroids

Recent Food and Drug Administration estimates indicate that the anabolic steroid market has reached the $100 million level. Although the news media report steroid-related deaths, there is little in the medical literature communicating the clinical implications concerning these drugs. Electrolyte disturbances, coagulopathies, hypertension, and dysrhythmias are a few of the potential side effects. The pharmacology and pathophysiology of anabolic steroids are presented with a discussion of the anesthetic and surgical concerns for the patient undergoing oral and maxillofacial surgery.

Performance-enhancing aids in sport: health consequences and nutritional alternatives

The use of anabolic-androgenic steroids is epidemic in the sporting world, and the recent recognition of their pervasive use by recreational and adolescent athletes has made the abuse of these drugs a public health concern. A critical review of the literature supports the doctrine that anabolic-androgenic steroids can improve muscular performance if certain criteria are met, but some of the health risks associated with their use may be irreversible, and life-threatening. Furthermore, polydrug abuse, restrictive diets, and dehydrating practices may potentiate the health risks associated with weight training and steroid use. Recent investigations of nutritional and training alternatives to anabolic-androgenic steroids are promising. To help lure athletes from drug abuse, the pursuit of new areas of research and education should be priorities in the campaign against the abuse of anabolic steroids.

Recent developments in the toxicology of anabolic steroids

Anabolic steroids are extensively abused as ergogenic aids by athletes (and others). A number of features of anabolic steroid use and toxicology have been recently reviewed in the Journal, and a large body of data has accumulated concerning their toxic nature. The lipoprotein profile induced by anabolic steroids carries a markedly adverse cardiovascular risk. Glucose metabolism is significantly altered and includes peripheral insulin resistance, hyperinsulinaemia and attenuated responses to glucagon. Hypertension has been noted. Psychiatric and psychological alterations are major toxicities of anabolic steroids, and probably constitute the major mechanism of their action. Hepatic neoplasia occurs in the setting of abuse of this class of drugs, and may be related to their use, although there is no convincing evidence that other malignancies are induced in athletes who abuse them. Gross disturbance of reproductive function occurs in both sexes: hypogonadal states are common and prolonged. The anabolic steroids are toxic drugs with both long and short term effects. Their abuse by athletes is to be decried, particularly in view of the frequent and prolonged use by the young.

Androgenic-anabolic steroid effects on serum thyroid, pituitary and steroid hormones in athletes

Endocrine responses in seven power athletes were investigated during a 12 week strength training period, when the athletes were taking high doses of androgenic-anabolic steroids, and during the 13 weeks following drug withdrawal. During the use of steroids significant decreases (P less than 0.05 to 0.001) in the serum concentrations of thyroid stimulating hormone, thyroxine, triidothyronine, free thyroxine, and thyroid hormone-binding globulin (TBG) were found, whereas the value of triidothyronine uptake increased (P less than 0.001). In relation to the changes in the thyroid function parameters measured, we suggest that the primary target of androgen action was TBG biosynthesis. In five of the seven subjects, serum concentrations of growth hormone increased at some point of the study 5 to 60-fold. Because of the use of exogenous testosterone, serum testosterone concentration tended to increase. This increase was associated with a corresponding increase (P less than 0.001) in serum estradiol. Furthermore, there were major decreases in serum LH (P less than 0.01) and FSH (P less than 0.01) concentrations, and testicular testosterone production was therefore decreased. This was characterized by a very low serum testosterone concentration (5.1 +/- 1.8 nmol/l) 4 weeks following drug withdrawal. Cessation of drug use resulted in return of all the variables measured to the initial values, except for serum testosterone, which was at a low level (14.6 +/- 8.8 nmol/l) 9 weeks after drug withdrawal, indicating prolonged impairment of testicular endocrine function. No consistent changes were found in the eight control athletes.

Synthetic Anabolic-Androgenic Steroids: A Plea for Controlled Substance Status

One way to combat the abuse of anabolic-androgenic steroids is to reclassify them as controlled substances under federal law. The author contends that the widespread abuse of steroids, their habit-forming properties, and their other adverse effects are good reasons for reclassification.

Weightlifting, weight training and injuries

Although millions of men and women in the United States are regularly involved in some form of weightlifting, the average physician knows, and frequently cares, little about the sports involved. As a result, his or her knowledge of the medical and physiological issues involved is limited This article attempts to address this lack by beginning with a brief introductory section outlining some of the similarities differences between the major weight lifting approaches (power lifting, olympic lifting, weight training and body building). Next it reviews major issues and controversies such as age restrictions for lifters, physiological effects, drug use, potential strength gains and hypertrophy. Finally, it discusses some of the more frequent and unique injuries that can occur in lifters.

Response of serum testosterone and its precursor steroids, SHBG and CBG to anabolic steroid and testosterone self-administration in man

The influence of high doses of testosterone and anabolic steroids on testicular endocrine function and on circulating steroid binding proteins, sex hormone binding globulin (SHBG) and cortisol binding globulin (CBG), were investigated in power athletes for 26 weeks of steroid self-administration and for the following 16 weeks after drug withdrawal. Serum testosterone and androstenedione concentrations increased (P less than 0.05) but pregnenolone, 17-hydroxypregnenolone, dehydroepiandrosterone, 5-androstene-3 beta, 17 beta-diol, progesterone and 17-hydroxyprogesterone concentrations strongly decreased (P less than 0.001) during steroid administration. Serum pregnenolone, 17-hydroxypregnenolone and dehydroepiandrosterone sulphate concentrations followed the changes of the corresponding unconjugated steroids but 5-androstene-3 beta, 17 beta-diol and testosterone sulphate concentrations remained unchanged during the follow-up time. During drug administration SHBG concentrations decreased by about 80 to 90% and remained low even for the 16 weeks following steroid withdrawal. Steroid administration had no influence on serum CBG concentrations. In conclusion, self-administration of testosterone and anabolic steroids soon led to impairment of testicular endocrine function which was characterized by low concentrations of testosterone precursors, high ratios of testosterone to its precursor steroids and low SHBG concentrations. Decreased concentrations of SHBG and testicular steroids were still partly evident during the 16 weeks after drug withdrawal. The depressed circulating levels of dehydroepiandrosterone and its sulphate may indicate that the androgenic-anabolic steroids also suppress adrenal androgen production.

Androgenic steroid effects on liver and red cells

Haematological and hepatic effects of testosterone/anabolic steroid self-administration were investigated in five power athletes during 26 weeks of training. During steroid administration blood haematocrit had increased 9.6% (p less than .05) in the study group (n = 5), but not in the control group (n = 6). This erythropoietic phenomenon was supported by increased (p less than .05) RBC and unchanged MCV. Blood haemoglobin concentration did not change markedly and consequently MCHC level in the study group decreased significantly (p less than .001). Also the erythrocyte sedimentation rate decreased (p less than .05) in the study group. The mean values of serum alanine aminotransferase, alkaline phosphatase and gamma-glutamyltransferase were and remained within normal range in both groups, although those of the study group were higher. The mean values of serum aspartate aminotransferase exceeded the normal range (56 U/l, at highest) but this may be of muscular rather than hepatic origin because of the severe training. It can be concluded that erythropoiesis was stimulated and liver function mildly impaired due to sustained high-dose testosterone/anabolic steroid administration.