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1.  Physiological upper limits of ventricular cavity size in highly trained adolescent athletes 
Heart  2005;91(4):495-499.
Objectives: To define physiological upper limits of left ventricular (LV) cavity size in trained adolescent athletes.
Design: Cross sectional echocardiographic study.
Setting: British national sports training grounds and Olympic Medical Institute.
Subjects: 900 elite adolescent athletes (77% boys) aged 15.7 (1.2) years participating in ball, racket, and endurance sports and 250 healthy controls matched for age, sex, and size.
Main outcome measures: LV end diastolic cavity size.
Results: Compared with controls, athletes had a larger LV cavity (50.8 (3.7) v 47.9 (3.5) mm), a difference of 6%. The LV cavity was > 54 mm in 18% athletes, whereas none of the controls had an LV cavity > 54 mm. The LV cavity exceeded predicted sizes in 117 (13%) athletes. Among the athletes with LV dilatation, 78% were boys, LV size ranged from 52–60 mm, and left atrial diameter and LV wall thickness were enlarged. Systolic and diastolic function were normal. None of the athletes in the study had an LV cavity size > 60 mm. LV cavity size correlated with age, sex, heart rate, and body surface area.
Conclusion: Highly trained junior athletes usually have only modest increases in LV cavity size. A proportion of trained adolescent athletes have LV cavity size exceeding predicted values but, in absolute terms, LV cavity rarely exceeds 60 mm as in patients with dilated cardiomyopathy. In highly trained adolescent athletes with an LV cavity size > 60 mm and any impairment of systolic or diastolic function, the diagnosis of dilated cardiomyopathy should be considered.
doi:10.1136/hrt.2004.035121
PMCID: PMC1768829  PMID: 15772210
adolescent; elite athlete; athlete’s heart; cardiomyopathy; ventricular cavity dilatation
2.  Adaptation of heart to training: A comparative study using echocardiography & impedance cardiography in male & female athletes 
The Indian Journal of Medical Research  2013;137(6):1111-1120.
Background & objectives:
Intensive regular physical exercise training is associated with a physiological changes in left ventricular (LV) morphology and functions. This cardiac remodeling observed in the athletes is associated with the specific haemodynamic requirements of the exercise undertaken. The main objective of this study is to evaluate the effect of endurance training on cardiac morphology, systolic and diastolic LV functions and haemodynamic parameters both in male and female athletes.
Methods:
Seventy nine healthy athletes (age 20.0 ± 2.6 yr; 49% male) and 82 healthy sedentary adolescent (age 20.8 ± 2.2 yr, 49% male) volunteered to participate in this study. All subjects underwent transthoracic echocardiography and impedance cardiography.
Results:
Both female and male athletes had greater LV end-diastolic cavity sizes, LV mass and stroke volume (SV) values when compared with controls. Also, in male athletes, LV mass index was higher than in female athletes. While male athletes had lower resting heart rate compared to female athletes, they had higher mean arterial blood pressure. In male athletes, basal septal and mid septal strain values were higher compared to controls. There were no significant differences in strain and peak systolic strain rate values between female athletes and controls. In male athletes, there was a weak positive correlation between SV and LV mass, basal lateral and septal strain values. In female athletes, only a weak positive correlation was found between SV and basal septal strain values.
Interpretation & conclusions:
Endurance-trained male and female athletes had higher LV mass, LV cavity dimensions and SV compared to sedentary controls. Although there was no difference in diastolic cardiac functions between athletes and controls, local enhanced systolic function was found with increase of SV. Both morphologic and haemodynamic differences were more evident in male athletes.
PMCID: PMC3734716  PMID: 23852292
Athlete's heart; endurance training; impedance cardiography; strain imaging; tissue Doppler
3.  Detraining-Related Changes in Left Ventricular Wall Thickness and Longitudinal Strain in a Young Athlete Likely to Have Hypertrophic Cardiomyopathy 
One of the diagnostic criteria in order to differentiate between physiological and pathological left ventricular hypertrophy is the wall thickness reduction after at least 3-month detraining period, which is considered a marker of the athlete’s heart. This report describes detraining-related regression of LV hypertrophy and improvement in myocardial deformation in a junior athlete likely to have hypertrophic cardiomyopathy.
Key pointsHypertrophic cardiomyopathy in adolescent athletes can be discovered by 12-lead ECGPhysical training is an important trigger for the clinical presentation of hypertrophic cardiomyopathyReverse LV remodeling (wall thickness reduction) with detraining is a common echocardiographic finding in athletes with physiological hypertrophyThis report demonstrates that reverse remodeling can also be found in adolescent athletes likely to have hypertrophic cardiomyopathy
PMCID: PMC3737922  PMID: 24149368
Athlete’s heart; detraining; echocardiography; hypertrophic cardiomyopathy; left ventricular hypertrophy; myocardial function; strain echocardiography.
4.  Echocardiographic measurement of the normal adult right ventricle. 
British Heart Journal  1986;56(1):33-44.
In studies of the right ventricle the complexities of chamber shape may be overcome by use of multiple tomographic imaging planes. An established protocol for the echocardiographic description of the heart was used to examine the right ventricle in an ordered series of transducer locations and orientations. Diastolic measurements were made of the right ventricular inflow tract, outflow tract, and right ventricular body, and the range and reproducibility of normal values for cavity size and right ventricular free wall thickness were established. These measurements of cavity size in 41 normal subjects were highly reproducible and the views that were used correctly described the truncated and ellipsoidal shape of the right ventricular inflow tract and body with a separately aligned outflow tract. Cavity trabeculation prevented measurement of the free wall thickness in some areas; however, values of nearly twice the previously reported upper limit of normal for anterior regions were measured from the apex or lateral right ventricular wall. These normal data provide a basis for future echocardiographic studies of the right ventricle.
PMCID: PMC1277383  PMID: 3730205
5.  Do big athletes have big hearts? Impact of extreme anthropometry upon cardiac hypertrophy in professional male athletes 
British Journal of Sports Medicine  2012;46(Suppl_1):i90-i97.
Aim
Differentiating physiological cardiac hypertrophy from pathology is challenging when the athlete presents with extreme anthropometry. While upper normal limits exist for maximal left ventricular (LV) wall thickness (14 mm) and LV internal diameter in diastole (LVIDd, 65 mm), it is unknown if these limits are applicable to athletes with a body surface area (BSA) >2.3 m2.
Purpose
To investigate cardiac structure in professional male athletes with a BSA>2.3 m2, and to assess the validity of established upper normal limits for physiological cardiac hypertrophy.
Methods
836 asymptomatic athletes without a family history of sudden death underwent ECG and echocardiographic screening. Athletes were grouped according to BSA (Group 1, BSA>2.3 m2, n=100; Group 2, 2–2.29 m2, n=244; Group 3, <1.99 m2, n=492).
Results
There was strong linear relationship between BSA and LV dimensions; yet no athlete with a normal ECG presented a maximal wall thickness and LVIDd greater than 13 and 65 mm, respectively. In Group 3 athletes, Black African ethnicity was associated with larger cardiac dimensions than either Caucasian or West Asian ethnicity. Three athletes were diagnosed with a cardiomyopathy (0.4% prevalence); with two athletes presenting a maximal wall thickness >13 mm, but in combination with an abnormal ECG suspicious of an inherited cardiac disease.
Conclusion
Regardless of extreme anthropometry, established upper limits for physiological cardiac hypertrophy of 14 mm for maximal wall thickness and 65 mm for LVIDd are clinically appropriate for all athletes. However, the abnormal ECG is key to diagnosis and guides follow-up, particularly when cardiac dimensions are within accepted limits.
doi:10.1136/bjsports-2012-091258
PMCID: PMC3603682  PMID: 23097487
6.  Cardiac remodelling: concentric versus eccentric hypertrophy in strength and endurance athletes 
Netherlands Heart Journal  2008;16(4):129-133.
Cardiac remodelling is commonly defined as a physiological or pathological state that may occur after conditions such as myocardial infarction, pressure overload, idiopathic dilated cardiomyopathy or volume overload. When training excessively, the heart develops several myocardial adaptations causing a physiological state of cardiac remodelling. These morphological changes depend on the kind of training and are clinically characterised by modifications in cardiac size and shape due to increased load. Several studies have investigated morphological differences in the athlete’s heart between athletes performing strength training and athletes performing endurance training. Endurance training is associated with an increased cardiac output and volume load on the left and right ventricles, causing the endurance-trained heart to generate a mild to moderate dilatation of the left ventricle combined with a mild to moderate increase in left ventricular wall thickness. Strength training is characterised by an elevation of both systolic and diastolic blood pressure. This pressure overload causes an increase in left ventricular wall thickness. This may or may not be accompanied by a slight raise in the left ventricular volume. However, the development of an endurancetrained heart and a strength-trained heart should not be considered an absolute concept. Both forms of training cause specific morphological changes in the heart, dependent on the type of sport. (Neth Heart J 2008;16:129-33.)
PMCID: PMC2300466  PMID: 18427637
ventricular remodelling; heart; sports; hypertrophy; Prinzmetal angina; acetylcholine; multifocal spasm
7.  A pilot study on left ventricular dimensions and wall stress before and after submaximal exercise. 
Left ventricle dimensions and wall stress were measured echocardiographically before and immediately after exercise in 14 athletes and 7 control subjects. Our findings suggest that afterload is an important determinant of cardiac performance and wall hypertrophy in athletes. In spite of major changes in heart rate and blood pressure, left ventricular wall stress remains unchanged following submaximal exercise, in trained and untrained hearts. It would appear that the changes in heart size during exercise are to a large extent limited in untrained ventricles, as smaller left ventricular dimensions are required, to "normalise" wall stress. This results in a lower stroke volume for a given stroke dimensional change. Consequently cardiac output is a function of heart rate rather than stroke volume in untrained subjects. The effect of increased muscle mass in athletes, is to permit larger left ventricular dimensions for a given afterload, thus stroke volume can be augmented. The increase h/R ratio suggests that afterload is more important than preload in the development of left ventricular hypertrophy in rowers and swimmers.
Images
PMCID: PMC1859767  PMID: 486884
8.  Reduction in left ventricular wall thickness after deconditioning in highly trained Olympic athletes. 
British Heart Journal  1993;69(2):125-128.
BACKGROUND--Clinical distinction between athlete's heart and hypertrophic cardiomyopathy in a trained athlete is often difficult. In an effort to identify variables that may aid in this differential diagnosis, the effects of deconditioning on left ventricular wall thickness were assessed in six highly trained elite athletes who had competed in rowing or canoeing at the 1988 Seoul Olympic Games. Each of these athletes showed substantial ventricular septal thickening associated with training (13-15 mm) which resembled that of hypertrophic cardiomyopathy. METHODS--The athletes voluntarily reduced their training substantially for 6-34 weeks (mean 13) after the Olympic competition. Echocardiography was performed at peak training and also after deconditioning, and cardiac dimensions were assessed blindly. RESULTS--Maximum ventricular septal thickness was 13.8 (0.9) mm in the trained state and 10.5 (0.5) in the deconditioned state (p < 0.005) (change 15-33%). CONCLUSIONS--The finding that deconditioning may be associated with a considerable reduction in ventricular septal thickness in elite athletes over short periods strongly suggests that these athletes had a physiological form of left ventricular hypertrophy induced by training. Such a reduction in wall thickness with deconditioning may help to distinguish between the physiological hypertrophy of athlete's heart and primary pathological hypertrophy (for example, hypertrophic cardiomyopathy) in selected athletes with increased left ventricular wall thickness.
Images
PMCID: PMC1024938  PMID: 8435237
9.  Left Ventricle Fibrosis Associated With Nonsustained Ventricular Tachycardia in an Elite Athlete: Is Exercise Responsible? A Case Report 
Journal of Athletic Training  2012;47(2):224-227.
Objective:
To emphasize the potentially harmful effects of high-intensity exercise on cardiac health and the fine line between physiologic and pathologic adaptation to chronic exercise in the elite athlete. This case also highlights the crucial need for regular evaluation of symptoms that suggest cardiac abnormality in athletes.
Background:
Sudden cardiac death (SCD) of young athletes is always a tragedy because they epitomize health. However, chronic, high-intensity exercise sometimes has harmful effects on cardiac health, and pathologic changes, such as myocardial fibrosis, have been observed in endurance athletes. In this case, a highly trained 30-year-old cyclist reported brief palpitations followed by presyncope feeling while exercising. Immediate investigations revealed nonsustained ventricular tachycardia originating from the left ventricle on a stress test associated with myocardial fibrosis of the left ventricle as shown with magnetic resonance imaging. Despite complete cessation of exercise, life-threatening arrhythmia and fibrosis persisted, leading to complete restriction from competition.
Differential Diagnosis:
Hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, myocarditis, postmyocarditis, use of drugs and toxic agents, doping, and systemic disease.
Treatment:
The arrhythmia could not be treated with catheter ablation procedure or drug suppression. Therefore, the athlete was instructed to withdraw completely from sport participation and to have a medical follow-up twice each year.
Uniqueness:
To our knowledge, no other report of left ventricle exercise-induced fibrosis associated with life-threatening arrhythmia in a living young elite athlete exists. Only postmortem evidence supports such myocardial pathologic adaptation to exercise.
Conclusions:
To prevent SCD in young athletes, careful attention must be paid to exercise-related symptoms that suggest a cardiac abnormality because they more often are linked to life-threatening cardiovascular disease.
PMCID: PMC3418136  PMID: 22488290
myocardial fibrosis; high-intensity exercise; sudden death
10.  The Role of Echocardiography in the Differential Diagnosis Between Training Induced Myocardial Hypertrophy Versus Cardiomyopathy 
Increased myocardial mass due to regular high-volume intense exercise training (so-called athlete’s heart) is not uncommon. Although directly correlated with the extent of training loads, myocardial hypertrophy is not present exclusively in well-trained or elite athletes. Athlete’s heart is considered a physiological phenomenon with no known harmful consequences. However, extreme forms of myocardial hypertrophy due to endurance training resemble a structural heart disease such as hypertrophic cardiomyopathy, a condition associated with substantially increased risk of cardiac event. Endurance sports such as rowing and road cycling, rather than strength/power training, are most commonly associated with left ventricular (LV) wall thickness compatible with hypertrophic cardiomyopathy. The differentiation between physiological and maladaptive cardiac hypertrophy in athletes is undoubtedly important, since untreated cardiac abnormality often possesses a real threat of premature death due to heart failure during intense physical exertion. Luckily, the distinction from pathological hypertrophy is usually straightforward using transthoracic echocardiography, as endurance athletes, in addition to moderately and proportionally thickened LV walls with normal acoustic density, tend to possess increased LV diameter. In more uncertain cases, a detailed evaluation of myocardial function using (tissue) Doppler and contrast echocardiography is effective. When a doubt still remains, knowledge of an athlete’s working capacity may be useful in evaluating whether the insidious cardiac pathology is absent. In such cases cardiopulmonary exercise testing typically resolves the dilemma: indices of aerobic capacity are markedly higher in healthy endurance athletes compared to patients. Other characteristics such as a decrease of LV mass due to training cessation are also discussed in the article.
Key pointsTransthoracic echocardiography is still the most common relevant differentiation technique applied to distinguish athlete’s heart from the cardiomyopathy.Conventional echocardiographic criteria such as left ventricular chamber size and diastolic function parameters are to be regarded first when making differential diagnosis between substantially increased wall thickness in athlete’s heart (i.e. physiological adaptation) versus a disease (usually hypertrophic cardiomyopathy).When conventional echocardiographic parameters fail to diagnose the nature of myocardial hypertrophy, other differentiation criteria such as aerobic fitness, cardiac performance in response to physical exertion, and changes in echocardiographic parameters due to detraining, must be taken into consideration.Tissue Doppler, contrast and three-dimensional imaging are state-of-the-art echocardiographic techniques which have recently appeared in the differential diagnostics.
PMCID: PMC3786236  PMID: 24149325
Left ventricle; physical exercises; physiological adaptation
11.  Usefulness of Doppler echocardiographic assessment of diastolic filling in distinguishing “athlete's heart” from hypertrophic cardiomyopathy 
British Heart Journal  1992;68(3):296-300.
Objective—In some athletes with a substantial increase in left ventricular wall thickness, it may be difficult to distinguish with certainty physiological hypertrophy due to athletic training from hypertrophic cardiomyopathy. The purpose of the present investigation was to determine whether assessment of left ventricular filling could differentiate between these two conditions.
Design—Doppler echocardiography was used to obtain transmitral flow velocity waveforms from which indices of left ventricular diastolic filling were measured. Normal values were from 35 previously studied control subjects.
Setting—Athletes were selected mostly from the Institute of Sports Science (Rome, Italy), and patients with hypertrophic cardiomyopathy were studied at the National Institutes of Health (Bethesda, Maryland).
Participants—The athlete group comprised 16 young competitive athletes with an increase in left ventricular wall thickness (range 13–16 mm; mean 14). For comparison, 12 symptom free patients with non-obstructive hypertrophic cardiomyopathy were selected because their ages and degree of hypertrophy were similar to those of the athletes.
Results—In the athlete group, values for deceleration of flow velocity in early diastole, peak early and late diastolic flow velocities, and their ratio were not significantly different from those obtained in untrained normal subjects; furthermore, Doppler diastolic indices were normal in each of the 16 athletes. Conversely, in patients with hypertrophic cardiomyopathy, mean values for Doppler diastolic indices were significantly different from both normal subjects and athletics (p = 0·01 to 0·003), and one or more indices were abnormal in 10 (83%) of the 12 patients.
Conclusions—Doppler echocardiographic indices of left ventricular filling may aid in distinguishing between pronounced physiological hypertrophy due to athletic training and pathological hypertrophy associated with hypertrophic cardiomyopathy.
PMCID: PMC1025074  PMID: 1389762
12.  Identifying the aetiology of left ventricular hypertrophy in an athlete: importance of lifestyle modification 
BMJ Case Reports  2009;2009:bcr1020081080.
The aetiology of left ventricular hypertrophy (LVH) in an athlete is often difficult to identify. We describe a 29-year-old fitness instructor who was referred for investigation of syncope. He gave a history of intensive weight lifting and anabolic steroid use at supra-therapeutic doses for the preceding 6 years. Electrocardiography showed inferolateral repolarisation abnormalities and a transthoracic echocardiogram demonstrated asymmetrical LVH with reduced left ventricular cavity dimensions. There was no left ventricular outflow tract obstruction or systolic motion of the anterior mitral valve leaflet. These findings were confirmed on cardiac magnetic resonance imaging (CMR). The differential diagnosis included athlete’s heart, steroid-induced cardiomyopathy and non-obstructive hypertrophic cardiomyopathy. The patient was advised to discontinue both steroid use and intensive training. After 3 years of steroid abstinence but continued training, the syncopal episodes and the ECG abnormalities completely resolved, associated with regression of LVH on echocardiography and CMR.
doi:10.1136/bcr.10.2008.1080
PMCID: PMC3028985  PMID: 22132027
13.  A Comparison of Whole-Body Vibration and Resistance Training on Total Work in the Rotator Cuff 
Journal of Athletic Training  2009;44(5):469-474.
Abstract
Context:
Whole-body vibration machines are a relatively new technology being implemented in the athletic setting. Numerous authors have examined the proposed physiologic mechanisms of vibration therapy and performance outcomes. Changes have mainly been observed in the lower extremity after individual exercises, with minimal attention to the upper extremity and resistance training programs.
Objective:
To examine the effects of a novel vibration intervention directed at the upper extremity as a precursor to a supervised, multijoint dynamic resistance training program.
Design:
Randomized controlled trial.
Setting:
National Collegiate Athletic Association Division IA institution.
Patients or Other Participants:
Thirteen female student-athletes were divided into the following 2 treatment groups: (1) whole-body vibration and resistance training or (2) resistance training only.
Intervention(s):
Participants in the vibration and resistance training group used an experimental vibration protocol of 2 × 60 seconds at 4 mm and 50 Hz, in a modified push-up position, 3 times per week for 10 weeks, just before their supervised resistance training session.
Main Outcome Measure(s):
Isokinetic total work measurements of the rotator cuff were collected at baseline and at week 5 and week 10.
Results:
No differences were found between the treatment groups (P > .05). However, rotator cuff output across time increased in both groups (P < .05).
Conclusions:
Although findings did not differ between the groups, the use of whole-body vibration as a precursor to multijoint exercises warrants further investigation because of the current lack of literature on the topic. Our results indicate that indirectly strengthening the rotator cuff using a multijoint dynamic resistance training program is possible.
doi:10.4085/1062-6050-44.5.469
PMCID: PMC2742455  PMID: 19771284
isokinetic testing; shoulder; upper extremity
14.  Echocardiographic characteristics of male athletes of different age 
Two dimensionally guided M mode and Doppler echocardiographic data for 578 male subjects (106 non-athletic and 472 athletes) were analysed from two aspects: (a) in the young adult category (19–30 years of age), competitors in different groups of sports were studied; (b) in the different age groups (children, 10–14 years; adolescent juniors, 15–18 years; young adults, 19–30 years; adults, 31–44 years; older adults 45–60 years), data for athletes and non-athletes were compared. Morphological variables were related to body size by indices in which the exponents of the numerator and denominator were matched. Morphological signs of athletic heart were most consistently evident in the left ventricular muscle mass: in the young adult group, the highest values were seen in the endurance athletes, followed by the ball game players, sprinters/jumpers, and power athletes. A thicker muscular wall was the main reason for this hypertrophy. Internal diameter was only increased in the endurance athletes, and this increase was more evident in the younger groups. The E/A quotient (ratio of peak velocity during early and late diastole) indicated more effective diastolic function in the endurance athletes. The values for E/A quotient also suggested that regular physical activity at an older age may protect against age dependent impairment of diastolic function.
Key Words: echocardiography; heart; athletic heart; age; male athletes
doi:10.1136/bjsm.35.2.95
PMCID: PMC1724312  PMID: 11273969
15.  Physiological upper limits of left ventricular dimensions in highly trained junior tennis players 
British Journal of Sports Medicine  2007;41(11):784-788.
Background
The differentiation between physiological cardiac enlargement and cardiomyopathy is crucial, considering that most young non‐traumatic deaths in sport are due to cardiomyopathy. Currently, there are few data relating to cardiac dimensions in junior elite tennis players. The aim of this study was to define the upper limits of left ventricular dimensions in a large cohort of national adolescent tennis players.
Methods
Between 1996 and 2003, 259 adolescent tennis players (152 males), mean (SD) age 14.8 (1.4) years (range 13–19) and 86 healthy age, gender and body surface matched sedentary controls underwent 12‐lead ECG and 2D‐transthoracic echocardiography.
Results
Inter‐ventricular septal end diastolic dimension (IVSd), left ventricular end diastolic dimension (LVEDd) and left ventricular end diastolic posterior wall dimension (LVPWd) in tennis players were significantly higher than in controls (8.9 mm vs 8.3 mm p<0.001, 48.9 mm vs 47.9 mm p<0.05 and 9 mm vs 8.3 mm p<0.001 respectively), however in absolute terms, the difference did not exceed 7%. None of the tennis players had a wall thickness exceeding 12 mm or a left ventricular cavity size exceeding 60 mm.
Conclusions
Tennis players exhibit modest increases in cardiac dimensions, which do not resemble those seen in individuals with cardiomyopathy affecting the left ventricle.
doi:10.1136/bjsm.2006.033993
PMCID: PMC2465269  PMID: 17957014
16.  Bilateral atraumatic medial meniscal tears in a 17-year-old rower 
BMJ Case Reports  2009;2009:bcr11.2008.1258.
Meniscal injury produces disability in a large portion of the population, and sports injuries are a common cause. Atraumatic meniscal tears may occur after repetitive low-energy loading. Rowing is a highly technical sport and very demanding on an athlete’s body. There are numerous reports on patellofemoral and iliotibial band friction syndrome in rowers but there is an extremely low incidence of meniscal tears reported in these athletes. This is a unique case report of a young adolescent athlete who suffered bilateral medical meniscal tears during sporting activity. Rowing is a low impact sport making this an unusual occurrence, especially in a young individual. This case report highlights the importance of considering all training activities when trying to isolate the mechanism of injury in an athlete.
doi:10.1136/bcr.11.2008.1258
PMCID: PMC3028201  PMID: 21686387
17.  Physiological left ventricular hypertrophy. 
British Heart Journal  1984;52(2):130-135.
Echocardiograms were recorded in 154 active athletes (from various sports) and 21 ex-athletes and compared with those in 40 normal control subjects (non-athletes). Diastolic cavity dimension and posterior wall and septal thickness were measured and left ventricular mass and the ratio of posterior wall thickness to cavity radius and of septum to posterior wall thickness calculated. As a group athletes had a significantly increased diastolic cavity dimension, posterior wall and septal thickness, and left ventricular mass. The ratio of posterior wall thickness to cavity radius was distributed as a single continuous variable with a significantly increased mean, and there was no separate subgroup of shot putters or weight lifters with inappropriate hypertrophy. The mean ratio of septum to posterior wall thickness was normal, but there was a wide range of values up to 2.1:1. Ex-athletes had entirely normal left ventricular dimensions and wall thickness. When athletes are categorised by their standard of competition national standard competitors had a significantly increased posterior wall and septal thickness and left ventricular mass compared with university and non-competitive sportsmen. In conclusion, strenuous activity results in left ventricular hypertrophy which is appropriate to the body size of the athlete and the degree of activity but not to its type.
Images
PMCID: PMC481601  PMID: 6743431
18.  Overview of Athletic Training Education Research Publications 
Journal of Athletic Training  2002;37(4 suppl):S-162-S-167.
Objective: To provide an overview of the limited amount of peer-reviewed literature on athletic training education that has been published in athletic training journals. Publications that related specifically to the development of evaluation tools or specific addenda to the required athletic training curriculum were not included.
Background: As education reform continues to unfold in athletic training, it is important for all certified athletic trainers to understand the research that undergirds the educational practices in athletic training. Many of the profession's educational practices have been taken from standards and methods developed by the discipline of education, with very little validation for applicability to the discipline of athletic training. A very limited number of comprehensive scientific investigations of the educational standards and practices in athletic training education have been carried out; however, for more research to be conducted, it is essential that the currently available research be reviewed.
Description: The summaries of athletic training educational research in this article include the topics of learning styles, facilitation of learning and professional development, instructional methods, clinical instruction and supervision, predictors of success on the National Athletic Trainers' Association Board of Certification certification examination, program administration, and continuing education. The amount of research in athletic training education is limited when compared with the amount and quality of educational research available in other professions, such as medicine, nursing, dentistry, physical therapy, and occupational therapy. In this article, I attempt to describe the existing literature and identify what is needed to expand the breadth and depth of research in athletic training education.
Clinical Advantages: This article is intended to help educators identify areas within athletic training education that require further validation and to provide both educators and clinicians with insight into the current validated educational practices that may be appropriate to incorporate into educational settings or practice.
PMCID: PMC164419  PMID: 12937539
learning styles; professional development; instructional methods; clinical instruction; clinical supervision; predictors of success; administration; continuing education
19.  Tissue Doppler Imaging can be useful to distinguish pathological from physiological left ventricular hypertrophy: a study in master athletes and mild hypertensive subjects 
Background
Transthoracic echocardiography left ventricular wall thickness is often increased in master athletes and it results by intense physical training. Left Ventricular Hypertrophy can also be due to a constant pressure overload. Conventional Pulsed Wave (PW) Doppler analysis of diastolic function sometimes fails to distinguish physiological from pathological LVH.
The aim of this study is to evaluate the role of Pulsed Wave Tissue Doppler Imaging in differentiating pathological from physiological LVH in the middle-aged population.
Methods
we selected a group of 80 master athletes, a group of 80 sedentary subjects with essential hypertension and an apparent normal diastolic function at standard PW Doppler analysis. The two groups were comparable for increased left ventricular wall thickness and mass index (134.4 ± 19.7 vs 134.5 ± 22.1 gr/m2; p > .05). Diastolic function indexes using the PW technique were in the normal range for both.
Results
Pulsed Wave TDI study of diastolic function immediately distinguished the two groups. While in master athletes the diastolic TDI-derived parameters remained within normal range (E' 9.4 ± 3.1 cm/sec; E/E' 7.8 ± 2.1), in the hypertensive group these parameters were found to be constantly altered, with mean values and variation ranges always outside normal validated limits (E' 7.2 ± 2.4 cm/sec; E/E' 10.6 ± 3.2), and with E' and E/E' statistically different in the two groups (p < .001).
Conclusion
Our study showed that the TDI technique can be an easy and validated method to assess diastolic function in differentiating normal from pseudonormal diastolic patterns and it can distinguish physiological from pathological LVH emphasizing the eligibility certification required by legal medical legislation as in Italy.
doi:10.1186/1476-7120-7-48
PMCID: PMC2774305  PMID: 19845938
20.  Echocardiographic examination of cardiac structure and function in elite cross trained male and female Alpine skiers 
OBJECTIVE: To assess cardiac structure and function in elite cross- trained male and female athletes (Alpine skiers). METHODS: Sixteen athletes (10 male, six female) and 19 healthy sedentary control subjects (12 male, seven female) volunteered to take part in the study. Basic anthropometry determined height, body mass, body surface area, and fat free mass. Cardiac dimensions and function were determined by two dimensional, M mode, and Doppler echocardiography. Absolute data and data corrected for body size (allometrically determined) were compared by two way analysis of variance and post hoc Scheffe tests. RESULTS: Absolute left ventricular internal dimension in diastole (LVIDd), septal and posterior wall thickness and left ventricular mass were larger in athletes than controls (p < 0.05) and also increased in the men (p < 0.05) compared with women (except for septal thickness in controls). An increased LVIDd, septal thickness, posterior wall thickness, and left ventricular mass in athletes persisted after correction for body size except when LVIDd was scaled by fat free mass. Cardiac dimensions did not differ between the sexes after correction for body size. All functional indices were similar between groups. CONCLUSION: There is evidence of both left ventricular chamber dilatation and wall enlargement in cross trained athletes compared with controls. Differences in absolute cardiac dimensions between the sexes were primarily due to greater body dimensions in the men. 



PMCID: PMC1756155  PMID: 10205689
21.  Supplement use by Young Athletes 
This paper reviews studies of supplement use among child and adolescent athletes, focusing on prevalence and type of supplement use, as well as gender comparisons. Supplement use among adult athletes has been well documented however there are a limited number of studies investigating supplement use by child and adolescent athletes. A trend in the current literature revealed that the most frequently used supplements are in the form of vitamin and minerals. While health and illness prevention are the main reasons for taking supplements, enhanced athletic performance was also reported as a strong motivating factor. Generally, females are found to use supplements more frequently and are associated with reasons of health, recovery, and replacing an inadequate diet. Males are more likely to report taking supplements for enhanced performance. Both genders equally rated increased energy as another reason for engaging in supplement use. Many dietary supplements are highly accessible to young athletes and they are particularly vulnerable to pressures from the media and the prospect of playing sport at increasingly elite levels. Future research should provide more direct evidence regarding any physiological side effects of taking supplements, as well as the exact vitamin and mineral requirements for child and adolescent athletes. Increased education for young athletes regarding supplement use, parents and coaches should to be targeted to help the athletes make the appropriate choices.
Key pointsSupplement use among the child and adolescent athlete population is widespread with the most frequently used supplement being a form of vitamin/mineral supplement.The effects of supplement use on the growth and development of children and adolescents remain unclear and thus use of supplements by this population should be discouraged.It is likely that there is a misunderstanding as to the role of vitamins and minerals in the diet, their function in maintaining overall health, their role in athletic performance, and how they are best obtained from the diet therefore further education for adolescent athletes and athletes in general is needed.
PMCID: PMC3787284  PMID: 24149420
Nutrition; sport; adolescent athletes; dietary supplement
22.  Comparison of Effect of Regular Unstructured Physical Training and Athletic Level Training on Body Composition and Cardio Respiratory Fitness in Adolescents 
Background: Childhood obesity and hypertension are global problems that are on the rise in India. Improving physical activity is an accepted main line of strategy for overcoming poor body composition, hypertension and reduced cardio respiratory fitness (CRF) all of which are considered as independent risk factors for the development of future cardiovascular complications.
Aim: Present study was conducted to evaluate the effect of regular unstructured physical training and athletic level training on anthropometric measures, body composition, blood pressure and cardio respiratory fitness in adolescents.
Settings and Design: This is a collaborative study between the Department of physiology, Jawaharlal Institute of Postgraduate Medical Education and Research and Residential school, Jawahar Navodhya Vidyalaya, Puducherry, India.
Method and Material: Student volunteers in the age group of 12–17 years were classified into athletes (group 1) and physically active non-athletes (group 2). Parameters measured and calculated were weight, height, body mass index, waist and hip circumference, body fat percentage (BF%), fat free mass (FFM), Systolic (SBP) & Diastolic blood pressure (DBP), Mean arterial pressure (MAP), Rate pressure product (RPP) and Predicted VO2 max.
Statistical Analysis used: Mean difference between the groups was analysed using unpaired Student’s t–test. All statistical analysis was carried out for two-tailed significance at the 5 % level using SPSS version 19 (SPSSInc, USA).
Results: Anthropometric measures, body composition measures and blood pressure values of both the group students were within the normal limits. There was no significant difference in anthropometric and body composition parameters between the group 1 and group 2 students. DBP, MAP and RPP were significantly lower in group 1 students when compared to group 2 students. VO2 max values were more in group 1 girls as compared to group 2 girls while the values of boys were comparable between the two groups.
Conclusion: Regular unstructured physical activity for 60 minutes daily for the duration of one year can help the students to maintain their anthropometric parameters, body composition measures and CRF at par with the athletes of the same age and gender. However, athletic level training further reduces the cardiovascular load of the adolescent students.
doi:10.7860/JCDR/2013/6853.3340
PMCID: PMC3809626  PMID: 24179887
Physical activity; Body composition; Fat free mass; Cardio respiratory fitness
23.  Echocardiographic Findings in Power Athletes Abusing Anabolic Androgenic Steroids 
Purpose
Anabolic androgenic steroids (AAS) abuse for improving physical appearance and performance in body builders is common and has been considered responsible for serious cardiovascular effects. Due to disagreement about cardiovascular side effects of these drugs in published articles, this case control study was designed to evaluate the echocardiographic findings in body builder athletes who are current and chronic abusers of these drugs.
Methods
Body builder athletes with continuous practice for the preceding two years and were training at least twice weekly were selected and divided into AAS abuser and non user and compared with age and BMI matched non athletic healthy volunteers (15 cases in each group).
Results
There was no significant difference in left ventricular size or function either systolic or diastolic in comparison to cases and control groups. The only difference was in diastolic size of septum and free wall but observed differences were only significant (P = 0.05) between first (athletic with AAS abuser) and third group (non athletic and nonuser). The difference between the above-mentioned indexes were not significant between two groups of athletes.
Conclusion
Observed differences in diastolic size of septum and free wall is in favor of that long term abuse of anabolic steroid results in accentuation of physiologic hypertrophy due to long term sport most probably due to higher rate pressure product. Furthermore long term abuse and supra pharmacologic doses do not have significant effect in size and left ventricular function.
PMCID: PMC3685154  PMID: 23785570
Androgenic Anabolic Agent; Body Builder; Left Ventricular Hypertrophy; Echocardiography
24.  Female athlete triad 
Abstract
Objective
To describe the components of female athlete triad, the proposed mechanisms that may relate to its causation, and some screening and treatment options that may be used by the clinician who encounters this clinical entity in patients.
Data Sources
A qualitative review of the literature was performed.
Results
This article provides the clinician with current information relevant to understanding and recognizing female athlete triad in at-risk patients. The components of the triad—amenorrhea, disordered eating, and osteoporosis—are interrelated in multifactorial etiology, pathogenesis, and consequences. Proposed causal factors include inadequate nutrition, menstrual status, training intensity and frequency, body size and composition, and psychological and physiological stress. There should be a high index of suspicion in all females athletes for the presence of and/or increased risk for female athlete triad. An increased awareness of the existence of the problem and its presenting signs and symptoms is the key to screening for this syndrome. The most efficacious treatment lies in its prevention.
Conclusions
Female athlete triad is an interrelated, multifactorial syndrome comprised of disordered eating, amenorrhea, and osteoporosis. It is a common entity among female athletes. Prevention, early detection, and early treatment are absolutely essential to maintain the athletes health into maturity and to prevent the serious consequences of this triad. The long-term effects of some triad components are still unknown.
doi:10.1016/S0899-3467(07)60011-1
PMCID: PMC2646928  PMID: 19674568
Women's Health; Athletics; Osteoporosis; Anorexia
25.  Upper Extremity Proprioceptive Training 
Journal of Athletic Training  1994;29(1):15-18.
Proprioception following lower extremity injuries is commonly recommended, but there is little information on proprioception training following upper extremity injuries. No studies have evaluated whether proprioception programs for athletes in open kinetic chain activities (throwing, shot putting) should be different than programs for athletes in closed kinetic chain activities (gymnastics, swimming, kayaking, or rowing). In this paper, we provide a rationale for proprioception training for upper extremity injuries in athletes and the importance of analyzing the athlete's sport and activity for specificity of proprioception exercises. We then discuss one popular proprioception exercise, rhythmic stabilization, and propose several additional upper extremity proprioception exercises, along with instructions for the athletic trainer on how to direct the athlete through these exercises.
Images
PMCID: PMC1317754  PMID: 16558254

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