THE DAWNING ERA OF SPORTS MEDICINE : Specialists of Every Type Called Upon to Improve the Performance of Athletes

“. . . the hip bone’s connected to the thigh bone, the thigh bone’s connected to the knee bone, the knee bone’s . . .” --From “Dry Bones,” lyrics by James Weldon Johnson

It used to be so simple.

Nowadays, athletes know that nutrition is connected to attitude, and that attitude is connected to endurance, and that endurance is connected to muscle-building, and that muscles have to be honed and conditioned just right to respond properly to what will be asked of them, and that conditioning is connected to injury-prevention, and that injury-preventing devices such as mouthpieces just might be connected to performance. . . .

Elite athletes want the best specialists in each field and a good physician to coordinate the whole effort. Weekend warriors want what they think elite athletes have.

As Dr. John Lombardo of Ohio’s Cleveland Clinic put it, “About 110 million people exercise regularly. A lot of them are going to injure themselves. It’s popular--it’s trendy--to go to a sports medicine clinic.”

So, the sports medicine field is booming.

But it’s not without its problems. For one thing, medical professionals specializing in sports can’t even agree on a good working definition of what sports medicine is. For another, there is no way of defining their ranks, knowing who is a sports medicine specialist and who is an opportunist.

And then there are the endless controversies over whose claims and discoveries and products to welcome as revolutionary breakthroughs in the field, and whose to shrug off as malarkey.

But it makes for an interesting forum.

Last month, when the American College of Sports Medicine (ACSM) held its annual convention in Las Vegas, more than 3,000 health professionals gathered to share the latest research and discuss concerns.

They addressed everything from the very specialized “Effect of a Topically Applied Counter-irritant/Analgesic on Skin Blood Flow” to the more everyday “Field Evaluation of Injuries.” From “Recreational Drug Abuse in Athletes” to “Sports Sociology: Participant and Spectator Violence.”

Also at the convention were exhibitors, companies that set up booths to demonstrate their products and services. That group ran the gamut from familiar old Ben-Gay to the latest in computerized bioresistance body composition analyzers and underwater treadmills.

To drink Gatorade or to drink one of the many other concoctions? That was one of the questions.

Which organizations to join? Which publications to buy? The Sports Medicine Digest? Optimal Health? And then which position papers and research analyses to believe?

Business is, indeed, booming. Let the buyer beware.

Jim Bush, who led the Bruins to five National Collegiate Athletic Assn. track and field titles when he was UCLA’s coach, has always been known for his willingness to try different forms of treatments and techniques to get optimum performance from his athletes.

Lately he has been working as a consultant to individual elite athletes, and to teams, including the Raiders and the Dodgers.

Along with his prescribed training programs, he recommends a whole range of specialists, including chiropractors.

“I think there’s a place for everybody,” Bush said. “The problem we’ve had over the years is that there is so much jealousy among the different fields. Most doctors feel threatened by chiropractors. It scares the devil out of most of them.

“One of the reasons that our country is so far behind the European and Communist Bloc countries in sports medicine is that too many doctors here don’t want to try new things or share information. People are afraid of the unknown.”

Bush is on the board of directors of a sports medicine clinic under construction in Culver City called Telesis Sports Institute, Inc. It is scheduled for completion this fall and, when completed, will offer a whole range of specialists.

Bush has been helping to choose the experts--orthopedic surgeons, podiatrists, nutritionists, psychologists, optometrists and others--who will be on the staff or on a list to be recommended by the clinic.

“We’re gathering some of the best,” Bush said. “But what worries all of us is that some of the other clinics might not be getting the best, and there is no way to tell.

“With the way sports medicine is growing now, there are people who know that this is the thing now. It’s going to attract a lot of athletes and a lot of money.

“The only way I know of telling people how to choose the right clinics or the right specialists is to say, check with the office of a doctor that has a good reputation in sports medicine--Dr. (Tony) Daly, Dr. (Robert) Kerlan, Dr. (Frank) Jobe--or check with one of the organizations, like the ACSM.”

Peter Raven, professor of physiology at the Texas College of Osteopathic Medicine and the new president of ACSM, said that the question of certification was one of the biggest, and most difficult, facing the membership.

“There are no defined sub-specialties in medicine,” Raven said. “What we have been working on is a set of criteria for voluntary certification.

“In sports medicine, we (the ACSM) are front-runners, but in terms of the medical field, compared to the American Medical Assn., we’re newcomers.”

Any doctor can hang out a shingle and proclaim himself a specialist in sports medicine. And a lot of doctors are doing just that.

Some of them have done intense, specialized studies. Some have worked with established sports specialists or taken internships. Some have participated in research and attended the conferences designed to share the latest findings.

Some haven’t.

Dr. Bert Mandelbaum, an orthopedic surgeon at UCLA, explained the sports medicine intern program at the UCLA Medical Center and then warned: “There’s a lot of hocus-pocus in sports. A lot of people who claim things happen and they do not. There are a lot of charlatans out there.”

Historically, it has been the job of the coach to see to the needs of his players. Coaches saw a need for a trainer to tape ankles and pass out ice bags and a need for one kind of sports doctor, the orthopedic surgeon, to fix broken bones and twisted knees.

Dr. Gerald Finerman, the orthopedic surgeon who serves as head team doctor at UCLA and who coordinates a whole range of specialists for UCLA athletes, mentions advances in orthopedic procedures as a reason for the “explosion” in the field of sports medicine.

“Advances in arthroscopy have allowed us to intervene and allow an athlete to return quickly to competition,” he said.

Advances in arthroscopy also helped to make for some superstar orthopedic surgeons. Suddenly, everyone with an athletic injury was looking for “the best” to get him back on the field as fast as the athletes they read about in the newspapers.

Continuous research and cooperative efforts by kinesiologists, muscle specialists, and biomechanics experts, body structure and function specialists, are expanding the field.

“There is significant research going on in sports medicine as everyone looks for something that may give them a little bit of an edge,” Finerman said. “Athletes are expecting to return quickly, as good as new.”

Mandelbaum and UCLA internist Dr. Carol Otis have been working together on a research project on stress fractures. If they can understand the causes and tendencies, they might be able to find a way to prevent that common sports injury.

“The goals in sports medicine are to maximize performance, minimize morbidity (down time) and promote prevention,” Mandelbaum said.

To do that requires a coordination of efforts. In a college setting, especially one such as UCLA’s with its own medical center, the athletes have access to the multi-disciplinary approach that private clinics are striving to offer.

“Another reason that sports medicine is growing is that athletes require more now,” Finerman said. “The level of competition is greater. Kids have to be better, so they’re interested in strength training, proper diet, vitamins, supplements--unfortunately some are interested in supplements like anabolic steroids that they shouldn’t be interested in--and we need to do a whole lot more for them.”

At UCLA, Finerman might direct an athlete to Dr. Jim Puffer, chief of the family practice clinic at UCLA--and the U.S. doctor for the next Olympic Games--for a problem such as stress-induced asthma.

He might turn to Otis for help in identifying Marfan’s syndrome, the disease that killed Olympic volleyball star Flo Hyman and for which UCLA now routinely tests.

“Carol Otis is an enormous help, too, because she can help our women athletes with problems like amenorrhea (suppression of menstruation) and eating disorders, problems that they might not come to me with.”

There are cases in which an eating disorder, for example, might also prompt Finerman to call in a psychologist.

SPORTS PSYCHOLOGY

Dr. William Morgan of the Sports Psychology Laboratory at the University of Wisconsin points up the problem of recognizing sports psychologists: “Very few of those who call themselves sports psychologists are trained in sports psychology. That seems like a paradoxical statement, but in point of fact, what we have going on is the following:

“There are physical education and sports science individuals who are very well trained, but not trained as psychologists. And there are very well trained clinical psychologists who are not trained in sports science. They typically don’t know the difference between oxygen debt and the national debt.

“We have one who thinks the head doesn’t have a body and one who thinks the body doesn’t have a head.”

Morgan added: “Most successful coaches are very good street-corner psychologists. They’ve learned by trial and error.”

Bush maintains that 75% of coaching is psychology.

Yet very few college or professional teams in this country use psychologists.

Morgan said the United States lags far behind other countries on this front.

“I would date the start of sports psychology in the United States to the late 1960s,” he said. “At that point in time, a Russian had already published a paper entitled, ‘The First Fifty Years in Soviet Sports Psychology.’

“It’s no different from when sports medicine got into effect here in the States. Sports science was already well established in European and Scandinavian countries. And we were clearly quite a bit behind.

“The Sports Psychology Committee of the U.S. Olympic Committee is approximately five years old.”

Morgan is interested in a wide range of motivational factors, from what it takes to keep the average person sticking to a program of daily exercise to what, actually, Knute Rockne did or did not say to his team about the Gipper.

He also notes the effect of society on athletes’ motivation.

“Did you notice the kinds of things the athletes were saying from Sarajevo?” he asked. “It was important, then, to concentrate on inner feelings of accomplishment. An interviewer would say, ‘Not too good today, huh?’ And the athlete would say, ‘Actually, I felt good about my performance.’ ”

Lately, sports psychologists have been called upon to deal with problems connected to nutrition--to the alarming increase of eating disorders among athletes, especially among women athletes.

SPORTS NUTRITIONISTS

It would seem that athletes would be aware of how much food, and what types of foods, they would need to function at an optimum level. But nutritionists report that many top athletes suffer the same problems of obsessive dieting and an inability to see their weight in the proper perspective that anyone with an eating disorder suffers.

In fact, elite women athletes are more likely to be perfectionists and more likely to equate dieting with discipline.

One study showed that even young girl swimmers showed a tendency to see themselves as overweight when they were not.

Nutritionists see some athletes who are interested in their general health and energy levels, but most athletes seek out specialized help either to lose weight or to gain weight. And, often, that involves the use of dietary supplements--vitamins, minerals, amino acids.

“All Americans, for many different reasons, are increasingly interested in nutrition,” said Ann Grandjean, a nutritionist at the Swanson Center in Omaha, Neb. “In the years I’ve been working with elite athletes, or serious athletes, I’ve found that they tend to be 5 to 10 years ahead of the general population in their interests and use of supplements.”

She also said: “I don’t think there is any area of the health arena in which there are more myths and misconceptions than in nutrition.”

According to Grandjean, there have been no major findings recently as to what and when to eat to maximize performance.

“The elite-level athletes have been interested in diet and nutrition for many years, and we are seeing more refinement with computer diet analyses and lactose testing.

“But the basics of nutrition don’t change. We’ve known for years that carbohydrate intake is important to an athlete for glycogen stores. We’ve known the importance of fluid intake. But I think the new level of interest is the result of reaching more people with that information. And the fact that amateur sports in the U.S. is more sophisticated and organized now.

“There is no diet in the world that will make a gold medalist out of a klutz, or I would have a lot of gold medals because I know how to eat.

“You have to have the genetics, the training, the coaching--all of the usual things. And then nutrition impacts at two places. You’ve got to have an adequate diet to be healthy so that you can train and become the best you can become, and you have to know the fine-tuning points, such as fluid balance for marathoners or road cyclists.

“But those things are day to day. Right before the ’84 Games, we started getting all these calls asking, ‘What’s going on in the area of nutrition? What are you doing for the athletes?’ After about the sixth call I realized, the perception is that it’s time to compete so it’s time to get your act together.

“No. The nutritionists are working now with 16-year-olds, trying to get them ready for ’92.”

Grandjean believes in the four basic food groups--meats and fish, dairy products, grains and cereals, and fruits and vegetables--not the supplements that account for billion-dollar sales every year.

“One of the problems of supplementation is that what foods are supplemented with are vitamins and minerals, but the problem of our diets, in general, is over-consumption of calories, over-consumption of fats and under-consumption of carbohydrates. We can take all the pills and use all the supplements, and it won’t solve those problems.”

Besides, Grandjean said, research shows that the athletes who take supplements are the ones who were eating well in the first place.

What about the use of amino acids as an alternative to anabolic steroids--bulk-producing manufactured male hormones? Grandjean says, first of all, that they just don’t work.

The rule that applies in the sticky issue of supplements is that every time one “expert” forms a rule, another breaks it.

Jack Youngblood of the Rams recently spoke out in favor of amino acids as an alternative to steroids.

Another, besides Grandjean, who begs to differ is James Small, assistant strength coach at Rutgers, who wrote:

“Hopefully we have come a long way since the days of the snake oil peddler who preyed upon the gullible and naive. Magic potions and pills only work in fairy tales. Reality demands that we use common sense and the many education sources available to use to make the correct decisions about our health.”

Small also wrote: “High protein-amino acid supplements confer no special advantages and may actually be harmful.”

Grandjean said that amino acid supplements can be dangerous when taken in large amounts because they cause an imbalance. She reported a long list of ill-effects reported to her by people using amino acid supplements, but she said that no definitive research has been done to determine if amino acid supplements cause ill effects.

“The research isn’t being done because by the time it would be complete, this idea will have faded out with athletes,” she said.

It’s not fading out, though, with the athletes who work with Bernd Friedlander, a chiropractor with offices in Santa Monica.

Track star-wide receiver Ron Brown swears by Friedlander’s program of nutrition and amino acid supplements. So does Howie Long of the Raiders.

Long is naturally a large man, but he reports a noticeable difference in his energy level and his general health. “I know that I’m stronger, and strength improves speed,” he said.

He thinks a program of amino acids is a good alternative for athletes who have been using steroids.

“I roll out of bed at 270 (pounds),” Long said. “I’ve never needed to use steroids, but I see the way they are being used and it’s an epidemic.

“I see guys with what I would call reverse anorexia--they never see themselves as being big enough. They use anabolic steroids, and they cause a terrible trickle-down effect. They affect mood, temper. These guys are on the edge all the time.”

As teams, the Houston Gamblers of the USFL reported positive results with Friedlander’s program, and the UCLA women’s crew documented improved strength and conditioning.

CONDITIONING EXPERTS

Coaches have long been aware that the better the condition of the athlete, the less likely he or she is to get hurt. But it has been only the last 10 years or so that teams have been hiring full-time strength and conditioning coaches.

Exercise physiologists are needed to help athletes draw up training programs that safely produce the desired results.

When John Arce, UCLA strength and conditioning coach, outlines a workout program, he doesn’t recommend the same things for a gymnast that he does for an offensive lineman.

And he, too, has to be involved in the multi-disciplinary approach, working in concert with the nutritionist planning the training table and the trainers and doctors who have evaluated each athlete and spotted, perhaps, areas that need work or areas that need to be left alone.

“Rehabilitation and conditioning are different,” Mandelbaum said. “There is no question that conditioning cuts down injuries. . . . We used to think that women had more injuries, but that was before women had the same conditioning.

“That’s where John Arce comes in, in our program.”

Arce’s guidebook, “Bruin Brawn,” not only outlines a weightlifting program but includes sections on motivation, nutrition and restorative measures.

“It’s up to the exercise physiologist to bring it all together,” Arce said. “The doctors know how the body works and the coaches know what they want the bodies to do, but the exercise physiologist knows how the body is going to respond to squats with 200 pounds.”

Just as the doctors and the trainers have their specialized organizations, strength coaches have theirs, the National Strength and Conditioning Assn.

“It’s an organization specifically to bridge that gap between the scientific community and the exercise physiologists who work with the athletes,” Arce said.

“It’s my job to take the information from the coaches, the MDs, the Ph.D.s and apply it, using my knowledge and experience, and apply it, practically.

“It all fits together, and we’re all learning to make it fit. The whole field of sports medicine is really in its infancy.”