Medicine Applied To Baseball

Gilberto ANTE VIDAL, Gianfranco BELTRAMI, Desmond BOKOR, William BOYD, Atsushi MASUJIMA, Leo VARRIALE

SPORTS MEDICINE APPLIED TO BASEBALL

INTERNATIONAL BASEBALL FEDERATION

FEDERACION INTERNACIONAL DE BEISBOL

CONTENTS

Preface

3

Introduction

4

1. Sport Training Medical Control Dr. Gilberto Ante Vidal

5

2. Public Health Issues in Baseball Dr. William Boyd

14

3. Nutrition in Baseball Dr. Gianfranco Beltrami

26

4. Children and Baseball Dr. Desmond Bokor

32

5. Infectious Diseases in Baseball Dr. Gianfranco Beltrami

37

6. Drugs: Use and Abuse Dr. William Boyd

43

7. Doping and Health Risks Dr. William Boyd

48

8. Injury Prevention in Baseball Dr. Gilberto Ante Vidal

53

9. Injuries in Baseball Players: Hand - Elbow - Shoulder Dr. Leo Varriale

59

10. Injuries in Baseball Players: Back - Thigh - Knee - Lower Leg - Ankle Dr. Atsushi Masujima

67

2

PREFACE

I am particularly pleased that the work carried out by the International BAseball Federation Medical Commission has led to the publication of the “Sports Medicine Applied to Baseball” which I believe will be extremely useful to all those who are active in our sport world. One of the fundamental objectives of our Federation must be the control and maintainance of all ages athletes’ health, as well as the checking of their physical and psychological attitude. From this point of view, a test to check in a clear, simple and extensive way so many important points for the health of the athlete, among which the functional assessment, nutrition, problems of the youth activities and doping is missing. I hope that the hard work carried out by our Medical Commission will be of useful assistance, not only for the sports physicians who are interested in Baseball, but also for all the leaders, the coaches and the trainers. On behalf of the IBAF and on my own behalf, I would like to thank all the authors for such an important contribution to our sport.

Aldo Notari

IBAF President

3

INTRODUCTION

Together with my colleagues of the International Baseball Federation Medical Commission, we have gathered, in this publication, the study of the most frequent medical problems one comes across when practicing Baseball. Our goal is to make our guidance and assistance available to those who deal with the health of athletes who practice this sport all over the world. The prevention and timely and efficient treatment of the different pathologies constitute a basic goal to all those who deal with sports medicine. Our wish is to disclose in this text our personal experiences in several fields in a concise way orthopedic issues and non orthopedic pathologies of medical interest which can be more frequently faced by athletes practicing Baseball at different ages. The following important issues are included: nutrition, functional assessment, use and abuse of drugs, doping, most frequent orthopedic injuries and the problems which arise at a young age. On behalf of my colleagues of the IBAF Medical Commission, I also would like to thank the President and Executive Committee of the International BAseball Federation who have facilitated the publication of our work which we hope will be released and appreciated by those who deal with the sports medicine applied to Baseball.

Gianfranco Beltrami IBAF Medical Commission Chairman

4

SPORT TRAINING MEDICAL CONTROL Dr. Gilberto Ante Vidal

MEDICAL CONTROL Medical control is a basic part of all sports medicine work. By controlling proper biological loads, we can find out about the morpho-functional state of an athlete at any training or competitive stage. This ensures that the necessary measures can be taken to prevent illness or injury to achieve good performance in a particular sport. When information gathered by the doctor during routine pedagogical, laboratory and on-field tests is discussed with the sport’s technical specialists, better results can be achieved. Controlling psychological aspects also plays an important role in the attainment of the targets set. In today’s sport, proper biomedical and psychological control is a must. Coaches can only then be sure that their athletes will successfully complete their training programs. PHYSIOLOGY It is essential to be aware of certain highly important aspects connected with playing sport, particularly Baseball in this instance. Working out the muscles is the key to physical activity.

Fig.1 Actin and myosin filaments 5

Sport Training Medical Control

Therefore, it is essential to know about the skeletal-muscular structure, its composition in fibres, myofibrils, sarcomeres (functional unit of the contractile system) and filaments. These filaments may be thick or thin. The former are composed of myosin protein and the latter are composed of actin protein. Both components interact to provoke the necessary release of energy to produce movement, when adenosine triphosphate (ATP) is broken down into inorganic phosphates. This is produced by actin filaments sliding over myosin filaments by bridges which are formed between them, in accordance with the sliding filaments theory. (Fig.1) In skeletal muscles, there are different fibre types which can be classified in terms of their speed of contraction and ability to break down ATP. • Slow-contracting fibres resistant to fatigue. • Fast-contracting fibres resistant to fatigue. • Fast-contracting fibres susceptible to fatigue. Some muscles contain a prevalent fibre type. Most consist of a combination of the three fibre types in varying proportions. This is important, because skeletal muscle has to fulfil several functions in different parts of the body. AEROBIC AND ANAEROBIC ENERGY SYSTEMS Physical activity needs energy. In the muscles, adenosine triphosphate (ATP) is the source of that energy. At initial contraction stage, the source that most immediately replaces ATP is creatine phosphate (CP), though only for a few seconds. If muscular activity continues or increases, there may be moderate levels of ATP generation using fatty acids as the main source by means of the oxidative phosphorylation process. If intense activity accelerates ATP breakdown, glycolysis provides a significant amount of the ATP required by the muscle. (Fig.2)

Fig.2 ATP and CP: anaerobic sources of phospate 6

Sport Training Medical Control

AEROBIC CAPACITY This refers to the use of aerobic energy. It is defined as the volume (V) of oxygen (O2) that a person needs to consume per minute during maximum exercise. Its ratio, expressed in ml of oxygen per kilogram of body weight, is often used. Aerobic capacity is important for both intermittent and continuous resistance activities. When the activity goes beyond three minutes, the importance of this system in terms of energy production increases rapidly. The anaerobic threshold, defined as the exercise intensity level from which lactate in the blood begins to increase, is more useful as a prediction factor for resistance tests. Well-trained aerobic athletes have an anaerobic threshold greater than 90% of VO2 max. This threshold represents the maximum limit of energy provided by predominantly aerobic sources. Aerobic training promotes, among other things, cardiac efficiency. It increases blood volume, increases the muscles’ use of arterial oxygen and raises haemoglobin, myoglobin and oxidative enzyme levels. (Fig.3)

Fig.3 Oxygen Transport System 7

Sport Training Medical Control

Athletes with greater aerobic capacity recover from intense anaerobic activity quicker than those with a lower capacity. To a large extent, aerobic capacity is decided by genetic factors although it can be improved by 20-25% with training. ANAEROBIC CAPACITY This is the anaerobic energy system’s maximum capacity to produce energy: adenosine triphosphate and creatine phosphate (ATP + CP) and glycolysis. The first two are high-energy components, stored in a limited way in muscle cells. They provide the necessary energy for high-intensity exercise, but they can only bear the activity for 6-8 seconds. Glycolysis provides energy for the activity for 60-90 seconds. One of the results of anaerobic glycolysis is the production of lactate and hydrogen ions. An increase in these ions leads to muscle fatigue. Anaerobic capacity is essential in disciplines requiring a degree of intense effort over a short period of time. Several tests have been designed to measure this capacity, although it is generally difficult to do so. One of the most usual ones is to measure lactate in the blood after exercising to exhaustion to calculate the production of anaerobic energy. In the first few seconds of exercise, ATP concentration falls by 2% and creatine phosphate by 80%. These non-lactic acid components account for 25-30% of available anaerobic energy in both trained and untrained individuals. Glycolysis (lactic acid component) provides 60% of anaerobically-obtained energy in untrained individuals and 70% in trained individuals. Most training to improve the muscles’ anaerobic energy capacity consists of exercises lasting between 40 and 60 seconds repeated several times with proper rest periods. This training improves glycolytic enzyme activity and lactate regulating and removal capacity from muscles in action. However, resistance training which encourages aerobic activity (improving circulation, muscle vascularisation and increasing haemoglobin, myoglobin and oxidative enzyme levels) helps to improve anaerobic activity, promoting lactate conveyance and oxidation. STRENGTH This is an important prerequisite for all competition athletes. It should therefore be reflected in their training programs. There are four types of muscle contraction: 1. 2. 3.

Isometric Contraction: tension increases and muscular length stays constant. Concentric Contraction: tension increases and muscular length gets shorter. This is the standard weight training method for most athletes. Eccentric Contraction: tension increases and muscular length gets longer. Progress may be greater in terms of strength than with other types of training, but the risk of muscular 8

Sport Training Medical Control

pain is run. Longer recovery periods between exercises are necessary. 4.

Isokinetic Contraction: concentric contraction where the articulation movement speed stays constant. Tension is variable depending on the speed at the reticular angle. This type of training needs special equipment like a cybex isometric dynamometer, though progress may be greater than with the resistance (concentric) or isometric methods.

Strength training develops muscle strength and contraction speed. Strength training must be as specific as possible in terms of contraction type and speed, the muscles used and the movements involved. Strength and muscle resistance maintenance after a major period of strength training can be done in one or two workouts per week. A total break in training does not have any effects on strength for the first four weeks. Maximum strength of a muscle group can be ascertained in the weight training room by the maximum weight that the group can fully lift three times. By means of tension indicators, isometric strength variations at varying articulation angles can be recorded. There is some isometric equipment capable of objectively measuring muscle tension. The Kio Com equipment calculates eccentric and isometric strength. FLEXIBILITY This is the ability of an articulation to perform a range of movements important to the sport and to prevent injury. It should be considered as an integral part of any training program. As far as this section is concerned, several guidelines are given below: • • • • • •

Start the session with gentle rhythmic exercises before proceeding to stretching exercises. This will raise the muscle temperature allowing the muscle/tendon unit to be stretched more. Before any passive stretching, perform an isometric contraction to promote flexibility (proprioceptive neuromuscular facilitation technique). Any flexibility program should be based on passive stretching held for 30-45 seconds. Stretching should not cause any pain. To get the best results, stretching should be done routinely, preferably every day, before and after each exercise session. Avoid thrusting or jerky stretching as it may injure the soft tissues.

It is a proven fact that greater flexibility reduces the rate of torn muscles. It is essential to stretch muscles bearing tension in the athlete’s particular discipline. Stretching must be performed in a stationary position. Flexibility increases using proprioceptive neuromuscular facilitation (PNF) techniques involving contraction-relaxation stretching. The principle of PNF is to stimulate the proprioceptors inside the muscles’ spindles and the tendons’ Golgi corpuscles.

9

Sport Training Medical Control

CHILDREN Sports programs for children have become increasingly important in recent years, and currently there are different children’s categories for competitions, starting at very early ages. So, it is absolutely essential to ensure that everyone involved in children’s Baseball knows about the morphological, functional and psychological characteristics of these little athletes. Besides calendar age, it is also essential to be aware of biological maturing characteristics. Children’s work capacity changes considerably with growth. Their response-to-exercise capacity is not the same as an adult’s, as their aerobic and anaerobic capacity and strength is not fully developed, neither are the muscular-skeletal, enzymatic or cardiorespiratory systems. These reach full development at puberty. So, although the human being’s physiological processes and functional capacities are marked by genetic factors and have a certain ceiling, proper education and appropriate teaching techniques lead to an improvement in health and have major beneficial side effects. Some of the main biomedical and psychological tests that can be used are: A) Laboratory Tests

B) On-Field Tests

A) Laboratory a) Rest a1) Kinanthropometric Tests - Body composition To ascertain weight, height, percentage of body fat, muscle development indices (AKS), kg fat, active body mass (ABM). a2) -

Somatotype Endomorph Mesomorph Ectomorph

a3) -

Cardiovascular Tests - Cardiorespiratory Clinical Check-up Electrocardiogram (ECG) Stationary Test (Pulse and arterial pressure in different positions) Echocardiogram

b) Exercise Ergometric Tests b1) Sub-maximum (not to exhaustion) To work out physical work capacity (PWC)

-

To work out maximum predictive or indirect oxygen consumption VO2 max. = PWC 170 X 2.2 + 1070 To work out maximum relative oxygen consumption VO2 / kg 10

Sport Training Medical Control

b2) Vita-maximum (to exhaustion) Can be done on a treadmill or cycle ergometer. A gas analyser is used, administering continuous loads with no breaks (increasing) until maximum oxygen consumption (VO2 max.) and other variables are established. b3) Wingate Test To ascertain anaerobic strength. b4) Neuromuscular Tests (Poliomyography) B) On-Field There is a large number of tests which can be used. We therefore recommend some general ones and some sport-specific ones. These tend to be very useful as they do not require expensive equipment or special trips to the laboratory. As a result, they are economical and simulate real activity. Taking heart rate readings at rest, at the end of the activity and during recovery is a vital element in establishing functional order. Other elements, like time and distance travelled in relation to heart rate, usually provide the opportunity of assessing the player at different stages of training. Biochemical variables are very often used and are of great diagnostic value. e.g.

Ascertaining lactic acid at rest and during recovery. Ascertaining urea 24 hours after the load received. Ascertaining proteinuria at the end of the day’s load.

Different pedagogical and standardized tests can be used, as well as different types of circuits. e.g.

Specific Performance Tests

Home - 1st Base run Home - 2nd Base run Home - 3rd Base run

Aerobic Energy System Tests

Mile Test Cooper Test Tokmakidis Test

Non-lactic Acid Anaerobic Energy Tests

Flying 50m Test Vertical Jump Test (no run-up)

Anaerobic Energy System Tests

40-second Marzudo Test

11

Sport Training Medical Control

PSYCHOLOGICAL Examining the psycho-physiological variables in the laboratory and on the field. 1. 2. 3. 4. 5. 6. 7. 8.

Simple and complex reaction time. Speed of action to simple and complex stimuli. Anticipation reaction. Space and time perception. Central and side vision. Muscle strength control. Personality characteristics study. Study of psychological phenomena involved in competitive activity.

In Children General and specific functional tests can be carried out. Measurements Strength: Press-ups, squats, body weight lifts, abdominals, jumps, medicine balls, etc. Speed: Progressive races, Home - 1st Base stretch, races between Bases, 30m races, 50m races, etc. Resistance: Cross-country, mile, auxiliary sports. Each category has its own assessment based on what each sport demands from each specific age group. Technically speaking, activities are carried out by positions and in accordance with the age of the corresponding competition category, which can be assessed periodically. e.g. -

Placement in position Fielding Throws Placement when receiving throws Other defensive plays Batting Etc.

From the age of 13, the tests suggested for players in general can be used. Other Points of Interest -

Dental control (until being given the OK) Vaccination in line with the program for different ages and the Tetanus and other vaccinations for adults Nutritional control Eye tests, because of the importance of good eyesight in this sport Clinical laboratory control at least twice a year 12

Sport Training Medical Control

Routine Analysis -

Differential Haemogram Urea Glycaemia Cholesterol Total Proteins Serology HIV Urine Stools

13

PUBLIC HEALTH ISSUES IN BASEBALL Dr. William Boyd

INTRODUCTION The health of the player vis-à-vis his environment is treated with emphasis on prevention. We shall take a cursory look at public health issues in sports through the prism of Baseball. As many countries are taking up Baseball at competitive levels, issues addressed in this chapter could be handy and informative to trainers, players and administrators. THE PLAYER Health Assessment During a game, especially at top level competitions, virtually all forms of human movements are performed. This may come across as an overstatement from a Baseball freak. But if you pay attention, you find that players run at various speeds. From a graceful trot around the bases after a Home Run to a flat-out dash to make it to first base, after a hit, to avoid an “out”; or from third base home to score. They dive, stretch, slide, jump, throw, turn, twist and so on. All parts of the body - the upper and lower extremities, trunk, head and neck - are put to use. This tells you that a good player must be both healthy and fit. In other words, he should be free from diseases, and his body which is the “human machine”, in top working condition. To protect and arm the player for high performance, it is necessary to ensure that he is well and can stand the rigors of the game; hence an assessment. Assessment is divided into two parts, clinical and physical. Clinical Assessment History A good medical history is essential. This must include a detailed past medical history, history of sporting activities and injuries, and family history. In children you will be looking out for hereditary diseases like asthma, sickle cell disease, heart conditions, anemia, infectious diseases, childhood immunizations, etc. The importance of a detailed history cannot be over emphasized because it could lead you to or away from identifying a potential hazard. It could also give you an idea how best a player can be utilized. All systems of the body – cardiovascular, alimentary, musculo skeletal, nervous and 14

Public Health Issues in Baseball

genito urinary – must be covered in detail. This may sound cumbersome, but with practice it takes less than ten minutes. A standard comprehensive format is shown in Appendix A. In most cases nothing abnormal is discovered, but compilation of these records often result in a useful data base for your players. Also, a good period of time devoted to history taking would afford you the opportunity to assess the player’s psychological disposition. Is he an aggressive personality, a loner, team player, leader, arrogant, etc. How can this player be best utilized? Examination A standard routine examination is sufficient. Attention should be paid to the mobility and integrity of the joints, reflexes, sight and flexibility. When an abnormal heart sound is noticed, the opinion of a specialist should be sought. Investigation This is often expensive and should not be routine. Where there is need, it is advisable to investigate instead of leaving it to chance. The average child in a third world country is slightly anemic and/or malnourished. They could get by the normal training and playing. But when preparing for high level tournaments, the players could be dewormed as routine, and placed on blood enriching pills like multivitamins, iron and other mineral supplements to withstand the increased demand on the system and the ware and tear of training. Physical Assessment A set of activities are recommended in Appendix B which do not require sophisticated equipment, but which gives a good indication to a player’s physical capacity at any time – be it pre-season, in season or return to game fitness. Also, the aerobic and endurance capacities are looked at, as well as the integrity of all the prominent joints – mid-foot, ankles, knees, hips, shoulders, elbows and wrists. Each trainer could adapt the tests to suit the category of players in question. Age The age group for special attention is the pre-puberty. It could be their first contact with organized sport. Where proper medical assessment is not easily available, as in most cases, the trainer should watch out for posturing of the kids. This is a key to identifying deformity in a child. Birth injuries could lead to discrepancies in development and/or stiffness of the shoulders. In teenagers, abnormal curvature of the spine could present some disadvantage. It is not unusual to find that lengths are functions of the lower limbs are compromised by spinal deformities. While most curved spines could be harmless and consequent on growth disparity, where the tilt is marked, the attention of an orthopedist should be drawn. (Fig.4) The trainer could learn a lot by keeping his eyes open, especially when kids take off their shirts. A child who is permanently lagging behind must be checked. In most cases, there must be a reason. If not physical, it could be psychological. But the trainer needs to find out the reason for 15

Public Health Issues in Baseball

Fig.4 Curvatures of the spine

the sake of the child’s safety or to get the best out of him. Illnesses This is an area where most trainers goof. In an attempt to give no room for nonsense and keep up the pressure and maintain the program on course, they often conclude that any complaint of illness is an excuse to dodge training. It would be a fallacy to deny that players do not feign illness. This attitude of players, especially the talented ones, is often very frustrating for a trainer building a team. But all said and done, when in doubt, the trainer should seek a physician’s opinion. Or when no physician is at hand, give the player the benefit of doubt. Common cold or flu can be very debilitating. Sufferers should be withheld from play. Some strains of the viruses which cause flu affect the covering of the heart and could be dangerous when subjected to strenuous exercise. All forms of febrile conditions should be completely treated before coming back to play. Also, any member of the team with an unexplained or recurrent fever should be laid off until proper attention is sought and full recovery established. A player who contracts infectious disease like measles, chicken pox, viral conjunctivitis, etc., should not be allowed to mix with the team. Even watching from the sideline is not allowed. This 16

Public Health Issues in Baseball

is to avoid the spread of the disease. In case of sporadic or mild outbreak of an epidemic, training should be suspended and request made to the national federation to assist with immunization where no concerted effort is in place. Hygiene It is not uncommon to associate the words unkempt and dirty with sportsmen generally. Because of the nature of the game, Baseball players must get dirty, wet with sweat and tired. It is part of character building and a healthy life style for trainers to insist on clean outfits and tidiness of person, outfit and equipment at all times. Players must be encouraged to bath/shower immediately after games and training. This is because the moist warm skin is a haven to disease causing organisms. A typical example is athlete’s foot. The trainer must watch out for other skin diseases, especially where uniforms are not personalized. Scabies and Tinea infections are the worst culprits. When contagious skin disease is discovered, the first step is to get the primary source and all those affected or have the itching sensation treated with the correct medication. The expertise of a physician is required here. The traditional boiling of clothing while washing in soap and disinfectant could be reassuring to players, but they could benefit more by applying a recommended medication such as prophylaxis, and ironing their uniforms with a very hot iron after washing. Open wounds must be covered and treated. Likewise, cuts and abrasions must be attended to immediately, because they turn to sores when neglected. Immunization against tetanus is recommended, and if a player is already immunized, a booster dose should be administered if need be when injuries occur. Spitting must be discouraged for what it is – an unhealthy and a gutter habit which is capable of spreading disease. With a little health campaign, tobacco chewing, which often leads to indiscriminate spitting among major league players, could be halted from spreading to new Baseball countries. It is a well established fact that tobacco chewing causes disease of the gum. THE ENVIRONMENT Field of Play Where a diamond exists, the players are lucky. A vast majority of players use any available field to train and play. Care must be taken to rake the field thoroughly before training or a game to fish out potential hazardous implements – rusted tins and scrap metals, broken bottles, plastic materials, stones and other sharp and blunt objects – especially along the running paths between and around the bases. It is not uncommon to find kids and youth playing barefooted. The national federations must ensure that players taking part in sanctioned tournaments must wear trainers, at least, where Baseball shoes are not easily available or affordable. It is imperative that clean toilet facilities with running water be located within reach of the playing field, for use of players and spectators. The absence of such facilities could lead to a great deal 17

Public Health Issues in Baseball

of inconvenience and potential health hazards. Visiting teams are advised to take along boiled/cooled water for drinking where potable water is a scarce commodity and bottled water is difficult to obtain. Equipment When the catcher’s gear is not personalized, especially under the circumstances when equipment is used by several teams, there is a need to keep them clean. The chest protector should be washed from time to time, and the gloves exposed to dry. Likewise, the inside of the helmets should be cleaned with disinfectant solution and left to dry to avoid head lice and unpleasant odor. In places where lack of equipment is perennial, it is not uncommon to have a batter in the box without helmet. Most of the time no harm is done. But when harm does occur, it is often grievous, potentially maiming and could be fatal. It must be religiously enforced that all batters, catchers and home plate umpires must be properly dressed. On no account shall this be compromised. Courtesy and decency demand that all equipment be wiped clean and stored away neatly in readiness for the next users. The team captains or the trainers must ensure good care of equipment. Temperature Trainers are advised to avoid training in extreme temperatures. Nobody would tell you not to train in snow, but there is always the error of underestimating the ambient temperature in hot climate. Training should start early in the mornings or evenings to avoid being caught when the sun is menacingly up and blistering. Apart from running the risk of heat stroke, all indices of performance are deterred in very hot weather. The players stand to lose rather improve any training effect. Training in hot conditions is not “toughening” as some trainers claim. Health Hazards Every environment has its particular hazards. It is the duty of the Baseball administrators to disclose this well in advance to visiting teams; including advice on how to contain them. For instance in equatorial rain forest regions, mosquito bite is a menace and the consequent malaria fever can be deadly. This could be avoided if information is made available. Similar hazards include the Acquired Immune Deficiency Syndrome, AIDS, over spiced local food leading to diarrhea or exacerbation of peptic ulcer, sandflies, bed bugs, etc. Swimming in local rivers and streams and unguided tours should also be avoided as much as possible.

18

Public Health Issues in Baseball

PREVENTION OF INJURIES Warm-Up It is not uncommon for players to enter the field and begin swinging and throwing, especially when the trainer is not around. That is the fastest way to cause damage. At rest, the muscles are “sleeping” or functioning at normal metabolic rate. During a game, they are expected to function at around their maximum capability to generate maximum or adequate energy. Something is bound to give way when a sleeping muscle group goes full blast from rest. It therefore stands to reason that it is safer to get the starting point of the muscles nearer its maximum capability before subjecting it to maximum work. This guarantees more effective function and coordination. That is the use of warm-ups. The metabolic rate is raised from “sleep” to a position where maximum energy could easily be generated. A player must be sweating to be sufficiently warmed up. It is only at this stage that specific training can start or a player is ready for a game. A great variety of warm-up exercises exist and trainers are perpetually producing more. Stretches Though strictly part of warm-up, stretches deserve special mention. Suppleness or flexibility is very necessary to each player – pitcher, hitter, etc. When stretches are correctly done during warm-up, the vital ligaments and tendons are stretched beyond their normal range, thus making them able to readily accommodate sudden abnormal movements which invariably occur during games. This minimizes damage. Little wonder therefore that it has been well documented that people who are supple are less prone to injuries and that stretching improve suppleness. (Fig.5)

Fig.5 Stretching

19

Public Health Issues in Baseball

Cool-Down The purpose of this is to minimize aches and pains. A number of waste products that accumulated in the muscles during exercise are “flushed” out during cool-down activities. This aid to recovery and repair takes place at rest after exercise. Intensity and Duration It is well noted that sudden increase in training workload and/or duration often lead to injuries. A trainer must have this in the back of his mind when drawing up a training program. When set targets are not being achieved, every coach forgets this. That is where the danger lies – no matter how great the temptation, increase in training load must be gradual. TRAVEL AND SLEEP When travelling for international engagements, a comprehensive immunization should be undertaken. This is essential for personal safety and to avoid running foul of the laws of the land. These include Yellow Fever, Cholera, Hepatitis B and in some regions, Typhoid Fever, Cerebrospinal Meningitis, etc. It would be a good habit to have the players in the national team update their immunization and international immunization certificates. A comprehensive information on relevant immunization requirement can be obtained on enquiry from the IBAF Headquarters. When time zones are crossed during international engagements, sleep deprivation and disturbances are bound to occur. This upsets the natural metabolic rhythm of the body. One could be awake and playing when chemically speaking, ones body is asleep. Speed and reaction time are among the parameters affected; and these are very crucial in Baseball. For optimum performance, the natural rhythm of sleep and wakefulness of the body must be reset. This phenomenon takes days to occur, depending on how many time zones are crossed. It is worse going from east to west. A very rough guide is that acclimatation takes about one day per time zone crossed; but most people are adequately adjusted within three to four days. Sleeping pills could be used to aid players but this must be under the direction of a physician. It is therefore necessary that organizers of international championships give this priority during planning of arrivals to the tournament venue to avoid cheating visitors from far away.

20

Public Health Issues in Baseball

NUTRITION The salient points to note on nutrition are as follows: 1. A balanced diet in satisfactory quantities is essentially all a player requires. A slight to moderate increase in protein and carbohydrate intake would be required when training is intensified for a particular championship. 2. Ingestion of high dosage of mega vitamins, minerals and other food supplements with the intention to improve training adaptation and/or performance is of very little, if any proven advantage. The body does not store excess of these supplements. It takes what it requires – usually in sufficient amounts in a well balanced and nutritious diet – and eliminates the excess. 3. A light pre-game meal is advised to be taken no later that two hours before a game. This is because it takes about this length of time for maximum absorption to occur and it is important that the stomach is relatively empty at game time to avoid discomfort, distraction and injury. Glycogen, the major source of energy for the game, is already stored away in the muscles anyway. 4. You are advised to take fluids liberally during the game. This is because by the time you start feeling thirsty, the body is already dehydrated at cellular level, which in itself is bad news because the performance of the cell is compromised. This is bound to affect overall performance in no time.

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Public Health Issues in Baseball

Appendix A 1. Player: Family Name:

First Name:

2. Address: 3. Sporting History Other sports played Present training program More than 6 hrs daily More than 3 hrs daily 1 to 2 hrs daily 1 to 2 hrs 3-4 times weekly 1 to 2 hrs less than 2 times/week 4. Past injuries Date Mild Moderate Head & Neck Shoulders Elbow Arm Wrist Fingers Hips Thigh Knees Ankle / Foot Others Moderate: suspended play 1-3 days. Severe : more than 1 week. 5. Past Medical History of Note Type Illness Surgery Accidents Home Industrial Road Traffic Recurrent Illnesses Allergies Epilepsy Jaundice Others

Severe

Stay in Hospital

22

Hospitalised

Prognosis

Public Health Issues in Baseball

6. Family History

Yes

Heart Disease High Blood Pressure Diabetes Mental Illness Others

No

7. Drug History Vitamins / Nutrients Prescription Drugs 8. Immunisation History

Yes Date

No

CARDIOVASCULAR Chest Pain Dizziness Palpitations Ankle Swelling Hypertension

Yes

No

GASTROINTESTINAL Nausea Vomiting Abdominal Pain Diarrhea Constipation Jaundice Rectal Bleeding Ulcer

Yes

No

Yellow Fever Cholera Small Pox Hepatitis B Typhoid Tetanus Polio

Diphtheria Whooping Cough Measles BCG

Yes Date

No

Yes

No

Yes

No

9. Medical Cough Breathlessness Pain with Breathing Asthma Hay Fever Wheeze NERVOUS SYSTEM Headache Fainting Unconsciousness Convulsions Fits

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Public Health Issues in Baseball

URINARY SYSTEM Blood in Urine Injury Infection

Yes

No

MUSCULO-SKELETAL Joint Pains Swelling (aches) Muscle Pulls SKIN

HEMATOLOGY Abnormal Bleeding Lethargy Tiredness

Yes

No

Yes

No

Bruising Anemia Nosebleeds Yes

No

TEETH

EYES OTHERS

10. Medical Examination Height: Weight: Pulse: Blood Pressure: Ear: Nose: Eyes: I D Teeth: Neck: Spine: Shoulders: Elbows: Hips: Knees: Thigh: Calf: Feet: Fingers: Chest: Abdomen: General Comments: Name & Signature of Examiner: Date:

Throat: Wrists: Ankles: Achilles:

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Public Health Issues in Baseball

Appendix B Physical Assessment Parameter

Test

Assessment

1. Endurance 2. Speed 3. Speed Endurance 4. Dynamic Strength

3 Mile Run (in groups) 60 Feet Sprint (preferably in pairs) Shuttle Sprint (between bases) 18 inches Bench Jump

Time Time Time Max no. in 2 mins.

5. Dynamic Strength

Pull Ups

Max no. in 2 mins.

6. Dynamic Strength

Bar Dip

Max no. in 2 mins.

7. Local Muscle Endurance

Straight Leg Raise

Max no. in 2 mins.

8. Static Strength 9. Flexibility

Vertical Jump Sit & Reach

Highest point Farthest point

(lower limbs)

(Upper L. Flexor)

(Upper L. Extensor)

(Trunk, Abd. & Hips)

(repeated over 45 degrees nonstop)

Two things are guaranteed by this test: 1. No player can successfully conceal any injury while scoring high at the same time. 2. Healing and rehabilitation must be complete before pre-injury scores are achieved if tests were properly done.

Scoring, grading and setting cut-off marks for qualification or return to game fitness is determined by the trainer based on a number of factors: age, level of fitness or unfitness, team’s average, quality of players, etc.

25

NUTRITION IN BASEBALL Dr. Gianfranco Beltrami

INTRODUCTION A correct nutrition forms the foundation for physical performance in every sport. Nutrition provides the fuel for biological work and the essential elements for synthesizing new tissue and repairing existing cells. For this reason, in every age, a well-balanced diet and adequate nutrition is very important for Baseball players. The carbohydrate, lipid and protein provide energy at rest and during physical activity and are very important in maintaining the structural and functional integrity of the organism.

Fig.6 The most important nutrients 26

Nutrition in Baseball

Carbon, hydrogen, oxygen and nitrogen are the primary structural units for most of the biological active substances in the body. Specific combinations of carbon with oxygen and hydrogen form carbohydrates and lipids whereas proteins are composed of combinations of carbon, oxygen and hydrogen with the addition of nitrogen and minerals. (Fig. 6) CARBOHYDRATES There are three kinds of carbohydrates: monosaccharides (sugar such as glucose and fructose), oligosaccharides (sucrose, lactose and maltose) and polysaccharides that contain three or more simple sugars to form starch, fiber and the large glucose polymer glycogen. Glycogen is a large polysaccharide polymer synthesized from glucose in the process of glucogenesis and is stored in the tissues of animals. In well nourished humans, approximately 375-475 g of carbohydrate is stored in the body. Of this, approximately 325 g is muscle glycogen, 90-110 g is liver glycogen and only about 5 g is present as blood glucose. As each gram of glycogen contains 4 calories of energy, the average person stores between 1500 and 2000 calories as carbohydrate. This is approximately enough energy to power a 20-mile run. During exercise, muscle glycogen is the major source of carbohydrate energy for the active muscles in which it is stored. In contrast, in the liver glycogen is reconverted to glucose and transported in the blood for use by the working muscles. The term glycogenolysis describes this reconversion process which provides a rapid extra-muscular supply of glucose for muscular action. For Baseball players, about 55-60% of daily calories should be carbohydrates predominantly of the unrefined fiber rich complex variety in fruits and vegetables. Carbohydrates serve as a major source of energy, particularly during exercise and helps to spare the breakdown of proteins. They are also essential for the proper functioning of the control nervous system. A carbohydrate deficient diet rapidly depletes muscle and liver glycogen and can profoundly affect both anaerobic and aerobic exercise capacities. LIPIDS Lipids are also an important source of energy. They provide the largest nutrient store of potential energy for biological work. They protect vital organs and provide insulation for the cold. Lipids also act as the carrier of the fat-soluble vitamins A, D, E and K. During moderate exercise, lipid contributes about 50% of the energy requirement. This percentage increases during prolonged work. For Baseball players, about 25-30% of daily calories should be lipids. Of this, 70-80% should be in the form of unsaturated fatty acids. 27

Nutrition in Baseball

PROTEINS Proteins differ chemically from lipids and carbohydrates because they contain nitrogen in addition to other elements such as sulfur, phosphorus and iron. They are formed from sub-units called amino acids. The body requires 20 different amino acids that form an infinite number of possible protein structures. Eight of the 20 amino acids cannot be synthesized in the body. They are known as essential amino acids and they must be consumed in the diet. Proteins are found in the cells of all animals and plants. Proteins containing all the essential amino acids are called complete proteins. Animal proteins found in eggs, milk, cheese, meat, fish are examples of higher quality complete proteins. Proteins provide the building blocks for synthesis of cellular material during anabolic process. The recommended dietary allowance or RDA for protein is an average of 0,83 grams of protein per kg of body mass. Generally, the protein requirements as well as the quantity of the required essential amino acids decrease with age. On the other hand, for infants and growing children, the daily-recommended protein intake is 2,0-4,0 g per kg of body mass. Recent research on protein balance in exercise presents a compelling argument that proteins are used as an energy fuel to a much greater extent than previously thought and that such protein utilization varies with energy expenditure and nutritional status. This is particularly true for the branded chain amino acids, leucine, valine and isoleucine that are oxidized in muscles rather than the liver. Exercise in a carbohydrate depleted state causes a significantly greater utilization of protein than when these were carbohydrate rescues, particularly for extended duration of exercise. Also, if energy intake is not equal to energy expenditure during heavy training, even an augmented protein intake of two times the RDA may be insufficient. Protein catabolism during exercise becomes most apparent when the body’s carbohydrate reserves are low. Such findings further support the wisdom of maintaining optimal levels of glycogen during training. For Baseball players, about 15% of daily calories should be proteins. VITAMINS Vitamins are organic substances that neither supply energy nor contribute to body mass. They serve crucial functions in many bodily processes and must be obtained from food or dietary supplementation. There are thirteen vitamins classified as either water or lipid soluble. The lipid soluble vitamins are A, D, E and K, vitamin C and the B complex are water-soluble. Excess of lipid soluble vitamins accumulate in the tissues and can increase to toxic concentrations. Generally, water-soluble vitamins are non toxic. Research generally shows that vitamin supplementation (above that obtained in the well balanced diet) is not related to improved exercise performance or the potential for training. Vita28

Nutrition in Baseball

mins regulate metabolism, facilitate energy release and are important in the process of bone and tissue synthesis. (Fig. 7)

Fig.7 The functions of vitamines

MINERALS Approximately 4% of body mass is composed of 22 elements called minerals. They are part of enzymes, hormones and vitamins. They are found in muscles, connective tissues and all body fluids. The most important minerals are calcium, phosphorus, potassium, sulfur, sodium, chlorine, mag29

Nutrition in Baseball

nesium, iron, selenium, iodine and chromium. A balanced diet provides generally adequate mineral intake, except perhaps in geographic locations in which there is a lack of certain mineral such as iodine. A regular physical activity sometimes creates a significant drain on the body’s iron reserves. As a result of excessive sweating during exercise, significant losses of body water and related minerals can occur. These should be replaced during and following exercise. WATER Water makes up to 40 - 60% of the total body mass. Muscle is 72% water by weight whereas water represents about 50% of the weight of body fat. Water is lost from the body each day in the urine (1-1,5 lt.), through the skin as insensible perspiration (0,5-0,7 lt.), as water vapor in expired air (0,25-0,30 lt.) and in feces (0,10 lt.). Exercise in hot weather greatly increases the body’s water requirement. In extreme conditions, the fluid needs can increase up to five or six times above normal. Excessive sweating combined with the ingestion of large volumes of plain water during prolonged exercise sets the stage for hyponatremia or water intoxication. (Fig.8)

Fig.8 Percentage of body water

RECOMMENDED DIET FOR BASEBALL PLAYERS Variety and moderation are the key principles of good eating. In a correct approach to nutrition for athletes, emphasis is placed on bread, cereal, rice and pasta, fruits and vegetables. Deemphasized are foods high in animal proteins, lipids and dairy products. The most important factor is the determination of the daily caloric requirement based on the level of physical activity. The daily caloric requirement is correlated to the weight of each subject and to the relation between lean mass and fat mass and to the daily energy consumption. 30

Nutrition in Baseball

For this reason, it is necessary that the athlete should undertake an anthropometric evaluation and a body composition to identify the body weight and the percentage of ideal fat and analyze the life style to know the energy consumption due to daily activity. Baseball is a discipline in which the energetic consumption differs depending on the various roles, and although energetic consumption is not very high for its technical gestures, it can be important for the duration of the game and for the high number of games played every week. During training, it is suggested to have 5 meals per day with small snacks during the morning and in the afternoon. The pre-competition meal should include food that is readily digested and contribute to the energy and fluid requirements of exercise. For this reason, the meal should be high in carbohydrates and relatively low in lipids and proteins. Clearly, the typical low carbohydrate “steak and egg diet” does not meet the requirements for optimal pre-event nutrition. Three hours should be sufficient to permit digestion and absorption of the pre-competition meal. If the game takes place in the afternoon, the meal can also contain lipids and proteins. If the game takes place in the morning, the meal must contain carbohydrates such as toasted bread with jam or honey. Amongst the dairy products, non-fat milk or non-fat yogurt is suggested. Lunch can contain cooked or raw vegetables, along with a main course of pasta or rice served with very little fat. This can be followed with a portion of low fat cake with jam, honey or fresh fruit. If it is not possible to consume a hot meal, it is possible a sandwich with cooked vegetables and non-fat cheese is sufficient. Commercially prepared liquid meals offer a practical approach to pre-competition nutrition and caloric supplementation. These meals are well-balanced in nutritive value, contribute to fluid meals and are absorbed rapidly. If the time between the two games is less than two hours, it is possible to eat cakes with jam, honey or fruit juice. If this period is longer, the meal can consist of a lunch. For what concerns the dinner, it must vary containing very digestible food and must consider apart from a good carbohydration support (pasta, rice, etc.) also the assumption of proteinic food (meat, skimmed cheese) which has been reduced during the day. Even the day after the game, it is important to introduce apart from carbohydrates, even food rich of proteins (meat, eggs, cheese, vegetables), vitamins and minerals (fruit and vegetables). It is very important for the Baseball player to drink without limits, even before being thirsty, avoiding fizzy drinks. Fluid ingestion before and during exercise attenuates detrimental effects of dehydration on cardiovascular dynamics, temperature regulation and exercise performance. For Baseball players, it is not necessary adding carbohydrates to the oral re-hydration solution. It is suggested to drink simple water and reserve the assumption of re-hydration solutions containing vitamins and minerals only in environmental conditions which cause abundant perspiration and when many games are played consecutively. The assumption of alcoholic drinks as for all sports must always be avoided.

31

CHILDREN AND BASEBALL Dr. Desmond Bokor

Children play sports and specifically Baseball to have fun, make new friends and by participation in the game, they learn and develop new motor skills. These are the factors that must be the foundation for the involvement and development of Baseball among younger players. It is important to remember that children are not just “little adults”. As such, they cannot be expected to perform under the same conditions as adults or acquire the same skills as adults. It should be remembered that sporting ability is NOT accelerated by an early start in Baseball. In general, children are less metabolically efficient than an adult is. They can improve their performance with better economy of movement. They are however prone to heat illness and to disturbances of bone growth from injuries. Numerous studies have shown that organized sport for children is no more or less dangerous than playing in other areas such as at home or at school. COACHING PROGRAM All participation in Baseball requires an appropriate coaching program to introduce, modify and perfect those skills necessary for safe and effective participation in the sport. It is recommended that all coaches for junior teams should have completed a coaching course accredited by their local Baseball association. Appropriate and properly fitted protective equipment should be available and used both at training and competition games. Children all develop at different rates. One 15 year old boy may be completing his puberty and developing adult musculature, while his friend may not have started to enter puberty, and as such be underdeveloped and still a child in both physical and psychological areas. Placing both these players in the same or opposing teams may increase the risk of injury to the late developing child. It might also frustrate and disillusion the immature child from further participation in Baseball. Coaches and competition organizers need to be understanding of these problems and try to match players of similar age, size, sex, strength, skill, physical and psychological maturity in appropriate teams and competitions. Because of the immaturity of muscle development in the younger age, weight training should not be introduced into a training program until the player is about 15 years old. Many of the skills and activities in Baseball place a significant stress on the shoulders. Pitching is the most strenuous load that can be exerted on the shoulders. In the younger player, there should be strict limits as to the number of pitches thrown during one game and the total of pitches thrown in a day. 32

Children and Baseball

Assignment

under 14 years

under 16 years

Under 18 years

Days of rest

MAJOR

55 pitches/game

65 pitches/game

80 pitches/game

80 pitches/day

90 pitches/day

110 pitches/day

SUBSTANTIAL

25-54 pitches

30-64 pitches

40-79 pitches

2

MINOR

less than 25 pitches

less than 30 pitches

less than 40 pitches

1

3

Depending on the assignment of the pitcher, 1-3 days rest should follow the days pitching. While this is a suggested program, individual variation can be made depending on the physical development and characteristics of the player. ENVIRONMENT Both hot and cold environments can affect the child’s safe participation in Baseball. Children are highly susceptible to extremes in temperature because they have poor control of their body temperature. Baseball is often played as a summer sport and as a result the child is often standing out in the field in the sun for long periods. Children do not sweat as readily as an adult and so are unable to cool their bodies as efficiently. They are prone to overheating. To minimize this, the following is recommended: * * * * *

Uniforms should be of an appropriate lightweight design. Baseball caps are essential. Sunscreen should be NON-oil based as the oil based sunscreens can block skin pores and affect the ability to sweat. Adequate fluid should be consumed before, during and after the game. Children should be encouraged to drink BEFORE they feel thirsty to maintain their hydration levels. Remember that thirst is a poor indicator of the need for fluid. Players should NOT share bottles of water in order to reduce the risk of spreading any infectious disease.

It is the coach’s responsibility to monitor the well-being of the players and if there is any suspicion of heat illness, then the child should be immediately withdrawn from the sport and medical advice sought. Signs of early stage heat illness in a child: Nausea Flushed skin Fainting Excessive sweating Tiredness

Hot Weakness Headache Cramps

In cold environments, children are more prone to hypothermia as they have a larger surface area to mass ratio. Children are unreliable to indicate when they may be too cold and again it is the 33

Children and Baseball

coach who needs to be aware of the conditions and ensure that the child stays warm. Avoid allowing the children to stand in wet clothes for long periods, in exposed or windy conditions and encourage the use of warm clothing such as a jacket. PARTICIPATION BY CHILDREN WITH AN ILLNESS OR A MEDICAL CONDITION Because children’s bodies are particularly vulnerable during times of illness, care needs to be taken when considering allowing such a sick child to continue their participation in Baseball. * * *

If the child has had a viral illness present in the last 24 hours prior to the game, he should not participate. If the child has generalized symptoms such as fever, aches, pains or general tiredness, then he should not participate. For uncomplicated upper respiratory tract symptoms such as runny nose, sneezing, etc., the child may participate for 15 minutes. If, at the end of that time, he feels unwell, then he should cease to play the sport. Otherwise he may continue.

Despite suffering from many medical conditions, children can still participate in Baseball, provided that the condition is medically supervised. These include: chronic infections, cardiac abnormalities, arthritis, and medical conditions such as diabetes, asthma and epilepsy. Children suffering from asthma should have an “asthma management plan” in case of an asthmatic attack. This is usually organized by their doctors and should be communicated to the coach or another responsible adult who may be present at the game. Children should have ready access to their inhaled medication. Coaches should be aware of any special conditions prior to the season starting. SOFT TISSUE INJURIES Contusions, strains and sprains are by far the most common injuries in children. If such an injury does occur, then the first 48 hours is vital in the effective management of the condition. Immediate treatment should include: rest, ice, compression, elevation and if it does not readily settle over the next day or two, then referral to a medical practitioner for accurate diagnosis and treatment is recommended. Overuse injuries do occur in children. There are a few important anatomical considerations in the younger child. Growing bone has a loose lining (“periosteum”) which means that less force can produce a traction overload. Different growth patterns in the length of bones relative to muscles result in tightness of various muscle groups and make these susceptible to overload injuries. Treatment of an overload injury includes: identifying and modifying the risk factor, controlling the pain, undertaking a progressive rehabilitation program with emphasis on restoration of full flexibility, endurance and strength, and developing a maintenance program to prevent new injuries or the recurrence of the old injury.

34

Children and Baseball

Fig.9 Types of fractures

FRACTURES Children’s bones are not as hard or brittle as those of adults. The bones can bend more easily without breaking. Hence, a child may fall and injure his arm without any deformity yet still has a significant fracture. The bones may bow slightly, buckle or have a partial crack, yet there will be no deformity. If the child injures himself and it does not settle over the next one to two days, then an X-ray is strongly recommended. It should be remembered that children often break their bones near the growth plate region and hence it is important to correctly diagnose and treat these injuries. Stress fractures do occur in children, though not as commonly as in adults. The most common site is the tibia, shinbone. (Fig.9) DISLOCATIONS These most commonly involve either the patella (kneecap) or the elbow. It is not uncommon for these dislocations to spontaneously relocate though the child will still complain of significant pain. The child should be removed from sport until all ligaments have healed and the joint has regained full function.

35

Children and Baseball

HIP INJURIES Around the pelvis bone, there are number of growth centers that may, during the course of an extreme muscular effort, fracture from their attachments. These are usually rested until motion and function return. The pre-puberty sportsperson may develop a painful limp due to a transient viral inflammation of the hip joint. The patient should be seen and assessed by a medical practitioner. The most common hip disorder in adolescents is slipping of the upper femoral growth center, i.e. the ball in the hip joint. The patient is seen with a limp and pain. All children who limp should be thoroughly examined by their medical practitioners to exclude major hip damage. Beware of the child with a persistent limp. KNEE As children grow, their bones often grow faster than the ligaments and tendons. As a consequence of this, pain may occur around the knee due to muscle imbalance, especially on the kneecap (patella). This usually settles with physiotherapy and time, but the child may need to be taken out of provocative activities if it is particularly painful. Ligament and meniscus (cartilage) injuries may occur in the child but these tend to be less common than in adolescents. It is important to have a medical practitioner assess any acute knee injury that is associated with swelling.

36

INFECTIOUS DISEASES IN BASEBALL Dr. Gianfranco Beltrami

Infectious diseases are very common in all sports and in Baseball teams. Most of them are very dangerous because if an athlete is ill, that illness may be contagious and the whole team can be at risk for contraction of the disease. The purpose of this chapter is to describe the most common infectious illnesses that may be present within Baseball teams. SKIN DISEASES The skin is a barrier against a variety of infections. In Baseball players, the copious sweating and the occlusion by uniforms, pads and footwear increase the skin’s environment for infection. There is also a risk for skin infections due to direct contact with competitors, along with cuts and abrasions from competition. Impetigo is an acute infection that is due to staphylococcus aureus or group a-beta hemolytic streptococci. The skin lesions are first vesicular and later crusted and can be present on the face, arms, legs and trunk. (Fig.10)

Fig.10 Impetigo

Athletic competition and training should be avoided while impetigo crusts are present to prevent infection in other athletes. All clothing, towels and linens should be laundered in hot water till the lesions have healed. The therapy is based on topic and systemic antibiotics. 37

Infectious Diseases in Baseball

Cellulitis is also an acute infection of dermal and subcutaneous tissues and is characterized by the red, hot, tender area of skin often surrounding the site of bacterial entry. It can be located in the arms and legs, but also in other parts of the body. The lymph nodes in the region are enlarged. The treatment includes rest, elevation of the area involved, immobilization, pain control and antibiotics such as dicloxacillina and erytromicina. The return to competition is possible only when the lesions have disappeared. Scabies is a parasitic skin infestation caused by the mite Sarcoptes scabei and is frequently associated with a secondary infection because of the itching. In athletes, the mode of transmission is sexual contact, use of infested towels or equipment or direct skin to skin contact. The diagnosis is frequently missed and should be considered in anyone with intractable pruritus. The physical examination includes burrows, vesicles, usually independent of the burrows and red nodules of circa 1 cm in size. If untreated, the lesion may develop into urticarial papules, eczematous plaques and rusted. The lesions are found in genital parts and in the flexor crease of the wrists, palms, chest, axillae, etc. Every examination of an athlete with pruritus should include a search of the mite, particularly in the form of burrows. The therapy of the various forms must be prescribed by a physician. FUNGAL INFECTIONS Like in other sports, typical fungal infections of the keratinized tissue of the skin are frequent also in Baseball. Tinea corporis (ringworm), tinea pedis (athlete’s foot), tinea cruris (jock itch) and tinea versicolor can be chronic and recurrent in athletes for any predisposing environmental factors (hot humid climates that promote perspiration). The transmission is acquired by one of three sources: person-to-person by fomites, animal-toperson and least commonly from soil. Ringworm is characterized by variety sized, scaling, sharply demarcated plaques with or without vesicles. The periphery is raised with central clearing. Areas of involvement are the neck and exposed arm in either single or multiple lesions. Athlete’s foot is usually localized initially to the inter-digital spaces between the third and fourth toes. It can then progress to involve the foot. The area is red with white scales and associated maceration with vesicles. (Fig.11) Tinea cruris (jock itch) is found in the intertrigineus areas and adjacent upper thighs.

38

Infectious Diseases in Baseball

Fig.11 Athlete’s foot

These red plaques are popular, scaling, sometimes centrally clearing and intensely pruritic lesions. Tinea versicolor is usually present for months to years before the athlete will present with the complaint of areas that will not tan. The lesions are usually sharply demarcated ovals with fine scales. In lighter colored skin, they are of a brownish tint and in darker skin pigmentation, the lesions are off white. Common areas include the upper trunk, abdomen, upper arms and neck. The diagnosis for all the fungal infections can be confirmed by direct microscopic examination. The treatment can be initiated with topical preparations. If the infection is not responsive, an oral agent is utilized. INFECTIVE GASTROENTERITIS The gastroenteritis infections, which cause nausea, sick, diarrhea and other general symptoms, are very common. In adolescent, young people and athletes, this infection is second only after the superior respiratory organs infections. The infective agents can be virus, bacteria, protozoa and in some cases, even fungus. Viral gastroenteritis can come all through the year, although the highest peak is in winter. The principle symptoms are diarrhea and sickness. Other symptoms may appear, such as high temperature, abdominal cramps, nausea, headache and mialgia. The beginning is acute and lasts 2-3 days or sometimes more. Even though this disease disappears on its own, a medical opinion is requested especially for athletes. The treatment must be simple and completely clarified. The fundamental point of the treatment is to take liquids, especially water with sugar and electrolytes. The most part of patients visited 39

Infectious Diseases in Baseball

by a doctor are dehydrated. Even though the level of dehydration is not high, this can be very important for an athlete. The dehydration state can be evaluated by the weight, volume of urine or dryness of skin. In case of short-term disease, it is advised that the athletes should lose at least 2% of its previous normal weight before starting sports activity. It is suggested to introduce little quantities of liquids in short periods. It is advised to avoid liquids containing caffeine, alcohol and aspirin. When the intensity of the disease extenuates, the diet can be enriched with more complex carbohydrates with fat and proteins. Food rich in fibers will be naturally added. In some cases with profuse diarrhea, it is also necessary to avoid milk and dairy products for at least 7-10 days. Infective gastroenteritis can be of bacterial origin. The diagnosis can be confirmed in laboratory. Water and food are usually accused of being the origin of the infection, even though very seldom these accusations are proved. For athletes of a team, who frequently use hygienic systems in common, it is necessary to identify the holder of the infection. Bacterial gastroenteritis receives the same treatment as for other causes. At the same time, it is possible to use antibiotics. Ampicillina is chosen for treating Shigella infection, tetraciclina for Cholera and doxicillina for Escherichia Coli. An occasional cause of intestinal infection in athletes, especially in those using contaminated water, is Giardia Lamblia. The diagnosis of this protozoaric disease concerns feces or duodenal liquid exams. The treatment is based on chloride of chinacrina or on metronidazolo. HEPATITIS A Hepatitis A, more diffused hepatitis type, is generally a disease lighter than hepatitis B. It is usually diffused interpersonally by fecal-oral way, however also food and water can be valid causes. The incubation period goes from 2-5 weeks and the viremia phase bests from 2-5 weeks before the symptoms are evident. Like the other viral diseases which appear spontaneously, the athlete should be able to start a limited activity as soon as the symptoms disappear. When the hepatic functionality becomes normal, a moderate activity without restrictions can begin. Therefore it is not necessary that hepatic enzymes should return to normal condition when beginning training. During a disease where a long time to recover is estimated such as hepatitis A, it is suggested to give the athlete an approximate valuation of the necessary time to recover strength, ability and endurance lost during the disease. The recovery needs at least the same time as the disease, having the possibility to be more. A disease that lasts 2 weeks requires 2-4 weeks to recover the necessary conditions to participate in competitions. The prophylaxis of hepatitis A is suggested for teams participating in international tournaments.

40

Infectious Diseases in Baseball

RESPIRATORY INFECTIONS Infections regarding the respiratory system represent the most common affections in subjects practicing physical exercise. (Fig.12)

Fig.12 Influenza virus

In the respiratory system, any part can be affected from bacterial or viral infection: pharynx, trachea and lungs. (Fig.13)

Fig.13 Early staphylococcal pneumonia

In the superior respiratory organs, the viral infections predominate and the most common symptoms are nasal congestion, sore throat and cough, together with temperature, headache, mialgia and uncomfortable feeling. 41

Infectious Diseases in Baseball

In 48-72 hours, there is an improvement in these symptoms, while after a period of 5-7 days they are gone. The treatment is of support. Aspirin is efficacious for temperature, headache and mialgia. Throat inflammation is cured by gargling hot water and salt. It is suggested to interrupt activity until the initial symptomatologies are turning down and re-start training at a reduced level. Nasal congestion can be a reason of limitation when restarting physical activity. Anti-istaminics and anti-inflammatories help relieve nasal congestion but cause sleepiness and dry throat. Nasal sprays are very efficacious and can be used in occasion of competition, but it is important to know that the use of these drugs can be subject to particular restrictions for the anti-doping control. Other elements which stop training are a reduced aerial flux, major reactivity of the aerial organs, cough and breathlessness observed up to 8 weeks after some viral syndromes. In those subjects where a frequent symptomatology occurs, such as temperature, productive cough and weariness lasting 5-7 days from when it started, it is possible that there is a bacterial sovereign infection in the respiratory system. An antibiotic therapy for a period of 7-10 days is usually efficacious in eliminating infection. It is necessary to avoid an indiscriminate use of antibiotics. Though the possibility of these complications, the most part of subjects are able to restart maximal training or physical exercise within one or two weeks from the beginning of the symptomatology. The bugbear of all the teams is the viral epidemic. Because of a shifty beginning, the virus is very often already diffused before the symptoms are evident. Regular use of anti-influential vaccination in athletes is suggested. Pneumonia, which is the result of pulmonary infection, generally starts after inhaling infections particles, usually during or straight after a respiratory viral infection. Among the various microorganisms, bacteria is able to most frequently infect the lungs. The most frequent bacteria responsible for pneumonia in subjects in good health and practicing sport are Streptococcus Pneumonia and Microplasma Pneumonia.

42

DRUGS – USE AND ABUSE Dr. William Boyd

The potentially harmful use of drugs took many forms, from overuse of food supplements and vitamins, to potentially damaging reliance on therapeutic drugs for treatment of injuries, to use of illegal stimulants and large doses of anabolic steroids. (WHO program on substance Abuse WHO/PSA/95.4) An active player is often healthier than most young men in his neighborhood, but in the same stride, he is bound to be exposed to a fairer share of drugs. This is because apart from injuries that are not uncommon with vigorous training and competition, he is also exposed to illnesses prevalent in his environment. It is in light of this that we intend to go through the common drugs used by players from time to time and look at problems that could arise when these are misused. The use of banned substances regarded as doping is not covered in this chapter. MEGADOSAGE OF VITAMINS AND SUPPLEMENTS When vitamins are taken in dosages over ten times the Recommended Daily Allowance (RDA), the dosage is referred to as mega-dose. Vitamins and some minerals take part in many metabolic processes going on in the body to ensure that essential enzymes are available in the right quantities for normal functioning of the body, including energy production. But the body requires very little amounts of these for natural process to go on. In an attempt to improve performance, scientists try to boost energy production by loading the body with high quantities of some of the chemicals that partake in these metabolic reactions. These include vitamins, minerals – copper, zinc, manganese, anti-oxidants, selenium, amino acids, lecithin, creatine, etc. When these chemicals are not excreted quickly or completely, they accumulate in the body and could have negative effects like any other drugs. Vitamin poisoning could then occur. This condition is referred to as hypervitaminosis. Players as a group would take anything, not on the banned list, to make them stronger and improve their performance. Through aggressive marketing, the players are exposed to all sorts of multivitamin preparations and food supplements purporting to make them super athletes. Fortunately, the human body takes the little it needs and discards the rest. Most of the high dose supplements consumed are therefore thrown away as waste. There is very little or no scientific proof that mega-dose vitamins and supplements improve strength or performance. There is also very little known about their side effects. If they are of 43

Drugs - Use and Abuse

any use at all, they provide psychological succor during periods of hard training. It is important to stress here that all the player needs is a nutritious well-balanced diet in sufficient quantities. Strength is increased through training and not injection of wonder pills. COMMON ILLNESSES Players are bound to suffer from common illnesses like cold, fevers, diarrhea and allergies. An elite player needs not be reminded that he should seek attention from qualified medical personnel; and where possible, medical personnel who are familiar with the IOC list of prohibited substances. It is also important that the player sticks to only prescribed drugs in terms of dosage and duration and also observes related instructions. Problems arise when a player decides to continue with a particular drug, based on self-diagnosis, because it brought the desired relief during a similar ailment. It is not uncommon to hear players say, “it worked like magic. I always keep it handy”. Side effects could become manifest and incompatible with training and distress or injuries may occur. Performance may be going down and the player may not be able to link this to his “handy drug”. The abuse of prescribed medications is common among players especially in countries where virtually any medication can be purchased without prescription. The effects of drug abuse sometimes are not dramatic as in cases of antibiotics. Here resistance to causative organisms may develop and this could be problematic in future. In other forms of abuse, toxicity may manifest, and unless a physician is aware, remedy from symptoms may be difficult. It is most unadvisable to take native herbs or preparations for treatment. The excuse that one tested positive following ingestion of some local beverage or food does not fly anymore. If for any reason steroid containing drugs are used for treatment of allergies, asthma or skin conditions, report must be made to the relevant authority. The team doctor must be informed, who in turn notifies the relevant medical authority prior to competitions. When purchasing over-the-counter drugs for conditions like the flu, a player should clear with the team doctor which brands to avoid. Ephedrine and similar compounds, which are common contents of cold preparations, are on the list of banned substances. Morphine and similar compounds, which are used in some anti-diarrhea medications, are also on the list. PAIN KILLERS Injuries are expected as part of sports. Injuries lead to pain and discomfort. The management of pain is therefore crucial. Pain is an indicator to the severity of an injury. Masking pain to permit use of an injured part of the body leads to more damage. It is therefore important that a diagnosis of the extent of injury is established before the commencement of the use of painkillers. But this is often not the case. As the use of painkillers is unavoidable, so is it prone to abuse. The most effective and com44

Drugs - Use and Abuse

monly used painkillers are the non-steroids containing anti-inflammatory drugs. This wide group of drugs includes aspirin-like drugs, ibuprofen, naproxen, phenylbutazone, piroxicam indomethacin, etc. They reduce both swelling and pain. Steroid containing medications for pain are commonly used as injections into joints and around damaged ligaments. For a player to derive best benefits from painkillers, it is crucial that drugs are taken soon after injury. The team physician would be in the best position to prescribe the most suitable type of non-steroid containing painkiller, in the right dosage. However, from experience, most players know what to take and they simply go for them. Some brands sold as over-the-counter drugs are the most abused. Some players, especially the stars, simply overawe their physicians and they get their demand all the time. Others get their drugs somehow - “don’t ask me”, all in the attempt to suppress pain and continue with training or competition. The worst thing that can happen to a good player is to be denied the opportunity to be part of the team due to injuries, especially in a major championship. Players therefore do anything possible to conceal injuries. Little wonder they love painkillers. In countries without strict restrictions on sale of pharmaceutical products, players simply stockpile their supplies. In most cases, this relationship between injuries and painkillers ends up in a vicious circle. Painkillers are used to suppress pain to allow play. Playing results in more damage. More painkillers are taken. Play is continued. Complete healing hardly occurs. Little wonder that players often remark, “that old nagging injury is playing up again”. The truth is that the injury was never properly healed in the first place. The only way around this is for team’s medical team to work out standard back-to-match assessment of injured parts of the body. Without doubt, players derive relief from painkillers, but these drugs are not without side effects. The more quantities consumed over longer periods, the more the side effects. In fact, these side effects are of particular concern. They range from mild stomach irritation, to heartburn, to stomach ulcer, to blood loss in the gut and even to anaemia. Some cause headaches, dizziness and light-headedness. More serious side effects, like water retention and interference with formation of normal blood cells, may also occur. As for steroid containing painkillers commonly used in chronic injuries, the story is worse. While they could be very effective, they have a host of side effects. They cause thinning of the bone (osteoporosis) which could manifest as freak or unexplained fractures. They also lead to the weakening of muscle fibers. This effect is noticed in rupture of muscles or tendons. Skin preparations of this class of drugs used in reducing swelling may lead to thinning of the skin and delay in wound healing. A not commonly used range of painkillers is the narcotics. Codeine, which is easily available alone or in combination with other drugs as oral pills, is in this class. They are used for intractable pain and are also contained in some drugs to suppress cough and diarrhea. Frequent use leads to dependency. Withdrawal symptoms like craving and anxiety often result when their use is terminated. In high doses they could lead to stupor and even coma. (Fig.14) Above all, some people could react violently to any of these drugs and such reactions could take any form, referred to as hypersensitivity reaction. As simple and harmless as they seem, 45

Drugs - Use and Abuse

Adverse Effects of Narcotics Addiction Physical dependance Withdrawal symptoms: pain nausea and vomiting chills and fever muscle spasm

Mental clouding Breathing problems Fall in blood pressure Gall bladder obstruction Constipation

Fig.14 Adverse effects of narcotics

anti-inflammatory and pain killers can be dangerous, especially when abused. ALCOHOL Alcohol is a drug commonly abused by the society at large and players are not excluded. Rarely do we see drunken player during training or competition. The mental picture of an alcoholic is not compatible with that of elite players, but some players drink heavily on a regular basis. There are three principle ways in which alcohol reduces performance. One. During exercise, some fat is converted to sugar in order to keep up the demand for energy. This form of sugar called glycogen is a main energy source for muscular activity. Alcohol blocks the conversion of fat to glycogen thereby depleting the level of blood glycogen. This could give rise to low blood sugar. Players who go out drinking the night before a game will confirm that they feel drained of energy half way during a game especially when playing a tough opponent. Two. Alcohol leads to poorer co-ordination of muscle activity and decreases its mechanical efficiency. This effect is noticed in the player’s reduction of reaction time, strength and skill. Three. The blood vessels in the skin are dilated by alcohol. This affects sweating pattern and temperature regulation during exercise. The muscle could thus become cold. Players are therefore advised to abstain from alcohol for at least 24 hours before games. SMOKING Smoking introduces chemicals into the body. These have harmful side effects and are considered here as drugs. It has been long established beyond doubt that the habit of smoking increases the risk of heart attack and causes cancer. It also has a number of undesirable effects on athletic performance. The red blood cells of the blood contain substances called hemoglobin, which car46

Drugs - Use and Abuse

ries oxygen to vital organs of the body. One of the by-products of smoking in the body is carbon monoxide. This chemical attracts hemoglobin of the red blood cells 200-3000 fold more than oxygen. It combines with hemoglobin to form carbon monoxide hemoglobin. The quantity of red blood cells involved could be from 5-10% depending on how heavily a person smokes. These red blood cells are temporarily out of function, thus reducing the overall amount of red blood cells that are available to transport oxygen to the muscles. This is a disadvantage to high intensity performance. Smoking also reduces the ability of the surface of the lungs to absorb oxygen, in some cases, up to 50%. That is not all. The heartbeats are a lot faster for any given level of exercise undertaken just after smoking. It is therefore necessary to stress that smoking drastically reduces performance. A serious player should keep away from smoking, especially close to tournaments.

47

DOPING AND HEALTH RISKS Dr. William Boyd

The incidence of doping recorded in IBAF tournaments up to now is low. Some people believe that with the increasing worldwide participation, the stakes are getting higher and competitiveness at world / intercontinental championships and Olympic tournaments is bound to become fiercer. Consequently, the pressure on players to perform better would escalate. These are the ingredients that pave way for a “win at all cost” attitude, the precursor to the use of performance enhancing substances. With the strict anti-doping rules recently being enforced by the IBAF, there is very little chance of escaping being caught if players indulge in banned substance(s). Of course, the consequences are devastating to the player, team and national pride. Hence the effort to educate players, trainers, managers and handlers of the futility of doping. While the game of Baseball is more brain than brawn, physical attributes are very essential. A good game is characterized by bursts of explosive energy in the forms of power hits, fast pitches, all-out-sprints to 1st base and often straight to 2nd and sometimes even to 3rd and of course home. The physiological needs to achieve these are strength and energy –strong powerful arms, shoulders and legs. In an attempt to achieve these and come on top, there is always the temptation to augment hard training with food supplements, mega-dose vitamins, minerals and inadvertently, or otherwise, banned substances. While most players would not want to cheat, yet they are very impressionable and gullible, ready to experiment with “safe” substances to get the extra energy when it matters most and improve their ability to excel. Others erroneously believe that the best among them is “using something” or that the substance in use is yet to be detected by the present testing technology, or that testers are not aware or conclusive of its effects. There is also the chance that “I may not be picked for testing” or so some believe. Traditionally, dope users are often a step ahead of testers. The IBAF anti-doping rules cover all the substances banned by the IOC Medical Commission. We shall however throw our spotlight on anabolic steroids, stimulants, narcotics and marijuana. We shall look at how they work, their effect on performance and the short and longtime consequences on the users. We shall also give an insight to how a user may be suspected or identified by his trainer. In this chapter also, we shall paint a vivid picture of the doping control procedure, to familiarize players/trainers of what to expect when invited for testing. This we believe would go a long way to remove the emotional stress and anxiety, which most players go through when picked. 48

Doping and Health Risks

ANABOLIC STEROIDS Players who use androgenic anabolic steroids (referred to here simply as steroid) hope to improve their strength, increase their muscle bulk and also increase recovery time to permit harder training. Steroid use also increases aggressiveness (competitiveness) and reduces body fat. Scientists differed in their opinions on the effects of steroids on performance. Some believe that there is no advantage in strength of muscles built on steroids and that built on pure physical training, hence the claims by players that their experience of positive changes is but a “placebo effect”. Currently however, the consensus opinion is that “the gains in muscular strength achieved through high intensity exercise and proper diet can be increased by use of androgenic - anabolic steroid in some individuals” (ACSM, 1984; Haup and Rovere 1984). Steroids confer undue advantage to the user. Undoubtedly, it provides psychological enhancement –the socalled “macho effect”. It is therefore cheating and unethical to sports and medicine. SIDE EFFECTS OF ANABOLIC STEROIDS The use of anabolic steroids increases the rate of thickening of blood vessels (arteriosclerosis). This leads to coronary heart disease (CHD) in apparently fit, healthy sportsmen under 40. Steroid use also causes water retention, which in turn leads to high blood pressure. Liver disease and cancer has also been linked to the use of steroids. Sperm production is reduced, and shrinking of the testis also occurs. Libido is reduced. Damages to tendons often occur. This could be because the muscle bulk is enlarged disproportionately to the tendons, and also because steroid inhibit the formation of collagen, an important constituent of tendons. Psychological defect in form of aggressive violent behavior has also been associated with the use of steroids. There is also evidence that users could get hooked on it after protracted use. To prevent these unwanted bad effects which are dependent on dose and length of use, steroids users have devised all sorts of methods, from taking a combination of different types, with and

Fig.15 Side effects of steroids 49

Doping and Health Risks

without other medications, to laying off for a period of time to give the body enough time to recuperate. Most competitive sportsmen use steroids to achieve their desired results and stop long enough before competitions to avoid detection, while continuing training to retain their new found strength. It is in the light of this that out-of-competition or pre-competition testing could be valuable in catching offenders. (Fig.15) STIMULANTS Most stimulants have little place in Baseball, but the effects of some of them could be of some advantage. The stimulants often abused by sportsmen include a wide range of drugs like amphetamines, cocaine, caffeine, ephedrine, pseudoephedrine, salbutamol and related substances. They have various modes of action but generally, they stimulate the nervous system and also have effect on the cardiovascular system. With regards to caffeine, ephedrine, salbutamol and similar substances, their concentration in urine must be above certain level to be labeled as dope. Depending on the dose, sportsmen use them to increase alertness, aggression, reaction time and the ability to concentrate. They also reduce fatigue. As one would expect, different sportsmen explore the different classes in this group to enhance performance in their sport. Hence, while the endurance athletes use them to combat fatigue, a Baseball player may explore their qualities of improving reaction time and concentration. SIDE EFFECTS These effects of stimulants are numerous and as varied as the substances in this classification. They include dependency, heart abnormalities, sleeplessness, elevated blood pressure, aggressive behaviour like fighting, impulsiveness and suspiciousness. (Fig. 16)

Adverse Effects of Stimulants Addiction Drug dependance Agitation Nervousness Tremor Delirium Sleeplessness

Loss of coordination Aggressive behaviour Psychosis High blood pressure Seizures Arrhythmias

Fig.16 Adverse effects of stimulants

50

Doping and Health Risks

NARCOTICS These substances are banned because of both their legal and medical consequences. They include morphine, pethidine, heroin, etc. They are not popular with sportsmen, but are very powerful painkillers. They are used to mask pain to enable the player to continue playing. This practice is medically unethical and exposes the player to more severe damage of the injured area. Morphine is sometimes found in anti-diarrhea preparations and the use of this would land the user in trouble. Ignorance is no excuse. Players are therefore advised to bear in mind while taking medications bought without prescription or those prescribed by doctors other than their team doctors. SIDE EFFECTS The major side effects of repeated use of narcotics are addiction and withdrawal symptoms. MARIJUANA Bearing in mind the adverse physiological effects of marijuana on performance, one wonders why some sportsmen indulge in the use. It reduces muscle strength and balance may be disturbed. Aggression and motivation may be blunted. These effects are however dose dependent. A first time user may find it disastrous prior to a game. Players who are no strangers to marijuana use it to release tension prior to competition. Marijuana is mostly a recreational drug that gives a sedate euphoria of well being. Its side effects include addiction, single mindedness and propensity for violent behaviour. Regardless of its good or bad medical attributes and its legal status in some states or countries, marijuana affects mood and use in sports is unethical. ANTI DOPING CONTROL PROCEDURE During IBAF tournaments, only one game per day and one player per team is tested during preliminaries. At the quarter and semifinals stages, still one game per day, but two players per team are subjected to doping control. In the final and third place matches, two players are tested per game. At the bottom of the 7th inning, lot is drawn to pick the players to be tested and a written notification is served to the “lucky” players at the end of the game. Each player is expected to report at the Anti-Doping Control Center within thirty minutes of the end of the game, accompanied by one team official or team doctor and an interpreter where necessary.

51

Doping and Health Risks

The procedure is quite simple. After the formalities of identification and documentation, the player is asked to choose one from a bunch of identical but differently numbered tamper-proof packages. One package contains a plastic container into which urine would be passed, two bottles and sealing containers. The player opens this package himself when he is ready to pass urine. He is escorted to the wash room within the same vicinity by the dope control medical officer who would witness him pass urine into the plastic container. Thereafter the player would pour his urine into the two bottles, A and B samples. He screws the bottles tight and places them in especially sealable containers and satisfies himself that they are completely sealed. The bottles could only be extracted by breaking the seal and this is done much later at an IOC accredited laboratory. The player is under no pressure whatsoever to produce urine and can take all the time he wants. There is however one provision. From the time the player is served with the notice for testing, he is obliged to remain within view of the escort who served him the notice and would direct him to the Dope Control Center. At the center, he must also remain within view of the doping control medical officer, until he provides the urine. It must however be stressed that the player is not under arrest. The escorts are trained to be polite and courteous. Also present at the Dope Control Center with the dope control medical officer are one representative of the Technical Commission and one representative of the Medical Commission. The player would be asked to disclose any medication taken recently, while he and/or his accompanying officials shall be asked to record their observations if any. The documentation provides places for both the player and accompanying officials to append their signatures. They are given a copy at the end. It is pertinent to note that the document accompanying the samples to the laboratory bears only numbers identical with those on the bottles. No name, team or nationality is revealed to the laboratory. As you can see, the anti-doping control procedure is very simple and not invasive either. Simply provide identification, answer some questions, produce urine, seal up both samples, sign the document and collect own copy. That is all. Only in case of a positive result for a banned substance would the player be called upon with his team official or doctor to answer more questions and be present when the B sample bottle would be opened for testing. The rest are administrative.

52

INJURY PREVENTION IN BASEBALL Dr. Gilberto Ante Vidal

Playing sports contributes overall to good health, producing several advantages for the body, including: * * *

Cardio-respiratory improvement Muscle strength Lessening of risks due to cholesterol, high blood pressure, cardiac conditions

On the negative side, there is the risk of injury. These may be caused by external factors (blows, strains) or by internal factors (bad technique, lack of training or over-performing). The prevention of sports injury should be kept in mind by doctors, managers and sports executives. Preventive measures have two objectives: 1. 2.

The avoidance of accidents and their negative effects on players. Public awareness of the possible risks of their participation in physical fitness or sports programs.

PREVENTIVE MEASURES I. II.

At an individual level. At the level of the playing conditions and the rules of the game.

ACTIVE PREVENTIVE MEASURES Medical check-up - Standard - Resistance to exertion - Cardio-respiratory function - Bio-medical and psychological test Nutrition A correct, balanced diet: - 55-65% carbohydrates - 15% protein - 20-30% fat 53

Injury Prevention in Baseball

Carbohydrates are essential as glucose is the basic substrate for muscle contraction. Hydration Maintain levels of liquid and mineral salts lost due to increased body temperature, sweating, breathing, urine and feces. Technical factors Warming up Get the body ready for exercise by: -

Activating the heart Increasing blood supply to body, increasing oxygen flow Raising body temperature Lung bronchi-dilation Freeing up articulations Stimulating neuro-vegetative nervous system

Stretching exercises -

Reduce muscular tension before and after exercise Increase size of movement of muscles and articulations Help prevent muscle lesions Facilitate and improve circulation in stretched muscles

Stretching must be gentle, progressive, and on relaxed muscles. (Fig. 17)

Fig.17 Stretching of the legs

Training Must be specific and correct. This allows the sportsman/woman to train their muscles, articulations and bone structure and to improve their coordination. Sports hygiene Sportsmen/women must take great care of their personal hygiene to avoid infections or other illnesses which may affect their sporting performance. 54

Injury Prevention in Baseball

- Showers - Clean clothes - Appropriate, comfortable clothing - Dental hygiene Psychological factors - Self control - Skill - Concentration - Information PASSIVE PREVENTIVE MEASURES Clothing and protectors Clothing and footwear a)

b)

* * * * * * * *

Clothing Comfortable Protects the sportsperson Reflects the climate Footwear Good adherence Comfortable Strong and adaptable Well aired (if the shoe includes additional protection, this should not hamper performance) Adapted to the anatomy of the foot, correcting any defects

Protectors Helmet *

*

Must cover a large part of the head and be easily adaptable Strong material which does not break easily Lining which absorbs sweat

*

Well ventilated and light

*

Genital protector * Strong material which can absorb or lessen an impact * Must not limit movement

Fig.18 Hear-flap helmet 55

Injury Prevention in Baseball

Other protective garments (to protect and keep joints stable): * Knee protectors * Ankle protectors * Wrist protectors * Elbow protectors * Shoulder protectors * Chest guards * Bandages * Shin pads BIO-MECHANICS Sports bio-mechanics has made great advances in recent years. By studying the movements made in different sports, scientists can analyze possible defects in these movements and suggest corrective procedures, thus avoiding injuries and improving performance. It brings together knowledge of physics, anatomy and other areas as well as the use of high technology (videos, computers etc) and has a wide and varied use. In the case of Baseball, this science has provided much useful information, particularly about pitchers. The study and correction of pitchers’ technique allows them to improve their pitching and to reduce injuries, in turn prolonging pitchers’ careers. SPORTS INJURIES These injuries often affect sportsmen and women and may be acute or chronic. Acute injuries These are normally caused by a single trauma - direct or indirect, endogenous or exogenous. * * *

A collision or blow An unusual, forced movement Self traumatism

Chronic injuries These develop slowly and have clinical symptoms, which may overlap. They are two main causes: * *

Consequences of acute injuries Over-use or overloading

To prevent injuries to athletes, the following factors should be remembered: 56

Injury Prevention in Baseball

*

Aptitude testing and frequent sports-medical monitoring (to determine the athlete’s morpho-functional and psychological condition at different points in the training program). We include special studies. The playing and training areas must be in good condition, so that players may play (both in offense and defense) without risk or worry.

*

- The field should be flat and even, with no divots. - The playing surface should not be too hard or too soft. - The boundary fences should be safe. - The height of the box should be correct. - The bases should be normal sized and consistent. *

Training

Training should be balanced and correctly programmed to improve performance while avoiding over-stretching and tiredness without negatively affecting players’ health. *

Massage

Improves circulation, prepares muscle groups, eliminates waste and helps recovery. This all goes together with the previously described nutrition, hydration, clothing, footwear and protection as well as psychological support to avoid stress and help self-control. BODY WEIGHT Baseball is not divided into weight categories, but it is still necessary for players to establish a correct body weight. This will help them avoid injuries as it reduces overloading of the bones and articulations and aids correct technique and movement. Although we have discussed nutrition above, we would like to underline the fact that a player who is following a correct diet is more able to: * * * * *

Follow a demanding training program and achieve optimum results Maximize their physical growth and development Resist illness and reduce lay-offs Avoid the risks of travel and periods in unusual environments Achieve a high level of mental concentration

It is well known that pitchers play an essential role in Baseball and we would recommend the following for them, to help avoid injury: *

* * * * *

Good pre-season physical and psychological training Correct warm-up exercises Good technique No over-use Crio-therapy on shoulder and elbow for 15-20 minutes after pitching Careful medical and technical planning of training in days following pitching 57

Injury Prevention in Baseball

Many factors are involved in the prevention of injury including, in addition to the strictly bio-medical and psychological, clinical laboratory analyses, vaccination, dentistry, the use of nutrients, ear, nose and throat check-ups etc. It is worth noting that Baseball allows managers to warm-up relief pitchers, substitutes and batters before they come on so that they are perfectly ready, both physically and psychologically. Failure to do this often results in injury and the resulting failure of the tactical task expected from the incoming player. The advantages of preventing injuries should be obvious: although most injuries are cured, some are not. Even following a rapid, accurate diagnosis, and correct treatment, some injuries are never completely cured and some take a long time, with negative effects on the player’s health and a layoff from the playing field. All ways of preventing sports injuries should therefore be given due attention.

58

INJURIES IN BASEBALL PLAYERS Hand - Elbow - Shoulder Dr. Leo Varriale

HAND INJURIES Hand injuries in Baseball are very common, usually occurring as a result of: 1. 2. 3.

Being hit by a ball or bat; running into a base or the wall Sliding or diving for a ball Contact with another player

There are also overuse problems such as blisters, calluses and strains. These hand injuries, which may seem trivial, can be very debilitating to a Baseball player. The inability to grip a ball or a bat properly can alter the athletes mechanics and cause injuries to other parts of the body. Understanding the anatomy and function of the hand requires years of training. Even the most seemingly simple injury to the hand should be evaluated by a physician with expertise in hand injuries. This is usually an orthopedic surgeon or a plastic surgeon with hand training. Injuries to the hand include: 1. 2. 3. 4.

Ligament sprains Fractures/dislocations Tendon ruptures/strains Lacerations

Ligament Injuries The finger and thumb joints are at high risk for injury in Baseball. In the fingers (index, long, ring and little), collateral ligament injuries are very common. Lots of the injuries will be partial tears, which can be tested by stressing the collateral ligaments with the joint in slight flexion. X-rays should be obtained to rule out a chip fracture. These injuries should be treated with a short period of immobilization, then dynamic taping (buddy taping) for two or three weeks. In the case of the metacarpal phalangeal finger joints, collateral ligament testing should be done at 90 degrees of flexion. At this angle, the joint should be very stable. If testing at this angle produced joint laxity, then the joint is unstable and should be immobilized. The period of immobilization will be up to the treating physician and can be anywhere from one one to three weeks. In any case of collateral ligament injury, you have to be suspicious for a dislocation that spontaneously reduced. 59

Injuries in Baseball Players

The finger proximal interphalangeal (PIP) joints can incur significant instability and permanent deformities as a result of a dislocation. These dislocations can reduce spontaneously or be reduced sometimes by the player, teammate or coach. Therefore, a careful history must be taken of the injury and of any treatment rendered. If the finger “looked funny” or if the athlete heard a “pop”, then a dislocation may have occurred. (Fig. 19)

Fig.19 Finger pathologies

Dorsal dislocations of the PIP joint (the middle phalanx moving dorsal to the proximal phalanx) can cause disruption to the volar plate. After reduction, if there is volar instability (hyperextension), the finger is splinted in flexion for two or three weeks or until stable. A swan neck deformity (hypertension PIP with the distral interphalangeal joint (DIP) in flexion) can result from this dislocation. (Fig. 20) 60

Injuries in Baseball Players

Fig.20 Ligament injuries

Volar dislocations of the PIP joint (the middle phalanx moving volar to the proximal phalanx) can disrupt the extensor mechanism to the joint. After reduction, the inability to fully extend the PIP joint can lead to a boutonniere deformity. This deformity is flexion of the PIP joint with hypertension of the DIP joint. Splinting the PIP joint in extension for two to three weeks or until stable is required. Dislocations of the DIP joints can result in disruption of the extensor mechanism or rupture of the flexor profundus tendon. Rupture of the extensor mechanism causes a mallet finger – DIP joint unable to extend. This requires splinting the DIP joint in extension and PIP joint in flexion for several weeks. Disruption of the flexor profundus tendon will require surgical repair. Disruption of the thumb MCP or carpometacarpal joint can result in significant weakness to the hand. Ligament injuries to the thumb MCP joint can range from minor sprains to the ligament and capsule to complete disruption. Minor sprains can be treated with a short period of immobilization and ice. A common and potentially disabling injury to MCP joint is a complete disruption of the ulna collateral ligament (UCL). This is frequently referred to as a Gamekeeper’s thumb or Skier’s thumb. Hyperabduction of the thumb is the mechanism of injury. Physical exam will reveal swelling and tenderness on the ulna aspect of the MCP joint. Stability should be tested with the joint in 30 degrees of flexion: testing in extension may be falsely stable if the volar plate is intact. Treatment of these cases should include splinting of the thumb, ice and referring to the appropriate hand surgeon. Surgery for this problem is likely due to the relatively high incidence of permanent laxity when treated just with immobilization. Ligamentous injuries to the thumb MCC joint can also lead to instability of the joint. A pure dislocation or subluxation of this joint can occur, but is not likely. Usually, injuries to this joint involve a fracture of the base of the thumb metacarpal and frequently require surgical fixation. In all the above cases of dislocations, the medical personnel on the field can try gentle longitudinal traction to reduce the joint. If this fails, a second manipulation is not recommended. The finger 61

Injuries in Baseball Players

should be splinted as is and ice applied. Whether the finger reduces on the field or not, I would again strongly urge referring the athlete to a surgeon familiar with hand injuries to fully assess and treat the problem. Fractures of the hand can present with, or without, gross deformity, swelling and pain. Anytime a fracture is suspected, the hand should be immobilized, iced and referred immediately for appropriate treatment. In the treatment of hand fractures, attention is paid to alignment and length of the involved bone. If the bone heals in malalignment, crossing over of the fingers when gripping a ball or bat will occur. This will cause a weak and painful grip. Treatment usually requires a period of cast immobilization and sometimes surgical pinning of the fracture. Tendon Injuries The extensor and flexor tendons can be injured by either a closed injury (hit by ball or bat) or open injury (laceration from being spiked). Diagnosing closed tendon injuries are more difficult because they are not usually suspected. Examination of the injured hand should include examining for active extension and flexion of all the MCP, PIP & DIP joints. At times, active movements is not possible due to pain and swelling. If an athlete presents with a loss of motion of a finger or thumb joint, immediate medical attention is recommended. Lacerations to the hand can result in injury to tendons, neurovascular bundles, ligaments and bones. Initial treatment should include cleansing of the wound with an antiseptic solution and covering with a sterile compression bandage: immediate medical attention is required. Overuse injuries to the hand include: 1. 2. 3. 4.

Chronic ligament sprains Tendonitis Callosities Blistering of skin

Chronic ligament sprains can present with persistent swelling of a joint without a particular injury. Motion is usually near normal with minor pain. Treatment should include anti-inflammatory medications, short period of immobilization (as needed) and buddy splinting to the adjacent finger. The differential diagnosis includes arthritis (traumatic or collagen-vascular), old chip fracture, gout and infection. These chronic sprains can cause swelling of the joint for several weeks. If the pain worsens or the joint gets reddened, then the athlete should be referred to a physician. Tendonitis of the extensor tendons present with chronic swelling and pain which is usually periarticular. These can be caused by overuse, blunt trauma or unrecognized partial tendon lacerations from a previous open injury. Flexor tendonitis and tenosynovitis can cause local or diffuse pain along a flexor tendon sheath. Secondary conditions from chronic flexor tendonitis include: 1. 2. 3.

Ganglion cyst Trigger finger Flexion contractures of a finger joint 62

Injuries in Baseball Players

Tendonitis is treated with rest, anti-inflamatories and heat. Painful callosities and blisters can develop about the hand, especially in the throwing hand. This is, of course, an overuse phenomenon that can be treated with relief pads, rest if needed and anti-inflammatory medications. Infections in the hand can be very fulminent and spread rapidly. The flexor sheaths have large interconnecting areas which can widely spread the infection. Warm soaks, immobilization and antibiotics are required. If an abscess is suspected, surgical drainage may be necessary. Immediate medical attention is advised once an infection is suspected. ELBOW INJURIES During the pitching motion, especially in the late cocking and early acceleration phase, there are tremendous forces put on the elbow. These forces are mainly compressive and valgus stresses. The problems that tend to develop in a pitcher are valgus instability, loose bodies, olecranon osteophytes and ulnar nerve neuritis. Valgus instability is the pathologic entity that usually causes the other above pathologic processes to occur (loose bodies, osteophytes, ulna neuritis). The structures that resist the valgus forces are ulnar collateral ligaments (UCL), media flexor muscle group and lateral bony structures (radio-capitellar joint). In an athlete that is fit, well conditioned and mechanically sound, the medial structures of the elbow are able to withstand the valgus stresses of pitching. Once one of the aboe conditions changes (i.e. poor mechanics, unconditioned athlete), the muscle fatigue in the flexor-pronator group can develop and this overloads the UCI, leading to micro-tears, swelling and inflammation of the ligament. Eventually, complete tears (medial laxity), calcifications and sometimes ossification can develop in the ligament. Valgus instability can be diagnosed by stressing the elbow at 30 degrees and palpating the laxity of the medial ulno-humeal joint. MRI and/or CAT scans with contrast can also help reveal tears of the UCL. Once valgus instability develops, the medial olecranon is wedged against the trochlear notch of the humerus causing osteophytes of the medial olecranon. This phenomenon is called valgus extensor overload. To diagnose this, a valgus stress is applied to the elbow while bringing the elbow from flexion into extension. An elbow with valgus extension overload will have posteromedial elbow pain. X-rays can sometimes reveal these osteophytes. Initial treatment of elbow injuries are rest (no throwing), anti-inflammatory medications and supervised muscle stretching and strengthening. Once there is no pain, then a gradual process of throwing is commenced; if pain persists after six months of therapy, then surgery is usually necessary. Surgery can include arthroscopy, removal of loose bodies, removal of posterior medial osteophytes of the olecranon, reconstruction of the UCL and ulna nerve transposition. (Fig. 21) If valgus instability is present, restoring stability to the medial elbow by an UCL reconstruction is critically important in returning the pitcher to a high level of throwing. After surgery, there is usually a high success rate in returning the pitcher to throwing.

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Fig.21 Loose body in the elbow

SHOULDER INJURIES Phases of Throwing Motion The throwing motion puts tremendous demands on the shoulder. This task requires the shoulder to go through an excessive range of motion and is controlled by the precise firing of many muscle groups. A throw, of course, is one continuous motion, but can be divided into five different phases: 1. 2. 3. 4. 5.

Windup (or balance) Arm Cocking Arm Acceleration Arm Deceleration Follow Through (Fig. 22)

I will be reviewing the mechanics of the pitcher’s throw, but many of the points are also referable to all types of throwers. The purpose of the windup is to put the pitcher in a good starting position to throw. The back foot is planted and the body is positioned perpendicular to the target. The arms are together in front of the chest and then the pitcher steps toward the target with the front foot. During the arm cocking phase, potential energy in the arm is created by a precise and coordinated sequence of body movements. The throwing arm externally rotates backward as the front foot strides forward. 64

Injuries in Baseball Players

Fig.22 Phases of pitching

This stretching between the upper and lower parts of the body starts to create the potential energy to release the ball. After the front foot comes down, the hip then the shoulder rotates forward to face the target. However, the arm continues to externally rotate back. This external rotation creates a tremendous amount of potential energy. Arm acceleration starts when the shoulder is maximally externally rotated. At this point, the elbow starts to extend and internal rotation of the shoulder is initiated. This acceleration continues until ball release. No matter what type of thrower you are (i.e. overhead, 3⁄4, sidearm), during acceleration shoulder abduction of 90 degrees to 100 degrees is felt to be ideal to prevent shoulder impingement. To decelerate the arm, shoulder external rotators are activated to slow down shoulder internal rotation and distraction. Elbow extension has to be slowed by the elbow flexors to prevent hyperextension. The follow through phase is very important in the prevention of arm injuries. A long balanced follow through helps to slowly dissipate the energy generated by the throw. The hand should con65

Injuries in Baseball Players

tinue to follow through ending up near the front foot, knee or hip depending if you throw overhead, 3⁄4, or sidearm respectively. Finishing the throw with the arm pointing to the target will eventually lead to shoulder problems. Shoulder Injuries – Rotator Cuff The rotator cuff, along with the biceps tendon, are important stabilizing structures of the glenohumeral joint. These structures help compress the gleno-humeral joint, controlling the distracting forces of the throw. The rotator cuff contracts eccentrically during deceleration to stop the tremendous internal rotation speed (7,000°/sec) of the shoulder. Because of this high demand placed on the rotator cuff, inflammation tendonitis and tearing can occur. This failure mechanism of the rotator cuff is called eccentric tensile overload. This failure initially causes a posterior capsulitis of the shoulder and under surface tears in the supraspinatous and infraspinatous tendons. On physical exam, there will be tenderness over the supraspinatous and/or infraspinatous. There may be no gross weakness; however, isokinetic testing at 90 degrees of abduction may reveal rotator cuff weakness. Impingement signs can be present. Initial treatment includes anti-inflammatory medication, no throwing and physical therapy. Once the pain subsides, progressive strengthening is started, emphasizing eccentric strengthening of the external rotators. If the tendonitis does not resolve after three to six months of physical therapy, then surgery may be necessary. This would include arthroscopy with rotator cuff debridement or repair of rotator cuff if a full thickness tear is present. Shoulder Injuries – Instability: The extreme external rotation of the shoulder required during throwing stretches the anterior capsular structures. What prevents this anterior laxity from becoming a painful instability is the stabilizing ability of the rotator cuff and biceps bracchi. If these two structures become inflamed, then they no longer have the ability to prevent anterior instability. These excessive stresses will cause tearing of the glenoid labrum and capsule. Posterior labral and capsule tears can also occur as a result of posterior humeral translation during the deceleration phase of throwing. SLAP lesions (labral tears about the biceps glenoid insertion) occur due to excessive forces required by the biceps to decelerate elbow extension and prevent shoulder distraction. Anterior shoulder instability causes anterior and posterior shoulder pain, especially during late cocking and acceleration. Clicking, popping and early arm fatigue will also be experienced. The anterior drawer and apprehension test will be helpful in making this diagnosis. MRI, especially with contrast, can help diagnose labral tears. (Fig. 25) The rehabilitation process includes anti-inflammatory medication and rest from throwing. Since the posterior capsule is usually contracted in throwers, stretching of this structure is very important. Once all inflammation has resolved, then gradual aggressive strengthening of the rotator cuff is performed. If 2-3 months of conservative treatment fails, then surgical treatment including labral debridement or repair of frank labral tears will be required. 66

INJURIES IN BASEBALL PLAYERS Back - Thigh - Knee - Lower Leg - Ankle Dr. Atsushi Masujima

BACK INJURIES Back pain is one of the most common complaints of Baseball players. It is usually caused by repeated rotation of the body during pitching and batting. To prevent back injuries it is important to acquire proper pitching and batting form to maintain the flexibility of the muscle groups of the back and to build up the strength of the abdominal and back muscles. Low Back Pain Acute low back pain is caused by muscle strain in the back and accumulated muscle fatigue. It is often relieved by resting for a few days. However, recurrence is common. Players should therefore make efforts to maintain the flexibility of the muscle groups of the back and to build up the strength of the abdominal and back muscles. Disc Herniation of the Lumbar Spine Herniation of an intervertebral disc is a condition in which an intervertebral disc, which serves as a cushion between vertebral bodies, protrudes posteriorly and compresses the nerve root. It causes pain in the lumbar region and restriction of lumbar motion, as well as pain and numbness and reduced muscle strength in the lower extremities (sciatica). Combined with X-ray examination, magnetic resonance imaging (MRI) is effective for assessing the degree of herniation. Most patients will recover following one or two months of rest and rehabilitation. If symptoms worsen or are persistent, surgery may be required to remove the intervetebral disc that is compressing the nerve root. (Fig. 23) Spondylolysis Spondylolysis is thought to be a condition in which stress fracture occurs in the lumbar spine as a result of the repeated rotation of the body during pitching and batting. Players in their teens, who are still in the growth phase, are most likely to develop this condition. The patient complains of lumbar pain and restricted lumbar motion (limited extension). 67

Injuries in Baseball Players

Fig.23 Disk hernanion

The diagnosis is confirmed by X-ray examination, but early cases may be difficult to assess radiographically. In such cases, computed tomography (CT) has been found to be effective. When the diagnosis is made in the early stage, union of fractured parts can sometimes be achieved by rest for two months and wearing a brace. Even when the condition has progressed beyond the acute stage and complete fracture is found, the player is still able to return to the field if appropriate rehabilitation is provided. THIGH INJURIES Thigh contusion (“charley horse”) Thigh contusions often occur when the head or knee of another player strikes the anterior thigh. In Baseball, this is most likely to happen during a “rundown” between a runner and an infielder or the catcher. The muscle groups adjacent to the femur are likely to be injured. In some cases, there may be partial or complete rupture of these muscles. It is therefore necessary to accurately assess the extent of injury. Ultrasonography and magnetic resonance imaging (MRI) have been found to be useful. A hematoma is likely to form, which may necessitate aspiration with a syringe in the acute stage. If the player returns to the field without receiving proper treatment or if the injury is repeated, the injured region may undergo ossification (myositis ossificans), requiring prolonged treatment. Accurate diagnosis and careful rehabilitation are extremely important.

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Thigh muscle strain Thigh muscle strains are likely to occur in the rectus femoris of the anterior thigh or in the biceps femoris, the semimembranosous, or the semitendinosus of the posterior thigh. Because these muscles extend over the hip joint and the knee joint, the sudden starts and stops that occur during running cause imbalances in these muscle groups, which may lead to muscle strains. In some cases, complete rupture of the rectus femoris or the biceps femoris may occur. As in thigh contusion, ultrasonography and MRI have been found to be useful in assessing the extent of injury. In particular, strains of the flexors of the thigh tend to occur repeatedly because players are often in a hurry to return to the field. Attention should be paid not only to the flexibility and strength of the muscles, but also to the balance between the extensors and flexors of the thigh. KNEE INJURIES Medial collateral ligament sprain Medial collateral ligament sprains often occur in crossed plays between a runner and an infielder or the catcher. This injury results from excessive stress applied from the lateral aspect of the knee. It is classified into three grades of severity, from first degree (minor) to third degree (complete rupture). Even when a medial collateral ligament sprain is associated with complete rupture, surgery is rarely performed because in many cases appropriate rehabilitation permits the player to return to the field more quickly than is possible following surgical treatment. In assessing medial collateral ligament sprains, special attention should be paid to the presence or absence of associated injuries, in particular, medial meniscus injury and anterior cruciate ligament sprain.

Anterior cruciate ligament sprain Of the many sports-related injuries, anterior cruciate ligament sprains are seen quite frequently, and constant improvements are being made in diagnosis, treatment and rehabilitation. In Baseball, this injury may occur during a rundown between a runner and an infielder or the catcher (contact injury) or when a player abruptly twists the knee while fielding (non-contact injury). MRI and arthroscopy are performed to confirm the diagnosis. Primary healing may be expected in some acute cases, but reconstructive surgery is required in chronic cases. In current surgical practice, it is common to employ the patellar tendon or the tendon of the semimembranosus or the gracilis. Rehabilitation following anterior cruciate ligament sprain may be prolonged, and it may be 6 to 8 months or more before the player can return to the field. Treatment should focus not only on ensuring the stability of the knee joint by surgery, but also on maintaining a full range of motion and muscular strength.

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Posterior cruciate ligament sprain Posterior cruciate ligament sprains are likely to occur when an outfielder strikes his or her knee against the fence while attempting to catch a long fly ball. Surgery is rarely performed, as is the case for medial collateral ligament sprains. Appropriate rehabilitation can permit the player to resume playing in approximately 2 months.

Meniscus Injuries Meniscus injuries may occur in isolation or in combination with ligament sprains. When a ligament sprain is present, therapy must simultaneously address both the meniscus injury and the ligament sprain. Isolated meniscus injuries are often caused by excessive twisting of the knee during fielding or batting. MRI is performed to confirm the diagnosis and appropriate treatment is selected based on the severity of the injury. Arthroscopic surgery involves either excision or suturing of the ruptured meniscus. In either case, 2 to 3 months of rehabilitation are required before the player can return to the field. (Fig. 24)

Fig.24 Rupture of the meniscus

Overuse Injuries of the Knee Overuse injuries of the knee, such as patellar tendinitis, iliotibial band friction syndrome and patellofemoral pain are often due to inappropriate training. It is also important to evaluate leg alignment. In this case, not only static alignment but also dynamic alignment during walking and running should be assessed to fabricate a brace or orthotic appliance which is best suited to the requirements of the individual player.

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Osgood-Schlatter Disease Osgood-Schlatter disease is often seen in boys of about 9 to 14 years of age. The chief complaint is pain in the knee. It is a disorder of the insertion of the patellar tendon caused by an imbalance between bone growth and growth of the muscle-tendon unit. X-ray imaging is employed to confirm the extent of the disease. If the pain is severe, the patient must be advised to refrain from playing Baseball. When the pain and the stress on the muscle-tendon unit has resolved, the patient can be permitted to resume playing Baseball.

LOWER LEG INJURIES Lower Leg Contusion This often occurs when a batter is hit by a foul tip. If the pain is severe or prolonged, fracture or muscle rupture should be suspected and X-ray or MRI examination may be required. Periostisis of the Tibia (“shin splints”) This injury is often caused by excessive running early in the season. As in overuse injuries of the knee, the training regimen should be reviewed and alignment of the lower legs should also be evaluated to fabricate an orthotic appliance suited to the needs of the individual player.

Achilles Tendinitis and Achilles Tendon Rupture Achilles tendinitis, as a running injury, requires appropriate treatment in the acute stage. If it becomes chronic, it is very difficult to treat and may sometimes progress to Achilles tendon rupture. Regular stretching of the Achilles tendon is the most effective preventive measure.

ANKLE JOINT INJURIES Ankle Sprains Ankle sprains often occur during fielding or in a crossed play. If the sprain is not serious, it can be treated by basic first-aid measures (RICE technique), but if there is a severe swelling or prolonged pain, X-ray examination should be performed to confirm whether there is a fracture.

Ankle Fractures When a player slides into base with spiked shoes, the spikes may catch, resulting in an ankle fracture. The best preventive measure is to improve the player’s sliding technique. If the player’s sliding technique is poor, there is always a risk of this fracture. (Fig.25)

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Fig.25 Ankle fracture

Stress Fractures In Baseball, as in other sports, repeated hard training may lead to the development of stress fractures in various parts of the body such as in the femur, the tibia, the tarsal bones and the metatarsal bones. Diagnosis should be confirmed at an early stage. The training regimen should also be evaluated and the alignment of the lower legs should also be assured to fabricate an orthopic appliance suited to the player’s individual requirements.

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Authors’ Biographies

Gilberto Ante Vidal Qualified 2nd Degree in Medicine as a Sport Medicine Specialist. Assistant Researcher. Instructor Lecturer. Director of the Cuban Sport Medicine Institute, IMD, 1993-1996. Chairman of the Pan American Baseball Confederation Medical Commission, COPABE. Member of the International BAseball Federation Medical Commission since 1994. Cuban Baseball National Team Physician.

Gianfranco Beltrami Graduated in Medicine from Parma University in 1978. Specialized in Sports Medicine, Cardiology and Physiokinesitherapy. Contracted Professor in Sports Physiology at the University of Parma. Physician of the Italian National Baseball Team since 1992. Chairman for the IBAF Medical Commission since 1995. President of the Sports University Center of Parma, 1988-1996. President of the Panathlon Club of Parma, 1996-2000. Member of the Rotary Club of Parma in the Sports Medicine category since 1988.

Desmond John Bokor Graduated in Medicine with honors from Monash University, Melbourne, Australia, in 1977. Qualified as a Specialist Orthopedic Surgeon in 1987. Completed Fellowships in sports medicine in Sydney, Australia and Ontario, Canada. Past president of the Shoulder and Elbow Society of Australia. Currently practicing in Sydney, Australia as a consultant orthopedic surgeon with Western Sydney Orthopedic Associates. Current Chairman of the Department of Orthopedic Surgery at the Hills Private Hospital. Member of the International BAseball Federation Medical Commission since 1991.

William Boyd Graduated from Lagos University Medical School in Nigeria in 1986 and received Post Graduate Diploma in Sports Medicine from the London Hospital Medical College in 1986. Member of Medical Commission of African Handball Confederation from 1982 – 1986. Head of Nigeria’s Medical Team to Regional, Continental and Olympic Games since 1992. Secretary General of the Nigerian Olympic Committee and Member of the International Federation of Sports Medicine. Member of the International BAseball Federation Medical Commission since 1996.

Atsushi Masujima Graduated in Medicine from Hokkaido University, Japan, in 1978. Worked in Department of Orthopedic surgery, Faculty of Medicine, University of Tokyo from 1976-1986. Instructor of Department of Sports Sciences, College of Arts and Sciences, University of Tokyo, 1986-1989. Head of Department of Sports medicine and Orthopedic surgery, Toshiba General Hospital since 1989. Instructor of Department of Sports medicine, Nippon College of Sports Sciences since 1994. Medical Commission Member of the Japanese Olympic Committee and the International BAseball Federation since 1994. Japanese Baseball National Team Physician at Barcelona’92, Atlanta’96 and Sydney 2000 Olympic Games.

Leo Varriale Graduated from the State University of New York Downstate in 1979. American Board of Orthopedic Surgeons Fellow, American Academy of Orthopedic Surgeons Fellow, American College of Surgeons Fellow. Director of the Orthopedic section at the Mercy Hospital, New York since 1991. Member of the International BAseball Federation Medical Commission since 1996. 73

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