Shoes: Evidence and Anecdotes

 Shoes: Evidence and Anecdotes

With the cost of shoes being what it is and the huge variety available in today’s market, it is absolutely imperative that you get yourself into something that suits 1st time round. There is little guidance in this regard from an evidence perspective. 40 odd years of shoe research, including the recent large number of studies into the barefoot phenomenon, have not shown any shoes to be causative or preventative in terms of injury. This makes perfect sense due to the host of confounding variables present including: training history and training errors (good evidence in terms of injury), age, biomechanics, previous injuries etc. This was highlighted recently with Vibram FiveFingers being slapped with a class action in the USA for claiming amongst others that their shoes helped prevent injuries (over 150000 claimants). Shoe fitting (and scarily enough – design) is thus far from a scientific process. Nevertheless with the advent of readily available and inexpensive hardware and software, filming and biomechanical analysis of the running gait is in the hands of most practitioners and shoe shop employees. This combined with knowledge of the running gait and a solid dash of common sense, although not infallible, removes a lot of the guess work. If new to running or contemplating a shoe change it is often a good idea to either visit a specialist running shop or health practitioner who deals with runners and knows shoes. The following aims to give you an insight into what’s out there and the basic thought process you can follow when selecting a shoe.

Basic shoe types

Terrain

 

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The first subdivision comes with terrain. Road and Trail shoes. This is fairly self explanatory and with the popularity of trail running exploding over the past few years there has been an increased divergence of the shoe types. Trail shoes have more rugged and grippy outsoles, are often stiffer in the midsole (unless very minimalist) and have hard wearing uppers in comparison to their road counterparts.

Stability

The next is the stability of the shoe. Road shoes are divided roughly into neutral and motion control or stability shoes (anti probation). Stability shoes will typically have a different colored, high density material inbuilt on the inside (arch) of the shoe. The thought process behind this is to prevent excessive inward motion or pronation of the mid foot. There are different levels of stability from mild motion control to more intense stability.

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As the name suggests a ‘neutral’ shoe will allow for a more natural motion of the foot. However, not all neutral shoes are created equal with numerous of the high end ‘cushioned’ neutral shoes being very stiff through the midsole.

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Often, due to the material utilized in construction, a stock standard trail shoe will be stiffer in the midsole than most neutral road shoes. By road standards they could be considered mild motion control shoes. This imparts more durability and a degree of stability on the varied terrain of the trail.

Heel to toe drop

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The relatively recent explosion of the barefoot movement, assisted greatly by the barefoot bible ‘Born To Run’ has confused matters further! To avoid being left behind all shoe manufacturers have changed up their offers. The reasoning behind will be discussed in greater detail later.
Barefoot shoes: Vibram FiveFingers, Vivo barefoot etc all offer ultra minimalist shoes that supposedly replicate the action of running barefoot

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Zero drop: brands such as Altra have created shoes that like the ‘barefoot’ shoe have a zero mm drop but have various levels of cushioning or padding underneath from a thin strip to a large chunk.

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The in betweens: most popular brands in both trail and road derivatives offer a variety of drops from 2mm, 4mm (popular) up to the 8mm mark.

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The High End: typically the flagship ‘cushioned’ models especially in the road market have a 10 – 12mm drop.

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Guiding your selection

Terrain

As mentioned earlier, trail and road shoes differ markedly in terms of construction. With their stiffer mid soles and grippy outsoles trail shoes are typically ill suited to road running despite the claims of numerous manufacturers that certain models are road and trail shoes.

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A regular trail shoe could generally be consider to be mild motion control road shoe. As a neutral runner being over corrected could potentially cause a host of problems including ITB and anterior knee issues. This relative increase in stability is largely nullified by the variety of trail terrain and decreased repetitive action as a result. Typically a safer bet if you want a single shoe for both pursuits go the road option, particularly if you are not running very technical trails. You obviously loose the grip and durability (trail destroys road shoes!) but you will at least not have the issues that come with being ‘over corrected’ on the road. However, if finances allow and if you are doing sufficient mileage on both buy a road and a trail shoe.

Stability

A 2015 article traced the history of the running shoe and examined whether selecting running shoes based on foot arch height influenced injuries. It also examined historical data on injury rates when physical training amongst military personal was performed in boots versus running shoes. ‘In the 1980s and into the 2000s, running shoe companies were advertising specialized shoes with “motion control,” “stability,” and “cushioning,” designed for individuals with low, normal, and high arches, respectively. Despite marketing claims that these shoes would reduce injury rates, coordinated studies in Army, Air Force, and Marine Corps basic training showed that assigning or selecting shoes on this basis had no effect on injury rates. Consistent with this finding, biomechanical studies have shown that the relationships between arch height, foot joint mobility, and rear-foot motion are complex, variable, and frequently not as strong as often assumed. In 1982, the US Army switched from PT in boots to PT in running shoes because of the belief that boots were causing injuries and that running shoes would reduce injury rates. However, a historical comparison of injury rates before and after the switch to running shoes showed virtually no difference in injury risk between the two periods. It is not clear at this point if the type of footwear effects injury incidence’
Due to numerous factors including, I believe, the minimalist movement, there has been an active shift away from the motion control shoe. I think this also has to do with more knowledge of running biomechanics and the ability to film. Previously (and still in certain settings), shop employees would look at customers standing and make a call on what shoe to fit or at best eyeball them running. As mentioned in the study, the biomechanics of the foot are ‘complex, variable’ and of course massively different when in motion. Activation of the dynamic stability mechanism (muscles) during running can transform a dropped looking arch in standing into a beautifully neutral foot. Likewise if somebody is a mid to forefoot striker not only will they typically do well in a neutral shoe, they would naturally nullify any inbuilt stability mechanism in the shoe! Interestingly relative stability shoes used to make up the lions share of the running market. The current statistics in specialist running stores show a roughly 70% neutral to 30% motion control split. This could potentially still be a bit high on the motion control front. Anecdotally, I have had to put very few people in motion control shoes over the years. Very few, but some. I have absolutely no doubt that some people can only successfully run as a result of stability shoes. We can argue nature or nurture being the causative factor in terms of why they need stability but at the end of the day they do as witnessed by a decrease in injuries and the ability to run relatively pain free in these individuals.

Heel to Toe Drop

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This is the real can of worms in terms of shoe dynamics. The barefoot movement attained cult like status a few years ago and although it has decreased in popularity in more recent times it still has an ardent following, largely amongst people to whom it has been quite revolutionary in terms of injury resolution. Despite the claims of fanatics it is not for everybody.

The Reasoning

imageDaniel Lieberman, an anthropologist from Harvard and quoted in Born to Run sums it up very succinctly in his article published in Nature, ‘Humans have engaged in endurance running for millions of years1, but the modern running shoe was not invented until the 1970s. For most of human evolutionary history, runners were either barefoot or wore minimal footwear such as sandals or moccasins with smaller heels and little cushioning relative to modern running shoes. We wondered how runners coped with the impact caused by the foot colliding with the ground before the invention of the modern shoe. Here we show that habitually barefoot endurance runners often land on the fore-foot (fore-foot strike) before bringing down the heel, but they sometimes land with a flat foot (mid-foot strike) or, less often, on the heel (rear-foot strike). In contrast, habitually shod runners mostly rear-foot strike, facilitated by the elevated and cushioned heel of the modern running shoe. Kinematic and kinetic analyses show that even on hard surfaces, barefoot runners who fore-foot strike generate smaller collision forces than shod rear-foot strikers. This difference results primarily from a more plantarflexed foot at landing and more ankle compliance during impact, decreasing the effective mass of the body that collides with the ground. Fore-foot- and mid-foot-strike gaits were probably more common when humans ran barefoot or in minimal shoes, and may protect the feet and lower limbs from some of the impact-related injuries now experienced by a high percentage of runners.’

The Biomechanics
As mentioned above, common biomechanical findings when performed on a force plate show that when running barefoot one is commonly more likely to strike with the front of the foot in comparison to a heel strike in a more traditional shoe. This allows the foot to more naturally shock absorb through unlocking the mid foot and eccentrically decelerating towards the ground. This in tern decreases the ground reaction force and hence the forces higher up the chain through hip and knee. In one study, barefoot running demonstrated less knee flexion during midstance, an 11% decrease in the peak internal knee extension and abduction moments and a 24% decrease in negative work done at the knee compared with shod conditions. The ankle demonstrated less dorsiflexion at initial contact, a 14% increase in peak power generation and a 19% increase in the positive work done during barefoot running compared with shod conditions.

The Evidence
Type barefoot running into google scholar and a plethora of articles spring forth. As with all shoe research due to the previously mentioned confounding variables all theories regarding injury causations and prevention are exactly that: theoretical.
The majority of research (very little of it good quality as highlighted by a 2013 systematic review) supports the biomechanical findings highlighted above. Sounds great right. Unfortunately what happens on the force plate and in real life are totally different things.
An interesting study evaluated a large sample of 236 non elite marathon runner’s foot strike at the 10 and 32 km mark. ‘A large percentage of runners switched from mid and forefoot strikes at 10km to rear foot strike at 32km…We found no significant relationship between foot strike and race times.’ 1
Another factor to consider is that even in the most minimalist of shoes, you are not running barefoot. ‘Running in a minimalist and lightweight shoe is not the same as running barefoot: a biomechanical study.’ This solid study published in the British Journal of sports medicine found similar biomechanical findings to the earlier mentioned in terms of the barefoot dynamic. It then compared the biomechanics of 3 shoe types (minimalist, racing flat and traditional neutral shoe) and found they all differed significantly from barefoot running but not from each other in terms of the running gait. 2

To sum it all up. One way or another the dynamics of barefoot running do show some promise in terms of biomechanical findings but wearing a pair of minimalist shoe does not necessarily mean you are running barefoot! As with all shoes, at this stage there is absolutely no evidence it is curative or causative of injuries. In numerous cases, both documented and personally witnessed, minimalist shoes have been revolutionary in changing long standing and often very debilitating running injuries. The cynic in me always wonders whether the enforced change (reduction) in the training load that comes about with the acclimatization into minimalist footwear doesn’t have a significant amount to do with it. One thing to be very cognisent of is the fact that running in minimalist footwear is extremely taxing. The workload of the intrinsic foot and calf musculature is way higher than in a traditional shoe. This may be great as a training modality or when running shorter distances but in extreme distances or on repetitive surfaces such as road a degree of stability and support may be very useful in preventing fatigue and repetitive injuries of other descriptions. The majority of people running 100 milers are doing so in the antithesis of a barefoot shoe with reason. While the majority of neutral, biomechanical sound runners will be able to train themselves with varying speed into more minimalist footwear, I stand by my earlier statement that some runners, likely due to a combination of nature and nurture will not be able to adopt a minimalist approach. Maybe with a laborious, years long approach and numerous setbacks they would but the likelihood of anybody staying the course is slim to none. The fact that more than 150 000 people took the time and effort to claim the 8 USD for their class action against FiveFingers is an obvious indicator they were transformed by the shoes!

What to choose: useful anecdotes.

  • Rule # 1: if it ain’t broke don’t fix it. If you have run 10 comrades in a motion control shoe without a single injury, please don’t listen to the young whippersnapper at your running club that says a racing flat will be revolutionary to your running. Stay with what works.
  • If you have been battling with multiple injuries consult a health professional who knows running. Evidence points towards the fact it will likely be training error based but they will be able to evaluate your biomechanics in conjunction with your current shoes and rule out obvious foot wear issues
  • New to running? Go to a specialist running shop or to the above mentioned. It will save you a host of time, money and future hassles. The benefit of paying the bit extra and seeing a professional is the fact you will likely get training, recovery and strengthening advice thrown into the mix.
  • The vast majority of people fall into the neutral bracket. As with most things in life, everything in moderation generally works best. A neutral shoe, with a degree of inbuilt stability and a moderate heel to toe drop generally works best for most runners, over most distances and in most conditions.
  • People moving into minimalist footwear will generally be more experienced runners or runners who have had a torrid time in more traditional footwear. I probably would not recommend it to new runners.
  • Barring people who have been utilizing them for a sustained time period, Stability shoes should also not be bought without proper guidance at a specialist running store or from a knowledgable health professional.
  • We all believe more expensive is better. Professionally, I’ve kept up to date with all the popular brands and models for years. With one brand, their entry level shoe which they advocate for shorter distance and novice runners is an exact replica of their top of the range shoe (recommended for ultra distance) from 10 years ago!
  • When trying on shoes, they must feel amazing on your feet. Wear socks, lace them up properly and run, jump and lunge in them. If they feel sketchy, try something else.
  • Don’t be guided by trends. At this stage most of the ‘science’ is marketing and smoke and mirrors. From an injury prevention perspective, focus on your training.

by Iain Sykes (physiotherapist)

Iain Sykes Physiotherapy

Cape Town South Africa

The South African Medical Quandary


Events over the last few years have made me increasingly disenchanted with the South African health profession in general. From blatant over management to a complete lack of consistency between professionals, the world of medicine is a torrid one to navigate. The following serves as an guide to members of the public in the hope it will assist them in making informed decisions regarding their medical management.

As a physiotherapist we are interestingly poised as health professionals in South Africa. We are first line practitioners and will often come into contact with patients who have been managed by other health professionals (including physio) for either the problem they are presenting with or others and also have the added benefit of typically spending more time with patients than the majority of medical practitioners. This, alas, frequently brings us into contact with patients that have been very poorly managed.

South Africa’s private medical framework is based on a system of financial rewards for intervention. Simply put we receive direct financial compensation for services rendered. The more patients I see daily, the more I earn. The more total hip replacements and orthopaedic surgeon performs per week, the more he / she earns. In no way do I suggest health professionals should not be excellently remunerated but this policy of pay as you treat (more intervention more income) coupled with the fact specialists can effectively pick a figure of x times medical aid rates has to create major conflicts of interest in terms of ethical management of patients. Testament to this is the rather ridiculous notion of Gap Cover (which I incidentally have) whereby we are covered by another policy for medical insurance shortfalls due to specialists charging 5 times medical aid rates!

South Africans are also extremely biased towards the notion of ‘the doctor knowing best’. While intensive entrance criteria, years of study and rigorous specialisation examinations certainly ensure a certain calibre of person, this does not mean that they are always correct or always have 100% your best interest at heart. While the majority of educated people will dogmatically investigate potential investment strategies they will commonly allow invasive surgery with no investigation or query whatsoever.

In the following I will discuss three hypothetical cases loosely based on reality in order to highlight and further discus pitfalls. In my professional capacity I deal largely with musculoskeletal injuries and ailments and hence in this article, the examples will all be related to such. The ideas and concepts are however readily transferable to other medical issues

Patient One: 23 year old female who rolled her ankle trail running. The ankle swelled rapidly but she could weight bear immediately. She did not seek any medical assistance initially and over a period of weeks the swelling subsided and the pain reduced but at around 6 weeks she was left with ongoing stiffness, mild occasional discomfort and a frequent non-painful click. On the recommendation of a friend she consulted an orthopaedic surgeon.

Medical management: X-rays (no fracture), MRI (grade 1 lateral ankle sprain), surgical intervention to stabilise lateral ligaments. Boot and crutches for 6 weeks. Numerous physiotherapy sessions. Period to functional recovery 3 months. Return to sport 6 months. Medical costs > R50000

Evidence based management of Gr1 Ankle Sprain: No x-ray required, crutches if necessary for 2-3 days, speed brace derivative worn constantly initially (around 1 week) and then only during sport for up to 9 months, 2 – 3 physio sessions incorporating progressive weight bearing rehab. Period to return to sport 3 – 4 weeks. Medical costs < R3000.

This is a worst case scenario but one that has been personally witnessed in various guises and pertaining to various areas of the body. The above situation can however readily be avoided. While it is unfortunate that the patient was extremely poorly managed by a specialist at the end of the day the responsibility is with the patient to make an informed decision with the information they are presented with.

Investigate: if your injury / ailment is not of sufficient severity to land you immediately in hospital, you have the time and ability to read and investigate. Look for solid, evidence based publications.
Choose the correct professional: Baring once again severe trauma, a specialist is often not the best place to start your medical journey. (You don’t start with an ENT for a sore throat). A skilled physio is typically a good clinical diagnostician and will thereafter be able to assess and guide if further investigation is required. It will be cheaper, they will spend more time with you and if further intervention is required they will be able to refer you to the right person for the job. if referral is required, don’t take their word for it. Always investigate the specialist and choose the right person for the job. An ankle and foot specialist for an ankle injury rather than a general surgeon!
Question: Always voice your concerns and questions. If somebody dismisses questions and fails to take a few minutes to adequately explain the necessity for an invasive procedure and associated risks and outcome are they the right person for the job?
Don’t settle: particularly with surgical interventions, if all does not completely add up get another or multiple opinions. The additional initial expense will offset the substantial expense and risk of uneccesary surgery.

Over management definitely does not only occur in the realm of surgeons.

Patient 2: a 35 year old male was playing 6 down touch with his friends. He accelerated rapidly for the ball and felt a solid snap at the back of his thigh. It was extremely painful initially and he had difficulty walking the next day. He went to physiotherapy 1 day post injury.

Medical Management: Diagnosed with a grade 2 Biceps Femoris (Hamstring strain). Treated 4 times in the first 2 weeks largely with a combination of electrotherapy (interferential and ultrasound) ice and then heat and a further 5 times over a 6 week period incorporating soft tissue mobilisation, needling and a home stretching program. Return to sport at 8 weeks followed by re-injury 20 mins into first match back. Medical costs: R4500

Evidence Based Management of Grade 2 Hamstring strain: offload and protect initially – crutches until walking pain free (2-3 days), ice, compress and take it easy. Beyond the initially assessment and guidance of what to do and not to do there is very little to be achieved by early ‘treatment’ including electrotherapy (poor evidence). A further 3 sessions spread over a 4 week period included most importantly graded rehab consisting of progressive loading (including eccentric). Graded return to straight-line running culminating in explosive acceleration / deceleration. Successful return to sport at 6 weeks. Medical costs: R2000

Although not as significant, particularly cost wise, as the first example, it is still equally frustrating particularly with a poor end outcome. This example is a tough one as with any soft tissue injury there will be a fairly linear healing process and it will get better if simply left alone. To the uninformed it will therefore appear that the treatment is working. The value in correct treatment lies largely in the management: What to do when and how to condition to 100% and prevent re-injury on return to play. Something I have seen relatively frequently is people having 12 – 14 physio of chiro sessions for treatment of lower back pain with no change whatsoever. This makes absolutely no sense to me from a clinician and patient perspective. For most scenarios I want to have made a difference after 1 session. If i have not changed things (even fractionally) by the 3rd session, I’m missing something or we need to investigate further. There are situations which take longer but the patient will have been informed at session #1. Education is key.

Once again in the scenario:

Investigate: you have a wealth of information at your fingertips. Google and particularly Google Scholar are fantastic resources. Take a bit of time and peruse a number of sites and publications and you will likely see trends emerging with regards to correct management strategies.
Question: Don’t be a passive bystander. If you impart information regarding your injury it forces the professional firstly to think and secondly to qualify what they are doing / achieving from a treatment and management perspective. It also allows you to sneakily evaluate their knowledge base. If not forthcoming, ask early what the person envisages from a management perspective: how many sessions, what needs to be done and likely return to sport.
Don’t settle: If the above does not make sense from what you have read and generally from a common sense perspective get a second opinion early in the game.

Under management (not necessarily from a cost perspective) is also something to beware of

Patient 3: 40 year old male who works in a sedentary environment. He is generally fairly active and goes to gym 2 – 3 x weekly and runs 5km twice a week. 8 weeks previously he started training at a functional training gym. He went 4 x in week 1. Into the second week his right achilles tendon was swollen and intensely painful when walking. He consulted his GP.

Medical Management: Diagnosed with ‘achilles tendinitis’. Given a course of non-steroidal anti-inflammatories and was put in a boot (had one from a previous ankle fracture) for a 6 week period. Was informed to not do any exercise while in the boot. Due to tendon feeling much better after 6 weeks, he went straight back into the high intensity training and after 2 sessions was back to square one.

Investigate: for various reasons, research into tendon pathology is fairly categoric with regards to successful management. Despite this, they remain extremely poorly managed! Nevertheless, with some basic reading, the patient would have realised that tendon pathology is not governed by active inflammation and hence ‘tendinitis’ is not a good term. He would also have realised that long term immobilisation of tendons is catabolic to the tendon structure.
Choose the correct professional: You do not consult your physiotherapist for a bladder infection or sore throat. Find a medical professional who deals with musculoskeletal, sport based injuries on a daily basis.
Question: ‘Is there a way I should ease myself back into activity after 6 weeks of doing nothing?’ or ‘Is there anything else I should potentially do during this time period?’ would have been good questions to ask in this scenario.
Don’t settle: Extreme time periods of immobilisation or time off sport / activity without sufficient logical explanation? Always get another opinion.

The goal of this article rather than to strike fear into your heart or make you shake you head in disgust as to the greed of the medical profession is to alert you to the fact that you are not a passive bystander in the sphere of the health and wellbeing. You can wail and gnash your teeth over how poorly managed you were and often, in all fairness, this is completely out of your control. Nevertheless it is your personal responsibility and obligation to take responsibility and make INFORMED decisions regarding your health. Not every medical opinion requires dogmatic investigation but the more potentially invasive, expensive and life altering the situation the greater the required research.

by Iain Sykes (physiotherapist)

Iain Sykes Physiotherapy

Cape Town South Africa

 

Doping in Sport

Recent years have been marked by a number of high profile international doping scandals. Doping is an ethical dilemma that rocks the very base of competitive sport. The following article  examines these ethical considerations and take an in depth look at banned substances, their abuse and methods to combat this in professional sport.

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History

‘When humans compete against one another, either in war, in business, or in sport, the competitors, by definition, seek to achieve an advantage over their opponent. Frequently they use drugs and other substances to gain the upper hand. Furthermore, there have always been individuals who in the pursuit of victory have transcended social norms.’ Charles E. Yesalis

While doping has gained more recognition and press in recent times it is by no means a current phenomenon. The use of drugs in sports has had a long and well documented history going as far back as Greek and Roman times where Early Olympians used extracts of mushrooms and plant seeds and Gladiators took substances to make their fights more vigorous and bloody.

In the last third of the nineteenth century, the use of stimulants among athletes was commonplace, and moreover, there was no attempt to conceal drug usage. Swimmers, distance runners, sprinters and cyclists used a wide assortment of drugs including strychnine, cocaine, caffeine and alcohol, to gain an edge over their opponents. 1886 marked the first recorded doping death with cyclist Arthur Linton overdosing on trimethyl. This was followed, in 1904, by the near death of Marathon runner Thomas Hicks at the Olympics in St Louis after mixing brandy and strychnine.

The 1930s marked the advent of Amphetamines which were created by the military to assist pilots and soldiers. By 1933 the word doping had become part of the English language. At the Rome Olympics (1960) amphetamine-taking Danish cyclist Knut Jensen collapsed, fractured his skull and died. This was followed in the 1967 Tour de France by another amphetamine death when Britain’s Tommy Simpson died of dehydration as a result. In response to this, Jacques Anquetil, a five-time winner of the Tour de France, stated: ‘For 50 years bike racers have been taking stimulants. Obviously we can do without them in a race, but then we will pedal 15 miles an hour [instead of 25]. Since we are constantly asked to go faster and to make even greater efforts, we are obliged to take stimulants’

In the 1950s the Soviets begin to use male hormones and the commencement of systematic use of anabolic steroids in sport has been largely attributed to the massively successful Soviet weightlifting teams in the early 1950s. Statistical analysis of the performance of the Soviet lifters during this period is consistent with anabolic steroid usage. The 1976 Olympics marked The culmination of a decades long series of documented clinical trials in The Germany Democratic Republic utilizing anabolic steroids on their athletes. It is estimated that some 9,000 former athletes, perhaps more, were doped, often unwittingly, in the program. Due to obvious ethical constraints this to date, remains one of the few documented, systematic reviews of performance enhancing drugs. Under a national plan, “State Plan 14.25,” the East German government “called for the administering of male hormones to male and female athletes.” The swimmers, and many other Olympic athletes, took the German manufactured steroid Oral-Turinabol, often believing they were vitamins. As a result in 1976 East German swimmers won 11 out of 13 Olympic events. The documented effects of this program down the line include: cancer, ovarian cysts, liver damage, heart disease, infertility and other ailments. Victims of the East German doping program were financially compensated after an extended legal battle in 2000. It may be a rather cynical sentiment, but doping trends in professional sport seem to suggest athletes will disregard the health risks in order to excel. It would be interesting to see how many of the athlete’s involved, would have willingly chosen to be part of the program to gain the high level of performance documented in the studies.

1972 marked a new era for doping when a Swedish doctor, Björn Ekblom, pioneered ‘blood doping’ which entailed removing blood, increasing the concentration of red blood cells in a centrifuge and then restoring it through transfusion. This obviously enhanced the oxygen transportation capacity of the blood. This was given further impotence in the late 80’s with the development of Erythropoietin (EPO) which effectively enhances red blood cell production.

And so begins a fairly consistent tale of drug test failures of professional, high profile athletes. Notables include: Ben Johnson – Seoul Olympics (1988). Diego Maradona – Soccer World Cup (1994). Linford Christie (1999)

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The 2000s are dominated by numerous high profile cycling busts, culminating in the ban for life and stripping of all titles, of 7 time Tour de France winner, Lance Armstrong. His doping strategies were termed “the most sophisticated, professionalized and successful doping program cycling has ever seen” by the US anti doping agency and highlight the extent to which professional sport people are willing to go in order to excel.

Estimates of doping prevalence varies massively according to the research. The simple answer is nobody knows. Estimates range from the World-Anti Doping Agency (WADA) official statistic of 2% right up to 35% depending on the approach. When athletes are asked about doping statistics, they guess around 10%. A recent German study showed that actual doping rates were eight times the positive test rate, so in the case of WADA’s 2% one could estimate a rate of 16% of athletes doping. Based on WADA’s, likely very low statistics, that means at least 200 (of the 10,000 or so) athletes in the London Olympics were doping.
If the German statistics hold true, this figure moves to 1600.

The International Association of Athletics Federations (IAAF) became the first International Sporting Federation to prohibit doping, doing so in 1928. However, soon after World War II with the advent of amphetamines, it became clear that many athletes in a wide range of sports were using drugs to enhance their performance. The aforementioned death of cyclists 1960 and 1967, as a result of drugs, brought doping into the public spotlight. as a result, the International Olympic Committee approved a ban on doping in 1968. The Committee defined the first list of Prohibited Substances and the first tests for stimulants were performed at the Winter Olympics in 1968. Steroids only became detectable in 1974. At the same time International Sports Federations initiated doping controls and the IAAF became the first to perform out-of-competition tests. Subsequently national Anti-Doping Agencies instituted doping controls and testing within their borders. Our local agency, the South African Institute for Drug Free Sport is responsible for testing within South Africa.

On 08/07/1998 the world was rocked by a doping scandal when Willy Voet, a masseur for the Festina cycling team was stopped at the Franco-Belgium border during the Tour de France. He was found to be in possession of more than 400 doping products. As a result of this and numerous other doping scandals, The World Anti- Doping Agency (WADA) was created in 1999 to harmonize and strengthen anti-doping actions and rules across all sports and countries. WADA also took over the role of publishing the list of Prohibited Substances, which is continually under review and formally updated on 1 January each year.

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Doping Testing Procedures

As mentioned above the national anti-doping agencies are responsible for the testing procedures. They develop a Test Distribution Plan according to:
Physical demands of the sport and possible performance-enhancing effect that doping may elicit
Available doping analysis statistics
Available research on doping trends
The history of doping in the sport and/or discipline
Training periods and the competition calendar
Information received on possible doping practices

Athletes may be tested either in or out of competition. An example of how athletes would be selected for in competition or event testing could be: Placed finishers, such as the top three finishers and randomly selected athletes, such as 5th, 7th, 12th, 18th, 19th, etc. Out of competition testing occurs according to the above criteria of the Test Distribution plan. Athletes who are part of the Testing Pool must provide a 60-minute time slot each day between 6 a.m. – 11p.m. Athletes, have to be available for testing without any advance notice in an out-of-competition setting and are subject to testing 365 days a year and do not have “off-seasons” or cutoff periods in which testing does not occur.

Currently Blood and urine samples are taken for lab testing. Through regular testing an athlete’s biological passport is created. This is basically an accurate Indicator of the athlete’s personal parameters. It is the equivalent of a physiological fingerprint. This allows anti-doping agency to quickly recognize if an athlete is utilizing performance enhancing substances when their test results stray outside of their normal criteria. Laboratory results that compared samples taken during Lance Armstrong’s return to cycling in the 2009 Tour de France to his biological passport, strongly point to his use of blood manipulation, including EPO or blood transfusions.
Anti-doping agencies are increasingly utilizing ‘intelligence’ gained from team members, other athletes, medical staff etc. to optimize their testing resources and to convict athletes transgressing the rules. Lance Armstrong is a case in point. The current evidence against Armstrong derives largely from the fact that 12 of his former teammates and support team gave evidence that Armstrong was centrally involved in systematic doping in the teams he was involved in. He either admitted to them, or they directly observed him using and encouraged them to use: erythropoietin, blood transfusion, cortisone, testosterone and human growth hormone from 1996 to 2005. For this, Armstrong was charged by the US Anti-Doping Agency with possession, distribution, use, administration and trafficking in prohibited substances. Additionally, he was charged with assisting, encouraging, aiding, abetting, covering up and other complicity in anti-doping rule violations. Olympic Gold medallist Marion Jones is another example. She was tested as frequently as Armstrong, but did not return a single positive test. She was found guilty and banned as a result of the BALCO scandal which uncovered systematic doping, largely by US athletes, using “designer steroids” that avoided detection. This wes only discovered through good intelligence work.

Common Substances: effects and side effects

In 2008, Bernard Kohl who placed 3rd in the Tour de France tested positive for CERA (EPO) and was banned for 2 years. After being found guilty, Kohl handed over his ‘doping diary’, revealing the extent and level of doping in professional cycling.

“I was tested 200 times during my career, and 100 times I had drugs in my body,” he said, according to the New York Times. “I was caught, but 99 other times, I wasn’t. Riders think they can get away with doping because most of the time they do. Even if there is a new test for blood doping, I’m not even sure it will scare riders into stopping. The problem is just that bad.”

“People know in cycling that’s it’s not possible to win the Tour de France without it. It’s three weeks, 3,000 km and you climb Mount Everest four times. That’s just not possible.”

When asked in 2010, whether Alberto Contador had used doped to win the Tour de France, Kohl wouldn’t directly speculate but noted that the average speeds ridden at the Tour might cause one to think so.

“Floyd Landis won the Tour de France and his average speed was 40 kph,” Kohl said. “This year it was Contador and it was also about 40. It was nearly the same average speed. Landis was doped.”

Interestingly, after a protracted battle, on february 6 this year, Contador was stripped of his 2010 title after testing positive for Clenbutarol.

In a scientifically designed doping program aimed at maximally enhancing performance and more importantly avoiding detection, Kohl’s admitted to using blood transfusions, EPO, anabolic steroids, cortisone, human growth hormone, insulin, HCG, thyroid hormone, and designer testosterone.

Substances are prohibited if they meet at least two of the following criteria:

  • Potential to enhance sports performance
  • Actual or potential health risk to an athlete
  • Its use violates the spirit of sport.

The following list is far from exhaustive but gives a brief glimpse into some of the commonly used doping substances and their effects / side effects.

ACTH or Corticotrophin

ACTH or Adreno-cortical stimulating hormone, stimulates the adrenal grand to produce cortisol, a natural steroidal hormonal with multiple physiological effects including anti-inflammatory properties to facilitate recovery.

Possible side effects: Water retention, edema, Hyperglycemia, Blood hypertension, Osteoporosis, Decrease in resistance to infections

Amphetamines

Amphetamines were first synthesized in 1887. The effects of the drug include a sense of well-being, a decrease in the perception of fatigue, an increase in self-confidence, in motor function and a decrease in appetite. As there are no positive long term effects, amphetamines are usually consumed just prior to competition. Due to their effects (perceived and real) they are very addictive.
Possible side effects: Confusion, Tremors, Delirium, Psychosis, Paranoid delirium, Insomnia, Nausea, Vomiting

Anabolic substances (steroids)

This class of doping substances includes all steroids that possess anabolic properties including testosterone. This in essence means they cause a marked, non-isolated increase in the muscular mass. In sports such as weightlifting and bodybuilding, these substances are often used in weeks preceding a competition. Cyclists seem to use anabolic substances in smaller quantities to facilitate muscular recovery. The side effects associated with the extensive of anabolic steroids have been scientifically observed and documented:

Possible side effects: Anomalies in the function of the liver and liver cancer, Hypercholesterolemia, prostate cancer, myocardial infarction, Diabetes, testicular atrophy, Feminization : gynecomastia (breast development in men) and high-pitched, castrato-like voice, Behavioral modifications including aggressiveness and groundless violence, Acne, Muscular rupture, Hair loss, Irreversible virilization or masculinization in women including Husky voice and Hirsutism (appearance of body hair in regions that are normally hairless.

Beta-blockers

They are beta receptor antagonists that prevent binding of adrenaline in adrenergic beta receptors. Beta blockers can be misused in certain sports, for example shooting, archery and golf to control the effects of nervousness, hand tremor and high heart rate

Possible side effects. The undesirable effects of beta-blockers stem from their inhibitory properties. Issues may include: bronchial spasms, Hypoglycemia, Troubles with digestion, Cardiac insufficiency, Cardiac rhythm problems

Codeine, opiates and other morphine derivatives

The use of pain killers is frequent in all sports. Professional obligations often necessitate competing with injuries.

Possible side effects: Addiction, Nausea, Vomiting, Withdrawal syndrome

Corticosteroids

Corticosteroids are potent systemic anti-inflammatory and immunosuprresant. There is a long and well documented history of corticosteriod abuse amongst sport people.

Possible side effects: side effects are numerous and serious.

Erythropoietin

Erythropoietin (often shortened to EPO) is a naturally occurring hormone, secreted by the kidneys, whose function is to regulate red blood cell production. It effectively stimulates bone marrow to produce more red blood cells (RBC) and therefore haemoglobin. The use of EPO started in the 1980’s as a quicker, cleaner alternative to blood doping. EPO is most commonly used amongst endurance athletes as a higher RBC count means better oxygen transportation and so a higher rate of aerobic respiration and decreased fatigue.
EPO is used in medical practice in cases of severe anemia and during treatment of chronic renal insufficiency, such as in dialysis patients.

Possible side effects: Increased viscosity of the blood with increases the risk of heart attack and stroke. The lack of knowledge regarding dosage and side effects of EPO has been linked to the death of a number of competitive cyclists in the late 80’s.

Chorionic gonadotropin (hCG)

This natural product is classified as a stimulant because it causes an increase in the production of endogenous testosterone. When exogenous anabolic substances are put into the male body, natural negative-feedback loops cause the body to shut down its own production of testosterone. This causes testicular atrophy and decreased endogenous testosterone. hCG is commonly used during and after steroid cycles to maintain and restore testicular size as well as normal testosterone production.

Possible side effects: largely related to excessive testosterone production so similar to anabolic sustances The associated dangers depend on dosage and vary according to sex. May also include Hypertension thrusts when the substance is introduced too rapidly, Vascular thrombosis, Convulsions.

Human growth hormone (hGH)

Growth hormone is used for the anabolic effects. It is thought to increases muscle mass and strength, and helps hasten recovery and repair Uncertainties remain about the safety of exogenous hGH. We still do not know what influence it may have on normal individuals, even though there is a good deal of information about side effects of endogenous hGH hyper secretion in acromegaly. This condition has an associated 50% mortality at age 50 and 89% mortality at age 60. hGH found on the black market may be extractive growth hormone (extracted from the pituitary gland of corpses). The method used to purify the hormone does not guarantee the removal of other biological molecules which can cause adverse reactions

Possible side effects: Tumefaction of soft tissue, arthritis, Thickening of the skin, Hirsutism (hair growth over the entire body), Increase in perspiration, Peripheral neuropathies, Myopathies, Hypertrophy of the viscera : spleen, salivary glands, liver, kidneys, heart, Glucose intolerance / diabetes mellitus

Insulin

Although it’s more usually associated with the regulation of blood glucose, the hormone insulin can also act as a powerful anabolic agent, helping to increase glycogen synthesis and lean muscle mass. Insulin is commonly used in conjunction with the anabolic steroids, obviously due to the anabolic effects but also to decrease the insulin resistance caused by anabolic steroids and growth hormones.
Possible side effects: Tremors, anxiety, myocardial infarction, Numerous drug interactions

Overdose: hypoglycemia may result from poorly estimated insulin dosage, a mistake in feeding or a unforeseen physical effort that is not compensated. The symptoms of hypoglycemia include hunger, sweat, asthenia, tremors, confusion, problems with vision, headaches, etc. Unless treated promptly, hypoglycemia may result in a coma.

Thyroid hormone drugs

These have mainly positive effects as long as the dosage is not increased too quickly and is not oversized, in which cases symptoms that are similar to hyperthyreosis appear, such as heart palpitation, arrhythmias, diarrhea, emaciation, decrease in temperature tolerance, insomnia, agitation, and even psychoses [2, 3].

For people with latent heart diseases, adverse heart related effects (arrhythmias, heart infarct) can be perilous [4]. Before starting a thyroid gland treatment, the doctor should carefully review the patient’s health including the functioning of the heart. The risks related to the treatment can thus be determined.

Prolonged thyroxine overdosing increases the risk of osteoporosis. Perilous agranulocytosis (lowered white blood cell count) is found in 0.1 to 0.5 percent of patients [5].

Acute large thyroxine doses lead to thyrotoxicosis. The symptoms are high body temperature, failing heart functioning and coma [6]. Overdosing of thyroid gland hormones have led to deaths.

Drug effects in sport

With the lack of research into many aspects of doping one may assume that numerous athletes are utilizing banned substances in response to a fear that their fellow competitors have a marked advantage over them. Their are however a few fascinating studies that cast light on just how effective doping may be.

Hormonal doping and androgenization of athletes: a secret program of the German Democratic Republic government Werner W. Franke1* and Brigitte Berendonk2 Clinical Chemistry 43:7 1262–1279 (1997)

“Several classified documents saved after the collapse of the German Democratic Republic (GDR) in 1990 describe the promotion by the government of the use of drugs, notably androgenic steroids, in high performance sports (doping). Top-secret doctoral theses, scientific reports, progress reports of grants, proceedings from symposia of experts, and reports of physicians and scientists who served as unofficial collaborators for the Ministry for State Security (“Stasi”) reveal that from 1966 on, hundreds of physicians and scientists, including top-ranking professors, performed doping research and administered prescription drugs as well as unapproved experimental drug preparations. Several thousand athletes were treated with androgens every year, including minors of each sex. Special emphasis was placed on administering androgens to women and adolescent girls because this practice proved to be particularly effective for sports performance. Damaging side effects were recorded, some of which required surgical or medical intervention. In addition, several prominent scientists and sports physicians of the GDR contributed to the development of methods of drug administration that would evade detection by international doping controls.”

As mentioned previously this remains the only, large scale, scientific reviews of doping in professional sport. It provides obvious graphical data of the effect of androgynous substances on performance of athletes, particularly in the throwing disciplines.

imageEffects of an androgenic-anabolic steroid, Oral-Turinabol, on the shot-put performance (in meters, y-axis) of a female athlete (code identification 1/68 in a, 1/69 in b, and 1/72 in c) The blocks on the x-axis signify ‘cycles’ of doping with resultant spikes in throwing performance

 

 

 

 

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Decreased performances in women’s strength-dependent events worldwide, after implementation in 1989 of some (though still insufficient) out-of-competition doping controls: cordinates present meters of performance of the world best (upper curve) and the average of the ten best (lower curve) athletes in the javelin throw (A), discus throw (B), and shot-put (C) for the years 1987–1993.

This visible decline in throwing and strength related sport performance after the introduction of random out-of-competition testing is obviously as a result of decreased doping . Decreased is the operative word; today’s best athletes are unlikely to be free from doping but are just doping less and better than previously. Another interesting discovery by GDR scientists was that “androgenic initiation” has permanent effects in girls and women and hence once a higher performance level is reached it does not return to pre-steroid levels on cessation if the doping. In this regard, many of today’s top athletes still profit from their previous doping.

Medvedyev, et.al. did a statistical analysis of the world records established in weightlifting particularly in the snatch and the clean and jerk. The results showed that the rate of improvement of world records in weightlifting accelerated from the period 1967 – 1973 up to 1980. This was followed by an even faster rate of improvement from 1980 up to 1988. The only plausible reason was the widespread use of performance enhancing drugs.As with the throwing disciplines, in the wake of stricter, more sophisticated testing procedures established in 1989 there was an obvious drop in the results at the major world events of 1990 and 1991.

J J Thomsen, et al of the Copenhagen Muscle Research Centre did an interesting study on the effects of EPO on a group of non-professional cyclists. Their results were an eye opener. ‘With rHuEpo (recombinant human erythropoietin) treatment VO2max increased (P<0.05) by 12.6 and 11.6% in week 4 and 11, respectively, and time-to-exhaustion (80% VO2max) was increased by 54.0 and 54.3% (P<0.05) after 4 and 11 weeks of treatment, respectively’

Ethical considerations

“The use of drug use in sport is both unhealthy and contrary to the ethics of sport. It is necessary to protect the physical and spiritual health of athletes, the values of fair play and of competition, the integrity and the unity of sport, and the rights of those who take part in it at whatever level.” IOC, 1990

“Equal conditions for all” definition of fair play, Oxford English Dictionary.

Beyond the health risks examined earlier, drug use by athletes clearly violates sporting ethical considerations and this remains the largest focus of the anti doping movement. Although it appears that athletes have been using performance enhancing substances for as long as sport has existed, the drive to professionalism and increased financial incentives has certainly blurred the lines. Increasingly athletes seem to have a “cheat-or-lose” philosophy.

The benefit of sport include: character building, dedication, perseverance, endurance and self-discipline. Sport helps us learn from defeat as much as from victory, and team sports facilitate co-operation, imparting moral and social values. It is also about integrating us as individuals, to bring about a healthy society. These considerations have clearly taken a back seat in numerous professional sporting settings. In present day professional sport the pressured on all concerned is immense. An athlete nowadays is faced with meeting expectations of the coach, teammates, family, friends, sponsors and spectators. Coaches are also faced with similar pressure.

Beyond doping being against the ethical ‘idea’ of sport, it goes against the philosophy of “equal conditions for all”. This means sport moves beyond skill levels, training etc. and becomes about who can throw the most resources at the problem. Sport is in essence replaced by a competition between doctors and biochemists and the regulating authorities! One of the more striking ethical considerations as health professionals is how complicit doctors and other health practitioners are in the procurement and provision of banned substances. The violates the basic ethical principles of medicine in many ways. Doctors are willingly providing substances that may well have negative implications on athletes

Pharmaceutical companies are also likely to blame, with many professionals having access to products before they come on the market. There has also been calls from WADA for pharmaceutical companies to place markers in their drugs to assist with testing, to no avail. Although cynical, this likely has a financial reason. In Italy, sales of a certain EPO drug far exceed documented cases of heart disease!

There is an emerging counter argument for the legalization of drugs in sport. Key points of this argument include:

  • Leveling of the playing field
  • Higher level of performance and increased spectatorship.
  • Better control of doping substances

This argument is totally incongruent with the ethical considerations cited earlier. From a health perspective, even if doping were legalized there still would have to be some forms of control and athlete’s would likely still be pushing the boundaries to gain competitive advantage.

Conclusion

The incidence of doping in sport likely exceeds estimations many fold. With increasing incentive to win, both from a fame and financial perspective, the anti-doping sector faces an uphill battle. Until punishments become truly prohibitive (lifetime ban for all guilty parties) and until sporting powers that be stop turning a blind eye and fully co-operate, it is likely to continue to be a battle of resources between sports people and anti-doping agencies.

by Iain Sykes (physiotherapist)

Iain Sykes Physiotherapy

Cape Town South Africa