Years ago I saw a patient in my practice who was in his early 60s. This gentleman had been lifting heavy weights for years and had an amazing physique. After I listened to his concerns and started to address them, he said to me “thanks for thinking about my medical problems and not being distracted by how I look.” He felt the need to say this because many health care providers seemed, to this patient, to be so impressed by his appearance that they seemed to be unwilling to consider that he may truly have an illness.
In more than 17 years of practice I have found that the experience of this athlete is not uncommon.
This article is intended as a basic guide, for athletes and their health care providers, to some of the unique characteristics and concerns of athletes. As an amateur athlete of modest ability, I will take the liberty of using the term “we” rather than “they”
We have unusual laboratory findings:
Athletes often demonstrate laboratory results that would appear abnormal in the sedentary population. The most well-known of these is pseudoanemia. Because, by conditioning, there is an increase in the volume of blood plasma, hemoglobin in the blood becomes diluted. This can lead to hemoglobin levels commonly 0.5g/dl lower than “normal,” but sometimes up to 1g/dl lower than “normal.” However, the total amount of hemoglobin in the blood, and, hence, the blood’s ability to carry oxygen, is not reduced.
Another common finding in athletes who are actively training and competing is a positive urine dip test for blood. When the athlete’s urine is examined under a microscope, there is no blood. This finding on the dip test is a false positive because the dip test cannot differentiate between hemoglobin (in red blood cells) and myoglobin (which is released from muscles that are injured during exercise).
Similar to myoglobin in the urine, signs of muscle damage are also detectable in the blood after strenuous exercise. These laboratory findings include elevated levels of myoglobin, creatine kinase, and aspartate aminotransferase (AST). Since AST is usually considered a measure of liver function, an elevated level may be taken to indicate liver damage.
Our hearts are different:
Athletes often have big hearts in every sense of the word. The physiologic version of our big hearts is called the “athlete’s heart.” A review on this subject stated that, in roughly 50% of athletes, their training induces:
“some evidence of cardiac remodeling, which consist of alterations in ventricular chamber dimensions, including increased left and right ventricular and left atrial cavity size (and volume), associated with normal systolic and diastolic function.”
In addition, marked enlargement of the left ventricular chamber (greater than or equal to 60 mm) occurs in approximately 15% of highly trained athletes.
In addition to, or, more likely, a function of, our enlarged hearts, our hearts can have strange-looking electrical patterns, with approximately 40% of trained athletes demonstrating abnormalities on 12-lead electrocardiograms.
Our heart rates are often ridiculously low. It is not unusual for highly trained male and female athletes to have resting heart rates in the 30s and 40s, respectively. This low heart rate is reflective of the increased efficiency of the cardiovascular system.
But we can still have serious heart disease:
There is significant overlap diagnostically between a physiologically unsurprising athlete’s heart and the potentially life-threatening condition, hypertrophic cardiomyopathy. Tragically, athletes die of this condition, as well as conduction abnormalities, coronary arteriosclerosis, and other heart abnormalities. The bottom line is that an unusual heart finding in an athlete should lead to serious consideration given to having an evaluation by a cardiologist who has experience differentiating between an athlete’s heart and dangerous heart disease.
We obsess about “small” health concerns:
Athletes train for months and years. For some athletes, training and racing is their full-time job. Often times, all of this training is directed toward a single race event. For some events, like the Olympics, there is no second chance. Either an athlete arrives and performs to his or her peak ability, or the years of intense training can be “wasted.” Therefore, a “little cough” or sore throat, a sore joint, or even a blister in a bad spot can be extremely important to an athlete. Even if “minor” health concerns do not appear to be at a level that could affect performance, lingering doubt can be a factor. It is extremely difficult for non-athletes to understand the degree of dedication it takes to reach a high level of athletic prowess and the amount of emotional and physiologic stress an athlete experiences before and during an event.
This is, actually, an area in which non-athletic physicians and athletes can find common ground. Physicians often make huge sacrifices of time and social relationships to get through the education and training that is required to practice. Just imagine, after years of stress and poor sleep, while your friends were going out to bars, buying homes, and starting families, not getting your medical diploma because you have a cold or a sore shoulder!
Fitness is not a hobby – athletes can’t just stop:
Aside from the loss of fitness (deconditioning) that occurs when athletes stop training, fitness is a lifestyle, a part of personal identity, and, for some, a career. When an athlete sees a physician about a health concern that could affect his or her ability to participate in exercise, the expectation is that every effort will be made to help him or her to return to full participation.
We are prone to fads and experimentation:
When I first got into triathlon, small wheels and beam bikes were a trend. Then there was barefoot running. Similarly, nutritional trends (avoiding gluten or milk, taking antioxidants, taking other nutritional supplements, etc.), whether based on evidence or not are very attractive to athletes. If an athlete believes that a legal nutritional intervention will lead to an improvement in performance, no matter how small, he or she may try it. It is important for physicians to ask athletes if they are taking supplements and what, from the athletes’ perspectives, are the expected effects of these supplements. Physicians who treat athletes should have some familiarity with such supplements and should be able to offer constructive, evidence-based, guidance.
We fear aging and decrepitude:
We athletes understand, intellectually, that most of us will not be running marathons with our grandchildren, but we don’t know how we will deal emotionally with loss of fitness and activity. Every year I look at my performances and think to myself “is this the year I am starting to decline?” Sadly, however, it is inevitable. This is why, when a middle-aged athlete like me visits his physician, a gain of a couple pounds of weight or of 5 points of blood pressure can seem like a crushing defeat.
Many athletes doctor-shop:
Many athletes have limited budgets and time. They will not put up with health care that they do not feel is helpful. If a brilliant physician gives excellent care in every regard, but is tone-deaf about the importance of peak fitness to patients who are athletes, those patients will seek care elsewhere.
Many of us have the same failings as everybody else:
I often find myself amazed when I read about a top athlete in his or her sport who is addicted to alcohol or drugs. These substances are so clearly detrimental to performance that it seems obvious that serious athletes would avoid them. Sadly, this is not true. Physicians need to ask the same questions about smoking, drugs, and addiction of their chiseled patients who are athletes as they do of any other patient.
It is essential for physicians who treat athletes to understand their patient’s concerns, even if they seem trivial, and become fully engaged in becoming part of the athlete’s “team.” This term, “team,” is not used trivially. When an athlete trains or competes, there often is an entire team of people (coaches, physical therapists, massage therapists, dietitians, physicians, etc.) who has supported that athlete.
From a physician’s perspective, it’s fun to be part of a top athlete’s team. I saw a patient for follow-up recently who is a superb runner and has asthma. He told me that he had recently broken the 4-minute mile. I can’t run that fast. Ever. But I feel like my small contribution, as his asthma doctor, gave me a tiny piece of that achievement.
Maron BJ and Pelliccia A. Contemporary Reviews in Cardiovascular Medicine: The Heart of Trained Athletes, Cardiac Remodeling and the Risks of Sports, Including Sudden Death. Circulation 2006;114:1633-1644.
Fieseler, C. What Runners Need to Know About Their Blood Test Results. http://www.runnersworld.com/health/blood-test-results-for-runners
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