Pujalte, George

Context: Testosterone is a steroid hormone produced primarily in the testes in men and ovaries in women, playing crucial roles in androgenic, anabolic, and psychological functions, including muscle growth, bone formation, erythropoiesis, risk-taking, and aggression, making it important for athletes. Sports performance is linked closely to testosterone level, prompting athletes to explore legal and illegal ways to boost testosterone. This review examines testosterone physiology and legal strategies for optimizing testosterone levels in athletes, as well as their practical applications. Evidence Acquisition: Database search. Study Design: Narrative review. Level of Evidence: Level 5. Results: Maintaining healthy testosterone levels requires energy balance and optimal nutrition with adequate macronutrients and micronutrients, especially for athletes prone to dieting and food restriction. Testosterone boosters are marketed widely but lack strong evidence for efficacy and may pose risks. While some substances show promise, further research is needed. Sleep is critical as testosterone secretion is linked to the rapid eye movement phase, highlighting the need for proper sleep hygiene and addressing sleep disorders. Moderate-to-high intensity free-weight resistance exercises are most effective for increasing testosterone, while the effects of sexual activity remain unclear. Endocrine-disrupting chemicals can lower testosterone levels and should be avoided. While cold-water immersion may decrease testosterone, sauna bathing appears to be neutral. Radiofrequency electromagnetic radiation from modern electronic devices may harm the hypothalamic-pituitary-gonadal axis, warranting limited use. Over-the-counter analgesics, such as nonsteroidal anti-inflammatory drugs and acetaminophen, may decrease testosterone levels, suggesting cautious use. Seasonal changes in testosterone levels require further study. Testosterone-optimizing strategies excluding banned substances may aid in treating functional low testosterone or reducing harm in anabolic-androgenic steroid users. Conclusion: Educating athletes on safe and effective strategies to increase testosterone is crucial, with ongoing research needed to explore additional methods. Strength-of-Recommendation Taxonomy: B.

Abstract Mitigating impact injuries is crucial in race car driving, requiring adherence to stringent safety standards. Helmets and head-neck support devices are essential for reducing the risk of concussions and serious injuries. The sport's high-risk nature demands a deep understanding of injury types, with attention to common areas such as the spine, shoulders, and knees. Continuous safety innovation focused on factors like posture, race duration, and physiologic response is imperative. Safety advancements have significantly reduced fatalities, with comprehensive protocols and specialized equipment ensuring rapid crash response. Medical and safety measures, including roll bars, harness systems, and heat-resistant clothing, protect drivers, while tailored regulations for different race car categories ensure specific safety needs are met. Overall, the intricate focus on safety balances the thrill of racing with driver well-being.

Abstract: A 49-year-old short-board goofy-stance competitive surfer presented with a 3-month history of bilateral, left foot pain associated with tender soft tissue plantar nodules. Magnetic resonance imaging of the left foot revealed foci of fibrotic tissue within the subcutaneous tissue adjacent to the first and fifth metatarsophalangeal joints compatible with surfers' knots . The patient underwent conservative treatment with oral ibuprofen as needed before competitions, topical diclofenac gel, wide toe box shoes, and use of a double-thick traction pad on his surfboard to alleviate the friction between the metatarsophalangeal joints of his left foot and the surfboard. He reported improvement of symptoms and full return to surfing at 8-month follow-up. We present a case of surfers' knots overlying the left first and fifth metatarsophalangeal joints of a male competitive surfer and highlight recommendations for successful conservative treatment options for symptomatic athletes.

A virtual medical visit, also known as telemedicine or telehealth, is a valuable alternative method of providing health care to patients who do not have easy access to a hospital, or during times when limited social interaction is crucial such as our current COVID-19 pandemic. A virtual approach to evaluating musculoskeletal system ailments is particularly challenging, for diagnosis of these conditions generally rely greatly on physical examination, which may be challenging. However, a properly planned and executed telemedicine visit will yield successful results in most cases. Our aim is to produce a document with instructions and suggestions, including physical examination maneuvers, to help physicians carry out a proper virtual medical visit with patients complaining of ankle musculoskeletal problems. Virtual visits should not be thought of as a replacement for traditional face-to-face medical consultations, but rather a complementary method to provide health care when deemed appropriate. By following this guide, and tailoring it to the specific case at hand, medical providers should be able to effectively carry out a successful telemedicine consultation for musculoskeletal ailments relating to the ankle. Levels of Evidence: Level V

Abstract: Athletes of all ages may be affected by medical and mental health issues. Sports medicine physicians should be familiar with common conditions that may affect the well-being of athletes, such as attention-deficit/hyperactivity disorder (ADHD). ADHD behaviors have the potential to affect a person's ability to concentrate. It is likely that social and cognitive therapies combined with pharmacotherapy will be the most effective way to treat ADHD in athletes. Medications used for ADHD, especially stimulant types, are known to improve alertness, reaction time, anaerobic performance, and endurance, which would potentially improve athletic performance. Furthermore, stimulant medications may enable student athletes with ADHD to focus on academic studies for longer periods of time, beyond usual levels of fatigue, important for those who may be exhausted after practices and games. The purported performance enhancement effects and potential adverse effects of stimulant medications have prompted many sports governing bodies to ban prescription stimulants or establish strict rules for their use. Athletes taking physician-prescribed stimulants to treat ADHD need to provide the appropriate documentation for approval before competition or risk punitive measures. Physicians should strive to provide a high quality of care to athletes with ADHD through early diagnosis, appropriate and careful multidisciplinary treatment, and complete and timely documentation to facilitate continued sports participation.

Background: Surgical site infection (SSI) is an adverse event that can lead to increased pain, increased cost, risk of death, and decreased patient satisfaction. Studies have investigated the best solutions to prevent SSI. Chlorhexidine has been suggested as the most efficacious antiseptic. However, scant data exist on application of antiseptic solutions and effectiveness of concentric versus back-and-forth strokes. Because a specific method may result in better outcomes, we aimed to review the literature to compare these two techniques. Methods: PubMed-indexed articles were reviewed using specific keywords, including “back-and-forth,” “concentric circle,” “chlorhexidine,” “iodine,” “surgical site infection,” “antiseptic,” and “skin preparation.” Because data showing the correlation between SSI and application method of skin preparation solutions were scant, studies that described skin preparation method but analyzed other types of infection, bacteremia, or colonization were also included in this review. Results: No consensus was found regarding the application method. Two articles showed the superiority of chlorhexidine applied using the back-and-forth technique, whereas one demonstrated the superiority of iodine applied in concentric circles. Conclusions: The method of applying antiseptic solution may be just as important as the choice of solution. More studies are needed to assess method of antiseptic application.

Background: Non-vitamin K antagonist oral anticoagulants (NOAC) have replaced vitamin K antagonist (VKA) oral anticoagulants as the first-line treatment option for stroke prevention in high-risk patients with atrial fibrillation. With VKA therapy, disease and treatment-related knowledge is associated with improved adherence and outcomes. There is concern that due to the lack of need for ongoing visits for laboratory monitoring in patients on NOACs, there is less opportunity for education, leading to poor disease- and treatment-related knowledge in this patient group. Methods: One hundred ninety-nine (199) patients presenting to 2 primary care clinics on NOAC therapy were surveyed regarding atrial fibrillation and their knowledge regarding NOACs. Chart review was completed to determine patient characteristics and data obtained was compared with survey results to determine the accuracy of the survey responses. Results: Patients with a lower degree of NOAC knowledge tended to be older ( P < .001), have higher Charlson Comorbidity Index scores ( P = .001), use apixaban more often ( P = .008), and have been on NOACs for a shorter time period ( P = .007). Conclusions: There is an opportunity to improve NOAC-related knowledge in patients with atrial fibrillation. When developing educational interventions, patient characteristics associated with poor knowledge should be considered. Based on our results, these are patients who are older, more medically complex, are on apixaban, and have been on NOAC therapy for a shorter duration.