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PubMed2000

No association between the angiotensin-converting enzyme ID polymorphism and elite endurance athlete status.

Several studies have reported that the insertion (I) allele of the angiotensin-converting enzyme (ACE) I/deletion (D) polymorphism is associated with enhanced responsiveness to endurance training and is more common in endurance athletes than in sedentary controls. We tested the latter hypothesis in a cohort of 192 male endurance athletes with maximal oxygen uptake >/=75 ml. kg(-1). min(-1) and 189 sedentary male controls. The ACE ID polymorphism in intron 16 was typed with the three-primer polymerase chain reaction method. Both the genotype (P = 0.214) and allele (P = 0.095) frequencies were similar in the athletes and the controls. Further analyses in the athletes revealed no excess of the I allele among the athletes within the highest quartile (> 80 ml. kg(-1). min(-1)) or decile (>83 ml. kg(-1). min(-1)) of maximal oxygen uptake. These data from the GENATHLETE cohort do not support the hypothesis that the ACE ID polymorphism is associated with a higher cardiorespiratory endurance performance level.

Alleles↗
PubMed2001

Effects of 3-day bed rest on physiological responses to graded exercise in athletes and sedentary men.

To test the hypotheses that short-term bed-rest (BR) deconditioning influences metabolic, cardiorespiratory, and neurohormonal responses to exercise and that these effects depend on the subjects' training status, 12 sedentary men and 10 endurance- and 10 strength-trained athletes were submitted to 3-day BR. Before and after BR they performed incremental exercise test until volitional exhaustion. Respiratory gas exchange and heart rate (HR) were recorded continuously, and stroke volume (SV) was measured at submaximal loads. Blood was taken for lactate concentration ([LA]), epinephrine concentration ([Epi]), norepinephrine concentration ([NE]), plasma renin activity (PRA), human growth hormone concentration ([hGH]), testosterone, and cortisol determination. Reduction of peak oxygen uptake (VO(2 peak)) after BR was greater in the endurance athletes than in the remaining groups (17 vs. 10%). Decrements in VO(2 peak) correlated positively with the initial values (r = 0.73, P < 0.001). Resting and exercise respiratory exchange ratios were increased in athletes. Cardiac output was unchanged by BR in all groups, but exercise HR was increased and SV diminished in the sedentary subjects. The submaximal [LA] and [LA] thresholds were decreased in the endurance athletes from 71 to 60% VO(2 peak) (P < 0.001); they also had an earlier increase in [NE], an attenuated increase in [hGH], and accentuated PRA and cortisol elevations during exercise. These effects were insignificant in the remaining subjects. In conclusion, reduction of exercise performance and modifications in neurohormonal response to exercise after BR depend on the previous level and mode of physical training, being the most pronounced in the endurance athletes.

Adult↗
PubMed2006

Effects of progressive and maximal exercise on plasma levels of adhesion molecules in athletes with sickle cell trait with or without alpha-thalassemia.

The aim of the study was to examine the effects of exercise on soluble vascular cell adhesion molecule-1 (sVCAM-1) and intercellular adhesion molecule-1 (sICAM-1) in sickle cell trait (SCT) athletes with or without alpha-thalassemia. Six athletes with SCT, seven athletes with both SCT and alpha-thalassemia (SCTAT), and seven control athletes (Cont) performed an incremental and maximal test on cycloergometer. Levels of sICAM-1 and sVCAM-1 were assessed at rest, immediately after the end of exercise, and 1, 2, and 24 h after exercise. Although Cont and SCTAT groups exhibited similar basal plasma levels of inflammatory and adhesion molecules, the SCT group had higher sVCAM-1 basal concentrations. Incremental exercise resulted in a significant increase of sVCAM-1 in all subjects, which remained elevated only in the SCT group during the recovery period. In conclusion, as sVCAM-1 increased with exercise and during the recovery period, our findings support the concept that SCT athletes might be at risk for microcirculatory disturbances and adhesive phenomena developing at rest and several hours after exercise. alpha-Thalassemia might be considered protective among exercising SCT subjects.

Adult↗
PubMed2002

Potential role of vitamin D receptor gene polymorphism in determining bone phenotype in young male athletes.

The genetic difference among individuals partly explains variance in adaptive response to exercise through gene-environment interaction. The aim of this cross-sectional study was to evaluate the role of the vitamin D receptor (VDR) gene polymorphism, which locates at the translation initiation site, in the adaptations of bone to long-term impact loading. The VDR genotypes, as detected by endonuclease Fok I, and bone phenotypes of the lumbar spine and femoral neck were examined in 44 highly trained young male athletes and 44 age-matched nonathletic controls. As a whole, the athletes had a significantly higher bone mineral content resulting from a combination of increased volume and density at both sites than the controls. When the athletes were compared with the controls within each VDR genotype, however, the increased spinal volume was found only in the athletes with the FF but not in those with the Ff genotype("F" for the absence of the endonuclease Fok I restriction site and "f" for its presence). Differences in bone mineral content in the lumbar spine and femoral neck between the controls and the athletes were greater in subjects with FF than those with Ff. Our results suggest a gene-environment interaction in that the bone phenotypes in individuals with FF adapt to impact loading by producing stronger bone structure than those with the Ff do.

Adult↗
PubMed2005

Frequency of the C34T mutation of the AMPD1 gene in world-class endurance athletes: does this mutation impair performance?

The C34T mutation in the gene encoding for the skeletal muscle-specific isoform of AMP deaminase (AMPD1) is a common mutation among Caucasians (i.e., one of five individuals) that can impair exercise capacity. The purpose of this study was twofold. First, we determined the frequency distribution of the C34T mutation in a group of top-level Caucasian (Spanish) male endurance athletes (cyclists and runners, n = 104). This group was compared with randomly selected Caucasian (Spanish) healthy (asymptomatic) nonathletes (n = 100). The second aim of this study was to compare common laboratory indexes of endurance performance (maximal oxygen uptake or ventilatory thresholds) within the group of athletes depending on their C34T AMPD1 genotype. The frequency of the mutant T allele was lower (P < 0.05) in the group of athletes (4.3%) compared with controls (8.5%). On the other hand, indexes of endurance performance did not differ (P > 0.05) between athlete carriers or noncarriers of the C34T mutation (e.g., maximal oxygen uptake 72.3 +/- 4.6 vs. 73.5 +/- 5.9 ml.kg(-1).min(-1), respectively). In conclusion, although the frequency distribution of the mutant T allele of the AMPD1 genotype is lower in Caucasian elite endurance athletes than in controls, the C34T mutation does not significantly impair endurance performance once the elite-level status has been reached in sports.

AMP Deaminase↗
PubMed1993

Electrocardiographic findings of heart rate and conduction times in athletic students and sedentary control subjects.

We have investigated resting electrocardiograms in 1,299 athletic students and 151 sedentary control subjects. Bradycardia was significantly more common in athletes. The athletic group was divided according to a heart rate < 50, 50-100, and above 100 beats/min. Atrioventricular conduction time, prevalence of ectopic beats and other rhythms, parameters of right and left ventricular hypertrophy, ST elevation, and T wave amplitude were increased in the sinus bradycardia group. A significant negative correlation was found between heart rate and PQ duration in athletes. In the sinus tachycardia group, the PQ duration was shorter and the ST depression more prominent than in the other groups. The subjects were also divided according to PQ > or = 0.22, 0.21-0.12, and < 0.12 s. Parameters of left ventricular hypertrophy were markedly increased in athletes with PQ > or = 0.22 s, while the heart rate was only slightly decreased, suggesting an association between prolonged atrioventricular conduction time and left ventricular hypertrophy. Incomplete right bundle branch block was associated with a lower heart rate, increased duration of QRS and QTC, voltage of precordial Q waves, indices of right ventricular hypertrophy, and negative T waves. These findings are typical of right ventricular hypertrophy, indicating a close relation of incomplete right bundle branch block to right ventricular hypertrophy.

Adaptation, Physiological↗
PubMed1991

High density lipoprotein metabolism in endurance athletes and sedentary men.

BACKGROUND: Endurance athletes have higher high density lipoprotein (HDL) concentrations than sedentary controls. To examine the mechanism for this effect, we compared HDL apoprotein metabolism in 10 endurance athletes aged 34 +/- 6 years (mean +/- SD) and 10 sedentary men aged 36 +/- 8 years. METHODS AND RESULTS: Subjects were maintained on controlled diets for 4 weeks, and metabolic studies using autologously labeled 125I HDL were performed during the final 2 weeks. Lipids and lipoproteins were measured daily during these 2 weeks, and the average of 14 values was used in the analysis. HDL cholesterol (58 +/- 14 versus 41 +/- 10 mg/dl), HDL2 cholesterol (26 +/- 10 versus 12 +/- 8 mg/dl), and apolipoprotein A-I (apo A-I) (144 +/- 18 versus 115 +/- 22 mg/dl) were higher in the athletes, whereas triglyceride concentrations (60 +/- 18 versus 110 +/- 48 mg/dl) were lower (p less than 0.01 for all). Postheparin lipoprotein lipase activity was not different, but hepatic triglyceride lipase activity was 27% lower (p less than 0.06) in the athletes. The athletes' mean clearance rate of triglycerides after an infusion of Travamulsion (1 ml/kg) was nearly twofold that of the inactive men (5.8 +/- 1.5 versus 3.2 +/- 0.9%/min, p less than 0.001). There was no differences in HDL apoprotein synthetic rates, whereas the catabolic rates of both apo A-I (0.15 +/- 0.02 versus 0.22 +/- 0.05 pools per day, p less than 0.01) and apolipoprotein A-II (apo A-II) (0.15 +/- 0.02 versus 0.20 +/- 0.04 pools per day, p less than 0.05) were reduced in the trained men. Apo A-I and apo A-II half-lives correlated with HDL cholesterol in each group (r greater than 0.76, p less than 0.05 for all) but not consistently with lipase activities or fat clearance rates. This relation between apoprotein catabolism and HDL cholesterol was strongest at HDL cholesterol concentrations of less than 60 mg/dl. CONCLUSIONS: We conclude that higher HDL levels in active men are associated with increased HDL protein survival. The mechanisms mediating this effect require better definition, and other factors appear to contribute to HDL cholesterol and protein concentrations among individual subjects.

Adult↗
PubMed1991

Left ventricular pressure-volume and Frank-Starling relations in endurance athletes. Implications for orthostatic tolerance and exercise performance.

BACKGROUND: Endurance athletes have a high incidence of orthostatic intolerance. We hypothesized that this is related to an abnormally large decrease in left ventricular end-diastolic volume (LVEDV) and stroke volume (SV) for any given decrease in filling pressure. METHODS AND RESULTS: We measured pulmonary capillary wedge (PCW) pressure (Swan-Ganz catheter), LVEDV (two-dimensional echocardiography), and cardiac output (C2H2 rebreathing) during lower body negative pressure (LBNP, -15 and -30 mm Hg) and rapid saline infusion (15 and 30 ml/kg) in seven athletes and six controls (VO2max, 68 +/- 7 and 41 +/- 4 ml/kg/min). Orthostatic tolerance was determined by progressive LBNP to presyncope. Athletes had steeper slopes of their SV/PCW pressure curves than nonathletes (5.5 +/- 2.7 versus 2.7 +/- 1.5 ml/mm Hg, p less than 0.05). The slope of the steep, linear portion of this curve correlated significantly with the duration of LBNP tolerance (r = 0.58, p = 0.04). The athletes also had reduced chamber stiffness (increased chamber compliance) expressed as the slope (k) of the dP/dV versus P relation (chamber stiffness, k = 0.008 +/- 0.004 versus 0.031 +/- 0.004, p less than 0.005; chamber compliance, 1/k = 449.8 +/- 283.8 versus 35.3 +/- 4.3). This resulted in larger absolute and relative changes in end-diastolic volume over an equivalent range of filling pressures. CONCLUSIONS: Endurance athletes have greater ventricular diastolic chamber compliance and distensibility than nonathletes and thus operate on the steep portion of their Starling curve. This may be a mechanical, nonautonomic cause of orthostatic intolerance.

Adult↗
PubMed2001

Increased cardiac sympathetic activity and insulin-like growth factor-I formation are associated with physiological hypertrophy in athletes.

Physiological hypertrophy represents the adaptive changes of the heart required for supporting the increased hemodynamic load in regularly trained healthy subjects. Mechanisms responsible for the athlete's hypertrophy still remain unknown. In 15 trained competitive soccer players and in 15 healthy men not engaged in sporting activities (sedentary control subjects) of equivalent age, we investigated the relationship among cardiac growth factor formation, cardiac sympathetic activity, and left ventricular morphology and function. Cardiac formation of insulin-like growth factor (IGF)-I, endothelin (ET)-1, big ET-1, and angiotensin (Ang) II was investigated at rest by measuring artery-coronary sinus concentration gradients. Cardiac sympathetic activity was studied by [(3)H]norepinephrine (NE) kinetics. Cardiac IGF-I, but not ET-1, big ET-1, and Ang II, formation was higher in athletes than in control subjects (P<0.01). NE levels in arterial and peripheral venous blood did not differ between groups. In contrast, coronary sinus NE concentration was higher in athletes than in control subjects (P<0.01). Cardiac, but not total systemic, NE spillover was also increased in athletes (P<0.01), whereas cardiac [(3)H]NE reuptake and clearance were not different. Echocardiographic modifications indicated a volume overload-induced hypertrophy associated with increased myocardial contractility. Multivariate stepwise analysis selected left ventricular mass index as the most predictive independent variable for cardiac IGF-I formation and velocity of circumferential fiber shortening for cardiac NE spillover. In conclusion, increased cardiac IGF-I formation and enhanced sympathetic activity selectively confined to the heart appear to be responsible for the physiological hypertrophy in athletes performing predominantly isotonic exercise.

Adult↗
PubMed1997

Intense exercise impairs the integrity of the pulmonary blood-gas barrier in elite athletes.

The blood-gas barrier must be very thin to allow gas exchange and it is therefore subjected to high mechanical stresses when the capillary pressure rises. In some animals, such as the thoroughbred race-horse during intense exercise, the stresses are so large that the capillaries fail and bleeding occurs. We tested the hypothesis that, in elite human athletes, the high capillary pressure that occurs during severe exercise alters the structure and function of the blood-gas barrier. We performed bronchoalveolar lavage (BAL) in six healthy athletes, who had a history suggestive of lung bleeding, 1 h after a 7-min cycling race simulation and four normal sedentary control subjects who did not exercise before BAL. The athletes had higher (p < 0.05) concentrations of red blood cells (0.51 x 10(5) versus 0.01 x 10(5).ml-1), total protein (128.0 versus 94.1 micrograms/ml), albumin (65.6 versus 53.0 micrograms/ml), and leukotriene B4 (LTB4) (243 versus 0 pg/ml) in BAL fluid than control subjects. The proportion of neutrophils was similar in athletes and control subjects but the proportion of lymphocytes in BAL fluid was reduced (p < 0.05). There were no differences in levels of surfactant apoprotein A, tumor necrosis factor bioactivity, lipopolysaccharide, or interleukin-8 (IL-8) between groups. These results show that brief intense exercise in athletes with a history suggestive of lung bleeding alters blood-gas barrier function resulting in higher concentrations of red cells and protein in BAL fluid. The lack of activation of proinflammatory pathways (except LTB4) in the airspaces supports the hypothesis that the mechanism for altered blood-gas barrier function is mechanical stress.

Adult↗
PubMed1979

Insulin binding to monocytes in trained athletes: changes in the resting state and after exercise.

Insulin binding to monocytes was examined in trained athletes (long distance runners) and in sedentary control subjects in the resting state and after 3 h of exercise at 40% of maximal aerobic power. At rest, specific binding of 125-I-insulin to monocytes was 69% higher in athletes than in sedentary controls and correlated with maximal aerobic power. The increase in insulin binding was primarily due to an increase in binding capacity. During acute exercise, insulin binding fell by 31% in athletes but rose by 35% in controls. The athletes had a smaller decline in plasma glucose and a lower respiratory exchange ratio during exercise than did controls. We conclude that physical training increases insulin binding to monocytes in the resting state but results in a fall in insulin binding during acute exercise. Changes in insulin binding in athletes thus may account for augmented insulin sensitivity at rest as well as a greater shift from carbohydrate to fat usage during exercise than is observed in untrained controls.

Adult↗
PubMed1994

Different alterations in the insulin-stimulated glucose uptake in the athlete's heart and skeletal muscle.

Physical training increases skeletal muscle insulin sensitivity. Since training also causes functional and structural changes in the myocardium, we compared glucose uptake rates in the heart and skeletal muscles of trained and untrained individuals. Seven male endurance athletes (VO2max 72 +/- 2 ml/kg/min) and seven sedentary subjects matched for characteristics other than VO2max (43 +/- 2 ml/kg/min) were studied. Whole body glucose uptake was determined with a 2-h euglycemic hyperinsulinemic clamp, and regional glucose uptake in femoral and arm muscles, and myocardium using 18F-fluoro-2-deoxy-D-glucose and positron emission tomography. Glucose uptake in the athletes was increased by 68% in whole body (P < 0.0001), by 99% in the femoral muscles (P < 0.01), and by 62% in arm muscles (P = 0.06), but it was decreased by 33% in the heart muscle (P < 0.05) as compared with the sedentary subjects. The total glucose uptake rate in the heart was similar in the athletes and control subjects. Left ventricular mass in the athletes was 79% greater (P < 0.001) and the meridional wall stress smaller (P < 0.001) as estimated by echocardiography. VO2max correlated directly with left ventricular mass (r = 0.87, P < 0.001) and inversely with left ventricular wall stress (r = -0.86, P < 0.001). Myocardial glucose uptake correlated directly with the rate-pressure product (r = 0.75, P < 0.02) and inversely with left ventricular mass (r = -0.60, P < 0.05) or with the whole body glucose disposal (r = -0.68, P < 0.01). Thus, in athletes, (a) insulin-stimulated glucose uptake is enhanced in the whole body and skeletal muscles, (b) whereas myocardial glucose uptake per muscle mass is reduced possibly due to decreased wall stress and energy requirements or the use of alternative fuels, or both.

Adult↗
PubMedDate not supplied

Boxer's knuckle in the professional athlete.

Injuries to the extensor mechanisms of the fingers can be career-ending in professional athletes if not treated appropriately. We identified 8 professional athletes who underwent 11 direct metacarpophalangeal joint extensor mechanism repairs including centralization of the extensor tendon and sagittal band repair between 1989 and 1994. Success of the operative procedure was determined by the athlete's attainment of full range of motion, return to professional sports, and no need for additional surgical intervention. The metacarpophalangeal joints of the long and little fingers were most commonly involved. The position of the extensor mechanism disruption and the direction of the tendon subluxation varied. Capsular tears were identified in seven joints and none were repaired. At follow-up, each athlete had regained full range of motion and each had returned to professional sport an average of 5 months postoperatively. No patient required additional surgery. In this series, the principal lesion in metacarpophalangeal joint injury was extensor mechanism disruption with a predictable sagittal band tear and either a radial or ulnar subluxation of the central tendon. We recommend centralization of the extensor tendon and sagittal band repair without capsular repair as a treatment of choice for this injury, particularly in the athlete.

Adult↗
PubMedDate not supplied

Valgus laxity of the ulnar collateral ligament of the elbow in collegiate athletes.

In this investigation, we determined the patterns of valgus laxity and acquired valgus laxity of the ulnar collateral ligament in the elbows of collegiate athletes involved in overhead and nonoverhead sports. Acquired valgus laxity of the elbow is defined as the differential amount of stress valgus opening between the dominant and nondominant elbows. Forty-eight asymptomatic male athletes involved in sports that require overhead arm movements (baseball, tennis, and swimming) and 88 asymptomatic male athletes involved in nonoverhead sports (track, lacrosse, fencing, and wrestling) underwent fluoroscan examination of both their elbows with (13 daN) and without (0 N) valgus stress. There were no statistically significant differences in the amount of valgus stress opening or in acquired valgus laxity between the two groups. In fact, 25% (34 of 136) of the athletes showed an acquired valgus laxity of more than 0.5 mm, and 51.5% (70 of 136) had an acquired valgus laxity that was actually negative. There was also no correlation between the number of years played and acquired valgus laxity. Our results show that acquired valgus laxity does not exist in asymptomatic athletes involved in overhead sports, and there is no threshold value of measurement indicative of acquired valgus laxity.

Analysis of Variance↗
PubMedDate not supplied

Factors affecting bone loss in female endurance athletes: a two-year follow-up study.

BACKGROUND: Low bone mass leading to stress fractures is a well-known and yet unsolved problem among female athletes. PURPOSE: To quantify the rate of bone loss in healthy female athletes and investigate the effects of estrogen and vitamin K supplementation on bone loss. STUDY DESIGN: Prospective cohort study. METHODS: We classified 115 female endurance athletes into amenorrheic, eumenorrheic, or estrogen-supplemented groups and randomized them to receive either placebo or vitamin K(1). The bone mineral densities of the subjects' femoral neck and lumbar spine were measured at baseline and after 2 years. RESULTS: Bone mineral density in the lumbar spine remained constant, but bone density in the femoral neck had decreased significantly after 2 years in all three subgroups. The decrease was higher in amenorrheic (-6.5% +/- 4.0%) than in eumenorrheic (-3.2% +/- 4.1%) and estrogen-supplemented athletes (-3.9% +/- 3.1%). Supplementation with vitamin K did not affect the rate of bone loss. CONCLUSIONS: The rate of bone loss in all three subgroups of female athletes was unexpectedly high; neither estrogen nor vitamin K supplementation prevented bone loss. CLINICAL RELEVANCE: High-intensity training maintained over several years must be regarded in women as a risk factor for osteoporosis, and protocols for optimal treatment should be developed.

Adolescent↗
PubMed2004

Endoscopic evaluation and treatment of groin pain in the athlete.

BACKGROUND: Chronic groin pain in athletes forms a major diagnostic and therapeutic challenge. HYPOTHESIS: Evaluate and treat undiagnosed groin pain in the athlete by endoscopy. STUDY DESIGN: Prospective cohort study. METHODS: Athletes who were referred to the Ikazia Hospital with undiagnosed chronic groin pain between January 1998 and August 2001 were included. Radiography, bone scintigraphy, and ultrasonography were performed. In 14 athletes, groin pain remained undiagnosed. Ten patients complained of unilateral, 4 of bilateral groin pain. Patients underwent a transabdominal or extraperitoneal diagnostic endoscopy. RESULTS: All patients were operated ambulatory without significant difficulties. Pathology found by endoscopy was hernia inguinalis (n = 9), hernia femoralis (n = 4), preperitoneal lipoma (n = 3), and hernia obturatoria (n = 1). Only once was there no pathology. In 17 groins, a Prolene mesh was placed preperitoneally. Thirteen patients (93%) returned to full activity within 3 months of surgery. One year after surgery, one patient had minor symptoms and one patient had persistent symptoms. All other patients had no complaints. CONCLUSIONS: An occult hernia should be high on the list of differential diagnoses in undiagnosed chronic groin pain in athletes. Operative treatment can return the patient to his sport within 3 months.

Adolescent↗
PubMedDate not supplied

Anabolic steroids in athletics: how well do they work and how dangerous are they?

The use of anabolic drugs by athletes who wish to increase lean body mass and improve muscular strength is widespread, especially among elite weight-trained athletes. The current regimens used for steroid doping include combinations of injectable and oral preparations of steroids at doses 10 to 40 times greater than those prescribed therapeutically. Most of the scientific studies of steroid use by healthy male athletes have used steroid doses substantially lower than those used by many athletes. Analysis of these studies suggests that most persons will gain an average of 2.2 kg of lean body weight during steroid administration but that there exist great individual differences in strength changes induced by steroids. Approximately 50% of the investigations show significant improvements in strength measurements with steroid treatment, whereas the remainder show indefinite effects. There is no substantial evidence to support the use of anabolic steroids for improving aerobic work capacity. Anabolic steroids cause interrupted growth and virilization in children, birth defects in the unborn, severe virilization in women, and testicular atrophy and reduced blood levels of gonadotropins and testosterone in adult males. In addition, the oral preparations of anabolic steroids are associated with liver dysfunction, including carcinoma and peliosis hepatis, and a number of other disorders including unpredictable changes in mood, aggression, and libido. Although there have been only rare reports of severe or life-threatening side effects in athletes who have abused steroids, such side effects may not appear obvious until 20 years or more of widespread steroid abuse.

Administration, Oral↗
PubMedDate not supplied

Traumatic fibular shaft fractures in athletes.

A direct blow to the leg resulted in fibular shaft fractures in three elite college athletes participating in contact sports. None of the athletes had prior symptoms suggestive of a stress fracture. All three athletes had benign-appearing fractures and were treated nonoperatively. Ultimate healing was delayed, occurring on average at 23 weeks, and each case was complicated by refracture. Fractures of the fibular shaft in athletes may require more aggressive treatment than other simple fractures to allow sufficient healing to withstand the rigors of athletics.

Adult↗