Authors:)Jacquelyn)Supplee,)ATC,)MPH)RD)Candidate)2014) Clinical)mentor:)Rachel)Stratton,)MS,)RDCLDN,)CSSD)
Paper)mentor:)Liza)Makowski,)Ph.D.) )
ABSTRACT)
* Injury*during*participation*in*college*athletics*is*common,*and*as*physical*demands* and*an*athlete’s*playing*time*increases,*so*do*the*odds*of*experiencing*an*injury.**According* to*the*National*Athletic*Trainer’s*Association*(NATA),*the*rate*of*injury*in*intercollegiate* athletics*is*one*injury*every*2*games,*and*one*injury*every*5*practices*for*a*team*of*50* participants6.*Fortunately,*most*of*these*injuries*do*not*result*in*extensive*loss*of*playing* time6.*Of*the*injuries*reported*by*the*NATA’s*Injury*Surveillance*System*(ISS)*in*15*men’s* and*women’s*NCAA*sports*(divisions*ITIII)*per*1,000*participants,*more*than*50%*(53.8%* during*game*time,*53.7%*during*practice)*were*to*the*lower*extremities.*One*injury*of* particular*concern*is*the*anterior*cruciate*ligament*(ACL)*tear.*During*the*NATA’s*ISS*16T year*collection*period,*approximately*5,000*ACL*injuries*were*reported*(about*313/year)* in*the*sample*of*NCAA*athletes,*which*included*just*over*1*million*exposure*records*and* 182,000*injuries*between*1988*and*20066.*Regardless*of*the*mechanism*of*injury*(contact* or*nonTcontact*with*another*player),*ACL*injuries*accounted*for*3%*of*all*injuries*in*the* observed*cases.*In*men’s*soccer*players,*ACL*injuries*had*a*frequency*of*168*incidences*–* about*1.3%*of*all*injuries*reported6.*These*numbers*show*that*the*ACL*injuries*are*in*fact* rare,*compared*to*other*injuries,*however*88%*of*ACL*injuries*reported*resulted*in*an* extensive*(greater*than*10*day)*time*loss*from*practice*or*sport*activity6.*This*loss*of* training*time*can*lead*to*deconditioning,*atrophy,*decreased*endurance*or*cardiovascular* conditioning*in*the*injured*athlete.***
Regardless*of*the*type*of*injury,*one*of*the*primary*goals*for*the*sports*medicine* staff*that*care*for*these*athletes*is*adequate*healing*and*ensuring*prevention*of*future* injuries*in*that*individual.*Primary*concerns*with*recovery*and*rehabilitation*are*focused* on*preventing*extensive*muscle*atrophy,*regaining*normal*range*of*motion*(ROM)*and* functionality*of*the*injured*area,*followed*by*total*body*strength,*agility*and*balance.* During*injury*recovery,*there*is*typically*prolonged*muscle*disuse,*which*results*in* progressive*loss*of*skeletal*muscle*mass23.*Nutrition*is*a*means*to*preserve*body*mass*by* ensuring*adequate*intake*and*balance*of*nutrients*in*concert*with*the*promotion*of*healing* and*rehabilitation*activities.**
* The*following*case*study*focuses*on*Pluto,*a*21Tyear*old*NCAA*Division*I*men’s* soccer*player*13*weeks*following*the*surgical*repair*of*a*torn*right*ACL*experienced*during* sport*activity.*After*surgery,*typical*lean*muscle*mass*as*a*result*of*disuse*atrophy*can*be* upwards*of*1*kg*per*week23.*At*UNC,*the*sports*medicine*team*utilizes*a*physical*
meals*and*snacks,*the*sports*dietitians*work*with*the*athletic*trainers,*team*physicians*and* physical*therapists*achieve*their*goals*for*a*more*effective*recovery*and*quicker*returnTtoT play*in*athletes.**
)
INTRODUCTION)
NATA’s*ISS*analysis*revealed*that*preseason*practices*have*the*highest*rate*of*injury* (6.6*per*1,000*participants)*versus*inTseason*and*postTseason*practices6.*This*could*be* explained*by*the*increased*practice*times*and*training*load,*as*well*as*deconditioned* athletes*returning*to*highTintensity*exercise6.**When*an*athlete*experiences*an*injury,*one* of*the*primary*goals*is*adequate*healing*and*ensuring*prevention*of*future*injuries.* Primary*concerns*with*recovery*are*surrounding*muscle*atrophy,*range*of*motion*(ROM)* and*functionality*of*the*injured*area.*During*injury*recovery,*there*is*typically*prolonged* muscle*disuse,*which*results*in*progressive*loss*of*skeletal*muscle*mass23.**Disuse*atrophy* can*result*in*impaired*functional*strength,*reduced*insulin*sensitivity,*decreased*basal* metabolic*rate*(BMR)*and*increased*body*fat*mass23.**Loss*of*skeletal*muscle*can*occur*up* to*0.5%*of*total*mass*per*day,*or*up*to*1*kg*muscle*mass*loss*per*week*as*a*result*of*disuse* or*immobility23.*With*loss*in*muscle*mass*comes*loss*of*strength*and*function,*which*could* result*in*between*0.3%*and*4.2%*in*overall*strength*declines*per*day23.*For*example,*if*a* person*was*able*to*perform*a*50kg*leg*extension,*he*would*only*be*capable*of*performing* the*same*exercise*at*40kg*following*2*weeks*of*immobilization23.**To*preserve*strength*and* muscle*mass,*through*promoting*anabolism*and*preventing*catabolism,*nutrition*in*
concert*with*physical*activity*via*rehabilitation*exercises*are*of*major*importance*to*the* recovering*athlete.**
The*sports*medicine*team*physicians,*athletic*trainers,*coaches,*strength*coaches,* and*sports*team*dietitians*work*together*to*promote*timely*recovery*and*returnTtoTplay*of* the*injured*athletes*they*work*with.**Nutrition*is*able*to*play*a*larger*part*in*the*recovery* process*in*order*to*prevent*catabolism,*or*breakdown*of*body*protein,*and*help*speed* recovery*by*providing*adequate*nutrients*through*food*and*supplemental*nutrition* products.**
The*following*case*study*will*outline*the*road*to*recovery*and*returnTtoTplay*of*a* NCAA*Division*I*men’s*soccer*player*with*surgical*reconstruction*following*a*right*anterior* cruciate*ligament*(ACL)*tear.**The*nutritional*concerns*and*benefits*of*interventions*
utilized*in*his*recovery*and*rehabilitation*are*discussed.** )
PHASES)OF)HEALING)
Healing*from*an*injury*occurs*in*2*stages,*which*are*then*broken*down*into*shorter* periods.*Nutrition*plays*a*role*in*each*of*these*phases,*and*has*an*influence*over*how*the* injury*progresses.*The*first*stage*is*tissue*repair,*immobilization*and*atrophy,*with*shorter* periods*of*inflammation,*cell*proliferation*and*remodeling21.*)
The*inflammatory*period*is*relatively*short,*and*marked*by*the*activation*of* processes*that*result*in*elimination*of*invading*microorganisms*and*initiation*of*tissue* healing21.*It*should*be*noted*that*some*level*of*inflammation*is*needed*for*tissue*healing,* with*the*goal*of*avoiding*excess*inflammatory*response.*Most*exerciseTinduced*injuries*in* otherwise*healthy*individuals*do*not*result*in*uncontrolled*inflammation21.*
tissue*formation21.*All*of*these*call*for*an*increase*in*protein*synthesis,*and*therefore* increased*protein*and*energy*needs*for*proper*healing*and*tissue*formation21.**
The*final*part*of*the*first*stage*of*healing*is*remodeling,*in*which*scar*tissue*formed* during*proliferation*is*broken*down*and*then*replaced*by*type*I*collagen,*so*both*
degradation*and*synthesis*of*proteins*are*occurring*during*this*period21.**
The*second*stage*of*injury*recovery*is*rehabilitation*and*hypertrophy,*during*which* the*individual*reTgains*strength*and*functionality*in*the*injured*limb.*Unfortunately,*the* rate*at*which*a*person*is*able*to*recover*both*size*and*strength*of*muscle*tissue*is*slower* than*the*rate*at*which*it*was*lost21.*Resistance*exercise*during*rehabilitation*will*result*in* increased*tendon*collagen*synthesis,*muscle*protein*turnover,*and*synthesis*of*myofibrillar* proteins,*all*leading*to*hypertrophy,*and*therefore*return*of*strength21.*This*too,*requires* more*calories*and*protein*as*activity*starts*to*increase,*and*more*protein*synthesis*is* occurring.*Therefore*the*ultimate*goals*during*the*two*phases*of*healing*are*to*promote*the* healing*of*damaged*tissue,*and*to*maintain*lean*muscle*mass*in*order*to*support*the*
structural*integrity*of*the*joint.*With*proper*rehabilitation,*strength,*stability,*and*the* function*of*the*injured*limb*can*return*to*what*they*were*before*injury.**
*
ANABOLIC)RESISTANCE)
There*are*a*plethora*of*problems*that*arise*from*extensive*immobilization,*leading* to*changes*in*protocols*in*recent*years*to*alter*how*long*after*an*injury*someone*should* remain*immobilized.*During*immobilization,*loss*of*muscle*due*to*disuse*can*cause* mitochondrial*oxidative*function*to*decline*through*downTregulation*of*mitochondrial* proteins,*as*well*as*a*decrease*in*mitochondrial*enzyme*activity*as*early*as*48*hours* following*inactivity21.**Insulin*responsive*glucose*transporter*GLUT4*action*and*content* can*decline*in*muscle*tissues*as*a*result*of*inactivity21.*GLUT*4*transporters*are*insulinT dependent*protein*found*in*skeletal*and*cardiac*muscle*cells,*as*well*as*adipocytes,*that* allow*glucose*to*enter*cells*from*the*blood*stream*for*energy*(ATP)*production.*With* declined*GLUT*4*transporters*or*decreased*insulin*and/or*insulin*resistance,*less*glucose*is* able*to*enter*cells,*and*unable*to*be*used*for*energy*production21.*Anabolic*resistance*can* occur*when*the*myofibrillar*proteins*become*unable*to*respond*to*stimuli*for*growth*such* as*amino*acids*and*insulin*as*a*result*of*immobility21.*If*unable*to*respond*to*amino*acids*in* concert*with*the*decline*in*glucose*uptake,*this*would*propel*the*catabolic*state*if*
nutritional*stimuli*such*as*amino*acids*or*insulin*could*not*promote*anabolism21.**With* decreased*muscle*building*paired*with*promotion*of*catabolic*activity,*muscle*atrophy*and* lean*tissue*losses*could*perpetuate*further.**
*
STRUCTURE)OF)THE)KNEE)AND)FEATURES)OF)THE)ACL)RECONSTRUCTION) PROCEDURE)
* The*ACL*attaches*on*the*proximal*end*of*the*anterior*tibia,*and*passes*backwards*to* the*inner*lateral*femoral*condyle13.*The*PCL*then*crosses*from*the*back*of*the*tibia*up*and* forward*to*the*anterior*portion*of*the*lateral*surface*of*the*femur’s*medial*condyle13.**The* patella*is*a*sesamoid*bone*located*within*the*tendon*of*the*quadriceps*femoris*muscle,*and* resides*within*the*femoral*condyles,*and*the*patellar*tendon*inserts*into*the*anterior* tibia13.*
* The*ACL*is*vulnerable*to*injury*when*the*tibia*is*externally*rotated*with*the*knee*in* a*valgus*position*(angled*medially),*or*as*a*result*of*a*direct*blow*or*contact*with*another* person*or*object13.*When*a*person*experiences*a*complete*(3°))ACL*sprain,*the*joint*is*left* very*unstable*and*reconstruction*involving*a*graft*from*either*the*patient*(autograft)*or* cadaver*(allograft),*or*through*intense*rehabilitation*depending*on*the*patient*and*care* provider.**Surgery*to*repair*the*torn*ACL*is*generally*indicated*for*individuals*who* participate*in*athletics,*or*someone*who*experiences*instability*in*the*knee*following*an* ACL*tear*during*exercise*or*routine*activity16.**
* At*UNC,*the*standard*treatment*of*ACL*surgeries*includes*pain*and*inflammation* management,*preT*and*postToperative*strength*exercises*to*prevent*extensive*loss*of* muscle*mass*and*function,*as*well*as*a*prescription*of*fish*oil*and*Juven*(an*Abbott*product* containing*glutamine,*arginine,*and*βTHydroxyTβTMethylbutyrate*(HMB)).**Athletes*may* also*elect*to*take*creatine*monohydrate*following*consultation*with*their*team*dietitian,* which*they*would*purchase*on*their*own.*Once*their*prescriptions*run*out,*athletes*are* able*to*purchase*these*on*their*own*from*any*drug*store.*The*benefits*and*dosing*protocols* for*those*supplements*are*outlined*following*the*case.*)
)
THE)CASE)
* Pluto*is*a*21TyearTold,*AfricanTAmerican*male,*weighing*71.7*kg*and*171.5*cm*tall.* He*plays*for*an*elite*level*men’s*soccer*team,*and*is*a*senior*in*college.**Previous*injuries* include*a*fractured*tibia*when*patient*was*10*years*old,*and*on*two*occasions*a*sprained* right*medial*collateral*ligament*(MCL)–*neither*of*which*indicated*surgical*repair.**He* experienced*a*torn*ACL*as*a*result*of*contact*with*another*player*during*a*voluntary* practice*on*August*4th.**Just*under*a*month*later,*on*September*2nd,*Pluto*had*a*patellar* tendon*autograft*ACL*reconstruction*of*his*right*knee.*In*the*month*between*his*injury*and* surgery,*Pluto*worked*with*his*physical*therapist*and*athletic*trainer*to*maintain*his* strength*in*both*legs*as*a*means*to*preserve*lean*mass*in*his*lower*extremities.**** * With*immobilization*following*surgery*combined*with*decreased*activity,*
preventing*extensive*muscle*atrophy,*return*of*function*and*stability*within*the*knee*joint* are*the*top*priorities*for*the*entire*sports*medicine*team.*This*is*where*the*nutritional* interventions*became*key*in*the*recovery*process.*At*UNC,*each*athlete*that*undergoes* surgical*repair*of*an*injury*receives*a*prescription*from*their*team*physician*for*Juven*and* fish*oil*supplements*for*the*duration*of*their*recovery.*Creatine*monohydrate*was*also* recommended,*for*the*first*12*weeks*following*surgery*according*to*the*creatine* supplementation*protocol*to*prevent*excess*muscle*catabolism*and*promote*lean*mass* preservation.*The*UNC*postTsurgery*and*creatine*protocols*are*outlined*in*the*next*section,* as*well*as*in*table*1.*
with*training*and*identify*those*who*may*be*at*risk*for*low*bone*density.*The*DEXA*also* provides*coaches*with*the*amounts*of*lean*and*fat*mass,*which*helps*the*team*dietitian* when*outlining*nutrition*interventions*and*monitoring*progress*of*body*composition.*The* team*DEXA*appointments*occurred*shortly*after*Pluto’s*injury*(August*7th).**A*followTup* DEXA*to*help*evaluate*Pluto’s*progress*with*regard*to*body*composition*was*performed*on* October*20th.*Results*of*the*DEXA*scan*are*presented*in*table*1,*as*well*as*figures*1*and*2.* Overall*body*weight*increased*by*0.8*kg*between*August*and*October,*and*percent*total* body*composition*as*lean*mass*has*decreased*2.4%*(1.0*kg*lean*mass*loss)*with*a*1.8*kg* gain*in*body*fat*mass.*In*his*right*leg,*he*has*a*loss*of*0.965*kg*lean*mass,*with*a*gain*in* 0.595*kg*of*body*fat.*In*his*left*leg,*he*has*experienced*a*0.083*kg*gain*in*lean*mass,*with* 0.039*kg*increase*in*fat.*Regarding*bone*mineral*density,*Pluto*had*an*overall*loss*of*0.023* g/cm2*between*the*August*and*October*DEXA*scans*(0.033*g/cm2*in*the*left*leg,*0.045* g/cm2*in*the*right*leg).**
His*estimated*energy*needs*were*calculated*at*25*–*30*kcal/kg*(1,792*T*2,151* kcal/day),*to*account*for*increased*energy*demands*of*the*wound*healing*process,*and*in* consideration*of*energy*expended*during*rehabilitation*exercises.*Estimated*protein*needs* were*calculated*using*1.4*–*2.0*g/kg,*or*86T122*g/day*to*account*for*wound*healing*and*to* prevent*body*protein*catabolism.***
The*UNC*Sports*Medicine*team*responsible*for*the*care*and*recovery*of*Pluto*and* other*athletes*includes*the*team*physician,*sports*dietitian,*athletic*trainer,*physical* therapist,*and*strength*coach.*The*goals*of*Pluto’s*rehabilitation*plan*involve*pain* management,*inflammation*control*utilizing*cold*and*compression*therapies,*improving* range*of*motion*(ROM),*strength*improvement,*and*finally*return*of*agility,*speed*and* functionality.**A*full*outline*of*Pluto’s*rehabilitation*plan*is*included*in*figure*3.*
Immediately*following*surgery,*he*was*instructed*to*do*light*ROM*and*muscle*contractions,* and*used*a*cold*compression*boot*(Game*Ready,*by*CoolSystems*Inc.)*to*help*with*pain,* blood*flow,*and*control*of*excessive*inflammation.*He*was*prescribed*hydrocodone*as* needed*for*pain,*and*was*instructed*to*wean*off*of*it*starting*24*hours*after*surgery*as* tolerated.**
Pluto’s*rehabilitation*program*with*UNC*Sports*Medicine*started*24*hours*following* surgery,*and*was*scheduled*for*appointments*5*days*a*week*throughout*his*recovery.**At* his*first*appointment*he*was*also*given*a*Game*Ready*boot*for*home*use,*crutches,*a*brace* that*allows*for*“locking”*for*controlled*ROM,*and*his*nutritional*supplements.*As*identified* in*the*timeline,*he*would*progress*with*weight*bearing*and*walking*without*crutches,*with* the*brace*ROM*unlocked*to*provide*greater*freedom,*then*finally*without*the*brace*(see* figure*3).**
* Since*the*injury,*Pluto*reported*loss*of*appetite*initially*which*he*thinks*was*due*to* decreased*physical*activity*and*at*times*would*have*to*force*himself*to*eat.*He*reported*a* loss*of*approximately*2.7*kg*in*the*first*few*weeks*following*the*injury,*which*he*gained* back*within*2*months*of*the*injury,*and*his*appetite*has*returned*to*normal*by*week*3* postTsurgery.*He*did*not*report*any*major*gastrointestinal*symptoms*as*a*result*of*the* medication,*since*he*was*only*on*the*hydrocodone*for*a*short*period*of*time.**His*biggest* challenges*were*pain*while*standing,*which*limited*time*that*he*was*able*to*spend*cooking,* decreased*appetite,*and*limited*time*to*prepare*and*eat*food*between*classes*and*his* rehabilitation*appointments.**
* **
UNC)SPORTS)MEDICINE)POSTCSURGICAL)PROTOCOL:)
Juven)(Abbott)Pharmaceuticals,)Inc.):*Pluto*was*instructed*to*take*2*packs/day,*1*after* each*rehab*appointment*(about*2:00pm*Monday*through*Friday)*and*1*before*bed,*mixed* with*an*orangeTflavored*drink*(to*improve*palatability)*per*packet*instructions.*The* prescription*provides*2*boxes*(60*packets)*of*Juven,*enough*for*30*days.**
The*use*of*Juven*(Abbott*Pharmaceuticals,*Inc.)*is*typically*indicated*in*acuteTcare* settings*for*patients*with*cancer,*AIDS,*and*extensive*tissue*damage*such*as*burns,*trauma,* surgical*incisions,*or*pressure*ulcers*to*prevent*body*protein*breakdown27.*It*is*comprised* of*three*major*components;*arginine,*glutamine*and*βTHydroxyTβTMethylbutyrate*(HMB,* referred*to*by*Abbott*Nutrition*as*“Revigor”).*A*study*by*Williams*et*al.*found*that*
supplementation*with*the*combination*of*arginine,*glutamine*and*HMB*resulted*in*greater* collagen*deposition*in*healthy*older*adults*after*voluntary*subcutaneous*
polytetrafluoroethylene*(PTFE)*tube*placement*versus*those*without*supplementation24.**
• Arginine)is*a*conditionally*essential*amino*acid*during*situations*such*as*stress,*
trauma,*or*injury*where*the*body*isn’t*capable*of*synthesizing*enough*arginine*to* meet*its*needs.*It*serves*as*a*gluconeogenic*amino*acid,*capable*of*being*utilized*for* glucose*production*under*conditions*such*as*exercise*or*starvation3.*Arginine*has* also*been*found*to*stimulate*growth*hormone,*which*plays*an*important*role*in* protein*anabolism*and*muscle*recovery3.*Arginine*also*plays*a*significant*role*in*the* synthesis*of*creatine*(benefits*explained*below),*and*production*of*nitric*oxide,* which*aids*in*vasodilation,*improved*bloodTflow*and*oxygen*delivery*to*tissues*as* well*as*myocyte*differentiation*and*glucose*homeostasis3.*In*a*study*by*Barbul*et*al.,* arginine*supplementation*of*either*30*gm*arginine*hydrochloride*(24.8*gm*free* arginine);*(2)*30*gm*arginine*aspartate*(17*gm*free*arginine)*daily*for*two*weeks1.** Both*doses*resulted*in*increased*collagen*deposition*after*subcutaneous*PTFE*tube* placement,*as*well*as*increased*lymphocyte*mitogenesis*in*healthy*humans,*
suggesting*a*role*in*immune*function*as*well*as*tissue*healing1.**
• Glutamine)is*an*amino*acid*found*in*abundance*in*the*body,*as*it*is*used*for*a*
prevent*muscle*breakdown12.**Intracellular*decreases*in*glutamine*levels*of*up*to* 50%*and*30%*in*plasma*glutamine*can*occur*during*times*of*catabolic*stress*(such* as*with*trauma*or*injury),*making*glutamine*an*important*nutritional*element*for* both*immunity*and*tissue*repair12.*Glutamine*is*an*important*factor*in*the*
stimulation*of*the*inflammatory*response*in*initial*phases*of*wound*healing,*as*well* as*lymphocyte*proliferation20.*)
• βCHydroxyCβCMethylbutyrate)(HMB),)a*metabolite*of*the*branchedTchain*amino*
acid*leucine*plays*a*major*role*in*preventing*catabolism,*as*well*as*HMGTCoA* necessary*for*cholesterol*biosynthesis*in*the*liver26.*One*hypothesis*supporting*the* importance*of*HMB*is*that*with*insufficient*amounts*of*HMB,*damaged*or*stressed* muscle*cells*are*unable*to*produce*enough*HMGTCoA*needed*for*de&novo*synthesis* of*cholesterol,*thus*inhibiting*proper*cellular*function26.**There*could*also*be*a* possible*influence*on*promotion*of*lean*tissue*mass*through*upTregulation*of*mTOR* signaling11,*or*via*HMB’s*ability*to*inhibit*ubiquitinTproteasome*degradation*that*is* responsible*for*muscle*protein*breakdown12,*18,*24.**Besides*the*direct*effects*on* muscle*proteolysis*during*exercise*and*disease,*HMB*can*decrease*muscle*damage* by*decreasing*the*leakage*of*phosphocreatine*out*of*muscle*cells26.*It*has*been* shown*that*postTprandial*increases*in*BCAA’s,*leucine*in*particular,*act*as*an* anabolic*stimulus*for*muscle*protein*synthesis23.*Leucine*has*also*been*found*to* help*overcome*anabolic*resistance*of*protein*synthesis*stimuli21.*By*increasing* leucine*content*in*food,*postTprandial*protein*synthesis*is*positively*affected*in* older*adults23.**By*decreasing*the*amount*of*muscle*tissue*degradation,*the*scale*will* tip*in*favor*of*synthesis,*thus*resulting*in*anabolism*if*not*maintenance*of*muscle* mass.*)
*
Fish)Oil)(NatureMade,)Inc.):*Pluto*was*instructed*to*take*2*tablets*(720*mg*capsules)* every*day*with*dinner,*starting*on*day*5*postTsurgery.*One*bottle*of*fish*oil*capsules*(120* capsules*total)*is*provided*by*the*prescription,*enough*for*60*days.**
* It*is*well*known*that*omegaT3*polyTunsaturated*fattyTacids*(PUFA)*have*antiT
inflammatory*properties,*mainly*due*to*eicosapentaenoic*acid*(EPA)*and*docosahexaenoic* acid*(DHA)*and*production*of*thromboxanes*and*prostaglandins*to*effect*platelet*
aggregation*and*inflammation20,*21.*
*OmegaT3*PUFA’s*also*have*effects*on*muscle*protein*synthesis.*A*study*by*Smith*et* al.*found*that*omegaT3*PUFA*supplementation*when*augmented*with*nutritional*stimuli* such*as*insulin*and*protein*intake*will*elicit*activation*of*mTOR*and*other*growthTsignaling* pathways*to*result*in*increased*muscle*cell*size*(as*determined*by*protein:*DNA*ratio)*and* protein*concentration19.**Supplementing*with*fish*oil*at*mealTtimes*would*prove*helpful*for* continued*anabolic*action*in*muscle*cells*and*further*preventing*catabolism,*along*with* prevention*of*excess*inflammation.**The*tablets*administered*to*Pluto*were*NatureMade* 720*mg*tablets*containing*360*mg*EPA*and*300*mg*DHA*per*tablet.*Supplementation*for* the*fish*oil*supplements*was*initiated*one*week*after*Pluto’s*surgery*to*allow*for*acute* inflammation*following*surgery*to*subside.**
UNC)SPORTS)NUTRITION)CREATINE)SUPPLEMENTATION)PROTOCOL:)
Creatine)monohydrate)(made*by*Dymatize,*Inc.):*Pluto*followed*the*12*week*postT surgery*protocol:*4*times*5*g*per*day*for*7*days,*3*times*5*g*per*day*for*3*weeks,*single* daily*dose*of*5*g*for*8*weeks.)*
Creatine*(as*creatine*monohydrate)*is*a*triTpeptide*compound*composed*of*the* amino*acids*glycine,*LTarginine,*and*methionine2.*Creatine*is*naturally*made*by*the* pancreas,*liver*and*kidneys,*and*is*converted*to*phosphocreatine*(PCr)*for*storage*in* skeletal*muscles2.*Phosphocreatine*is*capable*of*donating*a*phosphate*to*adenosine* diphosphate*(ADP)*to*produce*adenosine*triphosphate*(ATP),*which*the*muscle*uses* for*energy4.*This*process*is*known*as*the*PCrTEnergy*System,*and*is*commonly*used*in* shortTduration,*highTintensity*exercise,*such*as*sprinting,*swinging*a*bat,*or*throwing*a* shot*put,*but*has*also*been*researched*in*the*treatment*of*Alzheimer’s,*Parkinson’s* disease,*and*injury*recovery2,*4.*Creatine*is*often*used*as*a*supplement*or*ergogenic*aid* (any*supplement*or*training*device*that*may*help*improve*performance*or*enhance* training*adaptations*when*used)*in*healthy*athletes*to*improve*power*output*in*shortT burst*type*exercises,*as*it*causes*an*increase*in*skeletal*muscle*phosphocreatine* content,*which*allows*for*improved*ATP*delivery*as*a*result*of*phosphocreatine*
hydrolysis2,*4,*5,*23.*Creatine*supplementation*promotes*muscle*hypertrophy*and*muscle* mass*accretion*during*prolonged*resistance*training5,*23.*Creatine*has*also*been*found*to* attenuate*decreases*in*GLUT*4*transporters*in*skeletal*muscle*during*immobilization,* as*well*as*an*increase*in*GLUT*4*transporters*upon*rehabilitation*–*thus*preventing* insulin*sensitivity*in*skeletal*muscle23.**
In*a*doubleTblind*trial,*Hespel*et*al.,*showed*that*creatine*supplementation*can*be* effective*in*stimulating*muscle*hypertrophy*and*enhance*the*rehabilitation*of*muscle’s* functional*capacity*following*immobilization*and*disuse*atrophy5.**Pluto’s*dose*for* creatine*monohydrate*is*the*same*as*that*used*in*the*Hespel*et*al.*trial:*4*times*5*g*per* day*for*7*days,*3*times*5*g*per*day*for*3*weeks,*single*daily*dose*of*5*g*for*8*weeks.*The* use*of*creatine*has*been*found*to*be*safe*in*individuals*with*normal*kidney*function,*as* creatine*is*metabolized*to*creatinine*and*then*disposed*of*via*glomerular*filtration25.** The*kidneys*in*healthy*adults*are*able*to*compensate*for*the*increased*creatine*load* without*compromising*renal*function*in*both*long*and*shortTterm*use25.**Although*there* have*been*some*anecdotal*reports*of*muscle*cramping*or*injury,*creatine*
supplementation*has*been*found*to*have*no*negative*effects*on*hepatic*or*muscle* function15.**
)
ENERGY)AND)PROTEIN)NEEDS))
Since*Pluto*is*not*engaged*in*the*same*highTintensity*exercise*during*his* rehabilitation,*his*caloric*needs*are*less*than*his*preTinjury*state.*To*estimate*Pluto’s* energy*needs,*25*–*30*kcal/kg*(1,792*T*2,151*kcal/day)*was*used*to*calculate*caloric*needs* for*an*active*individual9,*22.*Pluto*still*requires*increased*calories*for*healing,*and*is*
Protein*needs*were*estimated*for*Pluto*at*1.2*–*1.7*g/kg*body*weight*(a*goal*of*86T 122*g/day),*to*factor*in*for*healing*of*both*his*ACL*and*patella*where*the*graft*was*taken.* Protein*needs*for*athletes*involved*in*intense*training*range*from*1.2*–*1.7*g/kg*to*support* muscle*repair*and*maintain*an*adequate*protein*balance28.*As*Pluto*is*not*performing* intense*exercise*during*recovery,*protein*intake*will*not*need*to*be*increased.**In*order*to* prevent*muscle*catabolism*and*support*muscle*tissue*growth*during*rehabilitation,*his* needs*are*still*elevated*above*what*a*nonTathletic,*healthy*individual*would*require.* Ideally,*eating*30g*of*protein*at*each*meal,*as*well*as*the*protein*provided*through*the* Juven*(14g*per*packet,*2*packets*per*day)*would*result*in*the*goal*of*86*–*122*g/day*being* reached.*Upon*advancement*of*his*rehabilitation*activities*and*return*to*play,*Pluto’s* protein*needs*will*increase*to*account*for*strength*training*and*practice,*which*will*be* approximately*1.5T2.0*g/kg*body*weight*(108*–*143g*protein/day)9.**
)
OTHER)SUGGESTIONS)
Pluto’s*dietitian*recommended*several*general*tips*to*optimize*healing*through*the* foods*he*was*consuming*daily*in*addition*to*the*recommended*supplements.*A*protein*goal* of*30*grams*at*each*meal*was*set;*suggestions*to*include*lean*meat,*eggs,*yogurt,*cheese,* nuts*and*fish.*The*sports*dietitian*also*suggested*Pluto*choose*colorful*fruits*and*
vegetables*that*would*provide*antioxidants,*vitamins*and*minerals*to*further*aid*in*healing* and*decrease*inflammation.*Vitamin*E,*for*example,*has*been*found*to*promote*gene*
expression*for*selected*muscle*proteins,*and*demonstrated*protective*effects*against* muscle*atrophy*in*immobilized*rats’*hind*limbs14.*Providing*antioxidants*through*food* would*potentially*combat*the*increase*in*mitochondrial*reactive*oxygen*species*(ROS)*and* oxidative*stress*caused*by*prolonged*muscle*inactivity14.**
Both*proteolysis*and*protein*synthesis*are*affected*by*the*disturbed*redox*signaling* in*damaged*muscle,*which*is*due*to*increased*ROS*and*diminished*antioxidant*capacity14.* In*inactive*skeletal*muscles*(due*to*immobilization*or*disuse,*for*example),*mitochondria* are*the*main*source*of*ROS*produced14.*In*a*study*by*Kavazis*et*al.,*mitochondria*in*the* diaphragm*of*mechanically*ventilated*mice*were*found*to*produce*higher*ROS*than*in*nonT ventilated*controls8.**It*was*also*found*that*ventilation*was*also*associated*with*lipid* peroxidation*and*protein*oxidation,*indicating*mitochondrial*damage*in*the*diaphragm8.* Fruits*and*vegetables*are*also*a*source*of*inorganic*nitrate*(NO3—),*which*provides*a* substrate*(via*reduction)*to*nitrite*(NO2—),*nitric*oxide*and*other*metabolites*that*result*in* vasodilation*and*improved*blood*flow*to*the*injury*site7.*Consumption*of*sodium*nitrate* (as*a*source*of*NO)*has*been*found*to*reduce*oxygen*consumption*in*exercise,*therefore* improving*efficiency*of*exercise10.**Nitric*oxide*is*also*produced*endogenously*via*arginine* metabolism,*as*well*as*during*reduction*of*nitrate*by*commensal*bacteria*in*the*saliva*and* GI*tract7.**
*
NUTRIENT)TIMING:)
65g*for*dinner)11.*In*breakfast*alone,*researchers*found*that*protein*synthesis*following*a* 30g*protein*breakfast*was*40%*higher*than*after*the*“skewed”*breakfast*of*10g,*even* though*daily*protein*intake*remained*the*same11.*Even*with*the*compensatory*intake*with* dinner,*protein*synthesis*in*the*evenly*distributed*protein*group*exceeded*that*of*the* skewed*group.*
)
PROGNOSIS))
* Pluto*is*currently*17*weeks*postTinjury*and*13*weeks*postTsurgery.*He*is*still*taking* supplements*according*to*the*UNC*Sport’s*Medicine*protocol*including*the*fish*oil*and* Juven,*and*has*completed*the*12Tweek*creatine*monohydrate*protocol.*Per*Pluto,*his*
compliance*with*the*prescribed*supplements*was*good.*He*states*that*at*times*he*may*have* forgotten*to*take*Juven*after*his*afternoon*rehabilitation*appointments,*but*creatine*and* fish*oil*he*was*at*100%*compliance.*He*is*continuing*with*his*rehabilitation*program*at* UNC*Sports*Medicine*five*days*a*week.*Currently*his*quadriceps*strength*is*unable*to*be* safely*assessed*as*it*is*contraindicated*due*to*vulnerability*in*his*patellar*tendon*from*the* autograft,*however*Pluto’s*hamstring*strength,*overall*flexibility,*and*quality*of*motion* have*seen*improvements*per*progress*notes*from*his*athletic*trainer.*A*timeline*of*Pluto’s* range*of*motion*and*ambulation*progress*(table*3),*as*well*as*planned*physical*
rehabilitation*activities*through*Pluto’s*return*to*play*(figure*3).**The*current*prognosis*for* return*to*play*is*March*2015*(6*months*after*his*surgery*date)*following*continued*
strength,*balance*and*agility*training*through*continued*rehabilitation*and*conditioning.** Pluto*will*continue*with*his*rehabilitation*daily*(except*on*weekends),*and*exercises* will*focus*on*first*decreasing*pain*with*movement,*then*increasing*ROM,*strength,*balance,* function,*and*finally*working*on*agility*and*sportTspecific*activities.*Before*being*cleared* for*play,*he*will*undergo*a*variety*of*performance*tests*(such*as*vertical*jump,*triple*hop,* weighted*squats,*10m*and*30m*sprints),*which*will*be*compared*to*his*preTinjury*test* scores*obtained*by*the*soccer*team’s*strength*coach.*Following*performance*testing,*Pluto* will*go*through*Physical*Readiness*and*Integrated*Movement*Efficiency*(PRIME)*testing*at* the*Sports*Medicine*Research*Lab,*which*assesses*quality*and*stability*of*movements*such* as*overhead*squat,*single*leg*squat,*singleTleg*tripleThop,*and*identifies*any*potential*risk* factors*for*future*ACL*injury.*One*test*in*particular,*the*Landing*Error*Scoring*System* (LESS)*test,*developed*at*UNC*Sports*Medicine,*is*an*objective*way*to*determine*risk*for* ACL*injury*based*on*the*amount*of*faults*seen*during*jump*landing.**
Following*successful*completion*of*these*tests*Pluto*will*be*allowed*to*participate*in* nonTcontact*aspects*of*practice,*then*in*unrestricted*practice*with*restricted*time*
allotments.*As*he*progresses,*the*time*Pluto*is*allowed*to*play*will*increase*until*he*is*fully* integrated*back*into*practice.***
*
CONCLUSION*
antioxidants*from*food*and*supplemental*sources,*the*nutrition*team*can*play*a*major*role* in*the*recovery*of*athletes.**
* Although*not*yet*fully*recovered,*Pluto*has*seen*few*setbacks*and*has*had*a*smooth* recovery*with*the*help*of*proper*nutrition*counseling*as*well*as*supplementation*of*omegaT 3*fatty*acids*(DHA*and*EPA),*creatine*monohydrate,*and*Juven*to*provide*HMB*CoA,*
arginine*and*glutamine.**His*muscle*and*lean*tissue*losses*have*been*minimal,*and*his* prognosis*is*promising*for*a*full*recovery*6*months*after*the*injury*date.*Utilizing*proper* nutrition*through*food*as*well*as*recognizing*the*benefit*of*proper*supplementation*can*be* effective*in*improving*recovery*outcomes.**The*prevention*of*extensive*disuse*atrophy*and* shortened*recovery*times*are*possible*in*athletes*who*require*surgical*intervention*
following*an*acute*musculoskeletal*injury.* *
*
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