1.	Figure Skating Injuries

		A. Boot-related injuries
			i.   Malleolar Bursitis
			ii.  "Pump Bumps"
			iii. Tibialis Anterior and Extensor Hallux Tendonitis
			iv. Achilles Tendonitis
			v.  Other Tendonitis
			vi. Other Problems  
B. Prevention of boot-related injuries
C. The ankle instability syndrome of the ice skater

2.	General Sports Nutrition

3.	Travel Smart

		A. Infectious Diseases
		B. Jet Lag

4.		Off Ice Conditioning Recommendations

5.		Blood Testing

 

1. Figure Skating Injuries

A. Boot Related Injuries

- this problem concerns almost all competitive skaters
- the cause is generally the boot, not the skater
- the main problem is the stiffness of the boot
- prevention must be systematic

i. Malleolar Bursitis

- frequently caused by boot pressure
- affects both the malleoli
- they are generally very well tolerated but can easily become inflamed with minor 
  irritation with a change of boot .

ii. "Pump Bumps" (Haglund's deformity of the calcaneal tuberosity).

- caused by a disproportion between the skater's heel and the excessive width of the 
  heel of the boot

iii. Tibialis Anterior and Extensor Hallux Tendonitis

- linked to repeated movements of dorsi flexion and plantar flexion, crossing laces and a 
  creasing of the boot tongue	  
- frequently there is crepitus present over the tendon
- cysts on tibialis anterior are frequent.

iv. Achilles Tendonitis

- relatively protected by the height of the boot heel, the Achilles tendon may be  
  compressed by the boot top with plantar flexion
- actually, the most frequent problem happens with off-ice training, when running or 
  jumping

v. Other Tendonitis are less frequent but it is possible to note on Magnetic Resonance 
   Imaging intra tendon fissuring and subluxation in front of the malleoli.

vi. Other Problems

- skin erythema caused by the compression of the shoe inducing pain among 
  recreational skaters
- bumps on the different prominence of the foot : base of the fifth metatarsal, 
  navicular.
- callouses, corns, and hammertoes
- all these problems are exacerbated by static pressure
 

B. Prevention of Boot Related Injuries

The boot should :

- fit well and adapt to the shape of the skater's foot easily
- be lightweight
- be made of materials as good as or better than the leather currently used.
- possess a broad forefoot
- be top padded with closed cell foam
- allow plantarflexion and dorsiflexion and, limit inversion and eversion
- be chosen at the end of the season (during a summer training period )
- never be worn alternately with the old boots.

To prevent malleolar bursitis :

- the boot should be : stretched with a ball and ring device.
- foam should be placed around  the malleoli, but never over it. 

The objective is to distribute the compressive force over a larger area.

To prevent "pump bump" :

- the boot should fit snugly at the heel.
- made to measure protection should be inserted at the heel.

To prevent tenosynovitis of the anterior tendons of the ankle

- tongue with denser cell foam should be used
- tongue creases and laces crossing (no more than one crossing and always lower than the top   
  of the boot tongue.) should be avoided.
- foam padding can be inserted in the area of the tongue affected to prevent pressure.

To prevent Achilles tendinitis

- great care should be exercised during off ice training
- the top of the boot should be padded with closed cell foam, especially the proximal rim.

The skater should :

- wear fine seamless socks and be sure the blade is mounted to suit their morphology.
- have adequate stretching exercise before and after the training
- have adequate off ice training for stabilization of lower extremity joints
 

C. The Ankle Instability Syndrome of the Ice Skater

The Ankle Instability Syndrome among ice skaters is characterised by the following points :

1. It almost only concerns skaters who train intensively on the ice (4 - 5 hours per day).
2. The instability involves not only the lateral ligament but also the medial deltoid ligament, the tibio fibula ligaments, the mid tarsal joints and fractures in the 5th metatarsal.
3. This injury from ankle instability can often occur off ice during running or walking on uneven ground or while training or competing on ice. There is a contrast between minimal cause and its disproportionate effect.
4. The frequency of this occurrence is sufficiently marked to necessitate a scientific study.
5. The skater's boot is certainly the principal cause of this syndrome. It possesses a 2 - 3 cm heel that is very rigid which limits certain movements of the foot. A skater spending 4 to 5 hours on-ice in rigid boots over many years loses part of his or her proprioceptive control of the foot.
6. The prevention of this syndrome is very important and it is necessary for the skater to do off-ice exercises which stimulates a proprioceptive effect from an early age. (exercises on balance platform and on air cushions).
7. In the event of a sprain a period of physiotherapy with proprioception and strengthening exercises may be necessary.

2. General Sports Nutrition

The diet should consist of a wide variety and sufficient amount of foods - breads and cereals, 
fruits and vegetables, dairy products and protein sources - to ensure that nutrient requirements 
are met.

Sources of Calories: General Recommendations: % of total calories consumed.

Carbohydrates 	55-65% (i.e. sugar, sweets, starch, pasta, broth, cereal, potato, rice) 
Protein 	15-20% (i.e. meat, fish, dairy products, eggs) 
Fats 	        25-30% (i.e. butter, meat, fried products, nuts)

The exercising athlete requires approximately 1-2 cups of fluids 30-60 minutes before activity 
and ½ cup fluids for every 15-20 minutes of exercise. Fluids and high carbohydrates foods/fluids 
should be available to the athletes at practices, competition and regularly throughout the day. 
Good choices would be water, juices, sport drinks, dried and fresh fruit.

If packed lunches/snacks are to be used for all day events they should include high carbohydrate 
foods especially from the 11 to 20 grams of carbohydrate per serving group.

When preparing the menus for the competition please consider the following recommendations.

1. Low fat protein sources should be available. ie : lean beef, skinless chicken, fish, legumes.
2. Use broth or stock rather than cream soups.
3. Avoid deep fried foods, instead have baked, broiled, roasted or barbecued foods.
4. Low fat dairy products should be available such as 1% milk and low fat yoghurt.
5. Please keep all sauces to the side. The availability of tomato, low fat milk and broth based sauces would be preferred.
6. Please have a vegetarian selection available. Preferably vegan with no meat, fish, poultry, dairy products or eggs.
7. Breakfast should be available a few hours before the first morning event. The dining hours should consider the schedule of the athletes so that all competitors have access to three meals per day, late night snack and replacement fluids and carbohydrates after competition and practice.
8. Plain rice, pasta, potatoes, breads should be available at all hot meals.

3. Travel Smart

A. Infectious Diseases

Participants in sport are subject to the same risks of infection as any other individual in the general population. Athletes travelling should be aware that they might be exposed to a population with a higher prevalence of viruses. Before travelling, athletes, coaches and officials should confirm the medical precautions required for each destination. The greatest risk with HIV (Human Immunodeficiency Virus) continues to be through sexual activity. The following recommendations are provided to reduce the risk of HIV and other infectious diseases including Hepatitis B (HBV) and C (HBC) viruses.

Prevention

1. Vaccination for Hepatitis B is now available and should be considered by athletes, coaches, officials and health care workers.
2. Check with a travel clinic or web site if you require any specific immunizations or precautions for your destination. Have the vaccinations as long as possible prior to competing as some may cause some short- term effects.
3. Vaccinations for other viruses such as influenza are available and are recommended prior to travel on aeroplanes or shared living accommodation.
4. Any instruments designed for piercing the skin, such as needles and syringes used for injection, ear-piercing, tattooing, acupuncture, and suturing should be sterile, not shared, used only once and disposed of appropriately in a puncture resistant container.
5. Any personal items that may pierce the skin or the mucus membranes should not be shared. This includes items like razors, toothbrushes, and nail clippers.
6. Blood and blood products must be screened for HIV, HBV and HCV before transfusion.
7. Safe sex and abstinence play a major role in decreasing infectious diseases including HIV.

B. Jet Lag

Jet lag is a group of symptoms that occur when the body's internal clock is trying to adjust to a new local time after crossing several time zones. It is important to try to minimize jet lag and maintain a training diet when travelling to other countries to compete. Below are some suggestions in order to make the transition as smooth as possible.

1. Prior to your flight eat a diet of complex carbohydrates to maximize your glycogen stores. Fluid stored with the glycogen will help to prevent dehydration.
2. During the flight emphasize moderate carbohydrate, low fat foods. Order your preference for foods prior to the flight ie: low fat, vegetarian.
3. Drink lots of cool fluids (bottled/mineral water, juices, clear carbohydrate soft drinks). Prior to the flight drink 2 cups of fluid in the hour before departure and during the flight aim for at least one cup of fluid per hour.
4. Avoid excess intake of caffeine (coffee, tea, and caffeinated soft drinks) which can promote dehydration.
5. Don't drink alcohol as it also dehydrates
6. Be prepared by carrying your own snacks of bottled water, cartons of fruit juice, fresh fruit, raisins, dry cereal bagels, crackers, fig newtons, plain cookies).
7. Set your watch to the destination time prior to take off.
8. Stretch and exercise (walk) around the aircraft as much as possible to limit stiffness.
9. Try to rest or sleep sometime during the flight.
10. On arrival at your destination, try to get out in the sunshine if you arrive early enough in the day. Do not stay in the artificial light indoors.
11. Try to live by the clock upon arrival. Allow yourself only a short nap if you arrive in the morning.
12. Be active and exercise.
13. Avoid large meals and caffeine prior to going to bed.

4. Off-Ice Conditioning Recommendations
(Conclusions from Medical Congress in Lausanne 1997)

A. The physiological parameters to incorporate in training skaters includes :
		i.   flexibility
		ii.  strength : muscle power
		iii. aerobic capacity
		iv. anaerobic capacity
		v.  co-ordination and balance

	If all of these components are well trained then performance improves and with 
	consistent performance comes overall self confidence and psychological well being.

B. Off ice training is beneficial and should be incorporated into the athletes training 
     program for the following reasons:-

i.   Off ice training is beneficial for developing balance, flexibility, strength, 
     and cardiovascular fitness.
ii.  It can be adapted to be sport specific i.e. slide board, practice pairs lifts, 
     rotations for singles and pairs skaters and ballet movement patterns.
iii. Off ice conditioning is useful in designing programs for maintenance of 
     fitness and strength while recovering from an injury
iv.  Off ice training programs can prevent soft tissue / overuse injuries from 
     overstraining.

C. Appropriate pre-ice warm up and cool down should be done to prevent injuries.

D. Off ice conditioning should be used as conditioning for participation in the sport. 
     Participation in the sport should not be used for conditioning.

E. Males and females mature at different ages (females 11-14yrs and males 12-15yrs) 
    and this must be considered when planning a training program.

F. The growth of a young skater should be monitored so training can be tapered during 
    phases of rapid growth to avoid injuries specific to children during this phase of     
    development.

G. Physiological testing (VO2 max, flexibility, vertical jump, body composition and 
     haematology) of elite skaters should be monitored in order to plan appropriate      
     training programs for maximum performance.

H. Do not use plyometrics before the age of 8 years.

            I. Use periodization training: 
-	early off season - rest and cross training 
-	late off season - train aerobically, strength, flexibility
-	pre-season - interval training, plyometric
-	in season - maintain preseason fitness, taper.

J. Coaches, physiologists, and physicians must maintain communication so research 
   can be directed towards specific goals for skaters to improve performance and 
   prevent injuries.

5. Blood Testing - Use of the SAFE (Safe And Fair Events) Paradigm by the International Skating Union

Background

Blood doping practices enhance endurance performance, thereby constituting a direct violation of the ethic of fair sport. Taken to an extreme, these practices can lead to more direct consequences for the athlete: harm to their health or even death. Fortunately, the degree of unfairness and health risk are related to the degree in which hemoglobin (concentration of molecule that carries oxygen) or hematocrit (percentage of red blood cells in blood) are raised. This has provided a starting point to control the problem.

The SAFE (Safe and Fair Events) paradigm has evolved from 2 lines of work. Both lines of work have had the goal of addressing the problem of blood doping practices in endurance sports.

The first line, which has been pursued by several international sports federations, is the use of hemoglobin or hematocrit limits to allow an athlete to start a race. FIS (cross country skiing and nordic combined) was first to impose limits, followed by cycling, biathlon and speed skating. The advantage of the limits is that it reduces both the degree of unfairness and the degree of risk to the athlete. The disadvantage is that there can be both false positive (unusual genetics, dehydration) and false negative (doping below the limits) results.

The second line of work has been conducted by several scientists around the world (Australia, Canada, China, France and Norway) and culminated in the EPO 2000 project where indirect markers of EPO use in blood were coupled with a direct test in urine to provide the first testing for EPO at the Sydney Olympic Games. The advantage is that the results can conclusively demonstrate the current or recent use of recombinant EPO (rhEPO). Disadvantages include that the tests partially rely on indirect markers and that the tests do not address other forms of blood doping.

The SAFE paradigm utilizes strengths from both these efforts to effectively and fairly, detect and deter the use of various blood doping practices.

All athletes must submit to an initial screening prior to competing. Three milliliters of blood is drawn and analyzed by the Bayer Advia 120 hematology analyzer. In addition to measuring hemoglobin and hematocrit as has been done before, various aspects of the analysis can be used to evaluate the rate of production of red blood cells, or erythropoiesis. Examination of these additional parameters can indicate the use of recombinant EPO (rhEPO), transfusions and hemoglobin based oxygen carriers(HBOC's).

Based on the Advia results that are placed in the SAFE paradigm, athletes are either allowed or not allowed to start the race and depending on results are subject to follow-up tests that would be used to prove various blood doping practices.

The net effect is to screen all, minimize risk to the athlete and focus blood doping detection efforts on those that are most likely to have behaved unethically.

Efforts of the ISU

The International Skating Union (ISU) has initiated a program in this endeavor. During its 1999-2000 season, a pilot program was begun whereby blood tests were performed on all of the athletes competing in two competitions (the World Speed Skating Championships and the World Speed Skating Championships Single Distances). The results of these blood tests were pooled with data from testing elite athletes from two other winter sports federations (International Ski Federation and International Biathlon Union), from which further refinement of the SAFE protocol was completed. In addition a data base of the results was also created for further comparison with subsequent blood tests performed on the ISU athletes.

During its 2000-2001 season the ISU has fully implemented the SAFE program, with publication of ISU Communication 565 (attached or Appendix 2) distributed to its Member countries defining the procedures and parameters from which any disciplinary actions would be taken. With Dr. Jim Stray-Gundersen, one of the scientists involved in the EPO 2000 project serving as consultant, testing was performed at three ISU competitions (a World Cup competition, the Junior World Championships Speed Skating, and the World Speed Skating Championships Single Distances). At each of these events, a screening blood test of all athletes competing was performed the day before the competition was scheduled to begin. Based on the SAFE algorithm categories decisions were made to either allow the athlete to compete or withdraw them from the competition, and further investigations were undertaken. These further investigations involved further analysis of the previously obtained blood sample for additional evaluation of the athlete's erythropoiesis, serum EPO determinations, and urine tests for rhEPO.

In addition, based on the previous years' blood test results and the testing from this season, a select number of athletes underwent out-of-competition testing of urine samples for detection of rhEPO.

The SAFE algorithm:

Note: For the 2002-2003 season, the ISU has converted from using Hematocrit in the algorithm to using Hemoglobin values.

S.A.F.E. testing
Level 1 Screen Hemoglobin (Hb)	Men: less than 17.2 g/dl Ladies: less than 15.7 g/dl		Men: Greater than or equal to 17.2 g/dl and less than 18.0 g/dl Ladies: Greater than or equal to 15.7 g/dl and less than 16.5 g/dl		Men: Greater than or equal to 18.0 g/dl Ladies: Greater than or equal to 16.5 g/dl
Level 2 Screen Rate of Erythropoiesis and/orChange from previous tests	Normal And less than ±2 standard deviations from previous tests	Abnormal Or greater than or equal to ±2 standard deviations from previous tests	Normal And less than ±2 standard deviations from previous tests	Abnormal Or greater than or equal to ±2 standard deviations from previous tests	Not Applicable
Category Name	A	B	C	D	E
Compete	Yes	Yes	Yes	No	No
Investigation*	No	Yes	Yes	Yes	Yes

The ISU believes the SAFE paradigm is an extension and refinement of using Hemoglobin or Hematocrit limits to allow an athlete to start a race. The improvements over the existing programs are the following:

1. The SAFE protocol allows for individuals with unusually high Hematocrit on the basis of genetics or dehydration to start, but also be investigated, thus reducing "false positives". This was particularly important in the altitude of Salt Lake City.

2. The SAFE protocol while still allowing the athlete to compete, starts an investigation of athletes that may be doping, but remain below the limit, thus reducing "false negatives".

3. The SAFE protocol is a screen that can initiate and direct further testing to identify doping practices including rhEPO/NESP use, transfusions and the use of free hemoglobin products. By screening, we make doping control less expensive and more effective.

4. The SAFE protocol is also a refinement of the tests performed at the Sydney Olympics. It uses some of the same variables initially and then, if warranted, measures the other parameters in blood and urine that comprised the Sydney Olympic testing.

5. The SAFE protocol is fair since all athletes are screened and is less stressful on the athletes (and staff) because blood does not need to be drawn in the hours before a competition. Rather, it is done at least a full day before the athlete's competition begins.

6. The SAFE protocol lends itself to longitudinal comparisons. By scheduling 6 blood draws (every 3-4 weeks) over the skating season, we can effectively eliminate the ability of an athlete to utilize unethical means of enhancing oxygen carrying capacity.

7. The SAFE protocol includes post race blood testing in athletes who have been selected for doping control. This allows to search for artificial oxygen carriers, plasma expanders and other types of manipulation.

Summary

In summary, this program provides extremely strong deterrence and detection against current known blood doping practices. It takes the uncertain athlete (coach or doctor) out of the ethical dilemma of thinking that unethical practices are the only way to win because "everyone else is doing them too". By implementing the SAFE paradigm the ISU ensures that athletes in speed skating can compete on a safe and even playing field.

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