Getting Ready For the Big Game

This weekend’s Super Bowl is sure to feature some incredible feats of athleticism. From their hearts and lungs to their muscles and joints, pro football players work hard to stay in peak physical condition. So, what can everyday athletes and weekend warriors learn from the pros?

Host, Jonathan Fialkow, M.D. welcomes a panel of experts with tips for everyday athletes striving to reach their own fitness goals.

Guests:

• Eli Friedman, M.D., medical director of sports cardiology at Baptist Health's Miami Cardiac & Vascular Institute
• Michael Swartzon, M.D., sports medicine physician at Miami Orthopedics & Sports Medicine Institute
• Amy Kimberlain, registered dietician with Baptist Health  

Transcript

Announcer:

At Baptist Health South Florida, it's our mission to care for you when you're injured or sick and help you stay healthy and fit.

Announcer:

Welcome to the Baptist HealthTalk podcast, where our respected experts bring you timely practical health and wellness information to improve your family's quality of life.

Dr. Fialkow:

Welcome Baptist HealthTalk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at Miami Cardiac & Vascular Institute, where I'm also Chief of Cardiology at Baptist Hospital and the Chief Population Health Officer at Baptist Health.

Dr. Fialkow:

This weekend's big football event is sure to highlight some incredible feats of athleticism. From their hearts and lungs to their muscles and joints, pro football players work hard to stay in peak physical condition. So what can everyday athletes and weekend warriors learn from following the professionals' example? I posed that question to a team of experts during a recent episode of Baptist Health resource live program, which I had the pleasure of hosting. My guests were Dr. Eli Friedman, Medical Director of Sports Cardiology at Baptist Health's Miami Cardiac and Vascular Institute, Dr. Michael Swartzon, sports medicine physician at Miami Orthopedics and Sports Medicine Institute, and Amy Kimberlain, a registered dietician and diabetes educator with Baptist health.

Dr. Fialkow:

Let's hear what they had to say.

Dr. Fialkow:

Eli, let's kick it off with you. I know you're an exercise enthusiast, you're a runner. You don't just walk the walk, you run the run, bad pun intended. We know it's important for everyone to be physically active for their overall health. Why is it even more important for athletes of all types to stay on top of their heart health? What does that mean? Speak a little bit towards heart health in an athlete?

Dr. Friedman:

Yeah, I appreciate you calling me a runner, it's more graceful falling at this point in time. But in any event, I think just by being human beings in the environment that we live in and certainly in this country in America, we're all at risk for heart disease, whether we've made maybe not the best dietary choices, maybe we've smoked at one point in time, or maybe our family history really isn't so great. Those things can accumulate over years. And then even occasionally in relation to the sport that one does, heart issues can arise. So it's always important to be aware of your body and specifically within the discipline that you and I focus, I think heart health is one of the things that we really want to pay a lot of attention to because it can create some problems if we're not aware of it.

Dr. Fialkow:

And exercise is important for heart health, but tell us how one should also pay attention to the body, such that one shouldn't think, "Well, I exercise, so I'm immune from possible hard complications?"

Dr. Friedman:

So I think you and I have established ad nauseam at this point via podcasts and other mediums that exercise is the best medicine out there. And certainly we have that data that accumulates that and supports it. But as we progress in that, and we become more and more fit, just being fit does not make you healthy, as one of our patients once told me. And so, again, as we discussed just a minute ago, we can accumulate bad dietary choices, smoking... but those things don't go away with exercise. It's not immune therapy. And so being aware of our bodies and our cardiovascular health to us is extremely important.

Dr. Fialkow:

So Michael, we all promote the importance of exercise and that might be someone who's very athletic, continuing to be athletic. But what about those folks that want to start an exercise routine? What advice would you have and what do you see in terms of both pacing themselves, but what would be perhaps the importance of warming up and cooling down to avoid exercise related injuries?

Dr. Swartzon:

Thanks, Jon.

Dr. Swartzon:

We always recommend that people who are eager to jump into it, to try and start off slow, if you were to see how the professional athletes prepare themselves for a game, they probably spend as much time in warmup as they do actually competing, between stretching, and activation, and massaging, and stretching again, and just doing different drills to get ready for their sport, both physically and mentally. If they're doing it, there's a reason for it. So it's very helpful for the novice athlete to understand you can't just jump into things when you're not prepared. And that preparation is key, thinking about what you want to do and coming up with a plan for success, right? So, for runners like Eli who've had years of experience, it's one thing, but there are nice programs to go from couch to 5k. And that doesn't mean you go out the first day and run a 5k. There's certain steps in between until you get to that goal.

Dr. Fialkow:

So I can certainly, and I may have even shared in a previous Facebook Live, I started running a few years ago. And the first day I pushed myself and tore a calf muscle and of course, couldn't run for three months. And of course, I should know better. Any rules of thumb... Clearly we all can't spend hours with massage therapists and physical therapists prior to going on exercise, so any particular rule of thumb regarding warmup?

Dr. Swartzon:

Yeah, concentrate on where you've had previous injuries, right? Your trouble areas really deserve the most attention. And so if it's, for you, for your calf, you should really be stretching your calf and getting it warmed up before every run.

Dr. Fialkow:

Which I do, but where were you a couple of years ago?

Dr. Swartzon:

Well, I was here. I was here. You never asked.

Dr. Fialkow:

My bad.

Dr. Swartzon:

And as far as cool down goes, really the most important part about cool down is the recovery aspect of it. So making sure you get re-hydrated, get your nutrients in for recovery. And then the most important part is the rest.

Dr. Fialkow:

Amy, Tom Brady gets a lot of press and I'll say notoriety for his diet, his eating habits, a lot of marketing behind his programs, leads to a lot of discussions though regarding how nutrition plays a role in athletic performance which is worthy. Eli alluded to the importance of exercise. I always say to patients, "We can't exercise your way out of a bad diet." So what are particular dietary guidelines you would recommend towards an athletic person, and then also someone who's beginning an exercise plan?

Amy Kimberlain:

I love how Dr. Swartzon, Michael, you mentioned just that part of warmup and cool down and how much time the athletes spend. And if I could only wish that, as a dietician, that people spend towards their food, right? And I think that when you think about the nutrition in all of the areas of time spent in training, if they train within their nutrition and thinking about how much of an impact that can improve their performance, right? So you said it, whether you're athlete, whether you're starting out a novice, all the in between, you have to know kind of what your nutritional needs are. It takes a little bit of time and reflection to sit back and say, "What is it that I'm eating?" People use that word diet, I just use it as the word food that they're eating, right? But knowing that not having an adequate amount of calories can also be hurtful as well, whether it's within the recovery part.

Amy Kimberlain:

I just had a discussion the other day with somebody talking about, "Well, how much protein do I need?" Everybody's individualized, and I think that, that's the biggest takeaway from this is that there's so many different athletes, whether it's for the big game or whether it's for just a runner that's going out. They just finished a marathon this past weekend, right? Everybody's individualized. So starting to take a reflection as to what they're taking in for a breakfast, a lunch, a dinner. And then going into the more specifics, whether it's that athlete that's doing two-a-days versus somebody that's just doing, again, the weekend warrior type example where they're just really going hard on the weekends. But it really boils down to the duration and intensity of their exercise, their fitness level. I know we're talking athletes, but if you are a novice, maybe you're not as fit. And so maybe you're thinking that someone needs this much protein and your needs are a little bit lower.

Amy Kimberlain:

And also, keeping in mind the timing of meals. I myself am a runner. And I can't tell you how much of an impact it makes in planning to wake up a little bit earlier, get in some pre-fuel, right? It's my week leading up to those big runs, making sure I'm adequately getting the proper nutrition with my carbohydrates, proteins, and fat, making sure all of my stored glucose and glycogen level there is. So that even though on that morning of the run, Jonathan, I'm really heading out and having now some actual fuel I'm using. So I don't have to tap into my stores.

Dr. Fialkow:

We're seeing athletes really performing at very high levels at later ages, and a lot of it is felt to be proper attention to nutrition. But you mentioned something I'm going to look for a clarification on because where I sit, I see a lot of misinformation, and if you're comfortable with, it's the concept of carb loading. And I see a lot of people who are overweight, plenty of energy storage, and they're going to start exercising and they have to carb load. You may need to carb load, you're thin, you don't have a lot of energy storage. Can you explain a little bit what that carb... or any of you can... what that carb loading is and where it does apply to the athlete, but where it may not apply to someone who's a [crosstalk 00:09:12] there with health?

Amy Kimberlain:

No, I mean, I think your question is great, Jonathan. And I think it's interesting because when I go into speaking to people, like you mentioned, Michael, the couch to 5k person versus someone that's already run marathons, I think it's really describing to them how many carbohydrates that they're getting and making sure that they're getting it throughout the week. That notion of doing a carb load, meaning just going excessively the night before for the next day's purpose, may not be necessary if you really, truly are each day tapping in and replenishing what you've used. And again, remember it makes a difference what type of exercise you're doing. You're alluding to storage and having more adequate than others. But regardless, you want to use carbs as your primary source of fuel.

Amy Kimberlain:

And so again, it comes back into that timing thing. If you're really going out for an early morning run at 6:00 AM, are you just waking up and going right out? Test it out and do it where now you have woken up a little bit earlier, and prior having something pre-run. Again, the amounts differ based on the individual, so it's hard to say for each person what they need. And obviously, you're taking into account different size examples. But it's also the different athleticism as well, because that makes a difference in what you're, again, being able to replenish and store as well. So I didn't get to the specifics because it's so individualized.

Dr. Fialkow:

So, I thank you.

Dr. Fialkow:

Yeah, exactly, that's a take home point. Everything's individualized, your age, where you are, your metabolic profile, [crosstalk 00:10:34], and of course, the activity.

Amy Kimberlain:

Age is just a number. I've heard in the news, there maybe a comeback already. I mean, after a week of retirement, come on.

Dr. Fialkow:

You got it, I like that. I like that concept.

Dr. Fialkow:

Michael, going back now towards warmups, cool downs. What are the more common sports medicine injuries that you see? And then specifically as relates to football, given the timing, what do you see as a trend regarding athletes in terms of their injuries?

Dr. Swartzon:

So, certainly bring up a good point that every sport has its own most common injuries, kind of the VIPs for that sport. With football, with the shoulder, again it's be very positioned specific. So football is a contact sport, so anytime the shoulder can hit the ground hard with a tackle while you're trying to hold the ball, you can cause a separation between two bones on the top of your shoulder and sprain those ligaments. If you're a quarterback, for example, you spend a lot of time throwing the ball, that overhead motion can result in rotator cuff damage or bursitis. And that's something we see very typically in the office, that's what we call impingement syndrome or just overuse of the shoulder.

Dr. Fialkow:

Do you see a difference, for example... Again, hopefully, it's a fair question... why do certain, let's say quarterbacks, have a very extended career, avoid a lot of injuries? Others might be injury prone. Does it have to do with style, or form, or luck? Any trends that you could speak towards?

Dr. Swartzon:

I do think there's a strong genetic predisposition for how the strength of the fibers are. As you've guys have mentioned earlier, there's the professional athlete and then there's the smart professional athlete that takes time for nutrition recovery. When the athletes aren't playing, or in the off season, their goal should be strengthening and cross training, right? Balance, form, all those things... For an athlete to do Pilates or other kind of core strengthening exercise is very important. And so there is some things that are entirely within their control, whereas some things are not.

Dr. Swartzon:

In football, if the offensive line isn't protecting the quarterback and you get hit more often than another quarterback, that certainly can increase your chances for injury. Some quarterbacks like to run and are very mobile. And once you leave that protected pocket, again you open yourself up to injury risk. And you could see on the sideline, if you watch a quarterback run, you'll see the whole sideline say, "Slide, get down, get out of the way." And if they don't, everyone's yelling at them. Even if they had a positive play, the concern is that the risk of injury in a contact sport is there, and the quarterback's an important position, and so they don't want that person to get injured.

Dr. Fialkow:

And similarly, at Miami Orthopedic Sports Medicine Institute and around the world, advancements in healing injuries, surgical procedures, et cetera, to extend careers is phenomenal as well compared to decades ago, right?

Dr. Swartzon:

Phenomenal. Yeah, for sure. When we go to the NFL Combine, what it was 10, 15 years ago, what we were seeing coming from college into the professional sports, to what we're seeing now, the athletes are in much better shape post-surgery than they were back then. So the advances are real.

Dr. Fialkow:

I still have scars in my memory, I was a big Joe Namath fan when I was a kid, and seeing his knee just all scarred up like Frankenstein's head. And we don't get that anymore, so enhancements are noted,

Dr. Fialkow:

Amy, we talked about diet and we will continue to talk about diet. And we know that athletes push themselves and their bodies more than the average person who might be healthy. Where, if any, is there a benefit towards performance enhancers and protein powders, supplements, those types of categories? We talked about diet, maybe carbohydrate loading in a certain situation. Speak a little bit about supplements.

Amy Kimberlain:

Just to go back though, when you think of energy and food as it relates... I mean, I'm always like a food-first person, but I do think it's still, what I said, kind of going through an intake for an athlete to see if they're really meeting the mark where it comes to protein. If their idea is that they want to gain some muscle, there's a lot of other areas that's been talked about, stress levels, sleep deprivation, alcohol injuries, all of that can make a difference then in what their actual needs are. And if they're not meeting the mark of where they need to be, I would say that would be the first place I'd start before heading towards a protein powder per se. And again, making sure that they understand where they can get it from food and showing the direct application, because a lot of times they're taking something like that, you're speaking towards maybe other types of supplements. I honed in on protein powder as an example. But again, if they're not really getting it from food and they can see how they get it, I think that's the simple, quick fix.

Amy Kimberlain:

Now, as to a thought process of saying, "Well, I want to improve my performance and I know that creatine's going to help build more muscle", maybe there is truth to that with certain studies. And I think, again, it comes back into each individual, what are their wants? How are they trying to improve their performance. But really targeting first the food before heading towards some of those areas where... Guess what? Supplements mean in addition to, it doesn't mean it's the replacement. And again, real important concept too for them to understand that they're not regulated in the same way as food, and finding a reputable source in order to make sure that they are using one that wouldn't be any cause for having something that could be a banned substance.

Dr. Fialkow:

I always enjoy teasing my... Well, maybe I should say educating my patients when they come in with a big belly and Big Mac sauce on their shirt and cigarette package. And it's like, "Is this protein powder good for my workouts?" And of course, it's in the context what's important, but let's not forget the simple things.

Amy Kimberlain:

No, I mean, it's... No, but it's just before you [crosstalk 00:16:45] it's that quick, simple thing of connection and what's the marketing, and there's a library marketing out there. And so again, if you're thinking like, "That says it does this, I want it", right? And I think, again, my job's not as like glamorous when saying, "You can just go eat some chicken." Or, if I'm a vegetarian, it might just be some beans or, again, maybe a peanut butter, or something of that sort that can really fit the bill.

Dr. Fialkow:

Right.

Dr. Fialkow:

It's the change in the lifestyle, taking very complex systems and reducing it to the magic berry, or this powder, or this pill.

Dr. Swartzon:

Just to add a minute for that discussion...

Dr. Fialkow:

Please.

Dr. Swartzon:

Amy's a 100% right, and I think supplements are rarely needed for the average person. And you're just spending your money unwisely and possibly adding something, like she said, a banned substance. Some of the reason why these products work is because there's actual testosterone or anabolic steroids in them. So please be careful.

Dr. Fialkow:

Well said.

Dr. Fialkow:

I know... turning over to Dr. Friedman... Eli, we've had those conversations as well regarding the lack of true benefit of supplements, especially in the average person who's just looking to become healthier.

Dr. Fialkow:

So Eli, now turning it back towards health and prevention, again we talked about earlier, athletes sometimes think they're immune for cardiovascular disease. What are the general recommendations that you have for the athletes that you take care of, or others should be aware of regarding, prevention, preventive care for cardiovascular disease avoidance and other types of screenings?

Dr. Friedman:

So bird's eye view on that is I think anytime we're having the ability or the opportunity to discuss with our patients, exercise and lifestyle should be one of the forefront things that we sort of come back to. So if they're already exercising at a high level, let's talk about it, talk about what their goals are and where they want to head. As I talked about a little bit earlier, there are very rarely and very occasionally certain cardiac conditions and health conditions in general, which can arise from very long term, very high intensity aerobic exercise, or other exercise as well. And I think we just continue to need to have those discussions with our patients as the opportunity arises, just to counsel them and make them aware. Now, these are not things that we would ever counsel people from exercising against, but I think it's still just setting expectations there.

Dr. Friedman:

With that being said, there are certain cardiovascular conditions that exercise can pose a problem. Now, fortunately, we're at a much better time now where we're looking for reasons people with those conditions to exercise, and not the other way around. But again, this needs to be done by people who are comfortable with it and having very detailed, nuanced risk-based discussions. And the buzzword in sports cardiology these days is shared decision making, making sure that the person in front of us understands what their risk is. And as we talk about, it's an ongoing discussion, it is not one appointment and done, and that's it. We need to constantly come back to that risk and reassess it.

Dr. Fialkow:

As you said, there are certain conditions that occur, and when we see a young athlete who might have a cardiac condition, even a fatal one, we sometimes assume it's the same things that older people commonly get. But as you mentioned, it's usually not. It's usually something either genetic, or congenital. Is that kind of a fair statement?

Dr. Friedman:

Yeah, absolutely. So we set that number at 35. So less than 35 years of age, if we're seeing heart conditions in our athletes, it's more than likely something they were either born with, or acquired via infection, or something else. So the ones you'll hear mostly about are hypertrophic cardiomyopathy, an abnormal thickening of the heart muscle, myocarditis, which has made the headlines a lot recently in the era of COVID, inflammation or infection of the heart. There are certain valvular disease or artery anomalies that we can be born with as well. So that's what we're going to see mainly in the young population. As those come up, as I said, 20 years ago, these athletes were put on the bench. They were told they could no longer exercise. And what we found was they were actually developing diabetes, hypertension, obesity, lots of things that could have been possibly prevented by continuing into exercise.

Dr. Friedman:

So now, again, we are encouraging these athletes to continued exercise. But again, as you like to allude to, Jon, it requires very specialized care and people who are really comfortable assessing that risk, having ongoing discussions with it, and are comfortable with the care of athletes. Athletes are a completely different subset of the population in all of medicine actually. And I'll toot to Amy and Michael's horns, even at the professional side with all of this, it requires a lot of detailed care, a lot of time, a lot of energy. It's not the glitz and the glamor that you would think Michael stands on the NFL sidelines on weekends. It's really vigorous and it requires a lot of time, a lot of attention. And so these are not easy discussions.

Dr. Fialkow:

And we welcome that approach and expertise, and I know the three of you work very well together in evaluating and helping assess and treat athletes. So again, it's great resource that we have. Hence, why you're on this Facebook Live as the experts.

Dr. Fialkow:

Michael, and to your expertise, someone has an injury, they get away from exercising. They now want to begin again recovering from that injury. You did mention a little bit of recovery, any general specifics you speak to your patients about if it's going to be getting back into an exercise routine after an injury?

Dr. Swartzon:

Absolutely.

Dr. Swartzon:

Speaking in general terms, there's three different main factors that you look at. Okay? One is obviously the physical aspect and then looking at the timeline. Some injuries are light ankle sprain, that's a few days which really doesn't need much. And other things can be in nine months. So, when you start getting into the chronic recovery, you need to talk about their nutrition, because if they keep their same diet with less exercise, they'll gain weight, which will make our recovery much more difficult.

Dr. Swartzon:

There's also a mental component, right? If you're used to exercising and getting those endorphins, and now you're not getting those and you don't have your way to socialize, or be with your high school friends, or your community group, it can be very difficult.

Dr. Swartzon:

And so those are two things that are not really orthopedic straightforward, but are very important in the recovery. And so to ignore those can lead to failure. Once those are taken into account, now you got to go usually with a professional, like a physical therapist, to help you go from the office where it's zero, to getting back on the field, or on the court, or on the track. And it's more of a graduated return that I kind of describe as your savings account, right? You put in a little every month and then with interest, it goes up a little by little, but then after a while it grows up a lot. So you start slow and you increase incrementally by percentage.

Dr. Fialkow:

I think that's fascinating, the diet, the socialization. Again, the secondary gain, if you will, of exercising, maybe your primary gain, on top of the physical components. That's a great perspective. Do you see people commonly re-injure themselves because they've resumed activities too rapidly or too forcefully?

Dr. Swartzon:

That's very commonly the case. The recovery is incomplete, or they push the envelope too far. Having setbacks in your rehab is common. I wouldn't necessarily always call those a re-injury, but things like hamstrings are seven times more likely to happen once you have them the first time. And so there's scar tissue, there's areas that just predispose you to having it again. And that's where part of the recovery is a new maintenance program that you're now going to be required to do for the rest of your life that you want to be active.

Dr. Fialkow:

Thanks for that response.

Dr. Fialkow:

Eli, something I know you're very passionate about, you spend a lot how to work with the community, both in educating and providing resources for. And that's of course, AEDs, defibrillators at sports sites and other public areas/ the student athlete, are they more susceptible for cardiac arrest? And if so, why? And perhaps the more important question, how can it be prevented?

Dr. Friedman:

So, this may be shocking to the majority of the audience, but all of us are at risk for having an acute heart attack or an acute issue during exercise. Like a lot of things though, the more you do, the less the risk happens to be. So the risk is there for everybody or anybody at any time, but the healthier we get and the more our bodies become accustomed, the less that risk actually becomes. Athlete are not more at risk than in that setting. Cardiac arrest is actually less likely to happen in this population, but despite our best efforts and we screen everybody, professional athletes, college athletes, which is not recommended for the majority of athletes quite honestly. These are specialized screenings for specialized populations, things still happen. And nothing probably more public in Christian Eriksen last summer who, during a professional soccer match, had a sudden cardiac arrest.

Dr. Friedman:

So really the key is preparedness in the setting and being aware of what cardiac arrest looks like in a sports setting, knowing how to recognize and respond to it quickly. And then knowing where your nearest AED is. and as always, I appreciate you giving me the chance to talk about it, because this is a life skill. This is not something that you learn once, and don't come back to. We really want people thinking about this and being aware of it, because you're far more likely to perform CPR in your own home than you are anywhere else. So, knowing what cardiac arrest is, how to do CPR, how to call for an AED and how to call 911 will undoubtedly save lives, and very much so of young athletes and school-aged children.

Dr. Fialkow:

So the risks are low, but they exist, as you said. And the preparation by both the individual, the family member, the community is really the way to best handle these unfortunate circumstances.

Dr. Friedman:

And anywhere that sponsors athletic activity is doing a disservice to the patrons of that facility if there's not an emergency action plan geared up and ready to go. And Michael's nodding his head vigorously, because I know he, with the Dolphins, practices this and rehearses it every single year. And that should be happening everywhere, anywhere that sponsors athletic activity needs an AED, needs to have people who know how to perform CPR. And it's not just enough to write it down, it needs to be rehearsed and practiced, because it will work and it will save lives.

Dr. Fialkow:

So to the viewers, please become advocates for this in whatever social or community setting where you may participate.

Dr. Fialkow:

What should athletes do before competing?

Amy Kimberlain:

Nothing new before game day, but that's the first thing. We don't want any issues on the field.

Amy Kimberlain:

But jokes aside, it comes back to that timing part. So again, having something three to four hours before, but then also 30 minutes to an hour ahead. So again, finding what works for that person, whether... I've heard of players getting so nervous that they throw up right before they go on, right? So maybe only a liquid would be something, in a smoothie type form, would be more appropriate versus just like a piece of fruit. So a simple carbohydrate, that quick energy of something to give them, again, that immediate energy in that moment. And again, it goes back to the meal prior as well to make a big difference also in what amounts of stored carbohydrate that they have. So again, looking for something like a balanced meal of some carbohydrates, so maybe some rice, grilled chicken, and again a vegetable of sorts. You don't want to go too high fiber or too high fat only because that can, obviously, have those implications GI wise on the field.

Dr. Fialkow:

To our listeners, remember, you can send us your comments and suggestions for future topics at baptisthealthtalk@baptisthealth.net. That's baptisthealthtalk@baptisthealth.net.

Dr. Fialkow:

On behalf of everyone at Baptist Health, thanks for listening and stay safe.

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