Sehr geehrte Damen und Herren,
Biathlon ist eine der beliebtesten Sportarten im Kanon der Olympischen Winterspiele. Der Wechsel aus Skilanglauf und Schießen begeistert – vor allem am Schießstand können die Zuschauer mitfiebern und dank der technischen Verbesserungen das Ergebnis verfolgen. Vom 3. bis 13. März 2016 findet die Biathlon-Weltmeisterschaft im norwegischen Oslo statt. Es werden bei Frauen und Männern in sechs Disziplinen (Sprint, Verfolgung, Einzel, Massenstart, Staffel, Mixed-Staffel) Medaillen vergeben. Welche Probleme Höchstleistungen bei Minusgraden bereiten, warum schwere Verletzungen im Wettkampf relativ selten sind und was das für die traumatologische Absicherung bei Wettkämpfen bedeutet, beschreiben Dr. Jan Wüstenfeld und Prof. Bernd Wolfarth im aktuellen GOTS-Newsletter.
Mit freundlichen Grüßen
Andreas Bellinger, presse@gots.org
Beim 31. Jahreskongress der GOTS vom 16. bis 18. Juni 2016 in München wird Professor Hideo Matsumoto, der Präsident der gleichnamigen japanischen Fachgesellschaft, einen Einblick in die Sportmedizin seines Heimatlandes Japan geben. Der orthopädische Chirurg von der Keyo Universität in Tokio wird über ein an seinem Institut entwickeltes allumfassendes Programm zur Wiederaufnahme der sportlichen Aktivitäten nach einer Verletzung referieren. „Dabei wird das ganze Versorgungsspektrum unter Einbeziehung der verschiedenen Disziplinen vorgestellt“, erklärt Kongress-Präsident Professor Romain Seil. Weitere Informationen finden Sie auf der Kongresswebsite unter www.gots-kongress.org
Risiken im Biathlon: Kalte Luft und Stürze
Der Begriff Biathlon kommt aus dem Griechischen und bedeutet soviel wie Zweikampf. Es ist ein olympischer Winterwettkampf, bestehend aus Skilanglauf (seit 1985 ausschließlich in der Skatingtechnik) und Schießeinlagen mit Kleinkalibergewehren (Kaliber 22/5,6mm). Die Trefferfläche der 50 Meter entfernten Metallscheibe hat beim Liegend-Schießen einen Durchmesser von 4,5 Zentimeter, in stehender Position beträgt sie 11,5. Die Laufstrecken variieren zwischen 6 (Staffel Frauen) und 20 Kilometer (Einzelwettkampf Männer).
Die Einführung neuer Wettkampfformen in den vergangenen Jahren, mit einer deutlichen Betonung der Schießeinlagen, hat zu einer wesentlichen Steigerung der Attraktivität und entsprechender medialer Aufmerksamkeit in Europa geführt. Biathlon gehört heute in Deutschland zu einer der beliebtesten Sportarten. Der erste olympische Biathlon-Wettkampf über 20 Kilometer war 1960 bei den VIII. Olympischen Winterspielen in Squaw Valley nur den Männern vorbehalten. Erst seit 1992 kämpfen auch Biathletinnen um olympische Medaillen. Aus der Nähe zum Skilanglauf ergeben sich die auftretenden Verletzungs- und Beschwerdemuster.
Staffelstart zum Frauen-Rennen in Presque Isle (USA).
Akute internistische Erkrankungen
Sportartspezifisch kommt es in der winterlichen Umgebung zu einer ausgeprägten Exposition mit kalter und sehr kalter Luft. Bei der im Biathlon als Leistungssport belastungsbedingt hohen Ventilationsrate, besteht ein großes Risiko der Reizung der Schleimhaut der oberen Atemwege. Dies führt vermehrt zu entzündlichen Veränderungen der Schleimhaut im Bereich des Nasen-Rachenraumes, des Kehlkopfes und der oberen Luftwege. Arztbesuche sind im Biathlon deshalb häufig ursächlich mit klinischen Symptomen von Erkältungskrankheiten wie Husten, Halsbeschwerden, Schnupfen und Nasennebenhöhlenbeschwerden verbunden.
Zur effektiven Vorsorge ist daher eine umfangreiche Verhaltensschulung der Athleten wichtig. Prophylaktische Maßnahmen beinhalten sämtliche Formen der Schleimhautpflege wie reichlich trinken (vorzugsweise Tee), Nasenspülungen, Inhalationen – aber auch infektionsprophylaktische Maßnahmen wie häufiges Händewaschen, Menschenansammlungen in der Wettkampfsaison zu meiden, die Kleider nach Belastung sofort zu wechseln und erkrankte Athleten zu isolieren.
Die Therapie der in der Regel viral bedingten Erkrankungen ist im Wesentlichen symptomatisch orientiert. Bewährt hat sich der Einsatz von Nasenspüllösungen, Inhalationen, Lutschpastillen und Phytopharmaka (Arzneimittel pflanzlichen Ursprungs). Medikamentös wird durch Einsatz von hochdosiertem Vitamin C, Zink und lokal antiseptischen Lösungen eine günstige Beeinflussung des Krankheitsverlaufes angestrebt. Der Einsatz von antiviralen Präparaten ist im Allgemeinen nicht sinnvoll. Das gilt ebenso für Antibiotika, die wegen der meist zugrundeliegenden viralen Infektion eine eher seltene Behandlungsoption sind und in der Regel der Therapie einer bakteriellen Superinfektion vorbehalten bleiben.
Andere internistische Krankheitsbilder sind dank der insgesamt günstigen Beanspruchung des kardiovaskulären Systems und der positiven Auswirkungen der Belastung auf den Gesamtorganismus als selten einzustufen. Aufgrund des sportartspezifisch sehr hohen Energieumsatzes muss eine hinreichende Versorgung mit kohlenhydratreicher, ausgewogener Kost gewährleistet werden, um ungewollte katabole Situationen und damit den Verlust von Muskelmasse zu vermeiden.
Belastungsinduzierte Atembeschwerden
Die vermehrte Schleimhautreizung der Atemwege, die durch häufige intensive Ventilation von kalter und sehr kalter sowie trockener Luft hervorgerufen wird, führt bei nordischen Skisportlern häufiger zu belastungsbedingten Atembeschweren im Sinne eines hyperreagiblen Bronchialsystems bzw. eines belastungsinduzierten Asthmas (EIA). Liegt ein belastungsbedingtes Asthma vor, ist eine frühzeitige antiinflammatorische (entzündungshemmende) Therapie mit inhalativen Glukokortikosteroiden angezeigt, um eine Progredienz der Erkrankung zu vermeiden.
Symptomatisch kann diese Therapie mit einem Beta-2-Mimetikum kombiniert werden, welche beispielsweise auch als kurzwirksame Beta-2-Mimetika unmittelbar vor intensiven Belastungen zur Prophylaxe von Anfällen eingesetzt werden können. Beta-2-Mimetika stehen zwar auf der Liste der verbotenen Substanzen/Methoden der Welt-Antidoping-Agentur (WADA), was den Einsatz bei Athleten eigentlich verbietet. Es gibt aber Sonderregelungen für die inhalative Anwendung von Salbutamol, Salmeterol und Formoterol, die für die Behandlung eines EIA-Asthmas unter bestimmten Bedingungen zugelassen sind; und nur bei Anti-Doping-Kontrollen angegeben werden müssen. Das gilt ebenso für inhalative Glukokortikosteroide.
Vom belastungsinduzierten Asthma sind die Formen der (zumeist inspiratorischen) belastungsinduzierten Atembeschwerden abzugrenzen. Sie sind meist in einer pathologischen Atemmechanik mit daraus resultierender Einengung auf Höhe der Stimmbänder begründet. Diese Atembeschwerden lassen sich in der Regel bereits in der Anamnese differenzieren und verursachen in der Regel inspiratorische Beschwerden, die der Sportler meist gut lokalisieren kann. Eine Therapie mit inhalativen Antiobstruktiva führt in der Regel zu keiner Besserung der Symptome. Die adäquate Therapie ist ein qualifiziert angeleitetes Training der Atemmechanik.
Akute sportartspezifische Verletzungen
Akute Traumen sind im Vergleich zu anderen Sportarten im Biathlon selten. Die Angaben in der Literatur (meist bezogen auf Skilanglauf) schwanken zwischen 0,5 und 5,5 Ereignisse pro 1.000 Sportler und Skilanglauf-Tag. Dies resultiert aus dem niedrigen Gefahrenpotenzial und aus dem fehlenden Breitensportcharakter mit Verletzungen ungeübter Aktiver.
Der Norweger Emil Hegle Svendsen vor Tomaz Sikora aus Polen und dem Schweden Carl Johan Bergmann bei einem Weltcup-Rennen in Fort Kent/USA.
Schussverletzungen traten im Verlauf der letzten Jahrzehnte nur äußerst selten auf. Trotz des kleinen Waffenkalibers kam es vereinzelt aber doch zu Verletzungen mit tödlichem Ausgang, was zu einer deutlichen Verschärfung der Sicherheitsrichtlinien im Regelwerk geführt hat. So wurde das Risiko auf ein Minimum reduziert.
Verletzungen während der Trainings- und Wettkampfeinheiten auf Skiern sind wesentlich seltener als Verletzungen in der Vorbereitungsphase vor der Wintersaison. Die Trainingsumfänge zu Fuß, auf dem Straßenrennrad, dem Mountainbike oder dem Haupttrainingsgerät, dem Skiroller, sind deutlich gefährlicher. Das Verletzungsrisiko auf den Skirollern ist vergleichbar mit dem beimInlineskaten. Die meisten Verletzungen resultieren daraus, dass in der Vorbereitung andere Sportarten im Training betrieben werden – Spielsportarten zum Beispiel.
Trainings- und Wettkampfeinheiten auf Langlaufski bergen zumeist sturzbedingte Verletzungsgefahren. Prellungen sowie Distorsionen mit Gelenkbinnenschädigungen im Bereich der Hände, der oberen Sprunggelenke und der Kniegelenke sind die Folge. Frakturen der Extremitäten oder im Bereich der Wirbelsäule und des Thorax sind sehr selten. Intensive Trainingseinheiten sind zum Teil von einer erhöhten Muskelverletzungsgefahr mit Zerrungen und Faserrissen begleitet.
Die Therapie dieser Verletzungen umfasst neben dem gesamten Spektrum der traumatologischen Akutversorgung die Physiotherapie mit ergänzender balneo-physikalischer Therapie, die Orthesenversorgung und auch die interventionelle Schmerztherapie. Operative Eingriffe sind im Skilanglauf/Biathlon insgesamt äußerst selten. Allerdings sind sie neben den absoluten Indikationen im Hochleistungsbereich im Gesamtkonzept zur Minimierung der Ausfallzeiten aber abzuwägen.
Sportartspezifische Überlastungsbeschwerden
Die Belastungszeit bei Biathlon-Wettkämpfen entspricht der von anderen olympischen Ausdauerdisziplinen. Dabei variiert die Dauer zwischen ca. 17 Minuten (Staffelwettkämpfe, Frauen) bis eine Stunde (Einzelwettkämpfe, Männer). Die Trainingszeitbelastungen sind dagegen sehr hoch und können bis zu 30 Stunden pro Woche betragen. Daraus resultieren Überlastungs- und Fehlbelastungssymptome; vor allem akute und chronische Muskeldystonien, Insertionstendinopathien, Tendinitiden und Tendovaginitiden. Knochenhautreizungen, besonders der unteren Extremitäten, werden häufig beobachtet; beispielsweise durch Schuhprobleme oder muskuläre Fehlbelastung.
Es finden sich inhomogen verteilte Beschwerdemuster im Bereich der oberen Extremität inklusive Hände und Schultergürtel, der Wirbelsäule im Bereich des lumbosakralen Übergangs, der unteren Extremität mit Knie- und Sprunggelenken wie auch der Füße. In Abhängigkeit von der Trainingsintensität und -akzentuierung ist neben der Technikkorrektur meist auch die ärztliche beziehungsweise physiotherapeutische Betreuung zur Behebung muskulärer Dysbalancen notwendig.
Durch die Entwicklung neuerer Schuh- und Bindungssysteme mit festeren Werkstoffen (meist Carbon), kommt es in jüngerer Zeit häufiger zu Reaktionen des Periostes, die durch eine hohe lokale Druckbelastung bedingt sind. Hier muss frühzeitig eingegriffen werden, damit die Beschwerden nicht chronisch werden, was bis zu einer äußerst schmerzhaften ossären Kallusbildung führen kann. Durch schuhorthopädische Korrekturen mit Reduktion des lokalen Drucks, möglicherweise auch eines Wechsels des Schuhmodels, lässt sich das Problem effektiv beheben. Im akuten Fall kann eine lokale Infiltrationstherapie notwendig sein.
Insbesondere bei eisigen Streckenverhältnissen, bei denen eine vermehrte Stabilisierung des Skis durch Ausgleichsbewegungen der Muskulatur des Unterschenkels notwendig wird, kommt es mitunter zu einem funktionellen Kompartmentsyndrom des Tibialis anterior. Diese äußerst schmerzhafte Verletzung führt nicht selten zur Aufgabe des Wettkampfes. Die Therapie ist schwierig und beinhaltet neben umfänglicher physiotherapeutischer Maßnahmen die Veränderung der Schuh- und Bindungsposition (gegebenenfalls mit Materialwechsel) sowie die Analyse und Therapie von muskulären Dysbalancen und Haltungsschwächen der muskulären Kette von Fuß-Knie-Hüfte-Lendenwirbelsäule. Der operative Ansatz mit Faszienspaltung des Musculus tibialis anterior, der in anderen europäischen Ländern häufiger favorisiert wird, scheint im Vergleich zur konservativen Therapie keine besseren Heilungschancen zu bieten.
Emil Hegle Svendsen (Norwegen/re.) im Schlussspurt mit Fredrik Lindström (Schweden).
Um den Vortrieb im Langlaufsport zu gewährleisten, wird der Oberkörper in einer Beugebewegung gegen die unteren Körperpartien bewegt und dann in eine Hyperextensionsposition aufgerichtet. Die zu entfaltende Kraft korreliert mit der Ausnutzung des Beuge- und Streckungszyklus. Diese Bewegung führt vor allem im Skilanglauf bei sehr hohen Wiederholungszahlen zu einer stärkeren Krafteinwirkung auf die Bewegungssegmente der Lendewirbelsäule und des lumbosakralen Überganges. Hier sind akute Beschwerden wie auch chronisch degenerative Veränderungen zu beobachten. Im Vergleich zum Skilanglauf ist im Biathlon mit einer geringeren Frequenz an Beschwerden und Langzeitfolgen zu rechnen, weil nur in der Skating-Technik und nicht auch in dem für die Lendenwirbelsäule vergleichbar belastenderen klassischen Stil gelaufen wird.
Ärztliche Betreuung im Biathlon
Biathleten gelten als äußerst professionell und das Risiko von akuten Verletzungen als äußerst gering. Deshalb wird eine traumatologische Absicherung bei Wettkämpfen nur für die jeweilige Gesamtveranstaltung (Rennarzt) als notwendig erachtet. Eine entscheidende Rolle im verbandsärztlichen Betreuungskonzept für den Biathlonsport spielt die interdisziplinäre Komponente. Neben dem betreuenden Mannschaftsarzt, muss ein gutes Netzwerk von konservativen Orthopäden, Internisten und chirurgisch erfahrenen Orthopäden vorgehalten werden.
In der Vor-Ort-Betreuung bei Trainingslagern und im Wettkampf stellen Infekte des oberen Respirationstraktes bei weitem die häufigste Behandlungsindikation dar. Der Präventionsschulung und Anleitung der Sportler und Trainer im Rahmen der sportmedizinischen Eignungs- und Saisoneingangsuntersuchungen kommt ebenfalls eine besonders wichtige Bedeutung bei. Um chronische Krankheitsverläufe zu vermeiden, ist eine frühzeitige Intervention mit konservativen Therapieformen zwingend erforderlich, und die enge Zusammenarbeit mit den zuständigen Physiotherapeuten ist essentiell.
Über die Autoren:
Dr. med. Jan Wüstenfeld ist Mannschaftsarzt der deutschen Biathlon-Nationalmannschaft und Ärztlicher Mitarbeiter im Fachbereich Sportmedizin am Institut für Angewandte Trainingswissenschaft in Leipzig. Als Biathlet hat Wüstenfeld an den Olympischen Winterspielen 1998 in Nagano teilgenommen und im Jahr 2000 bei der Europameisterschaft in Zakopane mit der Staffel die Goldmedaille gewonnen. Prof. Dr. med. Bernd Wolfarth ist Ordinarius für Sportmedizin an der Humboldt-Universität zu Berlin und leitet die Abteilung Sportmedizin der Charité Universitätsmedizin Berlin sowie den Fachbereich Sportmedizin am Institut für Angewandte Trainingswissenschaft in Leipzig. Wolfarth ist Leitender Disziplinarzt der deutschen Biathlon-Nationalmannschaft, Leitender Verbandsarzt des Deutschen Skiverbandes und Leitender Olympia-Arzt des Deutschen Olympischen Sportbundes.
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