REVIEW ARTICLE

THE MOLECULAR ATHLETE: EXERCISE

PHYSIOLOGY FROM MECHANISMS TO MEDALS
AUTHORS
Regula Furrer, John A. Hawley,
Christoph Handschin

CORRESPONDENCE
[email protected];
[email protected];
[email protected]

KEY WORDS
athlete; endurance training; exercise; resistance
training; skeletal muscle

CLINICAL HIGHLIGHTS
1) During human evolution, Homo sapiens emerged as mobile hunters and gatherers, dependent on the natural avail-
ability of food. However, today’s sedentary lifestyle and overabundant food availability place a major burden on our
metabolic health and are strong drivers underpinning the dramatic rise . in noncommunicable diseases.
2) A sedentary lifestyle, characterized by low maximal oxygen uptake (VO2max), unfavorable body composition, and low
muscle strength, is an independent risk factor for many chronic diseases and a strong predictor of morbidity and mor-
tality.
3) Despite marked interindividual differences in the response to standardized exercise training, regular physical activity
lowers the risk of and confers therapeutic benefits for many noncommunicable diseases.
4) Endurance- and resistance-based exercise training protocols confer distinct clinical and health-related benefits and
can prevent or reverse many lifestyle-induced metabolic diseases.
5) Clinical exercise tests based on established, validated physiological outcomes are essential for the diagnosis and
subsequent monitoring of clinical conditions.
6) Investigations of elite human performance provide valuable insights into the molecular, cellular, tissue, and whole
body adaptations to extreme metabolic loading. Identification of the mechanisms and pathways that limit exercise
capacity may ultimately aid in the identification of novel therapeutic targets to be prescribed to patient populations.

FURRER ET AL., 2023, Physiol Rev 103: 1693–1787

January 5, 2023; Copyright © 2023 The Authors. Licensed under Creative Commons Attribution CC-BY 4.0.
Published by the American Physiological Society.
https://doi.org/10.1152/physrev.00017.2022
Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 Physiol Rev 103: 1693–1787, 2023
First published January 5, 2023; doi:10.1152/physrev.00017.2022

REVIEW ARTICLE

THE MOLECULAR ATHLETE: EXERCISE

PHYSIOLOGY FROM MECHANISMS TO MEDALS
Regula Furrer,1 John A. Hawley,2 and Christoph Handschin1
1
Biozentrum, University of Basel, Basel, Switzerland and 2Exercise and Nutrition Research Program, Mary MacKillop Institute for
Health Research, Australian Catholic University, Melbourne, Victoria, Australia

Abstract
Human skeletal muscle demonstrates remarkable plasticity, adapting to numerous external stimuli including the
habitual level of contractile loading. Accordingly, muscle function and exercise capacity encompass a broad spec-
trum, from inactive individuals with low levels of endurance and strength to elite athletes who produce prodigious
performances underpinned by pleiotropic training-induced muscular adaptations. Our current understanding of the
signal integration, interpretation, and output coordination of the cellular and molecular mechanisms that govern
muscle plasticity across this continuum is incomplete. As such, training methods and their application to elite ath-
letes largely rely on a “trial-and-error” approach, with the experience and practices of successful coaches and ath-
letes often providing the bases for “post hoc” scientific enquiry and research. This review provides a synopsis of
the morphological and functional changes along with the molecular mechanisms underlying exercise adaptation to
endurance- and resistance-based training. These traits are placed in the context of innate genetic and interindivid-
ual differences in exercise capacity and performance, with special consideration given to aging athletes.
Collectively, we provide a comprehensive overview of skeletal muscle plasticity in response to different modes of
exercise and how such adaptations translate from “molecules to medals.”
athlete; endurance training; exercise; resistance training; skeletal muscle

suited for upright locomotion, with economy of move-

1. INTRODUCTION AND BACKGROUND 1693 ment for bipedal walking and running far exceeding that
2. OPTIMIZING TRAINING ADAPTATIONS TO... 1699 of other primates (2–5). Modifications in bone and carti-
3. PHYSIOLOGICAL AND CELLULAR... 1709 lage structure, larger limbs and joints, and spring-like
4. ACUTE MOLECULAR MECHANISMS... 1722 plantar arches (2, 3), combined with a robust system of
5. CAN WE ALL BECOME GOLD MEDALISTS? 1746 perception, fine motor control, and balance, were linked
6. SUMMARY, CONCLUSIONS, AND... 1754 to a larger brain size and associated cognitive sophisti-
cation (6–8). The evolution of the larger brain in humans
was likely facilitated by the running behavior of our
ancestors that enabled the procurement of high-pro-
1. INTRODUCTION AND BACKGROUND tein sources of food essential for brain development
(10). Bipedal, long-distance running not only necessi-
1.1. Historical Context: The Evolution of Human tates complex computation to control gait, balance,
Movement and stride but also requires large-scale cognitive
processes to recall landmarks associated with abun-
The evolution of humankind is inextricably linked to the dant sources of food, recognize prey and predators,
attainment of an upright, bipedal gait, which conferred and enable long-range orientation (10). Such adapta-
an advantage for locomotion, foraging, and recognition tions were supported by adequate energy availability
of prey and predators (FIGURE 1). Indeed, a superior en- and oxygen supply, coupled with a high degree of
durance capacity, coupled with an outstanding ability to metabolic regulation and flexibility (6–8). The superior
thermoregulate, was essential for human survival (1). human proficiencies as hunters, gatherers, and ulti-
Evolutionary theory describes the mechanism of natural mately farmers provided dietary subsistence that
selection as “survival of the fittest,” the underlying sup- enabled the evolution of our energy-costly brain. The
position being that the “fit,” as opposed to the “unfit,” coevolution of skeletal muscle and associated organ
had a greater likelihood of survival (9). In this regard, systems was characterized by progressive and itera-
human skeletal muscles, limbs, and the supporting venti- tive mutual interactions (10). The behavioral lifestyle
latory, cardiovascular, and metabolic systems were well and energy availability were determined by the

0031-9333/23 Copyright © 2023 The Authors. Licensed under Creative Commons Attribution CC-BY 4.0. 1693
Published by the AmericanatPhysiological
Downloaded from journals.physiology.org/journal/physrev Society.
CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

strength, and power could have affected the evolutionary

CLINICAL HIGHLIGHTS
process (1). Accordingly, although there exists a certain
1) During human evolution, Homo sapiens emerged as mobile degree of synergy, distinct control and adaptation to en-
hunters and gatherers, dependent on the natural availability of durance- and strength-based activities have evolved in
food. However, today’s sedentary lifestyle and overabundant humans.
food availability place a major burden on our metabolic health
and are strong drivers underpinning the dramatic rise in non-
communicable diseases. 1.2. Major Themes of This Review
2) A sedentary lifestyle, characterized by low maximal oxygen
uptake (VO_ 2max ), unfavorable body composition, and low mus-
cle strength, is an independent risk factor for many chronic dis- The importance of physical activity for health and well-
eases and a strong predictor of morbidity and mortality. being was recognized early in human history, dating
3) Despite marked interindividual differences in the response to back to records from 3000 BCE (18). The concept of
standardized exercise training, regular physical activity lowers
“exercise is medicine” and the appreciation of athletic
the risk of and confers therapeutic benefits for many noncom-
municable diseases. prowess were prominent in ancient Greek and Roman
4) Endurance- and resistance-based exercise training protocols civilizations (18). Notably, the evolutionary adaption of
confer distinct clinical and health-related benefits and can pre- humans to a phenotype eminently suitable to the pursuit
vent or reverse many lifestyle-induced metabolic diseases.
5) Clinical exercise tests based on established, validated physio-
of long-distance running confers important implications
logical outcomes are essential for the diagnosis and subse- for human health and athletic performance in the pres-
quent monitoring of clinical conditions. ent day. Unfortunately, the fundamental link between
6) Investigations of elite human performance provide valuable endurance-based activities and the evolution of numer-
insights into the molecular, cellular, tissue, and whole body
adaptations to extreme metabolic loading. Identification of the
ous human traits has been severely diminished in mod-
mechanisms and pathways that limit exercise capacity may ulti- ern societies in which voluntary physical activity is at an
mately aid in the identification of novel therapeutic targets to be all-time low and has recently been exacerbated by a
prescribed to patient populations. global pandemic (19, 20). Our twenty-first century life-
style that in many societies encompasses round-the-
periodic cycles of feasts and famines, with certain clock access to energy-dense, nutrient-poor food in the
genes evolving to regulate efficient storage and utili- face of prolonged periods of inactivity has resulted in
zation of endogenous fuel stores, the so-called “thrifty the proliferation in the rates of diagnosis of several met-
genes” (11, 12). abolic disease states, a rise in morbidity and mortality,
In contrast to the strong evolutionary pressure to opti- and a high financial burden on health care systems (21).
mize endurance capacity (1), the control of skeletal mus- Paradoxically, at the same time, the standard of athletic
cle mass and strength evolved in a more restrained performance at both the amateur and professional levels
manner. Although adequate muscle strength was closely continues to advance, indicating a historically unprece-
aligned to the prevailing environmental demands of the dented divergence between the physical capabilities
day and was indispensable for survival, genes encoding of the great majority of the world’s population of inactive
proteins that act on muscle cells to inhibit muscle cell individuals and a small cohort of elite athletes. Indeed,
growth, such as myostatin, escaped negative evolu- Olympic and/or world championship medalists, world re-
tionary selection. This would appear to be somewhat cord holders, and athletes achieving within 2% of world-re-
of a paradox, as naturally occurring mutations in the cord performance and/or world-leading performance
myostatin gene confer several benefits including a comprise <0.00006% (
5,000 individuals) of the entire
substantial increase in muscle mass in mice, dogs, cat- global population of 8 billion (22). In physiological terms,
tle, and even humans (13). In evolutionary terms, how- the measure of an individual’s maximal oxygen uptake
ever, a lower muscle mass would be associated with a (V_ O2max ), a marker of aerobic fitness, can be two- to three-
reduction in both resting and locomotive energy ex- fold higher in champion endurance athletes than untrained
penditure in times of food scarcity, along with the con- individuals (23). The most striking training-induced adapta-
servation of carbohydrate-based fuels obligatory for tions contributing to such differing values are an increased
preservation of brain function. Excessive muscle mass stroke volume of the heart, elevated capillary and mito-
can also lead to parturition issues (i.e., higher birth chondrial density, and a predominance of oxidative “slow-
weight and larger offspring), predisposing to evolu- twitch” fibers in the muscles of endurance-trained athletes
tionary disadvantages (14–16). Non-muscle-related (24, 25). While a high V_ O2max is a prerequisite for success-
functions of myostatin such as tendon maintenance ful endurance performance, this measure is also a better
and repair and injury risk could have contributed to predictor of morbidity and mortality than any other estab-
the positive selection of this factor (17). Finally, poten- lished risk factor or biomarker (26–30). Likewise, relative
tial trade-offs between the promotion of fatigue resist- muscle mass (31–33) and strength (34–36) are parameters
ance, stamina, and endurance versus muscle mass, with high predictive power for overall morbidity and

1694 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

Energetics:
-long, spring-like tendons
-plantar foot arch
-ankle ligaments
-long femur, short toes
-thinner heart ventricles, larger cavity
-increased hind limb muscle mass
Training
Stabilization: Nutrition
paradigms
-large erector spinae / gluteus maximus Supplements
-narrow waist, broad shoulders and strategies
-reduced forearm mass
-decreased facial length
-improved bio-tensegrity

Technological
innovations, Genetics
equipment, Epigenetics
Skeletal strength:
-large joint areas in lower,
facilities
but not upper limbs

Brain: Thermoregulation:
-expanded cerebello- -eccrine sweat glands
cerebralcortical circuitry -reduced body hair / fur
-cognitive abilities -mouth breathing
-perception -dense skin vascularization
-fine motor control and balance -large nasal epithelial area

FIGURE 1. From evolution to modern-day athleticism. Evolutionary selection of 5 main traits has facilitated the prolonged upright, bounding, bipedal
locomotion in humans. Energetic barriers are lowered by long, spring-like tendons (in particular the Achilles tendon), the longitudinal plantar foot arch,
ankle ligaments, long legs, in particular femur length, and short toes (to increase stride length and reduce vertical trajectories for better locomotor
economy), thinner heart ventricles and larger cavity, increased hind limb muscle mass, and other adaptations. Skeletal strength is conferred, e.g., by
larger joint areas in lower but not upper limbs to dissipate impact forces. Stabilization for bipedal movement is mediated by large erector spinae and
gluteus muscles opposed to reduced forearm mass and an elongated, narrow waist and broad shoulders to facilitate counterrotation of thorax and
arms, while decreased facial length helps head stabilization or an integrated system of bio-tensegrity for embedded perturbation repelling. Eccrine
sweat glands, with a particular high density in the head for brain cooling, reduced body hair, dense skin vascularization, mouth breathing, and a large
nasal epithelial area all contribute to thermoregulation. Finally, coevolution of locomotion and the brain resulted in expanded cerebello-cerebralcortical
circuitry (for anticipation, pre-preparation, sensory integration, pre-planned multilevel compensation to deal with perturbations and destabilizations),
cognitive capabilities (to recognize landmarks, long-range orientation, recognizing prey and predators, tracking and speculative tracking/anticipation),
perception, fine motor control, and balance. See Refs. 1–8 for more information. Modern-day athletic peak performances most likely exceed these gen-
eral evolutionary traits because of efficient training strategies and paradigms, nutrition and supplements, technological innovations, i.e., pertaining to
equipment and facilities, and genetic and epigenetic predispositions. Figure created with BioRender.com, with permission.

mortality. Clearly, the biology underlying maximal en- poorly understood. In particular, the training programs of
durance and resistance exercise performance confers world-class athletes owe more to tradition and the “trial-
advantages beyond the athletic arena (9, 37), and and-error” methods of pioneering coaches than exer-
while differences in physiological capacity between cise biologists or sport scientists. Determining the pre-
elite athletes and sedentary individuals highlight the cise role of exercise intensity, duration, and frequency in
huge disparity in performance capacity, they also pro- acutely modifying various signaling cascades and coor-
vide insights into the roles of various organ systems dinating specific training-induced physiological adapta-
and the potential limits to human performance. tions in athletes may offer valuable insights into some of
The last decade has seen major advances in unravel- the critical pathways to target in order to fight the battle
ing many of the putative mechanisms by which cellular, against inactivity-related diseases in the general popula-
molecular, and biochemical pathways are altered by tion. Not only may sedentary or “at-risk” populations
exercise (9, 18, 38–41). However, many of the adapta- benefit from “personalized” physical activity-based inter-
tions that underpin elite athletic performance remain ventions to prevent and treat chronic lifestyle-induced

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1695

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

pathologies (42–44), but mechanistic insights could witnessed in track and field (60), swimming (61), cycling
reveal targets for novel pharmacological interventions (62), and speed skating (FIGURE 2) (63), with such advan-
(45–47). A better understanding of the molecular mecha- ces filtering down to amateur athletes, epitomized by the
nisms that control skeletal muscle cell plasticity may also widespread access to new footwear that improves running
provide a stimulus for further improvements in elite ath- economy (64, 65). The use of novel technologies, such as
letic performance (48, 49). The fastest 100 m sprint by a fitness trackers, step counters in cell phones, or other wear-
male athlete under 18 (10.31 s, Brume Okeoghene, June ables, reveals behavioral aspects of physical activity linked
17, 2021) would have won the gold medal at the 1980 to performance outcomes at both a recreational and an
Olympics, whereas Usain Bolt’s 100 m world record of elite level. Such technologies can inform training design as
9.58 s in 2009 far exceeded predictive statistical models well as the impact of specific interventions on health and
at that time (50). In recent years, much scientific debate performance outcomes (66). In the final analysis, however,
has been focused on the limits to the men’s marathon progress in athletic performance is multifactorial, encom-
(42.195 km) (51–54). Changes in both the culture of sport passing gene-environment interactions (67–70), advances
and the recognition of modern sports science research in infrastructure, training paradigms, and design (71), nutri-
have supported emerging activities in which “barriers” to tion and ergogenic aids (72, 73), as well as techniques facili-
performance have been tackled as science-driven endeav- tating recovery and regeneration, social and economic
ors (55). The “sub-2 hour marathon project” is an example: factors, prior athletic experience and physical activity back-
the course design, ambient temperature, humidity, wind, ground (74), and, in an unknown number of athletes,
elevation above sea level, and comprehensive use of the use of sophisticated doping strategies (FIGURE 3) (58,
pacemakers in highly choreographed formations helped 75). The range in performance capabilities, the ongoing
Kenyan runner Eliud Kipchoge run 1:59:40.2 in a specially improvements in athletic records, and the accomplishments
paced time trial in October 2019 (53, 56). Likewise, there of older individuals at the masters level (57) in octogenar-
have also been substantial advances in world-best per- ians (76) or even centenarians (77) allude to the vast contin-
formances by female and masters-level athletes during uum of the adaptive response of muscle tissue and other
this time (57–59). organs to a sedentary lifestyle or exercise training. In this
Technological innovations in sport now drive perform- review, we provide a synopsis of the training strategies of
ance enhancements at the elite/professional level, as elite athletes, the bidirectional dialogue between science,

5,000 m speed skating records

12

11

10
Development of tight-fit suits
9
Time (min)

Clap skate (1996)

8

7 Women
Men
6
outdoor natural ice
5 outdoor artificial ice
Improvement of ice quality Indoor 400-m rinks (1986)
indoor artificial ice
0

1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030

Year

FIGURE 2. Innovations that contributed to the progress in the development of world records over time (light blue for women, dark blue for men).
Speed skating is one of many cases in which the progression of world records is driven by innovations (63). For example, the invention to improve ice
quality (natural vs artificial ice) by refrigerated ovals (first 1958), spraying tiny droplets of water to smoothen the surface (first 1960), followed by the ice
resurfacer “Zamboni” (Olympics 1960) and eventually indoor rinks all contributed to new records. Additionally, the development of gear such as tight-fit
suits to improve aerodynamics and the invention of the clap skate that enabled a longer contact with the ice as well as further enhanced aerodynamics
due to the crouched posture pushed the progress in world record development (http://www.speedskatingstats.com/index.php?file=records). Image on
left was taken at the 1932 Winter Olympics and is from Henriksen & Steen (public domain, via Wikimedia Commons); image on right was originally
posted to Flickr by adrian8_8.

1696 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

Nu
e Ergo trition
m gen
bio ic ai
Hallmarks icro ds
tm
Gu
of athletes

Tr jur reh
ai y p ab
In

ni
ng rev ilita
dy ve we ,
bo rs po ion

an en tion
ep e ,
pe ra r,

d tio
pe will ivat

rc nc
tio

re n
co an
t
Mo

ve d
Intensity
e

ry
Specificity Time
Prior athletic
N Recovery
experience

Equipment & facilities

ur
12
Epigenetic factors

00 :

tur
Lifestyle

e
Me Ac Ac
Me Me

ure
Family history

at
N
Family
on

Coaches Team

So Soc
iti

c io ial
s

Knowledge
po

-e en
c
is

o
Education
ed

no iro
r

m nm
v
cp

ic e
ti

st nt
ne

at
Ge

us
pe
noty Sleep
Chro

FIGURE 3. Elite athletic performance is determined by the complex interaction of intrinsic and extrinsic factors. Undisputedly, genetic predisposition,
even though poorly defined and understood, contributes to athletic prowess and trainability. In fact, the “right” genes might even be a prerequisite for
elite, world-class performance. The epigenetic landscape is at least in part inherited but, in contrast to the genome, can also be influenced by behavior,
including prior athletic experience, nutrition, and other lifestyle factors. A higher-than-average motivation and drive, the willpower to overcome obstacles,
adversities, and setbacks, perseverance, and the willingness to forgo activities common for non-athletic peers are essential. These factors as well as
daily training are shaped by body perception and prior athletic experience, including a multidisciplinary/multisport practice in youths. Most likely, nutri-
tion, ergogenic aids, and gut microbiomes mutually interact in an intimate manner, collectively affecting trainability and performance. Optimal training
strategies not only comprise personalized planning but should also integrate adequate consideration of recovery and injury prevention and, if the situa-
tion arises, rehabilitation. State-of-the-art equipment and facilities are part of a permissive environment, which is also strongly shaped by socio-economic
status and social interactions with coaches, medical and other staff, team members, parents, siblings, friends, and rivals. This network of supporting peo-
ple helps to optimize knowledge and education for proper planning and implementation. Finally, peak performance also relies on proper and personal-
ized sleep patterns, matched to the individual chronotype. The use of doping might confer performance enhancements in the short term but is linked to
long-term health detriments and is counter to the ethos of a fair and clean sport. Figure created with BioRender.com, with permission.

coaches, and athletes in training design and implementa- their translation to elite performance remains to be vali-
tion, and the inherent and acquired differences between dated (78). In contrast to several previous reviews, we
world-class athletes and the general population (sect. 2). address these issues for both endurance- and resistance-
Such concepts are linked to a discussion of the cellular, based exercise training. Wherever possible, direct links
morphological, and functional training-induced adaptations between training strategy, cellular adaptation, and molec-
in athletes (sect. 3). In sect. 4, our understanding of the mo- ular mechanisms are discussed in an attempt to integrate
lecular mechanisms that underpin the responses to acute these features. Finally, we provide a discussion on
exercise is outlined, although these insights have largely whether all individuals can become gold medal ath-
been obtained in non-athletes and/or animal models and letes (sect. 5).

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1697

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

A Periodization
Performance
peak
Training
Volume
Recovery

Training focus
Nutrition
Intensity

Psychology

Form
Skill
Macrocycle
General Specific
Competitions Transition
preparation preparation

Mesocycles / Phases

Blood flow Heat

HIIT ??
restriction training
"Train low" Altitude Chrono-
(glycogen) training exercise

Heterochronism of adaptations:
B Polarized
C different systems, training paradigms, intensity,...
Zone 1 Pyramidal Improvement

80% Supercompensation
Performance
Fitness level

75% Exercise
Volume

Zone 2 Zone 3 Time

20% 20%

5%
Decline
Intensity Recovery
Fatigue Repair Involution
Lactate/gas Critical power/ Homeostatic Adaptive
exchange disruption Regeneration
lactate turnpoint Adaptation dissipation
thresholds

D
Underrecovery
Undertraining
Overrecovery

Functional overreaching

Overtraining
Performance

Progression
Performance

Performance
Fitness level

Fitness level
Optimal training

Underrecovery
Non-functional

Time Time
and recovery

overreaching

Optimal training Undertraining

Increasing training load
Reduced recovery
Performance

Performance

Performance
Fitness level

Fitness level

Fitness level

Time Time Time

Retrogression Taper
Recovery
Rest
Plateau
or Overtraining Functional overreaching
Maintenance

1698 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

2. OPTIMIZING TRAINING ADAPTATIONS TO because the physiological response to specific stimuli is

ENHANCE ATHLETIC PERFORMANCE largely predictable. However, the magnitude of response
of one athlete to a standardized training protocol may differ
2.1. Principles of Exercise Training: Specificity, substantially from that of another because of innate genetic
Progressive Overload, Reversibility predisposition, environmental factors, access to training
facilities and sport science support, socio-cultural and eco-
A reductionist view of training for elite sport perform- nomic factors, and the interactions between these compo-
ance identifies a range of interdependent adaptations nents (FIGURE 3). The question of whether all individuals
that enable an athlete to sustain the highest rate of respond to exercise training (i.e., demonstrate a measura-
energy production for the duration of their event, opti- ble improvement in a specified physiological outcome
mize economy of motion, defend cellular homeostasis, measure) is discussed subsequently.
and delay the onset of fatigue (9, 54, 55, 79, 80). In addi- The principle of progressive overload states that once
tion to undertaking workouts that promote these adap- an athlete has adapted to a given training load, the sub-
tations, an athlete needs to attain the optimal physique sequent training stimuli must be progressively increased
and technical skills specific to their event(s). To achieve to perturb the homeostasis and thereby promote further
these goals, elite athletes engage in periodized training adaptation (FIGURE 4). Overload can be quantified
techniques involving long-term systematic planning for according to the volume of training (how much), the inten-
major events and undertake prolonged, intense work- sity (how hard), and the frequency (how often), with the
outs fueled by optimal nutritional practices, while build- magnitude of adaptation dependent on the interaction
ing resilience against illness and injury (55, 81, 82). between these variables, the prevailing fitness level of
Coaches integrate a series of workouts that individually the athlete, and their genetic ceiling. In addition, cellular
target important competition performance traits into a and whole body homeostasis can be amplified by expo-
periodized training program composed of short (7–21 sure to altitude, heat, or altered fuel availability (55). Such
days) microcycles and longer (3–8 wk) mesocycles, cul- approaches are based on the premise that by imposing
minating in targeted competition peaks within a season greater “metabolic stress” and provoking extreme distur-
or year (macrocycle) (FIGURE 4). There is a firm belief bances to homeostasis, intracellular responses in skeletal
that the training-induced changes in skeletal muscle muscle (and other tissues and organs) will be maximized,
resulting from the high-volume, high-intensity training thereby invoking superior training adaptation and
undertaken by elite athletes over several years is largely enhancing one (or more) of the factors underpinning per-
responsible for the observed improvements in perform- formance (84). Several training strategies are currently
ance over time. practiced by competitive athletes in the belief that they
Elite athletes present a narrow range of values in many amplify adaptation and lead to improved performance
morphological, biomechanical, physiological, metabolic, capabilities. Here, we describe a selection of training
perceptual, psychological, and other traits, depending on strategies that have high uptake by elite athletes and
their specialized event (83). Although there are multiple have plausible biological mechanisms that might explain
and varied approaches to optimize adaptation to enhance current practices (85–87).
sporting performance based on a multitude of mechano-bi- The principle of specificity states that any training-
ological descriptors, the general principles of exercise train- induced adaptations that accrue to an athlete are unique
ing focus on three main concepts: progressive overload, to the type of exercise mode performed; this is most evi-
specificity, and reversibility. These principles of training can dent when contrasting the divergent phenotypes that
be applied to individuals with a wide range of abilities result after undertaking either prolonged endurance- or

FIGURE 4. Training principles and strategies. A: to achieve peak performance at the time of competition, training volume, intensity, and form/specific-
ity have to be adapted in different cycles/phases. Specific paradigms, e.g., high-intensity interval training (HIIT), “train low,” and others, are likewise
periodized and matched to the prevailing volume/intensity/form requirements. Importantly, the periodization of training has to be matched to that of
nutrition (e.g., low glucose vs. carb loading), recovery, psychological aspects, and skill acquisition. B: within shorter cycles, e.g., weekly planning, polar-
ized or pyramidal partitioning of training volume at different intensities (e.g., defined by lactate/ventilatory thresholds between zones 1 and 2 and the
critical power/lactate turnpoint between zones 2 and 3) helps to improve performance and reduce overtraining. C: training adaptation is initiated by a
homeostatic disruption induced by exercise. After exercise cessation, recovery and repair mechanisms not only result in a return to baseline but trigger
adaptive mechanisms, optimally in a supercompensatory manner, which should help to protect muscle better from future perturbations. However, in
the absence of continued stimuli, i.e., detraining, this supercompensatory response is abolished by an adaptive dissipation. The amplitude and tempo-
ral aspects of this curve are strongly influenced by the training paradigm and related parameters. Moreover, within the same system, biochemical proc-
esses, cell types, or tissues can react in a different manner (heterochronism of adaptation). D: performance gains are controlled by the balance
between training load and recovery. A suboptimal planning can result in either undertraining with little or no gains or overtraining, in which performance
decreases (retrogression) and the risk for injuries increases. In proper conditions, a functional overreach helps to maximize progression and overcome
training plateaus. Figure created with BioRender.com, with permission.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1699

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

strength/resistance-based training (86, 88). The principle with 1- to 3-min rest or active recovery], 2) high-intensity
of specificity states that the closer the training routine is interval training (HIIT, comprising near-maximal efforts per-
to the requirements of competition, the greater the likeli- formed at the power output/speed that elicits V_ O2peak for
hood of successful outcomes. For this reason, the foun- 1–4 min, with 1- to 2-min rest or active recovery), and 3)
dation of any training program should reflect the desired moderate-intensity continuous interval training (performed
training adaptation necessary to enhance sports-specific at power output/speed that elicits between 85% and 90%
performance. The principle of specificity should operate of V_ O2peak performed for 5–10 min, with 1-min rest or
with regard to not only the modality of training but also active recovery). In untrained and recreationally active
the intensity and speed/power output at which an athlete individuals, both short-term SIT and HIIT are potent stimuli
performs training (discussed below). The principle of re- to induce physiological remodeling similar to that attained
versibility states that there will be a decline or complete after traditional prolonged endurance training, despite
loss of training-induced adaptations when an athlete markedly lower total exercise volume and training time
reduces or stops training for a substantial time (i.e., sev- commitment (101, 102).
eral weeks up to several months). Reductions in both The notion that interval training is a new, groundbreak-
training volume and intensity diminish many of the adap- ing scientific approach to physical conditioning, espe-
tations that accrue from daily or twice-a-day training, with cially for athletic performance, needs to be placed in
such a response leading to concomitant performance historical context. Coaches and athletes have appreci-
decrements. The time courses of loss of adaptations af- ated the value of this form of training since the early twen-
ter both well-trained endurance athletes and recreational tieth century, with many notable cases in which a range
sportspersons stop daily training are rapid: declines in of different work to rest intervals were trialed, tested, and
whole body maximal and submaximal responses to exer- refined to prepare for competition (99). Interval training
cise occur during the first 7–21 days of inactivity, becom- was widely used by a Finnish coach, Lauri Pikhala, who
ing somewhat stable after 2 mo of detraining (89–93). In worked with many champion runners including Paavo
athletes who predominantly train for strength and power, Nurmi and Hannes Kolehmainen. Between 1920 and
and depending on the type of strength test performed, 1930, Nurmi was the most dominant distance runner in
there is a limited decline in muscular strength during the world, winning a total of nine Olympic gold medals.
short-term (up to 21 days) inactivity, but decay rates The foundation of Pikhala’s training methods focused on
increase substantially after 4 wk and longer (89, 93–95). running a high number of repetitions (20–30 efforts) at
It is important to highlight that the principle of reversibility close to the athlete’s race pace interspersed with short
differs from a competitive “taper” before a major event/ (<60 s) rest intervals. Subsequently a German physician
competition: during a taper, the volume and frequency of and coach, Woldemar Gerschler, working with cardiolo-
training are deliberately reduced but the intensity is gist Herbert Reindel, fine-tuned a similar interval training
maintained or even increased, resulting in a performance approach focusing on the manipulation of the work:recov-
enhancement of 1–2% (96, 97). ery periods, based on an athlete’s heart rate. An athlete
would run over a distance fast enough to elicit a heart
2.2. Intensity vs. Volume to Optimize Training rate close to 180 beats/min, after which they rested until
Adaptation the heart rate dropped to
120 beats/min; at this time,
the next work bout was performed. Gerschler and
2.2.1. High-intensity, low-volume vs. low-intensity, Reindel proposed that the rest or recovery interval was
high-volume training to maximize endurance the most important aspect of their approach because it
training adaptation. was during this phase that the heart adapted, allowing it
to grow larger and stronger (99). In the 1960s, the New
Recently, there has been renewed scientific inquiry along Zealand running coach Arthur Lydiard advocated a shift
with widespread public interest in the potential for high-in- away from high-intensity interval-based training to high-
tensity interval training (HIIT) to induce physiological adap- volume, continuous training for endurance performance.
tations that are similar or even superior to a traditional, Lydiard advocated running as much as 160 km/wk during
continuous endurance-based exercise prescription for the preseason conditioning or “base” phase, with both
health and performance (98–100). HIIT broadly refers to middle- and long-distance runners undertaking similar
exercise that is characterized by relatively short bursts of volumes of work (103). Although there was a perception
vigorous activity interspersed by periods of rest or low-in- that such a high volume of training could only be per-
tensity exercise for recovery. A common classification sub- formed at low intensities (i.e., high volume, low intensity),
divides this type of training into 1) sprint interval training this was not the case: running during this phase of condi-
[SIT, supramaximal efforts performed at power outputs/ tioning was prescribed at speeds that corresponded to
speeds > peak oxygen uptake (V_ O2peak ), for 30–60 s, an athlete’s best 16 km race pace (for middle-distance

1700 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

athletes) or best marathon pace (for long-distance run- well-defined training cycles, at volumes, frequencies, and
ners). This conditioning phase could last from as short as absolute exercise intensities/power outputs that far
8 wk to half a year. Lydiard’s athletes had major success exceed those capable of being attained by their less ge-
over two Olympiads (Rome 1960 and Tokyo 1964), win- netically gifted counterparts. In this regard, a recent study
ning medals across a wide range of distances including reported reductions in mitochondrial respiration in skeletal
triple Olympic gold medalist Peter Snell (800 and 1,500 muscle in response to 4 wk of intensified HIT in moder-
m), John Davies (bronze medal 1,500 m), Murray Halberg ately trained individuals (106). The impairment in mito-
(gold medal 5,000 m), and Barry Magee (bronze medal, chondrial function occurred during the week of heaviest
marathon). training load but was dissociated from both mitochondrial
Despite these successful coach-driven approaches to activity and mitochondrial protein abundance, which both
conditioning for elite athletes, it was not until the 1960s peaked at that time (106). Despite the transient impair-
that the first scientific publications on the physiological ments to mitochondrial respiration, performance parame-
bases of training for human performance appeared, and ters all increased after the intensified HIT regimen.
even today the scientific literature on the unique effects of Furthermore, the training undertaken by the participants
specific training interventions on the performance of in that study consisted exclusively of maximal HIT (106)
highly trained athletes is sparse. Indeed, although the and can only be tolerated by highly trained athletes for
foundation of all training programs for the enhancement of more than a few successive days (107).
sport performance is the volume, intensity, and frequency Since the classic model of training periodization was
of exercise, the relative importance of these interdepend- first proposed over four decades ago (108), there has
ent variables has not been established for many of the been widespread discussion about how best to imple-
key physiological adaptations to training, nor their impact ment training stimuli to optimize adaptation and athletic
on performance outcomes (104, 105). This is because train- performance (109). Although several long-term period-
ing prescription is infinitely variable, with countless permu- ization approaches have been described (110), con-
tations around the core tenets of the general principles of trolled studies comparing the impact of these different
training (FIGURE 4). Adding to the complexity of training protocols on performance outcomes are lacking. As
prescription is the multiplicity of the physiological/technical noted, anecdotal testimonies from top athletes and their
demands of many athletic events, with many requiring coaches (111), case studies of elite performers (112, 113),
components of both endurance and strength/power, as and reports of small cohorts of top athletes from specific
well as different modes of exercise (i.e., swimming, cycling, sports (53, 114, 115) provide insights into the training
and running in the triathlon). Potential “interference practices of elite performers, but such studies merely
effects” between endurance- and strength/power-based document what successful athletes did; they do not
training regimens are discussed below. reveal what made those athletes successful or prove
There has been spirited scientific debate as to whether that the program they followed was optimal (116).
training volume or training intensity promotes the greatest Indeed, there may have been many athletes who fol-
adaptation in skeletal muscle (104, 105), with this dialogue lowed similar programs who were not successful, fell ill,
focusing predominantly on exercise-induced changes in suffered injury, or dropped out of the sport completely.
mitochondrial content, typically assessed by quantifying Notwithstanding these limitations, detailed analyses of
the maximal activity of citrate synthase, the first step of the the training methods of elite athletes enable sport scien-
tricarboxylic acid cycle, or skeletal muscle respiratory tists to examine relationships between training inputs
capacity (see sects. 3.4.1 and 4.5). Although higher inten- and variables directly or indirectly related to perform-
sities of exercise generally elicit greater increases in mito- ance (FIGURE 5). This information can also provide a ba-
chondrial content than lower exercise intensities per unit sis for hypothesis testing with respect to training load
of time or work (104), such a narrow perspective ignores and physiological adaptation. There have been multiple
any functional outcomes, such as athletic performance. empirical descriptions of the distribution of training in-
Perhaps more to the point, the data used to support one tensity in highly trained/elite athletes competing in en-
or the other position (i.e., volume vs. intensity overload) durance-based sports (110, 114, 117–121). Depending on
have come from studies that employed untrained or rec- the specific loading characteristics of the sport (i.e.,
reationally active subjects participating in short-term inter- weight bearing vs. non-weight bearing), international
ventions (2–6 wk) undertaking one-dimensional training athletes competing in endurance events typically train
programs consisting of either HIT or continuous, submaxi- for between 500–600 h (distance running) and up to
mal endurance-based training. It is not clear how these 1,000 h per year (rowing, swimming, cycling, triathlon),
results can be extrapolated to elite athletes with a pro- performed during 400–800 training sessions (122–124).
longed history of periodized training that includes a vari- This training volume is undertaken for a minimum of 11
ety of workouts with different goals, performed within mo a year, with the overall goal of achieving peak

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1701

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

FIGURE 5. Periodization of training for an elite athlete. Schematic representation of periodization of training along with physiological data collected
during preparation for the 2016 Rio Olympic Games for a gold medal-winning female rower. BLa, blood lactate; BM, body mass. See GLOSSARY for other
abbreviations. Figure created with BioRender.com, with permission.

performance throughout a specified time frame (usually this approach would be described as a “polarized training
4–6 wk) in the competitive season. However, there is intensity distribution” by Seiler and colleagues (121) as dis-
significant variability between sports, with professional tinct from a pyramidal training paradigm (FIGURE 4).
cyclists frequently racing
100 days and riding in excess Since then, there have been several reports that elite ath-
of 30,000 km during any 12-mo period (125, 126). letes follow both approaches to their competition prepa-
Longitudinal data suggest that the development of a ration (128). Coetzer et al. (129) reported that elite
world-class endurance athlete may take up to a decade distance runners with superior race performances trained
of specific training, with highly successful athletes often at a higher average intensity than a group of sub-elite run-
following a 2- or 4-yr cycle of preparation for world ners: the sub-elites spent 13% of their total weekly training
championships or Olympic events (110, 125). To maxi- volume running at speeds eliciting >80% of V_ O2peak ,
mize adaptation and reach one’s genetic potential, whereas the elite runners spent significantly more time
champion athletes must therefore be able to tolerate (36%) at this higher intensity. These observations agree
prodigious training loads. However, a high training vol- with others (118, 119) who have observed that elite Kenyan
ume alone does not guarantee sporting success. distance runners complete a greater volume of training
A quarter century ago, Mujika et al. (127) studied the as fast-paced “tempo” runs and short-interval training
relationships between training variables and performance compared to their non-elite counterparts. Guellich and
variations over the season in a group of elite swimmers. colleagues (130) reported that elite endurance ath-
They reported that training intensity, rather than volume letes from a range of sports including rowing, running,
or frequency, was the key variable inducing a training ad- cycling, and cross-country skiing perform only a small
aptation that led to subsequent performance improve- portion of their training at competition/race-pace
ments. These workers also observed a training intensity intensities, with the bulk of their workload comprising
distribution that placed emphasis on volume-overload low-intensity, high-volume workouts and exposure to
training conducted at submaximal intensities for most of a extreme HIT sessions.
season, with the inclusion of supramaximal high-intensity It has been hypothesized that a polarized approach to
sprint workouts nearer to a competition. A decade later, training, in which 75–80% of total training volume is

1702 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

performed at low intensities with 10–15% performed at sets  repetitions  load (expressed as a percentage of
supramaximal intensities, may be the optimal training in- 1RM), sets  repetitions  load (kg), load  sets  repeti-
tensity distribution for elite athletes who compete in tions for each exercise, or number of sessions  repeti-
intense endurance-based events (131). However, this prac- tions  sets (137). Resistance training intensity is typically
tice has recently been questioned and debated (116, 132– defined as a percentage of maximal strength (%1RM).
134). Alternative approaches to “polarized training” have Resistance training frequency represents the number of
been proposed, such as pyramidal or “threshold” training resistance training sessions performed in a specified
intensity distributions. At present, and to the best of our time period (i.e., per week) and for each muscle group.
knowledge, there are no studies that demonstrate that The frequency of resistance training sessions is impor-
adherence to a polarized training program produces tant when considering resistance exercise prescription,
superior outcomes compared with the pyramidal training as the recovery time between sessions must allow for
programs athletes typically practice or other possible muscle adaptation (i.e., net protein synthesis). The num-
training models (116, 132–134). Indeed, polarized training ber of training sessions provides an indication of the total
per se seems totally incompatible with the principle of resistance training work over a program’s duration,
training specificity, a cornerstone of any training program. whereas including load describes the total work of a sin-
Although it is tempting to attribute the superior perform- gle training session. Other parameters (e.g., load, num-
ances of elite athletes from a range of endurance sports ber of repetitions and sets, range of movement, time
to the adoption of a specific training regimen (i.e., polar- between sets, time under tension, and volitional muscle
ized training, HIT), the principle of individuality dictates failure) provide a comprehensive description of resist-
that the same training program will not equally benefit all ance training programs (138), even though the effect of
those who undertake it. Furthermore, the molecular and manipulating these variables on athletic performance
cellular mechanisms that underpin performance enhance- remains unclear (139).
ment after polarized and various other training interven- To maximize muscle hypertrophy, the American
tions are not well understood. Directly linking exercise- College of Sports Medicine (ACSM) recommends resist-
induced molecular signaling events in skeletal muscle to ance training intensities corresponding to a load of
defined metabolic responses and specific changes in
70–80% 1RM for 8–12 repetitions (140). Although such
gene and protein expression that occur after diverse train- loading is unlikely to be undertaken by elite athletes
ing regimens may provide clues as to why certain training competing in strength/power events, such advice is
methods (i.e., polarized training, HIT) are such potent largely based on the observation that higher loading
interventions both for promoting health outcomes and induces greater force development, an increased mus-
enhancing athletic performance. cle electromyography activity (141), and a greater recruit-
ment of muscle fibers. Evidence to support a dose-
2.2.2. High-intensity, low-volume vs. low-intensity, response relationship between external loading and
high-volume training to optimize resistance maximal rates of MPS comes from the work of Kumar et
training adaptation. al. (142), who showed that a plateau in MPS was reached
at intensities approaching 90% of 1RM. However, results
Analogous to endurance-based training, periodization is from other studies suggest that maximal rates of MPS
frequently used to promote muscle hypertrophy and can also be achieved by low-intensity, higher-volume
strength gains in response to a program of resistance loading. Burd et al. (143) studied 15 recreationally active
training (135). Indeed, when resistance training volume is males who performed four sets of unilateral leg exten-
similar, periodized training protocols induce greater sion exercise at different exercise loads and/or volumes:
gains in strength [i.e., one-repetition maximum (1RM)] 90% of 1RM until volitional failure (90FAIL,
5 repeti-
than non-periodized resistance training, at least in tions), 30% 1RM work-matched (WM) to 90%FAIL (30WM,
trained individuals (135). The process of skeletal muscle 14 repetitions), or 30% 1RM performed until volitional fail-
fiber hypertrophy and the concomitant gains in strength/ ure (30FAIL, 24 repetitions). Low-load, high-volume re-
power (discussed in sects. 3.2, 4.3–4.5, and 4.8) are the sistance exercise (30FAIL) was equally effective at
result of the confluence of a net positive muscle protein increasing rates of MPS as high-load, low-volume resist-
balance, with the addition of satellite cells to muscle ance exercise (90FAIL), eliciting increases in rates of
fibers a possible mechanism. Muscle hypertrophy only myofibrillar protein synthesis similar to those induced by
occurs when net positive muscle protein balance is the 90FAIL protocol in the postexercise recovery period.
maintained over several weeks/months and when the Furthermore, only the 30FAIL protocol sustained higher
rate of muscle protein synthesis (MPS) exceeds that of rates of MPS 24 h after exercise. Although these data
muscle protein breakdown (136). Resistance training vol- from a single bout of resistance training are intriguing,
ume can be defined as the number of sets  repetitions, there is support for the concept that measures of acute

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1703

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

postexercise MPS are qualitatively predictive of the contraction mode, and interset rest interval) are most
chronic training-induced phenotypic changes driven by effectively periodized to maximize both MPS and
repeated resistance exercise stimuli. In a study from the improvements in strength and other functional meas-
same laboratory, Mitchell et al. (144) studied 18 untrained ures (135, 139, 152, 153).
males who completed 10 wk of unilateral knee extension
resistance training. Each leg of a participant was randomly 2.3. Exercise Interference Effects and Concurrent
assigned in counterbalanced fashion to one of three possi- Training Responses
ble unilateral training conditions: one set of knee extension
performed to voluntary failure at 80% of 1RM (80%-1); three The inverse relationship between muscle fiber size and
sets of knee extension performed to the point of fatigue at oxidative capacity highlights the principle of the specific-
80% of 1RM (80%-3); or three sets performed to the point ity of training when comparing muscles of endurance
of fatigue with 30% of 1RM (30%-3). Each participant and strength/power athletes (154, 155). Accordingly,
trained both legs and was therefore assigned to two of simultaneously training for both endurance and strength
the three possible training conditions. The strength of results in a compromised adaptation compared with
this design is that both limbs are exposed to the same training for either exercise modality alone, at least in pre-
nutrient and hormonal milieu and therefore any pheno- viously untrained individuals. This phenomenon was first
typic changes can be ascribed solely to the training stim- described by Hickson (156), who reported impaired
ulus. There were significant training-induced increases strength development in training naive males when they
in muscle volume [measured by magnetic resonance incorporated both strength and endurance workouts
imaging (MRI)], but these were not different between the versus single-mode exercise into a short-term (10 wk)
training protocols. These results are in accordance with training program. Hickson (1980) coined this the “inter-
previous acute measurements of muscle protein syn- ference effect,” and since that seminal observation, a
thetic rates and demonstrate that a lower load lifted to number of animal and human studies have been con-
failure results in muscle hypertrophy similar to a heavy ducted in an effort to elucidate a molecular basis to
load lifted to failure. An important feature of this study explain this outcome (discussed in sect. 4.5.1). Of note
was that the training program was underpinned by was that training-induced gains in aerobic capacity in
adequate nutrition (i.e., sufficient amino acid availability) that study (156) were not compromised by concurrent
to support the increases in MPS that occur after each strength and endurance training. In fact, in contrast to
training session. These results support earlier findings the impaired strength gains observed when endurance
demonstrating that significant increases in muscle fiber training is undertaken simultaneously with resistance
area can be achieved after 16 wk of isometric training at training (156), there is potential for combined strength
30% of maximal voluntary contraction (MVC) (145). and endurance training to amplify endurance perform-
As is the case for most studies that have examined ance (157).
various endurance training protocols, most investiga- The study of “concurrent training” has received less
tions of different strength/resistance training programs scientific enquiry than single-mode training for endur-
have been undertaken with recreational and/or moder- ance or strength/power. Indeed, studies of concurrent
ately trained male college students. How such findings training interventions pose several unique experimental
translate to elite athletes who are likely to have reached challenges. The inability to match total work as well as
an upper limit in muscle hypertrophy and strength gains the type of stimulus and/or exercise mode makes com-
after many years of training is unclear. Elite athletes parisons between the results of studies of concurrent
competing in events that require strength/power will training problematic. Differences in experimental design
also be undertaking additional forms of training to maxi- and dependent variable selection also limit any mecha-
mize muscular force output such as plyometrics, which nistic insights in those studies that have determined
involves rapid and repeated stretch/contractions of the only performance-based outcomes. Finally, the majority
muscle of the lower limb (146–148), or hypoxic/blood of studies of concurrent training to date have focused
flow-restricted training (149–151). This makes it difficult to exclusively on acute molecular responses in moderately
determine the precise contribution of any single inter- trained individuals, employing modest workloads; the
vention to improvements in muscle hypertrophy and training practices of elite/professional athletes undertak-
strength. Inherent variability in the individual response ing concurrent training far exceed those reported in the
to resistance training is also a factor to consider in any literature for less well-trained subjects and are likely to
training protocol (discussed below). In summary, there is induce complex molecular profiles (88, 158). Over the
currently little consensus on how the variables related to past two decades, the mechanisms that generate the
resistance training (training load, volume, and fre- adaptive response to both endurance- and strength-
quency, muscle time under tension, lifting cadence, based exercise training have undergone intense

1704 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

investigation (9, 55, 85–87, 159–166). There are multi- 2.4. Altitude and Hypoxic Training to Enhance
ple stimuli associated with endurance- and resistance- Adaptation
based exercise and various signaling kinases that
respond to these different perturbations, in concert Of all the practices currently used to enhance training
with numerous downstream pathways and targets of adaptation and elite athletic performance, “altitude train-
these kinases. These events involve the increased ing” or exposure to hypoxic environments is the most
expression and/or activity of key proteins mediated by widespread (55, 97). The stimulus for a new era in
an array of signaling events, pre- and posttranscrip- research of high-altitude training practices was the 1968
tional processes, regulation of translation and protein Olympic Games held in Mexico City at an elevation of
expression, and modulation of protein/enzyme activ- 2,240 m above sea level. In the middle- and long-dis-
ities and intracellular localization (9, 55, 85, 87, 159). tance track events, runners who were born and trained
These molecular processes are described in detail in at altitude were dominant: in the men’s 10,000 m, the
sect. 4. Finally, there are complex spatial and temporal first five runners resided and trained at altitude. The
interactions between the various elements that ulti- world record holder at the time for both the 5,000 and
mately combine to produce the integrated response 10,000 m events going into the Mexico Games,
to an exercise challenge that, when repeated over Australian Ron Clarke, who was born and trained at sea
months and years, results in functional improvements level, collapsed after finishing 6th in the 10,000 m and
in performance and alterations in phenotype. had to be administered oxygen to recover. Since those
Although it is convenient to classify athletic events Olympics, male and female athletes from Kenya and
as either “endurance-based” or “strength-/power-based,” Ethiopia have dominated middle- and long-distance run-
with skeletal muscle from endurance- and strength- ning events, with elite athletes and coaches steadfastly
trained individuals representing diverse adaptive believing in the benefits of hypoxia-induced adaptive
states in response to selective activation and/or responses to optimize performance (97). This is despite
repression of signaling pathways that underpin these the paucity of scientific evidence supporting an altitude-
adaptations (9, 88, 159, 160, 166), such a one-dimen- induced performance-enhancing effect (55, 170, 171).
sional perspective ignores the fact that the majority of The mechanisms that underpin the adaptive response
athletic disciplines require a combination of both mus- to reduced oxygen availability are discussed below.
cular endurance and strength/power for successful
outcomes. As such, both endurance- and resistance- 2.4.1. Into thin air: altitude training strategies to
based training are frequently undertaken concomi- enhance endurance performance.
tantly as part of a periodized training program. These
practices encompass several scenarios: 1) a single There are several common approaches that athletes
training session during which an athlete performs adopt with regard to altitude training, involving several
both endurance- and resistance-based exercise; 2) days to several weeks of exposure to some form of alti-
two independent training sessions undertaken by the tude or hypoxic challenge (172). Regardless of the differ-
athlete on the same day, in one of which the focus is ent approaches used to induce hypoxic living/training
endurance adaptation (i.e., performed in the morning) conditions, the underlying physiological basis for alti-
and in the other strength/power adaptation (i.e., per- tude training is that the reduced barometric and partial
formed in the afternoon/evening); or 3) when an ath- pressure of oxygen results in lowered oxygen availabil-
lete incorporates both types of training on different/ ity causing an increase in erythropoietin (EPO) produc-
alternate days as part of a periodized training program tion in the kidney that stimulates erythropoiesis and
(88). Currently, little is known about the effects of con- thereby leads to enhanced hemoglobin (Hb) mass. As
current training in elite athletes on performance pro- acute exposure to hypoxia over several hours does not
gression, and it is conceivable that the degree of improve aerobic or anaerobic performance, these studies
interference may be discipline- and training paradigm- are not discussed here (173). The original altitude training
specific (1, 167). For example, in sports where endur- strategy involved athletes spending up to 6 wk living and
ance as well as high peak power/forces are required training at a moderate altitude (2,000–2,500 m) and
(such as in 2,000 m rowing), athletes aim to maximize returning to sea level just before a major sea-level com-
both muscle mass and oxidative capacity. Indeed, the petition (“live high, train high,” LHTH). The LHTH
peak power of Olympic rowers is positively correlated approach boosts EPO and Hb mass, which results in an
with thigh muscle volume but negatively correlated increase in V_ O2max . Such adaptations usually persist for
with V_ O2max (168). Similarly, sprint and endurance per- 1–2 wk upon return to sea level, with the athlete partici-
formance are inversely related in highly trained pating in several major competitions during this period. A
cyclists (169). limitation of the LHTH strategy is that training intensity is

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1705

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

often compromised, which is in line with the linear reduc- and their coaches continue to believe that some form
tion in V_ O2max with increasing altitude (
6–8% reduction of altitude training will confer a performance advant-
per 1,000 m) (174). A second strategy involves athletes age when competing at sea level. Guidelines and
continuing to reside at sea level but training at altitude measures to improve altitude acclimatization, toler-
(“live low, train high,” LLTH). Adaptations resulting from ance, and safety have been reviewed elsewhere (181).
LLTH are mainly confined to the trained musculature (i.e., Interestingly, preconditioning with hyperbaric oxygen
skeletal muscle mitochondrial volume density), with little has also been proposed to enhance performance,
effect on EPO or Hb mass. As with the LHTH approach, however with similar equivocal underpinnings (182).
the intensity of training is typically reduced with LLTH. A
third protocol, and the one that is most widely used and 2.4.2. Resistance training under hypoxic
has received widespread interest among scientists, conditions.
coaches, and athletes, is the “live high, train low” (LHTL)
approach, whereby athletes reside at altitude for several Acute hypoxia has been proposed to potentiate resist-
weeks but return to sea level to undertake the majority of ance training-induced hypertrophy by activating satellite
their training sessions. Compared with LHTH or LLTH cell-dependent myogenesis rather than an improvement
approaches, the LHTL approach permits athletes to main- in net protein balance. To test this hypothesis, van
tain their absolute training loads (volume and intensity) Doorslaer et al. (183) recruited 19 physically active male
while concomitantly gaining the physiological adaptations subjects who performed 4 wk of resistance training (6
that accrue with exposure to chronic hypoxia. Indeed, sets of 10 repetitions of a 1-leg knee extension exercise
when competitive runners completed 4 wk of supervised at 80% 1RM 3 times/wk) in either normoxic [fraction of
training as either LHTL, LHTH, or LLTH, performance of a inspired oxygen (FIO2 ): 21%; n = 9] or hypoxic (FIO2 : 13.5%,
5 km time trial at sea level was improved only in the LHTL n = 10) conditions. At the end of the intervention, the
athletes despite similar gains in the athletes’ V_ O2max in all strength gain was higher in individuals who trained
intervention groups (175). No muscle biopsies were taken under hypoxic compared with normoxic conditions, de-
in that investigation, so it was not possible to determine spite no changes in muscle thickness and the rate of
whether the different altitude-training regimens resulted MPS. Although these results suggest that training under
in changes in hypoxia-mediated signaling pathways or if hypoxic conditions may be a potent intervention to
there were changes in major training-induced signaling increase muscle strength, at least in the early phase of
proteins. A model pioneered by the Australian Institute of training, additional studies in well-trained athletes incor-
Sport (AIS) requires that athletes gain exposure to alti- porating long-term protocols are urgently needed to
tude/hypoxia by either living in a custom-built altitude determine whether hypoxic resistance training can fur-
house under conditions of simulated altitude (14 h/day) or ther maximize strength gains. Other protocols with
using altitude tents or intermittent hypoxic exposure with potential additive training effects due to reduced local
hypoxic breathing devices (176). However, even though muscle oxygen availability and exacerbated vascular
altitude paradigms increase Hb mass (172), the purported shear stress that leverage hypoxic stimuli (i.e., blood
performance gains from living at simulated moderate alti- flow restriction) are currently being investigated (150,
tude and training at low altitude have been questioned 151, 184) yet hampered by the heterogeneous responses
(177, 178). Therefore, whether training in hypoxia while liv- to ischemic preconditioning (185).
ing in normoxia or living under hypoxic conditions while
training at sea level (or low altitudes) is superior to living 2.5. The Lowdown on Training with Reduced
and training in normoxia for enhancing performance of Muscle Glycogen Stores
elite athletes near sea level is unclear and warrants fur-
ther investigation. There are also many challenges when A growing field of interest that has directly risen from a
assessing the effect of altitude exposure on performance better understanding of the molecular bases underlying
in elite athletes (179). For example, the scientific gold training adaptation is how nutrient availability has the
standard design of a double-blind, placebo-controlled, capacity to modify the regulation of many contraction-
crossover trial has seldom been conducted in studies of induced signaling networks in skeletal muscle (sects.
altitude training in elite athletes. A recent systematic 3.4.2 and 4.5) (9, 186–193). The interaction between exer-
review, albeit incorporating individuals with a wide range cise training-induced responses and nutrient availability
of athletic abilities, concluded that placebo and nocebo has long been recognized (194), and today it is well
effects can exert a small to moderate effect on sports per- accepted that carbohydrate-based fuels are critical for
formance (180). Yet despite equivocal scientific evidence prolonged, intense training and in the competition setting
to support a performance-enhancing effect of altitude/ where optimal endurance performance is desired (195).
hypoxic training practices, elite endurance athletes However, this premise does not address the issue of

1706 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

whether training adaptation is driven by a surplus or lack permit the results to be extrapolated to competitive ath-
of substrate (i.e., carbohydrate). During the past decade, letes. Several studies subsequently verified the finding
there has been a growing appreciation that commencing that, in well-trained athletes, chronic (3–10 wk) training
selected training sessions with reduced muscle glycogen programs in which selected workouts were deliberately
stores may promote training adaptation and enhance en- commenced with low muscle glycogen concentration
durance performance (196–198). Acutely manipulating increased the expression of genes and the abundance of
substrate availability (by either altering the composition proteins involved in carbohydrate and/or lipid metabolism
and/or timing of meals before training/competition or while promoting mitochondrial biogenesis to a greater
depleting endogenous fuel stores by exercise) rapidly extent than when all workouts are undertaken with nor-
alters the concentration of blood-circulating substrates mal or elevated glycogen stores (molecular mechanisms
and hormones that modulate several receptor-mediated underlying these observations are discussed in sect.
signaling pathways. The release of cytokines and growth 4.5.2) (199–201). Surprisingly, such adaptations accrued
factors from contracting skeletal muscle in response to notwithstanding a reduction of 7–8% in the athletes’ self-
the altered hormonal milieu also stimulates cell surface selected training intensity (200, 201). Yet despite aug-
receptors and activates many intracellular signaling cas- mented adaptations at the muscle level, studies that have
cades (described in sect. 4). These local and systemic fac- examined the “train low” glycogen model in well-trained
tors cause marked perturbations in the storage profile of athletes have often (201–204), but not always (197, 198),
skeletal muscle (and other insulin-sensitive tissues) that, failed to show a performance benefit (for review, see Ref.
in turn, exert pronounced effects on resting fuel metabo- 205). Such a disconnect between changes in selected
lism and patterns of fuel utilization during exercise. When molecular mechanistic variables (e.g., increases in the
repeated over weeks and months, such nutrient-exercise phosphorylation status of signaling molecules and/or
interactions have the potential to alter numerous adaptive increases in the expression of genes and proteins
processes in skeletal muscle that ultimately drive the phe- involved in mitochondrial biogenesis) and whole body
notype-specific variability observed between individuals functional outcomes (changes in training capacity or ath-
(55). However, linking these molecular events to direct letic performance) is hard to reconcile. However, it may
downstream effectors has proven elusive (199). Perhaps well be that elite athletes with a prolonged history of train-
more to the point, training adaptation requires an ing have already maximized many of the cellular path-
increase in the steady-state levels of exercise-induced ways involved in energy provision and that proteins in
proteins, and it was not until the pioneering study of these and other contraction-induced pathways that are
Hansen and colleagues (187) that the notion that endur- upregulated with the train low glycogen protocol are not
ance training undertaken with low muscle glycogen lev- rate limiting for performance.
els could augment adaptation gained scientific credibility. There is a scarcity of studies that have examined the
These workers tested previously untrained individuals effects of commencing resistance training with low mus-
before and after a 10-wk intervention in which both the cle glycogen stores. Nevertheless, some evidence
left and right legs of the same individual were subjected exists suggesting that reduced glycogen availability may
to specific work-matched training protocols in which one upregulate cellular pathways regulating mitochondrial
leg was trained once daily while the contralateral limb biogenesis after a single bout of exercise (206), even
trained twice every second day. As intended, the twice-a- though engaging in resistance training with low muscle
day training protocol decreased muscle glycogen content glycogen does not affect rates of MPS (207). These
after the first bout of exercise such that the second exer- results imply that commencing a bout of strenuous re-
cise session of the day was commenced with lowered sistance exercise with low muscle glycogen availability
(but not totally depleted) muscle glycogen content. The attenuates neither anabolic signaling nor rates of myofi-
activity of mitochondrial enzymes along with resting mus- brillar protein synthesis. In summary, despite no clear
cle glycogen concentration were all increased to a evidence of a performance-enhancing effect from the
greater extent when half the training sessions were exe- results of several well-controlled laboratory-based stud-
cuted with low glycogen availability. Exercise time to ies that have tested various train low (glycogen) strat-
exhaustion (a proxy for performance) involving a one-leg- egies, many athletes who compete in endurance-based
ged “kicking” task was elevated markedly for both legs events continue to incorporate such practices into their
after training but was twice as long for the limb that training programs. In contrast, there appears no reason
trained with low compared to high glycogen. The for athletes undertaking resistance training regimens to
strength of this study was the design that controlled for adopt low-glycogen workouts into their daily schedules.
both systemic and local effects. However, the authors A challenge for future investigations is to directly link
acknowledge that the controlled laboratory setting, some of the acute exercise-induced molecular signaling
coupled with the training status of their subjects, may not events in skeletal muscle that take place in response to

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1707

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

the greater metabolic loading imposed by various train- circadian timing are considered. These investigations
ing interventions (i.e., altitude and low glycogen) to show clear differences in performance profiles between
defined performance-related outcomes that occur after ECTs and LCTs, with LCTs exhibiting greater variation in
elite athletes undertake such practices. diurnal performance profiles, particularly in the morning
(231). Interestingly, performance peaks can be shifted by
2.6. A Time to Train, a Time to Compete? different measures such as active and passive warm-up,
caffeine, or training-competition time-of-day synchroni-
Since the awarding of the Nobel Prize in Physiology or zation (225). Moreover, individual shifts in chronotypes
Medicine in 2017 for the discovery that the molecular or time-of-day performance are observed (i.e., in older
clock is the primary mechanism underlying circadian athletes with a higher prevalence of “morningness” in
rhythms, there has been a dramatic increase in the num- training scheduling and work rates) (221).
ber of scientific publications regarding circadian biology The impact of exercise training at different times of the
and its impact on various aspects of human behavior, day has been well studied in animal models and healthy
including sporting performance. Circadian rhythms are moderately trained humans, with the primary outcome

24-h (circa diem) oscillations in biological and meta- typically being a measure of exercise capacity, often a
bolic pathways. The circadian clock is cell autonomous laboratory-based task designed to mimic performance, or
and present in most human tissues and organs and is a metabolic surrogate (232–234). However, studies inves-
organized in a hierarchical manner, with the hypothala- tigating the timing of exercise training in elite athletes and
mic suprachiasmatic nucleus (SCN) functioning as the the subsequent effect on performance outcomes are
“master clock” with “fine-tuning” by clocks in peripheral scarce. Once again, we are left to generalize from inter-
tissues (208–211). Although light is the dominant zeit- ventions in healthy, almost exclusively male, non-elite
geber (time giver) for the SCN oscillator, which in turn subjects until such gaps in the literature are filled. There
orchestrates rhythms in the peripheral organs/tissues at are several reports of greater increases in muscle mass
appropriate phases, both the timing of exercise (212– and strength after training late in the afternoon versus
216) along with the scheduling of meals (217–220) can early morning (221, 233–235), which is in line with the
impact circadian behavior (molecular underpinnings are generally higher peak forces attained in the afternoon/
discussed in sect. 4.9). early evening (236). Consistent with the enhanced reli-
Differences in the time of day for peak performance ance on fatty acid oxidation in a fasted state in the early
for strength and anaerobic power as well as oxidative morning in humans (237), there is a more robust meta-
capacity and endurance performance have been bolic impact of exercise in the fasted state (at the begin-
reported in many, albeit not all, human studies (221– ning of active phase in rodents) than in the fed state (at
224). However, there are large interindividual differen- the beginning of the rest phase) (214). Regardless, the
ces in circadian rhythms, and the time of day for peak results are likely to have limited translational value for elite
performance is affected by many additional factors athletes who typically undertake several workouts within
including time since awakening, timing of precompeti- any 24-h period supported by round-the-clock eating pat-
tion meals, sleep quality, body temperature, hormone terns necessary to meet the demands of training (81).
levels, psychological habituation, motivation, and prior While elite athletes are informed of the venues, dates,
muscle fatigue (225–227). Accordingly, the effect of the and times of major international competitions several
time of day of training on performance needs to be years in advance, the nations selected to host the
placed in the context of an athlete’s chronotype. An indi- Olympic Games and World Championships often adjust
vidual’s predisposition toward a preference for either competition times to accommodate and coincide with
morning or evening can be classified into early chrono- prime-time viewing hours for North American television
types (ECTs), late chronotypes (LCTs), or those in audiences. At the recent Tokyo Summer Olympics, the
between (intermediate chronotypes, ICTs) (228). ECTs, entire swimming program was “flip-flopped” such that
sometimes referred to as “larks,” have significantly ear- qualifying heats and semifinals (normally held in the
lier sleep-wake cycles compared with LCTs (or “night morning) were scheduled for the evening and all finals
owls”), who function better later in the day. These differ- were swum in the morning. As circadian oscillations affect
ences are not only observed in sleep-wake cycles but physiological, psychological, and molecular mechanisms
also multiple physiological (229), behavioral (228), and resulting in varying physical performance capacities over
genetic (230) oscillations that occur every 24-h period. the day, both the timing and relative size of these effects
The implications for competition performance are not are important for optimizing sport performance at the elite
entirely clear. Diurnal performance profiles have been level. To determine the extent to which elite athletes are
studied between ECTs and LCTs to determine whether affected by circadian fluctuations in physical performance,
there is significant variation when individual aspects of Lok et al. (238) assessed data from four Olympic Games

1708 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

(Athens 2004, Beijing 2008, London 2012, and Rio de can lead to detrimental outcomes, as observed for the
Janeiro 2016). The authors analyzed swimming perform- transient hype surrounding the so-called benefits of
ances, as these races are less likely to be influenced cold-water immersion, whole body cryotherapy, and
by confounding environmental effects (i.e., temperature, other passive recovery strategies that in certain con-
humidity, wind speed) and have little reliance on equip- texts can adversely affect recovery or performance
ment that could induce variation within and between ath- outcomes (246, 247). New training strategies are often
letes. Additionally, the water temperature in the pool is based on observations of athletic performance in
required to be within a narrow range across Olympic ven- extreme conditions, such as the high altitude of the
ues, providing a “clean” signal of daily variation in physical 1968 Olympic Games held in Mexico City or the high
performance (238). Their analysis revealed that perform- temperatures that were expected for the Tokyo 2020
ance in Olympic swimmers was significantly affected by Olympic Games (held in 2021 because of the coronavirus
the time of day, with best performance occurring in the pandemic). The former contributed to the widespread
late afternoon/early evening. The amplitude of the effects study and adoption of high-altitude training, whereas the
of time of day was 0.37%, and in 40% of the finals this latter was a primer to explore heat training as a modality
effect was larger than the time difference between gold to improve performance not only in hot environments but
or silver medal finishing times. Furthermore, time-of-day also in mild or cold temperatures. The potential mecha-
effects exceeded the time difference between the silver nisms for enhanced performance in thermoneutral envi-
and bronze medals in 64% of the finals and the time differ- ronments after heat exposure, improved thermotolerance,
ence between bronze and fourth place in 61% of the finals enhanced heat dissipation, expanded plasma volume, ele-
(238). These data indicate that despite athletes incorpo- vated hemoglobin mass, and other adaptations triggered
rating both morning and evening workouts, endogenous by heat exposure, are discussed in sect. 4.6.1 (248, 249).
circadian clocks still exert a time-of-day effect on elite Safety is an obvious concern for such an intervention,
swimming performance. Whether the application of circa- necessitating close monitoring of core body temperature
dian or time-of-day principles can optimize training and and cardiac-related parameters (250). In most cases,
improve performance of these elite athletes remains to many of the reservations about specific training strategies
be determined. stem from an inadequate understanding of the systemic,
organ/tissue, cellular, and molecular events that occur in
2.7. Training Strategies and Paradigms: Good, response to an acute exercise bout and how such infor-
Bad, or Indifferent? mation translates into long-term adaptation. In sects. 3
and 4, we summarize the current knowledge of the physi-
The identification of training strategies that consistently ological, cellular, and molecular underpinnings of muscle
enhance performance remains challenging because of plasticity triggered by both endurance- and resistance-
the multiple interdependent factors contributing to athletic based exercise.
success. Consensus emerging from observational studies
reflects the current practices in long (239), middle dis-
tance (146), or sprint (240) disciplines, but these are likely 3. PHYSIOLOGICAL AND CELLULAR
to be modified with technological advances and ADAPTATION TO EXERCISE TRAINING:
insights from coaches and “science-driven” initiatives, FUNCTIONAL RESPONSE
such as the “sub-2 hour” marathon project. However,
training intervention studies are often limited to low partici- The cellular, tissue/organ, and whole body adaptations
pant numbers, with a reliance on a restricted pool of that occur when exercise bouts are repeated over
young, male, college-educated, recreational or untrained months and years drive the phenotypic changes
cohorts. Extrapolation to other demographics, including observed in highly trained athletes. Such adaptations
women, underrepresented ethnicities, or elite athletes is include alterations in energy flux and metabolism, fiber
problematic. For example, significant sex differences exist type transformations, enhanced mitochondrial and capil-
in the response to both acute exercise and chronic training lary density, and muscle hypertrophy, highlighting the
adaptation (241–243), and the effects of reproductive sta- enormous plasticity of skeletal muscle (TABLE 1).
tus, endogenous and exogenous hormones, and the men- Although endurance training predominantly induces
strual cycle are underappreciated not only in research numerous metabolic adaptations that match muscle
studies but also in training program design and application energy supply to demand and improve economy of
(244). Importantly, sex differences extend to many motion, athletes engaging in sports that require high peak
other training-related factors, including muscle mass forces demonstrate marked changes in muscle morphology
and strength, injuries, and even training participation and cross-sectional area (CSA). When training adaptation is
rates (245). On occasion, understudied approaches maximized in the face of favorable genetic predisposition,

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1709

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

Table 1. Reference values of sedentary individuals and elite endurance athletes

Sedentary Elite Athlete
References
Men Women Men Women

V_ O2max , mL/min/kg <45 <40
70–85
60–75 (122, 251–265)

V_ Emax , L/min 120–140
95 165–185
125 (261, 263, 266–273)

Stroke volume, mL/beat (251, 253, 265)

At rest
65
55
110
70

Maximum
100
70 150–200
125

Cardiac output, L/min (251, 253, 265, 274–276)

At rest
5–6
3.5–4.5
5–6
3.5–4.5

Maximum
20
15
30–40
25

Lactate threshold, % V_ O2max
60
60 75–85 75–85 (80, 122, 264, 277)

Fiber type, % type I 40–50 40–50 >60 >60 (169, 254, 256, 278–284)

Capillary-to-fiber ratio 1.5–2 Similar or slightly lower 2.5–3 insufficient data (169, 254, 255, 278, 285–288)

Mitochondrial volume density, % 4–5 Similar or slightly lower 7.5–9 insufficient data (254, 255, 285, 286, 289, 290)

Sedentary men and women are between 20 and 30 yr of age. All values of muscle tissue originate from vastus lateralis biopsies. V_ Emax , maximal exer-
cise-induced pulmonary ventilation; V_ O2max , maximal oxygen uptake. Less data are available for female athletes and sedentary control subjects.

extraordinary performances can be achieved, such as the oxygen demand (9). When repeated over time (i.e., exer-
first sub-2-h marathon by Eliud Kipchoge in 2019 (unofficial cise training), there is a coordinated process of adapta-
record of 1:59:40.2), the 100 m time of 9.58 s in 2009 by tion that can be broadly categorized as either “central”
Usain Bolt, or the current world record holder Hafþo  r Júlíus (nervous, respiratory, and cardiovascular systems) or
€ rnsson, who was able to deadlift 501 kg. These perform-
Bjo “peripheral” (skeletal muscle). However, such a simplis-
ances highlight the remarkable potential of skeletal muscle tic classification does not completely characterize the
to generate huge amounts of energy (adenosine triphos- interdependent nature of these processes. For example,
phate, ATP) for a sustained period in order to run at a speed pulmonary oxygen diffusion, Hb levels, cardiac output,
of 21.2 km/h for
2 h, to rapidly contract muscles to be able vascularization of the muscle, as well as oxygen extrac-
to run at speeds exceeding 37 km/h for several seconds, or tion and utilization by the muscle during oxidative phos-
to lift 500 kg. In this section, we discuss the adaptations phorylation (OXPHOS) all contribute to the endurance
observed in elite athletes that allow such extraordinary training-induced increase in maximal oxygen uptake
efforts. (V_ O2max ) (FIGURE 6) (291). V_ O2max therefore is a measure
of the combined capacities of the central nervous sys-
tem to recruit motor units, the pulmonary and cardiovas-
3.1. Oxygen Transport and Maximal Oxygen cular systems to deliver oxygen to contracting muscles
Uptake (including erythrocyte number and heme loading), along
with the ability of those muscles to extract and use oxy-
Exercise of prolonged duration and/or high intensity gen via oxidative metabolic pathways (9). At rest, whole
presents a major challenge to whole body homeostasis body oxygen consumption is
3.5 mL/kg/min, with
and is associated with extensive perturbations in numer-
25% of this being taken up by skeletal muscle (251). In
ous cells, tissues, and organs that are caused by, or are untrained humans, V_ O2max is
10- to 15-fold greater
a response to, the increased metabolic activity of con- than resting values (i.e., 30–50 mL/kg/min). In elite en-
tracting skeletal muscles. To meet this challenge, multi- durance-trained athletes, V_ O2max can be twofold higher
ple integrated responses are rapidly engaged to blunt compared with non-athletes, with the highest V_ O2max
the acute homeostatic threats generated by exercise- values being 96 and 80 mL/kg/min for male and female
induced increases in muscle substrate turnover and endurance athletes, respectively (252, 292, 293). The

1710 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

Whole body adaptation Skeletal muscle adaptation

Respiration
↑ strength & endurance of respiratory muscles
capillary density↑ GLUT4 CD36

VO2max and endurance performance

↑ breathing frequency
↑ maximal ventilation

Heart
cardiac hypertrophy glycogen ↑
↑ resting/maximal stroke volume fatty acids ↑
↑ cardiac output glucose↑
IMCL ↑

Blood
↑ Hb mass myoglobin↑
↑ capillary density

Muscle mitochondrial biogenesis ↑

↑ slow oxidatve muscle fibers
β-oxidation↑
↑ myoglobin
↑ substrate uptake and storage OXPHOS ↑
↑ mitochondria
↑ OXPHOS

Neural
↓ intracortical inhibitory interneurons
↓ antagonistic activity
Peak power

myonuclei ↑
Heart
cardiac hypertrophy
↑ resting stroke volume      

MPS ↑
                       

Muscle
fiber hypertrophy      
                       
    
               

↑ myonuclei fiber hypertrophy

FIGURE 6. Whole body adaptations that contribute specifically to higher peak power or endurance performance. Although mainly neural and muscular
adaptations improve peak power, for endurance performance various organs and tissues show major changes. To maximize V_ O2max and thereby endur-
ance performance, changes in respiratory and cardiovascular function as well as adaptations in skeletal muscle are required. In skeletal muscle, the high
mitochondrial density, elevated substrate (i.e., fatty acids and glucose) uptake and storage, myoglobin content, and increased vascularization all contrib-
ute to the elevated performance of endurance athletes. Strength training-induced adaptations include increased muscle protein synthesis (MPS) result-
ing in fiber hypertrophy and optimally myonuclear accretion. CD36, platelet glycoprotein 4; GLUT4, glucose transporter type 4; IMCL, intramyocellular
lipids. See GLOSSARY for other abbreviations. Sport icon vectors were created by ibrandify/Freepik. Image created with BioRender.com, with permission.

lower V_ O2max values for women are reflected in the occur in athletes, including a greater strength and fa-
female world records for endurance events, which are tigue resistance of the respiratory muscles resulting in
typically 10–12% slower (294). Such differences are mainly higher maximal voluntary ventilation (MVV) and forced
due to the lower absolute and relative muscle mass in vital capacity (FVC) (266, 296–298). Maximal tidal vol-
women and the lower Hb levels (294). Differences in ume is similar in athletes and non-athletes, with the
V_ O2max are also observed based on the demands of the higher maximal exercise-induced ventilation brought
sport and the associated mode of training. Elite male about by an elevated breathing frequency (266). Hb lev-
cross-country skiers and rowers engage a larger propor- els are similar in highly trained endurance athletes and
tion of their muscle mass (upper and lower body) than untrained individuals (266) and are only elevated by alti-
cyclists or distance runners during training and exhibit tude training interventions, discussed in sect. 2.4. (299).
higher V_ O2max values. The training-induced increases in However, because of a training-induced increase in
V_ O2max are largely confined to athletes competing in en- blood volume, total Hb mass may be higher (300, 301). In
durance-based events: power/strength-trained individuals addition to the increased strength of respiratory muscles,
often have V_ O2max values similar to non-athletes (266). endurance athletes have cardiac hypertrophy that is char-
Therefore, parameters affecting V_ O2max are differentially acterized by greater left ventricular mass and relative wall
impacted by the training prescription. thickness resulting in a higher maximal and resting stroke
In most contexts, the limits of maximal oxygen con- volume and a corresponding lower resting heart rate
sumption are multifactorial and not attributable to any (253, 266). Although maximal stroke volume plateaus at
single parameter (295). However, in general, exercise
40–50% of V_ O2max in untrained individuals, stroke vol-
performance is not limited by the respiratory system, as ume increases until volitional exhaustion, contributing to
its capacity exceeds demand during maximal exercise the augmented V_ O2max in elite endurance athletes (253).
(296). However, functional training-induced changes still In these individuals, maximum stroke volumes of 200 mL/

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1711

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

beat have been reported, indicating that a cardiac output initiate muscle contractions, the central nervous system
of up to
35–40 L/min could be reached, a figure almost sends commands to the motor neurons located in the
double that observed in non-athletes (251, 274). Whereas ventral horn of the spinal cord (307). Motor neurons inte-
left ventricular mass and resting stroke volume are similar grate the signal from a number of different regions and
in power and endurance athletes, V_ O2max is not elevated nuclei in the cortex and brain stem, interneuron circuitries,
in power athletes, likely because of the increased maximal as well as the peripheral sensory input from afferent fibers
stroke volume and oxygen pulse per stroke volume after located in the muscle spindles and Golgi tendon organ
endurance but not resistance training (266). Finally, vascu- into an action potential. The action potential propagates
larization of skeletal muscle also contributes to V_ O2max along the axon of the motor neuron to the innervated
(154). Capillary density in all fiber types is
50% higher in muscle fibers and, through acetylcholine receptor activa-
elite endurance-trained compared with nontrained individ- tion and excitation-contraction coupling (ECC), results in
uals (254, 278), and athletes with superior muscle vascula- mechanical output by the muscle. In comparison to central
rization are even more fatigue resistant compared to nervous system synapses, the neuromuscular junction
athletes with similar V_ O2max values (80). The endurance (NMJ) has a very high safety factor, and a nerve action
training-induced vascularization occurs rapidly, with 6 wk potential results in an end-plate potential (EPP) of a local
of intense training being sufficient to elevate capillary den- depolarization of
30–40 mV, which is higher than
sity and capillary-to-fiber ratio (molecular mechanisms driv- required to elicit an action potential in the muscle. Several
ing this adaptation are described in sect. 4.5.3) (255, 302). morphological and functional parameters also contribute
In contrast, capillary density in power/strength-trained ath- to this high safety factor (308–310): first, an extraordinarily
letes does not increase with training and may be lower large size of the synapse,
100- to 200-fold bigger com-
than that in untrained individuals because of the fiber hy- pared with central nervous synapses in the mouse, and
pertrophy (278, 303). Collectively, central adaptations thus ample interaction surface; second, a high density
occur at multiple levels and play an important role in the of voltage-gated Ca21 channels in the active zones,
high V_ O2max in elite athletes. coupled to a high concentration of acetylcholine in a syn-
aptic vesicle; third, the number and density of acetylcho-
3.2. Neuromuscular Control and Force Generation line receptors, and the concentrated localization at the
crest of postsynaptic folds, adjacent to voltage-gated Na1
In contrast to the high V_ O2max required for optimal en- channels (Nav1.4) in the corresponding troughs; and fourth,
durance performance, many sports require high power the strong enzymatic activity of acetylcholinesterase in the
generation, including sprint events (running, swimming, synaptic cleft for rapid removal of acetylcholine and
cycling, and rowing) and weightlifting, powerlifting, and thereby prevention of repeated activation of individual ac-
throwing events. Maximal performance in elite strength/ etylcholine receptor channels in response to a single
power athletes is
15–20% lower in females than in action potential in the motor neuron. Together, these prop-
males (304), because of differences in lean body mass erties lead to an “all-or-none” activation (as first described
between men and women (168, 305). In line with the by Henry Pickering Bowditch in 1871 for cardiac muscle,
lower lean mass, fat mass of female athletes is about later expanded to skeletal muscle), meaning that once the
twofold higher compared to men with similar body mass stimulus threshold for an action potential in the motor neu-
(304). With increasing age, differences in maximal per- ron is reached (based on the integration of different incom-
formance in terms of world records in female and male ing signals), an action potential and contraction in the
masters athletes become greater, and records are muscle fiber is inevitably triggered. The frequency of acti-

30–50% lower in women, mirroring the sex differences vation (rate coding) of the muscle fiber is important for the
observed in untrained and recreationally trained individ- generation of force (311). In a single muscle twitch, Ca21
uals (304). reenters the sarcoplasmic reticulum and fiber relaxation
Voluntary muscle contraction is a complex task requir- becomes complete. A more frequent stimulation results in
ing a highly coordinated interplay on multiple levels wave summation, and thus greater force, ultimately maxi-
including supraspinal structures, spinal cells, afferent mizing in a tetanus, in which twitches overlap and no
feedback and efferent input, and the motor unit (306). relaxation can occur. In rodents, exercise-induced
The motor unit consists of the soma, dendrites, and NMJ remodeling has been observed affecting mor-
axon of the motor neuron as well as the innervated mus- phology and function of this synapse (312, 313). For
cle fibers. The force-generating capacity of the muscle example, endurance training boosts the amount of
is determined by the number of activated motor units, neurotransmitter released per action potential, con-
the discharge rate (also described as firing frequency comitantly with an upregulation of acetylcholinester-
or rate coding) of the motor neuron, and the size and ase (313, 314). Furthermore, an enlargement in the
contractile properties of the activated muscle fibers. To interaction surface is achieved by a modulation of the

1712 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

number and length of nerve terminal branches, coupled to different motor units exhibit considerable morphological
an elevation in the total area occupied by presynaptic neu- and functional differences (FIGURE 7). For example, motor
rotransmitter vesicles and postsynaptic acetylcholine recep- neurons innervating type II muscle fibers in general have
tors (314). Similar adaptations are observed in genetic larger somas and more dendrites as well as a larger axonal
mouse models of endurance training, with corresponding diameter sizes, the latter enabling faster conductance ve-
changes in neuromuscular transmission properties (315). locity (306, 319). The physical dimensions of the motor
Notably, however, size, complexity, and fragmentation of neuron somas contribute to the determination of the
murine and human NMJs can differ substantially (316). Data recruitment threshold (320). Thus, the larger surface area
describing training-induced NMJ plasticity can therefore and high number of ion channels in fast motor neurons
only be extrapolated to humans with caution, in particular result in a lower input resistance compared with the small
since corresponding interrogations in humans are lacking. surface area with fewer ion channels of slow motor neu-
Whereas hand muscles have fewer motor units than rons (320). According to Ohm’s law (V = I  R), the same
large limb muscles, the number of motor units of different synaptic input thus induces greater changes in the mem-
limb muscles varies and is not always related to muscle brane potential of small motor neurons (with a higher re-
size (317). In contrast, the average innervation number sistance) compared with large motor neurons (with a lower
(number of muscle fibers innervated by a single motor neu- resistance). Consequently, small motor neurons reach the
ron, also called motor unit size) strongly correlates with firing threshold with less synaptic input compared with
muscle size (317). Innervation numbers, even within one their larger counterparts. This orderly recruitment was
muscle, can range from tens to thousands, and thereby shown in animal preparations by Henneman (320), and
enable diverse actions such as fine-tuning of the move- according to Henneman’s size principle small motor neu-
ment or high force generation, respectively (317, 318). rons innervating slow type I muscle fibers are recruited
Whereas slow type I muscle fibers (discussed in sect. 3.3) first, subsequently followed by larger motor neurons inner-
are mostly part of motor units with a low innervation num- vating type IIA and finally IIX fibers (306). This leads to a
ber, motor units with a high innervation number often con- gradual and smooth increase in muscle force (graduation
nect to fast type II fibers (317). The motor neurons of these of contraction) and a predominant activation of slow and

intracortical
inhibition ↓
corticospinal
excitability ↑?
firing frequency ↑
motor unit recruitment ↑
excitatory
drive
↑
low threshold
motor unit

high threshold
motor unit

fiber size↑
NMJ
inhibition of remodeling ?
afferent feedback
and/or
↑?
spinal interneurons

agonists
synergists
stabilizers
↑

antagonists ↓

FIGURE 7. Neuromuscular adaptation to training. The number of activated motor units, their firing frequency, as well as size and contractile properties
of the muscle fibers determine total force-generating capacity. In trained individuals, neural adaptations include an increased excitatory drive that can
lead to an elevated firing frequency and higher number of activated motor units. In addition, the enhanced activation of agonists, synergists, and stabil-
izers together with the reduced coactivation of antagonists contribute to the increased force production after training. For many of these adaptations
only data in rodent models exist, and/or controversial findings in humans have been reported. NMJ, neuromuscular junction. Illustration of person was
created by kjpargeter/Freepik. Image created with BioRender.com, with permission.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1713

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

fatigue-resistant small motor units until these are over- muscle. The activity of intracortical inhibitory interneurons
whelmed by strong, powerful movements necessitating is lower in trained individuals, whereas data on corticospi-
the recruitment of fast-twitch, high peak force-generating nal excitability are equivocal and likely unaffected by train-
fibers (306). Although the size principle holds true for spe- ing (327–329). The reduction in intracortical inhibition in
cific laboratory conditions, physiological systems that response to strength training induces a higher excitatory
include excitatory and inhibitory inputs are much more drive, which may contribute to elevated strength in these
complex, and it is debatable whether motor units are individuals. With augmenting force generation, the number
always recruited in a graded manner (319, 321). Recent evi- of active motor units as well as their activity in terms of dis-
dence suggests that during slow, ramping movement charge rate increase (318, 330). Accordingly, the higher de-
orderly recruitment occurs, whereas high-frequency, sinu- scending neural input in strength-trained individuals could
soid types of contractile activity are not following the size explain the elevated discharge rate and adequate activa-
principle (322). Moreover, motor unit recruitment is tion of motor units, culminating in the observed enhanced
affected by the length of the muscle (322). This implies voluntary activation and maximal force (318, 331, 332). In
that, during ballistic training, recruitment is observed in a addition, the elevated neural drive might be important for
more selective manner corresponding to the functional explosive power, as a fast recruitment and a high discharge
movement according to the neuromechanical matching rate of motor units are important for the rate of force devel-
principle (319, 321). However, even during slow ramping opment (330). The lower recruitment threshold observed
movement, as might be encountered in weightlifting, fast after strength training suggests that, in addition to the
motor units can be recruited with submaximal load (138, changes in neural drive, intrinsic properties of motor neu-
323, 324). In fact, a number of studies have demonstrated rons may be altered by training (331). The timing of the
that even low-load exercises such as 30% 1RM result in action potentials discharged by concurrently active
recruitment of type I and II fiber if completed until failure, motor units of strength athletes appears to exhibit
inducing a hypertrophic response similar to high-load train- greater synchronization than that in untrained individ-
ing (138, 323–325). This finding might be explained by the uals, even though it is debatable whether these adap-
observation that with increasing muscle fatigue more tations in intramuscular coordination contribute to
motor units are being recruited to meet the same force strength gains (333). Intermuscular coordination is
output, even when lower loads are used (138, 323, 324). also improved at several levels. Besides the recruit-
Therefore, the recruitment of slow and fast motor units is ment of agonists, stabilizers/fixators, and neutralizers/
dependent not only on the applied load and generated synergists, reducing the coactivation of antagonists
force but also on the fatigue state, contraction velocity, significantly contributes to the maximal voluntary acti-
and length, as well as potentially other parameters that are vation and force generation in highly trained athletes
extracted from skeletal muscle in different exercise proto- (332–334). Whether these training adaptations
cols and paradigms. Some of these factors, such as velocity evoked by intermuscular coordination are primarily
and length, might induce selective rather than the orderly mediated by disinhibition of supraspinal signals,
recruitment of motor units postulated in Henneman’s size altered activity of Renshaw cells and other spinal inter-
principle. In summary, motor unit engagement, recruitment, neurons, and/or adaptations in afferent feedback,
and fatigue are still poorly understood. Moreover, the plas- such as decreased stretch inhibition by the proprio-
ticity of this structure in training and the specific adaptations ceptive system, is unclear. Nevertheless, the impor-
in elite athletes are largely unknown. Of note, based on the tance of early neural and neuromuscular adaptations
transcriptional profile, even more distinct motor neuron and the concomitant optimization of intra- and inter-
pools exist than the classically defined three types, fast fati- muscular coordination before structural changes of
gable, fast fatigue-resistant, and slow (326). The functional the muscle in resistance training adaptation is irrefuta-
relevance of this more fine-grained specification remains ble (FIGURE 7) (329, 335, 336). The corresponding
unknown. neural changes in endurance training are less well
characterized but could contribute to improved run-
3.2.1. Neural adaptations. ning economy, decreased fatigability, and other inter-
related parameters (337–339).
Increased force generation can be achieved by neural
adaptation, muscle hypertrophy, and/or intrinsic changes 3.2.2. Muscle hypertrophy.
in contractile properties (strength/power per unit of muscle
mass). MVC is substantially elevated in resistance training Powerlifting or hammer throw athletes rely on the gener-
before any increase in muscle CSA, suggesting that neural ation of instantaneous maximal peak forces, whereas
adaptations mainly contribute to the strength gains in the sports that involve short-duration sprints require high
initial phase, followed by structural changes within the contractile velocity of muscles over several seconds.

1714 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

Nonetheless, an increase in muscle mass to generate addition of sarcomeres in parallel rather than in series
high contractile forces is a common goal for these ath- causes an increase in fiber diameter (342). In line with the
letes. Indeed, the muscle volume of the lower limbs of high potential of type IIA fibers to increase CSA and force
both sprinters and other strength-trained athletes is generation (352), hypertrophy predominantly occurs in
higher compared with endurance athletes and untrained type IIA fibers in elite strength-trained athletes (303, 350).
individuals (340, 341). The training-induced gain in mus- Besides radial growth, inclusion of additional sarcomeres
cle CSA is not evenly distributed along the length of the in series leading to increased fascicle strength has been
muscle fiber but occurs predominantly in the midbelly reported (342). Limited data are available regarding the
region of the muscle, which explains why the percent longitudinal growth of the muscle in response to resist-
increase in CSA can exceed that of muscle volume (335, ance-based training, although there is evidence that fasci-
342). In humans most muscles are pennate, in which the cle length can increase (335, 343). For example, a longer
increase in physiological CSA of the muscle, reflecting fascicle length is observed in elite sprinters (345, 346),
the radial growth of the myofiber, can diverge from the which is positively correlated with performance times
increase in anatomical CSA. To optimize the limited (343, 353, 354). The longer fascicles could contribute to a
space of the aponeurosis, a larger CSA is usually accom- greater shortening velocity of a pennate muscle and
panied by a steeper pennation angle, which is greater thereby enhance sprint performance (353). However, the
in highly trained strength athletes compared with total number of sarcomeres in series in a muscle fiber and
untrained individuals (343) and strongly correlates with the effects of training are difficult to determine in humans,
muscle thickness (344). In contrast, in elite sprint athletes and the few studies in rodents revealed mixed results
(100 m sprinters and sprint cyclists), muscle thickness is (342). Moreover, recent evidence indicating a mesh-type
increased without changes in the pennate angle (345, network of branching sarcomeric structures instead of
346). As these observations in elite athletes are all cross individual sarcomeres existing in separated tubes further
sectional, it remains to be determined whether the archi- complicates the interpretation of changes in sarcomere
tectural differences contributing to peak performance numbers in series and in parallel (355).
are the result of long-term training adaptation or genetic Despite the fundamental contribution of radial muscle
predisposition. Despite these findings, the contribution growth to maximal power output, the relationship between
of the pennation angle and other architectural proper- force generation and muscle CSA is not linear, emphasiz-
ties to muscle functionality and power generation ing the contribution of other factors (356). One possibility
remains contentious (347, 348). could be that muscle quality rather than size is enhanced,
Of note, hypertrophy of myofibrillar and sarcoplasmic resulting in a higher specific force (force per CSA) (352).
compartments has been described, and the relative For example, the specific force of type I fibers has been
impact on muscle mass and strength gains remains equiv- shown to increase in response to resistance exercise
ocal, similar to the importance of “conventional” hypertro- (352). Additionally, changes in fiber type distribution could
phy with a proportional increase in myofibrillar protein enhance specific force capacity, since both the force-gen-
content and tissue growth compared with “unconven- erating capacity per myosin head as well as the fraction of
tional” hypertrophy, for example achieved by myofibrillar attached myosin heads are higher for fast myosin heavy
packing preceding an increase in fiber size (349). chain isoforms (357). Despite these changes, the increase
Nevertheless, in most cases resistance training induces in overall muscle strength is superior compared with the
radial growth of the muscle, resulting in a higher CSA integration of single-fiber strength gains, indicating that
(mechanisms underlying this response are described in optimal strength gains occur when both neural as well as
sects. 4.1 and 4.3–4.5) (342, 350). The expansion of myofi- muscular adaptations take place (352).
brillar protein resulting in fiber hypertrophy might contrib- The increase in myofibrillar proteins is often, but not
ute the most to enhanced force-generating capacity of a always, accompanied by elevation of the number of myo-
muscle fiber. Within the muscle fiber,
80% of the volume nuclei, potentially to optimize the hypertrophic response.
consists of myofibrils that are composed of sarcomeres, The syncytial nature of muscle cells has been hypothe-
the contractile units of the myofibril (351). The thin actin sized to be due to the limited capacity of (myo)nuclei to
and thick myosin filaments constitute the two major active provide transcripts for a certain volume of the cytoplasm,
components of the sarcomeres responsible for muscle defined as the myonuclear domain (358). According to
contraction. Upon Ca21 binding to troponin C (TnC), tro- this hypothesis, the upper limit of the myonuclear domain
pomyosin conformation changes to expose the myosin- is determined by the maximal transcriptional capacity of
binding site on the actin filament. The thick myosin fila- myonuclei. Once this ceiling is reached, the number of
ments, the force-generating elements of the sarcomere, myonuclei was thought to be increased by the fusion of
bind to actin and induce the sliding of actin filaments satellite cells to muscle fibers to maintain a relatively con-
along the myosin, resulting in muscle shortening. The stant DNA-to-cytoplasm ratio (reviewed in Ref. 358), a

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1715

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

concept that has subsequently been refined and cor- reached a power output of 2,750 W (29.3 W/kg) during his
rected (359). Moreover, in humans hypertrophy has also 100 m world record in 2009 (252). In contrast to these re-
been reported in the absence of myonuclear accretion markable power metrics for strength/sprint-trained athletes,
(360, 361). Furthermore, although the addition of myonu- power output (as measured by jump performance) remains
clei is greater when hypertrophy exceeds 22% of size largely unchanged in endurance-trained athletes (266). It
gain, it also occurs when hypertrophy is <10% (362). is clear that the adaptive response to training stimuli is
According to a recent meta-analysis, a definitive “hypertro- event-specific in terms of muscle hypertrophy and neuro-
phy threshold” required for myonuclear accretion remains muscular adaptation, resulting in distinct performance
tenuous, and thus the threshold hypothesis appears prob- characteristics between different sporting disciplines.
lematic (362). Nevertheless, cross-sectional data from ath-
letes often show hypertrophy to be positively correlated 3.3. Fiber Type Distribution
with myonuclear number (363). For example, in elite
powerlifters, both the size of the muscle fibers as well as Distinct properties of the muscle further contribute to
the number of myonuclei are higher compared with non- the performance of elite athletes, such as fiber type dis-
athlete control subjects, and the gradient of the correlation tribution. In addition to distinct innervation and recruit-
curve suggests that the myonuclear domains are higher in ment (as described in sect. 3.2), intrinsic properties of
large type II muscle fibers of powerlifters compared with muscle fiber types diverge in a multifaceted manner
those of untrained individuals (364). The use of anabolic (155, 357, 370–372). Muscle fiber types can be classified
steroids and testosterone in powerlifters results in a dispro- according to their predominantly expressed isoform of
portional increase in muscle size and number of myonu- the myosin heavy chains, which are the molecular
clei, thereby leading to a larger myonuclear domain (365). motors of the myofibrils and vary in the relative actin-
Although these data indicate a certain degree of myonu- activated ATPase activity that correlates with contraction
clear domain plasticity that could be explained by the velocity (357). Differences in fiber type distribution are
reserve capacity of the myonuclei to boost transcriptional accordingly observed in muscles of endurance- or
output (366), in most cases the myonuclear domains are strength-trained athletes and considerably contribute to
still within the reported range, also highlighting individual sports-specific performance. The three myosin heavy
heterogeneity. chain isoforms expressed in human muscle, type I
In summary, strength-trained athletes have a pro- (encoded by the MYH7 gene located on chromosome
nounced increase in muscle volume largely underpinned 14, 14q11.2), type IIA (encoded by MYH2, on chromosome
by the specific hypertrophy of type IIA fibers and accom- 17, 17p13.1), and type IIX (encoded by MYH1, adjacent to
panied by an increase in pennate angle, resulting in sub- MYH2 on chromosome 17, 17p13.1), have distinct me-
stantial gains in force-generating capacity. In addition to chanical properties conferring differences in contractile
the elevated muscle volume, the fascicles of sprint ath- velocity and force production. Type IIX fibers generate
letes are elongated, contributing to higher shortening the highest force and have the fastest shortening veloc-
velocity of the muscle and greater power generation. ity, resulting in high peak power, and are classified as
Although neuromuscular adaptations together with mus- “fast-twitch” fibers (357, 373). The enhanced force-gener-
cle hypertrophy explain the enhanced muscle perform- ating capacity is attributable not only to the larger size of
ance in highly trained athletes, these adaptations differ type II fibers but also to intrinsic differences (i.e., higher
among athletes in a discipline-dependent manner. For force-generating capacity of fast myosin heavy chain iso-
example, the musculature of strength-trained athletes has forms and a larger fraction of attached myosin heads),
a larger CSA and can produce greater maximal forces, resulting in a higher specific force of type II fibers, which
whereas power-trained athletes have slightly lower peak is observed in untrained individuals as well as elite ath-
forces but display a faster rate of force development (341). letes (357, 374–376). In addition to greater power-gener-
These differences are most pronounced within the first 50 ating capacity, fast type II muscle fibers exhibit shorter
ms of a contraction (341, 367). The enhanced explosive half-relaxation time due to differences in Ca21 transient
(i.e., high shortening velocity) and maximal forces in ath- kinetics (357). In response to an action potential, Ca21
letes result in remarkable power output. In male power release in fast murine muscle fibers is threefold higher
athletes, mean peak power, as assessed by a counter- compared with slow fibers, likely because of the greater
movement jump, ranges between 50 and 65 W/kg, with abundance of the Ca21 release channel ryanodine recep-
maximal values up to 85 W/kg for men and
70 W/kg for tor 1 (RYR1) (357). The inhibitory effect of intracellular
women (252, 303, 368, 369). The acceleration power Mg21 concentrations on Ca21 release is lower in slow
attained at the start of a 100 m sprint was estimated to be muscle fibers, possibly contributing to the higher fatigue
2,392 W or 30.3 W/kg for men and 1,494 W or 24.5 W/kg resistance of these fibers, as Mg21 levels rise during fa-
for women (252). It was calculated that Usain Bolt tigue (357). Fiber type-specific differences in Ca21

1716 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

transient related to the faster decline in cytoplasmic con- stress (i.e., more reduced and more increased, respec-
centrations are determined by the sequestration of Ca21 tively) compared with SERCA2 in slow fibers (357). In addi-
to binding and buffer proteins such as troponin C (TnC), tion, calsequestrin (CASQ) that binds Ca21 within the SR is
parvalbumin, and calmodulin, as well as the reuptake of found in greater abundance in fast compared with slow
Ca21 into the sarcoplasmic reticulum (SR) by the sarco- fibers, thereby providing an increased capacity to bind
plasmic/endoplasmic reticulum Ca21-ATPase (SERCA) free Ca21. Taken together, differences between Ca21
pumps (357). As the TnC isoform expressed in fast muscle transient and cross-bridge kinetics in slow and fast muscle
fibers has four Ca21-binding sites compared with the fibers contribute to the distinct contractile properties
three in the isoform expressed in slow fibers, Ca21 bind- (FIGURE 8). Accordingly, it is not surprising that the
ing is enhanced in fast muscle fibers. Moreover, the faster energy demand of these fiber types is different during
uptake of Ca21 by the SR is determined by the increased maximal isometric contraction. At rest, energy expenditure
SR volume and surface area as well as the higher density in muscle is relatively low,
0.008 mM/s of ATP turnover,
of SERCA pumps in fast fibers. Of note, the SERCA iso- and mainly used for the Na1-K1-ATPase in the sarco-
form expressed in fast fibers (SERCA1 vs. SERCA2 in slow lemma as well as protein synthesis (357). However, as
fibers) is more sensitive to changes in ADP concentration, muscles start to contract, the energy demand is substan-
which rises during muscle fatigue. As a result, Ca21-pump tially elevated by the myosin ATPases of the molecular
and -leak rates of SERCA1 are more affected by metabolic motor for cross-bridge cycling (
70% of overall ATP

glycolytic
muscle fiber oxidative
muscle fiber

RyR1 CASQ Contractile characteristics RyR1

CASQ
Ca2+-binding
proteins SR Ca2+
glycolytic SR
Ca2+ Ca2+-binding
proteins
Force

PPP PPP PPP PPP PPP

SERCA1 SERCA2
oxidative
ATP ATP
Time
MyHC-IIX MyHC-I

myoglobin Fatigue glycolysis

glycolysis

pyruvate
lactate pyruvate
IMCL OS
PH
Force

OX
OXP OS
HOS XPH
glycogen O
β-oxidation β-oxidation

Time

FIGURE 8. Contractile and metabolic properties of a strength/power-trained and an endurance-trained athlete. Characteristics of fast and powerful
muscles of strength/power athletes that are accompanied by a more fatigable muscle as compared with endurance-trained muscles with elevated oxi-
dative capacity that are more fatigue resistant. ATP, adenosine triphosphate; CASQ, calsequestrin; IMCL, intramyocellular lipids; MyHC, myosin heavy
21
chain; OXPHOS, oxidative phosphorylation; RyR1, ryanodine receptor 1; SERCA, sarcoplasmic/endoplasmic reticulum Ca -ATPase; SR, sarcoplasmic
reticulum. Illustrations of people were created by kjpargeter/Freepik. Image created with BioRender.com, with permission.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1717

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

consumption) and by the SERCA pumps for Ca21 reup- generating, fatigue-resisting fibers and high force-gen-
take (
30% of ATP consumption). Hence, during maximal erating, fatigable fibers, respectively. These properties
isometric contractions ATP turnover rates in human type I, emphasize the important contribution of fiber type distri-
IIA, and IIX fibers can increase up to
1,000-fold to 1.7, bution to endurance- or strength/power-based activities.
4.7, and 7.2 mM/s, respectively (357). These fiber-specific In untrained males, the vastus lateralis comprises
40–
differences underscore the remarkable capacity of fast 50% type I fibers (254, 256, 278, 387), though the rela-
muscle fibers to turn over ATP and enable the generation tive fiber type distribution depends on the site of biopsy
of high peak power. (388). Elite endurance athletes typically present with
To meet the distinct energy demands of different >60% type I fibers, with extremes of >90% (169, 254,
sport activities, slow and fast muscle fibers exhibit diver- 256, 279, 280, 389). These cross-sectional data, how-
gent metabolic properties. Type I fibers are highly oxida- ever, fail to provide evidence of whether prolonged en-
tive, whereas type IIX fibers are more glycolytic (357), durance training induces a shift in fiber distribution, or if
with the fast type IIA fibers of an intermediate phenotype elite endurance athletes are successful because of innate
containing high amounts of oxidative as well as glyco- fiber type patterns.
lytic enzymes. In line with the considerable energy In contrast to endurance athletes, well-trained strength
demand of fast glycolytic fibers, glycogenolytic activity is and power athletes tend to have a fiber type distribution
elevated in these fibers, and during short maximal con- that resembles that of untrained individuals, at least in
tractions ATP generation via glycolysis is double that of terms of overall glycolytic (type II) compared with oxida-
slow muscle fibers (357), with a corresponding rapid rate tive (type I) fibers, with some extremes toward a lower
of fatigue. In contrast, rates of fatty acid oxidation via the abundance of type I fibers (278, 303, 368, 390). A signifi-
b-oxidation pathway are two- to threefold higher in slow cant shift from IIX to IIA fibers has been reported in
fibers, with the lower ATP demand of these fibers met strength- and power-trained athletes, with the absolute
by mitochondrial respiration over prolonged periods area of fast muscle fibers substantially larger because of
(357). The increased oxidative capacity of type I fibers is specific hypertrophy of type IIA fibers (278, 303). In other
determined by the higher mitochondrial volume, account- studies, a preservation of type IIX fibers in response to
ing for 6% of the fiber volume in type I compared with sprint or plyometric training has been found, together
4.5% and 2.3% in type IIA and IIX fibers, respectively, as with a shift from type I to type IIA (372). Accordingly,
well as the greater density of the mitochondrial cristae sprinters seem to have a lower proportion of slow type I
and enzymatic activity (357). Additionally, the elevated ox- fibers (281, 391). As for elite endurance athletes, it is
ygen demand in slow fibers is met by a higher capillary unclear whether differences in fiber type distribution in
density and 50% increased myoglobin content compared power athletes and sprinters are due to preexisting fiber
with fast fibers (154, 357). Along with the capillary-to-fiber type patterns or whether the training-induced shift is
ratio, the percentage of type I fibers thus is a strong pre- affected by different training paradigms. It also remains
dictor of endurance capacity (377). The capillary density perplexing how a fiber type shift is brought about in terms
not only provides greater oxygen delivery and energy of the temporal and spatial coordination: is there a simul-
substrates but also promotes rapid removal of by-prod- taneous shift in metabolic and contractile properties com-
ucts of sustained contractile activity (i.e., ammonia or lac- bined with changes in the motor neuron phenotype, or
tate). Triglyceride stores are substantially higher in type I does one follow the other? Collectively, it is evident that
fibers compared with type II fibers (
0.5% of the fiber vol- the unique characteristics of type I, IIA, and IIX fibers
ume in type I fibers compared with <0.1% in type IIX regarding oxidative and force-generating capacities are
fibers), whereas conflicting results have been reported instrumental for sport-specific demand and thereby con-
regarding glycogen stores (279, 357, 378). Although fiber tribute to the achieved peak performances in athletes.
type-specific differences in glycogen content are not
always observed between fast and slow muscle fibers 3.4. Energy Metabolism and Oxidative Capacity
(379, 380), several studies report that glycogen concentra-
tion in type II fibers is 15–30% higher compared with type I In skeletal muscle, the three main sites for ATP consump-
(357, 381–385). It is unclear whether this is due to differen- tion are the Na1-K1-ATPases of the sarcolemma for mem-
ces in methodology or whether the training status has an brane excitability, the SERCA pumps of the SR membrane
impact on these findings, since the glycogen content is for Ca21 reuptake, and the myosin ATPases for cross-
similar in type I and type II fibers in elite athletes (386). bridge cycling. Because of the increased elevation in ATP
Collectively, the fiber type-specific differences in con- utilization by myosin ATPases and SERCA pumps associ-
tractile and metabolic properties reflected by the inverse ated with intense contractile activity, the high ATP
relationship between force generation and oxidative demand is a major bioenergetic challenge to the con-
capacity of type I, IIA, and IIX fibers result in low force- tracting myofibers (357). Given that intramuscular ATP

1718 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

stores are relatively small, metabolic pathways re- absolute exercise intensity in endurance-trained athletes
sponsible for ATP restoration must be rapidly acti- compared with untrained individuals (80, 257). Therefore,
vated such that ATP levels closely match demand. in addition to the higher V_ O2max and improved capillary
During sprint events lasting <20 s, the creatine phos- density, training-induced adaptations in skeletal muscle
phate system and anaerobic glycolysis are the main path- (i.e., the ability to oxidize fat-based fuels and spare muscle
ways engaged in ATP resynthesis (392). Although the glycogen along with a concomitant reduction in lactate
contribution to ATP provision during a 10-s sprint is similar appearance) enable elite endurance athletes to sustain
between the creatine phosphate system and anaerobic high absolute work rates or speeds and resist fatigue
glycolysis (53% and 44%, respectively), this is substantially for prolonged periods (80, 267, 395). These adaptive
changed during a 30-s sprint (23% and 49%, respectively, changes are discussed in sects. 3.4.1 and 3.4.2.
with 28% from mitochondrial respiration) at a time when
phosphocreatine stores are mostly depleted (392, 393). 3.4.1. Mitochondrial adaptations.
In contrast, to meet the elevated and sustained energy
demand for prolonged exercise (several minutes to sev- During prolonged submaximal exercise with adequate
eral hours), large amounts of ATP are generated by aero- oxygen availability, ATP is synthesized by OXPHOS in the
bic mitochondrial respiration, with the metabolism of electron transport chain located in the cristae of the inner
glucose, fatty acids, ketone bodies, and lactate resulting mitochondrial membrane. To optimize mitochondrial bio-
in a higher energy expenditure (392). In extreme endur- energetics and meet the increased energy requirements
ance events such as the Ironman triathlon (3.8 km swim- during prolonged exercise, highly coordinated adaptive
ming, 180 km cycling, 42.2 km running), rates of energy processes enhance the quality as well as the quantity of
expenditure 8- to 10-fold above resting metabolic rate mitochondria. For example, mitochondrial number and
(RMR) can be sustained for 10–15 h (394). To enable such morphology are altered by replication of mitochondrial
performances, adequate oxygen uptake, delivery, and DNA (mtDNA), synthesis of mitochondrial proteins, trans-
extraction concomitant with skeletal muscle ATP genera- port and incorporation of nuclear-encoded proteins into
tion using large amounts of fatty acids must be tightly the corresponding substructures and supercomplexes of
coordinated. mitochondria, and dynamic fusion and fission events
In addition to the higher V_ O2max values observed in (399). Mitochondrial dynamics are essential to maintain
elite endurance-trained athletes, these individuals also quality and are sensitive to physiological and pathological
have greater efficiency or economy of motion (i.e., a stimuli (400). Whereas fusion leads to elongated mito-
lower oxygen cost at any given work rate or speed of chondrial tubular networks (401), fission induces fragmen-
movement) combined with a greater fractional utilization tation of the mitochondria allowing the sequestration
of V_ O2max (i.e., the ability to use a greater proportion of of damaged or dysfunctional organelles by mitophagy
their higher V_ O2max ). Collectively, these attributes are (discussed in sect. 4.6.2) but also mitochondrial biogene-
associated with increased rates of fatty acid oxidation, a sis (402). More specifically, fission at the periphery of the
slower rate of depletion of muscle glycogen stores, and mitochondria enables the degradation of damaged com-
enhanced lactate kinetics (395, 396). For example, maxi- ponents of the network, whereas fission at the midzone
mal rates of whole body fatty acid oxidation in elite ath- of the mitochondria seems to be instrumental for the pro-
letes are twofold higher at submaximal workloads liferation of mitochondria, which cannot be generated de
compared with untrained individuals (0.6 g/min vs. 0.3 g/ novo (403). The fusion of the outer and inner membrane
min) (254) and can be reached at much higher intensities of the mitochondria is regulated by the transmembrane
(both relative and absolute) compared with untrained indi- proteins mitofusion 1 (MFN1) and MFN2 and optic atrophy 1
viduals (
45–60% vs.
35% of V_ O2max ). A “retooling” of (OPA1), respectively (401), and important proteins involved
the muscle by adaptation to a high-fat diet while under- in the fission process include dynamin-related protein 1
taking vigorous training can more than double these rates (DRP1), mitochondrial fission 1 (FIS1), and mitochondrial fis-
in world-class endurance-trained athletes to values sion factor 1 (MFF1) (399, 402). How mitochondrial dynamics
exceeding 1.5 g/min at work rates of
70% of V_ O2max are altered in muscles of highly trained athletes is not com-
(397). During exercise exceeding 80% of V_ O2max , the pletely understood (404), and most data are based on
availability or rate of appearance of fatty acids in the cir- changes in the abundance of proteins regulating fission
culation limits the oxidation of fat-based fuels by skeletal and fusion dynamics (289, 405). It has been suggested
muscle (398). In line with a superior ability to oxidize fat- that fission is elevated after acute exercise to promote
and spare carbohydrate-based fuels during exercise, the the removal of damaged organelles, whereas fusion
onset of blood lactate accumulation, fixed at a concentra- events are increased during the recovery phase (399,
tion of 4 mM (sometimes arbitrarily defined as “lactate 400, 406), leading to the elongation of mitochondria
threshold”) (255), is observed at both higher relative and (407). A functional mitochondrial reticulum is important for

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1719

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

ATP generation as well as energy distribution within mus- 3.4.2. Lipid and glycogen storage in muscle.
cle cells (408). In line with these observations, mitochon-
dria of oxidative muscle fibers are highly interconnected, Skeletal muscle is a major site for both glucose (in the
forming substantially larger mitochondrial networks, form of glycogen) and lipid (intramyocellular triglycer-
whereas glycolytic fibers have more fragmented mito- ides) storage. Endurance, but not strength/power,
chondria (407, 409). Recently, it has been suggested that training substantially increases the size of these
the two distinct subpopulations of mitochondria (subsar- depots: lipid content is approximately twofold higher in
colemmal and intermyofibrillar) are physically connected, the trained musculature of endurance athletes, which, in
building a large mitochondrial network (410, 411). These part, facilitates the higher rates of fatty acid oxidation (417,
interconnected mitochondrial networks enable a rapid 418). Although lipid droplet size is similar in muscle from
exchange of various factors between mitochondria to ulti- trained and sedentary individuals, the total intramyocellu-
mately improve ATP production in a spatially coordinated lar lipid pool is substantially higher in endurance-trained
manner (402). As demonstrated in murine muscles, the muscle. This is due to the combination of an increased
enrichment of complex IV in subsarcolemmal regions number of lipid droplets along with a greater proportion
near capillaries facilitates the generation of the proton of type I muscle fibers that have a greater capacity for
motive force in oxygen-rich areas whereas the higher lipid storage than type II fibers (417, 419, 420). These
abundance of complex V within the myofiber helps to droplets can be categorized into subsarcolemmal or inter-
generate ATP near the site of high energetic demand myofibrillar lipids, and whereas an elevated fraction of
(412). Elongated mitochondrial networks are related to subsarcolemmal lipid droplets is associated with insulin
enhanced oxidative metabolism (400), whereas frag- resistance (421), endurance-trained individuals predomi-
mented mitochondria are less efficient in generating ATP nantly store lipids in the intermyofibrillar fraction, often in
(402). This dynamic remodeling of mitochondria could close proximity to mitochondria, which favors high turn-
make a substantial contribution to improved mitochon- over kinetics and confers insulin sensitivity (417, 422), a
drial quality and function in trained muscle. phenomenon termed the “athlete’s paradox” (423).
Closely linked to changes in mitochondrial dynamics, Glycogen, a branched glucose polymer, is found in
mitochondrial biogenesis plays a major role in the adapt- three distinct subcellular compartments, with the major-
ive response to endurance training, with mitochondrial ity (75–85%) located between the myofibrils (intermyofi-
volume density being strongly correlated to V_ O2max brillar) near the SR and the mitochondria (424). Between
(254, 285, 413). The exercise-induced pathways 5% and 15% of the glycogen granules are located
including Ca21 signaling and metabolic, oxidative, beneath the sarcolemma (subsarcolemmal) and 5–15%
and heat stress that are instrumental for mitochon- between the contractile filaments within the myofibrils
drial adaptation are discussed in sects. 4.2.1, 4.4, (intramyofibrillar) (424). Whereas type I fibers have more
4.5.1, 4.5.2, and 4.6. In the vastus lateralis muscles of subsarcolemmal and intramyofibrillar glycogen, type II
untrained individuals, mitochondria comprise
4–5% fibers are enriched in intermyofibrillar glycogen (424).
of the muscle volume, the highest being in type I and The fiber type-specific location of glycogen favors the
the lowest in type IIX fibers (255, 289, 300, 302, 414). functional characteristics of type I and II fibers (i.e., fa-
In endurance-trained athletes, mitochondrial volume tigue resistance and fast contraction time, respectively)
density is 50% higher and citrate synthase activity is (351). Intermyofibrillar glycogen content is associated
elevated by 74% (254, 285). Accordingly, mitochon- with faster relaxation time and, at least in the type II fiber,
drial respiration is substantially enhanced in elite ath- is necessary to sustain the high rates of ATP turnover by
letes (415). The exercise training-induced increase in the SERCA pumps (351). In contrast, intramyofibrillar gly-
mitochondrial volume density occurs in all fiber cogen is correlated with Ca21 release from the SR and
types, including IIX, and ranges between 10% and fatigue resistance (256, 425). Accordingly, in type I
60% depending on the training impulse (414, 416). In fibers of endurance-trained athletes, intramyofibrillar gly-
addition to the greater mitochondrial volume density, cogen content is 60–65% greater, and in both fiber
accompanied by an absolute increase in crista sur- types subsarcolemmal and intermyofibrillar glycogen is
face, crista density is also higher in skeletal muscle increased by 60–65% and 20–25%, respectively, com-
from elite athletes (290), resulting in a further eleva- pared with non-athletes (351). During prolonged exercise
tion of muscle respiratory capacity. Thus, besides to fatigue, muscle glycogen concentration decreases in
improving oxygen delivery to the mitochondria, all subcellular compartments, with a preferential deple-
muscles can enhance respiratory capacity to meet tion of intramyofibrillar glycogen (underlying molecular
the high energy demand during exercise by increas- signals are described in sects. 4.1 and 4.5.1). As pre-exer-
ing mitochondrial and crista density as well as opti- cise muscle (and liver) glycogen content is strongly corre-
mizing the interconnected mitochondrial networks. lated with prolonged (>90 min) submaximal exercise

1720 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

capacity, higher muscle glycogen in trained muscle plays benefit from the elevated number of myonuclei even af-
an important role for maximal performance (386, 424, ter doping cessation, leading to a potential unfair
426). In addition, glycogen stores are not only replen- advantage in competitions long after bans have been
ished more rapidly in trained muscle but also to a served (435).
greater extent (“supercompensation”) compared with Although the enhanced growth rates of muscle mass
untrained muscles (described in sect. 4.8.3) (427, during retraining suggest the presence of some kind of
428). The restoration of muscle glycogen can be muscle memory (430), many of the training-induced
accelerated by high carbohydrate availability in the adaptations in muscle are the result of the complex tran-
first 3 h after exercise and can reach rates of synthesis scriptional response to repeated bouts of exercise,
of >10 mmol/kg wet muscle weight/h (428). Despite which necessitates accessible genomic regions for the
the capacity for high rates of fatty acid oxidation dur- transcriptional machinery. An open chromatin state is
ing submaximal exercise, when highly trained athletes generally indicative of enhanced transcriptional activity
compete in endurance events lasting up to 3 h carbo- (360), with the accessibility of chromatin associated with
hydrate-based, not fat-based, fuels are the predomi- modifications of nucleotides in the DNA and posttransla-
nant energy substrate for the working muscles. tional modification of histone proteins (histone code)
Accordingly, carbohydrate and not lipid availability (436, 437). Transcriptionally silent genes exhibit closed,
becomes rate limiting for performance in this context condensed chromatin (heterochromatin), an enrichment
(194). of hypermethylated DNA (5-methylcytosine instead of
cytosine), deacetylated histones, and methylation of dis-
3.5. Muscle Memory tinct histone residues [e.g., histone 3 lysine residue 9
(H3K9) or H3K27]. Gene transcription requires a state of
Skeletal muscle mass, V_ O2max , and other endurance open chromatin (euchromatin), linked to demethylated
training-induced adaptations rapidly decline upon ces- DNA, acetylated histones, and the methylation of
sation of a training stimulus (i.e., detraining, decondition- other histone residues (e.g., H3K4 or H3K26). Besides
ing), with many structural, metabolic, and performance- stable epigenetic markers that can be passed on to the
related parameters returning to pre-training values next generation, DNA methylation also occurs as a
within weeks to months, even in athletes with a lifelong dynamic process and is influenced by numerous stimuli
history of training. However, prior strength training including habitual level of physical activity, nutrient avail-
seems to facilitate the regain of muscle mass, surpass- ability, and (psychological) stress (360, 435, 438).
ing the gains that were achieved when training was Accordingly, promoter regions of genes involved in meta-
commenced from the naive state (429). This phenom- bolic pathways, myogenic processes, or oxidative stress
enon is referred to as “muscle memory” (430, 431) and, responses are hypomethylated and more accessible in
in part, is based on motor learning, intra- and intermus- lifelong physically active compared with inactive men
cular coordination, prior experience of body perception, (439). Inversely, the promoter region of the peroxisome
resilience to give into pain and fatigue, and anticipation proliferator-activated receptor (PPAR) c coactivator 1a
of exertion. In addition to these central mechanisms, (PGC-1a) is hypermethylated, and thus less accessible, af-
there is evidence for a cellular memory in muscle fibers ter bedrest and associated with reduced mRNA expres-
(432). According to the myonuclear domain theory, myo- sion (440). In recent years, a growing body of evidence
nuclei should be lost during detraining-induced muscle suggests the involvement of altered chromatin landscape
atrophy. However, at least in animal models, the number in response to exercise training as a possible contributor
of myonuclei remains elevated after a short period of to muscle memory (360, 430). For example, after endur-
disuse despite a loss in muscle mass (433). Thus, the ance or resistance training, widespread changes in DNA
greater myonuclear density and high transcriptional methylation status have been reported in muscle (438).
potential could facilitate muscle growth during retrain- Thus, exercise-responsive genes such as PGC-1a are
ing, contributing to muscle memory. In humans, this phe- hypomethylated before their induction in response to an
nomenon has received little scientific enquiry, and it is acute bout of high-intensity endurance exercise (441).
not known whether muscle memory exists, or for how Despite these observations, the contribution of DNA meth-
long accrued myonuclei might be preserved (361). A ylation to training adaptation and muscle memory is con-
large interindividual heterogeneity of the number of troversial. In some studies, endurance training promoted
myonuclei elevated after detraining has been reported, the demethylation of genes involved in angiogenesis or
and in most cases the pre-training number of myonuclei oxidative metabolism, associated with increased gene
is similar to that after detraining (434). Of note, athletes transcription (442, 443), whereas in others there was little
with a history of abuse of testosterone or other anabolic effect of HIIT or resistance training on DNA methylation
steroids, which boost myonuclear accretion, could still (444). A recent study reported that despite divergent

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1721

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

contractile stimuli (HIIT, endurance and resistance exer- repeated bouts of acute exercise that accumulate over
cise), changes in DNA methylation and mRNA expression time and result in new steady-state transcript and protein
in skeletal muscle were largely confined to the late (4–8 h) levels (87, 198), even though disparate outcomes for tran-
recovery period and similar between the different exercise script and proteins can occur (452). For example, the tran-
challenges (445). Many of the discrepancies between scription of many mitochondrial genes is transiently
investigations can likely be explained by the timing of the induced after a single bout of endurance exercise, leading
biopsy (446), with time course studies suggesting that to mitochondrial biogenesis, improved mitochondrial func-
some DNA methylation changes are retained for up to 48 tion, and elevated oxidative metabolism when the stimuli
h after the last training bout (442, 443), returning to base- are repeated over time (87, 405). This response, how-
line levels after 72 h (444). It is not known whether DNA ever, is not uniform across all transcripts and the pro-
methylation changes are retained after detraining and teins they encode. For example, in contrast to the
thereby contribute to muscle memory. Finally, the differ- change in trained muscle, robust transcriptional regu-
ence of the transcriptional response of an untrained com- lation of myosin heavy chains is not observed after
pared with a trained muscle and the involvement of acute exercise bouts (453), whereas other genes
epigenetic changes therein are currently unexplored. show an attenuated expression after repeated exer-
In contrast to endurance training, the evidence for cise exposure (438). Few studies have simultaneously
long-term epigenetic remodeling triggered by resistance investigated contraction-induced changes in mRNA
training is more robust. In response to a training protocol levels and subsequent training-induced changes in
of loading, unloading, and reloading, several CpG islands protein levels in human skeletal muscles following
remained hypomethylated during unloading, likely con- chronic interventions, and it is clear that exercise-
tributing to the elevated transcriptional response of the induced increases in mRNA levels do not always pre-
associated genes during reloading (430). These results cede increases in the proteins they encode (405, 452,
suggest that chronic changes in DNA methylation may 454). Clearly, several mechanisms regulate the train-
contribute to the transcriptional memory (430), although ing response/adaptation, and in the case of transcrip-
only a small fraction of the differentially methylated genes tional networks there may be additive or attenuated
displayed a distinct expression pattern (443, 447). responses over time. In sect. 4 we discuss our current
Nevertheless, epigenetic regulation of a few regulatory understanding of the molecular mechanisms that are
genes might be sufficient to induce a faster and/or involved in the acute response of muscle to endur-
greater response to recurring challenges. ance or resistance exercise bouts.
Collectively, our understanding of the epigenetic
changes in a trained state and the contribution to mus-
cle memory is rudimentary. Findings pertaining to epige-
netic remodeling in human muscle are heterogeneous 4. ACUTE MOLECULAR MECHANISMS
regarding the training protocols employed, the study UNDERPINNING ENDURANCE- AND
design/methodology, and the caliber of subjects under RESISTANCE-BASED EXERCISE
investigation. Individuals described as “low respond-
ers” to a training intervention may show attenuated epi- In this section, the sensors and major signaling path-
genetic modification compared with “high responders,” ways involved in the response of skeletal muscle to a
although further work is needed to corroborate this hy- single bout of endurance and resistance exercise are
pothesis (448). In elite athletes, data on epigenetic pro- summarized. We review the downstream effects of
files are almost exclusively from circulating blood cells these stimuli (e.g., transcriptional regulation and transla-
but not skeletal muscle (449, 450). However, the pres- tional control) that promote muscle adaptations in
ence of polymorphisms of genes encoding proteins response to two distinct training paradigms. In addition
involved in DNA methylation in elite athletes implies a to the well-described pathways such as Ca21-depend-
possible epigenetic predisposition (451). ent pathways, AMP-activated protein kinase (AMPK),
and mammalian target of rapamycin (mTOR) complex 1
3.6. How Are Physiological and Cellular Training (mTORC1) signaling reviewed above, we delineate the
Adaptation Brought About? important roles of other transducers such as mechano-
sensing and transduction, for which there is a scarcity of
Many of the training-induced morphological, biochemical, data on athletic populations. A brief discussion of the
physiological, and functional adaptations are the culmina- common signaling pathways activated by both endur-
tion of long-term (weeks to months) exposure to training ance and resistance training is provided, followed by a
stimuli (FIGURE 6). Many of the transcriptional changes comprehensive overview of the molecular events that
that underpin these adaptations are the transient effect of occur after an acute bout of exercise and underpin the

1722 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

differential responses to divergent contractile stimuli between and integration of these processes are not fully
described in sects. 2 and 3. understood.
A single bout of exercise sets in motion a complex pro-
gram of interconnected signaling events, along with the 4.1. Neuroendocrine Signaling in the Anticipatory
activation of numerous biochemical pathways and tran- Phase and During Muscle Contraction
scriptional networks that orchestrate the spatio-temporal
responses to muscle contraction and coordinate a pleio- An acute bout of exercise represents a “one-off” stressor
tropic response in other tissues and organs to control to whole body homeostasis, provoking widespread pertur-
energy substrate provisioning, oxygen availability, and bations in numerous cells, tissues, and organs that are
heat dissipation (9). These perturbations are initiated by caused by or are a response to the increased metabolic
numerous inputs, which can occur in parallel, overlap, or activity of contracting skeletal muscles (9, 55, 455).
be completely independent. Several critical regulatory Induction of the “fight or flight” response, including activa-
“nodes” provide the hub for signal integration and subse- tion of the sympathetic nervous system in parallel with the
quent control of transcription and enzymatic activity (9, motor system, responds to feedback from the exercise
55, 455). Repeated bouts of exercise over several weeks pressor reflex via group III/IV skeletal muscle afferents
or months result in a continuous modulation of this (458, 459). This reflex encompasses feedback that is
response and, over time, ultimately contribute to provoke evoked from mechanically (muscle mechanoreflex) and
chronic adaptations (456). Although the molecular mecha- metabolically (muscle metaboreflex) sensitive afferents
nisms underpinning many of the chronic responses to during contractions, leading to parasympathetic depres-
exercise training remain undefined, numerous insights sion and sympathetic activation (460). Consequently,
regarding acute exercise response have been described blood flow to skeletal muscle is increased as a result of
in recent years (9, 39, 41, 55, 163, 393, 455, 457). A caveat elevated heart rate, blood pressure, and rate of ventilation.
is that although the focus of this review pertains to data The exercise pressor reflex can be complemented by
obtained from exercise-trained humans, many of our cur- “central command,” in which stimulation of medullary
rent mechanistic insights have originated from rodent and and spinal circuitries by higher brain centers likewise
other in vivo and in vitro model systems. It is important to evokes respiratory and cardiovascular modulation (460).
make a distinction between voluntary, whole body in vivo Importantly, the sympathetic nervous system can also be
responses to exercise and those elicited by other experi- engaged by anticipation and other emotional factors pre-
mental models. Ex vivo electrical stimulation of an isolated ceding motor activation. Exercise leads to a substantial
skeletal muscle, for instance, evokes an action poten- increase in circulating catecholamines, a response that is
tial and “contraction” and triggers intracellular path- greater in trained compared with untrained individuals
ways with putative roles in training adaptation. However, exercising at the same relative intensity (458, 459). In part,
whole body, voluntary exercise induces a range of addi- centrally controlled modulation of the sympathetic nervous
tional physiological responses that are critical for muscle system is required for a systemic activation of events that
performance (and movement). Accordingly, many effects support muscle contraction, such as increased pulmonary
observed in animals and isolated systems can differ from and cardiovascular output or various metabolic pathways
those seen in humans in vivo, and care should be taken to liberate energy substrates. Importantly, muscle tissue is
when extrapolating responses from one set of conditions also innervated by the sympathetic nervous system
or a given experimental model to another (9). Here, we through the activation of b2-adrenoreceptors by catechol-
describe the signaling pathways and mechanistic events amines, with epinephrine having a higher affinity than nor-
that are principally involved in the response to an acute epinephrine for these receptors, and a higher density of
exercise bout and culminate in the subsequent training b2-adrenoreceptors on type I compared with type II muscle
adaptation. Mechanisms that are important in muscle at- fibers (458, 459). Besides affecting the microvasculature,
rophy and pathological situations are not discussed in the adrenergic system exerts other functions in this tissue,
detail, and because of space limitations we cite recent including direct effects on the neuromuscular system
reviews that serve as starting points for further reading (FIGURE 10) (458, 459). Initially, adrenergic action on the
and collections of primary literature. The following sec- presynaptic side of the NMJ helps synchronize neurotrans-
tions are structured based on the putative engagement mitter vesicle fusion and augment acetylcholine release.
of the respective pathways in muscle contraction, from Then, b2-adrenoreceptor action on the muscle fibers acti-
pre (anticipation)- to peri (start of activity, during the exer- vates the Na1-K1 pump and thereby fiber excitability,
cise bout)- to post (muscle fatigue and exercise cessation potentially attenuating fatigability. Muscle contractility, in
and finally recovery, repair, and regeneration)-exercise particular twitch force and relaxation rate, is modulated by
(FIGURE 9). It should be noted, however, that the exact the adrenergic effect on Ca21 release and reuptake via
temporal sequence of engagement and the interactions RYR1 and phospholamban, the latter of which is exclusively

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1723

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

Motor neuron
Sympathetic nervous signaling
system activation
Stress response:
mechanical
redox
heat
2 proteostatic
energetic
1 Initiation substrate availability
Anticipation oxygen availability
Exercise

2
1 Time

5
Muscle fiber repair and regeneration 3 3
Substrate refueling and proteostasis Activity Circadian
Functional retrieval 4
rhythms
Central and peripheral
processes, e.g., redox signaling

5
Recovery 4
Fatigue/
Exhaustion
FIGURE 9. Temporal engagement of different pathways and processes in skeletal muscle in exercise. Anticipation of activity is linked to elevated
sympathetic nervous system tone. Motor neuron firing triggers muscle contractions at the start of and during an activity. While contracting, muscle will
be affected by different stressors and the related reaction/mitigation, for example, mechanical stress, reactive oxygen and nitrogen species (redox) pro-
duction, heat, altered proteostasis and protein unfolding, metabolic changes, substrate availability, and oxygen provisioning. The exact temporal
sequence of engagement of and interactions between these pathways are unknown. Different mechanisms contribute to muscle fatigue, exhaustion,
and exercise cessation. Subsequently, muscle repair, regeneration, and refueling are important for functional retrieval. Many of these processes are
modulated by circadian input. Images: triathlon anticipation from Wikimeda Commons (CC-BY-SA 3.0, creator: Wiech), triathlon start from Wikimedia
Commons (CC-BY-SA 2.0, creator: IQRemix), triathlon cycling from PxHere.com (CC0 Public Domain), exhaustion from Wikimedia Commons (CC-BY-SA
4.0, creator: Wallco26), massage from Freepick.com (author: javi_indy), waking up from Freepik.com (author: diana.grytsku).

expressed in slow muscle fibers. Metabolically, b2-adreno- kinase B (PKB/Akt), exerts a negative effect on FOXO3
receptor activation antagonizes insulin to stimulate glyco- function as well as a positive modulation of protein syn-
gen breakdown and inhibit glycogen synthesis. Moreover, thesis by activation of mTORC1 (461).
b2-adrenoreceptor agonism represses proteolytic proc-
esses, leading to a transient anabolic effect on muscle 4.2. Motor Neuron Activation of Muscle Fiber
mass. As members of the G protein-coupled transmem- Contractions
brane receptor family, b2-adrenoreceptors engage numer-
ous signaling pathways and effectors in muscle cells (461). Muscle fiber contraction can be initiated via different
The exchange of GDP for GTP at the a stimulatory sub- mechanisms: neuronal activity in the motor cortex for
unit of guanine nucleotide-binding regulatory protein voluntary movement, sensory neuronal input for involun-
(Gas) results in an activation of adenylate cyclase, the tary reflex contractions such as elicited in proprioceptive
cyclic AMP (cAMP) signaling pathway, and ultimately or vestibular control, or hypothalamic activation of ther-
elevated transcriptional activity of the cAMP response mogenesis-promoting neurons for shivering (463–465).
element-binding protein (CREB), which stimulates the Regardless of the origin of the signal and upstream cir-
modulation of additional control genes, including cuitry, neuronal input converges on a-motor neurons in
PGC-1a, or myogenic factors such as myoblast deter- the ventral horn of the spinal cord (466). These motor
mination protein 1 (MyoD) (461). The inhibition of the neurons, their descending axons, and the innervated
Forkhead box 3 (FOXO3) by PGC-1a, and hence of pro- muscle fibers form a motor unit that transforms synaptic
tein degradation and fiber atrophy (462), is potentiated input into muscle contractions (318). Motor units differ in
by the effect of the Gbc subunit of the b2-adrenoreceptor, size, with one motor neuron interfacing with from a
which modulates the activity of phosphoinositide 3-ki- handful to many thousands of individual muscle fibers
nase (PI3K) and, via downstream activation of protein (318). Collectively, the motor units of one muscle are

1724 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

FIGURE 10. Neuroendocrine signaling by

the sympathetic nervous system in exer-
cise anticipation and muscle contraction.
Afferents
Sympathetic activation of the motor neuron
Action
and skeletal muscle cells results in modula-
potential Synchronization of vesicle fusion tion of fiber excitability and contractility,
symp. NS Augmented acetylcholine release metabolic and proteostatic remodeling,
and the activation of a transcriptional pro-
gram. These events prepare muscle cells for
Na+/K+ pump β2 AR
upcoming contractions and help to maintain
contractile activity upon engagement. b2 AR,
b2-adrenoreceptors; Akt, protein kinase B;
cAMP cAMP, cyclic AMP; FOXO3, forkhead tran-
PI3
Fiber K-A scription factor O3; mTOR, mammalian target
kt-
excitability mT TF of rapamycin; PGC-1a, peroxisome prolifera-
OR PGC-1α
tor-activated receptor c coactivator 1a; PI3K,
FOXO3 phophoinositide 3-kinase; PLN, phospholam-
SERCA PLN ban; RYR1, ryanodine receptor 1; SERCA, sar-
RYR1
coplasmic/endoplasmic reticulum Ca21-
Ca 2+ Ca2+ ATPase; symp. NS, sympathetic nervous sys-
Glycogen tem; TF, transcription factor. Image created
Fiber breakdown
contractility Proteolysis with BioRender.com, with permission.

referred to as the motor unit pool (318). At the synapse of respective Ser/Thr sites, subsequently binding to the
between motor neurons and muscle fibers, the NMJ, an promoter of the PGC-1a gene PPARGC1A and inducing
axonal action potential, results in the release of the neu- transcription of this coregulator protein, among others
rotransmitter acetylcholine, which, after traversing the (474). Once synthesized, PGC-1a competes with histone
synaptic cleft, binds to nicotinic acetylcholine receptors deacetylase 5 (HDAC5) to coregulate myocyte enhancer
that cluster at the entry points of subneural clefts on the factor 2 (MEF2) family members on its own promoter and,
muscle membrane (FIGURE 11A) (467, 468). Activation of using this positive autoregulatory loop, ensures robust
these ligand-gated ion channels results in influx of Na1 transcriptional expression (475, 476). Consistent with ele-
and a process called ECC, leading to depolarization of vated levels in slow and exercised muscle fibers, PGC-1a
the muscle membrane and, on the intracellular side of T mediates a broad remodeling of skeletal muscle, result-
tubules, the release of Ca21 from the SR, which ultimately ing in a slow-twitch, oxidative, fatigue-resistant phenotype
initiates and maintains muscle contractions (469). Thus, (477) that also includes extramyofiber adaptations such
one of the first events to occur in response to a single as at the microvasculature (478) or the presynaptic side
bout of exercise is initiation of Ca21-dependent signaling. of the NMJ (315). Mice with a skeletal muscle-specific
ablation of PGC-1a display abnormal glucose and insulin
4.2.1. Ca21 signaling. homeostasis (479), contraction-induced fiber damage,
impaired endurance capacity, and other characteristics
Besides binding to troponin C and initiating the interac- indicative of pathological inactivity (480).
tion between actin and myosin, intracellular Ca21 acti- The mechanisms that underlie the broad integration
vates a multitude of signaling pathways in myofibers, of a vast number of signaling pathway that are engaged
modulating numerous physiological functions (470). For in contracting muscle, and which mediate a tightly chor-
example, Ca21 signaling is associated with the control of eographed modulation of broad transcriptional pro-
glycolysis, mitochondrial function, and the rates of protein grams by PGC-1a, are unclear. Gene expression from
synthesis and degradation (471). The different Ca21 tran- different promoters and transcriptional start sites (474,
sients that are evoked by activation of muscle fibers by 481, 482), various isoforms (481, 482), context-specific
slow and fast motor neurons contribute to the specificity posttranslational modifications (474, 482), and the RNA
of different muscle fiber types (472, 473). Mechanistically, binding-dependent assembly of specific multiprotein-
the protein phosphatase calcineurin A (CnA) and Ca21/ containing transcriptional complexes and DNA regula-
calmodulin-activated protein kinase II (CaMKII) are Ca21- tory elements in sequestered nuclear condensates (483)
activated mediators involved in controlling gene tran- could all contribute to a coordinated spatio-temporal
scription linked primarily to a slow fiber phenotype (471). control of PGC-1a-mediated network control (482, 484).
In this context, CnA and CaMK activities converge on the Indeed, PGC-1a functionally and/or physically interacts
cAMP-dependent binding protein (CREB) and activating with multiple transcription factors and coregulators that
transcription factor 2 (ATF2, also called CREB2), which affect the exercise phenotype of skeletal muscle in
are activated by phosphorylation and dephosphorylation a dynamic manner (482, 485, 486). Thereby, spatial

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1725

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

A
Afferents

Action
symp. NS potential
Retrograde
signaling
β2 AR NTs

ECC
FIGURE 11. Motor neuron signaling and (neuro)endocrine
Ca2+ Ca effectors of contraction. A: motor neuronal signaling triggers
MK
, Cn
A excitation-contraction coupling and thereby evokes a rise in
TF intramyocellular calcium (Ca21), which enables fiber contrac-
PGC-1α tions, activates various signaling pathways, and modulates a
CREB
Fiber contraction transcriptional response, including retrograde feedback to the
ATF2
motor neuron. Motor neuron activity is modulated by sympa-
thetic tone and includes various neurotrophic factors besides
the neurotransmitter acetylcholine. B: exerkines, originating
from tissues including muscle (myokines), liver (hepatokines),
B Endocrine: adipose tissue (adipokines), and bone (osteokines) as well as
Adipo-, Hepato-, Osteokines other hormones coordinate a systemic response to contractile
Corticosteroids activity. Many of these factors exert auto-, para-, and endo-
Testosterone
Paracrine
crine effects. In addition, signals can be propagated by exer-
Growth hormone => IGF-1
cise-linked changes in different metabolites (myobolites or
...
GDF3 myometabokines). b2 AR, b2-adrenoreceptors; ATF2, activat-
Retrograde ing factor 2; CaMK, calcium/calmodulin-dependent protein ki-
signaling
Lactate IL-13
nase; CnA, calcineurin A; CREB, cAMP-responsive element
binding protein; ECC, excitation-contraction coupling; GDF3,
growth differentiation factor 3; IGF-1, insulin-like growth factor
1; IL-13, interleukin 13; NTs, neurotrophic factors; PGC-1a, per-
oxisome proliferator-activated receptor c coactivator 1a;
symp. NS, sympathetic nervous system; TF, transcription fac-
tor. Image created with BioRender.com, with permission.
TF

Myokines
Myobolites

Autocrine

Endocrine
Paracrine

specification, and the expression of synaptic genes in mode-specific manner. For example, training intensity
subsynaptic but not extrasynaptic myonuclei (487), or a and duration may be one of the factors that influence
temporal specification, such as the activation of cata- Ca21 fluctuations in the muscle and thereby influence
bolic and anabolic pathways like fatty acid b-oxidation Ca21-mediated signaling.
and de novo lipogenesis to increase intramyocellular lip-
ids (488), might be achieved (474, 489). Of note, Ca21 4.2.2. (Neuro)endocrine factors, exerkines, and
signaling also activates a number of additional transcrip- myokines.
tion factors with unclear epistatic relationship to PGC-1a,
including family members of the nuclear receptor 4A Besides neurotransmitter-mediated activation, motor neu-
(NR4A) family, of which NR4A2/NURR-1 and NR4A3/ rons and skeletal muscle fibers engage in a bidirectional
NOR-1 in turn regulate target genes involved in oxidative cross talk through several secreted factors (FIGURE 11B).
metabolism and improved muscle endurance (490, 491). Some of these, such as motor neuron-derived agrin, are
As Ca21 signaling is activated in response to both en- important for the development and stabilization of the
durance- and resistance-based exercise, it is still unclear NMJ (468). This synapse, however, also exhibits remark-
whether and how this pathway is affected in a training able plasticity in the mature state, with exercise providing

1726 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

a strong stimulus to alter morphology and function (312). of so-called “myokines” have been discovered and stud-
Neuregulin-1 is secreted by the motor neuron and acti- ied in recent years (498). Myokines, some of which are
vates signaling pathways in the muscle fiber that lead to only produced in contracting muscle fibers, sometimes
the phosphorylation of PGC-1a and the GA-binding pro- referred to as “exerkines,” elicit auto-, para-, and endo-
tein B [GABPB, also called nuclear respiratory factor 2b crine effects to coordinate local and systemic processes
(NRF-2b)] subunit of the GABP transcription factor com- (499, 500). For example, when secreted as a myokine,
plex (487). These local events, which primarily affect sub- interleukin (IL)-6 acts as a metabolic coordinator by pro-
synaptic myonuclei close to the NMJ, could provide the moting lipolysis in adipose tissue, gluconeogenesis in the
mechanistic basis of the spatial specification of PGC-1a to liver, and, via activation of AMPK, glucose uptake and fatty
exclusively regulate the transcription of postsynaptic NMJ acid oxidation in muscle (501). Paracrine effects of myokines
genes in these, and not extrasynaptic, nuclei (487). are also instrumental for an adequate response of muscle
Intriguingly, active muscle PGC-1a triggers a remodeling tissue to exercise, such as the proangiogenic effects of IL-6
process of the NMJ that extends to the presynaptic side or the vascular epithelial growth factor (VEGF) on epithelial
with altered mitochondrial and synaptic vesicle numbers cells (501) or the activation of resident macrophage polariza-
in the active zone and a quantal content reflecting slow tion by the B-type natriuretic peptide (BNP) and secreted
NMJ function (315). These observations go beyond the phosphoprotein 1 (SPP1) (502, 503). Many of the endurance
current view of a unidirectional control of muscle fiber exercise-induced myokines are under the transcriptional
type by the respective activity patterns of motor neurons, control of PGC-1a (501, 504), whereas the regulation of
in that elevation of muscle PGC-1a, observed in slow-type those modulated by resistance training is less clear (504,
or exercised fibers, affects motor neuron function, at least 505). Paracrine signaling from different cell types to myofib-
at the NMJ. Neurturin could be a mediator of this PGC-1a- ers is also important for a normal exercise response, such
dependent retrograde signaling, acting on the NMJ (492) as the exercise-induced secretion of IL-13 by type 2 innate
and even on motor neurons in the spinal cord (493). lymphoid and other immune cells that promotes an oxida-
Another example of such a factor, brain-derived neurotro- tive phenotype in muscle (506) or growth differentiation fac-
phic factor (BDNF), a signaling factor secreted from neu- tor 3 (GDF3) by macrophages (507), as well as endothelial
rons but also cells and tissues such as skeletal muscle cell-secreted lactate, both important for muscle regenera-
fibers (494), functions as a myokine, a hormonal entity tion (508). A complex dialogue between muscle and other
produced and secreted by muscle cells. BDNF expres- cell types, mediated by myokines, hepatokines, adipokines,
sion is elevated upon contractile activity, the protein and osteokines, ensures proper and coordinated local as
secreted, and besides a potential effect on the motor well as systemic adaptations to contractile activity, such as
neuron affects NMJ morphology and function postsynap- for the adiponectin-mediated activation of muscle AMPK
tically in an autocrine manner (495). (509, 510). Collectively, however, our understanding regard-
Several other (neuro)endocrine factors have also been ing hormones that affect skeletal muscle during contraction
identified in the context of exercise. For many of these, or throughout recovery and regeneration from exercise is
particularly testosterone and other classical steroid and rudimentary.
non-steroid hormones, regulation during an acute exer-
cise bout is probably of little significance compared with 4.3. Mechanosensing and Mechanostress
the chronic effects such as restoration of substrate stores, Mitigation
muscle repair and regeneration, and in extreme situations
overtraining/overreaching. For example, corticosteroids, 4.3.1. Cell membrane mechanosensing.
glucagon, and leptin are elevated when blood glucose
and/or muscle and liver glycogen concentrations are low Mechanical stress is exerted on muscle fibers at the initia-
and stimulate fatty acid oxidation in muscle by activation tion of and during exercise by passive stretching, sarco-
of AMPK (496). Testosterone, growth hormone, and the meric contraction, and other stimuli (FIGURE 12) (511). The
downstream target insulin-like growth factor 1 (IGF-1) are force-induced stretch and contraction/compression of mus-
induced after different types of resistance training and cle fibers in situ is not restricted to the longitudinal direction
exert anabolic effects by stimulating MPS and fiber repair but extends across orthogonal, radial, and tangential axes
(497). The regulation of these hormones in humans is (511). The ensuing shear, tension, and compressional stress
variable, and little is known about the exact molecular and cellular deformation present a high potential for dam-
mechanisms that mediate these adaptations. Indeed, age to the extracellular matrix (ECM), cell membrane, intra-
gain- and loss-of-function models of the receptors of cellular scaffolds, and other structures. Therefore, a
some of these hormones fail to reveal a clear picture complex system of mechanosensing exists to attenuate
regarding their function in exercise-induced muscle plas- damage and initiate adaptive processes that confer protec-
ticity (486). Besides these classic hormones, a novel class tion against acute and subsequent insults. Broadly,

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1727

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

Shear stress Integrins TRPC Contraction-Relaxation

FAC

Change in titin stiffness Stress kinases: p38 MAPK,

ERK, JNK, SAPK
Repair of sarcomeres mTORC1
Nuclear
Ca2+ deformation
Titin
Hippo TF
YAP/TEAD
Cytoskeleton

Immediate-early and delayed

primary gene expression:
SRF, EGR-1, AP-1, PGC-1α,...

FIGURE 12. Mechanosensing and mechanostress mitigation in the contracting muscle fiber. Mechanical stress is sensed and translated by structures
at the cell membrane and intramyocellular components in the cytosol, cytoskeleton, sarcomeres, or nucleus. As a consequence, resistance to shear
stress is increased, stiffness and integrity of sarcomeric structures adapted, and a broad program of immediate-early and delayed primary genes initi-
ated. AP-1, activating protein 1; EGR-1, early growth response gene 1; ERK, extracellular signal-regulated kinase; FAC, focal adhesion complex; JNK, c-
Jun NH2-terminal protein kinase; mTORC1, mammalian target of rapamycin complex 1; p38 MAPK, p38 mitogen-activated protein kinase; PGC-1a, per-
oxisome proliferator-activated receptor c coactivator 1a; SAPK, stress-activated
21
protein kinase; SRF, serum response factor; TEAD, TEA domain tran-
scription factor; TF, transcription factor; TRPC, mechano-gated Ca transient receptor potential channels; YAP, yes-associated protein. Image created
with BioRender.com, with permission.

mechanical stress is detected by different structures at the In this manner, the mitogen-activated protein kinase
cell membrane or by intracellular sensors. Stretch-activated (MAPK) signaling pathway is engaged, leading to elevated
channels (SACs) belong to the first category in skeletal activity of p38 MAPKs, extracellular signal-regulated ki-
muscle, of which the mechano-gated Ca21 transient recep- nases (ERKs), c-Jun NH2-terminal protein kinases (JNKs),
tor potential channels (TRPCs) are activated by mechanical and stress-activated protein kinases (SAPKs). The MAPK
stress (512). The expression and function of the mechano- pathway integrates TRPC Ca21-derived mechanosensing
sensing cation channel Piezo1 in skeletal muscle is less via transmembrane adhesion receptors such as integrins,
understood, at least in intact fibers (513). TRPC activity integrin-associated proteins, focal adhesion kinase (FAKs),
results in Ca21 influx, and the ensuing elevations in intra- and other components of the focal adhesion complex
myocellular Ca21 either directly affect target structures or, (512, 515). The stress-activated kinases then execute the
through the activation of distinct signaling pathways, result phosphorylation of enzymatic effectors and transcriptional
in the activation of calmodulin, CnA, MEF2, and nuclear regulators including PGC-1a (516), serum-response factor
factor of activated T cells (NFAT) (512). Dephosphorylation (SRF), JUN, and FOS, forming the activating protein 1 (AP-1)
of NFAT by CnA enables a cytoplasmic-nuclear transloca- complex or early growth response gene 1 (EGR-1), and
tion and subsequent regulation of gene expression by this thereby inducing the expression of immediate-early and
transcription factor, often together with MEF2 (512). NFAT delayed primary response genes (517). This program
binds to regulatory genes involved in muscle fiber type includes several transcription factors needed for second-
remodeling or hypertrophy, including induction of PGC-1a ary response gene transcription, some of which are
and, via a positive feedback loop, transcription of TRPCs, directly modified by stress kinase phosphorylation (518).
thereby sensitizing muscle fibers to future mechanoinsults Collectively, these early primary and secondary response
(512). Non-genomic effects of intracellular Ca21 include genes promote processes related to cell survival, cytos-
direct modulation of structural proteins such as titin or keletal rearrangement, and elevation of small heat shock
actin. Deformation of cytoskeletal structures thus medi- proteins (HSPs) and other chaperones, thus mitigating
ates mechanosensing by receptors at the cell membrane, potential harmful events in the contracting muscle fiber on
leading to a regulatory loop that reacts to changes in me- different levels (511, 512, 518).
chanical stress by adapting sensing and cell rigidity (512).
Ca21, for example, affects the assembly of actin filaments, 4.3.2. Cytosolic mechanosensing.
thereby driving a cytoskeletal rearrangement that affects
cell stiffness (512). Increases in intracellular Ca21 also Besides these mechanosensing systems originating at
result in the activation of Ras guanine nucleotide-releasing the cell membrane, at least two cytosolic signaling path-
factors (GRFs), which in turn activate the Ras GTPase (514). ways are important. First, mTORC1 activity is increased

1728 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

in mechanically stimulated fibers (519, 520). This protein and other hypertrophic programs and, in combination
kinase is the major regulator of cellular protein synthesis with PI3K-Akt activity, a reduction in catabolic proc-
and one of the key inhibitors of autophagy, thereby con- esses and apoptosis (519).
trolling cell size (521). In prohypertrophic states, mTORC1 In parallel to mTOR signaling, the Hippo pathway also
is activated and contributes to the regulation of muscle contributes to mechanostress-induced muscle cell remod-
mass (522) in a controlled manner. Dysregulation of mus- eling (526). The transcriptional coactivator Yes-associated
cle mTORC1 through ablation of the upstream inhibitor protein (YAP) is controlled by the Hippo pathway and is
tuberous sclerosis complex (TSC) results in an atrophic activated upon deformation or rearrangement of actin
phenotype (523). In contrast, inducible, skeletal muscle- and the subsequent regulation of various actin-associated
specific ablation of raptor, an essential component of proteins (526). After cytoplasmic-nuclear translocation,
mTORC1, has little effect on muscle mass in sedentary YAP coactivates TEA domain (TEAD) transcription factor
mice (524). These findings suggest that mTORC1 is an im- family members to control the expression of genes linked
portant, but not the only, regulatory factor governing skel- to decrease in apoptosis and increase in muscle hypertro-
etal muscle hypertrophy (525). The prototypical activators phy (526). Even though the prohypertrophic function of
of mTORC1 signaling are insulin and amino acids, in partic- YAP is mTOR independent, the Hippo/YAP pathway may
ular leucine, arginine, and glutamine, collectively repre- engage in cross talk with the Akt/mTOR pathway to pro-
senting an anabolic context with high nutrient availability mote muscle mass gains and with the transforming
(521). However, in muscle contraction and mechanosens- growth factor-b (TGF-b)/small worm phenotype/Mothers
ing, other stimuli may be more important to activate Against Decapentaplegic (SMAD) pathway to coordinate
mTORC1, although the specific exercise-stimulated mech- repair and regeneration, respectively (526).
anisms have not been identified (519). Candidate path-
ways include IGF-1 signaling or that of the muscle-specific 4.3.3. Structural mechanosensing at the
IGF-1 splice variant mechano growth factor (MGF), whose cytoskeleton, sarcomeres, and cell nucleus.
activity is increased by mechanical stimulation and could
engage mTORC1 via PI3K-Akt-dependent pathways. Intramyocellular structural components also contribute
However, even though IGF-1 exerts clear anabolic effects to mechanosensing, mostly filamentous actin and the
in muscle, experimental evidence indicates that acute sarcomeric proteins myosin and, in particular, titin, a
mechanosensing and activation of mTORC1 might be in- giant scaffold protein that is essential for forming the sar-
dependent of PI3K and Akt (519, 520). mTORC1 activation comeric structure (527–529). Because of reversible
could also be achieved by cross talk with established extension of specific domains, titin acts as a molecular
mechanosensing pathways such as intracellular Ca21 spring and determines the passive elastic properties of
engaging mTORC1 via activation of CaMK kinase a sarcomeres and muscle fibers and can even contribute
(CaMKKa) or phosphorylation of TSC and raptor by ERK ki- to active force and tension generation during muscle
nases (519, 520). Furthermore, different membrane-bound contractions (530). During stretch, physical deforma-
phospholipases and diacylglycerol kinase f (DGKf) are tion of titin leads to the release of several ankyrin-
activated by stretch, in part via Ca21, and then exert vari- repeat proteins including cardiac ankyrin-repeat pro-
ous functions related to the mechanoresponse (519). tein (CARP), diabetes-related ankyrin-repeat protein
Phospholipases activate the Raf-ERK as well as PI3K-Akt (DARP), and ankyrin-repeat-domain protein-2 (ANKRD2)
pathways, thereby regulating two potential upstream regu- that act as transcription factors to initiate sarcomerogene-
lators of mTORC1 (519). Moreover, phosphatidic acid pro- sis and fiber repair leading to adaptive muscle remodel-
duced by phospholipase D or DGKf directly stimulates ing and increased expression of structural proteins,
mTORC1 activity, most likely by binding to the 12-kDa including titin, desmin, and dystrophin (527, 528). At that
FK506-binding protein (FKBP12)-rapamycin binding (FRB) time, a complex formed by the muscle LIM protein (MLP)
domain of mTOR (519). Then, a mechanosensitive integ- is released from titin and interacts with NFAT signaling to
rin-FAK-TSC2-Ras homolog enriched in brain protein induce prohypertrophic genes. The titin-cap (T-CAP) acti-
(RHEB) axis could also converge on mTORC1 (515). vates the E3-ubiquitin ligase mouse double minute 2 hom-
Finally, several other mechanisms have been pro- olog (MDM2), which, together with the titin-associated
posed to mediate the activation of mTORC1 upon me- Ca21-dependent cysteine proteases calpain1 and calpain3
chanical stress and loading, including translocation of as well as the neighbor-of-BRCA1-gene-1 (NRB-1), promotes
TSC2, the cellular redox state, in particular reactive protein degradation and autophagy, hence a robust sys-
nitrogen species (RNS), and amino acid availability. tem of protein quality control to repair defective sarcomere
Regardless of the mode of upstream control, mTORC1 structures (527, 528). In the active muscle, in addition to
activity triggered by loading-induced mechanical constituting one of the major signaling hubs for mechano-
stress results in an upregulation of protein synthesis sensing, titin represents a tunable spring, acquiring

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1729

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

context-dependent stiffness and thereby conferring mechanosensing of the intracellular microtubule net-
enhanced tension and an increased passive force to mus- work (536). NOX2-derived ROS in turn affect TRPCs
cle cells (527, 528). Different posttranslational modifica- and, in a positive feedback loop, further sensitize muscle
tions of the titin protein and direct binding of Ca21 affect fibers to stretch. In a specific range of concentration, ROS
the stiffness of this protein to improve sarcomere integrity are important to stimulate maximal force generation,
during exercise and promote the effectiveness of acceler- even though the mechanistic aspects of this function are
ated contraction-relaxation cycles (527, 528). unclear. RNS could trigger adaptations similar to ROS in
Other intracellular structural components that are skeletal muscle. Nitric oxide (NO) is primarily produced by
involved in mechanosensing and transduction include the the type I neuronal nitric oxide synthase (nNOS) enzyme
cell nucleus (531, 532), often the most stiff element of the in the contracting muscle fiber (537, 538). Subsequently,
cell (533). The perinuclear cytoskeleton transmits forces to NO affects several systems in myofibers, either by direct
the Linker of Nucleoskeleton and Cytoskeleton (LINC) nitrosylation or by activation of NO-dependent guanylate
complex and various proteins of the nuclear envelope cyclases and the ensuing increase in cGMP (536–539).
such as lamins and emerin. The LINC complex provides a NO has a broad-ranging impact on muscle cell metabo-
mechanical connection between the cyto- and nucleoske- lism by increasing glucose uptake or reducing the activ-
leton. Remodeling of the nuclear lamina by mechanical ities of creatine kinase and several glycolytic enzymes
force can directly affect gene expression by changing the (536–539). Together with NO produced by epithelial
chromatin condensation state, histone modifications, (eNOS) and inducible (iNOS) NOS, positive effects on va-
gene repositioning, and the binding of transcription factors sodilation and the activation of satellite cells are
to accessible DNA regions. Inversely, the chromatin state achieved. Finally, both ROS and RNS engage numerous
and histone modifications might affect nuclear rigidity. signaling pathways and transcriptional regulators to pro-
Thereby, a bidirectional link between nuclear mechano- mote a myocellular remodeling (540). MAPK signaling
sensing and transcriptional regulation is achieved (532, pathways are redox sensitive, and an activation of JNK,
533). How this is affected by exercise is unclear. Signaling p38 MAPK, and ERK is observed upon elevated levels of
induced by mechanosensing occurs as soon as the mus- ROS and RNS (537). In terms of transcriptional regulation,
cle contracts, but it is not known whether resistance- and release of the redox-sensitive Kelch-like ECH-associated
endurance-type exercise affect mechanosensing in a simi- protein 1 (KEAP1) enables a cytoplasmic-nuclear shuttling
lar fashion and thereby activate the same pathways. of the transcription factor nuclear factor erythroid 2-related
Furthermore, it is possible that specific interventions or factor 2 (NRF2, also known as nuclear factor erythroid-
types of contractions (i.e., eccentric vs. concentric contrac- derived 2-like 2, NFE2L2), which then binds to antioxidant
tions) may enhance stretch or shear stress and thereby response elements (AREs) on regulatory sites of various
promote mechanosensing-induced signaling pathways. genes to promote a robust antioxidant response (541).
NRF2/NFE2L2 also induces the expression of nuclear re-
spiratory factor 1 (NRF1) and PGC-1a and increases mito-
4.4. Oxidative Stress chondrial biogenesis and substrate oxidation (541). NRF2/
NFE2L2 gene expression is controlled by an AMPK-PGC-
Oxidative stress and the associated cellular responses 1a axis, implying a robust mutual regulation of NRF2/
are closely linked to mechanical stress and mechano- NFE2L2 and PGC-1a, with both PGC-1a and NRF2/NFE2L2
sensing (FIGURE 13) (534). In contracting skeletal mus- being activated by MAPK pathway effectors (541).
cle cells, reactive oxygen species (ROS) are produced Furthermore, PGC-1a regulates the transcription of several
by NADPH oxidase enzymes NOX2 and NOX4 and to a genes encoding antioxidant enzymes, at least in part, in
lesser extent by mitochondria. Whereas NOX4 seems to an NRF2/NFE2L2-dependent manner (541). PGC-1a gene
be a more constitutive enzyme important for basal ROS transcription is also controlled by NO via the activation of
production in muscle, NOX2 activity is highly regulated cGMP-associated signaling, potentially in a bimodal fash-
by specific agonists such as angiotensin II or various ion (541). Upon redox-dependent oxidation of cysteine res-
cytokines. At the onset of contraction, phospholipase A2 idues (540) and a resulting stabilization of the tumor
is activated by elevated intracellular Ca21 to produce ar- suppressor gene p53, this transcription factor binds to and
achidonic acid from the cleavage of membrane phos- activates the promoter of PGC-1a to mediate some of its
pholipids. Arachidonic acid in turn increases ROS protective effects in muscle during exercise (542). Nuclear
production by NOX2 and mitochondria (534). Muscle factor κB (NF-κB) and AP-1 are two additional transcription
stretch, compression, or osmotic shock thereby results factors that can be activated in a redox-specific manner
in a rapid burst of intramyocellular ROS, which then (537). In this context, NF-κB is a strong regulator of antioxi-
serves as physiological signaling agent (535). In addi- dant genes, whereas AP-1 induces a more general stress
tion, NOX2 activity might be directly modulated by response (537). Of note, both transcription factors interact

1730 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

Enhanced stretch
sensitization
Shear stress Integrins TRPC Contraction-Relaxation
FAC

Stimulation of maximal
Antioxidant and stress
force generation
response genes
TF PGC-1α
L2
cGM
E2
P
/ NF
F2 RNS
NR Glucose
mTORC1
ROS
NOS

NOX Satellite cell

activation

Vasodilation

FIGURE 13. Redox stress by reactive oxygen and nitrogen species in muscle contraction. Redox regulation of muscle contractility and stress
response by reactive oxygen (ROS) and nitrogen (RNS) species during muscle contraction. ROS and RNS are primarily produced by enzymes at the
muscle cell membrane. Subsequently, a number of downstream effects are promoted, including an increase in energy substrate and oxygen availabil-
ity, enhancement of force generation, improvement of the resilience against oxidative stress, and modulation of a transcriptional program for muscle
remodeling. cGMP, cyclic guanylate monophosphate; FAC, focal adhesion complex; mTORC1, mammalian target of rapamycin complex 1; NOS, nitric
oxide synthase; NOX, NADPH oxidase; NRF2/NFE2L2, nuclear factor 21
erythroid-derived 2-like 2; PGC-1a, peroxisome proliferator-activated receptor c
coactivator 1a; TF, transcription factor; TRPC, mechano-gated Ca transient receptor potential channels. Image created with BioRender.com, with
permission.

with PGC-1a: AP-1, together with MEF2 family factors, con- enzymatic antioxidants such as reduced glutathione
trols PGC-1a gene expression, whereas PGC-1a binds to (GSH) that ameliorate redox homeostasis, are observed in
AP-1 to regulate some of its target genes (474, 537). In the muscles of trained individuals (544–547). Based on
contrast, a mutual negative interaction between NF-κB the role of these processes, inhibition of the production of
and PGC-1a may help to regulate homeostasis ROS and RNS with pharmacological and/or nutritional
between metabolism and inflammation in muscle antioxidants could be detrimental in promoting an optimal
(543). The cellular redox state also affects PI3K-Akt- cellular environment to maximize training adaptation
mTOR signaling to control rates of protein synthesis (548). Even though excessive ROS production has been
and muscle hypertrophy (534, 539). First, ROS-medi- linked to tumorigenesis, cardiovascular diseases, hyper-
ated activation of Akt results in an increase in mTORC1 tension, neurodegenerative disorders, and other chronic
function (534), whereas NO exerts a negative effect on pathologies, exercise training substantially reduces the
this pathway, presumably to keep hypertrophy in risk of these diseases, despite the contraction-induced
check (539). Both redox modalities merge in the pro- acute elevations of ROS and RNS in skeletal muscle (534).
duction of peroxynitrite, formed by the reaction of These epidemiological observations highlight the impor-
superoxide with NO, which leads to an activation of tance of a well-balanced and coordinated redox produc-
mTORC1 (534). Thus, the redox balance modulates and tion and detoxification system in muscle, without any
fine-tunes muscle hypertrophy. Collectively, adequate apparent pathological consequences in muscle tissue or
regulation of ROS and RNS is instrumental to react to beyond (549).
mechanical and other types of stress during exercise
and acutely affects contractility (534). Furthermore,
such a contraction-linked increase in ROS and RNS trig- 4.5. Energy Homeostasis, Substrate and Oxygen
gers a hormetic response, in which an upregulation of mi- Sensing
tochondrial uncoupling proteins, antioxidant enzymes,
and compounds blunts potential damage by future insults 4.5.1. Energy homeostasis and energetic stress.
(534). Accordingly, higher levels of antioxidant enzymes
such as superoxide dismutase (SOD) 1 and 2, catalase Muscle cell contractions are strongly linked to major
(CAT), and glutathione peroxidase (GPx), as well as non- metabolic remodeling (FIGURE 14A). In many situations,

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1731

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

A
Autophagy Mitochondrial
mTOR biogenesis and
function
ATP ADP / AMP P Fatty acid
AMPK PGC-1α transport and
SIRT1 TF oxidation
PGC-1α
NADH NAD+
FADH2 FAD
Ketone body
metabolism
Lactate
metabolism
Protein Glucose
Degradation Synthesis Glucose uptake

FIGURE 14. Energy homeostasis, substrate and oxygen

signaling. A: metabolic stress signaling in muscle contrac-
Fatty acids tion to increase energy provisioning. A decrease in energy
B
substrate availability leads to the activation of energy sen-
Glycogen Autophagy sors that reduce anabolic processes consuming ATP and
Metabolic induce catabolic pathways to produce more ATP. This
Metabolites remodeling:
broad response comprises direct modulation of protein
PPARα Transcription of and enzymatic activities by posttranslational modification
PPARβ/δ fatty acid as well as the control of a broad transcriptional program.
AMPK
TF oxidation genes, B: energy substrate signaling senses substrate levels and
glucose uptake leads to metabolic partitioning. Thereby, muscle cell me-
and metabolism,
mitochondrial
tabolism is coordinated with substrate availability and
mTOR anabolism balanced with catabolism. C: reduced oxygen
genes,...
availability in skeletal muscle is sensed by hypoxia-induci-
Mondo
Protein Modulation of ble factor (HIF)-1a and HIF-2a in acute and chronic set-
Degradation Synthesis
proteostasis tings, respectively. HIF-1a rapidly reduces pathways that
Amino acids consume O2, while promoting anaerobic glycolysis to gen-
erate ATP. HIF-2a promotes muscle oxygen extraction
Amino acids Glucose
Insulin and provisioning. AMPK, AMP-activated protein kinase;
IGF-1 ERRa, estrogen-related receptor a; FAD: flavin adenine di-
nucleotide; IGF-1, insulin-like growth factor 1; mTOR, mam-
malian target of rapamycin; NAD, nicotinamide adenine
C dinucleotide; PGC-1a, peroxisome proliferator-activated re-
ceptor c coactivator 1a; PPARa/-b/d, peroxisome prolifera-
tor-activated receptor a/-b/d; SIRT1, sirtuin 1; TF, transcription
factor. Image created with BioRender.com, with permission.

Acute, severe hypoxia/reduced physoxia Prolonged hypoxia/reduced physoxia

O2 O2

HIF-1α HIF-2α

HIF-1α HIF-2α PGC-1α

ERRα

Reduced PGC-1α and oxidative metabolism Increased myoglobin

Inhibition of mTORC1 and anabolic processes Increased vascularization (HIF-1α independent)
HIF-1α
Increased glycolysis and vascularization

the demand for ATP as a rapid energy source is only and liver glycogen as well as intramyocellular lipid stores
partially compensated by creatine phosphate system will be replenished. In parallel to the shift in adenosine
transfer and the subsequent increase in oxygen-inde- species, the relative abundance of nicotinamide adenine
pendent anaerobic and aerobic metabolism of glucose, dinucleotide (NAD1) and NADH as well as other cofactors
lipids, lactate, ketone bodies, and other energy sub- involved in myocellular redox reactions is affected by mi-
strates. This leads to a shift in the relative concentrations tochondrial OXPHOS, lactate dehydrogenase activity, as
of ATP, ADP, and AMP (393). During recovery from strenu- well as other processes (550, 551). These fundamental
ous exercise, and after optimal refueling, this catabolic metabolic changes triggered by the increased energetic
energetic state will pivot into an anabolic state and muscle demand of contracting muscle cells result in a complex

1732 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

modulation of signaling cascades and biochemical path- eIF2B and b-catenin to promote protein synthesis (560,
ways that are crucial for training adaptation. For example, 561). The strong inhibitory effect of mTORC1 on autophagy
a shift in the ATP-to-AMP ratio toward AMP leads to the is exerted by phosphorylation of ULK1 and transcription
activation of a signal transduction pathway centered on factor EB (TFEB), a key regulator of lysosomal biogenesis
AMPK, which in turn phosphorylates downstream protein (521, 562). TFEB and TFE3 are activated by Ca21/calci-
kinase substrates (552, 553). In addition, AMPK activity neurin signaling in contracting skeletal muscle, resulting in
is modulated by the cellular environment, in particular nuclear translocation and activation of autophagy, lysoso-
upstream kinases liver kinase B1 (LKB1) in exercise of short mal, and mitochondrial gene expression, in part by func-
duration (i.e., seconds to minutes) and CaMKKb during tionally interacting with PGC-1a (562). Thus, overall, AMPK
prolonged exercise bouts, or by signaling induced by vari- and mTORC1 exert opposite functions, promoting cata-
ous myokines such as IL-6, IL-15, BDNF, and leukemia in- bolic and anabolic processes, respectively, with a direct
hibitory factor (LIF) (498, 501, 554). Although the precise inhibition of mTORC1 by AMPK; this reciprocal control is
role of contraction-induced AMPK signaling in the regula- important to regulate specific adaptations to endurance-
tion of glucose uptake and fatty acid oxidation remains and resistance-based training stimuli but might also be rel-
controversial (555), AMPK activation leads to a general evant in the context of concurrent training and the training
catabolic response upon cessation of exercise, including interference effect (163, 521, 563). The molecular basis of
augmented uptake of glucose and fatty acids, reduced the interference effect underlying the compromised
rates of glycogen synthesis, elevated glycolysis, and strength gains observed when individuals simultaneously
improved mitochondrial activity (554). Furthermore, AMPK undertake both endurance and strength training pro-
is a potent activator of autophagy and promotes protein grams (described in sect. 2) was investigated at the mo-
degradation via the ATP-dependent ubiquitin-proteasome lecular level by Atherton and colleagues (564), who
system to liberate amino acids for energy production in studied isolated rat muscles that were electrically stimu-
muscle and gluconeogenesis in the liver (554). The regu- lated with either low frequency to mimic endurance exer-
lation of these two processes is tightly coordinated, with cise (3 h at 10 Hz) or high frequency to mimic resistance
inhibition or activation largely determined by the relative training (6  10 repetitions of 3-s bursts at 100 Hz). They
activity of AMPK and mTOR and the balance between the observed selective activation and/or downregulation of
catabolic and anabolic state of the muscle cell (556). For AMPK-PGC-1a or Akt-mTORC1 signaling pathways in
example, ketoacids resulting from the metabolism of the response to these divergent loading patterns. Specifically,
branched-chain amino acids valine, leucine, and isoleu- they reported that electrical stimulation that mimicked ei-
cine can be used to generate ATP via the tricarboxylic ther endurance- or resistance-based training switched sig-
acid (TCA) cycle in a catabolic state, whereas branched- naling to either an AMPK-PGC-1a- or Akt-mTOR-selective
chain amino acids can also activate mTOR in the face of state. They termed this activity the AMPK-Akt “master
high energy availability (557). In the former setting, AMPK switch” and hypothesized that such selective activation of
inhibits mTOR activity by phosphorylation of the mTORC1 AMPK-PGC-1a or Akt-mTORC1 signaling could explain
upstream inhibitors TSC1 and 2 as well as the mTORC1 specific adaptive responses to endurance or resistance
component raptor (521). Autophagy is directly stimulated training (564). However, Coffey et al. (565) demonstrated
by AMPK-mediated phosphorylation of the Unc-51-like ki- that in highly trained athletes prior training history attenu-
nase 1 (ULK1) (521, 554), whereas protein degradation is ated the “exercise-specific” signaling responses involved
boosted by phosphorylation and thereby activation of in single-mode adaptations to training and that a degree
FOXO3 (554), as well as transcriptional activation of of “response plasticity” was conserved at opposite ends
FOXO1 and FOXO3 (558). In an anabolic context, insulin of the endurance-resistance adaptation continuum.
or amino acid signaling as well as lysosomal recruitment Given that genotypes were originally selected to sup-
of mTOR strongly reduce autophagy and catabolic path- port diverse physical activity patterns obligatory for
ways so that protein synthesis and lipogenesis are human survival and that modern-day success in
enhanced (521). S6 protein kinase (S6K) and eukaryotic many sporting endeavors requires a high endurance
translation initiation factor 4E (eIF4E) are two important capacity coupled with superior explosive power, the
mTORC1 phosphorylation substrates that, together with conservation of multiple signaling networks to meet
increased transcriptional activity of RNA polymerases I divergent physiological demands seems to make
and III, subsequently coordinate ribosomal biogenesis sound evolutionary and biological sense (1).
and protein synthesis (521, 559). Insulin signaling-depend- AMPK and mTOR can also synergize and converge in
ent activation of Akt results in phosphorylation and nu- certain cellular contexts (563), potentially representing
clear exclusion of FOXO1 and 3, and thereby inhibition of the temporal specification of these two proteins in the
protein degradation, as well as activation of glycogen syn- response to contractile activity of skeletal muscle, or ad-
thase kinase 3b (GSK3b), which in turn phosphorylates aptation to mixed or concurrent forms of training. For

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1733

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

example, after training, AMPK improves insulin sensitivity mediated by these interactions (486). In addition, trans-
of myofibers, thereby potentiating the activation of mTOR ducers of regulated CREB-binding proteins 1, 2, and 3
(554). Moreover, both AMPK as well as mTOR converge [TORC1/2/3, also called cAMP-regulated transcriptional
on the activation of PGC-1a to promote mitochondrial bio- coactivators (CRTCs)] are coregulators that are strongly
genesis and oxidative metabolism of energy substrates modulated by environmental cues and, in turn, induce
(474, 521, 554). The interaction between these two key PGC-1a gene expression (486). The diversity of interac-
metabolic regulators, and the implications for muscle cell tions and hence the variety in PGC-1a-containing protein
plasticity, are therefore multifaceted and remain poorly complexes with different coregulators and transcription
understood. In addition to mTOR signaling, AMPK also factor binding partners likely contribute to the highly orch-
engages redox-sensitive pathways including the NAD1- estrated and coordinated transcriptional network control
dependent protein deacetylase sirtuin 1 (SIRT1), with exerted by this coactivator protein in skeletal muscle in
AMPK-mediated phosphorylation of PGC-1a preceding exercise (474, 481–486, 578).
SIRT1-dependent deacetylation and subsequent activa-
tion in skeletal muscle (566, 567). Lysine deacetylation by 4.5.2. Signaling mediated by substrates and
SIRT1, SIRT3, and other NAD1 sensors as well as the metabolites.
counterregulatory effect by acetyltransferases such as
general control non-repressed 5 (GCN5) are not re- Metabolites and energy substrates have additional
stricted to enhancing and decreasing the activity of PGC- effects on exercise adaptation in skeletal muscle, and
1a (568) but also other targets, including histones. even transient and subtle perturbation in cellular homeo-
Thereby, a tight coupling between the myocellular redox stasis can trigger broad downstream effects (FIGURE
state and transcriptional regulation in exercise is facili- 14B) (84). For example, glycogen binds to a carbohy-
tated (569, 570). Although the functional interaction drate-binding module on the AMPKb subunit to nega-
between PGC-1a acetylation and AMPK-dependent phos- tively affect AMPK activity (579), providing a molecular
phorylation has been proposed, the cross talk between explanation for the enhanced training effect when individ-
phosphorylation events by other kinases, protein methyl- uals commence exercise with low muscle glycogen
ation, ubiquitination, sumoylation, or O-linked b-N-acetyl- stores, as in “train low” (glycogen) protocols (81, 579).
glucosamination is less well understood (474, 482). Mondo transcription factors are activated by binding of
Posttranslational modifications of proteins can affect dif- glucose, leading to a modulation of the expression of
ferent properties, including stability or turnover, localiza- genes involved in glucose homeostasis by MondoA in
tion, interactions with other protein binding partners, DNA muscle, while concomitantly reducing fatty acid oxidation
recruitment, enzymatic activity, or structural conformation by PGC-1a, thereby providing an important metabolic
(571, 572). Indeed, once activated, PGC-1a interacts with switch between glucose and lipid oxidation in contracting
many different transcription factors, including estrogen- fibers according to the Randle cycle (580). Fatty acids are
related receptor a (ERRa), NRF1, NRF2/GABP, MEF2C, ligands for various nuclear receptors, including the
and MEF2D, to coordinate a complex, yet poorly under- PPARs, and liver X receptors (LXRs), leading to an
stood transcriptional network encoding the biological increase in rates of lipid oxidation and lipogenesis in skel-
program of endurance exercise adaptation encompass- etal muscle, respectively (485). Furthermore, as noted
ing vascularization, remodeling of the NMJ, or induction above, amino acids are potent activators of mTOR and
of a slow-type contractile phenotype (474, 573, 574). thus contribute to mTORC1-mediated control of muscle
Moreover, PGC-1a initiates a coordinated transcriptional proteostasis that promotes fiber hypertrophy in response
network encoding mitochondrial biogenesis and function, to resistance-based training (522). The requirement for
including TCA and OXPHOS, fatty acid uptake, transport, mTORC1 in inducing exercise hypertrophy seems to
and b-oxidation, ketone body and lactate metabolism, as depend on various factors, including temporal aspects or
well as glucose uptake and use in the pentose phosphate training stimuli, with considerable mTORC1-independent
pathway (474, 481, 575–577). Other transcription factors contributions (581). Moreover, amino acid supplementa-
such as ERRc or PPARb/d, for which the epistatic relation- tion to activate mTORC1 without concomitant resistance
ship to PGC-1a and the involvement in the exercise training is clearly insufficient to induce gains in muscle
response are less clear, evoke similar gene programs in mass and strength (582). Succinate, a citrate cell cycle in-
skeletal muscle (485). Finally, a multifaceted interaction termediate, accumulates in muscle, the interstitial space,
between PGC-1a and other coregulator proteins affects as well as the circulation during exercise. Signaling trig-
the activity of PGC-1a in the control of skeletal muscle gered by succinate binding to succinate receptor 1
plasticity. For example, nuclear corepressor 1 (NCOR1) (SUNCR1) induces adaptations in the gene expression pro-
competes with PGC-1a for binding to ERRa and PPARb/d, grams for axon guidance, neuronal projection, and muscle
thereby reducing PGC-1a target gene expression regeneration that collectively contribute to endurance

1734 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

exercise capacity (583). In addition to NAD1, other cofac- trained cyclists performed a standardized bout of submaxi-
tors at the intersection of metabolism and transcription mal endurance exercise with low versus normal glycogen
are likely affected by contractile activity in skeletal muscle, concentration (191). Even in response to resistance exer-
including flavin adenine dinucleotide (FAD) in the TCA cise, commencing exercise with low glycogen seems to
cycle and OXPHOS, a-ketoglutarate in the citrate promote mitochondrial adaptation, as demonstrated with
cycle, and acyl-CoA and acetyl-CoA in substrate oxi- increased phosphorylation of p53 and mRNA expression
dation and the citrate cycle (393). These cofactors are of PGC-1a (206). Although “train low” (glycogen) protocols
directly involved in epigenetic gene regulation by boost the training response in well-trained athletes, this
modulating histone and DNA demethylation and his- training paradigm failed to be superior to conventional pro-
tone acetylation (584). Whether such an epigenetic tocols with regard to performance enhancement.
coupling to metabolism exists in skeletal muscle dur-
ing exercise is unknown, even though epigenetic 4.5.3. Oxygen sensing.
mechanisms contribute to exercise-induced muscle
plasticity (578, 585). Finally, the extensive metabolic If oxygen consumption exceeds oxygen availability and
remodeling in muscle and other tissues during and af- uptake, “physiological hypoxia” (or “reduced physoxia”)
ter exercise is likely to include many other metabo- occurs, corresponding to a drop of mean oxygen ten-
lites with important signaling and regulatory functions sion from 30 mmHg to 2–3 mmHg in contracting skeletal
in the training response (586, 587), collectively muscle fibers (593–595). This drop is already observed
referred to as myobolites or myometabokines (588, at relatively low exercise intensities, implying that addi-
589). In addition to muscle-intrinsic effects, inter-tis- tional mechanisms might be contributing to oxygen
sue communication is also mediated by such circulat- availability for different structures in the muscle cells,
ing metabolites including b-aminoisobutyric acid such as myoglobin function or local intracellular oxygen
(BAIBA) that help to coordinate the general systemic levels and gradients (596–598). Hypoxia-inducible fac-
response (590). In a similar manner, altered muscle tor (HIF)-1a and HIF-2a are the major mediators of
metabolic capacity can affect the circulating levels of hypoxic stress (FIGURE 14C). Upon reduced oxygen
endogenous metabolites and, in the case of aberrant availability, HIF-1a proteolysis by prolyl-hydroxylases 2
levels of such metabolites, thereby contribute to a and 3 (PHD2/3) is alleviated and the HIF-1a protein stabi-
“detoxification” by lowering hyperketonemia (575) or lized (593). HIF-1a then controls gene programs involved
the conversion of kynurenine into kynurenic acid, in anaerobic glycolysis to sustain energy production in the
which is unable to cross the blood-brain barrier (591). absence of adequate oxygen supply and represses those
One of the first studies to propose a link between sub- programs that are oxygen dependent, such as mitochon-
strate availability and molecular signaling in exercising drial OXPHOS. This is brought about by inhibiting PGC-1a
human muscle was that of Wojtaszewski and colleagues expression and activity while promoting gene expression
(592). They measured muscle signaling responses and related to vascularization to improve oxygen supply via
substrate utilization during and after an acute bout of the myokine VEGF (593). Furthermore, the hypoxia-re-
steady-state cycling in well-trained subjects under condi- sponsive gene DNA damage inducible transcript 4
tions in which exercise was commenced with either low or (DDIT4) encoding the REDD1/RTP801 protein, an activator
high muscle glycogen content. After exercise started in a of TSC1/2, inhibits mTORC1 and downstream anabolic
low-glycogen state AMPKa2 and AMPKa1 activity was ele- pathways, thereby limiting ATP-consuming processes
vated to a greater extent compared to when the same (599). The paralog HIF-2a plays a permissive role in the
exercise bout was commenced with high glycogen con- acute hypoxic response compared with HIF-1a but a
tent (592). However, exercise commenced in the lowered greater function in long-term adaptation in which HIF-1a
glycogen state was associated with elevated catechol- activity is repressed (593). In this context, PGC-1a induces
amine concentrations compared with the glycogen-loaded the expression of HIF-2a, ERRa, the AP-1 complex, and
trial, making it difficult to determine whether fuel availabil- VEGF to promote angiogenesis and vascularization in a
ity and/or humoral factors contributed to the observed HIF-1a-independent manner (474, 600). With regard to
boosted AMPKa2 and AMPKa1 activity. Subsequently, the training, the temporary hypoxia in muscle can be exacer-
results of several other investigations demonstrated that, bated by vasoconstriction of capillaries in muscle tissue,
compared with normal glycogen levels, commencing en- for example by vascular occlusion or peak contraction
durance exercise with reduced glycogen availability (149). Accordingly, the exercise-induced increase in
increases the phosphorylation of p38 MAPK and transcrip- mRNA expression of all four postulated PGC-1a isoforms
tional activation of IL-6, pyruvate dehydrogenase kinase 4 is blunted when endurance exercise is performed with
(PDK4), hexokinase, and HSP72 (188). PGC-1a mRNA was blood flow restriction (601). However, in the long term,
also induced to a greater extent (8- vs. 3-fold) after highly training under hypoxic conditions may boost the adaptive

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1735

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

response in the muscle. It remains to be determined through vasodilation and sweating. Thermal stress can
whether such training paradigms are more effective in result in misfolding of proteins, impairing cellular function.
enhancing the performance of elite athletes than training To mitigate the potentially damaging effects of heat, exer-
under normoxic conditions. cise induces elevated activity and levels of HSPs, most
notably HSP72 of the HSP70 family (603, 604). The
upstream mechanisms of HSP activation in exercise are
4.6. Thermotolerance, Protein and Organelle poorly understood and likely depend on various meta-
Quality Control bolic, biochemical, and physical factors as well as training
status. Upon heat stress, HSPs are released from binding
4.6.1. Heat stress. to heat responsive factor 1 (HSF1) and act as chaperones
to refold misfolded proteins and control proteasomal deg-
Contractile activity is linked to the production of heat, with radation and autophagy (603, 604). HSF1 in turn promotes
only a small fraction of chemical energy (
25% depending the transcription of PGC-1a, and together these two pro-
on the type of muscular activity performed) being con- teins induce gene expression of HSPs and PGC-1a in an
verted into external force production (FIGURE 15A) (602). autoregulatory loop (603, 604). This cross talk with
Elevated muscle temperature has several advantages in PGC-1a mediates heat shock-boosted oxidative me-
terms of enzyme kinetics and activity and contributes to tabolism and mitochondrial function (603, 604). In
vasodilation and increased blood flow, permitting a better addition to acting as chaperones and inducing an oxi-
supply of oxygen and energy substrates, as well as more dative phenotype, HSPs exert various other effects in
efficient removal of by-products. Nevertheless, excess muscle. For example, by inhibiting JNK through direct
contraction-induced heat production must be dissipated interaction and upstream signaling pathways, there is

A
Shear stress

Ca2+ Ca2+ release and reuptake FIGURE 15. Heat and proteostatic stress. A: ther-
Mitochondrial activity
mosensing and the heat stress response mitigate
misfolding of proteins. Heat is produced by various
Heat UPRER processes in the contracting muscle fiber, including
shear stress, mitochondrial activity, Ca21 release
and reuptake, and ATP metabolism in contraction
cycling. Heat is sensed in the cell and a broad tran-
Contractile activity PGC-1α scriptional program engaged to increase mitigating
measures, e.g., chaperones to reduce thermally
HSF1 PGC-1α
HSF1 induced protein misfolding. B: proteostatic stress
HSPs and the ensuing response pathways reduce protein
load, misfolding, and organelle health. Dedicated
pathways in the endoplasmic reticulum and mito-
chondria are engaged by proteostatic dysbalances,
Increased chaperone activity e.g., excessive protein accumulation or misfolding.
At least in part, these two pathways converge to ini-
tiate a transcriptional program aimed at reversing
B protein misfolding, alleviating proteostatic stress by
reducing gene expression and protein synthesis
while enhancing protein degradation, and by ensur-
ing organelle functionality. ATF4/5/6a, activating
K

transcription factor 4/5/6a; CHOP, C/EBP homolo-

ER
,P

Activation of chaperones
gous protein; HSF1, heat shock factor 1; HSP, heat
α
E1

for protein refolding UPRER

IR

shock protein; IRE1a, inositol-requiring enzyme 1a;

α,
F6
AT

Inhibition of gene expression PERK, RNA-dependent protein kinase-like ER

and protein synthesis eukaryotic translation initiation factor 2a kinase;
Proteasome PGC-1a, peroxisome proliferator-activated re-
PGC-1α TF ATF Proteostasis ceptor c coactivator 1a; TF, transcription factor;
4, AT
F5, C
HOP
UPRmt UPRER, endoplasmatic reticulum unfolded pro-
Activation of protein
tein response; UPRmt, mitochondrial unfolded pro-
degradation
tein response. Image created with BioRender.com,
with permission.

Initiation of mito-
and autophagy Increased mitochondrial
dynamics

1736 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

a reduction in inflammation and enhanced insulin the transcription of genes encoding mitochondrial
sensitivity elicited by HSP72 (603, 604). These effects chaperones and proteases, as well as the integrated
can be potentiated by heat application to reduce muscle stress response (610). Mitochondrial and cellular pro-
soreness, improve muscle function during recovery from tein quality control are highly coordinated. Initially, cy-
damaging exercise, or enhance muscle mass gains tosolic processes only permit transport-competent
in strength training, potentially triggering a hormetic folding configurations of proteins to be imported into
response in which the heat shock response is pre- mitochondria, supported by the ubiquitin-proteasome
induced, thereby conferring earlier and/or greater pro- system that degrades damaged, mislocalized, or
tection (605). Paradoxically, cold-water immersion improperly imported proteins at the outer membrane
and other modalities to apply cold stressors after (611). Then, mitochondrial chaperones and proteases
exercise also reduce delayed-onset muscle sore- ensure proper folding and removal of misfolded proteins
ness (DOMS) and inflammation after a single applica- within mitochondria (611). The next step in escalation of
tion (606). However, unlike heat exposure, chronic damage results in a remodeling of the mitochondrial net-
cold therapy diminishes strength training effects by work by fission and fusion (402), removal of defective
reducing muscle blood flow, attenuating mTORC1 parts of mitochondrial by mitochondrion-derived vesicles
signaling and ribosomal biogenesis, and increasing or piecemeal mitophagy (612, 613), ultimately culminating
FOXO3 activity (606). Repeated cold therapy may in wholesome mitophagy (610, 614). Mitochondrial dy-
also interfere with the activation of HSPs by exercise namics, the balance between fission and fusion, are
(606). Some current guidelines for the treatment of instrumental not only for mitochondrial biogenesis but
soft tissue injuries in sports therefore completely also for proper morphology of the mitochondrial net-
omit cold application (607). work (615): fusion leads to larger mitochondria and
increased ATP production, whereas fission, promoted
4.6.2. Endoplasmic reticulum and mitochondrial in response to severe cellular stress, helps induce the
unfolded protein response. degradation of dysfunctional mitochondria (402, 616).
The cytosolic PTEN-induced kinase 1 (PINK1) is normally
HSPs also interact with the regular endoplasmic reticulum imported into the matrix of healthy mitochondria and
unfolded protein response (UPRER), which is activated by rapidly degraded. Upon deterioration of the membrane
accumulation of unfolded or misfolded proteins in the ER potential or the loss of ATP supply, PINK1 accumulates in
(FIGURE 15B) (605). During exercise, interaction between the outer membrane and phosphorylates the E3 ubiqui-
PGC-1a and cleaved ATF6a initiates the adaptive UPRER tin ligase Parkin, which in turn ubiquitinates mitochon-
in muscle (608, 609). ATF6a, inositol-requiring enzyme 1a drial proteins to target the organelle for mitophagy. An
(IRE1a), and the RNA-dependent protein kinase-like ER eu- acute bout of exercise might lead to elevated organelle
karyotic translation initiation factor 2 alpha kinase (PERK) turnover, through both mitophagy as well as general
normally reside in the ER membrane and are engaged autophagy, by increasing mitochondrial localization of
upon ER stress, such as in the context of dysregulated Parkin and activation of the AMPK-ULK1 axis, respec-
proteostasis triggered by resistance exercise bouts (608). tively (610, 614). However, the regulation and functional
Activation drives the release of BiP/glucose-regulating involvement of mito- and autophagy in acute exercise
protein 78 (GRP78), an ER chaperone that then binds to and chronic training adaptations remain poorly under-
misfolded ER proteins. IRE1a, PERK, and ATF6a subse- stood (617, 618), especially in elite athletes.
quently initiate signaling cascades aimed at constraining
gene expression and protein synthesis and providing 4.7. Exhaustion, Fatigue, and Event up to
adequate energy availability to normalize proteostasis Cessation of Exercise
and alleviate ER stress (608, 609). Exercise-induced ER
stress is diminished with repeated exercise bouts, indicat- The completion of an exercise bout is characterized by
ing either better control of proteostasis or more efficient several processes that contribute to exercise cessation.
resolution of ER protein misfolding after training (608, These can be classified and summarized as exhaustion, a
609). Like the ER, upon exercise muscle mitochondria process dependent on an increasing perception of sub-
also initiate an unfolded protein response (UPRmt) to jective effort that can, to some extent, be influenced and
mitigate dysbalanced proteostasis, protein import, and overcome by the individual’s willpower and motivation
(re)folding, as well as OXPHOS complex assembly by acti- (619). Physiological pathways resulting in a reduced ability
vating mitochondrial chaperones and proteases (610). If and ultimately an inability of muscles to contract, inde-
overwhelmed, a retrograde signaling is engaged to boost pendent of motivation and willpower, are referred to as
the activities of the transcription factors ATF4, ATF5, and fatigue, in which the continuation of contractile activity
C/EBP homologous protein (CHOP), which in turn regulate becomes impossible (619). These definitions already hint

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1737

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

A
Hyperthermia
Hypoglycemia
Dehydration Modulated neurotransmisson
Relative O2/CO2 levels (catecholamine, serotonin,
Exerkines/metabolites from dopamine, adenosine)
muscle and other tissues
Nociception
Motivation/willpower
Exhaustion

Compromised axonal branch point

Upstream input propagation (?)
Afferent feedback

Fatigue

Accumulation of by-products of
contraction and damage
Energy substrate depletion
Oxygen supply
Decreased motor ROS/RNS accumulation
neuron firing rate Ca2+ homeostasis dysregulation
Dampened excitation-contraction
coupling

B
Performance

ROS/RNS levels

C Nociceptor
activation
Decreased
synaptic activity
Reduced fiber
excitability
Na+/K+ pump

Reduced force RYR1

production Ca2+

f
tion 2+o
nsitiza
Dese ins to Ca
prote RNS
ROS
Reduced myosin
ATPase activity NOS

NOX

1738 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

at the multifactorial and multiorgan components that con- energy substrates and oxygen supply (619, 628). The
tribute to exercise cessation (FIGURE 16A). Central fac- accumulation of intra- and extracellular by-products
tors include catecholamine, serotonin, dopamine, and of prolonged contraction or metabolites enriched
adenosine signaling in different regions of the brain because of muscle fiber damage could likewise gov-
that evoke a state of mental fatigue (620). Some of ern fatigue, such as products of energy metabolism,
these alterations in central neurotransmission might oxidative stress, inflammation, or respiration (CO2)
be caused by heat sensing to prevent hyperthermia of (619, 628). In essence, the mechanistic underpin-
the brain, availability of energy substrates (in particu- nings of muscle-intrinsic fatigue are not entirely
lar hypoglycemia) to prevent catastrophic contractile clear. Interestingly, in contrast to the stimulating
failure and inadequate supply for neuronal function, effect of ROS and RNS on muscle contractility at
relative oxygen and CO2 levels, dehydration, pain/ lower levels, once a critical threshold is reached,
nociception, or metabolite signaling from contracting dampening effects of accumulated ROS and RNS on
muscle fibers such as excess ammonia or increased performance are observed (FIGURE 16B) (629). For
ratio of free tryptophan to branched-chain amino acids example, ROS induces muscle fatigue, mediated by a
in the circulation (619–621). Moreover, elevated cyto- desensitization of receptors and myofibrillar proteins
and exerkine profiles in exercise could modulate vari- to Ca21, and a decrease in Na1-K1 pump activity
ous processes, including immune cell activity in the (FIGURE 16C) (534). This concentration-dependent,
brain, and thereby also neuroenergetics and neuro- biphasic bell-shaped effect on muscle performance
transmission (622). These, and potentially other cen- and fatigue might be a protective mechanism against
tral mechanisms, most likely help to protect the brain excessive contractile activity and subsequent tissue
and other organs from detrimental outcomes trig- damage, with ROS serving as an internal rheostat for
gered by overexertion (623). Central fatigue can be the strain exerted on fibers (534). RNS evoke a simi-
overcome by direct peripheral stimulation of muscles. lar response by initiating processes such as muscle
This is not the case for peripheral causes mostly per- pain and fatigue to mitigate overexertion and over-
taining to the motor unit, ranging from peripheral nerv- load linked to excessive cellular and tissue damage.
ous system signaling to the muscle, ECC, energy For example, NO modulates synaptic transmission
supply, and contractility (619). Motor unit fatigue is not by retrogradely affecting presynaptic structures of
well understood, even though motor neurons are clas- the NMJ, activates nociceptor complexes containing
sified into fast and slow fatigable pools (329, 624, the NO-sensitive calcitonin gene-related peptide
625). Failures in axonal propagation, in particular (CGRP) receptor and thereby causes muscle pain, or
across branch points, or in NMJ transmission seem of reduces muscle force production, at least in part by
little significance in exercise settings and might pri- reducing myosin ATPase activity and Ca21 release
marily pertain to pathological situations (619). The from the SR by affecting the RYR and the SERCA
observed decrease in motor unit firing patterns and pumps (536–539). Thus, for both ROS and RNS,
discharge rates could be mediated by afferent feed- modulation of intramyocellular Ca21 homeostasis is
back and upstream input (619). In some paradigms, fa- central for the regulation of fatigue (629). Of note,
tigue of specific muscles, in particular the respiratory the benefits of inhibition of the production of ROS
muscles, will limit performance (626, 627). In muscle and RNS with pharmacological or nutritional antioxi-
cells, different processes have been proposed to dants to delay fatigue, reduce cellular damage, and
affect contractility and fatiguability, such as contrac- shorten the recovery period are superseded by the
tion-induced depletion of endogenous fuel stores to- dampening effects on the procontractile and per-
gether with inadequate provisioning of exogenous formance aspects of ROS and RNS during exercise,

FIGURE 16. Exhaustion and muscle fatigue. A: central and peripheral contributors to exhaustion (volitional) and fatigue (involuntary). Altered neuro-
transmission in the brain ensures protection of this and other organs from hyperthermia, hypoglycemia, dehydration, shifted O2/CO2 levels, and further
potentially detrimental processes in exercise. To a limited extent, these effects can be overcome by willpower and motivation. Peripheral factors of fa-
tigue involve the motor neuron and muscle fibers. Although impairments in action potential propagation and neuromuscular junction transmission
seem minor in healthy individuals, input from upstream brain regions and afferent feedback modulate motor neuron firing rate. Muscle-intrinsic contrac-
tility is affected by energy substrate and oxygen availability, accumulation of by-products of contraction and damage, elevation of reactive oxygen
1 1 21
(ROS) and nitrogen (RNS) species, a dampening of excitation-contraction coupling including the Na -K pump, and intramyocellular Ca homeostasis.
B: concentration-dependent, biphasic bell-shaped effect of ROS and RNS on muscle performance. During contractions, ROS and RNS sustain and
enhance contractile activity. However, once levels exceed a poorly defined threshold, a different set of processes is engaged that limits performance.
C: exceeding a certain concentration, ROS and RNS contribute to muscle fatigue by affecting fiber excitability and contractility, synaptic activation, and
nociception. A modulation of intramyocellular Ca homeostasis thereby plays a central role. Putatively, this “rheostat” helps to avoid overexertion and
21

to minimize muscle tissue damage. NOS, nitric oxide synthase; NOX, NADPH oxidase; RYR1, ryanodine receptor 1. Image created with BioRender.com,
with permission.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1739

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

resulting in an overall reduction in training response/ chemotactic protein-1 (CCL2/MCP1), tumor necrosis fac-
adaptation (534). Chronic elevation of ROS in inac- tor a (TNF-a), IL-1b, and interferon c (IFN-c) (635–637).
tive fibers such as in bedrest leads to pathological However, the composition of this cocktail depends on
outcomes of constitutively stimulated redox signal- the preceding exercise modality, load, and intensity. The
ing in muscle (630). In this context, restoration of release of a disintegrin, metalloproteinase 8 (ADAM8)
ROS levels and redox signaling pathway activity by and other proteases and the subsequent remodeling of
exercise, pharmacological, or nutritional interventions the ECM facilitate immune cell infiltration into muscle tis-
might confer clinical benefits (630, 631). However, antiox- sue (635–637). A shift of macrophage polarization from
idant treatment with supplements or nutritional compo- the pro-inflammatory M1 to the anti-inflammatory M2
nents must be carefully tailored to the specific context: type is a hallmark for the second phase, in which tissue
oxidative distress and potential antioxidant deficiencies is regenerated within hours to days (635–637). The
must be confirmed, an evidence-based, personalized release of IL-10, platelet-derived growth factor (PDGF),
treatment strategy designed, and the outcome of the transforming growth factor b (TGF-b), IGF-1, angiopoietin,
treatment monitored (631). Otherwise, ineffective treat- VEGF, follistatin, NO, hepatocyte growth factor (HGF),
ments or adverse effects might result, for example in and other signaling molecules from M2 macrophages, T
blunting oxidative eustress in exercising individuals (631). cells, mast cells, fibro-adipogenic progenitors, and type
2 pericytes boosts fibrotic activity and other pathways to
4.8. Repair and Regeneration, Multicellular Cross remodel the ECM to accommodate repaired and novel
Talk, and Refueling myofibers and stimulate the activation of satellite cells
and the formation of capillaries and related proc-
4.8.1. Multicellular interactions in muscle repair. esses that are required to reconstitute muscle tissue
(635–637, 639, 640). Functional retrieval is com-
Upon cessation of exercise, a pleiotropic, highly coordi- pleted by the expression of mature myosin heavy
nated program of repair, regeneration, and refueling is chains and subsynaptic NMJ genes to ensure proper
initiated. Skeletal muscle tissue comprises a complex contraction and innervation (635–637). This tightly
assortment of different cell types, many of which are still coordinated process is critical for proper regenera-
being identified with novel technical approaches such tion and tissue remodeling. The absence or elonga-
as single-cell RNA sequencing (scRNA-seq) (632–634). tion of the pro-inflammatory response or a reduced
As noted above, it is well accepted that the cross talk anti-inflammatory response impairs muscle regenera-
between different cells is involved in exercise adapta- tion and could result in detrimental events such as fi-
tion, such as the release of IL-13 from type 2 innate brosis. Regeneration is typically complete within 4–7
lymphoid cells (506). To date, however, data describing days for most exercise challenges (635–637). In
the processes involved in repair and regeneration of response to muscle-damaging exercise, the infiltra-
muscle tissue have, to a large extent, come from tion of neutrophils occurs within 24 h, followed by an
genetic, pharmacological, and other models of severe increase in macrophages after 2–7 days (637, 641).
physical damage (635–637), with little information However, the exact time course of muscle regenera-
derived from physiological in vivo exercise conditions tion in response to different exercise paradigms is
(638). Upon damage, a cascade of events is com- poorly understood, and it is unclear how these proc-
menced in which muscle fiber-derived and other signals esses are engaged in athletes. It remains to be deter-
activate resident immune cells, promote the infiltration mined whether trained muscles differ from untrained
of additional immune cell populations, orchestrate the muscles in terms of absolute number of specific cells
activation, polarization, and termination of immune cell such as tissue-resident macrophages, lymphocytes,
phenotypes, and engage satellite and other myogenic or fibro-adipogenic progenitors or the relative pro-
cells to mediate muscle repair and regeneration portion of a certain cell type (i.e., M2 macrophages).
(FIGURE 17A) (635–637). In exercised human skeletal The relative amount of myonuclei compared to total
muscle, resident and infiltrating neutrophils, leukocytes, nuclear number is lower in soleus compared with the
monocytes, and macrophages first promote an inflam- extensor digitorum longus (EDL) (
40% and 60%,
matory environment, phagocytose damaged tissue, and respectively), indicating a higher abundance of non-
clean up cellular debris within hours after an exercise muscle mononucleated cells in oxidative muscles that
bout (635–637). The infiltration and activation of these could potentially contribute to better regeneration
immune cells are at least in part orchestrated by a cock- (642). In line with this observation, a trained muscle
tail of cyto- and chemokines that is released from myo- might harbor a distinct cellular content and improved
fibers and other cells including IL-6, C-X-C motif ligand 8 regenerative capacity: for example, mice overex-
(CXCL8/IL-8), C-C motif chemokine ligand 2/monocyte pressing muscle PGC-1a exhibit a higher proportion of

1740 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

A Nociceptor
activation

Activation Macrophages, neutrophils,

Polarization monocytes, FAPs, pericytes, ...

Satellite cells
Stem cell niche

Ca2+

TF Auto- and mitophagy FIGURE 17. Muscle repair, regeneration, and refu-
Dysferlin Nuclear eling. A: multicellular interactions and intramyocellu-
MG53 migration lar processes that control muscle repair. Resident
and infiltrating cells of different types are engaged
by various signals in a temporally highly orchestrated
manner. Thereby, damaged material is removed,
Sarcomere repair and Mitochondrial dynamics muscle fibers repaired or de novo formed, and func-
sarcomerogenesis tional retrieval achieved. Activation of nociceptor sig-
naling should prevent further exertion and damage
during repair and regeneration. Moreover, the multi-
B Glucose cellular processes are complemented by intramyocel-
lular pathways to restore membrane and sarcomere
integrity as well as organelle function. B: postexercise
refueling of glycogen, intramyocellular lipids (IMCL),
Ribose-5-phosphate Glucose-6-phosphate and protein structures. Depleted intramyocellular
energy substrate stores are replenished after exercise
ADP ATP
depending on a systemic, anabolic context, i.e., the
availability of the corresponding substrates and
PGC-1α signaling of anabolic hormones. Because of the ener-
getic demand for protein, glycogen, and IMCL
TF synthesis, these processes are coordinated with mi-
Glycogen
tochondrial activity and ATP production. C: temporal
specification of catabolic and anabolic processes by
mTOR peroxisome proliferator-activated receptor c coacti-
vator 1a (PGC-1a). To avoid a futile cycle, the cata-
Protein
bolic activity of PGC-1a during contractions must be
IMCL separated from the anabolic function in regenera-
Degradation Synthesis
tion. The mechanistic underpinnings of the tran-
scriptional specification of this coactivator (and
other regulators with multipurpose roles) remain
Amino acids unknown. FAP, fibro-adipogenic precursor; MG53,
Insulin Fatty acids mitsugumin 53; mTOR, mammalian target of rapa-
IGF-1
mycin; TF, transcription factor. Image created with
C Contractile activity BioRender.com, with permission.

Altered ratio of PGC-1α

ATP/AMP and Glucose uptake
NADH/NAD+ Fatty acid oxidation
Mitochondrial activity

Recovery/regeneration

Adequate PGC-1α
energy De novo lipogenesis
availability Refueling of
intramyocellular lipid
and glycogen stores

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1741

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

anti-inflammatory M2 macrophages in muscle tissue activation of the bradykinin receptor B2-nerve growth fac-
and show improved regeneration upon muscle injury tor (NGF) and cyclooxygenase 2 (COX-2)-glial cell line-
(643, 644). Whether the time course of muscle regen- derived neurotrophic factor (GDNF) pathways, stimulate
eration is accelerated in athletes with a prolonged muscle nociceptors and thereby contribute to the pain
history of training, thereby hastening recovery, is cur- experienced in DOMS (637, 652). Of note, interference
rently unknown. with the inflammatory cascade, even the pro-inflammatory
phase, can be detrimental to muscle recovery and adapt-
4.8.2. Fiber repair and regeneration. ive remodeling (637, 653). Massage, thermal therapy (hot
or cold), compression, active regeneration, along with vari-
Muscle damage is greater after eccentric/plyometric/ ous pharmacological and nutritional approaches often
lengthening or isometric exercise undertaken with elon- have antagonistic effects on DOMS, muscle recovery, and
gated muscle length compared with concentric/miometric/ functional remodeling (654). Thus, probably the best prac-
shortening contractions (637). Exercise-induced muscle tice to reduce future/subsequent muscle damage is to
damage is characterized by a force reduction, systemic repeat a similar exercise bout, albeit at reduced intensity/
increase in myocellular enzymes and proteins such as cre- loading (637). Accordingly, in resistance-trained individuals,
atine kinase (CK) and myoglobin, muscle soreness upon recovery of maximum voluntary isometric torque occurs
palpation, but also swelling and a decrease in range of faster and is accompanied by reduced muscle soreness
motion (637). Although some of these symptoms appear and lower CK levels compared with untrained individuals
immediately after exercise (e.g., loss of muscle force), (655, 656). These attenuated symptoms of muscle dam-
others such as muscle soreness present 24–48 h later, of- age, which also resolve after a shorter period, are hall-
ten being disassociated from CK levels, which peak after marks of the “repeated bout effect” (637). A trained muscle
3–4 days (637). Different mechanisms exist to deal with therefore has greater protection against contraction-
muscle cell damage in an escalating manner (645). For induced damage. However, it is not clear whether this
example, membrane lesions are rapidly sensed and effect is conferred by better resilience against insults,
repaired, involving specialized features of membrane traf- more efficient repair and regeneration, or a combination of
ficking components, in particular the action of dysferlin these (637). The observation of the repeated bout effect
upon influx of Ca21 through gaps in the cell membrane extends to the contralateral, non-trained muscle and sug-
(646, 647), as well as other mediators such as the tripartite gests a systemic propagation of this signal (637). However,
motif (TRIM) protein 72 (TRIM72), alternatively called the underlying mechanisms are unknown. Nevertheless, it
Mitsugumin 53 (MG53), that also serves as a myokine for is clear that improved functional recovery is essential to
distal organ repair (648). The restoration of membrane sustain the high training intensities and volumes of athletes
damage is furthermore facilitated by the migration of myo- without overreaching/overtraining (657).
nuclei to the site of lesion (649), with this process most
likely supported by the exchange of proteins between 4.8.3. Muscle refueling.
nuclei (650), and the microtubule-dependent transport of
RNAs and ribonuclear proteins within the myofiber (651). Full functional retrieval requires additional processes,
Then, mechanical strain leads to non-uniformity and over- including restoration of organelle function, sarcomere
stretching of sarcomeres, as well as disruption of Z disks, repair, and replenishment of substrate stores (FIGURE
resulting in impaired force production and overload of sar- 17B). Optimally, a supercompensation is achieved, as
colemma and T tubules (637). Of note, fast muscle fibers observed for muscle glycogen stores (428). The effi-
are more susceptible to damage induced by eccentric con- ciency of refueling depends on promoting an optimal
tractions, which could be due to ultrastructural differences anabolic environment and is dependent on providing
such as the narrow and more fragile Z disks, suggesting adequate nutritional availability (81). In this setting,
that a training-induced shift toward slow muscle fibers energy sensors such as AMPK remain inactivated, and
might protect the muscle from damage (357). This the activity of anabolic regulators such as mTOR are
raises the question of whether muscles of athletes are increased by the availability of amino acids, glucose,
better protected against recurrent mechanical strains and fatty acids and stimulation by insulin, IGF-1, and
and/or trained muscles have an enhanced repair and other anabolic hormones (556, 557, 658). The ensuing
regeneration capacity. Mechanosensing, membrane rup- promotion of protein synthesis is instrumental to support
ture, stretch-activated channels, and dysregulated ECC the restoration and de novo formation of sarcomeric and
induce intracellular signaling pathways, such as higher in- other structures. Intracellular sensors of glucose and
tracellular Ca21, which result in degradation of damaged fatty acids help to restore glycogen and intramyocellular
structures as described above. Neurotrophic factors pro- lipid stores. For example, PGC-1a positively regulates
duced by muscle fibers and satellite cells, in particular the transcriptional program for lipogenesis, lipid droplet

1742 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

assembly, and perilipins (488, 659). As noted above, (662, 667). Circadian Locomotor Output Cycles Kaput
the increased intramyocellular lipid level in the mus- (CLOCK) and Brain and Muscle ARNT-Like 1 (BMAL1),
cle of endurance-trained athletes resembles the two other core clock components, regulate SIRT1 tran-
accumulation of these in muscle from patients with scription in skeletal muscle. SIRT1 in turn deacetylates
type 2 diabetes (the “athlete’s paradox”). However, PER2 and BMAL1, thus in part counteracting the acetyl-
although the diabetic patient is insulin resistant, the transferase activity of CLOCK (667). Bidirectional interac-
endurance-trained athlete is insulin sensitive based tions between the clock, mTOR, and protein synthesis
on the daily turnover and flux of lipid stores (660). contribute to a link between circadian oscillations and
PGC-1a also increases muscle glucose uptake while proteostasis (667). HIF-1a induces the transcription of
restricting the entry of glucose into glycolysis and PER1 and PER2, whereas NRF2/NRE2L2 and NF-κB
boosting glucose-6-phosphate activity in the pentose reciprocally control gene expression of nuclear receptor
phosphate pathway and glycogen resynthesis (488). subfamily 1 group D member 1 (NR1D1/REV-ERBa) (667).
PGC-1a matches these energy-demanding anabolic SIRT1-deacetylated PGC-1a induces the expression of
processes to adequate mitochondrial function and retinoic acid-related orphan receptor a (RORa/NR1F1)
ATP synthesis. Moreover, PGC-1a-mediated pentose and coactivates RORa in the transcriptional regulation of
phosphate pathway activity produces ribose-5-phos- BMAL1 (667). REV-ERBa and RORa are part of an acces-
phate, the building block for ATP and the other nucle- sory arm of clock control and exert opposite effects in
otides (488). Intriguingly, the anabolic function of core clock modulation. CREB activity is affected by CRY1
PGC-1a in this context is opposite to that during mus- and in turn controls gene expression of PER1 and PER2
cle contraction, in which this coactivator strongly (667). Finally, PPARa and BMAL1 exert mutual transcrip-
stimulates catabolic pathways, including fatty acid tional regulation (662). Many of these interactions have
b-oxidation (FIGURE 17C). Thus, to avoid futile cycles not been validated in human muscle skeletal, but there
a temporal specification of PGC-1a, including distinct is ample potential for cross talk between factors that are
transcription factor binding and DNA element recruit- modulated by contractile activity and those that entrain
ment, is likely, although the molecular characteristics and synchronize the molecular clock (662, 663, 665–
associated with such a specification are unknown. 667). Accordingly, the gene expression of several com-
ponents of the molecular clock are affected by exercise,
4.9. Circadian Clock such as BMAL1, PER2, and CRY1 (663). Curiously, other
clock components, including CLOCK, PER1, CRY2, and
Almost all physiological processes in humans are under REV-ERBb/NR1D2, were unaffected by skeletal muscle
the control of circadian rhythms (661). Locomotion and contractile activity in these studies, which conflicts with
physical activity belong to the most fundamental aspects a general modulation of clock phase and amplitude by
of the behavior of higher animals and in an evolutionary exercise. As such, these data suggest a specific control
context required coordination of activity with the avail- of a subset of clock genes and not a complete resynch-
ability of prey and food, the avoidance of predators, ronization. Such a targeted interaction could imply that
along with adequate rest, sleep, and related recovery some of these proteins might have additional functions
processes (662). As described in sect. 2, external cues, unrelated to the molecular clock such as the control of
such as timing of food and physical activity, serve as cellular metabolism. Indeed, the consequence of the
zeitgebers (time givers) to modulate the circadian clock cross talk between exercise factors and the molecular
in cell-autonomous peripheral tissues and thereby adapt clock for circadian rhythmicity, muscle function, and
many tissues/organs to the prevailing environmental exercise adaptation is unclear and is likely to be con-
conditions (663). Circadian control of the muscle pheno- founded by many factors including meal time, sleep,
type is influenced by circadian rhythmicity and executed psychological stress, and other zeitgebers (665). Animal
by a subset of the transcriptome oscillating in this tissue experiments with voluntary wheel running conducted
(662), with a reciprocal relationship between the core under a skeleton photoperiod suggest that skeletal mus-
molecular clock and external stimuli such as the time of cle clock oscillations are robust even in the face of per-
exercise training (FIGURE 18A). Several regulatory turbations induced by daytime running and feeding
nodes induced by an acute exercise response poten- (668). Moreover, studies of the transcriptome, proteome,
tially influence muscle clock oscillations (FIGURE 18B) and phosphoproteome of skeletal muscle of mice
(664–666). For example, activation of AMPK affects the undergoing maximal endurance tests at different times
stability of Period2 (PER2) and cryptochrome circadian of the day indicate a strong association with metabolic
regulator 1 (CRY1), two components of the core clock parameters such as muscle and liver glycogen concen-
(662, 667). CRY1 and CRY2 interact with PPARb/d and trations, suggesting more indirect effects of circadian
thereby reduce the oxidative phenotype of muscle cells oscillations (668). Thus, future studies need to determine

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1743

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

A 4.10. An Integrative View of the Molecular

Mechanisms

In this section, we summarized the molecular mecha-

nisms and pathways that are activated in skeletal mus-
Activity levels Central clock cle in response to endurance and/or resistance
and food intake exercise, with a focus on the putative pathways for
which an association between the acute exercise
response and chronic training adaptation has been
Metabolism consistently reported. Other reviews have discussed
the exercise-induced changes in various pathological
Skeletal muscle conditions such as muscle wasting, cachexia, or sar-
core clock
copenia (669–672), which may be completely distinct
or share some commonalities with those in healthy
Contraction
muscle in well-trained athletes. There are also several
pathways and factors that contribute to the pathoetiology
B CREB AMPK of muscle wasting and diseases. Although voluntary and
PPARβ/δ HIF-1α
forced muscle inactivity do not necessarily mirror con-
mTOR
CRY PER
tractile engagement (673), some of these could play a
role in exercise training adaptation. For example, the lev-
els of myostatin, which rise in several pathological states
BMAL1 CLOCK PER ROR
SIRT1 (15), are reduced by exercise (674), and the absence of
E box E box
CRY REV-ERB
PGC-1α
myostatin signaling may be an important contributor to
training adaptation. However, this might depend on fac-
ROR REV-ERB NFE2L2
NF-NB tors such as baseline control, exercise modality, or the
PPARα pathological context regarding comorbidities. Related
BMAL1 RORE

mechanisms such as the repression of activin receptor

FIGURE 18. Circadian regulation of skeletal muscle function and
type II (ActRII), for which myostatin is one of the ligands,
plasticity. A: circadian regulation of activity and muscle function. by the m(6)A methyltransferase-like-3 (METTL3) could
Circadian regulation of sleep-wake cycles, feeding, physical activity, also potentially contribute to muscle hypertrophy after
or other zeitgebers is sensed and translated by the master clock in
the suprachiasmatic nucleus as well as peripheral clocks in almost
exercise training (675). Readers are referred to recent
every cell in the human body. As a consequence, various physiologi- reviews on muscle atrophy and disease states (560,
cal processes, e.g., muscle cell metabolism or contractile perform- 676–679). Finally, many studies using gain- and loss-of-
ance, can be affected in a circadian manner. B: interactions between
core clock genes/proteins with regulators of muscle function and
function of targeted genes have reported altered muscle
plasticity. Such cross talk pertains to the regulation of gene expres- metabolism or contractile function, most of which require
sion, protein-protein interactions, and/or enzymatic activity. Thereby, validation after exercise interventions in both rodent mod-
physiological processes in muscle might be affected by the core
clock. Inversely, muscle fiber metabolism, contractile activity, oxygen
els and humans (485, 486, 680, 681). Many of these fac-
availability, redox balance, and other perturbations could modulate tors will undoubtedly add to our current knowledge
the skeletal muscle clock. AMPK, AMP-dependent protein kinase; regarding human exercise-induced muscle plasticity.
BMAL1, brain and muscle ARNT-like 1; CLOCK, circadian locomotor
output cycles kaput; CREB, cAMP response element binding protein;
Notwithstanding these limitations and caveats, we still
CRY, cryptochrome circadian regulator; HIF-1a, hypoxia-inducible have a poor understanding of how exercise adaptation is
factor 1a; mTOR, mammalian target of rapamycin; NFE2L2, nuclear regulated. Most studies focus on individual pathways and
factor erythroid-derived 2-like 2; NF-κB, nuclear factor κB; PER, pe-
riod; PGC-1a, peroxisome proliferator-activated receptor c coactiva-
factors, often centered on the “usual suspects,” and pre-
tor 1a; PPARa/b/d, peroxisome proliferator-activated receptor a/b/d; cisely how the complex and interdependent network of
REV-ERB, nuclear receptor subfamily 1 group D member 1/2; ROR, signaling pathways and mechanisms is spatio-temporally
retinoic acid-related orphan receptor; RORE, ROR elements; SIRT1,
sirtuin 1. Image created with BioRender.com, with permission.
coordinated and integrated is unclear (FIGURE 19). A
reductionist study of these pathways is difficult because
the extent of the influence of the molecular clock on the muscle activity and plasticity are under robust control,
exercise responses and vice versa, including functional with numerous redundancies (overlapping or parallel
consequences for acute endurance and resistance exer- pathways that are engaged in a physiological setting),
cise bouts, chronic training adaptations, and peak per- backups/contingencies (pathways that are engaged if
formance at competitions. other mechanisms are impaired, controlling the same

1744 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

biological program), and alternatives (processes that are recovery from exercise (581). Integrity of raptor is impor-
used when others are dysfunctional, leading to different tant for hypertrophy induced by synergist ablation over-
physiological adaptations but resulting in similar out- load but not the related boost in the rate of protein
comes) (18, 41, 682). For example, three of the most char- synthesis (684). Genetic models with inducible muscle-
acterized factors with putative roles in contraction- specific inhibition by ablation of raptor and sustained acti-
induced remodeling (AMPK, mTOR, and PGC-1a) are dis- vation of mTORC1 by disruption of TSC1 have little effect
pensable for many training-induced adaptations. First, in- on preserving muscle mass (524) or facilitating hypertro-
ducible ablation of muscle AMPKa does not affect whole phy (685), respectively. It is conceivable that such results
body substrate utilization, muscle glucose uptake, fatty are caused by flawed or imperfect experimental model
acid, or mitochondrial respiration during exercise (683). systems, with many studies relying on constitutive gain-
Similarly, muscle-specific knockout mice for PGC-1a still and loss-of-function. Moreover, targeting strategies might
increase mitochondrial biogenesis with training, at least be imprecise, such as the use of raptor and rictor to ge-
in some studies (576). The function of mTORC1, with netically ablate mTORC1 and mTORC2, respectively, lev-
roles in the early events leading to muscle hypertrophy, is eraging TSC1/2 to activate mTORC1 activity, or using
compensated by non-mTOR-dependent pathways during rapamycin as a pharmacological inhibitor of mTORC1.

Spatio-temporal signal coordination and integration?

Adipo-, hepato-, osteokines

e.g., adiponectin IGF-1, insulin
β2-AR Mechanosensing

Ca2+
Stress kinases branched chain
cAMP CnA CaMKII e.g., p38 MAPK amino acids
ATP/ADP/AMP
AMPK mTOR
ROS
NO
NADH/NAD+ CREB, ATF2
SIRT1 NFAT
Redundancies MEF2 HDAC5
NCOR1
Contingencies
Alternative pathways NR4A2 (NURR-1), NR4A3 (NOR-1)
PGC-1α PPARβ/δ, PPARα
ERRα, ERRγ

? CARP
DARP
ANKRD2
TF NRF1, GABP, TFAM
GR
SRF, AP-1, EGR-1
TFEB
MEF-2
MondoA
TAZ/YAP/TEAD1 HSF1
NRF2/NFE2L2 HIF-1α, HIF-2α
FOXO3A
ATF4, ATF5, ATF6, CHOP
PER, CRY1, BMAL1, CLOCK, REV-ERB
Motor unit
remodeling Contractility Metabolism Vascularization
Proteostasis Myokines
Fiber type Autophagy Myobolites

Output specification and coordination?

FIGURE 19. Molecular mechanisms in contracting muscle fibers. A small selection of molecular sensors and mediators as well as a simplified sum-
mary of the presumed interactions are depicted. Nota bene: the spatio-temporal integration and coordination of these pathways, functional redundan-
cies (e.g., overlapping or parallel pathways), contingencies (back-up processes with the same function), alternatives (back-up processes leading to
similar adaptations using different functions), specification and coordination of downstream effects and adaptations, in particular in chronic settings, as
well as many other aspects are still only understood at a very rudimentary level. b-AR, b-adrenoreceptor; CARP, cardiac ankyrin-repeat protein; CnA,
calcineurin A; CREB, cAMP-dependent binding protein; DARP, diabetes-related ankyrin-repeat protein; ERRa/c, estrogen-related receptor a/c; GR, glu-
cocorticoid receptor; HSF1, heat shock factor 1; NO, nitric oxide; PPARa/b/d, peroxisome proliferator-activated receptor a/b/d; ROS, reactive oxygen
species; SIRT1, sirtuin 1. See text for other abbreviations. Image created with BioRender.com, with permission.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1745

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

Even though raptor and rictor are unequivocal members not reflected in the transcriptional changes that occur after
of mTORC1 and mTORC2, many other potential interac- one acute exercise bout, such as the change in expression
tions of these proteins beyond their direct function in of different myosin heavy chains (9). Therefore, it is unlikely
forming the mTOR complexes have been proposed (686) that a trained muscle only reflects the additive or sustained
or demonstrated (687). Similarly, TSC1/2 and the down- changes that are induced in individual acute exercise bouts
stream effector RHEB clearly result in activation of mTOR (9). Epigenetic changes might be involved in priming and/or
but potentially also the modulation of the function of other altering the gene expression profile of trained versus sed-
proteins (688). Furthermore, physiological mTOR activity entary and of acute exercise-induced changes in the trained
is regulated transiently and in a pulsatile manner, quite dif- versus the naive state (41, 585, 691). Precisely how the tem-
ferent from the sustained, long-term loss- and gain-of- poral sequence of individual exercise bouts over time
function in the animal models. Finally, rapamycin is a results in training adaptation remains a fertile area for future
potent inhibitor of mTORC1 activity but at different dos- research. Together, sects. 2–4 have described training
ages and administration durations serves also as a modu- practices and the physiological and molecular pathways
lator of the activity of other protein complexes, including involved in the acute exercise response; sect. 5 integrates
mTORC2 and signal transducer and activator of transcrip- these aspects to discuss interindividual differences and the
tion 3 (STAT3) (689). Notably, STAT3, like mTORC1, exerts specific aspects that underpin elite athlete performance.
effects on muscle mass (690). However, these seemingly
paradoxical findings in relation to PGC-1a, AMPK, and
mTOR should not necessarily be interpreted as a sign of 5. CAN WE ALL BECOME GOLD MEDALISTS?
their dispensability or insignificance in the physiological
exercise response but rather as proof of the resilience of 5.1. Individual Responses to Training
whole body systems to adapt even under adverse condi-
tions. For example, although muscle-specific PGC-1a knock- Elite sporting performance is the result of the interaction
out animals can partially adapt to exercise training, this between genetic and training-related factors (692, 693),
adaptation differs from the physiological training response and although several genes or gene clusters have mod-
seen in wild-type animals and occurs despite a lack of vas- erate associations with performance or performance-
related phenotypes (694–696), the genomic signatures
cularization or metabolic adaptations in lactate and ketone
associated with elite athletic performance across a wide
body metabolism, thus presumably relying on alternative
range of events/sports have yet to be identified.
processes that provide similar benefits (575–577). How Notwithstanding the lack of direct links between genetic
such compensation is achieved is unclear, but it is conceiva- variants and elite performance, the notion that there exist
ble that the transcription factor binding partners still regulate interindividual responses to exercise training and that
the corresponding target genes even in the absence of this innate factors may explain a large part of the training-
and other coregulators, albeit at lower levels or altered tar- induced variance in maximal aerobic capacity in previ-
get specificity (474, 486). PGC-1a can regulate target genes ously untrained persons can be traced back to the classic
with different binding partners, such as those involved in HERITAGE studies conducted in the 1980s by Bouchard
the hypoxic response by coactivating AP-1 or ERRa, imply- and colleagues (697). In these and other recent investiga-
ing functional redundancies in the transcriptional network tions, the most common reported primary outcome mea-
engaged in exercise adaptation at different levels (474). sure in response to endurance-based training programs
Future studies should aim at obtaining an unbiased, holistic was an individual’s V_ O2max attained during an incremental
picture of the molecular mechanisms that control muscle exercise test to exhaustion, either treadmill walking/run-
plasticity in response to endurance and resistance training ning or ergometer cycling, usually lasting 10–15 min.
After 2–3 mo of endurance training (3 or 4 sessions
(18, 40). Such insights might also be important to better
per week), V_ O2max is typically increased by 10–15% at
understand training interference effects and help in the
the group level, but the magnitude of improvement
design of concurrent training programs for athletes involved
can be as little as 1–2% and as great as 35% (698). A
in multisport events (i.e., the triathlon) or who require traits of key observation from these early human training stud-
both endurance and power for successful performance. ies was that up to 20% of subjects demonstrated little
Finally, our knowledge about the mechanisms that control change in V_ O2peak in response to a standardized train-
chronic adaptations to endurance- or resistance-based ing protocol and were considered “exercise resistant”
training is sparse compared with that describing the (699). However, individuals who demonstrate a low
responses to a single bout of exercise. Many of the adapta- training response to one outcome measure (e.g., V_ O2max )
tions in elite athletes with a prolonged history of training are do not always display the same response in other

1746 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

parameters. This makes the concept of responders versus mechanisms that the chances of an individual exhibiting
non-responders open to different interpretations. Indeed, no single biological benefit is highly unlikely (701, 705).
exercise training induces a multitude of health- and per- Regarding elite athletic performance, the issue of low
formance-related benefits (9, 700), some of which may responders or non-responders becomes somewhat irrel-
even have a non-physiological basis (701). evant: to become an elite performer, one must be initially
Recently, the notion that there exist exercise-resistant well endowed in the traits that have critical roles in the
subjects or non-responders has been challenged on the athlete’s event, and one should also be a high responder
grounds that in those studies in which individuals exhibit to exercise training (83). Furthermore, without a rich
no meaningful change in a specified outcome variable, genetic endowment, world-class athletic performance is
the training impulse has been inadequate in terms of ei- unattainable (83). In this regard, there are substantial dif-
ther volume or intensity overload (702). To test this hy- ferences in performance-related traits measured in the
pothesis, Montero and Lundby (702) recruited 78 healthy sedentary state (i.e., before any training intervention).
young male volunteers and first subjected them to 6 wk of Individuals who have high levels of a trait before expo-
supervised training. Individuals trained in five groups dif- sure to exercise training are greatly predisposed to expe-
fering in the number of exercise sessions per week: they riencing early success, which also might have a big
performed 60 min of cycle ergometer exercise either one, impact on motivation and subsequent training adherence.
two, three, four, or five times a week, corresponding to This is not the case in non-elite sedentary populations in
60, 120, 180, 240, and 300 min total training time. After which no correlation is observed between the baseline
completing this first phase of training, the group mean level of fitness (i.e., V_ O2max ) and the response to an exer-
maximal work rate sustained during an incremental cycle cise training dose (699), suggesting a unique biology
test (Wmax) was increased in all groups apart from the underlying trainability. In support of this contention,
group who undertook just a single training session per Rønnestad et al. (292) report the case of an individual
week. In groups one, two, three, four, and five, 69%, 40%, with a V_ O2max of >70 mL/kg/min in the untrained state
29%, 0%, and 0% of individuals, respectively, were non- that increased by 30% after 3 yr of specialized training to
responders [i.e., did not have a significant increase in the >95 mL/kg/min and coincided with a world championship
maximal work rate (Wmax) attained during an incremental title. Animal studies of selected breeding for aerobic run-
test to exhaustion]. Subsequently, individuals classified as ning capacity also reveal high and low responders to
non-responders to the first phase of training performed a standardized exercise training. To determine the inher-
second 6-wk block of training in which two additional 60- ited components of acquired running capacity, a model
min sessions per week were included, independent of the of two-way artificial selection for animals that were either
number of sessions completed during the first 6 wk. low or high responders to exercise training was devel-
Following this protocol of volume overload, the lack of oped (706). These two animal lines were tested for maxi-
training-induced increase in Wmax was universally abol- mal treadmill running distance before and then after 8 wk
ished. Although further research needs to be undertaken of standardized treadmill run training protocol (i.e., the
to determine whether such findings can be extrapolated same absolute training load). After 15 generations of
to other populations, these results fundamentally chal- selection, and 8 wk of training, the high-response rats
lenge the notion of non-responders and suggest that if a improved an average of 223 m in run distance, whereas
training stimulus is of sufficient volume and/or intensity exercise capacity declined by 65 m in the low-response
and follows the principles of progressive overload and animals. Taken together, a continuum of responses to
specificity, then those individuals thought to be exercise standardized exercise training protocols exists (698), yet
resistant or low responders can indeed become “res- low sensitivity to adapt may be mitigated by revision of
ponders” (702). In this context, Booth and Laye (703) exercise prescription including training frequency, dura-
believe that the term non-responder should be replaced tion, and intensity (701, 702). Although an understanding
by individuals who demonstrate “low sensitivity” to a of how genetic factors contribute to interindividual train-
training stimulus and that such individuals merely require ing responses may improve personalization of training
increased training volumes and/or intensity to drive prescription, at present genomic predictors for response
favorable responses. At the population level, focusing on trainability are lacking (707).
only selected measures of training response and label-
ing an individual as a non-responder is somewhat of a 5.2. Genetic Predisposition to Becoming an Elite
reductionist approach to exercise. Indeed, if we accept Athlete
that exercise is a “polypill” (46, 704) exerting a plethora
of positive benefits (700), then by focusing on a small An indication of genetic predisposition toward athletic
number of measures of response we ignore the fact that prowess could be inferred from a variety of observa-
exercise works through so many different pathways and tions. For example, people from the western parts of

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1747

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

Africa (including Ghana and Nigeria) as well as the de- suggesting a role in high-velocity force contractions (717).
scendants of the slaves that were transported from The single-nucleotide polymorphism (SNP) in the ACTN3
these regions to the “New World” (the West Indies or gene results in a premature stop codon (X) instead of the
the United States) are excellent sprinters. In contrast, arginine (R) at position 577, and the XX genotype is defi-
athletes from Eastern Africa, such as Kenya and cient in expressing the ACTN3 protein (718). The 577R al-
Ethiopia, are famous for their extraordinary long-dis- lele has been associated with elite sprint/power athletes
tance running feats. In fact,
90% of elite marathon and explosive performances, RR being superior to RX
runners worldwide are of Ethiopian or Kenyan descent and XX genotypes (719, 720). In contrast, the XX variant is
(708). However, it is unclear whether different genetic, more frequently observed in elite endurance athletes
and in extension anthropometric (709) or rather envi- compared with non-athletes and is extremely rare in elite
ronmental, factors and training practice (118) explain power athletes (719). In line with these observations, the
this phenomenon. For example, the higher altitude absence of ACTN3 results in an increased endurance
plateaus of the Eastern African countries might facili- performance and higher oxidative phenotype in the mus-
tate endurance training adaptations in contrast to the
cle of knockout mice (721).
mostly sea-level landscape of Western Africa. Despite
During the last two decades, at least 155 polymor-
these alternative explanations, it is estimated that
phisms related to elite endurance (93 polymorphisms) or

65% of athletic ability can be explained by genetic
power athletes (62 polymorphisms) have been identified
factors (710). Moreover, there are data indicating that
(722). Endurance markers that have been replicated in at
maximal endurance capacity as well as trainability is
least three independent studies include ACE I, ACTN3
inherited (699, 711) and that the genetic makeup accounts
577X, HFE (homeostatic iron regulator), PPARA, and
for a substantial contribution to performance levels (712).
PPARGC1A, and power markers include ACE D, ACTN3
However, despite evidence that genetic components are
577R, AMPD1 (adenosine monophosphate deaminase 1),
strongly related to the phenotypic traits of elite athletes,
HIF1A, MTHFR (methylenetetrahydrofolate reductase),
knowledge of the specific genes underpinning this pre-
NOS3, and PPARG (722). Of all 93 polymorphisms associ-
disposition is limited. Rare examples for extreme genetic
ated with elite endurance athletes, the 3 located within
variants underline the genetic contribution to athlete sta-
the ADRB2 (adrenoceptor b2), ADRB3, or PPARGC1A
tus. One example is the mutation in the EPO receptor
genes have also been shown to be associated with base-
line V_ O2max of a non-athlete population (723) and the 5
gene that resulted in a more active truncated protein in
the Finnish cross-country skier Eero Ma €ntyranta (713). His
variants of the ACE, AMPD1, CKM, HIF1A, and PPARD
Hb levels were at least 200 g/L, which is substantially genes with V_ O2max trainability (724). However, even
higher compared with other endurance athletes or non- though several genetic variants have been identified
athletes (
150 g/L) and could thereby have contributed in genomewide association studies (GWASs) of elite
to the three Olympic gold medals and two World athlete status, there is no subset of genes that allows the
Championships he won over his career (266, 713). In identification of elite athletes (696). Often, studies are
broader populations, the two polymorphisms that are underpowered, which is not surprising regarding the lim-
most described and linked to athletic performance are ited number of elite athletes and accessibility of biological
located within the ACE and ACTN3 genes that encode samples, and therefore many results cannot be replicated
for the angiotensin I-converting enzyme and a-actinin-3, in different cohorts (696). Based on a meta-analysis
respectively (714). In fact, the first polymorphism that was including 1,520 endurance athletes and 2,760 non-ath-
associated with athlete status was ACE I/D (715). ACE is letes control subjects, a polymorphism in the GALNTL6
part of the renin-angiotensin system and is involved in gene, encoding for polypeptide N-acetylgalactosaminyl-
regulating blood pressure by converting angiotensin I to transferase-like 6, may be a significant marker for athletic
the active vasoconstrictor angiotensin II. ACE activity in performance (696). In endurance athletes, the C allele is
serum is lower in the presence of the insertion (I) allele overrepresented compared with non-athletes, whereas
containing 287 base pairs within intron 16 (716). The I al- the T allele of GALNTL6 is more frequently observed in
lele is associated with successful endurance capacity, elite power athletes compared with endurance athletes
whereas the deletion (D) allele is associated with prowess or non-athletes and is associated with higher peak power
in strength/power events (716). However, inconsistencies in active men (696, 725). Another recent meta-analysis in
exist within this classification: in elite endurance runners, elite endurance athletes identified polymorphisms in the
an association with the D allele or the I allele as well as a MYBPC3 (myosin-binding protein C3) and NR1H3 (nuclear
lack of any association have been reported (708, 714). In receptor subfamily 1 group H member 3/LXRa) genes that
comparison, data on ACTN3 polymorphisms are more ro- were also correlated with V_ O2max (726). Specific SNPs in
bust. ACTN3 is an actin-binding protein that is exclusively the HFE, NFIA-AS2 (nuclear factor I A antisense RNA 2),
expressed in type II fibers and located at the Z disk, and TSHR (thyroid stimulating hormone receptor) genes

1748 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

that are more frequently observed in elite endurance ath- Collectively, most of the identified polymorphisms dif-
letes compared with controls have also been associated fer between studies and only explain a very small frac-
with high V_ O2max among athletes (727–729). Additionally, tion of the interindividual differences in endurance and
athletes with homozygous C alleles of NFIA-AS2, encod- strength. As a consequence, the current knowledge is
ing a long noncoding RNA, have improved hematologic inadequate for talent identification or prediction of train-
parameters such as higher Hb levels, since NFIA-AS2 ing response (68). Besides the question of whether
may be involved in the regulation of the transcription fac- genetic talent identification will ever be feasible in the
tor NFIA and erythropoiesis (727, 728). However, even if future, ethical and practical issues also need to be con-
a combination of GWAS and selected physiological sidered (718, 730). “Genetic” prediction of athletic prow-
measures in elite athletes may help identify SNPs for vari- ess and specialization disregards personal preferences
ous genes, data including such measures are limited and and choices, with potential detrimental consequences
so far these candidates have not been replicated (722). In on enjoyment, motivation, and ultimately adherence.
the future, it might be possible to link polymorphisms to Talent identification and premature specialization might
the responsiveness of individuals (i.e., low vs. high res- also preclude the multidisciplinary practice in youths
ponders) to standardized training interventions, as a set of that predicts world-class performance (731). Moreover,
21 SNPs was able to predict almost 50% of the variation sensitive genetic information has potential for misuse
observed in the V_ O2max training response (698). However, and unexpected outcomes, and could have psychologi-
as noted, replication of these data remains difficult, and cal consequences that could even extend to other family
not all SNPs seem to affect trainability across all popula- members. Additionally, the reported associations are
tion groups (698). Importantly, the identified polymor- observed at the population level and hence have a very
phisms are based on associations, and for the large low predictive value at the individual level (732). In fact,
majority of these the functional relevance and mechanistic there are frequently individuals with a seemingly less
aspects of the gene variants in muscle biology are favorable genotype who achieve elite athlete status
unknown. Therefore, identification of SNPs with larger (718). Moreover, monozygotic twin studies revealed a
effect sizes, replication of the identified SNPs in independ- strong impact of discordant leisure-time physical activity
ent cohorts, as well as studies including a larger sample on performance, fitness, health, and well-being, to a
size and possibly additional physiological measures to dis- large extent disconnected from the genetic endowment
criminate individuals (i.e., V_ O2max and performance out- (733). In summary, the current scientific evidence sup-
comes) are necessary to gain knowledge about genetic porting the contributions of specific genetic variants to
factors that underpin elite athlete performance. These elite athletic performance phenotypes is weak (734).
studies will have to be combined with mechanistic investi- This is partly because complex traits are modulated not
gations of the functional effect of gene variants and SNPs by several genes with large effect sizes but instead by
to understand how differences are brought about. polygenic systems defined by hundreds or thousands of
Gain- and loss-of-function studies in mouse models loci, characterized by alleles with small effect sizes, plus
have identified 31 genes associated with endurance less frequent alleles (83). In contrast to the commercial
performance (681). For eight of these, genetic var- for-profit genetic testing to predict training selection and
iants have been reported to be associated with elite response, non-genetic testing, such as assessment of
endurance athletes (681, 722). The genes associated physical performance, might be more useful for athlete
with an elite endurance athlete status and enhanced stratification (68, 83, 692, 693, 735). Importantly, instead
endurance performance in a gain-of-function mouse of talent identification, genetic information could also be
model include PPARD, PPARGC1A, PPARGC1B, and used for the screening of polymorphisms that are associ-
PPP3CA (protein phosphatase 3 catalytic subunit a), ated with injury risk among athletes (i.e., stress fractures
and those correlated with endurance performance in or tendinopathies) to reduce injury by individualized pre-
a loss-of-function mouse model include ACTN3, ventative measures (718), with much fewer ethical consid-
ADRB2, BDKRB2 (bradykinin receptor B2), and HIF1A erations attached.
(681, 722). Although 47 genes were identified in mouse
models that induce hypertrophy in a gain- or loss-of-func- 5.3. The Aging Athlete and Athletic Performance:
tion model, no corresponding human polymorphisms Slowing Down with Speed
were described for most of the genes that were associ-
ated with a strength/power muscle phenotype (680). During the past century, there has been a steady
However, gene variants in IGF1 and ADRB2 have been increase in life expectancy among most countries in the
found in the phenotype of power athletes and are 2 of Western world. However, such enhanced longevity (life
the 47 genes that induce hypertrophy in a gain-of-func- span) has not always been accompanied by a propor-
tion model (722). tional elevation in healthy life expectancy, so-called

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1749

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

“healthy aging” or “healthspan” (736). Thus, an objective athletes are easier to obtain than longitudinal data, the
of medical and aging research is not necessarily to pro- former can only provide the age-related performance
long life span per se but instead to increase the health- decline for a population, whereas longitudinal data show
span and compress morbidity later in life (737). At the individual trajectories. A detailed analysis of the age-
population level, aging is strongly associated with a rise related declines in performance across multiple sporting
in sedentary behavior and concomitant declines in phys- events is beyond the scope of this review, and the reader
ical and mental capacity. An examination of the perform- is referred to previous work in this area (741–746). Here,
ance profiles of individuals who continue to train and we provide a general overview of the effects of aging on
compete throughout their entire life provides insights overall physical performance declines and discuss some
into the extremes of human function and the upper limits of the mechanisms that underpin this decay in perform-
of physiology during the human aging process (738, ance capacity.
739). The birth of the “masters” athlete movement (those
Plotting age-group world records for males and
individuals >35–40 yr of age, depending on the sport)
females across various sporting events provides insights
can be traced back to the late 1960s and early 1970s. At
into the rates of decline in performance capacity across
this time, there was a massive increase in the number of the healthspan (FIGURE 20). Such cross-sectional data
people who started exercising, either for health and offer the “best-case scenario” for each age band but do
pleasure or to pursue competitive endeavors. In the not provide any information on the individual athletes’
United States, this escalation in structured physical activ- decay curves. Several observations are noteworthy.
ity initially centered on distance running and was First, the rate of performance decline does not appear
inspired by a few select individuals such as Roberta to differ between or within sports (e.g., the various track
Gibb and Kathrine Switzer, who were the first female fin- and field events and multiple swimming strokes and dis-
ishers in the Boston marathon in 1966 and 1967, respec- tances) (745). Second, there are no major sex-related dif-
tively, and Frank Shorter, who won the gold medal in the ferences in the deterioration in performance for most
men’s Olympic marathon in 1972 and silver in the 1976 sports (746), and although there is a greater absolute
Olympics. Throughout the next two decades, there was drop-off in performance for females compared to males,
an explosion in the number of marathon races held in the relative decline is similar. Performance declines for
capital cities throughout the world, with applications to most of the running, swimming, and cycling events, inde-
run in these events far exceeding the number of avail- pendent of distance, are not linear but curvilinear (741).
able starting places. The mid-1970s also saw the birth of However, at
70 yr of age, there is an accelerated
the triathlon, which consisted of an amalgamation of increase in performance decrements for almost all sport-
three separate sports: swimming, cycling, and running. ing performances. For example, world records show
From humble beginnings (15 men started and 12 finished rapid declines after age 70 in swimming, long-distance
the inaugural “Ironman” triathlon in Hawaii in 1978), the running, and sprint performance (744). Although it is
Hawaii Ironman is generally considered one of the most unlikely that those athletes still training and competing
difficult 1-day sporting events in the world, and today after the age of 70 can maintain the same absolute train-
Ironman races attract almost half a million entries world- ing volumes and intensities, there is no reason to sus-
wide each year. These competitive, mass-participation pect that the relative training intensity has diminished. It
inner-city marathons and triathlons were the motivation is worth noting that only 5% of athletes competing at
for a generation of women and men to start training for age 80 yr are still competing at age 90 yr. Therefore,
specific competitions/races and laid the foundation for a world-best performances in these latter years may
generation of athletes who are now in their eighth or merely reflect a lower number of participants rather than
ninth decade of life and have participated in formal exer- any underlying physiological factor responsible for the
cise training throughout their life span (740). As such, we drop in performance capacity. Nevertheless, the per-
now have both cross-sectional and longitudinal data on a formance decline in athletes aged 80 yr is threefold
cohort of masters athletes who have maintained rigorous greater compared with athletes aged 30–69 yr (1.62%
training schedules over many decades and have better vs. 0.46% per year) and accelerates around 67 yr, espe-
health outcomes than their age-matched non-athletic cially for sprint/power disciplines (742, 743).
counterparts. Such well-trained individuals represent the The factors that constrain performance with aging are
optimum phenotype for examining the effects of aging on event-specific, meaning that for each sport/event there
performance and vice versa, as these individuals are may typically be one or more physiological/mechanical
most likely minimally affected by the negative effects of systems that limit exercise capacity. For example, the
the age-related decrease in voluntary physical inactivity decline in maximal running velocity (independent of dis-
and changes thus largely driven by an inherent aging pro- tance) is likely to be underpinned by deteriorations in sev-
cess (739). Although cross-sectional data on masters eral properties in skeletal muscle that include a decrease

1750 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

Masters athletes
Marathon records 100 m records
9 24
Women Women
8 22
Men Men
7 20
6 18
Time (h)

Time (s)
5 16
4 14
3 12
2 10
1 8
World record World record
0 0
9

4
-3

-4

-4

-5

-5

-6

-6

-7

-7

-8

-8

-9

-3

-4

-4

-5

-5

-6

-6

-7

-7

-8

-8

-9
35

40

45

50

55

60

65

70

75

80

85

90

35

40

45

50

55

60

65

70

75

80

85

90
Age group Age group

FIGURE 20. Age-related decline in records of sprint and endurance events. Records for marathons (https://world-masters-athletics.com/
championships/non-stadia/) and 100 m sprints (747) of masters athletes represent the age-induced reduction in tissue and organ function that despite
high training loads leads to a decrease in performance. However, they also highlight the potential of the human body to achieve incredible performan-
ces at advanced age with adequate training.

in the maximum strength or power output, a slower rate of muscle deterioration, they fail to provide a better
force development and transmission, and a reduction in understanding regarding the potential mechanisms
elastic energy storage and recovery of tendons (748). underlying this phenomenon.
During the normal aging process, there is a progressive With endurance-based sports, there is a decrease in
loss of muscle mass, mainly in the lower body, which V_ O2max of
1% per year after the age of 35 yr (754). This
increases after the age of
45 yr, with the absolute is due to a combination of factors including, but not lim-
decline being faster in men than in women (749). Even in ited to, an increase in ventricular stiffness that contributes
masters athletes who have undertaken a lifetime of train- to worsening left ventricular diastolic function reflected
ing, a reduction in size and function of muscle is observed, by reductions in early inflow velocity, ratio of early to late
which is most pronounced in the fast fibers (750). This inflow velocity, and early diastolic tissue velocity and
selective loss of fast-twitch fibers explains, in part, the increases in the isovolumic relaxation time and the time
greater magnitude of performance decline in sprint and constant of isovolumic pressure decay (755). Although
explosive events compared with endurance-based activ- lifelong exercisers have a greater stroke volume and con-
ities. Cross-sectional data from 37- to 90-yr-old masters sequently a superior functional capacity and cardiovascu-
athletes indicate that peak anaerobic power declines by lar reserve than their sedentary peers, there may be
7–14% per decade, with this reduction being similar some adverse consequences of a lifetime of rigorous en-
between male and female athletes (751). Despite the durance-based training. Several studies have reported
selective loss of fast muscle fibers, Cristea et al. (752) have increased risk of atrial fibrillation, atherosclerotic plaques,
shown that a 20-wk program that combined sprint training and aortic dilation in masters athletes compared with age-
with heavy and explosive strength exercises specifically matched untrained individuals (756–758). A J-shaped
targeting fast-twitch muscle fibers improved maximal, ex- association between exercise volume and all-cause mor-
plosive, and sport-specific force production in elite mas- tality, cardiovascular disease, and total cancer, as opposed
ters sprinters (aged 52–78 yr). Furthermore, at a single- to the L-shaped association with diabetes, would imply a
fiber level, it seems that power output per unit size (i.e., negative risk profile at very low and very high volumes of
muscle quality) is not reduced in muscles of aging activities (759). These findings, however, contrast with
athletes (753), suggesting that the loss in power out- results of other studies in different athlete populations, in
put can mainly be ascribed to the loss of fast muscle which a J-shaped association was not observed (760,
fibers rather than muscle quality. In contrast to 761). In fact, many studies and meta-analyses reveal
sprint-based activities, men and women with a pro- reduced mortality in former athletes (761–763), even in
longed history (5 days/wk for 7 h/wk over the past 52 those competing at the highest level such as United
yr) of endurance-based training have capillarization States, French, or Polish Olympians or French participants
and aerobic enzyme activity similar to younger (25 yr of the Tour de France (764–767). Often, assessment of
of age) exercisers, which in turn is 20–90% greater potential effects of genetic components and the benefits
than the parameters determined in elderly age- of lifelong training in elite athletes is confounded by
matched non-exercisers. Although whole muscle healthier lifestyle habits such as being more active or a
responses offer unique insights into age-related non-smoker (768, 769).

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1751

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

5.4. Looking Ahead: Personalized Training Using During the past decade, there has been a global
Wearables explosion in wearables in sport and other health-related
fields (772) underpinned by rapid developments in
The application of wearable appliances/sensors to sport “smart technologies” such as artificial intelligence (AI)
is a relatively new phenomenon. In 1978, a Finnish com- and machine learning. These technologies rely on sen-
pany pioneered the first wearable heart rate monitor, sor systems that collect, process, and transmit relevant
subsequently introducing a monitor with an integrated data (such as biomarkers and other training/competition
computer interface, which gave athletes the ability to indexes) that are crucial to evaluate an athlete’s condi-
view and analyze their training data on a computer for tion and maximize performance (771). In the sports set-
the first time. In 2009, a professional European soccer ting, these platforms have several objectives: 1) to
club used wearable devices for measuring player work- gather valid, reliable, high-quality, data-rich sensory in-
load during games. That device was among the first to formation from athletes in training/competition environ-
allow coaches real-time monitoring of each player’s bio- ments; 2) to apply sophisticated analytics methods to
metrics for signs of exhaustion or injury while on the field identify patterns for determining athlete health and
of play. The generation of real-time data during competi- training/competition status; 3) to obtain real-time data
tion situations is important: athletes have long been able regarding training-related metrics (i.e., training varia-
to monitor their physiological status under controlled bles, sleep quality, diet) while assisting athletes/
laboratory conditions, but competition demands includ- coaches to manage a range of performance variables
ing prevailing environmental factors (heat and humidity, and outcomes to detect early signs and symptoms of
wind speed, altitude, other athletes/players, crowds) overtraining (657); and 4) to establish novel perform-
impose a different set of stressors that cannot be mim- ance outcomes that supplement subjective, manually
icked in the laboratory (770). Over the last 20 years, the collected data and coach-based feedback with auto-
growing interdisciplinary merging of technologies has mated, objective data from devices. Data obtained
led to milestones in the field of advanced sportswear from wearables can furthermore be leveraged to learn
systems. Such systems are designed to assist athletes new techniques and provide real-time feedback on
to reach their desired fitness and performance goals by this process (770). For example, Samsung developed
helping to create an optimal micro- and macroenviron- the Samsung SmartSuit to optimize body posture dur-
ment and/or physiological state for comfort, to facilitate ing short-track speed skating. The suit includes five
best performances by providing real-time information on integrated sensors and enables real-time feedback to
the environment and state athlete status (770). Of note, the coach regarding the body position of the athlete:
most sensors for monitoring athletic training loads and in this scenario, real-time feedback is transmitted to
sports performance have been driven by technological the athlete with instructions to modify body position to
advances in other disciplines, mainly clinical medicine reduce drag and optimize performance. The Dutch
(e.g., continuous glucose monitoring systems) and the short-tracker Suzanne Schulting used this suit to pre-
military (770). pare for the Olympic Games in 2018 and became the
The concept of wearable sensors in sport is broad first Dutch Olympic gold medal winner for 1,000 m, a
and includes any information gathering system that an feat she repeated in 2022.
athlete can wear/carry while participating in normal train- Training load for sport performance encompasses both
ing/competition environments. Wearables can be worn external and internal dimensions, with external training
by athletes on their person, in their clothing, or within loads representing the physical work performed during a
their equipment and incorporate sensors, a microproc- training session and internal loads being the associated
essor, and a form of communication unit that enables biochemical and biomechanical stress responses. With
connectivity within a personal area network (PAN) where regard to athlete monitoring, wearables provide informa-
a smartphone or other appliance stores data and oper- tion over four broad domains (771, 773): 1) internal load,
ates as a gateway with connectivity to the internet (771). representing the psychophysiological responses to a
Sensors and devices for athletes must be small and given external load and typically determined by measure-
light, as well as flexible, durable, and impact resistant. ment of heart rate, oxygen uptake, blood lactate, and rat-
Perhaps most importantly, any device should not neg- ings of perceived exertion; 2) external load, determined
atively affect normal range of motion in an athlete’s by the physical demands associated with a given stimu-
chosen discipline. Simultaneously, wearables must lus, monitored by global navigation satellite systems, iner-
produce precise measurements of biometrics like tial measurement units, or linear/angular transducers that
motion, heart rate, blood pressure, respiration rate, provide measures related to distance covered at certain
oxygen kinetics, blood, saliva, and sweat markers, and velocities, acceleration/deceleration, and change of direc-
impact forces (772). tion forces; 3) well-being, monitored by subjective scales

1752 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

related to fatigue, DOMS, stress, quality of sleep, or mode medicine (786). However, to date, few studies have
state; and 4) readiness, assessed by measures of heart been undertaken in elite athletic cohorts (787).
rate variability, heart rate recovery, and variations in the Although there is some evidence to suggest that a com-
test results of selected neuromuscular or submaximal/ bined -omics solution will greatly facilitate discovery of the
maximal test protocols. As long-term improvements in genetic and non-genetic influences on sporting perform-
training adaptation and performance capacity are ulti- ance, training response, injury predisposition, and other
mately the result of an athlete’s cumulative internal load potential determinants of successful human performance
over multiple acute work bouts, the measurement of inter- (788), large-scale, collaborative efforts involving well-defined
nal load and the factors influencing these outcomes is of phenotypic cohorts will be essential for major progress to
paramount importance for the coach and athlete. A knowl- be made in the field of elite sport performance (782).
edge of the relationships between internal and external Indeed, integration of data from multiple -omics approaches
training loads has the potential to enhance training pre- will require large sample sizes, big data sets, and expertise
scription, periodization, and athlete management through in computational biology to resolve the complex biology
associated with the diverse exercise responses to endur-
a detailed assessment of training fidelity and efficacy
ance- and resistance-based training regimens. This will ne-
(773). Whether such information will provide coaches with
cessitate collaborative efforts between multiple research
an objective framework for evidence-based decisions
teams using common procedures and experimental
remains to be determined. Moreover, potential issues with
protocols to execute multicenter exercise/lifestyle
accuracy, dependability, or data security and privacy will intervention trials with the goal of collecting sufficient
have to be considered and solutions proposed that are functional and molecular data to further elucidate the
acceptable for all stakeholders (774). mechanisms responsible for adaptive response to var-
ious exercise training regimes. Issues of data privacy
5.5. The Application of “-Omics” Technologies to and accessibility will have to be considered.
Exercise Biology Such an approach is already underway: the Molecular
Transducers of Physical Activity Consortium (MoTrPAC)
In the past quarter century, the field of exercise biology is a multicenter study on the effects of two different
has evolved to include sophisticated analysis of multi-tis- forms of exercise (endurance and resistance training)
sues and organs through the application of established across individuals of different ages and sexes as well as
techniques already employed in other disciplines, as sedentary and well-trained individuals (782). There are
well as various -omics platforms to complement classic two main aims of MoTrPAC: the first is to study the
approaches (775, 776). Such inquiry has provided both a response to exercise at the whole body and cellular lev-
greater understanding of the biological bases of the els and to identify the molecular underpinnings that
health benefits of exercise (38) as well as knowledge of might be responsible for the adaptive process and varia-
muscle bioenergetics and adaptation to training in rec- tion among individuals. The second aim is to deliver
reationally active individuals and subelite athletes (55, a map of the biological molecules and pathways under-
160, 777). The application of molecular techniques to lying the systemic effects of acute and chronic exercise
exercise biology has provided novel insights into the (454, 782). Ultimately, the knowledge gained from
complexity and breadth of intracellular signaling net- MoTrPAC and other similar large-scale undertakings
works involved in response to both endurance- and re- (e.g., the Wu Tsai Human Performance Alliance) will give
sistance-based exercise (55, 161, 777). The recent biological science researchers and health professionals
explosion in global -omics technologies in the exercise the insights to develop personalized training protocols to
sciences has also provided new opportunities to map maximize performance and/or health benefits based on
the complexity and interconnectedness of biological the unique molecular signatures and specific targets
networks underlying the tissue-specific responses and identified. Notwithstanding the increased knowledge that
systemic benefits of exercise training (161, 455, 586, will accrue from a better understanding of these sophisti-
778–782). A “sportomics” approach (the use of -omics cated biological processes and pathways, advances in
sciences in sports) has even been proposed to comple- training techniques for achieving new limits in human ath-
ment existing methods of studying and monitoring an letic performance have rarely had their origins in science.
athlete’s state of fatigue and physical performance and Part of the reason that sport science and exercise biology
aid in talent identification (783, 784). There have been has failed to inform training practices stems from a reluc-
in-depth and integrated multiomics profiling efforts of tance of coaches to modify their methods, many of which
the response to acute exercise in subclinical populations have been nurtured and perfected over decades and are
(785), along with longitudinal “big data” approaches to firmly entrenched as coaching “lore.” Donating tissue
develop prediction models for biomarkers for precision samples for exercise biologists to gain mechanistic

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1753

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

insights into various training protocols has also met with CRISPR-Cas9-based approaches, and adeno-associ-
limited success. As such, knowledge of training methods ated viral (AAV) vectors have been applied in different
to enhance elite sport performance has traditionally settings and pathologies, including muscle diseases,
evolved by way of trial-and-error observations of a few in the preclinical setting, such as therapy of Duchenne
pioneering coaches and their athletes, with exercise sci- muscular dystrophy (796). AAV-based gene therapy is
entists playing “post hoc” roles attempting to explain the now also used clinically, for example, in spinal muscu-
underpinning biological mechanisms (99). Although major lar atrophy patients (797). Finally, progress is being
breakthroughs in the knowledge of how exercise acti- made in the recognition of our increasingly sedentary
vates numerous cellular, molecular, and biochemical lifestyle as a major risk factor for chronic metabolic
pathways have been witnessed, direct evidence linking diseases, the prescription of exercise-based interven-
such effects to specific performance outcomes and tions in the general population for preventing and/or
understanding how these effects exert their benefits in treating an ever-increasing number of widespread
different athletic populations remains elusive and a chal- conditions, and establishing physical activity as a cor-
lenge for future research. To do so, exercise biologists nerstone in medical practice and public health (26,
who investigate training adaptation and elite athletic per- 798, 799).
formance will have to integrate information pertaining to In elite sport, world records continue to be broken
an athlete’s genetic and epigenetic background with tis- across a wide range of events. Performance improve-
sue-specific gene expression, proteome, and metabolo- ments or declines depend on many factors, including
mic profiles to predict potential improvements in strength, technology, sports science, support for a particular
aerobic capacity, and other traits necessary for elite sport, talent identification, investment of time, and effec-
performance. tiveness of training protocols (800–802). Advances in
elite performance can also vary between individual
events in one sport, as is the case for Olympic swimming
6. SUMMARY, CONCLUSIONS, AND competitions, with strong trends for improvement in
PERSPECTIVES some strokes and a relative plateau in others (803). With
an increasing number of former Olympians and elite ath-
We stand on the shoulders of giants who have unraveled letes now participating in masters competitions, age-
seminal and fundamental aspects of muscle biology and group records are being surpassed and seemingly unat-
metabolism (789). Today, human studies are boosted by tainable performances recorded such as the sub-3 hour
technological and conceptual advances that enable the marathon by a 70-yr-old man (804). Although big data
investigation of molecular mechanisms, cellular functions, approaches will be facilitated by the rapidly evolving
multicellular dynamics, as well as inter-tissue and inter- tracking systems and wearables technologies combined
organ cross talk in an unprecedented manner. For exam- with machine learning, AI, and other analysis methods
ple, the identification of myokines resulted in the new defi- (66, 805, 806), it is questionable as to what extent train-
nition of skeletal muscle tissue as an endocrine organ, in ing practices of elite athletes have been facilitated by
fact the largest in our body (790, 791). Similarly, metabolism any major laboratory-based scientific breakthroughs to
of kynurenine (792) and excess ketone bodies in hyperke- date. Indeed, despite our greater understanding of
tonemia (575) in skeletal muscle, boosted by exercise, some of the mechanistic underpinnings of muscle plas-
imply a role for this tissue in the detoxification of dysregu- ticity and exercise adaptation, the upper limits of adapta-
lated endogenous metabolites, analogous to xenobiotic tion remain poorly studied (18). Even though numerous
detoxification in the liver. scRNA-seq has yielded novel potential regulatory and functional key players have
insights into the cellular composition of muscle, including been identified, we do not know whether the picture is
the identification of previously unidentified cell types and complete, how these factors are activated and engaged,
the first analyses of multicellular dynamics and interactions how different pathways are integrated, or how the regu-
(632–634). Likewise, single-nucleus RNA-seq (snRNA-seq) latory and functional outcome is specified, orchestrated,
reveals a hitherto unsuspected coordination between and coordinated. Moreover, the complexity of the appa-
nuclei in the same syncytial myofiber but also a surprising rent regulatory and functional redundancies, contingen-
heterogeneity and subspecification of transcriptional pro- cies, alternatives, and adaptive mechanisms that ensure
grams that extends beyond the classically defined robust regulation of muscle plasticity as one of the most
synaptic, extrasynaptic, and myotendinous nuclear fundamental aspects of human life and evolution
populations (793–795), combined with insights into remains enigmatic (18). Our insights into the regulation
protein transfer between nuclei (650), RNA transport of muscle plasticity in response to endurance-based
in the muscle fiber (651), and even the movement of training stimuli far surpasses that of resistance-based
myonuclei in specific contexts (649). Exon skipping, exercise, in part because of the availability of more

1754 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

robust or at least more commonly used animal models For example, based on mechanistic insights and mouse
and protocols that are more physiological and translat- experiments with so-called “exercise mimetics,” some
able for the former training practice (807, 808). coaches and athletes experimented with performance-
Compared to the muscle and whole body responses to enhancing compounds, most recently AMPK and PPARb/
an acute bout of exercise, the mechanistic aspects of d activators, without waiting for robust scientific validation
chronic training-induced plasticity are less well investi- from human trials (45, 46). Not only is there no evidence
gated and understood. Similarly, the mechanistic under- for performance enhancement in humans (815), but in
standing of the molecular bases of reduced training some cases (e.g., metformin, resveratrol, and rapamycin),
and/or detraining, as well as of retraining and muscle there may be a reduction of training adaptation (45, 46).
memory, remains rudimentary (433). Finally, we have lim- Moreover, such compounds may have a significant risk of
ited knowledge of the dynamic multidirectional cross severe adverse effects that might not be relevant in the
talk between muscle and other cell types, within and time frame of application and life expectancy in rodents
beyond muscle tissue, which is instrumental for but could have detrimental long-term effects in humans
adequate muscle function and delays a better delinea- (45, 46). For example, prolonged, sustained activation of
tion of training adaptation. For example, studies of the AMPK could lead to a catabolic state, lactic acidosis, car-
motor unit, the unity of muscle fiber and motor neuron, diac hypertrophy, brain inflammation, and reduced cogni-
should include sensory-motor circuits in the spinal cord tive abilities (45, 46, 816). PPARb/d ligands increase the
and supraspinal systems, brain stem neurons with de- risk of tumors in rodents when given at high doses over a
scending axons, and brain regions that are involved in prolonged period of time, and even AMPK’s action can
locomotor control and integrate sensory feedback, all switch from tumor suppressor to tumor promoter once
important for muscle control, resistance training adapta- cancer develops (45, 46, 817). It is encouraging to see
tion, muscle memory, and other processes (329, 456, that integrative approaches are increasingly pursued at
464, 809). different centers and organizations in which elite athlete
How will we overcome these shortcomings, and what training and health management is under the same roof
could the future of muscle research look like? In addition as integrative research. Thus, collectively, mechanistic
to new advances in technological possibilities, analysis understanding, implementation in training design, techno-
methods, and computational modeling approaches, one logical innovations, and other advances, cross-fertilized
aim would be stronger interaction, collaboration, and with data from psychology, nutrition, and sleep research,
networking between basic science, sports sciences, and will help to further optimize athletic performance in a
coaches as well as athletes (FIGURE 21). All these fields, safe, personalized, and evidence-based approach (818,
when optimally synergized, may help to obtain a better 819). Thereby, pseudoscience, baseless claims, “quick
understanding of muscle plasticity from the inactive to fixes,” and other potentially detrimental interventions can
the extreme (810, 811). Currently, training paradigms pio- be minimized and information separated from misinfor-
neered by athletes tend to inform and guide research, mation (820). Finally, integrative research in exercise
as was the case for interval training practiced by Paavo should be combined with exercise medicine to further our
Nurmi in the 1920s and Emil Zátopek in the 1950s for understanding of the immense potential of exercise-
middle- and long-distance running disciplines (812). based interventions to prevent and treat many chronic
Such innovative methods are currently enjoying intense diseases in the general population (821), along with
scientific scrutiny in the refined form of HIIT, for both ath- the use of training for injury rehabilitation in physical ther-
letic endeavors and the fitness and well-being of the apy. A better understanding in the athletic setting thus
general population (100). Athlete feedback is central to could and should inform interventions in the general popu-
understanding individualized training response, fatigue lation and in patients (822). For example, studies of resil-
recovery, or concurrent training design and helps to study ience and motivation might also help to design approaches
the mechanistic aspects that underlie these processes to facilitate and improve adherence and compliance to exer-
for iterative optimization of training and competition cise training (823–825). Such an approach could leverage
(71). Importantly, sports psychology and neurobiology novel avenues such as virtual reality exergames (826, 827).
should integrate morphological, cellular, and mecha- Insights into exercise physiology are leveraged in disease
nistic aspects to identify the relevant circuitries, diagnostic, prevention, treatment, and rehabilitation, e.g.,
regions, and signals involved in the control of these the use of blood pressure measurements during exercise
factors, including the cross talk between muscle and (exercise hypertension) to reveal undiagnosed or masked
brain (494, 813, 814). hypertension and predict cardiovascular disease risks
Bypassing this chain of research by jumping directly (828, 829). Many more areas exist in which concepts
from basic science to athletes often leads to a mismatch derived from elite sports will benefit non-athletes and
between preclinical data and “real-world” performance. patients (822). In this context, exercise sociology

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1755

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

Sports psychology
Nutritional sciences
Chronobiology and sleep research
ch
/ c oa
te ack
t hle edb
A fe
Individual athletes

Mechanisms,
Model organisms Causality

Human relevance
(descriptive, correlative)
Cell culture models,
organoids

Basic muscle Human exercise

science physiology
Molecular biology

Exercise is
Computational biology,
medicine
modeling Large cohort data, wearables

Prevention and treatment

FIGURE 21. The future of exercise science for safe, evidence-based, and personalized approaches. To overcome existing hurdles and efficiently
leverage the power of novel techniques and approaches, a close interaction between basic muscle research, applied human exercise physiol-
ogy, as well as athletes and coaches should be aimed for. Model organisms, cell culture, and molecular and computational biology might provide
insights into cause-effect relationships, epistasis, etiologies, and mechanisms complementing the descriptive and correlative studies in human
volunteers. Inversely, data from large cohorts that will become available because of widespread use of wearables and trackers as well as those
obtained in and based on feedback from athletes and coaches will reveal processes and pathways to be explored in mechanistic detail. The mo-
lecular athlete should furthermore be informed by sports psychology, e.g., in regard to motivation, perseverance, compliance and adherence,
nutritional sciences, chronobiology, sleep research, and other fields of relevance to training. Finally, a mutual exchange between the observa-
tions in training and those in various pathologies associated with an inactive lifestyle or inadequate muscle functionality will help to push the
boundaries of physical activity interventions in the prevention and treatment of numerous diseases. Image created with BioRender.com, with
permission.

could contribute to overcome existing individual an absolute manner, even though in many cases seem-
and societal challenges (830). Hopefully, exercise ingly conflicting, contradictory, or non-overlapping alter-
will firmly be recognized and accepted in all aspects native studies exist. Often, such studies depend on
of clinical practice and the political and societal relatively small subject numbers and might have to be
framework established to facilitate and promote an interpreted in light of age, sex, training protocol, sam-
active lifestyle. pling time, and other parameters (diet, sleep, comorbid-
Finally, an issue that will have to be addressed in the ities, fitness level, chronotype, and time of day of the
field of biological/sports science is the formulation of study) (831). Human and animal studies are guilty of this
hypotheses and interpretation of data and results. Too alike. Studies in model organisms have a limited predic-
often, papers claim to have solved an open question in tive power for human exercise physiology but enable

1756 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

causative and mechanistic insights, which are difficult to domain hypothesis was postulated to account for the
conduct in human trials that rely mainly on descriptive or syncytial nature of myofibers, implying that a nucleus is
correlative data. Moreover, while model organisms pro- needed for adequate support for transcription and trans-
vide access to all different types of muscle beds and lation within a specific cell volume, hence a fixed myonu-
allow the analysis of whole muscles, human studies are clear domain, in these extraordinarily large cells (838).
in most cases limited to small, single biopsies of one Accordingly, satellite cell recruitment would be needed
muscle (typically the vastus lateralis), taken at different to provide additional nuclei in fiber hypertrophy (839).
times before, during, or after exercise, with considerable However, the myonuclear domain hypothesis fails to
variability in outcomes and hence interpretation of provide an adequate and complete explanation for sev-
results (388, 446, 832). It might be advisable to be aware eral observations. First, removal of myonuclei in atro-
of possible limitations and keep an open mind vis-à-vis phy is controversial and not observed consistently
alternative interpretations, study-specific bias, and sys- (839–843). Second, the myonuclear domain has high
tem complexity surpassing simplistic explanations. For flexibility and scales with body size, fiber type, mito-
example, there most likely is more than one cause for chondrial activity, fiber hypertrophy, and other param-
muscle fatigue (833); satellite cell recruitment might be eters (838, 844–846). Third, even though the spacing
important for hypertrophy in some but not all cases between most myonuclei is roughly even, regional
(658); the relative contribution of training intensity and differences exist, most notably in the tight clusters of
volume on mitochondrial function in muscle might be three to five subsynaptic myonuclei at the NMJ and
very context-dependent (104, 105) as is the relative con- similar clusters at the myotendinous junction, for both
tribution of muscle hypertrophy to gains in strength of which one nucleus should theoretically be suffi-
(834, 835); and polarized or pyramidal intensity distribu- cient to serve the respective cytoplasmic domain
tions might be optimal for performance enhancement (468). Ample evidence exists of intracellular move-
(116, 132–134). Even “established principles,” “dogmas,” ment of myonuclei (847), as in postexercise fiber
and “laws” should constantly be questioned, validated, repair (649), exchange of proteins between nuclei
and refined. Unfortunately, more often than not, litera- (650), and microtubule-mediated transport of ribonu-
ture searches for such findings disappear into a trail of cleoproteins and RNAs within the myofiber (651), all of
never-ending, consecutive citations. In addition, data which imply a highly plastic system transcending a
and the arising hypotheses must be examined under more rigid definition of myonuclear domains. Finally,
consideration of the technical and conceptual possibil- in cells that rival myofibers in terms of size or length,
ities of the respective historical time period. For exam- such as certain motor neurons with an axonal length
ple, Henneman’s size principle of motor unit recruitment of >1 m (848) compared with some of the longest
(836) certainly holds up under the laboratory conditions muscle fibers in the human musculus sartorius reach-
using the exact preparations and the methods that were ing the length of
60 cm (849), one nucleus, located
used in the 1950s to 1970s. However, the rigid view of asymmetrically in the cell body in the spinal cord,
this principle has since been refined and modified with seems sufficient to provide transcripts for the whole
novel approaches (i.e., using more complex musculoten- cell. Thus, the evolutionary pressure for and physio-
don-skeletal systems, physiologically relevant range of logical function of the syncytial nature of myofibers
forces, physiological and neural stimulation as opposed remain largely mysterious.
to electromyography and -physiology, or consideration These are just a few examples to illustrate that in exer-
of neural drive, cortical and afferent input to each indi- cise biology and sport science, as in any place of scien-
vidual motor neuron) (319, 321, 330, 625). Moreover, it is tific and social discourse (850–852), we should have
not clear how the size principle can accommodate mus- passionate arguments but remain fair, civil, agnostic,
cle fiber type shifts in exercise (624), and recent scRNA- and open minded, carefully consider alternative results
seq and snRNA-seq approaches revealed a greater di- and hypotheses, and constantly challenge, validate, and
versity in motor neuron populations than the classically refine (or refute!) seemingly “established” principles. In
defined types based on transcriptional profiles (326, the final analyses, modern sports science and exercise
837). Thus, even though probably correct at its core, the biology offer numerous opportunities to assist elite ath-
size principle might be oversimplified, and motor unit letes to refine training methods, optimize adaptation,
recruitment and plasticity certainly warrant further study. stay healthy and injury free, achieve their desired phy-
Similarly, even though Nobel prize worthy, August sique, and fight against fatigue factors that limit success-
Krogh’s ideas on oxygen delivery and muscle microvas- ful performance. The accomplishments of elite athletes
culature have, for some aspects, not withstood the test will continue to entertain and amaze us, as science
of time or have been refined and altered by more mod- attempts to catch up and explain the biological bases of
ern and comprehensive methods (595). The myonuclear such feats.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1757

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

GLOSSARY DISCLOSURES

C.H. is an associate editor of Physiological Reviews and was

AMPK AMP-dependent protein kinase not involved in and did not have access to information regard-
ATP Adenosine triphosphate ing the peer-review process or final disposition of this article.
CSA Cross-sectional area An alternate editor oversaw the peer-review and decision-
DOMS Delayed-onset muscle soreness making process for this article. None of the other authors has
ECM Extracellular matrix any conflicts of interest, financial or otherwise, to disclose.
EPO Erythropoietin
Hb Hemoglobin
HIF-1a Hypoxia-inducible factor 1a
AUTHOR CONTRIBUTIONS
HIIT High-intensity interval training
IL Interleukin R.F., J.A.H., and C.H. prepared figures; drafted manuscript;
MPS Muscle protein synthesis edited and revised manuscript; and approved the final version
mTOR Mammalian target of rapamycin of the manuscript.
mTORC1 mTOR complex 1
NMJ Neuromuscular junction
OXPHOS Oxidative phosphorylation
REFERENCES
PGC-1a Peroxisome proliferator-activated receptor c coac-
tivator 1a (gene name PPARGC1A)
1. Marino FE, Sibson BE, Lieberman DE. The evolution of human fatigue
1RM One-repetition maximum
resistance. J Comp Physiol B 192: 411–422, 2022. doi:10.1007/
RYR Ryanodine receptor s00360-022-01439-4.
SERCA Sarcoplasmic/endoplasmic reticulum Ca2 1-
ATPase 2. Bramble DM, Lieberman DE. Endurance running and the evolution
of Homo. Nature 432: 345–352, 2004. doi:10.1038/nature03052.
SNP Single-nucleotide polymorphism
SR Sarcoplasmic reticulum 3. Hunter P. The evolution of human endurance: research on the biol-
VEGF Vascular epithelial growth factor ogy of extreme endurance gives insights into its evolution in humans
V_ O2max Maximal oxygen uptake and animals. EMBO Rep 20: e49396, 2019. doi:10.15252/embr.
201949396.

CORRESPONDENCE 4. Kim DS, Wheeler MT, Ashley EA. The genetics of human perform-
ance. Nat Rev Genet 23: 40–54, 2022. doi:10.1038/s41576-021-
C. Handschin ([email protected]); R. Furrer 00400-5.
([email protected]); J. A. Hawley ( john.hawley@acu. 5. Liebenberg L. The relevance of persistence hunting to human evo-
edu.au). lution. J Hum Evol 55: 1156–1159, 2008. doi:10.1016/j.jhevol.2008.
07.004.

6. Pontzer H. Economy and endurance in human evolution. Curr Biol

ACKNOWLEDGMENTS 27: R613–R621, 2017. doi:10.1016/j.cub.2017.05.031.

7. Kiely J, Collins DJ. Uniqueness of human running coordination: the

The authors thank the members of their research groups for integration of modern and ancient evolutionary innovations. Front
helpful discussions and comments regarding this manuscript. Psychol 7: 262, 2016. doi:10.3389/fpsyg.2016.00262.
We also thank the coaches and athletes for sharing training
8. Lieberman DE. Human locomotion and heat loss: an evolutionary
plans. Because of space limitations, we have been unable to
perspective. Compr Physiol 5: 99–117, 2015. doi:10.1002/cphy.
include all of the pertinent and original work by some of our c140011.
peers, for which we apologize in advance. The figures were
created with BioRender.com. Images were obtained from pub- 9. Hawley JA, Hargreaves M, Joyner MJ, Zierath JR. Integrative biology
of exercise. Cell 159: 738–749, 2014. doi:10.1016/j.cell.2014.10.029.
lic repositories and acknowledged in the respective figure
legends. 10. Mattson MP. Evolutionary aspects of human exercise—born to run
purposefully. Ageing Res Rev 11: 347–352, 2012. doi:10.1016/j.
arr.2012.01.007.

GRANTS 11. Neel JV. Diabetes mellitus: a “thrifty” genotype rendered detrimen-
tal by “progress”? Am J Hum Genet 14: 353–362, 1962.
Work in the laboratory of R.F. and C.H. related to this article 12. Booth FW, Chakravarthy MV, Gordon SE, Spangenburg EE. Waging
was supported by the Swiss National Science Foundation war on physical inactivity: using modern molecular ammunition
(310030_184832), the European Research Council (616830- against an ancient enemy. J Appl Physiol (1985) 93: 3–30, 2002.
MUSCLE_NET), Innosuisse (44112.1 IP-LS), the Swiss Society doi:10.1152/japplphysiol.00073.2002.
for Research on Muscle Diseases, the Jain Foundation, the 13. Rodriguez J, Vernus B, Chelh I, Cassar-Malek I, Gabillard JC, Hadj
Biozentrum, and the University of Basel. Sassi A, Seiliez I, Picard B, Bonnieu A. Myostatin and the skeletal

1758 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

muscle atrophy and hypertrophy signaling pathways. Cell Mol Life Cardiorespiratory fitness as a quantitative predictor of all-cause mor-
Sci 71: 4361–4371, 2014. doi:10.1007/s00018-014-1689-x. tality and cardiovascular events in healthy men and women: a meta-
analysis. JAMA 301: 2024–2035, 2009. doi:10.1001/jama.2009.681.
14. Bellinge RH, Liberles DA, Iaschi SP, O’Brien PA, Tay GK. Myostatin
and its implications on animal breeding: a review. Anim Genet 36: 29. Lavie CJ, Ozemek C, Carbone S, Katzmarzyk PT, Blair SN.
1–6, 2005. doi:10.1111/j.1365-2052.2004.01229.x. Sedentary behavior, exercise, and cardiovascular health. Circ Res
124: 799–815, 2019. doi:10.1161/CIRCRESAHA.118.312669.
15. Lee SJ. Targeting the myostatin signaling pathway to treat muscle
loss and metabolic dysfunction. J Clin Invest 131: e148372, 2021. 30. Katzmarzyk PT, Ross R, Blair SN, Despre s JP. Should we target
doi:10.1172/JCI148372. increased physical activity or less sedentary behavior in the battle
against cardiovascular disease risk development? Atherosclerosis
16. Rodgers BD, Garikipati DK. Clinical, agricultural, and evolutionary
biology of myostatin: a comparative review. Endocr Rev 29: 513– 311: 107–115, 2020. doi:10.1016/j.atherosclerosis.2020.07.010.
534, 2008. doi:10.1210/er.2008-0003. 31. Srikanthan P, Karlamangla AS. Muscle mass index as a predictor of
17. Eliasson P, Andersson T, Kulas J, Seemann P, Aspenberg P. longevity in older adults. Am J Med 127: 547–553, 2014.
Myostatin in tendon maintenance and repair. Growth Factors 27: doi:10.1016/j.amjmed.2014.02.007.
247–254, 2009. doi:10.1080/08977190903052539.
32. Linge J, Petersson M, Forsgren MF, Sanyal AJ, Dahlqvist Leinhard
18. Lavin KM, Coen PM, Baptista LC, Bell MB, Drummer D, Harper SA, O. Adverse muscle composition predicts all-cause mortality in the
Lixandrão ME, McAdam JS, O’Bryan SM, Ramos S, Roberts LM, UK Biobank imaging study. J Cachexia Sarcopenia Muscle 12:
Vega RB, Goodpaster BH, Bamman MM, Buford TW. State of knowl- 1513–1526, 2021. doi:10.1002/jcsm.12834.
edge on molecular adaptations to exercise in humans: historical
perspectives and future directions. Compr Physiol 12: 3193–3279, 33. Liu M, Zhang Z, Zhou C, Ye Z, He P, Zhang Y, Li H, Liu C, Qin X.
2022. doi:10.1002/cphy.c200033. Predicted fat mass and lean mass in relation to all-cause and
cause-specific mortality. J Cachexia Sarcopenia Muscle 13: 1064–
19. King AJ, Burke LM, Halson SL, Hawley JA. The challenge of main- 1075, 2022. doi:10.1002/jcsm.12921.
taining metabolic health during a global pandemic. Sports Med 50:
1233–1241, 2020. doi:10.1007/s40279-020-01295-8. 34. Rantanen T, Masaki K, He Q, Ross GW, Willcox BJ, White L. Midlife
muscle strength and human longevity up to age 100 years: a 44-
20. Jakobsson J, Cotgreave I, Furberg M, Arnberg N, Svensson M. year prospective study among a decedent cohort. Age (Dordr) 34:
Potential physiological and cellular mechanisms of exercise that 563–570, 2012. doi:10.1007/s11357-011-9256-y.
decrease the risk of severe complications and mortality following
SARS-CoV-2 infection. Sports (Basel) 9: 121, 2021. doi:10.3390/ 35. Sayer AA, Kirkwood TB. Grip strength and mortality: a biomarker of
sports9090121. ageing? Lancet 386: 226–227, 2015. doi:10.1016/S0140-6736(14)
62349-7.
21. Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G,
Carty C, Chaput JP, Chastin S, Chou R, Dempsey PC, DiPietro L, 36. Li R, Xia J, Zhang XI, Gathirua-Mwangi WG, Guo J, Li Y, McKenzie S,
Ekelund U, Firth J, Friedenreich CM, Garcia L, Gichu M, Jago R, Song Y. Associations of muscle mass and strength with all-cause
Katzmarzyk PT, Lambert E, Leitzmann M, Milton K, Ortega FB, mortality among US older adults. Med Sci Sports Exerc 50: 458–
Ranasinghe C, Stamatakis E, Tiedemann A, Troiano RP, van der 467, 2018. doi:10.1249/MSS.0000000000001448.
Ploeg HP, Wari V, Willumsen JF. World Health Organization 2020
guidelines on physical activity and sedentary behaviour. Br J Sports 37. Guan Y, Yan Z. Molecular mechanisms of exercise and healthspan.
Med 54: 1451–1462, 2020. doi:10.1136/bjsports-2020-102955. Cells 11: 872, 2022. doi:10.3390/cells11050872.

22. McKay AK, Stellingwerff T, Smith ES, Martin DT, Mujika I, Goosey- 38. Hargreaves M. Exercise and health: historical perspectives and
Tolfrey VL, Sheppard J, Burke LM. Defining training and performance new insights. J Appl Physiol (1985) 131: 575–588, 2021. doi:10.1152/
caliber: a participant classification framework. Int J Sports Physiol japplphysiol.00242.2021.
Perform 17: 317–331, 2022. doi:10.1123/ijspp.2021-0451.
39. McGee SL, Hargreaves M. Exercise adaptations: molecular
23. Levine BD. VO2max: what do we know, and what do we still need mechanisms and potential targets for therapeutic benefit. Nat
to know? J Physiol 586: 25–34, 2008. doi:10.1113/jphysiol.2007. Rev Endocrinol 16: 495–505, 2020. doi:10.1038/s41574-020-
147629. 0377-1.
24. Costill DL. Metabolic responses during distance running. J Appl 40. Lim C, Nunes EA, Currier BS, McLeod JC, Thomas AC, Phillips SM. An
Physiol 28: 251–255, 1970. doi:10.1152/jappl.1970.28.3.251. evidence-based narrative review of mechanisms of resistance exer-
cise-induced human skeletal muscle hypertrophy. Med Sci Sports
25. Costill DL, Fink WJ, Pollock ML. Muscle fiber composition and
enzyme activities of elite distance runners. Med Sci Sports 8: 96– Exerc 54: 1546–1559, 2022. doi:10.1249/MSS.0000000000002929.
100, 1976. 41. Egan B, Sharples AP. Molecular responses to acute exercise and
26. Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood their relevance for adaptations in skeletal muscle to exercise train-
JE. Exercise capacity and mortality among men referred for ing. Physiol Rev. In Press. doi:10.1152/physrev.00054.2021.
exercise testing. N Engl J Med 346: 793–801, 2002. doi:10.1056/
42. Booth FW, Roberts CK, Thyfault JP, Ruegsegger GN, Toedebusch
NEJMoa011858.
RG. Role of inactivity in chronic diseases: evolutionary insight and
27. Strasser B, Burtscher M. Survival of the fittest: VO2max, a key pre- pathophysiological mechanisms. Physiol Rev 97: 1351–1402, 2017.
dictor of longevity? Front Biosci (Landmark Ed) 23: 1505–1516, doi:10.1152/physrev.00019.2016.
2018. doi:10.2741/4657.
43. Handschin C, Spiegelman BM. The role of exercise and PGC1alpha
28. Kodama S, Saito K, Tanaka S, Maki M, Yachi Y, Asumi M, Sugawara in inflammation and chronic disease. Nature 454: 463–469, 2008.
A, Totsuka K, Shimano H, Ohashi Y, Yamada N, Sone H. doi:10.1038/nature07206.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1759

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

44. Tremblay MS, Colley RC, Saunders TJ, Healy GN, Owen N. 60. Haake SJ. The impact of technology on sporting performance in
Physiological and health implications of a sedentary lifestyle. Appl Olympic sports. J Sports Sci 27: 1421–1431, 2009. doi:10.1080/
Physiol Nutr Metab 35: 725–740, 2010. doi:10.1139/H10-079. 02640410903062019.

45. Handschin C. Caloric restriction and exercise “mimetics”: ready for 61. O’Connor LM, Vozenilek JA. Is it the athlete or the equipment?
prime time? Pharmacol Res 103: 158–166, 2016. doi:10.1016/j. An analysis of the top swim performances from 1990 to 2010.
phrs.2015.11.009. J Strength Cond Res 25: 3239–3241, 2011. doi:10.1519/JSC.
0b013e3182392c5f.
46. Hawley JA, Joyner MJ, Green DJ. Mimicking exercise: what matters
most and where to next? J Physiol 599: 791–802, 2021. doi:10.1113/ 62. Malizia F, Blocken B. Bicycle aerodynamics: history, state-of-the-art
JP278761. and future perspectives. J Wind Eng Indust Aerodyn 200: 104134,
2020. doi:10.1016/j.weia.2020.104134.
47. Weihrauch M, Handschin C. Pharmacological targeting of exercise
adaptations in skeletal muscle: benefits and pitfalls. Biochem 63. Kuper GH, Sterken E. Endurance in speed skating: the develop-
Pharmacol 147: 211–220, 2018. doi:10.1016/j.bcp.2017.10.006. ment of world records. Eur J Oper Res 148: 293–301, 2003.
doi:10.1016/S0377-2217(02)00685-9.
48. Berthelot G, Sedeaud A, Marck A, Antero-Jacquemin J, Schipman J,
re G, Marc A, Desgorces FD, Toussaint JF. Has athletic per-
Saulie 64. Dyer B. A pragmatic approach to resolving technological unfair-
formance reached its peak? Sports Med 45: 1263–1271, 2015. ness: the case of Nike’s Vaporfly and Alphafly running footwear.
doi:10.1007/s40279-015-0347-2. Sports Med Open 6: 21, 2020. doi:10.1186/s40798-020-00250-1.

49. Marck A, Antero J, Berthelot G, Johnson S, Sedeaud A, Leroy A, 65. Hunter I, McLeod A, Valentine D, Low T, Ward J, Hager R. Running
Marc A, Spedding M, Di Meglio JM, Toussaint JF. Age-related upper economy, mechanics, and marathon racing shoes. J Sports Sci 37:
limits in physical performances. J Gerontol A Biol Sci Med Sci 74: 2367–2373, 2019. doi:10.1080/02640414.2019.1633837.
591–599, 2019. doi:10.1093/gerona/gly165.
66. Emig T, Peltonen J. Human running performance from real-world
50. Godsey B. Comparing and forecasting performances in different big data. Nat Commun 11: 4936, 2020. doi:10.1038/s41467-020-
events of athletics using a probabilistic model. J Quant Anal Sports 18737-6.
8: 2, 2012. doi:10.1515/1559-0410.1434.
67. Joyner MJ. Genetic approaches for sports performance: how far
51. Hoogkamer W, Snyder KL, Arellano CJ. Modeling the benefits of co- away are we? Sports Med 49: 199–204, 2019. doi:10.1007/s40279-
operative drafting: is there an optimal strategy to facilitate a sub-2- 019-01164-z.
hour marathon performance? Sports Med 48: 2859–2867, 2018. 68. Williams AG, Wackerhage H, Day SH. Genetic testing for sports per-
doi:10.1007/s40279-018-0991-4. formance, responses to training and injury risk: practical and ethical
52. Hoogkamer W, Snyder KL, Arellano CJ. Reflecting on Eliud considerations. Med Sport Sci 61: 105–119, 2016. doi:10.1159/
Kipchoge’s marathon world record: an update to our model of co- 000445244.
operative drafting and its potential for a sub-2-hour performance. 69. Hecksteden A, Kraushaar J, Scharhag-Rosenberger F, Theisen D,
Sports Med 49: 167–170, 2019. doi:10.1007/s40279-019-01056-2. Senn S, Meyer T. Individual response to exercise training—a statistical
perspective. J Appl Physiol (1985) 118: 1450–1459, 2015. doi:10.1152/
53. Jones AM, Kirby BS, Clark IE, Rice HM, Fulkerson E, Wylie LJ,
japplphysiol.00714.2014.
Wilkerson DP, Vanhatalo A, Wilkins BW. Physiological demands of
running at 2-hour marathon race pace. J Appl Physiol (1985) 130: 70. Larsen HB, Sheel AW. The Kenyan runners. Scand J Med Sci
369–379, 2021. doi:10.1152/japplphysiol.00647.2020. Sports 25: 110–118, 2015. doi:10.1111/sms.12573.
54. Joyner MJ, Hunter SK, Lucia A, Jones AM. Physiology and fast mar- 71. Etxebarria N, Mujika I, Pyne DB. Training and competition readiness
athons. J Appl Physiol (1985) 128: 1065–1068, 2020. doi:10.1152/ in triathlon. Sports (Basel) 7: 101, 2019. doi:10.3390/sports7050101.
japplphysiol.00793.2019.
72. Guest NS, Horne J, Vanderhout SM, El-Sohemy A. Sport nutrige-
55. Hawley JA, Lundby C, Cotter JD, Burke LM. Maximizing cellular ad- nomics: personalized nutrition for athletic performance. Front Nutr
aptation to endurance exercise in skeletal muscle. Cell Metab 27: 6: 8, 2019. doi:10.3389/fnut.2019.00008.
962–976, 2018. doi:10.1016/j.cmet.2018.04.014.
73. Kerksick CM, Wilborn CD, Roberts MD, Smith-Ryan A, Kleiner SM,
56. Snyder KL, Hoogkamer W, Triska C, Taboga P, Arellano CJ, Kram R. €ger R, Collins R, Cooke M, Davis JN, Galvan E, Greenwood M,
Ja
Effects of course design (curves and elevation undulations) on mar- Lowery LM, Wildman R, Antonio J, Kreider RB. ISSN exercise &
athon running performance: a comparison of Breaking 2 in Monza sports nutrition review update: research & recommendations. J
and the INEOS 1:59 Challenge in Vienna. J Sports Sci 39: 754–759, Int Soc Sports Nutr 15: 38, 2018. doi:10.1186/s12970-018-0242-y.
2021. doi:10.1080/02640414.2020.1843820.
74. Coyle EF, Burton HM, Satiroglu R. Inactivity causes resistance to
57. Akkari A, Machin D, Tanaka H. Greater progression of athletic per- improvements in metabolism after exercise. Exerc Sport Sci Rev
formance in older Masters athletes. Age Ageing 44: 683–686, 50: 81–88, 2022. doi:10.1249/JES.0000000000000280.
2015.
75. Foster C, Barroso R, Beneke R, Bok D, Boullosa D, Casado A, Chamari
58. Lippi G, Banfi G, Favaloro EJ, Rittweger J, Maffulli N. Updates on K, Cortis C, Koning J, Fusco A, Haugen T, Lucía A, Mujika I, Pyne D,
improvement of human athletic performance: focus on world Rodríguez-Marroyo JA, Sandbakk O, Seiler S. How to succeed as an
records in athletics. Br Med Bull 87: 7–15, 2008. doi:10.1093/bmb/ athlete: what we know, what we need to know. Int J Sports Physiol
ldn029. Perform 17: 333–334, 2022. doi:10.1123/ijspp.2021-0541.

59. Lepers R, Stapley PJ. Master athletes are extending the limits of 76. Lepers R, Stapley PJ, Cattagni T, Gremeaux V, Knechtle B. Limits in
human endurance. Front Physiol 7: 613, 2016. doi:10.3389/ endurance performance of octogenarian athletes. J Appl Physiol
fphys.2016.00613. (1985) 114: 829, 2013. doi:10.1152/japplphysiol.00038.2013.

1760 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

77. Lepers R, Stapley PJ, Cattagni T. Centenarian athletes: examples of endurance and strength over time. J Strength Cond Res 35: 1449–
ultimate human performance? Age Ageing 45: 732–736, 2016. 1458, 2021. doi:10.1519/JSC.0000000000003964.
doi:10.1093/ageing/afw111.
94. McMaster DT, Gill N, Cronin J, McGuigan M. The development,
78. Booth FW, Laye MJ. Lack of adequate appreciation of physical retention and decay rates of strength and power in elite rugby
exercise’s complexities can pre-empt appropriate design and inter- union, rugby league and American football: a systematic review.
pretation in scientific discovery. J Physiol 587: 5527–5539, 2009. Sports Med 43: 367–384, 2013. doi:10.1007/s40279-013-0031-3.
doi:10.1113/jphysiol.2009.179507.
95. Mujika I, Padilla S. Muscular characteristics of detraining in humans.
79. Hawley JA. Adaptations of skeletal muscle to prolonged, intense Med Sci Sports Exerc 33: 1297–1303, 2001. doi:10.1097/00005768-
endurance training. Clin Exp Pharmacol Physiol 29: 218–222, 200108000-00009.
2002. doi:10.1046/j.1440-1681.2002.03623.x.
96. Mujika I. Intense training: the key to optimal performance before
80. Joyner MJ, Coyle EF. Endurance exercise performance: the physiol- and during the taper. Scand J Med Sci Sports 20: 24–31, 2010.
ogy of champions. J Physiol 586: 35–44, 2008. doi:10.1113/jphysiol. doi:10.1111/j.1600-0838.2010.01189.x.
2007.143834.
97. Mujika I, Sharma AP, Stellingwerff T. Contemporary periodization of
81. Burke LM, Hawley JA. Swifter, higher, stronger: what’s on the altitude training for elite endurance athletes: a narrative review.
menu? Science 362: 781–787, 2018. doi:10.1126/science.aau2093. Sports Med 49: 1651–1669, 2019. doi:10.1007/s40279-019-01165-y.

82. Jones CM, Griffiths PC, Mellalieu SD. Training load and fatigue 98. Gibala MJ. Physiological basis of interval training for performance
marker associations with injury and illness: a systematic review of enhancement. Exp Physiol 106: 2324–2327, 2021. doi:10.1113/
longitudinal studies. Sports Med 47: 943–974, 2017. doi:10.1007/ EP088190.
s40279-016-0619-5. 99. Gibala MJ, Hawley JA. Sprinting toward fitness. Cell Metab 25:
83. Sarzynski MA, Bouchard C. World-class athletic performance and 988–990, 2017. doi:10.1016/j.cmet.2017.04.030.
genetic endowment. Nat Metab 2: 796–798, 2020. doi:10.1038/ 100. MacInnis MJ, Gibala MJ. Physiological adaptations to interval train-
s42255-020-0233-6. ing and the role of exercise intensity. J Physiol 595: 2915–2930,
2017. doi:10.1113/JP273196.
84. Dent JR, Stocks B, Campelj DG, Philp A. Transient changes to met-
abolic homeostasis initiate mitochondrial adaptation to endur- 101. Burgomaster KA, Howarth KR, Phillips SM, Rakobowchuk M,
ance exercise. Semin Cell Dev Biol 143: 3–16, 2023. doi:10.1016/ Macdonald MJ, McGee SL, Gibala MJ. Similar metabolic adapta-
j.semcdb.2022.03.022. tions during exercise after low volume sprint interval and traditional
endurance training in humans. J Physiol 586: 151–160, 2008.
85. Camera DM, Smiles WJ, Hawley JA. Exercise-induced skeletal muscle
doi:10.1113/jphysiol.2007.142109.
signaling pathways and human athletic performance. Free Radic Biol
Med 98: 131–143, 2016. doi:10.1016/j.freeradbiomed.2016.02.007. 102. Gibala MJ, Little JP, van Essen M, Wilkin GP, Burgomaster KA,
Safdar A, Raha S, Tarnopolsky MA. Short-term sprint interval versus
86. Coffey VG, Hawley JA. The molecular bases of training adapta-
traditional endurance training: similar initial adaptations in human
tion. Sports Med 37: 737–763, 2007. doi:10.2165/00007256-
skeletal muscle and exercise performance. J Physiol 575: 901–911,
200737090-00001.
2006. doi:10.1113/jphysiol.2006.112094.
87. Egan B, Zierath JR. Exercise metabolism and the molecular regula-
103. Lydiard A, Gilmour G. Run to the Top (2nd rev. ed.). London: Arena
tion of skeletal muscle adaptation. Cell Metab 17: 162–184, 2013. Publications, 1968.
doi:10.1016/j.cmet.2012.12.012.
104. MacInnis MJ, Skelly LE, Gibala MJ. CrossTalk proposal: Exercise
88. Coffey VG, Hawley JA. Concurrent exercise training: do opposites training intensity is more important than volume to promote
distract? J Physiol 595: 2883–2896, 2017. doi:10.1113/JP272270. increases in human skeletal muscle mitochondrial content. J
Physiol 597: 4111–4113, 2019. doi:10.1113/JP277633.
89. Callahan MJ, Parr EB, Snijders T, Conceição MS, Radford BE,
Timmins RG, Devlin BL, Hawley JA, Camera DM. Skeletal muscle 105. Bishop DJ, Botella J, Granata C. CrossTalk opposing view: Exercise
adaptive responses to different types of short-term exercise train- training volume is more important than training intensity to promote
ing and detraining in middle-age men. Med Sci Sports Exerc 53: increases in mitochondrial content. J Physiol 597: 4115–4118, 2019.
2023–2036, 2021. doi:10.1249/MSS.0000000000002684. doi:10.1113/JP277634.
90. Coyle EF, Coggan AR, Hemmert MK, Ivy JL. Muscle glycogen utiliza- 106. Flockhart M, Nilsson LC, Tais S, Ekblom B, Apro  W, Larsen FJ.
tion during prolonged strenuous exercise when fed carbohydrate. J Excessive exercise training causes mitochondrial functional impair-
Appl Physiol (1985) 61: 165–172, 1986. doi:10.1152/jappl.1986. ment and decreases glucose tolerance in healthy volunteers. Cell
61.1.165. Metab 33: 957–970.e6, 2021. doi:10.1016/j.cmet.2021.02.017.
91. Coyle EF, Martin WH 3rd, Bloomfield SA, Lowry OH, Holloszy JO. 107. Hawley JA, Bishop DJ. High-intensity exercise training - too
Effects of detraining on responses to submaximal exercise. J Appl much of a good thing? Nat Rev Endocrinol 17: 385–386, 2021.
Physiol (1985) 59: 853–859, 1985. doi:10.1152/jappl.1985.59.3.853. doi:10.1038/s41574-021-00500-6.

92. Coyle EF, Martin WH 3rd, Sinacore DR, Joyner MJ, Hagberg JM, 108. Matwejew LP. Die periodisierung des sportlichen trainings.
Holloszy JO. Time course of loss of adaptations after stopping pro- Leistungssport 2: 401–409, 1972.
longed intense endurance training. J Appl Physiol Respir Environ
Exerc Physiol 57: 1857–1864, 1984. doi:10.1152/jappl.1984.57.6.1857. 109. Mujika I, Halson S, Burke LM, Balague  G, Farrow D. An integrated,
multifactorial approach to periodization for optimal performance in
93. Spiering BA, Mujika I, Sharp MA, Foulis SA. Maintaining physical individual and team sports. Int J Sports Physiol Perform 13: 538–
performance: the minimal dose of exercise needed to preserve 561, 2018. doi:10.1123/ijspp.2018-0093.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1761

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

110. Seiler S. What is best practice for training intensity and duration dis- 125. Jeukendrup AE, Craig NP, Hawley JA. The bioenergetics of world
tribution in endurance athletes? Int J Sports Physiol Perform 5: class cycling. J Sci Med Sport 3: 414–433, 2000. doi:10.1016/s1440-
276–291, 2010. doi:10.1123/ijspp.5.3.276. 2440(00)80008-0.

111. Hawley JA, Burke LM. Peak Performance: Training and Nutritional 126. Sanders D, van Erp T, de Koning JJ. Intensity and load characteris-
Strategies for Sport. St. Leonards, NSW, Australia: Allen & Unwin, tics of professional road cycling: differences between men’s and
1998, p. 456. women’s races. Int J Sports Physiol Perform 14: 296–302, 2019.
doi:10.1123/ijspp.2018-0190.
112. Jones AM. A five year physiological case study of an Olympic run-
ner. Br J Sports Med 32: 39–43, 1998. doi:10.1136/bjsm.32.1.39. 127. Mujika I, Chatard JC, Busso T, Geyssant A, Barale F, Lacoste L.
Effects of training on performance in competitive swimming. Can J
113. Solli GS, Tønnessen E, Sandbakk O. The training characteristics of Appl Physiol 20: 395–406, 1995. doi:10.1139/h95-031.
the world’s most successful female cross-country skier. Front
Physiol 8: 1069, 2017. doi:10.3389/fphys.2017.01069. 128. Rosenblat MA, Perrotta AS, Vicenzino B. Polarized vs. threshold
training intensity distribution on endurance sport performance: a
114. Leo P, Spragg J, Simon D, Lawley JS, Mujika I. Training characteris- systematic review and meta-analysis of randomized controlled tri-
tics and power profile of professional U23 cyclists throughout a als. J Strength Cond Res 33: 3491–3500, 2019. doi:10.1519/
competitive season. Sports (Basel) 8: 120167, 2020. doi:10.3390/ JSC.0000000000002618.
sports8120167.
129. Coetzer P, Noakes TD, Sanders B, Lambert MI, Bosch AN, Wiggins
115. Casado A, González-Mohíno F, González-Rave  JM, Foster C. T, Dennis SC. Superior fatigue resistance of elite black South
Training periodization, methods, intensity distribution, and volume African distance runners. J Appl Physiol (1985) 75: 1822–1827,
in highly trained and elite distance runners: a systematic review. Int 1993. doi:10.1152/jappl.1993.75.4.1822.
J Sports Physiol Perform 17: 820–833, 2022. doi:10.1123/ijspp.
2021-0435. 130. Guellich A, Seiler S, Emrich E. Training methods and intensity distri-
bution of young world-class rowers. Int J Sports Physiol Perform 4:
116. Burnley M, Bearden SE, Jones AM. Polarized training is not opti- 448–460, 2009. doi:10.1123/ijspp.4.4.448.
mal for endurance athletes: response to foster and colleagues.
Med Sci Sports Exerc 54: 1038–1040, 2022. doi:10.1249/MSS. 131. Laursen PB. Training for intense exercise performance: high-inten-
0000000000002924. sity or high-volume training? Scand J Med Sci Sports 20, Suppl 2:
1–10, 2010. doi:10.1111/j.1600-0838.2010.01184.x.
117. Bourgois JG, Bourgois G, Boone J. Perspectives and determinants
for training-intensity distribution in elite endurance athletes. Int J 132. Foster C, Casado A, Esteve-Lanao J, Haugen T, Seiler S. Polarized
Sports Physiol Perform 14: 1151–1156, 2019. doi:10.1123/ijspp.2018- training is optimal for endurance athletes. Med Sci Sports Exerc 54:
0722. 1028–1031, 2022. doi:10.1249/MSS.0000000000002871.

118. Casado A, Hanley B, Ruiz-Perez LM. Deliberate practice in training 133. Burnley M, Bearden SE, Jones AM. Polarized training is not optimal
differentiates the best Kenyan and Spanish long-distance runners. for endurance athletes. Med Sci Sports Exerc 54: 1032–1034,
Eur J Sport Sci 20: 887–895, 2020. doi:10.1080/17461391.2019. 2022. doi:10.1249/MSS.0000000000002869.
1694077.
134. Foster C, Casado A, Esteve-Lanao J, Haugen T, Seiler S. Polarized
119. Casado A, Hanley B, Santos-Concejero J, Ruiz-Perez LM. World- training is optimal for endurance athletes: response to Burnley,
class long-distance running performances are best predicted by Bearden, and Jones. Med Sci Sports Exerc 54: 1035–1037, 2022.
volume of easy runs and deliberate practice of short-interval and doi:10.1249/MSS.0000000000002923.
tempo runs. J Strength Cond Res 35: 2525–2531, 2021. doi:10.1519/
JSC.0000000000003176. 135. Moesgaard L, Beck MM, Christiansen L, Aagaard P, Lundbye-
Jensen J. Effects of periodization on strength and muscle hypertro-
120. Metcalfe AJ, Menaspà P, Villerius V, Quod M, Peiffer JJ, Govus AD, phy in volume-equated resistance training programs: a systematic
Abbiss CR. Within-season distribution of external training and rac- review and meta-analysis. Sports Med 52: 1647–1666, 2022.
ing workload in professional male road cyclists. Int J Sports Physiol doi:10.1007/s40279-021-01636-1.
Perform 12: S2142–S2146, 2017. doi:10.1123/ijspp.2016-0396.
136. Phillips SM. A brief review of critical processes in exercise-induced
121. Seiler KS, Kjerland GO. Quantifying training intensity distribution in muscular hypertrophy. Sports Med 44, Suppl 1: S71–S77, 2014.
elite endurance athletes: is there evidence for an “optimal” distribu- doi:10.1007/s40279-014-0152-3.
tion? Scand J Med Sci Sports 16: 49–56, 2006. doi:10.1111/j.1600-
0838.2004.00418.x. 137. Lyristakis PM, Wundersitz DW, Zadow EK, Mnatzaganian G, Gordon
BA. The influence of considering individual resistance training vari-
122. Billat V, Lepretre PM, Heugas AM, Laurence MH, Salim D, ables as a whole on muscle strength: a systematic review and
Koralsztein JP. Training and bioenergetic characteristics in elite meta-analysis protocol. PLoS One 17: e0262674, 2022. doi:10.1371/
male and female Kenyan runners. Med Sci Sports Exerc 35: 297– journal.pone.0262674.
304, 2003. doi:10.1249/01.MSS.0000053556.59992.A9.
138. Viecelli C, Aguayo D. May the force and mass be with you—evi-
123. Billat VL, Demarle A, Slawinski J, Paiva M, Koralsztein JP. Physical dence-based contribution of mechano-biological descriptors of re-
and training characteristics of top-class marathon runners. Med sistance exercise. Front Physiol 12: 686119, 2021. doi:10.3389/
Sci Sports Exerc 33: 2089–2097, 2001. doi:10.1097/00005768- fphys.2021.686119.
200112000-00018.
139. Schoenfeld BJ, Grgic J, Van Every DW, Plotkin DL. Loading recom-
124. Karp JR. Training characteristics of qualifiers for the U.S. Olympic mendations for muscle strength, hypertrophy, and local endurance:
Marathon Trials. Int J Sports Physiol Perform 2: 72–92, 2007. a re-examination of the repetition continuum. Sports (Basel) 9: 32,
doi:10.1123/ijspp.2.1.72. 2021. doi:10.3390/sports9020032.

1762 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

140. American College of Sports Medicine. American College of Sports 154. van der Zwaard S, Brocherie F, Jaspers RT. Under the hood: skele-
Medicine position stand. Progression models in resistance training tal muscle determinants of endurance performance. Front Sports
for healthy adults. Med Sci Sports Exerc 41: 687–708, 2009. Act Living 3: 719434, 2021. doi:10.3389/fspor.2021.719434.
doi:10.1249/MSS.0b013e3181915670.
155. van Wessel T, de Haan A, van der Laarse WJ, Jaspers RT. The mus-
141. Alkner BA, Tesch PA, Berg HE. Quadriceps EMG/force relationship cle fiber type-fiber size paradox: hypertrophy or oxidative metabo-
in knee extension and leg press. Med Sci Sports Exerc 32: 459– lism? Eur J Appl Physiol 110: 665–694, 2010. doi:10.1007/s00421-
463, 2000. doi:10.1097/00005768-200002000-00030. 010-1545-0.

142. Kumar V, Selby A, Rankin D, Patel R, Atherton P, Hildebrandt W, 156. Hickson RC. Interference of strength development by simultane-
Williams J, Smith K, Seynnes O, Hiscock N, Rennie MJ. Age-related ously training for strength and endurance. Eur J Appl Physiol
differences in the dose-response relationship of muscle protein Occup Physiol 45: 255–263, 1980. doi:10.1007/BF00421333.
synthesis to resistance exercise in young and old men. J Physiol
587: 211–217, 2009. doi:10.1113/jphysiol.2008.164483. 157. Rønnestad BR, Mujika I. Optimizing strength training for running
and cycling endurance performance: a review. Scand J Med Sci
143. Burd NA, West DW, Staples AW, Atherton PJ, Baker JM, Moore DR, Sports 24: 603–612, 2014. doi:10.1111/sms.12104.
Holwerda AM, Parise G, Rennie MJ, Baker SK, Phillips SM. Low-load
high volume resistance exercise stimulates muscle protein synthe- 158. Berryman N, Mujika I, Bosquet L. Concurrent training for sports per-
sis more than high-load low volume resistance exercise in young formance: the 2 sides of the medal. Int J Sports Physiol Perform
men. PLoS One 5: e12033, 2010. doi:10.1371/journal.pone.0012033. 14: 279–285, 2019. doi:10.1123/ijspp.2018-0103.

144. Mitchell CJ, Churchward-Venne TA, West DW, Burd NA, Breen L, 159. Bassel-Duby R, Olson EN. Signaling pathways in skeletal muscle
Baker SK, Phillips SM. Resistance exercise load does not determine remodeling. Annu Rev Biochem 75: 19–37, 2006. doi:10.1146/
training-mediated hypertrophic gains in young men. J Appl Physiol annurev.biochem.75.103004.142622.
(1985) 113: 71–77, 2012. doi:10.1152/japplphysiol.00307.2012.
160. Egan B, Hawley JA, Zierath JR. SnapShot: Exercise metabolism.
145. Alway SE, Sale DG, MacDougall JD. Twitch contractile adaptations Cell Metab 24: 342–342.e1, 2016. doi:10.1016/j.cmet.2016.07.013.
are not dependent on the intensity of isometric exercise in the
human triceps surae. Eur J Appl Physiol Occup Physiol 60: 346– 161. Hoffman NJ, Parker BL, Chaudhuri R, Fisher-Wellman KH, Kleinert
352, 1990. doi:10.1007/BF00713497. M, Humphrey SJ, Yang P, Holliday M, Trefely S, Fazakerley DJ,
€ ckli J, Burchfield JG, Jensen TE, Jothi R, Kiens B, Wojtaszewski
Sto
146. Haugen T, Sandbakk O, Enoksen E, Seiler S, Tønnessen E. JF, Richter EA, James DE. Global phosphoproteomic analysis of
Crossing the golden training divide: the science and practice of human skeletal muscle reveals a network of exercise-regulated ki-
training world-class 800- and 1500-m runners. Sports Med 51: nases and AMPK substrates. Cell Metab 22: 922–935, 2015.
1835–1854, 2021. doi:10.1007/s40279-021-01481-2. doi:10.1016/j.cmet.2015.09.001.

147. Włodarczyk M, Adamus P, Zielin ski J, Kantanista A. Effects of veloc- 162. Hood DA, Irrcher I, Ljubicic V, Joseph AM. Coordination of meta-
ity-based training on strength and power in elite athletes—a sys- bolic plasticity in skeletal muscle. J Exp Biol 209: 2265–2275,
tematic review. Int J Environ Res Public Health 18: 5257, 2021. 2006. doi:10.1242/jeb.02182.
doi:10.3390/ijerph18105257.
163. Hoppeler H. Molecular networks in skeletal muscle plasticity. J Exp
148. Cormie P, McGuigan MR, Newton RU. Developing maximal neuro- Biol 219: 205–213, 2016. doi:10.1242/jeb.128207.
muscular power: part 2—training considerations for improving maxi-
mal power production. Sports Med 41: 125–146, 2011. doi:10.2165/ 164. Perry CG, Hawley JA. Molecular basis of exercise-induced skeletal
11538500-000000000-00000. muscle mitochondrial biogenesis: historical advances, current
knowledge, and future challenges. Cold Spring Harb Perspect
149. Patterson SD, Hughes L, Warmington S, Burr J, Scott BR, Owens J, Med 8: a029686, 2018. doi:10.1101/cshperspect.a029686.
Abe T, Nielsen JL, Libardi CA, Laurentino G, Neto GR, Brandner C,
Martin-Hernandez J, Loenneke J. Blood Flow Restriction Exercise: 165. Yang Y, Creer A, Jemiolo B, Trappe S. Time course of myogenic
Considerations of Methodology, Application, and Safety. Front and metabolic gene expression in response to acute exercise in
Physiol 10: 533, 2019. doi:10.3389/fphys.2019.00533. human skeletal muscle. J Appl Physiol (1985) 98: 1745–1752,
2005. doi:10.1152/japplphysiol.01185.2004.
150. Pignanelli C, Christiansen D, Burr JF. Blood flow restriction training
and the high-performance athlete: science to application. J Appl 166. Hughes DC, Ellefsen S, Baar K. Adaptations to endurance and
Physiol (1985) 130: 1163–1170, 2021. doi:10.1152/japplphysiol.00982. strength training. Cold Spring Harb Perspect Med 8: a029769,
2020. 2018. doi:10.1101/cshperspect.a029769.

151. Wortman RJ, Brown SM, Savage-Elliott I, Finley ZJ, Mulcahey 167. Lundberg TR, Feuerbacher JF, S€ unkeler M, Schumann M. The
MK. Blood flow restriction training for athletes: a systematic effects of concurrent aerobic and strength training on muscle fiber
review. Am J Sports Med 49: 1938–1944, 2021. doi:10.1177/ hypertrophy: a systematic review and meta-analysis. Sports Med
0363546520964454. 52: 2391–2403, 2022. doi:10.1007/s40279-022-01688-x.

152. Burd NA, Holwerda AM, Selby KC, West DW, Staples AW, Cain NE, 168. van der Zwaard S, Weide G, Levels K, Eikelboom MRI, Noordhof
Cashaback JG, Potvin JR, Baker SK, Phillips SM. Resistance exer- DA, Hofmijster MJ, van der Laarse WJ, de Koning JJ, de Ruiter CJ,
cise volume affects myofibrillar protein synthesis and anabolic sig- Jaspers RT. Muscle morphology of the vastus lateralis is strongly
nalling molecule phosphorylation in young men. J Physiol 588: related to ergometer performance, sprint capacity and endurance
3119–3130, 2010. doi:10.1113/jphysiol.2010.192856. capacity in Olympic rowers. J Sports Sci 36: 2111–2120, 2018.
doi:10.1080/02640414.2018.1439434.
153. Williams TD, Tolusso DV, Fedewa MV, Esco MR. Comparison of
periodized and non-periodized resistance training on maximal 169. van der Zwaard S, van der Laarse WJ, Weide G, Bloemers FW,
strength: a meta-analysis. Sports Med 47: 2083–2100, 2017. Hofmijster MJ, Levels K, Noordhof DA, de Koning JJ, De Ruiter
doi:10.1007/s40279-017-0734-y. CJ, Jaspers RT. Critical determinants of combined sprint and

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1763

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

endurance performance: an integrative analysis from muscle 183. van Doorslaer de Ten Ryen S, Warnier G, Gnimassou O, Belhaj MR,
fiber to the human body. FASEB J 32: 2110–2123, 2018. Benoit N, Naslain D, Brook MS, Smith K, Wilkinson DJ, Nielens H,
doi:10.1096/fj.201700827R. Atherton PJ, Francaux M, Deldicque L. Higher strength gain after
hypoxic vs normoxic resistance training despite no changes in mus-
170. Lundby C, Millet GP, Calbet JA, Ba€rtsch P, Subudhi AW. Does ‘alti- cle thickness and fractional protein synthetic rate. FASEB J 35:
tude training’ increase exercise performance in elite athletes? Br J e21773, 2021. doi:10.1096/fj.202100654RR.
Sports Med 46: 792–795, 2012. doi:10.1136/bjsports-2012-091231.
184. Martin PM, Bart RM, Ashley RL, Velasco T, Wise SR. An overview
171. Lundby C, Robach P. Does ‘altitude training’ increase exercise of blood flow restriction physiology and clinical considerations.
performance in elite athletes? Exp Physiol 101: 783–788, 2016. Curr Sports Med Rep 21: 123–128, 2022. doi:10.1249/JSR.
doi:10.1113/EP085579. 0000000000000948.
172. Gore CJ, Sharpe K, Garvican-Lewis LA, Saunders PU, Humberstone 185. O’Brien L, Jacobs I. Methodological variations contributing to heter-
CE, Robertson EY, Wachsmuth NB, Clark SA, McLean BD, ogenous ergogenic responses to ischemic preconditioning. Front
Friedmann-Bette B, Neya M, Pottgiesser T, Schumacher YO, Physiol 12: 656980, 2021. doi:10.3389/fphys.2021.656980.
Schmidt WF. Altitude training and haemoglobin mass from the opti-
mised carbon monoxide rebreathing method determined by a 186. Bartlett JD, Hawley JA, Morton JP. Carbohydrate availability and
meta-analysis. Br J Sports Med 47: i31–i39, 2013. doi:10.1136/ exercise training adaptation: too much of a good thing? Eur J Sport
bjsports-2013-092840. Sci 15: 3–12, 2015. doi:10.1080/17461391.2014.920926.

173. Bergeron MF, Bahr R, Ba €rtsch P, Bourdon L, Calbet JA, Carlsen KH, 187. Hansen AK, Fischer CP, Plomgaard P, Andersen JL, Saltin B,
Castagna O, González-Alonso J, Lundby C, Maughan RJ, Millet G, Pedersen BK. Skeletal muscle adaptation: training twice every sec-
Mountjoy M, Racinais S, Rasmussen P, Singh DG, Subudhi AW, ond day vs. training once daily. J Appl Physiol (1985) 98: 93–99,
Young AJ, Soligard T, Engebretsen L. International Olympic 2005. doi:10.1152/japplphysiol.00163.2004.
Committee consensus statement on thermoregulatory and altitude
challenges for high-level athletes. Br J Sports Med 46: 770–779, 188. Hawley JA, Burke LM. Carbohydrate availability and training adap-
2012. doi:10.1136/bjsports-2012-091296. tation: effects on cell metabolism. Exerc Sport Sci Rev 38: 152–160,
2010. doi:10.1097/JES.0b013e3181f44dd9.
174. n J. Hemoglobin mass and aerobic per-
Wehrlin JP, Marti B, Halle
formance at moderate altitude in elite athletes. Adv Exp Med Biol 189. Hawley JA, Morton JP. Ramping up the signal: promoting endur-
903: 357–374, 2016. doi:10.1007/978-1-4899-7678-9_24. ance training adaptation in skeletal muscle by nutritional manipula-
tion. Clin Exp Pharmacol Physiol 41: 608–613, 2014. doi:10.1111/
175. Levine BD, Stray-Gundersen J. “Living high-training low”: effect of 1440-1681.12246.
moderate-altitude acclimatization with low-altitude training on per-
formance. J Appl Physiol (1985) 83: 102–112, 1997. doi:10.1152/ 190. Lane SC, Camera DM, Lassiter DG, Areta JL, Bird SR, Yeo WK,
jappl.1997.83.1.102. Jeacocke NA, Krook A, Zierath JR, Burke LM, Hawley JA. Effects of
sleeping with reduced carbohydrate availability on acute training
176. Saunders PU, Garvican-Lewis LA, Schmidt WF, Gore CJ. Relationship responses. J Appl Physiol (1985) 119: 643–655, 2015. doi:10.1152/
between changes in haemoglobin mass and maximal oxygen uptake japplphysiol.00857.2014.
after hypoxic exposure. Br J Sports Med 47, Suppl 1: i26–i30, 2013.
doi:10.1136/bjsports-2013-092841. 191. Psilander N, Frank P, Flockhart M, Sahlin K. Exercise with low glyco-
gen increases PGC-1alpha gene expression in human skeletal mus-
177. Siebenmann C, Robach P, Jacobs RA, Rasmussen P, Nordsborg N, cle. Eur J Appl Physiol 113: 951–963, 2013. doi:10.1007/s00421-012-
Diaz V, Christ A, Olsen NV, Maggiorini M, Lundby C. “Live high-train 2504-8.
low” using normobaric hypoxia: a double-blinded, placebo-con-
trolled study. J Appl Physiol (1985) 112: 106–117, 2012. doi:10.1152/ 192. Wojtaszewski JF, Jørgensen SB, Frosig C, MacDonald C, Birk JB,
japplphysiol.00388.2011. Richter EA. Insulin signalling: effects of prior exercise. Acta Physiol
Scand 178: 321–328, 2003. doi:10.1046/j.1365-201X.2003.01151.x.
178. Bejder J, Andersen AB, Buchardt R, Larsson TH, Olsen NV,
Nordsborg NB. Endurance, aerobic high-intensity, and repeated 193. Edinburgh RM, Koumanov F, Gonzalez JT. Impact of pre-exercise
sprint cycling performance is unaffected by normobaric “live high- feeding status on metabolic adaptations to endurance-type exercise
train low”: a double-blind placebo-controlled cross-over study. Eur training. J Physiol 600: 1327–1338, 2022. doi:10.1113/JP280748.
J Appl Physiol 117: 979–988, 2017. doi:10.1007/s00421-017-3586-0.
194. Hawley JA, Leckey JJ. Carbohydrate dependence during pro-
179. Gore CJ. The challenge of assessing athlete performance after alti- longed, intense endurance exercise. Sports Med 45, Suppl 1: S5–
tude training. J Appl Physiol (1985) 116: 593–594, 2014. doi:10.1152/ S12, 2015. doi:10.1007/s40279-015-0400-1.
japplphysiol.00029.2014.
195. Burke LM, Hawley JA, Wong SH, Jeukendrup AE. Carbohydrates
180. Hurst P, Schipof-Godart L, Szabo A, Raglin J, Hettinga F, Roelands for training and competition. J Sports Sci 29, Suppl 1: S17–S27, 2011.
B, Lane A, Foad A, Coleman D, Beedie C. The placebo and nocebo doi:10.1080/02640414.2011.585473.
effect on sports performance: a systematic review. Eur J Sport Sci
20: 279–292, 2020. doi:10.1080/17461391.2019.1655098. 196. Burke LM, Hawley JA, Jeukendrup A, Morton JP, Stellingwerff T,
Maughan RJ. Toward a common understanding of diet-exercise
181. Chapman RF, Stickford JL, Levine BD. Altitude training considera- strategies to manipulate fuel availability for training and competition
tions for the winter sport athlete. Exp Physiol 95: 411–421, 2010. preparation in endurance sport. Int J Sport Nutr Exerc Metab 28:
doi:10.1113/expphysiol.2009.050377. 451–463, 2018. doi:10.1123/ijsnem.2018-0289.

182. Alvarez Villela M, Dunworth SA, Kraft BD, Harlan NP, Natoli MJ, 197. Marquet LA, Brisswalter J, Louis J, Tiollier E, Burke LM, Hawley JA,
Suliman HB, Moon RE. Effects of high-intensity interval training with Hausswirth C. Enhanced endurance performance by periodization
hyperbaric oxygen. Front Physiol 13: 963799, 2022. doi:10.3389/ of carbohydrate intake: “sleep low” strategy. Med Sci Sports Exerc
fphys.2022.963799. 48: 663–672, 2016. doi:10.1249/MSS.0000000000000823.

1764 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

198. Marquet LA, Hausswirth C, Molle O, Hawley JA, Burke LM, Tiollier E, between clocks. Cell 174: 1571–1585.e11, 2018. doi:10.1016/j.cell.2018.
Brisswalter J. Periodization of carbohydrate intake: short-term 08.042.
effect on performance. Nutrients 8: 755, 2016. doi:10.3390/
nu8120755. 211. Smith JG, Sassone-Corsi P. Clock-in, clock-out: circadian timekeep-
ing between tissues. Biochem (Lond) 42: 6–10, 2020. doi:10.1042/
199. Yeo WK, McGee SL, Carey AL, Paton CD, Garnham AP, Hargreaves bio04202007.
M, Hawley JA. Acute signalling responses to intense endurance
training commenced with low or normal muscle glycogen. Exp 212. Adamovich Y, Dandavate V, Ezagouri S, Manella G, Zwighaft Z,
Physiol 95: 351–358, 2010. doi:10.1113/expphysiol.2009.049353. Sobel J, Kuperman Y, Golik M, Auerbach A, Itkin M, Malitsky S, Asher
G. Clock proteins and training modify exercise capacity in a daytime-
200. Hulston CJ, Venables MC, Mann CH, Martin C, Philp A, Baar K, dependent manner. Proc Natl Acad Sci USA 118: e2101115118, 2021.
Jeukendrup AE. Training with low muscle glycogen enhances fat doi:10.1073/pnas.2101115118.
metabolism in well-trained cyclists. Med Sci Sports Exerc 42:
2046–2055, 2010. doi:10.1249/MSS.0b013e3181dd5070. 213. Kemler D, Wolff CA, Esser KA. Time-of-day dependent effects of
contractile activity on the phase of the skeletal muscle clock. J
201. Yeo WK, Paton CD, Garnham AP, Burke LM, Carey AL, Hawley JA. Physiol 598: 3631–3644, 2020. doi:10.1113/JP279779.
Skeletal muscle adaptation and performance responses to once a
day versus twice every second day endurance training regimens. J 214. Sato S, Basse AL, Scho € nke M, Chen S, Samad M, Altıntas  A, Laker
Appl Physiol (1985) 105: 1462–1470, 2008. doi:10.1152/japplphysiol. RC, Dalbram E, Barre  s R, Baldi P, Treebak JT, Zierath JR, Sassone-
90882.2008. Corsi P. Time of exercise specifies the impact on muscle metabolic
pathways and systemic energy homeostasis. Cell Metab 30: 92–
202. Burke LM, Ross ML, Garvican-Lewis LA, Welvaert M, Heikura IA, 110.e4, 2019. doi:10.1016/j.cmet.2019.03.013.
Forbes SG, Mirtschin JG, Cato LE, Strobel N, Sharma AP, Hawley JA.
Low carbohydrate, high fat diet impairs exercise economy and neg- 215. Wolff CA, Esser KA. Exercise timing and circadian rhythms. Curr
ates the performance benefit from intensified training in elite race Opin Physiol 10: 64–69, 2019. doi:10.1016/j.cophys.2019.04.020.
walkers. J Physiol 595: 2785–2807, 2017. doi:10.1113/JP273230. 216. Wolff CA, Esser KA. Exercise sets the muscle clock with a calcium
203. Burke LM, Sharma AP, Heikura IA, Forbes SF, Holloway M, McKay assist. J Physiol 598: 5591–5592, 2020. doi:10.1113/JP280783.
AK, Bone JL, Leckey JJ, Welvaert M, Ross ML. Crisis of confidence 217. Eckel-Mahan KL, Patel VR, de Mateo S, Orozco-Solis R, Ceglia NJ,
averted: impairment of exercise economy and performance in elite Sahar S, Dilag-Penilla SA, Dyar KA, Baldi P, Sassone-Corsi P.
race walkers by ketogenic low carbohydrate, high fat (LCHF) diet is Reprogramming of the circadian clock by nutritional challenge. Cell
reproducible. PLoS One 15: e0234027, 2020. doi:10.1371/journal. 155: 1464–1478, 2013. doi:10.1016/j.cell.2013.11.034.
pone.0234027.
218. Greco CM, Koronowski KB, Smith JG, Shi J, Kunderfranco P,
204. Riis S, Møller AB, Dollerup O, Høffner L, Jessen N, Madsen K. Acute Carriero R, Chen S, Samad M, Welz PS, Zinna VM, Mortimer T, Chun
and sustained effects of a periodized carbohydrate intake using the SK, Shimaji K, Sato T, Petrus P, Kumar A, Vaca-Dempere M,
sleep-low model in endurance-trained males. Scand J Med Sci Deryagin O, Van C, Kuhn JM, Lutter D, Seldin MM, Masri S, Li W,
Sports 29: 1866–1880, 2019. doi:10.1111/sms.13541. Baldi P, Dyar KA, Mun ~oz-Cánoves P, Benitah SA, Sassone-Corsi P.
205. Gejl KD, Nybo L. Performance effects of periodized carbohydrate Integration of feeding behavior by the liver circadian clock reveals
restriction in endurance trained athletes—a systematic review and network dependency of metabolic rhythms. Sci Adv 7: eabi7828,
meta-analysis. J Int Soc Sports Nutr 18: 37, 2021. doi:10.1186/ 2021. doi:10.1126/sciadv.abi7828.
s12970-021-00435-3. 219. Lundell LS, Parr EB, Devlin BL, Ingerslev LR, Altıntas A, Sato S,
Sassone-Corsi P, Barre s R, Zierath JR, Hawley JA. Time-restricted
206. Camera DM, Hawley JA, Coffey VG. Resistance exercise with low
glycogen increases p53 phosphorylation and PGC-1alpha mRNA in feeding alters lipid and amino acid metabolite rhythmicity without
skeletal muscle. Eur J Appl Physiol 115: 1185–1194, 2015. doi:10.1007/ perturbing clock gene expression. Nat Commun 11: 4643, 2020.
s00421-015-3116-x. doi:10.1038/s41467-020-18412-w.

207. Camera DM, West DW, Burd NA, Phillips SM, Garnham AP, Hawley 220. Sato S, Parr EB, Devlin BL, Hawley JA, Sassone-Corsi P. Human
JA, Coffey VG. Low muscle glycogen concentration does not sup- metabolomics reveal daily variations under nutritional challenges
press the anabolic response to resistance exercise. J Appl Physiol specific to serum and skeletal muscle. Mol Metab 16: 1–11, 2018.
(1985) 113: 206–214, 2012. doi:10.1152/japplphysiol.00395.2012. doi:10.1016/j.molmet.2018.06.008.

208. Asher G, Sassone-Corsi P. Time for food: the intimate interplay 221. Atkinson G, Reilly T. Circadian variation in sports performance.
between nutrition, metabolism, and the circadian clock. Cell 161: Sports Med 21: 292–312, 1996. doi:10.2165/00007256-199621040-
84–92, 2015. doi:10.1016/j.cell.2015.03.015. 00005.

209. Dyar KA, Ciciliot S, Wright LE, Biensø RS, Tagliazucchi GM, Patel 222. de Goede P, Wefers J, Brombacher EC, Schrauwen P, Kalsbeek A.
VR, Forcato M, Paz MI, Gudiksen A, Solagna F, Albiero M, Moretti I, Circadian rhythms in mitochondrial respiration. J Mol Endocrinol
Eckel-Mahan KL, Baldi P, Sassone-Corsi P, Rizzuto R, Bicciato S, 60: R115–R130, 2018. doi:10.1530/JME-17-0196.
Pilegaard H, Blaauw B, Schiaffino S. Muscle insulin sensitivity and 223. Drust B, Waterhouse J, Atkinson G, Edwards B, Reilly T. Circadian
glucose metabolism are controlled by the intrinsic muscle clock. rhythms in sports performance—an update. Chronobiol Int 22: 21–
Mol Metab 3: 29–41, 2014. doi:10.1016/j.molmet.2013.10.005. 44, 2005. doi:10.1081/cbi-200041039.
210. Dyar KA, Lutter D, Artati A, Ceglia NJ, Liu Y, Armenta D, Jastroch M, 224. Facer-Childs E, Brandstaetter R. The impact of circadian phenotype
Schneider S, de Mateo S, Cervantes M, Abbondante S, Tognini P, and time since awakening on diurnal performance in athletes. Curr
Orozco-Solis R, Kinouchi K, Wang C, Swerdloff R, Nadeef S, Masri S, Biol 25: 518–522, 2015. doi:10.1016/j.cub.2014.12.036.
Magistretti P, Orlando V, Borrelli E, Uhlenhaut NH, Baldi P, Adamski
€ p MH, Eckel-Mahan K, Sassone-Corsi P. Atlas of circadian
J, Tscho 225. Kusumoto H, Ta C, Brown SM, Mulcahey MK. Factors contribut-
metabolism reveals system-wide coordination and communication ing to diurnal variation in athletic performance and methods to

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1765

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

reduce within-day performance variation: a systematic review. 240. Haugen T, Seiler S, Sandbakk O, Tønnessen E. The training and de-
J Strength Cond Res 35: S119–S135, 2021. doi:10.1519/JSC. velopment of elite sprint performance: an integration of scientific
0000000000003758. and best practice literature. Sports Med Open 5: 44, 2019.
doi:10.1186/s40798-019-0221-0.
226. Knaier R, Infanger D, Cajochen C, Schmidt-Trucksaess A, Faude O,
Roth R. Diurnal and day-to-day variations in isometric and isokinetic 241. Ansdell P, Thomas K, Hicks KM, Hunter SK, Howatson G, Goodall S.
strength. Chronobiol Int 36: 1537–1549, 2019. doi:10.1080/07420528. Physiological sex differences affect the integrative response to
2019.1658596. exercise: acute and chronic implications. Exp Physiol 105: 2007–
2021, 2020. doi:10.1113/EP088548.
227. Knaier R, Infanger D, Niemeyer M, Cajochen C, Schmidt-Trucksa €ss
A. In athletes, the diurnal variations in maximum oxygen uptake are 242. Landen S, Voisin S, Craig JM, McGee SL, Lamon S, Eynon N.
more than twice as large as the day-to-day variations. Front Physiol Genetic and epigenetic sex-specific adaptations to endurance
10: 219, 2019. doi:10.3389/fphys.2019.00219. exercise. Epigenetics 14: 523–535, 2019. doi:10.1080/15592294.
2019.1603961.
228. Roenneberg T, Wirz-Justice A, Merrow M. Life between clocks: daily
temporal patterns of human chronotypes. J Biol Rhythms 18: 80– 243. Besson T, Macchi R, Rossi J, Morio CY, Kunimasa Y, Nicol C,
90, 2003. doi:10.1177/0748730402239679. Vercruyssen F, Millet GY. Sex differences in endurance running.
Sports Med 52: 1235–1257, 2022. doi:10.1007/s40279-022-01651-w.
229. Bailey SL, Heitkemper MM. Circadian rhythmicity of cortisol and
body temperature: morningness-eveningness effects. Chronobiol 244. Sims ST, Heather AK. Myths and methodologies: reducing scientific
Int 18: 249–261, 2001. doi:10.1081/cbi-100103189. design ambiguity in studies comparing sexes and/or menstrual
cycle phases. Exp Physiol 103: 1309–1317, 2018. doi:10.1113/
230. Takahashi JS, Hong HK, Ko CH, McDearmon EL. The genetics of
mammalian circadian order and disorder: implications for physiol- EP086797.
ogy and disease. Nat Rev Genet 9: 764–775, 2008. doi:10.1038/ 245. Nuzzo JL. Narrative review of sex differences in muscle strength,
nrg2430. endurance, activation, size, fiber type, and strength training partici-
231. Facer-Childs ER, Boiling S, Balanos GM. The effects of time of day pation rates, preferences, motivations, injuries, and neuromuscular
and chronotype on cognitive and physical performance in healthy adaptations. J Strength Cond Res 37: 494–536, 2023. doi:10.1519/
volunteers. Sports Med Open 4: 47, 2018. doi:10.1186/s40798-018- JSC.0000000000004329.
0162-z.
246. Cullen ML, Casazza GA, Davis BA. Passive recovery strategies af-
232. Ammar A, Chtourou H, Souissi N. Effect of time-of-day on biochemi- ter exercise: a narrative literature review of the current evidence.
cal markers in response to physical exercise. J Strength Cond Res Curr Sports Med Rep 20: 351–358, 2021. doi:10.1249/JSR.
31: 272–282, 2017. doi:10.1519/JSC.0000000000001481. 0000000000000859.

233. Chtourou H, Driss T, Souissi S, Gam A, Chaouachi A, Souissi N. The 247. Ihsan M, Abbiss CR, Allan R. Adaptations to post-exercise cold
effect of strength training at the same time of the day on the diurnal water immersion: friend, foe, or futile? Front Sports Act Living 3:
fluctuations of muscular anaerobic performances. J Strength Cond 714148, 2021. doi:10.3389/fspor.2021.714148.
Res 26: 217–225, 2012. doi:10.1519/JSC.0b013e31821d5e8d.
248. Kissling LS, Akerman AP, Cotter JD. Heat-induced hypervolemia:
234. Chtourou H, Souissi N. The effect of training at a specific time of does the mode of acclimation matter and what are the implications
day: a review. J Strength Cond Res 26: 1984–2005, 2012. for performance at Tokyo 2020? Temperature (Austin) 7: 129–148,
doi:10.1519/JSC.0b013e31825770a7. 2019. doi:10.1080/23328940.2019.1653736.

235. K€
uu€smaa M, Schumann M, Sedliak M, Kraemer WJ, Newton RU, 249. Rønnestad BR, Hamarsland H, Hansen J, Holen E, Montero D,
Malinen JP, Nyman K, Ha€kkinen A, Ha
€kkinen K. Effects of morning Whist JE, Lundby C. Five weeks of heat training increases haemo-
versus evening combined strength and endurance training on globin mass in elite cyclists. Exp Physiol 106: 316–327, 2021.
physical performance, muscle hypertrophy, and serum hormone doi:10.1113/EP088544.
concentrations. Appl Physiol Nutr Metab 41: 1285–1294, 2016.
doi:10.1139/apnm-2016-0271. 250. Periard JD, Eijsvogels TM, Daanen HA. Exercise under heat stress:
thermoregulation, hydration, performance implications, and mitiga-
236. Knaier R, Qian J, Roth R, Infanger D, Notter T, Wang W, Cajochen C, tion strategies. Physiol Rev 101: 1873–1979, 2021. doi:10.1152/
Scheer F. Diurnal variation in maximum endurance and maximum physrev.00038.2020.
strength performance: a systematic review and meta-analysis.
Med Sci Sports Exerc 54: 169–180, 2022. doi:10.1249/MSS. 251. Joyner MJ, Casey DP. Regulation of increased blood flow (hypere-
0000000000002773. mia) to muscles during exercise: a hierarchy of competing physio-
logical needs. Physiol Rev 95: 549–601, 2015. doi:10.1152/
237. van Moorsel D, Hansen J, Havekes B, Scheer F, Jo €rgensen JA, physrev.00035.2013.
Hoeks J, Schrauwen-Hinderling VB, Duez H, Lefebvre P, Schaper
NC, Hesselink MK, Staels B, Schrauwen P. Demonstration of a day- 252. Haugen T, Paulsen G, Seiler S, Sandbakk O. New records in human
night rhythm in human skeletal muscle oxidative capacity. Mol power. Int J Sports Physiol Perform 13: 678–686, 2018. doi:10.1123/
Metab 5: 635–645, 2016. doi:10.1016/j.molmet.2016.06.012. ijspp.2017-0441.

238. Lok R, Zerbini G, Gordijn MC, Beersma DG, Hut RA. Gold, silver or 253. Zhou B, Conlee RK, Jensen R, Fellingham GW, George JD, Fisher
bronze: circadian variation strongly affects performance in Olympic AG. Stroke volume does not plateau during graded exercise in elite
athletes. Sci Rep 10: 16088, 2020. doi:10.1038/s41598-020-72573-8. male distance runners. Med Sci Sports Exerc 33: 1849–1854, 2001.
doi:10.1097/00005768-200111000-00008.
239. Haugen T, Sandbakk O, Seiler S, Tønnessen E. The training charac-
teristics of world-class distance runners: an integration of scientific 254. Dandanell S, Meinild-Lundby AK, Andersen AB, Lang PF, Oberholzer
literature and results-proven practice. Sports Med Open 8: 46, L, Keiser S, Robach P, Larsen S, Rønnestad BR, Lundby C.
2022. doi:10.1186/s40798-022-00438-7. Determinants of maximal whole-body fat oxidation in elite cross-

1766 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

country skiers: Role of skeletal muscle mitochondria. Scand J Med 270. Lucia A, Hoyos J, Chicharro JL. Physiology of professional road cy-
Sci Sports 28: 2494–2504, 2018. doi:10.1111/sms.13298. cling. Sports Med 31: 325–337, 2001. doi:10.2165/00007256-
200131050-00004.
255. Hoppeler H, Howald H, Conley K, Lindstedt SL, Claassen H, Vock P,
Weibel ER. Endurance training in humans: aerobic capacity and 271. Marinho AH, Cristina-Souza G, Santos PS, Santos-Mariano AC,
structure of skeletal muscle. J Appl Physiol (1985) 59: 320–327, Rodacki A, De-Oliveira FR, Bertuzzi R, Lima-Silva AE. Caffeine alters
1985. doi:10.1152/jappl.1985.59.2.320. the breathing pattern during high-intensity whole-body exercise in
healthy men. Eur J Appl Physiol 122: 1497–1507, 2022. doi:10.1007/
256. Ørtenblad N, Nielsen J, Saltin B, Holmberg HC. Role of glycogen
s00421-022-04934-2.
availability in sarcoplasmic reticulum Ca21 kinetics in human skele-
tal muscle. J Physiol 589: 711–725, 2011. doi:10.1113/jphysiol.2010. 272. Olfert IM, Balouch J, Kleinsasser A, Knapp A, Wagner H, Wagner
195982. PD, Hopkins SR. Does gender affect human pulmonary gas
exchange during exercise? J Physiol 557: 529–541, 2004.
257. Jones AM. The physiology of the world record holder for the
women’s marathon. Int J Sports Sci Coaching 1: 101–116, 2006. doi:10.1113/jphysiol.2003.056887.
doi:10.1260/174795406777641258. 273. Edvardsen E, Hansen BH, Holme IM, Dyrstad SM, Anderssen SA.
258. Sandbakk O, Holmberg HC. Physiological capacity and training rou- Reference values for cardiorespiratory response and fitness on the
tines of elite cross-country skiers: approaching the upper limits of treadmill in a 20- to 85-year-old population. Chest 144: 241–248,
human endurance. Int J Sports Physiol Perform 12: 1003–1011, 2013. doi:10.1378/chest.12-1458.
2017. doi:10.1123/ijspp.2016-0749.
274. Ekblom B, Hermansen L. Cardiac output in athletes. J Appl Physiol
259. Tønnessen E, Sylta Ø, Haugen TA, Hem E, Svendsen IS, Seiler S. 25: 619–625, 1968. doi:10.1152/jappl.1968.25.5.619.
The road to gold: training and peaking characteristics in the year
275. St Pierre SR, Peirlinck M, Kuhl E. Sex matters: a comprehensive
prior to a gold medal endurance performance. PLoS One 9:
comparison of female and male hearts. Front Physiol 13: 831179,
e101796, 2014. doi:10.1371/journal.pone.0101796.
2022. doi:10.3389/fphys.2022.831179.
260. Prommer N, Thoma S, Quecke L, Gutekunst T, Vo €lzke C,
Wachsmuth N, Niess AM, Schmidt W. Total hemoglobin mass and 276. Patel HN, Miyoshi T, Addetia K, Henry MP, Citro R, Daimon M, et al.
blood volume of elite Kenyan runners. Med Sci Sports Exerc 42: Normal values of cardiac output and stroke volume according to
791–797, 2010. doi:10.1249/MSS.0b013e3181badd67. measurement technique, age, sex, and ethnicity: results of the World
Alliance of Societies of Echocardiography Study. J Am Soc
261. rez M, San
Lucía A, Rabadán M, Hoyos J, Hernández-Capilla M, Pe Echocardiogr 34: 1077–1085.e1, 2021. doi:10.1016/j.echo.2021.05.012.
Juan AF, Earnest CP, Chicharro JL. Frequency of the Vo2max pla-
teau phenomenon in world-class cyclists. Int J Sports Med 27: 277. Coyle EF. Improved muscular efficiency displayed as Tour de
984–992, 2006. doi:10.1055/s-2006-923833. France champion matures. J Appl Physiol (1985) 98: 2191–2196,
2005. doi:10.1152/japplphysiol.00216.2005.
262. Pate RR, Sparling PB, Wilson GE, Cureton KJ, Miller BJ. Cardiore-
spiratory and metabolic responses to submaximal and maximal exer- 278. Tesch PA, Thorsson A, Kaiser P. Muscle capillary supply and fiber
cise in elite women distance runners. Int J Sports Med 8, Suppl 2: 91– type characteristics in weight and power lifters. J Appl Physiol
95, 1987. doi:10.1055/s-2008-1025712. Respir Environ Exerc Physiol 56: 35–38, 1984. doi:10.1152/
jappl.1984.56.1.35.
263. Daniels J, Krahenbuhl G, Foster C, Gilbert J, Daniels S. Aerobic
responses of female distance runners to submaximal and maximal 279. Saltin B, Henriksson J, Nygaard E, Andersen P, Jansson E. Fiber
exercise. Ann NY Acad Sci 301: 726–733, 1977. doi:10.1111/j.1749- types and metabolic potentials of skeletal muscles in sedentary
6632.1977.tb38242.x. man and endurance runners. Ann NY Acad Sci 301: 3–29, 1977.
doi:10.1111/j.1749-6632.1977.tb38182.x.
264. Mahler DA, Shuhart CR, Brew E, Stukel TA. Ventilatory responses
and entrainment of breathing during rowing. Med Sci Sports Exerc 280. Tesch PA, Karlsson J. Muscle fiber types and size in trained and
23: 186–192, 1991. untrained muscles of elite athletes. J Appl Physiol (1985) 59: 1716–
1720, 1985. doi:10.1152/jappl.1985.59.6.1716.
265. Wang E, Solli GS, Nyberg SK, Hoff J, Helgerud J. Stroke volume
does not plateau in female endurance athletes. Int J Sports Med 281. Costill DL, Daniels J, Evans W, Fink W, Krahenbuhl G, Saltin B.
33: 734–739, 2012. doi:10.1055/s-0031-1301315. Skeletal muscle enzymes and fiber composition in male and female
266. Degens H, Stasiulis A, Skurvydas A, Statkeviciene B, Venckunas T. track athletes. J Appl Physiol 40: 149–154, 1976. doi:10.1152/
Physiological comparison between non-athletes, endurance, power jappl.1976.40.2.149.
and team athletes. Eur J Appl Physiol 119: 1377–1386, 2019. 282. Larsen S, Nielsen J, Hansen CN, Nielsen LB, Wibrand F, Stride N,
doi:10.1007/s00421-019-04128-3.
Schroder HD, Boushel R, Helge JW, Dela F, Hey-Mogensen M.
267. Burtscher M, Nachbauer W, Wilber R. The upper limit of aerobic Biomarkers of mitochondrial content in skeletal muscle of healthy
power in humans. Eur J Appl Physiol 111: 2625–2628, 2011. young human subjects. J Physiol 590: 3349–3360, 2012. doi:10.1113/
doi:10.1007/s00421-011-1885-4. jphysiol.2012.230185.

268. Folinsbee LJ, Wallace ES, Bedi JF, Horvath SM. Exercise respiratory 283. Costill DL, Fink WJ, Flynn M, Kirwan J. Muscle fiber composition
pattern in elite cyclists and sedentary subjects. Med Sci Sports and enzyme activities in elite female distance runners. Int J Sports
Exerc 15: 503–509, 1983. Med 8, Suppl 2: 103–106, 1987. doi:10.1055/s-2008-1025714.

 n FJ, Alfonso A, Chicharro JL. Breathing

269. Lucía A, Carvajal A, Caldero 284. Staron RS, Hagerman FC, Hikida RS, Murray TF, Hostler DP, Crill
pattern in highly competitive cyclists during incremental exercise. MT, Ragg KE, Toma K. Fiber type composition of the vastus lateralis
Eur J Appl Physiol Occup Physiol 79: 512–521, 1999. doi:10.1007/ muscle of young men and women. J Histochem Cytochem 48:
s004210050546. 623–629, 2000. doi:10.1177/002215540004800506.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1767

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

285. Hoppeler H, L€ uthi P, Claassen H, Weibel ER, Howald H. The ultra- 299. Calbet JA, Rådegran G, Boushel R, Søndergaard H, Saltin B,
structure of the normal human skeletal muscle. A morphometric Wagner PD. Effect of blood haemoglobin concentration on VO2,max
analysis on untrained men, women and well-trained orienteers. and cardiovascular function in lowlanders acclimatised to 5260 m.
Pflugers Arch 344: 217–232, 1973. doi:10.1007/BF00588462. J Physiol 545: 715–728, 2002. doi:10.1113/jphysiol.2002.029108.

286. Ørtenblad N, Nielsen J, Boushel R, So € derlund K, Saltin B, Holmberg 300. Montero D, Cathomen A, Jacobs RA, Fl€ uck D, de Leur J, Keiser S,
HC. The muscle fiber profiles, mitochondrial content, and enzyme Bonne T, Kirk N, Lundby AK, Lundby C. Haematological rather than
activities of the exceptionally well-trained arm and leg muscles of skeletal muscle adaptations contribute to the increase in peak oxy-
elite cross-country skiers. Front Physiol 9: 1031, 2018. doi:10.3389/ gen uptake induced by moderate endurance training. J Physiol
fphys.2018.01031. 593: 4677–4688, 2015. doi:10.1113/JP270250.

287. Hostler D, Schwirian CI, Campos G, Toma K, Crill MT, Hagerman 301. n J. Contribution of
Skattebo O, Calbet JA, Rud B, Capelli C, Halle
GR, Hagerman FC, Staron RS. Skeletal muscle adaptations in elastic oxygen extraction fraction to maximal oxygen uptake in healthy
resistance-trained young men and women. Eur J Appl Physiol 86: young men. Acta Physiol (Oxf) 230: e13486, 2020. doi:10.1111/
112–118, 2001. doi:10.1007/s004210100495. apha.13486.

288. Cardinale DA, Horwath O, Elings-Knutsson J, Helge T, Godhe M, € sler K, Hoppeler H, Conley KE, Claassen H, Gehr P, Howald H.
302. Ro
Bermon S, Moberg M, Flockhart M, Larsen FJ, Hirschberg AL, Transfer effects in endurance exercise. Adaptations in trained and
Ekblom B. Enhanced skeletal muscle oxidative capacity and capil- untrained muscles. Eur J Appl Physiol Occup Physiol 54: 355–
lary-to-fiber ratio following moderately increased testosterone ex- 362, 1985. doi:10.1007/BF02337178.
posure in young healthy women. Front Physiol 11: 585490, 2020.
doi:10.3389/fphys.2020.585490. 303. Fry AC, Schilling BK, Staron RS, Hagerman FC, Hikida RS, Thrush
JT. Muscle fiber characteristics and performance correlates of male
289. Meinild Lundby AK, Jacobs RA, Gehrig S, de Leur J, Hauser M, Olympic-style weightlifters. J Strength Cond Res 17: 746–754,
Bonne TC, Fluck D, Dandanell S, Kirk N, Kaech A, Ziegler U, Larsen 2003. doi:10.1519/1533-4287(2003)017<0746:mfcapc>2.0.co;2.
S, Lundby C. Exercise training increases skeletal muscle mitochon-
drial volume density by enlargement of existing mitochondria and 304. Storey A, Smith HK. Unique aspects of competitive weightlifting:
not de novo biogenesis. Acta Physiol (Oxf) 222: e12905, 2018. performance, training and physiology. Sports Med 42: 769–790,
doi:10.1111/apha.12905. 2012. doi:10.1007/BF03262294.

290. Nielsen J, Gejl KD, Hey-Mogensen M, Holmberg HC, Suetta C, 305. Zaras N, Stasinaki AN, Spiliopoulou P, Hadjicharalambous M, Terzis
Krustrup P, Elemans CP, Ørtenblad N. Plasticity in mitochondrial cris- G. Lean body mass, muscle architecture, and performance in well-
tae density allows metabolic capacity modulation in human skeletal trained female weightlifters. Sports (Basel) 8: 67, 2020. doi:10.3390/
muscle. J Physiol 595: 2839–2847, 2017. doi:10.1113/JP273040. sports8050067.

291. Ferretti G, Fagoni N, Taboni A, Vinetti G, di Prampero PE. A century 306. Heckman CJ, Enoka RM. Physiology of the motor neuron and the
of exercise physiology: key concepts on coupling respiratory oxy- motor unit. In: Handbook of Clinical Neurophysiology, edited by Eisen A.
gen flow to muscle energy demand during exercise. Eur J Appl Amsterdam: Elsevier, 2004, p. 119–147.
Physiol 122: 1317–1365, 2022. doi:10.1007/s00421-022-04901-x.
307. Enoka RM, Pearson KG. The motor unit and muscle action. In:
292. Rønnestad BR, Hansen J, Stensløkken L, Joyner MJ, Lundby C. Principles of Neural Science (5th ed.). New York: McGraw-Hill
Case studies in physiology: temporal changes in determinants of Education, 2014.
aerobic performance in individual going from alpine skier to world
junior champion time trial cyclist. J Appl Physiol (1985) 127: 306– 308. Zou S, Pan BX. Post-synaptic specialization of the neuromuscular
311, 2019. doi:10.1152/japplphysiol.00798.2018. junction: junctional folds formation, function, and disorders. Cell
Biosci 12: 93, 2022. doi:10.1186/s13578-022-00829-z.
293. Weibel ER, Hoppeler H. Exercise-induced maximal metabolic rate
scales with muscle aerobic capacity. J Exp Biol 208: 1635–1644, 309. Ruff RL. Endplate contributions to the safety factor for neuromus-
2005. doi:10.1242/jeb.01548. cular transmission. Muscle Nerve 44: 854–861, 2011. doi:10.1002/
mus.22177.
294. Sandbakk O, Solli GS, Holmberg HC. Sex differences in world-re-
cord performance: the influence of sport discipline and competition 310. Wood SJ, Slater CR. Safety factor at the neuromuscular junction.
duration. Int J Sports Physiol Perform 13: 2–8, 2018. doi:10.1123/ Prog Neurobiol 64: 393–429, 2001. doi:10.1016/s0301-0082(00)
ijspp.2017-0196. 00055-1.

295. Wagner PD. Determinants of maximal oxygen consumption. J 311. Enoka RM, Duchateau J. Rate coding and the control of muscle
Muscle Res Cell Motil. In Press. doi:10.1007/s10974-022-09636-y. force. Cold Spring Harb Perspect Med 7: a029702, 2017. doi:10.1101/
cshperspect.a029702.
296. McKenzie DC. Respiratory physiology: adaptations to high-level
exercise. Br J Sports Med 46: 381–384, 2012. doi:10.1136/bjsports- 312. Neto WK, Ciena AP, Anaruma CA, de Souza RR, Gama EF. Effects
2011-090824. of exercise on neuromuscular junction components across age:
systematic review of animal experimental studies. BMC Res Notes
297. Dauty M, Georges T, Le Blanc C, Louguet B, Menu P, Fouasson- 8: 713, 2015. doi:10.1186/s13104-015-1644-4.
Chailloux A. Reference values of forced vital capacity and expira-
tory flow in high-level cyclists. Life (Basel) 11: 1293, 2021. 313. Deschenes MR. Adaptations of the neuromuscular junction to exer-
doi:10.3390/life11121293. cise training. Curr Opin Physiol 10: 10–16, 2019. doi:10.1016/j.
cophys.2019.02.004.
298. Segizbaeva MO, Aleksandrova NP. Respiratory muscle strength
and ventilatory function outcome: differences between trained ath- 314. Deschenes MR, Kressin KA, Garratt RN, Leathrum CM, Shaffrey EC.
letes and healthy untrained persons. Adv Exp Med Biol 1289: 89– Effects of exercise training on neuromuscular junction morphology
97, 2021. doi:10.1007/5584_2020_554. and pre- to post-synaptic coupling in young and aged rats.

1768 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

Neuroscience 316: 167–177, 2016. doi:10.1016/j.neuroscience.2015. review and meta-analysis. Eur J Neurosci 46: 2648–2661, 2017.
12.004. doi:10.1111/ejn.13710.

315. Arnold AS, Gill J, Christe M, Ruiz R, McGuirk S, St-Pierre J, Tabares 

329. Skarabot J, Brownstein CG, Casolo A, Del Vecchio A, Ansdell P.
L, Handschin C. Morphological and functional remodelling of the The knowns and unknowns of neural adaptations to resistance
neuromuscular junction by skeletal muscle PGC-1alpha. Nat training. Eur J Appl Physiol 121: 675–685, 2021. doi:10.1007/
Commun 5: 3569, 2014. doi:10.1038/ncomms4569. s00421-020-04567-3.

316. Jones RA, Harrison C, Eaton SL, Llavero Hurtado M, Graham LC, 330. Del Vecchio A, Negro F, Holobar A, Casolo A, Folland JP, Felici F,
Alkhammash L, Oladiran OA, Gale A, Lamont DJ, Simpson H, Farina D. You are as fast as your motor neurons: speed of recruit-
Simmen MW, Soeller C, Wishart TM, Gillingwater TH. Cellular and ment and maximal discharge of motor neurons determine the maxi-
molecular anatomy of the human neuromuscular junction. Cell Rep mal rate of force development in humans. J Physiol 597: 2445–
21: 2348–2356, 2017. doi:10.1016/j.celrep.2017.11.008. 2456, 2019. doi:10.1113/JP277396.

317. Duchateau J, Enoka RM. Distribution of motor unit properties across 331. Del Vecchio A, Casolo A, Negro F, Scorcelletti M, Bazzucchi I,
human muscles. J Appl Physiol (1985) 132: 1–13, 2022. doi:10.1152/ Enoka R, Felici F, Farina D. The increase in muscle force after 4
japplphysiol.00290.2021. weeks of strength training is mediated by adaptations in motor unit
recruitment and rate coding. J Physiol 597: 1873–1887, 2019.
318. Duchateau J, Semmler JG, Enoka RM. Training adaptations in the doi:10.1113/JP277250.
behavior of human motor units. J Appl Physiol (1985) 101: 1766–
1775, 2006. doi:10.1152/japplphysiol.00543.2006. 332. Cormie P, McGuigan MR, Newton RU. Developing maximal neu-
romuscular power: Part 1–biological basis of maximal power pro-
319. Hudson AL, Gandevia SC, Butler JE. A principle of neurome- duction. Sports Med 41: 17–38, 2011. doi:10.2165/11537690-
chanical matching for motor unit recruitment in human move- 000000000-00000.
ment. Exerc Sport Sci Rev 47: 157–168, 2019. doi:10.1249/JES.
0000000000000191. 333. Folland JP, Williams AG. The adaptations to strength training:
morphological and neurological contributions to increased
~ ez J, Farina D. Common synaptic input, syner-
320. Hug F, Avrillon S, Ibán strength. Sports Med 37: 145–168, 2007. doi:10.2165/00007256-
gies and size principle: control of spinal motor neurons for move- 200737020-00004.
ment generation. J Physiol 601: 11–20, 2023. doi:10.1113/JP283698.
334. Amiridis IG, Martin A, Morlon B, Martin L, Cometti G, Pousson M, van
321. Bawa PN, Jones KE, Stein RB. Assessment of size ordered recruit- Hoecke J. Co-activation and tension-regulating phenomena during
ment. Front Hum Neurosci 8: 532, 2014. doi:10.3389/fnhum.2014. isokinetic knee extension in sedentary and highly skilled humans.
00532. Eur J Appl Physiol Occup Physiol 73: 149–156, 1996. doi:10.1007/
BF00262824.
322. Marshall NJ, Glaser JI, Trautmann EM, Amematsro EA, Perkins SM,
Shadlen MN, Abbott LF, Cunningham JP, Churchland MM. Flexible 335. Seynnes OR, de Boer M, Narici MV. Early skeletal muscle hyper-
neural control of motor units. Nat Neurosci 25: 1492–1504, 2022. trophy and architectural changes in response to high-intensity
doi:10.1038/s41593-022-01165-8. resistance training. J Appl Physiol (1985) 102: 368–373, 2007.
doi:10.1152/japplphysiol.00789.2006.
323. Adam A, De Luca CJ. Firing rates of motor units in human vastus
lateralis muscle during fatiguing isometric contractions. J Appl 336. McKendry J, Stokes T, McLeod JC, Phillips SM. Resistance exercise,
Physiol (1985) 99: 268–280, 2005. doi:10.1152/japplphysiol. aging, disuse, and muscle protein metabolism. Compr Physiol 11:
01344.2004. 2249–2278, 2021. doi:10.1002/cphy.c200029.
324. Morton RW, Sonne MW, Farias Zuniga A, Mohammad IY, Jones A, 337. Ziliaskoudis C, Park SY, Lee SH. Running economy—a comprehen-
McGlory C, Keir PJ, Potvin JR, Phillips SM. Muscle fibre activation is sive review for passive force generation. J Exerc Rehabil 15: 640–
unaffected by load and repetition duration when resistance exer- 646, 2019. doi:10.12965/jer.1938406.203.
cise is performed to task failure. J Physiol 597: 4601–4613, 2019.
doi:10.1113/JP278056. 338. Barnes KR, Kilding AE. Running economy: measurement, norms,
and determining factors. Sports Med Open 1: 8, 2015. doi:10.1186/
325. Morton RW, Oikawa SY, Wavell CG, Mazara N, McGlory C, s40798-015-0007-y.
Quadrilatero J, Baechler BL, Baker SK, Phillips SM. Neither load nor
systemic hormones determine resistance training-mediated hyper- 339. Hunter SK. Performance fatigability: mechanisms and task specific-
trophy or strength gains in resistance-trained young men. J Appl ity. Cold Spring Harb Perspect Med 8: a029728, 2018. doi:10.1101/
Physiol (1985) 121: 129–138, 2016. doi:10.1152/japplphysiol.00154. cshperspect.a029728.
2016.
340. Fukutani A, Tsuruhara Y, Miyake Y, Takao K, Ueno H, Otsuka M,
326. Blum JA, Klemm S, Shadrach JL, Guttenplan KA, Nakayama L, Suga T, Terada M, Nagano A, Isaka T. Comparison of the relative
Kathiria A, Hoang PT, Gautier O, Kaltschmidt JA, Greenleaf WJ, muscle volume of triceps surae among sprinters, runners, and
Gitler AD. Single-cell transcriptomic analysis of the adult mouse spi- untrained participants. Physiol Rep 8: e14588, 2020. doi:10.14814/
nal cord reveals molecular diversity of autonomic and skeletal phy2.14588.
motor neurons. Nat Neurosci 24: 572–583, 2021. doi:10.1038/
s41593-020-00795-0. 341. Methenitis S, Karandreas N, Spengos K, Zaras N, Stasinaki AN,
Terzis G. Muscle fiber conduction velocity, muscle fiber composi-
327. Siddique U, Rahman S, Frazer AK, Pearce AJ, Howatson G, Kidgell tion, and power performance. Med Sci Sports Exerc 48: 1761–1771,
DJ. Determining the sites of neural adaptations to resistance train- 2016. doi:10.1249/MSS.0000000000000954.
ing: a systematic review and meta-analysis. Sports Med 50: 1107–
1128, 2020. doi:10.1007/s40279-020-01258-z. 342. Jorgenson KW, Phillips SM, Hornberger TA. Identifying the struc-
tural adaptations that drive the mechanical load-induced growth
328. Kidgell DJ, Bonanno DR, Frazer AK, Howatson G, Pearce AJ. of skeletal muscle: a scoping review. Cells 9: 1658, 2020.
Corticospinal responses following strength training: a systematic doi:10.3390/cells9071658.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1769

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

343. Ema R, Wakahara T, Yanaka T, Kanehisa H, Kawakami Y. Unique 359. Hansson KA, Eftestøl E, Bruusgaard JC, Juvkam I, Cramer AW,
muscularity in cyclists’ thigh and trunk: a cross-sectional and longi- Malthe-Sørenssen A, Millay DP, Gundersen K. Myonuclear content
tudinal study. Scand J Med Sci Sports 26: 782–793, 2016. regulates cell size with similar scaling properties in mice and
doi:10.1111/sms.12511. humans. Nat Commun 11: 6288, 2020. doi:10.1038/s41467-020-
20057-8.
344. Kawakami Y, Abe T, Kanehisa H, Fukunaga T. Human skeletal mus-
cle size and architecture: variability and interdependence. Am J 360. Beiter T, Niess AM, Moser D. Transcriptional memory in skeletal
Hum Biol 18: 845–848, 2006. doi:10.1002/ajhb.20561. muscle. Don’t forget (to) exercise. J Cell Physiol 235: 5476–5489,
2020. doi:10.1002/jcp.29535.
345. Abe T, Kumagai K, Brechue WF. Fascicle length of leg muscles is
greater in sprinters than distance runners. Med Sci Sports Exerc 361. Psilander N, Eftestøl E, Cumming KT, Juvkam I, Ekblom MM,
32: 1125–1129, 2000. doi:10.1097/00005768-200006000-00014. Sunding K, Wernbom M, Holmberg HC, Ekblom B, Bruusgaard JC,
Raastad T, Gundersen K. Effects of training, detraining, and retrain-
346. Lee HJ, Lee KW, Takeshi K, Lee YW, Kim HJ. Correlation analysis ing on strength, hypertrophy, and myonuclear number in human
between lower limb muscle architectures and cycling power via skeletal muscle. J Appl Physiol (1985) 126: 1636–1645, 2019.
ultrasonography. Sci Rep 11: 5362, 2021. doi:10.1038/s41598-021- doi:10.1152/japplphysiol.00917.2018.
84870-x.
362. Conceição MS, Vechin FC, Lixandrão M, Damas F, Libardi CA,
347. Charles J, Kissane R, Hoehfurtner T, Bates KT. From fibre to func- Tricoli V, Roschel H, Camera D, Ugrinowitsch C. Muscle fiber hyper-
tion: are we accurately representing muscle architecture and per- trophy and myonuclei addition: a systematic review and meta-anal-
formance? Biol Rev Camb Philos Soc 97: 1640–1676, 2022. ysis. Med Sci Sports Exerc 50: 1385–1393, 2018. doi:10.1249/
doi:10.1111/brv.12856. MSS.0000000000001593.

348. Lieber RL. Can we just forget about pennation angle? J Biomech 363. Murach KA, Fry CS, Kirby TJ, Jackson JR, Lee JD, White SH,
132: 110954, 2022. doi:10.1016/j.jbiomech.2022.110954. Dupont-Versteegden EE, McCarthy JJ, Peterson CA. Starring or
supporting role? Satellite cells and skeletal muscle fiber size regula-
349. Roberts MD, Haun CT, Vann CG, Osburn SC, Young KC. tion. Physiology (Bethesda) 33: 26–38, 2018. doi:10.1152/physiol.
Sarcoplasmic hypertrophy in skeletal muscle: a scientific “unicorn” 00019.2017.
or resistance training adaptation? Front Physiol 11: 816, 2020.
doi:10.3389/fphys.2020.00816. 364. Kadi F, Eriksson A, Holmner S, Butler-Browne GS, Thornell LE.
Cellular adaptation of the trapezius muscle in strength-trained
350. Aagaard P, Andersen JL, Dyhre-Poulsen P, Leffers AM, Wagner A, athletes. Histochem Cell Biol 111: 189–195, 1999. doi:10.1007/
Magnusson SP, Halkjaer-Kristensen J, Simonsen EB. A mechanism for s004180050348.
increased contractile strength of human pennate muscle in response
to strength training: changes in muscle architecture. J Physiol 534: 365. Eriksson A, Kadi F, Malm C, Thornell LE. Skeletal muscle morphol-
613–623, 2001. doi:10.1111/j.1469-7793.2001.t01-1-00613.x. ogy in power-lifters with and without anabolic steroids. Histochem
Cell Biol 124: 167–175, 2005. doi:10.1007/s00418-005-0029-5.
351. Nielsen J, Ørtenblad N. Physiological aspects of the subcellular
localization of glycogen in skeletal muscle. Appl Physiol Nutr 366. Cramer AA, Prasad V, Eftestøl E, Song T, Hansson KA, Dugdale
Metab 38: 91–99, 2013. doi:10.1139/apnm-2012-0184. HF, Sadayappan S, Ochala J, Gundersen K, Millay DP. Nuclear
numbers in syncytial muscle fibers promote size but limit the de-
352. Dankel SJ, Kang M, Abe T, Loenneke JP. Resistance training velopment of larger myonuclear domains. Nat Commun 11: 6287,
induced changes in strength and specific force at the fiber and 2020. doi:10.1038/s41467-020-20058-7.
whole muscle level: a meta-analysis. Eur J Appl Physiol 119: 265–
278, 2019. doi:10.1007/s00421-018-4022-9. 367. Tillin NA, Jimenez-Reyes P, Pain MT, Folland JP. Neuromuscular
performance of explosive power athletes versus untrained individu-
353. Kumagai K, Abe T, Brechue WF, Ryushi T, Takano S, Mizuno M. als. Med Sci Sports Exerc 42: 781–790, 2010. doi:10.1249/MSS.
Sprint performance is related to muscle fascicle length in male 100- 0b013e3181be9c7e.
m sprinters. J Appl Physiol (1985) 88: 811–816, 2000. doi:10.1152/
jappl.2000.88.3.811. 368. Fry AC, Webber JM, Weiss LW, Harber MP, Vaczi M, Pattison NA.
Muscle fiber characteristics of competitive power lifters. J
354. Nasirzade A, Ehsanbakhsh A, Ilbeygi S, Sobhkhiz A, Argavani H, Strength Cond Res 17: 402–410, 2003. doi:10.1519/1533-4287
Aliakbari M. Relationship between sprint performance of front crawl (2003)017<0402:mfcocp>2.0.co;2.
swimming and muscle fascicle length in young swimmers. J Sports
Sci Med 13: 550–556, 2014. 369. Zaras N, Stasinaki AN, Spiliopoulou P, Arnaoutis G, Hadjicharalambous
M, Terzis G. Rate of force development, muscle architecture, and per-
355. Willingham TB, Kim Y, Lindberg E, Bleck CK, Glancy B. The unified formance in elite weightlifters. Int J Sports Physiol Perform 16: 216–
myofibrillar matrix for force generation in muscle. Nat Commun 11: 223, 2021. doi:10.1123/ijspp.2019-0974.
3722, 2020. doi:10.1038/s41467-020-17579-6.
370. Greising SM, Gransee HM, Mantilla CB, Sieck GC. Systems biology
356. Reggiani C, Schiaffino S. Muscle hypertrophy and muscle strength: of skeletal muscle: fiber type as an organizing principle. Wiley
dependent or independent variables? A provocative review. Eur J Interdiscip Rev Syst Biol Med 4: 457–473, 2012. doi:10.1002/
Transl Myol 30: 9311, 2020. doi:10.4081/ejtm.2020.9311. wsbm.1184.

357. Schiaffino S, Reggiani C. Fiber types in mammalian skeletal 371. Qaisar R, Bhaskaran S, Van Remmen H. Muscle fiber type diversifi-
muscles. Physiol Rev 91: 1447–1531, 2011. doi:10.1152/physrev. cation during exercise and regeneration. Free Radic Biol Med 98:
00031.2010. 56–67, 2016. doi:10.1016/j.freeradbiomed.2016.03.025.

358. Prasad V, Millay DP. Skeletal muscle fibers count on nuclear num- 372. Plotkin DL, Roberts MD, Haun CT, Schoenfeld BJ. Muscle fiber type
bers for growth. Semin Cell Dev Biol 119: 3–10, 2021. doi:10.1016/j. transitions with exercise training: shifting perspectives. Sports 9:
semcdb.2021.04.015. 127, 2021. doi:10.3390/sports9090127.

1770 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

373. Percario V, Boncompagni S, Protasi F, Pertici I, Pinzauti F, Caremani study. J Neurol Sci 18: 111–129, 1973. doi:10.1016/0022-510x(73)
M. Mechanical parameters of the molecular motor myosin II deter- 90023-3.
mined in permeabilised fibres from slow and fast skeletal muscles
of the rabbit. J Physiol 596: 1243–1257, 2018. doi:10.1113/JP275404. 388. Horwath O, Envall H, Ro€ ja J, Emanuelsson EB, Sanz G, Ekblom B,
Apro W, Moberg M. Variability in vastus lateralis fiber type distribu-
374. Hvid LG, Gejl K, Bech RD, Nygaard T, Jensen K, Frandsen U, tion, fiber size, and myonuclear content along and between the
Ørtenblad N. Transient impairments in single muscle fibre contract- legs. J Appl Physiol (1985) 131: 158–173, 2021. doi:10.1152/
ile function after prolonged cycling in elite endurance athletes. japplphysiol.00053.2021.
Acta Physiol (Oxf) 208: 265–273, 2013. doi:10.1111/apha.12095.
389. Fink WJ, Costill DL, Pollock ML. Submaximal and maximal working
375. Hvid LG, Ortenblad N, Aagaard P, Kjaer M, Suetta C. Effects of age- capacity of elite distance runners. Part II. Muscle fiber composition
ing on single muscle fibre contractile function following short-term and enzyme activities. Ann NY Acad Sci 301: 323–327, 1977.
immobilisation. J Physiol 589: 4745–4757, 2011. doi:10.1113/jphysiol. doi:10.1111/j.1749-6632.1977.tb38210.x.
2011.215434.
390. Serrano N, Colenso-Semple LM, Lazauskus KK, Siu JW, Bagley JR,
376. Lamboley CR, Rouffet DM, Dutka TL, McKenna MJ, Lamb GD. Lockie RG, Costa PB, Galpin AJ. Extraordinary fast-twitch fiber
Effects of high-intensity intermittent exercise on the contractile abundance in elite weightlifters. PLoS One 14: e0207975, 2019.
properties of human type I and type II skeletal muscle fibers. J Appl doi:10.1371/journal.pone.0207975.
Physiol (1985) 128: 1207–1216, 2020. doi:10.1152/japplphysiol.
00014.2020. 391. Trappe S, Luden N, Minchev K, Raue U, Jemiolo B, Trappe TA.
Skeletal muscle signature of a champion sprint runner. J Appl
377. Mitchell EA, Martin NRW, Bailey SJ, Ferguson RA. Critical power is Physiol (1985) 118: 1460–1466, 2015. doi:10.1152/japplphysiol.00037.
positively related to skeletal muscle capillarity and type I muscle
2015.
fibers in endurance-trained individuals. J Appl Physiol (1985) 125:
737–745, 2018. doi:10.1152/japplphysiol.01126.2017. 392. Baker JS, McCormick MC, Robergs RA. Interaction among skeletal
muscle metabolic energy systems during intense exercise. J Nutr
378. Edwards R, Young A, Wiles M. Needle biopsy of skeletal muscle in
Metab 2010: 905612, 2010. doi:10.1155/2010/905612.
the diagnosis of myopathy and the clinical study of muscle function
and repair. N Engl J Med 302: 261–271, 1980. doi:10.1056/ 393. Hargreaves M, Spriet LL. Skeletal muscle energy metabolism during
NEJM198001313020504. exercise. Nat Metab 2: 817–828, 2020. doi:10.1038/s42255-020-
0251-4.
379. Ball-Burnett M, Green HJ, Houston ME. Energy metabolism in
human slow and fast twitch fibres during prolonged cycle exercise. 394. Ruby BC, Cuddy JS, Hailes WS, Dumke CL, Slivka DR, Shriver TC,
J Physiol 437: 257–267, 1991. doi:10.1113/jphysiol.1991.sp018594. Schoeller DA. Extreme endurance and the metabolic range of sus-
380. Nielsen J, Suetta C, Hvid LG, Schrøder HD, Aagaard P, Ortenblad tained activity is uniquely available for every human not just the elite
N. Subcellular localization-dependent decrements in skeletal mus- few. Comp Exerc Physiol 11: 1–7, 2015. doi:10.3920/CEP140025.
cle glycogen and mitochondria content following short-term disuse 395. Holloszy JO, Rennie MJ, Hickson RC, Conlee RK, Hagberg JM.
in young and old men. Am J Physiol Endocrinol Metab 299:
Physiological consequences of the biochemical adaptations to en-
E1053–E1060, 2010. doi:10.1152/ajpendo.00324.2010.
durance exercise. Ann NY Acad Sci 301: 440–450, 1977. doi:10.1111/
381. De Bock K, Derave W, Ramaekers M, Richter EA, Hespel P. Fiber j.1749-6632.1977.tb38220.x.
type-specific muscle glycogen sparing due to carbohydrate intake
396. MacRae HS, Dennis SC, Bosch AN, Noakes TD. Effects of training
before and during exercise. J Appl Physiol (1985) 102: 183–188,
on lactate production and removal during progressive exercise in
2007. doi:10.1152/japplphysiol.00799.2006.
humans. J Appl Physiol (1985) 72: 1649–1656, 1992. doi:10.1152/
382. Greenhaff PL, Nevill ME, Soderlund K, Bodin K, Boobis LH, Williams jappl.1992.72.5.1649.
C, Hultman E. The metabolic responses of human type I and II mus-
397. Burke LM. Ketogenic low-CHO, high-fat diet: the future of elite endur-
cle fibres during maximal treadmill sprinting. J Physiol 478: 149–
ance sport? J Physiol 599: 819–843, 2021. doi:10.1113/JP278928.
155, 1994. doi:10.1113/jphysiol.1994.sp020238.

383. Tsintzas OK, Williams C, Boobis L, Greenhaff P. Carbohydrate 398. Romijn JA, Coyle EF, Sidossis LS, Zhang XJ, Wolfe RR. Relationship
ingestion and single muscle fiber glycogen metabolism during pro- between fatty acid delivery and fatty acid oxidation during strenu-
longed running in men. J Appl Physiol (1985) 81: 801–809, 1996. ous exercise. J Appl Physiol (1985) 79: 1939–1945, 1995.
doi:10.1152/jappl.1996.81.2.801. doi:10.1152/jappl.1995.79.6.1939.

384. Albers PH, Pedersen AJ, Birk JB, Kristensen DE, Vind BF, Baba O, 399. Drake JC, Wilson RJ, Yan Z. Molecular mechanisms for mitochon-
Nøhr J, Højlund K, Wojtaszewski JF. Human muscle fiber type-spe- drial adaptation to exercise training in skeletal muscle. FASEB J 30:
cific insulin signaling: impact of obesity and type 2 diabetes. 13–22, 2016. doi:10.1096/fj.15-276337.
Diabetes 64: 485–497, 2015. doi:10.2337/db14-0590.
400. Bo H, Zhang Y, Ji LL. Redefining the role of mitochondria in exer-
385. Bell DG, Jacobs I. Muscle fiber-specific glycogen utilization in cise: a dynamic remodeling. Ann NY Acad Sci 1201: 121–128, 2010.
strength-trained males and females. Med Sci Sports Exerc 21: 649– doi:10.1111/j.1749-6632.2010.05618.x.
654, 1989. doi:10.1249/00005768-198912000-00004.
401. Liesa M, Palacín M, Zorzano A. Mitochondrial dynamics in mamma-
386. Gejl KD, Ørtenblad N, Andersson E, Plomgaard P, Holmberg HC, lian health and disease. Physiol Rev 89: 799–845, 2009.
Nielsen J. Local depletion of glycogen with supramaximal exercise doi:10.1152/physrev.00030.2008.
in human skeletal muscle fibres. J Physiol 595: 2809–2821, 2017.
doi:10.1113/JP273109. 402. Romanello V, Sandri M. The connection between the dynamic
remodeling of the mitochondrial network and the regulation of mus-
387. Johnson MA, Polgar J, Weightman D, Appleton D. Data on the dis- cle mass. Cell Mol Life Sci 78: 1305–1328, 2021. doi:10.1007/
tribution of fibre types in thirty-six human muscles. An autopsy s00018-020-03662-0.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1771

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

403. Kleele T, Rey T, Winter J, Zaganelli S, Mahecic D, Perreten Lambert unmask the apparent contradiction of the athlete’s paradox. Mol
H, Ruberto FP, Nemir M, Wai T, Pedrazzini T, Manley S. Distinct fis- Metab 17: 71–81, 2018. doi:10.1016/j.molmet.2018.08.004.
sion signatures predict mitochondrial degradation or biogenesis.
Nature 593: 435–439, 2021. doi:10.1038/s41586-021-03510-6. 418. Hoppeler H, Fluck M. Plasticity of skeletal muscle mitochondria:
structure and function. Med Sci Sports Exerc 35: 95–104, 2003.
404. Djalalvandi A, Scorrano L. Mitochondrial dynamics: roles in exercise doi:10.1249/01.MSS.0000043292.99104.12.
physiology and muscle mass regulation. Curr Opin Physiol 27:
100550, 2022. doi:10.1016/j.cophys.2022.100550. 419. van Loon LJ, Koopman R, Manders R, van der Weegen W, van
Kranenburg GP, Keizer HA. Intramyocellular lipid content in type 2
405. Perry CG, Lally J, Holloway GP, Heigenhauser GJ, Bonen A, Spriet LL. diabetes patients compared with overweight sedentary men and
Repeated transient mRNA bursts precede increases in transcriptional highly trained endurance athletes. Am J Physiol Endocrinol Metab
and mitochondrial proteins during training in human skeletal muscle. 287: E558–E565, 2004. doi:10.1152/ajpendo.00464.2003.
J Physiol 588: 4795–4810, 2010. doi:10.1113/jphysiol.2010.199448.
420. van Loon LJ, Koopman R, Stegen JH, Wagenmakers AJ, Keizer HA,
 re D, Fe
406. Jamart C, Francaux M, Millet GY, Deldicque L, Fre asson L. Saris WH. Intramyocellular lipids form an important substrate source
Modulation of autophagy and ubiquitin-proteasome pathways dur- during moderate intensity exercise in endurance-trained males in a
ing ultra-endurance running. J Appl Physiol (1985) 112: 1529–1537, fasted state. J Physiol 553: 611–625, 2003. doi:10.1113/jphysiol.
2012. doi:10.1152/japplphysiol.00952.2011. 2003.052431.

407. Mishra P, Varuzhanyan G, Pham AH, Chan DC. mitochondrial dy- 421. Nielsen J, Mogensen M, Vind BF, Sahlin K, Højlund K, Schrøder HD,
namics is a distinguishing feature of skeletal muscle fiber types and Ortenblad N. Increased subsarcolemmal lipids in type 2 diabetes:
regulates organellar compartmentalization. Cell Metab 22: 1033– effect of training on localization of lipids, mitochondria, and glyco-
1044, 2015. doi:10.1016/j.cmet.2015.09.027. gen in sedentary human skeletal muscle. Am J Physiol Endocrinol
Metab 298: E706–E713, 2010. doi:10.1152/ajpendo.00692.2009.
408. Glancy B, Balaban RS. Energy metabolism design of the striated
muscle cell. Physiol Rev 101: 1561–1607, 2021. doi:10.1152/physrev. 422. Koh HE, Nielsen J, Saltin B, Holmberg HC, Ørtenblad N.
00040.2020. Pronounced limb and fibre type differences in subcellular lipid
droplet content and distribution in elite skiers before and after ex-
409. Bleck CK, Kim Y, Willingham TB, Glancy B. Subcellular connectomic haustive exercise. J Physiol 595: 5781–5795, 2017. doi:10.1113/
analyses of energy networks in striated muscle. Nat Commun 9: JP274462.
5111, 2018. doi:10.1038/s41467-018-07676-y.
423. Li X, Li Z, Zhao M, Nie Y, Liu P, Zhu Y, Zhang X. Skeletal muscle lipid
410. Dahl R, Larsen S, Dohlmann TL, Qvortrup K, Helge JW, Dela F, Prats droplets and the athlete’s paradox. Cells 8: 249, 2019. doi:10.3390/
C. Three-dimensional reconstruction of the human skeletal muscle cells8030249.
mitochondrial network as a tool to assess mitochondrial content
and structural organization. Acta Physiol (Oxf) 213: 145–155, 2015. 424. Nielsen J, Holmberg HC, Schrøder HD, Saltin B, Ortenblad N.
doi:10.1111/apha.12289. Human skeletal muscle glycogen utilization in exhaustive exercise:
role of subcellular localization and fibre type. J Physiol 589: 2871–
411. Vincent AE, White K, Davey T, Philips J, Ogden RT, Lawless C, 2885, 2011. doi:10.1113/jphysiol.2010.204487.
Warren C, Hall MG, Ng YS, Falkous G, Holden T, Deehan D, Taylor
RW, Turnbull DM, Picard M. Quantitative 3D mapping of the human 425. Nielsen J, Schrøder HD, Rix CG, Ortenblad N. Distinct effects of
skeletal muscle mitochondrial network. Cell Rep 26: 996–1009.e4, subcellular glycogen localization on tetanic relaxation time and en-
2019. doi:10.1016/j.celrep.2019.01.010. durance in mechanically skinned rat skeletal muscle fibres. J
Physiol 587: 3679–3690, 2009. doi:10.1113/jphysiol.2009.174862.
412. Glancy B, Hartnell LM, Malide D, Yu ZX, Combs CA, Connelly PS,
Subramaniam S, Balaban RS. Mitochondrial reticulum for cellular 426. Hawley JA, Schabort EJ, Noakes TD, Dennis SC. Carbohydrate-
energy distribution in muscle. Nature 523: 617–620, 2015. loading and exercise performance. An update. Sports Med 24: 73–
doi:10.1038/nature14614. 81, 1997. doi:10.2165/00007256-199724020-00001.

413. Lundby C, Jacobs RA. Adaptations of skeletal muscle mitochondria 427. Holloszy JO. Regulation by exercise of skeletal muscle content of
to exercise training. Exp Physiol 101: 17–22, 2016. doi:10.1113/ mitochondria and GLUT4. J Physiol Pharmacol 59, Suppl 7: 5–18,
EP085319. 2008.

414. Howald H, Hoppeler H, Claassen H, Mathieu O, Straub R. 428. Burke LM, van Loon LJ, Hawley JA. Postexercise muscle glycogen
Influences of endurance training on the ultrastructural composition resynthesis in humans. J Appl Physiol (1985) 122: 1055–1067, 2017.
of the different muscle fiber types in humans. Pflugers Arch 403: doi:10.1152/japplphysiol.00860.2016.
369–376, 1985. doi:10.1007/BF00589248.
429. Staron RS, Leonardi MJ, Karapondo DL, Malicky ES, Falkel JE,
415. Jacobs RA, Lundby C. Mitochondria express enhanced quality as Hagerman FC, Hikida RS. Strength and skeletal muscle adaptations
well as quantity in association with aerobic fitness across recrea- in heavy-resistance-trained women after detraining and retraining.
tionally active individuals up to elite athletes. J Appl Physiol (1985) J Appl Physiol (1985) 70: 631–640, 1991. doi:10.1152/jappl.1991.
114: 344–350, 2013. doi:10.1152/japplphysiol.01081.2012. 70.2.631.

416. Granata C, Jamnick NA, Bishop DJ. Training-induced changes in mi- 430. Seaborne RA, Strauss J, Cocks M, Shepherd S, O’Brien TD, van
tochondrial content and respiratory function in human skeletal mus- Someren KA, Bell PG, Murgatroyd C, Morton JP, Stewart CE,
cle. Sports Med 48: 1809–1828, 2018. doi:10.1007/s40279-018- Sharples AP. Human skeletal muscle possesses an epigenetic
0936-y. memory of hypertrophy. Sci Rep 8: 1898, 2018. doi:10.1038/s41598-
018-20287-3.
417. Daemen S, Gemmink A, Brouwers B, Meex RC, Huntjens PR,
Schaart G, Moonen-Kornips E, Jo €rgensen J, Hoeks J, Schrauwen P, 431. Wen Y, Dungan CM, Mobley CB, Valentino T, von Walden F,
Hesselink MK. Distinct lipid droplet characteristics and distribution Murach KA. Nucleus type-specific DNA methylomics reveals

1772 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

epigenetic “memory” of prior adaptation in skeletal muscle. different exercise training modes in young and old humans. Cell
Function 2: zqab038, 2021. doi:10.1093/function/zqab038. Metab 25: 581–592, 2017. doi:10.1016/j.cmet.2017.02.009.

432. Egner IM, Bruusgaard JC, Eftestøl E, Gundersen K. A cellular mem- 445. Telles GD, Libardi CA, Conceição MS, Vechin FC, Lixandrão ME,
ory mechanism aids overload hypertrophy in muscle long after an Mangone FR, Pavanelli AC, Nagai MA, Camera DM, Hawley JA,
episodic exposure to anabolic steroids. J Physiol 591: 6221–6230, Ugrinowitsch C. Interrelated but not time-aligned response in myo-
2013. doi:10.1113/jphysiol.2013.264457. genic regulatory factors demethylation and mRNA expression after
divergent exercise bouts. Med Sci Sports Exerc 55: 199–208,
433. Snijders T, Aussieker T, Holwerda A, Parise G, van Loon LJ, Verdijk
2023. doi:10.1249/MSS.0000000000003049.
LB. The concept of skeletal muscle memory: evidence from animal
and human studies. Acta Physiol (Oxf) 229: e13465, 2020. 446. Kuang J, McGinley C, Lee MJ, Saner NJ, Garnham A, Bishop DJ.
doi:10.1111/apha.13465. Interpretation of exercise-induced changes in human skeletal mus-
cle mRNA expression depends on the timing of the post-exercise
434. Murach KA, Dungan CM, Dupont-Versteegden EE, McCarthy JJ,
biopsies. PeerJ 10: e12856, 2022. doi:10.7717/peerj.12856.
Peterson CA. “Muscle memory” not mediated by myonuclear num-
ber? Secondary analysis of human detraining data. J Appl Physiol 447. Turner DC, Seaborne RA, Sharples AP. Comparative transcriptome
(1985) 127: 1814–1816, 2019. doi:10.1152/japplphysiol.00506.2019. and methylome analysis in human skeletal muscle anabolism, hy-
pertrophy and epigenetic memory. Sci Rep 9: 4251, 2019.
435. Sharples AP, Stewart CE, Seaborne RA. Does skeletal muscle have
doi:10.1038/s41598-019-40787-0.
an ‘epi’-memory? The role of epigenetics in nutritional program-
ming, metabolic disease, aging and exercise. Aging Cell 15: 603– 448. Jacques M, Hiam D, Craig J, Barre  s R, Eynon N, Voisin S.
616, 2016. doi:10.1111/acel.12486. Epigenetic changes in healthy human skeletal muscle following
436. Cedar H, Bergman Y. Linking DNA methylation and histone modifi- exercise—a systematic review. Epigenetics 14: 633–648, 2019.
cation: patterns and paradigms. Nat Rev Genet 10: 295–304, doi:10.1080/15592294.2019.1614416.
2009. doi:10.1038/nrg2540. 449. Basang Z, Zhang S, Yang L, Quzong D, Li Y, Ma Y, Hao M, Pu WL,
437. Zhang T, Cooper S, Brockdorff N. The interplay of histone modifica- Liu X, Xie H, Liang M, Wang J, Danzeng Q. Correlation of DNA
tions—writers that read. EMBO Rep 16: 1467–1481, 2015. doi:10.15252/ methylation patterns to the phenotypic features of Tibetan elite
embr.201540945. alpinists in extreme hypoxia. J Genet Genomics 48: 928–935,
2021. doi:10.1016/j.jgg.2021.05.015.
438. Sharples AP, Seaborne RA. Exercise and DNA methylation in skele-
tal muscle. In: Sports, Exercise, and Nutritional Genomics: Current Status 450. Spolnicka M, Pospiech E, Adamczyk JG, Freire-Aradas A, Pepłon ska
B, Zbieć-Piekarska R, Makowska Z, _ Pięta A, Lareu MV, Phillips C,
and Future Directions, edited by Barh D, Ahmetov II. London:
_
Płoski R, Zekanowski C, Branicki W. Modified aging of elite athletes
Academic Press, 2019, p. 211–229.
revealed by analysis of epigenetic age markers. Aging (Albany NY)
439. Sailani MR, Halling JF, Møller HD, Lee H, Plomgaard P, Pilegaard H, 10: 241–252, 2018. doi:10.18632/aging.101385.
Snyder MP, Regenberg B. Lifelong physical activity is associated
with promoter hypomethylation of genes involved in metabolism, 451. Terruzzi I, Senesi P, Montesano A, La Torre A, Alberti G, Benedini S,
myogenesis, contractile properties and oxidative stress resistance Caumo A, Fermo I, Luzi L. Genetic polymorphisms of the enzymes
in aged human skeletal muscle. Sci Rep 9: 3272, 2019. doi:10.1038/ involved in DNA methylation and synthesis in elite athletes. Physiol
s41598-018-37895-8. Genomics 43: 965–973, 2011. doi:10.1152/physiolgenomics.00040.
2010.
440. Alibegovic AC, Sonne MP, Højbjerre L, Bork-Jensen J, Jacobsen S,
Nilsson E, Faerch K, Hiscock N, Mortensen B, Friedrichsen M, 452. Bishop DJ, Hawley JA. Reassessing the relationship between
Stallknecht B, Dela F, Vaag A. Insulin resistance induced by physi- mRNA levels and protein abundance in exercised skeletal muscles.
cal inactivity is associated with multiple transcriptional changes in Nat Rev Mol Cell Biol 23: 773–774, 2022. doi:10.1038/s41580-022-
skeletal muscle in young men. Am J Physiol Endocrinol Metab 00541-3.
299: E752–E763, 2010. doi:10.1152/ajpendo.00590.2009.
453. Pillon NJ, Gabriel BM, Dollet L, Smith JA, Sardon Puig L, Botella J,
441. Barre s R, Yan J, Egan B, Treebak JT, Rasmussen M, Fritz T, Caidahl Bishop DJ, Krook A, Zierath JR. Transcriptomic profiling of skeletal
K, Krook A, O’Gorman DJ, Zierath JR. Acute exercise remodels pro- muscle adaptations to exercise and inactivity. Nat Commun 11: 470,
moter methylation in human skeletal muscle. Cell Metab 15: 405– 2020. doi:10.1038/s41467-019-13869-w.
411, 2012. doi:10.1016/j.cmet.2012.01.001.
454. Amar D, Gay NR, Jean Beltran PM, Adkins JN, Almagro Armenteros
442. Nitert MD, Dayeh T, Volkov P, Elgzyri T, Hall E, Nilsson E, Yang BT, JJ, Ashley E, et al. Temporal dynamics of the multi-omic response
Lang S, Parikh H, Wessman Y, Weishaupt H, Attema J, Abels M, to endurance exercise training across tissues (Preprint). bioRxiv
Wierup N, Almgren P, Jansson PA, Ro € nn T, Hansson O, Eriksson 2022.09.2021.508770, 2022. doi:10.1101/2022.09.21.508770.
KF, Groop L, Ling C. Impact of an exercise intervention on DNA
methylation in skeletal muscle from first-degree relatives of patients 455. Gabriel BM, Zierath JR. The limits of exercise physiology: from per-
with type 2 diabetes. Diabetes 61: 3322–3332, 2012. doi:10.2337/ formance to health. Cell Metab 25: 1000–1011, 2017. doi:10.1016/j.
db11-1653. cmet.2017.04.018.

443. Lindholm ME, Marabita F, Gomez-Cabrero D, Rundqvist H, Ekstro €m 456. Akay T, Murray AJ. Relative contribution of proprioceptive and ves-
TJ, Tegner J, Sundberg CJ. An integrative analysis reveals coordi- tibular sensory systems to locomotion: opportunities for discovery
nated reprogramming of the epigenome and the transcriptome in in the age of molecular science. Int J Mol Sci 22: 1467, 2021.
human skeletal muscle after training. Epigenetics 9: 1557–1569, doi:10.3390/ijms22031467.
2014. doi:10.4161/15592294.2014.982445.
457. Taylor DF, Bishop DJ. Transcription factor movement and exercise-
444. Robinson MM, Dasari S, Konopka AR, Johnson ML, Manjunatha S, induced mitochondrial biogenesis in human skeletal muscle: cur-
Esponda RR, Carter RE, Lanza IR, Nair KS. Enhanced protein transla- rent knowledge and future perspectives. Int J Mol Sci 23: 1517,
tion underlies improved metabolic and physical adaptations to 2022. doi:10.3390/ijms23031517.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1773

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

458. Roatta S, Farina D. Sympathetic actions on the skeletal mus- 475. Handschin C, Rhee J, Lin J, Tarr PT, Spiegelman BM. An autoregula-
cle. Exerc Sport Sci Rev 38: 31–35, 2010. doi:10.1097/JES. tory loop controls peroxisome proliferator-activated receptor
0b013e3181c5cde7. gamma coactivator 1alpha expression in muscle. Proc Natl Acad
Sci USA 100: 7111–7116, 2003. doi:10.1073/pnas.1232352100.
459. Delbono O, Rodrigues AC, Bonilla HJ, Messi ML. The emerging role
of the sympathetic nervous system in skeletal muscle motor inner- 476. Czubryt MP, McAnally J, Fishman GI, Olson EN. Regulation of per-
vation and sarcopenia. Ageing Res Rev 67: 101305, 2021. oxisome proliferator-activated receptor gamma coactivator 1 alpha
doi:10.1016/j.arr.2021.101305. (PGC-1 alpha) and mitochondrial function by MEF2 and HDAC5.
Proc Natl Acad Sci USA 100: 1711–1716, 2003. doi:10.1073/pnas.
460. Teixeira AL, Vianna LC. The exercise pressor reflex: an update. Clin 0337639100.
Auton Res 32: 271–290, 2022. doi:10.1007/s10286-022-00872-3.
477. Lin J, Wu H, Tarr PT, Zhang CY, Wu Z, Boss O, Michael LF,
461. Joassard OR, Durieux AC, Freyssenet DG. beta2-Adrenergic ago- Puigserver P, Isotani E, Olson EN, Lowell BB, Bassel-Duby R,
nists and the treatment of skeletal muscle wasting disorders. Int J Spiegelman BM. Transcriptional co-activator PGC-1 alpha drives the
Biochem Cell Biol 45: 2309–2321, 2013. doi:10.1016/j.biocel.2013. formation of slow-twitch muscle fibres. Nature 418: 797–801, 2002.
06.025. doi:10.1038/nature00904.

462. Sandri M, Lin J, Handschin C, Yang W, Arany ZP, Lecker SH, 478. Arany Z, Foo SY, Ma Y, Ruas JL, Bommi-Reddy A, Girnun G, Cooper
Goldberg AL, Spiegelman BM. PGC-1alpha protects skeletal muscle M, Laznik D, Chinsomboon J, Rangwala SM, Baek KH, Rosenzweig
from atrophy by suppressing FoxO3 action and atrophy-specific A, Spiegelman BM. HIF-independent regulation of VEGF and angio-
gene transcription. Proc Natl Acad Sci USA 103: 16260–16265, genesis by the transcriptional coactivator PGC-1alpha. Nature 451:
2006. doi:10.1073/pnas.0607795103. 1008–1012, 2008. doi:10.1038/nature06613.

463. Schwartz AB. Movement: how the brain communicates with the 479. Handschin C, Choi CS, Chin S, Kim S, Kawamori D, Kurpad AJ,
world. Cell 164: 1122–1135, 2016. doi:10.1016/j.cell.2016.02.038. Neubauer N, Hu J, Mootha VK, Kim YB, Kulkarni RN, Shulman GI,
Spiegelman BM. Abnormal glucose homeostasis in skeletal mus-
464. Scott SH. Optimal feedback control and the neural basis of voli- cle-specific PGC-1alpha knockout mice reveals skeletal muscle-
tional motor control. Nat Rev Neurosci 5: 532–546, 2004. pancreatic beta cell crosstalk. J Clin Invest 117: 3463–3474, 2007.
doi:10.1038/nrn1427. doi:10.1172/JCI31785.

465. Madden CJ, Morrison SF. Central nervous system circuits that con- 480. Handschin C, Chin S, Li P, Liu F, Maratos-Flier E, Lebrasseur NK,
trol body temperature. Neurosci Lett 696: 225–232, 2019. Yan Z, Spiegelman BM. Skeletal muscle fiber-type switching, exer-
doi:10.1016/j.neulet.2018.11.027. cise intolerance, and myopathy in PGC-1alpha muscle-specific
knock-out animals. J Biol Chem 282: 30014–30021, 2007.
466. Stifani N. Motor neurons and the generation of spinal motor neuron doi:10.1074/jbc.M704817200.
diversity. Front Cell Neurosci 8: 293, 2014. doi:10.3389/fncel.
2014.00293. 481. Martínez-Redondo V, Pettersson AT, Ruas JL. The hitchhiker’s guide
to PGC-1alpha isoform structure and biological functions. Diabetologia
467. Li L, Xiong WC, Mei L. Neuromuscular junction formation, aging, 58: 1969–1977, 2015. doi:10.1007/s00125-015-3671-z.
and disorders. Annu Rev Physiol 80: 159–188, 2018. doi:10.1146/
482. Jannig PR, Dumesic PA, Spiegelman BM, Ruas JL. SnapShot:
annurev-physiol-022516-034255.
Regulation and biology of PGC-1alpha. Cell 185: 1444–1444.e1,
468. Tintignac LA, Brenner HR, Ruegg MA. Mechanisms regulating neu- 2022. doi:10.1016/j.cell.2022.03.027.
romuscular junction development and function and causes of mus- rez-Schindler J, Kohl B, Schneider-Heieck K, Leuchtmann AB,
483. Pe
cle wasting. Physiol Rev 95: 809–852, 2015. doi:10.1152/physrev.
Henríquez-Olguín C, Adak V, Maier G, Delezie J, Sakoparnig T,
00033.2014. Vargas-Fernández E, Karrer-Cardel B, Ritz D, Schmidt A, Hondele
469. Shishmarev D. Excitation-contraction coupling in skeletal muscle: M, Jensen TE, Hiller S, Handschin C. RNA-bound PGC-1alpha con-
trols gene expression in liquid-like nuclear condensates. Proc Natl
recent progress and unanswered questions. Biophys Rev 12: 143–
Acad Sci USA 118: e2105951118, 2021. doi:10.1073/pnas.2105951118.
153, 2020. doi:10.1007/s12551-020-00610-x.
484. Handschin C, Spiegelman BM. Peroxisome proliferator-activated re-
470. Tu MK, Levin JB, Hamilton AM, Borodinsky LN. Calcium signaling in
ceptor gamma coactivator 1 coactivators, energy homeostasis, and
skeletal muscle development, maintenance and regeneration. Cell
metabolism. Endocr Rev 27: 728–735, 2006. doi:10.1210/er.2006-
Calcium 59: 91–97, 2016. doi:10.1016/j.ceca.2016.02.005.
0037.
471. Gehlert S, Bloch W, Suhr F. Ca21-dependent regulations and sig-
485. Kupr B, Schnyder S, Handschin C. Role of nuclear receptors in exer-
naling in skeletal muscle: from electro-mechanical coupling to cise-induced muscle adaptations. Cold Spring Harb Perspect Med
adaptation. Int J Mol Sci 16: 1066–1095, 2015. doi:10.3390/ 7: a029835, 2017. doi:10.1101/cshperspect.a029835.
ijms16011066.
486. Schnyder S, Kupr B, Handschin C. Coregulator-mediated control of
472. Pette D, Vrbová G. The contribution of neuromuscular stimulation in skeletal muscle plasticity—a mini-review. Biochimie 136: 49–54,
elucidating muscle plasticity revisited. Eur J Transl Myol 27: 6368, 2017. doi:10.1016/j.biochi.2016.12.011.
2017. doi:10.4081/ejtm.2017.6368.
487. Handschin C, Kobayashi YM, Chin S, Seale P, Campbell KP,
473. Salmons S. The adaptive response of skeletal muscle: what is the Spiegelman BM. PGC-1alpha regulates the neuromuscular junction
evidence? Muscle Nerve 57: 531–541, 2018. doi:10.1002/mus. program and ameliorates Duchenne muscular dystrophy. Genes
25949. Dev 21: 770–783, 2007. doi:10.1101/gad.1525107.

474. Kupr B, Handschin C. Complex coordination of cell plasticity by a 488. Summermatter S, Baum O, Santos G, Hoppeler H, Handschin C.
PGC-1alpha-controlled transcriptional network in skeletal muscle. Peroxisome proliferator-activated receptor gamma coactivator 1alpha
Front Physiol 6: 325, 2015. doi:10.3389/fphys.2015.00325. (PGC-1alpha) promotes skeletal muscle lipid refueling in vivo by

1774 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

activating de novo lipogenesis and the pentose phosphate pathway. 502. Furrer R, Eisele PS, Schmidt A, Beer M, Handschin C. Paracrine
J Biol Chem 285: 32793–32800, 2010. doi:10.1074/jbc.M110.145995. cross-talk between skeletal muscle and macrophages in exercise
by PGC-1alpha-controlled BNP. Sci Rep 7: 40789, 2017. doi:10.1038/
489. Handschin C. Regulation of skeletal muscle cell plasticity by the per- srep40789.
oxisome proliferator-activated receptor gamma coactivator 1alpha. J
Recept Signal Transduct Res 30: 376–384, 2010. doi:10.3109/ 503. Rowe GC, Raghuram S, Jang C, Nagy JA, Patten IS, Goyal A, Chan
10799891003641074. MC, Liu LX, Jiang A, Spokes KC, Beeler D, Dvorak H, Aird WC,
Arany Z. PGC-1alpha induces SPP1 to activate macrophages and
490. Amoasii L, Sanchez-Ortiz E, Fujikawa T, Elmquist JK, Bassel-Duby R, orchestrate functional angiogenesis in skeletal muscle. Circ Res
Olson EN. NURR1 activation in skeletal muscle controls systemic 115: 504–517, 2014. doi:10.1161/CIRCRESAHA.115.303829.
energy homeostasis. Proc Natl Acad Sci USA 116: 11299–11308,
2019. doi:10.1073/pnas.1902490116. 504. Leuchtmann AB, Adak V, Dilbaz S, Handschin C. The role of the
skeletal muscle secretome in mediating endurance and resistance
491. Goode JM, Pearen MA, Tuong ZK, Wang SC, Oh TG, Shao EX, training adaptations. Front Physiol 12: 709807, 2021. doi:10.3389/
Muscat GE. The nuclear receptor, Nor-1, induces the physiological fphys.2021.709807.
responses associated with exercise. Mol Endocrinol 30: 660–676,
505. Zunner BE, Wachsmuth NB, Eckstein ML, Scherl L, Schierbauer JR,
2016. doi:10.1210/me.2015-1300.
Haupt S, Stumpf C, Reusch L, Moser O. Myokines and resistance
492. Mills R, Taylor-Weiner H, Correia JC, Agudelo LZ, Allodi I, Kolonelou training: a narrative review. Int J Mol Sci 23: 3501, 2022.
C, Martinez-Redondo V, Ferreira DMS, Nichterwitz S, Comley LH, doi:10.3390/ijms23073501.
Lundin V, Hedlund E, Ruas JL, Teixeira AI. Neurturin is a PGC-
506. Knudsen NH, Stanya KJ, Hyde AL, Chalom MM, Alexander RK, Liou
1alpha1-controlled myokine that promotes motor neuron recruit- YH, Starost KA, Gangl MR, Jacobi D, Liu S, Sopariwala DH,
ment and neuromuscular junction formation. Mol Metab 7: 12–22, Fonseca-Pereira D, Li J, Hu FB, Garrett WS, Narkar VA, Ortlund EA,
2018. doi:10.1016/j.molmet.2017.11.001. Kim JH, Paton CM, Cooper JA, Lee CH. Interleukin-13 drives meta-
bolic conditioning of muscle to endurance exercise. Science 368:
493. Correia JC, Kelahmetoglu Y, Jannig PR, Schweingruber C,
eaat3987, 2020. doi:10.1126/science.aat3987.
Shvaikovskaya D, Zhengye L, Cervenka I, Khan N, Stec M, Oliveira
M, Nijssen J, Martínez-Redondo V, Ducommun S, Azzolini M, 507. Varga T, Mounier R, Patsalos A, Gogolák P, Peloquin M, Horvath A,
Lanner JT, Kleiner S, Hedlund E, Ruas JL. Muscle-secreted neu- Pap A, Daniel B, Nagy G, Pintye E, Po  liska S, Cuvellier S, Larbi SB,
rturin couples myofiber oxidative metabolism and slow motor neu- Sansbury BE, Spite M, Brown CW, Chazaud B, Nagy L. Macrophage
ron identity. Cell Metab 33: 2215–2230.e8, 2021. doi:10.1016/j. PPARgamma, a lipid activated transcription factor controls the
cmet.2021.09.003. growth factor GDF3 and skeletal muscle regeneration. Immunity
45: 1038–1051, 2016. doi:10.1016/j.immuni.2016.10.016.
494. Pedersen BK. Physical activity and muscle-brain crosstalk. Nat Rev
Endocrinol 15: 383–392, 2019. doi:10.1038/s41574-019-0174-x. 508. Zhang J, Muri J, Fitzgerald G, Gorski T, Gianni-Barrera R,
Masschelein E, D’Hulst G, Gilardoni P, Turiel G, Fan Z, Wang T,
495. Delezie J, Weihrauch M, Maier G, Tejero R, Ham DJ, Gill JF, Karrer- Planque M, Carmeliet P, Pellerin L, Wolfrum C, Fendt SM, Banfi A,
Cardel B, R€uegg MA, Tabares L, Handschin C. BDNF is a media- Stockmann C, Soro-Arnáiz I, Kopf M, De Bock K. Endothelial lactate
tor of glycolytic fiber-type specification in mouse skeletal muscle. controls muscle regeneration from ischemia by inducing M2-like
Proc Natl Acad Sci USA 116: 16111–16120, 2019. doi:10.1073/pnas. macrophage polarization. Cell Metab 31: 1136–1153.e7, 2020.
1900544116. doi:10.1016/j.cmet.2020.05.004.

496. Steinacker JM, Brkic M, Simsch C, Nething K, Kresz A, Prokopchuk 509. Gonzalez-Gil AM, Elizondo-Montemayor L. The role of exercise in
O, Liu Y. Thyroid hormones, cytokines, physical training and meta- the interplay between myokines, hepatokines, osteokines, adipo-
bolic control. Horm Metab Res 37: 538–544, 2005. doi:10.1055/s- kines, and modulation of inflammation for energy substrate redis-
2005-870419. tribution and fat mass loss: a review. Nutrients 12: 1899, 2020.
doi:10.3390/nu12061899.
497. Kraemer WJ, Ratamess NA, Nindl BC. Recovery responses of tes-
tosterone, growth hormone, and IGF-1 after resistance exercise. J 510. Weigert C, Hoene M, Plomgaard P. Hepatokines-a novel group of
Appl Physiol (1985) 122: 549–558, 2017. doi:10.1152/japplphysiol. exercise factors. Pflugers Arch 471: 383–396, 2019. doi:10.1007/
00599.2016. s00424-018-2216-y.

498. Laurens C, Bergouignan A, Moro C. Exercise-released myokines in 511. Burkholder TJ. Mechanotransduction in skeletal muscle. Front
the control of energy metabolism. Front Physiol 11: 91, 2020. Biosci 12: 174–191, 2007. doi:10.2741/2057.
doi:10.3389/fphys.2020.00091.
512. Benavides Damm T, Egli M. Calcium’s role in mechanotransduction
499. Thyfault JP, Bergouignan A. Exercise and metabolic health: beyond during muscle development. Cell Physiol Biochem 33: 249–272,
skeletal muscle. Diabetologia 63: 1464–1474, 2020. doi:10.1007/ 2014. doi:10.1159/000356667.
s00125-020-05177-6. 513. Bernareggi A, Bosutti A, Massaria G, Giniatullin R, Malm T,
Sciancalepore M, Lorenzon P. The state of the art of Piezo1 chan-
500. Chow LS, Gerszten RE, Taylor JM, Pedersen BK, van Praag H,
nels in skeletal muscle regeneration. Int J Mol Sci 23: 6616, 2022.
Trappe S, Febbraio MA, Galis ZS, Gao Y, Haus JM, Lanza IR, Lavie
doi:10.3390/ijms23126616.
CJ, Lee CH, Lucia A, Moro C, Pandey A, Robbins JM, Stanford KI,
Thackray AE, Villeda S, Watt MJ, Xia A, Zierath JR, Goodpaster BH, 514. Cullen PJ. Decoding complex Ca21 signals through the modulation
Snyder MP. Exerkines in health, resilience and disease. Nat Rev of Ras signaling. Curr Opin Cell Biol 18: 157–161, 2006. doi:10.1016/
Endocrinol 18: 273–289, 2022. doi:10.1038/s41574-022-00641-2. j.ceb.2006.02.012.

501. Schnyder S, Handschin C. Skeletal muscle as an endocrine organ: 515. Rindom E, Vissing K. Mechanosensitive molecular networks involved
PGC-1alpha, myokines and exercise. Bone 80: 115–125, 2015. in transducing resistance exercise-signals into muscle protein accre-
doi:10.1016/j.bone.2015.02.008. tion. Front Physiol 7: 547, 2016. doi:10.3389/fphys.2016.00547.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1775

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

516. Wright DC, Han DH, Garcia-Roves PM, Geiger PC, Jones TE, 533. Jabre S, Hleihel W, Coirault C. Nuclear mechanotransduction in
Holloszy JO. Exercise-induced mitochondrial biogenesis begins skeletal muscle. Cells 10: 318, 2021. doi:10.3390/cells10020318.
before the increase in muscle PGC-1alpha expression. J Biol Chem
282: 194–199, 2007. doi:10.1074/jbc.M606116200. 534. Powers SK, Deminice R, Ozdemir M, Yoshihara T, Bomkamp MP,
Hyatt H. Exercise-induced oxidative stress: friend or foe? J Sport
517. Kramer HF, Goodyear LJ. Exercise, MAPK, and NF-kappaB signal- Health Sci 9: 415–425, 2020. doi:10.1016/j.jshs.2020.04.001.
ing in skeletal muscle. J Appl Physiol (1985) 103: 388–395, 2007.
doi:10.1152/japplphysiol.00085.2007. 535. Sies H, Jones DP. Reactive oxygen species (ROS) as pleiotropic
physiological signalling agents. Nat Rev Mol Cell Biol 21: 363–383,
518. Bahrami S, Drabløs F. Gene regulation in the immediate-early 2020. doi:10.1038/s41580-020-0230-3.
response process. Adv Biol Regul 62: 37–49, 2016. doi:10.1016/j.
jbior.2016.05.001. 536. Ward CW, Prosser BL, Lederer WJ. Mechanical stretch-induced acti-
vation of ROS/RNS signaling in striated muscle. Antioxid Redox
519. Goodman CA, Hornberger TA, Robling AG. Bone and skeletal mus- Signal 20: 929–936, 2014. doi:10.1089/ars.2013.5517.
cle: key players in mechanotransduction and potential overlapping
mechanisms. Bone 80: 24–36, 2015. doi:10.1016/j.bone.2015.04.014. 537. Di Meo S, Napolitano G, Venditti P. Mediators of physical activity
protection against ROS-linked skeletal muscle damage. Int J Mol
520. Attwaters M, Hughes SM. Cellular and molecular pathways control- Sci 20: 3024, 2019. doi:10.3390/ijms20123024.
ling muscle size in response to exercise. FEBS J 289: 1428–1456,
2022. doi:10.1111/febs.15820. 538. Nemes R, Koltai E, Taylor AW, Suzuki K, Gyori F, Radak Z. Reactive
oxygen and nitrogen species regulate key metabolic, anabolic, and
521. González A, Hall MN, Lin SC, Hardie DG. AMPK and TOR: the yin catabolic pathways in skeletal muscle. Antioxidants (Basel) 7: 85,
and yang of cellular nutrient sensing and growth control. Cell 2018. doi:10.3390/antiox7070085.
Metab 31: 472–492, 2020. doi:10.1016/j.cmet.2020.01.015.
539. Suhr F, Gehlert S, Grau M, Bloch W. Skeletal muscle function during
522. Yoon MS. mTOR as a key regulator in maintaining skeletal muscle exercise-fine-tuning of diverse subsystems by nitric oxide. Int J Mol
mass. Front Physiol 8: 788, 2017. doi:10.3389/fphys.2017.00788. Sci 14: 7109–7139, 2013. doi:10.3390/ijms14047109.
523. Bentzinger CF, Lin S, Romanino K, Castets P, Guridi M, Summermatter  HM. Redox metabolism: ROS as specific mo-
540. Lennicke C, Cocheme
S, Handschin C, Tintignac LA, Hall MN, Ruegg MA. Differential
lecular regulators of cell signaling and function. Mol Cell 81: 3691–
response of skeletal muscles to mTORC1 signaling during atrophy and
3707, 2021. doi:10.1016/j.molcel.2021.08.018.
hypertrophy. Skelet Muscle 3: 6, 2013. doi:10.1186/2044-5040-3-6.
541. Gureev AP, Shaforostova EA, Popov VN. Regulation of mitochon-
524. Ham AS, Chojnowska K, Tintignac LA, Lin S, Schmidt A, Ham DJ,
drial biogenesis as a way for active longevity: interaction between
Sinnreich M, R€
uegg MA. mTORC1 signalling is not essential for the
the Nrf2 and PGC-1alpha signaling pathways. Front Genet 10: 435,
maintenance of muscle mass and function in adult sedentary mice.
2019. doi:10.3389/fgene.2019.00435.
J Cachexia Sarcopenia Muscle 11: 259–273, 2020. doi:10.1002/
jcsm.12505. 542. Beyfuss K, Hood DA. A systematic review of p53 regulation of oxi-
dative stress in skeletal muscle. Redox Rep 23: 100–117, 2018.
525. Wackerhage H, Schoenfeld BJ, Hamilton DL, Lehti M, Hulmi JJ.
doi:10.1080/13510002.2017.1416773.
Stimuli and sensors that initiate skeletal muscle hypertrophy follow-
ing resistance exercise. J Appl Physiol (1985) 126: 30–43, 2019. 543. Eisele PS, Handschin C. Functional crosstalk of PGC-1 coactivators
doi:10.1152/japplphysiol.00685.2018. and inflammation in skeletal muscle pathophysiology. Semin
526. Fischer M, Rikeit P, Knaus P, Coirault C. YAP-mediated mechanotrans- Immunopathol 36: 27–53, 2014. doi:10.1007/s00281-013-0406-4.
duction in skeletal muscle. Front Physiol 7: 41, 2016. doi:10.3389/ 544. Nocella C, Cammisotto V, Pigozzi F, Borrione P, Fossati C, D’Amico
fphys.2016.00041. A, Cangemi R, Peruzzi M, Gobbi G, Ettorre E, Frati G, Cavarretta E,
527. Kr€ €tter S. Titin, a central mediator for hypertrophic signal-
uger M, Ko Carnevale R; SMiLe Group. Impairment between oxidant and anti-
ing, exercise-induced mechanosignaling and skeletal muscle oxidant systems: short- and long-term implications for athletes’
remodeling. Front Physiol 7: 76, 2016. doi:10.3389/fphys.2016. health. Nutrients 11: 1353, 2019. doi:10.3390/nu11061353.
00076.
545. Knez WL, Jenkins DG, Coombes JS. The effect of an increased
528. Nishikawa K, Lindstedt SL, Hessel A, Mishra D. N2A titin: signaling training volume on oxidative stress. Int J Sports Med 35: 8–13,
hub and mechanical switch in skeletal muscle. Int J Mol Sci 21: 2014. doi:10.1055/s-0033-1333746.
3974, 2020. doi:10.3390/ijms21113974.
546. Knez WL, Jenkins DG, Coombes JS. Oxidative stress in half and full
529. Ibata N, Terentjev EM. Why exercise builds muscles: titin mechano- Ironman triathletes. Med Sci Sports Exerc 39: 283–288, 2007.
sensing controls skeletal muscle growth under load. Biophys J 120: doi:10.1249/01.mss.0000246999.09718.0c.
3649–3663, 2021. doi:10.1016/j.bpj.2021.07.023.
547. Varamenti E, Tod D, Pullinger SA. Redox homeostasis and inflam-
530. Freundt JK, Linke WA. Titin as a force-generating muscle protein mation responses to training in adolescent athletes: a systematic
under regulatory control. J Appl Physiol (1985) 126: 1474–1482, review and meta-analysis. Sports Med Open 6: 34, 2020.
2019. doi:10.1152/japplphysiol.00865.2018. doi:10.1186/s40798-020-00262-x.

531. van Ingen MJ, Kirby TJ. LINCing nuclear mechanobiology with skel- 548. Pastor R, Tur JA. Antioxidant supplementation and adaptive
etal muscle mass and function. Front Cell Dev Biol 9: 690577, response to training: a systematic review. Curr Pharm Des 25:
2021. doi:10.3389/fcell.2021.690577. 1889–1912, 2019. doi:10.2174/1381612825666190701164923.

532. Niethammer P. Components and mechanisms of nuclear mechano- 549. Jackson MJ, Pollock N, Staunton C, Jones S, McArdle A. Redox
transduction. Annu Rev Cell Dev Biol 37: 233–256, 2021. control of signalling responses to contractile activity and ageing in
doi:10.1146/annurev-cellbio-120319-030049. skeletal muscle. Cells 11: 1698, 2022. doi:10.3390/cells11101698.

1776 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

550. Chini CC, Zeidler JD, Kashyap S, Warner G, Chini EN. Evolving con- metabolic adaptation to fasting and exercise in skeletal muscle.
cepts in NAD1 metabolism. Cell Metab 33: 1076–1087, 2021. Cell Metab 11: 213–219, 2010. doi:10.1016/j.cmet.2010.02.006.
doi:10.1016/j.cmet.2021.04.003.
567. Gurd BJ. Deacetylation of PGC-1alpha by SIRT1: importance for skele-
551. Glancy B, Kane DA, Kavazis AN, Goodwin ML, Willis WT, Gladden tal muscle function and exercise-induced mitochondrial biogenesis.
LB. Mitochondrial lactate metabolism: history and implications for Appl Physiol Nutr Metab 36: 589–597, 2011. doi:10.1139/h11-070.
exercise and disease. J Physiol 599: 863–888, 2021. doi:10.1113/
JP278930. 568. Dominy JE Jr, Lee Y, Gerhart-Hines Z, Puigserver P. Nutrient-depend-
ent regulation of PGC-1alpha’s acetylation state and metabolic func-
552. Trefts E, Shaw RJ. AMPK: restoring metabolic homeostasis over tion through the enzymatic activities of Sirt1/GCN5. Biochim Biophys
space and time. Mol Cell 81: 3677–3690, 2021. doi:10.1016/j. Acta 1804: 1676–1683, 2010. doi:10.1016/j.bbapap.2009.11.023.
molcel.2021.08.015.
569. Radak Z, Suzuki K, Posa A, Petrovszky Z, Koltai E, Boldogh I. The
553. Spaulding HR, Yan Z. AMPK and the adaptation to exercise. Annu systemic role of SIRT1 in exercise mediated adaptation. Redox Biol
Rev Physiol 84: 209–227, 2022. doi:10.1146/annurev-physiol- 35: 101467, 2020. doi:10.1016/j.redox.2020.101467.
060721-095517.
570. Vargas-Ortiz K, Perez-Vázquez V, Macias-Cervantes MH. Exercise
554. Kjøbsted R, Hingst JR, Fentz J, Foretz M, Sanz MN, Pehmøller C, and sirtuins: a way to mitochondrial health in skeletal muscle. Int J
Shum M, Marette A, Mounier R, Treebak JT, Wojtaszewski JFP, Mol Sci 20: 2717, 2019. doi:10.3390/ijms20112717.
Viollet B, Lantier L. AMPK in skeletal muscle function and metabo-
lism. FASEB J 32: 1741–1777, 2018. doi:10.1096/fj.201700442R. 571. Ramazi S, Zahiri J. Posttranslational modifications in proteins:
resources, tools and prediction methods. Database (Oxford) 2021:
555. McConell GK. It’s well and truly time to stop stating that AMPK regu- baab012, 2021. doi:10.1093/database/baab012.
lates glucose uptake and fat oxidation during exercise. Am J
Physiol Endocrinol Metab 318: E564–E567, 2020. doi:10.1152/ 572. Conibear AC. Deciphering protein post-translational modifications
ajpendo.00511.2019. using chemical biology tools. Nat Rev Chem 4: 674–695, 2020.
doi:10.1038/s41570-020-00223-8.
556. Simcox J, Lamming DW. The central moTOR of metabolism. Dev
Cell 57: 691–706, 2022. doi:10.1016/j.devcel.2022.02.024. 573. Memme JM, Hood DA. Molecular basis for the therapeutic effects
of exercise on mitochondrial defects. Front Physiol 11: 615038,
557. White JP. Amino acid trafficking and skeletal muscle protein synthe- 2020. doi:10.3389/fphys.2020.615038.
sis: a case of supply and demand. Front Cell Dev Biol 9: 656604,
2021. doi:10.3389/fcell.2021.656604. 574. Popov DV. Adaptation of skeletal muscles to contractile activity of
varying duration and intensity: the role of PGC-1alpha. Biochemistry
558. Sanchez AM, Candau RB, Bernardi H. FoxO transcription factors: (Mosc) 83: 613–628, 2018. doi:10.1134/S0006297918060019.
their roles in the maintenance of skeletal muscle homeostasis. Cell
Mol Life Sci 71: 1657–1671, 2014. doi:10.1007/s00018-013-1513-z. 575. Svensson K, Albert V, Cardel B, Salatino S, Handschin C. Skeletal
muscle PGC-1alpha modulates systemic ketone body homeostasis
559. von Walden F. Ribosome biogenesis in skeletal muscle: coordina- and ameliorates diabetic hyperketonemia in mice. FASEB J 30:
tion of transcription and translation. J Appl Physiol (1985) 127: 591– 1976–1986, 2016. doi:10.1096/fj.201500128.
598, 2019. doi:10.1152/japplphysiol.00963.2018.
576. Chan MC, Arany Z. The many roles of PGC-1alpha in muscle—
560. Vainshtein A, Sandri M. Signaling pathways that control muscle recent developments. Metabolism 63: 441–451, 2014. doi:10.1016/j.
mass. Int J Mol Sci 21: 4759, 2020. doi:10.3390/ijms21134759. metabol.2014.01.006.

561. Yoshida T, Delafontaine P. Mechanisms of IGF-1-mediated regula- 577. Summermatter S, Santos G, Pe  rez-Schindler J, Handschin C.
tion of skeletal muscle hypertrophy and atrophy. Cells 9: 1970, Skeletal muscle PGC-1alpha controls whole-body lactate homeosta-
2020. doi:10.3390/cells9091970. sis through estrogen-related receptor alpha-dependent activation
of LDH B and repression of LDH A. Proc Natl Acad Sci USA 110:
562. Markby GR, Sakamoto K. Transcription factor EB and TFE3: new 8738–8743, 2013. doi:10.1073/pnas.1212976110.
metabolic coordinators mediating adaptive responses to exercise
in skeletal muscle? Am J Physiol Endocrinol Metab 319: E763– 578. Kra€mer AI, Handschin C. How epigenetic modifications drive the
E768, 2020. doi:10.1152/ajpendo.00339.2020. expression and mediate the action of PGC-1alpha in the regulation
of metabolism. Int J Mol Sci 20: 5449, 2019. doi:10.3390/
563. Mesquita PH, Vann CG, Phillips SM, McKendry J, Young KC, Kavazis ijms20215449.
AN, Roberts MD. Skeletal muscle ribosome and mitochondrial bio-
genesis in response to different exercise training modalities. Front 579. Janzen NR, Whitfield J, Hoffman NJ. Interactive roles for AMPK and
Physiol 12: 725866, 2021. doi:10.3389/fphys.2021.725866. glycogen from cellular energy sensing to exercise metabolism. Int J
Mol Sci 19: 3344, 2018. doi:10.3390/ijms19113344.
564. Atherton PJ, Babraj J, Smith K, Singh J, Rennie MJ, Wackerhage H.
Selective activation of AMPK-PGC-1alpha or PKB-TSC2-mTOR sig- 580. Richards P, Ourabah S, Montagne J, Burnol AF, Postic C, Guilmeau
naling can explain specific adaptive responses to endurance or re- S. MondoA/ChREBP: the usual suspects of transcriptional glucose
sistance training-like electrical muscle stimulation. FASEB J 19: sensing; implication in pathophysiology. Metabolism 70: 133–151,
786–788, 2005. doi:10.1096/fj.04-2179fje. 2017. doi:10.1016/j.metabol.2017.01.033.

565. Coffey VG, Zhong Z, Shield A, Canny BJ, Chibalin AV, Zierath JR, 581. Goodman CA. Role of mTORC1 in mechanically induced increases
Hawley JA. Early signaling responses to divergent exercise stimuli in translation and skeletal muscle mass. J Appl Physiol (1985) 127:
in skeletal muscle from well-trained humans. FASEB J 20: 190–192, 581–590, 2019. doi:10.1152/japplphysiol.01011.2018.
2006. doi:10.1096/fj.05-4809fje.
582. Valenzuela PL, Morales JS, Emanuele E, Pareja-Galeano H, Lucia A.
566. Canto C, Jiang LQ, Deshmukh AS, Mataki C, Coste A, Lagouge M, Supplements with purported effects on muscle mass and strength.
Zierath JR, Auwerx J. Interdependence of AMPK and SIRT1 for Eur J Nutr 58: 2983–3008, 2019. doi:10.1007/s00394-018-1882-z.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1777

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

583. Reddy A, Bozi LH, Yaghi OK, Mills EL, Xiao H, Nicholson HE, 598. Bock JM, Kruse NT, Donnelly C, Hirai DM, Craig JC, Colburn TD,
Paschini M, Paulo JA, Garrity R, Laznik-Bogoslavski D, Ferreira JC, Musch TI, Poole DC, Rosenberry R, Tian F, Liu H, Nelson MD,
Carl CS, Sjøberg KA, Wojtaszewski JF, Jeppesen JF, Kiens B, Gygi Piknova B, Willis WT, Zuo L, Zhou T, Riveros-Rivera A, Cristancho E,
SP, Richter EA, Mathis D, Chouchani ET. pH-Gated succinate secre- Gunga HC. Commentaries on Viewpoint: Managing the power grid:
tion regulates muscle remodeling in response to exercise. Cell 183: how myoglobin can regulate Po2 and energy distribution in skeletal
62–75.e17, 2020. doi:10.1016/j.cell.2020.08.039. muscle. J Appl Physiol (1985) 126: 791–794, 2019. doi:10.1152/
japplphysiol.01107.2018.
584. Haws SA, Leech CM, Denu JM. Metabolism and the epigenome: a
dynamic relationship. Trends Biochem Sci 45: 731–747, 2020. 599. Brugarolas J, Lei K, Hurley RL, Manning BD, Reiling JH, Hafen E,
doi:10.1016/j.tibs.2020.04.002. Witters LA, Ellisen LW, Kaelin WG Jr. Regulation of mTOR function
in response to hypoxia by REDD1 and the TSC1/TSC2 tumor sup-
585. McGee SL, Hargreaves M. Epigenetics and exercise. Trends pressor complex. Genes Dev 18: 2893–2904, 2004. doi:10.1101/
Endocrinol Metab 30: 636–645, 2019. doi:10.1016/j.tem.2019.06.002. gad.1256804.

586. Belhaj MR, Lawler NG, Hoffman NJ. Metabolomics and lipidomics: 600. Rasbach KA, Gupta RK, Ruas JL, Wu J, Naseri E, Estall JL,
expanding the molecular landscape of exercise biology. Metabolites Spiegelman BM. PGC-1alpha regulates a HIF2alpha-dependent
11: 151, 2021. doi:10.3390/metabo11030151. switch in skeletal muscle fiber types. Proc Natl Acad Sci USA 107:
21866–21871, 2010. doi:10.1073/pnas.1016089107.
587. Dankel SJ, Mattocks KT, Jessee MB, Buckner SL, Mouser JG,
Loenneke JP. Do metabolites that are produced during resistance 601. Conceição MS, Chacon-Mikahil MP, Telles GD, Libardi CA, Júnior
exercise enhance muscle hypertrophy? Eur J Appl Physiol 117: EM, Vechin FC, De Andrade AL, Gáspari AF, Brum PC, Cavaglieri
2125–2135, 2017. doi:10.1007/s00421-017-3690-1. CR, Serag S, Spiegelman BM, Hawley JA, Camera DM. Attenuated
PGC-1alpha isoforms following endurance exercise with blood flow
588. Ibrahim A, Neinast M, Arany ZP. Myobolites: muscle-derived metab- restriction. Med Sci Sports Exerc 48: 1699–1707, 2016. doi:10.1249/
olites with paracrine and systemic effects. Curr Opin Pharmacol MSS.0000000000000970.
34: 15–20, 2017. doi:10.1016/j.coph.2017.03.007.
602. Barclay CJ. The basis of differences in thermodynamic efficiency
589. Maurer J, Hoene M, Weigert C. Signals from the circle: tricarboxylic among skeletal muscles. Clin Exp Pharmacol Physiol 44: 1279–
acid cycle intermediates as myometabokines. Metabolites 11: 474, 1286, 2017. doi:10.1111/1440-1681.12850.
2021. doi:10.3390/metabo11080474.
603. Archer AE, Von Schulze AT, Geiger PC. Exercise, heat shock pro-
590. Murphy RM, Watt MJ, Febbraio MA. Metabolic communication dur- teins and insulin resistance. Philos Trans R Soc Lond B Biol Sci
ing exercise. Nat Metab 2: 805–816, 2020. doi:10.1038/s42255- 373: 20160529, 2018. doi:10.1098/rstb.2016.0529.
020-0258-x.
604. Henstridge DC, Febbraio MA, Hargreaves M. Heat shock proteins
591. Agudelo LZ, Femenía T, Orhan F, Porsmyr-Palmertz M, Goiny M, and exercise adaptations. Our knowledge thus far and the road still
Martinez-Redondo V, Correia JC, Izadi M, Bhat M, Schuppe- ahead. J Appl Physiol (1985) 120: 683–691, 2016. doi:10.1152/
Koistinen I, Pettersson AT, Ferreira DMS, Krook A, Barres R, Zierath japplphysiol.00811.2015.
JR, Erhardt S, Lindskog M, Ruas JL. Skeletal muscle PGC-1alpha1
modulates kynurenine metabolism and mediates resilience to 605. McGorm H, Roberts LA, Coombes JS, Peake JM. Turning up the
stress-induced depression. Cell 159: 33–45, 2014. doi:10.1016/j. heat: an evaluation of the evidence for heating to promote exercise
cell.2014.07.051. recovery, muscle rehabilitation and adaptation. Sports Med 48:
1311–1328, 2018. doi:10.1007/s40279-018-0876-6.
592. Wojtaszewski JF, MacDonald C, Nielsen JN, Hellsten Y, Hardie DG,
Kemp BE, Kiens B, Richter EA. Regulation of 5 0 AMP-activated pro- 606. Petersen AC, Fyfe JJ. Post-exercise cold water immersion effects
tein kinase activity and substrate utilization in exercising human on physiological adaptations to resistance training and the underly-
skeletal muscle. Am J Physiol Endocrinol Metab 284: E813–E822, ing mechanisms in skeletal muscle: a narrative review. Front Sports
2003. doi:10.1152/ajpendo.00436.2002. Act Living 3: 660291, 2021. doi:10.3389/fspor.2021.660291.

607. Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and
593. Lindholm ME, Rundqvist H. Skeletal muscle hypoxia-inducible fac-
LOVE. Br J Sports Med 54: 72–73, 2020. doi:10.1136/bjsports-2019-
tor-1 and exercise. Exp Physiol 101: 28–32, 2016. doi:10.1113/
101253.
EP085318.
608. Bohnert KR, McMillan JD, Kumar A. Emerging roles of ER stress and
594. Brugniaux JV, Coombs GB, Barak OF, Dujic Z, Sekhon MS, Ainslie
unfolded protein response pathways in skeletal muscle health and
PN. Highs and lows of hyperoxia: physiological, performance, and
disease. J Cell Physiol 233: 67–78, 2018. doi:10.1002/jcp.25852.
clinical aspects. Am J Physiol Regul Integr Comp Physiol 315: R1–
R27, 2018. doi:10.1152/ajpregu.00165.2017. 609. Marafon BB, Pinto AP, Ropelle ER, de Moura LP, Cintra DE, Pauli JR,
da Silva AS. Muscle endoplasmic reticulum stress in exercise. Acta
595. Poole DC, Pittman RN, Musch TI, Østergaard L. August Krogh’s
Physiol (Oxf) 235: e13799, 2022. doi:10.1111/apha.13799.
theory of muscle microvascular control and oxygen delivery: a para-
digm shift based on new data. J Physiol 598: 4473–4507, 2020. 610. Zhang Y, Oliveira AN, Hood DA. The intersection of exercise and
doi:10.1113/JP279223. aging on mitochondrial protein quality control. Exp Gerontol 131:
110824, 2020. doi:10.1016/j.exger.2019.110824.
596. Clanton TL. Managing the power grid: how myoglobin can regulate
PO2 and energy distribution in skeletal muscle. J Appl Physiol 611. Song J, Herrmann JM, Becker T. Quality control of the mitochon-
(1985) 126: 787–790, 2019. doi:10.1152/japplphysiol.00614.2018. drial proteome. Nat Rev Mol Cell Biol 22: 54–70, 2021. doi:10.1038/
s41580-020-00300-2.
597. Richardson RS, Newcomer SC, Noyszewski EA. Skeletal muscle in-
tracellular PO2 assessed by myoglobin desaturation: response to 612.  P, Youle RJ. Mitophagy and quality control mecha-
Pickles S, Vigie
graded exercise. J Appl Physiol (1985) 91: 2679–2685, 2001. nisms in mitochondrial maintenance. Curr Biol 28: R170–R185,
doi:10.1152/jappl.2001.91.6.2679. 2018. doi:10.1016/j.cub.2018.01.004.

1778 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

613. Soubannier V, McLelland GL, Zunino R, Braschi E, Rippstein P, Fon 631. McKeegan K, Mason SA, Trewin AJ, Keske MA, Wadley GD, Della
EA, McBride HM. A vesicular transport pathway shuttles cargo from Gatta PA, Nikolaidis MG, Parker L. Reactive oxygen species in exer-
mitochondria to lysosomes. Curr Biol 22: 135–141, 2012. doi:10.1016/j. cise and insulin resistance: working towards personalized antioxi-
cub.2011.11.057. dant treatment. Redox Biol 44: 102005, 2021. doi:10.1016/j.
redox.2021.102005.
614. Sanchez AM, Candau R, Bernardi H. Recent data on cellular compo-
nent turnover: focus on adaptations to physical exercise. Cells 8: 632. Giordani L, He GJ, Negroni E, Sakai H, Law JY, Siu MM, Wan R,
542, 2019. doi:10.3390/cells8060542. Corneau A, Tajbakhsh S, Cheung TH, Le Grand F. High-dimensional
single-cell cartography reveals novel skeletal muscle-resident cell
615. Romanello V, Sandri M. Implications of mitochondrial fusion and fis-
populations. Mol Cell 74: 609–621.e6, 2019. doi:10.1016/j.molcel.
sion in skeletal muscle mass and health. Semin Cell Dev Biol 2022:
2019.02.026.
S1084-9521(22)00050-7, 2022. doi:10.1016/j.semcdb.2022.02.011.
633. Rubenstein AB, Smith GR, Raue U, Begue G, Minchev K, Ruf-
616. Tanaka T, Nishimura A, Nishiyama K, Goto T, Numaga-Tomita T,
Zamojski F, Nair VD, Wang X, Zhou L, Zaslavsky E, Trappe TA,
Nishida M. Mitochondrial dynamics in exercise physiology. Pflugers
Trappe S, Sealfon SC. Single-cell transcriptional profiles in human
Arch 472: 137–153, 2020. doi:10.1007/s00424-019-02258-3.
skeletal muscle. Sci Rep 10: 229, 2020. doi:10.1038/s41598-019-
617. Hood DA, Memme JM, Oliveira AN, Triolo M. Maintenance of skele- 57110-6.
tal muscle mitochondria in health, exercise, and aging. Annu Rev
634. De Micheli AJ, Laurilliard EJ, Heinke CL, Ravichandran H, Fraczek P,
Physiol 81: 19–41, 2019. doi:10.1146/annurev-physiol-020518-114310.
Soueid-Baumgarten S, De Vlaminck I, Elemento O, Cosgrove BD.
618. Guan Y, Drake JC, Yan Z. Exercise-induced mitophagy in skeletal Single-cell analysis of the muscle stem cell hierarchy identifies het-
muscle and heart. Exerc Sport Sci Rev 47: 151–156, 2019. erotypic communication signals involved in skeletal muscle regen-
doi:10.1249/JES.0000000000000192. eration. Cell Rep 30: 3583–3595.e5, 2020. doi:10.1016/j.celrep.
2020.02.067.
619. Ament W, Verkerke GJ. Exercise and fatigue. Sports Med 39: 389–
422, 2009. doi:10.2165/00007256-200939050-00005. 635. Morgan J, Partridge T. Skeletal muscle in health and disease. Dis
Model Mech 13: dmm042192, 2020. doi:10.1242/dmm.042192.
620. Meeusen R, Van Cutsem J, Roelands B. Endurance exercise-
induced and mental fatigue and the brain. Exp Physiol 106: 2294– 636. Forcina L, Cosentino M, Musaro  A. Mechanisms regulating muscle
2298, 2021. doi:10.1113/EP088186. regeneration: insights into the interrelated and time-dependent phases
of tissue healing. Cells 9: 1297, 2020. doi:10.3390/cells9051297.
621. Taylor JL, Amann M, Duchateau J, Meeusen R, Rice CL. Neural con-
tributions to muscle fatigue: from the brain to the muscle and back 637. Peake JM, Neubauer O, Della Gatta PA, Nosaka K. Muscle damage
again. Med Sci Sports Exerc 48: 2294–2306, 2016. doi:10.1249/ and inflammation during recovery from exercise. J Appl Physiol
MSS.0000000000000923. (1985) 122: 559–570, 2017. doi:10.1152/japplphysiol.00971.2016.

622. Proschinger S, Freese J. Neuroimmunological and neuroenergetic 638. Markus I, Constantini K, Hoffman JR, Bartolomei S, Gepner Y.
aspects in exercise-induced fatigue. Exerc Immunol Rev 25: 8–19, Exercise-induced muscle damage: mechanism, assessment and
2019. nutritional factors to accelerate recovery. Eur J Appl Physiol 121:
969–992, 2021. doi:10.1007/s00421-020-04566-4.
623. Noakes TD. Fatigue is a brain-derived emotion that regulates the
exercise behavior to ensure the protection of whole body homeo- 639. Ziemkiewicz N, Hilliard G, Pullen NA, Garg K. The role of innate and
stasis. Front Physiol 3: 82, 2012. doi:10.3389/fphys.2012.00082. adaptive immune cells in skeletal muscle regeneration. Int J Mol
Sci 22: 3265, 2021. doi:10.3390/ijms22063265.
624. Bawa P. Neural control of motor output: can training change it?
Exerc Sport Sci Rev 30: 59–63, 2002. doi:10.1097/00003677- 640. Burzyn D, Kuswanto W, Kolodin D, Shadrach JL, Cerletti M, Jang Y,
200204000-00003. Sefik E, Tan TG, Wagers AJ, Benoist C, Mathis D. A special popula-
tion of regulatory T cells potentiates muscle repair. Cell 155: 1282–
625. Heckman CJ, Enoka RM. Motor unit. Compr Physiol 2: 2629–2682,
1295, 2013. doi:10.1016/j.cell.2013.10.054.
2012. doi:10.1002/cphy.c100087.
641. Paulsen G, Crameri R, Benestad HB, Fjeld JG, Morkrid L, Halle n J,
626. Romer LM, Polkey MI. Exercise-induced respiratory muscle fatigue:
Raastad T. Time course of leukocyte accumulation in human mus-
implications for performance. J Appl Physiol (1985) 104: 879–888,
cle after eccentric exercise. Med Sci Sports Exerc 42: 75–85, 2010.
2008. doi:10.1152/japplphysiol.01157.2007.
doi:10.1249/MSS.0b013e3181ac7adb.
627. Thomas K, Goodall S, Howatson G. Performance fatigability is not
642. Bengtsen M, Winje IM, Eftestøl E, Landskron J, Sun C, Nygård K,
regulated to a peripheral critical threshold. Exerc Sport Sci Rev 46:
Domanska D, Millay DP, Meza-Zepeda LA, Gundersen K. Comparing
240–246, 2018. doi:10.1249/JES.0000000000000162.
the epigenetic landscape in myonuclei purified with a PCM1 antibody
628. Finsterer J. Biomarkers of peripheral muscle fatigue during exer- from a fast/glycolytic and a slow/oxidative muscle. PLoS Genet 17:
cise. BMC Musculoskelet Disord 13: 218, 2012. doi:10.1186/1471- e1009907, 2021. doi:10.1371/journal.pgen.1009907.
2474-13-218.
643. Dinulovic I, Furrer R, Di Fulvio S, Ferry A, Beer M, Handschin C.
629. Cheng AJ, Place N, Westerblad H. molecular basis for exercise- PGC-1alpha modulates necrosis, inflammatory response, and
induced fatigue: the importance of strictly controlled cellular Ca21 fibrotic tissue formation in injured skeletal muscle. Skelet Muscle 6:
handling. Cold Spring Harb Perspect Med 8: a029710, 2018. 38, 2016. doi:10.1186/s13395-016-0110-x.
doi:10.1101/cshperspect.a029710.
644. Handschin C, Mortezavi A, Plock J, Eberli D. External physical and
630. Powers SK, Schrager M. Redox signaling regulates skeletal muscle biochemical stimulation to enhance skeletal muscle bioengineer-
remodeling in response to exercise and prolonged inactivity. ing. Adv Drug Deliv Rev 82-83: 168–175, 2015. doi:10.1016/j.
Redox Biol 54: 102374, 2022. doi:10.1016/j.redox.2022.102374. addr.2014.10.021.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1779

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

645. Roman W, Mun ~oz-Cánoves P. Muscle is a stage, and cells and fac- lipid droplet programming in mice and humans. J Lipid Res 54:
tors are merely players. Trends Cell Biol 32: 835–840, 2022. 522–534, 2013. doi:10.1194/jlr.P028910.
doi:10.1016/j.tcb.2022.03.001.
660. Gemmink A, Schrauwen P, Hesselink MK. Exercising your fat (me-
 le
646. Barthe my F, Defour A, Le vy N, Krahn M, Bartoli M. Muscle cells fix tabolism) into shape: a muscle-centred view. Diabetologia 63:
breaches by orchestrating a membrane repair ballet. J Neuromuscul 1453–1463, 2020. doi:10.1007/s00125-020-05170-z.
Dis 5: 21–28, 2018. doi:10.3233/JND-170251.
661. Koronowski KB, Sassone-Corsi P. Communicating clocks shape cir-
647. Vassilopoulos S. Unconventional roles for membrane traffic pro- cadian homeostasis. Science 371: eabd0951, 2021. doi:10.1126/
teins in response to muscle membrane stress. Curr Opin Cell Biol science.abd0951.
65: 42–49, 2020. doi:10.1016/j.ceb.2020.02.007.
662. Gabriel BM, Zierath JR. Circadian rhythms and exercise - re-setting
648. Whitson BA, Tan T, Gong N, Zhu H, Ma J. Muscle multiorgan cross- the clock in metabolic disease. Nat Rev Endocrinol 15: 197–206,
talk with MG53 as a myokine for tissue repair and regeneration. Curr 2019. doi:10.1038/s41574-018-0150-x.
Opin Pharmacol 59: 26–32, 2021. doi:10.1016/j.coph.2021.04.005.
663. Gutierrez-Monreal MA, Harmsen JF, Schrauwen P, Esser KA.
649. Roman W, Pinheiro H, Pimentel MR, Segale  s J, Oliveira LM, García- Ticking for metabolic health: the skeletal-muscle clocks. Obesity
Domínguez E, Go  mez-Cabrera MC, Serrano AL, Gomes ER, Munoz- (Silver Spring) 28, Suppl 1: S46–S54, 2020. doi:10.1002/oby.22826.
Canoves P. Muscle repair after physiological damage relies on nu-
clear migration for cellular reconstruction. Science 374: 355–359, 664. Gabriel BM, Zierath JR. Zeitgebers of skeletal muscle and implica-
2021. doi:10.1126/science.abe5620. tions for metabolic health. J Physiol 600: 1027–1036, 2022.
doi:10.1113/JP280884.
650. Taylor-Weiner H, Grigsby CL, Ferreira DM, Dias JM, Stevens MM,
Ruas JL, Teixeira AI. Modeling the transport of nuclear proteins 665. Healy KL, Morris AR, Liu AC. Circadian synchrony: sleep, nutrition, and
along single skeletal muscle cells. Proc Natl Acad Sci USA 117: physical activity. Front Netw Physiol 1: 732243, 2021. doi:10.3389/
2978–2986, 2020. doi:10.1073/pnas.1919600117. fnetp.2021.732243.

651. Denes LT, Kelley CP, Wang ET. Microtubule-based transport is 666. Mansingh S, Handschin C. Time to train: the involvement of the mo-
essential to distribute RNA and nascent protein in skeletal muscle. lecular clock in exercise adaptation of skeletal muscle. Front
Nat Commun 12: 6079, 2021. doi:10.1038/s41467-021-26383-9. Physiol 13: 902031, 2022. doi:10.3389/fphys.2022.902031.

652. Hotfiel T, Freiwald J, Hoppe MW, Lutter C, Forst R, Grim C, Bloch 667. Morris AR, Stanton DL, Roman D, Liu AC. Systems level understand-
W, H€uttel M, Heiss R. Advances in delayed-onset muscle sore- ing of circadian integration with cell physiology. J Mol Biol 432:
ness (DOMS): Part I: pathogenesis and diagnostics. Sportverletz 3547–3564, 2020. doi:10.1016/j.jmb.2020.02.002.
Sportschaden 32: 243–250, 2018. doi:10.1055/a-0753-1884.
668. Maier G, Delezie J, Westermark PO, Santos G, Ritz D, Handschin C.
653. Urso ML. Anti-inflammatory interventions and skeletal muscle injury: Transcriptomic, proteomic and phosphoproteomic underpinnings
benefit or detriment? J Appl Physiol (1985) 115: 920–928, 2013. of daily exercise performance and zeitgeber activity of training in
doi:10.1152/japplphysiol.00036.2013. mouse muscle. J Physiol 600: 769–796, 2022. doi:10.1113/
JP281535.
654. Heiss R, Lutter C, Freiwald J, Hoppe MW, Grim C, Poettgen K, Forst
R, Bloch W, H€uttel M, Hotfiel T. Advances in delayed-onset muscle 669. Graham ZA, Lavin KM, O’Bryan SM, Thalacker-Mercer AE, Buford
soreness (DOMS): Part II: treatment and prevention. Sportverletz TW, Ford KM, Broderick TJ, Bamman MM. Mechanisms of exercise
Sportschaden 33: 21–29, 2019. doi:10.1055/a-0810-3516. as a preventative measure to muscle wasting. Am J Physiol Cell
Physiol 321: C40–C57, 2021. doi:10.1152/ajpcell.00056.2021.
655. Deyhle MR, Gier AM, Evans KC, Eggett DL, Nelson WB, Parcell AC,
Hyldahl RD. Skeletal muscle inflammation following repeated bouts 670. Harper C, Gopalan V, Goh J. Exercise rescues mitochondrial cou-
of lengthening contractions in humans. Front Physiol 6: 424, 2015. pling in aged skeletal muscle: a comparison of different modalities
doi:10.3389/fphys.2015.00424. in preventing sarcopenia. J Transl Med 19: 71, 2021. doi:10.1186/
s12967-021-02737-1.
656. Damas F, Phillips SM, Libardi CA, Vechin FC, Lixandrão ME, Jannig
PR, Costa LA, Bacurau AV, Snijders T, Parise G, Tricoli V, Roschel H, 671. Larsson L, Degens H, Li M, Salviati L, Lee YI, Thompson W, Kirkland
Ugrinowitsch C. Resistance training-induced changes in integrated JL, Sandri M. Sarcopenia: aging-related loss of muscle mass and
myofibrillar protein synthesis are related to hypertrophy only after function. Physiol Rev 99: 427–511, 2019. doi:10.1152/physrev.
attenuation of muscle damage. J Physiol 594: 5209–5222, 2016. 00061.2017.
doi:10.1113/JP272472.
672. Leal LG, Lopes MA, Peres SB, Batista ML Jr. Exercise training as
657. Weakley J, Halson SL, Mujika I. Overtraining syndrome symptoms therapeutic approach in cancer cachexia: a review of potential anti-
and diagnosis in athletes: where is the research? A systematic inflammatory effect on muscle wasting. Front Physiol 11: 570170,
review. Int J Sports Physiol Perform 17: 675–681, 2022. doi:10.1123/ 2020. doi:10.3389/fphys.2020.570170.
ijspp.2021-0448.
673. Deane CS, Willis CR, Phillips BE, Atherton PJ, Harries LW, Ames RM,
658. Solsona R, Pavlin L, Bernardi H, Sanchez AM. Molecular regulation Szewczyk NJ, Etheridge T. Transcriptomic meta-analysis of disuse
of skeletal muscle growth and organelle biosynthesis: practical rec- muscle atrophy vs. resistance exercise-induced hypertrophy in
ommendations for exercise training. Int J Mol Sci 22: 2741, 2021. young and older humans. J Cachexia Sarcopenia Muscle 12: 629–
doi:10.3390/ijms22052741. 645, 2021. doi:10.1002/jcsm.12706.

659. Koves TR, Sparks LM, Kovalik JP, Mosedale M, Arumugam R, 674. Domin R, Dadej D, Pytka M, Zybek-Kocik A, Ruchała M, Guzik P.
DeBalsi KL, Everingham K, Thorne L, Phielix E, Meex RC, Kien CL, Effect of various exercise regimens on selected exercise-induced
Hesselink MK, Schrauwen P, Muoio DM. PPARgamma coactivator- cytokines in healthy people. Int J Environ Res Public Health 18:
1alpha contributes to exercise-induced regulation of intramuscular 1261, 2021. doi:10.3390/ijerph18031261.

1780 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

675. Petrosino JM, Hinger SA, Golubeva VA, Barajas JM, Dorn LE, Iyer signaling independent of mTOR and a potential therapeutic target
CC, Sun HL, Arnold WD, He C, Accornero F. The m(6)A methyltrans- for Tuberous Sclerosis Complex. Sci Rep 5: 14534, 2015.
ferase METTL3 regulates muscle maintenance and growth in mice. doi:10.1038/srep14534.
Nat Commun 13: 168, 2022. doi:10.1038/s41467-021-27848-7.
689. Sun L, Yan Y, Lv H, Li J, Wang Z, Wang K, Wang L, Li Y, Jiang H,
676. Duan K, Gao X, Zhu D. The clinical relevance and mechanism of Zhang Y. Rapamycin targets STAT3 and impacts c-Myc to suppress
skeletal muscle wasting. Clin Nutr 40: 27–37, 2021. doi:10.1016/j. tumor growth. Cell Chem Biol 29: 373–385.e6, 2022. doi:10.1016/j.
clnu.2020.07.029. chembiol.2021.10.006.
677. Furrer R, Handschin C. Muscle wasting diseases: novel targets and 690. Guadagnin E, Mázala D, Chen YW. STAT3 in skeletal muscle func-
treatments. Annu Rev Pharmacol Toxicol 59: 315–339, 2019. tion and disorders. Int J Mol Sci 19: 2265, 2018. doi:10.3390/
doi:10.1146/annurev-pharmtox-010818-021041. ijms19082265.
678. Sartori R, Romanello V, Sandri M. Mechanisms of muscle atrophy
691. Seaborne RA, Sharples AP. The interplay between exercise metabo-
and hypertrophy: implications in health and disease. Nat Commun
lism, epigenetics, and skeletal muscle remodeling. Exerc Sport Sci
12: 330, 2021. doi:10.1038/s41467-020-20123-1.
Rev 48: 188–200, 2020. doi:10.1249/JES.0000000000000227.
679. Ebert SM, Al-Zougbi A, Bodine SC, Adams CM. Skeletal muscle atro-
692. Tucker R, Collins M. What makes champions? A review of the rela-
phy: discovery of mechanisms and potential therapies. Physiology
tive contribution of genes and training to sporting success. Br J
(Bethesda) 34: 232–239, 2019. doi:10.1152/physiol.00003.2019.
Sports Med 46: 555–561, 2012. doi:10.1136/bjsports-2011-090548.
680. Verbrugge SA, Scho € nfelder M, Becker L, Yaghoob Nezhad F,
Hrabe de Angelis M, Wackerhage H. Genes whose gain or loss-of- 693. Yan X, Papadimitriou I, Lidor R, Eynon N. Nature versus nurture in
function increases skeletal muscle mass in mice: a systematic litera- determining athletic ability. Med Sport Sci 61: 15–28, 2016.
ture review. Front Physiol 9: 553, 2018. doi:10.3389/fphys.2018. doi:10.1159/000445238.
00553.
694. Eynon N, Hanson ED, Lucia A, Houweling PJ, Garton F, North KN,
681. Yaghoob Nezhad F, Verbrugge SA, Scho € nfelder M, Becker L, Hrabe
 Bishop DJ. Genes for elite power and sprint performance: ACTN3
de Angelis M, Wackerhage H. Genes whose gain or loss-of-function leads the way. Sports Med 43: 803–817, 2013. doi:10.1007/s40279-
increases endurance performance in mice: a systematic literature 013-0059-4.
review. Front Physiol 10: 262, 2019. doi:10.3389/fphys.2019.00262.
695. Papadimitriou ID, Lucia A, Pitsiladis YP, Pushkarev VP, Dyatlov DA,
682. Qi Z, Zhai X, Ding S. How to explain exercise-induced phenotype Orekhov EF, Artioli GG, Guilherme JP, Lancha AH Jr, Ginevicienė V,
from molecular data: rethink and reconstruction based on AMPK Cieszczyk P, Maciejewska-Karlowska A, Sawczuk M, Muniesa CA,
and mTOR signaling. Springerplus 2: 693, 2013. doi:10.1186/2193- Kouvatsi A, Massidda M, Calo  CM, Garton F, Houweling PJ, Wang
1801-2-693. G, Austin K, Druzhevskaya AM, Astratenkova IV, Ahmetov II, Bishop
DJ, North KN, Eynon N. ACTN3 R577X and ACE I/D gene variants
683. Hingst JR, Kjøbsted R, Birk JB, Jørgensen NO, Larsen MR, Kido K,
influence performance in elite sprinters: a multi-cohort study. BMC
Larsen JK, Kjeldsen SA, Fentz J, Frøsig C, Holm S, Fritzen AM,
Genomics 17: 285, 2016. doi:10.1186/s12864-016-2462-3.
Dohlmann TL, Larsen S, Foretz M, Viollet B, Schjerling P, Overby P,
Halling JF, Pilegaard H, Hellsten Y, Wojtaszewski JF. Inducible dele- 696. Rankinen T, Fuku N, Wolfarth B, Wang G, Sarzynski MA, Alexeev
tion of skeletal muscle AMPKalpha reveals that AMPK is required DG, et al. No Evidence of a common DNA variant profile specific to
for nucleotide balance but dispensable for muscle glucose uptake world class endurance athletes. PLoS One 11: e0147330, 2016.
and fat oxidation during exercise. Mol Metab 40: 101028, 2020.
doi:10.1371/journal.pone.0147330.
doi:10.1016/j.molmet.2020.101028.
697. Bouchard C. Genomic predictors of trainability. Exp Physiol 97:
684. You JS, McNally RM, Jacobs BL, Privett RE, Gundermann DM, Lin
347–352, 2012. doi:10.1113/expphysiol.2011.058735.
KH, Steinert ND, Goodman CA, Hornberger TA. The role of raptor
in the mechanical load-induced regulation of mTOR signaling, pro- 698. Bouchard C, Sarzynski MA, Rice TK, Kraus WE, Church TS, Sung YJ,
tein synthesis, and skeletal muscle hypertrophy. FASEB J 33: Rao DC, Rankinen T. Genomic predictors of the maximal O2 uptake
4021–4034, 2019. doi:10.1096/fj.201801653RR. response to standardized exercise training programs. J Appl
685. Castets P, Lin S, Rion N, Di Fulvio S, Romanino K, Guridi M, Frank S, Physiol (1985) 110: 1160–1170, 2011. doi:10.1152/japplphysiol.00973.
Tintignac LA, Sinnreich M, R€ uegg MA. Sustained activation of 2010.
mTORC1 in skeletal muscle inhibits constitutive and starvation-
699. Bouchard C, An P, Rice T, Skinner JS, Wilmore JH, Gagnon J,
induced autophagy and causes a severe, late-onset myopathy. Cell
Perusse L, Leon AS, Rao DC. Familial aggregation of Vo2max
Metab 17: 731–744, 2013. doi:10.1016/j.cmet.2013.03.015.
response to exercise training: results from the HERITAGE Family
686. Orchard S, Ammari M, Aranda B, Breuza L, Briganti L, Broackes- Study. J Appl Physiol (1985) 87: 1003–1008, 1999. doi:10.1152/
Carter F, et al. The MIntAct project–IntAct as a common curation jappl.1999.87.3.1003.
platform for 11 molecular interaction databases. Nucleic Acids Res
42: D358–D363, 2014. doi:10.1093/nar/gkt1115. 700. Ruegsegger GN, Booth FW. Health benefits of exercise. Cold Spring
Harb Perspect Med 8: a029694, 2018. doi:10.1101/cshperspect.
687. Luciano AK, Korobkina ED, Lyons SP, Haley JA, Fluharty SM, Jung a029694.
SM, Kettenbach AN, Guertin DA. Proximity labeling of endogenous
RICTOR identifies mTOR Complex 2 regulation by ADP ribosylation 701. Pickering C, Kiely J. Do non-responders to exercise exist-and if so,
factor ARF1. J Biol Chem 298: 102379, 2022. doi:10.1016/j. what should we do about them? Sports Med 49: 1–7, 2019.
jbc.2022.102379. doi:10.1007/s40279-018-01041-1.

688. Alves MM, Fuhler GM, Queiroz KC, Scholma J, Goorden S, Anink J, 702. Montero D, Lundby C. Refuting the myth of non-response to exer-
Spek CA, Hoogeveen-Westerveld M, Bruno MJ, Nellist M, Elgersma cise training: ‘non-responders’ do respond to higher dose of train-
Y, Aronica E, Peppelenbosch MP. PAK2 is an effector of TSC1/2 ing. J Physiol 595: 3377–3387, 2017. doi:10.1113/JP273480.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1781

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

703. Booth FW, Laye MJ. The future: genes, physical activity and health. 718. Pickering C, Kiely J, Grgic J, Lucia A, Del Coso J. Can Genetic
Acta Physiol (Oxf) 199: 549–556, 2010. doi:10.1111/j.1748-1716.2010. Testing Identify Talent for Sport? Genes (Basel) 10: 972, 2019.
02117.x. doi:10.3390/genes10120972.

704. Fiuza-Luces C, Garatachea N, Berger NA, Lucia A. Exercise is the 719. Yang N, MacArthur DG, Gulbin JP, Hahn AG, Beggs AH, Easteal S,
real polypill. Physiology (Bethesda) 28: 330–358, 2013. doi:10.1152/ North K. ACTN3 genotype is associated with human elite athletic
physiol.00019.2013. performance. Am J Hum Genet 73: 627–631, 2003. doi:10.1086/
377590.
705. Radak Z, Taylor AW. Issues on trainability. Front Physiol 12:
790196, 2021. doi:10.3389/fphys.2021.790196. 720. Yang R, Shen X, Wang Y, Voisin S, Cai G, Fu Y, Xu W, Eynon N,
Bishop DJ, Yan X. ACTN3 R577X gene variant is associated with
706. Koch LG, Pollott GE, Britton SL. Selectively bred rat model system muscle-related phenotypes in elite Chinese sprint/power ath-
for low and high response to exercise training. Physiol Genomics letes. J Strength Cond Res 31: 1107–1115, 2017. doi:10.1519/JSC.
45: 606–614, 2013. doi:10.1152/physiolgenomics.00021.2013. 0000000000001558.

707. Williams CJ, Li Z, Harvey N, Lea RA, Gurd BJ, Bonafiglia JT, et al. 721. MacArthur DG, Seto JT, Raftery JM, Quinlan KG, Huttley GA, Hook
Genome wide association study of response to interval and contin- JW, Lemckert FA, Kee AJ, Edwards MR, Berman Y, Hardeman EC,
Gunning PW, Easteal S, Yang N, North KN. Loss of ACTN3 gene
uous exercise training: the Predict-HIIT study. J Biomed Sci 28: 37,
function alters mouse muscle metabolism and shows evidence of
2021. doi:10.1186/s12929-021-00733-7.
positive selection in humans. Nat Genet 39: 1261–1265, 2007.
708. Moir HJ, Kemp R, Folkerts D, Spendiff O, Pavlidis C, Opara E. Genes doi:10.1038/ng2122.
and elite marathon running performance: a systematic review. J
722. Ahmetov II, Egorova ES, Gabdrakhmanova LJ, Fedotovskaya ON.
Sports Sci Med 18: 559–568, 2019. Genes and athletic performance: an update. Med Sport Sci 61: 41–
54, 2016. doi:10.1159/000445240.
709. Vernillo G, Schena F, Berardelli C, Rosa G, Galvani C, Maggioni M,
Agnello L, La Torre A. Anthropometric characteristics of top-class 723. Bye A, Klevjer M, Ryeng E, Silva GJ, Moreira JB, Stensvold D,
Kenyan marathon runners. J Sports Med Phys Fitness 53: 403– Wisløff U. Identification of novel genetic variants associated with
408, 2013. cardiorespiratory fitness. Prog Cardiovasc Dis 63: 341–349, 2020.
doi:10.1016/j.pcad.2020.02.001.
710. De Moor MH, Spector TD, Cherkas LF, Falchi M, Hottenga JJ,
Boomsma DI, De Geus EJ. Genome-wide linkage scan for athlete 724. Williams CJ, Williams MG, Eynon N, Ashton KJ, Little JP, Wisloff U,
status in 700 British female DZ twin pairs. Twin Res Hum Genet 10: Coombes JS. Genes to predict Vo2max trainability: a systematic
812–820, 2007. doi:10.1375/twin.10.6.812. review. BMC Genomics 18: 831, 2017. doi:10.1186/s12864-017-4192-6.

711. Bouchard C, Daw EW, Rice T, Perusse L, Gagnon J, Province MA, 725. Díaz-Ramírez JD, Álvarez-Herms J, Castan ~ eda-Babarro A, Larruskain
Leon AS, Rao DC, Skinner JS, Wilmore JH. Familial resemblance J, Ramírez de la Piscina XR, Borisov OV, Semenova EA, Kostryukova
for Vo2max in the sedentary state: the HERITAGE family study. ES, Kulemin NA, Andryushchenko ON, Larin AK, Andryushchenko
Med Sci Sports Exerc 30: 252–258, 1998. doi:10.1097/ LB, Generozov EV, Ahmetov II, Odriozola A. The GALNTL6 Gene
00005768-199802000-00013. rs558129 polymorphism is associated with power performance.
J Strength Cond Res 34: 3031–3036, 2020. doi:10.1519/JSC.
712. Konopka MJ, van den Bunder JC, Rietjens G, Sperlich B, Zeegers 0000000000003814.
MP. Genetics of long-distance runners and road cyclists-A system-
726. Al-Khelaifi F, Yousri NA, Diboun I, Semenova EA, Kostryukova ES,
atic review with meta-analysis. Scand J Med Sci Sports 32: 1414–
Kulemin NA, Borisov OV, Andryushchenko LB, Larin AK, Generozov
1429, 2022. doi:10.1111/sms.14212.
EV, Miyamoto-Mikami E, Murakami H, Zempo H, Miyachi M,
713. €skelin AL, Juvonen E. Truncated erythropoietin
de la Chapelle A, Tra Takaragawa M, Kumagai H, Naito H, Fuku N, Abraham D, Hingorani
A, Donati F, Botre F, Georgakopoulos C, Suhre K, Ahmetov II,
receptor causes dominantly inherited benign human erythrocytosis.
Albagha O, Elrayess MA. Genome-wide association study reveals a
Proc Natl Acad Sci USA 90: 4495–4499, 1993. doi:10.1073/
novel association between MYBPC3 gene polymorphism, endur-
pnas.90.10.4495.
ance athlete status, aerobic capacity and steroid metabolism. Front
714. Ma F, Yang Y, Li X, Zhou F, Gao C, Li M, Gao L. The association of Genet 11: 595, 2020. doi:10.3389/fgene.2020.00595.
sport performance with ACE and ACTN3 genetic polymorphisms: a
727. Ahmetov I, Kulemin N, Popov D, Naumov V, Akimov E, Bravy Y,
systematic review and meta-analysis. PLoS One 8: e54685, 2013. Egorova E, Galeeva A, Generozov E, Kostryukova E, Larin A,
doi:10.1371/journal.pone.0054685. _
Mustafina L, Ospanova E, Pavlenko A, Starnes L, Zmijewski P,
Alexeev D, Vinogradova O, Govorun V. Genome-wide association
715. Montgomery HE, Marshall R, Hemingway H, Myerson S, Clarkson P,
study identifies three novel genetic markers associated with elite
Dollery C, Hayward M, Holliman DE, Jubb M, World M, Thomas EL,
endurance performance. Biol Sport 32: 3–9, 2015. doi:10.5604/
Brynes AE, Saeed N, Barnard M, Bell JD, Prasad K, Rayson M,
20831862.1124568.
Talmud PJ, Humphries SE. Human gene for physical performance.
Nature 393: 221–222, 1998. doi:10.1038/30374. 728. Malczewska-Lenczowska J, Orysiak J, Majorczyk E, Sitkowski D,
_
Starczewski M, Zmijewski P. HIF-1a and NFIA-AS2 polymorphisms
716. Jacob Y, Spiteri T, Hart NH, Anderton RS. The potential role of as potential determinants of total hemoglobin mass in endurance
genetic markers in talent identification and athlete assessment in athletes. J Strength Cond Res 36: 1596–1604, 2022. doi:10.1519/
elite sport. Sports (Basel) 6: 88, 2018. doi:10.3390/sports6030088. JSC.0000000000003686.
717. Del Coso J, Hiam D, Houweling P, Pe  rez LM, Eynon N, Lucía A. 729. Semenova EA, Miyamoto-Mikami E, Akimov EB, Al-Khelaifi F,
More than a ‘speed gene’: ACTN3 R577X genotype, trainability, Murakami H, Zempo H, Kostryukova ES, Kulemin NA, Larin AK,
muscle damage, and the risk for injuries. Eur J Appl Physiol 119: Borisov OV, Miyachi M, Popov DV, Boulygina EA, Takaragawa M,
49–60, 2019. doi:10.1007/s00421-018-4010-0. Kumagai H, Naito H, Pushkarev VP, Dyatlov DA, Lekontsev EV,

1782 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

Pushkareva YE, Andryushchenko LB, Elrayess MA, Generozov EV, to 94 years of age. Rejuvenation Res 24: 20–27, 2021. doi:10.1089/
Fuku N, Ahmetov II. The association of HFE gene H63D polymor- rej.2020.2337.
phism with endurance athlete status and aerobic capacity: novel
findings and a meta-analysis. Eur J Appl Physiol 120: 665–673, 744. Ganse B, Ganse U, Dahl J, Degens H. Linear decrease in athletic
2020. doi:10.1007/s00421-020-04306-8. performance during the human life span. Front Physiol 9: 1100,
2018. doi:10.3389/fphys.2018.01100.
730. Webborn N, Williams A, McNamee M, Bouchard C, Pitsiladis Y,
745. Ganse B, Kleerekoper A, Knobe M, Hildebrand F, Degens H.
Ahmetov I, Ashley E, Byrne N, Camporesi S, Collins M, Dijkstra P,
Longitudinal trends in master track and field performance through-
Eynon N, Fuku N, Garton FC, Hoppe N, Holm S, Kaye J, Klissouras
out the aging process: 83,209 results from Sweden in 16 athletics
V, Lucia A, Maase K, Moran C, North KN, Pigozzi F, Wang G. Direct-
disciplines. Geroscience 42: 1609–1620, 2020. doi:10.1007/s11357-
to-consumer genetic testing for predicting sports performance and
020-00275-0.
talent identification: consensus statement. Br J Sports Med 49:
1486–1491, 2015. doi:10.1136/bjsports-2015-095343. 746. Wiswell RA, Hawkins SA, Jaque SV, Hyslop D, Constantino N,
Tarpenning K, Marcell T, Schroeder ET. Relationship between phys-
731. G€
ullich A, Macnamara BN, Hambrick DZ. What makes a champion?
iological loss, performance decrement, and age in master athletes.
Early multidisciplinary practice, not early specialization, predicts
J Gerontol A Biol Sci Med Sci 56: M618–M626, 2001. doi:10.1093/
world-class performance. Perspect Psychol Sci 17: 6–29, 2022.
gerona/56.10.m618.
doi:10.1177/1745691620974772.
747. Gava P, Ravara B. Master World Records show minor gender differ-
732. Pickering C, Kiely J. Can genetic testing predict talent? A case
ences of performance decline with aging. Eur J Transl Myol 29:
study of 5 elite athletes. Int J Sports Physiol Perform 16: 429–434,
8327, 2019. doi:10.4081/ejtm.2019.8327.
2021. doi:10.1123/ijspp.2019-0543.
748. Arampatzis A, Degens H, Baltzopoulos V, Rittweger J. Why do older
733. Kujala UM, Leskinen T, Rottensteiner M, Aaltonen S, Ala-Korpela M, sprinters reach the finish line later? Exerc Sport Sci Rev 39: 18–22,
Waller K, Kaprio J. Physical activity and health: findings from Finnish 2011. doi:10.1097/JES.0b013e318201efe0.
monozygotic twin pairs discordant for physical activity. Scand J
Med Sci Sports 32: 1316–1323, 2022. doi:10.1111/sms.14205. 749. Janssen I, Heymsfield SB, Wang ZM, Ross R. Skeletal muscle mass
and distribution in 468 men and women aged 18-88 yr. J Appl
734. Wang G, Padmanabhan S, Wolfarth B, Fuku N, Lucia A, Ahmetov II, Physiol (1985) 89: 81–88, 2000. doi:10.1152/jappl.2000.89.1.81.
Cieszczyk P, Collins M, Eynon N, Klissouras V, Williams A, Pitsiladis
Y. Genomics of elite sporting performance: what little we know and 750. Grosicki GJ, Gries KJ, Minchev K, Raue U, Chambers TL, Begue G,
necessary advances. Adv Genet 84: 123–149, 2013. doi:10.1016/ Finch H, Graham B, Trappe TA, Trappe S. Single muscle fibre con-
B978-0-12-407703-4.00004-9. tractile characteristics with lifelong endurance exercise. J Physiol
599: 3549–3565, 2021. doi:10.1113/JP281666.
735. Sanchis-Gomar F, Pareja-Galeano H, Rodriguez-Marroyo JA, de
Koning JJ, Lucia A, Foster C. Olympic genes on the podium? Int J 751. Bagley L, McPhee JS, Ganse B, M€ uller K, Korhonen MT, Rittweger J,
Sports Physiol Perform 11: 973–974, 2016. doi:10.1123/ijspp.2016- Degens H. Similar relative decline in aerobic and anaerobic power
0421. with age in endurance and power master athletes of both sexes.
Scand J Med Sci Sports 29: 791–799, 2019. doi:10.1111/sms.13404.
736. Urtamo A, Jyva €korpi SK, Strandberg TE. Definitions of successful
ageing: a brief review of a multidimensional concept. Acta Biomed 752. Cristea A, Korhonen MT, Ha €kkinen K, Mero A, Ale n M, Sipila € S,
90: 359–363, 2019. doi:10.23750/abm.v90i2.8376. Viitasalo JT, Koljonen MJ, Suominen H, Larsson L. Effects of com-
bined strength and sprint training on regulation of muscle contrac-
737. Seals DR, Justice JN, LaRocca TJ. Physiological geroscience: tar- tion at the whole-muscle and single-fibre levels in elite master
geting function to increase healthspan and achieve optimal longev- sprinters. Acta Physiol (Oxf) 193: 275–289, 2008. doi:10.1111/j.1748-
ity. J Physiol 594: 2001–2024, 2016. doi:10.1113/jphysiol.2014. 1716.2008.01843.x.
282665.
753. Grosicki GJ, Standley RA, Murach KA, Raue U, Minchev K, Coen
738. Lazarus NR, Harridge SD. Declining performance of master ath- PM, Newman AB, Cummings S, Harris T, Kritchevsky S, Goodpaster
letes: silhouettes of the trajectory of healthy human ageing? J BH, Trappe S; Health ABC Study. Improved single muscle fiber
Physiol 595: 2941–2948, 2017. doi:10.1113/JP272443. quality in the oldest-old. J Appl Physiol (1985) 121: 878–884, 2016.
doi:10.1152/japplphysiol.00479.2016.
739. Gries KJ, Trappe SW. The aging athlete: paradigm of healthy aging.
Int J Sports Med 43: 661–678, 2022. doi:10.1055/a-1761-8481. 754. Fujimoto N, Hastings JL, Bhella PS, Shibata S, Gandhi NK, Carrick-
Ranson G, Palmer D, Levine BD. Effect of ageing on left ventricular
740. Gries KJ, Raue U, Perkins RK, Lavin KM, Overstreet BS, D’Acquisto compliance and distensibility in healthy sedentary humans. J
LJ, Graham B, Finch WH, Kaminsky LA, Trappe TA, Trappe S. Physiol 590: 1871–1880, 2012. doi:10.1113/jphysiol.2011.218271.
Cardiovascular and skeletal muscle health with lifelong exercise. J
Appl Physiol (1985) 125: 1636–1645, 2018. doi:10.1152/japplphysiol. 755. Beaumont A, Campbell A, Grace F, Sculthorpe N. Cardiac
00174.2018. response to exercise in normal ageing: what can we learn from mas-
ters athletes? Curr Cardiol Rev 14: 245–253, 2018. doi:10.2174/
741. Baker AB, Tang YQ. Aging performance for masters records in ath- 1573403X14666180810155513.
letics, swimming, rowing, cycling, triathlon, and weightlifting. Exp
Aging Res 36: 453–477, 2010. doi:10.1080/0361073X.2010.507433. 756. Churchill TW, Groezinger E, Kim JH, Loomer G, Guseh JS, Wasfy
MM, Isselbacher EM, Lewis GD, Weiner RB, Schmied C, Baggish AL.
742. Ganse B, Degens H. Current insights in the age-related decline in Association of ascending aortic dilatation and long-term endurance
sports performance of the older athlete. Int J Sports Med 42: 879– exercise among older masters-level athletes. JAMA Cardiol 5:
888, 2021. doi:10.1055/a-1480-7730. 522–531, 2020. doi:10.1001/jamacardio.2020.0054.

743. Ganse B, Drey M, Hildebrand F, Knobe M, Degens H. Performance 757. Myrstad M, Løchen ML, Graff-Iversen S, Gulsvik AK, Thelle DS,
declines are accelerated in the oldest-old track and field athletes 80 Stigum H, Ranhoff AH. Increased risk of atrial fibrillation among

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1783

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

elderly Norwegian men with a history of long-term endurance sport 771. Passos J, Lopes SI, Clemente FM, Moreira PM, Rico-Gonzaález M,
practice. Scand J Med Sci Sports 24: e238–e244, 2014. doi:10.1111/ Bezerra P, Rodrigues LP. Wearables and internet of things (IoT)
sms.12150. technologies for fitness assessment: a systematic review. Sensors
(Basel) 21: 5418, 2021. doi:10.3390/s21165418.
758. Newman W, Parry-Williams G, Wiles J, Edwards J, Hulbert S,
Kipourou K, Papadakis M, Sharma R, O’Driscoll J. Risk of atrial fi- 772. Cheng Y, Wang K, Xu H, Li T, Jin Q, Cui D. Recent developments in
brillation in athletes: a systematic review and meta-analysis. Br sensors for wearable device applications. Anal Bioanal Chem 413:
J Sports Med 55: 1233–1238, 2021. doi:10.1136/bjsports-2021- 6037–6057, 2021. doi:10.1007/s00216-021-03602-2.
103994.
773. McLaren SJ, Macpherson TW, Coutts AJ, Hurst C, Spears IR,
759. Momma H, Kawakami R, Honda T, Sawada SS. Muscle-strengthen- Weston M. The relationships between internal and external meas-
ing activities are associated with lower risk and mortality in major ures of training load and intensity in team sports: a meta-analysis.
non-communicable diseases: a systematic review and meta-analy- Sports Med 48: 641–658, 2018. doi:10.1007/s40279-017-0830-z.
sis of cohort studies. Br J Sports Med 56: 755–763, 2022.
doi:10.1136/bjsports-2021-105061. 774. Jiang D, Shi G. Research on data security and privacy protection of
wearable equipment in healthcare. J Healthc Eng 2021: 6656204,
760. Clarke PM, Walter SJ, Hayen A, Mallon WJ, Heijmans J, Studdert
2021. doi:10.1155/2021/6656204.
DM. Survival of the fittest: retrospective cohort study of the longev-
ity of Olympic medallists in the modern era. Br J Sports Med 49: 775. Heaney LM, Deighton K, Suzuki T. Non-targeted metabolomics in
898–902, 2015. doi:10.1136/bjsports-2015-e8308rep. sport and exercise science. J Sports Sci 37: 959–967, 2019.
doi:10.1080/02640414.2017.1305122.
761. Runacres A, Mackintosh KA, McNarry MA. Health consequences of
an elite sporting career: long-term detriment or long-term gain? A 776. Khoramipour K, Sandbakk Ø, Keshteli AH, Gaeini AA, Wishart DS,
meta-analysis of 165,000 former athletes. Sports Med 51: 289–301, Chamari K. Metabolomics in exercise and sports: a systematic
2021. doi:10.1007/s40279-020-01379-5. review. Sports Med 52: 547–583, 2022. doi:10.1007/s40279-021-
762. Lemez S, Baker J. Do elite athletes live longer? A systematic review 01582-y.
of mortality and longevity in elite athletes. Sports Med Open 1: 16,
777. Morville T, Sahl RE, Moritz T, Helge JW, Clemmensen C. Plasma
2015. doi:10.1186/s40798-015-0024-x.
metabolome profiling of resistance exercise and endurance exer-
763. Garatachea N, Santos-Lozano A, Sanchis-Gomar F, Fiuza-Luces C, cise in humans. Cell Rep 33: 108554, 2020. doi:10.1016/j.
Pareja-Galeano H, Emanuele E, Lucia A. Elite athletes live longer celrep.2020.108554.
than the general population: a meta-analysis. Mayo Clin Proc 89:
1195–1200, 2014. doi:10.1016/j.mayocp.2014.06.004. 778. Deshmukh AS, Steenberg DE, Hostrup M, Birk JB, Larsen JK,
Santos A, Kjøbsted R, Hingst JR, Sche ele CC, Murgia M, Kiens B,
764. Antero J, Tanaka H, De Larochelambert Q, Pohar-Perme M, Richter EA, Mann M, Wojtaszewski JF. Deep muscle-proteomic
Toussaint JF. Female and male US Olympic athletes live 5 years analysis of freeze-dried human muscle biopsies reveals fiber type-
longer than their general population counterparts: a study of 8124 specific adaptations to exercise training. Nat Commun 12: 304,
former US Olympians. Br J Sports Med 55: 206–212, 2021. 2021. doi:10.1038/s41467-020-20556-8.
doi:10.1136/bjsports-2019-101696.
779. Gomes C, Almeida JA, Franco OL, Petriz B. Omics and the molecular
765. Antero-Jacquemin J, Pohar-Perme M, Rey G, Toussaint JF, exercise physiology. Adv Clin Chem 96: 55–84, 2020. doi:10.1016/
Latouche A. The heart of the matter: years-saved from cardiovascu- bs.acc.2019.11.003.
lar and cancer deaths in an elite athlete cohort with over a century
of follow-up. Eur J Epidemiol 33: 531–543, 2018. doi:10.1007/ 780. Hoffman NJ. Omics and exercise: global approaches for mapping
s10654-018-0401-0. exercise biological networks. Cold Spring Harb Perspect Med 7:
a029884, 2017. doi:10.1101/cshperspect.a029884.
ska A. Examining mortality risk and rate
766. Lin Y, Gajewski A, Poznan
of ageing among Polish Olympic athletes: a survival follow-up from 781. Neufer PD, Bamman MM, Muoio DM, Bouchard C, Cooper DM,
1924 to 2012. BMJ Open 6: e010965, 2016. doi:10.1136/bmjopen- Goodpaster BH, Booth FW, Kohrt WM, Gerszten RE, Mattson MP,
2015-010965. Hepple RT, Kraus WE, Reid MB, Bodine SC, Jakicic JM, Fleg JL,
Williams JP, Joseph L, Evans M, Maruvada P, Rodgers M, Roary M,
767. Marijon E, Tafflet M, Antero-Jacquemin J, El Helou N, Berthelot G,
Boyce AT, Drugan JK, Koenig JI, Ingraham RH, Krotoski D, Garcia-
Celermajer DS, Bougouin W, Combes N, Hermine O, Empana JP,
Cazarin M, McGowan JA, Laughlin MR. Understanding the cellular
Rey G, Toussaint JF, Jouven X. Mortality of French participants in
and molecular mechanisms of physical activity-induced health ben-
the Tour de France (1947-2012). Eur Heart J 34: 3145–3150, 2013.
efits. Cell Metab 22: 4–11, 2015. doi:10.1016/j.cmet.2015.05.011.
doi:10.1093/eurheartj/eht347.

768. Kontro TK, Sarna S, Kaprio J, Kujala UM. Mortality and health- 782. Sanford JA, Nogiec CD, Lindholm ME, Adkins JN, Amar D, Dasari S,
related habits in 900 Finnish former elite athletes and their broth- et al. Molecular Transducers of Physical Activity Consortium
ers. Br J Sports Med 52: 89–95, 2018. doi:10.1136/bjsports-2017- (MoTrPAC): mapping the dynamic responses to exercise. Cell 181:
098206. 1464–1474, 2020. doi:10.1016/j.cell.2020.06.004.

769. Kettunen JA, Kujala UM, Kaprio J, Ba €ckmand H, Peltonen M, 783. Bongiovanni T, Pintus R, Dessì A, Noto A, Sardo S, Finco G,
Eriksson JG, Sarna S. All-cause and disease-specific mortality Corsello G, Fanos V. Sportomics: metabolomics applied to sports.
among male, former elite athletes: an average 50-year follow-up. The new revolution? Eur Rev Med Pharmacol Sci 23: 11011–11019,
Br J Sports Med 49: 893–897, 2015. doi:10.1136/bjsports-2013- 2019. doi:10.26355/eurrev_201912_19807.
093347.
784. Resende NM, de Magalhães Neto AM, Bachini F, de Castro LE,
770. Tang SL. Wearable sensors for sports performance. In: Textiles for Bassini A, Cameron LC. Metabolic changes during a field experi-
Sportswear, edited by Shishoo R. Cambridge, UK: Woodhead ment in a world-class windsurfing athlete: a trial with multivariate
Publishing, 2015, p. 169–196. analyses. OMICS 15: 695–704, 2011. doi:10.1089/omi.2011.0010.

1784 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

785. Contrepois K, Wu S, Moneghetti KJ, Hornburg D, Ahadi S, Tsai MS, 800. Ganse B, Degens H. Declining track and field performance trends in
et al. Molecular Choreography of Acute Exercise. Cell 181: 1112– recent years in the Austrian best results 1897-2019. J Musculoskelet
1130.e16, 2020. doi:10.1016/j.cell.2020.04.043. Neuronal Interact 21: 196–205, 2021.

786. Sch€ussler-Fiorenza Rose SM, Contrepois K, Moneghetti KJ, Zhou W, 801. Nugent FJ, Comyns TM, Warrington GD. Quality versus quantity
Mishra T, Mataraso S, Dagan-Rosenfeld O, Ganz AB, Dunn J, debate in swimming: perceptions and training practices of expert
Hornburg D, Rego S, Perelman D, Ahadi S, Sailani MR, Zhou Y, swimming coaches. J Hum Kinet 57: 147–158, 2017. doi:10.1515/
Leopold SR, Chen J, Ashland M, Christle JW, Avina M, Limcaoco P, hukin-2017-0056.
Ruiz C, Tan M, Butte AJ, Weinstock GM, Slavich GM, Sodergren E,
McLaughlin TL, Haddad F, Snyder MP. A longitudinal big data 802. Crowley E, Harrison AJ, Lyons M. The impact of resistance training
approach for precision health. Nat Med 25: 792–804, 2019. on swimming performance: a systematic review. Sports Med 47:
doi:10.1038/s41591-019-0414-6. 2285–2307, 2017. doi:10.1007/s40279-017-0730-2.

787. Nemkov T, Cendali F, Stefanoni D, Martinez JL, Hansen KC, San- 803. Crowley E, Ng K, Mujika I, Powell C. Speeding up or slowing down?
Millán I, D’Alessandro A. Metabolic signatures of performance in elite Analysis of race results in elite-level swimming from 2011-2019 to
world tour professional cyclists (Preprint). bioRxiv 2022.09.13.507793, predict future Olympic Games performances. Meas Phys Educ
2022. doi:10.1101/2022.09.13.507793. Exerc Sci 26: 130–140, 2022. doi:10.1080/1091367X.2021.1952592.
788. Tanaka M, Wang G, Pitsiladis YP. Advancing sports and exercise 804. Robinson AT, Watso JC, Babcock MC, Joyner MJ, Farquhar WB.
genomics: moving from hypothesis-driven single study approaches Record-breaking performance in a 70-year-old marathoner. N Engl
to large multi-omics collaborative science. Physiol Genomics 48: J Med 380: 1485–1486, 2019. doi:10.1056/NEJMc1900771.
173–174, 2016. doi:10.1152/physiolgenomics.00009.2016.
805. Moore IS, Willy RW. Use of wearables: tracking and retraining in en-
789. Lindinger MI, Ward SA. A century of exercise physiology: key con- durance runners. Curr Sports Med Rep 18: 437–444, 2019.
cepts in. . .. Eur J Appl Physiol 122: 1–4, 2022. doi:10.1007/s00421- doi:10.1249/JSR.0000000000000667.
021-04873-4.
806. Laranjo L, Ding D, Heleno B, Kocaballi B, Quiroz JC, Tong HL,
790. Karstoft K, Pedersen BK. Skeletal muscle as a gene regulatory en-
Chahwan B, Neves AL, Gabarron E, Dao KP, Rodrigues D, Neves
docrine organ. Curr Opin Clin Nutr Metab Care 19: 270–275, 2016.
GC, Antunes ML, Coiera E, Bates DW. Do smartphone applications
doi:10.1097/MCO.0000000000000283.
and activity trackers increase physical activity in adults? Systematic
791. Whitham M, Febbraio MA. The ever-expanding myokinome: discov- review, meta-analysis and metaregression. Br J Sports Med 55:
ery challenges and therapeutic implications. Nat Rev Drug Discov 422–432, 2021. doi:10.1136/bjsports-2020-102892.
15: 719–729, 2016. doi:10.1038/nrd.2016.153.
807. Murach KA, McCarthy JJ, Peterson CA, Dungan CM. Making mice
792. Cervenka I, Agudelo LZ, Ruas JL. Kynurenines: tryptophan’s metab- mighty: recent advances in translational models of load-induced
olites in exercise, inflammation, and mental health. Science 357: muscle hypertrophy. J Appl Physiol (1985) 129: 516–521, 2020.
eaaf9794, 2017. doi:10.1126/science.aaf9794. doi:10.1152/japplphysiol.00319.2020.

793. Dos Santos M, Backer S, Saintpierre B, Izac B, Andrieu M, 808. Poole DC, Copp SW, Colburn TD, Craig JC, Allen DL, Sturek M,
Letourneur F, Relaix F, Sotiropoulos A, Maire P. Single-nucleus O’Leary DS, Zucker IH, Musch TI. Guidelines for animal exercise
RNA-seq and FISH identify coordinated transcriptional activity in and training protocols for cardiovascular studies. Am J Physiol
mammalian myofibers. Nat Commun 11: 5102, 2020. doi:10.1038/ Heart Circ Physiol 318: H1100–H1138, 2020. doi:10.1152/ajpheart.
s41467-020-18789-8. 00697.2019.
794. Kim M, Franke V, Brandt B, Lowenstein ED, Scho €wel V, Spuler S, 809. Ferreira-Pinto MJ, Ruder L, Capelli P, Arber S. Connecting circuits
Akalin A, Birchmeier C. Single-nucleus transcriptomics reveals func- for supraspinal control of locomotion. Neuron 100: 361–374, 2018.
tional compartmentalization in syncytial skeletal muscle cells. Nat doi:10.1016/j.neuron.2018.09.015.
Commun 11: 6375, 2020. doi:10.1038/s41467-020-20064-9.
810. Thornton JS, Patricios J, Kemp J, Engebretsen L, Drezner J. Robin
795. Petrany MJ, Swoboda CO, Sun C, Chetal K, Chen X, Weirauch MT,
Hood in SEM? What can we take from elite sport to give back to
Salomonis N, Millay DP. Single-nucleus RNA-seq identifies tran-
wider public health? Br J Sports Med 55: 949–950, 2021.
scriptional heterogeneity in multinucleated skeletal myofibers. Nat
doi:10.1136/bjsports-2021-104266.
Commun 11: 6374, 2020. doi:10.1038/s41467-020-20063-w.
811. Millet GP, Seiler S, Millet GY. Opportunities and obstacles of trans-
796. Crudele JM, Chamberlain JS. AAV-based gene therapies for the
lating elite sport research to public health. Br J Sports Med 56: 64–
muscular dystrophies. Hum Mol Genet 28: R102–R107, 2019.
65, 2022. doi:10.1136/bjsports-2021-104374.
doi:10.1093/hmg/ddz128.

797. Mendell JR, Al-Zaidy SA, Rodino-Klapac LR, Goodspeed K, Gray SJ, 812. Billat LV. Interval training for performance: a scientific and empirical
Kay CN, Boye SL, Boye SE, George LA, Salabarria S, Corti M, Byrne practice. Special recommendations for middle- and long-distance
BJ, Tremblay JP. Current clinical applications of in vivo gene ther- running. Part I: aerobic interval training. Sports Med 31: 13–31, 2001.
apy with AAVs. Mol Ther 29: 464–488, 2021. doi:10.1016/j. doi:10.2165/00007256-200131010-00002.
ymthe.2020.12.007.
813. Delezie J, Handschin C. Endocrine crosstalk between skeletal mus-
798. Pedersen BK. The physiology of optimizing health with a focus on cle and the brain. Front Neurol 9: 698, 2018. doi:10.3389/fneur.
exercise as medicine. Annu Rev Physiol 81: 607–627, 2019. 2018.00698.
doi:10.1146/annurev-physiol-020518-114339.
814. Nay K, Smiles WJ, Kaiser J, McAloon LM, Loh K, Galic S, Oakhill JS,
799. Pedersen BK, Saltin B. Exercise as medicine—evidence for pre- Gundlach AL, Scott JW. Molecular mechanisms underlying the ben-
scribing exercise as therapy in 26 different chronic diseases. Scand eficial effects of exercise on brain function and neurological disor-
J Med Sci Sports 25, Suppl 3: 1–72, 2015. doi:10.1111/sms.12581. ders. Int J Mol Sci 22: 4052, 2021. doi:10.3390/ijms22084052.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1785

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 FURRER ET AL.

815. Heuberger J, Cohen AF. Review of WADA prohibited substances: 831. Schoenfeld B, Fisher J, Grgic J, Haun C, Helms E, Phillips S, Steele
limited evidence for performance-enhancing effects. Sports Med J, Vigotsky A. Resistance training recommendations to maximize
49: 525–539, 2019. doi:10.1007/s40279-018-1014-1. muscle hypertrophy in an athletic population: position stand of the
IUSCA. Int J Strength Cond 1: 1, 2021. doi:10.47206/ijsc.v1i1.81.
816. Guerrieri D, Moon HY, van Praag H. Exercise in a pill: the latest on
exercise-mimetics. Brain Plast 2: 153–169, 2017. doi:10.3233/BPL- 832. Elder GC, Bradbury K, Roberts R. Variability of fiber type distribu-
160043. tions within human muscles. J Appl Physiol Respir Environ Exerc
Physiol 53: 1473–1480, 1982. doi:10.1152/jappl.1982.53.6.1473.
817. Vara-Ciruelos D, Russell FM, Hardie DG. The strange case of
AMPK and cancer: Dr Jekyll or Mr Hyde? Open Biol 9: 190099, 833. Wan JJ, Qin Z, Wang PY, Sun Y, Liu X. Muscle fatigue: general
2019. doi:10.1098/rsob.190099. understanding and treatment. Exp Mol Med 49: e384, 2017.
doi:10.1038/emm.2017.194.
818. Wackerhage H, Schoenfeld BJ. Evidence-informed training plans
and exercise prescriptions for performance, fitness and health. 834. Loenneke JP. Muscle growth does not contribute to the increases in
strength that occur after resistance training. Med Sci Sports Exerc
Sports Med 51: 1805–1813, 2021. doi:10.1007/s40279-021-01495-w.
53: 2011–2014, 2021. doi:10.1249/MSS.0000000000002662.
819. Grindem H, Myklebust G. Be a champion for your athlete’s health. J
835. Folland JP, Balshaw TG. muscle growth does contribute to the
Orthop Sports Phys Ther 50: 173–175, 2020. doi:10.2519/jospt.2020.
increases in strength that occur after resistance training. Med
0605.
Sci Sports Exerc 53: 2006–2010, 2021. doi:10.1249/MSS.
820. Tiller NB, Sullivan JP, Ekkekakis P. Baseless claims and pseudo- 0000000000002732.
science in health and wellness: a call to action for the sports, exer- 836. Mendell LM. The size principle: a rule describing the recruitment of
cise, and nutrition-science community. Sports Med 53: 1–5, 2023. motoneurons. J Neurophysiol 93: 3024–3026, 2005. doi:10.1152/
doi:10.1007/s40279-022-01702-2. classicessays.00025.2005.
821. McCarthy O, Pitt JP, Keay N, Vestergaard ET, Tan AS, Churm R, 837. Alkaslasi MR, Piccus ZE, Hareendran S, Silberberg H, Chen L,
Rees DA, Bracken RM. Passing on the exercise baton: what can en- Zhang Y, Petros TJ, Le Pichon CE. Single nucleus RNA-sequencing
docrine patients learn from elite athletes? Clin Endocrinol (Oxf) 96: defines unexpected diversity of cholinergic neuron types in the
781–792, 2022. doi:10.1111/cen.14683. adult mouse spinal cord. Nat Commun 12: 2471, 2021. doi:10.1038/
s41467-021-22691-2.
822. Millet GP, Chamari K. Look to the stars—is there anything that
public health and rehabilitation can learn from elite sports? Front 838. Liu JX, Ho€ glund AS, Karlsson P, Lindblad J, Qaisar R, Aare S,
Sports Act Living 4: 1072154, 2023. doi:10.3389/fspor.2022. Bengtsson E, Larsson L. Myonuclear domain size and myosin iso-
1072154. form expression in muscle fibres from mammals representing a
100,000-fold difference in body size. Exp Physiol 94: 117–129,
823. Lightfoot JT, DE Geus EJ, Booth FW, Bray MS, DEN Hoed M, Kaprio 2009. doi:10.1113/expphysiol.2008.043877.
J, Kelly SA, Pomp D, Saul MC, Thomis MA, Garland T Jr, Bouchard
C. Biological/genetic regulation of physical activity level: consensus 839. Gundersen K. Muscle memory and a new cellular model for muscle
from GenBioPAC. Med Sci Sports Exerc 50: 863–873, 2018. atrophy and hypertrophy. J Exp Biol 219: 235–242, 2016. doi:10.1242/
doi:10.1249/MSS.0000000000001499. jeb.124495.

824. Morgan PJ, Young MD, Smith JJ, Lubans DR. Targeted health 840. Schwartz LM. Skeletal muscles do not undergo apoptosis during ei-
behavior interventions promoting physical activity: a conceptual ther atrophy or programmed cell death—revisiting the myonuclear
model. Exerc Sport Sci Rev 44: 71–80, 2016. doi:10.1249/JES. domain hypothesis. Front Physiol 9: 1887, 2018. doi:10.3389/
0000000000000075. fpls.2018.01887.

825. Sherwood NE, Jeffery RW. The behavioral determinants of exer- 841. Gundersen K, Bruusgaard JC. Nuclear domains during muscle atro-
cise: implications for physical activity interventions. Annu Rev Nutr phy: nuclei lost or paradigm lost? J Physiol 586: 2675–2681, 2008.
20: 21–44, 2000. doi:10.1146/annurev.nutr.20.1.21. doi:10.1113/jphysiol.2008.154369.

842. Schwartz LM, Gundersen K. Cross Talk opposing view: myonuclei

826. Tao G, Garrett B, Taverner T, Cordingley E, Sun C. Immersive virtual
do not undergo apoptosis during skeletal muscle atrophy. J Physiol
reality health games: a narrative review of game design. J
600: 2081–2084, 2022. doi:10.1113/JP282381.
Neuroeng Rehabil 18: 31, 2021. doi:10.1186/s12984-020-00801-3.
843. Kirby TJ, Dupont-Versteegden EE. Cross Talk proposal: myonuclei
827. Berg J, Haugen G, Wang AI, Moholdt T. High-intensity exergaming
are lost with ageing and atrophy. J Physiol 600: 2077–2080, 2022.
for improved cardiorespiratory fitness: a randomised, controlled
doi:10.1113/JP282380.
trial. Eur J Sport Sci 22: 867–876, 2022. doi:10.1080/17461391.
2021.1921852. 844. Van der Meer SF, Jaspers RT, Degens H. Is the myonuclear domain
size fixed? J Musculoskelet Neuronal Interact 11: 286–297, 2011.
828. Schultz MG, Sharman JE. Exercise hypertension. Pulse (Basel) 1:
161–176, 2014. doi:10.1159/000360975. 845. Murach KA, Englund DA, Dupont-Versteegden EE, McCarthy JJ,
Peterson CA. Myonuclear domain flexibility challenges rigid
829. W€urzburger L, Wiech P, Rossi VA, Neunha €userer D, Caselli S, assumptions on satellite cell contribution to skeletal muscle fiber
Schmied CM, Niederseer D. Hypertensive response to exercise in hypertrophy. Front Physiol 9: 635, 2018. doi:10.3389/fphys.2018.
athletes: unremarkable finding or relevant marker for future cardio- 00635.
vascular complications? Int J Hypertens 2022: 8476751, 2022.
doi:10.1155/2022/8476751. 846. Aman F, El Khatib E, AlNeaimi A, Mohamed A, Almulla AS, Zaidan A,
Alshafei J, Habbal O, Eldesouki S, Qaisar R. Is the myonuclear domain
830. Giulianotti R, Thiel A. New horizons in the sociology of sport. Front ceiling hypothesis dead? Singapore Med J. In Press. doi:10.11622/
Sports Act Living 4: 1060622, 2023. doi:10.3389/fspor.2022.1060622. smedj.2021103.

1786 Physiol Rev  VOL 103  JULY 2023  www.prv.org

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.
 THE MOLECULAR ATHLETE: FROM MOLECULES TO MEDALS

847. Azevedo M, Baylies MK. Getting into position: nuclear movement in 850. Beets MW, Weaver RG, Brazendale K. Daring to share requires inten-
muscle cells. Trends Cell Biol 30: 303–316, 2020. doi:10.1016/j. tional and collective commitment to civil discourse. Int J Behav Nutr
tcb.2020.01.002. Phys Act 17: 46, 2020. doi:10.1186/s12966-020-00950-7.

848. Cavanagh JB. The problems of neurons with long axons. Lancet 1: 851. Ledgerwood A. What do we want our scientific discourse to look
1284–1287, 1984. doi:10.1016/s0140-6736(84)92457-7. like? Observer 30: 18–19, 2017.

849. Wickiewicz TL, Roy RR, Powell PL, Edgerton VR. Muscle architec- 852. Sun Q, Wojcieszak M, Davidson S. Over-time trends in incivility
ture of the human lower limb. Clin Orthop Relat Res 179: 275–283, on social media: evidence from political, non-political, and mixed
1983. sub-reddits over eleven years. Front Polit Sci 3: e741605, 2021.

Physiol Rev  VOL 103  JULY 2023  www.prv.org 1787

Downloaded from journals.physiology.org/journal/physrev at CAPES-UNESP (200.145.106.058) on July 3, 2023.