Stiffness of Muscles and Tendons of the Lower Limb of Professional and Semiprofessional Athletes Using Shear Wave Elastography

OBJECTIVE

Shear wave elastography (SWE) allows assessment of muscle and tendon stiffness and can be used to diagnose soft tissue pathologies such as tendinopathies. In sports medicine, SWE may have the potential to uncover structural changes early on before they lead to functional impairment. To systematically analyze possible differences in tendon and muscle stiffness of the lower limb between professional (PG) and semiprofessional female athletes (SG) using SWE and to compile reference values for developing preventive medicine approaches for professional athletes.

METHODS

Standardized SWE of both lower limb tendons and muscles (Achilles tendon [AT], soleus muscle insertion [SM], patellar tendon [PT], quadriceps tendon [QT], vastus medialis muscle [VM]) in the longitudinal plane was performed with the tendons in relaxed position in 24 healthy professional female athletes (PG) in comparison with 24 healthy semiprofessional female athletes (SG).

RESULTS

Median tendon and muscle stiffness was significantly higher in professional athletes (AT:PG, 11.12 m/s vs SG, 7.33 m/s, P < .001; SM: 1.77 m/s vs 1.14 m/s, P < .001; VM: 1.63 m/s vs 0.87 m/s, P < .001; QT: 3.31 m/s vs 2.61 m/s, P < .05). There was no significant difference in patellar tendon stiffness between PG and SG (PT: 2.57 m/s vs 3.21, P = .25).

CONCLUSION

Professional female athletes have higher stiffness values than semiprofessional female athletes in lower limb muscles and tendons, except for the patellar tendon. Knowledge of such differences is necessary for diagnosing tendinopathy and injuries. Musculoskeletal SWE could offer great benefits in sports medicine as well as in rehabilitation and preventive medicine.

The Significance of Oral Inflammation in Elite Sports: A Narrative Review

Recently, there has been intense discussion about sports dentistry and potential interactions between oral health and athletes' performance. This narrative review aims to provide a comprehensive overview of the available literature about oral inflammation in sports. For this purpose, it presents the most common types of oral inflammation (gingivitis, periodontitis, pericoronitis, apical periodontitis), and their prevalence in athletes. Both the impact of oral inflammation on performance and causes for oral inflammation in athletes are discussed by presenting current literature. Finally, international recommendations for dental care in sports are presented. Several studies stated a high prevalence of oral inflammation in athletes, especially of gingivitis (58-97%) and periodontitis (41%). Also, many athletes report oral pain (17-30%) and a negative impact of oral health on training (3-9%). Besides this, a systemic impact of oral inflammation is discussed: In periodontitis patients, blood parameters and physical fitness are changed. In athletes, associations between muscle injuries and poor oral health are reported. There are deficits in oral health behavior. Furthermore, systemic changes due to physical stress could influence oral tissues. Overall, complex bidirectional interactions between competitive sports and oral inflammation are possible. Regular dental examinations and prevention strategies should be implemented in sports.

Salivary Diagnostic for Monitoring Strenuous Exercise-A Pilot Study in a Cohort of Male Ultramarathon Runners

Intense physical stress, such as that in ultramarathon running, affects the immune system. For monitoring in sports medicine, non-invasive methods, e.g., salivary analysis, are of interest. This pilot cohort study aimed to assess changes in salivary parameters in response to an ultramarathon. The results were compared to blood parameters. Male, healthy finishers (n = 9, mean age: 48 ± 8.8 years, mean height: 1.8 ± 0.1 m, mean weight: 72.5 ± 7.2 kg, mean BMI: 23.5 ± 1.9 kg/cm²) of a 160 km ultramarathon were included. Saliva and blood samples were collected at three time points: T1 (baseline), T2 (shortly after the ultramarathon) and T3 (after recovery). In saliva, cortisol, testosterone, IL-1β, IL-6, IL-8, IL-10, TNF-α, albumin, IgA, α-amylase, aMMP-8, and neopterin were assessed via ELISA. In blood, cortisol, testosterone, IL-1β, IL-6, IL-8, IL-10, TNF-α, blood cell counts, procalcitonin, CRP, osmolality, albumin, and α-amylase were analyzed. The statistical evaluation comprised longitudinal testing and cross-sectional testing between saliva and blood using ratios of T2 and T3 to baseline values. Various parameters in saliva and blood changed in response to the ultramarathon. Comparing blood and saliva, the longitudinal changes of testosterone (p = 0.02) and α-amylase (p = 0.03) differed significantly. Despite the limitations of the study, it underlines that saliva is an interesting option for comprehensive monitoring in sports medicine and necessitates further studies.

Schlafqualität und kardialer autonomer Tonus bei Leistungssporttreibenden und in einer Referenzgruppe Gesunder

Leistungssportlerinnen und Leistungssportler sind hohen physischen und psychischen Anforderungen ausgesetzt, um optimale Ergebnisse zu erzielen. Dafür ist auch die Funktion der Regenerationsphase wichtig, zu der maßgeblich ein erholsamer Schlaf beiträgt. Es gibt jedoch Hinweise, dass bei Leistungssportlerinnen und Leistungssportlern aufgrund verschiedener Belastungen im Rahmen des Trainings und der Wettkämpfe gehäuft eine Insomniesymptomatik auftreten kann. Zur objektiven Untersuchung der Schlafstruktur, Schlafqualität und Funktion des kardialen autonomen Tonus wurden Leistungssporttreibende (LS) und eine Gruppe ebenfalls gesunder Kontrollen (GK) mit einer vereinfachten ambulanten Schlafmessung untersucht.

Es wurde in der Gruppe LS bei n = 12 Probanden (Alter 25,1 ± 4,3 Jahre) und in der Gruppe GK bei n = 17 Probanden (Alter 26,1 ± 3,2 Jahre) jeweils weiblichen und männlichen Geschlechts erfolgreich im häuslichen Umfeld eine vereinfachte Schlafmessung einschließlich 1‑Kanal-EKG (SOMNOtouch™) durchgeführt. Mittels Fragebögen wurden die Tagesschläfrigkeit (Epworth Sleepiness Scale, ESS), Insomnieschwere (Insomnia Severity Index, ISI) und Symptome für Schlafapnoe (Aktualisierter STOP-Bang-Fragebogen, aSBF) erhoben. Es wurden visuell die Schlafstadien gescort und aus dem EKG mittels Zeitreihenanalyse Parameter der Herzfrequenz und Herzfrequenzvariabilität (HRV) ausgewertet.

Es traten keine Unterschiede zwischen den Gruppen LS und GK hinsichtlich der ESS und aSBF auf, jedoch war die ISI in der Gruppe LS gegenüber GK erhöht (5,7 ± 4,1 vs. 2,4 ± 2,0; p < 0,02). In Auswertung der Schlafstruktur gab es keine Unterschiede für die Einschlaflatenz (ESL), Gesamtschlafzeit (TST), Schlafeffizienz (SE) sowie für die prozentualen Anteile von Leicht- (N1 + N2), Tief- (N3) und REM-Schlaf (REM), jedoch war die Bettzeit (TIB) in der Gruppe LS erhöht (503,2 ± 52,7 vs. 445,5 ± 45,4 min; p < 0,02). In der Gruppe LS waren gegenüber der Gruppe GK die mittlere nächtliche Herzfrequenz verringert (48,5 ± 6,8 vs. 56,1 ± 5,4; p < 0,01) sowie die HRV-Parameter HRV-Standardabweichung (HRV-SD) (166,0 ± 33,2 vs. 138,2 ± 38,7; p < 0,04), HRV-SD1 (78,8 ± 11,7 vs. 63,2 ± 36,5; p < 0,01) und HRV-SD2 (220,6 ± 48,0 vs. 183,8 ± 45,8; p < 0,05) erhöht.

In der von uns untersuchte Gruppe von Leistungssportlerinnen und Leistungssportlern gibt es Anhaltspunkte für eine leichte Insomnie, wobei die objektiv gemessene Schlafstruktur sich nicht von der gesunder Kontrollen unterscheidet. Dabei ist die TST, mit einem Mittelwert von 6,8 h sowohl in der Gruppe LS als auch in GK, geringer als die von den Fachgesellschaften American Academy of Sleep Medicine (AASM), Sleep Research Society (SRS) und National Sleep Foundation (NSF) empfohlene Schlafdauer für junge Erwachsene. Dagegen war die kardiale autonome Regulation im Schlaf in der Gruppe LS signifikant besser als in der Gruppe GK und ist in Übereinstimmung mit Befunden aus 24-Stunden-Holter-EKG-Studien. Die Entwicklung objektiver, mobiler und belastungsarmer Messverfahren vereinfacht die Erfassung der Schlafstruktur und charakteristischer vegetativer Parameter und könnte zunehmend im personalisierten Gesundheits- und Leistungsmanagement bei Leistungssporttreibenden eingesetzt werden.

Muscle and Tendon Stiffness of the Lower Limb of Professional Adolescent Soccer Athletes Measured Using Shear Wave Elastography

BACKGROUND

While adolescents have specific risk factors for acute and chronic injury, there is a lack of preventive medicine algorithms for this vulnerable group. Shear wave elastography (SWE) is currently mainly used for assessing muscle and tendon stiffness in adult athletes and can diagnose tissue pathologies such as tendinopathy. The aim was to investigate differences in quadriceps tendon and muscle stiffness between adolescent and adult professional soccer players using SWE and identify lateral imbalances in order to improve the knowledge of preventive medicine algorithms for professional adolescent athletes.

METHODS

Standardized SWE examinations of both lower limb tendons and muscles (the quadriceps tendon (QT) and the vastus medialis (VM) muscle) in the longitudinal plane and relaxed tendon position were performed in 13 healthy adolescent soccer athletes (13-17 years), and a control group of 19 healthy adult professional soccer athletes (18-29 years).

RESULTS

Adolescent soccer players had lower stiffness values for both the quadriceps tendon (3.11 m/s vs. 3.25 m/s) and the vastus medialis muscle (1.67 m/s vs. 1.71 m/s) than adult athletes. Moreover, QT stiffness in adolescent soccer players was significantly lower on the right side (QT: adult 3.50 m/s (2.73-4.56) vs. adolescent 2.90 m/s (2.61-3.12); p = 0.031). Analysis of the lateral differences revealed softer QT and VM tissue on the right side in over two-thirds of adolescent soccer athletes. Over two-thirds of adults had stiffer QT and VM tissue on the right side.

CONCLUSION

In adolescent soccer players, the stiffness of the QT and VM muscle measured by SWE is lower in the right leg. SWE of the musculoskeletal system may thus become a relevant diagnostic tool to detect early lateral imbalances as a main risk factor for injury and may thus contribute to the prevention of acute and chronic injury prevention in adolescent athletes.

Effects of orally administered hormonal contraceptives on the musculoskeletal system of healthy premenopausal women—A systematic review

Introduction

The musculoskeletal system (MSK) is one of the extragonadal target tissues of sex hormones: osteoblasts and osteocytes express estrogen receptors, while in fibroblasts of the anterior cruciate ligament (ACL) and myocytes of the vastus lateralis muscle (MVL), estrogen and progesterone receptors can be detected by immunoassay. Indeed, upon binding of sex hormones to the extragonadal receptors, the MSK seems to respond to varying levels of sex hormones with structural adaptation. Hormonal contraceptives can affect the musculoskeletal system; however, there is a lack of high‐quality studies, and no recommendation for female athletes exists.

Material and Methods

This is a systematic review of publications on the effects of oral hormonal contraceptives on the biomechanical properties of tendons, muscles and ligaments, muscle strength, and soft tissue regeneration. A systematic database search was performed using MESH keywords and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) methodology in Pubmed and Cochrane to identify studies investigating the influence of oral hormonal contraceptives on muscles, tendons, and ligaments of healthy, adult, premenopausal women. The risk of bias in the studies included was assessed by two independent researchers using the ROBINS‐I Tool.

Results

Nine comparative studies were identified that met the inclusion criteria. Endpoints were muscle strength and biomechanical tissue properties. No significant influence of oral hormonal contraceptives on muscle strength was found, although general muscle growth and Type I fiber growth were found to be significantly increased in a dose‐dependent manner. There was a negative effect on regeneration of muscle strength after exercise. The stiffness of tendons remained unchanged, while their size adaptation to load increased.

Conclusion

The anabolic effect could be beneficial for specific sports, whereas reduced muscle regeneration could be disadvantageous for women exercising with high‐performance demands. The different effects on tendons and ligaments and the functional consequences of altered ligament and muscle stiffness, especially with regard to synthetic hormones, should be further investigated.

Associations of Blood and Performance Parameters with Signs of Periodontal Inflammation in Young Elite Athletes-An Explorative Study

This retrospective cross-sectional study aimed to explore interactions between signs of periodontal inflammation and systemic parameters in athletes. Members of German squads with available data on sports medical and oral examination were included. Groups were divided by gingival inflammation (median of papillary bleeding index, PBI ≥ median) and signs of periodontitis (Periodontal Screening Index, PSI ≥ 3). Age, gender, anthropometry, blood parameters, echocardiography, sports performance on ergometer, and maximal aerobic capacity (VO2max) were evaluated. Eighty-five athletes (f = 51%, 20.6 ± 3.5 years) were included (PBI < 0.42: 45%; PSI ≥ 3: 38%). Most associations were not statistically significant. Significant group differences were found for body fat percentage and body mass index. All blood parameters were in reference ranges. Minor differences in hematocrit, hemoglobin, basophils, erythrocyte sedimentation rates, urea, and HDL cholesterol were found for PBI, in uric acid for PSI. Echocardiographic parameters (n = 40) did not show any associations. Athletes with PSI ≥ 3 had lower VO2max values (55.9 ± 6.7 mL/min/kg vs. 59.3 ± 7.0 mL/min/kg; p = 0.03). In exercise tests (n = 30), athletes with PBI < 0.42 achieved higher relative maximal load on the cycling ergometer (5.0 ± 0.5 W/kg vs. 4.4 ± 0.3 W/kg; p = 0.03). Despite the limitations of this study, potential associations between signs of periodontal inflammation and body composition, blood parameters, and performance were identified. Further studies on the systemic impact of oral inflammation in athletes, especially regarding performance, are necessary.

Bilateral glenohumeral internal rotation deficit (GIRD) in elite gymnasts

INTRODUCTION

The "Glenohumeral Internal Rotation Deficit (GIRD)" is known as the difference in internal rotation range of motion (IRRM) between the dominant and non-dominant shoulder of overhead athletes as a result of asymmetric loading. As in contrast loading pattern in gymnastics are quite symmetric and structural changes often occur bilaterally, the question arises if GIRD might develop bilaterally in gymnasts as one source of common bilateral shoulder pathologies and to search for underlying structural adaptations.

MATERIALS AND METHODS

A group of 35 elite gymnasts (8-24 years) were recruited from a local Olympic Training Centre and compared to a paired cohort of 28 non-overhead athletes. Clinical examinations, digital range of motion (ROM)-measurement, ultrasonographic humeral torsion measurement, and standardized MRI scans of both shoulders were obtained and examined for structural pathologies, cross-sectional areas (CSA) of the rotator cuff muscles and capsular thickness.

RESULTS

ROM-measurements showed significant decrease in IRRM in the gymnasts groups by age, with IRRM of 48.6° (SD: 8.4°, CI 95%: 43.0-54.3°) at age group 1 (8-10 years) and IRRM of 10° (SD: 11.4°; CI 95%: 0-22.0°) at age group 4 (18-26 years), that was statistically significant for the entire cohort (p = 0.017) compared to the controls. CSA were not significantly different between the cohorts, while there was a slightly increased humeral retrotorsion in the gymnasts as well as a statistically significant posterior capsular thickening.

CONCLUSION

A new bilateral form of GIRD was identified in higher age groups of youth and senior elite gymnasts enrolled in this study. Despite to former definition of GIRD there was no compensatory increase in external rotation range of motion (ERRM) but an association with posterior capsular thickening, while there was no periscapular muscle hypertrophy. Humeral retrotorsion was also slightly increased in the gymnasts group.

Cardiovascular risk factors, exercise capacity and health literacy in patients with chronic ischaemic heart disease and type 2 diabetes mellitus in Germany: Baseline characteristics of the Lifestyle Intervention in Chronic Ischaemic Heart Disease and Type 2 Diabetes study

BACKGROUND

Lifestyle interventions are a cornerstone in the treatment of chronic ischaemic heart disease (CIHD) and type 2 diabetes mellitus (T2DM). This study aimed at identifying differences in clinical characteristics between categories of the common lifestyle intervention targets BMI, exercise capacity (peak V̇O₂) and health literacy (HL).

METHODS

Cross-sectional baseline characteristics of patients enrolled in the LeIKD trial (Clinicaltrials.gov NCT03835923) are presented in total, grouped by BMI, %-predicted peak V̇O₂ and HL (HLS-EU-Q16), and compared to other clinical trials with similar populations.

RESULTS

Among 499 patients (68.3±7.7 years; 16.2% female; HbA1c, 6.9±0.9%), baseline characteristics were similar to other trials and revealed insufficient treatment of several risk factors (LDL-C 92±34 mg/dl; BMI, 30.1±4.8 kg/m²; 69.6% with peak V̇O₂<90% predicted). Patients with lower peak V̇O₂ showed significantly higher (p < 0.05) CIHD and T2DM disease severity (HbA1c, CIHD symptoms, coronary artery bypass graft). Obese patients had a significantly higher prevalence of hypertension and higher triglyceride levels, whereas in patients with low HL both quality of life components (physical, mental) were significantly reduced.

CONCLUSIONS

In patients with CIHD and T2DM, peak V̇O2, BMI and HL are important indicators of disease severity, risk factor burden and quality of life, which reinforces the relevance of lifestyle interventions.

Change in Latent Gray-Matter Structural Integrity Is Associated With Change in Cardiovascular Fitness in Older Adults Who Engage in At-Home Aerobic Exercise

In aging humans, aerobic exercise interventions have been found to be associated with more positive or less negative changes in frontal and temporal brain areas, such as the anterior cingulate cortex (ACC) and hippocampus, relative to no-exercise control conditions. However, individual measures such as gray-matter (GM) probability may afford less reliable and valid conclusions about maintenance or losses in structural brain integrity than a latent construct based on multiple indicators. Here, we established a latent factor of GM structural integrity based on GM probability assessed by voxel-based morphometry, magnetization transfer saturation, and mean diffusivity. Based on this latent factor, we investigated changes in structural brain integrity during a six-month exercise intervention in brain regions previously reported in studies using volumetric approaches. Seventy-five healthy, previously sedentary older adults aged 63–76 years completed an at-home intervention study in either an exercise group (EG; n = 40) or in an active control group (ACG; n = 35). Measures of peak oxygen uptake (VO₂peak) taken before and after the intervention revealed a time-by-group interaction, with positive average change in the EG and no reliable mean change in the ACG. Significant group differences in structural brain integrity changes were observed in the right and left ACC, right posterior cingulate cortex (PCC), and left juxtapositional lobule cortex (JLC). In all instances, average changes in the EG did not differ reliably from zero, whereas average changes in the ACG were negative, pointing to maintenance of structural brain integrity in the EG, and to losses in the ACG. Significant individual differences in change were observed for right ACC and left JLC. Following up on these differences, we found that exercising participants with greater fitness gains also showed more positive changes in structural integrity. We discuss the benefits and limitations of a latent-factor approach to changes in structural brain integrity, and conclude that aerobic fitness interventions are likely to contribute to brain maintenance in old age.

No Evidence for a Boost in Psychosocial Functioning in Older Age After a 6-Months Physical Exercise Intervention

The beneficial effects of physical exercise on physical health and cognitive functioning have been repeatedly shown. However, evidence of its effect on psychosocial functioning in healthy adults is still scarce or inconclusive. One limitation of many studies examining this link is their reliance on correlational approaches or specific subpopulations, such as clinical populations. The present study investigated the effects of a physical exercise intervention on key factors of psychosocial functioning, specifically well-being, stress, loneliness, and future time perspective. We used data from healthy, previously sedentary older adults (N = 132) who participated in a 6-month at-home intervention, either engaging in aerobic exercise or as part of a control group who participated in foreign language-learning or reading of selected native-language literature. Before and after the intervention, comprehensive cardiovascular pulmonary testing and a psychosocial questionnaire were administered. The exercise group showed significantly increased fitness compared to the control group. Contrary to expectations, however, we did not find evidence for a beneficial effect of this fitness improvement on any of the four domains of psychosocial functioning we assessed. This may be due to pronounced stability of such psychological traits in older age, especially in older adults who show high levels of well-being initially. Alternatively, it may be that the well-documented beneficial effects of physical exercise on brain structure and function, as well as cognition differ markedly from beneficial effects on psychosocial functioning. While aerobic exercise may be the driving factor for the former, positive effects on the latter may only be invoked by other aspects of exercise, for example, experiences of mastery or a feeling of community.

Orofacial conditions and oral health behavior of young athletes - a comparison of amateur and competitive sports

PURPOSE

This retrospective cross-sectional study aimed to evaluate oral health status (dental, periodontal and functional) and oral health behavior in young German athletes including the comparison of competitive (CA) and amateur sports (AA).

METHODS

Data of CA (German national teams, perspective and youth squads) and AA aged between 18 and 30 years with an available oral examination in 2019 were included. Clinical examination: caries experience (DMF-T), non-carious wear (erosion, BEWE), partially erupted wisdom teeth, gingival inflammation (PBI), plaque index, periodontal screening (PSI), and temporomandibular dysfunction (TMD) screening. Questionnaires: oral health behavior, periodontal symptoms.

RESULTS

88 CA (w = 51 %, 20.6 ± 3.5 years) of endurance sports and 57 AA (w = 51%, 22.2 ± 2.1 years) were included. DMF-T was comparable (CA: 2.7 ± 2.2, AA: 2.3 ± 2.2; p = 0.275) with more D-T in CA (0.6 ± 1.0) than AA (0.3 ± 0.7; p = 0.046; caries prevalence: CA: 34 %, AA: 19 %; p = 0.06). Both groups had low severity of erosion (BEWE about 3.5). CA had more positive TMD screenings (43 % vs. 25 %; p = 0.014). In both groups, all athletes showed signs of gingival inflammation, but on average of low severity (PBI < 1). More CA needed complex periodontal treatment than AA (maximum PSI = 3 in 40% vs. 12%; p < 0.001). Oral health behavior was comparable (daily tooth brushing, regular dental check-ups in > 70%).

CONCLUSIONS

Young German athletes (CA and AA) generally showed signs of gingival inflammation and needed to improve their oral health behavior. CA showed slightly increased oral findings (more D-T, periodontal and TMD screening findings) than AA, but similar oral health behavior. This may imply an increased dental care need in competitive sports.

COVID-19 in German Competitive Sports: Protocol for a Prospective Multicenter Cohort Study (CoSmo-S)

Objective: It is unclear whether and to what extent COVID-19 infection poses health risks and a chronic impairment of performance in athletes. Identification of individual health risk is an important decision-making basis for managing the pandemic risk of infection with SARS-CoV-2 in sports and return to play (RTP).

Methods: This study aims 1) to analyze the longitudinal rate of seroprevalence of SARS-CoV-2 in German athletes, 2) to assess health-related consequences in athletes infected with SARS-CoV-2, and 3) to reveal effects of the COVID-19 pandemic in general and of a cleared SARS-CoV-2 infection on exercise performance. CoSmo-S is a prospective observational multicenter study establishing two cohorts: 1) athletes diagnosed positive for COVID-19 (cohort 1) and 2) federal squad athletes who perform their annual sports medical preparticipation screening (cohort 2). Comprehensive diagnostics including physical examination, laboratory blood analyses and blood biobanking, resting and exercise electrocardiogram (ECG), echocardiography, spirometry and exercise testing added by questionnaires are conducted at baseline and follow-up.

Results and Conclusion: We expect that the results obtained, will allow us to formulate recommendations regarding RTP on a more evidence-based level.

Home-Based Long-Term Physical Endurance and Inspiratory Muscle Training for Children and Adults With Fontan Circulation—Initial Results From a Prospective Study

Background

Patients with congenital heart disease (CHD)—including those after Fontan operation—are encouraged to be physically active.

Aim

To prospectively determine the effects of an individually adapted, home-based cycle ergometer endurance training in combination with inspiratory muscle training (IMT) in pediatric and adult Fontan patients. We, herein, report the results of the initial 10-months follow-up (phase 1).

Methods

18 patients (median age 16.5 years; range 10-43 years) completed baseline check-ups, and 4 and 10 months follow-up visits, which each included cardiopulmonary exercise testing (CPET), bodyplethysmography (including measurement of respiratory muscle strength), and a quality of life questionnaire (PedsQL™). The training program consisted of a home-based cycle ergometer endurance training on a “Magbike® AM-5i/3i” (DKN Technology®, Clermont-Ferrand, France) and IMT with a handheld “POWERbreathe® Medic plus” device. Patients performed 90 min of endurance training per week in addition to IMT (30 breaths per day, 6-7 times per week). After the first 4 months, patients underwent additional interval training.

Results

After 10 months of training, we observed significant increases in maximum relative workload (W/kg, p = 0.003) and in maximum inspiratory (MIP, p = 0.002) and expiratory (MEP, p = 0.008) pressures. Peak VO2 values did not increase significantly as compared to baseline (p = 0.12) in the entire cohort (n = 18), but reached statistical significance in a subgroup analysis of teenage/adult patients (n = 14; p = 0.03). Patients' subjective quality of life did not show any significant changes after 10 months of training.

Discussion

In Fontan patients, an individually adapted home-based training is safe and associated with improvements in some CPET variables. However, these improvements did not translate into an improved QoL after 10 months. With an unclear, but most likely negative, impact of the COVID-19 pandemic, improvements in QoL may become evident during further follow-up (phase 2 of the study).

Epidemiology of injuries in track and field athletes: a cross-sectional study of specific injuries based on time loss and reduction in sporting level

OBJECTIVES

To prevent the occurrence of injury in a sport, exact knowledge of injury patterns is needed. To synthesize sport-specific injuries in track and field comparing elite and recreational level athletes, as well as gender. Furthermore, analyze the time loss due to injury and reduction in athletic performance.

METHODS

Injury type-specific frequencies were recorded according to discipline, gender and performance level. Injury severity was assessed by time loss duration and performance reduction.

RESULTS

64% of athletes suffered at least one injury. In the top 10 ranking, 83% (n = 524) were located in the lower extremities. A muscle strain of the thigh had the highest prevalence in sprint (34%, n = 41), jump (15%, n = 15) and middle-distance running (16%, n = 6). More injuries occurred during training (75%, n = 165) as compared to competition (25%, n = 56). The longest time loss was documented in throwing with a downtime of 36 weeks after a ligament injury of the elbow and 39 weeks after a muscle injury of the elbow. The injury with the highest number of athletes with a reduced level of performance was the foot ligament injury in sprint athletes at 100%.

CONCLUSION

Assessing time loss and performance reduction in athletics, there are discipline-specific injury patterns. This study points out the high prevalence of training injuries, highlighting the need for future investigations to adapt training management, improve medical care and rehabilitation with respect to every discipline.

Joint position statement of the International Federation of Sports Medicine (FIMS) and European Federation of Sports Medicine Associations (EFSMA) on the IOC framework on fairness, inclusion and non-discrimination based on gender identity and sex variations

The IOC recently published its framework on fairness, inclusion and non-discrimination based on gender identity and sex variations. This framework is drafted mainly from a human rights perspective, with less consideration for medical/scientific issues. The framework places the onus for gender eligibility and classification entirely on the International Federations (IFs), even though most will not have the capacity to implement the framework. The position of no presumption of advantage is contrary to the 2015 IOC consensus. Implementation of the 2021 framework will be a major challenge for IFs that have already recognised the inclusion of trans and women athletes with differences of sexual development (DSD) using a scientific/medical solution. The potential consequences for sports that need to prioritise fairness or safety could be one of two extremes (1) exclusion of all transgender or DSD athletes on the grounds of advantage or (2) self-identification that essentially equates to no eligibility rules. Exclusion of all transgender or DSD athletes is contrary to the Olympic charter and unlawful in many countries. While having no gender eligibility rules, sport loses its meaning and near-universal support. Athletes should not be under pressure to undergo medical procedures or treatment to meet eligibility criteria. However, if an athlete is fully informed and consents, then it is their free choice to undergo carefully considered or necessary interventions for gender classification for sport to compete fairly and safely in their chosen gender. Free choice is a fundamental human right, but so is the right to fair and safe competition.

Blood pressure response to dynamic exercise testing in adolescent elite athletes, what is normal?

BACKGROUND

In general, only few studies are dedicated to blood pressure behavior under physical stress in children and adolescents. Even less is published about the blood pressure behavior of young high-performance athletes on the ergometer. For this reason, we evaluated the blood pressure behavior under stress compared to non-athletes in a large collective (n = 739) of young high-performance athletes (age 10-20 years, mean 15.8 years, male 442, female 297) of different sports. A complete echocardiographic examination was available in all athletes.

RESULT

Regardless of gender, the young competitive athletes achieved significantly higher maximum blood pressure values than investastigated populations from previous studies. Based on the data obtained, blood pressure percentiles are now defined explicitly for junior athletes across sports as well as age- and gender-dependent, which did not exist in this form of normal values for the special clientele of young competitive athletes. The echocardiographic examinations demonstrated stress-induced cardiac adaptation adaptations in the majority of athletes, which thus correlate with the comparatively higher stress blood pressures compared to non-athletes.

CONCLUSION

For the first time, blood pressure percentiles for exercise tests on the ergometer for age groups and gender in high performance athletes are defined based on a comparatively large collective of young competitive athletes. Upper limits were determined, in particular for systolic blood pressure under stress, and categorized according to gender and age. Performance diagnosticians and physicians are now enabled to make a more accurate assessment of the corresponding blood pressure regulation of young athletes under exercise conditions.

Establishing a Global Standard for Wearable Devices in Sport and Exercise Medicine: Perspectives from Academic and Industry Stakeholders

Millions of consumer sport and fitness wearables (CSFWs) are used worldwide, and millions of datapoints are generated by each device. Moreover, these numbers are rapidly growing, and they contain a heterogeneity of devices, data types, and contexts for data collection. Companies and consumers would benefit from guiding standards on device quality and data formats. To address this growing need, we convened a virtual panel of industry and academic stakeholders, and this manuscript summarizes the outcomes of the discussion. Our objectives were to identify (1) key facilitators of and barriers to participation by CSFW manufacturers in guiding standards and (2) stakeholder priorities. The venues were the Yale Center for Biomedical Data Science Digital Health Monthly Seminar Series (62 participants) and the New England Chapter of the American College of Sports Medicine Annual Meeting (59 participants). In the discussion, stakeholders outlined both facilitators of (e.g., commercial return on investment in device quality, lucrative research partnerships, and transparent and multilevel evaluation of device quality) and barriers (e.g., competitive advantage conflict, lack of flexibility in previously developed devices) to participation in guiding standards. There was general agreement to adopt Keadle et al.'s standard pathway for testing devices (i.e., benchtop, laboratory, field-based, implementation) without consensus on the prioritization of these steps. Overall, there was enthusiasm not to add prescriptive or regulatory steps, but instead create a networking hub that connects companies to consumers and researchers for flexible guidance navigating the heterogeneity, multi-tiered development, dynamicity, and nebulousness of the CSFW field.

Epidemiology of Injuries in Olympic Sports

Injuries effect the performance of athletes. Severity of injuries is determined by time loss and sporting performance reduction. To treat injuries adequately, it is necessary to get an overview of varied injuries types in different sports disciplines. In a retrospective study 7.809 athletes from Germany, Switzerland and Austria competing in competitive or recreational levels of sports were included. Injury prevalence was highest in team sports (75%), followed by combat (64%), racquet (54%) and track and field (51%). Knee (28%) and shoulder (14%) were the most at risk joints. Time loss in sporting activity after injury was longest in the region of knee (26 weeks). Of all reported injuries, 48% were accompanied by a reduced level of performance. The highest injury prevalence occurred in the year 2016 (45%). More injuries occurred during training (58%) compared to competition (42%). Across Olympic disciplines, a large number of injuries occurred during training sessions. Injury frequency increased as the Olympic games drew closer. Knee and shoulder injuries were the most severe injuries with respect to time loss and reduction sporting performance.

An Augmented Reality Device for Remote Supervision of Ultrasound Examinations in International Exercise Science Projects: Usability Study

Background

Support for long-distance research and clinical collaborations is in high demand and has increased owing to COVID-19–related restrictions on travel and social contact. New digital approaches are required for remote scientific exchange.

Objective

This study aims to analyze the options of using an augmented reality device for remote supervision of exercise science examinations.

Methods

A mobile ultrasound examination of the diameter and intima-media thickness of the femoral and carotid arteries was remotely supervised using a head-mounted augmented reality device. All participants were provided with a link to a YouTube video of the technique in advance. In part 1, 8 international experts from the fields of engineering and sports science were remotely connected to the study setting. Internet connection speed was noted, and a structured interview was conducted. In part 2, 2 remote supervisors evaluated 8 physicians performing an examination on a healthy human subject. The results were recorded, and an evaluation was conducted using a 25-item questionnaire.

Results

In part 1, the remote experts were connected over a mean distance of 1587 km to the examination site. Overall transmission quality was good (mean upload speed: 28.7 Mbps, mean download speed: 97.3 Mbps, mean ping: 21.6 milliseconds). In the interview, participants indicated that the main potential benefits would be to the fields of education, movement analysis, and supervision. Challenges regarding internet connection stability and previous training with the devices used were reported. In part 2, physicians’ examinations showed good interrater correlation (interclass correlation coefficient: 0.84). Participants valued the experienced setting as highly positive.

Conclusions

The study showed the good feasibility of the chosen design and a highly positive attitude of all participants toward this digital approach. Head-mounted augmented reality devices are generally recommended for collaborative research projects with physical examination–based research questions.

Herausforderungen für Mannschafts- und Verbandsärzte in Zeiten der COVID-19-Pandemie

Die weltumspannende COVID-19-Pandemie hat auch die tägliche Arbeit der Mannschafts- und Verbandsärzte entscheidend verändert. Bislang kaum bedeutsame Arbeitsfelder kamen hinzu und insbesondere organisatorische Aufgaben stellen den betreuenden Sportmediziner vor große Herausforderungen. Präventive Maßnahmen wie die Erstellung von Hygienekonzepten und Umsetzung von Teststrategien sind zentraler Bestandteil einer Verhinderung von Infektionsgeschehen (und deren Ausbreitung) und somit Voraussetzung der Fortführung von Trainings- und Wettkampfmaßnahmen. Erforderlich sind Kenntnisse im direkten medizinischen Umgang mit SARS-CoV-2, inklusive geeigneter medizinischer Maßnahmen zur gefahrlosen Wiederaufnahme der Sportausübung. Auch sekundäre Folgen der Pandemie, wie beispielsweise Einschränkungen notwendiger operativer und rehabilitativer Maßnahmen oder das Auftreten psychischer Erkrankungen, müssen berücksichtigt werden. Eine teaminterne, offene und vertrauensvolle Kommunikation ist Grundlage der Akzeptanz der vereinbarten Maßnahmen. Durch die sich stetig ändernde Pandemiesituation und den Zuwachs an wissenschaftlichen Erkenntnissen ist eine fortlaufende Re-Evaluation der ausgesprochenen Empfehlungen und vereinbarten Prozedere notwendig.