Risk factors for lower extremity injury: a review of the literature

Hamstring Injuries Prevention in Soccer: A Narrative Review of Current Literature

Hamstring injuries and reinjuries are one of the most important sport lesions in several sport activities including soccer, Australian football, track and field, rugby, and in general in all sport activities requiring sprinting and acceleration. However, it is important to distinguish between the lesions of the biceps femoris and semitendinosus and semimembranosus. Indeed, three muscles representing the hamstring complex have a very different injury etiology and consequently require different prevention strategies. This fact may explain, at least in part, the high incidence of reinjuries. In soccer, hamstring injuries cause an important rate of time loss (i.e., in average 15–21 matches missed per club per season). The hamstring injury risk factors may be subdivided in three categories: “primary injury risk factors” (i.e., the risk factors mainly causing a first lesion), “recurrent injury risk factors” (i.e., the risk that can cause a reinjury), and bivalent injury risk factors” (i.e., the risk factors that can cause both primary injuries and reinjuries). The high incidence of hamstring lesions caused consequently an important increase in hamstring injury research. However, although the prevention has increased paradoxically, epidemiological data do not show a loss in injuries and/or reinjuries but, on the contrary, they show an increase in hamstring injuries. This apparent paradox highlights the importance both of the improvement in the prevention programs quality and the criteria for return to play after hamstring injury.

Ten-year nationwide review of netball ankle and knee injuries in New Zealand

OBJECTIVES

To review netball ankle and knee injuries between 2008 and 2017.

DESIGN

Audit of insurance injury claims.

METHODS

Data were divided into 5 equal year groups (2008/9, 2010/11, 2012/13, 2014/15, 2016/17), and 3 age groups (10 to 14 years, 15 to 19 years, 20 to 24 years old). Raw injury counts and injury rates per 1000 affiliated players were reported. Changes in injury rates over the 10-year period and differences between age groups were expressed as Incident rate ratios (IRRs). A Shewhart control chart was created to identify monthly injury patterns.

RESULTS

10-14-year-olds showed the biggest increase in injury counts (ankle 84% increase and knee 133% increase). 20-24-year-olds had the highest mean injury rate over the ten-years (ankle = 77.8, knee = 71.6 injuries/1000 players). 10-14-year-olds had the biggest increase in risk of injury between 2008/09 to 2016/17, (ankle IRR = 2.0; knee IRR = 2.5), 15-19-year-olds (ankle IRR = 1.4; knee IRR = 1.5), 20-24 year olds (ankle IRR = 0.5; knee IRR = 1.9). The older two groups had a significantly higher mean risk of ankle and knee injury (IRR = 1.9 to 2.2; p < 0.001). Higher than expected yearly injury incidence was repeatedly seen in 10-19-year-olds.

CONCLUSION

Ankle and Knee injuries have increased with the biggest increase in 10-19-year-olds. Injuries in 20-24-year-olds still represent the highest cost and continue at a higher rate than in younger players. Spikes in injury are likely associated with intense periods of trialling and tournament play.

The association between genu recurvatum angle and the strength of the hip and knee muscles in standing workers

BACKGROUND

Increased genu recurvatum (GR) angle is a risk factor for knee injury. Identification of factors causing GR is important for the prevention and rehabilitation of GR. Few studies have investigated the association between muscle strength and GR.

OBJECTIVE

To examine the association between GR angle and hip and knee muscle strength in standing workersMETHODS:The participants in this study were 110 healthy volunteers (59 male, 51 female) who performed standing work in a theme park. The GR angle, muscle strength, and strength ratio of the lower extremities were measured to determine their associations with GR. The GR angle was measured using a Smart KEMA motion sensor, and muscle strength was assessed using a Smart KEMA strength sensor. Stepwise multiple regression models were used to investigate which muscles contributed most to the extent of the GR angle.

RESULTS

Stepwise multiple regression analysis showed that the decreased hip external rotator to hip internal rotator ratio, increased knee extensor to knee flexor ratio, and young age were associated with an increased GR angle.

CONCLUSIONS

Many factors are known to increase the GR angle. However, this study investigated the roles of only hip and knee muscle strength. The results suggest that muscle strength ratios are more important than the weakness of any muscle.

Previous and current injury and not training and competition factors were associated with future injury prevalence across a season in adolescent elite athletes

INTRODUCTION

Understanding the factors associated with different injury prevalence profiles in young athletes is needed for the design of tailored injury prevention programs.

OBJECTIVES

To explore the factors associated with different levels of injury prevalence in adolescent elite athletes.

METHODS

A total of 389 adolescent elite athletes (age range 15-19 years), participating in 16 different sports, were monitored repeatedly over 52 weeks using the Oslo Sports Trauma Research Center Overuse Injury Questionnaire. The athletes were grouped in three injury categories: (1) "Low injury"; (2) "Medium injury"; and (3) "High injury," based on the proportion of times the athletes reported substantial injury over the season.

RESULTS

Logistic and multinomial regression identified substantial injury the first week (odds ratio (OR) 53.9, 95% confidence interval (CI) 7.1-407.7), and an interaction between sex and previous injury (OR 3.9, 95% CI 1.1-12.4) as significant factors that increased the odds of belonging in the High injury compared to the Low injury group. A female athlete with a previous injury the last 12 months had a higher probability of belonging in the High injury group compared to a male athlete.No significant (p > .05) difference in training, sleep, or competition exposure was found across the injury category.

CONCLUSION

Current substantial injury and previous injury were strongly associated with the most injured athletes. Coaches and medical team should consider limiting the injured athlete competition exposure.

Foot impairments contribute to functional limitation in individuals with ankle sprain and chronic ankle instability

PURPOSE

To investigate the clinical measures of foot posture and morphology, multisegmented joint motion and play, strength, and dynamic balance in recreationally active young adults with and without a history of a lateral ankle sprain (LAS), copers, and chronic ankle instability (CAI).

METHODS

Eighty recreationally active individuals (healthy: n = 22, coper: n = 21, LAS: n = 17, CAI: n = 20) were included. Foot posture index (FPI), morphologic measures, joint motion (weight-bearing dorsiflexion (WBDF), rearfoot dorsiflexion, plantar flexion, inversion, eversion; forefoot inversion, eversion; hallux flexion, extension), joint play (proximal and distal tibiofibular; talocrural and subtalar, forefoot; 1st tarsometatarsal and metatarsophalangeal), strength (dorsiflexion, plantar flexion, inversion, eversion, hallux flexion, lesser toe flexion), and Star Excursion Balance Test (SEBT) (anterior, posteromedial, posterolateral) were assessed.

RESULTS

There were no group differences in FPI or morphological measures. LAS and CAI groups had decreased ankle dorsiflexion (p = 0.001) and greater frontal plane motion (p < 0.001), first MT plantar flexion, and sagittal excursion (p < 0.001); increased talocrural glide (p = 0.02) and internal rotation (p < 0.001) and decreased forefoot inversion joint play (p < 0.001); and decreased strength in all measures (p < 0.001) except dorsiflexion compared to healthy controls. The LAS group also demonstrated decreased distal tibiofibular (p = 0.04) and forefoot general laxity (p = 0.05) and SEBT performance (anterior: p = 0.02; posteromedial: p < 0.001; posterolateral: p < 0.001).

CONCLUSION

Individuals with LAS or CAI have increased pain, impaired physiologic and accessory joint motion, ligamentous tenderness, and strength in the foot and ankle. Clinicians should assess the multiple segments of the ankle-foot complex when caring for individuals with an LAS or CAI.

LEVEL OF EVIDENCE

II.

The effect of soft tissue manipulation and rest on knee extensor muscles fatigue: Do torque parameters and induced perception following muscle fatigue have enough reliability?

Background:

Muscle fatigue affects the precision of the subjects’ performance and limits the range of physical and sports activities. There is limited scientific evidence to support the use of soft tissue manipulation for enhancing muscle performance and its recovery. The aim of this study is to compare the effects of soft tissue manipulation and rest on the knee extensor muscle fatigue after maximal isokinetic contractions.

Methods:

Fifteen healthy females 20–30 years of age were selected for this research. This study implemented a semi-experimental test–retest measurement method. The subjects then either rested or received soft tissue manipulation on the knee extensors for a duration of 15 min. After intervention (soft tissue manipulation or rest), the parameters were evaluated for the third time.

Results:

The stability of the average of peak torque (APT), average power (AP), and visual analog scale (VAS) before performing fatigue protocol was 85%, 83%, and 31.9%, respectively. The stability after fatigue was 43%, 50%, and 93%, respectively. After maximal fatigue and a decrease in torque output to below 50% maximal torque, 15 min of soft tissue manipulation could change the APT after fatigue from a mean of 58.3 (nm) to 91.5 (nm), the AP from 39.4 to 63.6 (nm/s), and the VAS, from 90.0 to 12 (mm). But 15 min of rest could change the APT from 52.5 to 68.1 (nm), the AP from 37.6 to 48 (nm/s), and the VAS from 90.0 to 27.3 (mm).

Conclusion:

The study showed that soft tissue manipulation was more effective than rest as a strategy to return muscles to a normal state and caused more relief in perceived fatigue.

Making football safer for women: a systematic review and meta-analysis of injury prevention programmes in 11 773 female football (soccer) players

Objective

To evaluate the effects of injury prevention programmes on injury incidence in any women’s football code; explore relationships between training components and injury risk; and report injury incidence for women’s football.

Design

Systematic review and meta-analysis.

Data sources

Nine databases searched in August 2019.

Eligibility criteria

Randomised controlled trials evaluating any injury prevention programme (eg, exercise, education, braces) were included. Study inclusion criteria were: ≥20 female football players in each study arm (any age, football code or participation level) and injury incidence reporting.

Results

Twelve studies, all in soccer, met inclusion criteria, with nine involving adolescent teams (aged <18 years). All studies (except one) had a high risk of bias. Eleven studies examined exercise-based programmes, with most (9/11) including multiple (≥2) training components (eg, strength, plyometric, balance exercises). Multicomponent exercise programmes reduced overall (any reported) injuries (incidence rate ratio (IRR) 0.73, 95% CI 0.59 to 0.91) and ACL injuries (IRR 0.55, 95% CI 0.32 to 0.92). For exercise-based strategies (single-component and multicomponent), hamstring injuries were also reduced (IRR 0.40, 95% CI 0.17 to 0.95). While exercise-based strategies resulted in less knee, ankle and hip/groin injuries, and the use of multiple training components was associated with greater reductions in overall and knee injuries, further studies would be required to increase the precision of these results. The incidence of overall injuries in women’s football was 3.4 per 1000 exposure hours; with ankle injuries most common.

Conclusion

In women’s football, there is low-level evidence that multicomponent, exercise-based programmes reduce overall and ACL injuries by 27% and 45%, respectively.

PROSPERO registration number

CRD42018093527.

Leg Dominance Effects on Postural Control When Performing Challenging Balance Exercises

Leg dominance reflects the preferential use of one leg over another and is typically attributed to asymmetries in the neural circuitry. Detecting leg dominance effects on motor behavior, particularly during balancing exercises, has proven difficult. The current study applied a principal component analysis (PCA) on kinematic data, to assess bilateral asymmetry on the coordinative structure (hypothesis H1) or on the control characteristics of specific movement components (hypothesis H2). Marker-based motion tracking was performed on 26 healthy adults (aged 25.3 ± 4.1 years), who stood unipedally on a multiaxial unstable board, in a randomized order, on their dominant and non-dominant leg. Leg dominance was defined as the kicking leg. PCA was performed to determine patterns of correlated segment movements ("principal movements" PMks). The control of each PMk was characterized by assessing its acceleration (second-time derivative). Results were inconclusive regarding a leg-dominance effect on the coordinative structure of balancing movements (H1 inconclusive); however, different control (p = 0.005) was observed in PM3, representing a diagonal plane movement component (H2 was supported). These findings supported that leg dominance effects should be considered when assessing or training lower-limb neuromuscular control and suggest that specific attention should be given to diagonal plane movements.

Anthropometric, Body Composition, and Morphological Lower Limb Asymmetries in Elite Soccer Players: A Prospective Cohort Study

The aim of this study was to identify and compare parameters related to anthropometry, body composition (BC), and morphological asymmetry in elite soccer players in nine age categories at the same soccer club (n = 355). We used a bio-impedance analyzer to measure the following indicators of BC: body height (BH); body mass (BM); relative fat-free mass (FFMr); percentage of fat mass (FM); and bilateral muscle mass differences in the lower extremities (BLD∆). Age showed a significant influence on all parameters observed (F_64,1962 = 9.99, p = 0.00, λ = 14.75, η²_p = 0.25). Adolescent players (from U16 through adults) had lower FM values (<10%) compared to players in the U12-U15 categories (>10%). The highest FFMr was observed in the U18 category. Players in the U12 and U13 categories showed more homogenous values compared to older players. With increasing age, significantly higher FFMr was observed in the lower extremities. An inter-limb comparison of the lower extremities showed significant differences in the U17 category (t₂₇ = 2.77, p = 0.01) and in adult players (t₆₈ = 5.02, p = 0.00). Our results suggest that the end of height growth occurs around the age of 16 years, while weight continues to increase until 20 years. This increase is not linked to decreasing FM, nor to the FFMr, which remains stable. We found morphological asymmetries between limbs in players of the U17 category and in adult players.

Epidemiology of injuries among U18, U19, U21 and senior elite netball players

Background

Despite a substantial body of literature on injuries among elite netball players in South Africa, no study reports on the timing and type of injuries and the reason for injuries.

Objective

To determine the epidemiology of injuries in U18, U19, U21 and senior netball players in the Free State (FS), South Africa, over two consecutive netball seasons (2017/2018).

Methods

An injury questionnaire was used to collect data on 96 eligible players.

Results

A total of 48 injuries were reported. The profile of injuries revealed that 58% (n=28) of the injuries occurred during matches, 29% (n=14) during practice and 13% (n=6) during preseason training. Acute injuries accounted for 54% (n=26) of the total, while 46% (n=22) were overuse injuries. A third of all the injuries were re-injuries. The centre (C) position had the highest incidence of injuries in players (n=14; 29%). The ankle was the most frequently injured body part (n=18; 36%), followed by the lower leg and Achilles tendon (n=6; 13%) thus largely the ligaments and muscles. The overall incidence rate of injuries during match play was 33.9 injuries per 1 000 hours of match play.

Conclusion

Preventative strategies should consist of ankle and lower leg strengthening and neuromuscular balance techniques. The focus should be on correct landing techniques, results of abrupt change of direction movements and short bursts of speed.

The Association between Increased Body Mass Index and Overuse Injuries in Israel Defense Forces Conscripts

OBJECTIVES

To examine the association between body mass index (BMI) and overuse injuries (OI) among Israel Defense Forces soldiers, in different corps.

METHODS

Conscripts between 2003 and 2012, infantry, armored corps and intelligence corps (controls) were studied. OI data were taken from computerized patient records. The BMI was classified as underweight, low-normal (18.5-21.9), high-normal (22-24.9), overweight and obese. Multivariate analysis was performed using logistic regression.

RESULTS

There were 73,640 soldiers: 42,506 infantry, 20,781 armor and 10,353 intelligence. OI rates were 52.2, 51.6 and 27%, respectively. OI rate was directly proportional to BMI in all groups (relative risk compared to low-normal, underweight: 0.97, high-normal: 1.05, overweight: 1.11, obese: 1.19, p < 0.05 for all), increased height and younger age. By logistic regression, OI were significantly associated with training group, higher BMI, increased height, younger age, lower education, lower socioeconomic status and lower psychotechnical grading. Throughout the BMI range, each additional unit of BMI was associated with a 2% OI increase.

CONCLUSIONS

Higher BMI was associated with a higher rate of OI in all groups. Therefore there is no point in differentially assigning recruits based on BMI.

Dynamic balance and ankle injury odds: a prospective study in 196 Dutch physical education teacher education students

OBJECTIVE

The aim of this study was to investigate whether dynamic balance, measured with the anterior component of the Star Excursion Balance Test (SEBT-ANT), is a risk factor for ankle injuries in physical education teacher education (PETE) students.

DESIGN AND SETTING

A prospective monocentre study in first-year PETE students.

PARTICIPANTS

A total of 196 subjects, of which 137 men (70%) and 59 women (30%).

OUTCOME MEASURES

This study consisted of measures of the SEBT-ANT at baseline (September 2015) and an injury registration procedure during a follow-up period (September 2015-June 2016). The association between the SEBT-ANT score and subsequent ankle injury was analysed with generalised estimating equations analysis at the leg level.

RESULTS

Men and women had an average SEBT-ANT score of, respectively, 65.1% and 67.7% of leg length. In 20 (15%) subjects, the first injured body site involved the ankle. Across all participants, a below average SEBT-ANT score was not associated with increased ankle injury odds (OR OR=2.43, 95% CI: 0.94 to 6.29, p=0.07). In men, a below average SEBT-ANT score indicated sevenfold increased odds for ankle injury (OR=7.06, 95% CI: 1.43 to 34.92, p=0.02). In women, this relationship was not significant (OR=0.72, 95% CI: 0.19 to 2.71, p=0.62).

CONCLUSIONS

Below average normalised SEBT-ANT scores were associated with sevenfold likelihood for ankle injuries in men. In contrast, no relationship was found for the SEBT-ANT score and ankle injuries in woman. These results may provide directions for the implementation of screening tools, as part of an injury prevention programme, to identify male PETE students with an increased likelihood for ankle injuries.

ANALYSIS OF Y BALANCE TEST AND DORSIFLEXION LUNGE TEST IN PROFESSIONAL AND AMATEUR SOCCER PLAYERS

ABSTRACT Introduction The ankle has the highest incidence of soccer injuries (17 to 20% of injuries), which can cause personal and professional losses for the athlete. Ankle stability is due to a number of mechanisms, such as muscle control between agonists and antagonists, proprioception, balance, and muscle strength. If there are changes in any of these mechanisms, there is an increased risk of ankle injuries. Objective The purpose of this study was to analyze the ankle function of amateur and professional soccer players in the preseason, using Y Balance Test (YBT) and Dorsiflexion Lunge Test (DLT), observing possible functional deficits in this sample, and subsequently analyzing the relationship of results between the functional tests in this population. Methods A total of 107 soccer players were assessed, of whom 36 were amateur and 71 professional athletes. The volunteers initially underwent history taking, followed by a 5-minute warm-up on a stationary bicycle then the YBT and DLT functional tests. Results There was no significant difference in the DLT between dominant and non-dominant limbs in amateur and professional athletes. There was also no significant difference in the YBT between dominant and non-dominant limbs of amateur athletes, but there was a significant difference between dominant and non-dominant limbs in professional athletes. There was no correlation between the tests when the dominant and non-dominant limbs of the sample were analyzed. Conclusion The weak relationship between the functional tests indicates that both tests are recommended for athletes in clinical practice, since they serve as tools to assess different functional deficits. Level of Evidence III - Case-control study.

Italian consensus statement (2020) on return to play after lower limb muscle injury in football (soccer)

Return to play (RTP) decisions in football are currently based on expert opinion. No consensus guideline has been published to demonstrate an evidence-based decision-making process in football (soccer). Our aim was to provide a framework for evidence-based decision-making in RTP following lower limb muscle injuries sustained in football. A 1-day consensus meeting was held in Milan, on 31 August 2018, involving 66 national and international experts from various academic backgrounds. A narrative review of the current evidence for RTP decision-making in football was provided to delegates. Assembled experts came to a consensus on the best practice for managing RTP following lower limb muscle injuries via the Delphi process. Consensus was reached on (1) the definitions of 'return to training' and 'return to play' in football. We agreed on 'return to training' and RTP in football, the appropriate use of clinical and imaging assessments, and laboratory and field tests for return to training following lower limb muscle injury, and identified objective criteria for RTP based on global positioning system technology. Level of evidence IV, grade of recommendation D.

Automatic segmentation of all lower limb muscles from high-resolution magnetic resonance imaging using a cascaded three-dimensional deep convolutional neural network

High-resolution magnetic resonance imaging with fat suppression can obtain accurate anatomical information of all 35 lower limb muscles and individual segmentation can facilitate quantitative analysis. However, due to limited contrast and edge information, automatic segmentation of the muscles is very challenging, especially for athletes whose muscles are all well developed and more compact than the average population. Deep convolutional neural network (DCNN)-based segmentation methods showed great promise in many clinical applications, however, a direct adoption of DCNN to lower limb muscle segmentation is challenged by the large three-dimensional (3-D) image size and lack of the direct usage of muscle location information. We developed a cascaded 3-D DCNN model with the first step to localize each muscle using low-resolution images and the second step to segment it using cropped high-resolution images with individually trained networks. The workflow was optimized to account for different characteristics of each muscle for improved accuracy and reduced training and testing time. A testing augmentation technique was proposed to smooth the segmentation contours. The segmentation performance of 14 muscles was within interobserver variability and 21 were slightly worse than humans.

Is a low Functional Movement Screen score (≤14/21) associated with injuries in sport? A systematic review and meta-analysis

Objective

To assess whether Functional Movement Screen (FMS) score is associated with subsequent injuries in healthy sportspeople.

Design

Systematic review and meta-analysis.

Data sources

The following electronic databases were searched to December 2017: Medline, PubMed, PsycINFO, SPORTDiscus, Cumulative Index of Nursing and Allied Health Literature, Scopus, Embase, and Physiotherapy Evidence Database.

Eligibility criteria for selecting studies

Eligibility criteria included (1) prospective cohort studies that examined the association between FMS score (≤14/21) and subsequent injuries, (2) a sample of healthy and active participants without restrictions in gender or age, and (3) the OR was the effect size and the main outcome.

Results

Thirteen studies met the criteria for the systematic review and 12 were included in the meta-analysis. In 5 of the 12 studies, and among female athletes in 1 study, FMS score ≤14 out of 21 points was associated with subsequent injuries. The overall OR of the selected studies in the meta-analysis was 1.86 (95% CI 1.32 to 2.61) and showed substantial heterogeneity (I²=70%).

Summary/Conclusion

Whether or not a low FMS score ≤14 out of 21 points is associated with increased risk of injury is unclear. The heterogeneity of the study populations (type of athletes, age and sport exposure) and the definition of injury used in the studies make it difficult to synthesise the evidence and draw definitive conclusions.

Trial registration number

CRD42015015579.

Pressure pain sensitivity over nerve trunk areas and physical performance in amateur male soccer players with and without chronic ankle instability

OBJECTIVE

Chronic ankle instability (CAI) is reported after ankle sprain. Our aim was to assess differences in mechanical pain sensitivity of lower extremity nerve trunks and physical performance between amateur soccer players with and without CAI.

DESIGN

A cross-sectional case-control study.

SETTING

Amateur soccer teams.

PARTICIPANTS

Fifty-five male soccer players, 28 with and 27 without CAI participated.

MAIN OUTCOME MEASURES

The perceived instability was assessed with the Cumberland Ankle Instability Tool (CAIT). Pressure pain thresholds (PPTs) on the common peroneal and tibialis nerve trunks, vertical jump, lateral step-down test and joint position sense of the knee were assessed by a blinded assessor.

RESULTS

Soccer players with CAI showed lower PPTs over the common peroneal nerve than those without CAI (between-groups mean difference: 1.0 ± 0.8 kg/cm², P < 0.001). No differences for PPT over the tibialis posterior (P = 0.078) or any physical performance outcome (knee joint positioning sense [P = 0.798], lateral step-down test [P = 0.580] and vertical jump variables [all, P > 0.310]) were found. PPT over the common peroneal nerve exhibited a significant moderate correlation with the CAIT score (r = 0.528, P < 0.001).

CONCLUSION

Amateur soccer players with CAI have higher pressure pain sensitivity over the common peroneal nerve but exhibit similar physical performance to amateur soccer players without CAI.

Frequency and associated factors of poor knee alignment in young Brazilian volleyball players

Objectives: Poor knee alignment during the deceleration phase of closed kinetic chain movements, such as landings, is a relevant risk factor for injuries in sports. This study assessed the knee alignment and possible associated factors in young Brazilian volleyball athletes Methods: One hundred and seventeen athletes of both genders (9-19 years old) were assessed during a drop jump for the observation of knee alignment. Chi-square test was used to describe the association between poor knee alignment and: gender, age category (≤14 years and ≥15 years), sports experience, participation in competitions, the presence of knee pain during training, and history of lower limb injury Results: Seventy percent of athletes presented poor knee alignment, which was slightly associated with a sports experience lower than one year. Conclusion: Thus, considering the high number of volleyball practitioners and its strong presence in physical education classes, preventive measures should be adopted for young volleyball athletes of both genders, especially in the sports initiation phase.

The effects of wearing an Ankle Stabilizing Orthosis (ASO) Ankle Brace on ankle joints kinetics and kinematics during a basketball rebounding task

Following an ankle injury, athletes sometimes brace the injured ankle in hopes of minimizing the likelihood of suffering a recurring injury. This study aims to evaluate the effects of wearing an Ankle Stabilizing Orthosis (ASO) ankle brace unilaterally on the dominant side on bilateral ankle joint kinetics and kinematics and peroneus longus EMG activity. Since a significant proportion of ankle injuries in basketball occur during rebounding, data was collected during a simulated rebounding task. Rebounding is defined as the act of retrieving a missed shot attempt. Subjects oftentimes jump vertically to acquire the basketball as it rebounds from the backboard or rim. Sixteen subjects participated in the study (11 males, 5 females; mean age = 26.94 years, SD = 5.32; mean height 1.72 m, SD = 0.08; mean weight 73.95 kg, SD = 13.68). Participants completed the rebounding task in braced (ASO) and unbraced (UB) conditions. Ankle and foot inversion angles, ankle inversion moments and peroneus longus EMG activity were recorded and analysed to determine the effects of wearing an ankle brace unilaterally. In the dominant limb, when compared to UB, ASO reduced ankle and foot inversion, and increased ankle inversion moments. No significant differences were observed in peroneus longus EMG activity. In the non-dominant limb, no significant differences were observed for any of the parameters. These results suggest that wearing an ASO ankle brace on the dominant ankle reduces maximum ankle and foot inversion angles without posing an increased risk to the unbraced leg. However, the increased ankle inversion moments in the braced ankle suggest that there are adjustments regarding force distribution, perhaps due to the restricted range of motion.

Posture of rugby league players and its relationship to non-contact lower limb injury: A prospective cohort study

OBJECTIVE

This study aimed to identify posture deviations in rugby league players, and to observe relationships between posture and the incidence of non-contact lower limb injury.

DESIGN

Prospective cohort.

SETTING

Laboratory and on-field.

PARTICIPANTS

Junior representative, semi-professional and professional rugby league players (n = 207).

MAIN OUTCOME MEASURES

Static posture scores from photographs (Watson and MacDonncha tool) in pre-season; non-contact lower limb injury surveillance and exposure data.

METHODS

Chi-square and logistic regression analyses were used to observe relationships between postural components and the incidence of non-contact lower limb injury.

RESULTS

8.7% of players sustained a quadriceps injury; 7.2% sustained a calf injury. Semi-professional and professional players had the highest injury rates. The most common posture deviations were having a forward shoulder position (46.9%), a forward head position (33.3%), a varus knee interspace (32.9%) or a lumbar lordosis (30.9%). A moderate C-scoliosis deviation was associated with a decrease in injury risk (OR 1.57 95% CI 1.00-2.46 p = 0.052). Included in the model was player weight, which was associated with an increased risk of injury (OR 1.04 95% CI 1.01-1.07 p = 0.010).

CONCLUSIONS

Although postural deviations are common in rugby league players, given the lack of association with injury, they may not warrant intervention.

Evaluation of the Functional Movement Screen and a Novel Basketball Mobility Test as an Injury Prediction Tool for Collegiate Basketball Players

Bond, CW, Dorman, JC, Odney, TO, Roggenbuck, SJ, Young, SW, and Munce, TA. Evaluation of the functional movement screen and a novel basketball mobility test as an injury prediction tool for collegiate basketball players. J Strength Cond Res 33(6): 1590-1601, 2019-Identifying injury risk and implementing preventive measures can assist in reducing injury occurrence and may ultimately improve athletic performance. Improper movement patterns often contribute to musculoskeletal (MSK) injuries. The validity of the Functional Movement Screen (FMS) as an injury prediction tool for athletes remains unclear. We designed the Basketball-Specific Mobility Test (BMT) to represent the neuromuscular demands of basketball and identify deficiencies that may be indicative of greater MSK injury risk while playing this sport. The aim of this study was to examine the association of FMS and BMT scores with injury occurrence in collegiate basketball players. We hypothesized that the BMT would be a better predictor of injury risk than the FMS, and that scores from both tests would have a higher association with severe MSK injuries than minor, non-MSK injuries. One-hundred nineteen male and female collegiate basketball players from 4 Upper Midwest universities were assessed preseason (PRE) and postseason (POST) using the FMS and BMT. In-season injury records were collected from the schools' athletic trainers and were classified by type and severity. During the season, 56 of 119 players were injured, resulting in 96 total injuries. Injured athletes' PRE FMS scores demonstrated negligible effects compared with uninjured athletes' PRE scores (d < 0.20), whereas some BMT scores showed potentially meaningful effects (d > 0.20). Although specificity of the FMS and BMT to predict injury was relatively high (FMS 85.7-87.6; BMT 42.0-88.0), sensitivity (FMS 14.2-22.7; BMT 11.6-39.1), odds ratios (FMS 1.00-2.08; BMT 0.47-1.06), and injury prediction capacities (area under the curve; FMS 0.43-0.49; BMT 0.49-0.59) of the tests were low. Although the FMS and BMT may be suitable for identifying MSK deficiencies, they do not accurately determine injury risk in collegiate basketball players. Injury risk assessments may be improved by targeting specific injury mechanisms and the conditions in which they occur.

Effect of Injury Prevention Programs on Lower Extremity Performance in Youth Athletes: A Systematic Review

BACKGROUND

Understanding how existing youth injury prevention programs affect specific modifiable injury risk factors will inform future program development for youth athletes.

OBJECTIVE

To comprehensively evaluate the effects of injury prevention programs on the modifiable intrinsic risk factors associated with lower extremity performance in youth athletes.

DATA SOURCES

This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A systematic search of the literature was performed using multiple databases (PubMed, EBSCOhost [including CINAHL, Medline, and SPORTDiscus], and PEDro). Secondary references were appraised for relevant articles. Article types included randomized or cluster randomized controlled trials and randomized cohort designs with youth athletes engaged in organized sports, along with outcomes that included at least 1 physical performance outcome measure.

STUDY SELECTION

Eight studies met inclusion and exclusion criteria and were reviewed by 2 independent reviewers, with a third consulted in the case of disagreement, which was not needed.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 3.

DATA EXTRACTION

Included studies underwent review of methodological quality using the Physiotherapy Evidence Database scale.

RESULTS

Studies included mixed-sex samples of youth athletes who predominantly participated in soccer at different skill levels. The FIFA 11+ series was the most commonly used injury prevention program. Among studies, the mean percentage of improvement identified was 11.3% for force generation, 5.7% for coordination, 5.2% for posture, and 5.2% for balance. The lowest mean percentage improvement was in speed (2.2%). Endurance was not significantly affected by any of the programs.

CONCLUSION

This systematic review shows that injury prevention programs improve several modifiable intrinsic risk factors of lower extremity performance among youth athletes, particularly force generation. However, several intrinsic risk factors were either not significantly affected or specifically addressed by existing programs.

Body Composition and Bone Mineral Density of Division 1 Collegiate Football Players: A Consortium of College Athlete Research Study

Bosch, TA, Carbuhn, AF, Stanforth, PR, Oliver, JM, Keller, KA, and Dengel, DR. Body composition and bone mineral density of Division 1 collegiate football players: a consortium of college athlete research study. J Strength Cond Res 33(5): 1339-1346, 2019-The purpose of this study was to generate normative data for total and regional body composition in Division 1 collegiate football players using dual-energy x-ray absorptiometry (DXA) and examine positional differences in total and regional measurements. Data were used from the Consortium of College Athlete Research (C-CAR) group. Four hundred sixty-seven players were included in this study. Height, body mass, total and regional fat mass, lean mass, and bone mineral density were measured in each athlete in the preseason (June-August). Players were categorized by their offensive or defensive position for comparisons. Linemen tended to have the higher fat and lean mass measures (p ≤ 0.05 for all) compared with other positions. Positions that mirror each other (e.g. linemen) had similar body composition and body ratios. All positions were classified as overweight or obese based on body mass index (BMI) (>25 kg·m), yet other than offensive and defensive linemen, all positions had healthy percent body fat (13-20%) and low visceral fat mass (<500 g). The data presented here provide normative positional data for total and regional fat mass, lean mass, and bone density in Division 1 collegiate football players. Player position had a significant effect on body composition measures and is likely associated with on-field positional requirements. From a player's health perspective, although all positions had relatively high BMI values, most positions had relatively low body fat and visceral fat, which is important for the health of players during and after their playing career. The increased accuracy and reliability of DXA provides greater information, regarding positional differences in college football players compared with other methods.

Comparison of 3 ankle braces in reducing ankle inversion in a basketball rebounding task

Lateral ankle injury incidence rates are very high in the sport of basketball, with a significant proportion occurring during rebounding. Ankle braces are often used as preventative and rehabilitative techniques in the hope of minimizing the likelihood of experiencing excessive ankle inversion. This study aims to evaluate the effect of different ankle braces in preventing ankle inversion during a basketball rebounding task. Sixteen subjects participated in the study (11 males, 5 females; mean age = 26.94 years, SD = 5.32; mean height 1.72 m, SD = 0.08; mean weight 73.95 kg, SD = 13.68). Participants performed a simulated rebounding task in multiple braced conditions: unbraced (UB), Ossur Formfit (OF), Talarmade Ankleguard Air/Gel Stirrup (TAG) and Bauerfeind Malleoloc (BF). Ankle and foot inversion angles, ankle inversion moments and peroneus longus EMG activity were recorded and analysed to determine the effectiveness of each condition to resist inversion. All braced conditions reduced ankle and foot inversion angles compared to UB. In the non-dominant limb, OF showed reduced maximum ankle inversion compared to BF (non-dominant mean difference = 0.630°, p < 0.001) and reduced foot inversion compared to TAG (non-dominant mean difference = 0.966°, p = 0.035). Compared to UB, OF and TAG increased ankle inversion moments in the dominant ankle and showed decreases in the non-dominant ankle. BF reduced mean peak peroneus longus EMG activity compared to all other trials. Whilst statistically significant differences that were demonstrated between several braced conditions are relatively small, they are clinically significant knowing that the maximum barefoot inversion whilst standing is less than 17 degrees.

ANKLE SPRAIN RISK FACTORS: A 5-MONTH FOLLOW-UP STUDY IN VOLLEY AND BASKETBALL ATHLETES

ABSTRACT Introduction Ankle sprain is a frequent sports injury among volley and basketball players, and identifying risk factors is necessary to prevent injuries and prolong their careers. Objective To identify intrinsic and extrinsic factors in basketball and volleyball players related to the risk of ankle sprain injury over a five-month follow-up period. Methods Ninety-four Brazilian young competitive athletes (15.8±1.7 years, 47 basketball and 47 volleyball players) participated in this study. They were evaluated for intrinsic risk factors (previous history of ankle sprain, dominant lower limb, ankle ligament laxity, range of motion of the ankle-foot complex, electromyographic response time of ankle evertors, postural control and muscular torque of ankle invertors and evertors) and extrinsic risk factors (type of shoes worn, use of orthosis, previous injuries while training or competing, and the players’ position). Results During the study period, 18 (19%) athletes suffered unilateral sprains. Multivariate logistic regression analysis gave a final regression with four factors: dominant leg (p=0.161), type of shoes worn (p=0.049), player’s position (p=0.153), and peroneus brevis muscle reaction time (p=0.045). There was an 86.1% probability of an ankle sprain if the athlete had a left dominant leg, wore shoes without vibration dampeners, or played in the small forward, wing/hitter spiker, middle blocker, or opposite spiker positions, and had a peroneus muscle reaction time longer than 80ms. However, only the player’s position was significantly (p=0.046) associated with lesion occurrence. Conclusion The player’s position appeared to be a risk factor in both sports, and this result may help professionals to prevent ankle sprains. Level of Evidence I; High quality randomized clinical trial with or without statistically significant difference but with narrow confidence intervals.

Bilateral Strength Asymmetries and Unilateral Strength Imbalance: Predicting Ankle Injury When Considered With Higher Body Mass in US Special Forcesa

CONTEXT

Ankle injury is one of the most common conditions in athletics and military activities. Strength asymmetry (SA) and imbalance may represent a risk factor for injury, but past investigations have produced ambiguous conclusions. Perhaps one explanation for this ambiguity is the fact that these authors used univariate models to predict injury.

OBJECTIVE

To evaluate the predictive utility of SA and imbalance calculations for ankle injury in univariate and multivariate prediction models.

DESIGN

Prospective cohort study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 140 male US Air Force Special Forces.

MAIN OUTCOME MEASURE(S)

Baseline testing consisted of body composition, isometric strength, and aerobic and anaerobic capacity. A clinician conducted medical chart reviews 365 days posttesting to document the incidence of ankle injury. Strength asymmetries were calculated based on the equations most prevalent in the literature along with known physiological predictors of injury in the military: age, height, weight, body composition, and aerobic capacity. Simple logistic regression was conducted using each predictor, and backward stepwise logistic regression was conducted with each equation method and the physiological predictors entered initially into the model.

RESULTS

Strength asymmetry or imbalance or both, as a univariate predictor, was not able to predict ankle injury 365 days posttesting. Body mass (P = .01) and body mass index (P = .01) significantly predicted ankle injury. Strength asymmetry or imbalance or both significantly predicted ankle injury when considered with body mass (P = .002-.008).

CONCLUSIONS

As a univariate predictor, SA did not predict ankle injury. However, SA contributed significantly to predicting ankle injury in a multivariate model using body mass. Interpreting SA and imbalance in the presence of other physiological variables can help elucidate the risk of ankle injury.

Effects of Recent Concussion and Injury History on Instantaneous Relative Risk of Lower Extremity Injury in Division I Collegiate Athletes

BACKGROUND

Growing evidence suggests that concussion increases the risk of lower extremity (LE) musculoskeletal injury. However, it is unclear to how the effect of concussion on LE injury risk may be influenced by previous injuries. This study sought to examine the association between concussion, previous LE injuries, and the risk LE injury to the same previously injured limb (ipsilateral) or the opposite limb (contralateral).

METHODS

This retrospective study examined medical records from 110 concussed athletes and 110 matched controls for LE injuries in the 365 days before and after the concussion event. The effect of concussion on time to injury was assessed with a Cox proportional hazard model after adjusting for injury history. Fine and Gray subdistribution models assessed the cumulative risk of ipsilateral and contralateral injury by group.

RESULTS

Concussion was associated with an increased instantaneous relative risk of LE injury when adjusting for LE injury history [hazard ratio (HR) = 1.67, 95% confidence interval (CI) = 1.11-2.53], agreeing with previous results. Among individuals who had a history of LE injuries before the concussion event, a nonsignificant yet moderate effect of concussion on the instantaneous relative risk of ipsilateral injuries was found after adjusting for the competing risk of contralateral injuries and censored values (HR = 1.85, 95% CI = 0.76-4.46).

CONCLUSIONS

This study provides independent confirmation of previous studies, reporting an association between concussion and LE injury risk. Furthermore, this study suggests that future large-scale studies should consider the competing risk of ipsilateral, contralateral, and new injuries in populations with an injury history.

In vivo arthrometer measurements of mechanical ankle instability-A systematic review

Chronic ankle instability is caused by functional and/or mechanical deficits. To differentiate the two entities, mechanical ankle instability can be assessed using arthrometers. The measurement of mechanical instability is essential, since it can only be addressed surgically. The aim of this systematic literature review was to find out whether chronic mechanical ankle instability could be adequately and objectively assessed using in vivo arthrometer measurements. Articles were included if the main focus was to evaluate the contribution of mechanical deficits to chronic ankle instability and if they provided sufficient description of the device used. This systematic review was performed according to the PRISMA-recommendations. Initially 47 articles were screened for eligibility, of which 33 studies reporting 10 different devices were included. While the reliability of the measurements was mostly good to excellent, only two studies aimed to assess the sensitivity and specificity of their results in regard to chronic ankle instability. Several devices reported conflicting results about mechanical deficits. In summary, this systematic review reveals a substantial deficit in diagnostic accuracy when assessing mechanical ankle instability in a clinical setting. Biases in recruiting and classification of participants raise the question whether the two entities of functional and mechanical ankle instability are properly defined. Clinical Significance: In recent years, this may have led to a misinterpretation of mechanical deficits and the subsequent need for surgical intervention. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Gender Disparities Within US Army Orthopedic Surgery: A Preliminary Report

INTRODUCTION

Women account for approximately 15% of the active duty US Army, and studies show that women may be at an increased risk of musculoskeletal injury during sport and military training. Nationally, the field of orthopedic surgery comprises 14% women, lagging behind other surgical fields. Demographics for US Military orthopedic surgeons are not readily available. Similarly, demographic data of graduating medical students entering Military Medicine are not reported. We hypothesize that a gender disparity within military orthopedics will be apparent. We will compare the demographic profile of providers to our patients and hypothesize that the two groups are dissimilar. Secondarily, we examine the demographics of military medical students potentially entering orthopedics from the Uniformed Services University of the Health Sciences (USUHS) or the Health Professions Scholarship Program.

METHODS

A census was formed of all US Army active duty orthopedic surgeons to include staff surgeons and residents, as well as US Army medical student graduates and orthopedic patients.

RESULTS

There are 252 Army orthopedic surgeons and trainees; 26 (10.3%) are women and 226 (89.7%) are men. There were no significant demographic differences between residents and staff. Between 2014 and 2017, the 672 members of the USUHS graduating classes included 246 Army graduates. Of those, 62 (25%) were female. Army Health Professions Scholarship Program graduated 1,072 medical students, with women comprising 300 (28%) of the group. No statistical trends were seen over the 4 yr at USUHS or in Health Professions Scholarship Program. In total, 2,993 orthopedic clinic visits during the study period were by Army service members, 23.6% were women.

CONCLUSION

There exists a gender disparity among US Army orthopedic surgeons, similar to that seen in civilian orthopedics. Gender equity is also lacking among medical students who feed into Army graduate medical education programs. The gender profile of our patient population is not reflected by that of providers. Because patients prefer providers of the same gender, this is a limitation to patient satisfaction and access to care for musculoskeletal injuries. Further study is underway to identify perceptions and potential causes of these disparities, including the critical perspective of our patients. In addition to the inherent benefits offered by diversity (e.g., expanding the talent pool and more perspectives for decision-making), ultimately it affords a greater ability to maintain a fit and ready force.

Context Matters: Revisiting the First Step of the 'Sequence of Prevention' of Sports Injuries

It is possible to prevent sports injuries. Unfortunately, the demonstrated efficacy and effectiveness of injury prevention approaches are not translated into lasting real-world effects. Contemporary views in sports medicine and injury prevention suggest that sports injuries are ‘complex’ phenomena. If the problem we aim to prevent is complex, then the first step in the ‘sequence of prevention’ that defines the ‘injury problem’ already needs to have considered this. The purpose of this paper is to revisit the first step of the ‘sequence of prevention’, and to explore new perspectives that acknowledge the complexity of the sports injury problem. First, this paper provides a retrospective of the ‘sequence of prevention’, acknowledging contemporary views on sports injuries and their prevention. Thereafter, from the perspective of the socioecological model, we demonstrate the need for taking into account the complex nature of sports injuries in the first step. Finally, we propose an alternative approach to explore and understand injury context through qualitative research methods. A better understanding of the injury problem in context will guide more context-sensitive studies, thus providing a new perspective for sports injury prevention research.

Ankle Sprain Has Higher Occurrence During the Latter Parts of Matches: Systematic Review With Meta-Analysis

Context: Ankle sprains are common injuries in sports, but it is unclear whether they are more likely to occur in a specific period of a sporting game. Objective: To systematically review the literature investigating when in a match ankle sprains most likely occurred. Evidence Acquisition: The databases CINAHL, EMBASE, MEDLINE, and SPORTDiscus were searched up to August 2016, with no restriction of date or language. The search targeted studies that presented data on the time of occurrence of ankle sprains during sports matches. Data from included studies were analyzed as a percentage of ankle sprain occurrence by halftime and by quarters. Meta-analyses were run using a random effects model. The quality assessment tool for quantitative studies was used to assess the article's quality. Evidence Synthesis: The searches identified 1142 studies, and 8 were included in this review. A total of 500 ankle sprains were reported during follow-up time, which ranged from 1 to 15 years, in 5 different sports (soccer, rugby, futsal, American football, and Gaelic football). The meta-analyses, including all 8 studies, showed that the proportion of ankle sprains during the first half (0.44; 95% confidence interval [CI], 0.38-0.50) was smaller than the second half (0.56; 95% CI, 0.50-0.62). For the analyses by quarters, the proportion of ankle sprains in the first quarter (0.14; 95% CI, 0.09-0.19) was considerably smaller than the second (0.28; 95% CI, 0.24-0.32), third (0.25; 95% CI, 0.17-0.34), and fourth (0.29; 95% CI, 0.22-0.36) quarters. Conclusion: The results of this review indicate that ankle sprains are more likely to occur later in the game during the second half or during the latter minutes of the first half.

Clinical Measures and Their Contribution to Dysfunction in Individuals With Patellar Tendinopathy

CONTEXT

Patellar tendinopathy (PT) is prevalent in physically active populations, and it affects their quality of living, performance of activity, and may contribute to the early cessation of their athletic careers. A number of previous studies have identified contributing factors for PT; however, their contributions to self-reported dysfunction remain unclear.

OBJECTIVE

The purpose of this investigation was to determine if strength, flexibility, and various lower-extremity static alignments contributed to self-reported function and influence the severity of PT.

DESIGN

Cross-sectional research design.

SETTING

University laboratory.

PARTICIPANTS

A total of 30 participants with PT volunteered for this study (age: 23.4 [3.6] y, height: 1.8 [0.1] m, mass: 80.0 [20.3] kg, body mass index: 25.7 [4.3]).

MAIN OUTCOME MEASURES

Participants completed 7 different patient-reported outcomes. Isometric knee extension and flexion strength, hamstring flexibility and alignment measures of rearfoot angle, navicular drop, tibial torsion, q-angle, genu recurvatum, pelvic tilt, and leg length differences were assessed. Pearson's correlation coefficients were assessed to determine significantly correlated outcome variables with each of the patient-reported outcomes. The factors with the highest correlations were used to identify factors that contribute the most to pain and dysfunction using backward selection, linear regression models.

RESULTS

Correlation analysis found significant relationships between questionnaires and body mass index (r = -.35-.46), normalized knee extension (r = .38-.50) and flexion strength (r = -.34-.50), flexibility (r = .32-.38, q-angle (r = .38-.56), and pelvic tilt (r = -.40). Regression models (R² = .22-.54) identified thigh musculature strength and supine q-angle to have greatest predictability for severity in patient-reported outcomes.

CONCLUSIONS

These findings put an emphasis of bodyweight management, improving knee extensor and flexor strength, and posterior flexibility in PT patients.

Artificial intelligence and machine learning | applications in musculoskeletal physiotherapy

INTRODUCTION

Artificial intelligence (AI) is a field of mathematical engineering which has potential to enhance healthcare through new care delivery strategies, informed decision making and facilitation of patient engagement. Machine learning (ML) is a form of narrow artificial intelligence which can be used to automate decision making and make predictions based upon patient data.

PURPOSE

This review outlines key applications of supervised and unsupervised machine learning in musculoskeletal medicine; such as diagnostic imaging, patient measurement data, and clinical decision support. The current literature base is examined to identify areas where ML performs equal to or more accurately than human levels.

IMPLICATIONS

Potential is apparent for intelligent machines to enhance various areas of physiotherapy practice through automization of tasks which involve data analysis, classification and prediction. Changes to service provision through applications of ML, should encourage physiotherapists to increase their awareness of and experiences with emerging technologies. Data literacy should be a component of professional development plans to assist physiotherapists in the application of ML and the preparation of information technology systems to use these techniques.

Effects of table tennis multi-ball training on dynamic posture control

Background

Prior to the 2017 table tennis season, each participant performed the anterior, posteromedial, and posterolateral the star excursion balance test (SEBT) reach distances in a randomized order. The aim of this study was to assess the effects of table tennis multi-ball training and dynamic balance on performance measures of the SEBT for the male and female.

Methods

The limb lengths of the 12 table tennis athletes were measured bilaterally in the study. Besides warm-up end, the data of this study were recorded at a regular interval at approximately 16 min for the entire multi-ball training session, and they were defined as Phase I, Phase II, Phase II, respectively. The Borg rating of perceived exertion (RPE) scale was used to document the degree of physical strain.

Results

Reaching distances showed a decrease with training progression in all directions. Compared with the male table tennis athletes, the females showed poorer dynamic posture control, particularly when the free limb was considered with the right-leg stance toward posterolateral and posteromedial directions in phase I.

Discussion

This study suggests that during table tennis multi-ball training the male should have a regulatory protocol to compensate the deficit observed in phase II, but the females should be given the protocol in phase I.

Prediction of exertional lower extremity musculoskeletal injury in tactical populations: protocol for a systematic review and planned meta-analysis of prospective studies from 1955 to 2018

BACKGROUND

Musculoskeletal injuries (MSI) represent more than half of all injuries in tactical populations (i.e., military service and public safety workers including police, firefighters, emergency medical services (EMS)). Most lower extremity MSIs result from physical exertion during training, occupational tasks, and recreation. Such exertional lower extremity injuries (ELEI) produce a significant human and financial cost. Accordingly, significant efforts have been made to identify sensitive, specific, and reliable predictors of ELEI. There is a need to synthesize and evaluate the predictive value of risk factors for ELEI while addressing the influence of occupation, sex, exposure, injury characteristics, and study quality. Therefore, the purpose of this systematic review and planned meta-analysis is to evaluate risk factors for ELEI in tactical populations.

METHODS

After the development of a search strategy, comprehensive searches will be conducted in MEDLINE, EMBASE, Cochrane, and CINAHL databases. Articles will be screened with a multi-user process and delimited to prospective comparative cohort studies that directly measure injury occurrence in the target population(s). Extracted data will be synthesized and assessed for reporting bias, meta-bias, and overall quality, with subgroup analyses to determine the influence of participant, injury, and exposure characteristics in addition to study quality.

DISCUSSION

This systematic review and planned meta-analysis will comprehensively evaluate ELEI risk factors. Information gained will inform injury prevention protocols, facilitate the use of improved measurements, and identify requirements for future research.

TRIAL REGISTRATION

The systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 3 Jan 2018 (registration number CRD42018056977 ).

Risk Factors Associated With Musculoskeletal Injury: A Prospective Study of British Infantry Recruits

Background:

Musculoskeletal Injury (MSKI), a common problem in both military and physically active civilian populations, has been suggested to result from both extrinsic and intrinsic factors.

Objective:

To investigate prospectively whether gait biomechanics, aerobic fitness levels and smoking status as well as entry military selection test variables can be used to predict MSKI development during recruit training.

Methods:

British infantry male recruits (n = 562) were selected for the study. Plantar pressure variables, smoking habit, aerobic fitness as measured by a 1.5 mile run time and initial military selection test (combination of fitness, Trainability score) were collected prior to commencement of infantry recruit training. Injury data were collected during the 26 week training period.

Results:

Incidence rate of MSKI over a 26 week training period was 41.28% (95 % CI: 37.28 - 45.40%). The injured group had a higher medial plantar pressure (p < 0.03), shorter time to peak heel rotation (p < 0.02), current smoking status (p < 0.001) and a slower 1.5 mile run time (p < 0.03). In contrast, there were no significant differences (p > 0.23) in lateral heel pressure, age, weight, height, BMI and military selection test. A logistic regression model predicted MSKI significantly (p= 0.03) with an accuracy of 34.50% of all MSK injury and 76.70% of the non-injured group with an overall accuracy of 69.50%.

Conclusion:

The logistic regression model combining the three risk factors was capable of predicting 34.5% of all MSKI. A specific biomechanical profile, slow 1.5 mile run time and current smoking status were identified as predictors of subsequent MSKI development. The proposed model could include evaluation of other potential risk factors and if validated then further enhance the specificity, sensitivity and applicability.

Dynamic postural stability, is associated with competitive level, in youth league soccer players

OBJECTIVES

To assess the effect of competitive level on dynamic postural stability in young elite and sub-elite soccer players.

DESIGN

Cross-sectional study.

SETTING

Laboratory.

PARTICIPANTS

Fifty-four male soccer players of Under 16 and Under 17 categories (mean age 15.9 ± 0.6), divided into two groups who regularly compete at national (n = 28) and regional (n = 26) levels.

MAIN OUTCOME MEASURES

Dynamic Postural Stability Index (DPSI) and vertical Time to Stabilization (vTTS) for a forward-jump landing. Static postural sway was calculated on the basis of center-of-pressure trajectories for a 20 s one-legged stance.

RESULTS

Players at national level exhibit better dynamic postural control than those at regional level, as indicated by the significantly lower DPSI (0.327 vs. 0.373, p < 0.001) and vTTS (0.887 vs. 1.158 s, p = 0.003). In contrast, no differences between groups were found in any of the postural sway parameters for the static test.

CONCLUSIONS

Young soccer players at national level are characterized by better balance performance in terms of faster and more efficient stabilization after a forward jump, while one-leg static standing tests appear not challenging enough to reveal differences in balance abilities associated with the combination of superior technical and physical features.

Association between double-leg squat and single-leg squat performance and injury incidence among incoming NCAA Division I athletes: A prospective cohort study

OBJECTIVES

Determine the association between performance on the double-leg squat (DLS) and single-leg squat (SLS) and prospective injury incidence in athletes.

DESIGN

Prospective cohort study.

SETTING

National Collegiate Athletic Association (NCAA) Division I university.

PARTICIPANTS

111 incoming NCAA Division I athletes from 10 varsity sports teams.

MAIN OUTCOME MEASURES

Performance on the DLS and SLS were assessed as "poor" or "non-poor." Lower extremity (LE) injury data for the following year were extracted from electronic medical records. Multivariate Poisson regression was used to compare the incidence of LE injuries in athletes with poor versus non-poor performance on the DLS and SLS.

RESULTS

The final models for the DLS and SLS were adjusted for sex and LE injury history and yielded an incidence rate ratio (IRR) of 1.33 (95% CI: 0.80 2.22) for the DLS and 1.62 (95% CI: 0.98, 2.66) for the SLS when comparing poor to non-poor movers.

CONCLUSIONS

Athletes with poor LE movement quality assessed on the DLS or SLS had greater incidence of LE injury than those with non-poor movement quality. This is the first study to demonstrate an association between performance on the double-leg squat and single-leg squat and injury risk in NCAA athletes.

Epidemiology of injuries among Italian footballers: the role of the playing field

Background

Football has a higher injury rate compared with other team sports such as rugby, in terms of two main categories: intrinsic (individual) and extrinsic (environmental) factors. The playing field is an extrinsic risk factor which has been poorly investigated in the literature.

Purpose

The aim of our study was to define the incidence and risk factors of injuries in a cohort of footballers comparing the role of three different types of playing field (hard court, natural grass or synthetic grass).

Study design

This was a cross sectional prevalence study.

Methods

The population comprised footballers recruited by a convenience sample; the instrument used for the survey was an anonymous self-administered questionnaire.

Results

267 football players were enrolled (average age 23.4±4.8 years), of whom 33.7% (n=90/267) played on hard court, 33.0% (n=88/267) on natural grass and 33.3% (n=89/267) on synthetic grass. The overall incidence of injury was 40.1 (95% CI 34.1 to 46.8) ×1000 person-years of training, with higher values for ankle and knee injuries. Ankle injuries (aOR 0.4; P=0.021) were associated with playing on natural grass as a protective factor, while playing on natural grass seemed to be a risk factor for muscular injuries (aOR 2.3; P=0.026).

Conclusion

Our study showed a high lifetime prevalence of injury among footballers (57%), in particular among athletes who play and train on a hard court. We have studied a topic poorly investigated previously and provide the opportunity to understand interventions to increase the capacity of stakeholders in preventing injuries.

The Use of Orthotic Insoles to Prevent Lower Limb Overuse Injuries: A Critically Appraised Topic

Overuse injuries are common in physically active populations. Lower limb overuse injuries can occur anywhere in the lower-extremity and include injuries such as medial tibial stress syndrome, plantar fasciitis, and anterior knee pain. One reason that overuse injuries have received attention is because they have both short- and long-term consequences on health and burden the lives of physically active people. Over the years, a variety of approaches have been proposed for prevention of lower limb overuse injury that addresses various intrinsic or extrinsic risk factors. One extrinsic risk factor is footwear and the use of orthotic insoles to prevent injury. To date, there is no consensus as to whether these supports prevented lower limb overuse injuries. A critical appraisal of recent studies examining the injury prevention capabilities of orthotic insoles was completed. The long-term objective of this research is to help identify effective strategies for preventing injuries in physically active people.

Age, player position and 2 min suspensions were associated with match injuries during the 2017 Men's Handball World Championship (France)

AIM

To study the association between player characteristics, technical components of the game and the risk of match injuries during the 2017 Men's Handball World Championship.

METHODS

Team physicians of the participating teams (n=24) were requested to provide injury report forms throughout the Men's Handball World Championship (France, January 2017). The individual time played, age, number of international matches played and all technical and penalty variables for each player were extracted from the official International Handball Federation (IHF) online database and used as risk factors in a general logistic linear model analysis.

RESULTS

Of 387 players, 49 sustained one or more injuries (93 injuries in total). The total incidence of match injuries was 82.1 injuries per 1000 hours (95% CI 66.2 to 100.5), non-time-loss injury incidence was 40.6 injuries per 1000 hours (95% CI 29.3 to 54.9), while time-loss injury incidence was 30.9 injuries per 1000 hours (95% CI 21.5 to 42.9). Multivariate analysis showed that age (OR 1.1, 95% CI 1.02 to 1.18, p=0.011), player position (backs: OR 6.79, 95% CI 2.25 to 20.54, p=0.001; goalkeepers: OR 5.03, 95% CI 1.15 to 21.94, p=0.031) and 2 min suspensions (1-2 times: OR 2.77, 95% CI 1.27 to 6.04, p=0.011; 3 or more times: OR 2.66, 95% CI 1.18 to 6.38, p=0.029) were significant risk factors for getting injured during competition matches.

CONCLUSION

Age, player position (backs, goalkeepers) and 2 min suspensions were associated with match injury. Stricter rule enforcement should be considered to prevent match injuries in elite handball.