The International Olympic Committee (IOC) consensus statement on periodic health evaluation of elite athletes, March 2009

The role of cardiac magnetic resonance in sports cardiology: results from a large cohort of athletes

BACKGROUND

Cardiac magnetic resonance (CMR) provides information on morpho-functional abnormalities and myocardial tissue characterisation. Appropriate indications for CMR in athletes are uncertain.

OBJECTIVE

To analyse the CMR performed at our Institute to evaluate variables associated with pathologic findings in a large cohort of athletes presenting with different clinical conditions.

METHODS

All the CMR performed at our Institute in athletes aged > 14 years were recruited. CMR indications were investigated. CMR was categorised as "positive" or "negative" based on the presence of morphological and/or functional abnormalities and/or the presence of late gadolinium enhancement (excluding the right ventricular insertion point), fat infiltration, or oedema. Variables associated with "positive" CMR were explored.

RESULTS

A total of 503 CMR were included in the analysis. "Negative" and "positive" CMR were 61% and 39%, respectively. Uncommon ventricular arrhythmias (VAs) were the most frequent indications for CMR, but the proportion of positive results was low (37%), and only polymorphic ventricular patterns were associated with positive CMR (p = 0.006). T-wave inversion at 12-lead ECG, particularly on lateral and inferolateral leads, was associated with positive CMR in 34% of athletes (p = 0.05). Echocardiography abnormalities resulted in a large proportion (58%) of positive CMR, mostly cardiomyopathies.

CONCLUSION

CMR is more efficient in identifying a pathologic cardiac substrate in athletes in case of VAs (i.e., polymorphic beats), abnormal ECG repolarisation (negative T-waves in inferolateral leads), and borderline echocardiographic findings (LV hypertrophy, mildly depressed LV function). On the other hand, CMR is associated with a large proportion of negative results. Therefore, a careful clinical selection is needed to indicate CMR in athletes appropriately.

Relevance of the Get Active Questionnaire for Pre-Participation Exercise Screening in the General Population in a Tropical Environment

The Get Active Questionnaire (GAQ), developed by the Canadian Society for Exercise Professionals (CSEP), was recently recommended for pre-participation screening of the general population in Singapore before increasing their exercise levels. This literature review examines the evidence behind the GAQ and its relevance to our tropical environment. Searches were carried out via Pubmed, MEDLINE and the Cochrane Central Register of Controlled Trials. Resources referenced by the CSEPs were hand searched. The CSEP was also contacted for further information. The evidence behind each GAQ question was compared to international literature and guidelines, where applicable. Out of 273 studies, 49 were suitable for analysis. Two GAQ studies commissioned by the CSEP showed a high negative predictive value but high false negative rate. Of the nine GAQ questions, those on dizziness, joint pains and chronic diseases appear to be justified. Those on heart disease/stroke, hypertension, breathlessness and concussion require modification. The one on syncope can be amalgamated into the dizziness question. The remaining question may be deleted. No long-term studies were available to validate the use of the GAQ. Heat disorders were not considered in the GAQ. Modification of the GAQ, including the inclusion of environmental factors, may make it more suitable for the general population and should be considered.

Electrical and structural remodelling in female athlete's heart: A comparative study in women vs men athletes and controls

BACKGROUND

Athlete's heart is associated with physiological electrical and structural remodelling. Despite the plethora of data published on male athletes, solid data derived from female athletes, compared to male counterparts or sedentary women, are still scarce.

OBJECTIVES

We aimed to analyze the electrical, structural, and functional characteristics of athlete's heart in female and male athletes vs sedentary controls.

METHODS

Olympic athletes and sedentary controls were evaluated by resting ECG and echocardiography. Athletes were divided into 4 different sports groups.

RESULTS

The study population included 1096 individuals (360 female athletes, 410 male athletes, 130 sedentary women and 196 sedentary men). Female athletes had lower resting heart rate, longer PR interval, higher voltage of R, and T waves and more frequently incomplete RBBB, left ventricular (LV) hypertrophy, early repolarization, and anterior T-wave inversion as compared to controls. Biventricular cavity dimensions and LV wall thickness were greater in female athletes than in female controls. However, women showed a lower degree of training-induced structural remodelling than men. In female athletes, both cavity dimensions and LV wall thickness increased from those engaged in skill and power to mixed and endurance disciplines. However, in female athletes, contrary to males, the ECG changes were not significantly different according to the different types of sport discipline.

CONCLUSIONS

Highly-trained women demonstrate relevant training-induced electrical and structural remodelling. However, the type of sport did not influence ECG parameters in women, contrary to men, while it impacted biventricular morphologic remodelling, with endurance athletes showing the greatest degree of adaptation.

Causes of sudden cardiac arrest and death and the diagnostic yield of sport preparticipation screening in children

OBJECTIVE

Evidence on the increased risk of sports-related sudden cardiac arrest and death (SCA/D) and the potential benefit of cardiovascular preparticipation screening (PPS) in children is limited. We assessed the burden and circumstances of SCA/D and the diagnostic yield of cardiovascular PPS in children aged 8-15 years.

METHODS

Data on the incidence and causes of SCA/D from 2011 to 2020 were obtained from the Veneto region (Italy) sudden death registry, hospital records and local press. During the same period, we assessed the results of annual PPS in 25 251 young competitive athletes aged 8-15 years who underwent 58 185 evaluations (mean 2.3/athlete) in Padua, Italy.

RESULTS

Over 10 years, 26 SCA/D occurred in children aged 8-15 years in the Veneto region: 6 in athletes (incidence 0.7/100 000/year, all ≥12 years) versus 20 in non-athletes (0.7/100 000/year, 17/20 ≥12 years). In total, 4/6 athletes versus 1/20 non-athletes survived. The cause of SCA/D remained unexplained in four athletes and in nine non-athletes. No athlete suffered SCA/D from structural diseases potentially identifiable by PPS. The incidence of SCA/D in athletes and non-athletes was 0.2/100 000/year in the 8-11 years group versus 1.3/100 000/year in the 12-15 years group. PPS identified 26 new diagnoses of cardiovascular diseases (CVDs) at risk of SCA/D, more often in children ≥12 years old (0.06%/evaluation) than <12 years old (0.02%/evaluation, p=0.02). Among athletes with a negative PPS, two suffered unexplained SCA/D during follow-up, one during exercise.

CONCLUSIONS

In children aged 8-15 years, the incidence of SCA/D and the yield of PPS for identifying at-risk CVD were both substantially higher in those ≥12 years, suggesting that systematic PPS may be more useful beyond this age.

Sports cardiology: A glorious past, a well-defined present, a bright future

The attention towards sports cardiology has dramatically grown after the introduction of preparticipation screening and the need for specific education on electrocardiogram interpretation in athletes, given the differences between athletes and the general population. The present article stresses the need for specific skills, knowledge, and clinical expertise in sports cardiology, which are essential for appropriately screening competitive athletes to prevent sudden cardiac death and avoid overdiagnosis. However, disqualification from sports competitions may lead to sports inactivity, and athletes may enter a gray zone where little or no information is provided about what they can or cannot do to stay active. However, modern sports cardiology cannot neglect the patient's needs and the importance of the safe practice of regular exercise. In this context, the personalized exercise prescription plays a crucial role in the core curriculum and the clinical activity of professionals involved in sports cardiology programs. Given its specificities, sports cardiology requires a formal education plan for medical school students and all residents. Additional education and practice are required for young colleagues who want to focus their professional lives on sports cardiology. The future directions of emerging modern sports cardiology should not neglect the importance of a scientific community that works together, designing multicenter international outcomes-based research to address the many remaining areas of uncertainty.

Performance, Test-retest Reliability, and Measurement Error of the Upper Limb Seated Shot Put Test According to Different Positions of Execution

BACKGROUND

The unilateral Seated Shot-Put Test (USSPT) is an easy to apply, inexpensive tool that can be used to assess shoulder performance unilaterally. Two different positions of execution have been described in previous studies, however, differences regarding reference values and psychometric properties were not assessed.

PURPOSE

To investigate the performance, test-retest reliability and measurement error of the USSPT according to different positions of execution (floor versus chair) in overhead athletes. The hypothesis was that both positions would present similar values, good to excellent test-retest reliability and clinically acceptable measures.

STUDY DESIGN

Test-retest reliability.

METHODS

Forty-four overhead athletes performed the USSPT on the floor (USSPT-F) and on a chair (USSPT-C). Normative values were established according to gender, age, and dominance. Test-retest reliability was determined using Intraclass Correlation Coefficient and measurement error through Standard Error of Measurement, Smallest Detectable Change, as well as Bland and Altman plots.

RESULTS

Reference values for both positions were provided. Women performed better on the USSPT-C than USSPT-F. Excellent test-retest reliability 0.97 (0.89 - 0.99) for dominant side and 0.95 (0.80 - 0.98) for non-dominant side was found for the USSPT-F. Moderate to excellent reliability 0.91 (0.67 - 0.98) for dominant side and 0.74 (0.01 - 0.93) for non-dominant side was found for the USSPT-C. Presence of systematic error (14.76 cm) was found only for USSPT-C dominant (p=0.011).

CONCLUSION

Differences were found only for women with better performance on the USSPT-C. The USSPT-F presented higher reliability values. Both tests presented clinically acceptable measures. Presence of systematic error was found only in the USSPT-C.

LEVEL OF EVIDENCE

3.

Determinants of LV mass in athletes: the impact of sport, constitutional traits and cardiovascular risk factors

BACKGROUND

Whether cardiovascular (CV) risk factors might impact Left Ventricular (LV) mass in athletes is unknown.

METHODS

The impact of CV risk factors (Total/LDL cholesterol, triglycerides, positive family history, smoking, body fat, blood pressure), constitutional characteristics (age, sex, body mass index) and type of sport was assessed in 1111 Olympic athletes.

RESULTS

Multivariate logistic regression analysis demonstrated a significant impact: BMI ≥ 30 kg/m² (odds ratio [OR] = 2.8. 95° Confidence Interval [CI] 0.9-13.7; < 0.001; in males); age ≥ 20-year (OR = 2.1, CI 1.4-3.3; p < 0.001) in males; (OR = 2.3; CI 1.4-3.7) in females; systolic blood pressure ≥ 130 mmHg (OR = 1.1, CI 1.01-1.16; p < 0.001) in males; (OR = 1.03; CI 1.01-1.06; p < 0.03) in females; diastolic ≥ 85 mmHg (OR = 1.1, CI 1.03-1.2; p = 0.003) in males; (OR = 1.05, CI 1.02-1.08, p < 0.001) in females. No association was found for family history, smoking, body fat, LDL, total cholesterol, triglycerides. Overall, constitutional traits explain > 60% of the LV mass. Sport explains on average 14%, but large differences existed among disciplines, i.e., endurance showed the highest impact (55%, mixed: 20%, power: 17%, skill: 8%; p < 0.001).

CONCLUSION

LV mass in athletes is largely governed by constitutional traits and type of sport, and independent from CV risk factors, except for systolic and diastolic blood pressure. Overall, constitutional traits explain more than 60% of LV mass. The impact of sport is largely different in relation to the discipline, and highest in endurance, moderate mixed and power and mild in skill disciplines.

Can prognostic factors for indirect muscle injuries in elite football (soccer) players be identified using data from preseason screening? An exploratory analysis using routinely collected periodic health examination records

BACKGROUND

In elite football, periodic health examination (PHE) may be useful for injury risk prediction.

OBJECTIVE

To explore whether PHE-derived variables are prognostic factors for indirect muscle injuries (IMIs) in elite players.

DESIGN

Retrospective cohort study.

SETTING

An English Premier League football club.

PARTICIPANTS

134 outfield elite male players, over 5 seasons (1 July 2013-19 May 2018).

OUTCOME AND ANALYSIS

The outcome was any time-loss, lower extremity index IMI (I-IMI). Prognostic associations were estimated using odds ratios (ORs) and corresponding statistical significance for 36 variables, derived from univariable and multivariable logistic regression models. Missing data were handled using multiple imputation. Non-linear associations were explored using fractional polynomials.

RESULTS

During 317 participant-seasons, 138 I-IMIs were recorded. Univariable associations were determined for previous calf IMI frequency (OR 1.80, 95% CI 1.09 to 2.97), hamstring IMI frequency (OR 1.56, 95% CI 1.17 to 2.09), if the most recent hamstring IMI occurred >12 months but <3 years prior to PHE (OR 2.95, 95% CI 1.51 to 5.73) and age (OR 1.12 per 1-year increase, 95% CI 1.06 to 1.18). Multivariable analyses showed that if a player's most recent previous hamstring IMI was >12 months but <3 years prior to PHE (OR 2.24, 95% CI 1.11 to 4.53), this was the only variable with added prognostic value over and above age, which was a confirmed prognostic factor (OR 1.12 per 1-year increase, 95% CI 1.05 to 1.18). Allowing non-linear associations conferred no advantage over linear associations.

CONCLUSION

PHE has limited use for injury risk prediction. Most variables did not add prognostic value over and above age, other than if a player experienced a hamstring IMI >12 months but <3 years prior to PHE. However, the precision of this prognostic association should be confirmed in future.

TRIAL REGISTRATION NUMBER

NCT03782389.

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.

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.

Heads-Up: Risk-Specific Neurodegenerative Mortality and Years-Saved Analysis on the US Olympian Cohort

Purpose: This study aimed to identify the risk of neurodegenerative death (ND) that former Olympians endure due to their participation in sports grouped based on presumed repeated shocks to the head, and to understand the impact of their participation in such elite sports on their total longevity.

Materials and Methods: The cohort included all former US Olympians, who participated in the Olympic Games (OG) between 1948 and 1972, and whose vital status and causes of death were verified (n = 2,193). Olympic sports were classified into three categories of exposure: Collision (the highest presumed risk of repeated shocks to the head), Contact, and No-Contact. The Fine-Gray competing risk regression model was used to compare the risk of ND where the No-Contact category was a reference group. The years-saved analysis was performed to quantify the number of years saved or lost to ND and total longevity compared with the US general population.

Results: A total of 65 NDs were identified. Collision sports Olympians had a 3.11 (95% CI: 1.31–7.40) higher risk of ND while the Contact group showed a risk of 0.56 (95% CI: 0.21–1.48) compared with the No-Contact sports Olympians. Compared with the general population, the Collision group lost 0.61 (95% CI: -1.16—0.06) years of life from ND, while the Contact group saved 0.4 (95% CI: 0.26–0.54) and the No-Contact group saved 0.09 (-0.09–0.28) years of life up to the age of 90. Regarding the total longevity, Collision, Contact, and No-Contact groups saved 4.67 (95% CI: 3.13–6.22), 5.8 (95% CI: 4.93–6.67), and 6.24 (95% CI: 5.57–6.92) years of life, respectively, from all causes of death.

Conclusion: There is an elevated risk of ND among US Olympians, who engaged in sports with the highest presumed risk of repeated shocks to the head compared with those exposed to no such hazard. Such risk does not jeopardize the total longevity among Olympians in Collision sports.

Initial evaluation of a novel electrocardiography sensor-embedded fabric wear during a full marathon

Sudden cardiac accident (SCA) during a marathon is a concern due to the popularity of the sport. Preventive strategies, such as cardiac screening and deployment of automated external defibrillators have controversial cost-effectiveness. We investigated the feasibility of use of a new electrocardiography (ECG) sensor-embedded fabric wear (SFW) during a marathon as a novel preventive strategy against SCA. Twenty healthy volunteers participated in a full marathon race. They were equipped with a SFW hitoe® with a transmitter connected via Bluetooth to a standard smartphone for continuous ECG recording. All data were stored in a smartphone and used to analyze the data acquisition rate. The adequate data acquisition rate was > 90% in 13, 30-90% in 3, and < 10% in 4 runners. All of 4 runners with poorly recorded data were female. Inadequate data acquisition was significantly associated with the early phase of the race compared with the mid phase (P = 0.007). Except for 3 runners with poor heart rate data, automated software calculation was significantly associated with manual analysis for both the mean (P < 0.001) and maximum (P = 0.014) heart rate. We tested the feasibility of continuously recording cardiac data during a marathon using a new ECG sensor-embedded wearable device. Although data from 65% of runners were adequately recorded, female runners and the early phase of the race tended to have poor data acquisition. Further improvements in device ergonomics and software are necessary to improve ability to detect abnormal ECGs that may precede SCA.

Paradoxical Relationships between Serum 25(OH)D and Ferritin with Body Composition and Burnout: Variation by Sex and Sports Team

Adequate serum vitamin D and iron levels are thought to influence physical training adaptations and mood positively. The primary purpose of this prospective, observational study was to investigate relationships between serum 25-OH vitamin D/25(OH)D and serum ferritin levels with body composition and athlete burnout symptoms. Seventy-three collegiate athletes (female: n = 49; male: n = 24) from indoor (swimming, basketball) and outdoor (soccer, cross-country) sports were tested pre-season and post-season for serum 25(OH)D and serum ferritin (nutrient biomarkers) via venipuncture; body composition (total lean mass, bone mineral density/BMD, and % body fat) via dual energy X-ray absorptiometry (DXA) scans; and athlete burnout symptoms (post-season) via the athlete burnout questionnaire (ABQ). When male and female cohorts were combined, significant correlations (Pearson’s r) were noted between pre-season serum 25(OH)D versus the change (∆: post-season minus pre-season) in both BMD (r = −0.34; p = 0.0003) and % body fat (r = −0.28; p = 0.015). Serum ferritin ∆ was significantly associated with lean mass ∆ (r = −0.34; p = 0.003). For burnout symptoms, serum 25(OH)D ∆ significantly explained 20.6% of the variance for devaluation of the sport in the male cohort only. Across time, serum 25(OH)D levels decreased while serum ferritin levels increased, non-significantly, in both males and females. Relationships between nutrient biomarkers and body composition were opposite of physiological expectations.

The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part II: Diagnosis, Treatment, and Return-To-Play

ABSTRACT

The Male Athlete Triad is a medical syndrome most common in adolescent and young adult male athletes in sports that emphasize a lean physique, especially endurance and weight-class athletes. The 3 interrelated conditions of the Male Athlete Triad occur on spectrums of energy deficiency/low energy availability (EA), suppression of the hypothalamic-pituitary-gonadal axis, and impaired bone health, ranging from optimal health to clinically relevant outcomes of energy deficiency/low EA with or without disordered eating or eating disorder, functional hypogonadotropic hypogonadism, and osteoporosis or low bone mineral density with or without bone stress injury (BSI). Because of the importance of bone mass acquisition and health concerns in adolescence, screening is recommended during this time period in the at-risk male athlete. Diagnosis of the Male Athlete Triad is best accomplished by a multidisciplinary medical team. Clearance and return-to-play guidelines are recommended to optimize prevention and treatment. Evidence-based risk assessment protocols for the male athlete at risk for the Male Athlete Triad have been shown to be predictive for BSI and impaired bone health and should be encouraged. Improving energetic status through optimal fueling is the mainstay of treatment. A Roundtable on the Male Athlete Triad was convened by the Female and Male Athlete Triad Coalition in conjunction with the 64th Annual Meeting of the American College of Sports Medicine in Denver, Colorado, in May of 2017. In this second article, the latest clinical research to support current models of screening, diagnosis, and management for at-risk male athlete is reviewed with evidence-based recommendations.

Reliability of the Modified CKCUEST and correlation with shoulder strength in adolescent basketball and volleyball players

BACKGROUND

Physical performance tests provide a more complete picture of the functional status of the athlete's upper extremity.

OBJECTIVES

The primary purpose was to evaluate the reliability of the Modified Closed Kinetic Chain Upper Extremity Stability Test (MCKCUEST) in adolescent volleyball and basketball players. The secondary objective was to evaluate the relationship between the MCKCUEST and shoulder rotation isometric strength in this population.

METHODS

Seventy-three healthy basketball (n=39) and volleyball (n=34) players participated to establish the reliability and correlations of the MCKCUEST. We used a two-session measurement design to evaluate the reliability of the MCKCUEST. Shoulder rotation isometric strength was performed to determine relationships with the MCKCUEST.

RESULTS

The intraclass correlation coefficients (ICC_2,1) for intra-session reliability of the MCKCUEST ranged from 0.86 to 0.89, and the between days test-retest reliability (ICC_3,1) was 0.93. The standard error of measurement (1 touch) and the minimal detectable change (3 touches) showed clinically acceptable absolute reliability values. A weak correlation was found between the MCKCUEST power score and shoulder rotation isometric strength (r values between 0.3 and 0.4).

CONCLUSIONS

Results demonstrated good to excellent relative reliability and clinically acceptable absolute reliability values for the MCKCUEST on adolescent basketball and volleyball athletes. Performances on the MCKCUEST were weakly associated with shoulder rotation strength.

Protecting the world's finest athletes: periodic health evaluation practices of the top performing National Olympic Committees from the 2016 Rio or 2018 PyeongChang Olympic Games

AIM

To describe the periodic health evaluation (PHE) practices of the top performing National Olympic Committees (NOCs).

METHODS

We sent a survey to NOCs finishing in the top 8 for medal count at the 2016 Rio Olympic Games or 2018 PyeongChang Olympic Games. The survey included four sections: (1) PHE staff composition and roles, (2) beliefs regarding the PHE, (3) a ranking of risk factors for future injury and (4) details on the elements of the PHE.

RESULTS

All 14 NOCs with top 8 finishes at the 2016 Rio Olympic Games or 2018 PyeongChang Olympic Games completed the survey. NOCs included a median of seven staff specialties in the PHE, with physicians and physiotherapists having the highest level of involvement. There was agreement that PHEs are effective in identifying current health conditions (13/14) and that athletes should receive individualised action plans after their PHE (14/14), but less agreement (6/14) that PHEs can predict future injury. The practices of NOCs were diverse and often specific to the athlete population being tested, but always included the patient's health history, laboratory studies, cardiovascular screening and assessments of movement capacity. The top three risk factors for future injury were thought to be previous injury, age and training experience.

CONCLUSIONS

Among the top performing NOCs, the PHE is a comprehensive, multidisciplinary process aimed to identify existing conditions and provide baseline health and performance profiles in the event of future injury. Research linking PHEs to injury prevention is needed.

Dietary Thiols: A Potential Supporting Strategy against Oxidative Stress in Heart Failure and Muscular Damage during Sports Activity

Moderate exercise combined with proper nutrition are considered protective factors against cardiovascular disease and musculoskeletal disorders. However, physical activity is known not only to have positive effects. In fact, the achievement of a good performance requires a very high oxygen consumption, which leads to the formation of oxygen free radicals, responsible for premature cell aging and diseases such as heart failure and muscle injury. In this scenario, a primary role is played by antioxidants, in particular by natural antioxidants that can be taken through the diet. Natural antioxidants are molecules capable of counteracting oxygen free radicals without causing cellular cytotoxicity. In recent years, therefore, research has conducted numerous studies on the identification of natural micronutrients, in order to prevent or mitigate oxidative stress induced by physical activity by helping to support conventional drug therapies against heart failure and muscle damage. The aim of this review is to have an overview of how controlled physical activity and a diet rich in antioxidants can represent a "natural cure" to prevent imbalances caused by free oxygen radicals in diseases such as heart failure and muscle damage. In particular, we will focus on sulfur-containing compounds that have the ability to protect the body from oxidative stress. We will mainly focus on six natural antioxidants: glutathione, taurine, lipoic acid, sulforaphane, garlic and methylsulfonylmethane.

Electrocardiographic interpretation in athletes

Participation in regular exercise of moderate intensity is associated with a plethora of systemic benefits, including a reduction in risk factors for coronary atherosclerosis; however, intensive exercise may paradoxically culminate in sudden cardiac arrest among individuals harboring arrhythmogenic substrates. The precise mechanism for arrhythmogenesis is likely multifactorial, however, surges in catecholamines, electrolyte shifts, acid-base disturbances, increased core temperature and demand myocardial ischemia are potential contributors. Although most deaths occur in middle aged and older males with atherosclerotic coronary artery disease, a significant proportion also affect young athletes with inherited or congenital cardiac abnormalities. The impact of such catastrophes on society, particularly when a young high-profile athlete is affected could be considered a justified reason for identifying individuals who may be at risk. Given the rarity of deaths in young athletes, only the simplest screening test, such as the 12-lead electrocardiography (ECG) may be considered to be cost effective. The ECG is effective for detecting serious electrical diseases in young athletes such as congenital electrical accessory pathways and ion channel diseases but can also identify athletes with potential life-threatening structural diseases such as hypertrophic and arrhythmogenic cardiomyopathy. One of the concerns about ECG screening is that regular intensive exercise results in several physiological alterations in cardiac structure and function that are reflected on the athlete's ECG. Sinus bradycardia, first-degree atrioventricular block, incomplete right bundle branch block, minor J-point elevation and large QRS voltages are common. Conversely, some repolarization anomalies affecting the ST segment, T waves and QT interval may overlap with patterns observed in patients with serious cardiac diseases. The situation is complicated further because age, sex and ethnicity of the athletes also influence the ECG and there is a risk that erroneous interpretation could have serious consequences. This review will describe the normal electrical patterns of the "athlete's heart" and provide insights into differentiation physiological electrical patterns from those observed in serious cardiac disease.

Eye clinic attendance at the olympic and paralympic games Rio 2016 and its correlation to the WHO indicators on eye health

OBJECTIVES

To evaluate athletes' frequency of attendance at the eye clinic during the Olympic and Paralympic Games Rio 2016 and to correlate it to WHO core indicators on progress in ophthalmology care in a country.

METHODS

Frequencies of athletes' attendance at the eye clinic were calculated for each country. Countries were classified according to the World Bank income levels in high, upper-middle, low-middle or low-income country. Data on ophthalmology care for each country were derived from the International Agency for the Prevention of Blindness atlas. Data were analysed in view of WHO indicators for each country: visual impairment prevalence considering presenting visual acuity <6/18 to ≥3/60 in the better vision eye; number of ophthalmologists per million people and the cataract surgical rate per year, per million population.

RESULTS

The athletes' overall frequency of attendance in the eye clinic was 6.47%. Frequencies of attendance for high, upper-middle, low-middle or low-income country were 1.97%, 9.66%, 16.54% and 22.43%, respectively. A positive correlation was observed between the athletes' attendance frequency of a country and its visual impairment prevalence (r=0.2290, p=0.0017). A negative correlation was observed between the athletes' attendance frequency of a country and its eye health workforce (r=-0.2152, p=0.0026).

CONCLUSION

Countries with highest athletes' frequencies of attendance were those that face barriers to eye care provision. These results reinforce the importance of the eye clinic service during the Olympic and Paralympic Games proving access to specialised care to athletes and members of delegation.

Exercise and hypertrophic cardiomyopathy: Two incompatible entities?

A greater understanding of the pathogenic mechanisms underpinning hypertrophic cardiomyopathy (HCM) has translated to improved medical care and better survival of affected individuals. Historically these patients were considered to be at high risk of sudden cardiac death (SCD) during exercise; therefore, exercise recommendations were highly conservative and promoted a sedentary life style. There is emerging evidence that suggests that exercise in HCM has a favorable effect on cardiovascular remodeling and moderate exercise programs have not raised any safety concerns. Furthermore, individuals with HCM have a similar burden of atherosclerotic risk factors as the general population in whom exercise has been associated with a reduction in myocardial infarction, stroke, and heart failure, especially among those with a high-risk burden. Small studies revealed that athletes who choose to continue with regular competition do not demonstrate adverse outcomes when compared to those who discontinue sport, and active individuals implanted with an implantable cardioverter defibrillator do not have an increased risk of appropriate shocks or other adverse events. The recently published exercise recommendations from the European Association for Preventative Cardiology account for more contemporary evidence and adopt a more liberal stance regarding competitive and high intensity sport in individuals with low-risk HCM. This review addresses the issue of exercise in individuals with HCM, and explores current evidence supporting safety of exercise in HCM, potential caveats, and areas of further research.

The Value of Preseason Screening for Injury Prediction: The Development and Internal Validation of a Multivariable Prognostic Model to Predict Indirect Muscle Injury Risk in Elite Football (Soccer) Players

Background

In elite football (soccer), periodic health examination (PHE) could provide prognostic factors to predict injury risk.

Objective

To develop and internally validate a prognostic model to predict individualised indirect (non-contact) muscle injury (IMI) risk during a season in elite footballers, only using PHE-derived candidate prognostic factors.

Methods

Routinely collected preseason PHE and injury data were used from 152 players over 5 seasons (1st July 2013 to 19th May 2018). Ten candidate prognostic factors (12 parameters) were included in model development. Multiple imputation was used to handle missing values. The outcome was any time-loss, index indirect muscle injury (I-IMI) affecting the lower extremity. A full logistic regression model was fitted, and a parsimonious model developed using backward-selection to remove factors that exceeded a threshold that was equivalent to Akaike’s Information Criterion (alpha 0.157). Predictive performance was assessed through calibration, discrimination and decision-curve analysis, averaged across all imputed datasets. The model was internally validated using bootstrapping and adjusted for overfitting.

Results

During 317 participant-seasons, 138 I-IMIs were recorded. The parsimonious model included only age and frequency of previous IMIs; apparent calibration was perfect, but discrimination was modest (C-index = 0.641, 95% confidence interval (CI) = 0.580 to 0.703), with clinical utility evident between risk thresholds of 37–71%. After validation and overfitting adjustment, performance deteriorated (C-index = 0.589 (95% CI = 0.528 to 0.651); calibration-in-the-large = − 0.009 (95% CI = − 0.239 to 0.239); calibration slope = 0.718 (95% CI = 0.275 to 1.161)).

Conclusion

The selected PHE data were insufficient prognostic factors from which to develop a useful model for predicting IMI risk in elite footballers. Further research should prioritise identifying novel prognostic factors to improve future risk prediction models in this field.

Trial registration

NCT03782389

Canadian Cardiovascular Society Cardiovascular Screening of Competitive Athletes: The Utility of the Screening Electrocardiogram to Predict Sudden Cardiac Death

Prevention of sudden cardiac arrest/death (SCA/D) among athletes is a universal goal, although the optimal strategy for its achievement is controversial, with the inclusion of the 12-lead electrocardiogram (ECG) at the center of the debate. The ECG exhibits superior sensitivity over history and physical examination to detect conditions associated with SCA/D. However, the identification of disease does not necessarily lead to a significant reduction in SCA/D. The "Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes" recommended against the routine performance of an ECG for the initial cardiovascular screening of competitive athletes. The incidence of SCA/D among athletes (<35 years of age), the risk of SCA/D during sport participation among individuals with abnormalities found on screening ECG, the efficacy of the ECG to identify conditions associated with SCA/D, and the positive predictive value of an abnormal ECG to predict SCA/D are critically examined. This review presents the evidence informing the panel's recommendation.

Periodic Health Examination and Injury Prediction in Professional Football (Soccer): Theoretically, the Prognosis is Good

In professional soccer and other elite sports, medical and performance screening of athletes (also termed periodic health examination or PHE) is common practice. The purposes of this are: (1) to assist in identifying prevalent conditions that may be a threat to safe participation, (2) to assist in setting benchmark targets for rehabilitation or performance purposes and (3) to assist clinicians in determining which athletes may be at risk of future injury and selecting appropriate injury prevention strategies to reduce the perceived risk. However, when using PHE as an injury prevention tool, are clinicians seeking to identify potential causes of injury or to predict future injury? This Current Opinion aims to examine the conceptual differences between aetiology and prediction of injury while relating these areas to the capabilities of PHE in practice. We also introduce the concept of prognosis—a broader approach that is closely related to prediction—and why this may have greater applicability to PHE of professional athletes.

Energy Availability in Athletics: Health, Performance, and Physique

The reported prevalence of low energy availability (LEA) in female and male track and field athletes is between 18% and 58% with the highest prevalence among athletes in endurance and jump events. In male athletes, LEA may result in reduced testosterone levels and libido along with impaired training capacity. In female track and field athletes, functional hypothalamic amenorrhea as consequence of LEA has been reported among 60% of elite middle- and long-distance athletes and 23% among elite sprinters. Health concerns with functional hypothalamic amenorrhea include impaired bone health, elevated risk for bone stress injury, and cardiovascular disease. Furthermore, LEA negatively affects recovery, muscle mass, neuromuscular function, and increases the risk of injuries and illness that may affect performance negatively. LEA in track and field athletes may occur due to intentional alterations in body mass or body composition, appetite changes, time constraints, or disordered eating behavior. Long-term LEA causes metabolic and physiological adaptations to prevent further weight loss, and athletes may therefore be weight stable yet have impaired physiological function secondary to LEA. Achieving or maintaining a lower body mass or fat levels through long-term LEA may therefore result in impaired health and performance as proposed in the Relative Energy Deficiency in Sport model. Preventive educational programs and screening to identify athletes with LEA are important for early intervention to prevent long-term secondary health consequences. Treatment for athletes is primarily to increase energy availability and often requires a team approach including a sport physician, sports dietitian, physiologist, and psychologist.

Gender Differences in Eating Disorder Risk among NCAA Division I Cross Country and Track Student-Athletes

Purpose

This study compared gender differences in eating disorder risk among NCAA Division I cross country and track distance running student-athletes.

Methods

Six hundred thirty-eight male and female student-athletes competing at distances of 800m or greater completed the Eating Disorder Screen for Primary Care (ESP). Scores on the ESP were used as the risk of eating disorders.

Results

Females screened positive at higher rates for risk of eating disorders than males on the ESP at a cutoff of 2 (sensitivity 90-100%, specificity 71%) with rates of 45.95% ± 3.03 and 13.66% ± 1.80, respectively. Females were also screened positive at higher rates than males at a stricter cutoff of 3 (sensitivity 81%, specificity 92%), with rates of 21.69% ± 2.50 compared to 4.64% ± 1.10, respectively.

Conclusion

This study highlights that, among distance runners, both males and females are at risk of eating disorders, with females being at higher risk. It also emphasizes the need for screening for risk of eating disorders in this population.

The value of tibial mounted inertial measurement units to quantify running kinetics in elite football (soccer) players. A reliability and agreement study using a research orientated and a clinically orientated system

In elite football, measurement of running kinetics with inertial measurement units (IMUs) may be useful as a component of periodic health examination (PHE). This study determined the reliability of, and agreement between a research orientated IMU and clinically orientated IMU system for initial peak acceleration (IPA) and IPA symmetry index (SI) measurement during running in elite footballers. On consecutive days, 16 participants performed treadmill running at 14kmph and 18kmph. Both IMUs measured IPA and IPA SI concurrently. All measurements had good or excellent within-session reliability (intraclass correlation coefficient (ICC_2,1) range = 0.79-0.96, IPA standard error of measurement (SEM) range = 0.19-0.62 g, IPA SI SEM range = 2.50-8.05%). Only the research orientated IMU demonstrated acceptable minimal detectable changes (MDCs) for IPA at 14kmph (range = 7.46-9.80%) and IPA SI at both speeds (range = 6.92-9.21%). Considering both systems, between-session IPA reliability ranged from fair to good (ICC_2,1 range = 0.63-0.87, SEM range = 0.51-1.10 g) and poor to fair for IPA SI (ICC_2,1 range = 0.32-0.65, SEM range = 8.07-11.18%). All MDCs were >10%. For IPA and SI, the 95% levels of agreement indicated poor between system agreement. Therefore, the use of IMUs to evaluate treadmill running kinetics cannot be recommended in this population as a PHE test to identify prognostic factors for injuries or for rehabilitation purposes.

A study protocol for the development and internal validation of a multivariable prognostic model to determine lower extremity muscle injury risk in elite football (soccer) players, with further exploration of prognostic factors

BACKGROUND

Indirect muscle injuries (IMIs) are a considerable burden to elite football (soccer) teams, and prevention of these injuries offers many benefits. Preseason medical, musculoskeletal and performance screening (termed periodic health examination (PHE)) can be used to help determine players at risk of injuries such as IMIs, where identification of PHE-derived prognostic factors (PF) may inform IMI prevention strategies. Furthermore, using several PFs in combination within a multivariable prognostic model may allow individualised IMI risk estimation and specific targeting of prevention strategies, based upon an individual's PF profile. No such models have been developed in elite football and the current IMI prognostic factor evidence is limited. This study aims to (1) develop and internally validate a prognostic model for individualised IMI risk prediction within a season in elite footballers, using the extent of the prognostic evidence and clinical reasoning; and (2) explore potential PHE-derived PFs associated with IMI outcomes in elite footballers, using available PHE data from a professional team.

METHODS

This is a protocol for a retrospective cohort study. PHE and injury data were routinely collected over 5 seasons (1 July 2013 to 19 May 2018), from a population of elite male players aged 16-40 years old. Of 60 candidate PFs, 15 were excluded. Twelve variables (derived from 10 PFs) will be included in model development that were identified from a systematic review, missing data assessment, measurement reliability evaluation and clinical reasoning. A full multivariable logistic regression model will be fitted, to ensure adjustment before backward elimination. The performance and internal validation of the model will be assessed. The remaining 35 candidate PFs are eligible for further exploration, using univariable logistic regression to obtain unadjusted risk estimates. Exploratory PFs will also be incorporated into multivariable logistic regression models to determine risk estimates whilst adjusting for age, height and body weight.

DISCUSSION

This study will offer insights into clinical usefulness of a model to predict IMI risk in elite football and highlight the practicalities of model development in this setting. Further exploration may identify other relevant PFs for future confirmatory studies and model updating, or influence future injury prevention research.

Assessing the utility of yearly pre-season laboratory screening for athletes on a major professional sports team

OBJECTIVES

Professional athletes undergo annual pre-season laboratory screening, although clinical evidence supporting the practice is limited and no uniform set of guidelines on pre-season laboratory screening exists. The aim of this study was to assess the clinical value of annual pre-season laboratory screening tests for a major professional sports team over multiple years.

DESIGN

Retrospective chart review.

METHODS

A retrospective analysis was performed of all laboratory results as well as screening ECGs for a single major professional sports team over a 9-year timeframe (2009-2017).

RESULTS

The data show that 10.01% of initial screening test results were abnormal and 40.32% of abnormal tests resulted in additional testing. Overall, only 0.35% of initial tests resulted in a clinically significant outcome. Non-US born players showed a significantly higher average rate of abnormal tests/year compared to US-born players (p-value 0.006), but there was no difference in clinically significant outcomes. There was no relationship between athlete age and laboratory screening outcomes.

CONCLUSIONS

In our study population, yearly pre-season laboratory screening of professional athletes did not yield substantial clinically significant outcomes and would not be warranted under normal clinical standards. Future best practice guidelines should combine research concerning effects of family medical history, race, gender, country of origin, and type of sport on athlete health when creating recommendations for which pre-season laboratory screenings may be pertinent even with evidence of little utility.

A Review of Prevention, Diagnosis, and Treatment of Relative Energy Deficiency in Sport in Artistic (Synchronized) Swimming

The syndrome of relative energy deficiency in sport (RED-S) is a clinical entity characterized by low energy availability, which can negatively affect the health and performance of both male and female athletes. The underlying mechanism of RED-S is an inadequacy of dietary energy to support optimal health and performance. This syndrome refers to impaired physiological function, including metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health, with psychological consequences that can either precede (through restrictive dietary habits) or result from RED-S. The term RED-S extends beyond the condition termed the "Female Athlete Triad." Formerly known as synchronized swimming, artistic swimming is an Olympic sport requiring a high level of fitness as well as technical skill and artistry. The risk of RED-S is high in artistic swimming as it is an aesthetic, judged sport with an emphasis on a lean physique. RED-S is of significant concern in the sport of artistic swimming because of the potential negative effects on physical and mental health as well as consequences on athletic performance. This paper reviews health and performance consequences associated with low energy availability resulting in RED-S in artistic swimming. Medical and nutritional considerations specific to artistic swimming are reviewed, and methods to help detect and manage RED-S are discussed. Prevention and management of RED-S in this athlete population should be a priority for coaches, and the sport medicine professionals working with artistic swimming athletes should utilize the RED-S CAT, a Clinical Assessment Tool for screening and managing RED-S.

Musculoskeletal examination in young athletes and non-athletes: the Finnish Health Promoting Sports Club (FHPSC) study

Objectives

To determine the inter-rater repeatability of a musculoskeletal examination and to compare findings between adolescent athletes and non-athletes in Finland.

Methods

In this cross-sectional study, a musculoskeletal examination assessing posture, mobility and movement control was carried out by a sports and exercise medicine physician on 399 athletes aged 14–17 years and 177 non-athletes. Within 2 weeks another sports and exercise medicine physician repeated the examination for 41 adolescents to test the inter-rater repeatability.

Results

In total, 10 of the 11 tests performed had at least moderate inter-rater reliability (κ ≥0.4 or percentage agreement >80%). Athletes more often than non-athletes had one shoulder protruded (8.0% vs 4.0%, OR 2.81, 95% CI 1.16 to 6.81). Forty-six per cent of athletes had good knee control in the two-legged vertical drop jump test compared with 32% of non-athletes (OR 1.99, 95% CI 1.29 to 3.06). Athletes had better core muscle control with 86.3% being able to remain in the correct plank position for 30 s compared with 68.6% of non-athletes (OR 2.70, 95% CI 1.67 to 4.36). In the deep squat test, good lumbar spine control was maintained only by 35.8% of athletes and 38.4% of non-athletes.

Conclusion

A basic musculoskeletal examination is sufficiently reliable to be performed by trained physicians as a part of a periodic health evaluation. Shortfalls in mobility, posture and movement control are common in both athletes and non-athletes. These deficits could have been caused by sedentary behaviour, monotonous training, or both.

Muscle Strength Is a Poor Screening Test for Predicting Lower Extremity Injuries in Professional Male Soccer Players: A 2-Year Prospective Cohort Study

BACKGROUND

Lower extremity muscle strength tests are commonly used to screen for injury risk in professional soccer. However, there is limited evidence on the ability of such tests in predicting future injuries.

PURPOSE

To examine the association between hip and thigh muscle strength and the risk of lower extremity injuries in professional male soccer players.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Professional male soccer players from 14 teams in Qatar underwent a comprehensive strength assessment at the beginning of the 2013/2014 and 2014/2015 seasons. Testing consisted of concentric and eccentric quadriceps and hamstring isokinetic peak torques, eccentric hip adduction and abduction forces, and bilateral isometric adductor force (squeeze test at 45°). Time-loss injuries and exposure in training and matches were registered prospectively by club medical staff throughout each season. Univariate and multivariate Cox regression analyses were used to calculate hazard ratios (HRs) with 95% CIs.

RESULTS

In total, 369 players completed all strength tests and had registered injury and exposure data. Of these, 206 players (55.8%) suffered 538 lower extremity injuries during the 2 seasons; acute muscle injuries were the most frequent. Of the 20 strength measures examined, greater quadriceps concentric peak torque at 300 deg/s (HR, 1.005 [95% CI, 1.00-1.01]; P = .037) was the only strength measure identified as significantly associated with a risk of lower extremity injuries in multivariate analysis. Greater quadriceps concentric peak torque at 60 deg/s (HR, 1.004 [95% CI, 1.00-1.01]; P = .026) was associated with the risk of overuse injuries, and greater bilateral adductor strength adjusted for body weight (HR, 0.75 [95% CI, 0.57-0.97; P = .032) was associated with a lower risk for any knee injury. Receiver operating characteristic curve analyses indicated poor predictive ability of the significant strength variables (area under the curve, 0.45-0.56).

CONCLUSION

There was a weak association with the risk of lower extremity injuries for 2 strength variables: greater quadriceps concentric muscle strength at (1) high and (2) low speeds. These associations were too small to identify an "at-risk" player. Therefore, strength testing, as performed in the present study, cannot be recommended as a screening test to predict injuries in professional male soccer.

An investigation into the immediate effects of pelvic taping on hamstring eccentric force in an elite male sprinter - A case report

BACKGROUND

Hamstring Injuries commonly cause missed training and competition time in elite sports. Injury surveillance studies have demonstrated high injury and re-injury rates, which have not improved across sports despite screening and prevention programmes being commonplace. The most commonly suggested intervention for hamstring prevention and rehabilitation is eccentric strength assessment and training.

CASE DESCRIPTION

This case study describes the management of an elite sprinter with a history of hamstring injury. A multi-variate screening process based around lumbar-pelvic dysfunction and hamstring strength assessment using the Nordbord is employed. The effect of external pelvic compression using a taping technique, on eccentric hamstring strength is evaluated.

OUTCOMES

A persistent eccentric strength asymmetry of 17% was recorded as well as lumbar-pelvic control deficits. Pelvic taping appears to improve load transfer capability across the pelvis, resulting in correction of eccentric strength asymmetry.

DISCUSSION

Screening strategies and interventions to prevent hamstring injury have failed to consistently improve injury rates across various sports. In this case study external pelvic compression resulted in normalising eccentric strength deficits assessed using the Nordbord. The inclusion of lumbar-pelvic motor control assessment, in relation to hamstring strength and function, as part of a multi-variate screening strategy requires further research.

Emergency response facilities including primary and secondary prevention strategies across 79 professional football clubs in England

Aim

To assess the emergency response planning and prevention strategies for sudden cardiac arrest (SCA) across a wide range of professional football clubs in England.

Methods

A written survey was sent to all professional clubs in the English football league, namely the Premiership, Championship, League 1 and League 2. Outcomes included: (1) number of clubs performing cardiac screening and frequency of screening; (2) emergency planning and documentation; (3) automated external defibrillator (AED) training and availability; and (4) provision of emergency services at sporting venues.

Results

79 clubs (86%) responded to the survey. 100% clubs participated in cardiac screening. All clubs had AEDs available on match days and during training sessions. 100% Premiership clubs provided AED training to designated staff. In contrast, 30% of lower division clubs with AEDs available did not provide formal training. Most clubs (n=66; 83%) reported the existence of an emergency action plan for SCA but formal documentation was variable. All clubs in the Premiership and League 1 provided an ambulance equipped for medical emergencies on match days compared with 75% of clubs in the Championship and 66% in League 2.

Conclusions

The majority of football clubs in England have satisfactory prevention strategies and emergency response planning in line with European recommendations. Additional improvements such as increasing awareness of European guidelines for emergency planning, AED training and mentorship with financial support to lower division clubs are necessary to further enhance cardiovascular safety of athletes and spectators and close the gap between the highest and lower divisions.

The functional movement test 9+ is a poor screening test for lower extremity injuries in professional male football players: a 2-year prospective cohort study

Background

The 9+ screening battery test consists of 11 tests to assess limitations in functional movement.

Aim

To examine the association of the 9+ with lower extremity injuries and to identify a cut-off point to predict injury risk.

Methods

Professional male football players in Qatar from 14 teams completed the 9+ at the beginning of the 2013/2014 and 2014/2015 seasons. Time-loss injuries and exposure in training and matches were registered prospectively by club medical staff during these seasons. Univariate and multivariate Cox regression analyses were used to calculate HR and 95% CI. Receiver operating characteristic (ROC) curves were calculated to determine sensitivity and specificity and identify the optimal cut-off point for risk assessment.

Results

362 players completed the 9+ and had injury and exposure registration. There were 526 injuries among 203 players (56.1%) during the two seasons; injuries to the thigh were the most frequent. There was no association between 9+ total score and the risk of lower extremity injuries (HR 1.02, 95% CI 0.99 to 1.05, p=0.13), even after adjusting for other risk factors in a multivariate analysis (HR 1.01, 95% CI 0.98 to 1.04, p=0.37). ROC curve analysis revealed an area under the curve of 0.48, and there was no cut-off point that distinguished injured from non-injured players.

Conclusion

The 9+ was not associated with lower extremity injury, and it was no better than chance for distinguishing between injured and uninjured players. Therefore, the 9+ test cannot be recommended as an injury prediction tool in this population.

Interseason variability of a functional movement test, the 9+ screening battery, in professional male football players

BACKGROUND

The Nine Plus screening battery test (9+) is a functional movement test intended to identify limitations in fundamental movement patterns predisposing athletes to injury. However, the interseason variability is unknown.

AIM

To examine the variability of the 9+ test between 2 consecutive seasons in professional male football players.

METHODS

Asymptomatic Qatar Star League players (n=220) completed the 9+ at the beginning of the 2013 and 2014 seasons. Time-loss injuries in training and matches were obtained from the Aspetar Injury and Illness Surveillance Program. No intervention was initiated between test occasions.

RESULTS

A significant increase in the mean total score of 1.6 points (95% CI 1.0 to 2.2, p<0.001) was found from season 1 (22.2±4.1 (SD)) to season 2 (23.8±3.3). The variability was large, as shown by an intraclass correlation coefficient (ICC) of 0.24 (95% CI 0.11 to 0.36) and a minimal detectable change (MDC) of 8.7 points. Of the 220 players, 136 (61.8%) suffered a time-loss injury between the 2 tests. There was an improvement in mean total scores in the injured (+2.0±0.4 (SE), p<0.001) group but not in the uninjured group (+0.9±0.5, p=0.089). The variability from season 1 to season 2 was large both in the injured (ICC 0.25, 0.09 to 0.40, MDC 8.3) and uninjured (ICC 0.24, 0.02 to 0.43, MDC 9.1) groups.

CONCLUSIONS

The 9+ demonstrated substantial intraindividual variability in the total score between 2 consecutive seasons, irrespective of injury. A change above 8 points is necessary to represent a real change in the 9+ test between seasons.

Health conditions detected in a comprehensive periodic health evaluation of 558 professional football players

BACKGROUND

Despite the widespread use of periodic health evaluation (PHE) to detect and prevent injury and illness in athletes, its effectiveness in detecting health conditions and relevant risk factors is still debated.

AIM

To assess health conditions detected by a comprehensive PHE in professional male football players and evaluate their consequences for participation clearance.

METHODS

A total of 558 professional football players in Qatar completed a PHE prior to the 2013 or 2014 seasons: history, general medical (including blood test), cardiovascular (12-lead ECG and echocardiography) and a musculoskeletal examination, including a specific test battery targeting lower extremity strength and flexibility. On the basis of the PHE, players were either cleared or not cleared for participation.

RESULTS

In 533 players (95.5%), at least one health condition was detected requiring treatment or follow-up. Vitamin D deficiency or insufficiency (≤30 ng/mL) was the most common medical condition (n=499, 89.4%), followed by hepatitis B non-immunity or infection (n=164, 29.4%). Cardiac screening identified 48 players (8.6%) with one or more abnormal findings (ECG (n=19, 3.4%) and echocardiography (n=14, 2.5%)). Musculoskeletal conditions were observed in 180 players (32.3%); injuries to or strength deficits of the hip/groin and thigh accounted for the largest proportion. Medical clearance was temporarily not given in 69 players (12.4%), while further examinations were being conducted. One player was disqualified from competitive football.

CONCLUSIONS

PHE revealed a high prevalence of health conditions requiring treatment or follow-up in professional footballers; however, only 12.4% of conditions impacted on final clearance for participation.

The multi-modality cardiac imaging approach to the Athlete's heart: an expert consensus of the European Association of Cardiovascular Imaging

The term 'athlete's heart' refers to a clinical picture characterized by a slow heart rate and enlargement of the heart. A multi-modality imaging approach to the athlete's heart aims to differentiate physiological changes due to intensive training in the athlete's heart from serious cardiac diseases with similar morphological features. Imaging assessment of the athlete's heart should begin with a thorough echocardiographic examination.Left ventricular (LV) wall thickness by echocardiography can contribute to the distinction between athlete's LV hypertrophy and hypertrophic cardiomyopathy (HCM). LV end-diastolic diameter becomes larger (>55 mm) than the normal limits only in end-stage HCM patients when the LV ejection fraction is <50%. Patients with HCM also show early impairment of LV diastolic function, whereas athletes have normal diastolic function.When echocardiography cannot provide a clear differential diagnosis, cardiac magnetic resonance (CMR) imaging should be performed.With CMR, accurate morphological and functional assessment can be made. Tissue characterization by late gadolinium enhancement may show a distinctive, non-ischaemic pattern in HCM and a variety of other myocardial conditions such as idiopathic dilated cardiomyopathy or myocarditis. The work-up of athletes with suspected coronary artery disease should start with an exercise ECG. In athletes with inconclusive exercise ECG results, exercise stress echocardiography should be considered. Nuclear cardiology techniques, coronary cardiac tomography (CCT) and/or CMR may be performed in selected cases. Owing to radiation exposure and the young age of most athletes, the use of CCT and nuclear cardiology techniques should be restricted to athletes with unclear stress echocardiography or CMR.

The Psychological Impact of Cardiovascular Screening in Young Athletes: Perspectives Across Age, Race, and Gender

OBJECTIVE

To determine the psychological impact of electrocardiogram (ECG) screening in young competitive athletes based on age, race, and gender.

DESIGN

Prospective multisite cross-sectional investigation.

SETTING

Young competitive athletes.

PATIENTS

One thousand five hundred six high school athletes (59.3% male with a mean age of 15.5 years, 56.2% white, 24.5% African American).

INDEPENDENT VARIABLES

Athletes underwent screening with a standardized American Heart Association-based history, physical examination, and ECG.

MAIN OUTCOME MEASURES

Prescreen and postscreen validated assessments for health attitudes, anxiety, and impact of screening on sport.

RESULTS

Of the athletes participated, 76.3% had normal screens, 22.7% false-positive (FP) results (12.9% history, 4.2% examination, 3.1% ECG), and 0.9% were diagnosed with serious cardiac disorders. There were no differences in anxiety levels among athletes screening normal versus FP (P = 0.69). There was no difference in anxiety based on the reason for a FP result (history, physical examination, or ECG) both during (P = 0.95) and after (P = 0.40) screening. Analysis by age, race, and gender demonstrated that before screening, females were more likely to prefer knowing about underlying cardiac conditions compared with males (P < 0.001), and males were less concerned about having cardiac disease (P < 0.001) compared with females. African Americans were less concerned about underlying disease (P < 0.001) and less interested (P < 0.001) in cardiac screening compared with whites. Athletes diagnosed with a cardiac disease described anxiety after screening, but still believe that all athletes should receive an ECG before competition.

CONCLUSIONS

Electrocardiogram screening does not cause excessive anxiety in US high school athletes across spectrums of age, race, and gender. Recognition of age, race, and gender-specific perspectives could improve physician-patient dialogue and support mechanisms for those diagnosed with potentially lethal cardiac disorders.

CLINICAL RELEVANCE

This article provides evidence that undue anxiety should not be used as an argument against the implementation of ECG screening during the preparticipation examinaton for young athletes. Although males and African Americans seem to be at highest risk for sudden cardiac death during exercise, they actually report being the least concerned and least worried about potentially harboring an underlying condition that might predispose them to such an event. Emotional support should readily be available for athletes who are diagnosed with cardiovascular conditions as these individuals report emotional distress after their diagnosis.

Injuries and illnesses in the preparticipation evaluation data of 1693 college student-athletes

BACKGROUND

While the preparticipation evaluation (PPE) is widely used by medical practitioners, its overall effectiveness is unknown, in part because there are no standardized or centralized mechanisms to collect and analyze medical history information.

PURPOSE

To report on the injuries and illnesses identified with the use of an electronic PPE (ePPE) completed by first-time National Collegiate Athletic Association Division 1 varsity sport participants (N = 1693; 797 women, 896 men) upon entry to a single institution between 2010 and 2013.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

RESULTS

In total, 3126 discrete past injuries were reported (women, 1473 injuries; men, 1653 injuries). Time loss from sport participation averaged 31.4 days for each injury (women, 32.2 days; men, 30.7 days), and aggregate time loss from sport for all student-athletes before the ePPE was 256 years. Eleven percent of student-athletes had injuries that were unresolved and still symptomatic at the time of the ePPE. Thirty percent of injured student-athletes had a history of ≥1 surgeries for an injury (women, 176; men, 213), and these accounted for 57% of the time lost from sport before college participation. Head injuries accounted for 9% (110 women, 173 men), and loss of consciousness was reported in 19% of these. One in 3 student-athletes answered "yes" to ≥1 of the American Heart Association questions on cardiovascular health. While 15% of women reported a history of stress fracture, only 3% reported a diagnosed eating disorder.

CONCLUSION

While some data in this population are self-evident, we were not aware of the high frequency of past injuries, the magnitude of time lost from sport, the high frequency of past surgery, and the number of participants still symptomatic from injuries. The ePPE is a valuable tool for collecting and analyzing aggregate injury and illness data in athletes, such as the finding that 11% of injuries that were reported were unresolved and still symptomatic.

Modern standards of ECG interpretation in young athletes: yield and effectiveness

Although cardiovascular screening is recommended before participating in competitive sports, the role of the 12-lead electrocardiogram (ECG) has been debated. When added to the medical history and physical examination, an ECG used during the pre-participation screening (PPS) of young athletes can greatly enhance the ability to detect underlying cardiovascular pathology. Concerns over false positive rates, however, have posed an obstacle to large-scale implementation. The recent development of modern athlete-specific ECG interpretation criteria has dramatically reduced false positive rates to levels below other commonly used screening tests (e.g. breast cancer, prostate cancer) and subsequently improved cost effectiveness. There are also emerging data that certain sub-groups have a higher prevalence of ECG abnormalities, including males, athletes of Afro-Caribbean descent, basketball players, and endurance athletes. While false positive rates from a number of studies are reduced with the improved standards, there may be room for continued improvements. Future efforts should focus on refining criteria based on age, race, gender, ethnicity, and sport, while also clearly delineating the appropriate work-up strategies for those with abnormal findings, as this can lead to improved resource utilization.

The impact of triathlon training and racing on athletes' general health

Although the sport of triathlon provides an opportunity to research the effect of multi-disciplinary exercise on health across the lifespan, much remains to be done. The literature has failed to consistently or adequately report subject age group, sex, ability level, and/or event-distance specialization. The demands of training and racing are relatively unquantified. Multiple definitions and reporting methods for injury and illness have been implemented. In general, risk factors for maladaptation have not been well-described. The data thus far collected indicate that the sport of triathlon is relatively safe for the well-prepared, well-supplied athlete. Most injuries 'causing cessation or reduction of training or seeking of medical aid' are not serious. However, as the extent to which they recur may be high and is undocumented, injury outcome is unclear. The sudden death rate for competition is 1.5 (0.9-2.5) [mostly swim-related] occurrences for every 100,000 participations. The sudden death rate is unknown for training, although stroke risk may be increased, in the long-term, in genetically susceptible athletes. During heavy training and up to 5 days post-competition, host protection against pathogens may also be compromised. The incidence of illness seems low, but its outcome is unclear. More prospective investigation of the immunological, oxidative stress-related and cardiovascular effects of triathlon training and competition is warranted. Training diaries may prove to be a promising method of monitoring negative adaptation and its potential risk factors. More longitudinal, medical-tent-based studies of the aetiology and treatment demands of race-related injury and illness are needed.

What is a sports injury?

Current sports injury reporting systems lack a common conceptual basis. We propose a conceptual foundation as a basis for the recording of health problems associated with participation in sports, based on the notion of impairment used by the World Health Organization. We provide definitions of sports impairment concepts to represent the perspectives of health services, the participants in sports and physical exercise themselves, and sports institutions. For each perspective, the duration of the causative event is used as the norm for separating concepts into those denoting impairment conditions sustained instantly and those developing gradually over time. Regarding sports impairment sustained in isolated events, 'sports injury' denotes the loss of bodily function or structure that is the object of observations in clinical examinations; 'sports trauma' is defined as an immediate sensation of pain, discomfort or loss of functioning that is the object of athlete self-evaluations; and 'sports incapacity' is the sidelining of an athlete because of a health evaluation made by a legitimate sports authority that is the object of time loss observations. Correspondingly, sports impairment caused by excessive bouts of physical exercise is denoted as 'sports disease' (overuse syndrome) when observed by health service professionals during clinical examinations, 'sports illness' when observed by the athlete in self-evaluations, and 'sports sickness' when recorded as time loss from sports participation by a sports body representative. We propose a concerted development effort in this area that takes advantage of concurrent ontology management resources and involves the international sporting community in building terminology systems that have broad relevance.

Advancing the preparticipation physical evaluation: an ACSM and FIMS joint consensus statement

: While the preparticipation physical evaluation (PPE) is widely accepted, its usage and content are not standardized. Implementation is affected by cost, access, level of participation, participant age/sex, and local/regional/national mandate. Preparticipation physical evaluation screening costs are generally borne by the athlete, family, or club. Screening involves generally agreed-upon questions based on expert opinion and tested over decades of use. No large-scale prospective controlled tracking programs have examined PPE outcomes. While the panel did not reach consensus on electrocardiogram (ECG) screening as a routine part of PPE, all agreed that a history and physical exam focusing on cardiac risk is essential, and an ECG should be used where risk is increased. The many areas of consensus should help the American College of Sports Medicine and Fédération Internationale du Médicine du Sport in developing a universally accepted PPE. An electronic PPE, using human-centered design, would be comprehensive, would provide a database given that PPE is mandatory in many locations, would simplify PPE administration, would allow remote access to clinical data, and would provide the much-needed data for prospective studies in this area.