Anterior cruciate ligament injury: towards a gendered environmental approach

Toward designing human intervention studies to prevent osteoarthritis after knee injury: A report from an interdisciplinary OARSI 2023 workshop

Objective

The global impact of osteoarthritis is growing. Currently no disease modifying osteoarthritis drugs/therapies exist, increasing the need for preventative strategies. Knee injuries have a high prevalence, distinct onset, and strong independent association with post-traumatic osteoarthritis (PTOA). Numerous groups are embarking upon research that will culminate in clinical trials to assess the effect of interventions to prevent knee PTOA despite challenges and lack of consensus about trial design in this population. Our objectives were to improve awareness of knee PTOA prevention trial design and discuss state-of-the art methods to address the unique opportunities and challenges of these studies.

Design

An international interdisciplinary group developed a workshop, hosted at the 2023 Osteoarthritis Research Society International Congress. Here we summarize the workshop content and outputs, with the goal of moving the field of PTOA prevention trial design forward.

Results

Workshop highlights included discussions about target population (considering risk, homogeneity, and possibility of modifying osteoarthritis outcome); target treatment (considering delivery, timing, feasibility and effectiveness); comparators (usual care, placebo), and primary symptomatic outcomes considering surrogates and the importance of knee function and symptoms other than pain to this population.

Conclusions

Opportunities to test multimodal PTOA prevention interventions across preclinical models and clinical trials exist. As improving symptomatic outcomes aligns with patient and regulator priorities, co-primary symptomatic (single or aggregate/multidimensional outcome considering function and symptoms beyond pain) and structural/physiological outcomes may be appropriate for these trials. To ensure PTOA prevention trials are relevant and acceptable to all stakeholders, future research should address critical knowledge gaps and challenges.

A Biopsychosocial Model for Understanding Training Load, Fatigue, and Musculoskeletal Sport Injury in University Athletes: A Scoping Review

ABSTRACT

McClean, ZJ, Pasanen, K, Lun, V, Charest, J, Herzog, W, Werthner, P, Black, A, Vleuten, RV, Lacoste, E, and Jordan, MJ. A biopsychosocial model for understanding training load, fatigue, and musculoskeletal sport injury in university athletes: A scoping review. J Strength Cond Res 38(6): 1177-1188, 2024-The impact of musculoskeletal (MSK) injury on athlete health and performance has been studied extensively in youth sport and elite sport. Current research examining the relationship between training load, injury, and fatigue in university athletes is sparse. Furthermore, a range of contextual factors that influence the training load-fatigue-injury relationship exist, necessitating an integrative biopsychosocial model to address primary and secondary injury prevention research. The objectives of this review were (a) to review the scientific literature examining the relationship between training load, fatigue, and MSK injury in university athletes and (b) to use this review in conjunction with a transdisciplinary research team to identify biopsychosocial factors that influence MSK injury and develop an updated, holistic biopsychosocial model to inform injury prevention research and practice in university sport. Ten articles were identified for inclusion in this review. Key findings were an absence of injury surveillance methodology and contextual factors that can influence the training load-fatigue-MSK injury relationship. We highlight the inclusion of academic load, social load, and mental health load as key variables contributing to a multifactorial, gendered environmental, scientific inquiry on sport injury and reinjury in university sport. An integrative biopsychosocial model for MSK injury in university sport is presented that can be used to study the biological, psychological, and social factors that modulate injury and reinjury risk in university athletes. Finally, we provide an example of how causal inference can be used to maximize the utility of longitudinally collected observational data that is characteristic of sport performance research in university sport.

Symptomatology and knowledge regarding pelvic floor dysfunctions and influence of gender stereotypes in female athletes

Pelvic floor dysfunctions (PFD) are highly prevalent among females who do athletics, a sport requiring jumping, strength, and running. Although educational approaches are useful options, the educational need for this particular population remains unknown. The objective of the present study was to describe the level of knowledge regarding PFD and its relationship with symptomatology and gender stereotypes in female athletes in Spain. A total of 255 female athletes completed an anonymous online survey to explore their knowledge regarding urinary incontinence (UI), pelvic organ prolapse (POP), anal incontinence (AI), and sexual dysfunction (SexD), as well as their PFD symptoms and gender stereotyped beliefs related to sport. Educational level and sports characteristics (training volume, experience, and athletic modality) were also explored. Participants demonstrated a low level of knowledge in terms of POP (52.5%), AI (64.0%), and SexD (40%), but not for UI (70.8%). The proportion of PFD complaints was 63.5% for dyspareunia, 51.8% for urine leakage, 42.4% for pelvic pain, 17.3% for AI, and 9.0% for POP, with no associations with knowledge (p > 0.05). Lower knowledge about UI and SexD was related to greater gender stereotypes (p < 0.05) and rejection of professional healthcare (p = 0.010). As a conclusion, the level of knowledge about PFD was low in female athletes who train and compete in athletics in Spain, mainly with regard to sexual dysfunction. Although 63.5% of athletes had dyspareunia and 51.8% urinary leakages, symptomatology was not associated with level of knowledge. However, a lower level of knowledge was associated with more stereotyped beliefs and rejection of professional healthcare for PFD. These findings confirm the need to design appropriate educational interventions to disseminate information on all the types of PFD, particularly sexual contents. The potential influence of gender stereotypes makes it appropriate to include the gender perspective in these interventions.

'It's just my knee': a qualitative study investigating the process of reframing and young athletes' perceived quality of life between anterior cruciate ligament injury and surgery

OBJECTIVES

To understand the factors influencing young athletes' perceptions of quality of life (QOL) following an anterior cruciate ligament (ACL) rupture, prior to reconstructive surgery.

DESIGN

Qualitative descriptive study using semi-structured interviews and thematic analysis of data.

SETTING

Tertiary sports medicine clinic with patients recruited from the practices of three specialist orthopaedic surgeons.

PARTICIPANTS

Twenty athletes aged 14-25 provided consent to participate in the study and completed interviews prior to their ACL reconstruction surgery. Participants were eligible to participate if they were scheduled to undergo ACL reconstruction, were 25 years of age or younger, identified as athletes (participated in any level of organised sport), could communicate in English and agreed to be audio recorded. Participants were not eligible if they had experienced a multiligament injury or fracture.

RESULTS

Young athletes shared common factors that made up their QOL; social connections and support, sport, health, and independence. However, participants' perceptions of their current QOL were quite variable (13-95/100 on a Visual Analogue Scale). Participants who were able to reframe their injury experience by shifting focus to the positive or unaffected aspects of their lives tended to have more favourable perceptions of their QOL than participants who shifted focus to the losses associated with injury.

CONCLUSIONS

Young athletes who have experienced an ACL injury define their QOL based on social support, sport, health and independence. Individual processes of adaptation and cognitive reframing in response to an ACL injury may exert a greater influence on postinjury QOL than the physical ramifications of the injury itself. Understanding individual perceptions may help target potential interventions or supports to enhance athletes' adaptation to injury.

Barriers and enablers in doping, anti-doping, and clean sport: A qualitative meta-synthesis informed by the theoretical domains framework and COM-B model

To protect the integrity of sport, and the health of athletes, global anti-doping programmes seek to prevent doping, and elicit anti-doping and clean sport behaviours, through education, deterrence, detection, enforcement, and rules. To guide programme development, this meta-synthesis of qualitative research applied a behavioural science framework to identify barriers and enablers to doping, anti-doping, and clean sport. A systematic search of electronic databases up to May 2022, followed by critical appraisal, resulted in 73 included articles. Fifty-two articles reported the athlete perspective, thirteen included athletes, athlete support personnel (ASP), and other experts, and eight focused on ASP only. Rigorous methods of thematic synthesis were drawn upon to construct analytical themes in line with the theoretical domains framework (TDF) and the capability, opportunity, and motivation model of behaviour (COM-B). A wide range of barriers and enablers were identified which influenced capability, opportunity, and motivation to participate in a clean sport environment. The weight of evidence pointed to limitations in the current anti-doping education system in providing athletes and ASP with the knowledge and skills to protect against doping, as well as the significant influence of social and cultural norms in shaping doping and clean sport behaviours through a shared social identity, and risky contexts leading to moments of vulnerability to doping. We identified a need for anti-doping programmes to move beyond the current focus on athlete capability, and address the opportunity and motivation components of clean sport behaviours through a targeted and tailored focus on education, training, persuasion, modelling and environmental restructuring interventions.

Epidemiology of injuries in elite female rink hockey players: A two season observational study

OBJECTIVES

To record the time-loss injuries of female rink hockey players and describe the affected region, tissue, and onset of injury.

DESIGN

Cross-sectional survey study.

SETTING

First (Ok Liga) and Second (Plata) division clubs.

PARTICIPANTS

280 player-seasons.

MAIN OUTCOME MEASURES

Incidence of overall, training, and match injuries (number of injuries per 1000 h) from two seasons.

RESULTS

A total of 229 injuries occurred in 56,438 h of exposure. The overall incidence was 4 injuries per 1000 h (4/1000 h), with a significantly higher rate of injuries during matches (15.2/1000 h) compared to training sessions (2.6/1000 h) (p < 0.001). Injuries affecting the lower limb were the most common (2.3/1000 h), followed by upper limb (1.2/1000 h), and head/trunk (0.6/1000 h). The tissue with the highest incidence of injury was the muscle/tendon (1.3/1000 h), followed by the ligament (0.8/1000 h). Around one in every three injuries (31%) affected either the thigh or hip/groin (73 injuries).

CONCLUSIONS

The injury incidence in elite female rink hockey is moderate and occurs mainly during match sessions. Preventative measurements should be implemented in rink hockey with a special concern for injuries affecting the thigh, and hip/groin.

Interpersonal Coordination between Female Soccer Players: Leader-Follower Roles within a Collision-Avoidance Task

Background/Purpose

Return to sport decision-making may be improved by assessing an athlete's ability to coordinate movement with opponents in sport. The purpose was to investigate whether previous injuries associated with female soccer players' interpersonal coordination during a collision avoidance task. The authors hypothesized that external perturbations would disrupt the strength and stability of coordinated movement, and that individuals with a history of injury would be less likely to recover coordinated movement.

Study Design

Cross-Sectional.

Methods

Nine female athletes with a history of lower extremity injuries and nine without injuries were paired into dyads. Each dyad completed twenty trials of an externally paced collision-avoidance agility task with an unanticipated perturbation. Participant trajectories were digitized and analyzed using cross-recurrence quantification analysis (CRQA) to determine the strength and stability of interpersonal coordination dynamics. Trials in which participants with injury history assumed leader or follower roles within each dyad were then used to study how dyadic coordination varied across task stages (early, perturbation, and late) using linear mixed effect models. Cohen's d effect sizes were calculated to demonstrate magnitude of differences. In exploratory analysis, psychological readiness (i.e., self-reported knee functioning, fear of injury, and risk-taking propensity) was evaluated for their association with leader-follower status.

Results

Perturbation disrupted the strength (R2=0.65, p<0.001, early=49.7±1.7, perturbation=41.1±1.7, d=0.39) and stability (R2=0.71, p < 0.001, early=65.0±1.6, perturbation=58.0±1.7, d=0.38) of interpersonal coordination regardless of leader-follower status. Individuals with injury history failed to restore coordination after the perturbation compared to control participants (injury=44.2.0±2.1, control=50.8±2.6, d=0.39). Neither demographic nor psychological measures were associated with leader-follower roles (B=0.039, p=0.224).

Conclusion

Individuals with a history of lower extremity injury may have a diminished ability to adapt interpersonal coordination to perturbations, possibly contributing to a higher risk of re-injury.

Level of Evidence

3.

Cardiorespiratory fitness is a risk factor for lower-limb and back injury in law enforcement officers commencing their basic training: a prospective cohort study

We aimed to report the epidemiology of lower-limb and lumbosacral injuries in Police Force recruits. We performed a cohort study of Police Force recruits undergoing a six-month training program with prospective injury data collected between 2018 and 2021. Cardiorespiratory fitness was quantified by the beep-test and police-specific-functional-capacity was quantified using a specifically designed physical performance evaluation (PPE) tool. Injury frequency and prevalence were reported. Fifteen percent (n = 180) of study Police Force recruits (n = 1,181) sustained a lower-limb or lumbosacral injury. The six-month training program significantly improved cardiorespiratory fitness (p < 0.001) and functional capacity (p < 0.001). Increased cardiorespiratory fitness at baseline decreased injury risk (OR = 0.8, 95%CI: 0.66-0.97, p = 0.019). Injury rates decreased over time and females were injured significantly earlier than males (HR = 0.70, 95%CI: 0.52 to 0.95, p = 0.021). Interventions that can pre-condition Police Force recruits prior to the commencement of their basic physical training may reduce the number of lower-limb and lumbosacral injuries.

Socioeconomic deprivation and racialised disparities in competitive athletes with sudden cardiac arrest from the USA

OBJECTIVE

To explore the association of socioeconomic deprivation and racialised outcomes in competitive athletes with sudden cardiac arrest (SCA) in the USA.

METHODS

SCA cases from the National Center for Catastrophic Sports Injury Research (July 2014 to June 2021) were included. We matched Area Deprivation Index (ADI) scores (17 metrics to grade socioeconomic conditions) to the 9-digit zip codes for each athlete's home address. ADI is scored 1-100 with higher scores indicating greater neighbourhood socioeconomic deprivation. Analysis of variance was used to assess differences in mean ADI by racial groups. Tukey post hoc testing was used for pairwise comparisons.

RESULTS

391 cases of SCA in competitive athletes (85.4% male; 16.9% collegiate, 68% high school, 10.7% middle school, 4.3% youth) were identified via active surveillance. 79 cases were excluded due to missing data (19 race, 60 ADI). Of 312 cases with complete data, 171 (54.8%) were white, 110 (35.3%) black and 31 (9.9%) other race. The mean ADI was 40.20 (95% CI 36.64, 43.86) in white athletes, 57.88 (95% CI 52.65, 63.11) in black athletes and 40.77 (95% CI 30.69, 50.86) in other race athletes. Mean ADI was higher in black versus white athletes (mean difference 17.68, 95% CI 10.25, 25.12; p=0.0036) and black versus other race athletes (mean difference 17.11, 95% CI 4.74, 29.47; p<0.0001).

CONCLUSIONS

Black athletes with SCA come from areas with higher neighbourhood socioeconomic deprivation than white or other race athletes with SCA. Our findings suggest that socioeconomic deprivation may be associated with racialised disparities in athletes with SCA.

Meniscal allograft transplantation: A matched-pair analysis reveals worse sport activity level but similar clinical improvement and survival in women compared to men

PURPOSE

The aim of this study was to assess how gender might affect the clinical outcome and survival of meniscal allograft transplantation (MAT).

METHODS

A total of 358 patients (23.2% women, 76.8% men) were treated with fresh-frozen nonirradiated allografts implantated arthroscopically using a single- or double-tunnel technique without bone plugs and peripheral suture to the capsule with 'all-inside' stitches.

RESULTS

Patients were evaluated at baseline and 2-year follow-up with the Lysholm score, visual analogue scale (VAS) pain, the Knee Osteoarthritis Outcome Score (KOOS) subscales and Tegner score. Women presented higher body mass index (p < 0.0005), poorer baseline VAS (p = 0.012), Lysholm score (p = 0.005), KOOS symptom (p = 0.034) and KOOS pain (p = 0.030), Tegner score (preinjury and basal, p < 0.0001 and p = 0.002, respectively), a lower number of previous (p = 0.039) and concurrent (p = 0.001) anterior cruciate ligament reconstructions and a higher number of concurrent procedures (p = 0.032) and distal femoral osteotomies (p = 0.024). Worse results were documented in women at 2 years, with lower Lysholm score (p = 0.024) and Tegner score (p = 0.007) and a lower clinical survival rate (p = 0.03) (67.5% vs. 82.2%) in the overall patient cohort. However, the matched-pair analysis only confirmed a lower Tegner score value at 2 years (p = 0.016), while underlying the interplay of sex, age and concomitant cartilage lesions in determining the clinical outcome. The analysis of this large series of patients affected by postmeniscectomy syndrome and treated with MAT revealed gender differences.

CONCLUSION

While both genders benefited from a significant improvement, the female population presents more often with older age, concomitant cartilage lesions and a lower activity level, all factors contributing towards a lower clinical success after MAT.

LEVEL OF EVIDENCE

Level III, comparative study.

Differences in Biomechanical Determinants of ACL Injury Risk in Change of Direction Tasks Between Males and Females: A Systematic Review and Meta-Analysis

BACKGROUND

Change of direction (COD) movements are associated with non-contact anterior cruciate ligament (ACL) injuries in multidirectional sports. Females appear at increased risk compared to males, which could be attributable to whole body kinematic strategies and greater multiplanar knee joint loads (KJLs) during COD which can increase ACL loading.

OBJECTIVE

The aim of this systematic review and meta-analysis was to examine and quantitatively synthesise the evidence for differences between males and females regarding KJLs and their biomechanical determinants (whole body kinematic strategies determining KJLs) during COD tasks.

METHODS

Databases including SPORTDiscus, Web of Science, and PubMed were systematically searched (July 2021-June 2023) for studies that compared differences in knee joint loads and biomechanical determinants of KJLs during COD between males and females. Inclusion criteria were: (1) females and males with no prior history of ACL injury (18-40 years); (2) examined biomechanical determinants of KJLs and/ or KJLs during COD tasks > 20°; (3) compared ≥ 1 outcome measure between males and females. Studies published between 2000 and 2023 examining a cutting task > 20° with a preceding approach run that compared KJLs or the whole body multiplanar kinematics associated with them, between sexes, using three-dimensional motion analysis.

RESULTS

This meta-analysis included 17 studies with a pooled sample size of 451 participants (227 males, 224 females). Meta-analysis revealed females displayed significantly less peak knee flexion during stance (SMD: 0.374, 95% CI 0.098-0.649, p = 0.008, I2: 0%); greater knee abduction at initial contact (IC) (SMD: 0.687, 95% CI 0.299-1.076, p = 0.001, I2: 55%); less hip internal rotation (SMD: 0.437, 95% CI 0.134-0.741, p = 0.005, I2: 34%) and hip abduction at IC (SMD: -0.454, 95% CI 0.151-0.758, p = 0.003, I2: 33%). No significant differences were observed between males and females for any internal or externally applied KJLs. All retrieved studies failed to control for strength, resistance training or skill history status.

CONCLUSION

No differences were observed in KJLs between males and females despite females displaying greater knee abduction at IC and less peak knee flexion during the stance phase of CODs, which are visual characteristics of non-contact ACL injury. Further research is required to examine if this translates to a similar injury risk, considering morphological differences in strain characteristics of the ACL between males and females. This observation may in part explain the disproportionate ACL injury incidence in female multidirectional athletes. Further higher quality controlled research is required whereby participants are matched by skill training history, resistance training history and strength status to ensure an appropriate comparison between males and females.

Strength Training Frequency and Athletic Performance in High School Girls Basketball Players

This study investigated the effects of a six-week strength training intervention on the physical fitness of female high school athletes, with a focus on training frequency. Twenty-three female high school basketball athletes were recruited and split into two groups: one group participated in strength training once per week (S1), while the other participated in two training sessions per week (S2). The groups were not random as training sessions were voluntary, and some participants were only able to train once per week. Participants were tested before and after the intervention, and the data included: age, body height, body mass, body fat percentage, grip strength, leg/back dynamometer (LBD) strength, a seated medicine ball throw (MBT), a vertical jump (VJ), 505 tests from each foot, 0-5, 0-10, and 0-20 sprint times, and multistage fitness test shuttles. Data were analyzed by a two (time) x two (group) repeated measures analysis of variance (ANOVA; p < 0.05). When significant F ratios were detected in any ANOVA calculations, post hoc pairwise comparisons were conducted using the Bonferroni adjustment procedure. There were significant main effects for time that indicated the following: increased body height, body mass, grip strength, LBD strength, MBT distance, and VJ height, faster 505 times, and slower 0-5 and 0-10 m sprint times (p ≤ 0.021). There were no significant time by group ANOVAs or between-group main effects. These performance changes occurred irrespective of training frequency. High school girls who participate in at least one strength training session per week can improve their strength (grip, LBD), power (MBT, VJ), and change-of-direction speed (505).

Gender and socioecological level differences in stakeholders' perceptions of athlete attrition factors in an Australian high-performance pathway system

OBJECTIVES

This study aimed to build on previous work by the authors. It examines how socioecological level and gender influence high-performance sport system (HPSS) stakeholders' perspectives of the relative importance and feasibility to address athlete attrition factors within an Australian high-performance pathway system (HPPS).

DESIGN

Mixed methods.

METHODS

Sub-analysis was conducted of rating data from 30 participants who had contributed to identifying 83 statements in 13 clusters in a previous Concept Mapping study. The 13 clusters were statistically analysed in 'R' using cumulative link mixed models (CLMMs) to determine differences in perceived importance and feasibility between 1) socioecological levels, and 2) genders.

RESULTS

Mean ratings for 11 and three of the 13 clusters were statistically significantly different between at least two of the five socioecological levels, for importance and feasibility, respectively. Athletes had the largest variation in mean ratings from the most (athlete health 4.59), to least (performance potential 2.83) important cluster, when compared to the other four socioecological levels. There were statistically significant differences between the ratings between genders (Men/Women) for two clusters for each rating scale: Importance: 'athlete health' (M3.33:W3.84 [p 0.012]); 'performance potential' (M3.35:W2.57; [p 0.001]), Feasibility: 'abuse and mismanagement of health' (M2.97:W3.68; [p 0.000]) and 'athlete health' (M2.54:W3.33; [p 0.000]).

CONCLUSIONS

This study highlights the need to implement more robust athlete attrition monitoring protocols. It also highlights the importance of listening to youth athletes' voices, and enabling equal gender representation to ensure holistically tailored environments are created to retain talented athletes in high-performance pathway programmes.

Evaluation of a medical after-care intervention among deselected elite male Academy football players: a pilot study

Objective

This pilot study aimed to evaluate the perception and satisfaction of deselected male Academy professional footballers towards a medical after-care intervention.

Methods

A quasiexperimental study design, with deselected players (aged≥18 years) at a single Premier League Academy during the 2022/2023 season, were invited to participate. The intervention included individualised health recommendations, key medical information and signposting to key support resources. Participants' perceptions and satisfaction were assessed through an electronic survey. Descriptive analyses (mean, SD, frequency and/or range) were performed for all variables.

Results

Twelve out of 15 eligible participants (80% response rate) provided informed consent and completed the survey (mean age: 19.5 years). All (100%) of the participants were satisfied with receiving the medical information. Ten out of 12 (83.3%) participants agreed that all Academy players should receive this medical intervention on deselection. Nine (75%) players felt more prepared for the next steps in their careers due to the medical information shared with them.

Conclusion

Deselected male Academy footballers expressed high satisfaction with an individualised medical intervention which shared key health information and signposted them to important resources (eg, mental health). Future studies across multiple clubs should explore the broader impact of this intervention among deselected male and female Academy footballers. Football clubs should consider integrating a medical after-care process for deselected players as part of routine care.

'Considering the reality, I am very lucky': how professional players and staff perceive injury prevention and performance protection in women's football

OBJECTIVE

To explore the beliefs and perceptions of professional female footballers and staff regarding injury prevention and performance protection in professional women's football.

METHODS

This qualitative study applied semistructured interviews with 18 participants from 3 top-tier teams from 2 countries (Portugal and England) and 4 nationalities, including 2 physiotherapists, 5 players, 3 team doctors, 2 head coaches, 3 strength and conditioning coaches, 2 managers, and 1 head of performance. Data analysis applied constant comparison analysis, using principles of grounded theory. There were no major differences in the perspectives of players and staff, and the findings are presented together.

RESULTS

Identifying and reporting injuries and recognising potential injury risk factors were mentioned to influence the prevention of injury. Participants stated that the growth and evolution of women's football could influence injury risk. Before reaching the professional level, exposure to potential risk factors, such as lack of recovery, limited awareness and opportunities for prevention (eg, preventive exercises and load management strategies), was believed to impact players' injury risk. Players further described their experiences and the 'bumpy road' to becoming a professional player, their current context and potential future improvements for women's football regarding injury prevention and performance protection.

CONCLUSION

Professional female football players face different injury risks during different moments of their careers. According to elite players and staff, amateur and semiprofessionals have limited resources and lack injury prevention strategies. Professional players and staff perceived the current preventive measures as good and relied on the value of individualised care and a multidisciplinary approach. In the future, more resources and structured injury prevention strategies are needed in youth and non-professional levels of women's football to reduce injury risk and allow more players to reach their maximal performance.

Social support and therapeutic relationships intertwine to influence exercise behavior in people with sport-related knee injuries

OBJECTIVE

Explore how social support influences exercise therapy participation and adherence before and after enrolling in an education and exercise therapy intervention (Stop OsteoARthritis, SOAR).

METHODS

Study design: Interpretative description. We sampled participants with sport-related knee injuries from the SOAR randomized controlled trial. SOAR is a virtual, physiotherapist-guided, education and exercise therapy-based knee health program that targets individuals at risk of early osteoarthritis. One-on-one semi-structured interviews were completed, and an inductive approach was guided by Braun & Clarke's reflexive thematic analysis.

RESULTS

Fifteen participants (67% female, median age 26 [19-35] years) were interviewed. Three themes were generated that encapsulated participants' social support experiences that fostered exercise participation: 1) Treat me as a whole person represented the value of social support that went beyond participants' physical needs, 2) Work with me highlighted the working partnership between the clinician and the participant, and 3) Journey with me indicated a need for on-going support is necessary for the long-term management of participants' knee health. A theme of the therapeutic relationship was evident across the findings.

CONCLUSIONS

Insight was gained into how and why perceived support may be linked to exercise behavior, with the therapeutic relationship being potentially linked to perceived support. Social support strategies embedded within an education and exercise therapy program may boost exercise adherence after sport-related knee injuries.

Sport-related concussion research agenda beyond medical science: culture, ethics, science, policy

The Concussion in Sport Group guidelines have successfully brought the attention of brain injuries to the global medical and sport research communities, and has significantly impacted brain injury-related practices and rules of international sport. Despite being the global repository of state-of-the-art science, diagnostic tools and guides to clinical practice, the ensuing consensus statements remain the object of ethical and sociocultural criticism. The purpose of this paper is to bring to bear a broad range of multidisciplinary challenges to the processes and products of sport-related concussion movement. We identify lacunae in scientific research and clinical guidance in relation to age, disability, gender and race. We also identify, through multidisciplinary and interdisciplinary analysis, a range of ethical problems resulting from conflicts of interest, processes of attributing expertise in sport-related concussion, unjustifiably narrow methodological control and insufficient athlete engagement in research and policy development. We argue that the sport and exercise medicine community need to augment the existing research and practice foci to understand these problems more holistically and, in turn, provide guidance and recommendations that help sport clinicians better care for brain-injured athletes.

'More than likely the men come first. That's just very frustrating'. A qualitative exploration of contextual factors affecting the implementation of injury prevention initiatives and the provision of effective injury management in elite-level women's club football in Ireland

OBJECTIVES

The aim of our study was to explore the contextual factors that affect the implementation of football injury prevention initiatives and the provision of effective injury management in the Irish Women's National League (WNL).

METHODS

We used a criterion-based purposive sampling approach to recruit coaches (n=7), players (n=17) and medical personnel (n=8) representing eight of the nine clubs in the WNL to participate in one-to-one semistructured interviews. Our study was located within an interpretivist, constructivist research paradigm. The interview data were analysed using reflexive thematic analysis.

RESULTS

The participants identified academic and work pressures, financial challenges, conflict with college football, inadequate facilities and gender inequity as being barriers to the implementation of injury prevention initiatives and the provision of effective injury management. Financial constraints within clubs were perceived to limit the provision of medical care and strength and conditioning (S&C) support and this was deemed to be associated with a heightened risk of injuries.

CONCLUSION

Specific contextual factors were identified which curtail the implementation of injury prevention initiatives and the provision of effective injury management in elite-level women's club football in Ireland. Gender inequity was identified as one of the factors impacting the availability of high-quality medical care, S&C support, as well as access to training and match facilities. Our results provide new insights that could be used to inform the design and implementation of injury prevention and management initiatives for women football players in Ireland.

All-inside anterior cruciate ligament reconstruction with and without anterolateral ligament reconstruction: a prospective study

BACKGROUND

There is no clear consensus regarding the superiority of a combined anterior cruciate ligament reconstruction (ACLR) with anterolateral ligament reconstruction (ALLR) versus an isolated ACLR. In this study, we compared the postoperative stability profile, complications, and patient-reported outcomes of these procedures.

METHODS

Twenty-one patients with an anterior cruciate ligament (ACL) tear who were either treated by an isolated all-inside ACLR (n = 21) or a combined all-inside ACLR and ALLR (n = 20) were included. The outcomes were evaluated in the last follow-up and included the postoperative stability profile evaluated by the Lachman test, pivot shift test, and KT-1000 side-to-side difference, postoperative complications, and patient-reported outcomes evaluated by the International Knee Documentation Committee (IKDC) score and Lysholm knee scale.

RESULTS

The baseline characteristics of the two groups were not significantly different. The residual Lachman and pivot shift were not significantly different between the two groups (P = 0.41 and P = 0.18, respectively). The mean KT-1000 side-to-side difference was 1.93 ± 1.9 mm in the isolated and 1.635 ± 0.91 mm in the combined group (P = 0.01). The mean improvement of the IKDC score was not significantly different between the isolated and combined groups (24.7 vs. 25.2, P = 0.28). The mean improvement of the Lysholm scale was not significantly different between the isolated and combined groups (33.5 vs. 34.1, P = 0.19). ACL re-rupture occurred in three patients of the isolated group and no patient of the combined group.

CONCLUSION

The outcomes of patients in the present study support performing a combined ALL and ACL reconstruction.

Neo-Natal Castration Leads to Subtle Differences in Porcine Anterior Cruciate Ligament Morphology and Function in Adolescence

Female adolescent athletes are at a higher risk of tearing their anterior cruciate ligament (ACL) than male counterparts. While most work related to hormones has focused on the effects of estrogen to understand the increased risk of ACL injury, there are other understudied factors, including testosterone. The purpose of this study was to determine how surgical castration in the male porcine model influences ACL size and function across skeletal growth. Thirty-six male Yorkshire crossbreed pigs were raised to 3 (juvenile), 4.5 (early adolescent), and 6 months (adolescent) of age. Animals were either castrated (barrows) within 2 weeks after birth or were left intact (boars). Posteuthanasia, joint and ACL size were assessed via MRI, and biomechanics were assessed via a robotic testing system. Joint size increased throughout age, yet barrows had smaller joints than boars. ACL cross-sectional area (CSA), length, volume, and in situ stiffness increased with age, as did the percent contribution of the ACL anteromedial (AM) bundle to resisting loads. Boar ACL, AM bundle, and PL bundle volumes were 19%, 25%, and 15% larger than barrows across ages. However, ACL CSA, in situ stiffness, and bundle contribution were similar between boars and barrows. The barrows had smaller temporal increases in AM bundle function than boars, but these data were highly variable. Early and sustained loss in testosterone leads to subtle differences in ACL morphology but may not influence measures associated with increased injury risk, such as CSA or bundle forces in response to applied loads.

Epidemiology of Anterior Cruciate Ligament Tears in National Collegiate Athletic Association Athletes: 2014/2015-2018/2019

PURPOSE

This study aimed to describe the epidemiology of ACL tears in NCAA men's and women's sports.

METHODS

Injury and exposure data collected within the NCAA Injury Surveillance Program from 2014/2015 to 2018/2019 were analyzed. ACL tear frequencies, injury rates (IR), and injury proportions were used to describe injury incidence by sport, event type, injury mechanism, and injury history. Injury rate ratios (IRR) were used to examine differential injury rates, and injury proportion ratios (IPR) were used to examine differential distributions.

RESULTS

A total of 729 ACL tears were reported from 8,474,401 recorded athlete exposures (AE) during the study period (IR = 0.86 per 10,000 AE), and the competition-related ACL tear rate was higher than the practice-related rate (IRR = 5.52, 95% confidence interval [CI] = 4.75-6.39). Among men's sports, the highest overall ACL tear rate was observed in men's football (IR = 1.44 per 10,000 AE), whereas among women's sports, the highest overall rate was observed in women's soccer (IR = 2.60 per 10,000 AE). Among sex-comparable sports, ACL tear rates were higher in women's basketball, softball, and soccer, as compared with their men's counterparts. ACL tears were more prevalently attributed to player contact mechanisms in men's sports than women's sports (IPR = 1.73, 95% CI = 1.37-2.19), but more prevalently attributed to noncontact mechanisms in women's sports than men's sports (IPR = 1.17, 95% CI = 1.01-1.35).

CONCLUSIONS

ACL tear risk in women's sports continues to warrant attention and prevention efforts. Given the differential rates by event type, future research efforts may also evaluate initiatives to reduce competition-related injury burden in NCAA sports.

'Body on the line': experiences of tackle injury in women's rugby union - a grounded theory study

OBJECTIVES

Tackle-related injuries account for up to 67% of all match injuries in women's rugby union. The perspective of women players on tackle injury can help key stakeholders understand psychosocial determinants of tackle injury risk and prevention. We aimed to capture psychosocial processes that explain tackle injury experiences and behaviours in women's rugby union.

METHODS

We conducted a qualitative study using a grounded theory approach. Adult women players, with at least 1-year senior level experience, were recruited from Europe, South Africa and Canada between December 2021 and March 2022. Data were collected through semistructured interviews and analysed in line with grounded theory coding procedures.

RESULTS

Twenty-one players, aged 20-48 years with a mean 10.6 years of rugby playing experience, participated. In our analysis, we identified three categories central to participants' experiences of tackle injury: (1) embodied understandings of tackle injury, (2) gender and tackle injury risk and (3) influences on tackle injury behaviours. Participants reported a sense of fear in their experience of tackling but felt that tackle injuries were an inevitable part of the game. Tackle injury was described based on performance limitations. Tackle injury risks and behaviours were influenced by gendered factors perpetuated by relations, practices and structures within the playing context of women's rugby union.

CONCLUSION

Women's tackle injury experiences were intertwined with the day-to-day realities of marginalisation and under preparedness. Grounded in the voices of women, we have provided recommendations for key stakeholders to support tackle injury prevention in women's rugby.

Outcomes of Anterior Cruciate Ligament Reconstruction With Independently Tensioned Suture Tape Augmentation at 5-Year Follow-up

BACKGROUND

Reconstruction using autograft remains the gold standard surgical treatment for anterior cruciate ligament (ACL) injuries. However, up to 10% to 15% of patients will suffer a graft failure in the future. Cadaveric studies have demonstrated that the addition of suture tape augmentation to ACL autograft constructs can increase graft strength and reduce elongation under cyclical loading.

PURPOSE/HYPOTHESIS

This study aimed to investigate the clinical outcomes and rerupture rates after ACL reconstruction (ACLR) with suture tape augmentation. We hypothesized that augmentation with suture tape would lead to lower rerupture rates.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients undergoing primary ACLR using hamstring or patellar tendon autografts augmented with suture tape between 2015 and 2019 were recruited prospectively. Patients with multiligament injuries or a concomitant lateral extra-articular procedure were excluded. Patients were observed in person for 6 months, and patient-reported outcome measures (PROMs) were collected at 2 and 5 years postoperatively. All patients were contacted, and records were reviewed to determine the incidence of graft failure. PROMs collected were as follows: Knee injury and Osteoarthritis Outcome Score (KOOS), Veterans RAND 12-Item Health Survey (VR-12), Tegner and Marx activity scores, and visual analog scale for pain (VAS).

RESULTS

A total of 97 patients, with a mean age of 34.7 (±13.4) years, were included (76% men; 52 hamstring and 45 patellar tendon grafts). The mean graft diameter was 8 (±1) mm. There was 1 rerupture (1.1%) out of the 90 patients who were contactable at a mean of 5 years postoperatively. Median KOOS scores at 2 years were as follows: Pain, 94; Symptoms, 86; Activities of Daily Living, 99; Sport and Recreation, 82; and Quality of Life, 81. The postoperative scores were significantly higher than the preoperative scores (P < .001). The VR-12 Physical score improved from 43 preoperatively to 55 at 2 years and remained at 56 at 5 years. The VAS pain, Tegner, and Marx scores were 0, 6, and 9, respectively, at 2 years postoperatively. There was no difference in PROMs between graft types.

CONCLUSION

This study demonstrates encouraging results of suture tape augmentation of autograft ACLR for both hamstring and patellar tendon grafts. The failure rate of 1.1% at a mean follow-up of 5 years is lower than published rates for reconstruction, and PROMs results are satisfactory. The technique is safe to use and may permit a return to the preinjury sporting level with a lower chance of reinjury.

Differences in injury and concussion rates in a cohort of Canadian female and male youth Rugby Union: a step towards targeted prevention strategies

OBJECTIVE

To examine differences in match and training musculoskeletal injury and concussion rates and describe mechanisms of concussion while considering previous playing experience in female and male Canadian high school Rugby Union ('rugby') players.

METHODS

A 2-year prospective cohort study was completed in a high school league (n=361 females, 421 player-seasons; n=429 males, 481 player-seasons) in Calgary, Canada over the 2018 and 2019 rugby playing seasons. Baseline testing was completed at the start of each season and injury surveillance and individual player participation through session attendance was documented to quantify individual-level player exposure hours. Injury incidence rates (IRs) and incidence rate ratios (IRRs) were calculated using Poisson regression, offset by player exposure hours and clustered by team.

RESULTS

Overall match IR for females was 62% higher than males (overall IRR=1.62, 95% CI: 1.20 to 2.18) and the overall training IR was twice as high for females (overall IRR=2.15, 95% CI: 1.40 to 3.32). The female match concussion IR was 70% higher than the males (concussion IRR=1.70, 95% CI: 1.08 to 2.69). Females had a 75% greater tackle-related IR compared with males (IRR=1.75, 95% CI: 1.20 to 2.56). Additionally, female tacklers had a twofold greater rate of injury compared with male tacklers (IRR=2.17, 95% CI: 1.14 to 4.14). Previous playing experience was not associated with tackle-related injury or concussion IRs.

CONCLUSION

The rate of injury and concussion was significantly higher in females within this Canadian high school cohort. These results emphasise the need for development, implementation and evaluation of female-specific injury and concussion prevention strategies to reduce injury and concussion in female youth rugby.

Cumulative Incidence of All-Cause Knee Injury, Concussion, and Stress Fracture among Transgender Patients on Gender-Affirming Hormone Therapy: An Exploratory Retrospective Cohort Study

Previous research has shown a discrepancy in incidences of knee injuries, stress fractures, and concussions between cisgender men and women. Little is known regarding the incidence of musculoskeletal injuries among patients on gender-affirming hormone therapy (GAHT). This retrospective cohort study examines cumulative incidence of knee injuries, concussions, and stress fracture injuries among transgender patients on GAHT at one health system from 2011-2020. Using relevant ICD-9 and 10 codes, incidences of knee injury, concussion, and stress fracture were calculated. Cohorts included 1971 transgender and 3964 cisgender patients. Transgender patients had significantly higher incidence of all-cause knee injuries over the study period, 109 (5.5%) versus 175 (4.4%) (p < 0.001; OR: 2.14, 95% CI [1.17-3.92]). Subgroup analysis showed significantly higher incidence of knee injuries among cisgender men (5.6%) versus cisgender women (4.1%) (p = 0.042) and among transgender women (6.6%) versus cisgender women (4.1%) (p = 0.005). There were no significant differences between incidences of concussion and stress fracture between groups. This sample showed that patients on GAHT had increased cumulative incidences of all-cause knee injury compared to controls but similar cumulative incidences of concussion and bone-stress injuries. Transgender women on exogenous estrogen had significantly higher cumulative incidences of all-cause knee injuries compared to cisgender women.

Prepare to fail or failing to prepare? Acute performance after the 11+ with and without strength exercises

Objectives

The 11+ is an effective injury prevention warm-up programme but is often poorly adopted in practice. One reason for low compliance is the claim that the strength training part of the programme acutely impairs muscle performance before the football activity. This study aims to compare the acute effects of the 11+ with (WU+S) or without (WU-S) the strength training part on performance.

Methods

Fifteen female junior football players completed WU+S and WU-S on two separate days in randomised order. Maximal voluntary torque in knee extension and flexion (60°/s and 180°/s) and countermovement jump (CMJ) were tested before and after performing the warm-up protocol. Sprint performance and rating of perceived exertion (RPE) were assessed post-warm-up.

Results

Warm-up with strength training reduced peak torque in knee flexion at 180°/s more than WU-S, while no differences were found at 60°/s. Knee extension work was reduced more with WU+S than WU-S at 180°/s, but no differences at 60°/s. Peak torque angle and CMJ were unaffected. Players were slower on 20 and 30 m sprints after WU+S than WU-S. The RPE was higher after WU+S than WU-S, but there were no differences in readiness to train between the two protocols.

Conclusion

Performing the 11+ programme as a warm-up routine with the strength training part can impair subsequent knee flexion torque at high velocity and sprint performance in female junior football players compared with performing the 11+ warm-up without the strength part.

The association between knee muscle performance and clinical outcomes of knee function 1-4 years after a sport-related knee joint injury

OBJECTIVE

Estimate the association between index leg knee muscle strength and rate of torque development (RTD), and self-reported and performance-based (i.e., hop) knee function in persons 1-4 years after a sport-related knee joint injury.

METHODS

Data were collected at baseline of a clinical trial. Assessments included the Knee injury and Osteoarthritis Outcome Score Sport & Recreation subscale (KOOSsport), 6-m timed hop (TH), and peak concentric isokinetic knee extensor and flexor torque and isometric RTD. Associations between peak torque and RTD with KOOSsport and TH were assessed using multivariable regression with nonlinear transformations.

RESULTS

53 participants (64.2% female) were included. Knee extensor peak torque was nonlinearly related to TH time, with a strong inverse relationship at lower torque values that changed as torque increased. Results were inconsistent for flexor peak torque, extensor RTD and flexor RTD, with inconsistencies in relationship shape and estimates of association between primary and sensitivity analyses. There was no association between strength/RTD and KOOSsport.

CONCLUSION

There was a nonlinear relationship between knee extensor strength and hop function, with lower strength being associated with a stronger relationship. As strength values increased, the relationship attenuated. Knee extensor and flexor strength, or RTD, were not associated with self-reported function.

Some problems of research exploring sex differences in sport-related concussions: a narrative review

This narrative review scrutinizes research exploring sex-based differences in experiences of sport-related concussion. The article argues that the limitations of epidemiological studies identifying the greater incidence and severity of concussion among females require that these findings are read with caution. It secondly argues that the dominant explanations for these data are based on and extend historical tendencies to "other" female participation in sport and construct male experiences as the "norm". Finally, the article critiques policy recommendations related to these research findings, arguing that they are likely to embed rather than challenge sex inequality in sport, and that they are both impractical and unethical. While this commentary builds on a broader body of work advocating greater sex/gender equality in sports science research, the prominence of social concerns about concussions in sport makes the broader implications of the focus on sex and sport-related concussion particularly problematic and thus in need of redress.

Higher age and present injury at the start of the season are risk factors for in-season injury in amateur male and female football players-a prospective cohort study

PURPOSE

To describe the injury prevalence, injury pattern, and potential baseline risk factors for injuries in male and female adolescent and adult amateur football players.

METHODS

This prospective study followed adolescent and adult amateur football players over one season March-October 2020. The study was completed by 462 players (130 men, age 20.0 ± 5.7, 14-46 years) who answered a baseline survey and a weekly web survey during the season. A total of 1456 weekly surveys were registered from males and 5041 from females. Injuries were recorded with the Oslo Sports Trauma Research Center Overuse Injury Questionnaire (OSTRC-O2). Potential baseline risk factors (age, performance of strength/conditioning training, participation in other sports, perceived importance of sporting success, self-rated training and match load, perceived balance between training/match load and recovery, previous/present injury at start of season, and injury beliefs) and their association with injury were analysed with Poisson regressions within each sex.

RESULTS

Males reported 95 injuries (262 injury weeks, weekly prevalence 18.0% (95% CI 16.1-20.1)) and females 350 injuries (1206 injury weeks, weekly prevalence 23.9% (95% CI 22.8-25.1)). Gradual-onset injuries accounted for 57% of the injuries in males and 66% in females. For males, substantial injuries were most common in the hip/groin (weekly prevalence 3.8%), ankle (2.1%), posterior thigh (2.0%), and knee (2.0%); and for females, in the knee (4.3%), ankle (2.5%), and lower leg/Achilles tendon (2.0%). Significant risk factors for injury were higher age (rate ratio males 1.05 per year increase (95% CI 1.02-1.08), females 1.03 (95% CI 1.01-1.05)), and present injury at baseline (males 1.92 (95% CI 1.27-2.89), females 1.58 (95% CI 1.19-2.09)).

CONCLUSION

At any given week, almost one in five male and one in four female amateur football players reported new or ongoing injuries. Hip/groin injuries were more frequent in males, while female players had a higher prevalence of knee injuries. Older players and those with an existing injury at the start of the season were more prone to new injury during the season. Rehabilitation of pre-season injury and complaints are key to reduce the injury burden in amateur football.

LEVEL OF EVIDENCE

Level II. Trial registration number NCT04272047, Clinical trials.

Anterior cruciate ligament injuries in female athletes

The anterior cruciate ligament (ACL) is frequently injured in elite athletes, with females up to eight times more likely to suffer an ACL tear than males. Biomechanical and hormonal factors have been thoroughly investigated; however, there remain unknown factors that need investigation. The mechanism of injury differs between males and females, and anatomical differences contribute significantly to the increased risk in females. Hormonal factors, both endogenous and exogenous, play a role in ACL laxity and may modify the risk of injury. However, data are still limited, and research involving oral contraceptives is potentially associated with methodological and ethical problems. Such characteristics can also influence the outcome after ACL reconstruction, with higher failure rates in females linked to a smaller diameter of the graft, especially in athletes aged < 21 years. The addition of a lateral extra-articular tenodesis can improve the outcomes after ACL reconstruction and reduce the risk of failure, and it should be routinely considered in young elite athletes. Sex-specific environmental differences can also contribute to the increased risk of injury, with more limited access to and availablility of advanced training facilities for female athletes. In addition, football kits are designed for male players, and increased attention should be focused on improving the quality of pitches, as female leagues usually play the day after male leagues. The kit, including boots, the length of studs, and the footballs themselves, should be tailored to the needs and body shapes of female athletes. Specific physiotherapy programmes and training protocols have yielded remarkable results in reducing the risk of injury, and these should be extended to school-age athletes. Finally, psychological factors should not be overlooked, with females' greater fear of re-injury and lack of confidence in their knee compromising their return to sport after ACL injury. Both intrinsic and extrinsic factors should be recognized and addressed to optimize the training programmes which are designed to prevent injury, and improve our understanding of these injuries.

Female athlete health domains: a supplement to the International Olympic Committee consensus statement on methods for recording and reporting epidemiological data on injury and illness in sport

The IOC made recommendations for recording and reporting epidemiological data on injuries and illness in sports in 2020, but with little, if any, focus on female athletes. Therefore, the aims of this supplement to the IOC consensus statement are to (i) propose a taxonomy for categorisation of female athlete health problems across the lifespan; (ii) make recommendations for data capture to inform consistent recording and reporting of symptoms, injuries, illnesses and other health outcomes in sports injury epidemiology and (iii) make recommendations for specifications when applying the Strengthening the Reporting of Observational Studies in Epidemiology-Sport Injury and Illness Surveillance (STROBE-SIIS) to female athlete health data.In May 2021, five researchers and clinicians with expertise in sports medicine, epidemiology and female athlete health convened to form a consensus working group, which identified key themes. Twenty additional experts were invited and an iterative process involving all authors was then used to extend the IOC consensus statement, to include issues which affect female athletes.Ten domains of female health for categorising health problems according to biological, life stage or environmental factors that affect females in sport were identified: menstrual and gynaecological health; preconception and assisted reproduction; pregnancy; postpartum; menopause; breast health; pelvic floor health; breast feeding, parenting and caregiving; mental health and sport environments.This paper extends the IOC consensus statement to include 10 domains of female health, which may affect female athletes across the lifespan, from adolescence through young adulthood, to mid-age and older age. Our recommendations for data capture relating to female athlete population characteristics, and injuries, illnesses and other health consequences, will improve the quality of epidemiological studies, to inform better injury and illness prevention strategies.

Identifying modifiable risk factors and screening strategies associated with anterior cruciate ligament injury risk in children aged 6 to 13 years: A systematic review

Growing anterior cruciate ligament (ACL) injury incidence is reported in countries across Europe, North America and in Australia for 5-14-year-olds, yet research on injury risk reduction predominantly focuses on populations aged > 13 years. For injury risk reduction, it is crucial to understand (i) which modifiable risk factors are associated with ACL injury in children (6-13 years) and (ii) how these risk factors are assessed. Articles were grouped according to sex/gender and/or maturational/age differences and examined modifiable risk factors during different physical screening tasks. The included articles (n = 40) predominantly examined intrinsic risk factors in girls aged 10-13 years. Factors mechanically linked to increased ACL loading at this age included increased peak knee adductor moments, knee valgus angles, hip and knee extension, and ground reaction forces. Assessment focused on laboratory-based assessments (e.g., motion capture, force plates). This review concluded that modifiable risk factors are present in children aged 6-13 years and that injury risk reduction strategies should be implemented as early as possible regardless of sex/gender. Further, screening strategies need updating to be childhood specific and feasible for the wide community. Additional research on extrinsic risk factors, norm values and children aged 6-9 years could allow for more targeted risk reduction strategies.

Players', Head Coaches', And Medical Personnels' Knowledge, Understandings and Perceptions of Injuries and Injury Prevention in Elite-Level Women's Football in Ireland

BACKGROUND

To manage injuries effectively, players, head coaches, and medical personnel need to have excellent knowledge, attitudes, and behaviours in relation to the identification of risk factors for injuries, the implementation of injury prevention initiatives, as well as the implementation of effective injury management strategies. Understanding the injury context, whereby specific personal, environmental, and societal factors can influence the implementation of injury prevention initiatives and injury management strategies is critical to player welfare. To date, no qualitative research investigating the context of injuries, has been undertaken in elite-level women's football. The aim of our study was to explore the knowledge, attitudes, and behaviours of players, head coaches, and medical personnel in the Irish Women's National League (WNL) to injury prevention and injury management.

METHODS

We used qualitative research methods to explore the knowledge, attitudes, and behaviours of players, head coaches, and medical personnel in the Irish WNL to injury prevention and injury management. Semi-structured interviews were undertaken with 17 players, 8 medical personnel, and 7 head coaches in the Irish WNL. The data were analysed using thematic analysis. Our study is located within an interpretivist, constructivist research paradigm.

RESULTS

The participants had incomplete knowledge of common injuries in elite-level football, and many held beliefs about risk factors for injuries, such as menstrual cycle stage, which lacked evidence to support them. Jumping and landing exercises were commonly used to reduce the risk of injuries but evidence-based injury prevention exercises and programmes such as the Nordic hamstring curl, Copenhagen adduction exercise, and the FIFA 11+ were rarely mentioned. Overall, there was dissatisfaction amongst players with their medical care and strength and conditioning (S & C) support, with resultant inadequate communication between players, head coaches, and medical personnel.

CONCLUSION

Poor quality and availability of medical care and S & C support were considered to be a major obstacle in the effective implementation of injury risk reduction strategies and successful return-to-sport practices. More original research is required in elite-level women's football to explore injury risk factors, injury prevention initiatives, and contextual return-to-sport strategies, so that players, head coaches, and medical personnel can use evidence that is both up-to-date and specific to their environment.

What place does elite sport have for women? A scoping review of constraints

Introduction

Despite increases in participation and raised attention for girls and women in sports, female sport is still based on male evidence that ignores gendered differences and experiences of unequal treatment and marginalization from grassroots to elite sport. This paper aimed to critically interrogate the place that women have in the male preserve of elite sport by conducting a two-part study.

Methods

First, we provided a brief sociohistorical analysis of gender in sport as a means to move away from a decontextualized and universalized approach dominating in sport science literature. We then conducted a scoping review following PRISMA-ScR guidelines to synthesize existing sport science literature that implemented Newell's constraints-led approach to examine elite performance.

Results

Ten studies were identified, none of which collected demographic data or centred on female athletes and the effects of sociocultural constraints on their performance. Instead, male-centred, masculine sports and physiological profiles dominated the identified studies.

Discussion

We discussed these results considering critical sport research and cultural sport psychology literature to offer an integrative, interdisciplinary approach to advocate for more culturally sensitive, context-specific interpretations of gender as a sociocultural constraint. We put forth a call to action for sport science researchers, practitioners, and decision-makers to move away from implementing male evidence in female sport and attend to the unique needs of female athletes. Practical suggestions aimed to help stakeholders reimagine elite sport by celebrating these [potential] differences as strengths for promoting gender equity in sport.

Interdisciplinary sport injury research and the integration of qualitative and quantitative data

BACKGROUND

To understand and prevent sport injuries, scholars have employed different scientific approaches and research methods. Traditionally, this research has been monodisciplinary, relying on one subdiscipline of sport science and applying qualitative or quantitative research methods. Recently, scholars have argued that traditional approaches fail to address contextual components of sport and the nonlinear interactions between different aspects in and around the athlete, and, as a way forward, called for alternative approaches to sport injury research. Discussion of alternative approaches are today taking place, however, practical examples that demonstrate what such approaches entails are rare. Therefore, the purpose of this paper is to draw on an interdisciplinary research approach to (1) outline an interdisciplinary case analysis procedure (ICAP); and (2) provide an example for future interdisciplinary sport injury research.

METHODS

We adopt an established definition and application of interdisciplinary research to develop and pilot the ICAP for interdisciplinary sport injury teams aiming to integrate qualitative and quantitative sport injury data. The development and piloting of ICAP was possible by drawing on work conducted in the interdisciplinary research project "Injury-free children and adolescents: Towards better practice in Swedish football" (the FIT project).

RESULTS

The ICAP guides interdisciplinary sport injury teams through three stages: 1. Create a more comprehensive understanding of sport injury aetiology by drawing on existing knowledge from multiple scientific perspectives; 2. Collate analysed qualitative and quantitative sport injury data into a multilevel data catalogue; and 3. Engage in an integrated discussion of the collated data in the interdisciplinary research team.

CONCLUSION

The ICAP is a practical example of how an interdisciplinary team of sport injury scholars can approach the complex problem of sport injury aetiology and work to integrate qualitative and quantitative data through three stages. The ICAP is a step towards overcoming the obstacles of integrating qualitative and quantitative methods and data that scholars have identified.

A Global Women's Rugby Union Web-Based Survey

Rugby Union (rugby) is a full-contact team sport characterised by frequent collision events. Over one third (2.7 million) of global rugby participants are women and girls. Yet, most rugby research, laws, and regulations are derived from the men's game with limited transferability to the women's game. This includes research focused on injury and concussion management. Greater insights are urgently required to enable appropriate adaptations and support for all rugby participants. Therefore, this paper presents the protocol for a project that sought to gather insights into the understanding, experiences, and attitudes of players and coaches in women's rugby regarding key issues of concussion, injury, and training for injury prevention, as well as the implications of the menstrual cycle for training and performance. From August 2020 to November 2020, online, open, cross-sectional surveys for players and coaches were distributed globally through rugby governing bodies and women's rugby social media platforms using snowball sampling. Survey responses were recorded anonymously via a GDPR-compliant online survey platform, JISC (jisc.ac.uk, Bristol, England). Participant eligibility included being ≥18 years and either actively playing or coaching women's rugby 15s and/or sevens, or having done so in the past decade, at any level, in any country. To enhance the number and accuracy of responses, the survey was professionally translated into eight additional languages. A total of 1596 participants from 62 countries (27 ± 6 years; 7.5 ± 5.1 years of playing experience) and 296 participants from 37 countries (mean age = 36.64, SD = 9.09, mean experience = 6.53 years, SD = 3.31) completed the players' and coaches' surveys, respectively. Understanding women's participation in and experiences of rugby is important to enable lifelong engagement and enjoyment of the sport and health during and following participation.

Three-dimensional magnetic resonance imaging analysis shows sex-specific patterns in changes in anterior cruciate ligament cross-sectional area along its length

Smaller anterior cruciate ligament (ACL) size in females has been hypothesized to be a key contributor to a higher incidence of ACL tears in that population, as a lower cross-sectional area (CSA) directly corresponds to a larger stress on the ligament for a given load. Prior studies have used a mid-length CSA measurement to quantify ACL size. In this study, we used magnetic resonance imaging to quantify the CSA along the entire length of the intact ACL. We hypothesized that changes in the ACL CSA along its length would have different patterns in males and females. We also hypothesized that changes in ACL CSA along its length would be associated with body size or knee size with different associations in females and males. MR images of contralateral ACL-intact knees of 108 patients (62 females, 13-35 years) undergoing ACL surgery were used to measure the CSA along the ACL length, using a custom program. For both females and males, the largest CSA was located at 37%-39% of ACL length from the tibial insertion. Compared to females, males had a significantly larger CSA only within the distal 41% of the ACL (p < 0.001). ACL CSA was associated with patient height and weight in males (r > 0.3; p < 0.05), whereas it was associated with intercondylar notch width in females (r > 0.3; p < 0.05). These findings highlight the importance of standardizing the location of measurement of ACL CSA.

Let's talk about sex (and gender) after ACL injury: a systematic review and meta-analysis of self-reported activity and knee-related outcomes

OBJECTIVE

Investigate sex/gender differences in self-reported activity and knee-related outcomes after anterior cruciate ligament (ACL) injury.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Seven databases were searched in December 2021.

ELIGIBILITY CRITERIA

Observational or interventional studies with self-reported activity (including return to sport) or knee-related outcomes after ACL injury.

RESULTS

We included 242 studies (n=123 687, 43% females/women/girls, mean age 26 years at surgery). One hundred and six studies contributed to 1 of 35 meta-analyses (n=59 552). After ACL injury/reconstruction, very low-certainty evidence suggests females/women/girls had inferior self-reported activity (ie, return to sport, Tegner Activity Score, Marx Activity Scale) compared with males/men/boys on most (88%, 7/8) meta-analyses. Females/women/girls had 23%-25% reduced odds of returning to sport within 1-year post-ACL injury/reconstruction (12 studies, OR 0.76 95% CI 0.63 to 0.92), 1-5 years (45 studies, OR 0.75 95% CI 0.69 to 0.82) and 5-10 years (9 studies, OR 0.77 95% CI 0.57 to 1.04). Age-stratified analysis (<19 years) suggests female athletes/girls had 32% reduced odds of returning to sport compared with male athletes/boys (OR 0.68, 95% CI 0.41 to 1.13, I² 0.0%). Very low-certainty evidence suggests females/women/girls experienced inferior knee-related outcomes (eg, function, quality of life) on many (70%, 19/27) meta-analyses: standardised mean difference ranging from -0.02 (Knee injury and Osteoarthritis Outcome Score, KOOS-activities of daily living, 9 studies, 95% CI -0.05 to 0.02) to -0.31 (KOOS-sport and recreation, 7 studies, 95% CI -0.36 to -0.26).

CONCLUSIONS

Very low-certainty evidence suggests inferior self-reported activity and knee-related outcomes for females/women/girls compared with males/men/boys after an ACL injury. Future studies should explore factors and design targeted interventions to improve outcomes for females/women/girls.

PROSPERO REGISTRATION NUMBER

CRD42021205998.

Neo-natal castration leads to subtle differences in porcine anterior cruciate ligament morphology and function in adolescence

Female adolescent athletes are at a higher risk of tearing their anterior cruciate ligament (ACL) than male counterparts. While most work related to hormones has focused on the effects of estrogen to understand the increased risk of ACL injury, there are other understudied factors, including testosterone. The purpose of this study was to determine how surgical castration in the male porcine model influences ACL size and function across skeletal growth. Thirty-six male Yorkshire crossbreed pigs were raised to 3 (juvenile), 4.5 (early adolescent), and 6 months (adolescent) of age. Animals were either castrated (barrows) within 1-2 weeks after birth or were left intact (boars). Post-euthanasia, joint and ACL size were assessed via MRI, and biomechanics were assessed via a robotic testing system. Joint size increased throughout age, yet barrows had smaller joints than boars (p<0.001 for all measures). ACL cross-sectional area (CSA), length, volume, and stiffness increased with age (p<0.0001), as did ACL anteromedial (AM) bundle percent contribution to resisting loads (p=0.012). Boar ACL, AM bundle, and PL bundle volumes were 19% (p=0.002), 25% (p=0.003), and 15% (p=0.04) larger than barrows across ages. However, CSA, stiffness, and bundle contribution were similar between boars and barrows (p>0.05). The barrows had smaller temporal increases in AM bundle percent function than boars, but these data were highly variable. Thus, early and sustained loss in testosterone leads to subtle differences in ACL morphology, but may not influence measures associated with increased injury risk, such as CSA or bundle forces in response to applied loads.

Longitudinal study of six seasons of match injuries in elite female rugby union

ObjectiveTo establish match injury rates and patterns in elite female rugby union players in England.

METHOD

We conducted a six-season (2011/2012-2013/2014 and 2017/2018-2019/2020) prospective cohort study of time-loss match injuries in elite-level female players in the English Premiership competition. A 24-hour time-loss definition was used.

RESULTS

Five-hundred and thirty-four time-loss injuries were recorded during 13 680 hours of match exposure. Injury incidence was 39 injuries per 1000 hours (95% CIs 36 to 42) with a mean severity of 48 days (95% CIs 42 to 54) and median severity of 20 days (IQR: 7-57). Concussion was the most common specific injury diagnosis (five concussions per 1000 hours, 95% CIs 4 to 6). The tackle event was associated with the greatest burden of injury (615 days absence per 1000 hours 95% CIs 340 to 1112), with 'being tackled' specifically causing the most injuries (28% of all injuries) and concussions (22% of all concussions).

CONCLUSIONS

This is the first multiple-season study of match injuries in elite women's rugby union players. Match injury incidence was similar to that previously reported within international women's rugby union. Injury prevention strategies centred on the tackle would focus on high-burden injuries, which are associated with substantial player time-loss and financial costs to teams as well as the high-priority area of concussions.

"It's always the bare minimum" - A qualitative study of players' experiences of tackle coaching in women's rugby union

OBJECTIVES

Tackle coaching forms a cornerstone of training in rugby and is designed to enhance performance and mitigate tackle injury. The athlete voice can help key stakeholders understand the psychosocial determinants that shape skill development in relation to tackle coaching. We aimed to capture player experiences of tackle coaching in women's rugby union.

DESIGN

Qualitative study using the grounded theory approach.

METHODS

Current women rugby union players, with at least 1-year senior level experience, were recruited from Europe, Africa and North America between December 2021 and March 2022 to participate in the study. Data were collected through semi-structured interviews and analysed in line with grounded theory coding procedures.

RESULTS

The 21 players were aged 20-48 years with a mean 10.6 years of rugby playing experience. Analysis revealed that the experiences of tackle coaching that shaped women's tackle skill development and sense of preparedness ranged from constraining to empowering, and gender was a pivotal influence in creating meaning. Participants expected and accepted the bare minimum in tackle coaching as the price that they had to pay for inclusion in rugby.

CONCLUSIONS

Participants' experiences of tackle coaching were entangled in inequitable club structures and cultures where men's rugby is the norm. Empowering tackle coaching in women's rugby union must be bespoke to the given context and the needs of women players. The recommendations offered in this paper encourage discussion as to how best to empower women's tackle development in rugby.

ACLR and military service: time to rethink?

Anterior cruciate ligament (ACL) rupture is a common injury that affects young, active individuals, normally managed with reconstruction in this age group. Current UK Armed Forces policy precludes prospective applicants from joining with an anterior cruciate ligament reconstruction (ACLR). This isdue to the perceived risk of premature osteoarthritis (OA), graft rupture or clinical failure, all of which could make the service person medically non-deployable.The most recent evidence shows that an ACL rupture without associated significant meniscal or osteochondral defect has a similar likelihood of developing OA as to that of the uninjured knee after reconstruction at 20 years postoperatively.Applicants should be considered for service following an ACL rupture without significant concurrent meniscal or osteochondral defect who have undergone ACLR and 18 months of rehabilitation. We recommend these applicants to be graded P2 Medically Fully Deployable (MFD) as per the Joint Service Publication (JSP) guidance for service personnel who undergo ACLR.

Advancing feminist innovation in sport studies: A transdisciplinary dialogue on gender, health and wellbeing

Athlete health and wellbeing requires a holistic, multidimensional approach to understanding, supporting, and treating individual athletes. Building more supportive, inclusive, and equitable environments for the health and wellbeing of women and gender expansive people further requires gender-responsive approaches that promote broader cultural change. Feminist sport and exercise medicine practitioners, sports scientists, and social science researchers are increasingly coming together in their efforts to do this work. However, working across disciplines inevitably includes an array of ontological, epistemological, and political challenges. In this paper, we offer a curated 'dialogue' with a group of feminist scholars engaged in research and practice across disciplines, bringing them together to discuss some of the most pressing gendered issues in sport today (i.e., ACL injury, concussion, menstruation in sport, mental health, gender categories). In so doing, we amplify the voices of those working (empirically and clinically) at the disciplinary intersections of gender, sport and health, and learn about some of the current and future possibilities for transdisciplinary innovations and strategies for building (responsiveness to) cultural change.

Increasing incidence of anterior cruciate ligament reconstruction: a 17-year population-based study

PURPOSE

Anterior cruciate ligament (ACL) injuries are one of the most frequently studied injuries in orthopedic care and research. However, limited epidemiological data are available in Canada regarding trend and distribution of anterior cruciate ligament reconstruction (ACLR). In this paper, our purpose was to assess trends of ACLR between 2002/03 and 2018/19 by age, sex, season of surgery, and location (inpatient vs outpatient) of surgery.

METHODS

In this descriptive epidemiological study of retrospective data available from Alberta Ministry of Health, we report annual incidence of ACLR between 2002/03 until 2018/19 among Albertans aged 10 years and older. Information was collected by authors from physician claims database for primary ACLR and revision ACLR and linked with other databases. Incidence proportions (number of ACLR/100,000 population) were calculated and compared by age category and gender over the study period.

RESULTS

A total of 28,401 primary ACLR and 2085 revision ACLR were identified during the study period. Age-standardized annual incidence of primary ACLR increased from 40.6 to 51.2 per 100,000 population aged 10 years and older. Average annual increase in ACLR incidence was higher among females (1.8% per years) compared to males (0.96% per year). The overall peak incidence and peak incidence among males was observed in 20-29 year age group, whereas peak incidence in females was observed in 10-19 years of age. The number of ACLR in females outnumbers those among males for 10-19 year age group. Generally, a lower proportion of ACLR were conducted in summer compared to other seasons. Primary ACLR conducted in outpatient setting increased from 72% in 2002/03 to 97% in 2018/19.

CONCLUSION

The incidence of ACLR is increasing in Alberta, especially among females and among younger cohorts under 20 years of age. This information can help clinicians to provide patient education and policy-makers to design and implement targeted ACL injury prevention programs.

LEVEL OF EVIDENCE

Level III.

"I feel I'm leading the charge." Experiences of a virtual physiotherapist-guided knee health program for persons at-risk of osteoarthritis after a sport-related knee injury

Objective

Describe participants' perspectives about the feasibility of a virtual, physiotherapist-guided knee health program for people at risk of post-traumatic osteoarthritis after a sport-related knee injury.

Design

Qualitative description study nested within a quasi-experimental study evaluating the feasibility of the Stop OsteoARthritis (SOAR) with persons with sport-related knee injuries. SOAR includes: 1) one-time Knee Camp (group education, 1:1 exercise/activity goal-setting); 2) weekly home-based exercise/activity program with tracking, and; 3) weekly 1:1 physiotherapy-guided action-planning. Upon program completion, semi-structured 1:1 interviews were conducted with participants identified by convenience and maximum variation sampling (age, gender, program satisfaction). Open-ended questions elicited participants' experiences with the program. Content analysis was conducted.

Results

12 women and 4 men [median (min-max) age; 30 (19-46) years] were interviewed. Four categories depicted participants' experiences: 1) 'SOAR satisfies an unmet need' portrayed the perceived relevance and need for a program that promotes knowledge about knee health and self-efficacy for independent exercise behaviour, 2) 'Regaining control of knee health' described how SOAR empowered participants and fostered a sense of 'leading the charge' to their own knee health, 3) 'Social support encourages exercise participation' highlighted that weekly physiotherapy interactions provided accountability for achieving exercise goals, and that relating to other participants was inspirational, 4) 'Program refinements and barriers' suggested enhancements to meet the needs of future participants.

Conclusions

Participants report the SOAR program to be acceptable, relevant, and empowering. Improved knowledge about one's knee health, self-efficacy, autonomy, and social support may encourage exercise adherence and self-management of future knee OA risk.