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Oudmaijer CAJ, Paulino Pereira NR, Visser D, Wakker AM, Veltman WS, van Linschoten R. Lateral femoral neck stress fractures: A case report. World J Orthop 2024; 15:891-901. [DOI: 10.5312/wjo.v15.i9.891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Revised: 08/15/2024] [Accepted: 08/27/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND Sport-induced injuries particularly affect young, healthy, and active individuals. Running, a popular and accessible sport, can cause a wide range of injuries, including stress fractures. Stress fractures can occur during high-intensity training or competitions, especially among well-trained amateurs and professional athletes. Adequate diagnosis can be complicated by the typically young age, unremarkable medical history, and vital condition of the patient. Stress fractures present insidiously, and this is specifically the case with stress fractures of the femoral neck. Timely intervention is crucial to prevent progressive displacement, as this can damage the blood supply to the femoral head.
CASE SUMMARY A 30-year-old male runner presented to our outpatient clinic with persistent pain 3 weeks after running a marathon. X-ray showed a complete lateral fracture of the left femoral neck, which was treated surgically with a dynamic hip screw.
CONCLUSION It is essential for healthcare providers to be vigilant for the subtle symptoms of stress fractures to ensure timely treatment. Early recognition prevents complication and leads to a better prognosis.
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Affiliation(s)
- Christiaan AJ Oudmaijer
- Department of Surgery, Division of Hepatobiliary and Transplantation Surgery, Erasmus MC Transplant Institute, Rotterdam 3015 GD, Zuid-Holland, Netherlands
- Princess Maxima Center for Pediatric Oncology, Utrecht 3584 CS, Netherlands
| | - Nuno R Paulino Pereira
- Orthopaedics and Sports Medicine, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Zuid-Holland, Netherlands
| | - David Visser
- Orthopaedics and Sports Medicine, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Zuid-Holland, Netherlands
| | - Alexander M Wakker
- Department of Surgery, Division of Trauma Surgery, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Zuid-Holland, Netherlands
| | - Wout S Veltman
- Orthopaedics and Sports Medicine, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Zuid-Holland, Netherlands
| | - Robbart van Linschoten
- Orthopaedics and Sports Medicine, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Zuid-Holland, Netherlands
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Hardaker NJ, Hume PA, Sims ST. Differences in Injury Profiles Between Female and Male Athletes Across the Participant Classification Framework: A Systematic Review and Meta-Analysis. Sports Med 2024; 54:1595-1665. [PMID: 38536647 DOI: 10.1007/s40279-024-02010-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Female sex is a significant determinant of anterior cruciate ligament (ACL) injury. It is not understood if sex is a key determinant of other sports-related injuries. OBJECTIVE The aim of this systematic review was to identify where differences in injury profiles are most apparent between the sexes in all sports across the six-tiered participant classification framework. METHODS This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and the 'implementing PRISMA in Exercise, Rehabilitation, Sport medicine and SporTs science'(PERSiST) guidance. The databases PubMed, CINAHL, Web of Science, SPORTDiscus, Medline, Scopus, Cochrane Library and EBSCO were searched from database inception to 24 April 2023. Longitudinal, prospective and retrospective cohort studies and cross-sectional and descriptive epidemiology studies that used standard injury data collection were included. Studies were excluded if injuries were not medically diagnosed and if injuries were not reported and/or analysed by sex. Two reviewers independently extracted data and assessed study quality using the Downs and Black checklist. RESULTS Overall, 180 studies were included (8 tier-5, 40 tier-4, 98 tier-3, 30 tier-2, 5 tier-1 studies; one study included data in two tiers). Of those, 174 studies were of moderate quality and six studies were of limited quality. In sex-comparable sports, there was moderate evidence that female athletes had greater risk of knee injury (relative risk (RR) 2.7; 95% CI 1.4-5.5), foot/ankle injuries (RR 1.25; 95% CI 1.17-1.34), bone stress injury (RR 3.4; 95% CI 2.1-5.4) and concussion (RR 8.46; 95% CI 1.04-68.77) than male athletes. Male athletes were at increased risk of hip/groin injuries (RR 2.26; 95% CI 1.31-3.88) and hamstring injuries (RR 2.4; 95% CI 1.8-3.2) compared with females, particularly in dynamic sports. Male athletes were 1.8 (1.37-2.7) to 2.8 (2.45-3.24) times more likely to sustain acute fractures than female athletes, with the highest risk in competition. DISCUSSION Most studies in all cohorts were of moderate quality (mean/range of scores tier-5: 17 ± 2.2 [14-20], tier-4: 16.9 ± 1.9 [11-21], tier-3: 16.9 ± 1.5 [11-20], tier-2: 16.3 ± 2.2 [11-20], tier-1 studies: 15.6 ± 1.3 [14-17] out of 28 on the Downs and Black checklist), with only six studies of limited quality. Female athletes' propensity for bone stress injuries highlights opportunities to reinforce development of optimal bone health during adolescence and to outline the effects of energy availability. Earlier strength development and exposure to neuromuscular training programmes and modification of skill development in female athletes may be effective strategies for reducing lower limb injury risk. Key components of neuromuscular training programmes could be beneficial for reducing hip/groin and hamstring injury risk in male athletes. There may be a need for sex-specific prevention and return-to-sport protocols for sports-related concussion in female athletes. CONCLUSIONS Female sex was a key determinant of sports-related injuries beyond ACL injury including foot/ankle injury, bone stress injury and sports-related concussion. Male sex was a key determinant of hip/groin, hamstring injury and upper limb injury. TRIAL REGISTRY PROSPERO registration number: CRD42017058806 (last updated on 7th June 2023).
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Affiliation(s)
- Natalie J Hardaker
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Science, Auckland University of Technology, Auckland, New Zealand.
- Accident Compensation Corporation, Wellington, New Zealand.
| | - Patria A Hume
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Science, Auckland University of Technology, Auckland, New Zealand
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
- Tech & Policy Lab, Law School, The University of Western Australia, Perth, Australia
| | - Stacy T Sims
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Science, Auckland University of Technology, Auckland, New Zealand
- Stanford Lifestyle Medicine, Stanford University, Palo Alto, CA, USA
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Crunkhorn ML, Toohey LA, Charlton P, Drew M, Watson K, Etxebarria N. Injury incidence and prevalence in elite short-course triathletes: a 4-year prospective study. Br J Sports Med 2024:bjsports-2023-107327. [PMID: 38331566 DOI: 10.1136/bjsports-2023-107327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 02/10/2024]
Abstract
OBJECTIVE To characterise the prevalence, incidence rate (IR) and burden of injuries in elite short-course triathletes over a 4-year training and competition period. METHODS Fifty elite Australian triathletes were prospectively monitored for injury during four consecutive seasons (2018-2021). Injuries requiring medical attention were prospectively recorded and further subcategorised according to time loss. The IR and burden (injury IR×mean injury severity) were calculated per 365 athlete days, with sex differences in IR compared using IR ratios (IRR) from negative binomial regression models. RESULTS Two hundred and sixty-six injuries were reported in 46 (92.0%) athletes, of which 67.3% resulted in time loss. The injury IR was 1.87 injuries per 365 athlete days (95% CI 1.70 to 2.80), and comparable between sexes (IRR 0.82, 95% CI 0.64 to 1.04, p=0.109). Most injuries (70.7%) were training related. The most frequently injured body sites were the ankle (15.8%), foot (12.4%) and lower leg (12.0%). Bone stress injuries (BSIs) were the most burdensome injury type with 31.38 days of time loss per 365 days (95% CI 24.42 to 38.34). Twenty athletes (40.0%) reported at least one bone stress injury (BSI) (range 0-3). The rate of BSIs in female athletes was three times greater compared with male athletes (IRR 2.99, 95% CI 1.26 to 7.07, p=0.013). CONCLUSION Two-thirds of injuries reported in elite short-course triathletes resulted in time loss, with the majority occurring during training activities. Foot, ankle and other lower leg injuries had the highest incidence, with BSIs carrying the highest injury burden. The considerably higher rate of BSI observed in female athletes warrants consideration for future prevention strategies in female triathletes.
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Affiliation(s)
- Melissa Leith Crunkhorn
- University of Canberra Research Institute for Sport and Exercise, Canberra, Australian Capital Territory, Australia
- Queensland Academy of Sport, Nathan, Queensland, Australia
| | - Liam Anthony Toohey
- University of Canberra Research Institute for Sport and Exercise, Canberra, Australian Capital Territory, Australia
- AIS Performance, Australian Institute of Sport, Bruce, Australian Capital Territory, Australia
| | - Paula Charlton
- University of Canberra Research Institute for Sport and Exercise, Canberra, Australian Capital Territory, Australia
- Triathlon Australia, Gold Coast, Queensland, Australia
| | - Michael Drew
- University of Canberra Research Institute for Sport and Exercise, Canberra, Australian Capital Territory, Australia
| | - Kate Watson
- Performance Health, Queensland Academy of Sport, Nathan, Queensland, Australia
| | - Naroa Etxebarria
- University of Canberra Research Institute for Sport and Exercise, Canberra, Australian Capital Territory, Australia
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Regus S, Schoeffl I, Knetsch J, Schoeffl V, Haase K. [Iliac endofibrosis in high-performance sports: an interdisciplinary diagnostic challenge]. SPORTVERLETZUNG SPORTSCHADEN : ORGAN DER GESELLSCHAFT FUR ORTHOPADISCH-TRAUMATOLOGISCHE SPORTMEDIZIN 2023; 37:171-181. [PMID: 38048810 DOI: 10.1055/a-2133-9702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
OBJECTIVES Iliac endofibrosis (IE) is a rare arterial disease in endurance athletes, especially cyclists and triathletes. The diagnosis is considered challenging and the latency from the onset of initial symptoms to diagnosis is often several years. Diagnostic options include determination of the ankle brachial index (ABI) after maximal exercise as a non-invasive procedure, as well as duplex sonography, CT or MRI angiography, and invasive angiography. The aim of this paper is to analyse in more detail this time lag to correct diagnosis from the first description in 1985 to the year 2021, as well as to identify the most important diagnostic tools for practice. MATERIALS AND METHODS Literature research according to PRISMA criteria in PubMed, Web of Science, Cochrane databases, supplemented by a search in Google Scholar up to 10/18/2021. RESULTS We identified a total of 133 publications that dealt thematically with IE in endurance athletes. In 42 publications (40 case reports and 2 clinical trials), the diagnosis was confirmed intraoperatively, and in 32 (32/42; 74.4%), statements were made about the duration from the onset of the first symptoms to the final diagnosis (mean 45, median 36 months). This latency was constant over the entire observation period from 1985 to 2021, with no trend toward shortening. Twenty-four papers (24/42; 56%) reported detailed results of ABI determination as well as further diagnostic testing. In all cases, the ABI value decreased to less than 0.66 (in 5 case reports, this decrease was measured at rest; in 19 case reports, it occurred after stress), whereas further diagnostic testing by duplex sonography, DSA, MRA, or CTA revealed no abnormal findings in 3 cases (3/24; 12.5%) and showed no more than minor stenosis in 14 cases (14/24; 58.3%). CONCLUSIONS A drop in ABI after exercise is the most reliable method to diagnose iliac endofibrosis. This non-invasive and easy-to-perform examination should be integrated into the performance diagnostics of highly ambitious endurance athletes at risk. This may ideally prevent irreversible vessel wall damage by early diagnosis as well as a reduction of the presumed high number of undetected cases.
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Weinrich L, Dahne M, Lindner T, Stöckle U, Tsitsilonis S. Femoral Neck Stress Fracture of a Male, Healthy Marathon Runner - Case Report and Literature Review. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2022; 160:564-571. [PMID: 33782932 DOI: 10.1055/a-1401-0375] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In the present report, a case of a healthy, 38-year-old male recreational marathon runner who presented in the emergency department is discussed. He was diagnosed with a stress fracture of the femoral neck and treated surgically using a dynamic hip screw (DHS). One year after surgery, the patient was able to return to most of his previous sports activities. In the present report, the existing literature on the subject is exhibited and the points of interest in terms of incidence, risk factors, diagnosis, classification, treatment, and long-term outcome are analyzed. We suggest operative treatment of stress fractures of the femoral neck even in cases of complete undisplaced ones. This way, the risk of a displacement is counteracted, and patients can quickly return to daily activities without having to withstand long-term immobilization.
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Affiliation(s)
- Luise Weinrich
- Centrum für Muskuloskeletale Chirurgie, Charité University Hospital Berlin, Germany
| | - Michael Dahne
- Centrum für Muskuloskeletale Chirurgie, Charité University Hospital Berlin, Germany
| | - Tobias Lindner
- Zentrale chirurgische Notaufnahme, Charité University Hospital Berlin, Germany
| | - Ulrich Stöckle
- Centrum für Muskuloskeletale Chirurgie, Charité University Hospital Berlin, Germany
| | - Serafeim Tsitsilonis
- Centrum für Muskuloskeletale Chirurgie, Charité University Hospital Berlin, Germany
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Baldwin KM, Badenhorst CE, Cripps AJ, Landers GJ, Merrells RJ, Bulsara MK, Hoyne GF. Strength Training for Long-Distance Triathletes. Strength Cond J 2021. [DOI: 10.1519/ssc.0000000000000660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Knechtle B, Jastrzębski Z, Hill L, Nikolaidis PT. Vitamin D and Stress Fractures in Sport: Preventive and Therapeutic Measures-A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:223. [PMID: 33804459 PMCID: PMC7999420 DOI: 10.3390/medicina57030223] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/22/2021] [Accepted: 02/24/2021] [Indexed: 01/13/2023]
Abstract
There are numerous risk factors for stress fractures that have been identified in literature. Among different risk factors, a prolonged lack of vitamin D (25(OH)D) can lead to stress fractures in athletes since 25(OH)D insufficiency is associated with an increased incidence of a fracture. A 25(OH)D value of <75.8 nmol/L is a risk factor for a stress fracture. 25(OH)D deficiency is, however, only one of several potential risk factors. Well-documented risk factors for a stress fracture include female sex, white ethnicity, older age, taller stature, lower aerobic fitness, prior physical inactivity, greater amounts of current physical training, thinner bones, 25(OH)D deficiency, iron deficiency, menstrual disturbances, and inadequate intake of 25(OH)D and/or calcium. Stress fractures are not uncommon in athletes and affect around 20% of all competitors. Most athletes with a stress fracture are under 25 years of age. Stress fractures can affect every sporty person, from weekend athletes to top athletes. Stress fractures are common in certain sports disciplines such as basketball, baseball, athletics, rowing, soccer, aerobics, and classical ballet. The lower extremity is increasingly affected for stress fractures with the locations of the tibia, metatarsalia and pelvis. Regarding prevention and therapy, 25(OH)D seems to play an important role. Athletes should have an evaluation of 25(OH)D -dependent calcium homeostasis based on laboratory tests of 25-OH-D3, calcium, creatinine, and parathyroid hormone. In case of a deficiency of 25(OH)D, normal blood levels of ≥30 ng/mL may be restored by optimizing the athlete's lifestyle and, if appropriate, an oral substitution of 25(OH)D. Very recent studies suggested that the prevalence of stress fractures decreased when athletes are supplemented daily with 800 IU 25(OH)D and 2000 mg calcium. Recommendations of daily 25(OH)D intake may go up to 2000 IU of 25(OH)D per day.
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Affiliation(s)
- Beat Knechtle
- Medbase St. Gallen Am Vadianplatz, 9000 St. Gallen, Switzerland
- Institute of Primary Care, University Hospital Zurich, University of Zurich, Pestalozzistrasse 24, 8091 Zürich, Switzerland
| | - Zbigniew Jastrzębski
- Department of Health and Life Sciences, Gdansk University of Physical Education and Sport, 80-336 Gdańsk, Poland;
| | - Lee Hill
- Division of Gastroenterology & Nutrition, Department of Pediatrics, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada;
| | - Pantelis T. Nikolaidis
- Exercise Physiology Laboratory, 18450 Nikaia, Greece;
- School of Health and Caring Sciences, University of West Attica, 12243 Athens, Greece
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Abstract
Hintergrund Die labordiagnostische Untersuchung stellt eine wichtige Möglichkeit zur Beurteilung und Optimierung der Leistungs- und Regenerationsfähigkeit professioneller Athleten dar. Ferner ist sie für die Prävention, Diagnostik und Rehabilitation von Verletzungen und Überbelastungen von Bedeutung. Fragestellung Ziel dieser Arbeit ist die Darstellung muskuloskelettaler laborchemischer Parameter, die relevante Erkenntnisse für die medizinische Betreuung von Leistungssportlern liefern. Material und Methoden Literaturrecherche und narratives Review. Ergebnisse Die Bestimmung des Vitamin-D-, Calcium- und Knochenstoffwechsels stellt die laborchemische Basisdiagnostik im Rahmen der Beurteilung des Skelettstatus mit zusätzlichem präventivem Nutzen bezüglich muskuloskelettaler Verletzungen dar. Ferner können muskuläre Serummarker, z. B. Laktatdehydrogenase (LDH), Kreatinkinase (CK), Myoglobin und Aspartat-Aminotransferase (ASAT), helfen, eine metabolische Adaptation an das physische Training festzustellen und Aussagen über die muskuläre Arbeitslast und mögliche Schädigungen zu gewinnen. Die Energieverfügbarkeit kann durch eine entsprechende Bilanzierung sowie die laborchemische Bestimmung der Makro- und Mikronährstoffe eingeschätzt und optimiert werden. Schlussfolgerungen Die labordiagnostische Untersuchung besitzt in der Betreuung von Athleten eine sportartenübergreifende klinische Relevanz. Sie dient der Erreichung einer höchstmöglichen Leistungsfähigkeit sowie optimalen Prävention von Knochen- und Muskelverletzungen, wobei sämtliche Mangelzustände (z. B. Vitamin D) ausgeglichen werden sollten. Durch eine Periodisierung der laborchemischen Untersuchungen, mit zumindest zwei Labordiagnostiken im Jahr, und Aufstellung individueller Variabilitäts- und Referenzbereiche kann ferner eine bessere Beurteilbarkeit erreicht werden.
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Hotfiel T, Mayer I, Huettel M, Hoppe MW, Engelhardt M, Lutter C, Pöttgen K, Heiss R, Kastner T, Grim C. Accelerating Recovery from Exercise-Induced Muscle Injuries in Triathletes: Considerations for Olympic Distance Races. Sports (Basel) 2019; 7:sports7060143. [PMID: 31200464 PMCID: PMC6628249 DOI: 10.3390/sports7060143] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 05/14/2019] [Accepted: 06/04/2019] [Indexed: 12/15/2022] Open
Abstract
The triathlon is one of the fastest developing sports in the world due to expanding participation and media attention. The fundamental change in Olympic triathlon races from a single to a multistart event is highly demanding in terms of recovery from and prevention of exercise-induced muscle injures. In elite and competitive sports, ultrastructural muscle injuries, including delayed onset muscle soreness (DOMS), are responsible for impaired muscle performance capacities. Prevention and treatment of these conditions have become key in regaining muscular performance levels and to guarantee performance and economy of motion in swimming, cycling and running. The aim of this review is to provide an overview of the current findings on the pathophysiology, as well as treatment and prevention of, these conditions in compliance with clinical implications for elite triathletes. In the context of DOMS, the majority of recovery interventions have focused on different protocols of compression, cold or heat therapy, active regeneration, nutritional interventions, or sleep. The authors agree that there is a compelling need for further studies, including high-quality randomized trials, to completely evaluate the effectiveness of existing therapeutic approaches, particularly in triathletes. The given recommendations must be updated and adjusted, as further evidence emerges.
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Affiliation(s)
- Thilo Hotfiel
- Department of Orthopedic, Trauma, Hand and Neuro Surgery, Klinikum Osnabrück GmbH, Osnabrück 49076, Germany.
- Deutsche Triathlon Union (DTU), Frankfurt 60528, Germany.
- Department of Orthopedic Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen 91054, Germany.
| | - Isabel Mayer
- Department of Orthopedic Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen 91054, Germany.
| | - Moritz Huettel
- Department of Orthopedic Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen 91054, Germany.
| | - Matthias Wilhelm Hoppe
- Department of Orthopedic, Trauma, Hand and Neuro Surgery, Klinikum Osnabrück GmbH, Osnabrück 49076, Germany.
- Department of Movement and Training Science, University of Wuppertal, Wuppertal 42119, Germany.
| | - Martin Engelhardt
- Department of Orthopedic, Trauma, Hand and Neuro Surgery, Klinikum Osnabrück GmbH, Osnabrück 49076, Germany.
- Deutsche Triathlon Union (DTU), Frankfurt 60528, Germany.
| | - Christoph Lutter
- Department of Orthopedics, Rostock University Medical Center, Rostock 18057, Germany.
- Department of Sports Orthopedics, Sports Medicine, Sports Traumatology, Klinikum Bamberg, Bamberg 96049, Germany.
| | | | - Rafael Heiss
- Department of Radiology, University Hospital Erlangen, Erlangen 91054, Germany.
| | - Tom Kastner
- Deutsche Triathlon Union (DTU), Frankfurt 60528, Germany.
- Department of Sport Medicine Humboldt University and Charité University Medicine, Berlin 10117, Germany.
- Institute for Applied Training Science Leipzig (IAT), Leipzig 04109, Germany.
| | - Casper Grim
- Department of Orthopedic, Trauma, Hand and Neuro Surgery, Klinikum Osnabrück GmbH, Osnabrück 49076, Germany.
- Deutsche Triathlon Union (DTU), Frankfurt 60528, Germany.
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