Acute clinical evaluation for the diagnosis of lateral ankle ligament injuries is useful: A comparison between the acute and delayed settings

PURPOSE

To determine the diagnostic value of seven injury history variables, nine clinical tests (including the combination thereof) and overall clinical suspicion for complete discontinuity of the lateral ankle ligaments in the acute (0-2 days post-injury) and delayed setting (5-8 days post-injury).

METHODS

All acute ankle injuries in adult athletes (≥18 years) presenting up to 2 days post-injury were assessed for eligibility. Athletes were excluded if imaging studies demonstrated a frank fracture or 3 T MRI could not be acquired within 10 days post-injury. Using standardized history variables and clinical tests, acute clinical evaluation was performed within 2 days post-injury. Delayed clinical evaluation was performed 5-8 days post-injury. Overall, clinical suspicion was recorded after clinical evaluation. MRI was used as the reference standard.

RESULTS

Between February 2018 and February 2020, a total of 117 acute ankle injuries were screened for eligibility, of which 43 were included in this study. Complete discontinuity of lateral ankle ligaments was observed in 23 (53%) acute ankle injuries. In the acute setting, lateral swelling had 100% (95% confidence interval [CI]: 82-100) sensitivity, haematoma had 85% (95% CI: 61-96) specificity and the anterior drawer test had 100% (95% CI: 77-100) specificity. In the delayed setting, sensitivity for the presence of haematoma improved from 43% (95% CI: 24-65) to 91% (95% CI: 70-98; p < 0.01) and the sensitivity of the anterior drawer test improved from 21% (95% CI: 7-46) to 61% (95% CI: 39-80; p = 0.02). Clinical suspicion had a positive likelihood ratio (LR) of 4.35 (95% CI: 0.55-34.17) in the acute setting and a positive LR of 6.09 (95% CI: 1.57-23.60) in the delayed setting.

CONCLUSIONS

In the acute setting, clinical evaluation can exclude complete discontinuity (e.g., absent lateral swelling) and identify athletes with a high probability of complete discontinuity (e.g., positive anterior drawer test) of the lateral ankle ligaments. In the delayed setting, the sensitivity of common clinical findings increases resulting in an improved diagnostic accuracy. In clinical practice, this study underlines the importance of meticulous clinical evaluation in the acute setting.

LEVEL OF EVIDENCE

Level III.

Video review of the frequency and assessment of head impacts during the FIFA Arab Cup 2021TM

We used injury spotters and video footage review to establish the frequency of head impacts, their characteristics, and the subsequent medical assessment during the FIFA Arab Cup 2021TM. Six defined video signs of potential concussion based on an international consensus were used. A total of 88 head impacts were observed, with a median of 2 (IQR 1.5-4, range 0-7) head impacts per match, of which 44 (50%) resulted in on-pitch medical assessment. The median assessment duration was 51s (IQR 34-65s, range 19-262s). The most common mechanism was head-to-head contact (27% of all impacts and 43% of impacts with medical assessment). Seven head impacts showed video signs of potential concussion: six had one sign and one had two signs. The concussion substitution was used in three incidents. Head impacts during the FIFA Arab Cup were common and a median of 1 head impact per game required an on-pitch medical assessment. Only 8% of the head impacts showed any video sign of potential concussion, and only 3% resulted in a concussion substitution. The medical on-pitch assessments appeared too short (<1 min) to allow an appropriate assessment of all head impacts, indicating a need for further evaluation. Further standardisation of the injury spotter's role in football is recommended.

Acute clinical evaluation for syndesmosis injury has high diagnostic value

PURPOSE

To determine the diagnostic value of injury history, physical examination, six syndesmosis tests and overall clinical suspicion for syndesmosis injury.

METHODS

All athletes (> 18 yrs) with an acute ankle injury presenting within 7 days post-injury were assessed for eligibility. Acute ankle injuries were excluded if imaging studies demonstrated a frank fracture or 3 T MRI could not be acquired within 10 days post-injury. Standardized injury history was recorded, and physical examination was performed by an Orthopaedic Surgeon or Sports Medicine Physician. Overall clinical suspicion was documented prior to MRI. Multivariate logistic regression was used to determine the association between independent predictors and syndesmosis injury.

RESULTS

Between September 2016 and July 2019, a total of 150 acute ankle injuries were included. The median time from injury to acute clinical evaluation was 2 days (IQR 2). Prior to clinical evaluation, the median patient reported Visual Analog Scale for pain was 8/10 (IQR 2). Syndesmosis injury was present in 26 acute ankle injuries. An eversion mechanism of injury had a positive LR 3.47 (CI 95% 1.55-7.77). The squeeze tests had a positive LR of 2.20 (CI 95% 1.29-3.77) and a negative LR of 0.68 (CI 95% 0.48-0.98). Overall clinical suspicion had a sensitivity of 73% (CI 95% 52-88) and negative predictive value of 89% (CI 95% 78-95). Multivariate regression analyses demonstrated significant association for eversion mechanism of injury (OR 4.99; CI 95% 1.56-16.01) and a positive squeeze test (OR 3.25; CI 95% 1.24-8.51).

CONCLUSIONS

In an acute clinical setting with patients reporting high levels of ankle pain, a negative overall clinical suspicion reduces the probability of syndesmosis injury. Eversion mechanism of injury and a positive squeeze test are associated with higher odds of syndesmosis injury.

LEVEL OF EVIDENCE

Level III.

Injury prevention knowledge, beliefs and strategies in elite female footballers at the FIFA Women's World Cup France 2019

OBJECTIVES

This study assessed knowledge, beliefs and practices of elite female footballers regarding injury prevention.

METHODS

A survey was sent to players participating in the FIFA Women's World Cup France 2019. Questions covered three injury prevention domains: (1) knowledge; (2) attitudes and beliefs; (3) prevention practices in domestic clubs. Additionally, ACL injury history was assessed.

RESULTS

Out of 552 players, 196 women responded (35.5%). More than 80% of these considered injury risk to be moderate or high. Players listed knee, ankle, thigh, head and groin as the most important injuries in women's football. The most important risk factors identified were low muscle strength, followed by poor pitch quality, playing on artificial turf, too much training, reduced recovery and hard tackles. In these elite players, 15% did not have any permanent medical staff in their domestic clubs, yet more than 75% had received injury prevention advice and more than 80% performed injury prevention exercises in their clubs. Players identified the two most important implementation barriers as player motivation and coach attitude. Two-thirds of players used the FIFA 11+ programme in their clubs.

CONCLUSIONS

This diverse group of elite players demonstrated good knowledge of risk level and injury types in women's football. Of the risk factors emphasised by players, there was only one intrinsic risk factor (strength), but several factors out of their control (pitch quality and type, training volume and hard tackles). Still players had positive attitudes and beliefs regarding injury prevention exercises and indicated a high level of implementation, despite a lack of medical support.

Limited intrarater and interrater reliability of acute ligamentous ankle injuries on 3 T MRI

OBJECTIVES

To determine the diagnostic reliability of the Schneck grading system for acute ligamentous injuries of (1) the three major ligamentous ankle complexes, (2) the individual ankle ligaments and (3) the Sikka classification for syndesmosis injury.

METHODS

All acute ankle injuries in adult athletes (≥18 years), presenting to the outpatient department of a specialised Orthopaedic and Sports Medicine Hospital, within 7 days postinjury were screened for inclusion. Ankle injuries were excluded if imaging demonstrated a frank ankle fracture or if the 3 T MRI study could not be acquired within 10 days postinjury. Two radiologists graded the three major ligamentous complexes (lateral ankle complex, deltoid complex and syndesmosis complex) and their comprising individual ligaments according the four-grade Schneck grading system. Syndesmotic injuries were classified according the four-grade Sikka classification for consequent injury of the individual syndesmosis ligaments and the deltoid complex. Agreement and kappa (K) statistics were calculated to determine intrarater and interrater reliability.

RESULTS

Between September 2016 and September 2018, a total of 92 MR scans were obtained (87 patients). Interrater and intrarater reliability of the Schneck grading system was moderate to substantial for the lateral ankle complex (K=0.47-0.76), fair to almost perfect for the syndesmosis complex (K=0.37-0.89) and fair to moderate for the deltoid complex (K=0.14-0.51). For the individual ligaments, kappa values ranged from moderate to substantial for the anterior talofibular ligament (ATFL) (K=0.55-0.73), fair to substantial for the calcaneofibular ligament (K=0.31-0.62) and fair to almost perfect for the anteroinferior tibiofibular ligament (AITFL) (K=0.36-0.89). Diagnostic reliability of the Sikka classification ranged from moderate to almost perfect (K=0.51-0.95).

CONCLUSIONS

Grading of the three major ligamentous complexes and of the individual ankle ligaments according the Schneck grading system resulted in limited diagnostic reliability. When dichotomised for the presence of complete discontinuity, the interrater reliability of the Schneck grading system improved to substantial and almost perfect for the ATFL and AITFL, respectively. Classification of syndesmosis injury according the Sikka classification resulted in moderate interrater reliability.

Diagnostic value of ultrasonography in acute lateral and syndesmotic ligamentous ankle injuries

Objectives

To determine the diagnostic value of ultrasonography for complete discontinuity of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL) and the anterior inferior tibiofibular ligament (AITFL).

Methods

All acute ankle injuries in adult athletes (> 18 years old) presenting to the outpatient department of a specialised Orthopaedic and Sports Medicine Hospital within 7 days post-injury were assessed for eligibility. Using ultrasonography, one musculoskeletal radiologist assessed the ATFL, CFL and AITFL for complete discontinuity. Dynamic ultrasound measurements of the tibiofibular distance (mm) in both ankles (injured and contralateral) were acquired in the neutral position (N), during maximal external rotation (Max ER), and maximal internal rotation (Max IR). MR imaging was used as a reference standard.

Results

Between October 2017 and July 2019, 92 acute ankle injuries were included. Ultrasound diagnosed complete discontinuity of the ATFL with 87% (CI 74–95%) sensitivity and 69% (CI 53–82%) specificity. Discontinuity of the CFL was diagnosed with 29% (CI 10–56%) sensitivity and 92% (CI 83–97%) specificity. Ultrasound diagnosed discontinuity of the AITFL with 100% (CI 74–100%) sensitivity and 100% (CI 95–100%) specificity. Of the dynamic measurements, the side-to-side difference in external rotation had the highest diagnostic value for complete discontinuity of the AITFL (sensitivity 82%, specificity 86%; cut-off 0.93 mm).

Conclusions

Ultrasound has a good to excellent diagnostic value for complete discontinuity of the ATFL and AITFL. Therefore, ultrasound can be used to screen for injury of the ATFL and AITFL. Compared with ultrasound, dynamic ultrasound has inferior diagnostic value for complete discontinuity of the AITFL.

Key Points

• Ultrasound has a good to excellent diagnostic value for complete discontinuity of the anterior talofibular ligament (ATFL) and anterior inferior tibiofibular ligament (AITFL).

• Ultrasound can be used to screen for injury of the ATFL and AITFL.

• Compared with ultrasound, dynamic ultrasound has inferior diagnostic value for complete discontinuity of the AITFL.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-07305-7) contains supplementary material, which is available to authorized users.

Remote assessment in sport and exercise medicine (SEM): a narrative review and teleSEM solutions for and beyond the COVID-19 pandemic

Background

The COVID-19 pandemic forces sport and exercise medicine (SEM) physicians to think differently about the clinical care of patients. Many rapidly implement eHealth and telemedicine solutions specific to SEM without guidance on how best to provide these services.

Aim

The aim of this paper is to present some guiding principles on how to plan for and perform an SEM consultation remotely (teleSEM) based on a narrative review of the literature. A secondary aim is to develop a generic teleSEM injury template.

Results

eHealth and telemedicine are essential solutions to effective remote patient care, also in SEM. This paper provides guidance for wise planning and delivery of teleSEM. It is crucial for SEM physicians, technology providers and organisations to codesign teleSEM services, ideally involving athletes, coaches and other clinicians involved in the clinical care of athletes, and to gradually implement these services with appropriate support and education.

Conclusion

teleSEM provides solutions for remote athlete clinical care during and after the COVID-19 pandemic. We define two new terms—eSEM and teleSEM and discuss guiding principles on how to plan for and perform SEM consultations remotely (teleSEM). We provide an example of a generic teleSEM injury assessment guide.

Cohen's MRI scoring system has limited value in predicting return to play

PURPOSE

Numerous authors have hypothesised that MRI scoring systems provide a valid means of predicting return to play duration following an acute hamstring muscle strain. The purpose is to prospectively investigate the predictive value of the MRI scoring system of Cohen for return to sport (RTS), following an acute hamstring injury.

METHODS

Male football (soccer) players (n = 139) with acute onset posterior thigh pain underwent standardised clinical and MRI examinations within 5 days after injury. All players underwent a standardised physiotherapy regimen with RTS documented. The MRI scoring was statistically evaluated against RTS.

RESULTS

One hundred and ten MRI-positive hamstring injuries were evaluated with RTS duration ranging from 1 to 66 days. Total Cohen's MRI score accounted for approximately 4% of the variance in RTS duration. When comparing those with an MRI score of 10 or more took on average 9.8 days longer to RTS than those with an MRI score less than 10 (effect size: 0.85, p < 0.01).

CONCLUSIONS

Utilising the Cohen's MRI scoring system previously described, we were unable to provide a clinically useful prognosis for RTS in male soccer players. This may reflect the broader challenges of attempting to accurately determine RTS duration from imaging performed at a single point in time.

LEVEL OF EVIDENCE

Prospective case series, IV.

Review of the Local Organizing Committee (LOC) medical services during the 12th FINA World Swimming Championships (25 m) in Doha, Qatar

BACKGROUND

One of the primary roles of Fédération Internationale de Natation (FINA) is to promote athlete health. The planning and delivery of major international event medical services is carried out in collaboration with the Local Organizing Committee Medical Commission (LOCMC). Aspetar Orthopaedic and Sports Medicine Hospital provided the medical services to the 12th FINA World Swimming Championships (25 m) creating a unique opportunity for collaboration with FINA.

AIM

The purpose of this paper is to review the planning and delivery of medical services and athlete health promotion projects during the 12th FINA World Swimming Championships (25 m) to facilitate the planning of future sporting events of this size and scope.

METHODS

The 12th FINA World Swimming Championships (25 m) hosted 974 athletes from 166 countries. The LOC medical team recorded all medical encounters-newly incurred (or acute exacerbations of chronic) injuries and illnesses as well as follow-up consultations.

RESULTS

More than 90% of teams did not travel with a team physician and relied on the LOCMC for diagnosis and treatment of injuries and illnesses in athletes and accredited team officials. The LOC medical team had a total of 554 medical encounters: 385 therapy, 34 athlete injury, 65 athlete illness and 70 non-athlete encounters.

CONCLUSIONS

The LOCMC in collaboration with FINA delivered comprehensive medical services to athletes, officials and spectators attending the 12th FINA World Swimming Championships (25 m). This review paper provides information relevant to the planning and delivery of LOCMC medical services for future international swimming events contributing to the FINA objective of promoting athlete health.