Ligamentous Injuries and the Risk of Associated Tissue Damage in Acute Ankle Sprains in Athletes: A Cross-sectional MRI Study

Background: Ankle joint injuries are extremely common sports injuries, with the anterior talofibular ligament involved in the majority of ankle sprains. There have been only a few large magnetic resonance imaging (MRI) studies on associated structural injuries after ankle sprains. Purpose: To describe the injury pattern in athletes who were referred to MRI for the assessment of an acute ankle sprain and to assess the risk of associated traumatic tissue damage including lateral and syndesmotic ligament involvement. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 261 ankle MRI scans of athletes with acute ankle sprains were evaluated for: lateral and syndesmotic ligament injury; concomitant injuries to the deltoid and spring ligaments and sinus tarsi; peroneal, flexor, and extensor retinacula and tendons; traumatic and nontraumatic osteochondral and osseous changes; and joint effusion. Patients were on average 22.5 years old, and the average time from injury to MRI was 5.7 days. Six exclusive injury patterns were defined based on lateral and syndesmotic ligament involvement. The risk for associated injuries was assessed by logistic regression using ankles with no or only low-grade lateral ligament injuries and no syndesmotic ligament damage as the reference. Results: With regard to the injury pattern, there were 103 ankles (39.5%) with complete anterior talofibular ligament disruption and no syndesmotic injury, and 53 ankles (20.3%) had a syndesmotic injury with or without lateral ligament damage. Acute osteochondral lesions of the lateral talar dome were seen in 20 ankles (7.7%). The percentage of chronic lateral osteochondral lesions was 1.1%. The risk for talar bone contusions increased more than 3-fold for ankles with complete lateral ligament ruptures (adjusted odds ratio [aOR], 3.43; 95% CI, 1.72-6.85) but not for ankles with syndesmotic involvement. The risk for associated deltoid ligament injuries increased for ankles with complete lateral ligament injuries (aOR, 4.04; 95% CI, 1.99-8.22) compared with patients with no or only low-grade lateral ligament injuries. Conclusion: About 20% of athletes referred for MRI after suffering an acute ankle sprain had evidence of a syndesmotic injury regardless of lateral ligament involvement, while more than half had evidence of any lateral ligament injury without syndesmotic involvement. Concomitant talar osseous and deltoid ligament injuries are common

Medical resources deployed for the 2019 World Athletics Championships in Doha, Qatar

Background: International sporting events such as the World Athletics (WA) competition require proper medical coverage to ensure the wellbeing of athletes, support teams, and spectators 1 . Several factors may have an impact on people's requirements for medical attention such as the climate, altitude, and intensity of the sporting competition on the athletes 2,3 . The International Association of Athletics Federations (IAAF) held its 2019 competition in Doha, Qatar, and this study reports on the medical resources deployed to cover the event based on risk assessment. Case presentation: Although the competition was held for 10 days across two venues. The medical cover started 3 days earlier and also encompassed warm-up/training venues and official hotels (Table 1). It involved multiple healthcare organizations providing equipment, manpower, medical tents/clinics, and vehicles in case of transportation to the hospital was required. Results: Resources were allocated to various locations based on the risk assessment (Table 1) and depending on the number of people competing, training, or attending, and the size of the venue. Environmental factors were accounted for with the provision of cold-water immersion recovery baths at multiple locations and ample manpower with rostering of clinical staff from various relevant healthcare professions (Table 2). All resources were deployed on a rotational shift basis in the official locations well ahead of the start of each event until an hour or two after the completion of the event. Conclusion: Proper planning, communication, and collaboration among organizers, hosts, medical services providers, and other authorities play a vital role in the safety of athletes, support team members, and spectators. Such large events impose huge strain on the resources which can impact aspects of daily healthcare delivery to the rest of the community and hence need to be carefully considered. It is worth noting that the medical coverage provided was not overwhelmed by patient demand, hence; the medical coverage was appropriate

Delphi developed syllabus for the medical specialty of sport and exercise medicine : part 2

Training in the medical specialty of sport and exercise medicine (SEM) is available in many, but not all countries. In 2015, an independent Delphi group, the International Syllabus in Sport and Exercise Medicine Group (ISSEMG), was formed to create a basic syllabus for this medical specialty. The group provided the first part of this syllabus, by identifying 11 domains and a total of 80 general learning areas for the specialty, in December 2017. The next step in this process, and the aim of this paper was to determine the specific learning areas for each of the 80 general learning areas. A group of 26 physicians with a range of primary medical specialty qualifications including, Sport and Exercise Medicine, Family Medicine, Internal Medicine, Cardiology, Rheumatology and Anaesthetics were invited to participate in a multiple round online Delphi study to develop specific learning areas for each of the previously published general learning areas. All invitees have extensive clinical experience in the broader sports medicine field, and in one or more components of sports medicine governance at national and/or international level. SEM, Family Medicine, Internal Medicine, Cardiology, Rheumatology and Anaesthetics were invited to participate in a multiple round online Delphi study to develop specific learning areas for each of the previously published general learning areas. All invitees have extensive clinical experience in the broader sports medicine field, and in one or more components of sports medicine governance at national and/or international level. The hierarchical syllabus developed by the ISSEMG provides a useful resource in the planning, development and delivery of specialist training programmes in the medical specialty of SEM.http://bjsm.bmj.com2021-03-01hj2020Sports Medicin

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

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

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

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

Ligamentous Injuries and the Risk of Associated Tissue Damage in Acute Ankle Sprains in Athletes: A Cross-sectional MRI Study

Ankle joint injuries are extremely common sports injuries, with the anterior talofibular ligament involved in the majority of ankle sprains. There have been only a few large magnetic resonance imaging (MRI) studies on associated structural injuries after ankle sprains. To describe the injury pattern in athletes who were referred to MRI for the assessment of an acute ankle sprain and to assess the risk of associated traumatic tissue damage including lateral and syndesmotic ligament involvement. Cross-sectional study; Level of evidence, 3. A total of 261 ankle MRI scans of athletes with acute ankle sprains were evaluated for: lateral and syndesmotic ligament injury; concomitant injuries to the deltoid and spring ligaments and sinus tarsi; peroneal, flexor, and extensor retinacula and tendons; traumatic and nontraumatic osteochondral and osseous changes; and joint effusion. Patients were on average 22.5 years old, and the average time from injury to MRI was 5.7 days. Six exclusive injury patterns were defined based on lateral and syndesmotic ligament involvement. The risk for associated injuries was assessed by logistic regression using ankles with no or only low-grade lateral ligament injuries and no syndesmotic ligament damage as the reference. With regard to the injury pattern, there were 103 ankles (39.5%) with complete anterior talofibular ligament disruption and no syndesmotic injury, and 53 ankles (20.3%) had a syndesmotic injury with or without lateral ligament damage. Acute osteochondral lesions of the lateral talar dome were seen in 20 ankles (7.7%). The percentage of chronic lateral osteochondral lesions was 1.1%. The risk for talar bone contusions increased more than 3-fold for ankles with complete lateral ligament ruptures (adjusted odds ratio [aOR], 3.43; 95% CI, 1.72-6.85) but not for ankles with syndesmotic involvement. The risk for associated deltoid ligament injuries increased for ankles with complete lateral ligament injuries (aOR, 4.04; 95% CI, 1.99-8.22) compared with patients with no or only low-grade lateral ligament injuries. About 20% of athletes referred for MRI after suffering an acute ankle sprain had evidence of a syndesmotic injury regardless of lateral ligament involvement, while more than half had evidence of any lateral ligament injury without syndesmotic involvement. Concomitant talar osseous and deltoid ligament injuries are commo

Early versus delayed lengthening exercises for acute hamstring injury in male athletes: A randomised controlled clinical trial

Background: To evaluate the efficacy of early versus delayed introduction of lengthening (ie, eccentric strengthening) exercises in addition to an established rehabilitation programme on return to sport duration for acute hamstring injuries in a randomised controlled superiority trial. Methods: 90 male participants (age: 18–36 years, median 26 years) with an MRI-confirmed acute hamstring injury were randomised into an early lengthening (at day 1 of rehabilitation) group or a delayed lengthening (after being able to run at 70% of maximal speed) group. Both groups received an established rehabilitation programme. The primary outcome was time to return to sport (ie, time from injury to full unrestricted training and/or match play). The secondary outcome was reinjury rate within 12 months after return to sport. Other outcomes at return to sport included the Askling H-test, hamstring strength, clinical examination and readiness questions. Results: The return to sport in the early lengthening group was 23 (IQR 16–35) days and 33 (IQR 23–40) days in the delayed lengthening group. For return to sport (in days), the adjusted HR for the early lengthening group compared with the delayed lengthening group was 0.95 (95% CI 0.56 to 1.60, p=0.84). There was no significant difference between groups for reinjury rates within 2 months (OR=0.94, 95% CI 0.18 to 5.0, p=0.94), from 2 to 6 months (OR=2.00, 95% CI 0.17 to 23.3, p=0.58), and 6 to 12 months (OR=0.57, 95% CI 0.05 to 6.6, p=0.66). Conclusion: Accelerating the introduction of lengthening exercises in the rehabilitation of hamstring injury in male athletes did not improve the time to return to sport nor the risk of reinjury

Early versus delayed lengthening exercises for acute hamstring injury in male athletes: a randomised controlled clinical trial

BACKGROUND: To evaluate the efficacy of early versus delayed introduction of lengthening (ie, eccentric strengthening) exercises in addition to an established rehabilitation programme on return to sport duration for acute hamstring injuries in a randomised controlled superiority trial. METHODS: 90 male participants (age: 18-36 years, median 26 years) with an MRI-confirmed acute hamstring injury were randomised into an early lengthening (at day 1 of rehabilitation) group or a delayed lengthening (after being able to run at 70% of maximal speed) group. Both groups received an established rehabilitation programme. The primary outcome was time to return to sport (ie, time from injury to full unrestricted training and/or match play). The secondary outcome was reinjury rate within 12 months after return to sport. Other outcomes at return to sport included the Askling H-test, hamstring strength, clinical examination and readiness questions. RESULTS: The return to sport in the early lengthening group was 23 (IQR 16-35) days and 33 (IQR 23-40) days in the delayed lengthening group. For return to sport (in days), the adjusted HR for the early lengthening group compared with the delayed lengthening group was 0.95 (95% CI 0.56 to 1.60, p=0.84). There was no significant difference between groups for reinjury rates within 2 months (OR=0.94, 95% CI 0.18 to 5.0, p=0.94), from 2 to 6 months (OR=2.00, 95% CI 0.17 to 23.3, p=0.58), and 6 to 12 months (OR=0.57, 95% CI 0.05 to 6.6, p=0.66). CONCLUSION: Accelerating the introduction of lengthening exercises in the rehabilitation of hamstring injury in male athletes did not improve the time to return to sport nor the risk of reinjury