If the shoe fits should you just wear it? A complete calcaneal stress fracture in a female recreational runner.

Shoe choice by runners may follow trends related to purported generalised benefits rather than following an individual risk-benefit analysis. The benefits and risks related to minimalist footwear for running has been a much debated topic. The authors report a case of a complete calcaneal stress fracture in an otherwise healthy female recreational runner in the first three weeks following her conversion from a traditional cushioned running shoe to a minimalist type of running shoe. Clinicians should be aware of the potential added bone stress with reduced cushioning and the potential risks in transitioning to new footwear.

A "scattered" SCAT in a football goalkeeper: a case report.

Background: In an acute field-side setting, it is often challenging to differentiate benign sports-related concussion (SRC) from potential, more sinister, intracranial pathology. Moreover, recovery in the ensuing days and weeks is often complex as the resolution of classical signs and symptoms does not always follow a standard pattern. Aim: To highlight the value of a structured and repeated thorough clinical assessment approach toward SRC, particularly as atypical and unexpected sequences in patient recovery patterns may require further specialist referral and intervention. Findings: A football goalkeeper sustained a concussion in which symptoms failed to resolve as expected. Deterioration in his clinical condition led to an eventual diagnosis of Chiari malformation (type I), which required surgical intervention. Implications: Non-typical recovery patterns of concussion may be indicative of increased severity when considered retrospectively. However, clinicians should not discount the possibility of underlying conditions.

Eye tracking technology in sports-related concussion: a systematic review and meta-analysis.

OBJECTIVE: The development of objective quantitative tools for the assessment and monitoring of sports-related concussion is critical. Eye tracking is a novel tool that may provide suitable metrics. The aim of this review was to appraise current evidence for the use of eye tracking technology in sports-related concussion assessment and monitoring. APPROACH: A systematic literature review was conducted following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. A search was run using Google Scholar, Microsoft Academic and PubMed for literature published between January 1980 and May 2018. Included were empirical research studies in English where at least 50% of the research participants were athletes, the participants were individuals with a diagnosis of concussion, and eye movements were measured using an eye tracking device. MAIN RESULTS: This systematic review integrates 21 publications on sports-related concussion and eye tracking technology, nine of which also qualified for the meta-analysis. Overall, the literature reported significant findings for variables in each of the four classes of eye tracking measurements (movement, position, count, and latency). Meta-comparison was made for seven variables for the acute concussions (the difference between the concussed and the control groups was significant for all of them) and one variable for the latent concussions (the difference was not significant). SIGNIFICANCE: Most saccadic and pursuit deficits may be missed during clinical examination, and therefore eye tracking technology may be a useful and sensitive screening and monitoring tool for sports-related concussions. The inconsistencies between the eye movement metrics and methodology still make inferences challenging; however, using tasks that are closely related to brain areas involved in executive functions (such as memory-based saccade or antisaccade tasks) in the acute injury phase holds promise in differentiating between athletes who have a concussion compared to those who do not.

Cardiac rehabilitation delivery model for low-resource settings

"OBJECTIVE: Cardiovascular disease is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be cost-effective and efficacious in high-income countries. CR could represent an important approach to mitigate the epidemic of cardiovascular disease in lower-resource settings. The purpose of this consensus statement was to review low-cost approaches to delivering the core components of CR, to propose a testable model of CR which could feasibly be delivered in middle-income countries. METHODS: A literature review regarding delivery of each core CR component, namely: (1) lifestyle risk factor management (ie, physical activity, diet, tobacco and mental health), (2) medical risk factor management (eg, lipid control, blood pressure control), (3) education for self-management and (4) return to work, in low-resource settings was undertaken. Recommendations were developed based on identified articles, using a modified GRADE approach where evidence in a low-resource setting was available, or consensus where evidence was not. RESULTS: Available data on cost of CR delivery in low-resource settings suggests it is not feasible to deliver CR in low-resource settings as is delivered in high-resource ones. Strategies which can be implemented to deliver all of the core CR components in low-resource settings were summarised in practice recommendations, and approaches to patient assessment proffered. It is suggested that CR be adapted by delivery by non-physician healthcare workers, in non-clinical settings. CONCLUSIONS: Advocacy to achieve political commitment for broad delivery of adapted CR services in low-resource settings is needed."

High incidence of injury at the Sochi 2014 Winter Paralympic Games: a prospective cohort study of 6564 athlete days.

OBJECTIVE: To describe the epidemiology of injuries at the Sochi 2014 Winter Paralympic Games. METHODS: A total of 547 athletes from 45 countries were monitored daily for 12 days during the Sochi 2014 Winter Paralympic Games (6564 athlete days). Daily injury data were obtained from teams with their own medical support (32 teams, 510 athletes) and teams without their own medical support (13 teams, 37 athletes) through electronic data capturing systems. RESULTS: There were 174 total injuries reported, with an injury incidence rate (IR) of 26.5 per 1000 athlete days (95% CI 22.7% to 30.8%). There was a significantly higher IR recorded in alpine skiing/snowboarding (IR of 41.1 (95% CI 33.7% to 49.6%) p=0.0001) compared to cross-country skiing/biathlon, ice sledge hockey or wheelchair curling. Injuries in the shoulder region were the highest single-joint IR (IR of 6.4 (95% CI 4.6% to 8.6%)), although total upper and lower body IR were similar (IR 8.5 vs 8.4 (95% CI 6.4% to 11.1%)). Furthermore, the IR of acute injuries was significantly higher than other types of injury onset (IR of 17.8 (95% CI 14.7% to 21.4%)). CONCLUSIONS: In a Winter Paralympic Games setting, athletes report higher injury incidence than do Olympic athletes or athletes in a Summer Paralympic Games setting. The highest incidence of injury was reported in the alpine skiing/snowboarding sporting category. There was a similar incidence of injury in the upper and lower limbs. The joint with the greatest rate of injury reported was the shoulder joint. Our data can inform injury prevention programmes and policy considerations regarding athlete safety in future Winter Paralympic Games.

The incidence and patterns of illness at the Sochi 2014 Winter Paralympic Games: a prospective cohort study of 6564 athlete days.

OBJECTIVE: To describe the epidemiology of illness at the Sochi 2014 Winter Paralympic Games. METHODS: A total of 547 athletes from 45 countries were monitored daily for 12 days over the Sochi 2014 Winter Paralympic Games (6564 athlete days). Illness data were obtained daily from teams without their own medical support (13 teams, 37 athletes) and teams with their own medical support (32 teams, 510 athletes) through electronic data capturing systems. RESULTS: The total number of illnesses reported was 123, with an illness incidence rate (IR) of 18.7 per 1000 athlete days (95% CI 15.1% to 23.2%). The highest IR was reported for wheelchair curling (IR of 20.0 (95% CI 10.1% to 39.6%)). Illnesses in the respiratory system (IR of 5.6 (95% CI 3.8% to 8.0%)), eye and adnexa (IR of 2.7 (95% CI 1.7% to 4.4%)) and digestive system (IR of 2.4 (95% CI 1.4% to 4.2%)) were the most common. Older athletes (35-63 years) had a significantly higher IR than younger athletes (14-25 years, p=0.049). CONCLUSIONS: The results of this study indicate that Paralympic athletes report higher illness incidence rates compared to Olympic athletes at similar competitions. The highest rates of illness were reported for the respiratory and digestive systems, eye and adnexa, respectively. Thus, the results of this study form a basis for the identification of physiological systems at higher risk of illness, which can in turn inform illness prevention and management programmes with eventual policy change to promote athlete safety in future editions of the Winter Paralympic Games.

Paralympic athletes with cerebral palsy display altered pacing strategies in distance-deceived shuttle running trials.

This study investigated performance and physiology to understand pacing strategies in elite Paralympic athletes with cerebral palsy (CP). Six Paralympic athletes with CP and 13 able-bodied (AB) athletes performed two trials of eight sets of 10 shuttles (total 1600m). One trial was distance-deceived (DEC, 1000 m + 600 m) one trial was nondeceived (N-DEC, 1600 m). Time (s), heart rate (HR, bpm), ratings of perceived exertion (RPE, units), and electromyography of five bilateral muscles (EMG) were recorded for each set of both trials. The CP group ran slower than the AB group, and pacing differences were seen in the CP DEC trial, presenting as a flat pacing profile over the trial (P < 0.05). HR was higher and RPE was lower in the CP group in both trials (P < 0.05). EMG showed small differences between groups, sides, and trials. The present study provides evidence for a possible pacing strategy underlying exercise performance and fatigue in CP. The results of this study show (1) underperformance of the CP group, and (2) altered pacing strategy utilization in the CP group. We proposed that even at high levels of performance, the residual effects of CP may negatively affect performance through selection of conservative pacing strategies during exercise.

The epidemiology of injuries in powerlifting at the London 2012 Paralympic Games: An analysis of 1411 athlete-days.

Sport injury epidemiology has received increased recognition as a field of sport medicine research that can improve the health and safety of athletes. Injuries among Paralympic powerlifters have not previously been systematically studied. The purpose of this prospective cohort study was to characterize injuries among Paralympic powerlifters. Athletes competing in the sport of powerlifting were followed over the 7-day competition period of the 2012 London Paralympic Games. The main outcome measurements were injury incidence rate (IR; number of injuries per 1000 athlete-days) and injury incidence proportion (IP; injuries per 100 athletes). A total of 38 injuries among 163 powerlifters were documented. The overall IR was 33.3 injuries/1000 athlete-days (95% CI 24.0-42.6) and the overall IP was 23.3 injuries per 100 athletes (95% CI 16.8-29.8). The majority of injuries were chronic overuse injuries (61%). The most commonly injured anatomical region was the shoulder/clavicle (32% of all injuries), followed by the chest (13%) and elbow (13%). The information obtained in this study opens the door for future study into the mechanisms and details of injuries into powerlifters with physical impairments.

Therapeutic use of growth factors in the musculoskeletal system in sports-related injuries.

Growth factors (GFs) act as signalling agents for cells and become a more and more popular mean to influence the human body and its tissues. This review gives an overview of the current possibilities to use such agents in the field of sports related injuries and thus providing the athlete with a whole new potential to minimize recovery time. GFs and its application have been studied intensively for a long time starting with animal studies. For some of this GFs this research has been brought onto the next level to clinical phase trials. Agents such as insulin like growth factor 1 (IGF-1), mechano growth factor (MGF), basic fibroblast growth factor (B-FGF), platelet derived growth factor (PDGF), vascular endothelial growth factor (VEGF), transforming growth factor b (TGF-b), bone morphogenetic protein (BMP) and leukemia inhibitory factor (LIF) are being discussed in this review. These GFs not only have the potential to be used to cure injuries but also are being in the centre of interest for doping abusers and are a powerful yet not fully understood technique to gain performance.

Skeletal muscle pathology in endurance athletes with acquired training intolerance.

BACKGROUND: It is well established that prolonged, exhaustive endurance exercise is capable of inducing skeletal muscle damage and temporary impairment of muscle function. Although skeletal muscle has a remarkable capacity for repair and adaptation, this may be limited, ultimately resulting in an accumulation of chronic skeletal muscle pathology. Case studies have alluded to an association between long term, high volume endurance training and racing, acquired training intolerance, and chronic skeletal muscle pathology. OBJECTIVE: To systematically compare the skeletal muscle structural and ultrastructural status of endurance athletes with acquired training intolerance (ATI group) with asymptomatic endurance athletes matched for age and years of endurance training (CON group). METHODS: Histological and electron microscopic analyses were carried out on a biopsy sample of the vastus lateralis from 18 ATI and 17 CON endurance athletes. The presence of structural and ultrastructural disruptions was compared between the two groups of athletes. RESULTS: Significantly more athletes in the ATI group than in the CON group presented with fibre size variation (15 v 6; p = 0.006), internal nuclei (9 v 2; p = 0.03), and z disc streaming (6 v 0; p = 0.02). CONCLUSIONS: There is an association between increased skeletal muscle disruptions and acquired training intolerance in endurance athletes. Further studies are required to determine the nature of this association and the possible mechanisms involved.

Comparative effects of zopiclone and loprazolam on psychomotor and physical performance in active individuals.

OBJECTIVE: Sedative hypnotics are used by athletes to alleviate precompetition anxiety and insomnia. The effects of these agents on exercise tolerance have not been extensively researched. DESIGN: To determine the effects of sedative hypnotics on psychomotor and physical performance, a double-blind, placebo- (P) controlled, cross-over designed trial investigated the effects of zopiclone (Z) and loprazolam (L) on performance in 12 athletes. INTERVENTION: Subjects ingested either P, Z (7.5 mg), or L (2 mg) on three different occasions separated by a 1-week washout period. Eye-hand coordination tests, a 30-m sprint test, an agility test, and a graded treadmill run to exhaustion for determination of VO2max were performed 10 hours after drug administration. RESULTS: Subjects reported a significantly greater hangover effect following ingestion of L (8/11 subjects) compared with ingestion of Z (3/11 subjects; p < 0.01). A greater number of subjects felt alert after ingestion of P (9/11 subjects) and Z (9/11 subjects) compared with L (4/11 subjects; p < 0.01). The results of the eye-hand coordination tests, the 30-m sprint, the T-test, the VO2max, and the time to exhaustion during the treadmill run were not significantly altered following the ingestion of P, Z, and L. There was a significant difference between the delta values for Z and L for the number of missed responses in the eye-hand coordination tests (p < 0.02). Therefore, following the ingestion of L, subjects experienced a significant hangover effect and altered reaction time, whereas the ingestion of Z did not significantly impair either psychomotor or physical performance in the administered tests. CLINICAL RELEVANCE: Investigate the extent of the effects of sedative hypnotics on exercise performances, enabling team physicians to prescribe such drugs to the athlete more effectively.

The 'worn-out athlete': a clinical approach to chronic fatigue in athletes.

Chronic fatigue in the athletic population is a common but difficult diagnostic challenge for the sports physician. While a degree of fatigue may be normal for any athlete during periods of high-volume training, the clinician must be able to differentiate between this physiological fatigue and more prolonged, severe fatigue which may be due to a pathological condition. As chronic fatigue can be the presenting symptom of many curable and harmful diseases, medical conditions which cause chronic fatigue have to be excluded. The clinician must then be able to differentiate between chronic fatigue associated with training or chronic fatigue from other medical causes, and also between the chronic fatigue syndrome and the overtraining syndrome. Once the clinician has excluded all of the above medical conditions which cause chronic fatigue in athletes, a significant proportion of fatigued athletes remain without a diagnosis. Novel data indicate that skeletal muscle disorders may play a role in the development of symptoms experienced by the athlete with chronic fatigue. The histological findings from muscle biopsies of athletes suffering from the 'fatigued athlete myopathic syndrome' are presented. We have designed a clinical approach to the diagnosis and work-up of the athlete presenting with chronic fatigue. The strength of this approach is that it hinges on the participation of a multidisciplinary team in the diagnosis and management of the athlete with chronic fatigue. The athlete, coach, dietician, exercise physiologist and sport psychologist all play an important role in enabling the physician to make the correct diagnosis.

Pseudoephedrine is without ergogenic effects during prolonged exercise.

This study was designed to measure whether a single dose of 120 mg pseudoephedrine ingested 120 min before exercise influences performance during 1 h of high-intensity exercise. The effects of exercise on urinary excretion of the drug were also studied. Ten healthy male cyclists were tested on two occasions, separated by at least 7 days, by using a randomly assigned, double-blind, placebo-controlled, crossover design. Exercise performance was tested during a 40-km trial on a laboratory cycle ergometer, and skeletal muscle function was measured during isometric contractions. On a third occasion, subjects ingested 120 mg pseudoephedrine but did not exercise [control (C)]. Pseudoephedrine did not influence either time trial performance [drug (D) vs. placebo: 58.1 +/- 1.4 (SE) vs. 58.7 +/- 1.5 min] or isometric muscle function. Urinary pseudoephedrine concentrations were significantly increased 1 h after exercise (D vs. C: 114.3 +/- 27.2 vs. 35.4 +/- 13.1 micrograms/ml; P < 0.05). Peak plasma pseudoephedrine concentrations (P < 0.05) but not time taken to reach peak plasma concentrations or the area under the plasma pseudoephedrine concentration vs. time curve was significantly increased in the total group with exercise (D vs. C). In three subjects, plasma pseudoephedrine concentrations were not influenced by exercise. Only these subjects showed increased urinary pseudoephedrine excretion during exercise. We conclude that a single therapeutic dose of pseudoephedrine did not have a measurable ergogenic effect during high-intensity exercise of 1-h duration, but plasma drug concentrations and urinary excretion were altered by exercise. These findings have practical relevance to doping control regulations in international sporting competitions.

Chronic beta-blockade does not influence muscle power output during high-intensity exercise of short-duration.

Patients receiving beta-receptor antagonists for the treatment of hypertension frequently complain of impaired exercise tolerance. To determine whether these medications impair skeletal muscle contractile function, we measured isokinetic muscle function in ten healthy male cyclists receiving nebivolol (N), atenolol (A), propranolol (P) and the calcium channel antagonist diltiazem (D). The subjects performed standardized tests of muscle power on an isokinetic cycle ergometer following subacute ingestion of N, A, P, D and placebo (PL) in a double blind crossover trial. Subjects exercised maximally for 10 s at 90, 110, 120, 130 and 150 rpm with 2-min rest between sessions. Thereafter, they performed a 30-s fatigue test at 120 rpm. Resting heart rate was decreased 13.4%, 21.9% and 14.6% by N, A and P, respectively (P < 0.05 vs PL). Resting systolic blood pressure was decreased 6.7% by A only (P < 0.05 vs PL). Peak power, average power and work done was not different among treatment groups at any crank velocity, nor was there any difference in total work done or rate of work decline in the 30-s test. We concluded from our study that peak isokinetic muscle power during maximal exercise of short duration is not affected by beta-blockade or the calcium antagonist diltiazem. Fatigue during beta-receptor antagonism would not appear therefore to be due to changes in the ability of skeletal muscle to produce peak power output during exercise of short duration.

The effects of antihypertensive medications on the physiological response to maximal exercise testing.

This study compared the effects of clinically prescribed doses of cilazapril, nifedipine, and atenolol on maximal exercise performance in physically active subjects. In a double-blind crossover trial, 10 healthy male volunteers performed progressive aerobic exercise to exhaustion for determination of maximal oxygen consumption (VO2 max), after single dose ingestion of cilazapril, nifedipine, atenolol, and placebo. Measurements were made at exhaustion and at a single submaximal workload (250 W). Exercise time to exhaustion and peak workload were decreased by all agents (p less than 0.05 vs. placebo), but VO2 max was decreased by atenolol only (p less than 0.05 vs. placebo). Although both atenolol and cilazapril decreased the maximum systolic blood pressure, the peak heart rate was decreased only by atenolol (p less than 0.001 vs. placebo). Whereas submaximal oxygen consumption, minute ventilation, and blood lactate concentrations were not different between groups, ratings of perceived exertion were increased during submaximal exercise by atenolol and cilazapril (p less than 0.05 vs. placebo). Cilazapril, nifedipine, and atenolol all impaired exercise performance and increased ratings of perceived exertion during submaximal exercise without altering rates of oxygen consumption or blood lactate accumulation. Maximal exercise performance was impaired to a greater extent by atenolol than by nifedipine or cilazapril. This study suggests that either angiotensin-converting enzyme inhibitors or calcium-channel antagonists might be preferable for the management of hypertension in athletic patients as they have a lesser effect on exercise performance, at least in healthy individuals.