Unmasking Distorted Reflections: Exploring Body Image, Alcohol, and Drug Use in Nighttime Entertainment Districts.

Background: Violence within nighttime entertainment districts (NEDs) has been blamed on problematic masculinity and has predominantly been attributed to excessive alcohol intake and steroid use in men. In this report we conducted two studies to: (1) ascertain whether researchers could act as third-party raters of body weight and muscle mass in NED patrons; and (2) to examine the relationship between body self-image, inebriation, alcohol preloading behaviors and drug use in the NEDs. Methods: Study 1 employed an observational approach to establish inter-rater reliability for ratings of muscle mass and weight. In Study 2 data (n = 2,745) were collected through breathalyzing and questionnaires to examine individuals' self-image and drinking and drug-taking behaviors. Results: Participants' self-ratings of muscle and weight significantly differed from researchers' ratings, with males perceiving themselves as less muscular and females perceiving themselves as heavier. Perceived weight and muscle size did not relate to alcohol levels, but an interaction was found for female steroid users who perceived themselves as less muscular. Conclusions: Findings indicated a distortion in participants' perceived body image, with a desire for muscularity among both males and females. These results underscore the complex interplay between self-perception, societal ideals, and drug use in young NED patrons.

'Insulin is super dangerous if you don't know what you're doing': Situating the risks of insulin within the image and performance enhancing drug community.

INTRODUCTION: Insulin is an essential treatment within diabetes management; however, it takes on a role of enhancement within image and performance enhancing drug (IPED) communities due to its anabolic effects. This study sought to provide insight into how IPED users perceive and manage the risks linked to insulin. METHODS: We conducted semi-structured interviews with 10 individuals from Australia and United Kingdom who used insulin as part of their IPED protocols. The analysis followed an iterative categorisation approach and applied the lens of situated rationality theory. RESULTS: The decision to incorporate insulin was influenced by peers' experiences and preferences. Participants highlighted the risks and responsibilities associated with insulin use, emphasising the need for precise lifestyle habits. They recognised the potential dangers and called for comprehensive harm reduction strategies within IPED communities to respond to such concerns. Some participants expressed reluctance to discuss insulin openly, underlining the importance of education and awareness to mitigate health risks associated with underground and uninformed use. DISCUSSION AND CONCLUSIONS: While people who use IPEDs demonstrate awareness of the risks associated with insulin, their practices of routinisation moderate these risks within the context of IPED use. Silence as a risk-reduction strategy highlights vulnerabilities among certain prospective users, while the hierarchical structure of IPED use establishes expertise and status within the community. Reconsidering insulin risks entails reframing harm reduction messages to better match the social dynamics of IPED communities. Closer ties between IPED communities can enhance support accessibility, particularly through peers, who, with their firsthand knowledge, can offer tailored guidance.

Exploring the role of community pharmacies as a harm reduction environment for anabolic-androgenic steroid consumers: triangulating the perspectives of consumers and pharmacists.

BACKGROUND: While community pharmacies have been successful in providing harm reduction support for illicit substance consumers, little research has explored their role in addressing the needs of anabolic-androgenic steroid (AAS) consumers. OBJECTIVE: This study aimed to triangulate the attitudes and experiences of AAS consumers and community pharmacist's regarding AAS harm reduction. METHODS: Semi-structured interviews were conducted with AAS consumers (n = 8) and community pharmacists (n = 15) between December 2022 and August 2023 in Australia. Interview data were analysed using reflexive thematic analysis. RESULTS: While consumers emphasised easy access to pharmacies, particularly in urban areas, challenges were noted in rural regions. AAS consumers expressed a preference for community pharmacies, perceiving them as less confronting and a feasible avenue for accessing professional advice, highlighting the potential role of pharmacists in nurturing therapeutic alliances with AAS consumers. Similarly, pharmacists expressed receptivity to providing harm reduction information but acknowledged knowledge gaps, suggesting a need for tailored education programs to support AAS consumers effectively. CONCLUSIONS: Community pharmacies can be an important environment for AAS harm reduction. Strategies include utilising private spaces for open discussions with AAS consumers and enhancing pharmacists' understanding of AAS to foster trust and support. Further research is needed to address knowledge gaps and training needs for pharmacy staff, with the aim of creating a safer environment for AAS consumers.

'I mean, I wouldn't say I was sober': Exploring the psychosocial impact of e-scooter injuries and aligning a collaborative public health response.

ISSUE ADDRESSED: E-scooters are sought after for their cost-effectiveness, sustainability, and efficiency in urban transportation. However, this popularity has been accompanied by a surge in injuries, prompting a deeper investigation into the factors influencing risk perceptions among e-scooter users. METHODS: Using a qualitative approach, we conducted 19 interviews with those who attended an emergency department as a result of e-scooter injury. We aimed to understand the psychosocial effects of these incidents and employed thematic analysis to discern recurrent patterns in participants' experiences, focusing on alterations in daily life, community response, perception shifts, and avenues to enhance safety awareness. RESULTS: The findings underscored significant disruptions to daily life due to injuries, demonstrating enduring impacts on lifestyle and wellbeing. Participants exhibited a perceptual shift, transitioning from perceiving e-scooters as enjoyable to viewing them as dangerous. Recommendations for enhancing safety awareness included accessible and clear safety education, pre-ride briefings, real-time safety guidance, temporal rental restrictions, and mandatory breathalysers before e-scooter use. CONCLUSIONS: The study underscores the importance of considering not only the individual experiences and perceptions of e-scooter injuries but also the broader social context, including the night-time economy. Leveraging peer narratives and community engagement is vital to reshape risk perceptions and promote harm reduction messages. SO WHAT?: A comprehensive approach through proactive interventions and robust educational strategies is essential to foster responsible e-scooter usage and prioritise public safety.

Characterising differences between self-reported and wastewater-identified drug use at two consecutive years of an Australian music festival.

BACKGROUND: In the context of drug prohibition, potential adulteration and variable purity pose additional health risks for people who use drugs, with these risks often compounded by the outdoor music festival environment. Ahead of the imminent implementation of drug checking services in Queensland, Australia, this study aims to characterise this problem using triangulated survey and wastewater data to understand self-reported and detected drug use among attendees of a multi-day Queensland-based music festival in 2021 and 2022. METHODS: We administered an in-situ survey focusing on drug use at the festival to two convenience samples of 136 and 140 festival attendees in 2021 and 2022 respectively. We compared survey findings to wastewater collected concurrently from the festival's site-specific wastewater treatment plant, which was analysed using Liquid Chromatography Tandem Mass Spectrometry. RESULTS: Most survey respondents (82 % in 2021, 92 % in 2022) reported using or intending to use an illicit drug at the festival. Some respondents reported potentially risky drug use practices such as using drugs found on the ground (2 % in 2021, 4 % in 2022). Substances detected in wastewater but not surveys include MDEA, mephedrone, methylone, 3-MMC, alpha-D2PV, etizolam, eutylone, and N,N-dimethylpentylone. CONCLUSION: Many substances detected in wastewater but not self-reported in surveys likely represent substitutions or adulterants. These findings highlight the benefits of drug checking services to prevent harms from adulterants and provide education on safer drug use practices. These findings also provide useful information on socio-demographic characteristics and drug use patterns of potential users of Queensland's future drug checking service.

Sweating for Sobriety: Exploring the Relationship Between Exercise Engagement and Substance Use Disorders.

Despite various interventions available for substance use disorders, relapse rates remain substantial and, therefore, alternative strategies for attenuating dependence are needed. This study examined the associations between exercise frequency, illicit substance use, and dependence severity among a large sample of people who use drugs. The study utilized data from the Global Drug Survey 2018 (N = 57,110) to investigate the relationship between exercise frequency, illicit substance use, and substance dependence severity. Binomial regressions were employed to examine the relationship between exercise and SDS scores for 9 drugs. Greater exercise frequency correlated with reduced severity of substance dependence for specific drugs: cannabis (χ2 = 14.75, p < .001), MDMA (χ2 = 4.73, p = .029), cocaine (χ2 = 8.37, p = .015), amphetamine powder (χ2 = 6.39, p = .041), and methamphetamine (χ2 = 15.17, p < .001). These findings suggest a potential link between exercise and reduced substance use dependency. Further research is needed to understand the complex dynamics between exercise and substance use, considering potential bidirectional relationships and concurrent factors.

Big business: The private sector market for image and performance enhancing drug harm reduction in the UK.

This article draws on three mutually independent ethnographic studies to explore the private sector market for image and performance enhancing drug (IPED) harm reduction in the UK, specifically examining (1) steroid accessory supplements; (2) blood testing services; and (3) bloodletting services. After contextualising the work with a discussion of IPED use and harm reduction and the substantial growth of the global health and fitness industry, each private sector provision is critically interrogated with the following questions in mind: what is the role and utility of these services compared to public sector provision? Why has the private sector begun to deliver IPED harm reduction products and services in the UK? And how does this provision relate to the health and fitness industry more broadly? The paper concludes with some reflections about the future direction of IPED harm reduction, the importance of community-led services, and the need to think innovatively if we are to best protect users' health and wellbeing.

Is the use of performance and image enhancing drugs (PIEDs) in women an issue of concern? The findings from a stakeholder consultation.

OBJECTIVES: There is limited research into the use of performance and image enhancing drugs among women who participate in sport, despite evidence that women do use these substances and experience related harms. The aim of this project is to capture stakeholder perspectives on the current research, policy, and practice landscape in Australia regarding women's performance and image enhancing drug use in regulated and unregulated sport settings. DESIGN: Qualitative interviews. METHODS: Thirty-two semi-structured interviews were conducted online with stakeholders from Australia between September and December 2021. Interviews ranged between 15 and 90 min in duration. Data were imported into the NVivo (Version 12) platform and analysed using thematic analysis. RESULTS: Thirty-two participants (20 females and 12 males) who held a variety of roles (e.g., coach/strength coaches, gym owners, anti-doping agents, athletes) were interviewed. Fourteen participants reported performance and image enhancing drug use. There were four overarching themes generated from the data: 'participation in untested sports'; 'environmental factors driving use'; 'individual rationalisation'; and, 'the dark side of performance and image enhancing drug use'. CONCLUSIONS: Performance and image enhancing drug use was identified as an issue of concern for women competing in non-elite strength and power-based sports. Of particular concern is the influence of unqualified advice from third parties (i.e., coaches and partners) regarding performance and image enhancing drug use. The environments in which performance and image enhancing drug use occurs can impact individual decisions of women and eventuate in significant and long-lasting physical and psychological harms.

"They sent it away for testing and it was all bunk": Exploring perspectives on drug checking among steroid consumers in Queensland, Australia.

INTRODUCTION: Research supports the feasibility and acceptance of drug checking among nightlife and festival attendees. Interest in expanding drug checking to other groups of people who use drugs, including those who inject drugs, has grown. However, understanding the acceptability and feasibility of drug checking among specific cohorts, like anabolic-androgenic steroids (AAS) consumers, remains a research gap. This study explores AAS consumers' perspectives on drug checking and service preferences, aiding the preparation for drug checking delivery in Queensland, Australia. METHODS: A purposive sampling technique was used to recruit 15 AAS consumers (9 males, 6 females; Mage = 36.80 years, SD = 6.12) from Australia. One-on-one semi-structured qualitative interviews were conducted with questions exploring participants' views on drug checking/testing and their preferences for AAS analysis. Thematic analysis was conducted with final themes established through iterative consensus. RESULTS: Consumers expressed frustration with the prevailing stereotypes, social stigma, and the perception of criminality associated with the use of AAS. There was a strong dependence on personal connections and trusted suppliers, with coaches exerting significant influence. Participants expressed concerns about the widespread availability of counterfeit products and underground operations. The act of using unknown AAS was likened to a game of Russian roulette, underscoring the importance of obtaining accurate information and access to reliable drug checking services. Consumers expressed a preference for a web-based platform that enables individuals to access their own test results while contributing to a comprehensive database of brand-specific testing outcomes. DISCUSSION: AAS consumers recognise the significance of monitoring their AAS use and seek a service that can not only assist them in making informed decisions regarding AAS usage but also potentially contribute to the knowledge of the wider AAS-consuming community. These findings underscore the importance of tailored education, drug checking services, and harm reduction measures to address the diverse needs of AAS consumers.

'My mind pretty much went to mush': A qualitative exploration of trenbolone in the performance and image enhancing drug community.

INTRODUCTION: There are a variety of harms associated with anabolic-androgenic steroids (AAS), with some AAS associated with an increased risk profile for users. Despite potentially different risk profiles, these harms are seldom discussed with respect to specific compounds although recent ethnographic research has identified a need to do so. Specifically, myth has developed among users with trenbolone reportedly having more dramatic effects on individuals, with reports of aggression, violent behaviour and extreme mood disturbances, and this is reflected in extant literature. This paper aims to report on the narrative surrounding the use of trenbolone among AAS users. METHOD: As part of a larger qualitative study, a number of AAS users were interviewed regarding their usage practices. A narrative emerged regarding the physical and psychological harms which accompanied their AAS use of which trenbolone played a central role (N = 16). RESULTS: Of all the AAS, trenbolone was viewed as having the most deleterious consequences for those who used it. Users reported an extreme shift in risk profile for psychosocial harms, particularly increased aggression and violent behaviour, as well as impulsivity regulation issues. AAS-using peers and family members of users reported the readily observable effect of trenbolone. DISCUSSION AND CONCLUSIONS: Users should be cognisant of the potential for significant harms and health-care providers working with this group may consider more focused screening strategies. Future policy decisions regarding AAS may wish to consider the pivotal role trenbolone plays in adverse outcomes for this unique group of substance users.

The Liver King Lie: Misrepresentation, justification, and public health implications.

It is well-established that performance and image enhancing drugs (PIEDs) are effective in increasing muscle mass and strength. PIEDs are unique in that, while harm may result from use, there is little evidence of widespread individual or social harm comparable with other illicit substances. However, given the rapid growth of the online health and fitness industry, the digital consumption of hardcore fitness content represents a space ripe for indirect harms. A poignant example of this trend among the digital health and fitness community is the contestation around 'fake natty' users, who falsely claim to not use PIEDs. The non-disclosure of use has the potential to give individuals who are not enhanced the false impression that they too can achieve a bodily ideal which is similar, potentially resulting in psychological distress and risky behaviours. In this commentary, we discuss this harmful phenomenon using the case study of the fitness influencer Brian Johnson, more commonly known as Liver King. Employing a psycho-criminological lens, we use Social Identity Theories to understand the 'Primal' identity, before unpacking Johnson's disavowal of his PIED consumption through Sykes and Matza's (1957) techniques of neutralization. We conclude with an overview of the harms surrounding fake natural influencers and cognitive dissonance, before attempting to map a path towards emic harm reduction in collaboration with the digital fitness community.

How the physical appearance of companions affects females with high or low social physique anxiety: a virtual reality exercise study.

Technologies such as virtual reality (VR), an immersive computer-based environment that induces a feeling of mental and physical presence, are becoming increasingly popular for promoting participation in exercise. The purpose of this study was to explore changes in motivation and other psychological states when the physique of an exercise companion was altered during a VR-based exercise task, and whether trait social physique anxiety (SPA) altered these effects. Using a mixed experimental design, female participants (N = 43) categorised as high or low in SPA participated in two counterbalanced 10-min running tasks within a VR environment where the exercise companion was either overweight or in-shape. Across both running tasks, individuals with high SPA reported higher negative affect, pressure and tension, and lower perceived competencies, than those with low SPA. Pressure and tension were also higher when exercising with an in-shape companion than with an overweight companion for all participants. In addition, participants with high SPA reported a stronger preference to exercise with an overweight companion than those with low SPA in a real exercise setting, but not in a VR setting. The findings suggest that the physique of an exercise companion and the SPA of an exerciser have important, but independent, psychosocial effects during exercise. That an in-shape physique of a virtual exercise companion was not a deterrent among those with high SPA has provided preliminary evidence that VR-based exercise may be helpful among females who worry about their appearance or feel self-conscious while exercising.

Impact on the health service in the Top End, Northern Territory following the introduction of an electric scooter sharing service.

OBJECTIVE: To investigate patients presenting to EDs following the recent introduction of a shared electric scooter (e-scooter) scheme in Northern Territory (NT). METHODS: We conducted a prospective observational cohort study in Darwin, a regional city in NT, Australia with a population of approximately 150 000. Any patient who disclosed involvement of an e-scooter in the reason for their presentation to the ED was included. A descriptive analysis was derived for age, sex, triage time, alcohol level, injury type and the requirement of operating theatre, inpatient stay or ED discharge. Categorical variables were analysed using χ2 -tests, with odds ratios (ORs), 95% confidence intervals (CIs) and P-values reported. Costing analysis to ED of attendances and inpatient hospital admissions was undertaken. RESULTS: There were 111 presentations over the 8-month study period (January-September 2021). Forty-nine percent (n = 51) of patients were male and 51% (n = 54) were female. Extremity (n = 70) and craniofacial (n = 61) injuries were most common and approximately a quarter of patients (n = 24) required operative management for injuries sustained. Approximately half (n = 51) of patients were intoxicated and the average alcohol level of those tested was 0.18% (range 0.05-0.49%). The average cost per ED attendance was AU$777 and total cost of inpatient admissions being AU$352 255. All inpatient admissions were a result of injury while intoxicated. CONCLUSION: Harm minimisations strategies targeting implementation of alcohol testing and penalties for riders may be able to reduce the effect that the introduction of e-scooters on the strained health system in the NT.

Investigating the impact of COVID-19 on performance and image enhancing drug use.

BACKGROUND: Emerging research has suggested that the COVID-19 pandemic has had some impact on substance use patterns. The aim of the study was to conduct a rapid survey to assess the impact of COVID-19 on performance and image enhancing drug (PIED) use and training, and any subsequent negative physical or mental health outcomes. METHODS: During 2020, a convenience sample of 60 PIED consumers (mean age = 26.69; 68.3% located outside Australia) completed a quantitative anonymous online survey exploring how the coronavirus pandemic impacted patterns of PIED use and associated exercise habits. The survey was administered via the Qualtrics platform and distributed online through PIED forums as well as through the investigators' networks. Participants were asked about their PIED use and exercise habits prior to and during restricted movement 'lockdowns'. RESULTS: During pre-COVID, the majority of the sample opted to 'blast-cruise' (an initial high dose, followed by a lower maintenance dose; 71.7%, n = 43). During lockdown, 45% (n = 27) reported a change in PIED use as a result of the restrictions. In light of health concerns during COVID-19, a majority of men (60%, n = 36) did not take any extra precautions relating to their PIED use. A subgroup of men ceased using PIEDs completely (16.7%, n = 10) with the majority (80%, n = 8) of that subgroup following post-cycle therapy (PCT) of some kind. Only a small proportion of the sample reported negative mental health issues as a result of PCT access issues. CONCLUSIONS: This study contributes to the emerging literature of the impact of the COVID-19 pandemic on substance use, specifically PIED use among men. The results suggest that the pandemic did influence the choice of PIEDs that participants consumed, although there was little disruption to patterns of exercise, an important aspect of PIED use. Of the men who did cease use completely, the majority reported little issue with PCT access; those who reported difficulty accessing PCT compounds indicated experience some mental health concerns related to ceasing their PIED use. Clinicians and those who come into contact with this group should be alert for any negative physical or mental health concerns resulting from disrupted or ceased PIED use.

Performance- and image-enhancing drug use in the community: use prevalence, user demographics and the potential role of wastewater-based epidemiology.

Performance- and image-enhancing drug (PIED) misuse is a significant public health issue. Currently, seizure data, surveys, anti-doping testing, and needle service provider data are used to estimate PIED use in populations. These methods are time consuming, single point-in-time measurements that often consist of small sample sizes and do not truly capture PIED prevalence. Wastewater-based epidemiology (WBE) has been used globally to assess and monitor licit and illicit drug consumption within the general community. This method can objectively cover large populations as well as specific subpopulations (gyms, music festivals, prisons), and has potential as a complementary monitoring method for PIED use. Information obtained through WBE could be used to aid public health authorities in developing targeted prevention and education programmes. Research on PIED analysis in wastewater is limited and presents a significant gap in the literature. The focus is on anabolic steroids, and one steroid alternative currently growing in popularity; selective androgenic receptor modulators. This encompasses medical uses, addiction, prevalence, user typology, and associated public health implications. An overview of WBE is described including its benefits, limitations and potential as a monitoring method for PIED use. A summary of previous work in this field is presented. Finally, we summarise gaps in the literature, future perspectives, and recommendations for monitoring PIEDs in wastewater.

The impact of social media on self-evaluations of men striving for a muscular ideal.

This paper describes an innovative approach combining a content analysis of commentary and images on a Facebook page with a thematic analysis of the subjective experience expressed in interviews of those impacted by the text and images. Interview participants were asked about their perceptions of the representation of the muscularity-focused identity on social media, including the specific Facebook page. Content analysis of the Facebook page comments showed that very muscular male images attracted predominantly negative feedback from the public, a trend supported by the interview participants. Thematic analysis of the interviews indicated that a negative social media representation and commentary can affect young men's self-esteem and increase body concern. Some men represented on the Page found it humorous, which could serve as a form of bonding for the muscularity-focused online community. Other young men acknowledged how harmful such negative feedback can be on their self-evaluations and body image, consistent with the sociocultural framework whereby negative representations can lead to increased body dissatisfaction.

Information sought, information shared: exploring performance and image enhancing drug user-facilitated harm reduction information in online forums.

BACKGROUND: There is good evidence to suggest that performance and image enhancing drug (PIED) use is increasing in Australia and that there is an increase in those using PIEDs who have never used another illicit substance. Peers have always been an important source of information in this group, though the rise of the Internet, and the increased use of Internet forums amongst substance consumers to share harm reduction information, means that PIED users may have access to a large array of views and opinions. The aim of this study was to explore the type of information that PIED users seek and share on these forums. METHODS: An online search was conducted to identify online forums that discussed PIED use. Three discussion forums were included in this study: aussiegymjunkies.com, bodybuildingforums.com.au, and brotherhoodofpain.com. The primary source of data for this study was the 'threads' from the online forums. Threads were thematically analysed for overall content, leading to the identification of themes. RESULTS: One hundred thirty-four threads and 1716 individual posts from 450 unique avatars were included in this analysis. Two themes were identified: (1) personal experiences and advice and (2) referral to services and referral to the scientific literature. CONCLUSIONS: Internet forums are an accessible way for members of the PIED community to seek and share information to reduce the harms associated with PIED use. Forum members show concern for both their own and others' use and, where they lack information, will recommend seeking information from medical professionals. Anecdotal evidence is given high credence though the findings from the scientific literature are used to support opinions. The engagement of health professionals within forums could prove a useful strategy for engaging with this population to provide harm reduction interventions, particularly as forum members are clearly seeking further reliable information, and peers may act as a conduit between users and the health and medical profession.

A novel device using the Nordic hamstring exercise to assess eccentric knee flexor strength: a reliability and retrospective injury study.

STUDY DESIGN: Reliability and case-control injury study. OBJECTIVES: To determine if a novel device designed to measure eccentric knee flexor strength via the Nordic hamstring exercise displays acceptable test-retest reliability; to determine normative values for eccentric knee flexor strength derived from the device in individuals without a history of hamstring strain injury (HSI); and to determine if the device can detect weakness in elite athletes with a previous history of unilateral HSI. BACKGROUND: HSI and reinjury are the most common cause of lost playing time in a number of sports. Eccentric knee flexor weakness is a major modifiable risk factor for future HSI. However, at present, there is a lack of easily accessible equipment to assess eccentric knee flexor strength. METHODS: Thirty recreationally active males without a history of HSI completed the Nordic hamstring exercise on the device on 2 separate occasions. Intraclass correlation coefficients, typical error, typical error as a coefficient of variation, and minimal detectable change at a 95% confidence level were calculated. Normative strength data were determined using the most reliable measurement. An additional 20 elite athletes with a unilateral history of HSI within the previous 12 months performed the Nordic hamstring exercise on the device to determine if residual eccentric muscle weakness existed in the previously injured limb. RESULTS: The device displayed high to moderate reliability (intraclass correlation coefficient = 0.83-0.90; typical error, 21.7-27.5 N; typical error as a coefficient of variation, 5.8%-8.5%; minimal detectable change at a 95% confidence level, 60.1-76.2 N). Mean ± SD normative eccentric flexor strength in the uninjured group was 344.7 ± 61.1 N for the left and 361.2 ± 65.1 N for the right side. The previously injured limb was 15% weaker than the contralateral uninjured limb (mean difference, 50.3 N; 95% confidence interval: 25.7, 74.9; P<.01), 15% weaker than the normative left limb (mean difference, 50.0 N; 95% confidence interval: 1.4, 98.5; P = .04), and 18% weaker than the normative right limb (mean difference, 66.5 N; 95% confidence interval: 18.0, 115.1; P<.01). CONCLUSION: The experimental device offers a reliable method to measure eccentric knee flexor strength and strength asymmetry and to detect residual weakness in previously injured elite athletes.