Scientific Rationale for a Bottom-Up Approach to Target the Host Response in Order to Try and Reduce the Numbers Presenting With Adult Respiratory Distress Syndrome Associated With COVID-19. Is There a Role for Statins and COX-2 Inhibitors in the Prevention and Early Treatment of the Disease?

The inflammatory response to and the subsequent development of Adult Respiratory Distress Syndrome (ARDS) is considered to underpin COVID-19 pathogenesis. With a developing world catastrophe, we need to examine our known therapeutic stocks, to assess suitability for prevention and/or treatment of this pro-inflammatory virus. Analyzing commonly available and inexpensive immunomodulatory and anti-inflammatory medications to assess their possible effectiveness in improving the host response to COVID-19, this paper recommends the following: (1) optimize current health-cease (reduce) smoking, ensure adequate hypertension and diabetes control, continue exercising; (2) start on an HMG CoA reductase inhibitor "statin" for its immunomodulatory and anti-inflammatory properties, which may reduce the mortality associated with ARDS; and (3) consider using Diclofenac (or other COX-2 inhibition medications) for its anti-inflammatory and virus toxicity properties. For purposes of effectiveness, this needs to be in the early course of the disease (post infection and/or symptom presentation) and given in a high dose. The downsides to these recommended interventions are considered manageable at this stage of the pandemic.

Influence of type and duration of training on the presence of an abnormal ECG in high-performance athletes.

OBJECTIVE: To undertake an ECG in high level athletes to determine the morphology of the ECG and to assess the influences on the ECG of the amount of time in a high-performance programme and the type of sport played. DESIGN: Cross-sectional cohort study. SETTING: High-performance sports programme. INTERVENTIONS: Current symptoms (questionnaire) and length of time in a high-performance sports programme were recorded. Sports were classified as either high maximal oxygen uptake continuous, high maximal oxygen uptake repeated effort or static. An ECG was performed and classified by 2010 European Society of Cardiology guidelines into Groups 0 (normal), Group 1 (common and training-related ECG changes) and Group 2 (uncommon and training unrelated ECG changes). RESULTS: The following were recorded: length of time in high performance sport programme (mean 2.3 years), type of sport (Continuous 103, Repeated effort 133, Static 37), ECG changes Group 0 (n=83, 31%), Group 1 (n=173, 63%) and Group 2 (n=17, 6.2%). Athletes with an increased length of time in a high performance programme demonstrated a higher likelihood of Group 2 ECG changes when compared with Groups 0 and 1 (p=0.05). The questionnaire did not help detect athletes with Group 2 ECG changes. CONCLUSIONS: This study demonstrates that an increased length of time in a high performance programme was associated with an increased number of detectable Group 2 ECG changes. Overall, the further investigation rate was 6.2%.

Deducing a mechanism of all musculoskeletal injuries.

BACKGROUND: The mechanism of musculoskeletal (MSK) injuries is not well understood. This research applies principles of elastic motion to the anatomy and movement patterns of MSK structures. From this an insight into the application and timing of forces on MSK structures can be established and the mechanism/s of injury derived. METHODS CURRENT KNOWLEDGE: All MSK structures demonstrate varying degrees of elasticity. Movement occurs primarily as a consequence of Muscle Tendon Unit (MTU) shortening. The application of an applied external force results in MSK structure lengthening. RESULTS: The MTU acts as a non-idealised Hookean Spring. The resting length of MSK structures is the minimum distance between attachment points. The anatomical constraints results in MSK structures having adequate compressive strength during shortening. Thus MSK injuries only occur during lengthening of the MSK structure. From this with knowledge of MSK movement cycles, we can derive the mechanism of injury. CONCLUSIONS: MSK injuries result from an inability to counter applied forces whilst lengthening. Muscles, tendons and ligaments can only injure during their lengthening contraction phase. Insertional tendons and bone near attachment points injure during the MTU shortening phase. Injuries to other MSK structures can occur independent of the lengthening and shortening phases such as direct contact injuries.

Doha agreement meeting on terminology and definitions in groin pain in athletes.

BACKGROUND: Heterogeneous taxonomy of groin injuries in athletes adds confusion to this complicated area. AIM: The 'Doha agreement meeting on terminology and definitions in groin pain in athletes' was convened to attempt to resolve this problem. Our aim was to agree on a standard terminology, along with accompanying definitions. METHODS: A one-day agreement meeting was held on 4 November 2014. Twenty-four international experts from 14 different countries participated. Systematic reviews were performed to give an up-to-date synthesis of the current evidence on major topics concerning groin pain in athletes. All members participated in a Delphi questionnaire prior to the meeting. RESULTS: Unanimous agreement was reached on the following terminology. The classification system has three major subheadings of groin pain in athletes: 1. Defined clinical entities for groin pain: Adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain. 2. Hip-related groin pain. 3. Other causes of groin pain in athletes. The definitions are included in this paper. CONCLUSIONS: The Doha agreement meeting on terminology and definitions in groin pain in athletes reached a consensus on a clinically based taxonomy using three major categories. These definitions and terminology are based on history and physical examination to categorise athletes, making it simple and suitable for both clinical practice and research.

Physical principles demonstrate that the biceps femoris muscle relative to the other hamstring muscles exerts the most force: implications for hamstring muscle strain injuries.

Of the hamstring muscle group the biceps femoris muscle is the most commonly injured muscle in sports requiring interval sprinting. The reason for this observation is unknown. The objective of this study was to calculate the forces of all three hamstring muscles, relative to each other, during a lengthening contraction to assess for any differences that may help explain the biceps femoris predilection for injury during interval sprinting. To calculate the displacement of each individual hamstring muscle previously performed studies on cadaveric anatomical data and hamstring kinematics during sprinting were used. From these displacement calculations for each individual hamstring muscle physical principles were then used to deduce the proportion of force exerted by each individual hamstring muscle during a lengthening muscle contraction. These deductions demonstrate that the biceps femoris muscle is required to exert proportionally more force in a lengthening muscle contraction relative to the semimembranosus and semitendinosus muscles primarily as a consequence of having to lengthen over a greater distance within the same time frame. It is hypothesized that this property maybe a factor in the known observation of the increased susceptibility of the biceps femoris muscle to injury during repeated sprints where recurrent higher force is required.

Analysis of the Three Most Prevalent Injuries in Australian Football Demonstrates a Season to Season Association Between Groin/Hip/Osteitis Pubis Injuries With ACL Knee Injuries.

BACKGROUND: Injuries are common in contact sports like Australian football. The Australian Football League (AFL) has developed an extensive injury surveillance database that can be used for epidemiological studies. OBJECTIVES: The purpose of this study is to identify any association between the three most prevalent injuries in the AFL. PATIENTS AND METHODS: From the AFL injury surveillance data 1997-2012 the injury incidence (new injuries per club per season) and the injury prevalence data (missed games per club per season) were analysed to detect the three most common injuries that would cause a player to miss a match in the AFL. The three most prevalent injuries in the AFL are hamstring strains, groin/hip/osteitis pubis injuries and Anterior Cruciate Ligament (ACL) knee injuries. Following this, further study was undertaken to detect the presence of any statistical relationship between injury incidences of the three most prevalent injuries over this sixteen year study period. RESULTS: Statistical analysis demonstrates for any given year that there was an association between having a groin/hip/osteitis pubis injuriy and having a knee ACL injury (P < 0.05) over the entire sixteen years. In other words if the number of groin/hip/osteitis pubis injuries in any given season were higher than average (alternatively lower) then the number of knee ACL injuries were also higher than average (alternatively lower) for that same season. Hamstring injuries had the highest variance of incidence of the three most prevalent injuries. CONCLUSIONS: Analysis of the AFL injury data demonstrates an association between incidence of groin/hip/osteitis pubis injuries and incidence of knee ACL injuries for any given playing season. This finding is difficult to explain with further research being required.

Lower back injuries in rowing national level compared to international level rowers.

BACKGROUND: Rowing injuries are common, with lower back injuries having the highest incidence. OBJECTIVES: This study was to investigate the major rowing injuries seen at a single high performance rowing sports program over a 5 years training period and establish if any relationship exists between these injuries and the level of competition that the rower is partaking in. PATIENTS AND METHODS: All rowers at the South Australian Sports Institute (SASI) programs were designated as being either international or national level rowers. Injuries that caused greater than 5 days training loss during any one training year were recorded. The number of lower back injuries and rib stress injuries causing training time loss were analysed to assess whether there was any association between the level of rower and the nature and type of injury causing training time loss. RESULTS: Forty-five national rowers (97 training years) had 15 lower back injuries compared to 12 international rowers 35 training years) with 1 lower back injury. Thus a national level rower was more likely to have a lower back injury compared to an international rower P = 0.05. In contrast an international level was more likely to have a rib stress fracture compared to a national rower P = 0.04. 21% of all injuries in this study were a consequence of cycling injuries. CONCLUSIONS: Lower back injuries are a significant cause of training time lost in rowers. These injuries are much more likely to occur in national level rowers when compared to international level rowers. In contrast rib stress injuries are associated with international compared to national level rowers.

Chronic Achilles tendinopathy treated with eccentric stretching program.

BACKGROUND: This study assessed the efficacy of a modified eccentric heel-drop program (reduced time and increased duration of stretch) in treating chronic Achilles tendinopathy. METHODS: Athletes with at least 12 weeks of symptoms diagnosed clinically as chronic Achilles tendinopathy were enrolled in the study. The only treatment recommended was a 6-week eccentric stretching regimen, with each stretch being maintained for at least 15 seconds. Athletes were followed to assess the response to treatment using a Visual Analogue Scale (VAS) for pain and a patient effectiveness rating for treatment satisfaction as well as time to return to pre-injury activity level. Followup was successful in 156 (82%) of the athletes. A total of 190 athletes were seen with chronic Achilles tendinopathy. RESULTS: Mid-substance injuries were diagnosed in 168 (88%) with the remainder 22 (12%) having distal insertional injuries. Pain as assessed by VAS reduced from mean of 7.2 at commencement of the regimen to 2.9 (p<0.01) after 6 weeks of stretching. Six months post commencement of program mean pain was 1.1. Patient satisfaction was rated at 7 or above (excellent) in 124 (80%) of the athletes. For mid-substance injuries the satisfaction rating was excellent in 86%. Overall mean time to return to pre-morbid activity was 10 weeks. CONCLUSION: A modified 6-week eccentric heel-drop training regimen as the only treatment for chronic Achilles tendinopathy resulted in a high degree of patient satisfaction, reduced pain and a successful return to pre-morbid activity levels. These results were best for mid-substance rather than insertional tendinopathy.

Bone biopsy of the parasymphyseal pubic bone region in athletes with chronic groin injury demonstrates new woven bone formation consistent with a diagnosis of pubic bone stress injury.

BACKGROUND: There is little scientific evidence available regarding the pathologic basis for chronic groin injury in athletes, a known difficult clinical problem. HYPOTHESIS: Histological analysis of the superior pubic ramus in athletes with diagnosed chronic groin injury may reveal the nature of the pathologic process. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Ten athletes with a diagnosis of chronic groin injury by clinical criteria (at least 6 weeks of pain) and magnetic resonance imaging criteria (unequivocal increase in T2 signal intensity) underwent bone biopsy of the superior pubic ramus. The biopsy site was located in the parasymphyseal region in the area of increased magnetic resonance image signal intensity. Histologic analysis of the specimens was then undertaken. RESULTS: Evidence of new woven bone was seen in all biopsy specimens. Signs of old bony injury were seen in 8 of the 10 specimens. There was no evidence of inflammation or osteonecrosis. CONCLUSION: Histologic analysis of bone biopsy specimens taken from the parasymphyseal pubic bone region with magnetic resonance imaging T2-weighted increased signal intensity of athletes diagnosed by clinical and magnetic resonance imaging criteria as having chronic groin injury demonstrates new woven bone formation. This is consistent with the athlete having a bone stress injury that may contribute significantly to athletic groin pain.

Hip joint range of motion restriction precedes athletic chronic groin injury.

Although a restricted hip range of motion has been previously associated with chronic groin injury the temporal course of this association remains unclear. Accordingly the purpose of this prospective cohort study was to report preliminary findings examining whether hip joint range of motion restriction is associated with subsequent onset of athletic chronic groin injury. End-range internal and external hip joint range of motion was determined in 29 elite Australian football players, without previous history of groin injury. The players were followed for two subsequent playing seasons for the development of chronic groin injury. Four athletes developed chronic groin injury defined as at least 6 weeks of groin pain and missing match playing time. In athletes that developed chronic groin injury a lower body weight (p=0.02) and reduced total hip joint range of motion (p=0.03) were found to be associated. This study suggests that hip stiffness is associated with later development of chronic groin injury and as such may be a risk factor for this condition. This work should be viewed as preliminary and caution is advised in applying the conclusion to clinical practice as the numbers in this study were small.

Outcome of conservative management of athletic chronic groin injury diagnosed as pubic bone stress injury.

BACKGROUND: Little data exist on the results of treatment for sports-related chronic groin injury. HYPOTHESIS: Sports-related chronic groin injury treated with a conservative (rest) program results in a satisfactory outcome. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Professional Australian male football players, at the end of the playing season, had their groin injury diagnosed using specific clinical and magnetic resonance imaging (MRI) criteria. Those assessed as having a non-hip-related cause for their chronic groin injury were treated principally by 12 weeks of complete rest from active weightbearing activities. Response to treatment was assessed at different stages of rehabilitation by recording the number of athletes who had returned to playing football and the number of athletes without symptoms. RESULTS: Twenty-seven athletes were considered to have chronic groin injury. Clinical and MRI (pubic bone marrow edema N = 26 [96%]), hyperintense line N = 25 [93%]) criteria suggested a pubic bone stress injury as diagnosis for the chronic groin injury. Eighty-nine percent of athletes returned to sport in the subsequent playing season, with 100% having returned by the second playing season after diagnosis. Forty-one percent of the athletes were without symptoms at the commencement of the following playing season, rising to 67% by the end of that playing season. CONCLUSIONS: Conservative management of athletic chronic groin injury resulted in an excellent outcome when assessed by the return to sport criterion. However, the results were only satisfactory if the criterion of ongoing symptoms after treatment was used. More research is needed to compare the efficacy of all treatments that are used in this troublesome condition.

Assessment of physical examination and magnetic resonance imaging findings of hamstring injury as predictors for recurrent injury.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To examine clinical and magnetic resonance imaging (MRI) features of hamstring muscle injury to determine if any are predictive for recurrent injury. BACKGROUND: Hamstring muscle strain injury and subsequent recurrent injury are common. Little information exists on factors that may increase the risk for recurrent injury. METHODS AND MEASURES: The subjects were athletes from 3 professional Australian Rules football teams (n = 162). Anthropometric measurements, clinical signs, convalescent interval, and MRI assessment and measurement were undertaken and recorded in athletes with hamstring muscle strain injury. Athletes were followed for the presence, or absence, of recurrent injury to the same-side posterior thigh over the same and subsequent playing seasons. RESULTS: Thirty athletes met criteria for hamstring injury. Twelve (40%) of 30 athletes had recurrent injury within the same season, with an additional 7 athletes having recurrent injury in the subsequent season. None of the features examined were associated with increased recurrent injury risk within the same playing season. Statistical analysis demonstrated that when combining the same with the subsequent playing season a larger size of initial hamstring injury, as measured by MRI, was associated with an increased risk for recurrent injury (P<.01). A measured transverse size of injury greater than 55% of the muscle, or calculated volume of injury greater than 21.8 cm3, resulted in an increased risk for hamstring recurrence of 2.2 (95% CI, 0.88-5.32) and 2.3 (95% CI, 0.94-5.81) times, respectively, when compared to athletes with hamstring injuries below these measurements. CONCLUSIONS: A larger size of hamstring injury was indicative of higher risk for recurrent injury but only after the subsequent playing season was considered along with the same playing season. None of the other parameters tested, including a shorter convalescent interval and clinical features, were associated with an increased risk for recurrent injury. However, due to low sample size the certainty of these conclusions may be limited.

6. Doctor on the sidelines.

Effectively managing on-field emergencies is the most important role of the doctor on the sidelines. Pre-event preparation is essential and should include a formulated plan for dealing with emergencies and access to emergency equipment such as a stretcher and a bag and mask. Game day injuries should be assessed by adhering as closely as possible to a normal clinical consultation, with a proper history and examination being performed for all injuries. The athlete with an on-field head injury should be treated as having a concomitant cervical spine injury until proven otherwise. Athletes with any symptoms after head injury should be comprehensively and continuously assessed. Return-to-play decisions are made by balancing the risk of injury recurrence, the potential severity of injury recurrence and the benefits of returning to the field (which are higher at elite than amateur level). There is currently a shortage of doctors willing to cover sports events in Australia, which is partially explained by inadequate remuneration, inadequate facilities provided at venues, inadequate training opportunities in sports medicine, and fear of the medicolegal consequences in taking on the role as a team doctor.

Groin pain in footballers: the association between preseason clinical and pubic bone magnetic resonance imaging findings and athlete outcome.

BACKGROUND: Groin pain and tenderness are common in athletes from a variety of codes of football, but little attention has been directed to the influence of magnetic resonance imaging and such clinical findings on athlete participation. HYPOTHESIS: Preseason groin pain, tenderness, and magnetic resonance imaging findings such as pubic bone marrow edema are associated with restricted training capacity and missed games. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Fifty-two Australian footballers in the national competition were recruited. Preseason groin pain and focal tenderness were recorded, and magnetic resonance imaging of the groin was performed within 1 week of examination. Training restriction and games missed owing to groin pain were documented during the subsequent season. RESULTS: Magnetic resonance imaging showed pubic bone marrow edema in 19 of 52 (37%) footballers and linear parasymphyseal T2 hyperintensity in 16 of 52 (31%) footballers. Groin pain restricted training during the season in 22 of 52 (42%) footballers, and 9 of 52 (17%) footballers missed at least 1 game. Preseason pain (P = .0004), pubic bone tenderness (P = .02), and linear parasymphyseal T2 hyperintensity (P = .01) were associated with restricted training capacity during the subsequent season. Preseason groin pain (P = .03) was associated with missed games, but magnetic resonance imaging findings were not. CONCLUSION: Preseason pubic bone marrow edema, groin pain, and linear parasymphyseal T2 hyperintensity were associated with training restriction, but only preseason groin pain was associated with missed games.

Description of pain provocation tests used for the diagnosis of sports-related chronic groin pain: relationship of tests to defined clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria.

The clinical assessment of groin pain in athletes is difficult, with the lack of specific clinical tests being in part responsible. Three pain provocation tests used in the diagnosis of chronic groin pain are described and their relationship to defined clinical and MRI criteria has been assessed. Eighty-nine Australian Rules football players with and without groin symptoms underwent clinical examination followed by history. Three pain provocation tests were performed (named as the Single Adductor, Squeeze and Bilateral Adductor tests). All athletes subsequently underwent MRI of their groin region for the presence of significant pubic bone marrow oedema (BMO). Of the 89, 47 were defined as having chronic groin pain, and 46 had significant BMO with 37 having both chronic groin pain and BMO. The three pain provocation tests demonstrated only moderate sensitivity (range 30-65%). Positive predictive values were moderate to high (67-93%) depending upon the individual test. The Bilateral Adductor test was the most sensitive test with the highest positive predictive values. The high specificity (88-93%) demonstrated should be treated with caution due to the study methodology. Three pain provocation tests of potential value in assessing chronic groin pain in athletes are described. If positive, all three pain provocation tests demonstrated a high likelihood for the athlete having MR-detected parasymphyseal pubic BMO. Further research is required on assessing the clinical usefulness of these tests.

Diagnostic and prognostic value of clinical findings in 83 athletes with posterior thigh injury: comparison of clinical findings with magnetic resonance imaging documentation of hamstring muscle strain.

BACKGROUND: Little is known about the clinical features of posterior thigh injuries and their contribution to accurate diagnosis and prognostic assessment of hamstring muscle strain injury. HYPOTHESES: The clinical features of posterior thigh injury can be used to diagnose hamstring muscle strain and to predict duration of absence from competition. STUDY DESIGN: Prospective clinical study. METHODS: For two playing seasons, the clinical features of posterior thigh injury, timing of injury, and playing days lost were recorded for Australian Rules football players. Magnetic resonance imaging was used to confirm hamstring muscle injury. RESULTS: Posterior thigh injuries associated with pain and tenderness were recorded for 83 players, with magnetic resonance imaging confirming hamstring injury in 68 (82%). Most of the hamstring injuries were sudden onset (62; 91%) and occurred after a significant warm-up period (57; 84%). Of the patients whose injuries were sudden onset and occurred after the warm-up period (N = 59), 57 (97%) had hamstring muscle strain detected on magnetic resonance imaging. Hamstring muscle injury confirmed by magnetic resonance imaging was associated with a longer absence from competition (mean, 27 days) than injuries where no hamstring injury was detected (mean, 16 days). CONCLUSIONS: The clinical features of hamstring injury typically include sudden onset, pain, and tenderness, although exceptions do occur. Muscle fatigue may be important in the pathogenesis of hamstring injury.

Hamstring injury in athletes: using MR imaging measurements to compare extent of muscle injury with amount of time lost from competition.

OBJECTIVE: The purpose of this study was to examine relationships between MR imaging measurements of the extent of hamstring injury and the amount of time lost from competition in a group of athletes. SUBJECTS AND METHODS: Thirty-seven athletes with suspected hamstring injury underwent T1 and inversion recovery T2 turbo spin-echo MR imaging in axial and sagittal planes. The presence and dimensions of abnormal focal intra- and extramuscular T2 hyperintensity were independently recorded by two radiologists, and the muscles involved and intramuscular location of injury were noted. The percentage of abnormal cross-sectional muscle area, abnormal muscle volume, and length of extramuscular T2 hyperintensity were measured from T2-weighted images depicting the maximal extent of the injury. Time (days) lost from competition was noted during follow-up. RESULTS: MR imaging detected hamstring muscle and linear extramuscular T2 hyperintensity in 30 (81%) and 25 (68%) of 37 athletes, respectively. The long head of the biceps was the dominant site of injury in 21 cases. The musculotendinous junction was involved in 28 (76%) of 37 cases. A relationship was seen between days lost from competition and percentage of abnormal muscle area (r = 0.63, p = 0.001) and volume of muscle affected (r = 0.46, p = 0.01), but only a trend for linear extramuscular T2 hyperintensity (r = 0.33, p = 0.12) was shown. CONCLUSION: Rehabilitation time was related to MR measurements such as the percentage of abnormal muscle area and approximate volume of muscle injury. Hamstring injury most frequently involved the long head of the biceps femoris muscle, and involvement of the intramuscular tendon was common.