Background There is limited information on the association between habitual physical activity (PA) and renal function. Objective To report the longitudinal association between self-reported habitual PA and measures of renal function in a large cohort in Taiwan. Methods A total of 199 421 participants (aged ≥20 years) were selected from a Taiwan cohort between 1996 and 2014. All participants underwent at least two standardised medical examinations between 1996 and 2014. Self-administrated questionnaires were used to collect information on habitual PA. We used a generalised linear mixed model to investigate the associations between habitual PA and yearly change in estimated glomerular filtration rate (eGFR). The Cox proportional hazard regression model was used to investigate the associations between habitual PA and incident chronic kidney disease (CKD). Results Participants had a median follow-up duration of 4.2 years (0.2–18.9). The yearly mean (±SD) decrease in eGFR in participants with baseline very low-PA, low-PA, moderate-PA and high-PA was 0.46±1.01, 0.36±0.97, 0.30±0.94 and 0.27±0.91 mL/min/1.73 m2, respectively. Relative to the participants with very low-PA, the coefficients of yearly eGFR change were −43.93 (95% CI −79.18 to −8.68), 35.20 (95% CI −2.56 to 72.96) and 53.56 (95% CI 10.42 to 96.70) µL / min/1.73 m2, respectively, for the participants with low-PA, moderate-PA and high-PA, after controlling for a wide range of covariates. Relative to the very low-PA participants, those who had low-PA, moderate-PA and high-habitual PA had HRs of 0.93 (95% CI 0.88 to 0.98), 0.94 (95% CI 0.89 to 0.99) and 0.91 (95% CI 0.85 to 0.96) to develop CKD, respectively, after controlling for the covariates. Conclusions A higher level of habitual PA is associated with a smaller decrease in the level of eGFR and a lower risk of developing CKD.

Aim We aimed to identify patterns and mechanisms of injury situations in men’s professional handball by means of video match analysis. Methods Moderate and severe injuries (absence of >7 days) sustained in competition in one of six seasons (2010 to 2013 and 2014 to 2017) in men’s professional handball were prospectively analysed with a newly developed standardised observation form. Season 2013 to 2014 was excluded because of missing video material. Results 580 injuries were identified: 298 (51.4%) contact injuries, 151 (26.0%) indirect contact injuries and 131 (22.6%) non-contact injuries. Head (87.5%), hand (83.8%), shoulder (70.2%) and ankle (62.9%) injuries were mainly sustained during direct contact. Typical contact injuries included collision with an opponent’s upper extremity or torso, and ankle injuries mainly consisted of foot-to-foot collisions. A large proportion (41.7%) of knee injuries were caused by indirect contact, whereas thigh injuries mainly occurred (56.4%) through non-contact mechanism. Wing (56.9%) and pivot (58.4%) players had the highest proportion of contact injuries, whereas backcourt players had a high proportion of indirect contact injuries (31.5%) and goalkeepers of non-contact injuries (48.9%). The injury proportion of foul play was 28.4%. Most injuries occurred in the central zone between the 6-metre and 9-metre lines (26.1%) and during the last 10 min of each match half (OR 1.71, p=0.016). Conclusions In men’s professional handball in a league setting, contact — but not foul play — was the most common mechanism associated with moderate and severe injuries. Head, hand, shoulder and ankle injury were mainly sustained during direct contact.

More than 60 years of research have consistently shown that physical activity beneficially affects several health outcomes and reduces the risk of premature mortality. The Harvard Alumni Study, one of the first studies to suggest a dose–response association between physical activity and health, examined the association between ‘total’ physical activity (defined as strenuous sports, walking and stair climbing) and participation in strenuous sports and the risk of heart attack in about 17 000 men.1 ‘Total’ physical activity was categorised into groups based on energy expenditure in physical activity per week. The following were the important observations: (1) there was a substantial risk reduction when comparing the ‘inactive’ reference group expending <500 kcal per week in ‘total’ physical activity with the second group expending 500–999 kcal per week; (2) there was graded dose–response association, with declining risk up to about 3000 kcal per week of ‘total’ physical activity, beyond which the benefits plateaued; and (3) energy expenditure from strenuous sports appeared to have greater protective effect than ‘total’ volume of activity. However, the latter observation may partly be explained by more accurate reporting of sporting activities compared with physical activities of daily living of lower intensity (eg, stair climbing and walking). The dose–response curve from the landmark paper by Paffenbarger et al 1 was subsequently confirmed after accounting for confounding,2 and it has been replicated in women and ethnically diverse populations from low-income and middle-income countries.3–5 These previous studies assessed physical activity using different self-report instruments, which may be prone to cognitive biases (eg, recall bias) and which may result in overestimation of physical activity and underestimation of sedentary time. Due to …

Sports-related concussion (SRC) is a recognised sport-related injury and a growing global public health concern,1 accounting for between 1.3% and 9.1% of all injuries reported during cycling events.2 Road cycling, however, does not have a sport-specific SRC assessment protocol,3 particularly lacking a roadside screening (‘go/no go’) assessment protocol. We would therefore like to propose the creation of a cycling specific RoadsIde heaD injury assEssment (RIDE) protocol In order to account for the often transient, evolving or delayed onset of SRC symptoms, serial clinical evaluations should be embedded within a three-stage process to optimise the diagnosis of SRC.4 This RIDE protocol will evolve as epidemiological evidence on SRC in road cycling develops4 5 and feedback is received from interested parties. The three-stage diagnostic process involves (see figure 1): Figure 1 Cycling RoadsIde heaD Injury assEssment (RIDE) protocol (adapted from World Rugby HIA protocol).7 1. Initial road-side assessment immediately following head impact event (RIDE 1). 2. Reassessment immediately following completion of the stage on the same day of the injury (RIDE 2). 3. Reassessment the day following the initial injury …

Objective Para athletes reap significant health benefits from sport but are vulnerable to non-accidental harms. Little is known about the types and impacts of non-accidental harms Para athletes face. In this literature review, we summarise current knowledge and suggest priorities for future research related to non-accidental harms in Para athletes. Design Six electronic databases were searched between August and September 2017. 2245 articles were identified in the initial title/abstract review, and 202 records were selected for full-text review following preliminary screening. Two independent examiners evaluated each full text, and eight citations were selected based on inclusion/exclusion criteria. Data sources MEDLINE, Embase, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, Scopus and Academic Search Premier. Eligibility criteria for selecting studies Inclusion criteria: (A) human participants; (B) written in English; (C) descriptive, cohort and case series, case–control, qualitative, mixed methods studies and all clinical trials; and (D) data pertain to harassment/abuse of youth, recreational, collegiate, national-level and/or elite-level athletes with a physical and/or intellectual impairment. Results Most studies focused on young, visually impaired athletes and approximately half of all studies described high rates of bullying and its social implications. One study confirmed remarkably high rates of psychological, physical and sexual harms in Para athletes, compared with able-bodied peers. Conclusions Bullying in young, visually impaired athletes is described most commonly in the available literature. Due to the limited amount of data, the prevalence of non-accidental harms in Para athletes remains unclear and information on trends over time is similarly unavailable.

Objective To systematically review the biomechanical deficits after ACL reconstruction (ACLR) during single leg hop for distance (SLHD) testing and report these differences compared with the contralateral leg and with healthy controls. Design Systematic review with meta-analysis. Data sources A systematic search in Pubmed (Ovid), EMBASE, CINAHL, Scopus, Web of Science, PEDro, SPORTDiscus, Cochrane Library, grey literature and trial registries, was conducted from inception to 1 April 2018. Eligibility criteria for selecting studies Studies reporting kinematic, kinetic and/or electromyographic data of the ACLR limb during SLHD with no language limits. Results The literature review yielded 1551 articles and 19 studies met the inclusion criteria. Meta-analysis revealed strong evidence of lower peak knee flexion angle and knee flexion moments during landing compared with the uninjured leg and with controls. Also, moderate evidence (with large effect size) of lower knee power absorption during landing compared with the uninjured leg. No difference was found in peak vertical ground reaction force during landing. Subgroup analyses revealed that some kinematic variables do not restore with time and may even worsen. Conclusion During SLHD several kinematic and kinetic deficits were detected between limbs after ACLR, despite adequate SLHD performance. Measuring only hop distance, even using the healthy leg as a reference, is insufficient to fully assess knee function after ACLR. PROSPERO trial registration number CRD42018087779.

Background The vertical drop jump (VDJ) test is widely used for clinical assessment of ACL injury risk, but it is not clear whether such assessments are valid. Aim To examine if sports medicine professionals and coaches are able to identify players at risk of sustaining an ACL injury by visually assessing player performance during a VDJ test. Methods 102 video clips of elite female handball and football players performing a baseline VDJ test were randomly extracted from a 738-person prospective cohort study that tracked ACL injuries. Of the sample, 20 of 102 went on to suffer an ACL injury. These 102 videos were uploaded to an online survey. Sports medicine professionals and coaches were invited to assess athlete performance and rate each clip with a number between 1 and 10 (1 representing low risk of sustaining an ACL injury and 10 representing high risk). Receiver operating characteristic analyses were used to assess classification accuracy and between-group differences were analysed using one-way analysis of variance. Results 237 assessors completed the survey. Area under the curve values ranged from 0.36 to 0.60, with a mean score of 0.47, which is similar to random guessing. There were no significant differences in classification accuracy between groups (physicians, coaches, certified athletic trainers, researchers or physical therapists). Conclusion Assessors have poor predictive ability (no better than chance), indicating that visual assessment of a VDJ test is a poor test for assessing ACL injury risk in elite female handball and football players.

Objective To analyse differences between athletic disciplines in the frequency and characteristics of injuries during international athletics championships. Methods Study design, injury definition and data collection procedures were similar during the 14 international championships (2007–2018). National medical teams and local organising committee physicians reported all newly incurred injuries daily on a standardised injury report form. Results were presented as number of injuries and number of injuries per 1000 registered athletes, separately for male and female athletes, and for each discipline. Results From a total of 8925 male and 7614 female registered athletes, 928 injuries were reported in male and 597 in female athletes. The discipline accounting for the highest proportion of injuries was sprints, for both men (24%) and women (26%). The number of injuries per 1000 registered athletes varied between disciplines for men and women: highest in combined events for male athletes (235 (95% CI 189 to 281)) and female athletes (212 (95% CI 166 to 257)), and lowest for male throwers (47 (95% CI 35 to 59)) and female throwers (32 (95% CI 21 to 43)) and for female race walkers (42 (95% CI 19 to 66)). Injury characteristics varied significantly between disciplines for location, type, cause and severity in male and female athletes. Thigh muscle injuries were the main diagnoses in the disciplines sprints, hurdles, jumps, combined events and race walking, lower leg muscle injuries in marathon running, lower leg skin injury in middle and long distance running, and trunk muscle and lower leg muscle injuries in throws. Conclusions Injury characteristics differed substantially between disciplines during international athletics championships. Strategies for medical service provision (eg, staff, facilities) during athletics championships should be discipline specific and be prepared for targeting the main injuries in each discipline.

Objective To describe injuries and illnesses across traditional and new sports among the participating athletes of the Buenos Aires 2018 Youth Olympic Summer Games (BA YOG) (6–18 October 2018). Methods We recorded the daily number of athlete injuries and illnesses (1) through the reporting of all National Olympic Committee (NOC) medical teams and (2) in the polyclinic and medical venues manned by the BA YOG 2018 medical staff. Results In total, 3.984 athletes from 206 NOCs were observed. NOCs and BA YOG 2018 medical staff reported 619 injuries and 334 illnesses, equalling 15.5 injuries and 8.4 illnesses per 100 athletes over the 13-day period. The eight new sports on the Youth Olympic programme (futsal, beach handball, karate, roller speed skating, kitesurfing, BMX freestyle, climbing and break dancing) fell in between the other sports with respect to injury and illness risk. Injury incidence was highest in rugby (43% of all rugby players), followed by boxing (33%) and badminton (24%), and lowest in swimming, archery, roller speed skating, equestrian, climbing and rowing (<5%). The highest incidences of illness were recorded in golf (20%), followed by triathlon (16%), beach volleyball and diving (both 14%). Of the illnesses, 50% affected the respiratory system and 15% the gastrointestinal system. Injury and illness incidences varied between continents with athletes representing Europe having significantly fewer injuries and illnesses compared with other continents, apart from a similar illness incidence to Asian athletes. Conclusion The overall injury incidence of 15.5 injuries per 100 athletes was higher, while the overall illness incidence of 8.4 illnesses per 100 athletes was similar to previous youth and Olympic Games. The new sports did not differ significantly compared with the other sports with respect to injury and illness risk.

Background Little is known about athletes’ understanding of safe sport and occurrence of harassment and abuse in elite youth sport. Objective To evaluate the IOC Safe Sport educational experience at the Youth Olympic Games 2018 in Buenos Aires and to ascertain the athletes’ (1) understanding of what constitutes harassment and abuse, (2) perception of the occurrence in their sport, and (3) knowledge of where to report. Methods Athletes visiting the IOC Safe Sport Booth answered a survey related to athletes’ (1) understanding of harassment and abuse in sport, (2) perception of the occurrence of harassment and abuse in their sport, and (3) knowledge of where to report. Experts and volunteers answered an email survey on their experience. Results The response rate was 71.8%. When asked to define ‘safe sport’, the athletes mainly relate the concept to general physical and environmental safety, fair play and clean sport, rather than sport free from harassment and abuse. Almost half (46%) of the athletes expressed surprise by the definition of behaviours of harassment and abuse within sport. When asked if harassment and/or abuse occur in their sport, 47.5% reported ‘no’ or ‘not likely’, while 34% stated ‘likely’ or ‘very likely’; 19% were ‘unsure’. The majority (63%) of athletes knew where to seek help. Three quarters (71%) of the athletes rated the educational materials as ‘good’ to ‘excellent’. The experts and volunteers believed the intervention would result in change in athletes’ awareness, knowledge and behaviour. Conclusions This multinational cohort of elite youth athletes is not knowledgeable of the concept of harassment and abuse in sport, despite there being a significant perception of occurrence of harassment and abuse in their sports.

Objective We performed a randomised controlled trial (RCT) in patients undergoing ACL reconstruction (ACLR) using either quadriceps tendon graft (QT) or semitendinosus/gracilis hamstring (STG) graft. We compared subjective outcome (primary outcome) and knee stability, donor site morbidity and function (secondary outcomes). Methods From 2013 to 2015, we included 99 adults with isolated ACL injuries in the RCT. Fifty patients were randomised to QT grafts and 49 to STG grafts and followed for 2 years. Patient evaluated outcomes were performed by subjective International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, Kujala and Tegner activity scores. Knee laxity was measured with a KT-1000 arthrometer. Donor site morbidity was evaluated by the ‘donor site-related functional problems following ACLR score’. One-leg hop test tested limp strength symmetry. Results At 2-year follow-up, there was no difference between the two graft groups regarding subjective patient outcome, knee stability and reoperations. Also, at 2 years, donor site symptoms were present in 27% of patients in the QT group and 50% of patients in the STG group. The donor site morbidity score was 14 and 22 for the QT and STG, respectively. Hop test demonstrated lower limp symmetry for QT graft than STG graft of 91% and 97% respectively. Conclusion QT graft for ACLR did not result in inferior subjective outcome compared with STG graft. However, QT graft was associated with lower donor site morbidity than STG grafts but resulted in more quadriceps muscle strength deficiency than hamstring grafts. Both graft types had similar knee stability outcome. Trial registration number [NCT02173483][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT02173483&atom=%2Fbjsports%2F54%2F3%2F183.atom

![Figure][1] 1. 1. 2. Reardon CL , 3. Hainline B , 4. Aron CM , et al . Mental health in elite athletes: international Olympic Committee consensus statement (2019). Br J Sports Med 2019;53:667–99.[doi:10.1136/bjsports-2019-100715][2] [OpenUrl][3][

Hacking of the World Anti-Doping Agency’s (WADA’s) Anti-Doping Administrative & Management System (ADAMS) by an alleged Russian cyber espionage group ‘Fancy Bear’ disclosed incomplete information about Therapeutic Use Exemptions (TUEs) granted to more than 100 Olympic athletes from over 20 countries1 including some high-profile athletes. These unethical and illegal leaks of personal medical information provoked some criticism of the TUE system, much of it is ill-informed.2 3 In this discussion, I briefly review the concept of TUEs and advise how the TUE system can and should be strengthened. The TUE concept is both sound and essential, and the four criteria that must be met to approve a TUE have changed only marginally in 25 years4 (online appendix 1a). ### Supplementary data [bjsports-2018-100113supp001.pdf] After WADA approved the TUE guidelines in 2004 (that the IOC had adopted in 1991), WADA developed TUE Physician Guidelines —a valuable resource that currently outlines 19 of the different medical conditions that may necessitate an application for a TUE.5 These are updated regularly. TUEs are required to be uploaded …

There is no agreement on how to classify, define or diagnose hip-related pain—a common cause of hip and groin pain in young and middle-aged active adults. This complicates the work of clinicians and researchers. The International Hip-related Pain Research Network consensus group met in November 2018 in Zurich aiming to make recommendations on how to classify, define and diagnose hip disease in young and middle-aged active adults with hip-related pain as the main symptom. Prior to the meeting we performed a scoping review of electronic databases in June 2018 to determine the definition, epidemiology and diagnosis of hip conditions in young and middle-aged active adults presenting with hip-related pain. We developed and presented evidence-based statements for these to a panel of 37 experts for discussion and consensus agreement. Both non-musculoskeletal and serious hip pathological conditions (eg, tumours, infections, stress fractures, slipped capital femoral epiphysis), as well as competing musculoskeletal conditions (eg, lumbar spine) should be excluded when diagnosing hip-related pain in young and middle-aged active adults. The most common hip conditions in young and middle-aged active adults presenting with hip-related pain are: (1) femoroacetabular impingement (FAI) syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without a distinct osseous morphology (labral, chondral and/or ligamentum teres conditions), and that these terms are used in research and clinical practice. Clinical examination and diagnostic imaging have limited diagnostic utility; a comprehensive approach is therefore essential. A negative flexion–adduction–internal rotation test helps rule out hip-related pain although its clinical utility is limited. Anteroposterior pelvis and lateral femoral head–neck radiographs are the initial diagnostic imaging of choice—advanced imaging should be performed only when requiring additional detail of bony or soft-tissue morphology (eg, for definitive diagnosis, research setting or when planning surgery). We recommend clear, detailed and consistent methodology of bony morphology outcome measures (definition, measurement and statistical reporting) in research. Future research on conditions with hip-related pain as the main symptom should include high-quality prospective studies on aetiology and prognosis. The most common hip conditions in active adults presenting with hip-related pain are: (1) FAI syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without distinct osseous morphology including labral, chondral and/or ligamentum teres conditions. The last category should not be confused with the incidental imaging findings of labral, chondral and/or ligamentum teres pathology in asymptomatic people. Future research should refine our current recommendations by determining the clinical utility of clinical examination and diagnostic imaging in prospective studies.

Aim To describe the demographics, frequency, location, imaging modality and clinician-identified factors of rib stress injury in a cohort of elite rowers over the Rio Olympiad (2012–2016). Methods Analysis of prospectively recorded medical records for the Australian Rowing Team in 2013–2015 and the combined Australian Rowing Team and Olympic Shadow Squad in 2016, examining all rib stress injuries. Results 19 rib stress injuries (12 reactions and 7 fractures) were identified among a cohort of 151 athletes and included 12 female and 7 male cases, 11 open weight, 8 lightweight, 12 scull and 7 sweep cases. The most common locations of injury identified by imaging, were the mid-axillary line and rib 6. Period prevalence varied from 4% to 15.4% and incidence ranged from 0.27 to 0.13 per 1000 athlete days. There were no significant differences in prevalence by sex, sweep versus scull or weight class. There was a statistically significant increase in incidence in the pre-Olympic year (2015, p<0.001). MRI was the most commonly used modality for diagnosis. Stress fracture resulted in median 69 (IQR 56–157) and bone stress reaction resulted in 57 (IQR 45–78) days lost to full on water training. Conclusions In our 4-year report of rib stress injury in elite rowing athletes, period prevalence was consistent with previous reports and time lost (median ~10 weeks) was greater than previously published literature. Rib stress injury limits training and performance in elite rowers and MRI should be considered as a first line investigation.

The quality of sport and exercise physiotherapy has risen dramatically in the last few decades. Scope of practice still varies across the world, but physiotherapy/physical therapy consistently builds on a broad medical knowledge that underpins advanced decision-making and problem-solving. We work to support performance, prevent injury and provide clinical care. Pre-registration physiotherapy education provides the starter toolkit that ensures the entry level physiotherapist practices safely. How can physiotherapists ensure that they keep developing post-qualification, so that they can work at the highest level? To develop expertise—with an emphasis on the ‘expert’ part of that term—requires physiotherapists to keep abreast of advances in practice through both theoretical and experiential learning. The purpose of this editorial is to highlight how the International Federation of Sports Physical Therapy (IFSPT) can help a physiotherapist with this journey. Sports and exercise physiotherapy expertise, as defined by the IFSPT,1 is detailed on the IFSPT website.2 A modified model is presented in online supplementary material with this paper. It describes competencies required as a Registered International Sports Physical Therapist status.2 ### Supplementary data [bjsports-2019-101333supp001.pdf] Figure 1 describes a model of how a physiotherapist advances from novice to expert in decision-making and skill ‘development. Technical learning relates to science and general physiotherapy skills, largely attained at a novice level. Creative learning involves adapting decision-making and techniques to individual clinical presentations. Figure 1 Models of learning, encompassing reflective practice in developing experts. …

Objectives Regular walking is a critical target of physical activity (PA) promotion, and dog walking is a feasible PA intervention for a large segment of the population. The purpose of this paper was to review PA interventions that have involved canine interactions and to evaluate their effectiveness. A secondary aim of this review was to highlight the populations, settings, designs and intervention components that have been applied so as to inform future research. Design Systematic review. Data sources We carried out literature searches to August 2019 using six common databases. Eligibility criteria Studies included published papers in peer-reviewed journals and grey literature (theses and dissertations) in the English language that included any PA behaviour change design (ie, randomised controlled trial, quasi-experimental) that focused on canine-related intervention. We grouped findings by population, setting, medium, research design and quality, theory and behaviour change techniques applied. Results The initial search yielded 25 010 publications which were reduced to 13 independent studies of medium and high risks of bias after screening for eligibility criteria. The approaches to intervene on PA were varied and included loaner dogs, new dog owners and the promotion of walking among established dog owners. Findings were consistent in showing that canine-assisted interventions do increase PA (82% of the studies had changes favouring the canine-facilitated intervention). Exploratory subanalyses showed that specific study characteristics and methods may have moderated the effects. Compared with studies with longer follow-up periods, studies with shorter follow-up favoured behaviour changes of the canine intervention over the control condition. Conclusion Canine - based PA interventions appear effective, but future research should move beyond feasibility and proof of concept studies to increase rigour, quality and generalisability of findings.

Objective To investigate the risk of new meniscal tears after treatment for anterior cruciate ligament (ACL) injury, in children and adults with and without ACL reconstruction. Design Prognosis systematic review (PROSPERO registration number CRD42016036788). Methods We searched Embase, Ovid Medline, Cochrane, CINAHL, SPORTDiscus, PEDro and Google Scholar from inception to 3rd May 2018. Eligible articles included patients with ACL injury (diagnosis confirmed by MRI and/or diagnostic arthroscopy), reported the number of meniscal tears at the time of ACL injury diagnosis/start of treatment and reported the number of new meniscal tears that subsequently occurred. Articles with fewer than 20 patients at follow-up, and articles limited to ACL revision surgery or multi-ligament knee injuries were excluded. Two independent reviewers screened articles, assessed eligibility, assessed risk of bias and extracted data. We judged the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation (GRADE) working group methodology. Results Of 75 studies included in the systematic review, 54 studies with 9624 patients and 501 new meniscal tears were appropriate for quantitative analysis. Heterogeneity precluded data pooling. The risk of new meniscal tears was 0%–21% when follow-up was <2 years, 0%–29% when follow-up was 2 to 5 years, 5%–52% when follow-up was 5 to 10 years and 4%–31% when follow-up was longer than 10 years. The proportion of studies with high risk of selection, misclassification and detection bias was 84%, 69% and 68%, respectively. Certainty of evidence was very low. Conclusion New meniscal tears occurred in 0%–52% of patients between 4 months and 20 years (mean 4.9±4.4 years) following treatment for ACL injury. The certainty of evidence was too low to guide surgical treatment decisions. This review cannot conclude that the incidence of new meniscal tears is lower if ACL injury is treated with surgery compared with treatment with rehabilitation only.

Persistent musculoskeletal (MSK) pain across different body regions is frequently comorbid and shares common biopsychosocial risk profiles for pain and disability.1–3 Biopsychosocial factors require consideration; these include underactivity or overactivity, poor sleep, obesity as well as poor general and psychological health. As such, there is consensus across clinical guidelines on the recommendations …

This statement summarises and appraises the evidence on diagnosis, prevention and treatment of the most common lower extremity muscle injuries in sport. We systematically searched electronic databases, and included studies based on the highest available evidence. Subsequently, we evaluated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework, grading the quality of evidence from high to very low. Most clinical tests showed very low to low diagnostic effectiveness. For hamstring injury prevention, programmes that included the Nordic hamstring exercise resulted in a hamstring injury risk reduction when compared with usual care (medium to large effect size; moderate to high quality of evidence). For prevention of groin injuries, both the FIFA 11+programme and the Copenhagen adductor strengthening programme resulted in a groin injury risk reduction compared with usual care (medium effect size; low to moderate quality of evidence). For the treatment of hamstring injuries, lengthening hamstring exercises showed the fastest return to play with a lower reinjury rate compared with conventional hamstring exercises (large effect size; very low to low quality of evidence). Platelet-rich plasma had no effect on time to return-to-play and reinjury risk (trivial effect size; moderate quality of evidence) after a hamstring injury compared with placebo or rehabilitation. At this point, most outcomes for diagnosis, prevention and treatment were graded as very low to moderate quality of evidence, indicating that further high-quality research is likely to have an important impact on the confidence in the effect estimates.

Background Concussion is the most common injury in youth ice hockey. Whether mouthguard use lowers the odds of concussion remains an unanswered question. Objective To determine the association between concussion and mouthguard use in youth ice hockey. Methods Nested case–control design. Cases and controls were identified from two prospective cohort studies using valid injury surveillance methods. Cases were players concussed during a game or practice; controls were players who sustained a non-concussion injury during a game or practice. The primary exposure was mouthguard use at time of injury; mouthguard type (dental custom fit or off the shelf) was a secondary exposure. Physician-diagnosed or therapist-suspected concussion was the primary outcome. Dental injury was a secondary outcome. Multilevel logistic regression with random effect at a team level was used to obtain ORs for the mouthguard effect, adjusted for level of play, age group, position, concussion history, mechanism of injury, cohort, session type and body checking policy. Results Among cases, 236/315 (75%) were wearing a mouthguard at time of injury, while 224/270 (83%) controls were wearing a mouthguard at time of injury. Any mouthguard use was associated with an adjusted OR for concussion of 0.36 (95% CI 0.17 to 0.73). Off-the-shelf mouthguards were associated with a 69% lower odds of concussion (adjusted OR: 0.31; 95% CI 0.14 to 0.65). Dental custom-fit mouthguards were associated with a non-significant 49% lower odds of concussion (adjusted OR: 0.51; 95% CI 0.22 to 1.10). No dental injuries were identified in either cohort. Conclusion Mouthguard use was associated with lower odds of concussion. Players should be required to wear mouthguards in youth ice hockey.

The WHO Global Action Plan on Physical Activity (GAPPA) (#GAPPA)1 highlights the importance of a systems-wide approach to achieving the global goals for reducing physical inactivity at the national, community, individual and patient levels. Within this scope, objective 1.4 of that plan details the vision and strategy for capacity planning for the health workforce and the collaborations required for success. This objective is closely linked to existing global and national efforts to enable the future healthcare professional (HCP) workforce to have the capability and competencies to make every contact count for physical activity support and advice (via brief interventions). A significant part of these goals is to enable the future and current healthcare workforce to meet the challenges of non-communicable diseases (NCDs), sustainable development goals (SDGs) and person-centred healthcare, exemplars of which have been identified in most European countries.2 3 Indeed, a physical activity resource focused approach in undergraduate healthcare courses such as medicine, nursing and allied health is critical in higher education institutes’ (HEIs) strategies2 4 5 to deliver on these directives. Reaching the potential of knowledge and skill acquisition in physical activity interventions is a challenge in practice.6–8 Yet we know that HCP practice influences healthcare behaviours in patients: this is the basis of ‘making every contact count’ …

Objective To characterise whether preseason screening of shoulder range of motion (ROM) is associated with the risk of shoulder and elbow injuries in overhead athletes. Design Systematic review and meta-analysis. Data sources Six electronic databases up to 22 September 2018. Eligibility criteria Inclusion criteria were (1) overhead athletes from Olympic or college sports, (2) preseason measures of shoulder ROM, (3) tracked in-season injuries at the shoulder and elbow, and (4) prospective cohort design. Exclusion criteria were (1) included contact injuries, (2) lower extremity, spine and hand injuries, and (3) full report not published in English. Results Fifteen studies were identified, and they included 3314 overhead athletes (baseball (74.6%), softball (3.1%), handball (16.1%), tennis (2.0%), volleyball (2.0%) and swimming (2.2%)). Female athletes are unrepresented (12% of the overall sample). Study quality ranged from 11 to 18 points on a modified Downs and Black checklist (maximum score 21, better quality). In one study, swimmers with low (<93°) or high (>100°) shoulder external rotation were at higher risk of injuries. Using data pooled from three studies of professional baseball pitchers, we showed in the meta-analysis that shoulder external rotation insufficiency (throwing arm <5° greater than the non-throwing arm) was associated with injury (odds ratio=1.90, 95% confidence interval 1.24 to 2.92, p<0.01). Conclusion Preseason screening of shoulder external rotation ROM may identify professional baseball pitchers and swimmers at risk of injury. Shoulder ROM screening may not be effective to identify handball, softball, volleyball and tennis players at risk of injuries. The results of this systematic review and meta-analysis should be interpreted with caution due to the limited number of studies and their high degree of heterogeneity. PROSPERO registration number CRD42017072895.

Objective Determine whether impairments in lower limb muscle strength exist in individuals with chronic ankle instability (CAI) compared with uninjured controls. Design Systematic review with meta-analysis. Data source A comprehensive search of PubMed, Cochrane, CINAHL, Web of Science and EMBASE electronic databases from inception to 10 February 2019. Eligibility criteria for selecting studies Cross-sectional and case–control studies were included if they objectively measured lower limb muscle strength in individuals with CAI compared with controls. Risk of bias and quality of included studies were assessed. Data of included studies were extracted, and meta-analysis was conducted where appropriate. Results 12 397 unique studies were identified, of which 20 were included and 16 were eligible for meta-analysis. Reviewed studies clearly described the aim/hypothesis and main outcome measure, but most lacked sample size calculation and assessor blinding. Meta-analyses showed individuals with CAI had lower eccentric and concentric evertor strength (30 and 120°/s; Nm; standardised mean difference (SMD) between −0.73 and −0.95), eccentric invertor strength (60 and 120°/s; both Nm and Nm/kg; SMD between −0.61 and −1.37), concentric invertor strength (60 and 120°/s; Nm; SMD=−0.7) and concentric knee extensor strength (SMD=−0.64) compared with control participants. Ankle eccentric dorsiflexor strength was not different between groups. Although pooling was not possible, data from three separate studies indicated that hip flexor, abductor and external rotator strength, but not hip adductor and extensor strength, was lower in individuals with CAI than in control participants. Conclusion Individuals with CAI have ankle inversion and eversion strength deficits. Our data also point to differences between individuals with CAI and controls in hip and knee strength. These elements of the kinetic chain should be evaluated by clinicians who rehabilitate individuals with CAI. PROSPERO registration number CRD42016037759.

Changing a sport system requires the appointment of new leaders or a grass roots cultural revolution. ‘I got caught in a system designed by and for men, which destroys the bodies of young girls,’ said Mary Cain as she cast light on her toxic coach/athlete relationship and exposed unhealthy coaching and nutrition practices. Her candour has inspired a social media movement calling for changes to women’s sport.1 In the following days, major news publications followed up with similar reports of athletic women being body shamed.2–4 It is time for a drastic paradigm change in women’s sport, coupled with education at all levels to improve the long-term health and athletic achievement of female athletes. The shift needs to include: 1. Raising awareness of the negative effects of chronic low energy availability (LEA) (calorie restriction) so athletes can make wise choices for their own long-term health. 2. Updating and developing best-practice protocols and safe standards for monitoring body composition/weight. 3. Eliminating toxic training environments featuring abusive body shaming. Overexercising or underfueling, occurring consciously or subconsciously, can cause Relative …

My 9-year-old daughter woke up the morning after a long day of gymnastics training and complained that her muscle hurts. ‘I need a pill to stop the pain, NOW daddy’. Right, how do I deal with this one? Should I break out the pain education metaphors? Or give her a massage? Go for some contrast baths? I decided that the appropriate referral was a joint trip to the bakery. Over Finnish Pulla (cardamom sweet bread), we discussed that she had delayed-onset muscle soreness (DOMS), which is transient and not dangerous. During our cake-fuelled discussion, my daughter told me she had linked the use of ibuprofen for reducing a fever with helping her through the discomfort of well-earned DOMS. Rather than ‘endure’ the discomfort, she wanted a quick solution. If my 9-year-old daughter can make that connection, it is not difficult for others. Unfortunately, there is still excessive prophylactic use of prescribed …

A common question in sports injury research is ‘what proportion of athletes sustained an injury over a certain time period?’. In cross-sectional studies, where data are collected at a single point in time, the prevalence proportion is simply the number of injured athletes divided by the total sample. In prospective cohort studies, caution is needed as the injury incidence proportion (proportion of newly injured athletes during the observation period) is likely to be underestimated by simply using the approach that is valid for cross-sectional studies. As a part of the BJSM methods matter series,1 we here compare the analytical approaches for cross-sectional studies and prospective cohort studies (ie, without censoring and with censoring, respectively) to help the reader accurately estimate incidence proportion in prospective studies. To describe the proportion of sports injuries occurring over a given time period, one can calculate the CIP. The CIP can be calculated with or without censoring (in this paper, we discuss the concept of ‘right censoring’, but use the term ‘censoring’ only). For instance, the number of injured runners in a 1-year prospective cohort study was 252 of 931.2 Hence, the CIP calculated without censoring is 27% …

Excellence for elite athletes demands painstaking attention to detail to all aspects of health, well-being and performance. Researcher and Olympic Taekwondo Gold Medalist Lauren Burns and coauthors1 use the power of the athlete story to argue strongly and convincingly that central to achieving excellence is durable interpersonal support. ‘If we look at an athlete as a whole person, there is a fundamental duty of care to ensure they are supported to become their best, most resilient self, both on and off the field. Athletes therefore need to be encouraged to seek interpersonal support that evolves as they move along their development pathway’. These sentences, both important, appear sequentially; but I will make one distinction—the onus to create a supportive environment should not rest primarily on athletes. Where then does the duty of care lie? According to Fisher et al ’s heuristic model,2 the power differential in sport particularly positions coaches to hurt or help their athletes, and as such coaches are responsible for athlete’s welfare. Those, …

Rehabilitation of soft-tissue injuries can be complex. Over the years, acronyms guiding their management have evolved from ICE to RICE , then on to PRICE and POLICE .1 Although widely known, these previous acronyms focus on acute management, unfortunately ignoring subacute and chronic stages of tissue healing. Our contemporary acronyms encompass the rehabilitation continuum from immediate care ( PEACE ) to subsequent management ( LOVE ). PEACE and LOVE (figure 1) outline the importance of educating patients and addressing psychosocial factors to enhance recovery. While anti-inflammatories show benefits on pain and function, our acronyms flag their potential harmful effects on optimal tissue repair. We suggest that they may not be included in the standard management of soft-tissue injuries. Figure 1 PEACE and LOVE acronyms. ### P for protect Unload or restrict movement for 1–3 days to minimise bleeding, prevent distension of injured fibres and reduce the risk of aggravating the injury. Rest should be minimised as prolonged rest can compromise tissue strength and quality.1 Pain signals should guide the cessation of protection. ### E for elevate Elevate the limb higher …

Objective To determine whether antioxidant supplements and antioxidant-enriched foods can prevent or reduce delayed-onset muscle soreness after exercise. Methods We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, SPORTDiscus, trial registers, reference lists of articles and conference proceedings up to February 2017. Results In total, 50 studies were included in this review which included a total of 1089 participants (961 were male and 128 were female) with an age range of 16–55 years. All studies used an antioxidant dosage higher than the recommended daily amount. The majority of trials (47) had design features that carried a high risk of bias due to selective reporting and poorly described allocation concealment, potentially limiting the reliability of their findings. We rescaled to a 0–10 cm scale in order to quantify the actual difference between groups and we found that the 95% CIs for all five follow-up times were all well below the minimal important difference of 1.4 cm: up to 6 hours (MD −0.52, 95% CI −0.95 to −0.08); at 24 hours (MD −0.17, 95% CI −0.42 to 0.07); at 48 hours (mean difference (MD) −0.41, 95% CI −0.69 to −0.12); at 72 hours (MD −0.29, 95% CI −0.59 to 0.02); and at 96 hours (MD −0.03, 95% CI −0.43 to 0.37). Thus, the effect sizes suggesting less muscle soreness with antioxidant supplementation were very unlikely to equate to meaningful or important differences in practice. Conclusions There is moderate to low-quality evidence that high-dose antioxidant supplementation does not result in a clinically relevant reduction of muscle soreness after exercise of up to 6 hours or at 24, 48, 72 and 96 hours after exercise. There is no evidence available on subjective recovery and only limited evidence on the adverse effects of taking antioxidant supplements.

Objectives To identify common recommendations for high-quality care for the most common musculoskeletal (MSK) pain sites encountered by clinicians in emergency and primary care (spinal (lumbar, thoracic and cervical), hip/knee (including osteoarthritis [OA] and shoulder) from contemporary, high-quality clinical practice guidelines (CPGs). Design Systematic review, critical appraisal and narrative synthesis of MSK pain CPG recommendations. Eligibility criteria Included MSK pain CPGs were written in English, rated as high quality, published from 2011, focused on adults and described development processes. Excluded CPGs were for: traumatic MSK pain, single modalities (eg, surgery), traditional healing/medicine, specific disease processes (eg, inflammatory arthropathies) or those that required payment. Data sources Four scientific databases (MEDLINE, Embase, CINAHL and Physiotherapy Evidence Database) and four guideline repositories. Results 6232 records were identified, 44 CPGs were appraised and 11 were rated as high quality (low back pain: 4, OA: 4, neck: 2 and shoulder: 1). We identified 11 recommendations for MSK pain care: ensure care is patient centred, screen for red flag conditions, assess psychosocial factors, use imaging selectively, undertake a physical examination, monitor patient progress, provide education/information, address physical activity/exercise, use manual therapy only as an adjunct to other treatments, offer high-quality non-surgical care prior to surgery and try to keep patients at work. Conclusion These 11 recommendations guide healthcare consumers, clinicians, researchers and policy makers to manage MSK pain. This should improve the quality of care of MSK pain.

Objective To determine the effectiveness of conservative treatment (CT) on pain and function in patients with patellar tendinopathy (PT) compared with minimal intervention (MI) or other invasive intervention, or in addition to decline eccentric squat. Methods Searches were performed in MEDLINE, Embase, Cochrane, PEDro, SPORTDiscus, CINAHL and AMED databases. All randomised trials that evaluated CT (any intervention not involving invasive procedures or medication) in individuals with PT were included. Two reviewers screened studies, extracted data and assessed risk of bias of all included studies. Where suitable, meta-analyses were conducted; we assessed certainty of the evidence using GRADE methodology. Results When compared with MI, CT did not improve pain (weighted mean difference (WMD) −2.6, 95% CI −6.5 to 1.2) or function (WMD 1.8, 95% CI −2.4 to 6.1) in the short-term (up to 3 months) follow-up. When compared with invasive intervention, CT did not improve pain (WMD 0.7, 95% CI −0.1 to 1.4) or function (WMD −6.6, 95% CI −13.3 to 0.2) in the short-term follow-up. No overall effects were found for combined CT (when a conservative intervention was added to decline eccentric squat) on pain (WMD −0.5, 95% CI −1.4 to 0.4) or function (WMD −2.3, 95 % –9.1 to 4.6) at short-term follow-up. Single studies showed an effect on pain with iontophoresis at short-term follow-up (d = 2.42) or dry needling at medium/long-term follow-up (d = 1.17) and function with exercise intervention at medium/long-term follow-up (over 3 months) (d = 0.83). Summary/Conclusion Our estimates of treatment effect have only low to very low certainty evidence to support them. This field of sports medicine/sports physiotherapy urgently needs larger, high-quality studies with pain and function among the potential primary outcomes.

Objectives To determine whether individuals who sustained a sports concussion would exhibit persistent impairments in gait and quiet standing compared to non-injured controls during a dual-task assessment . Design Systematic review and meta-analysis using individual participant data (IPD). Data sources The search strategy was applied across seven electronic bibliographic and grey literature databases: MEDLINE, EMBASE, CINAHL, SportDISCUS, PsycINFO, PsycARTICLES and Web of Science, from database inception until June 2017. Eligibility criteria for study selection Studies were included if; individuals with a sports concussion and non-injured controls were included as participants; a steady-state walking or static postural balance task was used as the primary motor task; dual-task performance was assessed with the addition of a secondary cognitive task; spatiotemporal, kinematic or kinetic outcome variables were reported, and; included studies comprised an observational study design with case–control matching. Data extraction and synthesis Our review is reported in line with the Preferred Reporting Items for Systematic review and Meta-Analyses-IPD Statement. We implemented the Risk of Bias Assessment tool for Non-randomised Studies to undertake an outcome-level risk of bias assessment using a domain-based tool. Study-level data were synthesised in one of three tiers depending on the availability and quality of data: (1) homogeneous IPD; (2) heterogeneous IPD and (3) aggregate data for inclusion in a descriptive synthesis. IPD were aggregated using a ‘one-stage’, random-effects model. Results 26 studies were included. IPD were available for 20 included studies. Consistently high and unclear risk of bias was identified for selection, detection, attrition, and reporting biases across studies. Individuals with a recent sports concussion walked with slower average walking speed (χ2=51.7; df=4; p<0.001; mean difference=0.06 m/s; 95% CI: 0.004 to 0.11) and greater frontal plane centre of mass displacement (χ2=10.3; df=4; p=0.036; mean difference −0.0039 m; 95% CI: −0.0075 to −0.0004) than controls when evaluated using a dual-task assessment up to 2 months following concussion. Summary/conclusions Our IPD evidence synthesis identifies that, when evaluated using a dual-task assessment, individuals who had incurred a sports concussion exhibited impairments in gait that persisted beyond reported standard clinical recovery timelines of 7–10 days. Dual-task assessment (with motion capture) may be a useful clinical assessment to evaluate recovery after sports concussion. Protocol pre-registration This systematic review was prospectively registered in PROSPERO CRD42017064861.

Objective We compared data from the National Collegiate Athletic Association (NCAA) Concussion Study (1999–2001) and the NCAA-Department of Defense Concussion Assessment, Research and Education (CARE) Consortium (2014–2017) to examine how clinical management, return to play (RTP) and risk of repeat concussion in collegiate football players have changed over the past 15 years. Methods We analysed data on reported duration of symptoms, symptom-free waiting period (SFWP), RTP and occurrence of within-season repeat concussion in collegiate football players with diagnosed concussion from the NCAA Study (n=184) and CARE (n=701). Results CARE athletes had significantly longer symptom duration (CARE median=5.92 days, IQR=3.02–9.98 days; NCAA median=2.00 days, IQR=1.00–4.00 days), SFWP (CARE median=6.00 days, IQR=3.49–9.00 days; NCAA median=0.98 days, IQR=0.00–4.00 days) and RTP (CARE median=12.23 days, IQR=8.04–18.92 days; NCAA median=3.00 days, IQR=1.00–8.00 days) than NCAA Study athletes (all p<0.0001). In CARE, there was only one case of repeat concussion within 10 days of initial injury (3.7% of within-season repeat concussions), whereas 92% of repeat concussions occurred within 10 days in the NCAA Study (p<0.001). The average interval between first and repeat concussion in CARE was 56.41 days, compared with 5.59 days in the NCAA Study (M difference=50.82 days; 95% CI 38.37 to 63.27; p<0.0001). Conclusion Our findings indicate that concussion in collegiate football is managed more conservatively than 15 years ago. These changes in clinical management appear to have reduced the risk of repetitive concussion during the critical period of cerebral vulnerability after sport-related concussion (SRC). These data support international guidelines recommending additional time for brain recovery before athletes RTP after SRC.

Introduction The brain plays a key role in the perceptual regulation of exercise, yet neuroimaging techniques have only demonstrated superficial brain areas responses during exercise, and little is known about the modulation of the deeper brain areas at different intensities. Objectives/methods Using a specially designed functional MRI (fMRI) cycling ergometer, we have determined the sequence in which the cortical and subcortical brain regions are modulated at low and high ratings perceived exertion (RPE) during an incremental exercise protocol. Results Additional to the activation of the classical motor control regions (motor, somatosensory, premotor and supplementary motor cortices and cerebellum), we found the activation of the regions associated with autonomic regulation (ie, insular cortex) (ie, positive blood-oxygen-level-dependent (BOLD) signal) during exercise. Also, we showed reduced activation (negative BOLD signal) of cognitive-related areas (prefrontal cortex), an effect that increased during exercise at a higher perceived intensity (RPE 13–17 on Borg Scale). The motor cortex remained active throughout the exercise protocol whereas the cerebellum was activated only at low intensity (RPE 6–12), not at high intensity (RPE 13–17). Conclusions These findings describe the sequence in which different brain areas become activated or deactivated during exercise of increasing intensity, including subcortical areas measured with fMRI analysis.

Return to sport (RTS) is a dynamic process, during which practitioners must balance the risk that early reintegration to training/match-play increases reinjury risk with the benefit to the team of having key players available.1 Medical and performance staff must work together to formulate a plan considering the individual, the specifics of the injury, tissue healing time and potential risk factors for reinjury. A key element of this plan is the management and prescription of external running loads using global positioning systems (GPS) to return players to previous levels of chronic load prior to injury, relatively quickly and safely.2 3 Alongside …

OA is a leading cause of disability worldwide and associated with pain, impaired mobility and quality of life.1 Physical activity, including therapeutic exercise, patient education and weight control are recommended in key OA treatment guidelines.2 Nevertheless, the belief that therapeutic exercise may harm knee joint cartilage remains common among people with knee OA, and health professionals treating the condition, creating a prevailing barrier to implementing evidence-based care.3–5 The current discord between evidence and persistent beliefs highlights the need for better education. Providing a clear and engaging summary of the evidence to communicate the positive impact of therapeutic exercise and physical activity on the knee joint is crucial to encourage greater acceptance of, and participation in exercise and physical activity to …

Tramadol is a synthetic opioid widely used for the management of pain in sport setting.1 Tramadol is considered an effective substance to reduce acute and chronic pain because it acts by binding to the μ-opioid receptor to induce analgesia and sedation. However, tramadol also inhibits serotonin and norepinephrine reuptake and thus, it might play a role in the regulation of mood. In the past years, tramadol has caught attention of media and antidoping authorities because this substance might be the subject of abuse in some sports, notably cycling.2 WADA determined that the use of some narcotics are …

My research sought novel insight into how key intermediary organisations ‘bridge the gap’ between injury prevention research and its use in practice.1 The key intermediary organisations that contributed to this research were drawn from an existing partnership of a larger study—the National Guidance for Australian Football Partnerships and Safety project.2 The six organisations were: the Australian Football League, Victorian Health Promotion Foundation, New South Wales Sporting Injuries Committee, JLT Sport as a division of Jardine Lloyd Thompson Australia Pty Ltd, Sport and Recreation Victoria and Sports Medicine Australia. I wanted to better understand the role that key intermediary organisations play in making injury prevention research knowledge more accessible and useful for end-users (including athletes, parents, coaches, club administrators and so on). First, I theorised about the gap between injury prevention research knowledge and its use in practice—how it comes about and how researchers can potentially use different approaches to minimise its effects. …

To be a successful high-performance lightweight rower, I required exceptional physical attributes such as fitness and strength, together with high levels of dedication and resilience. However, when faced with frustrating setbacks such as injury and illness, like many athletes, the qualities that made me a champion became my own worst enemy. Vigorous specifically targeted training followed by sufficient recovery is essential to improve athletic performance. It is difficult to balance training and recovery and when you layer on the added constraint of a weight-limited sport like lightweight rowing, training becomes more complex. In my sport, lightweight rowing, women compete under 57 kg and men under 70 kg. Making weight was a real challenge for me at 5′7″, so I maximised every opportunity to burn calories. That often meant choosing an active recovery session over a rest day, in my already challenging training schedule. The extreme weight loss strategies I employed in the days leading up to the National Championships in 2000 seem ridiculous and incomprehensible now. I was not at race weight the night before the finals, so I severely restricted my food and drink intake, to the point of dehydration. I remember the blissful sensation of sucking the moisture out of my toothbrush, I savoured that moment when the cool, minty water slid down my throat. Despite turning the heating up and sleeping under …

Running and jogging are among the most popular types of exercise globally. Running is associated with improved indicators of cardiometabolic health.1–3 However, findings from previous studies showed inconsistent associations between running participation and all-cause, cancer and cardiovascular mortality. In our recent systematic review,4 published in the British Journal of Sports Medicine , we therefore synthesised the results of previous studies on this topic. We found 14 studies from six prospective …

Low back pain (LBP) is the leading cause of disability worldwide, and is often associated with costly, ineffective and sometimes harmful care.1 What drives disability and poor care?2 Unhelpful beliefs about LBP are associated with greater levels of pain, disability, work absenteeism, medication use and healthcare seeking.3 Unhelpful beliefs are common in people with and without LBP, and can be reinforced by the media, industry groups and well-meaning clinicians. In this editorial and infographic, we identify 10 common unhelpful beliefs about LBP and outline how they may influence behavioural and psychological responses to pain. We counter with 10 important facts about LBP, calling on clinicians to incorporate these into their interactions with patients. The infographic is designed for the public use (figure 1). Figure 1 What every person should know about low back pain. Unhelpful LBP beliefs are common, culturally endorsed and not supported by evidence.2 4 5

Osgood Schlatter ‘disease’ (OSD) is a condition that most have heard of, and that parents of elite adolescent athletes fear. Despite being so common, what do we actually know about OSD and what can we tell adolescents and their parents based on current available evidence? Osgood Schlatter is considered an apophysitis of the tibial tuberosity, and affects up to 1 in 10 adolescents aged 9–15- particularly athletes. The apophysis is the point of attachment of the patellar tendon onto the bone and may be vulnerable to high stress before maturation. Osgood Schlatter is characterised by localised pain and swelling at the tibial tuberosity. This injury has a negative effect on adolescent’s ability to participate in sports and is associated with decreased lower limb strength and power, poor function and low quality of life and pain.1 2 Osgood Schlatter was originally thought to be a result of repetitive loading causing traction of the patellar tendon at its’ insertion on the tibial tuberosity. Since being first described over 100 years ago, there have …

The 1st International Hip-related Pain Research Network meeting discussed four prioritised themes concerning hip-related pain in young to middle-aged adults: (1) diagnosis and classification of hip-related pain; (2) patient-reported outcome measures for hip-related pain; (3) measurement of physical capacity for hip-related pain; (4) physiotherapist-led treatment for hip-related pain. Thirty-eight expert researchers and clinicians working in the field of hip-related pain attended the meeting. This manuscript relates to the theme of physiotherapist-led treatments for hip-related pain. A systematic review on the efficacy of physiotherapist-led interventions for hip-related pain (published separately) was conducted and found that strong evidence for physiotherapist-led treatments was lacking. Prior to the meeting, draft consensus recommendations for consideration in the meeting were also developed based on the systematic review. The draft consensus recommendations were presented to all of the meeting participants via email, at least 1 week prior to the meeting. At the meeting, these recommendations were discussed, revised and voted on. Six recommendations for clinical practice and five recommendations for research were included and all gained consensus. Recommendations for clinical practice were that (i) Exercise-based treatments are recommended for people with hip-related pain. (ii) Exercise-based treatment should be at least 3 months duration. (iii) Physiotherapist-led rehabilitation after hip surgery should be undertaken. (iv) Patient-reported outcome measures, measures of physical impairment and measures of psychosocial factors should be used to monitor response to treatment. (v) Physical activity (that may include sport) is recommended for people with hip-related pain. (vi) Clinicians should discuss patient expectations, use shared-decision making and provide education. Recommendations for research were (i) Reporting of exercise programmes: Exercise descriptors such as load magnitude, number of repetitions and sets, duration of whole programme, duration of contractile element of exercise, duration of one repetition, time under tension, rest between repetitions, range of motion through which the exercise is performed, and rest between exercise sessions should be reported. (ii) Research should investigate the optimal frequency, intensity, time, type, volume and progression of exercise therapy. (iii) Research should examine the effect of patient education in people with hip-related pain. (iv) Research should investigate the effect of other treatments used in people with hip-related pain (for example: manual therapy, medications, injections). (v) Research should examine the impact of comorbidities and social determinants on treatment effectiveness in people with hip-related pain. Clinicians and researchers working with young to middle-aged active adults with hip-related pain may use these consensus recommendations to guide, develop, test and implement individualised, evidence-based physiotherapist-led rehabilitation programmes.

Hip-related pain can significantly impact quality of life, function, work capacity, physical activity and family life. Standardised measurement methods of physical capacity of relevance to young and middle-aged active adults with hip-related pain are currently not established. The aim of this consensus paper was to provide recommendations for clinical practice and research on standardised measurement methods of physical capacity in young and middle-aged active adults with hip-related pain. Four areas of importance were identified: (1) clinical measures (range of motion, muscle strength, functional impairments), (2) laboratory-based measures (biomechanics and muscle function (muscle activity, size and adiposity)), (3) physical activity, and (4) return to sport/performance. The literature was reviewed, and a summary circulated to the working group to inform discussion at the consensus meeting. The working group developed clinical and research recommendations from the literature review, which were further discussed and modified within the working group at the consensus meeting. These recommendations were then presented to all 38 International Hip-related Pain Research Network (IHiPRN) participants for further discussion, refinement and consensus voting. Therefore, the recommendations voted on were based on a combination of current evidence and expert opinion. The consensus meeting voted on 13 recommendations, six of which were clinically orientated, and seven more research specific. We recommended that clinicians working with young and middle-aged active adults with hip-related pain assess strength using objective methods of measurement, and clinically assess performance of functional tasks, including walking and running. Physical activity should be quantified using both self-reported and objective measures, and patient expectations of recovery should be quantified prior to treatment. It was recommended that return to physical activity (including sport and occupation) be quantified, and sport-specific activities should be assessed prior to return to sport. The IHiPRN participants were uncertain regarding recommendations for range of motion assessment. Research recommendations were that the measurement properties of range of motion, strength and functional performance tests be investigated, reported and improved in both clinical and research settings. Reporting of movement-related parameters (biomechanics and muscle function) should be standardised and the relationship among movement-related parameters, symptoms, function, quality of life, and intra-articular and imaging findings should be investigated. Quantification of return to physical activity (including sport and occupational demands) is required in future research, and the return to sport continuum should be used. Future research is required to determine the best criteria for rehabilitation progression and return to physical activity following hip-related pain management.

Sudden cardiac arrest (SCA), which occurs at a rate of about 1 in ~50 000 athlete years, is the most common cause of death in exercising young athletes.1 SCA is most frequently caused by lethal cardiac arrhythmias—that is, ventricular fibrillation (VF). If clinicians recognise key features of SCA early and accurately, they can immediately begin cardiopulmonary resuscitation (CPR) and use an automated external defibrillator (AED) as needed.2 This review aims to (1) assist health professionals recognise the signs (and avoid common pitfalls) of SCA and (2) emphasise best practice responder strategies for SCA on the pitch. Miklos Feher, a striker for Benfica, suffered a SCA on 25 January 2004. The event can be viewed at: https://youtu.be/T7-kKy_XDQU. The underlying cause of death was later reported to be VF in a patient with hypertrophic cardiomyopathy. How can clinicians and sports professionals rapidly recognise SCA on the field of play? Recognising SCA on the pitch can be challenging due to the sports setting, other mimicking causes and the rapid onset of signs following cerebral hypoperfusion. To prevent death or serious sequelae, it is key that clinicians recognise SCA immediately and start adequate management (ie, CPR and defibrillation). Figure 1 is a schematic of SCA from time T=0–60 s with corresponding signs, ECG, blood pressure tracing and breathing pattern. Prolonged, sudden cerebral hypoperfusion causes a typical …

> Different therapists have said different things [contradictory advice on pain with exercise]…and it makes you wonder which therapist to believe. Exercise is a proven treatment for managing at least some persistent pain, including musculoskeletal-related pain.1 2 But an area often overlooked is what type of pain and what intensity of pain should be associated with exercise. What would achieve the best results? No pain? A little pain? A moderate amount of pain? How does the patient judge what is ‘a little’ or ‘moderate’? How much pain is too much? Is there ‘good pain’ as patients often tell us when stretching or massaging a muscle, as well as ‘bad pain’ (presumably thought to be harmful)? Qualitative research tells us that many individuals with persistent pain are uncertain when it comes to pain and exercise.3 4 This is closely linked to pain-related fear and questions as to whether exercise is helpful or harmful. As one patient framed it, ‘Are you making it worse? And that’s the crux of it really…if this is hurting should I really be doing this?’.3 There are few …

Systematic reviews fulfil a vital role in modern medicine.1 However, the results of systematic reviews are only as valid as the studies they include.2 Pooling flawed, or biased, results from different studies can compromise the credibility of systematic review findings. Bias is a systematic deviation from the truth in the results of a research study that can manifest due to limitations in study design, conduct, or analysis.3 The results of sport and exercise medicine research, like results in other fields, are vulnerable to bias.4 It is important that systematic review authors assess for bias in a way that enables a judgement about whether a review outcome is at risk of bias due to methodological limitations in included studies. This two-part education primer focuses on how systematic review authors can perform and interpret risk of bias assessments to avoid misleading systematic review conclusions. In this editorial, we introduce the concept of risk of bias, and the principles of assessing risk of bias. Different biases have effects that vary in direction and magnitude.3 5 It is challenging to precisely determine how bias may overestimate or underestimate a study’s true findings. In fact, bias does not always result in distorted study findings and one can never be certain that bias is present when a study has methodological limitations. However, methodological limitations in study design, conduct, or analysis can be consistently associated with inflated research findings.5 Due to this uncertainty, study outcomes are considered to be at risk of bias rather than ‘biased’. Studies with ‘some concerns’ or at ‘high’ risk of bias in design, conduct, analysis, or reporting are at greater risk of inflated findings compared with studies at ‘low’ risk of bias, negatively …

Systematic reviews are a valuable tool to inform healthcare decision-making.1 2 While a single randomised controlled trial (RCT) is insufficient to definitively guide healthcare decisions, a systematic review synthesising multiple RCTs can overcome this limitation. The results of rigorous systematic reviews possess wide-ranging applicability to numerous stakeholders within the evidence-based medicine ‘ecosystem’. Clinicians consult systematic reviews to inform their clinical decisions.3 Researchers rely on systematic reviews to identify knowledge gaps in existing literature.4 Health policymakers use systematic review evidence to inform practice guidelines and legislation.5 6 Journal editors often prioritise systematic reviews for their impact on readership attention and journal metrics.7 Finally, patients are empowered by systematic reviews that assess the beneficial and harmful patient-important outcomes of available management strategies.8 Evidently, systematic review authors have an important responsibility to ensure their findings provide the most accurate results possible. The biomedical literature expands by 22 systematic reviews daily,9 with no evidence that production is waning. More systematic reviews are desirable if they identify and inform important research questions that improve patient care.10 However, production of this magnitude is problematic when systematic reviews offer ‘extensive redundancy, little value, misleading claims and/or vested interests’.11 As we outlined in part 1, bias is a systematic deviation from the truth in the results of a research study due to limitations in study design, conduct, or analysis.2 Deviations may either overestimate or underestimate a study’s true findings depending of the type and magnitude of bias. As the results of a systematic review are only as valid as the studies it includes, pooling biased results from different studies can compromise the credibility of systematic review findings when no assessment, or a poor assessment, of risk of bias is performed.3 12 Inadequate study design, conduct, or analysis …

Objectives To examine the ability of surgeons to predict the outcome of treatment for meniscal tears by arthroscopic partial meniscectomy (APM) and exercise therapy in middle-aged patients. Design and setting Electronic survey. Orthopaedic surgeon survey participants were presented 20 patient profiles. These profiles were derived from a randomised clinical trial comparing APM with exercise therapy in middle-aged patients with symptomatic non-obstructive meniscal tears. From each treatment group (APM and exercise therapy), we selected five patients with the best (responders) and five patients with the worst (non-responders) knee function after treatment. 1111 orthopaedic surgeons and residents in the Netherlands and Australia were invited to participate in the survey. Interventions For each of the 20 patient profiles, surgeons (unaware of treatment allocation) had to choose between APM and exercise therapy as preferred treatment and subsequently had to estimate the expected change in knee function for both treatments on a 5-point Likert Scale. Finally, surgeons were asked which patient characteristics affected their treatment choice. Main outcomes The primary outcome was the surgeons’ percentage correct predictions. We also compared this percentage between experienced knee surgeons and other orthopaedic surgeons, and between treatment responders and non-responders. Results We received 194 (17%) complete responses for all 20 patient profiles, resulting in 3880 predictions. Overall, 50.0% (95% CI 39.6% to 60.4%) of the predictions were correct, which equals the proportion expected by chance. Experienced knee surgeons were not better in predicting outcome than other orthopaedic surgeons (50.4% vs 49.5%, respectively; p=0.29). The percentage correct predictions was lower for patient profiles of non-responders (34%; 95% CI 21.3% to 46.6%) compared with responders (66.0%; 95% CI 57.0% to 75.0%; p=0.01). In general, bucket handle tears, knee locking and failed non-operative treatment directed the surgeons’ choice towards APM, while higher level of osteoarthritis, degenerative aetiology and the absence of locking complaints directed the surgeons’ choice towards exercise therapy. Conclusions Surgeons’ criteria for deciding that surgery was indicated did not pass statistical examination. This was true regardless of a surgeon’s experience. These results suggest that non-surgical management is appropriate as first-line therapy in middle-aged patients with symptomatic non-obstructive meniscal tears. Clinical trial registration ClinicalTrials.gov Identifier: [NCT03462134][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT03462134&atom=%2Fbjsports%2Fearly%2F2019%2F12%2F23%2Fbjsports-2019-100567.atom

The incidence of sports injuries has been reported to reach ~26 and 34 injuries per 1000 persons in the USA1 and the European Union,2 respectively, with the majority of these injuries occurring in the lower extremity (eg, ankle and knee sprains, hamstring strains, ACL tears).1 Sports injuries have important negative physical, psychological and medical consequences for the athlete, as well as technical, tactical and economical consequences for the team. Moreover, sports injuries have relevant implications for healthcare systems associated with the treatment costs.3 4 …

Have you ever wondered…‘Is physical therapy treatment (alone) just as good as arthroscopic partial meniscectomy (APM) in patients with non-obstructive partial meniscal tears?’ What would make you think it is just as good? What would you use as a measure of ‘goodness’? It is an interesting question, isn’t it? Clinical trials that test whether one treatment is not meaningfully worse than another are called ‘non-inferiority trials’, and they are an example of the increasing sophistication of study designs in the field of sport and exercise physiotherapy and medicine. In this editorial I discuss the concept of non-inferiority using the JAMA -published 2018 ESCAPE study as the example. The Dutch surgeon and epidemiologist authors randomised 321 patients with non-obstructive partial meniscal tears and concluded that physical therapy alone was not inferior to APM in those patients.1 That was based on clinical measures—the widely used International Knee Documentation Committee (IKDC) score. But what about costs? Wouldn’t physiotherapy alone be cheaper than surgery too? In the British Journal of Sports Medicine paper linked to this editorial, the authors of the ESCAPE trial report their economic evaluation.2 Patients randomised to the physical therapy intervention had lower healthcare and societal costs than patients randomised to APM. This, along with their incremental cost-effectiveness analyses, adds to the case that APM should not be the first-choice treatment for …

Objectives Most concussions in rugby union occur during tackles. We investigated whether legislating to lower maximum tackle height would change tackle behaviour, and reduce concussion incidence rate. Methods In a single group intervention, 12 elite men’s teams played in two competitions during the 2019/2020 season. The Championship (control, 90 games) retained standard Laws of Rugby for the tackle; the Championship Cup (intervention, 36 games) used revised laws—the maximum tackle height was lowered from the line of the shoulders on the ball carrier to the line of the armpits. Videos of tackles were analysed for ball carrier and tackler behaviour. Injury data were collected using standardised methods. Results In the intervention setting, there was a significantly lower proportion of tackles; (1) in which ball carriers (rate ratio (RR) 0.83, 95% CI 0.79 to 0.86) and tacklers (RR 0.80, 95% CI 0.76 to 0.84) were upright, (2) in which the tackler’s initial contact was to the ball carrier’s head or neck (RR 0.70, 95% CI 0.58 to 0.84) and (3) in which initial contact was above the line of the ball carrier’s armpit (RR 0.84, 95% CI 0.80 to 0.88). Concussion incidence rate did not differ between conditions (RR 1.31, 95% CI 0.85 to 2.01). Unexpectedly, compared with the control setting, tacklers in the intervention setting were themselves concussed at a higher rate as measured by; (1) incidence (RR 1.90, 95% CI 1.05 to 3.45) and (2) concussions per 1000 tackles (2.09, 95% CI 1.15 to 3.80) than in the control setting. Conclusions Legislating to lower the height of the tackle meant that tacklers made contact with the ball carrier’s head and neck 30% less often. This did not influence concussion incidence rates. Tacklers in the intervention setting—who were aiming to tackle lower—suffered more concussions than did tacklers in the control setting.

### Programme card Country/coverage Target population What modes/types/domains of physical activity (PA) does the programme promote? Which of the seven best investments the programme addresses? What sectors does it involve? Estimated programme reach: What is special about this programme? Key contacts: Programme …

Sport specialisation, conceptually understood to involve mono-training and repetition for the purpose of skill acquisition and athlete development for a single sport, is increasingly common in youth sports. However, it has not always been this way. Over the past 30 years, research on expertise and skill acquisition has profoundly influenced the focus and structure of youth sport programme. Particularly, Ericsson, Kramp and Tesch-Römer’s (1993) work in music renewed research interests related to the importance of deliberate practice in the development of expertise.1 Some studies in sport, using retrospective questionnaires, suggested that high volume of intense, sport-specific practice at a young age is necessary to attain expertise in one sport.2 This body of research has promoted the idea that a large quantity of intense sport-specific practice and early specialisation is a logical pathway towards adult elite sport performance, and has contributed to the popularity of youth sport specialisation. Simultaneously, biographical studies of elite level athletes suggested that their childhood sport experiences involved sport-specific practice, and play activities and engagement in various sports. In contrast with the early specialisation approach, Côté (1999) defined sampling as an early sport participation environment characterised by diversity, both within (eg, play, practice) and between sports.3 Considering both distinctive lines of research led to equivocal results, Côté, Ericsson and Law (2005) …

High systolic blood pressure (SBP) remains the major cause of premature death globally despite advances in pharmacological treatment.1 2 The global direct medical costs associated with hypertension treatment are estimated at $370 billion/year worldwide, with the healthcare savings from effective management of this condition projected at about $100 billion/year.3 Unfortunately, relatively little attention is given to non-pharmacological strategies, including structured exercise interventions. A recent network meta-analysis of randomised controlled trials (RCTs) published in the BJSM4 aimed to compare the effects of exercise interventions and medications on SBP. We highlight the key findings of this network meta-analysis that are particularly relevant for clinical practice and health policy. The study included 391 RCTs (39,742 …

Introduction The dissemination of research, and evaluation of its impact is an increasing priority for the scientific community and funders. We take the topic of golf and health and aim to outline processes that may contribute to improved research uptake, use and impact proposing a research impact (RI) tool. We then evaluate our published research using the Research Contributions Framework (RCF). Methods Building on existing research and frameworks we i) assessed the need for, ii) carried out and iii) published research, before iv) creating digital resources, v) sharing these resources widely and vi) evaluating our research. To evaluate uptake, use and impact of our three principal golf and health research outputs, we performed a contributions analysis, using the RCF first proposed by Morton. Results/Discussion We developed a specific six-step Research Impact tool. Having implemented this, research uptake and use included over 300 press articles, a dedicated website and social media channels. Golf’s global industry leadership dispersed information across >150 countries, embedded golf and health into curricula for industry professionals and used leading tournaments to promote health. National policy makers hosted dedicated meetings regarding golf and health and began to implement policy change. Conclusion To date, strong uptake and use can be demonstrated for these studies, while a final contribution to impact requires further time to determine. Frameworks we used aiming to maximise impact (Research Impact tool) and evaluate its contribution to uptake, use and impact (Research Contribution Framework) could potentially add value to public health/sports medicine researchers.

Increasing physical activity (PA) is a global public health priority.1 For decades, exercise referral schemes (ERS) have been a popular way for healthcare professionals in primary and secondary care to help patients increase their PA. Delivery of ERS varies widely, with the construction of an evidence base informing ‘what works best’ limited by a lack of understanding about what individual schemes deliver and how.2 Between-scheme analyses are extremely challenging due to varying quality of reporting (eg, of scheme delivery components and processes) and evaluations.3 4 As a consequence, overviews of ERS evidence5 6 are flawed by combining heterogeneous interventions (eg, falls prevention via physiotherapist referral and hypertension management via general practitioner (GP) referral) and datasets. Collectively, the underwhelming findings of such overviews lead to concerns over commissioning ERS, and the inability of national policy and best practice guidelines to recommend a ‘gold standard’ structure, or even comment on ‘what good looks like’.5 We do not know whether local tailoring of ERS is more effective and efficient than a standardised approach. To advance knowledge …

Objectives We systemically reviewed published studies that evaluated aerobic exercise interventions in patients with knee osteoarthritis (OA) to: (1) report the frequency, intensity, type and time (FITT) of exercise prescriptions and (2) quantify the changes in markers of cardiovascular health and systemic inflammation. Data sources PubMed, CINAHL, Scopus; inception to January 2019. Eligibility criteria Randomised clinical trials (RCT), cohort studies, case series. Design We summarised exercise prescriptions for all studies and calculated effect sizes with 95% CIs for between-group (RCTs that compared exercise and control groups) and within-group (pre-post exercise) differences in aerobic capacity (VO2), heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and inflammatory markers (interleukin-6 (IL-6), tumour necrosis factor-alpha). We pooled results where possible using random effects models. Results Interventions from 49 studies were summarised; 8% (4/49) met all FITT guidelines; 16% (8/49) met all or most FITT guidelines. Fourteen studies (10 RCTs) reported at least one marker of cardiovascular health or systemic inflammation. Mean differences (95% CI) indicated a small to moderate increase in VO2 (0.84 mL/min/kg; 95% CI 0.37 to 1.31), decrease in HR (−3.56 beats per minute; 95% CI −5.60 to −1.52) and DBP (−4.10 mm Hg; 95% CI −4.82 to −3.38) and no change in SBP (−0.36 mm Hg; 95% CI −3.88 to 3.16) and IL-6 (0.37 pg/mL; 95% CI −0.11 to 0.85). Within-group differences were also small to moderate. Conclusions In studies of aerobic exercise in patients with knee OA, very few interventions met guideline-recommended dose; there were small to moderate changes in markers of cardiovascular health and no decrease in markers of systemic inflammation. These findings question whether aerobic exercise is being used to its full potential in patients with knee OA. PROSPERO registration number [CRD42018087859][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=CRD42018087859&atom=%2Fbjsports%2Fearly%2F2019%2F12%2F17%2Fbjsports-2018-100231.atom

Tendinopathy is the most common disorder in sports medicine. Multiple hypotheses have been proposed for the aetiopathogenesis, but many aspects still remain elusive. Microdialysis studies have shown high levels of lactate within tendinosis, even at resting tendons,1 suggesting that hypoxia persists in tendinopathy. The presence of necrotic tenocytes, blocked arteries and anaerobic enzymes within tendinopathy lesions lend further support to the role of hypoxia in the aetiopathogenesis.2 Finally, ‘tendinosis’, the pathognomonic histopathological finding in tendinopathy, is composed of hypoxic, mucoid, hyaline and fibrinoid tissue.2 These tissue types are known to be hypoxia induced. Tendons are generally poorly vascularised, while certain regions—those most prone to injury—are almost avascular. This can be considered an evolutionary ‘design failure’ that makes tendons susceptible to chronic and acute injuries. As a consequence, healthy tendons have a virtually non-existent tissue turnover throughout adulthood.3 However, somewhat paradoxically, tissue turnover is increased in tendinopathic tendons.3 Given the persisting hypoxia and subsequent anaerobic metabolism,1 2 it comes as no surprise that the enhanced tissue turnover leads to production of poorly organised tissue—tendinosis—in tendinopathy.2 The fundamental survival mechanism of any cell under hypoxia is the activation of hypoxia-inducible factor-1α (HIF-1α),4 a transcription factor that turns …