The Tibial Tubercle-Trochlear Groove Distance/Trochlear Dysplasia Index Quotient Is the Most Accurate Indicator for Determining Patellofemoral Instability Risk.

PURPOSE: The primary aim of our study was to evaluate diagnostic accuracy of the tibial tubercle-trochlear groove (TT-TG) distance relative to associated quotients produced from trochlear width (TT-TG distance/TW) and trochlear dysplasia index (TT-TG distance/TDI) for detecting patellofemoral instability. Secondary aims included identifying thresholds for risk and comparing differences between cases and controls. METHODS: Consecutive sampling of electronic medical records produced 48 (21 males, 27 females) patellofemoral instability cases (19 ± 7 years old) and 79 (61 males, 18 females) controls (23 ± 4 years old) who had a history of isolated meniscal lesion, as evaluated by magnetic resonance imaging. Standardized methods were employed with measurements executed in a blinded and randomized manner. A receiver operating characteristic curve assessed accuracy by area under the curve (AUC). The index of union (IU) was employed to identify a threshold for risk. Two-sample t-tests examined group differences. P < .05 denoted statistical significance. RESULTS: The AUC values were .69 (.60, .79) for TT-TG distance, .81 (.73, .88) for TT-TG distance/TW, and .85 (.78, .91) for TT-TG distance/TDI. Thresholds were 14.7 mm for TT-TG distance, .36 for TT-TG distance/TW, and 1.88 for TT-TG distance/TDI. Cases demonstrated statistically significant (P < .001) greater values for each measure compared with controls: TT-TG distance (15.8 ± 4.2 mm vs 12.9 ± 3.6 mm, [1.4, 4.3]); TT-TG distance/TW (.51 ± .24 vs .31 ± .09, [.13, .27]); TT-TG distance/TDI (3.07 ± 1.55 vs 1.7 ± .7, [.9, 1.84]). CONCLUSION: The TT-TG distance, TT-TG distance/TW, and TT-TG distance/TDI measures were 69%, 81%, and 85%, respectively, accurate for determining patellofemoral instability risk. Thresholds for risk were 14.7 mm for TT-TG distance, .36 for TT-TG distance/TW, and 1.88 for TT-TG distance/TDI. The thresholds reported in this study may help in advancing clinical decision-making. LEVEL OF EVIDENCE: Level III, diagnostic retrospective comparative observatory trial.

Standing flexion deficits predict self-reported outcomes in women after ipsilateral hamstring anterior cruciate ligament reconstruction.

PURPOSE: To profile the standing flexion angle and its association with subjective outcomes in ipsilateral hamstring tendon autograft anterior cruciate ligament-reconstructed patients. A secondary aim was to describe prone position-measured hamstring strength as a predictor of flexion angle. METHODS: Fifteen women (mean age, 20.47 ± 1.96 years; mean height, 1.69 ± 0.08 m; mean weight, 68.51 ± 12.64 kg; mean Tegner score, 6.80 ± 1.52), at a mean of 25.93 ± 11.25 months after surgery, were matched to 15 healthy participants by sex and approximate age, height, mass, and activity level (mean age, 20.93 ± 1.22 years; mean height, 1.65 ± 0.06 m; mean weight, 66.52 ± 10.69 kg; mean Tegner score, 6.13 ± 1.06). The independent variable was leg condition (involved, uninvolved, or matched). Dependent variables included goniometric flexion angle, Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale scores, and absolute isokinetic hamstring strength. We used 1-tailed paired and 2-sample t tests to analyze side and group differences, respectively. Corresponding effect sizes (d) were also quantified. Linear regression assessed relations between flexion angle and the KOOS, as well as strength and flexion angle. P < .05 denoted statistical significance. RESULTS: The involved leg showed a significantly lesser flexion angle (112.9° ± 8.1°) compared with the uninvolved leg (116.1° ± 8.4°, P = .024) and matched leg (117.1° ± 4.5°, P = .044), with corresponding weak side (d = 0.380) and strong group (d = 0.958) effect sizes. Significant associations existed between flexion angle and subjective outcomes (r(2) = 60.3% and P = .001 for KOOS pain subscale, r(2) = 37.8% and P = .015 for KOOS subscale for function in activities of daily living, and r(2) = 39.2% and P = .012 for KOOS subscale for function in sports and recreation) for the involved leg. Hamstring strength was not a significant predictor of flexion angle for all legs (P > .05). CONCLUSIONS: Our results support the hypotheses that standing flexion angle insufficiencies exist for the involved leg, superior subjective outcomes are associated with greater flexion capacity, and hamstring strength at deep knee angles does not predict the standing flexion angle. LEVEL OF EVIDENCE: Level IV, therapeutic study, case series.

AOA Critical Issues: Dichotomies in Leadership. Presidential Address to the AOA, June 17, 2022.

ABSTRACT: This speech was given at the 2022 American Orthopaedic Association (AOA) meeting in Providence, Rhode Island, on June 17, 2022, and discusses the most important elements of leadership. A sense of extreme ownership is required for effective leadership. Ownership allows leaders to delegate responsibilities to others and to instill confidence and trust in the people closest to them. True leaders recognize that every situation creates value, regardless of the outcome, because each and every encounter is an opportunity to learn. Oftentimes, a situation creates a natural dichotomy or controversy. Good leaders must recognize this dichotomy and balance the decision-making that is required for such an occurrence for the ultimate good of the individual or organization. True leaders will include rather than exclude the people around them and will graduate the responsibilities of individuals as the skills and trust of those individuals develop. Those in charge must also recognize that leadership includes intelligence, compassion, and instinct. Leaders who are health-care providers must keep patient care as the true "North Star" so that appropriations of space, personnel, and finances are maximally utilized. Finally, true leaders achieve their goals through the core principles of balance, orchestration, growth, inclusion, and envision.

Treatment, Return to Play, and Performance Following Meniscus Surgery.

PURPOSE OF REVIEW: The standard of care in meniscal tear management is constantly evolving, especially for athletes and high-demand patients. Meniscus repairs, meniscus transplants, and partial meniscectomies are commonly performed, and rehabilitation methods following these operations are becoming more sophisticated. The ultimate goal of these procedures is returning patients to full activity with minimal risks. Return to play should be systematic, pathology dependent, and individualized to an athlete's needs, expectations, and level of play. This article provides a review of the current treatment modalities of meniscus tears, the rehabilitation protocols following each modality, and the return to play criteria that must be met before releasing the player to competition. In addition, it overviews articles that describe performance outcomes of patients that have undergone meniscus surgery. RECENT FINDINGS: Current research shows high return to play rates for athletes that undergo meniscus surgery and describes effective rehabilitation protocols to facilitate recovery. There is an increased emphasis on meniscus preservation in recent literature. In addition, meniscus allograft transplantation has demonstrated its efficacy as a salvage procedure and has become a stronger consideration in the athlete with meniscus pathology. No standardized return to play protocol can be applied uniformly to all kinds of meniscal surgeries, and two athletes with the same pathology cannot be expected to follow identical paths towards full recovery. A multidisciplinary approach to care should be provided to the patients, and in the case of patients with high levels of athleticism, the road to recovery starts even before the injury itself.

Fluoroscopy-Guided Suture Anchor Placement Yields Excellent Accuracy for Arthroscopic Acetabular Labral Repair: A Cadaveric Study.

PURPOSE: To determine the accuracy of fluoroscopy-guided suture anchor placement for arthroscopic acetabular labral repair in cadaveric hip specimens. METHODS: Two sports medicine fellowship-trained surgeons performed arthroscopic hip surgery on 6 cadaveric specimens each. Suture anchors were placed at the 11-, 12-, 1-, 2-, 3-, and 4-o'clock positions of the acetabulum in each specimen using a previously described fluoroscopically guided technique. Gross dissection and thin-cut computed tomography scans were performed to assess for accuracy. The insertion angle between the subchondral bone and the drill bit immediately prior to suture anchor insertion was measured, and fluoroscopic visualization of the subchondral bone at each clock-face position was qualitatively graded as good, fair, or poor by 2 independent reviewers. RESULTS: Overall, 90.3% of attempts (65 of 72) were entirely intraosseous, 5.5% (4 of 72) perforated the articular cartilage, and 4.2% (3 of 72) perforated the far cortex, rates that are comparable with those in previous cadaveric studies. There was no statistically significant difference in accuracy between the surgeons (P = .42) or between the various clock-face positions (P = .63). Neither the insertion angle (P = .26) nor visualization of the subchondral bone (P = .35) was significantly correlated with accuracy by gross dissection. CONCLUSIONS: In a cadaveric hip arthroscopy model, fluoroscopy-guided suture anchor placement yields excellent accuracy rates, similar to non-image-guided techniques. CLINICAL RELEVANCE: Intra-articular suture anchor placement and intrapelvic suture anchor placement are known complications of arthroscopic acetabular labral repair. Fluoroscopically guided suture anchor placement can be a useful tool for hip arthroscopy surgeons performing acetabular labral repair and reconstruction, potentially reducing the risk of these complications.

Effects of sleep disturbance on functional and physiological outcomes in collegiate athletes: A scoping review.

OBJECTIVE: To investigate sleep disturbances and circadian timing changes on functional and physiological correlates specifically in collegiate athletes. DESIGN: Scoping Review. DATA SOURCES: PubMed MEDLINE, SPORT-Discus, CINAHL, ERIC ProQuest, Web of Science. ELIGIBILITY CRITERIA: Articles in English, studying college athletes 18-24 years old, employing a sleep measurement, and a comparison measure of cognitive, academic performance, athletic performance, injury rate, biomarkers and physiological measures, or imaging. RESULTS: Thirty articles met inclusion criteria. There was wide range of study design, sport studied, modality used to measure sleep, frequency of sleep measurements, and functional and physiological outcomes across studies. Sleep measurements varied greatly in frequency of data collection and type of measurement tool, with the majority using a sleep questionnaire. While all variables of interest were represented within the review, most had a focus on cognitive performance, athletic performance, or injury rate as a function of sleep. Studies using biomarkers and physiological measures or imaging were largely underrepresented. Few studies used biomarkers and physiological measures, and one study used imaging measures. Most studies in this review reported negative cognitive and academic outcomes with worse sleep quality and quantity. CONCLUSIONS: Sleep is critical to maintaining optimal health and collegiate athletes represent a unique population given their unique time constraints, stresses, and sleep behaviors. Findings on athletic performance and injury rate as a function of sleep were mixed. Employing standardized objective methodologies in future work will allow for better understanding of the influence of sleep on the overall well-being and performance of college athletes.

The American Board of Orthopaedic Surgery Response to COVID-19.

The COVID-19 pandemic has disrupted every aspect of society in a way never previously experienced by our nation's orthopaedic surgeons. In response to the challenges the American Board of Orthopaedic Surgery has taken steps to adapt our Board Certification and Continuous Certification processes. These changes were made to provide flexibility for as many Candidates and Diplomates as possible to participate while maintaining our high standards. The American Board of Orthopaedic Surgery is first and foremost committed to the safety and well-being of our patients, physicians, and families while striving to remain responsive to the changing circumstances affecting our Candidates and Diplomates.

The effect of protective equipment on cervical spine alignment in collegiate lacrosse players.

BACKGROUND: Contact sports place athletes at risk for cervical spine injury. Protective helmets and shoulder pads worn by football and ice hockey athletes alter cervical spine alignment. The effect of helmet and shoulder pads on neck alignment in lacrosse athletes is not known. HYPOTHESIS: Helmets and shoulder pads worn by lacrosse athletes alter cervical spine alignment. STUDY DESIGN: Controlled laboratory study. METHODS: Sagittal plane cervical spine alignment was evaluated in 16 uninjured male collegiate lacrosse players using computed tomography. Patients were immobilized in the supine position on a standard spine board. Testing was performed without equipment, with both helmet and shoulder pads in place, and with the helmet removed. Angular measurements of the cervical spine were made and analyzed. RESULTS: The presence of both the helmet and shoulder pads caused an increase in overall cervical extension (mean, 6 degrees ) compared with the absence of both pieces of equipment (P = .002). Helmet removal alone resulted in a mean increase in cervical flexion of 4.7 degrees in the upper cervical spine compared with the presence of both pieces of equipment (P = .011). Compared with the absence of equipment, shoulder pads caused increased cervical flexion in the lower cervical spine (mean, 4.4 degrees ; P = .036). CONCLUSION: Protective equipment worn by lacrosse athletes causes statistically significant increases in cervical extension, and its removal causes statistically significant increases in cervical flexion. This alteration is different from that previously reported for protective equipment in football and ice hockey. CLINICAL RELEVANCE: The authors' recommendation is that both lacrosse helmets and shoulder pads be left in place until they can be completely removed in a controlled fashion. The effect of external equipment on neck position is different for lacrosse compared with football and ice hockey.

Clinical inquiries. How does tissue adhesive compare with suturing for superficial lacerations?

Tissue adhesives are effective and yield results comparable to those with conventional suturing of superficial, linear, and low-tension lacerations. The cosmetic outcome is similar; wound complications, such as infection and dehiscence, may be lower with tissue adhesives. Wound closure of superficial lacerations by tissue adhesives is quicker and less painful compared with conventional suturing (strength of recommendation: A, systematic reviews of randomized trials).

Injury and illness epidemiology at a summer sport-camp program, 2008 through 2011.

CONTEXT: University-sponsored summer sport camps often employ athletic trainers; however, there is a dearth of epidemiologic studies describing the injury and illness experience of sport-camp participants to guide clinicians. OBJECTIVE: To describe the injury and illness experience of youth participants at a university-sponsored summer sport-camp program during a 4-year period. DESIGN: Descriptive epidemiology study. SETTING: A National Collegiate Athletic Association Division I university that sponsored 76 to 81 camps for 28 sports each summer. PATIENTS OR OTHER PARTICIPANTS: A total of 44, 499 camp participants enrolled during the 4 years. Male and female participants ranged in age from 10 to 17 years and in athletic skill from novice to elite. MAIN OUTCOME MEASURE(S): Data from handwritten injury and illness log books, maintained by sports health care personnel, were accessed retrospectively, entered into an electronic spreadsheet, and coded. Data were applied to the National Athletic Injury/Illness Reporting System. Participant-personnel contacts, defined as any instance when a participant sought health care services from personnel, were calculated per 100 participants. Injury and illness rates were calculated per 10 ,000 exposures, measured in participant-days. The distribution of injury and illness conditions and affected body regions were calculated. RESULTS: There were 11 ,735 contacts, for an overall rate of 26 per 100 participants, and 4949 injuries and illnesses, for a rate of 1 per 10, 000 participant-days. Participants at single-sex camps were less likely to sustain injuries and illnesses than participants at coeducational camps (rate ratio [RR] = 0.49; 95% confidence interval = 0.45, 0. 35; P < .001, and RR = 0.47; 95% confidence interval = 0.43, 0.51; P < .001, respectively). The lower extremity was injured most frequently (27.9%). Most injury and illness conditions were dermatologic (37.1%). CONCLUSIONS: The contact and injury and illness differences observed among sports and between sexes demonstrated potential differences in the sports health care needs of camp participants. These data can be used to make evidence-based clinical decisions, such as determining injury-prevention strategies and sports health care staffing needs.

Injury patterns in big ten conference football.

BACKGROUND: In 1998, the National Collegiate Athletic Association legislated a decrease in the number of scrimmages and full-contact practices allowed during the spring season. HYPOTHESIS: A significantly increased risk of injury faced by the same player during the spring versus fall practice sessions does exist, but the National Collegiate Athletic Association regulations will not have the intended effect of reducing injury rates to equal or below those of the fall practice sessions. STUDY DESIGN: Retrospectively analyzed, descriptive study of prospectively collected injury surveillance data followed by a prospective, controlled, repeated-measures study after the rule change. METHODS: Phase 1: the Big Ten Conference Sports Injury Surveillance System database was reviewed from spring 1992 through fall 1997 for all reportable injuries. Phase 2: a prospective investigation was instituted from spring 1998 through fall 2000. This protocol was modified to also document updated individual player position descriptions and string as well as exposures for the old fall and spring practice categories (scrimmages, full contact, and limited contact) and the new spring practice designations (full pads with and without tackling, helmets only, spring game, and other scrimmages). RESULTS: Phase 1: There were 3950 fall injuries and 1007 spring injuries, with 469 of the 1007 attributable to the "spring risk factor." There was a statistically significant increase in injury rate in the spring (19.8) versus fall (10.6). Scrimmages (incidence density ratio = 2.4) and limited-contact practices (incidence density ratio = 2.5) showed more than twice the fall injury rate. Phase 2: There were 1502 fall injuries and 648 spring injuries, with 192 attributable to the spring risk factor. There was a 3-fold increase in injury rate in the spring (incidence density ratio = 3.2). Although the noncontact, helmets-only practices produced the lowest injury rates, the nonspring game scrimmages and the limited-contact practices defined as "practice with pads but without tackling" displayed the highest injury rates. In both spring and fall, nonplayers exhibited the highest injury rates for all string groups. CONCLUSIONS: There was and still is a statistically significant increase in spring practice injury risk. The 1998 rule change resulted in an even greater increase in spring practice injury risk. If the goal is to minimize the number of spring practice injuries, it will be best accomplished by limiting the number of scrimmages and limited-contact sessions.

Arthrofibrosis of the knee following ligament surgery.

Arthrofibrosis of the knee is one of the most serious complications that can result from ligament surgery. Reported incidence of arthrofibrosis following anterior cruciate ligament reconstruction ranges from 4% to 35%. The loss of motion caused by arthrofibrosis can be even more disabling than the instability for which the reconstruction was performed, often requiring extensive physical therapy and/or surgical lysis of adhesions. With aggressive rehabilitation and modifications in the bracing of knees undergoing ligament reconstruction, the incidence of this complication has decreased significantly. Additionally, delaying anterior cruciate ligament reconstruction until the acute inflammatory period has resolved has also been shown to be a significant factor in the reduction of postoperative knee stiffness.

Comparative immediate functional outcomes among cryotherapeutic interventions at the ankle.

PURPOSE/BACKGROUND: There is a lack of evidence detailing the immediate effects of different cryotherapy interventions at the ankle on functional outcomes such as balance and jumping tasks in a physically active population; therefore, the purpose of the present study is to compare the immediate effects of varied modes of cryotherapy applications to the ankle joint on Star Excursion Balance Test and vertical jump height performance. The authors hypothesized that cryotherapy would acutely decrease performance when compared to a control, and that concomitant compression would further hinder outcomes. METHODS: A crossover study was conducted in a controlled laboratory setting. Thirty (9 men, 21 women) participants (20.6 ± 1.0 years, 1.7 ± 0.1 m, 67.5 ± 11.7 kg) were enrolled. The independent variable was treatment mode; no ice, ice without compression and ice with compression. Dependent variables included center of pressure (COP) excursions, dynamic balance reach distances and vertical jump height for the dominant leg. Participants underwent three separate testing sessions separated by 72-hour rest intervals. The order of treatment and performance measures was randomized to prevent order effects. Normalized dynamic balance reach distances were assessed using the reliable modified Star Excursion Balance Test (SEBT). Center of pressure path length was assessed via a force platform during a single-legged static balance task under eyes-open and eyes-closed conditions. Relative vertical jump height was assessed using a single-legged vertical hop test. Group means and standard deviations were calculated by treatment mode. One-way analyses of variance with Tukey's post hoc test were used to calculate differences among treatment modes. p < 0.05 denoted statistical significance. RESULTS: No statistically significant differences existed for all the performance measures among treatment modes. CONCLUSIONS: These findings suggest no immediate differences in lower extremity performance outcome measures between the respective treatment modes applied to the ankle in a young, healthy and physically active population. Additional investigation is warranted to study the related delayed effects of these interventions. LEVELS OF EVIDENCE: III.

Injury/illness physician referral profile from a youth university-sponsored summer sport camp program.

Participation at university-sponsored summer sport camps is popular among youth athletes; however, there is a dearth of information to describe the injuries/illnesses experienced by camp participants. Data from a university-sponsored sport camp program from 2008 to 2011 were accessed retrospectively. The sport camp program had approximately 80 camps for 28 sports over 12 weeks annually. Male and female participants were 10 to 17 years old. Athletic trainers maintained medical documentation and provided medical referrals. Referrals were made for 9.9% (n=478) of all injuries/illnesses. Emergency department referrals were made for 2.9% of injuries/illnesses. University health services received 42.5% of referrals. There were 1.1 referrals per 100 participants. Boys comprised 60.7% of referrals. Rugby had the highest referral rate--5.0 per 100 participants. These data help increase physician preparedness and guide the delivery of sports medicine services for related sport camp programs as a means to improve quality of care delivered to participants.

The effects of two therapeutic patellofemoral taping techniques on strength, endurance, and pain responses.

OBJECTIVE: To compare the effects of taping techniques on clinical measures in patellofemoral pain syndrome (PFPS) patients. DESIGN: Crossover experimental design. SETTING: Controlled laboratory. PARTICIPANTS: Twenty physically active PFPS patients. MAIN OUTCOME MEASURES: Isokinetic strength and endurance, and perceived pain. RESULTS: Bilateral baseline differences existed for strength (involved = 1.8 ± 0.5 Nm/kg; uninvolved = 2.1 ± 0.5 Nm/kg; p = 0.001) and endurance (involved = 35.6 ± 14.0 J/kg; uninvolved = 40.2 ± 12.9 J/kg; p = 0.013). Strength (McConnell = 2.1 ± 0.6 Nm/kg, 95% SCI = (1.1, 4.2); Spider(®) = 2.1 ± 0.5 Nm/kg, 95% SCI = (0.9, 4.0)) and endurance (McConnell = 42.9 ± 13.8 J/kg, 95% SCI = (2.9, 11.6); Spider(®) = 42.5 ± 11.0 J/kg, 95% SCI = (2.6, -11.3)) increased when taped compared to baseline. Pain decreased during strength (baseline = 3.0 ± 2.2 cm; McConnell = 1.9 ± 1.7 cm, 95% SCI = (-1.8, -0.4); Spider(®) = 1.6 ± 2.0 cm, 95% SCI = (-2.0, -0.5)) and endurance (baseline = 2.5 ± 2.0 cm; McConnell = 1.5 ± 1.8 cm, 95% SCI = (-1.6, -0.4); Spider(®) = 1.1 ± 0.8 cm, 95% SCI = (-1.7, -0.5)) measurements when taped. Differences between taping techniques were insignificant. CONCLUSIONS: Taping improved clinical measures in PFPS patients. No differences existed between Spider(®) and McConnell techniques.

Stress fractures of the medial malleolus and distal fibula.

Stress fractures of the medial malleolus and distal fibula are rarely encountered. They typically affect the athletic and running population and manifest the usual signs and symptoms of stress fractures. Axial and torsional forces, muscular contractions, and alignment are believed to play a role in their development. Plain radiographs are often initially nondiagnostic. The diagnosis can be confirmed with radionuclide bone scanning or MRI. Most injuries are amenable to nonsurgical management. An operative intervention for athletes with medial malleolar stress fractures has been advocated under certain circumstances.

Influence of the menstrual cycle on proenkephalin peptide F responses to maximal cycle exercise.

Proenkephalin peptide F [107-140] is an enkephalin-containing peptide found predominantly within the adrenal medulla and is co-packaged with epinephrine within adrenal medullary chromaffin granules. Peptide F has been shown to have the classic opioid analgesia effects along with immune cell interactions. This is only the second peptide F study in women, and in it we compare the responses of peptide F to a maximal cycle exercise test and recovery values over the follicular and luteal phases of the menstrual cycle. Eight untrained (directly documented in this study) women who were eumenorrheic performed a progressive maximal exercise test to volitional exhaustion on a cycle ergometer, once during the follicular phase, and once during the luteal phases of the menstrual cycle. Blood was obtained pre-exercise, immediately post-exercise and at 0, 15, and 30 min into recovery. Typical exercise changes in response to the cycle tests were observed with blood lactate increases that remained elevated 30 min into recovery. No significant exercise-induced elevations were observed for peptide F concentrations with exercise nor were any differences observed between the two menstrual phases. Thus, the effects of the menstrual cycle on peptide F concentrations appear to be minimal under the conditions of this investigation. With high concentrations of peptide F observed at rest (approx. 0.2-0.3 pmol ml(-1)) pre-exercise arousal mechanisms may have obviated any exercise-induced response. In addition, inhibition via elevated epinephrine may have inhibited any post-exercise increases and finally adrenal medullary capacity for circulatory concentrations of peptide F may have been reached in such untrained women. Pre-exercise arousal mechanisms potentially related to analgesia may also be involved to prepare untrained women for the stress of maximal exercise.

Changes in exercise performance and hormonal concentrations over a big ten soccer season in starters and nonstarters.

As a consequence of the physiological demands experienced during a competitive soccer season, the antagonistic relationship between anabolic and catabolic processes can affect performance. Twenty-five male collegiate soccer players were studied throughout a season (11 weeks) to investigate the effects of long-term training and competition. Subjects were grouped as starters (S; n = 11) and nonstarters (NS; n = 14). Measures of physical performance, body composition, and hormonal concentrations (testosterone [T] and cortisol [C]) were assessed preseason (T1) and 5 times throughout the season (T2-T6). Starters and NS participated in 83.06% and 16.95% of total game time, respectively. Nonstarters had a significant increase (+1.6%) in body fat at T6 compared to T1. Isokinetic strength of the knee extensors (1.05 rad.sec(-1)) significantly decreased in both S (-12%) and NS (-10%; p < or = 0.05) at T6. Significant decrements in sprint speed (+4.3%) and vertical jump (-13.8%) were found at T5 in S only. Though within normal ranges (10.4-41.6 nmol.L(-1)), concentrations of T at T1 were low for both groups, but increased significantly by T6. Concentrations of C were elevated in both groups, with concentrations at the high end of the normal range (normal range 138-635 nmol.L(-1)) at T1 and T4 in NS and T4 in S, with both groups remaining elevated at T6. Data indicate that players entering the season with low circulating concentrations of T and elevated levels of C can experience reductions in performance during a season, with performance decrements exacerbated in starters over nonstarters. Soccer players should therefore have a planned program of conditioning that does not result in an acute overtraining phenomenon prior to preseason (e.g., young players trying to get in shape quickly in the 6 to 8 weeks in the summer prior to reporting for preseason camp). The detrimental effects of inappropriate training do not appear to be unloaded during the season and catabolic activities can predominate.