Fractures in professional footballers: 7-years data from 106 team seasons in the Middle East.

Epidemiological studies on fractures in European professional football (soccer) are in abundance. However, such data are lacking in Middle Eastern professional footballers and information on fracture treatment is scarce. The aim of this study is to describe the epidemiology of fractures across seven seasons in Qatar Stars League (QSL) footballers. A prospective study of fractures in professional male footballers over 7 consecutive seasons (2013 to 2020), involving 3255 players and 106 team' seasons. Time loss and injuries and illnesses were recorded using standardised digital tools in accordance with international consensus procedures. Fractures were recorded according to onset mechanism, location, diagnoses, treatment and return to play. A total of 108 players sustained fractures during 638,247 hours of player exposure (88.9% training and 11.1% matches), representing 2.7% of all time-loss injuries. The incidence was 0.17 fractures per 1000 h of exposure (match and training incidence of 0.9 and 0.07 fractures / 1000 h, respectively), equivalent to an average of one fracture per team per season. Fractures mostly occurred in the feet (28.2%), hands (21.1%), shoulders (11.3%) and head (i.e., face) (9.9%). Mean (median) absence was 71 (47 days), with 4.6% refractures. Only 34.3% of the fractures required surgery and nearly all players (98.1%) returned to play at the professional level. Almost all professional football players with fractures return to play at the same competitive level after an average of 10 weeks of absence (mean absence was 71 ± 81 (median: 47, Inter Quartile Range [14-93]) days). One in ten continue to play with symptoms and one in twenty may refracture. Long-term effects of fractures are still unknown.

Effect of peripheral defocus on axial growth and modulation of refractive error in children with anisohyperopia.

PURPOSE: To establish whether axial growth and refractive error can be modulated in anisohyperopic children by imposing relative peripheral hyperopic defocus (RPHD) using multifocal soft contact lenses. METHODS: This study is a prospective, controlled paired-eye study with anisohyperopic children. Axial growth and refractive error were observed without intervention for the first 6 months of the 3-year trial with participants wearing single vision spectacles. Then, participants wore a centre-near, multifocal, soft contact lens (+2.00 D add) in their more hyperopic eye for 2 years, with a single vision contact lens worn in the fellow eye if required. The 'centre-near' portion of the contact lens in the more hyperopic eye corrected distance refractive error while the 'distance' portion imposed hyperopic defocus in the peripheral retina. Participants reverted to single vision spectacles for the final 6 months. RESULTS: Eleven participants, mean age of 10.56 years (SD 1.43; range 8.25-13.42), completed the trial. No increase in axial length (AL) was found during the first 6 months in either eye (p > 0.99). Axial growth across the 2-year intervention period was 0.11 mm (SEM 0.03; p = 0.06) in the test eye versus 0.15 mm (SEM 0.03; p = 0.003) in the control eye. AL was invariant during the final 6 months in both eyes (p > 0.99). Refractive error was stable during the first 6 months in both eyes (p = 0.71). Refractive error change across the 2-year intervention period was -0.23 D (SEM 0.14; p = 0.32) in the test eye versus -0.30 D (SEM 0.14; p = 0.61) in the control eye. Neither eye demonstrated a change in refractive error during the final 6 months (p > 0.99). CONCLUSIONS: Imposing RPHD using the centre-near, multifocal, contact lens specified here did not accelerate axial growth nor reduce refractive error in anisohyperopic children.

Video review of the frequency and assessment of head impacts during the FIFA Arab Cup 2021TM.

We used injury spotters and video footage review to establish the frequency of head impacts, their characteristics, and the subsequent medical assessment during the FIFA Arab Cup 2021TM. Six defined video signs of potential concussion based on an international consensus were used. A total of 88 head impacts were observed, with a median of 2 (IQR 1.5-4, range 0-7) head impacts per match, of which 44 (50%) resulted in on-pitch medical assessment. The median assessment duration was 51s (IQR 34-65s, range 19-262s). The most common mechanism was head-to-head contact (27% of all impacts and 43% of impacts with medical assessment). Seven head impacts showed video signs of potential concussion: six had one sign and one had two signs. The concussion substitution was used in three incidents. Head impacts during the FIFA Arab Cup were common and a median of 1 head impact per game required an on-pitch medical assessment. Only 8% of the head impacts showed any video sign of potential concussion, and only 3% resulted in a concussion substitution. The medical on-pitch assessments appeared too short (<1 min) to allow an appropriate assessment of all head impacts, indicating a need for further evaluation. Further standardisation of the injury spotter's role in football is recommended.

Chronic Viral Hepatitis in Elite Athletes: Approaches to Risk Assessment, Prevention and Management.

Elite athletes who participate in contact sports are at risk of bleeding injuries, leading to transmission of blood-borne viruses including hepatitis type B, C and D (HBV, HCV and HDV) capable of causing chronic liver disease, liver failure and liver cancer. In view of the significant advances in the viral hepatitis field over the past decade, more structured approaches should be in place to screen for and manage viral hepatitis in elite athletes. HBV status should be assessed in all elite athletes, and those infected should receive nucleos(t)ide analogues for viral suppression, while uninfected individuals should receive HBV vaccination. The all-oral direct acting antivirals for HCV are highly effective and safe, thus the remaining challenge with hepatitis C is case identification and linkage to care. HDV is only found in HBV-infected individuals, which is characterized by rapid disease progression and higher rates of cirrhosis and liver cancer in infected subjects. Pegylated interferon was the mainstay of treatment for HDV infection until bulevirtide, a viral entry inhibitor, was recently approved by the European Union (EMA) and FDA in America, while multiple novel therapies are already in clinical trials as part of the HBV cure program. Overall, awareness of chronic viral hepatitis in athletes should be improved. Prevention remains the cornerstone of the management of viral hepatitis in sport coupled with rigorous disease assessment in infected individuals, and antiviral therapy where indicated.

The effect of peripheral defocus on axial growth and modulation of refractive error in hyperopes.

PURPOSE: To establish whether axial growth and refractive error can be modulated in hyperopic children by imposing relative peripheral hyperopic defocus using multifocal soft contact lenses. METHODS: A prospective controlled study with hyperopic participants allocated to a control or test group. Control group participants were corrected with single vision spectacles and changes to axial length and refractive error were followed for 3 years. For the test group, axial growth and post-cycloplegic refractive error were observed with participants wearing single vision spectacles for the first 6 months of the trial and then corrected with centre-near multifocal soft contact lenses with a 2.00 D add for 2 years. The central 'near' portion of the contact lens corrected distance refractive error while the 'distance' portion imposed hyperopic defocus. Participants reverted to single vision spectacles for the final 6 months of the study. RESULTS: Twenty-two participants, mean age 11.13 years (SD 1.72) (range 8.33-13.92), completed the trial. Axial length did not change during the first 6 months in either group (p = 1.00). Axial growth across the 2-year intervention period was 0.17 mm (SEM 0.04) (p < 0.0005) in the test group versus 0.06 mm (SEM 0.07) (p = 0.68) in the control group. Axial length was invariant during the final 6 months in either group (p = 1.00). Refractive error was stable during the first 6 months in both groups (p = 1.00). Refractive error change across the 2-year intervention period was -0.26 D (SEM 0.14) (p = 0.38) in the test group versus -0.01 D (SEM 0.09) (p = 1.00) in the control group. Neither the test (p = 1.00) nor control (p = 0.63) group demonstrated a change in refractive error during the final 6 months. CONCLUSIONS: The rate of axial growth can be accelerated in children with hyperopia using centre-near multifocal soft contact lenses.

Remote assessment in sport and exercise medicine (SEM): a narrative review and teleSEM solutions for and beyond the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic forces sport and exercise medicine (SEM) physicians to think differently about the clinical care of patients. Many rapidly implement eHealth and telemedicine solutions specific to SEM without guidance on how best to provide these services. AIM: The aim of this paper is to present some guiding principles on how to plan for and perform an SEM consultation remotely (teleSEM) based on a narrative review of the literature. A secondary aim is to develop a generic teleSEM injury template. RESULTS: eHealth and telemedicine are essential solutions to effective remote patient care, also in SEM. This paper provides guidance for wise planning and delivery of teleSEM. It is crucial for SEM physicians, technology providers and organisations to codesign teleSEM services, ideally involving athletes, coaches and other clinicians involved in the clinical care of athletes, and to gradually implement these services with appropriate support and education. CONCLUSION: teleSEM provides solutions for remote athlete clinical care during and after the COVID-19 pandemic. We define two new terms-eSEM and teleSEM and discuss guiding principles on how to plan for and perform SEM consultations remotely (teleSEM). We provide an example of a generic teleSEM injury assessment guide.

Self-Directed Oral Vitamin D Supplementation in Professional Ballet Dancers: A Randomized Controlled Trial Pilot Study.

Inadequate levels of vitamin D may lead to poor performance in professional dancers. Therefore, dietary supplementation may be essential in this population. This longitudinal pilot study to a randomized controlled trial assessed dancer compliance with self-directed oral vitamin D supplementation. Seventy-one dancers, 41 females and 30 males with a mean age of 31.1 years, were recruited from The Royal Ballet, London. Baseline serum 25(OH)D levels were measured and dancers were interviewed, examined, and provided with oral supplements for the winter period, November 2011 to March 2012. Dancers with normal serum 25(OH)D levels were provided with maintenance supplements (1,000 IU/ day) and those with insufficient or deficient serum 25(OH)D levels were given a loading dose of 60,000 IU weekly for 2 and 6 weeks, respectively. Serum 25(OH) D levels were measured at 1 and 2 years and dancers were sampled for compliance with instructions. Mean compliance during loading and maintenance was 86% and 50%, respectively. Mean serum 25(OH)D levels at start and end of the study period were 79.3 ± 31.6 nmol/L and 78.68 ± 19.8 nmol/L, respectively. Only one-third of dancers with insufficient (N = 5) and deficient (N = 5) serum vitamin D levels improved to normal values. It is concluded that professional ballet dancers demonstrate good compliance with self-directed loading doses of vitamin D supplementation but poor compliance with maintenance doses. Poor maintenance compliance may have accounted for the low rates of serum vitamin D level improvement among dancers with insufficient or deficient levels.

Stress fractures of the medial malleolus in the professional soccer player demonstrate excellent outcomes when treated with open reduction internal fixation and arthroscopic spur debridement.

PURPOSE: Despite a debilitating effect on athletic performance and an incidence of up to 4% of all stress fractures, there have been only 31 documented cases of medial malleolus stress fractures (MMSF) to our knowledge in the literature. The largest series to date is presented in this study, of 16 professional soccer players undergoing uniform operative treatment. The authors attempt to justify their preferred treatment of MMSFs in the professional soccer player, with an emphasis on patient satisfaction, clinical and radiographic union, and return to high level sport. The authors aim to prove an association between lower limb varus alignment and the development of MMSFs. METHOD: Sixteen professional soccer players of mean age 23.6 years were analysed. A biomechanic assessment was performed. Preoperative CT+-MRI scan were performed to assess fracture lines and the presence of anteromedial tibial and/or talar spurs; which are the likely pathognomic lesion in the development of MMSFs. All patients underwent open reduction and internal fixation with three screws, as well as arthroscopic debridement of impringement spurs, and concentrated bone marrow aspirate into the fracture site. Patients completed the Ogilvie-Harris score, and all patients had CT scans at 3 months and until union. RESULTS: All the patients in this cohort had causative bony spurs that were debrided at surgery. All of the cohort achieved clinical union. All patients were able to return to professional football; at the same level as prior to the injury. There was complete cohort follow up; and 81% of patients were graded as excellent and 19% as good by the Ogilvie-Harris score. We noted 50% of our cohort demonstrated varus malalignment, either genu varum or hindfoot varus. CONCLUSIONS: The authors conclude that open reduction and internal fixation of MMSFs with screws combined with arthroscopic spur debridement results in excellent clinical outcomes. It can be concluded that varus lower limb malalignment is a risk factor for MMSFs. Given the treatment controversy for these injuries, the results herein demonstrate that aggressive multimodal operative treatment produces excellent outcomes in high demand professional footballers. This study is the first to report a biomechanic association, which can alert the clinician to preventative measures; such as hindfoot orthoses. LEVEL OF EVIDENCE: IV.

Emergency response facilities including primary and secondary prevention strategies across 79 professional football clubs in England.

AIM: To assess the emergency response planning and prevention strategies for sudden cardiac arrest (SCA) across a wide range of professional football clubs in England. METHODS: A written survey was sent to all professional clubs in the English football league, namely the Premiership, Championship, League 1 and League 2. Outcomes included: (1) number of clubs performing cardiac screening and frequency of screening; (2) emergency planning and documentation; (3) automated external defibrillator (AED) training and availability; and (4) provision of emergency services at sporting venues. RESULTS: 79 clubs (86%) responded to the survey. 100% clubs participated in cardiac screening. All clubs had AEDs available on match days and during training sessions. 100% Premiership clubs provided AED training to designated staff. In contrast, 30% of lower division clubs with AEDs available did not provide formal training. Most clubs (n=66; 83%) reported the existence of an emergency action plan for SCA but formal documentation was variable. All clubs in the Premiership and League 1 provided an ambulance equipped for medical emergencies on match days compared with 75% of clubs in the Championship and 66% in League 2. CONCLUSIONS: The majority of football clubs in England have satisfactory prevention strategies and emergency response planning in line with European recommendations. Additional improvements such as increasing awareness of European guidelines for emergency planning, AED training and mentorship with financial support to lower division clubs are necessary to further enhance cardiovascular safety of athletes and spectators and close the gap between the highest and lower divisions.

Effect of Peripheral Defocus on Axial Eye Growth and Modulation of Refractive Error in Hyperopes: Protocol for a Nonrandomized Clinical Trial.

BACKGROUND: Hyperopia occurs due to insufficient ocular growth and a failure to emmetropize in childhood. In anisohyperopia, it is unclear why one eye may remain hyperopic while the fellow eye grows toward an emmetropic state. Animal studies have shown that manipulating peripheral defocus through optical means while simultaneously providing correct axial focus can either discourage or encourage axial eye growth to effectively treat myopia or hyperopia, respectively. Myopia progression and axial eye growth can be significantly reduced in children and adolescents through the use of multifocal contact lenses. These contact lenses correct distance central myopia while simultaneously imposing relative peripheral myopic defocus. The effect of correcting distance central hyperopia while simultaneously imposing relative peripheral hyperopic defocus is yet to be elucidated in humans. OBJECTIVE: The objective of our study is to understand the natural progression of axial eye growth and refractive error in hyperopes and anisohyperopes and to establish whether axial eye growth and refractive error can be modified using multifocal contact lenses in hyperopes and anisohyperopes. METHODS: There are 3 elements to the program of research. First, the natural progression of axial eye growth and refractive error will be measured in spectacle-wearing hyperopic and anisohyperopic subjects aged between 5 and <20 years. In other words, the natural growth of the eye will be followed without any intervention. Second, as a paired-eye control study, anisohyperopes aged between 8 and <16 years will be fitted with a center-near multifocal design contact lens in their more hyperopic eye and a single-vision contact lens in the fellow eye if required. The progression of axial eye growth and refractive error will be measured and compared. Third, subjects aged between 8 and <16 years with similar levels of hyperopia in each eye will be fitted with center-near multifocal design contact lenses in each eye; the progression of axial eye growth and refractive error in these subjects will be measured and compared with those of subjects in the natural progression study. RESULTS: Recruitment commenced on 6 June 2016 and was completed on 8 April 2017. We estimate the data collection to be completed by April 2020. CONCLUSIONS: This trial will establish whether axial eye growth can be accelerated in children with hyperopia by imposing relative peripheral hyperopic defocus using center-near multifocal contact lenses. TRIAL REGISTRATION: ClinicalTrials.gov NCT02686879; https://clinicaltrials.gov/ct2/show/NCT02686879 (Archived by Webcite at http://www.webcitation.org/71o5p3fD2). REGISTERED REPORT IDENTIFIER: RR1-10.2196/9320.

Outcomes of Cardiac Screening in Adolescent Soccer Players.

BACKGROUND: Reports on the incidence and causes of sudden cardiac death among young athletes have relied largely on estimated rates of participation and varied methods of reporting. We sought to investigate the incidence and causes of sudden cardiac death among adolescent soccer players in the United Kingdom. METHODS: From 1996 through 2016, we screened 11,168 adolescent athletes with a mean (±SD) age of 16.4±1.2 years (95% of whom were male) in the English Football Association (FA) cardiac screening program, which consisted of a health questionnaire, physical examination, electrocardiography, and echocardiography. The FA registry was interrogated to identify sudden cardiac deaths, which were confirmed with autopsy reports. RESULTS: During screening, 42 athletes (0.38%) were found to have cardiac disorders that are associated with sudden cardiac death. A further 225 athletes (2%) with congenital or valvular abnormalities were identified. After screening, there were 23 deaths from any cause, of which 8 (35%) were sudden deaths attributed to cardiac disease. Cardiomyopathy accounted for 7 of 8 sudden cardiac deaths (88%). Six athletes (75%) with sudden cardiac death had had normal cardiac screening results. The mean time between screening and sudden cardiac death was 6.8 years. On the basis of a total of 118,351 person-years, the incidence of sudden cardiac death among previously screened adolescent soccer players was 1 per 14,794 person-years (6.8 per 100,000 athletes). CONCLUSIONS: Diseases that are associated with sudden cardiac death were identified in 0.38% of adolescent soccer players in a cohort that underwent cardiovascular screening. The incidence of sudden cardiac death was 1 per 14,794 person-years, or 6.8 per 100,000 athletes; most of these deaths were due to cardiomyopathies that had not been detected on screening. (Funded by the English Football Association and others.).

Return to play criteria after hamstring muscle injury in professional football: a Delphi consensus study.

BACKGROUND: Hamstring muscle injury (HMI) is the most common injury in professional football and has a high re-injury rate. Despite this, there are no validated criteria to support return to play (RTP) decisions. AIM: To use the Delphi method to reach expert consensus on RTP criteria after HMI in professional football. METHODS: All professional football clubs in England (n=92) were invited to participate in a 3-round Delphi study. Round 1 requested a list of criteria used for RTP decisions after HMI. Responses were independently collated by 2 researchers under univocal definitions of RTP criteria. In round 2 participants rated their agreement for each RTP criterion on a 1-5 Likert Scale. In round 3 participants re-rated the criteria that had reached consensus in round 2. Descriptive statistics and Kendall's coefficient of concordance enabled interpretation of consensus. RESULTS: Participation rate was limited at 21.7% (n=20), while retention rate was high throughout the 3 rounds (90.0%, 85.0%, 90.0%). Round 1 identified 108 entries with varying definitions that were collated into a list of 14 RTP criteria. Rounds 2 and 3 identified 13 and 12 criteria reaching consensus, respectively. Five domains of RTP assessment were identified: functional performance, strength, flexibility, pain and player's confidence. The highest-rated criteria were in the functional performance domain, with particular importance given to sprint ability. CONCLUSION: This study defined a list of consensually agreed RTP criteria for HMI in professional football. Further work is now required to determine the validity of the identified criteria.

Injury prevention strategies at the FIFA 2014 World Cup: perceptions and practices of the physicians from the 32 participating national teams.

PURPOSE: The available scientific research regarding injury prevention practices in international football is sparse. The purpose of this study was to quantify current practice with regard to (1) injury prevention of top-level footballers competing in an international tournament, and (2) determine the main challenges and issues faced by practitioners in these national teams. METHODS: A survey was administered to physicians of the 32 competing national teams at the FIFA 2014 World Cup. The survey included 4 sections regarding perceptions and practices concerning non-contact injuries: (1) risk factors, (2) screening tests and monitoring tools, (3) preventative strategies and (4) reflection on their experience at the World Cup. RESULTS: Following responses from all teams (100%), the present study revealed the most important intrinsic (previous injury, accumulated fatigue, agonist:antagonist muscle imbalance) and extrinsic (reduced recovery time, training load prior to and during World Cup, congested fixtures) risk factors during the FIFA 2014 World Cup. The 5 most commonly used tests for risk factors were: flexibility, fitness, joint mobility, balance and strength; monitoring tools commonly used were: medical screen, minutes/matches played, subjective and objective wellness, heart rate and biochemical markers. The 5 most important preventative exercises were: flexibility, core, combined contractions, balance and eccentric. CONCLUSIONS: The present study showed that many of the National football (soccer) teams' injury prevention perceptions and practices follow a coherent approach. There remains, however, a lack of consistent research findings to support some of these perceptions and practices.

Does rebound tonometry probe misalignment modify intraocular pressure measurements in human eyes?

Purpose. To examine the influence of positional misalignments on intraocular pressure (IOP) measurement with a rebound tonometer. Methods. Using the iCare rebound tonometer, IOP readings were taken from the right eye of 36 healthy subjects at the central corneal apex (CC) and compared to IOP measures using the Goldmann applanation tonometer (GAT). Using a bespoke rig, iCare IOP readings were also taken 2 mm laterally from CC, both nasally and temporally, along with angular deviations of 5 and 10 degrees, both nasally and temporally to the visual axis. Results. Mean IOP ± SD, as measured by GAT, was 14.7 ± 2.5 mmHg versus iCare tonometer readings of 17.4 ± 3.6 mmHg at CC, representing an iCare IOP overestimation of 2.7 ± 2.8 mmHg (P < 0.001), which increased at higher average IOPs. IOP at CC using the iCare tonometer was not significantly different to values at lateral displacements. IOP was marginally underestimated with angular deviation of the probe but only reaching significance at 10 degrees nasally. Conclusions. As shown previously, the iCare tonometer overestimates IOP compared to GAT. However, IOP measurement in normal, healthy subjects using the iCare rebound tonometer appears insensitive to misalignments. An IOP underestimation of <1 mmHg with the probe deviated 10 degrees nasally reached statistical but not clinical significance levels.

The effect of spectral filters on visual search in stroke patients.

Visual search impairment can occur following stroke. The utility of optimal spectral filters on visual search in stroke patients has not been considered to date. The present study measured the effect of optimal spectral filters on visual search response time and accuracy, using a task requiring serial processing. A stroke and control cohort undertook the task three times: (i) using an optimally selected spectral filter; (ii) the subjects were randomly assigned to two groups with group 1 using an optimal filter for two weeks, whereas group 2 used a grey filter for two weeks; (iii) the groups were crossed over with group 1 using a grey filter for a further two weeks and group 2 given an optimal filter, before undertaking the task for the final time. Initial use of an optimal spectral filter improved visual search response time but not error scores in the stroke cohort. Prolonged use of neither an optimal nor a grey filter improved response time or reduced error scores. In fact, response times increased with the filter, regardless of its type, for stroke and control subjects; this outcome may be due to contrast reduction or a reflection of task design, given that significant practice effects were noted.

Visual stress symptoms secondary to stroke alleviated with spectral filters and precision tinted ophthalmic lenses: a case report.

Visual stress is a condition characterised by symptoms of eyestrain, headaches and distortions of visual perception when reading text. The symptoms are frequently alleviated with spectral filters and precision tinted ophthalmic lenses. Visual stress is thought to arise due to cortical hyperexcitability and is associated with a range of neurological conditions. Cortical hyperexcitability is known to occur following stroke. The case presented describes visual stress symptoms resulting from stroke, subsequently managed with spectral filters and precision tinted ophthalmic lenses. The case also highlights that the spectral properties of the tint may need to be modified if the disease course alters.