Search

To develop a core outcome set for Achilles tendinopathy (COS-AT) for use in clinical trials we performed a five-step process including (1) a systematic review of available outcome measurement instruments, (2) an online survey on truth and feasibility of the available measurement instruments, (3) an assessment of the methodological quality of the selected outcome measurement instruments, (4) an online survey on the outcome measurement instruments as COS and (5) a consensus in-person meeting. Both surveys were completed by healthcare professionals and patients. The Outcome Measures in Rheumatology guidelines with a 70% threshold for consensus were followed. We identified 233 different outcome measurement instruments from 307 included studies; 177 were mapped within the International Scientific Tendinopathy Symposium Consensus core domains. 31 participants (12 patients) completed the first online survey (response rate 94%). 22/177 (12%) outcome measurement instruments were deemed truthful and feasible and their measurement properties were evaluated. 29 participants (12 patients) completed the second online survey (response rate 88%) and three outcome measurement instruments were endorsed: the Victorian Institute of Sports Assessment-Achilles questionnaire, the single-leg heel rise test and evaluating pain after activity using a Visual Analogue Scale (VAS, 0-10). 12 participants (1 patient) attended the final consensus meeting, and 1 additional outcome measurement instrument was endorsed: evaluating pain during activity/loading using a VAS (0-10). It is recommended that the identified COS-AT will be used in future clinical trials evaluating the effectiveness of an intervention. This will facilitate comparing outcomes of intervention strategies, data pooling and further progression of knowledge about AT. As COS-AT is implemented, further evidence on measurement properties of included measures and new outcome measurement instruments should lead to its review and refinement., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe and categorise the injury-inciting circumstances of sudden-onset hamstring match injuries in professional football players using systematic video analysis., Methods: Using a prospective injury surveillance database, all sudden-onset hamstring match injuries in male football players (18 years and older) from the Qatar Stars League between September 2013 and August 2020 were reviewed and cross-referenced with broadcasted match footage. Videos with a clear observable painful event (ie, a player grabbing their posterior thigh) were included. Nine investigators independently analysed all videos to describe and categorise injury-inciting circumstances. We used three main categories: playing situation (eg, time of injury), player action(s) (eg, running) and other considerations (eg, contact). Player action(s) and other considerations were not mutually exclusive., Results: We included 63 sudden-onset hamstring match injuries out of 295 registered injuries between 2013 and 2020. Running was involved in 86% of injuries. Hamstring injuries occurred primarily during acceleration of 0-10 m (24% of all injuries) and in general at different running distances (0-50 m) and speeds (slow to fast). At 0-10 m distance, indirect player-to-player contact and inadequate balance were involved in 53% and 67% of the cases, respectively. Pressing occurred in 46% of all injuries (injured player pressing opponent: 25%; being pressed by opponent: 21%) and frequently involved player-to-player contact (69% of the cases when the injured player was pressing vs 15% of the cases when the opponent was pressing) and inadequate balance (82% vs 50%, respectively). Other player actions that did not involve running (n=9, 14% of all injuries) were kicking (n=6) and jumping (n=3)., Conclusion: The injury-inciting circumstances of sudden-onset hamstring match injuries in football varied. The most common single-player action (24%) was acceleration over a distance of <10 m. Pressing, inadequate balance and indirect contact were frequently seen player actions. Injury prevention research in football should look beyond high-speed running as the leading risk factor for sudden-onset hamstring injuries., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To investigate if a combination of an online and onsite implementation strategy was superior to an online-only strategy in enhancing the use of an injury prevention exercise programme (IPEP) and in reducing the risk of shoulder, knee and ankle injuries in youth community handball players (age 11-17) over a handball season., Methods: In this 30-week hybrid effectiveness-implementation cluster randomised type 3 study, 20 youth handball clubs were randomly assigned 1:1 to either a combined online and onsite implementation strategy (coach workshop using the health action process approach behaviour change model and health service provider (HSP) support) or an online-only strategy (control group). The primary implementation outcome was coach-reported adherence, measured as the average IPEP exercise usage by the team over 30 weeks. The primary effectiveness outcome was player-reported handball playing time to any new handball-related shoulder, knee and ankle injuries, reported weekly using the Oslo Sports Trauma Research Centre Questionnaire on Health Problems., Results: We enrolled 63 coaches (27% women) and 945 players (mean age 14.5 years, 55% girls). Intention-to-treat analyses showed no statistically significant difference between implementation strategies in adherence (between-group difference 1.4, 95% CI -0.5 to 3.4) or in cumulative injury risk (between-group difference 5.5% points, 95% CI -2.2 to 13.1)., Conclusion: Our findings demonstrate that in youth community handball, a combined online and onsite implementation strategy, including a coach workshop and HSP support, was not superior to an online-only strategy regarding adherence to an IPEP or in reducing shoulder, knee and ankle injury risk., Trial Registration Number: NCT05294237., Competing Interests: Competing interests: MM is associate editor for the British Journal of Sports Medicine., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To co-construct a sports medicine and exercise science research and translational agenda with Team USA elite female athletes serving as the experts on their health, performance and well-being., Methods: 40 Team USA female athletes across sports disciplines participated in an online, anonymous, modified Delphi survey by ranking topics on a Likert scale (1='strongly disagree' and 5='strongly agree') and providing qualitative justification regarding whether they believed having more information and research on each topic would support their athletic performance, health and well-being. After each Delphi round, quantitative rankings of topics and qualitative justifications were analysed, informing revisions to the list of topics for review in the subsequent round. Researchers provided athletes with a detailed report of findings and revisions following each round., Results: The final list contained 14 ranked topics. The top five were menstrual cycle symptoms (4.58±0.74), recovery (4.58±0.59), birth control (4.55±0.89), mental health (4.50±0.55) and fueling and the menstrual cycle (4.43±0.74). New topics originating from athletes included recovery, menstrual cycle symptoms, fueling and the menstrual cycle, mental health and sports performance, team dynamics, and institutionalised sexism., Conclusion: This is the first study to co-construct a research and translational agenda with Team USA elite female athletes. The list of sports science research topics developed by focusing on elite female athletes' voices lays the foundation for future research and provides valuable insight into the specific needs of female athletes., Competing Interests: Competing interests: KEA is a Deputy Editor of the BJSM and an Associate Editor of the BJSM IPHP., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To assess the clinical competence of sports medicine physicians to recognise and report harassment and abuse in sports, and to identify barriers to reporting and the need for safeguarding education., Methods: We implemented a cross-sectional cohort study design recruiting through social media and international sports medicine networks in 2023. The survey captured participant perceptions related to the harmfulness of harassment and abuse. The survey incorporated the reasoned action approach as a theoretical framework to design survey questions to identify attitudes and self-efficacy to detect and report suspicions of harassment and abuse and to identify barriers to reporting., Results: Sports medicine physicians (n=406) from 115 countries completed the survey. The situations of harassment and abuse presented in the survey were described by sports medicine physicians as having occurred in the 12 months before participating in the survey. Despite recognising the situations as harmful, sports medicine physicians were somewhat uncomfortable being vigilant for the signs and symptoms and reporting suspicions and disclosures of harassment and abuse (M=2.13, SD=0.67). In addition, just over one-quarter (n = 101, 26.9%) was unaware of where to report harassment and abuse, and over half did not know (n = 114, 28.1%), or were uncertain (n = 95, 23.4%) of who the safeguarding officer was in their sports organisation. Participants identified many barriers to reporting harassment and abuse, including concerns regarding confidentiality, misdiagnosis, fear of reprisals, time constraints and lack of knowledge. Over half felt insufficiently trained (n = 223, 57.6%), and most respondents (n=324, 84.6%) desired more education in the field., Conclusions: Educational programmes to better recognise and report harassment and abuse in sports are needed for sports medicine trainees and practising clinicians. An international safeguarding code for sports medicine physicians should be developed., Competing Interests: Competing interests: MM is a deputy editor of the BJSM and a member of the BJSM IPHP Editorial Board. EV is an associate editor of the BJSM, an associate editor of the BJSM IPHP and editor in chief of BMJ Open Sports and Exercise Medicine. JTF is the training, prevention and rehabilitation section editor for Current Sports Medicine Reports. AM is an associate editor of the BJSM., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: MM is a deputy editor of the BJSM and a member of the BJSM IPHP Editorial Board. EV is an associate editor of the BJSM, an associate editor of the BJSM IPHP and editor in chief of BMJ Open Sports and Exercise Medicine. JTF is the training, prevention and rehabilitation section editor for Current Sports Medicine Reports. AM is an associate editor of the BJSM,

Objective: To evaluate radiographic knee osteoarthritis (OA) progression, development of knee OA, patient-reported outcomes and knee muscle strength at 10-year follow-up after arthroscopic partial meniscectomy (APM) or exercise therapy for degenerative meniscal tears., Methods: Randomised controlled trial including 140 participants, with a degenerative meniscal tear and no or minimal radiographic OA changes. Participants were randomised to either APM or 12 weeks of exercise therapy (1:1 ratio). The primary outcome was knee OA progression assessed by the Osteoarthritis Research Society International (OARSI) atlas sum score (sum of medial and lateral compartment joint space narrowing and osteophyte score). Secondary outcomes included incidence of radiographic and symptomatic knee OA, patient-reported pain and knee function and isokinetic knee muscle strength., Results: The adjusted mean difference in change in the OARSI sum score was 0.39 (95% CI -0.19 to 0.97), with more progression in the APM group. The incidence of radiographic knee OA was 23% in the APM group and 20% in the exercise group (adjusted risk difference 3% (95% CI -13% to 19%)). No clinically relevant differences were found in patient-reported outcomes or isokinetic knee muscle strength., Conclusion: No differences in radiographic knee OA progression and comparable rates of knee OA development were observed 10 years following APM and exercise therapy for degenerative meniscal tears. Both treatments were associated with improved patient-reported pain and knee function., Trial Registration Number: NCT01002794., Competing Interests: Competing interests: BB reports grants from the South-Eastern Norway Regional Health Authority, during the conduct of this study. EMR is the copyright holder of Knee injury and Osteoarthritis Outcome Score (KOOS) and several other patient-reported outcome measures, and co-founder of the Good Life with Osteoarthritis in Denmark (GLA:D), a not-for-profit initiative to implement clinical guidelines in primary care hosted by University of Southern Denmark. ME reports consultancy for Grünenthal Sweden AB. MAR is the co-founder of the AktivA (www.aktivmedartrose.no) in Norway, a not-for-profit initiative to implement evidence-based guidelines hosted by the Oslo University Hospital. All other authors declare no competing interests., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To compare the efficacy of exercise, metformin and their combination on glucose metabolism in individuals with abnormal glycaemic control., Design: Systematic review and network meta-analysis., Data Sources: Embase, Web of Science, PubMed/MEDLINE and SPORTDiscus., Eligibility Criteria: Randomised controlled trials involving exercise, metformin or their combined treatments in individuals with prediabetes or type 2 diabetes mellitus (T2DM) were included. Outcomes included haemoglobin A1c (HbA1c), 2-hour glucose during oral glucose tolerance test, fasting glucose, fasting insulin and homeostasis model assessment of insulin resistance (HOMA-IR)., Results: 407 articles with 410 randomised controlled trials (n=33 802) were included. In prediabetes, the exercise showed greater efficacy than metformin on HbA1c levels (mean difference -0.16%, 95% CI (-0.23 to -0.09) vs -0.10%, 95% CI (-0.21 to 0.02)), 2-hour glucose (-0.68 mmol/L, 95% CI (-0.97 to -0.39) vs 0.01 mmol/L, 95% CI (-0.38 to 0.41)) and HOMA-IR (-0.54, 95% CI (-0.71 to -0.36) vs -0.23, 95% CI (-0.55 to 0.10)), while the efficacy on fasting glucose was comparable (-0.26 mmol/L, 95% CI (-0.32 to -0.19) vs -0.33 mmol/L, 95% CI (-0.45 to -0.21)). In T2DM, metformin was more efficacious than exercise on HbA1c (-0.88%, 95% CI (-1.07 to -0.69) vs -0.48%, 95% CI (-0.58 to -0.38)), 2-hour glucose (-2.55 mmol/L, 95% CI (-3.24 to -1.86) vs -0.97 mmol/L, 95% CI (-1.52 to -0.42)) and fasting glucose (-1.52 mmol/L, 95% CI (-1.73 to -1.31) vs -0.85 mmol/L, 95% CI (-0.96 to -0.74)); exercise+metformin also showed greater efficacy in improving HbA1c (-1.23%, 95% CI (-2.41 to -0.05)) and fasting glucose (-2.02 mmol/L, 95% CI (-3.31 to -0.74)) than each treatment alone. However, the efficacies were modified by exercise modality and metformin dosage., Conclusion: Exercise, metformin and their combination are efficacious in improving glucose metabolism in both prediabetes and T2DM. The efficacy of exercise appears to be superior to metformin in prediabetes, but metformin appears to be superior to exercise in patients with T2DM., Prospero Registration Number: CRD42023400622., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe the incidence and characteristics of injuries and illnesses among Team USA athletes competing at the Santiago 2023 Pan American Games (PAG) and Parapan American Games (PPAG), with a particular focus on the incidence of respiratory illnesses and on injuries for sports new to the Olympic and Paralympic programmes., Methods: Illnesses and injuries occurring among the 870 Team USA athletes competing in the Santiago 2023 PAG or PPAG were documented within Team USA's Injury and Illness Surveillance system. Illness and injury incidence per 1000 athlete-days (ADs) and incidence ratios (IR) were calculated, both with 95% CIs., Results: Illness (IR 2.5, 95% CI 1.6, 3.9) and injury (IR 1.8, 95% CI 1.3, 2.5) rates were greater during PPAG compared with PAG. Illness rates were higher in the pre-opening ceremony period compared with the competition period for both PAG (IR 2.7, 95% CI 1.1, 5.9) and PPAG (IR 1.9, 95% CI 0.9, 3.8). Respiratory illness was the most common illness with 3.2% and 8.9% of all Team USA athletes reporting a respiratory illness during the PAG and PPAG, respectively. Sports that are relatively new to the Olympic/Paralympic programmes exhibited the highest injury rates during the Games: breaking (250.0 (91.7, 544.2) per 1000 ADs), Para taekwondo (93.8 (19.3, 274.0) per 1000 ADs) and surfing (88.9 (24.2, 227.6) per 1000 ADs)., Conclusion: Respiratory illness rates were the most common type of illness during both PAG and PPAG and were more likely to occur prior to competition starting. Our data have identified high injury risk populations (breaking, surfing, Para taekwondo) and timing (pre-opening ceremony period) for further risk factor analysis., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Studies identifying clinical and MRI reinjury risk factors are limited by relatively small sample sizes. This study aimed to examine the association between baseline clinical and MRI findings with the incidence of hamstring reinjuries using a large multicentre dataset., Methods: We merged data from four prospective studies (three randomised controlled trials and one ongoing prospective case series) from Qatar and the Netherlands. Inclusion criteria included patients with MRI-confirmed acute hamstring injuries (<7 days). We performed multivariable modified Poisson regression analysis to assess the association of baseline clinical and MRI data with hamstring reinjury incidence within 2 months and 12 months of follow-up., Results: 330 and 308 patients were included in 2 months (31 (9%) reinjuries) and 12 months (52 (17%) reinjuries) analyses, respectively. In the 2-month analysis, the presence of discomfort during the active knee extension test was associated with reinjury risk (adjusted risk ratio (ARR) 3.38; 95% CI 1.19 to 9.64). In the 12 months analysis, the time to return to play (RTP) (ARR 0.99; 95% CI 0.97 to 1.00), straight leg raise angle on the injured leg (ARR 0.98; 95% CI 0.96 to 1.00), the presence of discomfort during active knee extension test (ARR 2.52; 95% CI 1.10 to 5.78), the extent of oedema anteroposterior on MRI (ARR 0.74; 95% CI 0.57 to 0.96) and myotendinous junction (MTJ) involvement on MRI (ARR 3.10; 95% CI 1.39 to 6.93) were independently associated with hamstring reinjury., Conclusions: Two clinical findings (the presence of discomfort during active knee extension test, lower straight leg raise angle on the injured leg), two MRI findings (less anteroposterior oedema, MTJ involvement) and shorter time to RTP were independently associated with increased hamstring reinjury risk. These findings may assist the clinician to identify patients at increased reinjury risk following acute hamstring injury., Trial Registration Numbers: NCT01812564; NCT02104258; NL2643; NL55671.018.16., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objectives: To investigate if the sport concussion assessment tool version 5 (SCAT5) could be suitable for application to Para athletes with a visual impairment, a spinal cord injury, or a limb deficiency., Methods: A 16-member expert panel performed a Delphi technique protocol. The first round encompassed an open-ended questionnaire, with round 2 onwards being composed of a series of closed-ended statements requiring each expert's opinion using a five-point Likert scale. A predetermined threshold of 66% was used to decide whether agreement had been reached by the panel., Results: The Delphi study resulted in a four-round process. After round 1, 92 initial statements were constructed with 91 statements obtaining the targeted level of agreement by round 4. The expert panellist completion rate of the full four-round process was 94%. In the case of athletes with a suspected concussion with either limb deficiencies or spinal cord injuries, the panel agreed that a baseline assessment would be needed on record is ideal before a modified SCAT5 assessment. With respect to visual impairments, it was conceded that some tests were either difficult, infeasible or should be omitted entirely depending on the type of visual impairment., Conclusion: It is proposed that the SCAT5 could be conducted on athletes with limb deficiencies or spinal cord injuries with some minor modifications and by establishing a baseline assessment to form a comparison. However, it cannot be recommended for athletes with visual impairment in its current form. Further research is needed to determine how potential concussions could be more effectively evaluated in athletes with different impairments., Competing Interests: Competing interests: There are no commercial or financial associations to report. However, it should be noted that one of the authors is currently employed as the chairperson of a Para sport national governing body and multiple authors are members of the International Paralympic Committee (IPC) Medical Committee., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To assess whether there is a difference in symptom severity at baseline and 24 weeks follow-up between conservatively managed patients with Achilles tendinopathy (AT) with low socioeconomic status (SES) compared with those with high SES., Methods: In this prospective cohort study, 200 patients with AT were included and treated according to current guidelines. We linked a neighbourhood SES indicator based on income, employment and education level and divided the patient population into quintiles, with Q1 being the highest SES and Q5 the lowest. Symptom severity at baseline and follow-up was assessed using the Victorian Institute of Sports Assessment-Achilles (VISA-A) score. Treatment adherence was not measured. We used a general linear model and the mean VISA-A scores at baseline and at 6, 12 and 24 weeks follow-up were compared between Q1 (n=45) and Q5 (n=39), while adjusting for age, sex, body mass index (BMI), Ankle Activity Score, symptom duration and baseline VISA-A score., Results: Patients had a median age of 51 years and median BMI of 25.4, 40% were female. 74%, 70% and 58% of the participants completed the VISA-A at 6, 12 and 24 weeks, respectively. VISA-A scores at baseline were similar for Q1 and Q5 (43.9 and 41.8, p=0.591). At 24 weeks, there was a mean (95% CI) difference of 11.2 (1.0 to 21.3, p=0.032) points in favour of Q1 on the VISA-A score., Conclusion: AT patients with low SES may have worse outcomes when treated using the current guidelines. The difference in VISA-A score at 24 weeks is larger than the minimal clinically important difference and might be clinically relevant, but comes with uncertainty due to the large dispersion in the data. Clinicians need to consider the impact of social inequality when developing and implementing treatment plans., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Stress urinary incontinence (SUI) is common among females during functional fitness training, such as CrossFit. The aim of this study was to assess the effect of pelvic floor muscle training (PFMT) on SUI in female functional fitness exercisers., Methods: This was an assessor-blinded randomised controlled trial with a PFMT group (n=22) and a control group (n=25). The PFMT group followed a 16-week home-training programme with 3 sets of 8-12 maximum pelvic floor muscle (PFM) contractions daily and weekly follow-up/reminders by phone. The primary outcome was change in a total score of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI-SF). The secondary outcomes were perceived change of symptoms of SUI, change of PFM strength measured by vaginal manometry and symptoms of anal incontinence (AI) and pelvic organ prolapse (POP)., Results: 47 women, mean age of 33.5 years (SD: 8.1), participated. At 16 weeks, there was a mean difference between groups of -1.4 (95% CI: -2.6 to -0.2) in the change of the ICIQ-UI-SF score in favour of the PFMT group. The PFMT group completed a mean of 70% (SD: 23) of the prescribed protocol. 64% in the PFMT group versus 8% in the control group reported improved symptoms of SUI (p<0.001, relative risk: 7.96, 95% CI, 2.03 to 31.19). There were no group differences in the change of PFM strength or AI/POP symptoms., Conclusion: A 16-week home-training programme of the PFM led to improvements in SUI in female functional fitness exercisers. However, PFM strength and AI and POP symptoms did not improve significantly in the PFMT group compared with the control group., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: YT is an associate editor of British Journal of Sports Medicine and BBF is an IPHP editorial board of British Journal of Sports Medicine.

Female athletes have identified a lack of guidance as a barrier to successfully returning to running postpartum, and existing guidelines are vague. Our aim was to define the current practice of determining postpartum run-readiness through a consensus survey of international clinicians and exercise professionals in postpartum exercise to assist clinicians and inform sport policy changes.A three-round Delphi approach was used to gain international consensus from clinicians and exercise professionals on run-readiness postpartum. Professionals who work with postpartum runners participated in an online survey to answer open-ended questions about the following postpartum return-to-running topics: definitions (runner and postpartum), key biopsychosocial milestones that runners need to meet, recommended screening, timeline to initiate running, support items, education topics and factors that contribute to advising against running. Consensus was defined as ≥75% participant agreement.One hundred and eighteen professionals participated in round I, 107 participated in round II (response rate 90.6%) and 95 participated in round III (response rate 80.5%). Responses indicated that, following a minimum 3-week period of rest and recovery, an individualised timeline and gradual return to running progression can be considered. Screening for medical and psychological concerns, current physical capacity, and prior training history is recommended prior to a return to running.This study proposes recommendations for the initial guidance on return-to-running postpartum, framed in the context of current research and consensus from professionals. Future research is needed to strengthen and validate specific recommendations and develop guidelines for best practice when returning-to-running after childbirth., Competing Interests: Competing interests: ISM is an associate editor of BJSM., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Evidence on the increased risk of sports-related sudden cardiac arrest and death (SCA/D) and the potential benefit of cardiovascular preparticipation screening (PPS) in children is limited. We assessed the burden and circumstances of SCA/D and the diagnostic yield of cardiovascular PPS in children aged 8-15 years., Methods: Data on the incidence and causes of SCA/D from 2011 to 2020 were obtained from the Veneto region (Italy) sudden death registry, hospital records and local press. During the same period, we assessed the results of annual PPS in 25 251 young competitive athletes aged 8-15 years who underwent 58 185 evaluations (mean 2.3/athlete) in Padua, Italy., Results: Over 10 years, 26 SCA/D occurred in children aged 8-15 years in the Veneto region: 6 in athletes (incidence 0.7/100 000/year, all ≥12 years) versus 20 in non-athletes (0.7/100 000/year, 17/20 ≥12 years). In total, 4/6 athletes versus 1/20 non-athletes survived. The cause of SCA/D remained unexplained in four athletes and in nine non-athletes. No athlete suffered SCA/D from structural diseases potentially identifiable by PPS. The incidence of SCA/D in athletes and non-athletes was 0.2/100 000/year in the 8-11 years group versus 1.3/100 000/year in the 12-15 years group. PPS identified 26 new diagnoses of cardiovascular diseases (CVDs) at risk of SCA/D, more often in children ≥12 years old (0.06%/evaluation) than <12 years old (0.02%/evaluation, p=0.02). Among athletes with a negative PPS, two suffered unexplained SCA/D during follow-up, one during exercise., Conclusions: In children aged 8-15 years, the incidence of SCA/D and the yield of PPS for identifying at-risk CVD were both substantially higher in those ≥12 years, suggesting that systematic PPS may be more useful beyond this age., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To examine the joint associations between physical activity and abdominal obesity with the risk of cardiovascular disease (CVD) events., Methods: We included 70 830 UK Biobank participants (mean age±SD=61.6 ± 7.9 years; 56.4% women) with physical activity measured by wrist-worn accelerometers and without major chronic diseases. Participants were jointly categorised into six groups based on their physical activity level (tertiles of total volume and specific intensity levels) and presence or absence of abdominal obesity based on measured waist circumference. Associations with incident CVD (fatal and non-fatal events) were determined using proportional subdistribution hazard models with multivariable adjustment., Results: After excluding events during the first 2 years of follow-up, participants were followed for a median of 6.8 years, during which 2795 CVD events were recorded. Compared with the low abdominal adiposity and highest tertile of physical activity, abdominal obesity was associated with higher risk of incident CVD, especially in those with low levels of vigorous-intensity physical activity (HR 1.42, 95% CI 1.22 to 1.64). Approximately 500 min per week of moderate-to-vigorous intensity and approximately 30-35 min of vigorous-intensity physical activity offset the association of abdominal obesity and the risk of having a CVD event., Conclusion: Physical activity equivalent to approximately 30-35 min of vigorous intensity per week appears to offset the association between abdominal obesity and incident CVD. About 15 times more physical activity of at least moderate intensity is needed to achieve similar results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Associations between occupational physical activity (OPA) and mortality risks are inconclusive. We aimed to examine associations between (1) OPA separately and (2) jointly with leisure time physical activity (LTPA), and risk of all-cause, cardiovascular disease (CVD) and cancer mortality, over four decades with updated exposure and covariates every 6-8 years., Methods: Adults aged 20-65 years from the Tromsø Study surveys Tromsø3-Tromsø7 (1986-2016) were included. We categorised OPA as low (sedentary), moderate (walking work), high (walking+lifting work) or very high (heavy manual labour) and LTPA as inactive, moderate and vigorous. We used Cox/Fine and Gray regressions to examine associations, adjusted for age, body mass index, smoking, education, diet, alcohol and LTPA (aim 1 only)., Results: Of 29 605 participants with 44 140 total observations, 4131 (14.0%) died, 1057 (25.6%) from CVD and 1660 (40.4%) from cancer, during follow-up (median: 29.1 years, 25th-75th: 16.5.1-35.3). In men, compared with low OPA, high OPA was associated with lower all-cause (HR 0.83, 95% CI 0.74 to 0.92) and CVD (subdistributed HR (SHR) 0.68, 95% CI 0.54 to 0.84) but not cancer mortality (SHR 0.99, 95% CI 0.84 to 1.19), while no association was observed for moderate or very high OPA. In joint analyses using inactive LTPA and low OPA as reference, vigorous LTPA was associated with lower all-cause mortality combined with low (HR 0.75, 95% CI 0.64 to 0.89), high (HR 0.67, 95% CI 0.54 to 0.82) and very high OPA (HR 0.74, 95% CI 0.58 to 0.94), but not with moderate OPA. In women, there were no associations between OPA, or combined OPA and LTPA, with mortality., Conclusion: High OPA, but not moderate and very high OPA, was associated with lower all-cause and CVD mortality risk in men but not in women. Vigorous LTPA was associated with lower mortality risk in men with low, high and very high OPA, but not moderate OPA., Competing Interests: Competing interests: M-LL has received lecture fees from Bayer, Sanofi and BMS/Pfizer not related to this study. The remaining authors declare no conflict of interest., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe the patterns of health problems among Norwegian Olympic candidates during their preparations for five consecutive Olympic Games (London 2012, Sochi 2014, Rio de Janeiro 2016, PyeongChang 2018 and Tokyo 2020)., Methods: This was a descriptive epidemiological study using the Oslo Sports Trauma Research Center Questionnaire on Health Problems to collect data on all self-reported health problems from Norwegian Olympic candidate athletes for 12-18 months prior to each Olympic Games. Team physicians and physiotherapists followed up the athlete reports, providing clinical care and classifying reported problems according to the International Olympic Committee 2020 consensus statement on methods for recording and reporting of epidemiological data on injury and illness in sport., Results: Between 2011 and 2020, 533 athletes were included in the Norwegian Olympic team monitoring programme, with a 78% response to the weekly questionnaire. During this time, athletes reported 2922 health problems, including 1409 illnesses (48%), 886 overuse injuries (repetitive mechanism, 30%) and 627 acute injuries (traumatic mechanism, 21%). Diagnostic codes were recorded for 2829 (97%) of health problems. Athletes reported, on average, 5.9 new health problems per year (95% CI: 5.6 to 6.1), including 1.3 acute injuries (CI: 1.2 to 1.4), 1.7 overuse injuries (CI: 1.6 to 1.9) and 2.9 illnesses (CI: 2.7 to 3.0). Each year, female and male athletes lost an average of 40 and 26 days of training and competition due to health problems, respectively. The diagnoses with the highest health burden were anterior cruciate ligament rupture, respiratory infection, lumbar pain and patellar tendinopathy., Conclusion: The injury burden was particularly high among female athletes and in team sports, whereas endurance sports had the greatest burden of illness. Our data provide a compelling argument for prioritising medical care and investing in prevention programmes not just during the Olympic Games, but also the preparation period., Competing Interests: Competing interests: KS is the coeditor of the British Journal of Sports Medicine-Injury Prevention and Health Protection. In the period these data were collected, the Oslo Sports Trauma Research Center has had non-financial research partnerships with SpartaNova (2013–2016) and FitStats Technologies (2017–present)., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Objective: To analyse injuries and illnesses during the 2020 Tokyo Olympic Summer Games., Methods: This retrospective descriptive study included 11 420 athletes from 206 National Olympic Committees and 312 883 non-athletes. Incidences of injuries and illnesses during the competition period from 21 July to 8 August 2021 were analysed., Results: A total of 567 athletes (416 injuries, 51 non-heat-related illnesses and 100 heat-related illnesses) and 541 non-athletes (255 injuries, 161 non-heat-related illnesses and 125 heat-related illnesses) were treated at the competition venue clinic. Patient presentation and hospital transportation rates per 1000 athletes were 50 and 5.8, respectively. Marathons and race walking had the highest incidence of injury and illness overall (17.9%; n=66). The highest incidence of injury (per participant) was noted in boxing (13.8%; n=40), sport climbing (12.5%; n=5) and skateboarding (11.3%; n=9), excluding golf, with the highest incidence of minor injuries. Fewer infectious illnesses than previous Summer Olympics were reported among the participants. Of the 100 heat-related illnesses in athletes, 50 occurred in the marathon and race walking events. Only six individuals were transported to a hospital due to heat-related illness, and none required hospital admission., Conclusion: Injuries and heat-related illnesses were lower than expected at the 2020 Tokyo Olympic Summer Games. No catastrophic events occurred. Appropriate preparation including illness prevention protocols, and treatment and transport decisions at each venue by participating medical personnel may have contributed to these positive results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Several sports have published consensus statements on methods and reporting of epidemiological studies concerning injuries and illnesses with football (soccer) producing one of the first guidelines. This football-specific consensus statement was published in 2006 and required an update to align with scientific developments in the field. The International Olympic Committee (IOC) recently released a sports-generic consensus statement outlining methods for recording and reporting epidemiological data on injury and illness in sport and encouraged the development of sport-specific extensions.The Fédération Internationale de Football Association Medical Scientific Advisory Board established a panel of 16 football medicine and/or science experts, two players and one coach. With a foundation in the IOC consensus statement, the panel performed literature reviews on each included subtopic and performed two rounds of voting prior to and during a 2-day consensus meeting. The panel agreed on 40 of 75 pre-meeting and 21 of 44 meeting voting statements, respectively. The methodology and definitions presented in this comprehensive football-specific extension should ensure more consistent study designs, data collection procedures and use of nomenclature in future epidemiological studies of football injuries and illnesses regardless of setting. It should facilitate comparisons across studies and pooling of data., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The purpose of this study was to determine the injury and illness incidence from Team USA athletes from the 2022 Beijing Winter Olympic and Paralympic Games and assess any sex-based differences or differences between Olympic and Paralympic athletes., Methods: Team USA Olympic (n=231, 48.5% female) and Team USA Paralympic (n=63, 22.2% female) athletes had medical encounters documented during the Games. Injuries and illnesses were defined according to the 2020 International Olympic Committee Consensus Statement and reviewed for accuracy by a physician. Incidence rates were calculated per 1000 athlete-days and further analysed by sex, sport, anatomical location, type of illness, injury event and injury mechanism, with incident rate ratios (IRRs) used for group comparisons., Results: There were no differences in illness (Olympic illness, IRR=0.99 (95% CI 0.48 to 2.07), p=0.998; Paralympic illness, IRR=1.43 (95% CI 0.41 to 4.97), p=0.572) or injury rates (Olympic injury, IRR=0.63 (95% CI 0.39 to 1.03), p=0.062; Paralympic injury, IRR=1.01 (95% CI 0.43 to 2.35), p=0.988) between male and female (reference group) athletes. However, Olympic athletes had significantly lower illness (IRR=0.41 (95% CI 0.22 to 0.76), p=0.003) and injury (IRR=0.56 (95% CI 0.37 to 0.87), p=0.009) risks compared with Paralympic athletes., Conclusion: No significant sex-related differences in injury or illness were detected in Team USA Olympic or Paralympic participating in the 2022 Beijing Winter Games. However, Paralympic athletes exhibited higher rates of injury and illness compared with their Olympic counterparts. This study highlights delegation-specific epidemiological data which may facilitate more focused approaches for injury and illness prevention., Competing Interests: Competing interests: The authors declare there are no conflicts of interest. JTF reports receiving royalties from Demos Publishing and UpToDate. WMA reports receiving royalties from Springer Nature., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The objective of this study is to describe the incidence of injuries and illnesses sustained during the Beijing Winter Olympic Games from 4 February 2022 to 20 February 2022., 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 by the Beijing 2022 medical staff., Results: In total, 2848 athletes (1276 women, 45%; 1572 men, 55%) from 91 NOCs were followed prospectively for the occurrence of injury and illness. NOC and Beijing 2022 medical staff reported 289 injuries and 109 illnesses, equalling 10.1 injuries and 3.8 illnesses per 100 athletes over the 17-day period. The injury incidence was highest in ski halfpipe (30%), ski big air (28%), snowboard slopestyle (23%) and ski slopestyle (22%), and lowest (1%-2%) in curling, alpine mixed team parallel slalom, Nordic combined and alpine super-G. The illness incidence was highest in ski aerials (10%), skeleton (8%), cross-country skiing (8%) and Nordic combined (7%). In the study period, COVID-19 affected 32 athletes, accounting for 29% of all illnesses affecting 1.1% of all athletes., Conclusion: Overall, 10% of the athletes incurred an injury and 4% an illness during the Beijing Winter Olympic Games. The incidence of illnesses overall, which was the lowest yet recorded in the Winter Olympic Games, and COVID-19 was mitigated through comprehensive countermeasures., Competing Interests: Competing interests: TS works as scientific manager in the Medical & Scientific Department of the International Olympic Committee. Kathrin Steffen is coeditor of the British Journal of Sports Medicine—Injury Prevention and Health Protection. RB is director of the Medical and Scientific Department of the International Olympic Committee. LE is Head of Scientific Activities in the Medical and Scientific Department of the International Olympic Committee, and Editor of the British Journal of Sports Medicine and associate editor of Journal of Bone and Joint Surgery. BGT is an associate editor of the British Journal of Sports Medicine and was a member of the medical staff for the United States at Beijing 2022 Winter Olympic Games., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Vertical jump tests are more sensitive in revealing asymmetries in performance metrics at the time of return to sport after anterior cruciate ligament (ACL) reconstruction (ACLR) than horizontal hop tests. However, it remains unclear which vertical tests (bilateral or unilateral) and which metrics (kinetics or performance) are most effective in informing the rehabilitation status and readiness for return to sport. We aimed to investigate the status of athletes during vertical jump testing at return to sport after ACLR., Methods: A dual force platform system was used to evaluate jumping performance of 126 recreational and professional athletes at the time of return to sport after ACLR, as well as 532 healthy control participants. Performance and kinetic metrics were collected during four jump tests: double-leg countermovement jump, single-leg countermovement jump, double-leg 30 cm drop jump and single-leg 15 cm drop jump. Between-limb and between-group differences were explored using mixed models analyses., Results: At the time of return to sport after ACLR, athletes still presented significant differences favouring the uninvolved side, particularly in the symmetry of the concentric impulse (p<0.001) in all jumps compared with the control group. Peak landing force asymmetry was greater in the ACLR group than the controls during the countermovement (p<0.001, MD=-11.6; 95% CI -15.4 to -7.9) and the double-leg drop jump (p=0.023, MD=-8.9; 95% CI -14.9 to -2.8). The eccentric impulse asymmetry was significantly greater (p=0.018, MD=-3.8; 95% CI -5.8 to -1.7) in the ACLR group during the single-leg drop jump only. Jump height was significantly lower (p<0001) in the ACLR group compared with controls in all tests except the double-leg drop jump., Conclusion: At the time of return to sport after ACLR, despite passing the traditional discharge criteria, athletes remained asymmetrical during all vertical jump tests, in the concentric (push-off) phase, during landing from bilateral jumps and for most performance metrics. Clinicians should aim to restore not only symmetry in ground reaction forces but also absolute performance metrics such as jump height, reactive strength index and contact times, to potentially reduce injury risk and improve overall athletic performance., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Overall athlete health is a stated priority by the International Olympic Committee (IOC), yet it can be difficult for athletes to safely balance nutritional needs, training load, recovery, social interactions, expectations and other demands. The effect of energy intake and, especially, low energy availability (LEA) on athlete mental health, is understudied. In this narrative review, we examine research that has included psychological factors and mental health variables when investigating the effect of LEA, dieting/restrictive eating and Relative Energy Deficiency in Sport (REDs), since the 2018 IOC consensus statement on REDs. Based on currently available data, early psychological indicators associated with problematic LEA are mood changes, fatigue and psychological conflict. More severe mental health outcomes associated with REDs are reduced well-being, elevated anxiety, depressive symptoms and eating disorders. We propose a psychological model that helps structure how possible risk factors (eg, body dissatisfaction, environmental demands or increased training load) and moderating (eg, gender, sport) and/or potential mediating (eg, social climate, self-esteem) factors are associated with LEA and ultimately REDs. The current scientific literature underscores the importance of including mental health factors when screening for REDs and for developing a clinical approach to address the psychological sequelae of REDs once diagnosed. An interdisciplinary perspective is recommended. Lastly, and importantly, the athlete perspective urges clinicians to not underestimate the drive for success and denial of health consequences that athletes demonstrate when pursuing their sport goals., Competing Interests: Competing interests: MM is a deputy editor of the BJSM and a member of the BJSM IPHP Editorial Board., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests MM is a Deputy Editor of the BJSM and a member of the BJSM IPHP Editorial Board. KEA is a Deputy Editor of the BJSM and an Associate Editor of the BJSM IPHP. EV is an Associate Editor of the BJSM, an Associate Editor of the BJSM IPHP and Editor in Chief of BMJ Open Sports and Exercise Medicine. RB is the IOC Medical and Scientific Director. LE is the IOC Head of Science Activities and an Editor of BJSM IPHP. UE is an IOC member and the Chair of the IOC Medical and Scientific Commission.

Relative Energy Deficiency in Sport (REDs) is common among female and male athletes representing various sports at different performance levels, and the underlying cause is problematic low energy availability (LEA). It is essential to prevent problematic LEA to decrease the risk of serious health and performance consequences. This narrative review addresses REDs primary, secondary and tertiary prevention strategies and recommends best practice prevention guidelines targeting the athlete health and performance team, athlete entourage (eg, coaches, parents, managers) and sport organisations. Primary prevention of REDs seeks to minimise exposure to and reduce behaviours associated with problematic LEA. Some of the important strategies are educational initiatives and de-emphasising body weight and leanness, particularly in young and subelite athletes. Secondary prevention encourages the early identification and management of REDs signs or symptoms to facilitate early treatment to prevent development of more serious REDs outcomes. Recommended strategies for identifying athletes at risk are self-reported screening instruments, individual health interviews and/or objective assessment of REDs markers. Tertiary prevention (clinical treatment) seeks to limit short-term and long-term severe health consequences of REDs. The cornerstone of tertiary prevention is identifying the source of and treating problematic LEA. Best practice guidelines to prevent REDs and related consequences include a multipronged approach targeting the athlete health and performance team, the athlete entourage and sport organisations, who all need to ensure a supportive and safe sporting environment, have sufficient REDs knowledge and remain observant for the early signs and symptoms of REDs., Competing Interests: Competing interests: MLM is a deputy editor of the BJSM and a member of the BJSM IPHP editorial board. KEA is a deputy editor of the BJSM and an associate editor of the BJSM IPHP., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

The IOC made recommendations for recording and reporting epidemiological data on injuries and illness in sports in 2020, but with little, if any, focus on female athletes. Therefore, the aims of this supplement to the IOC consensus statement are to (i) propose a taxonomy for categorisation of female athlete health problems across the lifespan; (ii) make recommendations for data capture to inform consistent recording and reporting of symptoms, injuries, illnesses and other health outcomes in sports injury epidemiology and (iii) make recommendations for specifications when applying the Strengthening the Reporting of Observational Studies in Epidemiology-Sport Injury and Illness Surveillance (STROBE-SIIS) to female athlete health data.In May 2021, five researchers and clinicians with expertise in sports medicine, epidemiology and female athlete health convened to form a consensus working group, which identified key themes. Twenty additional experts were invited and an iterative process involving all authors was then used to extend the IOC consensus statement, to include issues which affect female athletes.Ten domains of female health for categorising health problems according to biological, life stage or environmental factors that affect females in sport were identified: menstrual and gynaecological health; preconception and assisted reproduction; pregnancy; postpartum; menopause; breast health; pelvic floor health; breast feeding, parenting and caregiving; mental health and sport environments.This paper extends the IOC consensus statement to include 10 domains of female health, which may affect female athletes across the lifespan, from adolescence through young adulthood, to mid-age and older age. Our recommendations for data capture relating to female athlete population characteristics, and injuries, illnesses and other health consequences, will improve the quality of epidemiological studies, to inform better injury and illness prevention strategies., Competing Interests: Competing interests: ISM and HPD are an Associate Editor of BJSM. JST and NSM are Editors of BJSM. KEA, PCZ and MM are Deputy Editors of BJSM. EV is the Editor in Chief of BMJ Open Sports and Exercise Medicine., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The Sport Mental Health Assessment Tool 1 (SMHAT-1) was introduced as a critical component to the athlete health evaluation. However, the effectiveness of the initial triage step questionnaire (Athlete Psychological Strain Questionnaire (APSQ)) has yet to be analysed within a National Olympic and Paralympic Committee delegation. This study evaluated the ability of the APSQ to identify athletes at risk for mental health concerns., Methods: Athletes completed the APSQ and all subsequent screening questionnaires of the SMHAT-1 as part of their Tokyo and Beijing Olympic and Paralympic Games health history screening. Each questionnaire was scored according to published guidelines, and the false-negative rate (FNR) for the APSQ identifying athletes that were positively screened on the subsequent questionnaires was computed., Results: 1066 athletes from 51 different Olympic and Paralympic and Summer and Winter sports completed the SMHAT-1. The FNRs for all athletes who were positively screened on a subsequent questionnaire with an APSQ score of <17 ranged from 4.8% to 66.7%. The global FNR for being positively screened on any questionnaire was 67.5%. Female, Paralympic and Winter athletes scored higher on one or more questionnaires compared with male, Olympic and Summer athletes, respectively (p<0.05)., Conclusion: Due to the high FNR of the APSQ detecting a potential mental health concern, we recommend athletes complete the APSQ and all subsequent questionnaires of the SMHAT-1 rather than using only the APSQ as an initial screening test., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To compare the performance of various diagnostic bronchoprovocation tests (BPT) in the assessment of lower airway dysfunction (LAD) in athletes and inform best clinical practice., Design: Systematic review with sensitivity and specificity meta-analyses., Data Sources: PubMed, EBSCOhost and Web of Science (1 January 1990-31 December 2021)., Eligibility Criteria: Original full-text studies, including athletes/physically active individuals (15-65 years) who underwent assessment for LAD by symptom-based questionnaires/history and/or direct and/or indirect BPTs., Results: In 26 studies containing data for quantitative meta-analyses on BPT diagnostic performance (n=2624 participants; 33% female); 22% had physician diagnosed asthma and 51% reported LAD symptoms. In athletes with symptoms of LAD, eucapnic voluntary hyperpnoea (EVH) and exercise challenge tests (ECTs) confirmed the diagnosis with a 46% sensitivity and 74% specificity, and 51% sensitivity and 84% specificity, respectively, while methacholine BPTs were 55% sensitive and 56% specific. If EVH was the reference standard, the presence of LAD symptoms was 78% sensitive and 45% specific for a positive EVH, while ECTs were 42% sensitive and 82% specific. If ECTs were the reference standard, the presence of LAD symptoms was 80% sensitive and 56% specific for a positive ECT, while EVH demonstrated 65% sensitivity and 65% specificity for a positive ECT., Conclusion: In the assessment of LAD in athletes, EVH and field-based ECTs offer similar and moderate diagnostic test performance. In contrast, methacholine BPTs have lower overall test performance., Prospero Registration Number: CRD42020170915., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The primary aim was to evaluate risk factors for surgical site infections after anterior cruciate ligament reconstruction (ACLR). The secondary aim was to investigate the surgical site infection incidence rate and the mean time to postoperative surgical site infection symptoms., Design: Systematic review and meta-analysis., Data Sources: PubMed, Embase and Web of Science were searched from database inception to September 2021 and updated in April 2022., Eligibility Criteria: Quantitative, original studies reporting potential risk factors for surgical site infections after ACLR were included., Results: Twenty-three studies with 3871 infection events from 469 441 ACLRs met the inclusion criteria. Male sex (OR 1.78, p< 0.00001), obesity (OR 1.82, p=0.0005), tobacco use (OR 1.37, p=0.01), diabetes mellitus (OR 3.40, p=0.002), steroid use history (OR 4.80, p<0.00001), previous knee surgery history (OR 3.63, p=0.02), professional athlete (OR 4.56, p=0.02), revision surgery (OR 2.05, p=0.04), hamstring autografts (OR 2.83, p<0.00001), concomitant lateral extra-articular tenodesis (OR 3.92, p=0.0001) and a long operating time (weighted mean difference 8.12, p=0.005) were identified as factors that increased the risk of surgical site infections (superficial and deep) after ACLR. Age, outpatient or inpatient surgery, bone-patellar tendon-bone autografts or allografts and a concomitant meniscus suture did not increase the risk of surgical site infections. The incidence of surgical site infections after ACLR was approximately 1% (95% CI 0.7% to 1.2%). The mean time from surgery to the onset of surgical site infection symptoms was approximately 17.1 days (95% CI 13.2 to 21.0 days)., Conclusion: Male sex, obesity, tobacco use, diabetes mellitus, steroid use history, previous knee surgery history, professional athletes, revision surgery, hamstring autografts, concomitant lateral extra-articular tenodesis and a long operation time may increase the risk of surgical site infections after ACLR. Although the risk of surgical site infections after ACLR is low, raising awareness and implementing effective preventions for risk factors are priorities for clinicians to reduce the incidence of surgical site infections due to its seriousness., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe the incidence of injuries and illnesses sustained during the Tokyo Summer Olympic Games from 23 July to 8 August 2021., 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 by the Tokyo 2020 medical staff., Results: In total, 11 315 athletes (5423 women, 48%; 5892 men, 52%) from 206 NOCs were followed up prospectively for the occurrence of injury and illness. NOC and Tokyo 2020 medical staff reported 1035 injuries and 438 illnesses, equalling 9.1 injuries and 3.9 illnesses per 100 athletes over the 17-day period. Altogether, 9% of the athletes incurred at least one injury and 4% at least one illness. The incidence of injury was highest in boxing (27%), BMX racing (27%), BMX freestyle (22%), skateboarding (21%), karate (19%) and handball (18%), of which both BMX freestyle and skateboarding were new events, and lowest in diving, road cycling, rowing, marathon swimming and shooting (1-2%). Marathon and artistic swimming presented the highest illness incidences (both 8%), followed by skateboarding and karate (both 7%). In the study period, COVID-19 affected 18 athletes, accounting for 4% of all illnesses and 0.16% of all athletes. Exertional heat illness affected 78 athletes (18% of all illnesses, 0.7% of all athletes), the majority (88%) resulting in no time lost from sport., Conclusion: Overall, 9% of the athletes incurred an injury and 4% an illness during the Games. Comprehensive countermeasures helped mitigate both COVID-19 and exertional heat illnesses., Competing Interests: Competing interests: TSo works as scientific manager in the Medical and Scientific Department of the International Olympic Committee. KS is co-editor of the British Journal of Sports Medicine – Injury Prevention & Health Protection. MM is deputy editor of the British Journal of Sports Medicine. RB is director of the Medical and Scientific Department of the International Olympic Committee. LE is head of scientific activities in the Medical and Scientific Department of the International Olympic Committee, and editor of the British Journal of Sports Medicine and associate editor of the Journal of Bone and Joint Surgery., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: At present, there is no cure for osteoarthritis (OA), but severe hip joint degeneration can require total hip arthroplasty (THA). The literature on OA after elite sport is limited. We hypothesise that elite athletic activity increases the risk of receiving a THA later in life., Methods: We linked a cohort of former Norwegian world-class athletes (1402 females and 1902 males, active 1936-2006) to the Norwegian Arthroplasty Register (THA performed 1987-2020). We used standardised incidence ratio (SIR), one-minus Kaplan-Meier and relative Cox regression (relative HR, RHR), with 95% CIs, and funnel plots at age 75, to assess THA risk for different sport disciplines, joint impact categories of sport disciplines and sex. The risk of THA for the corresponding general Norwegian population was used as reference., Results: We found an overall increased risk for THA for the former elite athletes (SIR 2.11, 95% CI 1.82 to 2.40) at age 75 years, compared with the general population. THA risk at age 75 years was 11.6% for female athletes and 8.3% for male athletes. SIR was 1.90 (95% CI 1.49 to 2.31) for female and 2.28 (95% CI 1.87 to 2.70) for male athletes. Among males, high joint impact sport disciplines were associated with increased risk compared with low-impact sport disciplines (RHR 1.81, 95% CI 1.06 to 3.08, p=0.029)., Conclusion: Having been an elite athlete was associated with a doubling of THA risk compared with the general population for both sexes. High joint impact sport disciplines were associated with subsequent THA for male athletes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)