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Purpose To describe the perceived importance of suggested hamstring injury risk factors according to chief medical officers (CMOs) of European women’s professional football clubs. A secondary objective was to compare if these perceptions differed between teams with a lower-than-average and higher-than-average hamstring injury burden. Methods The CMOs of eleven European professional women’s football clubs were initially asked to suggest modifiable risk factors for hamstring injury. These risk factors were rated in according with their perceived importance on a 5-graded Likert scale. Participating teams were divided in two groups depending on their hamstring injury burden during the 2020/21 season. The LOW group consisted of six teams that had a lower-than-average hamstring injury burden. The HIGH group consisted of five teams that had a higher-than-average hamstring injury burden. Results Twenty-one risk factors were suggested, most of which were extrinsic in nature, hence associated with the coaching staff, the team or the club organization rather than with the players themselves. The risk factors with the highest average importance were: “lack of communication between medical staff and coaching staff” and “load on players” (each with a weighted average of 3.9), followed by “lack of regular exposure to high-speed football actions during training” and “playing matches 2–3 times a week” (weighted average of 3.8 and 3.7). Differently from the LOW group, the HIGH group perceived the coaching factors (style of coach leadership, training/exercise surveillance by coaching staff) as more important. Conclusion In accordance to the eleven CMOs recruited in this study, most risk factors for hamstring injuries are extrinsic in nature and associated with the club, the team, and the coaching staff, and not the players themselves. Level of evidence Level III.

ObjectivesLittle is known about figure skaters’ mental health. This study aimed to describe anxiety and depression caseness (defined as a screening condition qualifying for psychiatric examination) in competitive figure skaters and analyse factors associated with such caseness.MethodsA cross-sectional study was performed in April 2019 among all competitive figure skaters in the south-eastern region of Sweden (N=400). The primary outcomes were anxiety caseness, measured using the short-form Spielberger State-Trait Anxiety Inventory and depression caseness, measured using the WHO-5 index. Multivariable logistic regression models were employed to determine the association between anxiety caseness and explanatory factors.ResultsIn total, 36% (n=142) of the invited skaters participated. Only females (n=137), mean age 12.9 (SD 3.0) years) were selected for analysis. Of the participating skaters, 47% displayed anxiety caseness and 10% depression caseness. Overweight body image perception (OR 5.9; 95% CI 2.0 to 17.6; p=0.001) and older age (OR 1.2; 95% CI 1.1 to 1.4; p=0.005) were associated with anxiety caseness. Skaters reporting no caseness were younger than those reporting only anxiety caseness (mean age difference −1.9 years; 95% CI −3.1 to −0.7; p=0.001) or anxiety and depression caseness (OR −3.5 years; 95% CI −5.6 to −1.5 years; pConclusionAnxiety caseness was associated with overweight body image perception and older age in female competitive figure skaters. Older skaters reported generally worse mental health. More research on the mental health of figure skaters is warranted, considering comorbidity and focusing on those needing further assessment and support.

ObjectiveAlthough injury burden prompts elite athletics (track and field) athletes to engage in injury management, little is known about their health literacy. We investigated musculoskeletal (MS) health literacy in world-leading athletics athletes and associations with prechampionship injury acknowledgement by reduction of training load in different socioeconomic environments.MethodsAdult and youth athletics athletes (n=1785) preparing for World Championships were invited to complete the Literacy in Musculoskeletal Problems instrument and report acknowledgement of injury by reduction in training load during prechampionship tapering. Their socioeconomic standing was estimated through the Human Development Index of their home country. Demographic differences were examined using χ2tests and determinants of injury acknowledgement assessed using logistic regression.ResultsComplete data were obtained from 780 athletes (43.7%) with 26% demonstrating sufficient MS health literacy, higher in adult (41%) than youth (13%) athletes (pConclusionsThe prevalence of sufficient MS health literacy in world-leading athletics athletes is low. Associations between MS health literacy and injury acknowledgement in these athletes vary with the resourcefulness of the socioeconomic environment, implying that health literacy and resources for medical and performance support should be ascertained concurrently.

To investigate health-related factors associated with self-rated race performance outcomes among recreational long-distance runners.Panel study.Data were collected from runners one month before and after a community-level race event including distances from 8 to 42.2 km. The primary outcome measure was self-rated race performance outcome. The explanatory variables represented health complaints suffered during the build-up year, the pre-race month, and the race and among full marathon runners predicted objective performance outcome (mean pace equal to training pace or faster). Multiple logistic regression was used to determine factors associated with the self-rated performance outcome.Two-hundred forty-five runners (29%) provided complete data sets. Seventy-four percent of the runners reached their desired race performance outcome. Achievement of the performance outcome was more likely when having avoided illness during the build-up and pre-race periods (OR = 3.8; 95% CI:1.8-8.0, p 0.001), having avoided per-race injury (OR=3.0; 95% CI:1.2-7.4, p = 0.02) and avoided per-race illness (OR = 4.1; 95% CI:1.3-15, p = 0.020). Having obtained the self-rated performance outcome was also associated with running a shorter distance (OR=3.6; 95% CI: 1.7-8.0, p = 0.001) and being younger than 50 years of age (OR = 2.4; 95% CI:1.1-5.3-8.3, p = 0.03). Having met the predicted objective performance outcome predisposed marathon runners to also obtain the self-rated performance outcome (OR = 4.7, 95% CI: 1.5-16, p 0.01).Having avoided illness during build-up and pre-race was positively associated with self-rated race performance outcome among recreational runners. Adjusting the desired performance outcomes with regard to recent illness and age may help recreational runners to more often achieve their goals and thereby prevent them from leaving the sport.

Background: In the treatment of anterior cruciate ligament (ACL) injuries, there is little evidence of when and why a decision for ACL reconstruction (ACLR) or nonoperative treatment (non-ACLR) is made. Purpose: To (1) describe the key characteristics of ACL injury treatment decisions and (2) compare patient-reported knee instability, function, and preinjury activity level between patients with non-ACLR and ACLR treatment decisions. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 216 patients with acute ACL injury were evaluated during the first year after injury. The treatment decision was non-ACLR in 73 patients and ACLR in 143. Reasons guiding treatment decision were obtained from medical charts and questionnaires to patients and orthopaedic surgeons. Patient-reported instability and function were obtained via questionnaires and compared between patients with non-ACLR and ACLR treatment decisions. The ACLR treatment group was classified retrospectively by decision phase: acute phase (decision made between injury day and 31 days after injury), subacute phase (decision made between 32 days and up to 5 months after injury), and late phase (decision made 5-12 months after injury). Data were evaluated using descriptive statistics, and group comparisons were made using parametric or nonparametric tests as appropriate. Results: The main reasons for a non-ACLR treatment decision were no knee instability and no problems with knee function. The main reasons for an ACLR treatment decision were high activity demands and knee instability. Patients in the non-ACLR group were significantly older (P = .031) and had a lower preinjury activity level than did those in the acute-phase (P < .01) and subacute-phase (P = .006) ACLR decision groups. There were no differences in patient-reported instability and function between treatment decision groups at baseline, 4 weeks after injury, or 3 months after injury. Conclusion: Activity demands, not patient-reported knee instability, may be the most important factor in the decision-making process for treatment after ACL injury. We suggest a decision-making algorithm for patients with ACL injuries and no high activity demands; waiting for >3 months can help distinguish those who need surgical intervention from those who can undergo nonoperative management. Registration: NCT02931084 (ClinicalTrials.gov identifier).

Background: Knowledge to inform the identification of individuals with a poor long-term prognosis after anterior cruciate ligament (ACL) injury is limited. Identifying prognostic factors for long-term outcomes after ACL injury may inform targeted interventions to improve outcomes for those with a poor long-term prognosis. Purpose: To determine whether ACL treatment (early augmented or nonaugmented ACL repair plus rehabilitation, rehabilitation alone, or rehabilitation plus delayed ACL reconstruction [ACLR]) and 4-year measures (quadriceps and hamstrings strength, single-leg hop, knee laxity, flexion and extension deficit, self-reported knee function, activity level) are prognostic factors for patient-reported outcomes at 32 to 37 years after acute ACL injury. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 251 patients aged 15 to 40 years with acute ACL rupture between 1980 and 1985 were allocated to early ACL repair (augmented or nonaugmented) plus rehabilitation or to rehabilitation alone, based on birth year. One hundred ninety of 234 completed 32- to 37-year follow-up questionnaires (response rate, 81%); 18 people were excluded, resulting in 172 patients available for analysis (mean age, 59 ± 6 years; 28% female). Potential prognostic factors assessed 4 years after ACL injury were ACL treatment (early ACL repair, rehabilitation alone, or delayed ACLR), isokinetic quadriceps and hamstrings strength, single-leg hop performance, knee flexion and extension deficit, knee laxity, Tegner activity scale, and Lysholm score. Outcomes included Knee injury and Osteoarthritis Outcome Score (KOOS) subscales and the Anterior Cruciate Ligament Quality of Life (ACL-QOL) measure. Linear regression adjusted for age, sex, baseline meniscal injury, and contralateral ACL injury was used to assess potential prognostic factors for 32- to 37-year outcomes. Multiple imputation accounted for missing data. Results: A fair/poor Lysholm score (vs excellent/good) at 4 years was a prognostic factor for worse KOOS Pain (adjusted regression coefficient, −12 [95% confidence interval (CI), −19 to −4]), KOOS Symptoms (−15 [95% CI, −23 to −7]), KOOS Sport and Recreation (−19 [95% CI, −31 to −8]), and ACL QOL (−9 [95% CI, −18 to −1]) scores. A 4-year single-leg hop limb symmetry index

Objectives: The primary aim was to assess impact of early knee status on self-reported knee function at 3 and 12 months and on quadriceps strength at 12 months after non-surgically treated ACL injury. The secondary aim was to describe the recovery of muscle strength during the first year after the injury. Design: Prospective cohort study. Participants: 70 patients (42 males; mean age 27 +/- 7 years) with acute ACL injury. Main outcome: Knee symptoms, knee function and sporting activities were assessed with the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF). Muscle strength was assessed with an isokinetic dynamometer. Clinical assessment performed at baseline was used to evaluate early knee status. Results: Global knee function, knee joint stability during ADL, gait pattern and one-legged squat assessed in mean 2 weeks after injury hadimpact on self-reported knee function at 3 and 12 months (r(2) 0.105-0.267). Mean limb symmetry index (LSI) of muscle strength and jump performance were 91-98% at 12 months. Conclusion: Early knee symptoms affect self-reported knee function at 3 and 12 months, while other factors are important for gaining muscle strength. Muscle strength recovered during the first year after ACL injury and reached mean LSI above 90%. (C) 2021 The Authors. Published by Elsevier Ltd. Funding Agencies|Swedish Research CouncilSwedish Research CouncilEuropean Commission [VR 2015-03687, VR 2018-02563]; Swedish Research Council for Sport Science [CIF P2017-0151, P2018-0132, P2019-0071]; Medical Research Council of Southeast SwedenUK Research & Innovation (UKRI)Medical Research Council UK (MRC) [FORSS 662081]; ALF Grants Region Ostergotland [LIO-798907, 900721, 934538]

Objective: Explore prognostic factors for tibiofemoral (TFJ) and patellofemoral (PFJ) radiographic osteoarthritis (ROA) and symptoms plus ROA (SOA), 32-37 years following anterior cruciate ligament (ACL) injury. Design: Exploratory analysis, longitudinal cohort. Methods: In 1980-1985, 251 patients aged 15-40 years with acute ACL rupture were allocated to early augmented or non-augmented repair (5 +/- 4 days post-injury) plus rehabilitation, or rehabilitation alone. 127 of 190 participants who completed follow-up questionnaires were eligible. We classified ROA as TFJ/ PFJ K&L Grade >2, and SOA as ROA plus pain and/or symptoms. Multivariable age-adjusted logistic regression investigated potential prognostic factors (assessed at 4 +/- 1 year follow-up: ACL treatment, isokinetic quadriceps/hamstrings strength, single-leg-hop for distance, knee flexion/extension deficit, knee laxity, Tegner Activity Scale, Lysholm Scale; sex, baseline meniscus status). Results: 127 patients were aged 58 +/- 6 years; BMI 27 +/- 4 kg/m2; 28% female; 59% had TFJ-ROA, 48% had TFJ-SOA (including n = 9 knee-arthroplasties), 36% had PFJ-ROA; 27% had PFJ-SOA. Baseline meniscus surgery was a prognostic factor for TFJ-ROA (multivariable age-adjusted odds ratio (95% CI): 3.0 (1.2, 7.8)). A single-leg-hop limb symmetry index (LSI) < 90% was a prognostic factor for PFJ-ROA (5.1 (1.4, 18.7)) and PFJ-SOA (4.9 (1.2, 19.7)). Hamstrings strength LSI Funding Agencies|Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis; United Kingdom [21595]; National Health and Medical Research Council (NHMRC) Emerging Leadership FellowshipNational Health and Medical Research Council of Australia; Linkoping University, Sweden

Background:The long-term prevalence of knee osteoarthritis (OA) after anterior cruciate ligament (ACL) injury is unknown, especially in patients without a history of ACL surgery.Purpose:To (1) describe the prevalence of radiographic OA, symptomatic OA, and knee replacement surgery 32 to 37 years after acute ACL injury and to (2) compare the prevalence of radiographic OA, symptomatic OA, and knee symptoms between patients allocated to early ACL surgery or no ACL surgery and patients who crossed over to ACL surgery.Study Design:Cohort study; Level of evidence, 2.Methods:Participants aged 15 to 40 years at the time of ACL injury were allocated to surgical (augmented or nonaugmented ACL repair) or nonsurgical ACL treatment within 14 days of injury. At 32 to 37 years after the initial injury, 153 participants were followed up with plain weightbearing radiographs and completed 4 subscales from the Knee injury and Osteoarthritis Outcome Score (KOOS). Radiographic OA was defined as Kellgren and Lawrence grade 2 or higher. Symptomatic OA was defined as radiographic OA plus knee symptoms measured with the KOOS.Results:Participants allocated to ACL surgery (n = 64) underwent surgery at a mean ± SD of 5 ± 4 days (range, 0-11 days) after injury. Of the 89 participants allocated to no ACL surgery, 53 remained nonsurgically treated, 27 had ACL surgery within 2 years, and 9 had ACL surgery between 3 and 21 years after injury. In the total sample, 95 participants (62%) had radiographic tibiofemoral OA, including 11 (7%) who had knee replacement. The prevalence of radiographic tibiofemoral OA was lower in the group allocated to ACL surgery compared with the group who never had ACL surgery (50% vs 75%; P = .005). The prevalence of symptomatic OA (50% in the total sample) and patellofemoral radiographic OA (35% in the total sample) was similar between groups.Conclusion:Patients allocated to early ACL surgery, performed a mean 5 days after injury, had a lower prevalence of tibiofemoral radiographic OA at 32 to 37 years after injury compared with patients who never had ACL surgery. The prevalences of symptomatic OA, radiographic patellofemoral OA, and knee symptoms were similar irrespective of ACL treatment. Overall, the prevalence of OA after ACL injury was high.Registration:NCT03182647 (ClinicalTrials.gov identifier)

Little is known about provision of medical services to adolescents prior to participating in international top-level sports. This study aimed to investigate experiences of medical service provision among high-level adolescent athletics (track and field) athletes from three continents. A thematic narrative analysis was applied to data collected from 14 athletes by semi-structured interviews. Although competing at the highest international level, these adolescent athletes had difficulties making sense of symptoms of ill health, especially on their own. With increasing exercise loads, the athletes medical support needs had extended beyond the capacity of parents and local communities. As there was no organized transfer of the responsibility for medical support to sports organizations, the athletes often had to manage their health problems by themselves. There were major variations among the adolescent athletes with regards to medical service access and quality. The services used ranged from sophisticated computer-assisted biomechanical analyses to traditional healers. Decreased exercise load was the common sports injury treatment. The results of this study demonstrate how the ethical standards underpinning youth sports as well as the equal provision of medical services to adolescents are challenged across the world. Further research on health service provision to adolescent top-level athletes is warranted. Funding Agencies|Swedish Centre for Sports Research (CIF) [P2020-0137]

Background Athletes competing in athletics (track and field) at international level may be participating with underlying undiagnosed life-threatening cardiovascular conditions. Our objective was to analyse variations in pre-participation cardiac evaluation prevalence among athletes participating in two International Association of Athletics Federations (IAAF) World Athletics Championships, with regard to the human developmental level and global region of their home countries, as well as athletes' age category, gender, event group and medical insurance type. Design Cross-sectional web-based survey. Methods A total of 1785 athletes competing in the IAAF World Under 18 Championships Nairobi 2017 and World Championships London 2017 were invited to complete a pre-participation health questionnaire investigating the experience of a pre-participation cardiac examination. Results A total of 704 (39%) of the athletes participated. Among these, 59% (60% of women; 58% of men) reported that they had been provided at least one type of pre-participation cardiac evaluation. Athletes from very high income countries, Europe and Asia, showed a higher prevalence of at least one pre-participation cardiac evaluation. Conclusions The prevalence of pre-participation cardiac evaluation in low to middle income countries, and the African continent in particular, needs urgent attention. Furthermore, increases in evaluation prevalence should be accompanied by the development of cost-effective methods that can be adopted in all global regions.

Background:Many patients with anterior cruciate ligament (ACL) reconstruction who return to sport suffer new ACL injuries or quit sports soon after returning.Purpose:To prospectively follow a cohort of female soccer players with primary unilateral ACL reconstruction and matched knee-healthy controls from the same soccer teams to compare (1) the rate of new traumatic and nontraumatic knee injuries and other injuries, (2) the proportion of players who quit soccer, and (3) player-reported activity level and satisfaction with activity level and knee function.Study Design:Cohort study; Level of evidence, 2.Methods:A total of 117 active female soccer players (mean ± SD age, 19.9 ± 2.5 years) 18.9 ± 8.7 months after ACL reconstruction and 119 knee-healthy female soccer players (19.5 ± 2.5 years) matched from the same teams were prospectively followed for 2 years for new knee injuries, other injuries, soccer playing level, activity level according to the Tegner Activity Scale, and satisfaction with activity level and knee function.Results:Players with ACL reconstruction had a higher rate of new ACL injuries (n = 29 vs 8; 19 vs 4 per 100 player years; rate ratio [RR], 4.82; 95% CI, 2.20-10.54; P < .001), other traumatic knee injuries (29 vs 16 per 100 player years; RR, 1.84; 95% CI, 1.16-2.93; P < .01), and nontraumatic knee injuries (33 vs 9 per 100 player years; RR, 3.62; 95% CI, 2.11-6.21; P < .001) as compared with controls. There was no difference in the rate of other (not knee) injuries (43 vs 48 per 100 player years; RR, 0.90; 95% CI, 0.65-1.23; P = .494). During the 2-year follow-up, 72 (62%) players with ACL reconstruction quit soccer, as opposed to 43 (36%) controls ( P = .001). The median Tegner Activity Scale score decreased in both groups ( P < .001) but more for the ACL-reconstructed group ( P < .015).Conclusion:Female soccer players with ACL reconstruction had nearly a 5-fold-higher rate of new ACL injuries and a 2- to 4-fold-higher rate of other new knee injuries, quit soccer to a higher degree, and reduced their activity level to a greater extent as compared with knee-healthy controls.

To present a semi-automatic method with minimal user interaction for quantitative analysis of the patellofemoral motion pattern. 4D CT data capturing the patellofemoral motion pattern of a continuous flexion and extension were collected for five patients prone to patellar luxation both pre- and post-surgically. For the proposed method, an observer would place landmarks in a single 3D volume, which then are automatically propagated to the other volumes in a time sequence. From the landmarks in each volume, the measures patellar displacement, patellar tilt and angle between femur and tibia were computed. Evaluation of the observer variability showed the proposed semi-automatic method to be favorable over a fully manual counterpart, with an observer variability of approximately 1.5 $$^{\circ }$$ for the angle between femur and tibia, 1.5 mm for the patellar displacement, and 4.0 $$^{\circ }$$ –5.0 $$^{\circ }$$ for the patellar tilt. The proposed method showed that surgery reduced the patellar displacement and tilt at maximum extension with approximately 10–15 mm and 15 $$^{\circ }$$ –20 $$^{\circ }$$ for three patients but with less evident differences for two of the patients. A semi-automatic method suitable for quantification of the patellofemoral motion pattern as captured by 4D CT data has been presented. Its observer variability is on par with that of other methods but with the distinct advantage to support continuous motions during the image acquisition.

Background Due to the dominance of overuse injuries among runners, knowledge of how use of non-steroidal anti-inflammatory drugs (NSAIDs) and behavioral factors contribute to injury events is important. The aim of this study was to explore recreational marathon runners' strategies for coping with injury and illness, including use of drugs for control of pain and inflammation, and to investigate whether these strategies were associated with the 1-year prevalence of time-loss injury and illness. Methods An online questionnaire was used for data collection in this cross-sectional study. The population consisted of runners who had registered for a marathon (N.=341). Strategies used to understand and manage perceptions of injury and illness were measured with the Brief COPE instrument and the use of NSAIDs was investigated. Results Complete survey data were provided by 161 runners (47%). 42% reported NSAID use. A notable injury in the past year was reported by 43%, and 19% reported having had a time-loss illness episode. Runners who reported NSAID use in the past year reported significantly fewer time-loss injuries (P=0.003). Time loss due to illness only showed a negative correlation with using emotional support for coping (P=0.010) and a positive correlation with self-blame (P=0.039). Conclusions Runners stating NSAID use reported fewer time-loss running injuries than non-NSAID users. Time loss due to illness showed different correlates with NSAID use and coping strategies than time loss due to injury, i.e. no association with drug use, less use of emotional support for coping and more use of self-blame.

BACKGROUND International middle- and long-distance running competitions attract millions of spectators in association with city races, world championships, and Olympic Games. It is therefore a major concern that ill health and pain as a result of sports overuse lead to numerous hours of lost training and decreased performance among competitive runners. Despite its potential for sustenance of performance, approval of mHealth self-report monitoring (mHSM) in this group of athletes has not been investigated. OBJECTIVE To explore individual and situational factors associated with acceptance of long-term mHSM among competitive runners. METHODS The study used qualitative research methods with the Technology Acceptance Model as the theoretical foundation. The study population included 20 middle- and long-distance runners competing at national and international levels. Two mHSM applications asking for health and training data from track and marathon runners were created on a platform for web survey development (Briteback ABTM). Data collection for the technology acceptance analysis was performed by personal interviews before and after a 6-week monitoring period. Pre-use interviews investigated experience and knowledge of mHealth monitoring and thoughts on benefits and possible side effects. The post-use interviews addressed usability and usefulness, attitudes toward non-functional issues, and intentions to adhere to long-term monitoring. In addition, the runners’ trustworthiness when providing mHSM data was discussed. The interview data were investigated using a deductive thematic analysis. RESULTS The mHSM applications were considered technically easy to use. Although the runners read the instructions and entered data effortlessly, some still perceived mHSM as problematic. Concerns were raised about the selection of items for monitoring (eg, recording training load as running distance or time) and with interpretation of concepts (eg, whether subjective well-being should encompass only the running context or daily living on the whole). Usefulness of specific mHSM applications was consequently not appraised on the same bases in different sub-categories of runners. Regarding non-functional issues, the runners competing at international level requested detailed control over who in their sports club and national federation should be allowed access to their data; the less competitive runners had no such issues. Notwithstanding, the runners were willing to adhere to long-term mHSM provided the technology was adjusted to their personal routines and the output was perceived as contributing to running performance. CONCLUSIONS Achieving sustainable adherence to long-term mHSM among competitive runners requires clear definitions of monitoring purpose and population, repeated in-practice tests of monitoring items and terminology, and meticulousness regarding data-sharing routines. Further naturalistic studies of mHSM use in routine sports practice settings are needed, with non-functional ethical and legal issues included in the evaluation designs. Keywords: Long-distance running, mobile health technologies, self-reported health, web-based monitoring, evaluation, qualitative methods, thematic analysis.

Background International middle- and long-distance running competitions attract millions of spectators in association with city races, world championships, and Olympic Games. It is therefore a major concern that ill health and pain, as a result of sports overuse, lead to numerous hours of lost training and decreased performance in competitive runners. Despite its potential for sustenance of performance, approval of mHealth self-report monitoring (mHSM) in this group of athletes has not been investigated. Objective The objective of our study was to explore individual and situational factors associated with the acceptance of long-term mHSM in competitive runners. Methods The study used qualitative research methods with the Technology Acceptance Model as the theoretical foundation. The study population included 20 middle- and long-distance runners competing at national and international levels. Two mHSM apps asking for health and training data from track and marathon runners were created on a platform for web survey development (Briteback AB). Data collection for the technology acceptance analysis was performed via personal interviews before and after a 6-week monitoring period. Preuse interviews investigated experience and knowledge of mHealth monitoring and thoughts on benefits and possible side effects. The postuse interviews addressed usability and usefulness, attitudes toward nonfunctional issues, and intentions to adhere to long-term monitoring. In addition, the runners’ trustworthiness when providing mHSM data was discussed. The interview data were investigated using a deductive thematic analysis. Results The mHSM apps were considered technically easy to use. Although the runners read the instructions and entered data effortlessly, some still perceived mHSM as problematic. Concerns were raised about the selection of items for monitoring (eg, recording training load as running distance or time) and about interpretation of concepts (eg, whether subjective well-being should encompass only the running context or daily living on the whole). Usefulness of specific mHSM apps was consequently not appraised on the same bases in different subcategories of runners. Regarding nonfunctional issues, the runners competing at the international level requested detailed control over who in their sports club and national federation should be allowed access to their data; the less competitive runners had no such issues. Notwithstanding, the runners were willing to adhere to long-term mHSM, provided the technology was adjusted to their personal routines and the output was perceived as contributing to running performance. Conclusions Adoption of mHSM by competitive runners requires clear definitions of monitoring purpose and populations, repeated in practice tests of monitoring items and terminology, and meticulousness regarding data-sharing routines. Further naturalistic studies of mHSM use in routine sports practice settings are needed with nonfunctional ethical and legal issues included in the evaluation designs.

Purpose The purpose of the study was to (1) study and compare the factors that Swedish orthopaedic surgeons and physical therapists consider important for recommending ACL reconstruction and, (2) to assess how orthopaedic surgeons and physical therapists consider their own and each others, as well as patients’, roles are in the treatment decision. Methods A web-based survey assessing the relevance of 21 predetermined factors, in the choice to recommend ACL reconstruction, was sent to orthopaedic surgeons and physical therapists. Respondents were also asked to rate the importance of the assessment made by themselves, the other clinician (physical therapists rated the importance of surgeons, surgeons rated the importance of physical therapists), and the patients’ preferences. Result Orthopaedic surgeons agreed of eight, and physical therapists of seven factors as important in the choice to recommend ACL reconstruction. The factors both groups reported as important were; “patient’s wishes to return to contact/pivoting sports”, “instability in physical activity”, “instability in activities of daily living despite adequate rehabilitation”, “physically demanding occupation”, and “young age”. Both professions rated their own and each others assessments as well as patient’s wishes as important for the decision to recommend ACL reconstruction. Conclusion Orthopaedic surgeons and physical therapists agree about factors that are important for their decision to recommend ACL reconstruction, showing that both professions share a common ground in perceptions of factors that are important in recommending ACL reconstruction. Level of evidence Diagnostic study: Level III. Electronic supplementary material The online version of this article (10.1007/s00167-018-4846-1) contains supplementary material, which is available to authorized users.

Background: The optimal treatment for middle-aged patients with knee pain and meniscal lesions has been extensively debated. Most previous studies have revealed only short-term beneficial results of knee arthroscopic surgery. The authors have previously shown a positive benefit of knee arthroscopic surgery and an exercise program after 1 year when compared with an exercise program alone. Purpose: To evaluate if knee arthroscopic surgery combined with an exercise program provided an additional long-term benefit after 3 years compared with an exercise program alone in middle-aged patients with meniscal symptoms. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Of 179 eligible patients, aged 45 to 64 years, 150 were randomized to (1) a 3-month exercise program (nonsurgery group) or (2) the same as group 1 plus knee arthroscopic surgery within 4 weeks (surgery group). The primary outcome was the change in the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscore of pain between baseline and the 3-year follow-up. Results from the 1-year follow-up have been published previously. Results: Both treatment groups improved significantly in the KOOS pain subscore at 3 years’ follow-up in the intention-to-treat and as-treated analyses ( P < .001). The between-group difference for the change in the KOOS pain subscore between baseline and the 3-year follow-up was no longer statistically significant, neither in the intention-to-treat analysis (7.6 points; 95% CI, –0.6 to 15.9; P = .068) nor in the as-treated analysis (5.3 points; 95% CI, –3.1 to 13.8; P = .216). The factorial analysis of the effect of the intervention and age, onset of pain, and mechanical symptoms indicated that older patients improved more, regardless of treatment, and surgery may be more beneficial for patients without mechanical symptoms (as-treated analysis). The effect of the predictive factors on the KOOS pain subscore was uncertain because of the small sample size in the subgroup analyses. Conclusion: The benefit of knee arthroscopic surgery, seen at 1 year in middle-aged patients with meniscal symptoms, was diminished at 3 years and was no longer statistically significant. Clinical Relevance: Knee arthroscopic surgery may be beneficial for middle-aged patients with meniscal symptoms in addition to an exercise program. Older age and absence of mechanical symptoms should not be contraindications to surgery. Registration: NCT01288768 ( ClinicalTrials.gov identifier)

To translate to Swedish language and cross-culturally adapt the IKDC-SKF and to test the measurement properties of the Swedish version of IKDC-SKF in ACL-injured patients undergoing reconstruction surgery.The translation and cross-cultural adaption was performed according to guidelines. Seventy-six patients with an ACL injury filled out the IKDC-SKF and other questionnaires before ACL reconstruction and at 4, 6, and 12months after surgery. A total of 203 patients from the Swedish ACL Registry participated at 8months post-operative. Measurement properties were tested according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines.The Swedish IKDC-SKF had high internal consistency (Cronbachs alpha=0.90) and test-retest reliability (ICC2,1=0.92, CI 95%: 0.81-0.97, Pamp;lt;.001). A single factor solution accounted for 46.1% of the variance in IKDC-SKF scores. Criterion validity was moderate to high. All ten predefined hypotheses for hypothesis testing were confirmed. The six hypotheses for responsiveness testing were confirmed. The effect size was 1.8, the standardized response mean was 1.9, the and minimal clinically important difference was 13.9 points.The Swedish version of the IKDC-SKF had good measurement properties and can be recommended for use in a population of ACL-deficient patients undergoing ACL reconstruction. Funding Agencies|Swedish National Centre for Research in Sports

summary Objective: There is no evidence that a knee arthroscopy is more beneficial to middle-aged patients with meniscal symptoms compared to other treatments. This randomised controlled trial aimed to determine whether an arthroscopic intervention combined with a structured exercise programme would provide more benefit than a structured exercise programme alone for middle-aged patients with meniscal symptoms that have undergone physiotherapy. Method: 150 out of 179 eligible patients, aged 45 to 64 (mean:54 ± 5), symptom duration more than 3 months and standing X-ray with Ahlb€ grade 0, were randomised to: (1) a physiotherapy appointment within 2 weeks of inclusion that included instructions for a 3-month exercise programme (non-surgery group); or (2) the same as (1) plus, within 4 weeks of inclusion, knee arthroscopy for resection of any significant meniscal injuries (surgery group). The primary outcome was change in pain at 12 months, assessed with the Knee Injury and Osteoarthritis Outcome Score (KOOS PAIN ). Results: In the Intention-To-Treat analysis, pain at 12 months was significantly lower in the surgery than in the non-surgery group. The change in KOOSPAIN was significantly larger in the surgery than in the nonsurgery group (between-group difference was 10.6 points of change; 95% CI: 3.4 to 17.7, P ¼ 0.004). The As-Treated analysis results were consistent with the Intention-To-Treat analysis results. Conclusion: Middle-aged patients with meniscal symptoms may benefit from arthroscopic surgery in addition to a structured exercise programme. Patients' age or symptom history (i.e., mechanical symptoms or acute onset of symptoms) didn't affect the outcome. Trial registration: NCT01288768.

As many as one in four individuals develop knee osteoarthritis within ten years of anterior cruciate ligament (ACL) injury. However, the prevalence of knee impairment and the impact of the ACL-injured knee on quality of life (QOL), more than 30 years after ACL injury is unclear. Additionally, the impact of meniscus injury, surgical or non-surgical ACL treatment, and knee function at mid-term follow-up on patient-report outcomes (PROs) beyond 30 years of injury is uncertain. This study aimed to: i. Evaluate PROs 32-37 years following acute ACL injury ii. Assess whether ACL treatment, baseline meniscus injury and knee function at mid-term follow-up were related to differences in PROs at 32-37 year follow-up

In this paper, we present a novel visualization approach for the quantitative analysis of knee movement patterns in time-varying data sets. The presented approach has been developed for the analysis of patellofemoral instability, which is a common knee problem, caused by the abnormal movement of the patella (kneecap). Manual kinematic parameter calculations across time steps in a dynamic volumetric data set are time-consuming and prone to errors as well as inconsistencies. To overcome these limitations, the proposed approach supports automatic tracking of identified features of interest (FOIs) in the time domain and, thus, facilitates quantitative analysis processes in a semiautomatic manner. Moreover, it allows us to visualize the movement of the patella in the femoral groove during an active flexion and extension movement, which is essential to assess kinematics with respect to knee flexions. To further support quantitative analysis, we propose kinematic plots and time-angle profiles, which enable comparative dynamics visualization. As a result, our proposed visualization approach facilitates better understanding of the effects of surgical interventions by quantifying and comparing the dynamics before and after the operations. We demonstrate our approach using clinical time-varying patellofemoral data, discuss its benefits with respect to quantification as well as medical reporting, and describe how to generalize it to other complex joint movements.

Background About 2 out of 3 competitive runners sustain at least one health problem every season; most of these problems are non-traumatic injuries with gradual onset. The main known risk indicator for sustaining a new running-related injury episode is a history of a previous injury, suggesting that behavioural habits are part of the causal mechanisms. Objective To explore competitive runners9 cognitive appraisals of perceived symptoms on injury and illness and how these appraisals are transformed into behaviour. Design Qualitative study using semi-structured interviews for data collection. Setting Swedish competitive middle- and long-distance runners. Participants 14 runners from the national top 15 list. Assessment of Risk Factors Qualitative research methods were used to categorize interview data and perform a thematic analysis. Main Outcome Measurements Categories resulting from the analysis were used to construct an explanatory model. Results Symptoms interpreted to be caused by illness or injury with a sudden onset were found to lead to immediate responses and changes to training and competition programs (activity pacing). In contrast, perceptions interpreted to be due to injuries with gradual onset led to varied behavioural reactions. These behavioural responses were planned with regard to short-term effects and were characterized by indifference and neglect of long-term implications, consistent with an overactivity behavioural pattern. The latter pattern was consistent with a psychological adaptation to stimuli that is presented progressively to the athlete. Conclusions Competitive runners appraise whether a health problem requires immediate withdrawal from training based on whether the problem is interpreted as an illness and/or has a sudden onset. The ensuing behaviours follow 2 distinct patterns that can be termed activity pacing and overactivity. Recurrent health problems among competitive runners can be addressed through the premise that overactivity behaviours are balanced by support of health literacy and psychological flexibility.

Background This cross-sectional study aimed to examine whether appraisal of knee function, psychological and demographic factors were related to returning to the preinjury sport and recreational activity following anterior cruciate ligament (ACL) reconstruction. Method 164 participants completed a questionnaire battery at 1-7 years after primary ACL reconstruction. The battery included questionnaires evaluating knee self-efficacy, health locus of control, psychological readiness to return to sport and recreational activity, and fear of reinjury; and self-reported knee function in sport-specific tasks, knee-related quality of life and satisfaction with knee function. The primary outcome was returning to the preinjury sport or recreational activity. Results At follow-up, 40% (66/164) had returned to their preinjury activity. Those who returned had more positive psychological responses, reported better knee function in sport and recreational activities, perceived a higher knee-related quality of life and were more satisfied with their current knee function. The main reasons for not returning were not trusting the knee (28%), fear of a new injury (24%) and poor knee function (22%). Psychological readiness to return to sport and recreational activity, measured with the ACL-Return to Sport after Injury scale (was most strongly associated with returning to the preinjury activity). Age, sex and preinjury activity level were not related. Conclusions Less than 50% returned to their preinjury sport or recreational activity after ACL reconstruction. Psychological readiness to return to sport and recreation was the factor most strongly associated with returning to the preinjury activity. Including interventions aimed at improving this in postoperative rehabilitation programmes could be warranted to improve the rate of return to sport and recreational activities.

Background: Approximately 2 of every 3 competitive runners sustain at least 1 health problem each season. Most of these problems are nontraumatic injuries with gradual onset. The main known risk indicator for sustaining a new running-related injury episode is a history of a previous injury, suggesting that behavioral habits are part of the causal mechanisms. Purpose: Identification of elements associated with purposeful interpretations of body perceptions and balanced behavioral responses may supply vital information for prevention of health problems in runners. This study set out to explore competitive runners’ cognitive appraisals of perceived symptoms on injury and illness and how these appraisals are transformed into behavior. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The study population consisted of Swedish middle- and long-distance runners from the national top 15 list. Qualitative research methods were used to categorize interview data and perform a thematic analysis. The categories resulting from the analysis were used to construct an explanatory model. Results: Saturation of the thematic classification required that data from 8 male and 6 female runners (age range, 20-36 years) were collected. Symptoms interpreted to be caused by illness or injury with a sudden onset were found to lead to immediate action and changes to training and competition programs (activity pacing). In contrast, perceptions interpreted to be due to injuries with gradual onset led to varied behavioral reactions. These behavioral responses were planned with regard to short-term consequences and were characterized by indifference and neglect of long-term implications, consistent with an overactivity behavioral pattern. The latter pattern was consistent with a psychological adaptation to stimuli that is presented progressively to the athlete. Conclusion: Competitive runners appraise whether a health problem requires immediate withdrawal from training based on whether the problem is interpreted as an illness and/or has a sudden onset. The ensuing behaviors follow 2 distinct patterns that can be termed “activity pacing” and “overactivity.”

Purpose: To assess whether patient-reported outcomes (psychological factors, appraisals of knee function, and physical activity participation) were associated with satisfaction with knee function after anterior cruciate ligament (ACL) reconstruction. Methods: Participants who were aged 18 to 45 years and a minimum 12 months post primary ACL reconstruction completed a questionnaire battery evaluating knee self-efficacy, knee-related quality of life, self-reported function, and physical activity participation. Participants responses to the question "If you were to spend the rest of your life with your knee just the way it has been in the last week, would you feel.... (7-point ordinal scale; 1 = happy, 7 = unhappy)" were categorized as satisfied, mostly satisfied, or dissatisfied and used as the primary outcome. Ordinal regression was used to examine associations between independent variables and the primary outcome. Results: A total of 177 participants were included at an average of 3 years after primary ACL reconstruction. At follow-up, 44% reported they would be satisfied, 28% mostly satisfied, and 28% dissatisfied with the outcome of ACL reconstruction. There were significant differences in psychological responses and appraisal of knee function between the 3 groups (P = .001), and significantly more people in the satisfied group had returned to their preinjury activity (58%) than in the mostly satisfied (28%) and dissatisfied (26%) groups (P = .001). Multivariable analysis demonstrated that the odds of being satisfied increased by a factor of 3 with higher self-efficacy, greater knee-related quality of life, and returning to the preinjury activity. Conclusions: People who had returned to their preinjury physical activity and who reported higher knee-related self-efficacy and quality of life were more likely to be satisfied with the outcome of ACL reconstruction.

Psychological factors may be a hindrance for returning to sport after an anterior cruciate ligament (ACL) reconstruction. The ACL-Return to Sport after Injury scale (ACL-RSI) measures athletes' emotions, confidence in performance, and risk appraisal in relation to return to sport. The aim of this study was to translate the ACL-RSI scale from English to Swedish and to examine some of the measurement properties of the Swedish version. The ACL-RSI was translated and culturally adapted. A professional expert group and five patients evaluated face validity. One hundred and eighty-two patients completed the translated ACL-RSI, a project-specific questionnaire, the Tampa Scale of Kinesiophobia (TSK), the Knee-Self-Efficacy Scale (K-SES), the Multidimensional Health Locus of Control (MHLC-C), the Knee injury and Osteoarthritis Outcome Score (KOOS), and the Anterior Cruciate Ligament-Quality of Life (ACL-QoL) questionnaires. Fifty-three patients answered the ACL-RSI twice to examine reproducibility. The ACL-RSI showed good face validity, internal consistency (Cronbach's alpha = 0.948), low floor and ceiling effects and high construct validity when evaluated against the TSK, K-SES, MHLC-C, KOOS, and ACL-QoL scales. The reproducibility was also high (intra-class correlation = 0.893). Therefore, the ACL-RSI can be used to evaluate psychological factors relevant to returning to sport after ACL reconstruction surgery.

A quasi-static three-dimensional model of the rear foot was developed to enable calculation of joint motion and net torque with respect to talocrural and subtalar joint axes. The functional behaviour of these joints was analysed during single-limb stance. Six female soccer players with unilateral functional instability of the ankle joint were examined. Recordings were performed both with eyes open and eyes closed. The rear-foot model was implemented into an optoelectronic motion analysis system together with a force plate. The subtalar torque precedes the angular movement by 0.1-0.2 s, indicating active postural corrections. Up to a certain limit of subtalar joint inversion, the external everting torque increases. If the inversion is further increased an external inverting torque is obtained. With eyes closed the amplitudes increased for joint motions, torques, centre of pressure trajectories, shear forces, and vertical forces. All events found with external inverting torques occurred when standing on the injured foot with the eyes closed.

We studied nine patients with an isolated, unrepaired rupture of the anterior cruciate ligament to evaluate whether well-rehabilitated patients with an old rupture of the anterior cruciate ligament had adapted their patterns of motor control in situations that provoke knee instability and if the possible adaptation results in a measurable decrease of the deteriorating sagittal shear load. The study was performed by means of a movement analysis system with synchronized force plate and electromyographic recordings. A different movement and muscular-activation pattern was found for the injured leg compared to the noninjured when performing a one-legged jump for distance. An internal knee model was developed and implemented. In that way, a simultaneously decreased capsuloligamentous sagittal load at the landing moment was shown.

The objective of this study was to implement a dynamic, two-dimensional biomechanical model, a force plate, and electromyography in a three-dimensional, opto-electronic motion analysis system. Further objectives were to present kinematic and kinetic data for basic movements used in rehabilitation and athletic testing, and to make the system rapid and adaptable for clinical use. Kinematic data, including joint movements and muscle length changes, as well as kinetic data, including net torque and net power output, are presented for the ankle, knee and hip joints when performing two-legged vertical counter-movement jumps, walking, and one-leg long hops. Coefficients of variation for net torque and the net power output were between 1.6% and 18·1% when analysing the countermovement jumps, and there were similar results for walking. When performing the hop, the coefficients of variation for net torques were all less than 16%, but power output values were unequivocally non-satisfactory (30% maximum). In conclusion, reliability was acceptable for the counter-movement jumps and for the analysis of walking, but power output reliability for the hops at touch-down was found to be poor, probably due to soft tissue and marker movement relative to the underlying bone. The moderate amount of time needed for testing makes the system useful for clinical practice.

The postural control of ten male soccer players with functional instability (FI) of the ankle joint, i.e., recurrent sprains and/or a feeling of giving way, was studied before and after ankle disk training. Postural control was studied by means of stabilometry and an optoelectronic movement recording system. In the present study, we found increased postural sway in men with functional instability, which is in line with previous studies. We found improved postural control after ankle disk training as shown by stabilometry. Postural correction patterns were restored, and segmental displacement amplitudes reached even supranormal values. A subgroup of players with unilateral FI also decreased postural sway when standing on the non-symptomatic, untrained foot after ankle disk training. This bilateral improvement and the restored postural correction pattern do not tally with Freemans proprioceptive theory for postural control, but stresses the importance of central motor programs.

Fifteen patients with isolated old rupture of the anterior cruciate ligament (ACL) were examined to judge their functional disability. The following basic factors were used for evaluation: thigh muscle strength testing, stabilometry in a one-leg stance with straight and flexed knee, gait analysis, performance tests, knee function score, activity grading scale, and clinical joint laxity tests. We found that these rehabilitated patients mainly had impaired performance in those tests which greatly stressed the knee joint's sagittal stability. One-leg hop length was impaired for the injured limb. This group of patients had bilateral impairment of postural control compared with a reference group. This dysfunction was not revealed when comparing limbs. A derotation brace (ECKO) had neither a positive nor a negative effect in the tests. Different aspects of knee function evaluation are emphasized. Some of the altered functions are suggested to be due to central adjustments of motor control.