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Physiotherapists working in sport are expected to manage injuries from the moment they occur. When witnessing live sport, the physiotherapist watches for signs of trauma, overstretching or other unusual patterns of movement that can guide decision-making in a way that is of greatest help to the athlete. Regular training ensures that physiotherapists work as part of an inter-disciplinary team to provide treatment and timely removal from a field of play when necessary. Recognising important clues such as the degree of distress and injury mechanism can help shape the initial assessment and management based on training, experience and pattern recognition. This BJSM edition focuses on Acute Management, rather than Rehabilitation or Return to Sport that more frequently headline conferences and symposia, or are commonly found within journal pages, blogs and across social media. Acute management and athlete assessment are discussed in an assortment of varied contexts. Dr Charles Pedlar discusses medical encounters in recreational running events, such as the popular and global Parkrun ( see page 1420 ), while Yuri Hosokawa and colleagues present expert recommendations for …

BackgroundDespite being the most commonly incurred sports injury with a high recurrence rate, there are no guidelines to inform return to sport (RTS) decisions following acute lateral ankle sprain injuries. We aimed to develop a list of assessment items to address this gap.MethodsWe used a three-round Delphi survey approach to develop consensus of opinion among 155 globally diverse health professionals working in elite field or court sports. This involved surveys that were structured in question format with both closed-response and open-response options. We asked panellists to indicate their agreement about whether or not assessment items should support the RTS decision after an acute lateral ankle sprain injury. The second and third round surveys included quantitative and qualitative feedback from the previous round. We defined a priori consensus being reached at >70% agree or disagree responses.ResultsSixteen assessment items reached consensus to be included in the RTS decision after an acute lateral ankle sprain injury. They were mapped to five domains with 98% panellist agreement—PAASS: Pain (during sport participation and over the last 24 hours), Ankle impairments (range of motion; muscle strength, endurance and power), Athlete perception (perceived ankle confidence/reassurance and stability; psychological readiness), Sensorimotor control (proprioception; dynamic postural control/balance), Sport/functional performance (hopping, jumping and agility; sport-specific drills; ability to complete a full training session).ConclusionExpert opinion indicated that pain severity, ankle impairments, sensorimotor control, athlete perception/readiness and sport/functional performance should be assessed to inform the RTS decision following an acute lateral ankle sprain injury.Trial registration numberACTRN12619000522112.

Valid methods of quantifying sporting exposure and athlete response are essential to answering many sports injury research questions. External measures of exposure describe volume, duration or intensity of a match or training session and include time (eg, hours spent training), distance (eg, metres run) and number of events (eg, number of baseball pitches).1 Internal measures relate to the effect on, or experience of, an athlete during a session and include both subjective (eg, rating of percieved exertion (RPE)) and objective measures (eg, heart rate).1 Accurately recording exposure allows the direct comparison of injury incidence rates between different populations, sports, seasons and anatomical region, and should be accounted for in risk factor analyses.1 In addition to inconsistent terminology used to define injury and performance, the validity of any such analysis is dependent on the accuracy of the exposure data collected. Given the multifactorial nature of injury risk, a range of measures that reflect the physiological, psychological and biomechanical exposure load should be considered rather than focusing on a single metric. It is easy to fall into the trap of quantifying exposure metrics which are easily measured. Substantial …

To determine the effect of three different static-dynamic stretching protocols on sprint and jump performance in Gaelic footballers.Double-blind, controlled, crossover trial.Sports Institute research environment.Seventeen male elite level Gaelic footballers, aged 18-30 years, completed three stretching protocols.Athletic performance was measured by countermovement jump height and power, and timed 10 m, 20 m, and 40 m sprints.Static stretching reduced sprint speed by 1.1% over 40 m and 1.0% over 20 m. Static stretching also reduced countermovement jump height by 10.6% and jump power by 6.4%. When static stretching was followed by dynamic stretching, sprint speed improved by 1.0% over 20 m and 0.7% over 40 m (p 0.05). The static - dynamic stretching protocol also improved countermovement jump height by 8.7% (p 0.01) and power by 6.7% (p 0.01).Static stretching reduces sprint speed and jump performance. Static stretching should be followed by dynamic stretching during warm-up to nullify any performance deficits caused by static stretching.

Collaboration is an established and valued objective within the military, highly successful organisations, and applied sport. In the future, dissemination and realisation of high-quality research in sports medicine will be rooted in collaboration that bridges gaps between statisticians, researchers and clinical content experts. Distancing in this field is antisocial, smothering and silencing: ultimately keeping your distance undermines progress! Similar to the sentiment expressed by Exeter’s Dr Robert Mann (UK) in his editorial about athletes as a community (see page 1071) , we, the wider sports medicine community, have demonstrated during these times of distancing a remarkable social interconnection that helps make us all better. This Association of Chartered Physiotherapists in Sport and Exercise Medicine (ACPSEM) issue of BJSM offers much to professionals with an interest in teamwork, and who value cooperation to help validate the evidence that can be implemented with appropriate sporting populations for future success. An antidote to antisocial distanced silos! The extensive and fascinating analysis of 3600 muscle injuries over 23 years by …

Introduction: Lateral ankle sprains are the most prevalent injury in sports with the highest recurrence rate of all musculoskeletal injuries. Most individuals return to sport (RTS) quickly after a lateral ankle sprain, likely because lateral ankle sprains are often assumed to be minor injuries and there are currently no criteria-based guidelines to guide the RTS decision making. There is need to determine and collate expert opinion to inform RTS practice. The aim of this study was to use a Delphi approach to develop consensus for RTS criteria for individuals who have sustained an acute lateral ankle sprain injury. Methods: A Delphi approach was used to establish consensus of opinion from a panel of international experts. Panelists were required to be: i) a health professional; ii) currently working with athletes competing in nationally selected representative teams or teams in Tier/Division 1 national competitions; iii) currently working in field or court sports in which the primary gross motor skills are running and jumping/landing or changing direction and there is a high prevalence of lateral ankle sprain injuries; iv) involved in making RTS decisions for individuals with an acute lateral ankle sprain injury; v) proficiency in the English language. Consensus was a priori defined as > 70 % agreement between panelists. Results: Based on responses to the first Delphi survey, assessment of the following items reached consensus to be included as RTS criteria for individuals who have sustained an acute lateral ankle sprain injury: sport specific tasks, hopping, agility, jumping, pain severity of sport specific physical activity, pain severity of the last 24 hours, ankle range of motion, ankle muscle strength, ankle muscle endurance, dynamic postural control/balance, proprioception, perceived ankle reassurance/confidence, perceived ankle instability, and psychological readiness. Discussion: Collation of expert opinion through a Delphi approach informs the development of RTS criteria for acute lateral ankle sprain injuries. Our findings indicate the need to assess performance of sport-specific and athletic skills, pain severity, ankle muscle function, ankle range of motion, balance and proprioception, ankle perception and psychological readiness when determining the ability to athletes to RTS after an acute lateral ankle sprain injury. This information provides the basis for prospective cohort studies to test the use of the proposed criteria for successful RTS after acute lateral ankle sprain injuries.

Purpose: To determine the association between training-load (TL) factors, baseline characteristics, and new injury and/or pain (IP) risk in an endurance sporting population (ESP). Methods: Ninety-five ESP participants from running, triathlon, swimming, cycling, and rowing disciplines initially completed a questionnaire capturing baseline characteristics. TL and IP data were submitted weekly over a 52-wk study period. Cumulative TL factors, acute:chronic workload ratios, and exponentially weighted moving averages were calculated. A shared frailty model was used to explore time to new IP and association to TL factors and baseline characteristics. Results: 92.6% of the ESP completed all 52 wk of TL and IP data. The following factors were associated with the lowest risk of a new IP episode: (a) a low to moderate 7-d lag exponentially weighted moving averages (0.8–1.3: hazard ratio [HR] = 1.21; 95% confidence interval [CI], 1.01–1.44; P = .04); (b) a low to moderate 7-d lag weekly TL (1200–1700 AU: HR = 1.38; 95% CI, 1.15–1.65; P P P = .04). Conclusions: To minimize new IP risk, an ESP should avoid high spikes in acute TL while maintaining moderate to high chronic TLs. A history of previous IP should be considered when prescribing TLs. The demonstration of a lag between a TL factor and its impact on new IP risk may have important implications for future ESP TL analysis.

Deciding when to return to sport after injury is complex and multifactorial—an exercise in risk management. Return to sport decisions are made every day by clinicians, athletes and coaches, ideally in a collaborative way. The purpose of this consensus statement was to present and synthesise current evidence to make recommendations for return to sport decision-making, clinical practice and future research directions related to returning athletes to sport. A half day meeting was held in Bern, Switzerland, after the First World Congress in Sports Physical Therapy. 17 expert clinicians participated. 4 main sections were initially agreed upon, then participants elected to join 1 of the 4 groups—each group focused on 1 section of the consensus statement. Participants in each group discussed and summarised the key issues for their section before the 17-member group met again for discussion to reach consensus on the content of the 4 sections. Return to sport is not a decision taken in isolation at the end of the recovery and rehabilitation process. Instead, return to sport should be viewed as a continuum, paralleled with recovery and rehabilitation. Biopsychosocial models may help the clinician make sense of individual factors that may influence the athlete's return to sport, and the Strategic Assessment of Risk and Risk Tolerance framework may help decision-makers synthesise information to make an optimal return to sport decision. Research evidence to support return to sport decisions in clinical practice is scarce. Future research should focus on a standardised approach to defining, measuring and reporting return to sport outcomes, and identifying valuable prognostic factors for returning to sport.

Background: Soccer (football) players often have hip and groin symptoms (HGS), and a previous groin injury is a risk factor for a relapse. Decreased hip range of motion (HROM) has been related to both hip and groin pain and the presence of a cam deformity. How these factors interact is unknown. Purpose: The first aim was to study whether HGS are associated with HROM. The second aim was to study the association of the presence of a cam deformity with HROM. Additionally, the influence of a cam deformity on the relationship between HGS and HROM was examined. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Seasonal screening data of 2 professional soccer clubs were used. Variables for HGS were current hip or groin pain, the Copenhagen Hip and Groin Outcome Score (HAGOS), and previous hip- and groin-related time-loss injuries (HGTIs). HROM was determined for hip internal rotation (IR), external rotation, and total rotation (TR) in the supine position and for the bent knee fall out (BKFO) test. A cam deformity was defined by an alpha angle >60° on standardized anteroposterior pelvic and frog-leg lateral radiographs. Results: Sixty players (mean [±SD] age, 23.1 ± 4.2 years) were included. All were noninjured at the time of screening. Current hip or groin pain was not associated with HROM. Hips of players in the lowest HAGOS interquartile range (thus most affected by complaints; n = 12) showed less IR (23.9° ± 8.7° vs 28.9° ± 7.8°, respectively; P = .036) and TR (58.2° ± 13.5° vs 65.6° ± 11.8°, respectively; P = .047) than those in the highest interquartile range (n = 29). No such differences were found for BKFO ( P = .417). Hips of players with a previous HGTI showed less IR (21.1° ± 6.8° vs 28.3° ± 8.9°, respectively; P < .001) and TR (56.0° ± 8.2° vs 64.5° ± 13.6°, respectively; P < .001) than those without a previous HGTI. This was independent of the presence of a cam deformity. BKFO did not differ between groups ( P = .983). Hips with a cam deformity showed less but nonsignificant IR (25.5° ± 10.3° vs 29.0° ± 7.1°, respectively; P = .066) and TR ( P = .062) and higher but nonsignificant BKFO values (17.1 cm ± 3.4 cm vs 14.2 cm ± 4.6 cm, respectively; P = .078) than those without a cam deformity. Conclusion: Decreased HROM in professional soccer players is associated with more hip- and groin-related symptoms and with previous injuries, independent of the presence of a cam deformity.

Background: Benchmarking is an established means of identifying levels of specialist practice and competence-based interviews are a tool used to facilitate this. The London 2012 Olympic and Paralympic Games (LOCOG) provided an opportunity to introduce a pragmatic approach to assess expert behaviour in large numbers of volunteer physiotherapists. Aim: To test inter-tester repeatability of an assessment matrix used to score clinical expertise in a sporting context, followed by reporting on the findings for physiotherapy selection. Methods: Four volunteers were videoed answering an identical sport-specific clinical scenario. Recordings were initially scored by two experienced assessors (gold standard). Subsequently, nine assessors scored the same videos then compared with the gold standard. 602 physiotherapists were assessed during volunteer interviews for LOCOG. Scores were compared to those based on self-reported clinical experience. Cross-tabulation was used to determine levels of agreement for the initial scoring matrix and the relationship between the two scoring systems was analysed. Results: Levels of agreement ranged from 22% to 88%. A good correlation (r=0.754 p>0.001) was found between self-reported clinical experience and scenario scores. Marginal data points in the correlational analysis indicated that only 52% of participants attained the same score across assessments. Conclusions: A tool to facilitate assessment for large scale selection could be used for Host Nation physiotherapist selection for Major Games. There is a need to train assessors in this environment, as well as provide detailed matrices, specific to each context being assessed, to ensure that observations can be made on domain-specific and general, non-technical aspects.

Clear clinical reasoning relating to appropriate progression and regression of rehabilitation is essential to achieve positive clinical outcomes. A theoretical model to assist practitioners in this respect has previously been described.1 This model (figure 1) provides a visual means for clinicians to represent modification of rehabilitation stimuli with regard to progression of a single exercise. Figure 1 A theoretical model to describe progressions and regressions for exercise rehabilitation.1 In brief, the model encourages clinicians to regress modifiable variables within an exercise (eg, sets, reps, speed) to facilitate effective introduction of external stimuli or a change of environment. While useful as a reference for clinicians on progression of single exercises, the original model is limited in its ability to describe progressions within a multidimensional rehabilitation programme. The model suggests that a patient must be able to fully execute each stage of an exercise progression before the reintroduction of previously learnt components. In practice, rehabilitation is rarely linear with many …

Complex decision making is a central pillar of working in performance sport. Are players available for training or competition? What is the optimal training content and progression for an athlete? What is the best intervention for the athlete to resolve an injury while supporting performance? These and many other questions are part of any normal day working in sports medicine. This ACPSEM issue of BJSM (figure 1) highlights the complex and changing environment in which practitioners work and encourages us to avoid a simple linear approach but rather seek to synthesise a wide range of factors to help us make better judgements. Figure 1 The ACPSEM (@Physiosinsport) Autumn Study Day for 2019 focuses on hip and groin pain in sport. Belfast, November 23rd, 2019. Over recent years, complex systems theory has improved our understanding of the interactions between various factors and sports injury. …

> “There is in the human mind a sufficiently strong propensity not only to make divisions in knowledge where there are none in nature, and then to impose the divisions on nature, making the reality thus comfortable to the idea, but to go further, and to convert the generalisations made from observations into positive entities, permitting for the future these artificial creations to tyrannise over the understanding. ”1 The integrated nature of sports medicine has been a mainstay of good clinical practice for many years. The dichotomy between clinical disciplines and siloed working have given way to an interdisciplinary team focused around athlete health and sports performance. Similarly, the apparent dichotomous approach to holistic patient care is changing. The separation between the mental, physical …

Exercise works, exercise is medicine—this is something most readers will attest to. Exercise is the first line of intervention for many clinical presentations and has been repeatedly shown to outstrip pharmacological and surgical approaches to the management of a wide range of medical, musculoskeletal and psychological conditions. Whether we are physiotherapists, physicians, sports scientists or other sport and exercise medicine practitioners, we regularly prescribe exercise programmes to patients with a host of different symptoms. While not a panacea, exercise is an intervention that has a role to play in every aspect of sport and exercise medicine. In a sense our first question when considering treatment options should be, ‘What type of exercise should I prescribe?’ rather than ‘Should I prescribe exercise?’ But what guides our decision-making in determining the nature, type and volume of exercise for our …

The acronym PRICE (protection, rest, ice, compression and elevation) has traditionally been the cornerstone for treating acute soft tissue injury. Recently, its relevance in some cases has been questioned;1 of particular concern is that protection and rest may correspond with an excessively conservative approach that fails to harness the benefits of progressive tissue loading through exercise. Optimal loading may be defined as the load applied to structures that maximises physiological adaptation. Achieving optimal loading is challenging but should be driven by variables such as the tissue type, pathological presentation and the required tissue adaptation for eventual activity. Specific loading goals may include increased tensile strength, collagen reorganisation, increased muscle–tendon unit stiffness or neural reorganisation. Optimal loading works through various cellular and neural mechanisms to induce a wide range of changes (summarised in figure 1). Manipulation of loading variables can have profound effects on the nature, structure and function of the wider neuromusculoskeletal system. Figure 1 Effects of mechanical loading. One variable with …

The human body is attuned to respond to various forms of mechanical loading and that this is perhaps the primary tool in the repertoire of sports medicine professionals. If exercise is the intervention of choice for a range of conditions, we must appreciate the mechanisms that underpin adaptation so we can refine our prescription and better benefit patients. The current issue of BJSM highlights a range of strategies that can be used to better monitor, manipulate and apply load in a range of contexts. Mechanical loading can take many different forms and may involve …

Infographic: 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern