The Achilles tendon, although considered the toughest in the body, can rupture, with many such injuries involving sports enthusiasts in their 30s or 40s. Surgery might be required, and a prolonged period of rest, immobilisation, and treatment can be difficult to endure. Researchers in Japan have developed an approach using irradiation with plasma to accelerate healing.
A research team led by Osaka Metropolitan University Graduate School of Medicine’s Katsumasa Nakazawa, a graduate student in the Department of Orthopedic Surgery, Associate Professor Hiromitsu Toyoda, and Professor Hiroaki Nakamura, and Graduate School of Engineering Professor Jun-Seok Oh has focused on non-thermal atmospheric-pressure plasma (the electrically-charged gas such as found in a neon lamp – not blood plasma!) as a treatment method for tendon repair.
Their study, published in PLOS ONE, is the first to show that such plasma irradiation can accelerate tendon repair.
The team ruptured then sutured the Achilles tendon of lab rats. For one group of rats, the sutured area was irradiated with a helium plasma jet.
The plasma-irradiated group exhibited faster tendon regeneration and increased strength at two, four, and six weeks after surgery compared to the untreated group.
“We have previously discovered that irradiation of non-thermal atmospheric-pressure plasma has the effect of promoting bone regeneration. In this study, we discovered that the technology also promotes tendon regeneration and healing, showing that it has applications for a wide range of fields,” Professor Toyoda declared. “Combined with current tendon treatments, it is expected to contribute to more reliable tendon regeneration and shorter treatment time.”
Football players in England’s top-tier WSL were six times more likely to experience a muscle injury in the days leading up to their period compared to when they were on their period, according to a new study published in Medicine & Science in Sports & Exercise.
This the first prospective longitudinal study monitoring menstrual cycles alongside injuries in female footballers. The findings suggest there could be increased injury risk windows at particular times in the cycle.
Despite being a relatively small sample size, the data demonstrates the need to consider the menstrual cycle in elite sports, to reduce injury risk and to support the wellbeing of athletes.
Menstrual cycle symptoms are common and around two thirds of elite athletes feel that these can have negative impacts on their performance. There has been little previous research tracking injuries alongside the menstrual cycle in female sport, despite much speculation and anecdotal evidence suggesting that there may be some key times for increased injury risk. Given the increased professionalism, interest, growth, and investment in women’s sport, the authors say further research in this area is needed.
In this study, researchers at UCL and the University of Bath recorded time-loss injuries and menstrual cycle data for elite female football players across three seasons. All of the players were based at one Women’s Super League (WSL) club, the top tier of women’s football in England. During the study they tracked 593 cycles across 13 390 days, in which time 26 players experienced 74 injuries.
The authors divided each cycle into four main phases in their study. Each phase comes with assumed hormonal changes that have the potential to influence different aspects of a woman’s health and wellbeing.
Ally Barlow, first author of the study from the University of Bath and a physiotherapist at the WSL club, said: “We have been tracking player’s menstrual cycles for a number of seasons to observe trends in terms of symptoms and cycle characteristics. We were interested to learn more about the potential association between injury risk across the menstrual cycle. This study set out to collect specific scientific data so that we could learn more about the menstrual cycle and player’s injury risk.”
Analysis of the data found that players were six times more likely in the pre-menstrual phase (oestrogen and progesterone decrease to bring about the onset of menstruation) and five times more likely in the early-mid luteal phase (after ovulation when both oestrogen and progesterone are assumed to increase and remain high) to experience a muscle injury, compared to when they were in the menstrual phase.
Dr Georgie Bruinvels, senior author of the study from UCL Surgery & Interventional Science and the Institute of Sport, Exercise & Health (ISEH), said: “While these results must be viewed with caution, this data highlights a need to investigate this area further. Given the growth of women’s sport it’s an exciting time to be working in female physiology, but there are a number of known challenges when conducting research with female athletes, in part explaining why there is such a significant sex data gap.
“Conducting large-scale research is complex but must be prioritised to best support female athletes, and we hope studies like this will pave the way for this. Every woman has their own unique physiology, so it’s crucial to support and empower them in the right ways. If future research demonstrates that there are risk windows for certain injury types, we should be proactive in mitigating these risks to enable female athletes to exercise and compete on any given day.”
The authors emphasise that further data collected in a standardised manner is needed before the sports science community can start to look for biological explanations for this increased injury risk.
Dr Jo Blodgett, an author of the study from UCL Surgery & Interventional Science and the Institute of Sport, Exercise & Health (ISEH), said: “Though our sample size for this research was relatively small, we observed clear links between cycle phase and injury prevalence, and the size of the association – six times higher in the premenstrual phase and five times higher in the early-mid luteal phase for muscular injuries – was quite large.
“To better understand the variability in injury risk across the cycle we need more players and teams to continually track injury incidence, menstrual cycle and symptoms in a standardised manner. At the elite level, injuries to your squad can mean the difference between winning and losing, the difference between being crowned champions and runners-up. But perhaps more importantly, it means pain and suffering for players that could perhaps be avoided with better player-centred support.”
Concussions are commonplace in contact sports at junior and senior levels. Now, the investigators of a study published in the Journal of Science and Medicine in Sport are suggesting extended recovery times may be needed for youth athletes suffering from head trauma. The new research shows a concussion can increase future injury risk by 50%.
The world-first study from the University of South Australia tracked and evaluated the long-term impact of concussion and subsequent injury risk of 1455 sub-elite junior Australian rules football players.
This builds on previous UniSA research that found an approximate 1.5-fold increased risk of injury of sub-elite Australian rules football players returning from an injury, compared to those with no injury.
Tracking injuries over a seven-season period, researchers found that football players who suffered a concussion were also about 1.5 times more likely to be reinjured in the future when compared to players who had never been injured. This increased risk was the same as players returning from upper and lower limb injuries.
The finding comes ahead of the Australian Senate’s report into concussion injuries, and follows the AFL’s announcement for a $25 million study into the long-term effects of concussions and head knocks.
In the AFL, concussions are one of the most common injuries, with an average of six concussions every 1000 hours played, which involve around 70 to 80 male players every year.
In junior elite football as well as AFL and AFLW, the guidelines for concussion say that the earliest a player can return to play post-concussion is 12 days after the injury, after following the graded progression through a return-to-play program.
Lead researcher, UniSA’s Dr Hunter Bennett, says the significant and elevated risk of injury after a concussion may suggest a longer recovery time is required for some players to better recover before returning to play.
“The current recommendation of 12 days post-concussion may not be sufficient to allow full recovery in elite under-18 footballers,” Dr Bennett says.
It may also indicate that the physical qualities impacted by concussion should be assessed more thoroughly before an athlete is cleared to return to the sport.
“Concussion is a common injury in Australian rules football that can lead to impairments in balance, coordination, reaction time, and decision making – and these impairments can increase the risk of other injuries if an athlete returns to play before being fully recovered.”
A recent consensus statement on concussion in sport also indicates that children and teenagers may take up to four-weeks to recover from a sport related concussion.
“Concussions are a unique injury that occur without muscle tissue damage, instead impacting aspects of motor control,” Dr Bennett says.
“Recurrent injuries can significantly impact team success, player health, and career longevity.
“In elite sports, there is the potential for young athletes to overplay their readiness to return to sport after an injury, as they worry that missing games can exclude them from senior drafting or competition.
“When we know that athletes have a greater risk of another injury post a concussion, it suggests we need unique and careful rehabilitation strategies to monitor when an athlete is fully recovered and ready to return to play.”
Researchers say that future research should seek to identify optimal rehabilitation and injury prevention strategies for athletes who suffer from concussions.
Latest Consensus Statement on Concussion in Sport includes:
New and updated age appropriate tools to aid identification and management of condition
New versions of return to active sport and education strategies
Stronger evidence for benefits of light intensity exercise within first 48 hours to aid recovery
New targeted approach to rehabilitation
Call for interdisciplinary working group to guide research into potential long term effects
A group of more than 100 expert researchers and clinicians from around the world, co-chaired by Professor Jon Patricios of Wits Sport and Health (WiSH), University of the Witwatersrand (Wits University), has distilled and synthesised new scientific evidence and updated existing recommendations with the aim of optimising the care of athletes at all levels of participation who have, or who are at risk of, concussion.
Based on the outcomes from the International Conference on Concussion in Sport, held in Amsterdam in October 2022, and published in the British Journal of Sports Medicine (BJSM), the Statement is informed by 10 systematic reviews and methodology outlining the new consensus process. The entire process more than 4 years to complete.
In a bid to be more transparent and inclusive than in previous years, the process adopted anonymous voting, alternative viewpoints, open declarations of potential conflicts of interest, and included the views of athletes, a focus on para-athletes, and ethical perspectives.
The Statement includes a series of new (SCOAT6, Child SCOAT6) and updated (CRT6, SCAT6, Child SCAT6) age-appropriate tools for clinicians and sports organisations to help them better identify and manage sports related concussion in the short and longer term.
It features new evidence-based strategies for returning to active sport and education after concussion; early exercise and treatment recommendations; approaches to prevention; targeted rehabilitation; and a call for a working group to be set up to guide further research on the potential long term effects of concussion on health.
Among the key recommendations:
Prevention
Policy or rule changes to minimise collisions, such as disallowing body checking in ice hockey – a defensive move in which the player tries to separate the puck from his/her opponent
Neuromuscular training – aerobic, balance, strength, agility exercises +/-neck-specific components – in warm ups
Mouthguard use in ice hockey (all ages)
Implementing laws and protocols, such as mandatory removal from play after actual or suspected concussion; healthcare professional clearance to return to play; and education of coaches, parents, and athletes on the signs and symptoms of concussion
Early interventions
Strict rest isn’t recommended. There’s now stronger evidence that light intensity physical activity, such as routine activities of daily living, and aerobic exercise, such as walking and stationary cycling, can aid recovery, as can limiting screen time during the first 48 hours.
Rehabilitation
For those experiencing dizziness, neck pain and/or headaches for more than 10 days, the Statement recommends cervico-vestibular rehabilitation – physiotherapy exercises to reduce symptoms and improve function.
Rehabilitation should be targeted to the needs of the individual.
Persisting symptoms
Multidisciplinary team assessment to identify the types, pattern, and severity of symptoms and any other contributory factors is advised for those with symptoms lasting more than 4 weeks.
Recovery
Advanced neuroimaging, biomarkers (chemical signals from nerves or blood vessels), genetic tests, and other emerging technologies to assess recovery are useful for research into the diagnosis, outlook, and recovery from sports related concussion. But as yet, they are some way off from being used in clinical practice, says the Statement.
Return to education and sport
Academic support may be needed for some athletes in the form of a return to learn strategy: this can include modified school attendance, limiting screen time, avoiding any contact sports or game play, extra time to complete assignments/homework or tests.
Light intensity activity in the early phases of the return to sport strategy is now recommended, with full sports participation usually occurring within 1 month of injury.
But it’s best to manage athletes on an individual basis, accounting for specific factors that may affect their recovery, such as a history of migraine, anxiety, and social factors.
Potential long term effects
The Statement notes the “increasing societal concern about possible problems with later in life brain health in former athletes, such as mental health problems, cognitive impairment and neurological diseases.”
Studies tracking the mental health of people over time (cohort studies) have found that former amateur and professional athletes don’t seem to be at heightened risk of depression or suicidality later in life.
Similarly, no heightened risk of neurological disease has been reported in former amateur athletes in these types of study. But some studies of former professional athletes have reported an association between playing professional American football and professional soccer and neurological disease in later life.
But the studies to date on the links between early sports participation and later life dementia and neurological disease are limited because they haven’t been able to adjust for a range of potentially highly influential factors, says the Statement.
It recommends setting up an interdisciplinary working group to guide appropriate research into the potential long term effects of concussion on health.
Evidence gaps still to be filled
There’s limited evidence on the management of sports related concussion in 5-12 year olds and in para sport athletes, who are known to be at heightened risk of sports related concussion.
And little research on concussion exists for certain regions of the world, diverse cultural contexts, sex and genders.
Commenting on the Statement, Consensus Statement co-chair, Dr Kathryn Schneider of the University of Calgary, Canada, says: “This Statement sets out a range of new evidence-based recommendations, including those for concussion prevention as well as new versions of the concussion assessment tools and return to sport and school/learning strategies”.
“We encourage clinicians and sports organisations around the globe to adapt these recommendations to their own geographic and cultural environments to optimise the care of athletes who have sustained, or who are at risk of, concussion,” she adds.
“The differentiating aspects of this latest Concussion Consensus are the rigorous methodological process we adopted, the new generation of tools available to clinicians, and the emphasis on the positive impact of exercise and targeted rehabilitation as effective interventions,” explains Consensus Statement co-chair, Professor Jon Patricios of Wits University, Johannesburg, South Africa.
“These have the potential to positively change the management of sport-related concussion.”
Over the past 17 years, evidence on chronic traumatic encephalopathy (CTE) has piled up. While some sports organisations like the National Hockey League and World Rugby still claim their sports do not cause CTE, a new review article in the journal Acta Neuropathologica strengthens the case that repetitive head impact (RHI) exposure is the chief risk factor for the condition.
CTE is characterised by a distinctive molecular structural configuration of p-tau fibrils that is unlike the changes observed with aging, Alzheimer’s disease, or any other diseases caused by tau protein.
Though CTE made US headlines in 2007, it wasn’t until 2016 that the National Institute of Neurological Disorders and Stroke/National Institute of Biomedical Imaging and Bioengineering (NINDS-NIBIB) criteria for the neuropathological diagnosis of CTE were published, and they were refined in 2021. Rare, isolated case studies reporting aberrant findings or using non-accepted diagnostic criteria have been disproportionately emphasised to cast doubt on the connection between RHI and CTE.
In the review, Ann McKee, MD, chief of neuropathology at VA Boston Healthcare System and director of the BU CTE Center, stresses that now over 600 CTE cases have been published in the literature from multiple international research groups. And of those over 600 cases, 97% have confirmed exposure to RHI, primarily through contact and collision sports. CTE has been diagnosed in amateur and professional athletes, including athletes from American, Canadian, and Australian football, rugby union, rugby league, soccer, ice hockey, bull-riding, wrestling, mixed-martial arts, and boxing.
What’s more, 82% (14 of the 17) of the purported CTE cases that occurred in the absence of RHI, where up-to-date criteria were used, the study authors disclosed that families were never asked what sports the decedent played.
According to the researchers, despite global efforts to find CTE in the absence of contact sport participation or RHI exposure, it appears to be extraordinarily rare, if it exists at all. “In studies of community brain banks, CTE has been seen in 0 to 3 percent of cases, and where the information is available, positive cases were exposed to brain injuries or RHI. In contrast, CTE is the most common neurodegenerative disease diagnosis in contact and collision sport athletes in brain banks around the world. A strong dose response relationship is perhaps the strongest evidence that RHI is causing CTE in athletes,” she added.
“The review presents the timeline for the development of neuropathological criteria for the diagnosis of CTE which was begun nearly 100 years ago by pathologist Harrison Martland who introduced the term “punch-drunk” to describe a neurological condition in prizefighters,” explained McKee, corresponding author of the study. The review chronologically describes the multiple studies conducted by independent, international groups investigating different populations that found CTE pathology in individuals with a history of RHI from various sources.”
Contrary to popular belief, rest may not always be the best treatment after a concussion, according to the results of a large multi-centre study published in JAMA Network Open. In fact, an early return to school may be associated with a lower symptom burden after suffering a concussion and, ultimately, faster recovery.
“We know that absence from school can be detrimental to youth in many ways and for many reasons,” says study lead author Christopher Vaughan, PsyD, neuropsychologist at Children’s National Hospital. “The results of this study found that, in general, an earlier return to school after a concussion was associated with better outcomes. This helps us feel reassured that returning to some normal activities after a concussion – like going to school – is ultimately beneficial.”
In this cohort study, data from over 1600 youths aged five to 18 were collected across nine paediatric emergency departments in Canada. Because of the large sample size, many factors associated with greater symptom burden and prolonged recovery were first accounted for through the complex statistical approach used to examine the data. The authors found that an early return to school was associated with a lower symptom burden 14 days post-injury in the 8 to 12 and 13 to 18-year-old age groups.
“Clinicians can now confidently inform families that missing at least some school after a concussion is common, often between 2 and 5 days, with older kids typically missing more school,” Dr Vaughan says. “But the earlier a child can return to school with good symptom management strategies and with appropriate academic supports, the better that we think that their recovery will be.”
The results suggest a possible mechanism of therapeutic benefit to the early return to school. This could be due to:
Socialisation (or avoiding the deleterious effects of isolation).
Reduced stress from not missing too much school.
Maintaining or returning to a normal sleep/wake schedule.
Returning to light-to-moderate physical activity sooner (also consistent with previous literature).
A clinical study from Lund University in Sweden has shown that long-term problems such as dizziness and difficulty focusing after a concussion originate in an injury to the vestibular nerve. The researchers published their findings in the Journal of Neurotrauma.
Concussion resulting from a blow to the head is a hazard in many sports. In American football, where players who have suffered from repeated concussions have developed dementia, severe depression and cognitive impairment.
Concussion usually has only temporary symptoms, but an increasing number of athletes experience long-term problems that make it difficult to work, go to school or play sports. The symptoms are aggravated by activity or impressions and include headaches, depression, anxiety, nausea, difficulty focusing and problems with balance.
“It has been unclear what causes the symptoms, and it is difficult for healthcare professionals to help these athletes. We wanted to investigate this further to find out what really causes the symptoms,” said Professor Niklas Marklund, one of the study’s researchers.
The study included 21 healthy athletes without previous trauma to the head, and 21 athletes who all suffered from sports-related concussions and who had experienced persisting symptoms for more than six months. The researchers used a 7-Tesla MRI, to study the athletes’ brains to understand more about what caused the symptoms. They discovered impaired function of the balance organs in the inner ear of 13 athletes in the group with long-term problems. In the group of healthy athletes three people had similar findings.
“The test results show that the injury is located to the vestibular nerve, which is connected to the semicircular canals in a cavity inside the skull, and which is directly adjacent to the cochlea in the ear. These injuries lead to the inward nerve impulses not working properly, and the brain therefore does not receive important information about body movements and sensory impressions required to maintain a good balance,” said Anna Gard, doctoral student at Lund University and first author of the study.
Concussion often results from the head rotating too fast.
“We have not examined athletes with short-term problems after blows to the head, so we cannot say anything about them. This study applies to athletes with prolonged symptoms after concussion. The rotation of the head that occurs in connection with a concussion could lead to a stretch of the vestibular nerve, which then leads to impaired function. Now that we have more knowledge about where the problems are located, it is easier to find possible therapies that could help these athletes,” concluded Prof Marklund.
In high school American football, girls are at nearly double the risk of concussion compared to boys, according to a new study. Girls are also less likely to be removed from play and take longer to recover from the injury than their male counterparts.
Researchers at the University of Pennsylvania and Michigan State University along with Prof Willie Stewart, Honorary Professor at the University of Glasgow reviewed three years of injury data for a population of around 40 000 female high school American footballers in the Michigan High School Athletic Association, comparing them to a similar number of their male counterparts.
They found that, as seen in previous studies, the risk of sports related concussion among female footballers was 1.88 times higher than among males. The researchers also identified several sex-associated differences in sports concussion mechanism and management. This provides new insight into this kind of injury in this demographic.
Male footballers tended to be injured in collisions with another player and were 1.5 times more likely than females to be removed from play on the day of injury. Female footballers were most often injured from impacts involving equipment, such as the ball or a goalpost, and also took on two days longer on average to recover from injury and return to play. A recent study however showed no differences for concussion recovery time among male and female college athletes, but there could be differences depending on the type of sport.
These sex-associated differences among teenage athletes in mechanism of injury and in management and outcomes of concussion raise the question of whether sports should consider the adoption of sex specific approaches to both participation and concussion management.
Lead author Dr Abigail Bretzin, postdoctoral fellow and certified athletic trainer at the University of Pennsylvania, said: “This is the first study to look in this detail at sex-associated differences in concussion management and outcomes in teenage footballers. Our findings add to research showing that female athletes are at increased concussion risk compared to male athletes, and highlight the importance of sex-specific research in this field.”
Senior author Prof Stewart, said: “Given we know the importance of immediate removal from play for any athlete with suspected concussion, it is notable that “if in doubt, sit them out” appears more likely to happen for boys than girls. This, together with the finding that mechanism of injury appears different between boys and girls, suggests that there might be value in sex-specific approaches to concussion education and management in this age group.”
Journal information: Abigail C. Bretzin et al. Association of Sex With Adolescent Soccer Concussion Incidence and Characteristics, JAMA Network Open (2021). DOI: 10.1001/jamanetworkopen.2021.8191
Writing in the British Medical Journal, scientists have argued that the study of knee injuries in female athletes is too focused on biological factors and not enough on social factors.
It is said that female athletes experience anterior cruciate ligament (ACL) injury, at a rate three to six times higher than their male counterparts.The ACL is one of the key ligaments that helps to stabilise the knee joint. This can be a career-ending injury, and occurs most often in sports involving sudden changes of direction such as basketball.
The authors of the paper argued that much of the focus still falls on biological and hormonal factors, with little attention paid to how sex-based factors are affected by the social concept of gender and how they could influence each other.
They suggested that gendered experiences are relevant in shaping female sport participation as well as disparities in injury outcomes. They demonstrated that, over a lifetime, gendered expectations of physical abilities (eg ‘throw like a girl’), to inequitable access to funding, training, and facilities for women’s sport (eg disparities in access to weight training).
Lastly, the authors suggested there may also be differences between post-injury rehabilitation for men and women recovering from an ACL injury. These social and environmental factors play a much bigger role in how sports injuries occur than once thought, they said, urging that there should be much more weight given to these issues.
Dr Sheree Bekker from the Department for Health at the University of Bath (UK) explained: “We wanted to unpack the biases and assumptions that we were seeing in research into and practice around sports injuries in girls and women. Specifically, we wanted to challenge the increasingly pervasive idea that this is simply a problem for girls/women because they are inherently prone to injury just because of their female biology. Approaching ACL injury prevention and management from a strictly biological view can propagate sexism in sport with detrimental consequences for girls and women.”
Dr Joanne Parsons from the University of Manitoba (Canada) added: “Over 20 years of research focussed on biological traits has failed to decrease the ACL injury rate in girls and women. To make a difference, we need to approach the problem in a different way. The recent challenges that the NCAA women’s teams faced with access to adequate training equipment is a perfect example of why we have to include society’s influence when talking about injury risk for girls/women.”
Paper co-author Dr Stephanie Coen of the University of Nottingham said: “By extending the focus from individual bodies and biology to the gendered environments contextualizing ACL injury, our approach identifies new opportunities to intervene and achieve better outcomes for girls and women, with implications beyond athletes. As childhood and youth physical activity levels influence those in adulthood, the sequelae of ACL injury can be lifelong and particularly concerning for girls and women who already participate in physical activity at lower rates than boys and men. There is a wider health equity issue at stake.”
Journal information: Joanne L Parsons et al, Anterior cruciate ligament injury: towards a gendered environmental approach, British Journal of Sports Medicine (2021). DOI: 10.1136/bjsports-2020-103173
