Benjamin Clarsen

Development and validation of a new method for the registration of overuse injuries in sports injury epidemiology: the Oslo Sports Trauma Research Centre (OSTRC) Overuse Injury Questionnaire

Background Current methods for injury registration in sports injury epidemiology studies may substantially underestimate the true burden of overuse injuries due to a reliance on time-loss injury definitions. Objective To develop and validate a new method for the registration of overuse injuries in sports. Methods A new method, including a new overuse injury questionnaire, was developed and validated in a 13-week prospective study of injuries among 313 athletes from five different sports, cross-country skiing, floorball, handball, road cycling and volleyball. All athletes completed a questionnaire by email each week to register problems in the knee, lower back and shoulder. Standard injury registration methods were also used to record all time-loss injuries that occurred during the study period. Results The new method recorded 419 overuse problems in the knee, lower back and shoulder during the 3-month-study period. Of these, 142 were classified as substantial overuse problems, defined as those leading to moderate or severe reductions in sports performance or participation, or time loss. Each week, an average of 39% of athletes reported having overuse problems and 13% reported having substantial problems. In contrast, standard methods of injury registration registered only 40 overuse injuries located in the same anatomical areas, the majority of which were of minimal or mild severity. Conclusion Standard injury surveillance methods only capture a small percentage of the overuse problems affecting the athletes, largely because few problems led to time loss from training or competition. The new method captured a more complete and nuanced picture of the burden of overuse injuries in this cohort.

The Oslo Sports Trauma Research Center questionnaire on health problems: a new approach to prospective monitoring of illness and injury in elite athletes

Background Little information exists on the illness and injury patterns of athletes preparing for the Olympic and Paralympic Games. Among the possible explanations for the current lack of knowledge are the methodological challenges faced in conducting prospective studies of large, heterogeneous groups of athletes, particularly when overuse injuries and illnesses are of concern. Objective To describe a new surveillance method that is capable of recording all types of health problems and to use it to study the illness and injury patterns of Norwegian athletes preparing for the 2012 Olympic and Paralympic Games. Methods A total of 142 athletes were monitored over a 40-week period using a weekly online questionnaire on health problems. Team medical personnel were used to classify and diagnose all reported complaints. Results A total of 617 health problems were registered during the project, including 329 illnesses and 288 injuries. At any given time, 36% of athletes had health problems (95% CI 34% to 38%) and 15% of athletes (95% CI 14% to 16%) had substantial problems, defined as those leading to moderate or severe reductions in sports performance or participation, or time loss. Overuse injuries represented 49% of the total burden of health problems, measured as the cumulative severity score, compared to illness (36%) and acute injuries (13%). Conclusions The new method was sensitive and valid in documenting the pattern of acute injuries, overuse injuries and illnesses in a large, heterogeneous group of athletes preparing for the Olympic and Paralympic Games.

Reduced glenohumeral rotation, external rotation weakness and scapular dyskinesis are risk factors for shoulder injuries among elite male handball players: a prospective cohort study

Aim To determine whether rotator cuff strength, glenohumeral joint range of motion and scapular control are associated with shoulder injuries among elite male handball players. Methods A total of 206 players in the Norwegian elite handball league for men were tested prior to the 2011–2012 season. Measures included: (1) glenohumeral internal and external rotation range of motion, (2) isometric internal rotation, external rotation and abduction strength and (3) assessment of scapular dyskinesis. Players were followed prospectively for the entire regular season (30 weeks), with shoulder problems registered bi-weekly using the Oslo Sports Trauma Research Center Overuse Injury Questionnaire. A cumulative severity score was calculated for each player based on their questionnaire responses. This was used as the outcome measure in risk factor analyses. Results The average prevalence of shoulder problems throughout the season was 28% (95% CI 25% to 31%). The prevalence of substantial shoulder problems, defined as those leading to moderate or severe reductions in handball participation or performance, or to time loss, was 12% (95% CI 11% to 13%). Significant associations were found between obvious scapular dyskinesis (OR 8.41, 95% CI 1.47 to 48.1, p<0.05), total rotational motion (OR 0.77 per 5° change, 95% CI 0.56 to 0.995, p<0.05) and external rotation strength (OR 0.71 per 10 Nm change, 95% CI 0.44 to 0.99, p<0.05) and shoulder injury. Conclusions Injury prevention programmes should incorporate interventions aimed at improving glenohumeral rotational range of motion, external rotation strength and scapular control.

Overuse Injuries in Professional Road Cyclists

Background Little epidemiological information exists on overuse injuries in elite road cyclists. Anecdotal reports indicate anterior knee pain and lower back pain may be common problems. Purpose This study was conducted to register overuse injuries among professional road cyclists with special focus on anterior knee and lower back pain. Study Design Descriptive epidemiology study. Methods We attended training camps of 7 professional teams and interviewed 109 of 116 cyclists (94%) on overuse injuries they had experienced in the previous 12 months. Injuries that required attention from medical personnel or involved time loss from cycling were registered. Additional information on anterior knee pain and lower back pain was collected using specific questionnaires. Results A total of 94 injuries were registered; 45% were in the lower back and 23% in the knee. Twenty-three time-loss injuries were registered—57% in the knee, 22% in the lower back, and 13% in the lower leg. Fifty-eight percent of all cyclists had experienced lower back pain in the previous 12 months, and 41% of all cyclists had sought medical attention for it. Thirty-six percent had experienced anterior knee pain and 19% had sought medical attention for it. Few cyclists had missed competitions because of pain in the lower back (6%) or anterior knee (9%). Conclusion Lower back pain and anterior knee pain were the most prevalent overuse injuries, with knee injuries most likely to cause time loss and lower back pain causing the highest rates of functional impairment and medical attention. Clinical Relevance Future efforts to prevent overuse injuries in competitive cyclists should focus on lower back pain and anterior knee pain.

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

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 athletes 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.

Matching the choice of injury/illness definition to study setting, purpose and design: one size does not fit all!

What constitutes a ‘recordable event’ is arguably the most critical methodological factor affecting the results of sports injury and illness surveillance studies. Although numerous consensus statements have attempted to standardise surveillance methodology,1–6 there remains considerable variation in current definitions of injury. Underlying the choice of definition are a number of practical and theoretical issues, including the duration and setting of surveillance, the available resources, the type of injuries and illnesses of interest, how data are to be collected and what they are to be used for. It is also highly desirable that results are comparable between studies; both within and between sports. Above all, however, surveillance data must be valid. As no single definition is likely to suit all needs, the purpose of this article is to review the strengths and limitations of the three most commonly used definitions in sports epidemiology and to examine their appropriateness depending on the context and objectives of surveillance. We focus particularly on methods of data collection, as this may have important consequences on the reliability of data. Consensus recommendations have been made for several sports, including cricket,1 football (soccer),2 rugby union,3 tennis,4 thoroughbred horse racing5 and most recently, for athletics.6 Earlier statements have focused solely on injuries, which may be defined as physical complaints resulting from the transfer of energy at a rate or in an amount that exceeds that tissues threshold for damage.6 ,7 Recently they have also been expanded to include illnesses, defined as physical or psychological complaints that are unrelated to injury.6 However, common to all statements (with the notable exception of cricket) is the recommendation that a recordable incident should be defined as any physical or psychological complaint resulting from relevant sports participation regardless of its consequences, but that …

A one-season prospective study of injuries and illness in elite junior tennis

The objective of this study was to estimate the incidence and prevalence of injury and illness among elite junior tennis players. A cohort of 73 players (11–14 years) in the 2012–2013 Dutch national high‐performance program was followed for 32 weeks; all participants completed the study. The OSTRC Questionnaire on Health Problems was used to record self‐reported injuries and illnesses and to record training and match exposure. Main outcome measures were average prevalence of overuse injury and illness and incidence density of acute injury. On average, players practiced 9.1 h/week (SD 0.6; range 2.3–12.0) and had 2.2 h of match play (SD 0.6; range 2.3–12.0). During the course of the study, 67 players reported a total of 187 health problems. The average weekly prevalence of all health problems was 21.3% (95% CI: 19.2–22.9), of which 12.1% (95% CI: 10.9–13.3) constituted overuse injuries and 5.8% (95% CI: 4.6–6.9) illnesses. The incidence of acute injuries was 1.2/1000 h of tennis play (95% CI: 0.7–1.7). The high occurrence of overuse injuries among elite junior tennis players suggests that an early focus on preventative measures is warranted, with a particular focus on the monitoring and management of workload.

Preventing overuse shoulder injuries among throwing athletes: a cluster-randomised controlled trial in 660 elite handball players

Background Shoulder problems are highly prevalent among elite handball players. Reduced glenohumeral rotation, external rotation weakness and scapula dyskinesis have been identified as risk factors. Aim Evaluate the effect of an exercise programme designed to reduce the prevalence of shoulder problems in elite handball. Methods 45 elite handball teams (22 female teams, 23 male teams, 660 players) were cluster randomised (22 teams, 331 players in the intervention group, 23 teams, 329 players in the control group) and followed for 1 competitive season (7 months). The Oslo Sports Trauma Research Center (OSTRC) Shoulder Injury Prevention Programme, an exercise programme to increase glenohumeral internal rotation, external rotation strength and scapular muscle strength, as well as improve kinetic chain and thoracic mobility, was delivered by coaches and captains 3 times per week as a part of the handball warm-up. The main outcome measures, prevalence of shoulder problems and substantial shoulder problems, were measured monthly. Results The average prevalence of shoulder problems during the season was 17% (95% CI 16% to 19%) in the intervention group and 23% (95% CI 21% to 26%) in the control group (mean difference 6%). The average prevalence of substantial shoulder problems was 5% (95% CI 4% to 6%) in the intervention group and 8% (95% CI 7% to 9%) in the control group (mean difference 3%). Using generalised estimating equation models, a 28% lower risk of shoulder problems (OR 0.72, 95% CI 0.52 to 0.98, p=0.038) and 22% lower risk of substantial shoulder problems (OR 0.78, 95% CI 0.53 to 1.16, p=0.23) were observed in the intervention group compared with the control group. Conclusions The OSTRC Shoulder Injury Prevention Programme reduced the prevalence of shoulder problems in elite handball and should be included as a part of the warm-up. Trial registration number ISRCTN96217107.

A peek into the future of sports medicine: the digital revolution has entered our pitch

The current wide-scale availability of the internet and connected mobile devices is revolutionising healthcare. Patients and practitioners have unprecedented access to health information; they communicate with each more than ever before. It seems as if new technology is appearing daily and with it comes the promise of greater (cost) efficiency and quality of medical practise.1 The sports medicine community is currently buzzing about ‘eHealth’, which may be defined as the practise of medicine supported by electronic processes and communication. The newest buzzword is ‘mHealth’, referring to eHealth driven by the use of mobile devices, not limited to smartphones. Indeed, we are seeing an increased use of readily available technologies such as SMS messaging, social media platforms, apps and online questionnaires in both clinical and research settings. Grindem et al 2 illustrate how online technologies can aid clinical practice. Specifically they monitored return-to-sport after an anterior cruciate ligament (ACL) injury; one of the clinical ‘success’ measures of postinjury rehabilitation. Current methods that register sports activity after ACL injury are usually restricted to knee-demanding sports alone to limit the time-burden for patients and to ensure valid data collection. Participation …

Why we should focus on the burden of injuries and illnesses, not just their incidence

More and more sports medicine clinicians are taking an active approach to prevent injury and illness within their team.1–3 The first steps in developing a risk management plan is risk estimation and assessment.4–7 In this phase, the main questions are: what injuries can we expect? Or illnesses? And which are the most serious? Another question is: when is injury risk the greatest? The purpose is to identify which problems need to be focused on in a risk management plan in order to mitigate risk. These questions can be answered by establishing continuous injury surveillance within the team or by reviewing data from epidemiological studies on teams from a similar level.6 7 However, as a practitioner, you need to know how to interpret such data, whether they are your own or from others. A number of consensus statements have been published to encourage consistency in how injuries are defined and reported in epidemiological studies, initially on cricket (2005, updated in 2016),8 9 followed by football (2006)10 and several other sports such as rugby (2007),11 tennis (2009),12 athletics (2014)13 and aquatic sports (2016).14 In general, these recommend that the rate of injury should be reported as injury incidence, calculated as number of injuries per 1000 hours of exposure. This recommendation has since been followed by the vast majority of surveillance studies, and incidence is typically also the main outcome used to compare sports, genders, age groups and so on. However, we argue that focusing on injury/illness incidence alone may give an incomplete and even erroneous picture of risk. It should be noted that the consensus statements also recommend that injury severity be reported, generally as the number of days from the date of injury to the date of the player’s return to full participation. …