OBJECTIVES:To determine when netballers first sustain a lateral ankle ligament sprain and describe the prevalence of persistent symptoms, recurrent sprains, and perceived instability. DESIGN:Cross-sectional survey. SETTING:An online survey was distributed across Australia, United Kingdom, and New Zealand. were recruited and asked about their ankle sprain history. PARTICIPANTS:Netballers aged ≥14 years. MAIN OUTCOME MEASURES:History of lateral ankle ligament sprains, persistent symptoms, perceived instability using the Cumberland Ankle Instability Tool (CAIT) and ankle-related disability using the Foot and Ankle Ability Measure (FAAM). RESULTS:The survey received 2144 responses from Australia (52%, n = 1123), United Kingdom (29%, n = 627), and New Zealand (18%, n = 394). Most respondents (87%, n = 1872) reported a history of lateral ankle ligament sprain. Over half (54%, n = 1005) reported their first sprain before age fifteen, and most (89%, n = 1660) experienced persistent symptoms, including fear of re-injury (63%, n = 1172), pain (58%, n = 1080), and stiffness (52%, n = 965). Two-thirds (66%, n = 1423) suffered recurrent sprains, including almost half (42%, n = 897) with bilateral recurrences. Three-quarters (75%, n = 1397) had perceived ankle instability, but ankle disability was less frequent (35%, n = 647). CONCLUSION:Most netballers experience lateral ankle ligament sprains before age fifteen, and an extremely high proportion continue to suffer long-term symptoms and instability.
Anterior cruciate ligament (ACL) injury is multifactorial. Return-to-sport (RTS) practice after ACL reconstruction has also become increasingly multidimensional, but its dimensions are not weighted equally: physical capacity is assessed more routinely and objectively than perceptual, neurocognitive, contextual, and representative sport demands. Strength testing, hop performance, movement assessment, and patient-reported outcomes remain essential, but they sample only part of the system in which athletes are re-exposed to sport. This Masterclass proposes a determinant-alignment framework for late-stage rehabilitation and RTS assessment. Here, testing refers to discrete measures of capacity or performance, whereas assessment refers to the broader integration of tests, movement behavior, psychological readiness, exposure progression, and sport context. The framework is a hypothesis-generating clinical heuristic rather than a validated taxonomy, prediction algorithm, or evidence that broader assessment reduces second ACL injury. Its purpose is to identify potential assessment gaps and to progress from foundational capacity toward load management, perception-action integration, and representative sport re-exposure. The objective is alignment, not prediction.
Objectives To examine perceptions of physical literacy and physical activity (PA) and explore how components of physical literacy interact with PA participation in young adults with a history of ACLR. Design Qualitative descriptive analysis with a positive/negative deviance framework. Setting Research laboratory. Participants Forty-five young adults (ages 18-35) with a history of ACLR completed one-week of PA observation using an accelerometer. The positive/negative deviance framework identified ten participants to complete semi-structured interviews based on their PA participation. Main outcome measures Weekly moderate-to-vigorous PA. Individual semi-structured interviews were conducted in-person. A collaborative analysis process was used to identify themes and subthemes from participant interviews. Results The semi-structured interviews identified four higher-order themes: Barriers to PA; Facilitators to PA; Knowledge influences recovery and PA after sport; and Establishing a routine for PA. Within these, 12 sub-themes were identified in which participants discussed the roles of motivation, confidence, physical competence, and knowledge for PA participation after ACLR. Conclusion The results suggest that individuals with a history of ACLR may benefit from additional education and support throughout ACLR recovery and as they transition from organized sport into lifelong PA engagement.
OBJECTIVE:To examine self-regulation strategies, passion, and pain responses among runners with distinct injury recency profiles. DESIGN:Cross-sectional study. SETTING:Online survey. PARTICIPANTS:335 runners (50.5% male; median age 39 years, IQR 29-51). MAIN OUTCOME MEASURES:Demands, resources, and recovery (DISQ-R Sport 1.2); metacognition (Self-Regulation of Sport Practice Survey); 12-month injury severity (OSTRC-H2); passion (Passion Scale); and pain responses (Pain Responses Scale). RESULTS:Participants were grouped into four profiles: currently (n = 85), recently (n = 115), previously (n = 90), and never injured (n = 45). Currently and recently injured runners reported higher physical/emotional demands, evaluative overthinking, and maladaptive pain responses. Previously injured runners showed stronger cognitive/emotional recovery strategies, but high passion combined with frequent event participation increased remote-injury classification likelihood. Never-injured runners were characterized by lower demands, greater cognitive resources, fewer negative pain responses, older age, and more running experience. CONCLUSIONS:Distinct patterns of self-regulation, passion, and pain responses differentiate recent injury history profiles in runners. Integrating psychological and behavioural factors with physical training may improve understanding of psychological correlates across distinct injury histories and support more holistic strategies tailored to the runner's current injury status.
Objective To evaluate the diagnostic accuracy of patient history and physical examination for diagnosing common causes of low back pain in elite gymnasts, using MRI as the reference standard. Design Prospective cross-sectional study reported according to STARD guidelines. Index tests were acquired by an experienced musculoskeletal physiotherapist blinded to imaging. MRI scans were independently analysed by two specialist musculoskeletal radiologists. Setting MRI centre, Birmingham, UK. Participants Non-probability consecutive total-population sample of elite gymnasts, regardless of low back pain status. Main outcome measures Sensitivity and specificity of individual index tests and exploratory test clusters. Results Forty participants consented; 75% had abnormal MRI findings. Most specific findings were ‘eased by flexion’ and ‘erector spinae hypertrophy’ for degenerative disc disease, ‘erector spinae hypertrophy’, ‘pain on flexion in standing’, and ‘pain on extension/left side flexion’ for disc herniation, ‘pain on flexion in standing’ plus ‘pain on extension/left side flexion’ for pars oedema/spondylolysis; and ‘eased by flexion’ with the same cluster for spondylolisthesis. Conclusions Highly specific index tests and exploratory clusters showed diagnostic accuracy for identifying gymnasts without degenerative disc disease, disc herniation, and pars oedema/spondylolysis. All gymnasts were recruited regardless of low back pain; these findings need to be considered cautiously when applied clinically.
OBJECTIVES:Examine the association between the peak and impulse of patellofemoral joint force during running and the severity and duration of pain in adolescents with patellofemoral pain. DESIGN:Exploratory cross-sectional. PARTICIPANTS:Fifty-one physically active adolescents with patellofemoral pain (12-19 years). MAIN OUTCOME MEASURES:Kinematic, kinetic, and electromyography data were collected, and PFJ force (N) and impulse (N*s) during stance were estimated using an EMG-informed neuromusculoskeletal model. Pain was assessed as: (i) worst pain in the previous week (11-point numerical rating scale [NRS]), (ii) pain immediately after running (NRS), (iii) KOOS-Child pain (0-100), and (iv) pain duration (months). Associations were examined using linear regression adjusted for age, sex, and body mass. RESULTS:Each 100-N increase in peak patellofemoral joint force was associated with trivial changes of -0.01 (95% CI -0.03 to 0.01) in worst pain in the previous week, -0.02 (-0.05-0.01) in pain immediately following running, 0.01 (-0.19-0.21) in KOOS-Child pain, and -0.20 (-0.64-0.24) in duration of pain. Findings were similar for patellofemoral joint force impulse. CONCLUSION:These exploratory findings suggest the peak and impulse of patellofemoral joint force during running may not be important cross-sectional associates of pain severity or duration in adolescents with patellofemoral pain.
OBJECTIVES:To compare lower limb biomechanics during single-leg drop landings between individuals with low (2-4/year) and high (≥5/year) chronic ankle instability (CAI) recurrence frequencies. DESIGN:Cross-sectional study. SETTING:Biomechanics laboratory. PARTICIPANTS:Sixty males with unilateral CAI, stratified into High-CAI (n = 30) and Low-CAI (n = 30) groups. MAIN OUTCOME MEASURES:Peak vertical ground reaction force (vGRF), time to peak vGRF, vertical loading rate (LR), leg stiffness, and lower extremity kinematics. RESULTS:High-CAI participants demonstrated greater peak vGRF, shorter time to peak vGRF, higher LR, and greater hip flexion, hip abduction, and ankle inversion at initial contact than the Low-CAI group (all p ≤ 0.048; ηp2 = 0.066-0.275). Group × side interactions occurred for knee flexion, ankle inversion, and LR (p = 0.005-0.033; ηp2 = 0.076-0.128). Simple-effects analyses showed the unstable side of the Low-CAI group exhibited less knee flexion than its stable side, whereas the unstable side of the High-CAI group exhibited greater ankle inversion and LR than both the unstable side of the Low-CAI group and its stable side (all p ≤ 0.040; d = 0.350-1.221). CONCLUSIONS:High-frequency CAI recurrence (≥5 times/year) induces a maladaptive landing strategy with altered proximal compensations and impaired shock absorption. Frequency-based stratification is essential for optimizing management.
OBJECTIVES:To compare functional and biomechanical parameters related to ankle mobility, neuromuscular control, and dynamic balance in under-20 soccer players with and without a history of lateral ankle sprain. STUDY DESIGN:Multicenter cross-sectional observational study. SETTING:Training centers of two professional soccer clubs in Brazil. PARTICIPANTS:Seventy-five male soccer players aged 16-20 years. MAIN OUTCOME MEASURES:A comprehensive assessment was performed using the Cumberland Ankle Instability Tool (CAIT) to assess perceived ankle instability, the Foot and Ankle Ability Measure (FAAM) to evaluate self-reported function, the Weight-Bearing Lunge Test (WBLT) to measure ankle dorsiflexion, the Y-Balance Test (YBT) to assess dynamic balance, and the Hop Tests to evaluate lower-limb neuromuscular performance. RESULTS:Athletes with a history of lateral ankle sprain showed lower joint stability (p ≤ 0.005), reduced functionality (p ≤ 0.040), decreased dorsiflexion (p = 0.031), impaired dynamic balance (p = 0.046), and worse performance in hop tests (p ≤ 0.018) CONCLUSIONS: A history of lateral ankle sprain was associated with poorer ankle function, reduced dorsiflexion, impaired dynamic balance, and lower neuromuscular performance in under-20 soccer players. These findings support the use of comprehensive functional assessment to guide rehabilitation and return-to-sport strategies.
Objectives Analyze associations between lower extremity joint power during the eccentric and concentric phases of a single leg squat and hip symptom duration, hip function, and physical activity levels in individuals with hip joint-related groin pain. Design The cross-sectional design of the current study is a secondary analysis of an observational study consisting of a cohort design. Setting Biomechanics Laboratory. Participants Twenty-five adults aged 18 to 45 years with current hip pain were recruited for this study. Main outcome measures Participants self-reported quality of life and physical function using the iHOT-12, current activity level using the Tegner Activity Rating Scale, and hip symptom duration. Lower-limb joint power was calculated using three-dimensional biomechanics data. Spearman's correlation coefficients were used to examine the relationships between parameters. Results Our study found that lower hip joint power during the eccentric and concentric phases of a single leg squat task were associated with worse hip function, lower physical activity levels, and a longer duration of hip symptoms. Conclusions These findings highlight the importance of early intervention prior to the onset of severe muscle dysfunction that may lead to corresponding alterations in hip joint loading in individuals with hip joint-related pain.
Objectives To assess the effectiveness of two different neck strengthening protocols at increasing isometric neck strength in male and female rugby players. Design Cluster randomised controlled trial. Setting The team training facility of 3 amateur clubs. Participants 142 male and female amateur rugby players were recruited to take part in the study. Main outcome measures Isometric neck strength in flexion, extension, left and right side flexion, left and right rotation and sum of strength scores. Results Changes in neck strength were analysed for within-group and between group differences. Relative to the control group the male Band resisted group recorded the largest strength gain with statistically significant increases in sum of strength scores (p = 0.002), extension (p = 0.034), right flexion (p = 0.004), left rotation (p < 0.001) and right rotation scores (p < 0.001). The male Partner resisted group recorded improvements in left rotation (p < 0.001) and right rotation (p = 0.006). In the female band resisted group significant improvements in neck strength were recorded for sum of strength scores (p = 0.042), right rotation (p = 0.003) and left rotation (p = 0.005) however in the Partner resisted group significant improvements were recorded in right rotation only (p = 0.015). Conclusions We have developed two time efficient and low cost neck strengthening protocols that demonstrate efficacy at enhancing neck strengthen in a team setting.
Objectives To investigate the influence of cognitive demands on postural stability and ankle muscle activity during static and dynamic postural control in individuals with chronic ankle instability (CAI). Participants 21 individuals with CAI (age = 21.7 ± 1.5 years) Main outcome measures Postural stability was assessed using time-to-boundary (TTB) measures and normalized reach distances from the modified Star Excursion Balance Test (mSEBT). Ankle muscle activity was evaluated using integrated electromyography (iEMG) from tibialis anterior (TA), peroneus longus (PL), medial gastrocnemius (MG), and soleus muscles (SL). Results No significant differences in postural stability were observed between single- and dual-task conditions. However, ankle muscle activity significantly decreased under dual-task conditions. Specifically, MG (P = 0.002) and SL (P = 0.009) activity decreased during eyes-open static postural control. During dynamic postural control, TA activity decreased in posteromedial (P = 0.010) and posterolateral (P = 0.007) reaches, while PL decreased in posterolateral reach (P = 0.038). Concurrent cognitive performance did not differ significantly across postural tasks. Conclusion Cognitive loading reduced ankle muscle activity without impairing postural stability, suggesting that cognitive loading influences neuromuscular responses during postural control in individuals with CAI. These findings highlight the importance of considering cognitive demands during postural control assessment.
Eccentric training is a well-established method for developing strength and its implementation has become increasingly common in anterior cruciate ligament reconstruction (ACL-R) rehabilitation. Although traditionally introduced in later stages of recovery, early progressive eccentric exercise has been investigated from approximately three weeks post-operation in selected patients, with evidence suggesting potential benefits for quadriceps atrophy and strength deficits. Beyond improving strength, eccentric training may also enhance performance in return-to-sport (RTS) assessments. However, its implementation should be gradual and individualized, with consideration of clinical status and loading tolerance, particularly during the early phases of rehabilitation. Eccentric recumbent cycling offers a practical solution, allowing clinicians to monitor power outputs and regulate intensity through rate of perceived exertion (RPE) scales. This article explores the benefits of integrating eccentric cycling into ACL-R rehabilitation and outlines an exemplar eccentric cycling program.
Objectives To investigate the effects of combined physical and mental fatigue (PMF) on knee biomechanics during unanticipated sidestep cutting in male soccer players. Design Randomized crossover trial. Setting Biomechanics laboratory. Main outcome measures knee angles at initial contact (IC), range of motion (ROM), peak knee moments, three-dimensional ground reaction force (GRF), weight acceptance (WA) duration, and loading rate (LR) during the WA phase. Results Significant fatigue condition × time interactions were observed for knee flexion (p < 0.001) and abduction angle at IC (p < 0.001), WA duration (p = 0.003), peak knee abduction moment (p < 0.001), peak vertical GRF (p = 0.014), and LR (p = 0.016). Post hoc analyses showed that PMF increased knee abduction angle at IC (p < 0.001), peak knee abduction moment (p < 0.001), peak vertical GRF (p = 0.012), and LR (p = 0.006), while decreasing knee flexion angle at IC (p < 0.001) and WA duration (p < 0.001). Conclusions PMF resulted in greater alterations in knee biomechanics during unanticipated sidestep cutting compared with isolated fatigue states. These findings suggest that the combined effects of physical and cognitive fatigue should be considered when evaluating biomechanical responses during cognitively demanding motor tasks.
Medial tibial stress syndrome, also known as load-induced medial leg pain (LIMP), is common in runners. This study evaluated the effectiveness of non-invasive, physical therapy-related interventions for LIMP. Searches were conducted in MEDLINE, Cochrane CENTRAL, SPORTDiscus, EMBASE, and Web of Science to June 2, 2025. Randomized trials including runners with LIMP comparing non-invasive interventions were eligible. Primary outcomes were pain and physical function; secondary outcomes included perceived improvement, quality of life, and lower-limb kinematics. Risk of bias was assessed using RoB 2, certainty of evidence with GRADE, and intervention reporting with TIDieR. A narrative synthesis was performed. Of 319 records, three trials (130 runners with LIMP) were included. Most were female (n = 80, 61.54%), with a mean age of 25.7 ± 4.4 years. Arch-support foot orthoses plus multimodal care reduced short-term pain versus sham, but effects were not sustained. Exercise additions were not superior to comparators. No consistent between-group differences were observed for function. Some interventions improved quality of life and biomechanics, without consistent clinical benefits. Evidence for non-invasive LIMP interventions in runners is limited and heterogeneous, with no clearly superior treatment. High-quality trials with standardized outcomes are needed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD420251062879.
OBJECTIVES:In patients with ACL injury treated according to clinical practice, to explore: (1) the rate and time from injury to return to pre-injury sport IKDC sports level (RTS), (2) RTS rates to specific sports, and (3) patients' reported knee function. DESIGN:Prospective multicentre cohort study. PARTICIPANTS:270 patients (53% females). Within three years of the injury, 178 patients (66%) had undergone ACL reconstruction (ACLR). MAIN OUTCOME MEASURES:Time from injury to RTS. Patient-reported knee function was evaluated with the Single Numeric Assessment Scale (SANE). RESULTS:Overall, 210 (78%) patients RTS. IKDC level-I and level-II patients RTS later (12 [95% CI 10-13] and 10 [95% CI 7-13] vs. 2 [95% CI 2-3] months, p < 0.001) and fewer RTS compared to IKDC level-III patients (66% vs. 76%, compared to 100%, p < 0.001). RTS rates for football were 60%, floorball 71%, handball 88%, and running 100%. SANE did not differ between the IKDC level groups at follow-ups; however, IKDC level-III patients reported lower SANE at RTS. CONCLUSIONS:Patients RTS to all sports level regardless of ACLR. Fewer patients in sports placing high demands on the knee RTS, and they RTS later compared to sports that are less demanding on the knee.
Gymnastics is a unique athletic activity requiring different loading and weight bearing patterns through the entire body, especially the upper extremity (UE). Available literature on return to sport following a UE injury is predominately focused on return to throwing. Criteria regarding athlete appropriateness to return to UE weight bearing is limited. The purpose of this scoping review is to explore return to gymnastics and weight bearing following a UE injury. Computerized searches were performed using online databases. Grey literature, non-medical database sources and relevant study reference lists were manually reviewed. For screening and full-text determinations, two authors independently voted on inclusion based on established eligibility criteria and a third blinded author was used to resolve conflicts. Data related to interventions including any relevant protocols, outcomes, and return to sport criteria were extracted. In total, 1420 titles were retrieved. After duplicate removal, 1000 studies were screened, 40 were retained for final inclusion. Of the included studies, 8 specified return to gymnastics criteria. Limited and low-quality evidence of return to gymnastics following a UE injury was identified. The lack of evidence restricts clinical determination of readiness for return to UE loading making clinical care of gymnasts variable and potentially less effective.
