OBJECTIVES:To evaluate whether an 8-week smartphone-based multidisciplinary digital therapeutic (DTx) combining exercise and cognitive-behavioural therapy reduced usual knee pain at 8 weeks compared with education and exercise instruction in chronic patellofemoral pain (PFP). METHODS:This multicentre, parallel-group randomised controlled trial included 216 participants with chronic PFP, defined as anterior or retropatellar pain lasting at least 3 months with activity-related provocation, recruited from orthopaedic outpatient clinics at 10 hospitals in the Republic of Korea. Participants were randomly assigned to the DTx group (MORA Cure PFP) or a control group receiving PFP-related education, one-time exercise instruction, printed materials and self-monitoring exercise diaries. The DTx intervention included personalised home-based exercises, weekly cognitive-behavioural sessions and self-reflective daily worksheets. Outcomes were assessed at baseline, 4, 8 and 12 weeks. The primary endpoint was usual pain at 8 weeks, measured using a 0-100 mm visual analogue scale (VAS). Secondary outcomes included worst pain, knee function (Anterior Knee Pain Scale; AKPS), health-related quality of life assessed using the 5-level EQ-5D version (EQ-5D-5L) and the EQ visual analogue scale (EQ VAS), and psychological distress (Patient Health Questionnaire-9 and Pain Catastrophizing Scale (PCS)). Longitudinal changes were analysed using linear mixed-effects models. RESULTS:For the primary endpoint, usual pain at week 8 favoured the DTx group (between-group mean difference -12.5 mm, 95% CI -17.1 to -7.8). Secondary outcomes at week 8 also favoured the DTx group, including worst pain (-10.7 mm, 95% CI -15.9 to -5.4), knee function (AKPS, 5.2 points, 95% CI 2.7 to 7.7), health-related quality of life (EQ VAS 10.7 points, 95% CI 7.1 to 14.4) and pain catastrophising (PCS, -1.8 points, 95% CI -3.3 to -0.3). Exercise adherence exceeded 80%, with no device-related or intervention-related serious adverse events reported. CONCLUSION:An 8-week smartphone-based multidisciplinary DTx programme reduced usual pain at 8 weeks compared with education and exercise instruction in patients with chronic PFP, with improvements in pain, knee function, health-related quality of life and psychological outcomes. These findings support the potential role of an integrated DTx package for delivering exercise and cognitive-behavioural support in PFP care. TRIAL REGISTRATION NUMBER:NCT06260865.
OBJECTIVE:To characterise the prevalence, distribution pattern and clinical relevance of T wave inversion (TWI) on a screening preparticipation 12-lead ECG in high school athletes. METHODS:A retrospective cohort study analysed ECGs from athletes screened between 2010 and 2025 during a preparticipation event. Athletes with TWI in ≥2 contiguous leads were included. Longitudinal cardiac outcomes were assessed via electronic health records, semistructured interviews and extensive media and death registries review. RESULTS:Among 16 893 high school athletes screened (mean age 15.3±1.1 years), 61 (0.36%) demonstrated TWI in ≥2 consecutive leads, representing 20.2% of those flagged with abnormal ECGs. The majority of athletes with TWI were male (n=51, 83.6%), with 46 (75.4%) in black and 14 (23.0%) in non-black male athletes. Anterior+lateral + inferior TWI was the most frequent pattern (n=17, 27.9%). Four male athletes were identified with confirmed or presumed hypertrophic cardiomyopathy (HCM); two identified after screening, one identified 5 years after screening and one lost to follow-up who did not complete the diagnostic evaluation until after a cardiac arrest 2 years later. CONCLUSION:Abnormal TWI was rare in this large US adolescent athlete cohort, with higher prevalence among black males. All confirmed or presumed cases of HCM occurred in athletes with inferior+lateral TWI, underscoring the importance of a comprehensive assessment and longitudinal surveillance in athletes with this ECG phenotype.
OBJECTIVE:To determine whether autograft type (hamstring, patellar or quadriceps tendon) is associated with risk of revision anterior cruciate ligament reconstruction (ACLR) or contralateral ACLR in football players. METHODS:Nationwide cohort included all primary ACLRs performed in registered football players in Sweden between 2014 and 2023, identified by linkage of the Swedish Knee Ligament Registry and the Swedish Football Association. Return to competition (RTC) was defined as participation in at least one official match. Outcomes were revision ACLR (index knee) and contralateral ACLR. Sex stratified, cause specific Cox models adjusted for age and pre-injury level of play (Elite, Non-elite, Youth) were used, with hamstring tendon as graft reference. RESULTS:A total of 10 693 players were included, of whom 6238 (58%) RTC, mean age 22±7 years, mean follow up 5.2±2.9 years. Among RTC players, revision ACLR occurred in 232 women (10.8%) and in 349 (9.2%) men with no association between graft type and revision ACLR. Contralateral ACLR occurred in 263 women (12.2%) and 264 (6.9%) men. In women, quadriceps tendon was associated with a higher hazard of contralateral ACLR (HR 1.98, 95% CI 1.17 to 3.36). No graft-specific differences were seen in age-restricted sensitivity analyses or in the full cohort. Younger age and higher pre-injury level were consistently associated with greater subsequent ACLR risk. CONCLUSIONS:Graft choice was not independently associated with revision ACLR, including among young football players who RTC. An association between quadriceps tendon autograft and contralateral ACLR was observed among women. Across analyses, age and pre-injury level of play were the most consistent correlates of subsequent ACLR risk.
OBJECTIVES:Cerebral small vessel disease (CSVD) is associated with depressive symptoms. Exercise may reduce depressive symptoms for people with CSVD. We examined the effects of progressive resistance training (PRT) on depressive symptoms among adults with CSVD and mild cognitive impairment (ie, subcortical vascular cognitive impairment (SVCI)). METHODS:A single-site, 12-month, parallel group, secondary analysis of a randomised controlled trial (ClinicalTrials.gov identifier: NCT02669394). Community-dwelling adults (aged 55+ years) with SVCI were randomly allocated to 12 months of twice-weekly (1) PRT using Keiser pressurised air machines and free weights or (2) a balance and tone control group (BAT), which included stretches and light exercises. Our main outcome was depressive symptoms, indexed using the 10-item Centres for Epidemiologic Studies Depression Scale (CESD-10) at baseline, 6 months (midpoint) and 12 months (end of intervention). We examined treatment effects using a linear mixed model with restricted maximum likelihood estimation and followed the intention-to-treat principle. Covariates included baseline CESD-10 score, sociodemographic and health factors. RESULTS:91 participants were randomised (PRT=45; BAT=46). Mean age was 75 years (SD=6 years), 65.2% were female and mean CESD-10 score at baseline was 7.45 (SD=5.91). CESD-10 scores were significantly lower for PRT compared with BAT at 6 months (estimated mean difference: -3.17; 95% CI -6.12 to -0.22; p=0.036) and 12 months (estimated mean difference: -4.25; 95% CI -7.23 to -1.27; p=0.006). CONCLUSIONS:Following 12 months of PRT, adults with SVCI had fewer depressive symptoms than a BAT control group. Our results suggest PRT should be considered for adults with mild to moderate SVCI in order to mitigate depressive symptoms.
OBJECTIVE:To evaluate the diagnostic yield and clinical implications of so-called 'borderline' ECG findings and ectopic beats in elite football players, in accordance with the 2017 International Criteria (IC17) for ECG interpretation in athletes. METHODS:A total of 17 685 professional footballers (84.7% males) underwent cardiac screening including a 12-lead ECG and echocardiography between 2017 and 2024. Borderline ECG changes were classified according to the IC17. Supraventricular and ventricular ectopic beats were also analysed. Prevalence of cardiac pathology (major and minor) among athletes with borderline changes was compared with those athletes with normal ECGs. RESULTS:Borderline ECG findings were present in 1389 (7.9%) athletes (8.8% males, 2.6% females; p<0.001), with right atrial enlargement being the most frequently observed pattern (5.5%). Major cardiac pathology was incidentally identified in 2 (1.43%) athletes with isolated left atrial enlargement, compared with 9 (0.06%) athletes with normal ECGs (p=0.004), including 1 case of an anomalous coronary origin and another case with significant aortic root dilatation-both unrelated to the ECG findings. All other borderline patterns as well as ectopy did not reveal any major pathology. No major conditions were identified in 42 athletes with isolated ≥2 borderline ECG findings. Minor cardiac pathology was identified in 18 (1.41%) athletes with isolated borderline findings and in 3 (2.07%) athletes with isolated ectopy. When ≥2 borderline findings were present, 2.38% athletes revealed minor pathology (p=0.463). Minor cardiac pathology was found in 212 (1.34%) of athletes with normal ECGs (p=0.836). CONCLUSION:Borderline ECG criteria in the IC17 and ventricular ectopy are poor discriminators for major and minor cardiac pathology in athletes. Borderline changes including ≥2 findings do not warrant further evaluation and could be considered normal findings in future iterations of ECG interpretation criteria in athletes.
This consensus statement represents an update to Mental Health in Elite Athletes: International Olympic Committee Consensus Statement (2019) . To advance a more standardised, evidence-based approach to mental health in elite athletes, an International Olympic Committee (IOC) Consensus Group critically evaluated the current science via a systematic literature review, sought consensus using Delphi methodology and provided recommendations relevant to this topic. Key themes include that mental health symptoms and disorders are (1) common among elite athletes; (2) may have sport-related aetiologies and manifestations; and (3) can impact performance. Routine screening for and monitoring of mental health symptoms and disorders in elite athletes using validated instruments is recommended. Management strategies should promote mental well-being in addition to preventing and treating mental health symptoms and disorders. These strategies should address all contributors to mental health symptoms, including factors within the environments in which athletes train and compete. Treatment may include psychotherapy, medication and other culturally or contextually appropriate modalities. With appropriate support and treatment, many athletes experiencing mental health symptoms and disorders can continue to train and compete safely, but sometimes modification of sport participation may be necessary. Elite athletes who are transitioning out of sport, elite Para athletes and elite young (adolescent) athletes are relatively understudied and may have distinct mental health concerns, in addition to those impacting elite athletes in general.
OBJECTIVE:To investigate the results of cardiac screening, prevalence of cardiac diseases and subsequent health outcomes among elite female football players in the UK. METHODS:Between 2000 and 2024, 3121 elite female football players underwent the English Football Association (FA) cardiac screening programme, comprising a health questionnaire, 12-lead ECG and echocardiogram. The FA registry was interrogated for screening findings, subsequent testing, diagnosis and cardiac morbidity or mortality, including sudden cardiac arrest and death (SCA/SCD). Sex-based comparisons were performed in 2680 females screened between 2017 and 2024, matched 1:2 by age, ethnicity and screening period to 5360 male players screened through the same programme. RESULTS:Female athletes were 19.8±5.4 years old, and the majority (87%) were White. Among 3121 female football players, 193 (6.2%) had an abnormal screening result requiring further evaluation; positive health questionnaires were present in 321 (10.3%), of which two (0.6%) athletes were true-positive for major cardiac conditions. Abnormal ECGs were present in 77 (2.5%), of which four (5.2%) were true positives. Major cardiac conditions were diagnosed in six (0.2%), including four with long QT syndrome, one with Wolff-Parkinson-White syndrome and one with bicuspid aortic valve with moderate to severe aortic regurgitation. No female had cardiomyopathy diagnosed at baseline; however, one (0.03%) was diagnosed with arrhythmogenic cardiomyopathy 18 months later. During 19 193 person-years of follow-up, no female experienced SCA/SCD. In matched analysis, major cardiac conditions were diagnosed in five females (0.2%) and 29 males (0.5%; p=0.027), with higher estimated screening expenditure per major diagnosis in females (£146 809 vs £51 888). CONCLUSIONS:Cardiovascular screening in elite female football players identified a low prevalence of major cardiac conditions, predominantly electrical disorders, with no cardiomyopathy diagnosed at baseline and no SCA/SCD during follow-up. As female participation in elite sport continues to grow, these findings support the need for sex-appropriate interpretation and adequate budgeting for pre-participation cardiovascular evaluation.
OBJECTIVE:To describe the incidence, severity, burden and risk factors of training-related concussion injuries in elite men's Rugby Union. METHODS:Training-related concussions recorded as part of the Professional Rugby Injury Surveillance Project were examined between the 2016/2017 and 2023/2024 seasons. Incidence rates (per 1000 hours) were calculated with 95% CIs. Poisson regression and incidence rate ratios described season-to-season changes in concussion incidence. A generalised linear mixed model assessed the influence of time in season, match minutes played in the previous 28 days, dominant training type and previous concussion as fixed effects, accounting for weekly training exposure. Random intercepts included player and team. RESULTS:The incidence of concussions in training was 0.23 per 1000 hours (95% CI 0.22 to 0.29). The mean severity (days absent) of concussions was 18 days (95% CI 15 to 21). The burden of training concussions was 4.16 days absent per 1000 hours (95% CI 3.57 to 4.85). The tackle (46%) and accidental collisions (26%) were the most common inciting events. The incidence of training-related concussions was significantly higher in the 2021/2022, 2022/2023 and 2023/2024 seasons compared with the 2016/2017 season. Preseason (incidence rate ratio (IRR) 1.80 (95% CI 1.24 to 2.60), p=0.01) and full-contact training (IRR 2.20 (95% CI 1.17 to 4.12), p=0.01) were associated with a higher risk of concussion compared with the final 3 months of the season and non-contact training. CONCLUSION:Full-contact training and the preseason period are associated with an increased risk of training-related concussion. Accordingly, full-contact and preseason training should be strategically planned to minimise risk.
Objectives To assess (1) the association between mental health symptoms and subsequent injury and (2) the association between injury and subsequent mental health symptoms. Design Systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data sources EBSCO APA, PsycINFO, EBSCO SportDiscus, Scopus and PubMed (Medline) from inception until June 2025. Eligibility criteria We included original quantitative studies, written in English, of current or former elite athletes that included the incidence or prevalence of musculoskeletal injury (not including head injuries) resulting in time loss or modified sport activity and incidence or prevalence of mental health symptoms or disorders. Results A total of 25 studies were included; 13 prospective, 9 cross-sectional, 2 mixed and 1 interventional study. Differing definitions of injury and substantial heterogeneity of symptom measures (including related psychosocial outcomes) assessed mental health. Nine of 11 studies that assessed mental health symptoms found an association with subsequent injury and 10 of 13 studies that assessed injury found an association with subsequent mental health symptoms. Conclusions In elite athletes, there is an association between injuries and mental health symptoms though study designs limit the ability to determine bidirectionality. This warrants standardised screening for mental health symptoms in elite athletes as a potential risk factor for injury as well as in assessing the response to injury.
