Stress reactions occur from repetitive loads that weaken the bone and are often associated with nutritional deficiencies and metabolic dysfunction. More commonly, these injuries are reported in the lower extremities, with less literature on stress fractures in the upper extremities. Seven patients presented with chronic, atraumatic wrist pain that did not improve with conservative measures. Magnetic resonance imaging (MRI) demonstrated increased signal on T2, suggestive of carpal stress reaction. Patients had documented low vitamin D levels or levels obtained after MRI confirmation of stress injury. All patients showed improvement in symptoms after targeted vitamin D supplementation and nutritional management; none of the patients required surgical intervention. Stress reactions in the hand and wrist are relatively uncommon. These injuries, and underlying metabolic abnormalities, can be missed easily without a careful history and work-up. Recognizing these injuries and correcting contributing factors can help avoid more catastrophic skeletal stress injuries in the lower extremities, such as the tibia or femoral neck.
Background: Linemen make up over 90% of all exertional heat stroke (EHS) deaths in collegiate and secondary school American football deaths. Purpose: This document aims to accomplish 3 purposes: (1) briefly summarize the need for specific risk reduction recommendations for EHS in secondary school and collegiate American football linemen, (2) provide new recommendations for the reduction of EHS in football linemen developed with Delphi procedures to build consensus, and (3) summarize the evidence for the existing and new best-practice recommendations that currently exist for EHS risk reduction. Design: Delphi-based Task Force Recommendations. Level of Evidence: Level 3. Methods: A multidisciplinary group of experts was convened to build consensus on EHS risk reduction strategies for secondary school and collegiate football linemen. The process involved a narrative review of relevant literature, followed by iterative rounds of anonymous Delphi surveys to refine and validate the recommendations. Results: A total of 20 recommendations were identified, scored, and retained for EHS risk reduction in American football linemen. Key recommendations include the education of coaches and strength and conditioning coaches on EHS risk reduction and treatment, the implementation of heat acclimatization protocols, and weather-based exercise modifications. The recommendations emphasize the importance of the avoidance of high-intensity aerobic testing during transition periods and the importance of having on-site cooling modalities. Conclusion: The high rates of EHS in American football linemen highlight the need for targeted risk reduction strategies. In American football, the design and implementation of workouts for linemen must differ from other players on the team. Linemen require position-specific work-to-rest ratios and tailored training programs. Clinical Relevance: By adhering to best practices and continuously updating guidelines based on emerging evidence, the safety and well-being of American football players can be significantly enhanced. These recommendations provide a comprehensive framework for reducing the risk of EHS and improving outcomes for American football linemen.
Background: Sleep extension has been shown to improve varied aspects of athletic performance in collegiate athletes. Such studies have been conducted in small cohorts in controlled settings utilizing obsolete monitoring technology. The feasibility of sleep extension has not been evaluated in a broader cohort of collegiate athletes with modern monitoring technology. Hypothesis: Sleep extension may not be feasible in National Collegiate Athletic Association (NCAA) Division I athletes. Study Design: Crossover study. Level of Evidence: Level 3. Methods: Baseline sleep data were collected from NCAA Division I athletes (women’s soccer, men’s soccer, baseball, and football) during a 2-week period. Subjects were then instructed to extend their total sleep time to 10 hours per night for 2 weeks. All sleep baseline and extension data were collected in the offseason, remote from school examinations. WHOOP bands recorded all sleep metrics. Data were analyzed using paired-samples t tests and Wilcoxon signed rank tests. Results: A total of 50 subjects (14 female, 36 male) participated. The study compared total sleep time (hours) and sleep consistency (percent) - the stability of sleep-wake schedule over time, between baseline and sleep extension phases. Sample size varied for both metrics, ranging from 46 to 49 participants, respectively. There was a statistically significant increase in sleep consistency during the sleep extension phase (baseline, 60.09 ± 12.6%; extension, 64.42 ± 12.4%; P = 0.02). However, total sleep time showed no significant difference between the 2 phases (baseline, 7.63 ± 0.88 hours; extension, 7.51 ± 0.88 hours; P = 0.27). Conclusion: Extension efforts improved sleep consistency but did not significantly impact total sleep time suggesting that a sleep extension intervention can enhance sleep consistency in NCAA Division I athletes but does not significantly impact total sleep time. Sleep extension may be challenging for collegiate athletes given the time-intensive demands of both academics and sports. While sleep extension may be feasible in professional sports, it does not appear to be so in the college setting. Clinical Relevance: While the sleep extension intervention improved sleep consistency, it did not improve total sleep time, questioning the feasibility of sleep extension in collegiate sports.
Context: Ultramarathon events impose prolonged physiological and cognitive demands, often spanning 1 or more nights with limited sleep opportunity. Objective: To examine associations between pre-race and intra-race sleep strategies and physical and cognitive performance outcomes in ultramarathon runners. Data Sources: PubMed, EMBASE, PsycINFO, SPORTDiscus, and Web of Science were searched from inception to July 25, 2025. Study Selection: Primary observational or experimental studies published in English, or available in English translation were eligible when they involved ultramarathon runners (>42.2 km) and reported sleep as a variable of interest in relation to race performance or cognitive performance. Study Design: Systematic review. Level of Evidence: Level 3. Data Extraction: Two reviewers independently extracted study design, participant characteristics, race characteristics, sleep outcomes, performance outcomes, and cognitive outcomes. Methodological quality was assessed using the Joanna Briggs Institute critical appraisal checklists. Results: Nine studies involving 2262 participants were included, with overall low risk of bias. Of the 4 studies examining pre-race sleep, 3 reported a significant association or group difference with a race-performance outcome. Reduced sleep was generally associated with poorer physical and cognitive performance. Greater intra-race sleep duration was consistently associated with longer finish times, reflecting additional nonmoving time and increased sleep need in longer events. Greater pre-race sleep duration, including sleep extension, was associated with faster finish times, and better pre-race sleep quality was linked to higher cognitive performance. Conclusion: Pre-race sleep extension was associated with faster finish times, although the observational evidence does not establish causality. Further research using objective sleep measures and controlled designs is required.
Background: Magnetic resonance imaging (MRI) is the gold standard for monitoring the evolution of muscle injuries in athletes, although no established quantitative measure of recovery currently exists. Hypothesis: Apparent diffusion coefficient (ADC) values may provide a quantitative measure of muscle healing, and sex-related differences may exist in the evolution of muscle injuries. Study Design: Single-center retrospective observational cohort study. Level of Evidence: Level 2a. Methods: Twenty-six professional football (soccer) players (13 male ,13 female) undergoing MRI for muscle injury were retrospectively selected between October 2020 and June 2024. All athletes underwent MRI at baseline (T0) and at 2-week follow-up, including diffusion-weighted imaging (DWI) acquisitions with b values of 0-100-800 s/mm ² . Two musculoskeletal radiologists measured ADC values within the index lesions at each examination. Changes in ADC between the two time points (ΔADC) were assessed using a paired-samples t test, while sex-related differences were evaluated using the Mann–Whitney U test. Results: The overall mean ADC value at the lesion site decreased from 2.06 ± 0.35 mm 2 /s at T0 to 1.61 ± 0.30 mm 2 /s at follow-up corresponding to a mean ΔADC of 0.44 ± 0.20 and a 21.84% reduction. The difference between T0 and follow-up was statistically significant ( t = 8.12; P < 0.001). Mean ΔADC values were 0.32 ± 0.20 mm ² /s in male players and 0.56 ± 0.25 mm ² /s in female players, respectively, with a statistically significant difference between sexes (z = −2.95; P = 0.003). When only hamstring injuries were considered, female players showed a significantly greater decrease in ADC over time than male players (Mann–Whitney U test; exact P = 0.02), with mean ΔADC values of 0.56 ± 0.30 and 0.26 ± 0.08 mm ² /s, respectively. Conclusion: Muscle injury is associated with an acute increase in ADC values followed by a progressive decrease during healing. ADC may therefore represent a quantitative imaging biomarker for monitoring muscle recovery. Clinical Relevance: ADC measurement within muscle tears may provide a quantitative assessment of healing status and support individualized rehabilitation strategies in athletes. Sex-related differences may exist in injury pathophysiology and recovery patterns relevant to safe return to play.
