Although the strain of long-distance running on the skin and cardiorespiratory system is well recognized,1,2 strain on the venous and lymphatic systems is often overlooked. Here, we document a case of bilateral lower extremity inflammatory lymphedema (BLEIL) after an ultramarathon race in an otherwise healthy male endurance athlete.

We report catastrophic, displaced long bone fractures while jogging in three young (ages 19 to 21 years) active-duty military men without pain until the moment of fracture.

ABSTRACT Introduction/Purpose Bone stress injuries (BSI) are a leading medical diagnosis and cause of training disruptions and increased costs in US Air Force basic military training (BMT). Currently, as required by law, all trainees are issued athletic shoes upon arrival to BMT; however, the issued shoes are often disliked by trainees and are suspected of contributing to injury. This study investigated the effect of issuing shoes with lighter weight, lower heel-to-toe drop, and wider toe box than the standard-issue shoes to compare comfort, musculoskeletal injuries, and training outcomes. Methods In this blinded, randomized controlled product evaluation, trainees of a single BMT squadron were issued either the standard-issue shoes or a lighter-weight alternative; following completion of BMT, male and female cohorts were compared for differences in fitness assessment results, musculoskeletal injuries, and graduation delays using routinely collected databases. Associations between categorical variables were analyzed using a chi-square test with significance set to α ≤ 0.05. Results Among male trainees, issuing the lighter-weight shoe resulted in an absolute risk reduction of 6.05% (from 13.87% to 7.82%) and a relative risk reduction of 43.62% for BSI. Also, trainees who received the heavier standard-issue shoes noted the shoes to be “too uncomfortable to wear” at a significantly higher rate. Conclusion Issuing shoes with lighter weight, smaller heel-to-toe drop, and wider toe box appears to reduce the risk of BSI and shoe dissatisfaction among male BMT trainees; such shoe characteristics should be considered for use in populations engaging in similar physical training.

Abstract The COVID-19 pandemic has created numerous challenges in all walks of life. One such challenge was the strain and subsequent effects on medical education, including the elimination of in-person learning opportunities. Consequently, in March of 2020, a nationwide Sports Medicine fellowship online education series was developed. Presentations were available for live and recorded viewing. Over the course of the 2020–2021 academic year, 38 presentations were offered, covering 45 topics. Live viewership totaled nearly 1600 through the year, while views of recorded lecture reached nearly 34,000. There was no statistical difference in the number of viewers for musculoskeletal versus nonmusculoskeletal topics in either the live (46.50 ± 35.37 vs. 43.38 ± 27.28 viewers, respectively; P = 0.77) or recorded formats (843.60 ± 337.66 vs 876.67 ± 624.70 viewers, respectively; P = 0.85). This article presents the novel approach to sports medicine education by the American Medical Society for Sports Medicine in the 2020–2021 academic year through the genesis the National Online Fellowship Education Program along with analyses of viewership data.

Facing pressure to train for victory, warfighters and athletes encounter numerous health risks that are directly related to their regular physical training. The concept of universal training precautions (UTPs) signifies universal processes designed to prevent unnecessary bodily harm, including injury, illness, and death, during physical training programs. Although no formal guidelines exist for collectively implementing a defined set of UTPs to address a broad scope of exercise-related health risks, recommendations and guidelines have been published relating to preventing sudden death during high school sports and collegiate conditioning sessions. A long list of critical topics must be considered as UTPs, including physical fitness factors, transition-period accommodation, hydration, environmental factors and acclimatization, appropriate recovery, use of medications and dietary supplements, and importantly, leadership. In this article, we outline in detail, with corresponding Strength of Recommendation Taxonomy ratings, what should be considered universal recommendations to minimize the risk of warfighters and athletes coming to harm when participating in group physical activities.

Abstract Exertional rhabdomyolysis (ER) is an uncommon condition with a paucity of evidence-based guidance for diagnosis, management, and return to duty or play. Recently, a clinical practice guideline for diagnosis and management of ER in warfighters was updated by a team of military and civilian physicians and researchers using current scientific literature and decades of experience within the military population. The revision concentrated on challenging and controversial clinical questions with applicability to providers in the military and those in the greater sports medicine community. Specific topics addressed: 1) diagnostic criteria for ER; 2) clinical decision making for outpatient versus inpatient treatment; 3) optimal strategies for inpatient management; 4) discharge criteria; 5) identification and assessment of warfighters/athletes at risk for recurrent ER; 6) an appropriate rehabilitative plan; and finally, 7) key clinical questions warranting future research.

Sickle cell trait (SCT) is associated with incident exertional rhabdomyolysis, but its effect on disease progression and severity is poorly understood. Of 377 exertional rhabdomyolysis cases diagnosed between 2009 and 2018 in the active component of the U.S. Air Force, 200 had records available for chart review, and 185 of these had known SCT status. Pre- and post-event data were stratified by SCT status, and serum chemistry changes among SCT-positive (n=11) and SCT-negative (n=174) airmen were compared using Wilcoxon-Mann-Whitney tests. Of the 200 cases with records available for chart review, 110 (55.0%) were hospitalized; 98 (56.3%) of the 174 who were SCT-negative were hospitalized. Also hospitalized were 4 (36.4%) of the 11 who were SCT-positive, and 8 (53.3%) of the 15 with unknown SCT status. Of the 7 airmen who were admitted to intensive care, 4 required hemodialysis, and 1 underwent a fasciotomy; all 7 were SCT-negative. Alterations in creatine kinase, potassium, creatinine, troponin I, and hemoglobin were statistically equivalent between those with and without SCT. Providers should maintain a high index of suspicion for exertional rhabdomyolysis, especially in warm climates and in the context of high-intensity activities, but should not presume that the presence of SCT portends a higher risk of complications or worse clinical outcomes.

Webber, Bryant J. MD, MPH; Nye, Nathaniel S. MD; Harmon, Kimberly G. MD, FACSM; O'Connor, Francis G. MD, MPH, FACSM Author Information

Abstract Although largely benign, sickle cell trait (SCT) has been associated with exertion-related events, to include sudden death. In 2011, a summit on SCT introduced the term exercise collapse associated with SCT (ECAST). A series of ECAST deaths in military personnel in 2019 prompted reevaluation of current efforts and led to a second summit in October 2019 hosted by the Consortium for Health and Military Performance of the Uniformed Services University in Bethesda, MD. The goals were to (1) review current service policies on SCT screening, (2) develop draft procedural instructions for executing current policy on SCT within the Department of Defense, (3) develop draft clinical practice guidelines for management of ECAST, (4) establish a framework for education on SCT and ECAST, and (5) prepare a research agenda to address identified gaps.

Nine runners with varied experience but similar running-gait forms presented with the insidious and progressive onset of medial knee pain. Functional tightness of the semimembranosus (SM) tendon appeared to be a concomitant factor in the pain presentation of these patients. When evaluating atraumatic medial knee pain in runners, clinicians must consider bone stress injuries and atypical conditions. A functionally tight SM may induce pain and desmopathy of the medial collateral ligament through direct fiber entanglement or cause entrapment of infrapatellar branches of the saphenous nerve or both. Relieving SM tension resulted in short-term pain reduction while eliminating the overstride during the running gait over the long term appeared to prevent recurrence.

Background: A novel algorithm and clinical prediction rule (CPR), with 18 variables, was created in 2014. The CPR generated a bone stress injury (BSI) score, which was used to determine the necessity of imaging in suspected BSI. To date, there are no validated algorithms for imaging selection in patients with suspected BSI. Hypothesis: A simplified CPR will assist clinicians with diagnosis and decision making in patients with suspected BSI. Study Design: Prospective cohort study. Level of Evidence: Level 3. Methods: A total of 778 military trainees with lower extremity pain were enrolled. All trainees were evaluated for 18 clinical variables suggesting BSI. Participants were monitored via electronic medical record review. Then, a prediction model was developed using logistic regression to identify clinical variables with the greatest predictive value and assigned appropriate weight. Test characteristics for various BSI score thresholds were calculated. Results: Of the enrolled trainees, 204 had imaging-confirmed BSI in or distal to the femoral condyles. The optimized CPR selected 4 clinical variables (weighted score): bony tenderness (3), prior history of BSI (2), pes cavus (2), and increased walking/running volume (1). The optimized CPR with a score ≥3 yielded 97.5% sensitivity, 54.2% specificity, and 98.2% negative predictive value. An isolated measure, bony tenderness, demonstrated similar statistical performance. Conclusion: The optimized CPR, which uses bony tenderness, prior history of BSI, pes cavus, and increased walking/running volume, is valid for detecting BSI in or distal to the femoral condyles. However, bony tenderness alone provides a simpler criterion with an equally strong negative predictive value for BSI decision making. Clinical Relevance: For suspected BSI in or distal to the femoral condyles, imaging can be deferred when there is no bony tenderness. When bony tenderness is present in the setting of 1 or more proven risk factors and no clinical evidence of high-risk bone involvement, presumptive treatment for BSI and serial radiographs may be appropriate.

CONTEXT:Musculoskeletal injury is the leading cause of attrition from military training.OBJECTIVE:To assess the effect of an embedded athletic training musculoskeletal care model within a basic military training unit.DESIGN:Cluster randomized trial.SETTING:United States Air Force Basic Military Training, Joint Base San Antonio-Lackland.PATIENTS OR OTHER PARTICIPANTS:Military recruits randomly assigned to 1 of 3 training squadrons, 2 control and 1 experimental, between January 2016 and December 2018.INTERVENTION(S):A sports medicine care model was established in 1 squadron by embedding 2 certified athletic trainers overseen by a sports medicine fellowship-trained physician. The athletic trainers diagnosed and coordinated rehabilitation as the primary point of contact for recruits and developed interventions with medical and military leadership based on injury trends.MAIN OUTCOME MEASURE(S):Recruit attrition from basic training due to a musculoskeletal injury. Secondary outcomes were all-cause attrition, on-time graduation, rates of lower extremity injury and stress fracture, rates of specialty care appointments, and fiscal costs.RESULTS:Recruits in the athletic training musculoskeletal care arm experienced 25% lower musculoskeletal-related attrition (risk ratio = 0.75 [95% CI = 0.64, 0.89]) and 15% lower all-cause attrition (risk ratio = 0.85 [95% CI = 0.80, 0.91]), translating to a net saving of more than $10 million. The intervention reduced the incidence of lower extremity stress fracture by 16% (rate ratio = 0.84 [95% CI = 0.73, 0.97]).CONCLUSIONS:An embedded athletic training musculoskeletal care model outperformed usual care across operational, medical, and fiscal outcomes.

ABSTRACT Bone stress injuries (BSI) may be classified as high- or low-risk based on the anatomic location of injury and by grade based on severity. Kaeding grade II (K-GII) BSI are characterized by symptomatic marrow or periosteal edema without a fracture line. This retrospective cohort study aims to compare outcomes between high- and low-risk K-GII BSI. We hypothesize that patients with high- and low-risk K-GII BSI experience similar recovery rates. Data were collected via chart review on all patients at a primary care clinic with a magnetic resonance imaging–confirmed diagnosis of K-GII BSI during a 15-month surveillance period. High- and low-risk patients were compared for two primary outcomes—time to become asymptomatic and time to return to activity—and for the secondary outcome of treatments received. A total of 129 K-GII BSI were sustained by 87 patients. For all patients diagnosed with a K-GII BSI, the mean time to become asymptomatic was 40 ± 27 d, and the mean time to return to activity was 49 ± 31 d. There was no difference in time to become asymptomatic ( P = 0.762) or to return to activity ( P = 0.164) between high-risk ( n = 20) and low-risk ( n = 67) patients. Treatment modalities were similar between the two groups. All K-GII BSI healed with nonoperative treatment at similar rates, regardless of classification as high- or low-risk, to include tarsal navicular and talus BSI. Early identification of BSI, before progression to a fracture line, leads to favorable results for both high- and low-risk K-GII BSI.