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ObjectiveTo describe the epidemiology of injuries at the Sochi 2014 Winter Paralympic Games.MethodsA total of 547 athletes from 45 countries were monitored daily for 12 days during the Sochi 2014 Winter Paralympic Games (6564 athlete days). Daily injury data were obtained from teams with their own medical support (32 teams, 510 athletes) and teams without their own medical support (13 teams, 37 athletes) through electronic data capturing systems.ResultsThere were 174 total injuries reported, with an injury incidence rate (IR) of 26.5 per 1000 athlete days (95% CI 22.7% to 30.8%). There was a significantly higher IR recorded in alpine skiing/snowboarding (IR of 41.1 (95% CI 33.7% to 49.6%) p=0.0001) compared to cross-country skiing/biathlon, ice sledge hockey or wheelchair curling. Injuries in the shoulder region were the highest single-joint IR (IR of 6.4 (95% CI 4.6% to 8.6%)), although total upper and lower body IR were similar (IR 8.5 vs 8.4 (95% CI 6.4% to 11.1%)). Furthermore, the IR of acute injuries was significantly higher than other types of injury onset (IR of 17.8 (95% CI 14.7% to 21.4%)).ConclusionsIn a Winter Paralympic Games setting, athletes report higher injury incidence than do Olympic athletes or athletes in a Summer Paralympic Games setting. The highest incidence of injury was reported in the alpine skiing/snowboarding sporting category. There was a similar incidence of injury in the upper and lower limbs. The joint with the greatest rate of injury reported was the shoulder joint. Our data can inform injury prevention programmes and policy considerations regarding athlete safety in future Winter Paralympic Games.

ObjectiveTo describe the epidemiology of illness at the Sochi 2014 Winter Paralympic Games.MethodsA total of 547 athletes from 45 countries were monitored daily for 12 days over the Sochi 2014 Winter Paralympic Games (6564 athlete days). Illness data were obtained daily from teams without their own medical support (13 teams, 37 athletes) and teams with their own medical support (32 teams, 510 athletes) through electronic data capturing systems.ResultsThe total number of illnesses reported was 123, with an illness incidence rate (IR) of 18.7 per 1000 athlete days (95% CI 15.1% to 23.2%). The highest IR was reported for wheelchair curling (IR of 20.0 (95% CI 10.1% to 39.6%)). Illnesses in the respiratory system (IR of 5.6 (95% CI 3.8% to 8.0%)), eye and adnexa (IR of 2.7 (95% CI 1.7% to 4.4%)) and digestive system (IR of 2.4 (95% CI 1.4% to 4.2%)) were the most common. Older athletes (35–63 years) had a significantly higher IR than younger athletes (14–25 years, p=0.049).ConclusionsThe results of this study indicate that Paralympic athletes report higher illness incidence rates compared to Olympic athletes at similar competitions. The highest rates of illness were reported for the respiratory and digestive systems, eye and adnexa, respectively. Thus, the results of this study form a basis for the identification of physiological systems at higher risk of illness, which can in turn inform illness prevention and management programmes with eventual policy change to promote athlete safety in future editions of the Winter Paralympic Games.

Shoe choice by runners may follow trends related to purported generalised benefits rather than following an individual riskbenefit analysis. The benefits and risks related to minimalist footwear for running has been a much debated topic. The authors report a case of a complete calcaneal stress fracture in an otherwise healthy female recreational runner in the first three weeks following her conversion from a traditional cushioned running shoe to a minimalist type of running shoe. Clinicians should be aware of the potential added bone stress with reduced cushioning and the potential risks in transitioning to new footwear.

Background: In an acute field-side setting, it is often challenging to differentiate benign sports-related concussion (SRC) from potential, more sinister, intracranial pathology. Moreover, recovery in the ensuing days and weeks is often complex as the resolution of classical signs and symptoms does not always follow a standard pattern. Aim: To highlight the value of a structured and repeated thorough clinical assessment approach toward SRC, particularly as atypical and unexpected sequences in patient recovery patterns may require further specialist referral and intervention. Findings: A football goalkeeper sustained a concussion in which symptoms failed to resolve as expected. Deterioration in his clinical condition led to an eventual diagnosis of Chiari malformation (type I), which required surgical intervention.Implications: Non-typical recovery patterns of concussion may be indicative of increased severity when considered retrospectively. However, clinicians should not discount the possibility of underlying conditions. Keywords: concussion, soccer, sports-related head injury

This case series describes the observed presence of echogenic circular \"beads\" identified by high-resolution ultrasound imaging in the peripheral arterial walls of the lower limbs of three vascularly asymptomatic runners. The aetiology, mechanisms and clinical implications of these observations remain uncertain.

Background:Sports-related concussion (SRC) is an injury with important implications, especially in collision and contact sports, and has a high symptom burden. Student athletes face particular psychosocial challenges, especially female students with pre-existing anxiety/depression are at increased risk for SRC, and have a higher symptom burden before and after injury.Objectives:Describing female SRC presenting features at a collegiate campus-based sports medicine service; examining the association of prior concussion history (PCONC) and pre-existing anxiety/depression (PMHDx) with SRC.Methods:A retrospective cohort and statistical analysis (including corrected effect sizes) of Sport Concussion Assessment Tool (versions 3/5) data (Step 1: PCONC and PMHDx history; Step 2: symptom evaluation) of collegiate female athletes with SRC between 2012 and 2018.Results:Forty females with SRC were identified (age 23 ± 3). The five most frequent symptoms were headache (n = 34; 85%), feeling slowed down (n = 33; 83%), pressure in head (n = 33; 83%), don't feel right (n = 32; 80%) and fatigue/low-energy (n = 32; 80%). These five symptoms also had the highest self-rated severity (median (IQR): headache (3 (2-4)), feeling slowed down (3 (1-4)), fatigue/low-energy (3 (1-5)), don't feel right (3 (1-4)) and pressure in head (3 (2-4)). PMHDx (n = 8; 62.9 vs 38.6; p = 0.0192; Hedges' gs = 0.95; large ES), and not PCONC (n = 13; 51.0 vs 39.8; p = 0.2183; Hedges' gs = 0.48; small ES) was associated with increased mean total symptom severity.Conclusion:Headache, feeling slowed down, pressure in head, don't feel right and fatigue/low-energy had the highest symptom burden. Total symptom severity was no different in those with and without PCONC, but significantly higher in those with PMHDx.

To determine the feasibility of using a trial within cohort (TWIC) design as a model to study pragmatic interventions in a low-resource setting to ensure that (i) ethical concerns raised with the conventional clinical trial design could be alleviated, (ii) key parameters could be obtained that may promote implementation of interventions in low-resource settings, although retaining the methodological rigor required to assess real-world efficacy. A TWIC design was adopted to evaluate the feasibility of a community-based, patient-centered rehabilitation program, in an underprivileged South African community. Procedural aspects of the trial in relation to recruitment, retention, acceptance, and methodological rigor were evaluated. A total of 74 eligible participants, 36% of those who were identified as potential participants, agreed to participate and were randomized. Acceptance of the intervention (56%) was in line with previous research, and no reports of cross-contamination were received. Key lessons were learnt in the conduct of a TWIC design in low-resource settings, among others, related to blinding of the assessor, missing data, timing of recruitment, and various resource constraints. The findings of this study support further exploration for the use of this design in low-resource settings, particularly in settings where the conventional randomized clinical trial is ethically challenging or where detailed information on nonacceptance is paramount. •Challenges in the conduct of randomized clinical trials in low-resource settings may impede upscaling and policy initiatives that aim to promote health equity and more pragmatic designs may be needed.•Of particular concern is randomization to usual care when usual care is suboptimal or when the experimental intervention is in high desirable.•The Trial Within Cohort design may be a pragmatic alternative to the conventional RCT and may alleviate ethical concerns, while retaining methodological rigor.•Based on a feasibility study within the rehabilitation space, using a trial within cohort design, to potential value and challenges of using the trial within cohort design were explored.

Background: Sacroiliac tuberculosis is a rare condition for which early diagnosis and effective management frequently proves challenging. This report describes a case that was initially overlooked due to its presentation and unreported constitutional symptoms. Aim: To alert clinicians about skeletal tuberculosis, an often neglected diagnostic differential, which requires a high index of clinical suspicion, especially for patients from endemic areas. Findings: This patient's presentation (sports injury) and unreported constitutional symptoms resulted in a delay in the diagnosis and initial institution of treatment. Implications: This report illustrates the importance of specifically asking about constitutional symptoms, even in sports injury settings and being mindful of infectious diseases or other chronic medical conditions, which may masquerade as common sports injuries. Keywords: skeletal tuberculosis, sacroiliitis, hip pain

This case report discusses a stress fracture of the thoracic spine in a professional South African rugby union player. This is a rare anatomical location for this type of injury in this population and has not previously been described. Physicians should be aware that performance of rugby specific movements may lead to rare stress fractures in certain anatomic locations.