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September 2021 - Volume 31 - Issue 5

  • Christopher Hughes, MBBS, MSc
  • 1050-642X
  • 1536-3724
  • 6 issues / year
  • Orthopedics 27/81
    Sport Sciences 18/82
    Physiology 27/81
  • 3.638
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​Welcome to the fifth issue of the Clinical Journal of Sport Medicine in 2021. We have a bumper issue for you this month, with no less than nineteen Original Research papers included. 

We kick off with the topic of cardiovascular screening in sport. A variety of different cardiac screening strategies are adopted by different organizations and sports societies around the world, and controversy exists with regard to the role of cardiac screening and the content of cardiac screening programmes. Readers will recall that the American Medical Society for Sports Medicine has previously provided a comprehensive Position Statement on the cardiovascular screening of athletes, published in CJSM in 2016, which offers a framework for the assessment of screening recommendations together with future research directions, and is well worth revisiting.  

In our first Original Research article this issue, Orchard and Colleagues surveyed Chief Medical Officers in Australia regarding each of their respective sport's cardiac screening policies seeking information on applicability, screening components, and ECG interpretation criteria used. They found that most sports have a screening policy in place, with similar screening components used amongst most sports. Resting ECG screening was used in 89% of all sports surveyed. Interestingly, 42% of respondents indicated that the costs of screening tests were born by athletes, with over half of sports requiring athletes to pay out-of-pocket tests for follow-up tests as required. 

Cardiac screening can be a time-consuming and costly process, and efficiency is an important consideration when screening a large population.  

Dennison and Colleagues conducted a study to determine the feasibility of simultaneously conducting history and physical examination, together with ECG and limited cardiac echo measurements performed by front-line providers, on cohorts of college athletes at a single institution over 2 years. They compared a 3-station model incorporating a 12-lead ECG during the first year with a single-station model incorporating limb-lead ECG the year after. They found that examination time was significantly reduced using limb-lead ECG in the 2-station model rather than 12-lead ECG in the 3-station model. Limitations of the study due to sample size the single-institution study setting led the Authors to suggest that more studies are required to fully quantify any potential improvements and to ensure there are no unacceptable differences in screening sensitivity and specificity between the two methods of screening used in the study.

With regard to the outcome of the cardiac screening process for an athlete, an interesting ethical question may be posed as to whether this should lead to a 'yes or no' decision on eligibility for sports participation made by the assessing clinician on behalf of the patient, or whether a shared-decision making process should be adopted, with the ultimate decision on participation being taken by an informed patient in combination with the recommendations of the clinician

Shared decision-making is far from a new concept in medicine, but not all clinicians or others working in sport may be fully aware of its importance. 

In our Brief Report this month, Phelan and Colleagues surveyed athletic trainers (ATs) from the Ohio High School Athletic Association to assess familiarity with this term in the context of sports participation in student athletes with known cardiac disease. They found that most ATs were not familiar with the term in this context, and concluded that improving collaboration between ATs and clinicians is of primary importance if shared decision making strategies are to be adpoted and used widely. 

Our third article on a cardiac theme concerns the impact of sports participation on clinical outcomes following mitral valve repair for primary mitral regurgitation. Blanc and Colleagues retrospectively assessed patients who underwent mitral valve repair in one institution between 2010 and 2017, finding that participation in sports and physical activity did not appear to be related to the worst outcomes following surgery, and concluding that eligibility for sports participation following repair surgery should be considered on an individual basis in the absence of other contraindications. 

The race for global population vaccination in the context of the current SARS-CoV-2 pandemic is on. In addition to the huge problems posed by the pandemic, many clinicians are also worried about the possibility of a surge in winter influenza infections and are emphasizing the importance of seasonal flu vaccination programmes this year to prevent healthcare systems becoming overwhelmed.  

Krzywanski and Colleagues evaluated the safety and tolerance of influenza vaccines for the northern and southern hemispheres amongst Polish elite athletes who participated in the Rio 2016 Olympics, finding that the athletes generally tolerated immunization well with most adverse events occurring locally (pain at injection site), although advising that athletes may require training modification particularly in the first 2 days post-vaccination due to more general side effects. 

The historical concept of an enforced period of strict rest from exercise following sports-related concussion has recently been challenged, with studies now indicating the potential benefits of early supervised aerobic exercise for asymptomatic individuals diagnosed with sports-related concussion. However, many clinicians may be uncomfortable or inexperienced with prescribing exercise in this context. 

In our Practical Management article this month, Bezherano and Colleagues offer advice to clinicians who may wish to prescribe early subsymptom threshold aerobic exercise for patients with sports-related concussionThey present 3 suggested methods of exercise prescription, and consider the limitations of each of these. CJSM will be interested to hear from readers on their own views and experience of the use of early aerobic exercise in the context of sports-related concussion. 

In addition to these, we bring you a wealth of original research articles on the topic of sports-related concussion this issue including amongst others the acute effects of concussion in youth with pre-existing migraines, relationships between concussion history and attention-deficit / hyperactivity disorder in middle school children, and sport motivation as a possible indicator of concussion reporting intentions among young athletes. Other research topics this month include video analysis of acute injuries in field hockey, prognosis of incomplete avulsion of the proximal hamstring tendon in relation to the proximal hamstring tendon footprint, and arthroscopic primary repair for partial proximal anterior cruciate ligament tears amongst military personnel. 

Following on from our feature articles last issue from the female and male athlete triad coalition on the male athlete triad, CJSM Deputy Editor James MacDonald interviews the two lead Authors of these articles, Dr Aurelia Nattiv and Dr Michael Fredericson in our 50th CJSM podcast which will be available shortly in our podcast collection. 

CJSM is now on Instagram as well as our other social media outlets including Twitter and Facebook, so don't forget to keep an eye out for us on these sites as well as on the CJSM Blog to keep up to date with what's going on in the world of Sports Medicine. 

Our bank of CME articles on the Lippincott CME Connection website continues to grow, with recent additions on topics including injectable corticosteroids in sport, and there will be more to come later this month. Also, forget to test your clinical reasoning skills with our clinical case studies, produced in association with AMSSM and AOASM and available for free on our website​

Enjoy the issue. Wishing you a great September and October, and looking forward to touching base with you again in November. In the meantime, stay safe and look after yourselves. 

Best wishes,



Christopher Hughes MBBS MSc


Cardiovascular Screening of Elite Athletes by Sporting Organizations in Australia: A Survey of Chief Medical Officers

Orchard, Jessica J.; Orchard, John W.; Toresdahl, Brett; More

Clinical Journal of Sport Medicine. 31(5):401-406, September 2021.

Cardiovascular screening of elite athletes by sporting organizations in Australia: A survey of chief medical officers

“Shared Decision-Making” in Athletes With Known Cardiac Disease: Interpretation and Implementation in the Real World

Phelan, Dermot; Farokhrani, Amin; Retallick, Rachel; More

Clinical Journal of Sport Medicine. 31(5):453-454, September 2021.

Shared decision-making in athletes with known cardiac disease: Interpretation and implementation in the real world

Safety and Impact on Training of the Influenza Vaccines in Elite Athletes Participating in the Rio 2016 Olympics

Krzywanski, Jaroslaw; Kuchar, Ernest; Pokrywka, Andrzej; More

Clinical Journal of Sport Medicine. 31(5):423-429, September 2021.

Safety and impact on training of the influenza vaccines in elite athletes participating in the Rio 2016 Olympics