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July 2021 - Volume 31 - Issue 4

  • 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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​We've reached our fourth issue of the Clinical Journal of Sport Medicine in 2021 already, in what has been another busy year so far for us all. 

Despite the continuing challenges presented by the pandemic, the World of Sport and Exercise Medicine is as busy as ever with clinicians and academics working in our Specialty meeting these challenges head-on. 

Following the American Medical Society for Sport Medicine (AMSSM) annual meeting in April, May saw the annual conference of our Founder Society, the Canadian Academy of Sport and Exercise Medicine (CASEM) with both of these events being entirely virtual again this year. As always, CJSM has been proud to bring you the Conference Abstracts from both AMSSM and CASEM in our March and May issues respectively. 

It is clear that a great deal of academic activity continues, despite the necessary focus for those in clinical practice on public health issues and direct patient care as a result of COVID-19, with many of us working harder than usual and often in different clinical roles from ones we are used to. Your willingness and ability to adapt and to cope with these challenges is a credit to all of us working in Sport and Exercise Medicine around the World. 

We are fortunate to have some sporting events rescheduled from last year such as the European Soccer 2020 Championships already underway, and the 2020 Olympics and Paralympics​ are just around the corner. I am sure that many of you will already be involved, and will be busy with your preparations. Good luck to all of you, and fingers crossed things run smoothly and safely despite the difficulties we all continue to face at this time. 

And so to this issue, and what may be considered to be a landmark Consensus Statement published in two parts on the Male Athlete Triad. 

Most of us will be familiar with the Female Athlete Triad, a term which was first used back in 1992 to highlight a syndrome encountered amongst female athletes displaying a combination of eating disorder, amenorrhoea and osteoporosis. Our concepts and understanding of this condition have evolved significantly over the last 30 years or so, and new terminology such as the term Relative Energy Deficiency in Sport (RED-S) has been introduced in an attempt to encompass more of the elements of this condition. 

More recent observations of some similar clinical observations amongst Male athletes (in the absence of menstrual irregularities) have led to the concept of the Male Athlete Triad, and much research continues to emerge regarding this condition. 

In an attempt to consolidate the latest evidence-based research and to suggest a framework for future directions for research on this topic, the Female and Male Athlete Triad Coalition put together an expert panel who met at the American College of Sports Medicine (ACSM) Annual Meeting in 2017. The group have produced this thoroughly-comprehensive Consensus Statement in two parts. 

Part 1 focuses on definitions and the scientific rationale and evidence behind the model of the Male Athlete Triad, and Part 2 describes the clinical aspects of diagnosis, on-going management and return-to-play aspects of the condition. 

I am sure that clinicians and academics will find the Consensus Statement articles to be interesting, timely, and of great use in both recognising and managing patients with this condition. We would love to hear your feedback on the Consensus Statement, and look forward to hearing how this may impact on your clinical practice.

This Issue also sees the publication of the latest AMSSM Sports Ultrasound Curriculum Consensus Statement for Sports Medicine Fellowships. This is an updated version of the previous Statement previously published in CJSM back in 2015.

The Curriculum consists of 12 units presented in tabular form, with recommendations on how these should be navigated during Fellowship training. Supplemental information includes scanning protocols, suggested milestones in trainee development, and also a sample sports ultrasound OSCE checklist form. 

Our first two Original Research articles this issue are focused on the hip joint. 

Hirotaka and Colleagues highlight controversy regarding the effectiveness of hip arthroscopic surgery for femoroacetabular impingement (FAI) in the presence of osteoarthritis (OA), and in a retrospective case-control study, examine differences in clinical outcomes following arthroscopic hip surgery with labral preservation for femoroacetabular impingement between individuals with and without significant osteoarthritis. 

In this study of 97 patients with FAI, groups were divided according to Tonnis OA grading, and clinical outcomes were evaluated 2 years post-operatively and at final follow-up using Modified Harris Hip scores. Furthermore, conversion to total hip arthroplasty and failure rates were both assessed. 

The Authors found that patients with FAI in the presence of radiographic OA did not improve postoperatively, and that the rates of conversion to THA and failure were higher in this group, regardless of the success of acetabular preservation or reconstruction during procedures. 

Henne and Colleagues examined trends in the use of image guidance for hip joint injections (corticosteroid and hyaluronic acid) between 2007 to 2015 using insurance claim data, and found that the use of fluoroscopic and ultrasound guided injections has increased during this time, with less injections being performed using landmarks alone. They suggest that costs and radiation exposure may be mitigated by using ultrasound-guided injections rather than fluroscopic-guided injections. 

We bring you several other Original Research articles this month, including articles on the topic of anterior cruciate ligament reconstruction, pre-season vestibular ocular motor screening in children and adolescents, and a comparison of Stanford ECG left atrial criteria with International ECG criteria for screening. 

Arjawat and Colleagues present a Systematic Review article comparing Quadriceps Tendon Autografts with bone-patellar tendon-bone autografts and hamstring autografts for primary ACL reconstruction. From 10 studies which met the inclusion criteria for this review, the Authors found that functional outcome measures were similar between all 3 primary autografts, as were revision rates. However, the incidence of anterior knee pain was less with quadriceps tendon autografts compared with bone-patellar tendon-bone autografts. They conclude that Quadriceps tendon autografts are suitable alternative grafts for primary ACL reconstructions, achieving good clinical outcomes and a low incidence of anterior knee pain. 

We bring you 3 interesting Case Reports on Vanishing White Matter Disease after Athletic Concussion in an Adolescent Patient, Medial Tibial Crest Friction syndrome, and Atrial Fibrillation induced from Commotio Cordis. 

Keep up to date with events in the world of sport and exercise medicine on our CJSM Blog, our twitter account on @CJSMonline and on our Facebook account, and don't forget to check out our ever-increasing range of CME articles on the CME Lippincott CME Connection website

Finally, I encourage you to take a look at our Clinical Case Studies, presented in association with AMSSM and AOASM which can be found by clicking on the 'CME and Clinical Cases' tab on our website​. These Case Studies have been previously peer-reviewed, presented at Society conferences, and are used with permission. They offer a great opportunity for you to test your clinical reasoning skills as you progress through each of the cases. Best of all, they are entirely free! We will be offering more clinical case studies on an on-going basis, so keep checking our CME page for new additions. 

Have a great July and August, and looking forward to touching base with you all again ahead of our next issue in September. In the meantime, stay safe and don't forget to look after yourselves as well as your patients. 

Best wishes,



Christopher Hughes MBBS MSc


The Male Athlete Triad—A Consensus Statement From the Female and Male Athlete Triad Coalition Part 1: Definition and Scientific Basis

Nattiv, Aurelia; De Souza, Mary Jane; Koltun, Kristen J.; More

Clinical Journal of Sport Medicine. 31(4):335-348, July 2021.

The Male Athlete Triad - Consensus Statement Part 1

The Male Athlete Triad—A Consensus Statement From the Female and Male Athlete Triad Coalition Part II: Diagnosis, Treatment, and Return-To-Play

Fredericson, Michael; Kussman, Andrea; Misra, Madhusmita; More

Clinical Journal of Sport Medicine. 31(4):349-366, July 2021.

The Male Athlete Triad - Consensus Statement Part 2

American Medical Society for Sports Medicine Sports Ultrasound Curriculum for Sports Medicine Fellowships

Hall, Mederic M.; Bernhardt, David T.; Finnoff, Jonathan T.; More

Clinical Journal of Sport Medicine. 31(4):e176-e187, July 2021.

American Medical Society for Sports Medicine Sports Ultrasound Curriculum for Sports Medicine Fellowships