South African Journal of Sports Medicine <p>The&nbsp;<em>South African Journal of Sports Medicine (</em>S. Afr. j. sports med)&nbsp;is a peer-reviewed journal that publishes original research articles, reviews, commentaries, letters and case studies on topics related to the disciplines represented by the <a href="" target="_blank" rel="noopener">South African Sports Medicine Association</a>. One volume is published a year with articles added as they are ready for publication.&nbsp;These disciplines include sports medicine, biokinetics, physiotherapy, exercise and sports science, dietetics and psychology. Material that is particularly unique and relevant to South Africa and its inhabitants are given preference; however, any other material of general interest and relevance will also be considered.</p> <p>&nbsp;</p> South African Sports Medicine Association en-US South African Journal of Sports Medicine 1015-5163 The South African Journal of Sports Medicine reserves copyright of the material published. The work is licensed under a <a href="" target="_blank">Creative Commons Attribution 4.0 (CC BY 4.0) International</a> License. Material submitted for publication in the South African Journal of Sports Medicine is accepted provided it has not been published elsewhere. The South African Journal of Sports Medicine does not hold itself responsible for statements made by the authors. New format of the South African Journal of Sports Medicine New format of the South African Journal of Sports Medicine Mike Lambert ##submission.copyrightStatement## 2017-10-24 2017-10-24 29 1 1 1 The use of negative pressure wave treatment in athlete recovery <p>Background: Athletes need to recover fully to maximise performance in competitive sport. Athletes who replenish more quickly and more efficiently are able to train harder and more intensely. Elite athletes subjectively report positive results using lower body negative pressure (LBNP) treatment as an alternate method for rapid recovery, restoring and improving their impaired physical state. Objective data on the efficacy are lacking.<br />Objectives: To investigate the effect of intermittent vacuum therapy on accelerating acute recovery following an athlete’s normal daily training schedule of strenuous exercise. Objective measurements of biological markers of muscular fatigue were used to assess recovery.<br />Methods: Twenty-two male cricket players in a randomised cross-over study were divided into a treatment and control group respectively. Following a one-hour high-intensity gym session, the treatment group received three 30-minute LBNP exposure sessions over three consecutive days (0, 24 and 48 hours). Blood lactate and creatine kinase biomarkers were collected to measure the recovery process. After 14 days groups were crossed over and the trial repeated.<br />Results: Heart rate and blood pressure decreased noticeably during treatment, reverting to baseline levels after treatment. Lactate concentrations decreased in both groups after exercise termination; significantly more in the treatment (0.57±0.23 mmol/l) than control group (0.78±0.22 mmol/l), p&lt;0.001). Creatine kinase (CK) was similar in both groups. Athletes’ subjective assessments of recovery rated moderately high.<br />Conclusion: LBNP therapy applied as treatment during routine schedule may have a systemic effect in lowering serum lactate levels, but not CK levels. Enhanced recovery of athletes is still unconfirmed.</p> A Jansen van Rensburg ##submission.copyrightStatement## 2017-10-24 2017-10-24 29 1 1 7 Injury incidence and characteristics in South African school first team rugby: A case study <p>Background: Despite its apparent popularity, participation in the sport of rugby union is accompanied by a significant risk of injury. Concerned parties have recently questioned whether this risk is acceptable within school populations. This is difficult to assess within the South African schools’ population as no recent longitudinal injury studies exist.<br />Objectives: To determine the training habits, rugby-related exposure and injury risk within a population of South African high school first team rugby players.<br />Methods: Training and match exposure in both school and provincial competition were examined and the resultant injuries were longitudinally observed for the duration of a South African high school rugby season.<br />Results: Match (79, 95%CI 52-105 injuries/1 000 h) and training (7, 95%CI 3-11 injuries /1000h) injury incidences were demonstrated to be greater than previously reported incidences in similar populations in England and Ireland. Weeks where players were exposed to both school and provincial competition (34, 95%CI 19-49 injuries /1 000 h) had significantly (p&lt;0.05) greater injury incidences than during school competition alone (19, 95%CI 12-26 injuries /1 000 h).<br />Conclusion: The injury risk demonstrated was greater than expected and represents reasons for concern. Possible reasons for the high injury incidence recorded may be the frequency of games played within the season, and the overlap of school and provincial competitions. It should be noted that these results were taken from one school over one season and might not be representative of the incidence of school rugby injuries overall. However, this research demonstrates the need for a multischool longitudinal study within South African schools rugby to determine the overall risk.</p> J Tee ##submission.copyrightStatement## 2017-10-24 2017-10-24 29 1 1 7 The forgotten coracoid: A case report of a coracoid fracture in a male cyclist A fall onto the shoulder is a common mechanism of injury in cyclists. However, coracoid fractures remain unreported in the literature in this population. These authors report a case of a coracoid fracture missed on the initial plain film radiographs. Whilst these fractures can be easily missed on standard trauma series radiographs of the shoulder, alternate views and other imaging modalities can be used to detect these fractures. Clinical suspicion, judicious imaging and accurate diagnosis of these fractures are important, as stability of the coracoid influences the entire superior shoulder suspensory complex which allows normal function of the shoulder joint. E Duinslaeger ##submission.copyrightStatement## 2017-10-24 2017-10-24 29 1 1 2 The prevalence, risk factors predicting injury and the severity of injuries sustained during competition in professional mixed martial arts in Africa <p>Background: Professional mixed martial arts (MMA) has gained international popularity. No African-based studies have reported the prevalence or severity of injuries, risk factors associated with injuries or return-to-play (RTP) time. Objectives: To determine the prevalence of injuries and associated risk factors, as well as severity of injuries sustained by professional male MMA athletes competing at the Extreme Fighting Championships Africa (EFC Africa) from 2010 to 2014.<br />Methods: Permission to do the study and the medical records of all professional events (2010 – 2014) were obtained from EFC Africa. Data were obtained from 173 male competitors aged 18 to 44 years, who had participated in 300 professional MMA fights. Results from this prospective cohort study were compared to a similar study done in the United States of America (USA). An injury was defined as any damage to an athlete’s body that needed the attention of the ringside physician. Statistical analyses included descriptive statistics and a stepwise logistic regression. Odds of an injury were predicted with six independent variables: fight outcome, age, weight division, number of fights, injuries in the preceding fight and years of fighter experience.<br />Results: Head, face and neck injuries were most common (22%), followed by traumatic brain injuries (knockouts) (6%). Losing a fight was a significant predictor of injury when using the stepwise logistic regression model (p=0.040). The odds ratio indicated that a preceding fight injury almost doubled the risk of injury in the following fight (OR 1.91; p= 0.163). Traumatic brain injuries (TBIs) in this study of African-based competitions (6%) were substantially higher than reported in the American study (1.8%).<br />Conclusion: Head, neck and face injuries are common in African fighters. The high rate of TBIs in African competition compared to the USA study is concerning. This could reflect superior refereeing in the USA group, as fights may be ended sooner by stoppage. Further investigation of injury trends and preventative measures should be studied to reduce the incidence of injuries during African competitions.</p> S Venter ##submission.copyrightStatement## 2017-10-24 2017-10-24 29 1 1 5 Targeting sedentary behaviour for behavioural change: Opportunities for new strategies <p>Background: The South African online population is rapidly transforming into one which is always reachable. The economic benefits of this transition are vast; however, the impact on obesity and related diseases is potentially devastating<br />Discussion: In this commentary it is proposed that public health strategies be revisited to align with the contemporary digital evolution, particularly as increased web-based applications suggest higher amounts of sitting times.<br />Conclusion: It is necessary to gain a better understanding of the different domains of sedentary behaviour, and the manner in which they interact, to begin to develop strategies to reduce sitting time, and thereby reduce cardiovascular disease risk.</p> P Gradidge ##submission.copyrightStatement## 2017-10-24 2017-10-24 29 1 1 2 Concussion knowledge and attitudes among amateur South African rugby players <p>Background: The South African Rugby Union’s BokSmart programme currently educates coaches and referees on concussion. Rugby players are often more familiar with their teammates than the coach or referee. Therefore they are well-positioned to play a pivotal role in rugby safety if they have adequate knowledge to identify subtle signs and abnormal behaviour displayed by a concussed teammate. However, no programme focuses on concussion education among South African rugby players and there is a dearth of literature on concussion education programmes among rugby players which could lead to safer return to play (RTP) habits.<br />Objectives: To evaluate South African rugby players’ concussion knowledge and attitudes/behaviours regarding RTP following a concussion.<br />Methods: A descriptive, cross-sectional study was used. Participants (n=294) were divided into junior amateur high school (JAHS) (n=216) and senior amateur club (SAC) (n=78) players. The modified RoCKAS-ST questionnaire was used to evaluate their concussion knowledge index (CKI) and concussion attitudes/behaviours index (CAI) regarding RTP.<br />Results: On average, 62% (JAHS) and 60% (SAC) of the CKI questions were answered correctly. JAHS participants correctly identified 66% of concussion symptoms, similarly to the SAC participants (63%), rendering similar (p=0.37) overall CKI scores when comparing the two groups. The CAI questions yielded similar (p=0.98) results between the groups, reporting safe responses in 66% (JAHS) and 67% (SAC) of the items.<br />Discussion and conclusion: Junior and senior South African amateur rugby players lacked approximately one-third of essential concussion knowledge, which may lead to a display of unsafe attitudes/behaviours to concussion and RTP. Further research is warranted to inform educational programmes on concussion among rugby players.</p> C Viljoen ##submission.copyrightStatement## 2017-10-24 2017-10-24 29 1 1 6 Gait retraining as part of the treatment programme for soldiers with exercise-related leg pain: preliminary clinical experiences and retention <p>Background: Gait retraining as part of a treatment programme for exercise-related leg pain (ERLP) was introduced in the sports medicine department of the Royal Netherlands Army in 2013.<br />Objectives: To describe clinical experiences and retention of gait retraining in a military setting.<br />Methods: Sixty-one cases from the year 2015 were available for analysis of gait and gait retraining. In 2016, 32 of these patients were available for a follow-up survey, 28 of them also for the follow-up measurement of running biomechanics in running shoes.<br />Results: Soldiers received an outpatient treatment programme that lasted on average 129 days (SD 76). On average they received 2.4 gait retraining sessions, leading to significant and lasting changes in running biomechanics; in particular, reduction in maximal force (N) and maximal pressure (N/cm2) on the heels at 317 days follow-up (average, SD 108). Most soldiers were satisfied with gait retraining. At follow-up, 27 soldiers (84%) contributed some, the majority or all reduction of symptoms to it. Seventy percent reported that they had mastered the new running technique within two months. The Single Assessment Numeric Evaluation score increased from 55% to 78% for males and from 44% to 75% for females.<br />Discussion: This is the first study to report on gait retraining for Medial Tibial Stress Syndrome. In future, prospective studies in the military running in shoes and running in boots respectively should be investigated.<br />Conclusion: Soldiers with exercise-related leg pain (ERLP), among them patients with Medial Tibial Stress Syndrome, respond well to a treatment programme that included gait retraining. Ten months post-gait retraining, their running biomechanics still showed these positive changes from their time of intake.</p> W Zimmermann ##submission.copyrightStatement## 2017-10-24 2017-10-24 29 1 1 6 A simulated rugby match protocol induces physiological fatigue without decreased individual scrummaging performance <p>Background: A rugby union game consists of 80 minutes of strenuous exertion. Forwards are required to participate in the arduous activity of scrummaging throughout a game.<br />Objectives: The purpose of this study was to identify whether rugby-match simulated fatigue modified individual scrummaging technique and reduced performance.<br />Methods: Twelve forwards (body mass 106.2±13.3 kg; stature 179.5±8.4 cm) had individual scrum kinetics and kinematics assessed prior to and following a protocol that simulated a rugby match. The simulated rugby match protocol required participants to run at various velocities and perform rugby specific tasks. Rating of Perceived Exertion (RPE) was assessed using a 6-20 Borg scale and Visual Analogue Scale (VAS). Blood lactate, heart rate and RPE were measured prior to, at mid-point and after the simulated game, while markers of muscle damage (blood creatine kinase activity (CK) and urea) were measured prior to and following the protocol.<br />Results: RPE (p&lt;0.0001) and VAS (p&lt;0.0001) showed significant increases between the pre- and post-simulation values. Of the physiological markers, heart rate (p&lt;0.0001) and blood urea concentration (p=0.004) increased following the match simulation. No significant differences were observed for blood CK (p=0.281), individual scrummaging forces (p=0.433) or in the kinematic variables following the protocol. While physiological fatigue and subjective ratings of physiological fatigue may develop during a rugby simulation, no differences were observed in peak forces or in body kinematics at peak force.<br />Conclusion: Physiological fatigue does not influence individual scrummaging performance and technique.</p> A Green ##submission.copyrightStatement## 2017-10-24 2017-10-24 29 1 1 6 A 12-week primary prevention programme and its effect on health outcomes (the Sweet Hearts biokinetics pilot study) <div class="page" title="Page 1"><div class="section"><div class="layoutArea"><div class="column"><p><span>Background: </span><span>The prevalence of non-communicable diseases (NCDs) and physical inactivity are concerning within the South African population. To address these concerns, the </span><span>‘Strategic Plan for Prevention and Control of NCDs 2013</span><span>-</span><span>2017’ </span><span>was developed. In response to this plan, a 12-week pilot biokinetics community health programme, </span><span>Sweet Hearts</span><span>, was initiated. </span></p><p><span>Methods: </span><span>This study is a prospective pilot study evaluating the feasibility and effectiveness of the intervention. Twenty- five individuals participated in the intervention. Ten participants performed a battery of physiological tests pre and post intervention and 5 participants completed an email-based survey post intervention. The setting of the study was Tramway Football Club, Southfield, Cape Town, South Africa. The </span><span>Sweet Hearts </span><span>intervention was designed to promote physical activity and healthy nutritional habits in those who participated. A total of 27 exercise sessions consisting of cardiovascular, resistance and flexibility training were conducted. Brief-behavioural counselling was integrated into exercise sessions. </span></p><p><span>Results: </span><span>The intervention group had a high attrition rate with &gt;50% of participants not presenting for post-intervention testing. Results were evident despite a limited sample size. There were significant improvements in health outcome measures among participants who did attend all testing sessions. These improvements included: an increase in Global Physical Activity Questionnaire (GPAQ) score (</span><span>p </span><span>= 0.03), 12- minute walk distance (</span><span>p </span><span>= 0.01), sit-to-stand test repetitions (</span><span>p </span><span>= 0.001), and a decrease in waist circumference (</span><span>p </span><span>= 0.01). Improvements were also noted in self-reported eating restraint (</span><span>p </span><span>= 0.03). Five main themes were structured into post intervention surveys: 1) enjoyment of the intervention, 2) benefits of the intervention, 3) obstacles affecting adherence, 4) future improvements to the intervention, and 5) state of non-communicable diseases in South Africa. </span></p><p><span>Conclusion: </span><span>The results of the </span><span>Sweet Hearts </span><span>intervention demonstrate the difficulty and importance of maintaining adherence to a community health intervention. The favourable results of the small sample size demonstrate the potential benefit of biokinetics-based programmes in the public health sector; and provide proof of concept for the dedication of resources towards health promotion within a community setting. </span></p></div></div></div></div> R Evans ##submission.copyrightStatement## 2017-11-06 2017-11-06 29 1 1 6 Ultrasound comparison of the effects of prehabilitation exercises and the scapular assistance test on the acromiohumeral distance <div class="page" title="Page 1"><div class="section"><div class="layoutArea"><div class="column"><p><span>Background: </span><span>Prolonged participation in overhead sports creates shoulder muscle imbalances which eventually alter the efficacy of the shoulder stabiliser muscles and heighten injury risk, such as subacromial impingement syndrome. </span><span>Objectives: </span><span>The aim of this study was to determine if ultrasound is effective to measure the acromiohumeral distance (AHD) to compare the effect of the scapular assistance test (SAT) on the AHD with a prehabilitative exercise intervention programme in asymptomatic cricket players. </span></p><p><span>Methods: </span><span>Baseline testing on cricket players from the North- West University cricket squad (N=34) included AHD measurements performed by a sonographer at 0°, 30° and 60° humeral abduction angles respectively, with and without the SAT application. Players were then randomly assigned to an intervention and control group. The control group continued with their normal in-season programme, whereas the intervention group also performed shoulder stability exercises for six weeks. </span></p><p><span>Results: </span><span>The exercise intervention had a similar effect as the SAT on the AHD at 0o and 30o humeral abduction angles in the intervention group. The AHD measurements in the exercise intervention group indicated widening at all abduction angles after the six-week intervention period, whereas the AHD measurements in the control group were equal or smaller than baseline measurements without the SAT at 30o and 60o respectively. </span></p><p><span>Conclusion: </span><span>Exercise intervention has a similar effect on the AHD of asymptomatic cricket players compared to the SAT </span><span>– </span><span>especially in 0°and 30o of humeral abduction. Ultrasound can therefore be utilised to assist in identifying the risk of developing subacromial impingement syndrome (SIS) in asymptomatic overhead athletes by measuring the AHD at different angles of humeral abduction, without and with the SAT application. </span></p></div></div></div></div> M Gous ##submission.copyrightStatement## 2017-11-06 2017-11-06 29 1 1 6 The influence of nationality and playing position on relative age effects in rugby union: A cross-cultural comparison. <p>Background: Recent research in a French context suggested that relative age effects (RAEs) in rugby union may be influenced by playing position; specifically, that RAEs may be more pronounced in back row players who do not have as extreme an anthropomorphic profile as other forward positions. Methods: In the present study, dates of birth of 6 663 players from four nations (Australia, England, New Zealand, South Africa) were analysed for relative age effects. Results: The hypothesis that RAEs would be more pronounced in back row players was not supported. South African rugby was an obvious outlier due to the finding that RAEs were present across all playing units. These results suggest that late maturing players have been disproportionately lost to the South African system across all positions. Conclusion: Nation-specific youth sport culture appears to be more important than playing position for determining who is at risk of RAEs in rugby union.</p> P Kearney ##submission.copyrightStatement## 2017-10-24 2017-10-24 29 1 1 4 Factors associated with lumbo-pelvic pain in recreational cyclists <p>Background: Overuse injuries in cyclists are as high as 85%, with lower back and pelvis pain (LBPP) being common. The lower back and pelvis are pivotal to powering and controlling the bicycle and essential for optimal functioning, comfort and performance. Cyclists spend long, continuous hours in sustained forward flexion, which is regarded as a main contributor to LBPP. Cyclists with LBPP assume greater lumbar flexion but the reason has not yet been established. Objectives: To identify intrinsic and bicycle set-up factors associated with lumbo-pelvic pain in cyclists. Methods: This study was cross-sectional and descriptive. One hundred and twenty-one cyclists in Gauteng, South Africa, participated in this study. The factors proposed to be associated with LBPP were determined to be namely: lumbar curvature on the bicycle in all three handlebar positions, strength of the gluteus maximus (Gmax) and medius (Gmed), extensibility of the hamstrings, control of lumbar movement in the direction of flexion, neurodynamics, active straight leg raise, one leg stance test for lateral pelvic shift, leg length discrepancy and bicycle set-up (saddle height, set-back and angle, handlebar height, forward reach, cleat position). Results: Only the lumbar curvature in the brake lever position (p=0.03) and weakness of the Gmed (p=0.05) were related to LBPP in cyclists. Conclusion: This study was the first to assess the relationship between the multiple factors described above and LBPP in cyclists. Understanding the relationship between increased lumber flexion in the brake lever position and the weakness of the Gmed and LBPP may lead to the development of strategies to reduce LBPP occurrence.</p> M Rodseth ##submission.copyrightStatement## 2017-10-24 2017-10-24 29 1 1 8 Attitudes towards nutritional supplement use amongst adult gymnasium users in Johannesburg North <p>Background: Nutritional supplements refer to a product ingested to increase the nutritional content of a normal diet, to fill a dietary need and/or presumed deficiency. The usage and popularity of nutritional supplements, however, raises concerns from a health benefit and risk perspective. In South Africa, there is currently no adequate regulatory framework of enforcement for nutritional supplement products and undeclared constituents by the statutory body, the Medicines Control Council (MCC). Education awareness programmes by organisations that should take consumer protection and the general public health and wellness as a right, needs to be improved. Objectives: To investigate the attitudes toward nutritional supplements by adult gym users from commercial gymnasiums in the Johannesburg North region of South Africa. Methods: A cross-sectional quantitative design, using a selfadministered questionnaire was applied to 364 recruited study participants who attended commercial gymnasiums in Johannesburg North. Results: One hundred and fifty users (41%) claimed that they ‘always’ read the information about the nutritional values, benefits, and side effects of the supplements on the labels prior to use. Three hundred and three users (83%) indicated that the number of users of nutritional supplements in gymnasiums is on the increase. Two hundred and seventy-three (75%) of main information sources for nutritional supplements may be found on the internet, while 292 (80%) indicated the need for gymnasiums to provide educational programmes pertaining to nutritional supplement consumption. Conclusion: Gymnasium users are aware of the increase in nutritional supplement use in commercial gymnasiums. Many of the users were unaware of the potential mislabelling and health concerns regarding these supplements. Therefore there is a need for improved nutritional supplement education programmes and diligence at multiple levels.</p> X Mc Creanor ##submission.copyrightStatement## 2017-10-24 2017-10-24 29 1 1 5 Neuroimaging in contact sports: Determining brain fitness before and after a bout <p>Background: Professional boxing and mixed martial arts (MMA) are popular contact sports with high risk for both acute and chronic traumatic brain injury (TBI). Although rare, combatants have died in the ring/cage or soon after the completion of the bout. The cause of death in these cases is usually acute subdural hematoma, acute epidural hematoma, subarachnoid haemorrhage, intracranial haemorrhage, or second-impact syndrome (SIS). Neuroimaging or brain imaging is currently included in the process of registering for a license to fight in a combat sport in most states in the United States and around the world. However, the required imaging specifics and frequency vary.<br />Discussion: Neuroimaging serves two distinct roles in the individualised care of a combatant, representing a step towards personalised medicine and individual risk stratification. Neuroimaging prior to licensure helps to identify and/or exclude coincidental or clinically suspected brain lesions which may pose a risk for rupture, bleeding or other catastrophic and important brain injury. Neuroimaging in the immediate aftermath of a bout primarily serves to rule out acute traumatic brain injury. Neuroimaging may also be carried out to assess for evidence of structural brain injury which may make a combatant more likely to express late-life neuropsychiatric sequelae of brain injury, such as chronic traumatic encephalopathy. As such, neuroimaging plays a prognostic role and aids in the determination of whether the combatant should be allowed to continue to participate in future bouts or not.<br />Conclusion: Currently there are no established neuroimaging guidelines for contact sports. Standardising neuroimaging guidelines both for licensure as well as neuroimaging modality, and protocols to assess for both acute and chronic traumatic brain injury. This will assist in protecting the combatant’s health and safety, both in the ring/cage, and after their professional careers have ended. Some suggested guidelines are provided based on currently available medical literature. It is recommended that these guidelines be debated vigorously by the scientific community and that evidence-based guidelines be developed by the medical community in conjunction with professional boxing and MMA governing bodies.</p> N Sethi ##submission.copyrightStatement## 2017-10-24 2017-10-24 29 1 1 4 Case report: Pathological fracture of the manubrium sternum of unknown aetiology <p>A 26-year-old male professional football player presented with sternal discomfort after performing upper limb exercises. X-rays and a computed tomography (CT) scan of the manubrium sternum indicated an area of lysis with a fracture line. An MRI showed bone marrow oedema as well as presternal and retrosternal soft tissue mass. An incision biopsy of the site and the soft tissue were performed under general anaesthesia. Additional investigations included a bone marrow biopsy from the left iliac crest, a full blood count and C-reactive protein test, all of which were normal. The morphological features were mostly in keeping with a healing fracture site, and the investigations revealed no evidence of a tumour or structural abnormality. In bone injuries, where the level of force is not commensurate with the degree of injury or where the anatomical area and other factors in the presentation are unusual, they require careful investigation. Treating physicians should actively exclude the multitude of potential causes when investigating pathological fractures</p> J Swart ##submission.copyrightStatement## 2017-10-24 2017-10-24 29 1 1 2 Acute unilateral foot drop as a result of direct blunt trauma to the peroneal nerve in a professional mixed marital arts bout: A case report <p>As a result of its superficial location, the peroneal nerve is prone to compression injuries. This is a case report of an acute unilateral foot drop which occurred during a professional mixed martial arts (MMA) contest, specifically as a result of direct blunt trauma to the left peroneal nerve, without an accompanying fracture of the fibula.</p> N Sethi ##submission.copyrightStatement## 2017-10-24 2017-10-24 29 1 1 1