Background COVID-19 is a droplet-transmitted potentially fatal coronavirus pandemic affecting the world in 2020. The WHO recommended social distancing and human-to-human contact was discouraged to control the transmission. It has put many countries in a state of lockdown and sporting events (including the 2020 Olympics) have been affected. Participation in sports and exercise, typically regarded as healthy activities, were also debated. The local professional football leagues, governed by the Hong Kong Football Association, ultimately postponed all matches after much deliberation on the transmission risk for the spectators and on-field players. Large spectating crowds are well-known to be infectious hazards, but the infection risk for on-field players is less recognized. Aside from watching professionals exercise, many people opted to hike in the countryside during the weekends to avoid city crowds. This led to a widespread discussion on the issue of wearing a facemask during outdoor activities. Methods A small sample of video footage of professional football players were analysed to track each players’ time of close body contact and frequency of infection-risky behaviours to investigate the risk of virus transmission during football games. To investigate the physiological effect of wearing a facemask during exercise, we conducted a controlled laboratory, within-subject, repeated measures study of 23 healthy volunteers of various sporting backgrounds. They underwent graded treadmill walking at 4 km per hour for 6 min with and without wearing a surgical mask in a randomized order with sufficient resting time in between trials. The heart rate and the rate of perceived exertion (RPE) were recorded. Results In a 90 min match, the average duration of close contact between professional football players was 19 min and each player performed an average of 52 episodes of infection-risky behaviours. The heart rate and RPE of subjects wearing a facemask was 128 beats per minute and 12.7 respectively. In those without a facemask, the results were a heart rate of 124 beats per minute and a RPE of 10.8. Conclusion This suggests that the infection risk was high for the players, even without spectators. The laboratory study to investigate the physiological effect of wearing a facemask found that it significantly elevated heart rate and perceived exertion. Those participating in exercise need to be aware that facemasks increase the physiological burden of the body, especially in those with multiple underlying comorbidities. Elite athletes, especially those training for the upcoming Olympics, need to balance and reschedule their training regime to balance the risk of deconditioning versus the risk of infection. The multiple infection-control measures imposed by the Hong Kong national team training centre was highlighted to help strike this balance. Amidst a global pandemic affecting millions; staying active is good,...

Purpose To diagnose chronic anterior talofibular ligament (ATFL) injury, three different physical examinations were compared: the anterior drawer test (ADT), the anterolateral drawer test (ALDT), and the reverse anterolateral drawer test (RALDT). Methods A total of 72 ankles from potential ATFL-injured patients and the normal population were included and examined using the ADT, ALDT, and RALDT by two examiners without knowing the injury histories of any of the participants. Ultrasound examination was then applied as the gold standard to divide the ankles into the ATFL-injured group and the control group. The sensitivity (Se), specificity (Sp), false negative rate (FNR), false positive rate (FPR), accuracy, κ value, and p value of the two examiners' diagnoses were calculated to assess the diagnostic ability of each examination. Results There were 38 ankles in the injured group and 34 ankles in the control group. No significant difference was found between the two groups in terms of gender, age, body mass index (BMI), and included ankles. In the ADT and ALDT groups, the specificity reached one, while the sensitivity was relatively low (0.053 and 0.477 for the junior examiner and 0.395 and 0.500 for the senior examiner). In the RALDT, both the sensitivity and specificity were greater than 85% (0.868 and 0.912 for the senior examiner and 0.921 and 0.882 for the junior examiner). The κ value of the RALDT (0.639) was higher than that of the ALDT (0.528) and the ADT (0.196), whereas all the p values were less than 0.05. ConclusionThe ADT and ALDT are valuable physical tests to assess ATFL injuries. Compared with the traditional ADT and ALDT, however, the RALDT is more sensitive and accurate in diagnosing chronic ATFL injuries. Level of evidence II (diagnostic). KeywordsAnkle sprains • Anterior talofibular ligament • Anterior drawer test • Anterolateral drawer test • Reverse anterolateral drawer test * Yinghui Hua

Objective: To assess the degree of psychological impact among surgical providers during the COVID-19 pandemic. Summary of Background Data: The COVID-19 pandemic has extensively impacted global healthcare systems. We hypothesized that the degree of psychological impact would be higher for surgical providers deployed for COVID-19 work, certain surgical specialties, and for those who knew of someone diagnosed with, or who died, of COVID-19. Methods: We conducted a global web-based survey to investigate the psychological impact of COVID-19. The primary outcomes were the depression anxiety stress scale-21 and Impact of Event Scale-Revised scores. Results: A total of 4283 participants from 101 countries responded. 32.8%, 30.8%, 25.9%, and 24.0% screened positive for depression, anxiety, stress, and PTSD respectively. Respondents who knew someone who died of COVID-19 were more likely to screen positive for depression, anxiety, stress, and PTSD (OR 1.3, 1.6, 1.4, 1.7 respectively, all P < 0.05). Respondents who knew of someone diagnosed with COVID-19 were more likely to screen positive for depression, stress, and PTSD (OR 1.2, 1.2, and 1.3 respectively, all P < 0.05). Surgical specialties that operated in the head and neck region had higher psychological distress among its surgeons. Deployment for COVID- 19-related work was not associated with increased psychological distress. Conclusions: The COVID-19 pandemic may have a mental health legacy outlasting its course. The long-term impact of this ongoing traumatic event underscores the importance of longitudinal mental health care for healthcare personnel, with particular attention to those who know of someone diagnosed with, or who died of COVID-19.

Background:Adult acquired flatfoot deformity is a commonly seen condition with a large clinical spectrum. It ranges from asymptomatic subjects to severely disabled arthritic patients. Posterior tibialis tendon dysfunction is a common cause of adult acquired flatfoot deformity.Methods:This article systematically reviews the published literature from books and journals that were either originally written or later translated into the English language regarding the subject of posterior tibialis tendon dysfunction.Results:Posterior tibialis tendon dysfunction is a primary soft tissue tendinopathy of the posterior tibialis that leads to altered foot biomechanics. Although the natural history of posterior tibialis tendon dysfunction is not fully known, it has mostly been agreed that it is a progressive disorder. While clinical examination is important in diagnosing adult acquired flat-feet; further investigation is often required to delineate the different aetiologies and stage of the disease. The literature describes many different management choices for the different stages of posterior tibialis tendon dysfunction.Conclusion:Because of the wide range of symptom and deformity severity, surgical reconstruction is based on a-la-carte. The consensus is that a plethora of reconstructive options needs to be available and the list of procedures should be tailored to tackle the different symptoms, especially when managing complex multi-planar reconstructions.

Background: This article systematically reviews the current evidence regarding inflammation in Tendinopathy with the aim to increase understanding of a potential common pathophysiology. Methods: Following the PRISMA statements, the terms: (tendinopathy OR (tendons AND rupture)) AND (inflammation OR (inflammation AND cells) OR immune system OR inflammation mediators OR bacteria) were used. One thousand four hundred thirty-one articles were identified which was screened down to 53. Results: 39/53 studies mentioned inflammatory cells but had contradicting conclusions. Macrophages were the most common cell type and inflammatory markers were detectable in all the articles which measure them. Conclusions: The included studies show different conclusions, but this heterogeneity is not unexpected since the clinical criteria of 'tendinopathy' encompass a huge clinical spectrum. Different 'tendinopathy' conditions may have different pathophysiology, and even the same clinical condition may be at different disease stages during sampling, which can alter the histological and biochemical picture. Control specimen sampling was suboptimal since the healthy areas of the pathological-tendon may actually be subclinically diseased, as could the contralateral tendon in the same subject. Detection of inflammatory cells is most sensitive using immunohistochemistry targeting the cluster of differentiation markers, especially when compared to the conventional haematoxylin and eosin staining methods. The identified inflammatory cell types favour a chronic inflammatory process; which suggests a persistent stimulus. This means NSAID and glucocorticoids may be useful since they suppress inflammation, but it is noted that they may hinder tendon healing and cause long term problems. This systematic review demonstrates a diversity of data and conclusions in regard to inflammation as part of the pathogenesis of Tendinopathy, ranging from ongoing or chronic inflammation to non-inflammatory degeneration and chronic infection. Whilst various inflammatory markers are present in two thirds of the reviewed articles, the heterogenicity of data and lack of comparable studies means we cannot conclude a common pathophysiology from this systematic review.