• knee ACL
• cardiology
• osteoarthritis
• heat acclimatisation
• MRI

Welcome to this scintillating Norwegian issue of the BJSM. The Scandinavian knee ligament registries (See page 1259) were established 15 years ago, and they now inform us with data from >70 000 patients. Did you know that you can lower the risk of revision anterior cruciate ligament (ACL) reconstruction for hamstring versus patella tendon autograft by 14% for every 0.5 mm increase in hamstring graft diameter?1

In a cohort of professional male Norwegian football players followed up after 8 years (See page 1279), we found that 6 of the 595 players with negative preparticipation cardiac screening suffered a severe cardiovascular event; three of these six events were sudden cardiac arrests (SCA). Rather than introducing more preparticipation cardiac screening in Norway, we will focus on recognising athletes with early symptoms of cardiac disease. We will examine them thoroughly, and be prepared to treat SCA by having staff well trained and AEDs widely available. It is critical to recognise SCA early as proven by another Norwegian study (See page 1293) where authors analysed 35 sports-related SCAs that were captured on video. Agonal respiration, prone landing, seizure-like activity and abnormal eye gaze occurred in 66% of the events. Early cardiopulmonary resuscitation by bystanders is critical.

Sticking with the theme of early detection of disease, we should ‘adopt more thoughtful management approaches and referral practices that empower patients to engage in shared decision making based on the best available evidence’. This advice about preventing overdiagnosis and harms of too much medicine (See page 1314) is in line with the conclusion of two other papers, discussing the value of MRI of knees. In the first study (See page 1285), a multicentre randomised controlled trial, Swart and colleagues found no evidence that adding MRI to usual care in general practice for patients aged 18–45 years with traumatic knee complaints affected knee-related daily function a year later. In the second study (See page 1268), Culvenor et al’s systematic review and meta-analysis found knee osteoarthritis features on MRI in near half the knees in otherwise healthy, asymptomatic, uninjured adults aged ≥40 years. Both studies draw attention to the importance of providing correct information to patients in need—or not—of healthcare. Despite no difference in physical outcome or quality of life, patients in the first study were more satisfied with their treatment if they were randomised to (unnecessary) MRI. This paper is not the only one to emphasise the effect of patients’ perception of healthcare, on level of treatment and perceived outcome. In O’Keeffe et al’s editorial (See page 1261), they give several examples of how public misconceptions of backpain causes overtreatment. But fortunately, they provide suggestions for how to inform the public to ‘don’t take the back pain lying down’, based on a successful mass media campaign aired in the late 1990s. A similar campaign today, will include social media platforms, with ‘sticky’ messages targeted to different people. Martin Sinclair, represented in a patient voice paper (See page 1321), was born with cerebral palsy and got back to football after having total hip replacement (twice). He highlights that ‘Mindset is key!’ and encourages to help patients develop a ‘can do’ rather than a ‘can’t do’ mindset.

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Infographics is a popular way to promote key messages and that brings us to the last topic in this issue. Take a note of the highly increased risk of overheating, as well as potential performance decrements in athletes with tetraplegia in the infographic of thermoregulation in patients with spinal cord injury by Griggs et al (See page 1305). Facing the hot and humid environments during the Olympic and Paralympic Games in Tokyo 2020, we all need to know the impact of this temperature, and how to counter the harms. We can probably learn from Snipe’s carefully executed studies of prevention and management strategies of exertional heat stress-induced gastrointestinal perturbations in amateur athletes, presented as the PhD Academy Award (See page 1312). In short, combine water at a temperature of 22°C with regular carbohydrate consumption to support gastrointestinal health and reduce upper gastrointestinal symptoms during endurance running in the heat.