The use of cold therapy has been an established measure in the postoperative treatment of musculoskeletal injuries and operations for many years. The aim is to relieve pain, reduce swelling, and improve range of motion at an early stage. A recent systematic review and meta-analysis has now summarized and critically evaluated the existing evidence on this topic.

The analysis included 28 randomized controlled trials comparing various forms of cryotherapy with no cold application. Pain intensity, range of motion (ROM), swelling, and functional recovery were evaluated. Overall, cryotherapy showed significant advantages in terms of pain reduction and mobility in the immediate, short-term, and medium-
term postoperative phases. However, some of the effect sizes found were below the clinically relevant threshold (MCID), indicating rather moderate absolute improvements.

Small to moderate positive effects were observed in terms of range of motion, while only limited differences were observed for swelling and function. Nevertheless, the overall picture suggests that cold applications can make a supportive contribution to multimodal rehabilitation concepts – especially in the early stages of healing, when pain and tissue reaction limit the range of motion. A subgroup analysis showed that controlled cryo-compression systems tend to achieve more favorable effects than conventional applications with ice or gel packs. These devices were found to significantly reduce pain intensity (mean difference −1.03 points) and improve range of motion (mean +11.5°). These advantages are probably due to the combination of cooling and simultaneous compression, which affects both local blood flow and tissue pressure. However, it should be noted that the research situation is heterogeneous overall and the quality of the evidence was only low to moderate. In addition, almost all of the included studies refer to direct cooling methods– i.e., applications in which the cold is transferred directly to the skin via ice, gel packs, or cooling compression devices.

Other methods have hardly been investigated in the literature to date. Hyperbaric CO₂ cold therapy, in which compressed, expanding carbon dioxide is applied to the skin, is only found in individual case reports or small pilot studies. Cold air methods, in which convective heat removal is achieved by means of a fan, have also been researched only marginally to date. For both methods, there are currently no reliable randomized studies on postoperative application. Accordingly, it is not currently possible to make any well-founded statements about their effectiveness or their significance in comparison to established direct cooling methods.

Conclusion: Cryotherapy remains a useful measure in the postoperative management of musculoskeletal surgery, especially for short-term pain and swelling reduction. Although the observed effects are often below the clini­cally relevant threshold, they indicate a supportive effect within a comprehensive rehabilitation concept. Combinations of cold and compression appear to be somewhat more effective than simple ice applications. At the same time, the analysis reveals significant gaps in research: Indirect methods such as hyperbaric CO₂ cold therapy or cold air coo­ling have not yet been sufficiently investigated and should be given greater consideration in future studies in order to evaluate the entire spectrum of cryotherapy on a scientific basis.

Die Besetzung erfolgt strukturiert und eigenständig anhand nachvollziehbarer Kriterien: fachliche Qualität, praktische Erfahrung im konservativen, physikalischen und sportmedizinischen Kontext sowie die aktive Bereitschaft, Wissen zu vermitteln und weiterzuentwickeln. Ergänzend ist das Engagement im Dienst der Sportmedizin – regional wie international – ein zentraler Maßstab. Gemeint ist der konkrete Beitrag zur Weiterentwicklung von Anwendung, Ausbildung und Patientenversorgung. Dabei haben immaterielle medizinische Werte wie Haltung, Integrität, Verlässlichkeit und kollegialer Austausch einen festen Stellenwert.

Die Mitgliedschaft ist dynamisch angelegt und wird regelmäßig neu bewertet. Entscheidend ist nicht die formale Zugehörigkeit, sondern der kontinuierliche Beitrag zur Sache: eine praxisnahe, evidenzinformierte und umsetzbare Sportmedizin. Die Teilnahme an unseren Fortbildungen – nicht nur als Referent –, die Erstellung von Fachartikeln sowie der direkte edukative Austausch bilden die Grundlage für Auswahl und Weiterentwicklung des Boards. Ergänzend berücksichtigen wir Empfehlungen aus dem Kreis aktiver Mediziner, Therapeuten und Wissenschaftler.

Die sportärztezeitung übernimmt dabei bewusst die kuratierende und gestaltende Rolle: als Plattform, die Inhalte bündelt, einordnet und in die Anwendung bringt. Auf dieser Basis treffen wir die finalen Entscheidungen über Aufnahme, Fortführung oder Beendigung einer Zusammenarbeit – klar orientiert an Qualität, Aktivität und dem konkreten Beitrag zur Education im konservativen und sportmedizinischen Kontext.

Unsere Mission ist die globale GME – Guided Medical Education der Sportmedizin.

Weitere Infos dazu folgen in den nächsten Wochen

Veröffentlicht: 30.04.2026

In Germany, at least 9 million people currently live with DM [4]. Over 90 % of these patients have type 2 DM. Lifestyle changes can have multiple positive effects for them, including improved glycemic control [5]. In some cases, especially when the disease is not yet advanced, these changes can even lead to remission of the disease [6]. Therefore, a healthy diet and regular exercise are highly recommended as effective treatment methods [7]. 

Diets and exercise programs

Various diets are being discussed for improving blood sugar control (HbA1c), insulin sensitivity, or beta cell function, including low-carbohydrate diets, low-fat diets, a Mediterranean diet, and various energy-restricted diets. There is still disagreement about which diet is most effective for managing type 2 DM [8]. In addition to changes in dietary habits, regular physical exercise is an established approach to improving the health of people with type 2 DM [9]. The question arises which diets and exercise programs can best be combined to maximize positive health effects in this patient group. 

In a recently published systematic review, we included studies that combined different diets with the same exercise program in people with type 2 DM [10].

Energy-restricted low-carb diets with either high-fat or high-protein content showed superior effects in terms of some outcomes (medication dose, lipid profile, well-being) compared to diets with a higher carbohydrate content (in endurance or strength plus endurance training at moderate intensities). Other diets in direct comparison and in combination with exercise still need to be researched. In calorie-restricted diets, as well as in treatment with incretin mimetics for weight loss, targeted exercise interventions (especially strength training programs) can significantly reduce or even prevent the loss of muscle mass (which usually accompanies weight loss through calorie restriction) [11]. This is an important point, especially for people with type 2 DM, because a large proportion of the absorbed glucose is taken up by the muscles. In this case, more muscle mass means a higher likelihood for faster and more effective glucose clearance. Adequate protein intake is also crucial for optimizing the effects of strength training [12]. Another promising approach is the targeted combination of superfood consumption with exercise. For example, the consumption of certain foods, such as those with a high (poly)phenol content and correspondingly strong antioxidant effect (such as aronia berries), can have positive effects on chronic inflammation and glucose homeostasis in people with type 2 DM [13]. When it comes to exercise, timing is crucial.

Exercise-induced transient increases in oxidative stress are important for triggering training adaptations. Consuming foods with strong antioxidant properties too close to the time of exercise could therefore have a negative effect on long-term adaptations [14]. Exercise can also enhance the regene­ration-promoting and anabolic effects of some superfoods. In a recent pilot study, we investigated the effects of daily consumption of a red berry juice with a high aronia content during a strength/endurance training intervention in individuals with prediabetes. After just two weeks, benefits for muscle mass were already evident compared to placebo [15]. 

Conclusion and outlook

For people with type 2 DM, lifestyle interventions that integrate both diet and exercise hold significant potential. Low-carb diets combined with exercise currently promise the most positive effects in direct comparison with classic macronutrient distribution. However, it should be noted that there currently only few studies investigating the combined effects of other diets and exercise in this particular patient group (especially those providing direct comparisons of different diets alongside the same exercise intervention). When aiming for weight loss, dietary or pharmacological measures should be accompanied by strength training to reduce or even prevent the loss of muscle mass. An adequate intake of protein is important in this context. Consuming certain superfoods and exercising can also be particularly effective for some outcomes. Further studies are needed to investigate the combined effects of diet and exercise in people with type 2 DM.   

Literature

1 International Diabetes Federation. IDF Diabetes Atlas 11th Edition; International Diabetes Federation: Brussels, Belgium, 2025.

2 Tomic D, Shaw JE, Magliano DJ. The burden and risks of emerging complications of diabetes mellitus. Nat Rev Endocrinol 2022; 18: 525–539.

3 Kiran, SR, Sureka, RK. Prevalence of diabetes mellitus and its associated comorbidities: A population based study. Int J Community Med Public Health 2024; 11: 2085–2090.

4 Deutsche Diabetes Gesellschaft. Deutscher Gesundheitsbericht Diabetes 2024—Die Bestandsaufnahme; Deutsche Diabetes Gesellschaft: Berlin, Germany, 2023.

5 Magkos F, Hjorth MF, Astrup A. Diet and exercise in the prevention and treatment of type 2 diabetes mellitus. Nat Rev Endocrinol 2020; 16: 545–55.

6 Lean ME, Leslie WS, Barnes AC, Brosnahan N, Thom G, McCombie L, Peters C, Zhyzhneuskaya S, Al-Mrabeh A, Hollingsworth KG, Rodrigues AM, Rehackova L, Adamson AJ, Sniehotta FF, Mathers JC, Ross HM, McIlvenna Y, Stefanetti R, Trenell M, Welsh P, Kean S, Ford I, McConnachie A, Sattar N, Taylor R. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet 2018;10: 541-551.

7 Esefeld K, Kress S, Behrens M, Zimmer P, Stumvoll M, Thurm U, Gehr B, Halle M, Brinkmann C. Diabetes, Sports and Exercise. Exp Clin Endocrinol Diabetes 2025; 133: 343-353.

8 Papamichou D, Panagiotakos DB, Itsiopoulos C. Dietary patterns and management of type 2 diabetes: A systematic review of randomised clinical trials. Nutr Metab Cardiovasc Dis 2019; 29: 531–543.

9 Garcia SP, Cureau FV, Iorra FQ, Bottino LG, R C Monteiro LE, Leivas G, Umpierre D, Schaan BD. Effects of exercise training and physical activity advice on HbA1c in people with type 2 diabetes: A network meta-analysis of randomized controlled trials. Diabetes Res Clin Pract 2025; 221: 112027.

10 Amerkamp J, Benli S, Isenmann E, Brinkmann C. Optimizing the lifestyle of patients with type 2 diabetes mellitus – Systematic review on the effects of combined diet-and-exercise interventions. Nutr Metab Cardiovasc Dis 2025; 35: 103746.

11 Gross K, Brinkmann C. Why you should not skip tailored exercise interventions when using incretin mimetics for weight loss. Front Endocrinol (Lausanne) 2024; 15: 1449653.

12 Morton RW, Murphy KT, McKellar SR, Schoenfeld BJ, Henselmans M, Helms E, Aragon AA, Devries MC, Banfield L, Krieger JW, Phillips SM. A systematic review, meta-analysis and meta-regression of the effect of protein supplementation on resistance training-induced gains in muscle mass and strength in healthy adults. Br J Sports Med 2018; 52: 376–384.

13 Simeonov SB, Botushanov NP, Karahanian EB, Pavlova MB, Husianitis HK, Troev DM. Effects of Aronia melanocarpa juice as part of the dietary regimen in patients with diabetes mellitus. Folia Med 2002; 44: 20–23.

14 Margaritelis NV, Theodorou AA, Paschalis V, Veskoukis AS, Dipla K, Zafeiridis A, Panayiotou G, Vrabas IS, Kyparos A, Nikolaidis MG. Adaptations to endurance training depend on exercise-induced oxidative stress: exploiting redox interindividual variability. Acta Physiol (Oxf) 2018; 222

15 Valder S, Schick F, Pietsch N, Wagner T, Urban H, Lindemann P, Riemer L, Quenzer S, Herdegen V, Diel P, Isenmann E, Brinkmann C. Effects of two weeks of daily consumption of (poly)phenol-rich red berry fruit juice, with and without high-intensity physical training, on health outcomes in individuals with pre-diabetes mellitus. Nutr Metab Cardiovasc Dis 2025: 104121.

Aaron Nesmith, a player for the Indiana Pacers in the NBA, presented for the first time during the 2023/24 season playoffs with repetitive ankle problems, with a condition following multiple inversion traumas in the respective season. The initial diagnosis via EMG (myoact) showed clear deficits in the control of the peroneal muscles. The subsequent combination of osteopathy, manual therapy, and targeted facilitation via EMG biofeedback, partly with the aid of a blackboard, led to immediate improvement and ultimately to a convin­cing performance by the athlete until the Eastern Conference Finals of the season. Unfortunately, I was unable to continue treating the athlete during the off-season due to my work as a physical therapist for the national basketball team at the Olympic Games in Paris. 

A new assessment was therefore carried out at the beginning of the current 2024/25 season, with unsatisfactory results. The control of the peroneal muscles, i.e., M. peroneus longus, had fallen to a balance score of 38 % in a right / left comparison, with an MVA on the affected left side of 141 mV compared to a near-optimal value of 367 mV on the right side. The data was consequently forwarded to the Indiana Pacers medical team with a request to jointly develop an appropriate treatment strategy to prevent further recurrences. Unfortunately, a significant recurrence occurred on the following game day with a combination trauma and partial ruptures of the retinaculum peroneale and both peroneal tendons.

This event required a rethinking of the treatment approach in order to ensure not only a timely but also a long-term successful return to play. The team initially considered surgical intervention to restore continuity, particularly of the peroneal retinaculum, but after consultation with colleagues, this was rejected in favor of a conservative treatment approach. 

Conservative treatment approach & return to play

In order to determine the rehabilitation process for the subsequent subacute phase after conservative treatment in the acute phase, it was imperative to perform another EMG mapping via Myoact to establish the baseline. A further expected decline in control was observed, with 87 mV on the left vs. 344 mV on the right. In order to accele­rate the control and reintegration of the affected muscles and to treat damaged tendon and ligament structures in a targeted manner, extracorporeal shock wave therapy (ESWT) from EMS was used. The high energy density enabled by the device is unique and was the decisive factor in this case. The athlete was advised against taking Celebrex (the standard medication in the NBA after trauma) due to reduced gene expression of scleraxis, collagen I, and III, and instead received supportive anti-inflammatory treatment with phytopharmaceuticals (curcumin and boswellia). This also ensured that the ESWT treatment in the ligament and tendon area was successful. The rest of the rehabilitation process consisted of both manual therapy and osteopathic elements to restore functional synergy, as well as training therapy measures with the aid of biofeedback training via EMG. ESWT was always used before training therapy with 3,000 – 4,000 pulses, divided between the muscular part of the peroneus longus, the retinaculum peroneale, and the peroneal tendons, at intervals of four to five days. The intensity was continuously adjusted to ensure the continuous release of substance P for the treatment to be successful. A significantly increased response and associated increased effectiveness of the subsequent training load was observed. This was graphically illustrated at regular intervals with EMG mappings comparing pre- and post-treatment, thereby confirming the long-term success of the ESWT application.

Return to play can only be successful if the athlete can restore confidence in the injured structure. The highly competitive nature of competitive athletes in particular benefits from graphical representations of their training and success progress, ensuring compliance throughout a demanding rehabilitation program, but also helping us therapists to be honest. The most striking comparative measurement was taken after the first ESWT application, around two and a half weeks after the trauma. The success of the treatment could be clearly deduced from an increase in the balance score from 56 % to 80 % and from 133 mV to 280 mV (left) via EMG. In the following sessions, the average balance score did not fall below approximately 70 % and a continuously adequate control could be established. In general, a balance score of over 80 % is not necessarily expected or required for a basketball player due to the differentiated load requirements in the left/right comparison, as long as sufficient control in the 400 mV range is guaranteed. This was achieved after about four weeks of rehabilitation, and the player was able to participate in contact-free on-court activities again. In the following weeks, targeted load control led to the desired results, but was deliberately designed to be slow and gradual. His return to play comeback was not marked by any setbacks, enabling the athlete to play one of his best seasons to date and currently rank among the top 10 three-point shooters in the NBA. This is particularly noteworthy because successful three-point shooters depend on perfectly coordinated mechanics in their ankle joints.

Prevalence, injury patterns, and clinical relevance

The incidence of lateral ankle sprains in the general population is approximately one injury per 10,000 people per day, with the lateral ligament structure affec­ted in 85 % of cases. Young adults aged 15 – 35 are particularly affected. This rate is significantly higher in physically active populations, particularly in sports with a high jumping and pivoting load profile, such as basketball, handball, volleyball, and soccer [2 – 4]. The classic injury pattern, consisting of a combination of supination / inversion trauma with combined plantar flexion, often leads to a tear of the lateral capsular ligament apparatus at the upper ankle joint (USG). The most common injury (approx. 85 %) is to the anterior talo­fibular ligament (ATFL), followed by the calcaneofibular ligament (CFL) (52 – 75%) and, less frequently (< 10 %), the posterior talofibular ligament (PTFL).

The lateral capsular ligament apparatus of the OSG not only serves as a stabilizer against anterior talar translation and inversion in the upper ankle joint. The anterior and posterior fibulotalar ligaments, together with the anterior and posterior portions of the deltoid ligament, form a firm ligamentous ring in the transverse plane of the malleolar fork (Fig. 1). Injury to the lateral structures thus leads to complex rotational instability. Epidemiological data show that 20 – 40 % of patients develop persistent symptoms such as pain, impingement syndromes, and functional and structural chronic instabilities after initial ankle sprain [5]. In athletes, a recurrence rate of up to 34 % has been reported if no targeted neuromuscular and proprioceptive rehabilitation is performed [6]. The risk of a repeat ankle injury is five times higher after a lateral ligament rupture [7]. Long-term clinical studies show that even seemingly “simple” lateral ligament ruptures significantly increase the risk of post-traumatic ankle osteoarthritis, especially in cases of residual instability or incomplete rehabi­litation. Microinstabilities and repeated subtle sprains lead to chondral damage, which can result in degenerative joint destruction [5, 6]. 

Fig. 1 Transverse view of the upper ankle joint. The deltoid ligament (D) forms a stable ligamentous ring together with the posterior tibiofibular ligament (PTL) and anterior tibiofibular ligament (ATFL) (LLC = lateral malleolus, MLC = medial malleolus). Rupture of the LFTA leads to a break in continuity with rotational instability in the upper ankle joint.

Diagnosis

Clinical examination forms the basis of the diagnosis. Targeted systematic palpation of the typical pain points (LFTA, LFC, anterior syndesmosis, peroneal tendons), the anterior drawer test, and the talar tilt test (inversion test) are used to test mechanical joint stability. Immediately after the acute event, swelling, pain, and muscle guarding significantly limit the informative value of these tests. A reevaluation after 3 – 4 days, as advocated by Niek van Dijk, enables a much more reliable assessment with improved diagnostic sensitivity and specificity [8].

Conventional X-ray diagnostics are not indicated if a fracture is not suspected. In particular, static images of the ankle joint do not provide reliable information in the acute injury situation. Ultrasound has proven to be a diagnostic tool for imaging ligament continuity, hematoma extent, and joint effusion volumes. Radiological studies have shown that the sensitivity of sonographic examination is significantly higher than that of MRI for imaging ruptured LFTA (94 – 100 vs. 67 – 87) and LFC (94 vs. 40 – 47) [9]. The specificity is approximately equivalent. Ultrasound thus enables rapid and cost-effective confirmation of the diagnosis and prompt initiation of treatment. Magnetic resonance imaging (MRI) remains indicated in cases of complex injury patterns, suspected concomitant pathologies such as osteochondral talus lesions, syndesmotic injuries, or in the absence of clinical improvement [10].

Conservative therapy and functional treatment concept

According to S2k guideline 187 – 025, conservative therapy is considered the gold standard for lateral ligament rupture without accompanying injury, provided that there are no complete ruptures of all three lateral ligaments with pronounced mechanical instability.

The main therapeutic goals are rapid pain reduction, edema reduction, restoration of physiological joint mobility, and regaining active-dynamic stability while minimizing the recurrence rate. Instead of complete immobilization and relief, early functional therapy with a semi-rigid ankle orthosis, which limits inversion and supination and reduces plantar flexion, is considered the standard. Several studies show that early functional treatment with early mobilization in the orthosis, full weight-bea­ring after pain and swelling have subsided, and accompanying physical therapy leads to a significantly faster return to sport, less muscle atrophy, and less joint stiffness than prolonged immobilization [11, 12]. Modular ankle orthoses have been available on the market for several years. The underlying concept of this treatment is the gradual reduction of the orthosis’s stabilization from the acute stage to the rehabilitation phase, adapted to the ligament healing phases. Modular systems allow for initially higher lateral guidance in the acute phase with a gradual reduction in stability over time, which supports early functional mobilization while protecting against renewed inversion trauma. This is intended to support improved alignment of the collagen fibrils in the regenerated tissue as well as improved proprioceptive stimulation [13].

Proprioceptive and neuromuscular training – the focus of recurrence prevention

Proprioceptive and neuromuscular training is the most essential component of rehabilitation, as functional instability is not exclusively structural, but is also caused by disturbed afferent feedback and delayed peripheral muscle response patterns. Randomized controlled trials (RCTs) [3, 12, 14, 15] show that 8-12-week progressive proprioceptive programs (wobble board, balance pad, standing on one leg on unstable surfaces) reduce the recurrence rate of sprains by 35 – 41 % and significantly improve functional stability scores. Meta-analyses [16, 17] of more than 30 RCTs combined show a significant reduction in the risk of re-rupture by 39 – 47 % through structured sensorimotor training (level 1a evidence). The S2k guideline 187 – 025 recommends starting proprioceptive training as early as week 2 – 3 after the trauma, i.e., already in the orthotic treatment phase, with a progressive increase until week 12. The focus is on balance exercises, agility skills, reactive changes of direction, and sport-specific jump-landing sequences for high-level athletes. Effective exercises include standing on one leg on an unstable surface, the Star Excursion Balance Test (Fig. 2), lateral hop tests, and multi­directional jumps with defined landing patterns [18].

Biological regenerative adjuvants: PRP, hyaluronic acid, and ESWT

The use of platelet-rich plasma (PRP) in ligament ruptures aims to increase local growth factor concentrations to optimize ligament healing. Initial clinical studies report some positive effects on pain and subjective stability [19 – 21]. However, the current data are heterogeneous. Large-scale RCTs specifically on acute lateral OSG ligament ruptures are limited. The S2k guideline did not issue a strong recommendation for PRP in acute ligament injuries. Hyaluronic acid injections are mainly used to modu­late intra-articular inflammatory processes in soft tissue after an outer ligament rupture. Individual studies report faster pain reduction and a quicker return to sports [21, 22]. There is currently no consistent evidence of a benefit in accelerating ligament healing or reducing recurrent instability. At most, a complementary role may be considered in cases of associated chondral lesions. Preclinical models have demonstrated improved ligament regeneration, angiogenesis, and matrix remodeling with extracorporeal shock wave therapy (ESWT). No clinical data are available for this therapeutic measure in acute lateral ligament rupture, so there is no evidence-based recommendation. ESWT can be used as a selective option for reducing pain and swelling.

Conclusion

Consistent early functional therapy with adequate 6-week orthotic treatment, structured physical therapy, and intensive proprioceptive training form the main pillars of treatment. Proprioceptive training in the early phase and after removal of the orthosis is an essential factor in preventing functional instability and re-rupture.

Literature

1. Vuurberg G, Hoorntje A, Wink LM, van der Doelen BFW, van den Bekerom MP, Dekker R, van Dijk CN, Krips R et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med 2018, 52(15); doi: 10.1136/bjsports-2017-098106
2. Junge A, Engebretsen L, Mountjoy ML, Alonso JM, Renström PA, Aubry MJ, Dvorak J.Sports injuries during the Summer Olympic Games 2008. Am J Sports Med 2009, 37(11):2165-72; doi: 10.1177/0363546509339357
3. Doherty C, Delahunt E, Caulfield B, Hertel J, Ryan J, Bleakley C. The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies. Sports Med 2014, 44(1):123-40. doi: 10.1007/s40279-013-0102-5
4. van den Bekerom MP, Kerkhoffs GM, McCollum GA, Calder JD, van Dijk CN.Management of acute lateral ankle ligament injury in the athlete. Knee Surg Sports Traumatol Arthrosc 2013, 21(6):1390-5. doi: 10.1007/s00167-012-2252-7
5. Valderrabano V, Hintermann B, Horisberger M, Fung TS.Ligamentous posttraumatic ankle osteoarthritis. Am J Sports Med. 2006, 34(4):612-20. doi: 10.1177/0363546505281813
6. van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM.What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med 2008, 121(4):324-331.e6. doi: 10.1016/j.amjmed.2007.11.018
7. McKay GD, Goldie PA, Payne WR, Oakes BW.Ankle injuries in basketball: injury rate and risk factors. Br J Sports Med 2001, 35(2):103-8. doi: 10.1136/bjsm.35.2.103
8. van Dijk CN, Lim LS, Bossuyt PM, Marti RK. Physical examination is sufficient for the diagnosis of sprained ankles. J Bone Joint Surg Br 1996, 78(6):958-62. doi: 10.1302/0301-620x78b6.1283
9. Gribble PA.Evaluating and Differentiating Ankle Instability. . J Athl Train 2019, 54(6):617-627. doi: 10.4085/1062-6050-484-17. Epub 2019 Jun 4
10. Crema MD, Krivokapic B, Guermazi A et al. MRI of ankle sprain: the association between joint effusion and structural injury severity in a large cohort of athletes Eur Radiol 2019, 29(11):6336-6344. doi: 10.1007/s00330-019-06156-1
11. Kerkhoffs GM, Rowe BH, Assendelft WJ, Kelly K, Struijs PA, van Dijk CNImmobilisation and functional treatment for acute lateral ankle ligament injuries in adults. . Cochrane Database Syst Rev 2013, 28(3): CD003762. doi: 10.1002/14651858.CD003762
12. Rivera MJ, Winkelmann ZK, Powden CJ, Games KE.Proprioceptive Training for the Prevention of Ankle Sprains: An Evidence-Based Review J Athl Train 2017, 52(11):1065-1067. doi: 10.4085/1062-6050-52.11.16
13. Best R, Böhle C, Schiffer, T, Petersen W, Ellermann A, Brüggemann GP, Liebau C. Early functional outcome of two different orthotic concepts in ankle sprains: a randomized controlled trial. Arch Orthop Trauma Surg 2015, 135(7):993-1001. doi: 10.1007/s00402-015-2230-x
14. Grimm NL, Jacobs JC Jr, Kim J, Amendola A, Shea KG.Ankle Injury Prevention Programs for Soccer Athletes Are Protective: A Level-I Meta-Analysis. J Bone Joint Surg Am 2016, 98(17):1436-43. doi: 10.2106/JBJS.15.00933
15. Emery CA, Owoeye OBA, Räisänen AM, Befus K, Hubkarao T et al. The „SHRed Injuries Basketball“ Neuromuscular Training Warm-up Program Reduces Ankle and Knee Injury Rates by 36% in Youth Basketball. J Orthop Sports Phys Ther 2022, 52(1):40-48. doi: 10.2519/jospt.2022.10959
16. van der Wees PJ, Lenssen AF, Hendriks EJ, Stomp DJ, Dekker J, de Bie RA.Effectiveness of exercise therapy and manual mobilisation in ankle sprain and functional instability: a systematic review. Aust J Physiother 2006, 52(1):27-37. doi: 10.1016/s0004-9514(06)70059-9
17. Otsuka S, Papadopoulos K, Bampouras TM, Maestroni L.What is the effect of ankle disk training and taping on proprioception deficit after lateral ankle sprains among active populations? – A systematic review. J Bodyw Mov Ther 2022, 31:62-71. doi: 10.1016/j.jbmt.2022.04.001
18. VBG Fachwissen. Return-to-Competition. Testmanual zur Beurteilung der Spielfähigkeit nach akuter lateraler Bandverletzung am Sprunggelenk. Stand Juni 2022. https://www.vbg.de/cms/sport/return-to-competition/rtc-sprunggelenk
19. Ding Q, Wang X, Liu Y, Li Y, Zhang D, Wang H, Ma S, Han Q, Zhuang W.The efficacy of platelet-rich plasma in ankle disease: a systematic review and meta-analysis. . J Orthop Surg Res 2024, 31;19(1):895. doi: 10.1186/s13018-024-05420-5.
20. Zhang J, Wang C, Li X, Fu S, Gu W, Shi Z.Platelet-rich plasma, a biomaterial, for the treatment of anterior talofibular ligament in lateral ankle sprain. . Front Bioeng Biotechnol. 2022, 22(10):1073063. doi: 10.3389/fbioe.2022.1073063
21. Chen YT, Wu WT, Lee RP, Yu TC, Chen IH, Yeh KT.Platelet-rich plasma and hyaluronic acid in the treatment of acute ankle sprains: A review. Biomol Biomed 2025. doi:10.17305/bb.2025.13327.
22. Petrella RJ, Petrella MJ, Cogliano A.Periarticular hyaluronic acid in acute ankle sprain. Clin J Sport Med 2007, 17(4):251-7. doi: 10.1097/JSM.0b013e3180f6169f

Professional sports are undergoing a profound transformation through the integration of precision medicine, also known as personalized medicine. By tailoring training, nutrition, recovery, and injury prevention strategies to the individual genetic, physiological, and subjective profiles of each athlete, precision medicine aims to enhance performance, reduce the risk of injury, and ultimately extend athletic careers. This article examines the current applications, benefits, and future directions of precision medicine in professional sports.

Individualization as a new paradigm in sports medicine

Precision medicine has established itself in many areas of medicine as an individualized approach to tailoring therapy and prevention strategies more specifi­cally to the biological, genetic, and environmental characteristics of the athlete. In sports medicine, this approach is still in its infancy – but the change is noticeable: with the use of high-resolution diagnostics and modern technologies, the need for tailor-made care for athletes is growing. These technologies support the necessary shift towards individualized, data-supported care concepts that is resulting from the development of professional sports. 

The aim is to tailor training management, regenerative and preventive measures, and therapeutic interventions more closely to individual needs in order to specifically promote performance and identify injury risks at an early stage. Precision medicine provides the metho­dological basis for making data-­driven and individually informed decisions – beyond blanket recommendations. 

Fields of application and challenges

The implementation of precision medi­cine in sports medicine requires a deep understanding of individual resilience and adaptability. A central aspect is the close integration with performance diag­nostics, which makes relevant parameters measurable and interpretable. The focus is on the athlete as a complex system with numerous interconnected influencing factors.

Looking at the concepts of performance components in training science literature, the structural and functional complexity of athletic performance becomes clear – and with it the challenges associated with precision medicine [1]. Training and regeneration processes must be designed in such a way that they both promote performance deve­lopment and improve stress tolerance. Precision medicine provides the framework for collecting and analyzing data in a targeted manner and translating it into concrete measures.

This results in key areas of application:

• Prevention Analysis and targeted reduction of injury risk
• Rehabilitation Optimizing and shortening return processes and preventing relapses
• Regeneration Individualizing and accelerating recovery processes to increase stress tolerance and training effectiveness
• Injury cause analysis Better understanding injury mechanisms and using this knowledge for prevention
• Performance optimization Achieving maximum performance in a sustainable manner
• Increasing longevity Reducing cell age and optimizing function ultimately lead to a higher life expectancy for athletes

The following section explains the key aspects of the aforementioned areas of application for personalized sports medicine in more detail. 

Genetic profiling and personalized approaches

Advances in www.dnathlete.li have enabled the identification of specific mar­kers related to muscle building, endurance, injury susceptibility, and recovery rates. When coaches and medical teams know an athlete’s genetic predisposition, they can design training and prevention programs that are tailored to the athlete’s innate strengths and take potential weaknesses into account. For example, certain genetic profiles may indicate a predisposition to muscle, ligament, or tendon injuries, allowing targeted and additional preventive measures to be taken. Or another genetic predisposition may enable higher levels of performance when consuming caffeine, beta-alanine, or creatine, while this is not the case for others [2]. A study published in the World Academy of Science Journal highlights the integration of genetic profiles with traditional biochemical and physiological assessments to optimize performance and ensure longevity in sports [3].

The great potential of epigenetics – understanding and utilizing molecular individuality

Epigenetic processes add a dynamic component to this perspective: they control which genes are activated or deactivated under certain conditions – influenced by training, nutrition, stress, or environmental stimuli. 

These adjustments are reversible and make it possible to achieve long-term positive changes at the cellular level through targeted stimuli. Epigenetic age clocks are complex biomarkers based on DNA methylation patterns that usually reflect biological age more accurately than chronological age, thus providing insights into an individual’s health and aging process.

For athletes, these biomarkers have significant potential as they provide a personalized assessment of how training load, recovery, nutrition, and lifestyle affect long-term health and performance. Monitoring biological age can help optimize training plans, avoid over- or under-training, and take measures to prolong peak performance and reduce the risk of injury. In addition, epigenetic insights can provide information about personalized recovery strategies and serve as a valuable tool for planning the longevity of athletes [4, 5]. 

Biomarkers and their potential for performance optimization

Laboratory markers provide crucial insights into an athlete’s physiological state and are therefore a cornerstone of precision medicine in sports. Biomarkers, such as creatine kinase (CK), help monitor muscle damage and recovery and enable individual training adjustments that optimize performance while minimizing the risk of overtraining and injury. Elevated CK levels, for example, may indicate excessive muscular stress or insufficient recovery, allowing timely measures such as modified training load, nutritional support, or rest periods to be initiated. Regular monitoring of such markers ensures a data-driven approach to athlete care and enables tailored strategies that increase resi­lience, improve performance, and support long-term athletic development. Regular communication with the athlete is crucial in interpreting these values in order to integrate subjective assessments into the decision-making process and avoid misinterpretations.

Biomechanics – objectively analyzing and individually adapting movement patterns

Biomechanical analyses provide important insights for the individualized care of athletes. Every person moves differently, influenced by muscle control, joint structure, coordination, and movement experience. These individ ual movement patterns influence both the risk of injury and performance ability. Modern technologies such as motion capture systems, force plates, and electromyography (EMG) enable these patterns to be recorded as objectively as possible. Based on the data obtained, targeted analyses can be carried out and adjustments to technical training and load design can be derived with the aim of making movements more efficient, avoiding overload, and better meeting sport-specific requirements. EMG diagnostics provide valuable information on muscular control and enable early identification of neuromuscular deficits in prehabilitation and targeted correction using biofeedback-­based activation. Biomechanical analyses thus make an important contribution to performance optimization and injury prevention and are an essential component of personalized sports medicine concepts.

Wearable technology and real-time monitoring

The integration of wearable devices with built-in sensors enables the continuous recording of vital parameters, movement patterns, and stress data. These wearables provide real-time information on variables such as heart rate variability (HRV), oxygen saturation, and biomechanical efficiency. These insights enable immediate adjustment of training intensity and technique to optimize performance while minimizing the risk of injury. Recent developments include AI-driven smart sportswear that uses integrated sensors to monitor muscle activation and breathing patterns, for example, and provide real-time feedback on the quality of training execution [6].

Precision strategies for hydration and nutrition

Individualized hydration and nutrition plans are key components of precision medicine in sports. By analyzing individual sweat composition and metabolic responses, nutritionists can tailor electrolyte replacement and diet plans to the specific needs of each athlete.

This personalized approach ensures optimal energy availability, improves reco­very, and supports overall health. Genetic testing also plays a role in determining nutritional needs, as certain gene variants can influence nutrient metabolism, leading to more effective nutritional strategies. 

Pharmacogenomics and injury management

Pharmacogenomics – the study of how genes affect an individual’s response to medication – enables the customization of medication regimens for injury treatment and pain management. Understanding genetic variations in drug metabolism helps in selecting the most effective medications with minimal side effects, improving recovery outcomes and reducing downtime.

This approach ensures that medications and recovery programs are tailored to each athlete’s genetic predisposition, improving performance and reducing the risk of injury [7]. 

Neurocognition

Improving neurocognition offers significant benefits to athletes by enhan­cing mental processing speed, attention, reaction time, and decision-making under pressure, which are key components of peak athletic performance.

As part of a precision medicine approach, these interventions are tailored to the cognitive profile of the individual athlete, enabling customized strategies that complement physical training.

Cognitive improvements can help athletes better anticipate plays, adapt to changing environments, and focus in critical situations, which can lead to a competitive advantage in performance. This holistic strategy ensures that athletes are optimally prepared for success, not only physically but also mentally.

Numerous scientific studies have shown that any peripheral injury can be accompanied by changes in different parts of the brain. These findings also call for new, individualized prevention and rehabilitation strategies and allow for individualized preparation of athletes even before surgical interventions as prehabilitation. Tools such as SkillCourt are an example of the integration of neurocognitive training into precision sports medicine. SkillCourt uses interactive, data-driven technology to measure, analyze, and train visual perception, cognitive agility, and motor coordination in real time. By analyzing an athlete’s performance on these tasks, coaches and physicians can identify cognitive strengths and deficits and take targeted measures to improve overall game performance. Integrating such tools into an athlete’s training program supports injury prevention, rehabilitation, and sustained peak performance, bridging the gap between brain function and physical execution in sports [8 – 10].

Artificial intelligence and predictive analytics

The use of artificial intelligence (AI), especially machine learning techniques, enables sports medicine to precisely analyze large, complex data sets to predict injury risks and performance trends.

By processing data from various sources, such as wearables, training logs, and medical records, AI models can identify patterns and provide actionable insights that facilitate proactive interventions and strategic planning. Predictive analytics and machine learning are transforming injury prevention strategies in sports medicine by analyzing large amounts of data to identify patterns and trends that indicate an increased risk of injury. A well-thought-out data strategy is essential, because it is not the quantity, but the relevance, quality, and targeted use of data that determine the success of precision medicine applications. 

Conclusion

The integration of precision medicine into professional sports represents a paradigm shift in athlete care and performance optimization. Through individualized approaches based on genetic insights, real-time monitoring, and personalized analysis, sports organizations can sustainably improve the longevity, performance, and overall well-being of athletes. All of the technologies mentioned are already available today and should be used in a targeted manner as part of a basic sports medical examination in order to comprehensively assess the initial situation and identify individual deficits at an early stage. On this basis, tailor-made intervention programs can be developed, which can be adapted through regular re-testing in order to respond dynamically to changes. With advancing technological development, the potential of precision medicine to revolutionize athletic performance and health management is becoming increasingly tangible.

Literature

[1] Blobel, T. (2022). Sportinformationssysteme – Systemarchitektur, Anwendungsfälle und Marktanalyse. Dissertation. München: Technische Universität München. https://mediatum.ub.tum.de/doc/1639907/1639907.pdf

[2] Panagiotou, N., Sagonas, A., Salata, E., Fotis, T., & Ntoumou, E. (2025). Athlegenetics: Athletic characteristics and musculoskeletal conditions (Review). World Academy of Sciences Journal, 7, 44. https://doi.org/10.3892/wasj.2025.332

[3] Pfab, F., Sieland, J., Haser, C., Banzer, W., & Kocher, T. (2023). Genetische Faktoren bei Muskelverletzungen im Sport [Genetics in sports-muscle injuries]. Orthopadie (Heidelberg, Germany), 52(11), 889–896. https://doi.org/10.1007/s00132-023-04439-6

[4] Brooke, R. T., Kocher, T., Zauner, R., Gordevicius, J., Milčiūtė, M., Nowakowski, M., Haser, C., Blobel, T., Sieland, J., Langhoff, D., Banzer, W., Horvath, S., & Pfab, F. (2024). Epigenetic age monitoring in professional soccer players for tracking recovery and the effects of strenuous exercise [Preprint]. medRxiv. https://doi.org/10.1101/2024.11.28.24317877

[5] Gibbs, W. Biomarkers and ageing: The clock-watcher. Nature 508, 168–170 (2014). https://doi.org/10.1038/508168a

[6] Tang, C., Yi, W., Zhang, Z., Occhipinti, E., & Occhipinti, L. G. (2025). AI-driven smart sportswear for real-time fitness monitoring using textile strain sensors (arXiv Preprint No. 2504.08500). arXiv. https://arxiv.org/abs/2504.08500

[7] Roden, D. M., McLeod, H. L., Relling, M. V., Williams, M. S., Mensah, G. A., Peterson, J. F., & Van Driest, S. L. (2019). Pharmacogenomics. Lancet (London, England), 394(10197), 521–532. https://doi.org/10.1016/S0140-6736(19)31276-0

[8] Friebe, D., Hülsdünker, T., Giesche, F., Banzer, W., Pfab, F., Haser, C., & Vogt, L. (2023). Reliability and Usefulness of the SKILLCOURT as a Computerized Agility and Motor-Cognitive Testing Tool. Medicine and science in sports and exercise, 55(7), 1265–1273. https://doi.org/10.1249/MSS.0000000000003153

[9] Friebe, D., Sieland, J., Both, H., Giesche, F., Haser, C., Hülsdünker, T., Pfab, F., Vogt, L., & Banzer, W. (2024). Validity of a motor-cognitive dual-task agility test in elite youth football players. European journal of sport science, 24(8), 1056–1066. https://doi.org/10.1002/ejsc.12153

[10] Hülsdünker, T., Friebe, D., Giesche, F., Vogt, L., Pfab, F., Haser, C., & Banzer, W. (2023). Validity of the SKILLCOURT® technology for agility and cognitive performance assessment in healthy active adults. Journal of exercise science and fitness, 21(3), 260–267. https://doi.org/10.1016/j.jesf.2023.04.003

Muscle cramps are a temporary but intense and painful involuntary contraction of the skeletal muscles that can occur in many different situations. There is evidence that some cases are related to water and salt imbalances, while others appear to be triggered by persistent abnormal spinal reflex acti­vity as a result of fatigue in the affected muscles. This has led to alternative explanations, such as the theory of neuromuscular fatigue – i.e., impaired signal transmission between the brain and muscles after prolonged exertion.

Studies show that dehydration has no effect on the stimulation frequency required to trigger a cramp and confirm the involvement of spinal mechanisms. However, it is questionable to what extent these models are relevant to spontaneous cramps that occur during (exercise-associated muscle cramps (EAMC)) or after exercise. It has therefore been hypothesized that cramps are caused by persistent abnormal spinal reflex acti­vity, which appears to be secondary to muscle fatigue. In particular, EAMC has been attributed to a disturbance in the sustained activity of alpha motor neurons, which is based on a dysregulation of alpha motor neurons at the spinal level. Muscle fatigue was considered to be a triggering factor, as it increases the afferent activity of the muscle spindles (type Ia and II) and simultaneously inhibits the afferent activity of the type Ib Golgi tendon organs. Indirect evidence supporting this theory comes from the observation that passive stretching of the affected muscle during a cramp can alleviate the symptoms – presumably through autogenic inhibition via the tendon organ reflex. Nevertheless, this does not explain why cramps are not an inevitable consequence of every strenuous activity, why they occur more frequently in environments with high heat stress, or why some people are affected while others are spared.

In the human model of electrically induced cramps, it has been reported that pickle juice effectively shortens the duration of cramps. Miller et al. found that the duration of cramps was reduced by an average of about 37 % when 1 mL of pickle juice was consumed two seconds after the onset of cramps, compared to an experiment in which water was drunk. This did not affect the intensity of the cramp. Ingesting small amounts of pickle juice had no measurable effect on plasma concentrations of sodium, potassium, magnesium, or calcium, nor on plasma osmolality or plasma volume. Since the pickle juice did not cause any changes in circulating electrolytes, the authors suggested that the shortened cramp is mediated by the activation of receptors in the oropharynx, leading to a reduced discharge rate of the alpha motor neurons that innervate the affected muscle. However, it is important to emphasize that this was not a study of EAMC, but rather cramps triggered by electrical stimulation during a maximal voluntary contraction of a small foot muscle. In a randomized study (2023) involving 82 patients with liver cirrhosis and a history of more than four muscle cramps in the previous month, 1 tablespoon of pickle juice taken at the onset of a cramp improved cramp intensity without causing any adverse side effects.

Literature

1. Miller, K.C. Electrolyte and Plasma Responses After Pickle Juice, Mustard, and Deionized Water Ingestion in Dehydrated Humans. J Athl Train. 2014 May-Jun;49(3):360–367. doi: 10.4085/1062-6050-49.2.23
2. Elliot B Tapper et al. Pickle Juice Intervention for Cirrhotic Cramps Reduction: The PICCLES Randomized Controlled Trial. Am J Gastroenterol. 2022 Apr 13;117(6):895–901. doi:10.14309/ajg.0000000000001781
3. Ronald J Maughan, Susan M Shirreffs. Muscle Cramping During Exercise: Causes, Solutions, and Questions Remaining. Sports Med. 2019 Nov 6;49(Suppl 2):115–124. doi: 10.1007/s40279-019-01162-1.
4. Miller KC, Mack GW, Knight KL, et al. Reflex inhibition of electrically induced muscle cramps in hypohydrated humans. Med Sci Sports Exerc. 2010;42(5):953–961. doi: 10.1249/MSS.0b013e3181c0647e.
5. Miller KC, Mack G, Knight KL. Electrolyte and plasma changes after ingestion of pickle juice, water, and a common carbohydrate-electrolyte solution. J Athl Train. 2009;44(5):454–461. doi: 10.4085/1062-6050-44.5.454.
6. Kevin C Miller. Electrolyte and plasma responses after pickle juice, mustard, and deionized water ingestion in dehydrated humans. J Athl Train. 2014 May-Jun;49(3):360-7. doi: 10.4085/1062-6050-49.2.23. Epub 2014 Feb 12.
7. Jarett Peikert, Kevin C Miller, Jay Albrecht, Jared Tucker, James Deal. Pre-exercise ingestion of pickle juice, hypertonic saline, or water and aerobic performance and thermoregulation. Controlled Clinical Trial. J Athl Train. 2014 Mar-Apr;49(2):204-9.doi: 10.4085/1062-6050-49.2.11. Epub 2014 Feb 25.
8. McKenney, M.A.; Miller, K.C.; Deal, J.E.; Garden-Robinson, J.A.; Rhee, Y.S. Plasma and Electrolyte Changes in Exercising Humans After Ingestion of Multiple Boluses of Pickle Juice. J. Athl. Train. 2015, 50, 141–146.
9. Stephanie E Hooper Marosek, Vijay Antharam, Katayoon Dowlatshahi. Quantitative Analysis of the Acetic Acid Content in Substances Used by Athletes for the Possible Prevention and Alleviation of Exercise-Associated Muscle Cramps. J Strength Cond Res. 2020 Jun;34(6):1539-1546. doi: 10.1519/JSC.0000000000003595.

lowing “strong” recommendations stand out in the summary and deserve special attention in this article:

• For more sustainable healthcare, we recommend the following: […]
• Promotion of environmentally friendly lifestyles: Education and counseling on plant-based nutrition, active mobility (such as walking and cycling), and sustainable everyday practices.
• Prioritizing resource-saving treatment options (where therapies are equivalent): recommending non-surgical measures such as exercise therapy, behavioral modification, and weight
  management before considering invasive procedures. [1]

In addition to promoting an active lifestyle with a focus on mobility (e.g., walking and cycling in everyday life, taking the stairs instead of the elevator), exercise therapy is an evidence-based treatment method of undisputed fundamental importance, which should now finally be taken into account in healthcare practice. But what exactly should this exercise therapy look like? To give this originally sports medicine-related and at the same time highly translational field more contour, it is worth taking a look at the recently published systematic review and meta-ana­lysis by Yan et al. [4]. The team of authors compared six training methods in terms of their effect on pain reduction, function, gait pattern, and quality of life. Among these, aerobic exercise (walking, running, cycling, swimming) performed best as a first-line treatment. In addition, strengthening, flexibility, and coordination exercises, as well as so-called mind-body exercises [5], were also examined and rated positively. The latter form of exercise, as part of mind-body medicine [6], which has already been considered in earlier studies on knee osteoarthritis [7, 8], can make a valuable contribution to the treatment of osteoarthritis symptoms, shifting the focus from the painful knee joint to the whole person. This is entirely in line with the holistic concept of whole-person health [9], which is also becoming increasingly important in the context of prehabilitation [10]. The affected person becomes an active part of the treatment team, which focuses on self-efficacy and teamwork and promotes adherence. Interventions from mind-body medicine can also be used when “traditional” therapeutic approaches such as aerobic exercise cannot be carried out due to physical condition or other obstacles.

Targeted Nutrition

In addition to exercise as therapy and behavioral adjustment in the sense of strengthening self-efficacy, the S3 guideline also explicitly mentions plant-based nutrition [1] as an important component of osteoarthritis treatment, thus emphasizing the concept of targeted nutrition [11]. Key aspects include sufficient protein intake with a targeted amino acid composition, the intake of collagen [12, 13] and fiber [14, 15], as well as supplementary systemic enzyme therapy [12, 13, 16, 17], multi-substance mixtures [18], and phytopharmaceu­ticals. Curcuma [19 – 24] in particular is playing an increasingly scientifically proven role in pain reduction and functional improvement in degenerative diseases such as osteoarthritis.

This knowledge deserves to be taken into account in daily care and tested in practice – not as a replacement, but as a supplement to established forms of therapy. We should seize the opportunity to further examine, apply, and criti­cally observe such approaches in order to expand the field of conservative and regenerative medicine with valuable biological options.

Mind-body medicine and shared medical appointments

Mind-body medicine is considered to be of additional importance in reducing inflammatory biomarkers [25] and in the individual management of psychosocial stress [26]. Self-management and patient education are individual and closely linked to lifestyle medicine. They require targeted training and continuing education strategies for both patients and therapists. These approaches must now be consistently integrated into real-world care – analogous to the already established sports and exercise therapy. Oncology provides an interes­ting, differentiated, and precise approach with the concept of exercise oncology [27], while the currently evolving field of prehabilitation [10] can serve as a framework. The “open window” that is emerging in relation to prehabilitation offers the opportunity to anchor these innovative approaches in the long term. Let’s take advantage of it and make the necessary changes in medical care a reality. As already emphasized in the article by Lison & Lison, there is virtually no alternative to all these developments [28].

The salutogenic potential is far from exhausted – rather, it paves the way for a new era of medical care, in line with the mind-body medicine concept coined by Professor Herbert Benson and Professor Jon Kabatt-Zinn [29] [6, 30].

The cost-efficient concept of shared medical appointments (SMA) [31, 32] also appears to be particularly forward-looking in this context. This model of joint medical consultations [29] enables the efficient, interdisciplinary, and team-oriented implementation of mind-body approaches as well as lifestyle medicine – with patients as active members of their therapeutic process.

In the recent article “Bashing Doctors Instead of Science,” published in Orthopedics and Trauma Surgery 2025 15(5), the authors, Dr. Burkhard Lembeck (President of the BVOU) and Janosch Kuno (BVOU Press Officer), emphasize “that patients rightly expect their healthcare providers to exhaust all conservative therapies before resorting to surgery, even if the evidence for them is weak. This applies in particular to chronic conditions such as osteoarthritis or tendon irritation, when standard therapies do not help.” Especially from this perspective, the article “Integrative Osteoarthritis Therapy” seems more relevant and important to us than ever. We look forward to further developments in this field.

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“It is evident that over the past 30 years, medicine has recognized that the mysterious dynamic balance we call health encompasses both body and mind and can be strengthened through certain qualities of attention – qualities that can have a nourishing, regenerative, and healing effect. We all possess this ability – let’s put it to use.” Jon Kabat-Zinn from the book “Coming to Our Senses” (2005)

—————

Study Tip Tai Chi helps with knee pain and improves knee function in people with knee osteoarthritis. Zhu SJ, et al. Online Unsupervised Tai Chi Intervention for Knee Pain and Function in People With Knee Osteoarthritis: The RETREAT Randomized Clinical Trial. JAMA Intern Med. Published online October 27, 2025. doi:10.1001/jamainternmed.2025.5723

—————

Literature

[1] Deutsche Gesellschaft für Orthopädie und Unfallchirurgie e.V.: Prävention und Therapie der Gonarthrose Version 5.0, 15.07.2024: https://register.awmf.org/de/leitlinien/detail/187-050

[2] Stellungnahme des BVOU zur Kritik an IGeL-Leistungen. BVOU 2025 https://sportaerztezeitung.com/rubriken/therapie/20313/stellungnahme-des-bvou-zur-kritik-an-igel-leistungen/

[3] Hyaluron-Spritzen bei Kniearthrose. Nutzen und Risiko. NDR Visite 02.09.2025. https://sportaerztezeitung.com/rubriken/therapie/20498/hyaluron-spritzen-bei-kniearthrose/

[4] Yan L. et al. Comparative efficacy and safety of exercise modalities in knee osteoarthritis: systematic review and network meta-analysis. BMJ. 2025 Oct 15;391:e085242. doi: 10.1136/bmj-2025-085242. PMID: 41093618; PMCID: PMC12522397.

[5] Mind-body Exercises. sportärztezeitung online. https://sportaerztezeitung.com/rubriken/training/20038/mind-body-exercises/

[6] Erbeldinger, R. (2025). Mind-Body Medicine Completes Sports Medicine: Development of a Prophylaxis Model Through Sports Medicine. THE MIND Bulletin on Mind-Body Medicine Research, 7, 23-30. https://doi.org/10.61936/themind/202504306

[7] Kessler CS. et al. Effectiveness of an Ayurveda treatment approach in knee osteoarthritis – a randomized controlled trial. Osteoarthritis Cartilage. 2018 May;26(5):620-630. doi: 10.1016/j.joca.2018.01.022. Epub 2018 Feb 7. PMID: 29426006.

[8] Lim WB, Al-Dadah O. Conservative treatment of knee osteoarthritis: A review of the literature. World J Orthop. 2022 Mar 18;13(3):212-229. doi: 10.5312/wjo.v13.i3.212. PMID: 35317254; PMCID: PMC8935331.

[9] Whole Person Health: What It Is and Why It’s Important. National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/whole-person-health-what-it-is-and-why-its-important

[10] Erbeldinger R, Roßberg M, Hub S, Henze A. Prähabilitation (Prähab). sportärztezeitung online. https://sportaerztezeitung.com/rubriken/therapie/20728/praehabilitation-praehab/

[11] Erbeldinger R. Targeted Nutrition – Nutritional Education. sportärztezeitung online. https://sportaerztezeitung.com/rubriken/ernaehrung/20110/targeted-nutrition/

[12] Wild-Bode C. Kollagen und Enzyme. sportärztezeitung 02/25. https://sportaerztezeitung.com/rubriken/therapie/19713/kollagen-und-enzyme/

[13] Niemeyer P, Herbort M, Post F. Nahrungsergänzung – Was kann ich bei Knorpelschaden oder Arthrose in Bezug auf Ernährung und Nahrungsergänzung tun? Podcast Listen2Science. 29.11.2024. https://sportaerztezeitung.com/rubriken/ernaehrung/18261/ernaehrungstherapie-und-nahrungsergaenzung/

[14] Pang A. et al. Short-chain fatty acids from gut microbiota restore Th17/Treg balance in rheumatoid arthritis: Mechanisms and therapeutic potential. Journal of Translational Autoimmunity, Volume 11, December 2025, 100316. https://doi.org/10.1016/j.jtauto.2025.100316

[15] Häger J. et al. The Role of Dietary Fiber in Rheumatoid Arthritis Patients: A Feasibility Study. Nutrients 2019, 11, 2392. https://doi.org/10.3390/nu11102392

[16] Henrotin Y. et al. Oral enzyme combination therapy reduces systemic inflammation, urinary CTXII and pain in knee osteoarthritis: a proof-of-mechanism, randomised, crossover, double-blind, placebo-controlled trial. RMD Open. 2025 Aug 12;11(3):e005433. doi: 10.1136/rmdopen-2025-005433. PMID: 40803821; PMCID: PMC12352264.

[17] Klein G. et al. Efficacy and tolerance of an oral enzyme combination in painful osteoarthritis of the hip. A double-blind, randomised study comparing oral enzymes with non-steroidal anti-inflammatory drugs. Clin Exp Rheumatol. 2006 Jan-Feb;24(1):25-30. PMID: 16539815.

[18] Post F. Hafer und Herzgesundheit. sportärztezeitung 02/25. https://sportaerztezeitung.com/rubriken/ernaehrung/19698/hafer-und-herzgesundheit/

[19] Zeng L. et al. Efficacy and Safety of Curcumin and Curcuma longa Extract in the Treatment of Arthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trial. Front Immunol. 2022 Jul 22;13:891822. doi: 10.3389/fimmu.2022.891822. PMID: 35935936; PMCID: PMC9353077.

[20] Montagnino J. et al. Optimizing orthobiologic therapies with exercise, diet, and supplements. PM R. 2025 Apr;17(4):452-462. doi: 10.1002/pmrj.13320. Epub 2025 Jan 24. PMID: 39853939.

[21] Brockmüller A, Shakibaei M. Epigenetische Wirksamkeit von Curcumin. sportärztezeitung 04/23. https://sportaerztezeitung.com/rubriken/ernaehrung/15026/epigenetische-wirksamkeit-von-curcumin/

[22] Kuptniratsaikul V. et al. Efficacy and safety of Curcuma domestica extracts compared with ibuprofen in patients with knee osteoarthritis: a multicenter study. Clin Interv Aging. 2014 Mar 20;9:451-8. doi: 10.2147/CIA.S58535. PMID: 24672232; PMCID: PMC3964021.

[23] Peng Y. et al. Anti-Inflammatory Effects of Curcumin in the Inflammatory Diseases: Status, Limitations and Countermeasures. Drug Des Devel Ther. 2021 Nov 2;15:4503-4525. doi: 10.2147/DDDT.S327378. PMID: 34754179; PMCID: PMC8572027.

[24] Bittel M. et al. Kurkuma- und Curcuminoid-Behandlung bei Gonarthrose. Zeitschrift für Phytotherapie 2022; 43(06): 243-249 doi: 10.1055/a-1924-9460

[25] Mehta D. et al. Turning Down the Heat: Mind-Body Strategies Against Inflammaging. Journal of Integrative and Complementary MedicineVol. 31, No. 10. Published Online: 14 October 2025. https://doi.org/10.1177/2768360525138371

[26] Denninger JW. et al. Psychological assessments, allostatic load and gene expression analyses in a randomized controlled trial comparing meditation, yoga, and stress education. Front Psychol. 2025 Sep 12;16:1653242. doi: 10.3389/fpsyg.2025.1653242. PMID: 41020112; PMCID: PMC12463968.

[27] Voland, A. et al. Update onkologische Sport- und Bewegungstherapie. Fokus Onkol 28, 40–47 (2025). https://doi.org/10.1007/s15015-025-4316-9

[28] Lison A, Lison D. Teilhaben. Sportmedizin und Rehabilitation. sportärztezeitung 04/25

[29] Michalsen A. Ordnungstherapie, Stressreduktion und Mind-Body-Medizin – Begleittherapien bei chronischen Nierenerkrankungen. Dialyse aktuell 2015; 19(5): 264-269. DOI: 10.1055/s-0035-1556951

[30] Dossett ML, Fricchione GL, Benson H. A New Era for Mind-Body Medicine. N Engl J Med. 2020 Apr 9;382(15):1390-1391. doi: 10.1056/NEJMp1917461. PMID: 32268025; PMCID: PMC7486127.

[31] Erbeldinger R. Group Medical Visits. sportärztezeitung online. https://sportaerztezeitung.com/rubriken/therapie/20203/group-medical-visits/

[32] Branch A. How to use shared medical appointments in under-resourced communities. September 4, 2025. https://lifestylemedicine.org/how-to-use-shared-medical-appointments-in-under-resourced-communities/

Chronic pain after surgical procedures affects up to 30 – 50 % of patients who have undergone surgery and represents a significant challenge, including in follow-up care [1]. Scar tissue after lumbar spine surgery in particular can contribute to persistent pain due to increased tissue stiffness, reduced mobility, and nerve irritation [2]. The visible skin scar is only the “tip of the iceberg,” as fibrotic changes can continue deep into the tissue layers and affect nerve structures [3]. The aim of this study was to investigate the influence of microneedling on objective tissue parameters and subjective pain reports.

Study design and patient population

A prospective, descriptive observation was conducted. Thirty-one patients aged > 18 and < 80 years were included. All patients had chronic painful scarring for at least six months following surgery on the lumbar spine. Patients < 18 and > 80 years of age, with psychosomatic illnesses and secondary diseases that would have made it difficult to causally attribute the pain symptoms, were excluded. 

• Gender: 71 % female
• Median age: 57 years
• Average BMI: 28.7 kg/m²
• Observation period: 12 days (T1–T2) 

Intervention

Treatment was performed using micro­needling (Dermaroller®, Medical Device MC910 1.0 mm) in the area of the postoperative scar tissue with a force of approximately 2 newtons and a rolling speed of 10 cm per second.

Ten repetitions were performed in each direction on the scar tissue, as well as 0.5 mm to the right and left of the scar tissue along the scar. This application was repeated a total of three times per patient during the twelve days of inpatient stay.  

Measurement methods & statistics

Tissue stiffness: Of the five device-specific measurement parameters of the Myoton Pro, we selected the parameters Dynamic / Stiffness and Tone / Frequency in this study, as both parameters are best suited for indirectly determining tissue stiffness. The measurements were taken on the left, center, and right sides of the scar at fixed tissue markers. Indirect tissue stiffness was measured before the first treatment and one day after the last treatment.  Pain intensity: A numerical rating scale (NRS 0 – 10) was used before the first and after the last intervention. The evaluation was descriptive. 

Changes between T1 and T2 were represented by median values, and the NRS change was statistically tested.

Results

Dynamic/Stiffness (Fig. 2)

The measurements showed the following median changes between T1 and T2:

• Left: – 8.3  N/m
• Center: – 9.7  N/m
• Right: + 3.0  N/m

Tone / Frequency (Fig. 3)

Area LWS/erector spinae – left/right and scar area in T1 and T2 (descriptive)

Pain intensity (Fig. 4)

The median NRS was 5 points in T2, which was significantly lower than in T1 with 7 points (Wilcoxon test for paired differences, p <  0.001). The NRS thus showed a significant reduction in pain intensity between T1 and T2.

Discussion & limitations

The results of this study suggest that microneedling can reduce scar-associated tissue stiffness. The observed reduction in pain is consistent with previous stu­dies, which showed an improvement in scar-related parameters in up to 74 % of patients after microneedling [4, 5].

Whether altered tissue stiffness and improved pain symptoms can also positively influence tissue mobility and thus movement economy should be the subject of further studies. The limited number of cases and the absence of a control group limit the significance of the fin­dings. In addition, this is a very limited observation in the context of standard inpatient therapies. 

Conclusion for practice

Microneedling is a minimally invasive, easily integrated treatment option for chronic scar pain after lumbar spine surgery. The method leads to objective improvements in tissue stiffness and a significant reduction in pain intensity. Objective changes in tissue stiffness and a significant reduction in pain support its use in a comprehensive approach to scar-related pain. Microneedling can be an effective addition to a multimodal therapeutic approach for painful scar tissue. Randomized, controlled studies with functional endpoints are needed to confirm its full clinical relevance.

Literature

1. Brown BC et al. The hidden cost of skin scars: quality of life after skin scarring. J Plast Reconstr Aesthet Surg. 2008;61:1049–1058.
2. Tos P et al. Painful scar neuropathy: principles of diagnosis and treatment. Plast Aesthet Res. 2015;2:156–164.
3. Choinière M et al. Pain and paresthesia related to scar tissue. Pain. 1991.
4. Svenning M, Drejøe JB. Microneedling in mature burn scars. JMCRR. 2019;2:277–281.
5. Abd-Elsayed A et al. Diagnosis, treatment, and management of painful scar. J Pain Res. 2022;15:1–12.

Conflict of interest: There is no conflict of interest.