Introduction

In December 2019, various cases of atypical respiratory disease were reported in Wuhan, China, and rapidly expanded from Wuhan to other areas of the world. Soon it was tracked down that the novel coronavirus was responsible for all that disaster. This novel virus was termed severe acute respiratory syndrome coronavirus – 2 (SARS – CoV-2) because of its high resemblance to SARS – CoV, which causes acute respiratory distress syndrome¹. On February 11, 2020, the World Health Organization (WHO) named this pneumonia-like symptom causing virus Coronavirus disease-19 (COVID-19)². This outburst of SARS-CoV-2 was considered to have originated from the seafood market in Wuhan, China, via zoonotic transmission. With further research, it was identified that human-to-human transmission was also the cause of this outbreak³. The main target of this virus was the human respiratory system, whereas the involvement of other systems was also reported ⁴. In Pakistan, the first case of COVID – 19 has been reported on February 26, 2020, in Karachi, Sindh province, and it was confirmed by the Ministry of Health, Government of Pakistan.⁵.The constantly increasing ratio of positive cases focused the administration to work on a high level of action plans and management policies. On February 12, the “National Action Plan for Preparedness & Response to Coronavirus Disease (COVID-19) Pakistan” was presented, and this plan aimed to limit the spread of COVID-19 along with emergency measures for efficient and time-effective response to potential COVID–19 events⁶. Different initiatives were taken by the government of Pakistan, such as COVID–19 test facilities, quarantine centers, treatment opportunities, and spreading awareness among the public about the spread of the virus and its preventive measures to fight against this COVID-19 outbreak. This sudden implementation of the lockdown causes significant lifestyle changes for every individual. Limited outdoor activities and social distancing affect the daily activities of the individuals⁷. Life has become difficult as everyone has to stay healthy and safe while adopting new norms such as maintaining social distance, personal protective measures, and surface, and environment cleansing into daily long-term practice⁸.Along with the general population, this unusual situation has psychological, behavioral, and physical consequences on athletes as well. COVID-19 causes the postponement of all sports events, restriction of outdoor activities, and closure of fitness centers and gyms. All of these factors forced the athletes to alter their exercise programs and train at home without any supervision provided by the coaches and medical staff. Physical inactivity or prolonged breaks from training cause deconditioning of physiological systems, including the musculoskeletal, respiratory, neuromuscular, and cardiovascular systems as well as it also reduces physical capabilities such as power, strength, endurance, speed, and flexibility⁹. In team sports during the offseason physical inactivity shows a negative impact on the fitness and mental well-being of athletes¹⁰. Several studies reported psychological disorders due to physical inactivity caused by the lockdown, such as anxiety, post-traumatic stress disorders, and depression¹¹. Women tended to perceive more stress than men¹². No significant differences in perceived stress and psychological states were found between professional and non-professional players¹³. Studies have shown that sleep disturbances and mental health concerns are closely interrelated in the athletic population¹⁴. A possible relationship exists between sleep quality and individual match performance, and player efficacy¹⁵. It is therefore, important for athletes to maintain a balance between intensity and frequency of training and develop management strategies for physical and psychological health. Overtraining causes fatigue, performance decline, decreased motivation, and emotional instability¹⁶, while undertraining increases the risk of injury¹⁷. Risk factors for sports injuries fall into the genetic, psychological, morphological, and biomechanical categories¹⁸. Improper joint biomechanics, weakness in muscles, tendon, and ligaments, and insufficient planning and implementation of the training session are associated with sports injuries. Other than intrinsic factors some extrinsic factors, also affect the occurrence of injuries in athletes. These extrinsic factors include environment, weather conditions, atmosphere, and the type of sports equipment used¹⁹. To limit the reversal of training-induced adaptations, various exercise strategies are used by the athletes. Engaging in some alternate mode of training to avoid the detraining effects is the most common method used by the athletes. This type of detraining prevention using alternate ways of training is known as cross training effect²⁰. A study was conducted to determine the impact of COVID – 19 shutdown measures on the training habits and perception of athletes in the United States. A total of 105 participants completed this survey. This study showed that 99% of athletes continued to receive guidance from the coaches, but there was a significant decrease in self-reported participation time, especially sports specific activities²¹. A self-administered web-based survey was conducted to investigate the training exercise and injury prevention programs used by the athletes during the COVID–19 quarantine period. The results of this survey showed that 61% of the participants continued to do training at home during the quarantine period to maintain their physical activity level and limit the occurrence of injury upon their return to sports²². Other cross sectional study was conducted to determine the impact of Coronavirus on the perception of elite and semi- elite athletes. 692 participants were recruited in this study, and a Google form link was used to conduct this study. The author concluded that COVID–19 had a physical, nutritional, and psychological impact on the return to sports and the general health of athletes²³. A cross-sectional study was conducted through Google form link to determine the impact of lockdown on musculoskeletal health due to COVID – 19 outbreak in Bangladesh. 230 participants between the age group of 18-60 years participated by random sampling method. The study concluded that a strong association was seen between pain intensity, increased television watching time, use of mobile phones, and sleeping duration during the lockdown²⁴. In another study, author studied the impact of the COVID-19 lockdown on the epidemiology of soccer muscle injuries. The results of this study showed no significant differences between the pre and post-lockdown risk ratio for injury, and the incidence of muscle injuries among Italian professional soccer players had no significant changes after the COVID-19 lockdown phase²⁵. A case-controlled study was conducted to compare the effect of 3 months of lockdown on musculoskeletal pain, coronophobia and sleep quality among individuals who stay at home and those who continued to work. The author concluded that individuals who stayed at home had more low back pain and coronophobia than those who continued to work, however the sleep quality was similar in both groups²⁶. Previously available studies were related to the physical activity, psychological well-being of an individual or intellectual disability, or other short-term impact of a pandemic. But the literature is scarce regarding the various effects of the pandemic on the musculoskeletal health of athletes. In this retrospective study, we aim to investigate the impact of a pandemic on lower extremity musculoskeletal injuries in athletes who require more utilization of their lower limbs for sports activities (i.e., footballers, cricketers, rugby players, runners, sprinters, hockey, and volleyball players). The findings of this study will rebound to the benefit of athletes considering how pandemic-related restrictions affects the health of athletes, their performance, and return to sports. So, in the future, better management approaches will be considered in such pandemic conditions to minimize their effects on the health and performance of athletes. The objective of this study is to determine the occurrence of lower extremity musculoskeletal injuries during the COVID–19 lockdown in athletes.