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AMSSM Research Abstract Oral Poster Presentations

Clinical Journal of Sport Medicine: March 2016 - Volume 26 - Issue 2 - p e22–e57
doi: 10.1097/JSM.0000000000000303
Abstracts

ORAL POSTER PRESENTATIONS

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Ferritin and Strength Performance in Division I College Athletes: A Retrospective Review

Jennifer Albrecht, DO, Luke Perry, OMS-II, Abigail Russell, OMS-II, and Per Gunnar Brolinson, DO

Affiliation: Virginia Polytechnic Institute and State University & Edward Via Virginia College of Osteopathic Medicine, Blacksburg, Virginia.

Purpose: Iron supplementation can increase serum ferritin levels (F) and improve ventilatory threshold in iron-deficient, nonanemic trained subjects. We hypothesized that higher ferritin levels during competitive seasons correspond to greater strength in female collegiate athletes.

Methods and Study Design: This retrospective cohort study at a NCAA division I university utilized EMR data from a convenience sample of 43 women's soccer, lacrosse, softball and volleyball student-athletes from 2012 to 2015 with low F (<40 ng/mL) on initial preseason screening. We correlated pre- and post-season ferritin levels, which had been repeated after 3 months of supplementation with ferrous sulfate 325 mg and ascorbic acid 500 mg TID for F <30 ng/mL and a daily multivitamin for F <40 but >30 ng/mL, with pre- and postseason bench press (B), back squat (S), dips (D), pullups (P) and vertical jump (V) maximum lifting values via regression model building. Level of significance was set at 0.05.

Results: A 1 ng/mL increase in F for all athletes was associated with an increase in D of 0.99. Soccer showed a specific significance between F and D, with an increase of 1 ng/mL F corresponding to an increase of 0.96 D. Softball demonstrated a 0.74 lb increase in S with each 1 ng/mL increase in F. For volleyball, a 1 ng/mL increase in F was associated with an increase in V of 0.02 inches and an increase in P by 1. For each one unit increase in F for lacrosse, B decreased by 0.13 lbs.

Conclusions: Elevated ferritin levels were associated with increases in dips, back squat, vertical jump and pullups for athletes participating in varying team ball sports. Higher ferritin levels among lacrosse players were associated with decreases in bench press maximums.

Significance of Findings: Increasing ferritin levels in women's soccer, volleyball and softball may provide strength gains during the competitive season but may negatively impact performance in other sports.

Acknowledgments: Elaine Perrin, BS and Brandi Jones, BS of the Laboratory for Interdisciplinary Statistical Analysis of Virginia Tech.

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The Reliability of Serum Relaxin Levels at the Mid-Luteal Phase and the Relationship Between Relaxin and Knee Joint Laxity in Recreational Athletes

Adae Opoku Amoako, MD, Thomas H. Trojian, MD, and Ellen Casey, MD

Affiliation: Drexel University College of Medicine, Philadelphia, Pennsylvania.

Purpose: High serum relaxin concentrations (SRC) at the mid-luteal phase of the menstrual cycle (days 21-24) has been shown to be associated with ACL tears in college athletes. The purpose of this study was to confirm the reliability of checking one SRC at mid-luteal phase, and to investigate the relationship between SRC and knee joint laxity in recreational female athletes.

Methods and Study Design: A cohort of 27 recreational female athletes was enrolled. SRC were obtained at 6 different points of the menstrual cycle. Anterior tibial translation (ATT) was measured with a KT-2000 arthrometer. Kappa test was used to calculate the reliability of checking one SRC within the mid-luteal phase. Pearson's correlations coefficients were used to assess the relationship between SRC and ATT.

Results: Twenty-five of 27 participants completed study. Eighty-eight percent (22/25) had relaxin levels >6 pg/mL in the mid-luteal phase. Multiple SRC during mid-luteal phase was reliably classified in 24 of 25 subjects (kappa of 0.83). Mean SRC among all participants was 19.17 ± 11.17 pg/mL in the mid-luteal phase. Pearson's coefficients for correlation between SRC and right and left knees were −0.182 and −0.126 respectively.

Conclusions: Among female recreational athletes, it is reliable to check SRC one time in the mid-luteal phase. We found no correlation between SRC and ATT. Recreational as compared to college athletes are more likely to have elevated SRC during the mid-luteal phase.

Significance of Findings: We found that one mid-luteal phase SRC is reliable to classify participants as high or low SRC levels. We found non-elite athletes may more frequently have “high” SRC during mid-luteal phase and no association with ATT. Previous work correlating SRC to ACL tear risk may not be transferable to other levels of athletic participation.

Acknowledgments: None.

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Novel Mobile Device Tool to Document Sideline Contact With Athletes: The Vanderbilt Sports Medicine Outreach Documentation System

Rachel Apple, MD, Mitch Bellamy, ATC, and Ashley Rowatt Karpinos, MD, MPH

Affiliation: Vanderbilt University Medical Center Nashville, Tennessee.

Purpose: Vanderbilt Sports Medicine developed a novel mobile device tool, the Vanderbilt Sports Medicine Outreach Documentation System (ODS), which enables providers to document sideline encounters with injured athletes using mobile devices. The purpose of this study was to describe the implementation of ODS and the epidemiology of encounters between athletes and providers.

Methods and Study Design: We conducted a descriptive analysis of encounters documented using ODS in 2013 to 2015. We also assessed ODS users' preferences for this system of documentation as compared to paper charting.

Results: Between 2013 and 2015, Vanderbilt certified athletic trainers (ATCs) and physicians documented 6237 athlete contacts. Ninety-eight percent of the contacts were by ATCs and <2% were by physicians. The majority of contacts were among athletes participating in football (51%), soccer (15%) and basketball (12%). Fifty-three percent of injury contacts occurred at games. Contacts for knee (21%) and ankle (21%) injuries were most common. ODS users reported it was no slower than paper charting and provided better continuity of care. One hundred percent of users preferred ODS to paper charting.

Conclusions: We describe the successful implementation of a novel mobile device tool, the Vanderbilt Sports Medicine ODS, for real-time documentation of sideline evaluations of injured athletes by sports medicine providers. ODS provides an immediate and accessible means of recording contact between medical providers and injured athletes and assists in continuity of care. Minimal training is required to effectively incorporate ODS into a treatment routine, and ODS is preferred to former documentation systems. Encounters captured in 2 years of ODS use reveal an injury pattern which mirrors national trends.

Significance of Findings: The Vanderbilt Sports Medicine ODS represents a novel use of technology for sideline documentation of contact with athletes and highlights the value of on-site sports medicine providers for providing immediate and longitudinal care of injured athletes.

Acknowledgments: Kim Walters, Andrew Gregory, Alex Diamond, Tim Hoskins.

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The Impact of Exercise Restriction in Athletes With Hypertrophic Cardiomyopathy

Irfan M. Asif, MD, Rebecca Luiten, MS, CGC, Kelly Ormond, MS, CGC, Lisa Post, PhD, Matthew Wheeler, MD, PhD, and Colleen Caleshu, MS, CGC

Affiliation: Greenville Health System, University of South Carolina Greenville School of Medicine.

Purpose: To determine the challenges associated with exercise restriction in athletes previously diagnosed with hypertrophic cardiomyopathy (HCM).

Methods and Study Design: Mixed method (quantitative + qualitative). Individuals with HCM were recruited from an inherited cardiovascular disease clinic and queried to understand difficulty and adherence to exercise recommendations. A subset of patients who struggled with exercise restrictions underwent a semi-structured interview analyzed using a qualitative modality known as grounded theory.

Results: Fifty-four individuals (67% male, mean age 55.9) with HCM responded. The majority had engaged in competitive athletics during their lifetime (82%). Seventy-five percent of individuals were within 10 years of their diagnosis. The time spent exercising decreased significantly after diagnosis (6.2 vs 4.7 h/wk, P < 0.05). Twenty-four percent of patients reported not being given exercise recommendations and 36% described not following physical activity restrictions. Sixty-nine percent reported difficulty with recommendations to restrict physical activity. There was no association between the psychological challenges of exercise restriction and age, gender, or years since diagnosis. Sixteen athletes (56% male, mean age 52.4, 69% were <10 years since diagnosis) were interviewed for further characterization of the challenges associated with exercise restriction. Fifty-six percent reported significant weight gain post-diagnosis, while 50% felt uncertain on how to exercise safely and 56% felt the need to educate themselves on appropriate exercise guidelines. Finally, 69% reported the desire for clear and concrete exercise recommendations from their medical team.

Conclusions: Many individuals with HCM report challenges associated with the recommendations to restrict exercise post-diagnosis, leading to a decrease in time spent performing physical activity, unhealthy weight gain and potential psychological distress.

Significance of Findings: Clinicians should seek to improve their ability to educate HCM patients on safe physical activity recommendations. New exercise parameters could be considered for patients with cardiomyopathy in order to avoid the physical and psychological challenges that occur with strict adherence to the current guidelines.

Acknowledgments: None.

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The Use of Adiposity Indices for Wide Receivers From 2015 NFL Combine

Sultan M. Babar, MD

Affiliation: Carolinas Healthcare System.

Purpose: BMI is used a surrogate marker of adiposity. Even in otherwise healthy athletes, BMI is elevated. Previous studies have demonstrated that although NFL wide receivers have BMI in the overweight range, their percent body fat is within the normal range. Therefore, BMI has been deemed an inaccurate representation of adiposity in NFL wide receivers. CI, in a previous study, was demonstrated to have a higher sensitivity, specificity, positive predictive value, and negative predictive value than BMI. In this study, we analyze to see if corpulence index (CI) is a more accurate representation of body fat in Wide receiver who participated in the 2015 NFL Combine.

Methods and Study Design: This is a cross sectional study of the wide receivers that participated in the 2015 NFL combine (n = 44). Using the reported height and weight measurement, we looked at the distribution of BMI and CI within this group. A standard cut-offs of 25, and 15 for BMI and CI, respectively, were used. Additionally, given the extra muscular mass of these athletes, the cutoffs were increased to 27 and 16 and the data was re-analyzed.

Results: Average height of the wide receiver was 72.6 ± 2.1 (68–78) inches. Average weight was 203.9 ± 16.9 (156–238) lbs. The Average BMI was 27.5 ± 1.5 (22.4–30.1); and average CI was 14.8 ± 0.9 (12.6–16.9). Among the wide receivers, 93.2% of had a BMI greater than 25; 54.5% were greater than 27. In comparison, 34.1% of the athletes had CI greater than 15, and 11.4% were above 16.

Conclusions: Corpulence index is less likely to be falsely elevated in NFL wide receivers than is BMI.

Significance of Findings: CI may be a better adiposity index for athletes than BMI.

Acknowledgments: None.

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A Randomized Controlled Trial of Massage and Pneumatic Compression for Ultramarathon Recovery

Natalie Badowski, MD, Martin D. Hoffman, MD, Joseph Chin, BS, and Kristin J. Stuempfle, PhD

Affiliation: Sports Medicine Fellowship Program, O'Connor Hospital, San Jose, California.

Purpose: Examine the effectiveness of massage and pneumatic compression on recovery from a 161-km ultramarathon.

Methods and Study Design: Participants of the 2015 161-km Western States Endurance Run were randomized to a 20-minute post-race intervention of massage, intermittent sequential pneumatic compression or supine rest. Each subject completed two 400 m runs at maximum speed during the 21 days before the race, and on days 3 and 5 after the race, and also provided muscle pain and soreness ratings and overall muscular fatigue scores before and for 7 consecutive days after the race.

Results: Of 72 race finishers completing the study, comparison among intervention groups revealed no significant group or interaction effect on 400 m run time, but there was a significant (P < 0.0001) time effect. The subjective outcome variables also showed no group effect and significant (P < 0.0001) time effects. Interaction effects were present for both lower body muscle pain and soreness rating (P = 0.0017) and overall muscular fatigue score (P < 0.0001). Post testing showed a difference among groups only immediately post-treatment. At this time point, massage showed a lower (P < 0.0001) muscle pain and soreness rating than the control group, whereas both massage (P < 0.0001) and pneumatic compression (P < 0.01) showed lower overall muscular fatigue scores compared with the control group.

Conclusions: Single 20-minute sessions of post-race massage and intermittent sequential pneumatic compression provide some immediate subjective benefit. There is no evidence, however, that such treatments provide extended subjective or functional benefits of clinical importance.

Significance of Findings: Post-exercise recovery techniques are widely used, but little research has examined effectiveness. The study suggests that 2 of the popular recovery methods, massage and pneumatic compression, provide immediate, but not extended, benefits to runners after a 161-km ultramarathon.

Acknowledgments: The work was funded by the Western States Endurance Run Foundation, and also supported by the Rehabilitation Research Experience for Medical Students (RREMS) Program. This material is also the result of work supported with resources and the use of facilities at the VA Northern California Health Care System. We thank Sutter Auburn Faith Hospital for laboratory services; Ve Loyce Shackleton, Jarred Peters and Marcy Wilson for the skilled provision of massage to our subjects; James Milner and John Fors for phlebotomy services; and the following individuals for assistance with data collection: Dr. Michael Campian, Dr. Jeffrey A. Chan, Tyler Hamilton, Ryan Hoffman, Dr David Paris, Lisa Weiss, Casey Westbrooke and Kendall Wu. The contents reported here do not represent the views of the Department of Veterans Affairs or the United States Government.

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Mental Health and Competitive Athletes: Measuring the Psychological Response of Being Diagnosed With Potentially Lethal Cardiac Disease

Stephanie Bailey, MD, Joseph Ewing, MS, Jonathan A. Drezner, MD, Kimberly G. Harmon, MD, David E. Price, MD, Ashwin L. Rao, MD, and Irfan M. Asif, MD

Affiliation: Greenville Health Systems, Greenville, South Carolina.

Purpose: To measure the psychological response of athletes diagnosed with potentially lethal cardiac disease.

Methods and Study Design: Athletes with WPW, LQTS, and HCM completed the Impact of Event Scale (IES), to measure the psychological response to their diagnosis. Athletes with WPW (group 1) were compared to those with HCM or LQTS (group 2) to understand potential differences in responses of athletes with a potentially curable disease (WPW) versus those undergoing medical management with no definitive therapy (HCM or LQTS). Participants were >6 months beyond diagnosis. IES scoring = 0 to 88 (<11 = normal, 12-32 = recommend monitoring, >33 = significant stress reaction). Subscales include: Intrusion, Avoidance, and Hyper-arousal.

Results: 20 athletes (60% male, 83% Caucasian, mean age 18.5) participated, including 10 WPW, 6 HCM, and 4 LQTS. Eighty percent of group 1 athletes underwent successful catheter ablation, and all returned to athletic competition. Group 2 athletes were medically managed without surgical intervention, with the majority (90%) requiring sport modification/disqualification. The mean IES score for group 1 (WPW) athletes was 16.0 (SD = 13.0), [Intrusion 5.8 (SD = 5.3), Avoidance = 7.1 (SD = 5.9), Hyper-arousal = 3.1 (SD = 3.2)]. The mean IES score for group 2 athletes (HCM or LQTS) was 25.7 (SD = 12.3), [Intrusion 8.6 (SD = 3.7), Avoidance = 12.7 (SD = 6.8), Hyper-arousal = 4.4 (SD = 4.6)]. No significant differences existed in overall IES scores for group 1 vs group 2 (P = 0.097) or the subscales of Intrusion (P = 0.186), Avoidance (P = 0.066) or Hyperarousal (P = 0.470). Sixty percent of group 1 athletes and 90% of group 2 athletes had IES scores that fell within the recommended range for continued monitoring for psychological distress or above the range for significant stress reactions.

Conclusions: The impact of a cardiovascular diagnosis such as WPW, HCM, or LQTS requires monitoring to minimize effects on mental health regardless of continued sports participation or disqualification.

Significance of Findings: Mental health is often overlooked in the athletic population. All athletes with cardiovascular disorders, even those with potentially curable disease, should be offered psychological support to reduce the risk of long-term morbidity.

Acknowledgments: This study was funded by the American Medical Society for Sports Medicine Foundation.

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Relationships Between Demographics, Neurocognitive Measures and Near Point Convergence in Pediatric and Adolescent Concussion Patients

Joshua N. Berkowitz, MD,*,† Johna K. Register-Mihalik, PhD,* Mackenzie M. Herzog, MPH,* James G. Blount, MD,† Janna Fonseca, MEd,† Valerie J. DeMaio, MD,* and O. Josh Bloom, MD†

Affiliation: *The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and †Carolina Family Practice & Sports Medicine, Cary, North Carolina.

Purpose: To describe relationships between near point convergence (NPC), patient characteristics and clinical findings among pediatric patients evaluated for concussion.

Methods and Study Design: Athletes 8 to 18 years, presenting within 3 days of a sport-related concussion (SRC) to one of 3 primary care sports medicine clinics in a large urban/suburban practice from December 2014 to October 2015 were enrolled in an IRB-approved, prospective cohort. A standardized visit included clinical interview and exam, symptom checklist, the Immediate Post-Concussion and Cognitive Test (ImPACTTM), and visual-vestibular screening. Univariable and multivariable statistics were used to assess the association between NPC and neurocognitive outcomes, controlling for age and gender. NPC was recorded as a continuous variable (3 trial average), and was dichotomized as “normal” (≤5 cm) versus “abnormal” (>5 cm).

Results: One hundred thirty-one patients met study inclusion (mean age = 14.3 ± 2.0 years; 57% male). Mean NPC was 5.7 ± 6.5 cm (range = 1.3-40.0 cm), and 39 (31%) were considered abnormal (>5 cm). Younger patients had greater NPC scores (r = −0.21; P = 0.02) with patients aged 8 to 14 having higher average NPC scores compared to those 15+ (6.8 ± 7.8 cm vs 4.5 ± 4.3 cm; P = 0.04). There was no difference in NPC by gender (6.3 ± 7.1 cm vs 4.9 ± 5.5 cm; P = 0.23), history of head injury (5.4 ± 4.1 cm vs 6.3 ± 3.9 cm; P = 0.53), or total symptom score (r = 0.05; P = 0.55). There was no association between dichotomized NPC and any ImPACTTM composite score when controlling for patient age and gender (P > 0.05).

Conclusions: There is a significant relationship between patient age and average NPC, with older patients having lower NPC. NPC is not closely associated with patient gender, history of head injury, total symptom score, or ImPACTTM composite scores.

Significance of Findings: Clinicians should consider age when assessing NPC during SRC evaluation. New age-specific cut points for “normal” and “abnormal” convergence may need to be considered.

Acknowledgments: Study funded by the National Operating Committee on Standards for Athletic Equipment. Ms Fonseca, Drs Bloom, Blount, and Berkowitz are employed at the study setting.

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Massage Promotes Regeneration and Angiogenesis Following Eccentric Exercise-Induced Injury

Thomas M. Best, MD, PhD, Scott K. Crawford, PhD, Kunj Patel, MD, and Johnny Huard, PhD

Affiliation: The Ohio State University, Columbus, Ohio.

Purpose: To determine effects of massage on regeneration and repair following eccentric exercise (EEC).

Methods and Study Design: In this pilot study, seven female New Zealand White rabbits were instrumented with bilateral peroneal nerve cuffs for stimulation of the tibialis anterior (TA) muscle. One hindlimb was randomly selected to undergo a damaging bout of EEC. Animals were randomly selected for massage application immediately following EEC (n = 2), 24 hours after EEC (n = 2), or 48 hours after EEC (n = 2). One animal was designated as an exercised, non-massaged control. Massage was applied using a customized mechanical device for 4 consecutive days. At the end of 4 days of massage, animals were euthanized and the TAs excised and frozen for immunohistochemical analysis. The exercised, non-massaged control animal was euthanized 24 hours following EEC. H&E and Masson's trichrome staining was used to determine the amount of muscle regeneration (centronucleated fibers) and fibrosis, respectively. Angiogenesis was determined by the number of CD31 (a cell marker for endothelial cells) positively-stained blood vessels.

Results: The number of regenerating fibers increased 3.5% with massage compared to an average 0.7% increase in the contralateral limb. The average percent difference in regenerating fibers due to massage compared to the contralateral limb was 137% compared to only 26% in the control animal. Massage resulted in an average 14% increase (normalized to contralateral limb) in the number of CD31 positive vessels. Immediate massage was more effective than both delayed massage conditions in promoting regeneration and angiogenesis. Immediate massage was also most effective in reducing tissue fibrosis, resulting in 7% fibrotic area compared to 15% in the control.

Conclusions: Massage increases the percentage of regenerating muscle fibers, promotes angiogenesis, and decreases fibrosis following EEC injury.

Significance of Findings: Immediate massage was more effective than massage delayed 48 or 24 hours for promoting tissue regeneration and reducing fibrosis.

Acknowledgments: Supported by OSU Center of Integrative Health and Wellness Gold Pilot Grant.

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Is an Earlier Evaluation After a Sports-Related Concussion Beneficial?

Namita Bhardwaj, MD, Jose R. Rodarte, MD, Michael A. Hansen, MD, Gerardo Vazquez, MD, and Justin M. Wright, MD

Affiliation: Texas Tech University Health Science Center Sports Medicine Fellowship, El Paso, Texas.

Purpose: The purpose of this study is to evaluate if an earlier evaluation by physician who commonly sees concussions results in a shorter duration of the concussion and earlier return to play.

Methods and Study Design: This is a retrospective case-control study looking at sports-related concussions (SRC). Concussions were sampled from patients seen at our Sports Medicine Clinic, who were diagnosed with a concussion from August 1, 2011 to July 31, 2015 (n = 113). We did a retrospective chart review looking at current standards of care. Athletes >12 years old with SRC were analyzed. We analyzed the time between the date of concussion and date of evaluation and compared it to total concussion duration. We defined a concussion as lasting less than equal to 10 days and post-concussion disorder as concussion duration greater than 10 days.

Results: The average age was 16.03 years. Sixty-seven percent of the patients were male and 33% were female. Football (46.9%) and soccer (14.2%) were the most common sports. Average time to evaluation was 7.33 days; average treatment time was 11.51 days; average concussion duration was 18.84 days. We found a correlation coefficient (r) of 0.436 when comparing time to evaluation and concussion duration. An independent samples t-test was conducted to compare time to evaluation for athletes with concussion and post concussion disorder. There was a significant difference in the time to evaluation for those with concussion (M = 4, SD = 2.51) and those with post concussion disorder (M = 10, SD = 8.71) conditions; t(111) = 0.8667, P = 0.000024.

Conclusions: Based on our results, we noticed a moderately positive relationship between time to evaluation and concussion duration. When we compared the time to evaluation for those who had concussion and those who developed post concussion disorder, we found a statistically significant difference between their times to evaluation.

Significance of Findings: Earlier referral to Sports Medicine Physicians results in shorter concussion duration.

Acknowledgments: None.

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Prevalence of Inadequate Immunity to Measles, Mumps, Rubella and Varicella in Major League Baseball Players

Nicole T. Boniquit, MD, Brett G. Toresdahl, MD, and James J. Kinderknecht, MD

Affiliation: Hospital for Special Surgery, New York, New York.

Purpose: To determine the prevalence of inadequate immunity among Major League Baseball (MLB) players in the setting of recent viral outbreaks and evaluate demographic risk factors.

Methods and Study Design: MLB players were screened for serologic evidence of immunity to measles, mumps, rubella, and varicella at the start of the 2015 season. The results were designated as adequate (immune) or inadequate (equivocal or non-immune). Demographic data were also collected, including age, country of birth, and participation in collegiate sports.

Results: Sixty-two MLB players were screened. The prevalence of inadequate immunity was 32% for any virus, 12% for measles (n = 61), 16% for mumps (n = 50), 23% for rubella (n = 62), and 7% for varicella (n = 60). Comparing country of birth, the prevalence of inadequate immunity to any virus was 31% in non-U.S.-born players (n = 16) compared to 33% in U.S.-born players (n = 46). Comparing participation in collegiate sports, the prevalence of inadequate immunity was 36% in players who played baseball in college (n = 33) compared to 28% in players who did not (n = 29). Comparing younger versus older players, the prevalence of inadequate immunity was 38% in players under age 25 (n = 21) compared to 29% in players over age 25 (n = 41).

Conclusions: Nearly one third of MLB players have inadequate immunity to measles, mumps, rubella or varicella. No demographic risk factors were statistically significant in this small sample.

Significance of Findings: This is the first study to evaluate the prevalence of inadequate immunity among professional athletes. The results can guide future screening programs to prevent outbreaks of viral infections within professional sports. Additional data from MLB and other professional athletes are needed to determine demographic risk factors.

Acknowledgments: None.

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Impact of an Educational Video on Concussion Knowledge and Self-Reporting: A Study Among Pre-Professional Dancers

Lauren Borowski, MD, Christopher Miles, MD, Bethany Miller, BA, and Stephen Davis, MA

Affiliation: Department of Family and Community Medicine, Wake Forest University School of Medicine.

Purpose: To evaluate the incidence of self-reported concussions by college level dancers in a pre-professional program as well as to assess the effects of an educational video on their baseline concussion knowledge.

Methods and Study Design: Male and female dancers aged 18 years and older that attended the University of North Carolina School of the Arts (UNCSA) for the school year 2015 to 2016 were given a 20 question pre-test, watched an educational video on concussions, and then were given the same test to take after watching the video. Demographic questions were asked on the post-test.

Results: Eighty-four students completed both the pre- and post-tests and watched the video. There was a small but statistically significant increase in the mean number of correct answers after watching the educational video (17.0-17.4, P = 0.021). Females had a small but statistically significant higher score than males on pre- and post-tests. There were no differences between classes (freshman through senior) or between types of dance concentrations (ballet, contemporary). Of 84 students, 8 had been diagnosed with a concussion (9.5%), and of those, 4 stated the concussion was from dancing (4.8%). After watching the video, 4 students stated “yes,” they thought they may have incurred an undiagnosed concussion and 2 said “possibly” to the same question.

Conclusions: Although these dancers had a high baseline knowledge level about concussions, it was further improved after viewing an educational video on the subject. The educational video also led to the retrospective identification of concussion in multiple dancers.

Significance of Findings: This study shows that viewing an educational video on concussions affected knowledge and the self-reported incidence of dance-related concussions. Concussion education in dance curricula may improve early and appropriate self-reporting and timelier evaluation and management.

Acknowledgments: None.

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The Association of Sport Specialization and Training Volume Recommendations With Previous Overuse Injury in Adolescent Athletes

M. Alison Brooks, MD, MPH, Eric G. Post, MS, Jeremy W. Riekena, BS, Stephanie M. Trigsted, MS, Timothy A. McGuine, PhD, and David R. Bell, PhD

Affiliation: University of Wisconsin-Madison, Madison, Wisconsin.

Purpose: To determine the association between sport specialization, sport volume recommendations and history of overuse injury in adolescent athletes.

Methods and Study Design: Cross-sectional survey design. Two thousand eleven youth athletes (989 females) between the ages of 12 to 18 (mean age = 13.7 ± 1.6 years) were recruited at youth sports events to complete an anonymous survey. Participants completed a survey that included questions regarding sport participation patterns, sport training volume, and sport-related injury history. Specialization was classified as low, moderate, or high, using a previously published 3-point scale. Chi-square tests and Odds Ratios (OR, 95% CI) were calculated to investigate associations of specialization and volume of participation with previous injuries in the past year (a-priori P ≤ 0.05).

Results: Highly specialized athletes were more likely to report any previous overuse injury (P = 0.001, OR, 1.64, 1.21-2.22), an upper extremity overuse injury (P = 0.007, OR, 2.08, 1.22-3.55), or a lower extremity overuse injury (P = 0.01, OR, 1.55, 1.11-2.18) in the previous year compared to athletes in the low specialization group. Athletes who played their primary sport for more than 8 months out of the year were more likely to report any overuse injury (P < 0.001, OR, 1.69, 1.54-2.32), an upper extremity overuse injury (P = 0.03, OR, 1.71, 1.05-2.77) or a lower extremity overuse injury (P = 0.001, OR, 1.71, 1.26-2.35) in the previous year. Athletes who participated in their primary sport for more hours per week than their age were more likely to report an overuse injury (P = 0.02, OR, 1.30, 1.04-1.63) or a lower extremity overuse injury (P = 0.02, OR, 1.33, 1.04-1.71), but not an upper extremity overuse injury in the previous year.

Conclusions: Athletes who were highly specialized or exceeded sport volume recommendations were more likely to report a previous history of overuse injuries.

Significance of Findings: Sports medicine providers should be aware of the risks of early sport specialization and excessive sport training volume in order to provide appropriate recommendations to parents, coaches, and youth athletes.

Acknowledgments: None.

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Prevalence of Concussion Symptoms in Equestrian Athletes, Is it Underreported?

Stefan S. Buetow, DO, Piper Klemm, PhD, Aniko Szabo, PhD, and Anne Z. Hoch, DO

Affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin.

Purpose: While there is increased awareness of concussion in football and hockey, equestrianism is also a high risk sport for concussion. There is more attention being placed on potential dangers of concussion and its consequences.

Methods and Study Design: Equestrian athletes (1833) were surveyed from the United States Equestrian Federation (USEF). Frequencies, percentages, means, and standard deviations were produced in SAS version 9.4 (The SAS Institute, Cary, NC).

Results: The average age was 23.4 ± 12.2 years. 98.3% of the athletes were female and 1.7% were male. On average, the athletes had been riding 15 ± 11 years at time of the survey. 76.3% competed in Hunter, 62.2% competed in Jumper and 39.0% competed in both. The most common helmet to wear during practice and competition was the Charles Owen at 41.0% and 44.5% respectively. The 5 most common body areas to have been injured after falling off their horse were side of body (80.8%), buttocks (64.3%), head/neck (57.7%), back (11.3%) and knee/ankle/foot (7.7%). Of the athletes who hit their head or neck 73.4% returned to riding in less than 5 days. 71.6% had 1 or more symptoms of concussion, 31.1% had 5 or more symptoms of concussion and 12.5% had greater than 10 or more symptoms of concussion. Overall, of the 1833 athletes, 71.6% had concussion symptoms. Of the athletes that had symptoms, 40.9% were officially diagnosed with concussion. After having onset of symptoms, the athletes were most commonly seen by an MD/DO (44.4%). If the athlete was diagnosed with a concussion, it was most often done by a family physician (23.1%).

Conclusions: The data indicate that concussion symptoms are very common in equestrian athletes (71.6%) but only a minority of those with symptoms (40.9%) are officially diagnosed with a concussion.

Significance of Findings: We recommend greater awareness of concussion symptoms among the equestrian community.

Acknowledgments: Amy Ford, DO.

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Imaging Characteristics of Upper Lumbar Spondylolysis

Eliana Cardozo, DO, Richard G. Chang, MD, Julian Harrison, MA, Darryl B. Sneag, MD, and James F. Wyss, MD

Affiliation: New York Presbyterian Columbia-Cornell, New York, New York.

Purpose: Lumbar spondylolysis is a common cause of back pain, w/higher incidence in athletes. Upper lumbar spondylolysis, above L4, is very uncommon, representing <5% of all cases, but an important consideration. The clinical and imaging characteristics of upper lumbar spondylolysis have not been extensively studied in recent literature.

Methods and Study Design: A retrospective review of radiology reports for CT and/or MRI stored in the database of our large academic institution's radiology department showed 20 patients w/upper lumbar spondylolysis of L1, L2 or L3. One fellowship trained musculoskeletal radiologist reviewed all imaging and characterized the defect level, chronicity (edema on MRI, sclerosis on CT) laterality, additional lower levels of spondylolysis, transitional anatomy and presence of spondylolisthesis.

Results: Thirty-eight lesions were found in 20 patients, 13 had lesions at L3 (65%), 6 had lesions at L2 (30%) and 1 at L1 (5%). The mean age was 40 years, with 85% male patients. Eleven patients underwent Lumbar MRI, 3 underwent Lumbar Spine CT and 6 underwent both. Eighteen patients had bilateral spondylolysis (90%) and 6 (30%) had concomitant spondylolysis at lower lumbar levels. Of the lesions found on MRI, 14.7% showed edema. Of the 6 lesions found on CT, 1 showed sclerosis. Seven patients (35%) had spondylolisthesis, all at L3. Three patients (15%) were found to have transitional anatomy.

Conclusions: Our small retrospective review showed that of upper lumbar spondylolysis, L3 is the most common, followed by L2 and L1, this is consistent with the current limited literature. We did show a higher percentage of bilateral lesions (90%) than that typically seen in lower lumbar spondylolysis. Additionally, the only level with spondylolisthesis was L3.

Significance of Findings: Upper lumbar spondylolysis can be a cause of back pain and morbidity. Current literature on both clinical and imaging features is limited, further study is needed regarding laterality, predisposition to additional levels of spondylolysis and progression to spondylolisthesis.

Acknowledgments: None.

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Analysis of Blood Pressure and Symptom Scores in Patients With Concussions and Patients Without Concussions

Devon Carr, MD, Kelsey Logan, MD, MPH, and Eric Slattery, MS

Affiliation: Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

Purpose: Blood pressure (BP) is a multifaceted cardiovascular parameter under homeostatic control. It is well known that acute pain can cause elevated blood pressure due to increased sympathetic nerve activity, but there are few studies directly analyzing BP after mild traumatic brain injuries, including concussions. Vital signs, including BP, as well as a pain scale and Post-Concussion Symptom Inventory (PCSI) are standard of care measurements used in the evaluation of a patient with a concussion.

Methods and Study Design: We completed a retrospective analysis of patient encounters in sports medicine clinics from January 2012 to March 2015 to determine normative BP values in patients presenting with concussions and patients without concussions. We also sought to determine whether the presence of differing levels of pain in concussed vs non-concussed patients affected typically measured vascular parameters. Two thousand seven hundred six patients (1166 male, 1540 females), ages 6 to 23 (13.81 ± 2.7), split by 667 concussed and 2039 non-concussed, were included in the analyses. Patients were excluded if they lacked vitals, were previously diagnosed with hypertension, or were on a medication that effects BP.

Results: When analyzed by ANCOVA using pain scores, there were significant differences between the groups in DBP (P < 0.036), MAP (P < 0.046), and HR (P < 0.003). When controlled for age, there was no statistically significant difference when comparing SBP, DBP, PP, MAP, or HR between patients presenting with concussions and patients presenting with other chief complaints (typically musculoskeletal).

Conclusions: Results of this study do not support routine measurement of vascular function itself as a marker for concussive injury. However, the results do support prior research demonstrating that pain effects vascular measurements.

Significance of Findings: Changes in vasculature relative to normal in concussed youth are more likely related to pain than they are to the injury.

Acknowledgments: None.

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Assessment of the Readability of Online Resources for Common Primary Care Sports Medicine Conditions

Patrick Cleary, DO and Tanya Shneyder, DO

Affiliation: NYU Lutheran Medical Center, Brooklyn, New York.

Purpose: Given the increasing use of online medical resources, it is imperative that such materials be understood by their readers. The National Institute of Health recommends that printed health information be written at a sixth-grade reading level. Prior studies determined that materials in other fields did not meet this standard; we investigated whether this was also the case in Sports Medicine.

Methods and Study Design: We collected articles on 5 common Primary Care Sports Medicine topics, from 7 different websites. Each article was pasted into Microsoft Word and both a Flesch-Kincaid (F-K) Reading Level and word count were calculated. The mean and standard deviation were calculated by website, by topic and overall.

Results: The overall average Flesch-Kincaid Reading Level was 10.51, SD 2.54; average word count was 2191.2, SD 2430.03. Grouped by website, articles on Teen Health had the lowest F-K Reading Level (7.68), while articles on the AMSSM website had the lowest average Word Count (643.2). Medscape articles had both the highest F-K Reading Level (13.86) and the highest average Word Count (6965). Considered by topic, articles on Ankle Sprain had the lowest average F-K Reading Level (9.79), while articles on Stress Fracture had the lowest average word count (1186.14). Articles on the Female Athlete Triad had both the highest average F-K Reading Level (11.4) and the highest average Word Count (2606.86). Only 2 articles (5.7%) were written at or below the recommended sixth grade level, while 9 articles (25.7%), 4 from Wikipedia and all 5 from Medscape, had F-K Reading levels 12 or higher.

Conclusions: Online Sports Medicine materials did not meet the NIH's recommended reading level.

Significance of Findings: Acknowledging and making efforts to improve readability can benefit patients by promoting greater public health literacy.

Acknowledgments: None.

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Perceptions and Effectiveness of Musculoskeletal Ultrasound in a Medical School Anatomy Course

Justin Conway, MD, Jae-yeon Lee, Mackenzie Neumaier, Robert Monaco, MD, George Mulheron, PhD, and Jennifer Bukman, PhD

Affiliation: Rutgers—Robert Wood Johnson Medical School, New Brunswick, New Jersey.

Purpose: To evaluate the perceptions and effectiveness of the use of musculoskeletal ultrasound (MSKUS) in a first year medical student anatomy course.

Methods and Study Design: Subjects were first year medical students enrolled in the structure and function anatomy course (n = 190). Ultrasound training included a 1 hour introductory lecture, supplementary videos on ultrasound knobology and basic skills, and a 3 hour session consisting of a hands-on scanning workshop focusing on shoulder anatomy and dynamic evaluation paired with a case-based cadaveric dissection utilizing web-based modules including ultrasound images. Data was collected via a pre-workshop quiz on shoulder anatomy and MSKUS along with a 23-item survey and post-test administered immediately after the session.

Results: One hundred fifteen (60%) students completed the survey. Eighty-four percent of respondents agreed or strongly agreed that ultrasound helped increase their understanding of MSK anatomy and 68% felt that their overall experience during the ultrasound workshop was excellent or highly worthwhile. Eighty-three percent expressed interested in continued ultrasound training throughout their curriculum. Conversely, only 28% of respondents felt the overall experience with web-based modules was excellent or highly worthwhile. Average score on the 8 question pre-test was 62% (n = 190) compared to 77% on the post-test (n = 186).

Conclusions: The vast majority of students felt MSKUS was an effective tool in increasing their understanding of musculoskeletal anatomy and would like to see it implemented in other areas of the curriculum. Perceptions of the web-based multimedia modules were less favorable. Students appeared to gravitate to the hands-on nature of ultrasound with particular interest in dynamic evaluation in real time. Scores on pre- and post-test examination suggest that ultrasound may enhance understanding of MSK anatomy though further study in this area is needed.

Significance of Findings: Ultrasound is a valuable tool for the teaching and learning of musculoskeletal anatomy in medical school.

Acknowledgments: None.

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Prevalence of Vestibular and Vision Problems Following Concussion in Children Under 13

Emily Cross, BA, Daniel Corwin, MD, Julia Lockyer, MS, Eileen Storey, BA, Olivia Podolak, MD, Matthew F. Grady, MD, and Christina L. Master, MD

Affiliation: Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.

Purpose: Concussion is a common injury among children and adolescents. Most studies of pediatric concussion focus on adolescents, while less is known about concussion in children under age 13. This study aims to describe the prevalence of vestibular, balance and binocular vision problems seen following concussion in patients under the age of 13.

Methods and Study Design: This is a retrospective cohort study of patients under 13 years of age referred to the Minds Matter Concussion Program at The Children's Hospital of Philadelphia (CHOP) Sports Medicine Clinic with concussion from 2010 to 2015. Eligible patients were those with a diagnosis of concussion confirmed by the sports medicine physician at the initial visit. Data recorded from the initial visit included demographics, date and mechanism of the injury, symptoms experienced at the time of injury, and findings on physical examination.

Results: One hundred thirty-two patients were included, with a median age of 11 years (range, 3-12). 68.9% were male and 31.1% were female. 55.3% percent of injuries were sports-related; the most common sports involved were soccer (22.2%) and football (18.1%). Common presenting symptoms were headache (73.5%), dizziness (45.5%), fatigue (44.7%), and difficulty concentrating (41.7%). On physical examination, 65.9% had balance abnormalities, 60.0% had vestibular deficits, 56.6% had saccadic dysfunction, and 55.3% had convergence insufficiency.

Conclusions: There is a high prevalence of balance, vestibular and binocular vision problems following concussion in children under age 13.

Significance of Findings: Improved recognition of the deficits following concussion in young children is necessary to guide timely diagnosis and appropriate management, including appropriate school accommodations for binocular vision problems and vestibular therapy for balance and dizziness issues.

Acknowledgments: None.

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Cognitive and Physical Activity Levels in Pediatric Athletes Post Concussion: An Interim Analysis of an Observational Case Series

Angie Curtis, MD, MPT, Eric Slattery, MS, Adam Kiefer, PhD, and Paul Gubanich, MD, MPH

Affiliation: Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

Purpose: To quantify physical and cognitive activity levels in concussed athletes during their first 2 weeks of management after presentation.

Methods and Study Design: Athletes (N = 20; 13-17 years) who were symptomatic at time of presentation to a sports medicine clinic and within 2 weeks of their initial sport-related concussion were eligible. Subjects' performance measures and responses were recorded on 5 tests: (1) Post-Concussion Symptom Inventory (PCSI), (2) puck drop (PD), (3) King-Devick test (KD), (4) SCAT-3, and (5) ImPACT at the initial and follow-up visits (∼7 and 14 days post presentation). Subjects were instructed on appropriate physical (PA) and cognitive activity (CA) levels commensurate with their degree of symptomatology and recovery. These levels were tracked with patient logs and SenseWear armband accelerometry during the first 2 weeks of recovery.

Results: To date, 20 subjects completed the study; 6 were included in this analysis. PCSI declined as subjects recovered from their concussion (34.17 at presentation, 13.67 week 1, and 7.17 week 2). KD times decreased after week 1 but increased slightly week 2 (69.06 seconds À47.09 seconds À52.68 seconds). PD decreased during week 1 and remained level during week 2 (229 milliseconds À209 À209 milliseconds). Subjects reported slight increases in CA (55.80 minutes À61.12 minutes), and PA (12.39 minutes À14.29 minutes) over the study period which was recorded as increased accelerometry as increased PA duration and total daily steps. ImPACT domains also showed improvement in: VM (82.83 À83.83 À88.83), VisM (69.00 À70.50 À73.00), VMS (33.60 À39.90 À41.48), and RT (0.63 À0.55 À0.55).

Conclusions: This study examined PA and CA levels in a cohort of concussed pediatric athletes. Comparison of these levels with controls and a larger sample may improve our understanding of the daily living demands on this cohort. Future work should relate recovery to these levels.

Significance of Findings: As awareness and incidence of concussions increases, there is a growing need to develop standardized treatment guidelines.

Acknowledgments: Funded by Cincinnati Childrens Hospital, University of Cincinnati, and Ohio State University.

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Survey of Primary Care Sports Medicine Fellows on Perceived Importance of Sports Ultrasound in Fellowship Programs

Richard O. Davis, Jr, DO and Matthew McElroy, DO

Affiliation: Geisinger Medical Center, Danville, Pennsylvania.

Purpose: Sports ultrasound (SUS) has become increasingly popular among primary care sports medicine (PCSM) physicicians in the last 5 to 10 years. Finoff et al published a proposted sports ultrasound curriculum in October 2014 that outlines a standardized educational track for sports medicine fellowship programs. The purpose of our study was to assess the perceived importance to applicants for fellowship ranking and early feedback from current fellows noting SUS education and application in training.

Methods and Study Design: A survey was sent to all PCSM fellows registered with the AMSSM via email on September 1, 2015. The survey included 10 questions and sent out via surveymonkey, 55 total responses were received.

Results: There were 55 responses, of whom 29 (53%, 95% confidence interval, 39%-66%) reported a strong SUS experience played a role in their rankings of a fellowship. Thirty-nine out of 55 (70%, 95% CI, 57%-82%) applicants reported their fellowship had dedicated SUS lectures. Forty-two (77%, 95% CI, 63%-87%) report that it is very likely they will use SUS when they are finished with fellowship. Twenty-five (45%, 95% CI, 32%-59%) plan to sit for the ARDMS MSK certification exam.

Conclusions: The majority of fellows reported that a strong sports ultrasound curriculum played a role in their ranking of sports medicine fellowships.

Significance of Findings: The majority of prospective applicants want to learn SUS as part of their fellowship curriculum, and SUS plays a role in their rankings of a fellowship program.

Acknowledgments: AMSSM Account Managers and Research Committee.

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Cryoneurolysis for Treatment of Knee Pain Secondary to Osteoarthritis; a Retrospective Chart Review

Dore DeBartolo, DO

Affiliation: Private Practice.

Purpose: The purpose of this study was to evaluate the commercial use of Focus Cold Therapy (FCT), a novel, non-surgical minimally-invasive cryoneurolysis treatment for temporarily reducing pain secondary to knee osteoarthritis.

Methods and Study Design: This was an IRB-approved, retrospective chart review of patients (n = 122) who received cryoneurolysis between August 2013 and March 2015 by a single physician. All patients (245 treatments, 191 unique knees) received cryoneurolysis treatment applied to the infrapatellear branch of the saphenous nerve (ISN). Outcome measurements included range of motion (ROM), numeric rating scale (NRS) for pain, and patient diary reports. Number of treatments per knee and time between treatments were also analyzed. Patients who received steroid or viscosupplementation injections within 3 and 6 months, respectively, were excluded from the primary outcomes analyses (n = 113 treatments). One hundred thirty-two treatments (56 patients) were included in the primary outcomes analysis.

Results: One hundred fifty-six knees (82%) underwent a single treatment. Knees with multiple treatments ranged from 28 knees (15%) with 2 treatments to 1 knee with 9 treatments. Sixty-nine patients (57%) had bilateral treatments. Mean days between first and second treatments was 136 days (range, 28-418). The mean baseline NRS score of 7.2 decreased to 1.4 immediately post-treatment (P < 0.05). Pain reduction was maintained at 1 and 2 months post-treatment [mean NRS were 4.1 and 5.0, respectively (P < 0.05)]. Baseline flexion was maintained post-treatment, and there were no significant differences observed between baseline and follow-up flexion measurements. Of the patients that completed diaries, 75% (9/12) reported an increase in activities of daily living 24 hours post-treatment. Eighty-one percent (13/16) recommended cryoneurolysis.

Conclusions: The results demonstrated a statistically significant reduction in knee pain through 2 months post-treatment. Pain reduction beyond 2 months was also observed. The volume of repeated treatments demonstrates consistency with observed patient satisfaction.

Significance of Findings: FCT appears to be an effective therapy for temporary relief of pain secondary to knee osteoarthritis.

Acknowledgments: None.

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Vitamin D Supplementation Mitigates the Seasonal Variability of Serum Vitamin D Levels in Collegiate Athletes Training at Northern Latitude

Keri L. Denay, MD, Jeffrey A. Housner, MD, Caroline Mandel, CSSD, Amy C. Miller, MD, Paul Schmidt, ATC, PT, and Robert B. Kiningham, MD

Affiliation: University of Michigan, Ann Arbor, Michigan.

Purpose: To determine the seasonal variability of serum 25-hydroxyvitamin D levels in division I collegiate athletes training at 42 degree north latitude who were provided supplementation with 2000 IU vitamin D3 daily.

Methods and Study Design: A prospective cohort study was undertaken offering 256 first-year varsity athletes the opportunity to participate in a vitamin D supplementation program at the University of Michigan. The program consisted of providing 2000 IU of oral vitamin D3 daily to athletes who wished to participate. Participating athletes also had 4 blood draws—a summer baseline level followed by 3 additional blood draws separated by roughly 6 months to assess seasonal variability. Athletes also self-reported compliance with taking the supplement as “always/usually” taking or “never/rarely/inconsistently” taking.

Results: A total of 85 athletes (59 women and 26 men) completed all 4 blood draws. Baseline levels revealed a mean level of 43.9 ± 18.7 ng/dL with a range of 15 to 120. Four athletes were <20 ng/dL, 15 between 20 and 29 ng/dL, and 66 >30 ng/dL. Levels for the 23 athletes “always/usually” taking the supplement were: 44.6 ± 17.1, 42.4 ± 16.9, 53.1 ± 17.5, and 34.1 ± 11.0 ng/dL. For the 62 athletes “never/rarely/inconsistently” taking the supplement, the levels were: 43.6 ± 19.4, 28.2 ± 8.9, 43.9 ± 17.3, and 26.0 ± 6.0 ng/dL. Comparison between the groups yielded no significant difference at baseline (P = 0.41), yet statistically significant lower levels for those not taking the supplement in subsequent blood draws (P < 0.001, P < 0.02, and P < 0.001).

Conclusions: Athletes training at northern latitudes and regularly taking 2000 IU vitamin D3 daily have significantly higher serum vitamin D levels despite seasonal variability when compared to those not taking the supplement.

Significance of Findings: Vitamiin D supplementation in athletes training at northern latitudes may help mitigate the seasonal variability in serum levels.

Acknowledgments: University of Michigan Departments of Family Medicine and Orthopaedic Surgery University of Michigan Athletic Department.

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Detection of Knee Effusion: Ultrasonography Versus Orthopedic Physical Examination

Deanna Didiano, DO, ABFM, ATC, Karl B. Field, MD, ABFM, CAQSM, Charles Hansen, MA, CCRC, and John Pick-Jacobs, MD, ABFM

Affiliation: Department of Sports Medicine, Cone Health Medical Center, Greensboro, North Carolina.

Purpose: Improved technology and more widespread training have increased utilization of ultrasound (US) examination as a noninvasive, cost-effective, and time-efficient tool for detection of musculoskeletal pathology. The aim of this study is to determine if sonographic examination improves detection of knee effusion when compared to orthopedic examination. Presence of a knee effusion makes the likelihood of internal derangement higher and is a key clinical finding.

Methods and Study Design: Eight experienced orthopedic physicians were asked to determine if the patient presenting for evaluation of knee pain had a small, moderate, large or absent knee effusion. Subsequent to blinded orthopedic examination subjects underwent US examination.

Results: Fifty Participants including 29 females and 21 males, mean age 53.4 ± 17.7, mean BMI 30.1 ± 6.1. The sensitivity of orthopedic assessment was consistent with US, 86.4% (95% CI, 0.65-0.97) when effusion was present, 60.7% (95% CI, 0.40-0.78) when effusion was absent with an overall agreement of 72%. Orthopedists failed to identify a small effusion in 3 of 11 (27%) patients with mean BMI of 25. Interestingly, the orthopedists incorrectly classified 7 of the 13 (53.8%) patients with BMI >30.0 as having a small effusion when US detected no effusion.

Conclusions: Physical exam is not as sensitive in detecting smaller knee effusions in patients with larger BMI with a positive predictive value of only 42.8%. Conversely, the false negative examinations for small effusions in patients with lower BMI may underestimate the severity of injury in this group.

Significance of Findings: Ultrasound provides a point of care service to improve the diagnosis of a small knee effusion often missed on clinical exam. Factors such as joint deformities, muscular girth, and obesity further increase the likelihood of errors in physical examination. Ultrasound could potentially reduce the need for MRIs in patients with higher BMI, as many of these patients are incorrectly thought to have effusion.

Acknowledgments: Martha Delaney; Cone Health Sports Medicine; Murphy-Wainer Orthopedics; Guilford Orthopedics.

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Dietary Supplement Use and Source of Nutrition Information Among Collegiate Athletes

Todd J. Domeyer, MD, Rachel B. Parks, MS, RD, CNSC, CSSD, Scott Hetzel, MS, and M. Alison Brooks, MD, MPH

Affiliation: University of Wisconsin-Madison.

Purpose: To assess the usage of dietary supplements by NCAA division-I athletes and determine athletes' sources of nutrition information.

Methods and Study Design: A voluntary, confidential survey was made available online to all athletes (n = 738) at a single institution for the first 8 weeks of spring semester. Questions regarding supplements, behaviors, and sources of nutrition information were analyzed using χ2 testing with Holm correction comparing among genders, sports, year of eligibility and those with special diets.

Results: Survey response rate was 94% (n = 697) of which 69.8% reported use of supplements. The most frequently used supplements were protein (31.6%) and multivitamins (31.4%). Overall supplement usage was higher in males than females (P = 0.008) with males using more protein products (P < 0.001) and creatine (P < 0.001) while females used more minerals, most commonly iron and calcium (P < 0.001). Hockey and cross country had the highest rates of supplement use in men (93% each) and hockey and swimming/diving in women (88%; 86%). The most common source of information overall was family/friends (72.6%). Females were more likely to use family/friends (P = 0.001) and media (P = 0.012) while males were more likely to use coaches (P = 0.029). Athletes who reported using other sources of information were more likely to take: any supplement (P < 0.001) and vitamins (P < 0.001) − Nutrition staff; protein (P = 0.003) and vitamins (P = 0.043) − Coaches; minerals (P = 0.045) − Medical staff. Year of eligibility had no relation to supplement use (P = 0.579). Desire to gain weight was the only special diet associated with supplement use, with increased use of protein products (P < 0.001).

Conclusions: A significant portion of collegiate athletes in this study report supplement use. Patterns of use differed by gender and sport but not year of eligibility. Athletes who used nutrition, medical, or coaching staff as their source of nutrition information, were more likely to use certain supplements.

Significance of Findings: Athletes using reliable sources of information were more likely to take certain supplements.

Acknowledgments: None.

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Lower Extremity Injury Rates in NCAA Division 1 Baseball Pitchers

Mark Dundas, MD and Brian Krabak, MD, MBA

Affiliation: Department of Rehabilitation Medicine, University of Washington.

Purpose: Previous research of collegiate pitchers has focused on upper extremity injuries, but little is known about lower extremity injuries. The purpose of this study was to assess lower extremity injury rates in collegiate pitchers.

Methods and Study Design: A retrospective chart review of medical records was performed for all male pitchers participating in 2 division 1 baseball programs, Seattle University (2009-2010 through 2013-2014 seasons) and the University of Washington (2002-2003 through 2012-2013 seasons). A total of 99 pitchers representing 214 pitcher years, defined as the number of years a pitcher was part of the baseball team, were included in the final analysis. Data collection included pitcher age, height, weight and pitching arm. Injury data was collected on age, body region, diagnosis and laterality. Injuries to the pelvis and caudal were included for analysis.

Results: Thirty-seven pitchers reported a total of 45 lower extremity injuries resulting in a risk of injury of 21.0% per pitcher year. Bilateral injuries occurred in 5 pitchers and 3 pitchers reported 2 injuries in the same leg within the same year. The most common injuries were ankle sprains (45%) and hip adductor strains (17.8%), followed by diagnoses of patellar tendonitis, patellofemoral syndrome, tibial contusions, hamstring strains and knee injuries each reported at 8.9% of all injuries. Lower extremity injuries occurred ipsilateral to the throwing arm in 53% of injuries and 26.7% of pitchers with lower extremity injuries reported an injury to their pitching arm within the same year.

Conclusions: Lower extremity injuries are common in collegiate pitchers and may occur in the setting of a throwing arm injury. Further research should identify factors that may contribute to lower extremity injuries in this population.

Significance of Findings: Research and clinical attention focusing only on injuries to the throwing arm neglects other commonly injured aspects of the complex biomechanic movement of pitching in baseball.

Acknowledgments: The author would like to thank the athletes and training staff at the University of Washington and Seattle University for their assistance in completing this study.

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Complexity of Family Medicine Visits for Musculoskeletal Complaints

David S. Edwards, MD, Richard Young, MD, Sandra K. Burge, PhD, and Colleen Dolan, MA

Affiliation: Department of Family & Community Medicine, Sports Medicine Division, Texas Tech University Health Sciences Center, Lubbock, Texas.

Purpose: Assess complexity of patient visits to Family Medicine clinics including frequency of: musculoskeletal (MSK) reasons for visit, imaging and types and referral patterns.

Methods and Study Design: This was cross-sectional direct observation study. A visit survey was developed using a National Ambulatory Medical Care Survey format coupled with additional measures of complexity (health system issues, physician's diagnostic uncertainty, cultural and socioeconomic factors) ranked by the provider from low to high. The survey was completed through observation and interaction with faculty and resident physicians across 10 clinics in Texas. Complexity calculations were performed using Peek and Baird's Minnesota Complexity Assessment Method. Frequency and ANOVA tables were created, and χ2 tests were performed.

Results: Nine hundred eighty-two patients were studied (61% women, 57% Hispanic, 38% middle age) and 361 presented with MSK concerns (13% of all subjects with back pain, 18% hip and lower extremity pain, 10% shoulder and upper extremity pain, 5% with nonspecific muscle, joint or rib pain). Of those with MSK concerns, 14% received x-rays, 3% received MRI, 2.5% received CT, and 5% received ultrasound. Approximately 27% of patients were referred to a specialist compared to 19% of patients with no MSK concerns (P = 0.005). Approximately 31% of patients with back symptoms were referred compared to 20% of others (P = 0.009). On Peek and Baird's complexity count, patients with MSK concerns had 1.6 moderate-severe issues checked, while others had only 1.0 (P = 0.000).

Conclusions: MSK complaints were common and associated with increased complexity. There were no gender or ethnic differences among MSK diagnoses, but middle-aged adults were significantly more likely to present with MSK complaints (P < 0.001). Imaging was infrequent. Referrals were more likely for MSK concerns.

Significance of Findings: Results will be used to inform clinical practice within the research network.

Acknowledgments: Residency Research Network of Texas, Texas Academy of Family Practice for grant funding.

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Foot and Ankle Injuries in Elite Taekwondo Athletes; A Cross-Sectional Study

Mohammed Emam, MD, Jared R. Levin, MD, and Se Won Lee, MD

Affiliation: Depratment of Physical Medicine and Rehabilitation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.

Purpose: The aim of this study is to identify the specific diagnoses, prevalence and mechanisms of foot and ankle injuries among elite Taekwondo athletes.

Methods and Study Design: This is a cross-sectional study investigating foot and ankle injuries in elite Taekwondo athletes. IRB approval, and informed consent from all subjects was obtained. Nineteen elite Taekwondo world-ranked athletes were recruited. Clinical information including baseline characteristics, presence of current foot/ankle injuries, total foot/ankle injuries within the last 6 months, characteristics of pain, and mechanisms of injury were analyzed. All athletes were examined by one author.

Results: There was no significant difference in the rate of foot and ankle injuries between males and females (7/9 and 8/10 current cases respectively). Acute injuries were more common than overuse injuries (18/22 total and 12/15 current cases). The most common cause of acute injury was striking the dorsal foot against an opponent's knee or elbow (9/22 total and 5/15 current cases). Also common were injuries caused by rolling the ankle during a kick (6/22 total and 3/15 current cases). The hindfoot was the most common site of reported pain in current injuries followed by the forefoot (9/15 and 6/15 respectively). Lateral ankle sprain (anterior talofibular ligament) was the most common diagnosis followed by metatarsalgia in current injuries on examination. Injury rates were similar between competition and training (5/15 and 6/15 respectively). However, as athletes spend more time training than they do in competition, it may be that injuries are more likely to occur during competition time.

Conclusions: Acute injuries occur more commonly than overuse injuries in elite Taekwondo athletes. The most common injuries include ankle sprain and forefoot injury due to striking an opponent's elbow or knee. Injuries are more likely to occur in competition compared to training.

Significance of Findings: Modalities to stabilize the ankle joint and better protect the forefoot in Taekwondo may greatly decrease the rate of injury, especially during competition.

Acknowledgments: None.

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The Efficacy of Platelet Rich Plasma as an Intervention for Patellar Tendinopathy: A Case Series

Blaze Emerson, BS, MS, OMSIII, Melissa Tabor, DO, Christy Liggins, BS, Logan Huff, OMSIV, and Morey J. Kolber, PhD

Affiliation: Nova Southeastern University, Ft. Lauderdale, Florida.

Purpose: To determine the efficacy of platelet rich plasma (PRP) injections on pain, function, global rating of improvement, and tendon morphology among athletic subjects with patellar tendinopathy.

Methods and Study Design: This study was a one-group pretest to posttest design using 5 athletic individuals (age, 20-26) diagnosed with chronic patellar tendinopathy based on musculoskeletal ultrasound and clinical diagnosis. Subjects received 3 PRP injections over the course of 6-weeks. Dependent variables [verbal pain rating, palpable tenderness, patient specific functional scale (PSFS)] were assessed at baseline, 2-weeks, 1- and 3-months. Global rating of change (GROC) and tendon morphology using MSK/US was assessed at 2 weeks, 1- and 3- months following the initial intervention.

Results: All subjects demonstrated objective improvement on MSK/US with deceased thickening, increased linear patterning of tendon fibers, and decreased hypoechogenicity at the 3-month follow-up. With regard to dependent variables improvement occurred at all time points. At the 3-month follow up, average pain changed from a mean of 4/10 to 1/10 with 4 of the subjects having complete resolution of tenderness. Functional-sport impairments based on the PSFS identified an improvement from a mean 60% perceived limitation to 10%. The GROC identified self-perceived improvement among all participants.

Conclusions: A 3-injection PRP intervention improved pain, tenderness, function, and global rating of change to a level that satisfied the reported minimum clinically important difference for these outcome measures. Follow up MSK/US images showed return to normal tendon morphology and regeneration of tendon collagen.

Significance of Findings: Patellar tendinopathy is a common chronic pathology among athletic individuals with a point prevalence ranging from 3% to 45%. Our study indicates that PRP is a viable alternative to more aggressive surgical interventions and has the potential to reverse the pathological cascade without the cost, risks, and down-time associated with surgery.

Acknowledgments: Nova Southeastern University President's Faculty Research and Development Grant, as well as the Health Professions Division, Faculty Research Grant for providing funding.

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Individual Differences Between Non-Motorized and Motorized Treadmill Running in Recreational Distance Runners

Peter C. Fast, MD, David K. Brennan, MEd, and Thomas W. Allen, DO, MPH

Affiliation: Center for Exercise and Sports Medicine, School of Community Medicine, University of Oklahoma, Tulsa, Oklahoma.

Purpose: Determine if energy expenditure at running economy (RE) velocity will be greater for non-motorized treadmill (NMT) running compared to motorized treadmill (MTM) running.

Methods and Study Design: Convenience sample of 39 recreational distance runners (20 male/19 female) age 23 to 60 years with previous experience running on MTM. Day 1, subject performed V[Combining Dot Above]O2max test on MTM to determine 3 RE speeds. Day 2, subject performed RE test on MTM. Subject then performed 3, 4 minute steady state runs, at velocities representing 70%, 75% and 80% of V[Combining Dot Above]O2max. Day 3, subject performed RE test running on NMT using the MTM protocol. V[Combining Dot Above]O2 was measured utilizing TruOne 2400 metabolic cart, while running on MTM or NMT. HR recorded using Polar WearLink. Finger stick BL measurements collected using Lactate Plus portable photo spectrometer.

Results: Significant differences in mean values of V[Combining Dot Above]O2, HR, and BL in 39 recreational runners between a MTM and NMT. Energy expenditure measured by V[Combining Dot Above]O2 mL·kg−1·min−1 at RE pace (75% max MTM V[Combining Dot Above]O2 speed) was significantly greater on NMT than MTM. Differences statistically evaluated using student t test. Mean MTM and NMT values for V[Combining Dot Above]O2, HR, and BL calculated at 37.6 and 45.6 mL·kg−1·min−1 (P < 0.001). Mean HR was 156 and 169 bpm (P = 0.001). Mean BL was 2.33 and 5.44 mmol (P < 0.001) respectively.

Conclusions: Energy expenditure, measured by V[Combining Dot Above]O2 mL·kg−1·min−1, at RE pace in distance runners is significantly greater for NMT than MTM.

Significance of Findings: Establishing the magnitude of differences in energy expenditure between MTM and NMT can allow runners/coaches to design training programs using NMT with appropriate workloads to improve fitness/RE.

Acknowledgments: None.

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An Assessment of Mental Health in Division I Student-Athletes Using PHQ-9 and GAD-7 Surveys

Ashley Fields, MD, Giselle Aerni, MD, Eleanor Beltz, MS, ATC, and Dawn Shadron, LCSW

Affiliation: The University of Connecticut, Storrs, Connecticut.

Purpose: Mental health concerns are increasing in the collegiate population. The purpose of this study was to determine the epidemiology of depression and anxiety among division I student-athletes using standardized surveys, the PHQ-9 and GAD-7.

Methods and Study Design: Observational cross-sectional study. A total of 683 NCAA division I student-athletes participating in 22 sports, were asked to complete PHQ-9 and GAD-7 surveys via their electronic medical record patient portal. De-identified results were analyzed to determine the prevalence of positive depression and anxiety screening (scores ≥ 10). Results were also analyzed by gender and sport.

Results: A total of 195 student-athletes completed the survey (83 male, 112 females, mean age ± SD: 20.5 ± 1.5) for a response rate of 28.5%. Overall 6.7% of student-athletes screen positive on the PHQ-9 (4.8% of males and 8.0% of females) and 11.8% of student athletes scored positive on the GAD 7 (9.6% of males and 13.4% of females). Of sports with >80% respondents, women's ice hockey had the highest prevalence of depression (13.6%) and anxiety (22.7%) and men's ice hockey had the highest rate of anxiety (12.5%).

Conclusions: A significant proportion of student-athletes screened positive for depression and anxiety, with a greater overall prevalence of anxiety. Certain sports may have a higher prevalence of depression or anxiety.

Significance of Findings: Baseline mental health surveys for student-athletes may help identify groups at high risk for mental health challenges. Identifying high risk groups can help in the development of targeted educational and treatment programs to better support our student-athletes.

Acknowledgments: None.

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An Objective Assessment of the BESS: Normative Data for the iBess Measure

Alberts JL, PhD,*,† Ozinga S,*,† Figler R, MD,* Russman A, DO,* Cruickshank, J, ATC,* Dey, T,* and Linder SM, DPT*,†

Affiliation: *Cleveland Clinic Concussion Center, Cleveland, Ohio; and †Biomedical Engineering, Cleveland Clinic, Cleveland, OH.

Purpose: The objective evaluation of balance and postural stability prior to and post-concussion is one of the many tools utilized in concussion evaluation and management in a group of multi-disciplinary providers. An algorithm was developed to utilize the accelerometer and gyroscope data gathered from the iPad to quantify postural stability during performance of the Balance Error Scoring System (BESS); iBess. The aim of this project was to characterize potential differences in postural stability, using the iBess measure, as a function of age, gender and sport.

Methods and Study Design: A prospective study design was utilized to gather measurements during routine baseline testing of athletes across Northeast Ohio under the care of Cleveland Clinic Athletic Trainers. Participants completed all 6 conditions of the BESS. An iPad was attached at the sacral level of the athlete to record movement. A total of 6768 athletes (N = 2164 females) participated. Three age levels were tested. Age groupings were: <14 years, 14 to 18 years and 18+; consisting of 606, 4841 and 1321 respectively.

Results: Overall, the iBESS score was significantly greater in conditions in which participants were standing on the foam pad compared to the firm surface. Additional investigation of specific biomechanical measures of postural stability indicated that, in general, the youngest age group had significantly worse balance than the High School and College athletes as movement in the medial-lateral, anterior-posterior and trunk rotation was greater for the youngest group.

Conclusions: These initial results indicate that the youth athletes have significantly different levels of postural stability than their older counterparts.

Significance of Findings: Objective, age-specific measures of postural stability can be measured and utilized to facilitate the management of concussion and facilitate the uniformity amongst providers.

Acknowledgments: Cleveland Clinic Athletic Training Staff members for their dedication and hard work in assisting in collection of data during baseline evaluations.

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The Use of the Functional Movement Screen to Predict Injury in a Cohort of Professional Ice Hockey Athletes

Diana M. Filtz, MD, Cayce Onks, DO, MS, ATC, Scott Deihl, ATC, PTA, Robert Kelly, PT, ATC, and John R. Wawrzyniak, PT, ATC, CSCS

Affiliation: Pennsylvania State University College of Medicine.

Purpose: The Functional Movement Screen (FMS) is a tool used to identify asymmetries in functional movements, which may place an individual at increased risk of injury. Limited research has been conducted to verify the predictive value of the FMS for musculoskeletal injury risk, and no studies have focused specifically on ice hockey athletes. The purpose of this study was to investigate the use of the FMS in predicting musculoskeletal injury risk in a cohort of professional ice hockey athletes.

Methods and Study Design: This was a prospective cohort study. FMS scores of 37 professional ice hockey athletes were obtained during preseason. Participants were tracked prospectively over the course of 2 hockey seasons (2013-2014 and 2014-2015) and all sport-related musculoskeletal injuries resulting in restriction of play were documented by athletic training staff. The injury data was then used to calculate the composite FMS score that would place an athlete at greater risk for musculoskeletal injury.

Results: A cutoff score was determined using a receiver operator characteristic curve. A maximized odds ratio of 1.06 (95% confidence interval, 0.74-1.52) was found for individuals scoring a composite score of 17 or lower on the FMS. Thus, for every 1-unit decrease in the FMS score, the odds of an injury increased by a factor of 1.06 (ie, 6%); however, this was not statistically significant (P = 0.75).

Conclusions: Our results are contrary to previous research, and suggest that the FMS is not useful for predicting musculoskeletal injury, specifically in professional ice hockey athletes.

Significance of Findings: The results of our study suggest that the FMS has limited predictive usefulness for musculoskeletal injury in professional ice hockey athletes. Further studies are emerging that call into question the validity of the FMS as a predictive tool. Future studies should attempt to validate the FMS as a tool that can predict musculoskeletal injury.

Acknowledgments: The authors gratefully acknowledge Allen Kunselman, MA, for assistance with the statistical analysis, and Tyson Rose, PT, MS, ATC and Dan Stuck, EMT, for their contribution to the data collection. This project was made possible by a grant from the Penn State College of Medicine Junior Faculty Development Program.

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Community Heart Screens: A Retrospective Analysis of Students in West Michigan

Nathan Fitton, DO, Matthew Hilton, DO, and Ed Kornoelje, DO

Affiliation: Metro Health Hospital, Wyoming, Michigan.

Purpose: Evaluate why athletes were screening positive for cardiac risk, receiving echocardiograms and the subsequent results.

Methods and Study Design: From 2012 to 2015, seven cardiac screening events were conducted for local athletes (ages 11-30). Screening included a cardiac-focused history and physical and ECG interpretation using the Seattle Criteria. Athletes with a positive screen were further evaluated by an on-site echocardiogram. This was a retrospective cohort study.

Results: A total of 770 student athletes were screened. There were 73 echocardiograms performed for positive screening results: ECG, personal history, family history, murmur or any combination. Variables that included personal history and/or ECG were statistically significant predictors (P < 0.0001) of whether or not the athlete received an echocardiogram. Of the echocardiograms performed 45 (61.64%) included at least an abnormal ECG as the indication. Out of all the echocardiograms performed, 3 were interpreted as abnormal: enlarged ascending aorta, mitral regurgitation and bicuspid aortic valve. One case of Wolf Parkinson White (WPW) Syndrome was found on ECG alone. Although determined to be abnormal the bicuspid aortic valve was not held from play while the others including the case of WPW were pending expert consultation. This represents 0.39% of the sample population. Overall abnormalities were found in 4/770 or 0.52% of the sample cohort.

Conclusions: Personal history and abnormal ECG findings were significant predictors of obtaining an echocardiogram but in the athletes with an abnormal echocardiogram who were held from play, neither had a positive screening by history or exam, but did have an abnormal ECG. In addition the athlete with WPW also had a normal focused cardiac exam but positive ECG findings.

Significance of Findings: From our sample population both positive personal history and abnormal ECG were significant for predicting additional workup but the abnormalities that withheld athletes from play were found as a result of the screening ECG alone.

Acknowledgments: Metro Health Sports Medicine, Metro Heart and Vascular, Metro Health Hospital Foundation, Keeping the Beat volunteers, Metro Health Research Department.

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The Effect of Body Mass Index on Fluoroscopic Time and Radiation Dose During Intra-Articular Shoulder and Hip Injections

Benjamin R. Fogg, BS, Zachary L. McCormick, MD, Nathan D. Clements, BS, and Daniel M. Cushman, MD

Affiliation: University of Utah, Salt Lake City, Utah.

Purpose: Intra-articular injections are common therapeutic interventions for the shoulder and hip. Physicians often perform the procedure using image guidance, which have been shown to improve accuracy of needle placement. Fluoroscopic-guided intra-articular injections expose patients to varying amounts of radiation. The purpose of this study was to identify the relationship between body mass index (BMI) and fluoroscopy time and radiation dose during intra-articular injections of the shoulder and hip.

Methods and Study Design: Retrospective review of all patients who received fluoroscopic-guided intra-articular injections of the shoulder or hip at an academic orthopedic center. The main outcome measures were fluoroscopy time and radiation dose. A Bonferroni correction was implemented for multiple comparisons, defining statistical significance at P < 0.01.

Results: A total of 775 subjects receiving intra-articular injections (337 shoulders and 446 hips) were included. There were no significant associations between fluoroscopic time and BMI for hip (P = 0.148) or shoulder injections (P = 0.289). The mean radiation dose-area equivalents in patients receiving hip injections were 601, 678, and 1050 mGy-cm2, for normal, overweight, and obese BMI groups, respectively (P < 0.001, r = 0.29). However, the mean values in patients receiving shoulder injections showed no significant difference (660, 693, and 610 mGy-cm2, respectively, P = 0.918). There were no associations of age, needle length or trainee involvement to fluoroscopy time or dose.

Conclusions: Patients with increased BMI receiving hip injections receive a greater radiation dose, though this correlation did not exist with shoulder injections. Patients receiving hip and shoulder injections were not subjected to increased fluoroscopy time, however, based on their BMI. This suggests that the increased radiation exposure in hip injections is likely due to increased localized adiposity.

Significance of Findings: Patients with elevated BMI are likely exposed to increased radiation dose for fluoroscopic-guided hip injections, but not shoulder injections.

Acknowledgments: None.

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Improvement in Balance Error Scoring System (BESS) Scores Over Time—How Long is Improvement Seen?

Benjamin Fogg, BS, MS, John Hendricks, MD, Masaru Teramoto, PhD, MPH, and Dan Cushman, MD

Affiliation: University of Utah, Salt Lake City, Utah.

Purpose: Previous research suggests that the Balance Error Scoring System (BESS) returns to baseline within 5 days after sustaining a concussion. A subset of patients who have concussions, likely around 10% to 50% of all concussed athletes, exhibit prolonged recovery. We aimed to identify if and how patients who exhibit prolonged recovery (>10 days) demonstrate improvement in the BESS scores over time.

Methods and Study Design: Retrospective review of patients seen in a concussion clinic. All patients were included who had a clinically-diagnosed concussion at the time of the first visit and had 2 consecutive BESS tests performed by the same clinician over more than 10 days apart. Paired t tests were used to compare within-patient changes in total BESS scores. Times were classified as 10 or fewer days, 11 to 30 days, 31 to 180 days, and greater than 180 days.

Results: A total of 86 patients fit the inclusion criteria. In aggregate, patients improved on their subsequent BESS test (4.2 points, P < 0.001) and 81.4% of participants improved. All patients who were tested within the first 10 days of concussion showed improvement in their BESS scores on the subsequent test (5.3 points, P < 0.001). 85.9% of patients improved on their second test if tested within 180 days (4.4 points, P < 0.001). Patients whose first test occurred more than a month after concussion failed to improve (P = 0.08).

Conclusions: Patients tend to demonstrate continued improvement in the BESS, at least over the first 6 months. The majority of the recovery appears to be in the first month after concussion.

Significance of Findings: Recovery of balance appears to continue after the initial few days after a concussion. For patients who have prolonged recovery, monitoring for improvements in balance should still be considered by the clinician.

Acknowledgments: None.

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Femoroacetabular Impingment in Female Adolescent Single-Sport Athletes

Joana Fraser, MD, Dai Sugimoto, PhD, Michael Pepin, MA, Emily Hanson, ATC, Yi-Meng Yen, MD, and Andrea Stracciolini, MD

Affiliation: Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts.

Purpose: To investigate the bony morphology in a cohort of female single-sport athletes with FAI and to compare differences in FAI type (cam vs pincer) in this same study cohort.

Methods and Study Design: Retrospective chart review of female athletes 10 to 25 years with FAI. Angles were measured on AP, lateral (Dunn, frog-leg or cross table) and false profile views. Measurements included acetabular index (AI), alpha angle (AA), lateral center edge angle (LCEA), anterior center edge angle (ACEA), crossover and ischial spine sign. Radiographic cam deformity was defined as an alpha angle 355 degree; pincer deformity as LCEA 340 degree.

Results: Twenty dancers, 12 runners and 10 soccer athletes; 83 hips were measured. Cam lesions were found in 32% (27/83) and pincer deformity in 21.6% (18/83). Pincer lesions were found in 28% (11/40 hips) of dancers, 16.7% (4/24 hips) of runners and 15% (3/20) of soccer players. Mean ACEA was increased in dancers (36.1 ± 7.0) as compared to soccer players (30.3 ± 7.9) or runners (30.9 ± 7.6) however there was no significant difference (P = 0.065). In comparison, cam lesions were found in 40% (8/20 hips) of soccer players, 34.7% (8/23 hips) of runners and 28% (11/40 hips) of dancers. Mean AA in soccer players was greater as compared to runners (55.2 ± 7.0 vs 44.7 ± 13.7, P = 0.032). There was no significant difference in mean AI between all groups.

Conclusions: In this cohort of young female single-sport athletes with FAI, bony anatomy differed by sport/activity choice, with dancers revealing more pincer type anatomy, as compared to soccer players who had more cam type bony anatomy.

Significance of Findings: In young, female single-sport athletes, chosen sport/activity may influence FAI bony morphology development. Future studies on FAI bony morphology and sport/activity in young females will help guide injury prevention efforts.

Acknowledgments: None.

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Judo Injury Epidemiology: A Pilot Project Using Text Messaging for Injury Surveillance

Juan Galloza, MD, Juan Perez, MD, Gerardo Miranda, MD, and William Micheo, MD

Affiliation: Department of Physical Medicine, Rehabilitation and Sports Health, University of Puerto Rico—School of Medicine.

Purpose: Apply text messaging as a modern technique for injury surveillance in the sport of judo and to evaluate the incidence, prevalence and duration of traumatic and overuse injuries, as well as the injury rate during practice or competition.

Methods and Study Design: Ongoing prospective cohort study. A group of 19 judokas, ages 17 to 22 years, male and female will be surveyed each week for 1 year. They will be asked 3 questions via text message regarding exposure to training, competition and the presence of a time loss injury. Injured athletes will complete an injury report form that will evaluate the body area, type of injury, duration of traumatic and overuse injuries, and if the injury occurred during practice or competition, as well as other judo specific questions. Injury rates/1000 athletic exposures will be tested between different categories using χ2 test.

Results: In the first 15 weeks of surveillance the response rate to the weekly text messages has been 100% of all the athletes. A total of 1133 hours of practice and 72 competition combats were reported for athlete exposure. Seven injuries have been reported. Six injuries have been sustained during practice (5.3/1000 hours of exposure) and 1 injury during competition (13.9/1000 competition combats of exposure). Body parts affected were (Ankle/foot:5, Knee:1, Shoulder:1).

Conclusions: The use of text messaging seems to be an effective method for injury surveillance in the sport of judo. The high response rate provides more complete data in respect to injury description and athlete exposure for prospective studies.

Significance of Findings: Text messaging for injury surveillance is specifically significant in judo, since judo is not a team sport and the presence of medical staff is scarce during training or competition.

Acknowledgments: None.

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Concussion Policies Across Professional Sports Organizations

Sara Gould, MD, Joseph Ackerson, PhD, and Graham Cochrane, BS

Affiliation: University of Alabama at Birmingham Division of Orthopedics, Birmingham, Alabama.

Purpose: Concussion policies are increasingly being developed and adopted among professional sports organizations. We sought to compare the policies of The National Hockey League (NHL), The National Basketball Association (NBA), The National Football League (NHL), and Major League Baseball (MLB). Our objective was to summarize each policy and evaluate the extent to which each policy is organization-specific.

Methods and Study Design: We visited websites for the NHL, NBA, NHL, and MLB. We searched media articles reporting concussion policy. We utilized only publically available data. We collected information on each organization's approach to the definition of concussion, education provided about concussion, baseline testing requirements, minimum return to play time and return to play protocol.

Results: We found that concussion policies vary across professional sports organizations. Most organizations utilize the Concussion in Sport Group definition (2013) to define concussion. The NFL and NBA mandate preseason education. All organizations require some type of baseline testing. All organizations require sideline evaluation after suspected concussion. The NFL and MLB require SCAT testing for sideline evaluation of suspected concussion. MLB is the only organization to require minimum time before return to play. There is a return to play protocol in place for each organization. The NFL and MLB require independent neurologic consultation as part of their return to play protocol.

Conclusions: There is variability in concussion policy among the professional sports organizations. The most pronounced variation from Zurich guidelines (2012) is the variability in the minimum time to return to play. Further, the rules of the individual sports have a role in how concussion policy can be designed and implemented.

Significance of Findings: Professional sports set an example for thousands of recreational sports enthusiasts so their publically available policies on concussion have a large impact.

Acknowledgments: None.

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Mental Focus and Cognitive Orientation of Ultramarathoners

Heather Grothe, MD, Morteza Khodaee, MD, MPH, John Hill, DO, Brian Schneider, MD, and David Manthey

Affiliation: University of Colorado School of Medicine, Denver, Colorado.

Purpose: To evaluate cognitive factors, pain coping and mental focus involved in ultramarathon running.

Methods and Study Design: The Bear Chase Trail Race is a single-day, multi-distance race consisting of a 10K, half marathon, 50K, 50M and 100K run in Lakewood, Colorado at altitude of about 1680 m w/total altitude in climbs ranging from (663-2591 m). Observational cross sectional online survey study was conducted of ultramarathon (50K, 50M, and 100K) participants before the race in 08/2015, of which 123, 47 and 30 runners started these races, respectively. Race results matched to responses. Descriptive analyses were performed to help evaluate a psychological profile of the athlete.

Results: Out of 200 runners who started the races, 98 completed the survey (49%). Majority of runners of the 50K, 50M, and 100K races completed the race (91.9%, 87.2%, 63.3%, respectively). Over half the runners were male (61.2%) and average age = 39 (range, 21yo-74yo years). A significant majority (86%) of respondents hold a bachelor's degree or higher and over half (52%) have children. The majority of respondents (89%) reported “accept” or were “not worried” about the pain when they were asked about viewpoint on pain during ultramarathons. There was no statistical significance regarding viewpoint on pain between finishers and non-finishers or race distance. Half of respondents (54%) listed cognitive strength as the factor that mentally aids them through a race, followed by quality of training. This was consistent among all 3 distances. The direction of thought while running was spread nearly evenly between how one's body feels (ie, running technique), inward focus on anything irrelevant to running (ie, daydream), attention focused on running performance (ie, strategy) and attention focused outwardly irrelevant to task performance (ie, scenery). There were no statistical significance between finishers and non-finishers or by race distance.

Conclusions: No significant differences in mental focus, pain coping or cognitive orientations were found between finishers and non-finishers or by race distance. Overall, these results demonstrate the unique sport- specific cognitive orientations of ultramarathoners.

Significance of Findings: This allows us to further understand the unique cognition of ultramarathon runners and increases the possibilities for interventional strategies.

Acknowledgments: Bear Chase Race Director for assistance in distribution of the survey.

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King Devick Test Performance in Child and Adolescent Athletes

Paul J. Gubanich, MD, MPH, Eric Slattery, MS, and Kelsey Logan, MD, MPH

Affiliation: Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

Purpose: The King-Devick test (KD) has been used to assess visual motor deficits in sports related concussion. Test utility has been investigated in adults, but its clinical usefulness has not been established in children or adolescents. The purpose of this study is: (1) To determine KD age-specific normative values in children and adolescents. (2) To characterize KD test performance in a cohort of concussed individuals.

Methods and Study Design: Patients (ages, 8-18) who presented to SM clinics for evaluation and treatment of non-concussive injuries and whose presenting complaint was not believed to confound KD test administration (LE injury, recovered injury, etc) were recruited for baseline assessment. Similarly, patients referred to the same clinics who were subsequently diagnosed with concussion and who were symptomatic were recruited as injured subjects. Test results of injured subjects were then compared to this study's normative values and classified as normal (if <1 SD from the norm), or abnormal (if ≥1 SD from the norm). Subjects were classified as true positive if KD time was ≥1 SD from the norm and false negative if KD time was <1 SD from the norm.

Results: Three hundred seventy-seven control patients and 149 concussed patients were enrolled in the study. Regression analysis of the baseline results indicated a strong effect of age on overall KD time (R2 = 0.91). Analysis of the KD test revealed a sensitivity of 53.7% (80/149) and specificity of 85.9% (324/377) at one SD and sensitivity of 32.9% and specificity of 96.0% at 2 SD at the time of presentation which averaged 5.97 days post injury.

Conclusions: As a result of this study, normative values for the KD test were established for the pediatric population. Test performance varied with age. Analysis revealed high specificity but low sensitivity of KD performance at the time of presentation.

Significance of Findings: This is the first study to look at the KD in a large pediatric population.

Acknowledgments: None.

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BMI Screening During Athletic Preparticipation Physical Exams

Alicia Gustafson, DO and Holly McNulty, MD

Affiliation: University of Arizona Primary Care Sports Medicine Fellowship, Tucson, Arizona.

Purpose: To show that there is benefit to performing PPEs by looking at the BMI of athletes and identifying those that are underweight or overweight and educating or intervening to prevent future morbidity.

Methods and Study Design: A retrospective review is done looking at the BMI of Arizona student athletes ages 11 to 18 who had a PPE done within the past 2 years. The exams were done on different dates by different healthcare providers. Each athlete's BMI was calculated using their height and weight. The BMI was then plotted out on a pediatric growth chart. Those above the 95th percentile are considered obese, those in the 85th to 94th percentile are overweight and those under the 5th percentile are underweight based on the CDC's guidelines. The exam forms are also reviewed to see if any counseling was provided or if follow up was recommended and how the athlete answered 2 standardized questions- Are you happy with your weight? Do you limit or carefully control what you eat? N = 400.

Results: Seventy athletes are obese; 60 athletes are overweight; 3 athletes are underweight 97 athletes are not happy with their weight 95 athletes limit what they eat 12 athletes had their weight addressed during the PPE or recommended follow up.

Conclusions: Almost one-third of the youth athletes are overweight/obese and providers are not adequately addressing body image and weight.

Significance of Findings: Providers could use PPE data to better promote healthy lifestyles in our young athletes.

Acknowledgments: Dr Holly McNulty for her help executing this research project.

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Preseason Aerobic Fitness is Related to In-Season Injury in Male Collegiate Hockey Players

Erin Hammer, MD and Drew Watson, MD

Affiliation: University of Wisconsin, Madison, Wisconsin.

Purpose: To determine if preseason aerobic fitness or body composition are associated with in-season injury among male collegiate hockey players.

Methods and Study Design: Eighteen male NCAA division I hockey athletes underwent preseason determination of body fat percentage (BF%) and lean body mass (LBM) by dual x-ray absorptiometry, and maximal aerobic capacity (V[Combining Dot Above]O2max), time to exhaustion (Tmax), ventilatory threshold (VT) and time to ventilatory threshold (TVT) by maximal treadmill testing prior to the start of the season. Injuries were recorded during the season and body composition and fitness variables were compared between injured and uninjured players. Univariable logistic regression models were used to determine significant predictors of in-season injury using aerobic fitness and body composition measures as covariates.

Results: Ten injuries were recorded in 8 players. Players who suffered an in-season injury had lower levels of preseason VT (3.49 vs 3.89 L/min, P = 0.041) and TVT (10.1 vs 11.5 minutes, P = 0.047) than uninjured players, but differences in V[Combining Dot Above]O2max (4.9 vs 5.1 L/min, P = 0.20), Tmax (17.2 vs 18.4 minutes, P = 0.51), BF% (13.6% vs 17.6%, P = 0.71), and LBM (66.7 vs 68.5 kg, P = 0.852) were not significant. No significant predictors of in-season injury were identified among V[Combining Dot Above]O2max (OR, 0.83, 95% CI, 0.40-1.72, P = 0.59), Tmax (OR, 0.91, 95% CI, 0.75-1.11, P = 0.35), VT (OR, 0.72, 95% CI, 0.44-1.17, P = 0.17), TVT (OR, 0.91, 95% CI, 0.80-1.04, P = 0.16), BF% (OR, 1.00, 95% CI, 0.99-1.00, P = 0.61), or LBM (OR, 1.00, 95% CI, 0.96-1.04, P = 0.97).

Conclusions: Among this group of male collegiate hockey players, athletes injured during the season had lower pre-season VT TVT. Although aerobic fitness was not a significant predictor of in-season injury, this was likely limited by the small sample size. Preseason body composition and in-season injury were not associated.

Significance of Findings: Although further research is warranted, these initial results suggest that lower preseason aerobic fitness may be associated with an increased risk of in-season injury in male hockey players.

Acknowledgments: The authors would like to acknowledge the Sports Medicine staff at the University of Wisconsin-Madison Division of Intercollegiate Athletics for their commitment to the welfare of the student-athletes and contributions to the Badger Athletic Performance program.

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Incidence and Etiology of Sudden Cardiac Death and Arrest in High School Athletes

Irfan M. Asif, MD, Joseph Maleszewki, MD, David S. Owens, MD, MS, Jordan M. Prutkin, MD, MHS, Jack C. Salerno, MD, Rachel Ellenbogen, MS, Monica Zigman, MS, Michael J. Ackerman, MD, and Jonathan A. Drezner, MD

Affiliation: University of Washington.

Purpose: To determine the incidence and etiology of sudden cardiac arrest/death (SCA/D) in US high school athletes.

Methods and Study Design: A database of SCA/D in the young was queried for cases aged 14 to 18 from 7 states over 6 school years (2007-2013). Events details were investigated to determine participation on a high school athletic team, sex, sport, and occurrence during school-sponsored activity. Cases in non-athletes, without sufficient information, or non-cardiac cases were excluded. Sport participation numbers from the National Federation of State High School Associations were used. Autopsy reports were reviewed and cause of death adjudicated.

Results: 16 390 409 million athlete-seasons (AS) were examined representing 36% of the US high school athlete population. One hundred four cases of SCA/D were identified (35 arrests with survival, 69 deaths). The rate of SCA/D was 1:67 064 AY. Eighty-eight percent of events occurred in males. The rate of SCA/D in males was 1:44 832 AY and in females 1:237 510 AY (IRR 5.3, 95% CI, 2.9-10.6, P < 0.00001). Men's basketball was the highest risk sport with an incidence of 1:37 087 AY. Eighty percent of events were exertional and only 55% occurred while playing for a school sponsored team. Autopsy reports were obtained in 73% of cases. The most common findings on autopsy were idiopathic left ventricular hypertrophy/possible cardiomyopathy (13%, 26%), autopsy-negative sudden unexplained death (9%, 18%), hypertrophic cardiomyopathy (7%, 14%) and myocarditis (7%, 14%).

Conclusions: The rate of SCA/D in male high school athletes is higher than prior estimates with over half due to possible or confirmed cardiomyopathic disease.

Significance of Findings: A lower risk of SCA/D in high school athletes compared to other groups has been reported. This autopsy based study confirms a high rate of SCA/D with some higher risk athlete groups. Because it is based on media reports, this represents a minimum estimate.

Acknowledgments: None.

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Epidemiology of Shoulder Injuries Among US High School Athletes Across 22 Sports From 2007/2008 to 2013/2014

Christine Harris-Spinks, MD, MPH, Bernie Johnson, MD, Lina Brou, MPH, Sarah K. Fields, JD, PhD, Morteza Khodaee, MD, and R. Dawn Comstock, PhD

Affiliation: University of Colorado, Denver, Colorado.

Purpose: Describe rates and patterns of shoulder injuries in a large national sample of US high school athletes.

Methods and Study Design: In this retrospective cohort study, we analyzed athlete exposure and shoulder injury data from the National High School Sports-Related Injury Surveillance Study for 22 sports (boys' baseball, basketball, cross country, football, Ice hockey, lacrosse, soccer, swimming/diving, track and field, volleyball and wrestling; girls' softball, basketball, cross country, gymnastics, field hockey, lacrosse, soccer, swimming/diving, track & field and volleyball; and co-ed cheerleading) from 2007/2008 to 2013/2014. Rates were calculated per 100 000 athletic exposures (AE).

Results: Overall 3420 shoulder injuries occurred during 29 873 036 athlete exposures (AE); total shoulder injury rate of 11.4 per 100 000 AE with injury rates significantly higher in competition than practice (P < 0.001). The most common diagnoses were stains/sprains (40%), subluxations (14%) and dislocations (12%). Rates were highest in the collision sports: boys' football (42.3 per 10 000 AE), boys' wrestling (35.5) and boys' ice hockey (33.1), although the boys' lacrosse rate (13.9) was lower. Rates were similar in the gender comparable sports of baseball/softball (boys 14.6; girls 11.0), basketball (boys 4.9; girls 6.2), soccer (boys 4.4; girls 3.5), swimming & diving (boys 10.3, girls 13.9), and track & field (both 1.8). Injury mechanism varied by sport: athlete-athlete contact was the most common mechanism in the collision sports, boys' and girls' basketball and girls' lacrosse, while contact with the playing surface was most common in boys' and girls' soccer, and baseball/softball injuries were most frequently overuse/chronic.

Conclusions: Shoulder injuries are relatively common among high school athletes, yet rates and patterns of injury vary widely between competition and practice and by sport.

Significance of Findings: Understanding the epidemiology of shoulder injuries among high school athletes should drive the development of more effective, targeted injury prevention programs.

Acknowledgments: We thank the dedicated certified athletic trainers who report data to the National High School Sports-Related Injury Surveillance System.

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The Utility of Yearly Screening Laboratory in Professional Baseball

Marc Harwood, MD, Christopher Hwang, MD, Jeremy Close, MD, Kathryn Dwight, Eric Secrist, Adam Wallace, Joshua Okun, MD, Jill Kropa, MD, Christine Marschilok, MD, and Cody Clinton, MD

Affiliation: Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Purpose: To determine the utility of yearly laboratory screening of members of a major league baseball (MLB) organization.

Methods and Study Design: Retrospective chart review of lab work for all asymptomatic athletes and staff presenting to Spring Training in 2008 and 2009 for an MLB organization. Screening tests included fasting lipid panel, Chem 20, TSH and CBC.

Results: In our study, 461 individuals were tested in an MLB organization over a 2-year period from 2008 to 2009. This generated 22 128 initial lab values. This testing labeled 1577 lab values (7%) abnormal by system analysis, but further clinician review noted only 396 values (1.8%) as clinically significant. Eighteen abnormal values were identified in athletes released/traded from the organization before follow-up could be obtained. Sixty-seven abnormal values required further testing and/or treatment, referral to a specialist, or were not deemed significant enough to interrupt participation in baseball-related activity and recommended off-season PCP follow-up. The remaining 312 clinically significant values did not require a follow-up plan. Laboratory screening of our organization yielded the identification of medical disease in 20 cases of the 461 individuals tested.

Conclusions: Routine laboratory testing is done yearly for all members of MLB organizations. There is no standardized screening series. This practice is not supported by current screening guidelines for asymptomatic individuals in the general population. Our data shows that testing of these individuals led to a small number of positive results—most required some sort of follow-up, but rarely required treatment. None resulted in disqualification from sports.

Significance of Findings: Our review challenges the need for MLB organizations to order routine testing for asymptomatic individuals. This practice is labor-intensive and low yield for identifying significant disease. Given that all professional sports organizations have some form of yearly routine laboratory testing, our results are applicable not just to baseball but all professional sports.

Acknowledgments: Philadelphia Phillies, TJUH, RI.

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A Single Motion Shoulder Rehabilitation Protocol

Michael Henehan, DO, Ryan Hudson, MD, TK Park, MD, Jamie Nuwer, MD, and Vinit Madhvani, MD

Affiliation: O'Connor Hospital Sports Medicine Fellowship Program.

Purpose: To determine if a single movement exercise (SME) protocol is as effective as the classic exercise protocol in stimulating rotator cuff and scapular stabilizing muscles as measured by surface electromyography (EMG).

Methods and Study Design: Case controlled intervention trial using 8 subjects. Surface EMG sensors were placed over the supraspinatus, infraspinatus, teres minor, rhomboids, levator scapula, trapezius and serratus anterior. All 7 leads were monitored simultaneously and continuously during a 3-effort performance of the classic and SME protocols for each subject. The subjects selected a 5, 10, or 15 pound weight and used this consistently with all resistance exercises. The classic exercise series consisted of forward flexion, abduction (scaption), extension to 90 degree, external rotation to 90 degree, dip and push-up plus. The SME protocol consisted of a “figure of 8” movement pattern starting with the arm at the side, elbow in extension and holding the weight. Subjects made part of the “figure of 8” as a large circle in front of their body and the other half of the “figure of 8” as a large circle behind their back, crossing the middle of their body (umbilicus or lumbar spine, respectively) with each circle. The elbow was kept in extension and the arm below 70 degree of abduction throughout the SME.

Results: Based on average peak electrical activity (millivolt), the SME protocol activated all tested muscle groups at an equal or higher intensity than the classic exercises with the exception of push-up plus.

Conclusions: The SME protocol stimulated rotator cuff and scapular stabilizer muscles as effectively as the classic exercise protocol.

Significance of Findings: A simplified shoulder rehabilitation program consisting of a single movement exercise protocol may improve patient compliance and therefore possibly improve its effectiveness. A prospective, randomized study comparing the clinical efficacy of the 2 protocols in patients with rotator cuff tendonitis is planned.

Acknowledgments: John Kao, PhD, KyungMo Han, PhD.

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Risk of Lower Extremity Injury Between Single and Multisport Youth Athletes

Andrew S. Houghton, MD, Eleanor M. Beltz, MS, ATC, Hayley J. Root, MS, ATC, Jessica L. Martinez PhD, ATC, Samantha E. Scarneo, MS, ATC, Lindsay J. DiStefano, PhD, ATC, and Giselle A. Aerni, MD

Affiliation: University of Connecticut, Storrs, Connecticut.

Purpose: There is growing evidence that single sport athletes are at increased risk for injuries, but the rationale for this risk remains unclear. The purpose of this study was to compare injury risk, as measured by landing technique, between single-sport and multi-sport elite level adolescent athletes.

Methods and Study Design: Competitive youth soccer and basketball athletes (109 females, 45 males; age = 12 ± 2 years, height = 156 ± 12 cm, mass = 47.6 ± 13.3 kg) completed a questionnaire and a jump-landing task. The questionnaire identified the duration of all current and past sport participation. The jump-landing task was videotaped and scored by a single rater, blinded to sports participation, using the Landing Error Scoring System (LESS). The LESS is a valid and reliable tool that can predict anterior cruciate ligament (ACL) injury risk (≥5 errors: high risk; <5 errors: low risk). Participants were classified to be sport specialized (SINGLE) if they participated in only one sport or multi-sport (MULTI) if they were active in at least 2 sports during the past year. An independent t test compared LESS scores between SINGLE and MULTI groups. A χ2 test evaluated the association between risk (high risk, low risk) and sport groups (SINGLE, MULTI) (α = 0.05).

Results: There was no significant difference in LESS scores between SINGLE (n = 58, 6.0 ± 1.6 errors) and MULTI groups (n = 96, 5.8 ± 2.1 errors, P > 0.05, mean difference = 0.23 ± 0.33 errors, 95% CI, −0.4 to 0.9). However, the low risk group was more likely to be classified as MULTI (33/43, 76.7%) than SINGLE (10/43, 23.3%, c2(1) = 5.27, P = 0.02).

Conclusions: Youth soccer and basketball athletes at lower risk for ACL injury are more likely to be competing in more than one sport.

Significance of Findings: This study suggests there may be a protective benefit for youth athletes to participate in more than one sport to reduce ACL injury risk.

Acknowledgments: This study was supported by funding from the Charles H. Hood Foundation for Child Health Research.

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Examining College Athlete's Reporting of Depression in an Electronic Pre-Participation Exam

Adriana Isacke, DO, William Dexter, MD, Christina Holt, MD, and Amy Haskins, PhD

Affiliation: Maine Medical Center, Portland, Maine.

Purpose: College students have a high rates of depression and suicide, with 30.7% feeling so depressed that it was difficult to function and 48.4% experience overwhelming anxiety. The optimal way to reach athletes to ensure the most accurate assessment of their mental status or risk factors is still unknown. This study aimed to perform a retrospective review of self-reported depression and anxiety rates in college athletes via the electronic pre-participation exam (EPPE), to compare with previous reports on the prevalence of depression in athletes.

Methods and Study Design: De-identified EPPE data from athletes at University of Southern Maine between 2009 and 2015 were acquired from Privit, the online EPPE provider. A single question queried yes/no response to “neurologic problems” including depression, and then students filled in a free text box to name the condition. We calculated depression and anxiety rates if the student answered “yes” to the neurologic question and then named depression, anxiety or both disorders.

Results: Based on the data provided from Privit, 1910 athletes completed the EPPE between 2009 and 2015. Of the 1910 athletes over 6 years, 1047 (58%) were male and 760 (42%) were female. A total of 22 reported depression or anxiety (1.1%), 10 with anxiety only (0.5%), 6 with depression only (0.3%), 6 with both depression and anxiety (0.3%).

Conclusions: The results of this study show that a very small percentage of students reported problems with depression or anxiety (1.1%) via the EPPE. This is considerably lower than the overall depression rate of 30.7% in adolescents quoted in the literature. The EPPE as currently worded does not appear to screen effectively for depression in this population.

Significance of Findings: Because athletes at serious risk of depression or suicide may go unrecognized, it is important to have a tool that effectively identifies those at highest risk.

Acknowledgments: None.

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Effects of Sports Specialization on the Rates of IT Band Syndrome in Pediatric Athletes

Sarah S. Jackson, MD, CSCS, Dai Sugimoto, PhD, ATC, CSCS, David R. Howell, PhD, ATC, William P. Meehan III, MD, FAAP, and Andrea Stracciolini, MD, FAAP

Affiliation: Boston Children's Hospital—Department of Sports Medicine, Boston, Massachusetts.

Purpose: Sports specialization has recently been defined as participation in year round intensive training in a single sport at the exclusion of all other sports. Studies suggest an increased risk of overuse injuries among athletes specialized to a single sport when compared to multisport athletes. The effect of sports specialization on rate of specific injuries such as iliotibial band (ITB) syndrome has not been reported. The purpose of this study is to examine the effect of sports specialization on rates of ITB syndrome history in pediatric athletes

Methods and Study Design: In this cross-sectional study, participants completed electronic questionnaires describing their current sport participation and previous injury history (N = 549). Participants were categorized into 3 groups: those athletes who participated in 1, 2, or 3 sports throughout the year. The proportions of athletes with a history of ITB syndrome compared between the 3 groups using a χ2 analysis.

Results: Eighteen ITB cases were reported (mean age of athletes = 15.2 ± 1.9 years). The mean age in which athletes reported beginning organized sport(s) participation was; 1 sport athletes: 5.5 ± 2.3 years, 2 sport athletes: 5.7 ± 2.5 years, and 3 sport athletes: 5.1 ± 1.8 years. Thus, the athletes participated in organized sport(s) for approximately 10 years. A higher proportion of 1 sport athletes reported a history of ITB syndrome than 3 sport athletes (9% vs 2%; P = 0.045). No significant differences in the proportion of ITB cases were found between 1 and 2 sport athletes (P = 0.294) or between 2 and 3 athletes (P = 0.707).

Conclusions: Pediatric athletes who participate in a single sport reported a higher proportion of history of ITB syndrome compared to multiple sport athletes.

Significance of Findings: The findings of this study support the notion that training in a single sport place pediatric athletes at an increased risk for overuse injuries. Future research is needed to evaluate effect of sports specialization on other musculoskeletal injuries in pediatric athletes.

Acknowledgments: None.

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The Risks of Reinjury Related to Intense Sports Specialized Training Patterns: A Prospective 2+ Year Follow-Up Clinical Cohort Study

Neeru Jayanthi, MD, Cynthia LaBella, MD, Sara Iqbal, Dan Fischer, Jacqeuline Pasulka, BS, and Lara Dugas, PhD

Affiliation: Emory University Sports Medicine Center, Emory University School of Medicine.

Purpose: The purpose of this study is to prospectively determine the effect of sports training volumes and sports specialization on the recurrence of injury in a clinical population of young athletes (8-18 years old).

Methods and Study Design: This multi-center prospective cohort 2+ year follow up study followed injured young athletes recruited from sports medicine clinics and uninjured athletes recruited during their sports physical at primary care clinics. At baseline, all athletes completed a survey reporting training volumes, degree of sports specialization, and injury. This same data was collected from each participant at 6 month intervals for up to 3 years. Re-injury, repeat injury, and new injury rates were calculated during follow up evaluations for up to 3 years.

Results: One thousand one hundred ninety-one subjects were enrolled at baseline, with a total of 1083 follow up evaluations adequate for analysis over a 3 year follow up period. 39.4% (427/1083) of follow up evaluations reported an injury. Of those that reported an injury, there were 69.1% re-injury of any type (previously injured) with 30.9% reporting a new injury (previously uninjured). On follow up evaluations, injured athletes overall report more weekly hours/week of total physical activity (16.9 vs 14.4 h/wk; P = 0.00), organized sports (11.4 vs 9.1 h/wk; P = 0.00), and are more specialized (P = 0.00) then uninjured athletes.

Conclusions: There are high rates of injury in young athletes when followed longitudinally while the rate of re-injury is more then twice the rate of new injury. Injured young athletes report more weekly hours of organized and total sports activity, and also are more specialized than their uninjured counterparts.

Significance of Findings: The development of injury in young athletes may be may be most influenced by those with prior injury. The amount of training and specialization should be monitored closely in athletes with prior injury.

Acknowledgments: This research was supported by AMSSM Foundation grants.

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The Dynamic Approach to Evaluating and Managing Transversalis Fascia Diastasis Better Known as the “Sports Hernia”

Anthony Joseph, MD, Drew McRoberts, MD, James Kastilometes, BS, Jeremy Cree, MD, and Ethan Ostrom, MA

Affiliation: Pocatello Orthopaedics Sports Medicine Institute, and Idaho State University, Pocatello, Idaho.

Purpose: Transversalis diastasis better known as “sports” hernia, has gained recognition as a diagnosis for groin pain among high intensity athletes. This condition is not a true hernia because there is no evidence of a complete tear or defect in the transversalis fascia rather a tenting of the transversalis fascia during dynamic valsalva type movements. The aim of this investigation looks to assess both the diagnosis and surgical techniques using valsalva in a dynamic approach.

Methods and Study Design: The dynamic approach involves the patient performing Valsalva maneuver during diagnostic ultrasound and during conscious sedation in surgery to reproduce the symptoms and allow visualization of the transversalis diastasis. A retrospective cohort study was composed focusing on diagnostic ultrasound and surgical techniques for 40 patients. Return to training and return to sporting activity times were recorded.

Results: Average patient age was 25 (range, 14-52 years). The mean time for patients to return to training was 4.28 weeks. Mean time for all patients to return to their full sporting activity was 8.83 weeks. One patient reported never returning to full recovery during the duration of the study. Patients under 30 showed drastically quicker full recovery time (M = 6.7 weeks) versus patients 30 and above (M = 15.88 weeks). Six patients who reported recurring pain was due to scarring from the mesh and not a recurrence of the “sports” hernia.

Conclusions: Based on the outcomes from patient recoveries, and minor incidence of recurring pain, we believe using the dynamic approach is the best method in diagnosing and treating the transversalis diastasis or “sports hernia” because of the increased accuracy in diagnosis and surgical procedures.

Significance of Findings: Our methods allow the physician to accurately assess the transversalis fascia diastasis. The same technique allows the surgeon to corroborate the sports medicine physician's findings and provide accurate preperitoneal mesh placement.

Acknowledgments: We would like to acknowledge Johnathan Cree, MD and Rex Force, PhD for their contributions to this paper.

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The Feature of Cardiac Electrical and Structural Remodeling in Korean Elite Soccer Players

Jin-Bae Kim, MD, PhD, Jung-Myung Lee, MD, Jong Sin Woo, MD, PhD, Weon Kim, MD, PhD, Woo-Shik Kim, MD, PhD, and Kwonsam Kim, MD, PhD

Affiliation: Division of Cardiology, Department of Internal Medicine, College of Medicine, Kyung Hee University, Hoegi-dong1, Dongdaemun-gu, Seoul, Republic of Korea.

Purpose: Regular, intensive exercise like soccer results in physiological biventricular cardiac adaptation. Ethnicity is an established determinant of structural and electrical remodeling of heart. Furthermore, cardiac remodeling has not been characterized in Asian. Therefore, We investigated the features of heart remodeling of Korean elite athlete.

Methods and Study Design: Fifty-four national football team or professional team players were evaluated by use of ECG and echocardiography. Results were compared with 180 sedentary control subjects without any medical illness.

Results: There were no significant differences in left ventricular parameters between elite athlete and control subjects. Subjects of both group exhibited similar LV dimensions. But, RV dimensions were significantly smaller in controls than in athletes (proximal outflow tract, 27.9 ± 5.5 vs 30.8 ± 5.3 mm, P < 0.001; longitudinal dimension, 81.6 ± 9.5 vs 85.8 ± 9.6 mm, P < 0.001). RV enlargement compatible with diagnostic criteria for arrhythmogenic RV cardiomyopathy was observed in Elite athlete. Anterior T-wave inversion was present in 14.3% of athletes versus 3.7% of controls (P < 0.001). Marked RV enlargement with concomitant anterior T-wave inversion was observed in 5.0% of athletes versus 1.8% of controls (P = 0.01).

Conclusions: In young elite soccer athletes, endurance training over long periods of time (up to 20 years) was not associated with deterioration in LV function, significant changes in LV morphology. However, RV dimension and electrical remodeling are prominent in soccer player, a little different from previous report containing white or black athlete.

Significance of Findings: There is few data regarding the difference of cardiac remodeling between Asian and non-Asian. This data suggested that the electrical and structural remodeling of Asian is different from non-Asian.

Acknowledgments: None.

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Ankle Sprains in Top-Level Female Soccer Players

Yuka Kodama Tsukahara, MD, Takeshi Hashimoto, MD, PhD, Hiroshi Ikeda, MD, PhD, Shunpei Miyakawa, MD, PhD, and Nami Yamaguchi, MD

Affiliation: Institute for Integrated Sports Medicine, Keio University School of Medicine.

Purpose: To find out risk factors for ankle sprain in top-level female soccer players and figure out the cause.

Methods and Study Design: Observational descriptive study. Thirty international-level female athletes aged 17.8 ± 0.6 were asked to fill in a questionnaire related to histories of ankle sprain, and the range of motion, balance ability and other physical status were examined by the team physician. We divided the players in 3 groups as follows: (1) athletes who were not able to play soccer directly after the sprain (n = 17). (2) athletes who were able to play soccer directly after ankle the sprain (n = 9). (3) athletes who never sprained their ankles (n = 4).

Results: Among the (A) players, 12 of them were not able to bear weight after the injury and treated as follows: ultrasonic therapy (n = 6), cast immobilization (n = 5, for average of 2.4 weeks), electrotherapy (n = 2), taping, rest and bandage (n = 1, each). The weight bearing inversion angles of (A) were lower on both injured and non-injured feet than (B) (injured: 21.0 ± 11.5 and 30.8 ± 9.3, non-injured: 25.5 ± 8.6 and 39.2 ± 14.3, respectively; P < 0.05, impaired t test).

Conclusions: In our study, 87% of the players had ankle sprain in the past, a lot higher rate than that of amateur soccer players which was 24% according to a previous study (Fukubayashi et al). Since lower weight bearing inversion angle should denote weaker inversion muscle strength, the lower angles seen in both the injured and non-injured feet in (A) should indicate the possibility that the players with weak inversion muscle be prone to suffer serious ankle sprain. Further research is required to measure their inversion muscle strength accurately.

Significance of Findings: Training inversion muscle may be able to prevent ankle spain in top-level female soccer players.

Acknowledgments: None.

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Using Sideline Concussion Tests in the Emergency Department

Adam Kruse, MS, Andrew Nugent, MD, and Andrew Peterson, MD, MSPH

Affiliation: University of Iowa, Iowa City, Iowa.

Purpose: This study aims to evaluate the validity of 2 common sideline concussion tests for use in emergency departments (ED). The Concussion Symptom Severity Score (CSSS) and Balance Error Scoring System (BESS) tests are well-validated sideline concussion tests, but have not been validated in the settings of non-sport-related concussion, outside of the sideline or athletic training room or in moderate to severe TBI.

Methods and Study Design: Based on a priori power calculations, this study will enroll 153 subjects who have sustained a TBI within the previous 72 hours and 51 healthy controls. Each subject, if able, completed the CSSS and BESS. All subjects are between the ages of 18 and 65 years. Physicians rated each of the TBIs as minor, moderate or severe.

Results: Twenty-two minor TBIs and 1 moderate TBI subjects have been enrolled. The CSSS was collected for 22 TBI subjects but only 8 TBI subjects were able to complete the BESS. The CSSS was collected for all 31 control subjects and the BESS was completed for 30 control subjects. The average CSSS for TBI and control subjects was 26.8 and 0.645 respectively, P-value of 0.00000947. The average BESS for TBI and control subjects was 8.33 and 6.55 respectively, P-value 0.349. A CSSS greater than 5.65 was 95.0% sensitive and 90.9% specific for TBI.

Conclusions: The BESS is poorly tolerated and, among those who can complete the test, not sensitive to TBI in the ED. The majority of TBI patients were not able to perform the BESS, and the TBI subjects who were able to perform the BESS did not score significantly different from the control population. The CSSS is both sensitive to TBI and well tolerated.

Significance of Findings: The BESS should not be used to diagnose TBI in the ED. The CSSS can be used as a TBI screening test in the ED.

Acknowledgments: Nicole Adams, Deb Pfaf, Julie Amendola, Kim Meyer, Kim Springer, University of Iowa's Clinical Research Unit staff, and University of Iowa Emergency Department staff.

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In-Vivo Patellar Motion Under a Dynamic Weight-Bearing Condition in Individuals With Patellofemoral Pain Syndrome

Constance Marie Lebrun, MD, Fateme Esfandiarpour, PhD, Sukhvinder Dhillon, MD, and Pierre Boulanger, PhD

Affiliation: Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Alberta.

Purpose: Accurate quantitative information supporting the most accepted aetiology of Patellofemoral Pain Syndrome (PFPS), abnormal patellar tracking, is scarce. Understanding of exact mechanisms is limited by methodological challenges in evaluating in-vivo joint motion during dynamic activities. This study employed the most reliable methodology, combined Computed Tomography (CT) scan and bi-planar fluoroscopy technique, to examine 6 degree of freedom (DOF) patellar motion during squatting in individuals with PFPS and a control group.

Methods and Study Design: Nine females (29.2 ± 11.9 years) with PFPS, and 9 controls (24.7 ± 7.3 years) had one knee joint imaged in a fully extended position using a CT scanner, then with biplane fluoroscopy while squatting from full knee extension to approximately 90 degree flexion. To obtain patellar motion, the position and orientation of the knee bones' anatomical model, created from CT images, were adjusted in 6 DOF until the projections on the model matched the bones' contours on the fluoroscopy images using 3D-to-2D registration technique.

Results: Females with PFPS demonstrated significantly greater lateral patellar tilt at 45 degree (1.7 ± 8.3 vs −8.7 ± 10.7 degree, P = 0.035), 60 degree (5.4 ± 6.0 vs −7.9 ± 11.7 degree, P = 0.008) and 75 degree (5.0 ± 6.1 vs −9.6 ± 12.8 degree, P = 0.007) of knee flexion as compared to the control group. Negative and positive values denote medial and lateral tilt, respectively. There was also a significant difference between the superior-inferior shift of the patella at 45 degree of knee flexion between the groups (PFPS: −12.1 ± 8.3 vs controls: −19.9 ± 5.7 mm, P = 0.035). Negative values denote patellar inferior shift. No significant differences were found in other patellar motions.

Conclusions: Results provide reliable information indicating abnormal patellar tracking in individuals with PFPS.

Significance of Findings: Use of a highly accurate method for measurement of 6 DOF of patellar motion in PFPS individuals.

Acknowledgments: AMSSM Foundation for their generous support with a Clinical Research Grant.

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Comparison of Physical Examination Findings in Acute Sport Related Concussion (SRC) and Among Normal Adolescents

Kevin C. Lesh, MD, John Baker, PhD, Andrea Hinds, PhD, Natalie Czuczman, Barry Willer, PhD, and John Leddy, MD

Affiliation: University at Buffalo, Buffalo, New Year.

Purpose: To characterize physical examination findings after acute adolescent SRC compared to a normative sample.

Methods and Study Design: Prospective study of 84 adolescents (mean age 15.6 years, range, 12-19 years, 70% male) with recent SRC (n = 54, mean 4.5 days since injury, range, 1-9 days) and adolescents with no recent history of concussion (n = 30). All participants reported symptoms and had a physical examination (PE) including cervical musculoskeletal (8 tests), oculomotor (5 tests) and vestibular (3 tests) systems. PE tests were scored as positive or negative and summed for each of the 3 systems.

Results: Fourteen days after the initial visit, 43/54 participants with SRC had normal exercise tolerance and were assessed as recovered by blinded physician. Age and prior concussions were not different for the normal recovery (NR, n = 43), delayed recovery (DR, n = 11), and healthy control (HC, n = 30) groups. A one-way ANOVA was significant for differences in cervical, oculomotor, vestibular, and total PE findings for the 3 groups at visit day #1. The HC differed from NR and DR groups on oculomotor, vestibular, and total PE findings. For cervical, DR [mean positive tests = 0.45 (SD = 0.82), P < 0.008] differed from HC [0.00 (0.00)], whereas NR [0.21 (0.42)] did not differ from HC (P < 0.102). There were 12 positive cervical, 40 positive oculomotor, and 45 positive vestibular tests among SRC patients compared to 0, 6, and 6, respectively among HCs. Pertinent abnormal PE findings for SRC/HCs included; neck tenderness 12/0, smooth pursuits 30/1, convergence 26/6, saccades 23/0, VOR 14/0, VOR dizziness 18/0, tandem gait 16/1, and Romberg plus VOR 5/0.

Conclusions: Physical examination findings clearly distinguish patients with acute SRC from age matched healthy controls.

Significance of Findings: Physical examination findings are important in diagnosing acute concussion. Vestibular and oculomotor findings were most different. Cervical findings may signal delayed recovery from SRC.

Acknowledgments: We gratefully acknowledge the support of The Robert Rich Family Foundation, The Buffalo Sabres Foundation, Program for Understanding Childhood Concussion and Stroke, The Ralph C. Wilson Foundation, and the National Football League Charities.

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Prevalence of Nystagmus in Concussion Patients

Ruikang Liu, BA, Cayce A. Onks, DO, Matthew L. Silvis, MD, Harry P. Bramley, DO, and Bret C. Jacobs, DO

Affiliation: Penn State College of Medicine, Hershey, Pennsylvania.

Purpose: Physical signs and symptoms of concussion have been described as loss of consciousness and amnesia. The prevalence of other physical exam findings such as nystagmus has not been documented in concussion. The purpose of this study was to prospectively document the prevalence of nystagmus in patients presenting for evaluation of concussion at a regional concussion referral center.

Methods and Study Design: This was a case control study comparing the prevalence of nystagmus in concussed patients with a previously reported prevalence for the general population. Patients age 13 to 25 with a new onset of concussion symptoms and without a previous history of eye or brain surgery were recruited and consented. The diagnosis of concussion was confirmed and the presence of nystagmus on physical exam was documented. A one-sample binomial test was used to compare the proportion of nystagmus in concussion patients to a historical estimate of the prevalence of nystagmus in the general population.

Results: The proportion of concussed patients with nystagmus was 34 out of 78 (0.436) with a 95% confidence interval (CI) of 0.326 to 0.546. The estimated proportion of nystagmus in the general population has been reported as 24 per 10 000 people (0.0024) with a 95% CI of 0.00187 to 0.00293. The proportion of nystagmus in concussed patients was significantly different than the proportion of nystagmus in the general population (P-value < 0.001).

Conclusions: Nystagmus was found to be significantly more prevalent in patients with concussion compared to the general population.

Significance of Findings: Nystagmus may be a physical exam finding seen in patients with signs and symptoms consistent with concussion. Additional studies with larger sample sizes comparing symptom severity, length of symptoms, and number of previous concussions may add diagnostic and prognostic value to patients who have this finding.

Acknowledgments: Special thanks to our project coordinator Andrea Myers and our statistician Allen Kunselman all their contributions.

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Correlation Among Reaction Time Tests on Pre-Season Concussion Testing in Urban High School Athletes

Kelsey Logan, MD, MPH, Paul Gubanich, MD, MPH, and Eric Slattery, MS

Affiliation: Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio.

Purpose: A clinical measure of simple reaction time (RTclin) has been proposed as a simple, inexpensive tool that may be useful for testing reaction time (RT) in concussed athletes. The purpose of this study was to compare baseline RT results from ImPACT, a computerized neurocognitive assessment (RTcomp), with RTclin, determining correlation. A secondary purpose was to compare RTcomp with a novel finger tapping simple RT test performed on a tablet (RTtap).

Methods and Study Design: Simple RT tests how fast one can respond to a particular stimulus (eg, falling of the device or white light on the tablet), whereas choice RT or RTcomp measures speed of correct answers only. This retrospective cohort study analyzed data from 37 wrestlers and boys' basketball players from an urban high school who underwent preseason baseline testing, completing all 3 RT tests. Testing was completed in a single session with random assignment of order and with no prior exercise.

Results: RTcomp and RTclin showed no significant correlation (rs = 0.039, P = 0.82); RTcomp and RTtap showed no significant correlation (rs = 0.017, P = 0.92). On the contrary, RTclin and RTtap had moderately high correlation at rs = 0.442 (P = 0.01).

Conclusions: These results indicate there may not be a relationship between RT assessed on either RTclin or RTtap and RTcomp. When using RTcomp as a measurement “gold standard” for baseline RT, RTclin and RTtap do not appear to be useful as replacements. This may potentially be explained by the inherent differences in RT measurement as RTcomp is a choice RT test while the other 2 are simple RT tests.

Significance of Findings: This study's results do not demonstrate effectiveness of using a simpler, less time consuming RT task concurrently with RTcomp. However, use of RTclin and RTtap together may be beneficial as a substitute for RTcomp.

Acknowledgments: None.

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Micronized Oral Progesterone and Effect on Time Symptomatic From Concussion: A Pilot Study

John A. Lucas IV, MD, Chris Miles, MD, Stephen Davis, MA, Julienne Kirk, PharmD, and Edward Ip, PhD

Affiliation: Department of Family and Community Medicine Wake Forest University School of Medicine Winston-Salem, North Carolina.

Purpose: To ascertain whether study subjects diagnosed with concussion and treated with oral micronized progesterone (Prometrium) will have improved time to resolution and/or improved daily symptom scores compared to placebo.

Methods and Study Design: Twenty-five collegiate athletes (M = 23, F = 2) participated in this double-blind, randomized pilot study. The athletes were randomized in a 2:1 fashion to receive either oral progesterone (400 mg for 3 days, 200 mg 2 days) or placebo (5 days) within 24 hours of being diagnosed with concussion. Daily symptom scores were then recorded until either the end of 5 days or the complete resolution of symptoms, whichever was longer. Data were analyzed using SPSS (Chicago, IL).

Results: Eighteen athletes received study drug and seven received placebo. The group receiving progesterone had a mean of 7.3 days until symptom resolution, while the placebo group had a mean of 4.5 days (P = 0.42) There were 2 athletes that received study drug that had symptoms lasting longer than 30 days. When excluded, the means were both 4.5 days of symptoms (P = 0.95). Also, the mean symptom score decreased at a higher rate in the placebo group.

Conclusions: In this pilot trial, the use of oral micronized progesterone did not shorten the days symptomatic from concussion and, in fact, lengthened the time symptomatic. Also the rate of improvement was slower in the intervention group. The study design does show feasibility and tolerability of the medication. Additional, larger studies are needed given the benefit seen with progesterone in other models.

Significance of Findings: Animal models and human studies with moderate to severe brain injury have shown that progesterone is a promising intervention. This small pilot study did not show benefit of oral progesterone in the reduction of symptom score or days symptomatic. Prior to using progesterone in concussion additional studies are needed.

Acknowledgments: This study was funded by the American Medical Society for Sports Medicine Foundation. The authors would also like to acknowledge Carol Hildebrandt, Abbie Eaton, PhD, and the Wake Forest Sports Medicine staff for their contributions to this study.

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Sonographic Medial Ulnohumeral Laxity in Adolescent Baseball Pitchers

Daniel R. Lueders, MD, Jacob L. Sellon, MD, Adam M. Pourcho, DO, Diane L. Dahm, and Jay Smith, MD

Affiliation: Mayo Clinic, Rochester, Minnesota.

Purpose: To evaluate sonographically measured medial ulnohumeral laxity in the bilateral elbows of experienced adolescent baseball pitchers without a history of elbow complaints.

Methods and Study Design: Thirty high-school baseball pitchers ages 13 to 18 years with >3 consecutive years of pitching experience volunteered for bilateral elbow ultrasounds to evaluate medial ulnohumeral joint width measured deep to the UCL at 30 and 70 degree of elbow flexion, and with and without valgus stress (10-lb weight suspended from the forearm). All measurements were completed by a single, experienced examiner using an 18 to 5 MHz linear array transducer. Ulnohumeral joint width (millimeter) was measured for each condition, and ulnohumeral laxity (UHL, stress minus rest) and relative laxity (dominant vs non-dominant UHL) were calculated.

Results: Dominant arm sonographic UHL was 0.05 to 2.19 mm (mean 1.18 mm) at 30 degree and 0.28 to 2.59 mm (mean 1.36 mm) at 70 degree (P = 0.025). There was no significant difference in dominant versus non-dominant arm UHL at either 30 degree (1.18 vs 1.15 mm, P = 0.9) or 70 degree (1.36 vs 1.32 mm, P = 0.84). Relative UHL was not significantly different between 70 versus 30 degree of elbow flexion (0.045 vs 0.034 mm respectively, P = 0.97).

Conclusions: Sonographic medial UHL is generally <2.2 mm at 30 degree and <2.6 mm at 70 degree among experienced adolescent pitchers without previous elbow complaints and does not appear to be significantly affected by arm dominance. Dominant arm sonographic UHL >2.2 mm at 30 degree or >2.6 mm at 70 degree may be abnormal and warrants further investigation in the appropriate clinical setting. Dominant arm UHL appears to be greater at 70 degree than at 30 degree, suggesting an interaction between sonographic UHL and elbow position.

Significance of Findings: Sonographic evaluation of UHL can be performed in adolescent pitchers using the values presented herein provided that the position of elbow flexion is consistent during testing. Further research is indicated to evaluate the potential utility of UHL assessment at higher degree of elbow flexion (ie, 70 degree) than traditionally utilized.

Acknowledgments: None.

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Concussion and Lower Extremity Injuries in Collegiate Athletes: Is There an Association?

John R. Luksch, DO, David P. Webner, MD, Kevin M. DuPrey, DO, Tracy A. Llewellyn, MS, ATC, Frances C. Gilbert, MS, ATC, Thomas W. Kaminski, PhD, ATC, and Thomas A. Buckley, EdD, ATC

Affiliation: Crozer-Keystone Health System, Springfield, Pennsylvania.

Purpose: The purpose of this study was to examine concussion and lower extremity musculoskeletal injury rates across a diverse array of sports amongst collegiate student-athletes at the conclusion of their athletic careers.

Methods and Study Design: Retrospective Survey. At the conclusion of their intercollegiate athletic career, 335 student-athletes (62.1% female, aged 21.2 ± 1.4 years old, 3.3 ± 1.2 years of collegiate athletic experience) from 13 sports completed reliable injury history questionnaires. Respondents indicated the total number of concussions, which includes the cumulative total of reported, unreported, and potentially unrecognized concussions, as well as their lower extremity injuries, including ankle sprains, knee injuries and muscle strains. Chi-square analyses were performed to identify the association between the concussion and lower extremity injuries.

Results: There were significant associations between any concussion and lateral ankle sprain (P = 0.012), knee injury (P = 0.002), and muscle strain (P = 0.031). There were also significant associations between reported concussions and knee injury (P = 0.003); unreported concussions and knee injury (P = 0.002); unrecognized concussions and lateral ankle sprain (P = 0.001) and muscle strains (P = 0.006). The odds ratios for the relationships ranged between 1.6 and 2.9.

Conclusions: The primary finding of this study was a positive association between concussion history and lower extremity injuries amongst student-athletes at the conclusion of their intercollegiate careers with elevated odds ratio up to 2.9 times more likely to suffer a lower extremity injury. Further investigations are warranted to elucidate the mechanisms driving these associations, which may include lingering deficits in postural control or neurocognition.

Significance of Findings: This study demonstrates a possible relationship between sustaining a concussion and developing a subsequent lower extremity injury. As such, it may be beneficial to begin a lower extremity injury prevention program in collegiate student-athletes who have sustained a concussion to lower their risk of subsequent lower extremity injuries.

Acknowledgments: None.

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Disease Centricity Versus Prevention? Physician Barriers to Pediatric Physical Activity Evaluation and Treatment

Jennifer Luz, MD, Gregory Walker, MD, Nicholas M. Edwards, MD, Michael J. Pepin, MA, Avery Faigenbaum, EdD, Gregory D. Myer, PhD, and Andrea Stracciolini, MD

Affiliation: Boston Children's Hospital, Boston, Massachusetts.

Purpose: Current health care practices addressing pediatric Exercise Deficit Disorder (EDD) are primarily disease-centric and reactive to symptomatology. This study assessed current EDD evaluation and treatment during clinical visits.

Methods and Study Design: Electronic questionnaires were emailed to 4500 pediatricians, family practice and sports medicine healthcare professionals. Outcome measures included physician effort and attitudes, financial barriers, and medical education pertaining to EDD evaluation and treatment. Simple descriptive statistics were obtained.

Results: Of the 479 physicians who responded 16% of their clinical visit time was spent on EDD evaluation with 14% of patient interaction time spent on treatment, for a normal weight child. For an overweight or obese child, EDD evaluation treatment time increased to 26% and 30% respectively. While 96% of physicians strongly agreed that EDD is important for disease prevention, only 28% had ever made the diagnosis of EDD. As indicated by nearly two-thirds of the respondents, limited clinical time was the primary barrier to making a diagnosis of EDD. Eighty-five percent of respondents were unaware that ICD-9 codes exist for reimbursement of EDD evaluation. Insufficient insurance reimbursement was the largest barrier to diagnosing and treating EDD. Further contributing to this barrier, 81% reported a paucity of exercise science education in medical school.

Conclusions: Nearly all of physicians surveyed reported a perceived importance of EDD evaluation and intervention; however, the majority had never made the diagnosis. The results indicate that the inadequacy of identification and treatment of EDD is likely related to a lack of concern regarding EDD in the normal weight child, financial concerns surrounding clinic time and reimbursement, and a dearth of medical education in exercise science.

Significance of Findings: Current physician medical education, training, and practice are disease-centric and lack medical infrastructure and financial incentive for disease prevention. This research identifies modifiable physician barriers in EDD evaluation and treatment due to the varied challenges involved in adopting a primary prevention healthcare model.

Acknowledgments: None.

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Retrospective Review of Patient Outcomes Who Receive Radiographs

Daisy-Scarlett MacCallum, MD, Robert Saper, MD, and Douglas Comeau, DO

Affiliation: Boston University, Boston, Massachusetts.

Purpose: Discrepancies exist between medical societies on imaging criteria to make a diagnosis of secondary fracture with a normal physical exam outside of the primary fracture site. This study examines the effectiveness of providers using rule of examining via radiographs the joint above and below known Tib-Fib Fracture, number of views per joint, as well as the provider's perceptions of patient risk.

Methods and Study Design: Retrospective chart review of all patients that visited the ER via helicopter, EMS and walk-in requiring a Tib-Fib radiograph from January 1, 2012 to December 31, 2014. The sample size included all Tib-Fibs during the study period which yielded 257 out of 1049 patients. Statistical analysis of χ2, Proportions and Percents were implemented to yield significance in demographics, fracture sites, mode of arrival and mechanism of injury.

Results: There is a significant difference: imaging the joint above and below the fracture (z-score 5.38, P-value 0.001), gender (women z-score 3.237, P-value 0.001 vs men z-score 4.303, P-value < 0.001), high versus low mechanism of injury (χ2 12.11, P-value 0.005), 2 or more fractures (z-score 5.72, P-value < 0.0002) and in the optimal views for Tib/Fib (z-score 17.56, P-value < 0.001), Knee (z-score 15.81, P-value < 0.0001), Ankle (z-score 6.714, P-value < 0.0001) and Foot (z-score 4.088, P-value < 0.0001). There is no significant difference: age (χ2 4.595, P-value 0.2039), race (χ2 1.429, P-value 0.4895), PMH (χ2 2.08, P-value 0.149), location (χ2 1.429, P-value 0.4895) or arrival (χ2 3.197, P-value 0.2022).

Conclusions: While providers in the ED are following the guidelines, they are consistently not following the guidelines in obtaining the correct views and joint imaging either above, or below the fracture site.

Significance of Findings: Given the current environment in the hospital, more resources are being expended causing economic cost to the hospital and patient as well as risk of excessive radiographs. It would be prudent to have the organizations evaluate this further.

Acknowledgments: None.

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Examining for Mental Health Scores and Patient Satisfaction: Is There an Association Between Self-Reported Mental Health and Satisfaction at a Non-Operative Sports Medicine Clinic

Christine A. Marschilok, MD, Emily Levy, MD, and Marc I. Harwood, MD

Affiliation: Thomas Jefferson University, Philadelphia, Pennsylvania.

Purpose: Patient satisfaction is increasingly used as a surrogate outcome measure to assess physician and healthcare quality. We have concerns regarding the validity of satisfaction scores as accurate reflections of providers and institutions. Previous studies have linked disability and depression with poorer patient satisfaction scores.

Methods and Study Design: We conducted a retrospective chart review on new patients (age > 18) to a Sports Medicine practice between 2011 and 2014, who completed both the Short Form 12 [SF-12] Health Survey and a voluntary post-visit satisfaction survey. The satisfaction survey utilized a scale of 1 to 5 (1 = poor/strongly disagree, 3 = neutral, 5 = excellent/strongly agree). Two satisfaction questions were studied given their summative nature: “Based on my experience, I would recommend this practice” and “Please rate your overall level of satisfaction with the practice.” Individuals were grouped based on their answers into “low satisfaction” (1-3) and “high satisfaction” (4-5). Average SF-12 mental health scores were compared using T-tests to evaluate for differences between groups.

Results: Five thousand six hundred eighty-nine patients met inclusion criteria. Individuals who would recommend the practice had higher mental health scores (M = 55.23, SD = 8.85) than those who were neutral/would not recommend (M = 54.11, SD = 9.48), t(5689) = −3.91, P = 0.000. Individuals with high overall satisfaction had higher mental health scores (M = 55.34, SD = 8.77), than those with low satisfaction (M = 54.00, SD = 9.54), t(5689) = −4.97, P = 0.000.

Conclusions: Our study found a statistically significant difference in SF-12 mental health scores between high and low satisfaction patients, but this was not clinically meaningful. This is perhaps due to limited evaluation of mental health in the SF-12. A more thorough assessment of mental health might be needed to determine if baseline mental health issues affect patient satisfaction scores.

Significance of Findings: Further research is needed to examine for confounders in patient satisfaction scores.

Acknowledgments: None.

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Use of Ecologic Momentary Assessment to Compare Daily Physical and Cognitive Activity With Symptoms in Pediatric Patients With Concussion

Christina L. Master, MD, Eileen Houseknecht, MBA, Luke A. Basta, MS, Matthew F. Grady, MD, Michael Nance, MD, and Douglas Wiebe, PhD

Affiliation: Sports Medicine and Performance Center, Division of Orthopedics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania.

Purpose: To use ecologic momentary assessment to measure daily physical activity and compare to reports of cognitive and physical activity as well as symptoms among youth during the first 2 weeks after sustaining a concussion.

Methods and Study Design: Subjects, enrolled from a subspecialty concussion clinic, wore an accelerometer and carried an iPod Touch that randomly prompted subjects to complete a symptom/activity survey several times each day between clinic visits. Cognitive rest/exertion was calculated daily as a composite of indicators about number of texts sent, minutes of screen time and gaming, and minutes of reading or school work. Logistic regression was used to estimate the probability of being symptomatic based on activity levels.

Results: We classified patients' status each day according to being symptomatic (no if symptoms ≤ 8, yes if 9+ on Post Concussion Symptom Scale), physical activity (step count higher or lower than median), and cognitive activity (initial composite score higher or lower than median). Being symptomatic was more likely on days when physically active (OR, 2.4, 95% CI, 1.2-5.0) and cognitively active (OR, 2.0, 95% CI, 1.1-3.7) and became less common as they progressed through the follow-up time period. Regardless of activity levels however, most patients were not symptomatic at the end of the follow-up time period.

Conclusions: We found evidence that physical and cognitive rest corresponded to few symptoms during the recovery period but most patients were asymptomatic after 2 weeks. Level of physical and cognitive activity and severity of symptoms during the acute post-injury phase do not appear to adversely affect overall time to symptom recovery.

Significance of Findings: Physical and cognitive activity following concussion may cause symptoms during the recovery period but does not appear to prolong recovery from the acute injury.

Acknowledgments: None.

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Modified Brief Vestibular Oculomotor Screen (mVOMS) Is Useful in Identifying Vision Diagnoses in Children With Concussion

Christina L. Master, MD, Mitchell Scheiman, OD, Michael Gallaway, OD, Arlene Goodman, MD, Roni Robinson, CRNP, Stephen R. Master, MD, PhD, and Matthew F. Grady, MD

Affiliation: Sports Medicine and Performance Center, Division of Orthopedics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania.

Purpose: To determine the utility of a clinical modified brief vestibular oculomotor screen in identifying vision diagnoses in children with concussion.

Methods and Study Design: Cross-sectional study of 100 patients, ages 11 to 17 years (median 14.5), with the diagnosis of concussion. They underwent a standardized clinical exam including a modified brief vestibular oculomotor screen (mVOMS), including a brief clinical assessment of horizontal and vertical saccades, and convergence. In addition, subjects underwent a developmental vision exam, including an optometric assessment of visual symptoms, visual acuity, eye alignment, near point of convergence, vergence amplitude/facility, accommodative amplitude/facility, and saccadic eye movement speed and accuracy. Sensitivity and specificity for saccadic deficiency were determined for abnormal clinical saccades. A receiver operating characteristic curve was plotted for clinical convergence, with greater than 6 cm as the cutoff defining abnormal convergence and the area under the curve was calculated. Correlations between the mVOMS and computerized neurocognitive testing domains were determined using a Wilcoxon rank sum test.

Results: Symptoms with horizontal or vertical saccades had a positive predictive value of 0.75 and a negative predictive value of 0.33 for the diagnosis of saccadic deficiency. Abnormal convergence greater than 6 cm correlated with the diagnosis of convergence insufficiency with an area under the curve of 0.73. In relation to computerized neurocognitive testing, abnormalities on clinical saccades correlated with verbal memory composite score (P = 0.006).

Conclusions: The mVOMS in the clinical setting is useful in identifying saccadic deficiency and convergence insufficiency in adolescents with concussion. Clinical saccadic deficiency is correlated with poorer verbal memory composite scores on computerized neurocognitive testing, possibly related to the co-localization of these executive functions in the dorsolateral prefrontal cortex.

Significance of Findings: The mVOMS is useful in identifying patients with concussion who may benefit from further evaluation and treatment by developmental optometry for vision diagnoses, such as saccadic dysfunction and convergence insufficiency.

Acknowledgments: None.

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Online Pre-Race Education for Volunteers at a Marathon: Identifying Gaps in Knowledge and Areas to Improve Event Medical Coverage

Shane Maxwell, DO, Ben Nelson, MD, Robby Sikkaa, MD, Dave Olson, MD, Luke Widstrom, DO, Will Paulson, MD, and Trent Christensen, MD

Affiliation: University of Minnesota Primary Care Sports Medicine Fellowship.

Purpose: This study examined whether an online course would lead to increased knowledge regarding the medical issues volunteers encounter during a marathon.

Methods and Study Design: Health care professionals who volunteered to provide medical coverage for an annual marathon were eligible for the study. Demographic information about the medical volunteers including their profession, specialty, education level and number of marathons they had participated in was collected. A 15-question test about the most commonly encountered medical issues was created by the authors and administered before and after the volunteers took the online educational course.

Results: Fifty-five subjects were included in the final analysis and included volunteers who took the course and did both the pre- and post-tests. There were 25 nurses, PA or nurse practitioners, 15 physicians and 15 ATC included. The overall average score for the pre-test was 9 and for the post-test was 12 (P < 0.0001). First time marathon participants scores improved most and reached a level equal to those who had previously covered 1 to 5 marathons. The greatest improvement noted in nurses and PAs, who had an average improvement of 18%. Physicians had the least improvement at 10%. PC physicians who did not have sports medicine fellowship training scored lower than physicians from all other specialties on both the pre-test and post-test. The greatest improvement occurred in the questions about cardiac events and heat illness. Questions regarding electrolyte management and hyponatremia had the lowest average score for all groups of participants.

Conclusions: Online pre-race education improved test scores for volunteers who provide medical coverage at marathons. All providers are likely to see improvement, but particularly those with less marathon experience. Future studies should focus on identifying optimal times and strategies for pre-race education and directly compare if online education is superior to lecture based learning.

Significance of Findings: Online pre-race education improved test scores for volunteers who provide medical coverage at marathons.

Acknowledgments: Grandma's Marathon Volunteers.

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Perceptions of Google Glass as an Aide in Learning Musculoskeletal Ultrasound

Robert Monaco, MD, MPH, Anthony Shadiack, DO, Jennifer Buckman, PhD, and Mackenzie Neumaier, MS

Affiliation: Rutgers, RWJ Medical School, New Brunswick, New Jersey.

Purpose: To study Google Glass (GG) as a self-directed learning tool and assess the perceptions, effectiveness and value of the device for learning musculoskeletal ultrasound (MSKUS).

Methods and Study Design: Volunteers from a variety of specialties with varying experiences with MSKUS were recruited. (Sports Medicine, Family Medicine, Orthopedics, Physiatry, Medical Students). A multimedia web based learning module, was developed as a self-learning module covering ultrasound of the anterior knee. All participants were given a short, 20-minute video on knobology and briefed in person on operating the GG. After the completion of the module (25 minutes), participants were instructed to fill a 26-question survey.

Results: There were significant positive changes reported in knowledge of sonographic anatomy in our early learner group (med students, family med residents). This group also showed a significant positive change in each participant's confidence in probe positioning, performing dynamic maneuvers, and performing an ultrasound examination of the anterior compartment of the knee before and after the study. Ninety-two percent of all participants felt that using the GG to teach musculoskeletal ultrasound was an innovative method. Eighty-five percent had a positive experience using GG to complete the module. Forty-six percent did not want additional training in MSKUS using GG. They noted that video resources are superior to GG, textbooks, and online resources in learning MSKUS. Problems noted primarily were technical, for example, trouble switching attention from the GG, model and us machine as well as problems with the screen size of the glass.

Conclusions: Learners of MSKUS had a positive experience in using GG However, technical difficulties of the apparatus and software appeared to limit the value of this technology for MSKUS education at this time.

Significance of Findings: GG and other similar technologies may help enhance musculoskeletal ultrasound education, though technical issues will need to be addressed before it can be recommended.

Acknowledgments: None.

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The Efficacy and Implications of Mandatory ECG Cardiac Screening on a NCAA Division I Basketball Team

Daniel Morrissy, DO, Alexis Tingan, MD, Jonathan Santana, MD, Arsh Dhanota, MD, and Rahul Kapur, MD

Affiliation: University of Pennsylvania Healthcare System.

Purpose: Among NCAA athletes, the incidence of sudden cardiac death (SCD) is highest in male African-American division I basketball players. The purpose of this pilot study is to determine if preseason ECG screening is an appropriate initial screening tool for cardiac abnormalities in a subgroup of NCAA athletes. In particular, if subgroup ECG screening is an effective means of identifying athletes at increased risk for cardiac abnormalities.

Methods and Study Design: Screening study of 19 asymptomatic male NCAA division I basketball players who underwent a screening ECG as part of pre-participation physical examination. The study cohort included athletes aged 18 to 21. Eight of the 19 athletes studied were African American. The Seattle Criteria was applied to the screening ECGs to identify abnormal studies that warranted further cardiac tests.

Results: Two of the 19 ECGs performed were abnormal under the Seattle Criteria. The additional testing requirement was dependent on initial ECG findings, history and physical and determined by the Team Physician along with the consulting Cardiologist. Athlete 1 underwent a repeat ECG one week later, which did not show PVCs. He was cleared to play without restriction. Athlete 2 underwent a transthoracic echocardiogram and cardiac MRI which did not show evidence of structural abnormalities. Athlete 2 was cleared to play without restriction.

Conclusions: ECG screening did effectively identify 2 athletes (10.5%) who required further work up but ultimately there was no change in participation status. Secondary implications raised by the pilot study included the cost of testing, responsibility of paying for additional testing, coordination of medical teams making the decisions and the direct impact on the athlete.

Significance of Findings: In addition to evaluating ECG screening efficacy, this study identified multiple factors that need to be considered when deciding to implement a mandatory ECG pre-participation cardiac screening program in NCAA division I basketball teams.

Acknowledgments: None.

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Predicting the LESS in Collegiate Athletes

Ariel Nassim, DO, Thomas H. Trojian, MD, and Ellen Casey, MD

Affiliation: Drexel University College of Medicine, Philadelphia, Pennsylvania.

Purpose: Landing error scoring system (LESS) is a validated risk assessment tool. LESS score of ≥5 (“≥5”) has been shown to be predictive of increased ACL injury. We investigated whether college athletes could accurately predict their risk stratification, and if athletes who predict high-risk (“HIGH”) would be more willing to perform an Anterior Cruciate Ligament Injury Prevention Program (ACLIPP) compared to low-risk (“LOW”).

Methods and Study Design: Athletes were recruited during pre-participation physicals. Informed consent was obtained, and LESS was scored using recorded video analysis. Athletes then completed the survey on prediction of risk and willingness to participate in ACLIPP. Chi-square, and t test was used in analysis.

Results: Forty-seven collegiate athletes completed the LESS and survey, 61.7% of which were female. The “HIGH” evaluated to those scoring “≥5.” A small association (phi coefficient = 0.211) was found between athletes' ability to predict their risk level. But only 35% of those “≥5” accurately predicted their risk. Willingness to participate in a 5-minute ACLIPP–90.9% of “HIGH,” 75% of “LOW.” Willingness to participate in a 10-minute ACLIPP–81.8% of “HIGH,” 52.7% of “LOW.” Less than 33% of both groups would participate in an ACLIPP of 15, 20 or 30-minutes duration.

Conclusions: There is a small association of college athletes predicting ACL injury risk measured by LESS. However, the majority of those at high-risk don't correctly predict their risk. We found that “HIGH” are more willing to participate in a 5- and 10-minute ACLIPP than “LOW.”

Significance of Findings: Our study shows athletes at high-risk aren't able to predict their risk. Additionally, the willingness to participate in 5 and 10-minute ACLIPP is higher in those who feel they are at high-risk. Since those at elevated risk get the most benefit from ACLIPP, this illustrates the need to investigate further if compliance with ACLIPP varies by risk assessment.

Acknowledgments: None.

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Musculoskeletal Injury Risk and Prevention in High School Athletes: A Systematic Review

Vicki R. Nelson MD, PhD

Affiliation: Department of Family Medicine and Community Health, University Hospitals Case Medical Center, Cleveland, Ohio.

Purpose: To review available research regarding the risk factors for injury and effectiveness of interventions for prevention of injury in high school athletes.

Methods and Study Design: Data sources—Relevant manuscripts were identified through electronic databases. Keywords including high school, teen, athletic injury, sports injury, risk factor, and prevention were utilized. Additional articles were identified through citations. Exclusion criteria included publication before 1990, subjects outside of the identified age range (12-19), lab based studies, biomechanical studies, surgical studies, sample size <14, and those limited to concussion or brain injury. Information was extracted from the identified studies including design, sport, injury studied, sample size, subject description, variables, type of intervention if applicable, data reported and results. Qualitative analysis was performed on the extracted data and summarized.

Results: Three hundred ninety-five potential studies were identified, 47 (11.9%) met criteria for inclusion. Thirty-four percent examined a prevention strategy. Identified factors were divided into modifiable (potential targets of a prevention strategy) and non-modifiable risk factors. Non-modifiable factors identified to increase risk of injury include older age, competition, contact sports, Caucasian background, more years of play, higher level of competition and prior injury.

Conclusions: Modifiable risk factors identified for targeted interventions include obesity, disordered eating, decreased sleep, practice duration, absence of medical personnel, poor technique, inexperience coaching, anxiety and life stressors and a competitive team climate.

Significance of Findings: Several modifiable risk factors were identified that serve as potential areas for intervention and future research. Many identified risks include psychosocial components which are overall poorly represented in injury prevention. These provide behavior and lifestyle targets for primary care and team physicians to intervene on both an individual and group basis.

Acknowledgments: None.

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The Impact of Exercise on Novel Baseline Concussion Tests Performance in a Pediatric Population

Anthony Okamura, MD, Eric Slattery, MS, Adam Kiefer, PhD, and Paul Gubanich, MD, MPH

Affiliation: Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

Purpose: There is a paucity of validated concussion assessment tools in the pediatric population. The purpose of this study was to examine the test-retest reliability of the King-Devick test (KD), the puck-drop clinical reaction test (PD) and postural control (PC) in a normal pediatric population pre and post exercise.

Methods and Study Design: Youth participants, aged 6 to 13, active in sports were recruited for the study. Subjects with a history of concussion within the last year, or with a current lower extremity injury were excluded. Baseline testing including the KD, PD, and PC were administered pre and post exercise. KD and PD were performed using previously published standardized protocols. PC testing consisted of one 60 second trial of quiet standing with feet together and eyes closed in a relaxed stance which was then repeated while subjects performed a categorical memory recall test.

Results: Twenty-four subjects were enrolled. A repeated measures analysis of variance (ANOVA) indicated no significant differences between the KD subscores between pre to post-exercise for card 1 (P = 0.71), card 2 (P = 0.17), card 3 (P = 0.69), or total time (P = 0.39). A paired samples t test also indicated no significant differences in PD from pre to post exercise (P = 0.57). No significant differences were observed for PC measures of area (P = 0.09), path length (P = 0.22), unit path (P = 0.22), average velocity (P = 0.22), Higuchi's fractal dimension (HFDx), P = 0.29, or HFDy, P = 0.69, from pre to post exercise.

Conclusions: This study supports preliminary reliability of KD, PD and PC measurements in a pediatric population, as exercise did not have a statistically significant variation of test performance on these measures. Future studies will need to examine the effect of concussive injury and confounders on the performance of these tests.

Significance of Findings: Baseline performance of 3 possible concussion evaluation tools was obtained in the pediatric population. Current results indicate that exercise does not affect test performance in a healthy pediatric population.

Acknowledgments: We would like to thank the athletes for the Greater Cincinnati Area for their participation in this and future concussion studies.

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Downstream Cost Analysis of Including Electrocardiography Screening in Pre-Participation Cardiovascular Evaluation

Tim Partridge, MD, Miguel Linares, MD, Chris Guyer, MD, Sudheer Dhoop, and Rachel Rinaldi

Affiliation: Henry Ford Health System, Detroit, Minnesota.

Purpose: Compare the downstream costs associated with electrocardiogram (ECG) screening during pre-participation physical examination (PPE) to those associated with the traditional PPE.

Methods and Study Design: IRB-approved prospective cohort study. ECG screening offered at mass PPE events for athletes at high schools and colleges under coverage contract with Henry Ford Health System. Athletes not cleared for concerning cardiac history or physical examination finding enrolled under one arm (H&P), those not cleared for abnormal ECG finding enrolled in other arm (ECG). H&P clearance based on provider discretion with primary care sports medicine specialist overseeing final decision. ECG clearance based on cardiologist discretion. Those not initially cleared were encouraged to follow-up with their pediatrician for further guidance. Enrolled athletes contacted via telephone 6 months after enrollment date, total cost of subsequent evaluation calculated using Center for Medicare & Medicaid Services (CMS) average cost data. Costs compared between the 2 arms using a non-parametric Wilcoxon test.

Results: Fifteen athletes enrolled after not being initially cleared, 10 in the ECG arm, 5 in the H&P arm. Average downstream costs for ECG arm were $1276.00, and for the H&P arm $886.20, which did not reach statistical significance with P-value of 0.71.

Conclusions: The data indicates that there is not a statistically significant difference in the downstream costs between athletes not cleared due to an ECG abnormality compared with traditional PPE. This may support ECG screening implementation during the PPE, as this study demonstrates that it does not result in the increased utilization of healthcare resources.

Significance of Findings: This is the first study to look at the downstream costs associated with ECG screening during the pre-participation physical examination.

Acknowledgments: Chris Guyer, Sudheer Dhoop, Rachel Rinaldi, Yun Wang, Henry Ford & Wayne State Athletic Training Staffs, Henry Ford Department of Orthopedics & Sports Medicine.

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MRI Findings and Clinical History of Transient Patellar Dislocation Are Frequently Incomplete in Pediatric Patients

Ziva Petrin, MD, Sachin Dheer, MD, Anupam Sinha, DO, Adam C. Zoga, MD, and William B. Morrison, MD

Affiliation: Thomas Jefferson University, Philadelphia, Pennsylvania.

Purpose: To determine whether MRI findings of transient lateral patellar dislocation vary between pediatric and adult populations.

Methods and Study Design: Retrospective review of 10 consecutive adult and pediatric patients referred for knee MRI after acute injury, with either clinically suspect patellar dislocation, or MRI findings suggestive of patellar dislocation. Ten consecutive reports (5 male and 5 female) for each age group were independently reviewed by a fellowship-trained musculoskeletal radiologist.

Results: Mean age was 15.4 ± 1.74 years for pediatric patients and 40.2 ± 12.6 years for adults. The mean interval between the injury and MRI was not statistically different at 7.2 ± 3.25 days in the pediatric group and 8.5 ± 3.75 days in adults (P = 0.44). A clinical suspicion of dislocation was present in 4/10 of pediatric versus 8/10 of adult patients (P = 0.068). Statistically significant differences (P < 0.05) in radiological findings were found between the groups for patellar contusion (3/10 pediatric, 8/10 adult; P = 0.025), contusion of the lateral femoral condyle (3/10 pediatric, 9/10 adult; P = 0.006), sprain of the medial patellofemoral ligament (MPFL) (4/10 pediatric, 10/10 adult), and medial collateral ligament (MCL) sprain pattern (5/10 pediatric, 10/10 adult). Impact fractures of the lateral femoral condyle were more common in adults versus pediatric patients (1/10 pediatric, 5/10 adult) and approached statistical significance (P = 0.051).

Conclusions: Clinical history of patellar dislocation was contributory in a minority of pediatric patients, as opposed to adults. The incidence of MRI findings of transient patellar dislocation in pediatric patients is significantly lower than adults, requiring a higher index of suspicion in pediatric patients.

Significance of Findings: MRI findings and clinical history in pediatric patients with transient patellar dislocation may be less apparent than in adult patients.

Acknowledgments: None.

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Overuse Versus Acute Injury Quantification in Outpatient Pediatric Sports Medicine Clinic

Thomas L. Pommering, DO, Amy E. Valasek, MD, MSc, and Julie Young, MA, ATC

Affiliation: Nationwide Children's Hospital Sports Medicine, Department of Pediatrics and Family Medicine, The Ohio State University College of Medicine, Columbus, Ohio.

Purpose: To investigate overuse versus acute injury type presenting to outpatient pediatric sports medicine clinic.

Methods and Study Design: Retrospective chart review was performed on patients over a 2 year period from 2012 to 2014. Age, gender, diagnoses, mechanism of injury, body part injured was recorded. Also the number of days between injury and clinic presentation was recorded. Injuries were then coded as acute or overuse based on the mechanism of injury and physician diagnoses.

Results: A total of 5953 subjects were included in the chart review. 84.7% (5041) were coded as overuse and 15.3% (912) were coded as acute. Mean age was 13.35 ± 2.35 years. Mean days from injury to clinic presentation was 108.7 ± 234.4. The top 3 injured body parts were knee 32% (1899), spine 13% (780), ankle 10% (609). Overall, there were 3417 females and 2520 males (missing n = 16). Females were coded with an overuse injury significantly more often than males (P = 0.027). Additionally, pediatric patients with an overuse injury had a significantly longer time to present to clinic 114.9 ± 224.5 days versus 74.7 ± 165.0 days P > 0.0001).

Conclusions: Pediatric patients presenting to outpatient sports medicine clinic more often present with overuse injury. A lower extremity injury or spine injury is the most common type at presentation. Female gender more often present with an overuse injury which correlates with prior research.

Significance of Findings: The data set demonstrates a significant lapse of time from injury date to clinical presentation. This signifies the need for more coach, parental and patient education on injuries and injury prevention.

Acknowledgments: None.

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Field Validation of an Extended Range Critical Power Model for Cycling Performance Prediction and Quantification

Michael J. Puchowicz, MD, Jonathan R. Baker, PhD, and David C. Clarke, PhD

Affiliation: Arizona State University, Tempe, Arizona.

Purpose: To validate an extended range critical power (CP) model of cycling performance.

Methods and Study Design: After IRB approval, 9 cyclists trained and raced for 6 weeks with their own power meter equipped bicycle and completed 4 test time trials (TTs) in a double-blind cross-over study design. TTs were assigned to produce maximal efforts in the sprint, extreme, severe, and heavy domains. Fitting and parameter estimation was performed by nonlinear least squares. Data excluding tests was used as the initial training set. Model fit was assessed by residuals and root mean square error (RMSE). Parameter independence was assessed by correlation matrix. External validity was tested by linear regression of test point versus model for each domain. The effect of test session inclusion on parameter estimates was assessed by repeated measures ANOVA.

Results: All fits successfully converged from initial guesses. Time point residual means were not statistically different than 0, and RMSE was 5.4 watts. Linear regression of test versus model yielded statistically significant slopes of 0.99, 0.99, 1.13, and 1.27, R2 of 0.8, 1.0, 0.9, and 0.6, and standard error of the estimate of 12.0%, 5.8%, 4.4%, and 10.0% for the sprint, extreme, severe, and heavy domains respectively. Intercepts were not statistically different than 0. Parameter correlation was high for Pmax/W' (0.74) and Pmax/CP (0.84) and low for Pmax/alpha (−0.15), W'/CP (0.43), W'/alpha (−0.48), and CP/alpha (0.27). A trend toward increased parameter estimates was observed with test data inclusion but was not statistically significant.

Conclusions: The extended range CP model is valid for prediction and quantification of cycling performance. Further studies are needed to investigate the effect that different training, racing, and testing regimens have on model predictivity and parameter estimates.

Significance of Findings: This is the first study to validate an extended range CP model for prediction and quantification of cycling performance in the field.

Acknowledgments: None.

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Sports Medicine Fellows' Knowledge of Authorship in Biomedical Research: A National Survey

Sathish Rajasekaran, MD,* Mederic Hall, MD,* Jonathan Finnoff, DO†,‡

Affiliation: *Department of Orthopaedics and Rehabilitation, University of Iowa Sports Medicine, Iowa City, IA; †Department of Physical Medicine and Rehabilitation, Mayo Clinic School of Medicine, Rochester, Minnesota; and ‡Department of Physical Medicine and Rehabilitation, University of California Davis School of Medicine, Sacramento, California.

Purpose: To determine whether primary care sports medicine (PCSM) fellows are aware of authorship guidelines, if the topic should be included in their training and what their experience around the topic has been.

Methods and Study Design: PCSM fellows in accredited training programs across the United States were contacted by email with a link to our questionnaire on 3 occasions. The questionnaire topics revolved around the purpose of our study, and also included demographic questions.

Results: Our response rate was 25.4%. Of these, 87.7% were unaware of the International Committee of Medical Journals and Editors (ICMJE) authorship guidelines, 93.8% had not received formal authorship training, 43.1% had attended the annual American Medical Society for Sports Medicine (AMSSM) Fellows Conference, and 64.6% believed formal authorship training was important. Of those respondents who had research experience (89.2%), 18.4% had concerns with a coauthors contribution on a previous project, and 9.2% had concerns with authorship order. In total, 53.8% of respondents agreed with the ICMJE authorship criteria, but all noted that one or more non-authorship tasks as defined by the ICMJE warranted authorship.

Conclusions: The majority of respondents were unaware of the ICMJE authorship criteria, but felt formalized authorship training was important to provide. Most respondents agreed with the ICMJEs 4 authorship criteria, but none agreed with all of the ICMJEs non-authorship tasks. As non-authorship tasks are often why coauthorship is wrongly offered, the latter finding is important to reflect on, and may in part be why the rate of reported authorship concerns were low.

Significance of Findings: The low rate of awareness of the ICMJE authorship guidelines is a cause for concern. Increasing awareness of the topic in trainees may allow them to better determine what contributions warrant authorship.

Acknowledgments: None.

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A Novel Maneuver for Closed Reduction of Posterior Femoroacetabular Dislocation

Jeremiah W. Ray, MD and Michael Mallin, MD

Affiliation: University of Utah, Salt Lake City, Utah.

Purpose: Posterior hip dislocations present a unique clinical challenge to the provider. Patient pain often inhibits motion of the dislocated limb yet the potential for neurovascular compromise adds urgency to the need for adequate reduction. The prominent bony architecture of the femoroacetabular joint can pose a significant obstacle in timely closed joint reduction. Multiple closed reduction techniques exist. Some of these maneuvers require multiple providers and others require uncomfortable provider or patient positioning. We present a novel technique for closed reduction of posterior femoracetabular joint dislocation that regularly allows a single provider successful reduction with a single attempt without unique patient or provider positioning.

Methods and Study Design: This is a case series of 9 emergency room patients who suffered posterior hip dislocation. This study is an observational convenience sample.

Results: Hundred percent (9 of 9) of patients experienced successful closed reduction on first attempt with novel maneuver. 66.7% (6 of 9) failed other reduction techniques prior to attempt with novel maneuver. 77.8% (7 or 9) patients had pre-existing hip prosthesis. 22.2% (2 of 9) had associated acetabular fractures.

Conclusions: We present a novel closed reduction maneuver to better assist with the management of posterior femoroacetabular dislocation. This maneuver has high success rates with a single provider on initial attempts. The presence of hip prosthesis and the presence of acetabular fracture do not inhibit successful reduction.

Significance of Findings: With increased first time success rates for closed reduction of posterior femoracetabular joint reduction there are multiple potential benefits: potential decrease in patient discomfort; potential for decreased analgesic dosings; decreased number of conscious sedations; decreased ancillary staff time committed to patient monitoring; potential avoidance of traumatic reduction and iatrogenic fracture; potential for decreased injury to provider attempting reduction.

Acknowledgments: None.

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The Incidence of Stress Fractures in American Collegiate Athletes

Katherine H. Rizzone, MD, MPH, Kathryn Ackerman, MD, MPH, Thomas Dompier, PhD, and Zachary Kerr, PhD, MPH

Affiliation: University of Rochester Medical Center.

Purpose: Stress fractures are common sports-related injuries. Athletes in women's and endurance sports (eg, cross country) are at a higher risk than the general athlete population. There are over 460 000 collegiate athletes in the United States, but there is a lack of research estimating the incidence of stress fractures in this population. Our objective was to examine the epidemiology of stress fractures in National Collegiate Athletic Association athletes.

Methods and Study Design: Data were analyzed from the NCAA Injury Surveillance Program during the 2004-2005 to 2014-2015 academic years. A sample of schools provided injury and exposure data for 25 sports. Injury rates per 10 000 athlete-exposures (AE), injury rate ratios (RR) and 95% confidence intervals (CI) were calculated.

Results: There were 747 stress fractures were reported during 18 054 757 athletic exposures (AE) for an overall rate of 0.53/10 000AE (95% CI, 0.50-0.57). The stress fracture rate was higher in females than males (0.91 vs 0.44/10 000AE; RR = 2.06; 95% CI, 1.71-2.47). Specifically, rates were higher in females than males in cross country (RR = 1.77; 95% CI, 1.05-2.98), soccer (RR = 1.69; 95% CI, 1.09-2.63), and basketball (RR = 1.69; 95% CI, 1.26-2.28). The pre-season rate was larger than the regular-/post-season rate (1.06 vs 0.32/10 000AE; RR = 3.27; 95% CI, 2.83-3.78). The most common stress fracture locations occurred to the metatarsals (38.8%, N = 290), tibia (20.7%, N = 155), and the lower back/lumbar spine/pelvis (13.4%, N = 100). Also, 22.5% (N = 165) of stress fractures were recurrent.

Conclusions: Females had higher stress fracture rates than males. Future research needs to focus on improved screening tools for all female athletes, as sex differences were found across multiple sports. More than a fifth of stress fractures were recurrent, potentially highlighting the need to reassess post-injury return-to-play policies.

Significance of Findings: This is the only large study examining stress fracture in American collegiate athletes to date. Novel findings included higher rates of stress fractures in females participating in non-endurance sports.

Acknowledgments: None.

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Sports Specialization and Sports-Related Injury in Collegiate Athletes

Katherine Rizzone, MD, MPH, Alex Diamond, DO, MPH, and Christianne Roumie, MD, MPH

Affiliation: University of Rochester Medical Center.

Purpose: Sports specialization, playing a single sport, has been hypothesized to help youth athletes reach elite athletic status. Yet, there are also concerns that it may increase the risk of sports-related injury. Our objective was to determine if there was an association between collegiate athletes' age of specialization and their history of sports-related injuries.

Methods and Study Design: Student athletes from 2 division I institutions were surveyed using an electronically delivered, validated measure. Athletes were recruited through their team athletic trainer. Early specialization was defined as athletes who specialized before 14 years of age; very early as before 11 years of age.

Results: Two hundred forty-five athletes completed the survey out of 535 (45%). Mean age of specialization was 13.9 ± 3.5 years of age. Female athletes specialized at younger ages compared to male athletes (13.2 vs 14.7 years, P < 0.01). Very early specializers reported higher numbers of sports-related injuries overall (P < 0.05). Female early specializers reported a higher number of surgeries (P < 0.02), and male very early specializers reported a higher number of dislocations (P < 0.03). Individual sport athletes who were early and very early specializers reported a statistically greater number of overuse injuries as compared to team sport athletes. Athletes who played a high number of elite and organized sports were 2.2 and 2.8 times as likely respectively to have experienced an injury. Team sport athletes were 2.5 times as likely to have reported an injury as compared to individual sport athletes.

Conclusions: Female athletes specialized at younger ages than their male counterparts. Early specialization was associated with an increased risk of sports-related injury in certain categories but type and number of sports participated in during childhood may be better predictors of sports-related injury.

Significance of Findings: This is the only known study to date investigating the relationship between early specialization and sports-related injury in elite athletes in the United States.

Acknowledgments: None.

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What is the Symptom Profile of Hispanic Athletes Diagnosed With a Concussion in a Border City?

Jose R. Rodarte, MD, Namita Bhardwaj, MD, Justin M. Wright, MD, Gerardo Vazquez, MD, and Daniel Murphy, MD

Affiliation: Texas Tech University Health Science Center at El Paso, Texas.

Purpose: The purpose of this study is to recognize the most common concussion symptoms reported by a Hispanic population in a border city.

Methods and Study Design: This is a retrospective descriptive study looking at Hispanic patients with a sports related concussion. A chart review was performed looking at concussions diagnosed from August 1, 2011 to July 31, 2015 in our Sports Medicine Clinic. A total of 274 concussions where analyzed of which 127 were included in this study. Both male and female Hispanic athletes sustaining a sports related concussion with an age of 11 or above were included in the study. Data collected included age, gender, race/ethnicity and symptoms.

Results: The average patient age was 15.5 years. 64.56% of the patients were male and 35.43% were female. A total of 116 patients reported headaches (91%), 56 reported dizziness (44.09%), 36 reported difficulty concentrating (28.34%), 33 reported photosensitivity (25.98%), 29 reported nausea (22.83%), 20 reported phonosensitivity (15.74%), 16 reported blurred vision (12.59%), 11 reported balance issues (8.66%), 10 reported “feeling in a fog” (7.87%), 8 reported neck pain (6.29%), 7 reported sleep disturbances (5.51%), 5 reported memory issues (3.98%), 4 reported “not feeling right” (3.14%) and 2 reported feeling sad (1.57%).

Conclusions: Based on our study, the most common symptoms reported by Hispanic athletes diagnosed with a concussion are headache, dizziness and difficulty concentrating which are similar to symptoms reported by general athletic populations in previous studies.

Significance of Findings: Little published data is available regarding the symptom profile of concussions sustained by Hispanic athletes.

Acknowledgments: None.

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Decreased Pulmonary Function in Patellofemoral Pain Syndrome

Michael Ross, MD, Andrea Sconberg, PA-C, and Christine Marschilok, MD

Affiliation: Rothman Institute, Philadelphia, Pennsylvania.

Purpose: Patellofemoral pain is thought to develop from weakness in the pelvic stabilizer muscles, especially the gluteus medius and gluteus minimus. This study examines pulmonary function in recreational endurance athletes who have been diagnosed with patellofemoral pain. If there is a decrease in lung function, it will be harder to provide respiratory compensation for the lactic acidosis of exercise, leading to fatigue. Additionally if there is poor exhalation, there'll be air trapping which will also lead to decreased inhalation and decreased oxygenation, compounding fatigue. This study aims to establish a link between patellofemoral pain and decreased lung function.

Methods and Study Design: A retrospective analysis of runners who underwent cardiopulmonary exercise testing was performed. FEV1 and FEF50 were compared in asymptomatic controls (CON) and endurance athletes (ATH) with patellofemoral pain.

Results: Thirty-three patients (14 male and 19 female) and 26 controls (15 male and 11 female) were included in the study. Using a Mann-Whitney test, there are statistically significant differences between post-exercise FEV1 (P < 0.005, CON mean 113% ATH 103.3%), pre-exercise FEF50 (P < 0.01,CON mean 91.6%, ATH mean = 75.8%) and post-exercise FEF50 (P < 0.001, CON mean = 99.54%, ATH mean = 75%).

Conclusions: There is a statistical difference in post-exercise FEV1, and pre- and post-exercise FEF50 between the injured athlete patient group and the controls.

Significance of Findings: From these results, it follows that endurance athletes should be treated to keep their post exercise FEV1 greater than 100% of predicted and their post exercise FEF50 greater than 91% predicted. Developing overuse injuries is multi factorial, however, this study finds that there is a pulmonary component which likely contributes to fatigue which can also lead to poor biomechanics.

Acknowledgments: None.

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GAIT: Gluteal Augmentation Intervention Trial

Michael Ross, MD and Amber Siminitus, DPT

Affiliation: Rothman Institute, Philadelphia, Pennsylvania.

Purpose: The gluteus medius provides pelvic support and internal rotation of the hip. Gluteal weakness leads to foot external rotation, hip adduction, foot pronation and propulsion off the medial aspect of the MTP joint. Weakness leads to knee valgus, placing strain on the medial compartment and altering patellofemoral mechanics, contributing to arthritis, stress fracture and patellofemoral pain. This study looks at the metabolic affects of a gluteus taping protocol.

Methods and Study Design: A baseline V[Combining Dot Above]O2max test was obtained using a ramp treadmill protocol. Hip taping was used with Kinesiotape (KT Tape) to mimic the actions of the gluteus medius muscle in 11 subjects (mean age 44.2 years, 4 male, 7 female). Both hips were taped mimicking the anterior and posterior fibers in a muscle shortened position. V[Combining Dot Above]O2max testing was repeated.

Results: Results were compared using a t test and Wilcockon test. There is a significant increase in time to RER = 1 (P = 0.0005, mean tRER1: CON = 204 seconds, TAP = 256 seconds) without increasing time to V[Combining Dot Above]O2max. The aerobic ratio- the time spent in aerobic metabolism to the entire exercise time (tRER = 1/tV[Combining Dot Above]O2max) was calculated and is significantly increased (P < 0.005, CON = 0.05, TAP = 0.78). There is a significant increase in speed at RER = 1 (P < 0.0005, mean CON = 7.09 mph, TAP = 7.82 mph). V[Combining Dot Above]O2 (P < 0.01 mean CON 2504 mL, TAP 2803 mL) and V[Combining Dot Above]O2/kg (P < 0.01 mean CON 34.7 mL/kg, TAP 41 mL/kg) were both increased at RER1.

Conclusions: Hip taping prolongs lactic acid onset and improves running endurance.

Significance of Findings: This taping method can be used during rehabilitation of the runner or to help minimize fatigue in running. Because of the improvement in the aerobic ratio, this taping method can also be used as an ergogenic aid in distance running, allowing for more work before the onset of lactic acidosis.

Acknowledgments: None.

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Scapular Taping and Ventilation During Running

Michael Ross, MD

Affiliation: Rothman Institute, Philadelphia, Pennsylvania.

Purpose: To examine the role of scapular posture on pulmonary function during running. Scapular retraction can move the body to an upright breathing posture, which has been shown to improve inspiration allowing for better accessory muscle use. Scapular stabilization contributes to core strength and decreases inspiratory resistance. It is hypothesized that the activation of the scapular stabilizers will decrease work of breathing and inspiratory resistance, resulting in increased vital capacity and improved oxygenation at lactic acid onset (Rvalue = 1).

Methods and Study Design: Ten subjects underwent flow volume loops followed by 3 separate ramp treadmill cardio-pulmonary exercise tests to exhaustion. Each trial was performed with either no tape, scapular taping or sham taping. Scapular taping was performed with RockTape from the posterior acromion to the contralateral inferior scapular border. Sham tape was applied at the anchor points at the posterior acromion and at the inferior scapular borders.

Results: V[Combining Dot Above]O2 at R = 1 was significantly increased in the taping trials versus the control using a linear mixed model (P < 0.0001) (mean V[Combining Dot Above]O2 at R = 1: control 2851 mLO2/min SD 746.4, Sham 3190 mLO2/min SD 737.5, Tape 3300 mLO2/min SD 792.2). The Forced Vital Capacity was significantly increased in the taping trials versus the control using a linear mixed model (P < 0.0001) (mean FVC: Control 4.8 L SD 1.11, Sham 5.28 SD 1.48, Tape 5.20 SD 1.65).

Conclusions: Scapular taping allows for increased ventilation without increasing pulmonary function.

Significance of Findings: The V[Combining Dot Above]O2 at the onset of lactic acid allows for more oxygen uptake without an increase in lactic acid accumulation. The increase in FVC is from the increase in lung volumes, presumably from the decreased work of breathing by facilitating the accessory muscles and the expansion of the rib cage. From these results, we recommend scapular strengthening as an important adjunct to the rehabilitation of the runner.

Acknowledgments: None.

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Shin Pain and Pulmonary Function in Athletes

Michael Ross, MD

Affiliation: Rothman Institute, Philadelphia, Pennsylvania.

Purpose: The diagnosis of shin pain is common and includes medial tibial stress syndrome (MTSS), stress fracture and chronic exertional compartment syndrome (CECS). The muscles in the calf are relatively small and are the first muscles to fatigue during whole leg exercise, which can alter biomechanics. This study investigates a pulmonary component of shin pain in athletes.

Methods and Study Design: Patients with a history of shin pain, CECS, MTSS and tibial stress fractures who underwent cardiopulmonary exercise testing were reviewed. The pre- and post-exercise values for FEV1 and FEF50 were compared against controls (CON).

Results: When compared against controls using a Mann-Whitney test, there was a statistically significant difference in pre- and post-FEV1 (%predicted) from the CON in CECS (pre P < 0.05, post P < 0.005) MTSS (pre P < 0.001, post P < 0.005), Shin Pain (pre P < 0.05, post P < 0.005) (pre FEV1 means CON = 108.5, CECS = 101.76, MTSS = 97.2, Shin Pain = 100.53. post FEV1 means: CON = 112.9, CECS = 98, MTSS = 97, Shin Pain = 98.3). Controls are significantly different from shin pain in preFEF50 (%pred) (P < 0.005 means CON = 91.6, shin pain = 68.5), whereas the post-exercise FEF50 (%pred) is significantly different from control (99.54) in CECS (P < 0.05, 78.2), MTSS (P < 0.001, 61.95), shin pain (P = 0.001, 67.8) and stress fracture (P < 0.05, 77.8).

Conclusions: Patients with shin pain have decreased lung function from asymptomatic controls.

Significance of Findings: Decreased pulmonary function during exercise leads to decreased respiratory compensation of the acidosis of exercise and decreased oxygenation resulting in earlier fatigue of the fatiguable calf muscles. Fatigue will likely lead to weakness and altered biomechanics. Based upon the results of the study is reasonable to treat the FEV1 less than 100% of predicted and FEF50 less than 91% of predicted with asthma medication in a symptomatic runner with shin pain.

Acknowledgments: None.

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Decreased FEV1 and Small Airway Disease in Endurance Athletes With Gluteal Tendinitis

Michael Ross, MD and Andrea Sconberg, PA-C

Affiliation: Rothman Institute, Philadelphia, Pennsylvania.

Purpose: To investigate the role that pulmonary fatigue may play in developing of gluteal tendinitis. Lateral hip pain arises from weakness in pelvic stabilization. This study examines pulmonary function in runners who have been diagnosed with gluteal tendinitis. If there is a decrease in pulmonary function, the ability to exhale is limited, making it harder to provide respiratory compensation for the lactic acidosis of exercise. Incomplete exhalation causes air trapping which will lead to decreased inhalation and decreased oxygenation, compounding fatigue.

Methods and Study Design: A retrospective analysis of runners who underwent cardiopulmonary exercise testing was reviewed. Asymptomatic controls (CON, n = 26) were compared with athletes (ATH, n = 36) who had gluteal tendinitis. Pre and Post exercise values were obtained for FEV1 (%predicted), FEV1/FVC and FEF50 (%predicted).

Results: There are statistically significant differences between pre exercise FEV1 (P < 0.005, CON mean = 108.53%; ATH mean = 99.42%), post-exercise FEV1 (P < 0.005, CON mean 113% ATH 95.6%), post exercise FEV1/FVC (P < 0.05, CON mean 77, ATH mean 69.1), pre-exercise FEF50 (P < 0.01, CON mean 91.6%, ATH mean = 71.5%) and post-exercise FEF50 (P < 0.001, CON mean = 99.54%, ATH mean = 68.7).

Conclusions: There are significant differences between the gluteal tendinitis athlete group and the control in pre and post-exercise FEV1, post-exercise FEV1/FVC and pre and post exercise FEF50.

Significance of Findings: From these results, it follows that endurance athletes -and especially those with gluteal tendinitis- should be treated as asthma to keep their pre- and post-exercise FEV1 greater than 100% of predicted, and FEF50 to 90% of predicted. Treatment should also be initiated on those with FEV1/FVC <70. Developing overuse injuries is multi factorial, however, this study finds that there is a pulmonary component which can contribute to fatigue and lead to poor biomechanics.

Acknowledgments: None.

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A Conclusive Methodologic Approach to Ultrasound of the Piriformis: A Pilot Study

Joshua Rothenberg, DO, Usker Naqvi, MD, Doug Johnson-Greene, PhD, Jose Perez, BA, Spencer Summers, BA, Alexander Harrington, BS, MBA, Ricardo Vasquez-Duarte, MD, and Clifton Page, MD

Affiliation: Leonard M. Miller School of Medicine/Jackson Memorial Hospital.

Purpose: To test the hypothesis that in healthy controls where no clinical suspicion of piriformis syndrome exists, more reliable ultrasound measurements will be obtained following education with a standard protocol and use of the same ultrasound equipment across providers on the same day, enhanced group (G2), compared to measurements obtained by providers who have only baseline ultrasound knowledge of the piriformis alone, baseline group (G1).

Methods and Study Design: The study design was a cross sectional intervention study done in an ultrasound suite at a tertiary care academic medical center. Fifteen volunteer subjects, with an age range of 21 to 29 years old, were assigned to group 1 (n = 6) or group 2 (n = 9). Volunteer subjects in the G1 group underwent piriformis ultrasound in phase I of the study by 2 independent sports medicine fellowship trained physicians with general ultrasound knowledge using 2 different ultrasound machines at different time periods. Following education in the use of a standard protocol on piriformis ultrasound, and having watched an associated video, volunteer subjects in the G2 group underwent piriformis ultrasound in phase II of the study by the same 2 independent sports medicine fellowship trained physicians using the same ultrasound machine on the same day. The main outcome measure was to look at inter-rater reliability of piriformis ultrasound measurements.

Results: Cronbach's Alpha Coefficients were computed between the 2 raters for the phase I baseline group and for the phase II intervention group for each ultrasound measurement. For phase I measurements coefficients ranged from 0.05 to 0.33. In contrast, the intervention group measurements yielded Cronbach coefficients of 0.20 to 0.66. Only the right piriformis for phase II reaches statistical significance at P < 0.05. Nonetheless, the average inter-rater coefficient for phase I was 0.21 and was nearly double that for phase II at 0.41.

Conclusions: The results of this study suggest that although the inter-rater correlations doubled from phase I to phase II, only one of the phase II inter-rater correlations was found to be significant, probably as a function of a low n. The means are fairly close, but on a measure by measure heads up comparison, the phase II was just incrementally better than the phase I reliability.

Significance of Findings: A fundamental tenant is that anything lacking reliability precludes validity. This raises the possibility that ultrasound is not a reliable or valid tool for measuring piriformis length and width. The need for methodology rigor in conducting ultrasound studies should be emphasized going forward. Future studies should be conducted to confirm or refute the results of this study.

Acknowledgments: None.

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Ultrasound Guided Carpal Tunnel Release: A Systematic Review

Holly Ryan, BA,* Jay Smith, MD†

Affiliation: *University of Minnesota Medical School Student, Minneapolis, Minnesota; and †Department of Physical Medicine and Rehabilitation, College of Medicine, Mayo Clinic, Rochester, Minnesota.

Purpose: To review current literature evaluating ultrasound guided carpal tunnel release (UGCTR).

Methods and Study Design: PubMed and Ovid Medline databases were searched using “carpal tunnel” OR “carpal tunnel release” OR “carpal tunnel surgery” AND “ultrasound” OR “sonography” through November 2015. A total of 13 articles were identified for complete review based on reporting clinical or cadaveric data pertaining to UGCTR.

Results: Four articles described UGCTR in a total of 140 cadaveric specimens (10 embalmed, 26 unembalmed, 104 not specified). Eight articles reported on 201 patients treated with UGCTR, including 6 clinical studies (5 prospective, 1 retrospective) and 2 case series. One additional article presented both cadaveric (12 embalmed, 8 unembalmed) and prospective clinical (N = 91) experiences. In the 5 cadaveric studies, the rate of complete transverse carpal ligament (TCL) release was 98.8% (158/160) without injury to the median nerve, ulnar artery, or associated structures. Among the 9 clinical publications reporting on a total of 292 UGCTR treated wrists, there were no documented incomplete TCL releases, conversions to open CTR, or major complications. Eight publications reported clinical success in 99% of patients defined by lack of symptom recurrence at 1 to 26 month follow-up. One additional article reported 86% patient satisfaction, but did not include follow-up duration. Only 0.68% (2/292) hands were graded as unsatisfactory at final follow-up, not attributable to recurrent symptoms. Three clinical studies reporting comparative data suggest that patients treated with UGCTR may have reduced post-operative pain, faster recovery, and a more aesthetically pleasing scar when compared to traditional open CTR procedures.

Conclusions: UGCTR appears to be a safe and effective treatment for patients with CTS and may reduce post-operative morbidity compared to traditional CTR techniques.

Significance of Findings: Further clinical experience and research is warranted to define the role of UGCTR in the management of patients with refractory symptoms.

Acknowledgments: None.

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Sonographic Evaluation of the Axillary Nerve With Cadaveric Correlation Using an Anterior Approach

Holly Ryan, BA* and Jay Smith, MD†

Affiliation: *University of Minnesota Medical School Student, Minneapolis, Minnesota; and †Department of Physical Medicine and Rehabilitation, College of Medicine, Mayo Clinic, Rochester, Minnesota.

Purpose: (1) To describe and demonstrate the ultrasound scanning technique for axillary nerve (AxN) evaluation using cadaveric correlation. (2) To determine the extent of the AxN visualized using an anterior approach with respect to the quadrilateral space.

Methods and Study Design: Sonographic evaluation of the AxN using an anterior approach is challenging due to complex anatomy and non-anatomic positioning. The extent of the AxN visualized using an anterior approach has not been previously documented. Four unembalmed cadaveric shoulder specimens were dissected and the AxN tagged at the level of the posterior humeral shaft (distal to the quadrilateral space). Using anatomical and sonographic correlation, the previously described anterior scanning technique for identification and evaluation of the AxN was refined and demonstrated using reproducible landmarks. The extent of the AxN that could be sonographically examined via the anterior approach was documented and validated via dissection.

Results: Sonographic identification and evaluation of the AxN can be facilitated using the latissimus dorsi/teres major, subscapularis, radial nerve, long head of triceps and humeral head as landmarks. Key anatomical relationships in the abducted-externally rotated position include the perpendicularity of the latissimus dorsi/teres major relative to the humeral shaft, the vertical orientation of the subscapularis fibers relative to the body, and the position of the AxN adjacent to the humeral head and deep to the latissimus dorsi/teres major. Using an anterior approach, the entire segment of the AxN passing through the quadrilateral space could be visualized.

Conclusions: Sonographic evaluation of the AxN passing through the quadrilateral space is feasible from an anterior approach and can be facilitated by identification of reproducible osseous and soft tissue landmarks.

Significance of Findings: Clinicians can use reproducible sonographic landmarks to evaluate the AxN and quadrilateral space using an anterior acoustic window. The techniques described herein will facilitate additional clinical experience with AxN scanning.

Acknowledgments: None.

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Radiologic Approach to Chronic Knee Pain in Adults: A Retrospective Review of Imaging Modalities Used in a Resident Clinic

Erika Sadeghi, MD, Rokhsanna Sadeghi, MD, and Micheal Kernan, MD

Affiliation: St. Joseph's Hospital Health Center, Syracuse, New York.

Purpose: To investigate the imaging practices for older adults with chronic knee pain and to investigate whether MRIs are overused in a primary care setting.

Methods and Study Design: This is a retrospective analysis of 256 patients in a resident primary care clinic. A search of the EPIC EHR registry was completed to identify all patients diagnosed with the ICD-9 code of knee pain over a one year period. All imaging orders, or absence of orders, were linked to every patient encounter. Patients were excluded if there was a history of trauma, previous knee surgery, known diagnosis related to knee pain, or previous imaging on file ordered from another provider. Analysis was both statistical and qualitative.

Results: Of the 68 patients that met inclusion criteria, 82.3% had associated radiographs ordered. Of the 73 radiographs ordered, 0% were ordered as “weight-bearing view in 30 degree of flexion.” 20.5% were ordered as “standing anterior-posterior lateral views with weight-bearing” and 79.5% were ordered without mention of weight-bearing. Of these radiographs, 74% revealed a diagnosis of osteoarthritis. A total of 3 MRIs were ordered and 21 patients were referred to orthopedists.

Conclusions: The overwhelming majority of resident primary care physicians are not ordering the appropriate radiograph for older adults presenting with chronic knee pain. Contrary to previous studies, MRIs are not overused and are not related to an increased amount of referrals to orthopedists.

Significance of Findings: Chronic knee pain is most frequently caused by osteoarthritis in older adults and does not require extensive imaging to guide treatment. A quality improvement project can be easily implemented by linking the recommended imaging of a posterior-anterior weight-bearing view in 30 degree of flexion for the assessment of osteoarthritis in patients over 50 years of age.

Acknowledgments: None.

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Assessment of the Current Knowledge of the 3 Foot Bicycle Passing Law in Maine

Chris Lutrzykowski, MD

Affiliation: Evergreen Sports Medicine Fellowship, August, Maine.

Purpose: Define the current knowledge level of Maine motorists in regard to the 3 Foot Bicycle Passing Law.

Methods and Study Design: Survey based study design used to gather information from patients at the Sports Medicine Clinics in Augusta and Lewiston, ME who hold a current Maine Driver's License and are 18 years of age or older. Surveys were distributed at the time of the rooming process, and completed prior to being seen by the provider. Responses were collected to determine the current knowledge of the law in Maine. Surveys also collected information pertaining demographics, years of cycling experience, and injuries incurred while cycling. We plan to survey 200 patients in an attempt to gather enough information to achieve statistical significance. Data collection is ongoing at this time.

Results: Analysis has been done on 95 completed surveys. Fifty-one individuals (53.7%) were unaware of the 3 Foot Bicycle Passing Law. Of the individuals who were aware of the law, 96.2% abide by the law. Twenty-one of the individuals (22.1%) acknowledged cycling on the road, and only 52.3% of these cyclists were aware of the law. There are no statistically significant differences in knowledge based on age, gender, occupation or county of residence.

Conclusions: Preliminary analysis indicates that greater than 50% of individuals are unaware of the 3 Foot Bicycle Passing Law. Curiously, road bicyclists were also unaware of the law at a rate that mirrored the general population. No comparative data exists on the knowledge of bicycle laws at this time.

Significance of Findings: There is a lack of clarity with how to interpret bicycle safety laws and an apparent lack of awareness in regard to knowledge of these laws in Maine. This study will determine the current knowledge level and aid in how to educate communities throughout Maine.

Acknowledgments: None.

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Characteristics of Pediatric Concussion by Medical Insurance Type

Jonathan Santana, DO, Stephen R. Master, MD, PhD, Daniel Corwin, MD, Julia Lockyer, MS, Eileen Storey, AB, Olivia Podolak, MD, Matthew Grady, MD, and Christina Master, MD

Affiliation: Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Purpose: To compare the mechanisms of injury, presentation and recovery of concussions in children w/Medicaid insurance versus w/private insurance.

Methods and Study Design: We conducted a case control study of patients ages 5 to 18 years w/concussions referred to a pediatric hospital-affiliated sports medicine clinic from October 2010 to April 2015. A random sample of patient visits was reviewed. Insurance status determined between state Medicaid managed care plans and private insurance, comparing characteristics of these groups.

Results: A total of 48 Medicaid and 48 private insurance age and gender-matched patients chosen from sample set of 383 patients. Median age at injury was similar (15.1 years Medicaid vs 15.08 years private). No statistically significant difference in the proportion of concussions due to sports versus non-sports mechanisms of injury (67% Medicaid vs 62% private, P = 0.831) or missed school days (median 5.92 days Medicaid vs 4.81 days private, P = 0.450). There was a trend towards significance in time to presentation to clinic (mean 20.8 days Medicaid vs 14.9 days private P = 0.107). There were statistically significant differences in the presence of pre-injury co-morbidities in Medicaid patients (23 vs 11 study subjects, P = 0.018), time to return to sports (mean 36.1 days Medicaid vs 12.4 days private, P = 0.034) and number of follow up visits (mean 2.69 visits Medicaid vs 4.26 visits private, P = 0.013).

Conclusions: Medicaid is a proxy for socioeconomic status and may have an impact on concussion management and recovery. We found a trend towards delayed presentation to specialty care and fewer follow-up visits. There was a statistically significant difference in outcomes w/more days of sports missed when compared to private insurance patients.

Significance of Findings: Lower socioeconomic status may represent a barrier to timely and appropriate concussion care, which may negatively impact outcomes. Further research needed to characterize modifiable factors that might improve access to care, including early access to athletic trainers at schools and sports medicine physicians trained in concussion.

Acknowledgments: None.

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Physician Level of Confidence in Managing a Spine-Injured Football Player Wearing a Helmet and Shoulder Pads

Armand Scurfield, MD, Darrell Nesmith, MD, MPH, Beatrice Boateng, PhD, Jonathan Elrod, ATC, LAT, and Michael Israel, MD

Affiliation: Arkansas Children's Hospital and the University of Arkansas for Medical Sciences, Little Rock, Arkansas.

Purpose: To determine the level of confidence that physicians have regarding the evaluation and management of the spine-injured football player who is in shoulder pads and helmet.

Methods and Study Design: Online surveys were emailed to 2 groups of recipients: the Arkansas AAP chapter and graduating resident physicians from our institution. The surveys inquired about the recipients' level of confidence to recognize a cervical-spine injury on the field, manage the spine-injured athlete, and remove the helmet and shoulder pads.

Results: One hundred twenty-four subjects completed the survey (N = 92 from the AR AAP chapter and N = 32 from the graduating residents). Overall, respondents were confident in recognizing a cervical spine injury (56%), but they were not confident in managing the equipment-laden, cervical-spine injured football player while on the field (37% confident) or properly removing the helmet and shoulder pads (26% confident). Of note, 25% of resident respondents and 17% of practitioner respondents had received prior training on helmet and shoulder pad removal for a spine-injured athlete. Also of note, 29% of resident respondents and 38% of practitioner respondents who had not received any specific training in equipment removal reported feeling confident about properly removing the helmet and shoulder pads without potentially exacerbating the injury.

Conclusions: A majority of medical providers are confident in their ability to recognize a potential cervical spine injury, but there is an overall lack of confidence towards managing that injury or properly removing the helmet and shoulder pads. Despite consensus amongst position statements that these procedures should be practiced by sideline medical personnel, a substantial amount of respondents also felt confident in proper equipment removal without ever receiving specific training to do so.

Significance of Findings: Providing an avenue to train medical providers to properly manage a cervical spine injury would help increase the confidence of medical providers and the safety of any potentially injured athletes.

Acknowledgments: None.

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Does a Brief, Landmark Based, Joint Injection Teaching Course Improve Internal Medicine Resident Confidence in Performing Joint Injections?

Michael K. Seifert, MD, Michael Pitzer, MD, Xiyu Zheng, and Adam Sima, PhD

Affiliation: VCU Health System Internal Medicine Residency.

Purpose: Several previous studies have shown that resident physicians' lack confidence in performing common joint injections. Physicians report lack of training as the primary cause for low confidence. Dedicated workshops and curriculum have been shown in the past to improve the confidence of physicians with these procedures. However, previous studies used day long lectures and manufactured models in training. Our aim was to discover if a shorter, landmark-based, joint injection instruction could improve internal medicine resident confidence with joint injections.

Methods and Study Design: Fifteen internal medicine resident physicians were involved in this study. They took a survey both prior and following a 40 minute joint injection teaching course. The confidence level of each of the participants was assessed on a 5-point Likert-type scale ranging from “Very Confident” to “Not Confident” in performing injections on the knee, sub-acromial space, and trochanter bursa. A one-sided Wilcoxon signed rank test was performed to determine if change in confidence between baseline and post-test increased. The significance level for the one sided test was set to 0.05.

Results: There was a statically significant positive increase in joint injection confidence after the brief, landmark based joint injection teaching course.

Conclusions: The results of this small study support that a landmark based, joint injection teaching course improves internal medicine resident confidence in performing the injections.

Significance of Findings: The study suggests 2 main points: (1) That internal medicine residents who do not receive dedicated joint injection training are lacking in confidence in performing these procedures. (2) That even a brief lecture using a landmark based approach for joint injections can improve that confidence. This suggests that further involvement by sports medicine-trained physicians would be beneficial to internal medicine resident learning.

Acknowledgments: Thank you to Dr Michael Pitzer, Xiyu Zheng and Dr Adam Sima for their assistance with this study.

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A Retrospective Review of Baseline Balance Scores in College Athletes

Mallory Shasteen, MD, Keon Parsa, and B. Elizabeth Delasobera, MD

Affiliation: Georgetown University Hospital/MedStar Washington Hospital Center.

Purpose: Balance testing is a key component of concussion assessment. Comparison of post-concussion to baseline scores can be one factor used to guide safe return-to-play. This study examines differences in baseline balance scores in order to establish normative data in college athletes, and also determine the potential effect of gender, sport, and concussion history on baseline performance.

Methods and Study Design: De-identified information was obtained retrospectively from pre-participation evaluations of varsity athletes, ages 17 to 21, at The Catholic University of America in Washington, DC. Data from 2011 to 2015 yielded 961 records. Information obtained from each record included gender, sport, history of prior concussions, and baseline Balance Error Scoring System (BESS) scores. The baseline BESS scores were compared between genders, sport, and history of concussion using t tests and ANOVA.

Results: The baseline BESS score for all athletes averaged 16.13 (range, 2-38). Baseline BESS scores were significantly different in males (15.78) compared to females (16.84), with a difference of 1.056 (95% CI, 0.233-1.890, P = 0.013). Baseline scores averaged 17.40 in athletes with a history of concussion compared to 16.45 in athletes with no prior concussion (CI, 0.866-2.780, P = 0.301). When comparing scores by sport, there were no significant differences in baseline scores between females who played field hockey (16.76), softball (18.58), volleyball (16.87), basketball (17.62), lacrosse (15.89), or soccer (15.79). There were also no significant differences in baseline scores between males who played baseball (15.34), football (16.26), basketball (17.15), lacrosse (14.93), or soccer (15.17).

Conclusions: Values for balance scores vary, therefore averages and normative data is helpful when evaluating an athlete after injury. History of concussion and type of sport do not play a significant role in baseline balance assessment, however gender may alter the normative baseline data slightly.

Significance of Findings: Normative balance scores may be used in the absence of baseline scores.

Acknowledgments: Thanks to Sonja DeVaul, MD who completed the IRB proposal and athletic trainer Justin Wierenga for compiling the data.

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Functional, Electrical, and Morphological Characteristics of Athletic Populations at High Risk for Sudden Cardiac Death

Asad R. Siddiqi, DO, Joseph Ewing, MS, and Irfan M. Asif, MD

Affiliation: Greenville Health System/University of South Carolina School of Medicine Greenville.

Purpose: To determine the cardiovascular structural, functional, and electrical characteristics of young male basketball athletes.

Methods and Study Design: Retrospective, non-randomized controlled study. Between October 2014 and November 2015, 195 HS athletes underwent pre-participation examinations including standardized history and physical examination, ECG, and echo. One hundred thirty-one male high school basketball players (77% Caucasian, 15% African American, 5% Asian, 2% Hispanic, mean age 16.7, mean BMI 22.7) were compared to 64 male cross-country/track and field athletes (78% Caucasian, 6% Asian, 5% Hispanic, 3%% African American, mean age 16.0, mean BMI 21.5) for the presence of abnormalities in H&P, ECG or echo.

Results: There were more African Americans in the basketball group (14.5% for basketball vs 3.13% in track/CC). On AHA questioning, the basketball cohort was more likely to have a history of a heart murmur (P = 0.032), have had a previous medical diagnosis (P = 0.016), and be taking medication (P = 0.030). 7.7% of athletes had an abnormal ECG (7.6% in basketball and 7.8% in runners) with a total of 24 abnormalities in basketball and 13 abnormalities in runners. The most common ECG abnormalities were TWI and Q waves. On echo, the basketball cohort had an intraventricular septum thickness of 9.04 mm (SD 1.1) and LV posterior wall thickness of 9.34 mm (SD 1.7), compared to 8.6 mm (SD 1.3) and 8.8 mm (SD 1.1) respectively in the XC/track cohort (P = 0.038 and 0.005 respectively).

Conclusions: Differences exist in the functional and morphological characteristics of basketball and running athletes, but the rates of abnormal ECGs did not differ between these groups.

Significance of Findings: Normative data is extremely valuable for characterizing the patterns that place male basketball athletes at highest risk for sudden cardiac death during sport.

Acknowledgments: The authors thank the Max Schewitz Foundation for assistance in recruiting athletes for this study.

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Susan Komen Injury Research Trial (SKIRT)

Kyle Snell, DO, Robert Conway, MS2, Sara Dumich, MD, Randy Pearson, MD, Kenneth Thompson, MD, and Julie Phillips, MD

Affiliation: Michigan State University Sports Medicine Fellowship, East Lansing, Michigan.

Purpose: To prevent sports injuries through analyzing training methods in order to keep people active.

Methods and Study Design: We randomly surveyed participants of the Susan Komen 3-Day Walk. In this event participants walk 20 miles per day for 3 consecutive days, totaling approximately 60 miles. We hypothesized that participants who train in specific preparation for the event would be less likely to sustain a self-reported injury during the event. A strong correlation between training for the event and avoiding injury would support the benefits of pre-event training.

Results: Our results show that participants who trained for the event were not less likely to get an injury then those who did not train for the event. The data also suggests that those participants who report a higher baseline fitness level are less likely to report an injury, albeit this was not statistically significant (P = 0.136).

Conclusions: Our study disproved that pre-event training reduces self-reported injuries. To better gauge the baseline activity level of our participants, we added a question about self-reported “fitness level.” Our evidence was leaning towards the correlation: the higher the self-reported fitness level, the less likely the participant reported an injury during the event. Therefore, one's baseline fitness level may have a larger impact in preventing injury than training for a specific event. In future studies, we plan to survey a variety of events (5K races, marathons, etc) to expand our population size and intensity of events. We hope this future direction will lead to new ideas about what, if anything, can help prevent injuries at events.

Significance of Findings: Injuries during sporting events can take competitors out of their event, lead to expensive medical bills, or even cause chronic debilitating injuries. Preventing injuries is crucial to avoid the above sequela and keep people active.

Acknowledgments: None.

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Healthcare Utilization in Marathon Runners

Brian Snitily, MD and Mark Harrast, MD

Affiliation: University of Washington, Seattle, Washington.

Purpose: Assess self-perceived injury rates and healthcare utilization in half and full marathon runners.

Methods and Study Design: Survey-based cross sectional study of 2014 Seattle Full and Half Marathon participants. All race participants were invited to complete the survey, which was available for 2 weeks after the race. The survey assessed basic demographic information, prior race experience, training, injuries sustained during the race and healthcare utilization following the race.

Results: Demographics: 1433 out of 618 half (1012) and full (421) marathon runners completed the survey. Fifty-nine percent of participants had had a previous injury that affected their ability to run. Of these individuals, 26% had been injured within the last month before the race. Injury/Health care utilization: 42.1% of participants reported sustaining an injury during the race. Only 3.3% of participants stopped at a medical tent. 90.3% of participants didn't plan to seek care from a medical provider after the race. Of those who did seek care from a medical provider, 7.6% planned on seeing a physician, 1.6% planned on a holistic medical provider, and the remainder planned on seeing a nurse practioner or physician's assistant. 18.4% of all participants saw or planned to see an allied health professional. Massage therapists were most common (14.8%), followed by physical therapists (7%), chiropractors (6.3%) trainers (2.4%) and running coaches (1.8%).

Conclusions: Self-reported injuries are common in runners participating in the Seattle Marathon, however many of these individuals do not seek medical care with a physician or mid-level provider. Utilization of allied health professionals such as massage therapists, physical therapists and athletic trainers is more common but still infrequent.

Significance of Findings: This study suggests that many runners who feel they have injured themselves during the marathon do no seek evaluation or treatment. Further research is needed to understand the significance of this observation and better understand athlete-perceived barriers to seeking healthcare.

Acknowledgments: Seattle Marathon Association.

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Risk of Carbon Monoxide Exposure During Wake Surfing

Joshua D. Snodgrass, MD, John Kearney, MD, and Jeffrey Lai, MD

Affiliation: Long Beach Memorial Medical Center, Long Beach, California.

Purpose: The sport of wake surfing has grown in popularity. There is concern the sport may place participants at risk of carbon monoxide (CO) poisoning via the inhalation of motor boat exhaust. The investigators in this study intend to critically evaluate the risk of carbon monoxide, specifically in the sport of wake surfing.

Methods and Study Design: Wake surfing participants were assessed for CO ppm, at baseline, pre and post surf event, and repeat baseline at end of day. Readings were compared to non-participants observing from the boat. All participants were assessed using exhaled breath CO ppm. All activities were completed with a 2014 Super Air Nautique G23 with surf pipe system and compared with repeat testing on a Mastercraft X-80 with factory exhaust.

Results: Initial results obtained using 8 participants monitored over 3 weekends. Initial participants were male and range in age from 7 to 48 years old. Baseline measurements indicate 0 to 1 ppm (n = 8), with similar results on post-wake surf measurements. Comparison between active participants (n = 6) and observers (n = 2) showed no difference in ppm on post-wake surf readings. The time of exposure was 2.2, 2.8, 3.0 hours. The average time of wake surfing was 33.9 minutes per day.

Conclusions: No significant difference in measured CO between observers and active participants. There was a net decrease in ppm measured at the end of the day when compared to baseline, for all parties. Limited data suggests there is no appreciable risk of carbon monoxide toxicity while participating in wake surfing.

Significance of Findings: There are inconsistent applicable laws that govern water sports. This study will provide objective data for new legislation governing the sport of wake surfing.

Acknowledgments: Special thanks to Dr John Kearney for the use of his boat and wake surfing equipment. Special thanks to CareFusion for lending monitoring equipment.

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Psychological Attributes of Ultramarathoners

Jack Spittler, MD, Katherine Buck, PhD, Alex Reed, PhD, and Morteza Khodaee, MD

Affiliation: University of Colorado School of Medicine, Denver, Colorado.

Purpose: To evaluate cognitive, behavioral, emotional and relationship factors involved in ultramarathon running. Previous studies focus on marathon runners and little is known about psychological attributes of ultramarathoners.

Methods and Study Design: Bear Chase Trail Race is a single-day, multi-distance race consisting of a 10K, half-marathon, 50K, 50M and 100K run at a base altitude of about 1680 m w/total altitude in climbs ranging from 663 to 2591 m. Observational cross sectional online survey study of ultramarathon (50K, 50M and 100K) participants conducted before the race in 08/2015, of which 123, 47 and 30 runners started these races, respectively. Race results matched to responses. Descriptive analyses performed to help evaluate psychological profiles of athletes. Exercise Addiction Inventory (EAI) is a validated 6-question screening tool used to evaluate exercise addiction. The PHQ-2 screening tool for depression was also administered.

Results: Out of 200 runners who started race, 98 completed survey (49%). Majority of runners of the 50K, 50M and 100K races completed the race (91.9%, 87.2%, 63.3%, respectively). Over half of the runners = male (61.2%) and average age = 39yo (range, 21yo-74yo). A significant number (86%) of respondents hold a bachelor's degree or higher and over half have children. A large number of respondents (20%) screened positive for exercise addiction. Most respondents (81%) screened negative for depression (score < 2). Several other cognitive, behavioral, emotional and relationship factors were also analyzed.

Conclusions: A large number of ultramarathon respondents (20%) screened positive for exercise addiction via the EAI. No significant difference between finishers and non-finishers and between different race distances w/regards to exercise addiction. About 19% of respondents screened positive for depression using the PHQ-2 screening tool.

Significance of Findings: This study allows further understanding of unique psychological features of ultramarathoners. While there are physical benefits of endurance exercise, there may also be a significant impact that other factors, especially exercise addiction, have on the psychological health of this population.

Acknowledgments: Bear Chase Race director (David Manthey) for assistance in distribution of the survey.

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Assessment of Musculoskeletal Knowledge Among Emergency Medicine Physicians

Jaimon K. Stucki, MD, James Fox, MD, Marvin Griffin, MD, Andrew Keyser, MD, Allison Lane, MD, Holly McNulty, MD, and Anna Waterbrook, MD

Affiliation: University of Arizona School of Medicine, Tucson, Arizona.

Purpose: To assess musculoskeletal knowledge among emergency medicine (EM) junior and senior residents and attending physicians.

Methods and Study Design: A previously validated, open-ended, short answer exam with 25 questions based upon fundamental musculoskeletal knowledge was administered to emergency medicine junior and senior residents as well as attending emergency physicians. This examination was scored and converted to a percentage of the raw score. These scores were then compared to the previously established passing score for this exam. We tested for statistical significance using Student t test for independent samples.

Results: Sixteen attending physicians (29% response rate) and 13 resident physicians (25% response rate) completed a previously validated short answer exam based on fundamental musculoskeletal knowledge. Mean musculoskeletal knowledge score for attending physicians was 18.2 (SD 3.1, range, 11.0-24.75) and for resident physicians was 16.3 (SD 1.7, range, 13.5-19.0). There was a statistically significantly difference between the mean musculoskeletal scores between attending and resident physicians (P = 0.05). When converted to the 0 to 100 scale, musculoskeletal knowledge among attending physicians had a mean of 72.9 (SD 12.2, range, 44.0-99.0) and among resident physicians a mean of 65.3 (SD 6.8, range, 54.0-76.0). Both were below the previously established mean passing score of (73.1 ± 6.8) to demonstrate basic competency in musculoskeletal medicine. This difference was statistically significant for resident physicians (P = 0.001), but not for attending physicians (P = 0.95).

Conclusions: Emergency medicine attending and resident physicians failed to demonstrate competency in musculoskeletal knowledge on a previously validated examination of fundamental concepts.

Significance of Findings: While competency in musculoskeletal medicine is a consistently reported shortcoming in undergraduate and graduate medical education in many specialties, there have been no studies evaluating musculoskeletal knowledge of emergency physicians. This study highlights the need for improvement in musculoskeletal education among emergency medicine physicians.

Acknowledgments: None.

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The Cost and Effects of Pre-Participation ECG in NCAA Division I Athletes: A Pilot Study

Trent Tamate, BA and Justin Young, MD

Affiliation: John A. Burns School of Medicine, Honolulu, Hawaii.

Purpose: To evaluate the usefulness of ECG as a pre-participation screening tool in NCAA division I athletes and generalize recommendations based on athletic demographics.

Methods and Study Design: From 1/2014 to 9/2014, 55 competitive athletes from 3 different sports (men's basketball, women's softball, women's soccer) at the University of Hawaii at Manoa were evaluated with a health screening questionnaire and with ECG interpreted by a cardiologist. Athletes with concerning findings on either screening questionnaire or ECG underwent secondary testing. We conducted a retrospective chart review of all 55 athletes.

Results: Abnormal findings were present in 3/55 (5.5%) health screening questionnaires versus 7/55 (12.7%) on ECGs. Secondary testing revealed no significant cardiac abnormalities necessitating removal of athletes from competition. Health screening questionnaires were abnormal in 2/20 soccer (10%) and 1/14 basketball athletes (7.1%). ECG was abnormal in 4/20 soccer (20%), 1/21 softball (4.8%), and 2/14 basketball athletes (14.3%). Also noteworthy is the fact that of the 12 men's basketball athletes without concerning ECGs, 11 were found to have abnormal findings deemed normal for an athlete by Seattle Criteria.

Conclusions: Screening with ECG identified more athletes for secondary testing than questionnaire alone. However, there was an absence of significant underlying cardiac abnormalities on secondary testing. Our limited data seems to suggest that ECG is not an effective screening tool for our practice at this time. The pilot study was discontinued due to a lack of perceived benefit; however, data from a larger population of athletes would need to be collected in order to make definitive recommendations regarding the use of ECG as a screening tool in NCAA division I athletics.

Significance of Findings: The role of ECGs as a pre-participation screening tool remains controversial in the medical literature. This pilot study attempts to lay the groundwork for determining the effectiveness of ECG screening in the NCAA division I athlete population.

Acknowledgments: Hawaii Pacific Health; University of Hawaii Athletics; John A. Burns School of Medicine.

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Cross-Sectional Study of Point-of-Care Ultrasound Use in the Evaluation and Efficacy of Shoulder Injections

Timothy Tiu, MD, Brian Lee, DO, Andrea Cordova, MD, Jeremy Roberts, BS, Donald Lee BS, Matthew N. Bartels, MD, and Se Won Lee, MD

Affiliation: Montefiore Medical Center, Bronx, New York.

Purpose: There is strong evidence showing high accuracy for ultrasound-guided shoulder injections (USGSI). Evidence for increased efficacy is positive but less conclusive. The purpose of this study is to describe point-of-care (POC) ultrasound (US) in patients with USGSI and to determine clinical variables and US findings related to better outcomes.

Methods and Study Design: Retrospective review of individuals who received USGSI over the past 2 years. Patients were categorized as “responders” or “nonresponders” based on presence of clinically significant improvement in pain, defined by either a 50% reduction in the Numeric Rating Scale or patient reported significant improvement. Clinical variables assessed were: age, gender, body mass index (BMI), history of diabetes (DM), intensity and duration of pain, hand dominance, and diagnostic US findings. Post-injection utility of other clinical modalities [physical therapy (PT), surgery and additional imaging] were also investigated. Data were analyzed using Wilcoxon signed rank test and χ2 analysis.

Results: There were 131 responders and 24 nonresponders. There were no significant differences in age, gender, BMI, handedness, DM, duration of symptoms, or pre-injection pain. Responders tended to have more PT (44.1% vs 29.2%, P = 0.17) and less surgery (2.4% vs 8.7%, P = 0.119), but these findings were not significant. There were no significant differences in rotator cuff (P = 0.26), acromioclavicular joint (P = 0.28), or biceps tendon (P = 0.68) US findings. Nonresponders tended to have more shoulder x-rays (90.9% vs 62.0% in responders, P = 0.008), but there were no differences in shoulder magnetic resonance imaging (MRI) or cervical imaging.

Conclusions: There were no significant clinical variables and POC US findings associated with better outcomes after USGSI. USGSI was related to the decreased use of shoulder x-rays. PT after USGSI may improve efficacy.

Significance of Findings: Additional research in larger scale prospective design needs to be done to understand the clinical utility of USGSI, including the effect on patient outcomes and impact on additional imaging.

Acknowledgments: None.

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Epidemiology of Concussions in Semi-Professional Football Players

Timothy Tiu, MD, Hans Knopp, DO, Eugene Palatulan, MA, and Julio Martinez-Silvestrini, MD

Affiliation: Tufts Medical Center, Boston, Massachusetts.

Purpose: To evaluate the epidemiology of concussions in semi-professional football players. This population of athletes are less studied than their high school, collegiate and professional counterparts and play under different rules and regulations.

Methods and Study Design: Semi-professional football players in New England were referred to an online survey. A definition of concussion as well as associated symptoms were provided to participants prior to the survey. Instances of symptoms consistent with concussion, but were not formerly diagnosed, were labeled as “undiagnosed concussion” (UC).

Results: Twenty-nine players responded to the survey. 37.9% had at least 1 concussion. There were a total of 21 concussions, with 19 (90.4%) undiagnosed. 66.7% of concussions occurred during a game. 34.5% of players had UC. Nine (90%) of the undiagnosed players did not report any symptoms. Common reasons for not reporting were: not wanting to be pulled from the game or practice (77.8%), not wanting to let their teammates down (44.4%), and not thinking the symptoms were serious enough (44.4%). Prior to the season, 37.9% of players received concussion education from a medical professional, 34.8% pursued self-education, and 34.8% denied receiving any form of education.

Conclusions: These findings suggest a high prevalence of UC in semi-professional football players. The majority of players do not receive concussion education from a medical professional. Further studies need to be done in order to increase power and identify risk factors that may be unique to this population.

Significance of Findings: Semi-professional football players may have inadequate concussion education and medical coverage.

Acknowledgments: Supported by Tufts Clinical and Translational Science Institute grant UL1TR001064 from the National Institutes of Health Clinical and Translational Science Awards. Janis L. Breeze, MPH, Tufts University School of Medicine, Boston, MA assisted with study design. Andrew Johnston, MSTP and Kevin Shieh, MSTP of Albert Einstein College of Medicine, Bronx, NY assisted with statistical analysis.

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Cardiovascular Screening Practices in United States National Governing Bodies and Paralympic Committees

Brett G. Toresdahl, MD, Cindy J. Chang, MD, Jamie Confino, BS, and Irfan M. Asif, MD

Affiliation: Hospital for Special Surgery, New York, New York.

Purpose: To examine cardiovascular screening strategies among United States National Governing Bodies (NGBs) and National Paralympic Committees (NPCs).

Methods and Study Design: Medical team members for U.S. NGBs and NPCs were identified through online queries, affiliation with the American Medical Society for Sports Medicine, and professional contacts. The medical team members were then asked to complete an online assessment regarding the cardiovascular screening practices of their respective NGBs or NPCs.

Results: Medical team members for 49/72 (68%) of the U.S. NGBs and NPCs were contacted and 42/49 teams (86%) completed the assessment (34 from NGBs and 7 from NPCs). Twenty-one of 42 teams (50%) reported that there was a periodic health evaluation requirement that directed the cardiovascular screening components, frequency, and/or provider. The following screening components were reported as being performed at least once in all or most athletes: personal history (91% of teams), family history (86%), physical exam (81%), electrocardiogram (33%), echocardiogram (5%), and stress test (2%). For teams who did not screen athletes with ECG, the most frequently cited reasons were lack of ECG equipment (40%), lack of evidence (33%), and lack of follow-up test consensus (20%).

Conclusions: The U.S. NGBs and NPCs are a heterogeneous collection of athletic teams that have varying approaches to cardiovascular screening. Lack of infrastructure appears to be the biggest barrier to implementing advanced screening protocols.

Significance of Findings: Cardiovascular screening in athletes has recently been a focus of investigation and debate among the sports medicine community. The results of this study can be used to support and guide the U.S. NGB's and NPC's efforts to provide consistent cardiovascular screening of athletes with a goal of promoting athlete safety.

Acknowledgments: None.

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Coaches' Perception of the Components of an ACL IPP

Thomas H. Trojian, MD, Jessica C. Martinez, PhD, Kelly D. Pagnotta, PhD, and Lindsay J. DiStefano, PhD

Affiliation: Drexel University College of Medicine, Philadelphia, Pennsylvania.

Purpose: Anterior cruciate ligament injury prevention programs (ACLIPP) reduce injuries, but coach compliance is frequently low. Less than half of coaches implement programs as designed. Multiple reasons have been identified (ie, duration of ACLIPP, coach education, no advantage over current warm-up), but no studies have investigated coaches' perceptions about necessary program components. The purpose of this study was to evaluate youth coaches' perceptions about the necessary components of an ACLIPP to further refine implementation strategies.

Methods and Study Design: An internet-based email survey was sent to youth soccer and basketball coaches with open-ended questions on the components of an ACLIPP. Nine categories (Strength Training, Plyometrics, Agility, Stretching, Feedback, Core exercise, Balance, Other), determined a-priori, were used to classify answers. An additional category (cardio) was added after evaluation of answers. We compared the coaches' responses to recent meta-analysis on the effective components of ACLIPP's. Factorial ANOVA and χ2 test was used where appropriate.

Results: Eighty-two coaches responded. The top 5 components identified by coaches were: Strength Training, Plyometrics, Agility, Stretching, and Feedback (65.9%, 57.3%, 45.1%, 37.8%, and 31.7%; respectively). These were significantly higher than the other 5 categories (P < 0.05). There was no significant difference between soccer and basketball coaches (P > 0.05). The meta-analysis of effective components identified Strength Training, Plyometrics, Core (Proximal Muscle), Feedback and Balance exercises as key components.

Conclusions: Coaches' beliefs of what should be in an ACLIPP differ from the current effective components analysis. Coaches believe an ACLIPP should include agility and stretching exercises, which do not match current meta-analysis of effective components. This fact points to the need for education of coaches prior to ACLIPP implementation to ensure “buy-in” and increased compliance.

Significance of Findings: Since the majority of coaches alter ACLIPP's, this information may help develop a better knowledge transfer scheme to potentially increase compliance of ACL injury prevention programs and incorporation of the effective components.

Acknowledgments: None.

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A Retrospective Review of Autologous Platelet Rich Plasma for Symptomatic Acetabular Labral Tears Refractory to Conservative Treatment

Ali Valimahomed, MD and Jaspal Ricky Singh, MD

Affiliation: New York-Presbyterian Hospital; Columbia/Cornell, New York, New York.

Purpose: The purpose of this study was to assess the clinical outcomes of patients undergoing image guided PRP injections for the treatment of symptomatic acetabular labral tears.

Methods and Study Design: Retrospective case series. Nine patients ages 49 to 85 years-old with chronic hip pain, one or more positive physical exam maneuver(s), diagnosis of acetabular labral tear on MRI, and failure to improve satisfactorily with conservative treatment (physical therapy, oral medications, and or epidural injections) underwent image guided (ultrasound or fluoroscopic guided) platelet-rich plasma (PRP) injection to the acetabular labrum. Outcomes were measured at baseline, 2 weeks, and 12 weeks using the Visual Analogue Scale (VAS) for pain intensity and the Hip Disability and Osteoarthritis Outcome Score (HOOS).

Results: At 2 weeks, there was a statistically significant improvement (P < 0.05) of function in 3 HOOS subscales: Activities of Daily Living (ADL), Sports/Recreations, and Quality of Life (QOL). There was a statistically significant improvement in HOOS Pain (73.3 ± 13.6, P < 0.01), HOOS Symptoms (73.9 ± 12.8, P < 0.01), HOOS ADLs (75.8 ± 6.3, P < 0.01), HOOS Sport/Recreation (65.3 ± 11.9, P < 0.01), and HOOS QOL (80.3 ± 11.1, P < 0.01) at 12 weeks following PRP injection for acetabular labral tear from baseline. A statistical significant improvement in VAS was also observed at 12 weeks (baseline VAS 7 ± 0.7 → 12 weeks VAS 2.4 ± 1.0, P < 0.05) post-PRP injection for acetabular labral tears.

Conclusions: In patients with symptomatic acetabular labral tears, PRP injection may reduce pain and improve function at 12 weeks.

Significance of Findings: The results from this study suggest that in patients with symptomatic acetabular labral tears refractory to conservative treatment, PRP injection is a safe, minimally invasive technique, which appears to reduce pain and improve functional outcomes at 12 weeks.

Acknowledgments: None.

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Aerobic Fitness Is Predicted by Ventricular Size But Not Function in Female Youth Athletes

Andrew Watson, MD, MS, Kristin Haraldsdottir, MS, Stacey Brickson, PhD, Carol Coutinho, BS, and Marlowe Eldridge, MD

Affiliation: University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Purpose: To identify the relationship between aerobic fitness and cardiac morphology and function in children and whether this relationship varies with physical maturity.

Methods and Study Design: Forty-four adolescent female soccer players (13-18 years) underwent resting 2-D echocardiography for measurements of right ventricular end-diastolic diameter (RVEDD), RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), left-ventricular end-diastolic volume (LVEDV) and LV ejection fraction (LVEF) and maximal cycle ergometer testing for determination of maximal aerobic capacity (V[Combining Dot Above]O2max). Variables were initially compared across Tanner stage (3-5). Participants were stratified by Tanner stage and grouped by fitness level (high fit, low fit) based on V[Combining Dot Above]O2max median split and variables were compared between groups. Finally, multivariable regression analysis was used to determine the independent predictors of V[Combining Dot Above]O2max, using Tanner, RVEDD, LVEDV, RVFAC and LVEF as covariates.

Results: No significant differences were identified between Tanner 3, 4 and 5 with respect to V[Combining Dot Above]O2max (2.97 vs 3.21 vs 3.54 L/min, respectively, P = 0.18), RVEDD (2.4 vs 2.5 vs 2.9 cm, P = 0.415), RVFAC (47.0% vs 43.5% vs 42.5%, P = 0.625), TAPSE (2.45 vs 2.40 vs 2.35 cm, P = 0.67), or LVEF (64.0% vs 61.0% vs 60.5%, P = 0.347), while increases across Tanner stage were noted in LVEDV (76.0 vs 76.5 vs 85.5 mL, P = 0.033). Compared to low fit, high fit participants had significantly greater RVEDD (P = 3.0 vs 2.4 cm, P = 0.002), but not LVEDV (77.5 vs 76.0 mL, P = 0.319), LVEF (58.0% vs 62.5%, P = 0.192), RVFAC (P = 42.5% vs 45.0%, P = 0.70), or TAPSE (P = 2.4 vs 2.4 cm, P = 0.97). V[Combining Dot Above]O2max was independently associated with LVEDV (P = 0.021) and RVEDD (P = 0.046), but not Tanner (P = 0.79), LVEF (P = 0.37) or RVFAC (P = 0.48).

Conclusions: In adolescent female athletes, higher fitness is associated with increased LV and RV size, but not ventricular function.

Significance of Findings: The relationship between aerobic fitness and ventricular morphology in this population appears to be independent of physical maturity level.

Acknowledgments: None.

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Early Analysis of Concussion Prevention in NCAA Football: Changes in Lower Extremity Injury Rates Across the 2009/10 to 2013/14 Seasons

Robert W. Westermann, MD, Peter W. Wehr, MD, Zack Kerr, PhD, and Annunziato Amendola, MD

Affiliation: Family Medicine Residency Spokane Spokane, Washington.

Purpose: Lower extremity and head injuries are common in American Football players. Beginning in 2008 and later expanded in 2013, the NCAA introduced rule changes with the intent to halt or reverse the increasing rates of concussions in its players. We hypothesize that there may be a compensatory increase in lower extremity injury rates as players act to avoid head-to-head contact and comply with instated rules.

Methods and Study Design: The NCAA Injury Surveillance System (NCAA ISS) database was queried for injuries suffered between 2009 and 2014. Injuries were included that occurred in competition, resulted in time loss, and sustained in the lower extremity. All concussions resulting in lost time were also identified for comparison. Data regarding athletic exposures was collected to calculate incidence of injury per athletic exposure (AE).

Results: Between 2009 and 2014, 48 NCAA Football programs provided data on 123 team-seasons to the NCAA ISS for analysis. The incidence of lower extremity injuries increased from 9.45 injuries per 1000 AE in the 2009 to 2010 season to 12.63 injuries per 1000 AE in the 2013 to 2014 season. The rate of concussions suffered by American football players, during the same time period did not significantly change (1.64 concussions vs 2.87 concussions per 1000 AE's).

Conclusions: Since the initiation of NCAA rule changes in 2008, concussion rates have remained relatively stable while lower extremity injuries have increased. In order to comply with rule changes, players may be targeting the lower extremities to avoid head-to-head contact. Further data analysis is necessary to explore this phenomenon.

Significance of Findings: Rule changes to keep American football players safe have been repeated throughout the history of the sport. Unintended consequences of new rules to prevent concussions are concerning as lower extremity injuries and post-traumatic osteoarthritis are common causes of disability in retired American football players.

Acknowledgments: Datalys Center, NCAA Injury Surveillance Program.

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Five Year Follow-Up on PRP for Rotator Cuff Injury

Scott A. Weiss, MD and Patrick Cleary, MD

Affiliation: Brooklyn Premier Orthopedics, Brooklyn, New York.

Purpose: To investigate the long-term effects of PRP injections on pain and shoulder function, specifically overhead mobility, in patients with rotator cuff tendinopathy, with or without partial tears.

Methods and Study Design: Study Design: Case series; Level of evidence, IV Methods: 17 patients, ranging from age 31 to 75 and under the care of one Sports Medicine physician, were followed over a period of approximately 5 years, after receiving at least one ultrasound-guided PRP injection to treat their shoulder pain; all patients then had no further intervention. Patients were followed at 3 months and 1, 3 and 5 years after the PRP injection(s) and assessed using both a Visual Analog Scale (VAS) and a 4-point quartile scale to describe their overhead mobility and function.

Results: Average VAS scores decreased over time, by an average of 2.76, 4.59, 5.38, and 5.73 points over 3 months and 1, 3, and 5 years respectively (P < 0.0001) while overhead function increased over those same intervals. At 5 years, approximately half of the patients reported a VAS score of 0. Patients gave an average score of 5.47 on a 1 to 10 scale regarding the pain of the injection itself; a large majority of patients would recommend PRP injection to a friend.

Conclusions: At 5-year follow-up, ultrasound-guided PRP injection in patients with rotator cuff tendinopathy and/or partial tears appears to significantly lower subjective pain score while increasing subjective overhead function and mobility.

Significance of Findings: Rotator cuff injury is a common cause of shoulder pain. While the treatment for full-thickness tears is most commonly operative, conservative management strategies are routinely applied in cases of tendinopathy or partial-thickness tears. One such conservative measure, platelet-rich plasma (PRP) injection, has been suggested to be beneficial in these cases. In our case series, it has been shown that PRP is an effective treatement for long-term relief for supraspinatus tendinopathy with/without partial supraspinatus tears.

Acknowledgments: References Andia I, Latorre PM, Gomez MC, Burgos-Alonso N, Abate M, Maffulli N. Platelet-rich plasma in the conservative treatment of painful tendinopathy: a systematic review and meta-analysis of controlled studies. British Medical Bulletin (2014) 110(1):99-115. Balasubramaniam U, Dissanayake R, Annabell L. Efficacy of platelet-rich plasma injections in pain associated with chronic tendinopathy: A systematic review. Phys Sportsmed 2015 Jul;43(3):253-61 Kesikburun S, Tan AK, Yilmaz B, Yaşar E, Yazicioglu K. Platelet-Rich Plasma Injections in the Treatment of Chronic Rotator Cuff Tendinopathy: A Randomized Controlled Trial with 1-Year Follow Up. Am J Sports Med. 2013 Nov;41(11):2609-16. Rodeo SA, Delos D, Williams RJ, Adler RS, Pearle A, Warren RF. The effect of platelet-rich fibrin matrix on rotator cuff tendon healing: a prospective, randomized clinical study. Am J Sports Med. 2012 Jun;40(6):1234-41.

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The Utilization of Anterior Cruciate Ligament Knee Injury Prevention Exercise Programs by NCAA Collegiate Women's Basketball, Soccer and Volleyball Teams

Linnea K. Will, MD and Andrew W. Nichols, MD

Affiliation: Sports Medicine Fellowship Program, Department of Family Medicine and Community Health, John A. Burns School of Medicine, University of Hawaii at Mānoa, Honolulu, Hawaii.

Purpose: To determine knowledge levels among NCAA divisions I, II, and III collegiate women's basketball, soccer and volleyball coaches regarding anterior cruciate ligament (ACL) knee injuries, and the usage of ACL injury prevention exercise programs (ACL-IPEPs) by their teams.

Methods and Study Design: A 21-item online survey was sent via email to the head coach (or, if not available, the assistant coach) of 3201 teams. Completion of the survey signified consent to participate in the study. Data collected included sport, division level, coaches' experience, as well as coaches' understanding of ACL injury risk, familiarity with specific ACL-IPEPs, and the usage of these programs.

Results: Surveys were completed by 424 programs (response rate = 13.2%), including 115 basketball, 142 soccer, and 167 volleyball teams. Of respondents, 89.4% have already implemented an ACL-IPEP, with 90.1% utilizing the exercises during both the regular and off-season. Nearly all teams (98.4%) incorporate an ACL-IPEP into practices, and 48.4% also perform them prior to games. A majority of teams (69.2%) devote 5 to 15 minutes to ACL-IPEP exercises per training day. Most teams modify ACL-IPEPs due to time limitations and/or to target specific exercises for their athletes. Soccer coaches were significantly more likely to be aware that ACL-IPEPs have been shown to reduce ACL injury risk compared to basketball (Χ2 = 4.66, P < 0.05) or volleyball (Χ2 = 18.26, P < 0.05) coaches, while basketball coaches were similarly more aware of the preventive benefits of ACL-IPEPs than volleyball (Χ2 = 4.78, P < 0.05) coaches. No significant differences were noted in ACL-IPEP usage rates between sports, divisions of play, and years of coaching experience.

Conclusions: An overwhelming majority of NCAA collegiate women's basketball, soccer', and volleyball teams currently include an ACL-IPEP as part of their routine training program.

Significance of Findings: This is the first widespread study to confirm the extensive usage of ACL-IPEPs among NCAA collegiate women's basketball, soccer and volleyball teams.

Acknowledgments: None.

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Evaluation of Educational Intervention on Concussion Knowledge and Behaviors in High School Athletes

Julia Bedard, MS III

Affiliation: University of Arizona School of Medicine - Phoenix, Phoenix, Arizona.

Purpose: Evaluate the effectiveness of Barrow Brainbook (BBB) Concussion Education program as a tool to increase concussion knowledge amongst Arizona high school athletes to modify attitudes, beliefs, and behaviors regarding concussion.

Methods and Study Design: A cross sectional study of Arizona high school athletes utilizing a 31 question multiple-choice de-identified survey. Attitude, knowledge, and behavior questions, as well as sport and level of participation were analyzed using the Wilcoxon Rank Sum test. Means between groups were analyzed using a 2-way ANOVA. Linear regression was used to determine if there was a relationship between number of years since completing BBB and concussion knowledge.

Results: Surveys were distributed to 383 student athletes with 363 of those being completed. Two hundred twenty-four students participated in BBB (62%). Knowledge and behaviors regarding concussion were not statistically significant when comparing students who had and had not participated in BBB. Those who participated in BBB scored more poorly on questions regarding attitudes about concussion than those who had not (P = 0.026). Two-way ANOVA testing showed that students who had sustained a concussion scored worse (P < 0.01) and completing BBB did not significantly affect attitude (P = 0.384). Sixty-seven students (18%) reported 101 total concussions. Football and varsity level participation was significant for a higher mean number of concussions (P < 0.05, P < 0.05). There was no relationship between time since taking BBB and concussion knowledge (R2 was 0.007).

Conclusions: In this study, there was no evidence to show that participating in BBB improved concussion knowledge, attitudes, or behaviors. Number of years since taking BBB was not a good predictor of concussion knowledge. Students who played football and participated at a varsity level were significantly more likely to sustain a concussion. Sustaining a concussion was associated with riskier attitudes.

Significance of Findings: This is the first evaluation of an educational tool specifically designed for adolescents that unfortunately was not proven to be effective in increasing knowledge and modifying attitudes, beliefs and behaviors.

Acknowledgments: None.

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Decreasing Morbidity and Mortality in Adolescent Sports through Increased Early Recognition Via Educational Symposia

Jason L. Zaremski, MD, JoAnna McCelland, MS, LAT, ATC, M. Seth Smith, MD, Bryan R. Prine, MD, and MaryBeth Horodyski, EdD, LAT, ATC

Affiliation: Department of Orthopaedics & Rehabilitation, University of Florida, Gainesville, Florida.

Purpose: This study's purpose was to assess baseline knowledge of coaches, administrators, and undergraduate athletic training students who attended a free sports medicine symposium. Our specific aims were: (1) to assess baseline knowledge in common areas of sports medicine that can cause life-threatening injuries/illnesses, and (2) to determine if a lecture based format can show a short term (or temporary) increase in basic knowledge in these topics.

Methods and Study Design: Our Institutional Review Board (IRB) approved this retrospective descriptive survey study. A 13 question pre-test was provided prior to the start of a free educational symposium. Coaches, administrators, and undergraduate first year athletic training students attended 4 lectures on heat illness, sudden cardiac death and sickle cell disease in athletes, sports concussions, and rehabilitation after a concussion. The attendees re-took the test at the end of the symposium. Statistical analysis of the 13 question pre- and post-test was then completed. One question was subsequently removed due to confusing wording. No identifiers were put on the pre and post tests.

Results: Of the 52 attendees, 49 answered both pre and post tests. Data were analyzed using an ANOVA with repeated measures. The pretest mean was 10.55/12 compared to the post-test mean of 11.53/12 (P = 0.001). When subdivided based on topic, the Heat questions had a pre-test mean of 4.51/5 and post-test mean of 5.00/5 (P = 0.001); the Cardiac and Sickle Cell questions had a pre-test mean of 3.73/4 and post-test mean of 3.86/4 (P = 0.278); the Head questions had a pre-test mean of 2.31/3 and post-test mean of 2.67/3 (P = 0.001).

Conclusions: Educational symposia emphasizing life-threatening injuries/illnesses to the sports administrators, coaches and first-year athletic training students may decrease these preventable injuries/illnesses in adolescent athletes.

Significance of Findings: A significant proportion of athletic associated morbidity and mortality may be preventable with early recognition through education to non-medical personnel.

Acknowledgments: None.

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Pitching Injury Prevalence in Collegiate Baseball Pitchers Based on Geographic Location of High School Baseball Participation: A Multi-Centered Study

Jason L. Zaremski, MD, Laura Ann Zdziarski, LAT, Brian J. Krabak MD, MBA, Mark Dundas, MD, Kenneth Mautner, MD, John Dunham, MS, ATC, Paul Wolkoff, MEd, ATC, Mederic M. Hall, MD, Andrew D. Papendieck, MD, and MaryBeth Horodyski, EdD, LAT

Affiliation: University of Florida, Department of Orthopaedics & Rehabilitation, Gainesville, Florida.

Purpose: The primary purpose of this investigation was to determine whether geographic location of baseball pitching in both high school and college influences injury rates among collegiate pitchers.

Methods and Study Design: A retrospective analysis of 264 male collegiate baseball pitchers (591 pitcher-years) from 5 institutions was completed for the 2002-2003 through 2012-2013 seasons. A pitcher's residence prior to college was classified into either Northern (NorthHS) or Southern (SouthHS) high school groups. Location for collegiate play was defined by the geographic location of the university (NorthU or SouthU). Injury data was collected for the throwing arm. Only injuries as a result of throwing were retained for analysis.

Results: A total of 146 injuries (0.25 injuries/pitcher-year) occurred during the 10 year study period. NorthU pitchers sustained 0.23 injuries/pitcher-year and SouthU pitchers 0.26 injuries/pitcher-year. Of the injuries that occurred 12.2% occurred in the shoulder, 10.0% in the elbow, 0.5% in the wrist/hand, and 1.2% other. There were no significant differences in injury prevalence between NorthU and SouthU (P = 0.275). Kaplan Meier Survival analysis resulted in no significant difference for time to first collegiate injury by geographical location (P = 0.385). Time to first injury (years ± SE) was: SouthHS-NorthU = 2.2 ± 0.259, SouthHS-SouthU = 3.4 ± 0.183, NorthHS-NorthU = 3.2 ± 0.172, NorthHS-SouthU = 3.0 ± 0.204. SouthHS pitchers pitching at a NorthU had the shortest time to first injury compared to pitchers from SouthHS pitching at SouthU (P = 0.087).

Conclusions: SouthHS to NorthU pitchers were more likely to sustain an injury earlier in their collegiate career compared to all other geographical combinations of high school to collegiate play. Future research should encompass prospectively collected data that includes information on pitching activity and training protocols. Geographical location (climate) may have an impact on training protocols and warrants further research.

Significance of Findings: Pitchers in northern climates may be exposed to less year round pitching practices, but further study is necessary to evaluate exposures.

Acknowledgments: None.

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Effect of ACL Graft Type on Side-Step Cutting in Young Athletes

Tracy L. Zaslow, MD, Nicole M. Mueske, MS, Ricardo A. Padilla, MS, ATC, J. Lee Pace, MD, Mia J. Katzel, DPT, Bitte S. Healy, MSPT, Bianca R. Edison, MD, and Tishya A. L. Wren, PhD

Affiliation: Children's Hospital Los Angeles, Los Angeles, California.

Purpose: Due to a slightly higher re-tear rate for ACL reconstruction (ACLR) with hamstring (HT) versus patellar tendon (PT), movement strategy differences were assessed during cutting in young athletes with recent ACLR to determine if graft type affected post-operative motion.

Methods and Study Design: Dominant limbs from 21 athletes without lower extremity injury/previous surgery (14.9 ± 2.0 years) and 26 limbs with unilateral ACLR (5.1-8.0 months post-operative) were included, 18 with HT grafts (16.6 ± 3.7 years) and 8 with PT (16.7 ± 1.2 years). Lower extremity 3-dimensional data was recorded during the deceleration phase of a 45 degree cut. Group differences were assessed using analysis of variance with Bonferroni post-hoc tests.

Results: The HT group had a slower approach velocity than controls (P = 0.006) with intermediate velocity in the PT group. Both ACLR groups had lower peak ground reaction force (GRF) compared to controls (P ≤ 0.02), along with lower peak knee flexion moments (P = 0.002). The PT group had less power absorption at the knee than controls (P = 0.07), while the HT group had more at the hip (P = 0.04). The HT group also had higher peak hip flexion (P ≤ 0.06) and hip sagittal plane excursion (P ≤ 0.05) than the PT and control groups. The HT group had lower peak knee valgus moments than controls (P = 0.01) and a greater range of frontal plane pelvic (P = 0.03) and hip (P = 0.05) motion.

Conclusions: While both ACLR groups showed reduced GRFs and knee flexion moments compared to controls, the HT group demonstrated greater adaptations proximally with increased hip flexion and frontal plane pelvic and hip excursion. The reduced hip motion in the PT group may be due to anterior knee pain associated with PT grafts.

Significance of Findings: Since the HT group exhibited movement adaptations, but no observable pathologic movement patterns, other factors likely account for the observed higher re-tear rate in HT versus PT ACLR.

Acknowledgments: None.

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