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2020 CASEM Podium Presentations

Clinical Journal of Sport Medicine: May 2020 - Volume 30 - Issue 3 - p e111-e117
doi: 10.1097/JSM.0000000000000845
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The Development and Reliability of Helmet Fit Criteria in High School Tackle Football Players

Ash T. Kolstad, BSc (Hons),*,†,‡ Amanda M. Black, CAT(C), PhD,*,†,‡,§ M. Patrick Pankow, BKin,* Stacy Sick, CAT(C),* Bonnie Sutter, CAT(C),¶ Brent E. Hagel, PhD,*,‡,║,**,†† and Carolyn A. Emery, PT, PhD*,†,‡,§,║,**,††

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; †Integrated Concussion Research Program, University of Calgary, Calgary, AB, Canada; ‡Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; §Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada; ¶Varsity Athletics, University of Calgary, Calgary, AB, Canada; ║Departments of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; **Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; ††O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada; and ‡‡McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.

Objective: To develop and evaluate inter-rater reliability of helmet fit criteria in high school football players.

Study Design: Cross-sectional.

Subjects: Face validation of football helmet fit criteria with key informants (eg, coaches, equipment managers, therapists) was informed by previously developed ice hockey helmet fit criteria. Inter-rater reliability was evaluated with grade 10 high school football players in Calgary, Canada.

Interventions/Observation Technique: Football helmet fit criteria were created by adapting ice hockey helmet fit criteria, along with reviewing helmet manufacturer guidelines, previous literature, and expert opinions from elite football team equipment managers, coaches, and athletic therapists. Two trained raters independently assessed football helmet fit on all participants.

Outcome Measures: All 13 helmet fit criteria were rated as yes or no (eg, helmet fits snuggly–yes/no). Percent agreement (PA) between the 2 raters was used to assess inter-rater reliability for the fit criteria.

Results: Thirteen criteria were included to assess football helmet fit based on helmet condition, positioning on head, mobility, and facemask position. Eleven grade 10 football players (ages 14-16) agreed to have their helmet fit assessed by both raters. Preliminary inter-rater reliability suggests that all criteria have good agreement (PA > 0.80). The lowest agreement (PA = 0.82) was seen in criteria assessing chin piece fit and criteria associated with helmet positioning. The highest agreement (PA = 1.00) was seen in criteria assessing helmet condition, cheek pad fit, helmet skull coverage, helmet influence on neck movement, and facemask positioning.

Conclusions: Preliminary results suggest promising agreement between the 2 raters on the football helmet fit criteria. On-going data collection will allow for future evaluation of reliability using Cohens Kappa statistic. These helmet fit criteria will be related to high school football concussion risk in future work.

Acknowledgments: The Sport Injury Prevention Research Centre is one of the International Research Centre's for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge the funding from the National Football League's Scientific Advisory Board, Integrated Concussion Research Program, and Alberta Children's Hospital Research Institute. We acknowledge Johnny Carr, Football Canada, and all coaches, teachers, parents, and players involved in completing this research project.

Are Pregnant Women Meeting the United Kingdom's National Physical Activity Recommendations at Their Booking Appointment?

A. J. Ridout,* R. Smith,* S. Scanlan,† H. Reid,* and L. Mackillop†

Affiliations: *Department of Sport & Exercise Medicine, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; and †Women's Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.

Objective: United Kingdom guidelines advise pregnant women perform an aerobic component of at least 150 min/wk of physical activity (PA). PA is rarely discussed and/or recorded at the booking appointment. This study evaluates self-reported PA levels at 10 to 12 weeks of pregnancy.

Study Design: A quality improvement project.

Subjects: Thirteen thousand thirty-four women who attended their booking appointment at 10 to 12 weeks of pregnancy, between April 2018 and October 2019.

Intervention: A modified Exercise Vital Sign (EVS) (designed to identify individuals not meeting PA recommendations, quick and acceptable for use in consultation) was incorporated into the electronic record system used at the Oxford University Hospitals NHS Foundation Trust booking appointment, and used to identify women not meeting the aerobic component of the recommendations to assist with PA promotion. A very brief advice prompt was then delivered, according to PA levels.

Outcome Measures: Self-reported EVS was recorded by midwives and coded into 3 categories; (1) Green (>150 min/wk), (2) Amber (30-150 min/wk) and (3) Red (<30 min/wk).

Results: Thirteen thousand thirty-four women were assessed over 19 months. Mean booking age was 30.8 years (14-53 yrs), mean booking weight 70.8 kg (32.9-187.9 kg) and mean booking BMI 25.9 kg/m2 (13.98-65.02 kg/m2). Seven thousand five hundred sixteen (57.7%) were coded green, 3731 (28.6%) amber and 1787 (13.7%) red. A significant association was found between increased BMI and lowest category of PA levels (P < 0.05). 16.1% of women (n = 405) with BMI ≥30 kg/m2 were in the lowest PA category compared to 13.1% women (n = 1382) with BMI less than 30 kg/m2. There was no significant association between PA levels and age <31 yrs compared to ≥31 yrs.

Conclusions: At their booking appointment, less than two-thirds of women reported meeting recommended PA levels and approximately 1 in 7 were very inactive. Having a BMI ≥30 kg/m2 was associated with lower self-reported physical activity levels. This helps identify those who may benefit from PA advice during their antenatal contacts. Future works should explore other influencing variables and interventions to improve PA levels in pregnant women.

Acknowledgments: All staff involved the Oxford University Hospital Foundation Trust PA feasibility project, part of the Moving Medicine project commissioned by Public Health England and the Faculty of Sport and Exercise Medicine (FSEM) and funded by Sport England with Money from the National Lottery.

Player Experiences in High School Rugby: Understanding Risks, Benefits and the Context for Injury Prevention

Jocelyn H. McCallum, BHPE, CAT(C),*,†,‡ Jeffrey G. Caron, PhD,§ Carolyn A. Emery, PT, PhD,*,†,‡,¶,║,** and Amanda M. Black, CAT(C), PhD*,†,‡

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary; †Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary; ‡Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary; §School of Kinesiology and Physical Activity Sciences, Université de Montréal, Montreal; ¶Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary; ║Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary; and **O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary.

Objectives: This study aimed to (1) contextualize the rugby culture and environment in high school students in Calgary, Alberta, (2) explore how players negotiate injury risk, (3) understand opportunities for injury prevention.

Study Design: Qualitative, focus group sessions.

Subjects: Eighteen rugby players (aged 15-18 years, 15 female, 3 male) who had completed at least one season of high school rugby.

Observation Technique: We conducted 5 focus groups. The focus group interview guide explored participants' experiences, perceptions of injury statistics, as well as current awareness of prevention strategies.

Outcome Measures: Using thematic analysis, we explored themes related to rugby culture and environment, risk, and injury prevention.

Results: Key themes related to rugby culture and environment included an opportunity self-improvement (eg, leadership, resiliency, accountability). Participants described the rugby environment as inclusive with a family-like bond and the rugby culture as one that teaches respect. Most players acknowledged injury risk but felt that it was no different than other sports, and that the benefits of participation outweighed the risks. Regarding injury prevention, the athletes mentioned that increased education around skills and rules were strategies to prevent injury. When evidence-informed approaches (eg, neuromuscular training warm-up programs, tackling techniques) were described, players were open to trying and implementing new strategies on an individual and team level.

Conclusions: The positive aspects of rugby described by participants included feeling part of a “family,” the inclusiveness of the sport, and personal growth. These are important considerations informing potential discontinuation of rugby in high schools in Canada. Importantly, the players' awareness of evidence-informed prevention strategies and openness for implementation suggests they should be evaluated before recommending that rugby is “too dangerous” for high school students.

Acknowledgments: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge funding from the National Football League Scientific Advisory Board, Canadian Institutes of Health Research, Alberta Innovates, Hotchkiss Brain Institute, and Alberta Children's Hospital Foundation. We would like to acknowledge the Calgary Board of Education, the Calgary Catholic School District, and all teachers, coaches, and players involved for their time and support in completing this project.

Predictors of Recovery Following Concussion in Youth Ice Hockey Players

Carolyn A. Emery, PT, PhD,*,†,‡,§,¶,║ Vineetha Warriyar K.V., PhD,* Amanda M. Black, CAT (C), PhD,*,†,‡ Luz Palacios-Derflingher, PhD,*,║ Stacy Sick, CAT(C),* Chantel Debert, MD, MSc,‡,║ Brian Brooks, PhD,†,‡,¶,║ Keith Yeates, PhD,†,‡,¶,**,†† Martin Mrazik, PhD,‡‡ Connie Lebrun, MD, MSc,¶¶ Brent E. Hagel, PhD,*,†,‡,§,¶ and Kathryn J. Schneider, PT, PhD*,†,‡,¶¶

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Canada; †Alberta Children's Hospital Research Institute, University of Calgary, Canada; ‡Hotchkiss Brain Institute, University of Calgary, Canada; §O'Brien Institute of Public Health, University of Calgary, Canada; ¶Department of Pediatrics, Cumming School of Medicine, University of Calgary, Canada; ║Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Canada; **Department of Clinical Neurosciences and Division of Physical Medicine and Rehabilitation, Cumming School of Medicine, University of Calgary, Canada; ††Department of Psychology, Faculty of Arts, University of Calgary, Canada; ‡‡Faculty of Education, University of Alberta, Edmonton, AB, Canada; §§Family Medicine, Faculty of Medicine and Dentistry and Glen Sather Sport Medicine Clinic, University of Alberta, Edmonton, AB, Canada of Alberta, Edmonton, AB, Canada; and ¶¶Sport Medicine Centre, University of Calgary, Calgary, AB, Canada.

Objective: To evaluate predictors of recovery following concussion in youth ice hockey players.

Study Design: Prospective cohort study.

Subjects: Three thousand three hundred fifty-two hockey players (ages 11-17) were recruited from teams in Calgary, Edmonton and surrounding areas over 5 seasons (2013-2018).

Observation Technique: A validated injury surveillance methodology was used.

Outcome Measures: Any player with a suspected concussion was referred to a study sport medicine physician for diagnosis. A Sport Concussion Assessment Tool [(including post-concussion symptom score (PCSS)] was completed at first visit. Two Accelerated Failure Time models clustered by participants were used to estimate days to clearance to return to play (RTP). Model 1 considered PCSS symptom severity score and Model 2 considered specific symptom scores [none-mild (0-2), moderate-severe (3-6)] (eg, headache, neck pain, dizziness) at first visit. Co-variables in both models included time to first visit (≤7 days, ≥8 days), age group (11-12, 13-14, 15-17), sex, league type [body checking (BC), noBC], tandem stance [modified Balance Error Scoring System (mBESS) (≥4 errors/10)] at first visit and previous concussions (0, 1, 2, 3+).

Results: In total 329 players with at least one diagnosed concussion (366 concussions) were considered in the analyses. The median days to clearance to RTP was 18 (95% CI; 17-20). Model 1 demonstrated that longer time to first physician visit (≥8 days) [Time Ratio (TR) = 1.627 (95% CI; 1.331-1.996)], greater symptom severity [TR = 1.016 (95% CI; 1.011-1.02)] and poorer tandem stance score at first visit [TR = 1.195 (95% CI; 1.002-1.425)] were predictive of longer recovery. Model 2 demonstrated that longer time to first visit (≥8 days) [TR = 1.687 (95% CI; 1.39-2.049)], headache (moderate/severe) [TR = 1.326 (95% CI; 1.119-1.572)] and poorer tandem stance score [TR = 1.252 (95% CI; 1.054-1.487)] at first visit were identified as predictors of longer recovery. Age, sex, league type, concussion history and other symptoms at first visit were not found to be predictors of recovery, but included as potential confounders.

Conclusions: Clearance to RTP was longer with delays in physician assessment, poorer tandem stance, greater symptom severity and moderate/severe headache at first visit. These results suggest timely access to physician assessment for concussion is important and that early symptom severity can help guide management strategies. Further evaluation of clinical and psychosocial predictors of concussion recovery is warranted.

Acknowledgments: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge the funding from Canadian Institutes of Health Research, Alberta Innovates Health Solutions, Hotchkiss Brain Institute, and Alberta Children's Hospital Foundation. We would like to acknowledge Hockey Canada, Hockey Calgary, and all coaches, players, and parents involved for their time and support in completing this research project.

Clinical Presentation and Time to Recovery Following a Sport-Related Concussion

Corson Johnstone, BHSc,* Luz Palacios-Derflingher, PhD,*,† Cody van Rassel, MKin,* Michaela Chadder, MKin,* Stacy Sick, CAT(C),* Kathleen MacGregor, MD,‡ Victor Lun, MD,‡ Ryan Shields, MD, MSc,‡ Melissa Merritt, BScPT,‡ Shane Vrani, MSc,§,¶, and Kathryn J Schneider, PT, PhD*,‡,║,**

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; †Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; ‡Acute Sport Concussion Clinic, Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; §Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; ¶Neuropsychology Service, Alberta Children's Hospital, Calgary, AB, Canada; ║Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; and **Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.

Objective: To describe multifaceted clinical characteristics and time to recovery of individuals aged 13 to 60 who have recently suffered a sport-related concussion.

Study Design: Case series as part of a larger prospective cohort.

Subjects: Subjects aged 13 to 60 years who presented to the Acute Sport Concussion Clinic (ASCC) and were diagnosed with a sport-related concussion according to the fifth Consensus Statement on Concussion in Sport.

Observation Technique: At the time of the initial assessment, history and multifaceted clinical examination findings were collected and summarized. Subjects followed-up with an interdisciplinary team (sport medicine physician and athletic therapist/physiotherapist) until they were medically cleared to return to sport.

Outcome Measures: Time to medical clearance (days) and clinical examination measures including: tests of cervical spine function (limited range of motion and positive cervical flexion rotation test), vestibulo-ocular reflex (positive head thrust test or a loss of greater than 2 lines of vision with dynamic visual acuity testing), oculomotor function (abnormal test for cranial nerve III, IV, VI), and Sport Concussion Assessment Tool 5 (SCAT5). Medical clearance was determined by a study sport medicine physician according to the fifth Consensus Statement on Concussion in Sport.

Results: A total of 314 subjects [Median 18 (13-60) years of age; 159 males (50.64%)] participated in this study. Limited cervical range of motion and positive flexion rotation test were present in 95 (30.25%) and 57 (18.27%) subjects respectively; 81 (25.80%) subjects exhibited oculomotor dysfunction; 16 (5.10%) subjects had a positive head thrust test and 182 (57.96%) subjects lost >2 lines of vision with dynamic visual acuity. Three (0.96%) subjects had clinical findings in all 3 of these domains. The most frequently reported symptoms were “difficulty concentrating” (83.8%), “headache” (83.5%), and “pressure in head” (82.3%). One-hundred eighty-four participants were medically cleared to return to sport in a median time of 43 days [Interquartile range (IQR): 24-64]. Forty-two (13.38%) patients continued to experience symptoms for >3 months and were referred to an additional multidisciplinary team for chronic concussion treatment.

Conclusions: Clinical findings of cervical, vestibulo-ocular reflex and oculomotor dysfunction were evident following concussion. Future evaluation to evaluate these clinical measures as predictors of recovery is warranted.

Acknowledgments: We acknowledge funding from Alberta Children's Hospital Research Institute, the Integrated Concussion Research Program (ICRP) and the Vi Riddell Pediatric Rehabilitation Research Program. Thank you to the Acute Sport Concussion Clinic at the Sport Medicine Centre at the University of Calgary and all of the patients and their families for supporting this research project. The Sport Injury Prevention Research Centre is one of the International Research Centers for the Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee.

Modeling Tendon Damage From Athlete Workload May Be Relevant for Overuse Injuries

Lauren C. Benson, PhD,* Oluwatoyosi B. A. Owoeye, PT, PhD,*,† Carlyn Stilling, BSc,* W. Brent Edwards, PhD,‡,§ and Carolyn A. Emery, PT, PhD,*,§,¶,║,**

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Canada; †Department of Physical Therapy and Athletic Training, Doisy College of Health Sciences, Saint Louis University, Saint Louis, MO, United States; ‡Faculty of Kinesiology, University of Calgary, Calgary, Canada; §McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada; ¶Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada; ║Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada; and **Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada.

Objective: To describe the relationship between external workload and overuse injury in youth basketball players and to identify differences in workload metrics and estimated tendon damage between injured and uninjured athletes.

Study Design: Prospective cohort with matched-pair (injured-uninjured) analysis.

Subjects: Fifty (25 F, 25 M; 16.5 years; 66.2 kg; 173.5 cm) youth basketball players on 4 teams.

Observation Technique: Participants wore an IMU (VERT) to record jump count and jump height during practices and games throughout the 17-week season.

Outcome Measures: The acute:chronic workload ratio (ACWR) was calculated as the 1:4 weeks ratio of jump count and jump height. Damage accumulated in tendon due to workload was estimated by raising jump height to a power equal to the slope of the stress–life curve for tendon. Ten athletes (7 F, 3 M) were diagnosed with either patellar or Achilles tendinopathy, and were matched by height and weight with teammates that had no injuries. Paired t-tests compared mean ACWR of injured and uninjured athletes for each measure of workload and damage estimation.

Results: The pattern of weekly jump count ACWR tended to follow the weekly injury prevalence for males but not females. The mean jump height ACWR was similar throughout the weeks of the season. There was no significant effect of injury status for jump count ACWR [injured mean (95% CI): 1.077 (1.011-1.132), uninjured: 1.025 (0.906-1.162); P = 0.121] or jump height ACWR [injured: 1.079 (1.015-1.136), uninjured: 1.018 (0.886-1.155); P = 0.081]. ACWR with jump height weighted for tendon damage was higher for injured [1.075 (0.929-1.243)] compared to uninjured athletes [0.939 (0.729-1.266); P = 0.045].

Conclusions: The pattern of weekly jump count and jump height did not always correspond with the weekly injury prevalence. When workload was used to model damage accumulation in tendon due to repetitive loading, differences between injured and uninjured athletes became apparent. This model may be used to monitor the risk of overuse injuries in youth basketball.

Acknowledgments: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge funding support from the National Basketball Association and General Electric.

Reliability of a New Osteoarthritis Grading Scale for Anterior Cruciate Ligament Deficient Knees

Nicholas Mohtadi, MD, MSc, FRCSC,*,† Denise Chan, MBT, MSc,* Dana Hunter, BA,* Fazeela Mulji,* Pablo Bertiche, MD,‡ and Richard E. Walker, MD, FRCPC†,§

Affiliations: *University of Calgary Sport Medicine Centre, Calgary, AB, Canada; †McCaig Institute for Bone and Joint Health, Calgary, AB, Canada; ‡Sanatorio Allende, Cordoba, Argentina; and §University of Calgary, Department of Radiology, Calgary, AB, Canada.

Purpose: To compare the intra- and inter-rater reliability of a new x-ray grading scale to the International Knee Documentation Committee (IKDC) scale for assessing radiographic osteoarthritis (OA) in Anterior Cruciate Ligament (ACL) deficient patients.

Methods: Standardized weight-bearing, bilateral P-A flexed radiographs from 44 patients (age 15-60 years, mean 37.5 years) with ACL deficiency, were presented as either: (1) Original; or (2) Blinded (surgical tunnels/hardware digitally removed, affected knee not identified) images. The 88 radiographs were randomly sorted and rated by 2 orthopaedic surgeons and one musculoskeletal radiologist.

The new grading scale evaluates joint space narrowing (JSN), uniformity (U), and osteophytes (O) for both medial and lateral tibiofemoral compartments, relative to the opposite knee. JSN was graded as Normal, Detectable, Obvious <50%, Obvious >50%, and Bone-on-bone; U as Uniform or Non-uniform; and O as Absent or Present in the medial and lateral compartments.

Cohen's Kappa and Fleiss Kappa statistics were used to measure the intra- and inter-rater reliability.

Results: Intra-rater reliability of all 3 raters was moderate to almost perfect and statistically significant, for the both the new scale and the IKDC, except for a fair reliability (Unblinded) for lateral compartment uniformity. Inter-rater reliability ranged from slight to substantial for all categories of the new scale, with statistically significant kappa values (P < 0.05), except for agreement on lateral osteophytes (Unblinded). For both scales, intra- and inter-rater reliability was the same or was higher for the Blinded radiographs.

Conclusions: The intra-rater reliability of the new osteoarthritis grading scale for ACL deficient knees is moderate to almost perfect, and the same or better than the IKDC. The inter-rater reliability for joint space narrowing using the new grading scale is comparable to the IKDC scale. Blinding the surgical tunnels, hardware and affected side may remove rater biases when assessing for radiographic osteoarthritis.

Balancing Return to Sport and a Functional Knee: Exploring the Perceptions of Exercise Therapy and Physical Activity of Youth 1 to 2 Years After a Sport-Related ACL Injury

Linda K. Truong, PT, PhD Student,*,† Amber D. Mosewich,‡ Maxi Miciak,* Andrea Pajkic,‡ Linda Li,§,¶, and Jackie L Whittaker, PT, PhD*,§,¶,║

Affiliations: *Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta; ‡Faculty of Kinesiology, Sport and Recreation, University of Alberta; §Department of Physical Therapy, Faculty of Medicine, University of British Columbia; ¶Arthritis Research Canada, Richmond, BC, Canada; and ║Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary.

Objective: Explore the attitudes towards, priorities for, and experiences of exercise-based activities of youth who have suffered a sport-related ACL tear at least 12-months previously.

Study Design: Qualitative (Interpretative Descriptive) study.

Subjects: Ten youth athletes (6 girls, 4 boys) with an ACL tear in the past 12 to 24 months identified through purposive sampling (balance by sex, age, return-to-sport status, physical activity) from an inception cohort. Participant median age 17.5 years (15-18).

Observation Technique: One-on-one semi-structured interviews were conducted.

Outcome Measures: Participants were asked open-ended questions (interview guide) about current attitudes, priorities, and experiences of rehabilitation, physical activity, and sport participation. Using management software NVivo v12.4, meaningful units of data (codes) were identified and sorted into higher-level themes. Reflexive journaling, memoing, and a detailed audit trail promoted data trustworthiness. Analyses followed an inductive approach guided by an analytic interpretative description process. A patient partner (AP) assisted with interview guide design and data interpretation.

Results: Seven participants had undergone an ACL reconstruction, 3 were non-surgically managing their ACL tear, and 6 had returned to pre-injury sport. Three overarching themes were identified: (1) Overcoming challenges and finding support; (2) Reframing perceptions of exercise therapy and physical activity; and (3) Balancing the desire to return-to-sport and a functional knee long-term. Social support and interactions with injured athletes and physiotherapists promoted positive attitudes towards exercise-based rehabilitation and resiliency to overcome psychological (eg, fear of re-injury) and physical (eg, pain, instability) symptoms perceived to limit physical activity. Reinforcing and reshaping beliefs about the physical activity benefits were seen as important for facilitating exercise participation. Finally, motivation to complete rehabilitation exercises and participate in sport were strongly driven the desire to return-to-sport or beliefs that being proactive would ensure life-long mobility and health.

Conclusions: Perceptions, attitudes, and priorities of exercise-based activities shape how youth engage in these activities beyond the typical ACL injury recovery period. Social support, social interactions and reshaping beliefs about physical activity benefits may be important methods to ensure that these individuals meet recommended levels of physical activity. Motivators for exercise-based activities in this population are the desire to return-to-sport and maintain life-long mobility and health.

Acknowledgments: This project is funded by an Arthritis Society Young Investigator Operating Grant and Faculty of Rehabilitation Medicine New Investigator Catalyst. The authors would like to acknowledge the assistance of Erika Francis, Monika Viktorova, Chris Holt, Josh Kennedy, Wasim Labban, Christina Le, Shirley May and Miki Nguyen.

Sport Participation and Injury Rates in High School: A Survey of 2029 High School Students

Amanda M. Black, CAT(C), PhD,*,†,‡ Derek Meeuwisse, BKin,* Paul H. Eliason, MSc,*,†,‡ Brent E. Hagel, PhD,*,‡,§,¶,║, and Carolyn A. Emery, PT, PhD*,†,‡,§,¶,║

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; †Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; ‡Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada; §Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; ¶Department of Pediatrics, Cumming School of Medicine, University of Calgary, Canada; and ║O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.

Objective: To examine sport and recreational activity participation and injury rates (IR) in high school students (ages 14-19).

Study Design: Cross-sectional.

Subjects: High school students (n = 2029; 958 male, 1048 female, 23 identified as “other”) from 24 of 63 (38%) schools targeted for recruitment in Alberta, Canada.

Observation Technique: Students completed an anonymous web-based survey during class (October 2018-March 2019). Students identified their top 3 sport and/or recreational activities over the past year.

Outcome Measures: Self-reported IR for (1) any sport- and/or recreational-related over the last year, (2) most serious injury resulting in medical attention, and (3) most serious time-loss injury resulting in restriction from sport ≥ one day, adjusting for clustering by school.

Results: 1763/2029 (86.9%) of respondents [861/958 (89.9%) males, 886/1048 (84.5%) females, 16/23 (69.6%) of those identifying as “other”] participated in a sport and/or recreational activity in the past year. Top sports for male participation were basketball (n = 317; 33.1%; 95% CI: 27.7-39.0), ice hockey (n = 196; 20.5%; 95% CI: 14.9-27.5) and soccer (n = 186; 19.4%; 95% CI: 15.7-23.8). Top sports for female participation were dance (n = 236; 22.5%; 95% CI: 18.0-27.8), basketball (n = 192; 18.3%; 95% CI: 14.3-23.1) and badminton (n = 187; 17.8%; 95% CI: 13.4-23.4). Of the 1971 students who completed the sport injury question, 892 reported at least one injury during the past year [IR = 45.3 injuries/100 students/year (95% CI: 40.1-50.8)]. The medical attention IR was 27.8 injuries/100 students/year (95% CI: 23.4-32.7) and time loss IR was 35.9 injuries/100 students/year (95% CI: 40.4-41.8).

Conclusions: Sport- and recreational-related injury rates are high for high school students with approximately one in 4 adolescents reporting at least one injury requiring medical attention in the past year. Injury prevention strategies targeted at this age group are necessary.

Acknowledgments: The Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We acknowledge funding from the National Football League Scientific Advisory Board, Canadian Institutes of Health Research, Alberta Innovates, Hotchkiss Brain Institute, and Alberta Children's Hospital Foundation. We would like to acknowledge the research coordinators, research assistants, school districts and all of teachers and students involved for their time and support in completing this project.

The Association Between Reports of Symptom Exacerbation With Physical and Mental Activity and Findings of Cervical Spine (CS), Vestibulo-Ocular Reflex (VOR), Oculomotor (OM) Dysfunction, Balance Performance, and Delayed Recall Scores Following Sport-Related Concussion

Joel S. Burma, BHK,*,† Corson Johnstone, BHSc,* Cody van Rassel, MKin, CEP,* Victor Lun, MD, MSc,§ Kathleen MacGregor, MD,§ Ryan Shields, MD, MSc,§ and Kathryn J. Schneider, PT, PhD*,†,‡,§,¶

Affiliations: *Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; †Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada; ‡Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; §Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada; and ¶Evidence Sport and Spinal Therapy, Calgary, AB, Canada.

Objective: To evaluate the association between self-reported worsening of concussion symptoms with physical and mental activity (yes/no) and findings of cervical spine (CS), vestibulo-ocular reflex (VOR), oculomotor (OM) dysfunction, balance performance, and delayed recall scores following sport-related concussion.

Study Design: Cross sectional study that is part of a prospective cohort study.

Subjects: Two-hundred eighty-six participants (144 females and 142 males) aged 13 to 60 years presenting to the University of Calgary Acute Sport Concussion Clinic who were diagnosed with a sport-related concussion.

Intervention/Observation Technique: Participants completed the Sport Concussion Assessment Tool 5 (SCAT5) and CS, VOR, and OM measurements at the time of their initial presentation to the clinic.

Outcome Measures: The primary outcome of interest was report of symptom exacerbation (yes/no) on the SCAT5 with (1) physical activity and (2) mental activity. Exposure variables included CS findings (positive cervical flexion rotation test and/or painful trigger points and/or reduced cervical range of motion), VOR (positive head thrust test and/or loss of more >2 lines of vision with clinical dynamic visual acuity testing), or OM (observed abnormal Cranial nerve III, IV, VI exam), total errors on the modified balance error scoring system (mBESS) (x/30) on the SCAT5 and delayed recall scores (x/5) on the SCAT5. Multiple variable logistic regression was used to evaluate the association between reports of symptom exacerbation with (1) physical activity and (2) mental activity and exposure variables including adjustment for age, sex, and previous history of concussion.

Results: Of the 286 participants, 234 (81%) and 230 (80%) self-reported symptom exacerbation with physical and mental activity, respectively. The adjusted odds of self-reported symptom exacerbation during physical activity was 2.74 (95% CI: 1.06-7.09) times greater in those with CS dysfunction. The adjusted odds of symptom exacerbation with self-reported cognitive activity was 2.01 (95% CI: 1.06-3.82) times greater in participants with VOR abnormalities.

Conclusions: Participants who self-report symptom exacerbation with physical activity had a greater odds of cervical spine findings, whereas those self-reporting symptom exacerbation with mental activity demonstrated a greater odds of VOR findings. Further research to understand the physiological mechanisms underlying exertional symptoms is warranted.

Acknowledgments: We acknowledge funding from the Alberta Children's Hospital Research Institute. We would like to acknowledge the support from all the clinicians and staff at the University of Calgary Sport Medicine Centre.

The Sport Injury Prevention Research Centre is one of the International Research Centers for the Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee.

The Novel Ripstop Suture Pattern is Superior to the Traditional Suture Bridge: A Matched Cohort Study

Zachary Oleynik, BEd, CoM Class of 2022,* Jeremy Reed, MD, FRCSC,*,†,‡ Mitchell Thatcher, BSc, CoM Class of 2023,* Aden Mah, BSc (Hon), CoM Class of 2021,* and Megan Dash, BSc (Hon), MD, CCFP*,‡

Affiliations: *University of Saskatchewan, Saskatoon, SK, Canada; †Assistant Professor of Surgery, University of Saskatchewan, Saskatoon, SK, Canada; and ‡Dash&Reed Sport Medicine, Emerald Park, SK, Canada.

Objective: To quantify the success rates of a newly developed rotator cuff repair (RCR) suture configuration called the “Ripstop.” We set out to quantify this by comparing failure rates of a traditional suture bridge (TSB) repair verse the Ripstop (RS) repair.

Study Design: Retrospective, Matched Cohort. Cohorts were matched according to rotator cuff tear size (0-1.5 cm, 1.6-3.0 cm) and age (10-year strata).

Subjects: One hundred fifty-four subjects (105 males, 49 females) qualified for chart review and phone survey, 77 subjects in each cohort, Traditional Suture Bridge and Ripstop.

Observation Technique: Rotator cuff repair success was observed through electronic medical record chart reviews followed by a phone call survey.

Outcome Measures: Primary outcome: failure of rotator cuff repair within the first year since operative date, confirmed by magnetic resonance imaging or ultrasound imaging. Secondary outcomes: satisfaction and function scores, determined through telephone survey questionnaire.

Results: Exact matches of each of the cohorts (RS and TSB) were identified using the case control matching in SPSS version 22. Cases were matched into 10-year strata and degree of tear. The TSB cohort had a failure rate of 12.99% (10/77) and the RS cohort had a significantly reduced failure rate of 2.60% (2/77), P = 0.017. The average time to failure in both cohorts was 6.00 months, P = 0.909.

Conclusions: This study provides strong, but not conclusive, evidence supporting the theory that a novel medial row suture pattern, the “ripstop,” offers statistically significant improved rates of success for rotator cuff repair surgery.

Examining How Time From Sport-Related Concussion to Initial Assessment Predicts Return-To-Play Clearance

Taylor Pratile, MSc,* Carol DeMatteo, MSc,* and Cameron Marshall, DC†

Affiliations: *Department of Rehabilitation Science, McMaster University, Hamilton, ON, Canada, Canada; and †Complete Concussion Management Inc., Oakville, ON, Canada.

Objective: To determine an optimal time to assess and manage an athlete with a sport-related concussion by prospectively analyzing data from Complete Concussion Management Inc. (CCMI) Concussion Database System.

Study Design: Prospective cohort.

Subjects: One thousand two hundred thirteen athletes (731 male and 482 female), age 8 to 18 years, who sustained a sport-related concussion, assessed 30 days or less from injury and were treated at partnered CCMI clinics across Canada.

Intervention/Observation Technique: Time of initial injury assessment by a licensed health care provider.

Outcome Measure: The primary outcome measures was recovery, defined as CCMI discharge, which includes an athlete having completed all return-to-school and return-to-play steps and passed the Gapski–Goodman test without symptom exacerbation.

Results: Days between injury and initial assessment (P = 0.00) and sex (P = 0.00) were significant predictors of time to discharge. A log-rank test revealed a significant difference (P = 0.00) in time to discharge with athletes assessed <10 days of injury discharged at a mean of 23.5 days (95% CI, 22.5-24.5) and those assessed at day 10 to 30 were discharged at a mean of 37.1 days (95% CI, 33.7-40.5). Athletes who were assessed at 0 to 9 days from injury were 2× more likely to be discharged sooner compared to those athletes assessed 10 to 30 days from injury (HR 2.03, P = 0.00).

Conclusion: Time from sport-related concussion to initial assessment significantly predicted time to discharge, with those presenting sooner experiencing a faster discharge. The results aid in establishing recommended timelines for evaluation following a sport-related concussion in order to prevent or mitigate athletes experiencing a prolonged recovery and encourage timely access to care and a quicker return to life post-concussive injury.

Iliopsoas Tenotomy During Hip Arthroscopy: A Systematic Review of Post-operative Outcomes

Kyle Gouveia, BSc,* Ajay Shah, MD cand,* Jeffrey Kay, MD,† Muzammil Memon, MD,† Nicole Simunovic, MSc,† Josip N. Cakic, MD, PhD,‡ Anil S. Ranawat, MD,§ and Olufemi R. Ayeni, MD, PhD†

Affiliations: *Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; †Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada; ‡The Centre for Sports Medicine and Orthopaedics, Johannesburg, South Africa; and §Hospital for Special Surgery, New York, NY.

Objective: Arthroscopic iliopsoas tendon release or lengthening is a surgical treatment option for the painful snapping hip, though it has been associated with controversy surrounding potential complications including decreased hip flexion strength, iatrogenic hip instability, and iliopsoas atrophy. The purpose of this study was to systematically assess the efficacy and safety of arthroscopic iliopsoas tenotomy during hip arthroscopy as an intervention for the painful snapping hip.

Data Sources: Three online databases (Embase, PubMed, and MEDLINE) were searched for relevant literature from database inception until September 2019 for studies investigating iliopsoas tenotomy during hip arthroscopy. Studies were screened by 2 reviewers independently and in duplicate, and levels I to IV evidence studies investigating arthroscopic iliopsoas tendon release were included. Demographic data as well as data on treatment success, functional outcome scores, and radiological outcomes were recorded. A risk of bias assessment was performed for all studies.

Main Results: Overall, 21 studies were identified with a total of 824 patients (875 hips). These patients were 82.5% female (680/824) with a mean age of 28.1 years (range 12-62) and a mean follow-up of 32.1 months (range 12-62). Arthroscopic iliopsoas tenotomy was performed at the level of the labrum in 811 hips (92.7%) and lesser trochanter in 64 hips (7.3%). Overall reported success of the procedure in resolving the snapping hip was 93% (266/286), and all studies reported improvement of functional outcome scores post-operatively. Only 6 studies (93 hips) reported post-operative hip flexion strength; reporting complete recovery of strength in 4 studies (47 hips) and mild decreases in the other 2 (46 hips). Iliopsoas atrophy was evaluated radiologically (3 studies, 66 hips), and was found to be present in 92.4% (61/66) of hips post-operatively. No major complications were reported.

Conclusions: Arthroscopic release of the iliopsoas tendon is effective for alleviating pain and persistent clicking associated with a snapping hip. Although patients experience some degree of early post-operative weakness and iliopsoas muscle atrophy on radiological imaging, the results from published studies to date demonstrate satisfactory clinical function and return to sport/activity. High quality comparative studies are needed to further assess arthroscopic iliopsoas tendon release, to determine optimal technique and location of tendon release.

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