2023 AMSSM Research Podium Presentations : Clinical Journal of Sport Medicine

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2023 AMSSM Research Podium Presentations

Clinical Journal of Sport Medicine 33(3):p 283-298, May 2023. | DOI: 10.1097/JSM.0000000000001128
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The Tele-Exercise and Multiple Sclerosis (TEAMS) Study: Evaluating Predictors of Physical Activity Outcomes in the Deep South

Primary Author/Presenter: Irfan M. Asif, MD

Affiliation: University of Alabama at Birmingham, Birmingham, AL.

Coauthors: Tapan Mehta, PhD, Salma Aly, MD, Hui-Ju Young, PhD, Tracy Tracy, OT/L MSCS, Jim Rimmer, PhD

Topic: Rehabilitation.

Study: RCT.

Purpose: To evaluate physical activity (PA) outcomes in multiple sclerosis (MS) patients receiving a home-based tele-exercise program with prerecorded videos on an app (TeleCAM) versus in-clinic exercise program by a PT (DirectCAM).

Objective PA measures: Timed up and go (TUG), 6-min walking test (6MWT), and timed 25-foot walk (T25WT).

Methods: Patients with MS enrolled in a 12-week, 20-session exercise program with asynchronous TeleCAM or in-person DirectCAM. TeleCAM received monthly interactive voice response (IVR) calls with behavioral support. PA measures recorded at 3 and 12 months. Moderators included age, type of MS, residence location (metropolitan vs. micropolitan vs. small town), and disease severity. Statistical analysis used linear mixed models and ML.

Results: Seven hundred fifty-nine MS patients (377 = TeleCAM, 382 = DirectCAM; 89.1% women, 23.7% black, age = 50.0) from 43 OP PT clinics in AL/MS/TN participated. Residential area and functional disability were significant effect modifiers at 3 months. TeleCAM was superior to DirectCAM at 3 months in people residing in small towns, with improvement of 2.83 m in the 6MWT (95% CI: 1.3, 4.3), whereas no differences was observed in patients living in micropolitan and metropolitan areas. For patients with moderate disability, 3-month TUG scores were superior in DirectCAM compared with TeleCAM by 1.26 secs (95% CI: 0.16, 2.35), but differences for TUG scores were not found between TeleCAM and DirectCAM in mild or severe disability. Machine learning ridge shrinkage model identified health coaching with IVR for self-efficacy to be an important predictor of T25FW scores in TeleCAM at 3 and 12 months. Patients with MS who engaged with health coaching through IVR had better 6MWT scores at 12 months if using self-efficacy, social support, and exercise goal-setting tools.

Conclusions: Residential location and level of functional disability are critical modifiers for physical activity outcome measures, and they may determine who can benefit from a low-cost, asynchronous tele-exercise program versus a program with in-person support. Monthly psychosocial assessments with IVR are important predictors of PA outcomes and could be used to develop tailored adaptive tele-exercise programs.

Significance: SDH, psychosocial factors, and disease severity are vital when designing exercise programming to improve PA outcomes, particularly in those with limited access to care. Using IVR technology for health coaching is a unique modality to improve PA outcomes.

Gender Differences in Hip and Thigh Muscle Strength in NCAA Soccer Players

Primary Author/Presenter: David Bakal, MD

Affiliation: Emory University Department of Sports Medicine, Atlanta, GA.

Coauthors: Farah Hussain, MD, Justin Dzierzawski, MD, Holli Dawson, MS, ATC, Daniel Meyer, MS, ATC, Oluseun Olufade, MD

Topic: NCAA.

Study: Case–control.

Purpose: There are different injury patterns in NCAA men's and women's soccer players. Strength imbalances of the hip and thigh are known risk factors for many of these injuries. We performed hip and thigh strength assessments in NCAA soccer players to evaluate for differences between the genders.

Methods: Using a handheld dynamometer, we calculated weight-normalized isometric strength of 6 muscle groups (hip flexors, extensors, abductors and adductors, knee flexors and extensors) in NCAA soccer players. The strength ratio of each agonist/antagonist muscle was also calculated (hip flexors/extensors, hip abductors/adductors, knee extensors/flexors). Data were compared between the genders using t-tests.

Results: Thirty-six NCAA soccer players (18 men and 18 women) from a single institution were enrolled. Men were taller (178.2 vs 166.4 cm, P = 0.001) and heavier (74.1 vs 63.0 kg, P = 0.001) than women, although both the groups were similar in age (mean 20.4 years). Compared with men's players, women's players had decreased weight-normalized strength for hip extension in both the dominant (0.172 vs 0.215, P = 0.029) and nondominant (0.172 vs 0.207, P = 0.029) limbs, as well as for hip abduction in the dominant (0.178 vs 0.205, P = 0.047) and nondominant (0.162 vs 0.202, P = 0.005) limbs. There were no significant differences in strength between the genders for hip flexion, hip adduction, knee flexion, or knee extension. When comparing agonist/antagonist strength ratios, there were significant differences between women's and men's players for hip flexion/extension in the nondominant limb (1.730 vs 1.289, P = 0.003) and hip abduction/adduction in the nondominant limb (1.361 vs 1.577, P = 0.029).

Conclusions: Compared with men's players, women's players had decreased weight-normalized strength with hip extension and abduction in both the dominant and nondominant limbs. Consequently, the agonist/antagonist strength ratios for hip flexion/extension and hip abduction/adduction were different between the genders, although these differences were only significant in the nondominant limb. Otherwise, strength profiles were similar between the genders.

Significance: NCAA women's soccer players were deficient in hip extension and abduction. Future research can evaluate whether these disparities contribute to the different injury patterns seen in women's soccer, including the higher incidence of knee ligament injuries.

Acknowledgments: The authors acknowledge the Emory University intercollegiate soccer teams and sports medicine department for their contributions to this research.

Primary Author/Presenter: Joshua A. Beitchman, MD, MBS

Affiliation: Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas; Pediatric Residency Program, Children's Health, Dallas, Texas.

Endophenotype Presentation of Athletes With Concussion Contingent Upon Sex and Time Since Injury

Coauthors: Jacob Jones, MD, Nyaz Didehbani, PhD, Jane Chung, MD, Shane Miller, MD, Mathew Stokes, MD, Munro Cullum, PhD

Topic: Concussion.

Study: Other.

Purpose: Concussed athletes present with heterogeneous symptoms and clinical trajectories. Identifying endophenotypes helps improve prognostication and focused treatments. We evaluated how endophenotypes differ among athletes based on sex and injury time line.

Methods: Athletes aged 12-18 years in the North Texas Concussion Network Registry (ConTex) were divided based on days since injury. Results of KD, BESS, Concussion Symptom Log, GAD-7, PHQ-8, and Pittsburgh Sleep Quality Index were grouped into endophenotypes based on established data elements outlined by the Concussion Subtype Workgroup, and correlations were examined regarding days post injury (DPI) and sex.

Results: Distinct clusters in endophenotype matrices identified time points of maximum symptom correlations in 1385 athletes (M:51%; F:49%). Acutely (0-3DPI), male athletes demonstrated cognitive (r = 0.2-0.68) and headache (r = 0.59-0.74) endophenotypes, whereas female athletes had no predominant endophenotype. Subacutely (4-7DPI), female athletes demonstrated headache (r = 0.58-0.84), cognitive (r = 0.42-0.72), and vestibular (r = 0.15-0.76) endophenotypes, whereas male athletes had no predominant endophenotype. In the 8-28 DPI group, female athletes had a cognitive endophenotype (r = 0.43-0.7), whereas male athletes showed cognitive (r = 0.35-0.72) and vestibular (r = 0.13-0.72) endophenotypes. Chronically (29+DPI), female athletes had a mood (r = 0.130-0.8), sleep (r = -.42-.71), and cognitive (r = 0.41-0.71) endophenotypes, whereas male athletes had a mood (r = 0.16-0.8), sleep (r = -0.45-0.77), and headache (r = 0.49-0.76) endophenotypes. Correlation matrices in the chronic stage indicated mood and sleep symptoms were moderately correlated (r > 0.5) with cognitive, vestibular, and headache endophenotypes.

Conclusions: Concussed athletes experience symptoms differently based on sex and time since injury. This influences symptom clusters, with implications for concussion endophenotypes related to sex and injury time line. Chronically, endophenotypes appear most interrelated with dysregulated mood and sleep. These interactions may contribute to the multifactorial etiology of persistent postconcussion symptoms.

Significance: Proper characterization of sports-related concussion into endophenotypes requires consideration of gender and injury time line. Improved identification of clinical trajectories may allow for a targeted clinical approach of concussed athletes.

Fibula Stress Fractures Correlation to Pes Planus and Hindfoot Valgus Deformity

Primary Author/Presenter: Greta Bires, MD

Affiliation: Thomas Jefferson University Hospital, Philadelphia, PA.

Coauthors: Marya Ghazzi, Imana Rhoden, MD, Christopher Mehallo, DO, Marc Harwood, MD

Topic: Musculoskeletal.

Study: Cohort

.Purpose: Approximately 10% of stress fractures occur in the fibula. The pathogenesis and predisposing characteristics are not completely understood as the largest study is an n = 12 case series. Our hypothesis is that pes planus and hindfoot valgus are significantly associated with fibula stress fractures.

Methods: A retrospective study analyzed fibula stress fracture patients with visits in 2015-2020. χ2 and T-test for categorical and continuous variables, respectively, assessed pes planus and hindfoot valgus rates using Meary angle (MA), calcaneal pitch, and tibiotalar angle (TTA). Logistic regressions assessed rates of pes planus, MA > 4, and hindfoot valgus, TTA < 90, controlling for covariates.

Results: Sixty-two patients were analyzed. Baseline demographics showed female preponderance (74.2% female vs 25.8% male), average age = 42.2 years (SD 19.4), average BMI = 25.0 (SD 5.47), more nonsmokers (59 to 1), and a higher rate of sports injuries than not (40 patients or 64.5% vs. 22 patients or 35.5%). Thirty-one patients (50%) had a Meary angle < -4 (pes planus), 23 (37.1%) ranged 4 to -4, and 8 (12.9%) ranged > 4 (pes cavus) (P< 0.001). Of the 31 patients with pes planus, 27 (43.5%) ranged -4 to -15 (mild deformity) and 4 (6.45%) ranged -15 to -30 (moderate deformity). Twenty-six patients (41.9%) had calcaneal pitch 10-20 (pes planus), 35 (56.5%) had 20-30, and 1 (1.61%) had 30+ (pes cavus) (P value < 0.001). Thirty-nine (62.9%) had tibiotalar angle < 90 degrees compared with 23 (37.1%) with tibiotalar angle > 90 degrees (P = 0.004). There was continued significance of pes planus (P < 0.001) and hindfoot valgus (P = 0.004) rates when controlling for age, sex, BMI, and sports injury.

Conclusions: Baseline demographics showed higher rate of fibula stress fractures in women and through sports injuries. There was a higher rate of pes planus and hindfoot valgus among the population. These relationships remained significant when controlling for covariates such as age, sex, BMI, and sport injuries, supporting our hypothesis.

Significance: The results suggest the importance of pes planus and hindfoot valgus in those with fibula stress fractures. This study presents the largest study to date with a comprehensive analysis of characteristics and pes planus rates in this population.

Acknowledgments: Statistics were done by statistician Matthew Sherman.

Sleep Extension and Consistency Improve Athletic Performance in NCAA Division I Collegiate Athletes

Primary Author/Presenter: Nelson Boland, MD

Affiliation: University of California, Los Angeles—Division of Sports Medicine, Santa Monica, CA.

Coauthors: Brian Donohoe, MD, Calvin Duffaut, MD, Joshua Goldman, MD, MBA

Topic: NCAA.

Study: RCT.

Purpose: To determine the effects of sleep extension and sleep consistency interventions on athletic performance metrics, including sprint speed, reaction time, and sport-specific accuracy measurements, in NCAA Division I men's soccer, women's soccer, and men's water polo players.

Methods: This is a randomized, controlled, crossover study. Forty-six NCAA Division I athletes wore a validated device to quantify sleep time and consistency during a 2-week sleep consistency intervention, then a 2-week washout phase, followed by a 2-week sleep extension intervention. Baseline performance data were obtained at the beginning of the study and was repeated after each sleep intervention.

Results: The soccer cohort was 38% male (N = 8) and 62% female (N = 13; age 18-22 years). The water polo cohort was 100% male (N = 25; age 18-22 years). In soccer players, there was a significant improvement in 40-yard sprint time from baseline with sleep extension (5.64 s vs 5.49 s, P = 0.05) and sleep consistency interventions (5.64 s vs 5.38 s, P < 0.01). There was a significant improvement in shooting accuracy with sleep extension (44.7% vs 51.8%, P = 0.04) and sleep consistency interventions (44.7% vs 57.7%, P < 0.01). There was a significant improvement in reaction time with sleep extension (203 ms vs 184 ms, P < 0.01) and sleep consistency interventions (203 ms vs 193 ms, P = 0.04). In water polo players, there was a significant improvement in 50-yard swim time (24.7 s v 23.9 s, P < 0.01) and reaction time (192 ms vs 167 ms, P = 0.04) with the sleep consistency intervention. In all athletes, there was no change in mood state with any intervention (baseline POMS = -10.8, extension POMS = -6.3, P = 0.21; consistency POMS = -4.8, P = 0.10).

Conclusions: NCAA Division I soccer and water polo players showed significant improvement in athletic performance metrics after sleep extension and sleep consistency interventions. There was no difference in mood as assessed by the abbreviated profile of mood survey. These findings suggest that sleep extension and consistency interventions are effective tools for enhancing athletic performance but do not necessarily improve mood.

Significance: This is the first study to evaluate the effects of sleep extension on athletic performance in collegiate soccer and water polo players and the first to evaluate the effects of sleep consistency on athletic performance in any sport or athletic cohort.

Acknowledgments: The investigators acknowledge the UCLA athletic trainers and students who assisted with data collection. The team also thank WHOOP Inc. for their donation of activity tracking devices and statistical support.

Sport Specialization Is Associated With Increased Return-to-Play Time Periods in Youth Athletes

Primary Author/Presenter: Anna Buser, BS

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

Coauthors: Ally Render, BS, Stacey Schley, MD, Mario Ramirez, BS, Caleb Truong, Stephanie Logterman, MD, Jeffery Webb, MD, Neeru Jayanthi, MD

Topic: Pediatrics.

Study: Cohort.

Purpose: To evaluate the effect of the degree of sport specialization in relation to return-to-play time periods (short (<10), intermediate (10-30), or long (>30 days)) in youth athletes. To evaluate the association of sport specialization with injury type and stage of biologic maturation.

Methods: Injured athletes aged 10 to 23 years who presented to sport medicine clinic reported their degree of sport specialization. Biologic maturation was measured by the Khamis–Roche method for the percentage of predicted adult height (PPAH). Injury type and return-to-sport (RTS) time frames were categorized from physician documentation. Multiple χ2 tests assessed potential associations between the variables.

Results: At submission, there were 359 subjects enrolled, and at analysis, 329 subjects (mean age = 15.5 years) had data on the degree of specialization, RTS, injury type, and PPAH. There is a strong association between the degree of sport specialization and return-to-play time periods (P = 0.034) with highly specialized athletes more likely to have longer return-to-play time periods. In addition, the degree of sport specialization was strongly associated with injury type (P = 0.0005), showing a higher incident of overuse and serious overuse injuries among highly specialized athletes. There is no association between the degree of specialization (categorized as low, middle, or high) and PPAH.

Conclusions: (1) There is a significant association between the degree of sport specialization and longer return-to-play time periods. (2) There is a significant association between the degree of sport specialization and overuse injury type. (3) There is no association between sport specialization and biologic maturation, nor individual specialization parameters and PPAH.

Significance: Highly specialized athletes may be more likely to have overuse injuries and longer return-to-play time periods. Anticipatory guidance of highly specialized athletes is recommended. The optimal stage of development for specialization is still unknown.

Acknowledgments: Funding Source: Emory University Department of Orthopedics intramural seed grant.

Longitudinal Patient-Reported Outcomes Among Osteoarthritis Patients Injected With Zilretta or Triamcinolone Acetate

Primary Author/Presenter: Cher Chang, MD

Affiliation: UBMD Department of Orthopaedics and Sports Medicine, University at Buffalo, Buffalo, NY.

Coauthors: Mohammad N. Haider, MD, PhD, Nomi Weiss-Laxer, PhD, MPH, MA, Jesse M. Galina, BS, Sibtain Mustafa, BS, Sophia Bisson, Leslie J. Bisson, MD

Topic: Musculoskeletal.

Study: Other.

Purpose: Triamcinolone acetate (TA) and the newer extended-release Zilretta (ZA) are effective when compared with other corticosteroids with limited research comparing them. We compared patient-reported outcomes (Knee injury and Osteoarthritis Outcome Scores [KOOS]) in patients who received either injection.

Methods: Retrospective chart review of patients diagnosed with knee osteoarthritis (OA) who had TA (n = 522, 61.6 ± 10.9 years, 61% F, 33.6 ± 8.3 kg/m2) or ZA (n = 273, 58.3 ± 11.8 y/o, 58% female, 34.1 ± 6.5 kg/m2) injections from January 1, /2021, to December 31, 2021. KOOS data were collected at the initial visit and monthly for 6 months and analyzed using mixed-model linear regression.

Results: TA began with higher (better) KOOS pain scores than ZA (47.7 vs 43.9, P = 0.003). On mixed model regression, pain score changed over time (F = 6.1, P = 0.014) and was associated with preinjection score (F = 576.3, P < 0.001), but there was no significant effect of injection (F = 0.4, P = 0.545) or the interaction of injection with time (F = 0.3.3, P = 0.069).However, TA had a mean improvement from baseline at 1 month (12.0 [9.8, 14.3]), 2 months (8.9 [6.4, 11.3]), and 3 months (4.7 [2.4, 7.0]), whereas ZA had a mean improvement from baseline at 1 month (14.0 [10.4, 17.5]) and 2 months (7.6 [3.9, 11.4]) but not at 3 months (0.7, [-2.9, 4.5]). No differences from baseline were seen beyond 4 months for either injection. The same pattern existed for activities of daily living (ADL), sports and recreational activity, and symptom scores. Quality of life was better than baseline for both injections only at 1, 2, and 3 months.

Conclusions: We found that patient-reported outcomes over the first 6 months following an injection depended on the degree of patient-reported symptoms/activities at the time of injection. There was no difference in pain or outcomes between ZA or TA over time. It is even possible that TA offers symptom relief for a longer period than ZA, but future randomized controlled trials testing comparing the 2 drugs are warranted.

Significance: Our results are important for doctors and patients when deciding which injection to use. We found no evidence that ZA ($652.32) was better than TA ($17.75) for self-reported pain or other symptoms, ability to perform ADL, or sport participation.

Visual Perception Training for Basketball Affects Lower Extremity Motion and Loading

Primary Author/Presenter: Jaineet Chhabra, MS

Affiliation: Marshall University Joan C. Edwards School of Medicine, Huntington, WV.

Coauthors: Kassandra Flores, MS, Kasey Stickler, MD, David Rupp, MD, Steven Leigh, PhD

Topic: Training.

Study: RCT.

Purpose: We aimed to determine the short-term effects of four-weeks of visual perception training on lower extremity limb movement precision and joint forces of recreational basketball players performing common basketball skills.

Methods: Healthy, experienced, youth, basketball players were tested in basketball drills as their movements were recorded by a 3-D motion capture system and force plates. Players completed 4 weeks of randomly assigned general play or visual perception training and were then retested. Movement precision measures and joint forces were calculated from the motion analysis and force plate data using MatLab.

Results: Lower extremity position at impact was calculated as the combined, instantaneous hip, knee, and ankle angles at maximum ground reaction force. The precision (reproducibility) of this position was assessed with the coefficient of multiple correlation and was greater for the post test of the visual perception training group than for the general training group for the layup skill (0.860 vs 0.790) and the rebound skill (0.860 vs 0.648). Knee joint resultant force was similar for both the groups for the posttest of the layup and rebound skills. Ankle joint lateral shear force was significantly lower for the post test of the visual perception training group than for the general training group for the reactive defensive slide skill (21 ± 2 N/kg vs 25 ± 2 N/kg, t = 2.62, P < 0.05).

Conclusions: The greater joint position reproducibility for the visual perception training group suggests that these players' movements became more precise as they improved their proprioception. Because injuries tend to occur with inconsistent/unpredictable motion, greater movement precision is beneficial. The lower ankle lateral shear force for the visual perception training group indicates that they are at a lower risk of a lateral ankle sprain after the training.

Significance: These findings draw attention to potentially risky movement patterns that increase joint loading and suggest that perception and visualization techniques can be added to effective injury prevention interventions without adding an additional time burden.

Acknowledgments: The authors thank the participants for volunteering their valuable time with us.

Screening College Athletes for Sexual Violence: Current Trends and Athletes' Opinions on Best Practices

Primary Author/Presenter: Sherilyn DeStefano, MD

Affiliation: Oregon Health and Science University, Portland, OR.

Coauthors: Emily Peterson, MD, Derek C. Pham, Nicholas J. Jackson, PhD, MPH, Derjung M. Tarn, MD, PhD, Dena Florczyk, MD, Aurelia Nattiv, MD

Topic: NCAA.

Study: Other.

Purpose: Twenty-nine percent of student-athletes experience sexual violence during college, but only 9% formally report it. There is little data assessing screening for sexual violence among this population. This study examined past screening among athletes and athletes' opinions on best screening methods.

Methods: This was a cross-sectional survey study of intercollegiate and club athletes at a Division I university. Outcomes included the number of participants previously screened, personnel conducting screening, and timing of screening. Survey participants were invited to partake in follow-up group interviews on best screening practices. Interviews were transcribed then coded using thematic analysis.

Results: One hundred sixty-five participants (62% female and 38% male) completed the survey. One hundred twenty-four (75%) responded that they had not received previous screening. Of those who had been previously screened, this was most frequently completed by a health care provider (54%), and for 83%, it occurred within the past 2 years. Twelve student-athletes (8 female athletes and 4 male athletes) from a range of different sports participated in the group interviews. Areas of needed focus around sexual violence screening were identified: population-wide education, normalizing the conversation, emphasizing mental health, and decreasing stigma. Participants suggested that knowledge on the subject, shared experience, and a sense of caring/compassion are important components in the person conducting screening. They also identified several best practices for screening, including priming individuals for sensitive questions, creating a comfortable and private environment, being transparent about how the information will be used, and screening at regular intervals.

Conclusions: These results suggest that college athletes are not routinely being screened for sexual violence. Components such as regular screening, importance of a comfortable and private environment, building trust, decreasing stigma, transparency, and increasing population-wide knowledge on the subject were identified as important practices when developing and implementing screening protocols.

Significance: This study is the first to gather data directly from college athletes about their opinions on how health care teams can most effectively and sensitively screen this at-risk population to allow early intervention.

Acknowledgments: Funded in part by a grant from the American Medical Society for Sports Medicine (AMSSM) Foundation and supported by NIH/National Center for Advancing Translational Science (NCATS) UCLA CTSI Grant Number UL1TR001881. The opinions expressed herein are those of the authors.

Primary Author/Presenter: Bianca Edison, MD, MS

Affiliation: Children's Hospital Los Angeles, University Southern California.

Changes in Sports Participation, Specialization, and Burnout From 7th to 12th Grade: Final Results

Coauthors: Jacquelyn Valenzuela-Moss, BA, Milo Sini, MPA, Tishya Wren, PhD

Topic: Pediatrics.

Study: Cohort.

Purpose: This study examined changes in sports participation, specialization, and burnout in students followed longitudinally from 7th through 12th grade. We have now collected data through the participants' final year of high school and report results for the entire middle and high school period.

Methods: The same class (graduating class of 2023) was surveyed longitudinally in the fall of each school year from 7th to 12th grade (n = 35-77, depending on the year). Survey questions asked about sports participation, specialization, and burnout. Responses were analyzed by grade level using mixed-effects linear and logistic regression accounting for repeated measures.

Results: The number of days/week in which students engaged in at least 60 minutes of strenuous exercise progressively decreased from 7th through 12th grade from 4.0 to 2.3 days/week (P< 0.001). The percentage of students participating in sports also decreased from 7th to 12th grade from 82% to 41% (P< 0.001). More students stopped participating in a sport (38% vs. 21-29%, P = 0.046), quit a sport to focus on a single sport (60% vs. 46-49%, P = 0.02), or reported that one sport was most important to them (71% vs. 54-67%, P = 0.06) in 9th grade, although the percentage of athletes spending at least 75% of their time in a single sport did not differ significantly across grade level (59-75%, P> 0.09). Burnout in sports did not differ significantly by grade level (9-29%, P = 1.00). By contrast, burnout in school was significantly more common in high school (15-36%) compared with middle school (17%, P = 0.001) because homework load increased from an average 2.4 of hours to 3.4 per school night (P< 0.001).

Conclusions: Organized sports participation and exercise activity decreased throughout middle and high school, with the entry into high school at 9th grade being a time at which a significant number of students dropped other sports to specialize in a single sport or stopped participating. Burnout in sports did not appear to increase with age; however, there was an increase in school-related burnout as students transitioned from middle to high school.

Significance: Research ascertaining whether burnout from school and mental health challenges affect decreased physical activity or if decreased physical activity in turn affects school-related burnout would be important to develop impactful interventions and resources.

Acknowledgments: The authors thank the HW Institute of Scholastic Sports Science and Medicine for their help with project planning and implementation.

Primary Author/Presenter: Georgia Griffin, MD

Affiliation: University of Washington, Seattle, WA.

Project Nature: A Pilot to Promote Childhood Outdoor Physical Activity Through Primary Care

Coauthors: Carolina Nieto, PhD, Kirsten Senturia, PhD, Marshall Brown, MS, Kim Garrett, MPH, Elizabeth Nguyen, MD, Pooja Tandon, MD

Topic: Pediatrics.

Study: Other.

Purpose: We aimed to develop a family-centered and easily disseminated tool to promote active outdoor play during well-child visits and to meet the needs of diverse families living in areas where opportunities for outdoor recreation may be limited.

Methods: We adapted Project Nature, a tool consisting of a brochure and toy used by pediatric providers to encourage outdoor play. We conducted a mixed-methods pilot study (before/after surveys and qualitative interviews) of 20 families with children aged 4 to 10 years being seen for well-child visits at an urban clinic serving families from diverse backgrounds. We conducted quantitative and qualitative analyses.

Results: All parents surveyed felt that time in nature and daily physical activity were important. Parents recalled their child's medical provider encouraging daily outdoor time during a well-child visit in the past year: 67% of the time preintervention and 100% of the time postintervention. Children were reported to be physically active for at least 20 minutes for a median of 5 days per week preintervention (vs 6 days per week postintervention) and play outside for a median of 4 days per week preintervention (vs 5 days per week post-intervention). The most popular toys chosen were seed packets and shovel, chalk, magnifying glass, frisbee, and kite. Most (80%) parents liked the Project Nature kit, and they found the toy helpful because it provided a tangible activity to help their children be more active, and even helped parents be more active as well. Parents wished the nature kit had more emphasis on how to help their kids be more active during cold and wet times of the year.

Conclusions: The Project Nature kit was a practical intervention to employ during well-child visits, and it was acceptable and welcomed by families. This study shows that well-child visits are a feasible and potentially effective setting to promote active outdoor play.

Significance: Providing a nature toy as part of an intervention to promote outdoor activity during well-child visits may be one strategy to reduce disparities in children's physical activity and time in nature.

Primary Author/Presenter: Kimberly Harmon, MD, FAMSSM

Affiliation: University of Washington.

How Accurate Are the SCAT 5 and King–Devick for the Acute Diagnosis of Concussion?

Coauthors: Bridget Whelan, MPH, Heather Elkington, MS, ATC, Gabrielle Garruppo, MHS, Marissa Holliday, MEd, ATC, Calvin Hwang, MD, Sourav Poddar, MD, Douglas Aukerman, MD

Topic: Concussion.

Study: Case–control.

Purpose: The purpose of this study was to determine the diagnostic accuracy of components of the SCAT 5 (Symptom Score (SS), Symptom Severity Score (SEV), the 10-word Standardized Assessment of Concussion (SAC), and the modified-Balance Error Scoring System (m-BESS)) and of the King–Devick Test (KD).

Methods: NCAA Division I college athletes from four schools completed baseline testing including the SCAT-5 and KD. When an athlete presented acutely with suspected concussion from February 2020 to December 2022 (sideline/within 24 hours), the tests were repeated. If a concussion was diagnosed, a control was identified to test, matched on comorbid conditions, gender, team, season, and baseline scores.

Results: Baseline and postinjury data were collected on 147 concussed and 147 matched control athletes. Athletes were predominantly male (n = 152, 52%), with the most concussions among football (n = 56, 38%), volleyball (n = 21, 14%), softball (n = 15, 10%), and women's soccer (n = 9, 6%) and other sports (n = 46, (31%). SS and SEV were the most sensitive and specific measures with sensitivities of 84% and 88% (3-point increase in scores) and AUC of 0.93 (0.90-0.96) and 0.94 (0.91-0.96), respectively. The 10-word SAC had poor test–retest reliability with ICC of 0.56 (0.38-0.69), poor sensitivity (53% with 1-point decrease), and fair AUC at 0.70 (0.64-0.76). m-BESS also had poor test–retest reliability ICC of 0.43 (0.28-0.56), poor sensitivity (37% with 3-point increase), and poor AUC at 0.61 (0.55-0.68). The KD had fair test–retest reliability of 0.71 (0.62-0.79), the best sensitivity of the objective tests at 84% (with any increase in time), but only fair AUC of 0.74 (0.69-0.80).

Conclusions: Symptoms are the most accurate indicator of concussion but are subjective and require the athlete to accurately recognize and report them. Of the objective measures, the KD had the best test–retest reliability, was the most sensitive indicator of concussion, and had the best AUC. The 10-word SAC and m-BESS were not reliable or sensitive indicators of concussion but were more specific as errors increased.

Significance: Understanding the psychometric properties of recommended concussion tests is critically important in their accurate interpretation. Although the SAC and the m-BESS are not sensitive, they become specific with increasing errors.

Acknowledgments: The authors acknowledge funding support from generous donations from the University of Washington alumni Jack and Luellen Charneski and the Chisholm Foundation.

Primary Author/Presenter: Brian S Harvey, DO

Affiliation: Children's Mercy Hospital, Kansas City 2401 Gillham Road Kansas City, MO.

Injury Patterns in Elite US Youth Soccer Players

Coauthors: Jonathan Warren, MD, Shannon Margherio, PT, OCS, Thomas Munro, MD, James Roberson, MD, Kevin Latz, MD

Topic: Epidemiology.

Study: Cohort.

Purpose: Reducing the incidence and severity of injury is one of the primary goals of health care in sports medicine. However, to prevent injury overall injury patterns and epidemiological factors of the injuries must be understood.

Methods: The soccer database for local developmental academy teams U12 (12 years and under) to U19 (19 years and under) was reviewed. We analyzed data from the 2019-2020, 2020-2021, and 2021-2022 seasons, including injury frequency, hours played, type, and location of injury were then compared between the teams.

Results: Over three seasons, there were 94,400 total hours played with an injury rate of 3.7/1,000 hours. Older teams had higher injury rates than younger teams with the U15s, U17s, and U19s having injury rates of 4.6 per 1000 hours and the U14s, 13s, and 12s having injury rates of 3 per 1000 hours. Among injury types, 38.2% were muscle injuries and 18.6% were ligament injuries. The thigh was the most commonly injured location (20.9%). The hip/groin (15.9%), knee (14.1%), and ankle (13.5%) were also common injury locations. The most frequent (40.5%) injury severity was classified as “moderate” requiring 8 to 28 days of recovery. The U13s (24%) had the highest frequency of bone injury compared with all other groups. Among injury types, the U19s (P equals 0.046) and U17s (P equals 0.012) had significantly more muscle and ligament injuries and fewer concussions compared with the U12s. There were no other significant differences in injury type or location between the teams.

Conclusions: Among elite youth soccer athletes in the United States, muscle and ligament injuries are the most common types of injury. The hip, groin, knee, and ankle are the most common injury locations. Athletes experience significantly more muscle and ligament injuries as well as fewer head injuries as they get older. Bone injury (most commonly apophysitis) had the highest frequency in the U13 team, indicating an age component to this injury type.

Significance: There is very little data on injury patterns for elite youth soccer athletes. These data suggest that certain age groups may be more likely to sustain specific injuries, allowing providers to create preventive, age-based strategies.

Acknowledgments: Kurt Andrews.

Primary Author/Presenter: Marc Heronemus, MD

Affiliation: University of Colorado.

Concussion History Does Not Affect Smartphone-Based Dual-Task Performance in Adolescents

Coauthors: Matthew Wingerson, MS, Samantha Magliato, BS, Katherine Smulligan, PT, DPT, Julie Wilson, MD, Vipul Lugade, PhD, David Howell, PhD, ATC

Topic: Concussion.

Study: Cohort.

Purpose: Impairments in dual-task function (concurrent motor/cognitive task) emerge following concussion in adolescents. The cumulative effect of prior lifetime concussions on dual-task performance in patients within 14 days of current concussion requires further investigation.

Methods: We tested 3 groups of participants: uninjured controls with no concussion history, patients seen within 14 days after their first lifetime concussion, and patients seen within 14 days after their second or greater concussion. Outcomes assessed under single- and dual-task conditions were gait velocity, auditory Stroop accuracy, and response time. We compared performance using 1-way ANOVAs.

Results: Forty-eight participants were included, n = 15 (31%) following their first lifetime concussion, n = 12 (25%) following their second or greater lifetime concussion, and n = 21 (43%) with no concussion history. There were no significant demographic or injury characteristic differences among the groups. No between-group differences for single-task (0.91 ± 0.13 vs. 0.94 ± 0.21 vs. 0.92 ± 0.16 m/s; P = 0.91) or dual-task (0.84 ± 0.13 vs. 0.92 ± 0.21 vs. 0.89 ± 0.13 m/s; P = 0.38) gait velocity or single-task (79 ± 24% vs. 84 ± 16% vs. 75 ± 15% correct; P = 0.41) or dual-task (79 ± 25% vs. 86 ± 19% vs. 75.0 ± 18.3% correct; P = 0.29) Stroop accuracy were identified. The first lifetime concussion group had significantly slower single-task Stroop response times (1707 ± 148 ms) than the other groups (1442 ± 193 and 1499 ± 197 ms; P = 0.001). The control group demonstrated significantly faster dual-task Stroop response times (1283 ± 117 ms) than the 2 concussion groups (1593 ± 174 and 1566 ± 324 ms; P< 0.001).

Conclusions: Smartphone-assessed dual-task response time, but not response accuracy or single-task or dual-task gait velocity, is negatively impacted by concussion within 14 days of injury. There does not appear to be a cumulative effect of multiple lifetime concussions on postconcussion single-task or dual-task gait velocity, response time, or accuracy as participants with prior concussions did not have worse outcomes than the first lifetime concussion group.

Significance: Assessing dual-task performance may be useful as an additional tool for concussion evaluation. The effect of multiple concussions on dual-task function in adolescents warrants further research given our small sample size.

Acknowledgments: This study was funded by the National Institute of Neurological Disorders and Stroke (R43NS108823) and the Tai Foundation.

Primary Author/Presenter: Rajiv Jain, MD

Affiliation: UBMD Department of Orthopaedics and Sports Medicine, University at Buffalo, Buffalo, NY.

The Effect of Exertion on Common Sideline Assessments Of Concussion In Healthy Adolescent Athletes—Randomized Controlled Trial

Coauthors: Kendall Marshal, ATC, Mohammad Haider, MD, PhD, Antony Surace, ATC, Griffen Spatorico, ATC, Nomi Weiss-Laxer, MPH, PhD, Jason Matuszak, MD, John Leddy, MD

Topic: Concussion.

Study: RCT.

Purpose: Common sideline concussion assessments, i.e., Sport Concussion Assessment Tool 5 (SCAT5) and Vestibular Ocular Motor Screen (VOMS), are sensitive in identifying deficits immediately after head injury. This study's purpose is to see how level of exertion affects these assessments in healthy athletes.

Methods: Athletic adolescents with no concussion within past 1 month performed concussion assessments at rest and then were randomized to perform (1) no exertion (15 minute seated rest); (2) minimal exertion (15-minute walking at 50-55% of heart rate [HR] max); and (3) moderate exertion (15-minute jogging at 70-75% HR max). Participants performed assessments again after exertion and were compared.

Results: No demographic differences were seen between no (n = 16, 15.6 ± 1.1 y/o, 56% male, 38% history of concussion), minimal (n = 16, 15.9 ± 1.1 y/o, 56% male, 44% history of concussion), or moderate (n = 15, 15.7 ± 1.1 y/o, 60% male, 13% history of concussion) exertion groups. Before exertion, groups did not differ in symptoms (1.4 ± 1.5, 2.7 ± 4.7, 2.2 ± 4.7, P = 0.789), orientation (4.9 ± 0.3, 4.9 ± 0.3, 4.8 ± 0.4, P = 0.370), immediate memory (14.8 ± 0.4, 14.5 ± 1.0, 14.5 ± 0.5, P = 0.468), mBESS (3.1 ± 2.8, 3.9 ± 2.2, 3.5 ± 3.2, P = 0.578), or VOMS (0.1 ± 0.3, 0.1 ± 0.3, 0.1 ± 0.3, P = 0.836). Groups reached different HR during exertion (84.1 ± 14.3, 133.9 ± 15.9, 155.1 ± 19.0, P < 0.001). After exertion, groups did not differ in symptoms (0.7 ± 1.2, 1.8 ± 3.4, 1.7 ± 5.1, P = 0.872), orientation (4.9 ± 0.3, 4.9 ± 0.3, 4.9 ± 0.4, P = 0.725), immediate memory (14.6 ± 0.7, 14.1 ± 1.3, 14.2 ± 1.1, P = 0.305), mBESS (3.4 ± 3.0, 4.0 ± 3.0, 3.5 ± 2.8, P = 0.801), or VOMS (0.1 ± 0.5, 0.1 ± 0.3, 0.1 ± 0.3, P = 0.810).

Conclusions: This study did not find any groupwise differences in concussion assessment performance after different levels of exertion (none, minimal, or moderate). The effects of maximal exertion cannot be commented on because they were not assessed in this study. In addition, no obvious learning effect was observed in participants who were randomized to the no exertion group, which may be attributed to the ceiling effect.

Significance: This randomized controlled trial did not find any differences in concussion assessment after healthy adolescents had performed no exertion, minimal exertion, or moderate exertion, suggesting that these tests are appropriate for sideline assessment.

Acknowledgments: Galen Argyle.

Primary Author/Presenter: James Jastifer, MD

Affiliation: Western Michigan University Homer Stryker M.D. School of Medicine Department of Orthopaedic Surgery, Ascension Borgess Hospital, Kalamazoo, MI.

COVID-19 in Ultramarathon Runners: Findings of The Ultrarunner Longitudinal TRAcking Study

Topic: COVID.

Study: Cohort.

Purpose: Ultramarathon runners are a unique patient population who have been shown to be free of nearly all severe chronic medical conditions. The effect that COVID-19 infection has on this population and their running behavior is unknown.

Methods: The Ultrarunner Longitudinal TRACking Study (ULTRA Study) is the largest known longitudinal study of ultramarathon runners. Questions on general health status, running behavior, performance, and COVID-19 infection were included.

Results: Six hundred sixty-two ultramarathon runners participated in the study. This group exercised an average of 10.0 hours per week, including running an average of 26.8 miles per week; 52.1% of ultramarathon runners reported ever being symptomatic from a COVID-19 infection with 6.3% testing positive multiple times. Severe infection occurred in 0.3% (2 patients) requiring a total of 3 days of hospitalization. Of those who were infected, 84% were fully vaccinated at the time of their infection; 67% of infections effected running for a mean of 33.1 days. The most common other symptoms included fever (73.3%), fatigue (68.7%), sore throat (67.5%), runny nose (67.0%), and cough (66.7%). Cardiovascular symptoms, which are of particular interest in the running population, included shortness of breath (46.4%), increased heart rate (45.2%), chest pain (34.2%), and wheezing (32.5%). Of 662, 48 (7.3%) of ultrarunners reported Long COVID (symptoms lasting more than 12 weeks).

Conclusions: Severe COVID-19 infection is rare in ultramarathon runners, although symptomatic infection that affects running is common. These rates, along with Long COVID, are lower than is reported in the literature for the population on average.

Significance: Ultrarunners are at very low risk of COVID-19 symptoms requiring hospital care but significant risk of infection that effects running. Cardiovascular symptoms are common, and the long-term significance of these symptoms in runners is unknown.

Primary Author/Presenter: Jacob Jones, MD

Affiliation: Scottish Rite for Children, Dallas, TX.

Increased Ultrasonographic Humeral Retrotorsion in Young Overhead Athletes With Little League Shoulder or Elbow

Coauthors: Cassidy Schultz, BS, Joseph Chang, MD, Hamza Alizai, MD, Jane Chung, MD, Shane Miller, MD, Henry Ellis, MD, Phil Wilson, MD

Topic: Ultrasound.

Study: Cohort.

Purpose: Humeral retrotorsion differences have been noted in older baseball athletes with a history of Little League shoulder. Our purpose is to compare ultrasound humeral retrotorsion angles in young baseball athletes with active upper extremity (UE), physeal, overuse injuries against healthy controls.

Methods: Data were collected prospectively through UE ultrasound registry. Subjects included injured overhead athletes, uninjured overhead athletes, and non-UE athletes who presented to a tertiary, pediatric, sports medicine clinic. Demographics and sports history were obtained. Humeral retroversion angle differences (dominant vs nondominant) were measured through a validated ultrasound method and compared.

Results: Forty-four total athletes with an average age of 11.98 years were included. Three cohorts existed including 21 with active overuse upper extremity physeal injuries (Little League elbow or shoulder), 9 with uninjured overhead athletes, and 14 with non–upper extremity athletes. No significant differences in age, height, weight, race, or ethnicity exist between the groups. Injured and uninjured overhead athlete groups had more male athletes than the non-UE cohort (P = 0.01). Humeral retrotorsion angle differences were observed between athletes with active overuse injuries and non-UE athletes (P = 0.04). No significant angle differences were noted between the active overuse injury group and the uninjured overhead athletes (P = 0.72) or between uninjured overhead athletes and non-UE athletes (P = 0.18). Subanalysis of the injured group shows that those with Little League elbow (n = 9, P = 0.048) showed greater differences than those with Little League shoulder (n = 12, P = 0.13) against non-UE athletes.

Conclusions: Young overhead athletes with active elbow or shoulder physeal overuse injuries have greater humeral retrotorsion angle differences between dominant and nondominant arms compared with non–upper extremity athletes. These differences may be seen more in those with overuse injuries at the distal humerus (Little League elbow) compared with proximal humerus (Little League shoulder). Larger studies are needed to further corroborate these findings.

Significance: This study suggests that greater humeral retrotorsion differences are associated with active upper extremity overuse injuries in overhead athletes. This may have a future role in injury prevention.

Primary Author/Presenter: Daniel Kim, MD

Affiliation: USC Epstein Family Center for Sports Medicine, University of Southern California, Los Angeles, CA.

Evaluation of Spin in Systematic Reviews and Meta-Analyses of Platelet-Rich Plasma Injections for Hip Osteoarthritis

Coauthors: Bryan Bashrum, BA, Cory Mayfield, MD, Ashley Thompson, MD, Maya Zahra, BA, Mina Huang, BA, Frank Petrigliano, MD, Joseph Liu, MD


Study: Other.

Purpose: The primary objective of this study was to describe the incidence and types of spin in abstracts of systematic reviews of PRP injections for hip OA. The secondary objective of this study was to determine whether patterns in study characteristics can be identified among studies with spin.

Methods: A database search was conducted for systematic reviews or meta-analyses of intra-articular PRP injections for hip osteoarthritis. Each included study's abstract was assessed for the presence of the 15 most common types of spin, as described by Yavchitz et al. Study characteristics such as funding source and adherence to PRISMA were obtained, and full texts were assessed by AMSTAR 2.

Results: After duplicate removal and title, abstract, and full-text screening, ultimately 15 studies of the 44 returned in the database search were included in this study. All studies contained at least 2 types of spin (range: 2-9), with a median of 2. The most common type of spin was type 14 (“Failure to report a wide confidence interval of estimates”), which was observed in 10 studies (10 of 15, 67%). The second most common type of spin was type 13 (“Failure to specify the direction of the effect when it favors the control intervention”), which was found in 6 studies (6 of 15, 40%). The spin category that was identified with highest frequency was misleading reporting, which was observed in all 15 studies (15 of 15, 100%). All but one study was found to have a rating of critically low (14 of 15, 93%) according to AMSTAR 2. Lower AMSTAR 2 score was associated with spin type 13 (“Failure to specify the direction of the effect when it favors the control intervention”) (P = 0.0428).

Conclusions: Spin is highly prevalent in abstracts of systematic reviews of PRP in the treatment of hip OA. Several associations were found between spin types and the study characteristics of AMSTAR 2 rating, Scopus CiteScore, journal impact factor, and PROSPERO preregistration. When present, spin in the abstracts of reviewed studies tended to favor the use of PRP in hip osteoarthritis.

Significance: Given the high prevalence of spin in this field, It is especially important to use caution in relying on abstracts to inform clinical decision making and to assess the methodological quality of existing studies using critical appraisal tools.

Acknowledgments: The authors thank the research fellows and faculty of the USC Epstein Family Center of Sports Medicine for their support of this research project.

Primary Author/Presenter: Emily Kraus, MD

Affiliation: Stanford University, Stanford, CA.

Developing a Sports Research Agenda and Translational Practice Informed by Team USA Female Athletes

Coauthors: Julie McCleery, PhD, Kathryn Ackerman, MD, MPH, Ellie Diamond, BS, Rory Kelly, BS, William Adams, PhD, ATC, Longxi Li, PhD

Topic: Education.

Study: Survey.

Purpose: This study used the elite female athlete's voice to drive sports science and sports medicine research agendas and translational practices by identifying topics in which athletes believe that having more research and knowledge is important to their performance, health, and well-being.

Methods: Olympic and Paralympic female athletes competing for Team USA were recruited to gain consensus on sports science and sports medicine topics using a 3-round Delphi survey and Likert scale rating system (5 = strongly agree). Modifications for each round were determined by statistical analysis (mean, topic ranking, mean comparisons of preestablished groups), athlete, and advisory panel feedback.

Results: Forty female athletes (age, 29 years; sports, n = 22; Olympians, n = 34; Paralympians, n = 6) completed Delphi surveys through 2 rounds. The highest ranked topics included fueling and the menstrual cycle (mean = 4.65), birth control options and their impact on health and performance (mean = 4.63), symptoms during menstrual cycle phases (mean = 4.53), strategies to support mental health (mean = 4.50), and recovery (mean = 4.40). Following modification, mean scores for the following topics increased: low energy availability (3.86 to 4.28), birth control options (4.40 to 4.63), and the effect of pregnancy and postpartum on health and performance (4.12 to 4.30). Participant feedback revealed identification of four new topics (nutrition and menstruation, menstrual cycle phases, male-dominated spaces, and team dynamics), which achieved mean scores greater than 4.20 and were ranked within the top 9 (out of 19) topics in the second round. The final Delphi round is underway.

Conclusions: Team USA female Olympic and Paralympic athletes ranked menstrual cycle, birth control, and mental health as top areas where more information on these topics would benefit their health, well-being, and performance. New topics, such as male-dominated spaces and team dynamics, can positively impact coaching and training environments, highlighting the value in coconstructing a research agenda driven by and for elite female athletes.

Significance: The results from this athlete-driven survey have wider implications on a public health and health promotion systems level because they can drive future research strategy and translational practice development for targeting broader populations of athletes.

Acknowledgments: The authors thank Voice in Sport Foundation for funding this study, United States Olympic & Paralympic Committee for help in athlete recruitment, and the Wu Tsai Human Performance Alliance for research program support.

Primary Author/Presenter: Alexandre Lavigne, MD

Affiliation: Department of Physical Medicine and Rehabilitation, Faculty of Medicine, University of Montreal, Quebec, Canada.

Modification of the Tendon Integrity in Midportion Achilles Tendinopathy Monitored With Quantitative Ultrasound Imaging

Coauthors: Dany Gagnon, PT, PhD, Martin Lamontagne, MD

Topic: Ultrasound.

Study: Cohort.

Purpose: To assess the evolution of the Achilles tendon biological integrity according to quantitative ultrasound imaging (QUI) biomarkers in adults affected by midportion Achilles tendinopathy treated with eccentric strengthening and to assess its correlation with pain improvement and treatment adherence.

Methods: A prospective observational study. Participants performed Alfredson eccentric strengthening protocol for 12 weeks. Ultrasound assessments were performed at weeks 0, 12, and 24 to follow the tendon integrity evolution. The QUI biomarkers obtained at each ultrasound assessment were the thickness, echogenicity, variance, and homogeneity. Pain intensity and treatment adherence were documented weekly.

Results: Thirty-one adults affected by midportion Achilles tendinopathy diagnosed clinically and confirmed with ultrasound imaging, and symptomatic for more than 6 weeks and less than 2 years were recruited. The average age was 49.9 years, the average duration of pain since the Achilles tendinopathy onset was 28.8 weeks, and the average initial pain intensity was 6.9/10 at the time of recruitment. Over the 24-week study, the average longitudinal homogeneity decreased from 0.612 to 0.591 (P = 0.02), and the average transverse echogenicity increased from 64.5 to 74.1 (P less than 0.0001), which both represent an improvement in the tendon integrity. The other biomarkers also varied in the hypothesized way but did not reach statistically significant differences. The Pearson correlation coefficient was low (less than 0.30) for both the longitudinal homogeneity and the transverse echogenicity when compared with either the pain improvement or the treatment adherence.

Conclusions: The tendon biological integrity in midportion Achilles tendinopathies seems to improve over time when performing eccentric strengthening exercises, according to our QUI analysis. The most responsive QUI biomarkers were the longitudinal homogeneity and the transverse echogenicity. A greater pain improvement or treatment adherence did not translate into a superior tendon integrity improvement.

Significance: This study confirms the usefulness of QUI biomarkers extrapolated with artificial intelligence software so that sports medicine clinicians can follow in vivo healing of tendon tissue when going through a specific tendinopathy treatment.

Acknowledgments: The research team wants to thank Mrs. Marie-Claude Bois, who helped recruit and schedule participants.

Primary Author/Presenter: Warren Lawless, DO

Affiliation: Community Health Network Primary Care Sports Medicine Fellowship Indianapolis, IN.

Do Social Determinants of Health Have an Impact on Return to Play From Concussion?

Coauthors: William Long, DO, Andrew Jeon, DO, Jacklyn Kiefer, DO

Topic: Concussion.

Study: Other.

Purpose: Determine the role of social determinants of health (SDoH) in starting the “return-to-play” progression following a sports-related concussion in high school athletes. We hypothesized that high school athletes with 2 or more positive SDoH will take longer to return to play.

Methods: This is a retrospective study. Eligible participants included high school athletes diagnosed with sports-related concussion between August 1, 2021, and January 31, 2022, seen in Indianapolis. Athletes with a history of 3 or more concussions, neurological or mental health disorders, or previous prolonged concussion recovery (over 8 weeks) were excluded. Families of eligible athletes completed the SDoH survey.

Results: Two hundred twenty-one athletes were initially identified. Of these, 117 athletes were excluded based on the criteria listed above. Each of the 104 remaining families were called on 3 separate occasions to complete a brief SDoH survey. Responses were received from 53 families with the remaining participants' families either not answering the call or declining participation. Of these 53 responses, 36 athletes were deemed low risk (1 SDoH or less) and 17 were deemed high risk (2 SDoH or more). The median number of days to clearance for both the low-risk and high-risk groups were 16 days. The range of clearance for low-risk athletes was 4 to 46 days, and the range of clearance for high-risk athletes was 3 to 74 days. Comparison was completed using a Mann–Whitney U test, which showed no statistically significant difference between the number of days to starting the return-to-play progression between low-risk and high-risk SDoH athletes (P = 0.970).

Conclusions: SDoH do not play an important role in determining concussion recovery time in high school athletes who sustained the injury during sport because the average time to starting the return-to-play progression was 16 days for both the groups. One limitation includes selection bias because we were unable to reach 51 of our eligible athletes. Future prospective studies with the completion of SDoH surveys at the time of diagnosis could aid in reducing this bias.

Significance: This study indicates that SDoH in high school athletes do not play a role in the duration of concussion recovery. As a result, we likely do not need to alter current outreach strategies for concussed high school athletes in the high-risk SDoH group.

Primary Author/Presenter: Artemii Lazarev, MD

Affiliation: Mount Sinai Hospital, Chicago, IL.

Asymptomatic Radiologic Groin Region Findings in Professional Soccer Players

Coauthors: Eduard Bezuglov, MD, Alesya Brodskaya, MD, Sergey Izmailov, Anastasia Lyubushkina, Anton Emanov, Ryland Morgans

Topic: Musculoskeletal.

Study: Other.

Purpose: To investigate the prevalence of asymptomatic radiologic groin region findings in adult professional soccer players using magnetic resonance imaging (MRI) and examine the influence of age and limb dominance on their occurrences.

Methods: In this cross-sectional study, a total of 47 male professional soccer players (age 24.5 ± 5.4 years, height 181.5 ± 5.7 cm, weight 75.1 ± 6.8 kg, and BMI 22.8 ± 1.3) underwent a presigning groin MRI scan with a magnetic field induction of 1.5 T and the Copenhagen Standardized MRI protocol. The prevalence of asymptomatic radiologic groin region findings was assessed.

Results: Image analysis revealed an extremely high prevalence of asymptomatic changes in the pubic bones in adult professional soccer players. Fifty pubic bones and adjacent regions (53.2%) highlighted 1 to 4 changes, whereas another 44 pubic bones and adjacent regions (46.8%) demonstrated 5 or more changes. The most frequent changes observed were pubic bone joint surface irregularities (100%), symphyseal sclerosis (93.6%), parasymphyseal high-intensity line (55.3%), fatty infiltration in bone marrow (38.3%), adductor tendinopathy (34%), and subchondral cysts (29.8%). Pubic bone swelling was also common (56.4%). It was most often of the first degree (30.8%), but swelling of the second and third degrees was also quite common (17% and 8.5% of bones, respectively). In the dominant and nondominant limbs, no statistically significant differences were found. Among all the changes found, only the prevalence of fatty infiltration in bone marrow and symphyseal sclerosis were associated with age.

Conclusions: Asymptomatic radiologic groin region findings are extremely common in adult professional soccer players with no prior complaints. Bone marrow fatty infiltration and symphyseal sclerosis were associated with age. None of these changes were associated with limb dominance.

Significance: Knowledge of the high prevalence of asymptomatic radiologic groin region findings is important in the assessment of soccer players with groin pain. This fact should be taken into account during diagnostic evaluation and treatment planning.

Primary Author/Presenter: Joshua E Lider, DO

Affiliation: University of California, Davis, Sacramento, CA.

National Rates of Headgear Use in High School Varsity Girls Lacrosse

Coauthors: Mitchell P. Anderson, MD, Leon Luong, BS, Ryotaro Fukuda, MS, Lily Justine, BS, Patricia M. Kelshaw, PhD, ATC, Shane V. Caswell, PhD, ATC, Daniel C. Herman, MD, PhD

Topic: Concussion.

Study: Other.

Purpose: State mandated headgear (HG) use in girls' lacrosse (GLAX) is associated with lower concussion risk; however, little is known about voluntary HG use in states without mandates. The goal of this study was to investigate nationwide rates of GLAX HG use and school characteristics associated with use.

Methods: The total number of athletes and those using HG (excluding goalies) were recorded once for each GLAX team (excluding Florida, which mandates HG) using a national game film database from the 2022 season. Teams were categorized by school (public or private) and region (established or emerging). χ2 tests were used to assess for proportional differences by these characteristics.

Results: Two thousand two hundred fifty-four teams representing 42,395 athletes were evaluated, with only 668 athletes (1.58%) observed as wearing HG. There were 18 teams with all athletes wearing HG (0.80% of 2,254 teams). Athletes from these 18 teams accounted for 43.7% of total HG use; excluding these teams as outliers resulted in a HG use rate of 0.89% (376 of 42,103 athletes). Use of HG was similar among public (0.96% of 34,600 athletes) and private (0.84% of 7,572 athletes) school teams (χ2 = 0.938, P = 0.333). We observed a lower proportion of HG use in established regions (Northeast and Mid-Atlantic, 0.67% of 22,103 athletes) versus emerging regions (South, Midwest, and West, 1.14% of 19,981 athletes, χ2 = 24.84, P < 0.001). We conducted a post hoc analysis using published concussion rates from HG and non-HG GLAX play and estimated that a national HG mandate may result in an annual reduction of 559 concussions just among the athletes represented in our data set.

Conclusions: Use of HG in GLAX athletes among states without mandates is exceedingly low. Although no differences in school type were observed, differences between the regions suggest that regions with more established lacrosse traditions as categorized by a previously established classification system may contribute to reluctancy to use HG. Given these low levels of use, a large opportunity for concussion prevention exists through education or mandates regarding lacrosse HG.

Significance: This study establishes a baseline level of HG use to evaluate the response to emerging evidence supporting HG. Different policy strategies or communication approaches may be needed to increase HG use among athletes in different regions.

Acknowledgments: Th authors thank the National Operating Committee for Standards on Athletic Equipment for their grant support of this project.

Primary Author/Presenter: David Mikhail, BS

Affiliation: University of Texas Southwestern Medical Center, Dallas, TX.

A Longitudinal Evaluation of Differences Between First and Second Concussion Among Pediatric Patients

Coauthors: Omair Muzaffar, BS, Linda Hynan, PhD, Munro Cullum, PhD, Shane Miller, MD

Topic: Concussion.

Study: Survey.

Purpose: Sports participation is a popular activity among youth with many benefits. Sport-related concussion is a common injury in youth athletes. Recurrent concussions among pediatric patients have been associated with longer symptom duration and recovery times with subsequent injuries.

Methods: Data were obtained from 31 participants (14 females) in The North Texas Concussion Registry (ConTex) of 6 to 17 years who suffered a second concussion (M = 19.7 months later) after study enrollment. Symptom logs, GAD-7, PHQ-8, and BRS scores, which evaluate anxiety, depression, and resilience, and ImPACT scores, which examine neurocognitive functioning, were compared at the initial visit and 3-month follow-up.

Results: Comparing mean scores at the initial visit and 3-month follow-up, a repeated-measures ANOVA showed significant differences for symptom log total (P < 0.001), number of endorsed symptoms (P < 0.001), GAD-7 (P = 0.00), PHQ-8 (P = 0.044], and BRS (P = 0.002) with all measures improved at 3-month follow-up. No significant differences were found between concussions 1 and 2 for these variables. A paired samples t-test was conducted to determine the effect of the number of concussions on neurocognitive functioning using ImPACT scores at the initial presentation. A slight improvement in scores was observed after the second concussion. Headache, photophobia, and trouble concentrating were the most frequently reported symptoms for both concussions. Cognitive symptoms were more commonly reported with the second concussion. At the 3-month follow-up, 22 of 28 patients after their first concussion and 24 of 28 patients after their second concussion reported being cleared to return to play.

Conclusions: Pediatric patients presented similarly following first and second concussion and demonstrated similar time to return to play. The shift to more cognitive symptoms in the second concussion may be of some concern; however, this requires further evaluation. Neurocognitive abilities were not shown to be negatively impacted by a subsequent concussion.

Significance: The similar presentation of a second concussion in young athletes may be attributed to the long period to recover from the first concussion. Conservative vigilant treatment is necessary to improve concussion outcomes in pediatric patients.

Acknowledgments: The North Texas Concussion Registry (ConTex) is supported by a grant from the Texas Institute for Brain Injury and Repair at the UT Southwestern Medical Center. This study was conducted as a part of the UT Southwestern Medical Student Summer Research Fellowship.

Primary Author/Presenter: Emily Miro, MD, MPH

Affiliation: University of Utah.

Does Hormone Treatment Affect Incidence of Sports Injury in Transgender Patients: A Scalable Pilot Study

Coauthors: Andrew Curtin, MSTAT, Michael Newman, PhD, MS, Dominik Ose, PhD, Eliza Tayler, MPH, Theodore Paisley, MD, Jordan Knox, MD

Topic: Epidemiology.

Study: Cohort.

Purpose: Research shows an effect of estrogen on injury rate discrepancies between cisgender male and female patients, particularly in ACL injury, stress fracture, and concussion. Little is known regarding the incidence of sports injuries among patients on gender affirming hormone therapy (GAHT).

Methods: This retrospective cohort study evaluated one large academic health system from 2011 through 2020. Transgender patients were identified using ICD-9 and ICD-10 codes and relevant GAHT medications in their record. Cisgender age-matched controls were assigned in a 1:2 ratio of cases to controls. Using relevant ICD-9 and ICD-10 codes, incidence of ACL injury, concussion, and stress fracture were calculated.

Results: One thousand nine hundred seventy-five cases and 3964 controls were identified. Of these, 62% cases were on feminizing GAHT, and 38% were on masculinizing GAHT. Transgender cases had statistically significantly higher incidence of ACL injuries compared with controls (5.7% versus 4.4%, P < 0.001). There was no significant difference between the incidence of concussions or stress fractures in cases versus controls. Data on ACL injury were further analyzed to examine incidence in cisfemale, cismale, transfemale, and transmale patients. There was a statistically significant difference in the incidence of ACL injuries among transfemale versus cisfemale controls (5.7% versus 4.1%, P < 0.001). No significant difference in incidence was found between cismale and transfemale patients (5.6% versus 5.7%, P = 0.92) or cisfemale versus transmale patients (4.1% versus 5.0%, P = 0.26).

Conclusions: This study found that patients on GAHT had significantly increased incidence of ACL injuries compared with controls. Furthermore, patients on feminizing therapy had significantly increased incidence of ACL injuries compared with cisfemales. Notably, this study is limited by small sample size of relevant injuries. Further study is warranted to develop more detailed description of the incidence of sports injuries in the transgender athlete population.

Significance: The observed difference in the incidence of ACL injuries suggests an impact of GAHT on musculoskeletal health. In studying injuries in transgender patients, we hope to ultimately provide improved health care to this vulnerable population.

Acknowledgments: This work was supported in part by the Health Studies Fund, Department of Family and Preventive Medicine, University of Utah Spencer Fox Eccles School of Medicine.

Primary Author/Presenter: Vicki Nelson, MD, PhD

Affiliation: Steadman Hawkins Clinic of the Carolinas, Prisma Health Upstate, Greenville, SC.

Identified Screening Decreases Self-Reported Mental Health Symptoms in College Athletes

Coauthors: Franklin Sease, MD

Topic: NCAA.

Study: Cohort.

Purpose: To identify the effect of anonymous versus identified screening for depression, anxiety, and eating disorders in college student athletes.

Methods: NCAA athletes were screened for mental health disorders from 2020 to 2022 using the PHQ-9 (depression), GAD-7 (anxiety), and SCOFF (eating disorder) questionnaires. A positive result was identified as greater than or equal to PHQ-9, 10; GAD-7, 10; and SCOFF, 2. Surveys were completed through the same online platform with or without collection of names. The χ2 test was used to compare groups.

Results: One thousand five hundred twenty-six collegiate athletes (two-third male) participated. Overall, 1079 athletes completed identified screening, whereas 447 reported anonymously. Positive screening captures were significantly reduced in each category in the identified group compared with the anonymous screening. Prevalence of positive screening dropped from 11.3% to 1.2% (P < 0.0001) on the PHQ-9, from 15.3% to 2.5% (P < 0.00001) on the GAD-7, and from 6.4% to 3.1% (P < 0.01) on the SCOFF. Overall, positive screening on any of the tools dropped from 22.6% to 5.3% (P < 0.00001).

Conclusions: The prevalence of positive mental health screening in student athletes is dramatically lower when athletes are identified compared with anonymous screening. Of note, the prevalence seen in anonymous screening is comparable to previously reported studies among college students and student athletes leading us to believe that the identified screening reflects an underreporting of symptoms.

Significance: Mental health symptoms are prevalent in the collegiate population. Universal screening in athletes is difficult, and this study suggests that additional strategies may be needed to accurately identify at-risk athletes and combat underreporting.

Primary Author/Presenter: Hye Chang Rhim, MD, MPH

Affiliation: Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, Massachusetts.

Reliability of an Ear-Worn Wearable Device for Measuring Running Gait Parameters

Coauthors: Chang Keun Jung, MS, Jinkyuk Kim, BS, Hyeob Choi, PhD

Topic: Running.

Study: Cohort.

Purpose: The purpose of this study was to determine the reliability and agreement of an ear-worn wearable device compared with a reference system composed of motion capture system and forced treadmill for estimating running gait parameters.

Methods: Twenty young, healthy adults (10 men and 10 women) participated in this experiment. The participants ran at 3 different speeds (2, 2.5, 3 m/s) for 2 minutes. Gait parameters, including cadence, stance time, flight time, peak force, instantaneous vertical loading rate (IVLR), and vertical oscillation, were collected through both ear-worn device and reference system and then compared.

Results: Reliability levels were established by calculating the intraclass correlation coefficient (ICC) using a 2-way random-effects model between the ear-worn device and the reference system. Interrater reliability was found to be excellent for all running parameters: cadence (ICC, 1.00; 95% CI 1.00-1.00), stance time (ICC 0.96; 95% CI 0.93-0.98), flight time (ICC, 0.96; 95% CI 0.93-0.98), peak force (ICC 0.98; 95% CI 0.96-0.99), IVLR (ICC 0.93; 95% CI 0.88-0.96), and vertical oscillation (ICC 0.95; 95% CI 0.87-0.97). The agreement level between the systems were assessed with Bland–Altman plots, bias, and limits of agreements (LOA): cadence (bias -0.0029 steps/min, LOA -0.468-0.411), stance time (bias -0.001s, LOA -0.024-0.022), flight time (bias 0.001s, LOA -0.022-0.024), peak force (0.012G, LOA -0.133-0.157), IVLR (bias 0.183 G/s, LOA -28.1-28.5), and vertical oscillation (bias -0.003 m, LOA -0.017-0.01). Most of the trial data were within the upper and lower LOA.

Conclusions: The results of the current study showed excellent reliability and good agreement between the ear-worn wearable device and the traditional, laboratory-based reference system for running gait parameters. This ear-worn wearable device can be a simple and inexpensive alternative to conventional gait analysis equipment for selected running parameters.

Significance: IVLR has been implicated in running-related injuries, and this ear-worn device can be used for gait retraining to reduce IVLR for injury prevention in natural environment without requiring laboratory, expensive equipment, and trained personnel.

Acknowledgments: This study was supported by The Sports Promotion Fund of Seoul Olympic Sports Promotion Foundation from the Ministry of Culture, Sports and Tourism. (1375027355).

Primary Author/Presenter: Brendon S. Ross, DO, MS

Affiliation: University of Chicago.

Physician Recommendations and Perceptions of Cannabinoids Within Sports Medicine

Coauthors: Thomas Trojian, MD, Daniel Cushman, MD

Topic: Musculoskeletal.

Study: Survey.

Purpose: To determine if sports medicine (SM) physicians are recommending Cannabidiol (CBD) and Cannabis for therapeutic purposes, as well as analyze perceptions regarding CBD and Cannabis within SM and performance.

Methods: Physician members of the American Medical Society for Sports Medicine (AMSSM) completed an anonymous survey regarding demographics, CBD and Cannabis recommendations, and attitudes toward CBD and Cannabis within SM and performance. In addition, factors associated with perceptual differences and those recommending CBD and Cannabis were identified using multivariate logistical regression.

Results: A total of 333 responses were completed (10.8% response rate). The following groups were less likely to agree with allowing Cannabis for recreational purposes: female gender (coeff. = 0.79 [95% CI 0.33-1.25], P = 0.001), advanced age (coeff. = 0.04 [0.02, 0.07], P < 0.001), and rural respondents (compared with baseline urban, coeff. = 1.16 [0.36, 1.95], P = 0.004). Similarly, these three factors were associated with a higher likelihood of disagreeing with WADA removing Cannabis from the prohibited substance list and with NCAA permitting CBD use by collegiate athletes (P ≤ 0.045). CBD was less likely to be recommended by pediatricians, rural physicians, and academic physicians (P ≤ 0.030). Male physicians and younger physicians were less likely to identify Cannabis as performance enhancing (P ≤ 0.042).

Conclusions: AMSSM physician members are recommending CBD and Cannabis not only for chronic musculoskeletal and neuropathic pain but also for sport-related concussion and sports performance anxiety. Although SM physicians generally have favorable attitudes toward CBD and Cannabis, these perceptions appear to be significantly affected by age, practice type, and gender.

Significance: This study is the first to illustrate the evolving recommendations and perceptions of CBD and Cannabis among SM physicians.

Primary Author/Presenter: Leinaala Song, MD

Affiliation: University of Washington Sports Medicine, Seattle, WA.

Long-Term Outcomes of Percutaneous Ultrasound Guided Tenotomy—A Retrospective Analysis of 286 Cases

Coauthors: Ashwin Rao, MD, FAMSSM

Topic: Musculoskeletal.

Study: Other.

Purpose: Percutaneous ultrasound guided tenotomy is a promising emerging treatment for chronic refractory tendinopathy. The purpose of this study is to evaluate pain reduction, patient satisfaction, and return-to-play outcomes for patients undergoing the Tenex procedure.

Methods: We conducted a retrospective review of the University of Washington Sports Medicine clinic patients who underwent percutaneous ultrasound-guided tenotomy from 2017 to 2022. Data were collected by chart review followed by a patient survey to supplement any missing data. Primary outcomes included decrease in pain, patient satisfaction, and rate of return to activity between tendon targets.

Results: Two hundred eighty-six subjects ages 21 to 79 years receiving the Tenex procedure were included. The majority (62.9%) of patients had experienced pain for over a year before the procedure and had failed numerous prior treatments, including formal physical therapy (88.6%), oral analgesics (82.9%), steroid injection (34.3%), and PRP injections (17.1%). Treatment sites included the common extensor tendon (21.68% of total cases), rotator cuff (22.73%), patellar tendon (16.08%), Achilles (25.52%), quadriceps tendon (0.70%), gluteal tendons (2.80%), iliotibial band (0.35%), and plantar fascia (10.14%); 90.9% of patients had improvement in pain, of which 54.5% had complete resolution of pain. Only 9.1% reported no improvement. Post procedure satisfaction rate was 84.8%, with the highest satisfaction rates with the plantar fascia, common extensor, and rotator cuff tendons; 78.8% of patients were able to return to activity. There was a correlation between poor satisfaction and those with comorbid psychiatric conditions.

Conclusions: Percutaneous ultrasound-guided tenotomy is safe, effective, and beneficial in the treatment of tendinopathy and fasciopathy, appearing to be most effective for plantar fasciopathy, common extensor, and rotator cuff tendinopathy. Psychiatric comorbidity may predict a poor response to this treatment.

Significance: Although many case studies report decreased pain and sustainability after percutaneous tenotomy, this is the first study comparing outcomes between targeted locations in a large cohort, while tracking patient satisfaction, pain, and return to activity.

Acknowledgments: University of Washington Sports Medicine Stadium Clinic.

Primary Author/Presenter: Austin Stoner, BS

Affiliation: Female Athlete Science and Translational Research (FASTR) Program, Department of Orthopaedic Surgery, Stanford University, Palo Alto, CA.

A Novel Approach to Female Athlete Sports Science Education and Impact

Coauthors: Megan Roche, MD, Abby McIntyre, BS, Ellie Diamond, BS, Carolyn Oliver, MS, Emily Kraus, MD

Topic: Education.

Study: RCT.

Purpose: The aim of this study is to assess engagement, impact, and change in knowledge in high school female runners using a novel, educational video platform about female athlete health and performance with expert teaching and stories from top athletes compared with more traditional means of education.

Methods: Participants completed a baseline survey and were randomized to 2 groups. The intervention group was given videos and the control group educational links covering Triad/RED-S, nutrition, bone health, menstrual cycle, and mental health. Postcontent quizzes were given. A final survey assessed self-reported impact (Likert scale 1-5). Data analysis included mean comparisons and paired t-tests.

Results: Eighty-two female runners (mean age, 15.9 years) at 14 US high schools completed baseline surveys; 86.8% (33/38) of controls and 79.6% (35/44) in the intervention completed all study components. Overall knowledge scores increased from 77.9% to 93.6% and from 75.7% to 93.1% in the control and in the intervention groups, respectively. Baseline knowledge scores were lowest for menstrual cycle and bone health in both the groups. Exposure to new information was higher in the intervention group compared with controls for bone health (4.32, 3.82, P = 0.019) and menstrual cycle (4.15, 3.52, P = 0.002). Interest in the topic was higher in the intervention compared with controls for Triad/RED-S (4.18, 3.27, P < 0.001), nutrition (4.15, 3.52, P = 0.002), bone health (4.03, 3.48, P = 0.019), menstrual cycle (4.25, 3.67, P = 0.005), and mental health (4.13, 3.67, P = 0.035). Impact on behavior was higher in the intervention compared with controls for bone health (4.00, 3.39, P = 0.006) and menstrual cycle (3.78, 3.15, P = 0.013).

Conclusions: We saw high participation of adolescent female runners in an educational intervention on health and performance with improved knowledge in both the intervention and control groups. Self-reported interest, new information, and impact on behavior were increased in the intervention group compared with controls for several topics. Further research is needed to assess the impact of educational platforms on long-term health, performance, and behavior.

Significance: This study demonstrates the efficacy of novel educational videos with expert teaching and stories from top athletes to educate young female athletes on topics surrounding Triad/RED-S and to offer potential long-term cognitive and behavioral change.

Acknowledgments: The authors thank the Wu Tsai Human Performance Alliance for funding this study.

Primary Author/Presenter: Brett Toresdahl, MD

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

Investigating Novel Risk Factors for Training Injuries Among Runners of the New York City Marathon

Coauthors: Briana Quijano, MS, Mark A. Fontana, PhD

Topic: Running.

Study: Cohort.

Purpose: Given the high incidence of injury during marathon training, a better understanding of the factors associated with injury is needed. The purpose of the study was to investigate an expanded set of baseline factors of marathon runners to determine the association with injury during training.

Methods: Adult registrants of the 2022 New York City Marathon were recruited by email for a 16-week observational study. The baseline survey included demographics, running/injury/COVID history, race goal, orthotic use, grit scale, risk-taking scale, injury risk self-assessment, happiness and life satisfaction scales, and perceived risks of running. Injury surveys were collected weekly during training.

Results: A total of 894 runners registered for the study and were uninjured at the start of the study. Average age was 44.5 years (standard deviation 11.8), 55% were female, and 76% had previously participated in a marathon. During the 16 weeks before the race, 221 of 894 (24.7%) experienced an injury, including 36 of 894 (4.0%) who did not participate in the race. Each of the baseline factors were assessed in a logistic regression model controlling for age, sex, body mass index, base weekly mileage, and number of prior marathons. The baseline factors associated with injury were orthotic use (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.12-2.74, P = 0.01), happiness (OR 0.71, 95% CI 0.58-0.88, P = 0.001), and injury risk self-assessment (OR 1.13 for each 10% self-assessed risk, 95% CI 1.05-1.21, P = 0.001). There was no association with age, sex, body mass index, running/injury/COVID history, race goal, grit, risk-taking behavior, life satisfaction, and perceived risks of running.

Conclusions: Although age, sex, experience, and history of injury have been previously identified as risk factors for running-related injury, this was not the case in this large cohort of runners training for a marathon. Instead, orthotic use and self-assessed risk of injury were associated with higher rates of injury training, and a higher level of happiness was associated with lower rates of injury.

Significance: The results show the value of a comprehensive running injury risk assessment, which could be standardized to facilitate comparative research. Accounting for these factors is important when assessing future injury prevention interventions.

Acknowledgments: The authors wish to thank New York Road Runners for their assistance with recruiting runners for this study.

Primary Author/Presenter: David Tramutolo, DO

Affiliation: University of Missouri, Columbia, MO.

Convergence Insufficiency Is an Objective Predictor of Persistent Postconcussion Symptoms and Chronic MTBI

Coauthors: Andrew Prouty, Kort Brashears, Brian Toedebusch, MD, Brett Dusenberry, MD, Leslie Streeter, DNP, Leila Samsan, DNP, Mo Mortazavi, MD

Topic: Concussion.

Study: Cohort.

Purpose: Twenty percent to thirty percent of patients with mild traumatic brain (mTBI) injury may develop prolonged postconcussion symptoms (PPCS). No valid predictor model exists to identify those at risk for PPCS. The purpose of this study is to determine whether convergence insufficiency has a predictive value for PPCS.

Methods: A retrospective cohort study of 50 mTBI patients. Inclusion criteria included age < 25 years and near point convergence (NPC) evaluation within 1 month of mTBI onset at presenting visit. NPC was measured with a digital device and confirmed by a concussion specialist. Patients were dichotomized based on PPCS duration (<3 months, n = 16, group 1; >3 months, n = 34, group 2). T-test was used for comparison.

Results: NPC break was lengthened in the chronic recovery group, Group 2 (mean ± SD, 13.7 ± 8.4 cm) compared with the subacute group 1 (6.7 ± 2.7 cm, P = 0.002). In group 2, 50% of patients had a presenting NPC greater than 12 cm, and only 15% of patients had a normal presenting NPC less than 6 cm. The remaining patients presented with NPC between 6 and 12 cm. In group 1, none of the group presented with an NPC of >12 cm at the initial evaluation, and 50% of patients had a normal presenting NPC lower than 6 cm. The remaining patients presented with NPC between 6 and 12 cm. All subjects presenting with an initial NPC of >12 cm had prolonged recoveries, and a chronic course with symptoms of >3 months.

Conclusions: Our preliminary data showed a significant difference in presenting mean NPC break between subacute (<3 months) and chronic (>3 months) postconcussion symptoms. Moreover, our data suggest that there may be a critical NPC break threshold for predicting chronic course in patients with PPCS longer than 3 months because all patients with NPC break of >12 cm were noted to have PPCS of >3 months.

Significance: The notion of an NPC break critical level being related to PPCS may have prognostic value but requires further study. Validation of such an objective tool for prognostic purposes would be a significant advancement in the care of mild TBI patients.

Primary Author/Presenter: Andrew Watson, MD, MS

Affiliation: University of Wisconsin School of Medicine and Public Health Madison, WI.

Race and Socioeconomic Status Influence the Benefits of Returning to Sports During COVID-19

Coauthors: Kristin Haraldsdottir, PhD, Scott Anderson, MS, Quinn Stiner, BS, Timothy McGuine, PhD

Topic: COVID-19.

Study: Cohort.

Purpose: It is unknown whether certain populations of athletes benefit more from returning to sport following COVID-19 restrictions than others. The purpose of this study was to determine whether socioeconomic status (SES), race, or gender moderate the benefits of returning to sports during COVID-19.

Methods: Adolescents who participated in sports before COVID-19 reported sport participation, anxiety (GAD-7), and depression (PHQ-9) in May 2021. The interactions of return to sport (yes [PLY], no [DNP]) and (1) sex, (2) race (white, non-white), and (3) SES (low vs high county household income) to predict anxiety and depression were evaluated, adjusted for age, school instruction, and concern about COVID-19.

Results: Four thousand eight hundred seventy-four participants were included (16.1 ± 1.3 years; 52% female; PLY = 4456; DNP = 418). DNP had greater symptoms of anxiety (7.8 ± 0.6 v 5.6 ± 0.5, P < 0.001) and depression (8.8 ± 0.6 v 5.7 ± 0.6, P < 0.001) and had significantly more non-white athletes (36% v 19%, P < 0.001), but no significant differences were identified with respect to gender, instructional delivery method, median county household income, or age. Compared with white athletes, adolescent athletes from racial minority groups who returned to sports had relatively greater decreases in anxiety (interaction estimate (b) = -1.18 ± 0.6, P = 0.036) and depression (b = -1.19 ± 0.6, P = 0.045). Similarly, athletes from counties with lower household incomes who returned to sports had relatively greater decreases in anxiety (b = -1.23 ± 0.5, P = 0.017) and depression (b = -1.21 ± 0.6, P = 0.032). The benefits of returning to sports for female athletes were similar to male athletes with respect to anxiety (b = -0.16 ± 0.5, P = 0.76) and depression (b = 0.49 ± 0.6, P = 0.37).

Conclusions: In this nationwide sample of adolescent athletes, returning to sport during COVID-19 was associated with significant mental health benefits for adolescent athletes. However, the greatest benefits were seen among athletes from racial minority groups and areas of lower household income. No differences in the mental health benefits of returning to sports were identified between male and female athletes.

Significance: Restriction from sports may disproportionately impact the mental health of certain groups of adolescent athletes. Expanding access to sports for traditionally underserved groups can potentially provide significant mental health benefits.

Primary Author/Presenter: Matthew W. Wise, DO

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

Association of Asymptomatic Tendinopathy on Ultrasound With Future Injuries in Collegiate Athletes

Coauthors: Andrea Carefoot, MD, Luke Johnson, BS, Daniel Cushman, MD

Topic: Ultrasound.

Study: Cohort.

Purpose: Pathologic changes to tendons on ultrasound (US) in asymptomatic runners are associated with pain in these tendons at 1 year. We aim to determine whether asymptomatic signs of tendinopathy on US are associated with any future lower extremity musculoskeletal (MSK) injuries across sport.

Methods: Preseason US scans of the patellar and Achilles tendons were performed on male and female NCAA Division I student athletes across 11 sports. Blinded review of the scans was performed to identify abnormalities: hypoechogenicity, thickening, and neovascularity. Student athletes were monitored over a full year for any future lower extremity MSK injury related or unrelated to the affected tendon.

Results: A total of 243 student athletes from 3 institutions were enrolled. Sonographic abnormalities were seen in 17.7% of athletes' Achilles tendons (one or both) and 49.0% of their patellar tendons. A preexisting Achilles tendon abnormality was associated with 2.00 times the odds of developing another musculoskeletal injury (95% CI 1.02, 3.90; P = 0.042), based on a univariate logistic regression analysis. Patellar abnormalities were not related to future injury (P = 0.535). Subanalysis by sex and sport did not reveal any further significant associations.

Conclusions: Preexisting structural changes to the Achilles tendon on US were seen in 18% of athletes. Over 1 year, athletes with these findings, regardless of sex or sport, were 2 times more likely to develop any other lower extremity MSK injury. This study only identified an association and did not identify the etiology of this relationship.

Significance: US evaluation of tendons may be useful in identifying asymptomatic structural changes that, in the Achilles tendon, are associated with future lower extremity MSK injuries. Further research is needed to identify effective preventive interventions.

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