Impact of Minimally Invasive Ultrasound Guided Tenotomy on Long-Term Recovery From Tennis Elbow
Primary Author/Presenter: Joseph Panzera, DO
Affiliation: Crozer Family Medicine Residency, Springfield, PA
Co-Authors: Peter Cronholm, MD, MSCE, FAAFP, David Webner, MD, FAMSSM
Purpose: The purpose of this study is to establish a comprehensive understanding of the use of ultrasound-guided elbow percutaneous tenotomy for long-term improvement of symptom burden and functional status in patients with lateral epicondylosis, commonly known as tennis elbow.
Methods: DASH questionnaire responses were summed to generate a total score. A symptom-item averaging approach was used to generate a total symptom score. Univariate descriptives were generated with means and SD for continuous variables and proportions for categorical variables. Paired t-testing was used for differences in continuous variables and ANOVA using the t-test function for associations.
Results: A total of 62 patients (52% female; median age in years (IQR): 55 (34, 75)) completed the DASH questionnaire before ultrasound-guided percutaneous elbow tenotomy. Of the 62 patients, 45 (73%) completed a second DASH questionnaire, an average of 1001.4 days (IQR: 268, 1761) post-tenotomy. Participants achieved an average improvement in total score from an average of 78.7 to 35.1 with a total difference of 43.27 (SD 22.42) and an improvement in symptom score from 40 to 4 with a total difference of 36.1 (SD 18.68). Significant improvement in total score and symptom score (P = < 0.0001) were observed. Most patients (n = 61 (98%)) reported an improvement in symptom score post-tenotomy. There were no discernable differences among gender, race, age, or insurance type. No significant difference in results between athletes and nonathletes, laterality of procedure performed, or type of activity of greatest impact were observed.
Conclusions: Ultrasound-guided percutaneous tenotomy produces clinically significant improvement in patient symptom burden and functional status determined by total DASH score for lateral epicondylosis. Results suggest there is long lasting improvement in symptom burden an average of 1000 days (3 years) post-tenotomy. Further research is required to determine whether improvement in symptoms after tenotomy continues beyond 3 years post-tenotomy procedure.
Significance: Ultrasound-guided percutaneous tenotomy is a useful treatment modality improving symptom burden and long-term clinical outcomes with no discernable differences among age, gender, laterality, and insurance type in those with lateral epicondylosis.
Acknowledgments: Special thank you to Crozer Sports Medicine.
The Relationship Between Subjective and Objective Cognition in Older Former NFL Players With Varying Head Injury History
Primary Author/Presenter: Andrew Allen, BS
Affiliation: Medical College of Wisconsin, Milwaukee Wisconsin
Co-Authors: Wesley Cole, PhD, Zachary Kerr, PhD, Samuel Walton, PhD, Avinash Chandran, PhD, William Meehan III, MD, Michael McCrea, PhD, Benjamin Brett, PhD
Purpose: The objectives of the study were to: (1) examine the association between subjective and objective indicators of cognition in former professional football players ages 50-70 with and without covariates and (2) investigate the association of concussion history with subjective and objective cognition.
Methods: PROMIS and Neuro-QoL inventories measured subjective cognition. Objective episodic memory and executive functioning was assessed with the Brief Test of Adult Cognition by Telephone (BTACT). Covariates included depression and race. Regression models examined the association between subjective and objective cognition, and associations of concussion history and years of football with cognition.
Results: Former players (n = 172) completed measures of cognition within 3 months of each other. Concussion history was as follows, 0 (n = 12;7%), 1-2 (n = 21;12.2%), 3-5 (n = 41;23.8%), 6-9 (n = 26;15.1%), 10+ (n = 72;41.9%). General subjective cognition (PROMIS) was significantly associated with episodic memory (ηp2 = 0.120, P < 0.001) and executive function (ηp2 = 0.178, P < 0.001) on the BTACT. Including covariates reduced the strength of association (episodic memory, ηp2 = 0.081; executive function ηp2 = 0.088, ps < 0.001). Subjectively rated emotional and behavioral dyscontrol (Neuro-QoL) was significantly associated with episodic memory (ηp2 = 0.034, P = 0.014) and executive function (ηp2 = 0.089, P < 0.001), although weakened with inclusion of covariates (episodic memory, ηp2 = 0.021, P = 0.061; executive function, ηp2 = 0.049, P = 0.003). More lifetime concussions was significantly associated with worse self-reported cognitive function, but not objective cognition.
Conclusions: Findings from this cohort of older professional football players are consistent with previous work in former collegiate players at early midlife. Specifically, a modest relationship between subjectively rated and objectively assessed cognition was observed, which was further influenced by psychological and sociodemographic factors. Findings also indicated that subjective, but not objective cognition, was associated with concussion history.
Significance: This is the first study to directly examine the association between objective and subjective cognition in older former athletes, where subjective cognitive complaints may also be associated with aging-related pathologic processes.
Acknowledgments: We are grateful for the participation of the athletes, without whom this research would not be possible. This study (NFL-LONG) was funded by the National Football League (NFL) and supported by the National Institutes of Health National Institute on Aging.
NFL Hamstring Injuries—A Retrospective Study of Risk and Prognosis
Primary Author/Presenter: John Bianchi, DO
Affiliation: Northwell Health, Brooklyn, NY
Co-Authors: Brett Spain, DO, Pooja Jaisinghani, DO, Jeremy Watson, MD, Ryne Jenkins, DO, Jason Shinners, DO, Charles Ruotolo, MD
Purpose: Hamstring strains are a common and recurring injury in the NFL that cause a player to miss time and negatively affects future performance. Understanding which players are at risk and their postinjury prognosis for return to play is important for those affected.
Methods: The data collected for this study are extracted from the official NFL database of injuries. All reported hamstring injuries were collected and organized by each week of the regular and postseason of the 2008-2019 seasons. Statistical analyses were performed to determine the mean time that a hamstring injury would leave a player listed on the IR, and the probability of reinjury.
Results: 4,813 hamstring injuries were documented on the NFL IR list from the 2008 season through the 2019 season. Data show the average number of consecutive weeks on the IR is 2.51 Weeks with risk of re-injury at 24.39%. Linebackers (LB) were most likely to be on this list, making up 20.11%, followed by Wide Receivers (WR) at 19.9%, and Cornerbacks (CB) at 18.68%. Offensive and defensive linemen combined (Centers (C), Guards (G), and Tackles (T)) only made up 4.2% of hamstring injuries, whereas defensive players are most likely to injure the hamstring (57.26%). From the 2009-2019 seasons, Weeks 1 and 17 had the least hamstring injuries listed on the IR (4.59% and 4.77% respectively), while Weeks 5 and 6 had the most hamstring injuries (7.49% and 7.23% respectively). The 2011-12 season had the most hamstring injuries occur (12.72%). The team with the most hamstring injuries over the 11 year data collection was the Houston Texans with 276 (5.73%).
Conclusions: Our data analysis shows that, although these elite athletes receive a high level of care and have a relatively fast recovery time to return to play, they have a high probability of re-injury to the hamstring. We can also see that defensive skill position players, specifically linebackers, have the highest risk of sustaining a hamstring injury within a normal NFL season.
Significance: These data affect the treatment of professional athletes with hamstring injuries and lead to a re-evaluation of return to play because of high risk of re-injury. It also encourages preseason conditioning of the hamstrings of players at high risk.
Acknowledgments: Department of Orthopaedic Surgery, Nassau University Medical Center, East Meadow, NY
Gender Participation by Sport in Published Sports and Exercise Medicine Original Research
Primary Author/Presenter: Anna E. Buehler, MD
Affiliation: University of Colorado Internal Medicine Residency Program Denver, Colorado
Co-Authors: Kaitlyn. Bertin, MS, Brittany Becker, MD, Caroline Walsh, BS, Carly Setterberg, BS, Bradley Changstrom, MD, Karin VanBaak, MD
Purpose: A prior study has shown that there were fewer female than male participants in sports and exercise medicine research articles published between 2011–2013. This study compared the rates of participation by gender or sex in research specific to athletes of sports popular among all genders.
Methods: The number of participants by gender/sex and the sports of athlete participants were extracted from original research articles published in 2020 in the top 3 sports and exercise medicine journals by impact factor (BJSM, MSSE and AJSM). In a meta-analysis, gender proportions of pooled “participants” (analysis observations) were compared overall and within sport-specific article subsets.
Results: Data were extracted from 293 articles. No articles reported transgender or nonbinary participants, thus for the purpose of analysis, gender groups were defined as “men” (males/men/boys) and “women” (females/women/girls). Of the 1,406,103 participants in 286 articles (excluding 7 articles with only American football players), 759,765 (54.0%) were men and 646,338 (46.0%) were women, with 0.85 odds of being a woman. On average, women represented 38.6% of athletes per article. Based on article counts, soccer and running were the most common team and individual sports studied, respectively. In 10 articles involving soccer players only, there were 51,298 (94.9%) men and 2,781 (5.1%) women participants with 0.05 odds of being a woman and women representing 11.1% of soccer players per article. In 11 articles involving runners only, there were 615 (44.4%) men and 771 (55.6%) women participants with 1.25 odds of being a woman and women representing 38.0% of runners per article.
Conclusions: In this sample, there were fewer women than men studied in sports medicine research overall and this held true for research specific to sports popular among both genders. In soccer-specific articles, there was a much larger proportion of men than women participants. In running-specific articles, although there were more women than men participants total, the average percentage participation per article was still lower for women.
Significance: Participation of women in sports medicine research may be increasing; however, disparities remain even in sports, popular among both genders. There may be disproportionate sampling or recruitment leading to more men than women participants.
The Relationship Between Nutrition Knowledge and Low Energy Availability Risk in Collegiate Athletes
Primary Author/Presenter: Sydney Burger, BS
Affiliation: University of California, Irvine, School of Medicine, Irvine, CA
Co-Authors: Alexandra Bray, MD, Brian Kim, MD, MS
Purpose: To examine the relationship between nutrition knowledge (NK) and risk for low energy availability (LEA) in male and female NCAA Division I athletes across multiple institutions.
Methods: Athletes completed a survey comprised of the validated Abridged Nutrition for Sport Knowledge Questionnaire (A-NSKQ) and the Low Energy Availability in Females Questionnaire (LEAF-Q) or screening questions from the 2021 Male Athlete Triad Consensus Statement (MAT). LEAF-Q and A-NSKQ scores were compared with a t-test; MAT and A-NSKQ were compared using Pearson Correlation Coefficient.
Results: 189 athletes from three NCAA Division I institutions completed the survey (66.5% completion rate, 64.6% female, 18 sports represented). Mean A-NSKQ score was 15.4 ± 4.3 (max possible score 35). There was no significant difference in A-NSKQ scores between genders (females 15.7 ± 4.3, males 14.8 ± 4.2, P = 0.203). 55% of females had LEAF-Q scores greater than or equal to 8, indicating that they were at risk for LEA. Female athletes with LEAF-Q scores greater than or equal to 8 had significantly higher A-NSKQ scores than those with scores < 8 (16.6 vs 14.5, P = 0.007). Mean MAT score was 1.48 ± 1.08. There was a very weak correlation between MAT and A-NSKQ scores (R squared = 0.012). Those who reported prior nutrition education scored significantly higher on the A-NSKQ versus those who reported none (16 vs 14.6, P = 0.02).
Conclusions: Interestingly, females with higher NK scores were more likely to be at risk for LEA, indicating a possible relationship between NK and LEA. Females who seek out nutrition information may be more likely to alter their diet in ways that adversely affect energy availability, although the mechanism is unclear. The correlation between MAT scores and NK in males was weak. This may reflect gender differences or limitations of the MAT screening tool.
Significance: LEA threatens athlete well-being. Here, we present a relationship between NK and LEA. Further research should explore mechanisms underpinning observed differences in NK between risk groups, and effects of nutrition interventions on LEA risk.
Acknowledgments: We thank the Medical Student Research Program at UC Irvine School of Medicine for their support.
Sonographic Screening of Achilles Tendon, Patellar Tendon, and Plantar Fascia in NCAA Division 1 Collegiate Athletes
Primary Author/Presenter: Daniel M. Cushman, MD
Affiliation: University of Utah, Salt Lake City, UT
Co-Authors: Blake Corcoran, MD, Leyen Vu, DO, Michael Fredericson, MD, Masaru Teramoto, PhD, MPH, PStat, Sarah Eby, MD, PhD
Purpose: Achilles tendinopathy, patellar tendinopathy, and plantar fasciopathy are common injuries in sport. The goal of this study was to identify whether sonographic abnormalities of the tendons and fascia of student-athletes in three division 1 schools develop into symptomatic tendinopathy.
Methods: NCAA Division 1 student-athletes received an ultrasound evaluation of their Achilles tendons, patellar tendons, and plantar fasciae at the beginning of the year. Blinded review was performed by experienced sonographers to identify abnormalities: hypoechogenicity, thickening, and neovascularity. Student-athletes were tracked over the year to identify injuries in the three structures.
Results: Of the 242 eligible student-athletes (484 tendons/fasciae) from 3 institutions, 57.8% were female and 51.7% engaged in explosive sports. Abnormalities were identified in 10.4%, 37.4%, and 3.5% of all Achilles tendons, patellar tendons, and plantar fasciae, respectively. The risk of developing an injury over the year based on the presence of a preseason abnormality was 15.2 (4.3, 53.3; P < 0.001), 10.0 (2.1, 47.2; P = 0.003), and 27.5 (4.0, 186.6; P = 0.001), respectively. The positive predictive values were 14.0, 10.3, and 11.8%, whereas the negative predictive values were 99.1, 99.0, and 99.6%, respectively.
Conclusions: A simple ultrasound evaluation of the Achilles tendon, patellar tendon, and plantar fascia at the beginning of a season is highly correlated with the development of pain over the year in student-athletes. They exhibit very high negative, but low positive predictive values.
Significance: Sonographic abnormalities may be a useful screening tool to identify athletes at risk of future Achilles tendinopathy, patellar tendinopathy, or plantar fasciopathy. Future studies need to identify specific morphologic sonographic risk factors.
Race Day Medical Emergencies
Primary Author/Presenter: Elizabeth Fierro, DO
Affiliation: Rusk Rehabilitation at NYU Langone Health
Co-Authors: Stephanie Kliethermes, PhD, Lianna Mack, MD, Brett Toresdahl, MD
Purpose: The goal of this study was to measure the incidence of medical emergencies during running races and determine the association between the incidence of medical emergencies and race distance and weather.
Methods: A survey was distributed via REDCap to race directors and medical leaders of road running races (distance > = 10K) within the United States. Race contacts were identified by an online search. The survey included information on race characteristics (distance, number of runners), number and type of medical emergencies, and weather.
Results: Data collected from March 2019 to October 2022 included 114 races (10K, n = 14; half marathon, n = 40; marathon, n = 37; and other distance, n = 23), representing 212,628 race starters. Cases of heat stroke totaled 176 with an incidence of 83/100,000 starters (95% confidence interval (CI) 71-95). There were 56 cases of hypothermia, incidence 26/100,000 (95% CI 19-33). Also reported was 1 sudden cardiac arrest (survived) and 1 fatality (etiology not specified). Poisson regression for heat stroke showed that the relative risk (RR) was 1.26 for every 5 mile-increase in race distance (95% CI 1.09-1.46), 1.87 for every 5 degree-increase in temperature (Fahrenheit) at the start of the race (95% CI 1.58-2.22), and 1.35 for every 5 degree-increase in change in temperature during the race (95% CI 1.13-1.61). The RR for hypothermia was 2.50 for every 5-mile increase in race distance (95% CI 1.75-3.59). The incidence of hypothermia was not associated with weather.
Conclusions: Medical emergencies occur during running races for which medical staff need to be prepared. Heat stroke was the most common emergency reported and was associated with race distance, temperature at the start, and change in temperature. The risk of hypothermia increased as race distance increased; however, weather characteristics were not found to be associated with hypothermia.
Significance: With this information, race directors and medical teams can better prepare for medical emergencies based on race distance and weather. Educating runners on the risks of medical emergencies may also help prevent events during races.
Acknowledgments: I would like to thank all the race directors who responded to this survey. Without their efforts, this study would not have been feasible.
Epidemiology of Division I NCAA Collegiate Soccer Injuries
Primary Author/Presenter: Madison Goon, BS
Affiliation: Charles E. Schmidt College of Medicine at Florida Atlantic University
Co-Authors: Joshua Goldman, MD, MBA, Alexandra M. Klomhaus, PhD, Emily M. Miller, MD
Purpose: There is limited description of soccer-related injuries in the U.S., particularly at the collegiate level. This study reviews the epidemiology of NCAA Division I soccer injuries and compares injury patterns between genders as recorded by the PAC-12 injury surveillance database from 2016-2022.
Methods: This was a retrospective cohort study using de-identified data from the PAC-12 Health Analytics program. Data were stratified by body part, player position, gender, event, and injury mechanism. Gender differences were compared with P-values from a χ2 test. Incidence rate ratios with 95% confidence intervals & P-values were obtained from a Poisson regression.
Results: There were 3,809 soccer related injuries & illnesses reported (65.6% female, 34.4% male). Ligament sprains were the most reported injury type (22.2%). The knee was the most injured body part (19.5%), making up 20.6% of female and 17.5% of male injuries (P < 0.0001). MCL sprains were the most reported knee injury (10.6% of knee injuries). Noncontact was the most reported mechanism of injury for females (31.9%). Contact with another player was the most common injury mechanism for males (32.5%). Defenders were at the most injured position (27.5%), followed by midfielders (23.6%). There was a higher rate of injury per event during off-season than during season (IRR = 1.4; CI: 1.30,1.52; P < 0.0001); no significant difference between postseason (IRR = 0.98; CI:0.82,1.17; P = 0.7899) and preseason (IRR = 0.93; CI: 0.84,1.03; P = 0.1470) compared with season. The injury rate per event was higher during competition than practice (IRR = 6.05; CI:5.63,6.49; P < 0.0001).
Conclusions: Direct comparison of male and female collegiate soccer cohorts suggests females experience more injuries than males and are more often injured via noncontact mechanisms. Although injury risk is increased in competition compared with training, exposure data also suggest there is a higher overall risk of injury during the off-season. Further evaluation into other factors that could influence injury risk, such as scheduling & season duration, is needed.
Significance: This study identifies significant differences between male and female injury distributions, temporal patterns, and rates in collegiate soccer athletes. This can guide the development of season and gender-specific programming to reduce injury risk.
Acknowledgments: National Center for Advancing Translational Science (NCATS) of the National Institutes of Health under the UCLA Clinical and Translational Science Institute grant number UL1TR001881. Pac-12 Health Analytics Program (HAP)
Long-Term Outcomes of Ultrasound-Guided Percutaneous Fasciotomy and Debridement for Chronic Plantar
Primary Author/Presenter: Chris Ha, DO
Affiliation: Mayo Clinic, Rochester, MN
Co-Authors: Joshua Romero, MD, Karina Gonzales Carta, MD, Jacob Sellon, MD, Brennan Boettcher, DO
Purpose: To determine long-term pain and patient satisfaction outcomes after ultrasound-guided percutaneous fasciotomy and debridement (USPFD) for plantar fasciopathy.
Methods: A single-center, retrospective study of patients treated with USPFD for plantar fasciopathy between June 6, 2008 and April 20, 2018 was conducted. Patient-reported outcomes were obtained via the electronic medical record, electronic patient surveys, and phone interviews. Primary outcomes were the visual analog scale for pain (VAS-Pain) and patient satisfaction ratings using a Likert scale.
Results: Eighty unique procedures were identified among 73 patients (mean age at 51 ± 9 years; 56 female, 17 male). Five sports medicine physicians with advanced ultrasound training performed the USPFD procedures. Seven patients (9.6%) had bilateral and/or repeat procedures. Sixty-two patients (85%) responded to surveys or phone calls, and follow-up data was collected for 67/80 procedures (84%) at a mean time postprocedure of 6.7 ± 1.9 years. Baseline VAS-Pain was 6.8 ± 2.1. At final follow-up, patient-reported VAS-Pain with first 5 steps was 1.0 ± 1.7, VAS-Pain with weight-bearing through the day was 1.3 ± 2.0, and global assessment of function was 8.6 ± 2.5. Overall, for 59/67 (88%) of the procedures, patients responded they were “satisfied” or “very satisfied,” and 56/67 (84%) would recommend the procedure to others. No complications were reported by medical record review or followup. Eleven of 73 patients (15%) and 13 of 80 procedures (16%) were lost to follow-up.
Conclusions: USPFD provides long-term pain relief and high satisfaction for most patients with chronic plantar fasciopathy. Complications from USPFD are uncommon when performed by physicians with advanced ultrasound training/experience.
Significance: USPFD is a safe, effective, and durable treatment option for chronic plantar fasciopathy. To our knowledge, this is the longest-term study to date of outcomes using USPFD in the management of plantar fasciopathy.
Differences in Sports Biomechanics Between Preteen and Teenage Athletes
Primary Author/Presenter: Ryan Kelln, DO
Affiliation: Children's Hospital Los Angeles, Los Angeles, CA
Co-Authors: Sarah Adams, BS, Mia Katzel, DPT, Tishya Wren, PhD
Purpose: The purpose of this study is to compare sports biomechanics between preteen and teenage athletes. Recent literature has emphasized the need for understanding biomechanical movement risk factors for injury and its application in youth sports.
Methods: Uninjured pediatric athletes underwent biomechanical assessment using 3D motion analysis. Subjects performed heel touch, drop jump, lateral shuffle, deceleration, single leg hop, and side-step cut. Each limb was scored for hip, pelvic, and trunk stability, shock absorption, and hip strategy. Percent scores were compared between preteen (age < 13 years) and teen (age >= 13 years) athletes.
Results: Data from the 3D motion analysis was obtained for 84 assessments, 45 preteen (age 8.1-12.9), and 39 teenage (age 13.0-17.6) uninured athletes. It was found that shock absorption, hip strategy, single-leg hop, and total score were significantly worse in the preteen group compared with the teen group. For shock absorption, the preteen group average score was 55.2 (SD 18.0) compared with 66.4 (21.5) in the teen group (P = 0.01). For hip strategy, the preteen group average score was 55.1 (9.97) compared with 65.3 (12.7) in the teen group (P = 0.0001). For single-leg hop, the preteen group average score was 68.2 (13.1) compared with 75.6 (12.7) in the teen group (P = 0.01). For total score, the preteen group average score was 67.8 (5.3) compared with 70.6 (7.3) in the teen group (P = 0.04). However, pelvic stability (frontal plane motion) had significantly higher scores in the preteen group (70.8, SD = 10.0) compared with the teen group (64.0, SD = 13.4) (P = 0.01).
Conclusions: Teenage athletes demonstrated better overall biomechanics than preteen athletes, particularly through better shock absorption and hip strategy. This may reflect developmental differences in limb control and muscle development and suggests the importance of teaching younger athletes correct biomechanics. The single-leg hop may be particularly useful for identifying younger athletes in need of biomechanical training.
Significance: By identifying poor neuromuscular control early, intervention can be implemented to improve biomechanics and prevent injury. Using objective biomechanical data can identify those who will benefit from improved biomechanics and neuromuscular control.
Trends in Mood Disorders in Incoming Freshman Division One Collegiate Cross Country and Track And Field Athletes
Primary Author/Presenter: Erica Mantell, MD
Affiliation: The Ohio State University, Columbus, OH
Co-Authors: Sean Jones, MA, LAT, ATC, Kendra McCamey, MD, James Borchers, MD, MPH
Purpose: This study's purpose was to evaluate trends in mood disorders in incoming collegiate cross-country and track and field athletes to appropriately allocate resources. The prevalence of mood disorders surrounding the COVID-19 pandemic was of interest.
Methods: Preparticipation questionnaires of incoming first-year cross country and track and field athletes at The Ohio State University were reviewed between the years 2018-2022 (n = 138). Data regarding psychiatric history were collected and evaluated for trends based on year of matriculation, reported gender, family history of mood disorders, and specific sporting event.
Results: The prevalence of history of mood disorder or counseling in incoming first-year cross country and track and field athletes was not statistically different across the five years from 2018 to 2022. Female athletes were 2.6 times more likely to report a history of mood disorder or counseling compared with male athletes (P = 0.02, CI 1.17-5.96). Prevalence of history of mood disorder or counseling was highest in distance runners, lower in field athletes, and least in sprinters, but this difference was not significant (P = 0.322). Athletes who reported a personal history of mood disorder or counseling were 42.9 times more likely to also report family history of a mood disorder (P < 0.001, CI 5.2-351.5).
Conclusions: The prevalence of mood disorders in first-year cross country and track and field athletes have remained stable over the past five years despite the COVID-19 pandemic and increased normalization of mental health problems. Female cross country and track and field athletes are more than twice as likely as males to start college with a history of a mood problem. There is a strong association between personal and family history of mood disorders.
Significance: More psychological resources may need to be allotted to female cross country and track and field athletes compared with males. It may not be necessary to increase mood resources overall, because prevalence remains stable over the years.
Acknowledgments: Statistical analysis by Angela Pedroza, MPH
Computerized Cognitive Testing in Long COVID Patients With Prolonged Symptoms of Brain Fog and Cognitive Impairment
Primary Author/Presenter: Daniella Rivera, MS
Affiliation: A.T. Still University- School of Osteopathic Medicine in Arizona, Mesa, Arizona
Co-Authors: Mo Mortazavi, MD, Taylor Seitz, Tyler Marx, MS, Leslie Streeter, DNP, Leila Samsam, DNP, Sarah Lawson, DO
Purpose: To identify cognitive impairments in patients (pts) with long COVID using the Cambridge Brain Sciences (CBS) computerized cognitive test (CCT) commonly used to evaluate cognitive function after concussions and traumatic brain injuries.
Methods: Retrospective review from May 2021-Sept 2022 of 16 (4 male, 12 female) patients with long COVID, ages 13-66 (avg 46), with average of 10 months from COVID infection to time of evaluation. Cognitive (cog) performance and concussion profile symptom scores were assessed with CBS CCT and the Concussion Clinical Profiles screening tool (CP screen) respectively.
Results: The total CP symptom score average was 34/89 (ranging 7-68) in the cohort. The predominant profile was cog fatigue scoring (1.8/3) on average. CBS CCT tested cog impairment (CI) and was divided into 5 categories (0-4): no CI, borderline (scores between the 21st-30th percentile), mild (1 test < / = 20th percentile), moderate (2-3 tests < / = 20th percentile), and severe CI (>3 tests < /= 20th percentile). Data showed 2/16 (13%) patients had no CI, 5/16 (31%) had borderline CI, 5/16 (31%) had mild CI, 3/16 (19%) had moderate CI, and 1/16 (6%) pts had severe CI. Although not significant, there was a positive correlation between CI and cog profile score (P = 0.3149) when performing a linear regression test. Deficits were most common in the CBS CTT composites of grammatical reasoning/verbal processing and attention, with 4/16 patients scoring < 20th percentile for each test. The lowest average percentile scores for the cohort were in visuospatial processing and verbal short-term memory.
Conclusions: Most long COVID patients assessed with CCT demonstrated signs of CI, in particular in verbal processing and memory, followed by visual processing. In addition to the CCT results illustrating CI, the top CP profile of cognitive fatigue in this cohort suggests that the brain fog experienced by long COVID patients may be quantified.
Significance: CCT may be a useful tool in assessing and quantifying those with Long COVID with chronic symptoms of cognitive fog, fatigue, or impairment. Targeted interventions aimed at specific deficits can aid in treatment and recovery.
Acknowledgments: SPARCC. Sports Medicine, Rehabilitation and Concussion Center.
Predictors of Lost Academic Time Following Concussion: The Sport Concussion Outcomes in PEdiatrics (SCOPE) Study
Primary Author/Presenter: Jeremy Roberts, MD
Affiliation: Children's Hospital Colorado, Aurora, Colorado
Co-Authors: Mark E. Halstead, MD, Shane M. Miller, MD, Jonathan A. Santana, DO, Tamara C. Valovich McLeod, PhD, ATC, Julie C. Wilson, MD, David R. Howell, PhD
Purpose: After concussion, many pediatric patients note difficulty in returning to school because of cognitive, social, or emotional dysfunction. These factors can effect academic supports. The goal of this study was to assess patient-specific predictors of total school time lost after pediatric concussion.
Methods: We performed a prospective cohort study of adolescents & children (6-18 years) seen after concussion at 1 of 7 different sports medicine clinics across the US. We collected data on academic concerns using the validated Concussion Learning Assessment & School Survey (CLASS) and constructed a multivariable predictive model evaluating patient factors, including associated with total school time lost.
Results: A total of 167 patients participated across 7 primary care sports medicine clinics (mean age = 14.5 ± 2.2 years; 46% female). Patients were assessed initially at 5.0 ± 3.0 days postinjury and had a follow-up assessment at 24.5 ± 20.0 days postinjury. Across the sample, participants missed a median of 2 days of school (IQR = 0.5-4), and 21% reported their grades dropped after their concussion. When examining demographics, medical history, injury, and academic characteristics, multivariable model results showed that higher initial symptom severity rating (B = 0.06, 95% CI = 0.03-0.08, P < 0.001) and grades dropping after concussion (B = 1.37, 95% CI = 0.28-2.45, P = 0.01) were significantly associated with more academic time missed after concussion. Those who reported their grades dropping reported missing significantly more school (mean = 5.0, SD = 4.7 days missed of school) than those who reported their grades did not drop (mean = 2.2, SD = 2.6 days missed of school; P < 0.001; Cohen d = 0.87.
Conclusions: The students reported missing a median of 2 days of school after concussion, and 21% reported their grades dropping after concussion. Greater initial symptom severity and reporting that grades dropped demonstrated an independent relationship with total academic time lost after a concussion. These findings support recommendations that students should return to school first, with academic supports if needed, to ensure a successful return to learning.
Significance: Children and adolescents with concussion are at risk of grades dropping and missed time from school. Clinicians and schools should partner on appropriate academic support and symptom management plans to mitigate school absences and grade drops.
Acknowledgments: The PRISM Concussion RIG (SCOPE: Sport Concussion Outcomes in Pediatrics Study). Contributing members: Amanda Black PhD6, Rachel A. Coel, MD PhD7, Matthew L. Fazekas, MD8, Matthew F. Grady, MD9, Christina L. Master, MD9, Traci Snedden, PhD, RN, CPNP10
Effects of Workload and Sex on Overuse Injury and Return to Sport Duration: A Prospective Cohort Study of Youth Athletes
Primary Author/Presenter: Stacey Schley, MD
Affiliation: Emory University School of Medicine, Atlanta, GA
Co-Authors: Ally Render, Mario Ramirez, Caleb Truong, Stephanie Logterman, MD, Jeffrey Webb, MD, Neeru Jayanthi, MD
Purpose: To determine whether pre-injury workloads or sex influence injury type (acute vs chronic) or return to sport (RTS) duration of youth athletes who have sustained an injury during competitive sport.
Methods: Injured athletes 10-23yo reported workloads and RTS (full competition) via online survey. RTS was categorized as short (30 days). χ2 testing was used to evaluate the association between workloads, injury type, and RTS. Multivariable logistic regression and odds ratio was used to assess incidence of overuse injuries vs sports training ratio and sex.
Results: 359 athletes were enrolled and by analysis, 329 athletes had RTS with 42.2% female, 57.8% male, and mean age 15.5. Primary sports represented were tennis 38.3%, soccer 15.4%, and football 9.9%. Most athletes were highly (37.3%) or moderately (36.3%) specialized and required long duration of return to sport (51.6%) vs intermediate (29.2%) or short (19.2%). Duration of RTS was not associated with acute-to-chronic workload ratio (ACWR, P = 0.42), competition-to-training ratio (CTR, P = 0.18), workload vs age (P = 0.65), sports training ratio (STR, P = 0.27), or sex (P = 0.99). Injury type was associated with acute workload (P = 0.04), ACWR (P = 0.02), and STR (P = 0.06), with a greater percentage although lower incidence of overuse injuries for STR of < /= 2:1 (34/52, 65.4%) vs > 2:1 (141/277, 50.9%). Multivariable logistic regression of female sex vs injury type and STR < /= 2:1 vs injury type demonstrated an association with overuse injuries, P = 0.005 and 0.02, odds ratio 1.9 and 2.1, respectively.
Conclusions: Most athletes were highly specialized and required long durations of RTS. There does not seem to be an association with individual workload factors and RTS duration, or with sex and RTS duration; however, the cumulative effect of these risk factors on RTS duration will be determined with further data collection and analysis. Female sex and an STR < /= 2:1 were independent risk factors for overuse injuries relative to acute injuries.
Significance: This study is the first to evaluate workload factors with RTS duration after injury. This also confirms, as in prior data, that female athletes are more likely to develop overuse injury, which may have clinical implications for the training.
Acknowledgments: Funding source: Emory University Department of Orthopedics intramural seed grant.
Perceived Preparedness of Sports Medicine Fellows for Practice
Primary Author/Presenter: Timothy Tiu, MD
Affiliation: University of Miami, Miami, FL
Co-Authors: Michelle Henne, MD, Ibrahim Zeini, PhD, Elan Goldwaser, DO, Christopher Cherian, MD, Bittu Kuruvilla, MD, Se Won Lee, MD
Purpose: To determine whether graduating fellows in Primary Care Sports Medicine (PCSM) believe they are prepared for subspecialty practice based on their fellowship training. The secondary aim is to qualify perceived preparedness in specific areas of PCSM practice.
Methods: This was a survey‐based study. A survey was designed using Qualtrics and disseminated to graduating PCSM fellows. Using a Likert scale (1-5, 5 being “extremely well prepared”), fellows were asked about preparedness in various domains and subdomains, including evaluation and management based on conditions and populations, physician roles, procedures, imaging, and nonclinical aspects of practice.
Results: 131 of 336 fellows fully completed the survey (39%). For musculoskeletal conditions, fellows were most comfortable with osteoarthritis (M = 4.5), and least with spine pathology (M = 3.3). Fellows felt underprepared for sports-related ophthalmology (M = 2.7), ENT/dental (M = 2.8), hematology (M = 2.8), and genitourinary (M = 2.9). They reported preparedness for coverage: sideline (M = 4.2) and mass event (M = 3.9), but not ringside (M = 2.6). They were underprepared for managing adaptive athletes (M = 2.6) and special needs athletes (M = 2.4). They were overall prepared for procedures, except for those with fluoroscopy (M = 1.7). Nonclinically, fellows were uncomfortable with administrative responsibilities such as serving as a medical director and marketing (M = 2.7), and contract negotiation (M = 2.6). They were unfamiliar with RVUs, FTEs, billing vs. collections, prior authorizations, and the process for academic promotion.
Conclusions: Graduating PCSM fellows overall feel at least moderately well prepared for subspecialty practice. Although this is inclusive of nonclinical practice as a whole, they were underprepared for non–sports-specific and non–academic-specific aspects. Further analyses should be performed to evaluate differences among subsets of fellows, including their primary specialty and fellowship sponsoring specialty.
Significance: PCSM fellowships seem to largely prepare future sports medicine physicians for practice. Individual programs may identify their own relative strengths and weakness in education and revise their curriculum as appropriate.
Measures of Strength and Mobility as Predictors of Injury in Adolescent Distance Runners
Primary Author/Presenter: Sydnie Vo, MD
Affiliation: UCLA Department of Family Medicine
Co-Authors: Frances Tao, MD, MPH, Joseph Coppiano, MD, Kuan-Ting Chen Nicholas J. Jackson, PhD, MPH, Nelson Boland, MD, Summer Runestad, ATC, Joshua Goldman, MD, MBA, Emily Miller, MD
Purpose: Although some youth runner characteristics (e.g. sex) are known risk factors for running-related injury, less is known about biomechanical factors. In this group of Students Run Los Angeles athletes, we sought to characterize baseline strength & mobility biomechanics and evaluate their role in injury.
Methods: During the 2021-22 marathon training season, students at 3 high schools (HS) completed demographic & biomechanical assessments of static & dynamic strength, mobility, & balance. Postrun surveys on training mileage & injury occurrence were completed. Welch's t-test was used to compare measurement means for the right (R) and left (L) side between injured and noninjured participants with P < 0.05.
Results: Of 76 total participants (mean age 15.9, range 13-18, 47% female, 53% male), 14 (18.4%) were injured. Calf muscle endurance and strength, as measured by single leg heel rise, was not different between the injured and noninjured athletes (R P = 0.71, L P = 0.72). Bilateral hamstring flexibility between the injured and noninjured was also not statistically different (R P = 0.31, L P = 0.27). There was no difference in ligamentous laxity, as measured by the Beighton score, between injured (mean 2.86, SD 1.85) and noninjured (mean 2.52, SD 2.44) participants (P = 0.63). Dynamic balance, as assessed by the Y balance bilaterally for injured and noninjured, was also not different between groups (all P > 0.05). Drop jump dynamic Q angle did not vary between injured (R mean 12.67, SD 5.29; L mean 13.53, SD 5.48) and noninjured (R mean 12.97, SD 6.25; L 13.35, SD 6.03) individuals (R P = 0.85, L P = 0.91).
Conclusions: Adolescent runners who experience running-related injuries do not seem to differ significantly from noninjured runners in basic measures of strength, flexibility, and balance. Generalizability of our findings is limited by small sample size, short follow-up, and inconsistent injury reporting by athletes. Additional data are needed to determine the utility of biomechanical testing in evaluating an adolescent's risk of running-related injury.
Significance: This pilot study is a step toward understanding whether specific biomechanical testing can determine risk of running-related injury during adolescent marathon training, leading to development of specific injury-reducing mobility & strengthening programs.
Acknowledgments: AMSSM Young Investigator Grant, Students Run Los Angeles, Orthopedic Institute for Children, Anthony Luke MD MPH, RunSafe, NIH/National Center for Advancing Translational Science (NCATS) UCLA CTSI Grant UL1TR001881.
A Retrospective Analysis of the Sway System for Predicting Prolonged Recovery in Concussion
Primary Author/Presenter: Barrett Weiss, MD
Affiliation: Baylor University Medical Center, Dallas, Texas
Co-Authors: Christa Ochoa, MPH, Monica Bennett, PhD, James Sterling, MD
Purpose: To assess whether and how sway balance system scores correlate with time from injury to time of clearance for sport (TCS) and total symptom scores (TSS) in adolescents with concussion. Association of changes in sway scores from 1st to 2nd visits with TCS and TSS was also assessed.
Methods: Analysis of a concussion registry of 499 unique patients (524 concussions) with known TCS, TSS, and 2 sway scores at initial visit. Associations between 1st, 2nd, and average Sway Scores during the 1st visit with TSS and TCS were evaluated with linear and negative binomial regression. Association of change of 1st visit SWAY scores to 2nd visit SWAY scores with TSS and TCS were evaluated similarly.
Results: Patients were 59 percent male with an average age of 15.1 years old. 87 percent of concussions were sports related. Analysis adjusted for age, sex, mechanism of injury, ADD/ADHD diagnosis, learning disorder, migraine history, anxiety diagnosis, depression diagnosis, and prior concussion revealed significant correlation (R = -0.13, -0.15, -0.14 respectively) between 1st, 2nd, and average SWAY score of 1st visit with lower TSS (all P-value of < 0.001). Analysis revealed significant correlation (R = -0.21, -0.26, -0.24 respectively) between 1st, 2nd, and average SWAY score of 1st visit with quicker TCS (P-value of 0.047, < 0.001, 0.005 respectively). All SWAY score components except for feet together eyes closed and left single leg eyes closed scores were significantly correlated with lower TSS (all P-value < 0.001) and quicker TCS (all P-Values < 0.05). The change in SWAY score from 1st to 2nd visit was significantly correlated (R = -0.2) with quicker TCS and lower TSS (P-Value 0.001).
Conclusions: This study demonstrates that there is a positive correlation between SWAY balance system scores and TCS and a negative correlation between SWAY scores and TSS, and associations between most components of the SWAY system and these outcomes. In addition, this study demonstrates that there is a positive correlation between change in SWAY scores from one visit to the next and TCS, even when adjusted for time between SWAY scores.
Significance: This study demonstrates that the SWAY system may identify adolescents with concussion at risk for prolonged TCS times and higher TSS. It also demonstrates that repeated SWAY scores may also have prognostic indications for prolonged TCS.
Acknowledgments: Jeffrey Mattis
Platelet-Rich Vs. Platelet-Poor Plasma for the Treatment of Thigh Muscle Injuries
Primary Author/Presenter: Logan Wilz, MD
Affiliation: University of Iowa Hospitals & Clinics University of Iowa Sports Medicine Iowa City, IA
Co-Authors: Jordan Eisenmann, BS, Ryan Kruse, MD
Purpose: The purpose of this study was to evaluate the time to return to sport/activity in patients treated with platelet-rich plasma (PRP) vs platelet-poor plasma (PPP) after acute thigh muscle injuries.
Methods: 100 athletes with acute thigh muscle injuries were treated with PRP or PPP in addition to a course of rehabilitation. Ultrasound was used to grade and characterize the injuries. The primary outcome was time to return to sport/activity. Secondary outcomes included VAS pre and postprocedure and injury recurrence.
Results: The PPP group demonstrated a statistically significant faster time to return to sport/activity, lower VAS scores 24 hours post-procedure, and a shorter duration of postprocedure pain when compared with the PRP group. When including all grades of injury, mean days until full recovery was 28.29 for the PPP group and 47.71 for the PRP group. VAS scores 24 hours postprocedure were 2.13 points lower in the PPP group compared with the PRP group, and duration of postprocedure pain was 1.12 days shorter in the PPP group compared with the PRP group. No differences in baseline demographics or severity of muscle injury between the two groups was observed. Being in-season or out of season did not impact recovery time. There was no difference in injury recurrence between the groups.
Conclusions: Our results suggest that PPP decreases time to return to sport/activity in patients with acute thigh muscle injuries. PPP also significantly decreases the severity and duration of postprocedure pain. Additional clinical studies, including randomized trials, are needed to further investigate our findings.
Significance: PPP treatment for acute thigh muscle injuries may allow patients to return to their desired level of activity more quickly than other treatments options, and also improves the procedural experience because of decreased postprocedure discomfort.
Acknowledgments: Special thanks to the Clinical Research Team of the University of Iowa Department of Orthopedics and Rehabilitation.
Injury Rates Following Sport-Related Concussion in Adolescents After Aerobic Exercise Intervention
Primary Author/Presenter: Matthew Witte, MD
Affiliation: UBMD Department of Orthopaedics and Sports Medicine, University at Buffalo, Buffalo, NY
Co-Authors: Mohammad Haider, MD, PhD, John Leddy, MD
Purpose: The risk for subsequent concussion and musculoskeletal injury is increased after Sport-Related Concussion (SRC). Our objective was to investigate the risk of subsequent injury after SRC recovery in patients who were prescribed aerobic exercise versus a placebo stretching intervention.
Methods: This RCT was completed at three sports medicine concussion centers in the USA. Male and female adolescent athletes (aged 13-18 years) presenting within 10 days of SRC were randomly assigned to individualized aerobic exercise or to stretching exercise for at least 20 minutes daily, for up to 4 weeks after injury. The primary outcome was self-reported MSK injury or concussion within 4 months of SRC.
Results: 122 participants were randomized (63 to exercise, 59 to stretching). 4-month follow-up data were available for 73 participants (43 in exercise, 30 in stretching). Participants prescribed stretching had a nonsignificantly lower follow-up rate (P = 0.06). All participants who reported subsequent injuries were male. 3/73 participants reported a subsequent concussion (1 in exercise, 2 in stretching), which was not statistically significant (P = 0.564). 10/43 participants reported a subsequent MSK injury (3 in exercise, 7 in stretching). The rate of MSK injury in the aerobic exercise group was lower (6.97%) than the stretching group (23.33%), but the difference was not statistically significant (P = 0.08). It is likely that this analysis was underpowered and may have shown statistical significance in a larger sample. A future validation study would require 75 participants in each group.
Conclusions: Prior studies have shown increased risk of MSK injury in the year after SRC among athletes of various skill levels and ages, including adolescents. Our analysis showed a trend that adolescents who completed aerobic exercise treatment may be at lower risk of subsequent MSK injury; however, a larger sample is required to confirm this. Males seem to be at greater risk of subsequent injury in the 4 months after concussion recovery.
Significance: Our data suggest that early aerobic exercise treatment may reduce the rate of subsequent injuries in adolescents after SRC, especially for males. This may represent a yet-to-be-understood benefit of aerobic exercise treatment.
How Does Number of Sports Affect Health-Related Quality of Life Measures in Young Athletes?
Primary Author/Presenter: Benjamin Zacks, MD
Affiliation: University of Colorado Pediatrics—13123 E 16th Ave, Aurora, CO
Co-Authors: David Howell, PhD, Madison Brna, BS, Aubrey Armento, MD, Gregory Walker, MD
Purpose: There are many health benefits to organized sports and exercise participation. Our purpose was to evaluate the association between the number of lifetime sports played on quality-of-life (QOL) measures including anxiety, depression, peer relationships, and quality of sleep among adolescent athletes.
Methods: Healthy high school athletes completed a set of questionnaires addressing the number of sports played and QOL. We stratified participants into groups as: not currently playing a sport, single-sport athletes, and multisport athletes at the time of exam. We created multivariable models evaluating the relationship between current sports played and QOL, while adjusting for demographic covariates.
Results: The no current sport group was younger (14.6 ± 1.1 vs. 15.4 ± 1.2 vs. 15.6 ± 1.2 years of age; P = 0.007), shorter (164.5 ± 8.3 vs. 168.6 ± 8.3 vs. 171.5 ± 9.0 cm; P = 0.003), had a lower proportion of varsity athletes (5% vs. 35% vs. 47%; P = 0.002), current contact sport athletes (20% vs. 41% vs. 51%; P = 0.002), and history of time-loss MSK injuries (5% vs. 36% vs. 54%; P < 0.001) than single-sport and multisport groups. There was a lower proportion of girls in the single-sport group relative to the no sport and multisport groups (41% vs. 70% vs. 65%; P = 0.002). The no-current sport group reported fewer lifetime sports played (contact and non/limited-contact sports) than the other two groups (P < 0.001). There was no independent relationship between the number of sports played and QOL, including burnout (P = 0.70), sleep quality (P = 0.56), anxiety (P = 0.23), depressive symptoms (P = 0.43), fatigue (P = 0.25), peer relationships (P = 0.20), pain interference (P = 0.82), or pain scale rating (P = 0.30)
Conclusions: Our hypothesis was that single sport athletes are predisposed to decreased QOL factors when compared with multisport athletes. Our results, however, show that there is no relationship between the number of sports played at the time of the cross-sectional evaluation and QOL measures, including burnout, sleep quality, anxiety, depressive symptoms, fatigue, peer relationships, and pain.
Significance: Although it is known that sports specialization is associated with higher incidence of MSK related injuries, our cross-sectional data indicate that a higher or lower number of sports played in high school was not associated with worse QOL measures.
Acknowledgments: University of Colorado Sports Medicine Department.