Mechanisms of Injury as a Diagnostic Predictor of Sport-Related Concussion Severity in Football, Basketball, and Soccer: Results From a Regional Concussion Registry

Incidence of concussion and associated risk factors in collegiate soccer: findings from the NCAA-DoD CARE consortium

This retrospective cohort study aims to examine concussion incidence rates (IR) in collegiate soccer players and compare IRs based on risk factors including sex, competition level, games/practices, history of concussion, and playing position. Collegiate soccer players were recruited (n = 2,471) from 23 institutions from the NCAA-DoD Concussion Assessment, Research, and Education (CARE) Consortium. Incidence rates for concussion per 1000 athlete exposures (AEs) were calculated across the 2015-16/2016-17 seasons. Incidence rates (IR) comparing risk factor groups were also calculated. A total of 162 concussions occurred during the study, for an IR of 0.08/1000 AEs. Females were more likely to have a concussion than males overall (IR = 1.47) and were more likely to have a concussion in games (IR = 1.42) and practices (IR = 2.91). Concussions were more likely during competition compared to practice (IR = 2.53), and less likely in Division III, compared to Divisions I and II, χ2 = 6.5, p > .05. In the concussed group, male sex was associated with 2.47 times higher odds of playing defender and 2.29 times higher odds of a collision mechanism. Results confirm previous findings that females and game exposures have higher concussion IR than males and practice exposures. Findings also supported sex differences in IRs based on exposure type, position, and mechanism.

A Biopsychosocial Model for Understanding Training Load, Fatigue, and Musculoskeletal Sport Injury in University Athletes: A Scoping Review

ABSTRACT

McClean, ZJ, Pasanen, K, Lun, V, Charest, J, Herzog, W, Werthner, P, Black, A, Vleuten, RV, Lacoste, E, and Jordan, MJ. A biopsychosocial model for understanding training load, fatigue, and musculoskeletal sport injury in university athletes: A scoping review. J Strength Cond Res 38(6): 1177-1188, 2024-The impact of musculoskeletal (MSK) injury on athlete health and performance has been studied extensively in youth sport and elite sport. Current research examining the relationship between training load, injury, and fatigue in university athletes is sparse. Furthermore, a range of contextual factors that influence the training load-fatigue-injury relationship exist, necessitating an integrative biopsychosocial model to address primary and secondary injury prevention research. The objectives of this review were (a) to review the scientific literature examining the relationship between training load, fatigue, and MSK injury in university athletes and (b) to use this review in conjunction with a transdisciplinary research team to identify biopsychosocial factors that influence MSK injury and develop an updated, holistic biopsychosocial model to inform injury prevention research and practice in university sport. Ten articles were identified for inclusion in this review. Key findings were an absence of injury surveillance methodology and contextual factors that can influence the training load-fatigue-MSK injury relationship. We highlight the inclusion of academic load, social load, and mental health load as key variables contributing to a multifactorial, gendered environmental, scientific inquiry on sport injury and reinjury in university sport. An integrative biopsychosocial model for MSK injury in university sport is presented that can be used to study the biological, psychological, and social factors that modulate injury and reinjury risk in university athletes. Finally, we provide an example of how causal inference can be used to maximize the utility of longitudinally collected observational data that is characteristic of sport performance research in university sport.

Attention-Deficit Hyperactivity Disorder and Learning Disabilities Modify Recovery and Sport Behavior Following Sport-Related Concussion

Limited evidence exists concerning how a diagnosis of attention-deficit hyperactivity disorder and/or learning disabilities (ADHD/LD) modifies recovery and behavior following sport-related concussion (SRC). To understand how ADHD/LD modifies the post-SRC experience, we conducted a retrospective cohort study of concussed young athletes through phone interviews with patients and guardians. Outcomes included time until symptom resolution (SR) and return-to-learn (RTL), plus subjective changes in post-SRC activity and sports behavior. Multivariate Cox and logistic regression was performed, adjusting for biopsychosocial characteristics. The ADHD/LD diagnosis was independently associated with worse outcomes, including lower likelihood to achieve SR (hazard ratio [HR] = 0.62, 95% confidence interval [CI] = [0.41-0.94]; P = .02) and RTL (HR = 0.55, 95% CI = [0.36-0.83]; P < .01) at any time following injury, and increased odds of changing sport behavior after concussion (odds ratio [OR] = 3.26, 95% CI = [1.26-8.42], P = .02), often to a safer style of play (62.5% vs 39.6%; P = .02) or retiring from the sport (37.5% vs 18.5%; P = .02). These results provide further evidence of the unique needs for athletes with ADHD/LD following SRC.

Association of Sex With Adolescent Soccer Concussion Incidence and Characteristics

Importance

Because of the negative consequences of concussion, considerable research efforts have been directed toward understanding the risk factors for sport-related concussion (SRC) and its outcomes to better inform strategies for risk reduction. Girls are suggested to have an increased risk of concussion, warranting exploration into sex-dependent variations in concussion presentation and management, with the potential that this information might inform sex-specific rules directed toward risk reduction within sports.

Objective

To compare sex-associated differences in epidemiology and concussion management in adolescent soccer players within a prospective, longitudinal high school injury surveillance project.

Design, Setting, and Participants

This prospective, longitudinal cohort study assessed male and female soccer athletes from all high schools in the Michigan High School Athletic Association (MHSAA) during academic years 2016-2017 to 2018-2019.

Exposures

Sport-related concussion captured in the MHSAA Head Injury Reporting System.

Main Outcomes and Measures

Outcomes included details regarding each documented SRC event, including injury mechanism, immediate management, and return-to-play time. Multiple comparisons were made between male and female athletes regarding SRC risk, mechanism, short-term management, and outcomes.

Results

A total of 43 741 male and 39 637 female soccer athletes participated in MHSAA soccer during the 3 consecutive academic years of study (2016-2017: n = 751 schools; 2017-2018: n = 750 schools; and 2018-2019: n = 747 schools). During the 3 years of surveillance, 1507 of the 83 378 soccer athletes (1.8%) were reported to have SRC during soccer participation, including 557 boys (37.0%) and 950 girls (63.0%). Documented SRC risk in female soccer participants was greater than in male soccer participants (risk ratio, 1.88; 95% CI, 1.69-2.09; P < .001). Male soccer athletes most often sustained SRC from contact with another player (48.4%), whereas SRCs in female soccer players recorded in the Head Injury Reporting System were most often from nonplayer contact events (41.9%; P < .001). Adolescent male soccer players with a documented SRC were more likely to be removed from play on the day of injury (odds ratio, 1.54; 95% CI, 1.15-2.06; P = .004). Although the overall median time to return to play was 11 days (interquartile range [IQR], 7-15 days), male athletes typically returned 2 days earlier than female athletes (median, 10 [IQR, 7-14] days vs 12 [IQR, 7-16] days; Peto test P < .001).

Conclusions and Relevance

In this cohort study, sex-associated differences were revealed among adolescent soccer athletes in SRC risk, mechanism of injury, immediate management, and outcomes in injuries documented in a statewide injury reporting system. Thus, consideration might be given to sex-specific approaches to participation and concussion management in the sport.

Sway Balance Mobile Application: Reliability, Acclimation, and Baseline Administration

OBJECTIVES

To describe historic baseline session administration practices, to assess the utility of a practice trial (an acclimation trial) before the official balance session, and to examine the within-session reliability of the Sway Balance Mobile Application (SBMA).

DESIGN

Retrospective observational study.

SETTING

Middle schools, high schools, and colleges across the United States.

PARTICIPANTS

More than 17 000 student-athletes were included in the Sway Medical database with 7968 individuals meeting this study's inclusion criteria.

INDEPENDENT VARIABLES

The Sway Medical database included the following subject characteristics for each student-athlete: age, sex, weight, and height.

MAIN OUTCOME MEASURES

Balance assessment score generated by the SBMA.

RESULTS

Variable administration practices with significant differences between baseline session averages across methods were found. Individuals who performed an acclimation trial had a significantly higher baseline session average than those who did not. Within-session reliability estimates were in the low to adequate range (r = 0.53-0.78), with higher estimates found for 2 consecutive baseline tests (r = 0.75-0.78).

CONCLUSIONS

For maximum clinical utility, a standardized protocol for postural control baseline acquisition is necessary. Acclimation trial should be administered before a baseline session to minimize variability, especially with only 1 to 2 baseline tests. The highest reliability was observed across 2 consecutive baseline tests within the same baseline session. We suggest obtaining baseline balance measurements with an acclimation trial followed by a baseline session with 2 baseline tests. Prospective studies are required for validation.

Concussion in soccer: a comprehensive review of the literature

Sports-related concussion has been examined extensively in collision sports such as football and hockey. However, historically, lower-risk contact sports such as soccer have only more recently garnered increased attention. Here, we review articles examining the epidemiology, injury mechanisms, sex differences, as well as the neurochemical, neurostructural and neurocognitive changes associated with soccer-related concussion. From 436 titles and abstracts, 121 full texts were reviewed with a total of 64 articles identified for inclusion. Concussion rates are higher during competitions and in female athletes with purposeful heading rarely resulting in concussion. Given a lack of high-level studies examining sports-related concussion in soccer, clinicians and scientists must focus research efforts on large-scale data gathering and development of improved technologies to better detect and understand concussion.

Head Injury in Soccer: From Science to the Field; summary of the head injury summit held in April 2017 in New York City, New York

There has been an increased focus and awareness of head injury and sport-related concussion (SRC) across all sports from the medical and scientific communities, sports organisations, legislators, the media and the general population. Soccer, in particular, has been a focus of attention due to the popularity of the game, the frequency of SRC and the hypothesised effects of repetitive heading of the ball. Major League Soccer, US Soccer and the National Women’s Soccer League jointly hosted a conference entitled, ‘Head Injury in Soccer: From Science to the Field’, on 21–22 April 2017 in New York City, New York. The mission of this conference was to identify, discuss and disseminate evidence-based science related to the findings and conclusions of the fifth International Conference on Concussion in Sport held by the Concussion in Sport Group and apply them to the sport of soccer. In addition, we reviewed information regarding the epidemiology and mechanism of head injuries in soccer at all levels of play, data regarding the biomechanics and effects of repetitive head impacts and other soccer-specific considerations. We discussed how to release the information raised during the summit to key stakeholders including athletes, parents, coaches and healthcare providers. We identified future areas for research and collaboration to enhance the health and safety of soccer (football) players.

Epidemiological profile of soccer-related injuries in a state Brazilian championship: An observational study of 2014-15 season

BACKGROUND

Soccer related injuries are often reported in studies, but epidemiological research on this theme is rare in Brazil, Furthermore, the conditions in which athletes have returned to sports practice, namely, either symptomatic or asymptomatic, have been neglected in research.

OBJECTIVES

The aim of this study was to describe the epidemiological features of injuries among professional Brazilian soccer players in relation to location, type, mechanism, severity, recurrence, treatment and, lastly, symptoms in return to sport.

STUDY DESIGN

Descriptive and cross-sectional, observational study.

STUDY CENTER

School of Physical Therapy of the University of Mato Grosso do Sul, Brazil.

METHODS

116 male professional athletes of teams from a Brazilian state championship were interviewed and information about injuries was recorded using a retrospective reported morbidity questionnaire. Data were analyzed in mean ± SD for physical characteristics and sports practice history in absolute and relative frequencies (chi-square test with Bonferroni's correction) for characterization of soccer injuries in terms of type, location, severity, recurrence and symptoms in return to sport.

RESULTS

The numbers of injuries per athlete and per injured athlete were 0.92 and 1.43 respectively. The injuries of muscle-tendon unit and the joint types localized on lower limbs constituted the most important clinical occurrences with significant difference both in relation to other types (p < 0.05). Moderate and severe injuries were the most frequent occurrences. In relation to mechanisms for each type of injury, body contact was at least three times more responsible for injury cases. This type of mechanism was associated with a significantly greater impairment of joint structures. Concerning occurrence and recurrence of cases, the number of recurrent injuries of the muscle-tendon unit reached about 7.5% of the first-time injuries, while the number of joint recurrent injuries integrated almost 40% of the first-time cases. Significant differences between first-time injuries and recurrent injuries were found only for muscle-tendon and joint structures (p < 0.05), while significant differences among the type of injuries within each type of occurrence (first-time or recurrent injuries) were also found between muscle-tendon and joint injuries (p < 0.05). In relation to athletes with symptoms, in return to sport, 77.6% of them were treated for their injuries but more than half of them returned with symptoms still present when compared to those who returned without any symptoms. Among athletes who did not receive treatment, a lower percentage (58.3%) returned to the sport with symptoms still present. Significant associations between treatment and symptomatology were not found.

Prognostic Factors in Pediatric Sport-Related Concussion

PURPOSE OF REVIEW

Sport-related concussion (SRC) and mild traumatic brain injury (mTBI) have been thrust into the national spotlight, with youth athletes bearing the burden of this public health problem. The current review aims to provide a practical summary of pediatric SRC, including key terminology, return to play/school, and risk factors for post-concussion syndrome (PCS).

RECENT FINDINGS

While the majority of youth athletes recover within 2 to 4 weeks, approximately 10% of athletes experience a protracted recovery with symptoms lasting months, impacting social, scholastic, and sporting activities. In the pediatric population, the strongest predictors of PCS are initial symptom burden and prior concussion, with mixed results behind the factors of gender, headaches, and learning disability. The role of psychiatric, family history, sports, and socioeconomic factors remain in their infancy.

Initial symptom presentation after high school football-related concussion varies by time point in a season: an initial investigation

Background

Schedule-based and in-season factors (e.g., competition type) have been shown to be associated with symptom reporting patterns and injury severity in sport-related concussion (SRC). To determine if acute neurocognitive and symptom presentation following SRC differ by time point within a high school football season.

Methods

Multicenter ambispective cohort of high school football players who sustained a SRC (N = 2594). Timing (early, mid, and late season) of SRC was based on median dates for the start of the pre-season, regular season, and playoffs of each states’ football schedules. Analysis of covariance (ANCOVA) investigated differences across season period groups for: (1) neurocognitive test scores, (2) total symptom scores (TSS), and (3) individual symptom increases from baseline within 1-week post-injury.

Results

Significant group differences were observed in TSS, F(2, 2589) = 15.40, p <  0.001, η_p² = 0.01, and individual symptom increases from baseline, F(2, 2591) = 16.40, p <  0.001, η_p² = 0.01. Significant increases were seen from baseline to both midseason and late season in both TSS, χ² = 24.40, p <  0.001, Φ = 0.10 and individual symptoms, χ² = 10.32, p = 0.006, Φ = 0.10. Post hoc tests indicated a linear trend, with late-season injured athletes reporting approximately twice the TSS (13.10 vs. 6.77) and new symptoms (5.70 vs. 2.68) as those with early-season injuries.

Conclusion

In a cohort of American high school football student-athletes, those suffering SRC in the late-season time period had increased acute symptom burden. SRC sustained later in-season may require more conservative management.