Middle school injuries: a 20-year (1988-2008) multisport evaluation

Injury and Treatment Characteristics of Middle School-Aged Patients Under the Care of Athletic Trainers From 2010 to 2022: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

Exploring sports-related musculoskeletal injuries and treatment characteristics in middle school sports may help inform patient care decisions such as appropriate medical coverage.

OBJECTIVE

To describe injury and treatment characteristics of middle school-aged athletes receiving care from athletic trainers within the Athletic Training Practice-Based Research Network (AT-PBRN).

DESIGN

Descriptive study.

SETTING

Middle school.

PATIENT OR OTHER PARTICIPANTS

Middle school-aged athletes (n = 1011; male = 503, female = 506, 2 declined to answer) with sports-related musculoskeletal injuries.

MAIN OUTCOME MEASURES

Electronic patient records were analyzed from the AT-PBRN from 59 athletic trainers across 14 states between 2010 and 2022. Summary statistics (frequency, percentages, median, and interquartile ranges [IQR]) were used to describe injury (age at injury, sex, sport, body part, and diagnosis) and treatment characteristics (type of treatment, number of visits, and number of procedures per visit).

RESULTS

Football (17.7%, n = 179), basketball (17.6%, n = 178), and soccer (14.9%, n = 151) reported the highest number of injuries. The ankle (17.2%, n = 174), knee (16.5%, n = 167), and head (14.1%, n = 143) were the most common injury locations. Concussion (13.0%, n = 131), ankle strain/sprain (12.4%, n = 125), and thigh/hip/groin sprain/strain (11.1%, n = 112) were the most reported diagnoses. Therapeutic exercise or activities (27.6%, n = 1068), athletic trainer evaluation or re-evaluation (24.7%, n = 957), and hot/cold packs (19.8%, n = 766) were the most common services, with a median of 2 visits (IQR = 1 to 4) and 2 procedures (IQR = 1 to 2) per visit.

CONCLUSIONS

Football, basketball, and soccer reported the most musculoskeletal injuries for middle school-aged athletes. Concussions were the most frequent diagnosis, followed by ankle sprains/strains. Our findings are similar to prior investigations at the high school and collegiate levels. Treatments at the middle school level were also similar to those that have been previously reported at the high school level with therapeutic exercise/activity, athletic trainer evaluation or re-evaluation, and hot/cold packs being the most common treatments. This information may be useful for informing patient care decisions at the middle-school level.

Running-related injuries in middle school cross-country runners: Prevalence and characteristics of common injuries

BACKGROUND

Understanding the prevalence and factors associated with running-related injuries in middle school runners may guide injury prevention.

OBJECTIVE

To determine the prevalence of running-related injuries and describe factors related to a history of injury.

DESIGN

Retrospective cross-sectional study.

SETTING

Survey distributed online to middle school runners.

METHODS

Participants completed a web-based survey regarding prior running-related injuries, training, sleep, diet, and sport participation.

MAIN OUTCOME MEASUREMENTS

Prevalence and characteristics differentiating girls and boys with and without running-related injury history adjusted for age.

PARTICIPANTS

Youth runners (total: 2113, average age,  13.2 years; boys: n = 1255, girls: n = 858).

RESULTS

Running-related injuries were more prevalent in girls (56% vs. 50%, p = .01). Ankle sprain was the most common injury (girls: 22.5%, boys: 21.6%), followed by patellofemoral pain (20.4% vs. 7.8%) and shin splints (13.6% vs. 5.9%); both were more prevalent in girls (p < .001). Boys more frequently reported plantar fasciitis (5.6% vs. 3.3%, p = .01), iliotibial band syndrome (4.1% vs. 1.4%, p = .001) and Osgood-Schlatter disease (3.8% vs. 1.2%, p = .001). Runners with history of running-related injuries were older, ran greater average weekly mileage, ran faster, had fewer average hours of sleep on weekends, skipped more meals, missed breakfast, and consumed less milk (all p < .05). Girls with history of running-related injuries reported higher dietary restraint scores, later age of menarche, more menstrual cycle disturbances, and higher likelihood of following vegetarian diets and an eating disorder diagnosis (all p < .05). Runners with no history of running-related injuries were more likely to have participated in ≥2 years of soccer or basketball (p < .001).

CONCLUSIONS

Most middle school runners reported a history of running-related injuries and certain injuries differing by gender. Modifiable factors with the greatest association with running-related injuries included training volume, dietary restraint, skipping meals, and less sleep. Sport sampling, including participation in ball sports, may reduce running-related injury risk in this population.

Reporting of Concussion Symptoms by a Nationwide Survey of United States Parents of Middle School Children

This cross-sectional study assessed concussion symptom knowledge of parents of middle school (MS) children (aged 10-15 years) through a free-response item that solicited concussion symptoms and compared findings to a pre-validated scale-based measure. A self-administered online questionnaire was sent to a panel of randomly selected United States residents who were recruited by a third-party company, aged ≥ 18 years, and identified as parents of MS children. Via a free-response item, parents listed what they believed were concussion symptoms. Multiple sections later, parents identified potential concussion symptoms via a scale measure, which featured 25 items (22 actual symptoms, three distractor symptoms) with three response options: yes, no, maybe. Free-response item responses were coded into specific symptoms. The 1062 eligible parents that provided complete data commonly identified the symptoms of dizziness (90.2%), blurred vision (87.4%), and balance problems (86.4%) on the scale-based measure. However, these and other symptoms were less commonly identified via the free-response item (dizziness: 44.4%; blurred vision: 16.5%; balance problems: 3.5%). Concussion symptoms commonly reported via the scale-based measure were reported less frequently within the free-response item. Future research must explore strategies to help clinicians working with parents and their children to measure and assess concussion symptom reporting and knowledge.

The influence of maturation and sex on pelvis and hip kinematics in youth distance runners

OBJECTIVES

This study aimed to investigate differences in stance phase pelvic and hip running kinematics based on maturation and sex among healthy youth distance runners.

DESIGN

Cross-Sectional.

METHODS

133 uninjured youth distance runners (M = 60, F = 73; age = 13.5 ± 2.7 years) underwent a three-dimensional running analysis on a treadmill at a self-selected speed (2.8 ± 0.6 m·s^-1). Participants were stratified as pre-pubertal, mid-pubertal, or post-pubertal according to the modified Pubertal Maturational Observation Scale. Stance phase pelvis and hip range of motion (RoM) and peak joint positions were extracted. Two-way ANCOVAs (sex, maturation; covariate of running velocity) were used with Bonferroni-Holm method to control for multiple comparisons with a target alpha level of 0.05.

RESULTS

A two-way interaction between sex and maturation was detected (p = 0.009) for frontal plane pelvic obliquity RoM. Post-hoc analysis identified a maturation main effect only among females (p˂0.008). Pelvic obliquity RoM was significantly greater among post-pubertal (p = 0.001) compared to pre-pubertal females. Significant main effects of sex (p = 0.02), and maturation (p = 0.01) were found for hip adduction RoM. Post-hoc analysis indicated a significant increase in hip adduction RoM from pre-pubertal to post-pubertal female runners (p = 0.001). A significant main effect of sex was found for peak hip adduction angle (p = 0.001) with female runners exhibiting greater maximum peak hip adduction compared to males.

CONCLUSIONS

Maturation influences pelvic and hip kinematics greater in female than male runners. Sex differences became more pronounced during later stages of puberty. These differences may correspond to an increased risk for running-related injuries in female runners compared to male runners.

Adolescent Running Biomechanics - Implications for Injury Prevention and Rehabilitation

Global participation in running continues to increase, especially amongst adolescents. Consequently, the number of running-related injuries (RRI) in adolescents is rising. Emerging evidence now suggests that overuse type injuries involving growing bone (e.g., bone stress injuries) and soft tissues (e.g., tendinopathies) predominate in adolescents that participate in running-related sports. Associations between running biomechanics and overuse injuries have been widely studied in adults, however, relatively little research has comparatively targeted running biomechanics in adolescents. Moreover, available literature on injury prevention and rehabilitation for adolescent runners is limited, and there is a tendency to generalize adult literature to adolescent populations despite pertinent considerations regarding growth-related changes unique to these athletes. This perspective article provides commentary and expert opinion surrounding the state of knowledge and future directions for research in adolescent running biomechanics, injury prevention and supplemental training.

Characteristics of Injuries Occurring During Cross-Country: A Report from the Athletic Training Practice-Based Research Network

CONTEXT

Cross-country is a popular sport activity, particularly in adolescent populations. Although epidemiologic investigations have provided insight into patient and injury characteristics associated with running injuries, little is known about how these injuries are managed at the point of care.

OBJECTIVE

To describe injury and treatment characteristics of injuries sustained during cross-country.

DESIGN

Cross-sectional study.

SETTING

High school athletic training clinics within the Athletic Training Practice-Based Research Network.

PATIENTS OR OTHER PARTICIPANTS

Patient cases were included if the patient was diagnosed with an injury that occurred during interscholastic cross-country participation. All patients received usual care by an athletic trainer.

MAIN OUTCOME MEASURE(S)

We used summary statistics to describe injury (sex, age, participation level, time of injury, mechanism of injury, body part, injury type, diagnosis) and treatment (type, amount, duration, number of services) characteristics.

RESULTS

Most cross-country injuries occurred to the lower extremity and were musculotendinous or ligamentous in nature. The most common injury types were sprain/strain (43.8%), tendinopathy (18.5%), and general pain (9.5%). Injured body parts and diagnoses were typically similar between sexes. The most frequently used treatment was therapeutic exercises or activities (28.7%), and patients received an average of 7.4 ± 17.4 total athletic training services during 5.5 ± 15.1 episodes of care over 27.8 ± 87.5 days.

CONCLUSIONS

Adolescent cross-country student-athletes frequently sustained non-time-loss injuries that required up to 1 month of treatment and management. These findings will generate awareness surrounding the role of athletic trainers in providing care for cross-country athletes.

Epidemiology of Concussion in the National Football League, 2015-2019

BACKGROUND

Concussion in American football, and specifically the National Football League (NFL) is a major area of interest and key focus for injury prevention. Complete and accurate characterization of when, how, and to whom these injuries occur can facilitate injury reduction efforts. Existing studies of concussion in the NFL use publicly available data, potentially limiting data quality and the inferences that can be made.

HYPOTHESIS

Concussion incidence in the NFL decreased across the 2015-2019 seasons.

STUDY DESIGN

Descriptive epidemiology study.

LEVEL OF EVIDENCE

Level 4.

METHODS

Concussion incidence, including counts, one-season risk, and rates per game and player-plays, among active NFL players from 2015 to 2019 is described by year, season, play type, and roster position.

RESULTS

A total 1302 concussions were identified from 2015 to 2019 among 1004 players. Of these, 80% occurred in NFL games. The average annual incidence of in-season game concussions changed over the study period, from 230.7 per season (2015-2017) to 177.0 per season (2018-2019); this represented a 23% decrease in game settings (P < 0.01). Practice concussions fluctuated across the years of the study from 38 to 67 per season (average = 50.8/season). There were 70.6 concussions per 100 preseason games, which was slightly higher than the regular season rate per game of 61.7. Overall, there were 790 regular season game concussions across 4,657,243 player-plays and 114,428 player-games during the 5-year study. In regular season games, the majority of concussions were sustained on running and passing plays (n = 119/season), and the highest average rate per play occurred on kickoffs (0.69/100 plays). Defensive secondary (cornerbacks, safeties, and generic defensive backs) and offensive line incurred the most concussions, and the highest rates of concussion were among tight ends and wide receivers.

CONCLUSION AND RELEVANCE

Concussions in the NFL are a key focus for player safety. Concussion reduction strategies were implemented before 2018, after which there was a sustained 2-year decrease in concussion incidence, providing a new benchmark from which to work toward further injury reduction.

Recommendations on Youth Participation in Ultra-Endurance Running Events: A Consensus Statement

Participation in ultra-endurance running (UER) events continues to grow across ages, including youth athletes. The 50- and 100-km are the most popular distances among youth athletes. Most youth athletes are between 16-18 years; however, some runners younger than 12 years have successfully completed UER events. Parents, athletes, coaches, race directors, and medical professionals often seek advice regarding the safety of youth athletes participating in these events, especially with regard to potential short and long-term health consequences. UER may impact key organ systems during growth and development. We propose a decision-making process, based on current knowledge and the experience of the consensus group that addresses age regulations, medical and psychological well-being, training status and race-specific factors (such as distance, elevation change, remoteness, ambient temperatures, level of medical assistance, and type of provisions provided by the race organizers) to use until evidence of long-term consequences of UER in youth athletes is available. These recommendations are aimed at safe participation in UER events for youth athletes with a proper and individualized assessment.

Factors associated with concussion-symptom knowledge and attitudes toward concussion care seeking in a national survey of parents of middle-school children in the US

BACKGROUND

Developing appropriate concussion prevention and management paradigms in middle school (MS) settings requires understanding parents' general levels of concussion-related knowledge and attitudes. This study examined factors associated with concussion-symptom knowledge and care-seeking attitudes among parents of MS children (aged 10-15 years).

METHODS

A panel of 1224 randomly selected U.S. residents, aged ≥ 18 years and identifying as parents of MS children, completed an online questionnaire capturing parental and child characteristics. The parents' concussion-symptom knowledge was measured using 25 questions, with possible answers being "yes", "maybe", and "no". Correct answers earned 2 points, "maybe" answers earned 1 point, and incorrect answers earned 0 point (range: 0-50; higher scores = better knowledge). Concussion care-seeking attitudes were also collected using five 7-point scale items (range: 5-35; higher scores = more positive attitudes). Multivariable ordinal logistic regression models identified predictors of higher scores. Models met proportional odds assumptions. Adjusted odds ratios (aORs) with 95% confidence intervals (95%CIs) (excluding 1.00) were deemed statistically significant.

RESULTS

Median scores were 39 (interquartile range: 32-44) for symptom knowledge and 32 (interquartile range: 28-35) for care-seeking attitude. In multivariable models, odds of better symptom knowledge were higher in women vs. men (aOR = 2.28; 95%CI: 1.71-3.05), white/non-Hispanics vs. other racial or ethnic groups (aOR = 1.88; 95%CI: 1.42-2.49), higher parental age (10-year-increase aOR = 1.47; 95%CI: 1.26-1.71), and greater competitiveness (10%-scale-increase aOR = 1.24; 95%CI: 1.13-1.36). Odds of more positive care-seeking attitudes were higher in white/non-Hispanics vs. other racial or ethnic groups (aOR = 1.45; 95%CI: 1.06-1.99) and in older parental age (10-year-increase aOR = 1.24; 95%CI: 1.05-1.47).

CONCLUSION

Characteristics of middle school children's parents (e.g., sex, race or ethnicity, age) are associated with their concussion-symptom knowledge and care-seeking attitudes. Parents' variations in concussion knowledge and attitudes warrant tailored concussion education and prevention.

Impact of COVID-19 Social Distancing Restrictions on Training Habits, Injury, and Care Seeking Behavior in Youth Long-Distance Runners

Purpose: The COVID-19 pandemic impacted the sporting and exercise activities of millions of youth. Running is an activity that could be maintained while social distancing restrictions were implemented during the pandemic. If running-related injuries do occur, these restrictions may also influence the access to care or care seeking behavior of this population. Therefore, the purpose of this study was to determine if the social distancing restrictions during the 2020 COVID-19 pandemic influenced training habits, injury, and care seeking behavior in youth long-distance runners. Methods: A customized, open online questionnaire was provided to runners 9-19 years of age who participated in long-distance running activities including team/club cross-country, track and field (distances ≥800 m), road races, or recreational running. Participants responded to questions about demographics, running habits, RRIs, and health care provider visits 6-months before as well as during social distancing restrictions due to COVID-19. Wilcoxon signed rank tests compared differences for ratio data and Chi-square tests were used to compare proportions before and during COVID-19 social distancing restrictions. Statistical significance was set at p ≤ 0.05. Results: A total of 287 youth long-distance runners (male = 124, female = 162, unspecified = 1; age = 15.3 ± 1.7 years; running experience = 5.0 ± 2.3 years) participated. Compared to their pre-COVID-19 responses, youth long-distance runners reported lower distances run per week (p < 0.001), fewer runs per week (p < 0.001), fewer hard runs per week (p < 0.001), fewer number of injuries (p < 0.001), and fewer injuries per 1,000 km (p = 0.002) during the COVID-19 social distancing restrictions. A lower proportion of participants reported in-person health care provider visits (p < 0.001) and a lower proportion of visits were made to an athletic trainer during COVID-19 social distancing restrictions compared to prior to COVID-19 (p < 0.001). Conclusion: The COVID-19 pandemic resulted in significant decreases in both training and injuries which were different compared to previous reports in an adult population. Many of the runners who sustained an injury during COVID-19 social distancing restrictions did not seek care, with the most prominent reduction in visits to an athletic trainer. This could impact future injury and chronic pain.

Injury characteristics in male youth athletics: a five-season prospective study in a full-time sports academy

OBJECTIVES

To describe the injury characteristics of male youth athletes exposed to year-round athletics programmes.

METHODS

Injury surveillance data were prospectively collected by medical staff in a cohort of youth athletics athletes participating in a full-time sports academy from 2014-2015 to 2018-2019. Time-loss injuries (>1 day) were recorded following consensus procedures for athletics. Athletes were clustered into five event groups (sprints, jumps, endurance, throws and non-specialised) and the number of completed training and competition sessions (athletics exposures (AE)) were calculated for each athlete per completed season (one athlete season). Injury characteristics were reported overall and by event groups as injury incidence (injuries per 1000 AE) and injury burden (days lost per 1000 AE).

RESULTS

One-hundred and seventy-eight boys (14.9±1.8 years old) completed 391 athlete seasons, sustaining 290 injuries. The overall incidence was 4.0 injuries per 1000 AE and the overall burden was 79.1 days lost per 1000 AE. The thigh was the most common injury location (19%). Muscle strains (0.7 injuries per 1000 AE) and bone stress injuries (0.5 injuries per 1000 AE) presented the highest incidence and stress fractures the highest burden (17.6 days lost per 1000 AE). The most burdensome injury types by event group were: bone stress injuries for endurance, hamstring strains for sprints, stress fractures for jumps, lesion of meniscus/cartilage for throws and growth plate injuries for non-specialised athletes.

CONCLUSION

Acute muscle strains, stress fractures and bone stress injuries were identified as the main injury concerns in this cohort of young male athletics athletes. The injury characteristics differed between event groups.

Youth running consensus statement: minimising risk of injury and illness in youth runners

Despite the worldwide popularity of running as a sport for children, relatively little is known about its impact on injury and illness. Available studies have focused on adolescent athletes, but these findings may not be applicable to preadolescent and pubescent athletes. To date, there are no evidence or consensus-based guidelines identifying risk factors for injury and illness in youth runners, and current recommendations regarding suitable running distances for youth runners at different ages are opinion based. The International Committee Consensus Work Group convened to evaluate the current science, identify knowledge gaps, categorise risk factors for injury/illness and provide recommendations regarding training, nutrition and participation for youth runners.

Comparison of head impact exposure in practice drills among multiple youth football teams

Objective

Limiting contact in football practice can reduce the number of head impacts a player receives, but further research is needed to inform the modification of optimal drills that mitigate head impact exposure (HIE) while the player develops the skills needed to safely play the game. This study aimed to compare HIE in practice drills among 6 youth football teams and to evaluate the effect of a team on HIE.

Methods

On-field head impact data were collected from athletes (ages 10–13 years) playing on 6 local youth football teams (teams A–F) during all practices using the Head Impact Telemetry System. Video was recorded and analyzed to verify and assign impacts to a specific drill. Drills were identified as follows: dummy/sled tackling, half install, install, install walk through, multiplayer tackle, Oklahoma, one-on-one, open field tackling, other, passing, position skill work, scrimmage, special teams, tackling drill stations, and technique. HIE was quantified in terms of impacts per player per minute (ppm) and peak linear and rotational head acceleration. Generalized linear models were used to assess differences in head impact magnitude and frequency among drills as well as among teams within the most common drills.

Results

Among 67 athlete-seasons, a total of 14,718 impacts during contact practices were collected and evaluated in this study. Among all 6 teams, the mean linear (p < 0.0001) and rotational (p < 0.0001) acceleration varied significantly among all drills. Open field tackling had significantly (p < 0.001) higher mean linear acceleration than all other drills. Multiplayer tackle had the highest mean impact rate (0.35 ppm). Significant variations in linear acceleration and impact rate were observed among teams within specific drills. Team A had the highest mean linear acceleration in install, one-on-one, and open field tackling and the highest mean impact rate in Oklahoma and position skill work. Although team A spent the greatest proportion of their practice on minimal- or no-player versus player contact drills (27%) compared to other teams, they had the highest median (20.2g) and 95th percentile (56.4g) linear acceleration in practice.

Conclusions

Full-speed tackling and blocking drills resulted in the highest HIE. Reducing time spent on contact drills relative to minimal or no contact drills may not lower overall HIE. Instead, interventions such as reducing the speed of players engaged in contact, correcting tackling technique, and progressing to contact may reduce HIE more effectively.

The Epidemiology of Injuries in Middle School Football, 2015-2017: The Advancing Healthcare Initiatives for Underserved Students Project

BACKGROUND

Although data exist on injuries in youth football leagues, there are limited recent data on injury incidence in middle school football. Updated injury incidence estimates can help drive the development of injury prevention strategies.

PURPOSE

Describe the epidemiology of injuries in middle school football during school years 2015-2016 to 2017-2018.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Data originated from 9 public middle schools in Virginia during school years 2015-2016 to 2017-2018. Certified athletic trainers collected injury and athlete-exposure (AE) data from school-sanctioned games and practices in boys', football. Injury counts and rates per 1000 AEs were calculated. Injury rate ratios with 95% CIs compared rates between games and practices.

RESULTS

Overall, 664 middle school boys', football injuries were reported, leading to an overall injury rate of 20.54 per 1000 AEs (95% CI, 18.98-22.11). The time loss injury rate (inclusive of injuries with participation restriction time ≥24 hours) was 9.28 per 1000 AEs (95% CI, 8.23-10.33). The injury rate was higher in competition than practice (36.19 vs 17.97 per 1000 AEs; injury rate ratio, 2.01; 95% CI, 1.69-2.40). Most injuries were to the head/face (competition, 20.6%; practice, 15.8%) and hand/wrist (competition, 18.8%; practice, 16.4%) and were diagnosed as contusions (competition, 30.9%; practice, 25.9%) and sprains (competition, 19.4%; practice, 12.6%). Competitions also had a large proportion of concussions (10.3%). Overall, 80.0% and 66.9% of injuries were due to contact in competition and practice, respectively; of these contact-related injuries, 62.1% and 41.6% were specifically player contact.

CONCLUSION

Injury distributions parallel those found in previous research from middle school and other sport settings. Injury rates in middle school football were higher than those reported in previous findings in high school and college. However, caution must be taken when interpreting findings in relation to other surveillance systems with varying methodologies. Still, the findings highlight the need for injury prevention strategies within middle school football, particularly as related to contact-related mechanisms.

Acute and overuse injuries among sports club members and non-members: the Finnish Health Promoting Sports Club (FHPSC) study

Background

Physical activity in adolescence is promoted for its multi-dimensional health benefits. However, too intensive sports participation is associated with an increased injury risk. Our aim was to compare the occurrence of acute and overuse injuries in Finnish sports club members and non-members and to report training and competing habits associated with a higher injury risk in sports club members.

Methods

In this cross-sectional survey targeted at 14–16-year-old adolescents, a structured questionnaire was completed by 1077 sports club members and 812 non-members. The main outcome measures were self-reported acute and overuse injuries, their location and type.

Results

At least one acute injury in the past year was reported by 44.0% of sports club members and 19.8% of non-members (P < 0.001). The sex-adjusted odds ratio (OR) for acute injury in sports club members compared to non-members was 3.13 (95% confidence interval (95% CI) 2.54–3.87). Thirty-five percent of sports club members and 17.4% of non-members (P < 0.001) reported at least one overuse injury during the past year. The overuse injury OR for sports club members was 2.61 (95% CI 2.09–3.26). Sports club members who trained 7–14 h per week during training (OR 1.61, 95% CI 1.21–2.12, P = 0.001) or competition season (OR 1.55, 95% CI 1.18–2.06, P = 0.002) were more likely to report an injury compared to members who trained 3–6 h per week. Those sports club members who participated in forty competitions or more compared to 7–19 competitions per year were more likely to report an acute injury (OR 1.55, 95% CI 1.05–2.08, P = 0.028) or for an overuse injury (OR 1.53, 95% CI 1.02–2.30, P = 0.038).

Conclusions

Both acute and overuse injuries are common among youth sports club members, and the number increases along with increasing amounts of training and competitions. More effective injury prevention is needed both for adolescents engaging in sports club activities and for other adolescents.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2417-3) contains supplementary material, which is available to authorized users.

Leading Causes of Fatal and Nonfatal Unintentional Injury for Children and Teens and the Role of Lifestyle Clinicians: A Commentary

Unintentional injury and death as a public health concern has not been established in the pediatric population. This is a commentary on a review of epidemiological data of unintentional deaths and injuries with a focus on age, sex, and racial differences in this population. The review takes in-depth look at children aged 0-19 years in the US, followed by a discussion of strategies suggested to address mechanisms of these injuries/deaths. Lifestyle clinicians have a significant role in educating this population and their parent/guardians. Therefore providing insight into the interpretation of the data can support practical education and prevention interventions.

Functional movement screen and Y-Balance test scores across levels of American football players

Few studies have investigated differences in functional movement assessment performance across scholastic levels of competition. This study examined Functional Movement Screen (FMS) performance in middle school (MS), high school (HS) and collegiate (COL) American football players and Y-Balance test (YBT) scores in MS and HS players. Functional movement measurements were collected for MS (N = 29; age = 12.8 ± 0.7 years), HS (N =52; age = 15.7 ± 1.2 years), and COL (N =77; age = 19.9 ± 1.4 years) football players prior to each group’s competitive season. Differences in composite FMS and YBT measurements were examined using Welch’s ANOVA and Mann-Whitney U-tests, respectively. Chi-square analyses examined normality of score distributions for individual FMS tests. The MS group displayed a lower composite FMS (12.9 ± 1.9) than both HS (14.0 ± 1.7) and COL (14.1 ± 2.1) groups (p = 0.019). COL players scored significantly lower on the Shoulder Mobility (SM) but higher on the Deep Squat (DS), In-line Lunge (ILL), Active Straight-Leg Raise (ASLR) and Push-Up (PU) than both HS and MS groups. No differences were found between MS and HS groups for any YBT normalized reach distances and side-to-side reach distance differences. FMS performance varied with football competition level whereas YBT performance did not. The results suggest that football competition levels normative data and injury-risk thresholds should be established when using FMS scores to guide performance and injury prevention programming.

Determinants of intention to disclose concussion symptoms in a population of U.S. military cadets

OBJECTIVES

Non-disclosure of concussion complicates concussion management, but almost nothing is known about non-disclosure in military settings. This study describes concussion disclosure-related knowledge, attitudes, perceived social norms, perceived control, and intention. Additionally, the study identifies determinants of high intention to disclose concussion symptoms.

DESIGN

Cross sectional survey.

METHODS

First-year service academy cadets completed a cross-sectional survey to assess perceptions of concussion disclosure. Independent variables included: gender, race, ethnicity, high school athlete status, NCAA athlete status, previous concussion history, previous concussion education, socioeconomic proxy, concussion-related knowledge, attitudes about concussion, perceived social norms (perceived peer/organizational support and actions), and perceived control over disclosure. Log-binomial regression was used to identify determinants of high intention to disclose concussion symptoms.

RESULTS

A total of 972 first-year military service academy cadets completed the survey [85% response; age=18.4±0.9y]. In the simple models, previous concussion history was associated with lower intention to disclose concussion symptoms. High perceived control over disclosure, higher concussion knowledge, more favorable attitudes and social norms about concussion were associated with high intention to disclose. In the multivariable model, a 10% shift towards more favorable perceived social norms (PR=1.28; p<0.001) and attitudes (PR=1.07; p=0.05) about concussion were associated with high intention to disclose concussion symptoms. High perceived control over disclosure was associated with high intention to disclose concussion symptoms (PR=1.39; p=0.08).

CONCLUSIONS

Concussion-related perceived social norms, attitudes, and perceived control are associated with intention to disclose. Organizationally appropriate intervention strategies can be developed from these data.

Physiological underarousal as a mechanism of aggressive behavior in university athletes with a history of concussion

INTRODUCTION

Research has indicated that athletes who engage in high-risk athletic activities, such as football and hockey, have riskier personalities than their low-risk and nonathlete counterparts (Ahmadi et al., 2011, Procedia Soc Behav Sci, 30 and 247-251; Zuckerman, 1983, Biological bases of sensation seeking, impulsivity, and anxiety, Lawrence Erlbaum Assoc Inc.). For instance, increased sensation-seeking and aggression are common in high-risk athletes, rendering these individuals more likely to sustain a subsequent injury, such as concussion. Elevated levels of certain personality traits, including impulsivity and aggression, have also been observed after concussion (Goswami et al., 2016, Brain Struct Funct, 221 and 1911-1925). The purpose of this study therefore was to determine whether aggressive behavior in university athletes may be accounted for, in part, by a history of concussion, rather than exclusively athletic status.

METHODS

Using a quasi-experimental design, 66 university students (n = 18 nonathletes, n = 24 low-risk athletes, n = 24 high-risk athletes) with (n = 27) and without a history of concussion (n = 39) completed the Buss & Perry Aggression Questionnaire (BPAQ; Buss & Perry, , J Pers Soc Psychol, 63 and 452) and provided electrodermal activation (EDA) as an index of physiological arousal.

RESULTS

It was found that decreased physiological arousal among students with a history of concussion was associated with greater endorsement of physical aggression. Moreover, athletic status did not account for this pattern of aggression, as athletes and nonathletes did not differ in terms of self-reported aggressive tendencies.

CONCLUSIONS

Physiological compromise after concussive injury may act as an independent mechanism of aggressive behavior in athletes beyond factors, such as athletic status.

Using opinion leaders to address intervention gaps in concussion prevention in youth sports: key concepts and foundational theory

Behavioral interventions to increase disclosure and proper management of concussion in youth sports have unrealized potential when it comes to preventing concussion. Interventions have focused on changing individual athlete behavior and have fallen short of the potential for sustained systemic behavioral change. One potentially critical reason for this shortfall is that other key determinants of risk behaviors at all levels of the socio-ecological model (e.g. interpersonal, community, policy) are not addressed in extant programming. There is a critical need for theory-driven interventions that address concussion prevention and education at the community level and target sustainable culture change. The Popular Opinion Leader (POL) intervention, a multi-level intervention model previously successfully employed in multiple public health contexts, is theoretically well positioned to affect such change. POL is based on the Diffusion of Innovations framework and involves identifying, recruiting, and training well-respected and trusted individuals to personally endorse prevention and risk-reduction within their social networks. Critical behavioral changes related to concussion disclosure and management have been shown to diffuse to others if enough opinion leaders endorse and support the behaviors. This article summarizes the concepts and principles of POL and describes how it could be adapted for and implemented in youth sport settings. For optimal impact, POL needs to adapt to several factors unique to youth sports settings and culture. First, adult involvement may be important, given their direct involvement in the athlete's medical care. However, parents and coaches' opinions on injury care-seeking, competition, and safety may affect their perceptions of POL. Second, youth sports are structured settings both physically and socioculturally. Games and practices may provide opportunities for the informal interactions that are critical to the success of POL. However, youth sport setting membership is transient as players get older and move to other sport settings; POL approaches need to be self-sustaining despite this turnover. Moreover, stakeholder value placed on athlete development and competition, alongside safety, must be considered. Formative research is needed to ensure that POL principles are translated into the youth sport setting while maintaining fidelity to the concepts and principles that have made POL successful for other health outcomes.

Concussion Rates in U.S. Middle School Athletes, 2015-2016 School Year

INTRODUCTION

Concussion incidence estimates in middle school sports settings are limited. This study examines concussion incidence in nine U.S. middle schools during the 2015-2016 school year.

METHODS

Concussion data originated from nine public middle schools in Prince William County, Virginia, during the 2015-2016 school year. Certified athletic trainers collected concussion and athlete exposure (AE) data in school-sanctioned games and practices in boys' baseball, basketball, football, soccer, track, and wrestling; and girls' basketball, cheerleading, soccer, softball, track, and volleyball. Athletic trainers also acquired data on non-school sanctioned sport concussions. In 2017, concussion rates were calculated per 1,000 AEs. Injury rate ratios with 95% CIs compared rates between games and practices and by sex.

RESULTS

Overall, 73 concussions were reported, of which 21.9% were from non-school sanctioned sport settings. The 57 remaining game and practice concussions were reported during 76,384 AEs, for a concussion rate of 0.75/1,000 AEs. Football had the highest concussion rate (2.61/1,000 AEs). Concussion rates were higher in games versus practices (injury rate ratio=1.83, 95% CI=1.06, 3.15), and in girls versus boys in sex-comparable sports, i.e., baseball/softball, basketball, soccer, and track (injury rate ratio=3.73, 95% CI=1.24, 11.23).

CONCLUSIONS

Current findings parallel those found in high school and college sports settings in that higher concussion rates were reported in girls and competitions. However, concussion rates exceeded those recently reported in high school and youth league settings, highlighting the need for continued research in the middle school sports setting. Given that one in five concussions were from non-school sanctioned sport settings, prevention efforts in middle school sports settings should consider sport and non-sport at-risk exposure.

The Epidemiology of Overuse Conditions in Youth Football and High School Football Players

CONTEXT

  High-intensity sport training at the youth level has led to increased concern for overuse conditions. Few researchers have examined overuse conditions in youth sports.

OBJECTIVE

  To examine the rates, risks, and distributions of overuse conditions between youth and high school football players.

DESIGN

  Descriptive epidemiologic study.

SETTING

  Youth and high school football teams.

PATIENTS OR OTHER PARTICIPANTS

  The Youth Football Safety Study (YFSS) investigated youth football athletes from age 5 to 14 years. The National Athletic Treatment, Injury and Outcomes Network (NATION) focused on high school football athletes 14 to 18 years old. The YFSS data consisted of 210 team-seasons, and the NATION data consisted of 138 team-seasons.

MAIN OUTCOME MEASURE(S)

  Athletic trainers collected football injury and exposure data during the 2012 and 2013 seasons. Injury rates, risks, and distributions were calculated, with injury rate ratios, risk ratios, and injury proportion ratios with 95% confidence intervals (CIs) comparing youth and high school football players.

RESULTS

  The YFSS reported 1488 injuries, of which 53 (3.6%) were overuse conditions. The NATION reported 12 013 injuries, of which 339 (2.8%) were overuse conditions. The overuse condition rate did not differ between high school and youth football (3.93 versus 3.72/10 000 athlete-exposures; injury rate ratio = 1.06; 95% CI = 0.79, 1.41). However, the 1-season risk of overuse condition was higher in high school than in youth football players (2.66% versus 1.05%; risk ratio = 2.53; 95% CI = 1.84, 3.47). Compared with high school football players, youth football players had greater proportions of overuse conditions that were nontime loss (ie, <24 hours participation-restriction time; 83.0% versus 67.0%; injury proportion ratio = 1.24; 95% CI = 1.07, 1.43) and affecting the lower extremity (92.5% versus 62.5%; injury proportion ratio = 1.48; 95% CI = 1.32, 1.65).

CONCLUSIONS

  Overuse conditions may not present a primary concern in youth and high school football players. However, differences existed between the 2 levels of competition. Although additional research on the incidence of overuse conditions across all youth and high school sports is needed, these findings may highlight the need for programming that is specific to competition level.

Preseason Aerobic Fitness Predicts In-Season Injury and Illness in Female Youth Athletes

Background:

Although preseason aerobic fitness has been suggested as a modifiable risk factor for injury in adult athletes, the relationship between aerobic fitness, injury, and illness in youth athletes is unknown.

Purpose:

To determine whether preseason aerobic fitness predicts in-season injury and illness risk in female adolescent soccer players.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

Fifty-four female adolescent soccer players underwent preseason evaluation to determine years of experience, body mass index (BMI), maximal aerobic capacity (VO_2max), and time to exhaustion (T_max) during cycle ergometer testing. All injuries and illnesses during the subsequent 20-week season were recorded. Variables were compared between individuals with and without a self-reported injury and individuals with and without a self-reported illness. Separate Poisson regression models were developed to predict number of injuries and illnesses for each individual by use of age, years of experience, BMI, VO_2max, and T_max.

Results:

Twenty-eight injuries and 38 illnesses in 23 individuals were recorded during the season. Although not a statistically significant finding, individuals who reported an in-season injury had lower VO_2max than those who did not (54.9 ± 7.3 vs 58.3 ± 8.5 mL/kg/min, P = .13). Individuals who reported an illness had significantly lower VO_2max than those who did not (54.5 ± 9.9 vs 58.8 ± 6.2 mL/kg/min, P = .014). With the Poisson regression models, VO_2max was a significant predictor of both injury (odds ratio [OR], 0.95; P = .046) and illness (OR, 0.94; P = .009), while no significant relationships were identified between injury or illness and age, years of experience, T_max, or BMI (all P > .05).

Conclusion:

Among adolescent female soccer players, greater preseason aerobic fitness is associated with a reduced risk of in-season injury and illness. Off-season intervention to promote aerobic fitness may help reduce the risk of lost time during the season due to injury and illness.

Examining Play Counts and Measurements of Injury Incidence in Youth Football

CONTEXT

  Whereas researchers have provided estimates for the number of head impacts sustained within a youth football season, less is known about the number of plays across which such impact exposure occurs.

OBJECTIVE

  To estimate the number of plays in which youth football players participated during the 2013 season and to estimate injury incidence through play-based injury rates.

DESIGN

  Descriptive epidemiology study.

SETTING

  Youth football.

PATIENTS OR OTHER PARTICIPANTS

  Youth football players (N = 2098; age range, 5-15 years) from 105 teams in 12 recreational leagues across 6 states.

MAIN OUTCOME MEASURE(S)

  We calculated the average number of athlete-plays per season and per game using independent-samples t tests to compare age groups (5-10 years old versus 11-15 years old) and squad sizes (<20 versus ≥20 players); game injury rates per 1000 athlete-exposures (AEs) and per 10 000 athlete-plays; and injury rate ratios (IRRs) with 95% confidence intervals (CIs) to compare age groups.

RESULTS

  On average, youth football players participated in 333.9 ± 178.5 plays per season and 43.9 ± 24.0 plays per game. Age groups (5- to 10-year-olds versus 11- to 15-year-olds) did not differ in the average number of plays per season (335.8 versus 332.3, respectively; t_2086.4 = 0.45, P = .65) or per game (44.1 versus 43.7, respectively; t_2092.3 = 0.38, P = .71). However, players from smaller teams participated in more plays per season (373.7 versus 308.0; t_1611.4 = 8.15, P < .001) and per game (47.7 versus 41.4; t_1523.5 = 5.67, P < .001). Older players had a greater game injury rate than younger players when injury rates were calculated per 1000 AEs (23.03 versus 17.86/1000 AEs; IRR = 1.29; 95% CI = 1.04, 1.60) or per 10 000 athlete-plays (5.30 versus 4.18/10 000 athlete-plays; IRR = 1.27; 95% CI = 1.02, 1.57).

CONCLUSIONS

  A larger squad size was associated with a lower average number of plays per season and per game. Increasing youth football squad sizes may help reduce head-impact exposure for individual players. The AE-based injury rates yielded effect estimates similar to those of play-based injury rates.

Anthropometrics, Physical Performance, and Injury Characteristics of Youth American Football

BACKGROUND

Prior research has described the anthropometric and physical performance characteristics of professional, collegiate, and high school American football players. Yet, little research has described these factors in American youth football and their potential relationship with injury.

PURPOSE

To characterize anthropometric and physical performance measures, describe the epidemiology of injury, and examine the association of physical performance measures with injury among children participating within age-based divisions of a large metropolitan American youth football league.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Demographic, anthropometric, and physical performance characteristics and injuries of 819 male children were collected over a 2-year period (2011-2012). Injury data were collected by the league athletic trainer (AT) and coaches. Descriptive analysis of demographic, anthropometric, and physical performance measures (40-yard sprint, pro-agility, push-ups, and vertical jump) were conducted. Incidence rates were computed for all reported injuries; rates were calculated as the number of injuries per 1000 athlete-exposures (AEs). Multinomial logistic regression was used to identify whether the categories of no injury, no-time-loss (NTL) injury, and time-loss (TL) injury were associated with physical performance measures.

RESULTS

Of the 819 original participants, 760 (92.8%) completed preseason anthropometric measures (mean ± SD: age, 11.8 ± 1.2 years; height, 157.4 ± 10.7 cm; weight, 48.7 ± 13.3 kg; experience, 2.0 ± 1.8 years); 640 (78.1%) players completed physical performance measures. The mean (±SD) 40-yard sprint and pro-agility measures of the players were 6.5 ± 0.6 and 5.7 ± 0.5 seconds, respectively; the number of push-ups and maximal vertical jump height were 16.5 ± 9.3 repetitions and 42.3 ± 8.4 cm, respectively. Players assigned to different teams within age divisions demonstrated no differences in anthropometric measures; 40-yard dash and pro-agility times differed significantly (P < .05) between players assigned to different teams. A total of 261 NTL and TL injuries were reported during 35,957 AEs (games: 22%, n = 7982 AEs; practices: 78%, n = 27,975 AEs). The overall incidence rate was 7.26 per 1000 AEs (95% CI, 6.37-8.14). Physical performance measures did not predict NTL or TL injuries (P > .05).

CONCLUSION

No practically meaningful differences existed in anthropometric or physical performance measures between teams within age-based levels of play. Findings suggest that age-only criterion for player groupings can evenly match in terms of physical performance.

Epidemiologic Measures for Quantifying the Incidence of Concussion in National Collegiate Athletic Association Sports

CONTEXT

Injury rates compare the relative frequency of sport-related concussions across groups. However, they may not be intuitive to policy makers, parents, or coaches in understanding the likelihood of concussion.

OBJECTIVE

To describe 4 measures of incidence (athlete-based rate, athlete-based risk, team-based rate, and team-based risk) during the 2011-2012 through 2014-2015 academic years.

DESIGN

 Descriptive epidemiology study.

SETTING

Aggregate injury and exposure data collected from the National Collegiate Athletic Association Injury Surveillance Program in 13 sports (men's baseball, basketball, football, ice hockey, lacrosse, soccer, and wrestling and women's basketball, ice hockey, lacrosse, soccer, softball, and volleyball).

PATIENTS OR OTHER PARTICIPANTS

Collegiate student-athletes.

MAIN OUTCOME MEASURE(S)

Sport-related concussion data from the National Collegiate Athletic Association Injury Surveillance Program during the 2011-2012 through 2014-2015 academic years were analyzed. We calculated concussion rates per 1000 athlete-exposures (AEs), concussion risk, average number of concussions per team, and percentage of teams with at least 1 concussion.

RESULTS

During the 2011-2012 through 2014-2015 academic years, 1485 concussions were sustained by 1410 student-athletes across 13 sports. Concussion rates ranged from 0.09/1000 AEs in men's baseball to 0.89/1000 AEs in men's wrestling. Concussion risk ranged from 0.74% in men's baseball to 7.92% in men's wrestling. The average ± SD number of concussions per team ranged from 0.25 ± 0.43 in men's baseball to 5.63 ± 5.36 in men's football. The percentage of teams with a concussion ranged from 24.5% in men's baseball to 80.6% in men's football.

CONCLUSIONS

  Although men's wrestling had a higher concussion rate and risk, men's football had the largest average number of concussions per team and the largest percentage of teams with at least 1 concussion. The risk of concussion, average number of concussions per team, and percentage of teams with concussions may be more intuitive measures of incidence for decision makers. Calculating these additional measures is feasible within existing injury surveillance programs, and this method can be applied to other injury types.

Critical review on the socio-economic impact of tendinopathy

There are currently no studies that determine the total burden that tendinopathy places on patients and society. A systematic search was conducted to understand the impact of tendinopathy. It demonstrated that the current prevalence is underestimated, particularly in active populations, such as athletes and workers. Search results demonstrate that due to the high prevalence, impact on patients' daily lives and the economic impact due to work-loss, treatments are significantly higher than currently observed. A well-accepted definition by medical professionals and the public will improve documentation and increase awareness, in order to better tackle the disease burden.

Interrater and intrarater reliability of the semmes-weinstein monofilament 4-2-1 stepping algorithm

INTRODUCTION

Semmes-Weinstein Monofilaments (SWM) are used to examine light touch sensation of the skin. Reliability of the 4-2-1 stepping algorithm approach for determining light touch detection thresholds has not been examined. The purpose of this study was to determine the interrater and intrarater reliability of the SWM 4-2-1 stepping algorithm on the plantar surface of the foot.

METHODS

Four raters with varying levels of SWM assessment experience tested light touch sensation over the plantar aspect of the first metatarsal head in 14 healthy adults. During the initial session, all raters performed the 4-2-1 stepping algorithm technique on each subject to determine interrater reliability. One week later, subjects were reassessed by 2 raters to determine intrarater reliability.

RESULTS

Interrater reliability ranged from moderate-to-good (ICC2,1  = 0.62-0.92). Intrarater reliability also ranged from moderate-to-good (ICC2,1  = 0.61-0.85).

CONCLUSIONS

The 4-2-1 stepping algorithm demonstrated acceptable interrater and intrarater reliability when measured in healthy adults. Muscle Nerve 53: 918-924, 2016.