TOPIC: Pediatrics

STUDY TYPE: Survey

Mental Health, Physical Activity, and Adolescent Health-Related Quality Of Life

Submitting Author/Presenter: Amy Valasek, MD, MS, FAMSSM

Enas Alshaikh, PhD, Katherine Ellee Allison, BS, James Onate, PhD, ATC, Jingzhen Yang, PhD, MPH, and Julie Young, PhD, ATC

Affiliation: Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio.

Purpose: Poor mental health and physical inactivity can diminish adolescent health-related quality of life (PQoL). This study assessed how anxiety, depression, sleep, physical activity (PA), musculoskeletal pain, and body mass index (BMI) are related to PQoL in adolescents.

Methods and Study Design: We recruited adolescents aged 12 to 18 from sports medicine clinic, adolescent medicine clinic, and a high school to complete survey packet. Surveys included the GAD-7, PHQ-9, PQoL, Pittsburgh Sleep Quality Inventory PSQI, physical activity, and pain. A structural equation model (SEM) examined how mental health, PA, pain, and BMI percentiles were associated with and affect PQoL.

Results: Of a total of 395 participants, 146 (37%) were male and average age of 15.8 (SD = 1.8). The average daily physical activity reported was 334 minutes. The average scores for anxiety symptoms, depression symptoms, and sleep were 4.1 (GAD-7), 4.7 (PHQ-9), and 5.3 (PSQI) on respective screenings. The average PQoL score was 78% on screening for this group. The latent variable of mental health was significantly associated with anxiety symptoms (Β = 0.86, P = < 0.01), depression symptoms (Β = 0.91, P = < 0.01), and sleep (Β = 0.73, P = < 0.01). The structural equation model accounted for 70% of the variability in PQoL. Specifically, low score of poor mental health (Β = − 0.81, P = < 0.01) and high level of physical activity (Β = 0.11, P = 0.02) was significantly associated with high PQoL score, respectively. While low pain score (Β = −0.06, P = 0.07) and low BMI percentile (Β = −0.04, P = 0.27) were associated with high PQoL score, the associations were not statistically significant.

Conclusions: Mental health and physical activity are significantly associated with PQoL in adolescents. Future research investigating mental health and physical activity relationships in diverse geographic locations is needed. Promotion of good physical health during adolescence can positively impact health-related quality of life and nurture into adulthood.

Significance: 1. Good mental health and physical activity significantly improved health-related quality of life in adolescents. 2. The mental health variable was inversely related to reported health-related quality of life in adolescents.

Acknowledgements: This study was funded by Nationwide Children's Intramural Grant.

TOPIC: HPV

STUDY TYPE: Survey

Exploring Opportunities to Improve Vaccination Rates in the Sports Medicine Setting

Submitting Author/Presenter: Justin Ceasar, BS

Cayce Onks, DO, MS, ATC, Eva Frank, PhD, LAT, ATC, Rebecca Hall, LAT, ATC, and Cole Hartert, LAT, ATC

Affiliation: Penn State College of Medicine, Hershey, PA.

Purpose: Human Papillomavirus (HPV) has one of the lowest vaccination rates. Though Sports Medicine teams are well suited to advocate for vaccination, Athletic Trainers’ (ATs) historically haven’t engaged. This study aims to examine ATs’ knowledge of HPV and their perception of their role in vaccination.

Methods and Study Design: We designed a cross-sectional survey sent to middle school, high school, and collegiate ATs through the National Athletic Trainers’ Association data collection service program. The survey consisted of a consent form, demographic, knowledge, and perception-based questions. An optional open-ended section was developed for ATs to leave comments on their thoughts about this topic.

Results: A total of 460 ATs participated in the study, with 59% of participants under the age of 40. A significant number of ATs did not display high levels of knowledge regarding HPV and HPV vaccination, with only 46% of all ATs scoring above 70% on the knowledge-based portion of the survey. Importantly, those with previous HPV-related training displayed significantly more knowledge (average score of 77.5%) versus those without training (64%). Those with HPV-related training also significantly felt that ATs are responsible for assisting with general medical conditions that may affect their athletes (P =0.007). Additionally, ATs previously offered (P =0.0001) or having received at least one dose of the HPV vaccine (P < 0.0001) had significantly more knowledge on the survey. Finally, on average, ATs with higher levels of educational history (doctorate and master’s versus bachelor’s degree) tended to agree that ATs should play a role in educating their athletes about HPV and HPV vaccination.

Conclusions: HPV-related disease is a common preventable medical condition seen within the patient population that ATs treat. As such, ATs as allied health care providers are well suited to educate and advocate for HPV vaccination. However, knowledge levels are low within the athletic training community. This indicates a need for curricular change and the development of a novel approach for HPV vaccination implementation within the athletic training setting.

Significance: This is the first attempt to understand if ATs could be an important partner in advocating for HPV vaccination. This advocacy could increase vaccination rates thus decreasing HPV infection and cervical cancer rates within this vulnerable population.

Acknowledgements: Funding was provided by the Department of Family and Community Medicine at Penn State COM and Lebanon Valley College Department of Athletic Training. Statistics by Research Data Analyst Sandeep Pradhan, MBBS, MPH. Numerous individuals piloted the survey p.

TOPIC: Ultrasound

STUDY TYPE: Other

Accuracy and Benefit of a Novel Longitudinal Ultrasound-Guided Iliopsoas Tendon Injection after Total Hip Arthroplasty

Submitting Author/Presenter: Matthew Kaufman, MD

Chantal Nguyen, MD, Yue Meng, MD, and Eugene Roh, MD

Affiliation: Stanford University, Redwood City, CA.

Purpose: Post-THA patients' ultrasound imaging can be technically challenging due to distortion of the iliopsoas tendon by indwelling hardware. This abstract describes the accuracy and benefit of a new technique for performing ultrasound-guided needle placement for iliopsoas tendon sheath injections.

Methods and Study Design: Retrospective case series from June 2017 to December 2019 of those with previous total hip arthroscopy and iliopsoas impingement that had a longitudinal in-plane approach for an US-guided steroid injection. Confirmatory fluoroscopic tenograms were taken prior to injection to ensure accuracy. Pre and post VAS scores were used to assess pain. Patients were followed for 6 months to assess outcomes.

Results: Using an ultrasound-guided longitudinal in-plane approach provided direct visualization of the length of the iliopsoas tendon adjacent to acetabular hardware, multiple sonographic landmarks, and distribution of medication around the areas of mechanical stress. Within our study 19/26 (84.6%) had appropriate needle placement that was confirmed with fluoroscopic imaging and did not require repositioning, showing an accurate approach that provides direct visualization of the target. The accuracy in this approach stems from both the benefits of ultrasound and the improvement of visualization without distention from the arthroscopic components. Four patients received repeat injections and 3 patients ultimately pursued surgical intervention for recurrent symptoms or hardware failure. On average, VAS pain scores improved 61% after iliopsoas tendon injection, with mean pre-procedure pain of 5.8 (2.1) and mean post-procedure pain 2.4 (2.1) on a 10-point scale. A minority of patients, 2 out of 19, pursued further surgical intervention with tendon release.

Conclusions: Our novel technique of an ultrasound-guided longitudinal in-plane approach is viable for those with post-THA anatomy. This approach overcame technical challenges, provided direct visualization of the iliopsoas tendon adjacent to acetabular hardware, multiple sonographic landmarks, and distribution of medication around the areas of mechanical stress with high accuracy, large reduction in pain scores and limited progression to surgery.

Significance: In conclusion, this series illustrated that a longitudinal in-plane approach for iliopsoas peritendinous injections using a 3-step sign provides an accurate and reliable method for ultrasound guidance and could limit need for fluoroscopy.

Acknowledgements: Anthony Kenrick MD, Derek Amanatullah MD.

TOPIC: Ultrasound

STUDY TYPE: Other

Posterior Intra-articular Hip Injections: A Pilot Study Investigating a New Approach

Submitting Author/Presenter: Matthew Kaufman, MD

Chantal Nguyen, MD, Yue Meng, MD, and Eugene Roh, MD

Affiliation: Stanford University, Redwood City, CA.

Purpose: To investigate a novel posterior intra-articular hip injection approach while discussing the clinical pearls for methodology, accuracy, and related adverse events. The goal was to investigate if this approach could potentially be used in those where the typical anterior access would be challenging.

Methods and Study Design: Ten adults with hip osteoarthritis or femoral acetabular impingement with labral tearing were studied. In prone position, posterior structures were seen. Medication was injected at the head-neck junction of the femur in a inferolateral-superomedial approach. A fluoroscopic arthrogram evaluated accuracy. Needle location, contrast flow, anterior portal conversion rate and adverse events were tracked.

Results: A confirmatory fluoroscopic arthrogram showed appropriate needle placement via ultrasound guidance on first attempt in 9 patients. One patient was converted to the anterior approach due to inability to obtain the expected arthrogram from the posterior approach despite what looked like appropriate needle placement on both ultrasound and fluoroscopy. There were 2 patients with the needle tip noted to be in the inferior half of the femoral head-neck junction in the initial fluoroscopy images. Two patients (20%) demonstrated mild adverse events after this procedure. One patient reported increased urinary frequency that lasted for 3 days without any weakness, numbness, or neurological symptoms in the sciatic nerve distribution. Both adverse events were considered mild as they were self-limiting. Another patient reported new posterior and lateral leg numbness of the injected side 2 hours after the injection, which resolved by the following day. The patient that was converted to the anterior approach reported a moderate amount of pain as measured by VAS with the posterior approach.

Conclusions: In conclusion, ultrasound-guided posterior approach hip injections are accurate and without serious adverse events in our study. The posterior approach can be considered as an alternative approach for patients who cannot tolerate the anterior hip approach. Future studies can evaluate a broader patient population, including those with BMI > 35 and those without a native hip joint.

Significance: A posterior approach could be helpful for those who cannot tolerate an anterior approach, such as those with spasticity, skin lesions on the anterior hip, or difficult anterior surface or bony anatomy. This study shows that this approach is viable.

Acknowledgements: Patricia Zhang, MD.

TOPIC: Musculoskeletal

STUDY TYPE: Other

Flippin' Out Over Gymnast Wrist: Presentation and Treatment of Distal Radial Physeal Stress Syndrome

Submitting Author/Presenter: Naomi Brown, MD

David VanEenenaam, Joseph Yellin, MD, Scott Mahon, BS, and Apurva Shah, MD, MBA

Affiliation: Children’s Hospital of Philadelphia Philadelphia, PA.

Purpose: Current literature on gymnast wrist is limited when describing the overall treatment outcomes. This study aimed to understand the demographics, treatment outcomes, and return-to-sport timelines in a large single tertiary care institution patient sample.

Methods and Study Design: Pediatric patients from 2016 to 2023 were identified using ICD-10 codes for “gymnast wrist” and wrist pain. Adults, acute fractures, non-gymnasts, and congenital etiologies were excluded. We collected patient data, Child Opportunity Index (COI), activity, treatment, radiographs, and outcomes. Statistical tests included χ2, t-test, and Wilcoxon rank-sum analysis.

Results: Seventy-eight wrists in 62 patients (60 female) with an average age of 11.8 (range 6.9-15.4) were included. Average time to presentation was 12.2 weeks after symptom onset. All patients had physeal wrist pain; 35.5% dominant sided, 38.7% nondominant sided and 25.8% bilaterally. Gymnastics participation/week averaged 15.9 ± 9.1 hours. On initial wrist radiographs, 43 (69%) had distal radial physeal widening, 45 (73%) juxtaphyseal sclerosis, and 12 (19%) positive ulnar variance. 55 (89%) were initially treated with splint/rest ± PT, 5 (8%) short arm cast, and 2 (3%) underwent surgery. 32 (53%) patients had resolved tenderness and return to sport after initial non-operative treatment. Of those 32 patients, average time to resolved tenderness was 7.4 weeks and return to sport 8.6 weeks. Twenty-three percent of those initially treated conservatively developed recurrent symptoms requiring another period of rest. 7 (11%) patients progressed to physeal growth arrest, all eventually treated with ulnar shortening osteotomy.

Conclusions: Only about half of patients with gymnast wrist responded well to conservative treatment. Recurrence rates are high, necessitating extended breaks from competitive gymnastics. More than 10% of patients progressed to growth arrest requiring surgery.

Significance: Further prospective research is needed to identify risk factors for persistent or recurrent wrist pain in gymnasts and to identify who would do best with surgery.

Acknowledgements: Dr. Apurva Shah.

TOPIC: Training

STUDY TYPE: Survey

Assessing the Beliefs and Impacts of Strength Training in Collegiate Gymnastics

Submitting Author/Presenter: Tammy Ng, MD

Tyler Bendrick, MD, Mary Swanstrom, ATC, Machelle Wilson, PhD, Kevin Burnham, MD, and Marcia Faustin, MD

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

Purpose: There is scarce literature on the effects of strength training on performance and injury prevention in gymnastics. This study assessed perceptions of collegiate gymnasts and coaches regarding strength training after starting their inaugural training with a certified strength and conditioning coach.

Methods and Study Design: Anonymous surveys were distributed to gymnasts at a National Collegiate Athletic Association (NCAA) Division I gymnastics program. Survey responses were collected between August and September 2023. Descriptive statistics were performed to analyze demographics, characterize the current strength training program, and evaluate perceptions of injury rates regarding the impact of strength training.

Results: Of the 23 gymnasts surveyed, 17 (74%) responded. Mean age was 19.9 (SD = 1.48). All gymnasts reported participating in strength and conditioning, with a mean of 2.74 (SD = 1.20) sessions per week, lasting, on average, 55.6 (SD = 10.29) minutes per session. Most gymnasts agreed (35%) or strongly agreed (59%) that weight training may improve performance. All gymnasts either disagreed (59%) or strongly disagreed (41%) that weight training is not safe. Forty-one percent disagreed, 29% strongly disagreed, and 17% agreed that weight training may negatively impact body shape. Most gymnasts either disagreed (59%) or strongly disagreed (18%) that weight training decreases flexibility; 4 (24%) felt neutral. 94% (59% strongly agree, 35% agree) felt that weight training had positive impact on performance. More than half of the gymnasts either agreed (24%) or strongly agreed (29%) they had less injuries the season after implementing strength training, compared to prior seasons.

Conclusions: Most gymnasts expressed positive perceptions of the safety of strength and conditioning with a certified coach. A small number expressed concerns regarding the effects of weight training on body shape and flexibility. Still, the majority of gymnasts perceived an improvement in their gymnastics performance. Although the impact of strength training on injury prevention was mixed, more than half of the gymnasts perceived a decreased injury risk.

Significance: This pilot study demonstrates positive perceptions of strength training among collegiate gymnasts, including reduction in injury risk and improved performance, warranting further objective research on the effects of strength training in gymnastics.

Acknowledgements: The authors would like to thank the UC Davis Gymnasts and Coaches, UC Davis Intercollegiate Athletics Sports Medicine Team, UC Davis Sports Medicine Oversight and Continuous Quality Improvement Committee (SMOCQI), and the UC Davis Health Clinical and Tran.

TOPIC: Musculoskeletal

STUDY TYPE: Survey

Ultrasound-Guided Shoulder Injections: A Randomized-Controlled Trial Assessing Patient Satisfaction

Submitting Author/Presenter: Connie Oh, MD

Harin Parikh, MD and Michael Stone, MD

Affiliation: Cedars Sinai, West Hollywood, CA.

Purpose: To investigate patient satisfaction between ultrasound guidance versus landmark guidance for injections administered in the shoulder girdle and identify differences in efficacy of pain reduction between ultrasound guided and landmark guidance.

Methods and Study Design: This was a prospective randomized study evaluating patient satisfaction with and without US guided injections of the shoulder. Patients were randomized to US guided (US), or landmark guided injections (Non-US). Patient questionnaires were completed in office pre and post injection. Descriptive data was analyzed, student's t-test was used, pre-hoc power analysis was performed with beta set to 0.8.

Results: One hundred twenty patients met inclusion criteria—77 patients in the US group and 43 in the Non-US group. There were no statistically significant differences in demographics between groups. Average age in US group was 64.7 ± 13, and 69.0 ± 12.6 years in the Non-US group. The most common location of injection was SA space (n = 58, 48.3%), followed by GH joint (n = 37, 30.8%), BT (n = 17, 14.2%), and AC joint (n = 8, 6.7%). There were no statistically significant differences in any of the satisfaction survey scores between the US and Non-US groups. Pain scores improved after injection in both groups (US Δ2.3, P < 0.001; Non-US Δ2.4, P < 0.001), however there were no statistically significant differences in pain scores between groups with or without US (P = 0.95).

Conclusions: We did not detect differences in satisfaction or comfort in patients randomized to either the landmark guided or ultrasound guided injection groups. Moreover, though injection administration overall led to improvements in pain scores in both groups, there were no statistically significant differences between groups pertaining to the degree of improvement encountered.

Significance: US guided shoulder injections showed no benefit in patient satisfaction or pain scores compared to Non-US guided injections, however pain scores were improved in both groups. Routine use of US guided injections for the shoulder should be reassessed.

TOPIC: Epidemiology

STUDY TYPE: Survey

Figure Skating Injuries and Training Modifications Following Changes to the Competition Season Schedule

Submitting Author/Presenter: Connor G. Richmond, DO

Michelle Djohan, MD and Christina Oleson, MD

Affiliation: Case Western University School of Medicine/Metrohealth, Cleveland, OH.

Purpose: In 2022, US Figure Skating created a new National Qualifying Series (NQS), which resulted in earlier season events and reduced preparation time. The purpose of our study was to investigate the frequency of injuries and training modifications with the new competitive structure.

Methods and Study Design: Surveys were sent to over 24 skating clubs across the country. To participate, coaches needed at least one regional or higher-level skater in the NQS. Coach demographics, injury causes, frequency, and training adaptations were analyzed. A significant training related injury was defined as requiring more than one week off the ice or more than 2 weeks of adjustments to the training program.

Results: Twenty-seven coaches from 14 states completed the survey. Training data from 178 skaters was included in the study. A significant training-related injury occurred in 27 figure skaters (15%). The majority of skaters who did not experience an injury had changes made to their training regimen (63%) compared to those with no changes (37%). Performing a new element was the most common mechanism of injury (41%) followed by overuse injury (33%). Significant differences were found between training facility level (international, national, sectional, and regional) and injury frequency (P = 0.048). Those training at an international or national level facility had significantly lower injury rates compared with skaters training at regional or sectional facilities (P = 0.042). There was no association between injury rates and off-ice strength and conditioning programs (P = 0.16).

Conclusions: Skaters training at higher level facilities and those whose coaches proactively adjusted their training regimens were less likely to become injured. Training intensity modifications and extra vigilance when teaching new elements may prevent future injuries.

Significance: There are no prior studies investigating injury frequency or training adjustments with the new NQS timeline. Recognition of injury risk with schedule changes and interventions to avoid such injuries are essential for individual skaters' success.

TOPIC: Rehabilitation

STUDY TYPE: Other

Implementing a Remote Therapeutic Monitoring Program in a Sports Medicine Clinic: A Pilot Study

Submitting Author/Presenter: Hirotaka Nakagawa, MD

Justin Dzierzawski, MD, Kristin Mitchell, MS, ATC, LAT, Negar Ahmadian, BS, Marc Gruner, DO, Robert Bowers, DO, PhD, and Walter Sussman, DO

Affiliation: Tufts Medical Center.

Purpose: The purpose was to study adherence and treatment outcomes of a remote therapeutic monitoring (RTM) program implemented within a clinical setting.

Methods and Study Design: This was a retrospective study conducted at a non-operative sports medicine clinic, involving the first 30 patients enrolled in the RTM program from May 2022 to August 2022. Patient-Reported Outcomes Measurement Information System (PROMIS) pain and function scores were assessed at the program's start and at 4-week intervals until completion.

Results: Out of the 30 patients, 26 (87%) completed the initial assessment, and 23 patients (77%) had at least 2 PROMIS measures collected. The diagnoses were diverse, including gluteal tendinopathy (35%), lateral epicondylitis (13%), knee osteoarthritis (13%), hamstring tendinopathy (9%), rotator cuff tendinopathy (9%), Achilles tendinopathy (9%), patellar tendinopathy (4%), chronic Osgood Schlatter disease (4%), and 1 non-specified wrist pain (4%). Only 5 out of the 23 patients (22%) achieved the goal of at least 3 exercise sessions per week on average. On average, patients completed 1.9 sessions per week, and the program lasted an average of 15.7 weeks. Statistically significant improvement in PROMIS-Pain scores were seen for those who completed 4 PROMIS surveys at 3rd month (P = 0.007) and those who completed 5 PROMIS surveys at 4th month (P = 0.035). Statistically significant improvement in PROMIS-Function scores were seen for those who completed 5 PROMIS surveys at 4th month (P = 0.004).

Conclusions: The pilot study demonstrated high adherence (77%) in initiating RTM upon prescription, a notably higher rate compared to that reported for conventional physical therapy in existing literature. Nonetheless, the study also revealed poor adherence (22%) in maintaining at least 3 sessions per week. Statistically significant enhancements in pain and functional levels were observed in individuals who completed more than 4 PROMIS surveys.

Significance: This pilot study demonstrated that RTM can be effectively implemented in a sports medicine clinic, resulting in improved function and reduced pain levels. RTM could potentially serve as a promising alternative to conventional physical therapy.

TOPIC: Mental Health

STUDY TYPE: Survey

The Yips in Baseball and Softball—Discoveries from a Survey of Athletic Trainers and Coaches

Submitting Author/Presenter: Jordan Knox, MD

Kyle Jones, MD, Michelle White, BS, Karishma Shah, BS, and Adrik Da Silva, BS

Affiliation: University of Utah Department of Family & Preventive Medicine, Salt Lake City, UT.

Purpose: Task-specific dystonia (the yips) is poorly-understood and can be detrimental to sports performance. Common in golf, there are fewer reported cases in baseball. This study aimed to assess its prevalence in college baseball and softball players and explore coach and trainers’ perceptions of the yips.

Methods and Study Design: This cross-sectional survey study was approved by the IRB. PAC-12 softball and baseball coaches and athletic trainers we invited by email to complete a web-based survey. Questions included both multiple-choice and free-response types, inquiring about personal and player experience with the yips. Data were aggregated and analyzed using Fisher’s Exact test; significance set at 0.05.

Results: Thirteen coaches and 10 athletic trainers responded, for a response rate of 18.5% (23/124). Two of the 23 responses were from females (9%). Of baseball coaches, 11/43 (26%) responded; of softball coaches, 2/23 (9%) responded; and of athletic trainers that covered baseball and/or softball, 10/58 (17%) responded. Respondents were divided regarding whether the yips are something athletes are willing to talk about, with 11/23 (48%) indicating yes and 12/23 (52%) indicating no. Nearly 3-quarters (74%) of respondents reported psychological factors to be the perceived main cause of the yips, with the remaining 6/23 (24%) reporting multiple factors perceived as the main cause. Of all responses, only 4 (17%) had never had a player with the yips. The other 19/23 had coached or cared for at least one player in high school, college, and/or professional baseball. Four of the 23 respondents (one coach, 3 athletic trainers) reported ever personally experiencing the yips.

Conclusions: The yips in baseball may be more common than publicly acknowledged; athlete’s unwillingness to talk about it may be a contributing factor. Psychological etiology is thought to be common cause. Further research design should take into account the perceived taboo nature of the topic.

Significance: With the paucity of research on the yips in softball and baseball, any data is vital to understand perceptions and guide effective treatment. This small sample contributes to the emerging body of research, and may inform future research design.

Acknowledgements: This project was supported in part by the Health Studies Fund, Department of Family and Preventive Medicine, University of Utah.

TOPIC: Musculoskeletal

STUDY TYPE: Other

Investigation of Immediate Effects of Osteopathic Manipulation of Spine and Pelvis on Lacrosse Shot Accuracy and Power

Submitting Author/Presenter: Steven Gawrys, BS

Alexander Matthias, BS, Andrew Roush, BS, Holly Wilson, BS, Jillian Nicholas, BS, Chris Edwards, DO, Kevin Mangum, DO, and Brent Pickett, DO

Affiliation: Rocky Vista University, Ivins, Utah.

Purpose: To Evaluate the Effect of Osteopathic Manipulative Treatment (OMT) and key biomechanics contributing to lacrosse shot power and accuracy.

Methods and Study Design: Thirteen from from the Salt Lake Storm, a Men's Senior-A Box Lacrosse Team were evaluated for lacrosse shot speed and accuracy. Speed was evaluated by giving the players 2 attempts at a high-velocity lacrosse shot and the highest miles per hour (MPH) was recorded. Accuracy was evaluated by shooting 10 yards from the goal and recording the proportion of the 5 shots that hit the 20.5" by 20.5" target.

Results: A total of 13 players participated in the study. All participants were adults who identified as male. A paired, 2-tailed t-test resulted in a mean accuracy difference of a marginal improvement of 0.08 (P = 0.829, 95% CI −0.68 to 0.84) and a slight mean speed increase of 0.23 MPH (P = 0.804, 95% CI −1.75 to 2.21).

Conclusions: Based on the results of the study, OMT focused on the lumbar and pelvis regions has failed to demonstrate a statistically significant benefit on shot accuracy or throwing power in a Men's Senior-A Box Lacrosse Team in the Box Lacrosse League.

Significance: These findings can be of use to researchers investigating OMT's effect on sports performance by either improving upon the limitations that are inherent in this study or investigating other body regions to evaluate the role of OMT in athlete care.

Acknowledgements: We would like to thank the athletes from the Salt Lake Storm Sr.-A Box Lacrosse Team for using their valuable time to participate in this study.

TOPIC: Epidemiology

STUDY TYPE: Case-Control

The Tommy John Epidemic: A 50 Year Analysis of UCL Surgeries Using Publicly Available Data in Profes

Submitting Author/Presenter: Jason Zaremski, MD, FAMSSM

Robert L. Bowers, DO, PhD, Marissa Pazik, MS, LAT, ATC, Peter K. Kriz, MD, and MaryBeth Horodyski, EdD, ATC, LAT, FNATA

Affiliation: University of Florida Gainesville, Florida.

Purpose: Ulnar collateral ligament-reconstructions (UCL-R) in baseball players, first performed in 1974, have substantially increased in the past twenty years. The intent of this study was to analyze the data using a public dataset to assess for trends such as volume and average age of UCL-R.

Methods and Study Design: Using publicly available data via the “Tommy John Surgery List” maintained by Mr. Jon Roegele (@MLBPlayerAnalys), an analysis of UCL surgical interventions (aka “Tommy John Surgery” in professional baseball players was undertaken to assess for trends. The link for the dataset is https://docs.google.com/spreadsheets/d/1gQujXQQGOVNaiuwSN680Hq-FDVsCwvN-3AazykOBON0/htmlview#gid=0. Accessed 10/10/23).

Results: One thousand seven hundred eighty-two UCL surgeries have been performed in pro baseball players (89.6% pitchers, 3.7% catchers, and 6.7% infielders, outfielders, and designated hitters collectively). The United States (1328), Dominican Republic (183), and Venezuela (99) represent player country of origin most commonly. From 1974 to 1994 74 total UCL surgeries were performed. UCL surgical interventions subsequently increased from 224 (1995-2004) to 617 (2005-2014) to 870 (2015-present). There have been 148 revision surgeries since 1974 including 135 (91.2%) in pitchers. Mean time between initial and revision surgery was 56.1 ± 42.8 months. Mean age of UCL surgical interventions has decreased 12.7% since 1974. From 1974 to 1994 the mean age was 26.6 years, 1995 to 2004, 25.4, 2005 to 2014, 23.7, and 2015 to present 23.2. At the Rookie and A-Ball levels of pro baseball, the number of UCL surgical interventions increased from 7 (1974-1994), to 58 (1995-2004), to 217 (2005-2014), to 437 (2015-present), an increase of more than 62-fold.

Conclusions: These data confirm that the incidence of elbow UCL surgeries has significantly increased over the last several decades. More troubling is that the average age of players undergoing these surgeries continues to decrease.

Significance: In light of these data, the baseball medicine community needs to better understand the primary risk factors for UCL injuries as well as develop improved injury prevention strategies.

TOPIC: Musculoskeletal

STUDY TYPE: Other

A Targeted Diagnostic Approach to Persistent Periscapular Pain

Submitting Author/Presenter: Irene Kalbian, MD

Rebecca Maitin, DO and Richard Chang, MD

Affiliation: Mount Sinai Hospital, New York City, NY.

Purpose: The purpose of this case was to examine the utility of using targeted diagnostic tests to obtain a comprehensive evaluation and management plan for persistent periscapular pain consistent with long thoracic neuropathy that had not responded adequately to physical therapy aimed at this diagnosis.

Methods and Study Design: Patient records were reviewed including initial visit and follow up documentation, diagnostic tests including EMG and NCS studies, MRI of brachial plexus and shoulder, and shoulder and scapula xray, as well as prior physical therapy notes.

Results: Repeat electrodiagnostic tests revealed evidence of a mild, chronic right long thoracic neuropathy without signs of active denervation. Of note, there was reduced sensory response of the right lateral cutaneous nerve suggesting additional lateral cord involvement and raising the possibility of a limited brachial neuritis etiology. However, MRI of the brachial plexus did not show evidence of plexus or nerve root abnormality. MRI shoulder also did not reveal any abnormalities of the long thoracic nerve or serratus anterior, but found mild rotator cuff tendinosis and anterior inferior labral tear. Patient was referred for further physical therapy for scapulothoracic stabilization, isometric strengthening, and shoulder range of motion exercises to prevent further dysfunction and promote neural recovery. Trigger point injections were offered for myofascial pain. He was counseled on activity modification including avoiding overhead activity and proper lifting technique. For inflammation, he will trial a longer course of prescription strength ibuprofen as well as gabapentin at bedtime.

Conclusions: Patient's complaint of right periscapular pain, medial scapula winging on exam, and history of injury while lifting suggests right long thoracic nerve injury with chronic compensatory myofascial pain of the rhomboids, trapezius and levator scapula. He will follow up after another 4 to 6 weeks. If the patient has not had adequate improvement then therapeutic next steps include US guided right serratus anterior plane block and hydrodissection

Significance: It is important to utilize strategic diagnostic tests to rule out additional pathologic processes that may contribute to persistent pain such as referred pain from the spine, brachial plexopathy, intra-articular labral disorders, or tendinopathy.

Acknowledgements: Co-authors Dr. Chang and Dr. Maitin for their collaboration.

TOPIC: Education

STUDY TYPE: Survey

Improving Internal Medicine (IM) Resident Examination and Diagnostic Confidence Using an Examination Workshop Series

Submitting Author/Presenter: Melissa Le Roux, MD

Joshua Berkowitz, MD, Gregory Summerville, MD, Sandra Lee, PhD, Taylor Holmes, MD, Karen Kimel-Scott, MD, and Nailah Adams Morancie, MD

Affiliation: University of North Carolina, Chapel Hill, North Carolina.

Purpose: MSK complaints account for up to 30% of visits to primary care internists but many feel under prepared to manage them due to inadequate training. We aimed to evaluate the effectiveness of a series of 3 joint examination workshops with regards to resident confidence in examination and diagnostics.

Methods and Study Design: The setting was an academic half-day within UNC IM ambulatory curriculum. Participants were IM interns. An IM curriculum guide written by AMSSM members was used to design and implement knee, shoulder, and hip joint workshops. Surveys using 5-point Likert scales were used to assess confidence in examination and diagnostics, and were conducted at baseline and at 2 intervals following workshops.

Results: At baseline, IM interns (N = 22) agreed that MSK teaching is important in training, should be emphasized, and will help them take care of patients (means 4.4-4.7). They responded neutrally about confidence in performing a knee examination (2.9) and diagnosing common knee ailments (2.9). They responded neutrally about confidence in performing a shoulder examination (2.8) and disagreed or felt neutral about diagnosing common shoulder ailments (2.5). They disagreed that they could confidently perform a hip examination (2.3) and responded neutrally about diagnosing common hip ailments (2.6). They felt neutral or agreed about confidence in taking focused joint histories (2.9-3.5). Following the workshops using paired t-tests we saw significant positive changes in all confidence statements (P values 0.001-0.02). IM interns (N = 19) agreed that they could confidently perform an examination, diagnose common ailments, and take a focused history for the knee, shoulder, and hip joints (means all >4).

Conclusions: Immediately after implementation of the workshops, we saw significant changes in confidence statements, with trainees tending to feel confident in performing an examination, diagnosing common ailments, and taking a focused history for the knee, shoulder, and hip joints. We will further assess durability of confidence gains by administering surveys 4 months post-workshop.

Significance: 1% of IM didactics are devoted to MSK topics despite residents rating as highly important. MSK education delivered as part of a foundation curriculum may allow residents to build confidence for clinics and expand on this knowledge in future years.

Acknowledgements: In addition to my UNC mentors, I would like to thank Drs. Kalli Hose and Anna Quan for their inspiration for this Med Ed project, as well as allowing me to share some of their educational content as supplementation to the workshops.

TOPIC: Musculoskeletal

STUDY TYPE: Survey

Training Factors Influencing Current Pain Levels in Retired Division 1 Female Athletes

Submitting Author/Presenter: Irene Kalbian, MD

Rebecca Maitin, DO, Andrew Delgado, PhD, Jasmin Harounian, MD, Katharine Holmes, BA, Miguel Escalon, MD, MPH, and Joseph Herrera, DO

Affiliation: Department of Rehabilitation and Human Performance, The Icahn School of Medicine at Mount Sinai, New York, NY.

Purpose: The purpose of this study was to evaluate how incidence and anatomic location of major injuries affects pain in the post-retirement period and examine impact of other collegiate and pre-collegiate training factors including age of sport specialization, time spent training, and injury treatment.

Methods and Study Design: A cross-sectional survey was shared with former NCAA D1 female athletes via social media. Data on demographics, age of sport specialization, hours spent training before and during college, sport-related injuries and treatment, and current musculoskeletal pain was collected. Descriptive statistics were used to present means. Multiple regression analysis assessed risk factors for current pain.

Results: The survey was completed by 389 of 501 respondents. More than 50% of respondents from each represented sport, except skiing, reported having current pain. There were significant associations with pain intensity for multiple factors including experiencing injuries, having surgery, age of specialization and time spent training prior to college. Having any number of major injuries (1-4 versus 0) was associated with an increase in current pain intensity ranging from 0.96 points for 1 injury to 1.99 points for 4+ injuries. Having surgical treatment was associated with a 1.46 average point increase in pain intensity versus no surgery. Older age of sport specialization was associated with decreased odds of current pain with a 0.11 point decrease in pain intensity for every 1 year increase in specialization age. Furthermore, training 20+ hours per week before college was associated with a 0.91 point increase in average pain intensity versus 0 to 10 hours per week. Finally, respondents who reported.

Conclusions: Experiencing injury before, during or after college as well as undergoing surgery were factors associated with risk of increased pain in former D1 female athletes. Importantly, younger age of specialization and increased time spent training prior to college were also associated with increased pain. These findings suggest intensity of training and injuries from a young age can affect pain levels in female athletes in adulthood.

Significance: Our findings suggest that female athletes' youth sport and injury history contributes to their long-term physical health, longevity and quality of life, necessitating further research to better inform youth athletic participation.

TOPIC: Ultrasound

STUDY TYPE: Other

Inter-rater Reliability of Sonographic Assessment of Achilles Tendon, Patellar Tendon, and Plantar Fascia Videos

Submitting Author/Presenter: Dalton Brady, MD

Derek Stokes, MD, Daniel Cushman, MD, and Ryan Petersen, DPT

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

Purpose: Prior studies have examined the reliability for sonographic assessment of a variety of structures, but used live subjects or still images. This study aims to determine the inter-rater reliability of interpreting sonographic videos of the Achilles tendon, patellar tendon, and plantar fascia.

Methods and Study Design: Collegiate athletes from a variety of sports were scanned by an experienced sonographer. Video recordings of the Achilles tendons, patellar tendons, and plantar fasciae were later reviewed by 4 blinded individuals with varying levels of training. Inter-rater reliability was assessed using kappa statistics focused on describing the magnitude of agreement.

Results: Videos from 40 athletes (240 total structures) were evaluated by all reviewers assessing for hypoechogenicity, thickening, and neovascularity. The experienced reviewer was utilized as the comparator for the other 3 reviewers who varied in level of training (moderate, minimal, and untrained). In the trained versus moderately-trained comparison, kappa values were near perfect (kappa 1.000 Achilles, 0.947 patellar, and 1.000 plantar fascia); Trained versus minimally trained (kappa values: 0.661 Achilles, 0.787 patellar, and 0.490 plantar fascia); Trained versus untrained (kappa values: 0.490 Achilles, 0.810 patellar, and 0.661 for plantar fascia).

Conclusions: This study suggests that inter-rater reliability utilizing dynamic video ultrasound recordings to identify tendinous abnormalities may be superior to static image review. This holds true across different levels of training, with an expected decrease in agreement when comparing moderately trained versus minimally trained, and untrained individuals to the experienced reviewer.

Significance: The results of this study provide value for future research protocols. When an accurate, blinded secondary interpretation of sonographic abnormalities is desired, dynamic video should be considered over static image review.

TOPIC: NCAA

STUDY TYPE: Case-Control

Sleep Consistency as a Predictor for Increased Risk of Injuries in Division I Athletes

Submitting Author/Presenter: Jeremy Swisher, MD

Kimberly Burbank, MD, Zachary Sitton, MD, and Chris Miles, MD

Affiliation: Wake Forest University School of Medicine.

Purpose: This study aimed to analyze the impact of sleep consistency on the frequency of injuries in Division I women's soccer athletes. We also examined the epidemiology of resting heart rate, heart rate variability, and important sleep metrics.

Methods and Study Design: Twenty-eight women's soccer athletes from Wake Forest University were analyzed retrospectively over 2 years (2021-2023), resulting in 10,893 unique lines of data. Baseline cardiovascular data, sleep architecture, and injury rates were calculated for each athlete. Sleep consistency was analyzed, and athletes were put in groups of poor sleep consistency (n = 14) and good sleep consistency (n = 8).

Results: The average total sleep time was 7 hours and 3 minutes. The average sleep consistency was 67.05. For those who had greater than 69 sleep consistency, RHR was 51.41 (compared to 59.76 for those with less than 66 sleep consistency), and HRV was 107.77 (compared to 82.38). This was despite less total sleep at 6 hours and 42 minutes compared to 7 hours and 16 minutes. The average number of injuries for a player during the study was 2.50. The average number of injuries for those with poor sleep consistency was 3.70, when controlling for high HRV (greater than 115). The average number of injuries for those with good sleep consistency was 1.75 (P = 0.04). Among the athletes with ankle sprains specifically, sleep consistency in the month prior to injury was 64.87 as opposed to 69.35 during the injury (P = 0.0038). In athletes who suffered concussions, sleep consistency slightly decreased during concussion to 68.76 from 70.53, but did not reach significance (P = 0.68).

Conclusions: Division I soccer athletes sleep less than the recommended 8 hours a night and less than the average WHOOP user of 7.6 hours. When they had poor sleep consistency, there was an increased number of injuries compared to those with good sleep consistency. We controlled for high HRV due to the protective nature of a well-rested heart rate variability. In athletes with ankle sprains, sleep consistency was significantly lower the month before injury.

Significance: This research elucidates the importance of sleep consistency on injury risk in Division 1 athletes. This increased risk of injuries was despite more total sleep time, which may indicate sleep consistency being more impactful than sleep extension.

Acknowledgements: We would like to thank WHOOP and Wake Forest University for their assistance in creating this dataset!

TOPIC: Ultrasound

STUDY TYPE: Cohort

Natural History of the Development and Resolution of Patellar and Achilles Tendon Sonographic Abnormalities in NCAA Athletes

Submitting Author/Presenter: Derek Stokes, MD

Kristin S. Hilger, MS, Masaru Teramoto, PhD, MPH, PStat, Blake Corcoran, MD, Leyen Vu, DO, Michael Fredericson, MD, Sarah F. Eby, MD, PhD, and Daniel M. Cushman, MD, PhD

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

Purpose: The natural course of tendon morphologic changes in the athletic population is not well understood. Therefore, this study aimed to prospectively identify the natural history of the development and resolution of patellar tendon and Achilles tendon sonographic abnormalities in collegiate athletes.

Methods and Study Design: This was a prospective, observational study of collegiate student-athletes. Experienced sonographers recorded protocolized ultrasound video scans on bilateral patellar and Achilles tendons of student-athletes from 3 Division I programs during consecutive annual pre-season physicals. Blinded assessment of the videos was then performed identifying tendon changes between years 1 and 2.

Results: A total of 74 athletes were included (52 females; 20.9 ± 1.3 years of age; 22.7 ± 2.7 kg/m2 of body mass index; 9.3 ± 3.2 years of sport experience). Of those athletes, 20 (27%) participated in cross country/track, 18 (24.3%) basketball, 17 (23.0%) volleyball, 13 (1