Topic: Gender-Affirming Care

Study Type: Cohort

Testosterone Levels Among Transgender Women on Gender-affirming Hormone Therapy

Submitting Author/Presenter: Emily Miro, MD, MPH

Katherine Rizzone, MD, MPH, Tiffany Ho, MD, MPH, Bayarmaa Mark, PhD, Erika Sullivan, MD, MS, and Daniel Cushman, MD

Affiliation: University of Utah.

Purpose: Little is known regarding duration of gender-affirming hormone therapy (GAHT) required to suppress testosterone within the range required for participation in women's sport, often less than 2.5 or 5 nmol/L. This study aimed to elucidate trends in testosterone levels among transgender women on GAHT.

Methods and Study Design: Participants included in our retrospective chart review were seen at an academic hospital between 2003 and 2023 with record of at least one ICD9/10 diagnosis code associated with transgender individuals. We included patients on combined estradiol and spironolactone who had testosterone lab values in our electronic medical record obtained after starting GAHT. Mean testosterone values were calculated.

Results: A total of 261 patients met study criteria. Patients’ mean testosterone level on initial testing after starting GAHT was 6.04 nmol/L (95% CI [5.57, 6.51]). After 12 months on GAHT, the 261 patients demonstrated a mean testosterone level of 3.39 nmol/L (95% CI [3.00, 3.78]). After 24 months, 112 patients had testosterone levels drawn with a mean level of 3.90 nmol/L (95% CI [3.19, 4.61]). At initial testing, 37.2% of patients had higher testosterone values than the 5 nmol/L threshold, while 48.3% were higher than the 2.5 nmol/L threshold. At one year, 19.5% and 23.8% were above the respective thresholds, while 22.3% and 25.0% were above at 2 years.

Conclusions: Many organizations have testosterone-based policies restricting sports participation of transgender women. Policies vary in testosterone threshold and length of testosterone suppression. Testosterone levels less than 5 nmol/L or 2.5 nmol/L are required by many organizations. These data suggest that there is a wide variability in testosterone levels, and a large percentage of patients still have supra-threshold values at one and 2 years.

Significance: Further understanding of duration of GAHT and degree of endogenous hormone suppression required to meet guidelines for participation in women's sports is needed.

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

Topic: Ultrasound

Study Type: Cohort

Prevalence of Sonographic Abnormalities in Patellar Tendons, Achilles Tendons, and Plantar Fasciae in 473 NCAA Athletes

Submitting Author/Presenter: Derek Stokes, MD

Blake Corcoran, MD, Leyen Vu, DO, Michael Fredericson, MD, Jami Montagnino, MD, Masaru Teramoto, PhD, MPH, PStat, Luke Johnson, BS, and Daniel M. Cushman, BS

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

Purpose: Tendinopathy and fasciopathy are common conditions affecting athletic performance. The purpose of this study was to evaluate the prevalence of sonographic abnormalities in the patellar tendons, Achilles tendons, and plantar fasciae of NCAA Division I student-athletes.

Methods and Study Design: This was a prospective, observational study. Protocolized ultrasound video scans were performed on bilateral patellar tendons, Achilles tendons, and plantar fasciae of consented athletes from 3 Division I programs during pre-season physicals. Blinded assessment of the videos was then performed, identifying the presence of hypoechogenicity, morphologic thickening, and neovascularity.

Results: A total of 473 athletes from 3 institutions over 2 years of data collection were included (57.7% females; 20.1 ± 1.6 years of age; 23.1 ± 2.8 kg/m2 of body mass index; 9.4 ± 3.6 years of sport experience). Of the 946 scans for each structure (right and left), sonographic abnormalities were seen in 334 (35.3%) patellar tendons, 87 (9.2%) Achilles tendons, and 29 (3.1%) plantar fasciae. Significant predictors for patellar tendon abnormalities included (prevalence ratio [PR] with 95% confidence interval [CI]): age (PR = 0.92 [95% CI = 0.86, 0.98], P = 0.023), male gender (PR = 1.44 [95% CI = 1.12-1.86], P = 0.005), explosive sport (PR = 4.09 [95% CI = 1.68-9.98], P = 0.002), running sport (PR = 3.76 [95% CI = 1.50-9.42], P = 0.005), and skill-based sport (PR = 2.95 [95% CI = 1.14-7.59], P = 0.025). Age was also a significant predictor for abnormalities of the Achilles tendon (PR = 1.28 [95% CI = 1.08-1.47], P = 0.003) and plantar fascia (PR = 1.34 [95% CI = 1.06-1.71], P = 0.016).

Conclusions: Ultrasound abnormalities are common in tendon and fascial structures of collegiate athletes, especially in patellar tendons. Factors, such as age, gender, and type of sport participation, could be associated with abnormal ultrasound findings in these structures. Future studies are required to identify the significance of sonographic abnormalities in these structures, correlation with injury risk, and utility of preventative modalities.

Significance: Tendinopathy and fasciopathy are common injuries in athletes. Ultrasound is useful for identifying abnormalities and may also provide valuable information regarding the health of tendons and fascial tissues, even in the absence of symptoms or injury.

Topic: Load Management

The Relationship Between Load Management and Injury Risk in the NBA: A 9 Year Analysis

Submitting Author/Presenter: John DiFiori, MD, FAMSSM

Mackenzie Herzog, Alexandra Chretien, Rahul Gondalia, Kristin Shiue, and Christina Mack

Affiliation: HSS.

Purpose: The use of load management has been proposed to reduce injury risk. The purpose of this study was to assess relationships in the NBA between managing load by selectively reducing game participation and injury risk, including factors such as schedule density, travel, and cumulative NBA participation.

Methods and Study Design: A 9-year retrospective study of NBA players (2014-15-2022-23 seasons) was conducted using the League-wide EMR. The League requires entry for games missed using uniform criteria for injury, illness, or load management (listed as “rest” or “load management”). Cox proportional hazards models and Poisson regression were used to analyze injury risk for players who missed games for load management.

Results: One thousand two hundred twenty-six player seasons contributing 1,538,917 player-minutes of gameplay were included. Games missed for load management were found to increase over the study period. Among starter-level players who missed games for load management, there was no significant difference in injury risk compared to players who did not miss games for load management (1-2 games missed: HR = 1.24, 95% CI: 0.92-1.65; 3-5 games missed: HR = 0.91, 95% CI: 0.39-1.80; 6+ games missed: HR = 2.16, 95% CI: 0.53-5.78). Results were adjusted for age, prior injury history, and average minutes played per regular season game in the previous season, current season, and career. Similarly, there was no significant difference in injury risk considering schedule density (including back-to-back games, and games over 7- or 14-day windows) or travel (total miles or time zones). Study limitations include inability to assess non-game training load (data reporting not required), other potential internal and external load measures, and player-level factors (eg, intensity of play).

Conclusions: This analysis of available data within the NBA did not demonstrate that managing load by reducing game participation decreases injury risk, even when adjusted for cumulative injury history, per-minute game participation, and age. Although NBA players have an average of 3 to 4 games each week, future studies that include non-game load, other internal and external load measures, and analysis of individual player factors are needed.

Significance: Sport-specific data is essential to injury prevention. This first study of load management and injury risk using NBA data emphasizes the complexity of injury prevention and the need for additional research to address these issues better.

Topic: Pediatrics

Study Type: Cohort

Using the Fat Pad Sign in Pediatric Occult Elbow Fractures: Is It As Reliable As We Think?

Submitting Author/Presenter: Logan Garfield, MD

Stephen Chenard, MSc, William Hollabaugh, MD, Jacquelyn Pennings, PhD, PStat, and Andrew Gregory, MD

Affiliation: Vanderbilt University Medical Center, Nashville, TN.

Purpose: Elbow fractures account for about 15% of pediatric fractures but are often occult. The radiographic fat pad sign (FPS) is frequently used to assist with this diagnosis. Our study evaluated the sensitivity, specificity, and predictive value of the FPS in diagnosing occult elbow fractures in children.

Methods and Study Design: Single-center retrospective cohort study of patients 2 to 21 years-old with acute elbow injury who had an elbow x-ray from 2013 to 2023. We identified the anterior FPS (AFPS), posterior FPS (PFPS), fracture, and fracture type on initial and follow-up x-rays. For occult fractures initially classified as a clinical diagnosis, bony healing on follow-up x-ray was used for confirmation of elbow fracture.

Results: Seven hundred fifty-two patients met initial inclusion criteria. After randomization of cases via random number generator, 204 total cases were reviewed and 50 (24.51%) were excluded: loss-to-follow-up, nonapplicable indications for x-ray, lack of mention of a fat pad. Of the 154 cases included in the final analysis, 88 patients (57.1%) had an elbow fracture. Ninety-nine patients (64.3%) had a positive FPS. The sensitivity of a positive FPS was 94.3% (95% confidence interval [CI], 87.2%-98.1%) with a specificity of 75.8% (95% CI, 63.6% 85.5%) and a negative predictive value (NPV) of 91% (95% CI, 80.9%-96%). The sensitivity of an AFPS was 83.9% (95% CI, 74.5%-90.9%) with a specificity of 84.8% (95% CI, 73.9%-92.5%) and a NPV of 80% (95% CI, 71%-86.7%). The sensitivity of a PFPS was 62.1% (95% CI, 51.0%-72.3%) with a specificity of 89.4% (95% CI, 79.4%-95.6%), and a NPV of 64.1% (95% CI, 57.4%-70.3%).

Conclusions: Our study suggests that the presence of an AFPS on elbow x-ray strongly predicts an occult elbow fracture. The absence of a PFPS is less reliable in ruling out an occult fracture, but if present, strongly predicts a fracture. When combined, they are even more predictive of fracture. The location of fracture cannot be distinguished based on the FPS. Therefore, clinicians should rely on the history and physical exam to determine fracture location.

Significance: Our study presents a novel contribution to the literature on the use of the FPS in diagnosing pediatric occult elbow fractures. Our findings support the value of the AFPS and that a present FPS does not correlate with elbow fracture location.

Acknowledgements: We would like to thank the Department of Orthopaedic Surgery and Pediatrics and the Department of Biostatistics at Vanderbilt University Medical Center for their part in facilitation of this project.

Topic: Gender Reporting

Study Type: Other

Gender and Sex Reporting in Sport and Exercise Medicine Original Research

Submitting Author/Presenter: Anna Buehler, MD

Lucianne Olewinski, MD and Karin VanBaak, MD

Affiliation: University of Colorado, Aurora, Colorado.

Purpose: Gender and sex are meaningful demographic data with specific definitions. While there are guidelines (Sex and Gender Equity in Research-SAGER) for reporting this information, it is often done unclearly or inaccurately. We analyzed this problem in sport and exercise medicine (SEM) original research.

Methods and Study Design: Original research articles published in 2020 in 3 SEM journals (BJSM, MSSE, AJSM) were reviewed to extract participant numbers by gender and sex. We analyzed how well articles adhered to SAGER guidelines, by evaluating whether demographic data were reported at all; and if so whether by gender, sex or inappropriate use of both terms interchangeably; and in binary or nonbinary categories.

Results: Data were extracted from 579 articles representing 1,693,304 participants. 45.6% of participants were women, girls or females and 54.4% of participants were men, boys or males. 96.2% of articles reported gender and/or sex of participants. Of these articles 65.6% reported sex only, 15.7% reported gender only and 14.9% reported sex and gender interchangeably. No articles declared an intention to collect both gender and sex, so this was deemed interchangeable use of terms. Due to significant variability and lack of specific reporting, we were unable to collect data on how sex and gender were defined. 3.8% of articles did not report any gender or sex, but we inferred that participants were men/male due details such as the referenced sport or league. The only article that included transgender categories recruited only transgender participants and used generally unaccepted terminology to describe participants (“transmen” and “transwomen” rather than “transgender men” and “transgender women”).

Conclusions: The recommended approach to gender/sex reporting in not clearly followed in much of SEM research. Men and males are considered the default participants. It is common to use “gender” and “sex” interchangeably and uncommon to identify both the sex assigned at birth and gender of participants, or to report how sex and gender of participants is determined. People who are transgender are not well represented in SEM research.

Significance: Accurate collection and reporting of sex and gender demographic data is important to appropriately represent research participants. This allows researchers to identify well-represented and under-represented groups and improve research translation.

Acknowledgements: Brittany Becker, MD.

Topic: Epidemiology

Study Type: Other

Epidemiology of Ice Hockey Versus Roller Hockey-Related Injuries in the United States Emergency Departments 2013-2022

Submitting Author/Presenter: Nathan Michalak, MD

Nicholas Thornton, MD and Petra Aboulhosn, MD

Affiliation: New York Medical College, Metropolitan Hospital, New York, NY.

Purpose: We aim to compare injury demographics in ice hockey (metal skates, ice) vs roller hockey (wheeled skates, dry surface). Both sports share similarities in rules and equipment, but differences in surface, skating mechanics and legality of body checking could provide insight for safety recommendations.

Methods and Study Design: Data on 10906 ice hockey and 615 roller hockey related injuries contained within the National Electronic Injury Surveillance System were analyzed over a 10-year period (January 2013-December 2022). Ice hockey included product codes 1279 (“ice hockey”) and 3272 (“hockey”). Roller hockey included product codes 3245 (“street hockey”) and 5032 (“roller hockey”).

Results: Injuries were most common in the 11 to 15 age group in both ice hockey and roller hockey (38.1% and 34.2%, respectively). Males represented the majority of patients in both ice hockey and roller hockey (88.6% and 80.1%, respectively). Caucasian race constituted about 56.6% and 65.3% of all cases in ice and roller hockey, respectively. The 3 most common locations for injury in ice hockey were head (20.9%), face (12.3%) and shoulder (12.1%), while for roller hockey they were head (17.6%), face (16.6%), ankle (8.9%). The 3 most common types of injury in ice hockey were fracture (18.7%), laceration (17.8%), and contusion (12.5%), while for roller hockey they were fracture (18.1%), strain/sprain (16.4%), and laceration (16.3%).

Conclusions: Head and face injuries predominated in both sports, suggesting rule adjustments for facial protection. Ice hockey exhibited more shoulder injuries, attributed to its physicality and board/body checking, which is prohibited in roller hockey. Roller hockey had increased ankle injuries, possibly linked to wheeled skate maneuverability and faster pace due to less stoppage time. Fractures were the most common injury type, with lacerations also common.

Significance: Analyzing these injury patterns informs targeted safety regulations to prevent common injuries in each sport. Adjusting face equipment rules benefit players in both sports. Special attention to prevent ankle sprains in roller hockey is warranted.

Topic: Heat Illness

Study Type: Cohort

Correlations Between WBGT Temperatures and NWS Heat Index Readings in Secondary School Settings

Submitting Author/Presenter: Thomas Jason Meredith, MD

Adam Rosen, PhD, Colleen Vogel, MS, and Samuel Wilkins, PhD

Affiliation: University of Nebraska Medical Center, Omaha, Nebraska.

Purpose: Wet Bulb Globe Temperature (WBGT) is considered best practice to monitor heat stress for sports. Many schools have relied on heat index (HI) values to make decisions about practices and competitions. The purpose of this study was to determine the relationship between WBGT readings and HI values.

Methods and Study Design: Cohort design. ATCs recorded daily pre-event WBGT (pWBGT) readings and highest recorded WBGT (hWBGT) readings during activity using Kestral 5400 devices. WBGT data was submitted electronically daily and were date and time matched with HI data from the nearest NWS. Pearson r correlations were calculated to determine relationship between pWBGT and hWBGT readings and NWS HI values (alpha < 0.05).

Results: Thirty-eight high school athletic trainers participated in the study, recording a total of 504 unique data entries (mean pWBGT: 78.94 ± 6.72, hWBGT 81.36 ± 6.4, NWS HI: 89.39 ± 9.94). A positive strong correlation was calculated between pWBGT reading and HI reading (r = 0.768, P < 0.001) and hWBGT reading during activity and HI reading (r = 0.779, P < 0.001). Thirty-four (6.7%) total pWBGT readings were reported in the “black” range. All data was collected in WBGT geographic region 2. Green was the most frequent pWBGT category recorded (55.2%), followed by Yellow (28.3%), Black (6.7%), Orange (6.3%), and finally Red (2.0%). Most athletic trainers reported measuring WBGT on artificial turf (73.9%), followed by natural grass (20.6%), concrete (5.0%) and dirt (0.4%). Athletic trainers reported 50 cases of heat cramps, 2 cases of heat syncope, 11 cases of heat exhaustion, and no cases of heat stroke during the reporting period.

Conclusions: A strong positive correlation was found between pWBGT and HI, as well as hWBGT and HI. Despite this correlation, in some cases where “red” and “black” WBGT readings (highest risk for heat illness) were measured while HI measured less than 90 degrees. This HI would indicate the least risk for participating in outdoor sports. Differences in these risk calculations could impact athlete health through increased risk for exertional heat illness.

Significance: Team physicians should encourage their schools to use WBGT to measure heat stress in outdoor activities to mitigate the risk of heat illness for their student athletes.

Acknowledgements: We would like to thank the certified athletic trainers in Nebraska who helped collect data for this project.

Topic: Epidemiology

Study Type: Cohort

Comparison of Injuries Sustained on Grass and Artificial Turf by USL1 Mens Soccer Team. Part 2: Total Athlete Expos

Submitting Author/Presenter: Michael Osterholt, MD

Jason Meredith, MD

Affiliation: University of Nebraska Medical Center, Omaha, NE.

Purpose: Athlete safety on artificial turf (AT) playing surfaces is a reoccurring topic for debate. This study aims to analyze and compare the incidence, type, and location of injuries sustained on AT and natural grass (NG) playing surfaces for a United Soccer League, League 1 (USL1) men's soccer team.

Methods and Study Design: Union Omaha's ATC documented injury data including event location, anatomic location of injury, and type of injury sustained. Team physicians retrospectively reviewed data for 3 USL1 seasons (2020-2022). Injury incidence rates, calculated with 95% confidence intervals, were reported in terms of 1000 athlete exposures. Exposure was an athlete's participation in one practice session or match.

Results: There were 3444 exposures on NG and 5550 exposures on AT over the 3-year period. 295 injuries were registered on AT versus 259 on NG. Overall incidence of injuries was 53.15 per 1000 exposures on AT compared to 75.20 per 1000 exposures on NG (Incidence ratio 0.71, P value 0.001). Subgroups for location of injury comparing incident rate on AT to NG: Head/neck 2.88, 7.55 (IR 0.38, P 0.002), Upper limb 1.98, 4.68 (IR 0.43, P 0.030), Trunk 6.13, 7.26 (IR 0.84, P 0.520), and Lower limb 42.16, 55.75 (IR 0.76, P 0.004). Subgroups for type of injury comparing incident rate on AT to NG: Fracture/Bone Stress 0.54, 1.16 (IR 0.47, P 0.317), Joint(non-bone)/Ligament/Cartilage 10.81, 10.16 (IR 1.06, P 0.771), Muscle/Tendon 28.47, 33.39 (IR 0.85, P 0.193), Contusion 8.83, 22.36 (IR 0.39, P 0.001), laceration/Skin Lesion 2.70, 2.61 (IR 1.03, P 0.936), Central/Peripheral Nervous System 1.44, 3.77 (IR 0.38, P 0.032), Other 0.36, 1.74 (IR 0.21, P 0.054).

Conclusions: Overall, the incidence of injuries per athlete exposure was significantly lower on AT than NG. Injuries subdivided into location demonstrate statistically lower rates of head/neck, upper limb, and lower limb injuries on AT. Additionally, with regards to type of injury, the rate of contusions and central/peripheral nervous system injuries were statistically lower AT.

Significance: Artificial turf playing surfaces have become more common as technology and engineering has advanced. This study suggests that new generation artificial turf may be safer than natural grass when comparing injuries on a professional men's soccer team.

Acknowledgements: Justin Annin, ATC whose attention to detail in his injury logs made this retrospective research project possible. Dr. Jenenne A. Geske for completing all our statistical analysis.

Topic: Rehabilitation

Study Type: RCT

Timing of Physical Therapy in Adolescent Athletes With Spondylolysis: A Multi-Center Randomized Trial

Submitting Author/Presenter: Emily A Sweeney, MD

Anastasia Fischer, MD, Madison Brna, BS, and Mitchell Selhorst, PhD, DPT

Affiliation: University of Colorado School of Medicine; Children's Hospital Colorado, Sports Medicine Center, Aurora, CO.

Purpose: To assess the effectiveness of an immediate functional progression physical therapy program (IFPP) to treat adolescent athletes with an acute lumbar spondylolysis. We hypothesize athletes in the IFPP group will have quicker improvements than athletes who wait to start physical therapy (PT).

Methods and Study Design: This was a multi-center randomized trial. Adolescent athletes with acute lumbar spondylolysis diagnosed by MRI were randomized to IFPP or to usual care, (start PT once pain-free with ADLs). The Micheli Functional Scale (MFS), a 100-point scale, (0 = no pain/disability) was used to assess pain and disability at baseline, 1, and 3 months. Time out of sport and recurrence of back pain were assessed.

Results: Forty-five adolescent athletes (14.5 ± 1.6 years; 35% female) with a mean duration of symptoms 9 ± 6 weeks were enrolled; IFPP (n = 20) and usual care (n = 25). At baseline, athletes in both groups had similar levels of pain and disability on the MFS (IFPP 50 ± 17, usual care 52 ± 15; P = 0.70). At 1 month, athletes in the IFPP had a significantly lower score on the MFS (IFPP 16 ± 14, usual care 36 ± 22; P < 0.001). At 3 months, both groups had similar minimal MFS scores (IFPP 5 ± 10, usual care 10 ± 18; P = 0.13). Adolescent athletes in the IFPP passed predetermined return to sport criteria 33 days sooner (IFPP 69 ± 17 days, usual care 102 ± 34 days; P < 0.001). To date, no participants (0%) in the IFPP and 4 participants (16%) in the usual care group had a significant recurrence of low back pain after returning to sport.

Conclusions: Starting PT immediately and progressing based on functional ability (IFPP) resulted in significantly quicker improvements in pain and disability for adolescent athletes with acute lumbar spondylolysis. Starting PT early, as opposed to waiting until the athlete is pain-free, led to a significantly sooner return to sport with fewer recurrences in back pain. In the future, we will assess imaging and one-year outcomes.

Significance: This is the first randomized trial to assess a controlled PT program for adolescent athletes with acute lumbar spondylolysis. These results suggest that beginning a controlled rehabilitation program sooner is a feasible option.

Acknowledgements: We want to acknowledge the AMSSM-CRN for grant funding for this project.

Topic: Concussion

Study Type: Cohort

Effectiveness of Helmet Add-on Shell Devices to Prevent Sport-related Concussion in High School Football Players

Submitting Author/Presenter: Erin Hammer, MD, MPH

Tim McGuine, PhD, AT-C, Sam Mosiman, MS, Alison Brooks, MD, MPH, and Adam Cordum, MD

Affiliation: University of Wisconsin-Madison.

Purpose: There is limited evidence that aftermarket add-on shell devices for football helmets (ie, Guardian Caps [GCs]) are effective in reducing sport-related concussion (SRC). The purpose of this study was to determine if GC use was associated with a lower risk of SRC in high school football players.

Methods and Study Design: Football players from 40 high schools were recruited. Schools were classified as YesGC or NoGC based on GC use. Athletic trainers (ATs) reported football exposures and SRCs that occurred during practices and games. Negative binomial modeling with exposure offset was used to assess the difference in risk of SRC/1000 exposures, accounting for school setting (rural, suburban, urban) and enrollment.

Results: A total of 2480 players were enrolled (mean age 15.9 ± 1.2 years old; YesGC = 22 schools with 1367 players, NoGC = 18 schools with 1113 players). The athletes participated in 106,201 practice exposures and 22,077 game exposures during the 2023 regular season. During practices, 51 players sustained an SRC (YesGC = 26, NoGC = 25). There was no difference in the SRC rate sustained in practice between the YesGC (0.45 SRCs/1000 exposures) and NoGC (0.51 SRCs/1000 exposures) cohorts (RR 0.88, 95% CI [0.51-1.53], P value 0.66). During games, 108 players sustained an SRC (YesGC = 65, NoGC = 43), though neither cohort wore GCs during games. There was no difference in the rate of SRC sustained in games between the YesGC (5.30 SRCs/1000 exposures) and NoGC (4.38 SRCs/1000 exposures) cohorts (RR 1.21, 95% CI [0.76-1.90], P value 0.41).

Conclusions: In this sample of high school football players, GC use was not associated with a lower relative risk of SRC in practice. Similarly, there was no difference in the risk of SRC during games between the cohorts, though neither cohort wore GCs during the games.

Significance: Preventing SRC in football remains an elusive goal. High schools should consider investing in evidence-based strategies to reduce the incidence and morbidity of injury such as employing ATs in lieu of add-on shell devices for football helmets.

Acknowledgements: We want to thank all participating high schools, athletic trainers, players, coaches, and parents for their willingness to take part in this study.

Topic: Epidemiology

Study Type: Cohort

The NICA Injury Surveillance System: Details from 119,098 Student-Athlete-Years of Injury Data

Submitting Author/Presenter: Meredith Ehn, DO, DPT

Rachel Andres, BS, MS-III, Masaru Teramoto, PhD, MPH, Aaron Provance, MD, Daniel M. Cushman, MD, and Stuart Willick, MD

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

Purpose: To describe injury characteristics of youth mountain bike racers. The National Interscholastic Cycling Association (NICA) Injury Surveillance System (ISS) was implemented in 2018 to gather data on injuries in youth mountain bike racing, which can help inform targeted injury-prevention strategies.

Methods and Study Design: From 2018 to 2022 (5 seasons), a prospective, longitudinal ISS was developed that collects data weekly from NICA teams across the country using a web-based survey instrument designed in REDCap. A designated reporter from each team reports on injury characteristics, race and practice environments, and factors associated with a crash.

Results: In 119,098 student-athlete years over 5 years, there were 2,655 injury events (overall injury event proportion = 2.23%). The wrist/hand was the most common body part injured (23.2%), followed by head (concussion) (23.0%), and shoulder/clavicle (15.9%). Nearly half of all injury events (49.7%) resulted in a trip to an emergency room. About 75% of injuries occurred on trails familiar to the rider with many injuries attributed to “rider inexperience” and the “technical nature of the trail.” Interestingly, male riders experienced a significantly higher proportion of upper limb injuries than females (57.6% vs. 49.6%, P < 0.001) and were more likely to sustain a fracture (Relative Risk = 1.38, 95% Confidence Interval = 1.17-1.63). Using data from the ISS, NICA implemented enhanced skills programs after the 2019 season; the overall injury event proportion significantly decreased from 2.79% in 2018-2019 to 2.05% in 2021-2022 (P < 0.001), which was equivalent to a 27% reduction in injury rate.

Conclusions: Acute traumatic injuries are common in youth cross-country mountain bike racing. One major cause of injury events appears to be inadequate skill level for technical trails at a given speed. Injury characteristics differ between males and females, possibly due to differences in rider speed, body position, and bike setup. Implementation of an enhanced skills training program was associated with decreased injury rates in youth riders.

Significance: To our knowledge, the NICA ISS is the largest database of mountain bike injuries in the world. Results from this ISS are being used to develop additional data-driven injury-prevention strategies that will help reduce injury rates in youth riders.

Acknowledgements: We would like to thank the NICA student-athletes, coaches, parents, and other stake-holders, without whose participation this ISS could not be successful.

Topic: NCAA

Study Type: Cohort

Mental Health Screening With SMHAT-1 Compared to Diagnostic DSM Interview in Collegiate Athletes

Submitting Author/Presenter: Vicki Nelson, MD, PhD

Christina Gutta, MD and Raphaela Fontana, MD

Affiliation: University of South Carolina School of Medicine - Greenville, Greenville, SC.

Purpose: This study aimed to evaluate the performance of the IOC Sports Mental Health Assessment Tool-1 (SMHAT-1) in an NCAA collegiate athlete population for mental health screening by comparison to a psychiatric diagnostic interview.

Methods and Study Design: Collegiate athletes (n = 1640) underwent mental health screening including the SMHAT-1 components APSQ, GAD-7, PHQ-9, CAGE, AUDIT, ASSQ and BEDA during pre-participation evaluation. 212 athletes additionally underwent the Structured Clinical interview for DSM Diagnoses (SCID-5) components for generalized anxiety (GAD), major depressive disorder (MDD), anorexia nervosa and bulimia nervosa (BN).

Results: 41.8% of athletes were positive on at least one instrument: 2.6% GAD-7, 1.0% PHQ-9, 1.2% PHQ item 9, 1.1% CAGE, 0% AUDIT, 11.2% ASSQ, 34.1% BEDA. 9.7% of athletes were positive on APSQ triage. APSQ had a 18.8% sensitivity and 96.8% specificity for specific instrument screening. 81.2% of athletes with a positive follow up screen were missed on triage. APSQ detected a majority of positive GAD-7 (n = 42 69.0% detected), PHQ-9 (n = 16 81.3%), and PHQ item 9 (n = 19 57.9%) positives while missing the majority of ASSQ (n = 184 28.8%), CAGE (n = 18 27.8%) and BEDA positives (n = 560 18.8% detected). Two hundred twelve athletes underwent diagnostic interview. Only 1.4% met DSM criteria for at least one diagnosis (1 GAD, 3 MDD, 1 BN). 2/3 athletes were identified on APSQ triage, 0/1 athletes with GAD were identified on GAD-7, 1/3 with depression on the PHQ-9 and 0/3 on item 9, 1/1 athletes with BN were identified on BEDA. APSQ had 66.7% sensitivity and 90.3% specificity for DSM diagnoses.

Conclusions: APSQ had low sensitivity and positive predictive value for any positive screen (19%, 81%) or DSM diagnosis (67%, 1.3%). The prevalence of positive screening was low for GAD, MDD and substance use for a collegiate population and the low rate of DSM diagnoses potentially limits accuracy of predictive value calculation in this sample. The low prevalence raises concern for over detection by screens vs underreporting in interview.

Significance: It is unclear that current screening cutoffs are appropriate for the pre-participation setting or the collegiate athlete population. Identification or adjustment of screening tools for higher clinical utility is needed for effective care.

Topic: Concussion

Study Type: RCT

Sex Differences Throughout an Aerobic Exercise Intervention for Sport-Related Concussion

Submitting Author/Presenter: Sarah Robinson, DO

Elizabeth Castro, John J Leddy, MD, Mohammad N. Haider, MD, PhD, Barry Willer, PhD, and Haley M. Chizuk, PhD, ATC

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

Purpose: Aerobic exercise reduces the incidence of persisting symptoms and speeds recovery from sport-related concussion (SRC). We assessed sex differences in motivation, perceived competence, and prescription adherence through SRC recovery to evaluate the impact of these factors on exercise treatment.

Methods and Study Design: Athletes with SRC (n = 32, 66% male, 15.6 + 1.4 y) and controls (n = 28, 66% male, 16.0 + 1.6 y) were randomly assigned 2 weeks of aerobic exercise at high (5 days/wk, 30 min) or low volumes (3 days/wk, 20 min). Exercise intensity was based on exercise test results. Participants completed a Treatment Self-Regulated Questionnaire (TSRQ), a Perceived Competence Scale (PCS), and a clinical exam weekly.

Results: Concussed males and females did not differ in days to initial visit (4.29 + 2.85 vs. 6.18 + 2.21, P = 0.22) or days to recovery (16.9 + 10.74 vs. 20.22 + 15.44, P = 0.53). At the initial visit, concussed females achieved higher heart rates on exercise testing compared to males. (150.83 + 20.99 vs. 141.59 + 20.94) This same trend was found in healthy females compared to males (165.11 + 8.96 vs. 150.56 + 15.31). Therefore, females were prescribed higher target heart rates. There were no sex differences in exercise volume (P = 0.64). Healthy participants had higher exercise volumes than concussed patients (P = 0.004). Concussed females were less adherent to their prescriptions than healthy females (22% vs. 87%, P = 0.020) whereas concussed males were equally adherent vs. healthy males (50% vs. 47%, P = 0.29). No differences were found in any TSRQ motivation components. Concussed females reported lower PCS scores at the initial visit vs. healthy females (P = 0.030) whereas males had no differences in PCS scores.

Conclusions: Females were provided higher-intensity exercise prescriptions because they achieved higher heart rates during exercise testing. Nevertheless, females and males completed similar volumes of exercise. The data suggest it is unlikely that a lack of motivation or competence reduced concussed female adherence. Although not significant, females took an average of 3 more days to recover than males, which may be attributed partly to reduced adherence.

Significance: Aerobic exercise speeds recovery from SRC; however, concussed females did not meet exercise prescriptions as often as males. Future research should assess alternate prescriptions, such as longer duration lower intensity exercise, in females with SRC.

Topic: Epidemiology

Study Type: Case-Control

Risk Factors for Achilles Tendon Rupture After Quinolone Exposure

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

Sung Jae Kim, MD, PhD

Affiliation: Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, MA.

Purpose: While it is well known that quinolone antibiotics are associated with tendon injuries, risk factors for Achilles tendon rupture (ATR) after quinolone exposure are not well characterized. The purpose of this study was to identify risk factors associated with ATR after quinolone exposure.

Methods and Study Design: Using the Korean National Health Insurance Service database, a nested case-control study was conducted. Quinolone exposure was defined as prescription duration of 6 days or longer and searched up to 180 days prior to the date of ATR. Multiple logistic regression was performed with ATR as an outcome and independent variables including patient demographics and types of quinolone antibiotics.

Results: From 2009 to 2019, a total of 40,240 ATRs and 160,960 controls were included. The results of multiple logistic regression analysis demonstrated that the odds of ATR were higher in females (OR 1.23, 95% CI 1.19-1.28), obese patients (OR 2.20, 95% CI 2.09-2.32 for BMI 30∼34.9 and OR 2.12, 95% CI 1.87-2.41 for BMI 35 or greater), patients with alcohol consumption (OR 1.11, 95% CI 1.06-1.16), patients with high physical activity level (OR 1.29, 95% CI 1.25-1.34), and patients exposed to levofloxacin (OR 1.28, 95% CI 1.13-1.44). The odds of ATR were lower in older adults than those of younger patients below 40 years old (OR 0.86, 95% CI 0.83-0.90), and there was a trend of decreasing odds with increasing age (P < 0.001 for trend). Other quinolones including ciprofloxacin, fleroxacin, lomefloxacin, norfloxacin, ofloxacin, and moxifloxacin were not associated with increased odds of ATR.

Conclusions: Our case-control study identified potential risk factors for developing ATR after quinolone exposure including female sex, obesity, alcohol consumption, high physical activity, and young age. Among various quinolone antibiotics, only levofloxacin was associated with increased odds of ATR.

Significance: Patients should be warned against potential ATR when prescribed with quinolone antibiotics. Levofloxacin should be judiciously prescribed, especially in patients who are young, female, obese, physically active, and/or consuming alcohol.

Topic: Cardiology

Study Type: Cohort

Echocardiographic Findings Associated With Rapid Weight Loss in Collegiate Wrestlers

Submitting Author/Presenter: Eric Twohey, MD

Brennan Boettcher, DO, Kathryn Larson, MD, Nadia Elfessi, PA, Thomas Allison, PhD, MPH, and Darrell Newman, MD

Affiliation: Mayo Clinic Physical Medicine and Rehabilitation Department, Rochester, Minnesota.

Purpose: Rapid weight loss (RWL) is common in wrestling and known to impact health and performance. Much is known about chronic adaptions seen in the “Athlete's Heart Syndrome,” but little is known about the effects of RWL. This study aimed to evaluate cardiac structure and function associated with RWL.

Methods and Study Design: Preseason baseline testing included height, weight, heart rate (HR), blood pressure (BP), and comprehensive transthoracic echocardiogram (TTE) with left and right ventricular global longitudinal strain. RWL was defined as the difference between maximum and minimum weight the week prior to the first tournament. Repeat (post RWL) comprehensive TTE was performed the night before the first tournament.

Results: Fifteen wrestlers completed both pre- and post-testing. Three wrestlers did not undergo RWL due to their weight class (n = 2) or injury prohibiting them from competing (n = 1). Of the remaining twelve wrestlers, the mean RWL was 5.1 kg (range 2.9-10.6 kg). HR was significantly increased after RWL (baseline 63.6 vs. 71.2 BPM, P = 0.005) whereas both systolic (123.8 vs. 114.1 mmHg, P = 0.04) and diastolic (77.8 vs. 67 mmHg, P = 0.003) both decreased. On TTE, mitral inflow E wave on Pulse Wave Doppler (0.75 vs. 0.64, P = 0.03) and Mitral inflow E/A ratio (2.26 vs. 1.63, P = 0.024) were significantly reduced after RWL. There was a trend to a lower E/e' ratio (P = 0.06). Calculated LVEF (58.3% vs. 56.5%, P = 0.042) and GLS (−21.3% vs. −19.5%, P = 0.012) were also significantly reduced after RWL.

Conclusions: Increased HR and lower BP post-RWL likely reflect loss of body water and relative dehydration. There were statistically significant but very modest reductions in select measures of systolic and diastolic function on TTE. The small sample size of our study is a significant limitation.

Significance: RWL is associated with relative dehydration and modest decrease in measures of systolic and diastolic function on TTE. Future studies are warranted to clarify the clinical significance of these findings for athletic performance and wrestler safety.

Acknowledgements: Thank you to the Mayo Clinic Cardiology Department for helping fund this research project.

Topic: Musculoskeletal

Study Type: Cohort

The Efficacy of Ultrasound Versus Fluoroscopic Guided Knee Genicular Nerve Blocks

Quinn Howard, MD, Rohila Kusampudi, BS, Alexandra E. Warrick, MD, Jennifer Paul, MD, Katherine Rizzone, MD, MPH, and Daniel C. Herman, MD, PhD

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

Purpose: Genicular nerve blocks are performed prior to genicular radiofrequency ablation when treating knee osteoarthritis, but there have been no comparisons of imaging guidance efficacy. The aim of this study was to compare the efficacy of knee genicular nerve blocks using fluoroscopy versus ultrasound.

Methods and Study Design: This study employed a cohort design using historical data from 2020 to 2023 at 2 medical centers. Outcomes were percent pain improvement and the proportions of patients with 50% and 80% improvement in pain. Group comparisons were via t, Mann-Whitney U, and χ2 tests (alpha = 0.05). Regression analyses were used to assess potential predictive factors (age, BMI, osteoarthritis severity) of outcomes.

Results: A total of 349 knees (M = 110, F = 239) in 252 patients (M = 77, F = 175) were included for study. Fluoroscopic guidance (FG) was used in N = 240 (M = 66, F = 174) and ultrasound guidance (UG) in N = 109 (M = 44, F = 65) knees. There were no differences in age (FG = 68.08 ± 12.1, UG = 68.89 ± 12.1, P = 0.563), BMI (FG = 34.6 ± 8.9, UG = 32.9 ± 9.2, P = 0.166), or Kellgren-Lawrence (KL) osteoarthritis severity (FG = 3.2 ± 0.8, UG = 3.1 ± 0.7, P = 0.068) between the groups. There were no statistically significant differences between the groups in % overall improvement (FG = 81.8 ± 26.22%, UG = 82.8 ± 20.41%, P = 0.211), or the proportion of cases with at least 50% improvement in pain (FG = 90.4%, UG = 92.7%, P = 0.201) or at least 80% improvement in pain (FG = 78.8%, UG = 79.8%, P = 0.820). Linear and logistic regression models were used to determine if patient characteristics (age, sex, BMI, KL severity) predicted percentage improvement in pain or membership in the groups with 50% or 80% improvement in pain; however, no patient factors loaded into any of the regression models (P > 0.05 in all cases).

Conclusions: Ultrasound guidance may be equivalent in efficacy to fluoroscopic guidance when performing diagnostic genicular nerve blocks. This relationship is not modified by patient clinical factors. The rate of genicular nerve block success, defined as 50% or greater reduction in pain, is high regardless of the imaging guidance used. Research regarding the efficacy of fluoroscopy versus ultrasound for genicular nerve ablations is warranted.

Significance: Given the higher costs of fluoroscopy, the use of ionizing radiation with fluoroscopy, the ease of point-of-care use of ultrasound, and equivalent efficacy, ultrasound should be considered for guidance when performing genicular nerve blocks.

Topic: Concussion

Study Type: Cohort

Abnormal Neurophysiology and P300 Event Related Potentials in MTBI Patients With Chronic Persistent Post-Concussion Symtpoms

Submitting Author/Presenter: David Tramutolo, DO

Benjamin Washburn, MD, Brett Dusenberry, MD, Leslie Streeter, DNP, Leila Samsan, DNP, James Dill, MD, David Oakley, PhD, and Mo Mortazavi, PhD

Affiliation: University of Missouri, Columbia, Missouri.

Purpose: To identify symptoms and objective neurophysiological markers associated with late-stage persistent post-concussion symptoms (PPCS) persisting beyond one year.

Methods and Study Design: A retrospective cohort study of 31 patients with PPCS. Patients were screened for symptoms with the validated concussion profile (CP) screen and tested with oddball audio EEG protocol with P300 event related potential (ERP) voltage and latencies extracted. Patients were divided into 2 groups based on symptom duration (group A = < 3 months, group B = > 1 year). Data were compared using t-tests.

Results: