Outcomes of Adolescent Athletes with Lateral and Inferolateral T-Wave Inversions on Screening ECG

Primary Author/Presenter: Leanna Brooks, MD, MS

Magdalena Babinska-Hogan, MD and David Price, MD

Affiliation: Atrium Health Carolinas Medical Center.

Assigned #: R2022-0173

Presentation Type: Podium

Purpose: Lateral and inferolateral t-wave inversions (TWI) on screening ECGs have been associated with the presence or development of cardiomyopathy in athletes. Our investigation sought to identify outcomes in adolescent athletes with TWI noted on pre-participation ECGs.

Methods: Retrospective cohort analysis from 2010-2019 of high school athletes in Charlotte, NC. Participants underwent resting 12-lead ECG which was interpreted using modern interpretation standards. Athletes with TWI in lateral or inferolateral leads were further evaluated and followed over time evaluating prevalence of subclinical heart disease, incidence of cardiac arrest/death, and rate of follow up.

Results: 244/10,072 (2.4%) athletes had an abnormal screening ECG. 35 (14.3%) had lateral or inferolateral TWI. 5 athletes had normal repeat ECGs on subsequent evaluation, and 1 was found to have WPW pattern requiring ablation, leaving 29 athletes (11.9%) needing further work-up. Of the 29 athletes, 3 were lost to follow up. The remaining 26 athletes underwent further evaluation with echocardiogram (TTE) and if indicated, exercise stress test, cardiac MRI, and/or Holter monitor. 11 (42.3%) athletes had evidence of cardiac disease (2 definite hypertrophic cardiomyopathy (HCM), 2 probable HCM, 5 LVH secondary to hypertension, 1 myocardial fibrosis on CMR with non-sustained ventricular tachycardia on Holter, and 1 anomalous coronary artery). Of the 2 athletes with definitive HCM, 1 was diagnosed at the screening and 1 developed it within 2 years. No athlete suffered cardiac arrest or death. Despite efforts to follow these athletes, only 8 attended follow up > 1 year after initial evaluation.

Conclusions: A significant percentage (42.3%) of adolescent athletes with lateral or inferolateral TWI were found to have subclinical heart disease. Fortunately, there were no cases of cardiac arrest or death in the 21 of 26 athletes which we were able to contact or find recent records for. Most concerning was the lack of compliance with recommended follow-up with cardiology despite the potentially significant risks of not doing so.

Significance: Many adolescent athletes with lateral and inferolateral TWI on screening ECG may have or develop underlying cardiac pathology and need ongoing follow up but don't get it. Further investigation into barriers to follow up is warranted.

Acknowledgements: We would like to thank Dermot Phelan, MD for his advice, suggestions and support.

The Association of Socioeconomic Disadvantage and Racialized Disparities in Sudden Cardiac Arrest in Competitive Athletes

Primary Author/Presenter: Megan Burleson, DO

Randi DeLong, MPH, Kristen Kucera, PhD, Barbara Goettsch, MSW, Jared Schattenkerk, BS, Sheree Bekker, PhD, and Jonathan Drezner, MD

Affiliation: Department of Family Medicine and the Center for Sports Cardiology, University of Washington, Seattle, Washington.

Assigned #: R2022-0121

Presentation Type: Podium

Purpose: Racialized marginalization, including via socioeconomic disparities, is a recognized social determinant of health, and studies show Black athletes are at higher risk of SCA. This study examines the association of socioeconomic disadvantage and racialized outcomes in competitive athletes with SCA.

Methods: SCA cases from the NCCSIR database (7/2014-6/2021) were included. We matched Area Deprivation Index (ADI) scores (17 metrics to grade socioeconomic conditions based on U.S. census blocks) to the 9-digit zip codes for each athlete's home address. Analysis of variance (ANOVA) was used to assess differences in mean ADI by racial groups. Tukey post hoc testing was used for pair-wise comparisons.

Results: 391 cases of SCA in competitive athletes (85.4% male; 16.9% collegiate, 68% high school, 10.7% middle school, 4.3% youth) were identified via longitudinal surveillance by the NCCSIR. 79 cases were excluded from the analyses due to missing data (19 race, 60 ADI). Of the 312 cases with complete race and ADI data, 171 (54.8%) were White, 110 (35.3%) Black, and 31 (9.9%) Other. ADI is scored 0-100 with higher scores indicating greater neighborhood socioeconomic disadvantage. The mean ADI was 40.20 (95% CI [36.64, 43.86]) in White athletes, 57.88 (95% CI [52.65, 63.11]) in Black athletes, and 40.77 (95% CI [30.69, 50.86]) in Other athletes. ANOVA demonstrated a significant difference in mean ADI scores by racial group (F=16.54, p= < 0.001). Pair-wise comparisons revealed a significant difference in mean ADI in Black versus White athletes (mean difference 17.68, 95% CI [10.25, 25.12], p=0.0036) and Black versus Other athletes (mean difference 17.11, 95% CI [4.74, 29.47], p= < 0.0001).

Conclusions: This is the first study to analyze the relationship between socioeconomic disadvantage and racialized outcomes in competitive athletes with SCA. Black athletes with SCA have higher neighborhood socioeconomic disadvantage than White athletes or Other athletes with SCA. In the context of structural marginalization in the U.S., our findings suggest that socioeconomic disadvantage is associated with racialized disparities in SCA in athletes.

Significance: Detailed insight into how socioeconomic disadvantage may disproportionately have racialized outcomes is key to advancing our understanding of health inequities in sport. This is critical to developing effective strategies for SCA prevention.

Functional Recovery Threshold Changes on KOOS after ACL Reconstruction and Return-to-Sport

Primary Author/Presenter: Stephanie W. Casella, MD

Staci Thomas, MS, Christin Zwolski, PT, PhD, Matthew P. Ithurburn, PT, PhD, Paul J. Gubanich, MD, Laura C. Schmitt, PT, PhD, and Mark V. Paterno, PT, PhD

Affiliation: Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

Assigned #: R2022-0172

Presentation Type: Podium

Purpose: The purpose was to test the hypothesis that the proportion of young athletes meeting functional recovery (FR) targets on the Knee injury and Osteoarthritis Outcome Score (KOOS) would increase in the 12 months after return to sport (RTS) following anterior cruciate ligament reconstruction (ACLR).

Methods: This is a longitudinal analysis of the ACL-RELAY Study, which is an ongoing, prospective cohort study evaluating outcomes in young athletes after ACLR. Sixty athletes (age=17.3 ± 2.9 yrs) who completed the KOOS every 3 months after RTS were included in this analysis. We evaluated the proportions of participants meeting age- and activity-relevant FR targets on the KOOS at each follow-up.

Results: Previously-defined FR targets for young athletes on each KOOS subscale were: Pain ≤ 94/100, Symptoms ≤ 92/100, ADL ≤ 97/100, Sport ≤ 92/100, and Quality of Life (QoL) ≤ 92/100. At RTS after ACLR, 13.3% (8/60) met the FR targets on all KOOS subscales. The proportions meeting FR on each KOOS subscale were Symptoms, 38.3%; Pain, 70%; ADL, 80%; Sports, 45%; QOL 18.3%. McNemar tests were used to identify differences in the proportions of patients meeting individual KOOS subscale FR targets and all KOOS FR targets between RTS and each subsequent timepoint. Compared to the time of RTS, the proportion of athletes meeting FR targets became significantly higher at 6 months for the KOOS-QOL (36.7%; p=0.007) and significantly higher at 9 months for the KOOS-Symptoms (63.8%; p=0.001), KOOS-Sport (67.2%; p=0.017), and for meeting all KOOS subscale targets (29.3%; p=0.004). By 12 months post-RTS, 36.2% met FR targets on all KOOS subscales.

Conclusions: After ACLR in young athletes, there is no significant improvement in the proportions of patients meeting FR targets on the Koos-Symptoms, KOOS-Sports, KOOS-QOL, and KOOS overall until 6 to 9 months after RTS. Despite these improvements on the subscales, the majority of patients after ACLR still fail to meet FR targets on all KOOS subscales at 12 months post-RTS.

Significance: Despite medical release to RTS after ACLR, most young athletes are not meeting age- and activity-relevant FR thresholds on KOOS scores until 6-9 months after RTS, suggesting athletes may not be fully recovered in currently recommended RTS timelines.

Acknowledgements: Thank you to the faculty and staff at CCHMC for their support and guidance and to the patients for allowing this study to be possible.

Correlation of Serial Ultrasonography with Clinical Outcomes for Lower Extremity Bone Stress Injuries

Primary Author/Presenter: Justin J. Conway, MD

Marci Goolsby, MD, Lisa Callahan, MD, Theodore Miller, MD, Christian Gennette, MD, Brianna Quijano, MS, Brandon Schneider, MS, and Brett Toresdahl, MD

Affiliation: Crystal Run Healthcare, Newburgh, New York.

Assigned #: R2022-0144

Presentation Type: Podium

Purpose: The purpose of this study is to evaluate the utility of ultrasonography (US) for monitoring bone stress injury (BSI) healing by measuring the correlation between serial sonographic assessments of lower extremity BSIs and clinical outcomes.

Methods: Adults age 18-50 with recent diagnosis of exercise-associated BSI of the tibia, fibula, or metatarsals by MRI were enrolled. US was performed every 2 weeks for 12 weeks measuring soft tissue edema, periosteal reaction, hyperemia, and callus formation. Clinical outcomes included pain on visual analog scale (VAS) and self-reported ability to return to the activity that caused the injury (scale 0-4).

Results: Thirty patients were enrolled, mean age 35.3 [standard deviation (SD) 7.7], and 21 (70.0%) female. The tibia was most frequently affected (n=15, 50.0%), followed by metatarsals (14, 46.7%) and fibula (1, 3.3%). Half (15 of 30) returned to sport or exercise at their pre-injury level. Pain on VAS decreased (repeated measures ANOVA p-value < 0.001) and ability to return to exercise/sport increased (scale 0-4, p < 0.001) over the study period. Patient-reported pain was positively correlated with hyperemia at Week 4 (0.45, 95% confidence interval [0.09, 0.69]) and Week 6 (0.42 [0.07, 0.67]) and soft tissue edema at Week 6 (0.38, [0.02, 0.65]). Correlation with return to sport was significant for hyperemia at Week 6 (-0.45, [-0.68, -0.09]). Subsequent clinical outcomes were compared for subjects with and without hyperemia at Week 6 using repeated measures ANOVA between-subjects effects, demonstrating a significant correlation with subsequent pain (p=0.039) but not return to sport (p=0.062).

Conclusions: Sonographic appearance of lower extremity BSI was correlated with clinical outcomes at multiple time points. Hyperemia appears to be the most valuable US finding given the positive correlation with subsequent pain.

Significance: Serial ultrasonography of lower extremity BSIs in athletes can provide objective measures of healing that may be used in the future to both optimize treatment and more accurately assess readiness for return to sport and exercise.

Acknowledgements: This study was funded by the NBA & GE Healthcare Orthopedics and Sports Medicine Collaboration. The authors also wish to thank members of the Hospital for Special Surgery Primary Care Sports Medicine Service for assistance with recruitment.

COVID-19 Vaccines and the College Athlete: Attitudes and Beliefs

Primary Author/Presenter: Shane Davis, MD

Shivali Shah, DO, David Tullis, MD, and Anthony Beutler, MD

Affiliation: Utah Valley Hospital, Provo, Utah.

Assigned #: R2022-0140

Presentation Type: Podium

Purpose: This study aims to assess vaccination rates among collegiate athletes and gain insight into their attitudes towards vaccination. This information will be valuable in the ongoing education of athletes and other young adults.

Methods: An anonymous survey was distributed to collegiate athletes at an NCAA division I university through email and in-person encounters during pre-participation examinations and routine medical appointments. 654 athletes (324 male, 330 female) were asked to complete the survey. 50% participated (136 male, 193 female, 137 freshman, 67 sophomores, 63 juniors, 34 seniors, 28 5th year or above).

Results: 89% received at least one vaccine dose. Vaccinated athletes are more likely to have vaccinated parents (89% vs 42%) and more concerned about themselves or others getting sick from COVID. They are also more concerned about missing athletic participation due to COVID, which was their primary motivator for getting vaccinated. They are less likely to have had prior COVID infection (61% vs 33%). 59% of vaccinated athletes have no concerns about the vaccine compared to 6% of the unvaccinated. Common concerns for both groups are not knowing enough about the vaccine, having had prior COVID infection and feeling that they are healthy enough that they do not need the vaccine. Inconvenience was also a deterrent for the vaccinated group, while concern the vaccines were developed too quickly, belief that vaccines cause fertility issues and distrust of government and healthcare were also leading concerns amongst the unvaccinated. 52% of the unvaccinated are unlikely to get vaccinated in the future.

Conclusions: Despite high vaccination rates amongst collegiate athletes at this university, concerns about COVID vaccination safety are still common and many do not feel they are well-enough educated on the topic. Misinformation and distrust are more common areas of concern for the unvaccinated. Risk of missing athletic participation appears to be the primary motivating factor for vaccination in this group.

Significance: Collegiate athletes may be a uniquely motivated to received COVID vaccination but still need ongoing education. Vaccine development and fertility questions may a particularly important areas of misinformation to address with these individuals.

Experience with COVID Mitigation During the Tokyo 2020 Olympic and Paralympic Games

Primary Author/Presenter: Sarah F. Eby, MD, PhD

Tod Olin, MD and Stuart Willick, MD

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

Assigned #: R2022-0076

Presentation Type: Podium

Purpose: The WHO declared the COVID-19 outbreak a pandemic on March 11, 2020. Within weeks, the Tokyo 2020 Olympic and Paralympic Games (Tokyo 2020) were postponed, and ultimately rescheduled for summer 2021. The purpose of this study is to present results from the COVID mitigation effort during Tokyo 2020.

Methods: Airport testing on arrival to Japan was conducted by the Japanese health authorities. Subsequent daily screening with rapid antigen testing on saliva was conducted by the Tokyo Organizing Committee of the Olympic and Paralympic Games (TOCOG). Positive samples were tested via saliva PCR. Final confirmatory testing occurred via nasopharyngeal PCR; if positive, the individual was required to isolate.

Results: During the Games, 40-50,000 quantitative antigen saliva screening tests were performed daily. From 1 July to 7 September, 54,236 COVID-19 tests were performed on Games-related personnel arriving at the Haneda and Narita Airports, with 54 positive tests, for a positivity rate of 0.10%. A subsequent 1,017,190 COVID-19 tests were performed within the Tokyo 2020 bubble by TOCOG, with 312 positives, yielding a positivity rate of 0.03%. Out of a total 11,476 Olympic athletes, 24 tested positive and required isolation; 13 of 4,303 Paralympic athletes tested positive and required isolation. Close contact tracing throughout Toyko 2020 lead to additional screening of 402 individuals, and resulted in the identification of 2 confirmed cases. A small number of athletes had a series of three positive results (saliva screening, saliva PCR, and NP PCR), but were able to produce sufficient documentation outlining recent COVID-19 infection and subsequent recovery, and thus were allowed to participate.

Conclusions: The Tokyo 2020 COVID-19 mitigation plan relied on the formation of a Tokyo 2020 bubble, extensive testing, distancing, masking, contact tracing, quarantining and isolation. The athlete testing structure was designed to limit false positive results which might unfairly disqualify athletes from participation.

Significance: With comprehensive, effective infection control strategies, large sports events can be conducted safely despite respiratory viral pandemics.

Acknowledgements: The authors would like to acknowledge all members of the Japanese public health authorities, the Tokyo 2020 Organizing Committee for the Olympic and Paralympic Games, and all Olympic and Paralympic team members and other stakeholders who took part in the Games for their tireless efforts and compliance with testing, contact tracing, quarantining, isolation, mask wearing, distancing, hand washing and all other precautions required to conduct safe sports competitions.

Physical Activity Levels Following Concussion Related Retirement from Contact Sports

Primary Author/Presenter: Ahmed El-Sayed, DO

Kevin Walter, MD, Matthew Hernandez, BS, Andrew Ernst, MD, Sergey Tarima, PhD, and Joy Liu, MS

Affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin.

Assigned #: R2022-0015

Presentation Type: Podium

Purpose: The aim of this study was to examine athlete compliance with physician recommendations to retire from contact sports in the setting of concussion complications, and to assess subsequent levels of physical activity in both the non-complying and complying retired athletes.

Methods: We identified athletes using EMR search who received a physician retirement recommendation between the years 2013 to 2019. Patients were between the ages of 10-22 at the time of the retirement. All patients answered an 8-question telephone survey which collected information regarding compliance with cessation of contact sports and volume of subsequent aerobic and resistance activity.

Results: Overall, we found that most patients comply with retirement recommendations with only 12.5% of patients returning to play contact sports against medical advice. In the short term, non-compliant patients had a mean of 5.8 hours per week aerobic vs 2.53 hours in the compliant group (p=0.042), and mean of 4 hours resistance vs 1.53 hours resistance in the compliant group (p=0.042). In the long term, non-compliant patients had a mean of 4 hours resistance vs 1.75 hours in the compliant group (p=0.034).

Conclusions: The vast majority of patients do comply with physician recommended retirement from contact sports due to concussion complications. After adjustment for vocational exercise, retiring athletes from contact sports appears to result in significantly lower volumes of both aerobic and resistance activity in the short term, and lower resistance activity volume in the long term.

Significance: This is the first study to demonstrate compliance levels with concussion related physician retirement recommendations. This is also the first study to demonstrate physical activity levels following a retirement recommendation from contact sports.

Acknowledgements: Children's Hospital of Wisconsin.

Exercise-Induced Vision Dysfunction Predicts Persistent Post-Concussive Symptoms In Adolescents

Primary Author/Presenter: Alexander Fleming, DO

Mohammad Haider, MD, PhD and John Leddy, MD

Affiliation: UBMD Department of Orthopaedics and Sports Medicine, University at Buffalo, Buffalo, New York.

Assigned #: R2022-0169

Presentation Type: Podium

Purpose: Vision problems are common in adolescents after sport-related concussion (SRC) and affect prognosis. We determined exercise-induced vision dysfunction (EIVD) identified within 10 days of SRC predicted Persistent Post-Concussion Symptoms (PPCS) in patients prescribed exercise or placebo stretching.

Methods: Multicenter randomized clinical trial comparing King Devick (KD) test performance in adolescents within 10 days of SRC who were prescribed aerobic exercise or a placebo stretching program. KD test was performed before & after the Buffalo Concussion Treadmill Test to symptom exacerbation. A >0.6 s increase in performance time or worsening of symptoms on post-exercise KD defined EIVD.

Results: 99 adolescents with SRC (Exercise group: n=50, 15.3(±)1 y/o, 60% M, 22% with PPCS; Rest group: n=49, 15.9(±)1 y/o, 65% M, 35% with PPCS) were tested a mean of 6(±)2 days since injury. No differences in pre- or post-exercise absolute KD times or physician-performed oculomotor tests were identified in adolescents who developed PPCS versus those with normal recovery in either cohort. However, there was a higher incidence of pre- to post-exercise EIVD in those who developed PPCS versus those who did not (Exercise: 64% vs 28%, p=0.031; Rest: 76% vs 41%, p=0.017; Total: 71% vs 34%, p < 0.001). EIVD was associated with a relative risk of 2.11 (1.42, 3.16) and an odds ratio of 4.90 (1.88, 12.74) for developing PPCS.

Conclusions: Adolescents with EIVD (i.e., reduced performance, symptom exacerbation on the KD test) had significantly greater risk of developing PPCS, regardless of whether they were treated with exercise rehabilitation or the previous standard of care (advice to rest). Assessing visual performance after an exercise stressor may identify subtle impairments that predispose patients to delayed recovery that may be missed by visual assessments performed at rest.

Significance: Adolescent athletes with EIVD after SRC are more likely to develop PPCS whether they are treated with aerobic exercise or rest. Exertional testing may provoke subtle visual dysfunction and prompt prescribing vision therapy to reduce risk of PPCS.

Acknowledgements: Thank you to everyone at the University of Buffalo, Children's Hospital of Philadelphia, and Boston Children's Hospital for contributing and helping complete this study.

Serial Ultrasonography for the Assessment of Healing Lower Extremity Bone Stress Injury

Primary Author/Presenter: Marci Goolsby, MD, FAMSSM

Justin Conway, MD, Theodore Miller, MD, Christian Genette, MD, Brianna Quijano, MS, Lisa Callahan, MD, and Brett Toresdahl, MD

Affiliation: Hospital for Special Surgery, New York, New York.

Assigned #: R2022-0010

Presentation Type: Podium

Purpose: Ultrasonography (US) has previously been shown to be useful in the diagnosis of certain bone stress injuries (BSIs) but has not been used to monitor the healing of BSIs. The purpose of this study is to evaluate the use of serial US to assess the healing of lower extremity BSIs.

Methods: Adults 18 to 50 year old with a recent diagnosis of exercise-associated BSI of the tibia, fibula, or metatarsals by MRI were enrolled. US was performed every 2 weeks for 12 weeks with a repeat MRI at 12 weeks. The sonographic appearance of BSI (soft-tissue edema, periosteal reaction, hyperemia, callus) was correlated with MRI. Changes in MRI and sonographic findings over the study were assessed.

Results: Thirty patients were enrolled, mean age 35.3 and 21 (70.0%) were female. Tibia was most commonly injured (n=15, 50.0%), followed by metatarsals (n=14, 46.7%), and fibula (n=1, 3.3%). Throughout the 12-week study, soft-tissue edema was observed in 13 subjects (43.3%), periosteal reaction in 19, (63.3%), and hyperemia in 13 (43.3%). Callus was observed in only 1 subject, who had a metatarsal stress fracture. At least one US finding was observed in 13/19 (68.4%) at Week 2 and in 25/30 (83.3%) at Week 4. Five subjects (16.7%) had no sonographic findings at the site of the BSI at any point during the study. Soft-tissue edema, periosteal reaction, and hyperemia decreased over the 12 weeks (repeated measures ANOVA p-value.

Conclusions: Serial ultrasonography can provide objective measures of healing of lower extremity BSIs. Hyperemia and soft tissue edema were particularly valuable with a high percentage of subjects having positive findings that decreased over time. Persistent marrow edema by MR was present in over half of the subjects at 12 weeks.

Significance: US may be used in the future to monitor recovery from certain BSIs and more objectively assess readiness for return-to-play. Further research is needed to better understand the prognostic value of these sonographic indicators of BSI healing.

Acknowledgements: Special thanks to the NBA & GE Healthcare Orthopedics and Sports Medicine Collaboration for grant support.

Availability of PCSM Fellowship Positions for Emergency Medicine Physician Applicants—A Program Director Survey

Primary Author/Presenter: Michael Hall, DO

Catherine Fairgrieve-Appel, DO, Kayla Prokopakis, DO, Eric Daubach, DO, BA Ross, Mathiasen, MD Aaron, Barksdale, MD

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

Assigned #: R2022-0075

Presentation Type: Podium

Purpose: The purpose of our study was to help future emergency medicine (EM) applicants to primary care sports medicine (PCSM) fellowships by identifying which fellowships have the infrastructure and ability to accept and train applicants who had received their primary training in EM.

Methods: The study utilized a 13-question survey designed to provide future EM applicants with information to determine how accommodating a PCSM fellowship is towards EM applicants. In programs accepting EM applicants, it attempted to identify how they intended for the applicant to accomplish the continuity requirement in EM under the ACGME guidelines (i.e. working in an ED, UC or other means).

Results: One hundred ninety-six programs were asked to complete the survey. We received a total of 121 responses, blank forms and duplicates were removed and 117 responses remained. Of those, 83 programs reported acceptance of applications from EM trained applicants. The average response rate for each answer type was then made for each of the 13 questions of the survey from the answers of these 83 programs. Key takeaways from the data analysis: Nearly 25% of programs do not have the necessary agreements in place for the potential fellow to complete the ACGME required “continuity training” in emergency medicine. Roughly 13% of programs reported that they do not know in what setting the potential fellow would work to fulfill the “continuity training” requirement (ie emergency department, urgent care, etc). Lastly, just over 20% of programs did not know if the potential fellow would function as a PGY 4 or an attending in the “continuity training".

Conclusions: Although a complete analysis of the data could not be discussed in the results section above, approximately one out of every four responding programs do not have the necessary infrastructure in place to accept an EM candidate. This confirms the suspicion that accepting EM applications does not equate to an ability to match said applicants. This data set is a resource for EM applicants when they are examining which programs to apply to.

Significance: These findings will help future EM applicants identify which PCSM fellowships have the capacity and infrastructure to train them. These findings also specify the setting in which the candidate will complete their “continuity training”.

Acknowledgements: University of Nebraska Medical Center.

Effect of Degree of Weight Cutting on In-Competition Injury Risk in Collegiate Division I Wrestlers

Primary Author/Presenter: Erin Hammer, MD, MPH

Scott Hetzel, MS and Jennifer Sanfilippo, MS, LAT, ATC

Affiliation: University of Wisconsin-Madison, Madison, Wisconsin.

Assigned #: R2022-0037

Presentation Type: Podium

Purpose: Weight cutting is thought to offer a competitive advantage in sports like wrestling. Collegiate wrestlers dehydrate themselves prior to weighing in 1-2 hours before to competition. Dehydration has deleterious effects on physical and cognitive function, which may increase the risk of injury.

Methods: Data were collected prospectively in collegiate wrestlers over six seasons. Change in weight, body fat, and lean mass were measured with DXA scans between the preseason, midseason, and competition. Cox proportional-hazard ratios were calculated for risk of in-competition injury with athlete cluster effect after imputation. Pearson correlations were calculated for weight loss and win percentage.

Results: Among 73 unique Division 1 collegiate wrestlers (178 athlete-seasons), there were 59 injuries (51 injuries in unique athlete-seasons). There was no difference in absolute weight change, percent weight change, percent body fat change, or percent lean mass change between injured and non-injured wrestlers from the preseason to midseason. Injured wrestlers lost a mean 10.5 lbs, SD 6.5 [-6.3% body weight (BW), SD 3.7] before every competition compared to a mean 8.8 lbs, SD 6.0 (-5.2% BW, SD 3.5) among non-injured wrestlers. For every pound of BW lost, wrestlers had a 5% increased hazard of injury during competition (HR 1.05, 95% CI 1.01-1.09, p=0.011). For every 1% of BW lost, wrestlers had 8% increased hazard of injury during competition (HR 1.08, 95% CI 1.02-1.15, p=0.011). Win percentage was not correlated with absolute weight change, percent weight change, or change in body fat or lean mass from preseason to midseason or midseason to competition.

Conclusions: Division 1 wrestlers lose 8-10 pounds (5-6% BW) primarily via dehydration on average before every competition. For every percent weight loss, wrestlers had 8% increased hazard of injury during competition. There was no significant difference in weight loss or change in body composition from the preseason to midseason between injured and non-injured athletes. Degree of weight cutting was not associated with win percentage.

Significance: Degree of weight cutting increases the risk of in-competition injury among collegiate wrestlers and does not confer a performance advantage. Organizations responsible for student-athlete wellbeing should consider rule changes to make wrestling safer.

Acknowledgements: he authors would like to acknowledge the Sports Medicine staff at the University of Wisconsin-Madison Division of Intercollegiate Athletics for their commitment to the welfare of the student-athletes and contributions to the Badger Athletic Performance Program.

Return to Play After ACL Injury is Related yo Neurocognitive Performance and Modified by Sex

Primary Author/Presenter: Daniel C. Herman, MD, PhD

Troy Hamner, BS, Whitman Wiggins, BS, and James R. Clugston, MD, MS

Affiliation: University of California at Davis Department of Physical Medicine and Rehabilitation, Sacramento, California.

Assigned #: R2022-0200

Presentation Type: Podium

Purpose: ACL injury (ACL-I) risk has been shown to be related to poor neurocognition; however, the influence of neurocognition on time to return to play (T-RTP) is unknown. The purpose of this study was to determine the relationship of neurocognitive performance on T-RTP after ACL-I in collegiate athletes.

Methods: Athlete training room records for 2005-06 to 2015-16 were reviewed at a D-I institution for cases of ACL injuries. Neurocognitive performance was determined using pre-season ImPACT testing. Pearson's r and multiple linear regression analyses were used to determine the relationship of Verbal Memory, Visual Memory, Visual Motor Speed, and Reaction Time composite scores with T-RTP (alpha < 0.05).

Results: Eighty athletes (Male: N= 46, Age= 19.5 ± 1.3yrs, Ht= 73.6 ± 2.1in, Wt= 222.8 ± 39.2lbs; Female: N= 34, Age= 19.0 ± 1.2yrs, Ht= 66.5 ± 3.8in, Wt= 142.3 ± 18.7lbs) were included. Verbal Memory (r(78)= -0.164, p= 0.146), Visual Memory (r(78)= -0.051, p= 0.653), and Reaction Time (r(78)= 0.110, p= 0.332) did not significantly correlate with T-RTP, whereas Visual Motor Speed had a significant moderately-strong inverse association with T-RTP (r(78)= -0.502, p < 0.001). Multiple regression analysis indicated that the model was a significant predictor of T-RTP (F(4,75)= 6.398, p < 0.001) and explained 25.4% of T-RTP variance, with Visual Motor Speed as the only significant contributing variable (B= -4.36, p < 0.001). Post-hoc regression analyses by sex demonstrated a greater influence of Visual Motor Speed on T-RTP in female athletes (R^2= 0.415; F(4,29)= 5.140, p= 0.003; B= -6.26, p < 0.001) than in male athletes (R^2= 0.267; F(4,41)= 3.732, p= 0.011; B= -2.61, p= 0.039).

Conclusions: Visual Motor Speed is predictive of T-RTP after ACL-I, with each additional point of performance equating to a reduction of 4.36 days in T-RTP. This relationship is modified by sex, with each additional point of performance equating to a reduction of 6.26 days in female athletes, but only 2.61 days in male athletes. Studies are needed to investigate the relationship of neurocognition with functional outcomes and rehabilitation approaches.

Significance: This is the first study demonstrating a relationship between neurocognitive performance and T-RTP after ACL-I. Neurocognitive performance may have utility in predicting rehabilitation needs after ACL-I in collegiate athletes.

Acknowledgements: The authors would like to acknowledge the assistance of the University of Florida University Athletics Association with this research.

Injury Patterns in United States High School Swimming snd Diving

Primary Author/Presenter: Steven Jow, MD

Eleanor Belilos, BA and Matthew Maxwell, MD

Affiliation: MedStar Health/Georgetown-National Rehabilitation Hospital, Washington, DC.

Assigned #: R2022-0078

Presentation Type: Podium

Purpose: Despite the increasing availability of high school swimming and diving, research with respect to injuries within this age group is limited. This study describes injury patterns across high school swimmers and divers with respect to demographic exposure data and injury-specific characteristics.

Methods: A retrospective epidemiological analysis of injury and exposure data between 2008-2019 was conducted by analyzing an internet-based data collection tool used in National High School Sports-Related Injury Surveillance Study. Aims of this study were to calculate overall injury rates, compare injury rates by sex and practice versus competition, and examine patterns in injury characteristics.

Results: From 2008-2019, there were 563 swimming and diving injuries that occurred during 2,171,260 athlete exposures (0.26 per 1000 athlete exposures). Injury rates were higher in practice versus competition. Girls had higher injury rates than boys overall (rate ratio 1.57, p < 0.05), in practice (rate ratio 1.53, p < 0.05), and competition (rate ratio 1.81, p < 0.05). The majority of injuries were to the upper extremity with shoulder being the most commonly injured body part (41%) in boys and girls. Among swimmers, injuries were most commonly sustained in the freestyle event, but this was not statistically significant. Amongst divers, the head/face was the most common injured body part and concussion was the most common injury (32%).

Conclusions: Girls had statistically significantly higher injury rates than boys overall, in practice, and in competition. Consistent with studies of collegiate swimmers, stroke specialty in high school swimmers was also not significantly associated with any increase in injury risk. Coaches and athletic trainers should also be aware of the most common injuries seen in high school swimmers and divers, respectively.

Significance: Injury rates of high school swimming and diving varied by event, sex, and competition versus practice. Targeted strategies for injury prevention should be implemented given the differences in injury patterns.

Acknowledgements: We would like to acknowledge our biostatisticians Sameer Desale and Kavya Sanghavi for their assistance with statistical analyses.

Effects of Surgical Mask Use During Isokinetic Strength Testing

Primary Author/Presenter: Matthew Kampert, DO, MS

Matthew Kampert, DO, MS, Jacob Barkley, PhD, and Bailey Lanser, DPT, LAT

Affiliation: Cleveland Clinic, Cleveland, Ohio.

Assigned #: R2022-0124

Presentation Type: Podium

Purpose: To investigate the effects of wearing a surgical face mask(SM) while performing resistance exercise(RE) on total work(TW), peak heart rate(HRpeak), %oxygen saturation (SpO2) and breathing discomfort (BD).

Methods: A cross-over study design was utilized in which 20 participants completed a RE protocol utilizing an isokinetic testing system on 2 separate days, once with no mask(NM) and once with SM. For each leg, 3 sets comprised of 5 repetitions set to 60 degrees per second of an isokinetic, concentric knee extension and flexion. Each set was followed by a 90 second period of recovery.

Results: Descriptive statistics were used to characterize the patient cohort (n=20, female 55%), with a mean age of 38 ± 12. There was no statistically significant difference between the mean TW performed 1095.67 ± 354.39, 1073 ± 328.47 joules for M and NM, respectively (t=0.528,p=0.604), mean HRpeak obtained, 123 ± 5.02, 124 ± 3.65 for M and NM, respectively (t=0.329,p=0.746), or mean SpO2, 98.1% ± 0.60, 97.6% ± 0.94 for M and NM, respectively (t=2.236, p=0.038). However, there was statistically significant difference between the mean BD score, 3.30 ± 2.41, 2.00 ± 1.95 for M and NM, respectively (t=2.56, p=0.019). The overall effect of mask condition on continuous variables of these physiological and psychological responses were analyzed using a paired sample t-tests. Two-tailed significance will be determined using an alpha level set at p < 0.05. Analyses was performed using SPSS statistical software.

Conclusions: This crossover trial found that perceived breathing resistance during RE is uniquely and significantly elevated when RE is performed while wearing a surgical mask. Performing RE with a mask did not yield lower TW or SpO2, nor did it cause an elevation in HRpeak. To our knowledge this is the first study to assess the effects of wearing protective nose and face covering on resistance exercise capacity, HR, SpO2, and BD.

Significance: Our findings could be utilized to potentially decrease the closure of fitness facilities by adopting universal mask recommendations, when appropriate during resistance exercise. With the emergence of COVID-19 variants, this is more urgent than ever.

Acknowledgements: Cleveland Clinic Sports Medicine and Physical Therapy Department for their support in conducting this research.

Second ACL Injury and Motion Analysis Scores Following ACL Reconstruction and Return to Sport in Pediatric Athletes

Primary Author/Presenter: Ryan Kelln, DO

Mia Katzel, DPT, Adriana Conrad-Forrest, MS, Curtis VandenBerg, MD, and Tishya Wren, PhD

Affiliation: Children's Hospital Los Angeles, Los Angeles, California.

Assigned #: R2022-0194

Presentation Type: Podium

Purpose: This study examines reinjury patterns following return to sport (RTS) for pediatric athletes with anterior cruciate ligament reconstruction (ACLR).

Methods: Patterns of RTS and subsequent knee injury were examined for 56 pediatric athletes (37 female; mean age 14.5 years, SD 2.4, range 7-20) who had undergone primary unilateral ACLR and motion analysis testing prior to RTS and were able to be contacted by phone or email or were subsequently seen in our hospital system allowing surveillance for second knee or ACL injury.

Results: Of 232 patients seen for motion analysis testing post-ACLR, follow-up data were obtained for 56 (24%). 93% of these patients (52/56) returned to sport an average of 12.6 months (SD 5.9, range 6-35) post-surgery. Of those who RTS, 26 suffered a subsequent knee injury, including 23 ACL injuries and 3 isolated meniscus tears. The side of ACL injury was 43% (10/23) ipsilateral and 57% (13/23) contralateral. The mechanism of injury was primarily non-contact (14/23, 61%), with 22% (5/23) being contact and 13% (3/23) indirect contact. Average time from surgery to second ACL injury was 19.3 months (range 8.9-37.1). Patients with subsequent knee or ACL injury did not differ significantly from those without subsequent injury in terms of time from surgery to RTS (p > 0.58). Biomechanical scores were similar between the ACLR and contralateral sides (p = 0.52) but were lower for patients who went on to a second ACL or knee injury compared with patients who remained injury free (p ≤ 0.05).

Conclusions: This study provides preliminary evidence that biomechanical scores from motion analysis testing may be predictive of risk of second ACL injury. The injury rate was likely overestimated in our study cohort since patients were more likely to be included if they returned to our hospital for a subsequent injury. However, for those able to be followed, motion analysis scores tended to be lower for those who went on to a second ACL or knee injury.

Significance: This type of surveillance to track injuries after RTP is needed to determine risk factors for second ACL injury. Motion analysis may reveal risk factors that are not currently recognized which could be improved by targeted biomechanical training.

Follow-Up of Cardiac Abnormalities after COVID-19 Infection in NCAA Athletes

Primary Author/Presenter: Catherine Kirbos, MD

Scott Meester, MD, Aaron Monseau, MD, FACEP, Brenden Balcik, MD, and Nicholas Chill, MD

Affiliation: WVU Sports Medicine, West Virginia University - Morgantown, West Virginia.

Assigned #: R2022-0182

Presentation Type: Podium

Purpose: Pericardial and myocardial enhancement has been found in patients after COVID-19 infection. This study aims to identify follow-up cardiac magnetic resonance imaging (CMR) after clinical resolution of COVID-19 in athletes who had CMR abnormalities on initial workup.

Methods: Cohort study of 19 student athletes who were found to have CMR abnormalities as part of initial clearance protocol which was in place for all our athletes after COVID-19 infection. All 19 had follow-up imaging between three and nine months later to assess for change post-COVID infection and return to sport.

Results: Of 19 athletes in the study (mean age 19; 89% male), 13 (68%) had symptomatic infection, while 6 (32%) were asymptomatic. On initial CMR, 14 athletes had pericardial effusion. One athlete showed decreased left ventricular ejection fraction (LVEF), while two athletes showed decreased right ventricular ejection fractions. Pericardial involvement was seen in 9 (47%) athletes, and myocardial involvement was noted in 4 (21%) athletes. Two (11%) athletes exhibited both pericardial and myocardial involvement. Native T1 values were measured and within normal range for all athletes. Repeat CMR showed abnormalities in 5 (26%) athletes. One had a new decrease in LVEF. Pericardial involvement was seen in 4 (21%) athletes with two new and two persistent but improved. One athlete had new myocardial involvement that was not present on initial CMR. The remaining athletes showed no residual myocardial involvement. There were no significant differences noted in native T1 measurements on repeat CMR.

Conclusions: Of 19 athletes who had abnormalities on initial CMR, a quarter had abnormalities on repeat CMR. Only one athlete showed evidence of myocarditis that wasn't present on initial imaging. There was no significant change among native T1 measurements. There are reasonable concerns regarding cardiac health of athletes infected with COVID-19. Additional studies are needed on the clinical implications of cardiac abnormalities after COVID-19 in athletes.

Significance: As we continue to uncover effects of COVID-19 in athletes, it appears there may be lasting effects on CMR and even new findings on follow-up imaging. Further study is needed to quantify the clinical impact of these findings.

Acknowledgements: WVU Athletics; Athletic Training Staff.

Non-COVID Cardiovascular Pathology from Return-to-Sport Cardiac Screening in College Athletes after SARS-CoV-2 Infection

Primary Author/Presenter: Christian Klein, MD

Bradley Petek, MD, Nathanial Moulson, MD, Aaron Baggish, MD, Timothy Churchill, MD, Kimberly Harmon, MD, Stephanie Kliethermes, PhD, and Jonathan Drezner, MD

Affiliation: Department of Medicine, University of Washington, Seattle, Washington.

Assigned #: R2022-0018

Presentation Type: Podium

Purpose: Concerns for cardiac involvement after SARS-CoV-2 infection led to widespread cardiac testing in athletes prior to a return-to-sport. The purpose of this study was to examine non-COVID cardiovascular pathology in college athletes undergoing cardiac screening after SARS-CoV-2 infection.

Methods: The Outcomes Registry for Cardiac Conditions in Athletes captured testing and outcomes data from 45 institutions 9/2020-6/2021. Athletes with an electrocardiogram (ECG) and transthoracic echocardiogram (TTE) and no preexisting condition were included. Findings were defined as major (associated with SCD or required intervention), minor (warranted surveillance), or incidental (no follow-up needed).

Results: 2900 athletes (mean age 20 ± 1, 32% female, 64% white, 27% black) were screened with both ECG and TTE. 35 (1.2%) athletes had an abnormal ECG. Of these, 33 (94.3%) had a normal TTE, and 2 (5.7%) had an abnormal TTE and were diagnosed with a cardiomyopathy (hypertrophic-1, dilated-1). One athlete with a normal TTE had atrial fibrillation and required cardioversion. 2865 (98.8%) athletes had a normal ECG, of whom 2811 (98.1%) had a normal TTE and 54 (1.9%) had an abnormal finding on TTE. Of these 54 with an abnormal TTE, 3 (5.6%) had aortic root dilatation ≥40 mm, 15 (27.8%) had minor structural abnormalities, 25 (46.3%) had incidental findings, and 11 (20.4%) had false-positive results with subsequent normal testing. Overall, 6 (0.2%) athletes had major cardiac conditions. The sensitivity/specificity for major cardiac conditions were 50%/98.9% for ECG and 83.3%/98.2% for TTE. Coronary anatomy and aortic dimensions were inconsistently reported; thus, pathology may have been missed.

Conclusions: In college athletes undergoing post-COVID cardiac testing, major non-COVID cardiovascular pathology was identified in 1 in 500 athletes. In athletes with a normal ECG, the added value of TTE was limited to pathologic aortic root dilatation in approximately 1 in 1000 athletes and minor structural abnormalities warranting surveillance in approximately 1 in 160 athletes. Two-thirds of abnormal TTE findings were incidental or false-positive results.

Significance: Cardiac testing after COVID-19 or during routine screening will detect undiagnosed cardiac conditions. Given the resources needed to perform TTE and the high proportion of incidental or false-positive results, more study is needed to define its role.

Acknowledgements: Special thanks to the collaborators for the ORCCA registry.

Attitudes and Opinions Regarding Female Sports Medicine Physicians During Pregnancy and the Postpartum Period

Primary Author/Presenter: Yuka Kodama, MD, Yuka Tsukahara, MD, PhD

Melissa Novak, DO, Irfan Asif, MD, Seira Takei, MD, PhD, and Carly Day, MD