TOPIC: Epidemiology

STUDY: Other

Snowboarding Versus Surfing-Related Injuries in the United States Emergency Departments 2012-2021

Primary Author/Presenter: Petra Abou lhosn, MD

Nick Thornton, MD, Anusha Lekshminarayanan, MD, and Shane M. Drakes, MBBS

Affiliation: NYMC/Metropolitan, New York City, New York.

Purpose: Board sports including snowboarding and surfing have gained immense popularity. Snowboarding and surfing are considered extreme sports. While one is dependent on land and snow, the other relies on water waves. Understanding the mechanisms for injury could provide insight for safety recommendations.

Methods: Data on 6098 snowboarding and 1847 surfing-related injuries contained within the National Electronic Injury Surveillance System over a 10-year period (January 2012-December 2021) were analyzed.

Results: On comparison of injuries sustained while snowboarding versus surfing, injuries were most common among the 11 to 20 age group for both (51.6% vs 28.8%), followed by 21 to 30 age group (30.2% vs 20.6%). Male injuries dominated in snowboarding and surfing (73.1% vs 73.7%). Caucasian participants sustained the most injuries (64.8% vs 50.7%). Injuries to the wrist (18.0%), head (17.8%), and shoulder (16.8%) were the most common in snowboarding. Injuries to the head (12.9%), face (12.2%) and foot (10.3%) were the most common in surfing. Fractures (34.7%) were the most common injuries in snowboarding, followed by strains/sprains (20.9%) and concussions and contusions (9.8%). While lacerations were the most common type of injury in surfing (26.5%) followed by strain/sprain (16.4%) and fracture (15.2%).

Conclusions: Injuries were common among young Caucasian males. Head injuries were commonly noted in either sport Lacerations are the most common type of injury among surfers likely due to environmental hazards, sharp edges on the surfboard, reef, and lack of protective equipment. In contrast, fractures were the most common in snowboarding, likely because of the speed able to be achieved while riding combined with the terrain- hard snow, rocks, trees and ice.

Significance: Helmets, elbow, knee, and wrist pads may serve to protect snowboarders from fractures. Surfers may benefit from placing protective barriers on the sharp edges of their surfboard such as the nose and fins to prevent lacerations.

Acknowledgments: Thank You Dr Drake and Dr Lekshminarayanan for your support of metropolitan residents with sports medicine interest

TOPIC: Pediatrics

STUDY: Cohort

Concussion Trends in Pediatric Sports Medicine During the COVID-19 Pandemic in Florida

Primary Author/Presenter: John Anderson, DO

Sarah Irani, MD, Lauren Irwin Harper, PhD, Danielle Ransom, PsyD, and P. Patrick Mularoni, MD

Affiliation: Johns Hopkins All Children’s Hospital, St. Petersburg, Florida.

Purpose: Florida allowed for return to sport in both high school and recreational leagues earlier than most of the United States after COVID lockdowns. This study aims to evaluate trends in concussion in the year preceding and during the COVID-19 pandemic.

Methods: Demographic characteristics were extracted as part of a retrospective chart review of youth (M = 15.74, SD = 1.91) diagnosed with concussion in a sports medicine specialty clinic. Subjects were included if concussion was diagnosed within one of 2 date ranges: (1) March 15, 2019 to March 15, 2020 (Pre-COVID-19 Pandemic cohort) or (2) March 16, 2020 to March 16, 2021 (COVID-19 Pandemic cohort).

Results: Fewer patients presented with concussion in the Pandemic cohort (n = 244) compared with the Pre-Pandemic cohort (n = 419). Results of χ2 analyses did not demonstrate statistically significant group differences in sex, type of insurance, and injury mechanism (all P values were greater than 0.05). Analyses exploring race/ethnicity indicated significant differences between cohorts, with significantly more subjects opting not to report race/ethnicity in the Pandemic Cohort in comparison to the Pre-Pandemic cohort. Additionally, results of t-tests comparing group differences in age, time from injury to clinic presentation, and time to recovery revealed no significant differences between the groups (all P values were greater than 0.05).

Conclusions: Although fewer patients presented with concussion during the first year of the COVID-19 pandemic in comparison to the previous 12 months, we did not observe statistically significant differences in demographic characteristics of those patients presenting for evaluation. Furthermore, there was no measurable variation in time to clinic presentation and time to recovery, despite the lockdown, when compared to prior to the pandemic.

Significance: Findings are not consistent with reported pediatric pandemic-related trends in disparate access to care based upon demographics. Further work is needed to understand the role of social determinants in concussion care access and recovery.

Acknowledgments: Research funding support was provided by the Kart for Kids Concussion Initiative. Research assistant, Katelyn Heinz, ATC.

TOPIC: Other

STUDY: Survey

Diet Tracking App Use Not Associated With Disordered Eating Risk in Division I Athletes

Primary Author/Presenter: Sydney Asselstine, MD

Jill Kropa, MD and Jason Womack, MD

Affiliation: Rutgers RWJMS Sports Medicine Fellowship, New Brunswick, New Jersey.

Purpose: This pilot study aimed to determine if use of diet tracking apps by division I athletes was associated with screening positive for disordered eating compared to those not using them. Frequency and motivation for use were also examined for correlation with disordered eating as secondary endpoints.

Methods: Current division I athletes over 18 years old were invited to complete an anonymous electronic survey that assessed their use of diet tracking apps as well as the Brief Eating Disorder in Athletes Questionnaire (BEDA-Q), a validated screening tool for disordered eating. All participants received referral information for eating concerns. Statistical analysis was applied using Microsoft Excel.

Results: Seventy-two student athletes completed the survey; 55 females and 17 males, ages 18-23, ranging across 11 teams. Of these, 24 athletes (33.3%) acknowledged use of diet tracking apps in the past 6 months. Additionally, 34 athletes (47.2%) screened positive for disordered eating; 30 females, and 4 males represented from 9 teams. There were 13 of these positively screened athletes (38.2%) that used diet tracking apps, however this association was not significant (P = 0.40). Additionally, there was no significant correlation between frequency of app use and BEDA-Q score. There was a significant association between those that were currently dieting and using diet tracking apps (52.2% of 23 athletes, X2 5.4, P < 0.05). Most common reasons for app use included to lose weight (50% of users), to ensure adequate caloric intake for energy expended, and to maintain weight; the majority of app users who screened positive for disordered eating were motivated to lose weight (69.2%).

Conclusions: Use of diet tracking apps, regardless of frequency, does not increase risk for disordered eating in division I athletes based on this preliminary data. Athletes currently dieting may be more likely to use these apps. Common motivators for use were to lose weight, to ensure adequate caloric intake, and to maintain weight. Athletes with disordered eating may be motivated to use these apps to lose weight.

Significance: Diet tracking apps can be utilized by athletes without increasing risk for disordered eating. Healthcare providers may opt to use these apps to assess or manage eating habits in athletes without contributing to disordered eating behaviors.

Acknowledgments: Thank you to the Rutgers University Athletic Department and Sports Medicine Department for their support of this project.

TOPIC: Musculoskeletal

STUDY: Survey

Needs Assessment of Common Injuries in Freestyle Soccer

Primary Author/Presenter: Peter Azzam, MD

Andrew Nobe, MD

Affiliation: UCI Family Medicine Residency, Irvine, California.

Purpose: To identify common injuries among freestyle soccer athletes and initiate serve as a precursor to further research in this sport.

Methods: A 10-question survey was designed and sent to freestyle soccer athletes via email, text message, and social media.

Results: The most common injury reported by the 45 survey respondants was hip/groin injury (about 21), followed by knee injury (About 11), spine (neck and lower back; about 7), ankle (about 6), and loss of muscle memory impeding sport performance (3). The last condition was described by a few athletes and involved the sudden regression of muscle memory and an inability to continue juggling the soccer ball; this condition always involved one ankle and significantly limited performance. The vast majority of injuries described were chronic overuse injuries.

Conclusions: Among survey participants, the most common freestyle soccer injuries were hip/groin injuries, followed by knee injuries, neck/back injuries, ankle injuries, and a syndrome involving regression of muscle memory. The vast majority of these were chronic overuse injuries as opposed to acute injuries.

Significance: This initial needs assessment provides a basis for common injuries in freestyle soccer, which can serve as a springboard for further research in this sport.

Acknowledgments: UCI Family Medicine Residency and Sports Medicine Track Andrew Nobe, MD, director of UCI Sports Medicine Track Christopher Kroner, MD, and Brian Kim, MD, sports medicine faculty at UCI Health and close mentors of mine UCI Family Medicine Faculty.

TOPIC: Running

STUDY: Survey

Runner Health Promotion and Injury Prevention: Current Practices and Interest of Recreational Runners

Primary Author/Presenter: Dylan Bennett, MD

Brett Toresdahl, MD, Mark Fontana, PhD, Joseph Janosky, DrPHc, MSc, PT, ATC, and Elizabeth Fierro, DO

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

Purpose: The purpose of this study was to measure the interest of runners in health promotion, as well as to understand runners' current injury prevention strategies and sources of information.

Methods: An electronic survey was distributed by email to runners who recently participated in running medicine research studies. Inclusion criteria included age 18+, participation in 1+ road race in the past year, or plan to participate in 1+ race in the upcoming year.

Results: A total of 238 runners participated, mean age 46.5(standard deviation [SD] 23.8), 49% women, with 43% having experienced an injury in the past year. Staying injury free was rated as very important by 198/231 (86%), whereas achieving a goal finishing time was rated very important by 38/238 (16%). Most runners (181/230, 79%) are willing to invest 90 min/wk in rehab-type exercises for an absolute risk reduction (ARR) for injury of 5%. A third of runners (69/213, 32%) are willing to modify their training and accept a slower race finishing time (15 minutes slower for marathon, 7.5 minutes for half) for an ARR of 5%. Current injury prevention strategies used by runners include the following: rehab-type exercises/strength training (119/228, 52%), specific shoes/orthotics (91, 40%), and supplements (82, 36%). The most common sources of injury prevention information used by runners are the internet (167/231, 72%), physical therapists (102, 44%), and friends (93, 40%).

Conclusions: Health promotion and injury prevention is very important to runners, and they are willing to invest significant time in exchange for a modest decrease in injury risk. While most runners do not rate race performance as very important, fewer runners are willing to prevent injury by modifying their training if it has a negative impact on their race performance.

Significance: Given the high rate of injuries experienced by runners, there is both a need for and an interest in health promotion/injury prevention programs. The results of this study will help guide the creation of future running injury prevention interventions.

TOPIC: Education

STUDY: Survey

Educating Trainees on Pre-Participation Physicals of the Special Olympics Athletes—An Evaluation

Primary Author/Presenter: Greta Bires, MD

Allison Casola, PhD, MPH, MCHES, Caitlyn Haines, MD, Jeremy Close, MD, MPH, and Mary Stephens, MD, MPH

Affiliation: Thomas Jefferson University Hospital.

Purpose: Patients with intellectual and developmental disabilities (IDD) experience several obstacles accessing quality health care, compounded by lower physical activity levels. Increasing provider knowledge including dedicated training on considerations for physical activity participation is key.

Methods: Students participated in a round robin case-based discussion to introduce and familiarize them with the pre-participation evaluation including special considerations for those with IDD. Participants were invited to complete a brief, mixed-methods, post-event feedback survey. Data were exported from Qualtrics into Excel for cleaning and analysis.

Results: Twenty medical students and 5 faculty participated with 15 completing the post-evaluation survey (70%). Seven (46.67%) were very satisfied and 8 (53.55%) were satisfied with the event with 15 (100%) want to attend future workshops. Participants reported that working through the cases with discussions and hearing firsthand experiences from the facilitators was the most enjoyable aspect of the event. The participants were surprised by many things including that “patients with epilepsy can be cleared to swim,” “the level of clearance you can comfortably give to even patients with some complicated medical history,” and how many sports (especial power lifting) are available through the Special Olympics. They also expressed interest in learning more about “common physical comorbidities to look for in those with IDD,” “common adaptive equipment for those with IDD” and “how medical students can best support those with IDD.”

Conclusions: We created an event that increased medical students' interest in the care of those with intellectual and developmental disabilities. All students were satisfied with the event and expressed interest in learning more on this and other related topics. The high likelihood they would attend another event highlights a potential opportunity to create or develop additional courses, workshops, or electives that expand on care of patients with IDD.

Significance: This novel event introduced trainees to caring for patients with IDD; a prominent gap in current medical education and training. There is potential to replicate this event at medical schools around the country to reach more students.

Acknowledgments: We would like to acknowledge the Special Olympics for their support with this event.

TOPIC: Other

STUDY: Survey

A Multi-Institutional Cross-Sectional Survey of Nutrition Knowledge in NCAA Division I Athletes

Primary Author/Presenter: Alexandra Bray, MD

Sydney Burger, BS and Brian Young Kim, MD, MS

Affiliation: OHSU Hillsboro Family Medicine Residency, Portland, Oregon.

Purpose: To better understand current trends in collegiate athlete nutrition knowledge (NK) across multiple institutions and sports, through subgroup analyses of responses to the Abridged Nutrition for Sport Knowledge Questionnaire (A-NSKQ).

Methods: Collegiate athletes completed a survey consisting of demographic questions and the validated Abridged Nutrition for Sport Knowledge Questionnaire (A-NSKQ). Leanness versus non-leanness sport designation was determined using the classification from Torstveit and Sundgot-Borgen (2005). Total and subgroup analyses were performed using t-test and ANOVA.

Results: One hundred eighty-nine athletes from 3 NCAA division I institutions completed the survey (66.5% completion rate, 64.6% female, 18 sports represented). Mean A-NSKQ score was 15.4 ± 4.3 (max possible score 35). There was no significant difference in A-NSKQ scores between genders (females 15.7 ± 4.3, males 14.8 ± 4.2, P = 0.2) There was no significant difference in A-NSKQ scores between athletes in leanness versus non-leanness sports (15.7 vs 15.1, P = 0.4). Prior to completing the A-NSKQ, 36.5% of participants rated their NK as good or excellent. After completing the A-NSKQ, 13.2% rated their NK as good or excellent. There was a significant difference between A-NSKQ scores in individuals who had prior nutrition education versus those who did not (16 vs 14.6, P = 0.02). A site effect was observed, with a mean difference of 3 points separating the highest- and lowest-scoring sites (P < 0.001).

Conclusions: Mean A-NSKQ scores in this population were similar to those previously reported. Both male and female athletes demonstrated poor NK. Completing the A-NSKQ seems to have changed athlete perception of their NK. There was no significant difference in NK between gender, or between leanness versus non-leanness sports. Athletes with prior nutrition education may have retained this knowledge, demonstrated by higher A-NSKQ scores.

Significance: Nutrition is an important component of athlete health. Notably, athletes with prior nutrition education had higher NK. Future research should focus on how to disseminate nutrition information to athletes in a meaningful and effective manner.

Acknowledgments: We thank the Medical Student Research Program at UC Irvine School of Medicine for their support.

TOPIC: Other

STUDY: Survey

ART (Assessment, Recognition, Treatment) Pilot to Identify Athletes at Risk for Mental Health Symptoms

Primary Author/Presenter: Jason Brayley, MD

Jennifer Salib, PsyD and Andy Ma, MD

Affiliation: Greater Sacramento Valley Family Medicine Residency Program, Sacramento, California.

Purpose: Ninety-day quality improvement pilot: (1) Identify patients at risk or experiencing mental health symptoms; facilitate timely connection to resources; routinely screen all new patients (2) Understand the demand for mental health services (3) Add to the scholarly literature.

Methods: When rooming the patient, MA read brief script introducing the mental health screening tool; patient completed form; physician reviewed; if score below threshold of concern encouraged patient try free digital therapeutic mindfulness app & reminded patient how to access mental health support. Elevated scores referred to psychologist for further evaluation with language that normalized & encouraged.

Results: One hundred four patients referred to psychologist for further evaluation; 4 declined services. One hundred (70 children & 30 adults) contacted; 88 (64 children & 24 adults) had single outreach consultation; 12 (6 children & 6 adults) received additional follow up care; 25 had history of previous mental health treatment. Soccer (17) & basketball (12) were the most common sports, followed by dance (7) & softball (6). Twenty-nine patients noted they were multisport athletes. Physicians surveyed about their comfort & experience; all reported some specialty training in behavioral health. Half reported discomfort screening for mental health needs without a tool; most somewhat comfortable screening with a tool; less than half reported comfort providing psychoeducation to athletes endorsing mild to moderate mental health concerns; most were comfortable suggesting digital therapeutic apps; all reported comfort referring to mental health services; most mentioned concern about availability of mental health services.

Conclusions: Acknowledging mental health as part of whole health is essential and an important message that sports medicine physicians can emphasize to athletes. Routinely screening for mental health symptoms can reinforce that mental health & physical health are inextricably linked. Continuing to destigmatize mental health and normalize athletes seeking help is crucial. Our quality improvement pilot identified a demand for & method to do this important work.

Significance: Prevalence of mental health concerns among athletes is substantial & similar to the general population, however athletes are less likely to seek help. More work must be done to shift this culture, and there is opportunity to include sports physicians.

TOPIC: COVID

STUDY: Cohort

How Compressed Sports Seasons in High School Athletics, Due to COVID, Impacted Injury Rate and Severity of Injuries

Primary Author/Presenter: Breanne Brown, DO, CAQSM, FAAFP

Eric Marchek, MPT, PT, CSCS

Affiliation: Providence St Joseph Health, Portland, Oregon.

Purpose: To evaluate the injury rate during a compressed sports season with COVID 19 compared to a normal sports season with preseason leading up to competition in high schools with employeed ATCs. These findings can help with injury prevention in the future for student athletes.

Methods: Injuries and treatments provided are documented by the athletic trainers at the schools. With the use of Healthy Roster as an EMR, we can track injuries and treatments in this population. This data was used to compare injury rates from past sports seasons to the condensed season. These condensed seasons occurred following activity stoppage from March 2020 to March 2021 due to COVID-19.

Results: Data was gathered using Healthy Rosters as an EMR platform. Injury and treatment data was input and collected from 14 Providence school-based athletic trainers with schools that had condensed seasons. 1 concussions (compared to 24 in 12-week season) 17 dislocations (compared to 12 in 12-week season) A total of 1588 injuries were documented over a 7-week period beginning March 1, 2021. This represented 44% of all injuries in a normal 42-week school year. 16006 total treatments were recorded in the 7-week period. This represents 78% of all treatments in a normal school year 65 fractures (compared to 50 in 12-week season).

Conclusions: The rate, incidence and severity of injuries was increased with a compressed sports season. Factors contributing to this may be reduced activity during COVID restrictions, lack of pre-season conditioning and limited access to indoor facilities/regular training opportunities in the year prior to the condensed seasons. Most schools included in the data are public high schools who may lack resources a funds which may impact their fitness & wellbeing

Significance: Higher injury rate and a condensed sports season can lead to more athletes leaving sports which has significant impacts on future physical and mental wellbeing. Knowing this can help implement infracstructure to limit injuries and support athletes.

Acknowledgments: Tom Burton, Director of Operations Ortho/Neuro Institute; Joel Marick, Lead ATC Oregon region; Keith Eggleston, Lead athletic trainer, Spokane Region; Rebecca Valderrama, Senior Program Manager, System Orthopedic and Sports Medicine Institute.

TOPIC: Pediatrics

STUDY: Other

Recurrence Rate of Ganglion Cysts of the Wrist and Hand After US Guided Aspiration in Pediatric and Young Adult Athletes

Primary Author/Presenter: Douglas Bryant, MD

Paige Chase, MD and Stephen Schaaf, MD

Affiliation: Vanderbilt University Medical Center, Nashville, Tennessee.

Purpose: Describe the recurrence rate of ganglion cysts of the wrist and hand after ultrasound guided aspiration in pediatric and young adult athletes which has not been reported. Additional outcomes include symptom resolution, return to sport, and complications following treatment.

Methods: This study is a case series examining 5 pediatric and young adult athletes with ganglion cysts of the wrist/hand seen in a PM&R sports medicine clinic by a single ACGME sports medicine fellowship trained physician. Each athlete was treated with an US-guided aspiration with or without an injection of corticosteroid (1 mL of Kenalog 40 mg) following aspiration. Data was obtained via chart review.

Results: Median age of the athletes was 17, with a range of 14 to 23. There were 2 female and 3 male athletes. The sports that these athletes participated in included lacrosse, bowling, track and field, softball, and gymnastics. Two cysts emanated from the dorsal scapholunate interval, 2 from the dorsal radiocarpal joint, and one dorsal between the dorsal third and fourth metacarpal space. The mean size of the ganglion cysts was 1.76 cm, with a range of 1.4 cm to 2 cm. All 5 athletes had a successful ultrasound-guided aspiration of their ganglion cyst. Three of the 5 athletes received an injection of corticosteroid. Following their procedure, all patients reported resolution of their wrist or hand pain and were able to return to full participation in their respective sports. There were no post-procedure complications noted. One of the 5 athletes had recurrence of their symptoms and ganglion cyst as confirmed on ultrasound at secondary follow up at 307 days.

Conclusions: Our study demonstrated a 20% recurrence rate of ganglion cysts in the wrist and hand in pediatric and young adult athletes following US-guided aspiration. All athletes had symptom resolution and returned to sport immediately following their procedure. Thus, US-guided aspiration is an effective and safe treatment option for ganglion cysts of the wrist and hand in pediatric and young adult athletes. Further studies on a large scale are indicated.

Significance: The best management strategy of wrist and hand ganglion cysts in pediatric and young adult athletes remains underreported. Non-operative intervention including US-guided aspiration is beneficial and has advantages over operative management.

Acknowledgments: Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center.

TOPIC: Education

STUDY: Survey

Trauma Informed Sport Mobilizing Trauma Informed Practice into Action

Primary Author/Presenter: Beatrice Caballero, MD

Ashwin Rao, MD, FAMSSM and Bridget Whelan, MPH

Affiliation: University of Washington, Seattle, Washington.

Purpose: Childhood trauma is a pervasive public health issue thought to have significant impact on sport performance. This study measured the level of understanding of trauma informed sport among high school (HS) coaches and athletic trainers and assessed the need for education on trauma-sensitive practices.

Methods: HS coaches and trainers (>18 years old) from the Seattle metropolitan area completed a survey between December 2021 and June 2022. Primary outcomes were understanding of trauma-informed sport and adverse childhood experiences (ACEs). Secondary outcomes were level of comfort providing resources for trauma-exposed athletes, interest in training, and barriers to receiving training in trauma-informed sport.

Results: Among the 45 participants (36 coaches, 9 athletic trainers), 69% (n = 31) either “disagree or strongly disagree” with understanding the meaning of trauma-informed sport and 73% (n = 33) of participants reported never applying trauma-informed practices in their career. 93% (n = 42) “agree or strongly agree” retraumatizing an already traumatized athlete in a new setting (home versus sport environment) can occur unintentionally. 87% (n = 39) were “somewhat or very comfortable” with recognizing signs of trauma in young athletes with 93% (n = 42) “somewhat or very comfortable” in referring athletes to additional resources and support systems. 96% (n = 43) participants “agree or strongly agree” there is a connection between ACEs and sports performance. 82% (n = 37) “disagree or strongly disagree” with having enough resources needed to engage in trauma-informed sport. 93% of participants (n = 42) attested they are interested in learning more about trauma-informed sport, while citing cost and time as barriers.

Conclusions: Almost all participants agree there's a connection between ACEs and sports performance and that athletes can be unintentionally triggered in a sport environment. However, nearly 70% of participants do not understand what trauma informed sport means. Only 18% have enough resources to engage in trauma informed sport. This study highlights the important role for education on structured techniques to redesign sport to counteract the impacts of trauma.

Significance: Competitive sport can trigger or amplify ACEs. It is essential to equip the youth-serving community to respond to the unique needs of trauma-exposed athletes to mitigate negative experiences while promoting positive outcomes on and off the field.

TOPIC: Rehabilitation

STUDY: Survey

Adherence to Physical Therapy in a Primary Care Residency Office

Primary Author/Presenter: Brian Chan, DO

Alana Payne, DO and Bryan Botti, MD

Affiliation: Mainline Bryn Mawr Family Medicine Residency, Bryn Mawr, Pennsylvania.

Purpose: The purpose of this study is to assess adherence rate, risk factors and reasons for nonadherence with a physical therapy regimen prescribed in a primary care setting to improve patient care.

Methods: Epic EMR was used to compile a list of 140 patients who had been given a PT referral within the last year by a single sports medicine physician in a primary care clinic. Patients were contacted by phone or portal to determine if they had attended physical therapy. Data was also collected regarding the patients' age, gender, zip code, ICD-10 code, and reason (if they had not attended PT).

Results: The data showed that knee and shoulder pathologies received the majority of PT referrals. More female patients (51%) were referred to PT than male patients (45%), and a greater proportion of patients who do not identify as male or female did not attend PT (9.1%). The average age for patients receiving a PT referral was 48.4. In general, most patients (56.7%) surveyed stated that they were adherent to PT. However, a sizeable number of patients did not reply to the survey (25.7%). Those that were not adherent (17.6%) listed time constraints (30.3%) or other factors (33.3%) as limiting their participation with self-resolving of the problem being the next most common reason (24%). Additionally, more patients of a low socioeconomic status did not attend PT (27.3%), while more patients of a high SES did attend PT (86.7%).

Conclusions: In this study of 140 patients, we found that patients in general are adherent to PT. While none of the differences between groups of risk factors in our data are statistically significant, we did have some interesting findings (P < 0.1): differences in gender and SES status. Future studies should include more patients expanding the entire practice to better assess these characteristics.

Significance: The results of this study will further enable providers at our practice to account for biopsychosocial factors that influence adherence to PT referrals and overall patient care.

Acknowledgments: Special thanks to Georgia Montone, Stephanie Kjelstrom, and Sharon Larson at Lankenau Institute for Medical Research (LIMR) for their aid in statistical analysis.

TOPIC: Concussion

STUDY: Cohort

Autonomic Pupillary Light Reflex (PLR) Markers in Patients After Mild Traumatic Brain Injury (MTBI)

Primary Author/Presenter: Alicia Chen, BS

Tyler Marx, MS, Saikaashyap Sarva, MBS, Kate Paulsen, BS, Arvind Balaji, MD, Brett Dusenberry, MD, James Dill, MD, and Mo Mortazavi, MD

Affiliation: SPARCC Sports Medicine, Rehabilitation, Concussion Center, Tucson, Arizona.

Purpose: Assess pupillary light reflex (PLR) autonomic response in mild traumatic brain injury (mTBI) in all age groups. We hypothesize that mTBIs will have a slower and smaller change in pupil size compared to non-mTBI patients.

Methods: A retrospective cohort study of 430 patients between the ages of 6 and 81 who had 1629 total clinical tests within 335 days of injury for concussive symptoms between October 28, 2019 and July 11, 2022. A standardized application was utilized at every visit to obtain PLR measures focused on maximum pupillary diameter (MaxPD) (mm), minimum pupillary (MinPD) (mm), and maximum constriction velocity (MCV) (mm/s).

Results: The data were compared to normative values from a control group totaling 4487 tests and were broken down into age ranges by groups of 12 starting with age 6 to 81. The age-correlated mean MaxPD was 6.44 ± 1.38, 5.76 ± 1.14, 5.64 ± 1.20, 5.63 ± 1.18, 5.10 ± 1.11, and 5.27 ± 1.40, MinPD was 3.97 ± 0.63, 3.74 ± 0.61, 3.63 ± 0.65, 3.66 ± 0.67, 3.38 ± 0.54, and 3.27 ± 0.57, and MCV 11.85 ± 7.37, 9.98 ± 6.12, 9.43 ± 5.94, 9.80 ± 6.83, 8.43 ± 5.06, and 8.94 ± 5.30. P-values for mean MaxPD were 0.0001, 0.4616, 0.2385, 0.0007, 0.1133, >0.0001, and 0.9023, MCV was >0.0001 × 6, and 0.0042.

Conclusions: The size of our pupils changes in the presence of light allowing us to adapt to our environment in what is known as the PLR. The presence of a PLR is indicative of an intact autonomic nervous system. PLR is potentially a quick and useful marker for post-concussive evaluation and autonomic assessment. The biomarkers MaxPD, MinPD, and MCV may be more useful in determining the concussive state of patients.

Significance: Based on our population, MaxPD, MinPD, and MCV all showed to be accurate biomarkers of suggested blunted autonomic response in patients with mTBI, with MaxPD significant in ages 54 and younger, MinPD in 3 out of 7 groups, and MCV in all age groups.

Acknowledgments: The Reflex team for the use of their technology and data for normative values.

TOPIC: Concussion

Diffusion Tensor Imaging Using 3 Tesla Magnetic Resonance Imaging in Patients With Persistent Post C

Primary Author/Presenter: Alicia Chen, BS

Alicia Chen, BS, Prem Thirunagari, BS, Hector Preciado, BS, David Lefkowitz, MD, Brett Dusenberry, MD, David Oakley, PhD, and Mo Mortazavi, MD

Affiliation: Rutgers University, New Brunswick, New Jersey.

Purpose: Using 3T MRI with DTI with respect to fractional anisotropy and mean diffusivity to highlight regional structural abnormalities and correlate with clinical tools such as CP Symptom Screening and Evoked Response Potential to understand the impact of regional injuries on concussion manifestation.

Methods: Seventy-two patients (ages 10-72) with mTBI and PPCS. 3T MRI with DTI performed under standardized protocol. DTI examined 70 ROI's, measuring fractional anisotropy (FA) and mean diffusivity (MD) per ROI >95th percentile of MD values and the <5th percentile of FA values deemed abnormal. Validated CP symptom screen and P300 Evoked response potentials (ERP) were obtained in all patients.

Results: There are 29 ROI's with ≥1 abnormal MD values, with the Anterior Thalamic Radiation, Striatal Inferior Frontal Cortex, and Corticospinal tract the most incident. Eighteen ROI's/29 ROI's with ≥1 abnormal MD values show left-right abnormality symmetry. There are 20 ROI's with ≥1 abnormal FA values, with the Forceps Major, Inferior Frontal Superior Frontal Cortex, and Superior Corticostriate the most incident. Six ROI's/20 ROI's with ≥1 abnormal FA values show left-right abnormality symmetry. Two groups were made from 72 patients; group 1(patients with ≥1 abnormal MD/FA value in any ROI) and group 2 (patients without abnormal MD/FA values in any ROI). Group 1 (n = 24) dominant concussion profiles (CP): cognitive, cervical, and vestibular. Group 2 (n = 47) dominant CP: mood, cognitive and ocular. Likewise, changes in ERP in patients with (group 1) and without abnormal (group 2) DTI findings were evaluated. Group 1, n = 24, had P300 ERP of 7.33. Group 2, n = 47, had P300 ERP of 10.48 (P-value 0.06).

Conclusions: 25/72 patients (35%) had ≥1 abnormal MD and/or FA value in 71 ROI and commonly present in specific regions. They were also associated with reduced P300 ERPs (cognitive resources) as well as the cognitive fatigue profile. PPCS is a chronic condition often requiring a brain MRI. In tandem, DTI can help identify regional microstructural injuries that may correlate with cognitive and neurophysiologic deficits, and help guide targeted management.

Significance: Beyond this pilot, extending DTI research to compare regional abnormalities with specific clinical tools used to evaluate clinical manifestations of regional injuries, such as cognitive fatigue, exercise intolerance, and vestibular deficits.

TOPIC: Running

STUDY: Other

Balanced Pacing Between the First and Second Halves in Marathon Races Correlates With Improved Overa

Primary Author/Presenter: Kaitlyn Chin, DO

Joseph Dadabo, MD, Allison Carroll, PhD, and Prakash Jayabalan, MD, PhD

Affiliation: Northwestern McGraw University/Shirley Ryan Ability Lab, Chicago, Illinois.

Purpose: Although several factors impact marathon performance, optimal pacing strategy for an individual during the race remains unknown. The present study evaluated the relationship between negative and positive split strategies with performance times in marathon runners in 4 World Marathon Majors.

Methods: Retrospective review of publicly available result databases of elite (defined by the race, n = 505) and non-elite runners (n = 505) from the Chicago, New York, Tokyo, and London marathons 2017 to 2019. Negative splitting is defined as running the first half of the race slower than the second half of the race and positive splitting as the opposite. Statistical analyses were performed using SPSS.

Results: The mean age of elite runners was 30.1 and non-elite runners was 29.7. In both groups, the number of females was 213. Mean finish time for elite runners was significantly faster 2.35 hours versus non-elite runners 4.49 hours (P < 0.001). Frequency of negatively splitting races was 14% in elite compared to 11% of non-elite runners. When a runner negatively split, the difference in pace between each half of the race was less (−110 seconds) compared to non-elite (−376 seconds, P < 0.001). Across the full cohort, there was a significant correlation between a worse final place in the race and a greater difference in time between each half of the marathon (r = 0.659, P < 0.001) and was seen in elite (r = 0.257, P < 0.001) and non-elite runners (r = 0.535, P < 0.001). Regression analyses showed negative splitters had faster finish times by 1113 seconds (P < 0.0001). Univariate analyses revealed being an elite runner and male was associated with faster predicted finish times (P < 0.0001).

Conclusions: By utilizing data across multiple marathons, our study shows elite and non-elite runners who negatively split their race, had better race times, and placed higher overall. Elite runners generally had less differences in pace between the first and second halves of the marathon. Non-elite athletes tended to positively split their races and had greater variability of pace between splits which was associated with worse race times and place finish.

Significance: A balanced pace across each half of the race is associated with better marathon performance. This is the first study of its kind, to our knowledge, that provides pivotal information for runners planning their pacing strategies to improve performance.

TOPIC: Ultrasound

STUDY: Cohort

Evaluation of Percutaneous Ultrasonic Tenotomy (PUT) in Diabetic Patients and Potential Protective Role of Metformin

Primary Author/Presenter: Kuntal Chowdhary, MD

George Raum, DO, Connor Fultz, MD, Sidharth Sahni, DPT, and Kentaro Onishi, DO

Affiliation: University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania.

Purpose: To investigate the complication rate of percutaneous ultrasonic tenotomy (PUT) in diabetic patients, and evaluate the protective aspects of metformin in its ability to impact healing potentials in diabetics patients that had undergone PUT.

Methods: Retrospective chart review was performed for all cases of tendon injury treated with PUT between November 1, 2017 and December 31, 2020. Demographic factors and medical history prior to intervention, and complications following PUT were evaluated for each case. Descriptive statistics were completed to determine the rate of complications. Rates were compared using chi-square analysis (JASP Version 0.16.4).

Results: A total of 65 procedures utilizing PUT were identified through search of the electronic health record. The most common complication was increased pain or stiffness following PUT, and was identified after 11/65 procedures (16.92%). Of the 9 procedures performed on patients with diabetes, increased pain or stiffness occurred in 1/6 (16.67%) patients taking metformin, and in 1/3 (33.33%) patients not taking metformin. This value was not statistically significant. When pre-diabetic patients were also included in the subgroup analysis, an increase in pain or stiffness following the procedure occurred in 2/7 (28.57%) patients not taking metformin versus 1/6 (16.67%) patients taking metformin. This value was not statistically significant. The other complication identified was a deep venous thrombosis. This did not occur in a patient with diabetes.

Conclusions: Strong evidence has demonstrated diabetes mellitus is associated with a higher risk of tendinopathy, and contributes to poorer outcomes of healing. Metformin has been identified as a possible treatment for tendinopathy by inhibiting inflammatory mediators during tissue stress. In our sample, diabetics had poorer outcomes following PUT, and patients on metformin had a lower complication rate of development of increased pain/stiffness.

Significance: While not statistically significant, the findings of this study are suggestive of a protective role played by metformin in patients with diabetes mellitus, and warrants further evaluation with a larger patient sample size.

TOPIC: Pediatrics

STUDY: Other

Athletic Identity and Injury Patterns in Pediatric Ballet Dancers

Primary Author/Presenter: Jane S. Chung, MD

Ashley Erdman, MBA, Sophia Ulman, PhD, Emily Stapleton, PsyD, Shane Miller, MD, Jacob Jones, MD, Jessica Dabis, DPT, and Henry Ellis, MD

Affiliation: Scottish Rite for Children, Frisco, Texas.

Purpose: Many dancers specialize at an early age and train year-round. Purpose was to evaluate for correlations between sport specialization characteristics, including athletic identity (AI) and injury patterns in pediatric ballets dancers, as high AI is a risk factor for mental health concerns after injury.

Methods: Pediatric pre-professional ballet dancers who train en pointe were enrolled in an AMSSM funded study. The Athletic Identity Measurement Scale (AIMS) questionnaire was administered to measure the degree to which each dancer identified with the athlete role, comprised of 3 subscales: social identity (SI), exclusivity (EX), and negative affectivity (NA). Injury history was also collected.

Results: Data were collected on 46 female dancers (age 14.4 ± 1.9 years). Average total AI was 54/70, with SI, EX, NA subscores of 19/21, 19/28, 11/14, respectively. Dancers reported a mean of 10.3 years of dance experience, with 3.3 years of training en pointe. Total AI (P = 0.04), SI (P = 0.02), and NA (P = 0.01) subscores exhibited moderate correlations to age, increasing in older dancers. Increased practices/week were correlated to total AI, EX, NA subscores (P = 0.02, P = 0.04, P = 0.04, respectively). Number of years en pointe demonstrated a weak correlation to EX (P = 0.049). Dancers who reported past injury had an increased SI subscore (P < 0.01), but no difference in EX or NA subscores compared to non-injured dancers. Past injury was more prevalent with increased age, years in dance, and years en pointe (P < 0.01, P = 0.01, P = 0.02, respectively).

Conclusions: Pediatric ballet dancers strongly identify with sport. Older dancers tended to identify more strongly as athletes. Those who practiced more identified more exclusively as dancers, with both groups reporting higher AI and propensity for negative affect with sport setbacks. Dancers with past injuries were more likely to strongly identify as athletes. More training years en pointe correlated with increased degree of self-worth tied to sport.

Significance: This information may be useful for providers, since a pediatric ballet dancer's self-identity is strongly shaped by sport and increases with training volume and age, putting them at risk for negative mental health outcomes following setbacks.

Acknowledgments: This study is supported by the AMSSM Foundation grant.

TOPIC: Musculoskeletal

STUDY: Cohort

Knee Injury Prevalence in Division I Men's Ice Hockey Players Over a Seven Year Time Period

Primary Author/Presenter: Dustin Collins, MD

Megan Kusner, ATC, Tyler Daigneault, ATC, Kendra McCamey, MD, Angela Pedroza, MPH, and James Borchers, MD, MPH

Affiliation: The Ohio State University Family Medicine Department, The Ohio State University Jameson Crane Sports Medicine Institute, Columbus, Ohio.

Purpose: To investigate the prevalence of knee injuries for division I Men's Ice Hockey Players during a 7 year time frame to highlight the importance of the continued need for strength training for injury prevention of the knee in elite ice hockey players.

Methods: Cohort study involving 189 Men's Ice Hockey student athletes at a division I university over a 7 year time period from 2016 to 2022. Athletes were asked before each season via questionnaire if they have suffered an injury to their knee and to give details and date of injury. Data was translated into a strict percentage of players with knee injuries divided by those who did not report a knee injury.

Results: Out of the 189 responses, 14 student athletes reported either a previous or current knee injury (7%). Year 2016 had the highest self-reporting percentage of knee injury at 4/28 (14%) and the year 2020 with the lowest percentage at 0/25 (0%). It is noted the year 2020 had less man games played in that year secondary to the COVID-19 pandemic. Most common type of knee injury reported included meniscal injury (42%), followed by ACL (28%), MCL (28%) and PCL (14%) respectively. It is noted that the some respective injuries occurred at the same time as another respective injury.

Conclusions: Given the average number of players with current or previous knee injury in any given year was 7% shows that knee injury is a common and prevalent injury among division I Men's Ice Hockey players. This is consistent when compared to other studies. Additionally, of the knee injuries sustained the most common was internal derangement such as meniscus, ACL and PCL.

Significance: Given the prevalence of knee injuries in the division I Men's Ice Hockey population there should be continued attention towards highlighting the importance of continued strength training for injury prevention of the knee in elite ice hockey players.

Acknowledgments: I would like to thank Katie Walker, ATC for the help in data collection for this study.

TOPIC: Epidemiology

STUDY: Survey

Investigating the Prevalence of Cubital Tunnel Syndrome Among R