Clinical Journal of Sport Medicine

TOPIC: Biologics

STUDY TYPE: Other

Platelet-Rich Plasma for Treatment of Scaphoid Fracture Nonunion: A Review and Quality Analysis of Existing Literature

Thomas Shelton, MD

All Other Authors: Jake Ayisi, BS, Sidney Gregorek, BS, Emily Lu, MD, and Bryant Walrod, MD

Affiliation: Champlain Valley Physicians Hospital—UVM Health Network, Plattsburgh, New York.

Purpose: Recent clinical research has investigated Platelet-Rich plasma (PRP) as a therapy for scaphoid fractures, which are at high risk of nonunion. This study aims to review existing research and analyze its quality to assess the current level of evidence for PRP in scaphoid fracture.

Methods and Study Design: A literature search was conducted across multiple databases for terms related to scaphoid fracture and PRP. Only clinical studies were included. Papers were screened then analyzed by 2 reviewers. All papers were given numerical quality scores using MINORS criteria. CLEAR and Coleman assessment scores were also used. Scores were averaged between reviewers and used to determine quality.

Results: The literature search resulted in 6 total results, no difference in studies were found between databases. One paper was excluded because it was not a clinical study. The papers included 199 total patients, 94 of whom received PRP intervention alone or as an adjunctive therapy. Primary outcome measure across studies was the presence of scaphoid union or time to union. One hundred percent of comparative studies found improved outcomes in patients receiving PRP. This was reflected in improved healing time, decreased pain, or decreased functional imitation. Mayo wrist function score was used in 40% of papers, and was found to be significantly affected by PRP. Studies had an average MINOR score of 18.25/24 with standard deviation of 2.21 for comparative studies. One hundred percent of studies were found to be of moderate quality, defined as 15–22 for comparative studies and 9–14 for non comparative studies. The lowest score minors criteria was “prospective calculation of the study size with an average score of 0.2.” Coleman scores for all papers were also obtained with an average score of 55 and STD of 9.6.

Conclusions: These results suggest that PRP may be an effective intervention for scaphoid fracture alongside traditional therapies. However, drawing firm conclusions is limited by the small number of studies and the limited sample size. Given the significant impact seen in the literature and the low risk of bias we have shown in early research, PRP for scaphoid fractures should be further investigated with larger clinical studies.

Significance: These findings are the first review of current clinical evidence for PRP in scaphoid fracture and are the first analysis of literature quality. Our work provides a review of this novel intervention and offers a call for further high quality research.

Acknowledgments: Special thanks to Dr. Walrod for his editorial help on this project.

TOPIC: Concussion

STUDY TYPE: Survey

Preserving Identity Risking Health Name Image and Likeness Policy Changes and Adolescent Athlete

Derek Woessner, MD

All Other Authors: Nathan Li, Andrew Ko, BS, Michael Ulmer, DO, Sharon Welburn, PhD, Andy Grubbs, MEd, and Charles Webb, DO

Affiliation: Hughston Medical Group 6262 Veterans Parkway Columbus, GA.

Purpose: Concussions are common sports-related injuries. Prior studies have demonstrated the unwillingness of athletes to disclose concussive symptoms. Recent changes in name, image, and likeness (NIL) policies in high school and collegiate athletes provide additional conflicts of interest for the athlete.

Methods and Study Design: Survey was distributed to 686 high school and collegiate athletes in May 2023 during a free pre-screening physical exam. Demographic measures, concussion history, concussion knowledge, and opinions and perceptions of recent NIL rule changes were collected.

Results: Overall, 25% of participants stated they would withhold information to protect NIL opportunities. Football players, male athletes, and individuals familiar with recent NIL rule changes were more likely to withhold information and soccer players, female athletes, and individuals with less familiarity with recent NIL rule changes were less likely to withhold information. Race and ethnicity were not associated with decision to withhold information.

Conclusions: A large proportion of adolescent athletes are willing to withhold concussive symptoms to preserve potential NIL opportunities. This poses significant long-term risk of progressive morbidity and mortality from additional head trauma.

Significance: This study is the first to characterize the impact of recent NIL policy change on athlete attitudes towards concussive symptom disclosure. Further efforts should be made to ensure professional trainer coverage at all adolescent sporting events.

TOPIC: Concussion

STUDY TYPE: Cohort

Impact of Rotational Protective Helmets on Concussions among Competitive Motorcycle Athletes

Marisa McDow, MD

All Other Authors: Eric Swanson, MD, Keeli Hanzelka, MD, Jason Knudsen, EMT, James Buskirk, PhD, Lawrence H. Brown, PhD, and Carl I. Price, MD

Affiliation: The University of Texas at Austin Dell Medical School.

Purpose: Rotational forces contribute to motorcycle crash-related brain injuries. This study evaluated whether the use of helmets designed to protect from rotational impact forces reduced the incidence of concussions among competitive motorcycle athletes who crashed during competition.

Methods and Study Design: This observational cohort study utilized standardized data collected by race medical personal for all crashes occurring during the 2024 MotoAmerica competitive season. Data included crash characteristics, helmet type, observed injuries, and evidence of concussion. The association between helmet type and concussion was reported using risk ratio (RR) with 95% confidence interval (CI).

Results: There were 498 crashes during the 2024 MotoAmerica competitive season. Only 30 athletes were wearing a rotational protective helmet at the time of their crash. The type of crash did not differ for athletes wearing or not wearing a rotational protective helmet (83% vs 81% “lowside” crashes). Suspected concussions were reported for 1 (3.3%) of 30 athletes wearing a rotational protective helmet, compared with 40 (8.6%) of 468 athletes who were not wearing a rotational protective helmet (RR: 0.39; CI: 0.06–2.74). With only one concussion among athletes wearing a rotational protective helmet, multivariable modeling to explore the effects of other rider or crash characteristics was not possible.

Conclusions: The incidence of concussions was lower among athletes wearing rotational protective helmets who crashed during the 2024 MotoAmerica competitive season. The association was not statistically significant due to the low rate of rotational protective helmet use, but the observed effect is clinically meaningful, as only one athlete wearing a rotational protective helmet experienced a concussion.

Significance: Understanding the effectiveness of helmet technology is crucial for motorsport athlete safety. These findings underscore the critical role of helmet technology in enhancing athlete safety.

Acknowledgments: We thank MotoAmerica for providing the data underlying this analysis.

TOPIC: Concussion

STUDY TYPE: Cohort

Does Grit Impact Clinical Presentation Following a Sport-related Concussion in Pediatric Athletes

Jane Chung, MD

All Other Authors: Katherine Lampe, BS, Cassidy Schultz, BS, James McGinley, BS, Jacob Jones, MD, Shane Miller, MD, Mathew Stokes, MD, Munro Cullum, MD, and Munro Cullum, PhD

Affiliation: Scottish Rite for Children, Frisco, TX.

Purpose: Grit is the perseverance and passion for long-term goals. Studies have reported a positive effect of resilience and grit on injury recovery, but little is known about its effect on concussion recovery. The purpose was to identify if there is an association with grit and concussion presentation.

Methods and Study Design: Data were prospectively collected for a multi-center concussion registry (ConTex). Patients ≤18 years who presented ≤30 days to clinic after sport-related concussions and completed the 12-item Grit Scale were included. Grit scores, demographics, concussion symptom scale and injury data were analyzed. Comparison analyses included Mann-Whitney U, Kruskal-Wallis Test, and Pearson’s Correlation.

Results: Forty-five athletes (age 14.09 ± 1.83 years; 62.2% male) with sports related concussions were analyzed. Football (42.2%), soccer (20.0%), and cheerleading (13.3%) were the most common sport being played when injured. Concussion mostly occurred during practice (52.3%) or games (38.6%), and during school-related (64.4%) or club (24.4%) activities. 46.7% of patients continued to play after their injury. Patients had a mean 12-item Grit Scale score of 3.25 ± 0.59 (range 2.08–4.67). The Grit Scale is scored from 5 (extremely gritty) to 1 (not at all gritty). No significant differences were found for patient 12-item Grit Scale scores when analyzed by sex (P = 0.944), immediate injury and symptom reporting (P = 0.222), sport playing when injured (P = 0.624), continued play (P = 0.081), sport level (P = 0.653), and event in which injury occurred (P = 0.311). No correlations found between Grit scores and age (P = 0.276), time to clinic after injury (P = 0.629), SCAT6 Total Symptoms (P = 0.540), Symptom Severity Score (P = 0.899), Brief Resilie.

Conclusions: Grit scores in concussed pediatric athletes did not show a significant relationship with sport, athletic competition level, patients’ time to clinic presentation, or symptom burden. Future research should be performed to gather a larger sample size and more follow-up data for robust analysis and evaluate the long-term effects of grit and recovery following a concussion in the pediatric population.

Significance: Grit score did not display a significant relationship with sport, athletic competition level, symptom burden, or resilience in pediatric athletes following concussion. This data marks one of the first uses of the grit scale in this injury population.

Acknowledgments: We would like to thank all members of the ConTex research team for their contributions to this dataset.

TOPIC: Concussion

STUDY TYPE: Cohort

Prescribing Patterns for Prolonged Post Concussive Syndrome in an Academic Sports Medicine Practice

Robert Freeman, DO

All Other Authors: Jill Maples, PhD, Bron McPherson, DO, Thomas Bell, MD, and Rebecca Kemmet, MD

Affiliation: University of Tennessee Graduate School of Medicine Department of Family Medicine Primary Care Sports Medicine Fellowship Knoxville, Tennessee.

Purpose: Currently, there are no evidence-based guidelines for the management of post concussive symptoms, only expert opinion. The purpose of this single center (retrospective) study is to describe the prescribing patterns for prolonged post concussive syndrome in an academic sports medicine practice.

Methods and Study Design: This single center retrospective study included patients seen in a sports medicine clinic from 1 July, 2014 to 30 June, 2024 with a Disease Related Group code indicating a primary diagnosis of concussion S60.01. Medications to treat post concussive symptoms for patients with prolonged concussive symptoms were extracted from EMR. Descriptive statistical analyses were conducted. STROBE guidelines followed.

Results: Among the 267 patients presenting with a concussion diagnosis, 72 (27.0%) presented with prolonged post concussive symptoms (greater than 21 days). Among those 72 patients, 29 (40.3%) were prescribed medication for symptoms. A total of 54 indications were documented: 66.5% (36/54) for headache, 20.4% (11/54) for sleep issues, 3.7% (2/54) for cognitive issues, 3.7% (2/54) for balance issues, 3.7% (2/54) for nausea, and 1.9% (1/54) for affective symptoms. The most frequently prescribed medications for headache were TCA (15/36 = 41.7%), followed by Triptans (5/36 = 13.9%) and Gabapentin (5/36 = 13.9%), followed by Topiramate (3/36 = 8.3%), and antihistamine (2/36 = 5.6%). The following medications were prescribed once (1/36 = 2.8%): propranolol, oxycodone-acetometaphine, methocarbomal, butalb-tylenol-caffeine, diclofenac, and mexolicam. The most frequently prescribed medications for sleep issues were melatonin (7/11 = 63.6%), trazadone (2/11 = 18.2%), TCA (1/11 = 9.1%) and antihistamine (1/11 = 9.1%).

Conclusions: Presenting with prolonged concussive symptoms in our population was rare. Among those receiving a prescription, headache followed by sleep were the most common indications for medications prescribed. Cognitive, balance, and affective symptoms as an indication were isolated events. TCA’s (amitriptyline, nortriptyline) were the most common medication class used for headaches followed by melatonin for sleep.

Significance: The indications for (headache, sleep) and medications used are in line with what has been reported in prior studies. Given these are the most commonly reported post concussive symptoms, future work should focus on developing treatment guidelines.

Acknowledgments: UT Graduate School of Medicine Department of Family Medicine.

TOPIC: Concussion

STUDY TYPE: Other

Improving the Quality of Concussion Management Principles for Family Medicine Residents

Elie Feghali, DO

All Other Authors: Stephen Titus, MD

Affiliation: Baylor University Medical Center Family Medicine Residency, Dallas, Texas.

Purpose: To increase family medicine resident knowledge and comfort with diagnosing and treating sports related concussions (SRC) and clearing patients to return to play using a standardized education tool. The AMSSM Position Statement on Concussion in Sport (2019) was used as the sole educational resource.

Methods and Study Design: This quality improvement survey based resident education study included a lecture to family medicine residents on SRC using the AMSSM Position Statement on Concussion in Sport as the lone resource. A survey was completed before the lecture and 2 weeks post intervention which tested residents’ knowledge and assessed their comfort level with diagnosing, treating, and clearing patients with SRC.

Results: Prior to the intervention, the average self reported comfort level with diagnosing a sports related concussion was a 2.73 on a Likert scale of 1 to 5 ranging from very uncomfortable (1) to very comfortable (5). Pre intervention, comfort with treating sports related concussions was a 2.55 and comfort with clearing patients with sports related concussions was a 2.45. Two weeks post intervention, comfort diagnosing increased to 4.1 (50 percent increase), comfort treating increased to 3.9 (53% increase), and comfort clearing patients with sports related concussions increased to 3.9 (59% increase). Prior to the intervention, residents scored an average of 49% correct on the 10 question concussion knowledge portion of the survey. Two weeks post intervention, the average number of questions correct increased to 8%. The number of participants of the study was 11, and included 5 PGY1 residents, 3 PGY2 residents, and 3 PGY3 residents.

Conclusions: This pilot study elicited a positive, sustained effect on family medicine resident knowledge and comfort with diagnosing, treating and clearing patients with SRC using a single lecture during residency training. The AMSSM Position Statement on Concussion in Sport (2019) was shown to be an effective and comprehensive teaching resource. The next step is to apply this study to a broader range of programs and follow residents’ long term retention.

Significance: This study proposes an effective, standardized educational method for increasing primary care residents’ comfort level and knowledge regarding diagnosing, treating, and clearing patients with sports related concussions.

TOPIC: Concussion

STUDY TYPE: Other

Concussion Knowledge and Attitude as Predictors of Immediate Concussion Reporting

Patrick Sajak, MD, MS

All Other Authors: David Baxter, DO and Thomas Buckley, EdD, ATC

Affiliation: Premier Orthopedics Springfield Sports Medicine, Springfield, Pennsylvania.

Purpose: Timely concussion reporting is critical to reduce risk of further injury and improve concussion outcomes; however, delayed reporting remains prevalent. The purpose of this study was to assess immediate vs delayed concussion reporting based on concussion knowledge and attitudes of student-athletes.

Methods and Study Design: Sixty-seven NCAA athletes completed the valid and reliable Rosenbaum Concussion Knowledge (CKI, score 0–25) and Attitudes (CAI, score 15–75) Survey (RoCKAS) during pre-participation exam and had a subsequent concussion with initial graded symptom checklist (GSC) scores (0–132). The outcome measure was immediate vs delayed concussion reporting, assessed by a binary logical regression with the 3 predictors.

Results: Of the 67 student-athletes, there was no difference between immediate vs delayed reporting characteristics in age (19.1 ± 1.1 y.o. and 18.9 ± 1.0 y.o., P = 0.295) and concussion history (0.7 ± 0.9 and 0.6 ± 1.1, P = 0.542). The immediate reporting group had a higher initial GSC (30.2 ± 20.6 and 19.8 ± 19.3, P = 0.037), but lower (worse) CAI (51.9 ± 6.8 and 55.8 ± 9.1, P = 0.049) and no difference in CKI (20.2 ± 2.9 and 19.8 ± 2.5, P = 0.501). The overall model and the 2-way interactions were both significant (R2 = 0.234, P = 0.001). Amongst the predictors, the CKI (P = 0.028) and CAI (P = 0.010) scores as well as GSC (P = 0.027) were significant. The interactions of CKI × GSC (P = 0.003) and CAI × CKI (P = 0.033) were also significant. Both higher CKI (OR: 1.31, 95% CI: 1.01–1.70) and GSC (OR: 1.05, 95% CI: 1.00–1.09) increased the odds of immediate reporting whereas higher CAI had lower odds of immediate reporting (OR: 0.89, 95% CI: 0.81–0.99).

Conclusions: The results of this study showed a higher (better) knowledge of concussions and more initial symptoms were both associated with more immediate reporting; however, higher (better) attitude was associated with lower odds of immediate reporting. This finding suggests that health care providers need continued focus on concussion related attitudes to help improve timely reporting of potential concussion symptoms.

Significance: Earlier reporting of possible concussions is associated with better health outcomes. As such, these better outcomes might be a more appropriate focus of educational interventions as opposed to standard knowledge and symptom-based approaches.

TOPIC: Concussion

STUDY TYPE: RCT

Effects of Landing Impacts & Running on Balance Error Scoring System Performance:Implications for Acute Concussion Assessment

Trocon Davis, MD

All Other Authors: David Baxter, DO, Barry Munkasy, PhD, and Thomas Buckley, EdD

Affiliation: Premier Orthopedics Sports Medicine Fellowship, Springfield, PA.

Purpose: The Balance Error Scoring System (BESS) is commonly used during concussion assessment. Physical activity can adversely affect balance and potentially limit BESS efficacy. The purpose of this study was to investigate the effects of a brief exercise bout of running or jumping on BESS performance.

Methods and Study Design: Fifty-two college athletes (50% Female, 21.8 + 1.5 y.o., 171.1 + 9.1 cm) were randomly assigned into 3 groups: (1) Running—3 minutes on a treadmill, (2) Jumping—10 drop jumps from a 50 cm box, or (3) Control—rest. Participants complete the BESS (3 stances, 2 surfaces) before and immediately after the intervention. A 3 (group) by 2 (time) repeated measures ANOVA was performed with sex as a covariate.

Results: There was a significant group by time interaction (F = 7.396, P = 0.002) with a large effect size (β² = 0.239) and high observed power (0.926). There was a significant decrease (improvement) in BESS score for the control group (PRE: 13.9 + 4.5; POST: 10.5 + 2.9, P = 0.019, d = 0.89). There was no significant difference for either Running (PRE: 13.1 + 3.1; POST: 12.6 + 3.1, P = 0.579, d = 0.16) or Landing (PRE: 12.3 + 4.5; POST: 12.6 + 4.4, P = 0.849, d = 0.07).

Conclusions: A brief exercise intervention resulted in participants failing to improve a subsequent BESS assessment. Control participants who rested for 5 minutes committed significantly fewer (3.4) errors. These results suggest that even low to moderate intensity, submaximal exercise can result in a failure to improve with repeat BESS administration. Caution must be taken when interpreting BESS as part of a sideline assessment in fatigued athletes.

Significance: Clinicians must consider short-term effects of physical activity when performing sideline concussion balance assessments. Other balance assessments such as Tandem Gait may be more stable measures and could be utilized in acute concussion assessment.

TOPIC: Concussion

STUDY TYPE: Cohort

Distance to Pediatric Concussion Evaluation: Underutilization of Satellite Clinics by Patients of Lower Social Standing

Jonathan Santana, DO

All Other Authors: Annika Myers, BS, Abigail Padilla, BS, Tishya Wren, PhD, and Anita Hamilton, PhD, ABPP-CN

Affiliation: Jackie and Gene Autry Orthopedic Center, Children‘s Hospital Los Angeles; Keck School of Medicine, University of Southern California, Los Angeles.

Purpose: Large urban hospital systems have developed satellite specialty clinics to improve access to pediatric concussion care. This study examines satellite clinic utilization and its association with travel distance, time to evaluation, and socioeconomic status for patients receiving concussion care.

Methods and Study Design: Insurance status, Child Opportunity Index (COI), and distance from each patient’s zip code to all clinic locations were collected for patients presenting to a large tertiary children’s hospital and satellite clinics for concussion evaluation. Distance to the location providing the patient’s care vs. the closest possible location was compared, and the relationship to insurance and COI was examined.

Results: Of 332 patients included in this study, 68% (227/332) were seen at the main hospital. Only 45% (103/227) of these presented to the location closest to their home compared with 62% (65/105) of patients seen at satellite locations (P = 0.007). Thus, 55% of patients seen at the main hospital could have been seen at a satellite location closer to their home. These patients traveled a median of 13.4 (IQR 13) miles farther than the closest satellite to reach the main hospital. Those seen at the hospital clinic had delayed presentation compared to those seen at satellite clinics (median 27 vs. 10 days post injury, P P ≤ 0.006). Of the patients who lived closest to a satellite location, patients with private insurance (46.6% vs. 5%, P P

Conclusions: Shortening the travel distance required to receive concussion care can promote timely concussion evaluation and follow-up compliance. However, patients of lower socioeconomic status often travel farther to reach the main hospital when a closer satellite clinic is available, which may delay their time to evaluation post-injury and increase risk for prolonged recovery, an effect that impacts patients of lower social standing disproportionately.

Significance: Our findings suggest that pediatric patients of lower socioeconomic status seeking concussion care have decreased use of satellite clinics which could help reduce transportation barriers and improve their access to care.

TOPIC: Concussion

STUDY TYPE: Cohort

Difference in Pediatric Concussion Time to Clearance Based on Age, Gender and Injury Mechanism

Jonathan Santana, DO

All Other Authors: Abigail Padilla, BS, Tishya Wren, PhD, and Anita Hamilton, PhD, ABPP-CN

Affiliation: Children’s Hospital Los Angeles, CA; University of Southern California, Los Angeles, CA.

Purpose: Children and adolescents may require more time to recover from concussions than is expected for adults. The purpose of this study was to determine the typical time range to clearance for pediatric concussion and its relationship to age, gender, and injury mechanism.

Methods and Study Design: A prospective convenience sample of concussion patients at a large tertiary children’s hospital system was studied. Time to clearance was examined as a function of age, gender, and injury mechanism using Spearman rank correlation and Mann-Whitney rank sum tests. Multivariable linear regression was also performed on log transformed time to clearance to account for skewness of that variable.

Results: Among 104 concussions included in the study (43 male; age 6–20 years), the median time to clearance was 65 days (IQR 117.5). Time to clearance was shorter following sports-related concussions compared to other mechanisms of injury (median 54 vs. 91 days, P = 0.036). Time to clearance was also shorter for males compared with females (median 45 vs. 91 days, P = 0.0007) and tended to be shorter with older age (rho = −0.187, P = 0.057). Among sports related concussions, 74% (54/73), 48% (35/73), and 32% (23/73) of patients still had symptoms 30, 60, and 90 days after injury. Rates of prolonged symptoms were even higher after non-sports concussions at 84% (26/31), 61% (19/31), and 52% (16/31), respectively. The difference in the rate of persisting symptoms beyond 90 days in sports vs. non-sports injury was close to statistical significance (P = 0.076). Multivariable analysis indicated that time to clearance was more strongly related to gender (P P = 0.061) than mechanism of injury (P = 0.173).

Conclusions: The time needed to recover from concussion is longer in children and adolescents compared with adults, often exceeding 3 months. Recovery time decreases with age through adolescence and is shorter when the injury occurs during sports. Females take longer to recover than males with female athletes being cleared later than male athletes and non-athletes.

Significance: Time to recover from pediatric concussion varies with age, gender, and injury mechanism. Awareness of these effects is needed to manage expectations and monitor recovery as pediatric concussion symptoms often persist months after injury.

TOPIC: Concussion

STUDY TYPE: Cohort

Clinical and Demographic Comparisons of Sport-Related Concussion and Non-Sport Related Concussion in Youth Aged 5–12

Jorge Sucar-Marquez, MD

All Other Authors: Lauren Harper, PhD, Cristina Robles, PsyD, Danielle Ransom, PsyD, Sarah Irani, MD, and Patrick Mularoni, MD

Affiliation: Johns Hopkins All Children‘s Hospital.

Purpose: The 6th International Consensus Statement on Concussion in Sport has acknowledged that limited evidence exists on concussion in pre-teen patients. This study aims to enhance clinicians’ understanding of demographic factors, symptom presentation and clinical course in concussion patients aged 5–12.

Methods and Study Design: A retrospective chart review was conducted on youth aged 5–12 diagnosed with concussion at a sports medicine clinic. Subjects were grouped by injury mechanism (sport vs. non-sport). Inclusion required recovery within 2 standard deviations of the mean. Demographic and injury characteristics were compared between groups using independent t-tests and χ² analyses.

Results: In our sample 55% of subjects presented with sport-related concussion (n = 252) and 45% presented with non-sport-related concussion (n = 212). Overall males outnumbered females, but a higher proportion of female patients was observed in the non-sport injured cohort (43%) compared to the sport-injured cohort (26%; P = P = 0.036). Patients with sport-related injuries experienced significantly shorter recovery times (M = 17.06, SD = 10.94; P = 0.042) compared with those with non-sport injuries (M = 19.07, SD = 14.18).

Conclusions: In this 5–12-year-old cohort, males were more likely to present with concussion in both the non-sport and sport groups. Although there were not statistically significant differences in clinical presentation or reported symptoms at presentation, individuals in the sport group returned to baseline sooner than the non-sport group. Interestingly, a high proportion of patients had not returned to school at the time of presentation.

Significance: This study examines concussions in children aged 5–12, addressing gaps noted by the 6th International Consensus on Concussion in Sport. Findings highlight demographic and clinical trends, revealing sport-related injuries had shorter recovery times.

Acknowledgments: Michael Barrins, Research coordinator.

TOPIC: Concussion

STUDY TYPE: Case-Control

Correlative Analysis of Modified Vestibulo-Ocular Motor Screen and Objective Oculomotor Tracking Testing

Tyler Marx, MS

All Other Authors: Joseph Marshall, BS, Alicia Chen, BS, Amal Anilkumar, BS, Luke Maes, BS, Brett Dusenberry, MD, Tony Gross, DO, and Mo Mortazavi, DO

Affiliation: Midwestern University, Glendale, AZ.

Purpose: The mVOMS is a clinical screen used to assess concussions. Objective oculomotor tracking tools may offer similar clinical utility. This study aims to investigate mVOMS correlation to an objective oculomotor tracking testing (OOTT) summary score to determine clinical significance.

Methods and Study Design: Retrospective case-control study of 353 patients aged 6–77 with a concussion. After evaluation by concussion specialists, patients underwent mVOMS evaluation and OOTT. The mVOMs include smooth pursuit, horizontal saccades, horizontal vestibular-ocular reflex, and visual motion sensitivity. The OOTT tracked pursuit-based eye movements of a target. The mVOMS was correlated to the OOTT summary score.

Results: The average mVOMS score was 1.69 out of 4 in this cohort suggesting mild to moderate VOM deficits on the exam. Our population had 74 positives in smooth pursuit (SP), 214 in horizontal vestibular-ocular reflex (hVOR), 163 in vision motion sensitivity (VMS), and 145 in horizontal saccades (hS). The mVOMS had a statistically significant positive correlation to the objective oculomotor tracking summary score, r = 0.23898, P P P = 0.03429 VMS: r = 0.19685, P = 0.0002 hS: r = 0.19815, P = 0.00018.

Conclusions: A statistically significant positive correlation was demonstrated between both the mVOMS individual components and the total score when correlated to the OOTT summary score. These findings suggest the clinical utility of OOTT as an aid for concussion evaluations and diagnosis. Further investigation with more participants and correlation with a diverse set of OOTT markers is needed to make definitive conclusions.

Significance: OOTT may have significant clinical utility as a diagnostic aid to guide treatment decisions in concussions. The strong correlation with the mVOMS highlights the role of visual tracking abnormalities as primary generators of visio-vestibular symptoms.

Acknowledgments: Thank you to everyone involved in the research project.

TOPIC: Concussion

STUDY TYPE: Cohort

The Role of Biological Sex and Healthcare Access in Recovery From Adolescent Sport-Related Concussion

Sarah Irani, MD, FAAP, CAQSM

All Other Authors: P. Patrick Mularoni, MD and Danielle Ransom, PsyD

Affiliation: Johns Hopkins All Children‘s Hospital, Saint Petersburg, FL.

Purpose: Recovery from sport-related concussion (SRC) is multifaceted, often influenced by individual factors and healthcare access. This study aimed to explore the impact of biological sex and healthcare access on recovery duration and the risk of persistent symptoms in adolescent athletes following SRC.

Methods and Study Design: This retrospective cohort study included athletes aged 13–18 evaluated through a pediatric sports medicine program at a hospital-based clinic or on-site at a sports-focused boarding school. Inclusion criteria were evaluation within 7 days post-SRC and recovery duration within 2 standard deviations of the mean. Primary variables were biological sex and clinical setting where they received care.

Results: Linear regression revealed a significant association between female sex and longer recovery time (female mean days = 18.55, 95% CI = 15.71–24.28; male mean days = 14.26, 95% CI = 11.55–20.12; P P 2 tests demonstrated a significant association between biological sex and recovery status in the hospital-based clinic (P P = 0.649). Results also indicated that athletes from the sport-focused boarding school experienced lower rates of persisting symptoms (P = 0.003) and overall shorter recovery duration (mean days = 12.48, 95% CI = 9.26–18.27) than female athletes from the hospital-based clinic.

Conclusions: The study provides evidence that biological sex is a determinant of recovery duration and symptom persistence in adolescent SRC, with females at a disadvantage compared to males. However, healthcare accessibility mitigates these sex-based differences, comparable to findings in collegiate athletes.

Significance: These findings underscore the importance of personalized care and early access to comprehensive rehabilitation in managing SRC, considering both the biological and socio-environmental factors influencing recovery.

Acknowledgments: Michael Barrins, Clinical Research Coordinator.

TOPIC: Concussion

STUDY TYPE: Cohort

Length of Recovery in Pediatric Sport-Related Concussions: An Age Based Comparison

Sarah Irani, MD, FAAP, CAQSM

All Other Authors: Hilary Howard, DO and Danielle Ransom, PsyD

Affiliation: Johns Hopkins All Children’s Hospital, Saint Petersburg, FL.

Purpose: Pediatric concussions are a prevalent injury seen in sports medicine clinics but are underrepresented in the literature and consensus statements. This study aims to characterize recovery duration for pediatric sports-related concussions, comparing children aged 5–12 and adolescents aged 13–18.

Methods and Study Design: This retrospective cohort study included athletes aged 5–18 years evaluated at a pediatric sports medicine clinic following sport-related concussion. Participants were included in analyses if their initial visit occurred within 28 days of injury and their recovery length was within 2 standard deviations of the sample mean.

Results: A total of 1636 participants with sport-related concussions were included: 15.5% were 5–12 years (M = 11.12, SD = 1.5) and 84.5% were 13–18 years (M = 15.87, SD = 1.37). There were no significant differences between the age groups in recovery length. On average, the younger age group recovered in 17.06 days (SD = 10.94) and the older age group recovered in 18.03 days (SD = 12.65). There were also no significant differences between the groups in days to presentation to a sports medicine clinic following injury. The younger group presented to the clinic in 5.85 days (SD = 4.84) following injury and the older group presented in 5.46 days (SD = 4.76) from injury. Football and soccer were the 2 most common sports played when sustaining a concussion across age groups. Football accounted for 34.6% of concussions in the younger group and 31.6% of concussions in the older group. Soccer accounted for 24.8% of concussions in the younger group and 23.5% of concussions in the older group.

Conclusions: When comparing pediatric patients aged 5–12 and 13–18 who presented with sports-related concussions, this study found no significant differences in recovery duration. Additionally, there were no clinically significant differences in the time to presentation at a sports medicine specialty clinic. Football and soccer were identified as the most common sports associated with concussions in both age groups.

Significance: Few studies specifically address pediatric concussions. This study broadens the existing knowledge on pediatric concussions and contributes to the development of evolving clinical guidelines for youth athletes as well as future research.

Acknowledgments: Michael Barrins, Clinical Research Coordinator.

TOPIC: Concussion

STUDY TYPE: Other

Exploring Diffusion Tensor Imaging (DTI) of White Matter Regions as Predictors of Chronic Concussion Symptom Severity

Michael Lopez, MD

All Other Authors: Joseph Marshall, BS, Brett Dusenberry, MD, Leslie Streeter, DNP, James Dill, MD, Mo Mortazavi, MD, and Alex Dugum, DO

Affiliation: SPARCC Sports Medicine, Rehabilitation, and Concussion Center, Tucson, AZ; Midwestern University, AZ; University of Arizona, AZ.

Purpose: Investigate whether microstructural changes in white matter regions of the brain detected by Diffusion Tensor Imaging (DTI), can predict the severity of concussion symptoms as quantified by a validated clinical profile (CP) screen in a cohort of 67 patients with chronic concussion symptoms.

Methods and Study Design: Sixty-seven patient’s DTI data were gathered. The Mean Diffusivity (MD) and Fractional Anisotropy (FA) of 18 white matter regions were analyzed and used to identify the degree of axonal micro damage. Validated CP screen was used for symptom severity screen and profiling. A multiple regression (MR) assessed whether MD/FA z-scores in the specific brain regions predicted CP score variability.

Results: The regression model revealed significant associations between MD and FA in certain regions and concussion symptom severity score. The overall model was significant (F(4, 62) = 8.95, P 2 = 0.37). Significant regions included the Cingulum (Para hippocampal) FA Z score (P = 0.007), Inferior Longitudinal Fasciculus MD z score (P = 0.00017), and the Striatal Inferior Frontal Cortex MD Z score (P = 0.017). Negative associations were found with the Cingulum, Inferior Longitudinal Fasciculus (ILF), and Striatal Inferior Frontal Cortex. Findings suggest that white matter damage in these specific regions have a moderate influence on concussion symptom severity.

Conclusions: This study identifies specific white matter regions, including the Cingulum (Para hippocampal), ILF, Striatal Inferior and Frontal Cortex as potential regions impacting chronic concussion symptoms. The findings further support Diffusion Tensor Imaging (DTI) as a potentially critical tool in chronic concussion diagnostics and prognosis.

Significance: Identification of microstructural axonal damage may help in understanding symptom severity and profiles. DTI could complement brain MRIs in complex concussion, allowing for more accurate diagnoses and personalized treatment strategies to improve care.

Acknowledgments: SPARCC Sports Medicine, Rehabilitation, and Concussion Center, Tucson, AZ.

TOPIC: Concussion

STUDY TYPE: Cohort

Objective Oculomotor Tracking Utility in Return to Learn/Work (RTL/W) Decision Making for MTBI Patients

Michael Lopez, MD

All Other Authors: Joseph Marshall, BS, Amal Anilkumar, BS, Luke Maes Maes, Brett Dusenberry, MD, Mo Mortazavi, MD, and Tony Gross, DO, DO

Affiliation: SPARCC Sports Medicine, Rehabilitation, and Concussion Center, AZ; University of Arizona, AZ.

Purpose: Return to learn/work (RTL/W) steps enable strategic incremental increases in cognitive load. This study’s goal is to assess the correlation between RTL/W progression and objective oculomotor tracking summary score to help determine the clinical utility of such a tool RTL/W planning.

Methods and Study Design: Retrospective study of 335 patients aged 6–77 with mTBI seen at a concussion center. Patients underwent computerized neurocognitive testing (CNT) and were given a RTL/W step based on CNT performance and symptom burden. Steps were consistent with 6th consensus statement RTL strategy steps 1–4. OOTT was also completed and a summary score determined based on patients ability to track a visual target.

Results: The RTL/W steps were correlated to the oculomotor tracking summary scores and statistical significance was determined. Lower steps indicated lower cognitive/work capacity and higher steps indicated greater or normal capacity. OOTT summary score is scaled 0–20 with higher scores indicating greater tracking dysfunction. RTL/W steps had a statistically significant negative correlation with oculomotor tracking summary score illustrating greater oculomotor/pursuit dysfunction in those with lower academic/work tolerance. Correlation coefficient is −0.2054 and P-value is 0.000158.

Conclusions: There is a statistically significant negative correlation between these 2 markers. OOTT may provide clinical utility in predicting or guiding cognitive capacity and RTL/W step. There does appear to be a notable relationship between oculomotor pursuit dysfunction and academic/work tolerance. Continued investigation with a greater number of participants is indicated to draw more definitive conclusions.

Significance: OOTT shows potential for predicting cognitive/work capacity and RTL/W progression. Suggesting its potential as an additional metric to be used in RTL/W decisions for mTBI patients.

Acknowledgments: SPARCC Sports Medicine, Rehabilitation, and Concussion Center, AZ, USA, University of Arizona, AZ.

TOPIC: Concussion

STUDY TYPE: Other

Vestibular Sway Velocities and Oculomotor Tracking Deficits in MTBI Patients

Kyle Kener, MD

All Other Authors: Joseph Marshall, BS, Amal Anilkumar, BS, Luke Maes, Ajuni Choudhary, DO, Jaden Todd-Nelson, and Mo Mortazavi, MD

Affiliation: SPARCC Sports Medicine, Rehabilitation, and Concussion Center, AZ; University of Arizona, AZ.

Purpose: Force plate sway velocities (FPSV) and eye trackers can serve as reliable objective markers to assess vestibulocular dysfunction and aid in diagnostic/treatment decisions. This study looks to correlate FPSV to objective oculomotor tracking testing (OOTT) to discern their relationship.

Methods and Study Design: Retrospective study of 332 encounters with patients aged 6–77 who visited a concussion center. Each patient underwent FPSV testing. FPSV were motion-captured in 4 positions degrees/sec per protocol. Protocols A (bilateral) and B (unilateral) were used based on patients’ degree of dysfunction. OOTT was also completed and a summary score was determined based on patients ability to track a visual.

Results: The FPSV for each protocol was correlated to the oculomotor tracking summary score for both protocol A (bilateral stances with eyes open/closed and on foam pad) and B (unilateral single leg stance with eyes open/closed). T tests were then completed and P-values were determined to assess statistical significance. Protocol A (n = 258): r = 0.278, P P = 0.393. In the larger group (n = 258) who all completed protocol A there was a statistically significant relationship with a positive correlation. Indicating that as vestibular dysfunction increases, as indicated by larger FPSV values, so does OOTT summary scores and oculomotor deficits. Protocol B (n = 74) did not have a statistically significant relationship but does show likely trends towards significance.

Conclusions: A statistically significant correlation between bilateral FPSV and OOTT summary score was demonstrated. This suggests clinical utility of OOTT as an aid for concussion evaluations and recovery tracking. While not statistically significant, unilateral FPSV and OOTT summary scores appear to trend towards significance. Investigation with a greater number of patients and longitudinal follow-up may yield a greater perspective into these relationships.

Significance: There is a significant interplay between balance and eyetracking. Further objective metrics for diagnosis and treatment planning for concussions are needed. OOTT may be useful in this regard and offer supportive data for existing clinical metrics.

Acknowledgments: Brett Dusenberry MD, Leslie Streeter DNP, Jaden Bailey PA-C, James Dill MD, and Tony Gross DO who also assisted with this project.

TOPIC: Concussion

STUDY TYPE: Other

Oculomotor Tracking Tool Utility in Predicting Tolerance to High Intensity Training After Concussion

Kyle Kener, MD

All Other Authors: Joseph Marshall, BS, Amal Anilkumar, BS, Luke Maes, Mo Mortazavi, MD, Brett Dusenberry, MD, Leslie Streeter, DNP, Jaden Bailey, DNP, and Jaden Bailey, PA-C

Affiliation: SPARCC Sports Medicine, Rehabilitation, and Concussion Center, AZ; University of Arizona, AZ.

Purpose: Return-to-play (RTP) protocols continue to be refined and established. Tools such as objective oculomotor tracking testing (OOTT) may offer additional metrics to determine readiness for clearance testing. This study aims to investigate OOTT’s role as an objective marker for clearance readiness.

Methods and Study Design: Retrospective study of 63 concussion patients aged 8–48. All patients passed multi-directional high intensity interval training (HIIT-MD) exertional testing as determined by a concussion specialist. Patients also completed OOTT in which they follow a moving video with their eyes and a machine generates a summary score based on the patient’s ability to track the visual.

Results: The HIIT-MD step tolerance/passing was correlated to the OOTT summary score and P-value was determined. HIIT-MD exit/clearance protocol had a negative correlation with OOTT summary score, with a correlation coefficient = −0.03657 and P-value = 0.776.

Conclusions: There is a weak negative correlation that does not quite present with statistical significance. However, such a trend aligns with what is seen clinically and suggests a trend towards significance. It is unclear whether the summary score could provide clinical utility in determining readiness for RTP protocol. A greater number of participants will be necessary to draw more definitive conclusions.

Significance: Objective oculomotor tracking testing may have utility as an additional metric for RTP decision making in concussion patients. Further investigation with a larger sample size will be needed to draw definitive conclusions.

Acknowledgments: Leila Samsam DNP, James Dill MD, Tony Gross DO, Leah Gawin DNP, and Alex Dugum DO for their assistance with this project.

TOPIC: Concussion

STUDY TYPE: Cohort

Implementation of Tonometry for Concussion Management in Secondary School Setting

Rabiah Fresco, MD

All Other Authors: Bijan Origel, DO, Crystal Estrada, MD, Matt Simok, DAT, Jay Shah, DO, and Jesse Cheung, MD

Affiliation: Pomona Valley Hospital Medical Center, Pomona, CA.

Purpose: Concussions are one of the most common injuries among athletes but currently no objective assessments exist. In this study we will investigate if tonometry can reliably diagnose concussions due to the suspected increase in intraocular pressure (IOP) during acute concussions and subacute recovery.

Methods and Study Design: In a cohort of 61 high school student athletes baseline IOP measurements were taken at rest. In the event of a suspected concussion, a typical care concussion exam was performed followed by IOP measurements to minimize bias. A t-test was used to compare post-concussion IOP to baseline measurements and to compare those diagnosed with concussion and those without a concussion diagnosis.

Results: Preliminary data found that two-thirds (14 out of 21) of athletes diagnosed with a concussion had an intraocular pressure in at least one eye of 20 mm Hg or greater, which is considered pathologic. In comparison, athletes without a clinical diagnosis of concussion only had a 29% rate (4 out of 14) of elevated IOP of 20 mm Hg or greater. The average IOP in patients diagnosed with a concussion was 19.4 mm Hg versus 15.9 mm Hg in those not diagnosed with a concussion. The baseline average IOP was 17.1 mm Hg. A t-test was run and found a statistically significant difference in IOP between baseline measurements and patients diagnosed with a concussion (P = 0.0281) and between IOP in patients diagnosed with concussion versus those not diagnosed with a concussion (P = 0.0420).

Conclusions: Based on our preliminary data, tonometry is a promising tool for diagnosing concussions. In our study patients with a clinical diagnosis of a concussion had higher average IOP compared to baseline measurements of athletes at rest and athletes not diagnosed with a concussion. The initial data is limited by a small sample size and lack of baseline measurements for all athletes.

Significance: The development of an objective tool for concussion diagnosis such as tonometry could expedite diagnosis and treatment of concussions leading to lower rates of long term complications such as chronic traumatic encephalopathy (CTE).

TOPIC: Concussion

STUDY TYPE: Cohort

Chronic Concussion Predictors: Presenting Symptom Clusters as Potential Predictors of Persistent Post Concussive Syndrome

Daniella Rivera, DO

All Other Authors: Taylor Seitz, BA, Joseph Marshall, BS, and Mo Mortazavi, MD

Affiliation: Travis Family Medicine Residency, Travis AFB, CA.

Purpose: Evaluate predominant symptom clusters (profiles) from the validated Concussion Clinical Profile Screening Tool (CP Screen) in patients with acute/subacute symptoms vs persistent post concussive syndrome (PPCS) patients, and determine if specific profiles may serve as predictors of PPCS development.

Methods and Study Design: Retrospective longitudinal review of 100 subjects from 2020 to 2024 over 3 visits. Patients were divided into non-chronic (symptoms 3 months). Profile scores from the CP screen (migraine, mood, cognitive fatigue (CF), vestibular, ocular, sleep, and cervical profiles) were analyzed at each visit along with age, gender, total symptom severity, and chronicity.

Results: The chronic group had higher total mean CP scores at presenting visit (and all subsequent visits) as compared to the non-chronic group. Chronic and non-chronic groups had a statistically significant difference on initial/presenting visit CP scores for migraine profile (P = 0.001) and vestibular profile (P = 0.013). Chronic group mean presenting migraine profile score was 2.01/3 while non-chronic group was 1.37/3. Chronic group mean presenting vestibular profile was 1.98 while non-chronic group was mean presenting vestibular profile 1.3. The vestibular profile continued to show a statistically significant difference at the last visit between the 2 groups, with the chronic mean value of 0.91 and non-chronic mean of 0.2 (P = 0.003), while the migraine profile did not. Overall cognitive fatigue profile was the predominant profile in both groups on all presentations, but with no statistical significance at any visits.

Conclusions: Chronic/PPCS patients had higher symptom burden on presentation and throughout their course. Vestibular and migraine profiles were the significant presenting profiles in the chronic group as predictors of chronic concussion. CF was the most common and predominant profile on presentation in both groups, but does not appear to be a predictor at initial visit for PPCS development.

Significance: High presenting vestibular or migraine profiles may be predictors of PPCS. Further studies are needed to determine if predominant profiles on routine screens like the CP screen can guide earlier/aggressive management to improve outcomes.

TOPIC: Concussion

STUDY TYPE: Cohort

Validated Concussion Clinical Profiles Screening Tool Correlated With Objective Oculomotor Tracking Summary Score

Daniella Rivera, DO

All Other Authors: Joseph Marshall, BS, Luke Maes, Amal Anilkumar, Jaden Todd-Nelson, Taylor Seitz, BA, Tanya Polec, OD, and Mo Mortazavi, OD

Affiliation: Travis Family Medicine Residency, Travis AFB, CA.

Purpose: Validated clinical profile (CP) scores offer useful subjective data while screening for visual dysfunction is open to novel objective screening tools to serve as diagnostic aids. This study aims to assess the correlation between CP scores and the objective oculomotor tracking device summary score.

Methods and Study Design: Cross-sectional retrospective study of 351 encounters aged 6–77 with mTBI who completed subjective CP screen tool and objective oculomotor tracking during the same visit. The total symptom score (CP score) and individual CP scores (symptom, migraine, mood, cognitive fatigue, vestibular, visual/ocular, sleep, and cervical) were correlated to the objective oculomotor tracking summary score.

Results: Total symptom score (CP score) did have statistically significant correlation to oculomotor tracking summary score as determined with P-values that were obtained from correlation coefficients using t-distribution with n-2° of freedom. Visual/ocular, mood, vestibular, sleep, and cognitive profiles did demonstrate a statistically significant positive correlation with the objective oculomotor tracking summary score (see below). Cervical and migraine profile scores did not demonstrate a statistically significant relationship (see below). CP profile scores had the following correlations: Total Symptom Score (CP score) 0.1298 (P = 0.01496). Visual/Ocular 0.1808 (P = 0.0006660). Cognitive fatigue Profile 0.1655 (P = 0.001864). Vestibular Profile 0.1561 (P = 0.003367). Sleep 0.1317 (P = 0.01354). Mood Profile 0.1223 (P = 0.02192). Migraine Profile 0.0894 (P = 0.09447). Cervical 0.0289 (P = 0.5895).

Conclusions: A statistically significant correlation with the oculomotor tracking summary score was found with the total CP symptom score, as well as with certain profiles, most notably cognitive, vestibular, visual/ocular. The visual profile score had the most significant correlation to the oculomotor tracking device, while the cervical profile did not show a correlation.

Significance: A statistically significant correlation between subjective data from a clinically validated symptom screen and an objective oculomotor tracking device summary score highlights its potential utility as a complementary diagnostic tool in concussions.

TOPIC: Concussion

STUDY TYPE: Other

Investigating the Role of Vestibular Sway Abnormalities on Exercise Tolerance in Concussion Recovery

Ajuni Choudhary, DO, MPH

All Other Authors: Joseph Marshall, BS, Tyler Marx, BS, Brett Dusenberry, MD, Leslie Streeter, DNP, Jaden Bailey, PA-C, Tony Gross, DO, and Mo Mortazavi, DO

Affiliation: University of Arizona College of Medicine, Tucson, Arizona.

Purpose: This study investigates the correlation between exercise tolerance and sway velocity to determine whether sway velocities may be predictive of exercise tolerance.

Methods and Study Design: Concussion patients’ exercise tolerance was measured by exertional level (1 = light, 2 = moderate, 3 = vigorous, 4 = submaximal, 5 = Multi Directional High Intensity Interval Training (HIIT-MD)). Sway velocity was quantified by using force plate (FP) testing. Patients in the advanced protocol were included to evaluate FP score and exertional level via correlation coefficient and P-value calculation.

Results: Participants who completed the advanced protocol (unilateral stances with eyes opened/closed and on foam pad; n = 75) were included. The exertional level was determined by a concussion specialist based on heart rate intensity threshold prior to developing any signs/symptoms of exercise intolerance. Correlation coefficient was calculated between these 2 variables, followed by T-statistic calculation in order to determine the P-value. Correlation coefficient −0.056 T-statistic −0.475 P-value 0.318. The correlation between FP comprehensive score and exertional level was not found to be statistically significant. Although, the correlation coefficient and T-statistic are negative, suggesting that as comprehensive sway velocity decreases, the exercise tolerance increases.

Conclusions: The analysis did not show a statistically significant correlation between FP score and exertional level. However, the negative correlation coefficient and T-statistic suggest that patients with a lower (better) sway velocity score may achieve higher exertional levels. This could serve as an objective measure to assess readiness for high exercise levels and return-to-activity. Further data collection is necessary to prove statistical significance.

Significance: Sway velocity may be used as a potential predictor of exercise tolerance in post-concussive patients if proven to be statistically significant. This can play a role in providing an objective measure for return-to-activity and sport decisions.

TOPIC: Concussion

STUDY TYPE: Other

Near Point Convergence and King-Devick (KD) Testing as a Correlative to an Objective Oculomotor Tracking Tool

Ajuni Choudhary, DO, MPH

All Other Authors: Joseph Marshall, BS, Amal Anilkumar, BS, Jaden Todd-Nelson, Sanvi Lamba, Brett Dusenberry, MD, Tanya Polec, OD, and Mo Mortazavi, OD

Affiliation: University of Arizona College of Medicine, Tucson, Arizona.

Purpose: King Devick (KD) and Near Point Convergence (NPC) tests are useful clinical tools that allow for efficient visual assessment of concussion patients. This study’s goal is to investigate KD and NPCS tests correlation with objective oculomotor tracking testing (OOTT).

Methods and Study Design: Retrospective study of 336 patients aged 6–77 with a concussion. Patients underwent KD and NPC testing and subsequent OOTT. KD testing includes 3 numbered cards that are read as fast as possible and individually timed. NPC break and recovery are measured in cm. The OOTT tracked pursuit-based eye movements of a target and a summary score is calculated based on visual tracking and pursuits.

Results: Sum of all 3 KD times was correlated with the OOTT summary score to find correlation coefficient. Statistical significance was then determined. It was found that KD card times and OOTT summary score had a statistically significant summary score with a correlation coefficient of 0.20 and P-value of 0.00127. NPC break and recovery numbers were also correlated with OOTT summary score. Statistically significant relationship was found between NPC break and OOTT summary score with a correlation coefficient of 0.243 and P-value of 0.000082. Statistically significant relationship between NPC recovery and OOTT was also seen with correlation coefficient of 0.196 and P-value of 0.0015.

Conclusions: A positive statistically significant correlation was seen between OOTT summary score and both KD and NPC (break and recovery) tests. Positive correlations seem to indicate that OOTT captures components of dysfunction that are seen clinically with established KD and NPC testing. Further investigation with a diverse set of OOTT markers is needed to make definitive conclusions about OOTT’s clinical utility.

Significance: Established efficient means of evaluating oculomotor dysfunction offer great utility in evaluation and diagnosis of concussions. OOTT may serve a similar purpose in this regard. Further investigation will better determine the extent of this.

TOPIC: Concussion

STUDY TYPE: Survey

Concussion Incidence and Return-to-Play Times in Women’s Sports at a D1 College

Margarita Tsionsky, DO

All Other Authors: Robert Lutz, MD

Affiliation: Atrium Health Cabarrus; Davidson College.

Purpose: The aim of this study is to describe the concussion rates and return-to-play (RTP) times among female athlete population of Davidson college in the last 9 years and establish any patterns between different sports.

Methods and Study Design: The ATS EMR was used to generate a list of female athletes who had a PPE between 2015 and 2024. Records were reviewed to extract years played, past medical history, diagnosed concussion date, and date of clearance from the concussion. If no clearance was noted, the concussion was considered career ending. Data was analyzed in excel both for all women athletes and by team.

Results: Concussion incidence is reported in number per seasons played. Incidence of career-ending concussions is reported as a number per seasons played as well as a percentage of concussions. Time to RTP is calculated using the date of injury and date of final release from concussion monitoring protocol. Preliminary results indicate an overall incidence of 10.5 concussions per 100 player seasons amongst all evaluated women’s sports. Career-ending concussions have an overall incidence of 1.1 concussions per 100 player seasons, which represents 10% of sustained concussions. RTP time ranges between 7–254 days with a median time of 15 days and an average time of 38 days. RTP times exhibit a right-skewed distribution, with 10% of cases significantly increasing average recovery times. Current data does not indicate any relationship between duration of recovery and number of prior concussions. Further subgroup analysis of data will establish inter-sport differences in incidence and RTP between the 8 women’s sports teams analyzed.

Conclusions: The review of women’s concussion incidence and RTP times over the past 9 years establishes a baseline that allows tracking trends in incidence on an annual basis and evaluation of changes to practice routines or recovery protocols and their impact on concussion epidemiology. Subgroup analyses identify higher concussion incidence sports and establish if there is a statistically significant variability of RTP time among women’s sports.

Significance: This information, while potentially difficult to generalize to other institutions, will serve as a basis for analyzing season to season changes that may impact concussion management.

TOPIC: Education

STUDY TYPE: Other

Improving Patient Education in Sports Medicine Clinic: A Quality Improvement Project

Carolyn Landsberg, MD

All Other Authors: Nicholas Stetkevich, DO, Kirsten Schneider, MD, Phillip Ribbeck, MD, Stephanie Casella, MD, and Daren Molina, MD

Affiliation: Texas Children‘s Hospital/Baylor College of Medicine, Austin, TX.

Purpose: Patient education is vital for good outcomes. Patients rate written education as higher quality than verbal methods. At baseline, Sports Medicine providers used mostly verbal education. The aim of our quality improvement study is to improve the percentage of patients receiving written material.

Methods and Study Design: New Sports Medicine clinic patients with chronic knee conditions were included. Data for each cycle was collected for 3 months. Medical record numbers were obtained and filtered by ICD-10 codes corresponding to the diagnoses to be included. Patients’ charts were reviewed to confirm they met inclusion criteria and whether or not educational information was included in the instructions.

Results: A baseline was established using data from the 3 months prior to beginning the project. A total of 170 patients were included. Eleven (6.5%) received written patient education. For the first 3-month intervention cycle, a list of educational material options was put together and shared with all providers. Additionally, providers were reminded to include educational material at monthly faculty meetings. For the first intervention cycle, a total of 160 patients were included. Forty-two (26%) received written patient education. For the second intervention period, reminder signs were created and put up in provider workspaces. Additionally, reminder messages were sent out to each provider through the electronic medical records program at the beginning of each month. A total of 212 patients were included in the second intervention cycle. Seventy-six (36%) received written patient education, for an overall improvement of 30% from baseline.

Conclusions: Our interventions increased the percentage of Sports Medicine patients receiving written educational material. Increasing awareness of available resources and the importance of written education was helpful. Frequent reminders were also effective in improving providers’ compliance. Further interventions may include incorporating reminders to include educational material into the electronic medical records charts.

Significance: Young patients have less distress, improved adherence, and decreased school absence with all educational interventions. Including written education in patients’ charts can provide high quality education that patients can easily access at any time.

Acknowledgments: Additional thanks to Colleen Haller, Alexandra Halloran, Jackson Massanelli, and Agustina Reca for their contributions to the project.

TOPIC: Education

STUDY TYPE: Cohort

Role of a Novel Sideline Sports Coverage Curriculum in Improving Resident Comfort Providing Sideline Care

Patrick Davis, MD

All Other Authors: Cameron Smock, MD, Jessica Buttinger, MD, Cecilia Mitchell, MD, John Hollman, PT, PhD, and Amy Rabatin, MD

Affiliation: Mayo Clinic, Rochester, MN.

Purpose: To evaluate the efficacy of a novel sideline sports coverage (SSC) curriculum in improving physical medicine and rehabilitation (PM&R) resident physician comfort providing sideline coverage via 6 hands-on and didactic educational sessions covering several topics relevant to SSC.

Methods and Study Design: The SSC curriculum was developed in collaboration with PM&R and Sports Medicine faculty. Six educational sessions were delivered during the first quarter of the 2024–2025 academic year. Fifteen PM&R residents from a single institution completed pre- and post-intervention surveys (11-point Likert-type scale) to assess comfort level providing SSC and managing sports-related injuries.

Results: Pre-intervention data showed a low level of comfort among PM&R residents providing independent sideline coverage (n = 16, 3.44 ± 2.19). Post-intervention survey data showed a statistically significant improvement in overall level of comfort providing SSC (3.60 to 5.47, P P P = 0.003), understanding the basics of SSC (4.27 to 7.27, P P P = 0.005), concussion and spine care (3.67 to 6.47, P P = 0.005). Post graduate year (PGY) 3 and 4 residents reported statistically higher average comfort ratings than PGY-2 residents both pre- and post-training for overall level of comfort with SSC (P = 0.017), understanding the basics of SSC (P = 0.13), and musculoskeletal injuries (P = 0.028). There was no statistically significant difference in the degree of pre- and post-training improvement between the PGY-2 cohort and PGY-3/PGY-4 cohort.

Conclusions: The results of this study suggest that a targeted SSC educational intervention can contribute directly to improving resident comfort in providing SSC and in specific knowledge domains covered during the educational sessions. Additionally, more experienced trainees reported similar benefit compared to less experienced trainees, suggesting a benefit from this SSC curriculum regardless of prior clinical or coverage experience level.

Significance: Prior studies show that residents often do not feel comfortable providing independent SSC. This dedicated SSC curriculum directly improved resident comfort level. Residents in other residency programs may benefit from similar educational curricula.

TOPIC: Education

STUDY TYPE: Survey

Getting into the Game of Pediatric Sports Medicine Education: Effectiveness of a Pediatric Sports Medicine Curriculum

Logen Breehl, DO

All Other Authors: John C Wigal II, DO and Miraides Brown, PhD

Affiliation: Akron Children‘s Hospital.

Purpose: The primary purpose of this study was to evaluate the effectiveness of the curriculum created by the authors for a pediatric sports medicine rotation amongst medical students, pediatric and family medicine residents, with differing levels of training and sports medicine experience.

Methods and Study Design: Prospective observational cohort study of pre/post curriculum surveys by email. Surveys: 4 demographic, 4 Likert based and 5 knowledge-based questions. Post-survey also 10 curriculum evaluation questions. Curriculum: 3 independent lectures and quizzes, 1 in person/virtual board review lecture. Summary statistics all variables, plan for group comparisons and regression models once more enrolled.

Results: Five participants took pre-survey, 3 took post survey; approximately 15 more expected to enroll by spring 2025. Two pediatric and 2 family medicine residents, 1 medical student took pre-survey, 1 of each category took post. One completed prior sports med rotation. Pre-survey 60% said neutral to comfortability with MSK exam v. 60% said agree and 33% said strongly agree post. Eighty percent agreed to comfortable examining pediatric athlete pre, 100% noted strongly agree post. Sixty percent were neutral to confident diagnosing peds overuse injuries pre v. 66% noted strongly agree post. Eighty percent were neutral to confidence answering sports med board questions pre v.100% noted strongly agree post. Average score knowledge-based questions 3/5 pre, 4.3/5 post. Post-survey 100% completed the lectures, 1/3 used the additional resources, 1 very satisfied with the curriculum, 2 mostly satisfied. 2/3 felt curriculum was applicable in clinic. 2/3 felt curriculum applicable to future practice.

Conclusions: In the early stages of evaluating our curriculum participants appear to have increased their confidence and comfortability with the pediatric sports medicine exam and topics. Participants appear satisfied with curriculum, and it appears applicable to their practice. Once more have enrolled we can then begin to look at differences in level or training, prior experience and if our curriculum is significantly affecting the scores on our survey.

Significance: MSK complaints make up majority of pediatric visits, and medical school and pediatric graduates notably have low confidence and competence with MSK exam and topics. Hope to address these gaps and create a starting point for curriculum development.

Acknowledgments: Akron Children’s Sports Health, Rebecca D. Considine Research Institute.

TOPIC: Education

STUDY TYPE: Other

Efficacy of a Novel Elbow Joint Dislocation Trainer in Residency Training

Eric Daubach, MD

All Other Authors: Nicole Prendergast, MD, Nicklaus Ashburn, MD, and Cedric Lefebvre, MD

Affiliation: Wake Forest Baptist Hospital, Winston-Salem, NC.

Purpose: Half of all elbow dislocations (44.5%) occur during sport and require prompt diagnosis and appropriate management. Our team recently developed a novel elbow joint dislocation trainer. The objective of this study is to evaluate its feasibility and efficacy in residency training.

Methods and Study Design: We conducted a before-and-after study at a large academic institution from June 2023 to April 2024. Resident volunteers attempted reduction of the model while study team members collected data on procedural success (feasibility) and time to reduction. All participants returned for a second encounter. Data from the 2 sessions were compared (efficacy) by medians and interquartile ranges (IQR).

Results: During the study period, 30 residents were enrolled and each participated twice. Participants with prior exposure to the model demonstrated improved rates of successful reduction and faster time to reduction of elbow dislocation. Median time to achieve successful reduction was 19.5 seconds (IQR 13.0, 24.0) among first-time participants and 9.8 seconds (IQR 7.0, 12.0) for second-time participants. Median time to start applying force to the task trainer for first-time participants was 11.0 seconds (IQR 4.0, 13.0) compared to 4.9 seconds (IQR 4.0, 6.0) for second-time participants.

Conclusions: Our novel elbow dislocation reduction trainer was associated with improved time to reduction and time to begin the reduction on the second use of the model compared to the first. It may be possible to use this model to enhance trainee proficiency and confidence with joint reductions in clinical practice. This raises the potential advantage of simulation training to provide an educational environment to practice a particularly painful procedure.

Significance: This study introduces a dislocation reduction trainer and opens avenues for future procedural education research extending to trainees in multiple medical specialties that encounter joint dislocation such as sports medicine and athletic training.

TOPIC: Education

STUDY TYPE: Survey

An Analysis of Interview Formats for Primary Care Sports Medicine Fellowships

Justin Chu, MD

All Other Authors: Matthew Leiszler, MD, Siobhan Statuta, MD, and Jordan Hilgefort, MD

Affiliation: University of Louisville, Louisville, KY.

Purpose: Primary care sports medicine fellowships across the country conduct fellowship interviews in different formats (virtual, in-person, and hybrid). Fellowship applicants are forced to create a Rank Order List based on difficult comparisons from varying interview experiences.

Methods and Study Design: Two surveys will be administered using REDCap. One survey will be for sports medicine program directors. A second survey will be for recent graduates of sports medicine fellowship, current fellows, and current applicants for primary care sports medicine.

Results: A total of 23 fellowship applicants & 52 program directors completed the survey. All applicants participated in virtual interviews, with 73.9% attending in-person interviews (mostly between 1 and 4) and 26.1% using a hybrid format. Hybrid interviews were least preferred by applicants (60.9% rated as least favorite), while in-person interviews were most favored (54.5%). Among program directors, 51.9% offered virtual interviews, 32.7% in-person, and 25% hybrid formats. Directors strongly preferred in-person interviews (75% rated as favorite) over virtual (15.4%). Applicants expressed concerns about disadvantages of virtual interviews when in-person options were available (87%), & 82.6% said there were interviews they wouldn’t have been able to attend if not for virtual format. Directors found signaling to influence interview offers (57.7%), but fewer thought it would affect rank lists (30.8%). Engagement levels were higher in in-person settings for both groups. Overall, 100% of applicants and 96.2% of directors were satisfied with their fellowship matches.

Conclusions: Primary care sports medicine fellowship applicants and program directors are forced to create a rank order list by comparing differing interview experiences. Currently, there is no standardization for what types of interviews are offered to applicants. The findings from this study demonstrate that applicants are primarily participating in virtual interviews. A majority of program directors (91%) and fellows (80%) are happy with their match.

Significance: This study helps analyze the current outlook on the primary care sports medicine fellowship interview format. Additional research needs to be completed to determine the next steps to make the experience favorable for both the applicant and program.

Acknowledgments: The authors would like to thank Drs. Megan Agnew and Stephanie Kliethermes for their assistance in survey design and the Fellows-Matters subcommittee for their feedback on the survey questions.

TOPIC: Education

STUDY TYPE: Survey

A Day in Sports Medicine: Outreach and Education for Mid-Michigan Youth

Udit Thawani, BS

All Other Authors: Nicholas Chiaramonti, MS, Kayleigh Crane, BS, Michael Wolohan, MD, and Angel Bermudez, MD

Affiliation: Central Michigan University College of Medicine, Saginaw, Michigan.

Purpose: This study aimed to assess the impact of thorough exposure to sports medicine careers on high school students’ self-reported interest in and knowledge of sports medicine. Using the AMSSM Agostini grant, a creative program exposed local high schoolers in Mid-Michigan to sports medicine.

Methods and Study Design: This was a survey-based study in which 20 high school students completed surveys before and after undergoing a 4-hour program. Responses were anonymous and correlated using a unique identifier. In the surveys, students reported their knowledge of and interest in sports medicine on a scale from 1 to 5, with 1 corresponding to minimal knowledge/interest, and 5 corresponding to vast knowledge/interest.

Results: Of the 20 participants who completed the pre-event and post-event surveys, all but one reported an increased knowledge of the field of sports medicine after the event. On a 5-point Likert scale as detailed above, students rated their knowledge as 2.25 pre-event, and this increased to 3.85 post-event. This indicates a 71.11% increase in the group’s self-reported knowledge of sports medicine after the programming. Interest in pursuing a career within the field of sports medicine also increased after the event, from 3.65 pre-event, to 4.3 after the event, indicating a 17.81% increase in this metric. Subjectively, 100% of surveyed participants reported that they enjoyed the program and found the sessions informative. Several participants expressed a desire to have this program occur annually.

Conclusions: The program accomplished its purpose of providing sports medicine exposure to high schoolers. Students completed a sports physical, interacted with pre-medical and medical students, and listened to a board-certified sports medicine physician. After this programming, responses demonstrated a measurable increase in students’ knowledge of and interest in sports medicine, showing efficacy and possible utility for underrepresented populations.

Significance: The findings demonstrate the efficacy of outreach programs to engage the next generation of physicians and sports medicine providers. Such programs can benefit students who otherwise may not have exposure to career opportunities in sports medicine.

Acknowledgments: This programming was supported by the AMSSM Agostini Grant, Mid-Michigan AHEC, Saginaw Valley State University, and Central Michigan University.

TOPIC: Education

STUDY TYPE: Other

Magnetic Resonance Imaging (MRI) Measurements in Patients With a History of Patellar Dislocation

Alexis Acernese, MD

All Other Authors: Kaitlyn Mamak, MD, Weiping Zhang, MD, Hunter Buchanan, DO, Jason Epstein, MD, Kelsie Sirak, MD, and Christopher Mehallo, DO, DO

Affiliation: Rothman Orthopaedics, Orlando, Florida.

Purpose: Tibial tubercle-trochlear groove (TT-TG) and tibial tubercle-posterior cruciate ligament (TT-PCL) distances were compared in patients with patellar dislocation history. TT-TG is influenced by femoral morphology, so it was hypothesized that TT-PCL is a more accurate predictor of dislocation risk.

Methods and Study Design: This is a retrospective study. Patients with history of patellar dislocation and MRI images available for review in a single institution over a period of 5 years were included. TT-TG and TT-PCL distances were measured. Patella Alta (Insall-Salvati ratio) and trochlear angle were measured. General demographic information, number of dislocations and surgical intervention were also collected.

Results: This study included 392 patients with MRI-confirmed patellar dislocations; there was a mean age 23.5 years, with 198 (50.5%) female. 229 (58.4%) had one dislocation, and 163 (41.6%) had 2 or more. Elevated TT-TG distance was found in 195 (57.4%), and elevated TT-PCL distance in 103 (33.9%). Mean TT-TG and TT-PCL distances were 15.8 mm and 22.8 mm, respectively. Patella Alta was observed in 230 (68.5%), and the mean trochlear angle was 142. Patients with elevated TT-TG (>15 mm) were more likely to also have elevated TT-PCL (>24 mm) (P 145) were not significant risks for multiple dislocations. Males were more likely than females to have elevated TT-TG (P P

Conclusions: This study hypothesized that TT-PCL distance was a more accurate measurement to determine risk for initial or recurrent patellar dislocation. However, only 33.9% had elevated TT-PCL, which did not increase the risk of initial or recurrent dislocation. Elevated TT-TG was more common in the population. Males were more likely than females to have elevated TT-TG and TT-PCL distances.

Significance: The lack of statistical significance between TT-PCL and the history or recurrence of patellar dislocation does not support its use as a superior clinical measure to those currently available. Normal TT-TG and TT-PCL distances also differ by gender.

TOPIC: Education

STUDY TYPE: Survey

The State of Sports Ultrasound Education and Training Among Sports Medicine Fellowships 2023–2024

Derek Stokes, MD

All Other Authors: Masaru Teramoto, PhD, MPH, PStat, Kayle Noble-Taylor, DO, Carlton Covey, MD, and Oluseun Olufade, MD

Affiliation: University of Colorado, Aurora, CO.

Purpose: The purpose of this study is to assess current sports ultrasound educational practices among sports medicine fellowships and to evaluate training effectiveness as it relates to self-reported confidence levels. This information will be utilized to inform future sports ultrasound educational efforts.

Methods and Study Design: Cross-sectional survey design conducted by the AMSSM Ultrasound Committee—2023–2024 primary care sports medicine fellows were eligible for inclusion. Survey format included 27 multiple choice or 5-point Likert-type scale questions. Descriptive statistics, correlation coefficients, and multivariate analysis were utilized to identify associations between training types and confidence ratings.

Results: Eighty-eight sports medicine fellows participated in this survey. 72.7% indicated that their fellowship program followed a formalized sports ultrasound curriculum. All fellows reported access to ultrasound and 93.2% reported formal ultrasound skill assessment at least once per year. Most fellows (64.8–98.9%) reported a high degree of confidence (e.g., fairly/completely confident) for ultrasound basics, while ratings for regional diagnostic ultrasound scans were more heterogenous (most common—fairly confident). Time spent in clinical setting was associated with higher confidence ratings in 6 of 7 ultrasound basics categories. Time spent on practical, hands-on instruction and self-directed, independent learning revealed significant associations with confidence ratings for all diagnostic ultrasound scans. Multivariate analysis identified that no single type of training was superior for training of ultrasound basics, while practical, hands-on instruction and self-directed, independent learning showed superior associations with confidence ratings for diagnostic scans.

Conclusions: This study aids in the understanding of sports ultrasound training among fellows in sports medicine training. Most fellows are participating in formalized sports ultrasound curriculum. Confidence ratings of ultrasound basics were high overall. Confidence ratings for regional diagnostic scans varied with the strongest associations being identified with time spent on practical, hands-on instruction and self-directed, independent learning.

Significance: The findings of this study help to provide an understanding for several aspects of sports ultrasound training during fellowship and may provide additional information to help programs optimize training when developing curricula.

Acknowledgments: AMSSM Ultrasound Committee and participating 2023–2024 primary care sports medicine fellows.

TOPIC: Education

STUDY TYPE: Other

Increasing Disparities in Arthroscopic Case Volumes Among Orthopaedic Residents: A Long-term Review

Humberto Cardona, BSN, MSMS

All Other Authors: Joshua Hancock, BS, Raahil Patel, MD, Jordan Larson, BS, and D. Trey Remaley, DO

Affiliation: FORE, Tampa, Florida.

Purpose: With the broadening of arthroscopy’s surgical applications, adequate exposure to arthroscopic cases is crucial during orthopaedic residency to ensure sports medicine competency. This study evaluated arthroscopic case volumes among graduating orthopaedic surgery residents (GOSRs) from 2014 to 2024.

Methods and Study Design: Publicly available case log data reported by the Accreditation Council for Graduate Medical Education (ACGME) of 8,247 GOSRs was assessed for hip, knee, and shoulder arthroscopy. Mean case volumes from 2014 to 2024 were compared. Trends in the differences in case volumes between the 10th and 90th percentiles from 2014 to 2024 were analyzed using Spearman correlation (ρ) and linear regression.

Results: Between 2014 (n = 684) and 2024 (n = 871), mean arthroscopy case volumes significantly increased in the hip (+106.4%, 4.7 vs. 9.7, P P P = 0.125). Fold-differences in case volumes between the 10th and 90th percentiles were undefined in hip (0 vs. 14–25) and ranged from 3.4–3.9x in shoulder (28–34 vs. 108–114) and 2.6–3.1x in knee (63–64 vs. 168–194). The differences between the 10th and 90th percentiles experienced significant year-over-year increases throughout the study period in the hip (+0.70 cases/year, ρ = 0.679, P = 0.022), shoulder (+3.25 cases/year, ρ = 0.902, P P = 0.016), indicating a significantly increasing gap in arthroscopic case volumes between the lowest- and highest-volume residents.

Conclusions: Mean arthroscopic caseloads have increased since the institution of case minimums in 2013; however, there is a growing gap in hip, shoulder, and knee arthroscopy case volumes between the top and bottom decile GOSRs. Identifying and quantifying these disparities are the first steps in ensuring that each GOSR obtains the proper breadth and depth of arthroscopic experience.

Significance: Evaluation of long-term arthroscopic case volume trends can offer residency directors, fellowship directors, and accreditation bodies insight into the range of orthopaedic surgery residency experiences, which may help guide future policy decisions.

TOPIC: Education

STUDY TYPE: Other

From Algorithms to Injections: Evaluating AI Generated Patient Materials for PRP

Andrew Roberts, MD

All Other Authors: Megan Lyden, BS, Aman Kapadia, BS, and Roderick Geer, MD

Affiliation: Physical Medicine & Rehabilitation MedStar NRH/Georgetown University, Washington, DC.

Purpose: To evaluate the content and quality of AI Chatbot generated patient education materials using the most commonly searched questions about Platelet-Rich Plasma (PRP).

Methods and Study Design: The top 4 clinically relevant Google Trends searches for PRP were selected and entered into 4 free and common public AI Chatbots. Each chatbot search response was evaluated using 5 outcome measures: A) DISCERN instrument, B) PEMAT understandability and actionability, C) Likert scale for clinical misinformation, D) Flesh-Kincaid readability and grade-level, E) presence of commercial bias.

Results: Average Discern item response score was 3.08, highest in Google Gemini (3.29) and “PRP Injection” (3.5). Average PEMAT Understandability was 82% and Actionability 21%. Understandability was highest in Google Gemini and Microsoft CoPilot (83%) and “What is PRP” (88%). Actionability was highest in Google Gemini (40%) and “PRP Cost” (45%). Average Flesch-Kincaid Readability was 38.18, highest in Google Gemini (40) and “PRP injection” (41.9). Average reading grade-level was 12.96, highest in ChatGPT (14.5) and “PRP Cost” (13.45), and lowest in Google Gemini (9.8). No commercial bias or clear misinformation was noted. ANOVA for Readability (alpha P = 0.001547) showed statistical significance across chatbots, with further Bonferroni corrected alpha (P P = 0.005), Gemini vs. Copilot (53.5 vs. 38.35; P = 0.011), and Perplexity vs. Gemini (31.8 vs. 53.5; P = 0.003).

Conclusions: AI chatbot responses for PRP demonstrate low readability and actionability, while requiring an advanced reading comprehension compared to the national average 7th–8th grade reading level. Given the statistical superiority for readability with the lowest reading grade level, Google Gemini may be the most effective at communicating PRP-related information for the average patient across AI chatbots.

Significance: AI Chatbots provide patients with moderate quality PRP-related information without commercial bias or misinformation. Google Gemini offers more accessible knowledge given its superior readability and closeness to the national average reading level.

TOPIC: Education

STUDY TYPE: Survey

Current Landscape of Regenerative Medicine Education and Training in PMR Residency Programs

Kevin De Jesus, MD

All Other Authors: Humberto Ramirez-Negron, MD, Ivan Perez, MD, Jose Quintana, MD, and Fernando Sepulveda-Irizarry, MD

Affiliation: University of Puerto Rico—School of Medicine, San Juan, PR.

Purpose: To evaluate the implementation and extent of Regenerative Medicine education and training in PM&R residency programs, and to assess resident exposure and preparedness upon graduation.

Methods and Study Design: An online survey was conducted among program directors of PM&R residency programs across the United States from August 1, 2024 to October 1, 2024. The survey was created in the REDCap platform and was distributed via email with contact information from the American Medical Association Residency & Fellowship Database or the program’s website. Program directors could appoint a faculty member if needed.

Results: A total of 28 programs completed the survey (25.0% response rate), with 82.1% being University-based. Half (50.0%) reported not offering Regenerative Medicine (RM) education. Programs with RM curricula cover areas such as basic science (85.7%), evidence-based applications (78.6%), and contraindications (71.4%), dedicating 1–5 hours annually, mainly in theoretical format. Common educational activities include lectures (85.7%), journal clubs, and clinical rotations (both 57.1%). For evaluation, 42.9% use direct observation, 35.7% use case-based discussions, while 35.7% have no formal evaluation. Hands-on practice averages 13.4 ± 14.8 hours, primarily in platelet-rich plasma injections (9.4 ± 9.9 cases per resident). Only 50.0% have residents involved in RM research, with 28% of program directors rating residents as proficient in RM knowledge and 15.6% in procedures. Upon graduation, most residents (46.2%) are rated as Novice on the NIH proficiency scale.

Conclusions: Only half of responding PM&R residency programs offer Regenerative Medicine (RM) education, primarily in theoretical formats with limited clinical exposure. Few residents gain substantial hands-on experience or engage in RM research, with most achieving a Novice skill level upon graduation. Efforts to enhance RM education, expand hands-on training, and improve resident preparedness are needed to meet future demands.

Significance: This study highlights gaps in RM education and training in PM&R programs, highlighting the need for enhanced curricula to better prepare residents for future practice.

Acknowledgments: We extend our sincere gratitude to Dr. Charles Kenyon, Dr. Luis Baerga, Dr. Gerardo Miranda-Comas, and Dr. Tracy Espiritu-McKay for their invaluable insights as expert panel members during the survey development phase. We also thank the program directors who generously took the time to complete our survey, providing essential data for this study.

TOPIC: Epidemiology

STUDY TYPE: Survey

Pain in Pickle Ball: A Survey Diving into the Demographics of Injuries Occurring in the Growing Sport of Pickleball

Bryan Wacker, DO

All Other Authors: Zacharie Finneman, DO, Brian Toedebusch, MD, and William Arnold, MD

Affiliation: University of Missouri Department of Physical Medicine and Rehabilitation.

Purpose: With the growing popularity of pickleball, sports medicine clinics are seeing an abundant number of patients seeking evaluation for injuries sustained during play. The aim of this survey was to examine the relationship of gender to pickleball injury characteristics and treatments.

Methods and Study Design: A 12-question survey was distributed via social media to the Missouri pickleball community. Participants provided data on demographics, frequency of play, number of injuries, injury type, location or injury, treatments and duration of recovery. Statistical analysis was completed with Fisher’s Exact Test and Mann-Whitney U test to identify injury trends and risk factors.

Results: Eighty-nine total surveys were completed, 60 females and 29 males. The average age of participant was 55 with a SD = 14 and age range between 20 and 79. The most common injury was muscle strain/tear (51%) with a majority occurring in the lower extremity. Fifty-three percent of participants were evaluated by a physician after injury with the most common treatment being medications and rest. Physical therapy was prescribed in 32% of patients and surgery was completed for 8% of injuries. The most common duration for injury recovery was 1–6 months. Three correlations were found to be statistically significant between gender, injury, and treatment. In female players, increasing age was associated with less injuries (P = 0.008) but longer recovery times (P = 0.01). Male players who participated in pickleball for longer periods of time sustained higher number of injuries (P = 0.01). There was no significant correlation between fracture occurrence in males or females (P = 0.26). There was no significant increase in injuries seen with males (P = 0.35) or females (P = 0.39) who played at a higher frequency.

Conclusions: Overall, data shows a longer duration of pickleball play was associated with higher number of injuries in males but not females. In females, older players sustained fewer injuries but have a longer duration of recovery. Several gender correlations did not show any significance between fracture risk, playing frequency and injury risk, as well as likelihood to seek physician evaluation.

Significance: The data collected provides insight into the demographics of injuries in the growing sport of pickleball. These results can be used to promote awareness and develop future injury prevention strategies for this rapidly growing sport.

Acknowledgments: University of Missouri Physical Medicine and Rehabilitation.

TOPIC: Epidemiology

STUDY TYPE: Other

Judo-Related Injuries in the US: A Descriptive Analysis of NEISS Data From Emergency Departments (2014–2023)

Anthony Kwon, MD

All Other Authors: Maya Ushijima, MS and Justin Mark J. Young, MD

Affiliation: John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii.

Purpose: There is limited current literature on judo-specific injury data in the U.S. The primary purpose of this study is to evaluate judo-related injuries in U.S. emergency departments from 2014 to 2023, by identifying the most common diagnoses, body parts injured, and mechanisms of injury.

Methods and Study Design: The U.S. Consumer Product Safety Commission’s (CPSC) National Electronic Injury Surveillance System (NEISS) database was queried for martial arts-related injuries, focusing on judo. From this retrospective review, injury codes, and narratives were then further analyzed for judo-related cases, examining patient demographics, injury types, and mechanisms to generate a detailed injury profile.

Results: A total of 7525 martial arts-related ER visits were selected for review, and of those cases, 234 were found to be judo-specific. Fractures (25%), sprains/strains (25%), and other injuries (14%) were the most commonly reported type of injury. The shoulder (18%), head (14%), and ankle (9%) were the most frequently injured body parts. Among fractures, 32% involved the shoulder, with 84% of shoulder fractures identified the clavicle as the injured bone. Of the sprains/strains, ankle (28%), knee (17%), and shoulder (14%) sprains were most prevalent. The most common mechanisms of injury were “not listed” (28%), during takedown maneuvers (21%), falls onto ground or opponent falling onto the participant (18%), and contact from another opponent (14%). Head injuries were most frequent in teenagers (27%), followed by 9–12-year-olds (24%), and 20–24-year-olds (20%). The primary cause of head injuries was contact with the mat (56%).

Conclusions: Judo participants sustained fractures and sprains/strains most frequently in the shoulder, ankle, and knee. Shoulder fractures were often clavicular. Teenagers experienced the highest number of reported head injuries, typically from mat contact. Further studies are needed to validate these findings and enhance safety measures in judo.

Significance: This study provides an updated profile of injuries among judo participants in U.S. emergency departments. Children and teenagers may be at increased risk for head injuries. Further research is needed to explore these risks and improve safety in judo.

Acknowledgments: We would like to thank the Hawaii Pacific Health Research Institute and Andrea Sid, MPH, RAC for their support of this study.

TOPIC: Epidemiology

STUDY TYPE: Other

The Effect of Pitch Clock Rules on Pitching Injuries in MiLB from 2012 to 2024

Scott Goodsell, DO

All Other Authors: T. Jason Meredith, MD, Samuel J. Wilkins, PhD, and Adam B. Rosen, PhD

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

Purpose: The impact of pitch clock rules in professional baseball on pitcher health and safety remains unclear. This study examines the relationship between pitch clock regulations and the number of days pitchers spent on the injury list (IL) in minor league baseball (MiLB).

Methods and Study Design: Data was obtained from a public database containing all MiLB IL entries for the 2012–2024 seasons. Pitching injuries were placed into one of 3 groups: Group 1 (no pitch clock rules), Group 2 (original pitch clock rules), and Group 3 (updated pitch clock rules with disengagement limits). A 1-way ANOVA, Tukey’s post hoc tests, Levene’s test, and effect size calculations were completed.

Results: In total, 11795 injuries were reported across the 2012–2024 seasons and included in the analysis. Significant differences were observed among the groups in days spent on the IL (P P P

Conclusions: The updated pitch clock rules were associated with longer appearances on the IL, suggesting potential unintended consequences of increased game pace and limited disengagement opportunities. Conversely, the absence of a pitch clock and the original rules were associated with shorter injury durations. These findings highlight the need for further investigation into the physical demands and recovery implications of pitch clock regulations.

Significance: The pitch clock has been present in MiLB in some form since 2015. No previous published study has utilized this large data pool to assess the role that the pitch clock may (or may not) play in professional baseball pitcher injury rates and severity.

TOPIC: Epidemiology

STUDY TYPE: Other

Is the Last Run Worth It? Evaluating Skiing and Snowboarding Injuries at a Large Western Ski Clinic by Time of Day

Jennifer Kordell, MD

All Other Authors: Jennifer Horton, MD, Aaron Provance, MD, Jamie Egbert, BS, MPH, Luke Johnson, BS, Masaru Teramoto, PhD, MPH, Daniel M. Cushman, MD, Stuart Willick, MD, and Stuart Willick, MD

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

Purpose: Anecdotal evidence suggests that as the day progresses, fatigue increases the risk of skiing and snowboarding injuries. Limited data exist to confirm this hypothesis. Our study analyzed severity of injuries over different times of day at a major Western ski clinic over 4 seasons (2020–2024).

Methods and Study Design: We conducted a retrospective chart review of more than 4,800 new-mountain injury encounters during the 2020/2021–2023/2024 winter seasons. Encounters were classified as severe if narcotics were administered or codes for splinting, fractures, or dislocations were used. Data was further stratified by variables including age, sex, mechanism of injury, injury location, and time of day.

Results: Overall, 19.9% of total new-mountain injuries were classified as severe injuries, with males sustaining severe injuries more frequently than females (21% vs 18.2% respectively). Severe injuries more frequently presented from 11 am–12 pm (22.9%) and 3–4 pm (22.2%). No statistical significance was identified between injury severity and time of day. There was an overall male predominance in ski clinic presentations (60.9% of total new-mountain injuries), but the margin between male and female injuries overall is narrower at the end of the day with females making up 42.9%, 43.2%, and 48.2% of total new-mountain injuries from 3–4 pm, 4–5 pm, and 5–6 pm respectively. Injury frequency by time of day showed 29% of total new-mountain injury encounters occurred before 12pm versus 71% occurring after 12 pm, but exposure data are unknown throughout the times of day.

Conclusions: This study found no significant correlation between injury severity and time of day. In accordance with previous studies, the majority of injuries were sustained by males. Males also suffered more severe injuries in our study. The total number of injuries increased in the afternoon and evening hours. The proportion of female injury encounters increased with the time of day. Future research will investigate this injury pattern among females.

Significance: This study challenges the belief that snow sports injuries increase in severity and frequency throughout the day. However, confounding factors such as injuries from prior days, treatment at other clinics, and lack of exposure data must be considered.

Acknowledgments: Meredith Ehn, DO.

TOPIC: Epidemiology

STUDY TYPE: Cohort

Epidemiology of Ski and Snowboard Injuries at a Large Western Ski Resort

Jennifer Horton, MD

All Other Authors: Jennifer Kordell, MD, Aaron Provance, MD, Jamie Egbert, BS, MPH, Luke Johnson, BS, Masaru Teramoto, PhD, MPH, Daniel M. Cushman, MD, Stuart Willick, MD, and Stuart Willick, MD

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

Purpose: Winter sports participants are at risk for a variety of injuries. The purpose of this study is to characterize the demographics and epidemiologic characteristics of injuries evaluated at a large western ski resort medical clinic over 4 consecutive seasons from 2020 to 2024.

Methods and Study Design: Data were collected retrospectively for all encounters during the 2020/2021–2023/2024 winter seasons. We included new mountain injury visits presenting to clinic and excluded follow-up visits and non-mountain injuries or illnesses. The data was analyzed and stratified by variables such as age, gender, mechanism of injury, injury location, and location of the patient’s primary residence.

Results: Preliminary data revealed a total of 3,778 new mountain injury visits with a clear male predominance (60.9%). Alpine skiers made up 77% of injury presentations, with snowboarders comprising the remaining 23%. The largest percentage (24%) of injuries were sustained in patients aged 26–35 years old, with 21% in 18–25 years old, and 13% in 46–55 years old. Injuries were most often sustained when patients “caught an edge” (47.8%), while other mechanisms of injury included “out of control” (13.3%), “twisted an extremity” (12.1%), “collided with a natural object” (9.2%), and “fell on an outstretched arm” (4.9%). Patients most frequently presented with knee injuries (33.8%); the shoulders (14%) and head (7.7%) were also commonly injured. Lower extremity injuries (56% of injuries) presented via Ski Patrol more often despite only 44.7% of patients arriving via sled, whereas upper extremity injuries (68.7%) usually walked into clinic. Out-of-state patients comprised 70.6% of reported injuries.

Conclusions: Previous studies have demonstrated an increased occurrence of lower extremity injuries in skiers, given the typical mechanism of injury of “catching an edge,” as well as a significant male predominance in patients presenting to ski clinics. This study confirms the aforementioned findings and shows that individuals aged 26–35 years are most likely to sustain snow sport injuries, particularly of the knee, regardless of sex.

Significance: These data provide additional insight into the epidemiology of winter sport injuries, which can inform providers who care for these patients, ensure ski resorts are equipped to manage such injuries, and inform targeted injury prevention strategies.

Acknowledgments: The authors would like to acknowledge the invaluable contributions of Meredith Ehn CAQSM, DO, DPT for their expertise on the epidemiology of skiing injuries.

TOPIC: Epidemiology

STUDY TYPE: Survey

Urogenital Overuse Injuries in Professional/Elite Cyclists With Labia/Vulvas

Luci Olewinski, MD

All Other Authors: Jill Maples, PhD, Calla Walters, MD, and Paige Johnson, MD

Affiliation: University of Tennessee Health Science Center College of Medicine, Knoxville.

Purpose: To survey elite cyclists with labia/vulvas to better understand the prevalence of urogenital overuse injuries (saddle health) in this sporting population, the impact this has on their cycling careers and their life off the bike, and the prevention, mitigation, or treatment strategies they use.

Methods and Study Design: Novel mixed methods survey with questions on pain, numbness, abrasions, ulcerations, folliculitis, abscesses, and non-infected swelling. Questions focused on issues unique to athletes who rely on cycling as part of their career. Surveys were distributed via The Cyclist Alliance, a union for professional cyclists with approximately 200 members, with an option for forwarding the link to the survey.

Results: Sixteen eligible racers (11 pro/5 elite) were included in this descriptive analysis. All had pain with riding, most (greater than 80%) had issues with abrasions, ulcerations, abscesses and non-infected swelling that impaired their training; and in the case of pain, ulcerations, and abscesses, their racing performance. Our hypothesis that core/strength training would help by leading to more stability on the bike could not be proven as few racers had tried this as an intervention. Across all issues racers tended to try chamois cream, changing chamois type, switching saddles, or a bike fit as solutions, with chamois cream, chamois type, and saddle style being the most helpful. Over half reported a prior bike fit that contributed negatively to their saddle health; most (greater than 90%) felt like their labia “got in the way” while cycling. Swelling persisted permanently in 5 of the 14 racers with swelling, 4 had considered labioplasty to improve saddle health (with one having had surgery).

Conclusions: In a volunteer sample urogenital overuse injuries were common and had a negative impact on training and racing. Bike fits were not always helpful; saddles and chamois were both contributors to and alleviators of issues. More research with a larger sample size and known denominator is needed to determine true prevalence and impact of urogenital overuse injuries among elite/professional cyclists with vulvas, a unique cohort not previously studied.

Significance: This is the first study on how saddle health impacts professional and elite cyclists’ careers and is part of a wider movement to (1) gather evidence to replace anecdotes to prevent and treat saddle sores, (2) break the taboo on discussing saddle health.

Acknowledgments: Thank you to all the racers who participated! No prior published study had respondents at the elite and professional level, and pro racers comment that they are scared to discuss this with team staff for fear of being seen as either not fit to race or as a problematic team member.

TOPIC: Epidemiology

STUDY TYPE: Survey

Hula Dance-Related Injuries on Oahu and the Effect of Intense Hula Training on Injury Rates

Courtney Taum, MD

All Other Authors: Andrew Nichols, MD, Chathura Siriwardhana, PhD, and Jennifer King, DO

Affiliation: University of Hawai’i Sports Medicine Fellowship, Department of Family Medicine & Community Health Honolulu, Hawai’i.

Purpose: To identify the incidence and most common types of injuries that affect adult hula dancers on the island of O’ahu, Hawai’i and to evaluate the impact of periods of intensive training on hula injury rates.

Methods and Study Design: An on-line 56-question survey was distributed to hula dancers (>17 years) via 20 hula schools (hālau) on the island of O’ahu. The survey included questions on dancer demographics, dance history, prior hula injuries, and injury management. Data were analyzed using simple statistics and a Fisher’s-exact test to determine if increased injury rates were related to periods of more intense training.

Results: Of the 106 hula dancer survey participants (mean age 47 years old; range 18–82 years old; 14% Male, 86% Female), 59% identified as Native Hawaiian/Pacific Islander, 27% as Asian, and 9% as Caucasian. Fifty percent of dancers had >20 years of hula dance experience. Underlying health conditions affected 50% of dancers, with hypertension being the most common (22%). Seventy-eight percent had previously engaged in intense pre-competition training (>50% increase from baseline for >2 weeks). Average practice time increased from 3 hours/week to 5 hours/week during intense training and lasted >6 weeks for 47% of dancers. Overall, 48% of dancers reported hula injuries, with 46% occurring within the last 12 months, and 74% of those during periods of intense training. The most common injury sites were knee (51%) and foot (11%), and the most common type was muscle strain (44%). Forty percent of injuries were self-diagnosed and 29% by a physician. Injuries more frequently affected dancers who engaged in periods of intense training (54%) compared to those who did not (27%) (P = 0.03; OR = 3.1).

Conclusions: The most commonly reported hula dance related injuries were strains of the knee and foot. Injuries were more common during periods of intense training in preparation for competitions or special events. Future studies should focus on greater numbers of participants and expanded geographical reach.

Significance: The art of hula dancing has been an important component of Hawaiian culture for many generations. This is the first study to identify the most common injuries in adult hula dancers and its association with intense pre-competition training.

Acknowledgments: Mahalo nui to the halau and hula dancers on Oahu who participated in the survey.

TOPIC: Epidemiology

STUDY TYPE: Cohort

Epidemiology of Hamstring Injuries in the United States Emergency Departments 2014–2023

Nathan Michalak, MD

All Other Authors: Petra Aboulhosn, MD and Shane M. Drakes, MD

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

Purpose: Hamstring injuries (HSI) are common in athletes and can lead to prolonged absence from sport. We aim to analyze the trend of HSI over time in a variety of sports and provide insight for injury prevention recommendations.

Methods and Study Design: Data on HSI within the National Electronic Injury Surveillance System were analyzed over a 10-year period (2014–2023). The database was queried for cases in the “Sports and Recreational Equipment” product group. HSI were identified by filtering the “Narrative” field for the word “hamstring.” Sports-related HSI were identified by checking product codes that were sport-related activities (50 codes).

Results: A total of 1364 HSI were identified between January 2014 and December 2023. Of these, 1332 were deemed sport-related hamstring injuries. Injuries were most common in the 11–15 and 16–20 age groups (19.5% and 19.6%, respectively). Males represented the majority of patients (70.0%). Caucasian race constituted about 34.8% of all injuries followed by 23.7% of athletes being African American, although 33.0% did not specify race. Except for 2020, where only 87 (6.5%) sport-related HSI were reported, there were a similar number of injuries each year with a mean of 131 (9.86%, SD 22) cases per year. The category “exercise” had the highest incidence of HSI (22.7%). The 3 most common specific sporting activities with HSI were football (10.4%), soccer (8.9%), track & field (7.1%).

Conclusions: The most common sports with HSI presenting to United States emergency departments were football, soccer and track & field. The incidence of sport-related HSI appears to remain constant over time. These data suggest that there is unmet need for addressing HSI prevention as well as further understanding risk factors for HSI in athletes at each level of sport.

Significance: HSI cause significant morbidity and time lost from sports. Analyzing these injury patterns highlights the need for risk assessment and targeted prevention strategies to reduce the burden of hamstring injuries in high-risk sports.

TOPIC: Epidemiology

STUDY TYPE: Survey

Bowel Habits of Collegiate Club Athletes and Changes Associated With Competition

Genevra Stone, MD, OLY

All Other Authors: Masaru Teramoto, PhD, MPH, PStat and Brett Toresdahl, MD

Affiliation: Cambridge Health Alliance, Cambridge, MA.

Purpose: Little is known about athletes’ bowel habits and their effect on athletic performance. This study aimed to evaluate bowel habits in collegiate club athletes in order to determine the impact on performance, differences between training and competition days, and differences between sports.

Methods and Study Design: A cross-sectional survey was distributed to athletes of PAC-12 winter and spring club sports by athletic trainers and team representatives. Data collected included demographics, sport, bowel habits on practice and competition days, and the perceived effect of bowel habits on performance. Data were analyzed using descriptive statistics and rank-based nonparametric tests.

Results: The survey was completed by 150 athletes (47.3% females; mean age 20.6; 12 sports). Most athletes reported 1–2 bowel movements (BMs) daily (79.4% practice vs 64.0% competition). On competition days, 35.3% of athletes reported increased BMs (21.3% lesser, 43.4% unchanged; P = 0.023). Bristol scale of 3–4 (regarded as normal within GI literature) was more common on practice days (64.0%) than competition days (41.4%). 21.3% of athletes reported that bowel habits had a moderate or major effect on performance on competition days, which was significantly higher than on practice days (10.6%, P P P P = 0.027).

Conclusions: Many athletes reported softer stool, greater urgency, and more abdominal discomfort on competition days. While one-third had an increase in BMs on competition days, the majority stayed within normal range (0.5–2.0 daily per GI literature). Softer stools on competition days were more prevalent in endurance sports than ball sports. One in 5 athletes reported these bowel habits affected performance to a moderate or major extent on competition days.

Significance: This study shows many athletes experience bowel habit changes on competition days and have their performance affected by bowel habits. More research and athlete education is needed to address the negative effects of bowel habits on performance.

Acknowledgments: Thank you to the University of Utah and to the athletes who completed the survey.

TOPIC: Epidemiology

STUDY TYPE: Other

Recorded Intra-Event Medical Encounters Among Athletes With Pre-Existing Endocrinopathies at the Boston Marathon

Courtney Duckworth, MD

All Other Authors: Emma Gossman, BS, Olivia Elie, Maggie Jones, MD, Alexandra F. DeJong Lempke, ATC, PhD, Pierre A. d’Hemecourt, MD, FAMSSM, Chris Troyanos, ATC, Kristin E. Whitney, ATC, and Kristin E. Whitney, MD, MA

Affiliation: Boston Children‘s Hospital, Harvard Medical School, Boston, MA.

Purpose: To characterize the epidemiology of intra-event medical encounters (ME) for acute medical conditions among Boston Marathon participants with pre-existing endocrinopathies.

Methods and Study Design: Institutional Review Board (IRB-P00043223) and event medical program approval were obtained. Paper medical records from the 2016, 2017, and 2021 Boston Marathons were reviewed to extract: demographics, medical history, marathon experience, chief complaint, vitals, treatment, ME duration, and disposition. Data were entered into a secure database (REDCap) and analyzed descriptively in SPSS.

Results: A total of 3,491 ME records were extracted with 63 (1.8%) having documented pre-existing endocrinopathies. These included thyroid disorders (n = 48), type 1 diabetes (n = 9), type 2 diabetes (n = 4), syndrome of inappropriate antidiuretic hormone (n = 1), pituitary adenoma (n = 1), and polycystic ovarian syndrome (n = 2). Of these, 61 (97%) of MEs recorded daily medications: 45 on heart and respiratory rate (levothyroxine, liothyronine), 13 with effects on glucose (insulin, metformin, sulfonylureas), 2 on sodium and fluid balance (furosemide and spironolactone), and 1 on blood pressure (ramipril and nicorandil). Common chief complaints included: muscle cramps (n = 22, 35%), altered mental status (n = 20, 32%), lightheadedness (n = 20, 32%), and nausea/vomiting (n = 20, 32%). Of the 13 MEs with recorded diabetes, 7 (54%) had point of care blood analysis and 4 (31%) required electrocardiograms with 4 (31%) needing glucose supplementation, 1 receiving IV fluids, and 1 requiring medical transport.

Conclusions: Many athletes with endocrinopathies compete in the Boston Marathon with a majority using daily medications with potential for acute alterations in vital signs and/or electrolytes. A substantial percentage presented with altered mental status and the need for point of care blood lab analysis (i.e., isolated glucose measurement, or basic metabolic panel including glucose and electrolytes) as part of their medical evaluation.

Significance: A growing number of athletes with endocrinopathies compete in endurance events. Clinicians’ awareness of athlete medical history and daily medications is paramount as athletes may be unable to provide information due to altered mental status.

Acknowledgments: The authors would like to acknowledge the Boston Athletic Association as well as Boston Marathon volunteers and athletes for making this study possible. Additionally, we thank the Eleanor and Miles Shore Faculty Development Awards Program, Harvard Medical School: Boston Children’s Hospital Department of Orthopaedic Surgery and Sports Medicine Award for funding support.

TOPIC: Epidemiology

STUDY TYPE: Survey

Incidence of Injury Among Female High School Wrestlers

Daniel Chilcote, DO

All Other Authors: Margaret Gibson, MD

Affiliation: University of Missouri-Kansas City, Kansas City, MO.

Purpose: In 2023, nearly 50,000 females participated in wrestling. Prior studies have not examined female high school wrestlers’ injuries presenting to certified athletic trainers. This study aims to quantify injury rates amongst female wrestlers and learn more about practice and competition environments.

Methods and Study Design: Anonymous surveys were sent electronically to high school athletic trainers in the Midwest regarding wrestling injuries during the prior high school season. Descriptive statistics, including proportions and means were calculated to summarize the data. Bivariate data was examined utilizing Fisher’s exact test and chi-square tests.

Results: 10 surveys were completed. Twenty-nine injuries were reported for 367 total participants. Injury incidence for male wrestlers was 3.56%, with 10 injuries among 281 wrestlers. For female wrestlers, injury incidence was significantly higher at 22.09%, with 19 injuries among 86 wrestlers (P P = 0.0195). Female wrestlers who practiced in spaces with enough room per athletic trainer opinion had a significantly lower injury rate (11.94%) than those who did not (57.89%, P P = 0.0038). However, competing against male wrestlers did not significantly impact injury rates (P = 0.886). Female wrestlers at schools with 1–5 years of experience had a higher injury rate (25%) than those with wrestling for 5–10 years (16.67%).

Conclusions: Female wrestlers have significantly higher injury rates than males, especially in season-ending injuries. Factors like practice space and training with male opponents may increase injury risk. Time that each school offered female wrestling did not significantly affect injury rates. Further prospective studies are needed to better understand and minimize injury risk in female wrestlers.

Significance: This study is the first to analyze training room injury data for high school female wrestlers, revealing higher injury rates than males. It highlights the need for targeted prevention strategies and further research to reduce injury risk.

Acknowledgments: An-Lin Cheng, PhD UMKC Dept. of biomedical and health information Statistics Gwen Sprague, MLS.

TOPIC: Epidemiology

STUDY TYPE: Cohort

Middle School Athletes Demonstrate a High Incidence of Medial Tibial Syndrome

Nicole Leonard, MD

All Other Authors: Shane Caswell, PhD, ATC and Daniel Herman, MD, PhD, FAMSSM

Affiliation: University of California at Davis; Sacramento, CA.

Purpose: Medial tibial stress syndrome (MTSS) is a common athletic injury; however, prior studies on incidence rates (IR) are primarily limited to adult collegiate, military, and recreational running athletes. This study examines the IR and clinical impact of MTSS across a range of middle school (MS) sports.

Methods and Study Design: MTSS cases and athlete exposures (AEs) were obtained from the ACHIEVES Project (2015 to 2022). IRs were calculated as ((cases/AE) × 10000). 95% confidence intervals (CI) were calculated for incidence rate ratios (IRR) using Poisson regression with values excluding 1.00 as significant. Descriptive statistics and the Mann-Whitney U test analyzed time loss and treatment days (alpha = 0.5).

Results: There were 221 MTSS cases over 550,420 AEs across all sports, resulting an IR of 4.02 (95% CI: 3.52–4.58). Track and field (T&F) had the highest IR at 15.88 (95% CI: 13.65–18.47), followed by soccer (IR = 2.81, 95% CI: 1.72–4.58) and basketball (IR = 2.05, 95% CI: 1.34–3.14). All other sports—boys’ football, wrestling, and baseball, and girls’ softball, volleyball, and cheerleading—had IRs ranging from 0.91 to as low as zero. Girls had a higher IR than boys across all sports (IRR = 1.38, 95% CI: 1.05–1.80) and sex-comparable sports (IRR = 1.37, 95% CI: 1.04–1.81). Notably, this disparity was primarily driven by basketball (IRR = 5.02, 95% CI: 1.48–17.03), while no sex differences were observed in T&F (IRR = 0.88, 95% CI: 0.65–1.19) or soccer (IRR = 2.18, 95% CI: 0.80–6.00). Median time loss was 0 days (IQR: 0–1), and median treatment duration was 8 days (IQR: 2–25.5). Boys experienced significantly greater time loss (U = 4.473, P = 0.049), while treatment days were similar (U = 0.286, P = 0.690).

Conclusions: This study is the first to report on MTSS rates in MS athletes across multiple sports. These findings diverge from existing literature, with MTSS rates approximately 15x higher in MS T&F athletes than in collegiate T&F athletes. Additionally, no sex-based differences previously described in adult athletes were observed. However, consistent with prior research time loss due to MTSS was minimal.

Significance: This study addresses a critical gap in the literature concerning MS athletes. The notably high rates of MTSS among MS T&F athletes suggests a need for targeted prevention strategies in this population.

Acknowledgments: We want to express our gratitude to the ACHIEVES Project athletic trainers and school personnel for their commitment to enhancing pediatric sports medicine.

TOPIC: Epidemiology

STUDY TYPE: Other

Ten Year Musculoskeletal Injury Trends in Pickleball and Tennis

Daniel Kiehl, DO

All Other Authors: Rosalynn Conic, MD, PhD, MPH and Heather K. Vincent, PhD

Affiliation: University of Florida, Department of Physical Medicine and Rehabilitation, Gainesville, FL.

Purpose: Many recreational tennis players are transitioning to pickleball, even without prior racquet sport experience. The purpose of this analysis was to compare rates and types of pickleball and tennis related injuries among patients who presented to the Emergency Department (ED) over the last 10 years.

Methods and Study Design: This comparative epidemiologic analysis utilized the National Electronic Injury Surveillance System (NEISS) database to determine patterns of tennis and pickleball injury. Injury prevalence, anatomical site, and type were extracted. Data were analyzed between sports by age and sex.

Results: Pickleball players were older compared to tennis players (64.9 ± 13.1 vs 49.0 ± 3.0; P 65 years old reported to the ED more often than younger patients irrespective of sport (63.8% pickleball vs 37.0% tennis; P P P

Conclusions: To offset injury risk, sport clubs could offer preparatory classes to learn technique and safety considerations. Pickleball conditioning programs could be developed that emphasize pre-participation warmup, muscle strengthening, power and neuromotor control. For tennis players who transition to pickleball, instructional technique, sport conditioning and safety considerations are needed, especially for recreational players with advanced age.

Significance: Pickleball participation rates and ED visits are increasing. Careful review of injury mechanisms, conditioning and sport preparation efforts are needed to identify strategies to help physically prepare and protect participants from injury.

Acknowledgments: I would like to thank Dr. Heather K. Vincent for her incredible guidance, mentorship, and support for this project. Additionally, I would like to thank Dr. Rosalynn Conic for her assistance with data collection, statistical analysis, and collaborative efforts with coordinating this study. Lastly, I would like to thank the University of Florida Department of Physical Medicine and Rehabilitation for providing funding to attend the 2025 American Medical Society of Sports Medicine Annual Meeting.

TOPIC: Epidemiology

STUDY TYPE: Other

Epidemiology of Injuries in Bowling Related Injuries 2013–2022

Steven Gay, DO

All Other Authors: Patrick Rowe, MD and Jon Rittenberger, MD

Affiliation: Guthrie Robert Packer Hospital.

Purpose: To examine the trends of injuries relating to bowling who presented to US emergency departments and their breakdown by macro, micro, and rural environments.

Methods and Study Design: Data were collected and analyzed from the US Consumer Product Safety Commission’s National Electronic Injury Surveillance System.

Results: The number of injuries was fairly consistent from 2013 to 2019, with estimated population frequencies ranging from 16,544, 95% CI = (14,657, 18,431), in 2018 to 17,680 (15,601, 19,759) in 2015. In 2020, the count plummets to 7,322 (6,022, 8,622) and does not fully recover in the following 2 years. When broken down by age the largest count is in the middle-aged (35–49) group, with an estimated 49,637 injuries over the entire period. The next largest group is under 18, with an estimated 35,680 injuries. In between these 2 age groups there were 13,403 reported injuries, and frequencies taper off after the age of fifty. Metro predominated with number of injuries over micro or rural. When broken down by injury location, lower trunk with 20,031 estimated cases. This is followed by the finger (19,034), knee (18,216), wrist (11,280), and upper trunk (10,763). Strains and sprains were the most common injury type followed by fractures, contusions, lacerations, internal injuries, and nerve damage.

Conclusions: Bowling in America is largely viewed as a leisure activity. Our data show that there are a significant number of injuries reported from participants. By better understanding injury trends, targeted education could potentially lead to improved safety and decreased injury rates.

Significance: Bowling injury trends have been studied before, however this is the only study we could find to look at the effect the global pandemic had on injury rate and to break down injuries on population size (metro, micro, and rural).

Acknowledgments: We would like to thank the NEISS and Mr Albright for working our data set.

TOPIC: Epidemiology

STUDY TYPE: Survey

Wheelchair Basketball Injury and Illness Surveillance

Lindsey Kim, MD

All Other Authors: Kristen Santiago, MD, Xiaoyu Pan, MBBS, PhD, MPH, Stephen Urias, LAT, ATC, and Donald Kasitinon, MD

Affiliation: UT Southwestern Medical Center, Dallas, TX.

Purpose: The purpose of the study is to determine the incidence of injuries and illnesses among collegiate wheelchair basketball athletes. There are few prior studies focused on prospective injury rates in intercollegiate wheelchair basketball and to our knowledge, none completed after the COVID-19 pandemic.

Methods and Study Design: This was a retrospective study based on a prospective cohort where injury and illness data was collected from the wheelchair basketball athletes with a pre-season, within-season, and post-season REDCap survey. At the end of the season, the team athletic trainer also completed a REDCap survey for each athlete.

Results: The athletes participated in 120–150 practices and 16–28 games per season from 2021 to 2024. In 2021–2022 male athletes reported 12 injuries, while female athletes reported 18 injuries. In 2022–2023 male athletes did not report any injuries, while female athletes reported 21 injuries. In 2023–2024 male athletes reported 9 injuries, while female athletes reported 8 injuries. The majority of the injuries occurred in the arm/upper extremity across all 3 seasons. The calculated injury rate based on 1000 injury per 1000 athlete exposures across all 3 seasons was 4.78 (95% CI 2.74–6.82) for male athletes, 7.25 (95% CI 5.18–9.32) for female athletes, and 6.25 (95% CI 4.77–7.73) overall. The relative risk of injury by gender was 1.52 (95% CI 0.91–2.54, P 0.112). Illnesses were reported as 3 for male athletes and 8 for female athletes in 2021–2022, no illnesses reported in 2022–2023, and 2 illnesses for male athletes and 4 for female athletes in 2023–2024.

Conclusions: The overall rate of injury for female wheelchair basketball athletes is similar to previously published data for able-bodied NCAA basketball athletes (6.54, 95% CI 6.22–6.85), whereas the rate of injury for male wheelchair athletes is lower than able-bodied NCAA basketball athletes (7.97, 95% CI 7.65–8.30). Limitations include sample size, diligence in reporting, and discrepancies between within-season and post-season surveys.

Significance: Collegiate wheelchair basketball athletes experience injuries at a similar rate to able-bodied basketball athletes. Further research is needed to best anticipate their medical needs and support their physical wellbeing.

Acknowledgments: Thank you to co-authors Kristen Santiago, Norman Pan, Stephen Urias, and Donald Kasitinon.

TOPIC: Epidemiology

STUDY TYPE: Other

10 Year Rugby Epidemiology from the NEISS Database a Quantitative and Qualitative Analysis

Sheung Man Alexander Sin, MD

All Other Authors: Shivram Kumar, MBBS, Katherine Rizzone, MD, MPH, and Courtney Jones, PhD, MPH

Affiliation: Louisiana State University Health Sciences Center (LSUHSC) Lafayette, Lafayette, Louisiana.

Purpose: To describe the frequency and type of rugby injuries in the Unites States using data from the National Electronic Injury Surveillance System (NEISS) database.

Methods and Study Design: A retrospective epidemiologic study was conducted. All data were extracted from NEISS database which is a nationally representative sample of ER visits in the US. All cases from 2013 to 2023 associated with Rugby (product#3234) were included. Entries with age ≥65 and narrative indicating rugby as not the primary cause of injury were excluded. Statistical weighting was used to generate national estimates.

Results: A total of 2,917 cases were extracted. Concussion frequency peaked in 2016, Other injury types were most frequent in the age groups ≥13, and peaked in 2013, and had a gradual decline 2016–2019. All injury types sharply decreased in 2020, due to restrictions on sports due to COVID-19, and slightly increased from 2021 to 2023. There was a small increase in all injuries in 2021 and the frequency remained steady from 2021 to 2023. Most injuries occurred in September (15.6%), October (15.3%), April (15.1%), and March (12.9%). Reviewing demographic data, 73.7% of injuries occurred in males and 26.2% in females. The majority of patients were White (54.8%). Most injuries involved the head/neck (41.7%), followed by lower extremities (25.6%) and upper extremities (25.2%); with most classified as strain/sprain (21.5%) followed by fracture (17.3%). Most injuries were associated with contact (61.9%). The most frequent mechanism of injury was player collision (31.4%), of which tackle was the most common type of characterized player collision (16.4%).

Conclusions: Review of the NEISS database 2013–2023 data showed an overall decline in most injuries in the past 10 years with a sharp decrease in 2020 and resulting increase 2021–2023. Most injuries occur in age ≥13, in March/April/September/October, and are mostly associated with contact, especially with player collision in the form of tackles. Continued surveillance data is important to evaluate if policy changes in rugby are effective in injury prevention.

Significance: This is the first study of its kind to utilize narrative data in NEISS database to evaluate mechanism of injuries occurring in Rugby in US. This update from the past year provides additional 2023 data and 2917 entries of qualitative narrative data.

Acknowledgments: Data is obtained from the National Electronic Injury Surveillance System (NEISS) database managed by the U.S. Consumer Product Safety Commission (CPSC).

TOPIC: Musculoskeletal

STUDY TYPE: Other

A Systematic Review and Meta-Analysis of High-Volume Injections for Achilles Tendinopathy

Connie Hsu, MD

All Other Authors: John Walton, MD and Rajiv Verma, MD

Affiliation: University of Chicago, Chicago, IL Endeavor Health, Chicago, IL.

Purpose: The purpose of this study is to conduct a systematic review and meta-analysis evaluating the efficacy of high-volume injections for mid-portion Achilles tendinopathy.

Methods and Study Design: Embase, Web of Science, and Pubmed were searched for prospective cohort studies, retrospective case series and randomized controlled trials evaluating the efficacy of high-volume injections for Achilles tendinopathy utilizing the primary outcomes of change in function measured by The Victoria Institute of Sport Assessment-Achilles (VISA-A) Scale and pain measured by the Visual Analog Scale (VAS).

Results: Four hundred eighty-four studies were identified for evaluation and 12 studies met inclusion criteria. Eleven studies (384 patients) evaluated change in VISA-A score and were included in the meta-analysis. A random-effects meta-analysis evaluating for change in VISA-A score following HVI resulted in a statistically significant improvement in VISA-A scores at mean follow-up duration of 29 months (SMD, 1.23; 95% CI 0.96, 1.49). Eight studies (174 patients) evaluated change in VAS score and were included in the meta-analysis. A random-effects meta-analysis of change in VAS score following HVI resulted in statistically significant improvement in VAS scores at a mean follow-up duration of 25 months (SMD, −1.77; 95% CI 1.39, 2.14).

Conclusions: This systematic review and meta-analysis demonstrates that HVI may be beneficial in improving pain and function in patients with mid-portion Achilles tendinopathy. More randomized controlled trials are necessary to compare the efficacy of high-volume injections with first or second-line treatments for Achilles tendinopathy and placebo.

Significance: Patients who fail to respond to physical therapy have many options available, but with little high-quality supporting evidence. This systematic review and meta-analysis demonstrates that HVI is an evidence-based treatment option worth considering.

Acknowledgments: Thank you to Dr. Kelly McInnis for introducing me to this treatment. Thank you to Dr. Rajiv Verma for encouraging my research interests.

TOPIC: Musculoskeletal

STUDY TYPE:

Evaluating the Impact of Training Activities on Shoulder Pain in Competitive Swimmers

Connie Hsu, MD

All Other Authors: Rajiv Verma, DO, Holly Benjamin, MD, Brian Cunningham, DPT, Brian Krabak, MD, and Joanne Borg-Stein, MD

Affiliation: Spaulding Rehabilitation Hospital, Boston, MA University of Chicago, Chicago, IL.

Purpose: The purpose of this study is to evaluate the potential relationship between training activities and exacerbation of existing shoulder pain in a population of competitive swimmers.

Methods and Study Design: This cross-sectional observational study was approved by the IRB. Competitive swimmers were asked to complete a questionnaire evaluating for current or prior history of shoulder injury as well as their demographic information, training activities (yardage, hours trained per week, equipment usage, dryland activities), competition level, and stroke specialties.

Results: Of the 96 swimmers that completed the survey, 32 swimmers (mean age: 19, range: 15–23, 67% female) reported experiencing a current or prior shoulder injury. Of the training activities evaluated, swimmers reported that butterfly (Proportion: 81%, 95% CI: 65%, 92%), freestyle (Proportion: 72% 95% CI: 55%, 85%), and paddle usage (Proportion: 69%, 95% CI: 52%, 83%) were the mostly likely activities to exacerbate shoulder pain from injury. Conversely, the training activities that swimmers reported were least likely to exacerbate shoulder pain from injury were aerobic dryland (Proportion: 9.4%, 95% CI: 3%, 24%), kickboard usage (Proportion: 31%, 95% CI: 18%, 48%), flipper usage (Proportion: 6.3%, 95% CI: 1.3%, 20%) and starts/turns practice (Proportion: 16%, 95% CI: 6%, 31%).

Conclusions: Interfering shoulder pain is largely present in competitive swimmers and varies greatly between different training activities. Several training activities including freestyle stroke, butterfly stroke, and paddle usage appear to aggravate existing shoulder pain. Activities such as kickboard usage, flipper usage, and practicing starts/turns appear to be least likely to cause worsening shoulder pain in swimmers.

Significance: Understanding which training activities exacerbate swimming injuries is important in management of swimming shoulder injuries and may assist in creating a blueprint for activity modification and skills development during injury rehabilitation.

Acknowledgments: Thank you to Dr. Borg-Stein and Dr. Krabak for encouraging my research in swimming medicine!

TOPIC: Musculoskeletal

STUDY TYPE: Survey

Pickled Pain: A Survey on Age-Related Injuries in Pickleball Players

Zacharie Finneman, DO

All Other Authors: Bryan Wacker, DO, William Arnold, MD, and Brian Toedebusch, MD

Affiliation: University of Missouri, Columbia, MO.

Purpose: Pickleball is a sport of rapidly growing popularity among recreational adults, accompanied by an exponential rise in injuries. The aim of our study was to identify the most common injuries sustained during pickleball play, with a particular focus on the relationship between age and injury patterns.

Methods and Study Design: A 12-question survey was distributed via social media to the Missouri pickleball community. Participants provided data on demographics, frequency of play, number of injuries, injury type and location, injury treatment and duration of recovery. Statistical analyses, including correlation analysis, Fisher’s Exact Test, and Mann-Whitney U test were used.

Results: A total of 89 surveys were completed, with participants’ ages ranging from 20 to 79 years and a mean age of 55. Sixty female and 29 male participants took part in the survey. A significant positive correlation between age and injury duration emerged among female participants (P = 0.0112), suggesting that older female players may experience longer recovery times. Additionally, older female players were more likely to report multiple injuries compared to younger female players (P = 0.0081), indicating a potentially increased risk of recurrent injuries in this demographic. A trend toward increased injury recovery duration with advancing age was observed, although this association did not reach statistical significance (P = 0.0740). No significant differences were found in the prevalence of specific injury types (joint sprains, muscle strains, and fractures) between players under 65 and those aged 65 and older.

Conclusions: These findings suggest that while older players, particularly females, may experience more frequent and prolonged injuries, the types of injuries are similar across age groups. This is concerning, as injuries can affect quality of life, reduce participation, and have public health implications as pickleball continues to grow. Targeted injury prevention and awareness strategies could help mitigate these risks and promote safer participation.

Significance: While previous studies have relied on injury databases, this research represents a novel approach as the first survey-based investigation specifically focused on pickleball-related injuries.

TOPIC: Musculoskeletal

STUDY TYPE: Survey

Prevalence of Shoulder Examinations and Proper Communication by Providers: A Study in a Sports Medicine Center

Tyler Beers, MD, ATC

All Other Authors: Gaby Jabbour, MD and William Post, MD

Affiliation: Cornerstone care, Mount Morris, PA.

Purpose: To assess the prevalence of shoulder clinical examinations during patient consultations, and to evaluate the quality of communication regarding diagnosis and treatment. The study seeks to identify gaps in the physical examination process and the overreliance on imaging.

Methods and Study Design: A cross-sectional survey was conducted with a sample of adult patients attending a sports medicine clinic. Participants were asked whether they had been physically examined by a doctor during their most recent consultation. Data on demographic factors (age, gender) and type of consultation (referral, physical exam type, imaging, proper communication) were also collected.

Results: Of the 112 participants included in the study, mean age was 57 years, 50% were females. Most patients were referred by friends or family (31.3%), and 42.9% were seen by another orthopedic surgeon. During examination, most patients (64%) reported improper inspection (covered shoulders). 27.7% reported that the symptomatic shoulder was not physically examined, and 79.5 % reported that the normal shoulder was not touched. 73.2% reported no neck examination. Most providers recommended imaging (X-rays and MRIs), but the majority did not show the images (66.1% and 69.6% for X-ray and MRI) or discuss relevant findings with patients (50.9% for MRI)

Conclusions: This study highlights that most of the patients report not being properly examined; and that when imaging was ordered, there was no proper discussion of the findings. This suggests no proper physical examination and overreliance on imaging, warranting further investigation into the factors influencing sports medicine clinical practice

Significance: This study addresses critical issues in clinical practice related to shoulder examinations and patient-provider communication. Key aspects include identification of gaps in physical examinations, overreliance on imaging, and standardization of care

Acknowledgments: We would like to express our sincere gratitude to all the patients who participated in this study. We also wish to thank the healthcare providers and staff at the sports medicine center for their support and cooperation throughout the data collection process.

TOPIC: Musculoskeletal

STUDY TYPE: Cohort

Vitamin B6 Induced Peripheral Neuropathy in Patients—A Case Series Study

Madhavi Varuputoor, MD

Affiliation: Kaiser Permanente.

Purpose: Peripheral neuropathy has significant impact on quality of life and needs extensive evaluation. Among the causes of Peripheral neuropathy Vitamin B6 levels are not included in the routine diagnosis. Our purpose is to identify abnormal vitamin B6 levels as one of common cause of peripheral neuropathy.

Methods and Study Design: Retrospective Monocenter case series study. We identified total of 6 patients between ages 60–75 who presented to primary care clinic with symptoms of burning pain, tingling and numbness from 2023 to 2024. These patients did not have uncontrolled Diabetes, kidney disease, alcohol abuse, active or history of cancer, or malabsorption conditions like celiac disease, Crohn’s, or ulcerative colitis.

Results: Fasting Vitamin B6 levels were ordered as part of diagnostic evaluation at the time of presentation. Of the 6 patients, 4 had vitamin B6 levels greater than 125 nmol, and 2 patients had levels less than 20 nmol. The 4 patients with excess of vitamin B6 reported of taking vitamin B complex or one a day (centrum that contained vitamin B6) for general health for a few years, and 2 patients with low vitamin B6 levels reported that their diet is not balanced in last 6 months but also having alcohol drinks 1–2 drinks a week and they were not taking supplements. The patients with excess of vitamin B6 were asked to stop taking vitamin B complex supplements and those who were having low B6 levels were treated with vitamin B6 100 mg orally daily or period of 3 months. The patients were followed after 3 months of initial presentation and had repeat lab work that showed normalization of vitamin B 6 levels and they had resolution of symptoms of peripheral neuropathy.

Conclusions: Abnormal Vitamin B6 levels are one of the cause of reversible peripheral neuropathy and testing vitamin B6 levels at the time of diagnosis is likely a cost effective approach for treatment for symptom management and improving quality of life for patients with peripheral neuropathy, who otherwise undergo extensive evaluation and treatment with neuropathic medications that have undesirable side effects.

Significance: Vitamin B6 is water soluble vitamin and toxicity is most often associated with supplemental mega doses of more than 50 mg/day but toxicity seems to occur in smaller doses as well and highlights the need for further research in this area.

TOPIC: Musculoskeletal

STUDY TYPE: Other

Management and Outcomes of Pediatric and Adolescent Patients With Morel-Lavallee Lesions

Naomi Brown, MD

All Other Authors: Sean Owens, BS, Sean Schoeman, MBChB, Kelly McNult, MD, Seth Vatsky, DO, Michael Acord, MD, and Shaun Mendenhall, MD, MD

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

Purpose: The purpose of this study was to describe the various treatment pathways and associated outcomes of pediatric and adolescent patients at a single medical center with Morel-Lavallee lesions (MLLs) to better characterize the presentation and management of these injuries in the pediatric population.

Methods and Study Design: A retrospective review was conducted on patients ages 8–25 with at least 3 months of elapsed treatment for a MLL at a single institution from January 1, 2018, to September 31, 2024. Patient demographics, lesion details, conservative, interventional radiology (IR), and surgical treatment data, and patient outcomes were collected and analyzed.

Results: Eighty-four patients met study criteria. Seventy-three patients had MLLs from trauma (86.9%), of which the majority were from sports injuries (58.9%) and motor vehicle accidents (17.8%). Most common MLL locations were at the knee (56.8%) and thigh (17.0%). Seventy-three patients were seen by orthopedics (86.9%), with targeted compression alone as the most common treatment choice (n = 46, 63.0%). Other treatments by orthopedics included other conservative management (n = 7), drainage with or without further IR/surgical treatment (n = 10, n = 4), and referral to IR/surgical treatment without initial drainage (n = 6). Eleven patients were initially seen by IR or surgery and not orthopedics. Six patients receiving compression alone by orthopedics (13.0%) required further IR and/or surgical treatment. Nineteen patients (22.6%) had drainage and/or sclerotherapy by IR and 13 patients (15.5%) had surgical bursa excision and drain placement. Only 15 patients had sufficient clinical or radiographic documentation of lesion resolution, all of which had full resolution of their MLLs.

Conclusions: MLLs in youth tend to occur more during sports and about the knee. Most patients receiving compression only management did not further obtain IR or surgical treatment. Collaboration among specialties can ensure that patients’ treatment progression is most conducive to their needs. Maximizing patient follow-up to ensure resolution and prevent recurrence could allow for improved outcomes both from a clinical and patient satisfaction standpoint.

Significance: Characterizing the current treatment progressions for pediatric and young adult patients presenting with MLLs and understanding the influence of patient and lesion characteristics allows clinicians to provide the most effective treatment pathways.

Acknowledgments: CHOP Orthopedics, Interventional Radiology, and Plastic Surgery Research.

TOPIC: Musculoskeletal

STUDY TYPE: Other

Validation of Wearable Sensors for Measuring Trunk and Lower Extremity Motions During Squat and Stoop Posture Lifting Tasks

Rajit Banerjee, MD

All Other Authors: Rutuja Kulkarni, BS and Alicia Koontz, PhD

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

Purpose: To validate wearable Inertial Measurement Units (IMUs) compared to gold standard VICON motion capture (MoCap) in quantifying trunk and lower extremity joint motions during squat and stoop lifting tasks, addressing a critical gap in evaluating sensor performance for complex musculoskeletal movements.

Methods and Study Design: Four able-bodied participants performed lift-pivot tasks with a 10 lb weight across 3 different start and end height conditions during squat and stoop postures. Noraxon Ultium IMUs and MoCap cameras recorded trunk and lower extremity joint angle kinematics via standardized sensor and reflective marker sets placed on participants. Correlation coefficient and error were used to compare system accuracy.

Results: For all subjects across height conditions as well as both squat (proper) and stoop (improper) postures, preliminary results indicate very strong correlations (>0.9) in bilateral knee flexions (KF) (R KF: 0.95 ± 0.09, L KF: 0.91 ± 0.16), strong correlations (0.7–0.9) in trunk flexion (TF) and bilateral ankle flexion (AF) and rotation (AR) (TF: 0.78 ± 0.25, R AF: 0.87 ± 0.16, R AR: 0.72 ± 0.24, L AF: 0.88 ± 0.14, L AR: 0.75 ± 0.21), and weak correlation (0.1–0.4) in trunk rotation (TR) (TR: 0.38 ± 0.26). Root Mean Square Error (RMSE) ranged from 4.43 ± 3.08° to 11.09 ± 9.12° in all joint angle kinematics except trunk flexion which was 24.66 ± 9.69°.

Conclusions: IMUs show promise for detecting complex multi-planar motions but is dependent on the joint angle of interest. For example, IMUs may not be applicable for trunk rotation, however differences may be due to the way rotational angles are derived based on reference points for the sensors and reflective markers. Regardless, IMUs offer a useful alternative to MoCap due to practicality and feasibility for use outside of the laboratory setting.

Significance: IMUs have potential applicability for real-time musculoskeletal injury detection and can be used as an adjunct by sports medicine professionals to provide athlete-specific guidance to injury prevention, rehabilitation, and performance optimization.

Acknowledgments: Shantanu Satpute, MS.

TOPIC: Musculoskeletal

STUDY TYPE: Cohort

Outcomes of Lower Extremity Muscle Tears Classified by BAMIC in American Football College Athletes: A 2-Year Study

Wikien Hung Pinto, MD

All Other Authors: William Hollabaugh, MD, Tyler Hill, ATC, Jacquelyn Pennings, PhD, Lauren Porras, MD, Charles Cox, MD, MPH, and Robert Fitch, MD, MD

Affiliation: Department of Orthopaedic Surgery, Division of Sports Medicine, Vanderbilt University Medical Center, TN.

Purpose: To assess clinical outcomes, specifically, time to return to play (TRTP) and re-injury rate (RIR), classified by The British Athletics Muscle Injury Classification (BAMIC) in National Collegiate Athletic Association Division-I (NCAA-DI) American football athletes during the 2023 and 2024 seasons.

Methods and Study Design: This is a retrospective cohort study of American football NCAA-DI athletes who sustained a hamstring (HS) or quadricep (QD) tear and underwent magnetic resonance imaging (MRI) of the affected muscle group at a single institution during the 2023 and 2024 seasons. RIR and differences in TRTP by BAMIC (0a–3b), grade (0–3), injury site (a-c), and muscle group were assessed.

Results: There were 27 HS, 4 QD and 3 HS and QD tears in 34 (28%) of the 121 active roster athletes (20 + 1.3 years; 100.0% male). BAMIC muscle tears included: 0a (1), 1a (2), 1b (3), 2a (6), 2b (11), 2c (4), 3a (1), 3b (6). Most (67.6%) injuries were BAMIC 2a–b and 3b. Most (88.3%) tears occurred prior to the season and all (100%) tears occurred in practice. Excluding grade 0 injures and athletes who suffered a re-injury prior to return to play, all injured athletes (n = 28) missed 1–7 weeks of play with a median of 29 days (IQR = 18.8–39.5). RIR was 17.64% (6/34). Re-injures occurred 7–46 days after the index injury. There was no statistically significant relationship between BAMIC, injury grade, injury site or muscle group with TRTP. However, there was a non-significant trend towards increased TRTP for injury site “c” or intra-tendinous injuries compared to “a” and “b” injuries. The low number of re-injuries precluded assessment of the relationship between BAMIC and RIR.

Conclusions: HS and QD tears are common in American football college athletes, especially in practice and preseason. The severity of these injuries is typically BAMIC Grade 2, and most occur at the myotendinous junction. Although there was no significant relationship between HS and/or QD tears and BAMIC, intra-tendinous injuries may require more TRTP. Most athletes miss 4–5 games, regardless of BAMIC, and approximately 1 in 5 athletes suffer a re-injury.

Significance: This is the first appraisal of BAMIC in college and American football athletes. The high prevalence of muscle tears highlights the need for prevention. While BAMIC lacked value in this study, larger studies should evaluate BAMIC in this population.

TOPIC: Musculoskeletal

STUDY TYPE: Other

Functional Outcomes in Patients Receiving Shockwave Therapy for Tendinopathies of the Hip/Pelvis: A Retrospective Case Series

Sara Lim, MD

All Other Authors: Jennifer Cheng, PhD, James Wyss, MD, PT, Jesse Charnoff, MD, and Sophia Perez, BA

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

Purpose: Extracorporeal shockwave therapy is a non-invasive treatment that has been used in various musculoskeletal conditions, but there are limited studies evaluating its use in tendinopathies of the hip/pelvis. The goal of this study is to investigate changes in pain and physical function after treatment.

Methods and Study Design: This was a retrospective case series of prospectively collected data. Patients 18 years and older who underwent a new course of shockwave with a participating physician for gluteal or hamstring tendiniopathy from April 1, 2021 to September 1, 2024 were included. Patients were sent baseline and follow up questionnaires 1, 3, 6, and 12 months post-shockwave. Descriptive analyses were used.

Results: Eleven patients were included. A majority were female (72.7%), caucasian (90.9%), and had a normal BMI (average 23.5 ± 3.3, range 17.8–28.7). The average age was 60.6 ± 13.6 (range 31–77). On average, patients had symptoms for 23.3 ± 11.7 months prior to shockwave. All had tried physical therapy, but the next most common treatments were NSAIDs (n = 6) and bursal steroid injection (n = 6). Five received radial shockwave, 4 had a combination of focused and radial, and 2 started with radial then switched to the combination. There were no associated complications. At least half of patients rated their change in function/symptoms as at least moderately improved with a noticeable change or better at 1, 3, and 6 months post-shockwave. PROMIS pain intensity and pain interference decreased compared to baseline at 1, 3, 6, and 12 months post-shockwave. PROMIS physical function increased compared to baseline at 1, 3, 6, and 12 months post-shockwave. The biggest change in all 3 PROMIS T-scores was seen at 6 months post-shockwave.

Conclusions: In our study, shockwave was administered to patients with, on average, nearly 2 years of symptoms after a trial of more traditional conservative options. It is a safe option for the treatment of hip/pelvis tendinopathies. It showed decreases in pain intensity and pain interference as well as increases in physical function. The biggest change was seen at 6 months post-shockwave, although improvements were seen at earlier time points as well.

Significance: There are limited studies evaluating the use of shockwave for tendinopathies of the hip/pelvis. We demonstrated that shockwave is a viable and safe treatment option that can be associated with functional improvements.

TOPIC: Musculoskeletal

STUDY TYPE: Survey

Ace Wrapping Versus Ankle Strapping for Ankle Immobilization

Jason Cummings, MD

All Other Authors: Samah Olomi, BS, Kevin George, MD, Kenneth Chang, DO, Christine Miyake, MD, Alberto Hazan, MD, and Patrick Olivieri, MD

Affiliation: Valley Health System, Las Vegas, NV.

Purpose: Immobilization methods for ankle injuries include boots, ace wrap, and ankle strapping. The literature comparing these different immobilization methods is sparse. The aim of this study is to compare the comfort level and range of motion (ROM) afforded by these different ankle immobilization methods.

Methods and Study Design: Study participants had their ankles immobilized with the following 3 methods: Aircast boot, ace wrap and ankle strapping using a “figure of six” technique. Ankle ROM was measured using a goniometer. Participants completed a standardized form asking comfort levels for each immobilization method using a 7-point Likert Scale during the following activities: walking, sitting, standing, squatting.

Results: Twenty-two adult participants completed this study. The boot was rated as the least comfortable modality overall (4.8 out of 7) while ankle strapping was rated as the most comfortable overall (6.3 out of 7). Furthermore, on average, the boot was rated as least comfortable during each activity performed whereas ankle strapping was rated as the most comfortable (table 1). Statistical analysis of the unpaired t-tests that were performed for comparison of the ankle strapping and ace wrapping cohorts revealed ankle strapping to be significantly more comfortable overall (5.5 vs. 6.3, P = 0.0157) as well as for walking (5.2 vs. 6.5, P = 0.0041), standing (5.5 vs. 6.4, P = 0.0158) and squatting (5.3 vs. 6.1, P = 0.0418) (table 2). Sitting was the only activity measured that did not reveal a statistically significant difference in comfort levels between ace wrapping and ankle strapping (5.8 vs. 6.4, P = 0.0667). There were no statistically significant differences in plantarflexion (29.2 vs. 27.4, P = 0.3223) or dorsiflexion (18.4 vs. 19.0, P = 0.3985) between the ace wrapping and ankle strapping cohorts (table 3).

Conclusions: These results suggest that ankle strapping provides superior overall comfort levels as well as superior comfort during various activities while maintaining ankle range motion when compared to ace wrapping and Aircast boots. This study is limited by its relatively small sample size and healthy patient population. Future prospective, randomized controlled trials with a larger sample size are needed to validate the results of this pilot study.

Significance: Ankle strapping requires more expertise and time from the provider than other methods of immobilization. These results suggest that the increased time and cost associated with ankle strapping may be justified by providing clinically superior results.

Acknowledgments: Special thanks to all volunteers who participated as subjects in this study.

TOPIC: Musculoskeletal

STUDY TYPE: Cohort

Comparison of Ketamine, Propofol and Ketofol for Procedural Sedation of Musculoskeletal Injuries

Jason Cummings, MD

All Other Authors: Noa Grunfeld, BS, Christine Miyake, MD, Alberto Hazan, MD, and Patrick Olivieri, MD

Affiliation: Valley Health System, Las Vegas, NV.

Purpose: It is unclear if there any advantages between propofol, ketamine or a combination of the 2 (ketofol) for conscious sedation. This study aims to compare the length of stay, procedure length and safety profile of these 3 medication choices when used in the setting of musculoskeletal injuries.

Methods and Study Design: Retrospective chart review was conducted on patients undergoing conscious sedation with either ketamine, propofol or ketofol. Data recorded included: injury type, procedure length, hospital length of stay, time from procedure start to discharge and complications. Unpaired t-tests were performed for comparison of continuous data and fisher’s exact testing was used for analysis of categorical data.

Results: Twenty-one patients were included for analysis in this study (Tables 1, 2 and 3). The average ED length of stay was 238 minutes (range: 77–453). The average procedure length in the Propofol, Ketamine and Ketofol cohorts was 19 minutes, 16 minutes and 20 minutes, respectively. There were no statistically significant differences noted when comparing the average length of stay between the Ketamine vs. Propofol (266 minutes vs. 212 minutes, P = 0.2505), Ketamine vs. Ketofol (266 minutes vs. 252 minutes, P = 0.4278) or Ketofol vs. Propofol (252 minutes vs. 212 minutes, P = 0.1591) cohorts. Similarly, there were no statistically significant differences in the time from procedure start to discharge between the Ketamine versus Propofol (68 minutes vs. 110 minutes, P = 0.1515), Ketamine vs. Ketofol (68 minutes vs. 86 minutes, P = 0.3434) or Ketofol vs. Propofol (86 minutes vs. 110 minutes) cohorts. There were 2 complications (25.0%) seen in the Ketofol cohort and 1 (10.0%) in the propofol cohort. Fisher’s exact testing did not reveal any significant differences in the complication rates between the 3 cohorts.

Conclusions: There was no significant difference noted between the cohorts in length of stay, time from procedure start to discharge, procedure length or complication rates. These results suggest that these medications all provide similar efficacies and safety profiles for conscious sedation based on this limited sample size and patient population. Further studies with a larger sample size and expanded patient population are needed to validate these results.

Significance: The literature comparing the safety and efficacy of ketamine, propofol and ketofol for bedside conscious sedation in the setting of musculoskeletal injuries remains inconclusive. These results suggest that none of these choices are clearly inferior.

Acknowledgments: No additional Acknowledgments.

TOPIC: Musculoskeletal

STUDY TYPE: Cohort

Carpal Tunnel Syndrome and Carpometacarpal Osteoarthritis Concomitance as a Function of Thumb and Thenar Muscle Weakness

Gavin Ajami, MD, MPH

All Other Authors: Nicolette Schurhoffb, BS, Haley McKissack, MD, Palina Woodhouse, MD, Ashfaq Ahmed, MS, PhD, and Elizabeth Anne Ouellette, MD, MBA

Affiliation: Emory University School of Medicine, Department of Physical Medicine & Rehabilitation, Atlanta, GA.

Purpose: Carpal tunnel syndrome (CTS) and carpometacarpal joint osteoarthritis (CMC OA) have a reported co-incidence of 4–43%, though little has been elucidated on the etiology. Purpose of this study was to investigate underlying clinical similarities between CTS and CMC OA.

Methods and Study Design: This study design is a retrospective review of patients aged 18 and older with CTS or CMC OA diagnosis per ICD-CPT code. Charts were screened for duplicates and mined for CTS and CMC OA severity analysis per clinical exam findings, X-Ray analysis, and EMG study results. Statistical analysis included spearman correlation test value.

Results: Total of 1,481 patients (769 CTS/712 CMC OA) consisting of 77% females and mean age of 65.8 years. Co-incidence was 72% overall (61% males) with 78% and 66% for CMC OA and CTS groups, respectively. Thenar weakness in left and right affected hands was significantly correlated to positive CMC tenderness to palpation. Thenar atrophy in left and right affected hands was significantly correlated to positive CMC tenderness to palpation. Among female patients ages 19–39 years old, thenar weakness in the right affected hand was significantly correlated with positive CMC tenderness to palpation, positive CMC joint grind, and subluxation of the CMC joint. Among male patients, positive CMC joint grind was significantly correlated with right hand median sensory neuron latency in ages 40–59 years old and with left hand median sensory neuron amplitude in ages 60 years and older.

Conclusions: The current study reports a 72% co-incidence (61% for males) of CTS and CMC OA in patients evaluated for either condition. CTS clinical findings such as thenar weakness and thenar atrophy were significantly associated with CMC OA clinical findings such as positive CMC tenderness to palpitations across both sexes and age groups. These findings point towards underlying similarities in disease processes through overuse and chronic inflammation.

Significance: This study further supports and delineates the correlation between first CMC OA and CTS and provides strong indication for further investigation into the underlying mechanism of action behind these pathologies.

Acknowledgments: Special thanks to Mrs. Anna-Lena Makowski for helping pioneer this study as our valued research coordinator.

TOPIC: Musculoskeletal

STUDY TYPE: Cohort

The Etiology of the Subfibular Ossicle: A Prospective Ultrasound Study

Jacob Jones, MD

All Other Authors: Cassidy Schultz, BS, Kate Lampe, BS, Bobby Van Pelt, MPH, Shane Miller, MD, Jane Chung, MD, and Philip Wilson, MD

Affiliation: Scottish Rite for Children, Dallas, TX.

Purpose: Debate remains whether the subfibular ossicle (SO) is congenital or post-traumatic. Patients with an SO are susceptible to chronic ankle pain and instability. The purpose of this study was to assess the development of an OS 6–12 months after a lateral ankle injury.

Methods and Study Design: Data were extracted from an IRB-approved, prospective lateral ankle ultrasound study. Patients 5–12 years old with a diagnosis of first-time lateral ankle injury were included. Demographics, patient-reported outcomes (PROs), X-rays, and ultrasound were obtained during the initial visit and repeated at 6–12 post-enrollment. Statistical analysis included Mann-Whitney and Cohen’s Kappa tests.

Results: Seventy-two patients (69.4% female) with a mean age of 10.32 ± 2.05 were enrolled. Nineteen avulsions (26.4%) were discovered, with 13 patients (18.1%) having a lateral ankle avulsion fracture found through ultrasound imaging alone. All patients were treated with temporary immobilization (booting/bracing) with early range-of-motion exercises. Forty-three eligible patients (59.7%) returned 6–12 months (7.71 ± 2.98 months) later for repeat imaging and PROs. Twelve of the 19 patients (63.2%) with an avulsion returned. All 12 avulsion patients developed an SO on repeat imaging, while the 31 non-avulsion patients did not. Cohen’s Kappa determined there is perfect agreement between initial US imaging and SO detection at a follow-up visit (k = 1.000, P P > 0.05).

Conclusions: This study suggests the subfibular ossicle develops after a lateral ankle avulsion fracture, which is often radiographically silent in children. Ultrasound is useful in identifying these lateral avulsion fractures that can develop into a subfibular ossicle. Investigations about optimal treatment for lateral ankle avulsions to potentially prevent subfibular ossicle development in this population are needed.

Significance: This prospective ultrasound study provides evidence that a lateral ankle avulsion fracture will develop into a subfibular ossicle. These avulsion fractures are often radiographically silent but can be detected with musculoskeletal ultrasound.

TOPIC: Musculoskeletal

STUDY TYPE: Other

The Association Between Menstrual Phase and Acute Female Athlete Injuries

Cassidy Foley Davelaar, DO

Affiliation: Nemours Children‘s Health, Orlando, Florida and University of Central Florida College of Medicine, Orlando, Florida.

Purpose: To understand the effect of estradiol on skeletal muscle, ligament and tendon by associating injury incidence with the menstrual cycle phase in which it occurred. Injury rates were compared between the low estrogen, early follicular phase and the high estrogen, late follicular and mid-luteal phases.

Methods and Study Design: A retrospective review was performed of 353 female athletes, aged 12–21 years and one year out from their onset of menses when they were injured. Patients were excluded for incomplete data regarding BMI, menses onset, date of last menstrual cycle, date of injury and type of injury diagnosed. They were also excluded if they reported hormonal contraceptive use, irregular cycles or chronic illnesses.

Results: The 28-day menstrual cycle was divided into 3 phases; early follicular phase when estradiol is lowest (days 1–5), late follicular when estradiol is the highest (days 10–14), and mid-luteal when progesterone and estradiol are high together (days 19–23). Injuries were placed in their associated menstrual phase and using McNemar’s test with 0.5 within subject correlation, the percentage of injury occurrence was calculated based on 80% statistical power and 0.05 significance level. Initial results reveal 61.1% of injuries occurred during either the late follicular or the mid luteal phase when estradiol is at its highest concentrations, and not in the low estrogen, early follicular phase.

Conclusions: Estradiol can enhance neutrophil infiltration into injured muscle which accelerates strength recovery. Similarly, when estradiol is low, the adaptive potential of muscle is affected, resulting in injury, decreased muscle mass and strength. However, our early results mirror that of a systematic review which found peak estradiol correlated with increased laxity in ligaments, tendons, and poor use of neuromuscular control, leading to more injuries.

Significance: An increased number of knee injuries have been reported in female athletes during the low hormone phase of the menstrual cycle. However, the few studies that show estrogen’s effects on athletic performance are contradictory leaving a knowledge gap.

Acknowledgments: Natalie Marshall, Hunter Slosser and Eddie Geagea, MD.

TOPIC: Musculoskeletal

STUDY TYPE: Other

Quantitative MRI Identification of Cartilage Abnormality in Adolescents With Patellofemoral Pain Syndrome

Aaron Lear, MD

All Other Authors: Lutul Farrow, MD, Ahmet Hakan, MD, Richard Lartey, PhD, Mei Li, MD, PhD, and John Elias, PhD

Affiliation: Cleveland Clinic Akron General, Akron, OH.

Purpose: Patellofemoral pain in adolescents increases the risk of future patellofemoral osteoarthritis. The study uses quantitative MRI to investigate patellofemoral cartilage in adolescents with PFPS comparing them to healthy controls to identify characteristics associated with cartilage degradation.

Methods and Study Design: Ten adolescents with patellofemoral pain and 14 healthy adolescents participated in quantitative MRI to measure T1ρ relaxation times for patellofemoral cartilage. Long T1ρ relaxation times indicate a low concentration of proteoglycans, suggesting damage to the cartilage. Relaxation times were compared between the 2 groups and correlated against characteristics of the subjects and knees.

Results: Based on t-tests, T1ρ relaxation times were significantly (P P P = 0.003). Parameters that were not significantly correlated with T1ρ relaxation times included BMI, Caton-Deschamps index (patellar height), lateral trochlear inclination (trochlear depth), and bisect offset index (lateral patellar position). Based on t-tests, no significant differences in relaxation times were identified between males and females with pain (P > 0.3).

Conclusions: Quantitative MRI detected patellofemoral cartilage degradation for adolescents diagnosed with patellofemoral pain, as compared to healthy adolescents. A low age was more strongly correlated with cartilage degradation than any other demographic or anatomic parameter, although a lateral pull of the patellar tendon was related to T1ρ relaxation times at the medial patella.

Significance: Early cartilage degradation related to patellofemoral pain could potentially initiate progression to patellofemoral osteoarthritis, particularly for patients who develop pain early in adolescence.

Acknowledgments: Cleveland Clinic Program for Advanced Musculoskeletal Imaging Pilot Project Grant.

TOPIC: Musculoskeletal

STUDY TYPE: Other

Crystals and Biomarker Analysis via Synovial Fluid Sampling in Patients With Knee Effusion With Radiographic Correlation

Benjamin Rogers, MD

All Other Authors: Christopher Mehallo, DO, Stephen Stache, MD, Adam Chrusch, MD, Philip Motley, MD, Bradley Smith, MD, Grant Thomas, BS, William Studt, BS, and William Studt, BS

Affiliation: Thomas Jefferson University, Philadelphia, PA.

Purpose: Synovial fluid biomarker analysis is a developing modality for subcategorizing arthritis type. We examined radiographic evidence of chondrocalcinosis and osteoarthritis severity in relation to their respective biomarker levels or detection on the Synovasure RISC panel.

Methods and Study Design: This is a monocentric, cross-sectional, non-controlled, and non-randomized, case series study. Patients with a knee effusion and planned arthrocentesis were included. Eight hundred synovial fluid samples were obtained from consenting eligible patients as part of standard of care and sent via Synovasure specimen kits for analysis. Samples were further categorized based on biomarker results.

Results: A total of 800 synovial fluid samples were analyzed. Crystals were found to be present in 166 (N = 20.8%) of samples. Isolated crystals included calcium pyrophosphate (N = 148; 18.5%) and monosodium urate (N = 17; 2.13%), with one sample screening positive for both (N = 1; 0.13%). The mean Cartilage Oligomeric Matrix Protein (COMP)/Interleukin-8 (IL-8) ratio was 30.6 (SD = 26). Three hundred five subjects (38.3%) had a Kellgren-Lawrence (KL) grade of 4 representing a plurality for the total cohort. The COMP/IL-8 ratio was found to increase with ascending KL-grade (P-value P P = 0.766).

Conclusions: This study demonstrates statistically significant findings with respect to the presence of radiographic chondrocalcinosis and crystal detection positivity rates via synovial fluid analysis. It also demonstrates a significant correlation between arthritis severity, as qualified by radiographic KL grade, and the ratio of COMP to IL-8. Calcium pyrophosphate crystals were predominant in subjects with radiographic chondrocalcinosis.

Significance: This study highlights the relationship between crystals, biomarkers, and their associated conditions, emphasizing the crucial role of synovial fluid analysis in diagnosing and treating arthritis.

Acknowledgments: The study group would like to acknowledge Zimmer Biomet for its role in sample processing and data collation.

TOPIC: Musculoskeletal

STUDY TYPE: Cohort

Impact of Comorbid Conditions on Failure Rate of Anterior Knee Pain Management

Andrew Jeon, DO

All Other Authors: Logen Breehl, DO, Melanie Morscher, PT, Nikki McKenna, PA-C, Andrew Newsom, Brian Reilly, MD, Zaid Khatib, MD, John Polousky, MD, and John Polousky, MD

Affiliation: Akron Children‘s Hospital, Akron, Ohio.

Purpose: Current literature shows anterior knee pain refractory to conservative management are correlated with certain physical and psychological risk factors. We hypothesize that patients who see multiple specialties may be at greater risk for initial treatment failure of anterior knee pain.

Methods and Study Design: This is a retrospective cohort study. Eligible participants are 12–18 years old with specific ICD-10 diagnoses for knee pain seen with sports medicine or orthopedics at Akron Children’s Hospital locations from January 1, 2015 to July 30, 2024. Collected data includes status at last follow-up, number and type of specialty referrals for comorbid conditions, and psychosocial factors.

Results: Two hundred seventy-seven charts were initially identified, with 159 being excluded. The 118 charts that met inclusion criteria were divided into 2 groups: the comorbid group that was represented by 27 charts that had record of visits to at least one other specialty, and the non-comorbid group that was represented by 91 charts that did not have any record of visits to another specialty. 29.6% of charts in the comorbidity group had unresolved anterior knee pain at follow-up within 2 months compared to 27.5% in the non-comorbid group. Comparison of these groups showed that there were no differences in the rate of initial treatment failure in patients that saw multiple medical specialties when compared to patients that did not.

Conclusions: We demonstrated that patients who see multiple medical specialties were no more likely to fail initial treatment than patients who do not see multiple medical specialties. Both groups had high rates of resolution of their anterior knee pain with initial treatment. Our study was limited by many factors. Due to the retrospective nature of our study and inherent differences in physicians’ notes, the data collected was not always conclusive.

Significance: This study indicates that there is no difference in treatment failure in patients who see multiple medical specialties. That is, the presence of comorbid conditions is not predictive of poor outcome in the treatment of anterior knee pain.

Acknowledgments: Akron Children’s Sports Health, Akron Children’s Rebecca D. Considine Research Institute, and Dr. Richard Steiner, PhD.

TOPIC: Musculoskeletal

STUDY TYPE: Cohort

Predictive Factors of Functional Outcomes Using Hydrodilatation to Treat Adhesive Capsulitis of the Shoulder

Andres Ramos, BS

All Other Authors: Daniel Herman, MD, PhD, FAMSSM

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

Purpose: Hydrodilatation is a common treatment for adhesive capsulitis; however, there is alack of understanding on factors that predict outcomes. This study evaluates the influence of patient-specific factors on a standardized hydrodilatation protocol (HP) in improving range of motion (ROM) and function.

Methods and Study Design: A prospective cohort design was used. Baseline ROM, Shoulder Pain and Disability Index (SPADI), medical history (diabetes, thyroid disease, and smoking), and demographics (age, sex, BMI) were recorded. ROM and SPADI at 2 weeks were compared to baseline using paired t-tests (alpha = 0.05) and Cohen’s d for effect size. Linear regression was used to identify factors predictive of change in SPADI.

Results: One hundred thirty-six shoulders from 124 patients (M = 54, Age = 59.0 ± 10.7 years, BMI = 27.0 ± 4.1 kg/m²; F = 70, Age = 56.8 ± 9.8 years, BMI = 28.7 ± 6.2 kg/m²) were analyzed. Briefly, the HP used genicular nerve blocks of the shoulder under ultrasound guidance using 1% lidocaine, followed by injecting a mixture of 40 mg triamcinolone, 4 mL 1% lidocaine, and 60 mL normal saline into the capsule until rupture or all 65 mL of fluid had been injected. This was then followed by a brisement. The HP significantly improved ROM in forward flexion (90.0 ± 14.6 vs 143.2 ± 23.4°, d = 3.4, P P P P 2 = 0.64, F = 13.01, P P = 0.006), thyroid disease (β = 11.87, P = 0.013), baseline forward flexion ROM (β = −0.542, P = 0.020), abduction ROM (β = 0.384, P = 0.046), and SPADI (β = −0.709, P

Conclusions: The HP in this study provided functional gains with large effect sizes that were much greater than previously reported HP methods. Older age and baseline forward flexion ROM predict greater benefits, while presence of thyroid disease may hinder outcomes. Interestingly, higher baseline SPADI scores and abduction ROM were respectfully associated with better and worse outcomes; this may be the result of ceiling effects with these variables.

Significance: Clinicians may better identify patients who may benefit from a HP and counsel patients regarding potential outcomes on an individualized basis. Use of HPs with appropriate anesthesia, particularly high volumes, and brisements may be warranted.

TOPIC: Musculoskeletal

STUDY TYPE: Other

Synovial Fluid Analysis in Patients Presenting With Knee Inflammation and Effusions

Sean Delany, MD

All Other Authors: Neelam Ferrari, BS, Grant Thomas, BS, Stephanie Gwin, MD, Stephen Stache, MD, Adam Chrusch, MD, Bradley Smith, MD, Christopher Mehallo, MD, and Christopher Mehallo, DO

Affiliation: Jefferson University, Philadelphia, PA.

Purpose: To use the Synovasure RISC panel to clarify a differential diagnosis with patients presenting with knee pain and inflammation or effusion.

Methods and Study Design: This was a monocentric, cross-sectional, non-controlled, and non-randomized case series study. This study included patients with knee effusion and planned arthocentesis who consented to Synovasure RISC fluid analysis. The Synovasure RISC panel analyzes synovial fluid for various biomarkers and presence or absence of crystals which may help determine the type of arthritis present.

Results: A total of 849 unique samples were collected. Fifty percent were female and there was an average age of 66.1 years old. A collagen oligomeric protein (COMP) and interleukin-8 (IL-8) ratio >4.3 ng/pg was used to determine presence of osteoarthritis (OA). There were 696 samples positive for OA (82%) and 153 samples negative (N = 25, 2.9%) or indeterminate (N = 128, 15.1%). Radiologic characterization of the OA, using Kellgren-Lawrence (KL) grading, was distributed as the following: KL 1 (6.7%), KL 2 (15.2%), KL 3 (31.9%), KL 4 (46.2%). Anti-cyclic citrullinated peptide (anti-CCP) was positive in 2.13% of samples. The average rheumatoid factor (RF) value was 40.5 in samples negative for OA and 5.10 in samples positive for OA. Crystals were present in 174 samples (20.5%) and negative in 675 samples (79.5%). Finally, >3000 cells/uL or polymorphonuclear leukocytes (PMN) >70% triggered a native septic arthritis panel in 82 samples. Of those 82, 10 had alpha defensins and lactate present.

Conclusions: This study demonstrated that there were several causes for patients’ knee effusions, including OA, inflammatory, crystalline arthritis and cartilage damage. OA was the predominant cause in up to 82% of samples. Several samples also had evidence for multiple types of arthritis at once. Seven individuals (0.8%) were positive for both anti-CCP and RF which may suggest the presence of an underlying rheumatologic condition.

Significance: Comprehensive biomarker analysis of synovial fluid using Synovasure RISC panel may help differentiate the cause of knee effusion. This would help determine appropriate, targeted treatment for improved management of synovitis.

Acknowledgments: The study group would like to acknowledge Zimmer Biomet for its role in sample processing and data collation.

TOPIC: Musculoskeletal

STUDY TYPE: Cohort

Adverse Outcomes of Intra-articular Corticosteroid Injections in Patients With Knee Osteoarthritis

Evan O’Malley, DO

All Other Authors: Aaron Lear, MD, Rachida Bouhenni, PhD, and Chanda Mullen, PhD

Affiliation: Cleveland Clinic Akron General.

Purpose: Multiple recent retrospective studies have shown an increase in rapid progression of osteoarthritis (OA) in the knee or hip with use of intra-articular corticosteroid injections (IACS). This project aimed to evaluate the risk of rapid advancement of OA in the knee within 6 months of a IACS injection

Methods and Study Design: The Osteoarthritis initiative was a prospective cohort study which included adults with, or at risk for OA of the knees. Subjects were followed for 4 years with annual imaging and questionnaire. Subjects who answered yes to IACS injection in the past 6 months were compared with subjects who had not reported injection. The outcome was x-ray progression of 2 classes on the Kellgren Lawrence scale

Results: Four thousand seven subjects were included in the analysis, 2295 (57%) were female. Over the 4 year period, a total of 396 subjects reported receiving a corticosteroid injection in the 6 months prior to annual visit, with 39 (10%) showing rapid progression of OA. 151 (4.2%) of the 3611 subjects not reporting injection showed rapid progression of OA by imaging. Those receiving cortisone injections were on average significantly older 66 compared to 60 (P P P 2 = P

Conclusions: IACS injections are a common treatment for OA of the knee. Recent data suggesting increased risk for rapid advancement of OA has been primarily retrospective in nature. This study appears to be the most reliable data yet that IACS injections contribute to the risk of developing this condition. While important, the results should be interpreted with caution due to the potential confounding that can occur in cohort studies.

Significance: We believe this is the first prospective analysis focused on rapidly advancing OA of the knee after corticosteroid injection. This data adds more weight to the idea that corticosteroid injections increase the risk for this negative outcome.

Acknowledgments: Cleveland Clinic Akron General research foundation grant.

TOPIC: Musculoskeletal

STUDY TYPE: Other

Radiofrequency Ablation vs. Corticosteroid Injections for Lumbar Facet Joint Syndrome: A Systematic Review and Meta-Analysis

Andrew Atschinow, BA

All Other Authors: Justin Le, BS, Lisa Huang, BA, Jason Tran, BS, Han Jie Liu, BS, MS, Anish Rana, BA, and Mark Mirabelli, MD, MD

Affiliation: Rowan-Virtua School of Osteopathic Medicine, Stratford, NJ.

Purpose: Facet joint syndrome (FJS) is a common cause of chronic lumbar back pain (CLBP), with radiofrequency ablation (RFA) and corticosteroid injections as common treatments. Due to limited evidence comparing effectiveness, our study aims to assess the efficacy of RFA vs corticosteroid injections for FJS.

Methods and Study Design: This review adhered to PRISMA 2020 guidelines for systematic reviews and meta-analyses. A boolean string was used to search PubMed, Embase, Web of Science, Cochrane Library, and Scopus. Included studies were controlled trials with RFA or steroid injections for lumbar FJS. Outcomes were measured via the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) at 3 and 6 months.

Results: At 3 months, corticosteroid injections and RFA improved ODI scores compared to baseline (corticosteroids: d = −1.74, P P = 0.01) with no significant difference in effectiveness (Q = 1.58, P = 0.21). At 6 months, corticosteroid injections showed borderline statistical significance (d = −4.29, P = 0.06), while RFA maintained effectiveness (d = −1.72, P = 0.008), with no difference in group effectiveness (Q = 1.13, P = 0.29). For VAS, both treatments were effective at 3 months (P P P = 0.03). Despite high heterogeneity (I2 > 83%), both treatments improved pain and disability, with RFA showing better-sustained efficacy overall.

Conclusions: Our study supports the conclusion that both RFA and corticosteroid injections are effective treatments for CLBP. However, the high heterogeneity across studies indicates differences in methodologies, patient populations, and intervention protocols. Therefore, future studies are needed to better understand the nuanced efficacy of RFA and corticosteroid injections for CLBP due to FSJ.

Significance: Given the prevalence of FJS and chronic back pain, effective treatments such as RFA and corticosteroids can provide life-changing pain relief. Both treatments demonstrate efficacy, allowing patients to choose the option that best fits their needs.

TOPIC: Musculoskeletal

STUDY TYPE: Cohort

Assessing Injury Screening Tests in Collegiate Female Athletes in Rested and Fatigued States

Olumide Sokunbi, MD

All Other Authors: Kuntal Chowdhary, MD, Brandon Hassid, MD, Stanley Guillaume, MD, and Jennifer Soo Hoo, MD

Affiliation: New York Presbyterian/Columbia Cornell New York, NY.

Purpose: The purpose of this study was to determine the effect of fatigue on established injury screening tests in D1 collegiate female soccer athletes. Secondarily, this study aims to identify which injury screening test may be most sensitive in identifying biomechanical risk factors with fatigue.

Methods and Study Design: This cross-sectional study was conducted in a field setting with a cohort of collegiate female soccer players. The Functional Movement Screen (FMS), Landing Error Scoring System (LESS), and Tuck Jump Assessment (TJA) were tested in the rested and fatigue states. Fatigue was assessed by completing an established fatigue protocol and subjectively reporting fatigue via the Rate of Perceived Exertion.

Results: The study included 23 participants with mean age of 19.3 years. Mean differences in screening test scores were calculated to evaluate the effect of fatigue. Paired t-tests were conducted to assess statistical significance. Eighteen TJA baseline rested scores were greater than 6, the at risk cutoff for potential injury. For the TJA, the mean difference was 0.48 (P = 0.52), with a mean score of 7.65 in the rested state and a mean score of 8.13 at fatigue. Twenty LESS baseline rested scores were greater than 5, the at risk cutoff for potential injury. The mean difference for the LESS was 0.96 (P = 0.17), with a mean score of 7.17 at rest and a mean score of 8.13 at fatigue. FMS mean scores for rested and fatigue states were 17.84, therefore, statistical analysis was not performed.

Conclusions: Overall, fatigue resulted in worse scores on the TJA and LESS. The TJA and LESS tests highlight potential biomechanical deficits in female soccer players under fatigued conditions, which may predispose to injury. Notably, baseline TJA and LESS scores at rest were high (in the at risk category) in this group of female athletes. These findings may help inform future studies aimed at developing injury prevention programs for female soccer players.

Significance: Few studies have compared female and male athletes in fatigue versus rest states. The findings of this study suggest that neuromuscular factors may increase female athletes’ susceptibility to lower extremity injuries compared to males.

Acknowledgments: I would like to acknowledge Dr. Kuntal Chowdhary, Dr. Brandon Hassid, Dr. Stanley Guillaume, and Dr. Jennifer Soo Hoo for their work and expertise on this project. I would like to thank our study participants.

TOPIC: Musculoskeletal

STUDY TYPE: Other

Effect of Pre-existing Mental Health Diagnosis on Outcomes After Injection for Knee Osteoarthritis

Simran Singh, DO

All Other Authors: Mohammad Haider, MD, Leslie Bisson, MD, and Michael Freitas, MD

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

Purpose: Preexisting Mental Health (MH) conditions are suspected to have negative effects on patient reported outcomes when undergoing treatment for osteoarthritis. This study aims to compare changes in Knee injury and Osteoarthritis Outcome Score (KOOS) between patients with and without a MH condition.

Methods and Study Design: This retrospective study includes adult patients undergoing triamcinolone injection (normal and extended release) for knee osteoarthritis between January and December 2021. MH diagnoses were obtained by manually screening electronic health records (intake paperwork and pre-injection medication review). All MH discrepancies were reviewed by 2 physicians. KOOS subscales were compared over 4 months.

Results: Out of 396 eligible injections during the enrollment period, 179 non-duplicative patients with complete PROM are included in the analysis. 45 (25.1%) had a preexisting MH diagnosis. Most common conditions were depression (n = 24), anxiety (n = 10), or a combination of anxiety and depression (n = 9). Patients with MH condition were younger (57.9 years vs 61.9 years, P = 0.022) and more predominantly female (75% vs 50%, P = 0.003). Before injection, patients with MH condition reported worse physical function (50.5 vs 46.0, P = 0.049) and sport/recreational activity (19.9 vs 30.7, P = 0.003). At 4-month follow-up, patients with MH condition reported worse on daily living (49.4 vs 60.3, P = 0.017), physical function (52.8 vs 42.2, P = 0.006), quality of life (26.7 vs 37.0, P = 0.018), and sport/recreational activity (22.8 vs 37.0, P = 0.008). For individual questions, MH diagnosis most strongly associated with difficulties with heavy domestic duties (P = 0.005), ascending stairs (P = 0.008) and squatting (P = 0.008).

Conclusions: Patients with a preexisting MH condition did not experience the same level of benefit after a pain-relieving corticosteroid injection than those without, and significant differences were observed after injection in activities of daily living and quality of life which were not present before the injection.

Significance: This study highlights the importance of knowing if your sports medicine patient has a preexisting MH condition since it is a risk factor for poor outcomes. Future studies should see if improving symptoms of anxiety and depression improves outcomes.

TOPIC: Musculoskeletal

STUDY TYPE: Survey

Patient Experiences Before Hip Arthroscopy: A Qualitative Study

Sonal Singh, MD

All Other Authors: Lindsay Sullivan, PhD and William Vasileff, MD

Affiliation: The Ohio State University Wexner Medical Center, Columbus, OH.

Purpose: Despite the increasing rate of hip arthroscopy for FAI, very little research has examined the lived experiences of individuals scheduled to undergo hip arthroscopy for FAI. The aim of this study was to understand the experiences of individuals scheduled to undergo hip arthroscopy for FAI.

Methods and Study Design: Conducted 12 semi-structured phone interviews with individuals aged 18 and older with hip impingement (women = 9, men = 3, age = 39 ± 18.8 years). All participants were scheduled for a hip arthroscopy for FAI within 30 days of the interview. Interviews were conducted between March 2023 and February 2024. Data were analyzed using the methods of open coding, axial coding, and selective coding.

Results: Identified 9 themes during data analysis, which were divided into 3 categories: impact of hip condition, attitudes towards surgery, and views about recovery. The impact of hip condition category included 4 themes: (1) pain, (2) emotional well-being, (3) activities of daily living, and (4) social support and coping strategies. The attitudes towards surgery category included 2 themes (1) initial feelings towards surgery and (2) preparation for surgery. The views about recovery category included 3 themes: (1) feelings about the initial postoperative period; (2) facilitators and barriers to recovery, and (3) goals for recovery.

Conclusions: FAI can negatively impact quality of life, social participation, & emotional wellbeing. The results support the need for interventions that promote social & emotional wellbeing in individuals scheduled for & recovering from hip arthroscopy for FAI. The findings show that individuals with FAI often experience a range of emotions upon learning that they must undergo surgery. Understanding patients’ lived experiences may allow for better outcomes.

Significance: To inform the development of pre-op preparation programs that provide emotional & cognitive support for hip arthroscopy & recovery from surgery for individuals w/FAI. Comprehensive programs to meet the needs of this vulnerable & growing population.

TOPIC: Musculoskeletal

STUDY TYPE: Survey

Pain Self-Efficacy and Outcomes in Hip Arthroscopy Recovery

Sonal Singh, MD

All Other Authors: Lindsay Sullivan, PhD and William Vasileff, MD

Affiliation: The Ohio State University Wexner Medical Center, Columbus, OH.

Purpose: Psychological factors hinder the rehabilitation process & contribute to suboptimal patient-reported outcomes following hip arthroscopy for FAI. Little is known about the impact of pre-operative & post-operative pain self-efficacy on patient-reported outcomes following hip arthroscopy for FAI.

Methods and Study Design: Patient-reported pain self-efficacy prior to surgery & at 3-, 6- and 12-months post-op using PSEQ. Outcomes at 3-, 6-, and 12-months post-op using iHOT33 & the HOS ADL Scale. Spearman’s correlations to examine relation between pre-op PSEQ scores & post-op iHOT33 & HOS ADL scores. Linear regressions to examine the effect of post-op PSEQ scores on odds of achieving a MCID for the iHOT33 & HOS ADL.

Results: Analyzed patient-reported outcomes data collected from hip arthroscopy patients using Patient IQ, a patient engagement technology. Of the 332 patients, most were female (n = 244, 73.5%) and White (n = 297, 89.5%). Found a significant relationship between pre-operative Pain Self-Efficacy Questionnaire (PSEQ) scores and iHOT33 and Hip Outcome Score Activity of Daily Living (HOS ADL) scores, respectively, at 3- (r = 0.76, 95% CI = 0.61–0.86; r = 0.72, 95% CI = 0.56–0.83), 6- (r = 0.75, 95% CI = 0.56–0.86; r = 0.71, 95% CI = 0.53–0.83) and 12-months (r = 0.79, 0.63–0.89; r = 0.82, 95% CI = 0.69–0.90) post-surgery. No significant associations were found between post-operative PSEQ scores and the odds of achieving a minimally clinically important difference (MCID) for the iHOT33 and HOS ADL.

Conclusions: Observed a significant association of pre-operative PSEQ scores on hip-specific patient-reported outcomes at 3-, 6-, and 12-months following hip arthroscopy. Findings suggest that self-efficacy-enhancing interventions may be a promising tool to improve hip-specific patient-reported outcomes following hip arthroscopy for FAI. Further research is needed to confirm these findings.

Significance: This study examined the relation between pre-op & post-op pain self-efficacy & hip specific patient-reported outcomes following hip arthroscopy for FAI. The findings of this study help identify modifiable attributes to enhance post-op outcomes.

TOPIC: Musculoskeletal

STUDY TYPE: Other

Total Body Z-score as an Indicator of Bone Health in D1 Collegiate Athletes

Nihal Bondugula, BS

All Other Authors: Bridget Whelan, MPH, Ally Gallop, RD, Andrea Kussman, MD, Kathetine Fahy, MD, and Kelly Schloredt, PhD

Affiliation: University of Washington School of Medicine, WA.

Purpose: Relative Energy Deficiency in Sport (RED-S) can lead to decreased bone mineral density (BMD), which is assessed with a DXA. DXA’s report a Z-score at the lumbar spine and hip in young adults. The purpose of this study is to evaluate if total body Z-scores correlate with site-specific Z-scores.

Methods and Study Design: In this single site observational study, DXA results of D1 collegiate athletes with an eating disorder (ED), RED-S or a history of disordered eating were extracted from the electronic medical record. Total body and site-specific Z-scores were compared using paired t-tests to calculate the correlation coefficients. All analysis was conducted at an alpha level of less than 0.05.

Results: This study included 19 D1 collegiate athletes with an age range of 18–24 years old (average age 21 years old). These athletes had a history of an ED, a current ED or RED-S and had both site-specific and total body Z-scores on prior DXA scans. Seventeen of those participants were female with 2 male participants. Endurance athletes made up 14 of 19 study participants. Paired t-tests showed no statistically significant differences between whole-body Z-scores and Z-scores at the lumbar spine, right/left total hip and right/left femoral neck at an alpha level of 0.05. The correlation coefficient (95% CI) between the total body Z-score and lumbar spine was 0.74 (0.42–0.89). For the total body and the right/left hips, the correlation coefficients were 0.79 (0.49–0.92) and 0.86 (0.66–0.94), respectively. Correlations between the total body and the right/left femoral necks were 0.84 (0.58–0.94) and 0.79 (0.52–0.91), respectively.

Conclusions: Our study showed a positive correlation between whole body Z-scores and site-specific Z-scores. This indicates that total body Z-scores could be used as a reliable measure of bone health and may have a helpful role as a screening tool. Our study was limited by the small sample size from a single institution. Additional research in the future should include a larger and more diverse population.

Significance: The total body Z-score shows potential as an efficient, cost-effective screening tool for bone health. This could be a helpful tool in screening for decreased BMD in athletes with low energy availability, although additional research is needed.

Acknowledgments: We would like to acknowledge the Wellness, Health and Energy Availability Team (WHEAT) at the University of Washington and the athletic trainers, team physicians, psychologists and team dietitians who helped coordinate the medical care that led to our research data.

TOPIC: Musculoskeletal

STUDY TYPE: Other

Comparative Analysis of Jump Metrics in D1 Mens Lacrosse Players Who Sustained Hamstring Injuries: A Retrospective Study

John Turner, DO

All Other Authors: Nikki Yates, EdD, LAT, ATC, David Baxter, DO, and Matthew Costa, DO

Affiliation: Crozer Health Sports Medicine Institute, Springfield, PA.

Purpose: The overall burden of lower extremity injuries, particularly hamstring injuries, warrants further attention in this population. This study attempts to identify potential objective measures that may mitigate risk for hamstring injury in NCAA D1 men’s lacrosse.

Methods and Study Design: Twenty-three male lacrosse intercollegiate athletes who sustained a hamstring injury were matched to healthy controls. CMJs were performed pre- and post-injury on force plates using the Sparta Science platform. Metrics extracted and available for both groups included: Sparta Score, Load, Explode, Drive, and Jump Height. Data were analyzed using independent t-tests and Cohen’s d effect sizes.

Results: In comparison to the healthy controls, there was a statistically significant difference in Load score, which represents the average eccentric rate of force (t = 2.916, df (23), P = 0.008). The pre-injury load scores were higher than the healthy controls (51.88 and 49.54, respectively). There were no significant differences in Sparta Score (t = −0.658, df (23), P = 0.517), Explode (t = −0.203, df (23), P = 0.841), Drive (t = −0.247, df (23), P = 0.807), or Jump Height (t = −0.741, df (23), P = 0.466). Additionally, with respect to pre- and post- injury data, there was a statistically significant difference in Jump Height (t = −2.587, df (23), P = 0.016) in which the pre-injury group had lower jump height scores than the post-injury group. There were no significant differences in Sparta Score (t = −0.762, df (23), P = 0.454), Load (t = −0.900, df (23), P = 0.377), Drive (t = −1.683, df (23), P = 0.106) or Explode (t = −0.841, df (23), P = 0.409).

Conclusions: The difference in pre-injury load scores (eccentric) combined with similar drive scores (concentric) between groups demonstrates the importance of balancing the anterior and posterior chain in preventing future injury. Additionally, the increase in post-injury jump height following a rehabilitation program supports the notion of implementing a preventative program, such as the Nordic hamstring protocol, to mitigate hamstring injuries.

Significance: The literature has highlighted several risk factors for hamstring injuries, however, evidence is lacking regarding objective measures to identify injury risk, guide rehabilitation programs or return-to-play metrics.

Acknowledgments: University of Delaware Athletic Training Research Laboratory.

TOPIC: Musculoskeletal

STUDY TYPE: Cohort

Vitamin D Status and Association With Soft Injuries in Professional Baseball Athletes

Jenny Nguyen, BSE

All Other Authors: Jesse Seilem, MD, Codi-Ann Reid, BS, and Robert Bowers, DO, PhD

Affiliation: Emory School of Medicine, Department of Orthopedics, Atlanta, GA.

Purpose: 25-hydroxyvitamin D (vitamin D) has a role in musculoskeletal health, and deficiency is prevalent. Previous data in athletes has shown a relationship between vitamin D levels and soft tissue injury. This study aims to investigate this same relationship in a sample of professional baseball players.

Methods and Study Design: Vitamin D levels were collected from 790 athletes across 5 MLB clubs during 2023 Spring Training. Soft-tissue injury data from the 2023 season was obtained from the MLB EMR. Vitamin D levels were classified as normal or low using thresholds of ≥30 ng/mL and ≥20 ng/mL. Fisher’s exact test and Wilcoxon rank-sum tested association of vitamin D levels between injured and non-injured players.

Results: Wilcoxon rank-sum testing showed no significant difference in vitamin D levels between players who experienced soft-tissue injuries (35.25 ± 10.58; 95% CI: (34.09, 36.41)) and those who did not (34.10 ± 10.53; 95% CI: (33.15, 35.05)) (U = 81,236.5, P = 0.06). Using ≥30 ng/mL as the threshold for normal vitamin D levels, 32.53% of the 790 players were classified as vitamin D deficient, and 36.19% of these 257 players sustained a soft-tissue injury. However, Fisher’s exact test indicated no significant association between vitamin D deficiency and soft-tissue injury at this threshold (P = 1.00). When ≥20 ng/mL was used as the threshold, 2.41% of the 790 players were classified as vitamin D deficient, with 15.79% of these 19 players experiencing a soft-tissue injury. At this lower threshold, Fisher’s exact test revealed a significant association, with a higher proportion of players with vitamin D deficiency experiencing soft-tissue injuries.

Conclusions: This study identified the prevalence of vitamin D deficiency in MLB players with and without soft tissue injuries. Approximately one-third of players were vitamin D deficient. For players with borderline-normal vitamin D levels, there was no significant association between deficiency and soft-tissue injuries. However, for players with significant deficiencies below 20 ng/mL, there was an association between deficiency and soft-tissue injury.

Significance: This study highlights the prevalence of vitamin D deficiency in MLB players and its potential link to soft tissue injuries, especially below 20 ng/mL. This study adds to data on vitamin D’s role in MSK health, emphasizing the need for further study.

TOPIC: Musculoskeletal

STUDY TYPE: Cohort

Lower Extremity Strength Imbalances Influences Jump Landing Biomechanics Differently Based on Sex

Lily Justine, BS

All Other Authors: Daniel Herman, MD, PhD

Affiliation: University of California Davis School of Medicine, Sacramento, CA.

Purpose: Sex differences in ACL injury risk emerge during puberty and are linked to changes in biomechanics. Strength imbalances between the lower extremities are also tied to injury risk, but their impact on biomechanical development throughout puberty remains uncertain.

Methods and Study Design: Middle school athletes were assessed with the Puberty and Maturation Observational Scale (PMOS), dynamometry of the knee extensors/flexors and hip extensors/abductors, and Landing Error Scoring System (LESS). T-tests were used to assess mean differences, while linear regressions were used to assess the relationship between LESS, strength symmetry, and pubertal status for each sex (alpha = 0.05).

Results: N = 107 athletes (M = 48, Age = 12.8 ± 0.8 years, H = 1.61 ± 0.09 m, W = 50.5 ± 12.5 kg, PMOS = 4.7+/2.5; F = 59, Age = 12.8 ± 0.9 years, H = 1.58 ± 0.08 m, W = 52.5+/15.0 kg, PMOS = 5.5 ± 2.5; P > 0.05 for all comparisons) were assessed. Absolute differences between the limbs were similar for the knee extensors (0.45 ± 0.41 vs 0.47 ± 0.33 kg/m²), knee flexors (0.56 ± 0.55 vs 0.43+/0.43 kg/m²), hip extensors (0.65 ± 0.62 vs 0.54 ± 0.44 kg/m²) and hip abductors (0.65 ± 0.62 vs 0.53 ± 0.40 kg/m²) for males and females, respectfully (P > 0.05 for all comparisons). Linear regression was statistically significant (R² = 0.35, F = 3.70, P = 0.005) with hip extensor (β = 0.81, P = 0.014) and abductor (β = 0.81, P 2 = 0.29, F = 3.57, P = 0.005) but instead with knee extensor asymmetry (β = 1.48, P

Conclusions: The results of this study support previous findings that sex-based differences in strength development of the dominant limb quadriceps in females and dominant limb hip extensors/abductors in males impact biomechanical performance in later maturational stages. However, limb strength asymmetry appears to influence all maturation levels, though its predictive value for jump-landing biomechanics is limited.

Significance: While strength training may be a strategy to help prevent maladaptive biomechanics during the transition from mid-to-late maturation, limb strength asymmetry should also be taken into account in a sex-specific manner across all maturational stages.

Acknowledgments: This study was supported by the Medical Student Research Program at the University of California at Davis School of Medicine and the Foundation for PM&R.

TOPIC: NCAA

STUDY TYPE: Cohort

Comparison of Injury Rates in High School Mountain Biking to Other Sports: Insights from the NICA Injury Surveillance System

Devan Sheffield, DO

All Other Authors: Aaron Provance, MD, Meredith Ehn, DO, Masaru Teramoto, PhD, MPH, Daniel M. Cushman, MD, Luke Johnson, BS, Jamie Egbert, BS, MPH, Stuart Willick, BS, MPH, and Stuart Willick, MD

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

Purpose: This study aims to estimate the injury rate in organized scholastic mountain biking and compare it to estimated injury rates of other high school sports.

Methods and Study Design: From 2018 to 2022 the National Interscholastic Cycling Association (NICA) Injury Surveillance System (ISS) collected weekly data from scholastic mountain biking teams nationwide on mountain biking injuries, practice and race environments, and associated crash factors. Injury rates in mountain biking were estimated and compared to injury rates from other sports using the High School RIO database.

Results: From 2018 to 2022 (5 seasons), student athletes participated in an average of 5 competitions per season. Each season spanned 16 weeks, with 3 practices per week (48 practices). On average athletes missed 3 events (practice or competition) per season, approximately 50 exposures per athlete. From 2018 to 2022 there were approximately 2,655 injury events. Over 5 years of data collection there were approximately 120,000 student athletes and 6,000,000 total exposures. The estimated NICA injury event rate was calculated as: (2,655 injury events divided by 6,000,000 total exposures) multiplied by 1,000 athletes, resulting in a rate of 0.44 injury events per 1,000 athlete exposures (95% CI, 0.43–0.46). We compared this rate to estimated injury rates for other high school sports from the High School RIO database, reported per 1,000 athlete event exposures: 12.3 for football, 5.6 for ice hockey, 4.3 for lacrosse, and 3.5 for soccer and wrestling.

Conclusions: The calculated injury rate of 0.44 injury events per 1,000 athlete exposures among high school mountain biking athletes appears lower than that of other common high school sports. These findings can help athletes, coaches, and parents make evidence-based decisions regarding injury risk in high school mountain biking.

Significance: This is the first estimation of high school mountain biking injury rate using the NICA ISS data presented in the literature. To our knowledge the NICA ISS is the largest repository of high school mountain biking injury information in the world.

Acknowledgments: We would like to thank the NICA student athletes, coaches, parents, and other stakeholders whose participation was essential for the success of this ISS.

TOPIC: NCAA

STUDY TYPE: Survey

Evaluating Medical Coverage Gaps for Club Sport Athletes at Division I Universities

Alexandra Adelman, MD

All Other Authors: Julie Burland Burland, PhD, ATC and Matthew Hall, DO, CAQSM

Affiliation: University of Arizona, Tucson, AZ.

Purpose: This study evaluates reported medical coverage for club sport athletes at Division 1 universities, focusing on pre-participation clearance and sideline care. It aims to identify gaps in coverage for moderate to high-risk sports and advocate for improved healthcare for club athletes.

Methods and Study Design: An online survey was sent to representatives of the 364 NCAA Division 1 institutions. Responses were analyzed to identify statistical correlations between the number and type of club sports, preventative screenings, and the nature of medical coverage available. Data was compared to the gold standard of medical coverage for varsity athletes to make recommendations for improving current practices.

Results: Responses from 148 schools revealed a mean of 945.75 ± 759.91 total club athletes. A strong positive correlation was found between the number of high-risk club sports and both athletic trainer (AT) coverage (rho = 0.749, P P P = 0.009) and physician coverage (rho = 0.253, P = 0.002). The number of high-risk sports was positively correlated with the presence of full-time ATs for club sports (rho = 0.417, P P = 0.184). No significant correlation was found with pre-participation exam (PPE) requirements for club sports (rho = −0.014, P = 0.875). A weak positive correlation was found with concussion baseline testing requirements (rho = 0.190, P = 0.026). Moderate risk sports showed similar trends.

Conclusions: The results indicate that universities with more moderate and high-risk club sports tend to allocate more medical resources, including ATs, EMTs, and physicians. However, full-time AT staffing is not similarly correlated to number of sports. Also, PPE requirements do not significantly vary with sport risk levels and only a slight correlation was found between high-risk sports and concussion baseline testing indicating a lack of preventative care.

Significance: Universities with more high-risk sports allocate increased medical resources, but gaps remain in full-time AT staffing, PPE requirements, and concussion protocols. This highlights the need for policies to improve safety and care for student athletes.

Acknowledgments: We thank the survey respondents for their time and dedication to improving healthcare for athletes across the country.

TOPIC: NCAA

STUDY TYPE: Other

High Prevalence of Iron Deficiency & Low Vitamin D With Normal Bone Mass in Black Collegiate Runners

Altelisha Taylor, MD

All Other Authors: Michelle Barrack, PhD, Carla Moore, PhD, and Rochelle Benjamin, MD

Affiliation: Morehouse School of Medicine in Atlanta, GA.

Purpose: This is a secondary analysis of a larger study evaluating energy availability, dietary habits, bone mass, and nutrition status among Black collegiate runners. The study identifies the rate of iron deficiency, low Vitamin D, and correlations between eating behaviors and bone mineral density (BMD).

Methods and Study Design: Thirty male (n = 6) and female (n = 24) collegiate cross country and track & field team athletes completed assessments for CBC, ferritin, and vitamin D. Athletes underwent a DXA scan to evaluate BMD and body composition, completed a 24-hour dietary recall and survey to assess exercise, food intake and dietary supplement use, wore the OURA ring, and completed a doubly labeled water assessment.

Results: Among the participants, (avg. age 19.3, mean BMI 24.9 kg/m²), iron deficiency, defined as ferritin 20 ng/mL and P

Conclusions: All females in the study had iron deficiency or iron deficiency anemia, only male athletes (n = 4) exhibited optimal ferritin levels. Nearly all (96.7%) athletes exhibited suboptimal vitamin D. Only one athlete was supplementing iron and no athlete reported taking vitamin D. Despite the elevated prevalence of low vitamin D, no athlete in the study had low bone mass.

Significance: Despite adequate bone mass, the rate of low vitamin D and iron deficiency in Black collegiate track and field athletes is higher than expected. Athletes may benefit from supplementation or dietary modifications to optimize vitamin D and iron status.

Acknowledgments: I would like to thank the Morehouse School of Medicine research team, the Clinical Research Education and Career Development program, and the National Institute on Minority Health and Health Disparities for supplying the funds for this study.

TOPIC: NCAA

STUDY TYPE: Survey

The Prevalence of Food Insecurity Among NCAA Division I Student-Athletes

Christina Mallery, DO

All Other Authors: Allison Schafer, DO

Affiliation: University of Connecticut Farmington, CT.

Purpose: Food insecurity (FI) is the condition in which an individual has limited or uncertain access to adequate food. College students are at high risk of FI and even less is known about FI in college athletes. The purpose of our study was to determine the prevalence of FI in NCAA Division I athletes.

Methods and Study Design: Deidentified pre-participation physicals of Division I athletes and practice players were reviewed from the Fall 2024 semester at a single university. The Hunger Vital Sign, included in the pre-participation screening, is a simple and validated 2-item questionnaire identifying FI. Any affirmative answer indicated FI. A one-tailed t-test was used for statistical analysis.

Results: 88 NCAA Division I student-athletes and practice players were screened using the Hunger Vital Sign. Two athletes screened positive for food insecurity making the prevalence of a positive food insecurity screen 2.3%. The Hope Center’s 2020 annual survey screened 3,506 student athletes using the USDA’s 18-item household food security survey; 24% of their Division I athletes were found to be food insecure. Our study’s prevalence of food insecurity was significantly lower than that of the Hope Center’s 2020 annual survey (P = 0.0256).

Conclusions: The prevalence of food insecurity as determined by a positive Hunger Vital Sign screen was 2.3% in our incoming NCAA Division I student-athletes and practice players. This prevalence was significantly lower than what is known in current literature. This may be due a difference in screening questionnaires utilized, time between data samplings, or study sample size.

Significance: FI screening is a worthwhile endeavor to better tailor care of college athletes. These results demonstrate a more sensitive screen may be beneficial as the Hunger Vital Sign may not adequately identify FI among NCAA Division I student athletes.

TOPIC: NCAA

STUDY TYPE: Cohort

Bone Mineral Density and Early Sport Specialization in NCAA Division I Athletes

Karin VanBaak, MD

All Other Authors: Dana Bielinski, MS, RD, Hannah Scheid, BS, Gabby Juarez, MS, RD, Brennyn Lewis, BS, and Theresa Hernandez, PhD

Affiliation: University of Colorado, Boulder, CO.

Purpose: Participation in low impact sports is a risk factor for low bone mineral density (BMD). Our primary purpose was to examine early sport specialization as a modifiable risk factor for low BMD in NCAA Division I athletes from a range of sports, and secondarily to examine this in distance runners.

Methods and Study Design: This was a prospective cohort study of modifiable risk factors and BMD in NCAA athletes. BMD Z-score was measured at 6 regions. Demographics, lowest BMD Z-score (BMDZ), sports in high school (HS) and age at sport specialization were analyzed descriptively for the entire cohort and distance runners. Mean BMDZ was compared between early (age ≤12) and late sport specializers using 2 sample T-test.

Results: For all participants (n = 100, 10 sports, 63 F (age 20.9 ± 1.72), 37 M (age 20.4 ± 3.15)), 45% competed in 1 sport in HS. Twenty-one percent specialized in their sport at age ≤10, 20% at 11–12, 19% at 13–14, 20% at 15–16 and 20% at >16. Mean BMDZ was 0.490 for those who specialized ≤10, 0.585 (95% CI: 0.107–1.063) at 11–12, −0.037 (95% CI: −0.455 to 0.381) at 13–14, −0.360 (95% CI −0.746 to 0.026) at 15–16, and −0.425 (95% CI −0.948 to 0.098) at >16. There was a higher mean BMDZ in early sport specializers (0.537, n = 41 vs. −0.278, n = 59), P 1 sport in HS, and the mean BMDZ was −0.773 ± 0.802. 2.5% specialized ≤10, 10% at 11–12, 27.5% at 13–14, 27.5% at 15–16, and 32.5% at >16. Mean BMDZ was 0.600 (95% CI: N/A) for those who specialized ≤10, −0.725 (95% Cl: −1.133 to −0.317) at 11–12, −0.527 (95% CI: −0.927 to −0.127) at 13–14, −0.991 (95% CI: −1.330 to −0.652) at 15–16, and −0.915 (95% CI: −1.518 to −0.313) at >16. Mean BMDZ was not different between early and late specializers (−0.460, n = 5 vs. −0.817, n = 35), P = 0.179.

Conclusions: In athletes in multiple sports there is an even distribution of age at sport specialization. Mean BMDZ was higher in early sport specializers. Distance runners specialize at older ages. Distance runners trend toward lower Z-scores than all athletes. There is a trend toward lower Z-scores with later sport specialization in both cohorts. In distance runners, mean BMDZ did not differ between early and late sport specializers.

Significance: BMD in young adulthood is critical to long term bone health. These results contrast with the hypothesis that early sport specialization is a risk factor for low BMD. Further study test this relationship in distance runners and other athletes.

Acknowledgments: This research was partially funded by a grant from the American Sports and Performance Dietitians Association.

TOPIC: NCAA

STUDY TYPE: Cohort

Prevalence of Upper Extremity Injuries in Division 1 Baseball Players

Wesley Baker, DO

All Other Authors: Ishan Dhankani, MS, Adrian Ramon, ATC, Kendra McCamey, MD, and James Borchers, MD, MPH

Affiliation: The Ohio State University Jameson Crane Sports Medicine Institute, The Ohio State University Department of Athletics, Columbus, OH.

Purpose: The most common injuries found at all levels of competitive baseball involve the upper extremity. This study sought to quantify injury rates and patterns amongst Division 1 baseball players at a single institution over a 7-year time frame.

Methods and Study Design: Retrospective cohort study involving 151 baseball players at Division 1 university over a 7-year period from 2018 to 2024. Student athlete data was gathered from our athletic trainer, who monitored and tracked these injuries over the course of the study. For the purposes of this study, upper extremity injuries are defined as those that involve either the shoulder or elbow.

Results: A total of 31 upper extremity injuries were recorded out of the 151 athletes (21%). Shoulder injuries accounted for 9 of the 31 injuries (29%). Elbow injuries accounted for 22 of the 31 (71%). Of the shoulder injuries, 4 required surgery (44%). Of the elbow injuries, 10 required surgery (45%). A total of 28 athletes had recorded an upper extremity injury. There were 2 athletes that had 5 total injuries recorded among them. Of the 28 athletes, 21 were pitchers (75%).

Conclusions: Overall prevalence of upper extremities injuries at this institution is comparable to previous NCAA data. However, there were twice as many elbow injuries compared to the shoulder which is not consistent with previous studies that show shoulder injuries being more common. Percentage of shoulder and elbow injuries requiring surgical intervention were also much higher in this study compared to the literature.

Significance: Future research is needed to identify risk factors that may predispose a baseball player to these injuries to further develop injury prevention programs. Smaller sample size of data collected from a single institution limit this study.

TOPIC: NCAA

STUDY TYPE: Survey

Hydration Knowledge, Habits, and Barriers in Female Collegiate Equestrian Athletes

Sara Gould, MD, MPH

All Other Authors: Lauren Picken, BS, Anna Crawford, BS, Gerald McGwin, PHD, Devon Serrano, ATC, and Caroline Cohen, PhD

Affiliation: University of Alabama at Birmingham, department of orthopedics, division of sports medicine. Birmingham, AL.

Purpose: Objective: To characterize hydration knowledge, habits, and barriers in female colligate equestrians. We aim to address gender disparity in the body of literature regarding this subject, which has been reported as being predominately (>90%) male to date.

Methods and Study Design: Sixty-five collegiate equestrian athletes were surveyed regarding their hydration practices, competition environment and incidence of heat-related illness. Athletes were members of the National Collegiate Equestrian Association, which is an emerging NCAA sport.

Results: A large proportion (61.5%) of participants reported a heat-related illness that they attributed to being dehydrated while riding, and 15.4% reported that such an episode occurred multiple times. Further, 61.5% of participants had experienced an episode of decreased performance that they attributed to dehydration. The vast majority (86.2%) of participants reported not using any method to monitor their hydration status. These incidents play a major role in the outcome of sport performance.

Conclusions: Collegiate equestrians report experiencing symptoms of dehydration and diminished performance related to dehydration. Despite this, the majority do not monitor their hydration status.

Significance: There exists ample opportunity for collegiate teams to incorporate education, personalized planning and enhanced availability of beverages on the competition sidelines. Future prospective studies should be dedicated to this predominantly female population

Acknowledgments: The NCEA for supporting our research endeavors.

TOPIC: NCAA

STUDY TYPE: Survey

Head Injuries in the Wild West: A Comparison in English and Western Collegiate Equestrian Athletes

Sara Gould, MD, MPH

All Other Authors: Lauren Picken, BS, Anna Crawford, BS, Gerald McGwin, PHD, and Devon Serrano, ATC

Affiliation: University of Alabama at Birmingham, Department of Orthopedics, Division of Sports Medicine. Birmingham, AL.

Purpose: Participation in equestrian sports is associated with a high risk of head injury, however little is known about relative risk between the disciplines of English and Western equestrian sports. We sought to compare the incidence of head injury, number of falls, and helmet use between disciplines.

Methods and Study Design: This cross-sectional survey study design was conducted among 357 collegiate equestrians. This survey was sent to members of the Intercollegiate Horse Show Association and the National Collegiate Equestrian Association, an NCAA emerging sport.

Results: Two hundred ninety-seven athletes reported competing in English style riding, and 60 reported competing in Western style riding. There was a significantly higher proportion of English-style equestrians who reported always wearing a helmet while riding (92.5%), in comparison to just 23.3% of Western style riders. There were significantly more Western equestrians than English equestrians who reported multiple head injuries as a result of falls in the previous year. However, there was no difference between head injuries sustained, or in history of past head injury between the 2 disciplines.

Conclusions: All equestrians have a high incidence of head injuries, however Western riders reported a higher number of falls in the previous year than their English counterparts. Additionally, Western riders reported less consistent helmet use when compared to their English counterparts, who are more likely to always wear helmets when riding.

Significance: Further work is needed to develop targeted strategies to encourage helmet use in all equestrian athletes and to develop a centralized injury surveillance database to better understand discipline-specific head injury risk.

Acknowledgments: The authors would like to acknowledge Avinash Chandran, PhD for his guidance on surveillance database systems.

TOPIC: NCAA

STUDY TYPE: Other

7 Years of Pre-Season and in-Season NeuroVisual Training Resulted in Significantly Improved Batting Statistics

Hagar Elgendy, MD, MS

All Other Authors: Joseph Clark, PhD

Affiliation: University of Cincinnati, University of North Carolina.

Purpose: NeuroVisual Training (NVT) improved Batting Statistics in an NCAA DI Baseball Team.

Methods and Study Design: NVT was performed over 7 years out of a 12-year period with The University of Cincinnati baseball team. Batting statistics for the team over the years of the study were collected using a public database found at www.gobearcats.com.

Results: The University of Cincinnati baseball team participated in vision training for 7 years and no vision training for 5 years. During the years of vision training batting average, Slugging %, on base % and On Base % + Slugging % (OPS) were significantly improved compared to the non-NVT years. Improvements were: 0.030, 0.107, 0.042 and 0.035 respectively. The winning percentage for the NVT years was 47.6 compared to 40.5% for non-NVT, although statistical significance was not found.

Conclusions: In this paper we present a retrospective analysis of batting performance comparing 7 years of NVT and 5 years of no-NVT. The results are highly suggestive that NVT has a positive benefit on batting performance supporting the role of NVT for performance enhancement.

Significance: NVT carries the capacity to improve and strengthen visual neural processing and translate it to functional gains. More work is needed, such as a randomized controlled study to further validate NVT as a batting performance activity.

Acknowledgments: University of Cincinnati Department of Sports Medicine University of North Carolina Department of Physical Medicine & Rehabilitation.

TOPIC: NCAA—Concussion

STUDY TYPE: Other

Compliance of a NCAA DI University’s Concussion Management Plan With the 2023 NCAA Concussion Safety

Tianna Morton, MD

All Other Authors: Ryan Giang, DO, Alexander Sin, MD, Iridi Pavliqoti, MD, and Amanda Phillips, MD

Affiliation: LSU Health Sciences Center Lafayette, LA.

Purpose: To assess compliance with an updated NCAA university’s Concussion Management Plan (CMP) and the 2023 NCAA Concussion Safety Protocol Checklist (CSPC). The review aims to identify gaps in protocols, policies, and student-athlete records, highlighting areas for further improvements.

Methods and Study Design: Medical records of all student-athletes who experienced concussions during the 2022–2024 academic years were reviewed for compliance with the 50 components of the 2023 NCAA CSPC. Compliance rates, including item and category-level assessments, were compared by demographic information. We also assessed progress by comparing the 2022–2023 data to the university’s updated 2023–2024 protocol.

Results: Compliance rates showed varied results. Preseason Education remained at 85.71% for both 2022–2023 and 2024–2025. Pre-Participation Assessment improved from 36.84% to 79.89%, a 43.04% increase. Recognition & Diagnosis of Concussion rose from 73.68% to 100%, a 26.32% gain. Initial Suspected Concussion Evaluation improved from 86.84% to 96.55%, a 9.71% increase. The Concussion Emergency Action Plan increased from 0% to 100%, a 100% improvement. Scat 6 (Off Field Same Day) rose from 36.84% to 50%, a 13.16% increase. Scoat (72 hours to weeks post-injury) improved from 0% to 20.69%. Rest and Exercise declined from 94.74% to 70.69%, a 24.05% drop. The Re-Evaluation Plan rose from 0% to 66.67%. Return to Learn (RTL) increased from 11.84% to 19.40%. Return to Sport (RTS) improved from 29.47% to 93.28%, a 63.80% increase. Reducing Head Impact Exposure improved from 0% to 100%. Overall compliance increased from 38.00% to 73.57%, a 35.57% increase.

Conclusions: The overall compliance rate and category-level compliance with the 2023 NCAA CSPC requirements highlighted several areas of opportunity for improvement in current CMP protocols, policies, and documentation. However, we observed significant improvement in multiple areas when comparing the 2022–2023 to the 2023–2024 seasons, reflecting the effectiveness of the initial protocol adjustments made following last year’s evaluation.

Significance: This study’s findings will guide updates to the university’s CMP documents to improve compliance with the 2023 NCAA CSPC. The study has the potential to assist other programs in enhancing/improving policies for concussion management across the NCAA.

Acknowledgments: The University of Louisiana Lafayette Athletic Department and LSU Health Sciences Center.

TOPIC: Orthobiologics

STUDY TYPE: Other

Funding Sources Improve Access to Platelet-Rich Plasma: A Single Center Experience

Wikien Hung Pinto, MD

All Other Authors: Anant Shukla, MD, Alicia Hymel, MS, Jacquelyn S. Pennings, PhD, and Lauren Porras, MD

Affiliation: Department of Orthopaedic Surgery, Division of Sports Medicine, Vanderbilt University Medical Center, TN.

Purpose: There is a lack of demographics reported and non-white patient representation in the orthobiologic literature. Platelet-Rich plasma therapy is usually self-funded, raising concerns about access to certain groups. We looked at patients’ demographics with access to PRP with and without funding sources.

Methods and Study Design: We conducted a retrospective chart review, looking at age, sex, race, zip code, and insurance status. All adults who received PRP injections for primary knee, shoulder, and hip osteoarthritis (OA) at Vanderbilt University Medical Center from 2021 to 2024 were included. Differences in demographics, funding, and socioeconomics, in terms of the Distressed Communities Index (DCI), were evaluated.

Results: Pearson’s χ² test and Fisher’s exact test were used for binomial data distribution and Wilcoxon rank sum test for non-normal distribution data analysis. There were 155 (65.95%) patients that paid out-of-pocket and 80 (34.04%) patients that paid through funding sources (insurance or bundle care models). Female representation was high in both groups, with 89 (57%) patients in the out-of-pocket group and 62 (78%) (P 0.002) patients in the funded group. Patients in the out-of-pocket group had a mean (SD) age of 62 (13) compared with 53 (11) (P 0.001) and a non-white population representation of 16 (11%) patients compared with 20 (25%) (P 0.007) patients in the funded group. The latter was mainly driven by the Black patient group with 19 (24%) patients in the out-of-pocket group compared with 25 (11%) (P 0.009) patients in the funded group. There was no statistically significant relationship in DCI between the out-of-pocket and the insurance group.

Conclusions: A higher proportion of black, especially female, patients have access to PRP therapy when it is funded. Patients with funding sources that receive PRP tend to be younger, which may reflect the older one third of the US labor force. This study was ultimately not powered to identify changes in socioeconomic status.

Significance: This study is the first to demonstrate that access to funding for PRP improves access to certain groups of patients, particularly black and female patients.

TOPIC: Orthobiologics

STUDY TYPE: Other

Comparison of Concentration Yields in 2 Commercially Available Platelet-Rich Plasma Concentrating

Walter Sussman, DO

All Other Authors: Kate Davitt, ATC, Erek Latzka, MD, Grace Harkness, ATC, Kristen Mitchell, ATC, and Paige Occhipinti, MA

Affiliation: Tufts University, Boston, MA.

Purpose: This study compares platelet concentrate products prepared by 2 commercially available Platelet-Rich plasma (PRP) concentrating systems. In 2024, the EmCyte Corporation released the PurePRP TWO system and retired their LEGACY PurePRP Double Spin system, but no comparative analysis is available.

Methods and Study Design: A retrospective review of registry data (Databiologics LLC) of 20 consecutive patients treated with an intra-articular PRP injection for knee osteoarthritis (OA) was performed. The PRP was processed according to kit specifications using the 120 mL LEGACY Emcyte and 120 mL PurePRP TWO Emcyte double spin systems. Baseline and PRP values were analyzed using the Horiba Micros 60 ABX hematology analyzer.

Results: There was no significant difference in platelet recovery rate (P = 0.4094) or deliverable platelet dose (P = 0.4104) between the LEGACY PurePRP system (platelet recovery rate = 74.1% ± 11.95; platelet dose = 15.5 billion platelets ± 5.13) and PurePRP TWO (platelet recovery rate = 78.3% ± 10.22; platelet dose = 17.4 billion platelets ± 4.73). Analysis of the overall final composition of the PRP showed no significant difference in WBC count (P = 0.4379) or RBC count (P = 0.1596) with the LEGACY PurePRP system (mean WBC = 16.59 × 103/mm³ ± 12.4; mean RBC = 0.13 × 103/mm³ ± 0.02) and PurePRP TWO (mean WBC = 19.98 × 103/mm³ ± 5.48; mean RBC = 0.16 × 103/mm³ ± 0.06).

Conclusions: Commercially available PRP systems can produce dramatically differing products, and there has not been any published analysis of the “new” Emcyte system compared to the “old” system. This study found that both Emcyte kits had a similar efficiency with no statistically significant difference in platelet recovery rates between the 2 system. There was also no significant difference in the platelet dose or WBC and RBC counts between the systems

Significance: An emerging consensus has emerged that PRP injections should include at least 10 billion platelets to reach a clinically therapeutic threshold in knee OA, and this study demonstrates that both systems reach this “dose” and have a similar efficiency.

TOPIC: Orthobiologics

STUDY TYPE: Cohort

Intra-articular Platelet-rich Plasma in the Management of Acetabular Labral Tears: A Prospective Study

Alexandra Beling, MD

All Other Authors: Derek Stokes, MD, Luke A. Johnson, BS, Jamie Egbert, BS, MPH, and Daniel M. Cushman, MD

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

Purpose: This study aimed to determine if Platelet-Rich plasma (PRP) injection of the hip joint under ultrasound guidance improves pain and functional outcomes for patients with acetabular labral tears (ALT), taking into consideration platelet concentration of whole blood and after centrifugation.

Methods and Study Design: These are preliminary results of an ongoing prospective cohort study. Eligible patients are 50% relief after a hip injection with anesthetic only. Subjects undergo a 9 mL leukocyte-poor PRP injection, and are followed for 1 year; only those with the first month of follow-up were included in this analysis.

Results: Twenty-five subjects (68% female) had a full month (1m) of follow-up, while 14 had 3-month (3m) follow-up data. Response rate was 100%. Participants had a mean age of 34 (standard deviation ± 9.4) years, and BMI of 24.3 ± 3.1 kg/m². Whole blood platelet concentrations were an average of 177,000 ± 67,000 platelets/microliter, and average PRP (neutrophil poor) concentration was 452,000 ± 101,000 platelets/microliter. Injection satisfaction was 60% (1m) and 71% (3m); global satisfaction increased from 37% at baseline to 44% (1m) and 64% (3m). International Hip Outcome Tool scores improved from 52 ± 17 at baseline to 69 ± 21 (1m) and 73 ± 22 (3m), with follow-up scores meeting the Minimum Clinically Important Difference (MCID) of 13. No serious adverse effects were reported.

Conclusions: Interim analysis suggests PRP may be a viable treatment option for ALT. Ultimately, this study provides pilot data for a blinded, randomized, and controlled trial.

Significance: Platelet-Rich plasma may be a viable option for acetabular labral tears.

Acknowledgments: AMSSM Research Grant.

TOPIC: Orthobiologics

STUDY TYPE: Other

A Bundled-Cost Program Improves Access to Platelet-Rich Plasma in Certain Minority Groups

Anant Shukla, MD

All Other Authors: Alexander Sin, MD, Wikien Hung Pinto, MD, Lauren Porras, MD, Alicia Hymel, MS, and Jackie Pennings, PhD

Affiliation: Vanderbilt University Medical Center.

Purpose: To evaluate whether the implementation of a novel hospital-based bundled-cost program will improve access to Platelet-Rich plasma (PRP) for the treatment of osteoarthritis for patients of a more diverse population in terms of age, gender, race, ethnicity, and socioeconomic status.

Methods and Study Design: We performed a retrospective chart review from 2021 to 2024 to examine the race and ethnicity of patients receiving PRP treatment under a bundled-cost program at Vanderbilt University Medical Center (for knee, shoulder, or hip arthritis). Distressed Communities Index (DCI) scores corresponding to patient zip codes were used to test for differences in access due to socioeconomic status.

Results: Of the patients who accessed Platelet-Rich plasma as a treatment for osteoarthritis, a significantly greater proportion of women were enrolled in a bundle program compared to men (P = 0.002). In addition, non-white patients (94% of whom were Black or African American) were more likely than white patients to access Platelet-Rich plasma treatment fusing bundles (P = 0.018). We found no significant differences in the socioeconomic status of patients enrolled in the bundles compared to out of pocket, (P = 0.3) Differences between bundle and out-of-pocket groups were examined using Pearson’s χ² and Fisher’s exact tests for categorical variables and Wilcoxon rank sum tests for continuous variables.

Conclusions: Our retrospective chart review examining the Bundles program (N = 223) from 2021 to 2024 showed that its implementation has expanded access to Platelet-Rich plasma to African-American and female patients with shoulder, knee and hip osteoarthritis. We found no significant differences in terms of access to lower socioeconomic status patients.

Significance: The implementation of a hospital-based bundled-cost program increased access to Platelet-Rich plasma for black patients and women.

Acknowledgments: The Orthopedics Statistical Team (Alicia Hymel, MS and Jackie Pennings, PhD).

TOPIC: Other

STUDY TYPE: Survey

The Case Study: Caffeine and Sports/Exercise

Anthony Noll, DO, MHA

All Other Authors: Michele Collingsworth, DO, Yousef Hasanain, DO, Karanvir Takhar, DO, and Alexander Hinckley, DO

Affiliation: Corewell Health Lakeland Hospital; Saint Joseph, MI.

Purpose: To analyze the use of caffeine for sports/exercise, side effects reported, subjective perception of caffeine’s impact on exercise, and healthcare professional recommendations for caffeine usage in exercises within a local population.

Methods and Study Design: This is a 10-question survey project which targets specific data points identified in the “Purpose” of this project, along with ancillary data points and variables. This study took place over the course of one calendar year with an N-value of 97. Correlation statistics were run to confirm/reject study hypotheses. PHI gathered was limited to the patient’s age only, and IRB exemption was obtained.

Results: Hypothesis 1: Patients less than 50 years of age will consume more caffeine with exercise than patients 50 years of age or greater, Result: The = 50 age group was between 50 and 100 mg of caffeine; Hypothesis 2: Patients who report side effects to caffeine were less likely to consume it for exercise, Result: No Correlation (−0.03); Hypothesis 3: Patients who consume caffeine with exercise are more likely to report a positive benefit with caffeine usage, Result: Moderate Positive Correlation (+0.46)

Conclusions: Within this study population, patients less than 50 years of age reported nearly double the amount of caffeine consumption when compared to patients 50 years of age or greater. Additionally, patients who reported caffeine consumption paired with exercising were more likely to report increased subjective health benefits. Lastly, there was no correlation of patients avoiding caffeine usage if they had side effects to it prior.

Significance: Caffeine in appropriate amounts is linked with improved cardiovascular health and endurance exercises. In this study, patients were more likely to report a benefit with caffeine usage even if they were experiencing side effects paired with caffeine.

Acknowledgments: Thank you to the patients who participated in this study, Corewell Health Lakeland GME, Corewell Health Lakeland Hospital, and the Corewell Health Royalton Primary Care Clinic.

TOPIC: Other

STUDY TYPE: Survey

The PAIN Study: Pain and Injury Nuisance

Anthony Noll, DO, MHA

All Other Authors: Michele Collingsworth, DO, Yousef Hasanain, DO, Karanvir Takhar, DO, and Alexander Hinckley, DO

Affiliation: Corewell Health Lakeland Hospital; Saint Joseph, MI.

Purpose: To analyze the impact of a patient’s pain/pain level on their activities of daily living, perceptions of healthcare/care plans provided, and mental health within a local population.

Methods and Study Design: This is an 11-question survey project which targets specific data points identified in the “Purpose” of this project, along with ancillary data points and variables. This study took place over the course of one calendar year with an N-value of 83. Correlation statistics were run to confirm/reject study hypotheses. PHI gathered was limited to the patient’s age only, and IRB exemption was obtained.

Results: Hypothesis 1: Patients that report better satisfaction with pain control will report higher satisfaction scores with their provider, Result: Strong Positive Correlation (+0.72); Hypothesis 2: Patients that report activities of daily living being impacted by pain are more likely to report an impact on their mental health as well, Result: Borderline Weak/Moderate Positive Correlation (+0.39); Hypothesis 3: Patients who report higher pain scores will be more likely to report impacts on their mental health, Result: Moderate Positive Correlation (+0.49).

Conclusions: Patients in this study population reported increased provider satisfaction and reduced mental health burden when their pain was more controlled, compared to patients who had higher pain scores/uncontrolled pain. The majority of patients in this population experienced a chronic pain (>6 months), but the findings noted were seen in both acute and chronic pain patients.

Significance: Pain has been linked with mental health impact, usually when paired with impairments in ADLs. In this study population, patients reported less impact on their mental health when pain was controlled, regardless of its chronicity.

Acknowledgments: Thank you to the patients who participated in this study, Corewell Health Lakeland IRB and GME, Corewell Health Lakeland Hospital, and the Corewell Health Royalton Primary Care Clinic.

TOPIC: Other

STUDY TYPE: Other

Non-English Language of Care (LOC) is a Barrier to Care for Knee Replacement Surgery

Audrey DeFusco, MD

All Other Authors: Krystian Bigosinski, MD, Amy Haskins, PhD, and Christina Holt, MD, MSc, MA

Affiliation: MaineHealth Maine Medical Center/Portland, Maine.

Purpose: The purpose of this study was to evaluate if patients referred for joint replacement and seen by a joint replacement clinic who use English as their language of care undergo knee replacement surgery at the same rate as patients who use non-English languages as their language of care.

Methods and Study Design: This was a retrospective study. Patients from a Joint Replacement clinic in Maine from January 1, 2017 to December 31, 2021 with age >50, BMI

Results: A total of 8,108 patients were included in the study, with 95 (1.2%) classified as non-English language of care. Significantly more English-speaking patients completed surgery (48.4%) compared to non-English speakers (33.7%), P-value 0.004. In addition to language, surgery completion was associated with younger age (P P = 0.0004). Among patients with commercial insurance, 48.4% completed surgery compared to 34.9% with Medicaid, 48.7% with Medicare, and 33.9% with no insurance. Surgery was not significantly associated with gender or race/ethnicity.

Conclusions: Among those with knee arthritis, LOC was associated with knee replacement surgery in our population. Those that used English as their LOC had a higher percentage of surgery completed compared to those using other languages. Insurance type was associated with knee replacement surgery. Participants with no insurance and Medicaid had lower percentage of surgery, while those with commercial insurance and Medicare had higher percentage of surgery.

Significance: Non-English LOC and insurance type may be barriers to accessing knee replacement surgery in our population. More efforts are needed to address these barriers including in-person interpreters and longer visits for patients who don’t speak English.

Acknowledgments: Thank you to Drs Bigosinski, Haskins, and Holt for your help with this project.

TOPIC: Other

STUDY TYPE: Cohort

Motorized and Non Motorized Scooter Accidents at California State University Northridge

Stephano Abusleme, DO

All Other Authors: Eric Sletten, MD and Mandeep Ghuman, MD

Affiliation: Dignity Health Medical Center, Northridge, California.

Purpose: The purpose of this study is to examine the wide variety of scooter accidents seen on campus. We examined 6 months of scooters accidents prior to a campus police intervention and 6 months after this intervention to evaluate for any decrease in amount or severity of accidents seen.

Methods and Study Design: Students who have had encounters with any of the physicians in the CSUN Student Health Center for a scooter injury will be included in the study. Data was collected while on campus for 6 months before the campus police intervention and 6 months after the intervention. HIPAA trained and certified providers used our electronic medical record to search for keyword “scooter” to collect our data.

Results: A total of 73 patients were seen in the first 6 month pre-intervention interval and 44 patients were seen in the second 6 month post-intervention interval for scooter accidents. There were 101 total motorized scooter accidents and 16 non-motorized scooter accidents seen during this entire 12-month period. There were 25 joint sprains in the pre-intervention group compared to 17 joint sprains in the post-intervention group. However, there were 6 fractures in the pre-intervention group compared to 9 fractures in the post-intervention group. Fifty-three cases of abrasions/contusions were seen in the pre-intervention group and 21 cases of abrasions/contusions were seen in the post-intervention group. Ten cases of head trauma were seen in the pre-intervention group compared to only 1 case of head trauma in the post-intervention group. There was only 1 fracture that required surgery in the pre-intervention group, but there were 3 fractures that required surgery in the post-intervention group. There were 4 lacerations in the pre-intervention group and 3 lacerations in the post-intervention group.

Conclusions: There was a significant amount of scooter injuries seen in the 12 months of data collected at this campus. Motorized scooter accidents were far more common than non-motorized scooter accidents. However, the campus intervention appears to have mixed results in regards to decreasing the amount and severity of scooter injuries. While the amount of accidents was decreased after the campus intervention, there were still more fractures and surgeries.

Significance: Scooters are used on many college campuses and have been involved with a wide variety of significant accidents. This campus intervention may have not been enough to decrease the amount and severity of these accidents and may lead to more restrictions.

Acknowledgments: California State University Northridge: Klotz Student Health Center was the location of all these patient encounters used for this study. Point and Click Electronic Medical Record was used to collect our data.

TOPIC: Other

STUDY TYPE: Other

The Missing Physician: Analyzing the Representation of Emergency Medicine Physicians Within Professional Sports

Marisa McDow, MD

All Other Authors: Lawrence H. Brown, PhD

Affiliation: The University of Texas at Austin Dell Medical School, Austin, Texas.

Purpose: The purpose of this study is to describe the prevalence of emergency medicine physicians among sports medicine physicians working with professional teams in the National Football League (NFL), National Hockey League (NHL), Major League Baseball (MLB), and National Basketball Association (NBA).

Methods and Study Design: This observational study used internet searches of publicly available websites to identify and compile information on NFL, NHL, MLB and NBA team physicians. Individual professional sports team websites, as well as public websites with information on the physicians (e.g., their academic institutions’ public webpages) were used for data collection including team affiliation and medical specialty.

Results: Among 570 individual physicians working with NFL, NHL, NBA, and MLB teams, 33 (5.8%) were board-certified in emergency medicine. There were 124 total professional teams represented, with 23 (18.5%) teams having at least one emergency medicine physician. At the sport-specific level, the NHL had the highest representation of emergency medicine physicians (n = 21, 12.7%), followed by the NFL (n = 9, 4.8%), MLB (n = 3, 2.1%) and NBA (n = 2, 1.6%). Orthopedic surgery was the most common specialty represented (48.2%), followed by family medicine (20.2%) and internal medicine (12.6%). Nearly half (n = 15, 45.5%) of the emergency medicine physicians were also fellowship-trained in sports medicine, and 4 (12.1%) were fellowship-trained in emergency medical services.

Conclusions: Emergency medicine physicians comprise only a small proportion of the sports medicine physicians working with professional sports teams. This appears to be true across all 4 major league sports. Additional work is needed to increase emergency medicine representation among sports medicine physicians, working with professional sports teams to ensure appropriate emergency care where needed.

Significance: Recent high-profile events, including on-field cardiac arrests, have highlighted the need for emergency medicine specialists within professional sports, especially with sudden cardiac death being the leading cause of death in athletes.

Acknowledgments: Special thank you to the emergency medicine residency leadership team at Dell Med for their continued support in scholarly activities.

TOPIC: Other

STUDY TYPE: Survey

Is there an Association Between PM&R Physician Knowledge, Confidence, and Frequency of Exercise Prescription?

Flynn McGuire, MD, MS

All Other Authors: James Whitlock, MD, Ragav Sharma, DO, and Daniel Cushman, MD

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

Purpose: Exercise prescription practices vary widely by physician. This study explores how multiple variables including familiarity with Cardiovascular Fitness (CRF) and resistance training (RT) guidelines among PM&R physicians correlate with their exercise prescription patterns in clinical practice.

Methods and Study Design: A survey was created based on American College of Sports Medicine’s Guidelines for Exercise Testing assessing basic knowledge of cardiorespiratory and Resistance Training. The survey was then input into REDCap and an email with a REDCap link was sent to the AAP registered PM&R Residency Listserv and Program Coordinator’s forwarded the survey to their respective departments.

Results: There was a significant difference between residents and fellows/attendings on CRF and RT guideline familiarity based on CRF/RT quiz scores, with residents (mean = 47/100) scoring lower than fellows/attendings (mean = 68/100, P-value = 0.035). Additionally, higher CRF/RT quiz scores were correlated with increased confidence in creating an exercise regimen (ρ = 0.51), confidence in prescribing a regimen (ρ = 0.54), and confidence in progressing a regimen (ρ = 0.47). However, there was a weaker correlation between confidence in prescribing an exercise regimen and actual frequency of exercise prescription in clinical practice (ρ = 0.31). Additionally, there was no correlation between CRF/RT quiz scores and frequency of exercise prescription (ρ = 0.04). The number of days per week a physician exercised did not appear to correlate strongly with CRF/RT quiz scores (ρ = 0.16) nor exercise prescription patterns (ρ = 0.03).

Conclusions: This study showed that PM&R physicians with a higher level of training were more knowledgeable regarding the CRF and RT guidelines. This increased knowledge correlated with a physician’s confidence in creating, prescribing, and progressing a specific exercise regimen; however, increased familiarity with exercise guidelines nor any of the other variable examined had a strong correlation with actual frequency of exercise prescription.

Significance: Exercise prescription is a vital component of patient care and plays a large role in patient outcomes. Additional research is needed to identify factors that affect frequency of exercise prescription so that it can become more broadly adopted.

Acknowledgments: We could like to acknowledge Dr. Cushman for his mentorship during this project.

TOPIC: Other

STUDY TYPE: Cohort

Impact of Airbag Suits on Incidence of Injury among Competitive Motorsport Athletes

Eric Swanson, MD, MSc

All Other Authors: Marisa McDow, MD, Keeli Hanzelka, MD, James Buskirk, PhD, Jason Knudsen, EMT, Lawrence H. Brown, PhD, and Carl I. Price, MD

Affiliation: University of Texas at Austin Dell Medical School, Austin, Texas.

Purpose: Motorcycle crashes are common in competitive motorsport racing, rendering athletes susceptible to serious injury. This study evaluated whether the use of specialized airbag suits reduced the incidence of injury among competitive motorsport athletes who crashed during competition.

Methods and Study Design: This observational cohort study utilized standardized data collected by race medical personnel for all crashes occurring during the 2024 MotoAmerica competitive season. Data included crash characteristics, airbag suit usage, observed injuries, and medical care. The association between airbag suit usage and incidence of injury was evaluated using risk ratio (RR) with a 95% confidence interval (CI).

Results: There were 498 crashes during the 2024 MotoAmerica competitive season. The majority of athletes were wearing an airbag suit at the time of their crash (296, 59.6%). The type of crash was characterized by mechanism: low-side (403, 80.9%), high-side (62, 12.5%), collision (28, 5.6%), or undetermined (5, 1.0%). Crashes were further characterized by severity: red-flag (67, 13.5%), yellow-flag (404, 81.1%), and no flag (27, 5.4%). Within the most common mechanism of crash (low-side crashes), the incidence of injury for athletes wearing an airbag suit was 6.0% (14/235) vs. 10.2% (17/167) for athletes not wearing an airbag suit (RR = 0.6; CI: 0.3–1.2). Within the most severe crashes (red-flag), the incidence of injury for athletes wearing an airbag suit was 49% (21/43) vs. 63% (15/24) for athletes not wearing an airbag suit (RR = 0.8; CI: 0.5–1.2). Of the 296 athletes wearing an airbag suit, only 9 (3.0%) had the airbag deploy and a “rider down” status after the crash. Of the 201 riders without an airbag suit, 10 (5.0%) had a “rider down” status after the crash.

Conclusions: During the 2024 MotoAmerica competitive season, the incidence of injury was lower among athletes wearing airbag suits who were involved in the most common (low-side) and the most severe (red-flag) crashes. The association was not statistically significant due to the low injury rate in low-side crashes and the small population of red-flag crashes. Still, this study yields clinically relevant and novel insights.

Significance: Understanding the potential of airbag suits to reduce injury is essential for promoting widespread use. This study utilizes data-driven analyses to fill an existing gap in research and better inform both competitive and recreational motorcyclists.

Acknowledgments: We thank MotoAmerica for providing the data underlying this analysis.

TOPIC: Other

STUDY TYPE: Survey

Enhancing Sideline Emergency Preparedness through Simulation Training

Fouad El Bach, DO

All Other Authors: Brad Gable, MD, MS, FACEP, Sarah Vengal, MD, and Logan Maag, MD

Affiliation: OhioHealth Riverside Methodist Hospital, Columbus, Ohio.

Purpose: This project aims to improve simulation-based training to prepare for sideline emergencies. By examining emergency action plans and simulating limb or life-threatening injuries, this project evaluates how training enhances skills, knowledge and confidence to improve emergency response effectiveness.

Methods and Study Design: A simulation was developed to manage sideline medical emergencies in athletics, including: traumatic head injury, concussion, cervical spine injury, heat illness, and cardiac arrest. Various health care specialties participated, including: Sports fellows, FM residents, medical students, paramedics, and ATCs. A Return on Learning questionnaire assessed participant reactions and confidence gained.

Results: Percentages reflect total learner responses. Relevance & Knowledge Acquisition: 87% found the content relevant to their roles, aligning with sports medicine responsibilities. Eighty-two percent reported the simulation provided new insights or clarified existing knowledge, confirming its effectiveness as a learning tool. Confidence in Skills: Participants reported significant gains in confidence, with over 90% feeling more prepared to handle cervical spine injuries and 85% more confident in managing urgent cardiac conditions during events. Feedback & Satisfaction: Participants valued hands-on practice and real-life simulation scenarios, recommending more practice stations and improved scenario structure. The training received high satisfaction ratings, emphasizing its value in preparing healthcare professionals for sideline emergencies. Additionally, as a result of the education ATCs and paramedics identified latent safety threats, and adapted protocols as a direct result of the education.

Conclusions: This simulation-based training effectively improved healthcare professionals’ knowledge, confidence, and preparedness for managing sideline medical emergencies. Participants’ positive feedback underscores the need for structured education in sports medicine, particularly for urgent cardiac and cervical spine situations. Overall, the training highlights the value of multidisciplinary approaches in sports medicine education.

Significance: Training programs that enhance multi-disciplinary collaboration and individual skills boost readiness for sideline emergencies. Emphasizing simulation-based education is key in preparing practitioners to manage the complexities of emergency care.

Acknowledgments: Special thanks to all who contributed to the simulation-based training, including sports fellows, family medicine residents, medical students, paramedics, and athletic trainers (ATCs).

TOPIC: Other

STUDY TYPE: Cohort

The Effect of Travel Load on Minor League Baseball (MiLB) Injuries Part 2 Injury Frequency by Position

Spencer Cooper, DO

All Other Authors: T. Jason Meredith, MD, Samuel Wilkins, PhD, and Adam Rosen, PhD

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

Purpose: Travel fatigue is an accumulative disorder from repetitive travel that can result in increased injures in athletes. A 2021 MiLB schedule change reduced that cumulative travel load for each team. The purpose of our study was to observe the effect of travel load on position specific injury frequency.

Methods and Study Design: A retrospective cohort study analyzed data from minor league baseball players using a public database from 4 seasons per-schedule change (2016–2019) and 4 seasons post-schedule change (2021–2024) at each level of baseball (AAA, AA, A+, A). Data was further separated by position; pitchers, catchers, infielders, and outfielders. An ANOVA analysis was used for comparison between positions.

Results: Exposures were calculated per primary position played for each competition period and pooled per league. Pre-schedule change, there were 7733 injuries across 858,829 exposures, while post-schedule change, there were 6430 total injuries across 844,172 total exposures. According to the ANOVA analysis, there was a significant position by schedule change interaction effect across all variables (P

Conclusions: The schedule modification implemented in minor league baseball appears to have led to a statistically significant reduction in the overall number of injuries. This study shows that decreasing the amount of travel built into a schedule is particularly advantageous to decreasing injury frequency among position players compared to pitchers.

Significance: The findings indicate that while the schedule change alleviates injury frequency among MiLB players, there is a need for further strategies to address injury severity and duration, particularly for pitchers.

TOPIC: Other

STUDY TYPE: Survey

Optimizing Wearable Technology and Overcoming Barriers to WHOOP Device Usage in Division I Athletes

Kimberly Burbank, MD

All Other Authors: Matthew Waldrop, MD, Jeremy Swisher, MD, Christopher Miles, MD, and Neil Sparks, DO

Affiliation: Wake Forest University School of Medicine, Winston-Salem, North Carolina.

Purpose: Wearable technology has become fundamental for optimizing performance in sports medicine. Previous studies highlight the benefits of wearable technology but note compliance issues. This study aimed to identify these barriers to improve adherence, optimize performance, and enhance athlete well-being.

Methods and Study Design: This cross-sectional survey evaluated WHOOP device usage among Division I athletes aged 18–30 at Wake Forest University from July 1, 2024, to July 1, 2025. Participants included athletes with access to a WHOOP device from women’s soccer, baseball, field hockey, and track & field. Athletes unable to participate due to injury or without device access were excluded.

Results: There were 19 responses from 4 Division I teams from Wake Forest University. Of the athletes that reported wearing their WHOOP device, 58% reported wearing it 7 days a week, with 63% reporting WHOOP use 17–24 hours a day. The greatest perceived benefit to wearing WHOOP by the athletes was access to their sleep data at 42%. Training data was the next highest reported benefit at 26%, with recovery data closely behind at 21%. In regards to wearing their WHOOP, 50% of the athletes reported that no change to the device would encourage them to utilize it more, 33% would like aesthetic changes to the device, and 17% of the athletes would like a better understanding of the metrics or more information on the accuracy of WHOOP data. Overall, 60% of the athletes had positive comments about their WHOOP device, 30% of the athletes feel the expense of the device and mobile app is a limiting factor to use, and 10% of the athletes question the accuracy of the data.

Conclusions: Wearable technology offers novel intel and insight into data that may enhance athlete performance and improve overall well-being. This study revealed that athletes largely acknowledge the benefits of wearing a WHOOP device and appreciate the data collected, but they struggle with the cost and aesthetics of the device and also question its accuracy.

Significance: This study elucidates the importance of addressing cost, design, and accuracy to improve athlete adoption of wearable technology. Communication and tailored feedback are critical for optimizing adherence and maximizing the benefits of these devices.

TOPIC: Other

STUDY TYPE: Other

Analysis of Para-Dressage Scores during the Paris Paralympic Cycle

Nathan Boys, DO

All Other Authors: Nikolas Jen, DO and Sajiv Alias, MD

Affiliation: Northeast Georgia Medical Center Family Medicine Residency, Gainesville, GA.

Purpose: Classification plays a crucial role in Paralympic sports, particularly in para-dressage, where the influence of the horse on the athlete adds complexity. This study aims to evaluate the scores of para-dressage athletes to identify any discrepancies in the current classification system.

Methods and Study Design: This retrospective observational study evaluated scores of para-dressage athletes from September 6th, 2021 to September 8th, 2024. Para-riders on the publicly available FEI Database were selected for analysis. Riders with a confirmed Grade and Profile and who performed the highest-level test were included. Statistical analysis was done using the Kruskal-Wallis Test and the Dunn-Bonferroni Test.

Results: The highest and lowest average score in Grade 1 was Profile 13 with 71.524 and Profile 7 with 65.22. Grade 2 was Profile 12b with 71.167 and Profile 6 with 62.712. Grade 3 was Profile 17a with 70.156 and Profile 28 with 64.383. Grade 4 was Profile 18b with 72.467 and Profile 19a with 56.341. Grade 5 was Profile 26b with 73.392 and Profile 22 with 65.354. The Dunn-Bonferroni Test found the Profile with the highest average score in each Grade either had or was tied for the lowest percentage of Profiles with statistically similar scores, with Profile 13 in Grade 1 having 17%, Profile 12b in Grade 2 having 20%, Profile 17a in Grade 3 having 25%, Profile 18b in Grade 4 having 0%, and Profile 26b in Grade 5 having 13%. The Profiles with the lowest average score in each Grade either had or were tied for the highest percentage of Profiles with statistically similar scores except for Grade 5.

Conclusions: There were statistically significant differences in average scores between Rider Profiles in each Grade of para-dressage during the most recent Paralympic cycle. It is uncertain whether this is due to differences in horsemanship, judging bias, training, or physical ability.

Significance: Our analysis revealed score differences across profiles in each grade, warranting further investigation for underlying causes and potential changes of the current para-dressage classification system to align with the IPC’s evidence-based mandate.

TOPIC: Other

STUDY TYPE:

Perceptions and Barriers to Treatment for Urinary Incontinence in Collegiate Athletes

Zoe Roth, DO

All Other Authors: Megan Agnew, MS, Jennifer Sanfilippo, MS, M. Allison Brooks, MD, and Erin Hammer, MD

Affiliation: University of Wisconsin Department of Family Medicine and Community Health.

Purpose: This is a mixed methods study performed to investigate the epidemiology of stress urinary incontinence (SUI) symptoms in nulliparous NCAA D1 female athletes and to explore athletes’ perceptions of SUI and barriers to treatment.

Methods and Study Design: Female D1 collegiate athletes were completed a survey regarding their experience with SUI. Athletes who had previously screened positive for SUI were recruited for qualitative semi-structured interviews. Baseline demographic and clinical characteristics of athletes who reported SUI were compared using t-tests or Chi squared tests. Zoom transcriptions were then analyzed for common themes.

Results: Of the 279 athletes who completed the survey (62% response rate), 83 female athletes reported SUI symptoms (29.7%). Prevalence reported in different sports was: rowing 22.9%, swimming 61.5%, track and field 73%, ice hockey 31.6%, soccer 30.8%, spirit squad 37.9%, softball 16.7%, volleyball 36.4%. The timing of the first incidence of SUI was before high school 6.8%, high school 56.8%, college 36.5%. Approximately half of athletes reported telling a teammate (51.3%), friend (48.7%), family member (26.3%), athletic trainer (21.1%), coach (6.6%), physician (6.6%), or physical therapist (2.6%). Additionally, 28.9% of athletes reported telling no one. Ten athletes (13.2%) reported changing the way they move to avoid SUI. Twenty athletes who had screened positive for SUI participated in structured one-on-one interviews. Themes of these interviews included: normalization of SUI between peers, non-medical behavioral adjustments to manage SUI, and unawareness of SUI as treatable medical condition.

Conclusions: Nearly a third of D1 female athletes experience SUI and over half started having symptoms before college. Unexpectedly, 16/26 swimmers (61.5%) reported SUI which opposes popular belief that impact sport athletes are at highest risk for SUI. Athletes are reluctant to seek treatment and demonstrate a profound degree of normalization surrounding an abnormal, treatable physical ailment.

Significance: This novel study elucidates perceptions and barriers to seeking care for a highly treatable condition, evidences a discrepancy in sex-based differences in care and demonstrates an area of needed improvement in the care of female athletes so far.

TOPIC: Other

STUDY TYPE: Cohort

Sport Climbers’ Weight Conundrum

Omri Besor, MD, MPH

All Other Authors: Naama Constantini, Prof. MD, DFM, FACSM, Dip. Sport Med. (CASM) and Evert A. Verhagen, Prof. PhD

Affiliation: Maccabi Health Care Services, Tel Aviv, Israel.

Purpose: There is currently a concern regarding weight, deliberate weight restriction, and resulting negative health implications for elite athletes in sport climbing. This study explored changes in BMI over the years among elite climbers and examine their relation to performance, as indicated by ranking

Methods and Study Design: This retrospective cohort study analyzed BMI trends among elite sport climbers competing in the International Federation of Sport Climbing (IFSC) World Cups (WC) from 2013 to 2023. Measurements included weight, height, age, sex, and climbing discipline. BMI and competition rankings were analyzed using longitudinal and regression analyses, accounting for repeated measures and covariates.

Results: A total of 389 athletes were screened during 2013–2023 IFSC WC. There were 122 females in the Lead discipline and 92 in Boulder (mean age 22.1 ± 3.8 (SD) and 22.5 ± 3.5 years, respectively); 130 males in Lead and 88 in Boulder (mean age 23.6 ± 4.3 and 24.5 ± 4.1 years, respectively). The mean BMI of female Lead climbers was 19.4 kg/m² (±1.6) and significantly lower (P 2 ± 1.7). Among males, Lead climbers had a slightly higher BMI (21.2 kg/m² ± 1.5) than Boulder climbers (20.8 kg/m² ± 1.3). Male climbers demonstrated a consistent increase in BMI across years in both disciplines. In contrast, female Boulder climbers showed a minor increase, whereas female Lead climbers experienced a steady decrease in BMI. Males showed non-significant ranking improvements with decreasing BMI in Boulder (P = 0.09) and an opposite trend in Lead (P = 0.20). Female climbers showed significant ranking improvements with a decrease in BMI for both Boulder (R = 0.26, P P

Conclusions: Male climbers showed an increase in mean BMI over time, while female Lead climbers demonstrated a steady decrease, raising concerns about weight reduction in this discipline. The improved ranking of females who reduced weight is concerning because of its impact on the field. The results constitute the need to further investigate climbers’ weight, BMI, health, and performance outcomes.

Significance: Some athletes and coaches believe that “the lighter you are, the better you will climb.” The trend we noticed of reduced BMI in female climbers needs to be explored further to assess its relation to world ranking and, its impact on climbers’ health.

Acknowledgments: First, we would like to acknowledge and appreciate the International Federation of Sport Climbing (IFSC) support and involvement. Hadas Vagman and Nirdi Besor for their help with the data.

TOPIC: Other

STUDY TYPE: Survey

Building Trust through Coordinated Outreach through Athletics in Colleges and High Schools (COACHS)

Christopher Johnson, MD

All Other Authors: Christopher Ledford, MD, Kathleen McIntyre, Zoe Gunthert, Alison Chase, Nicolas Arrowood, Lillie Williamson, PhD, Christy Ledford, PhD, and Christy Ledford, PhD

Affiliation: Augusta University, Augusta, Georgia.

Purpose: Embedded high school athletic trainers (ATs) interact with students in a familiar setting in which they can develop trusting relationships. In this setting, ATs could provide whole-athlete care for athletes. This study explored athlete trust in ATs and willingness to talk to ATs about health.

Methods and Study Design: At an annual preparticipation exam (PPE) event in April 2024, researchers invited athletes and their parents to complete an instrument prior to the PPE. Athletes completed scales to assess trust in ATs and health literacy, as well as willingness and demographic items. Parents completed scales to assess trust in ATs and healthcare system distrust.

Results: 42 athletes (ages 13–17) and 37 parents completed the instrument; 36 matched pairs are included in analysis. In a linear regression, parent trust in ATs, parent distrust in the healthcare system, athlete health literacy, and athlete age predicted athlete trust in ATs, P t-test, athletes were significantly less willing to talk to ATs about depression and anxiety than injuries, P

Conclusions: Findings here indicate that ATs are trusted health professionals who are well positioned to provide whole-athlete care. Athletes are open to talking to ATs about concussions, headaches, and mental health concerns. As ATs and health systems look to leverage the role of outreach ATs, they must consider the influence of parent trust and broader distrust in the health system as they build relationships with student-athletes.

Significance: The willingness of student-athletes to talk to trainers about depression and anxiety signals a need for athletic trainers to receive additional training in responding to athlete needs outside of their traditional (injury-focused) role.

Acknowledgments: The authors would like to thank the outreach athletic trainers, Marissa Lucas, DAT, ATC; Lauren Holliday, ATC; Leah Afsarfraid, ATC; Marquise Sims, ATC; Mrs. Britney Pooser, executive director Augusta Hub for Community Innovation; Dr. Ebony Whisenant, medical director for Harrisburg Family Health and Dr Monte Hunter, chair Orthopaedic Surgery, Medical College of Georgia.

TOPIC: Other

STUDY TYPE: Cohort

Disparities in Pediatric Orthopedic Care in Los Angeles: An Analysis of Wait Times for Physical Therapy

Shane Hervey, MD

All Other Authors: Ashley Lopez, BS, My Nguyen, BS, Alex Soto, MD, Emily Miller, MD, and CJ Duffaut, MD

Affiliation: University of California, Los Angeles, Department of Family Medicine, Division of Sports Medicine.

Purpose: This study examines disparities in pediatric musculoskeletal care, comparing wait times for physical therapy across clinical sites using the Social Vulnerability Index (SVI), ethnicity, race, language, and insurance coverage. It aims to identify inequities and inform interventions to improve access.

Methods and Study Design: This retrospective cohort study analyzes medical records to calculate wait times from referral to first PT session. Pediatric patients aged 8–17 seen in orthopedic clinics from July 1, 2019 to June 30, 2024 were included. Data management and analysis, using R-Studio, involve median wait times, correlation tests, and ongoing modeling efforts.

Results: Of 252 records, the median PT wait time was 18.9 days for patients identifying as African-American, 19.9 for Caucasian, and 19.5 for Other Identified Groups. No statistically significant difference was observed across races (Kruskal-Wallis: χ² = 0.55, df = 2, P = 0.76). Median PT wait time was 18 days for Hispanic/Latino patients, 19.9 for Not Hispanic/Latino patients, and 21.5 for Other Identified Ethnicities with no statistically significant difference was observed (KW: χ² = 2.16, df = 2, P = 0.34). Median PT wait time was 20.0 days for English speakers, 17.3 for Spanish, 18.6 for Korean, and 34.7 for Japanese with no statistically significant difference observed (KW: χ² = 3.13, df = 3, P = 0.37). Median PT wait times were 22 days with Commercial insurance, 19 with Government, and 64.1 with Other coverage with no statistically significant difference was observed (KW: χ² = 0.17, df = 2, P = 0.92).

Conclusions: No statistically significant differences were observed across race, ethnicity, primary language, or insurance coverage. These findings suggest that these factors may not independently influence PT wait times within this dataset. Future research with additional variables, such as socioeconomic status using SVI data, may provide further insights into disparities in physical therapy access and approval processes.

Significance: Delays in musculoskeletal care can have long-term consequences for pediatric patients. Findings may inform policy decisions aimed at reducing health disparities in the referral process and resource allocation for a more equitable healthcare system.

Acknowledgments: Data collection was supported by the Clinical and Translational Science Institute (CTSI), UCLA Health. We thank the Department of Statistical Methods and Data Analytics at UCLA for their assistance with data management and statistical analysis.

TOPIC: Other

STUDY TYPE: Other

A Comparison of Traditional vs. Personalized Hydration in NCAA Divison 1 Womens Lacrosse Athletes

Jeremy Calderwood, DO

All Other Authors: Joseph Armen, DO, Joseph Barsa, MD, Patrick Rider, MSc, Kristina Coe, RD, and Megan Juergens, ATC

Affiliation: East Carolina University Sports Medicine Fellowship Greenville, NC.

Purpose: To determine whether a personalized rehydration strategy improves physical capacity (measured by external workload), sport specific skill and/or ratings of perceived exertion in NCAA Division I female lacrosse athletes when compared to a traditional approach.

Methods and Study Design: Twenty-two female college lacrosse athletes consented to participate in a randomized crossover design involving 2 separate training sessions during the preseason. Sweat and electrolyte losses were measured, and replacement occurred ad lib with Gatorade verses a personalized combination of water and LNMT electrolyte powder. Physical capacity, sports specific skill and RPE were measured for analysis.

Results: There were no significant group effects between traditional and personalized groups (all values respectively arranged) in physical capacity metrics (e.g., 71.8 ± 16.1 vs 70.1 ± 15.8 total loading), sport specific skill performance (4.6 ± 0.7 vs 5.1 ± 1.2 shooting scores) and RPE values (7.2 ± 1.0 vs 6.9 ± 1.1). There was a significant group effect for electrolytes consumed between traditional and personalized groups (449 mg ± 149 vs 1022 mg ± 559), and while not significant (P = 0.08) there was a trend to more fluid volume consumed in the traditional group (29 oz ± 9 vs 26 oz ± 10). There were slight differences in temperature (81 vs 80) and humidity (79% vs 75%) between D1 to D2. There were significant day effects for several workload values with D1 slightly more intense than D2. RPE was significantly higher D1 to D2 (7.6 ± 0.75 vs 6.5 ± 0.96). There was also a significant day effect on sport skill with D2 performances being better than D1 (shooting scores: 4.3 ± 0.9 vs 5.4 ± 1).

Conclusions: Both hydration strategies in non-extreme outdoor conditions appear to result in comparable performance and perceived exertion despite differences between groups in quantities of fluid and electrolytes consumed. Day 1 workloads and perceived exertion was greater possibly due to environmental differences, whereas performance improved in sport specific skill testing on day 2, probably due to increased familiarity with the testing procedures.

Significance: Traditional hydration appears to be equivalent to a personalized approach on an athletes’ ability to handle the demands of a practice, although results might differ in more extreme environmental conditions or with more extended practice exposures.

Acknowledgments: This research was partially supported by East Carolina University Department of Family Medicine. We also thank the student-athletes and coaches from the Department of Athletics for their participation in this study along with Daniela Ramirez, Benjamin Shahady and Alexis Schroeder for their assistance with data collection.

TOPIC: Other

STUDY TYPE: Other

A Scoping Review of Mental Health in Amateur and Professional Women’s Ice Hockey

Ryan Hebel, MD

Affiliation: Vassar Brothers Medical Center.

Purpose: Primary: to summarize the data on mental health within the game of female ice hockey from amateur to professional. Secondary: to organize the literature in country where data was collected, comparison with men’s hockey and control data, specific mental health topics, and treatment modalities used.

Methods and Study Design: PubMed, Cochrane library, EMBASE, and were searched using the terms “female ice hockey” and “mental health,” “depression,” “anxiety,” “substance abuse” using PRISMA guidelines, and 7 studies involving female ice hockey and mental health were identified. Studies were divided based on country, study structure, level of play, comparison to male hockey players/controls, mental disorder, and treatment.

Results: A total of 7 articles met the inclusion criteria and were performed between 2018 and 2024, with 2 articles posted as dissertations (2018, 2023) and 0 articles published in a scientific journal prior to 2023. There was a total of 591 female ice hockey players enrolled in the above studies with a weighted average age of 22.4 amongst all female participants. 89.6% of these athletes were enrolled in Swedish professional leagues, 6.7% were North American college athletes, and 1.5% were North American professional athletes. 57.1% of these articles were cross-sectional survey studies, 28.6% were longitudinal survey studies, 14.3% were interviews. 59.2% of the female athletes were compared to professional male ice hockey players, while only 2.8% of athletes were compared to control subjects. Depression was evaluated in 57.1% of studies, anxiety in 57.1% of studies, alcohol consumption in 14.2%, stress levels in 57.1%, burnout in 14.2%, resilience in 14.2%. 0% of studies evaluated treatment modalities for female ice hockey players.

Conclusions: As highlighted in this scoping review, there is a gap in research regarding mental health and the female ice hockey player. The current data on this topic is ascertained from surveys and interviews, with most of the participants from Swedish professional leagues. There are few articles comparing female hockey players to the general public. There were 0 articles published prior to 2023 and 0 articles highlighting treatment options for this cohort.

Significance: This scoping review appears to be the first to attempt to summarize the research on mental health as it relates to the female hockey player. With the recent rapid growth of women’s hockey, there is much opportunity for continued research.

Acknowledgments: Thank you to Dr. Justin Conway for the support on this project.

TOPIC: Other

STUDY TYPE: Other

A Review of HbA1c Profiles in Endurance Athletes

Ilona Schwarz, MD

Affiliation: Rutgers New Jersey Medical School.

Purpose: Blood tests such as Hemoglobin A1c and fasting glucose are common screens for diabetes. However, such metrics in isolation may be interpreted inappropriately in athletes, especially endurance athletes, who by the nature of their training, confer metabolic adaptations that impact glucose regulation.

Methods and Study Design: The PubMed, Cochrane, and Embase databases were searched for relevant articles published up to December 1, 2024. Searches were limited to full-text, English-language studies, and texts that focused on the report of glycemic control in healthy endurance athletes without diabetes. Endurance athletes were defined as middle to long distance runners, cyclists, triathletes, and/or swimmers.

Results: A combined total of 189 articles were reviewed. One hundred sixty-nine articles remained after the removal of duplicates. Opinion pieces, single case reports, basic science studies, and articles focusing on any populations besides healthy athletes were excluded. After additional screening, only 8 studies discussed HbA1c or plasma glucose in healthy athletes, but only 3 of these articles investigated or evaluated glycemic control in endurance athletes. Rather, several studies support the phenomena of “exercise-induced insulin resistance,” where a trained individual biases towards fatty acid oxidation for fuel and preserves glucose. This is relevant because lifestyle counseling for diabetes management, such as dietary and activity modifications, may be harmful to an athlete’s health and performance. Encouragement of unnecessary carbohydrate restriction and activity modification may lead to underfueling, over-training, inadequate recovery, and place athletes at greater risk of disordered eating, Relative Energy Deficiency in Sports (REDS), injury, and illness including anxiety and depression.

Conclusions: Metabolic tests in athletes should be interpreted in the context of the athlete’s training profile. Athletes, especially endurance athletes, are consistently reported to have higher HbA1c and fasting plasma glucose values that, without context, may lead a provider towards an unnecessary and, potentially physiologically and psychologically harmful intervention plan.

Significance: HbA1c and fasting plasma glucose may be inappropriate diabetes screens in trained endurance athletes such as middle to long-distance cyclists, runners, triathletes, and swimmers because of the metabolic adaptations of their training.

Acknowledgments: Thank you to my many mentors.

TOPIC: Other

STUDY TYPE: Survey

Evaluation of Woman’s Tennis Association (WTA) Player Development Programs on Behavioral Outcomes and Stress

Neeru Jayanthi, MD

All Other Authors: Carol Otis, MD, Keber Ashley, BS, Thomas Livingood, BS, Vitkova Sarka, BS, Stephanie Kliethermes, PhD, Lara Dugas, PhD, Kathleen Stroia, PhD, and Kathleen Stroia, MPT, ATC

Affiliation: Emory Sports Medicine Center.

Purpose: The Woman’s Tennis Association (WTA) has developed player development programs (PDP’s) since 1994 in order to reduce stressors, lengthen careers, and improve behaviors. The purpose of this study is to determine if there is an association between completion of PDP’s by players and desired behaviors.

Methods and Study Design: A cross-sectional survey was distributed to the top 300 WTA singles and players and top 50 WTA doubles in players (in a variety of languages) either electronically or in person. The survey tool was developed after lengthy iterations through the WTA Player Development Medical Advisory Panel that included training patterns, and and adherence to PDP behaviors. T-tests performed to evaluate PDP’s.

Results: One hundred ninety-eight WTA Professional tennis players completed the survey (61.1%), mean age increased with ranking from 20.3 years (1.6) to 27.6 (3.9) years. Players who reported that they utilized each of the PDP’s also reported a statiscially higher number of identified desired professional behaviors than players who reported that they did not utilize a PDP in 17/18 of PDP’s (P

Conclusions: This is the first analysis of the effectiveness of WTA PDP’s in woman’s professional tennis to achieve desired behaviors. Players with compliance with PDP’s were more likely to achieve desired professional behaviors. while stress scores were low to moderate, players with lower stress and higher happiness did not report injury, had higher rankings, and were able to train at higher loads.

Significance: WTA PDP’s may be effective in achieving desired professional behaviors in woman’s professional tennis, and may potentially contribute to mitigating stress and improving happiness. Other sport organizations may consider PDP’s to achieve outcomes.

Acknowledgments: The WTA player development advisory panel contributed to the development of this study and analysis and interpretation of the findings.

TOPIC: Other

STUDY TYPE: Other

Factors Associated With Reaching the NBA A Matched-pairs Analysis of Top-ranked Male US Youth Basketball Players

John DiFiori, MD, FAMSSM

All Other Authors: Arne Gullich, PhD, Pete Meisel, MPH, Jean Cote, PhD, Robert Malina, PhD, Joel Brenner, MD, Brian Hainline, MD, Edward Ryan, MD, and Edward Ryan, ATC

Affiliation: National Basketball Association, NY, NY.

Purpose: Elite international athletes report later sport specialization, more multi-sport participation and fewer injuries in youth compared to less successful peers. Few comparisons exist for US athletes. Purpose: determine if such factors differentiate future success among top US youth basketball players.

Methods and Study Design: Cross-sectional follow-up study of top-ranked male US youth basketball players. A questionnaire was completed regarding sport participation patterns for basketball and other sports, and self-reported injuries. Players who eventually signed NBA contracts were matched by age and player ranking with peers who did not reach the NBA. Matched-pairs analyses included t-tests and logistic regression.

Results: Six hundred twenty-seven top-ranked male US youth basketball players (16.6 (1.3) years) were surveyed in 2018 and 2019. Forty players eventually signed NBA contracts. Players who eventually signed NBA contracts reported exclusively focusing on basketball at older ages than matched non-NBA peers (12.9 (2.2) vs. 9.6 (2.5 years; P = 0.001). They reported more organized participation in sports other than basketball until age 14 years (90.0% vs. 52.5%; P = 0.001), began playing on select teams at older ages (10.7 (2.4) vs. 9.1 (2.5) years; P = 0.007), and at the time of the survey they spent relatively less time in both organized and non-organized basketball than matched non-NBA peers (P less than 0.05). They also reported fewer severe injuries at 14 years or older (25.0% vs. 47.5%; P = 0.036). They were less likely to relocate residence, receive scholarships/funding, or stay back in school (P less than 0.05 respectively). Binary logistic regression correctly classified 85.0% of NBA and non-NBA players.

Conclusions: Similar to elite international athletes, top-ranked male US youth basketball players who eventually signed NBA contracts specialized at later ages, exhibited more multi-sport participation, and reported fewer significant injuries in youth compared to peers who did not reach the NBA. Such findings further question the benefit of early specialization and highlight the potential impact of youth injuries on long-term health and future sport success.

Significance: While further study is needed, the consistency of this youth sport participation pattern across different sports and countries suggests these findings should be considered when developing programs for youth athletes.

Acknowledgments: The Jr. NBA and NBA Player Health Department.

TOPIC: Other

STUDY TYPE: Survey

Evaluation of Burnout, Pressure and Sleep Quality among Various Levels of Competitive Youth Rock Climbers

Brittany Becker, MD

All Other Authors: Rachel Meyers, DPT, Bobby Van Pelt, MPH, Bayley Potter, BS, Shane Miller, MD, and Aaron Provance, MD

Affiliation: University of Colorado, Aurora, CO.

Purpose: There remains limited literature regarding the rates of burnout and pressure among youth athletes. While several studies describe rates of burnout between 9.8–15.3% in youth athletes, there are no current studies evaluating burnout, pressure, and sleep quality in competitive youth rock climbers.

Methods and Study Design: Competitive youth rock climbers, ages 8–18, were recruited across the United States to complete a one-time survey. Climbers competed at the local, regional, national and international levels. The main outcome of burnout, pressure, number of hours of sleep per night and sleep quality, and total number of injuries was assessed among various levels of competition in youth rock climbers.

Results: A total of 117 participants were included (13.74 ± 2.7 years, 61.5% female) in our study. 38.9% of participants competed at either the national or international level. Overall, 28.8% of this cohort reported ever feeling burnout, and 70.1% reported at least a little bit of pressure. Participants reported the most pressure from themselves (42.9%), coaches (28.6%) and teammates (21.8%). Among the participants, 23.7% had less than the recommended number of 8 hours of sleep per night, and 41.3% subjectively reported average or poor sleep quality. There were no significant correlations found between levels of competition and rates of burnout, pressure, number of hours of sleep per night and sleep quality. As a secondary outcome, there were also no significant correlations found between the number of injuries in the past 12 months and the rates of burnout, pressure, number of hours of sleep per night and sleep quality.

Conclusions: This study highlights a higher prevalence of burnout and pressure in competitive youth rock climbers compared to other sports. The high rates of burnout within this cohort may be due to a high percentage of climbers competing at the national level or higher, a high percentage of females who completed the survey and that rock climbing is an individual sport, as these risk factors have been associated with higher rates of burnout in prior studies.

Significance: Given the higher prevalence of burnout and pressure in youth rock climbers than prior studies in youth athletes, this study stresses the need for further literature on risk factors for and methods to mitigate burnout and pressure among rock climbers.

TOPIC: Other

STUDY TYPE: Survey

Understanding the Perspective of the Recreational to Paralympian Adaptive Athlete

Chantal Nguyen, MD

All Other Authors: Matthew Kaufman, MD and Jeremy Stanek, MD

Affiliation: Stanford University, Palo Alto, CA.

Purpose: Adaptive athletes are more prone to injury than able-bodied athletes during participation in sport. This study aims to understand the perspective, safety concerns, and injury risks uniquely facing adaptive athletes at multiple levels of organized competition.

Methods and Study Design: An online survey focusing on demographic data, primary sport participation, highest level of competition, and safety concerns, logistical challenges, or barriers to safe participation in sport was distributed via email to adaptive athletes by physiatrists at one large academic center. A total of 9 adaptive athletes were recruited.

Results: The average age of athletes was 47 years old, with 3/9 (33%) women and 6/9 (67%) men. Primary diagnoses included 5/9 (56%) spinal cord injury (SCI), 2/9 (22%) amputees, 1/9 (12%) stroke, and 1/9 (12%) SCI/amputee. Primary sports were 5/9 (56%) para-archery, 1/9 (12%) wheelchair rugby, 1/9 (12%) para-swimming, 1/9 (12%) adaptive golf, 1/9 (12%) adaptive CrossFit, and 1/9 (12%) multi-sport. Highest level of competition was recreational/national in 5/9 (56%) and international/Paralympian in 4/9 (44%). Acute medical complications in sport occurred for 3/9 (33%) athletes, but 6/9 (67%) witnessed this in other participants, including autonomic dysreflexia (2/9, 22%), temperature dysregulation (6/9, 66%), and concussion (1/9, 12%). Athletes wanted changes to rules (2/9, 22%), logistics (4/9, 44%), or equipment (1/9, 12%) to optimize safe participation. Subjects also cited transportation issues, with 4/9 (44%) having equipment damaged during travel. Most (5/9, 56%) reported average or below average adaptations during sport and travel, including lack of privacy during bowel/bladder care.

Conclusions: Many adaptive athletes, at all levels of competition, have either witnessed or experienced acute medical complications during sport, many of which are preventable but can be life-threatening when untreated. Sport-specific, legislative, and travel-related barriers to participation in sport have been uniquely identified by adaptive athletes as a way to improve safety in all para-sports.

Significance: Given adaptive athletes’ increased injury risk and medical complication rates, understanding their unique perspectives can guide further research, thus improving awareness, leading to decreased injury, and promoting safer participation in sport.

TOPIC: Other

STUDY TYPE: Other

Limited English Proficiency as a Barrier to Telemedicine in Orthopedics and Sports Medicine

Justin Ham, DO

All Other Authors: Kristian Bigosinski, MD, Amy Haskins, PhD, and Tina Holt, MD

Affiliation: MaineHealth, Portland, ME.

Purpose: Despite the increasing use of telemedicine in recent years, there have been limited studies to identify barriers that could hinder patients from accessing medical care virtually. This study was to investigate whether having limited English proficiency is one of challenges in using telemedicine.

Methods and Study Design: A retrospective observational study was designed to examine the visit records of all patients aged 18 and over at Orthopedics and Sports Medicine offices within the MaineHealth network between 2017 and 2023. Encounters were divided into 2 groups—English and non-English—based on patients’ self-identified preferred language. The proportion of telemedicine between the 2 groups was compared.

Results: Of the total 412,643 visits during the defined period, 6,835 visits were completed by patients who reported other than English as their primary language. Among the visits by patients who speak English as their primary (n = 405,808), 4,528 encounters were conducted virtually—the portion of telemedicine at 1.12%. By comparison, among the group who did not speak English as their primary language, only 0.4% of visits were done via telemedicine. While the disparity between the 2 cohorts may appear to be small, due to the small proportion of tele-visits, the difference was found to be statistically significant with a P-value less than 0.0001. Other variables, including legal sex and insurance coverage also showed a statistical difference in telemedicine.

Conclusions: Having limited English proficiency appears to be a barrier when seeking medical care via tele-visits. Other variables such as age, legal sex, and insurance also showed statistical difference in adoption of telemedicine. Virtual visits can eliminate time for travel, enhance convenience, and increase access to specialists in areas that are medically underserved. More studies can be done to identify other limiting factors.

Significance: Inequitable healthcare access among those with limited English proficiency has been well documented. As telemedicine becomes more prevalent, identifying barriers to its access and addressing those limiting factors can improve patient care.

Acknowledgments: Krystian Bigosinski, MD, Amy Haskins, PhD, Tina Holt, MD, and MHMG Analytics.

TOPIC: Other

STUDY TYPE: RCT

Can Melatonin Help Athletes With Altitude Illness, Cognition, Sleep, and Blood Pressure on Denali

Christian Dean, DO, MS

All Other Authors: Christopher Jung, PhD, Peter Hackett, MD, Paul Huske, BS, and Diane Redwood, PhD

Affiliation: St. Anthony’s North.

Purpose: Millions of athletes visit high altitudes annually. A readily available and economical drug with few side effects to counteract the pathologic effects of altitude has yet to be studied. Because melatonin has sedative, antioxidant, and vasodilatory properties, it might be such a dietary supplement but has yet to be studied.

Methods and Study Design: A randomized placebo-controlled, double blind, crossover, within subjects design was conducted at 4,300 m on Denali. Athletes were studied on 2 consecutive evenings, receiving melatonin one evening and placebo the other evening. We used a wireless sleep recording device, measured vitals and administered a Stroop cognitive test.

Results: There was significantly less wakefulness after sleep onset (WASO) and a decrease in sleep onset latency (SOL) with melatonin when compared to the placebo control (P P P

Conclusions: Performing optimally at high altitudes is of major importance for athletes. The decrease in wakefulness following melatonin administration could play a role in improved cognitive performance. Despite use in extreme conditions of cold and high altitude (non-laboratory conditions), melatonin decreased systolic blood pressure when compared to placebo and baseline. This could decrease the risk of acute mountain sickness.

Significance: Melatonin is a safe, natural, and readily available over-the-counter dietary supplement that could benefit athletes training and competing at altitude as it has proven to counter some negative pathologic effects at altitude.

Acknowledgments: Faculty Development and Foundation Grants from the College of Arts and Sciences, University of Alaska Anchorage sponsorship from Mountain Hardwear, Inc.

TOPIC: Pediatrics

STUDY TYPE:

The Fight Within: A Study of Depression and Resilience in Youth MMA Athletes

Jeffrey Fujimoto, MD

All Other Authors: Alexandra Boyd, Karen Ladnier, and Carlos Uquillas, MD

Affiliation: UCLA Health, Los Angeles, CA.

Purpose: The popularity of Mixed Martial Arts (MMA) has increased rapidly over recent decades. However, youth participation in MMA is controversial. Further, mental health has not been well-studied in this population. This study is the first to study depression and resilience in youth MMA athletes.

Methods and Study Design: A cross-sectional survey was administered to youth MMA athletes registered in 2023 with the United States Fight League (USFL), a Youth MMA organizing body. Outreach was via email, promotional video, and reminders at the 2024 USFL Nationals. Depression screening was performed via Short Mood and Feelings Questionnaire (SMFQ). Resilience was assessed via Connor Davidson Resilience Scale (CD-RISC 2).

Results: Two hundred seventy-six athletes were contacted with 118 responses for a 43% response rate. There were 108 total responses after removing 10 incomplete surveys. The average age was 13.4 years (range 8–17). Males and females accounted for 70% and 30% of respondents respectively. White, American Indian/Alaska Native, and Black/African American athletes represented 66%, 10%, and 4% of respondents respectively with 18% electing not to disclose race. Eighty percent of respondents had 2 years or less of USFL competition experience. Thirty-six percent practiced 15 hours or more per week. The average SMFQ score was 1.3. In total, 4 athletes (3.7%) screened positive for depression using a SMFQ score of 8 as a cutoff for positive screening. The average CD-RISC 2 score was 6.97. Age, gender, race, years of USFL experience, and practice hours were not significantly associated with depression or resilience scores.

Conclusions: Our study finds a low rate of depression and high resilience scores among youth MMA athletes. For comparison, other studies have found US adolescent rates of depression to be around 15.8%. Internationally, SMFQ scores are 2.5 to 4.6 on average in UK adolescents and CD-RISC 2 scores are 6.14 in German students. Limitations of the study include sample size and response rate.

Significance: These findings suggest that youth MMA participation may be associated with lower rates of depression and greater resilience. Further research would be beneficial to validate these findings longitudinally.

Acknowledgments: Jon Frank, Joe Stevenson.

TOPIC: Pediatrics

Scurvy as a Cause of Leg Pain and Limp in Pediatric and Adolescent Patients

Naomi Brown, MD

All Other Authors: Christopher DeFrancesco, MD, David Kell, MS, Sean Owens, MS, and Matthew Grady, MD

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

Purpose: This case series highlights subtle hints of Vitamin C Deficiency (VCD) that may be overlooked, describe imaging and lab findings among these patients, and recognize patterns in presentation and treatment to help orthopedic clinicians avoid missing the diagnosis in the future.

Methods and Study Design: Patients presenting with lower extremity pain/limping due to VCD at a tertiary care children’s hospital from January 1, 2012, to September 1, 2024, were identified using Vitamin C Deficiency diagnosis codes (ICD-9 code 267, ICD-10 code E54). Demographic information (age, sex, race, ethnicity, and body mass index (BMI) percentile), relevant lab findings, and disease courses were recorded.

Results: Ten patients were identified and included in this series. Vitamin C levels were low in all patients and undetectable in 8 patients (≤5 μmol/L). Seven (70%) of the patients had autism spectrum disorder (ASD), and all 10 had restrictive eating. Many had cutaneous findings consistent with scurvy that were overlooked. Knee radiographs in skeletally immature patients showed periphyseal vitamin C disease-related changes, although these were not commonly recognized at the time of the studies. MRI findings in skeletally immature patients showed symmetrically increased signal in long bone metaphyses on fluid-sensitive sequences mirrored by symmetrically decreased signal in these areas on T1-weighted sequences. In those without a prior diagnosis of VCD, testing of Vitamin C levels was typically not performed until 2–3 weeks after presentation. Four patients underwent general anesthesia for MRI or invasive diagnostic testing.

Conclusions: Astute history taking, critical review of imaging, thorough physical examination, and a high index of suspicion are important to efficiently making the diagnosis of scurvy in the child presenting with nonspecific lower extremity pain or limping. In these patients, a simple question about diet when taking the history could help zero in on the diagnosis and prevent the need for unnecessary anesthetic events and invasive diagnostic procedures.

Significance: The lessons of this case series might help clinicians to identify VCD efficiently in the future, improving patient care and decreasing the need for serious diagnostic procedures.

Acknowledgments: CHOP Orthopedic Center Research.

TOPIC: Pediatrics

STUDY TYPE: Survey

Associations of Grit, Athletic Identity, and Mental Health Measures among Adolescent Athletes

Zainab Shirazi, MD

All Other Authors: Veronica Hogg-Cornejo, MS, Sarah Petersen, BA, Madison Brna, BS, Rachel Meyers, DPT, David Howell, PhD, and Aubrey Armento, MD

Affiliation: University of Colorado.

Purpose: Athletic identity and grit influence in an athlete’s ability to overcome challenges and cope with injury in sport. This study aimed to assess the relationship between psychological well-being and intrinsic athlete characteristics (athletic identity and grit) among adolescent athletes.

Methods and Study Design: We conducted a cross-sectional study of high school athletes participating in organized sports. We constructed 2 multivariable linear regression models. In each model, we assessed the association between grit and athletic identity (outcomes) with anxiety, depressive symptoms, body appreciation, and peer relationship ratings (predictors), adjusting for age and sex (covariates).

Results: There were 201 participants (85% female, avg age 16.1 ± 1.7 years, avg BMI 21.7 ± 3.4); n = 166 included in the model for grit, and n = 61 included in the model for athletic identity. Participants reported moderate grit (3.3 ± 0.7), low to moderate athletic identity (33.4 ± 5.5), normal to moderate anxiety (52.1 ± 9.5), normal to mild depressive symptoms (48.5 ± 10.3), moderate to high body appreciation (38.9 ± 7.7), and good peer relationships (49.9 ± 7.8). Multiple linear regression results indicated that higher body appreciation was significantly associated with higher grit (β = 0.02; 95% CI = 0.01, 0.03; P = 0.01), while anxiety, depressive symptoms, and peer relationships were not significantly associated with grit. Higher anxiety ratings were significantly associated with stronger athletic identity (β = 0.22; 95% CI = 0.01, 0.44; P = 0.04), while depressive symptoms, peer relationships, and body appreciation ratings were not significantly associated with athletic identity.

Conclusions: Higher body appreciation was associated with higher grit, while mental health (anxiety, depression) and social health (peer relationships) were not found to be indicators of grit. Higher anxiety was associated with stronger athletic identity, while emotional health (body appreciation, depression) and social health were not found to be indicators of athletic identity.

Significance: Athletes with higher body appreciation may have more grit, while athletes with more anxiety may have a stronger athletic identity—both of which play a significant role in an athlete’s ability to overcome challenges and cope with injury in sport.

TOPIC: Pediatrics

STUDY TYPE: Cohort

Associations Between Menstrual Dysfunction, Injury, and Attempt to Lose Weight Among Female Adolescent Flag Football Athletes

Kaylee Blevins, BA

All Other Authors: Madison Brna, BS, David Howell, PhD, and Aubrey Armento, MD

Affiliation: University of Colorado School of Medicine, Aurora, CO.

Purpose: The aim of this study was to compare in-season injuries and weight loss behaviors between adolescent female flag football athletes with and without menstrual dysfunction (MD).

Methods and Study Design: Participants completed pre-season surveys assessing menstrual history and weight loss behaviors and weekly surveys to record sports-related injuries during the flag football season. Participants were classified into MD or No-MD groups. We compared injury occurrence, whether participants reported worrying about weight and were actively trying to lose weight between MD vs No-MD groups.

Results: We enrolled 83 female adolescents, with 14 excluded due to contraceptive use and 69 included in the final analysis. Participants who reached menarche after 15 years of age, were over 15 years old and had not yet had a menstrual period, did not have a period for 3 or more consecutive months prior to the pre-season assessment, and/or had 9 or fewer periods in the last 12 months were classified as having MD. There were n = 18 (26%) with MD and n = 51 (74%) with No-MD. There were no significant differences between groups in age (mean = 16.3 years), race, ethnicity, or BMI (mean = 21.7 kg/m²). There was no significant difference between groups in the proportion of participants who sustained a sport-related time-loss injury during the season (MD = 11% vs. No MD = 20%; P = 0.72) or who reported worrying about their weight (MD = 72% vs. No MD = 59%; P = 0.31). However, a significantly greater proportion of the MD group reported that they were trying to actively lose weight (44% vs. 20%; P = 0.04).

Conclusions: Female adolescent flag football athletes with pre-season MD were more likely to report actively trying to lose weight, possibly reflecting MD secondary to low energy availability at the time of the pre-season assessment, compared to athletes without MD. However, there was no significant difference in the proportion of those who sustained in-season injuries between groups.

Significance: Flag football is a rapidly growing sport among female adolescents. Clinicians should be aware of the risk of MD and weight loss attempts among adolescent female flag football athletes, and the associations with injury risk should be further explored.

Acknowledgments: This study was supported by funding from the Denver Broncos Foundation.

TOPIC: Pediatrics

STUDY TYPE: Cohort

Evaluating Risk Factors of Running-Related Injuries in Youth Female Runners

Heather Burton, MD

All Other Authors: Jessica Fritz, PhD and Shayne Fehr, MD

Affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin.

Purpose: This study aims to analyze the biomechanical profile of female youth runners, track activity data, and monitor the development of running-related lower extremity injuries over the course of a structured 8-week running program.

Methods and Study Design: Female youth runners (ages 7–12) underwent a biomechanical assessment including a health/activity questionnaire, gait analysis, and functional strength tests all prior to an 8-week running program. Participants used FitBits to track activity throughout the running program and completed weekly questionnaires to monitor participation and report any lower-extremity pain or injuries.

Results: Twelve premenstrual female youth runners (ages 8–11, average age 9) were recruited for the study. Five had prior experience in structured running programs, and 9 participated in other sports, with 7 doing so during the study. Only one trained in running for more than 8 months per year. No running-related injuries were reported during the program. Functional strength, assessed via a single-leg squat test, showed no correlation with maximum internal thigh rotation or knee valgus angle observed in gait analysis.

Conclusions: This study highlights the complexity of identifying biomechanical and training-related risk factors in youth runners. Due to the absence of running-related injuries, no specific risk factors were identified. The lack of correlation between functional strength and gait parameters suggests that common clinical assessments may not accurately reflect youth biomechanics. However, further analysis may uncover additional insights.

Significance: Youth running offers many benefits but poses injury risks, with limited data on its impact. This study aims to validate and quantify biomechanical and training risk factors, support safer protocols, and identify high-risk athletes.

Acknowledgments: The authors would like to acknowledge Janelle Cross, Nicholas Giebel, Cody Dziuk, and Maeve McDonald for their valuable contributions to this research.

TOPIC: Pediatrics

STUDY TYPE: RCT

Sport Prevention of Overuse Injury by Research in Training (SPORT)

Haruki Ishii, MD

All Other Authors: Anna Buser, MD, Cole Rigsby, BS, Caleb Truong, BS, BA, Lucy Avant, BS, Bridget Doyle, DO, and Neeru Jayanthi, MD

Affiliation: New York University, New York, NY.

Purpose: In a prior randomized control trial, injury reduction occurred in the group receiving recommendations without change in adherence. The aim of the study was to assess if weekly educational videos highlighting healthy training or healthy sport recommendations can increase adherence to recommendations.

Methods and Study Design: This is a single-center cross-over randomized control study. Eligible youth athletes ages 8–18 completed a baseline survey and were randomized to 2 groups. Subjects received 6 weekly videos of either healthy participation (HP) or healthy training (HT) recommendations based on stage of development and sex. A 6-week follow-up survey was completed to assess adherence to the recommendations.

Results: At the time of submission, 150 subjects were enrolled in the study. Seventy-four subjects were randomized to the HP group, and 76 subjects were randomized to the HT group. Approximately 43% of the subjects in the HP group were female with a mean age of 14.7 years, and approximately 41% of the subjects in the HT group were female with a mean age of 15.1 years. Mean video compliance rates were 66% in the HP and 64% in the HT groups (median 83% in both). Seventy-three subjects completed the baseline and the follow-up surveys. At baseline, less than 20% of subjects adhered to the recommendations of participating in less than 2 practices in the 48 hours prior to a competition (15.6% and 20%, respectively). There was an increase in adherence at the follow-up in both groups (52.8% and 62.2%, respectively). There was also a rise in adherence to the injury prevention program recommendation at the follow-up (69.4% and 40.5% vs 83.3% and 81.1%, respectively). There was a reduction in acute workload, measured by training and competition hours in the one week prior to the survey, at the follow up in both groups.

Conclusions: Our study demonstrates that serial online individualized educational videos highlighting training and injury prevention youth sport recommendations may increase the adherence of youth athletes to healthy sports and training recommendations. Cross-over randomization of HP and HT videos will occur for the second 6 weeks and then adherence of recommendations will be determined at 12 and 24 weeks.

Significance: This is the first study to use individualized brief online educational videos to promote youth sport recommendations based on developmental stage along with published safety training recommendations in youth athletes.

Acknowledgments: Thank you to Gabriella Lei for her assistance with the statistical analysis.

TOPIC: Pediatrics

STUDY TYPE: Other

Practice Patterns and Outcomes of Treating Anterior Knee Pain at a Single Pediatric Institution

Logen Breehl, DO

All Other Authors: Andrew Jeon, DO, Melanie Morscher, PT, Nikki McKenna, PA-C, Andrew Newsom, Brian Reilly, MD, Zaid Khatib, MD, John Polousky, MD, and John Polousky, MD

Affiliation: Akron Children‘s Hospital-Akron, Ohio.

Purpose: The purpose of this study is to describe practice patterns and follow up outcomes for patients treated for idiopathic anterior knee pain (AKP) within the sports medicine and orthopedics departments at a free-standing children’s hospital.

Methods and Study Design: Retrospective chart review of patients 12–18 yo seen by 5 sports medicine/orthopedic providers for initial visit for AKP. Descriptive statistics applied to demographics; # of imaging, bracing and physical therapy orders at initial visit; and subsequent imaging/procedures. Follow up rates within 8 weeks of the initial visit and patient status at that visit were also studied.

Results: 118 of 277 cases met inclusion criteria. Seventy-seven female, 41 male. Average age at presentation 15.14 ± 1.86. Seventy-eight percent of patients had an x-ray ordered at initial visit, with 15% presenting with x-ray prior to that appointment, for 95% having a knee x-ray at or around time of presentation. None of those x-rays showed significant findings to change management. Eighty-four percent of patients had physical therapy (PT) and 33% had braces ordered at initial visit. There were no significant differences in x-ray, PT and bracing orders between sports medicine and orthopedics or individual providers. Twenty MRIs ordered either at or after the initial visit; 80% ordered after initial visit. Seventy percent of the MRIs had no significant findings. Thirty-five percent of patients followed up within 2 months of initial visit, with 68% of those that followed up being within sports medicine. Sixty-six percent of those that followed up showed some improvement, 34% showed no change or were worse. Three patients had subsequent knee surgery, 2 had injections.

Conclusions: In the setting of AKP our patients were managed similarly by both providers within orthopedics and sports medicine, except in relation to routine follow up visits. Most patients showed some improvement with conservative management. Utilization of MRI was low. A large percentage of patients had x-ray imaging without findings to impact management which could argue the necessity of x-ray imaging at the initial visit for AKP.

Significance: Further support for conservative management of AKP. Providers studied followed typical practice patterns with little variation. A starting point for future research or QI into the necessity of x-ray at the initial visit.

Acknowledgments: Akron Children’s Sports Health, Akron Children’s Rebecca D. Considine Research Institute.

TOPIC: Pediatrics

STUDY TYPE: Case-Control

Low Back Pain Duration and Clinical Exam Findings in Adolescent Athletes With Spondylolysis: A Large Retrospective Review

Peter Dzaugis, MD, PT

All Other Authors: Madison Brna, BS, Sarah Petersen, BA, Andrea Zuzarte, BS, Luke Enthoven, BS, David Howell, PhD, and Emily Sweeney, MD

Affiliation: Children’s Hospital Colorado, Aurora, Colorado.

Purpose: To determine if injury characteristics, as defined by the duration of low back pain (LBP) prior to evaluation, or positive clinical examination findings regarding the Stork and Prone Hyperextension tests, are associated with an increased likelihood of spondylolysis diagnosis in adolescent athletes.

Methods and Study Design: We conducted a retrospective chart review study of 1088 adolescent athletes ages 10–19 years old with LBP who were seen in a pediatric sports medicine clinic between January 1, 2015, and December 31, 2023. We compared the pain duration and clinical findings (Stork and Prone Hyperextension tests) of the athletes with spondylolysis to those without a spondylolysis as diagnosed by MRI or x-ray.

Results: Athletes had an average of 218 (SD = 348) days of pain before evaluation with 847 (79%) athletes experiencing pain >3 weeks and 700 (65%) athletes with pain >6 weeks. There was a significantly lower proportion of those with pain >6 weeks who had a positive MRI than those with pain ≤ 6 weeks (23% vs. 35%, P = 0.001). There were no significant associations between athletes with a positive Stork test and an MRI positive spondylolysis (87% of positive MRI had positive Stork test vs. 85% of negative MRI had positive Stork test; P = 0.60) or positive X-ray (79% vs. 73%; P = 0.23). There were no significant associations between Prone Hyperextension test with MRI positive spondylosis (11% vs. 13%; P = 0.46) or positive X-ray (15% vs. 25%; P = 0.07). There was no significant association between the proportion of those who had positive findings for both Stork and Prone Hyperextension tests with MRI (95% vs. 94%; P = 0.68) or X-ray (89% vs. 84%; P = 0.20) positive spondylolysis.

Conclusions: Shorter pain duration (≤6 weeks) at the time of evaluation had a significant positive association with a spondylolysis diagnosis when compared to longer durations of time (>6 weeks). Neither a positive Stork test nor a positive Prone Hyperextension test in isolation or in combination demonstrated a significant association with a diagnosis of spondylolysis.

Significance: This retrospective review suggests Prone Hyperextension and Stork tests are unreliable indicators of spondylolysis thus additional factors should be considered. Alternative diagnoses should be considered in adolescents with chronic LBP (>6 weeks).

TOPIC: Pediatrics

STUDY TYPE: Survey

Youth Baseball Players Attitudes Toward Pitch Count Limitations

Andy Johnson, MD

All Other Authors: Marcus Fearing, MD, Dylan Schumacher, MD, and Meg Gibson, MD

Affiliation: University of Missouri at Kansas City Sports Medicine.

Purpose: Youth sports and specialization have garnered notable interest in recent years. However, there is a scarcity of data regarding youth athletes’ perceptions of initiatives which affect them. Our study aims to begin filling this void in the literature, specifically in regard to baseball pitch counts.

Methods and Study Design: This study was completed via a cross-sectional survey of baseball athletes aged 7 to 18-years-old with approval from guardians. Questions included athletes’ perception of pitch counts, information regarding baseball-specific training, and history of injuries. We used bivariate analysis such as chi squared tests and 2 sample proportions to examine associations between survey responses.

Results: Most respondents were aged 9 to 12 (59 out of 127) and 115 throw with their right arm. The children played a wide range of positions, and many played multiple positions. The most common selection was infield (97) followed by pitcher (94). Eighty-nine out of 127 responders (70.1%) report taking extra pitching lessons other than normal team practice. 70.1% follow a pitch count and only 17% of athletes count warm-up or bullpen pitches in their total counts. Ninety-six percent feel that pitch counts are “good for baseball.” 23.6% have missed a game due to an arm injury and of those 30 athletes, 18 out of 30 were aged 15–18 (P 0.001). Of those same 30 who were injured, 28 reported taking extra pitching lessons (P 0.0011). Twenty-four out of 30 people (80%) who missed games due to an arm injury played pitcher. 92.9% of respondents had aspirations to play in high school followed by 67.5% in college, and 46% professional.

Conclusions: A total of 127 youth athletes participated in this survey. Most participants believe pitch counts are good for baseball (96%). However, in our data, only 70.1% reported following a pitch count. Nearly 1 in 4 respondents missed a game due to an arm injury and most of these participate in extra pitching lessons (28 out of 30). Being a pitcher had a significant association with missing games due to an arm injury.

Significance: To our knowledge, this is the first study to examine youth athletes’ perceptions of pitch counts. Participants overwhelmingly supported the use of pitch counts regardless of that individual’s age, position, or long-term goal regarding the sport.

Acknowledgments: An-Lin Cheng, PhD UMKC Dept. of biomedical and health information Statistics Gustavo Vilchez Lagos UMKC Dept. of biomedical and health information Statistics Gwen Sprague MLS.

TOPIC: Pediatrics

STUDY TYPE: Cohort

Tibial Bone Microarchitecture and Strength among Adolescent Female Athletes With and Without Menstrual Irregularities

Aubrey Armento, MD

All Other Authors: Madison Brna, BS, Christine Swanson, MD, MCR, Wendy Kohrt, PhD, and David Howell, PhD

Affiliation: University of Colorado School of Medicine, Aurora, CO.

Purpose: To examine differences in tibial bone microarchitecture and estimated strength (acquired by high-resolution peripheral quantitative computed tomography; HR-pQCT) between adolescent female athletes with vs. without menstrual irregularities.

Methods and Study Design: We recruited 13 to 18-year-old female athletes who were normal weight, >2 years post-menarchal, with no hormonal contraception use. Participants were classified as menstruating (ME; eumenorrheic or anovulatory) or amenorrhoeic (AM; no menstrual period for at least the prior 3 consecutive months). HR-pQCT was performed on the non-dominant distal tibia, and bone outcomes were compared between groups.

Results: Participants in the ME group underwent a 3-month protocol including menstrual cycle tracking, urinary ovulation testing, and blood hormone testing to be classified as eumenorrheic or anovulatory. There were 21 participants who completed the study (n = 9 eumenorrheic/n = 3 anovulatory, n = 9 amenorrhoeic; avg age = 16 years). There were no significant differences in race, ethnicity, BMI, or training volume (hrs/wk) between groups; the AM group had significantly lower body fat percentage (23.6 vs 30.3; P = 0.03) and lower serum estradiol levels (58.9 vs 101.0 pg/mL; P = 0.09) than the ME group. There were no significant differences and small effect sizes (Cohen’s d) between the ME and AM groups for all HR-pQCT outcomes: trabecular volumetric bone mineral density (vBMD) (204.0 vs 199.9 mgHA/cm³; P = 0.76, d = 0.14), trabecular thickness (0.28 vs 0.27 mm; P = 0.45, d = 0.34), cortical vBMD (902.7 vs 901.0 mgHA/cm3; P = 0.88, d = 0.07), cortical porosity (1.11 vs 1.08%; P = 0.90, d = 0.06), stiffness (204,680 vs 200,114 N/mm; P = 0.79, d = 0.12), and failure load (10,909 vs 10,722 N; P = 0.84, d = 0.09).

Conclusions: In this sample of normal weight female adolescent athletes, bone microarchitecture/strength at the distal tibia did not significantly differ between the ME and AM groups. Our findings differ from prior studies suggesting that amenorrhoeic athletes have impaired bone microarchitecture/strength compared to eumenorrheic athletes. Weight-bearing exercise may offer some protection from the negative impacts of amenorrhea on bone health in athletes.

Significance: Future directions include examining the associations of menstrual status and energy status on bone microarchitecture/strength outcomes in female adolescent athletes, particularly at the weight-bearing tibia vs the non-weight-bearing radius.

Acknowledgments: We would like to thank the Ludeman Family Center, the Colorado Specialized Center of Research Excellence on Sex Differences, and the Colorado Clinical and Translational Sciences Institute HR-pQCT Core for their support of this study.

TOPIC: Pediatrics

STUDY TYPE: Cohort

Pediatric Bowling Injuries Presenting to U.S. Emergency Departments: A Descriptive Epidemiologic Study

Tyra Swanson, MD

All Other Authors: David Mikhail, BS, Dai Sugimoto, PhD, ATC, David Soma, MD, Jacob Jones, MD, and Luke Radel, MD

Affiliation: Mayo Clinic, Rochester, MN.

Purpose: Bowling is a popular youth sport both recreationally and competitively. While it is a sport played by many, there is limited research of pediatric bowling-related injuries. This study aims to determine common injury locations and types and evaluate these differences based on age and sex.

Methods and Study Design: Data was analyzed over a 10-year period (2014–2023) from the National Electronic Injury Surveillance System, focusing on bowling-related injuries in individuals 18 years old or younger. Injuries were categorized by body location and diagnosis and treated as main outcome variables. Chi-square tests were used to compare injury distributions by age and sex.

Results: A total of 755 injuries were included in this study: 375 injuries occurred in pre-adolescents (5–10 years old) and 380 occurred in adolescents (11–18 years old). Three hundred ninety-nine injuries occurred in males and 356 occurred in females. The top 5 overall injured body parts were: finger (30.7%), face (9.3%), wrist (8.6%), knee (7.4%), and lower trunk (6.8%). χ² analyses demonstrated that the pre-adolescents had more finger and face injuries whereas the adolescents had more wrist, knee, and lower trunk injuries. Males had more finger injuries and females had more wrist injuries. The top 5 diagnoses were: strain/sprain (22.6%), fracture (19.1%), contusions/abrasions (15.4%), laceration (11.0%), and crushing (2.5%). The pre-adolescents sustained a greater proportion of fractures, contusions/bruises, lacerations, and crushing injuries. Adolescents suffered more sprains/strains. Males were diagnosed with fractures at a higher rate, and females suffered more sprains/strains.

Conclusions: Finger, face, and wrist injuries were most common among pediatric bowlers, likely due to the physical demands of handling a heavy ball. Pre-adolescents experienced more fractures, contusions, and lacerations, while adolescents had more sprains and strains. Males sustained more fractures, whereas females had more sprains and strains. These results may be attributed to differences in skeletal maturity, physiology and experience between the groups.

Significance: This study highlights age and sex differences in youth bowling injuries, revealing distinct patterns and risks. These insights are crucial for developing targeted prevention strategies and guiding future research to improve safety for young bowlers.

TOPIC: Pediatrics

STUDY TYPE: Other

Performance Enhancing Substance Use in High School Athletes: A Scoping Review

James Smith, MD, MPH

All Other Authors: Edward Smith, DO, Laura Nilan, DO, Ian Durbin, MD, Jordan Treder, DO, Dave Olson, MD, Jacob Lentner, DO, Alex Bisch, DO, and Alex Bisch, DO

Affiliation: University of Minnesota.

Purpose: Review the current knowledge base, assess for quality, and identify knowledge gaps in products that are being used for performance enhancement in adolescent athletes. The majority of the research on the effects and efficacy of these products involved adults with heterogeneity in study design.

Methods and Study Design: The following databases were searched: Medline(R) ALL (via Ovid), Embase+Embase Classic (via Ovid), SPORTDiscus, Scopus, and Web of Science (Core Collection). Search concepts of: supplements + high school athletes. Screening conducted by 2 reviewers and conflicts resolved by a third. Inclusion criteria: English adolescent athletes using PES for performance enhancement. Excluded: use for medic.

Results: There were 45 articles that met inclusion criteria. Three of the articles were published before 2000 and only 7 were published after 2020. The majority of the studies were surveys (n = 22), followed by systematic reviews (n = 17) and, lastly, interventional studies only numbering 6 articles. When looking at the goal performance outcomes of the studies, the top 3 answers were muscle mass/strength (n = 33), weight/body composition (n = 18), and endurance (n = 16), although there were studies that did not specify what type of performance the subjects were trying to enhance (n = 11) and some listed as only generic performance improvement (n = 2). The 6 interventional studies looked at: caffeine, portobello mushrooms, vitamin D, beetroot juice, protein-carb drink and betaine. The studies with more than 30 participants (n = 2) involved protein-carbohydrate drinks, vitamin D, and mushrooms. The most common outcome studied was a measure of muscle gain and strength (n = 4), with statistically significant improvements occurring in 3 of them. Only 1 of the interventional studies discussed adverse side effects.

Conclusions: PED use is frequent in adolescents with 56% of male and 30% female reported use. It’s important to have updated and quality data to provide care. The review showed there are few interventional studies done amongst adolescents and the substances studied are not frequently used. None of the studies had a lead author who was in a sports medicine dept. There was significant heterogeneity in measuring the same outcomes such as strength gain.

Significance: The scoping review showed the limited knowledge available and exposes the poor quality of the studies performed. More research is needed to establish standards for measuring outcomes to facilitate head-to-head comparison.

Acknowledgments: Nicole Theis-Mahon—UMN Health Sciences library Evidence Synthesis Librarian Sherri Fong—UMN Department of Family Medicine research facilitator.

TOPIC: Pediatrics

STUDY TYPE: Survey

Pandoras Box of Pediatric Sports Medicine: Assessing ChatGPT Responses to Questions Regarding Femoroacetabular Impingement

Logan Garfield, MD

All Other Authors: Martha Kebeh, AB, Sean Owens, BS, Morgan Swanson, BS, Brendon Mitchell, MD, Christopher DeFrancesco, MD, Thomas Swaffield, MD, Naomi Brown, MD, and Naomi Brown, MD

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

Purpose: Studies investigating the ability of Chat Generative Pre-trained Transformer (ChatGPT) to answer common orthopedic questions have rarely involved sports medicine. We aimed to assess ChatGPT’s responses to questions about femoroacetabular impingement (FAI), a condition with several treatment options.

Methods and Study Design: We presented 5 frequently asked questions (FAQ) and 5 complex questions to ChatGPT. Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) determined response readability after response rating by orthopaedic sports medicine physicians. Rater agreement was assessed by Kendall’s coefficient of concordance (KCC). Kruskal-Wallis testing assessed influence of rater or question type on score.

Results: The mean FGKL and FRE were 14.48 ± 1.08 and 28.88 ± 6.14, respectively. There was no significant difference in response readability by question type. Agreement among all raters was fair (KCC = 0.23). Agreement among nonoperative raters was fair (KCC = 0.38) while agreement among operative raters was moderate (KCC = 0.42). Scoring across raters for accuracy, relevance, and clarity each resulted in a median of 4.0 (IQR 4.0–5.0). There were no significant differences in response scores based on rater specialty, question type, or scoring domain. Scoring differed by training level (P = 0.0078), with fellows awarding a median score of 5.0 (IQR 4.0–5.0), while senior attendings awarded a median score of 4.0 (IQR 4.0–5.0) and early-career attendings awarded a median score of 4.0 (IQR 3.0–5.0). No scores of 0 were given for any responses. Comments from raters noted redundancy within responses, inclusion of accurate but extraneous information, and presentation of information at a high reading level.

Conclusions: In response to questions about FAI, ChatGPT provided information at a college reading level that was generally awarded high scores from sports medicine physicians for accuracy, relevance, and clarity. Fellows were found to award higher scores than physicians with full board certification status. There was fair to moderate agreement among scores given by raters, which was greater when comparing scoring within specialties than across specialties.

Significance: The use of ChatGPT is rapidly increasing, including among patients seeking orthopaedic care. It provides information regarding FAI at the college reading level and using content which sports medicine physician raters grade as having good quality.

Acknowledgments: We would like to thank the Orthopedic Center and Sports Medicine and Performance Center at the Children’s Hospital of Philadelphia as well as Dr. Kathleen Maguire for her contribution to this project.

TOPIC: Pediatrics

STUDY TYPE: Other

The Prevalence of Pediatric Spondylolysis on Imaging in Athletes With Low Back Pain

Luke Enthoven, BS

All Other Authors: Madison Brna, BS, Sarah Petersen, BA, Andrea Zuzarte, BA, Peter Dzaugis, MD, David Howell, PhD, and Emily Sweeney, MD

Affiliation: University of Colorado School of Medicine, Aurora, Colorado.

Purpose: To determine the proportion of patients who present to a tertiary pediatric sports medicine clinic with low back pain (LBP) who have MRI or X-ray findings of spondylolysis, to compare the results of these imaging modalities, and to determine the frequency of comorbid abnormal imaging findings.

Methods and Study Design: This was a single-site retrospective review of adolescents who presented to a pediatric sports medicine clinic with LBP between January 1, 2015, and December 31, 2023. The diagnostic imaging modalities and imaging results were collected and analyzed. Patients with positive spondylolysis on imaging were assessed and stratified by medical and demographic factors.

Results: 1,088 adolescent patients (mean 14.4, SD = 1.9; Range = 10–19 years of age) were included. 95% (1,035/1,088) underwent X-rays, and 59% (646/1,088) received an MRI. 8% (82/1,035) had spondylolysis on X-ray and 26% (170/646) had spondylolysis on MRI. Overall, the proportion of patients who presented with LBP and were diagnosed with spondylolysis using either MRI or X-ray was 20% (214/1064). Among patients who received an MRI, 23% (148/646) had an additional abnormal MRI finding. When treating MRI as the reference standard for spondylolysis diagnosis, X-ray had a sensitivity of 0.23, a specificity of 0.94, and a positive predictive value of 0.62.

Conclusions: Spine X-rays are effective as a broad screening tool for diagnosing adolescent LBP. Despite this, MRI was found to be more effective than X-ray in diagnosis of spondylolysis. Additional abnormal findings were common among those who received an MRI, indicating the potential of MRI to assess a variety of LBP etiologies using only one scan.

Significance: This analysis highlights X-ray as a screening tool for spondylolysis and not as a definitive diagnostic modality. Providers who are suspicious of spondylolysis should consider MRI for definitive diagnosis in the adolescent athletic population.

Acknowledgments: No Acknowledgments.

TOPIC: Pediatrics

STUDY TYPE: Survey

Exploring Risk Factors for and the Prevalence of Disordered Eating in Adolescent Athletes

Christina Mallery, DO

All Other Authors: Claire Murphy, Sharon Smith, MD, Allison Crepeau, MD, and Adam Weaver, PT, DPT

Affiliation: University of Connecticut Farmington, CT.

Purpose: This study aimed to determine the prevalence of adolescent athletes at risk for disordered eating behaviors and characterize those athletes screening positive using the Disordered Eating Screen for Athletes (DESA).

Methods and Study Design: This is a cross-sectional study of adolescent athletes aged 12–18 presenting to a Sports Medicine clinic. Participants completed the DESA questionnaire. Demographic information, BMI, and primary sport was also collected. Data analysis involved descriptive statistics and prevalence calculations to characterize the study population and assess disordered eating prevalence.

Results: Of 80 participants, 55% were female, and 45% male. Seventeen adolescent athletes screened positive on the DESA, a prevalence rate of 21.3%. Of the 17 positive cases, 58.8% were female. The average BMI percentile for all participants was 65.8%. Those screening positive on the DESA had an average BMI percentile of 84.0%, those screening negative had an average of 59.8% (P P = 0.55). The average DESA score for those screening positive was 4.4 compared to the average score for those screening negative was 0.22, (P

Conclusions: This study demonstrates the high prevalence of adolescent athletes at risk for disordered eating. We found DESA scores of individuals identified to be at risk for disordered eating to be significantly higher than those at low risk. Female athletes appear to be at an increased risk of disordered eating compared to male athletes.

Significance: Disordered eating is well studied in college and professional athletes but there is a scarcity of research on disordered eating in adolescent athletes. This study demonstrates the high prevalence of adolescent athletes at risk for disordered eating.

TOPIC: Pediatrics

STUDY TYPE: Cohort

Physical Fitness in Transgender Adolescents Immediately Before Gender-Affirming Hormone Therapy

Sigrid Wolf, MD

All Other Authors: Lisa Kuhns, PhD, MPH, Raina Voss, MD, MPH, Jamie Burgess, PhD, Rebecca Carl, MD, Delanie Rybacki, BA, and Robert Garofalo, MD, MPH

Affiliation: Ann & Robert H. Lurie Children‘s Hospital of Chicago/Northwestern University Feinberg School of Medicine, Chicago, IL.

Purpose: The purpose of this study was to characterize the physical fitness of transgender youth immediately before the use of gender-affirming hormone therapy (GAHT).

Methods and Study Design: In this prospective cohort pilot study, we recruited transgender adolescents ages 13–18 years starting GHAT in the next 6 months from a single academic center’s gender development program. The FitnessGram and Physical Activity Questionnaire (PAQ) were administered, and each subject’s performance was compared to age-matched male and female Healthy Fitness Zone (HFZ) performance standards.

Results: We enrolled 25 transgender adolescents and 21 completed testing (14 transgender males, 7 transgender females). Mean participant age was 14.8 ± 1.5 years. Mean BMI was 23.2 ± 5.8 kg/m². The average PAQ score for cisgender adolescents is estimated to be 2.51, but the mean PAQ score for our cohort was 1.9 ± 0.5. While 23–35% of cisgender adolescents in the US typically meet at least 5/6 HFZ performance standards, only 4.7% of participants met 5/6 male HFZ standards, and 4.7% of participants met 5/6 female HFZ standards. No participants in our cohort met 6/6 HFZ male or female performance standards. Participants met a mean of 3.0 ± 0.9/6 HFZ standards for gender assigned at birth and mean 2.7 ± 1.0/6 HFZ standards for affirmed gender.

Conclusions: Transgender adolescents performed poorly overall on the FitnessGram compared to cisgender adolescent norms, particularly on measures of aerobic capacity. There is uncertainty as to which gender’s FitnessGram performance standards should be used for transgender adolescents who have not yet started gender-affirming hormone therapy. Transgender adolescents in our cohort may be less active than their cisgender peers.

Significance: Our study provides data on physical fitness in transgender adolescents, an area with sparse research. More data is needed on physical fitness in transgender adolescents, particularly after starting GAHT, to guide fair, equitable sports regulations.

Acknowledgments: Our study team is grateful for the support of the staff, patients, and families in our institution’s Gender Development Program in undertaking this study.

TOPIC: Pediatrics

STUDY TYPE: Survey

The Relationship Between Food Insecurity and Depressive Symptoms in a Pediatric Athletic Population

Danielle Kulpins, MD

All Other Authors: Stephanie Jones, MD, Rachel Baca, MD, Patrick Rivers, PhD, Karen Lutrick, PhD, and Holly Beach, MD

Affiliation: University of Arizona, Tucson, Arizona.

Purpose: The purpose of this study was to further assess the relationship between food insecurity (FI) and depression in a pediatric athlete population, which is a particular group of patients for which the relationship is not well-characterized.

Methods and Study Design: In this cross-sectional study, we collected demographic and health information (age, sex, blood pressure, height, weight, and PHQ-4 responses) from preparticipation exam questionnaires of youth whose parents consented, as well as responses to a 2-question validated food insecurity screener. Ordinal and linear regression models were used to examine associations between FI and PHQ-4 screens.

Results: There were 101 participants in the study (N = 101), with a mean age of 13 years old (SD 2.3) and 51% female. Thirty-five (34.7%) participants screened positive for FI. A total of 13 (12.9%) participants screened positive for psychological distress on the PHQ-4, defined as a score of 3 or higher. Thirty-one (22.8%) and 14 (13.9%) individuals indicated little interest in doing things or feeling depressed, respectively, while 27 (26.7%) and 16 (15.8%) reported feelings of anxiety or worry, respectively. Statistically significant results of regression models were conflicting, with “food didn’t last” having a positive relationship with “feeling nervous, anxious or on edge” (OR 4.2, 95% CI 1.4–13.1) but the combined FI predictor was protective (OR 0.46, 95% CI 0.20–0.93). Results of FI responses on depressive symptoms were not statistically significant.

Conclusions: Our results suggest there is no correlation between FI and depressive symptoms. The inconsistent relationship between FI on individual and grouped anxiety symptoms was unexpected. These conflicting results may be due to the small N in our study with FI and depressive/anxiety symptoms and the statistical challenges that presents. Interestingly, the FI prevalence (34.7%) in this study was higher than in other reported estimates.

Significance: The high prevalence of FI in this population has potential implications on school performance, injuries, and mental health. The study seems worth replicating on a greater scale to further examine the relationship between FI and mental health.

Acknowledgments: Thank you to Dr. Lutrick and Dr. Beach for their help in creating the study design, Dr. Rivers for his statistical analysis, University of Arizona Family Medicine residents for helping spread awareness of the study during the sports physicals event, and Hailey Freeman and Nina Wittmer for their assistance with data collection.

TOPIC: Pediatrics

STUDY TYPE: Cohort

The Association Between Developmental Stage and Return to Play Times in Youth and College Athletes

Benjamin Zacks, MD

All Other Authors: Mario Ramirez, BS, Ally Render, BS, Caleb Truong, BS, BA, Kirk Easley, MApStat, MS, Stacey Schley, MD, and Neeru Jayanthi, MD, MD

Affiliation: Emory School of Medicine, Atlanta, GA.

Purpose: This clinical study’s purpose is to determine the relationship between the stage of development measured by percentage of predicted adult height (PPAH) of youth and college athletes and the return to play (RTP) time. We hypothesized that developmentally advanced athletes have longer RTP time.

Methods and Study Design: In this prospective cohort study, PPAH at the time of injury was calculated according to the Khamis-Roche method for injured athletes at a sports medicine clinic. Time to return to modified play (RTMP) was collected from electronic medical records. χ² tests were used to evaluate potential associations between PPAH and RTMP.

Results: Four hundred seventy-one athletes ages 10–23 were included in the study with an average age of 15.33, 40.55% were female, average PPAH of 96.74%, and an average physical activity level of 19.83 hours per week. Athletes were stratified into 3 groups based on the PPAH relative to peak-height-velocity (PHV): pre-PHV (PPAH 96%). 45.44% of all athletes had RTMP time of less than 10 days, 34.18% had a RTMP time of 10–30 days, and 20.38% had a RTMP time of over 30 days. Preliminary data suggests a potential positive/direct relationship between RTMP and PPAH but additional multivariable analyses are needed to confirm the relationship. However, there was no statistically significant association between the developmental stage and RTMP (P = 0.22).

Conclusions: The majority of patients in the study had RTMP time of less than 30 days. Although there was a trend towards a significant difference with longer time for RTMP with the post-PHV group compared to pre-PHV and circa-PHV groups, there was no statistically significant association found between stage of development and RTMP.

Significance: Most athletes had shorter RTMP periods. There may be a trend for longer RTMP periods for post-PHV athletes, with more skeletally mature athletes having a propensity for more challenging injuries and a need for anticipatory guidance and counseling.

Acknowledgments: Emory School of Medicine.

TOPIC: Pediatrics

STUDY TYPE: Cohort

Monitoring Athlete Well-Being Aftermath of Injury in Female Flag-Football Athletes

Robert Martin, MD

All Other Authors: Madison Brna, BS, Catherine Donahue, PhD, Veronica Hogg-Cornejo, MS, Aubrey Armento, MD, and David Howell, PhD

Affiliation: University of Colorado, Anschutz Medical Campus.

Purpose: Among adolescent athletes, subjective well-being may be enhanced by sport participation or negatively influenced by injury. We evaluated the changes in several brief well-being measures in the week before vs. after injury among female adolescent flag-football athletes.

Methods and Study Design: We conducted a prospective longitudinal study, in which female adolescent flag-football athletes were enrolled prior to their 8-week season. They rated sleep, energy, mood, and stress on a 0–10 Likert scale (score of 10 reflecting an elevated rating) along with any time-loss sport-related injuries. Using a paired samples t-test, we compared the ratings in the week prior to and after injury.

Results: Eighty-three athletes were initially enrolled, and 19 reported a sports-related, time-loss injury. This injured group was majority White (n = 16) with a roughly even split between low, medium and high levels of sports specialization (n = 28%, 39%, and 33%, respectively). A significant portion of these athletes had pre-existing, comorbid diagnoses of ADHD (26%), anxiety (37%), or depression (21%). The type of injury varied with finger sprain (n = 5) and concussion (n = 4) being the most common. On average, they reported missing 3.2 (SD = 2.9) days of sport participation due to their injury. Ratings were completed 6.2 (SD = 4.7) days prior and 7.9 (SD = 6.5) days after injury. There were no significant differences between pre-and post-injury reported energy (mean = 4.8 ± 1.9 vs. 4.5 ± 2.1; P = 0.52), mood (5.8 ± 2.6 vs. 6.3 ± 1.5; P = 0.53) and sleep (5.5 ± 2.2 vs. 5.4 ± 2.0; P = 0.93) ratings. However, reported stress increased significantly after injury (5.5 ± 2.5 vs. 6.8 ± 1.8; P = 0.027).

Conclusions: Our data indicates that sustaining an injury led to acute increased levels of stress among female adolescent athletes without co-existing changes in energy, mood, or sleep ratings. This highlights a difference from current literature in other athletic populations in terms of subjective well-being measures impacted by injury.

Significance: Identifying well-being measures (such as reported stress levels) that are negatively impacted by injury within specific athletic populations allows for more individualized and targeted support during injury recovery.

Acknowledgments: University of Colorado, Anschutz Medical Campus Department of Orthopedics.

TOPIC: PPE

STUDY TYPE: Survey

Socioeconomic Barriers to the Preparticipation Physical Evaluation

Tammy Ng, MD

All Other Authors: Bridget Whelan, MPH, Jessica Drezner, Jonah Drezner, and Jonathan Drezner, MD

Affiliation: University of Washington, Seattle, WA.

Purpose: Although a preparticipation physical evaluation (PPE) is required for school sports participation, there is little evidence evaluating access to PPEs in lower-resourced settings. This study aimed to determine barriers to getting PPEs among students from a socioeconomically disadvantaged community.

Methods and Study Design: Anonymous surveys were distributed to parents of youth attending a free PPE event for a socioeconomically disadvantaged school district. This study examined barriers to care such as cost, insurance, transportation, childcare, time away from work, language, and access to medical services. Logistic regression evaluated associations between the Social Deprivation Index (SDI) and perceived barriers.

Results: Surveys were submitted by 123/130 (95%) parents of students entering grades 6–12. Students were 59% male and represented 10 different racial/ethnic backgrounds (27% Hispanic/Latino, 20% White, 19% Black/African, 12% multi-racial, 22% other). Nineteen languages were spoken at home, with English the primary language in 56% of households. Seventeen percent of students did not have a primary care provider, and 28% would not have gotten a PPE if not for this free event. Of the parents surveyed, 86 (70%) completed questions on perceived barriers using a 5-point Likert scale. Barriers reported (strongly agree or agree) included: cost (16%), health insurance (14%), transportation (12%), childcare (6%), time away from work (23%), language (8%), and access to medical services (7%). Controlling for race/ethnicity and primary language at home, higher SDI was associated with stronger agreement that transportation (OR = 1.90, 95% CI: 1.11–3.36; P = 0.02) and time away from work (OR = 1.84, 95% CI: 1.10–3.12; P = 0.02) were barriers to PPEs. All other perceived barriers did not have significant associations with SDI.

Conclusions: Transportation to appointments and time away from work represent significant barriers to a PPE for families with higher socioeconomic deprivation. PPE requirements can be an unintended barrier to youth sports participation. Without a free PPE event, 1 in 4 students in this study would not have been able to participate in sports because they would not have access to a PPE.

Significance: This study is the first to evaluate the association of socioeconomic deprivation and barriers to access a PPE among youth athletes. Efforts to support equity in youth sports participation require initiatives that address barriers to PPEs.

Acknowledgments: The authors would like to thank the Nick of Time Foundation, the Mukilteo School District, Dr. Katherine Fahy, Dr. Joshua Go, Dr. Lauren Paladino, Dr. Katherine Wainwright, and the University of Washington Department of Family Medicine Sports Medicine Section for their support.

TOPIC: PPE

STUDY TYPE: Other

Sports Pre Participation Evaluation: A Look at Current Practices and Cost Analysis at an NCAA Division One Institution

Nathan Rodricks, DO, MHSc

All Other Authors: John Suarez, BSc, Jenny Berezanskaya, DO, and Thomas Best, MD, PhD

Affiliation: University of Miami/Jackson Health System.

Purpose: There are no universally accepted protocols for preparticipation evaluations (PPE) prior to clearance for sports. This study reviews data from our institution’s PPE screenings to conduct a cost analysis of the current approach and assess its effectiveness.

Methods and Study Design: A retrospective study was conducted using PPE data from incoming freshman and transfer athletes from 2019–2024. The PPE included resting EKG, labs extracted from the EPIC EMR, along with subsequent tests due to abnormal results. A cost analysis of these tests was performed using average Medicare reimbursement rates.

Results: A total of 727 athletes aged 17–25 completed the PPE. Of these, 254 EKGs were interpreted as possibly abnormal, with 16 requiring further evaluation for conditions {number of cases} such as right bundle branch block {3}, RSR'{1}, left ventricular hypertrophy voltage criteria{4}, Wolf-Parkinson-White(WPW){1}, T-wave abnormalities{5}, and possible left atrial enlargement{5}. One case of WPW was confirmed via stress EKG, while remaining evaluations (echocardiogram, stress test, cardiac MRI) were within normal limits for the 15 other individuals. Complete blood counts (CBC), complete metabolic panels (CMP), ferritin, and vitamin D levels were analyzed. Ferritin and vitamin D levels were below lab reference range in 9.3% and 28.7% of athletes, respectively, leading to supplementation and repeat testing. There was asymptomatic anemia in 4.2% of the cases, while CMP data revealed transaminitis in 4.6%. Total costs for cardiac and laboratory testing were $114,821 and $216,632, respectively.

Conclusions: Preparticipation EKGs and lab tests incur significant costs at our institution. While most EKG abnormalities have a low diagnostic yield in this study, it is the most cost-effective method to detect potentially dangerous abnormalities. Low levels of vitamin D, and ferritin levels were common, but the clinical significance is unclear given mixed reports in the literature.

Significance: The PPE aims to identify medical conditions affecting safe sports participation, but testing relies on expert opinion. Our findings indicate more research is needed to optimize efficacy, reduce unnecessary tests, and lower healthcare costs in PPE.

Acknowledgments: We would like to thank the numerous athletic trainers that care for athletes and make this research possible.

TOPIC: PPE

STUDY TYPE: Other

Texas 2 Step 2-Part Blood Pressure Screen During PPEs

Namita Bhardwaj, MD, MS, MPH

All Other Authors: Uzoma Dike, MD, Jatinder Singh, DO, MS, Erica Withjack, DO, MS, Eladio Camarillo, MD, MPH, Renard Simmons, Jr., and Wei-Chen Lee, PhD, MSPH, MJur

Affiliation: The University of Texas Medical Branch, Galveston, TX.

Purpose: The optimal way to include multiple blood pressure readings in the setting of mass pre-participation sports physicals is unclear. The purpose of this study is to determine if a 2-step process helps to identify those athletes with hypertension compared to a single blood pressure measurement.

Methods and Study Design: This study is an observational study of station-based-PPEs in Galveston County, Texas. Student athletes with elevated blood pressure, checked with automated blood pressure machine, as defined by the 2017 AAP guidelines are flagged. The blood pressure is rechecked by a manual blood pressure cuff after a 5-minute rest period. The blood pressure percentiles determined final clearance status.

Results: We performed 770 sports physicals. Four hundred thirty-seven student athletes screened positive in the initial step for elevated blood pressure based on the 2017 AAP guidelines. The physicians remeasured the blood pressure of these athletes by performing a manual blood pressure screen after approximately 5 minutes of rest. Ultimately 30 athletes were not cleared due to elevated blood pressure based on the 2-step method due to stage 2 HTN. Based on the preliminary data analysis we identified a higher rate of hypertension among our patient populations with males having a 6.7% rate of stage 2 hypertension and females having a 7.3% rate of stage 2 hypertension. The highest improvement in identification of high blood pressure was best among the athletes who were diagnosed as obese and females. Limitations include the use of 2 sets of guidelines for blood pressure evaluation and using over the counter blood pressure machines that are not calibrated for adolescents.

Conclusions: Our goal with this project is to show that a simple 2-step process for blood pressure evaluation during PPEs helps to better identify the athletes who are hypertensive than a single blood pressure measurement alone. With rates of pediatric hypertension increasing, it is imperative that correct identification of those that may need further evaluation are recognized and given the resources to follow up.

Significance: Hypertension in adolescents may lead to increased risk of cardiovascular disease in later life. Early identification and treatment of uncontrolled hypertension helps to decrease that risk.

Acknowledgments: This research was funded by a generous grant from the Texas Academy of Family Physicians Foundation.

TOPIC: PPE

STUDY TYPE: Other

An Opportunity for Risk Reduction in Collegiate Female Athletes During PPE’s: Unintended Pregnancy

Katherine Mazurek, MD

All Other Authors: Kevin Lennon, MS, ATR, AT, Kendra McCamey, MD, and James Borchers, MD, MPH

Affiliation: The Ohio State University, Columbus, OH.

Purpose: To establish the prevalence of hormonal contraceptive (HC) use amongst NCAA D1 female athletes as they embark on collegiate careers, and to highlight the opportunity for team doctors to counsel on contraception initiation at the time of pre-participation examinations to prevent unintended pregnancy.

Methods and Study Design: This is a descriptive study. The population studied is incoming varsity female athletes at a D1 university of the 2023–2024 academic year. Data was pulled from the standardized PPE form, the question asked was, “Do you use a prescription birth control method? Yes/No. Please list birth control method.” Prevalence of HC use was obtained from this information.

Results: There were 125 incoming varsity female athletes in the 2023–2024 academic year. Of the 125 athletes, 39% reported being on a prescribed hormonal contraception method. The sports represented (N of sport, % utilizing contraception) were basketball (5, 0%), cheer/spirit (5, 20%), cross country (6, 50%), dance (6, 33.3%), fencing (7, 28.6%), field hockey (9, 44.4%), golf (2, 0%), gymnastics (3, 33.3%), ice hockey (10, 40%), lacrosse (13, 84.6%), pistol (4, 25%), rifle (2, 0%), rowing (2, 0%), soccer (9, 33.3%), softball (5, 20%), swim and dive (6, 50%), synchronized swimming (6, 33.3%), tennis (4, 25%), track and field (15, 46.7%), and volleyball (6, 50%). Of the 49 athletes who report using HC, 69% use OCPs, 18.4% have an IUD, 4.1% use Depo-Provera, and 8.2% have a Nexplanon implant.

Conclusions: This cohort has lower prevalence (39%) of HC use than general population adolescents(50.3%). Sexual activity doubles from 40.5% to 81% as females go from adolescent to college age, creating a high-risk environment for unintentional pregnancies. This data creates opportunity with PPE’s to ask more about sexual activity, non-HC methods, and more to drive productive patient counseling and identify protective and risk factors for this cohort.

Significance: There’s a concerning mismatch in sexual activity and HC use in college females- D1 student athletes are no exception, and this cohort is behind the curve. This highlights an opportunity for risk-reduction during PPE’s as part of the team doctor role.

Acknowledgments: Ohio State University Athletics Department.

TOPIC: PPE

STUDY TYPE: Other

Features of Youth Student Athletes Screened in a New, Free Pre-Participation Exam Clinic

Ellie McNulty, MD, MHS

All Other Authors: Chad Cohen, DO, Michelle Eventov, MD, Melissa Schwartz, MD, Cecilia Cordova Vallejos, MD, Emam Mohammed, MD, Eva Seligman, MD, Alexis Coslick, MD, and Alexis Coslick, DO

Affiliation: Johns Hopkins University School of Medicine, Baltimore, MD.

Purpose: A knowledge gap exists for issues faced by athletes in lower-income urban areas. Our study described athletes presenting for a free pre-participation exam (PPE), determined areas in Baltimore with athletes utilizing the event, and identified reasons for denial of clearance for sport participation.

Methods and Study Design: This is a retrospective chart review of middle and high school athletes who participated in a free PPE clinic in August 2024. Data collected included age, gender, zip code, sport, past medical history, family history, physical exam findings, and decision on clearance for participation in sport. Descriptive statistics were used to identify common reasons for denial of clearance.

Results: 384 youth athletes signed up for the PPE event, 212 presented to clinic, and 130 PPE forms were analyzed. Patients were excluded if PPE forms were not uploaded in the medical record. There were 70 male, 59 female and 1 nonbinary athletes, with an average age of 15.3 years. Of the 130 athletes, 106 (82%) were cleared for sports participation, 14 (10%) were not cleared, and 10 (8%) were cleared with recommendations. There were 5 zip codes from which the most athletes presented to clinic: 21215 (n = 11), 21218 (n = 10), 21213 (n = 10), 21206 (n = 10), 21205 (n = 9). The most common reasons for denial of clearance were the need for further evaluation by a cardiologist (4.6%), an orthopedist because of recent injury (1.5%), or primary care provider for an EKG (2.3%). For athletes cleared with recommendations, most needed follow up with a primary care provider for hypertension (3.8%) or an ophthalmologist (3.8%).

Conclusions: One in 10 student-athletes who presented to the PPE event were unable to be cleared for participation in sport. These athletes were from areas in Baltimore with the highest poverty levels by zip code, all of which exceed the state and national poverty averages by zip code. The common themes resulting in rejection of medical clearance or need for follow-up included cardiac concerns, need for care of a recent orthopedic injury, and vision care.

Significance: This study identified not only the geographic areas but also the medical areas of need for athletes from low-income areas in Baltimore, MD. Future PPE events can work to streamline access to services needed by this population with limited access.

Acknowledgments: AMSSM Community Outreach Grant. Additional co-author: Nate McClain, DPT.

TOPIC: PPE

STUDY TYPE: Other

Impact of Sports Physicals on Pediatric Healthcare in Rural Communities

Christine Lomiguen, MD

All Other Authors: Christopher Rial, DO, Jenna Mitchell, MS, and John Kalata, DO

Affiliation: LECOM Health, Erie, PA.

Purpose: The purpose of this study was to provide insight on the necessity for new or continued care with a primary care physician and/or medical specialist prior to obtaining clearance to participate in sports in rural middle schools and high schools.

Methods and Study Design: This original research study analyzed medical eligibility determinations from preparticipation physical evaluations conducted at 4 rural middle schools and high schools in Pennsylvania. Retrospective chart review was performed for 2 academic school years, 2023–2024 and 2024–2025.

Results: A total of 760 preparticipation physical evaluations were conducted at rural middle schools and high schools for students in all sports. Of the 760 participants, 16.32% (n = 124) required further physical or medical record evaluation. Of the 124 requiring further evaluation, 0.395% (n = 3) required new specialty consultation with cardiology (n = 2) or otorhinolaryngology (n = 1); 2.37% (n = 18) required continued specialty care with cardiology (n = 3), orthopedic surgery (n = 11), behavioral health (n = 3), or neurosurgery (n = 1), 1.84% (n = 14) required returning to their primary care physician due to cardiac (n = 4), allergy/asthma/shortness of breath (n = 9), or dizziness (n = 1) concerns; 1.97% (n = 15) required continued care with the primary care sports medicine physician conducting sports physicals; 3.42% (n = 26) required review of medical records from primary care physicians or specialists prior to determination of eligibility, 1.05% (n = 8) were not cleared for sports participation due to poor visual acuity.

Conclusions: This study revealed approximately 16% of students at rural middle school and high schools required further evaluation, primarily for orthopedic surgery, cardiology, allergic/pulmonary, and ophthalmology concerns. While latest guidelines recommend the preparticipation physical evaluation take place in a physician’s office rather than in a group setting, this study revealed positive benefits of in-school evaluations in rural communities.

Significance: This study highlights the importance of preparticipation physical evaluations for pediatric health in rural communities, as approximately 1 in 6 children required further physical or medical record evaluation.

Acknowledgments: The investigators of this study would like to acknowledge the staff of Corry Area Middle School and High School of Corry, PA, Union City Middle School and High School of Union City, PA, Meadville Area Middle School and High School of Meadville, PA, and Cochranton Junior Senior High School in Cochranton, PA for their continued support and dedication to our school-aged children.

TOPIC: REGENMED

STUDY TYPE: Other

Comparing Percutaneous Needle Tenotomy Techniques and Instrumentation for Lateral Epicondylitis

Ryan Arboleda, MPH

All Other Authors: Matthew McDonald, BS, Benjamin Pfeiffer, MS, Michael Day, BS, and Kathryn Vidlock, MD

Affiliation: Rocky Vista University College of Osteopathic Medicine, Englewood, CO.

Purpose: When first line treatments for lateral epicondylitis fail, platelet-rich plasma (PRP) injections and percutaneous needle tenotomy (PNT) are commonly used. This review evaluates the efficacy of PNT, identifies any consensus for clinical recommendations, and explores future avenues for research.

Methods and Study Design: A systematic literature search was conducted on PubMed Central, Embase, and Cochrane Library using the keywords “percutaneous tenotomy” and “platelet-rich plasma,” and “lateral epicondylitis” or “tennis elbow.” This yielded a total of 181 articles. After refining for inclusion and exclusion criteria, 12 articles were included in this review.

Results: After reviewing 12 articles, it was found that percutaneous needle tenotomy is a viable treatment option to recommend to patients with recalcitrant lateral epicondylitis. Both ultrasonic and high-pressure saline systems demonstrated significant improvements in long-term clinical outcomes. However, there is a lack of literature comparing the therapeutic efficacy and safety profile of these 2 modalities. The addition of PRP may also augment the effects of PNT. However, further trials would need to be performed to identify the efficacy of combined PRT and PRP injections to support this treatment.

Conclusions: Both ultrasonic and high-pressure saline tenotomy instrumentation systems have been shown to improve symptoms and functional outcomes long-term. Furthermore, variations in needling techniques do not appear to significantly change clinical outcomes. Based on these studies, PNT can be a safe and effective treatment modality that should be offered to patients with lateral epicondylitis who have failed other conservative treatment options.

Significance: This study is significant as it reviews the state of the current literature in PNT and shows that PNT improves clinical outcomes long term.

TOPIC: REGENMED

STUDY TYPE: Cohort

Subacromial Bursa Platelet-Rich Plasma Injections for Partial Thickness Supraspinatus Tears

Patrick Davis, MD

All Other Authors: Elena Jelsing, MD

Affiliation: Mayo Clinic, Rochester, MN.

Purpose: To evaluate ultrasound-guided subacromial (SA) bursa Platelet-Rich plasma (PRP) injections in providing pain relief and improved function in patients with partial-thickness supraspinatus tendon tears (PTSTs).

Methods and Study Design: This study identified patients with magnetic resonance imaging-proven PTSTs who received ultrasound-guided SA bursa PRP injections. Patients completed patient-reported outcome assessments at baseline and 9- to 16 months after injection. The primary outcome was change in patient-reported outcomes measurement information system (PROMIS) pain interface and physical function tests.

Results: Three patients (2 male and one female) underwent ultrasound-guided SA bursa PRP injections for PTSTs. No tenotomy or intratendinous injection of PRP was simultaneously performed. The median age of identified patients was 65.5 years. All had trialed physical therapy prior to the injection. None had undergone a prior SA bursa corticosteroid injection. All tears were articular-sided with two 3–6 mm and one greater than 6 mm. No patients displayed signs of muscle atrophy on imaging. Follow-up ranged from 9 to 16 months following the PRP injection. All 3 patients reported improvement in PROMIS pain interface (58 to 49, 54 to 50, and 58 to 39) and physical function scores (38 to 54, 46 to 51, and 48 to 65). Subjective shoulder value (SSV) and visual analog scale (VAS) on repeat assessment showed a median follow-up SSV of 90 and a median follow-up VAS of 1. The median time course to maximal improvement was 13 weeks. All patients completed either a home exercise program or dedicated physical therapy following the procedure. There were no reported adverse outcomes.

Conclusions: Patients with articular-sided PTSTs experienced improvement in both pain and physical function lasting at least 9- to 16-months following ultrasound-guided SA bursa PRP injections based on patient-reported outcome scores. Ultrasound-guided SA bursa PRP injections were also shown to be safe with no reported adverse outcomes. The results of the present study warrant further investigation in a prospective manner.

Significance: Ultrasound-guided SA bursa PRP injections for articular-sided PTSTs have been shown to be safe and clinically effective. Historically, treatment of these tears with intra-tendinous PRP injections has required significant post-procedure restrictions.

TOPIC: REGENMED

STUDY TYPE: Other

Ulnar Neuropathy: A Review of Current Management and a Case Series Highlighting a Novel Treatment With Platelet Lysate

Nicholas Hooper, MD, MS

All Other Authors: Christopher Williams, MD

Affiliation: Emory University, Atlanta, GA.

Purpose: Ulnar neuropathy (UN) is a commonly encountered condition due to both trauma as well as chronic compression. The goal of this study was to conduct a review of hydrodissection as a treatment for UN, as well as to provide a case series outlining a novel therapy with platelet lysate.

Methods and Study Design: A comprehensive search was performed examining both databases and grey literature for studies examining hydrodissection for UN. Evidence levels 1–4 were included in the review. Lastly, we report a case series of 4 patients who underwent hydrodissection for UN with platelet lysate and dextrose.

Results: Six studies were found to examine the use of hydrodissection for UN. Of those studies, only one was a randomized controlled trial, one a prospective cohort, and 4 case reports. Of the included studies, 5 conducted hydrodissection with an injectate including corticosteroid and lidocaine, while only one used prolotherapy (dextrose). All of the studies found a reduction in neuropathic symptoms. There were 4 patients included in the case series. Two of the patients were female and 2 male. Follow-up for the patients ranges between 8 and 67 months (average 28.75). All of the patients were injected with between 2 and 4cc of concentrated platelet lysate as well as dextrose. The average baseline VAS score for these patients was a 5/10. At their long-term follow-up, the average VAS was 0.5 (range 0–1). In addition, 3 out of the 4 patients found a greater than 80% SANE.

Conclusions: Hydrodissection has been emerging recently as a potential non-surgical procedure for ulnar neuropathy. Although there remains a paucity of literature reporting patient outcomes following ulnar nerve hydrodissection, the current evidence suggests potential therapeutic efficacy as a treatment. This case series of 4 patients suggests that platelet lysate may be a therapeutic injectate to provide long-term improvement in neuropathic symptoms.

Significance: While future research is warranted, these cases suggest that hydrodissection with dextrose and platelet lysate may provide a viable treatment option in patients with ulnar neuropathy.

TOPIC: REGENMED

STUDY TYPE: Other

Platelet-Rich Plasma for Ulnar Collateral Ligament (UCL) Injuries in Collegiate Baseball Pitchers: Return to Play and Metrics

Anant Shukla, MD

All Other Authors: Christopher Frey, MD, Jack Kilgore, MD, Logan Lucosio, BA, Lauren Porras, MD, and Chris Matarazzo, ATC

Affiliation: Vanderbilt University Medical Center.

Purpose: Ulnar collateral ligament (UCL) injury can cause pain and decreased performance for the overhead athlete. This study aimed to share a single institution’s return to play and dynamometry data in 5 overhead athletes with UCL injuries treated non-operatively with PRP.

Methods and Study Design: Retrospective review of 5 Division 1 baseball pitchers who sustained low- to intermediate-grade UCL injuries from 2023 to 2024 as determined by ultrasonography or magnetic resonance imaging. All athletes underwent 1 PRP injection, physical therapy, and a standardized return to play (RTP) protocol. Dynamometry measures were analyzed pre-season and at the end of the RTP protocol for all athletes.

Results: Five consecutive baseball players with UCL injuries were evaluated. Pre-season dynamometry testing was performed on all players prior to the seasons and when they first arrived to the team. Players received PRP injections on average 36 days after their injury and started a protocoled rehab program on average about 48 days after PRP. Players were cleared to full return to play at a mean 174 days post-injury. Follow-up examination at that time demonstrated full range of motion of the elbow without tenderness to palpation over the UCL for all athletes. All athletes were able to continue to play at the same level of competition as before the injury occurred without any complaints. No players had repeat injury during the same or following seasons. Comparing pre-injury to clearance dynamometry, external rotation measures on average slightly decreased from 194 to 190 Newtons while grip strength increased from 586 to 646 Newtons, on average.

Conclusions: Successful return to play was possible in 5 collegiate baseball pitchers after nonoperative treatment including injection of PRP at a mean 174 days following injury. Performance metrics including external rotation and grip strength were consistent pre-injury and upon clearance.

Significance: This case series serves to provide Sport Medicine physician clinicians with more data, and specific metrics, to counsel patients with UCL injuries on non-operative management and their return to play and expected dynamometry results.

Acknowledgments: We would like to thank the Vanderbilt University Athletics and the Alicia Hymel from the orthopedics stats team.

TOPIC: REGENMED

STUDY TYPE: Cohort

Wharton Jelly Derived-Mesenchymal Stem Cells (WJ-MSCs) Therapy for Knee Osteoarthritis (KOA) and Chondromalacia Patellae (CP)

Robert Palumbo, MD

All Other Authors: Freddy Andres Barrios-Arroyave, MD, Masters, PhD, Natalia Zapata, MD, Karolynn Halpert-Correa, MD, Luz Adriana Palacio, MD, Mauricio Daza-Saenz, MD, Mario Alberto Mercado, MD, Melissa Molina-Barrios, MD, and Melissa Molina-Barrios, MD

Affiliation: BioXcellerator, Phoenix, AZ, US BioXcellerator Regenerative Medicine Clinic, Medellin, Colombia.

Purpose: KOA and CP have been the focus of research on ortho-biologics and regenerative medicine. In a Real-World-Evidence observational retrospective single-cohort study, we evaluated the preliminary safety and clinical efficacy following umbilical cord WJ-MSCs therapy in KOA and CP patients.

Methods and Study Design: The study was approved by the IRB (0435-11-2022). Clinical outcomes were measured by the SF12, VAS, and Western-Ontario-McMaster-Index (WOMAC) questionnaires. Assessments were performed at baseline and 3-6-12 months after intra-articular delivery of a single dose of 40 × 10⁶ WJ-MSCs per target knee. Previously, WJ-MSCs were expanded up to passage 7. Cell markers and differentiation were verified.

Results: One hundred eighty-seven knees (112 patients) were treated between November/2021 to October/2023. All patients completed 12 months of follow-up. Eighty-eight percent of patients were male. The mean age was 59 (SD = 18). The radiographical status (Kellgren-Lawrence grading system) was classified as mild (46%), moderate (40%), and severe (14%). The average pre-therapy VAS score was 5 and decreased to 2 at 12 months (P P = 0.022). The mean pre-therapy WOMAC-pain score was 7 and post-therapy was 4 (P P = 0.045, P = 0.040). The mean baseline SF12-physical score was 52.38, and the 12-month was 64.28 (P = 0.003). After 12 months, the global SF12 score improved compared with the baseline (P = 0.009). The responder status (a target knee that achieved a WOMAC-general score difference ≥20% between baseline and post-treatment) was obtained by 66% of treated knees. No serious adverse events were reported.

Conclusions: Intraarticular WJ-MSCs ultrasound-guided delivery was proven to be safe and showed relevant clinical effects in KOA and CP patients. Statistically significant improvements were demonstrated in pain (VAS and WOMAC-pain scores), functional limitation (WOMAC-function) and stiffness (WOMAC-stiffness) after 12 months of therapy compared to baseline. Improvements were also observed in health-related quality of life according to the SF-12 questionnaire.

Significance: These findings contribute to the understanding of the therapeutic benefits of WJ-MSCs as an ortho-biological treatment in a regenerative medicine real-life scenario regarding pain, functionality and quality of life domains.

Acknowledgments: We would like to thank the entire team of sports physicians and orthopedists at BioXcellerator, Colombia for their professionalism and for providing the information for this observational clinical research. We would also like to thank our patients, both from the sports field and patients in general, for trusting us to provide their clinical data for academic research purposes.

TOPIC: Rehabilitation

STUDY TYPE: Cohort

The Effect of Stretching on Patient-Reported Outcomes for Greater Trochanteric Pain Syndrome

Anish Rana, BA

All Other Authors: Rondy Michael Lazaro, MD, Nicholas Grzibowski, MD, Namara Haq, MD, Shreya Mandalapu, BA, Meherab Hossain, BS, and Tyler Murray, DPT, DPT

Affiliation: University of Rochester School of Medicine and Dentistry.

Purpose: The purpose of this study is to evaluate the impact of hip adduction stretches during physical therapy (PT) for greater trochanteric pain syndrome (GTPS) on Patient-Reported Outcome Measurement Information System (PROMIS) scores for Physical Function, Pain Interference, and Depression.

Methods and Study Design: This retrospective study included GTPS patients treated in an academic PT setting. PROMIS scores for Physical Function (PF), Pain Interference (PI), and Depression (D) were collected at baseline and 16 weeks post-PT. Patients were grouped by whether or not hip adduction stretches were performed in PT. Linear regression models also accounted for age, BMI, and initial scores (alpha = 0.05).

Results: 52.9% (n = 73) of the 138 patients treated for GTPS performed hip adduction stretches during PT. Linear models showed that initial PROMIS scores were strong predictors of final scores across PF, PI, and D domains (P P = 0.076). No significant differences between the 2 groups were observed in the PF (P = 0.223) or D domains (P = 0.895). No other covariates, including age, sex, BMI, or number of PT sessions, were significantly associated with changes in PROMIS scores from baseline to 16 weeks.

Conclusions: Initial PROMIS scores were strong predictors of final scores across all domains. While there was a trend toward increased pain interference with patients who did hip adduction stretches, this difference was not statistically significant. Further prospective studies are needed to investigate whether stretching, particularly hip adduction stretches, could potentially worsen symptoms in GTPS due to compression of the gluteal tendons.

Significance: This is the first study to investigate the effect of stretching on patient-reported outcomes in GTPS management. The findings indicate the need for evidence-based guidelines to optimize treatment approaches for this prevalent condition.

Acknowledgments: We would like to acknowledge the Department of Physical Medicine and Rehabilitation at the University of Rochester Medical Center.

TOPIC: Rehabilitation

STUDY TYPE: Cohort

The Association Between Objective Wearable Sleep Duration, Well-being, and Time Loss Injury Risk in Female Collegiate Volleyball Athletes

Joseph Park, MD

All Other Authors: Andrew Watson, MD and Jennifer Sanfilippo, MS

Affiliation: University of Wisconsin, Madison, WI.

Purpose: Self-reported sleep is related to well-being and injury risk in athletes, but the associations with wearable sleep data are poorly defined. We sought to evaluate the associations between objective sleep duration, subjective well-being, and injury risk in female collegiate volleyball athletes.

Methods and Study Design: Fifteen female NCAA Division I volleyball players wore Oura rings to measure sleep duration over the 2023–2024 season. Subjective well-being (mood, energy, soreness, rated 1–10) was reported each morning and injuries were recorded by the team athletic trainer. Separate mixed-effects logistic regression models were used to evaluate the association between sleep duration, well-being, and injury.

Results: Sleep duration was significant associated with mood (estimate = 0.10, SE = 0.01, P = P = P = 0.07). A total of 11 time-loss injuries were recorded during the study period. In-season injury was significantly predicted by mood (odds ratio (OR), 0.51 (95% CI, 0.28–0.91); P = 0.022) and soreness (OR, 0.54 (95% CI, 0.36–0.82); P = 0.0036). However, sleep quantity was not significantly associated with injury (OR, 1.05 (95% CI, 0.76–1.45); P = 0.76).

Conclusions: This study suggests that objective sleep duration from a wearable device is predictive of well-being and improved subjective well-being is associated with decreased injury risk in collegiate female volleyball athletes. Nonetheless, objective sleep duration is not associated with injury. Further research is needed to define the relationship between objective sleep characteristics and injury risk in different populations of athletes.

Significance: Although sleep and well-being have been found to be predictive of injury in athletes, the relationships between sleep and injury may differ based on the data collection method.

Acknowledgments: Andrew Watson, Jennifer Sanfilippo, University of Wisconsin Women’s Volleyball Team.

TOPIC: Rehabilitation

STUDY TYPE: Other

AI vs. Protocols: Can a Large Language Model (LLM) Deliver Accurate ACL Rehab Plans?

Kevin De Jesus, MD

All Other Authors: William Micheo, MD

Affiliation: Physical Medicine, Rehabilitation, and Sports Medicine—University of Puerto Rico.

Purpose: This study evaluated a large language model’s (LLM) ability to generate a rehabilitation protocol after an anterior cruciate ligament (ACL) reconstruction surgery. The output was compared against established guides and assessed for completeness, timeline accuracy, and appropriateness.

Methods and Study Design: A ROT (Reliable, Objective, Thorough) prompt describing a typical ACL tear case was presented to an LLM, requesting a rehabilitation protocol. The output was compared with 3 established rehabilitation protocols for ACL reconstruction. We quantified a coverage score, the Mean Average Deviation (MAD) from guideline-recommended timelines, and evaluated additional recommendations for appropriateness.

Results: Coverage scores for the LLM were 47% (47/99) for the Mass General protocol, 38% (51/134) for MOON, and 32% (22/69) for KNGF. The MAD was 3.75 weeks compared to Mass General and 1.7 weeks compared to MOON. The KNGF protocol lacked a defined timeline, preventing MAD calculation. There were 16, 24, and 37 deviations (e.g., additional interventions or evaluations) from the guidelines, respectively. Most deviations from the guidelines were categorized as appropriate by reviewers (87.5%, 100%, and 100%, respectively), aligning with general rehabilitation principles but outside guideline specifics when compared to established protocols.

Conclusions: The LLM’s suggested rehabilitation protocol for ACL reconstruction demonstrated partial alignment with established guides, lacking more than half of the elements and detailed recommendations specified. While additional recommendations were often appropriate, adherence to protocols was limited. LLM’s suggested rehabilitation is based on generic and general recommendations and lacks the expertise needed from a Sports Medicine specialist.

Significance: This study highlights the current limitations of LLMs in providing expert-level rehabilitation protocols for athletes. While LLMs show potential, there is still a critical gap in expertise recommendations to assist in athlete care reliably.

Acknowledgments: We thank Chris Lewis, MD for his input and knowledge on methodology.

TOPIC: Running

STUDY TYPE: Cohort

Assessing the Association of Injury and Illness on the Mental Health of Runners: An RHC Study

Dalton Brady, MD

All Other Authors: Jamie Egbert, MPH, Mark Fontana, PhD, Stephanie Kliethermes, PhD, Emily Kraus, MD, Emily Kroshus, PhD, Adam Tenforde, MD, Brett Toresdahl, MD, and Brett Toresdahl, MD

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

Purpose: To determine the association of injuries and illness with symptoms of depression and anxiety among runners training for a race.

Methods and Study Design: A prospective analysis of adult runners in the Runner Health Consortium training for a ≥ 10 km race. Biweekly health surveys assessed injury, illness, and mental health. Inclusion criteria required completion of baseline and ≥1 interval surveys. Mixed effects linear regression examined the association of injury and illness with PHQ2 and GAD2 scores controlling for age, gender, and race experience.

Results: A total of 2,187 runners (mean age 39.2 (SD 11.5), 60.0% women, mean race experience 10.1 (SD 8.9) years) completed 13,071 health surveys. Overall, 972 runners (44%) reported ≥ 1 injury and 1,072 (49%) reported ≥ 1 illness. Runners without injury or illness on a given survey had median PHQ2 of 0 (0: 76%, 1: 11%, 2: 11%, 3–6: 2%) and GAD2 of 0 (0: 59%, 1: 21%, 2: 15%, 3–6: 6%). Compared to no injury, injury severity was associated with PHQ2 scores as follows: minor β = −0.026 (95% CI = −0.083, 0.030, P = 0.36); moderate β = 0.114 (95% CI = 0.060, 0.169, P P P P = 0.02); moderate β = 0.072 (95% CI = 0.012, 0.133, P = 0.02); severe β = 0.216 (95% CI = 0.136, 0.297, P P

Conclusions: Among runners training for a race, injury and illness were associated with higher (worse) mental health symptom scores on the PHQ2, while only injury was associated with higher GAD2 scores. More severe injuries and illnesses were associated with higher mental health symptom scores than milder setbacks. Runners who had to withdraw from their race due to injury or illness reported the highest mental health symptom scores.

Significance: This study establishes an association between injury, illness, and runners’ mental health. This information is useful for recognizing and supporting the mental health of runners affected by injury or illness during training.

Acknowledgments: The authors wish to thank our race partners, including Bank of America Chicago Marathon, New York Road Runners, and the Seattle Marathon Association for contributing to enrollment for this study. The Runner Health Consortium is funded by an AMSSM CRN Grant.

TOPIC: Running

STUDY TYPE: Survey

Uniformed Family Physician Attitudes Regarding Running Footwear

Melinda Ng, MD

All Other Authors: Rukayat Balogun, MD and Alexander Knobloch, MD, CAQSM, FAAFP

Affiliation: Travis Sports Medicine Fellowship David Grant Medical Center Fairfield, CA.

Purpose: Modifying running footwear is a strategy to prevent running-related injury (RRI), yet patient-oriented evidence remains limited. This study investigates uniformed family physician perceptions and self-reported practices on footwear prescriptions as a means to reduce RRI risk.

Methods and Study Design: Using an online platform, a cross-sectional survey was administered to 588 family physician and resident attendees of the 2023 Uniformed Services Academy of Family Physicians Annual Meeting. Main outcome measures included prescription discussion frequency and obstacles, perceptions of evidence underlying prescriptions, and associations between previous training and the aforementioned variables.

Results: With a 69.9% response rate, most respondents (89%) feel footwear prescriptions reduce RRI risk. However, 64% of respondents discuss prescriptions in less than half of appropriate patients. The largest obstacles are lack of knowledge (39%) and time (34%). Discussion frequency was significantly associated with obstacle reported (X2 (12,N = 354) = 79.09, P P P P = 0.01).

Conclusions: While most uniformed family physicians believe running footwear prescriptions can reduce RRI risk, only a limited number engage in patient discussions on this topic. Significant barriers include physician lack of knowledge and time, while sports medicine fellowship and previous footwear training increase discussions. The largest obstacle is highlighted by low respondent knowledge in identifying correct evidence-based footwear recommendations.

Significance: This study suggests further research is necessary to investigate strategies assisting family physicians in prescribing running footwear, particularly those aimed at increasing knowledge of current evidence-based recommendations.

Acknowledgments: The authors thank the members of the USAFP Clinical Investigations Committee for the opportunity to participate in the 2023 USAFP Omnibus Survey project and Dr. Jennifer Thornton for invaluable assistance in data analysis. This abstract was presented at the 2024 Uniformed Services Academy of Family Physicians Annual Meeting.

TOPIC: Running

STUDY TYPE: Cohort

The Evolving Ultrarunner: Findings of the Ultrarunner Longitudinal TRAcking Study (ULTRA Study)

James Jastifer, MD

All Other Authors: Luke Malocha, Ethan Jastifer, and Martin Hoffman, MD

Affiliation: Western Michigan University Department of Mechanical and Aerospace Engineering.

Purpose: Ultramarathon participation has surged which may bring different types of athletes into the sport. Understanding the differences among these new athletes is important for sports medicine. This study aims to evaluate changes in ultrarunners’ motivations and definitions of success over time.

Methods and Study Design: 1,347 ultramarathon runners in 2014, and 87 in 2024 participated in the ULTRA Study. The study included obtaining general health status, running behavior, and performance metrics, along with the validated Motivation for Marathoners Scale and Perception of Success Questionnaire. Results from 2014 were compared to the results from 2024.

Results: 2024 ultramarathon runners scored lower on health orientation, weight concern, personal goal achievement, competition, recognition, and affiliation (all P P > 0.05). Additionally, 2024 Ultrarunners scored similarly to the 2014 cohort in Task orientation (P = 0.08) but were less Ego driven (P P = 0.12).

Conclusions: This study quantifies the difference in motivation and perception of success between Ultrarunners in 2024 compared to 2014. Modern Ultrarunners are less competition and health driven but have similar psychological motivations (coping, life meaning, self-esteem) compared those of the previous cohort.

Significance: This study offers insights on the evolving psychological and motivational factors of modern Ultrarunners. These results should help create tailored support strategies that consider both the psychological and physical health of ultramarathon runners.

Acknowledgments: NA.

TOPIC: Running

STUDY TYPE: Cohort

10-Year Followup of the Motivations of Ultramarathon Runners, Does Motivation Change Over Time?

James Jastifer, MD

All Other Authors: Luke Malocha, Ethan Jastifer, and Martin Hoffman

Affiliation: Western Michigan University Department of Mechanical and Aerospace Engineering.

Purpose: Little is known about how ultramarathon runner motivation to run and definition of success changes over time. This study investigates the long-term changes in motivations of ultramarathon runners over a 10-year period.

Methods and Study Design: A cohort of 848 ultrarunners participated in both the baseline (2014) and follow-up (2024) assessments of the Ultrarunner Longitudinal TRAcking (ULTRA) Study. The research utilized validated instruments, including the Motivation for Marathoners Scale and Perception of Success Questionnaire. Additionally, general health status, running behavior, and performance metrics were collected.

Results: Results revealed significant changes in runners’ motivations over the decade. Participants demonstrated decreased motivation across multiple dimensions, including weight concern, personal goal achievement, competition, recognition, affiliation, psychological coping, life meaning, and self-esteem (all P P = 0.07). Interestingly, runners showed increased task orientation and ego scores in 2024 compared to 2014 (both P P

Conclusions: After 10 years, ULTRA participants were less motivated to run in all dimensions except health orientation. They were also more likely to stop participation if it were thought to be detrimental to their health. These findings provide valuable insights into the evolving motivations and perceptions of ultramarathon runners over time.

Significance: The current study highlights the evolving nature of runners’ commitment and perceptions, and help the clinician guide these athletes over their careers in the sport.

Acknowledgments: NA.

TOPIC: Running

STUDY TYPE: Cohort

Evaluating the Value of DXA Screening for Female Collegiate Runners

Alexandra Beling, MD

All Other Authors: Brandon Christnovich, DO, Veronic Boire, Jessie Rozario, MATRN, LAT, ATC, Megan McClelland, RD, CSSD, and Daniel M. Cushman, MD

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

Purpose: This study aimed to assess if data from Dual X-Ray Absorptiometry (DXA) scans including Z-score, percent fat mass (%FM), or percent lean mass (%LM) predicts the risk of bone stress injury (BSI) or non-traumatic lower extremity musculoskeletal (MSK) injury in female collegiate running athletes.

Methods and Study Design: This was a retrospective study of D1 cross country and/or track & field athletes at a single institution between 2021 and 2024. Injuries were captured through evaluation by the team athletic trainer or physician. The data was analyzed using descriptive statistics for demographic characteristics, and logistic regression to examine the association between Z-score, %FM, and %LM to BSI and MSK injuries.

Results: Sixty distinct athletes were included in the study. Of these, 32 athletes (53%) sustained a BSI or MSK injury. Of these, 22 (37%) were MSK injuries, and 10 (17%) were BSI. Mean Z-scores were +2.2 (standard deviation ± 0.95), with a total of 3 (5%) athletes having Z-scores below 1, and none below 0. The cohort had a mean weight of 131 ± 15 pounds, with average 21.9 ± 3.7 %FM, and average 75 ± 3.5 %LM. Z-scores were not correlated with risk of BSI or MSK injury (P > 0.05). Furthermore, %FM and %LM were not correlated with risk of BSI or MSK injury (P > 0.05).

Conclusions: We found that DXA results including Z-score, %FM, or %LM did not predict the risk of subsequent BSI or MSK injury. This suggests that little prognostic information was obtained through a universal screening protocol. However, none of the athletes in our sample had low bone mineral density (BMD) for age or osteoporosis per ACSM criteria, which may not reflect the population of D1 female collegiate running athletes in the country.

Significance: This study indicates that policies calling for annual pre-season DXA screening in collegiate running athletes must be re-evaluated. The benefits of the data attained must be countered by the associated cost, time, and cumulative radiation exposure.

Acknowledgments: University of Utah Athletics Department.

TOPIC: Running

STUDY TYPE: Other

Epidemiology of Injuries in U.S. High School Track and Field Running Events from 2008 to 2019

Raymond Guo, MD

All Other Authors: Dylan Combs, MD, Jennifer Su, MD, Sydney Karnovsky, MD, Hye Chang Rhim, MD, MPH, Toqa Afifi, MD, Mitchell Rauh, PT, PhD, Adam Tenforde, PT, PhD, and Adam Tenforde, MD

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

Purpose: The purpose of this descriptive epidemiology study was to investigate the injury rates and patterns associated with high school track and field running events by using data from a longitudinal national sports injury surveillance system in U.S. high schools.

Methods and Study Design: Data was acquired from the National High School Sports Related Injury Surveillance System, High School Reporting Information Online from 2008 to 2019. Through this system, athletic trainers reported weekly injury and athletic exposure (AE) data. An AE was defined as one athlete’s participation in one practice or competition. Hurdles, sprints, and mid-to-long distance running events were analyzed.

Results: 2629 total injuries during 5,486,279 AEs were recorded. Standardized to AE, injury rate was higher in competition than practice (RR = 2.13, 95% CI: 1.96–2.31). Injury rate was higher for girls than boys in practice (RR = 1.56, 95% CI: 1.41–1.73); however, injury rate was lower for girls than boys in competition (RR = 0.82, 95% CI: 0.71–0.95). Injuries were most common in the thigh (35.1%) and leg (19.8%). The overall most common injury was muscle strain (42.2%). Recurrent injuries accounted for a higher proportion of chronic injuries compared to new injuries (IPR = 1.44, 95% CI: 1.28–1.62). By event, sprints had more injuries (n = 1507) than mid-to-long distance (n = 712) or hurdles (n = 391). Concussion was most common in hurdles, tendonitis was most common in mid-to-long distance running, and avulsion was most common in sprints.

Conclusions: Injury types were different by event and suggest the need to develop injury prevention strategies specific to demands of each event.

Significance: This study describes the injury characteristics of high school track and field running athletes from 2008 to 2019, adding to the limited prior epidemiologic research on track and field running injuries in high school athletes.

Acknowledgments: We thank the Datalys Center for providing the data and athletic trainers who participated to make this study possible.

TOPIC: Running

STUDY TYPE: Case-Control

Ground Reaction Forces and Injury Risk among Collegiate Cross-Country Runners

Derek Day, MD

All Other Authors: Blake Dickenson, MD, Laura Lamarche, DPT, Jessie Rozario, ATC, and Daniel Cushman, MD

Affiliation: University of Utah Health.

Purpose: The primary objective of this study is to identify potential biomechanical predictors of injury among collegiate cross-country runners. Ultimately, this could guide the development of effective injury prevention and rehabilitation programs in this population.

Methods and Study Design: Preseason gait analysis was completed for 33 female collegiate cross-country runners (38 analyses over 2 seasons), including ground reaction force (vertical and anteroposterior), step frequency, stride width, and swing/stance time. Overuse injury data were reported by athletic trainers and team physicians. A case-control analysis then compared gait metrics of injured versus uninjured runners.

Results: A total of 16 runners (48%) developed a lower extremity overuse injury during the season following their respective gait analysis. Among runners who sustained lower extremity injuries, preseason mean peak vertical ground reaction force/body weight was 2.84 (SD 0.16), while in uninjured runners it was 2.73 (SD 0.19), P = 0.074. No significant differences were observed between groups for step frequency, anteroposterior impulse, stride width, or swing/stance time.

Conclusions: A greater mean peak vertical ground reaction force/body weight was noted in injured versus uninjured runners, with the difference nearing statistical significance. Insufficient sample size likely limits the power of this preliminary study to detect a significant difference; however, from a mechanistic perspective, greater relative ground reaction forces plausibly contribute to the development of overuse injuries.

Significance: These findings warrant further study with a larger cohort of runners. If confirmed, this presents a promising opportunity for targeted biomechanical interventions to reduce injury risk in cross-country runners.

TOPIC: Running

STUDY TYPE: Other

Predictive Factors That May Contribute to the Outcomes of High Volume Injections (HVI) to Treat Achilles Tendinopathy

John Walton, MD

All Other Authors: Connie Hsu, MD, Rajiv Verma, MD, and Hallie Labrador, MD

Affiliation: University of Chicago.

Purpose: Conduct a systematic review and meta analysis evaluating potential predictive factors that contribute to the efficacy of High Volume Injections (HVI) in treatment of Achilles Tendinopathy (AT). Factors evaluated include age, duration of symptoms, sex, follow up, and use of corticosteroid (CS).

Methods and Study Design: Embase, Web of Science, and Pubmed were searched for prospective cohort studies, retrospective case series and randomized controlled trials evaluating the efficacy of HVI for treatment of AT utilizing the primary outcomes of change in VISA-A functional scores and pain measured by the VAS score.

Results: Four hundred eighty-four studies were identified for evaluation and 11 studies met inclusion. A total of 11 studies with 328 patients were included in the VISA-A analysis and 8 studies with 174 patients were included in the VAS analysis. The analysis evaluated differences in outcomes (VISA-A and VAS) between patient age, duration of symptoms, sex, follow-up, and whether CS was included within the administered HVI. There was no significant difference in functional outcomes measured by the VISA-A score between any of the aforementioned predictive variables. There was a statistically significant reduction in pain measured by the VAS score when there was a higher percentage of women in the study and follow-up interval was shorter.

Conclusions: Although more studies are needed to further investigate the predictive factors and benefits of HVI for treatment of AT, the current study results suggest that female sex and shorter follow up are associated with greater reduction in pain outcomes, but not function, when compared to other contributing factors such as age, CS use, or duration of symptoms.

Significance: Sex and follow-up period appear to be predictive factors that may affect treatment outcomes with HVI in management of AT but more studies assessing predictive factors and there relationship with treatment outcomes is needed.

Acknowledgments: Thank you to my Co-Fellow, Connie Hsu, for the assistance in conducting a systematic review along with analysis and inspiration for further breaking down of the study into predictive factors.

TOPIC: Running

STUDY TYPE: Survey

Analysis of Injury Data and Outcomes from the Columbus Marathon

Kyle Hopkins, DO

All Other Authors: Amelia Chapman-Rose, DO, MBA, Marcus Penza, DO, Jessica McRae, DO, Navkiran Bedi, OMS, Gabrielle Lopez, OMS, Catherine Maas, OMS, Benjamin Bring, OMS, and Benjamin Bring, DO, MBA

Affiliation: OhioHealth Dublin Methodist Hospital Family Medicine Residency Dublin, Ohio.

Purpose: Our analysis looks to evaluate the impact of various factors, namely weather conditions, on presenting injuries to the medical staff at the Columbus Marathon over the last 16 years. We aim to create a template for race directors to predict an expected number of injuries and treatments required.

Methods and Study Design: Our study was conducted by retrospective data analysis. Complete records available from runners 16 years and older who ran the half or full marathon between 2008 and 2023 were analyzed. Data was collated in a secure database and analyzed utilizing linear regression models or χ² tests as appropriate. Weather data was obtained via historical records when onsite data was unavailable.

Results: Our study’s preliminary results indicated a correlation between warmer than average temperatures and number of runners presenting to the medical tent in an exponential fashion. This included both warmer start temperatures as well as rising temperatures throughout the race day. Temperature extremes were associated with longer lengths of time spent in the treatment tent prior to final disposition. Cold and rainy conditions did bring out a higher incidence of hypothermia, but there was comparatively less hypothermia than there was hyperthermia at warmer temperatures. The peak time for runners to seek medical care was between 3 and 4 hours into the race. Ice, fluids, and bananas/protein snacks were the top 3 most utilized resources. Prior to final statistical analysis, there were no identified gross overarching trends in injuries presenting to the medical tent over the period studied. At the time of this abstract, gender data breakdown, formal linear regression modeling, and χ² analysis remain in progress.

Conclusions: The number and types of injuries evaluated were similar to previously reported studies on weather conditions. However, there did not appear to be a specific correlation between pace and presenting complaint, suggesting that these injuries may be more specific to weather conditions. Thus, using our model, race teams can predict the number of injuries throughout a race day, which will allow for more specific planning needed to keep runners safe.

Significance: To our knowledge this is the first longitudinal study of this magnitude to assess the breakdown of injury data and corresponding impact of weather on outcomes. We hope that this data benefits race directors across the country, as well as our own team

Acknowledgments: The authors would like to express their thanks to several individuals and groups who made this project happen. Namely this includes Dr. Darrin Bright who served as the Medical Director of the Columbus Marathon from 2007 to 2021. The data collection, organization, and storage comes directly with his help and we thank him for his part in making this project happen. We would also like to thank the numerous athletic trainers, HAM radio operators, Columbus Police and Fire, and race day event staff (and specifically those with M3 Sports) for their support of our team and helping to provide a great race experience where runners can perform at their best while maintaining safety. We could not do our jobs without each and every one of these teams doing theirs.

TOPIC: Running

STUDY TYPE: Other

Use of Carbon Fiber Plate Shoes in Marathon Runners: An RHC Study

Elizabeth Roux, BS

All Other Authors: Evan Sirls, BS, Logan Gaudette, MS, Michelle Bruneau, PhD, Mark A. Fontana, PhD, Stephanie Kliethermes, PhD, Emily Kraus, MD, Adam Tenforde, MD, and Adam Tenforde, MD

Affiliation: Harvard Medical School, Boston MA.

Purpose: Carbon fiber plate (CFP) shoes have increased in popularity among runners due to improved performance. However, there are emerging concerns about injury risk. The purpose of this study is to understand the prevalence and factors of runners using CFP shoes for training and endurance racing.

Methods and Study Design: Survey data from the Runner Health Consortium (RHC) included adult runners training for a marathon in the Fall of 2024. Surveys collected runner characteristics including experience level and CFP shoe use. Results were descriptive of the proportion of runners using CFP shoes during training and racing separated by experience level and gender.

Results: Surveys were completed by 2059 runners (59% female, mean age 39 ± 11 years and BMI of 24 ± 4 kg/m²). Among novice or recreational runners, 325/1584 (21%) reported using CFP shoes in training at least some of the time, and 566/1251 (45%) reported using CFP shoes during their race. For experienced or professional runners, 102/265 (39%) reported using CFP shoes during training at least some of the time, and 170/199 (85%) reported using CFP shoes during their race. Among runners who “never” or “rarely” used CFP shoes during training, 404/1086 (37%) used them during the race. When considering gender, 203/1093 (19%) women, 221/737 (30%) men, and 1/13 (8%) nonbinary and transgender runners used CFP shoes at least some of the time during training (X² 60.5, P 2 73.9, P

Conclusions: Our findings suggest many runners use CFP shoes during training or racing distance. Notably, a portion of runners complete races without using this footwear in prior training. Differences exist in CFP shoe use by experience level and gender. These findings can guide future research on the appropriate use of CFP shoes and their association with injury risk.

Significance: CFP shoes have revolutionized running performance. Recognizing the high proportion of runners of all abilities using these shoes justifies the need to better understand how CFP shoes may influence injury risk.

Acknowledgments: The authors wish to thank the Runner Health Consortium race partners, including Bank of America Chicago Marathon, New York Road Runners, and the Seattle Marathon Association for contributing to enrollment for this study. The Runner Health Consortium is funded by an AMSSM CRN Grant. Complete author list in order (only 7 spaces in form above): Elizabeth Roux, BS Evan Sirls, BS Logan Gaudette, MS Michelle Bruneau, PhD Mark A. Fontana, PhD Stephanie Kliethermes, PhD Emily Kraus, MD Adam Tenforde, MD Brett Toresdahl, MD.

TOPIC: Running

STUDY TYPE: Other

Runners’ Insights: A Scoping Review and Thematic Synthesis

Andrew Nowak, MD, JD

All Other Authors: Angela T. Ryck, MD, MPH, MS, Kate Mihevc Edwards, PT, DPT, OCS, Kate Joshua, MLIS, and Sara N. Raiser, MD

Affiliation: University of Pittsburgh Medical Center, Pittsburgh, PA.

Purpose: To review and synthesize research on runners’ knowledge, attitudes, perceptions, and opinions on running-related topics to identify knowledge gaps, treatment barriers, and misconceptions, improve patient care, guide programs, protocols, and policies, and direct future research.

Methods and Study Design: This scoping review followed the Levac et al. framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews Checklist (PRISMA-SrC). Articles from PubMed, Embase, Web of Science, and Sport Discus were screened in 2 blinded rounds with conflicts resolved by consensus. The final articles underwent thematic synthesis and categorization.

Results: The initial search yielded 2037 articles, which were screened to 122 articles that examine runners’ opinions, attitudes, knowledge, and perceptions on numerous running-related topics across various study methodologies. From these articles, 4 major umbrella themes emerged: motivations/well-being, injury/treatment/prevention, performance/training, and nutrition/hydration. Minor themes of environment, technology, drugs/supplements, footwear, REDs/female athlete triad, and apparel were also uncovered. Notably, throughout all themes, few articles addressed access/accessibility, para-/adaptive-/runners with disabilities. Only a minority of articles intentionally considered sex/gender. Males were the most studied population across studies. Critically, most studies only partially considered runners’ opinions, attitudes, knowledge, and perceptions as part of their larger research questions.

Conclusions: This scoping review and synthesis highlight a gap in knowledge and implementation. Few studies explore how to best pair evidence-based insights on injuries, recovery, nutrition, and other topics while considering runners holistically. These insights are critical for coupling evidence with patient-centered care. Future studies should prioritize the investigation of runners’ inclusive insights to inform patient-tailored interventions.

Significance: Most research focuses on solutions without input from runners. This study explores runners’ qualitative feedback to enhance patient-centered care, addressing a critical gap to improve trust, communication, shared decision-making, and health outcomes.

TOPIC: Running

STUDY TYPE: Other

Running Medicine and Social Media: A Mixed-Methods Study of YouTube Content on the Most Common Running Injuries

Andrew Nowak, MD, JD

All Other Authors: Richard J. Lawley, MD, Alexandra Beling, MD, Adam Lewno, DO, and Daniel M. Cushman, MD

Affiliation: University of Pittsburgh Medical Center, Pittsburgh, PA.

Purpose: To evaluate the content, quality, credibility, reliability, and understandability of YouTube videos on the 6 most common running injuries and offer pearls and pitfalls for clinicians and patients.

Methods and Study Design: A total of 120 YouTube videos covering the 6 most common running injuries were assessed using validated tools. Four reviewers each analyzed videos from 3 distinct categories. The top twenty videos were selected for each category with 2 blinded reviewers per category. Reviewers then underwent a structured 60-minute interview. Transcripts and review notes were qualitatively synthesized.

Results: This mixed-methods study on YouTube video assessment utilized the Journal of the American Medical Association Benchmark Criteria, DISCERN, the Patient Education Materials Assessment Tool (PEMAT-A/V), and the Global Quality Score, providing a comprehensive evaluation of the health educational content. No significant differences were noted between the apparent gender or race of the presenter for any outcome measure. The amount of likes or views for videos were not correlated with any outcome measure. Outcome scores were higher for physical therapist presenters than other medical professionals (GQS 3.4 vs 2.3, JAMA 2.3 vs 1.6, PEMAT 2.8 vs 2.0, mDISCERN 3.0 vs 1.8; all P

Conclusions: This study highlights the potential use of YouTube as an educational tool for patients and clinicians. YouTube videos from physical therapists offer the highest quality videos when presented with current research in an organized, easy-to-understand fashion. This combination emphasizes the importance of professionally led, evidence-based practice paired with patient-centered care. However, caution is noted with unguided YouTube content engagement.

Significance: This study systematically evaluates the influential and unregulated running-related health information on YouTube and identifies knowledge gaps, pearls, and pitfalls to better inform practical applications for clinicians and patients.

TOPIC: Training

STUDY TYPE: Cohort

Effects of a 7-Day Heat Acclimation on Preseason Practices in Division 1 Women Lacrosse Players

Eric Coris, MD

All Other Authors: Candi Ashley, PhD, Dallas Dominguez, MD, Alex Refowich, MD, Christian Coris, BS, Grace Hatch, BS, Sydney Learn, BS, Rebecca Lopez, BS, and Rebecca Lopez, PhD, ATC, CSCS, FNATA

Affiliation: USF Morsani College of Medicine, Department of Family Medicine, Department of Orthopedics and Sports Medicine, Tampa, Florida.

Purpose: To examine the effects of heat acclimation on heat strain and hydration in Division 1 women’s lacrosse players in the southeast United States. Women’s lacrosse has gained popularity across the United States. However, there is little research on women’s lacrosse players, and heat acclimation.

Methods and Study Design: Twelve Division 1 women lacrosse players participated in the study. Six athletes acclimated for 7 days in an environmental chamber while cycling for one hour. Gastrointestinal temperature, heart rate, urine specific gravity, urine color, urine osmolality, percent body mass loss, and sweat rate were assessed during acclimation and at 3 practices; one indoors, and 2 outdoors. MVA utilized.

Results: There were no between-group differences at baseline for any measures. There were no differences between the acclimated group and control group for any variables (P > 0.05), and no group X practice interaction (P > 0.05). Fluid intake and sweat rate were greater in the indoor practice and the first outdoor practice (P P P

Conclusions: There were no differences in heat strain and urinary hydration measures between the acclimated and control groups. However, it is possible that the control group attained at least some acclimation through outdoor activities as the study was conducted in late summer months in the Southeast U.S. The differences in HR and Tgi between practices were not surprising.

Significance: To our knowledge, this is the first study looking at the effects of heat acclimation on collegiate women lacrosse players.

Acknowledgments: Additional authors: Samuel Blake BS, Keon Johnson, BS Special thanks to the USF College of Public Health, and the USF Heat Lab.

TOPIC: Training

STUDY TYPE: Other

SDir in Post-Menopausal Women: A Crucial Metric for Personalized Training Regimens

Mark Carrasco, MD

All Other Authors: Salma Aly, PhD, Ian McKeag, MD, Irfan M. Asif, MD, Tim Church, MD, PhD, and Drew Sayer, PhD

Affiliation: The University of Alabama at Birmingham Sports and Exercise Medicine, Birmingham, Alabama.

Purpose: Treatment response heterogeneity (TRH) could influence exercise prescriptions. However, TRH remains poorly quantified. This study used the standard deviation of individual responses (SDir) to assess TRH in weight and VO2 changes in postmenopausal women.

Methods and Study Design: Six-month randomized exercise trial (RCT) in overweight/obese postmenopausal women who were divided into control and 3 exercise groups based on energy expenditures (4, 8, 12 kcal/kg/week (KKW)). SDir compared pre-post variability in weight change, relative VO2, and absolute VO2 across groups to identify exercise-induced TRH.

Results: Four hundred eleven women participated (control n = 94, 4 KKW n = 139, 8 KKW n = 85, 12 KKW n = 93, mean age 57.2 years, and 29.9% African American) SDir revealed no significant TRH for weight change (4 KKW CI: −6.724, 3.550; 8 KKW CI: −7.238, 3.789; 12 KKW CI: −6.423, 3.250) and relative VO2 (4 KKW CI: −1.741, 0.385; 8 KKW CI: −1.686, 0.721; 12 KKW CI: −1.029, 1.450) between exercise and control groups. For absolute VO2, SDir values indicated greater variability in controls for the 4 KKW (SDir −0.057, CI: −0.063, −0.051) and 8 KKW (SDir −0.019, CI: −0.026, −0.012) exercise groups. Positive SDir in the 12 KKW group (SDir 0.065, CI: 0.057, 0.072), highlighted potential TRH at higher exercise volumes, suggesting tailored interventions may benefit high-dose responders.

Conclusions: SDir is a robust method for evaluating TRH. Findings indicate uniform response for weight change and relative VO2, but variability in absolute VO2 at higher exercise doses, underscoring the potential for precision exercise prescriptions to optimize outcomes for specific populations, such as post-menopausal women.

Significance: SDir offers a new lens to evaluate exercise heterogeneity, revealing dose-dependent response patterns. Insights could guide tailored training regimens, optimizing outcomes for diverse populations, including aging athletes.

TOPIC: Training

STUDY TYPE: Other

Paced Breathing Interventions for Sleep, Stress, and Athletic Recovery: A Systematic Review and Meta-Analysis

Chris Grijalba, DO

All Other Authors: Mark Carrasco, MD, Druss Hays, BS, Christopher M. Janelle, PhD, Ian McKeag, MD, Irfan M. Asif, MD, and Taylor Taylor, MEd., PhD

Affiliation: University of Alabama at Birmingham.

Purpose: Maladaptive sleep habits and poor stress management hinder athletic performance and recovery. Breathing interventions offer a low-cost, drug-free solution, but their effectiveness varies. We evaluated the impact of 3 paced breathing techniques on sleep and stress outcomes relevant to athletes.

Methods and Study Design: A systematic review and meta-analysis were conducted on healthy adults (ages 18–43), examining cue-paced, biofeedback-paced, and yogic-paced breathing techniques. Validated measures of sleep quality, arousal, and stress were analyzed. Cohen’s d was calculated for individual and pooled effect sizes on sleep and stress-related metrics.

Results: Data from 177 participants (mean age 26.08; 67.92% female) across 6 studies were analyzed. Biofeedback-paced breathing showed the strongest effect on reducing arousal and heart rate (d = −0.58; P P

Conclusions: Paced breathing interventions benefit sleep and stress outcomes, supporting their use in athletic recovery. Biofeedback-paced breathing was most effective for objective stress reduction, while cue-paced and yogic-paced methods improved subjective sleep and stress. Tailoring breathing interventions offers potential to enhance recovery in athletes under high stress.

Significance: Breathing interventions provide evidence-based, cost-effective tools for managing stress and optimizing sleep in athletes. Tailored approaches can enhance recovery and performance, making them valuable strategies in athletic wellness and training.

TOPIC: Training

STUDY TYPE: RCT

Patient Preferences and their Impact on Engagement and Outcomes in a Resistance Training and Nutrition Intervention

Alex Hanna, MD

All Other Authors: Katie M. Ellison, PhD, Lauren A. Fowler, PhD, Ian D. McKeag, MD, Irfan M. Asif, MD, and R. Drew Sayer, PhD

Affiliation: The University of Alabama at Birmingham.

Purpose: Patient preferences may influence adherence and outcomes in lifestyle interventions. This study evaluates how baseline preferences for resistance training (RT) or a high protein (HP) diet affect study engagement, adherence, and body weight and composition changes in a randomized weight loss trial.

Methods and Study Design: Participants (50–75 years, BMI 30–50) in a 16 week group-based weight loss program were randomized to either self-directed full-body RT (3 day/week; n = 42) or HP diet (∼40% protein; n = 41). Intervention preference was assessed before randomization. Class attendance and changes in grip strength, BUN, weight, and fat-free mass were compared between those matched vs mismatched to their preferred intervention.

Results: Before randomization, 37.3% of participants preferred RT, 32.5% HP diet, and 27.7% had no preference. Among those with preferences (n = 58), 40 were randomly matched to their preferred intervention, and 18 were mismatched. Weekly weight loss class attendance was similar across groups (matched 87.3 ± 15.7%, mismatched 80.9 ± 26.0%, no preference 89.3 ± 13.9%). Grip strength (representing RT adherence) increased more in matched participants in the RT arm (6.64 ± 6.93 lbs) vs mismatched (4.67 ± 6.97 lbs). In the HP diet arm, BUN (representing HP diet adherence) increased similarly in matched (4.00 ± 4.54 mg/dL) and mismatched participants (4.11 ± 5.62 mg/dL), both of which were modestly greater than those with no preference (3.60 ± 4.65 mg/dL). Weight loss was comparable (matched 10.2 ± 5.1 kg, mismatched 10.6 ± 6.6 kg, no preference 9.8 ± 6.3 kg), but fat-free mass loss was greater in mismatched participants (2.68 ± 2.76 kg) than in matched (1.50 ± 2.20 kg) or no preference (1.77 ± 2.23 kg).

Conclusions: Baseline preferences for resistance training or diet interventions may influence adherence and outcomes in lifestyle programs. Resistance training outcomes (e.g. fat-free mass retention, handgrip strength) were attenuated when preferences were not aligned. Matching interventions to patient preferences may optimize outcomes.

Significance: Exercise prescription is critical in lifestyle counseling interventions. This study highlights how aligning patient preferences with prescribed interventions can improve adherence and optimize outcomes, particularly in resistance training.

Acknowledgments: National Institutes of Health and National Institute of Diabetes and Digestive and Kidney Diseases (Grant K01DK124244), UAB Nutrition Obesity Research Center (Grant P30DK056336).

TOPIC: Ultrasound

STUDY TYPE: Other

Sonographic Tendon Abnormalities in Collegiate Athletes a 3 Year Study

Blake Dickenson, DO

All Other Authors: Luke Johnson, BS, Derek Stokes, MD, Leyen Vu, DO, Blake Corcoran, MD, Michael Fredericson, MD, Masaru Teramoto, PhD, MPH, Pstat, Daniel Cushman, PhD, MPH, Pstat, and Daniel Cushman, MD

Affiliation: Department of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, UT.

Purpose: This study investigated the prevalence of ultrasound abnormalities in the Achilles tendon, patellar tendon, and plantar fascia among collegiate athletes across 22 distinct sports at 3 Division I institutions over 3 years.

Methods and Study Design: Observational cross-sectional study across 3 Division I institutions. Exclusion criteria were athletes under age 18 or those who underwent prior surgeries to the tendons/fascia being studied. Bilateral ultrasound scans were recorded as videos by experienced sonographers and later reviewed by a blinded experienced sonographer.

Results: A total of 540 collegiate athletes involved in a variety of sports participated in this study. Subjects were 57.5% female with a mean age of 19.8 (SD 1.59) years, body mass index of 23.2 (SD 2.86) kg/m², and had been competing in their sport for 9.3 (SD 3.82) years. Ultrasound abnormalities were identified in 36%, 7.0% and 2% of patellar tendons, Achilles tendons and plantar fascia, respectively. Logistic regression revealed that the following variables were associated with the presence of abnormalities (all P

Conclusions: This presentation analyzes 3 years of sonographic data collected from 540 student athletes at Division I Institutions across multiple sports. It identifies the prevalence of ultrasound abnormalities in the Achilles tendon, the patellar tendon, and plantar fascia with a goal of informing the development of preventative training and rehabilitation programs.

Significance: These findings can be utilized for developing targeted prevention and rehabilitation strategies tailored to specific sports and individual risk profiles, ultimately enhancing athlete health and performance.

Acknowledgments: The authors would like to acknowledge and thank the efforts of the athletes, sonographers, and training staff from each of the 3 collection sites at Utah, Stanford, and the University of Washington.

TOPIC: Ultrasound

STUDY TYPE: Other

Using Ultrasound to Improve Wrist Palpation Skills of Physical Medicine and Rehabilitation Residents: A Pilot Study

Nirmal Maxwell, DO

All Other Authors: Connor Richmond, DO, Daniela Mehech, MD, and Erin Barnes, MD

Affiliation: Case Western Reserve/Metrohealth Physical Medicine and Rehabilitation Residency Cleveland, OH.

Purpose: The purpose of this pilot study is to make an initial estimate of the effect of an ultrasound-based training session on the accuracy of wrist palpation skills in PM&R residents. The primary outcome was the change in distance of pins from the landmark before and after the ultrasound workshop.

Methods and Study Design: Fifteen PM&R residents placed 1-cm wires on 5 landmarks (CMC joint, TFCC, Scaphoid, SL ligament, 1st dorsal extensor compartment) on 2 models, before and after attending a 45-minute wrist US workshop. For each landmark, a Sports Medicine physiatrist saved an US image with the pin visible if within range. Blinded images were graded and distance from pin to landmark was compared pre and post-workshop.

Results: Four PGY-2, 5 PGY-3, and 6 PGY-4 residents participated in pre-training and post-training testing, with 2 PGY-2s and one PGY-4 resident dropping out at the 6-week test. The median number of MSK rotations completed was 2. A score of 2-cm was assigned if the pin was not close enough to be visualized to the target. The median score for pre-training testing was 2 cm, while the median score for post-training testing was 0.36 cm. The median scores based on landmarks were 1st Ext Comp = 0.17 cm, CMC = 0.49 cm, Scaphoid = 2 cm, SL Lig = 1.75 cm, TFCC = 0.46 cm. Using an N-way ANOVA, there was a statistically significant difference in scores between pre and post-training test (P P P P = 0.12).

Conclusions: Based on our results, our ultrasound-based training session led to a significant improvement in resident’s palpation accuracy for key wrist landmarks.

Significance: Accurate palpation is an essential skill for physicians. As more medical training programs incorporate ultrasound didactics, it is worthwhile to examine if ultrasound enhances clinical skills and justifies the increased time and resources it entails.

TOPIC: Ultrasound

STUDY TYPE: Case-Control

Pulley Plasticity: Understanding Anatomic Differences in the Fingers of Recreational Rock Climbers

Gavin Kirby, BS

All Other Authors: Nicola Crouch, OMS IV, Leo Oneill, MS, and Kathryn Vidlock, MD

Affiliation: Rocky Vista University Parker, CO.

Purpose: Elite rock climbers have increased flexor tendon to bone distance (TBD)2. This study evaluates if these findings are present in a recreational climbing population when compared to the general population. Understanding these differences could guide clinical judgement when assessing for pulley injury.

Methods and Study Design: This study of 78 fingers compares tendon to bone distance in recreational rock climbers versus the general population. High frequency ultrasound was used to evaluate the 3rd and 4th flexor tendons at the level of the A2 pulley, with and without load using a standardized rig maintaining 40° of flexion at the PIP. If prior injury was reported, the involved digit was excluded.

Results: After collecting and interpreting the images, the data shows a significant difference between the TBD of rock climbers versus non rock climbers. Since TBD under load at approximately 40° of PIP flexion is commonly used as a proxy for A2 pulley laxity or defect, this was the primary focus of our data analysis. In rock climbers, the TBD under load values were 1.5 mm and 1.4 mm while the TBD under load for non rock climbers was 1.2 mm (P less than 0.01) and 1.1 mm (P of 0.02) for the 3rd and 4th fingers respectively. The A2 pulleys of the fingers in recreational rock climbers were more similar to those of elite rock climbers than those of non-climbers.

Conclusions: This study suggests that the soft tissue anatomy in the fingers of rock climbers is different than that of non rock climbers. This could represent anatomic adaptation of these structures to mitigate injury. This could also represent a low grade chronic injury pattern. Future investigations should obtain a larger data set comparing TBD in healthy vs. injured fingers to establish more consistent cutoff values to guide diagnosis of pulley injury.

Significance: These findings must be considered when using ultrasound for the diagnosis and management of pulley injuries in a large and growing recreational rock climbing population.

Acknowledgments: Rocky Vista University Ubergrippen Indoor Crag.

TOPIC: Ultrasound

STUDY TYPE: RCT

Efficacy of Pre-Conference Learning Materials in Sports Medicine Fellow Ultrasound Education: A Pilot Study

Zachary Ryan, MS

All Other Authors: Aaron Lange, Kathryn Vidlock, MD, and Lauren Rudolph, MD

Affiliation: Rocky Vista University College of Osteopathic Medicine Parker, Colorado.

Purpose: The study aims to refine methodological approaches and determine the viability of using a randomized controlled trial (RCT) design comparing the impact of video pre-conference materials on learning outcomes of fellows attending a one-day ultrasound education conference at the start of fellowship.

Methods and Study Design: Forty-one participants attending a one-day ultrasound education conference were randomly assigned to one of 2 groups. All participants underwent pre- and post-tests to assess their knowledge and skills. The intervention group received additional recommended pre-conference learning materials, whereas the control group did not. Both groups attended the same one-day learning conference.

Results: The intervention group scored an average of 12.3/20 on the pre-test and 12.4/20 on the post-test. The control group scored an average of 11.9/20 on the pretest and an average of 12.3/20 on the post-test. While the control group had a larger increase, it was not statistically significant. Among primary specialties (emergency medicine, family medicine, internal medicine, pediatrics and physical medicine and rehabilitation) there was no significant difference in scores or in increase from pretest to posttest.

Conclusions: This pilot study evaluating the efficacy of video pre-conference education on learning outcomes of new fellows attending a one-day musculoskeletal (MSK) ultrasound education conference did not show a statistically significant change in scores.

Significance: The study failed to show a difference in pretest to posttest score after providing pre-conference educational videos to incoming fellows. More studies are needed to evaluate the efficacy of current sports ultrasound educational materials.

Acknowledgments: We would like to acknowledge Jack Spittler, and AMSSM for their help in organizing this at the Fellows Conference.

TOPIC: Ultrasound

STUDY TYPE: Cohort

Comparing Pectoralis Minor Stiffness Between Throwing and Non-Throwing Arms in Baseball Players Using Shear Wave Elastography

Haruki Ishii, MD

All Other Authors: George Raum, DO, Jenny Nguyen, MS, and Robert Bowers, DO, PhD

Affiliation: New York University, New York, NY.

Purpose: Adaptive shortening of the pectoralis minor has been associated with throwing arm pain in overhead athletes. The aim of this study was to assess the difference in pectoralis minor stiffness between throwing and non-throwing arms using shear wave elastography to detect chronic impacts of throwing.

Methods and Study Design: Division 1 collegiate baseball players were evaluated immediately after the completion of the 2024 season. Subjects were examined with shear wave elastography while at rest in a supine position. The measurement site of the pectoralis minor muscle was defined as the midpoint between the coracoid process and the fourth rib and sternum junction, as noted in a previous study.

Results: A total of 9 baseball players and 3 non-throwing athlete controls participated in the study. All of the participants were right-hand dominant and all baseball players were pitchers. Each ultrasound elastography measurement was performed up to 5 times as needed to achieve a reliability measure index (RMI) of greater than 0.6. For the subjects that had more than one measurement that reached the RMI cutoff, a mean value of those measurements was used for statistical analysis. Among the baseball players, the pectoralis minor shear wave elastography value was significantly greater on the throwing arm side compared to the non-throwing arm side (38.16 kPA vs 18.93 kPA, P = 0.026). On the other hand, there was no significant side-to-side difference in pectoralis minor muscle stiffness among the non-throwing athlete controls (18.00 kPA vs 22.04 kPA, P = 0.222).

Conclusions: This pilot study demonstrates that the stiffness of the pectoralis minor muscle, as measured by shear wave elastography, was significantly greater on the throwing arm side in baseball players. This was not seen in non-throwing individuals. These findings suggest that adaptive pectoralis minor muscle stiffness may be due to throwing. Future study is warranted to validate the results and identify the clinical relevance of pec minor stiffness.

Significance: The findings of this study will allow sports medicine clinicians to identify a potential target for injury prevention, intervention, and rehabilitation in throwing athletes through the course of a baseball season.

TOPIC: Ultrasound

STUDY TYPE: Cohort

Ultrasound-guided Microinvasive Trigger Thumb Release With an 18-gauge Blade-tipped Needle

Ricardo Colberg, MD

All Other Authors: Tomas Vega, MD, Victor Kremser, MD, Matt Ithurburn, DPT, PhD, and Alex Yates, MA

Affiliation: Andrews Sports Medicine & Orthopeadic Center American Sports Medicine Institute Birmingham, AL.

Purpose: Ultrasound-guided trigger finger release is a promising alternative to open surgery; however, there is concern of neurovascular injury in the thumb. This study evaluated the outcomes of patients undergoing ultrasound-guided trigger thumb release using an 18-gauge blade-tipped needle.

Methods and Study Design: This is a retrospective, case-series study of patients treated with ultrasound-guided trigger thumb release using an 18-gauge blade-tipped needle at a single, academic institution between September 2019 and June 2023. Outcomes assessed were mechanical symptom resolution, minor and major complications, numeric pain rating scale, Nirschl phase rating scale, and revision rates.

Results: Twenty-eight patients (29 thumbs) participated in this study and completed follow-up at an average of 3.4 years post-procedure (Standard deviation 1.2). Average age was 59.2 years and 52% were female. All the patients (100%) reported complete resolution of catching/locking/mechanical symptoms. No major or minor complications (including neurovascular injuries) were documented or reported. No patient required a revision ultrasound-guided or open release. Average Numeric Pain Rating Scale was 0.2 of 10 (SD 0.5) and Nirschl Phase Rating Scale was 0.1 of 7 (SD 0.3). All the patients (100%) were able to return to work and 96% were able to return to recreational activities.

Conclusions: Ultrasound-guided microinvasive trigger thumb release with an 18-gauge blade-tipped needle is a safe and effective procedure. It provided significant symptomatic relief, no reported complications, and no recurrence or need for subsequent revision trigger thumb release. Specifically, the risk of neurovascular injury was minimal given the direct sonographic visualization of at-risk structures when performing the procedure.

Significance: Ultrasound-guided microinvasive trigger thumb release with an 18-gauge blade-tipped needle is a safe and effective technique with low risk for neurovascular injury.

TOPIC: Ultrasound

STUDY TYPE: Cohort

Swimming-Induced Pulmonary Edema in Ironman Athletes: Assessing Diagnostic Criteria at High Altitude

Brady Patterson, BS

All Other Authors: Harrison Steins, MS and Kathryn Vidlock, MD

Affiliation: Rocky Vista University, Parker, CO.

Purpose: Swimming-induced pulmonary edema (SIPE) is an immersion pulmonary edema reported in open-water swimmers. The pathology is not fully understood and diagnostic guidelines are unclear. This study compares the utility of the current diagnostic guidelines in Ironman events in the altitudes of UT & CO

Methods and Study Design: Seventy athletes who started the open water races were evaluated. Thirty-six had traditional symptoms of SIPE. All athletes who dropped during the swim were evaluated using symptoms, vitals, CV and pulmonary exam, and ultrasound. The validated Blue Protocol was used with handheld sono-health ultrasound. This study was done on races at elevations of 822 m (2679 ft) and 1655 m (5430 ft).

Results: The results showed 36 patients with symptoms or ultrasound findings of SIPE. Thirteen of these had cough, 22 had shortness of breath (SOB). Lung findings in included crackles in 7 and crackles or stridoror wheezes in 11. In patients with crackles the PPV of a positive lung US finding was 86% and the NPV was 83% (P value P value P = 0.98). In patients with SOB the PPV was 36% and NPV was 79% (P = 0.34). USing a receiver-operating characteristic (ROC) curve to evaluate the diagnostic value of SPpO2 showed a value of 93% SpO2 with an area under the curve of 0.70. Previously validated criteria has shown crackles to have a high PPV and both cough and SOB have had lesser PPV which is consistent with our data. However, SpO2 in previous data, done at lower elevations, was highly diagnostic at a level of 95% with an ROC area under the curve of 0.893.

Conclusions: The study findings show crackles and lung abnormalities to be of high PPV of ultrasound findings of SIPE, while the presence of a cough or SOB to be of lesser value. In contrast to previous studies, SpO2 of less than 95% at these levels of elevation was not a good diagnostic marker. More studies need to be done at various elevations.

Significance: This study adds to the literature on symptoms and signs of SIPE and differs from previous studies in that SpO2 was not found to be a good diagnostic predictor of lung US findings in altitudes higher than previous studies.

Acknowledgments: Elyssa Morgan, Lillian Granley.

TOPIC: Ultrasound

STUDY TYPE: Cohort

Swimming Induced Pulmonary Edema in Ironman Athletes: POCUS Evaluation of Incidence

Harrison Steins, MS

All Other Authors: Brady Patterson, BS and Katherine Vidlock, MD

Affiliation: Rocky Vista University, Parker CO.

Purpose: Swimming-induced pulmonary edema (SIPE) is an immersion pulmonary edema reported in open water swimmers. The pathology is not fully understood and the incidence has been reported in a few studies, although none at higher altitudes. This study evaluates the incidence of SIPE at IronMan.

Methods and Study Design: Seventy athletes out of 8,500 who started the open water races were evaluated. Thirty-six had traditional symptoms of SIPE. All athletes who dropped during the swim were evaluated using symptoms, vitals, CV, pulmonary exam, and ultrasound. The validated Blue Protocol was used with handheld ultrasound devices to track the quantity and location of B-lines in lung fields.

Results: Over 8,000 athletes competed in included events, 70 individuals were scanned and enrolled, and 36 (51.42%) of those individuals presented with physical exam findings of swimming-induced pulmonary edema (wheeze, SOB, cough, increased sputum). Of the 70 individuals scanned 22.8% (n = 16) presented with positive ultrasound findings (3 or more B-lines present in at least one lung field). Of the positive ultrasound findings, individuals presenting without traditional symptoms comprised 37.5% (n = 6). In patients who had 3 or more B-lines present on ultrasound, 56.25% (n = 9) had unilateral B-lines and 43.75% (n = 7) had fulminant pulmonary edema with B-lines present in bilateral lung fields. On average the right lung fields had more B-lines in both symptomatic and asymptomatic patients compared to the left (R Lung B-line average of 7.6, L lung B-line average of 5.66).

Conclusions: The study reveals a higher incidence of SIPE in endurance swimming athletes than previously described in the literature. This study examined both symptomatic and asymptomatic patients who presented to the race medical tent and found that both groups could present with 3 or more B-lines. Pulmonary edema without a history of SIPE, respiratory, or cardiac medical conditions in an acute setting suggests the exertion, cold water, and wetsuit may have

Significance: This demonstrates an incidence of SIPE higher than previously described. The distribution of B-lines in both symptomatic and asymptomatic swimmers, without a hx of SIPE, indicates a need for further research with swimmers regardless of symptomology.

Acknowledgments: Elyssa Morgan, Lily Granley.

TOPIC: Ultrasound

STUDY TYPE: Cohort

Ultrasound Guided Diagnostic Injections for Neurogenic Thoracic Outlet Syndrome: An Outcomes Based Cohort Study

Farah Hussain, MD

All Other Authors: Andrew Alexander, MD, Benjamin Zacks, MD, Eric Wagner, MD, and Robert Bowers, DO, PhD

Affiliation: Emory University, Atlanta, Georgia.

Purpose: Neurogenic thoracic outlet syndrome (NTOS) causes chronic shoulder pain from brachial plexus compression, commonly in overhead athletes. With no specific diagnostic tests, NTOS is a diagnosis of exclusion. This study explores the use of ultrasound-guided (USG) injections to confirm NTOS diagnosis.

Methods and Study Design: This retrospective chart review analyzed diagnostic blocks by a single upper extremity sports physician (10/2022–10/2024). Blocks included injections to the pectoralis minor (PM), scalenes, suprascapular nerve, or quadrilateral space. Primary outcome: patient-reported relief. Subgroup analysis of all athletes was also performed, specifically comparing response to pectoralis minor vs scalene.

Results: Two hundred three patients who underwent blocks were included in the study (F = 121, M = 81, non-binary = 1). Median age 32.5 (range 12–76). There were 45 athletes (overhead athletes = 42). One hundred eighty-six underwent PM block (positive block = 125), 130 underwent scalene block (positive block = 85), 76 underwent SSN (positive block = 36), and 11 underwent quadrilateral space block (positive block = 4). Ninety-nine patients had both PM and scalene blocks, 47 of these patients had best relief with PM, 44 with scalenes and 7 reported combinations of both provided best relief. Sub analysis of athletes showed N = 45 (F = 23, M = 22) with median age 31 (range 14–37). Forty-five underwent PM block (positive block = 36), 22 patients underwent scalene block (positive block = 13), 18 underwent SSN (positive block = 9), and 3 patients had quadrilateral space block (positive block = 1). Twenty-two athletes had both PM and scalene blocks, 16 had best relief with PM, 4 had best relief with scalene, and 1 reported neither.

Conclusions: PM injection was most likely to be the most effective diagnostic block in both cohorts and when compared directly with scalene injection. Our findings suggest that the PM is a more significant contributor to NTOS than previously believed, especially in overhead athletes. PM should be targeted for diagnostic injections for NTOS in the general population and amongst overhead athletes.

Significance: No definitive test exists for NTOS. While scalenes are often implicated, diagnostic blocks suggest the pectoralis minor, especially in overhead athletes, plays a larger role. This warrants greater consideration in NTOS diagnosis and treatment.

Acknowledgments: Justin Dzierzawski MD, Nicholas Hooper MD, Jasper Tseng MD, Yash Mehta MD.

TOPIC: Ultrasound

STUDY TYPE: Other

Clavipectoral Fascial Plane Nerve Blocks in the Emergency Department Setting

Mike Kelleher, MD, MS

All Other Authors: Neil Wallace, MD

Affiliation: University of Arizona College of Medicine- Tucson Department of Emergency Medicine. Banner University Medical Center.

Purpose: The purpose of our study was to evaluate and demonstrate the efficacy of clavipectoral fascial plane blocks in the ED setting, and their effectiveness as an opioid sparing long-acting analgesic that can be utilized in both admitted and discharged patients.

Methods and Study Design: This is a case series that recruited patients who presented with traumatic injuries that lead to proximal, midshaft, or distal clavicle fractures with varying° of angulation or displacement. Open fractures or skin-tenting injuries were excluded. Each patient underwent a pre-procedure as well as a post-procedure pain score at fixed time intervals to assess for effectiveness of analgesia.

Results: Six patients underwent clavipectoral fascial plane blocks with ages ranging from 12 to 65 years old. Each patient had experienced a traumatic mechanism resulting in a closed clavicular fracture. Each patient received an equal ratio of weight-based lidocaine and bupivacaine, and the blocks were performed utilizing an in-line approach under US guidance with both aspects of the fracture sites bathed appropriately with anesthetic. US images were clipped and saved. A pain assessment was performed both prior to, immediately after, and 15 minutes after the procedure. Of the patients who participated in the pain assessment, the pre-procedure pain assessment noted scores ranging from 4 to 9/10 at rest and 5 to 7/10 with gentle palpation. When the pain scores were reassessed at the immediately after mark as well as the 15 minutes post-procedure mark, scores were noted to be 0 out of 10 at rest and with gentle palpation in all 3 of the respondents. There were no adverse or safety events during any of these procedures. The blocks were performed successfully by ED providers ranging from PGY1-PGY3.

Conclusions: Our pain scores performed before and after the blocks showed significant analgesia with complete resolution of pain at the immediately following, and 15 minutes post-procedure mark. This included scores of 0/10 pain both at rest and with gentle palpation in recorded patients. Utilizing an in-line approach afforded direct visualization of the fracture sites/target areas which aided in the success/degree of analgesia.

Significance: US guided clavipectoral fascial plane blocks offer a safe and effective opioid-sparing modality for analgesia in adult and pediatric patients. It is an easily teachable US skill that is accessible to providers both early and advanced in training.

Acknowledgments: Dr. Neil Wallace The University of Arizona COM-T Department of Emergency Medicine.

TOPIC: Ultrasound

STUDY TYPE: Survey

Non-Musculoskeletal Ultrasound for Sports Medicine Fellows

Arthur Landry, MD

All Other Authors: Venkat Subramanyam, MD and William Karalis, DO

Affiliation: University of Connecticut Emergency Medicine Residency, Farmington, CT.

Purpose: Sports fellows are well trained in MSK ultrasound, but are less likely to be proficient in non-MSK ultrasound, which may be applicable to their practice. This study aims to evaluate the impact of hands-on teaching sessions on fellows’ comfort and knowledge of non-musculoskeletal ultrasound.

Methods and Study Design: The study consisted of pre-and post-surveys with a didactic session in between. Fellows from 4 programs anonymously completed pre-surveys on comfort and knowledge of non-MSK ultrasound. They were then given lectures and participated in hands-on teaching. Post-training surveys were analyzed for changes in comfort and knowledge after teaching sessions. Data spanned 2 years.

Results: Fellows were asked to gauge comfort with acquiring and interpreting views for non-MSK ultrasound including cardiac (echo), pulmonary (pneumothorax), abdominal (FAST), and ocular exams on a scale of Very Comfortable, Somewhat Comfortable, Neither Comfortable nor Uncomfortable, Somewhat Uncomfortable, or Very Uncomfortable. They then completed 8 multiple choice knowledge-based questions related to use of non-MSK ultrasound in Sports Medicine scenarios. The fellows were then given lectures by ultrasound faculty on the 4 non-MSK ultrasound exams. Following the didactic sessions and hands-on training, the fellows were asked to complete the same survey to assess their retention. Pre- and post-didactic comfort levels and scores on knowledge-based questions were analyzed. The pre-survey had 14 responses, an average comfort level of 4.23 (5 being least comfortable, 1 being most comfortable), and an average knowledge score of 4.1 correct responses out of 8. The post survey had 11 responses and had an average comfort level of 1.76 and an average knowledge score of 5.4/8.

Conclusions: Fellows showed significant improvement in their comfort level with both obtaining and interpreting non-MSK ultrasound views after teaching sessions with ultrasound trained faculty. They also scored significantly higher on knowledge-based questions after lectures and hands-on teaching sessions. This shows that the teaching by ultrasound faculty was effective and offers potential for future incorporation into sports medicine fellowship curriculum.

Significance: This research shows that non-MSK ultrasound teaching is effective and beneficial for sports medicine fellows. We propose that steps should be taken to integrate non-MSK ultrasound training into sports medicine fellowship curriculum moving forward.

Acknowledgments: University of Connecticut Emergency Medicine Residency Program University of Connecticut School of Medicine UConn Emergency Medicine Ultrasound Faculty UConn John Dempsey Hospital.

TOPIC: Ultrasound

STUDY TYPE: Case-Control

Hip Microinstability Observed on Dynamic Ultrasound as a Factor in Pain Outcomes Following Injection

Thomas Swaffield, MD

All Other Authors: Sean Owens, BS, Morgan Swanson, BA, Monika Thothadri, Pharm D, MPH, Nakul Thalathi, MD, Kathleen Maguire, MD, Wudbhav Sankar, MD, Naomi Brown, MD, and Naomi Brown, MD

Affiliation: Children‘s Hospital of Philadelphia.

Purpose: The purpose of this study was to evaluate the relationship between patient factors, including hip microinstability (HMI) assessed via dynamic ultrasound (US), and pain relief following lidocaine and steroid hip injection, which may help clinicians guide patient expectations on pain relief.

Methods and Study Design: Patients at a single institution with acute or chronic hip pain receiving dynamic US guided lidocaine and steroid injections also evaluated for HMI from June 2022 to July 2024 were included. Demographics, diagnoses, and numerical pain scale (0 to 10) for passive hip flexion (PHF), scour, impingement (FADIR), Stinchfield, FABERs, and psoas stretch maneuvers pre/post injection, were collected.

Results: Sixty-two patients met study criteria, 28 of which had HMI (45.2%). Pre-injection PHF pain, age and race were significantly related, with younger and African American patients reporting higher pain (P = 0.0138, P = 0.0026). Diagnosis of femoroacetabular impingement (n = 7), labral/chondral pathology (n = 13), or hip pain (n = 42) was not significantly related to pre-injection PHF pain (P = 0.052) or HMI presence (P = 0.173). Mean pre-injection pain scores with PHF were higher in patients without HMI than with HMI (P = 0.004). HMI and pain with other maneuvers were not significantly related. Upon multivariate linear regression, HMI (P = 0.012), age (P = 0.025), and race (P = 0.005) persisted as significant predictors of pre-injection PHF pain. Patients with HMI experienced less median improvement in pain scores during PHF (−1 point) after injection than those without HMI (−3 points) (P = 0.009), but significance was lost when controlling for pre-injection PHF pain (P = 0.094).

Conclusions: Higher pre-injection PHF pain scores were most associated with younger, African American patients, without HMI. HMI remained a significant predictor of pre-injection PHF pain when controlling for age and race. Individuals with more severe hip flexion pain at baseline tend to experience greater pain improvement post injection, regardless of their HMI status.

Significance: Hip microinstability should be considered in patients with hip pain when evaluating pre-injection pain levels and utility of therapeutic hip injection.

TOPIC:

STUDY TYPE:

Exploring the Impact of Sleep Extension on Performance Among Competitive Esports Athletes

Peter Hoang, MD

All Other Authors: Mark Deppe, Brenden Alvarez, Alaina Klaes, John Billimek, PhD, and Brian Kim, MD

Affiliation: University of California, Irvine—Irvine, CA.

Purpose: Research shows that adequate sleep contributes to improved athletic performance. However, there is limited data on performance, sleep, and stress response among esports athletes. Our study explores the role of sleep counseling and extension on performance and heart rate variability in esports.

Methods and Study Design: We enrolled competitive Valorant esports athletes. Participants maintained their sleep schedule for 4–6 weeks, followed by a 4-week sleep extension phase. They were encouraged to increase sleep duration during this period. Health data were collected via a wearable device called the Oura Ring. We evaluated performance through neurocognitive tests and by analyzing Valorant match statistics.

Results: The study revealed that participants did not significantly improve sleep overall. Despite this, we observed statistically significant improvements in some regions of neurocognitive testing, but not in-game performance, before and after sleep counseling. Heart rate variability significantly increased after sleep counseling. Participants had very favorable ratings for the Oura Ring device’s overall quality, battery life, comfortability, and ease of use.

Conclusions: Sleep counseling, despite limited sleep extension, improved reaction times in neurocognitive tests, suggesting gains in concentration, decision-making, and executive function, though not basic motor response. Sleep counseling also led to improved heart rate variability during the study and points to health benefits tied to sleep quality over time. The Oura Ring was a promising alternative to polysomnography for sleep-related research.

Significance: Our study provides promising data that highlights the correlation between esports performance and sleep. These findings demonstrate the importance of sleep education and the value of heart rate variability as a marker for recovery in future research.

Acknowledgments: The authors gratefully appreciate the following individuals for their efforts in helping perform this work: Vishal Nathani, Laura Monje-Paulson, Jason Reitman, and Megan Agnew.

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STUDY TYPE: Survey

Injuries in Bhangra and Bollywood Fusion Dancers: A Survey Study

Nirmal Maxwell, DO

All Other Authors: Heather Rainey, MD

Affiliation: Metrohealth/Case Western Reserve University PM&R Residency Cleveland, OH.

Purpose: This study’s purpose is to determine the incidence of injuries among Bhangra and Bollywood Fusion in a competitive season and potential risk factors for injury. We hypothesize a higher rate of lower body overuse injuries, and that higher hours spent dancing will lead to higher injury rates.

Methods and Study Design: We created a 16-question survey with an age verifier and e-consent form on REDcap. We asked about demographics, weekly practice time, and history of a dance-related injury in the 2023–2024 season, with further questions specifying location and type. We posted the survey weekly for one month on private Discord channels related to Desi Dance Network (DDN), the governing body for both circuits.

Results: We received 80 responses, with fifty-one Bhangra dancers and 29 Bollywood Fusion dancers responding. We created a logistic regression model of injury as predicted by respondent gender, dance style, and hours trained per week. Sixty-nine percent of Bollywood dancers reported an injury versus 63% of Bhangra dancers (P = 0.2110). Seventy-three percent of women reported an injury versus 53% of men (P = 0.0491). Eighty-four percent of Bhangra injuries were lower extremity while 65% of Bollywood Fusion injuries were lower extremity. Individuals who reported an injury trained for a mean of 11.7 ± 5.6 hours/week versus individuals who did not report an injury training 7.4 ± 3.8 hours/week (P = 0.0015). Eleven percent of male injuries were upper extremity versus 34% of female injuries (P = 0.11). Twenty-one percent of Bhangra-related injuries were upper extremity versus 35% of Bollywood-related injuries (P = 0.80). Individuals with upper extremity injuries reported training of 12 ± 7 hours/week versus individuals with lower extremity injuries reported training for 11 ± 5 hours/week (P = 0.57). Most dancers were kept out of dance on average of 0–2 weeks.

Conclusions: There was a 63% injury rate for Bhangra dancers and 69% injury rate for Bollywood Fusion dancers in the 2023–2024 season. Eighty-four percent of Bhangra injuries were lower extremity while 65% of Bollywood Fusion injuries were lower extremity. There was a statistical significance to Women reporting more injuries than men. There was a statistical significance with injuries reported for training an average of 11.7 hrs a week versus training 7.4 hours a week.

Significance: The Indian dance circuit has grown significantly over the past decade. Our goal is to provide knowledge of the incidence, type, and risk factors of injuries to help educate Bhangra and Bollywood fusion dancers on how to prevent them from happening.

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STUDY TYPE: Survey

The Prevalence of Elbow Overuse Injuries in Wheelchair Rugby Athletes: A Pilot Study

Nicholas Tranchitella, MD

All Other Authors: Odell Minnefield, BS, Ryan Nussbaum, DO, Rajit Banerjee, MD, Robin Tipps, MD, and Connor Fultz, MD

Affiliation: UPMC—Pittsburgh, PA.

Purpose: There is a paucity of research focused on the prevalence of elbow overuse injuries in athletes who use wheelchairs. The goal of this pilot study was to determine the prevalence of elbow overuse injuries in Wheelchair Rugby (WR) athletes and how this results in functional impairment.

Methods and Study Design: This cross-sectional study evaluated 22 WR Athletes at a WR tournament. Athletes completed a demographic survey, followed by the Oslo Sports Trauma Research Center (OSTRC) Elbow Overuse Questionnaire and the Oxford Elbow Score (OES). The prevalence of elbow overuse injuries and the level of functional impairment was determined based on the athletes’ survey score.

Results: Twenty-two participants (17 males, 4 females, and 1 nonbinary) completed the questionnaires. The average age was 39.3 years old, and the primary diagnosis was incomplete spinal cord injury in 17 of the 22 athletes (77.2 percent). All athletes utilized a wheelchair as their primary mode of transport. Athletes were wheelchair-dependent for an average of 18 years and used a manual wheelchair an average of 79.5% of the time and for an average of 11.7 hours per day with approximately 11.5 transfers per day. Athletes competed in some form of wheelchair sport for an average of 10.6 months per year. Using the OSTRC elbow overuse severity scale, 8 of 22 athletes (36.4%) reported some degree of elbow-related overuse. Of those 8 athletes, 6 athletes reported minimal severity, and 2 athletes reported mild severity. There were no athletes who reported moderate to severe overuse injuries. Based on OES survey results, 4 of 22 athletes (18.2%) reported mild functional impairment due to their elbow pain.

Conclusions: This cross-sectional pilot study evaluated the prevalence of elbow overuse injuries in WR Athletes and how these injuries affect their daily life. About one third of WR athletes suffered from some level of elbow-related overuse. Of those athletes, approximately half experienced mild functional impairment due to their elbow injury.

Significance: Wheelchair Rugby Athletes are at risk of suffering from elbow overuse injuries, and to some extent, functional impairment. This pilot study indicates a need to further understand the characteristics of elbow overuse injuries in WR athletes.

Acknowledgments: Pittsburgh Steel Wheelers, Debbie Harrington (Research Coordinator).

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STUDY TYPE:

Hydroplasty Injection in Treatment of Adhesive Capsulitis

Derrick Spencer, BA

All Other Authors: Stanley Hunter, MD, Joseph Giannetta, MD, and Max Kammerman, MD

Affiliation: Upstate Medical University, Syracuse, NY.

Purpose: Adhesive capsulitis (AC) is a condition characterized by a prolonged course of pain, limited range of motion, and significant disability. This pilot study validates our intra-articular hydroplasty protocol as a treatment that significantly improves range of motion rapidly.

Methods and Study Design: This is a prospective cohort study. Patients received intra-articular glenohumeral joint injection under US guidance, first injecting 16 mL 1% mepivacaine + 2 mL 40 mg/mL triamcinolone + 2 mL 30 mg/mL ketorolac, followed by normal saline in two 20 mL syringes. ROM measurements of affected and contralateral shoulders were obtained pre-procedure, post-procedure, and at a 2 week follow up PT visit.

Results: Prior to hydroplasty, all patients had markedly reduced passive range of motion (PROM). The mean differences in PROM between the affected and unaffected shoulders prior to intervention ranged from 51.1 to 88.3°, with the greatest deficit seen in abduction of the affected shoulder (M = 88.3, SD = 39.5). Measurements obtained during same-day physical therapy appointments following hydroplasty demonstrated statistically significant improvements in all planes of the affected shoulder. The greatest improvement in PROM was seen in abduction, with a 68.17% decrease in PROM difference between affected and unaffected shoulders (P = 0.004). Two week post-procedure PROM measurements were obtained for 7/19 patients, which demonstrated further improvement in flexion (P = 0.018), abduction (P = 0.025), and internal rotation with shoulder at 90° abduction (P = 0.015).

Conclusions: Our analysis supports the use of hydroplasty as an intervention that provides rapid improvement in ROM. Flexion and abduction PROM exhibited the greatest initial deficits but demonstrated substantial recovery post-intervention. External and internal rotations showed slower recovery patterns, with persistent deficits at 2 weeks post-intervention. Overall, the data highlights variability in recovery rates among different PROMs.

Significance: This pilot study validates our hydroplasty protocol as a means to dramatically decrease the symptomatic time course of AC from many months down to several weeks. Additionally, this study supports the use of ketorolac as a component of the injection.

Acknowledgments: Thank you to the faculty and staff at UHS orthopedics and physical therapy for their support and to the patients for allowing this study to be possible.

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STUDY TYPE:

Comparison of Patient-reported Outcomes Among Patients Participating in a Lifestyle Medicine Program

Gloria Coden, MD

All Other Authors: Devyani Hunt, MD and Abby Cheng, MD

Affiliation: Washington University in St. Louis School of Medicine, St. Louis, MO.

Purpose: It is unclear how to optimally measure musculoskeletal patients’ described benefits from participating in a lifestyle medicine program. We compared patients’ changes on Patient-Reported Outcomes Measurement Information System (PROMIS) measures to their global ratings of change in function and pain.

Methods and Study Design: We retrospectively reviewed patients who participated in an interprofessional lifestyle medicine program for chronic musculoskeletal pain. Patients completed PROMIS Physical Function and Pain Interference measures at baseline and program completion. They reported percent improvement in function and pain at program completion. Pearson correlation coefficients were calculated.

Results: Among 60 patients (mean (SD) age 55 (13) years, 49 (92%) female, mean (SD) participation duration 196 (126) days), 32 (53%) patients reported at least 50% perceived improvement in function and 32 (53%) reported at least 50% improvement in pain by program completion. Percent improvement in function did not correlate with changes in PROMIS Physical Function scores (r = 0.22, P = 0.09), and percent improvement in pain did not correlate with changes in PROMIS Pain Interference scores (r = −0.11, P = 0.39). Across all quartiles of global ratings of change in function and pain, mean PROMIS score improvements approximated or were less than previously published minimal clinically important differences (maximum mean (SD) PROMIS Physical Function improvement: 2.3 (3.3) points for patients reporting 75–100% functional improvement (n = 14); maximum mean (SD) PROMIS Pain Interference improvement: −3.0 (4.7) points for patients reporting 50–75% pain improvement (n = 20)).

Conclusions: Among patients who participated in an in an interprofessional lifestyle medicine program for chronic musculoskeletal pain, changes in PROMIS Physical Function and Pain Interference scores did not correlate with global ratings of change in function and pain, respectively. PROMIS score improvements were generally more modest than global ratings of improvement.

Significance: PROMIS physical health measures may underestimate musculoskeletal patients’ functional and pain-related improvements from participating in a lifestyle medicine program. Further research is needed to identify ideal quantitative outcome measures.

Acknowledgments: The authors thank Adriana Martin and the WashU Living Well Center clinical team for their contributions to data acquisition.

TOPIC: Other

Acute Effects of Oral Cannabidiol (CBD) on Maximal Aerobic Capacity (VO2 Max) and Time to Exhaustion in Healthy Active Adults

Brendon Ross, DO, MS

All Other Authors: Karla Hanson, PhD

Affiliation: University of Chicago, Chicago, IL.

Purpose: The purpose of this study was to evaluate the acute effects of Cannabidiol (CBD) versus placebo on maximal aerobic capacity (VO2 Max) and time to exhaustion in healthy active adults.

Methods and Study Design: Fifteen subjects performed a maximal treadmill test to exhaustion with gas exchange as part of a randomized, double-blind crossover design. All subjects completed a supplement (CBD Isolate: 150 mg) and placebo (PLA) condition separated by minimum of 7 days. VO2 max (mL/kg/min), time to exhaustion (s), time to ventilatory anaerobic threshold (VAT (s), RER = 1.0) were recorded for analysis.

Results: Fifteen recreationally active males and females (males = 10, females = 5; age = 28.53 ± 8.99 years; height = 67.6 ± 4.26 inches; weight = 194.25 ± 39.30 pounds) completed this study. There were no significant differences observed between CBD and PLA in VO2max (ml/kg/min) (CBD (49.14 ± 8.62), PLA (49.41 ± 8.02), P = 0.65); Time to VAT (s) (CBD (555.2 ± 69.82 seconds), PLA (539.67 ± 91.42 seconds), P = 0.49), and Heart Rate at VAT (bpm) (CBD (175.13 ± 15.8), PLA (172.2 ± 13.37), P = 0.22). While there was a trend toward reaching time to exhaustion earlier following ingestion of CBD (Time to Exhaustion (s) (CBD (695.4 ± 101.89), PLA (710.93 ± 89.03), P = 0.12)), this is not significant.

Conclusions: These novel data suggest that CBD has no effect on VO2 Max or time to exhaustion in a general population of active adults. While there is a trend toward reaching time to exhaustion earlier following ingestion of CBD isolate, this is not significant.

Significance: This is currently the largest study evaluating the acute effects of CBD on VO2 Max and TTE in healthy active adults. With rising CBD use for pain control, anxiety, and sleep, these results help clarify potential effects of CBD on aerobic performance.

Acknowledgments: Immense thanks to Concordia University Chicago, Exercise & Sports Science Laboratory.