TOPIC: Concussion
STUDY TYPE: Cohort
Association of Physical Activity and Mood Symptoms in Adolescents With Concussion
Julie Wilson, MD, FAMSSM
All Other Authors: Mathew Wingerson, MS, Katherine Smulligan, PT, PhD, Joshua Kniss, PT, DPT, Catherine Donahue, ATC, PhD, and David Howell, PhD
Affiliation: Children’s Hospital Colorado/University of Colorado School of Medicine, Aurora, Colorado.
Purpose: Physical activity (PA), an important modifier of mental health in adolescents, facilitates faster concussion recovery. Yet, the optimal PA dose for mental health in concussion recovery is not known. We evaluated the association of PA with mood symptoms among adolescents recovering from concussion.
Methods and Study Design: Adolescents within 21 days of concussion wore a wrist-worn actigraphy device to track PA (steps/day). After concussion symptom resolution, participants rated depressive and anxiety symptoms (PROMIS Pediatric Global v.1.1, anxiety/depressive symptom sub-scales). We compared PA between those who did (T score ≥55 in either domain) and did not endorse anxiety and/or depressive symptoms.
Results: We included 84 adolescents with concussion (initial assessment: 10.2 ± 4.2 days post-injury) and analyzed PA recorded in the first 2 weeks after initial assessment. N = 15 (18%) endorsed anxiety or depressive symptoms at follow-up assessment (47.8 ± 19.5 days post-injury). Those who endorsed anxiety and/or depressive symptoms at follow-up had greater initial symptom burden (61.5 ± 25.7 vs. 43.2 ± 23.6; P = 0.009), a higher proportion of female participants (87% vs. 54%; P = 0.02), and a higher proportion with pre-injury history of depression (40% vs. 14%; P = 0.03). Those who reported anxiety and/or depressive symptoms at follow-up took significantly fewer steps/day in the monitoring period than those who did not, with a medium effect size (5761 ± 1366 vs. 7614 ± 2534; P = 0.04, Cohen’s d = 0.77). After adjusting for pre-specified covariates of initial symptom burden, sex, age, and pre-injury mental health diagnosis, PA volume was not significantly associated with the presence of subsequent anxiety and/or depressive symptoms (adjusted odds ratio 0.78, 95% confidence interval 0.52, 1.18, P = 0.24).
Conclusions: Adolescents who endorsed anxiety or depressive symptoms after concussion symptom resolution recorded lower PA levels during recovery. However, after multi-variable analysis, PA during recovery was not significantly associated with presence of anxiety or depressive symptoms. Further research may investigate whether an individualized PA intervention in those with mood symptoms following concussion is beneficial.
Significance: While PA is an important factor in concussion recovery, the relationship of PA with mental health outcomes after concussion appears complex. The contribution of PA dose (intensity, frequency, duration) should be further investigated in this context.
Acknowledgements: Funding sources: Tai Foundation, Eunice Kennedy Shriver National Institute of Child Health & Human Development (R01HD108133).
TOPIC: Concussion
STUDY TYPE: Case-Control
How Accurate is the M-BESS for the Acute Diagnosis of Concussion?
Ian Benjamin, MD
All Other Authors: Bridget Whelan, MPH, Katherine Wainwright, MD, Heather Elkinton, MS, Gabrielle Garruppo, MHS, Marissa Holliday, Doug Aukerman, MD, Calvin Hwang, MD, and Calvin Hwang, MD
Affiliation: University of Washington, Seattle, WA.
Purpose: The purpose of this study was to determine the diagnostic utility of the modified-Balance Error Scoring System (m-BESS) in acute concussion.
Methods and Study Design: NCAA Division I college athletes from 4 institutions across multiple sports completed baseline testing in the m-BESS. When an athlete presented acutely with suspected concussion the tests were repeated. If a concussion was diagnosed, a control was identified to test, matched on comorbid conditions, gender, team, season, and baseline scores.
Results: Baseline and post-injury data were collected on 105 concussed and 105 matched control athletes. Athletes were predominantly male (n = 112, 53%), with the most concussions amongst football (40, 38%), women’s volleyball (15, 14%), women’s soccer (8, 8%), and softball (6, 6%). The test-retest reliability was 0.48 (95% CI: 0.26–0.57, P
Conclusions: In this diverse cohort of college athletes with sport-related concussion, the m-BESS had poor predictive ability with an AUC of 0.65. The specificity of the m-BESS is very high with 4 or greater errors (90%), however only just over a quarter (27%) of athletes with concussion will have this finding.
Significance: Balance may be affected in athletes with concussion. Other measures of balance should be explored to increase diagnostic accuracy. Better understanding of the psychometric properties of the m-BESS may lead to improved test interpretation.
Acknowledgements: We would like to acknowledge University of Washington alumni Jack and Luellen Cherneski for their support, the hard work of the athletic trainers for their collection of this data, and the student-athletes who participated in the study.
TOPIC: Concussion
STUDY TYPE: Other
Racial and Ethnic Disparities in ED Utilization and Diagnosis for Pediatric Sports-Related Head Injuries from 2009 to 2023
Howard Nelson-Williams, MD, MPH
All Other Authors: Oluwatobi Lasisi, MD, Elizabeth Ordor, MD, Sarah Omer, MD, and Chinemere Ekezie, MD
Affiliation: Howard University Hospital, Washington DC.
Purpose: To assess racial and ethnic differences in Emergency Department (ED) utilization and diagnosis for children aged 7–18 years with sports-related head injuries.
Methods and Study Design: Retrospective, cross-sectional analysis of population-weighted ED visits from 2009 to 2023 using the National Electronic Surveillance System data for children aged 7–18 years with a sports-related injury. We compared the probability of an ED visit being for head injury or diagnosed as a concussion, by race or ethnicity, and adjusted for age, gender, sports, year and location where injury occurred.
Results: We identified 14,270,522 population-weighted ED visits for paediatric sports-related injuries, of which 2,088,453 were head injuries and 901,370 were diagnosed as concussions. Black children were significantly less likely than non-Hispanic white children to have their ED visit be for head injury (Odds Ratio (OR) 0.73, 95% CI 0.66–0.81) or concussion (OR 0.63, 95% CI 0.54–0.73). Among children that presented to the ED with a head injury, black children were significantly less likely than non-Hispanic white children to be diagnosed with concussion (OR 0.74, 95% CI 0.63–0.87).
Conclusions: Racial differences continue to be demonstrated in the utilization of EDs for sports-related head injuries and in the diagnosis of concussion. Further study is needed to elucidate the factors contributing to these differences and ensure the highest quality of care is provided for all brain injured athletes, regardless of race or ethnicity.
Significance: Potential racial bias may be resulting in the under-diagnosis of concussion in black relative to non-Hispanic white athletes, which may have serious implications for post-injury care for pediatric sports-related injury and appropriate return to play.
Acknowledgements: The leadership of the Howard University Hospital Department of Community and Family Medicine for their support of this study.
TOPIC: Epidemiology
STUDY TYPE: Cohort
Pre-competition Body Composition & Final Weight Class for MN State High School Wrestling Qualifiers, 2003–2023
Eric Twohey, MD
All Other Authors: Andrew Jagim, PhD, William Roberts, MD, and Mark Berg, MD
Affiliation: Mayo Clinic, Rochester, MN.
Purpose: The growth of girl’s wrestling has brought up concern over the body fat percentages used in the mandated pre-competition body composition analysis in high school wrestling. This study examines trends in high school wrestlers’ body fat percentage, weight classes, and seasonal weight loss since 2003.
Methods and Study Design: This retrospective study (2003–2023), exempted by the University of Minnesota IRB (STUDY00023325), analyzed de-identified data on preseason body fat, certified weight, and State competition weight classes for non-heavyweight wrestlers. Skinfold measurements by the same examiner ensured consistency, with analyses in SPSS v26.
Results: 12,144 non-heavyweight wrestlers qualified for the MN State High School League wrestling tournament from 2003 to 2023. Our sample included 91 male qualifiers. 48 (52.7%; C.I. 42.5%–63%) of these wrestlers competed at their minimum weight class (MWC) at the state competition, while 43 competed in 1–2 classes above their MWC. 36 (39.6%) potentially gained weight during the season, while 38 (41.8%) lost 0–4.5% of their body weight between pre-season weight certification and state competition weigh-ins. One wrestler (1.1%) lost 16.5–18% of his body weight, and 2 (3.3%) lost 7.5–9%. Body fat percentage correlated with certification weight (r = 0.721; P P = 0.003). Average pre-competition BF% decreased by 0.23% annually since 2003. 82 of the 91 (90.1%) wrestlers would have still been eligible to compete in their weight class had a minimum body fat percentage of 10% been used instead of the currently established 7%.
Conclusions: A small fraction of state entrants would have been affected by a higher minimum BF%. Nearly half competed in weights above their minimum certification, with significant variation in weight changes from certification to state competition. Over 20 years, trends toward lower preseason BF% and weight fluctuations suggest influences from sports specialization and year-round training, reducing the emphasis on extreme leanness for competitive advantage.
Significance: Raising the minimum BF% would impact few wrestlers and could potentially decrease pressure to engage in harmful weight loss practices. Similar findings have recently been shown in girls. This could open discussions on other health-related policies.
TOPIC: Musculoskeletal
STUDY TYPE: Other
Match Injury Incidence and Risk Factors Among Elite Youth Soccer Athletes
Collin Ellenbecker, MD
All Other Authors: Kristin Haraldsdottir, PhD and Andrew Watson, MD, MS
Affiliation: UW Health, Madison, WI.
Purpose: While injury incidence is higher in matches than training in youth soccer, the risk factors for match injuries in elite youth soccer players are not well-defined. This study aims to identify injury incidence and risk factors during competition in elite youth soccer athletes.
Methods and Study Design: Injuries at 26 Elite Club National League events were recorded by athletic trainers regarding mechanism, type, body part, return-to-play (yes, no), day of event (1–3), and time of year (regular, post-season). Comparisons between groups were made with chi-square tests and associations of injury incidence with age, gender, day of event and time of year wereassessed through Poisson regression models.
Results: Eight hundred six injuries were reported, of which 76% were contact and 76% of injured athletes did not return to play. The most common locations were head (27%) and knee (19%), and types were sprains (32%) and concussions (20%). Males and females did not differ with respect to injury mechanism (contact 79% vs 75%, respectively, P = 0.56) or severity (return to play 23% vs 25%, P = 0.72). Injury incidence was 4.3 per 1000 player-hours overall and similar between males and females (4.1 vs 4.4 per 1,000 player-hours, respectively). Concussion incidence was 0.86 per 1,000 player-hours and similar between males and females (0.84 vs 0.87 per 1,000 player-hours, respectively). In the multivariable model, no significant independent associations were identified between injury incidence and age (incidence rate ratio (IRR) = 0.99 (95% CI 0.94–1.0), P = 0.60), gender (female IRR=0.98 (0.85–1.1), P = 0.83), or day of competition (day 2 IRR = 0.87 (0.73–1.0), P = 0.12; day 3 IRR = 0.87 (0.73–1.0), P = 0.13). Injury incidence was found to be higher during the regular season than the post-season (IRR = 1.57 (1.2–2.0), P = 0.001).
Conclusions: Overall injury and concussion incidence reported here are lower than previous studies of youth soccer match injuries. Among this group of elite youth soccer players, match injury mechanism, severity, overall incidence and concussion incidence was similar between males and females, and injury incidence was not independently associated with age, gender, or later days of events. Injury incidence was lower in the post-season than regular season.
Significance: This represents the initial findings from a data collection framework embedded within a nationwide youth soccer organization. Further research will continue to inform strategies to promote safe and healthy participation in youth soccer events.
TOPIC: Musculoskeletal
STUDY TYPE: Cohort
Can Micro-Doppler Radar Identify NCAA Athletes at Risk For Lower Extremity Musculoskeletal Injury?
Caitlyn Haines, MD
All Other Authors: Bilal Abou Al Ardat, MD, Fauzia Ahmad, PhD, Jannatul Ferdous, Leonard Kishel, MS, and Cayce Onks, DO
Affiliation: Pennsylvania State University College of Medicine, Hershey, PA.
Purpose: Musculoskeletal injuries (MSKI) cause significant morbidity and cost. Absent from care is a validated risk assessment tool. We aimed to identify collegiate athletes who are at higher risk for sustaining MSKI using micro-Doppler radar.
Methods and Study Design: This is an IRB approved prospective observational cohort study of NCAA athletes. Athletes performed a series of 5 movements in front of the micro-Doppler radar and data was collected in the form of a micro-Doppler signature (MDS). MDS were analyzed to identify those at risk for MSKI from baseline data prior to their injury.
Results: We collected data from 113 collegiate athletes from 2 colleges. Of these, 79 (69.9%) athletes were male, 34 (30.0%) were female. The mean age of participants was 19.76. Athletes included in this study spanned a variety of sports including: men’s soccer (20.0%), men’s football (15.9%), men’s baseball (12.3%), men’s cross country (9.7%), women’s soccer (8.8%), and women’s volleyball (7.9%). Other sports included were: track & field, basketball, field hockey, tennis, and softball. Multilinear discriminant analysis-based features in a nearest neighbor classifier were used to classify the data. The classifier was able to accurately identify injured athletes when compared with uninjured athletes with 83% accuracy when the training data was included. This accuracy slightly decreased to 73% accuracy when training data was excluded.
Conclusions: This study demonstrates that MDS can be used to identify those at risk for lower extremity MSKI. Our results show MDS predict the injured vs. uninjured athletes with 83% accuracy based on data collected at their pre-participation physicals. This finding is significant as we can prospectively target high risk groups with limited preventative resources. Future research will aim to identify those at risk for specific injuries such as ACL injuries.
Significance: To our knowledge this is the first study looking at the use of micro-Doppler radar technology for injury risk prediction. The ability to identify athletes at risk for MSKI prior to participation can guide targeted preventative intervention.
Acknowledgements: This work was supported by the Department of Defense through the FY21, Peer Reviewed Orthopaedic Research Program under Award No. W81XWH2210684. Opinions, interpretations, conclusions and recommendations are those of the author and are not necessarily endorsed by the Department of Defense.
TOPIC: Musculoskeletal
STUDY TYPE: Other
Performance of Clinical Exam Maneuvers for Diagnosing Gluteal Tendinopathy
Kevin Nasre-Esfahani, DO, MS
All Other Authors: Daniel Herman, MD
Affiliation: UC Davis Health, Sacramento, CA.
Purpose: To evaluate Single Leg Stance (SLS), Flexion/Abduction/External Rotation (FABER), Flexion/Adduction/External Rotation (FADER), Side Adduction (ADD), and ADD and FADER with resistance (ADD-R and FADER-R) in differentiating gluteal tendinopathy (GT) from non-gluteal tendinopathy (NGT) hip pain.
Methods and Study Design: Patients with any hip pain and a positive lidocaine response (≥80% improvement) at the site of clinical diagnosis were included in this chart review. Sensitivity (SN), specificity (SP), PPV, and NPV were calculated for lateral hip pain response and for any hip area pain response. χ2 and t-tests were used to assess for demographic and imaging differences between the groups (alpha = 0.05).
Results: Sixty-eight cases in 60 patients (GT: M = 8, F = 21, Age = 64.9 ± 10.4 years, BMI = 28.3 ± 5.2 kg/m2; NGT: M = 5, F = 24, Age = 62.4 ± 14.6 years, BMI = 28.7 ± 6.7 kg/m2) were included. Age, BMI, Tonnis hip osteoarthritis grade, and presence of gluteal calcification were not different between the groups (P > 0.05 for all comparisons). When using “lateral pain” as the response, the active tests FADER-R (SN = 91.7%, SP = 96.9%, PPV = 97.1%, NPV = 91.2%), SLS (SN = 72.2%, SP = 93.8%, PPV = 92.9%, NPV = 75.0%), and ADD-R (SN = 63.9%, SP = 96.9%, PPV = 70.5%, NPV = 95.8%) generally demonstrated better overall metrics compared to passive tests FABER (SN = 55.6%, SP = 90.6%, PPV = 87.0%, NPV = 64.4%), FADER (SN = 80.6%, SP = 96.9%, PPV = 96.7%, NPV = 81.6%), and ADD (SN = 19.4%, SP = 100%, PPV = 100%, NPV = 52.5%). Specificity decreased without corresponding increase in sensitivity when using “any hip pain” as the response, most notably for FABER (90.6% vs. 21.9%, respectively). Male patients typically demonstrated higher test sensitivity results, particularly for FADER (M = 100% vs. F = 73.1%), ADD-R (M = 80.0% vs. F = 42.3%), and SLS (M = 90.0% vs. F = 65.4%).
Conclusions: Tests with active muscle engagement have strong diagnostic performance for differentiating gluteal tendinopathy from other causes of hip pain. There may be a differential response by sex, but this is based on limited numbers. The sensitivities and NP vs. in the current study are generally much higher compared to prior studies that use MRI findings as the reference standard, emphasizing the influence of different reference standard approaches.
Significance: These results validate these tests as effective clinical tools for diagnosing gluteal tendinopathy, particularly those with active muscle engagement. Clinicians should be precise regarding the location of pain response when employing these tests.
TOPIC: NCAA
STUDY TYPE: Cohort
Correlation Between Division I Collegiate Athletes’ Preseason Mental Health and Prospective Injury Rates
Connie Oh, MD
All Other Authors: Calvin J. Duffaut, MD, Emily M. Miller, MD, Sessen Dudek, MD, and Aurelia Nattiv, MD
Affiliation: UCLA, Westwood, CA.
Purpose: This study aims to evaluate the association between mental health concerns and prospective injury rates among Division I male and female collegiate athletes across various sports using the Counseling Center Assessment of Psychological Symptoms-62 (CCAPS-62).
Methods and Study Design: Division I athletes were recruited during the 2024–2025 season. Preseason depression, generalized anxiety, social anxiety, academic distress, eating concerns, family distress, hostility, and substance use were measured using CCAPS-62. Injuries were recorded by athletic trainers. Injury rates were calculated by dividing the injuries by athletic exposures.
Results: One hundred thirty student athletes (103 female, 27 male) have enrolled with 16 injuries reported to date. At preseason assessment, 12.3% (16) athletes reported depression, 16.1% (21) anxiety, 20% (26) social anxiety, 17.6% (23) academic distress, 20.8% (27) eating disorders, 7.7% (10) hostility, 14.6% (19) family distress, and 7.7% (10) substance use. Athletes with preseason substance use had a significantly higher injury rate compared to those without substance use (RR = 4.31; 95% CI, 1.01–14.22, P = 0.048). Injured athletes had 2.41 times greater (P = 0.001) number of mental health concerns than non-injured athletes. Athletes with depression (RR = 1.08; 95% CI 0.31–3.77, P = 1.0), anxiety (RR = 1.87; 95% CI 0.68–5.15, P = 0.342), social anxiety (RR = 2.23; 95% CI 0.81–6.15, P = 0.205), academic distress (RR = 1.95; 95% CI 0.59–5.75, P = 0.296), eating disorder (RR = 1.65, 95% CI = 0.45–5.16, P = 0.502), hostility (RR = 1.81; 95% CI 0.516–6.35, P = 0.537), and family distress (RR = 2.49; 95% CI 0.89–7.0, P = 0.153) did not have significantly higher injury rate compared to those without respective mental health concerns.
Conclusions: While mental health concerns such as depression, anxiety, and social anxiety were prevalent among student-athletes, only substance use was significantly associated with a higher injury rate. Injured athletes had a greater overall burden of mental health issues, but most individual mental health conditions did not predict injury risk.
Significance: These findings highlight the importance of identifying substance use and increased number of mental health concerns in athletes for injury prevention while underscoring the complex relationship between mental health and athletic performance.
Acknowledgements: We gratefully acknowledge the UCLA Advanced Research Computing Statistics team, and UCLA Athletic Trainers for their support of the research.
TOPIC: NCAA
STUDY TYPE: Cohort
The Association Between Psychological Resilience and Mental Health Disorders Among Athletes
Ruth Amaku, MPH
All Other Authors: Vicki Nelson, MD and Franklin Sease, MD
Affiliation: University of South Carolina School of Medicine Greenville, Greenville, SC.
Purpose: This study evaluates physiological resilience and its association with psychiatric disorders that can impact concentration, including anxiety, depression, and ADHD among collegiate athletes.
Methods and Study Design: Data was collected during pre-season with NCAA Division II collegiate athletes (n = 1559) from 2021 to 2023. Physiological resilience was obtained from self-reported responses to the Brief Resilience Screen. Anxiety and depression were evaluated using the GAD-7 and PHQ-9. ADHD was evaluated using the ASRS. Associations were assessed with Pearson Correlation Coefficient.
Results: Of the 1559 athletes, 71 (5%) screened positive for anxiety, 37 (4%) for depression, and 148 (9%) for ADHD. Athletes with positive screens for these conditions had significantly lower BRS scores compared to their peers (Anxiety: 3.15 vs. 3.88, Depression: 3.08 vs. 3.89, ADHD: 3.52 vs. 3.88). Strong negative correlations were observed between resilience (BRS) and psychiatric conditions: anxiety (−0.38 4 × 10−55), depression (−0.29 × 10−31), and ADHD (−0.18 × 10−13) (all P
Conclusions: This research highlights how psychological disorders impairing concentration can reduce resilience in collegiate athletes, hindering their ability to perform at peak potential. Focusing on efforts that promote resilience may prove beneficial to maintain mental wellness.
Significance: As mental health gains attention in athletics, this study helps provide context to understanding its relationship with resilience, particularly among collegiate athletes managing psychiatric disorders that affect focus and ultimately performance.
Acknowledgements: The author extends gratitude to Dr. Vicki Nelson for her invaluable insights and support with data analysis.
TOPIC: Other
STUDY TYPE: Other
Differences in Diagnostic Imaging for Spondylolysis Amongst Athletes of Varying Socioeconomic Status
Emily Sweeney, MD
All Other Authors: Andrea Zuzarte, BA, Madison Brna, BS, Sarah Petersen, BA, Luke Enthoven, BS, Peter Dzaugis, MD, and David Howell, PhD
Affiliation: University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO.
Purpose: Spondylolysis commonly occurs in athletes who participate in extension-based sports (EBS), some of which have high financial costs (e.g., gymnastics). We sought to identify if participation in EBS and socioeconomic status (SES) are associated with diagnosis of spondylolysis.
Methods and Study Design: A retrospective chart review was performed in adolescent athletes presenting to a sports medicine clinic for low back pain (LBP). Child Opportunity Index (COI), a zip-code based marker, was used to approximate SES. The distributions of COI and sport type (EBS vs. others) were compared for those with and without spondylolysis.
Results: 1,093 patients (mean age = 14.5, SD = 1.9 years of age) were seen for LBP. Higher COI was significantly associated with having X-ray ordered (P = 0.006). COI was also higher for patients who had an MRI ordered than those who did not. Most patients (92%) reported being active in sport, and approximately half (N = 525, 48%) reported participating in EBS (cheer, dive, football, gymnastics, baseball, wrestling, volleyball, dance, tumbling, and Poms). Participants in EBS had greater odds of getting an X-ray (odds ratio (OR) = 2.06, P = 0.02) and significantly greater odds of getting an MRI (OR = 1.70, P P
Conclusions: Patients of higher COI were more likely to receive diagnostic imaging, which supports current evidence that patients with fewer financial resources experience different, and often inferior, levels of care. Patients in EBS received more diagnostic imaging, suggesting that clinicians have a lower threshold for ordering imaging in patients with a convincing sport history.
Significance: Utilizing history elements like sport participation may help safeguard against disparities in imaging practices. Advocating for equitable care for adolescents with suspected spondylolysis can help improve diagnosis.
TOPIC: Other
STUDY TYPE: Cohort
High School Sports Participation and Treatment for Substance Misuse in Early Adulthood
Agatha Ambrozy, DO
All Other Authors: Jamie Gajos, PhD, Irfan Asif, MD, and Ian McKeag, MD, MS
Affiliation: UAB-Cahaba Sports Medicine Fellowship Birmingham, AL.
Purpose: This study examines the relationship between high school sports participation and receiving treatment for substance misuse in early adulthood through analysis of the Future of Families and Child Wellbeing Study (FFCWS), a nationally representative birth cohort with socioeconomic vulnerabilities.
Methods and Study Design: This secondary analysis used de-identified data from the FFCWS, which followed 4,898 children born between 1998 and 2000 in large U.S. cities. The study oversampled unmarried births, creating a diverse cohort with significant Black, Hispanic, and low-income representation. Wave 7 (N = 2,599; age 22) assessed HS sports participation and substance use counseling. Data was analyzed with logistic regression.
Results: Among these young adults (52% female, 48% non-White, 80% with health insurance, mean BMI = 27.6), 39% reported a mental health diagnosis. Less than 3% reported receiving treatment for alcohol or drug use, 45% participated in sports several times weekly, and 38% reported no sports participation. Greater sports involvement was associated with higher odds of substance use treatment (OR = 1.19, CI = 1.02–1.37). A mental health diagnosis significantly increased odds of treatment (OR = 5.67, CI = 3.11–10.31), while higher education decreased odds (OR = 0.68, CI = 0.48–0.96).
Conclusions: Socioeconomically vulnerable individuals who frequently participated in sports had 19% higher odds of receiving treatment for substance misuse in early adulthood. Mental health diagnoses increased this likelihood, while higher education was protective. These findings underscore multi-faceted relationships between sports, mental health, and substance use treatment.
Significance: This study highlights the complex role of HS sports participation-often considered protective-in substance use treatment. Findings from a diverse, national cohort stress the importance of research on athlete wellbeing and long-term mental health.
Acknowledgements: The author would like to express sincere gratitude to Dr. Gajos for their invaluable guidance and mentorship throughout this research project. Special thanks to Dr. Asif and Dr. McKeag for sharing their time and insights.
TOPIC: Other-Nutrition
STUDY TYPE: Survey
Intuitive Eating Scores in NCAA Student-Athletes Using the IES-3
Haley Oosterhouse, MD
All Other Authors: Anthony Luke, MD, MPH
Affiliation: UCSF, San Francisco, CA.
Purpose: Intuitive eating is a framework emphasizing internal cues of hunger and satiety to guide eating habits. This study aims to evaluate normative intuitive eating scores in collegiate athletes using the IES-3 (Intuitive Eating Scale), and the variation of score by gender, sport, school, and division.
Methods and Study Design: This is an anonymous cross-sectional survey of intuitive eating scores in NCAA student-athletes at 3 universities in the San Francisco Area. We analyzed demographic data including gender, school, year in school, and sport, followed by the validated 12-question IES-3, in which higher scores indicate stronger alignment with intuitive eating.
Results: One hundred fifty-two survey responses met inclusion criteria. 39% of respondents were male and 61% were female. 89% were from Division I Universities and 11% were from Division II Universities. Twenty-eight sports teams were represented. Average intuitive eating score was 44.56 out of 60 possible points (CI 43.43–45.60, SD 6.8). There was no significant difference in total IES-3 score between gender, school, division, history of eating disorder, year in school, or history of being told to change weight. However, there were differences in IES-3 sub scores; females had significantly lower scores in Unconditional Permission to Eat than males (P P P
Conclusions: This study provides an example of normative scoring for the IES-3 in NCAA athletes that can be used for interpretation when applied in the clinical setting. Our study demonstrates that total scores are similar across different genders, years, and school divisions, however, can vary in sub scores and by sport. Further studies can assess the application of IES-3 as a nutritional screening tool.
Significance: Prior studies have linked higher IES scores to improved psychological health and protection against eating disorders. The IES-3 can be a tool for providers working with NCAA athletes to help optimize nutrition, psychological health, and performance.
Acknowledgements: Alisha Parker, MS, RDN, LDN, UC Berkeley Athletics Performance Nutrition. Ryan Cobb, MS, ATC, Senior Associate Athletic Director. Megan Agnew, PhD, MPH, Research Methodologist, AMSSM Collaborative Research Network. Nicolas Hatamiya, DO, FAAFP, UCSF Primary Care Sports Medicine Fellowship Program Director.
TOPIC: Pediatrics
STUDY TYPE: Cohort
Trends in Legal Performance Enhancing Substance (PES) Use in Young Athletes from 2013 to 2024
Michael McNaughton, DO
All Other Authors: Danielle Jango, MS, Laura Berbert, MS, William Meehan III, MD, and Andrea Stracciolini, MD
Affiliation: Brown Health at Hasbro Children’s, Department of Pediatrics, Providence, RI.
Purpose: To investigate trends of reported legal PES use in young athletes over the last decade (2013–2024). Our second aim was to report trends in legal PES use among young athletes before and after publication and availability of pertinent position statements and educational initiatives in 2016.
Methods and Study Design: Our study was an observational cohort study of prospectively collected data from athletes undergoing an injury prevention evaluation (IPE) at a tertiary-level pediatric hospital-affiliated sports injury prevention center. Surveys from 2020 and 2021 (n = 4) were excluded due to decreased availability secondary to the COVID-19 pandemic. Logistic regression models were used for statistical analyses.
Results: Of the 1021 athletes, the median age was 14 (range 6–25 years), 55.7% were female, 76.5% were white, and 71.2% were from middle to upper income households. 15.4% of athletes used legal PES during this time frame (157/1021, 95% CI, 13.3–17.7%). 11.9% used caffeine (121/1021), 2.8% used creatine (29/1021), and 3.4% used nutritional weight gain supplements (35/1021). 54.8% (86/157) of athletes who used legal PES were male. Overall legal PES use was not statistically significantly different over the course of the study. Age group and gender differences in legal PES use were observed. Males were 1.66 (95% CI: 1.19, 2.32, P = 0.003) times more likely to use legal PES compared to females after controlling for the year of the survey. High-school (OR 3.58, 95% CI: 2.42, 5.38, P P
Conclusions: Legal PES use in the young athlete population, seen more predominantly in males and older athletes over the past decade, is not decreasing despite relevant position statements and educational initiatives from 2016.
Significance: Continued interventions, including policy changes, position statements, and educational initiatives regarding the efficacy and safety of legal PES use in young athletes is timely and warranted among the pediatric and sports medicine communities.
TOPIC: REGENMED—Orthobiologics
STUDY TYPE: Other
The Use of Trend Statements in Sports Medicine Platelet Rich Plasma Literature
Connor Richmond, DO
All Other Authors: Nirmal Maxwell, DO, Madison Burns, BS, GianMarco Douglas, BS, and Allison Schroeder, MD
Affiliation: Case Western University School of Medicine/Metrohealth, Cleveland, Ohio.
Purpose: Using “trend” statements to describe non-statistically significant results can lead readers to draw misleading conclusions. This study investigated the frequency and context of trend statements in relation to non-significant findings of platelet-rich plasma (PRP) within the field of sports medicine.
Methods and Study Design: Original research articles examining the use of platelet-rich plasma for osteoarthritis or tendinopathy, published between January 2020 and September 2024, were searched on PubMed. Instances where non-statistically significant results were labeled as a “trend” or included trend-related statements were examined to evaluate their usage and context within the articles.
Results: A total of 1,968 articles were reviewed, comprising 473 on tendinopathy and 1,495 on osteoarthritis. Of these, 242 met the inclusion criteria for analysis: 37 in 2020, 53 in 2021, 58 in both 2022 and 2023, and 36 in 2024. Trend statements were found in 44 articles (18.2%) to describe non-significant data. Seven in 2020, 11 in both 2021 and 2022 (20.8% and 19%, respectively), 9 in 2023 (15.5%), and 6 in 2024 (16.7%). Among these, 31 articles (70.5%) reported an associated P-value, while 13 (29.5%) did not. Additionally, 29 articles (65.9%) used trend statements for multiple findings, whereas 15 (34.1%) referred to a single finding. Of the reported P-values, 13 (29.5%) were between 0.05 and 0.10, 1 (2.3%) between 0.15 and 0.20, and 17 (38.6%) were greater than 0.20. No article provided a formal definition of a trend, and 15 articles (34.1%) included a trend statement while acknowledging the lack of statistical significance. Thirteen articles (29.5%) made conclusive statements about the statistical trend, with 16 (36.4%) including both an acknowledgement and conclusive statement.
Conclusions: Trend statements are frequently used to characterize non-statistically significant findings in the PRP literature, which may lead readers to draw incorrect statistical conclusions. Importantly, many trend statements were employed to describe multiple findings, often without an associated P-value. To address this issue, it is crucial to implement measures that clearly define trends in the methods or statistical analysis sections of manuscripts.
Significance: This study is the first to investigate the use of trend statements in PRP literature. It emphasizes the importance for clinicians to recognize bias and subjectivity when differentiating between clinically and statistically significant results.
TOPIC: Running
STUDY TYPE: Survey
The Association of Carbon-plated Shoes With Running-related Injuries During New York City Marathon Training: An RHC Study
McKenna Campbell-Potter, MD
All Other Authors: Todd McGrath, MD, Samantha Stuek, MD, Mark Fontana, PhD, Stephanie Kliethermes, PhD, Adam Tenforde, MD, and Brett Toresdahl, MD
Affiliation: Hospital for Special Surgery, New York, NY.
Purpose: Given the increased use of carbon-plated shoes by elite and recreational runners, we examined the association of carbon-plated shoes with running-related injury (RRI) sustained by runners in the Runner Health Consortium (RHC) while training for the 2024 New York City (NYC) Marathon.
Methods and Study Design: Data from the RHC included adult runners training for the 2024 NYC Marathon. Biweekly surveys tracked shoe type and RRI. A multivariable logistic regression controlling for age, gender, BMI, baseline mileage, and goal finish time evaluated the association of RRI with prior marathon experience and carbon-plated shoe use, as measured by most frequent response on a 5-point scale (1 = never, 5 = always).
Results: A total of 661 runners participated, mean age of 38.8 (SD 11.4), 63% women, and 33% first-time marathon runners. Carbon-plated shoes were used very often or always by 9.1% of runners and never by 56.2% of runners. Overall, 40.7% of the cohort reported RRI, including 21.0% who sustained RRI in the lower leg, ankle, and foot. Incidence of RRI was highest in runners who did not train in carbon-plated shoes (48.9%) and lowest in runners training always or very often in carbon-plated shoes (31.0%; χ2 = 17.7, P = 0.001). A multivariable logistic regression revealed an inverse association between carbon-plated shoe usage and all RRI (OR 0.76 for each point on a 5-point Likert for carbon-plated shoe usage, CI 0.63–0.90, P = 0.002) as well as injuries of the leg, ankle, and foot (OR 0.69, CI 0.53–0.89, P = 0.004). Prior marathon experience was associated with reduced RRI in the leg, ankle or foot (OR 0.92, CI 0.87–0.98, P = 0.01).
Conclusions: In this cohort of runners training for the 2024 NYC Marathon, over 40% sustained RRI during training. Use of carbon-plated shoes during training was associated with a lower incidence of RRI although more experienced runners had lower incidence of RRI.
Significance: Experienced marathon runners were less likely to sustain RRI and carbon-plated shoes were not associated with higher incidence of RRI. The impact of carbon-plated shoe use on RRI should be assessed through a randomized controlled trial.
Acknowledgements: The authors wish to thank the New York Road Runners for contributing to enrollment for this study. The Runner Health Consortium is funded by an AMSSM CRN Grant.
TOPIC: Training
STUDY TYPE: Other
Paced Breathing Interventions: Impacts on Anxiety and Psychomotor Performance With Influence on Athletic Performance
Mark Carrasco, MD
All Other Authors: Chris Grijalba, DO, Druss Hays, BS, Christopher M. Janelle, PhD, Ian McKeag, MD, Irfan M. Asif, MD, and Taylor Taylor, PhD
Affiliation: The University of Alabama at Birmingham Sports and Exercise Medicine, Birmingham, Alabama.
Purpose: Excelling under pressure is critical in athletic contexts, where anxiety and psychomotor performance often determine outcomes. Breathing interventions may modulate these factors, but the specific effects of different breathing techniques in high pressure situations remain underexplored.
Methods and Study Design: We conducted a systematic review and meta-analysis of 14 RCTs and quasi-experimental studies examining paced breathing (cue, biofeedback, and yogic paced) interventions on anxiety and psychomotor performance in healthy adults (N = 529, ages 18–60 y/o, mean age = 23.87, SD = 6.68, 37.42 % female). Effect sizes (Cohen’s d) were calculated to evaluate pooled and individual outcomes.
Results: Paced breathing reduced anxiety (10 studies; small effect, d = −0.23; P > 0.05; CI = −0.86 to 0.41) and improved psychomotor performance (4 studies; medium effect, d = 0.54; P P P P P
Conclusions: Paced breathing interventions reduced anxiety and improved psychomotor performance in healthy adults. Cue paced and biofeedback paced breathing showed strong effects on anxiety, while yogic and cue paced breathing positively influenced performance. Findings highlight their relevance for stress management in performance contexts.
Significance: This study highlights the role of paced breathing in anxiety reduction and performance enhancement. Future research should evaluate its effectiveness in high stakes settings, where precise psychomotor skills and anxiety regulation are critical.
TOPIC: Training
STUDY TYPE: RCT
Power-up Trial Performance Output With Haptics Evaluating Athlete Response and Unrealized Potential
Jason Taporco, MD, MPH
All Other Authors: Alex Adelman, MD, Ryan Donovan-Schager, John Konhilas, PhD, Peter Hurwitz, PhD, and Mark Sakr, DO
Affiliation: University of Arizona, Tucson, AZ.
Purpose: The purpose of this study is to evaluate athletic performance in NCAA Division 1 varsity athletes after use of a drug- free, non-invasive patch (VICTORY Patch; The Super Patch Company Inc.) to determine if new vibrotactile technology impacts complex athletic function.
Methods and Study Design: This double-blinded, randomized, crossover study involved 70 athletes who wore either a VICTORY or placebo patch on the dominant thigh across 2 testing sessions. Each session included force plate testing for countermovement jumping (CMJ), knee extension (KE), and knee flexion (KF), followed by patch placement. Testing was repeated 7–10 days later with the alternative patch.
Results: For CMJ, athletes were measured in both average and maximum power (watts) and then averaged by body weight to allow consistency amongst sport and body types. Athletes exhibited an increase in maximum force (0.02 W/kg) and decrease in average force (−0.01 W/kg) when utilizing the placebo patch, and decrease in maximum and average force (−0.43 W/kg and −0.07 W/kg) when utilizing the VICTORY patch. This difference in average (P = 0.92) and maximum (P = 0.52) power output by body weight was not statistically significant by 2-tailed, paired t-test. For KE and KF, athletes were measured in both average and maximum force (Newtons) in individual and combined force. With both patches, athletes exhibited greater average and maximum force. The greatest force increase was noted in KF (25.1 N) when utilizing the VICTORY patch as compared to the placebo patch (10.8 N), which was statistically significant (P = 0.01) by 2-tailed, paired t-test.
Conclusions: Preliminary results for functional movement (CMJ) identified no statistically significant difference amongst baselines, placebo, or VICTORY patch. However, in isolated force production (KE, KF) athletes exhibited generalized increased performance, particularly with KF, which did show statistically significant increased force production when utilizing the VICTORY patch.
Significance: Preliminary results show increased force production in knee extension and flexion with the VICTORY patch but no change in countermovement jumping. Further research is needed to confirm its efficacy and potential benefits for athletic performance.
Acknowledgements: Nicholas McIntee, MA Jaime Fernandez, MS.
TOPIC: Ultrasound
STUDY TYPE: Cohort
Ultrasound-Based Return to Play Protocol Following Muscle Injury
Will Daniels, BA, MS
All Other Authors: Mederic Hall, MD, Yumeng Gao, MS, and Natalie Glass, PhD
Affiliation: Carver College of Medicine, Iowa City, IA.
Purpose: The purpose of this study was to evaluate a new ultrasound-based return to play protocol for thigh muscle injuries in a population of collegiate track & field and soccer athletes at the University of Iowa using recurrent injury rate data from before and after protocol implementation.
Methods and Study Design: Injury recurrence rates from the 2014–2019 seasons were compared to 2019–2024 (pre and post protocol implementation). The 2019–2024 group was also sorted into a protocol-adherent and non-adherent group and analyzed by recurrence rate. To account for within-subject correlation, GEE statistical models were used to calculate odds ratios for each of these comparisons.
Results: A total of 151 injuries were included, 86 in the pre-protocol control group and 65 in the protocol intervention group. The recurrence rate for the control group was 19.8% (17/86) while the protocol-adherent group was 3.3% (1/30). The non-adherent protocol group had a recurrence rate of 20% (7/35). When comparing the protocol-adherent group to the pre-protocol control group for recurrence rate, the odds ratio was 0.13 (95% CI: 0.01–1.15, P = 0.068). The comparison between adherent and non-adherent cases from the protocol group yielded an odds ratio of 0.12 (95% CI: 0.01–1.24, P = 0.072).
Conclusions: Our results showed a decrease in recurrent injury rate from 20% to 3% with adherence to a novel ultrasound-based return to play protocol. However, these findings only reached marginal statistical significance. Given the small sample sizes in the protocol group, it is likely that our study lacked sufficient power to demonstrate a strong statistical difference between groups.
Significance: Our novel ultrasound-based return to play protocol showed promise in reducing recurrent injury rates for thigh muscle injuries in elite athletes. These findings warrant further evaluation with a well-powered prospective experimental design.
Acknowledgements: Thank you to Jon Fravel, Doug West, Dr. Tyler Slayman and Dr. Tim Thomsen for their assistance with data collection and interpretation. Thank you also to Erin Mullins and the CCOM Summer Research Fellowship program for their support of this project.
TOPIC: Ultrasound
STUDY TYPE: Other
Establishing a Protocol for Rapid Assessment of Shoulder Pain (RASP) Using Point-of-Care Ultrasound: A Pilot Study
Alejandro Sanoja, MD
All Other Authors: Sarah Chrabaszcz, MD, Joshua Altman, MD, Gabriel Gomez, DO, LaRae Seemann, MD, Mariah Cruz, DO, Osvaldo Duran-Melendez, MD, De Portu Giuliano, MD, and De Portu Giuliano, MD
Affiliation: University of Florida, Gainesville, FL.
Purpose: This pilot study sought to establish a point-of-care ultrasound (US) protocol to identify clinically relevant anatomy for rapid assessment of the shoulder in the Emergency Department (ED) in order to improve diagnostic accuracy of shoulder pain in the acute setting.
Methods and Study Design: A 6-view US protocol was developed by 2 emergency medicine (EM) faculty who are sports medicine fellowship-trained. Seven first-year EM residents participated in a hands-on training session to learn the protocol. They were tested for immediate (1-hour) and delayed recall (2-months) after the training session. The outcome was image accuracy as determined by US fellowship-trained EM faculty.
Results: The 7 participants performed a total of 14 shoulder ultrasound protocol scans on a healthy volunteer with normal anatomy. Seven were performed at the 1-hour and 2-month post-training sessions, respectively. All residents were able to correctly reproduce accurate images 1 hour after the training session, except for one who did not accurately identify the supraspinatus. Time was not recorded. The residents at 2-months post-training accurately reproduced 21 of 42 views (50%). The biceps tendon view was the most accurate (85.71%), followed by subscapularis (71.42%), acromioclavicular (42.86%), supraspinatus short (42.86%), supraspinatus long (28.57%), and glenohumeral (28.57%). The average time to complete the scan after 2 months post-training was 5 minutes and 40 seconds.
Conclusions: Trainees are capable of learning a focused shoulder US protocol in a short period of time as evidenced by the 1-hour post-training session. Image accuracy for delayed recall decreased, however, suggesting more extensive training is needed to retain and master the protocol as currently formulated.
Significance: The US protocol has promise for focused shoulder examination and potential for implementation in the acute setting. Learners may benefit from more extensive training in shoulder US for practical use in the ED.
Acknowledgements: We would like to thank all emergency residents at the University of Florida who participated in our study as sonographers. We also thank our volunteers for their time in this study. Special thanks to Drs. Marco Elegante and Leslie Connor Nickels for their support and assistance with training sessions.
TOPIC: Ultrasound
STUDY TYPE: Cohort
Feasibility and Reliability of Youth Athlete Splenic Measures Among Differently Trained Physicians
Carrie Johnson, MD, PhD
All Other Authors: Joshua Romero, MD, Tobias Kummer, MD, Neha Raukar, MD, MS, Aidan Mullan, MA, Kristina Colbenson, MD, and Larissa Shiue, MD
Affiliation: Mayo Clinic, Rochester, MN.
Purpose: Establish a baseline splenic measures in youth athletes by demographics and anthropometrics; assess feasibility of splenic ultrasound with portable probes, including exam length and inter-observer reliability between sports medicine (SMP) and ultrasound fellowship-trained (USP) physicians.
Methods and Study Design: All physicians completed an hour training on splenic ultrasound (US). Athletes with prior splenectomy or recent (6 weeks) infectious mononucleosis (IM) were excluded. At pre-participation sports physicals, athletes were placed supine and portable US devices were used. Each athlete was scanned by 1 USP and 1 SMP. The splenic hilum was visible for all measures for standardization.
Results: A total of 52 athletes completed the study (35 male), ranging in ages 11–17. Median spleen length, width, depth, and volume for females was 9.55 cm, 4.41 cm, 8.27 cm, and 194.48 cm3 respectively. For males, the same measures were 11.03 cm, 5.04 cm, 9.12 cm, and 274.31 cm3. Of these, the mean spleen length (P = 0.003), width (P = 0.032), and volume (P = 0.010) were significantly different between males and females. Regarding the anthropometric variables of sex, age, BMI, and BSA, all were positively correlated with spleen volume. In a multivariable linear regression model, sex (P = 0.007), age (P = 0.004), and BSA (P = 0.023) were significant variables in predicting spleen volume. Overall, the SMPs completed the scan in an average of 2.00 minutes. The USPs performed it significantly faster (P
Conclusions: In middle and high school athletes, male spleen size was larger than female spleen size in length, width, and volume (P = 0.003, 0.032, and 0.010, respectively). Even after adjusting for BMI and BSA, sex remained an independent predictor of spleen volume (P = 0.007), as did age (P = 0.004). The study showed high inter-observer reliability for multiple measures. The mean exam completion time differed by 37.8 seconds between groups.
Significance: Return to play guides in athletes after IM are variable, as are individual splenic measures. The short duration of splenic US supports feasibility of incorporating it into pre-participation evaluations, warranting further discussion on its utility.
Acknowledgements: Gratitude to the middle and high school athletes and their parents or guardians who consented to participating in this study.