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Objective: Management of sport-related and recreation-related concussions (SRCs) in children and adolescents is challenging as brain maturation affects prognosis. However, impact seizure was removed as a prognosis modifying factor in children and adolescents with SRCs in the 2017 consensus statement on concussion in sport, based mostly on adult literature. Therefore, this study evaluates the association of impact seizure on the recovery in children and adolescents with SRCs. Design: Retrospective matched case–control study. Setting: Tertiary pediatric sports medicine service, from January 1, 2015, to June 30, 2022. Patients: A cohort of 452 patients, aged 7 to 18 years, with new episode of SRC was seen. From this cohort, 396 patients were included in the analysis, including 22 with impact seizures. Controls were generated using the propensity score matching approach. Patients with moderate or severe traumatic brain injury or incomplete treatment were excluded. Independent Variable: Impact seizure during SRC. Main Outcome Measures: Primary outcome was recovery duration in number of days. Results: The median recovery duration was longer in the cases (73 days, interquartile range [IQR] = 38-143 days) as compared with controls (49.5 days, IQR = 30.5-93.5 days). There was no difference in patients with prolonged recovery (ie >28 days) between both groups (OR 1.6, 95% CI, 0.4-6.6, P = 0.505). Conclusions: Impact seizures prolonged the recovery duration in children and adolescents with SRCs and therefore have a potential concussion modifying prognostic role. These findings could help provide evidence-based management principles for children and adolescents with SRCs in subsequent concussion consensus statements. [ABSTRACT FROM AUTHOR]

Objective: To describe shoulder-related injury rates (IRs), types, severity, mechanisms, and risk factors in youth ice hockey players during games and practices. Design: Secondary analysis of data from a 5-year prospective cohort study, Safe-to-Play (2013-2018). Setting: Canadian youth ice hockey. Participants: Overall, 6584 player-seasons (representing 4417 individual players) participated. During this period, 118 shoulder-related games and 12 practice injuries were reported. Assessment of Risk Factors: An exploratory multivariable mixed-effects Poisson regression model examined the risk factors of body checking policy, weight, biological sex, history of injury in the past 12 months, and level of play. Main Outcome Measures: Injury surveillance data were collected from 2013 to 2018. Injury rates with 95% confidence interval (CI) were estimated using Poisson regression. Results: The shoulder IR was 0.35 injuries/1000 game-hours (95% CI, 0.24-0.49). Two-thirds of game injuries (n = 80, 70%) resulted in.8 days of time-loss, and more than one-third (n = 44, 39%) resulted in >8 days of time-loss. An 83% lower rate of shoulder injury was associated with policy prohibiting body checking compared with leagues allowing body checking (incidence rate ratio [IRR], 0.17; 95% CI, 0.09-0.33). A higher shoulder IR was observed for those who reported any injury in the last 12-months compared with those with no history (IRR, 2.00; 95% CI, 1.33-3.01). Conclusions: Most shoulder injuries resulted in more than 1 week of time-loss. Risk factors for shoulder injury included participation in a body-checking league and recent history of injury. Further study of prevention strategies specific to the shoulder may merit further consideration in ice hockey. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to analyze changes in physical activity (PA) recommendations after pediatric concussions and examine the associations of patient and injury characteristics with physicians' PA recommendations. Design: Retrospective observational study. Setting: Concussion clinics associated with a pediatric hospital. Patients: Patients aged 10 to 18 years with a concussion diagnosis, presenting to the concussion clinic within 14 days of the injury were included. A total of 4727 pediatric concussions and corresponding 4727 discharge instructions were analyzed. Independent Variables: The independent variables for our study were time, injury characteristics (eg, mechanism and symptom scores), and patient characteristics (eg, demographics and comorbidities). Main Outcome Measures: Physician PA recommendations. Results: From 2012 to 2019, the proportion of physicians recommending light activity at an initial visit increased from 11.1% to 52.6% (P < 0.05) within 1-week postinjury and from 16.9% to 64.0% during the second week postinjury (P < 0.05). A significantly increased odds of recommending “light activity” (odds ratio [OR] = 1.82, 95% confidence interval [CI], 1.39-2.40) and “noncontact PA” (OR = 2.21, 95% CI, 1.28-2.05), compared with “no activity” within 1-week postinjury, was observed in each consecutive year. In addition, higher symptom scores at the initial visit were associated with lower likelihood of recommending “light activity” or “noncontact PA.” Conclusions: Physician recommendation of early, symptom-limited PA after a pediatric concussion has increased since 2012, which mirrors a shift in acute concussion management. Further research assessing how these PA recommendations may facilitate pediatric concussion recovery is warranted. [ABSTRACT FROM AUTHOR]

Objective: Previous research, including high-quality systematic reviews, has found that cervical injury, which often accompanies concussive head injury, can delay recovery from concussion. One pilot randomized controlled trial found that focused cervical assessment and appropriate intervention in children and young adults with persisting postconcussive symptoms (PPCS) improved recovery outcomes. Our sports medicine clinics adopted this approach early (within 2 weeks) in children (aged 10-18 years) after concussion. This study describes our clinical management protocol and compares the recovery trajectories in children after concussion with and without a concomitant cervical injury. Design: Prospective cohort study. Setting: Three university-affiliated outpatient sports medicine clinics from September 2016 to December 2019. Patients: One-hundred thirty-four concussed children with cervical impairment (mean age 14.9 years, 65% male, and 6.2 days since concussion) were compared with 130 concussed children without cervical impairment (mean age 14.9 years, 57% male, and 6.0 days since concussion). Independent Variables: Examination findings related to the cervical spine (range of motion, cervical spasm, and cervical tenderness). Main Outcome Measures: Recovery time (measured in days), concussion symptom burden (Postconcussion Symptom Scale), and incidence of PPCS. Results: Children with cervical impairment reported a higher initial symptom burden; however, there were no differences in recovery time (33.65 [28.20-39.09] days vs 35.98 [27.50-44.45] days, P = 0.651) or incidence of PPCS (40.0% vs 34.3%, P = 0.340). Conclusions: We conclude that within this pediatric population, early identification and management of cervical injuries concomitant with concussion may reduce the risk of delayed recovery. [ABSTRACT FROM AUTHOR]

Objective: To evaluate clinic visits and running-related injury (RRI) characteristics among child and adolescent runners seeking care at an outpatient clinic over a 10-year time frame. Design: Retrospective chart review. Setting: Outpatient hospital-affiliated Injured Runners Clinic. Patients: Children and adolescent runners (6-17 years) with RRIs. Independent Variables: We examined electronic medical records (EMRs) among child and adolescent patients in the hospital database from 2011 to 2021 to obtain RRI characteristics and key demographic factors. Main Outcome Measures: We assessed volume and frequency of patient visits to the clinic by RRI characteristics. Chi square analyses were used to compare the proportion of clinic visits over time and injury trends by body region and diagnosis. Results: There were 392 patients (sex; 277 F; mean age: 16.1 ± 1.3years) and an average of 5 clinic visits per diagnosis (5 ± 4 visits; min: 1 visit, max: 31 visits). Number of visits generally increased over time up to 2016 but declined most drastically during the years of the pandemic (2020-2021; χ² = 644, P < 0 .001). Of the 654 new injury diagnoses, 77.68% were attributed to repetitive stress. Bone stress injuries to the tibia were the most common RRI (χ² = 1940,P < 0.001; N = 132; 20.2% of all injuries) and constituted most of the clinic visits (χ² = 9271, P < 0.001; N = 591; 25.4% of all visits). Conclusion: We identified that adolescents with overuse injuries, particularly bone stress injuries to the tibia, constituted most of the visits to the outpatient healthcare setting. Clinicians should emphasize injury prevention efforts in clinical practice to reduce RRI burden. [ABSTRACT FROM AUTHOR]

Objective: To compare self-reported osteoarthritis of the knee and hip in adults who ran at least 1 marathon as a child with adults who ran high-school cross country (HSCC). Design: Subject self-recall retrospective survey. Setting: Electronic survey. Participants: 319 adults who either ran a marathon under age 18 or ran HSCC recruited from running clubs, marathon participants, and on-line interest groups. Interventions: Survey. Main Outcome Measures: Self-reported history of osteoarthritis (OA), joint pain, anterior cruciate ligament injury, still running or running marathons, and number of marathons as an adult. Results: One hundred twenty-three respondents ran a marathon under age 18 (26% female) and were 40 years old (sd 16) and 196 ran HSCC (53% female) and were 36 years old (sd 13). The mean age of first marathon was 15 (sd 2.3, range 5-17); 50% ran 1 % and 50% ran >1 marathon. Child marathoners reported a family history of OA in knees or hips (26%) or a joint replacement (30%) compared with 24% and 28% of HSCC runners. 10% of child marathoners and 7% of HSCC reported OA and 24% and 21% reported daily or weekly joint pain. 91% of all respondents are still running; 78% of child marathoners (mean 17, range 1-91) and 80% HSCC ran≥1 marathons as adults (mean 10, range 1 -80). Conclusions: Adults who ran marathons as children compared with adults who ran HSCC self-report similar rates of the knee and hip OA, chose to participate of their own accord, continue to run as adults, played other sports, and did not "specialize" in marathons. [ABSTRACT FROM AUTHOR]

Objective: Little is known about the prognostic value of the Buffalo Concussion Treadmill Test (BCTT) after the acute phase of sport-related concussion (SRC). We examined the added prognostic value of the BCTT performed 10 to 21 days after SRC in children, in addition to participant, injury, and clinical process characteristics on days to recovery. Design: Historical clinical cohort study. Setting: Network of approximately 150 Canadian multidisciplinary primary-care clinics. Participants: 855 children (mean age 14 years, range 6-17 years, 44% female) who presented between January 2016, and April 2019 with SRC. Assessment of risk factors: Participant, injury, and clinical process characteristics, with focus on BCTT exercise intolerance assessed 10 to 21 days after injury. Outcome: Days to clinical recovery. Results: Children who were exercise intolerant experienced an increase of 13 days to recovery (95% CI, 9-18 days). Each additional day between SRC and first BCTT was associated with a recovery delay of 1 day (95% CI, 1-2 days), and prior history of concussion was associated with a recovery delay of 3 days (95% CI, 1-5 days). Participant, injury, and clinical process characteristics, and the first attempt BCTT result explained 11% of the variation in recovery time, with 4% accounted for by the BCTT. Conclusion: Exercise-intolerance assessed 10 to 21 days after SRC was associated with delayed recovery. However, this was not a strong prognostic factor for days to recovery. [ABSTRACT FROM AUTHOR]

Objective: To examine patient and injury factors that may predict quality of life (QoL) and symptom duration after concussion. Design: Prospective, longitudinal. Settings: Six children’s hospital-based medical centers and 9 secondary school athletic training facilities. Patients: Pediatric patients (8-18 years) were enrolled as part of the Sport Concussion Outcomes in Pediatrics (SCOPE) study during their initial visit for a diagnosis of sport-related concussion. Interventions: Patients completed a medical history, the Postconcussion Symptom Inventory (PCSI), and Patient-Reported Outcomes Measurement Information System Pediatric Profile-25 (PROMIS-PP). Main Outcome Measures: Eight predictor variables [age, sex, assessment time, loss of consciousness, amnesia and history of concussion, migraines, or attention-deficit hyperactivity disorder or (ADHD)] were assessed using regression models constructed for each dependent variable. Results:A total of 244 patients (15.162.1 years, 41% female) were enrolled (mean 5 5 6 3 days after concussion; range 5 1-14 days). Female sex, later initial assessment, and presence of amnesia were associated with lower QoL scores on several domains, whereas loss of consciousness was associated with higher QoL for fatigue. A history of migraines was associated with lower peer relationship QoL. Patients who subsequently developed persisting symptoms had lower mobility scores and higher anxiety, depressive symptom, fatigue, and pain interference scores. Conclusions: Female sex, later clinic presentation, and amnesia were associated with a lower QoL related to mobility, anxiety, depressive symptoms, fatigue, and pain interference. Interestingly, previous concussion and preinjury ADHD diagnosis did not negatively impact postinjury QoL at the initial visit. Future studies should assess the influence of these factors on QoL at later postinjury time points using a concussion-specific outcomes instrument. [ABSTRACT FROM AUTHOR]

Objective: To examine differences in individual symptom report prevalence between children and adolescents experiencing 1 to 2 versus ≥3 persistent postconcussion symptoms. Design: A prospective cohort study. Setting: Three community practice concussion clinics within a family practice network. Patients: Children and adolescents aged 8 to 18 years presenting to clinics within 72 hours of a sport-related or recreation-related concussion. Those with complete symptom data from a 1-month follow-up time point (n = 236) were included in analyses. Independent Variables: One hundred thirty-six patients (n = 136) reported 0 symptoms as worse than preinjury at the 1-month time point. Participants reporting 1+ symptoms as worse than preinjury at 1 month were assigned to groups based on the number of symptoms endorsed: those with 1 to 2 (n = 38) compared with those experiencing ≥3 (n = 62). Main Outcome Measures: Fisher exact tests were used to compare symptom report prevalence for each item of the Rivermead Postconcussion Symptoms Questionnaire. This research question was formulated and examined after completion of data collection. Results: Across both groups, headache and fatigue were the most commonly reported persistent postconcussion symptoms. Several emotional symptoms (eg, irritability, depression) were primarily or only present in those reporting ≥3 persistent symptoms. Conclusions: Findings provide detail regarding the clinical manifestation of experiencing fewer versus more persistent postconcussion symptoms, underscoring the importance of developing individualized, multifaceted rehabilitation programs. [ABSTRACT FROM AUTHOR]

Objective: To examine the association between self-reported and parent-reported attention problems and hyperactivity and rates of injury and concussion in Canadian youth ice hockey players. Design: Secondary analyses of 2 prospective cohort studies. Setting: Canadian youth ice hockey teams. Participants: Ice hockey players (ages 11-17 years) were recruited by team, over 4 seasons (2011-2016). A combined 1709 players contributing 1996 player-seasons were analyzed (257 players participated in more than one season). Assessment of Risk Factors: Data were collected from preseason baseline questionnaires, including child and parent proxy forms of the Behavior Assessment System for Children, second edition. Main Outcome Measures: Injury and concussion rates and incidence rate ratios (IRR) comparing players with and without self-identified or parent-identified attention problems and hyperactivity, adjusted for covariates (ie, body checking policy, previous injury/concussion, and age) and a random effect for team, were estimated using multiple multilevel negative binomial regression. Results: When analyzed continuously, rates of concussion increased with higher self-reported and parent-reported measures of attention problems [IRRSELF = 1.025; 95% confidence interval (CI): 1.011-1.040; IRRPARENT = 1.032; 95% CI: 1.008-1.057]. Self-reported hyperactivity was significantly associated with concussion (IRR = 1.021; 95% CI: 1.007-1.035), but parent-reported hyperactivity was not (IRR = 1.005; 95% CI: 0.983-1.028). A T score ≥ 60 cutoff combining attention problems and hyperactivity scores (an estimate of probable attention-deficit hyperactivity disorder) was not significantly associated with rates of injury or concussion. Conclusions: Attention problems and hyperactivity may place youth ice hockey players at increased risk of concussion and injury. Preseason assessments could identify players for targeted concussion education and risk reduction strategies. [ABSTRACT FROM AUTHOR]

This case report highlights a rare type of primary spinal cord tumor, myxopapillary ependymoma, in a pediatric patient who presented to clinic with worsening chronic unilateral thigh pain and neurologic deficits. He was appropriately treated with total gross resection of the tumor and adjuvant radiotherapy and was cleared for competitive sports without any restriction within 1 year of his diagnosis and treatment. Although most musculoskeletal complaints among pediatric patients are of benign etiology, as evidenced by our case, clinicians should have a low threshold to further investigate with advanced imaging modalities should the clinical history and examination be consistent with a more concerning pathologic process. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Objective: To determine whether slow processing speed is associated with risk of sport-related concussion. Design: We conducted a retrospective cohort study using computerized neurocognitive assessments (Immediate Post-concussion Assessment and Cognitive Testing [ImPACT]) from the Massachusetts Concussion Management Coalition. Slow processing speed was defined as 2 SD below the sample mean (n = 131) and fast processing speed as 2 SD above the sample mean (n = 259). We used a binary logistic regression model to determine the odds of sustaining a concussion with our main predictor being processing speed (high or low) adjusted for the effects of age, sex, and prior number of concussions. Setting: Massachusetts Concussion Management Coalition, Institutional care. Participants: Three hundred ninety junior high soccer players ages 10 to 15 with a baseline score for ImPACT. Independent Variables: Processing Speed. Main Outcome Measures: Risk of sustaining a concussion. Results: Those with slow processing speed had a visual motor composite score of ≤19.92, those with fast-processing speed had a score of ≥46.20. Athletes with slow processing speed were younger (13 vs 14 years; P < 0.001) and more likely to be male (57% vs 49%; P = 0.014). After adjusting for the effects of age, sex, and prior concussions, there was no significant difference in the odds of sustaining a concussion between groups (aOR 1.01; 95% CI, 0.99-1.04). Conclusions: Despite previous research showing that slow processing speed is a risk factor for musculoskeletal injuries during sports, our study suggests that processing speed is not associated with the risk of sustaining a concussion among junior high school soccer players. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to identify the accuracy of the McMurray test in the adolescent and pediatric population. Design: Retrospective case series. Setting: Tertiary care, institutional. Patients: Inclusion criteria included patients who presented with unilateral knee pain and were seen by pediatric sports medicine physicians. Patients were excluded if their knee pain was related to any underlying conditions. Three hundred patient charts were reviewed, and 183 patients (age range: 8-18 years, mean: 14 years; 74 male) met the inclusion criteria. Interventions: Symptoms at initial visit (knee pain). Main Outcome Measures: Presence of a meniscal tear using the McMurray test. Results: Eighty-four percent (160/191) of patients had a McMurray test documented as performed by the physician, and 17% (27/160) elucidated a positive response. Of 26 patients who had a positive McMurray and underwent magnetic resonance imaging (MRI), 16 (62%) showed a meniscal tear on their MRI. However, of the 87 patients who had a negative McMurray and still underwent MRI, 25 (29%) had a positive meniscal tear. The sensitivity, specificity, positive predictive value, and negative predictive value were 39%, 86%, 62%, and 71%, respectively. Conclusion: In a pediatric and adolescent population, the McMurray test was negative for 61% (23/38) of meniscal tears identified on MRI. Clinical Relevance: Although the test can be a useful tool as a part of a thorough evaluation, combining it with mechanical symptoms, patient history and imaging may be more helpful to diagnose a meniscus tear. [ABSTRACT FROM AUTHOR]

Objective: To determine the relationship between patient characteristics and performance on the visio-vestibular examination (VVE) in a cohort of healthy youth athletes and explore the potential association between the VVE and other standardized concussion batteries. Design: Cross-sectional. Setting: Suburban middle and high school. Patients: One hundred ninety subjects age 11 to 18 enrolled before their respective scholastic sport season between August 2017 and March 2020. Assessment of Independent Variables: Patient age, sex, concussion history, comorbidities, hours of weekly exercise, Sport Concussion Assessment Tool, 5th edition (SCAT-5), King–Devick (K–D), Postconcussion Symptom Inventory (PCSI). Main Outcome Measures: Visio-vestibular examination abnormalities (smooth pursuit, horizontal and vertical saccades, horizontal and vertical gaze stability, convergence, right and left monocular accommodation, complex tandem gait). Results: Overall, 29.5% of subjects had at least one of 9 VVE elements abnormal, 7.9% at least 2, and 3.2% at least 3. None of 72 comparisons of the VVE elements, when stratified by age, sex, concussion history, history of headaches, attention deficit hyperactivity disorder, learning issues, psychiatric problems, motion sickness, or weekly hours of exercise, reached significance using the Benjamini–Hochberg procedure at a false discovery rate of 5%. There were no significant associations between VVE elements and the SCAT-5, K–D, or PCSI. Conclusions: The VVE is robust across multiple patient characteristics. Although healthy subjects may have one abnormal element, multiple abnormal elements are a less common feature, making multiple abnormal elements more indicative of concussion, highlighting the use of this assessment in the setting of injury. The VVE tests unique domains when compared with the PCSI, SCAT-5, and K–D. [ABSTRACT FROM AUTHOR]

Objective: To explore the prognostic ability of the vestibular/ocular motor screening (VOMS), King–Devick (K-D) Test, and C3 Logix Trails A and B to identify protracted recovery from sports-related concussion (SRC) in patients aged 8 to 12 years. Design: Retrospective cohort analysis. Setting: Specialty pediatric sports concussion clinic. Participants: A total of 114 youth athletes aged 8 to 12 years who were diagnosed with an SRC within 7 days of injury. Independent Variables: A positive screen on the VOMS, K-D, and C3 Logix Trails A and Trails B. Combined positive screens on multiple tests (ie, 2, 3, or all 4 positive screens of 4 possible). Main Outcome Measures: Recovery time in days and protracted recovery (recovery time ≥30-days) were the primary outcomes of interest. Results: A positive VOMS screen was associated with 1.31 greater days to SRC recovery (P = 0.02) than a negative VOMS screen. The K-D and C3 Logix tests were not significantly associated with recovery time, nor were any combinations of tests (P > 0.05). The VOMS demonstrated moderate prognostic ability to predict normal recovery (negative predictive value = 80.78% [95% CI = 63.73-90.95]). Overall predictive accuracy of normal versus protracted recovery was strongest when a participant screened positive on all 4 tests (Accuracy = 76.32% [95% CI = 67.45-83.78]). Conclusions: The VOMS was associated with overall recovery time and proved to be a useful test to identify those who would experience a normal recovery time. Combining the 4 tests improved the prognostic accuracy of the protocol in predicting protracted versus normal recovery. These findings suggest that combining multiple, varied assessments of cognition and vestibular/ocular functions may better explain factors contributing to protracted recovery. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Objective: To determine whether an association exists between fear of pain and recovery time from sports-related concussion in a pediatric population. Design: Prospective observational study. Setting: Primary outpatient sports medicine clinic of a large pediatric hospital. Patients: One hundred twenty-eight pediatric patients aged 8 to 18 years who presented to clinic with a primary diagnosis of concussion from September 2018 to March 2020. Inclusion criteria included presentation within 2 weeks of injury and symptomatic on initial visit. Patients who sustained a concussion because of motor vehicle collisions or assault were excluded. Independent Variables: There was no intervention. Study participants who met inclusion criteria were administered the Fear of Pain Questionnaire (FOPQ) at their initial visit. Main Outcome Measures: Time to clinical recovery was the main outcome measure and was determined by the fellowship-trained sports medicine physician based on resolution of concussion symptoms, resumption of normal physical and cognitive daily activities, no use of accommodations or medications, and normalization of physical exam. Results: There was a significant difference in FOPQ scores for those with prolonged recovery (M = 33.12, SD = 18.36) compared with those recovering in fewer than 28 days (M = 26.16, SD = 18.44; t [126] = −2.18, P = 0.036). Conclusions: Consistent with the adult literature, we found that pediatric patients are more likely to have a prolonged recovery from concussion when they have higher fear of pain. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Objective: To describe the frequency with which children are affected by lower-limb apophyseal injuries, and subgroups at greater risk. Design: Systematic review. Setting: N/A. Participants: N/A. Interventions: N/A. Main Outcome Measures: Systematic review of Medline OVID, PsycINFO, Cinahl, and PubMed from inception until February 21st, 2020. Articles reporting prevalence and/or incidence of an apophyseal injury (eg, calcaneal apophysitis) or its eponym (Severs or Sever disease). Per person data relating to the incidence or prevalence. Subgroup comparisons were made between sex groups and between activity participant groups. Results: There was wide variation in measurement approaches and follow-up timeframes with the majority of studies reporting on traction apophysitis of the tibial tubercle (Osgood–Schlatter disease). This condition had a point prevalence of 10% in the general population of children between the ages of 12 and 15 years, whereas the lifetime incidence has been reported as 13%. Point prevalence was higher among those who participated in sport compared with those who did not {relative risk [95% confidence interval (CI): 1.98 (1.31-2.99)]}, whereas lifetime incidence was higher among those who participated in sport at the age of 13 years compared with those who did not [relative risk (95% CI): 4.63 (2.31-9.26)]. Other apophyseal injuries did not report enough data to permit comparisons. Conclusion: Sports participation is likely to substantially increase the frequency of traction apophysitis of the tibial tubercle. Further research is required with standardized approaches to compare frequencies between different apophyseal injuries and subgroups of interest. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Objective: To determine whether high or low adiposity is associated with youth sport-related injury. Data Sources: Ten electronic databases were searched to identify prospective studies examining the association between adiposity [body mass index (BMI) or body fat] and a future time-loss or medical attention sport-related musculoskeletal injury or concussion in youth aged 20 years and younger. Two independent raters assessed the quality (Downs and Black criteria) and risk of bias (Joanna Briggs Institute Critical Appraisal Tool). Random-effects meta-analyses were used to calculate pooled odds ratio [95% confidence interval (CI)] of injury. Main Results: Of 11 424 potentially relevant records, 38 articles were included with 17 eligible for meta-analyses. In qualitative synthesis, no clear association was identified between adiposity and any sport injury; however, 16/22 studies identified high adiposity as a significant risk factor for lower-extremity injury. Meta-analyses revealed higher BMI in youth with any sport-related injury and lower BMI in youth who developed a bone stress injury (BSI) compared with noninjured controls. The pooled OR (95% CI) examining the association of BMI and injury risk (excluding bone injury) was 1.18 (95% CI: 1.03-1.34). A major source of bias in included articles was inconsistent adjustment for age, sex, and physical activity participation. Conclusions: Level 2b evidence suggests that high BMI is associated with greater risk of youth sport injury, particularly lower-extremity injury and excluding BSI or fracture. Although pooled mean differences were low, anthropometric risk of injury seems to be dependent on type and site of injury in youth sport. [ABSTRACT FROM AUTHOR]

Objective: To describe the collaborative findings across a broad array of subspecialties in children and adolescents with postconcussion syndrome (PCS) in a pediatric multidisciplinary concussion clinic (MDCC) setting. Design: Retrospective analysis. Setting: Multidisciplinary concussion clinic at a pediatric tertiary-level hospital. Patients: Fifty-seven patients seen in MDCC for evaluation and management of PCS between June 2014 and January 2016. Interventions: Clinical evaluation by neurology, sports medicine, otolaryngology, optometry, ophthalmology, physical therapy, and psychology. Main Outcome Measures: Specialty-specific clinical findings and specific, treatable diagnoses relevant to PCS symptoms. Results: A wide variety of treatable, specialty-specific diagnoses were identified as potential contributing factors to patients' postconcussion symptoms. The most common treatable diagnoses included binocular vision dysfunction (76%), anxiety, (57.7%), depression (44.2%), new or change in refractive error (21.7%), myofascial pain syndrome (19.2%), and benign paroxysmal positional vertigo (17.5%). Conclusions: Patients seen in a MDCC setting receive a high number of treatable diagnoses that are potentially related to patients' PCS symptoms. The MDCC approach may (1) increase access to interventions for PCS-related impairments, such as visual rehabilitation, physical therapy, and psychological counseling; (2) provide patients with coordinated medical care across specialties; and (3) hasten recovery from PCS. [ABSTRACT FROM AUTHOR]

Objectives: Examine sociodemographic differences (gender, age, and language spoken at home) on baseline Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5) scores and establish normative reference data for the Child SCAT5 among middle school student athletes. Design: Cross-sectional study. Setting: Nine middle schools in Virginia. Participants: A sample of 1355 athletes playing competitive school-sponsored sports (ages 11-13, M = 12.3 +/- 0.8; 40.1% girls, 59.9% boys) during the 2017 and 2018 school year. Certified athletic trainers administered the Child SCAT5 within the first 2 weeks of the sport season. Independent Variables: Self-reported gender, age, and language spoken at home. Main Outcome Measures: All Child SCAT5 outcome measures. Results: Gender, age, and language spoken at home were associated with Child SCAT5 scores, but the magnitude of differences was generally small. Specifically, girls endorsed more symptoms (girls: M = 8.4 +/- 5.7, boys: M = 7.5 +/- 5.7; P = 0.003) and greater symptom severity (girls: M = 11.6 +/- 9.4, boys: M = 10.4 +/- 9.3; P = 0.006) than boys and performed slightly better than boys on cognitive and balance tasks. Older students performed slightly better than younger students on tests of cognition (eg, SAC-C: 11-year-olds: M = 21.3 +/- 2.1, 13-year-olds: M = 21.7 +/- 2.1; P = 0.02). Total symptoms (P = 0.01), symptom severity (P = 0.01), immediate memory (P < 0.001), delayed recall (P = 0.001), and SAC-C total scores (P = 0.002) differed across language groups. Conclusions: Gender, age, and language spoken in the home are associated with baseline scores on multiple components of the Child SCAT5 among middle school students, although the magnitudes of observed differences are small. Normative reference values are provided for clinicians when interpreting Child SCAT5 scores. [ABSTRACT FROM AUTHOR]

Objective: To describe the epidemiology of sledding-related injuries among children and adults treated in US emergency departments (EDs). Design: The researchers performed a retrospective analysis using data from the National Electronic Injury Surveillance System (NEISS). Setting: The NEISS collects data on consumer products-related and sports-related injuries treated in US EDs from approximately 100 hospitals that represent a probability sample of >5000 hospitals. Patients: Children (≤19 years of age) and adults who were treated for sledding-related injuries in EDs from 2008 to 2017. Independent Variables: The researchers analyzed characteristics that included sex, body part injured, injury diagnosis, disposition from the ED, injury locale, injury mechanism, and sled type. Main Outcome Measures: All cases of sledding-related injuries were identified using NEISS product codes for sleds (1217), toboggans (1273), snow disks (1274), and snow tubes (1299). Results: An estimated 220 488 patients [95% confidence interval (CI): 169 839-271 137] were treated in EDs for sledding-related injuries. Overall, the injury rate decreased significantly for both children and adults. Children accounted for 69.7% of the injury cases. Fractures were the most common injury diagnosis for children (23.9%) and adults (27.4%). Compared to adults, children were more likely to sustain a head injury [relative risk (RR): 1.91 (95% CI: 1.73-2.13)] and be diagnosed with a concussion or closed-head injury (CHI) [RR: 1.58 (95% CI: 1.35-1.84)]. Most patients were injured by a collision (63.2%). Snow tube and disk riders were more likely to sustain a concussion or CHI compared to sled and toboggan riders [RR: 1.53 (95% CI: 1.18-1.99)]. Injuries predominantly occurred when patients collided with objects in the environment (47.2%). Conclusions: Although sledding-related injuries decreased over the study period, more research and education to prevent these injuries is needed. The injury patterns and risk of injury type differed by age, with more head injuries sustained by children. Sledding should be performed in obstacle-free areas to reduce the risk of collision and while wearing helmets to mitigate head injuries. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Objective: The need to have a pediatric-specific concussion management protocol on Return to School (RTS) and Return to Activity (RTA) after concussion has been recognized internationally. The first step to evaluate the protocol effectiveness is to establish whether children and youth are adhering to these recommendations. The objective of this study was to explore the prevalence and predictors of adherence to RTS and RTA concussion management protocols for children/youth. Design: A prospective cohort of children/youth with concussion. Setting: Childhood Disability Research Centre. Participants: One hundred thirty-nine children/youth aged 5 to 18 years, diagnosed with concussion and symptomatic upon enrollment, were followed for up to 6 months. Primary recruitment occurred from a Children's Hospital Emergency Department. Intervention: Provision of RTS/RTA guidelines. Main Outcome Measures: Measurement of adherence came from multiple sources, including the child's and parent's knowledge of protocols, research personnel evaluations, and self-reported stages of RTS/RTA and Post-Concussion Symptom Scale (PCSS) scores. Results: Spearman correlations and logistic regression were used, investigating the relationship between PCSS and progression of protocols and determining predictors of adherence. Significant negative associations between total PCSS score and stage of RTS/RTA protocols were found. Fifty-three percent and 56% of the participants adhered to the RTS and RTA protocols, respectively. Conclusions: Children's knowledge of protocols and total PCSS scores significantly predicted adherence to RTS/RTA and may be the most important factors in predicting adherence during recovery from concussion. [ABSTRACT FROM AUTHOR]

Objective: The study sought to present normative and psychometric data and reliable change formulas for the Health and Behavior Inventory (HBI), a postconcussive symptom rating scale embedded in the Child Sport Concussion Assessment Tool 5th edition (Child SCAT5). Design: Prospective cohort study with longitudinal follow-up. Setting: Pediatric emergency departments (EDs). Participants: As part of 3 studies conducted in the United States and Canada between 2001 and 2019,450 children aged 8 to 16 years with mild orthopedic injuries were recruited during ED visits and assessed postacutely (M = 9.38 days, SD = 3.31) and 1 month and 3 months postinjury. Independent variables were rater (child vs parent), sex, and age at injury. Main Outcome Measure: HBI ratings. Methods: Children and parents rated children's symptoms at each time point; parents also rated children's preinjury symptoms retrospectively. Normative data (mean, SD, skewness, kurtosis, and percentiles) were computed for child and parent ratings. Internal consistency was assessed using Cronbach alpha (a), and test-retest reliability and interrater agreement were assessed with intraclass correlations (ICCs). Reliable change formulas were computed using linear regression and mixed models. Results: HBI ratings were positively skewed. Mean ratings and percentiles were stable overtime. Child and parent ratings demonstrated good-to-excellent internal consistency (a 0.76-0.94) and moderate-to-good test-retest reliability (ICC 0.51-0.76 between adjacent assessments). However, parent-child agreement was poor to moderate (ICC 0.31-0.69). Conclusions: The HBI demonstrates acceptable normative and psychometric characteristics. Modest parent-child agreement highlights the importance of multiple informants when assessing postconcussive symptoms. The results will facilitate the use of the HBI in research and clinical practice. [ABSTRACT FROM AUTHOR]

Objectives: The primary purpose of this study was to examine vestibular/ocularmotor screening (VOMS) test performance in a sample of healthy youth ice hockey players. A particular focus was to investigate the potential effects of age and pre-existing health conditions, including concussion history, attention-deficit/hyperactivity disorder (ADHD), learning disability (LD), headaches/migraines, and depression/anxiety on preseason baseline VOMSperformance, including the near point of convergence (NPC) distance.Design:Crosssectional cohort. Setting:Outpatient physiotherapy clinic.Participants: Three hundred eighty-seven male youth hockey players,with an average age of 11.9 years (SD = 2.2, range = 8-17), completed the VOMS and responded to self- or parent-reported demographic and medical history questionnaires during preseason baseline assessments. Independent Variables Assessed: Age, sex, and mental and physical health history including ADHD, headaches, depression, anxiety, migraine, and LD. Outcome Measure: Vestibular/ocular motor screening. Results: The large majority of boys scored within normal limits on the VOMS, ie, they reported no symptom provocation ofmore than 2 points on any VOMS subset (89%) and had a normal NPC distance, ie, <5 cm(78%). The individual VOMS subtests had low abnormality rates, and demographic and pre-existing health conditions, such as age, headache or migraine history, previous neurodevelopmental conditions, or mental health problems, were not associated with clinically meaningful symptom provocation during the VOMS. Conclusions: There was a low rate of abnormal findings for the individual VOMS subtests, with the exception of NPC distance, among male youth hockey players during preseason assessment. [ABSTRACT FROM AUTHOR]

Objective: To examine changes in blood biomarkers, serumneurofilament light (Nf-L), and plasma tau, as well as the relationship between blood biomarkers and symptomreports, in athletes with a sports-related concussion.Design: Prospective cohort study. Setting: Private community-based concussion clinic. Participants: Athletes aged 13 to 18 years old with a diagnosed sports- related concussion presenting to a concussion clinic within 7 days of injury and noninjured athletes with no history of concussion aged 13 to 23 years old. Assessment and Main Outcome Measures: Injured athletes provided a blood sample at the initial clinical evaluation and again at least 6 months after injury. Noninjured athletes provided a single blood sample. All participants completed symptom reports during each visit. Statistical comparisons of biomarker concentrations and symptom reports were conducted.Results: Themean rank for tauwas significantly lower for concussed athletes comparedwith nonconcussed athletes. In contrast, the mean rank of Nf-L was higher for concussed athletes than for nonconcussed athletes, although the difference was nonsignificant. Plasma tau was significantly lower postinjury compared with 6 months after injury, whereas serum Nf-L was significantly higher postinjury. There was a weak but significant inverse relationship observed between tau and the number of symptoms reported, but no relationship was observed between Nf-L and the number of symptoms reported. Conclusions: These data indicate that in the days following a sports-related concussion, the blood biomarkers tau and Nf-L display contrasting patterns of change but may not be related to self-reported symptom scores. [ABSTRACT FROM AUTHOR]

Objective: Many schools and sports leagues provide preseason concussion education to parents/guardians, and in some jurisdictions, it is required for interscholastic sports participation. However, directives about content are absent or vague. The purpose of this study was to obtain expert consensus about what parents/guardians need to know to about concussion. Design: A modified Delphi process with nationally recognized expert panel members was used to obtain consensus about parent/guardian behaviors relevant to concussion prevention, identification, and management and knowledge domains relevant to performance of those behaviors. Results: Sixteen parent/guardian behaviors and 24 knowledge domains were identified. However, consensus was not achieved regarding whether it is realistic to expect parents/guardians to perform approximately one-third of the behaviors that experts agreed mattered. This variability may reflect underlying uncertainty about the capacities of some parents/guardians to put knowledge into action or the belief that there are other barriers to action. Furthermore, for most knowledge domains, there was a lack of agreement about whether or not there could be a "correct" answer on the basis of current scientific knowledge. Conclusions: These findings raise practical and ethical questions: how can we expect parents/guardians to help prevent, identify, or manage concussion if they cannot have all the information required to engage in these behaviors due to lack of scientific consensus? This issue is not unique to concussion. Best practices for risk communication and shared decision-making can inform how we think about educating parents/guardians about concussion inside and outside of the health care setting. [ABSTRACT FROM AUTHOR]

Objective: Review the use of upper-extremity orthoses and casts after injuries to the wrist and hand in the pediatric, adolescent, and young adult population. The common injuries reviewed include pediatric distal radius fractures, scaphoid fractures, metacarpal fractures, mallet fingers, volar plate injuries of the proximal interphalangeal (PIP) joint, and ulnar collateral ligament (UCL) tears of the thumb metacarpophalangeal (MCP) joint. Data sources: We conducted a literature review from 1985 to 2016 of upper-extremity orthotic interventions. Non-English language citations and animal studies were excluded. Citations from retrieved studies were used to identify other relevant publications. This review included cases of common injuries to the upper extremity, which required orthotic intervention. Main results: Immobilization recommendations for nonsurgical pediatric distal radius fractures, nonsurgical metacarpal fractures, mallet fingers, and UCL tears of the thumb MCP include a removable orthosis. Nondisplaced scaphoid fracture orthosis recommendations include initial immobilization in a nonremovable short-arm thumb spica cast. Volar plate injuries of the PIP joint require buddy straps for healing. Conclusions: The literature demonstrates the effectiveness of removable orthoses in healing, patient satisfaction, and time to return to activity after many common upper-extremity injuries. Removable orthoses should be considered an equal or superior treatment method to cast immobilization, immobilization of additional joints, or longer periods of immobilization. [ABSTRACT FROM AUTHOR]

Objective: To determine whether graded exercise testing can predict recovery trajectory of concussion in children and adolescents. Design: Prospective study. Setting: Children's Hospital, Westmead, Australia. Participants: One hundred thirtynine children aged 12 to 16 years at 5 to 7 days after an acute concussive injury. Intervention: Graded exercise testing on a treadmill at the subacute phase to assess symptom provocation and determine clinical recovery indicating readiness to commence a return to activity (RTA) protocol. Exercise time to symptom exacerbation and clinical recovery were measured. Main Outcome Measures: Standard concussion assessment and clinical testing (neurocognitive, vestibular/ocular, and balance) were conducted to determine major clinical drivers/indicators. Results: Participants (mean age 12.4 ± 2.8 years, 73% male) had a confirmed sport-related concussion. The main clinical drivers identified on exercise testing were headache, balance, and vestibular dysfunction. Participants fell into 1 of 2 groups, exercise-tolerant (54%) and exercise-intolerant (46%). Exercise-tolerant patients showed mild clinical indicators, no symptom exacerbation during 10.3 ± 3.3 minutes of exercise, were safely transitioned to a RTA protocol, and recovered within 10 days. Exercise-intolerant patients had high clinical indicators, significant symptom exacerbation at 4.2 ± 1.6 minutes of exercise, and prolonged recovery of 45.6 days. No adverse effects from exercise were reported in either group. Combined use of provocative exercise and clinical testing was 93% predictive of outcome. Conclusions: Exercise testing during the subacute phase after a concussion can predict longer recovery. Exercise testing can identify a unique window where patients can be safely transitioned to activity, enabling clinicians to better inform patients and families, allocate resources and streamline care. [ABSTRACT FROM AUTHOR]

Objective: Compare outcomes of operative and nonoperatively managed medial epicondyle fractures in upper-extremity athletes. Design: Retrospective chart review and phone survey. Setting: Level 1, tertiary-referral pediatric hospital. Patients: Propensity scores (probability of operative treatment) were estimated from a logistic regression model that included sex, age, displacement, limb dominance, and injury severity (presence of an additional fracture, nerve injury, or elbow dislocation). These were used to match subjects in the operative group to the nonoperative group. Main Outcome Measures: Return to sport, duration of time required to return to sport, pain, range of motion (ROM), need for physical therapy, and complications were recorded for both groups. Results: Twenty-eight nonoperative subjects were matched to 14 operative subjects. There was no significant difference in the proportion of subjects who returned to the same sport (92.9% in each group), performance at preinjury level of competition, or median time to return to play (P = 0.7106). There was no significant difference in functional limitations in social-/work-related activities (P > 0.9999), pain in the past 30 days (P = 0.0640), need for physical therapy (P = 0.5680), ROM limitations (P = 0.0988), difficulty in sleeping (P = 0.4773), or complications (P = 0.4081). Conclusions: Our study found no statistical difference in outcomes or complications between operative and nonoperatively treated moderately displaced medial epicondyle fractures in adolescent upper-extremity athletes. Our data show that similar outcomes may be achieved with both treatment groups for medial epicondyle fractures in upper-extremity athletes. [ABSTRACT FROM AUTHOR]

Objective: The primary objective is to evaluate the feasibility (safety and acceptability) of implementing early active rehabilitation (AR) for concussion management in youth with symptoms persisting 2 weeks after injury. A secondary and exploratory objective was to estimate the potential efficacy of early AR compared with standard AR. We hypothesize that AR at 2-weeks postconcussion will be safe and acceptable to patients. Design: Randomized clinical trial. Setting: The Montreal Children's Hospital of the McGill University Health Center (MCH-MUHC), a tertiary care pediatric teaching hospital affiliated with McGill University in Montreal, Canada. Participants: Twenty youth aged 9 to 17 years old with postconcussion symptoms for at least 2 weeks. Intervention: Active rehabilitation (aerobic exercise, coordination drills, visualization, and education/reassurance) was administered by physiotherapists in-person, and then continued as a home program. Methods: Twenty participants were randomized to either early AR (initiated 2 weeks after injury) or standard AR (initiated 4 weeks after injury). Results: Two adverse events (one in each group) were identified through an online survey more than one-month postconcussion. Postconcussion symptoms decreased over time for both groups. Conclusions: The results from this pilot study indicate that a full clinical trial estimating the efficacy of early AR (starting 2 weeks after injury) is feasible. Further study is needed to determine the superiority of this strategy over current treatment approaches. [ABSTRACT FROM AUTHOR]

Objectives: The Centers for Disease Control and Prevention (CDC) published an evidence-based guideline on the diagnosis and management of pediatric mild traumatic brain injury (mTBI) in 2018. This commentary provides key practice takeaways for sports medicine providers outlined in the Guideline recommendations. Data Sources: The CDC Pediatric mTBI Guideline was developed through a rigorous scientific process using a modified Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. A systematic review of the scientific literature published over a 25-year period for all causes of pediatric mTBI formed the basis of the Guideline. Main Results: The key practice takeaways for sports medicine providers focus on preseason evaluations, neuroimaging, symptom-based assessment, managing recovery, monitoring for persistent symptoms, and return to activity, including sport and school. Conclusions: Sports medicine providers play an integral part in the implementation of evidence-based practices that promote appropriate diagnosis and management of mTBI in children. This commentary highlights key practice takeaways that sports medicine providers can implement. [ABSTRACT FROM AUTHOR]

Objective: Report the clinical findings and outcomes among pediatric patients diagnosed with benign paroxysmal positional vertigo (BPPV) after sports-related concussion (SRC). Design: Retrospective case series. Setting: Multidisciplinary pediatric concussion program. Patients: Patients younger than 19 years with a sport or recreation activity-related concussion referred for comprehensive vestibular physiotherapy assessment. Main outcome measure: Symptom resolution after targeted particle repositioning (PR). Results: During the study period, 115 pediatric SRC patients underwent vestibular physiotherapy assessment including 12 (10.4%) who were diagnosed with BPPV. Unilateral posterior semicircular canal (SCC) BPPV was diagnosed in 8/12 (75%) patients, and unilateral anterior SCC BPPV diagnosed in 4/12 (25%) patients. Benign paroxysmal positional vertigo was successfully treated in all patients with a mean of 1.58 targeted PR maneuvers (range = 1-4). Conclusions: Comprehensive management of pediatric SRC requires a multidisciplinar^ approach to address the heterogeneous pathophysiology of persistent postconcussion symptoms. Pediatric SRC patients with coexisting BPPV should be considered for targeted PR. [ABSTRACT FROM AUTHOR]

Objective: To investigate CrossFit-related injuries presenting to a pediatric sports medicine clinic. Design: Retrospective review of pediatric CrossFit-related injuries from between January 1,2003, and June 31,2016. Setting: Pediatric sports medicine clinic at a tertiary-level academic medical center. Patients: Patients with injury related to CrossFit participation. Independent Variables: Sex, age, injury site, diagnosis, diagnostic imaging, and treatment. Main Outcome Measures: Annual CrossFit-related injury proportion (%) overtime. Results: One hundred fifteen medical identified (N = 55 female; mean age, 25.2 ± 10.4 years). Proportion of CrossFit-related injuries presenting to clinic relative to overall clinic volume consistently increased over time (Pearson r = 0.825; P = 0.022). Injury location included head (0.08%), trunk/spine (25.2%), upper extremity (27.0%), and lower extremity (47.0%). Common injured joints included knee (27%), spine (24.3%), and shoulder (16.5%). Nearly half of patients had a single diagnostic imaging (49.6%; 57 of 115). Most common diagnostics included magnetic resonance imaging (60.0%; 69 of 115), plain radiographs (51.3%; 59 of 115), ultrasound (10.4%; 12 of 115), and computerized tomographic scan (9.6%; 11 of 115). Most commonly prescribed treatments included physical/occupational therapy (38.3%; 44 of 115), activity modification (19.1%; 22 of 115), crutches/brace/splinting/compression sleeve (13.0%; 15 of 115), and non-steroidal anti-inflammatory medications (10.4%; 12 of 115). Conclusions: CrossFit-related injury proportion presenting to a pediatric sports medicine clinic increased overtime. A notable proportion of injuries occurred to the trunk and spine. Advanced imaging was obtained in approximately half of these youth athletes. Further research in youth CrossFit athletes is required surrounding mechanism of injury to prevent future injury in this mode of training for youth athletes. [ABSTRACT FROM AUTHOR]

Objective: The incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) after pediatric knee arthroscopy is unknown. The purpose of this study was to determine the incidence of venous thromboembolism (VTE) after knee arthroscopy in the pediatric and adolescent population in a high-volume center. Design: Retrospective cohort study. Setting: Tertiary care children's hospital. Patients: All patients who underwent arthroscopy of the knee for a sports-related injury by 2 surgeons were reviewed. Chief complaint, past medical/surgical history, medications, procedure performed, intraoperative findings, intraoperative complications, and postoperative recovery were reviewed. The incidences of postoperative VTE within 30 days after the procedure were reviewed. Results: Seven hundred forty-six (358 male and 388 female patients) knee arthroscopies performed from September 2011 to October 2016 by 2 pediatric orthopedic surgeons specializing in sports-related injuries were included. The average age was 15.2 ± 2.72 years. Five patients were suspected to have either DVT or PE postoperatively (0.67%). The overall incidence of symptomatic confirmed VTE after knee arthroscopic procedures was 0.27% (one DVT after a partial lateral meniscectomy and one PE after fixation of an osteochondral lesion). Conclusions: The incidence of VTE after pediatric sports medicine knee arthroscopies is low, 0.27%. Patients who present with calf swelling or pain, chest pain, or shortness of breath after arthroscopic surgery should be examined closely. Level of Evidence: Level III. [ABSTRACT FROM AUTHOR]

Objective: To examine the effect of low-intensity pulsed ultrasound (LIPUS) on early-stage spondylolysis in young athletes. Design: Case–control study. Setting: A single outpatient orthopedic and sports clinic. Patients: A total of 82 young athletes (80 boys and 2 girls; mean age, 14.8 years; range, 10-18 years) with early-stage lumbar spondylolysis were enrolled in this study. All patients were examined by plain radiography and magnetic resonance imaging. Interventions: Patients received either standard conservative treatment combined with LIPUS (n = 35) or without LIPUS (n = 47), according to the sequence of admission. The standard conservative treatment included thoracolumbosacral brace, sports modification, and therapeutic exercise. Main Outcome Measures: The time required to return to previous sports activities was analyzed by using Kaplan–Meier methods with the log-rank test. Results: The baseline parameters of both groups were not significantly different. The median time to return to previous sports activities was 61 days [95% confidence interval (CI): 58-69 days] in the group treated with LIPUS, which was significantly shorter than that of the group treated without LIPUS (167 days, 95% CI: 135-263 days; P < 0.01). Conclusions: These results suggest that LIPUS combined with conservative treatment for early-stage lumbar spondylolysis in young athletes could be a useful therapy for quick return to playing sports. [ABSTRACT FROM AUTHOR]

Objective: To examine differences in bone mass between children and adolescents swimming competitively at nonelite levels (locally and regionally) and nonathletes and to assess changes in bone mass in these 2 groups over 24 months after taking into consideration several known confounders of bone mass. Design: Observational prospective study. Participants: White nonelite swimmers (n = 128) and nonathletes (n = 106) 8 to 18 years of age from Memphis, Tennessee, USA. Main Outcome Measures: Participants underwent dual-energy x-ray absorptiometry to assess total body and hip bone mineral content (BMC) at baseline and 12 and 24 months later. Results: At baseline, swimmers had 4.2% and 6.1% higher adjusted BMC for the total body and hip, respectively, compared with nonathletes (P values < 0.027). Averaging across assessment points, swimmers had 73.5 and 2.2 g higher BMC for the total body and hip, respectively, than nonathletes. Although there was a significant annual increase in total body and hip BMC in both groups (33.5 and 0.7 g, respectively), there was no difference in annualized bone accrual between swimmers and nonathletes for either total body BMC (swim by time effect; P = 0.213) or hip BMC (P = 0.265). Conclusions: Competitive swimming at nonelite levels during childhood and adolescence does not seem to compromise bone accrual. [ABSTRACT FROM AUTHOR]

Objective: Benefits of physical activity has been shown in children with congenital heart disease (CHD). In several forms of CHD, the risk of sudden death remains a major concern both for parents and clinicians, who in turn will have to consider the risk–benefit ratio of sport participation versus restriction. Data source: A literature search was performed within the National Library of Medicine using the keywords: Sport, CHD, and Eligibility. The search was further refined by adding the keywords: Children, Adult, and Criteria. Main Results: Fifteen published studies evaluating sport eligibility criteria in CHD were included. Seven documents from various scientific societies have been published in the past decade but which of them should be adopted remains unclear. Our research highlighted accuracy and consistency of the latest documents; however, differences have emerged between the US and European recommendations. Eligibility criteria were consistent between countries for simple congenital heart defects, whereas there are discrepancies for borderline conditions including moderate valvular lesions and mild or moderate residual defects after CHD repair. Furthermore, some of the more severe defects were not evaluated. Multiple recommendations have been made for the same CHD, and cut-off values used to define disease severity have varied. Published eligibility criteria have mainly focused on competitive sports. Little attention was paid to recreational activities, and the psychosocial consequences of activity restriction were seldom evaluated. Conclusions: Comprehensive consensus recommendations for sport eligibility evaluating all CHD types and stages of repair are needed. These should include competitive and recreational activities, use standardized classifications to grade disease severity, and address the consequences of restriction. [ABSTRACT FROM AUTHOR]

Objectives: We quantified the length of recovery time by week in a cohort of pediatric sports--related concussion patients treated at concussion clinics, and examined patient and injury characteristics associated with prolonged recovery. Design: A retrospective, cohort design. Setting: Seven concussion clinics at a Midwest children's hospital. Patients: Patients aged 10 to 17 years with a diagnosed sports-related concussion presenting to the clinic within 30 days of injury. Main Outcome Measures: Length of recovery by week. Methods: Unadjusted and adjusted multinomial logistic regression analyses were used to model the effect of patient and injury characteristics on length of recovery by week. Results: Median length of recovery was 17 days. Only 16.3% (299/1840) of patients recovered within one week, whereas 26.4% took longer than four weeks to recover. By 2 months postinjury, 6.7% of patients were still experiencing symptoms. Higher symptom scores at injury and initial visit were significantly associated with prolonged symptoms by week. Patients who presented to the clinic more than 2 weeks postinjury or who had 2 or more previous concussions showed increased risk for prolonged recovery. Females were at greater risk for prolonged recovery than males (odds ratio = 2.08, 95% confidence interval = 1.49-2.89). Age was not significantly associated with recovery length. Conclusions: High symptom scores at injury and initial visit, time to initial clinical presentation, presence of 2 or more previous concussions, and female sex are associated with prolonged concussion recovery. Further research should aim to establish objective measures of recovery, accounting for treatment received during the recovery. Clinical Relevance: The median length of recovery is 17 days among pediatric sports--related concussion patients treated at concussion clinics. Only 16.3% of patients recovered within one week, whereas 26.4% took longer than 4 weeks to recover. [ABSTRACT FROM AUTHOR]

Objective: To determine the normative, baseline performance and psychometric properties of the Child Sport Concussion Assessment Tool 3 (Child-SCAT3) in 5- to 13-year-old athletes. Design: Cross-sectional study. Setting: Practice fields. Participants: Contact sport athletes (N = 155) 5 to 13 years old. Independent Variables: Age, gender, verbal intellectual functioning (receptive vocabulary). Main Outcome Measures: Child-SCAT3: self-reported and parent-reported symptoms, cognitive performance (child form of the Standardized Assessment of Concussion; SAC-C), and balance (modified Balance Error Scoring System, mBESS-C; tandem gait). A subset of the sample repeated the Child-SCAT3 at another date. Some subjects also completed the Adult-SCAT3 version of the symptom checklist and mBESS. Results: Small-to-medium-sized effects of age were observed on all Child-SCAT3 components. Effects of gender and receptive vocabulary were observed on select components of the SCAT3. Younger age and lower receptive vocabulary were independently associated with greater symptom endorsement, yet parents rated higher symptom burden for older children. internal consistency reliability and stability of symptom ratings was good to excellent. Stability was more modest for SAC-C and tandem gait scores and very poor for mBESS-C scores, perhaps due to restricted variance. Inter-rater reliability (self-rated vs parent-rated symptoms) was fair. Conclusions: The Child-SCAT3 self-report symptom checklist may be inappropriate to administer to younger school-aged children. Some of the age effects observed warrant use of demographically appropriate norms in Child-SCAT3 interpretation. The findings can provide guidance for clinicians assessing children of varying ages and point to directions for further development of refined approaches for pediatric concussion assessment. [ABSTRACT FROM AUTHOR]

Objective: To identify a method to predict the maximal heart rate (MHR) in children and adolescents, as available prediction equations developed for adults have a low accuracy in children. We hypothesized that MHR may be influenced by resting heart rate, anthropometric factors, or fitness level. Design: Cross-sectional study. Setting: Sports medicine center in primary care. Participants: Data from 627 treadmill maximal exercise tests performed by 433 pediatric athletes (age 13.7 ± 2.1 years, 70% males) were analyzed. Independent Variables: Age, sex, sport type, stature, body mass, BMI, body fat, fitness level, resting, and MHR were recorded. Main Outcome Measures: To develop a prediction equation for MHR in youth, using stepwise multivariate linear regression and linear mixed model. To determine correlations between existing prediction equations and pediatric MHR. Results: Observed MHR was 197 ± 8.6 b⋅min-1. Regression analysis revealed that resting heart rate, fitness, body mass, and fat percent were predictors of MHR (R² = 0.25, P < 0.001), whereas age was not. Resting heart rate explained 15.6% of MHR variance, body mass added 5.7%, fat percent added 2.4%, and fitness added 1.2%. Existing adult equations had low correlations with observed MHR in children and adolescents (r = -0.03-0.34). Conclusions: A new equation to predict MHR in children and adolescents was developed, but was found to have low predictive ability, a finding similar to adult equations applied to children. Clinical Relevance: Considering the narrow range of MHR in youth, we propose using 197 b⋅min-1 as the mean MHR in children and adolescents, with 180 b⋅min-1 the minimal threshold value (-2 standard deviations). [ABSTRACT FROM AUTHOR]

Objective: Pediatric concussion is an extensive public health concern with a complex clinical presentation. Balance assessment has been well-studied in the adult population, but has been limited in children. We aimed to assess the reliability and minimum detectable change (MDC) of the Balance Error Scoring System (BESS) in healthy children. Design: This prospective observational study included 373 healthy children aged 5 to 14. Interrater reliability was assessed by having 4 assessors review videos of 50 random subjects distributed evenly by age and sex across the entire cohort. Intrarater reliability was performed by having assessors review videos of other assessors' live evaluations. Test-retest reliability was obtained by comparing BESS scores as recorded live at the 2 separate time points by the same rater. Setting: Local elementary and junior high schools. Participants: Three hundred and seventy three healthy children between the ages of 5 and 14. Interventions: The BESS was performed on all children. Main Outcome Measures: Intraclass Correlation Coefficients (ICCs) and MDC Scores. Results: The overall interrater ICC was determined to be 0.93 [95% confidence interval (CI), 0.79-0.97] and intrarater ICC was 0.96 (95% CI, 0.95-0.97) with individual intrarater ICCs ranging between 0.69 and 0.99. The test-retest reliability was 0.90 (95% CI, 0.88-0.92). The MDCs were 9.6, 4.6, and 7.3 points at the 95% CIs for interrater, intrarater, and test-retest comparisons, respectively. No learning effect was seen. Conclusions: The BESS demonstrates excellent reliability in the pediatric population without evidence of a learning effect. [ABSTRACT FROM AUTHOR]

Objective: Pediatric head injuries occur commonly and are being reported in increasing numbers. Balance testing is a key component in the evaluation of suspected concussion, and the balance error scoring system (BESS) is likely the most well-known and widely used measure. To date, normative BESS scores for adults have been reported but not for children. Design: Normative data for BESS scores and modified BESS scores were created in a cohort of healthy children. Potential variables were analyzed as predictors of BESS performance. Setting: Local elementary and junior high schools. Participants: A total of 373 healthy children between the ages of 5 and 14. Interventions: The BESS was performed on all children. Assessment of Risk Factors: Gender, body mass index percentile, previous concussions, athletic participation, age, and the parental opinion of child's balance ability were examined as factors associated with the BESS score. Main Outcome Measures: BESS scores. Results: Normative data are reported, stratified by age groups of 5 to 7 years, 8 to 10 years, and 11 to 14 years of age, for both BESS and modified BESS. Median BESS scores are 23 for children aged 5 to 7, 18 for children aged 8 to 10, and 16 for children aged 11 to 14. Median modified BESS scores are 8 for children age 5 to 7, 5 for children age 8 to 10, and 4 for children age 11 to 14. Increasing age and positive parental opinion regarding their child's balance ability were independently correlated with decreasing BESS scores (P < 0.01). Conclusions: The normative data on BESS scores for healthy children reported here provide age-stratified reference values for suspected balance alterations. [ABSTRACT FROM AUTHOR]

Objective: Young athletes not uncommonly complain of back pain. Many patient-reported outcome measures are used to evaluate back pain, but none have been designed specifically to assess young, athletic patients. The Micheli Functional Scale (MFS) was developed to measure impairment due to back pain in this population. This study examined the reliability, validity, and responsiveness of the MFS used in routine clinical assessments. Design: Retrospective Cohort Study. Setting: Pediatric sports medicine specialty clinic. Interventions: Patients presenting with a chief concern of back pain over 1 year (n = 93) were enrolled in the study. Study subjects were administered the MFS and the revised Oswestry Disability Index (ODI) at each visit as part of routine clinical care. Main Outcome Measures: Reliability of the MFS was assessed by calculating Cronbach alpha (a). Concurrent validity was determined by measuring Spearman coefficient (rs) for the correlations between the MFS and ODI. Results: Ninety-three patients (50 female, 43 male), mean age 14.1 ± 2.3 years were enrolled and 242 clinic encounters (71 initial/ 171 follow-up visits) analyzed. The MFS had acceptable item reliability (α = 0.786) and concurrent validity: the MFS and ODI were strongly and positively correlated [rs = 0.824 (P < 0.001)]. The MFS was comparatively more reliable and valid when used in follow-up versus initial visits. Conclusions: The MFS is a reliable and valid instrument in assessing young athletes with back pain, although the instrument has different performance characteristics on initial versus follow-up assessments. Further work is needed to refine the MFS to enhance the instrument's reliability, validity, and responsiveness. Clinical Relevance: This study provides further insight into an outcome measure of clinical use in evaluating young athletes with back pain. [ABSTRACT FROM AUTHOR]

Here, we present a rare case of a preadolescent boy with a prominent bony bump on the femoral neck. The main histological feature was concordant with a reactive osteochondromatous lesion possibly induced by repetitive microtrauma, probably because of overtraining as a soccer goalkeeper. The nature of this pathological change is consistent with the growth of a cam deformity. Especially in the preadolescent age group, we should note that repetitive use of the same joint kinematics may induce a prominent cam deformity. [ABSTRACT FROM AUTHOR]

Background: Preparticipation physical examinations (PPEs) are required for children and adolescents before sports participation to identify at-risk athletes. These evaluations can be completed in a traditional office-based setting or in a station-based format. It is unclear if one format is superior to the other in identifying at-risk athletes. Methods: We performed a retrospective chart review of children and adolescents between the ages 10 and 18 years who received their PPE in our office or in a station-based setting in a local high school between the years 2009 and 2015. Results: We reviewed 2934 PPEs total, 1136 in the office-based format and 1798 in the station-based setting. A similar proportion of athletes were excluded or required further evaluation before participation in the office compared with the station-based setting (4.84% vs 5.67%). No statistically significant associations were seen between site of PPE or athlete sex and rate of clearance. There was, however, a statistically significant association between PPE site and reason for exclusion (P = 0.0456) with higher rates of exclusion for vision-related issues in the station-based setting and higher rates of exclusion for musculoskeletal or cardiopulmonary reasons in the office-based setting. Conclusion: When conducted by the same examiners, the office-based and team-based PPE excluded or referred equal number of athletes, although the reason for further evaluation does differ based on setting. [ABSTRACT FROM AUTHOR]

Objective: To examine postural instability in children acutely after concussion, using the Wii Balance Board (WBB). We hypothesized that children with traumatic brain injury would have significantly worse balance relative to children without brain injury. Design: Prospective case-control pilot study. Setting: Emergency department of a tertiary urban pediatric hospital. Participants: Cases were a convenience sample 11-16 years old who presented within 6 hours of sustaining concussion. Two controls, matched on gender, height, and age, were enrolled for each case that completed study procedures. Controls were children who presented for a minor complaint that was unlikely to affect balance. Interventions: Not applicable. Main Outcome Measures: The participant's postural sway expressed as the displacement in centimeters of the center of pressure during a timed balance task. Balance testing was performed using 4 stances (single or double limb, eyes open or closed). Results: Three of the 17 (17.6%) cases were too dizzy to complete testing. One stance, double limbs eyes open, was significantly higher in cases versus controls (85.6 vs 64.3 cm, P = 0.04). Conclusions: A simple test on the WBB consisting of a 2-legged standing balance task with eyes open discriminated children with concussion from non-head-injured controls. The low cost and feasibility of this device make it a potentially viable tool for assessing postural stability in children with concussion for both longitudinal research studies and clinical care. Clinical Relevance: These pilot data suggest that the WBB is an inexpensive tool that can be used on the sideline or in the outpatient setting to objectively identify and quantify postural instability. [ABSTRACT FROM AUTHOR]

Objective: The current study examines the demographics, injury characteristics, and outcomes associated with the presence of postconcussion amnesia in young concussion clinic patients. Design: Cross-sectional, retrospective clinical cohort. Setting: Concussion services clinic. Patients: Pediatric and adolescent concussion services program patients, presenting within 10 days postinjury, aged 10-18 years, with the goal of returning to sport (n = 245). Assessment of Risk Factors: Age, gender, race, head trauma history, injury mechanism, loss of consciousness (LOC), injury-related visit to an emergency department, cognitive and balance scores, symptoms, and management recommendations. Main Outcome Measures: Univariate and multivariate analyses determined adjusted odds ratios for reported presence of any postconcussion amnesia (anterograde or retrograde). Results: Factors associated with amnesia (univariate, P, 0.10) and included in the multivariate model were race, head trauma history, mechanism of injury, LOC, injury-related visit to an emergency department, management recommendations and time of injury and initial visit symptom severity. Age and gender were also included in the model due to biological significance. Of the 245 patients, 181 had data for all model variables. Of the 181 patients, 58 reported amnesia. History of head trauma [odds ratio (OR), 2.7; 95% confidence interval (CI), 1.3-5.7]; time of injury (TOI) symptom severity .75th percentile (OR, 2.6; 95% CI, 1.2-5.3) and LOC (OR, 2.2; 95% CI, 1.1-4.6) were found to have significant and independent relationships with amnesia in the multivariate model. Conclusions: This study illustrates that patients presenting with postconcussion amnesia are more likely to have a history of head trauma, LOC, and greater symptom severity. Future research is needed to better understand amnesia following concussion. Clinical Relevance: Amnesia presence, previous head trauma, LOC, and increased symptom severity may aid in identifying patients with a greater initial injury burden who warrant closer observation and more conservative management. [ABSTRACT FROM AUTHOR]

Abstract: Children, older adults, disabled and special needs athletes, and female athletes who participate in outdoor and wilderness sports and activities each face unique risks. For children and adolescents traveling to high altitude, the preparticipation physical evaluation should focus on risk assessment, prevention strategies, early recognition of altitude-related symptoms, management plans, and appropriate follow-up. As the risk and prevalence of chronic disease increases with age, both older patients and providers need to be aware of disease and medication-specific risks relative to wilderness sport and activity participation. Disabled and special needs athletes benefit from careful pre-event planning for the potential medical issues and equipment modifications that may affect their health in wilderness environments. Issues that demand special consideration for female adventurers include pregnancy, contraceptive use, menses, and ferritin levels at altitude. A careful preparticipation evaluation that factors in unique, populationspecific risks will help special populations stay healthy and safe on wilderness adventures. The PubMed and SportDiscus databases were searched in 2014 using both MeSH terms and text words and include peer-reviewed English language articles from 1977 to 2014. Additional information was accessed from Web-based sources to produce this narrative review on preparticipation evaluation for special populations undertaking wilderness adventures. Key words include children, adolescent, pediatric, seniors, elderly, disabled, special needs, female, athlete, preparticipiation examination, wilderness medicine, and sports. [ABSTRACT FROM AUTHOR]

Objective: Complete traumatic avulsion of the ischial tuberosity in young athletes is rare, and the optimal treatment is unclear. The purpose of this article is to present our experience and the efficacy of surgical repair of avulsions of the ischial tuberosity with bony dislocation of more than 2 cm and to discuss the complex postoperative rehabilitation. Methods: Three young athletes sustained complete avulsion of the ischial tuberosity with bony dislocation during different sport activities (long jump, soccer, sprinting). The age at the time of injury ranged from 13.8 to 15 years. All underwent surgical repair with reattachment of the hamstring muscle complex to the origin on the ischium. The time from injury to repair varied from 2 to 22 weeks. All patients underwent a specific postoperative rehabilitation program. Follow-up ranged from 12 to 24 months. Results: All athletes had improved with surgery and had good subjective and objective functional results. One patient needed operative revision 1 day after primary repair because of suture loosening because of excessive muscle contractions during wake up after general anesthesia. Finally, all returned to their preinjury sport at the same level. Conclusions: Young athletes with traumatic avulsion of the ischial tuberosity and dislocation of more than 2 cm benefit from operative repair. Good results were achieved in all cases on the basis of functional recovery and patient satisfaction. Chronic complaints could be avoided, and also return to sport was possible. Surgery under spinal anesthesia is recommended. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine male-female differences in pediatric overuse sports injuries. STUDY DESIGN: Cross-sectional epidemiological study. SETTING: Tertiary level sports medicine division in a large academic pediatric medical center. PARTICIPANTS: Five percent probability sample of patients 5 to 17 years seen from January 1, 2000 to December 31, 2009. About 3813 charts reviewed. Final study cohort included 1614 patients. INTERVENTION: Nonlinear decomposition analysis of male-female differences in overuse injuries. MAIN OUTCOME MEASURES: Age, body mass index, history of previous injury, and activity type (contact/collision, team vs individual, "high overuse"). RESULTS: Females sustained approximately half of the total injuries. Fifty-two percent of the injuries were overuse, 61% to the lower extremity. A high proportion of tennis players, swimmers, dancers, track athletes, runners, gymnasts, and cheerleaders were seen for overuse injuries. Females sustained more overuse injuries versus males (63% and 40%, respectively). Males playing team sports have a 5.3 times higher likelihood of being seen for an overuse injury compared with males not playing team sports (P < 0.01). High-overuse sport participation increased overuse injury odds by a factor of 10 for males versus 3.6 for females (P ≤ 0.01 for males and females). Forty-six percent of the male-female difference in overuse injuries could be attributed to sport/activity characteristics-contact/collision, team, and high overuse. CONCLUSIONS: A large proportion of the sex discrepancy in overuse injuries in this cohort was attributed to compositional differences in sports played. Future research is needed to investigate the independent effect of sex on risk for pediatric sports injuries. CLINICAL RELEVANCE: This study provides a unique analysis of male-female differences in pediatric sports injuries and is the first study to estimate the impact of the different characteristics (ie, collision, team, high overuse) of sports children play on overuse injuries sustained by young athletes. The findings will help guide future prevention efforts. [ABSTRACT FROM AUTHOR]