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In this report, we discuss the case of a now 23-year-old athlete who was diagnosed with mild hemophilia, successfully played varsity soccer throughout high school, and continued to play intramural and club soccer while in college. A prophylactic protocol was developed by the athlete's hematologist to allow his safe participation in contact sports. Similar prophylactic protocols have been discussed by Maffet et al that successfully allowed an athlete to participate in high-level basketball. However, significant barriers still exist for an athlete with hemophilia who wants to engage in contact sports. We discussed how athletes with adequate support networks can participate in contact sports. Decisions need to be made on a case-by-case basis and involve the athlete, family, team, and medical personnel. [ABSTRACT FROM AUTHOR]

Significant health care disparities exist in the United States based on socioeconomic status (SES), but the role SES has in secondary school athletes' access to athletic training services has not been examined on a national scale. To identify differences in access to athletic training services in public secondary schools based on school SES. Cross-sectional study. Database secondary analysis. Data for 3482 public high schools. Data were gathered from the Athletic Training Locations and Services (ATLAS) database, US Census Bureau, and National Center for Education Statistics. We included schools from 5 states with the highest, middle, and lowest poverty percentages (15 states total) and collected county median household income, percentage of students eligible for free or reduced-price lunch, race and ethnicity demographics, and access to athletic training services (full-time athletic trainer [AT], part-time AT only, no AT) for each school. Data were summarized in means, SDs, medians, interquartile ranges (IQRs), frequencies and proportions, 1-way analyses of variance, and Kruskal-Wallis tests. Differences were present in school SES between schools with full-time, part-time-only, and no athletic training services. Schools with greater access to athletic training services had fewer students eligible for free or reduced-price lunch (full time: 41.1% ± 22.3%, part time only: 45.8% ± 24.3%, no AT: 52.9% ± 24.9; P <.001). Similarly, county median household income was higher in schools with increased access to athletic training services (full time median [IQR]: $56 026 [$49 085–$64 557], part time only: $52 719 [$45 355–$62 105], and no AT: $49 584 [$41 094–$57 688]; P <.001). Disparities in SES were seen in access to athletic training services among a national sample of public secondary schools. Access to ATs positively influences student-athletes' health care across several measures. Pilot programs or government funds have been used previously to fund athletic training services and should be considered to ensure equitable access, regardless of school SES. [ABSTRACT FROM AUTHOR]

Running programs traditionally monitor external loads (eg, time and distance). Recent efforts have encouraged a more comprehensive approach to also account for internal loads (eg, intensity, measured as the session rating of perceived exertion [sRPE]). The combination of external and internal loads accounts for the possible interaction between these loads. Although weekly changes in training loads have been reported between external loads and the combination of external and internal loads during 2- and 4-week training cycles, no authors have indicated whether these differences occur during an entire cross-country season in high school runners. To compare changes in training loads, as measured by (1) external loads and (2) combined external and internal loads in high school runners during an interscholastic cross-country season. Case series. Community-based setting with daily online surveys. Twenty-four high school cross-country runners (females = 14, males = 10, age = 15.9 ± 1.1 years, running experience = 9.9 ± 3.2 years). Week-to-week percentage changes in training load were measured by external loads (time, distance) and combined external and internal loads (time × sRPE [timeRPE] and distance × sRPE [distanceRPE]). Overall, the average weekly change was 7.1% greater for distanceRPE than for distance (P =.04, d = 0.18). When the weekly running duration decreased, we found the average weekly change was 5.2% greater for distanceRPE than for timeRPE (P =.03, d = 0.24). When the weekly running duration was maintained or increased, the average weekly change was 10% to 15% greater when external and internal loads were combined versus external loads alone, but these differences were nonsignificant (P =.11–.22, d = 0.19–0.34). Progression in the training load may be underestimated when relying solely on external loads. The interaction between internal loads (sRPE) and external loads (distance or time) appears to provide a different measure of the training stresses experienced by runners than external loads alone. [ABSTRACT FROM AUTHOR]

With 8 million annual US high school student-athletes, the epidemiology of sport-related injuries has garnered significant interest. The most recent studies examining overuse injury rates in high school sports were based on data from 2012 to 2013 and, therefore, may not reflect current overuse injury rates in high school sports. To (1) determine overuse time-loss (TL) and non–time-loss (NTL) injury rates among high school student-athletes using National Athletic Treatment, Injury and Outcomes Network Surveillance Program (NATION-SP) data collected from 2014–2015 to 2018–2019 and (2) compare overuse injury rates based on student-athlete sex defined by whether it was a boys' sport or a girls' sport, the sport itself, and the injury location. Descriptive epidemiology study. Online injury surveillance from 211 high schools (345 individual years of high school data). Athletes who participated in secondary school–sponsored boys' or girls' sports. Boys' and girls' overuse injury data from the NATION-SP during the 2014–2015 to 2018–2019 school years were analyzed. Overuse injuries were identified using a combination of the reported injury mechanism and diagnosis. Time-loss injuries resulted in restriction from participation beyond the day of injury; NTL injuries did not result in restriction from participation beyond the day of injury or involved no lost time due to the injury. Injury counts, rates, and rate ratios (IRRs) were reported with 95% CIs. The total overuse injury rate was 5.3/10 000 athlete-exposures (AEs; 95% CI = 5.1, 5.7), the NTL overuse injury rate was 3.4/10 000 AEs (95% CI = 3.1, 3.6), and the TL overuse injury rate was 2.0/10 000 AEs (95% CI = 1.8, 2.2). The overuse injury rate was greater in girls' sports compared with boys' sports (IRR = 1.9; 95% CI = 1.7, 2.1). The highest rates of overuse injury were observed in girls' cross-country (19.2/10 000 AEs; 95% CI = 15.0, 24.2), girls' track and field (16.0/10 000 AEs; 95% CI = 13.5, 18.8), and girls' field hockey (15.1/10 000 AEs; 95% CI = 10.2, 21.6). Overuse injury rates were higher for the lower extremity than the upper extremity (IRR = 5.7; 95% CI = 4.9, 6.7) and for the lower extremity than the trunk and spine (IRR = 8.9; 95% CI = 7.3, 10.8). Awareness of the overuse injury risk, as well as prevention and intervention recommendations, is necessary and should be specifically targeted at cross-country, field hockey, and track and field athletes. [ABSTRACT FROM AUTHOR]

Where a person lives can have a significant effect on health. Limited access to health care, food insecurity, lack of affordable housing, and violence increase a person's likelihood of poor health. Athletic trainers (ATs) can contribute to identifying and improving the determinants of health that affect student-athletes. (1) What were the current perceptions ATs had about the health behaviors (specifically mental health and substance use) of high school student-athletes? (2) What were the barriers that ATs experienced when providing health services to high school student-athletes? (3) How did the developed environment affect the health behaviors and barriers that ATs observed? Qualitative study. Online survey. Certified National Athletic Trainers' Association members employed in the secondary school setting. Demographics of ATs were collected, and the ATs' perceptions of the health of student-athletes across developed environments, prevalence of mental health issues, tobacco and substance use, barriers to health care services, and housing and food insecurities among student-athletes were surveyed. Descriptive statistics for the outcome measures were reported. A total of 7600 electronic surveys were distributed to the ATs and 911 responded (females = 62%, average age = 36 years, average experience = 12.5 years). The school setting was identified by 82.5% as public and the environment as suburban by 43.7%, rural by 30.1%, and urban by 26.1%. Participants perceived a high average prevalence of mental health concerns (32%), e-cigarette use (31.7%), and marijuana use (26.9%) among student-athletes. Significant perceived barriers to health included limited access to transportation, poverty, and housing and food insecurities. This study highlights the health disparities and barriers ATs observed when addressing the health care needs of student-athletes. Understanding the determinants of health in order to identify the causes of health disparities may better prepare ATs to manage the health needs of underserved student-athletes. [ABSTRACT FROM AUTHOR]

Concussion underreporting leads to delays in diagnosis and treatment, prolonging recovery time. Athletes' self-reporting of concussion symptoms, therefore, reduces risk. To evaluate the effectiveness of 3 concussion-education programs in improving concussion-reporting intention. Randomized controlled clinical trial. Three high schools in California. A total of 118 male football players (age = 14.88 ± 1.19 years). Participants were randomly assigned to receive concussion education via CrashCourse (CC), Centers for Disease Control and Prevention (CDC) video education materials (CDC-Vi), or CDC written education materials (CDC-Wr). The primary outcome was concussion-reporting intention, which was assessed at baseline, immediately after education, and at 1-month follow-up. Secondary outcomes were concussion knowledge, concussion-reporting attitudes, perceived concussion-reporting norms, and perceived behavioral control. Across all education formats, a total sample of athletes improved in concussion-reporting intention at immediate and 1-month follow-ups (mean improvements = 6.8% and 11.4%, respectively; F4,224 = 11.1, P <.001). Similar findings were observed across all education formats in secondary analyses examining knowledge, attitudes, and perceived behavioral control. However, we noted differences in concussion-reporting intention by education format and time (F4,224 = 2.8, P =.03). Post hoc analysis showed that athletes who received CC had increased concussion-reporting intentions at immediate and 1-month follow-ups (baseline = 4.7, immediate follow-up = 6.1, 1-month follow-up = 6.0; F16,61.1 = 6.1, P =.007) compared with increases only at 1-month follow-up for CDC-Vi (baseline = 4.3, immediate follow-up = 5.2, 1-month follow-up = 5.8; F1.6,61.6 = 8.4, P =.001) and no improvement for CDC-Wr (P =.10). Secondary analyses indicated differences between CC and both CDC interventions in concussion knowledge and attitudes at immediate and 1-month follow-ups. We identified no differences in perceived behavioral control among interventions (F4,216 = 0.2, P =.93) or perceived concussion-reporting norms across (F4,224 = 0.3, P =.73) or among (F4,224 = 1.7, P =.15) interventions. All athletes exhibited an improved intent to report concussions, increased concussion knowledge, better concussion attitudes, and more perceived behavioral control at both immediate and 1-month follow-ups. However, athletes randomized to receive CC reported a greater intent to report concussion, more knowledge, and improved concussion-reporting attitudes when compared with those who received CDC-Vi and CDC-Wr. [ABSTRACT FROM AUTHOR]

In spring 2020, schools closed to in-person teaching and sports were cancelled to control the transmission of COVID-19. The changes that affected the physical and mental health among young athletes during this time remain unknown. To identify changes in the health (mental health, physical activity, and quality of life) of athletes that occurred during the COVID-19 pandemic. Cross-sectional study. Sample recruited via social media. A total of 3243 Wisconsin adolescent athletes (age = 16.2 ± 1.2 years, 58% female) were surveyed in May 2020 (During COVID-19). Measures for this cohort were compared with previously reported data for Wisconsin adolescent athletes (n = 5231; age = 15.7 ± 1.2 years, 47% female) collected in 2016 to 2018 (PreCOVID-19). Demographic information included sex, grade, and sport(s) played. Health assessments included the Patient Health Questionnaire-9 Item to identify depression symptoms, the Pediatric Functional Activity Brief Scale to gauge physical activity, and the Pediatric Quality of Life Inventory 4.0 to evaluate health-related quality of life. Univariable comparisons of these variables between groups were conducted via t or χ2 tests. Means and 95% CIs for each group were estimated using survey-weighted analysis-of-variance models. Compared with preCOVID-19 participants, a larger proportion of During COVID-19 participants reported moderate to severe levels of depression (9.7% versus 32.9%, P <.001). Scores of the During COVID-19 participants were 50% lower (worse) on the Pediatric Functional Activity Brief Scale (mean [95% CI] = 12.2 [11.9, 12.5] versus 24.7 [24.5, 24.9], P <.001) and the Pediatric Quality of Life Inventory 4.0 compared with the PreCOVID-19 participants (78.4 [78.0, 78.8] versus 90.9 [90.5, 91.3], P <.001). During the COVID-19 pandemic, adolescent athletes described increased symptoms of depression, decreased physical activity, and decreased quality of life compared with adolescent athletes in previous years. [ABSTRACT FROM AUTHOR]

In the spring of 2020, US schools closed to in-person teaching and sports were cancelled to control the transmission of coronavirus disease 2019 (COVID-19). It is critical to understand the mental and physical health of adolescent athletes during this time. To describe the health of athletes during COVID-19–related school closures and sport cancellations. Cross-sectional study. A national sample recruited via social media. A total of 13 002 US adolescent athletes (age = 16.3 ± 1.2 years, females = 52.9%, males = 47.0%) completed an anonymous online survey. Demographic information collected was sex, grade, sport(s) played, and zip code. Assessments used were the General Anxiety Disorder 7-Item for anxiety, Patient Health Questionnaire 9-Item for depression, the Pediatric Functional Activity Brief Scale for physical activity, and the Pediatric Quality of Life Inventory 4.0 for quality of life. Mental health, physical activity, and health-related quality-of-life variables were compared among sex, grade, sport(s) played, and poverty level using means and 95% confidence intervals (CIs) from the survey-weighted analysis of variance. Females reported a higher prevalence of moderate to severe anxiety symptoms (females = 43.7% versus males = 28.2%). The Pediatric Functional Activity Brief Scale score was highest (best) for grade 9 (mean = 14.5, 95% CI = 14.0, 15.0) and lowest for grade 11 (mean = 10.9, 95% CI = 10.5, 11.3). The prevalence of depression symptoms was highest in team sport (74.1%) and lowest in individual sport (64.9%) participants. The total Pediatric Quality of Life Inventory score was lowest (worst) for athletes from counties with the highest poverty levels (high: mean = 74.5, 95% CI = 73.7, 75.3; middle: mean = 78.9, 95% CI = 78.0, 79.8; and low: mean = 78.3, 95% CI = 77.4, 79.1). The health of US adolescents during the COVID-19–related school closures and sport cancellations varied to differing degrees depending on sex, grade level, type of sport participation, and level of poverty. Health policy experts should consider these findings in the future when creating and implementing policies to improve the health of adolescents in the United States. [ABSTRACT FROM AUTHOR]

Context: Researchers investigating collision and contact sport participation during high school have found mixed results. Understanding the association between current contact and collision sport participation and quality-of-life outcomes can enhance our knowledge about the risks and benefits of sport participation. Objective: -To examine quality-of-life outcomes among high school athletes who reported participation in collision and limitedcontact sports in the year preceding assessment compared with no- or limited-contact sport athletes. Design: Cross - sectional study. Setting: Preparticipation physical examination. Patients or Other Participants: High school athletes 13 18 years of age. Main Outcome Measure(s): We obtained sport participation and Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric-25 outcomes, which assess self-reported, quality-of-life domains in the preceding 7 days (ie, state assessment). Our grouping variable was collision and contact versus no- or limited-contact sport participation during the year preceding assessment. We used multivariable linear regression models to identify the associations between PROMIS scores and associcollision and contact sport participation and adjusted for sex; age; history of bone, muscle, ligament, ortendon injury; history acute fracture or dislocation; and history of concussion. Results: A total of 143 (51 %) athletes reported collision and contact sport participation (24% female, mean age = 15.1 * 1.7 years) and 138 (49%) reported no- or limited-contact sport participation (66% female, mean age = 15.4 i 1.2 years). A higher proportion of collision and contact sport athletes reported history of time loss for bone, muscle, ligament, and tendon injuries (51 % versus 29 %, P < .001) and for acute fracture or dislocation (46% versus 26%, P < .001) than did no- or limitedcontact contact athletes. After adjusting for covariates, we found that collision and contact sport participation was significantly associated with lower state anxiety (B =- 1.072, 95% confidence interval =- 1.834, -0.310, P = . 006) and depressive (13 =-0. 807 % confidence interval =- 1.484, -0.130, P =. 020) symptom scores. Conclusions: Collision and contact sport athletes reported fewer anxiety and depressive symptoms in the week preceding evaluation than did no- or limited-contact sport athletes, but they had more extensive orthopaerlic injury histories. Potential benefjts and risks are associated with collision and contact sport participation. These data reinforce the need to examine the assumption that youth collision and contact sports are associcollision ated with negative quality of life. [ABSTRACT FROM AUTHOR]

Context: Female patients with anterior cruciate ligament reconstruction (ACLR) are less likely to return to sport than males. Psychological readiness predicts successful return to sport, but it is unclear if psychological experiences differ between males and females during recovery. Objective: To explore gender differences in psychological readiness factors of return to sport after ACLR. Design: Qualitative study. Setting: Laboratory. Patients or Other Participants: A total of 12 male (months since surgery = 6.2 ± 1.2) and 13 female (months since surgery = 6.4 ± 1.3) high school athletes with a history of ACLR. Data Collection and Analysis: Participants were interviewed before physician clearance to return to activity. Transcribed interviews were analyzed using deductive thematic coding of 5 themes identified from previous research (psychological distress, self-efficacy, locus of control, athletic identity, and fear of reinjury) and inductive secondary subthematic coding. Gender comparisons were generated within primary themes and secondary subthemes. Results: All deductive themes were consistently reinforced. Male and female participants reported fear of movement, loss of athletic identity, and motivational mindsets for return to sport and self-improvement. Males reported a stronger sense of internal locus of control using positive internal reinforcement, whereas females described balancing internal and external control and valuing external support systems. Male participants described mood changes influenced by physical and social limitations. Female participants closely monitored their emotions throughout recovery and were influenced by rehabilitation fluctuations. Conclusions: Male and female high school athletes described different psychological factors related to return to sport and locus of control as well as psychological distress. Genderspecific psychological interventions may be warranted to overcome psychological barriers after ACLR. [ABSTRACT FROM AUTHOR]

Context: Although it has been suggested that developmental and sociological factors play a role in concussion reporting, the empirical evidence related to this is limited. Objective: To examine the influences of sex, school level, school location, concussion-reporting history, and socioeconomic status on concussion-related knowledge, attitudes, and reporting intentions among middle school and high school athletes. Design: Cross-sectional study. Setting: Master students and High School athletes attending pre-participation examinations (PPEs) were asked to complete paper-based surveys. Patients or Other Participants: Overall, 541 athletes representing 18 sports returned fully completed surveys. Main Outcome Measure(s): Outcomes were concussionrelated knowledge, perceived seriousness, positive feelings about reporting, and self-reporting intentions. We examined group differences in these outcomes across levels of the explanatory variables of sex, school level (middle school versus high school), school location (urban versus rural), concussion self-reporting history (yes or no), and socioeconomic status (free or reduced-price lunch versus no free or reduced-price lunch) using Wilcoxon rank sum tests. Then we used multivariable ordinal logistic regression models to identify predictors of higher score levels for each outcome. Odds ratio (OR) estimates with 95% confidence intervals (Cis) excluding 1.00 were deemed significant. Results: Odds of higher levels of knowledge were higher in urban versus rural school student-athletes (ORAdjusted = 1-81; 95% Cl = 1.03, 3.17), and lower in student-athletes on free or reduced-price lunch versus those not on free or reduced-price lunch (ORAd¡usted = 0.52; 95% Cl = 0.36, 0.77). Similarly, odds of higher levels of seriousness were lower in male versus female student-athletes (ORAdjusted = 0.48; 95% Cl = 0.32, 0.72). Further, odds of higher levels of self-reporting intentions were lower among male versus female student-athletes (ORAdjUSted = 0.53; 95% Cl = 0.37, 0.75). Conclusions: Developmental and sociological factors were differentially associated with concussion-related knowledge, attitudes, and self-reporting intentions. These results can inform medical providers, parents, and coaches with regard to contextspecific clinical assessments of concussion symptoms. [ABSTRACT FROM AUTHOR]

Context: Football is the most popular sport among US high school students and among the highest for sport-related concussion (SRC) incidence. Limited data detail how SRCs affect high school football players' psychosocial and health status beyond short-term injury recovery. Objective: To longitudinally assess how SRCs affected symptoms, depression, and health-related quality of life (HRQoL) in high school football players up to 12 months after SRC. Design: Prospective cohort study. Setting: Thirty-one Wisconsin high schools. Patients or Other Participants: A total of 1176 interscholastic football players (age = 16.0 ± 1.2 years). Main Outcome Measure(s): Participants completed the Post-concussion Symptom Scale (PCSS) from the Sport Concussion Assessment Tool 3 (SCAT3), Patient Health Questionnaire-9 (PHQ-9) for depression, and Pediatric Quality of Life Inventory 4.0 (PedsQL) for HRQoL at enrollment. Participants who sustained an SRC repeated each measure within 72 hours of their injury (onset) and at 7 days (D7), return to play (RTP), and 3 months (M3), 6 months (M6), and 12 months (M12) after SRC. Scores at each time point were compared with each participant's baseline using linear mixed models for repeated measures while controlling for age and previous SRC with participant as a random effect. Results: Sixty-two participants sustained an SRC. Participants reported a higher number of PCSS symptoms, greater symptom severity, and lower PedsQL physical summary scores at onset and D7. From RTP through M12, PCSS symptoms, PCSS severity scores, PedsQL total scores, physical summary, and psychosocial summary were unchanged or improved relative to baseline. The PHQ-9 scores were not higher than baseline at any post-SRC interval. Conclusions: High school football players in this study who sustained an SRC described no sustained adverse health outcomes (increased PCSS symptoms or symptom severity, increased depression symptoms, or lower HRQoL) after their RTP through M12 after injury. [ABSTRACT FROM AUTHOR]

Context: Many factors can affect the injury risk and quality of life among high school athletes. Early sport specialization and club sport participation may be components to consider when assessing the injury risk and quality of life. Objective: To investigate patient-reported quality-of-life and injury-history measures among adolescent athletes at different sport-specialization levels and to compare these measures between those who did and those who did not report participating in club sports. Design: Cross-sectional study. Setting: High school athletic facility. Patients or Other Participants: High school student athletes 13 to 18 years of age were recruited and tested during their annual preseason athletic physical examinations. Main Outcome Measure(s): Our primary grouping variables were sport-specialization level (classified as low, moderate, or high) and club sport participation (organized sport outside of traditional school athletics). Our outcome variables were the Patient-Reported Outcome Measurement Information System Pediatric Profile-37 rating, Severity Measure for Depression--Child score, and injury history. Results: A total of 97 individuals participated (mean age = 15.2 ± 1.1 years; 38% female). Relatively similar proportions of individuals reported participating at each level of sport specialization (low = 34%, moderate ¼ 40%, high ¼ 26%). Forty-six (48%) participants stated they participated in club sports. No differences were evident in quality of life (P values = .15-.92 across domains), depression (P=.60), or injury history (P > .70) among the specialization groups. Those who described participating in club sports had a higher proportion of time-loss musculoskeletal injuries (63% versus 29%; P = .002) and of injuries requiring imaging, injection, a cast, a brace, or crutches (72% versus 46%; P = .013) than those who did not. Conclusions: Although no injury-history differences were found among the sport-specialization groups, a higher proportion of club sport athletes than nonclub sport athletes reported a history of injury. Club sports are generally seen as more competitive, and the higher number of injuries seen in this setting could be related to a higher level of play among club sport athletes. [ABSTRACT FROM AUTHOR]

Context: In 2009, the National Athletic Trainers' Association Inter-Association Task Force (NATA-IATF) released preseason heat-acclimatization guidelines for gradually acclimatizing high school (HS) athletes to the environment during the first 2 weeks of the preseason and reducing the risk of exertional heat illness. However, researchers who studied the 2011 preseason found a low level of overall compliance. Objective: To assess compliance with the NATA-IATF guidelines during the 2017 preseason and compare the findings with 2011 preseason data and between states mandating and not mandating the guidelines. Design: Cross-sectional study. Setting: Preseason HS football, 2017. Patients or Other Participants: A total of 1023 athletic trainers working with HS football (14.2% response rate). Main Outcome Measure(s): Using a survey, we acquired information from athletic trainers on their HS football programs, including location and compliance with 17 NATA-IATF guidelines during the 2017 football preseason. The outcome measures were full compliance with all 17 NATA-IATF guidelines and compliance with >-10 NATA-IATF guidelines. Prevalence ratios (PRs) with 95% confidence intervals (CIs) compared findings between (1) the 2017 and 2011 preseasons and (2) states whose HS athletic associations imposed a full or partial or no mandate to follow the NATA-IATF guidelines. Results: Overall, 3.9% reported full compliance with NATAIATF guidelines; 73.9% complied with >-10 guidelines. The proportion reporting full compliance was higher in 2017 than in 2011 but not statistically different (3.9% versus 2.5%; PR¼1.54; 95% CI ¼ 0.96, 2.46). However, the proportion reporting compliance with >-10 guidelines was higher in 2017 (73.9% versus 57.9%; PR ¼ 1.28; 95% CI ¼ 1.20, 1.36). The proportion of respondents reporting their HSs were fully compliant was highest among the with-mandate group (9.4%), followed by the partial-mandate group (4.6%) and the without-mandate group (0.6%). Group differences retained significance when we examined compliance with >-10 guidelines. Conclusions: Although full compliance with NATA-IATF guidelines remained low, many HS football programs complied with >-10 guidelines. [ABSTRACT FROM AUTHOR]

Context: Implementation of health and safety best practices for the leading causes of sudden death and catastrophic injury has been shown to mitigate risk. However, to our knowledge, no authors have examined progress toward health and safety policy implementation at the state level. Objective: To investigate the progress made by state secondary school leaders in developing and implementing health and safety policies (ie, exertional heat stroke, sudden cardiac arrest, concussion, emergency action plans) and to explore perceived barriers to and strategies for implementation. Design: Mixed-methods study. Setting: State high school athletics associations and sports medicine advisory committees. Patients or Other Participants: Collaborative Solutions for Safety in Sport meeting attendees participated in this study. Thirty-five state leaders (current role experience = 8 ± 6 years) completed the survey. Ten of the 35 participated in follow-up interviews. Data Collection and Analysis: A survey assessing progress on health and safety policy implementation was administered. Respondents indicated whether their state had implemented a policy, made progress without implementation, or made no progress. We conducted follow-up telephone interviews so they could expand on the survey responses. The data were analyzed using descriptive statistics and the general inductive approach. Results: A total of 89% of respondents reported their states made progress on or implemented health and safety policies during the 2015-2016 academic year. Barriers to policy implementation included cost, a lack of understanding regarding policies versus recommendations, the content and value of policy change, and a false sense of security. Strategies for implementation included varying approaches to change, education of all constituents, and collaborative relationships among key stakeholders. Conclusions: Although a majority of respondents reported progress in implementing health and safety policies in their states, perceived barriers pointed to the need for the continued education of state leaders in charge of developing and implementing health and safety policies. Despite these barriers, collaboration among key stakeholders is crucial to successful implementation of best-practice policies in secondary school athletics. [ABSTRACT FROM AUTHOR]

Context: The advent of Web-based sports injury surveillance via programs such as the High School Reporting Information Online system and the National Collegiate Athletic Association Injury Surveillance Program has aided the acquisition of boys' and men's baseball injury data. Objective: To describe the epidemiology of injuries sustained in high school boys' baseball in the 2005-2006 through 2013-2014 academic years and collegiate men's baseball in the 2004-2005 through 2013-2014 academic years using Webbased sports injury surveillance. Design: Descriptive epidemiology study. Setting: Online injury surveillance from baseball teams in high school boys (annual average= 100) and collegiate men (annual average= 34). Patients or Other Participants: Boys' or men's baseball players who participated in practices and competitions during the 2005-2006 through 2013-2014 academic years in high school or the 2004-2005 through 2013-2014 academic years in college, respectively. Main Outcome Measure(s): Athletic trainers collected timeloss injury and exposure data. Injury rates per 1000 athleteexposures (AEs) were calculated. Injury rate ratios (IRRs) with 95% confidence intervals (CIs) compared injury rates by school size or division, time in season, event type, and competition level. Results: The High School Reporting Information Online system documented 1537 time-loss injuries during 1 573 257 AEs; the National Collegiate Athletic Association Injury Surveillance Program documented 2574 time-loss injuries during 804 737 AEs. The injury rate was higher in college than in high school (3.20 versus 0.98/1000 AEs; IRR=3.27; 95% CI=3.07, 3.49). The competition injury rate was higher than the practice injury rate in high school (IRR= 2.27; 95% CI= 2.05, 2.51) and college (IRR= 2.32; 95% CI= 2.15, 2.51). Baseball players at the high school and collegiate levels sustained a variety of injuries across the body, with the most common injuries reported to the upper extremity. Many injuries also occurred while fielding or pitching. Conclusions: Injury rates were greater in collegiate versus high school baseball and in competition versus practice. These findings highlight the need for injury-prevention interventions focused on reducing the incidence of upper extremity injuries and protecting batters from pitches and fielders from batted balls. [ABSTRACT FROM AUTHOR]

Context: Although sport-related internal organ injuries among athletes are relatively infrequent, combining data sources enables a more comprehensive examination of their incidence. Objective: To describe the incidence and characteristics of sport-related internal organ injuries due to direct-contact mechanisms among high school (HS) and collegiate athletes from 2005-2006 through 2014-2015. Design: Descriptive epidemiology study. Setting: United States HS and collegiate sports data from 3 national sports injury-surveillance systems: High School Reporting Information Online (HS RIO), the National Collegiate Athletic Association Injury Surveillance Program (ISP), and the National Center for Catastrophic Sport Injury Research. Patients or Other Participants: High school and collegiate athletes in organized sports. Main Outcome Measure(s): Characteristics of the athlete, event, and injury were examined and stratified by data source and sport. Descriptive statistics of internal organ injuries via direct-contact mechanisms consisted of frequencies and incidence rates (IRs) per 1 000 000 athlete-exposures and 95% confidence intervals (CIs). Results: During the 10-year period, 174 internal organ injuries were captured: 124 in HS RIO and 41 in the ISP; 9 were catastrophic. Most noncatastrophic injuries occurred among males (RIO= 85%, ISP= 89%), in football (RIO= 65%, ISP= 58%), and during competitions (RIO= 67%, ISP= 49%) and were due to player-player contact (RIO=78%, ISP=68%). The highest injury rates were in male contact sports: RIO football (IR= 11.7; 95% CI= 9.1, 14.2) and lacrosse (IR= 10.0; 95% CI= 3.1, 16.9); ISP: football (IR= 8.3; 95% CI= 5.0, 11.6) and ice hockey (IR= 7.9; 95% CI= 1.0, 14.7). A quarter of noncatastrophic injuries were season ending (RIO= 25%, ISP= 23%). Of the 9 catastrophic injuries, most occurred in HS (7/9) and football (7/9) and were due to player-player contact (6/9). Four resulted in death. Conclusions: Direct-contact internal organ injuries occur infrequently; yet when they do occur, they may result in severe outcomes. These findings suggest that early recognition and a better understanding of the activities associated with the event and use or nonuse of protective equipment are needed. [ABSTRACT FROM AUTHOR]

Context: The advent of Web-based sports injury surveillance via programs such as the High School Reporting Information Online system and the National Collegiate Athletic Association Injury Surveillance Program has aided the acquisition of girls' and women's softball injury data. Objective: To describe the epidemiology of injuries sustained in high school girls' softball in the 2005-2006 through 2013-2014 academic years and collegiate women's softball in the 2004-2005 through 2013-2014 academic years using Webbased sports injury surveillance. Design: Descriptive epidemiology study. Setting: Online injury surveillance from softball teams in high school girls (annual average= 100) and collegiate women (annual average= 41). Patients or Other Participants: Girls' or women's softball players who participated in practices and competitions during the 2005-2006 through 2013-2014 academic years in high school and the 2004-2005 through 2013-2014 academic years in college. Main Outcome Measure(s): Athletic trainers collected timeloss injury and exposure data. Injury rates per 1000 athleteexposures (AEs) were calculated. Injury rate ratios (IRRs) with 95% confidence intervals (CIs) compared injury rates by competition level, school size or division, event type, and time in season. Results: The High School Reporting Information Online system documented 1357 time-loss injuries during 1 173 722 AEs; the National Collegiate Athletic Association Injury Surveillance Program documented 1848 time-loss injuries during 579 553 AEs. The injury rate was higher in college than in high school (3.19 versus 1.16/1000 AEs; IRR=2.76; 95% CI=2.57, 2.96). The competition injury rate was higher than the practice injury rate in high school (IRR= 2.02; 95% CI= 1.82, 2.25) and in college (IRR= 1.39; 95% CI= 1.27, 1.52). Softball players at both levels sustained a variety of injuries, with the most common being ankle sprains and concussions. Many injuries also occurred while fielding or running bases. Conclusions: Injury rates were greater in collegiate versus high school softball and in competitions versus practices. These findings highlight the need for injury-prevention interventions, including strength-training and prevention programs to reduce ankle sprains and provide protection for batters from pitches and fielders from batted balls. [ABSTRACT FROM AUTHOR]

Context: Emergency action plans (EAPs) are policies that improve response times and ensure access to emergency equipment for the management of patients with acute injuries and medical conditions, yet the extent to which EAP standards are adopted and implemented is unknown. Objective: To describe the extent of EAP adoption and implementation in secondary school (SS) athletics with athletic trainer (AT) services in the United States. Design: Cross-sectional study. Setting: Web-based questionnaire. Patients or Other Participants: A national sample of ATs (n = 9642) was invited to participate in a Web-based questionnaire. Main Outcome Measure(s): Twelve components of EAP minimum best practices were derived from the "National Athletic Trainers' Association (NATA) Position Statement: Emergency Planning in Athletics.'' Emergency action plan components were analyzed using descriptive statistics with 95% confidence intervals (CIs) around proportions. Contingency tables (2 x 2) were used to calculate odds ratios (with 95% CIs) to assess adoption of the components (dichotomized as yes or no), An estimated 7.8 million athletes participated in secondary school (SS) sports in the United States in 2014-2015, a number that has nearly doubled in the past 40 years.1'2 Unfortunately, the number of injuries sustained in SS sports has increased with participation. Between 1982 and 2015, 752 fatalities were reported among SS athletes, and some of these deaths might have been prevented if emergency action plans (EAPs) had been in place.23 Similar to the procedures for fire drills employment factors (eg, full time versus part time, employed by clinic/district), and access to emergency equipment. Results: The response rate for the questionnaire was 13.2% (n = 1273). A majority of ATs (89.1%) reported having an EAP; however, only 9.9% described implementing all 12 components cited in the NATA position statement. Athletic trainers stated that they created the EAP in 62.8% (95% CI = 60.1%, 65.4%) of schools with an EAP. Athletic trainers employed full time were at greater odds of adopting 9 or more components of the EAP compared with ATs employed part time (odds ratio = 2.42 [95% CI = 1.66, 3.53]). A total of 85.7% of ATs noted access to an automated external defibrillator. Conclusions: Although a majority of SSs had EAPs, the EAPs were often incomplete and lacked the necessary components for full compliance with the NATA position statement. These findings demonstrate the need for efforts to promote the adoption and implementation of comprehensive EAPs in SS athletics. [ABSTRACT FROM AUTHOR]

Context: The advent of Web-based sports injury surveillance via programs such as the High School Reporting Information Online system and the National Collegiate Athletic Association Injury Surveillance Program has aided the acquisition of boys' and men's lacrosse injury data. Objective: To describe the epidemiology of injuries sustained in high school boys' lacrosse in the 2008-2009 through 2013-2014 academic years and collegiate men's lacrosse in the 2004-2005 through 2013-2014 academic years using Webbased sports injury surveillance. Design: Descriptive epidemiology study. Setting: Online injury surveillance from lacrosse teams of high school boys (annual average = 55) and collegiate men (annual average = 14). Patients or Other Participants: Boys' and men's lacrosse players who participated in practices and competitions during the 2008-2009 through 2013-2014 academic years in high school or the 2004-2005 through 2013-2014 academic years in college. Main Outcome Measure(s): Athletic trainers collected timeloss (>24 hours) injury and exposure data. Injury rates per 1000 athlete-exposures (AEs), injury rate ratios (IRRs) with 95% confidence intervals (CIs), and injury proportions by body site and diagnosis were calculated. Results: High School Reporting Information Online documented 1407 time-loss injuries during 662 960 AEs. The National Collegiate Athletic Association Injury Surveillance Program documented 1882 time-loss injuries during 390029 AEs. The total injury rate from 2008-2009 through 2013-2014 was higher in college than in high school (3.77 versus 2.12/1000 AEs; IRR = 1.78; 95% CI = 1.63, 1.94). Most injuries occurred during competitions in high school (61.4%) and practices in college (61.4%). Injury rates were higher in competitions compared with practices in high school (IRR = 3.59; 95% CI = 3.23, 4.00) and college (IRR = 3.38; 95% CI = 3.08, 3.71). Lower limb injuries, muscle strains, and ligament sprains were common at both levels. Concussion was the most frequent competition diagnosis for all high school player positions. Conclusions: Rates of time-loss injury were higher in college versus high school and in competitions versus practices. Attention to preventing common lower leg injuries and concussions, especially at the high school level, is essential to decrease their incidence and severity. [ABSTRACT FROM AUTHOR]

Context: Web-based sports injury surveillance via programs such as the High School Reporting Information Online system and the National Collegiate Athletic Association Injury Surveillance Program has aided efforts to collect data on ice hockey injuries. Objective: To describe the epidemiology of injuries sustained in high school boy's ice hockey in the 2008-2009 through 2013-2014 academic years and collegiate men's and women-s ice hockey in the 2004-2005 through 2013-2014 academic years using Web-based surveillance. Design: Descriptive epidemiology study. Setting: Online injury surveillance of ice hockey teams of high school boys (annual average=34), collegiate men (annual average = 20), and collegiate women (annual average = 11). Patients or Other Participants: Boys', men's, and women's ice hockey players who participated in practices and competitions during the 2008-2009 through 2013-2014 high school academic years or the 2004-2005 through 2013-2014 collegiate academic years. Main Outcome Measure(s): Athletic trainers collected timeloss (≥24 hours) injury and exposure data. We calculated injury rates per 1000 athlete-exposures (AEs), injury rate ratios (IRRs) with 95% confidence intervals (CIs), and injury proportions by body site and diagnosis. Results: The High School Reporting Information Online system documented 831 boys' ice hockey time-loss injuries during 356 997 AEs; the National Collegiate Athletic Association Injury Surveillance Program documented 2611 men's ice hockey time-loss injuries during 552 -642 AEs and 752 women's ice hockey injuries during 232 051 AEs. Injury rates were higher in collegiate men than in high school boys during 2008-2009 through 2013-2014 (4.38 versus 2.33/1000 AEs; IRR = 1.88; 95% CI = 1.73, 2.05) and collegiate women during 2004-2005 through 2013-2014 (IRR = 1.46; 95% CI = 1.34, 1.58). Most injuries occurred during competitions (boys = 80.0%, men = 66.9%, women = 55.3%); injury rates were higher in competitions than in practices for boys (IRR = 8.14; 95% CI = 6.87, 9.65), men (IRR = 6.58; 95% CI = 6.06, 7.13), and women (IRR = 3.63; 95% CI = 3.14, 4.19). At all levels, most injuries occurred to the head/face and shoulder/clavicle and resulted in concussions, contusions, or ligament sprains. Conclusions: Injury rates varied across sports but were consistently higher in competitions than in practices. In competitions, concussions were common injuries, highlighting the need for continued development of injury-prevention strategies. [ABSTRACT FROM AUTHOR]

Context: The advent of Web-based sports injury surveillance via programs such as the High School Reporting Information Online system and the National Collegiate Athletic Association Injury Surveillance Program has aided the acquisition of wrestling injury data. Objective: To describe the epidemiology of injuries sustained in high school boys' wrestling in the 2005-2006 through 2013-2014 academic years and collegiate men's wrestling in the 2004-2005 through 2013-2014 academic years using Webbased sports injury surveillance. Design: Descriptive epidemiology study. Setting: Online injury surveillance from wrestling teams of high school boys (annual average = 100) and collegiate men (annual average = 11). Patients or Other Participants: Male wrestlers who participated in practices and competitions during the 2005-2006 through 2013-2014 academic years in high school or the 2004-2005 through 2013-2014 academic years in college. Main Outcome Measure(s): Athletic trainers collected timeloss (≥24 hours) injuries and exposure data during this time period. Injury rates per 1000 athlete-exposures (AEs), injury rate ratios with 95% confidence intervals, and injury proportions by body site and diagnosis were calculated. Results: The High School Reporting Information Online documented 3376 time-loss injuries during 1 416 314 AEs; the National Collegiate Athletic Association Injury Surveillance Program documented 2387 time-loss injuries during 257 297 AEs. The total injury rate was higher in college than in high school (9.28 versus 2.38/1000 AEs; injury rate ratio = 3.89; 95% confidence interval = 3.69, 4.10). In high school, the most commonly injured body parts for both practices and competitions were the head/face (practices = 19.9%, competitions = 21.4%) and shoulder/clavicle (practices = 14.1%, competitions = 21.0%). In college, the most frequently injured body parts for both practices and competitions were the knee (practices = 16.7%, competitions = 30.4%) and head/face (practices = 12.1%, competitions = 14.6%). Conclusions: Injury rates were higher in collegiate than in high school players, and the types of injuries sustained most often differed. Based on these results, continued study of primary and secondary prevention of injury in wrestlers across levels of competition is warranted. [ABSTRACT FROM AUTHOR]

Context: In many US high schools, the athletic trainer (AT) has the responsibility to identify and manage athletes with concussions. Although the availability of ATs varies a great deal among schools, how the level of AT availability in high schools affects the reported incidence and management of sport-related concussions (SRCs) is unknown. Objective: To determine how the presence of an AT affects the reporting and management of SRCs. Design: Prospective cohort study. Patients or Other Participants: A total of 2459 (female = 37.5%, age=16.1 ± 1.2 years) athletes from 31 Wisconsin high schools were categorized as having low availability (LoAT), mid availability (MidAT), or high availability (HiAT) of ATs. Athletic trainers recorded the incidence, days lost from sport, and postconcussion management through return to sport. The incidence of SRC reporting among categories was examined using a multivariate Cox proportional hazards model. Fisher exact tests were used to determine if postconcussion management differed based on AT availability. Results: The incidence of reported SRCs was lower for the LoAT schools (2.4%) compared with the MidAT (5.6%, hazard ratio = 2.59, P = .043) and HiAT (7.0%, hazard ratio = 3.33, P = .002) schools. The median time before the first AT interaction was longer for LoAT schools (24.0 hours) than for MidAT (0.5 hours, post hoc P = .012) and HiAT (0.2 hours, post hoc P = .023) schools. The number of post-SRC interactions was different in all groups (LoAT = 2 interactions, MidAT = 3, and HiAT = 4; all post hoc P values, .05). Days lost were greater for MidAT and HiAT (both 14 days lost) schools compared with LoAT schools (11.5 days lost, post hoc P = .231 and P = .029, respectively). Athletes at LoAT schools were less likely to undergo a return-to-play protocol (9/18 SRCs, 50.0%) than athletes at MidAT (44/47 SRCs, 93.6%; post hoc P = .001) or HiAT (64/64 SRCs, 100%; post hoc P,< .001) schools. Conclusions: The level of AT availability positively influenced the reported incidence of SRCs as well as postconcussion management activities in this sample of high schools. [ABSTRACT FROM AUTHOR]

Context: The advent of Web-based sports injury surveillance via programs such as the High School Reporting Information Online system and the National Collegiate Athletic Association Injury Surveillance Program has aided the acquisition of girls' and women's basketball injury data. Objective: To describe the epidemiology of injuries sustained in high school girls' basketball in the 2005-2006 through 2013-2014 academic years and collegiate women's basketball in the 2004-2005 through 2013-2014 academic years using Web-based sports injury surveillance. Design: Descriptive epidemiology study. Setting: Online injury surveillance from basketball teams in high school girls (annual average = 100) and collegiate women (annual average = 57). Patients or Other Participants: Girls' and women's basketball players who participated in practices and competitions during the 2005-2006 through 2013-2014 academic years in high school or the 2004-2005 through 2013-2014 academic years in college. Main Outcome Measure(s): Certified athletic trainers collected time-loss (24 hours) injury and exposure data. Injury rates per 1000 athlete-exposures (AEs) were calculated. Injury rate ratios (IRRs) with 95% confidence intervals (CIs) were used to compare injury rates by school size or division, time in season, event type, and competition level. Results: The High School Reporting Information Online system documented 2930 time-loss injuries during 1 609 733 AEs; the National Collegiate Athletic Association Injury Surveillance Program documented 3887 time-loss injuries during 783 600 AEs. The injury rate was higher in college than in high school (4.96 versus 1.82/1000 AEs; IRR=2.73; 95% CI =2.60, 2.86). The injury rate was higher in competitions than in practices for both high school (IRR = 3.03; 95% CI = 2.82, 3.26) and collegiate (IRR = 1.99; 95% CI = 1.86, 2.12) players. The most common injuries at both levels were ligament sprains, concussions, and muscle/tendon strains; the majority of injuries affected the ankle, knee, and head/face. These injuries were often caused by contact with another player or a noncontact mechanism. Conclusions: Injury rates were higher in collegiate than in high school athletes and in competitions than in practices. Similarities in distributions of injuries by body parts, specific diagnoses, and mechanisms of injury suggest that both levels may benefit from similar injury-prevention strategies. [ABSTRACT FROM AUTHOR]

Context: The advent of Web-based sports injury surveillance via programs such as the High School Reporting Information Online system and the National Collegiate Athletic Association Injury Surveillance Program has aided the acquisition of data for girls' and women's field hockey injuries. Objective: To describe the epidemiology of injuries sustained in high school girls' field hockey in the 2008-2009 through 2013-2014 academic years and collegiate women's field hockey in the 2004-2005 through 2013-2014 academic years using Web-based sports injury surveillance. Design: Descriptive epidemiology study. Setting: Online injury surveillance from field hockey teams in high school girls (annual average=61) and collegiate women (annual average = 14). Patients or Other Participants: Girls' and women's field hockey players who participated in practices and competitions during the 2008-2009 through 2013-2014 high school academic years and the 2004-2005 through 2013-2014 collegiate academic years. Main Outcome Measure(s): Athletic trainers collected timeloss (≥24 hours) injury and exposure data. Injury rates per 1000 athlete-exposures (AEs), injury rate ratios (IRRs) with 95% confidence intervals (CIs), and injury proportions by body site and diagnosis were calculated. Results: The High School Reporting Information Online system documented 983 time-loss injuries during 569 551 AEs; the National Collegiate Athletic Association Injury Surveillance Program documented 996 time-loss injuries during 185 984 AEs. The injury rate from 2008-2009 through 2013-2014 was higher in college than in high school (3.25 versus 1.73/1000 AEs; IRR= 1.89; 95% CI = 1.63, 2.18). Most injuries occurred during practices in high school (52.0%) and college (60.7%). Injury rates were higher during competitions than practices in high school (IRR = 2.00; 95% CI = 1.76, 2.26) and college (IRR = 1.96; 95% CI = 1.73, 2.23). At both levels, injuries most commonly occurred to the lower extremity and head/face and resulted in muscle/tendon strains and contusions. However, injury patterns varied between practices and competitions. Conclusions: Injury rates and patterns varied across age groups and between practices and competitions, highlighting the need for development of targeted injury-prevention strategies at both levels of play. [ABSTRACT FROM AUTHOR]

Context: The advent of Web-based sports injury surveillance via programs such as the High School Reporting Information Online system and the National Collegiate Athletic Association Injury Surveillance Program has aided in the acquisition of girls' and women's volleyball injury data. Objective: To describe the epidemiology of injuries sustained in high school girls' volleyball in the 2005-2006 through 2013-2014 academic years and collegiate women's volleyball in the 2004-2005 through 2013-2014 academic years using Webbased sports injury surveillance. Design: Descriptive epidemiology study. Setting: Online injury surveillance from high school girls' (annual average=100) and collegiate women's (annual average = 50) volleyball teams. Patients or Other Participants: Girls' and women's volleyball players who participated in practices and competitions during the 2005-2006 through 2013-2014 academic years in high school and the 2004-2005 through 2013-2014 academic years in college. Main Outcome Measure(s): Athletic trainers collected timeloss (≥24 hours) injury and exposure data. Injury rates per 1000 athlete-exposures (AEs), injury rate ratios (IRRs) with 95% confidence intervals (CIs), and injury proportions by body site and diagnosis were calculated. Results: The High School Reporting Information Online system documented 1634 time-loss injuries during 1 471 872 AEs; the National Collegiate Athletic Association Injury Surveillance Program documented 2149 time-loss injuries during 563 845 AEs. The injury ratewas higher in college than in high school (3.81/ 1000 versus 1.11/1000 AEs; IRR=3.43; 95%CI=3.22, 3.66), and higher in high schools with ≤1000 students than in those with .1000 students (IRR=1.35; 95% CI=1.23, 1.49). Injury rates did not vary by collegiate division. The injury rate was higher during competitions than practices for high school (IRR=1.23; 95% CI= 1.12, 1.36) but not for college (IRR= 1.01; 95% CI= 0.92, 1.10). Ankle sprains were common in both the high school and collegiate setting. However, liberos had a high incidence of concussion. Conclusions: Injury rates were higher among collegiate than high school players. However, injury rates differed by event type in high school, unlike college. Concussion injury patterns among liberos varied from those for other positions. These findings highlight the need for injury-prevention interventions specific to setting and position. [ABSTRACT FROM AUTHOR]

Context: Recent recommendations have emphasized return- to-learn (RTL) protocols to aid athletes in recovery from sport-related concussion (SRC) but have been based primarily on anecdotal evidence. Objective: To investigate the RTL practices of certified athletic trainers (ATs) after an SRC. Design: Cross-sectional study. Setting: Online survey. Patients or Other Participants: A total of 1083 individuals (27%) from a random sample of 4000 ATs in the National Athletic Trainers' Association membership database completed an electronic survey. Participants consisted of 729 self-identified secondary school ATs (SSATs; 67.3%; experience=14.0 6 9.7 years) and 354 self-identified collegiate ATs (CATs; 32.7%; experience = 13.4 ± 6 9.7 years). Main Outcome Measure(s): We used x2 analyses to assess respondent differences related to current knowledge, current practices, and available resources. Independent t tests were used to compare SSATs and CATs on years of certification and annual number of SRCs evaluated. Results: Of our total respondents, 41.2% (n=446) correctly indicated the absence of evidence-based RTL guidelines. Whereas most (73.9%, n=800) respondents had an established RTL policy, only 38.1% (n = 413) used such guidelines in their clinical practice. Most (97.1%, n = 708) SSATs and 82.2% (n = 291) of CATs had access to (a) mental health professional(s); however, minorities of SSATs (21.4%, n = 156) and CATs (37.0%, n = 131) never accessed these resources to care for concussed student-athletes. Conclusions: Our results suggested that, despite the absence of empirical evidence, most surveyed ATs incorporated some form of RTL protocol in their SRC management policy. The varying AT knowledge, clinical practices, and resources highlighted by our results should be considered when creating or refining an RTL protocol. [ABSTRACT FROM AUTHOR]

Context: Participation in high school athletics carries a substantial risk of musculoskeletal injury, particularly to the knee. However, limited information is available on the care being provided by athletic trainers (ATs) for athletes with these injuries. Design: Descriptive epidemiology study. Setting: Data on athletic training facility visits and AT services were collected from 147 high schools in 26 states. Patients or Other Participants: High school studentathletes who participated in 13 boys' sports and 14 girls' sports and sustained a diagnosed knee injury during the 2011-2012 through 2013-2014 academic years. The ATs documented 6797 knee injuries, with 4242 sustained in boys' sports and 2555 sustained in girls' sports. Main Outcome Measure(s): The number of athletic training facility visits and individual AT services as well as the average, median, and interquartile range of athletic training facility visits (per injury) and AT services (per injury) were calculated by sport and for time-loss (TL; participation restricted for ≥ 24 hours) and non- time-loss (NTL; participation restricted for <24 hours) injuries. Results: In total, 28 788 athletic training facility visits were reported, with an overall average of 4 athletic training facility visits per knee injury over the 3-year period. Most athletic training facility visits (72.6%) were associated with NTL injuries, but the majority of AT services (68.6%) were associated with TL injuries. A total of 81 245 AT services were provided for all knee injuries. Therapeutic activities or exercise were the most common type of AT service (52.5%). Overall, an average of 12 AT services were reported per knee injury. Compared with NTL injuries, TL injuries had a larger average number of AT services per injury (34 versus 9; P < .001). Conclusions: Knee injuries at the high school level are a considerable health care burden. This report demonstrates a high proportion of AT attention to the evaluation and treatment of these injuries. This study confirms the recommended management of knee injuries, with neuromuscular and therapeutic activities being the primary services after knee injury. [ABSTRACT FROM AUTHOR]

Context: Data regarding the epidemiology of emergencytransport incidents (ETIs) of patients with sport-related injuries are lacking. Understanding the use of emergency services by athletic trainers can help improve emergency preparedness and prehospital care for injured student-athletes. Objective: To determine the frequencies and types of ETIs resulting from athletic participation. Design: Descriptive epidemiology study. Setting: Participating colleges and high schools during 2009-2010 to 2014-2015 and 2011-2012 to 2013-2014, respectively. Patients or Other Participants: Student-athletes in 23 high school and 25 intercollegiate sports. Main Outcome Measure(s): Data on injuries requiring emergency transport were collected by each team's athletic trainer via their respective online injury-tracking software. Athletic trainers also collected data on athlete-exposures (AEs). Emergency-transport incident frequencies and injury rates per 10 000 AEs with 95% confidence intervals (CIs) were reported. For each ETI, the sport, body part, injury mechanism, and final diagnosis were recorded. Results: A total of 339 and 146 ETIs were reported in collegiate and high school players, respectively. Collegiate women's ice hockey had the highest ETI rate (1.28/10 000 AEs; 95% CI = 0.71, 1.86). In high school, football had the highest rate at 0.80 per 10 000 AEs (95% CI = 0.64, 0.97). Athletes with head or face injuries required the most transports in college (n = 71, 20.9%) and high school (n = 33, 22.6%) across all sports. Strains (n = 50, 14.7%) and fractures (n = 35, 24.0%) were the leading diagnoses for patients undergoing transport in college and high school, respectively. Conclusions: Athletic trainers should maintain a high level of emergency preparedness when working with sports that have high rates and numbers of ETIs. Athletes with injuries to the head/face required the most frequent transport across competition levels. Athletic trainers should have the appropriate equipment and protocols in place to handle these patients. Future researchers should examine the differences between field and hospital diagnoses to help improve prehospital care and decrease the likelihood of unnecessary emergency transports. [ABSTRACT FROM AUTHOR]

Context: The advent of Web-based sports injury surveillance via programs such as the High School Reporting Information Online system and the National Collegiate Athletic Association Injury Surveillance Program has aided the acquisition of boys' and men's soccer injury data. Objective: To describe the epidemiology of injuries sustained in high school boys' soccer in the 2005-2006 through 2013-2014 academic years and collegiate men's soccer in the 2004-2005 through 2013-2014 academic years using Webbased sports injury surveillance. Design: Descriptive epidemiology study. Setting: Online injury surveillance from soccer teams of high school boys (annual average = 100) and collegiate men (annual average = 41). Patients or Other Participants: Boys' or men's soccer players who participated in practices and competitions during the 2005-2006 through 2013-2014 academic years in high school and the 2004-2005 through 2013-2014 academic years in college, respectively. Main Outcome Measure(s): Athletic trainers collected timeloss (24 hours) injury and exposure data. Injury rates per 1000 athlete-exposures (AEs), injury rate ratios (IRRs) with 95% confidence intervals (CIs), and injury proportions by body site and diagnosis were calculated. Results: High School Reporting Information Online documented 2912 time-loss injuries during 1 592 238 AEs; the National Collegiate Athletic Association Injury Surveillance Program documented 4765 time-loss injuries during 686 918 AEs. The injury rate was higher in college than in high school (6.94 versus 1.83/1000 AEs; IRR = 3.79; 95% CI = 3.62, 3.97). Injury rates increased with smaller school size for high schools and were higher in Division I than in Divisions II and III. The injury rate was higher during competitions than during practices in both high school (IRR = 3.55; 95% CI = 3.30, 3.83) and college (IRR= 3.45; 95% CI = 3.26, 3.65). Most injuries were to the lower extremity. However, concussion was a common injury, particularly in collegiate goalkeepers and at all positions for high school players. Concussions accounted for more than one-fifth of injuries in high school games. Conclusions: Injury-prevention interventions should be tailored to reflect variations in the incidence and type of injury by level of competition, event type, and position. [ABSTRACT FROM AUTHOR]

Context: The advent of Web-based sports injury surveillance via programs such as the High School Reporting Information Online system and the National Collegiate Athletic Association Injury Surveillance Program has aided the acquisition of girls' and women's soccer injury data. Objective: To describe the epidemiology of injuries sustained in high school girls' soccer in the 2005-2006 through 2013-2014 academic years and collegiate women's soccer in the 2004-2005 through 2013-2014 academic years using Webbased sports injury surveillance. Design: Descriptive epidemiology study. Setting: Online injury surveillance from soccer teams in high school girls (annual average = 100) and collegiate women (annual average = 52). Patients or Other Participants: Female high school and collegiate soccer players who participated in practices or competitions during the 2004-2005 through 2013-2014 academic years. Main Outcome Measure(s): Athletic trainers collected timeloss (=24 hours) injury and exposure data. Injury rates per 1000 athlete-exposures (AEs), injury rate ratios (IRRs) with 95% confidence intervals (CIs), injury proportions by body site, and diagnoses were calculated. Results: The High School Reporting Information Online system documented 3242 time-loss injuries during 1 393 753 AEs; the National Collegiate Athletic Association Injury Surveillance Program documented 5092 time-loss injuries during 772 048 AEs. Injury rates were higher in college than in high school (6.60 versus 2.33/1000 AEs; IRR =2.84; 95% CI =2.71, 2.96), and during competitions than during practices in high school (IRR = 4.88; 95% CI = 4.54, 5.26) and college (IRR = 2.93; 95% CI = 2.77, 3.10). Most injuries at both levels affected the lower extremity and were ligament sprains or muscle/tendon strains. Concussions accounted for 24.5% of competition injuries in high school but 14.6% of competition injuries in college. More than one-third of competition injuries to high school goalkeepers were concussions. Conclusions: Injury rates were higher in college versus high school and during competitions versus practices. These differences may be attributable to differences in reporting, activity intensity, and game-play skill level. The high incidence of lower extremity injuries and concussions in girls' and women's soccer, particularly concussions in high school goalkeepers, merits further exploration and identification of prevention strategies. [ABSTRACT FROM AUTHOR]

Context: Implementation of best-practice health and safety policies has been shown to be effective at reducing the risk of sudden death in sport; however, little is known about the extent to which these policies are required within secondary school athletics. Objective: To examine best-practice health and safety policies pertaining to the leading causes of sudden death and to concussion management in sport mandated at the state level for secondary school athletics. Design: Descriptive observational study. Setting: State high school athletic associations (SHSAAs), state departments of education, and enacted legislation. Patients or Other Participants: United States (including the District of Columbia) SHSAAs. Main Outcome Measure(s): A review of SHSAA health and safety policies for the 2016-2017 academic year, state department of education policies, and enacted legislation was undertaken to assess the polices related to the leading causes of sudden death and concussion management in sport. Current best-practice recommendations used to assess health and safety policies were specific to emergency action plans, Context: Implementation of best-practice health and safety policies has been shown to be effective at reducing the risk of sudden death in sport; however, little is known about the extent to which these policies are required within secondary school athletics. Objective: To examine best-practice health and safety policies pertaining to the leading causes of sudden death and to concussion management in sport mandated at the state level for secondary school athletics. Design: Descriptive observational study. Setting: State high school athletic associations (SHSAAs), state departments of education, and enacted legislation. Patients or Other Participants: United States (including the District of Columbia) SHSAAs. Main Outcome Measure(s): A review of SHSAA health and safety policies for the 2016-2017 academic year, state department of education policies, and enacted legislation was undertaken to assess the polices related to the leading causes of sudden death and concussion management in sport. Current best-practice recommendations used to assess health and safety policies were specific to emergency action plans, [ABSTRACT FROM AUTHOR]

Context: The advent of Web-based sports injury surveillance via programs such as the High School Reporting Information Online system and the National Collegiate Athletic Association Injury Surveillance Program has aided the acquisition of football injury data. Objective: To describe the epidemiology of injuries sustained in high school football in the 2005-2006 through 2013-2014 academic years and collegiate football in the 2004-2005 through 2013-2014 academic years using Web-based sports injury surveillance. Design: Descriptive epidemiology study. Setting: Online injury surveillance from football teams of high school boys (annual average = 100) and collegiate men (annual average = 43). Patients or Other Participants: Football players who participated in practices and competitions during the 2005-2006 through 2013-2014 academic years in high school or the 2004-2005 through 2013-2014 academic years in college. Main Outcome Measure(s): Athletic trainers collected time-loss injury (≥24 hours) and exposure data. Injury rates per 1000 athlete-exposures (AEs), injury rate ratios (IRRs) with 95% confidence intervals (CIs), and injury proportions by body site and diagnosis were calculated. Results: The High School Reporting Information Online system documented 18 189 time-loss injuries during 4 539 636 AEs; the National Collegiate Athletic Association Injury Surveillance Program documented 22 766 time-loss injuries during 3 121 476 AEs. The injury rate was higher among collegiate than high school (7.29 versus 4.01/1000 AEs; IRR = 1.82; 95% CI = 1.79, 1.86) athletes. Most injuries occurred during competitions in high school (53.2%) and practices in college (60.9%). The competition injury rate was higher than the practice injury rate among both high school (IRR = 5.62; 95% CI = 5.46, 5.78) and collegiate (IRR = 6.59; 95% CI = 6.41, 6.76) players. Most injuries at both levels affected the lower extremity and the shoulder/clavicle and were diagnosed as ligament sprains and muscle/tendon strains. However, concussion was a common injury during competitions among most positions. Conclusions: Injury rates were higher in college than in high school and higher for competitions than for practices. Concussion was a frequent injury sustained during competitions, which confirms the need to develop interventions to mitigate its incidence and severity. [ABSTRACT FROM AUTHOR]

Objective: To describe the methods of the National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP) and High School Reporting Information Online (HS RIO) system as a complement to the sport-specific manuscripts that will follow. Background: The NCAA-ISP and HS RIO collect injury and exposure data from samples of collegiate and high school sports programs, respectively. The NCAA-ISP, which the NCAA has maintained since 1982, was relaunched as a Web-based platform at the beginning of the 2004-2005 academic year. In 2005, the HS RIO was introduced to capture data on high school athletes and modeled after the NCAA-ISP. Relevant data are shared with the NCAA and high school sport and policy committees to develop evidence-based rules and programs that help protect the health and safety of student-athletes. Description: The NCAA-ISP and HS RIO monitor participation in school-sanctioned competitions and practices that occur from the first preseason practice to the final postseason contest for more than 25 sports. For this series of publications in the Journal of Athletic Training, injury information on 13 sports at the collegiate level during the 2004-2005 through 2013-2014 academic years and the high school level during the 2005-2006 through 2013-2014 academic years was evaluated. Conclusions: Athletic trainers have been a vital source of data collection over the past decade to help produce the largest datasets of collegiate and high school sports injuries. Such data have helped various sport and policy committees advance protocols that aim to increase sports safety. This series of publications will aid by continuing to provide data to stakeholders in the sports community. [ABSTRACT FROM AUTHOR]

Context: Annually, more than 1 million youth athletes in the United States receive or are suspected of receiving a concussion. The Balance Error Scoring System (BESS) is the most commonly used clinical balance evaluation designed to provide a better understanding of the motor-control processes of individuals with concussion. Despite the widespread use of the BESS, a fundamental gap exists in applying this tool to young athletes, as normative values are lacking for this population. Objective: To determine age- and sex-specific normative values for the BESS in youth, high school, and collegiate athletes. Design: Cross-sectional study. Setting: Local youth sport organizations, high schools, and colleges. Patients or Other Participants: Student-athletes (N = 6762) completed preseason baseline concussion testing as part of a comprehensive concussion-management program. Groups were youth males aged 5 to 13 years (n = 360), high school males aged 14 to 18 years (n = 3743), collegiate males aged 19 to 23 years (n=497), youth females aged 5 to 13 years (n = 246), high school females aged 14 to 18 years (n = 1673), and collegiate females aged 19 to 23 years (n = 243). Main Outcome Measure(s): Errors according to the BESS specifications. Results: Performance on the BESS was worse (P , .01) in youth athletes than in high school and collegiate athletes. In the youth and high school cohorts, females exhibited better scores than males (P , .05). Sex was not a factor for collegiate athletes. Data from the youth cohort were further subdivided into 4-year bins to evaluate potential motor-development differences. The error count was highest for 5- to 9-year-old males and decreased with age. Conclusions: Performance on the BESS depended on sex and age, particularly in youth athletes. These sex- and agespecific normative values provide a reference to facilitate and unify clinical decision making across multiple providers caring for youth athletes with concussions. [ABSTRACT FROM AUTHOR]

Context: Injury risks in professional and community rugby union have been extensively described; however, less is known about injury epidemiology at the schoolboy level. Objective: To investigate the injury risk in English schoolboy rugby union matches, comparing an elite competition (Achieving Academic and Sporting Excellence [AASE]) with subelite matches (non-AASE). Design: Retrospective cohort study. Setting: Rugby union academy, consisting of 16- to 19- year-old males, based at an elite sports college in England. Patients or Other Participants: A total of 132 participants (mean age=17.5 years) were included in the study; 64 athletes experienced a total of 103 time-loss injuries over a 3-season period (2012-2015). All injuries were assessed and recorded by the team therapist using consensus statement definitions. Main Outcome Measure(s): Injury characteristics were recorded and compared between groups. Primary outcome measures were injury incidence (per 1000 h match exposure) and injury burden (days absent/1000 h), and rate ratios and 95% confidence intervals are presented throughout. Results: A total of 131 matches were played (34 AASE, 97 non-AASE) and a total of 103 injuries were recorded (47 AASE, 56 non-AASE). The injury incidence in AASE matches (77/1000 h) was greater than in non-AASE matches (34/1000 h). The concussion incidence in AASE matches (20/1000 h) was 5 times that of non-AASE matches (4/1000 h). The head/face had the highest injury incidence for a specific location, followed by the shoulder region (AASE = 19/1000 h, non-AASE = 5/1000 h), which had the greatest injury burden (553/1000 h and 105/1000 h, respectively) for any specific body location. More than 50% of all injuries were associated with tackles. Conclusions: A much greater incidence of all injuries occurred at the highest level of competition, and the concussion incidence was greater than that reported in any previously published study of youth rugby. Given the high incidence and burden of concussions and shoulder injuries, prevention and management deserve specific focus. [ABSTRACT FROM AUTHOR]

Context: Many high school pitchers play another position after they have finished pitching for the day or on their rest days from pitching. Because of the cumulative demands on the arm, pitchers who also play catcher may have a greater risk of developing a throwing-related shoulder or elbow injury. Objective: To compare the rate of throwing-related upper extremity injuries between high school baseball pitchers who also played catcher as a secondary position and those who did not play catcher. Design: Prospective cohort study. Setting: Field laboratory. Patients or Other Participants: A total of 384 male high school baseball pitchers were recruited from 51 high school teams. Pitchers who reported their secondary position as catcher were classified into the pitcher/catcher group and those who did not report playing catcher as a secondary position were classified into the other group. Main Outcome Measure(s): Participants completed a demographic questionnaire preseason and then athlete participation and injury status were tracked during the subsequent season. Athlete-exposures were monitored and the shoulder and elbow injury proportion rates were calculated. Results: Athlete-exposures did not differ between groups (P = .488). The pitcher/catcher group's risk of shoulder or elbow injury was 2.9 times greater than that of the other pitchers (15% versus 5%; injury proportion rate = 2.9; 95% confidence interval = 1.03, 8.12). Conclusions: Pitchers who reported also playing catcher were at a greater risk of sustaining a throwing-related shoulder or elbow injury than the other pitchers. These findings suggest that pitchers should consider not playing catcher as their secondary position in order to allow adequate time for recovery and to decrease their overall throwing load. Serial physical examinations of pitchers/catchers during the season may be useful in determining if their physical characteristics are changing during the season because of the cumulative throwing load. [ABSTRACT FROM AUTHOR]

Context: Subclinical postural-control changes may persist beyond the point when athletes are considered clinically recovered postconcussion. Objective: To compare postural-control performance between former high school football players with or without a history of concussion using linear and nonlinear metrics. Design: Case-control study. Setting: Clinical research laboratory. Patients or Other Participants: A total of 11 former high school football players (age range, 45-60 years) with 2 or more concussions and 11 age- and height-matched former high school football players without a history of concussion. No participant had college or professional football experience. Main Outcome Measure(s): Participants completed the Sensory Organization Test. We compared postural control (linear: equilibrium scores; nonlinear: sample and multiscale entropy) between groups using a 2 3 3 analysis of variance across conditions 4 to ± (4: eyes open, sway-referenced platform; 5: eyes closed, sway-referenced platform; 6: eyes open, sway-referenced surround and platform). Results: We observed a group-by-condition interaction effect for medial-lateral sample entropy (F2,40 = 3.26, P = .049, gp 2=0.140). Participants with a history of concussion presented with more regular medial-lateral sample entropy values (0.90 ± 0.41) for condition 5 than participants without a history of concussion (1.30 ± 0.35; mean difference = -0.40; 95% confidence interval [CI] =-0.74, -0.06; t20 =-2.48, P = .02), but conditions 4 (mean difference=-0.11; 95% CI: -0.37, 0.15; t20 =-0.86, P = .40) and ± (mean difference =-0.25; 95% CI: -0.55, 0.06; t20=-1.66, P = .11) did not differ between groups. Conclusions: Postconcussion deficits, detected using nonlinear metrics, may persist long after injury resolution. Subclinical concussion deficits may persist for years beyond clinical concussion recovery. [ABSTRACT FROM AUTHOR]

Context: The fourth edition of the Preparticipation Physical Evaluation recommends functional testing for the musculoskeletal portion of the examination; however, normative data across sex and grade level are limited. Establishing normative data can provide clinicians reference points with which to compare their patients, potentially aiding in the development of future injury-risk assessments and injury-mitigation programs. Objective: To establish normative functional performance and limb-symmetry data for high school-aged male and female athletes in the United States. Design: Cross-sectional study. Setting: Athletic training facilities and gymnasiums across the United States. Patients or Other Participants: A total of 3951 male and female athletes who participated on high school-sponsored basketball, football, lacrosse, or soccer teams enrolled in this nationwide study. Main Outcome Measure(s): Functional performance testing consisted of 3 evaluations. Ankle-joint range of motion, balance, and lower extremity muscular power and landing control were assessed via the weight-bearing ankle-dorsiflexion-lunge, single-legged anterior-reach, and anterior single-legged hop-for-distance (SLHOP) tests, respectively. We used 2-way analyses of variance and χ² analyses to examine the effects of sex and grade level on ankle-dorsiflexion-lunge, single-legged anterior-reach, and SLHOP test performance and symmetry. Results: The SLHOP performance differed between sexes (males = 187.8% ± 33.1% of limb length, females = 157.5% ± 27.8% of limb length; t = 30.3, P < .001). A Cohen d value of 0.97 indicated a large effect of sex on SLHOP performance. We observed differences for SLHOP and ankle-dorsiflexion-lunge performance among grade levels, but these differences were not clinically meaningful. Conclusions: We demonstrated differences in normative data for lower extremity functional performance during preparticipation physical evaluations across sex and grade levels. The results of this study will allow clinicians to compare sex- and grade-specific functional performances and implement approaches for preventing musculoskeletal injuries in high school-aged athletes. [ABSTRACT FROM AUTHOR]

Context: An estimated 40 million school-aged children (age range = 5-18 years) participate annually in sports in the United States, generating approximately 4 million sport-related injuries and requiring 2.6 million emergency department visits at a cost of nearly $2 billion. Objective: To determine the effects of a school-based neuromuscular training (NMT) program on sport-related injury incidence across 3 sports at the high school and middle school levels, focusing particularly on knee and ankle injuries. Design: Randomized controlled clinical trial. Setting: A total of 5 middle schools and 4 high schools in a single-county public school district. Patients or Other Participants: A total of 474 girls (222 middle school, 252 high school; age = 14.0 ± 1.7 years, height = 161.0 ± 8.1 cm, mass = 55.4 ± 12.2 kg) were cluster randomized to an NMT (CORE; n = 259 athletes) or sham (SHAM; n = 215 athletes) intervention group by team within each sport (basketball, soccer, and volleyball). Intervention(s): The CORE intervention consisted of exercises focused on the trunk and lower extremity, whereas the SHAM protocol consisted of resisted running using elastic bands. Each intervention was implemented at the start of the season and continued until the last competition. An athletic trainer evaluated athletes weekly for sport-related injuries. The coach recorded each athlete-exposure (AE), which was defined as 1 athlete participating in 1 coach-directed session (game or practice). Main Outcome Measure(s): Injury rates were calculated overall, by sport, and by competition level. We also calculated rates of specific knee and ankle injuries. A mixed-model approach was used to account for multiple injuries per athlete. Results: Overall, the CORE group reported 107 injuries (rate = 5.34 injuries/1000 AEs), and the SHAM group reported 134 injuries (rate = 8.54 injuries/1000 AEs; F1,578 = 18.65, P < .001). Basketball (rate = 4.99 injuries/1000 AEs) and volleyball (rate = 5.74 injuries/1000 AEs) athletes in the CORE group demonstrated lower injury incidences than basketball (rate = 7.72 injuries/1000 AEs) and volleyball (rate = 11.63 injuries/1000 AEs; F1,275 = 9.46, P = .002 and F1,149 = 11.36, P = .001, respectively) athletes in the SHAM group. The CORE intervention appeared to have a greater protective effect on knee injuries at the middle school level (knee-injury incidence rate = 4.16 injuries/1000 AEs) than the SHAM intervention (knee-injury incidence rate = 7.04 injuries/1000 AEs; F1,261 = 5.36, P = .02). We did not observe differences between groups for ankle injuries (F1,578 = 1.02, P = .31). Conclusions: Participation in an NMT intervention program resulted in a reduced injury incidence relative to participation in a SHAM intervention. This protective benefit of NMT was demonstrated at both the high school and middle school levels. [ABSTRACT FROM AUTHOR]

Context: Dynamic balance during functional movement may provide important clinical information after concussion. The Sport Concussion Assessment Tool, version 3 (SCAT3), includes a timed tandem-gait test (heel-to-toe walking) administered with a pass-fail scoring system. Minimal evidence supports inclusion of the tandem-gait test in the SCAT3, especially in high school athletes. Objective: To determine (1) the percentage of healthy high school athletes who passed (best trial≤14 seconds) the tandem-gait test at baseline, (2) the association between sex and test performance (pass versus fail), and (3) the relationships among sex, age, height, and tandem-gait test score. Design: Cross-sectional study. Setting: High school sports medicine center. Patients or Other Participants: Two hundred athletes from 4 high schools (age ± 15.8 6 1.2 years, height ± 170.3 6 10.3 cm, weight ± 64.8 6 14.5 kg). Main Outcome Measure(s): Healthy participants completed 4 trials of the SCAT3 tandem-gait test and a demographic questionnaire. Outcome measures were passing rate at baseline on the tandem-gait test and tandem-gait test score (time). Results: Overall, 24.5% (49/200) of participants passed the test. Sex and performance were associated (v2 ± 15.15, P , .001), with a passing rate of 38.6% (32/83) for males and 14.5% (17/117) for females. The regression model including predictor variables of sex and height, with the outcome variable of tandem-gait test score and time, was significant (R2±0.20, P , .01). Conclusions: Our findings suggest that the tandem-gait test had a high false-positive rate in high school athletes. Given that more than 75% of healthy participants failed the tandem-gait test, the 14-second cutoff appears to have limited clinical utility in the adolescent population. Functional movement deficits after concussion need to be accounted for, but the 14-second cutoff for the SCAT3 tandem-gait test does not appear to be an ideal way to assess these deficits in high school athletes [ABSTRACT FROM AUTHOR]

Context: Although an association between concussion and musculoskeletal injury has been described in collegiate and professional athletes, no researchers have investigated an association in younger athletes. Objective: To determine if concussion in high school athletes increased the risk for lower extremity musculoskeletal injury after return to activity. Design: Observational cohort study. Setting: One hundred ninety-six high schools across 26 states. Patients or Other Participants: We used data from the National Athletic Treatment, Injury and Outcomes Network surveillance system. Athletic trainers provided information about sport-related concussions and musculoskeletal injuries in athletes in 27 sports, along with missed activity time due to these injuries. Main Outcome Measure(s): Three general estimating equations were modeled to predict the odds of sustaining (1) any lower extremity injury, (2) a time-loss lower extremity injury, or (3) a non-time-loss lower extremity injury after concussion. Predictors were the total number of previous injuries, number of previous concussions, number of previous lower extremity injuries, number of previous upper extremity injuries, and sport contact classification. Results: The initial dataset contained data from 18 216 athletes (females = 39%, n = 6887) and 46 217 injuries. Lower extremity injuries accounted for most injuries (56.3%), and concussions for 4.3% of total injuries. For every previous concussion, the odds of sustaining a subsequent time-loss lower extremity injury increased 34% (odds ratio [OR] = 1.34; 95% confidence interval [CI] = 1.13, 1.60). The number of previous concussions had no effect on the odds of sustaining any subsequent lower extremity injury (OR = 0.97; 95% CI = 0.89, 1.05) or a non-time-loss injury (OR=1.01; 95% CI=0.92, 1.10). Conclusions: Among high school athletes, concussion increased the odds of sustaining subsequent time-loss lower extremity injuries but not non-time-loss injuries. By definition, time-loss injuries may be considered more severe than non-time-loss injuries. The exact mechanism underlying the increased risk of lower extremity injury after concussion remains elusive and should be further explored in future research. [ABSTRACT FROM AUTHOR]

Context: High-intensity sport training at the youth level has led to increased concern for overuse conditions. Few researchers have examined overuse conditions in youth sports. Objective: To examine the rates, risks, and distributions of overuse conditions between youth and high school football players. Design: Descriptive epidemiologic study. Setting: Youth and high school football teams. Patients or Other Participants: The Youth Football Safety Study (YFSS) investigated youth football athletes from age 5 to 14 years. The National Athletic Treatment, Injury and Outcomes Network (NATION) focused on high school football athletes 14 to 18 years old. The YFSS data consisted of 210 team-seasons, and the NATION data consisted of 138 team-seasons. Main Outcome Measure(s): Athletic trainers collected football injury and exposure data during the 2012 and 2013 seasons. Injury rates, risks, and distributions were calculated, with injury rate ratios, risk ratios, and injury proportion ratios with 95% confidence intervals (CIs) comparing youth and high school football players. Results: The YFSS reported 1488 injuries, of which 53 (3.6%) were overuse conditions. The NATION reported 12 013 injuries, of which 339 (2.8%) were overuse conditions. The overuse condition rate did not differ between high school and youth football (3.93 versus 3.72/10 000 athlete-exposures; injury rate ratio = 1.06; 95% CI = 0.79, 1.41). However, the 1-season risk of overuse condition was higher in high school than in youth football players (2.66% versus 1.05%; risk ratio =2.53; 95% CI = 1.84, 3.47). Compared with high school football players, youth football players had greater proportions of overuse conditions that were nontime loss (ie, <24 hours participation-restriction time; 83.0% versus 67.0%; injury proportion ratio = 1.24; 95% CI = 1.07, 1.43) and affecting the lower extremity (92.5% versus 62.5%; injury proportion ratio = 1.48; 95% CI = 1.32, 1.65). Conclusions: Overuse conditions may not present a primary concern in youth and high school football players. However, differences existed between the 2 levels of competition. Although additional research on the incidence of overuse conditions across all youth and high school sports is needed, these findings may highlight the need for programming that is specific to competition level. [ABSTRACT FROM AUTHOR]

Context: Comprehensive, multidomain assessment is the standard of care after sport-related concussion. However, the relationship between performance on sideline concussionassessment tools and in-office computerized neurocognitive testing has received little attention, and the prognostic utility of sideline measures is unknown. Objective: To evaluate concurrent impairment on commonly used concussion measures 24 to 48 hours postinjury while also determining the predictive utility of sideline measures on computerized neurocognitive testing in the acute to subacute recovery periods postinjury. Design: Case-control study. Setting: High school and collegiate athletics. Patients or Other Participants: A total of 125 high school and college-aged athletes (85 males, 40 females) 14 to 23 (16.8 ± 2.21) years old. Main Outcome Measure(s): Participants were administered sideline concussion-assessment measures (ie, Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT], Standardized Assessment of Concussion [SAC], and Balance Error Scoring System [BESS]) 24 to 48 hours postinjury and completed ImPACT and the Post-Concussion Symptom Scale 5 to 7 and 10 to 14 days postinjury. Outcome measures were the ImPACT composite (verbal memory, visual memory, reaction time, visual-motor speed), SAC, and BESS scores and total symptom score on the Post-Concussion Symptom Scale. Results: Participants demonstrated heterogeneous patterns of impairment on measures 24 to 48 hours postinjury, with the most common pattern being impairment on ImPACT and the SAC. Performance on the SAC and BESS at 24 to 48 hours after injury did not distinguish between those with and those without impairment on ImPACT at 5 to 7 days postinjury (χ² = 5.076, P = .079) or 10 to 14 days postinjury (χ² = 2.04, P = .361). Conclusions: More than 90% of athletes were impaired on at least 1 sideline or neurocognitive measure 24 to 48 hours after sport-related concussion. Although sideline measures are useful for concussion diagnosis, they are not suitable for prognostication of impairment or the presence of symptoms 1 to 2 weeks postinjury. [ABSTRACT FROM AUTHOR]

Context: Recent researchers have reported that athletes' knowledge of sport-related concussion (SRC) has increased but that athletes still lack knowledge of all the signs and symptoms of SRC. Understanding the signs and symptoms of SRC and the dangers of playing while symptomatic are critical to reporting behaviors in high school athletes. Objective: To examine sex differences in knowledge of SRC symptoms and reasons for not reporting a suspected SRC to an authoritative figure in high school athletes. Design: Cross-sectional study. Setting: Survey. Patients or Other Participants: A total of 288 athletes across 7 sports (198 males [68.8%] and 90 females [31.2%]). Main Outcome Measure(s): A validated knowledge-of-SRC survey consisted of demographic questions, a list of 21 signs and symptoms of SRC, and reasons why athletes would not report their SRC. The independent variable was sex. Athlete knowledge of SRC symptoms was assessed by having participants identify the signs and symptoms of SRC from a list of 21 symptoms. Knowledge scores were calculated by summing the number of correct answers; scores ranged from 0 to 21, with a score closer to 21 representing greater knowledge. Reporting-behavior questions asked athletes to choose reasons why they decided not to report any possible SRC signs and symptoms to an authoritative figure. Results: A sex difference in total SRC symptom knowledge was found (F286 = 4.97, P = .03, d = 0.26). Female high school athletes had more total SRC symptom knowledge (mean 6 standard deviation = 15.06 ± 2.63; 95% confidence interval = 14.54, 15.57) than males (14.36 ± 2.76; 95% confidence interval = 13.97, 14.74). Chi-square tests identified significant relationships between sex and 8 different reasons for not reporting an SRC. Conclusions: High school males and females had similar SRC symptom knowledge; however, female athletes were more likely to report their concussive symptoms to an authoritative figure. [ABSTRACT FROM AUTHOR]

Context: Variations in knee-sprain incidence among competition levels are unclear but may help inform prevention strategies in American football players. Objective: To describe the epidemiology of knee sprains in youth, high school, and collegiate football players. Design: Descriptive epidemiology study. Setting: Injury and athlete-exposure (AE) data were collected from 3 injury-surveillance programs at the youth, high school, and collegiate competition levels. Patients or Other Participants: Data from 310 youth, 184 high school, and 71 collegiate football team-seasons were collected during the 2012 through 2014 seasons. Main Outcome Measure(s): Knee-sprain rates and risks were calculated for each competition level. Injury rate ratios (IRRs) and risk ratios (RRs) compared knee-sprain rates by competition level. Injury proportion ratios (IPRs) compared differences in surgery needs, recurrence, injury mechanism, and injury activity by competition level. Results: Knee-sprain rates in youth, high school, and collegiate football were 0.16/1000 AEs, 0.25/1000 AEs, and 0.69/1000 AEs, respectively. Knee-sprain rates increased as the competition level increased (high school versus youth: IRR = 1.60; 95% confidence interval [CI]=1.12, 2.30; collegiate versus high school: IRR = 2.73; 95% CI = 2.38, 3.96). Knee-sprain risk was highest in collegiate (4.3%), followed by high school (2.0%) and youth (0.5%) athletes. Knee-sprain risk increased as the competition level increased (high school versus youth: RR = 3.73; 95% CI = 2.60, 5.34; collegiate versus high school: RR = 2.14; 95% CI = 1.83, 2.51). Collegiate football had the lowest proportion of knee sprains that were noncontact injuries (collegiate versus youth: IPR = 0.54; 95% CI = 0.31, 0.95; collegiate versus high school: IPR = 0.59; 95% CI = 0.44, 0.79) and the lowest proportion that occurred while being tackled (collegiate versus youth: IPR = 0.44; 95% CI = 0.26, 0.76; collegiate versus high school: IPR =0.71; 95% CI=0.51, 0.98). Conclusions: Knee-sprain incidence was highest in collegiate football. However, level-specific variations in the distributions of knee sprains by injury activity may highlight the need to develop level-specific policies and prevention strategies that ensure safe sports play. [ABSTRACT FROM AUTHOR]

Context: Research on non-time-loss (NTL) injuries, which result in less than 24 hours of restriction from participation, is limited. Objective: To describe the epidemiology of NTL injuries among collegiate and high school student-athletes. Design: Descriptive epidemiology study. Setting: Aggregate injury and exposure data collected from a convenience sample of National College Athletic Association varsity teams and 147 high schools in 26 states. Patients or Other Participants: Collegiate and high school student-athletes participating in men's and boys' baseball, basketball, football, lacrosse, soccer, and wrestling and women's and girls' basketball, field hockey, lacrosse, soccer, softball, and volleyball during the 2009-2010 through 2013-2014 and the 2011-2012 through 2013-2014 academic years, respectively, participated. Collegiate student-athletes participating in men's and women's ice hockey were also included. Main Outcome Measure(s): Injury data from the National Collegiate Athletic Association Injury Surveillance Program and the National Athletic Treatment, Injury and Outcomes Network were analyzed. Injury counts, rates per 1000 athlete-exposures (AEs), and rate ratios were reported with 95% confidence intervals (CIs). Results: A total of 11 899 and 30 122 NTL injuries were reported in collegiate and high school student-athletes, respectively. The proportion of NTL injuries in high school studentathletes (80.3%) was 1.61 times greater than that of collegiate student-athletes (49.9%; 95% CI = 1.59, 1.63). The NTL injury rate in high school student-athletes (8.75/1000 athlete-exposures [AEs]) was 2.18 times greater than that of collegiate student-athletes (4.02/1000 AEs; 95% CI = 2.13, 2.22). Men's ice hockey (5.27/1000 AEs) and boys' football (11.94/1000 AEs) had the highest NTL injury rates among collegiate and high school athletes, respectively. Commonly injured body parts in collegiate and high school student-athletes were the hip/thigh/upper leg (17.5%) and hand/wrist (18.2%), respectively. At both levels, contusions, sprains, and strains were the most frequent diagnoses. Contact with another player was the most cited injury mechanism (college = 38.0%, high school = 46.3%). Conclusions: Non-time-loss injuries compose large proportions of collegiate and high school sports injuries. However, the NTL injury rate was higher in high school than in collegiate student-athletes. Tracking NTL injuries will help to better describe the breadth of injuries sustained by athletes and managed by athletic trainers. [ABSTRACT FROM AUTHOR]

Context: Sports participation is one of the leading causes of concussions among nearly 8 million US high school student-athletes. Objective: To describe the epidemiology of sport-related concussion (SRC) in 27 high school sports during the 2011- 2012 through 2013-2014 academic years. Design: Descriptive epidemiology study. Setting: Aggregate injury and exposure data from 27 sports in 147 high schools in the National Athletic Treatment, Injury and Outcomes Network (NATION). Patients or Other Participants: Boy and girl high school athletes during the 2011-2012 through 2013-2014 academic years. Main Outcome Measure(s): Sport-related concussion counts, percentages, rates per 10 000 athlete-exposures (AEs), rate ratios (RRs), and injury proportion ratios (IPRs) were reported with 95% confidence intervals (CIs). Rate ratios and IPRs with 95% CIs not containing 1.0 were considered significant. Results: Overall, 2004 SRCs were reported among 27 high school sports, for a rate of 3.89 per 10 000 AEs. Football had the highest SRC rate (9.21/10 000 AEs), followed by boys' lacrosse (6.65/10 000 AEs) and girls' soccer (6.11/10 000 AEs). The SRC rate was higher in competition than in practice (RR = 3.30; 95% CI = 3.02, 3.60). Among sex-comparable sports, the SRC rate was higher in girls than in boys (RR=1.56; 95% CI=1.34, 1.81); however, the proportion of SRCs due to player-to-player contact was higher in boys than in girls (IPR = 1.48; 95% CI = 1.27, 1.73). Common symptoms reported among all athletes with SRCs were headache (94.7%), dizziness (74.8%), and difficulty concentrating (61.0%). Only 0.8% of players with SRCs returned to play within 24 hours. The majority of athletes with SRCs (65.8%) returned to play between 7 and 28 days. More players had symptoms resolve after 7 days (48.8%) than less than a week (40.7%). Conclusions: Our findings provide updated high school SRC incidence estimates and further evidence of sex differences in reported SRCs. Few athletes with SRCs returned to play within 24 hours or a week. Most injured players returned after 7 days, despite a smaller proportion having symptoms resolve within a week. [ABSTRACT FROM AUTHOR]

Context: Clinicians sometimes treat concussed individuals who have amnesia, loss of consciousness (LOC), a concussion history, or certain symptom types more conservatively, but it is unclear whether recovery patterns differ in individuals with these characteristics. Objective: To determine whether (1) amnesia, LOC, and concussion history influence the acute recovery of symptoms, cognition, and balance; and (2) cognition and balance are influenced by acute symptom type. Design: Cohort study. Setting: Seven sports at 26 colleges and 210 high schools. Patients or Other Participants: A total of 8905 collegiate (n = 1392) and high school (n = 7513) athletes. Main Outcome Measure(s): The Graded Symptom Checklist, Standardized Assessment of Concussion, and Balance Error Scoring System were administered to all athletes during the preseason. To allow us to track recovery patterns, athletes diagnosed with a concussion (n = 375) repeated these assessments immediately after the injury, 3 hours postinjury, 1 day postinjury, and at 2, 3, 5, 7, and 90 days after injury. Results: Athletes who experienced amnesia had markedly greater deficits in and a slower recovery trajectory on measures of symptoms, cognition, and balance. Athletes with 2 or more prior concussions demonstrated poorer balance than those with no previous history. Otherwise, LOC and concussion history largely did not affect symptoms, cognition, or balance. Greater deficits in balance scores were observed in athletes with all symptom types. Regardless of these characteristics, most athletes recovered within 7 to 10 days. Conclusions: Athletes who experienced amnesia had more symptoms and greater deficits in cognition and balance. Symptoms and cognitive or balance deficits were not consistently associated with LOC or concussion history. Acute symptoms had a strong influence on balance scores and, to a lesser extent, on cognition. However, we found no evidence to support more cautious return-to-play decisions for athletes with these characteristics, as group recovery occurred within normal timelines. Our study supports current clinical practice: recommending that athletes be withheld from activity until they are asymptomatic, followed by a graduated return-to-play progression. [ABSTRACT FROM AUTHOR]

Context: Increased sport participation and sport-related concussion incidence has led to an emphasis on having an appropriate medical professional available to high school athletes. The medical professional best suited to provide medical care to high school athletes is a certified athletic trainer (AT). Access to an AT may influence the reporting of sport-related concussion in the high school athletic population; however, little is known about how the presence of an AT affects concussion knowledge, prevention, and recognition. Objective: To evaluate knowledge of concussion and reporting behaviors in high school athletes who did or did not have access to an AT. Design: Cross-sectional study. Setting: Survey. Patients or Other Participants: A total of 438 athletes with access to an AT and 277 without access to an AT. Intervention(s): A validated knowledge-of-concussion survey consisting of 83 items addressing concussion history, concussion knowledge, scenario questions, signs and symptoms of a concussion, and reasons why an athlete would not report a concussion. The independent variable was access to an AT. Main Outcome Measure(s): We examined the proportion of athletes who correctly identified knowledge of concussion, signs and symptoms of concussion, and reasons why high school student-athletes would not disclose a potential concussive injury by access to an AT. Frequency statistics, χ² tests, independent t tests, and linear regression were conducted to analyze the data. Results: The underreporting of concussion among high school athletes was 55%. Athletes with access to an AT had more knowledge of concussion than did athletes without such access (P ≤ .001). Chi-square tests did not demonstrate a significant relationship between AT access and a higher percentage reporting concussions. Conclusions: High school athletes with access to an AT had more concussion knowledge, but they did not report suspected concussions to an authority figure more frequently than athletes without access to an AT. [ABSTRACT FROM AUTHOR]