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OBJECTIVE: To provide certified athletic trainers, team physicians, emergency responders, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in the athlete. BACKGROUND: The relative incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and the timeliness of transfer to a controlled environment for diagnosis and treatment. RECOMMENDATIONS: Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport, such as football, hockey, or lacrosse; and considerations in the emergency department. [ABSTRACT FROM AUTHOR]

BACKGROUND: Female college basketball and soccer athletes have higher rates of anterior cruciate ligament injury than do their male counterparts. Rates of anterior cruciate ligament injuries for women and men in collegiate lacrosse have not been examined. Understanding anterior cruciate ligament injury patterns in lacrosse, a full-contact sport for men and noncontact sport for women, could further injury prevention efforts. HYPOTHESES: Female anterior cruciate ligament injury rates will decrease over time owing to longer participation in sports. Lacrosse anterior cruciate ligament injury rates will be lower than rates in basketball and soccer possibly owing to beneficial biomechanics of carrying a lacrosse stick. STUDY DESIGN: Cohort study (Prevalence); Level of evidence, 2. METHODS: Data from the National Collegiate Athletic Association Injury Surveillance System were analyzed to compare men's and women's anterior cruciate ligament injuries in basketball, lacrosse, and soccer over 15 years. RESULTS: Anterior cruciate ligament injury rates in women's basketball and soccer were 0.28 and 0.32 injuries per 1000 athlete exposures, respectively, and did not decline over the study period. In men's basketball, injury rate fluctuated between 0.03 and 0.13 athlete exposures. Rates of anterior cruciate ligament injury did not significantly change in men's soccer over the study period. The rate of anterior cruciate ligament injury in men's lacrosse (0.17 athlete exposures, P < .05) was significantly higher than in men's basketball (0.08 athlete exposures) and soccer (0.12 athlete exposures). Injury rate in women's lacrosse (0.18 athlete exposures, P < .05) was significantly lower than in women's basketball and soccer. CONCLUSION: There was no discernable change in rate of anterior cruciate ligament injury in men or women during the study period. Men's lacrosse is a high-risk sport for anterior cruciate ligament injury. Unlike basketball and soccer, the rates of anterior cruciate ligament injury are essentially the same in men's and women's lacrosse. The level of allowed contact in pivoting sports may be a factor in determining sport-specific anterior cruciate ligament risk. [ABSTRACT FROM AUTHOR]

Context: Among American sports, football has the highest incidence of exertional heat stroke (EHS), despite decades of prevention strategies. Based on recent reports, 100% of high school and college EHS football fatalities occur during conditioning sessions. Linemen are the at-risk population, constituting 97% of football EHS deaths. Linemen heat up faster and cool down slower than other players., Evidence Acquisition: Case series were identified from organized, supervised football at the youth, high school, and collegiate levels and compiled in the National Registry of Catastrophic Sports Injuries. Sources for event occurrence were media reports and newspaper clippings, autopsy reports, certificates of death, school-sponsored investigations, and published medical literature. Articles were identified through PubMed with search terms "football," "exertional heat stroke," and "prevention.", Study Design: Clinical review., Level of Evidence: Level 5., Results: Football EHS is tied to (1) high-intensity drills and conditioning that is not specific to individual player positions, (2) physical exertion as punishment; (3) failure to modify physical activity for high heat and humidity, (4) failure to recognize early signs and symptoms of EHS, and (5) death when cooling is delayed., Conclusion: To prevent football EHS, (1) all training and conditioning should be position specific; (2) physical activity should be modified per the heat load; (3) understand that some players have a "do-or-die" mentality that supersedes their personal safety; (4) never use physical exertion as punishment; (5) eliminate conditioning tests, serial sprints, and any reckless drills that are inappropriate for linemen; and (6) consider air-conditioned venues for linemen during hot practices. To prevent EHS, train linemen based on game demands., Strength-Of-Recommendation Taxonomy: n/a., Competing Interests: The following authors declared potential conflicts of interest: J.K.D. is an employee of the Gatorade Sports Science Institute, a division of PepsiCo. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of PepsiCo, Inc. R.C. is on the medical advisory board for BOA. J.K.D. has stock options from PepsiCo.

Background: A previous report revealed an average of 7.2 (0.67 per 100,000 participants) sport-related structural brain injuries (SRSBIs) with macroscopic lesions per year in high school (HS) and college football players. The Lystedt law and other rule changes have been implemented with intent to reduce the risk of brain injury in football., Hypothesis: To update the profile of SRSBIs in HS and college football players and evaluate the efficacy of legislation intended to reduce brain injuries., Study Design: Descriptive epidemiology study., Level of Evidence: Level 4., Methods: We retrospectively reviewed 18 academic years (July 2002 through June 2020) of SRSBIs catalogued by the National Registry of Catastrophic Sports Injuries. The incidence of SRSBIs was assessed at the HS level during the pre (July 2002 through June 2009), transitional (July 2009 through June 2014), and post (July 2014 through June 2020) universal adoption time periods of the Lystedt law. In addition, the incidence of SRSBIs during the second half of the study (2011-2012 through 2019-2020) was compared with the first half of the study (2002-2003 through 2010-2011)., Results: During the study period, there was a total of 228 SRSBIs (12.7 per year, 1.01 per 100,000 participants): 212 (93%, 11.8 per year, 1.00 per 100,000) in HS athletes and 16 (7%, 0.89 per year, 1.17 per 100,000) in college athletes. There were 52 fatalities (2.9 per year, 0.22 per 100,000 participants) with 46 (2.56 per year, 0.22 per 100,000) in HS athletes and 6 (0.33 per year, 0.43/100,000) in college athletes. There was no significant difference in risk of HS total SRSBIs or fatalities during the 3 Lystedt periods. The risk of combined SRSBI cases [relative risk (RR) = 1.22, P = 0.13] and fatalities (RR = 1.20, P = 0.52) was similar in the second half of the study compared with the first half of the study., Conclusion: Despite implementation of rule changes intended to reduce head injury, in particular the Lystedt law, the incidence of SRSBIs has remained unchanged. Further research is necessary to develop effective prevention programs for SRSBIs., Clinical Relevance: SRSBIs remain a persistent problem in HS and college American football. The recent head injury rule changes have not been effective at reducing SRSBIs.

Background: Nontraumatic fatalities occur on a regular basis in high school (HS) and college football athletes, primarily in obese linemen performing high-intensity exercise. One contributing factor to these deaths may be a mismatch between baseline aerobic (cardiorespiratory) fitness and exercise regimens., Hypothesis: There is a wide range of aerobic fitness in HS and college football players. Body mass index (BMI) is a safe and simple method for estimating baseline aerobic fitness., Study Design: Retrospective cohort study., Level of Evidence: Level 3., Methods: A retrospective review was performed on 79 HS football athletes who had VO 2Peak (mL·kg -1 ·min -1 ) measured during the offseason. Multivariate regression analysis was used to determine if BMI (obese, overweight, and normal; kg/m 2 ), position played (linemen vs other), year in school (freshmen vs other), and/or race (African American vs White) were risk factors for poor aerobic fitness. A separate cohort of 135 (48 HS; 87 college) football athletes performed a 6-minute run test to determine speed (miles/min), extrapolate VO 2Max , and calculate reference values for suggested upper threshold safe starting speeds (85% of maximum) for aerobic training based on BMI. The relationship between BMI and VO 2Peak was assessed. The exercise regimens (speeds) of 2 collegiate football fatalities from the public domain were used to predict their VO 2Max values., Results: Mean VO 2Peak (mL·kg -1 ·min -1 ) was 38.5 ± 8.6 (range 19.1-60.6); when grouped by BMI, low scores (<40) were found in 87.5% of obese (32.4 ± 7.7), 47.8% of overweight (40.8 ± 7.6), and 45.2% of normal (41.4 ± 7.8) athletes. VO 2Peak was significantly lower in linemen (32.8 ± 6.4; P = 0.007) compared with nonlineman (41.8 ± 7.9), and in obese players (by BMI; 32.4; P = 0.019) compared with nonobese players (41.4 ± 7.6), but did not differ by age, year in school, or race. Means for speed (min/mile) and extrapolated VO 2Max (mL·kg -1 ·min -1 ) for the 6-minute run test by BMI groups were both significantly different ( P = 0.001) for normal (7.0 ± 0.6; 51.1 ± 2.6), overweight (7.6 ± 0.8; 46.5 ± 3.2), and obese (8.9 ± 1.5; 36.8 ± 5.9) athletes. There was a significant negative correlation ( r = -0.551; P = 0.001; R 2 = 0.304) between VO 2Peak and BMI. Safe starting speed recommendations for running 1 mile range from 7.3 to 12.1 min/mile for BMIs 20 to 40 kg/m 2 for HS and college athletes. For the 2 fatalities (mean, BMI of 36.5 kg/m 2 ) repetitive sprint speeds were 49 and 89% higher than our safe starting speeds for their BMI., Conclusion: A large spectrum of baseline aerobic fitness was noted in HS and college football players. Obese players and linemen had statistically lower baseline aerobic fitness, a major risk factor for possible heat illness. BMI is an acceptable surrogate for VO 2Peak and can be employed to develop safe training regimens without the need for a maximum fitness test, which can place the athlete at risk for a medical event., Clinical Relevance: Knowledge of BMI provides an estimate of baseline aerobic fitness and a foundation for prescribing safe, individualized exercise regimens.

Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: K.M.F. has received honoraria and consulting fees from Flexion Therapeutics and education payments from Supreme Orthopedic Systems. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: A novel algorithm and clinical prediction rule (CPR), with 18 variables, was created in 2014. The CPR generated a bone stress injury (BSI) score, which was used to determine the necessity of imaging in suspected BSI. To date, there are no validated algorithms for imaging selection in patients with suspected BSI., Hypothesis: A simplified CPR will assist clinicians with diagnosis and decision making in patients with suspected BSI., Study Design: Prospective cohort study., Level of Evidence: Level 3., Methods: A total of 778 military trainees with lower extremity pain were enrolled. All trainees were evaluated for 18 clinical variables suggesting BSI. Participants were monitored via electronic medical record review. Then, a prediction model was developed using logistic regression to identify clinical variables with the greatest predictive value and assigned appropriate weight. Test characteristics for various BSI score thresholds were calculated., Results: Of the enrolled trainees, 204 had imaging-confirmed BSI in or distal to the femoral condyles. The optimized CPR selected 4 clinical variables (weighted score): bony tenderness (3), prior history of BSI (2), pes cavus (2), and increased walking/running volume (1). The optimized CPR with a score ≥3 yielded 97.5% sensitivity, 54.2% specificity, and 98.2% negative predictive value. An isolated measure, bony tenderness, demonstrated similar statistical performance., Conclusion: The optimized CPR, which uses bony tenderness, prior history of BSI, pes cavus, and increased walking/running volume, is valid for detecting BSI in or distal to the femoral condyles. However, bony tenderness alone provides a simpler criterion with an equally strong negative predictive value for BSI decision making., Clinical Relevance: For suspected BSI in or distal to the femoral condyles, imaging can be deferred when there is no bony tenderness. When bony tenderness is present in the setting of 1 or more proven risk factors and no clinical evidence of high-risk bone involvement, presumptive treatment for BSI and serial radiographs may be appropriate.

Background: The incidence of nontraumatic fatalities in high school (HS) and National Collegiate Athletic Association (NCAA) football players has continued at a constant rate since the 1960s., Purpose: To describe the causes of nontraumatic fatalities in HS and NCAA football players and provide prevention strategies., Study Design: Descriptive epidemiology study., Methods: We reviewed 187 fatalities in HS and NCAA nontraumatic football players catalogued by the National Registry of Catastrophic Sports Injuries during a 20-year period between July 1998 and June 2018., Results: The majority (n = 162; 86.6%) of fatalities occurred during a practice or conditioning session. Most fatalities, when timing was known, (n = 126; 70.6%) occurred outside of the regular playing season, with the highest incidence in the August preseason (n = 64; 34.2%). All documented conditioning sessions were supervised by a coach (n = 92) or strength and conditioning coach (n = 40). The exercise regimen at the time of the fatality involved high-intensity aerobic training in 94.7%. Punishment was identified as the intent in 36 fatalities. The average body mass index of the athletes was 32.6 kg/m 2 . For athletes who died due to exertional heat stroke, the average body mass index was 36.4 kg/m 2 , and 97.1% were linemen., Conclusion: Most nontraumatic fatalities in HS and NCAA football players occurred during coach-supervised conditioning sessions. The primary cause of exertion-related fatalities was high-intensity aerobic workouts that might have been intended as punishment and/or excess repetitions. Exertion-related fatalities are potentially preventable by applying standards in workout design, holding coaches accountable, and ensuring compliance with the athlete's health and current welfare policies., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: K.M.F. has received consulting fees from Flexion Therapeutics. AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

Background: Football has the highest number of nontraumatic fatalities of any sport in the United States., Purpose: To compare the incidence of nontraumatic fatalities with that of traumatic fatalities, describe the epidemiology of nontraumatic fatalities in high school (HS) and college football players, and determine the effectiveness of National Collegiate Athletic Association (NCAA) policies to reduce exertional heat stroke (EHS) and exertional sickling (ES) with sickle cell trait (SCT) fatalities in athletes., Study Design: Descriptive epidemiology study., Methods: We retrospectively reviewed 20 academic years (1998-2018) of HS and college nontraumatic fatalities in football players using the National Registry of Catastrophic Sports Injuries (NRCSI). EHS and ES with SCT fatality rates were compared before and after the implementation of the NCAA football out-of-season model (bylaw 17.10.2.4 [2003]) and NCAA Division I SCT screening (bylaw 17.1.5.1 [2010]), respectively. Additionally, we compiled incidence trends for HS and college traumatic and nontraumatic fatalities in football players for the years 1960 through 2018 based on NRCSI data and previously published reports., Results: The risk (odds ratio) of traumatic fatalities in football players in the 2010s was 0.19 (95% CI, 0.13-0.26; P < .0001) lower in HS and 0.29 (95% CI, 0.29-0.72; P = .0078) lower in college compared with that in the 1960s. In contrast, the risk of nontraumatic fatalities in football players in the 2010s was 0.7 (95% CI, 0.50-0.98; P = .0353) in HS and 0.9 (95% CI, 0.46-1.72; P = .7413) in college compared with that in the 1960s. Since 2000, the risk of nontraumatic fatalities has been 1.89 (95% CI, 1.42-2.51; P < .001) and 4.22 (95% CI, 2.04-8.73; P < .001) higher than the risk of traumatic fatalities at the HS and college levels, respectively. During the 20 years studied, there were 187 nontraumatic fatalities (average, 9.4 per year). The causes of death were sudden cardiac arrest (57.7%), EHS (23.6%), ES with SCT (12.1%), asthma (4.9%), and hyponatremia (1.6%). The risk of a nontraumatic fatality was 4.1 (95% CI, 2.8-5.9; P < .0001) higher in NCAA compared with HS athletes. There was no difference in the risk of an EHS fatality in NCAA athletes (0.86 [95% CI, 0.17-4.25]; P = .85) after implementation in 2003 of the NCAA football out-of-season model. The risk of an ES with SCT fatality in Division I athletes was significantly lower after the 2010 NCAA SCT screening bylaw was implemented (0.12 [95% CI, 0.02-0.95]; P = .04)., Conclusion: Since the 1960s, the risk of nontraumatic fatalities has declined minimally compared with the reduction in the risk of traumatic fatalities. Current HS and college nontraumatic fatality rates are significantly higher than rates of traumatic fatalities. The 2003 NCAA out-of-season model has failed to significantly reduce EHS fatalities. The 2010 NCAA SCT screening bylaw has effectively prevented ES with SCT fatalities in NCAA Division I football., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: K.M.F. has received consulting fees from Flexion Therapeutics. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

Introduction: Sports participation is among the leading causes of catastrophic cervical spine injury (CSI) in the United States. Appropriate prehospital care for athletes with suspected CSIs should be available at all levels of sport. The goal of this project was to develop a set of best-practice recommendations appropriate for athletic trainers, emergency responders, sports medicine and emergency physicians, and others engaged in caring for athletes with suspected CSIs., Methods: A consensus-driven approach (RAND/UCLA method) in combination with a systematic review of the available literature was used to identify key research questions and develop conclusions and recommendations on the prehospital care of the spine-injured athlete. A diverse panel of experts, including members of the National Athletic Trainers' Association, the National Collegiate Athletic Association, and the Sports Institute at UW Medicine participated in 4 Delphi rounds and a 2-day nominal group technique meeting. The systematic review involved 2 independent reviewers and 4 rounds of blinded review., Results: The Delphi process identified 8 key questions to be answered by the systematic review. The systematic review comprised 1544 studies, 49 of which were included in the final full-text review. Using the results of the systematic review as a shared evidence base, the nominal group technique meeting created and refined conclusions and recommendations until consensus was achieved., Conclusions: These conclusions and recommendations represent a pragmatic approach, balancing expert experiences and the available scientific evidence., (© by the National Athletic Trainers' Association, Inc.)

Sport-related spine injury can be devastating and have long-lasting effects on athletes and their families. Providing evidence-based care for patients with spine injury is essential for optimizing postinjury outcomes. When caring for an injured athlete in American tackle football, clinicians must make decisions that involve unique challenges related to protective equipment (eg, helmet and shoulder pads). The Spine Injury in Sport Group (SISG) met in Atlanta, Georgia, March 2-3, 2019, and involved 25 health care professionals with expertise in emergency medicine, sports medicine, neurologic surgery, orthopaedic surgery, neurology, physiatry, athletic training, and research to review the current literature and discuss evidence-based medicine, best practices, and care options available for the prehospital treatment of athletes with suspected cervical spine injuries.1,2 That meeting and the subsequent Mills et al publication delineate the quality and quantity of published evidence regarding many aspects of prehospital care for the athlete with a suspected cervical spine injury. This paper offers a practical treatment guide based on the experience of those who attended the Atlanta meeting as well as the evidence presented in the Mills et al article. Ongoing research will help to further advance clinical treatment recommendations., (© by the National Athletic Trainers' Association, Inc.)

Background:: Cheerleading is a specialized athletic activity that can lead to catastrophic injuries. Cheerleading rules are in place to maximize safety of participants. The purpose of this study was to describe catastrophic cheerleading injuries among high school and collegiate-level participants in the United States and to explore whether the 2006-2007 basket toss rule change was effective at reducing the number of catastrophic injuries., Hypothesis:: The 2006-2007 basket toss rule change contributed to a reduction in the number of catastrophic injuries among high school and collegiate cheerleaders., Study Design:: Case series., Level of Evidence:: Level 4., Methods:: Data on catastrophic cheerleading injuries were collected by the National Center for Catastrophic Sport Injury Research from July 2002 to June 2017. Information collected included cheerleader, event, and injury characteristics. The impact of the 2006-2007 rule change banning the basket toss on any hard surfaces was assessed by comparing injury rates and 95% CIs before and after the rule change., Results:: There were 54 catastrophic cheerleading injuries, or 3.6 injuries per year. From July 2002 through June 2017, the injury rate was 2.12 per 1,000,000 cheerleaders (95% CI, 1.56-2.69). Most cheerleaders sustained serious injuries (n = 27; 50%) during practice (n = 37; 69%) to the head (n = 28; 52%) and cervical spine (n = 17; 32%). From July 2002 through June 2017, basket tosses were the stunt that accounted for the highest proportion of injuries (n = 19; 35%). The basket toss injury rate decreased from 1.55 to 0.40 per 1,000,000 cheerleaders among both high school and collegiate cheerleaders after the rule change., Conclusion:: Catastrophic injury rates in cheerleading decreased dramatically after the 2006-2007 rule change banning basket tosses from being performed on any hard surfaces. In particular, there was a nearly 4-fold reduction in the rate of catastrophic basket toss injuries.

Background: Patellofemoral pain is one of the most common forms of knee arthralgia in adolescent females. Unlike in adults, in whom the etiology of patellofemoral pain is considered to be multifactorial (eg, altered bone shape and musculoskeletal dynamics), the etiology of adolescent patellofemoral pain has been historically attributed to overuse. Although it is highly plausible that adolescent patellofemoral pain results from excessive maltracking, as suggested by recent research, an increase in patellar, relative to femoral, size could also contribute to patellofemoral pain through altered cartilage stresses/strains, resulting in overloading of the subchondral bone. Because the role of bone morphology in the genesis of patellofemoral pain in adolescent females remains largely unknown, research is needed in this area to improve our understanding of patellofemoral pain and advance diagnosis/treatment., Questions/purposes: (1) Are patellar volume and width increased, and femoral trochlear width decreased, in female adolescents with patellofemoral pain compared with asymptomatic females? (2) Are measures of patellofemoral size correlated with patellofemoral tracking?, Methods: Twenty adolescent females with patellofemoral pain (age, 13.7 ± 1.3 years) and 20 asymptomatic female control participants (age, 13.6 ± 1.3 years) were enrolled in this case-control institutional review board-approved study. This study focused on a strict definition of patellofemoral pain, peripatellar pain in the absence of other structural pathologic conditions (eg, tendinitis, ligament injury, Osgood-Schlatter disease) or a history of dislocations/trauma. Control participants with no history of patellofemoral pain or other lower extremity pathology were matched for age (within 6 months) and body mass index (within 5 kg/m). Participants self-referred and were recruited through clinicaltrails.gov, printed advertisements, and word of mouth. Three-dimensional (3-D), static, T1-weighted, gradient recalled echo MR images were acquired, from which 3-D patellofemoral models were created. Patellar volume and width, patellar-to-femoral volume and width ratios, and femoral trochlear width were compared across cohorts. In addition, 3-D patellofemoral tracking was quantified from dynamic MR images captured during cyclical flexion-extension volitional movements of the lower extremity. The size measures and ratios were correlated to patellofemoral tracking., Results: Compared with control participants, the cohort with patellofemoral pain had greater patellar volume (13,792 ± 2256 versus 11,930 ± 1902 mm; 95% confidence interval [CI], 1336 mm; p = 0.004; d = 0.89) and width (38.4 ± 3.0 versus 36.5 ± 2.7 mm; 95% CI, 1.8 mm; p = 0.021; d = 0.67). The femoral trochlear width was smaller (32.0 ± 1.8 versus 32.9 ± 1.8 mm; p = 0.043, d = 0.54). The patellar-to-femoral volume ratio and the patellar-to-trochlear width ratio were greater in adolescents with patellofemoral pain (0.15 ± 0.02 versus 0.13 ± 0.01, p = 0.006, d = 0.83 and 1.20 ± 0.09 versus 1.11 ± 0.09, p = 0.001, d = 1.02). No correlations were found between patellar size and patellofemoral tracking (r < 0.375, p > 0.103)., Conclusions: In adolescent females with patellofemoral pain, the increased patellar volume/width and patellar-to-trochlear width ratio, along with the decreased femoral trochlear width, may initiate a pathway to pain through improper engagement of the patella within the femoral trochlea. Specifically, the mean differences between cohorts in patellar and femoral trochlear width (1.9 mm and 0.9 mm) are 58% and 37% of the mean patellar and femoral cartilage thickness in females, respectively, as reported in the literature. Further studies are needed to fully elucidate the mechanism of pain., Level of Evidence: Level III, prognostic study.

Background: Although eye injuries constitute a small percentage of high school and college sports injuries, they have the potential to be permanently debilitating., Hypothesis: Eye injury rates will vary by sport, sex, and between the high school and college age groups., Study Design: Descriptive epidemiology study., Level of Evidence: Level 3., Methods: Data from eye injury reports in high school and college athletes were obtained from the National High School Sports-Related Injury Surveillance System, High School Reporting Information Online (HS RIO) database over a 10-year span (2005-2006 through 2014-2015 school years) and the National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP) over an 11-year span (2004-2005 through 2014-2015 school years). Injury rates per 100,000 athlete-exposures (AEs), injury rate ratios (RRs), and 95% CIs were calculated. Distributions of eye injuries by diagnosis, mechanism, time loss, and surgery needs were also examined., Results: A total of 237 and 273 eye injuries were reported in the HS RIO and the NCAA ISP databases, respectively. The sports with the highest eye injury rates (per 100,000 AEs) for combined high school and college athletes were women's basketball (2.36), women's field hockey (2.35), men's basketball (2.31), and men's wrestling (2.07). Overall eye injury rates at the high school and college levels were 0.68 and 1.84 per 100,000 AEs, respectively. Eye injury rates were higher in competition than practice in high school (RR, 3.47; 95% CI, 2.69-4.48) and college (RR, 3.13; 95% CI, 2.45-3.99). Most injuries were contusions (high school, 35.9%; college, 33.3%) and due to contact (high school, 89.9%; college, 86.4%). Only a small percentage of injuries resulted in time loss over 21 days (high school, 4.2%; college, 3.0%)., Conclusion: Eye injury rates and patterns vary by sport, sex, and between the high school and college age groups. Although severe injuries do occur, most eye injuries sustained by high school and college athletes are minor, with limited time loss and full recovery., Clinical Relevance: Additional focus needs to be placed on preventing eye injuries at the collegiate level in women's and men's basketball, women's field hockey, and men's wrestling.

Background: Patellofemoral pain is one of the most common conditions seen in sports medicine practices, particularly among adolescent females. However, the natural history of the underlying pathology in patellofemoral pain during puberty remains poorly understood., Purpose: The purpose of this longitudinal study is to assess changes in patellar maltracking patterns in subjects with patellofemoral pain as they mature from mid- to late adolescence., Study Design: Cohort study; Level of evidence, 3., Methods: Three-dimensional patellofemoral kinematic data were acquired during active knee extension-flexion using dynamic magnetic resonance imaging in 6 girls (10 knees; mean age, 14.0 years) with clinically diagnosed patellofemoral pain. The subjects then returned as late adolescents (mean age, 18.5 years) for follow-up scanning. Three-dimensional patellofemoral kinematic parameters were evaluated across the range of motion, but comparison between time points was restricted to 10° of flexion. Participation in impact and nonimpact physical activities, pain score based on the visual analog scale, and the anterior knee pain score were also compared across initial and follow-up visits., Results: All subjects reported improved patellofemoral pain symptoms at follow-up, and one subject reported complete resolution. However, relative to the initial visit, no differences were found in patellar maltracking. There was a decrease in hours engaged in impact physical activities for all subjects at follow-up., Conclusion: This study provides insight into the natural history of patellofemoral pain in adolescent females. The relatively unchanged patellofemoral maltracking across subjects suggests that potential anatomic and kinematic abnormalities contributing to patellofemoral pain during mid-adolescence persist during skeletal maturation. Symptom improvement for these subjects did not result from a change in patellofemoral tracking, but rather from other causes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This research was supported by the Intramural Research Program of the National Institutes of Health (NIH), Clinical Center, Functional and Applied Biomechanics Section.

Background: There is limited information on the relationship between football helmet fit and concussion severity., Hypothesis: Poor helmet fit may predispose football players to a more severe concussion., Study Design: Descriptive epidemiology study., Level of Evidence: Level 3., Methods: Data from concussion injury reports were obtained from the National High School Sports-Related Injury Surveillance System over a 9-year period. Symptoms, duration, and helmet parameters (fit, interior padding) were analyzed for all first-time concussions., Results: Data from 4580 concussions were analyzed. Patients who suffered concussions with a helmet that did not fit properly (3.22%), as determined by an athletic trainer, had higher rates of drowsiness (RR, 1.46; P = 0.005), hyperexcitability (RR, 2.38; P = 0.047), and sensitivity to noise (RR, 1.88; P < 0.001); had more symptoms (5.34 vs 4.54, P = 0.004); and had longer symptom duration (P = 0.04). Athletes with helmets lined with an air bladder had greater rates of sensitivity to light (RR, 1.13; P = 0.02), sensitivity to noise (RR, 1.25; P = 0.009), and longer symptom duration (P = 0.004) compared with foam or gel liners., Conclusion: An improperly fitted football helmet is a risk factor for a concussion with more symptoms and of longer duration. Concussions of longer duration are also more common in players with an air bladder-lined helmet. Current high school football rules should mandate supervision and maintenance of helmet fit throughout the season, prior to impact., Clinical Relevance: Team physicians, athletic trainers, coaches, and high school officials should ensure proper oversight of helmet fit in high school athletes to decrease concussion severity and duration., (© 2016 The Author(s).)

Recent studies have focused on gender differences in movement patterns as risk factors for ACL injury. Understanding intrinsic and extrinsic factors which contribute to movement patterns is critical to ACL injury prevention efforts. Isometric lower-extremity muscular strength, anthropometrics, and jump-landing technique were analyzed for 2,753 cadets (1,046 female, 1,707 male) from the U.S. Air Force, Military and Naval Academies. Jump-landings were evaluated using the Landing Error Scoring System (LESS), a valid qualitative movement screening tool. We hypothesized that distinct anthropometric factors (Q-angle, navicular drop, bodyweight) and muscle strength would predict poor jump-landing technique in males versus females, and that female cadets would have higher scores (more errors) on a qualitative movement screen (LESS) than males. Mean LESS scores were significantly higher in female (5.34 ± 1.51) versus male (4.65 ± 1.69) cadets (P<.001). Qualitative movement scores were analyzed using factor analyses, yielding five factors, or "patterns", contributing to poor landing technique. Females were significantly more likely to have poor technique due to landing with less hip and knee flexion at initial contact (P<.001), more knee valgus with wider landing stance (P<.001), and less flexion displacement over the entire landing (P<.001). Males were more likely to have poor technique due to landing toe-out (P<.001), with heels first, and with an asymmetric foot landing (P<.001). Many of the identified factor patterns have been previously proposed to contribute to ACL injury risk. However, univariate and multivariate analyses of muscular strength and anthropometric factors did not strongly predict LESS scores for either gender, suggesting that changing an athlete's alignment, BMI, or muscle strength may not directly improve his or her movement patterns.

Heat stroke in athletes is entirely preventable. Exertional heat illness is generally the result of increased heat production and impaired dissipation of heat. It should be treated aggressively to avoid life-threatening complications. The continuum of heat illness includes mild disease (heat edema, heat rash, heat cramps, heat syncope), heat exhaustion, and the most severe form, potentially life-threatening heat stroke. Heat exhaustion typically presents with dizziness, malaise, nausea, and vomiting, or excessive fatigue with accompanying mild temperature elevations. The condition can progress to heat stroke without treatment. Heat stroke is the most severe form of heat illness and is characterized by core temperature >104 degrees F with mental status changes. Recognition of an athlete with heat illness in its early stages and initiation of treatment will prevent morbidity and mortality from heat stroke. Risk factors for heat illness include dehydration, obesity, concurrent febrile illness, alcohol consumption, extremes of age, sickle cell trait, and supplement use. Proper education of coaches and athletes, identification of high-risk athletes, concentration on preventative hydration, acclimatization techniques, and appropriate monitoring of athletes for heat-related events are important ways to prevent heat stroke. Treatment of heat illness focuses on rapid cooling. Heat illness is commonly seen by sideline medical staff, especially during the late spring and summer months when temperature and humidity are high. This review presents a comprehensive list of heat illnesses with a focus on sideline treatments and prevention of heat illness for the team medical staff.

Background: Catastrophic head injuries in football are rare but tragic events., Purpose: To update the profile of catastrophic head injuries in high school and college football players and to describe relevant risk factors., Study Design: Case series; Level of evidence, 4., Methods: We reviewed 94 incidents of severe football head injuries reported to the National Center for Catastrophic Sports Injury Research during 13 academic years (September 1989 through June 2002)., Results: In the study period there were an average of 7.23 (standard deviation = 2.05) direct high school and college catastrophic head injuries in scholastic football participants per year. There were 0.67 injuries per 100 000 (95% confidence interval: 0.54, 0.81 per 100 000) high school and 0.21 injuries per 100 000 (95% confidence interval: 0.0, 0.49 per 100 000) college participants for a risk ratio of 3.28 (95% confidence interval: 0.81, 13.3). The injuries resulted in subdural hematoma in 75 athletes, subdural hematoma with diffuse brain edema in 10 athletes, diffuse brain edema in 5 athletes, and arteriovenous malformation or aneurysm in 4 athletes. Fifty-nine percent of the contacts reported that the athlete had a history of a previous head injury, of which 71% occurred within the same season as the catastrophic event. Thirty-nine percent of the athletes (21 of 54) were playing with residual neurologic symptoms from the prior head injury. There were 8 (9%) deaths as a result of the injury, 46 (51%) permanent neurologic injuries, and 36 (40%) serious injuries with full recovery. Most players sustained a major impact to the head either from tackling or being tackled., Conclusion: The incidence of catastrophic head injuries in football has remained low since the advent of the modern day football helmet in the early 1970s. The incidence of catastrophic head injuries in football is dramatically higher at the high school level than at the college level. Although the reason for this discrepancy is unclear, an unacceptably high percentage of high school players were playing with residual symptoms from a prior head injury. Coaches, athletes, athletic trainers, and medical personnel need to adhere to the guideline that an athlete with any neurologic symptoms from a head injury should be strongly discouraged from returning to play.

Background: The mechanisms of anterior cruciate ligament injury in basketball are not well defined., Purpose: To describe the mechanisms of anterior cruciate ligament injury in basketball based on videos of injury situations., Study Design: Case series; Level of evidence, 4., Methods: Six international experts performed visual inspection analyses of 39 videos (17 male and 22 female players) of anterior cruciate ligament injury situations from high school, college, and professional basketball games. Two predefined time points were analyzed: initial ground contact and 50 milliseconds later. The analysts were asked to assess the playing situation, player behavior, and joint kinematics., Results: There was contact at the assumed time of injury in 11 of the 39 cases (5 male and 6 female players). Four of these cases were direct blows to the knee, all in men. Eleven of the 22 female cases were collisions, or the player was pushed by an opponent before the time of injury. The estimated time of injury, based on the group median, ranged from 17 to 50 milliseconds after initial ground contact. The mean knee flexion angle was higher in female than in male players, both at initial contact (15 degrees vs 9 degrees , P = .034) and at 50 milliseconds later (27 degrees vs 19 degrees , P = .042). Valgus knee collapse occurred more frequently in female players than in male players (relative risk, 5.3; P = .002)., Conclusion: Female players landed with significantly more knee and hip flexion and had a 5.3 times higher relative risk of sustaining a valgus collapse than did male players. Movement patterns were frequently perturbed by opponents., Clinical Relevance: Preventive programs to enhance knee control should focus on avoiding valgus motion and include distractions resembling those seen in match situations.

Background: Catastrophic cervical spine injuries in football are rare but tragic events., Purpose: To update the incidence of catastrophic cervical injuries in scholastic football players and identify new injury patterns., Study Design: Descriptive epidemiology study., Methods: The authors retrospectively reviewed 196 incidents of catastrophic high school and collegiate football injuries reported to the National Center for Catastrophic Sports Injury Research during 13 academic years (September 1989 through June 2002)., Results: There were 15.08 direct catastrophic cervical spine injuries in scholastic football participants per year, an incidence of 1.10 and 4.72 injuries per 100 000 high school and 100 000 college participants, respectively. Seventy-six athletes had quadriplegia (5.85 per year), 0.50 per 100 000 high school players and 0.82 per 100 000 college players. Spear tackling by players on defense continued to be the predominant mechanism of injury causing quadriplegia. Five athletes had a Brown-Séquard-like syndrome; only 1 made a full recovery. One athlete with Brown-Séquard-like syndrome and permanent neurologic symptoms reported a cervical cord neurapraxia event before the study period. Forty-three athletes (3.31 per year) had diagnosed cervical cord neurapraxia. In addition to hyperflexion and hyperextension injuries, axial forces were found to cause cervical cord neurapraxia. Sixteen of the 43 athletes returned to football after a cervical cord neurapraxia episode, and none of the 16 suffered a permanent quadriplegic event. Nine athletes sustained an isolated injury at the C1 or C2 level, and 7 sustained a combined injury at the C1, or C2 level and at a subaxial level., Conclusion: The total number of quadriplegic events for high school and college football players is approximately 6 per year, with a higher incidence at the college level. Cervical cord neurapraxia can be caused by hyperflexion, hyperextension, and axial compression forces. Upper level cervical injuries involving the atlas and axis can occur in football players and may be associated with noncontiguous subaxial injuries.

Catastrophic spine injuries in sports are rare but tragic events. The sports with the highest risk of catastrophic spinal injuries are football, ice hockey, wrestling, diving, skiing and snowboarding, rugby, cheerleading, and baseball. A common mechanism of injury for all at-risk sports is an axial compression force to the top of the head with the neck slightly flexed. We review common mechanisms of injury and prevention strategies for spine injuries in the at-risk sports.