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Patellofemoral pain (PFP) is defined as retro- or peri-patellar knee pain without a clear structural abnormality. Unfortunately, many current treatment approaches fail to provide long-term pain relief, potentially due to an incomplete understanding of pain-disrupted sensorimotor dysfunction within the central nervous system. The purposes of this study were to evaluate brain functional connectivity in participants with and without PFP, and to determine the relationship between altered brain functional connectivity in association with patient-reported outcomes. Young female patients with PFP (n = 15; 14.3 ± 3.2 years) completed resting-state functional magnetic resonance imaging (rs-fMRI) and patient-reported outcome measures. Each patient with PFP was matched with two controls (n = 30, 15.5 ± 1.4 years) who also completed identical rs-fMRI testing. Six bilateral seeds important for pain and sensorimotor control were created, and seed-to-voxel analyses were conducted to compare functional connectivity between the two groups, as well as to determine the relationship between connectivity alterations and patient-reported outcomes. Relative to controls, patients with PFP exhibited altered functional connectivity between regions important for pain, psychological functioning, and sensorimotor control, and the connectivity alterations were related to perceived disability, dysfunction, and kinesiophobia. The present results support emergent evidence that PFP is not localized to structural knee dysfunction, but may actually be resultant to altered central neural processes. Clinical significance: These data provide potential neuro-therapeutic targets for novel therapies aimed to reorganize neural processes, improve neuromuscular function, and restore an active pain-free lifestyle in young females with PFP.

Musculoskeletal (MSK) and sports-related conditions are relatively common in the pediatric population. Pediatric residencies should provide residents with the knowledge and skills to assess and manage both acute and chronic MSK and sports injuries and complaints. Residents should develop the competencies and attitudes to safeguard and promote a healthy and active lifestyle for youth. Programs can use a variety of educational tools, both in the clinic and on the field, to provide a well-rounded MSK curriculum throughout the residency years. This article provides a review of general pediatric sports medicine curriculum guidelines and suggested implementation strategies.

To quantify the effects of an externally worn collar device for mitigating the influence of repetitive head impacts on alterations to diffusion tensor imaging (DTI) metrics of white matter. Fifteen female high-school soccer athletes (age: 14.00–16.98 yrs) completed pre- and post-season DTI over two consecutive years, including measures of diffusivity, changes in which may be associated with brain dysfunction. The collar was worn during year 1 (Yr1) but not during year 2 (Yr2). Athlete exposures (AEs) and head impact exposure were recorded over the competitive seasons. There were no significant differences in AEs or head impact exposures between Yr1 and Yr2 (P > 0.05). In Yr2, there was significant pre- to post-season mean diffusivity and/or axial diffusivity reduction in multiple WM regions (corrected P

Background: Characterization of, and evaluation of strategies to mitigate, the effects of sub-concussive impacts (SCI) on brain structure and function are crucial to understanding potential long-te...

Objective To investigate the impact of pediatric mild traumatic brain injury (mTBI), using a broad parent-reported measure, and to determine whether parent-ratings of mTBI symptoms are higher among those with premorbid attention-deficit/hyperactivity disorder (ADHD) and females. Design Retrospective case-control. Setting Hospital-based sports medicine clinic. Participants The retrospective chart review included 1346 (age: M = 13.11 years, SD = 2.6; 61.7% male) pediatric patients with (n = 209) and without (n = 1137) ADHD. Independent variables Group membership (ADHD vs non-ADHD) and sex (male vs female). Main outcome measures Baseline and current Post-Concussion Symptom Inventory-Parent Report Form (PCSI-P) Physical, Emotional, Cognitive, and Fatigue subscale scores. This study used a retrospective chart review; therefore, the hypotheses reported for the current study were formed after data were collected. Results Controlling for patient age and days from mTBI, patients with ADHD had significantly higher retrospective parent-reported pre-mTBI ratings of physical, emotional, and cognitive symptoms (ds = 0.17-0.62) and higher post-mTBI ratings across all 4 symptom domains (ds = 0.18-0.57) than those without ADHD. There was no group × time interaction for any of the PCSI-P subscales. Females overall had higher retrospective parent-reported pre-injury Fatigue and Emotional symptoms (ds = 0.13-0.19) and higher post-mTBI symptoms in all 4 PCSI-P symptom domains (ds = 0.23-0.35), relative to males. Conclusions Attention-deficit/hyperactivity disorder-related postinjury exacerbations in parent-reported symptoms can be explained, in part, by elevated retrospective parent-reported ADHD-related pre-mTBI ratings. These results highlight the importance of assessing a patient's baseline symptoms post-mTBI. These data also indicate that ADHD status and sex should be considered when interpreting mTBI symptom severity during clinical evaluation of concussion.

Sports-related concussion (SRC) can exert serious acute and long-term consequences on brain microstructure, function, and behavioral outcomes. We aimed to quantify the alterations in white matter (WM) microstructure and global network organization, and the decrements in behavioral and cognitive outcomes from pre-season to post-concussion in youth athletes who experienced SRC. We also aimed to evaluate whether wearing a jugular compression neck collar, a device designed to mitigate brain "slosh" injury, would mitigate the pre-season to post-concussion alterations in neuroimaging, behavioral, and cognitive outcomes. A total of 488 high school football and soccer athletes (14-18 years old) were prospectively enrolled and assigned to the non-collar group (

To establish the King-Devick test (KD) performance values for children and adolescents.Prospective cohort.Pediatric sports medicine clinics.Five hundred seven athletes presenting to a pediatric sports medicine clinic for non-concussion-related evaluations.Age, sex, and risk factors for abnormal concussion recovery.The King-Devick test time.Four hundred eighty-three participants were included in the final analysis, which included 60.5% girls (n = 292) and 39.5% boys (n = 191). The KD test performance varied by age with a steady decrease in test time yearly from 8 years through 14 years of age, where some plateauing occurred. Baseline scores changed approximately 31 seconds over ages 8 to 18. Analysis of variance results revealed a strong effect of age on overall mean KD time (P0.001). The KD test performance was not associated with sex or other studied concussion risk factors or comorbid conditions.The KD test performance was reported in a cohort of youth aged 8 to 18 years, allowing for comparison of performance in individuals who may not have a baseline assessment. If baseline testing is desired, at least yearly intervals seems to be appropriate through childhood and early adolescence.

This case of a hockey player with a back injury that is not improving illustrates the need to consider medical causes of musculoskeletal pain in athletes. The young athlete in this case presents for evaluation of low back pain 4 months after a fall in hockey; he is not improving in physical therapy as expected. In addition, he is complaining of symptoms such as morning stiffness, widening area of pain, and weight loss that are inconsistent with a lingering musculoskeletal injury.

The purpose of this clinical trial was to examine whether internal jugular vein compression (JVC)-using an externally worn neck collar-modulated the relationships between differential head impact exposure levels and pre- to postseason changes in diffusion tensor imaging (DTI)-derived diffusivity and anisotropy metrics of white matter following a season of American tackle football. Male high-school athletes (n = 284) were prospectively assigned to a non-collar group or a collar group. Magnetic resonance imaging data were collected from participants pre- and postseason and head impact exposure was monitored by accelerometers during every practice and game throughout the competitive season. Athletes' accumulated head impact exposure was systematically thresholded based on the frequency of impacts of progressively higher magnitudes (10 g intervals between 20 to 150 g) and modeled with pre- to postseason changes in DTI measures of white matter as a function of JVC neck collar wear. The findings revealed that the JVC neck collar modulated the relationships between greater high-magnitude head impact exposure (110 to 140 g) and longitudinal changes to white matter, with each group showing associations that varied in directionality. Results also revealed that the JVC neck collar group partially preserved longitudinal changes in DTI metrics. Collectively, these data indicate that a JVC neck collar can provide a mechanistic response to the diffusion and anisotropic properties of brain white matter following the highly diverse exposure to repetitive head impacts in American tackle football. Clinicaltrials.gov: NCT# 04068883.

Background: Cumulative exposure to repetitive sub-concussive head impacts in contact sports may have deleterious effects on brain function, even in the absence of acute symptoms. Moreover, anatomical and biomechanical factors may predispose female athletes to higher risk compared to males. At present, there is no effective injury prevention strategy to protect female athletes from sports-related head impact. Hypothesis/Purpose: (1). We aimed to use resting-state fMRI to investigate the effect of a full season of competitive soccer on brain functional network integrity in female high school athletes. (2). We also aimed to evaluate the efficacy of a jugular vein compression neck collar device, designed to mitigate potential injury by reducing the brain slosh effect. Methods: A total of 125 high school female soccer athletes were included in this study. These athletes were assigned randomly to a non-collar (n=55, age=16.06±1.06 yrs) or collar group (n=70, 15.81±0.95 yrs) before the season started. High resolution 3D T1-weighted images and resting-state fMRI data were collected prospectively at pre-season and again at post-season. Data processing and analysis were conducted in the MATLAB-based programs Statistical Parametric Mapping (SPM12) and Connectivity Toolbox (Conn). Functional connectivity was computed between each pair of 105 anatomically delineated regions of interest (ROI). Network Based Statistics were applied to detect coherent patterns of altered connectivity from pre- to post-season. Results: The non-collar group showed a significant pattern of altered connectivity (p-FWE = 0.047) spanning 60% of ROIs (63/105) and 1.7% of ROI-ROI connections (94/5,460). 65 of the 94 altered connections were weakened from pre-to-post season and tended to occur in the right hemisphere. 29 of the 94 altered connections were strengthened from pre-to-post season and tended to involve regions in the occipital lobe. The collar group did not show any statistically significant change (p-FWE = 0.223). Conclusion: The results of this study indicate that exposure to repetitive sub-concussive head impacts during a single season of competitive female soccer induces changes in brain functional connectivity. The observed increases and decreases of functional connectivity strength comprising the pattern of altered connectivity are congruent with a heterogeneous response to insult wherein some connections are reduced in strength due to neuronal damage and other “detour” connections are strengthened to preserve network function. Comparatively, the absence of alterations in the collar group suggest that the jugular vein compression collar may have generated a potentially protective effect to preserve brain functional network integrity during exposure to head impacts. [Figure: see text]

Background: Patellofemoral pain (PFP) is a chronic knee condition that affects over 1 in 4 physically-active girls. PFP symptomology contributes to dysfunctional motor control and heightened kinesiophobia (i.e., fear of pain/movement). Both chronic pain and kinesiophobia induce substantial changes throughout the central nervous system (CNS) in many populations who experience pain (e.g., low back pain), but such relationships have not been explored in pediatric patients with PFP. As current treatment approaches for PFP generally fail to provide complete symptom mitigation, identifying the mechanisms by which kinesiophobia exacerbate PFP and disrupt the CNS could provide mechanistic neural pathways to guide novel, brain-based treatments for pain relief. Hypothesis/Purpose: The purpose of this study was to determine the relationship between kinesiophobia and brain functional activation during a knee motor control task in pediatric patients with PFP. Methods: Girls clinically diagnosed with PFP ( n = 15; 14.3 ± 3.2 yrs) were positioned supine in a 3 Tesla magnetic resonance imaging (MRI) scanner and completed a series of unilateral 45° knee extension/flexion movements during functional MRI (fMRI). Patients completed this open kinetic chain movement at a frequency of 1.2 Hz (Figure 1.1). Patients also completed the Tampa Scale of Kinesiophobia (TSK; scores range from 0 – 68, with scores greater than 37 indicating high kinesiophobia). Correlation analyses were performed to determine whether kinesiophobia was associated with brain activity during the motor task. Statistical corrections were made to account for multiple, voxel-wise comparisons. Results: Study patients exhibited high kinesiophobia, with a mean TSK score of 38.27 (SD = 5.79). Neuroimaging analyses revealed that greater kinesiophobia was directly associated with increased brain activity in a cluster located within the occipital pole/cuneus, supracalcarine cortex, and intracalcarine cortex (p < .001, z-max = 4.30; Figure 1). Conclusion: The results revealed that the degree of kinesiophobia was related to the magnitude of visual-related brain activity for knee motor control. As perceived fear of movement increases, patients with PFP may recruit additional visual resources to compensate for pain-disrupted somatosensory processing. Future interventions that promote sensorimotor engagement and reduce visual feedback for motor control (i.e., dynamic movements with occluded vision) may be beneficial to reorganize neural processes, decrease kinesiophobia, and restore an active lifestyle in young girls with PFP. Tables/Figures: [Figure: see text]

Background: Patellofemoral pain (PFP) is a chronic knee condition that inhibits movement quality and can cascade into kinesiophobia (i.e., fear of pain/movement). Despite its high prevalence in adolescent girls, PFP etiology has remained elusive, potentially due to an incomplete understanding of how pain, motor control, and kinesiophobia interact with central nervous system (CNS) functioning. Discovering linkages between motor control, kinesiophobia, and the CNS for patients with PFP could provide novel opportunities to refine neural therapeutic strategies for enhanced, personalized treatment approaches. Hypothesis/Purpose: To identify neural markers of kinesiophobia in pediatric patients with PFP. Methods: Adolescent girls clinically diagnosed with PFP ( n = 14; 14.3 ± 3.2 yrs) were positioned supine in a magnetic resonance imaging (MRI) scanner. A modified Clarke’s test (patellofemoral grind test) was administered to the left knee of patients during brain functional MRI (fMRI) acquisition. The experimenter placed a hand at the superior patellar border applying intermittent distal pressure while the patient contracted her quadriceps. Patients also completed a quadriceps contraction test without application of external pressure (control). Kinesiophobia was measured using the Tampa Scale of Kinesiophobia. fMRI analyses compared brain activation between the two tasks, and correlation analyses were performed to assess relationships between task-induced brain activity and kinesiophobia. Statistical corrections were made to account for multiple, voxel-wise comparisons. Results: Evidenced in Table 1 and Figure 1A, neuroimaging analyses revealed distinct bidirectional activation during the Clarke’s test compared to the control (all p corrected < .05, all z max > 3.1). Table 1 and Figure 1B further highlight that greater kinesiophobia was associated with increased brain activity during the Clarke’s test in two clusters (both p corrected < .05, both z max > 3.1), but no relationships between kinesiophobia and brain activity during the control test were observed (all p corrected > .05, all z max < 3.1). Conclusion: The current results indicate that the Clarke’s test induced differential pain-related brain activity relative to the control (e.g., paracingulate gyrus). The patients’ degree of kinesiophobia was also related to brain activity in regions important for sensorimotor control, attention, and pain. Collectively, these data indicate that PFP may be due to alterations in nociceptive processing throughout the CNS, providing novel complementary pathways for targeted restoration of patellofemoral joint dysfunction. Future research should consider combined mechanistic pain profiling, sensorimotor, psychometric, and CNS assessments to identify patients most susceptible to kinesiophobia to refine treatment approaches that work towards a goal of disease prevention. Tables/Figures: [Figure: see text][Table: see text]

The objective was to evaluate the use and utility of a novel set of emergency department discharge instructions (DIs) for concussion based on a child's ongoing symptoms: symptom-guided DIs (symptom DIs). Differences in clinical outcomes were also assessed.A convenience sample of 114 children aged 7 to 17 years presenting to an urban pediatric emergency department with a complaint of concussion was assembled. Children were randomized to standard DIs or symptom DIs. Children completed a graded symptom checklist (GSC) and completed daily the GSC for 1 week. Telephone follow-up was performed at 7 days after enrollment using a standardized survey.Fifty-eight children received the symptom DIs, and 56 received the standard DIs. Rates of use were similar with reported rates of 92% for symptom DIs and 84% for standard DIs. Caregivers with symptom DIs reported that the DIs were more helpful in determining when their child could return to school and physical activity (P0.05) than caregivers with standard DIs. Children continued to have postconcussive symptoms days and weeks after their injury with 44% of children with symptom DIs and 51% of children with standard DIs reporting symptoms on the GSC at 1 week.Both study groups reported frequent use of the DIs. Caregivers with symptom DIs found them particularly helpful in determining when their child could return to school and physical activity. Larger-scale investigations are needed to further develop instructions that are easy to use and that may decrease the postconcussive period.

To evaluate whether a mobile health application that employs elements of social game design could compliment medical care for unresolved concussion symptoms.Phase I and Phase II (open-label, non-randomized, ecological momentary assessment methodology).Outpatient concussion clinic.Youth, aged 13-18 years, with concussion symptoms 3+ weeks after injury; Phase I: n = 20; Phase II: n = 19.Participants received standard of care for concussion. The experimental group also used a mobile health application as a gamified symptoms journal.Phase I: feasibility and satisfaction with intervention (7-point Likert scale, 1 high). Phase II: change in SCAT-3 concussion symptoms (primary), depression and optimism.Phase 1: A plurality of participants completed the intervention (14 of 20) with high use (110 +/- 18% play) and satisfaction (median +/- interquartile range (IQR) = 2.0+/- 0.0). Phase II: Groups were equivalent on baseline symptoms, intervention duration, gender distribution, days since injury and medication prescription. Symptoms and optimism improved more for the experimental than for the active control cohort (U = 18.5, p = 0.028, effect size r = 0.50 and U = 18.5, p = 0.028, effect size r = 0.51, respectively).Mobile apps incorporating social game mechanics and a heroic narrative may promote health management among teenagers with unresolved concussion symptoms.

Interest and participation in organized sports for children, preadolescents, and adolescents continue to grow. Because of increased participation, and younger entry age, in organized sports, appropriate practice, game schedules, and content become more important, taking into account athlete developmental stage and skills. Parental support for organized sports in general, with focus on development and fun instead of winning, has emerged as a key factor in the athlete’s enjoyment of sports. Schools and community sports organizations who support multiple levels of sport (eg, recreational, competitive, elite) can include more youth who want to play sports and combat sport dropout. This report reviews the benefits and risks of organized sports as well as the roles of schools, community organizations, parents, and coaches in organized sports. It is designed to complement the American Academy of Pediatrics clinical reports “Physical Activity Assessment and Counseling in Pediatric Clinical Settings” and “Sports Specialization and Intensive Training in Young Athletes” by reviewing relevant literature on healthy organized sports for youth and providing guidance on organized sport readiness and entry. The report also provides guidance for pediatricians on counseling parents and advocating for healthy organized sports participation.

Examining association between serial participation in youth organized sports (OS) and concurrent cardiometabolic risk factors, with long-term health status, will aid understanding the role of OS participation. Combining data from a prospective study and a follow-up survey, we aimed to determine association between youth OS participation and cardiometabolic risk factors with health and physical activity (PA) in young adulthood. Cardiometabolic risk factors were monitored yearly, and OS involvement through middle school, high school, and college, together with current status was recorded 12 years after the initial study began; 462 participants completed follow-up. Cardiometabolic risk factors included: body mass index (BMI), waist circumference, blood pressure, total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL) cholesterol and triglycerides, fasting glucose and insulin. Participants continuing OS participation from middle to high school and/or college had significantly lower BMI/BMI z-scores [24.7 vs 27.4 (p

Background: Sports-related concussion is a significant public health problem which may result in exacerbated or prolonged neurologic deficits. A neck collar device has been developed to apply mild jugular vein compression, increasing intracranial blood volume, with the intent of reducing brain slosh and preventing damage to brain microstructure from head impact exposure. Hypothesis/Purpose: We aimed to quantify the alterations in white matter (WM) diffusion properties and network structural connectivity in high school athletes after sports-related concussion and to test the effect of a jugular vein compression collar device worn during the concussive event. Methods: 379 athletes (male American football and female Soccer) were included in this report. Of the 16693 total athlete exposures, 40 resulted in a diagnosed concussion and were included in these analyses. Prospective longitudinal MRI data were collected at pre-season and post-concussion: 20 athletes were in the non-collar group (12M, age =15.93±1.27yrs) and 20 athletes were in the non-collar group (16M, age=16.37±1.06yrs). DTI parameters, including fractional anisotropy (FA), and mean, axial and radial diffusivity (MD/AD/RD), were calculated to determine post-concussion alterations in WM diffusion properties. Graph analysis was utilized to quantify post-concussion changes in WM structural connectivity. Results: Diffusion property results revealed significant pre-season to post-concussion increases in MD, AD and RD within the non-collar group (p0.05). The pre-season to post-concussion MD, AD, or RD increase was significantly greater (pDiscussion & Conclusion: Results indicate that sports related concussion is associated with alterations in WM diffusion properties. The mean local efficiency of the network, a structural connectivity index reflecting network wiring redundancy and tolerance to brain injury, was also found to decrease after the concussion. Results indicate that wearing a neck collar device has the potential to limit these WM changes following a concussive event. Further studies are warranted to investigate the temporal progression of these changes for preventing long-term, neurologic squeala. [Figure: see text][Figure: see text]

Objective To identify factors associated with entry into primary care sports medicine (PCSM) fellowship programs. Design Primary care sports medicine fellowship directors (FDs) and fellowship faculty were surveyed regarding preferences for accepting applicants into their programs. Setting Survey study. Participants Primary care sports medicine FDs and fellowship faculty. Assessment of risk factors Questions were designed to delineate factors [clinical experience, letters of recommendation (LOR), scholarship, service commitment, interview performance, etc] perceived to be associated with entry into PCSM fellowship (1-10 scale; 10 = highest value). Weighted mean ± SD were calculated for each question. Main outcome measures Determination of most valued factors for entry into PCSM fellowship. Results Responses were provided by 242/2332 (10.4%) of the American Medical Society for Sports Medicine members, including 77 of 175 (44%) FDs. The top 3 factors for entry into PCSM fellowships for all respondents were as follows: interview performance (9.17 ± 1.13), LOR from SM fellowship faculty (8.20 ± 1.67), and high school game/event coverage (7.83 ± 1.70). Musculoskeletal ultrasound experience (4.50 ± 2.23) and residency training in pediatrics (4.58 ± 2.54), internal medicine (4.48 ± 2.44), emergency medicine (4.44 ± 2.59), and physical medicine and rehabilitation (4.40 ± 2.83) received the lowest scores. Conclusions Applicants seeking entry into SM fellowships should prioritize performance during interviews, LOR from SM fellowship faculty, and team game/event coverage experiences.

Recent neuroimaging studies have suggested that repetitive subconcussive head impacts, even after only one sport season, may lead to pre- to post-season structural and functional alterations in male high school football athletes. However, data on female athletes are limited. In the current investigation, we aimed to (1) assess the longitudinal pre- to post-season changes in functional MRI (fMRI) of working memory and working memory performance, (2) quantify the association between the pre- to post-season change in fMRI of working memory and the exposure to head impact and working memory performance, and (3) assess whether wearing a neck collar designed to reduce intracranial slosh via mild compression of the jugular veins can ameliorate the changes in fMRI brain activation observed in the female high school athletes who did not wear collars after a full soccer season. A total of 48 female high school soccer athletes (age range: 14.00-17.97 years) were included in the study. These athletes were assigned to the non-collar group (n = 21) or to the collar group (n = 27). All athletes undewent MRI at both pre-season and post-season. In each session, a fMRI verbal N-Back task was used to engage working memory. A significant pre- to post-season increase in fMRI blood oxygen level dependent (BOLD) signal was demonstrated when performing the N-back working memory task in the non-collar group but not in the collar group, despite the comparable exposure to head impacts during the season between the two groups. The collar group demonstrated significantly smaller pre- to post-season change in fMRI BOLD signal than the non-collar group, suggesting a potential protective effect from the collar device. Significant correlations were also found between the pre- to post-season increase in fMRI brain activation and the decrease in task accuracy in the non-collar group, indicating an association between the compensatory mechanism in underlying neurophysiology and the alteration in the behavioral outcomes.

American football remains one of the most popular sports for young athletes. The injuries sustained during football, especially those to the head and neck, have been a topic of intense interest recently in both the public media and medical literature. The recognition of these injuries and the potential for long-term sequelae have led some physicians to call for a reduction in the number of contact practices, a postponement of tackling until a certain age, and even a ban on high school football. This statement reviews the literature regarding injuries in football, particularly those of the head and neck, the relationship between tackling and football-related injuries, and the potential effects of limiting or delaying tackling on injury risk.

Background: Patellofemoral pain (PFP) is a common knee pain condition that affects up to 30% of adolescents and is disproportionately distributed between sexes, affecting females 2-10 times more frequently than male counterparts (Fulkerson, 2002). PFP, characterized by retro- or peripatellar pain, can be debilitating, leading to cessation of physical activity in 74% of adolescents (Fairbank, Pynsent, van Poortvliet, & Phillips, 1984). Aberrant lower-extremity biomechanics for those with PFP has been identified (Souza & Powers, 2009; Willson & Davis, 2008), but the underlying brain activation patterns contributing to pain-disrupted knee motor control is unknown. Patients with knee ligament deficiency demonstrate decreased sensorimotor activity and increased prelimbic activity in response to knee pain, compared with matched controls (Kadowaki, Tadenuma, Kumahashi, & Uchio, 2017), and those with knee ligament reconstruction demonstrate a disrupted sensory-motor brain activation strategy to control the knee (Grooms et al., 2017; Grooms, Page, & Onate, 2015). As PFP has been identified as a contributing factor to knee osteoarthritis later in life (Utting, Davies, & Newman, 2005), identifying the neural mechanisms driving pain-disrupted motor control could guide innovative neural-targeted interventions to treat and reduce knee pain. We hypothesized that patients with PFP, like those with knee ligament deficiencies and reconstruction, would demonstrate decreased sensorimotor brain activation and increased medial pain network brain activation to control the knee. We used our previously established knee motor control neuroimaging paradigm that simulates knee flexion and extension movements (Grooms et al., 2015) to identify altered neural activation patterns for those with PFP and compared those with matched controls. Methods: Four adolescent girls with patellofemoral pain (PFP: n = 4, 15.4 ± 2.2yrs, 158.5 ± 5.4 cm, 61.5 ± 15.6 kg) were matched with four adolescent girls with no history of knee pain (controls) based on age, height, and weight (Con: n =4, 16.4 ± 1.8yrs, 161.8 ± 5.1 cm, 54.9 ± 6.9 kg). Participants were positioned supine in a magnetic resonance imaging (MRI) scanner and completed a series of unilateral 45° knee extension/flexion movements at a velocity of 1.2 Hz (Figure 1; Left Panel). Various torso straps and head packing procedures were utilized to restrict excessive head motion. A second level mixed-effects (FLAME 1+2) independent samples t-test contrasted brain activation between the PFP and controls using a significance level set a priori at p < .05; Gaussian random field cluster corrected and z threshold set at z > 1.5. Results: Results revealed significantly depressed brain activation in the right parietal operculum cortex (z = 5.99, p < .001) and left Heschl’s gyrus (z = 3.83, p < .001) for the PFP compared to the controls (Figure 1; Right Panel). Discussion: The present study revealed significant differences in the neural activation patterns to control the knee between adolescent girls with PFP and those with no knee pain. Patients with PFP demonstrated less activation in sensorimotor cortices, seen in the parietal operculum, and sensory integration, seen in Heschl’s gyrus, when compared to healthy controls (Grooms et al., 2017; Kadowaki et al., 2017). These results indicate that pain may be suppressing sensory integration to control the knee for those with PFP. Congruent with previous neuroimaging investigations assessing those with knee injury (Grooms et al., 2017; Kadowaki et al., 2017), PFP appears to also induce neuroplastic effects identifiable using fMRI. These results provide a potential neural target for interventions that aim to restore sensorimotor integration in those with PFP, reduce pain, and restore an active lifestyle in young females. [Figure: see text]

a concussion, it is common for children and adolescents to experience difficulties in the school setting. Cognitive difficulties, such as learning new tasks or remembering previously learned material, may pose challenges in the classroom. The school environment may also increase symptoms with exposure to bright lights and screens or noisy cafeterias and hallways. Unfortunately, because most children and ado- lescents look physically normal after a concussion, school officials often fail to recognize the need for academic or environmental adjustments. Appropriate guidance and recommendations from the pediatrician may ease the transition back to the school environment and facilitate the recovery of the child or adolescent. This report serves to provide a better understanding of possible factors that may contribute to diffi- culties in a school environment aftera concussion and serves as a frame- workfor the medical home, the educational home, and thefamily hometo guide the student to a successful and safe return to learning. Pediatrics 2013;132:948-957

Objective The aim of the current review was to systematically identify, evaluate and synthesise trials that examine concussion prevention via equipment, educational programmes and training programmes. Data sources PubMed and EBSCO host (CINAHL, MEDLINE, SPORTDiscus). Eligibility criteria for selecting studies The electronic databases PubMed and EBSCO were searched using the phrases: concussion prevention equipment , concussion prevention training and concussion prevention education . Included studies utilised a prospective study design to evaluate the preventative effect of: (1) equipment, (2) training or (3) educational programmes on the incidence of concussions in comparison to a control group. Data extraction Demographic data and intervention methods were recorded. Intervention and control group concussion rates and superficial head injury rates were extracted and combined using random-effects relative risk meta-analysis. Results 14 studies evaluated interventions of novel protective equipment. One prospective investigation evaluated an educational programme. The relative risk of concussion for participants enrolled in the interventional arms of trials was not significantly different from that in standard practice arms (RR=0.78, 95% CI 0.55 to 1.11, χ 2 =1.8, p=0.17; I 2 =85.3%, 95% CI 71.5% to 90.8%). The relative risk of concussion for participants wearing protective equipment (ie, headgear, full face shields) relative to their counterparts wearing standard or no equipment, calculated from seven available reports, showed no effect of intervention (RR=0.82, 95% CI 0.56 to 1.20, χ 2 =1.06, p=0.30; I 2 =86.7%, 95% CI 73.3% to 91.8%). The relative risk of superficial head injury for participants wearing protective equipment relative to their counterparts, calculated from three reports, showed a significant risk reduction (RR=0.41, 95% CI 0.31 to 0.56, χ 2 =34.13, p 2 =53.1%, 95% CI 0% to 85.2%). Conclusions Prospective controlled studies indicate that certain protective equipment may prevent superficial head injury, but these items are suboptimal for concussion prevention in sport.

The quests for performance gains in sport have become increasingly prominent over the past 30 years with steady increases in marathon participation, cycling, and triathlons. Children today are exercising for performance gains at an earlier age than ever before. It is imperative to recognize the medical considerations for such endeavors, including physiologic adaptations to training. With the following, we intend to illustrate the medical concerns associated with marathon and long-distance running, cycling, swimming, and triathlon participation. Additionally, we will review the literature in regard to exercise-induced adaptations to exercise in children.

Consider stress fracture as a diagnosis in adolescent athletes complaining of worsening vague pain without a clear mechanism of injury. Remember that initial radiographs may be normal, especially early in the clinical course. If the fracture is of low risk for delayed or non-union, conservative management is indicated, with repeat radiographs 2 weeks after initiation of treatment. If a high-risk fracture is suspected, early diagnosis with MRI, bone scan, and, in some cases, CT is important for surgical decision making.

Athletic opportunities for females have come a long way since the passage of Title IX in the USA in 1972, and the first Olympic women's marathon in 1984. More than three million girls participate in high-school sports each year in the USA; there have been consecutive increases in participation in the past 24 years. With a steady rise in participation, come the positives and negatives. The positives range from improved academic performance in school age individuals to enhanced well-being in older athletes, in addition to many other benefits that extend across the lifespan. Negative consequences are inevitable, but are largely preventable. In this issue, several articles highlight the impact of sports and exercise on the health of female athletes. Dr De Souza and colleagues1 review the existing literature and present guidelines on clearance …