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As more women are deployed into combat environments, preliminary findings have been inconsistent regarding gender differences in symptoms of posttraumatic stress disorder (PTSD) following deployment. Very little is known about the experiences of Navy and Marine Corps personnel deployed to combat zones.The study population consisted of Navy and Marine Corps personnel who completed a Post-Deployment Health Assessment upon return from deployment to Iraq, Afghanistan, or Kuwait during 2008 and 2009 and a Post-Deployment Health Reassessment approximately 6 months later. These instruments included screening questions for PTSD.The final sample of 31,534 service members included 29,640 men and 1,894 women. Within occupation categories, women were overrepresented relative to men in the roles of functional support/administration and healthcare specialists, whereas men were overrepresented in the role of combat specialist. Screening rates were similar by gender, with a slightly higher percentage of women compared with men screening positive for PTSD (6.6% vs. 5.3%). These symptoms of PTSD among men and women in this sample could not be attributed to combat exposure or other deployment-related characteristics.Relative to men, women in this sample had a similar probability of screening positive for PTSD following deployment. These PTSD symptoms were not associated with deployment-related variables, suggesting that deployment to a combat zone does not affect women differently from men. This finding could have meaningful implications for policies surrounding women in the military.

Context:Prospective measures of high external knee-abduction moment (KAM) during landing identify female athletes at increased risk of patellofemoral pain (PFP). A clinically applicable screening protocol is needed.Objective:To identify biomechanical laboratory measures that would accurately quantify KAM loads during landing that predict increased risk of PFP in female athletes and clinical correlates to laboratory-based measures of increased KAM status for use in a clinical PFP injury-risk prediction algorithm. We hypothesized that we could identify clinical correlates that combine to accurately determine increased KAM associated with an increased risk of developing PFP.Design:Descriptive laboratory study.Setting:Biomechanical laboratory.Patients or Other Participants:Adolescent female basketball and soccer players (n = 698) from a single-county public school district.Main Outcome Measure(s):We conducted tests of anthropometrics, maturation, laxity, flexibility, strength, and landing biomechanics before each competitive season. Pearson correlation and linear and logistic regression modeling were used to examine high KAM (>15.4 Nm) compared with normal KAM as a surrogate for PFP injury risk.Results:The multivariable logistic regression model that used the variables peak knee-abduction angle, center-of-mass height, and hip rotational moment excursion predicted KAM associated with PFP risk (>15.4 NM of KAM) with 92% sensitivity and 74% specificity and a C statistic of 0.93. The multivariate linear regression model that included the same predictors accounted for 70% of the variance in KAM. We identified clinical correlates to laboratory measures that combined to predict high KAM with 92% sensitivity and 47% specificity. The clinical prediction algorithm, including knee-valgus motion (odds ratio [OR] = 1.46, 95% confidence interval [CI] = 1.31, 1.63), center-of-mass height (OR = 1.21, 95% CI = 1.15, 1.26), and hamstrings strength/body fat percentage (OR = 1.80, 95% CI = 1.02, 3.16) predicted high KAM with a C statistic of 0.80.Conclusions:Clinical correlates to laboratory-measured biomechanics associated with an increased risk of PFP yielded a highly sensitive model to predict increased KAM status. This screening algorithm consisting of a standard camcorder, physician scale for mass, and handheld dynamometer may be used to identify athletes at increased risk of PFP.

Background: Inadequate energy intake has been hypothesized to partially contribute to runners’ low BMD levels. Purpose: To assess the nutritional adequacy of adolescent runners’ diets and identify ...

Background:Identifying the risk factors associated with a bone stress injury (BSI), including stress reactions and stress fractures, may aid in targeting those at increased risk and in formulating prevention guidelines for exercising girls and women.Purpose:To evaluate the effect of single or combined risk factors as defined by the female athlete triad—a syndrome involving 3 interrelated spectrums consisting of energy availability, menstrual function, and bone mass—with the incidence of BSIs in a multicenter prospective sample of 4 cohorts of physically active girls and women.Study Design:Cohort study; Level of evidence, 3.Methods:At baseline, participants’ (N = 259; mean age, 18.1 ± 0.3 years) anthropometric characteristics, eating attitudes and behaviors, menstrual function, sports participation or exercise activity, and pathological weight control behaviors were assessed. Dual-energy x-ray absorptiometry (DXA) measured the bone mass of the whole body, total hip, femoral neck, lumbar spine, and body composition. Participants were followed prospectively for the occurrence of injuries; those injuries confirmed by a physician were recorded.Results:Twenty-eight participants (10.8%) incurred a BSI. Forty-six percent of those who had ≥12 h/wk of purposeful exercise, a bone mineral density (BMD) Z score 2, oligo- or amenorrhea, elevated dietary restraint, and/or participation in a leanness sport exercise/activity at baseline, incurred a BSI during the prospective study period. Single factors significantly ( P < .05) associated with the development of a BSI included ≥12 h/wk of purposeful exercise (14.7%), BMI 2(15.3%), and low bone mass (BMD Z score Conclusion:In the sample, which included female adolescents and young adults participating in competitive or recreational exercise activities, the risk of BSIs increased from approximately 15% to 20% for significant single risk factors to 30% to 50% for significant combined female athlete triad–related risk factor variables. These data support the notion that the cumulative risk for BSIs increases as the number of Triad-related risk factors accumulates.

Context: Brazilian jiujitsu is a modern combat martial art that uses joint locks to submit an opponent and achieve victory. This form of martial art is a relatively young but rapidly growing combat sport worldwide. Objective: To determine the cumulative injury incidence and risk of injury by belt rank and body region at an international-level Brazilian jiujitsu tournament. Design: Descriptive epidemiology study. Setting: World Jiu-Jitsu No-Gi Championship 2009 in Long Beach, California. Patients or Other Participants: We monitored 951 athletes (age range, 18–50 years) enrolled to compete in the World Jiu-Jitsu No-Gi Championship 2009. Intervention(s): Fighters were categorized by belt level for group comparisons (belt experience). Incidence rates per 1000 athlete-exposures (AEs) and incidence rate ratios were compared by belt rank. Main Outcome Measure(s): Incidence rates and incidence rate ratios. Results: During the tournament, 1606 AEs and 62 total injuries were reported. Of these injuries, 40 affected the joints, for an overall incidence rate of 24.9 per 1000 AEs. The joint incidence rate by belt rank was 21.5 per 1000 AEs for blue, 21.3 per 1000 AEs for purple, 25.2 per 1000 AEs for brown, and 35.1 per 1000 AEs for black. We found no differences for incidence rate ratios of joint injury among individual belt groups (P > .05). More experienced (brown belt and black belt) competitors had a higher injury risk than the less experienced (blue belt and purple belt) competitors; however, the difference was not significant (incidence rate ratio = 1.65, 95% confidence interval = 0.9, 2.9; P = .06). The incidence of joint injury was highest at the knee (7.5 per 1000 AEs) and elbow (7.5 per 1000 AEs). Conclusions: The data from this international Brazilian jiujitsu tournament indicated that the risk of joint injury was similar among belt ranks or experience during this Brazilian jiujitsu competition. The knee and elbow were the joints most susceptible to injury. Future investigation of injury mechanism is warranted to develop strategies to reduce potential risk factors attributed to injury.

To empirically identify latent classes of service members according to persistent postconcussive symptom patterns and to characterize the identified classes relative to other postdeployment variables including posttraumatic stress disorder (PTSD) and mild traumatic brain injury (TBI) screening results. Such comparisons may directly inform policy regarding these routine assessments and translate to improved treatment decisions.Self-report data were obtained for 12,581 combat-exposed male U.S. Navy and Marine Corps personnel who returned from deployment in 2008-2009 and completed a Post-Deployment Health Assessment (PDHA) and an associated Post-Deployment Health Reassessment (PDHRA). Persistent postconcussive symptoms indicated on the PDHRA were used as manifest variables in a latent class analysis yielding 4 distinct classes: systemic, cognitive/behavioral, comorbid, and nonpresenting.Although the nonpresenting class endorsed few or no postconcussive symptoms, the systemic and cognitive/behavioral classes displayed elevated likelihoods of neurological and mental health symptoms, respectively. Members of the comorbid class had an increased probability of reporting a wide range of symptoms across both domains. Characterization of identified classes suggested that class membership may indicate the presence or absence of persistent conditions resulting from head injury and/or mental health issues. Under this assumption, estimated class membership probabilities implied a rate of probable neurological injury among this sample to be 17.9%, whereas the standard assessments aimed at identifying repercussions of mild TBI reported a positive screening rate of only 13.1%.Findings suggest that the routinely administered PDHA and PDHRA appear to underestimate the true prevalence of service members experiencing postdeployment health problems. Supplemental items or an alternative screening algorithm incorporating persistent postconcussive symptoms may enable identification of additional cases requiring treatment following return from deployment.

Ample evidence links stress to psychiatric and neurological disease. Although many studies examine stress hormone secretion and receptor activity, exciting new developments signify a shift in focus to neuromodulatory systems influencing neuronal development, survival, and neuroplasticity. The purpose of this study was to characterize salivary nerve growth factor (sNGF) responses to intense stress exposure in healthy military members undergoing survival training. A second purpose was to explore effects of age, sex, education, and body mass index (BMI). One hundred sixteen military members (80% male) were studied before, during, and 24 h after a stressful mock-captivity exercise. sNGF was measured at all three time points. Reactivity, recovery, and residual elevation of sNGF were computed. General linear modeling with repeated measures evaluated effect of stress exposure, as well as the roles of age, sex, education, and BMI. sNGF increased 137% from baseline to intense stress. During recovery, sNGF remained elevated an average of 67% above baseline (i.e., residual elevation). Men showed greater sNGF reactivity than women quantified by larger absolute T1-T2Δ (+148.1 pg/mL vs. +64.9 pg/mL, p0.017). A noteworthy trend of higher sNGF concentrations in low BMI participants was observed (p=0.058). No effects of age or education were shown. This study shows substantial reactivity and residual elevation of sNGF in response to intense stress exposure in healthy humans. Further research is needed to refine the sNGF assay, fully characterize the sNGF stress response, delineate correlates and mechanisms, and validate therapeutic applications.

To determine the incidence rate of injury among high school cross country runners over a 15-year period.Prospective-longitudinal.Twenty-three high schools in western Washington State under the surveillance of the University of Washington Athletic Health Care System between 1979-1994.One hundred and ninety-nine cross country teams.Injuries resulting from running in a cross country practice or meet.There were 1,622 injuries for an overall injury rate of 13.1/1,000 athletic exposures (AEs), i.e., participation of a runner in a practice or meet. Girls had a significantly higher overall injury rate (16.7/1,000 AEs) than boys (10.9/1,000 AEs) (p0.0001). Girls also had significantly higher injury rates than boys for both initial (p0.0001) and subsequent injuries (p0.0001), especially those at the same body location (p = 0.0001). This difference in risk estimates was consistent over a 15-year period. Nearly three-fourths of the injuries resulted inor =4 days of disability. Overall, higher rates of initial injuries were reported during practices (9.2/1,000 AEs) than in meets (7.8/1,000 AEs) (p = 0.04). Shin injuries had the highest overall rates of new injury (1.9/1,000 AEs) and reinjury at the same body location (53.9/1,000 AEs). Girls had significantly higher initial injury rates than boys for shin (p0.0001), hip. and foot injuries (p0.01), and higher reinjury rates for knee. calf, and foot injuries, respectively (p0.05).The results of this study suggest that girl cross country runners are at higher risk of injury and reinjury than boy cross country runners.

The cumulative effect of the female athlete triad (Triad) risk factors on the likelihood of low bone mineral density (BMD) in exercising women is unclear.This study aimed to determine the risk of low BMD in exercising women with multiple Triad risk factors.We retrospectively examined cross-sectional data from 437 exercising women (mean ± SD age of 18.0 ± 3.5 yr, weighed 57.5 ± 7.1 kg with 24.5% ± 6.1% body fat) obtained at baseline from 4 prospective cohort studies examining Triad risk factors. Questionnaires were completed to obtain information on demographic characteristics, self-reported eating attitudes/behaviors, menstrual function, sport/activity participation, and medication use. Height and body weight were measured. BMD was measured using dual energy x-ray absorptiometry. Low BMD was defined as z-scores of-1 and ≤-2. Chi-square tests were performed to determine the percentage of women with low BMD who met the criteria for individual (current oligo/amenorrhea, late menarche, low body mass index (BMI), elevated dietary restraint, lean sport/activity participation) or multiple (2, 3, 4, or 5) Triad risk factors.Late menarche and low BMI were associated with the highest percentage of low BMD (z-score-1), 55% and 54%, respectively, and low BMD (z-score ≤-2), 14% and 16%, respectively. The percentage of participants with low BMD (z-score-1 and ≤-2) increased from 10% to 62% and from 2% to 18%, respectively, as women met the criteria for an increasing number of Triad risk factors.A cumulative number of Triad risk factors were associated with an increased risk of low BMD, suggesting a dose-response association between the number of Triad risk factors and BMD in exercising women. Further research should be conducted to develop a user-friendly algorithm integrating these indicators of risk for low BMD in exercising women (particularly factors associated with low BMI/body weight, menstrual dysfunction, lean sport/activity participation, and elevated dietary restraint).

In Operation Iraqi Freedom and Operation Enduring Freedom, blast-related injuries associated with combat are frequent and can result in traumatic brain injury (TBI) symptoms that may be difficult to distinguish from psychological problems. Using data from the Post-Deployment Health Assessment and Reassessment, we identified 12,046 male U.S. Navy sailors and Marines with reported combat exposure from 2008 to 2009. Symptoms potentially associated with blast-related TBI and posttraumatic stress disorder (PTSD) that were reported immediately after deployment were compared with symptoms present several months later. Our study supports others that have found that subjects with blast-related injuries may experience the development or worsening of symptoms during the months following deployment. Additionally, our study found that those who screened positive for PTSD and TBI formed a unique group, with the presence of TBI exacerbating development of PTSD symptoms at reassessment. Providers should recognize the late development of symptoms, consider the possibility of comorbidity, and be prepared to treat multiple symptoms rather than a specific diagnostic category.

Summary. Prior studies suggest that diagnosis of gestational diabetes is associated with increased risk for development of gestational diabetes in future pregnancies, and with subsequent onset of established diabetes. The magnitudes of these risks have not been measured. Using linked birth certificate data from Washington State it is possible to identify all women with two or more births occurring during 1984-91. All women with gestational diabetes (n= 1375) or with established diabetes (n= 220), during their pregnancy for the second or greater birth were identified, and a control group consisting of women whose second or greater birth was not complicated by either condition was randomly selected (n = 6380). Data from the birth certificate, for the previous birth, were compared in order to estimate the risks of developing gestational or established diabetes in a subsequent pregnancy among women with prior gestational diabetes relative to women without gestational diabetes. The age-adjusted risk of developing gestational diabetes in the pregnancy for the subsequent birth associated with prior gestational diabetes was 23.2 (95% (confidence interval) CI = 17.2–31.2); the risk of having developed established diabetes by the time of the subsequent birth was 55.5 (95% CI = 34.4–89.4). Women who had a macrosomic infant (> 4000 gm) in the prior birth were also at increased risk for developing gestational diabetes (odds ratio OR = 3.3, 95% CI = 2.9-3.8) or established diabetes (OR = 5.8, 95% CI = 4.0–8.5). When data were restricted to patients with only one prior birth, to patients with early prenatal care, to delivery at facilities with long-established protocols for diagnosing gestational diabetes, or to more recent years, the risk estimates remained similarly elevated. The 23-fold increased risk of gestational diabetes associated with having gestational diabetes indicated on the birth certificate of a woman's previous baby, although not unexpected, is still remarkable and reinforces the importance of careful monitoring of women with this history. Although changes in how screening is conducted may account for some of the elevation in risk, our results stayed consistently elevated even when restrictions were made within the data to control for this. The fact that there was a 56-fold increased risk of having developed established diabetes by the time of the subsequent birth on record, associated with prior gestational diabetes, and a 6-fold increased risk associated with a macro-somic infant, supports the idea that these may be early steps in the development of established diabetes, and identifies a group that may benefit from close monitoring and possible intervention.

Injury rates for softball players are similar to baseball players yet information regarding risk factors, pitching, and physical characteristics for high school windmill softball pitchers is limited. This information is needed to guide prevention, training, and rehabilitation efforts. The purpose of this study was to report descriptive data regarding the physical characteristics and pitching volume experienced by high school softball pitchers during one academic season. A secondary aim was to track and describe upper extremity injuries suffered by high school softball pitchers throughout the course of the 2009 season.Twelve uninjured female softball pitchers (13-18y) from 5 Greenville, South Carolina high schools participated. Prior to the 2009 season, the pitchers' shoulder internal, external, total arc of rotation and horizontal adduction PROM was measured. During the 10-week season, aggregate pitch counts (pitch volume) and occurrence of upper extremity injury were tracked for each pitcher.Mean preseason internal, external, and total arc of rotation PROM was observed to be similar between the pitchers' dominant and non-dominant shoulders. The PROM measures of horizontal abduction (HA) appear to demonstrate a side-to-side difference with less HA on the dominant arm of the pitchers who were examined. Subjects threw in an average of 10.1 games (±4.9) during the season. Six pitchers threw in 60% or more of the team's games and 3 of 12 pitchers pitched less than 25% of games. Pitchers averaged 61.8 pitches per game (±31.5) and 745.8 (±506.4) per season. Pitch count data did not appear to be different between injured and non-injured pitchers.Knowledge of pitch volume can be used to prepare windmill softball pitchers for the seasonal stresses, guide establishment of goals when recovering from injury, or assist in training for an upcoming season. Further research is needed to examine larger samples of pitchers over multiple seasons and years.III.

Many U.S. Marines have experienced routine combat deployments during Operation Iraqi Freedom, which present numerous occupational hazards that may result in low back pain (LBP). The objective of this retrospective cohort study was to identify new-onset LBP among Marines following initial deployment to Operation Iraqi Freedom. Active duty Marines deployed to Iraq or Kuwait between 2005 and 2008 were identified from deployment records and linked to medical databases (n = 36,680). The outcome of interest was an International Classification of Diseases, 9th Revision, Clinical Modification code indicating LBP (724.2) within 1 year postdeployment. Multivariate logistic regression examined the effect of occupation on LBP. Overall, 4.1% (n = 1,517) of Marines were diagnosed with LBP. After adjusting for covariates, the service/supply (odds ratio 1.33, 95% confidence interval, 1.12-1.59) and electrical/mechanical/craftsworker occupations (odds ratio 1.31, 95% confidence interval, 1.12-1.53) had higher odds of LBP when compared to the administrative/other referent group. Within these groups, the highest LBP prevalence was in the construction (8.6%) and law enforcement (6.2%) subgroups. Although infantry occupations purposefully engage the enemy and often face sustained physical rigors of combat, LBP was most prevalent in noninfantry occupations. Future studies should include detailed exposure histories to elucidate occupation-specific etiologies of LBP in order to guide prevention efforts.

Postural sway is defined as the movement of a body’s center of mass within the base of support to maintain postural equilibrium. Deficits in postural sway are present after ACL injury; however, current evidence linking it to future injury risk is unclear. The purpose of this study was to determine if postural sway deficits persist after ACL reconstruction (ACLR). The hypothesis tested was that after ACLR, patients who return to sport (RTS) would demonstrate differences in postural sway compared to control (CTRL) subjects. Fifty-six subjects with unilateral ACLR released to RTS, and 42 uninjured CTRL subjects participated. Dynamic postural sway was assessed and 3-way (2×2×2) ANOVA was used to analyze the variables. A side X group X sex (p=0.044) interaction in postural sway was observed. A side X group analysis also revealed an interaction (p=0.04) however, no effect of sex was observed (p=0.23). Analysis within the ACLR cohort showed less (p=0.001) postural sway on the involved side (1.82 ± 0.84°) versus the uninvolved side (2.07 ± 0.96°). No side-to-side differences (p=0.73) were observed in the CTRL group. The involved limb of subjects after ACLR demonstrated the least postural sway. In conclusion, these findings indicate that dynamic postural sway may be significantly altered in a population of athletes after ACLR and RTS compared to CTRL subjects. Further investigation is needed to determine if deficits in postural sway can be used as an effective criterion to assist in the decision to safely RTS after ACLR.

Context: The female athlete triad describes the interrelatedness of energy availability, menstrual function, and bone density. Although associations between triad components and musculoskeletal injury (INJ) have been reported in collegiate athletes, limited information exists about menstrual irregularity (MI) and INJ in the high school population. Objective: To determine the prevalence of and relationship between MI and INJ in high school athletes. Design: Cross-sectional study. Setting: High schools. Patients or Other Participants: The sample consisted of 249 female athletes from 3 high schools who competed in 33 interscholastic, school-sponsored sport teams, dance teams, and cheerleading or pom-pon squad during the 2006–2007 school year. Each athlete remained on the roster throughout the season. Main Outcome Measure(s): Participants completed a survey regarding injury type, number of days of sport participation missed, and menstrual history in the past year. Results: The prevalences of MI and INJ were 19.7% and 63.1%, respectively. Athletes who reported MI sustained a higher percentage of severe injuries (missing ≥22 days of practice or competition) than did athletes who reported normal menses. Although the trend was not significant, athletes with MI were almost 3 times more likely to sustain an injury resulting in 7 or more days of time lost from sport (odds ratio = 2.7, 95% confidence interval = 0.8, 8.8) than those who sustained an injury resulting in 7 or fewer days of time lost. Conclusions: The incidences of MI and INJ in this high school population during the study period were high. Athletes who reported MI sustained a higher percentage of severe injuries than did athletes who reported normal menses. Education programs to increase knowledge and improve management of MI and its potential effects on injury in female high school athletes are warranted.

Context: Participation in high school sports has grown 16.1% over the last decade, but few studies have compared the overall injury risks in girls' softball and boys' baseball. Objective: To examine the incidence of injury in high school softball and baseball players. Design: Cohort study. Setting: Greenville, South Carolina, high schools. Patients or Other Participants: Softball and baseball players (n = 247) from 11 high schools. Main Outcome Measure(s): Injury rates, locations, types; initial or subsequent injury; practice or game setting; positions played; seasonal trends. Results: The overall incidence injury rate was 4.5/1000 athlete-exposures (AEs), with more injuries overall in softball players (5.6/1000 AEs) than in baseball players (4.0/1000 AEs). Baseball players had a higher initial injury rate (75.9/1000 AEs) than softball players (66.4/1000 AEs): rate ratio (RR) = 0.88, 95% confidence interval (CI) = 0.4, 1.7. The initial injury rate was higher than the subsequent injury rate for the overall sample (P < .0001) and for softball (P < .0001) and baseball (P < .001) players. For both sports, the injury rate during games (4.6/1000 AEs) was similar to that during practices (4.1/1000 AEs), RR = 1.22, 95% CI = 0.7, 2.2. Softball players were more likely to be injured in a game than were baseball players (RR = 1.92, 95% CI = 0.8, 4.3). Most injuries (77%) were mild (3.5/1000 AEs). The upper extremity accounted for the highest proportion of injuries (63.3%). The incidence of injury for pitchers was 37.3% and for position players was 15.3%. The rate of injury was highest during the first month of the season (7.96/1000 AEs). Conclusions: The incidence of injury was low for both softball and baseball. Most injuries were minor and affected the upper extremity. The injury rates were highest in the first month of the season, so prevention strategies should be focused on minimizing injuries and monitoring players early in the season.

The objective of this study was to identify changes in weight that occurred during deployment to Iraq or Kuwait between 2005 and 2008. Data on length and type of deployment among 16,365 male U.S. Navy personnel were combined with weight measurements before and after deployment from the Physical Readiness Information Management System. Weight measurements were available for 10,886 men who did not exceed Navy weight recommendations before deployment. In general, weight increased after deployment and, for those who did not exceed Navy recommendations before deployment, factors associated with weight gain included being enlisted and having a deployment longer than 228 days. Among 1,108 men with 2 deployments, a dwell time shorter than the combined deployed time was a risk factor for weight gain during the second deployment. Future studies should explore the combined effects of long deployments and short dwell times in maintaining the readiness of military personnel.

Introduction Cigarette smoking has been reported to be higher among deployed military men than among similarly aged civilian or nondeployed men, but the short-term effect of smoking on physical fitness among these young healthy men is unclear. This study examined self-reported smoking status and change in objectively measured fitness over 1-4 years while controlling for body mass index (BMI). Methods This study included a large sample of male U.S. navy personnel who deployed to Iraq or Kuwait between 2005 and 2008. A mixed modeling procedure was used to determine factors contributing to longitudinal changes in both BMI and fitness (measured by run/walk times, curl-ups, and push-ups). Results Of the total sample (n = 18,537), the 20% current smokers were more likely than nonsmokers to be enlisted, younger, and have lower BMI measurements at baseline. In addition, smokers had slower 1.5-mile run/walk times and could do fewer curl-ups and push-ups compared with nonsmokers. The run/walk time model indicated that over 4 years, smokers (compared with nonsmokers) experienced a significantly greater rate of decrease in cardiorespiratory fitness, even after controlling for changes in BMI. Conclusions These results call for continued attention to the problem of nicotine use among young healthy men.

There is a growing need to accurately assess exercise energy expenditure (EEE) in athletic populations that may be at risk for health disorders because of an imbalance between energy intake and energy expenditure. The Actiheart combines heart rate and uniaxial accelerometry to estimate energy expenditure above rest. The authors’ purpose was to determine the utility of the Actiheart for predicting EEE in female adolescent runners (N = 39, age 15.7 ± 1.1 yr). EEE was measured by indirect calorimetry and predicted by the Actiheart during three 8-min stages of treadmill running at individualized velocities corresponding to each runner’s training, including recovery, tempo, and 5-km-race pace. Repeated-measures ANOVA with Bonferroni post hoc comparisons across the 3 running stages indicated that the Actiheart was sensitive to changes in intensity (p < .01), but accelerometer output tended to plateau at race pace. Pairwise comparisons of the mean difference between Actiheart- and criterion-measured EEE yielded values of 0.0436, 0.0539, and 0.0753 kcal · kg−1 · min−1 during recovery, tempo, and race pace, respectively (p < .0001). Bland–Altman plots indicated that the Actiheart consistently underestimated EEE except in 1 runner’s recovery bout. A linear mixed-model regression analysis with height as a covariate provided an improved EEE prediction model, with the overall standard error of the estimate for the 3 speeds reduced to 0.0101 kcal · kg−1 · min−1. Using the manufacturer’s equation that combines heart rate and uniaxial motion, the Actiheart may have limited use in accurately assessing EEE, and therefore energy availability, in young, female competitive runners.

Background Athletes who return to sport participation after anterior cruciate ligament reconstruction (ACLR) have a higher risk of a second anterior cruciate ligament injury (either reinjury or contralateral injury) compared with non—anterior cruciate ligament— injured athletes. Hypotheses Prospective measures of neuromuscular control and postural stability after ACLR will predict relative increased risk for a second anterior cruciate ligament injury. Study Design Cohort study (prognosis); Level of evidence, 2. Methods Fifty-six athletes underwent a prospective biomechanical screening after ACLR using 3-dimensional motion analysis during a drop vertical jump maneuver and postural stability assessment before return to pivoting and cutting sports. After the initial test session, each subject was followed for 12 months for occurrence of a second anterior cruciate ligament injury. Lower extremity joint kinematics, kinetics, and postural stability were assessed and analyzed. Analysis of variance and logistic regression were used to identify predictors of a second anterior cruciate ligament injury. Results Thirteen athletes suffered a subsequent second anterior cruciate ligament injury. Transverse plane hip kinetics and frontal plane knee kinematics during landing, sagittal plane knee moments at landing, and deficits in postural stability predicted a second injury in this population (C statistic = 0.94) with excellent sensitivity (0.92) and specificity (0.88). Specific predictive parameters included an increase in total frontal plane (valgus) movement, greater asymmetry in internal knee extensor moment at initial contact, and a deficit in single-leg postural stability of the involved limb, as measured by the Biodex stability system. Hip rotation moment independently predicted second anterior cruciate ligament injury (C = 0.81) with high sensitivity (0.77) and specificity (0.81). Conclusion Altered neuromuscular control of the hip and knee during a dynamic landing task and postural stability deficits after ACLR are predictors of a second anterior cruciate ligament injury after an athlete is released to return to sport.

This study tracked changes in bone mineral density (BMD) over a 7-year period in competitive male master cyclists (n = 19) and nonathletes (n = 18). Participants completed health/exercise history and food frequency (for calcium intake) questionnaires and underwent BMD testing by dual-energy X-ray absorptiometry. At initial and 7-year assessments, there was a consistent pattern of lower BMD in cyclists compared to nonathletes at all bone sites measured. Repeated measures analysis of covariance adjusted for changes in body mass index, lean mass, calcium intake, and exercise habits indicated a significant interaction at the total body site, indicating greater BMD decline in cyclists than nonathletes (p < 0.05). Among all study participants, those who reported participating in weight training or impact exercise since the baseline assessment lost significantly less BMD at the spine and femoral neck compared to participants who reported no weight training/impact exercise since baseline (p < 0.05). A significantly greater percentage of cyclists than nonathletes met the International Society of Clinical Densitometry criteria for osteopenia or osteoporosis at baseline (84.2% vs. 50.0%) and at follow-up (89.5% vs. 61.1%, p < 0.05). Further, 6 of the 19 (31.6%) cyclists who had osteopenia at baseline became osteoporotic, compared to 1 (5.6%) of the nonathletes. The high percentage of male master cyclists with low BMD, combined with a high risk for fracture from falls associated with competitive cycling, warrant attention among this population. Coaches and health professionals interacting with cyclists need to promote alternative exercise such as weight training, plyometrics, or other high impact activity as a complement to cycle training to help minimize bone loss in this population.

The aims of this study were to determine the prevalence and incidence of patellofemoral pain (PFP) in young female athletes and prospectively evaluate measures of frontal plane knee loading during landing to determine their relationship to development of PFP. We hypothesized that increased dynamic knee abduction measured during preseason biomechanical testing would be increased in those who developed PFP relative to teammates who did not develop PFP.Middle and high school female athletes (n=240) were evaluated by a physician for PFP and for landing biomechanics prior to their basketball season. The athletes were monitored for athletic exposures and PFP injury during their competitive seasons.At the beginning of the season, the point prevalence of PFP was 16.3 per 100 athletes. The cumulative incidence risk and rate for the development of new unilateral PFP was 9.66 per 100 athletes and 1.09 per 1000 athletic exposures, respectively. All new PFPs developed in middle school athletes who demonstrated mean International Knee Documentation Committee score of 85.6+/-7.7 at diagnosis. The new PFP group demonstrated increased knee abduction moments at initial contact (95% CI: 0.32 to 4.62Nm) on the most-symptomatic limb and maximum (95% CI: 1.3 to 10.1Nm; P=0.02) on the least-symptomatic (or no symptoms) limb relative to the matched control limbs. Knee abduction moments remained increased in the new PFP group when normalized to body mass (P0.05).The increased knee abduction landing mechanics in the new PFP group indicate that frontal plane loads contribute to increased incidence of PFP.

We aimed to evaluate patterns of bone mineral accrual among a cross-sectional sample of female adolescent runners and girls participating in a nonendurance running sport. One-hundred and eighty-three interscholastic competitive female athletes (age 16.0 +/- 0.1 years), 93 endurance runners and 90 nonrunners, completed a menstrual and sports history questionnaire, had their height and weight measured, and underwent a dual-energy X-ray absorptiometry scan for the measurements of body composition and bone mass. For the majority of analyses, the girls were separated into four groups according to their age (13 to 14 years, 15 years, 16 years, and 17 to 18 years). Runners' height, weight, body mass index (BMI), percent body fat, lean tissue mass, number of menstrual cycles in the past year, and months of participation in a non-lean-build/variable-impact-loading sport were significantly lower than mean values for nonrunners. Although bone mass rose at all sites in the nonrunners between the ages of 13 to 14 years and 17 to 18 years, no such increase was noted in the runners. Runners compared with nonrunners exhibited significantly lower body weight and height-adjusted total body and lumbar spine bone mineral content (BMC) values and lower bone mineral density (BMD) Z-score values among the older (16 years and/or 17 to 18 years) but not younger (13 to 14 years and/or 15 years) age groups. These findings suggest that the runners, in contrast to the nonrunners, exhibited a suppressed bone mineral accrual pattern, which supports the notion that female adolescent endurance runners may be at risk for inadequate bone mass gains and thus a low peak BMD.

Context:Prior authors have reported associations among increased risk of injury and factors of the female athlete triad, as defined before the 2007 American College of Sports Medicine position stand, in collegiate and adult club sport populations. Little is known about this relationship in an adolescent competitive sports population.Objective:To examine the relationship among disordered eating, menstrual dysfunction, and low bone mineral density (BMD) and musculoskeletal injury among girls in high school sports.Design:Prospective cohort study.Setting:The sample consisted of 163 female athletes competing in 8 interscholastic sports in southern California during the 2003–2004 school year. Each participant was followed throughout her respective sport season for occurrence of musculoskeletal injuries.Main Outcome Measure(s):Data collected included daily injury reports, the Eating Disorder Examination Questionnaire that assessed disordered eating attitudes and behaviors, a dual-energy x-ray absorptiometry scan that measured BMD and lean tissue mass, anthropometric measurements, and a questionnaire on menstrual history and demographic characteristics.Results:Sixty-one athletes (37.4%) incurred 90 musculoskeletal injuries. In our BMD z score model of ≤−1 SD, a history of oligomenorrhea/amenorrhea during the past year and low BMD (z score ≤−1 SD) were associated with the occurrence of musculoskeletal injury during the interscholastic sport season. In our BMD z score model of ≤−2 SDs, disordered eating (Eating Disorder Examination Questionnaire score ≥4.0), a history of oligomenorrhea/amenorrhea during the past year, and a low BMD (z score ≤−2 SDs) were associated with musculoskeletal injury occurrence.Conclusions:These findings indicate that disordered eating, oligomenorrhea/amenorrhea, and low BMD were associated with musculoskeletal injuries in these female high school athletes. Programs designed to identify and prevent disordered eating and menstrual dysfunction and to increase bone mass in athletes may help to reduce musculoskeletal injuries.

This study was designed to identify correlates of change in walking for exercise. Respondents to a random sample mailed exercise survey were asked to complete a follow-up questionnaire 24 months after the first. Responses were obtained from 1,739 adults, reflecting an 86.6% return rate. Nonrespondents did not differ from respondents for baseline level of walking for exercise. Respondents overrepresented Caucasian and middle to high education (or income) adults. Residualized measures of change in walking for exercise served as the dependent variable, adjusted for baseline walking. Similarly, key independent variables, subject to change over time, were included after residualization. At both baseline and 24 months follow-up, adults walked for exercise an average of just under 1 hour per week, and 23.5% of the initially active adults ceased walking for exercise at 2 years. Multiple regression analyses explained more variance in walking for exercise among women than men. Change in dynamic variables such as friend's support and vigorous physical activity accounted for most of the explained variance. Results suggest that dynamic variables may need to be sustained to maintain walking for exercise. The limited explained variance suggests that more precise measures and additional determinants of walking for exercise need to be identified.

Purpose: Identify the prevalence of and traits that may increase the risk of low bone mineral density (BMD) among 93 female adolescent competitive endurance runners. Methods: Participants were 93 high school runners, ages 13-18 yr, from southern California. Eating attitudes and behaviors were assessed using the Eating Disorder Examination Questionnaire (EDE-Q). Menstrual and sports participation history were evaluated using an interviewer-assisted, self-report questionnaire. Bone mineral density (BMD) of the spine (L1-L4), total hip, and total body were measured by dual-energy x-ray absorptiometry. The -2 and -1 BMD age-matched, gender-specific z-score cutoffs were used to categorize girls as having low bone mass for age. Results: Among the female runners, 11.8% and 28% met the -2 and -1 BMD z-score cutoffs, respectively, whereas 25.8% reported menstrual irregularity (MI). Total hip BMD, lumbar spine BMD, and lumbar spine BMD z-score were significantly lower in runners with MI after adjusting for body mass index (BMI) and lean tissue mass. Runners that participated in five or more compared with three seasons of endurance running exhibited a significantly lower total body and lumbar spine BMD z-score after adjusting for BMI, lean tissue mass, and number of menstrual cycles in the past year. Multiple regression analysis indicated that MI, participation in five or more seasons of endurance running, BMI, and lean tissue mass were independent predictors of low BMD. Conclusion: Female adolescent endurance runners may represent a population with an increased risk of low bone mass. Future studies are necessary to further understand the factors contributing to low bone mass in young runners and to identify behavioral strategies that will promote optimal bone mineral accumulation during the adolescent years.

Prospective cohort study.To determine the relationship between quadriceps angle (Q-angle) and risk of lower extremity injury among adolescent cross-country runners.No consensus exists on the role of the Q-angle as a risk factor for lower-extremity overuse injury, especially the effect of large Q-angle or right-left Q-angle difference.The Q-angles of 393 high school cross-country runners, 13 to 19 years of age, were goniometrically measured in a static, standing position with quadriceps relaxed. The runners were followed during a cross-country season to assess lower extremity injuries resulting from running in practices or competitions.Runners with a Q-angle20 degrees were at 1.7 times greater risk of injury (relative risk [RR], 1.7; 95% confidence interval [CI]: 1.2, 2.4) compared with runners whose Q-angle was 10 degrees to15 degrees . The RR estimates were similar among girls and boys. Runners with4 degrees absolute right-left Q-angle difference were at 1.8 times greater risk (RR, 1.8; 95% CI: 1.4, 2.5) compared to runners with a smaller difference. Runners with a Q-angle20 degrees were more likely to injure their knee, while runners with4 degrees Q-angle difference were more likely to injure their shin. Runners with a Q-angle20 degrees had greater time lost due to injury.High school cross-country runners with large or asymmetric Q-angles may be at greater risk for running injury. Our study suggests that Q-angle measurement be included in preseason screening exams.

Girls' participation in high school sports has increased 79.5% since 1975-1976. The incidence of injury among boys in high school sports has been well documented, but information regarding the incidence, severity, and type of injury among girls in high school sports is limited.To examine the effects of subsequent injuries among high school girls in 5 sports.Observational cohort.Existing data from the 1995-1997 National Athletic Trainers' Association High School Injury Surveillance database.Girl athletes (n = 25 187 player-seasons) participating in 5 varsity high school sports: basketball, field hockey, soccer, softball, and volleyball.Injury status, body location, injury type, time lost from injury, and number of players at risk for injury as recorded by athletic trainers and submitted to the Sports Injury Monitoring System.Overall, 23.3% of the athletes had 2 or more injuries within a sport; basketball and soccer athletes were most vulnerable. Overall, the probability of an athlete sustaining 3 or more injuries was 38.6%, and the risk was highest for field hockey players (61.9%). The risk of subsequent injury at a new body location was almost 2 times higher than reinjury at the same body location (risk ratio = 1.7, 95% confidence interval = 1.6, 1.8) and was similar for all sports except volleyball. Only in softball was the proportion of reinjuries causing 8 or more days lost from participation greater than the proportion of new injuries causing similar time loss. Softball and volleyball had the highest proportion of reinjuries at the shoulder, especially rotator cuff strains. The proportion of knee reinjuries was significantly higher than new injuries for all sports except soccer. The proportion of anterior cruciate ligament injuries was significantly higher for volleyball players only. Overall, the proportion of reinjuries was significantly higher for stress fractures and musculoskeletal condition injuries.Patterns of subsequent injury risk appear to vary among these 5 sports. Almost one quarter of the athletes incurred 2 or more injuries over a 3-year period, so the effects of subsequent injuries deserve more consideration.

Background: Because disordered eating (DE) has been related to menstrual irregularity (MI) and low bone mineral density (BMD) in some studies of female athletes but not in others, it seems beneficial to assess the DE attitudes and behaviors most associated with these conditions. Objective: We aimed to determine the relation between Eating Disorder Examination Questionnaire (EDE-Q) subscale scores, pathologic behaviors, MI, and low BMD in adolescent female runners. Design:Participantswere93femalecompetitivecross-countryrunners 13–18 y old. The EDE-Q, composed of subscales for weight concern, shape concern, eating concern, and dietary restraint, was used to assess DE. Menstrual history was determined by using a questionnaire derived from a medical history form administered before participation in high school athletics. The International Society for Clinical Densitometry and the World Health Organization criterion of2or1 SD, respectively, was used to categorize runners as having low BMD. Results: Runners with elevated restraint had a significantly (P 0.001)greaterincidenceoflowBMDthandidrunnerswithelevated weight and shape concern. After adjustment for possible confounding variables (including menstrual history), lumbar spine BMD, bone mineral content, and BMD z score values were lowest in runners with elevated restraint. In addition, total-body BMD and totalbody BMD z scores were significantly (P 0.05) lower in runners with elevated restraint than in those with elevated weight or shape concern.ElevatedEDE-Qscoresforweightorshapeconcern,pathologic behaviors, or any combination of the 3 without concurrent dietary restraint were not significantly associated with low bone mass. Conclusion: These findings suggest that, in adolescent female runners, dietary restraint may be the DE behavior most associated with negative bone health effects. Am J Clin Nutr 2008;87:36–43.

The authors’ purpose was to determine the prevalence and compare associations of disordered eating (DE) and menstrual irregularity (MI) among high school athletes. The Eating Disorder Examination Questionnaire (EDE-Q) and a menstrual-history questionnaire were administered to 423 athletes (15.7 ± 1.2 y, 61.2 ± 10.2 kg) categorized as lean build (LB; n = 146) or nonlean build (NLB; n = 277). Among all athletes, 20.0% met the criteria for DE and 20.1% for MI. Although the prevalence of MI was higher in LB (26.7%) than NLB (16.6%) athletes (P = 0.01), no differences were found for DE. For both sport types, oligo/amenorrheic athletes consistently reported higher EDE-Q scores than eumenorrheic athletes (P < 0.05). Athletes with DE were over 2 times as likely (OR = 2.3, 95%CI: 1.3, 4.2) to report oligo/amenorrhea than athletes without DE. These data establish an association between DE and MI among high school athletes and indicate that LB athletes have more MI but not DE than NLB athletes.

Prospective cohort.To determine (1) the cumulative seasonal incidence and overall injury rate of medial tibial stress syndrome (MTSS) and (2) risk factors for MTSS with a primary focus on the relationship between navicular drop values and MTSS in high school cross-country runners.MTSS is a common injury among runners. However, few studies have reported the injury rate and risk factors for MTSS among adolescent runners.Data collected included measurement of bilateral navicular drop and foot length, and a baseline questionnaire regarding the runner's height, body mass, previous running injury, running experience, and orthotic or tape use. Runners were followed during the season to determine athletic exposures (AEs) and occurrence of MTSS.The overall injury rate for MTSS was 2.8/1000 AEs. Although not statistically different, girls had a higher rate (4.3/1000 AEs) than boys (1.7/1000 AEs) (P = .11). Logistic regression modeling indicated that only gender and body mass index (BMI) were significantly associated with the occurrence of MTSS. However, when controlled for orthotic use, only BMI was associated with risk of MTSS. No significant associations were found between MTSS and navicular drop or foot length.Our findings suggest that navicular drop may not be an appropriate measure to identify runners who may develop MTSS during a cross-country season; thus, additional studies are needed to identify appropriate preseason screening tools.

Weight-bearing exercise during adolescence may enhance peak bone mineral density (BMD) and reduce osteoporosis risk. The association of sports participation before and after menarche with areal BMD (by central DXA) was investigated in 99 female high school athletes (age 15.5+/-1.3 year). The frequency and duration of structured sports (school-based or other organized team) were assessed using an interviewer-assisted questionnaire. Overall, the average number of years of weight-bearing sport participation was 7.4+/-3.4 years; 72% of the athletes began sport participation before menarche. Training patterns and BMD were examined by tertiles of yearly weight-bearing sport participation (hours/year) before (WBpre), after (WBpost) menarche, and in total (WBtotal). After adjusting for chronological age, gynecological age, and BMI, compared to athletes in the WBtotal low tertile, athletes in the WBtotal high tertile had significantly greater BMD at the spine (p=0.009), total hip (p=0.03), trochanter (p=0.03), and total body (p=0.009). Similar patterns were found by WBpre or WBpost status, separately, with the exception of spine BMD which was significantly different across tertiles in WBpost only (p

Background Stress fractures account for substantial morbidity for young women undergoing U.S. Marine Corps basic training. Hypothesis Certain pretraining characteristics identify women at increased risk of stress fractures during boot camp. Study Design Cohort study; Level of evidence, 2. Methods Data collected included baseline performance on a timed run (a measure of aerobic fitness), anthropometric measurements, and a baseline questionnaire highlighting exercise and menstrual status among 2962 women undergoing basic training at the Marine Corps Recruit Depot, Parris Island, in 1995 and 1996. Results One hundred fifty-two recruits (5.1%) had 181 confirmed lower extremity stress fractures, with the most common sites being the tibia (25%), metatarsals (22%), pelvis (22%), and femur (20%). Logistic regression models revealed that having low aerobic fitness (a slower time on the timed run) and no menses during the past year were significantly associated with the occurrence of any stress fracture and with pelvic or femoral stress fracture during boot camp. Conclusion These findings suggest that stress fractures may be reduced if women entering Marine Corps Recruit Depot training participated in pretraining activities designed to improve aerobic fitness. Furthermore, women reporting no menses during the previous year may need additional observation during training. Clinical Relevance Consistent with previous studies, we found that low aerobic fitness was the only modifiable risk factor associated with stress fractures during boot camp.

Objectives: The incidence of second anterior cruciate ligament (ACL) injury in the first 12 months after ACL reconstruction (ACLR) and return to sport in a young, active population has been reported to be 15 times greater than a previously uninjured cohort. It is unknown if this high relative rate of injury continues beyond the first year after return to sport following ACLR. The tested hypothesis was that the incidence rate of a subsequent ACL injury in the 2 years following ACLR and return to sports would be less than the incidence rate reported within the first 12 months after return to sport, but greater than the ACL injury incidence rate in an uninjured cohort of young athletes. Methods: Seventy-eight subjects who underwent ACLR and were ready to return to a pivoting/cutting sport (RTS) and 47 controls were prospectively enrolled. Each subject was followed for injury and athletic exposure (AE) data for a 24-month period after return to sport. Twenty-three subjects after ACLR and 4 control subjects suffered an ACL injury during this time. Incidence rate ratios (IRR) were calculated to compare the rates (per 1000 athletic exposures [AEs]) of ACL injury in athletes in the ACLR group and control group. For the ACLR group, similar comparisons were conducted for side of injury by sex. Results: The overall incidence rate of a second ACL injury within 24 months after ACLR and RTS (1.39/1000 AE) was nearly 6 times greater (IRR=5.71, 95% CI: 2.0, 22.7, p=0.0003) than healthy control subjects (0.24/1,000 AE). Female ACLR athletes demonstrated 4 times greater rate of injury within 24 months of RTS (IRR=4.51; 95% CI: 1.5-18.2, p=0.0004) than female controls. Within the ACLR group, there was a trend for female subjects to be over two (RR=2.43, 95% CI: 0.8, 8.6) times more likely to suffer a contralateral injury (1.13/1000 AEs) than an ipsilateral injury (0.47/1000 AEs). Overall, 29.5% of athletes suffered a second ACL injury within 24 months of RTS with 20.5% sustaining a contralateral injury and 9.0% incurring an ipsilateral graft re-tear injury. A higher proportion of females (23.7%) suffered a contralateral injury compared to males (10.5%). Conversely, for ipsilateral injuries, the incidence proportion between females (8.5%) and males (10.5%) were found to be similar. Conclusion: These data support the hypothesis that in the 24 months following ACLR and RTS, patients are at greater risk (nearly 6 times) to suffer a subsequent ACL injury compared to young athletes without a history of ACL injury. Additionally, the contralateral limb of female patients appears to be at greatest risk. These 24 month outcome data, analyzed in conjunction with recent 12 month outcome data which noted a 15 times greater risk of ACL injury compared to healthy control subject, indicate that the greatest risk of second ACL injury after ACLR occurs during the initial 12 months after ACLR and RTS than the second year after RTS.

Servicemembers with combat-related limb loss often require substantial rehabilitative care. The prevalence of traumatic brain injury (TBI), which may impair cognitive and functional abilities, among servicemembers has increased. The primary objectives of this study were to determine the frequency of TBI among servicemembers with traumatic amputation and examine whether TBI status was associated with discharge to civilian status and medical and rehabilitative service use postamputation. U.S. servicemembers who had a combat-related amputation while deployed in Iraq or Afghanistan between 2001 and 2006 were followed for 2 yr postamputation. Data collected includes injury mechanism; postinjury complications; Injury Severity Score (ISS); and follow-up data, including military service discharge status and number of medical, physical, occupational therapy, and prosthetic-related visits. Of the 546 servicemembers with combat-related amputations, 127 (23.3%) had a TBI diagnosis. After adjusting for ISS and amputation location, those with TBI had a significantly greater mean number of medical and rehabilitative outpatient and inpatient visits combined (p < 0.01). Those with TBI were also at greater odds of developing certain postinjury complications. We recommend that providers treating servicemembers with limb loss should assess for TBI because those who sustained TBI required increased medical and rehabilitative care.

Objectives: To determine the prevalence of corporal punishment in Washington State and the factors associated with its use in Washington elementary and secondary schools. Design: Cross-sectional mail survey performed during the summer of 1992. Setting: All elementary and secondary schools in the state of Washington. Results: One thousand eighteen schools (47%) responded to the survey, of which 80% were publicly funded and 63% were located in urban areas. The study sample closely resembled the profile of all schools in the state. Almost 11% of participating schools permitted corporal punishment at the time of the survey and 3.2% reported its actual use during the 1991-1992 school year, resulting in an estimated prevalence of 7.2 incidents per 1000 students per year. Sixteen percent of corporal punishment actions occurred in schools not permitting its use. Ninety percent of public schools relied on district policy regarding corporal punishment. School characteristics associated with the use of corporal punishment included rural location (crude odds ratio, 2.2; 95% confidence interval, 1.5 to 3.4), enrollment of less than 500 students (crude odds ratio, 1.7; 95% confidence interval, 1.1 to 2.7), and kindergarten to eighth-grade or kindergarten to 12th-grade enrollment (crude odds ratio, 2.5; 95% confidence interval, 1.6 to 3.9). Conclusions: The lack of a statewide ban on school corporal punishment at the time of this survey was associated with the continued use of corporal punishment against children in districts that continued to permit it. School policies against corporal punishment were associated with much lower prevalence. Continued efforts are needed to enact and enforce laws in the remaining states that have not yet banned corporal punishment. (Arch Pediatr Adolesc Med. 1995;149:529-532)