Aristarque Djoko

Concussion Symptoms and Return to Play Time in Youth, High School, and College American Football Athletes

IMPORTANCE To our knowledge, little research has examined concussion across the youth/adolescent spectrum and even less has examined concussion-related outcomes (ie, symptoms and return to play). OBJECTIVE To examine and compare sport-related concussion outcomes (symptoms and return to play) in youth, high school, and collegiate football athletes. DESIGN, SETTING, AND PARTICIPANTS Athletic trainers attended each practice and game during the 2012 to 2014 seasons and reported injuries. For this descriptive, epidemiological study, data were collected from youth, high school, and collegiate football teams, and the analysis of the data was conducted between July 2015 and September 2015. The Youth Football Surveillance System included more than 3000 youth football athletes aged 5 to 14 years from 118 teams, providing 310 team seasons (ie, 1 team providing 1 season of data). The National Athletic Treatment, Injury, and Outcomes Network Program included 96 secondary school football programs, providing 184 team seasons. The National Collegiate Athletic Association Injury Surveillance Program included 34 college football programs, providing 71 team seasons. MAIN OUTCOMES AND MEASURES We calculated the mean number of symptoms, prevalence of each symptom, and the proportion of patients with concussions that had long return-to-play time (ie, required participation restriction of at least 30 days). Generalized linear models were used to assess differences among competition levels in the mean number of reported symptoms. Logistic regression models estimated the odds of return to play at less than 24 hours and at least 30 days. RESULTS Overall, 1429 sports-related concussions were reported among youth, high school, and college-level football athletes with a mean (SD) of 5.48 (3.06) symptoms. Across all levels, 15.3% resulted return to play at least 30 days after the concussion and 3.1% resulted in return to play less than 24 hours after the concussion. Compared with youth, a higher number of concussion symptoms were reported in high school athletes (β = 1.39; 95% CI, 0.55-2.24). Compared with college athletes, the odds of return to play at least 30 days after injury were larger in youth athletes (odds ratio, 2.75; 95% CI, 1.10- 6.85) and high school athletes (odds ratio, 2.89; 95% CI, 1.61-5.19). The odds of return to play less than 24 hours after injury were larger in youth athletes than high school athletes (odds ratio, 6.23; 95% CI, 1.02-37.98). CONCLUSIONS AND RELEVANCE Differences in concussion-related outcomes existed by level of competition and may be attributable to genetic, biologic, and/or developmental differences or level-specific variations in concussion-related policies and protocols, athlete training management, and athlete disclosure. Given the many organizational, social environmental, and policy-related differences at each level of competition that were not measured in this study, further study is warranted to validate our findings.

The Epidemiology of Lateral Ligament Complex Ankle Sprains in National Collegiate Athletic Association Sports

Background: Ankle sprains are a common injury in collegiate sports. Few studies have examined the epidemiology of individual ligament injuries, specifically the lateral ligament complex (LLC) of the ankle. Purpose: To describe the epidemiology, including the estimated yearly national incidence, of LLC sprains among National Collegiate Athletic Association (NCAA) athletes. Study Design: Descriptive epidemiology study. Methods: Injury surveillance data for 25 sports from the NCAA Injury Surveillance Program (NCAA-ISP) for the academic years 2009-2010 to 2014-2015 were used for analysis. All injuries included for analysis had a diagnosis of an LLC sprain. LLC sprain rates and rate ratios (RRs) with 95% CIs were calculated. From the sample, national estimates of the annual incidence of LLC sprains across the entire student-athlete body from these 25 sports were also calculated. Results: During the 2009-2010 to 2014-2015 academic years, 2429 LLC sprains were reported, for a rate of 4.95 per 10,000 athlete-exposures (AEs). LLC sprains comprised 7.3% of all reported collegiate sports injuries in the NCAA-ISP. Also, an estimated 16,022 LLC sprains occurred annually among the 25 sports. The sports with the highest LLC sprain rates were men’s basketball (11.96/10,000 AEs) and women’s basketball (9.50/10,000 AEs). Most LLC sprains occurred during practices (57.3%); however, the LLC sprain rate was higher in competitions than in practices (RR, 3.29; 95% CI, 3.03-3.56). Also, 11.9% of LLC sprains were identified as recurrent injuries, with the largest proportions of recurrent LLC sprains being found within women’s basketball (21.1%), women’s outdoor track (21.1%), women’s field hockey (20.0%), and men’s basketball (19.1%). In 44.4% of LLC sprains, the athlete returned to play in less than 24 hours; in 3.6%, the athlete required more than 21 days before returning to play (including those who did not return to play at all). Conclusion: LLC sprains were the most commonly reported injury diagnosis among United States collegiate student-athletes. Continued examination of interventions that aim to reduce the incidence, severity, and recurrence of LLC sprains, specifically in women, is warranted.

Epidemiologic Measures for Quantifying the Incidence of Concussion in National Collegiate Athletic Association Sports

CONTEXT Injury rates compare the relative frequency of sport-related concussions across groups. However, they may not be intuitive to policy makers, parents, or coaches in understanding the likelihood of concussion. OBJECTIVE To describe 4 measures of incidence (athlete-based rate, athlete-based risk, team-based rate, and team-based risk) during the 2011-2012 through 2014-2015 academic years. DESIGN  Descriptive epidemiology study. SETTING Aggregate injury and exposure data collected from the National Collegiate Athletic Association Injury Surveillance Program in 13 sports (mens baseball, basketball, football, ice hockey, lacrosse, soccer, and wrestling and womens basketball, ice hockey, lacrosse, soccer, softball, and volleyball). PATIENTS OR OTHER PARTICIPANTS Collegiate student-athletes. MAIN OUTCOME MEASURE(S) Sport-related concussion data from the National Collegiate Athletic Association Injury Surveillance Program during the 2011-2012 through 2014-2015 academic years were analyzed. We calculated concussion rates per 1000 athlete-exposures (AEs), concussion risk, average number of concussions per team, and percentage of teams with at least 1 concussion. RESULTS During the 2011-2012 through 2014-2015 academic years, 1485 concussions were sustained by 1410 student-athletes across 13 sports. Concussion rates ranged from 0.09/1000 AEs in mens baseball to 0.89/1000 AEs in mens wrestling. Concussion risk ranged from 0.74% in mens baseball to 7.92% in mens wrestling. The average ± SD number of concussions per team ranged from 0.25 ± 0.43 in mens baseball to 5.63 ± 5.36 in mens football. The percentage of teams with a concussion ranged from 24.5% in mens baseball to 80.6% in mens football. CONCLUSIONS   Although mens wrestling had a higher concussion rate and risk, mens football had the largest average number of concussions per team and the largest percentage of teams with at least 1 concussion. The risk of concussion, average number of concussions per team, and percentage of teams with concussions may be more intuitive measures of incidence for decision makers. Calculating these additional measures is feasible within existing injury surveillance programs, and this method can be applied to other injury types.

Epidemiology of 3825 injuries sustained in six seasons of National Collegiate Athletic Association men's and women's soccer (2009/2010-2014/2015)

Aim To describe the epidemiology of National Collegiate Athletic Association (NCAA) mens and womens soccer injuries during the 2009/2010–2014/2015 academic years. Methods This descriptive epidemiology study used NCAA Injury Surveillance Program (NCAA-ISP) data during the 2009/2010–2014/2015 academic years, from 44 mens and 64 womens soccer programmes (104 and 167 team seasons of data, respectively). Non-time-loss injuries were defined as resulting in <24 h lost from sport. Injury counts, percentages and rates were calculated. Injury rate ratios (RRs) and injury proportion ratios (IPRs) with 95% CIs compared rates and distributions by sex. Results There were 1554 mens soccer and 2271 womens soccer injuries with injury rates of 8.07/1000 athlete exposures (AE) and 8.44/1000AE, respectively. Injury rates for men and women did not differ in competitions (17.53 vs 17.04/1000AE; RR=1.03; 95% CI 0.94 to 1.13) or practices (5.47 vs 5.69/1000AE; RR=0.96; 95% CI 0.88 to 1.05). In total, 47.2% (n=733) of mens soccer injuries and 47.5% (n=1079) of womens were non-time loss. Most injuries occurred to the lower extremity and were diagnosed as sprains. Women had higher concussion rates (0.59 vs 0.34/1000AE; RR=1.76; 95% CI 1.32 to 2.35) than men. Conclusions Non-time-loss injuries accounted for nearly half of the injuries in mens and womens soccer. Sex differences were found in competition injuries, specifically for concussion. Further study into the incidence, treatment and outcome of non-time-loss injuries may identify a more accurate burden of these injuries.

Epidemiology of Acromioclavicular Joint Sprains in 25 National Collegiate Athletic Association Sports 2009-2010 to 2014-2015 Academic Years

Background: No previous studies have described the incidence of acromioclavicular (AC) joint injuries in a large sample of National Collegiate Athletic Association (NCAA) student-athletes. Such data are needed to understand the injury prevalence, mechanisms of injury, and recovery patterns in NCAA student-athletes. Purpose: To describe the epidemiology of AC joint sprain injuries in 25 NCAA championship sports. Study Design: Descriptive epidemiology study. Methods: AC joint sprains were analyzed from the NCAA Injury Surveillance Program during the 2009-2010 to 2014-2015 academic years. AC joint sprain injury rates, rate ratios, and injury proportion ratios (IPRs) were reported with 95% CIs. Results: In the 25 NCAA sports examined during the 2009-2010 to 2014-2015 academic years, a total of 844 AC joint sprains were reported, for a rate of 1.72 per 10,000 athlete-exposures (AEs). The majority of AC joint sprains were reported in football (50.4%, n = 425). Most AC joint sprains occurred in competitions (66.0%, n = 557), and the competition rate was 8.58 times the practice rate (95% CI, 7.44-9.89). In sex-comparable sports (ie, soccer, basketball, ice hockey, lacrosse, baseball/softball, indoor track, outdoor track, cross-country, tennis, and swimming and diving), the AC joint sprain rate in men was 4.67 times that of women (95% CI, 3.56-6.14). Most AC joint sprains were caused by player contact (54.7%, n = 462), followed by surface contact (29.0%, n = 245). Of all AC joint sprains, 47.5% resulted in a time loss of <24 hours, and 5.9% were severe. In addition, 9.7% were recurrent, and only 1.0% required surgery. In sex-comparable sports, male athletes had a larger proportion of injuries due to player contact than did female athletes (IPR, 1.50; 95% CI, 1.06-2.13); female athletes had a larger proportion of injuries due to surface contact than male athletes (IPR, 1.55; 95% CI, 1.01-2.38). Also, compared with women, men had a larger proportion of AC joint sprains that were recurrent (IPR, 10.29; 95% CI, 1.45-72.90). Conclusion: The highest rates of AC joint sprains occurred in men’s football, ice hockey, and wrestling as well as women’s ice hockey. Most AC joint sprains across all sports occurred because of a contact mechanism, particularly from player-player contact. Further research into the specific activities and exposures at the time of injury may lend a better understanding of the causation of these injuries and lead to appropriate interventions to decrease their incidence and severity.

Comparison of Indiana High School Football Injury Rates by Inclusion of the USA Football “Heads Up Football” Player Safety Coach

Background: In Indiana, high school football coaches are required to complete a coaching education course with material related to concussion awareness, equipment fitting, heat emergency preparedness, and proper technique. Some high schools have also opted to implement a player safety coach (PSC). The PSC, an integral component of USA Football’s Heads Up Football (HUF) program, is a coach whose primary responsibility is to ensure that other coaches are implementing proper tackling and blocking techniques alongside other components of the HUF program. Purpose: To compare injury rates in Indiana high school football teams by their usage of a PSC or online coaching education only. Study Design: Cohort study; Level of evidence, 2. Methods: Athletic trainers (ATs) evaluated and tracked injuries at each practice and game during the 2015 high school football season. Players were drawn from 6 teams in Indiana. The PSC group, which used the PSC component, was comprised of 204 players from 3 teams. The “education only” group (EDU), which utilized coaching education only, was composed of 186 players from 3 teams. Injury rates and injury rate ratios (IRRs) were reported with 95% confidence intervals (CIs). Results: During 25,938 athlete-exposures (AEs), a total of 149 injuries were reported, of which 54 (36.2%) and 95 (63.8%) originated from the PSC and EDU groups, respectively. The practice injury rate was lower in the PSC group than the EDU group (2.99 vs 4.83/1000 AEs; IRR, 0.62; 95% CI, 0.40-0.95). The game injury rate was also lower in the PSC group than the EDU group (11.37 vs 26.37/1000 AEs; IRR, 0.43; 95% CI, 0.25-0.74). When restricted to concussions only, the rate was lower in the PSC group (0.09 vs 0.73/1000 AEs; IRR, 0.12; 95% CI, 0.01-0.94), although only 1 concussion was reported in the PSC group. No differences were found in game concussion rates (0.60 vs 4.39/1000 AEs; IRR, 0.14; 95% CI, 0.02-1.11). Conclusion: Findings support the PSC as an effective method of injury mitigation in high school football. Future research should seek to replicate this study using larger samples from additional states.

Epidemiology of National Collegiate Athletic Association men's and women's tennis injuries, 2009/2010–2014/2015

Background This study describes the epidemiology of mens and womens tennis injuries reported by the National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP) during the 2009/2010–2014/2015 academic years. Methods Injuries and athlete-exposure (AE) data originated from 19 varsity mens programmes (38 team-seasons); womens tennis data originated from 25 varsity programmes (52 team-seasons). Injury rates, injury rate ratios (IRRs) and injury proportions ratios (IPRs) were reported with 95% CIs. Results The ISP captured 181 and 227 injuries for mens and womens tennis, respectively, for injury rates of 4.89 and 4.88/1000 AE for men and women, respectively. There were 32.2% and 63.9% reductions in mens and womens tennis practice injury rates between 2009/2010–2011/2012 and 2012/2013–2014/2015, but no reductions in competition injury rates. Competition injury rates were higher than practice injury rates in mens (IRR=2.32; 95% CI 1.72 to 3.13) and womens tennis (IRR=1.77; 95% CI 1.35 to 2.33). Most injuries in mens and womens tennis occurred to the lower extremities (47.0% and 52.4%, respectively), compared with the trunk (16.6% and 17.6%, respectively) and upper extremities (23.8 and 23.8, respectively). Conclusions Injury rates in NCAA mens and womens tennis were similar overall. Practice injury rates in mens and womens tennis have declined, although competition rates have not changed. These findings may help inform injury prevention programmes in the future.

The Epidemiology of Hip/Groin Injuries in National Collegiate Athletic Association Men's and Women's Ice Hockey: 2009-2010 Through 2014-2015 Academic Years.

Background: There is limited research regarding the epidemiology of hip/groin injuries in ice hockey, the majority of which is restricted to time-loss injuries only. Purpose: To describe the epidemiology of hip/groin injuries in collegiate men’s and women’s ice hockey from 2009-2010 through 2014-2015. Study Design: Descriptive epidemiology study. Methods: Hip/groin injury data from the National Collegiate Athletic Association Injury Surveillance Program (NCAA-ISP) during the 2009-2010 through 2014-2015 seasons were analyzed. Injury rates, rate ratios (RRs), and injury proportion ratios (IPRs) were reported with 95% confidence intervals (CIs). Results: During the 2009-2010 through 2014-2015 seasons, 421 and 114 hip/groin injuries were reported in men’s and women’s ice hockey, respectively, leading to injury rates of 1.03 and 0.78 per 1000 athlete-exposures (AEs), respectively. The hip/groin injury rate was greater in men than in women (RR, 1.32; 95% CI, 1.08-1.63). In addition, 55.6% and 71.1% of hip/groin injuries in men’s and women’s ice hockey, respectively, were non–time loss (NTL) injuries (ie, resulted in participation restriction time <24 hours); 7.6% and 0.9%, respectively, were severe (ie, resulted in participation restriction time >3 weeks). The proportion of hip/groin injuries that were NTL injuries was greater in women than in men (IPR, 1.28; 95% CI, 1.11-1.48). Conversely, the proportion of hip/groin injuries that were severe was greater in men than in women (IPR, 8.67; 95% CI, 1.20-62.73). The most common hip/groin injury diagnosis was strain (men, 67.2%; women, 76.3%). Also, 12 (2.9%) and 3 (2.6%) cases of hip impingement were noted in men’s and women’s ice hockey, respectively. Conclusion: Hip/groin injury rates were greater in men’s than in women’s ice hockey. Time loss varied between sexes, with men sustaining more injuries with time loss over 3 weeks. Despite increasing concerns of femoroacetabular impingement in ice hockey players, few cases of hip impingement were reported in this dataset.

Epidemiology of Exertional Heat Illnesses in Youth, High School, and College Football.

INTRODUCTION Data on exertional heat illness (EHI) in youth football are limited and have not been compared across competition levels. PURPOSE This study describes the epidemiology of EHI events in youth, high school (HS), and college football in the 2012-2014 seasons. METHODS One hundred and eighteen youth teams (players age 5-14 yr), 96 HS programs (~14-18 yr), and 34 college programs (~18-23 yr) participated. During games and practices, athletic trainers recorded EHI events and athlete exposures (AE), defined as one athlete participating in one game/practice. We calculated the number of reported EHI by time in season, game/practice, and need for emergency transportation. EHI rates, risk, included rate ratios (IRR), and risk ratios (RR) with 95% confidence intervals (CI) were calculated in 2015. RESULTS EHI rates for youth, HS, and college football were 1.82, 0.57, and 1.67/10,000 AE, respectively. Rates were highest during the preseason (youth: 2.76; HS: 1.47; college: 3.66/10,000 AE). Game rates were higher than practice rates in youth (4.04 vs 1.22/10,000 AE; IRR = 3.31; 95% CI, 1.75-6.26) and college (4.42 vs 1.38/10,000 AE; IRR = 3.21; 95% CI, 2.00-5.16); the practice rate was higher than the game rate in HS (0.63 vs 0.27/10,000 AE; IRR = 2.33; 95% CI, 1.01-5.38). The EHI risk was higher in college (0.9%) than in youth (0.6%; RR = 1.59; 95% CI, 1.06-2.37) and HS (0.5%; RR = 2.01; 95% CI, 1.43-2.81). Common EHI events included heat cramps (youth: 15.8%; HS: 28.6%; college: 45.6%), heat exhaustion (youth: 42.1%; HS: 32.9%; college: 20.0%), and dehydration (youth: 31.6%; HS: 28.6%; college: 28.9%). CONCLUSIONS EHI risk was low. Higher preseason football EHI rates across levels emphasize developing and continually modifying preseason heat acclimatization policies. Lower EHI rates in HS games and youth practices may be attributable to night events, suggesting the importance of modifying/canceling events based on environmental conditions.

The Epidemiology of High Ankle Sprains in National Collegiate Athletic Association Sports

Background: Ankle sprains are among the most common injuries experienced by collegiate athletes. The type of ankle sprain is rarely differentiated in epidemiological studies. This differentiation is necessary, as each ankle sprain type has a unique injury mechanism and recovery period. High ankle sprains commonly result in long recovery periods. Thus, a further examination of the epidemiology of high ankle sprains is warranted. Purpose: To describe the epidemiology of high ankle sprains in National Collegiate Athletic Association (NCAA) sports during the 2009/2010-2014/2015 academic years. Study Design: Descriptive epidemiology study. Methods: NCAA Injury Surveillance Program high ankle sprain data and athlete-exposures (AEs) from 25 sports were evaluated. Certified athletic trainers recorded sport-related injury, event, and AE data during team-sanctioned events. High ankle sprain injury rates per 10,000 AEs were calculated. Percentage distributions were calculated for the amount of time lost from sport and percentage of recurrent injuries. Injury rate ratios (RRs) and 95% CIs compared injury rates by event type, participation restriction time, and sex. 95% CIs not containing 1.00 were considered statistically significant. Results: The overall high ankle sprain injury rate was 1.00 per 10,000 AEs. Overall, 56.7% of high ankle sprain injuries occurred during competitions, and 9.8% of high ankle sprain injuries were recurrent. Men’s football (2.42/10,000 AEs), wrestling (2.11/10,000 AEs), and ice hockey (1.19/10,000 AEs) had the highest high ankle sprain injury rates. In sex-comparable sports, men had higher injury rates (RR, 1.77; 95% CI, 1.28-2.44). Player contact was the most common injury mechanism (60.4%), and 69.0% of injuries resulted in ≥1 day of participation restriction, with 47.1% resulting in ≥7 days of participation restriction and 15.8% resulting in >21 days of participation restriction. Conclusion: High ankle sprains resulted in significant participation restriction time from sport participation. The majority of high ankle sprain injuries resulted from player contact and were observed in contact/collision sports. The large proportion of high ankle sprains resulting from player contact, specifically in male contact sports, is worthy of further investigation. Clinical Relevance: The enhanced understanding of the epidemiology of high ankle sprains provided in our study will aid clinicians in developing targeted injury prevention strategies to mitigate the negative consequences of these injuries.