James C. Puffer

Lifestyles and health risks of collegiate athletes: a multi-center study.

ObjectiveTo determine whether college athletes are at greater risk for maladaptive lifestyle and health-risk behaviors than their nonathletic peers and to identify high risk taking groups by gender, sport, and other identifiers. DesignMulticenter, cross-sectional study. SettingSeven major geographically represented collegiate institutions in the United States. ParticipantsA total of 2,298 college athletes and 683 randomized nonathlete controls completed a confidential survey questionnaire between the summer of 1993 and winter of 1994, assessing lifestyle and health-risk behaviors over the previous 12 months. Main outcome measuresSelf-reports of lifestyle behaviors and health risks in the following areas: motor-vehicle safety, substance abuse, sexually transmitted diseases and contraception, mental health, cancer prevention, nutrition, exercise and general preventive health issues. ResultsAthletes demonstrated significantly higher risk-taking behaviors (p < 0.05) than their nonathlete peers in the following areas: less likely always to use seatbelts; less likely always to use helmets with motorcycles, mopeds, and bicycles; more often drive as a passenger with a driver under the influence of alcohol or drugs; greater quantity and frequency of alcoholic beverages; greater frequency of smokeless tobacco and anabolic steroid use; less-safe sex; greater number of sexual partners; less contraceptive use; and more involvement in physical fights. Female athletes reported a higher prevalence of irregular menses, amenorrhea, and stress fractures compared with female nonathletes. Male athletes had more risk-taking behaviors than did female athletes (p < 0.05), and athletes in contact sports demonstrated more risk-taking behaviors than did athletes in noncontact sports (p < 0.05). Athletes with one risk-taking behavior were likely to have multiple risk-taking behaviors (p < 0.05). ConclusionsCollege athletes appear to be at higher risk than their nonathletic peers for certain maladaptive lifestyle behaviors. Athlete subgroups at highest risk include male athletes and athletes participating in contact sports. Athletes at risk for one high-risk behavior demonstrated an increased risk for multiple risk-taking behaviors. Preventive health interventions deserve further study to determine strategies for risk reduction in high-risk groups.

Injuries in runners: a prospective study of alignment.

Objective:To determine if measurable lower extremity alignment is a risk factor for overuse running injuries. Design:Prospective cohort study. Setting:Thirty-two week marathon training program. Patients or Participants:Three hundred fifty-five volunteers from the marathon training program began the study; 255 finished the study. Interventions:None. Main Outcome Measures:Past training and injury history was determined by questionnaire, and five lower extremity alignment measures were performed at the beginning of the training program: arch index (AI), heel valgus (HV), knee tubercle-sulcus angle (TSA), knee varus (KV), and leg-length difference (LLD). Overuse injuries, incurred by the runners and categorized by anatomic parts, were recorded during the training period. Results:Ninety subjects experienced overuse injuries. Multivariate analyses with stepwise Poisson regression showed few consistent relationships between alignment and overuse injury rates. Higher AI was protective against overall injuries and knee injuries; higher HV was protective against knee and foot injuries; higher TSA was associated with shin injuries; higher KV was associated with shin injuries; and low LLD was associated with more overall injuries. Conclusions:Minor variations in lower extremity alignment do not appear conclusively to be major risk factors for overuse injuries in runners. Because of the study limitations and the likely multifactorial nature of running injuries, further study is suggested, perhaps in more novice runners.

Lower extremity alignment and risk of overuse injuries in runners.

A group of 304 runners enrolling in a marathon training program had alignment measurements performed and completed a questionnaire on training practices and injuries over the previous 12 months. The alignment measures consisted of arch index (AI), heel valgus (HV), knee tubercle-sulcus angle (TSA), knee varus (KV), and leg-length difference (LLD). Results indicated few consistent statistical associations between these alignment measures and risk of injuries, either bivariately or multivariately: left AI with hamstring injuries; right AI with shin injuries; right HV with back injuries; left TSA with ankle injuries; KV with hip injuries; and LLD with back, ankle, and foot injuries. A few statistically significant relationships were also found between other training and anthropometric factors and injuries: mileage with hamstring injuries; interval training with shin injuries; hard surfaces with back and thigh injuries; shoe use patterns with foot and overall injuries; and body mass index with heel injuries. We conclude that lower-extremity alignment is not a major risk factor for running injuries in our relatively low mileage cohort; however, prospective studies are necessary to confirm or refute these findings.

Distal Radial Growth Plate Injury and Positive Ulnar Variance in Nonelite Gymnasts

To assess the prevalence of stress injury to the distal radial growth plate and of positive ulnar variance in a nonelite gymnast population, we administered a radio graphic survey and questionnaire to 44 skeletally im mature nonelite gymnasts (27 girls and 17 boys). The subjects trained an average of 11.9 hours per week. Radiographic findings consistent with stress injury of the distal radial physis were found in 25% (11 of 44) of participants. Ulnar variance was found to be more positive in the gymnasts when compared with age- predicted norms. An average side-to-side difference in ulnar variance of 0.9 mm was observed. Radiographic findings of stress injury to the growth plate and the amount of ulnar variance were not associated with age, sex, training intensity, wrist pain, height, or weight. There was also no significant relationship between ulnar variance and radiographic findings. The mean ulnar variance in nonelite gymnasts was between that measured for elite gymnasts and nongymnasts. These results indicate that stress injury of the distal radial growth plate occurs in a significant percentage of non elite gymnasts. It also appears that ulnar variance is more positive than would otherwise be predicted, sug gesting growth inhibition of the distal radius, a growth stimulation of the ulna, or a combination of both.

The sprained ankle

The sprained ankle is the most common musculoskeletal injury seen by physicians caring for active youngsters and adults. It accounts for approximately one fourth of all sports-related injuries and is commonly seen in athletes participating in basketball, soccer, or football. It has been shown that one third of West Point cadets suffer an ankle sprain during their 4 years at the military academy. While diagnosis and management of the sprained ankle is usually straightforward, several serious injuries can masquerade as an ankle sprain, and it is important for the clinician to recognize these to prevent long-term morbidity. In this article the basic anatomy of the ankle, mechanisms by which the ankle is injured, and the differential diagnosis of the acutely injured ankle are reviewed. Appropriate evaluation of the injured ankle and the criteria that should be utilized for determining the necessity of radiographs are discussed as well as management of the acutely sprained ankle and the role of prevention in reducing the risk of ankle injury.

Wrist pain in young gymnasts: frequency and effects upon training over 1 year.

ObjectiveTo determine the frequency and characteristics of wrist pain in young, nonelite gymnasts over a 1-year training period, and to describe the effects of chronic wrist upon gymnastics training. DesignProspective cohort study. SettingLos Angeles-based gymnastics club. ParticipantsForty-seven nonelite female and male gymnasts between 5 and 16 years of age. AssessmentsEach subject completed an interview-based questionnaire and received a physical exam at the study onset and at the end of 1 year of training. The questionnaire detailed training habits and elicited a history and description of wrist pain. Main Outcome MeasuresThe frequency of wrist pain and several measures of training were reported at the study onset and at 1 year. Gymnasts with wrist pain were compared with those who were pain-free. Main ResultsWrist pain was reported by 57% (27 of 47) of subjects at the study onset. Eighty-nine percent (24 of 27) reported wrist pain both at the study onset and 1 year later. Nineteen gymnasts (40%) were pain-free at each collection. The floor exercise, the pommel horse, and the balance beam were most frequently associated with wrist pain symptoms. Multivariate analysis revealed that adolescent gymnasts between 10 and 14 years of age were significantly more likely to report wrist pain at each survey than those who were either above or below this age range (p = 0.03). Forty-two percent of subjects with wrist pain at each survey reported that the symptoms interfered with training. Only five gymnasts with wrist pain were seen by physicians. Training intensity increased in gymnasts with and without wrist pain. The relative increase within each group was statistically significant among pain-free gymnasts (p = 0.003), but was not for those with wrist pain (p = 0.08). ConclusionsWrist pain among young, nonelite gymnasts is common, and appears to persist with continued training in the vast majority of those who report symptoms. Adolescent gymnasts between 10 and 14 years of age training at this level are significantly more likely to have wrist pain. Wrist pain appears to have a negative effect upon training, based upon both self-report and training intensity measures; however, more study is needed with respect to this issue.

Baseball and Softball Sliding Injuries Incidence, and the Effect of Technique in Collegiate Baseball and Softball Players

We prospectively observed seven softball and three baseball Division I collegiate teams to study the incidence of sliding injuries, the types of injuries resulting from the sliding technique, and the amount of time lost from participation. Slides were categorized as either feet- or head-first on the basis of the leading part of the body during the slide. Slides were further stratified depending on whether a diveback technique was performed. We recorded 37 injuries in 3889 slides in 637 games and 7596 athlete game exposures. The overall incidence of sliding injuries was 9.51 per 1000 slides and 4.87 per 1000 game exposures. Softball players had a significantly higher incidence of sliding injuries (12.13 per 1000 slides) than did baseball players (6.01 per 1000 slides). In baseball, the injury rate was higher for feet-first slides (7.31 per 1000 slides) than for head-first slides (3.53 per 1000 slides) or divebacks (5.75 per 1000 divebacks). In softball, injury rates were higher for head-first slides (19.46 per 1000 slides) than for feet-first slides (10.04 per 1000 slides) or divebacks (7.49 per 1000 divebacks). The majority of injuries sustained were minor, with only four (11%) injuries causing the athlete to miss more than 7 days of participation.

Sun-protective behavior among high-school and collegiate athletes in Los Angeles, CA.

ObjectivesTo evaluate the use, knowledge, and perceptions of sun-protective behavior (SPB), among young athletes in Southern California.DesignCross-sectional survey, assessing various measures of SPB, sun exposure, attitudes, and knowledge.Setting and ParticipantsA total of 1006 students from 2 publ

An unusual presentation of liver laceration in a 13-yr-old football player

Abdominal injury occurs infrequently from athletic trauma, yet when it does occur, it can be very serious. Although rupture of a major blood vessel can lead to rapid loss of blood, insidious blood loss can also result from apparently insignificant injury of the spleen, liver, or kidney and lead to delayed problems. Awareness of the potential for such injury is vital because outcome can be adversely affected by a low index of suspicion, and this can be compounded by the fact that the initial physical examination is not always a reliable indicator of the severity of injury. Classic reports of these injuries describe splenic injury from a left-sided blow and hepatic injury from right-sided trauma. We present a case report of liver laceration in a young football player not only to comment on its unusual mechanism and presentation, but also to illustrate the importance of rapid assessment and transport of the athlete with a serious abdominal injury to avoid the consequences of delayed diagnosis and treatment.

Concussion Assessment in Football and Soccer Players

AMSSM Research Abstracts (Clin J Sport Med 2004;14:310–311) Concussion Assessment in Football and Soccer Players Suzanne Hecht,* James C. Puffer,† Clifford Clinton,‡ Bassil Aish,§ Philip Cohen, Andrew Concoff,¶ Robert Hosey,# Alex Lai,* Joseph Luftman,** Henry Tsai* Daniel Vigil.** *UCLA Sports Medicine, Los Angeles, CA 90095, †American Board of Family Practice, Lexington, KY, ‡David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, §Huntington Beach, CA, Rutgers University Health Services, New Brunswick, NJ, ¶University of Texas—Houston, Houston, TX, #University of Kentucky, Lexington, KY, **Kaiser Permanente Sports Medicine, Los Angeles, CA. Purpose: This longitudinal study examined the reliability and clinical utility of the Standardized Assessment of Concussion (SAC) in football and soccer players over 4 years. Methods: The SAC is a brief sideline examination developed in accordance with the American Academy of Neurology and the Colorado Guidelines to evaluate neuropsychological changes following a concussion. Baseline SAC evaluations were administered to 691 athletes from 1997 to 2001 (198 NCAA Division 1 and 410 high school football players, and 83 NCAA Division 1 soccer players). The SAC was repeated on days 0, 1, 3, and 10 following concussion to the concussed player and a paired nonconcussed control player. Results: Reliability testing revealed intrarater and interrater reliability correlation coefficients equal to 0.74 and 0.60, respectively. Seventy-seven players suffered 87 concussions, with 99% of the concussions occurring in football players. The mean SAC score of concussed players was significantly decreased on day 0 compared to their mean baseline score (24.9 ± 3.9 vs. 27.0 ± 1.7; P < 0.0001) Nonconcussed control players’ mean SAC scores on day 0 significantly increased compared to their mean baseline SAC scores (26.9 ± 2.3 vs. 27.8 ± 1.8; P = 0.001). The mean difference of day 0 SAC scores in concussed players was significantly decreased as compared to their paired, nonconcussed controls. No significant difference was seen on day 1. On day 0, 29% of concussed players achieved a SAC score greater than their baseline score, and 100% of those players were symptomatic at the time of testing. Conclusions: The SAC is a reliable test. The clinical utility of the SAC is limited since 1/3 of players were able to improve their SAC score while still symptomatic from a concussion. Cumulative Effects of Concussion in High School and College Athletes Douglas B. McKeag,* Micky Collins,† Mark R. Lovell,† Corrine Ganglion.‡ *IU Sports Medicine, Indianapolis, IN, †UPMC Center for Sports Medicine, Pittsburgh, PA, ‡Sports Concussion Program, Pittsburgh, PA. Purpose: The potential cumulative effects of concussion are poorly understood. One prior study (Collins et al., JAMA. 1999;282:964–970) utilized traditional neuropsychological measures in college athletes and found deficits in speed of processing in those sustaining 2 or more prior concussions. With the recent advent of computerized neuropsychological testing, potential exists for large databases of pertinent information regarding concussion. Moreover, there is no current data examining the cumulative effects of concussion in high school athletes. The current study was designed to evaluate these issues in a very large sample of high school and college athletes. Methods: A total of 2553 high school and college athletes underwent preseason computerized neuropsychological testing utilizing ImPACT. Controlling for years of education, 3 groups were compared on their baseline ImPACT performance: those with no history of concussion (43%; n = 1098), those with 1 prior concussion (37%; n = 945), and those with 2 or more prior concussions (20%; n = 510). Results: Multivariate analysis of covariance revealed significant differences between the three groups across processing speed (PS) and reaction time (RT) composite scores (F = 4.18; P < 0.002). There was a significant decrease in processing speed and increase in reaction time (both worse performances) in the 1 (PS, mean = 35.8; RT, mean = .579) and 2 or more (PS, mean = 35.0; RT, mean = .587) concussion groups when compared to those sustaining no prior concussions (PS, mean = 36.1; RT, mean = .568). Conclusions: The cumulative effects of concussion appear to involve a decrease in mental processing speed and increase in reaction time. These data derived from ImPACT are consistent with previous data utilizing paper and pencil measures. The current analysis is the first to suggest cumulative effects of concussion in high school athletes. The Neuropsychological Consequences of Participation in an Amateur Boxing Tournament James Moriarity,* Alexander Collia,†‡ David Olson,§ John Buchanan, Patrick Leary,* Michael McStephen,† Paul McCrory.‡ *University of Notre Dame, Notre Dame, IN, †CogState Ltd., Melbourne, Victoria, Australia, ‡University of Melbourne, Parkville, Victoria, Australia, §Wauwatosa, WI, Mercy Walworth Medical Center, Lake Geneva, WI. Context: Participation in professional boxing has been demonstrated to cause chronic cognitive injury. Few studies have reported the acute cognitive function in amateur boxers postbout and none have documented the effects of repeated boxing bouts within a short time frame. Objective: To determine whether repeated concussive and subconcussive head trauma sustained by amateur boxers during a 7-day tournament causes an acute deterioration in cognitive performance. Study Design: Prospective study of 82 collegiate amateur boxers with no history of recent concussion or past history of brain injury who participated in a 7-day single-elimination boxing tournament. Neuropsychological assessment using the CogSport computerized test battery was performed at baseline and after each bout. Main Outcome Measure: Change in postbout neuropsychological performance when compared to the boxer’s own baseline performance. The cognitive tests administered in this study are simple reaction time, complex reaction time, 1-back, and continuous learning. These tasks measure psychomotor function/information processing, decision-making, working memory, and new learning, respectively. Results: The 82 study subjects fought a total of 159 times. CogSport testing was performed in 142 of the possible 159 postbout opportunities for testing. The postbout neuropsychological performance of boxers participating in 3 bouts was equivalent to that of boxers participating in 1 bout or 2 bouts. No significant changes from baseline performance were observed in any individual boxers, including those receiving standing 8 counts or for whom the referee stopped the contest. Conclusions: Amateur boxing conducted in a supervised competition does not result in acute cognitive impairment, even in boxers subjected to repeated bouts over a short time frame. CHAMPS: Characteristics of Athletic Medical Providers Study: A National Look at Sports Medicine Within Primary Care 2002 Christy Tharenos, Dan Vinson. University of Missouri–Columbia, Columbia,