M. Alison Brooks

Injuries of the Head, Face, and Neck in Relation to Ski Helmet Use

Background: The extent to which helmet use reduces the risk of injury in ski- and snowboard-related accidents is unclear. We studied the association of helmet use with injuries of the head, face, and neck among skiers and snowboarders involved in falls and collisions. Methods: We conducted a case-control study, using ski patrol injury reports for the years 2000–2005 from 3 ski resorts in the western United States. We identified all skiers and snowboarders involved in falls or collisions who received care from the ski patrol. Helmet use among persons with injuries of the head (n = 2537), face (n = 1122), or neck (n = 565) was compared with helmet use among those involved in falls and collisions who received care for injuries below the neck (n = 17,674). We calculated odds ratios for head, face, and neck injury among helmeted compared with unhelmeted persons. Results: The adjusted odds ratios were 0.85 for head injury (95% confidence interval = 0.76–0.95), 0.93 for facial injury (0.79–1.09), and 0.91 for neck injury (0.72–1.14). Conclusions: Helmets may provide some protection from head injury among skiers and snowboarders involved in falls or collisions.

Evaluation of skiing and snowboarding injuries sustained in terrain parks versus traditional slopes

This study compares skiing and snowboarding injuries in terrain parks versus slopes at two ski areas, 2000–05. A total of 3953 (26.7%) injuries occurred in terrain parks, predominantly among young male snowboarders. Terrain park injuries were more likely to be severe, involving head (RR 1.31, 95% CI 1.16 to 1.48) or back (RR 1.96, 95% CI 1.67 to 2.29).

Concussion Increases Odds of Sustaining a Lower Extremity Musculoskeletal Injury After Return to Play Among Collegiate Athletes

Background: Previous studies have identified abnormalities in brain and motor functioning after concussion that persist well beyond observed clinical recovery. Recent work suggests subtle deficits in neurocognition may impair neuromuscular control and thus potentially increase risk of lower extremity musculoskeletal injury after concussion. Purpose: To determine the odds of sustaining an acute lower extremity musculoskeletal injury during the 90-day period after return to play from concussion in a cohort of National Collegiate Athletic Association (NCAA) Division I collegiate athletes. Study Design: Cohort study; Level of evidence, 3. Methods: Included in this study were 87 cases of concussion among 75 athletes (58 men; 17 women) participating in NCAA Division I football, soccer, hockey, softball, basketball, wrestling, or volleyball at a single institution from 2011 to 2014. The 90-day period after return to play for each case of concussion was reviewed for acute noncontact lower extremity musculoskeletal injury. Each 90-day period after return to play was matched to the same 90-day period in up to 3 controls. Control athletes without a history of concussion in the previous year were matched to concussed athletes by sport team/sex, games played, and position. A total of 182 control (136 men; 46 women) 90-day periods were reviewed for acute injury. Conditional logistic regression was used to assess the association between concussion and subsequent risk of acute lower extremity musculoskeletal injury. Results: The incidence of acute lower extremity musculoskeletal injury was higher among recently concussed athletes (15/87; 17%) compared with matched controls (17/182; 9%). The odds of sustaining an acute lower extremity musculoskeletal injury during the 90-day period after return to play were 2.48 times higher in concussed athletes than controls during the same 90-day period (odds ratio, 2.48; 95% CI, 1.04-5.91; P = .04). Conclusion: Concussed athletes have increased odds of sustaining an acute lower extremity musculoskeletal injury after return to play than their nonconcussed teammates. The study results suggest further investigation of neurocognitive and motor control deficits may be warranted beyond the acute injury phase to decrease risk for subsequent injury.

Protective Equipment and Player Characteristics Associated With the Incidence of Sport-Related Concussion in High School Football Players A Multifactorial Prospective Study

Background: The incidence of sport-related concussion (SRC) in high school football is well documented. However, limited prospective data are available regarding how player characteristics and protective equipment affect the incidence of SRC. Purpose: To determine whether the type of protective equipment (helmet and mouth guard) and player characteristics affect the incidence of SRC in high school football players. Design: Cohort study; Level of evidence, 2. Methods: Certified athletic trainers (ATs) at each high school recorded the type of helmet worn (brand, model, purchase year, and recondition status) by each player as well as information regarding players’ demographics, type of mouth guard used, and history of SRC. The ATs also recorded the incidence and days lost from participation for each SRC. Incidence of SRC was compared for various helmets, type of mouth guard, history of SRC, and player demographics. Results: A total of 2081 players (grades 9-12) enrolled during the 2012 and/or 2013 football seasons (2287 player-seasons) and participated in 134,437 football (practice or competition) exposures. Of these players, 206 (9%) sustained a total of 211 SRCs (1.56/1000 exposures). There was no difference in the incidence of SRC (number of helmets, % SRC [95% CI]) for players wearing Riddell (1171, 9.1% [7.6%-11.0%]), Schutt (680, 8.7% [6.7%-11.1%]), or Xenith (436, 9.2% [6.7%-12.4%]) helmets. Helmet age and recondition status did not affect the incidence of SRC. The rate of SRC (hazard ratio [HR]) was higher in players who wore a custom mouth guard (HR = 1.69 [95% CI, 1.20-2.37], P < .001) than in players who wore a generic mouth guard. The rate of SRC was also higher (HR = 1.96 [95% CI, 1.40-2.73], P < .001) in players who had sustained an SRC within the previous 12 months (15.1% of the 259 players [95% CI, 11.0%-20.1%]) than in players without a previous SRC (8.2% of the 2028 players [95% CI, 7.1%-9.5%]). Conclusion: Incidence of SRC was similar regardless of the helmet brand (manufacturer) worn by high school football players. Players who had sustained an SRC within the previous 12 months were more likely to sustain an SRC than were players without a history of SRC. Sports medicine providers who work with high school football players need to realize that factors other than the type of protective equipment worn affect the risk of SRC in high school players.

Prevalence of Sport Specialization in High School Athletics A 1-Year Observational Study

Background: The prevalence of sport specialization in high school athletes is unknown. This information is needed to determine the scope of this issue in an active population. Purpose: To determine the prevalence of sport specialization in high school athletes and to determine if specialization is influenced by classification method, year in school, sex, and school size. A secondary purpose was to determine if highly specialized athletes would be more likely to report a history of lower extremity injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: High school athletes between the ages of 13 and 18 years from 2 local high schools completed both a sport specialization survey and an injury history survey. Athletes were classified into low, moderate, or high specialization groups using a recently developed 3-point system and were also classified using a self-classification method. Results: A total of 302 athletes completed the surveys and were classified as low specialization (n = 105, 34.8%), moderate specialization (n = 87, 28.8%), or high specialization (n = 110, 36.4%). Athletes from the small school were more likely to be classified in the low specialization group (low, 43%; moderate, 32%; high, 25%) compared with those from the large school (low, 26%; moderate, 26%; high, 48%) (P < .001). Athletes in the high specialization group were more likely to report a history of overuse knee injuries (n = 18) compared with moderate (n = 8) or low specialization (n = 7) athletes (P = .048). Athletes who trained in one sport for more than 8 months out of the year were more likely to report a history of knee injuries (odds ratio [OR], 2.32; 95% CI, 1.22-4.44; P = .009), overuse knee injuries (OR, 2.93; 95% CI, 1.16-7.36; P = .018), and hip injuries (OR, 2.74; 95% CI, 1.09-6.86; P = .026). Using the self-classification method, more participants self-classified as multisport (n = 213, 70.5%) than single sport (n = 89, 29.5%). Athletes from the small school were more likely to classify themselves as multisport (n = 128, 86%) (P < .001) than those from the large school (n = 85, 56%). There were no differences in the history of hip, knee, or ankle injuries between athletes who self-classified as single sport (hip: n = 10, 3%; knee: n = 19, 6%; ankle: n = 35, 12%) versus those who self-classified as multisport (hip: n = 45, 8%; knee: n = 23, 15%; ankle: n = 98, 33%) (P > .370). Conclusion: Classification method and school size influenced the prevalence of specialization in high school athletes. Highly specialized athletes were more likely to report a history of overuse knee or hip injuries. Participating in a single sport for more than 8 months per year appeared to be an important factor in the increased injury risk observed in highly specialized athletes.

A Systematic Review of Bone Health in Cyclists

Context: Low bone mineral density (BMD) is a serious public health problem. Osteoporotic fractures are associated with low bone mass, occurring frequently in the hip and spine. Previous studies have demonstrated a positive relationship between BMD and weightbearing exercise but not a similar positive relationship with nonweightbearing exercise. There is concern that cycling, a weight-supported sport, does not benefit bone health. Objective: To systematically review the evidence suggesting that cyclists have impaired bone health at the femoral neck and lumbar spine. Data Sources: Articles in PubMed, Cochrane Library, and CINAHL were identified in December 2009 What is the start date for the search?based on the following terms and combinations: bicycling, bone density, cyclist. Study Selection: Thirteen studies satisfied inclusion criteria: 2 prospective studies (level of evidence 2b) and 11 cross-sectional studies (level of evidence 2c). Data Extraction: Data included sample size, demographics, description of cycling and control criteria, and BMD (g/cm2) at the lumbar spine, femoral neck, and hip. Results: Two prospective studies showed a decrease in femoral neck, total hip, or lumbar spine BMD in cyclists over the study period. Four cross-sectional studies compared cyclists with sedentary controls, and 3 found cyclists’ lumbar spine and femoral neck BMD similar to that of controls, whereas 1 found cyclists’ BMD to be lower than that of controls. Seven cross-sectional studies compared cyclists with active controls: 2 found no differences in femoral neck and lumbar spine BMD between cyclists and controls; 4 found that cyclists had lower lumbar spine BMD than did active controls, including runners; and 1 reported a trend toward lower lumbar spine BMD in cyclists versus controls. Conclusions: There is concerning but inconsistent, limited-quality disease-oriented evidence—primarily from cross-sectional data—indicating that cyclists may be at risk for low bone mass, particularly at the lumbar spine. Additional longitudinal controlled intervention trials are needed.

The Association of Sport Specialization and Training Volume With Injury History in Youth Athletes

Background: Recommendations exist to encourage safe youth participation in sport. These recommendations include not specializing in 1 sport, limiting participation to less than 8 months per year, and limiting participation to fewer hours per week than a child’s age. However, limited evidence exists to support or refute these recommendations. Hypothesis: High levels of specialization will be associated with a history of injuries and especially overuse injuries, independent of age, sex, or weekly sport training hours. Athletes who exceed current sport volume recommendations will be more likely to have a history of injuries and overuse injuries. Study Design: Case-control study; Level of evidence, 3. Methods: Youth athletes (n = 2011; 989 female and 1022 male; 12-18 years of age) completed a questionnaire regarding their specialization status, yearly and weekly sport participation volume, and injury history. Specialization was classified as low, moderate, or high using a previously utilized 3-point scale. Athletes were classified into groups based on either meeting or exceeding current volume recommendations (months per year and hours per week). Odds ratios (ORs) and 95% CIs were calculated to investigate associations of specialization and volume of participation with a history of sport-related injuries in the past year (P ≤ .05). Results: Highly specialized athletes were more likely to report a previous injury of any kind (P < .001; OR, 1.59; 95% CI, 1.26-2.02) or an overuse injury (P = .011; OR, 1.45; 95% CI, 1.07-1.99) in the previous year compared with athletes in the low specialization group. Athletes who played their primary sport more than 8 months of the year were more likely to report an upper extremity overuse injury (P = .04; OR, 1.68; 95% CI, 1.06-2.80) or a lower extremity overuse injury (P = .001; OR, 1.66; 95% CI, 1.22-2.30). Athletes who participated in their primary sport for more hours per week than their age (ie, a 16-year-old athlete who participated in his or her primary sport for more than 16 h/wk) were more likely to report an injury of any type (P = .001; OR, 1.34; 95% CI, 1.12-1.61) in the previous year. Conclusion: High levels of specialization were associated with a history of injuries, independent of age, sex, and weekly organized sport volume. Athletes who exceeded volume recommendations were more likely to have a history of overuse injuries. Clinical Relevance: Parents and youth athletes should be aware of the risks of specialization and excessive sport volume to maximize safe sport participation.

Genetic Testing and Youth Sports

GENETIC TESTING IS BECOMING AVAILABLE TO CONsumers for many applications such as ancestry exploration, future disease risk, and prenatal carrier testing. Now there is another option— sports performance from online genetic testing companies offering everything from single gene tests to multiplex testing of numerous purported sports performance genes. In the “winning is everything” sports culture, societal pressure to use these tests in children may increasingly present a challenge to unsuspecting physicians. The aim of this Commentary is to bring this issue to the attention of physicians, provide evidence regarding this testing, and encourage clinicians to advocate for young patients when necessary.

High School Sport Specialization Patterns of Current Division I Athletes

Background: Sport specialization is a strategy to acquire superior sport performance in 1 sport but is associated with increased injury risk. Currently, the degree of high school specialization among Division I athletes is unknown. Hypothesis: College athletes will display increased rates of specialization as they progress through their high school careers. Study Design: Descriptive epidemiological study. Level of Evidence: Level 4. Methods: Three hundred forty-three athletes (115 female) representing 9 sports from a Midwest Division I University completed a previously utilized sport specialization questionnaire regarding sport participation patterns for each grade of high school. McNemar and chi-square tests were used to investigate associations of grade, sport, and sex with prevalence of sport specialization category (low, moderate, high) (a priori P ≤ 0.05). Results: Specialization increased throughout high school, with 16.9% (n = 58) and 41.1% (n = 141) of athletes highly specialized in 9th and 12th grades, respectively. Football athletes were less likely to be highly specialized than nonfootball athletes for each year of high school (P < 0.001). There was no difference in degree of specialization between sexes at any grade level (P > 0.23). Conclusion: The majority of Division I athletes were not classified as highly specialized throughout high school, but the prevalence of high specialization increased as athletes progressed through high school. Nonfootball athletes were more likely to be highly specialized than football athletes at each grade level. Clinical Relevance: Most athletes who are recruited to participate in collegiate athletics will eventually specialize in their sport, but it does not appear that early specialization is necessary to become a Division I athlete. Athletes should be counseled regarding safe participation in sport during high school to minimize injury and maximize performance.

A Prospective Study on the Effect of Sport Specialization on Lower Extremity Injury Rates in High School Athletes.

Background: Sport specialization is associated with an increased risk of musculoskeletal lower extremity injuries (LEIs) in adolescent athletes presenting in clinical settings. However, sport specialization and the incidence of LEIs have not been investigated prospectively in a large population of adolescent athletes. Purpose: To determine if sport specialization was associated with an increased risk of LEIs in high school athletes. Study Design: Cohort study; Level of evidence, 2. Methods: Participants (interscholastic athletes in grades 9-12) were recruited from 29 Wisconsin high schools during the 2015-2016 school year. Participants completed a questionnaire identifying their sport participation and history of LEIs. Sport specialization of low, moderate, or high was determined using a previously published 3-point scale. Athletic trainers reported all LEIs that occurred during the school year. Analyses included group proportions, odds ratios (ORs) and 95% CIs, and days lost due to injury (median and interquartile range [IQR]). Multivariate Cox proportional hazard ratios (HRs) with 95% CIs were calculated to investigate the association between the incidence of LEIs and sport specialization level. Results: A total of 1544 participants (50.5% female; mean age, 16.1 ± 1.1 years) enrolled in the study, competed in 2843 athletic seasons, and participated in 167,349 athlete-exposures. Sport specialization was classified as low (59.5%), moderate (27.1%), or high (13.4%). Two hundred thirty-five participants (15.2%) sustained a total of 276 LEIs that caused them to miss a median of 7.0 days (IQR, 2.0-22.8). Injuries occurred most often to the ankle (34.4%), knee (25.0%), and upper leg (12.7%) and included ligament sprains (40.9%), muscle/tendon strains (25.4%), and tendinitis/tenosynovitis (19.6%). The incidence of LEIs for moderate participants was higher than for low participants (HR, 1.51 [95% CI, 1.04-2.20]; P = .03). The incidence of LEIs for high participants was higher than for low participants (HR, 1.85 [95% CI, 1.12-3.06]; P = .02). Conclusion: Athletes with moderate or high sport specialization were more likely to sustain an LEI than athletes with low specialization. Sports medicine providers need to educate coaches, parents, and interscholastic athletes regarding the increased risk of LEIs for athletes who specialize in a single sport.