Participation In Collision Sports Research Articles

Risk Factors for Recurrent Anterior Shoulder Instability after Arthroscopic Stabilization in Adolescent Athletes

Objectives: Arthroscopic stabilization has become the preferred surgery for adolescent athletes with anterior instability without significant bone loss. Although successful for most patients, 10-40% will experience recurrent instability. The purpose of the current study was to compare a consecutive series of patients who had failed an arthroscopic stabilization to an age and gender matched cohort of patients who had no evidence of recurrent instability with a goal of identifying risk factors for future instability. Methods: A retrospective review was undertaken of all patients undergoing an arthroscopic shoulder stabilization for anterior instability between 2009 and 2016. Patients over the age of 18 years and those with underlying syndromes affecting the musculoskeletal system were excluded. Two patient cohorts were identified: (1) Patients with recurrent instability (frank dislocations or subluxations) after their arthroscopic stabilization; (2) An age and gender matched cohort of patients with no recurrent instability at a minimum of 2 years follow-up from surgery. Patient demographic, injury, radiographic, and surgical variables were recorded. In particular, bone loss measurements were performed on both the glenoid and humerus, and Hill-Sachs lesions were classified as “on-track” or ”off-track”. Variables at p<0.10 on univariate analysis were entered into a binary logistic multivariate regression analysis. Results: 35 patients were identified that failed an arthroscopic stabilization at a mean of 1.2 ± 1.0 years after their index surgery. A separate age and gender matched cohort of 35 patients was also identified with no symptoms of recurrent instability. Univariate analysis identified the following 4 risk factors for recurrent instability (glenoid bone loss > 10%, glenoid retroversion < 5◦, skeletal immaturity, and patients with more than one pre-surgical instability event). Collision sport participation, the presence and size of a Hill-Sachs deformity, and the glenoid track were not predictive of failure. Multivariate regression analysis revealed that loss of glenoid retroversion, skeletal immaturity, and a greater number of prior instability events best predicted future recurrence with two risk factors having a 3x increased risk and patients with all three risk factors having a 4x increased risk of recurrent instability after arthroscopic stabilization. Conclusion: Anterior glenoid bone loss, glenoid version, skeletal immaturity, and multiple pre-operative instability events are risk factors for failed arthroscopic stabilization in adolescent athletes with anterior instability. In the setting of multiple risk factors, patients and families should be counselled of the increased odds of surgical failure and other forms of surgical stabilization may need to be considered.

Cognitive Disorders Among Incoming College Football Athletes: Legal and Medical Implications of Undisclosed Inclusion in Concussion Research

Concussion research in the United States commonly relies on collegiate athletes as study subjects. Such research recognizes learning disabilities and attention deficit disorders (LD/ADHD) as co-morbidities that should be addressed in concussion research and management. This forensic study has three objectives: 1) to investigate the prevalence of such diagnoses and examine neuropsychological test results among incoming college football players at a major US university 2) to examine how LD/ADHD diagnoses were addressed in concussion research that included such athletes, and 3) to address the implication of these results for ongoing concussion litigation. This study observed LD/ADHD rates among football athletes exceeding 50% in multiple cohort-years, a degree of magnitude greater than the rate among general college student populations. Neuropsychological testing revealed scores among some incoming freshman college football players consistent with those of severe traumatic brain injury (TBI) patients. Evidence of cognitive impairment among incoming college football players raises concern over the potential effects of cumulative exposure to head trauma and the increased risk associated with continued participation in collision sports. We discuss the implications of our findings for concussion litigation and research ethics.

Oculomotor Cognitive Control Abnormalities in Australian Rules Football Players with a History of Concussion.

This study used oculomotor, cognitive, and multi-modal magnetic resonance imaging (MRI) measures to assess for neurological abnormalities in current asymptomatic amateur Australian rules footballers (i.e., Australia's most participated collision sport) with a history of sports-related concussion (SRC). Participants were 15 male amateur Australian rules football players with a history of SRC greater than 6 months previously, and 15 sex-, age-, and education-matched athlete control subjects that had no history of neurotrauma or participation in collision sports. Participants completed a clinical interview, neuropsychological measures, and oculomotor measures of cognitive control. MRI investigation involved structural imaging, as well as diffusion tensor imaging and resting-state functional MRI sequences. Despite no group differences on conventional neuropsychological tests and multi-modal MRI measures, Australian rules football players with a history of SRC performed significantly worse on an oculomotor switch task: a measure of cognitive control that interleaves the response of looking towards a target (i.e., a prosaccade) with the response of looking away from a target (i.e., an antisaccade). Specifically, Australian footballers performed significantly shorter latency prosaccades and found changing from an antisaccade trial to a prosaccade trial (switch cost) significantly more difficult than control subjects. Poorer switch cost was related to poorer performance on a number of neuropsychological measures of inhibitory control. Further, when comparing performance on the cognitively more demanding switch task with performance on simpler, antisaccade/prosaccades tasks which require a single response, Australian footballers demonstrated a susceptibility to increased cognitive load, compared to the control group who were unaffected. These initial results suggest that current asymptomatic amateur Australian rules football players with a history of SRC may have persisting, subtle, cognitive changes, which are demonstrable on oculomotor cognitive measures. Future studies are required in order to further elucidate the full nature and clinical relevance of these findings.

Parent Beliefs about Chronic Traumatic Encephalopathy: Implications for Ethical Communication by Healthcare Providers

The objective of this study was to assess the beliefs of parents of youth soccer players about Chronic Traumatic Encephalopathy (CTE), concussion, and retirement from sport decisions and compare them to those of concussion-specialized clinicians. An electronic survey was completed by parents of youth club soccer players (n=247/1600, 15.4% response rate) and concussion-specialized clinicians (n=18/47, 38.3% response rate) located in a large U.S. urban center. Parents believed more strongly in the causal relationship between concussions and CTE, and between CTE and harm than did clinicians. Parents who themselves had participated in sport at a high level had more conservative beliefs than other parents about the number of concussions after which an athlete should retire from contact or collision sport. Results are discussed in the context of ethical risk communication between clinicians and parents. This includes the importance of communicating information about CTE to parents and youth athletes in an understandable way so that they can make informed choices about contact and collision sport participation. Further research is encouraged to evaluate approaches of communicating evidence about CTE to a diverse population of families of youth athletes.

Normative Tandem Gait in Collegiate Student-Athletes: Implications for Clinical Concussion Assessment

Background:Impaired balance is common after concussion. The third edition of the Sport Concussion Assessment Tool (SCAT-3) recommends the Balance Error Scoring System (BESS) and/or tandem gait for postconcussion balance assessment. The limitations of the BESS are well documented; however, tandem gait has received little attention throughout concussion literature. The purpose of this study was to provide normative data for tandem gait in collegiate student-athletes based on sport type, concussion history, and gender.Hypothesis:Tandem gait will be influenced by concussion history, sport, and gender.Study Design:Cohort study.Level of Evidence:Level 3.Methods:Four hundred collegiate student-athletes from both collision/contact (n = 200) and limited contact/noncontact (n = 200) sports performed 4 tandem gait trials, consistent with SCAT-3 guidelines. The dependent variables included the best of the 4 trials (BEST), the mean of the 4 trials (MEAN), and the mean of each of the trials individually (ORDER). Separate multivariate analyses of variance were performed for each of the independent variables to determine effect on BEST and MEAN trial times. Significant main effects were followed up with a 1-way analysis of variance (ANOVA). A separate 1-way ANOVA was used to assess ORDER differences.Results:The mean BEST was 10.37 ± 1.76 seconds, and the MEAN was 11.32 ± 0.70 seconds. There were no significant differences in BEST or MEAN tandem gait times, respectively, between those with and without concussion history (P = 0.41 and P = 0.69, respectively), sport type (P = 0.57 and P = 0.42, respectively), or gender (P = 0.73 and P = 0.49, respectively). There were significant differences (P < 0.05) between ORDER of the 4 tandem gait trials across the population, with improved times at each trial.Conclusion:The results of this study provide a normative data set for tandem gait in healthy collegiate student-athletes and suggest that common determinants of balance, including concussion history, collision sport participation, and gender do not appear to influence performance, but ORDER could have significant clinical implications.Clinical Relevance:Clinicians may use these data to distinguish important determinants of tandem gait performance and improve awareness when returning an individual to play after a concussion.

Altered Blood Biomarker Profiles in Athletes with a History of Repetitive Head Impacts.

The long-term health effects of concussion and sub-concussive impacts in sport are unknown. Growing evidence suggests both inflammation and neurodegeneration are pivotal to secondary injury processes and the etiology of neurodegenerative diseases. In the present study we characterized circulating brain injury and inflammatory mediators in healthy male and female athletes according to concussion history and collision sport participation. Eighty-seven university level athletes (male, n = 60; female, n = 27) were recruited before the start of the competitive season. Athletes were healthy at the time of the study (no medications, illness, concussion or musculoskeletal injuries). Dependent variables included 29 inflammatory and 10 neurological injury analytes assessed in the peripheral blood by immunoassay. Biomarkers were statistically evaluated using partial least squares multivariate analysis to identify possible relationships to self-reported previous concussion history, number of previous concussions and collision sport participation in male and female athletes. Multiple concussions were associated with increases in peripheral MCP-1 in females, and MCP-4 in males. Collision sport participation was associated with increases in tau levels in males. These results are consistent with previous experimental and clinical findings that suggest ongoing inflammatory and cerebral injury processes after repetitive mild head trauma. However, further validation is needed to correlate systemic biomarkers to repetitive brain impacts, as opposed to the extracranial effects common to an athletic population such as exercise and muscle damage.

Risk Factors for Sustaining a Lower Extremity Injury in an Army Reserve Officer Training Corps Cadet Population.

Injuries acquired during Reserve Officer Training Corps (ROTC) participation can potentially affect a cadet's future and career in the armed forces. The purpose of this study was to identify risk factors associated with lower extremity injuries in an Army ROTC cadet population. There were 195 (165M, 30F) cadets enrolled in an Army ROTC program, 18 to 33 years old, with an average body mass index (BMI) of 23.5 ± 2.85. Injury data were retrospectively obtained from the electronic medical records maintained by a Certified Athletic Trainer. Descriptive statistics, frequencies, and incidence rate for physical training (PT) were calculated. Survival analysis determined association between injury and several variables (Military Science [MS] year, army physical fitness test scores, BMI, sex, previous lower extremity injury, PT exposures, most frequent boot worn, current and prior physical activity, and collision sport participation). Kaplan-Meier curves were used for the categorical variables. Incidence rate was 60 lower extremity injuries/100 person-years during PT. The survival analysis revealed MS year (p < 0.001) and PT exposures (p < 0.001) were significant in predicting risk of injury. All other variables were not significant. On the basis of this preliminary data, footwear and activity have no implications on risk of lower extremity injury. Preventative measures should be focused toward younger cadets because of their increased risk for injury.

Division III Collision Sports Are Not Associated with Neurobehavioral Quality of Life.

We sought to determine whether the exposure to the sub-concussive blows that occur during division III collegiate collision sports affect later life neurobehavioral quality-of-life measures. We conducted a cross-sectional study of alumni from four division III colleges, targeting those between the ages of 40-70 years, using several well-validated quality-of-life measures for executive function, general concerns, anxiety, depression, emotional and behavior dyscontrol, fatigue, positive affect, sleep disturbance, and negative consequences of alcohol use. We used multivariable linear regression to assess for associations between collision sport participation and quality-of-life measures while adjusting for covariates including age, gender, race, annual income, highest educational degree, college grades, exercise frequency, and common medical conditions. We obtained data from 3702 alumni, more than half of whom (2132) had participated in collegiate sports, 23% in collision sports, 23% in non-contact sports. Respondents with a history of concussion had worse self-reported health on several measures. When subjects with a history of concussion were removed from the analyses in order to assess for any potential effect of sub-concussive blows alone, negative consequences of alcohol use remained higher among collision sport athletes (β-coefficient 1.957, 95% CI 0.827-3.086). There were, however, no other significant associations between exposure to collision sports during college and any other quality-of-life measures. Our results suggest that, in the absence of a history of concussions, participation in collision sports at the Division III collegiate level is not a risk factor for worse long-term neurobehavioral outcomes, despite exposure to repeated sub-concussive blows.

Open Bankart Repair in Contact Athletes: Why and How

Anterior shoulder instability is a common problem in athletes. The risk factors for recurrent instability include young age, male gender, number of previous instability events, and contact or collision sport participation. Owing to the high rate of recurrent instability in the young athlete, surgical management is often indicated. Although arthroscopic Bankart repair has grown in popularity over the last several years, we still consider the open Bankart repair with capsular shift a superior form of treatment in the highest-risk patient (ie, the young male collision athlete). Arthroscopy followed by open repair allows the surgeon the opportunity to address all critical aspects at once—Bankart repair, capsular tensioning, rotator interval closure, bony defects, and any humeral avulsion glenohumeral ligament lesions. In this report, we review the indications for open Bankart repair in athletes and describe in detail our particular surgical approach and rehabilitation protocol.

Collision Sports and Risk of Bleeding in Children With Hemophilia

IN THIS ISSUE OF JAMA, BRODERICK AND COLLEAGUES 1 report results of their study of the association of vigorous sports with bleeding rate in 104 children and adolescents with moderate or severe hemophilia. Most participants were receiving prophylactic infusions of replacement clotting factor, which has been established as the standard of care for children and adolescents with hemophilia. Activities were scored as category 1, 2, or 3, depending on the expected trauma related to frequency and severity of collisions associated with the activity; category 2 and 3 activities can be referred to as collision sports. The study results indicate that the risk of bleeding events requiring acute factor replacement was increased following collision sports, with an odds ratio of 2.7 for category 2 activities (such as basketball or baseball) and 3.7 for category 3 activities (such as wrestling or US football). However, because exposure time to the higher-risk activities was a small percentage of total life hours and because the annual rate of bleeding was low, the absolute increase in risk was low. Additional statistical modeling, in which factor level was inferred from infusion schedule and known recovery and half-life, revealed that each 1% increase in plasma factor activity was associated with a 2% lower bleeding risk, thus suggesting therapeutic strategies that might further reduce the bleeding risk associated with collision sports. The study was strengthened by a novel and robust prospective case-crossover design. Data were acquired for each bleeding event from the 24-hour period preceding the event, as well as the 2 preceding 24-hour periods that served as control time periods during which exposure to sports and factor infusions were compared. To evaluate the accuracy of activity estimates during the control periods, participants were also asked to report their physical activity during randomly chosen times without bleeding events, along with the 2 preceding 24-hour intervals. This accuracy check found activity levels that were comparable with the control periods. The study by Broderick et al expands previous data on injury and bleeding rates related to sports participation in children with severe hemophilia. A study of school-aged children by Ross et al comparing 299 high-impact-sports seasons in 27 children and 46 low-impact-sports seasons in 10 children (92% using clotting factor prophylaxis) found a very low rate and no between-group differences for joint hemorrhage, injuries, or new target joint development related to high-impact sports. Similar bleeding outcomes were found in a study by Tiktinsky et al of 44 children with hemophilia not using prophylaxis. Both studies suggested that bleeding events related to sports in children with severe hemophilia represent a small proportion of total bleeding episodes. Evidence that participation in collision sports does not worsen the outcome of severe hemophilia may seem counterintuitive and inconsistent with conventional wisdom. However, the study by Broderick et al suggests that a factor level below a critical threshold is a more important determinant of bleeding risk than modest exposure to vigorous activities. All children need to feel part of their peer group. The label of a rare disorder, requirements for frequent intravenous infusions, and exclusion from sports intensify a painful sense of being different for children with hemophilia. Hemophilia almost exclusively affects males and peer participation of boys in many societies is centered around competitive sports. Participation in a popular sport can be important to reduce the sense of isolation experienced by many boys with hemophilia. Participation in desired but possibly higher-risk sports may be a strong motivator for positive health-promoting activities such as self-infusion of prophylactic factor replacement, year-round conduct of strengthening exercises, and increased body awareness with early bleed recognition. In the study by Ross et al, all participants, with their parents, underwent counseling regarding the risks and benefits of the sports in question as well as techniques to minimize risks and maximize health benefits. In addition, prophylaxis regimens were carefully reviewed and optimized. The analyses by Broderick et al suggest that higher factor level at the time of collision was preventive for tempo-

Arthroscopic Anterior and Posterior Capsulolabral Advancement for Higher-Risk Athletes

Arthroscopic stabilization has continued to improve and has become comparable to open repairs in terms of redislocation rates. However, many surgeons would still prefer an open procedure in case of bone loss (Hill-Sachs lesions or bony Bankart lesions), multidirectional instability, participation in collision sports, previous stabilization attempts, and in those patients with numerous pre-operative dislocations. We have adapted an arthroscopic technique that addresses both the anterior and posterior aspects of the Inferior Glenohumeral Ligament (IGHL) complex which we call the “Hammock procedure.” Based on our early experience, it appears to be a satisfactory arthroscopic alternative for these higher-risk instability patients.

Head to Head on Spear Tacklerʼs Spine

To The Editor: In the Current Concepts Review article Injuries to the Cervical Spine in American Football Players (2002;84:112-22), by Torg et al., the authors represented the spear tackler's spine as being an absolute contraindication to participation in collision sports. We acknowledge the contributions of Dr. Torg and his colleagues to the understanding of cervical spine injuries in football players, and we generally agree with, and advocate, the guidelines that they have presented. The authors defined the characteristics of spear tackler's spine as (1) a canal-vertebral body ratio (Pavlov ratio) of <0.8, (2) a straight or kyphotic alignment of the neck on a neutral lateral radiograph, (3) a posttraumatic radiographic abnormality, and (4) documentation of the patient's use of the spear-tackling technique. The authors' conclusion that spear tackler's spine is an absolute contraindication for return to play is based on their previously published retrospective review of fifteen football players who had sustained trauma to the cervical spine during play 1. The patients had either been referred to the lead author (J.S.T.) or identified through the National Football Head and Neck Injury Registry, from 1987 to 1990. All fifteen players were retrospectively found to meet the criteria of spear tackler's spine. Eleven of the fifteen patients had full neurological recovery, while four had a permanent neurological deficit. All four of these players had antecedent cervical or neurological symptoms prior to the sentinel injury, and three had sustained fracture-dislocations and/or disc herniations of the cervical spine. The remaining eleven patients had anatomical abnormalities, including disc herniations (six patients) and congenital anomalies (two patients). The authors' conclusion that spear tackler's spine is an absolute contraindication to participation in contact sports and collision activities is well intended but based on anecdotal evidence. The case reports of the four patients with spear tackler's spine …

Injuries to the cervical spine in American football players.

A national registry has documented data on more than 1300 cervical spine injuries resulting from tackle football. Axial loading of the cervical spine is the primary injury mechanism, an observation with profound implications regarding implementation of preventative measures. Characteristic injury patterns involving the middle (third and fourth) cervical segment and the more favorable response to prompt reduction of these injuries are emphasized. The marked instability and grave prognosis of axial load teardrop fractures are attributed to the associated sagittal vertebral body and posterior arch fractures. Spear tackler’s spine is described and is classified as an absolute contraindication to participation in collision sports. Cervical cord neurapraxia, with or without transient quadriplegia, is neither associated with nor presages permanent neurologic sequelae. However, there is a considerable risk of recurrence, which can be predicted on the basis of canal diameter data. The concept of spinal cord resuscitation is proposed as a means of obtaining maximum neurologic recovery by reversing the secondary injury phenomenon that occurs in acute spinal cord trauma. Athletic trauma to the cervical spine resulting in injury to the spinal cord is an infrequent but potentially catastrophic event. Recognition of the problems presented by injury to the cervical spine and spinal cord led to a series of field, clinical, and basic research studies conducted over the past twenty-five years. As a result of these efforts, basic questions have been answered regarding the epidemiology, prevention, pathomechanics, pathophysiology, and histochemical responses of reversible and irreversible cervical cord injuries. Allen et al.1 studied 165 closed indirect fractures and dislocations of the lower cervical spine, demonstrating various “spectra of injuries,” and developed a classification based on the mechanism of injury as determined by the presumed attitude of the cervical spine at the time of failure and the initial dominant mode of failure. The common …

Participation of Athletes With One Testicle-Reply

In Reply .—Perhaps Dr Ushkow is somewhat overstating the case of exclusion from sport participation because of absence of one testicle. The Sports Medicine Committee nearly 20 years ago stated that the absence of one of any of the paired organs should raise questions regarding the participation in collision sports. This included absence of an eye, lung, kidney, or testicle and the sports such as American football, ice hockey, wrestling, and lacrosse. Since that time, epidemiologic studies of sport injuries, clinical experience, and in many ways a changing sport scene have combined to prompt most physicians to avoid excluding sport participation for individuals missing one of the paired organs and to provide informed counsel to prospective athletes and their parents regarding risks, equipment for protection, and sport alternatives. In the presence of informed serious concern, early direction to appropriate noncollision sports is extremely important. The appropriately counseled young athlete with

Physical Maturity Screening for Participation in Sports

In an effort to develop screening criteria to allow nonphysicians to detect physically immature boys prior to interscholastic sports competition, 364 male adolescents were studied as part of their group preparticipation health evaluation. Handgrip and self-assessed Tanner stage were measured, in addition to the routine preparticipation health evaluation procedures. Of the 118 boys who were Tanner 3 or less (immature), 103 (87%) had weak grips (less than 55 lb [24.9 kg]), and 88 (75%) rated themselves as Tanner 3 or less. Of the 246 boys who were greater than Tanner 3 (mature), 223 (91%) had strong grips (greater than or equal to 55 [24.9 kg]), and 229 (93%) rated themselves as greater than Tanner 3. Six of the 118 immature boys (5%) had both a strong grip and mature self-assessed Tanner stage; three of the 246 mature boys (1%) had both a weak grip and an immature self-assessed Tanner stage. Only 67 of 364 (18%) boys had grips and self-assessed Tanner staging that were discordant. Use of grip strength and self-assessed Tanner staging may obviate the need for physician assessment of Tanner stage for the majority of adolescent boys prior to participation in collision sports.