Background:High school athletes are increasingly encouraged to participate in 1 sport year-round to increase their sport skills. However, no study has examined the association of competition volume, club sport participation, and sport specialization with sex and lower extremity injury (LEI) in a large sample of high school athletes.Hypothesis:Increased competition volume, participating on a club team outside of school sports, and high levels of specialization will all be associated with a history of LEI. Girls will be more likely to engage in higher competition volume, participate on a club team, and be classified as highly specialized.Study Design:Cross-sectional study.Level of Evidence:Level 3.Methods:High school athletes completed a questionnaire prior to the start of their competitive season regarding their sport participation and previous injury history. Multivariable logistic regression analyses were used to investigate associations of competition volume, club sport participation, and sport specialization with history of LEI, adjusting for sex.Results:A cohort of 1544 high school athletes (780 girls; grades 9-12) from 29 high schools completed the questionnaire. Girls were more likely to participate at high competition volume (23.2% vs 11.0%, χ2 = 84.7, P < 0.001), participate on a club team (61.2% vs 37.2%, χ2 = 88.3, P < 0.001), and be highly specialized (16.4% vs 10.4%, χ2 = 19.7, P < 0.001). Athletes with high competition volume, who participated in a club sport, or who were highly specialized had greater odds of reporting a previous LEI than those with low competition volume (odds ratio [OR], 2.08; 95% CI, 1.55-2.80; P < 0.001), no club sport participation (OR, 1.50; 95% CI, 1.20-1.88; P < 0.001), or low specialization (OR, 2.58; 95% CI, 1.88-3.54; P < 0.001), even after adjusting for sex.Conclusion:Participating in high sport volume, on a club team, or being highly specialized was associated with history of LEI. Girls were more likely to participate at high volumes, be active on club teams, or be highly specialized, potentially placing them at increased risk of injury.Clinical Relevance:Youth athletes, parents, and clinicians should be aware of the potential risks of intense, year-round participation in organized sports.

Sport-related concussion (SRC) is a major health problem, affecting millions of athletes each year. While the clinical effects of SRC (e.g., symptoms and functional impairments) typically resolve within several days, increasing evidence suggests persistent neurophysiological abnormalities beyond the point of clinical recovery after injury. This study aimed to evaluate cerebral blood flow (CBF) changes in acute SRC, as measured using advanced arterial spin labeling (ASL) magnetic resonance imaging (MRI). We compared CBF maps assessed in 18 concussed football players (age, 17.8 -1.5 years) obtained within 24 h and at 8 days after injury with a control group of 19 matched non-concussed football players. While the control group did not show any changes in CBF between the two time-points, concussed athletes demonstrated a significant decrease in CBF at 8 days relative to within 24 h. Scores on the clinical symptom (Sport Concussion Assessment Tool 3, SCAT3) and cognitive measures (Standardized Assessment of Concussion [SAC]) demonstrated significant impairment (vs. pre-season baseline levels) at 24 h (SCAT, p < 0.0001; SAC, p < 0.01) but returned to baseline levels at 8 days. Two additional computerized neurocognitive tests, the Automated Neuropsychological Assessment Metrics and Immediate Post-Concussion and Cognitive Testing, showed a similar pattern of changes. These data support the hypothesis that physiological changes persist beyond the point of clinical recovery after SRC. Our results also indicate that advanced ASL MRI methods might be useful for detecting and tracking the longitudinal course of underlying neurophysiological recovery from concussion.

Limited data exist comparing the performance of computerized neurocognitive tests (CNTs) for assessing sport-related concussion. We evaluated the reliability and validity of three CNTs—ANAM, Axon Sports/Cogstate Sport, and ImPACT—in a common sample. High school and collegiate athletes completed two CNTs each at baseline. Concussed (n = 165) and matched non-injured control (n = 166) subjects repeated testing within 24 hr and at 8, 15, and 45 days post-injury. Roughly a quarter of each CNT's indices had stability coefficients (M = 198 day interval) over .70. Group differences in performance were mostly moderate to large at 24 hr and small by day 8. The sensitivity of reliable change indices (RCIs) was best at 24 hr (67.8%, 60.3%, and 47.6% with one or more significant RCIs for ImPACT, Axon, and ANAM, respectively) but diminished to near the false positive rates thereafter. Across time, the CNTs' sensitivities were highest in those athletes who became asymptomatic within 1 day before neurocognitive testing but was similar to the tests' false positive rates when including athletes who became asymptomatic several days earlier. Test–retest reliability was similar among these three CNTs and below optimal standards for clinical use on many subtests. Analyses of group effect sizes, discrimination, and sensitivity and specificity suggested that the CNTs may add incrementally (beyond symptom scores) to the identification of clinical impairment within 24 hr of injury or within a short time period after symptom resolution but do not add significant value over symptom assessment later. The rapid clinical recovery course from concussion and modest stability probably jointly contribute to limited signal detection capabilities of neurocognitive tests outside a brief post-injury window.

Context In many US high schools, the athletic trainer (AT) has the responsibility to identify and manage athletes with concussions. Although the availability of ATs varies a great deal among schools, how the level of AT availability in high schools affects the reported incidence and management of sport-related concussions (SRCs) is unknown. Objective To determine how the presence of an AT affects the reporting and management of SRCs. Design Prospective cohort study. Patients or Other Participants A total of 2459 (female = 37.5%, age = 16.1 ± 1.2 years) athletes from 31 Wisconsin high schools were categorized as having low availability (LoAT), mid availability (MidAT), or high availability (HiAT) of ATs. Athletic trainers recorded the incidence, days lost from sport, and postconcussion management through return to sport. The incidence of SRC reporting among categories was examined using a multivariate Cox proportional hazards model. Fisher exact tests were used to determine if postconcussion management differed based on AT availability. Results The incidence of reported SRCs was lower for the LoAT schools (2.4%) compared with the MidAT (5.6%, hazard ratio = 2.59, P = .043) and HiAT (7.0%, hazard ratio = 3.33, P = .002) schools. The median time before the first AT interaction was longer for LoAT schools (24.0 hours) than for MidAT (0.5 hours, post hoc P = .012) and HiAT (0.2 hours, post hoc P = .023) schools. The number of post-SRC interactions was different in all groups (LoAT = 2 interactions, MidAT = 3, and HiAT = 4; all post hoc P values &lt; .05). Days lost were greater for MidAT and HiAT (both 14 days lost) schools compared with LoAT schools (11.5 days lost, post hoc P = .231 and P = .029, respectively). Athletes at LoAT schools were less likely to undergo a return-to-play protocol (9/18 SRCs, 50.0%) than athletes at MidAT (44/47 SRCs, 93.6%; post hoc P = .001) or HiAT (64/64 SRCs, 100%; post hoc P &lt; .001) schools. Conclusions The level of AT availability positively influenced the reported incidence of SRCs as well as postconcussion management activities in this sample of high schools.

BackgroundThere have been no large randomised controlled trials to determine whether soccer headgear reduces the incidence or severity of sport-related concussion (SRC) in US high school athletes.ObjectiveWe aimed to determine whether headgear reduces the incidence or severity (days out from soccer) of SRCs in soccer players.Methods2766 participants (67% female, age 15.6±1.2) (who undertook 3050 participant years) participated in this cluster randomised trial. Athletes in the headgear (HG) group wore headgear during the season, while those in the no headgear (NoHG) group did not. Staff recorded SRC and non-SRC injuries and soccer exposures. Multivariate Cox proportional hazards models were used to examine time-to-SRC between groups, while severity was compared with a Wilcoxon rank-sum test.Results130 participants (5.3% female, 2.2% male) sustained an SRC. The incidence of SRC was not different between the HG and NoHG groups for males (HR: 2.00 (0.63–6.43) p=0.242) and females (HR: 0.86 (0.54–1.36) p=0.520). Days lost from SRC were not different (p=0.583) between the HG group (13.5 (11.0–018.8) days) and the NoHG group (13.0 (9.0–18.8) days).ConclusionsSoccer headgear did not reduce the incidence or severity of SRC in high school soccer players.Trial registration numberNCT02850926.

Background Preseason baseline testing is increasingly performed on athletes using computerized neurocognitive tests (CNTs). Adequate effort is critical to establish valid estimates of ability, yet many users do not evaluate performance validity, and the conditions that impact validity are not well understood across the available CNTs. Purpose We examined the rates and predictors of invalid baseline performance for three popular CNTs: ANAM (Automated Neuropsychological Assessment Metrics), Axon Sports, and ImPACT (Immediate Post-Concussion Cognitive Assessment and Testing). Study Design Cross-sectional study. Methods High school and collegiate athletes (N = 2,063) completed two of three CNTs each during pre-season evaluations. All possible pairings were present across the sample, and order of administration was randomized. Examiners gave one-on-one, scripted pre-test instructions emphasizing the importance of good effort. Profile validity was determined by the manufacturers’ standard criteria. Results The overall percentage of tests flagged as of questionable validity was lowest for ImPACT (2.7%) and higher for ANAM and Axon (10.8% and 11.3%, respectively). The majority of invalid baselines were flagged as such due to failure on only one validity criterion. Several athlete and testing factors (e.g., attention deficit-hyperactivity disorder/ADHD, estimated general intellectual ability, administration order) predicted validity status for one or more CNTs. Considering only first CNT administrations and participants without ADHD and/or learning disability (n = 1,835) brought the rates of invalid baselines to 2.1%, 8.8%, and 7.0%, for ImPACT, ANAM, and Axon, respectively. Invalid profiles on the Medical Symptom Validity Test (MSVT) were rare (1.8% of subjects) and demonstrated poor correspondence to CNT validity outcomes. Conclusion These CNTs’ validity criteria may not identify the same causes of invalidity or be equally sensitive to effort. The validity indicators may not be equally appropriate for some athletes (e.g., those with neurodevelopmental disorders). The data suggest that athletes do not put forth widespread low effort or that some validity criteria are more sensitive to invalid performance than others. It is important for examiners to be aware of the conditions that maximize the quality of baseline assessments and to understand what sources of invalid performance are captured by the validity criteria they obtain.

Background: The long-term effect of sport-related concussion on mood in adolescent athletes is largely unknown. Hypothesis: Longitudinal measures of depression will worsen acutely after sport-related concussion and improve with concussion symptom resolution. Study Design: Prospective cohort study. Level of Evidence: Level 3. Methods: A population-based sample of 2160 high school athletes from 31 urban, suburban, and rural high schools completed preseason baseline concussion symptom evaluation and Patient Health Questionnaire–9 (PHQ-9) assessments over 2 years. Athletic trainers recorded onset of sport-related concussion, and concussed athletes completed the PHQ-9 assessment within 24 to 72 hours, 7 days, date of return to sport, 3 months, 6 months, and 12 months after sport-related concussion. Scores at each time point were compared to baseline with mixed-effects models and repeated-measures analysis of variance. Sex-based differences were assessed using mixed-effect models. Results: Of the 2160 athletes enrolled in the study, 125 (5.8%; 80 males, 45 females) sustained a sport-related concussion. PHQ-9 scores worsened from baseline at 24 to 72 hours (+1.05; 95% CI, 0.26-1.84; P = 0.003) and 7 days (+0.91; 95% CI, 0.23-1.60; P = 0.006). However, PHQ-9 scores improved from baseline to date of return to sport (−1.38; 95% CI, −2.20 to −0.55; P < 0.001), 3 months (−1.08; 95% CI, −1.88 to −0.28; P = 0.003), 6 months (−1.19; 95% CI, −2.04 to −0.34; P = 0.001), and 12 months after sport-related concussion (−0.76; 95% CI, −1.43 to −0.08; P = 0.028). Female athletes reported more severe concussion symptoms 24 to 72 hours after sport-related concussion compared with male athletes (female, 20.5 [interquartile range (IQR), 10.0-36.2]; male, 9.0 [IQR, 4.0-19.5]; P = 0.003). Neither PHQ-9 scores nor change in PHQ-9 scores differed between male and female athletes at any time point. Conclusion: Sport-related concussion did not worsen longitudinal measures of depressed mood in this cohort of high school athletes. Clinical Relevance: Emotional symptoms are common after sport-related concussion, but typically resolve by return to sport.

In comparison with prior published data collected from 1999 to 2004, utilization and duration of SFWPs were higher in the current study samples (99.3% vs 60.3% of athletes reported an SFWP; mean duration, 6.1 vs 3.2 days), and athletes were withheld from sports for more days than previously reported (12.3 vs 7.4 days). Rate of same-season repeat concussion was equivalent to that of prior published data. The findings support improved adherence to clinical management guidelines through increased utilization of SFWPs after SRC.