Secondary School Athletic Trainers' Strategies and Barriers to Overuse Injury Treatment in Adolescent Athletes.

CONTEXT: Studies have illustrated that overuse injuries occur in adolescent athletes more often than previously reported. The general purpose of this study was to provide a thorough report of secondary school athletic trainers encounters, practices, and perceptions of overuse injury in adolescent athletes. DESIGN: Cross-sectional. METHODS: An anonymous online questionnaire was distributed via email to athletic trainers in the secondary school setting. The questionnaire was sent to participants during the summer of 2021 and 430 participants (highest educational degree earned: master's degree = 66%) completed the survey. Various survey methods were used to evaluate athletic trainers (1) demographics, (2) estimations about what percentage of injuries evaluated and treated were classified as overuse, (3) methods for treating overuse injuries, (4) confidence in treating overuse injuries and the complete implementation of their treatment plan, (5) perceptions of various barriers to treating overuse injuries, and (6) perception as to why patients did not want to reduce activity to treat their overuse injuries. RESULTS: Participants reported that about half of all evaluations and treatments in a year were overuse injuries and they were "fairly" or "completely" confident (90%) in their ability to treat these injuries. The most common treatments cited were stretching (91%) and reducing activity (90%). Only 61% of participants were "fairly" or "completely" confident in the complete implementation of their treatment plan. Participants believed that patients' reluctance to reduce sport activities (82% "moderate" or "extreme" barrier) was the most significant barrier to treatment. Participants cited athletes' avoidance of missing games as the most common reason athletes were reluctant to reduce sporting activity. CONCLUSIONS: Participants felt confident in treating overuse injuries yet faced significant barriers in treating these injuries. Clinicians should be prepared to have conversations about the importance of reducing sporting activity to allow proper healing for overuse injuries in adolescent athletes.

Different Perceptions of Parents and Children on Factors Influencing Sport Specialization.

CONTEXT: Sport specialization among youth athletes has been associated with increased risk of overuse injuries. Previous research demonstrates that children perceive specialization to be beneficial in making their high school team and receiving athletic college scholarships. Previous research demonstrates that parents play a significant role in their child's sport experience. However, it is unknown if parents and children answer questions related to specialization factors in a similar manner. OBJECTIVE: To evaluate the beliefs of youth athletes and parents on factors related to sport specialization and evaluate the level of agreement between dyads on sports specialization. DESIGN: Cross-sectional. SETTING: Online and paper surveys. PATIENTS OR OTHER PARTICIPANTS: Aim 1: 1998 participants (993 children and 1005 parents). Aim 2: 77 paired parent-child dyads. INTERVENTIONS: Self-administered survey. MAIN OUTCOME MEASURES: The responses were summarized via frequency and proportions (%). Chi-squares were calculated between parent and child responses. Kappa coefficients were calculated for dyads to determine level of agreement. Sport specialization was classified using a common 3-point scale. RESULTS: The parents were more concerned about risk of injury in sports compared with children (P < .001, χ2 = 231.4; parent: extremely: 7.1%; child: extremely: 3.7%). However, children were more likely to believe that specialization was associated with their chances of obtaining an athletic college scholarship compared with parents (P < .001, χ2 = 201.6; parent: very/extremely likely: 13.7%; child: very/extremely likely: 15.8%). Dyad subanalysis indicated a moderate level of agreement for "quitting other sports to focus on one sport" (κ = .50) and a low level of agreement for "identifying a primary sport" (κ = .30) and "training >8 months per year in primary sport" (κ = .32). CONCLUSIONS: Parents and youth athletes had differing beliefs on the factors related to sport specialization. Dyad analysis shows that parents and children answer sport specialization classification questions differently. Health care providers should be aware of these differences, and messaging should be individualized to the audience.

Secondary School Athletic Trainers' Perceptions of How Youth Sport Specialization Impacts Workload.

BACKGROUND: Youth sport specialization is a growing trend in youth sports and is associated with an increased risk of injuries and burnout. However, it is unknown how sport specialization is perceived to be affecting the working environment of secondary school athletic trainers (ATs). The purpose of this paper is to describe how ATs perceive youth sport specialization impacting their workload and whether they perceive it to impact patient safety. HYPOTHESIS: ATs will perceive that youth sport specialization impacts their workload and could impact patient safety. STUDY DESIGN: A sequential, explanatory mixed methods design with 2 phases: (1) cross-sectional surveys and (2) individual interviews. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 487 secondary school ATs completed the online survey (access rate, 8.4%; completion rate, 85.4%). The survey consisted of Likert questions and included sections about aspects of workload impacted by specialization, impacts on patient safety, demographics. Ten participants were selected to complete a semi-structured interview via video conference. RESULTS: Approximately two-thirds of ATs perceive that sport specialization impacts their workload. (Somewhat, 38.6%; Quite a bit, 25.5%; A great deal, 5.5%) Attempts to reduce or modify patient activity and a patient's time for rehabilitation were the highest rated aspects of workload impacted by sport specialization. Approximately 30% ATs (29.9%) perceive that sport specialization impacts their workload to where it may influence patient safety (Somewhat, 21.6%; Quite a bit, 6.4%; A great deal, 1.9%). Three themes and subsequent subthemes were identified from the qualitative interviews: (1) current youth sport expectations, (2) conflict between school and club sports, and (3) AT job impacts. CONCLUSION: Secondary school ATs perceive their workload to be negatively impacted by youth sport specialization and some believe it may impact patient safety. CLINICAL RELEVANCE: Youth sport specialization is impacting youth sport stakeholders, including ATs, in a variety of ways.

The Influence of Race, Socioeconomic Status, and Physical Activity on the Mental Health Benefits of Sport Participation During COVID-19.

BACKGROUND: The purpose of this study was to compare the benefits of sport participation with no sport participation during the COVID-19 pandemic and determine the moderating effects of race and ethnicity, socioeconomic status (SES), and physical activity (PA) on mental health in adolescent athletes. HYPOTHESIS: Sport participation would be associated with greater improvements in mental health for athletes from racial and ethnic minority and lower SES groups compared with White and high SES groups. PA would mediate <30% of the mental health benefits of sport participation. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 4. METHODS: In May 2021, adolescent athletes completed an online survey (demographics, sport participation, measures of anxiety and depression, PA). Participants were classified as those who played sports (PLY) and those who did not (DNP). Mental health symptoms for the PLY and DNP groups were compared via analysis of variance models that controlled for demographic variables. Moderating analyses assessed the interaction of sport participation status by (1) race and ethnicity (White/non-White) and (2) SES (high/low) with mental health. Mediation analyses assessed the degree that PA scores explained the differences in anxiety and depression between the 2 groups. RESULTS: Participants included 4874 adolescent athletes (52% female; age, 16.1 ± 1.3 years; PLY, 91%). Athletes who returned to sport from racial minority groups and low SES had greater decreases in anxiety (race and ethnicity: interaction estimate (b) = -1.18 ± 0.6, P = 0.04; SES, b = -1.23 ± 0.5, P = 0.02), and depression (race and ethnicity: b = -1.19 ± 0.6, P = 0.05; SES, b = -1.21 ± 0.6, P = 0.03) compared with White and high SES athletes, respectively. PA explained 24% of anxiety (P < 0.01) and 20% of depression scores (P < 0.01). CONCLUSION: Athletes who identify as a racial or ethnic minority and from areas of lower household income experienced disproportionately greater negative mental health impacts from sport restrictions during COVID-19. CLINICAL RELEVANCE: Improving access to sports in traditionally underserved areas may have significant mental health impact for adolescents.

Sport Specialization and Sport Motivation in Middle School-Aged Athletes.

CONTEXT: Sport specialization has been assumed to have psychosocial ramifications for athletes, especially autonomous motivation, which has been associated with continued sport participation. Sport dropout is common in youth athletes, yet it is unknown how sport specialization may affect this population psychosocially. OBJECTIVE: To determine the association of sport specialization with autonomous and controlled motivation and amotivation in middle school-aged athletes. DESIGN: Cross-sectional study. SETTING: An anonymous online questionnaire was distributed to athletes via schools, club sports, and social media. PATIENTS OR OTHER PARTICIPANTS: A total of 178 athletes (male = 59%; private school = 51%; grade: sixth = 20%, seventh = 32%, eighth = 48%) completed the questionnaire. MAIN OUTCOME MEASURE(S): The questionnaire assessed demographics, sport participation, and motivation using the Youth Behavioral Regulation in Sport Questionnaire. Sport specialization was defined using a modified 3-point scale (low, moderate, or high) and multisport versus single-sport athletes. Nonparametric tests were used to analyze the differences among the types of motivation and specialization levels and between multisport and single-sport athletes. RESULTS: Sport specialization categories were not significantly associated with autonomous motivation, controlled motivation, or amotivation. No significant associations were present between multisport or single-sport athletes and any type of motivation. However, multisport athletes had higher scores for intrinsic motivation, a subscale of autonomous motivation, compared with single-sport athletes (single sport: median = 5.00, 25th-75th quartile = 4.50-5.00; multisport: median = 5.00, 25th-75th quartile = 5.00-5.00; P = .04). CONCLUSIONS: Sport motivation did not differ between sport specialization groups in middle school athletes. Dropout from sport is common in this age group but is multifactorial in nature. A lack of sport motivation could be a factor for some athletes, but all specialization groups appeared to have similar outcomes. Our exploratory analysis suggests that clinicians may consider having an open dialogue with single-sport athletes, their parents or guardians, and coaches to ensure that athletes are enjoying their sport.

COVID-19 Planning in United States Adolescent Sports: A Survey of 1880 Organizations Representing More Than 500 000 Youth Athletes.

CONTEXT: High schools and youth sport organizations that restarted participation in the fall of 2020 during the COVID-19 pandemic relied on information sources to develop risk-mitigation procedures. OBJECTIVE: To compare the risk-mitigation procedures and information sources used by high school athletic departments and youth sport organizations. DESIGN: Cross-sectional study. SETTING: Surveys of high school and youth sport organization programs from across the United States. PATIENTS OR OTHER PARTICIPANTS: A total of 1296 high schools and 584 youth sport organizations, representing 519 241 adolescent athletes, responded to the surveys. MAIN OUTCOME MEASURE(S): Surveys regarding restarting sport, COVID-19 cases, risk-reduction procedures, and the information sources used to develop risk-reduction plans in the fall of 2020 were distributed to high school athletic directors and youth sport directors throughout the United States. The proportions of high schools and youth sport organizations using different risk-reduction procedures and information sources were compared using the χ2 test. RESULTS: High schools used more risk-reduction procedures than did youth sport organizations (high schools = 7.1 ± 2.1 versus youth sport organizations = 6.3 ± 2.4; P < .001) and were more likely than youth sport organizations to use symptom monitoring (high schools = 93% versus youth sport organizations = 85%, χ2 = 26.3; P < .001), temperature checks on site (66% versus 49%, χ2 = 53.4; P < .001), face masks for athletes during play (37% versus 23%, χ2 = 38.1; P < .001) and when off the field (81% versus 71%, χ2 = 26.1; P < .001), social distancing for staff (81% versus 68%, χ2 = 43.3; P < .001) and athletes off the field (83% versus 68%, χ2 = 57.6; P < .001), and increased facility disinfection (92% versus 70%, χ2 = 165.0; P < .001). Youth sport organizations relied more on information from sport national governing bodies than did high schools (youth sport organizations = 52% versus high schools = 10%, χ2 = 411.0; P < .001), whereas high schools were more likely to use information from sources such as the National Athletic Trainers' Association (high schools = 20% versus youth sport organizations = 6%, χ2 = 55.20; P < .001) and the National Federation of State High School Associations (high schools = 72% versus youth sport organizations = 15%, χ2 = 553.00; P < .001) for determining risk-reduction strategies. CONCLUSIONS: High schools and youth sport organizations reported using a broad range of risk-reduction procedures, but the average number was higher among high schools than youth sport organizations. Use of information from the Centers for Disease Control and Prevention and local health authorities was high overall, but use of information from professional health care organizations was low. Professional health care organizations should consider using additional measures to improve information uptake among stakeholders in youth sports.

Does Increased Physical Activity Explain the Psychosocial Benefits of Sport Participation During COVID-19?

CONTEXT: Although the return to sports during COVID-19 has been associated with improvements in mental health and quality of life (QOL), whether these benefits are primarily due to increases in physical activity (PA) is unknown. OBJECTIVE: To determine whether PA increases were responsible for the improvements in mental health and QOL among adolescents who returned to sport during the COVID-19 pandemic. DESIGN: Cross-sectional study. SETTING: Wisconsin secondary schools. PATIENTS OR OTHER PARTICIPANTS: A total of 559 adolescent athletes (age = 15.7 + 1.2 years, females = 43.6%) from 44 schools completed a survey in October 2020. MAIN OUTCOME MEASURE(S): Demographic information, whether they had returned to sport participation, school instruction type, anxiety (Generalized Anxiety Disorder-7), depression (Patient Health Questionnaire-9), QOL (Pediatric Quality of Life Inventory 4.0), and PA (Hospital for Special Surgery Pediatric Functional Activity Brief Scale). Mediation analysis was used to assess whether the relationships between sport status and anxiety, depression, and QOL were mediated by PA. RESULTS: At the time of the study, 171 (31%) had returned to play and 388 (69%) had not. Athletes who had returned to play had less anxiety (3.6 ± 0.4 versus 8.2 ± 0.6, P < .001) and depression (4.2 ± 0.4 versus 7.3 ± 0.6, P < .001) and higher QOL (88.1 ± 1.0 versus 80.2 ± 1.4, P < .001) and more PA (24.0 ± 0.5 versus 16.3 ± 0.7, P < .001). Physical activity explained a significant, but small, proportion of the difference in depression (22.1%, P = .02) and QOL (16.0%, P = .048) but not anxiety (6.6%, P = .20) between athletes who had and those who had not returned to play. CONCLUSIONS: Increased PA was responsible for only a small portion of the improvements in depression and QOL among athletes who returned to sports. This suggests that most of the mental health benefits of sport participation for adolescents during the COVID-19 pandemic were independent of the benefits of increased PA.

Reported COVID-19 Incidence in Wisconsin High School Athletes in Fall 2020.

OBJECTIVE: To describe the incidence of COVID-19 in Wisconsin high school athletes and investigate the relationship of COVID-19 incidence with sport and face mask use. DESIGN: Retrospective survey. SETTING: High schools across Wisconsin during September 2020. PATIENTS OR OTHER PARTICIPANTS: Athletic directors representing 30 074 high school athletes with or without SARS-CoV-2. MAIN OUTCOME MEASUREMENT(S): The COVID-19 rates among athletes, counties, states, as well as school instruction type (virtual versus in person), sport type, and face mask use were assessed. Reported athlete case rates were compared with the county's general population and associations between COVID-19 incidence and sport type and face mask use, adjusting for each school's county incidence using multivariable negative binomial regression models. RESULTS: The COVID-19 incidence rates for 207 of 244 responding schools were 32.6 cases per 100 000 player-days. Reported case rates for athletes in each county were positively correlated with the county's general population case rates (ß = 1.14 ± 0.20, r = 0.60, P < .001). One case (0.5%) was attributed to sport contact by the reporting schools. No difference was identified between team and individual sports (incidence rate ratio [IRR] = 1.03 [95% CI = 0.49, 2.2], P = .93) or between noncontact and contact sports (IRR = 0.53 [0.23, 1.3], P = .14). Outdoor sports had a lower incidence rate than indoor sports, although this finding did not reach statistical significance (IRR = 0.52 [0.26, 1.1], P = .07). No significant associations were found between COVID-19 incidence and face mask use during play for those sports with greater than 50 schools reporting on face mask use (P values > .05). CONCLUSIONS: The incidence of reported COVID-19 among high school athletes was related to the county incidence, and most cases were attributed to nonsport contact. A lower COVID-19 incidence in outdoor sports approached statistical significance. The lack of a significant benefit demonstrated for face mask use may be due to relatively low rates of COVID-19 in Wisconsin during September 2020. Further research is needed to better define COVID-19 transmission risk factors during adolescent sport participation.

Comparing High School Sport Specialization Trends Between Division I and Club Collegiate Athletes.

BACKGROUND: Adolescent athletes report that sports specialization improves their ability to receive a collegiate athletics scholarship, though this is not well-understood. The purpose of this study was to examine self-reported trends in high school specialization and influences for sport participation between Division I (D-I) and college-aged club (club) athletes. HYPOTHESIS: There would be no difference in high school sport specialization or sport participation influences between D-I and club athletes. STUDY DESIGN: Retrospective cross-sectional study. LEVEL OF EVIDENCE: Level 3. METHODS: A survey included specialization classification (low, moderate, and high) for 9th to 12th grade, age that the athlete started organized sport and his or her collegiate sport, and several influential factors for participation in one's primary high school sport (1 = no influence to 5 = extremely influential). Chi-square analyses were used to compare specialization classifications between groups. Nonparametric tests were used to determine significant differences in age-related variables and influential factors between D-I and club athletes. All analysis were also conducted with boys and girls separately. RESULTS: Participants included 266 D-I (girls, 155; 58%) and 180 club (girls, 122; 68%) athletes. Club athletes were more likely to be classified as low specialization at every grade in high school, and this difference was more pronounced between D-I and club female athletes than male athletes. The number of years an athlete was classified as highly specialized in high school was not different between D-I and club athletes. Club athletes were more influenced by playing with friends than D-I athletes and D-I athletes were more influenced by pursuing a collegiate scholarship than club athletes. CONCLUSION: High levels of specialization in high school sport may not be necessary for playing at the collegiate level, though some level of specialization in high school might be necessary. CLINICAL RELEVANCE: Clinicians should advocate for healthy long-term athlete development, which does not support high specialization in high school sports.

COVID-19 in US Youth Soccer Athletes During Summer 2020.

CONTEXT: As sports are reinitiated around the United States, the incidence of COVID-19 among youth soccer athletes remains unknown. OBJECTIVE: To determine the incidence of COVID-19 among youth soccer athletes and the risk-mitigation practices used by youth soccer organizations. DESIGN: Cohort study. SETTING: Survey distributed to Elite Clubs National League member clubs. PATIENTS OR OTHER PARTICIPANTS: Youth soccer club directors throughout the United States. MAIN OUTCOME MEASURE(S): Surveys were completed in late August 2020 regarding the club's current phase of return to soccer (individual only, group noncontact, group contact), date of reinitiation, number of players, cases of COVID-19, and risk-reduction procedures being implemented. Case and incidence rates were compared with national pediatric data and county data from the prior 10 weeks. A negative binomial regression model was developed to predict club COVID-19 cases using the local incidence rate and phase of return as covariates and the log of club player-days as an offset. RESULTS: A total of 124 respondents had reinitiated soccer, representing 91 007 players with a median duration of 73 days (interquartile range = 53-83 days) since restarting. Of the 119 clubs that had progressed to group activities, 218 cases of COVID-19 were reported among 85 861 players. Youth soccer players had a lower case rate and incidence rate than children in the United States (254 versus 477 cases per 100 000; incidence rate ratio = 0.511, 95% CI = 0.40, 0.57; P < .001) and the general population in the counties where data were available (268 versus 864 cases per 100 000; incidence rate ratio = 0.202, 95% CI = 0.19, 0.21; P < .001). After adjusting for the local COVID-19 incidence, we found no relationship between the club COVID-19 incidence and the phase of return (noncontact: b = 0.35 ± 0.67, P = .61; contact: b = 0.18 ± 0.67, P = .79). Soccer clubs reported using a median of 8 (interquartile range = 6-10) risk-reduction procedures. CONCLUSIONS: The incidence of COVID-19 among youth soccer athletes was relatively low when compared with the background incidence among children in the United States during the summer of 2020. No relationship was identified between the club COVID-19 incidence and the phase of return to soccer.

COVID-19 Risk in Youth Club Sports: A nationwide sample representing over 200,000 Athletes.

CONTEXT: The COVID-19 pandemic has affected almost every aspect of life including youth sports. Little data exists on COVID-19 incidences and risk mitigation strategies in youth club sports. OBJECTIVE: To determine the reported incidence of COVID-19 cases among youth club sport athletes and the information sources used to develop COVID-19 risk mitigation procedures. DESIGN: Cross-sectional study. SETTING: Online surveys. PATIENTS: Soccer and volleyball youth club directors. INTERVENTION: A survey was completed by directors of youth volleyball and soccer clubs across the country in October 2020. Surveys included self-reported date of re-initiation, number of players, player COVID-19 cases, sources of infection, COVID-19 mitigation strategies, and information sources for the development of COVID-19 mitigation strategies. MAIN OUTCOME MEASURES: Total number of cases reported, number of players, and days since club re-initiation were used to calculate an incidence rate of cases per 100,000 player-days. To compare reported incidence rates between soccer and volleyball, a negative binomial model was developed to predict player cases with sport and state incidence as covariates and log(player-days) as an offset. Estimates were exponentiated to yield a reported incidence rate ratio (IRR) with Wald confidence intervals. RESULTS: A total of 205,136 athletes (soccer=165,580; volleyball=39,556) were represented by 437 clubs (soccer=159; volleyball=278). Club organizers reported 673 COVID-19 cases (soccer=322; volleyball=351), for a reported incidence rate of 2.8 cases per 100,000 player-days (soccer=1.7, volleyball=7.9). Volleyball had a significantly higher reported COVID-19 incidence rate compared to soccer (reported IRR = 3.06 [2.0-4.6], p<0.001). Out of 11 possible mitigation strategies, the median number of strategies used by all clubs was 7 with an interquartile range of 2. CONCLUSIONS: The incidence of self-reported cases of COVID-19 was lower in soccer clubs than volleyball clubs. Most clubs report using many COVID-19 mitigation strategies to reduce the risk of COVID-19.

Association of lower extremity injuries and injury mechanism with previous concussion history in adolescent athletes.

OBJECTIVE: Determine the association between concussion and subsequent contact, non-contact, and overuse lower extremity (LE) injuries in a cohort of adolescent athletes. Secondarily, to identify this association between males and females. STUDY DESIGN: Cross-sectional. SETTING: Summer athletic events with participants ages 12-18. MAIN OUTCOME: Anonymous survey included sport-related injuries (injury month/year) and participants classified injuries as a contact, non-contact, overuse injury, or concussion. Multivariable logistic regression analyses were used to examine associations between a concussion event and a subsequent LE injury while controlling for age and any previous LE injury. RESULTS: A concussion was reported in 219 athletes (Female = 96, 44%) and were matched with 219 non-concussed athletes (438 total participants). Concussion was not association with a specific injury mechanism but was significant for any subsequent LE injury (OR = 1.58 95%CI = [1.03-2.41]; p < 0.05). Concussed females were more likely to report any subsequent LE injury compared to non-concussed female athletes (2.49[1.31, 4.74]; p < 0.01). This relationship was not observed between concussed and non-concussed males (1.11[0.62-1.99]; p > 0.5). CONCLUSION: A history of concussion was associated with any subsequent LE injury, but not associated with a specific mechanism of injury. The association with concussion and a subsequent LE injury was different between males and females.

High School Sport Specialization and Injury in Collegiate Club-Sport Athletes.

CONTEXT: Sport specialization during adolescence may affect future injury risk. This association has been demonstrated in some professional sport athletes. OBJECTIVE: To determine the association between adolescent sport specialization levels in high school and injuries sustained during collegiate club sports. DESIGN: Cross-sectional study. SETTING: Paper and online surveys. PATIENTS OR OTHER PARTICIPANTS: Collegiate club-sport athletes. MAIN OUTCOME MEASURES(S): An anonymous survey was administered from September 2019 to May 2020. The survey included sport specialization classification via a commonly used 3-point scale (low, moderate, high) for each high school year (9th-12th), high school sports participation, and collegiate club-sport injury history. The number of years (0-4) an individual was highly specialized in high school was calculated. Individuals who participated in the same sport in high school and college were compared with individuals who played a different sport in college than in high school. An injury related to sport club activities was classified as arising from a contact, noncontact, or overuse mechanism required and the individual to seek medical treatment or diagnosis. Injuries were classified into overuse and acute mechanisms for the upper extremity, lower extremity (LE), and head/neck. RESULTS: Single-sport participation and the number of years highly specialized in high school sport were not associated with college club-sport injuries (P > .1). Individuals who played a different collegiate club sport than their high school sport were more likely to report an LE or head/neck acute injury compared with athletes who played the same collegiate and high school sport (LE = 20% versus 8%, χ2 = 7.4, P = .006; head/neck = 16% versus 3%, χ2 = 19.4, P < .001). CONCLUSIONS: Adolescent sport specialization was not associated with reported injuries in collegiate club-sport athletes. Collegiate club-sport athletic trainers should be aware that incoming students exploring a new sport may be at risk for LE and head/neck acute injuries.

Musculoskeletal Injuries and Their Association With Previous Concussion History: A Prospective Study of High School Volleyball and Soccer Players.

BACKGROUND: Sports-related concussions may have a neurobiological recovery period that exceeds the period of clinical recovery, and one consequence of an extended neurobiological recovery may be the risk of subsequent musculoskeletal injuries. Most literature citing an increased risk of musculoskeletal injury after a sports-related concussion has been reported in populations other than adolescent athletes. PURPOSE/HYPOTHESIS: The purpose was to prospectively determine if incidence rates of musculoskeletal injury differ between adolescent athletes with and without a previous sports-related concussion, while controlling for sex, sport, and age. A secondary aim was to determine if this relationship differs between male and female athletes of the same sport. Our hypotheses were that acute-noncontact injury rates would be higher in athletes with a previous sports-related concussion when compared with athletes without a previous sports-related concussion, and that this relationship would exist only in female athletes and not male athletes. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: High school soccer and volleyball players were recruited in 2 prospective cohort studies that observed 4837 athletes during their sporting season (females, 80%; soccer, 57%; mean [SD] age, 15.6 [1.1] years). At preseason, all participants self-reported demographics and previous sports-related concussion within the past 12 months. During the sport season, team athletic trainers electronically recorded athlete exposures and injury data, including injury characteristics. Injury rates per 1000 athlete exposures and injury rate ratios (IRRs) with 95% confidence intervals were calculated. All injury rates and IRRs were adjusted for sex, age, and sport. RESULTS: The rate of acute-noncontact lower extremity injury was 87% greater (IRR, 1.87; 95% CI, 1.29-2.74) in participants with a previous sports-related concussion versus those without one. The acute-noncontact lower extremity injury rates (IRRs) for females and males with a previous sports-related concussion were 1.76 (95% CI, 1.19-2.59) and 2.83 (95% CI, 0.85-9.50), respectively. No difference was detected in acute-contact (IRR, 0.98; 95% CI, 0.56-1.73) or overuse (IRR, 1.09; 95% CI, 0.51-2.37) lower extremity injury rates by previous sports-related concussion. CONCLUSION: Female adolescent athletes who reported a sports-related concussion within the past 12 months were more likely to sustain an acute-noncontact lower extremity injury during their high school sports season when compared with female athletes without a previous sport-related concussion.

Mental Health, Physical Activity, and Quality of Life of US Adolescent Athletes During COVID-19-Related School Closures and Sport Cancellations: A Study of 13 000 Athletes.

CONTEXT: In the spring of 2020, US schools closed to in-person teaching and sports were cancelled to control the transmission of coronavirus disease 2019 (COVID-19). It is critical to understand the mental and physical health of adolescent athletes during this time. OBJECTIVE: To describe the health of athletes during COVID-19-related school closures and sport cancellations. DESIGN: Cross-sectional study. SETTING: A national sample recruited via social media. PATIENTS OR OTHER PARTICIPANTS: A total of 13 002 US adolescent athletes (age = 16.3 ± 1.2 years, females = 52.9%, males = 47.0%) completed an anonymous online survey. MAIN OUTCOME MEASURE(S): Demographic information collected was sex, grade, sport(s) played, and zip code. Assessments used were the General Anxiety Disorder 7-Item for anxiety, Patient Health Questionnaire 9-Item for depression, the Pediatric Functional Activity Brief Scale for physical activity, and the Pediatric Quality of Life Inventory 4.0 for quality of life. Mental health, physical activity, and health-related quality-of-life variables were compared among sex, grade, sport(s) played, and poverty level using means and 95% confidence intervals (CIs) from the survey-weighted analysis of variance. RESULTS: Females reported a higher prevalence of moderate to severe anxiety symptoms (females = 43.7% versus males = 28.2%). The Pediatric Functional Activity Brief Scale score was highest (best) for grade 9 (mean = 14.5, 95% CI = 14.0, 15.0) and lowest for grade 11 (mean = 10.9, 95% CI = 10.5, 11.3). The prevalence of depression symptoms was highest in team sport (74.1%) and lowest in individual sport (64.9%) participants. The total Pediatric Quality of Life Inventory score was lowest (worst) for athletes from counties with the highest poverty levels (high: mean = 74.5, 95% CI = 73.7, 75.3; middle: mean = 78.9, 95% CI = 78.0, 79.8; and low: mean = 78.3, 95% CI = 77.4, 79.1). CONCLUSIONS: The health of US adolescents during the COVID-19-related school closures and sport cancellations varied to differing degrees depending on sex, grade level, type of sport participation, and level of poverty. Health policy experts should consider these findings in the future when creating and implementing policies to improve the health of adolescents in the United States.

Changes in the Health of Adolescent Athletes: A Comparison of Health Measures Collected Before and During the COVID-19 Pandemic.

CONTEXT: In spring 2020, schools closed to in-person teaching and sports were cancelled to control the transmission of COVID-19. The changes that affected the physical and mental health among young athletes during this time remain unknown. OBJECTIVE: To identify changes in the health (mental health, physical activity, and quality of life) of athletes that occurred during the COVID-19 pandemic. DESIGN: Cross-sectional study. SETTING: Sample recruited via social media. PATIENTS OR OTHER PARTICIPANTS: A total of 3243 Wisconsin adolescent athletes (age = 16.2 ± 1.2 years, 58% female) were surveyed in May 2020 (During COVID-19). Measures for this cohort were compared with previously reported data for Wisconsin adolescent athletes (n = 5231; age = 15.7 ± 1.2 years, 47% female) collected in 2016 to 2018 (PreCOVID-19). MAIN OUTCOME MEASURE(S): Demographic information included sex, grade, and sport(s) played. Health assessments included the Patient Health Questionnaire-9 Item to identify depression symptoms, the Pediatric Functional Activity Brief Scale to gauge physical activity, and the Pediatric Quality of Life Inventory 4.0 to evaluate health-related quality of life. Univariable comparisons of these variables between groups were conducted via t or χ2 tests. Means and 95% CIs for each group were estimated using survey-weighted analysis-of-variance models. RESULTS: Compared with preCOVID-19 participants, a larger proportion of During COVID-19 participants reported moderate to severe levels of depression (9.7% versus 32.9%, P < .001). Scores of the During COVID-19 participants were 50% lower (worse) on the Pediatric Functional Activity Brief Scale (mean [95% CI] = 12.2 [11.9, 12.5] versus 24.7 [24.5, 24.9], P < .001) and the Pediatric Quality of Life Inventory 4.0 compared with the PreCOVID-19 participants (78.4 [78.0, 78.8] versus 90.9 [90.5, 91.3], P < .001). CONCLUSIONS: During the COVID-19 pandemic, adolescent athletes described increased symptoms of depression, decreased physical activity, and decreased quality of life compared with adolescent athletes in previous years.

Consensus Definition of Sport Specialization in Youth Athletes Using a Delphi Approach.

CONTEXT: A single, widely accepted definition of sport specialization does not currently exist. A consensus definition is necessary to guide youth sport stakeholders on topics associated with sport specialization. OBJECTIVE: To develop a consensus definition of youth sport specialization and identify elements that support the construct of specialization. DESIGN: Delphi study. SETTING: Directed surveys. PATIENTS OR OTHER PARTICIPANTS: A consensus panel of 17 experts was created to provide a broad multidisciplinary perspective on sport specialization in youth athletes. DATA COLLECTION AND ANALYSIS: The final definition was developed per an iterative process that involved 4 rounds of review. A comprehensive review of the literature and expert input supported our initial proposed umbrella definition that included 6 additional elements. The study team reviewed the results after each round, and changes were made to the definition based on panel feedback. MAIN OUTCOME MEASURE(S): Panel members were provided with the definition and 6 elements and then asked to rate each specific to importance, relevance, and clarity using a 4-point Likert scale. RESULTS: In 4 Delphi consensus rounds, 17 experts reviewed the umbrella definition and 6 elements before consensus was reached. The umbrella definition and 3 of the initial 6 elements achieved greater than 80% agreement for importance, relevance, and clarity after the fourth round of review. The remaining 3 components did not reach greater than 80% agreement, even after iterative edits, and were removed. The process resulted in a final consensus definition: Sport specialization is intentional and focused participation in a single sport for a majority of the year that restricts opportunities for engagement in other sports and activities. CONCLUSIONS: A consensus-based conceptual definition for sport specialization was developed using a Delphi method. This definition has important implications for clinicians and sports medicine professionals who support youth athletes.

Training Load and Injury Among Middle School-Aged Athletes.

CONTEXT: Young athletes are encouraged to participate in high-intensity sport programs. However, most research on the association between training volume (TV) and injury has been performed on adult or professional athletes. OBJECTIVE: To evaluate the association between acute and chronic TV (hours/week) and reported injury (yes/no) and evaluate the relationship between acute : chronic TV and injury while controlling for sex, age, and prior injury in young athletes. DESIGN: Cohort study. SETTING: Online surveys. PATIENTS OR OTHER PARTICIPANTS: Middle school-aged adolescents. MAIN OUTCOME MEASURE(S): We conducted a baseline survey at the start of the 2017-2018 academic year. The baseline survey solicited information regarding demographics, injury history, and primary sport. Subsequent surveys were delivered electronically at the start of each week. Information obtained with the weekly survey included weekly TV and injuries sustained the previous week. Injuries were reported and classified (eg, acute or gradual onset) by the participants. Weekly TV was aggregated as rolling averages over the prior 2, 3, and 4 weeks. Acute:chronic TV was calculated for each participant for every week as the prior week TV divided by the TV during the prior 2 (1 : 2), 3 (1 : 3), and 4 (1 : 4) weeks of the study period. RESULTS: A total of 244 recruits participated. Higher average TV over the prior 4 weeks (odds ratio [OR] = 0.97; 95% confidence interval [CI] = 0.93, 1.00; P = .05) was associated with fewer reported injuries. Additionally, higher average TV over the prior 2 (OR = 0.96; 95% CI = 0.93, 0.99; P = .04), 3 (OR = 0.95; 95% CI = 0.91, 0.99; P = .02), and 4 (OR = 0.95; 95% CI = 0.91, 0.99; P = .05) weeks was associated with fewer reported acute injuries the following week. Acute:chronic TV and any injury type were not related. CONCLUSIONS: Consistent, higher levels of physical activity may offer protection against acute injury in young athletes.

Evaluation of adolescent sport specialization and injury mechanism by sex: A secondary analysis.

OBJECTIVES: The purpose of this study was to compare the association of sport specialization with previous overuse and acute injuries between male and female adolescent athletes. DESIGN: Cross-sectional study. METHODS: Questionnaires were completed by adolescent athletes from various sports at sport club summer events in the state of Wisconsin. Adolescent athletes (12-18 years old) who were active in organized sports in the previous year were recruited. The questionnaire contained demographics, sport participation, sport specialization classification, and previous injury history. Sport specialization classification was determined using common methods in sport specialization research. Previous injury was restricted to athletic injuries that occurred in the past year. RESULTS: Two-thousand and eleven participants (age=13.7±1.6 years, females=989) completed the questionnaire. Highly specialized athletes were more likely to report both acute and overuse injuries compared to low specialization athletes. However, this relationship differed by sex, with only moderate and highly specialized females being more likely (Moderate: OR [95%CI]=1.74 [1.18-2.58], p=0.005; High: OR [95%CI]=1.69 [1.14-2.53], p=0.010) to report an overuse injury compared to low specialization females. Highly specialized female athletes were more likely to report an acute injury (High: OR [95%CI]=1.46 [1.06-2.02], p=0.022) compared to low specialization females. Highly specialized male athletes were not associated with overuse or acute injuries. CONCLUSIONS: Highly specialized athletes were more likely to report acute and overuse injuries. However, when this analysis was separated by sex, only highly specialized females were more likely to report a previous overuse or acute injury.

Sport-Specific Associations of Specialization and Sex With Overuse Injury in Youth Athletes.

BACKGROUND: Significant evidence has emerged that sport specialization is associated with an increased risk of overuse injury in youth athletes. Several recommendations exist to reduce the risk of overuse injury in youth sports, but the risk of overuse injuries may be dependent on specific movements required by a given sport. HYPOTHESES: Associations between specialized sport participation and overuse injury will exist in volleyball athletes but not soccer or basketball athletes. Female athletes will be more likely to report an overuse injury in the previous year, regardless of sport. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 3. METHODS: Youth athletes between the ages of 12 and 18 years were recruited in-person at club team tournaments, competitions, and events around the state of Wisconsin during the 2016-2017 school year. Participants were asked to complete an anonymous questionnaire that consisted of (1) participant demographics, (2) sport specialization status, (3) monthly and weekly sport volume, and (4) sport-related injury history in the previous year. RESULTS: A total of 716 youth athletes completed the questionnaire (70.8% female; mean age, 14.21 ± 1.50 years; 43.2% basketball, 19.4% soccer, 37.4% volleyball; 41.8% highly specialized; 32.3% reported overuse injury in the previous year). Sex was associated with overuse injury among basketball athletes, with female basketball athletes nearly 4 times more likely to report an overuse injury compared with male basketball athletes (odds ratio, [OR], 3.7; 95% CI, 2.1-6.6; P < 0.001). High specialization (OR, 2.3; 95% CI, 1.1-4.9; P = 0.02) and participating in a single sport for more than 8 months per year (OR, 2.0; 95% CI, 1.1-3.5; P < 0.05) were associated with overuse injury only among volleyball athletes. CONCLUSION: Specialization and exceeding 8 months per year in a single sport was associated with overuse injury in volleyball, which is one of the most popular youth sports for female athletes. Specialization was not associated with overuse injury in basketball or soccer athletes. Female basketball athletes were nearly 4 times more likely to report a history of overuse injury compared with male basketball athletes. The sex of a youth athlete and the sport that he or she plays may influence the risk of overuse injury associated with sport specialization. CLINICAL RELEVANCE: Youth athletes, parents, and clinicians should be aware that the potential risks of specialization might vary based on the athlete's sport and sex.