Fair Play as an Injury Prevention Intervention: Do Yellow Card Accumulation Policies Reduce High School Soccer Injuries?

OBJECTIVES: Evaluate yellow card policies' (YCPs) effectiveness in reducing competition contact injuries (CCIs). DESIGN: Retrospective cohort. SETTING: High schools. PARTICIPANTS: Soccer players from High School (HS) Reporting Information Online participating schools, 2005/06 to 2017/18. INDEPENDENT VARIABLES: Athlete exposure (AE), CCIs from HS competitions collected from states with/without YCPs. MAIN OUTCOME MEASURES: Rate and rate ratio (RR) of athlete-athlete CCIs recorded by athletic trainers were compared between states with/without YCPs and pre-YCPs/post-YCPs among the states with YCPs using Poisson regressions. Proportions of severe athlete-athlete CCIs were also described in states with/without YCPs. RESULTS: Fifteen states implemented YCPs between 2005/06 and 2017/18; 901 athlete-athlete CCIs occurred during 352 775 competition AEs in states with YCPs, and 3525 injuries during 1 459 708 competition AEs in states without YCPs. There was no significant difference in injury rates between schools in states with/without YCPs (RR 1.07; 95% confidence interval [CI]: 0.97-1.17). Among state with YCPs, injury rates were not significantly different between pre-YCP and post-YCP implementation (RR 1.15; 95% CI: 0.98-1.34). Although a significantly lower proportion of injuries resulting in >3 weeks' time loss (TL) occurred in states with YCPs (injury proportion ratio 0.81; 95% CI: 0.66-0.997), no significant differences were observed in proportions of other severe athlete-athlete CCIs between states with/without YCPs. CONCLUSIONS: Yellow card policies were ineffective in lowering HS soccer athlete-athlete CCI rates, although injuries resulting in >3 weeks' TL were less prevalent in states with YCPs. Implementation of YCPs alone, without proper enforcement, may not be a sufficient injury prevention strategy.

A Battery of Easily Accessible, Simple Tools for the Assessment of Concussion in Children.

OBJECTIVE: To determine whether a non-proprietary, novel testing battery can identify recently concussed children within 8 weeks of injury. STUDY DESIGN: In total, 568 clinic outpatients aged 10-18 years were sorted into 3 groups: 316 had never been concussed, 162 had ever been concussed before 8 weeks earlier, and 90 had been recently concussed within 8 weeks. At initial and any subsequent visits, a neurologic examination and 4 procedures were performed: Stick Drop, Wall Ball, Sharpened Modified Romberg (SMR), and Animal Naming. Analysis included inter-group and intra-person performance differences using a series of t tests on the Stick Drop, Wall Ball, SMR, and Animal Naming. RESULTS: The recently concussed group performed worse (P < .01 for all) on Stick Drop, total Wall Ball bounces and drops, and SMR compared with never-concussed and ever-concussed groups. This effect for Stick Drop, SMR, and Wall Ball but not Animal Naming persisted beyond the 4 weeks commonly stated to define recovery. Of 59 recently concussed subjects who returned for ≥1 visit, there were improvements in Stick Drop average (P = .004) and maxima (P = .02) as well as SMR (P = .01) but not Animal Naming between initial and subsequent visits. CONCLUSIONS: This novel, rapid testing battery distinguished groups of children ages 10-18 years who had and had not experienced a recent concussion. A view that physical concussion symptoms resolve within a month of injury may be incomplete. Deployment of this readily available, inexpensive and non-proprietary battery should be compared with other tools and studied further in serial assessments.

Incidence of Combat Sport-Related Mild Traumatic Brain Injuries Presenting to the Emergency Department From 2012 to 2016.

OBJECTIVES: We sought to investigate the incidence and characteristics of traumatic brain injuries [mild traumatic brain injury (MTBI)] presenting to the emergency department as a result of boxing, wrestling, and martial arts (MA). DESIGN: Retrospective cross-sectional study of MTBI in combat sport athletes who were evaluated in emergency departments in the United States. SETTING: Patient data were taken from the National Electronic Injury Surveillance System. PARTICIPANTS: All patients with MTBI from 2012 to 2016, which occurred during participation in boxing, MA, or wrestling. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The incidence of combat sport-related MTBI presenting to emergency departments in the United States. RESULTS: The mean annual incidence of MTBI due to wrestling was significantly larger (269.3 per 100 000 person-years) than boxing (85.6 per 100 000 person-years) and MA (61.0 per 100 000 person-years) (P < 0.01). The average age at injury was significantly lower for wrestling compared with boxing and MA (15.0 years [SD ± 3.9] vs 21.7 years [SD ± 8.2] vs 19.9 years [SD ± 10.5]; P < 0.01). A significantly larger proportion of MTBIs (95.3%; P < 0.01) in patients younger than 20 years were related to wrestling, compared with boxing (55.8%) and MA (54.1%). Most patients with combat sport-related MTBIs were treated and discharged (96.3%), with only 1.7% of patients being admitted and 0.6% of patients being held for observation. CONCLUSION: Combat sports athletes are at high risk of sustaining an MTBI. Such athletes presenting to the emergency department for combat sport-related MTBI were more likely to be male and younger than 20 years. Of these athletes, wrestlers experience the highest incidence of MTBI-related emergency department visits.

Concussion Symptom Profiles Among Child, Adolescent, and Young Adult Athletes.

OBJECTIVES: (1) To examine how age influences initial symptom presentation following concussion; and (2) to determine whether specific symptom profiles are associated with duration of postconcussion symptoms, and whether they vary by age group. DESIGN: A total of 689 patients (20% children 7-12 years of age, 69% adolescents 13-18 years of age, and 11% young adults 19-30 years of age) were seen and diagnosed with a concussion within 21 days after injury. Patients completed the Post-Concussion Symptom Scale (PCSS) and were followed until they no longer required care. SETTING: Two specialty care sport concussion clinical practices. MAIN OUTCOME MEASURES: Overall PCSS score was obtained, as well as severity ratings from somatic, vestibular-ocular, cognitive, sleep, and emotional symptom domains. We also calculated total symptom duration time. RESULTS: No significant main effect of age, or age by sex associations were identified among the symptom domains. Females endorsed a higher somatic symptom severity rating than males (9.8 ± 6.7 vs 8.1 ± 6.7; P = 0.03). For patients between 7 and 12 years of age, higher somatic [ß-coefficient = 1.57, 95% confidence interval (CI), 1.47-1.67] and cognitive (ß-coefficient = 2.50, 95% CI, 2.32-2.68) symptom severities were associated with longer duration of concussion symptoms. Among adolescents, longer total symptom duration was associated with more severe somatic (ß-coefficient = 1.25, 95% CI, 0.34-2.15) and vestibular-ocular (ß-coefficient = 2.36, 95% CI, 1.49-3.23) symptoms. CONCLUSIONS: Within 21 days after concussion, symptom-reporting behavior seems to be similar across the age spectrum, but the relationship between symptom profiles and time to symptom resolution varies by age. Although overall symptom ratings are beneficial in determining clinical pathways, symptom domain use may provide a beneficial method to determine individualized patient care that differs between children and adolescents after concussion.

Epidemiology of Snow Skiing- Versus Snowboarding-Related Concussions Presenting to the Emergency Department in the United States from 2010 to 2014.

OBJECTIVES: To examine the trend of concussions in skiers and snowboarders from 2010 to 2014; and to quantify and compare the incidence of concussions injuries in skiers and snowboarders who presented to emergency departments in the United States in 2014. DESIGN: Cross-sectional study of concussions in skiers and snowboarders who were evaluated in emergency departments in the United States. MAIN OUTCOMES MEASURE: Incidence of concussions. RESULTS: The trend of the annual incidence of concussions for skiers and snowboarders remained stable from 2010 to 2014. An estimated total of 5388 skiing-related concussions and 5558 snowboarding-related concussions presented to emergency departments in the United States between January 1st, 2014, and December 31st, 2014. This represented an incidence of 16.9 concussions per 1 000 000 person-years for skiers and 17.4 concussions per 1 000 000 person-years for snowboarders. The incidence of concussions in the pediatric and young adult population of skiers was significantly higher than the incidence in the adult population. Similarly, the incidence of concussions in the pediatric and young adult population of snowboarders was significantly higher than the incidence in the adult population. The incidence of concussions was significantly higher in males compared with females in both skiing and snowboarding. CONCLUSIONS: The incidence of concussions from 2010 to 2014 plateaued in both skiers and snowboarders. Pediatric and young adult skiers and snowboarders had significantly higher incidences of concussion than the adult population. In contrast to the higher incidence of concussions in females in several sports including ice hockey, soccer, and basketball, the incidence of concussions was higher in males compared with females in both skiing and snowboarding.

Physical Maturity and Concussion Symptom Duration among Adolescent Ice Hockey Players.

OBJECTIVE: To investigate the association between physical maturity and risk of prolonged concussion symptoms in adolescent ice hockey players. STUDY DESIGN: Prospective cohort study of 145 patients ages 13-18 years with concussion referred to 3 hospital-affiliated sports medicine clinics between September 1, 2012 and March 31, 2015. Concussion evaluations included Post Concussive Symptom Score, neurologic examination, and postinjury computerized neurocognitive testing. Pubertal development at initial visit was assessed by the Pubertal Developmental Scale. Duration of concussion symptoms (days) was the main outcome. Statistical comparisons were conducted using Student t test, Wilcoxon rank sum, and logistic regression. RESULTS: Mean symptom duration was 44.5 ± 48.7 days. Nearly one-half (48.3%) of all players enrolled had prolonged concussion symptoms (≥ 28 days); most (86.9%) had symptom resolution by 90 days. Among males, less physically mature adolescents took longer to recover than more physically mature players (54.5 days vs 33.4 days; P = .004). "Early" Pubertal Category Score was the strongest predictor of prolonged symptoms (OR = 4.29, 95% CI 1.24-14.85; P = .021) among males. Among females, heavier weight increased the odds of experiencing prolonged symptoms (OR 1.07, 95% CI 1.00-1.14; P = .039). CONCLUSIONS: Among adolescent ice hockey players, early-pubertal stage is independently associated with longer recovery from concussion in males, and heavier weight is associated with longer concussion recovery in females. Until further studies determine valid physical maturity indicators, peripubertal collision sport athletes should compete in leagues grouped by relative age and be discouraged from "playing up" on varsity teams.

Two-Dimensional Video Analysis of Youth and Adolescent Pitching Biomechanics: A Tool For the Common Athlete.

Three-dimensional (3D) motion analysis is the gold standard for analyzing the biomechanics of the baseball pitching motion. Historically, 3D analysis has been available primarily to elite athletes, requiring advanced cameras, and sophisticated facilities with expensive software. The advent of newer technology, and increased affordability of video recording devices, and smartphone/tablet-based applications has led to increased access to this technology for youth/amateur athletes and sports medicine professionals. Two-dimensional (2D) video analysis is an emerging tool for the kinematic assessment and observational measurement of pitching biomechanics. It is important for providers, coaches, and players to be aware of this technology, its application in identifying causes of arm pain and preventing injury, as well as its limitations. This review provides an in-depth assessment of 2D video analysis studies for pitching, a direct comparison of 2D video versus 3D motion analysis, and a practical introduction to assessing pitching biomechanics using 2D video analysis.

Pars Interarticularis and Pedicle Stress Injuries in Young Athletes With Low Back Pain: A Retrospective Cohort Study of 902 Patients Evaluated With Magnetic Resonance Imaging.

BACKGROUND: Previous studies have reported that spondylolysis occurs predominantly at the L5 and L4 levels, with defects at higher levels occurring in <5% of cases. However, computed tomography and radiography were the primary imaging modalities in these studies. Current evidence regarding diagnostic imaging for pediatric lumbar spondylolysis suggests that magnetic resonance imaging (MRI) is as accurate as computed tomography in detecting early stress reactions of the pars interarticularis or pedicles without fractures while avoiding radiation exposure. The early detection of spondylolysis results in a higher likelihood of bony union and a decreased likelihood of spondylolisthesis. HYPOTHESIS: The increased use of MRI may reveal a larger proportion of spondylolysis in patients who experience an injury at a higher spinal level than previously reported. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: The medical records of 902 pediatric and adolescent athletes (364 female, 538 male) diagnosed with symptomatic pars interarticularis and pedicle stress injuries at 2 academic medical centers between 2016 and 2021 were retrospectively reviewed. All patients had MRI scans taken at the time of diagnosis. Only patients with pars/pedicle edema on MRI were included. Data regarding spondylolysis stage, spinal level of injury, unilateral versus bilateral injury, sport participation, and MRI protocol over the 5-year study period were analyzed. RESULTS: Male patients presented at older ages than female patients (P < .001). Soccer was the most common sport at symptom onset and the second most common single-sport activity among those who specialized (participating in 1 sport year-round at the exclusion of others), behind gymnastics. The mean symptom duration was 4.0 months. Although most patients (83.5%) had exclusively lower lumbar stress injuries, 9.1% of injuries occurred at or above the L3 level. Over half of the patients had active single-level pars/pedicle fractures on MRI, with a mean symptom duration before presentation in this subgroup of 4.0 months. Even when pars/pedicle stress reactions were excluded from analysis, 7.1% of patients were injured at or above the L3 level. CONCLUSION: Among male and female athletes aged 8 to 21 years presenting with symptomatic pars interarticularis and pedicle stress injuries evaluated by MRI at the time of initial diagnosis, there was a higher incidence of upper lumbar stress injuries than previously reported.

Effect of High School Showcase Exposures and Timing of Ulnar Collateral Ligament Tear on Professional Baseball Careers in Elite Pitchers.

BACKGROUND: Showcase participation has been considered a risk factor for elbow injuries. It remains unclear whether high school (HS) showcase volume negatively affects pitchers' career paths. Because pitchers are achieving 90 mph thresholds at younger ages, it is unknown whether shorter time intervals between achieving 90 mph thresholds and dates of ulnar collateral ligament reconstruction (UCL-R), known as time to tear (TTT), may affect career trajectory. HYPOTHESIS: Elite pitchers with higher HS showcase volumes would be less likely to reach Major League Baseball (MLB) level compared with elite pitchers with fewer HS showcase appearances. Elite pitchers with longer TTT intervals would be more likely to achieve MLB level. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Demographic, HS showcase and professional performance, and injury data from pitchers selected in the first 5 rounds of the MLB draft (2011-2017) were gathered from publicly available databases. Continuous and categorical variables were compared for the following subgroups: UCL-R group and pitcher group not undergoing UCL-R; "early" and "late" UCL-R groups; and pitchers achieving and pitchers not achieving MLB level. Multivariable analysis was performed using logistic regression. Standard deviations of ±1 SD were used to define early career versus late career UCL-R subgroups after normal distribution was confirmed (Shapiro-Wilk test; P = .227). The early UCL-R group was defined as those pitchers undergoing UCL-R ≤-1 SD from the mean age at first injury (group mean age, 19.43 years), whereas the late UCL-R group was defined as ≥+1 SD from that age (group mean age, 25.19 years). RESULTS: Of 611 pitchers, 455 (74.5%) had HS showcase performance data, and 608 (99.5%) had professional performance data. In total, 184 (30.1%) pitchers underwent UCL-R. Fewer pitchers who underwent early UCL-R achieved the MLB level compared with pitchers who underwent late UCL-R (48.1% vs 86.2%; P = .006). Elite pitchers who pitched in ≥10 showcases in HS had half the odds of achieving the MLB level compared with pitchers who participated in <10 HS showcases (adjusted odds ratio, 0.50; 95% CI, 0.29-0.86; P = .012). For every year longer that an elite pitcher did not tear his UCL after achieving the 90 mph threshold at an HS showcase (TTT after 90 mph [per year]), the likelihood of achieving the MLB level increased by 24% (adjusted odds ratio, 1.24; 95% CI, 1.02-1.52; P = .032). CONCLUSION: Higher HS showcase volume in elite pitchers was associated with a lower likelihood of achieving MLB level. A longer TTT after 90 mph (per year) was significantly associated with achieving MLB level in elite pitchers.

Ulnar Collateral Ligament Tear in Elite Baseball Pitchers: Are High School Showcase Exposures Associated With Injury?

BACKGROUND: Ulnar collateral ligament reconstruction (UCLR) surgeries have increased significantly in amateur and professional baseball pitchers. Although showcase participation has been considered an injury risk factor, limited data are available to corroborate this association. HYPOTHESIS: Elite pitchers achieving fastball velocities ≥90, ≥92, and ≥95 mph at younger ages would be more likely to undergo UCLR earlier in their careers compared with pitchers not achieving these velocity thresholds at younger ages. Elite pitchers participating in high showcase volumes would be more likely to undergo UCLR compared with elite pitchers participating in fewer showcases. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Descriptive, showcase performance, and injury data from pitchers selected in the first 5 rounds of the Major League Baseball draft (2011-2020) were gathered from publicly available databases. Continuous and categorical variables for pitchers undergoing UCLR and those not undergoing UCLR were compared, and multivariable analysis was performed using logistic regression. We used standard deviations (SDs) of ±1 SD of mean age at first UCLR to define early-career versus late-career UCLR subgroups after normal distribution was confirmed (Shapiro-Wilk test; P = .183). The "early" UCLR group was defined as ≤-1 SD (19.09 years), whereas the "late" UCLR group was defined as ≥+1 SD (24.79 years). Trends in time were evaluated using linear regression. RESULTS: Of the 845 pitchers selected, 659 pitchers (78.0%) had retrievable showcase performance data. Of the 845 pitchers, 229 (27.1%) underwent UCLR. Peak fastball velocity recorded at showcases was the strongest predictor of UCLR (adjusted odds ratio, 1.19; 95% CI, 1.02 to 1.39; P = .03). Peak fastball velocity in high school (HS) was significantly higher among pitchers who underwent UCLR compared with pitchers in the no-UCLR group (91.57 vs 90.71 mph, respectively; 95% CI, -1.43 to -0.29; P < .01). Age at which pitchers participated in their first HS showcase was significantly younger for the early versus the late UCLR group (15.53 vs 16.51 years, respectively; 95% CI, -1.53 to -0.41; P < .01). Elite pitchers with early UCLR participated in nearly twice as many showcases compared with the late UCLR group (5.38 vs 2.89, respectively; 95% CI, 0.43 to 4.54; P = .02). The mean number of HS showcases that elite pitchers attended more than doubled during the 2011-2020 study period (from 2.88 to 6.00 total showcases; P < .001). Mean age at which pitchers attended their first HS showcase steadily declined as well over the 10-year period (from 16.52 to 15.63 years; P < .001). CONCLUSION: Peak fastball velocity was the strongest predictor of UCLR in elite pitchers before initiating professional careers. Elite amateur pitchers attended more showcases at younger ages in a decade-long trend. Overall, the variables included in this multivariable analysis were weak predictors, explaining only 3.8% of the variance in UCLR rates.

Design Features and Rationale of the BEAR-MOON (Bridge-Enhanced ACL Restoration Multicenter Orthopaedic Outcomes Network) Randomized Clinical Trial.

BACKGROUND: BEAR (bridge-enhanced anterior cruciate ligament [ACL] restoration), a paradigm-shifting technology to heal midsubstance ACL tears, has been demonstrated to be effective in a single-center 2:1 randomized controlled trial (RCT) versus hamstring ACL reconstruction. Widespread dissemination of BEAR into clinical practice should also be informed by a multicenter RCT to demonstrate exportability and compare efficacy with bone--patellar tendon-bone (BPTB) ACL reconstruction, another clinically standard treatment. PURPOSE: To present the design and initial preparation of a multicenter RCT of BEAR versus BPTB ACL reconstruction (the BEAR: Multicenter Orthopaedic Outcomes Network [BEAR-MOON] trial). Design and analytic issues in planning the complex BEAR-MOON trial, involving the US National Institute of Arthritis and Musculoskeletal and Skin Diseases, the US Food and Drug Administration, the BEAR implant manufacturer, a data and safety monitoring board, and institutional review boards, can usefully inform both clinicians on the trial's strengths and limitations and future investigators on planning of complex orthopaedic studies. STUDY DESIGN: Clinical trial. METHODS: We describe the distinctive clinical, methodological, and operational challenges of comparing the innovative BEAR procedure with the well-established BPTB operation, and we outline the clinical motivation, experimental setting, study design, surgical challenges, rehabilitation, outcome measures, and planned analysis of the BEAR-MOON trial. RESULTS: BEAR-MOON is a 6-center, 12-surgeon, 200-patient randomized, partially blinded, noninferiority RCT comparing BEAR with BPTB ACL reconstruction for treating first-time midsubstance ACL tears. Noninferiority of BEAR relative to BPTB will be claimed if the total score on the International Knee Documentation Committee (IKDC) subjective knee evaluation form and the knee arthrometer 30-lb (13.61-kg) side-to-side laxity difference are both within respective margins of 16 points for the IKDC and 2.5 mm for knee laxity. CONCLUSION: Major issues include patient selection, need for intraoperative randomization and treatment-specific postoperative physical therapy regimens (because of fundamental differences in surgical technique, initial stability construct, and healing), and choice of noninferiority margins for short-term efficacy outcomes of a novel intervention with evident short-term advantages and theoretical, but unverified, long-term benefits on other dimensions.

Effect of air travel on exercise-induced coagulatory and fibrinolytic activation in marathon runners.

OBJECTIVE: Air travel and exercise change hemostatic parameters. This study investigated the effect of air travel on exercise-induced coagulation and fibrinolysis in endurance athletes. DESIGN: A prospective longitudinal study. SETTING: The 114th Boston Marathon (April 19, 2010). PARTICIPANTS: Forty-one adults were divided into travel (T: 23 participants, living >4-hour plane flight from Boston) and nontravel (C: 18 participants, living <2-hour car trip from Boston) groups. INDEPENDENT VARIABLES: Age, anthropometrics, vital signs, training mileage, and finishing time were collected. MAIN OUTCOME MEASURES: Subjects provided venous blood samples the day before (PRE), immediately after (FINISH), and the day following the marathon after returning home (POST). Blood was analyzed for thrombin-antithrombin complex (TAT), tissue plasminogen activator (t-PA), hematocrit (Hct), and the presence of Factor V Leiden R506Q mutation. RESULTS: Thrombin-antithrombin complex increased more in T subjects in PRE to FINISH samples (5.0 ± 4.0 to 12.9 ± 15.6 µg/L) than in C subjects (4.0 ± 1.2 to 6.1 ± 1.2 µg/L; P = 0.02 for comparison). The t-PA increased in both the T (5.4 ± 2.3 to 25.1 ± 12.2 ng/mL) and C (5.6 ± 2.0 to 27.7 ± 11.3 ng/mL) groups in PRE to FINISH samples, and this response did not differ between groups (P = 0.23 for comparison). Both groups exhibited similar t-PA and TAT values at POST that were not different than PRE (all P > 0.35). Age was related to the FINISH TAT values in T (r = 0.19; P = 0.04) but not in C (r = 0.03; P = 0.53) subjects. CONCLUSIONS: Results suggest that the combination of air travel and marathon running induces an acute hypercoaguable state; this hemostatic imbalance is exaggerated with increasing age.

Prevention of Sport-Related Concussion.

Concussion remains a common injury among sports participants. Implementing risk-reduction strategies for sport-related concussion (SRC) should be a priority of medical professionals involved in the care of athletes. Over the past few decades, a multifaceted approach to reducing SRC risk has been developed. Protective equipment, rule and policy change/enforcement, educational programs, behavioral modifications, legislation, physiologic modifications, and sport culture change are a few of the programs implemented to mitigate SRC risk. In this article, the authors critically review current SRC risk-reduction strategies and offer insight into future directions of injury prevention for SRC.

Outpatient Management of Sport-Related Concussion, Return to Learn, Return to Play.

Outpatient sports-related concussion (SRC) management continues to evolve as evidence emerges supporting a multidisciplinary approach to the clinical assessment of SRC. Early active rehabilitation has replaced strict cognitive and physical rest. With this paradigm shift in management, pragmatic approaches are highly sought by busy clinicians that provide direction to individualized treatment, which can potentially expedite symptom resolution. Treatment strategies that address domain-based symptom constellations continue to be developed by clinician researchers. Although the optimal timing and dose of these domain-specific therapies has yet to be determined, future directions of SRC treatment will answer these and other questions regarding SRC management.

Home Run Derby Participation in Major League Baseball Players: Is There Associated Injury Risk and Impact on Second-Half Performance?

BACKGROUND: The Major League Baseball (MLB) All-Star Game (ASG) Home Run Derby (HRD) remains a highly anticipated event, during which contestants can take hundreds of maximum-effort swings en route to hitting a multitude of home runs. Critics have openly questioned the risk-benefit of HRD participation as it pertains to injury, alterations in swing mechanics, and timing. PURPOSE: To determine whether participation in the MLB ASG HRD was associated with both increased injury risk and decline in second-half performance in MLB players. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: MLB players who participated in the HRD between 2006 and 2019 were identified through publicly available internet databases. A control group of ASG participants who had the highest home run totals in the first half of the corresponding MLB season were selected as a control group. Multivariable linear regression was used to determine independent associations between HRD participation and batting metrics in the second half of the season. Multivariable logistic regression also assessed the impact of HRD participation on injured list placement during the second half of the concurrent MLB season. RESULTS: A total of 114 HRD participants and 114 ASG participant controls competed during the study period. No statistically significant differences were seen in batting metrics in the second half of the MLB season between HRD participants and ASG controls, although HRD participants had a significantly lower wins-above-replacement statistic for the season compared with controls (4.69 ± 2.06 vs 5.33 ± 2.08; P = .021). HRD participation was not significantly associated with injury during the second half. The number of HRD rounds in which a player participated did not result in a statistically significant increased odds of injury during the second half of the MLB season. CONCLUSION: HRD participants did not have increased odds of being placed on the injured list during the second half of the MLB season compared with controls, nor did they experience second-half performance declines in offensive production versus controls when multivariable linear regression analysis was performed.

Medical Advisability of Youth Pitching Recommendations on the Internet.

BACKGROUND: As the incidence of youth pitching injuries and surgical procedures attributed to overuse has drastically increased, there are quality concerns about popular internet resources regarding arm care for youth pitchers. PURPOSE/HYPOTHESIS: To assess the medical advisability of online arm care recommendations for youth pitchers. It was hypothesized that websites contain misleading arm-care information that is discordant with medical advice. STUDY DESIGN: Cross-sectional study. METHODS: We reviewed the first 100 websites populated after a Google search for youth pitching recommendations. Websites were categorized by type (athletic organization, commercial, or educational) and content quality (medically advisable, discordant, or neutral), the latter with respect to the Pitch Smart guidelines used by Major League Baseball. Chi-square tests of independence and z tests of independent proportions were used to compare column proportions among categories of website content quality for each type of website source. Given the small sample sizes in some instances, the Fisher-Freeman-Halton exact test was performed to assess the relationship between website source type and quality of information. RESULTS: Of the 99 qualifying websites, 76 were categorized as medically advisable, 16 as discordant, and 7 as neutral. In addition, 92% of educational websites and 94.7% of athletic organization websites featured exclusively advisable content, whereas only 54.8% of commercial websites were advisable. Of the 16 discordant websites, 15 were commercial sites. Educational websites were significantly more advisable and neutral in content when compared with discordant information, while commercial websites were significantly predictive of discordant content. Among the first 50 websites populated according to Google, 42 (84%) were advisable, 6 (12%) discordant, and 2 (4%) neutral. The remaining websites (n = 49) featured 34 (69.4%) that were advisable, 10 (20.4%) discordant, and 5 (10.2%) neutral. CONCLUSION: Study findings indicated that websites of an educational nature are predictive of medically advisable content, while commercial websites (eg, blogs) are associated with discordant information. The abundance and availability of inaccurate internet information should be appreciated by medical professionals and parents/coaches of youth baseball players.

Reliability of an Observational Biomechanical Analysis Tool in Adolescent Baseball Pitchers.

BACKGROUND: Improper pitching mechanics are a risk factor for arm injuries. While 3-dimensional (3D) motion analysis remains the gold standard for evaluation, most pitchers and clinicians do not have access to this costly technology. Recent advances in 2-dimensional (2D) video technology provide acceptable resolution for clinical analysis. However, no systematic assessment tools for pitching analysis exist. PURPOSE: To determine the reliability of the Assessment of biomeChanical Efficiency System (ACES) screening tool using 2D video analysis to identify common biomechanical errors in adolescent pitchers. STUDY DESIGN: Cross-sectional. METHODS: Adolescent baseball pitchers underwent analysis using 2D video in indoor settings. Observational mechanics were collected using a 20-item scoring tool (ACES) based on 2D video analysis. Fleiss' kappa, interclass correlation coefficients (ICC), and frequencies were used to examine intra-/interrater reliability based on common pitching errors. RESULTS: Twenty asymptomatic pitchers ages 12-18 years were included. Total ACES scores ranged from 1 to 13, normally distributed. ACES total score demonstrated excellent intra-rater reliability within each rater (ICC for rater 1 = 0.99 (95% CI; 0.98, 0.99); ICC for rater 2 = 0.94; 95% CI: 0.84, 0.97); ICC for rater 3 = 0.98 (95% CI: 0.96, 0.99)). There was excellent interrater reliability across the trials and raters (ICC = 0.91; 95% CI: 0.82, 0.96). The ACES tool demonstrated acceptable kappas for individual items and strong ICC 0.91 (95% CI: 0.82, 0.96) for total scores across the trials. Regarding identification of biomechanical errors, "front side position" was rated erroneous in 84/120 ratings (70%), stride length in 52/120 ratings (43.3%) and lead hip position in 53/120 ratings (44.2%). CONCLUSIONS: The 20-item ACES scoring tool with 2D video analysis demonstrated excellent intra- and interrater reliability when utilized by raters of different musculoskeletal disciplines. Future studies validating 2D vs. 3D methodology are warranted before ACES is widely disseminated and utilized for adolescent pitchers. ACES is a practical and reliable clinical assessment tool utilizing 2D video analysis for coaches, instructors, and sports medicine providers to screen adolescent pitchers for common biomechanical errors. LEVEL OF EVIDENCE: 3b.