Suicide in professional American football players in the past 95 years.

OBJECTIVE: To examine publicly-available information on all identified cases of suicide in active or former American professional football players between 1920 and the spring of 2015. DESIGN: Retrospective cohort study. SETTING: Professional American Football in the US. PARTICIPANTS: A cohort of 26 702 athletes who had died, retired or were currently playing in the NFL from nfl.com since 1920 was identified. MAIN OUTCOME MEASURES: Internet queries identifying 26 professional football players who completed suicide. Obituaries and news reports were reviewed. The primary outcome measures included mortality, demographic characteristics and life circumstances in professional American football players completing suicide. RESULTS: From 1920-2015, the median age of the 26 men who completed suicide was 39.5 years (range = 23-85). The median number of years after retirement was 6.5 (range = 0-63). Most of the deaths since 1920 have occurred in the past 15 years (58.7%) and a large percentage have occurred since 2009 (42.3%). Most of the men suffered from multiple life stressors prior to their deaths, such as retirement from sport, loss of steady income, divorce, failed business ventures, estrangement from family members and medical, psychiatric and/or substance abuse problems. CONCLUSIONS: A disproportionate number of completed suicides in current and former professional football players have occurred since 2009 (42.3%). It is well established in the literature that the causes of depression and suicidality are diverse, often multifactorial and treatable. Providing at-risk retired athletes with mental health treatment will likely reduce their suffering and improve their quality-of-life.

Nonsteroidal anti-inflammatory drug use in collegiate football players.

OBJECTIVE: To determine prevalence of nonsteroidal anti-inflammatory drug (NSAID) use in college football players and whether positions sustaining the most contact would use NSAIDs more frequently. DESIGN: Prospective cross-sectional study. SETTING: American college football programs. PATIENTS: An anonymous survey was given to 211 college football players before the season. INDEPENDENT VARIABLE: Use of NSAIDs. MAIN OUTCOME MEASURES: The dependent variables are the different patterns in NSAID usage among positions and the frequency of NSAID use before and after the season. RESULTS: Of the athletes surveyed, 95.7% had or were using NSAIDs. Athletes first used NSAIDs in junior high school (45.6%), high school (48.5%), or college (5.8%). Athletes were separated into high (daily or weekly) or low (monthly or rarely) utilizers of NSAIDs. High utilization of NSAIDs was more frequent during the season (50.0%) than in the off-season (14.6%), P < 0.001. High NSAID utilization among all players was more prevalent after than before games (32.7% vs 10.9%, P = 0.002). Players with a higher body mass index (BMI; >28) were significantly higher utilizers of NSAIDs, reporting higher rates of use in season compared with other players (57.4% vs 39.5%, P = 0.011, OR = 2.06). CONCLUSIONS: Use of NSAIDs in collegiate football players is common. It is concerning that those athletes with the highest cardiovascular risk (ie, elevated body mass index) use greater amounts of NSAIDs. Further investigation is needed to delineate the short-term and long-term consequences of NSAID utilization in young athletes.

Genomic Epidemiology of a Severe Acute Respiratory Syndrome Coronavirus 2 Outbreak in a US Major League Soccer Club: Was It Travel Related?

Background: Professional soccer athletes are at risk of acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). United States Major League Soccer (MLS) uses protocol-based SARS-CoV-2 testing for identification of individuals with coronavirus disease 2019. Methods: Per MLS protocol, fully vaccinated players underwent SARS-CoV-2 real-time polymerase chain reaction testing weekly; unvaccinated players were tested every other day. Demographic and epidemiologic data were collected from individuals who tested positive, and contact tracing was performed. Whole genome sequencing (WGS) was performed on positive specimens, and phylogenetic analyses were used to identify potential transmission patterns. Results: In the fall of 2021, all 30 players from 1 MLS team underwent SARS-CoV-2 testing per protocol; 27 (90%) were vaccinated. One player who had recently traveled to Africa tested positive for SARS-CoV-2; within the following 2 weeks, 10 additional players and 1 staff member tested positive. WGS yielded full genome sequences for 10 samples, including 1 from the traveler. The traveler's sample was Delta sublineage AY.36 and was closely related to a sequence from Africa. Nine samples yielded other Delta sublineages including AY.4 (n = 7), AY.39 (n = 1), and B.1.617.2 (n = 1). The 7 AY.4 sequences clustered together; suggesting a common source of infection. Transmission from a family member visiting from England to an MLS player was identified as the potential index case. The other 2 AY.4 sequences differed from this group by 1-3 nucleotides, as did a partial genome sequence from an additional team member. Conclusions: WGS is a useful tool for understanding SARS-CoV-2 transmission dynamics in professional sports teams.

Intraarticular Hyaluronic Acid Preparations for Knee Osteoarthritis: Are Some Better Than Others?

OBJECTIVE: This literature review summarizes evidence on the safety and efficacy of intraarticular hyaluronic acid (IAHA) preparations approved in the United States for the treatment of osteoarthritis of the knee. DESIGN: A systematic literature search was performed in PubMed, Ovid MEDLINE, and SCOPUS databases. Only studies in which clinical outcomes of individual IAHA preparations alone could be assessed when compared to placebo, no treatment, other standard knee osteoarthritis treatments, and IAHA head-to-head studies were selected. RESULTS: One hundred nine articles meeting our inclusion criteria were identified, including 59 randomized and 50 observational studies. Hylan G-F 20 has been the most extensively studied preparation, with consistent results confirming efficacy in placebo-controlled studies. Efficacy is also consistently reported for Supartz, Monovisc, and Euflexxa, but not for Hyalgan, Orthovisc, and Durolane. In the head-to-head trials, high-molecular-weight (MW) Hylan G-F 20 was consistently superior to low MW sodium hyaluronate preparations (Hyalgan, Supartz) up to 20 weeks, whereas one study reported that Durolane was noninferior to Supartz. Head-to-head trials comparing high versus medium MW preparations all used Hylan G-F 20 as the high MW preparation. Of the IAHA preparations with strong evidence of efficacy in placebo-controlled studies, Euflexxa was found to be noninferior to Hylan G-F 20. There are no direct comparisons to Monovisc. One additional IAHA preparation (ie, Synovial), which has not been assessed in placebo-controlled studies, was also noninferior to Hylan G-F 20. CONCLUSION: IAHA efficacy varies widely across preparations. High-quality studies are required to assess and compare the safety and efficacy of IAHA preparations.

Evaluation of Hylan G-F 20 Treatment with Opioid Prescriptions and Intraarticular Corticosteroid Injections in Patients with Osteoarthritis of the Knee Using a Claims Database.

OBJECTIVE: Assess how treatment with the viscosupplement hylan G-F 20 relates to opioid prescriptions and intraarticular corticosteroid injections (IACS) in patients with osteoarthritis of the knee (OAK). DESIGN: Case-crossover; adult patients with OAK identified in a claims database were treated with hylan G-F 20 from July 1, 2007, to June 29, 2017. Opioid or IACS prescriptions in the 6 months before treatment were compared to the 6 months after. Patients with comorbid conditions requiring pain medications were excluded, resulting in a 29,395-patient cohort. Four subgroups were investigated: patients with (1) opioids before hylan G-F 20 (OB; n = 6,609); (2) opioids before and after hylan G-F 20 (OBF; n = 3,320); (3) IACS before hylan G-F 20 (CB; n = 11,162); and (4) IACS before and after hylan G-F 20 (CBF; n = 2,810). All opioids were converted to morphine milligram equivalents (MME). RESULTS: OB subgroup patients had a significant decrease (P < 0.01) in total MME (-14.0%), MME per day (-14.2%) and opioid prescription days (-12.6%) after treatment versus before. Only 50.2% of patients prescribed opioids before hylan G-F 20 were prescribed an opioid after treatment. OBF subgroup patients had a significant increase (P < 0.01) in opioid prescription days (7.8%) before versus after treatment. There was a significant decrease (P < 0.01) in the number of IACS after versus before treatment for the Total Cohort (-56.1%), and subgroups CB (-72.6%) and CBF (-4.1%). A total of 74.8% of patients receiving an IACS before treatment did not receive an IACS after treatment. CONCLUSIONS: Hylan G-F 20 is associated with a reduction in opioid prescriptions and IACS in OAK patients.

Playing field issues in sports medicine.

The use of artificial turf on playing fields has increased in popularity. Advances in technology have allowed for the development of turf that closely mimics the properties of natural grass. Overall injury incidence does not differ between the two surfaces, but unique injury patterns are apparent between the two surfaces. Differences in shoe-surface interface, in-shoe foot loading patterns, and impact attenuation may provide insight into the different injury patterns. Player perceptions of artificial turf vary and may be related to different physiological demands between the two surfaces. Artificial turf has been implicated in skin infections, but concerns about other health consequences related to the synthetic materials have not been proven yet. Understanding the differences between artificial turf and natural grass will help physicians, athletic trainers, and coaches better care for and train their athletes.

Bone density in competitive cyclists.

To investigate current theories of the contributing factors to osteopenia/osteoporosis in competitive cyclists, we present a narrative review of published cross-sectional studies investigating plausible etiologies of decreased bone density in competitive cyclists. Aggregate from multiple published studies as cited. Bone mineral density in cyclists appears to be correlated positively to the cumulative amount of bone loading forces experienced over a lifetime. However, decreases in bone mineral density are noted over the short term if bone loading forces are removed, despite previous gains. There also appears to be a negative correlation between bone mineral density and dermal calcium losses during exercise. Data are mixed on whether calcium supplementation improves bone mineral density in this setting. No correlation was found between sex hormones and bone mineral density in the competitive cyclists studied. Knowledge of the underlying contributors to reduced bone mineral density in cyclists can aid in making preventative and therapeutic recommendations that potentially could decrease the morbidity and mortality related to osteoporosis.

Physical examination and magnetic resonance imaging in the diagnosis of superior labrum anterior-posterior lesions of the shoulder: a sensitivity analysis.

PURPOSE: The overall purpose of our study was to examine the sensitivity of physical examination, magnetic resonance imaging (MRI), and magnetic resonance (MR) arthrogram for the identification of arthroscopically confirmed SLAP lesions of the shoulder. METHODS: An analysis of 51 consecutive patients with arthroscopically confirmed SLAP lesions and no history of shoulder dislocation was performed. Before undergoing surgery, all patients underwent a standardized physical examination and had either an MRI and/or MR arthrogram performed. Sensitivity analysis was then performed on the results of both the physical examination maneuvers and the radiologic imaging compared to the arthroscopic findings at surgery. RESULTS: The sensitivity of O'Brien's (active compression) test was 90%, whereas the Mayo (dynamic) shear was 80% and Jobe's relocation test was 76%. The sensitivity of a physical examination with any 1 of these 3 SLAP provocative tests being positive was 100%. Neer's sign (41%) and Hawkin's impingement tests (31%) each had low sensitivity for SLAP lesions. The sensitivity of MRI for SLAP lesions was 67% when interpreted by the performing surgeon, 53% when read by a radiologist. When the MR arthrograms were analyzed alone, the sensitivity was 72% (surgeon) and 50% (radiologist), respectively. CONCLUSIONS: All 3 physical examination maneuvers traditionally considered provocative for SLAP pathology (O'Brien's, Mayo shear, and Jobe's relocation) were sensitive for the diagnosis of SLAP lesions. MRI and MR arthrogram imaging had lower sensitivity than these physical examination tests in diagnosing SLAP lesions. Patient history, demographics, and the surgeon's physical examination should remain central to the diagnosis of SLAP lesions. LEVEL OF EVIDENCE: Level II, development of diagnostic criteria on basis of consecutive patients with universally applied gold standard.

Ulnar collateral ligament reconstruction in major league baseball pitchers.

BACKGROUND: Ulnar collateral ligament reconstruction is commonly performed in major league pitchers, but little is known about pitching performance after a return to major league play. HYPOTHESIS: Pitching performance after ulnar collateral ligament reconstruction returns to baseline by the second season after surgery. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: Data were reviewed for 68 major league pitchers who pitched in at least 1 major league game before undergoing ulnar collateral ligament reconstruction between 1998 and 2003. Mean innings pitched per season, earned run average, and walks and hits per inning pitched were compared for each major league pitcher before and after surgery. All demographic and performance variables were analyzed for an association with ulnar collateral ligament insufficiency and a successful return to major league play. RESULTS: Fifty-six (82%) pitchers returned to major league play at a mean of 18.5 months after surgery with no significant change in mean earned run average or walks and hits per inning pitched. The mean innings pitched per season was not statistically different from controls by the second season after surgery. Starting pitchers demonstrated a higher risk of ulnar collateral ligament injury requiring reconstruction. More experienced pitchers and those with a higher earned run average were less likely to require ulnar collateral ligament reconstruction. No factors predictive of a successful return to play were identified. CONCLUSION: Most major league pitchers return from ulnar collateral ligament reconstruction by the second season after surgery with no statistical change in mean innings pitched, earned run average, or walks and hits per inning pitched from preinjury levels.

Convergence Insufficiency Identifies Athletes at Risk of Prolonged Recovery From Sport-Related Concussion.

BACKGROUND: Sensitive and specific screening methods are needed to identify athletes at risk of prolonged recovery after sport-related concussion (SRC). Convergence insufficiency (CI) is a common finding in concussed athletes. PURPOSE: To assess the relationship between CI and recovery after SRC at the initial office visit. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: In this retrospective cohort study, 270 athletes (147 male, 123 female), mean ± SD age 14.7 ± 2.0 years (range, 10-21 years), with the diagnosis of SRC who presented for initial office visit between January 2014 and January 2016 were evaluated for near point of convergence (NPC). The athletes were categorized into 2 groups: normal near point of convergence (NPC ≤6 cm), and convergence insufficiency (NPC >6 cm). These athletes were then followed to determine recovery time. RESULTS: Athletes presented for initial office visit at a mean of 5.2 ± 4.2 days (range, 1-21 days) after SRC. Half of the athletes had CI after SRC (50.4%; n = 136). Athletes with CI (NPC 12.3 ± 4.7 cm) took significantly longer to recover after SRC, requiring 51.6 ± 53.9 days, compared with athletes with normal NPC (4.1 ± 1.3 cm), who required 19.2 ± 14.7 days ( P < .001). After controlling for potential confounding variables, CI significantly increased the odds of prolonged recovery (≥28 days from injury) by 12.3-fold ( P < .001; 95% confidence interval, 6.6-23.0). CI screening correctly classified 75.2% of our sample with 84.2% sensitivity and 70.0% specificity. The positive predictive value for CI and prolonged recovery was 62.5%, and the negative predictive value was 88.1%. CONCLUSION: CI at the initial office visit identified athletes at increased risk of prolonged recovery after SCR. Clinicians should consider measuring NPC in concussed athletes as a quick and inexpensive prognostic screening method.

Baseline Time to Stabilization Identifies Anterior Cruciate Ligament Rupture Risk in Collegiate Athletes.

BACKGROUND: There is a need for successful screening methods to identify athletes at increased risk of anterior cruciate ligament (ACL) injury. Previous research showed that collegiate athletes with ACL tears demonstrated slower time to stabilization during jump landing after reconstruction. HYPOTHESIS: Collegiate athletes with baseline deficiencies in time to stabilization are at increased risk of subsequent ACL rupture. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 278 National Collegiate Athletic Association Division I college athletes (166 men, 112 women; mean age, 18.5 years; height, 178.8 cm; mass, 79.9 kg) in the high-risk sports of men's football; women's volleyball and field hockey; and men's and women's lacrosse, basketball, and soccer were measured to obtain baseline time to stabilization for backward, forward, medial, and lateral single-legged jump landing tasks. Athletes were followed for ACL rupture over a 4-year period. Independent t tests were used to evaluate differences in time to stabilization for each jump landing task between athletes with subsequent ACL rupture and uninjured athletes. Logistic regression models were used to assess time to stabilization as a predictor for ACL rupture. RESULTS: Nine athletes sustained noncontact ACL ruptures (5 men, 4 women). These 9 athletes took significantly longer to stabilize compared with uninjured athletes during baseline backward jump landing (1.58 ± 0.39 and 1.09 ± 0.52 seconds, respectively; P = .0052). The odds of ACL rupture increased 3-fold (odds ratio, 2.95; 95% CI, 1.28-6.77) for every second increase in backward time to stabilization observed between injured and uninjured athletes. CONCLUSION: Collegiate athletes with slower baseline backward time to stabilization were at increased risk of ACL rupture.

Acute injuries in track and field athletes: a 3-year observational study at the Penn Relays Carnival with epidemiology and medical coverage implications.

BACKGROUND: Few studies have examined acute injuries in track and field in both elite and subelite athletes. PURPOSE: To observe the absolute number and relative rates of injury in track and field athletes across a wide range of competition levels and ages during 3 years of the Penn Relays Carnival to assist with future medical coverage planning and injury prevention strategies. STUDY DESIGN: Descriptive epidemiology study. METHODS: Over a 3-year period, all injuries treated by the medical staff were recorded on a standardized injury report form. Absolute number of injuries and relative injury rates (number of injuries per 1000 competing athletes) were determined and odds ratios (ORs) of injury rates were calculated between sexes, competition levels, and events. Injuries were also broken down into major or minor medical or orthopaedic injuries. RESULTS: Throughout the study period, 48,473 competing athletes participated in the Penn Relays Carnival, and 436 injuries were sustained. For medical coverage purposes, the relative rate of injury subtypes was greatest for minor orthopaedic injuries (5.71 injuries per 1000 participants), followed by minor medical injuries (3.42 injuries per 1000 participants), major medical injuries (0.69 injuries per 1000 participants), and major orthopaedic injuries (0.18 injuries per 1000 participants). College/elite athletes displayed the lowest relative injury rate (7.99 injuries per 1000 participants), which was significantly less than that of high school (9.87 injuries per 1000 participants) and masters athletes (16.33 injuries per 1000 participants). Male athletes displayed a greater likelihood of having a minor orthopaedic injury compared with female athletes (OR, 1.36 [95% CI, 1.06-1.75]; χ2 = 5.73; P = .017) but were less likely to sustain a major medical injury (OR, 0.33 [95% CI, 0.15-0.75]; χ2 = 7.75; P = .005). Of the 3 most heavily participated in events, the 4 × 400-m relay displayed the greatest relative injury rate (13.6 injuries per 1000 participants) compared with the 4 × 100-m and 4 × 200-m relays. CONCLUSION: Medical coverage teams for future large-scale track and field events need to plan for at least 2 major orthopaedic and 7 major medical injuries per 10,000 participants. Male track and field athletes, particularly masters male athletes, are at greater risk of injury compared with other sexes and competition levels.

Sudden cardiac arrest and death in United States marathons.

PURPOSE: There is no reporting system for marathon-associated sudden cardiac arrest (SCA) or sudden cardiac death in the United States. The purpose of this study was to estimate and characterize the risk of marathon-related SCA to assist with emergency planning. METHODS: A retrospective Web-based survey was sent out to all US marathon medical directors (n = 400) to gather details of SCA including demographics, resuscitation efforts, mortality, and autopsy results, if available. RESULTS: A total of 88 surveys (22%) were returned from marathons run from 1976 to 2009 for a total of 1,710,052 participants. Risks of SCA and sudden cardiac death were 1 in 57,002 and 1 in 171,005, respectively. Men made up the vast majority of SCA victims (93%, mean age = 49.7 yr, range = 19-82 yr). Arrest site distributions were 0-5, 6-14, 15-22, and 23-26.2 miles. CAD was reported as the cause of death at autopsy in 7 of the 10 fatalities. An automated external defibrillator (AED) was used in 20/30 cases and associated with a higher survival (17/20 survivors vs 3/10 deaths, P = 0.0026). CONCLUSIONS: SCA occurs in approximately 1 in 57,000 marathon runners, is more common in older males, and usually occurs in the last 4 miles of the racecourse. Prompt resuscitation including early use of an AED improves survival. Emergency planning to include trained medical staff and sufficient AEDs throughout the racecourse is recommended.

Normative SF-36 values in competing NCAA intercollegiate athletes differ from values in the general population.

BACKGROUND: The Short Form-36 (SF-36) is a valid and reliable generic indicator of health status. The scoring distributions for the general and specific populations have been extensively reported in the literature and vary according to age, gender, the type and severity of a medical condition, and socioeconomic status. However, normative data pertaining specifically to athletic populations are limited. The purpose of the present study was to establish SF-36 reference norms for athletes cleared for participation in intercollegiate sports. METHODS: Six hundred and ninety-six United States National Collegiate Athletic Association Division-I and II student athletes who had been cleared for participation in intercollegiate sports completed the self-administered form of the SF-36 at the time of pre-participation evaluations. Demographic information and history of injuries were also recorded. RESULTS: Compared with the general population and an age-matched sample of the general population, the athletes scored significantly higher in all health domains (p < 0.01) except for bodily pain (p = 0.05). Among the athletes, men scored significantly higher than women in the general health domain only (p = 0.0006). Athletes with no reported history of injury scored significantly higher than those with previous injuries in all health domains, except in role limitations due to emotional problems. CONCLUSIONS: Intercollegiate athletes cleared for participation reported significantly higher SF-36 scores in comparison with a similarly aged sample of the general population. These normative values are important in the evaluation of health status of intercollegiate athletes before and after intervention.

Recurrent fracture after operative treatment for a tibial stress fracture.

We report a patient with a recurrent stress fracture and subsequent nonunion around an intramedullary nail placed for treatment of a more proximal, chronic tibial stress fracture. After 9 months of failed nonoperative treatment, we performed an exchange intramedullary nailing with open bone graft. At 8 months postoperatively, the patient showed clinical and radiographic signs of healing.