Concussion-Recovery Trajectories Among Tactical Athletes: Results From the CARE Consortium.

CONTEXT: Assessments of the duration of concussion recovery have primarily been limited to sport-related concussions and male contact sports. Furthermore, whereas durations of symptoms and return-to-activity (RTA) protocols encompass total recovery, the trajectory of each duration has not been examined separately. OBJECTIVE: To identify individual (eg, demographics, medical history), initial concussion injury (eg, symptoms), and external (eg, site) factors associated with symptom duration and RTA-protocol duration after concussion. DESIGN: Cohort study. SETTING: Three US military service academies. PATIENTS OR OTHER PARTICIPANTS: A total of 10 604 cadets at participating US military service academies enrolled in the study and completed a baseline evaluation and up to 5 postinjury evaluations. A total of 726 cadets (451 men, 275 women) sustained concussions during the study period. MAIN OUTCOME MEASURE(S): Number of days from injury (1) until the participant became asymptomatic and (2) to complete the RTA protocol. RESULTS: Varsity athlete cadets took less time than nonvarsity cadets to become asymptomatic (hazard ratio [HR] = 1.75, 95% confidence interval = 1.38, 2.23). Cadets who reported less symptom severity on the Sport Concussion Assessment Tool, third edition (SCAT3), within 48 hours of concussion had 1.45 to 3.77 times shorter symptom-recovery durations than those with more symptom severity. Similar to symptom duration, varsity status was associated with a shorter RTA-protocol duration (HR = 1.74, 95% confidence interval = 1.34, 2.25), and less symptom severity on the SCAT3 was associated with a shorter RTA-protocol duration (HR range = 1.31 to 1.47). The academy that the cadet attended was associated with the RTA-protocol duration (P < .05). CONCLUSIONS: The initial total number of symptoms reported and varsity athlete status were strongly associated with symptom and RTA-protocol durations. These findings suggested that external (varsity status and academy) and injury (symptom burden) factors influenced the time until RTA.

Reconsidering Return-to-Play Times: A Broader Perspective on Concussion Recovery.

BACKGROUND: Return-to-play protocols describe stepwise, graduated recoveries for safe return from concussion; however, studies that comprehensively track return-to-play time are expensive to administer and heavily sampled from elite male contact-sport athletes. PURPOSE: To retrospectively assess probable recovery time for collegiate patients to return to play after concussion, especially for understudied populations, such as women and nonelite athletes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Medical staff at a military academy logged a total of 512 concussion medical records over 38 months. Of these, 414 records included complete return-to-play protocols with return-to-play time, sex, athletic status, cause, and other data. RESULTS: Overall mean return to play was 29.4 days. Sex and athletic status both affected return-to-play time. Men showed significantly shorter return to play than women, taking 24.7 days (SEM, 1.5 days) versus 35.5 days (SEM, 2.7 days) (P < .001). Intercollegiate athletes also reported quicker return-to-play times than nonintercollegiate athletes: 25.4 days (SEM, 2.6 days) versus 34.7 days (SEM, 1.6 days) (P = .002). These variables did not significantly interact. CONCLUSION: Mean recovery time across all groups (29.4 days) showed considerably longer return to play than the most commonly cited concussion recovery time window (7-10 days) for collegiate athletes. Understudied groups, such as women and nonelite athletes, demonstrated notably longer recovery times. The diversity of this sample population was associated with longer return-to-play times; it is unclear how other population-specific factors may have contributed. These inclusive return-to-play windows may indicate longer recovery times outside the population of elite athletes.

Successful Return to Sport After Arthroscopic Shoulder Stabilization Versus Nonoperative Management in Contact Athletes With Anterior Shoulder Instability: A Prospective Multicenter Study.

BACKGROUND: The debate continues regarding the optimal treatment of intercollegiate contact athletes with in-season anterior shoulder instability. PURPOSE: To examine return to sport and recurrent instability in the season after the index in-season anterior instability event. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Forty-five contact intercollegiate athletes treated nonoperatively or with arthroscopic stabilization were prospectively followed in a multicenter observational study to evaluate return to play (RTP) and recurrent instability in the season after an initial in-season anterior glenohumeral instability event. Baseline data collection included sport played, previous instability events, direction of instability, type of instability (subluxation or dislocation), and treatment method (nonoperative management or arthroscopic stabilization). All nonoperatively treated athletes underwent a standardized accelerated rehabilitation program without shoulder immobilization. Surgical stabilization was performed arthroscopically in all cases, and successful RTP was evaluated during the next competitive season after complete rehabilitation. RESULTS: Thirty-nine of 45 intercollegiate contact athletes had remaining National Collegiate Athletic Association eligibility and were followed through the subsequent competitive season after the index instability event. Of the 10 athletes electing nonoperative treatment, 4 (40%) successfully returned to play without recurrence during the subsequent season. Of the 29 athletes treated surgically, 26 (90%) were able to successfully return to play without recurrence the following season (recurrence: n = 1; inadequate function: n = 2). Athletes who underwent surgical reconstruction before the next season were 5.8 times (95% CI, 1.77-18.97; P = .004) more likely to complete the subsequent season without recurrent instability. Of the 29 athletes electing surgical stabilization, there was no difference (risk ratio, 0.95; 95% CI, 0.10-9.24; P > .99) in RTP between the 9 stabilized after a single instability event (90% RTP rate) and the 20 stabilized after multiple in-season recurrent instability events (89% RTP rate). CONCLUSION: Collegiate contact and collision athletes with in-season anterior shoulder instability are significantly more likely to successfully return to sport without subsequent instability events the next season if they undergo surgical repair in the off-season.

Return to play and recurrent instability after in-season anterior shoulder instability: a prospective multicenter study.

BACKGROUND: There is no consensus on the optimal treatment of in-season athletes with anterior shoulder instability, and limited data are available to guide return to play. PURPOSE: To examine the likelihood of return to sport and the recurrence of instability after an in-season anterior shoulder instability event based on the type of instability (subluxation vs dislocation). Additionally, injury factors and patient-reported outcome scores administered at the time of injury were evaluated to assess the predictability of eventual successful return to sport and time to return to sport during the competitive season. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: Over 2 academic years, 45 contact intercollegiate athletes were prospectively enrolled in a multicenter observational study to assess return to play after in-season anterior glenohumeral instability. Baseline data collection included shoulder injury characteristics and shoulder-specific patient-reported outcome scores at the time of injury. All athletes underwent an accelerated rehabilitation program without shoulder immobilization and were followed during their competitive season to assess the success of return to play and recurrent instability. RESULTS: Thirty-three of 45 (73%) athletes returned to sport for either all or part of the season after a median 5 days lost from competition (interquartile range, 13). Twelve athletes (27%) successfully completed the season without recurrence. Twenty-one athletes (64%) returned to in-season play and had subsequent recurrent instability including 11 recurrent dislocations and 10 recurrent subluxations. Of the 33 athletes returning to in-season sport after an instability event, 67% (22/33) completed the season. Athletes with a subluxation were 5.3 times more likely (odds ratio [OR], 5.32; 95% CI, 1.00-28.07; P = .049) to return to sport during the same season when compared with those with dislocations. Logistic regression analysis suggests that the Western Ontario Shoulder Instability Index (OR, 1.05; 95% CI, 1.00-1.09; P = .037) and Simple Shoulder Test (OR, 1.03; 95% CI, 1.00-1.05; P = .044) administered after the initial instability event are predictive of the ability to return to play. Time loss from sport after a shoulder instability event was most strongly and inversely correlated with the Simple Shoulder Test (P = .007) at the time of initial injury. CONCLUSION: In the largest prospective study evaluating shoulder instability in in-season contact athletes, 27% of athletes returned to play and completed the season without subsequent instability. While the majority of athletes who return to sport complete the season, recurrent instability events are common regardless of whether the initial injury was a subluxation or dislocation.

Fractures of the thoracolumbar spine sustained by soldiers in vehicles attacked by improvised explosive devices.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To analyze the types of orthopedic spine fractures sustained by North Atlantic Treaty Organization soldiers when vehicles are attacked by improvised explosive devices (IEDs), with specific focus on the flexion-distraction type thoracolumbar fracture (Chance fracture). SUMMARY OF BACKGROUND DATA: Operation Enduring Freedom is the North Atlantic Treaty Organization's effort in Afghanistan. IED attacks on armored vehicles are common and account for high proportion of soldiers' deaths and injuries. METHODS: Retrospective record review was accomplished on soldiers admitted to a military hospital with orthopedic spine fractures after IED attacks on vehicles from January 1, 2008 to May 15, 2008. Thoracolumbar fractures were classified using the McAfee classification system. RESULTS: Twelve male patients with 16 thoracolumbar fractures were identified (3 patients with multiple fractures). The 16 thoracolumbar fractures included 6 flexion-distraction fractures in 5 patients (38%, 6/16: two T12, two L1, one L3, and one L4), 7 compression fractures in 5 patients (44%, 5/16; one T7, one T8, two L1, one L2, one L3, and one L4), and 3 burst fractures (19%, 3/16; two L1 and one L2). CONCLUSION: The incidence of flexion-distraction thoracolumbar (Chance) fractures has been reported to be between 1.0% and 2.5% in most spine fracture series. In this small study, Chance fractures represented 38% of all tho-racolumbar fractures sustained after IED attack on armored vehicles. The blast pattern associated with IED explosion may be responsible for the high rate of these injuries in vehicle occupants.

Arthroscopic evaluation of radiofrequency chondroplasty of the knee.

BACKGROUND: Considerable debate exists over the use of radiofrequency-based chondroplasty to treat partial-thickness chondral defects of the knee. This study used second-look arthroscopy to evaluate cartilage defects previously treated with bipolar radiofrequency-based chondroplasty. HYPOTHESIS: Partial-thickness articular cartilage lesions treated with bipolar radiofrequency-based chondroplasty will show no progressive deterioration. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: One hundred ninety-three consecutive patients underwent bipolar radiofrequency-based chondroplasty over 38 months; 15 (25 defects treated with bipolar radiofrequency-based chondroplasty) underwent repeat arthroscopy for recurrent or new injuries. Time from the initial to repeat arthroscopy ranged from 0.7 to 32.7 months. At both procedures, the location, size, grade, and stability of lesions were evaluated, recorded, and photographed arthroscopically. RESULTS: At the initial procedure, 25 lesions treated using bipolar radiofrequency-based chondroplasty ranged from 9 to 625 mm2 (mean, 170.2 +/- 131.2 mm2; median, 120 mm2); at second look, lesion size was 9 to 300 mm2 (mean, 107.7 +/- 106.7 mm2; median, 100 mm2). At second look, 3 (12%) demonstrated unstable borders with damage in the surrounding cartilage that appeared to be progressive. Eight (32%) lesions were unchanged in size. Eight (32%) demonstrated partial filling with stable repair tissue, and 6 (24%) demonstrated complete filling with stable repair tissue. Lesions in the tibiofemoral compartments showed better response to radiofrequency chondroplasty than did those within the patellofemoral joint (P < .05). CONCLUSION: Only 3 of 25 lesions demonstrated progression. More than 50% showed partial or complete filling of the defect. Bipolar radiofrequency chondroplasty is an effective way to treat partial-thickness cartilage lesions; however, long-term effects of this treatment on cartilage remain unknown.