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Ross LK, Lalka A, Keeter C, Hamati MC, Robell K, Howell DR, Zona NE, Hunt KJ. Playing surface and sport contact status modulate time to lower extremity musculoskeletal injury at a greater level than concussion history among collegiate student-athletes. J ISAKOS 2024; 9:628-634. [PMID: 38925353 DOI: 10.1016/j.jisako.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 05/17/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES While previous investigations have demonstrated a positive correlation between previous concussion and risk of subsequent lower extremity musculoskeletal injury (LEMSKI), the effect of sport- and patient-specific factors on time to injury has not been thoroughly described. This study's main objective was to evaluate the relationship between prior concussion and time to LEMSKI among a population of collegiate student-athletes. Secondary objectives were to evaluate the relationship between playing surface, sport contact status, and biologic sex on time to LEMSKI. We hypothesized that those with previous concussions, those competing on synthetic surfaces, and those competing in collision sports would experience decreased latency to LEMSKI overall. METHODS A retrospective observational analysis of National Collegiate Athletic Association (NCAA) Division I student-athletes was conducted utilizing a mixed linear model analysis with contrasts. Inclusion criteria included participation in the Pac-12 Health Analytics Program with a documented LEMSKI between 2017 and 2020. Exclusion criteria included concurrent concussion and LEMSKI, injury resulting in serious morbidity or mortality, and incomplete medical record. Participants were classified by whether they sustained a concussion prior to LEMSKI in each athletic season. RESULTS Of 1179 athletes included, 1140 had no previous concussion and 37 had a previous concussion. There was no observed effect of previous concussion (F = 0.038; p = 0.846) on time to LEMSKI overall. Student-athletes competing on constructed surfaces sustained a subsequent LEMSKI 14.5 days sooner (SE = 5.255; p = 0.045), and those competing on organic surfaces sustained a subsequent LEMSKI 23.5 days sooner (SE = 4.018; p < 0.001) in the season than those competing on synthetic surfaces. Contact sport student-athletes sustained a subsequent LEMSKI 52.1 days sooner than collision sport student-athletes (SE = 5.248; p < 0.001), and limited contact sport student-athletes sustained a subsequent LEMSKI 42.29 days sooner than collision sport student-athletes (SE = 4.463; p < 0.001). There was no observed effect of biologic sex (F = 0.602; p = 0.438) on time to LEMSKI overall. CONCLUSION There was no observed impact of concussion on time on LEMSKI overall in this collegiate athletic population. Contact sports were associated with decreased time to LEMSK, while synthetic surfaces were associated with increased time to LEMSKI in this population. There was no observed impact of biologic sex on time to LEMSKI. LEVEL OF EVIDENCE Case-control, level of evidence III.
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Affiliation(s)
- Lexie K Ross
- Department of Orthopaedics, University of Colorado School of Medicine, 13001 E. 17th Place, Aurora, CO, 80045, USA.
| | - Andy Lalka
- Department of Orthopaedics, University of Colorado School of Medicine, 13001 E. 17th Place, Aurora, CO, 80045, USA.
| | - Carson Keeter
- Department of Orthopaedics, University of Colorado School of Medicine, 13001 E. 17th Place, Aurora, CO, 80045, USA.
| | - Mary C Hamati
- Department of Orthopaedics, University of Colorado School of Medicine, 13001 E. 17th Place, Aurora, CO, 80045, USA.
| | - Kevin Robell
- Pac-12 Health Analytics Program, 12457 Alcosta Blvd, San Ramon, CA, 94583, USA.
| | - David R Howell
- Department of Orthopaedics, University of Colorado School of Medicine, 13001 E. 17th Place, Aurora, CO, 80045, USA.
| | - Nathaniel E Zona
- Department of Orthopaedics, University of Colorado School of Medicine, 13001 E. 17th Place, Aurora, CO, 80045, USA
| | - Kenneth J Hunt
- Department of Orthopaedics, University of Colorado School of Medicine, 13001 E. 17th Place, Aurora, CO, 80045, USA.
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2
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Gardner CH, Kotlier JL, Fathi A, Castonguay J, Thompson AA, Bolia IK, Petrigliano FA, Liu JN, Weber AE, Gamradt SC. NCAA football players are at higher risk of upper extremity injury after first-time concussion. PHYSICIAN SPORTSMED 2024:1-5. [PMID: 38454779 DOI: 10.1080/00913847.2024.2327275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 03/04/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Previous research has demonstrated that concussions increase the risk of subsequent lower extremity musculoskeletal injury in athletes. However, the risk of upper extremity injury in athletes' post-concussion is poorly understood. METHODS All concussed football players within a National Collegiate Athletic Association (NCAA) Division I conference athletic database were identified between 2017 and 2021. After exclusions, each athlete experiencing their first concussion was then retrospectively reviewed for upper extremity injuries in the year prior to their concussion and in the year beginning at 90 days after their concussion. All upper extremity injuries were identified and the odds ratio, 95% confidence interval, and statistical significance between groups were calculated in Microsoft Excel. RESULTS 160 de-identified football players from a single conference who were first diagnosed with concussions in the seasons from 2017 through 2021 met inclusion criteria. In these athletes the odds of upper extremity injury in year following first diagnosed concussion were 2.36 times higher than in the year prior (95% CI 1.13-4.95, p = 0.02). Shoulder was the most common site of injury with 57.7% of injuries compared to 19.2% in the hand, 15.4% in the elbow, 7.7% in the forearm, and 0% in the wrist. CONCLUSION This study demonstrates that collegiate football players are at a 2.36 times greater risk of upper extremity injury in the year following their first diagnosed concussion compared to the year preceding it. The most common site of upper extremity injury after concussion was the shoulder. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Carson H Gardner
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Jacob L Kotlier
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Amir Fathi
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Justin Castonguay
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Ashley A Thompson
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Ioanna K Bolia
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Frank A Petrigliano
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Joseph N Liu
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Alexander E Weber
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Seth C Gamradt
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
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3
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Oldham JR, Bowman TG, Walton SR, Beidler E, Campbell TR, Smetana RM, Munce TA, Larson MJ, Cullum CM, Bushaw MA, Rosenblum DJ, Cifu DX, Resch JE. Sport Type and Risk of Subsequent Injury in Collegiate Athletes Following Concussion: a LIMBIC MATARS Consortium Investigation. Brain Inj 2024:1-9. [PMID: 38317302 DOI: 10.1080/02699052.2024.2310782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 01/23/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE To investigate the association between sport type (collision, contact, non-contact) and subsequent injury risk following concussion in collegiate athletes. MATERIALS AND METHODS This retrospective chart review of 248 collegiate athletes with diagnosed concussions (age: 20.0 ± 1.4 years; height: 179.6 ± 10.9 cm; mass: 79.0 ± 13.6 kg, 63% male) from NCAA athletic programs (n = 11) occurred between the 2015-2020 athletic seasons. Acute injuries that occurred within six months following concussion were evaluated. Subsequent injuries were grouped by lower extremity, upper extremity, trunk, or concussion. The independent variable was sport type: collision, contact, non-contact. A Cox proportional hazard model was used to assess the risk of subsequent injury between sport types. RESULTS Approximately 28% (70/248) of athletes sustained a subsequent acute injury within six months post-concussion. Collision sport athletes had a significantly higher risk of sustaining any injury (HR: 0.41, p < 0.001, 95% CI: 0.28, 0.62), lower extremity (HR: 0.55, p = 0.04, 95% CI: 0.32, 0.97), and upper extremity (HR: 0.41, p = 0.01, 95% CI: 0.20, 0.81) injuries following concussion. No differences between sport types were observed for other injuries. CONCLUSION Collision sport athletes had a higher rate of any subsequent injury, lower, and upper extremity injuries following concussion. Future research should focus on sport-specific secondary injury prevention efforts.
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Affiliation(s)
- Jessie R Oldham
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Thomas G Bowman
- Department of Athletic Training, College of Health Sciences, University of Lynchburg, Lynchburg, Virginia, USA
| | - Samuel R Walton
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Erica Beidler
- Department of Athletic Training, Duquesne University, Pittsburgh, Pennsylvania, USA
| | - Thomas R Campbell
- College of Health Sciences, Old Dominion University, Norfolk, Virginia, USA
| | - Racheal M Smetana
- Neuropsychology Assessment Clinic, University of Virginia Health, Charlottesville, Virginia, USA
| | - Thayne A Munce
- Environmental Influences on Health & Disease Group, Sanford Research, Sioux Falls, South Dakota, USA
| | - Michael J Larson
- Department of Psychology and Neuroscience Center, Brigham Young University, Provo, Utah, USA
| | - C Munro Cullum
- Departments of Psychiatry, Neurology, and Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Daniel J Rosenblum
- United States Navy, Virginia Beach, Virginia, USA
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia, USA
| | - David X Cifu
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Jacob E Resch
- United States Navy, Virginia Beach, Virginia, USA
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia, USA
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4
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Buckley TA, Chandran A, Mauntel TC, Kerr ZY, Brown DW, Boltz AJ, Herman DC, Hall EE, Lynall RC. Lower Extremity Musculoskeletal Injuries After Concussion in Collegiate Student-Athletes. Am J Sports Med 2023; 51:511-519. [PMID: 36255302 DOI: 10.1177/03635465221125155] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND An association has been identified between concussion and lower extremity musculoskeletal injury (LEMSKI) after return to sports participation. However, the collegiate student-athlete studies have relied on relatively small single-institution studies, which limits generalizability. PURPOSE To assess odds of, and time to, LEMSKI after concussion in US collegiate athletes, using the National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP). STUDY DESIGN Descriptive epidemiology study. METHODS Data from the NCAA ISP during the 2010-2011 through 2019-2020 athletic seasons were considered for analysis. Frequency distributions were examined for details related to the initial and subsequent injuries (injuries to bone, bursa, joint, ligament, muscle, or tendon). Multivariable logistic regression models and random-effects Poisson regression models examined odds of time loss (TL) and non-time loss (NTL) LEMSKI after concussion, as well as the time interval between initial concussion and subsequent LEMSKI in a single athletic season, or initial musculoskeletal injury (MSKI) and subsequent LEMSKI in a single athletic season. Analyses were performed separately for football and other sports. RESULTS A total of 31,556 initial injuries were recorded (football: 11,900; other sports: 19,656), which were followed by 0 or 1 injury in the same season. Overall, first injury type was not a significant predictor of subsequent LEMSKI, although certain contrasts yielded significant estimates. In football, the odds of NTL LEMSKI were higher after concussion than after upper extremity MSKI (UEMSKI; adjusted odds ratio [ORAdj], 1.56; 95% CI, 1.06-2.31). In football, the odds of TL LEMSKI were lower after concussion than after UEMSKI (ORAdj, 0.71; 95% CI, 0.51-0.99). No other significant effect estimates were observed for football or other sports. CONCLUSION First injury type, either concussion or upper extremity, was not associated with an elevated risk of LEMSKI. Specifically, the results of this study did not identify an elevated odds of LEMSKI after a concussion. However, the authors observed greater odds of NTL LEMSKI and lower odds of TL LEMSKI in football.
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Affiliation(s)
- Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA.,Biomechanics and Movement Science Interdisciplinary Program, University of Delaware, Newark, Delaware, USA
| | - Avinash Chandran
- Datalys Center for Sports Injury Research and Prevention Inc, Indianapolis, Indiana, USA
| | - Timothy C Mauntel
- DoD-VA Extremity Trauma & Amputation Center of Excellence, Womack Army Medical Center, Fort Bragg, North Carolina, USA
| | - Zachary Yukio Kerr
- Department of Exercise and Sport Science, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Derek W Brown
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Adrian J Boltz
- Michigan Concussion Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel C Herman
- Department of Physical Medicine and Rehabilitation, University of California, Davis, Davis, California, USA
| | - Eric E Hall
- Department of Exercise Science, Elon University, Elon, North Carolina, USA
| | - Robert C Lynall
- Department of Kinesiology, University of Georgia, Athens, Georgia, USA
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5
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Reyes MA, Probasco MO, Worby TN, Loertscher DE, Soderbeck LK, Huddleston WE. Lower Kinetic Chain, Meet the Thinking Brain: A Scoping Review of Cognitive Function and Lower Extremity Injury Risk. Int J Sports Phys Ther 2022; 17:787-815. [PMID: 35949381 PMCID: PMC9340845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 05/04/2022] [Indexed: 12/04/2022] Open
Abstract
The classic model of non-contact ACL injury includes environmental, anatomical, hormonal and biomechanical risk factors which directly impact either the amount of stress placed on the ligament or the relative capacity of ligament to withstand the forces placed on it. However, cognition also clearly plays a role in successful athletic performance, yet diminished cognitive function is rarely considered a risk factor for injury. Objective To examine the existing literature to determine the extent to which cognitive function (both cognitive ability and task cognitive load) influences non-contact lower extremity injury risk in male and female athletes with a broad variety of athletic expertise. Study Design Scoping Review. Methods An electronic search was conducted of CINAHL, SPORTDiscus, Google Scholar, and MEDLINE using the PRISMA method. Search terms included Boolean combinations of "cognition", "concussion", "ImPACT", "cognitive deficit", "mild traumatic brain injury (mTBI)", and "neuropsychological function" as cognitive descriptors and the terms "injury risk" and "lower extremity injury" as injury descriptors. Inclusion criteria included papers written in English published between 2000-2021. Exclusion criteria included neurological and cognitively atypical populations, except for concussion (included). Included articles were appraised using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results Fifty-six studies utilizing across the spectrum of levels of evidence met inclusion criteria. Forty-one articles had good, fourteen had fair, and one had poor methodological quality. Studies examined baseline cognitive function in healthy athletes (n=7); performance during dual-task paradigms (n=13); and the impact of concussion on dual-task performance (n=4), LE injury risk (n=22), or post-concussion testing (n=10). Six articles examining cognitive function and all dual-task studies (including concussion studies) found altered biomechanics associated with injury or increased processing demands. Studies related to concussion and injury incidence consistently found an increased risk of LE injury following concussion. Half of the studies that examined concussion and post-concussion cognitive testing demonstrated significant effects. Discussion Consistent across participant demographics, tasks, and dependent measures, fifty-one of fifty-six assessed articles concluded that decreased cognitive ability or increased cognitive load led to risky LE mechanics or a direct increase in non-contact LE injury risk. Conclusion The robustness of results across gender, performance level, sport, cognitive ability, task cognitive load suggest that the inclusion of cognitive training in the design of optimal LE injury prevention programs warrants further study. Level of Evidence: Ia.
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Affiliation(s)
- Michaela A Reyes
- Rehabilitation Sciences & Technology, University of Wisconsin - Milwaukee
| | - Mark O Probasco
- Rehabilitation Sciences & Technology, University of Wisconsin - Milwaukee
| | - Trina N Worby
- Rehabilitation Sciences & Technology, University of Wisconsin - Milwaukee
| | - Dylan E Loertscher
- Rehabilitation Sciences & Technology, University of Wisconsin - Milwaukee
| | | | - Wendy E Huddleston
- Rehabilitation Sciences & Technology, University of Wisconsin - Milwaukee
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6
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McCann R, Schussler E, Martinez J, Ramirez V. The Effect of Concussion History on Lower Extremity Injury Risk in College Athletes: A Systematic Review and Meta-Analysis. Int J Sports Phys Ther 2022; 17:753-765. [PMID: 35949388 PMCID: PMC9340842 DOI: 10.26603/001c.36810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 04/26/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Collegiate athletes who suffer a concussion may possess prolonged impairments even after clearance for return-to-participation, which may place them at an increased risk of lower extremity injury. Objective To conduct a systematic review and meta-analysis of studies examining risk of lower extremity musculoskeletal injury following a concussion in collegiate athletes. Methods A literature search was performed using the following databases: PubMed, CINAHL, SPORTDiscus. The following search terms were used to identify relevant articles, ["concussion" OR "brain injury" OR "mild traumatic brain injury" OR "mTBI"] AND ["lower extremity injury" OR "musculoskeletal injury"]. Articles were included if they were published between January 2000 and July 2021 and examined collegiate athletes' risk of sustaining a lower extremity musculoskeletal injury following a concussion. Methodological quality of included studies was performed with a modified Downs and Black Checklist. The primary outcome of interest was the risk of sustaining a lower extremity musculoskeletal injury following a concussion. A random effects meta-analysis was conducted in which a summative relative risk (RR) for sustaining a lower extremity injury in athletes with and without a history of concussion was calculated. Results Seven studies met the eligibility criteria to be included in the systematic review. There were 348 athletes in the concussion group and 482 control athletes in the included studies. Most of the studies were of good or excellent quality. Five of the seven studies were able to be included in the meta-analysis. College athletes who suffered a concussion possessed a 58% greater risk of sustaining a lower extremity musculoskeletal injury than those who did not have a history of a concussion (RR = 1.58[1.30, 1.93]). Conclusions Lower extremity injury risk is potentially increased in college athletes following a concussion compared to those without a history of a concussion. Further research is needed to investigate the mechanism behind this increased risk. Clinical assessments throughout the concussion return-to-play protocol may need to be improved in order to detect lingering impairments caused by concussions. Level of Evidence 1.
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Affiliation(s)
- Ryan McCann
- Rehabilitation Sciences, Old Dominion University
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7
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Buckley TA, Browne S, Hunzinger KJ, Kaminski TW, Swanik CB. Concussion is not associated with elevated rates of lower-extremity musculoskeletal injuries in National Football League Players. PHYSICIAN SPORTSMED 2022:1-6. [PMID: 35591786 DOI: 10.1080/00913847.2022.2080515] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Emerging evidence has identified an ~2x elevated risk of musculoskeletal (MSK) injury in the year following a concussion. Most of these studies have examined a single college/university athletic department and may lack generalizability to professional sports. Therefore, the purpose of this study was to assess the odds of post-concussion MSK injury utilizing publicly available National Football League (NFL) injury reports. METHODS Concussions were identified through a review of published NFL injury reports during the 2015, 2016, and 2017 regular seasons. Concussed players were matched by team and position, and injuries were tracked for both groups for the remainder of the season. A chi-square analysis compared the frequency of MSK injury in both groups and a Cox Proportional Hazard model calculated the risk of sustaining a subsequent MSK injury. RESULTS There were 322 concussed NFL players who met inclusion criteria and were successfully matched. From the time of concussion through the remainder of the season, 21.4% of the concussed players were injured and 26.4% of control participants were injured. There was no difference in MSK injury rates (p = 0.166), and the relative risk ratio was 0.90 for subsequent injury in the concussion group. There was no difference in the time to event for subsequent MSK between the two groups (p = 0.123). CONCLUSION The primary finding of this study was no elevated risk of post-concussion MSK in NFL football players.
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Affiliation(s)
- Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA.,Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware, Newark, DE, USA
| | - Steven Browne
- Department of Intercollegiate Athletics, University of Delaware, Newark, DE, USA
| | - Katherine J Hunzinger
- Department of Epidemiology, Biostatistics, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Thomas W Kaminski
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA.,Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware, Newark, DE, USA
| | - Charles Buz Swanik
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA.,Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware, Newark, DE, USA
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8
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Jildeh TR, Castle JP, Buckley PJ, Abbas MJ, Hegde Y, Okoroha KR. Lower Extremity Injury After Return to Sports From Concussion: A Systematic Review. Orthop J Sports Med 2022; 10:23259671211068438. [PMID: 35111864 PMCID: PMC8801663 DOI: 10.1177/23259671211068438] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/25/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Recent studies have suggested increased rates of lower extremity (LE) musculoskeletal injury after a diagnosed concussion, although significant heterogeneity exists. Purpose: To examine the current body of research and determine whether there is an increased risk for LE musculoskeletal injury after a concussion and to identify populations at an increased risk. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review of current literature using MEDLINE and PubMed databases was performed. Keywords included concussion, athlete, lower extremity injury, and return to sport. Inclusion criteria required original research articles written in the English language examining the rate of LE injuries after a diagnosed concussion. Results: A total of 13 studies involving 4349 athletes (88.1% male and 11.9% female; mean age, 19.8 years) met inclusion criteria. Athletes were classified as high school (46.1%), collegiate (17.0%), or professional (36.9%). Of the 13 studies, 4 demonstrated an increased risk of LE injury within 90 days of a diagnosed concussion (odds ratio [OR], 3.44; 95% CI, 2.99-4.42), and 6 revealed an elevated risk of injury within 1 year of concussion (OR, 1.85; 95% CI, 1.73-2.84). Increased risk was seen in professional (OR, 2.49; 95% CI, 2.40-2.72) and collegiate (OR, 2.00; 95% CI, 1.96-2.16) athletes compared with high school athletes (OR, 0.97; 95% CI, 0.89-1.05). A stepwise increase in risk of sustaining an LE injury was observed with multiple concussions, with increasing risk observed from ≥2 (OR, 2.29; 95% CI, 1.85-2.83) to ≥3 (OR, 2.86; 95% CI, 2.36-3.48) career concussions. Conclusion: An increased incidence of LE injuries was observed at 90 days and 1 year after the diagnosis of a concussion. Higher levels of competition, such as at the collegiate and professional levels, resulted in an increased risk of sustaining a subsequent LE injury after a diagnosed concussion. These results suggest an at-risk population who may benefit from injury prevention methods after a concussion. Future studies should focus on identifying which injuries are most common, during what time period athletes are most vulnerable, and methods to prevent injury after return to sports.
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Affiliation(s)
- Toufic R. Jildeh
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Joshua P. Castle
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Patrick J. Buckley
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Muhammad J. Abbas
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Yash Hegde
- Michigan State University College of Human Medicine, East Lansing, Michigan, USA
| | - Kelechi R. Okoroha
- Division of Sports Medicine, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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9
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Avedesian JM, Covassin T, Dufek JS. The Influence of Sport-Related Concussion on Lower Extremity Injury Risk: A Review of Current Return-to-Play Practices and Clinical Implications. INTERNATIONAL JOURNAL OF EXERCISE SCIENCE 2020; 13:873-889. [PMID: 32922630 PMCID: PMC7449327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Sport-related concussions (SRCs) are now classified as a major health concern affecting athletes across all sporting levels, with recent evidence suggesting upwards of 3.8 million SRCs occur each year. Multiple injury surveillance datasets have recently determined that athletes post-SRC, compared to non-concussed counterparts, are at greater risk for lower extremity (LE) injury beyond the resolution of traditional SRC assessment batteries. However, it is presently uncertain if common clinical practices (symptom reporting, neuropsychological (NP) examination, and static postural control analysis) can determine athletes at risk for LE injury following an SRC. A comprehensive review of the literature determined that these tools may not reveal subtle cognitive and neuromuscular deficits that lead to subsequent LE injury during dynamic sporting tasks. Current return-to-play (RTP) protocols should consider clarifying the addition of specific objective locomotor analysis, such as gait tasks and sport-specific maneuvers, to determine the risk of LE injury after an athlete has sustained an SRC.
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Affiliation(s)
- Jason M Avedesian
- Department of Kinesiology and Nutrition Sciences, University of Nevada, Las Vegas, NV, USA
| | - Tracey Covassin
- Department of Kinesiology, Michigan State University, East Lansing, MI, USA
| | - Janet S Dufek
- Department of Kinesiology and Nutrition Sciences, University of Nevada, Las Vegas, NV, USA
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10
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Lynall RC, Campbell KR, Mauntel TC, Blackburn JT, Mihalik JP. Single-Legged Hop and Single-Legged Squat Balance Performance in Recreational Athletes With a History of Concussion. J Athl Train 2020; 55:488-493. [PMID: 32216655 DOI: 10.4085/1062-6050-185-19] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Researchers have suggested that balance deficiencies may linger during functional activities after concussion recovery. OBJECTIVE To determine whether participants with a history of concussion demonstrated dynamic balance deficits as compared with control participants during single-legged hops and single-legged squats. DESIGN Cross-sectional study. SETTING Laboratory. PATIENTS OR OTHER PARTICIPANTS A total of 15 previously concussed participants (6 men, 9 women; age = 19.7 ± 0.9 years, height = 169.2 ± 9.4 cm, mass = 66.0 ± 12.8 kg, median time since concussion = 126 days [range = 28-432 days]) were matched with 15 control participants (6 men, 9 women; age = 19.7 ± 1.6 years, height = 172.3 ± 10.8 cm, mass = 71.0 ± 10.4 kg). INTERVENTION(S) During single-legged hops, participants jumped off a 30-cm box placed at 50% of their height behind a force plate, landed on a single limb, and attempted to achieve a stable position as quickly as possible. Participants performed single-legged squats while standing on a force plate. MAIN OUTCOME MEASURE(S) Time to stabilization (TTS; time for the normalized ground reaction force to stabilize after landing) was calculated during the single-legged hop, and center-of-pressure path and speed were calculated during single-legged squats. Groups were compared using analysis of covariance, controlling for average days since concussion. RESULTS The concussion group demonstrated a longer TTS than the control group during the single-legged hop on the nondominant leg (mean difference = 0.35 seconds [95% confidence interval = 0.04, 0.64]; F2,27 = 5.69, P = .02). No TTS differences were observed for the dominant leg (F2,27 = 0.64, P = .43). No group differences were present for the single-legged squat on either leg (P ≥ .11). CONCLUSIONS Dynamic balance-control deficits after concussion may contribute to an increased musculoskeletal injury risk. Given our findings, we suggest that neuromuscular deficits currently not assessed after concussion may linger. Time to stabilization is a clinically applicable measure that has been used to distinguish patients with various pathologic conditions, such as chronic ankle instability and anterior cruciate ligament reconstruction, from healthy control participants. Whereas the single-legged squat may not sufficiently challenge balance control, future study of the more dynamic single-legged hop is needed to determine its potential diagnostic and prognostic value after concussion.
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Affiliation(s)
- Robert C Lynall
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens
| | - Kody R Campbell
- Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill
| | - Timothy C Mauntel
- US Department of Defense-Veterans Affairs Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - J Troy Blackburn
- Human Movement Science Curriculum, Division of Allied Health Sciences, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill
| | - Jason P Mihalik
- Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill
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Harada GK, Rugg CM, Arshi A, Vail J, Hame SL. Multiple Concussions Increase Odds and Rate of Lower Extremity Injury in National Collegiate Athletic Association Athletes After Return to Play. Am J Sports Med 2019; 47:3256-3262. [PMID: 31513431 DOI: 10.1177/0363546519872502] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Concussion in collegiate athletics is one of the most prevalent sport-related injuries in the United States, with recent studies suggesting persistent deficits in neuromuscular control after a concussion and an associated increase in risk of lower extremity injury. PURPOSE To expand on the relationship between concussion and lower extremity injury by examining the effect of multiple concussions (MC) on rate and odds of future lower extremity injury in collegiate athletes after return to play (RTP) compared with matched controls. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS From 2001 to 2016, 48 National Collegiate Athletic Association Division I athletes sustaining multiple concussions at a single institution were identified. Athletes with multiple concussions (MC) were matched directly to athletes with a single concussion (SC) and to athletes with no concussion history (NC) by sex, sport, position, and games played. Incidence of, time to, and location of lower extremity injury were recorded for each group after RTP from their first reported concussion until completion of their collegiate career. Logistic regression was used to analyze odds ratios (ORs) for sustaining lower extremity injury, whereas time to injury was summarized by use of Kaplan-Meier curves and log rank test analysis. RESULTS The incidence of lower extremity injury after RTP was significantly greater (P = .049) in the MC cohort (36/48, 75%) than in SC athletes (25/48 = 52%) and NC athletes (27/48 = 56%). Similarly, odds of lower extremity injury were significantly greater in the MC cohort than in SC athletes (OR, 3.00; 95% CI, 1.26-7.12; P = .01) and NC athletes (OR, 1.66; 95% CI, 1.07-2.56; P = .02). Time to lower extremity injury was significantly shorter in the MC group compared with matched controls (P = .01). No difference was found in odds of lower extremity injury or time to lower extremity injury between SC and NC athletes. CONCLUSION Collegiate athletes with MC were more likely to sustain a lower extremity injury after RTP in a shorter time frame than were the matched SC and NC athletes. This may suggest the presence of a cohort more susceptible to neuromuscular deficits after concussion or more injury prone due to player behavior, and it may imply the need for more stringent RTP protocols for athletes experiencing MC.
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Affiliation(s)
- Garrett K Harada
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Caitlin M Rugg
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Armin Arshi
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Jeremy Vail
- Department of Athletics, University of California, Los Angeles, Los Angeles, California, USA
| | - Sharon L Hame
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
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History of concussion and risk of subsequent injury in athletes and service members: A systematic review and meta-analysis. Musculoskelet Sci Pract 2019; 42:173-185. [PMID: 31014921 DOI: 10.1016/j.msksp.2019.04.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/28/2019] [Accepted: 04/09/2019] [Indexed: 12/13/2022]
Abstract
Risk of secondary injury after a primary concussion in sports and military contexts is an emerging area of interest in research. The purpose of this review was to provide an evidence synthesis describing risk of injury in athletic and military populations with and without a history of concussion. Electronic database searches were completed through September 7, 2018 in PubMed, EMBASE, CINAHL and SCOPUS. Peer-reviewed observational studies of any design with participants who were athletes or service members; measured the outcome of any type of injury; and compared injury between those with and without a history of concussion were included. Risk of bias was assessed using the Q-Coh II. Twenty-seven articles were included. Seventeen meta-analyses were completed for risk of any injury, risk of concussion, and risk of extremity injury using odds, hazard, and rate ratios. The results indicate significantly increased odds of all injuries (OR = 2.55; 95%CI 1.85,3.52); concussion (OR = 3.73; 95%CI 2.41,5.78); and lower extremity injuries (OR = 1.60; 95%CI 1.32,1.94) in those with a history of concussion compared to those without. Additional analyses reveal this increased risk is apparent when looking at time to event data and rate of injury based on number of exposures. While the reasons for the increased incidence of secondary injury associated with a concussion are not yet understood, there are potentially behavioral attributes and motor control deficits that contribute. It is suggested that research is needed to determine if active therapeutic treatment for disturbances in sensorimotor and neuromotor control after concussion could attenuate the increased risk for injury.
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