Athletic trainers are increasingly used in nontraditional settings, such as in law enforcement, where they can contribute to healthcare management, including concussion management of law enforcement officers (LEOs). Despite the prevalence of concussions among LEOs, there is a notable gap in concussion management guidelines for this population. LEOs may lack the education and resources necessary for concussion recognition and proper management. Drawing on advancements in concussion management in athletes and military personnel, here, we present a comprehensive framework for concussion management in LEOs encompassing concussion education, a graduated return-to-duty protocol, and considerations for implementation and documentation specific to law enforcement. We also present several barriers and facilitators to implementation. Due to job requirements, it is critical for law enforcement organizations and their medical providers to adopt a concussion management strategy. Without proper concussion management, LEOs may risk subsequent injury and/or suffer from prolonged recovery and adverse long-term outcomes.
Underreporting of concussion symptoms in college athletics presents a challenge for sports medicine clinicians in evaluating and diagnosing such injuries. Some athletes do not report concussion symptoms because they do not recognize that they have a brain injury; however, many athletes intentionally withhold symptoms to avoid removal from sport participation. To examine individual factors that influence college athletes’ intentions to report concussion symptoms. Cross-sectional study. Collegiate athletics. Participants were 2649 student-athletes from 23 sports, across 22 colleges and universities. The primary outcome was intention to report concussion symptoms. Predictor variables included demographics (age, race/ethnicity, sex, sport type, number of years in sport, number of previous concussions, and perceived concussion symptom knowledge), athletic identity, attitudes toward symptom reporting, perceived social pressure (injunctive and descriptive norms), and perceived behavioral control (capacity and autonomy). Hierarchical ordinary least-squares regression revealed positive effects of attitude (b = 0.063, P = .005), descriptive norms (b = 0.131, P < .001), injunctive norms (b = 0.107, P < .001), and capacity (b = 0.196, P < .001) on intention to report symptoms. Athletic identity and participation in collision sports had small negative indirect effects on intention, and perceived concussion knowledge had a small positive indirect effect. The full regression model explained 14.24% of the variance in concussion-reporting intention. These findings may help clinicians develop more focused interventions that address key social and individual determinants of underreporting, including attitude, injunctive and descriptive norms, and capacity to report. Athletic identity, sport type, and perceived understanding of concussion symptoms also influence reporting intention to a lesser extent. Previous research in this area has often failed to address a diverse population of college-age athletes from different sports and National Collegiate Athletic Association divisions.Context
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Little information exists regarding what exertional heatstroke (EHS) survivors know and believe about EHS best practices. Understanding this would help clinicians focus educational efforts to ensure survival and safe return-to-play following EHS. We sought to better understand what EHS survivors knew about EHS seriousness (eg, lethality and short- and long-term effects), diagnosis and treatment procedures, and recovery. Multiyear cross-sectional descriptive design. An 11.3-km road race located in the Northeastern United States in August 2022 and 2023. Forty-two of 62 runners with EHS (15 women and 27 men; age = 33 ± 15 years; pretreatment rectal temperature [TREC] = 41.5°C ± 0.9°C). Medical professionals evaluated runners requiring medical attention at the finish line. If they observed a TREC of ≥40°C with concomitant central nervous system dysfunction, EHS was diagnosed, and patients were immersed in a 189.3-L tub filled with ice water. Before medical discharge, we asked EHS survivors 15 questions about their experience and knowledge of select EHS best practices. Survey items were piloted and validated by experts and laypersons a priori (content validity index of ≥0.88 for items and scale). Survey responses. Sixty-seven percent (28/42) of patients identified EHS as potentially fatal, and 76% (32/42) indicated that it negatively affected health. Seventy-nine percent (33/42) correctly identified TREC as the best temperature site to diagnose EHS. Most patients (74%, 31/42) anticipated returning to normal exercise within 1 week after EHS; 69% (29/42) stated that EHS would not impact future race participation. Patients (69%, 29/42) indicated that it was important to tell their primary care physician about their EHS. Our patients were knowledgeable on the potential seriousness and adverse health effects of EHS and the necessity of TREC for diagnosis. However, educational efforts should be directed toward helping patients understand safe recovery and return-to-play timelines following EHS.Context
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Patients with lateral ankle sprains (LASs) often have deficient patient-reported outcomes (PROs) at return to activity (RTA), potentially increasing risk for recurrent LAS and ankle pain. Additionally, applied care strategies are known to correct impairments, but their ability to mitigate risk for long-term consequences remains unknown. To determine if applied care strategies and PRO scores at RTA and 6 months after RTA predict recurrent LAS and ankle pain 12 months after an acute LAS. Prospective cohort study. Online survey. We enrolled 63 individuals within 1 week of sustaining an acute LAS. Participants completed online surveys about their health history and recent LAS. At RTA and 6 months after RTA, participants completed online surveys regarding demographics, applied care strategies, and PROs, including the Foot and Ankle Disability Index (FADI), Identification of Functional Ankle Instability, Godin Leisure-Time Exercise Questionnaire, and Short Form-8 (SF8). At 12 months post-RTA, we asked participants if they sustained recurrent LASs. Chi-square analyses determined if recurrent LAS and ankle pain at 12 months were related to applied care strategies or ankle pain at RTA. Independent t tests compared demographics and PROs at RTA and 6 months between participants with and without a recurrent LAS or ankle pain at 12 months. Logistic regression and area under the receiver operating characteristic analyses determined if demographics, applied care strategies, ankle pain at RTA, and PRO scores at RTA and 6 months predicted recurrent LAS and ankle pain at 12 months. Participants with a recurrent LAS had a lower walking boot use (P = .05) and were taller than those without (P = .03). Increased height and lack of walking boot use were predictive of recurrent LAS (P < .01, R2 = 0.33, area under the receiver operating characteristic = 0.81 [0.68, 0.95]). Individuals with LAS who are taller and do not use a walking boot might have greater risk for a recurrent LAS withing 12 months of RTA.Context
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Researchers have shown that patients with chronic ankle instability (CAI) have deficits in memory and attention allocation. This functional deficit affects lower extremity performance. Motor-cognitive dual-task training may improve lower limb dysfunction caused by central nervous system injury. Further study is needed to determine whether dual-task training is more favorable than single-task training for improving neuromuscular control in patients with CAI. To compare the effects of balance-cognition dual-task training and balance single-task training on lower limb function and electroencephalography changes during static postural control in patients with CAI. Randomized clinical trial (Chinese Clinical Trial Registry: ChiCTR2300073875). Rehabilitation training room. A total of 24 patients with CAI (age = 22.33 ± 2.43 years, height = 175.62 ± 7.7 cm, mass = 70.63 ± 14.59 kg) were block randomized into 2 groups. Protocols were performed 3 times per week for 6 weeks. The single-task group underwent 1-legged static balance training with eyes open and closed and hopping balance training. The dual-task group underwent balance and cognitive training (backward-counting task). Cortical activity, proprioception, muscle onset time (difference between the muscle activation time and touchdown time), and dynamic balance were assessed before and after the interventions. We performed multivariate analyses of variance to identify main effects and interactions across groups and time. A post hoc Bonferroni test was performed for pairwise comparisons when interactions were present. All participants successfully completed the 6-week interventions. Proprioception, peroneus longus (PL) muscle onset time, and dynamic postural control improved after the interventions in both groups (P < .05). Dual-task training was superior to single-task training in improving joint position sense in plantar flexion, shortening PL muscle onset time, and altering cortical activity (P < .05). A 6-week program of balance training or balance combined with cognitive training could improve the functional deficits associated with CAI. The dual-task training could also improve joint position sense in plantar flexion, PL muscle onset time, and cortical activity.Context
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Repeated ankle sprains can lead to injuries, including those of the anterior talofibular ligament (ATFL); however, the extent to which these ligament injuries are associated with symptoms of chronic ankle instability (CAI) remains unclear. To examine the influence of ATFL injury and ankle anterior displacement on symptoms of CAI. Case-control study. University laboratory. A total of 122 of 426 college students who completed a questionnaire on the history of ankle sprain were enrolled in healthy (n = 34; 24 men, 10 women; age = 20.6 ± 0.5 years), coper (n = 49; 38 men, 11 women; age = 20.2 ± 1.2 years), and CAI groups (n = 39; 24 men, 15 women; age = 20.1 ± 1.1 years). One examiner measured the ATFL delineation using ultrasound and anterior ankle displacement using a capacitance-type sensor device. The Cumberland Ankle Instability Tool was applied to assess pain and perceived instability. The ATFL was normal more frequently in the healthy group and abnormal more frequently in the CAI group (χ2 = 18.45, P < .001). Anterior ankle displacement was greater in the coper and CAI groups than in the healthy group (both, P < .001), but no difference was observed between the coper and CAI groups (P = .16). We observed no correlation between the anterior ankle displacement and Cumberland Ankle Instability Tool scores (r = −0.004, P = .71) in participants with previous ankle sprains. Observation of an abnormal ATFL on ultrasonography was associated with anterior displacement of the ankle joint. However, the influence of anterior ankle displacement due to damage to the ATFL on the pain and perceived instability in CAI was assumed to be small.Context
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Two long-distance runners developed medial tibial stress syndrome (MTSS; male age = 26.3 years, female age = 47.5 years) after baseline assessment of plantar-flexor muscle structure and function and spatiotemporal running variables. B-mode ultrasound and lean leg girth characterized plantar-flexor muscle structure. Handheld dynamometry and a single-leg heel raise–to-failure protocol characterized plantar-flexor muscle function. Finally, spatiotemporal running variables were determined during a treadmill protocol. The 2 runners who developed MTSS demonstrated less plantar-flexor strength and endurance capacity than published comparative control data and marked variability in muscle structure. Reduced plantar-flexor strength and endurance capacity were thought to contribute to an impaired ability to resist tibial-bending moments during midstance due to earlier muscle fatigue. Earlier muscle fatigue could, in turn, contribute to increased tibial-bending moments and MTSS development. Therefore, assessing plantar-flexor muscle strength and endurance might help to identify athletes at risk of developing MTSS.
Although the landing phases of the single-leg hop for distance (SLHD) are commonly assessed, limited work reflects how the take-off phase influences hop performance in patients with anterior cruciate ligament reconstruction (ACLR). To compare trunk and lower extremity biomechanics between individuals with ACLR and matched uninjured controls during take-off of the SLHD. Cross-sectional study design. Laboratory setting. Sixteen individuals with ACLR and 18 uninjured controls. Normalized quadriceps isokinetic torque, hop distance, and respective limb symmetry indices were collected for each participant. Sagittal and frontal kinematics and kinetics of the trunk, hip, knee, and ankle as well as vertical and horizontal ground reaction forces were recorded for loading and propulsion of the take-off phase of the SLHD. Those with ACLR had weaker quadriceps peak torque in the involved limb (P = .001) and greater strength asymmetry (P < .001) than control individuals. Normalized hop distance was not statistically different between limbs or between groups (P > .05), and hop distance symmetry was not different between groups (P > .05). During loading, the involved limb demonstrated lesser knee flexion angles (P = .030) and knee power (P = .007) than the uninvolved limb and lesser knee extension moments than the uninvolved limb (P = .001) and controls (P = .005). During propulsion, the involved limb demonstrated lesser knee extension moment (P = .027), knee power (P = .010), knee (P = .032) and ankle work (P = .032), and anterior-posterior ground reaction forces (P = .047) and greater knee (P = .016) abduction excursions than the uninvolved limb. Between-limb differences in SLHD take-off suggest a knee underloading strategy in the involved limb. These results provide further evidence that distance covered during SLHD assessment can overestimate function and fail to identify compensatory biomechanical strategies.Context
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People with patellofemoral pain (PFP) may have lower performance during the forward step-down and single-leg hop with their painful (unilateral complaints) or most painful (bilateral complaints) limb when compared with pain-free controls. However, no authors have investigated the appropriateness of using the pain-free or less painful limb as a reference standard in clinical practice or whether deficits might be present depending on the laterality of pain. To compare performance scores and proportion of side-to-side limb symmetry during the forward step-down and single-leg hop tests among people with unilateral and bilateral PFP and pain-free controls. Cross-sectional study. Laboratory. Fifty-two young adults (18–35 years old) with unilateral PFP, 72 with bilateral PFP, and 76 controls. Group × limb interactions on performance during the step-down (repetitions) and single-leg hop (distance [cm] normalized by the limb length) tests were investigated using a repeated-measures analysis of covariance controlling for sex. Pairwise comparisons were interpreted using effect sizes. A χ2 test was used to compare the proportion of symmetry/asymmetry (cutoff point of ≥90% for symmetry indices) across groups and tests. Main effects for groups (small to medium effects) but not limbs indicated lower performance of both limbs of individuals with unilateral and bilateral PFP than controls during forward step-down and single-leg hop tests. No significant differences for the proportion of symmetry/asymmetry were identified across groups (P ≥.05), which further suggests an impaired physical performance of the contralateral limb. Our results indicate bilateral deficits in the physical performance of people with unilateral and bilateral PFP when compared with pain-free controls during the forward step-down and single-leg hop tests. Limb symmetry indices greater than 90% should be interpreted with caution, as they may overstate physical performance by not assuming bilateral deficits.Context
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Baseball pitching requires fast and coordinated motions of the whole body to reach high ball speeds, putting considerable strain on the musculoskeletal system, particularly the shoulder and elbow. To describe musculoskeletal symptoms and the functional status of the shoulder and elbow in male high school baseball pitchers. Descriptive epidemiology study. Dutch baseball talent academies. One hundred twenty-five male high school baseball pitchers aged 12 to 18 years who participated in 1 of the 6 Dutch baseball talent academies and the Dutch National U-18 team were recruited and enrolled. Musculoskeletal symptoms, functional status of the shoulder and elbow were registered for each player every 6 months over 2 consecutive baseball seasons through self-assessment questionnaires, including the Kerlan-Jobe Orthopaedic Clinic (KJOC) and the Western Ontario Shoulder Instability Index (WOSI) questionnaires. Five hundred seventy musculoskeletal (MSS) symptoms in 93 of the 125 players were reported. The average 6-month prevalence for symptoms of the throwing shoulder was 37% (95% CI = 33%–41%), and for the elbow 37% (95% CI = 31%–42%), followed by the lower back with 36% (95% CI = 26%–45%). The baseball pitchers who experienced only shoulder symptoms had an average KJOC score of 80.0 (95% CI = 75.3–84.7) points, whereas those with only elbow symptoms reported a score of 90.2 (95% CI = 89.2–95.3). On the WOSI questionnaire, baseball pitchers scored an average of 421.2 (95% CI = 200.1–642.4) points. In a cohort of Dutch high school baseball pitchers, one-third reported shoulder and elbow symptoms on the throwing side, with reduced functional status and lower back symptoms. Future efforts should focus on developing preventive strategies through early symptom detection, aiming to prevent symptom progression and, ultimately, the development of severe injuries.Context
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The best practice for cleaning wrestling mats is using a residual disinfectant with continued antibacterial action. Recently available wash-in silver additives claim to confer a residual effect to fabric. To test the efficacy of laundering with a wash-in silver additive in reducing athletes’ exposure to potentially infectious microbes on apparel. A 4-part controlled laboratory study/parallel group comparison study. (1) To test whether fabrics in athletic clothing would be affected differently, we applied bacteria to control fabrics washed in detergent alone and test counterparts washed in detergent plus wash-in silver additive. Bacteria were applied to fabrics, extracted, plated, incubated, and counted. (2) To see if wash-in silver affected various bacteria differently, we washed cotton t-shirts with detergent alone or with detergent plus wash-in silver. We applied 4 bacterial species commonly found in the wrestling environment. Bacteria were extracted, plated, incubated, and counted. (3) To see if wash-in silver was effective in reducing bacterial contamination during practice, 32 collegiate wrestlers paired off with one wearing a test silver-treated t-shirt and their partner wearing a control shirt. Wrestler rotations exposed shirts to 2, 4, or 8 wrestlers. Identical swatches of fabric were cut from the t-shirts. Bacteria were extracted, plated, incubated, and counted. (4) We simulated prolonged/repeated bacterial exposure as occurs during tournaments by applying bacteria directly to silver-treated and untreated singlet material repeatedly over time. Test samples were taken at regular intervals to see if bacterial growth was inhibited by the presence of the silver nanoparticles. Bacteria were extracted, plated, incubated, and counted. Laboratory and practice. Collegiate Division III wrestling team. Wash-in silver would be considered effective if a statistically significant reduction in bacterial count was observed at 95% confidence. Wash-in silver reduced bacterial growth at low levels of contamination but did not significantly reduce bacterial growth at levels seen during contact sport competitions. This was true for all bacterial species and all fabrics tested. The environmental and potential health risks in using a wash-in silver nanoparticle laundry additive in the wash cycle for clothing worn by wrestlers outweigh any potential infection control benefits to these athletes. We do not currently recommend adopting wash-in silver treatment as part of the laundering regimen for wrestling programs until further testing of alternate methods of silver impregnation into sports fabrics has been investigated.Context
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California is the only state that does not regulate the athletic training profession, allowing unqualified personnel to be hired and call themselves athletic trainers (ATs). The benefits of employing a certified AT in the secondary school setting are numerous, but efforts to push regulation legislation continue to fail in California. To describe the availability of certified ATs in California secondary schools and explore factors influencing AT employment. Cross-sectional study. Online survey. Participants from 1538 California secondary schools. Officials from member schools completed the 2022–2023 California Interscholastic Federation Participation Census. Participants provided information specific to enrollment, sport participation, access to automated external defibrillators, and whether the school had ATs on staff. The AT’s certification status was independently verified. Enrollment data specific to ethnicity, race, and percentage of students eligible for free meals were obtained through the California Department of Education Statistics. More than half (51.6%) of California secondary schools did not employ a certified AT, and 8.3% employed unqualified personnel as ATs. Nearly half (43%) of student-athlete participants were enrolled at schools with no certified AT. Schools that employed certified ATs had a lower proportion of students eligible to receive free and reduced-price meals. The average percentage of Hispanic or Latino students was greater in schools with no certified AT and schools that employed unqualified personnel as ATs than schools that employed certified ATs. Data indicate that, in a 5-year period, access to athletic training services in California secondary schools has not improved. Large gaps in access to athletic training services and clear socioeconomic and racial and ethnic disparities exist. Efforts to educate stakeholders on the importance of athletic training regulation in California should continue.Context
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To synthesize the best available evidence regarding the perceptions and current clinical practices of athletic trainers (ATs) in integrating psychological skills into patient management. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL; via EBSCOhost), PsycInfo (via EBSCOhost), SPORTDiscus (via EBSCOhost), and Scopus (via Elsevier). Studies had to investigate the current clinical practices and perceptions of certified ATs in integrating psychologically informed practice for patient management. Studies that had level 4 evidence or higher were included. Studies were excluded if they were published before 1999, the primary language was not English, they involved athletic training students or other rehabilitation specialists, or they explored the athlete’s and/or patient’s perception of psychosocial techniques or strategies. This systematic review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 Statement in Exercise, Rehabilitation, Sport Medicine and Sports Science guidance. A total of 1857 articles were reviewed, and 8 met inclusion criteria. Two studies had level 2a evidence, 4 studies had level 4a evidence, and 2 studies had level 4b evidence. Six studies were rated as good quality, and 2 studies were rated as lesser quality. The included studies demonstrated a high-quality body of evidence with consistent results, which strengthens the review findings. Athletic trainers have the knowledge to identify when athletes are psychologically affected by injury and can identify common psychological responses. Although ATs acknowledge the value of implementing psychosocial strategies, a lack of confidence in implementing basic or advanced techniques, feeling underprepared by their educational program, and a lack of clinical training appear to affect the use of psychosocial techniques in clinical practice and the rate of mental health recognition and referral among ATs.Objective
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Medical disqualification (MDQ) following concussion is a challenging decision clinicians may encounter with little evidence-based guidance. To (1) describe the MDQ following concussion cases athletic trainers (ATs) have been involved in, (2) describe beliefs about MDQ following concussion, and (3) explore factors that ATs believed should be involved in the MDQ following concussion process. Mixed methods. Online cross-sectional survey with follow-up semistructured interviews. Athletic trainers (n = 502) employed at the collegiate setting completed a survey (completion rate = 82.3%, n = 413/502; men = 175, 34.9%; women = 235, 46.8%, prefer not to answer = 4, 0.8%; no response = 88, 17.5%; age = 35.3 ± 10.8 years). Twenty participants were also interviewed (men = 13, 65.0%; women = 7, 35.0%; average age = 40.7 ± 11.0 years). Participants completed a cross-sectional survey comprised of 3 sections of MDQ experience and specific case information, MDQ beliefs, and demographic items. We also interviewed participants who completed the survey and indicated involvement in at least 1 MDQ following a concussion case. We addressed aims 1 and 2 using descriptive statistics and aim 3 with a 5-cycle content analysis. Nearly half of respondents had been involved in an MDQ case following concussion (49.0%, n = 246; not involved = 51.0%, n = 256). Athletic trainers who had been involved in at least 1 MDQ case were involved in an average of 2.3 ± 1.9 cases (n = 241). Participants often described many factors that they believed should influence the MDQ decision, including sport type, concussion history and recovery, health-related quality of life, and academic performance. Our findings highlight that nearly half of participants were involved in an MDQ case following concussion and navigated this process without guidelines. Given this, multiple factors were considered to evaluate the patient’s well-being holistically. The number of ATs involved in MDQ cases following concussion and factors that guided this process warrant further research to develop evidence-based recommendations that assist clinicians in these difficult decisions.Context
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Reliability and Validity of the Functional Assessment of Neurocognition in Sport (FANS): A Paradigm Shift in Post-Concussion Return-to-Sport Decision-Making
Driving After Concussion: Clinical Measures Associated with Post-concussion
The role of shoulder posture in pitching mechanics and injury risk in high school baseball pitchers
Corticospinal Excitability during Standing and Its Association with Postural Control Following Acute Lateral Ankle Sprain.
The socio-economic cost of anterior cruciate ligament injuries and lateral ankle sprains in amateur football and basketball.
JAT eISSN: 1938-162X
JAT ISSN: 1062-6050
ATEJ ISSN: 1947-380X