Clinical Question : Among health care professionals, does CPR training and performance with real-time feedback improve adherence to guideline-recommended compression depth compared with standard CPR training and delivery methods? Clinical Bottom Line : CPR training and performance using real-time feedback devices help health care providers achieve compression depths that more closely follow current guidelines, compared with standard training without feedback devices. In four randomized controlled trials, feedback delivered through audiovisual or smartwatch devices consistently increased both the percentage of compressions within the correct depth range and the overall average depth. Instructor-only feedback showed smaller, nonsignificant improvements, suggesting that the type of feedback devices and timing play a key role in their effectiveness.
Objective: To evaluate whether anterior cruciate ligament (ACL) injury incidence differs between female and male rugby players. Data Sources: PubMed. Study Selection: Studies reporting sex-comparative ACL injury incidence in rugby players of any age or competition level were included. Injuries were included if they occurred during rugby practices or matches. Eligible designs were prospective or retrospective cohort studies, surveillance-based epidemiologic studies, or case series reporting sex-specific incidence rates or ratios. Data Extraction: Data on study design, participant characteristics, ACL injury definitions, exposure metrics, and sex-stratified incidence rates were extracted. Study quality was assessed using the Newcastle-Ottawa Scale. Data Synthesis: A total of 160 potential studies were identified, with four studies meeting inclusion criteria. Two studies examined first-time ACL injuries, both reporting higher, but statistically nonsignificant incidence rates in female compared with male rugby players. Two additional studies evaluating all ACL sprain grades produced mixed findings: one identified a 5.3-fold greater incidence among females, while the other found no significant sex difference. Conclusions: Rugby ACL injury overall may not differ by sex, but available evidence was limited and inconsistent. Small samples, variable ACL injury definitions, and broad knee-injury definitions hindered clear interpretation. Larger epidemiologic studies applying standardized definitions are needed to clarify whether female rugby players experience greater ACL injury incidence.
This study aimed to investigate the surface electromyography (sEMG) activity of hamstring muscles-biceps femoris long head, semitendinosus, semimembranosus, and biceps femoris short head-during isometric prone leg curls at 15 degrees, 45 degrees, 75 degrees, and 105 degrees of knee flexion (0 degrees was considered full extension). Thirteen recreationally active men participated in this study. Results revealed that the biceps femoris short head sEMG activity increased with deeper knee flexion angles. However, the biceps femoris long head and semimembranosus sEMG activities increased with shallower flexion angles, and semitendinosus's sEMG activity was unaffected. Therefore, to maximize biceps femoris short head activation, deep knee flexion angles might be more advantageous.
The National Athletic Trainers’ Association emphasizes the importance of emergency action plans (EAPs) in managing catastrophic injuries, yet compliance remains inconsistent in secondary schools. This clinical commentary describes a quality improvement framework implemented to improve compliance with EAP recommendations outlined in the 2024 National Athletic Trainers’ Association position statement in a South Carolina secondary school. The project increased compliance from 80.7% to 92.3% for the existing eight venue-specific EAPs and identified time constraints and emergency medical services collaboration as ongoing challenges. Additionally, 11 new sport-specific EAPs were developed. This framework offers a replicable model to enhance emergency preparedness across secondary schools nationwide.
Clinical Scenario: Athletic trainers (ATs) are health care professionals who are skilled in evaluation, diagnosis, and management of musculoskeletal injuries in physically active individuals. Focused Clinical Question: What is the impact of athletic training services on attrition and cost savings in the military setting? Summary of Search: A systematic literature search was conducted to identify peer-reviewed studies published between 2018 and 2025. Electronic databases were searched using the following keywords: "athletic training" OR "athletic trainers" AND "military." Three independent reviewers screened titles and abstracts independently. Three studies (one cluster randomized trial and two cohort studies) were identified. Key findings showed that AT services in military settings were associated with lower attrition rates and cost savings of $10-23 million. Clinical Bottom Line: Current evidence supports the positive impact of ATs in military settings on attrition and cost savings. Implementing ATs has been found to decrease musculoskeletal-related attrition by 25% and decrease all-cause attrition by 15%. With these decreased attrition rates, cost savings exceeded $10 million. Strength of Evidence: The evidence gathered to answer the question about the impact of ATs in the military setting aligns with the strength of recommendation of Grade B using the Strength of Recommendation Taxonomy.
Military clinical practice settings have undergone rapid growth in recent years, and the literature suggests that these emerging clinical practice settings have better job satisfaction. This study explored job satisfaction and intention to leave among 25 athletic trainers working with tactical athletes in the military clinical practice setting and found that they are satisfied with their jobs and have low intention to leave. They are especially satisfied with their nature of work and their coworkers. They are satisfied with their salary but are dissatisfied with the lack of opportunities for promotion and raises. Employer policies that create clear advancement opportunities and opportunities for raises could enhance job satisfaction further.
Focused Clinical Question: In youth athletes, does taking a stimulant medication for the treatment of Attention-Deficit Hyperactivity Disorder (ADHD), compared with not taking a stimulant medication, affect incidence of concussion and postconcussion recovery? Clinical Bottom Line: Athletes with ADHD taking stimulant medication have a reduced incidence of concussion compared with their peers. Athletes with ADHD taking stimulant medications performed similarly on neurocognitive assessments initially postinjury but had less neurocognitive declines approximately 1-week postinjury compared with their peers. The Level of Evidence is 3. The Grade of Recommendation is C.
We sought to quantify 3 years of musculoskeletal injuries recorded by on-site athletic trainers at an undergraduate performing arts campus, the services rendered, and the clinic time required to perform those services. The most common musculoskeletal injuries recorded were overuse injuries of the lower extremity and low back region. The most common athletic training service provided and clinician time involved hot and cold thermotherapy (21.5%) and electrical stimulation techniques (18.4%). Undergraduate performing arts clinics should receive sufficient equipment, funding, and staffing to provide athletic training services for a high proportion of lower extremity and lumbar region overuse injuries.
Focused Clinical Question: How does motivation mediate the perfectionism-athlete burnout relationship in junior and collegiate athletes? Clinical Bottom Line: There is currently moderate-quality, patient-oriented evidence demonstrating the divergent nature of motivational pathways mediating the perfectionism-athlete burnout relationship in junior and collegiate athletes. Specifically, the evidence from this Critically Appraised Topic indicates that fostering autonomous motivation and perfectionistic strivings while lessening feelings of controlled motivation and perfectionistic concerns can decrease the likelihood of athlete burnout. Members of the athlete support team (e.g., athletic trainers, physical therapists, coaches) working with junior and collegiate athletes should encourage self-determined behavior by emphasizing satisfaction of psychological needs. Future research should examine the role of specific motivational pathways in the perfectionism-athlete burnout relationship in different age groups of junior and collegiate athletes to develop effective self-determination-based interventions. Due to the consistent but limited patient-oriented evidence included in this Critically Appraised Topic, a grade of B is recommended by the Strength of Recommendation Taxonomy.
A 63-year-old woman initially presented to the emergency department complaining of left midfoot pain following a fall at home. Initial non-weight-bearing radiographs identified a displaced fracture of the first metatarsal, and the provider referred the patient to an orthopedist for further evaluation and follow-up. Subsequent weight-bearing radiographs and computed tomography, 2D and 3D, were required to identify a dorsomedial intra-articular avulsion fracture of the first metatarsal with an associated avulsion fracture of the second metatarsal base at the Lisfranc ligament attachment. Current literature suggests that a first metatarsal fracture is rare, occurring in approximately 1.5% of metatarsal fractures, and is more common in children than in adults. Interventions included open surgical stabilization of the tarsometatarsal disruption, with intraoperative fluoroscopy and subsequent immobilization. The patient will begin physical therapy for mobilization and progressive return to activities at 12 weeks postoperative. This case highlights an atypical medial-column Lisfranc injury in an older adult and underscores the diagnostic challenges associated with subtle injury patterns that require advanced imaging for accurate identification.
Balance is commonly assessed during lower-extremity evaluations due to its influence on functional activities and injury risk. Similarly, the foot is often assessed by clinicians to qualify patients as having a high, neutral, or low arch or having a mobile or rigid foot. The purpose of this study was to examine the influence of foot posture and foot mobility on dynamic balance. Neither foot posture nor foot mobility, alone, affected balance; however, the interaction of these measures demonstrated significant differences in balance. Our findings reinforce the need to consider foot posture and mobility together when assessing balance and related functions.
Research on ImPACT Pediatric is limited. We reviewed pediatric baseline tests conducted over 6 years and compared scores from our athlete cohort (N=230) with means in the testing manual (athlete status not specified). We also examined test stability over time (n = 48) and compared change scores with reliable change index thresholds in the testing manual. The athletic population had higher scores in six of the eight measured subtests. Visual Memory was correlated over time (rs[46]= .372, p = .009). Visual Memory and Rapid Processing were higher at Test 2 (z = 2.78, p = .005, r = .40; z = 2.53, p = .011, r = .37). Most scores fell within established reliable change index thresholds. Athletic trainers who work with athletes ages 6-11 should recognize potential differences in scores when reviewing baseline tests and possibly test ImPACT Pediatric baselines more frequently than ImPACT.
Evidence demonstrates that anterior cruciate ligament reconstruction impacts cardiovascular system and physical activity; however, the association between quadriceps strength and these factors remains unclear. We aimed to examine the association between quadriceps strength and cardiovascular function or self-reported physical activity post anterior cruciate ligament reconstruction. Weaker quadriceps strength was associated with higher central pulse wave velocity (r = -.438, p = .042), higher augmentation index (r = -.597, p = .005), lower peak oxygen uptake (r = .536, p = .010), and lower physical activity on the Marx scale (r=.438, p=.041). Our findings highlight the importance of understanding quadriceps strength as a modifiable factor associated with cardiovascular function and physical activity post anterior cruciate ligament reconstruction.
Introduction/Clinical Scenario: Peak health and physical fitness are essential for military readiness across all military branches. Functional Movement Screen (FMS) composite scores are correlated with performance on military physical fitness assessments. FMS evaluates movement patterns and may help identify modifiable risk factors of service members to improve military readiness. Focused Clinical Question: Is the FMS able to identify modifiable risk factors that can affect military operational readiness? Summary of Key Findings: A literature review was conducted for articles including functional movement screens in military populations. The search included 52 articles within the last 10 years; 18 of those articles included FMS. Three cross-sectional studies specific to FMS performed in military populations were selected. FMS composite scores of <14 are associated with higher risk of injury and lower performance on military physical performance test. Clinical Bottom Line: Research supports the use of FMS to identify modifiable risk factors and faulty movement patterns to decrease the number of noncombat musculoskeletal injuries in military personnel. Strength of Recommendation: Overall, there are moderate levels of evidence that support the recommendation for FMS assessments to be a part of standard evaluation tools in military populations.
Introduction/Clinical Scenario: Chronic ankle instability (CAI) is characterized by repeated ankle sprains, frequent episodes of giving way, and sensorimotor impairments including poor balance, and gait alterations. Foot morphology differences particularly loading induced changes in arch height (e.g., navicular drop), have been suggested to be a contributing factor to CAI and its associated impairments. However, the evidence is mixed, and no comprehensive evaluation of the literature has been completed. Focused Clinical Question: Does loading induced changes in arch height differ between those with and without CAI? Summary of Key Findings: A comprehensive search yielded three cross-sectional studies comparing loading induced changes in arch height between those with and without CAI. No significant differences in the magnitude of arch height change were noted between groups in the original investigations. Clinical Bottom Line: Based on the limited existing evidence, loading induced changes in arch height do not differ between those with and without CAI. Strength of Recommendation: Consistent findings in moderate to high quality studies suggest a level B strength of recommendation regarding the clinical bottom line.
Clinical Scenario: Chronic ankle instability (CAI) often leads to sensorimotor deficits, impaired dynamic balance, and an increased risk of early joint degeneration if left untreated. Blood flow restriction training (BFRT) can be used to enhance muscle strength and hypertrophy across the ankle joint muscles in those with CAI. Individuals with CAI frequently demonstrate muscle weakness and atrophy around the ankle joint, which further contributes to instability and recurrent sprains. However, its efficacy for improving dynamic balance in CAI remains unknown. Clinical Question: Does adding BFRT to traditional rehabilitation result in greater improvements in dynamic balance in individuals with CAI compared to traditional rehabilitation alone? Summary of Key Findings: Three randomized controlled trials evaluating dynamic balance outcomes following BFRT interventions in individuals with CAI were reviewed. Results showed that BFRT did not lead to additional improvement in dynamic balance outcomes compared with traditional rehabilitation alone, regardless of whether BFRT was applied independently or in combination with rehabilitation. Clinical Bottom Line: Adding BFRT to standard rehabilitation does not provide additional improvements in dynamic balance for individuals with CAI. While BFRT remains beneficial for improving muscle strength and activation, clinicians should continue to prioritize conventional neuromuscular and proprioceptive rehabilitation strategies to address dynamic balance deficits. Strength of Recommendation: Grade B evidence supports BFRT does not improve dynamic balance in those with CAI.
Clinical Scenario: Individuals with knee osteoarthritis (OA) frequently experience difficulty sleeping, and insomnia in this population has been associated with elevated levels of systemic inflammation. Cognitive behavioral therapy designed to treat insomnia is a nonpharmacological intervention that may reduce inflammation by improving sleep quality. Clinical Question: In patients with comorbid knee OA and insomnia, does implementation of Cognitive Behavioral Therapy for Insomnia (CBT-I), compared to control interventions, reduce systemic inflammation as measured by blood biomarker concentrations? Summary of Key Findings: Two randomized controlled trials were included. The two identified studies assessed the impact of CBT-I on inflammatory markers among adults with knee OA and insomnia disorder. Both studies measured inflammation using blood biomarker concentrations to evaluate systemic inflammation. Although neither study found that CBT-I significantly reduced systemic inflammation overall, both reported improvements in sleep and pain-related outcomes, suggesting that the intervention may offer clinical benefits even in the absence of measurable changes in inflammation. Clinical Bottom Line: There is currently inconsistent, limited-quality, patient-oriented evidence that does not support the use of CBT-I to reduce systemic inflammation in patients with knee OA and insomnia compared with the standard of care group. Future research should explore the long-term effects of CBT-I on systemic inflammation and pain outcomes in individuals with comorbid knee OA and insomnia to strengthen clinical applicability. Strength of Recommendation: The grade of B is recommended by the Strength of Recommendation Taxonomy for inconsistent, limited-quality, patient-oriented evidence.
Context: Per-diem athletic trainers (ATs) are essential for providing emergency care at athletic events, yet they often face inconsistent access to critical resources and unclarity about who is responsible for supplying them. Purpose: To explore ATs' perspectives and identify essential resources needed for safe and effective patient care in the per-diem setting. Methods: Twenty ATs with recent per-diem experiences developed a standardized list of resources using the nominal group technique. Results: Eight resources were consistently identified across all groups: an automated external defibrillator (AED), emergency action plan (EAP), detailed job outline, ice, splints, tape, gauze, and band-aids. Of these, an AED, EAP and a detailed job outline were ranked as most important across all groups. In addition, a comprehensive resource list, encompassing items and ideas from all five groups, was created. Interpretation: Establishing standardized resource expectations can help ensure organizational accountability for resource provision and maintenance, improve emergency preparedness, and support ATs in delivering high-quality care. These findings highlight gaps in communication and responsibility that may affect patient safety and provide a foundation for future work to tailor resource lists to specific event types and environments.
Evidence suggests that athletic trainers are not always comfortable performing emergency medical skills, but it is unclear if state regulatory language impacts their comfort or perceived ability to provide care in medical emergencies. Using a concurrent mixedmethods approach, athletic trainers were asked to review regulatory language and indicate if they would be allowed to perform specific emergency skills in different employment settings. Results indicate that athletic trainers identify barriers to performing emergency medical skills in state practice language, including supervising physician oversite and narrow definitions of patient populations. Our results provide insight specific to the potential impact of regulatory language on clinical practice.
