BACKGROUND:High ankle sprains are common athletic injuries and can be associated with long-term sequelae. Regardless of operative or nonoperative treatment, there is a paucity of data in the literature about the long-term outcomes of high ankle sprains. HYPOTHESIS:Nonoperative treatment of high ankle sprains utilizing a standardized protocol will result in good long-term outcomes. STUDY DESIGN:Case series; Level of evidence, 4. METHODS:Patients who experienced a high ankle sprain without radiographic diastasis of the syndesmosis were identified from a previous study database and contacted for long-term follow-up. All patients were high school or National Collegiate Athletic Association Division IA athletes at initial injury and were treated nonoperatively with the same standardized protocol. Patients completed a questionnaire that included documentation of any interim ankle injuries, 2 different patient-reported outcome scores, and ankle radiographs to conduct Kellgren-Lawrence scoring for ankle osteoarthritis. RESULTS:In total, 76 cases in 74 patients were identified in the database. A total of 40 patients were successfully contacted, and 31 patients (24 collegiate and 7 high school athletes) with 33 high ankle sprains completed the survey (31/40; 77.5%). The mean age at follow-up was 45 years (range, 34-50 years), with a mean time from injury to follow-up of 25 years. Overall, 93.5% (n = 29) of the respondents were male, and 42% (n = 13) of the respondents reported an ipsilateral ankle injury since their initial injury, with 16% (n = 5) having ankle or Achilles surgery. The mean Patient-Reported Outcomes Measurement Information System-10 score was 53.4 (SD, 8.3; range, 37.4-67.7), PROMIS median (IQR), 54.1 (39.9, 68.3), and the mean Self-reported Foot and Ankle Score score was 42.7 (SD, 5.86). Follow-up ankle radiographs were obtained in 11 (35%) of the respondents; 27% had Kellgren-Lawrence grade >2 osteoarthritis, and 36% had signs of heterotopic ossification on imaging. The mean tibiofibular clear space was 4.5 mm, and the mean tibiofibular overlap was 7.15 mm, with 27% of patients demonstrating some tibiotalar narrowing. CONCLUSION:At long-term follow-up, nonoperative management of high ankle sprains without diastasis on imaging was associated with acceptable patient-reported functional outcomes and low rates of subsequent ankle injuries. There was a high incidence of arthritis, but most cases were not clinically significant. This case series shows the natural history of nonoperatively treated high ankle sprains and may serve as a comparison for different management techniques in the future.

Background: It is difficult to diagnose and grade bony stress injury (BSI) in the athletic adolescent population without advanced imaging. Radiographs are recommended as a first imaging modality, but have limited sensitivity and, even when findings are present, advanced imaging is often recommended. Hypothesis: It was hypothesized that the significance of radiographs is underestimated for BSI in the adolescent with positive clinical examination and history findings. Study design: Case series Level of evidence: Level 4 Methods: A total of 80 adolescent athletes with a history of shin pain underwent clinical examination by an orthopaedic surgeon. On the day of clinical examination, full-length bilateral tibial radiographs and magnetic resonance imaging (MRI) scans were obtained. MRI scans were reviewed using Fredericson grading for BSI. At the completion of the study, radiographic images were re-evaluated by 2 musculoskeletal (MSK) radiologists, blinded to MRI and clinical examination results, who reviewed the radiographs for evidence of BSI. Radiographic results were compared with clinical examination and MRI findings. Sensitivity, specificity, negative predictive value, and positive predictive value were calculated based on comparison with MRI. Results: All radiographs were originally read as normal. Of the tibia studied, 80% (127 of 160) showed evidence of BSI on MRI. None of the original radiographs demonstrated a fracture line on initial review by the orthopaedic surgeons. Retrospective review by 2 MSK radiologists identified 27% of radiographs (34 of 127) with evidence of abnormality, which correlated with clinical examination and significant findings on MRI. Review of radiographs found evidence of new bone on 0 of 28 Fredericson grade 0, 0 of 19 Fredericson grade I, 11 of 80 (13.7%) Fredericson grade II, 18 of 28 (64%) Fredericson grade III, and 5 of 5 (100%) Fredericson grade IV. Sensitivity of radiographs showed evidence of new bone on 27% (34 of 127) of initial radiographs, with presence more common with greater degree of BSI, as 23 of 33 (70%) were higher-grade injuries (III of IV) of BSI. Specificity and positive predictive value were 100%, while negative predictive value was 17%. Conclusion: These findings highlight the importance of initial radiographs in identifying high-grade BSI. As radiographs are readily available in most office settings of sports medicine physicians, this information can influence the management of adolescent athletic BSI without the need to delay treatment to obtain an MRI. Clinical Relevance: Adolescent athletes with radiographic evidence of BSI should be treated in a timely and more conservative manner, given the likelihood of higher-grade BSI. In addition, clinicians knowledgeable of the radiographic findings of high-grade BSI should feel more confident that a negative initial radiograph is not likely to be a high-grade BSI and can modify their treatment plans accordingly.

BACKGROUND:Tarsal navicular bone stress injuries (BSIs) are considered "high risk" because of prolonged healing times and higher rates of nonunion in adult populations but, to our knowledge, have not been comprehensively examined in adolescent athletes.PURPOSE:To describe the characteristics of tarsal navicular BSIs in adolescents.STUDY DESIGN:Case series; Level of evidence, 4.METHODS:A retrospective analysis of patients aged 10 to 19 years with a radiographically diagnosed tarsal navicular BSI was performed at 8 academic centers over a 9-year study period. Age, sex, body mass index (BMI), primary sport, physical examination findings, imaging, treatment, surgical technique, return-to-sport time, and complications were analyzed.RESULTS:Among 110 patients (mean age, 14.7 ± 2.7 years; 65% female), common primary sports were cross-country/track and field (29/92 [32%]) and gymnastics/dance (25/92 [27%]). Grade 4 BSIs were identified in 44% (48/110) of patients, with fracture lines present on radiography or magnetic resonance imaging. Nonoperative treatment (mean age, 14.4 ± 2.6 years), consisting of protected weightbearing and either a protective boot (69/88 [78%]) or a cast (19/88 [22%]), was trialed in all patients and was successful in 94 patients (85%). Operative treatment (mean age, 17.1 ± 1.4 years) was ultimately pursued for 16 patients (15%). Patients who required surgery had a higher BMI and a higher percentage of fracture lines present on imaging (nonoperative: 36/94 [38%]; operative: 14/16 [88%]). The median time to return to weightbearing, running, and full sport was significantly longer in duration for the operative group than the nonoperative group (P <.05). Complications associated with surgery included 1 case each of delayed union, nonunion, and painful implants, the latter of which required secondary surgery.CONCLUSION:Adolescent tarsal navicular BSIs were identified most commonly in female patients in leanness sports. Adolescents who required surgery were more likely to be older, have higher BMIs, and have grade 4 BSIs, and they returned to sport within a median of 5 months after single- or double-screw fixation with a low risk of postoperative complications. A better understanding of the presenting signs and symptoms and appropriate diagnostic imaging of navicular BSIs may lead to an earlier diagnosis and improved outcomes.

ABSTRACT Introduction: Across all youth sports, the trend of single sport specialization continues at a concerning pace and often at an increasingly younger age. Objectives: To determine the prevalence of youth single sport specialization among current professional lacrosse athletes. Methods: An online survey was distributed to each athlete of a men's professional lacrosse league. Athletes were asked if they specialized to play lacrosse at the exclusion of other sports. We analyzed the rate and age of early sport specialization, reasons for specialization, and the athlete's perceptions pertaining to this topic. Results: A total of 158 out of 164 athletes completed the survey, for a response rate of 96.3%. Less than one-third, (48/158 = 30.4%) of men's professional lacrosse athletes specialized to play lacrosse at the exclusion of other sports during their childhood/ adolescence. Of the athletes that did specialize, they did so at an average age of 16.5 ± 1.58 years old. Only 2.5% of professional lacrosse athletes specialized prior to the age of 13, with the majority (88.6%) of athletes classifying themselves as "multi-sport" athletes during high school. 96.8% of professional lacrosse athletes would not recommend single sport specialization to their own children. Conclusion: For the professional lacrosse athletes studied, single sport specialization was not necessary to achieve elite status in their sport. The majority of current professional lacrosse athletes were multi-sport athletes in high school. This study adds to the growing body of literature challenging the trend of single sport specialization among current youth athletes.

Objectives: To describe demographic and presenting clinical characteristics, diagnostic features, treatment approaches, and clinical outcomes of adolescent tarsal navicular BSI’s. Methods: A retrospective chart review of patients with tarsal navicular BSIs was performed at eight academic centers. Diagnosis was confirmed by radiologic imaging in all cases. The following variables were collected utilizing a REDCap database and analyzed with basic descriptive and comparative statistics: age, sex, primary sport, physical exam (PE) findings, diagnostic imaging modality, treatment modalities, surgical technique (when applicable), time of protected weight-bearing, time to running, and time to return to sport. Results: 110 patients (mean age: 14.7 years +/-2.7 years; 65% female) met inclusion criteria, 103 (94%) of whom reported a primary sport, most commonly cross country/track and field (33%) and gymnastics/dance (27%). Common PE findings included navicular tenderness (96%), pain with walking (89%), and pain with resisted inversion (55%). Both x-ray and MRI were obtained in the majority of patients (91%), while CT was obtained for 30%. A radiologically detectable fracture line was present in 44%, most commonly on the dorsal navicular cortex. Non-operative treatment was successful in 85% of patients, consisting of protective boot (79%) or cast (21%). Operative treatment was pursued for 15% of patients, with 73% treated with open reduction internal fixation and 27% undergoing percutaneous screw fixation. All operative patients underwent fixation with either 1 (50%) or 2 screws (50%). Bone grafting was performed in 5 patients (31%). Significant differences between non-operative and operative cohorts included presence of fracture line (38% vs. 88%, P<0.001), age (14.3 years vs. 17.1, P<0.001), time of protected weightbearing (7 weeks vs 10 weeks, P=0.012), time to running (12 weeks vs 18 weeks, P=0.001), and time to return to sport (14 weeks vs 20 weeks, P=0.001). Conclusions: Adolescent tarsal navicular BSIs occur most commonly in sports involving repetitive loading, such as cross country, track and field, gymnastics, and dance. The most common PE findings are navicular tenderness to palpation, pain with walking, and pain with resisted inversion. Patients that ultimately require surgical treatment were more likely to have a radiologic fracture line, prolonged return to weightbearing, running and sport than those successfully treated non-operatively. Table 1: Total Cohort Demographics of patients with bone stress injury to the tarsal navicular bone from eight institutions across the United States from 2013 to 2021 Table 2: Demographic and clinical characteristics of non-operative vs. operative patients with tarsal navicular bone stress injuries from eight institutions across the United States from 2013 to 2021

Tibial bone stress injuries (BSIs) are common injuries experienced by active adolescent athletes. The current literature lacks consensus of BSI nomenclature and appropriate use of imaging modalities. Injury classification, severity, or grade may differ substantially according to imaging modalities used and location of injury. This leads to inconsistency in understanding prevalence of injury, communication of diagnosis and management, and can cause confusion for patients and their entourages. As such, the purpose of this Current Concept Review was to identify existing classification of atraumatic tibial pain/BSI, propose unifying nomenclature, and review imaging tools available to clinicians caring for young athletes. Limited literature was identified pertaining to adolescent aged athletes. Thus, we expanded our search to included adult literature and identified 32 publications for atraumatic tibial pain. Multiple grading scales and various imaging modalities were used in the literature highlighting a lack of consensus of terminology and imaging for formalizing diagnosis of BSI. Tibial BSI is common in athletes and has large discrepancies in reported incidence. Unified terminology and recommended imaging modalities for the adolescent athlete with these injuries would improve patient care and professional communication. We propose using “Bone Stress Injury” (BSI) to describe overuse injury of the tibia with associated physical examination findings. When needed for guidance of management, imaging can be used to confirm the diagnosis of BSI. Radiography is recommended as the first imaging modality, and MRI should be considered to confirm diagnosis and determine grade of injury.

Stress injuries to the bone and physis of the knee are common in the active adolescent patient and can be broken down into bone stress injuries (BSIs) and chronic physeal stress injuries. BSIs result from prolonged, repetitive bone loading, whereas chronic physeal stress injuries develop from repetitive loading to the apophysis or epiphysis. Most stress injuries of the knee resolve with relative rest but will occasionally need surgical intervention in more severe cases. Early and accurate identification is paramount for optimal management and to avoid long-term consequences.

Background: Tibial bone stress injuries are common among the athletic adolescent population. A thorough patient history and clinical examination are essential to identify the location and extent of injury. However, there has been little description or any validation of clinical tests to help guide clinicians. Consequently, a formal diagnosis is usually dependent on results from proper imaging. Hypothesis: Clinical examinations will be both highly sensitive and specific determining the incidence, grade, and location of tibial bone stress injury as compared with magnetic resonance imaging (MRI). Study Design: Case-control. Level of Evidence: Level 2. Methods: A total of 80 consecutive athletic adolescents, from various sports, with greater than 1-week history of shin pain were enrolled in this institutional review board–approved study. Exclusion criteria were age >19 years and history of traumatic injury. Patients underwent a standardized clinical examination, which included a fulcrum test (FT), tap/percussion test (TT), vibration test (VT) utilizing a 128-Hz tuning fork, weight bearing lunge test (WBLT) to determine degree of dorsiflexion range of motion (ROM), and vertical single leg hop test (VSLHT) for height, landing, and pain. Bilateral lower extremity MRI was completed on the same day as clinical evaluation and served as the injury reference. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to evaluate each clinical examination for its ability to identify a bone stress injury. Results: A total of 159 tibiae in 80 patients were evaluated. No single test or combination of tests was both highly sensitive and specific. Individual clinical tests demonstrated sensitivity ranging from 0.11 to 0.72 and specificity ranging from 0.37 to 0.93. The VSLHT noting an increase in pain was the most sensitive test (0.72; 95% CI, 0.62-0.78); however, its specificity was only 0.37 (95% CI, 0.19-0.55), with a PPV of 0.84 (95% CI, 0.78-0.91) and NPV of 0.20 (95% CI, 0.089-0.31). The WBLT demonstrated a mean ROM of 8 cm, with side-to-side differences (range 0-4 cm) not influencing incidence of injury. Combinations of tests demonstrated low sensitivity (0.03-0.40), with better specificity (0.63-1.0). When considering ability to identify higher grades of injury (grade III/IV), all tests had a high NPV indicating that if clinical tests were negative, there was a high likelihood that the patient did not have a grade III or IV injury. Conclusion: No single test or combination of tests was both highly sensitive and specific. Clinicians cannot solely rely on clinical examination for determining extent or severity of bone stress injury in the athletic adolescent population, but when combinations of tests are negative, there is likely not a high-grade bone stress injury. Clinical Relevance: Clinical tests utilized in the evaluation of adolescent tibial bone stress injury may help indicate the presence or absence of higher grade tibial bone stress injury.

Femoral neck bone stress injuries (FNBSI) are an uncommon diagnosis of groin or hip pain in the adolescent athlete. The true incidence is currently unknown and needs to be considered in the young athlete with atraumatic hip or groin pain. The current literature is sparse in describing the workup and treatment of FNBSI in the adolescent and pediatric population, and the literature lacks consensus of FNBSI nomenclature and appropriate use of imaging for all ages. This leads to inconsistency in understanding the etiology of the injury, prevalence of injury, workup of risk factors for FNBSI, and communication of diagnosis and management. The purpose of this Current Concept Review is to explore the pathophysiology, risk factors and clinical presentation for pediatric and adolescent femoral neck bone stress injuries, discuss existing classification of atraumatic FNBSI, and review imaging tools available to clinicians caring for young athletes. FNBSI occurs as young as age 5 and incidence increases during adolescence. Females are more at risk than males, as are certain sports. Initial imaging of choice is x-rays of the pelvis, followed by an MRI if there is suspicion for a FNBSI. Compression sided FNBSI less than 50% femoral neck width have a high success rate in non-operative treatment, while surgical fixation should be considered for tension sided injury, compression injury >50% femoral neck width, or for those who fail conservative management.

Background: Most bone stress injuries (BSI) affect weight-bearing bones of the lower extremity. While femoral neck BSIs (FNBSI) are less common, they occur in the pediatric and adolescent population, accounting for 0.7%-21.1% of all sports-related injuries. A recent publication showed a 4-fold increase in the incidence of pediatric BSI. Literature detailing FNBSI in the pediatric population is limited to small case studies. Recommendations are lacking for imaging protocols and grading of injury. Purpose: To assess available evidence-based literature for pediatric and adolescent FNBSI in order to better understand the incidence, risk factors, work up and treatment practices of pediatric and adolescent FNBSI. Methods: A systematic review was conducted to find FNBSI studies in the pediatric and adolescent population. Due to a paucity of literature, information was gleaned from adult FNBSI literature, other areas of BSI in pediatric patients and biomedical papers looking at pediatric growth and bone health. Papers discussing potential risk factors to bone health and pediatric, adolescent and collegiate athletes at higher risk for BSI were also included. Regarding meta-analysis: Search terms included “Femoral Neck,” “Bone Stress Injury; Hip,” “Stress Fracture,” “Stress Fracture + Adolescent.” For the meta-analysis, patients under 20 years of age were reviewed and available information documented. Patients were excluded if they had a known metabolic or chronic medical condition that could be the primary reason or main contributor to their BSI. Results: A total of 66 fractures (57 patients) were identified, 9 bilateral, ranging from 5-19 years. All but 9 (86%) had compression sided fractures; 4/9 tension sided fractures were displaced. 35% (23/66) occurred in military and 30% (20/66) were athletes. Radiographs were most often initial imaging; 22/55 (40%) of those were abnormal, 4 inconclusive. If initial radiographs were negative (or none obtained), 14/33 had repeat positive x-rays, 15/33 positive BS, 12/33 positive MRI. MRI frequently was used to confirm positive radiographs. 6/57 (11%) patients treated conservatively would go on to require surgical fixation. Conclusions: FNBSI is a diagnosis that must be considered in the young, especially when the chief complaint is hip, thigh or groin pain. Radiographs should be the initial diagnostic test, but further imaging is usually necessary to establish the diagnosis and determine a treatment plan. Understanding the specific risk factors to this population is crucial. Further studies in this population are needed to develop a pediatric specific understanding of FNBSI, formulate a proper workup and develop a treatment plan.

Background: There is much concern over the incidence of concussion in high school sports, with a growing focus on soccer, necessitating the need for legislation and formal rule changes for safety reasons. Objective: To note differences in concussive injury between boys and girls soccer and determine the change in reported concussion rates from 2011 vs. 2017 in order to study the impact of legislation and rule changes on the rates of concussion in high school soccer in the state of New Jersey. Design: Comparative Study Methods: Licensed athletic trainers working in the secondary school setting in the state of New Jersey voluntarily participated in an online survey on the incidence of concussion in boys and girls soccer. This de-identified data was compared with data collected from a similar survey conducted in 2011. Results: In 2017 there were 168 concussions occurred among 3255 male soccer athletes. Eight-five percent of concussions (145/168) occurred during games, with the remainder occurring in practice. Forty-five percent (76/168) occurred to varsity players with the majority occurring during games (84%). Fewer concussions were reported to junior varsity and freshman players.. In 2017, Incidence Rate (IR) for all male soccer athletes was calculated at 0.36 concussions per 1000 athletic exposures (AE). Injury Proportion (IP) was 5%. Clinical Incidence was 0.05 concussions per athlete. This represented a 38% increase in IR/1000 AE from 2011 to 2017, and a 39% increase in IP 2011 vs 2017 In 2017, a total of 2604 female soccer athletes, reported 195 concussions with the majority occurring during games (83%). Varsity athlete reported the higher number of concussions relative to junior varsity and freshman soccer athletes IR/1000 AE was 0.48 vs 0.43 in 2011 (12% increase), while IP was 7% vs 6% in 2011 (17% increase Females had a greater IR/1000 AE than males (.48 vs. .36). Clinical incidence was also greater for female soccer athletes than male soccer athletes (0.075 vs. 0.05). Conclusion: Despite legislation and rule changes, the incidence of concussion in both boys and girls high school soccer is increasing and particularly during games. Playing at the varsity level and game play has the highest association with injury and should be subject to greater scrutiny. Additionally, more concussions are occurring to female soccer athletes than male players. This information provides a snapshot of a significant problem that deserves greater attention. Table 1. Boys Soccer Comparison Boys Soccer: Overall 2017 62 Highs Schools Reporting 3255 Athletes 168 Concussions Reported 2011 45 Schools Reporting 1984 Athletes 72 Concussions Reported Incidence Proportion: 5%; SE(IP)= 0.0038; 95% CI: 4.3%, 5.8% 3.6%; SE(IP)=0.0041; 95% CI:2.8%, 4.4% Incidence Rate: 0.35 concussions/1,000 AE; SE(IR)=2.75E-05; 95% CI:0.3, 0.4 .26/1,000 AE; SE(IR)3.03E-05;95% CI:02,0.32 Clinical Incidence: .05 concussions/athlete; SE=0.0038; 95% CI: 0.04, 0.06 .36 concussions/athlete; SE(IP); 95% CI: .03, 0.04 Games: Incidence Proportion 4.93%; SE(IP)=0.004; 95% CI: 0.37, 0.51 2.9%; SE(IP)=0.004; 95%CI: 2.2%,3.7% Incidence Rate 1.722 concussions/1,000 AE; SE(IR):0.00014; 95% CI: 1.722, 1.723 0.975 concussions/1,000 AE; SE(IR)= 0.00013; 95% CI: 0.724, 1.23 Clinical Incidence 0.04 concussions/athlete; SE=0.004; 95% CI: 0.037, 0.051 0.029 concussions/athlete; SE=0.004; 95% CI: 0.029, 0.037 Practices: Incidence Proportion 0.7%; SE(IP)=0.002; 95% CI: 0.4%, 1.1% 0.7%; SE(IP)= 0.002; 95% CI: 0.3%,1% Incidence Rate 0.069 concussions/1,000 AE: SE(IR):1.39E-05; 95% CI:0.03, 0.08 0.066 concussions/1,000 AE; SE(IR)=1.82E-05; 95% CI: 0.03, 0.1 Clinical Incidence 0.007 concussions/athlete; SE=0.004, 95% CI: 0.004, 0.011 0.07 concussions/athlete; SE=0.002; 95% CI: 0.03, 0.01 Table 2. Girls Soccer Comparison: Girls Soccer Overall 2017 60 High Schools Reporting 2604 athletes 195 concussions 2011 45 High Schools Reporting 1987 Athletes 119 Concussions Incidence Proportion 7%; SE(IP)= 0.0049; 95% CI: 6%, 8% 6%; SE(IP)=0.005; 95% CI: 5%,7% Incidence Rate 0.48 Concussions/1,000 AE; SE(IR)=3.58E; 95% CI: 0.4, 0.6 0.44 concussions/1,000 AE; SE(IR)=0.006; 95% CI: 0.43, 0.45 Clinical Incidence 0.075 concussions/athlete; SE=0.0049; 95% CI: 0.07, 0.09 0.06 concussions/athlete; SE=0.005, 95% CI: 0.05, 0.07 Games: Incidence Proportion 5.7%; SE(IP)=0.005; 95% CI: 4.8%, 6.6% 5.6%; SE(IP) = 0.005; 95% CI: 4.6%, 6.6% Incidence Rate 2.24 concussions/1,000 AE; SE(IR)= 0.00018; 95% CI: 1.88, 2.60 1.86 concussions/1,000 AE; SE(IR) = 0.00013; 95% CI: 1.85, 1.87 Clinical Incidence 0.06 concussions/athlete; SE = 0.005; 95% CI: 0.05, 0.07 0.056 concussions/athlete; SE= 0.005; 95% CI: 0.046, 0.066 Practices: Incidence Proportion 1.2%; SE(IP)= 0.002; 95% CI: 0.8%, 1.7%, 0.6%; SE(IP)= 0.002; 95% CI: 0.2%, 0.9% Incidence Rate 0.11 concussions/1,000 AE; SE(IR)= 1.97E-05; 95% CI: 0.07, 0.15 0.055 concussion/1,000 AE; SE(IR) = 0.002; 95% CI: 0.05, 0.06 Clinical Incidence 0.01 concussions/athlete; SE= 0.002; 95% CI: 0.008, 0.017 0.06 concussions/athlete; SE= 0.002; 95% CI: 0.002, 0.009

BACKGROUND:Bony stress injuries (BSIs) are common among adolescents involved in high school sports. A better understanding of factors that contribute to adolescent BSI is needed to target preventative measures.HYPOTHESIS:Individuals who suffer a BSI will demonstrate significant differences in training methods, sleep, diet, and history of injury compared with a healthy, noninjured control group.STUDY DESIGN:Descriptive epidemiologic study.METHODS:Data from the National High School Stress Fracture Registry (NHSSFR), an internet-based adolescent BSI survey, were used to identify variables reported with adolescent (13-18 years of age) BSI. These findings were compared with a survey of 100 (50 males, 50 females) healthy athletic controls to identify significant differences between healthy adolescents and those with BSI.RESULTS:A total of 346 stress fractures were reported in 314 (206 females, 108 males) athletes within the NHSSFR. Comparison with healthy control participants demonstrated multiple significant findings. In particular, body mass index was significantly lower for patients with BSI injury compared with controls (P < 0.001). Patients slept significantly less than the control group (7.2 vs 7.95 hours; F = 34.41; P < 0.001). Females also slept significantly less hours than males (7.2 vs 7.63 hours; F = 11.02; P < 0.001). Fifty-eight percent of those who reported a BSI did not engage in any weight training. Those with a BSI had significantly higher average stress ratings than control participants (1.67 vs 1.42; P < 0.001), and females also rated their stress levels significantly higher than males (1.8 vs 1.38; P < 0.001). A significant difference between patients with any BSI and control participants existed for history of "shin splints" (Pearson χ2 = 28.31; P < 0.001), and females also expressed having shin pain lasting for longer than 4 weeks (Pearson χ2 = 8.12; P < 0.001) and more often (Pearson χ2 = 5.84; P = 0.02) than males. There was also a significant difference between patients with BSI and control subjects regarding dairy intake (2.25 vs 2.69; F = 6.43; P = 0.01).CONCLUSION:Findings revealed significant differences between those who reported a BSI relative to healthy athletic adolescents. These differences included body mass index, prior history of shin splints, involvement in weight training, amount of sleep, daily stress, and dairy intake. Preventive measures should be developed to address these areas to reduce the incidence of BSIs in the adolescent population.

BACKGROUND:The incidence of adolescent overuse injuries, including bone stress injuries (BSIs), is on the rise. The identification of a BSI in the early stages is key to successful treatment. The Shin Pain Scoring System (SPSS) was developed to aid clinicians in identifying patients with a BSI. HYPOTHESIS:The SPSS will correlate with magnetic resonance imaging (MRI) grading of a BSI in an adolescent population. STUDY DESIGN:Cohort study (diagnosis); Level of evidence, 2. METHODS:Enrolled in this study were 80 adolescent high school athletes between the ages of 13 and 18 years participating in a variety of sports with more than 1 week of atraumatic shin pain. The SPSS questionnaire was completed for each participant, and physical examination findings were recorded. Each question and physical examination item was allotted a point value, which totaled 29 points. Radiographs and MRI scans of both lower legs were obtained for each participant. The SPSS score was statistically analyzed using logistic regression, a classification matrix, and a 2 × 2 contingency table to evaluate validity and predictability. RESULTS:Logistic regression analysis of our data determined that 3 categories of SPSS scores provided the highest diagnostic value when compared with MRI grading based on the Fredericson classification (0-4). The SPSS correctly identified 43.5% of injuries for category 1 (MRI grades 0-1), 62.5% for category 2 (MRI grade 2), and 50.0% for category 3 (MRI grades 3-4). Overall, the SPSS correctly identified the degree of BSI in 54.4% of all tibias studied. Binary analysis for validity demonstrated a sensitivity of 96%, specificity of 26%, positive predictive value of 76%, and negative predictive value of 71% for the SPSS relative to the "gold standard" MRI results. CONCLUSION:The SPSS is a potentially valid method to identify tibial BSIs, given the sensitivity and negative and positive predictive values. It also provides helpful categorization to alert clinicians to the presence of a BSI and direct further diagnostics and/or interventions. The SPSS should be considered as an additional tool to use when evaluating adolescents with atraumatic tibial BSIs.

OBJECTIVETo present recommendations for athletic trainers and other allied health care professionals in the conservative management and prevention of ankle sprains in athletes.BACKGROUNDBecause ankle sprains are a common and often disabling injury in athletes, athletic trainers and other sports health care professionals must be able to implement the most current and evidence-supported treatment strategies to ensure safe and rapid return to play. Equally important is initiating preventive measures to mitigate both first-time sprains and the chance of reinjury. Therefore, considerations for appropriate preventive measures (including taping and bracing), initial assessment, both short- and long-term management strategies, return-to-play guidelines, and recommendations for syndesmotic ankle sprains and chronic ankle instability are presented.RECOMMENDATIONSThe recommendations included in this position statement are intended to provide athletic trainers and other sports health care professionals with guidelines and criteria to deliver the best health care possible for the prevention and management of ankle sprains. An endorsement as to best practice is made whenever evidence supporting the recommendation is available.

Sixty consecutive collegiate athletes with "high" ankle symptoms were prospectively evaluated over a 3-year period in an effort to better define this debilitating ankle injury. All athletes included in this study had tenderness over the distal anterior tibiofibular ligament, tenderness proximally along the interosseous membrane, and functional disability. No study subject had a fracture or frank tibia-fibula diastasis. The severity of the sprain was quantified using the interosseous "tenderness length." A standard rehabilitation protocol was followed by all patients. Athletes returned to competition when they could perform all functional testing without difficulty. Time to return to full competitive activity averaged 13.4 days. The number of days missed from competition was statistically related to the interosseous tenderness length (P = 0.0001) and to positive results on the squeeze test (P = 0.03). Fifty-three of the 60 injured athletes were evaluated at least 6 months after injury. Patients rated their outcomes as good or excellent. Six of the patients experienced occasional ankle pain and stiffness, four patients reported recurrent ankle sprains, and one patient had heterotopic ossification formation.