OBJECTIVE:To understand factors associated with missed academic time after concussion to improve support for patients. Our goal was to assess patient-specific predictors of total school time lost after pediatric/adolescent concussion. STUDY DESIGN:We performed a prospective cohort study of children and adolescents (8-18 years of age) seen within 14 days of concussion from seven pediatric medical centers across the United States. We collected outcomes via the Concussion Learning Assessment & School Survey (CLASS) and constructed a multivariable predictive model evaluating patient factors associated with school time loss. RESULTS:167 patients participated (mean age = 14.5 ± 2.2 years; 46% female). Patients were assessed initially at 5.0 ± 3.0 days post-injury and had a final follow-up assessment 24.5 ± 20.0 days post-concussion. Participants missed a median of 2 days of school (IQR = 0.5-4), and 21% reported their grades dropped after concussion. Higher initial symptom severity rating (β = 0.06, 95% CI = 0.03-0.08, p < 0.001) and perception of grades dropping after concussion (β = 1.37, 95% CI = 0.28-2.45, p = 0.01) were significantly associated with more days of school time missed after concussion. Those who reported their grades dropping reported missing significantly more school (mean = 5.0, SD = 4.7 days missed of school) than those who reported their grades did not drop (mean = 2.2, SD = 2.6 days missed of school; p < 0.001; Cohen's d = 0.87). CONCLUSIONS:Children and adolescents reported missing a median of 2 days of school following concussion, and more missed school time after a concussion was associated with more severe concussion symptoms and perception of grades dropping. These findings may support recommendations for minimal delays in return-to-learn after concussion.

BACKGROUND:Early diagnosis and appropriate management of concussion/mild traumatic brain injury (mTBI) is critical for preventing poor outcomes and minimizing health care burden. Current clinical guidelines for concussion management focus mostly on diagnosis and return to cognitive and physical activity but provide limited guidance on the use of specific therapeutic interventions. OBJECTIVE:To systematically review the available evidence on therapeutic interventions for concussion/mTBI and develop an evidence-based consensus statement on the use of these interventions in clinical practice. LITERATURE SURVEY:A systematic literature search was performed first in 2018 and 2019, and again in 2022, to identify relevant original research on these interventions. A total of 6303 articles were retrieved through the systematic literature search and screened for inclusion. Eighty articles met inclusion criteria and were included in this review and consensus process. METHODOLOGY:A multispecialty panel was convened to explore management of concussion/mTBI. Interventions evaluated included rest, exercise, rehabilitation, and return to activity (RTA) protocols. Studies were assessed for relevance and methodologic quality and were voted upon to develop an evidence-based consensus statement on the therapeutic appropriateness of these interventions for concussion/mTBI. A meta-analysis was not performed. SYNTHESIS:There was sufficient evidence to recommend exercise as an appropriate therapy for adolescents with acute concussion/mTBI. In other age groups and for other therapeutic modalities, although some studies demonstrated benefits for some of the interventions, mixed results and study limitations prevented the panel from drawing firm conclusions on the efficacy of those interventions. The panel found evidence of detrimental effects from strict rest and high-intensity physical activity. CONCLUSIONS:The panel recommended exercise as an appropriate therapy for acute concussion in adolescents. The evidence on other therapeutic interventions for concussion/mTBI remains limited to small randomized controlled trials and observational studies of moderate to low quality. The panel found no strong evidence to support or recommend against the other evaluated interventions but found most interventions to be safe when used judiciously and in consideration of individual patient needs. High-quality randomized studies with sufficient power are needed to evaluate the effects of rest, rehabilitation, and RTA protocols for the management of concussion/mTBI.

BACKGROUND:A validated clinical risk tool has been developed to identify pediatric and adolescent patients at risk of developing persisting symptoms after concussion, but has not been prospectively investigated within a sample of athletes seen after concussion by primary care sports medicine physicians and/or athletic trainers.PURPOSE:To determine whether a validated clinical risk prediction tool for persistent postconcussive symptoms (PPCSs) predicted which patients would develop PPCSs when obtained within 14 days of concussion among a multicenter sample of adolescent athletes.STUDY DESIGN:Cohort study; Level of evidence, 2.METHODS:Pediatric and adolescent patients (8-18 years of age) from 7 pediatric medical centers and 6 secondary school athletic training facilities who were diagnosed with a concussion and presented ≤14 days after concussion were enrolled as part of the Sport Concussion Outcomes in Pediatrics (SCOPE) study during their initial visit and were followed until symptom resolution. Clinical risk scores (Predicting and Preventing Post-concussive Problems in Pediatrics [5P]) and total symptom severity were obtained using the Post-Concussion Symptom Inventory at the initial visit (mean, 4.9 ± 2.9 days after concussion). Participants were then compared based on symptom resolution time: PPCS group (≥28 days to symptom resolution) and no-PPCS group (<28 days). The authors assessed the odds of developing PPCSs based on the 5P risk score using a binary logistic regression model and the utility of the clinical risk prediction tool to identify total time to symptom resolution using a Cox proportional hazards model.RESULTS:A total of 184 participants enrolled, underwent initial evaluation, and were followed until symptom resolution (mean age, 15.2 ± 2.1 years; 35% female). The mean time to symptom resolution across the entire sample was 17.6 ± 3.7 days; 16% (n = 30) of participants developed PPCS. Those in the PPCS group had significantly greater mean initial total 5P risk scores than those in the no-PPCS group (7.9 ± 1.7 vs 5.9 ± 2.3, respectively; P < .001). After adjustment for initial symptom severity, time to assessment, and assessment setting, a higher initial total 5P risk score was associated with a significantly greater odds of developing PPCSs (adjusted odds ratio, 1.49; 95% CI, 1.07-2.08; P = .019). Furthermore, a higher 5P risk score was significantly associated with longer total symptom resolution time (hazard ratio, 0.80; 95% CI, 0.74-0.88; P < .001).CONCLUSION:In a multicenter sample of youth athletes seen in different outpatient health care settings, the 5P risk score accurately predicted which athletes may be at risk for developing PPCSs.

Objective: To examine patient and injury factors that may predict quality of life (QoL) and symptom duration after concussion. Design: Prospective, longitudinal. Settings: Six children's hospital-based medical centers and 9 secondary school athletic training facilities. Patients: Pediatric patients (8-18 years) were enrolled as part of the Sport Concussion Outcomes in Pediatrics (SCOPE) study during their initial visit for a diagnosis of sport-related concussion. Interventions: Patients completed a medical history, the Postconcussion Symptom Inventory (PCSI), and Patient-Reported Outcomes Measurement Information System Pediatric Profile-25 (PROMIS-PP). Main Outcome Measures: Eight predictor variables [age, sex, assessment time, loss of consciousness, amnesia and history of concussion, migraines, or attention-deficit hyperactivity disorder or (ADHD)] were assessed using regression models constructed for each dependent variable. Results: A total of 244 patients (15.1 ± 2.1 years, 41% female) were enrolled (mean = 5 ± 3 days after concussion; range = 1-14 days). Female sex, later initial assessment, and presence of amnesia were associated with lower QoL scores on several domains, whereas loss of consciousness was associated with higher QoL for fatigue. A history of migraines was associated with lower peer relationship QoL. Patients who subsequently developed persisting symptoms had lower mobility scores and higher anxiety, depressive symptom, fatigue, and pain interference scores. Conclusions: Female sex, later clinic presentation, and amnesia were associated with a lower QoL related to mobility, anxiety, depressive symptoms, fatigue, and pain interference. Interestingly, previous concussion and preinjury ADHD diagnosis did not negatively impact postinjury QoL at the initial visit. Future studies should assess the influence of these factors on QoL at later postinjury time points using a concussion-specific outcomes instrument.

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.

Background: Concussion produces diverse symptoms, functional impairment, and societal limitations that may result in decreased quality of life (QoL). Various factors, including sex, prior concussion and mental health history have been associated with a reduction of QoL compared to baseline. However, the influence of various factors on post-concussion QoL has not been investigated in a prospective, multi-site investigation. Hypothesis/Purpose: To examine factors that may predict decreased post-concussion QoL and increased symptom severity. Methods: Pediatric patients (6-18 years) were enrolled as part of the Sport Concussion Outcomes in Pediatrics (SCOPE) study at 6 children’s medical centers and 9 secondary schools during the initial visit for a diagnosis of sport-related concussion. Patients completed a medical history, the Post-Concussion Symptom Inventory (PCSI), and Patient-Reported Outcomes Measurement Information System Pediatric Profile-25 (PROMIS-PP). The PCSI is an age-specific, validated symptom survey on which patients rate their current concussion symptoms. Higher numbers indicate greater symptom severity. The PROMIS-PP includes six domains: physical functioning and mobility, anxiety, depressive symptoms, fatigue, peer relationships, and pain interference. Lower scores indicate higher QoL for all domains, except peer relationships, where a higher score indicates better QoL. Eight predictor variables (Table 1) were assessed using negative binomial regression models constructed for each dependent variable. Results: The analysis included 141 patients (14.9±2.4 years, 40.4% female). Patients were enrolled 5.2±3.1 days post-concussion (range=1-14 days). The percentage (frequency) of patients with a positive self-reported medical history included prior concussion (38%, n=55), migraines (4% (n=5), ADD/ADHD (11%, n=55), LOC at time of injury (7%, n=10), and amnesia at time of injury (20%, n=29). Table 1 presents the pre-injury characteristics associated with each QoL domain and the total PCSI score. Self-reported amnesia was a significant predictor of lower QoL for the anxiety, depressive symptoms, fatigue, and pain interference domains. Migraines were associated with higher QoL scores in the anxiety domain. Younger age and longer time since injury were associated with higher symptom severity. Conclusion: Self-reported amnesia at the time of concussion was associated with a lower QoL related to anxiety, depressive symptoms, fatigue, and pain interference. Interestingly prior concussion and other pre-injury factors did not significantly impact post-injury QoL at the initial visit. Future studies should assess the influence of these factors on QoL at later post-injury time points using a concussion-specific outcomes instrument. Patients may be able to better reflect on the impact of the concussion on QoL over time during recovery. Table 1. Patient characteristics associated with each quality-of-life domain and total PCSI score. Due to the zero-inflated count variable nature of the PROMIS variables, negative binomial regression models were constructed for each domain. *Significant predictor of QoL domain.

Background Concerns that athletes may be at a higher risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission has led to reduced participation in sports during the COVID-19 pandemic. We aimed to assess COVID-19 incidence and transmission during the spring 2021 high school and college water polo seasons across the United States. Methods This prospective observational study enrolled 1825 water polo athletes from 54 high schools and 36 colleges. Surveys were sent to coaches throughout the season, and survey data were collected and analyzed. Results We identified 17 COVID-19 cases among 1223 high school water polo athletes (1.4%) and 66 cases among 602 college athletes (11.0%). Of these cases, contact tracing suggested that three were water polo–associated in high school, and none were water polo–associated in college. Quarantine data suggest low transmission during water polo play as only three out of 232 (1.3%) high school athletes quarantined for a water polo–related exposure developed COVID-19. In college, none of the 54 athletes quarantined for exposure with an infected opponent contracted COVID-19. However, in both high school and college, despite the physical condition of water polo athletes, both high school (47%) and college athletes (21%) had prolonged return to play after contracting COVID-19, indicating the danger of COVID-19, even to athletes. Conclusions While COVID-19 spread can occur during water polo play, few instances of spread occurred during the spring 2021 season, and transmission rates appear similar to those in other settings, such as school environments.

ABSTRACT BACKGROUND Return to learn (RTL) after mild traumatic brain injury (mTBI) presents unique challenges for school professionals. A multidisciplinary team approach is necessary yet training school professionals is logistically difficult. This paper describes an innovative pilot RTL program and its evaluation. METHODS Utilizing the telehealth/telementoring program Project ECHO® (Extension for Community Healthcare Outcomes), this study utilized a multidisciplinary team of subject matter experts to deliver five 1‐hour sessions across 5 cohorts of school‐based professionals (total of 133 participants). The evaluation used a mixed‐methods approach of post‐session and post‐program participant surveys and post‐program participant focus groups. RESULTS Participants who completed a post‐program survey reported statistically significant improvements in essential aspects of RTL knowledge and self‐efficacy. This included improvements in how to manage a student with an mTBI (44.8% to 86.9%), benefits of early return to school for students following mTBI (31.8% to 86.9%), and the importance of written RTL policies/procedures (55.1% to 97.1%). CONCLUSIONS This study demonstrates that RTL training via a telementoring approach may be a positive and effective way to train school‐based professionals and improve knowledge and self‐efficacy, especially when attending face‐to‐face trainings are difficult. This model has the potential to produce programmatic and systematic improvements for RTL education.

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

Background: Persistent postconcussive symptoms (PPCS) can negatively impact quality of life, school, and return to sport. The Predicting and Preventing Postconcussive Problems in Pediatrics [5P] clinical risk score has been validated in the Emergency Department setting to predict pediatric patients at risk of PPCS using 9 variables. Hypothesis/Purpose: To determine if the 5P risk score, obtained within 14 days of concussion, predicts which athletes seen in an athletic training or pediatric sports medicine clinic setting develop PPCS in a multi-center sample. Methods: Data were prospectively collected from participants enrolled in the Sport Concussion Outcomes in Pediatrics (SCOPE) study between September 2018-May 2021 across seven sites. Participants aged 6-18 years diagnosed with a concussion who presented within 14 days of injury were included. Demographics, medical history, and the Postconcussion Symptom Inventory (PCSI) were reviewed to calculate the 5P risk score. 5P risk scores were stratified as low (0-3 points), medium (4-8 points), and high risk (9-12 points). Participants were grouped based on symptom resolution time: PPCS (≥28 days) and no PPCS (<28 days). We compared total symptom resolution time among the 5P risk categories using one-way ANOVA and assessed the odds of developing PPCS based on 5P risk score using a binary logistic regression model. Results: We included 117 participants: 23 with PPCS (19.7%). A higher proportion of the PPCS group were female, were seen in a sports medicine clinic setting, and had a longer time to initial presentation (Table 1). Both PCSI symptom severity and 5P risk score were significantly higher in the PPCS group compared to the no PPCS group (p<0.001). Participants with high risk 5P scores had a significantly longer mean symptom resolution time compared to those with low risk scores (Figure 1; 28.4±18.2 vs 7.1±6.8 days, p=0.009). After adjusting for potential confounding variables of initial symptom severity, time to presentation, and assessment setting, each point increase on the 5P risk score was associated with a 1.7x odds of developing PPCS (odds ratio=1.66; 95% CI=1.13, 2.41; p=0.009). Conclusion: In a multi-center sample of youth athletes, the 5P risk score accurately predicted which athletes were at risk for developing PPCS. The odds of developing PPCS increases with each point increase on the risk score. The 5P risk score can help clinicians identify which athletes are likely to develop PPCS, which may aid in educating families on expectations of recovery and/or provide opportunities for targeted intervention to facilitate sooner recovery. Table 1. 5 P Variables and other Patient Characteristics Comparing PPCS and no PPCS groups Figure 1. Symptom resolution time among the three 5P risk categories ( Low : n=15; Medium : n=80; High : n=25; p=0.009)

Background: Post-concussion sequelae in adolescents include physical, cognitive, and psychosocial effects that may result in reduced quality of life (QOL) and academic challenges when returning to school. The COVID-19 pandemic resulted in altered teaching and learning models outside the traditional in-person classroom, and elevated psychosocial stress and isolation among adolescents. It is unknown whether these changes affected QOL or academic challenges post-concussion. Hypothesis/Purpose: To compare self-reported QOL and academic challenges among concussed adolescents prior to and during the COVID-19 pandemic. Methods: Concussed adolescents were enrolled from secondary schools and children’s medical centers across seven sites into the Sport Concussion Outcomes in Pediatrics (SCOPE) study (PRiSM Concussion RIG). Participants completed demographics, medical history, symptom report, the Concussion Learning Assessment and School Survey (CLASS) and QOL via PROMIS Pediatric Global 25 during their first evaluation visit. Participants were grouped by date ranges: September 2018-January 2020 (Pre-COVID-19) and September 2020-May 2021 (COVID-19). No participants were enrolled between February-August 2020 (cessation of clinical research activities during this time.). Results: A total of 141 patients were enrolled. Mean age=14.9±2.4 years, 61% self-reported as male, 82% white and 85% not Hispanic or Latino, 5.2 + 3.1 days post-injury (range=1-14 days). Seventy-four patients were enrolled prior to COVID, and 67 were enrolled during COVID ( Table 1 ). No significant differences were found between the ‘Pre-COVID-19’ group versus ‘During COVID-19’ group in symptom resolution, symptom severity score, QOL, or academic concerns ( Table 2 ). The only difference was the ‘person at school who is best to coordinate support.’ A significantly lower proportion of participants who sustained their concussion during COVID-19 reported their principal/assistant principal would be the best person to coordinate support compared to those who sustained their concussion before the COVID-19 pandemic. In contrast, a significantly higher proportion of those who sustained their concussion during the COVID-19 pandemic reported their coach would be the best person to coordinate support. Conclusion: In this convenience yet nationally representative sample, students who sustained a concussion during the pandemic did not report increased academic concerns or reduced QOL compared to those whose injury was prior to the pandemic. Median symptom severity was lower during the pandemic, though not statistically significant. These findings could represent shifted priorities of the principal/assistant principal but still adequate support from medical and school-based staff; less academic stress and greater flexibility during the COVID-19 pandemic; or may represent limitations in the CLASS instrument to detect differences that occurred during the pandemic. Table 1 Participant characteristics by group. Data are presented as mean (standard deviation) or n (% within group). Table 2 Clinical and Quality of Life characteristics (via PROMIS Pediatric Global 25) between groups, assessed at the initial post-concussion assessment. Data are presented as median [interquartile range] and compared using Mann Whitney U tests.

Background: Concussion may cause physical and cognitive deficits that can affect the ability of students to perform at their typical academic level in school. Symptomatic students and their parents have previously reported concern about the impact of concussion on school performance. However, student confidence in their school’s ability to support return to school and its relationship with recovery time and overall academic concern has not been investigated. Hypothesis/Purpose: To determine if student confidence in their school’s ability to support return to school following concussion is associated with recovery time and other academic concerns. Methods: Student-athletes were enrolled in the Sport Concussion Outcomes in Pediatrics (SCOPE) study by a physician or athletic trainer across seven sites. Students and their parent/guardian completed the Concussion Learning Assessment and School Survey (CLASS) along with other standardized assessments. Participants were grouped based on responses to the CLASS question about confidence in their school’s ability to support return to school (very confident vs. not/mildly/moderately confident). Symptom resolution time, initial symptom severity, academic outcomes and parent-reported expected academic supports were evaluated using separate Chi-squared analyses. Results: A total of 141 patients were included; 72 (51%) reported being very confident in their school’s ability to support return to school. There was no significant difference in time to symptom resolution between groups (p = 0.84; mean difference= 0.9 days [95% CI= -7.4, 9.2]). The group who was very confident in school support reported a significantly lower initial symptom severity (p <0.001; mean difference= 0.12 [95% CI= 0.05, 0.18]). A higher proportion of those who felt very confident in school support reported no concern about concussion affecting school learning and performance (Table 2; 36% vs 10%, p=0.005). A lower proportion of those who felt very confident in their school support felt the concussion might affect their grades compared to those who expressed no/mild/moderate confidence in school support (Table 2; 56% vs 23%, p=0.001). Conclusion: In this multi-center study, although there was no difference in symptom resolution between groups, students who reported being very confident in their schools’ ability to support return to school had a lower initial symptom severity, expressed less concern about the concussion affecting their school learning, performance, and grades. These findings support recommendations for a collaborative team to assist students returning to school following concussion. Table 1. Patient characteristics for the two participant groups. Data are presented as mean (sd) or number within group (% within group). Table 2. Academic outcomes for both participant groups.

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.

Abstract Musculoskeletal (MSK) and sports-related conditions are relatively common in the pediatric population. Pediatric residencies should provide residents with the knowledge and skills to assess and manage both acute and chronic MSK and sports injuries and complaints. Residents should develop the competencies and attitudes to safeguard and promote a healthy and active lifestyle for youth. Programs can use a variety of educational tools, both in the clinic and on the field, to provide a well-rounded MSK curriculum throughout the residency years. This article provides a review of general pediatric sports medicine curriculum guidelines and suggested implementation strategies.

Background: Concussion is a complicated injury that affects many facets of life in children and adolescents. Neurocognitive and self-reported symptom outcomes are commonly used to understand post-concussion effects. The degree to which concussion affects quality-of-life (QoL) and school performance remains difficult to determine among this age group. Purposes and Hypotheses: Our first purpose was to compare QoL domains using the Patient-Reported Outcomes Measurement Information System (PROMIS) among concussed children to healthy children. We hypothesized that concussed children would report worse QoL than controls. Our second purpose was to identify school-related difficulties that children encounter post-concussion. We hypothesized that the majority of patients would report moderate-to-high academic concerns. Methods: We conducted a multi-site study of patients evaluated at pediatric sports medicine centers and healthy controls undergoing pre-participation physical examinations. All participants were less than 19 years of age and those with a concussion were evaluated <14 days post-injury. Our primary outcomes were derived from PROMIS and Concussion Learning Assessment and School Survey (CLASS) questionnaires. The CLASS was completed only among the concussed group. We compared PROMIS outcomes using Mann Whitney U tests and constructed linear regression models to control for the effect of age and sex. Results: Forty-four individuals participated: 22 with concussion and 22 controls. No significant differences were noted between groups in regard to sex or age. On average, the concussion group missed 2.8 days of school, required 25 days for symptom resolution, and 40 days until return to sports clearance (Table 1). The concussion group reported significantly worse mobility, fatigue, pain interference, and pain visual analog scale (VAS) ratings than the control group (Table 2). After adjusting for age and sex, the concussion group still had significantly worse mobility (β=6.6; 95% CI=4.8,8.4), fatigue (β=6.8; 95% CI=4.5,9.2), pain interference (β=6.1; 95% CI=3.5,8.7), and pain VAS ratings (β=4.5; 95% CI=3.7,5.3) than healthy controls. Among the concussed cohort, 52% reported a moderate or very high overall concern related to the perceived effect their concussion had on school performance with 50% reporting that headaches interfered with their schoolwork and 55% reporting that reading/English were the most troubling classes (Table 3). Conclusion: Within 14 days of injury, concussed children reported significantly worse mobility, fatigue and pain outcomes relative to healthy controls, and reported troubling academic concerns related to their injury. Assessment of patient-reported outcomes following concussion may provide valuable insights to direct management plans beyond typical assessments of concussion symptoms or neurocognitive function. Table 1. Characteristics of concussion and control groups. Continuous variables are presented as means (sd) and categorical variables are presented as n (%). Variable Concussion (n=22) Control (n=22) P value Female sex 12 (55%) 12 (55%) 1.00 Age (years) 13.5 (3.4) 14.8 (1.7) 0.11 Assessment time (days post-injury) 7.6 (3.6) - - Number of school days missed (days) 2.8 (1.7) - - Symptom resolution time (days) 25.1 (16.4) - - Return to play time (days) 40.1 (26.5) - - Table 2. Comparison between concussion and control groups on PROMIS outcome measures. Data are presented as median [interquartile range]. Domain Concussion Control P value Mobility 8 [2-9] 0 [0-0] < 0.001 Anxiety 2 [0-8] 2 [0-6] 0.63 Depressive 2.5 [1-5] 1 [0-2] 0.05 Fatigue 8 [6-12] 1 [0-3] < 0.001 Peer relationships 16 [12-16] 15 [12-16] 0.55 Pain interference 9 [5-12] 0 [0-2] < 0.001 Pain VAS rating 5 [3-6] 0 [0-1] < 0.001 Table 3. School-related difficulties reported by concussion patients on the CLASS survey. Factor Response % (n) Concern about injury affecting school performance Very concernedModerately concernedMildly concernedNot concerned 19% (4)33% (7)29% (6)19% (4) School factor most concerned about Grades droppingAbility to learn, remember, concentrateAmount of work/falling behindOther 52% (10)21% (4)16% (3)11% (2) Types of problems experienced after concussion Headaches interferingCan’t pay attention in classToo tiredHomework is taking longerDifficulty studying for testsDifficulty taking notesDifficulty understanding material 50% (11)45% (10)41% (9)27% (6)27% (6)23% (5)14% (3) Classes/subjects producing the most trouble after concussion Reading/EnglishMathScienceSocial Studies/HistoryForeign LanguagePhysical EducationArtMusic 55% (12)32% (7)18% (4)14% (3)9% (2)9% (2)5% (1)5% (1) Grades affected since injury? YesNot yet, but worried they mightNo 39% (7)33% (6)28% (5) Kind of help needed in returning to school Rest breaksExtra time to complete workI don’t knowReduced homeworkShortened dayNo testsShorter classes 55% (12)45% (10)32% (7)27% (6)23% (5)14% (3)5% (1) Best person at school to coordinate support Guidance counselorHomeroom teacherAthletic trainerPrincipal/Assistant PrincipalSchool nurseCoachSchool psychologistSpecial education teacher 27% (6)27% (6)18% (4)18% (4)14% (3)14% (3)5% (1)5% (1)

Objective: Youth athletes are believed to be more susceptible to white matter (WM) degradation resulting from head impact exposure relative to high school (HS) athletes; this hypothesis has not been objectively tested. The purpose of this study was to determine preseason to postseason changes in WM integrity from repetitive head impacts for youth football (YFB) players compared with HS football players during a competitive football season. Design: Prospective cohort. Setting: One season of YFB (grades 7 and 8) and varsity HS football (grades 10-12). Patients or Other Participants: Twelve YFB (13.08 ± 0.64 years) and 21 HS (17.5 ± 0.78 years) athletes. Interventions: Participants completed 2 magnetic resonance imaging sessions: preseason and postseason. Head impact exposure was recorded during practice and games using a helmet-mounted accelerometer. Main Outcome Measures: Tract-based spatial statistics were used to evaluate group differences in preseason to postseason changes in diffusion tensor imaging, including fractional anisotropy and mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD). Results: The HS group exhibited significant preseason to postseason reductions in MD, AD, and RD (P < 0.05, corrected) in widespread WM areas. Significant WM reductions for the YFB group were only observed for AD (P < 0.05, corrected), but was more limited in extent compared with HS. Conclusions: Significant preseason to postseason AD reduction was found in both YFB and HS groups after one season of competitive play. Our results did not confirm recent speculation that younger children are more susceptible to the deleterious effects of repetitive head impacts compared with their older counterparts.

Context: Patients with anterior cruciate ligament (ACL) tears are likely to have deficient dynamic postural stability compared with healthy sex- and age-matched controls. Objectives: To test the hypothesis that patients undergoing ACL reconstruction have decreased dynamic postural stability compared with matched healthy controls. Design: Prospective case-control study. Setting: Orthopedic sports medicine and physical therapy clinics. Patients or Other Participants: Patients aged 20 years and younger with an ACL tear scheduled for reconstruction were enrolled prospectively. Controls were recruited from local high schools and colleges via flyers. Interventions: Patients underwent double-stance dynamic postural stability testing prior to surgery. recording time to failure and dynamic motion analysis (DMA) scores. Patients were then matched with healthy controls. Main Outcome Measures: Demographics, time to failure, and DMA scores were compared between groups. Results: A total of 19 females and 12 males with ACL tears were matched with controls. Individuals with ACL tears were more active (Marx activity score: 15.7 [1.0] vs 10.8 [4.9], P < .001); had shorter times until test failure (84.4 [15.8] vs 99.5 [14.5] s, P< .001); and had higher (worse) DMA scores (627 [147] vs 481 [132], P < .001), indicating less dynamic postural stability. Six patients with ACL deficiency (1 male and 5 females) demonstrated lower (better) DMA scores than their controls, and another 7 (4 males and 3 females) were within 20% of controls. Conclusions: Patients undergoing ACL reconstruction had worse global dynamic postural stability compared with well-matched controls. This may represent the effect of the ACL injury or preexisting deficits that contributed to the injury itself. These differences should be studied further to evaluate their relevance to ACL injury risk. rehabilitation, and return to play.

PURPOSE The purpose of this article is to familiarize healthcare providers and parents with educational language, laws, and processes as they relate to a comprehensive ascending level of academic supports as it pertains to promoting a smooth and supported transition to school following a concussion. BACKGROUND Returning to learn (RTL) following a concussion is of parallel importance to returning to sport (RTS). A successful RTL is a critical part of concussion management. Many RTL articles advise healthcare providers and parents to request formalized educational supports, also known as Tier 2 or Tier 3 services, for children with concussion as they return to school. FINDINGS Premature requests for formal (Tier 2 or 3) educational services, rather than allowing for immediate informal educational supports (known as Tier 1), can actually delay academic supports and have the potential to cause adversarial relationships between parents and schools. Additionally, this practice contradicts current research demonstrating the need for fast, flexible, temporary academic supports within the first month post-injury. CONCLUSION Allowing school districts to direct the application of existing ascending levels of educational support for students with concussion as they return to school can promote robust and positive outcomes.

Sport-related concussion is an important topic in nearly all sports and at all levels of sport for children and adolescents. Concussion knowledge and approaches to management have progressed since the American Academy of Pediatrics published its first clinical report on the subject in 2010. Concussion's definition, signs, and symptoms must be understood to diagnose it and rule out more severe intracranial injury. Pediatric health care providers should have a good understanding of diagnostic evaluation and initial management strategies. Effective management can aid recovery and potentially reduce the risk of long-term symptoms and complications. Because concussion symptoms often interfere with school, social life, family relationships, and athletics, a concussion may affect the emotional well-being of the injured athlete. Because every concussion has its own unique spectrum and severity of symptoms, individualized management is appropriate. The reduction, not necessarily elimination, of physical and cognitive activity is the mainstay of treatment. A full return to activity and/or sport is accomplished by using a stepwise program while evaluating for a return of symptoms. An understanding of prolonged symptoms and complications will help the pediatric health care provider know when to refer to a specialist. Additional research is needed in nearly all aspects of concussion in the young athlete. This report provides education on the current state of sport-related concussion knowledge, diagnosis, and management in children and adolescents.