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Objectives: Soccer is one of the most popular youth sports in the United States and worldwide. Due to growing concerns regarding repeated head trauma, in 2015 the United States Soccer Federation (USSF) banned headers for athletes aged 10 and under and limited athletes aged 11 to 13 to practicing headers for 30 minutes per week. The purpose of this study was to assess whether the USSF header policy was associated with fewer soccer-related concussions that presented to emergency departments following the 2015 season. Methods: A retrospective cohort from the National Electronic Injury Surveillance System database was assessed. Age, sex, and injury type were extracted for all soccer-related emergency department visits between January 1st, 2012, and December 31st, 2023. Univariate and multivariable regression analyses were conducted to assess concussions as a percentage of all soccer-related injuries based on sex, age, and year. Results: The number of concussions as a percentage of all soccer-related injuries decreased from 8.2% in 2012-2015 to 6.1% in 2020-2023 (p<0.01). From 2012-2023, the concussion rate among 14-17-year-olds and 10-13-year-olds was higher than 6-9-year-olds (8.9% and 6.6% compared to 4.9%, p<0.01). Despite a lower soccer-related injury rate overall, females were diagnosed with a greater proportion of concussions than males (9.6% compared to 6.2%, p<0.01). In a multivariable regression analysis, injuries that occurred in the years 2020-2023 were associated with lower odds of concussion compared to 2012-2015 (OR: 0.75, 95% CI: 0.69- 0.81). The 10-13-year-old age group, 14-17-year-old age group, and female sex were associated with higher odds of concussion compared to the 6-9-year-old age group and male sex respectively (OR: 1.30, 95% CI: 1.16- 1.45; OR: 1.79, 95% CI: 1.61- 1.99; OR: 1.53, 95% CI: 1.43- 1.63). Conclusions: The USSF youth soccer header policy introduced in 2015 was associated with a 25.6% relative risk reduction to sustain a soccer-related concussion and present to the emergency department in 2020-2023 compared to 2012-2015. A header ban in players under 10 years old and limitation to 30 minutes of header practice a week in players under 13 years old may improve player safety by reducing head impacts in the youth population.

Background: Knee injuries are among the most common injuries in female basketball players. Despite the growing popularity of professional women's basketball, particularly the Women's National Basketball Association (WNBA), there are limited recent data evaluating the incidence of and risk factors for knee injuries in WNBA athletes. Hypothesis: Older age, minutes played per game, number of games played, and player usage rate would be significantly associated with having a knee injury in WNBA players from the 2017 to 2022 seasons. Study Design: Descriptive epidemiology study. Methods: Publicly available data on the injury history and player records of active WNBA players between the 2017 and 2022 seasons were reviewed to identify players with a knee injury resulting in ≥1 games missed. The primary outcome was the incidence of knee injuries reported per 1000 minutes-exposures (MEs). Player demographics, statistics, and injury characteristics were recorded. Secondary analysis was conducted using bivariate and multivariable logistic regression to investigate risk factors associated with having a knee injury. Results: A total of 87 players (10.8% of all players) sustained a combined 104 knee injuries between the 2017 and 2022 seasons, indicating a rate of 6.03 knee injuries per 1000 MEs. Accounting for potential confounders, having a knee injury was significantly associated with older age (OR, 1.11; 95% CI, 1.05-1.18; P = .0002) and higher usage rate (OR, 1.06; 95% CI, 1.02-1.11; P = .02). Conclusion: This study showed that knee injuries occurred in 10.8% of players, with an overall rate of 6.03 injuries per 1000 MEs. The most significant risk factors associated with having a knee injury in WNBA athletes were older age and higher player usage rate. Implementing targeted load management strategies for players with higher usage rates or advanced age may help reduce the incidence of knee injuries among female basketball athletes.

Objectives: Tobacco use is a known modifiable risk factor for postoperative complications and revision surgery after anterior cruciate ligament reconstruction (ACLR). Prior studies focus on “tobacco” as a broad categorization of traditional cigarette smoking, smokeless tobacco, and other forms of nicotine use. It is unclear if differences in the type of nicotine used lead to similar adverse outcomes after ACLR. Thus, the purpose of this study was to (1) assess the incidence of postoperative complications among ACLR patients who use smokeless tobacco, and (2) compare these outcomes with those of patients who do not use tobacco and those who smoke cigarettes. Methods: A retrospective cohort study utilizing a large insurance database was conducted. Patients undergoing primary ACLR without concomitant knee procedures with a minimum 2-year follow-up were included. Smokeless tobacco only users, cigarette only users, and non-tobacco users were matched based on demographic variables and comorbidities. Postoperative complications within 90 days of surgery and subsequent knee surgery within 2 years were compared among groups. Multivariable logistic regressions were employed to control for confounding variables. Results: After applying exclusion criteria, there were 241,194 ALCR patients eligible for analysis. Of these, there were 898 (0.37%) patients that used smokeless tobacco only, 22,062 (9.1%) patients that exclusively used cigarettes, and 207,462 (86%) patients that did not use any tobacco products. Compared to non-users, smokeless tobacco users demonstrated increased risk of emergency department (ED) utilization (20.4% vs 8.7%, OR: 6.29; 95% CI: 3.70-10.9, p<0.001), pneumonia (1.2% vs 0.5%, OR: 3.36; 95% CI: 1.41-7.90, p=0.005), and acute kidney injury (AKI) (1.2% vs 0.1%, OR:12.7; 95% CI: 3.77-52.8, p<0.001) within 90 days of surgery. Additionally, smokeless tobacco users had a markedly increased risk of subsequent ACLR (13.5% vs 3.2%, OR: 4.75; 95% CI: 3.60-6.26, p<0.001) and meniscus surgery (12.9% vs 4.9%, OR: 2.89; 95% CI: 2.23-3.73, p<0.001) within 2 years compared to controls. When compared to cigarette smokers, smokeless tobacco users showed increased risk of ED visits (20.6% vs 19.3%, OR: 1.55; 95% CI: 1.25-1.90, p<0.001), pneumonia (1.2% vs 0.6%, OR: 3.25; 95% CI: 1.33-7.78, p=0.008), and AKI (1.3% vs 0.3%, OR: 7.63; 95% CI: 2.72-22.5, p<0.001) within 90 days. They also demonstrated a significantly increased risk of subsequent ACLR (13.4% vs 4.1%, OR: 4.81; 95% CI: 3.58-6.47, p<0.001) and meniscus surgery (12.8% vs 5.5%, OR: 2.45; 95% CI: 2.45-4.26, p<0.001) within 2 years when compared to cigarette smokers. Conclusions: Smokeless tobacco use was associated with increased risk of medical complications, ED utilization, and subsequent procedures compared to non-user controls and traditional smokers. These findings highlight the importance of considering specific forms of tobacco use in preoperative screening for patients undergoing ACLR.

Background: Decreases in Medicare reimbursement have been noted among many medical specialties. An in-depth analysis of the subspecialty of orthopaedic sports medicine is needed to determine changes in Medicare reimbursement in this field. Purpose/Hypothesis: The purpose was to elucidate the trends in inflation-adjusted Medicare reimbursement for orthopaedic sports medicine procedures between 2000 and 2020. It was hypothesized that Medicare reimbursement decreased substantially during the study period. Study Design: Economic decision and analysis; Level of evidence, 4. Methods: The Physician Fee Schedule Look-up Tool was used to extract Medicare reimbursement information between 2000 and 2020 for 67 procedures related to orthopaedic sports medicine. These values were adjusted for inflation using the Consumer Price Index. The compound annual growth rate (CAGR) was calculated to measure the annual rate of change, and descriptive analyses were performed using the Student t test. Results: Between 2000 and 2020, inflation-adjusted Medicare reimbursement for the 67 included procedures decreased by an average of 33% (CAGR = –2.2%; R 2 = 0.78). Reimbursement decreased for procedures related to the shoulder and elbow by 34% (CAGR = –2.3%; R 2 = 0.80), for hip-related procedures by 23% (CAGR = –1.4%; R 2 = 0.77), for knee-related procedures by 31% (CAGR = –2.0%; R 2 = 0.81), and for procedures relating to the foot and ankle by 38% (CAGR = –2.5%; R 2 = 0.79). Conclusion: Study findings indicated that inflation-adjusted Medicare reimbursement decreased substantially between 2000 and 2020 for orthopaedic sports medicine procedures, ranging from a 23% decrease for hip-related procedures to a 38% decrease for foot and ankle–related procedures. The results of this study could be used to provide further context for health care policy decisions and help ensure sustainable financial environments for orthopaedic sports medicine surgeon.

Background: Concussions have previously been shown to have persistent neurological changes represented by altered reaction time and postural stability in high-level athletes. The effects of concussions on professional basketball players’ performance and subsequent injuries during the 90 days after return to play (RTP) have not been investigated. Purpose/Hypothesis: the purpose of this study was to evaluate player statistical performance and risk of musculoskeletal (MSK) injury within 90 days of RTP from a diagnosed concussion. It was hypothesized that within the 90 days after RTP from a concussion, players would be at a greater risk for MSK injury with an associated decrease in player statistical performance. Study Design: Descriptive epidemiology study. Methods: Concussions sustained by National Basketball Association (NBA) players between the 2015-2016 and 2021-2022 seasons, excluding the 2019-2020 season, were evaluated using a publicly available database. The database was queried to identify any MSK injury in the 90-day post-RTP period after a concussion, along with time loss after subsequent injury. Performance statistics were obtained from each player’s preindex season and postindex season, as well as defined time points within the 90-day post-RTP period. Each concussed player was matched 1 to 1 with a nonconcussed control using position, win shares, player efficiency rating, and points per game. MSK injury incidence and player statistics in the concussion group were compared with controls using unpaired Student t tests. Results: A total of 70 concussions were identified in 70 professional basketball players and included in this analysis. A total of 49 players sustained an MSK injury in the 90-day post-RTP period (70%). Compared with controls, the odds of sustaining an MSK injury in the concussed cohort were 11.3 times greater (95% CI, 5.04-25.2; P < .001). Games missed after subsequent MSK injury were similar between the concussed and control groups (P = .687). Comparisons over the 90-day post-RTP period did not reveal any significant changes in points per game, minutes per game, or true shooting percentage (P > .05). When compared with controls, no changes in performance statistics were significantly different (P > .05). Conclusion: Our analysis demonstrates that basketball players who sustain concussions are at a significantly increased risk for subsequent MSK injury within the 90-day post-RTP period but not player performance. Knowledge of this increased risk of MSK injury in concussed athletes can help guide concussion management for proper RTP and targeted rehabilitation in professional basketball players.

Background: Classically, arthroscopy has been considered one of the diagnostic gold standards for assessing intra-articular knee and shoulder abnormality. Purpose: To assess the risks associated with in-office needle arthroscopy. Study Design: Case series; Level of evidence, 4. Methods: A retrospective case series analysis was performed by evaluating consecutive diagnostic needle arthroscopies performed by 13 physicians at 13 independent institutions. The findings of both major and minor complications were reported by each of the 13 surgeons based on office documentation. The data were analyzed as a lump sum of both knee and shoulder cases and then subdivided and examined separately. The patients’ ages ranged from 14 to 78 years, and no statistical difference was noted between the numbers of men and women. A major complication was defined as infection, chondral toxicity, or the need for alternative treatment at an urgent care or emergency room secondary to the procedure. Minor complications were defined as a vasovagal event, pain that persisted after 24 hours, or the need for crutches or sling postprocedure. Results: Of the 1419 cases, no major complications were reported. The overall rate of vasovagal events was 1.9% for all procedures (1.6% in knees, 3% in shoulders). Persistent pain longer than 24 hours postprocedure was reported in 0.3% of cases. No patient required crutches or a sling. Postarthroscopy magnetic resonance imaging was needed in 1.4% of cases. No device failures were reported. Conclusion: Previous literature has evaluated the efficacy, sensitivity, and specificity of in-office diagnostic arthroscopy, and this study validates needle arthroscopy as safe in the office setting, with minimal risk of major or minor complications.

Background: Shoulder and elbow function is essential to basic basketball actions. Outside of anterior shoulder instability, injuries in these joints are not well characterized in National Basketball Association (NBA) players. Purpose: To describe the epidemiology and associated risk factors of shoulder and elbow injuries in NBA players and identify factors that influence player performance upon return to play. Study Design: Descriptive epidemiology study. Methods: Historical injury data from the 2015-2020 NBA seasons were retrieved from Pro Sports Transactions, a public online database. An injury was defined as a health-related concern resulting in an absence of ≥1 NBA games. Primary measures included pre- and postinjury player efficiency rating (PER) and true shooting percentage (TS%) with interquartile ranges (IQRs), stratified by extremity dominance. Multivariate logistic regression analyses with stepwise regression were performed to identify risk factors associated with return-to-play performance. Results: A total of 192 shoulder and elbow injuries were sustained among 126 NBA athletes, with incidence rates of 1.11 per 1000 game exposures (GEs) and 0.30 per 1000 GEs, respectively. Sprain/strain and general soreness were the most common injury types in both the shoulder and the elbow. In the 2 years after injury, baseline PER was achieved in all groups, except for players with dominant shoulder injuries (baseline PER, 16 [IQR, 14-18] vs 2-year PER, 13 [IQR 11-16]; P = .012). Younger age was associated with quicker return to baseline PER (odds ratio, 0.77 [95% CI, 0.67-0.88]). Shoulder and elbow injuries did not negatively influence TS% upon return to play (baseline TS%, 0.55% [IQR, 0.51%-0.58%] vs 1-year TS%, 0.55% [IQR, 0.52%-0.58%]; P = .13). Conclusion: Dominant shoulder injuries negatively influenced PER during the first 2 seasons upon return to play in NBA players. Therefore, expectations that players with this type of injury immediately achieve baseline statistical production should be tempered. Shooting accuracy appears to remain unaffected after shoulder or elbow injury.

Background: Ankle injuries are more common in the National Basketball Association (NBA) compared with other professional sports. Purpose/Hypothesis: The purpose of this study was to report the incidence and associated risk factors of ankle injuries in NBA athletes. It was hypothesized that factors associated with an increased physiologic burden, such as minutes per game (MPG), usage rate, and associated lower extremity injury, would be associated with increased ankle injury risk and time loss. Study Design: Descriptive epidemiology study. Methods: Ankle injury data from the 2015-2016 through 2020-2021 NBA seasons were evaluated. The truncated 2019-2020 season due to the COVID-19 pandemic was omitted. The primary outcome was the incidence of ankle injuries, reported per 1000 game-exposures (GEs). Secondary analysis was performed to identify risk factors for ankle injuries through bivariate analysis and multivariable logistic regression of player demographic characteristics, performance statistics, injury characteristics, and previous lower extremity injuries. Factors influencing the time loss after injury were assessed via a negative binomial regression analysis. Results: A total of 554 ankle injuries (4.06 injuries per 1000 GEs) were sustained by NBA players over 5 NBA seasons, with sprain/strain the most common injury type (3.71 injuries per 1000 GEs). The majority of ankle injury events (55%) resulted in 2 to 10 game absences. The likelihood of sustaining an ankle injury was significantly associated with a greater number of games played (P = .029) and previous injury to the hip, hamstring, or quadriceps (P = .004). Increased length of absence due to ankle injury was associated with greater height (P = .019), MPG (P < .001), usage rate (P = .025), points per game (P = .011), and a prior history of foot (P = .003), ankle (P < .001), and knee injuries (P < .001). Conclusion: The incidence of ankle injuries was 4.06 per 1000 GEs in professional basketball players. Games played and prior history of hip, hamstring, or quadriceps injuries were found to be risk factors for ankle injuries. Factors associated with physiologic burden such as MPG and usage rate were associated with an increased time loss after injury.

Background: The lever sign test is a new physical examination tool to diagnose anterior cruciate ligament (ACL) tears. Preliminary results suggest almost 100% sensitivity and specificity to diagnose acute and chronic complete ACL tears and clinically significant partial tears as compared with magnetic resonance imaging (MRI). Purpose: To assess the sensitivity and specificity of the lever sign test for the diagnosis of acute ACL injuries, as compared to MRI. We also aimed to determine the accuracy of the lever sign test compared with 3 other tests (anterior drawer, Lachman, and pivot shift) when performed by providers of various training levels, and with the patient awake or under anesthesia. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: We evaluated patients with a chief concern of acute (≤4 weeks) knee pain seen between October 2014 and January 2015, with a thorough history, physical examination, and standard radiographs. MRI was the reference standard; patients without an MRI evaluation were excluded. The 4 physical examination maneuvers were performed on each symptomatic knee during the initial clinic visit (for nonsurgical patients) or under anesthesia in the operating room (for surgical patients) by a randomly assigned undergraduate student, medical student, orthopaedic resident, or orthopaedic fellow. The senior author trained all staff to perform the lever sign test. Statistical analyses were performed. Results: Of 102 patients, 54 were surgical (28 female, 26 male), and 48 were nonsurgical (16 female, 32 male); the mean patient age was 23 years (range, 15-66 years). The overall accuracy of the lever sign test was 77% (63% sensitivity, 90% specificity); the accuracy was similar between patients under anesthesia and awake (77% vs 76%, respectively). There were no significant differences when comparing the sensitivity and specificity of the lever sign test with patients under anesthesia and awake (sensitivity: under anesthesia, 86%, and awake, 68% [P = .40]; specificity: under anesthesia, 85%, and awake, 96% [P = .17]). Furthermore, the accuracy of the lever sign test was similar when performed on female versus male patients (75% vs 79%, respectively) or when performed by undergraduate students and medical students compared with orthopaedic residents and fellows (84% vs 88%, respectively). Conclusion: Our study results challenge the exceptional sensitivity and specificity values (both 100%) of the lever sign test, as reported by the original author of the test.

Objectives: The purpose of this study is to evaluate the effect of low-intensity blood flow restriction (LI- BFR) training utilized in a pre-rehabilitative setting for patients undergoing anterior cruciate ligament reconstruction (ACLR) on postoperative outcomes by minimizing postoperative atrophy and impairment of the quadriceps. We hypothesize that postoperative strength and hypertrophy of the quadriceps will be greater in a population that undergoes preoperative LI-BFR training than that of a population that undergoes low-intensity sham control (LI-SHAM) training. Methods: Twenty-eight subjects undergoing primary ACLR underwent 2 weeks of either a BFR intervention or a SHAM intervention at a rate of 2 sessions per week before surgery. Quadriceps strength and cross-sectional area were measured as well as other exploratory outcomes were measured before and after the intervention before surgery and at 5 different time points after surgery, through 6 months postoperative. Quadriceps strength was assessed through handheld dynamometry and a leg press test and quadriceps cross-sectional area was assessed using musculoskeletal ultrasound imaging. Results: Adjusting for sex, time, and strength/hypertrophy at baseline, there were no significant differences found between treatment groups for the primary endpoints. Compared to 24-48 hours pre- op, this suggests that the post-op average hypertrophy remains significantly lower through 24 weeks post-op, while leg strength is similar at 24 weeks post-op as measured by handheld dynamometer and even significantly larger at 24 weeks as measured by the leg press test. Conclusions: A 2-week preoperative program of LI-BFR training may not be effective to improve postoperative quadriceps strength and hypertrophy after ACLR.