Daniel C. Herman

Headgear designed to protect girls' lacrosse athletes is widely available and permitted for voluntary use; however, it remains unknown how policies mandating headgear use may change the sport and, particularly regarding impacts during game-play. Therefore, this study compares the impact rates and game play characteristics of girls' high school lacrosse in Florida which mandates headgear use (HM), with states having no headgear mandate (NHM). Video from 189 randomly-selected games (HM: 64, NHM: 125) were analyzed. Descriptive statistics, Impact Rates (IR), Impact Rate Ratios (IRR), Impact Proportion Ratios (IPR), and 95% Confidence Intervals (CI) were calculated. IRRs and IPRs with corresponding CIs that excluded 1.00 were deemed statistically significant. 16,340 impacts (HM:5,821 NHM: 10,519; 86.6 impacts/game, CI: 88.6-93.3) were identified using the Lacrosse Incident Analysis Instrument (LIAI). Most impacts directly struck the body (n = 16,010, 98%). A minority of impacts directly struck a player's head (n = 330, 2%). The rate of head impacts was significantly higher in the HM cohort than NHM cohort (IRR = 2.1; 95% CI = 1.7-2.6). Most head impacts (n = 271, 82%) were caused by stick contact in both groups. There was no difference in the proportion of penalties administered for head impacts caused by stick contact between the HM and NHM cohorts (IPR IRRHM/NHM = 0.98; CI = 0.79-1.16). However, there was a significantly greater proportion of head impacts caused by player contact that resulted in a penalty administered in the HM cohort (IPR = 1.44 CI = 1.17-1.54). These findings demonstrate that mandating headgear use was associated with a two-fold greater likelihood of sustaining a head impact during game play compared to NHM states. A majority of head impacts in both HM and NHM states were caused by illegal stick contact that did not result in penalty.

Objectives Headgear use is a controversial issue in girls’ lacrosse. We compared concussion rates among high school lacrosse players in an American state with a headgear mandate (HM) to states without an HM. Methods Participants included high schools with girls’ lacrosse programmes in the USA. Certified athletic trainers reported athlete exposure (AE) and injury data via the National Athletic Treatment, Injury and Outcomes Network during the 2019–2021 seasons. The HM cohort was inclusive of high schools from the state of Florida, which mandates the use of ASTM standard F3137 headgear, while the non-HM (NHM) cohort was inclusive of high schools in 31 states without a state-wide HM. Incidence rate ratios (IRRs) and 95% CIs were calculated. Results 141 concussions (HM: 25; NHM: 116) and 357 225 AEs were reported (HM: 91 074 AEs; NHM: 266 151 AEs) across all games and practices for 289 total school seasons (HM: 96; NHM: 193). Overall, the concussion injury rate per 1000 AEs was higher in the NHM cohort (0.44) than the HM cohort (0.27) (IRR=1.59, 95% CI: 1.03 to 2.45). The IRR was higher for the NHM cohort during games (1.74, 95% CI: 1.00 to 3.02) but not for practices (1.42, 95% CI: 0.71 to 2.83). Conclusions These findings suggest a statewide HM for high school girls’ lacrosse is associated with a lower concussion rate than playing in a state without an HM. Statewide mandates requiring ASTM standard F3137 headgear should be considered to reduce the risk of concussion.

Background: Studies have demonstrated an increased risk of musculoskeletal (MSK) injury after concussion in collegiate and professional athletes, but there has been relatively little study of this relationship in younger athletes.Objective: To determine the odds of experiencing a subsequent MSK injury after concussion in high school athletes. It was hypothesized that concussion would increase the risk of MSK injury within 365 days of the concussion event.Design: Retrospective observational study.Setting: Twelve high school sports programs.Participants: Athletes (n = 14,461) from athletic training room records queried between 2010 and 2017.Independent Variables: History of concussion and history of concussion and MSK injury in the year preceding MSK injury.Main Outcome Measures: General estimating equation analyses were conducted to examine the odds of MSK injury related to (1) concussion within the preceding 365 days of injury; and (2) concussion and MSK injury within the preceding 365 days of concussion.Results: Respectively, 8% and 8.3% of athletes were identified with a concussion and MSK injury. After controlling for gender and sport, athletes with a concussion and prior MSK injury (odds ratio = 2.19, 95% confidence interval: 1.02–4.67) and athletes with a concussion alone (odds ratio = 1.67, 95% confidence interval: 1.15–2.44) both had higher odds of experiencing a subsequent MSK injury compared to athletes without prior concussion.Conclusions: High school athletes who sustain a concussion have elevated odds of MSK injury at rates comparable to those for collegiate athletes. These findings support the use of neuromuscular–based rehabilitation and injury prevention protocols in the post‐concussion period. These findings may also suggest exploring methods to modify concussion return‐to‐play criteria with the goal to reduce the risk of future MSK injury.

Headgear adoption is a controversial issue in girls’ lacrosse due to concerns that headgear use will facilitate greater risk-taking by players and contribute to more aggressive game play behaviours. The purpose of this pilot study was to evaluate high school girls’ lacrosse players’ attitudes towards headgear before and after a season of use. Twenty-five high school girls’ lacrosse athletes wore headgear for one competitive season and completed a pre- and post-season survey. The survey evaluated players’ attitudes towards headgear use, with Aggressiveness, and Anger scales. Wilcoxon ranked tests were conducted to compare scores pre- and post-season. Players’ attitude towards headgear largely remained unchanged and “neutral” after a season of wearing headgear. Players endorsed slightly greater agreement for three Headgear survey items post-season compared to pre-season: “ … headgear allows me to be more aggressive … ” (p = .01), “ … players should wear more protective equipment ” (p = .04) and “ … wearing headgear increases how often I am hit in the head … ” (p = .04). However, Aggressiveness and Anger scale scores were not changed following headgear use. Our findings suggest the perception of headgear use in high school girls’ lacrosse is complex and could be associated with minor perceived changes in game play behaviours.

Two female athletes presented to clinic following a head injury and exhibited signs of concussion. Both athletes experienced exacerbation of symptoms secondary to dysautonomia related to concussion injury on the Buffalo Concussion Treadmill Test (BCTT). On repeat evaluation, both athletes exhibited neck pain with symptoms immediately provoked by palpation of the occipital nerves. After a third occipital nerve block, both athletes had complete resolution of symptoms and subsequently tolerated BCTT to the maximum rate of perceived exertion with no provoked symptoms. The athletes were cleared for return to sport without issue. These cases indicate a potential limitation in the utility of the BCTT for determining the etiology and management of concussion and postconcussion syndrome.

Sex-based differences in neuromuscular characteristics relevant to anterior cruciate ligament (ACL) injury risk may arise as compensation for divergent strength development during puberty. Strength training during this period may prevent the development of these undesirable neuromuscular characteristics. Strength-trained middle school girls will have improved jump-landing biomechanics compared with control participants. Cohort study. Level 3. Maximum voluntary isometric contraction in hip extension and abduction and knee extension and flexion as well as Landing Error Scoring System (LESS) scores were collected for healthy female middle school students of grades 6 to 8. Strength-training participants (STR: N = 30; height, 1.63 ± 0.07 m; mass, 48.1 ± 7.6 kg; age, 12.5 ± 1.0 y) were matched with control participants (CON: N = 30; height, 1.60 ± 0.09 m; mass, 47.2 ± 8.9 kg; age, 12.6 ± 0.9 y). The training consisted of a 6-month strength-training program administered through a gym class curriculum that targeted the lower extremity. A repeated-measures mixed-model analysis of variance was used for comparisons between groups and across time (α = 0.05). Stepwise linear regression was used to examine the relationship between strength change and LESS score change. Strength values (N·m/kg) increased across time and to a greater degree in STR for hip extension (baseline 3.98 ± 1.15 vs follow-up 4.77 ± 1.80), hip abduction (4.22 ± 1.09 vs 5.13 ± 2.55), and knee flexion (3.27 ± 0.62 vs 3.64 ± 1.40) compared with CON. LESS grades significantly decreased across time in STR (5.58 ± 1.21 vs 4.86 ± 1.44) and were significantly lower than CON (5.98 ± 1.42) at follow-up (P < 0.001). The change in hip extension and knee extension strength explained 67% of the variance (P < 0.001) in the LESS change score in the STR group. A school-based strength-training program that focused on hip and knee musculature significantly improved jump-landing biomechanics (as determined by LESS) relevant to ACL injury risk. Further investigation using different strength-training approaches in this age group is warranted. Strength training during adolescence holds promise as an injury prevention program. The use of a school-based approach is novel and may represent a robust opportunity for injury prevention programs, as physical education class is often mandatory in this age group.

Many sports medicine physicians are currently considering introducing regenerative medicine into their practice. Regenerative medicine and the subclassification of orthobiologics are a complicated topic and have produced widely varying opinions. Although there is concern by government regulators, clinicians, scientists, patient advocacy organizations, and the media regarding the use of regenerative medicine products, there is also excitement about the potential benefits with growing evidence that certain regenerative medicine products are safe and potentially efficacious in treating musculoskeletal conditions. Sports medicine physicians would benefit from decision-making guidance about whether to introduce orthobiologics into their practice and how to do it responsibly. The purpose of this position statement is to provide sports medicine physicians with information regarding regenerative medicine terminology, a brief review of basic science and clinical studies within the subclassification of orthobiologics, regulatory considerations, and best practices for introducing regenerative medicine into clinical practice. This information will help sports medicine physicians make informed and responsible decisions about the role of regenerative medicine and orthobiologics in their practice.