Concussion is a significant public health issue and is of concern to all health care providers working in sports medicine due to the impacts on the long term well-being in athletes.
Post concussion, there is an increased risk for lower extremity injury:
Pietrosimone et al (2015):
Data from 2429 players (66.6% response rate) were available for analysis. Nearly 61% reported suffering a concussion while competing in the NFL. Meniscal tear was the most commonly reported musculoskeletal injury (32%). Compared to NFL players who did not sustain a concussion, retired NFL players with 1, 2, or 3+ concussions had between 18-63%, 15-126%, and 73-165% higher odds of reporting various musculoskeletal injuries, respectively.
Lynall et al (2015):
Within 1-year post-concussion, the concussed group was 1.97 (95% CI: 1.19-3.28; P=0.01) times more likely to have suffered an acute lower extremity musculoskeletal injury post-concussion than prior to concussion, and 1.64 times (95% CI: 1.07-2.51; P=0.02) more likely to have suffered an acute lower extremity musculoskeletal injury post-concussion than their matched non-concussed cohort over the same time period. Up to 180-days post-concussion, the concussed group was 2.02 (95% CI 1.08-3.78; P=0.02) times more likely to have suffered an acute lower extremity musculoskeletal injury post-concussion than prior to concussion.
Nordström et al (2014)
During the follow-up period, 66 players sustained concussions and 1599 players sustained other injuries. Compared with the risk following other injuries, concussion was associated with a progressively increased risk of a subsequent injury in the first year (0 to
Brooks et al (2016)
The incidence of acute lower extremity musculoskeletal injury was higher among recently concussed athletes (15/87; 17%) compared with matched controls (17/182; 9%). The odds of sustaining an acute lower extremity musculoskeletal injury during the 90-day period after return to play were 2.48 times higher in concussed athletes than controls during the same 90-day period (odds ratio, 2.48; 95% CI, 1.04-5.91; P = .04).
Westermann et al (2016):
NCAA tackling rule changes that penalize head to head contact, and encourage tackling of the lower extremity have had some proven impacts in collegiate football. However, according to researchers presenting their work at the American Orthopaedic Society for Sports Medicine’s (AOSSM) Specialty Day, an unintended consequence of these rule changes may be higher rates of knee, ankle and thigh injuries. “Nearly a third of all concussions in collegiate athletics occur during football. With the relatively recent rule changes, concussion rates have not decreased. Our analysis of the NCAA Injury Surveillance Database though noted increased rates of ankle and knee injuries, which may result in osteoarthritis and disability issues later in life for these athletes,”
The adverse biomechanical effects of concussion can persist for up to two years, but short-term visual deficits may help identify athletes who are most at risk for gait-related effects
Martini et al (2016):
The data indicate that an adolescent concussion history has a non-observable effect on gait across the lifespan
DuBose et al (2016):
The concussion group showed an increase in hip stiffness, a decrease in knee and leg stiffness, but no change in ankle stiffness
Westermann et al (2016)
Increasing Lower Extremity Injury Rates Across the 2009-2010 to 2014-2015 Seasons of National Collegiate Athletic Association Football
An Unintended Consequence of the “Targeting” Rule Used to Prevent Concussions?
Herman et al (2016)
Lower extremity musculoskeletal injuries occurred at a higher rate in the concussed athletes (45/90 or 50 %) than in the non-concussed athletes (30/148 or 20 %; P < 0.01). The odds of sustaining a musculoskeletal injury were 3.39 times higher in the concussed athletes (95 % confidence interval 1.90–6.05; P < 0.01).
Gilbert et al (2016)
There was a positive association between concussion history and lower extremity injuries (odds ratios, 1.6-2.9 elevated risk) among student-athletes at the conclusion of their intercollegiate athletic careers.
Herman et al (2017)
Lower extremity musculoskeletal injuries occurred at a higher rate in the concussed athletes (45/90 or 50 %) than in the non-concussed athletes (30/148 or 20 %; P < 0.01). The odds of sustaining a musculoskeletal injury were 3.39 times higher in the concussed athletes (95 % confidence interval 1.90–6.05; P < 0.01). Overall, the number of days lost because of injury was similar between concussed and non-concussed athletes (median 9 versus 15; P = 0.41).
Buckley et al (2017)
There was a positive association between concussion history and lower extremity injuries (odds ratios, 1.6–2.9 elevated risk) among student-athletes at the conclusion of their intercollegiate athletic careers. The nature of the injuries suggests these could be secondary to lingering deficits in motor or postural control.
Howell et al (2017)
Thiose with a poorer post conscussion score exhibited slower gait speed and shorter stride lengths than healthy controls.
Fino et al (2017)
Concussion was associated with an increased instantaneous relative risk of LE injury when adjusting for LE injury history [hazard ratio (HR) = 1.67, 95% confidence interval (CI) = 1.11-2.53]
Sixty-two percent of concussed athletes selected for this study sustained a lower extremity musculoskeletal injury within 180 days after RTP following their concussion as compared to 26% of matched control athletes. These results indicate that the odds for an athlete with history of concussion, sustaining a lowering extremity musculoskeletal injury after RTP following a concussion is 7.37 greater than an athlete with no history of concussion.
Lynall et al; 2017:
For every previous concussion, the odds of sustaining a subsequent time-loss lower extremity injury increased 34% (odds ratio [OR] = 1.34; 95% confidence interval [CI] = 1.13, 1.60).
Manaseer et al (2017)
These findings suggest that individuals who have suffered a concussion may sway more in the frontal plane, and walk slower compared to healthy controls
Kardouni et al (2018)
The rate of LE musculoskeletal injury among this population of physically active adults is higher following concussion, and the risk remains elevated for more than a year following injury.
McPherson et al (2018)
Systematic review and meta-analysis to determine the risk of lower extremity MSK injury after concussion: “athletes who suffered a concussion had 2.06 times the odds of sustaining a lower extremity injury after RTS compared to a control group (OR = 2.06, 95% CI 1.48-2.88). Athletes who suffered a concussion had a 1.67 times higher incidence rate of lower extremity injury per athletic exposure after
RTS (IRR = 1.67, 95% CI 1.42-1.96).”
Lynall et al (2018)
Although evidence suggests that high school, college, and professional athletes are at increased risk for musculoskeletal injury following concussion, no increased risk was observed in this sample of youth football players
McPherson et al (2018)
Meta-analysis results indicated that athletes who had a concussion had 2 times greater odds of sustaining a MSK injury than athletes without concussion (OR, 2.11; 95% CI, 1.46-3.06). In addition, athletes with concussion demonstrated a higher incidence of MSK injury after return to sport compared with nonconcussed athletes (IRR, 1.67; 95% CI, 1.42-1.96).
Krill et al (2018)
There was no initial increase in LE IRs immediately after a concussion; however, there was an increased LE IR more than 12 months after a concussion. There was no increase in LE IRs demonstrated by skill and other position groups. Line position players experienced an increased LE IR the next season after a concussion or greater than 12 months after the injury
Within one year of RTP, the study group was 2.95 (95% Confidence Interval (CI), 1.5, 5.78) times more likely than the control group to sustain any MSK injury, 2.09 (95% CI, 1.07, 4.06) times more likely to experience any LE injury, and 2.25 (95% CI, 1.16, 4.36) times more likely to have a LE Non-Contact (NC) injury.
Reneker et al (2019)
The results indicate significantly increased odds of all injuries (OR = 2.55; 95%CI 1.85,3.52); concussion (OR = 3.73; 95%CI 2.41,5.78); and lower extremity injuries (OR = 1.60; 95%CI 1.32,1.94) in those with a history of concussion compared to those without.
Harada et al (2019)
Collegiate athletes with MC were more likely to sustain a lower extremity injury after RTP in a shorter time frame than were the matched SC and NC athletes. This may suggest
the presence of a cohort more susceptible to neuromuscular deficits after concussion or more injury prone
due to player behavior, and it may imply the need for more stringent RTP protocols for athletes experiencing MC
Hunzinger et al (2019)
Preliminary results showed that there was no statistically significant association between concussion and LE-MSI among ROTC cadets at this university
DiFabio et al (2019)
The main finding of this study is that greater HIK do not predict whether individuals sustained either an acute LEI or concussion during the season, albeit from a small sample. As HIK load is related to concussion incidence, it is possible HIK load may also be related to LEI, however, these results suggest HIK alone is not related to either in an ice hockey cohort.
Buckley et al (2019)
None of the common clinical concussion assessments were a significant predictor of subsequent LE-MSK potentially due to a high injury rate (72.3%)
Buckly et al (2019)
The results of this study suggest females are at higher risk of post-concussion subsequent MSK injury over the course of their collegiate athletic career.
Oldham et al (2020)
There were significant differences in gait characteristics and cognitive accuracy between those who did and did not sustain a LEMSK injury after concussion. The LEMSK group demonstrated a conservative gait strategy both before and after their concussive injury.
Hunzinger et al (2020)
Community rugby players with a history of concussion are >2x more likely to also experience an lower extremity musculoskeletal injury than those without a history of concussion.
Hunzinger et al (2020)
Cadets with any concussion history (n=42) had a significantly (p=0.035) higher association with LE-MSI (OR 2.47, 95% CI 1.05 to 5.83) than those without. Cadets who had a reported concussion (n=33) had a significantly (p=0.026) higher association with LE-MSI (OR 2.95, 95% CI 1.11 to 7.84) compared to cadets without.
Jildeh et al (2020)
Thirty-six (25.7%) athletes sustained a LE injury within 90 days of concussion; 26 (20.2%) were non–season-ending and included in RTP analysis. The odds of sustaining an acute LE musculoskeletal injury within the 90-day period after concussion was 4.69 times greater in concussed players compared with controls.
Biese et al (2021a)
A history of concussion was associated with any subsequent LE injury, but not associated with a specific mechanism of injury. The association with concussion and a subsequent LE injury was different between males and females.
Biese et al (2021b)
The rate of acute-noncontact lower extremity injury was 87% greater (IRR, 1.87; 95% CI, 1.29-2.74) in participants with a previous sports-related concussion versus those without one.
Wilson et al (2021)
History of recent concussion or recent lower extremity injury are both risk factors for subsequent lower extremity injury in male, collision sport, high school athletes.
Avedesian et al (2021)
Decreased reaction time and working memory performance were moderately correlated with decreased sagittal plane knee motion and increased frontal plane knee loading in collegiate athletes with a history of sports-related concussion.
Mansouri et al (2021)
The predictive models combined with a mobile platform for data collection have great potential to monitor a large group of athletes and identify the at-risk population.
Switzer et al (2022)
12.7% (N=54) of those who sustained a concussion had either a musculoskeletal injury or another concussion within 1 year, with the highest proportion of injuries being a second concussion (33.3%) or ligament sprain (35.2%).
Buckley et al (2022)
The primary finding of this study was no elevated risk of post-concussion MSK in NFL football players.
Jildeh et al (2022)
Systematic review; “An increased incidence of LE injuries was observed at 90-days and one year following the diagnosis of a concussion. Higher levels of competition, such as at the collegiate and professional level, resulted in an increased risk of sustaining a subsequent LE injury following a diagnosed concussion.”
McCann et al (2022)
Systematic review; “College athletes who suffered a concussion possessed a 58% greater risk of sustaining a lower extremity musculoskeletal injury than those who did not have a history of a concussion (RR = 1.58[1.30, 1.93]).”
Bennett et al (2023)
“Subsequent injury risk, severity, and location in junior Australian football are similar following concussion compared to non-concussion index injuries, although contact injuries are less likely.”
The reason for the increased risk is not known but could be due to altered neuromuscular patterns, proprioception, response times and motor control due to the lingering neurological damage post-concussion
Concussion and the lower limb and as a public health issue (Podiatry Arena)
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