Context

Although research indicates that the key to minimizing the effect of musculoskeletal injury, improving care, and mitigating long-term effects is to improve early injury care seeking, little is known about barriers to early musculoskeletal injury disclosure and care seeking.

Objective

To identify which determinants predicted sport-related musculoskeletal (MSK) injury disclosure by adolescent athletes.

Design

Cross-sectional study.

Setting

Online survey.

Patients or Other Participants

A total of 564 adolescent athletes (58% male, age = 15.81 ± 1.8 years).

Main Outcome Measure(s)

Online survey exploring determinants of age, gender, race, socioeconomic status, injury knowledge, attitudes, perceived social norms, and perceived behavioral control surrounding MSK injury disclosure, intention to disclose MSK injury, and actual behavior of disclosing MSK injury.

Results

Of the respondents, 457 (80.2%) reported having sustained ≥1 (mean = 3.2 ± 2.2; range = 1–10) MSK injuries related to sport. Those who endorsed having experienced an MSK injury disclosed not reporting or purposefully hiding 77% of their suspected MSK injuries. Several factors influenced a high intention to disclose MSK injury. Specifically, for each unit increase in total MSK injury knowledge (Exp[β] = 1.061, β=0.054, P = .020, 95% CI = 1.031, 1.221) and attitude (Exp[β] = 1.070, β = 0.064, P < .001, 95% CI = 1.027, 1.115) score, 6% and 7% increases in the likelihood of a high intention to disclose an MSK injury, respectively, were observed. Moreover, for each unit increase in the social norm score (Exp[β] = 1.178, β=0.164, P < .001, 95% CI = 1.119, 1.241), an 18% increase in the likelihood of a high intention to disclose an MSK injury was noted.

Conclusions

Designing interventions geared toward increasing the knowledge of signs and symptoms of MSK injury, improving attitudes surrounding disclosure, and better understanding the social context of disclosing MSK injuries may improve MSK injury disclosure behavior and reduce the associated social and economic burdens of these injuries.

Key Points
  • Most participants reported a low level of knowledge regarding musculoskeletal injury symptoms and consequences.

  • Fewer than one-quarter of the athletes indicated that they believed it was necessary to disclose an injury, even if it was bothering them, as long as they could still play.

An estimated 12 million individuals are affected annually by musculoskeletal (MSK) injury, accounting for approximately 20 to 25 million lost school and work days and US $33 billion in health care costs each year.1,2  These MSK injuries are characterized by damage or injury to bones, ligaments, tendons, muscles, or nerves that vary in severity from minimally painful during high-intensity exercise to severely debilitating even at rest.3  The key to minimizing the effect of MSK injury, improving care, and mitigating long-term effects is to improve early injury care seeking.4,5  Early disclosure and care of MSK injury symptoms leads to early intervention, helping to offset the risk of developing a more debilitating injury that may plague the individual for years and decades to come.5 

Despite being frequently discussed anecdotally among health care providers, little is known about the determinants of MSK injury disclosure in relation to both if and when an injury is reported and to whom an injury is disclosed.4  Early symptoms, such as pain with activity, pain at rest, tightness, muscle fatigue, and stiffness, exist, are often excused as “just part of the process” due to the “no pain, no gain” philosophy that is prominent in sport circles.6,7  Furthermore, it remains unclear what criteria individuals perceive must be met to necessitate disclosing an MSK injury, such as injury severity or level of disability.5  Approximately 45% to 60% of US adolescents participate in organized youth sport.8,9  Moreover, 70% of adolescents who compete in organized sports participate in multiple sports, further increasing their sport exposure burden and risk of injury.10  Adolescent athletes are particularly vulnerable to MSK injury.11  A major contributor to this risk is their disproportionate size and athletic capacity and the large fluctuations in training volume frequently experienced by those participating in >1 sport.1215 

This is not the first time disclosure has been a major obstacle to the identification and treatment of sport-related injury. Approximately 1 decade ago, preliminary studies demonstrated that upward of 50% of adolescents did not report symptoms of a suspected concussion.1618  Early research on concussion disclosure behavior was guided by the Theory of Planned Behavior in examining several determinants, such as knowledge of symptoms and potential consequences, perceived social norms, perceived control over disclosure, and attitudes toward disclosure, as well as demographic identifiers, such as socioeconomic status, age, race, and gender.1820  Subsequent interventional studies targeting modifiable factors have resulted in increased intention to disclose concussion symptoms.21  These findings related to both athletes’ intentions toward and behaviors related to concussion disclosure suggest that researchers who desire to further understand determinants of MSK injury disclosure could start by leveraging the previously identified determinants.

As such, the primary purpose of our study was to identify and predict potential determinants of sport-related MSK injury disclosure in adolescent athletes. We hypothesized that a high intention to disclose an MSK injury and the actual behavior of disclosure would be influenced by each individual’s race, ethnicity, gender, knowledge of injury signs and symptoms and consequences of the injury, attitudes toward disclosure, perceived social norms, and perceived control over disclosure based on findings from concussion disclosure literature.

Research Design

This study used a cross-sectional survey administered via an online platform (Qualtrics, Inc) as part of a larger study to assess the intention to disclose both the symptoms of MSK injury and the symptoms of concussion. In this article, we report the results of only the MSK injury components. Specifically, the survey included items designed to evaluate proposed determinants of intention to disclose symptoms of MSK injury. Proposed determinants were age, gender, race, socioeconomic status, presence of an athletic trainer, and MSK injury-specific behavioral factors (MSK injury history, MSK injury-related knowledge, attitudes, perceived social norms, and perceived control). The study was approved by the institutional review board at the University of Texas at San Antonio before participant recruitment.

Sample and Participants

Because the study was conducted with minors in high school and middle school settings, permission was given for the research team to provide the survey link to administrators at the selected schools, but no direct interaction with the participants was authorized. Potential participants were approached by administrators at their respective schools and invited to complete the survey via email. Select schools also made additional announcements; however, this was site dependent as we were not allowed to have any contact with the surveyed population. An estimated 1300 high school and 750 middle school student-athletes were eligible to participate in the study. The survey was distributed on the campuses of 4 high schools and 3 middle schools that were strategically identified as representing the diverse characteristics of student-athletes. Each school was located in a large metropolitan city in the southern portion of the United States. Three of the 4 high schools and 2 of the 3 middle schools were located in largely affluent, predominately White school districts, whereas the fourth high school and third middle school were located in an intercity school district. All students had access to athletic trainers on an as-needed basis, but only the 3 suburban high schools employed full-time athletic trainers. Of the estimated 2050 eligible individuals, a total of 564 (27.5%) consented to participate and completed all aspects of the survey. A detailed description of the survey was provided to participants on the first page, and they were asked to indicate that their parents consented to their involvement and that they had read the description and provided assent to participate before beginning the survey. Only those individuals who clicked to consent, moved to the second page of the survey, and indicated that they had read the instructions were allowed to proceed with the survey.

Survey Instrument

The survey instrument was based on previously validated items and included questions concerning participant demographics, the presence of an athletic trainer, MSK injury history, and sport participation. In addition, MSK injury knowledge, attitudes toward disclosure of MSK injury, and perceived social norms surrounding MSK injury disclosure were assessed using modified existing scales to predict MSK injury disclosure behavior.17,18,22  Additionally, single-item measures of perceived control over disclosure and intention to disclose future MSK injury were included.

The MSK injury history and disclosure were evaluated by first giving participants the following definition of MSK injury: “Musculoskeletal injuries are ANY injury to the muscles, tendons, ligaments, cartilage, and/or bones. They can include, but are not limited to, sprains, strains, dislocations, tears, ruptures, and fractures.” After reading the definition, participants were asked, “Given the definition above, have you ever had an MSK injury related to sport or other activities (Yes/No)?” Those who answered yes were asked follow-up questions: “How many MSK injuries have you had?” and “How many of these injuries did you report/disclose to a medical professional or someone in authority at the time of injury?” Lastly, all participants were asked, “How many injuries have you purposefully hidden or not reported?”

Their MSK injury knowledge was assessed using 41 yes, no, or maybe items concerning symptom recognition, potential signs and symptoms, potential long-term side effects, effects of premature return to play, and consequences of incurring multiple MSK injuries. Correct answers were scored as 2 points, and incorrect answers were scored as 0 points; participants who selected maybe were given 1 point. Potential scores ranged from 0 to 82, with a maximum composite score of 82 (higher scores meant better MSK injury knowledge).

The MSK attitude questions were adapted from previously used and validated concussion attitude questions.18,20,22  Eight validated items scored on a 7-point scale reflect attitudes toward and perceptions of MSK injury disclosure. Answers to all 8 items were summed, resulting in a composite attitude score ranging from 1 to 56, with higher scores representing more favorable disclosure attitudes toward MSK injury disclosure. For example, the previously validated concussion attitude question read, “Disclosing possible concussive symptoms to a medical professional or someone in authority during physical activity is …,” whereas the MSK attitude question replaced the phrase “concussive symptoms” with “musculoskeletal symptoms,” followed by the same 8 items. Athletes were asked to rate their attitudes to each item on a 7-point scale: cowardly (1) to brave (7), shameful (1) to prideful (7), harmful (1) to beneficial (7), extremely difficult (1) to extremely easy (7), bad (1) to good (7), unimportant (1) to important (7), a waste of time (1) to worthwhile (7), and weak (1) to strong (7).

The MSK injury perceived social norms consisted of 7 validated 7-point scale items measuring each participant’s perceptions of their organization’s expectations, social referent expectations, and their peers’ actions concerning MSK injury disclosure. Answers were summed, resulting in an MSK composite social norm score ranging from 1 to 49, with higher scores representing more favorable perceived social norms surrounding MSK injury.

Perceived behavioral control over disclosing an MSK injury was explored using a single 7-point scale question regarding how much control student-athletes believed that they had over disclosing MSK injury. A perceived control score was categorized as higher (score of 6 or 7), indicating agreement regarding having control over MSK injury disclosure, or lower (score of 1 to 5), indicating some agreement to strong disagreement regarding having control over MSK injury disclosure.

Intention to disclose an MSK injury consisted of a single 7-point scale question on a student-athlete’s intention to disclose the symptoms of an MSK injury. Intention scores were categorized as higher (score of 6 or 7), reflecting agree or strongly agree with intentions of disclosing symptoms of MSK injury, or lower (score of 1 to 5), reflecting somewhat disagree to strongly disagree with intention to disclose symptoms of MSK injury. In addition to the intention to disclose future MSK injury, prior MSK injury disclosure behavior was also measured by asking the following question to anyone who reported having had an MSK injury: “How many of these musculoskeletal injuries did you report/disclose to a medical professional or someone in authority at the time of injury?” Subsequently, these data were transformed into a disclosure percentage ([number of injuries participant reported disclosing at the time of injury/total MSK injuries participant disclosed having sustained previously] × 100).

Data Analysis

General descriptive statistics were used to describe the demographic information of participants (age, gender, race, academic grade, primary sport, estimated household income, and MSK injury history; Table 1). We conducted Cronbach α tests to determine the internal consistency for each of the summative domains in the survey (MSK knowledge, MSK attitudes, and MSK social norms). Before running models, variables were examined for multicollinearity. The disclosure percentage was defined as the number of previous MSK injuries disclosed by each athlete divided by the total number of previous injuries the athlete recalled having sustained. Intention to disclose an MSK injury was converted into a categorical variable and dichotomized as high (6 or 7) or low (0 to 5) to explore differences between those who reported a higher intention to disclose an injury and those who reported a lower intention to disclose, in accordance with previous literature.22  Last, a multivariate binomial regression mode including gender, race, ethnicity, knowledge of injury signs and symptoms and consequences of injury, attitudes toward disclosure, perceived social norms, and perceived control over disclosure was used to identify which of the hypothesized determinants influenced higher intentionality for MSK injury disclosure.

Table 1.

Participants’ Demographic Information

Participants’ Demographic Information
Participants’ Demographic Information

Athlete Beliefs, Knowledge, Attitudes, Perceived Social Norms, and Control Over MSK Injury Disclosure

When asked to select all the reasons that apply to when an MSK injury should be revealed, 54% of athletes chose when the pain was initially felt but only if the injury seemed serious. In contrast, 37% of respondents reported that an MSK injury should be disclosed at the first sign of pain if it was not thought to be too serious. Last, 17.4% of participants believed that an MSK injury should be reported if it only hurt a little and was not affecting their game play (Table 2).

Table 2.

Participants’ Musculoskeletal Injury Disclosure Beliefs

Participants’ Musculoskeletal Injury Disclosure Beliefs
Participants’ Musculoskeletal Injury Disclosure Beliefs

Athlete knowledge total scores ranged from 4 to 72 out of a possible 82 (mean = 44.8 ± 10.03; Table 3). Higher scores indicated greater knowledge of MSK injury symptoms and consequences of injury. Respondents’ attitude scores toward disclosure of MSK injury ranged from 8 to 56 out of a possible 56 (mean = 34.9 ± 6.6), with higher attitude scores representing more favorable attitudes (Table 4, Figure 1). Participants’ social norms received scores ranging from 12 to 42 out of a possible 49 (mean = 27.8 ± 6.8), and higher scores represented greater perceived support and social acceptance for MSK injury disclosure (Table 5). Last, respondents endorsed an average of 4.5 ± 1.7 (range = 1–7) related to perceived control over MSK injury reporting, with higher scores indicating more control, which would be equivalent to somewhat agree (Figure 2).

Figure 1

Attitudes toward musculoskeletal injury disclosure.

Figure 1

Attitudes toward musculoskeletal injury disclosure.

Close modal
Figure 2

Perceptions of social norms surrounding musculoskeletal injury disclosure.

Figure 2

Perceptions of social norms surrounding musculoskeletal injury disclosure.

Close modal
Table 3.

Participants’ Knowledge of Musculoskeletal Injury and Consequences

Participants’ Knowledge of Musculoskeletal Injury and Consequences
Participants’ Knowledge of Musculoskeletal Injury and Consequences
Table 4.

Participants’ Attitudes Toward Musculoskeletal Injury Disclosure

Participants’ Attitudes Toward Musculoskeletal Injury Disclosure
Participants’ Attitudes Toward Musculoskeletal Injury Disclosure
Table 5.

Participants’ Perceived Social Norms and Control Over Musculoskeletal Injury Disclosure

Participants’ Perceived Social Norms and Control Over Musculoskeletal Injury Disclosure
Participants’ Perceived Social Norms and Control Over Musculoskeletal Injury Disclosure

Athlete Reporting Behaviors

In total, 457 (80.2%) of the athletes described having sustained ≥1 MSK injury related to sport; the mean number of MSK injuries was 3.32 ± 2.2 (range = 1–10). When asked how many of those injuries were not reported to a coach or a health care provider, respondents noted having not reported or purposefully hidden 77%.

Determinants of a High Intention to Disclose an MSK Injury

Student-estimated household income, knowledge of MSK injury symptoms and consequences, attitudes toward MSK injury disclosure, and perceived social norms surrounding the disclosure of an MSK injury were significant predictors of a high intention to disclose MSK injuries (Table 6). Specifically, for each unit increase in total MSK injury knowledge (Exp[β] = 1.061, β=0.054, P = .020, 95% CI = 1.031, 1.221) and attitude (Exp[β] = 1.070, β = 0.064, P < .001, 95% CI = 1.027, 1.115) scores, 6% and 7% increases in the likelihood of a high intention to disclose an MSK injury, respectively, were observed. Moreover, for each unit increase in the social norm score (Exp[β] = 1.178, β=0.164, P < .001, 95% CI = 1.119, 1.241), an 18% increase in the likelihood of a high intention to disclose an MSK injury was seen. However, gender (Exp[β] = 1.116, β=0.066, P = .54, 95% CI = 0.776, 1.606), race (Exp[β] = 0.848, β=0.059, P = .091, 95% CI = 0.700, 1.028), presence of an athletic trainer (Exp[β] = 0.912, β=0.042, P = .615, 95% CI = 0.637, 1.306), and MSK injury history (Exp[β] = 1.544, β=0.641, P = .187, 95% CI = 0.810, 2.943) were not significant predictors of a high intention to disclose future MSK injury.

Table 6.

Binary Logistic Regression Predicting a High Intention to Disclose a Musculoskeletal Injury

Binary Logistic Regression Predicting a High Intention to Disclose a Musculoskeletal Injury
Binary Logistic Regression Predicting a High Intention to Disclose a Musculoskeletal Injury

We demonstrated 3 primary findings. First, most participants reported a low level of knowledge regarding MSK symptoms and consequences. Second, fewer than one-quarter of athletes believed it was necessary to disclose an injury, even if it was bothering them, as long as they could still play. Third, several previously identified determinants of high intention to disclose signs or symptoms of a concussion, such as knowledge of signs and symptoms, injury consequences, attitudes toward disclosure, and perceived social norms surrounding disclosure, were significant predictors of a high intention to disclose an MSK injury.

Knowledge of Symptoms and Consequences of MSK Injury

When asked about the consequences of MSK injury, more than 70% of participants answered either yes or maybe to whether “no bad things” could happen if someone continued playing “through the pain,” returned to sport or physical activity too soon, or had multiple MSK injuries during their lifetime. This finding suggests that MSK injuries may not be perceived as significant or meaningful unless they cause significant disability or pain sufficient to substantially restrict an athlete’s ability to participate. This idea is in direct conflict with the idea that early disclosure and early treatment of injury could help reduce the overall burden of MSK injury.23  Therefore, adolescent athletes may benefit from education related to the potential side effects and consequences of “playing through the pain,” returning too early, or sustaining multiple MSK injuries over time without proper recovery.7,11 

In addition to a lack of understanding regarding the consequences of MSK injury, respondents lacked a clear understanding of MSK injury symptoms, such that no single listed symptom was correctly identified as an indicator of MSK injury by >50%. Although many of the listed symptoms may also reflect another condition and might have elicited a maybe answer, early evidence of a general lack of knowledge concerning MSK injury symptoms among adolescent athletes was present.

A lack of knowledge of the symptoms and consequences of MSK injury may also play a role in the prevention, treatment, and risk of reinjury. For example, certain injuries, such as ankle sprains, medial tibial stress syndrome, shoulder impingement, and many more, have several early signs and symptoms. If these symptoms are recognized by the athlete and reported in a timely fashion, the total injury burden, such as time loss and economic expense, associated with the treatment of chronic injuries, such as chronic ankle instability, shoulder impingement, and low back pain, could be dramatically reduced. For each unit increase in total MSK injury knowledge, there was a 6% increase in the likelihood of a high intention to report MSK injuries. Incremental increases in knowledge could be addressed through proper educational efforts and may serve as a starting point for targeted intervention programs geared at promoting and encouraging early disclosure of MSK injury.

Attitudes Toward Disclosure and Perceived Social Norms

Overall, 77% of MSK injuries that participants sustained were either not reported or were purposefully hidden at the time of injury, suggesting a generalized perception of not needing to disclose most MSK injuries. Previous researchers in the concussion space have demonstrated the effectiveness of simple educational programing to improve the prevalence of injury disclosure. For example, up to a 40% difference was evident in the disclosure of concussion among individuals who had received educational programing compared with those who had not.19  Documented success from educational programing designed to increase concussion reporting behavior indicates that practitioners interested in increasing the disclosure of MSK injury can start by mirroring these interventions.

In general, when participants were asked to rate their attitudes toward MSK injury disclosure, their scores were relatively low (34.8 ± 7.9 out of a possible 56) and similar to early observed attitude scores related to concussion.19,20  However, many recent studies reflect improvements after educational programing and increased global awareness surrounding and supporting the disclosure of concussion symptoms to a health care provider.2427  Such attitude scores pertaining to MSK injury in the present population are close to the preliminary scores of concussion patients approximately 10 years ago before widespread educational efforts were implemented.17,18  Our respondents’ average score for each question in the attitude subcomponent was 4.4. Multiple interventional studies have shown the positive effect of educational interventions that not only target athlete knowledge of signs and symptoms but also focus on a socioecological framework incorporating interpersonal relationships between athletes and their coaches and peers, societal and community acceptance, and intrapersonal components surrounding athlete concerns about disclosing an injury.19,28  For each unit increase in attitude score, the likelihood of a high intention to disclose an MSK injury increased 7%. Based on the concussion literature, attitudes toward MSK injury may be similarly improved by applying a socioecological educational framework that targets multiple levels of injury disclosure, such as policy and societal, community, and interpersonal and intrapersonal considerations.

In the same way, low perceived social norm scores in our adolescent athletes surrounding the disclosure of MSK injury were consistent with perceived social norm scores in the early concussion symptom reporting literature.17,29,30  However, if we again look back across the past decade, we see several successful examples of reducing barriers to concussion symptom reporting through educational programing that seeks to improve the social context of accepting concussion disclosure as a positive factor.29,30  For each unit increase in social norms, the likelihood of patients endorsing a high intention to disclose a future MSK injury increased 18%. Recent findings in the concussion literature support the theory that targeted educational programing aimed at improving the social context of injury disclosure may also benefit efforts to improve the early reporting of MSK injuries.

Determinants of a High Intention to Disclose MSK Injuries

Despite a general lack of investigation into determinants of MSK injury disclosure, a few elements, such as age and gender, have been implicated in influencing MSK injury disclosure.7,31  Moreover, the authors of 1 study identified correlations in collegiate sport athletes between determinants of intention to disclose concussion injury, such as knowledge of injury symptoms and consequences, attitudes toward injury disclosure, perceived social norms, perceived behavior control, and a high intention to disclose an MSK injury.22 

We found that knowledge of MSK injury, attitudes toward MSK injury disclosure, and social norms surrounding the disclosure of MSK injury were all significant predictors of a high intention to disclose an MSK injury among adolescent athletes. Moreover, household income determined the MSK injury disclosure intention. With each unit increase in household income, the likelihood of endorsing a high intention to disclose future MSK injuries increased 34%. In contrast, other hypothesized predictors, such as gender, race, presence of an athletic trainer, and MSK injury history, were not significant predictors of a high intention to report an MSK injury. To our knowledge, this is the first examination of predictors of adolescent intentions to disclose an MSK injury. These results identify key starting points for researchers, coaches, parents, and relevant health care professionals interested in reducing the economic and social burden of MSK injury in adolescents: the development of educational programs pertaining to the symptoms of MSK injury, helping athletes understand the context in which MSK injury should be disclosed, and what type of information should be shared with a health care provider. Moreover, perceived social norms influenced MSK injury disclosure decisions. Thus, it is important to consider the entire socioecological framework targeting multiple levels of injury disclosure, such as policy and societal, community, interpersonal, and intrapersonal considerations.

Limitations

Although we worked with the school staffs who disseminated the survey, we did not have direct access to the participants, and therefore, do not know if each site promoted and distributed the survey in a similar fashion. Several other biases, such as response, social desirability, recall, and selection bias, may have also played roles in the outcomes. Every effort was made to reduce such biases by recruiting each student in the same manner and not targeting particular students or groups of students. Furthermore, participants were instructed that their individual responses would not be shared or linked to their identifiable information, and the results would be shared only as aggregate data to decrease the likelihood of their answers being biased out of fear of what others might think.

Adolescent athletes reported a low level of knowledge of the symptoms and consequences of MSK injury, with most (77%) of their past MSK injuries either going undisclosed or being purposely hidden. Also, several identified determinants of intention to disclose concussive injuries, including knowledge, attitudes, and perceived social norms, accounted for the intentionality of participants to report MSK injuries. Previous researchers demonstrated the success of multifactorial interventional educational programs targeted at improving the social context surrounding concussion disclosure and enhancing the knowledge of potential signs, symptoms, and consequences. These studies highlighted the significance of interventions designed to expand knowledge of an injury while improving the social environment, attitudes, and perceptions of injury disclosure and the context of sport participation to make disclosure of injury more socially acceptable.21,32  Investigators who want to better understand the barriers and social context surrounding the disclosure of MSK injuries can learn from the interventional models applied to encourage concussion symptom disclosure. These models could serve as a starting point to enhance MSK injury disclosure behavior and reduce the social and economic burden of MSK injury.

1.
Legault
ÉP
,
Descarreaux
M
,
Cantin
V.
Musculoskeletal symptoms in an adolescent athlete population: a comparative study
.
BMC Musculoskelet Disord
.
2015
;
16
:
210
.
2.
Vos
T
,
Flaxman
AD
,
Naghavi
M
, et al
Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010
.
Lancet
.
2012
;
380
(9859)
:
2163
2196
.
3.
Van Eerd
D
,
Munhall
C
,
Irvin
E
, et al
Effectiveness of workplace interventions in the prevention of upper extremity musculoskeletal disorders and symptoms: an update of the evidence
.
Occup Environ Med
.
2016
;
73
(1)
:
62
70
.
4.
Smith
L
,
Westrick
R
,
Sauers
S
, et al
Underreporting of musculoskeletal injuries in the US Army: findings from an Infantry Brigade Combat Team survey study
.
Sports Health
.
2016
;
8
(6)
:
507
513
.
5.
Hubbard
MJ
,
Hildebrand
BA
,
Battafarano
MM
,
Battafarano
DF.
Common soft tissue musculoskeletal pain disorders
.
Prim Care
.
2018
;
45
(2)
:
289
303
.
6.
Eckard
TG
,
Padua
DA
,
Hearn
DW
,
Pexa
BS
,
Frank
BS.
The relationship between training load and injury in athletes: a systematic review
.
Sports Med
.
2018
;
48
(8)
:
1929
1961
.
7.
van Wilgen
CP
,
Kaptein
AA
,
Brink
MS.
Illness perceptions and mood states are associated with injury-related outcomes in athletes
.
Disabil Rehabil
.
2010
;
32
(19)
:
1576
1585
.
8.
Lincoln
DJ
,
Clemens
SL.
Where children play sport: a comparative analysis of participation in organised sport in school and club settings
.
Health Promot J Austr
.
2021
;
32
(52)
:
158
166
.
9.
DiFiori
JP
,
Benjamin
HJ
,
Brenner
JS
, et al
Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine
.
Br J Sports Med
.
2014
;
48
(4)
:
287
288
.
10.
Bell
DR
,
Post
EG
,
Trigsted
SM
,
Hetzel
S
,
McGuine
TA
,
Brooks
MA.
Prevalence of sport specialization in high school athletics: a 1-year observational study
.
Am J Sports Med
.
2016
;
44
(6)
:
1469
1474
.
11.
Kaeding
CC
,
Whitehead
R.
Musculoskeletal injuries in adolescents
.
Prim Care
.
1998
;
25
(1)
:
211
223
.
12.
Walters
BK
,
Read
CR
,
Estes
AR.
The effects of resistance training, overtraining, and early specialization on youth athlete injury and development
.
J Sports Med Phys Fitness
.
2018
;
58
(9)
:
1339
1348
.
13.
McGuine
TA
,
Post
EG
,
Hetzel
SJ
,
Brooks
MA
,
Trigsted
S
,
Bell
DR.
A prospective study on the effect of sport specialization on lower extremity injury rates in high school athletes
.
Am J Sports Med
.
2017
;
45
(12)
:
2706
2712
.
14.
McGowan
J
,
Whatman
C
,
Walters
S.
The associations of early specialisation and sport volume with musculoskeletal injury in New Zealand children
.
J Sci Med Sport
.
2020
;
23
(2)
:
139
144
.
15.
Dahab
K
,
Potter
MN
,
Provance
A
,
Albright
J
,
Howel
DR.
Sport specialization, club sport participation, quality of life, and injury history among high school athletes
.
J Athl Train
.
2019
;
54
(10)
:
1061
1066
.
16.
Caccese
JB
,
Iverson
GL
,
Hunzinger
KJ
, et al
;
CARE Consortium Investigators
.
Factors associated with symptom reporting in US service academy cadets and NCAA student athletes without concussion: findings from the CARE Consortium
.
Sports Med
.
2021
;
51
(5)
:
1087
1105
.
17.
Register-Mihalik
JK
,
Guskiewicz
KM
,
McLeod
TC
,
Linnan
LA
,
Mueller
FO
,
Marshall
SW.
Knowledge, attitude, and concussion-reporting behaviors among high school athletes: a preliminary study
.
J Athl Train
.
2013
;
48
(5)
:
645
653
.
18.
Register-Mihalik
JK
,
Linnan
LA
,
Marshall
SW
,
Valovich McLeod
TC
,
Mueller
FO
,
Guskiewicz
KM.
Using theory to understand high school aged athletes’ intentions to report sport-related concussion: implications for concussion education initiatives
.
Brain Inj
.
2013
;
27
(7–8)
:
878
886
.
19.
Register-Mihalik
JK
,
Marshall
SW
,
Kay
MC
, et al
Perceived social norms and concussion-disclosure behaviours among first-year NCAA student-athletes: implications for concussion prevention and education
.
Res Sports Med
.
2021
;
29
(1)
:
1
11
.
20.
Register-Mihalik
JK
,
Cameron
KL
,
Kay
MC
, et al
Determinants of intention to disclose concussion symptoms in a population of US military cadets
.
J Sci Med Sport
.
2019
;
22
(5)
:
509
515
.
21.
Register-Mihalik
JK
,
Kay
MC
,
Kerr
ZY
, et al
Influence of concussion education exposure on concussion-related educational targets and self-reported concussion disclosure among first-year service academy cadets
.
Mil Med
.
2020
;
185
(3–4)
:
e403
e409
.
22.
Cheever
K
,
Nedimyer
AK
,
Dewig
D
,
Register-Mihalik
JK
,
Kossman
MK.
The identification and comparison of factors affecting musculoskeletal and concussion injury disclosure
.
J Athl Train
.
2023
;
58
(6)
:
563
572
.
23.
Wahlquist
VE
,
Kaminski
TW.
Purposeful heading in youth soccer: a review
.
Sports Med
.
2021
;
51
(1)
:
51
64
.
24.
Feiss
R
,
Lutz
M
,
Reiche
E
,
Moody
J
,
Pangelinan
M.
A systematic review of the effectiveness of concussion education programs for coaches and parents of youth athletes
.
Int J Environ Res Public Health
.
2020
;
17
(8)
:
2665
.
25.
Houston
MN
,
O’Donovan
KJ
,
Trump
JR
, et al
Progress and future directions of the NCAA-DoD Concussion Assessment, Research, and Education (CARE) Consortium and Mind Matters Challenge at the US service academies
.
Front Neurol
.
2020
;
11
:
542733
.
26.
Conaghan
C
,
Daly
E
,
Pearce
AJ
,
King
DA
,
Ryan
L.
A systematic review of the effects of educational interventions on knowledge and attitudes towards concussion for people involved in sport—optimising concussion education based on current literature
.
J Sports Sci
.
2021
;
39
(5)
:
552
567
.
27.
Mallory
KD
,
Saly
L
,
Hickling
A
,
Colquhoun
H
,
Kroshus
E
,
Reed
N.
Concussion education in the school setting: a scoping review
.
J School Health
.
2022
;
92
(6)
:
605
618
.
28.
Caron
JG
,
Bloom
GA
,
Falcao
WR
,
Sweet
SN.
An examination of concussion education programmes: a scoping review methodology
.
Inj Prev
.
2015
;
21
(5)
:
301
308
.
29.
Kerr
ZY
,
Register-Mihalik
JK
,
Marshall
SW
,
Evenson
KR
,
Mihalik
JP
,
Guskiewicz
KM.
Disclosure and non-disclosure of concussion and concussion symptoms in athletes: review and application of the socio-ecological framework
.
Brain Inj
.
2014
;
28
(8)
:
1009
1021
.
30.
Pennock
KF
,
McKenzie
B
,
Steacy
LM
,
Mainwaring
L.
Under-reporting of sport-related concussions by adolescent athletes: a systematic review
.
Int Rev Sport Exerc Psychol
.
Published online October 6, 2020. doi:10.1080/1750984X.2020.1824243
31.
Almeida
SA
,
Trone
DW
,
Leone
DM
,
Shaffer
RA
,
Patheal
SL
,
Long
K.
Gender differences in musculoskeletal injury rates: a function of symptom reporting?
Med Sci Sports Exerc
.
1999
;
31
(12)
:
1807
1812
.
32.
Kroshus
E
,
Baugh
CM
,
Daneshvar
DH
,
Nowinski
CJ
,
Cantu
RC.
Concussion reporting intention: a valuable metric for predicting reporting behavior and evaluating concussion education
.
Clin J Sport Med
.
2015
;
25
(3)
:
243
247
.