Factors That Impact Time to Athletic Trainer Evaluation Following Acute Injury Among Secondary School Athletes: A Report From the Athletic Training Practice-Based Research Network

We performed a retrospective analysis of deidentified patient records collected within the Athletic Training Practice-Based Research Network. All patient records were created via a web-based electronic medical record (EMR) during routine care by ATs within the secondary school setting. For the current study, there was a total of 333 clinical practice sites across 40 different states that represented the South (n = 13), Midwest (n = 10), Northeast (n = 8), West (n = 8), and Pacific (n = 1) regions of the United States, as classified by the US Census Bureau.¹⁸ 

Patients who were diagnosed with an acute injury that occurred during in-season sport participation between 2010 and 2023 were included in this study. All patients were secondary school athletes receiving care from an AT within the Athletic Training Practice-Based Research Network. This study was determined as exempt by the institutional review board at the University of Wisconsin-Madison, as it was a retrospective analysis of deidentified patient records.

Data were recorded in the Athletic Training Practice-Based Research Network’s EMR by ATs who successfully completed a training session before data collection.¹⁹  Data extraction procedures were similar to Lam et al and Marshall et al.^20,21  One research team member (K.C.L.) was responsible for the daily management of the EMR’s regional database and completed the data extraction for quality assurance procedures.²²  Patient cases were identified by the number of days between injury onset and AT evaluation and diagnosis. Then, using the unique identifier (ie, days since injury) associated with each patient case, we identified and extracted the remaining study variables from the EMR database for analysis.

Three Board-certified ATs and authors of this study (M.N.R., E.C.S., and S.N.A.) independently classified each International Classification of Disease (ICD) diagnostic code as acute or not acute. Disagreements in classification of an injury resulted in a discussion between the research team until a consensus was reached. A total of 193 ICD-10 codes were used to diagnose patients, 104 of which were determined to be acute. Only acute injuries that were evaluated by an AT less than or equal to 14 days from when they were sustained were included in analyses.

The CORE-AT EMR (www.core-at.com) is a web-based documentation system that features standard documentation forms, an injury surveillance feature, and patient-reported outcome forms. It is Health Insurance Portability and Accountability Act compliant, and in-depth descriptions of the features and functionality of the CORE-AT EMR have been described in previous investigations.^19,23  Patient characteristic variables were extracted from the demographics form and included sex, sport, activity during injury (ie, practice and competition), mechanism of injury, diagnosis (ICD-10 code), and days from injury to AT evaluation. Our main outcome measure, the time to AT evaluation, was measured as the number of days between injury onset, reported by the patient, and AT evaluation.

Mann-Whitney U and Kruskal-Wallis tests were used to examine the effect of sex (male or female), setting (practice or game), and sport level (freshman, junior varsity [JV], or varsity) on time to AT evaluation. Alpha was set a priori at P < .05. If a Kruskal-Wallis test was significant, separate Mann-Whitney U tests were conducted to determine where differences occurred with an adjusted P value (P < .017). All statistical analyses were conducted using SPSS 28.0 software (SPSS Inc).

A flow diagram on how the final dataset was reached can be seen in Figure 1. A total of 17 354 patient cases, representing 20 different sports, were included in this report. Athlete demographics can be viewed in Table 1. Football had the highest number of patient records in this report (37.1%), followed by basketball (16.3%), soccer (13.2%), volleyball (7%), and track (6.1%). Athletes represented in this sample were predominantly male (61.7%) and played at the varsity level (62.4%). Concussions (17.4%), ankle sprain/strains (12.8%), and thigh/hip/groin sprain/strains (8.6%) were the most diagnosed injuries.

Overall, 46.9% (n = 8138) of patients who sustained an acute injury during in-season play were evaluated by an AT the same day, 68.3% (n = 11 849) were evaluated the following day, 76.5% (n = 13 271) were evaluated after 2 days, and 84% (n = 2725) were evaluated after 3 days (Figure 2). A similar percentage of male and female athletes were evaluated 3 days after sustaining an injury, but a higher percentage of male athletes were evaluated the same day and 1 day following injury (male versus female; same day: 48.3% versus 44.6%; 1 day: 69.1% versus 66.9%; 2 days: 76.4% versus 76.5%; 3 days: 84.7% versus 82.9%). These percentages can be seen in Figure 3. Significant group differences were reported for sex (P < .001), setting (P < .001), and sport level (P = .002), with female athletes and in-game injuries associated with longer times to AT evaluation. Furthermore, freshmen athletes were evaluated sooner than JV (P = .007) and varsity (P < .001) athletes. No difference was observed between JV and varsity athletes (P = .34). Associations between athlete variables and the number of days from injury to AT evaluation are displayed in Table 2.

The most important finding of our study was that approximately half of high school athletes received medical care the same day they sustained an acute injury during in-season play, and over 80% of athletes were evaluated 3 days following injury. Evaluation within 72 hours is clinically relevant for athletes who are injured during Friday night play or over the weekend, and it also marks the end of the inflammatory phase of tissue remodeling following injury.²⁴  Thus, qualified health care is accessible for many student-athletes through ATs, and our study highlights how quickly ATs can help youth athletes enter the health care system. However, we observed several factors that were associated with a longer time to an AT evaluation following injury. Specifically, female athletes, athletes playing at the JV or varsity level, and athletes who sustained an injury during a game were associated with longer time to AT evaluation.

AT employment (full time or part time) has often been used as a proxy for AT accessibility in the literature, but the availability of an AT at a school does not necessarily represent their accessibility to different groups of student-athletes.^8,9,12  It is possible that the time to AT evaluation may be a more sensitive measure of AT availability than AT employment and, thus, a better representation of AT accessibility within this population. Associations between general availability of AT services and secondary school factors such as size, type (ie, public versus private), geographic location, and socioeconomic status are well established, but very few studies have observed medical coverage discrepancies between sport, sport level, and gender. We believe we are the first study to quantify AT availability as the time to AT evaluation following injury and evaluate differences in AT availability between different athlete groups and settings.

Several publications have investigated differences in sideline medical coverage between sports in the secondary school setting. These studies surveyed high school athletic directors or coaches, and both found that the largest disparity in immediate medical coverage was between football and all other sports, regardless of sex.^25,26  Subanalyses of our dataset showed similar results, as no statistical significance was found for the time to AT evaluation between sex when football was removed (male, n = 4312; female, n = 6598; P = .691). However, sex discrepancies in the time to a medical evaluation and availability of medical care following an injury may still exist. We found a significant difference in the time to an AT evaluation between male and female athletes for several sex-equivalent sports, such as basketball (male, n = 1264; female, n = 1558; P = .047) and soccer (male, n = 841; female, n = 1442; P = .47), but not in track (male, n = 472; female, n = 579; P = .71). Male basketball athletes who sustained an acute injury during in-season play were evaluated sooner, on average, and a higher percentage were evaluated within 24 hours than female basketball athletes (days to evaluation: male = 1.45 ± 2.46 and female = 1.62 ± 2.59; percentage of athletes evaluated within 24 hours: male = 48.3% and female = 45.1%). Similar results were found for soccer athletes (days to evaluation: male = 1.65 ± 2.69 and female = 1.8 ± 2.71; percentage of athletes evaluated within 24 hours: male = 45.7% and female = 41.1%). Thus, more research is needed to understand how and why the availability of medical care may differ between male and female athletes overall and in sex-equivalent sports.

Injury reporting patterns may help explain why athletes were evaluated sooner if they sustained an injury during practice or played at the freshman level than athletes who were injured during a game and athletes playing at the varsity and JV levels. For example, some athletes may not be as forthcoming about sustaining an injury as others for a variety of reasons. They may not understand the extent of their injury, or, as concussion research shows, athletes may choose not to report their injury for fear of being removed from participation.²⁷  This may explain why there was an increased time to AT evaluation in athletes playing at the JV and varsity levels compared with athletes playing at the freshman level. For example, JV athletes may not want to disclose an injury if they feel that participating will eventually allow them to play at the varsity level, and varsity athletes may wait to report an injury if they want to keep playing in hopes of being recruited. This fear of being removed from participation may also explain why athletes were evaluated sooner after sustaining an injury during practice than during games. However, research on concussion reporting behaviors suggests that female athletes are more likely to report concussion symptoms to a coach, AT, or teammate.^28,29  If female athletes are more likely to report sustaining an injury, the true discrepancy in immediate medical coverage between male and female athletes may be larger than indicated in this study. More research on how injury reporting patterns differ between athlete sex and sport level for a variety of injuries is needed.

Additionally, ATs may be more likely to be available for athletes during practices, especially if they are practicing on school grounds, than during games, which are not always at the school where the AT is employed. This provides another explanation for why there is a decreased time to AT evaluation for athletes who sustain an injury during practice compared with injuries sustained during games in the current study. The location of home athletic events may have implications on the athlete’s access to their schools’ AT, and additional research is needed to evaluate associations between immediate AT availability and the proximity of home athletic events to the athletic training clinic.

This study only included patient records for athletes who attended a secondary school that provided AT services in any capacity. Future research should evaluate how the time from sustaining an injury to being evaluated by a medical professional changes for athletes who become injured, and their school or sports club does not provide AT services. Approximately one-third of secondary schools in the United States provide no AT services, and although the availability of medical providers at club sporting events is unknown, club sport coaches were less likely to report that ATs are responsible for medical care during practices and games than high school coaches.^8,10,30  This leaves many athletes without medical coverage during athletic participation, which is alarming because life- or limb-threatening injuries are unpredictable and can occur without warning during physical activity at any level of participation.^31,32 

This study is not without limitations. Our main outcome variable, the time to AT evaluation, was patient reported, and we relied on the patient being truthful to the AT regarding how long ago they sustained the injury. Additionally, this variable was reported in days, and a more sensitive measure of the time to AT evaluation, such as hours, may give researchers a better idea of how quickly athletes are evaluated following injury and the true discrepancies in immediate AT access between athletes. This study did not control for school factors, such as school size, type, and socioeconomic status, which have been found to influence general AT availability, and future studies should evaluate how these factors may influence the time to AT evaluation following injury. Further, this sample of patient records included a large percentage of male athletes who played at the varsity level. Lastly, the large size of this dataset allowed us to find statistical significance between the groups of interest but raised concern regarding its clinical significance. For example, female athletes waited an additional 0.2 days to be evaluated by an AT following injury. Although this delay in care could have detrimental implications in emergent conditions, how a delay of less than a day affects long-term recovery and health outcomes in other sport-related injuries has yet to be established.

There is undisputed importance in having qualified and appropriate medical care readily accessible to athletes, and our study advocates for the profession of athletic training, as almost half of patients who sustained an acute injury were evaluated by their secondary school AT the same day. The National Athletic Trainers’ Association recommends that each student-athlete should have equitable access to appropriate medical care, regardless of sport, gender, or level of competition. However, we found several of these factors to be associated with a longer time to an AT evaluation following injury. We recognize that if a school provides AT services in any capacity, a single AT is typically responsible for providing care to all student-athletes. To increase the accessibility of AT services in the secondary school setting, school administrators should consider hiring additional ATs, while athletic directors and coaches may consider planning sporting events in a way that allows the AT to be more accessible to each athlete.