Clinical assessment, treatment, and referral trends for adolescent runners seeking care at an injured runners’ clinic

2.1Patients

This study was a retrospective chart review of electronic patient records from a tertiary-care Children’s Hospital Sports Medicine Division IRC, where participating fellowship-trained sports medicine physicians treated adolescent patients with RRIs between 2011 and 2021. The IRC is a multidisciplinary clinic consisting of sports medicine physicians, athletic trainers, strength and conditioning specialists, physical therapists, sports nutrition specialists, and mental health professionals. The IRC is designed to provide special care for injured runners through diagnosis and/or injury recovery and return to running. The clinic is held twice weekly, and typically patients are runners referred from primary care physicians, general orthopedics/sports medicine physicians and surgeons, and/or adolescent medicine specialists. This specialty clinic operates within the hospital’s sports medicine and orthopedics departments and an affiliated sports injury prevention and rehabilitation center. The attending sports medicine physicians in the IRC had specialized training in running gait biomechanics through fellowship training. These physicians completed all physical assessments and diagnoses for any active running-related injuries using standard clinical assessment and care. They performed real-time running gait biomechanics assessments for patients to help guide return to running and running-related re-injury prevention when appropriate.

For the purpose of this study, patients between the ages 10 and 17 years who were diagnosed with a current RRI were included. The lower age limit reflected the youngest age of a patient seeking care in the clinic, and the upper limit was chosen to focus on only adolescent patients. Patients who had a previous surgery for their injury were excluded as this would affect patients’ course of care. Additionally, those whose mechanism of injury was not running-related were excluded from this analysis to ensure that true RRIs were assessed. The study was approved by the hospital’s Institutional Review Board. Participant assent and parental consent were exempt due to the retrospective design.

2.2Data collection

Treating physicians used a web-based secure electronic medical record system (PowerChart®, Cerner Corporation, North Kansas City, MO, USA) to record the date of visit, chief complaint, history of present injury, review of systems, physical examination, imaging, and the assessment/plan of action for all patient encounters.

2.3Data extraction

Patient health care records were identified within the hospital database using a formal search by department and encounter type (e.g., orthopedics, sports medicine, IRC), and filtered by year (2011–2021) to identify pertinent patient medical record numbers. Two members of the research team (AFDL, SBW) screened patient records to ensure patients fit the inclusion criteria for this study. One researcher (AFDL) extracted data for the qualifying patients to ensure data integrity. All patient encounters were extracted for each injury for which they presented to the IRC. Extracted data included injury details (injured body region, injury type [bone vs. soft tissue]) using ICD-9/10 codes. Data were also extracted pertaining to the number and type of clinical assessments, imaging, assistive devices provided or prescribed (e.g., crutches, walking boots, orthoses), medications administered or prescribed, and patient referrals for therapeutic interventions or consultations across all patient visits using Current Procedural Terminology (CPT) codes. Clinical assessments were categorized as physical examinations used to rule in or rule out injuries, including manual tests, such as palpation of injured body regions, and special tests using specific hands-on assessments, such as a Thompson test for Achilles tendon injury. All data were entered in a secure online platform (REDCap, Vanderbilt University, Nashville, TN, USA).

2.4Statistical analyses

Descriptive statistics were used to summarize the number and type of clinical assessments, assistive devices, medications/supplements prescribed or administered overall, and referrals by injured body region and by injury type. Chi-square analyses were used to compare proportions of services rendered by injury details (injured body region, injury type), and to assess the change in services rendered over the 10-year time frame. Apparent differences across injuries or demographics were further compared using post-hoc pairwise proportion comparisons. Alpha was set a priori to 0.05 for all analyses. All analyses were conducted in Jamovi (Version 2.3.21.0).

3.1Clinical assessments

Foot, calf, shin, and hip injuries all received an average of 1.75 clinical assessment tests per clinic visit (Table 1). Manual and/or special tests comprised the majority of clinical assessments (56%), followed by x-rays (12%), MRIs (11%), and running gait assessments (10% ; Table 1). There were significant differences in the proportion of clinical assessments by injured body region (X²(N = 2,326, df = 4) = 69.7, p = 0.002). Shin injuries accounted for the largest proportion of clinical assessments (40% of all clinical assessments), followed by hip injuries (16% of all clinical assessments). Shin injuries had the largest proportion of all imaging services ordered (39%), with MRI being the most frequently used imaging service (45% of imaging for shin injuries; Table 1). Running gait analyses (42%) and blood panels/urinalyses (59%) were primarily performed for patients with shin injuries (Table 1).

There were no significant differences in number of clinical assessments performed across injury types (X²(N = 2,326, df = 2) = 2.9, p = 0.71), sex (X²(N = 2,326, df = 2) = 0.1, p = 0.81), nor year of visit (X²(N = 2,326, df = 10) = 59.7, p = 0.16). There were significant differences in assessment types by injury types; a larger proportion of patients with bone stress injuries received blood panels/urinalyses (X²(N = 150, df = 2) = 7.0, p = 0.01) and dual-energy x-ray absorptiometry (DEXA) scans (X²(N = 131, df = 2) = 48.5, p <  0.001) compared to patients with soft tissue injuries (Table 1). There were also significant differences in assessment types by year (X² range: 40.7–749.0, p <  0.001). A larger proportion of blood panels/urinalyses were performed in or after the year 2018 (average of 11% of visits) compared to 2011–2017 (average of 5% of visits; Fig. 1). Manual and/or special tests were more infrequently performed during the years 2020–2021 during the COVID-19 pandemic (average of 66% of visits in 2020–2021 vs. 100% previous years), as clinic visits shifted to telemedicine assessments (average of 33% of visits in 2020–2021 vs. 0% previous years; Fig. 1).

Fig. 1

Significant changes in clinical assessment, referral, device, and medication type trends over time. Caption: Pictogram depicting the percentage of visits including the respective diagnostic, referral, device, and medication/supplementation administration clinic trends from 2011-2021 (x-axis). Stars along the x-axis indicate the emergence of specific consensus statements regarding the management and care of injuries and adolescent runners.^{7,15,16,17,27} Darker hues represent more visits including the services. Only specific types of outcomes that were statistically significantly different over time are presented. Abbreviations: BJSM, British Journal of Sports Medicine; NSAIDs, non-steroidal anti-inflammatory drugs; IOC, International Olympic Committee; PM&R, Physical Medicine & Rehabilitation; RRI, running-related injuries; Meds, Medications; Supplem., Supplements..

3.2Assistive devices

Orthoses (41% of all devices) and walking boots (26%) were the most frequently provided devices for adolescent patients with RRIs (Table 2). There were significant differences in the proportion of assistive devices provided by injury types (X² range: 76.9–106.0, p <  0.001). Those with toe/feet and knee injuries received the highest number of assistive devices per visit (Table 2). Braces and/or compression sleeves were most frequently provided to patients with knee injuries (39%), followed by ankle injuries (19%) and lower back injuries (16% ; Table 2). Walking boots and orthoses were most frequently provided to those with shin (boots: 53% ; orthoses: 29%) and toe/foot injuries (boots: 33% ; orthoses: 25%) compared to other injured body regions (Table 2).

There was not a significant difference in the number of assistive devices provided or prescribed by injury type (X²(N = 427, df = 4) = 1.2, p = 0.76), sex (X²(N = 427, df = 2) = 0.04, p = 0.84), nor year (X²(N = 427, df = 10) = 11.3, p = 0.336). There was a significant difference in the proportion of devices provided by year (X²(N = 427, df = 6) = 28.1, p = 0.002). A larger proportion of braces and/or compression sleeves were provided between 2011–2012 compared to later years (average 9% vs. 3%), and the same trend was noted for orthoses (average of 16% visits vs. 9% ; Fig. 1). There were no significant differences in specific devices by injury types or sex.

3.3Medications and supplements

The majority of medications and supplements administered or prescribed were vitamin D (26%), followed by non-steroidal anti-inflammatories (NSAIDs; 22%), calcium (18%), and ultrasound-guided corticosteroid injections (9% ; Table 3). Foot injuries received the highest number of medications or supplements per visit with administration or prescription (1.45±0.55), followed by injuries to the shins (1.43±0.50) and injuries to the thighs (1.36±0.50; Table 3). There was a significant difference in the types of medications and supplements by injury types (X² range: 23.6–71.4; p-range: <  0.001–0.003); vitamin D, calcium, and iron supplements were most frequently administered or prescribed for patients with shin injuries (vitamin D: 56% ; calcium: 56% ; iron: 50%) compared to other injured body regions. NSAIDs were primarily provided for patients with shin injuries, while corticosteroid injections were primarily performed for those with hip injuries (Table 3).

A larger proportion of medications and supplements were prescribed or administered for patients with bone stress injuries compared to soft tissue injuries (X²(N = 397, df = 2) = 15.4, p <  0.001; Table 3). However, when assessing specific medication and supplement subtypes, there were comparable proportions of administrations or prescriptions across injury types. Although the proportion of medications and supplements prescribed or administered was similar across the observed years, there were significant differences in the types of medications and supplements by year (X² range: 19.6–26.8; p-range: 0.003–0.03). NSAIDs were more frequently administered during the years 2011–2012 compared to later years (average of 9% of visits vs. 5% ; Fig. 1). Iron supplements were more frequently administered from 2018–2021 compared to previous years (average of 3% of visits vs. 1% ; Fig. 1). There were no significant differences in number or type medications by sex (X²(N = 397, df = 2) = 2.4, p = 0.12).

3.4Referrals

The majority of referrals across all injuries were for physical rehabilitation (52% of all referrals), followed by gait-training (14%) and nutrition consultations (8%). Patients with shin (43% gait-training referrals), knee (16%), and hip injuries (15%) were most frequently referred for gait-training compared to other injured body regions (X²(N = 2,116, df = 4) = 24.6, p = 0.002; Table 4). Patients with shin injuries had the highest number of total referrals (N = 1,465, 42% of all referrals) and referrals per visit (X²(N = 2,116, df = 4) = 132.0, p <  0.001; Table 4). Approximately half of all referrals for nutrition were for patients with shin injuries (X²(N = 286, df = 4) = 70.6, p <  0.001; Table 4).

There were significant differences in the proportion of nutrition types by year (X² range: 23.8–31.0; p-range: <  0.001–0.01). There were higher proportions of nutrition referrals between the years 2015–2021 compared to 2011–2014 (average of 14% of visits vs. 7% ; Fig. 1). A similar trend was observed for increased gait-training referrals between 2014–2021 compared to 2011–2013 (22% of visits vs. 13% ; Fig. 1). There were significantly higher proportions of referrals for psychiatric consultation during the 2020–2021 years of the pandemic compared to previous years (4% of visits vs. 1% ; Fig. 1). There was not, however, a significant difference in the number of patient referrals by injury type (X²(N = 2,116, df = 4) = 3.6, p = 0.61), sex (X²(N = 2,116, df = 2) = 0.01, p = 0.94), nor year (X²(N = 2,116, df = 10) = 6.4, p = 0.78). Additionally, there were no significant differences in the specific types of referrals by injury type or sex.

4.1Future directions

With the continued development of novel treatment parameters (e.g., platelet-rich plasma injections) [36, 37] and continued research on micro- and macro-level contributors to injury [11], it will be important to continue to assess therapeutic interventions and successes for adolescent athletes seeking care. There is also a need to bolster the evidence regarding age-specific approaches to care for adolescent runners, given that metabolic assessments have been primarily conducted among adults [16, 17]. The continued impact on advancements in sports medicine will be essential to determine changes in assessment and treatment components of clinic visits as well as long-term outcomes following clinical intervention.

4.2Limitations

This study focused on clinic visit trends from a single location. The majority of the patients in the dataset were White females. Given this limitation, the findings may not reflect nationwide trends in more diverse populations. The study team did not have access to information regarding training volume and intensity, nor additional injury characteristics (e.g., time loss vs. non-time loss). However, these factors may have influenced patient care. The hospital-affiliated clinic had access to specialists for referrals to complement treatments, such as gait analysis and gait-training, which may not be possible across all clinical sites. As the hospital system was affiliated with a university, education regarding athlete health and best practices may have been more prevalent compared to other clinical settings. There were no data available to determine treatment success; however, future research should collect and measure patient-reported outcomes and other clinical markers to address this gap in the literature. All RRIs in this study were non-surgical and did not reflect treatment and referral patterns for more severe RRI cases.