The Link Between Concussions and Sprains and Strains
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September 24, 2019
By Carrie Baker, PhD, ATC
For better or worse, the topic of concussions and their lingering effects has become very prevalent among sports medicine research, as well as in the global media. Recent evidence suggests that concussions may not only cause apparent disruptive signs and symptoms, such as impaired cognition, sleep disorders, impaired memory and headaches, but may actually increase the risk of future musculoskeletal injury as well. According to P. McCrory in “Consensus statement on concussion in sport-the 5th International Conference on Concussion in Sport held in Belin October 2016” published in the British Journal of Sports Medicine in 2017 as well as R. C. Lynall, T. C. Mauntel, D. A. Padua and J. P. Mihalik in “Acute lower extremity injury rate increase after concussion in college athletes” published in Medicine and Science Sports and Exercise in 2015, impaired function of higher brain centers and disrupted cortical pathways associated with a concussion may alter neuromuscular control and affect the way one moves after apparent deficits subside.
Subtle impairments, such as impaired motor control and delayed reaction time, are not as easily measured by current common screenings, and may lead to an increased risk of musculoskeletal injury according to G. B. Wilkerson, D. R. Grooms and S. N. Acocello in “Neuromechanical considerations for postconcussion musculoskeletal injury risk management” in Current Sports Medicine Reports in 2017 as well as A. Nordstrom, P. Nordstrom and J. Ekstrand in “Sports-related concussion increases the risk of subsequent injury by about 50% in elite male football players” published in the British Journal of Sports Medicine in 2014.
Several studies have been conducted to investigate the relationship between individuals with a history of concussion and subsequent injury. Populations including elite athletes, such as professional American football players, boxers and soccer players, as well as collegiate athletes have demonstrated a positive association between a history of concussion and subsequent lower extremity injury. These findings are supported by F. Gilbert, G. Burdette, A. Joyner, T. Llewllyn and T. Buckley in “Association between concussion and lower extremity injuries in collegiate athletes” published in Sports Health in 2016 as well as B. Pietrosimone, Y. Golightly, J. Mihalik and K. Guskiewicz in “Concussion frequency associates with musculoskeletal injury in retired NFL players” published in Medicine and Science Sports and Exercise in 2015.
A. Nordstrom, P. Nordstrom and Ekstrand further elaborate on a study that investigated elite soccer players who had a history of concussion determined that individuals were at an increased risk of all types of injury in the year after concussion. Further supporting the link between concussion and musculoskeletal injury risk, Wilkerson, Grooms and Acocello report the findings of several investigations that have documented diminished motor performance in parallel with changes in brain activity or structural connectivity.
The idea that an individual may have impaired responsiveness following a concussion may result in an inability to properly react to environmental stimuli. According to S. D. Livingston, E. N. Saliba, H. P. Goodkin, J. T. Barth, J. N. Hertel and C. D. Ingersoll in “A preliminary investigation of motor evoked potential abnormalities following sport-related concussion” published in Brain Injury in 2010, the impairments may inhibit coordinated movement patterns or alter movement patterns that decrease the ability to avoid obstacles that may cause injury. Understanding what might affect an injury in this population may lead to more precise screenings that can help identify potential impairments. Wilkerson, Grooms and Acocello report that dual task tests requiring an individual to focus on a cognitive task as well as complete a task that requires balance or reaction time testing, as well as decision-making and perception tasks may help detect the subtle impairments that demonstrate evidence of lingering effects of a concussion. In addition, C. Ardern, P. Glasgow and A. Schneiders in “2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern” in British Journal of Sports Medicine in 2016 as well as G. Wilkerson, D. Nabhan and W. Moreau in “Long-term visuospatial performance abnormalities among elite athletes reporting history of concussion” published in the Annals of Physical and Rehabilitation Medicine in 2018 report testing that requires whole body movement responses may better quantify injury risk.
Screenings or post-concussion testing should focus not only on the standardized concussion protocols, such as symptom checklists, stress testing and exercise progression, but may also need to incorporate dual-task testing. Wilkerson, Nabhan and Moreau mention that some studies suggest utilizing a whole body reactive agility test, where the individual needs to respond to changing stimuli by moving themselves to one point in space to another. Another potential mechanism to detect the subtle changes may be the use of a dual-task assessment using postural control and a cognitive reaction activity, such as the Eriksen flanker test. According to Wilkerson, Grooms and Acocello, the flanker test is a simple test where individuals have to identify the direction indicated by a centrally-located arrow within a 5-arrow visual display that is congruous (i.e.,>>>>> or <<<<<) or incongruous (i.e., >><>> or <<><<) that flashes on a screen. The test can be administered while the individual is balancing on an unstable surface, such as a foam pad.
While a cause and effect relationship cannot be established with retrospective analysis, there is evidence to establish a strong relationship between concussion history and subsequent musculoskeletal injury. Results may suggest that a more thorough medical evaluation is required following a concussion, focusing on assessment of neurological and cognitive functions. Lynall, Mauntel, Padua, Mihalik and as well as A. Nordstrom, P. Nordstrom and Ekstrand report that the results also suggest that following concussion, participants should be closely monitored for at least one year. Clinicians are trained to recognize the common signs and symptoms of a concussion, and the majority of patients with concussions recover from these signs and symptoms within seven to ten days, however the developing evidence points to potential changes in the way we should screen and monitor patients who have been diagnosed or who are suspected to have a concussion.
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2. Lynall RC, Mauntel TC, Padua DA, Mihalik, JP. Acute lower extremity injury rate increase after concussion in college athletes. Medicine and Science Sports and Exercise. 2015;12:2487-2492.
3. Wilkerson GB, Grooms DR, Acocello SN, Neuromechanical considerations for postconcussion musculoskeletal injury risk management. Current Sports Medicine Reports. 2017;6:419-427.
4. Nordstrom A., Nordstrom P., Ekstrand J. Sports-related concussion increases the risk of subsequent injury by about 50% in elite male football players. British Journal of Sports Medicine. 2014;48:1447-1450
5. Gilbert FC, Burdette GT, Joyner AB, Llewllyn TA, Buckley TA. Association between concussion and lower extremity injuries in collegiate athletes. Sports Health. 2016;8(6): 561-567
6. Pietrosimone B., Golightly Y., Mihalik J., Guskiewicz K. Concussion frequency associates with musculoskeletal injury in retired NFL players. Medicine and Science Sports and Exercise. 2015;47 (11):2366-72.
7. Livingston SC, Saliba EN, Goodkin HP, Barth JT, Hertel JN, Ingersoll CD. A preliminary investigation of motor evoked potential abnormalities following sport-related concussion. Brain Injury. 2010;24(6):904–13.
8. Ardern CL, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. British Journal of Sports Medicine. 2016; 50:853Y64.
9. Wilkerson, G., Nabhan, D., & Moreau, W. (2018). Long-term visuospatial performance abnormalities among elite athletes reporting history of concussion. Annals of Physical and Rehabilitation Medicine, 61, e40.
About the Author
Carrie Baker, PhD, ATC is the Program Director for the Professional Graduate Athletic Training Program at the University of Tennessee at Chattanooga. She received degrees from Castleton State College in 2000, Old Dominion University 2002 and the University of Kentucky 2012. She has spent most of her career as a faculty member teaching athletic training courses, working in Division I athletics, as well as volunteering outreach services to high schools in a variety of locations. Baker has research interests in self-efficacy, balance and injury prevention. In her spare time, she loves spending time with her daughter and husband.