Subclinical, long-term psychological symptoms following sport-related concussion: are athletes more depressed than we think?

ABSTRACT

Introduction

In adolescent and collegiate athletes with sport-related concussion (SRC), we sought to evaluate the prevalence and predictors of long-term psychological symptoms.

Methods

A cohort study was conducted of athletes 12–24-year-old diagnosed with SRC between November 2017 and April 2022. Athletes/proxies were interviewed on psychological symptoms (i.e. anger, anxiety, depression, and stress). Participants who scored ≥75th percentile on one or more PROMIS (Patient-Reported Outcomes Measurement System) measures were operationalized to have subclinical, long-term psychological symptoms. Uni/multivariable regressions were used.

Results

Of 96 participants (60.4% male), the average age was 16.6 ± 2.6 years. The median time from concussion to interview was 286 days (IQR: 247–420). A total of 36.5% athletes demonstrated subclinical, long-term psychological symptoms. Univariate logistic regression revealed significant predictors of these symptoms: history of psychiatric disorder (OR = 7.42 95% CI 1.37,40.09), substance use (OR = 4.65 95% CI 1.15,18.81), new medical diagnosis since concussion (OR = 3.43 95% CI 1.27,9.26), amnesia (OR = 3.42 95% CI 1.02,11.41), other orthopedic injuries since concussion (OR = 3.11 95% CI 1.18,8.21), age (OR = 1.24 95% CI 1.03,1.48), days to return-to-play (OR = 1.02 95% CI 1.00,1.03), and psychiatric medication use (OR = 0.19 95% CI 0.05,0.74). Multivariable model revealed significant predictors: orthopedic injuries (OR = 5.17 95% CI 1.12,24.00) and return-to-play (OR = 1.02 95% CI 1.00,1.04).

Conclusions

Approximately one in three athletes endorsed long-term psychological symptoms. Predictors of these symptoms included orthopedic injuries and delayed RTP.

KEYWORDS:

• Sport-related concussion
• psychological symptoms
• return-to-play
• post-concussion syndrome
• mild traumatic brain injury

Introduction

Sport-related concussion (SRC) is a public health concern among the youth (1,2). While most recover fully from any affective, physical, cognitive, or sleep symptoms within 2 weeks of initial injury, approximately 15% experience persisting symptoms from any of the four symptom clusters (3). The range of these symptoms may be heterogeneous, from physical, cognitive, to emotional (4–6). Emotional symptoms include anxiety/nervousness, sadness, feeling more emotional, and irritability (5,7).

Prior studies have shown that psychological symptoms and emotional disturbances are common following SRC, occurring in as many as 94.7% (7) of athletes during recovery. Adolescent and collegiate athletes, often temporarily advised to limit athletic and scholastic participation during the initial phase of their recovery (8), may endure emotional distress from reduction of social interactions and physical activity (4,9–11). While efforts have been made to identify, examine, and improve various interpersonal factors (i.e., social support, communication) that may contribute to psychologic symptoms following SRC (12–14), some athletes continue to experience persistent emotional symptoms long after initial injury (15,16).

Many studies have investigated psychological symptoms that appear acutely following SRC; however, the literature on longer-lasting, subclinical psychological and emotional symptoms remains limited. Therefore, in a cohort of athletes who were diagnosed with a SRC at a regional sports concussion center, we sought to: 1) characterize the prevalence of subclinical, long-term psychological symptoms, and 2) investigate predictors of such symptoms.

Materials and methods

Study design and patient selection

A retrospective, cohort study with a prospective arm was conducted examining athletes 12–24-years-old who were diagnosed with an SRC at a regional sports concussion center. Patients evaluated for concussions between November 1, 2017 and April 4 2022 were screened for eligibility (n = 2,059). Institutional Review Board (IRB#220761) approval was obtained. Consent was acquired via a phone call and REDCap survey from each participant (≥18 years) or parent proxy (<18 years). All participants/parent proxies were prospectively interviewed via phone-call surveys. The selection process and phone-interviews took place between April 1, 2022 and August 1, 2022. Data were stored into a secure REDCap database (17,18). No incentives were provided for study participation.

Independent variables

Several variables were obtained from a retrospective chart review. Demographics (i.e., age, sex, race, and ethnicity), past medical history (i.e., number of prior concussions, personal/family psychiatric history), injury characteristics (i.e., initial symptom severity, days to present, loss of consciousness [LOC], amnesia), and recovery outcomes (i.e., days to return-to-play) were obtained via review of the electronic medical record. Initial concussion symptom severity was measured at the first visit using the Post-Concussion Symptom Scale (PCSS), a 22-item self-reported measure recording symptom severity on a 7-point Likert scale (19). The PCSS was used as a continuous independent variable in the univariate and multivariable models.

Phone calls

The prospective phone call interview included a background questionnaire as well as the Patient-Reported Outcomes Measurement Information System (PROMIS) (20) and Diagnostic Interview for Anxiety, Mood, and Obsessive-Compulsive and Related Neuropsychiatric Disorders (DIAMOND) instruments (21). The background questionnaire assessed each patient’s concussion history (including additional concussions after receiving treatment at our center), medical history (including any additional injuries since the concussion that was treated at our center), medication history, and substance use history. Each participant was asked about emotional symptoms that may have occurred following the injury (i.e., depression, anxiety, and anger); each domain was assessed separately. If the participant reported experiencing a symptom, the onset (when did this symptom develop? Choices: first week following concussion; after first week but within 1 month of concussion; after 1 month) and duration (how long did this symptom last? Choices: less than 2 weeks; between 2 weeks and 3 months; more than 3 months; still occurring) of this symptom was assessed.

PROMIS surveys for patient (≥18 years) or parent proxy (<18 years) included specific measures for: Anger (20,22) (five items patient; five items proxy), Anxiety (23) (four items patient; eight items proxy), Depression (24) (four items patient; six items proxy), and Stress (25) (four items patient; eight items proxy). Each measure was summed, and the raw score was converted to a T-Score based on the published normalized data found in the manuals for these measures (mean = 50, standard deviation = 10) (25). For those ≥18 years, we administered portions of the DIAMOND (21), an empirically validated semi-structured diagnostic interview, to assess if any participants met DSM-5 diagnostic criteria for Major Depressive Disorder (MDD) or Generalized Anxiety Disorder (GAD). Detailed information on background questionnaire and PROMIS/DIAMOND surveys are shown in Table 1. Of note, all prospective phone call interviews were administered between 04/01/2022 and 08/01/2022, approximately during the timeframe of the COVID pandemic.

Table 1. Surveys.

Patient (patient ≥18 years)	Parent Proxy (patient <18 years)
Background Questionnaire	Background Questionnaire
Repeat Concussion (since your concussion, have you had another concussion?)	Repeat Concussion (since your child’s concussion, has he/she had another concussion?)
Other Injuries (since your concussion, have you had any other injuries?)	Other Injuries (since your child’s concussion, has he/she had any other injuries?)
New Diagnosis (since your concussion have you been diagnosed with any new medical diagnosis?)	New Diagnosis (since your child’s concussion, has he/she been diagnosed with any new medical diagnosis?)
Substance use (have you ever used alcohol, marijuana, or other recreational drugs?)	Substance use (has your child ever used alcohol, marijuana, or other recreational drugs?)
Psychiatric Medications (are you currently on any psychiatric medications?)	Psychiatric Medications (is your child currently on any psychiatric medications?)
PROMIS	PROMIS
Anger	Anger
Anxiety	Anxiety
Depression	Depression
Stress	Stress
DIAMOND
Major Depressive Disorder
Generalized Anxiety Disorder

PROMIS = Patient-Reported Outcomes Measurement Information System.

DIAMOND = Diagnostic Interview for Anxiety, Mood, and OCD and Related Neuropsychiatric Disorders.

Anger (patient) = PROMIS Short Form v1.1 Emotional Distress Anger 5a.

Anger (parent proxy) = PROMIS Parent Proxy Short Form v2.0 Anger 5a.

Anxiety (patient) = PROMIS Short Form v1.0 Emotional Distress Anxiety 4a.

Anxiety (parent proxy) = PROMIS Parent Proxy Short Form v2.0 Anxiety 8a.

Depression (patient) = PROMIS Short Form v1.0 Emotional Distress Depression 4a.

Depression (parent proxy) = PROMIS Parent Proxy Short Form v2.0 Depressive Symptoms 6a.

Stress (patient) = PROMIS Short Form v1.0 Psychological Stress Experiences 4a.

Stress (parent proxy) = PROMIS Parent Proxy Short Form v1.0 Psychological Stress Experiences 8a.

Dependent Variable

The primary outcome, long-term subclinical psychological symptoms, was defined as scoring ≥75th percentile on one or more negative affect PROMIS questionnaires. The PROMIS questionnaires covered areas of anger, anxiety, depression, and stress, and were answered by patient (for ≥18 years) or parent proxy (for <18 years).

Statistical Analysis

Descriptive statistics were performed to present sample demographics, past medical history, injury characteristics, and other health information obtained from our prospective phone calls. The proportions of our sample that endorsed having psychiatric symptoms (i.e., depression, anxiety, anger) were presented, along with the onset and duration of symptoms. Correlation of negative affect was performed between different PROMIS measures. The proportions of those that met our definition of long-term subclinical psychological symptoms was presented. A logistic regression was used to assess for predictors of long-term subclinical psychological symptoms. Covariates were then determined accordingly based on significance, for the multivariable model. The final covariates included: age (continuous), history of psychiatric disorder (yes/no), other injuries (yes/no), new medical diagnosis (yes/no), substance use (yes/no), psychiatric medications (yes/no), LOC (yes/no), amnesia (yes/no) and days to RTP (continuous). Statistical significance was set a priori at p < 0.05. Analyses were performed using SPSS 27 (IBM, Armonk, NY).

Results

Demographics

A total of 300 phone calls were made to former patients. Of those, 117 former patients/parent proxies were successfully reached, 96 (82.1%) of whom (28 athletes and 68 parents) consented to participate in the study. The majority were male (n = 58, 60.4%), white (n = 82, 85.4%), and non-Hispanic/Latino (n = 93, 96.9%). Patient age at survey was 16.6 ± 2.6 years. Majority of athletes were between ages 15–17 at the time of injury (ages 12–14, n = 16; ages 15–17, n = 52; ages ≥18, n = 28). Regarding medical history, 8 (8.3%) participants had history of psychiatric disorder, 13 (13.5%) had family history of psychiatric disorder, and 38 (39.6%) had a prior history of concussions. The average time from concussion to initial clinic presentation was 7.7 ± 12.5 days and initial total PCSS was 26.9 ± 50.1 (Table 2).

Table 2. Sample characteristics.

	Patient Cohort (n = 96)	Parent Cohort (n = 68)
Age (M ± SD)	16.6 ± 2.6	44 ± 7.2
Sex
Male	58 (60.4%)	8 (8.3%)
Race
White	82 (85.4%)	59 (61.5%)
Black	9 (9.4%)	6 (6.3%)
Other/Unknown	5 (5.2%)	3 (3.1%)
Ethnicity
Non-Hispanic/Latino	93 (96.9%)	67 (69.8%)
Past Medical History
History of Psychiatric Disorder	8 (8.3%)
Family History of Psychiatric Disorder	13 (13.5%)
Prior Concussion (1)	24 (25.0%)
Prior Concussions (≥2)	14 (14.6%)
Injury Characteristics
Initial Post Concussion Symptom Score	26.9 ± 50.1
Time to Present (days)	7.7 ± 12.5
Loss of Consciousness	7 (7.3%)
Amnesia	14 (14.6%)
Days to Return-To-Play	40.5 ± 53.3
Other Health Questions
Repeat Concussion	14 (14.6%)
Other Injuries	23 (24.2%)
New Diagnosis	22 (22.9%)
Substance use	11 (11.5%)
Psychiatric Medications	12 (12.5%)

Background questionnaire

The median time from concussion to phone survey was 286 days (IQR: 247–420). Of 96 athletes, 14 (14.6%) endorsed having had another concussion since being treated in our concussion center. Of all athletes, 23 (24.2%) answered to having experienced another injury since their concussion, the majority of which were orthopedic-related injuries (n = 19, 82.6%) and the remainder of which were eye trauma (n = 1, 4.3%) or missing information (n = 3, 13.0%). A sizable minority (n = 22, 22.9%) reported being diagnosed with a new medical condition since the concussion. Of the new medical diagnosis, 5 (22.7%) were psychiatric diagnosis (3 anxiety and depression, 1 post-traumatic stress disorder and depression, 1 anxiety only), all of whom were started on a new psychiatric medication. At the time of the interview, 12 (12.5%) of the total sample were taking a psychiatric medication. Finally, 11 (11.5%) patients in our cohort endorsed substance use prior to their concussion (e.g., alcohol, marijuana, recreational drug) (Table 2).

A large portion of our sample endorsed having psychiatric symptoms following concussion (depression 63.5%; anxiety 45.8%; anger 46.9%). When asked about the onset of these symptoms, most reported experiencing them in the first week post-injury (depression 67.2%; anxiety 45.5%; anger 77.8%), while less reported an initial onset of >1-month post-injury (depression 8.2%; anxiety 15.9%; anger 2.2%) (Figure 1). Regarding the duration of symptoms, many participants stated that their depression and anger symptoms lasted between 2 weeks and 3 months (depression: 47.5%; anger: 53.3%), while many endorsed that their anxiety symptoms were still occurring (45.5%) at the time of the survey (Figure 2).

Figure 1. Onset of psychiatric symptoms following concussion.

Figure 2. Duration of psychiatric symptoms following concussion.

PROMIS and DIAMOND measures

The average T-scores for the four PROMIS measures approached the mean of the normative sample, with the tendency of having less emotional symptoms than the normative sample. The mean values across the four measures included: PROMIS Anger, 41.6 ± 11.9; PROMIS Anxiety, 46.1 ± 10.9; PROMIS Depression, 44.5 ± 10.0; PROMIS Stress, 51.5 ± 9.7 (Table 3). Pearson correlations between PROMIS measures were strong (r = .60–.67) (Table 4). A minority of participants achieved a score suggestive of high psychological symptoms on each measure (i.e., at or above the 75^th percentile of the normative population): 12 (12.5%) endorsed high anger symptoms, 16 (16.7%) endorsed high anxiety symptoms, 13 (13.5%) endorsed high depressive symptoms, and 30 (31.3%) endorsed high-stress symptoms. A total of 35 (36.5%) demonstrated subclinical, long-term psychological symptoms. Of the 28 participants who completed the DIAMOND diagnostic interviews, none (0%) met diagnostic criteria for GAD and 3 (10.7%) met the diagnostic criteria for MDD. The PROMIS measures took approximately 10–20 minutes to administer per patient/parent.

Table 3. PROMIS scores and proportions with subclinical long-term psychological symptoms.

Measure	T-Score (M ± SD) (n = 96)	Scores ≥75^th %
Anger	41.6 ± 11.9	12 (12.5%)
Anxiety	46.1 ± 10.9	16 (16.7%)
Depression	44.5 ± 10.0	13 (13.5%)
Stress	51.5 ± 9.7	30 (31.3%)

Table 4. Correlation of negative affect.

	Anxiety	Depression	Stress
Anger	0.67*	0.60*	0.61*
Anxiety	–	0.60*	0.60*
Depression	–	–	0.62*

* signifies p < 0.001.

Predictors of subclinical, long-term psychological symptoms

In a series of simple univariable regressions, the variables that significantly predicted subclinical, long-term psychological symptoms were (listed in order of magnitude from largest to smallest): history of psychiatric disorder (OR = 7.42 95% CI 1.37, 40.09), substance use (OR = 4.65 95% CI 1.15, 18.81), new medical diagnosis since concussion (OR = 3.43 95% CI 1.27, 9.26), amnesia (OR = 3.42 95% CI 1.02, 11.41), other orthopedic injuries since concussion (OR = 3.11 95% CI 1.18, 8.21), older age (OR = 1.24 95% CI 1.03, 1.48), days to return-to-play (RTP) (OR = 1.02 95% CI 1.00, 1.03), and psychiatric medication use (OR = 0.19 95% CI 0.05, 0.74; i.e., the absence of psychiatric medications were associated with subclinical psychological symptoms). In our multivariable model, the only significant variables that predicted subclinical psychological symptoms were orthopedic injuries since concussion (OR = 5.17 95% CI 1.12, 24.00) and days to RTP (OR = 1.02 95% CI 1.00, 1.04). All other covariates were non-significant (Table 5).

Table 5. Predictors of subclinical long-term psychological symptoms.

	Univariable Model							Multivariable Model
Measures	B	S.E.	Wald	df	p	Exp (B)	95% C.I. Exp (B)	B	S.E.	Wald	df	p	Exp (B)	95% C.I. Exp (B)
Age	0.21	0.09	5.42	1	.020	1.24	1.03–1.48	0.02	0.25	0.00	1	.952	1.02	0.62–1.67
Gender	0.82	0.43	3.70	1	.054	2.28	0.98–5.29
History of Psychiatric Disorder	2.00	0.86	5.43	1	.020	7.42	1.37–40.09	3.81	3.11	1.50	1	.221	45.14	0.10–20087.04
Family History of Psychiatric Disorder	0.75	0.64	1.39	1	.238	2.11	0.61–7.34
Number of Prior Concussions	0.02	0.27	0.00	1	.955	1.02	0.60–1.73
Initial Post Concussion Symptom Score	0.01	0.01	0.65	1	.420	1.01	0.99–1.03
Repeat Concussion	0.79	0.59	1.80	1	.180	2.19	0.70–6.92
Other Injuries	1.14	0.50	5.26	1	.022	3.11	1.18–8.21	1.64	0.78	4.41	1	.036	5.17	1.12–24.00
New Diagnosis	1.23	0.51	5.92	1	.015	3.43	1.27–9.26	0.49	1.02	0.24	1	.628	1.64	0.22–12.11
Substance use	1.54	0.71	4.63	1	.031	4.65	1.15–18.81	−1.60	3.37	0.23	1	.635	0.20	0.00–147.70
Psychiatric Medications	−1.69	0.70	5.73	1	.017	0.19	0.05–0.74	4.30	3.30	1.70	1	.192	73.90	0.12–47196.17
Loss of Consciousness	0.38	0.81	0.23	1	.634	1.47	0.30–7.12
Amnesia	1.23	0.62	3.99	1	.046	3.42	1.02–11.41	1.06	0.85	1.54	1	.214	2.88	0.54–15.30
Days to Return-To-Play	0.02	0.01	4.21	1	.040	1.02	1.00–1.03	0.02	0.01	5.15	1	.023	1.02	1.00–1.04

Discussion

The current study aimed to characterize the prevalence and predictors of subclinical, long-term psychological symptoms in a cohort of adolescent and collegiate athletes diagnosed with SRC. Greater than one-third of our sample met the operational definition of subclinical, long-term psychological symptoms. Approximately half of our cohort endorsed having any psychiatric symptom (i.e., depression, anxiety, and anger) following their SRC, with most symptoms appearing during the first week following injury and lasting less than 3 months; however, a notable proportion reported ongoing anxiety symptoms at the time of survey administration. Independent predictors of having these symptoms were additional orthopedic injury and delayed RTP. These results suggest that subsequent orthopedic injuries, further delay to sport participation, and an overall lack of physical activity may be associated with subclinical, long-term psychological symptoms following SRC.

The finding that approximately one-third of patients who had recovered from a SRC are experiencing subclinical psychological symptoms may be consistent with large, general population studies. For instance, a large European epidemiologic study investigating the prevalence of subthreshold depression and anxiety in a healthy adolescent population (26) found that 32.0% exhibited subthreshold anxiety and 29.2% demonstrated subthreshold depression at the time of interview, via self-report on validated questionnaires. According to the Centers for Disease Control and Prevention (27), current estimates for having an official psychiatric diagnosis by healthcare professional among children ages 3–17 are 9.4% for anxiety and 4.4% for depression, both of which have significantly increased during and after the COVID pandemic (28,29), approximately the timeframe in which these surveys were delivered to patients/parents. Our results, which should garner attention from concussion providers and future researchers, may reflect the already high prevalence of subclinical psychiatric symptoms in the general, healthy adolescent population today. However, given our operational definition of what constitutes subclinical, long-term psychological symptoms, no direct comparisons can be made between our results and the prevalence of mental health illnesses cited in prior literature. Of note, among the 28 participants who completed the DIAMOND diagnostic interviews, which may provide better comparisons, none (0%) met diagnostic criteria for GAD and 3 (10.7%) met the diagnostic criteria for MDD. Evaluating whether long-term psychological symptoms seen in our cohort indeed truly represent those with persistent symptoms following SRC or reflect the mental health status of the healthy adolescent and collegiate population is unclear and beyond the scope of the study.

Independent predictors of subclinical psychological symptoms were having a longer RTP following the concussion as well as an additional orthopedic injury. Beleckas et al. (30), in a large cross-sectional study involving 14,965 patients presenting to a tertiary orthopedic center, found that 20% of those presenting with orthopedic problems exceeded threshold score for anxiety on PROMIS measures, and anxiety level was strongly correlated to level of physical functioning. Prior literature has explored the benefits of both physical exercise (31–33) and team sports (34–37) on mental health across all ages (38). Adolescents who undergo significant physiologic, hormonal, and emotional changes during their formative pubertal years may be more influenced by the benefits of exercise and sports – and therefore, to the detriments of lack thereof (39–42). Systematic reviews evaluating the effects of school, home, or community-based physical activity interventions in the youth found strong evidence for improvements in physical self-perceptions and self-esteem (41) as well as in overall mental health (42). In our study, the common denominator between orthopedic injury and delayed RTP is that they can both independently deprive one from physical exercise, team sports, and active socialization. Therefore, it may be possible that emotional disturbance following SRC may be associated with lack of physical activity. With the emerging evidence (6,43) that early activity following concussion (e.g., sub-symptom threshold aerobic exercises, active rehabilitation) is beneficial in recovery and reduces the risk of persisting symptoms, returning adolescent and collegiate athletes to appropriate physical activity and team sports following SRC is of paramount importance. However, determining the causality of the relationship between physical activity and recovery following SRC was beyond the scope of the current study. Furthermore, RTP should only be started after full symptom resolution, thereafter with light, moderate, then heavy non-contact aerobic activity, followed by participation in practice and full competition (44), as premature RTP may lead to adverse outcomes following SRC.

Approximately half of our cohort endorsed having psychiatric symptoms (i.e., depression, anxiety, and anger) in the weeks following SRC. Most patients reported that the onset of their psychiatric symptoms occurred within the first week after their injury and rarely reported that they started greater than a month post injury. While most depression and anger symptoms lasted less than 3 months, most anxiety symptoms were still occurring at the time of survey. Prior studies have investigated the anxiety/mood profile, characterized by emotional disturbance, feelings of depression/anxiety, and sleep dysregulation, in those with persistent, post-concussive symptoms (4,45). While evaluating whether long-term symptoms seen in our cohort truly represent those with persistent symptoms following SRC is unclear, our data provides novel insight into both the onset and duration of psychiatric symptoms following SRC, and furthermore reinforces the importance of physical activity and RTP in adolescents and collegiate athletes suffering from persistent and subclinical psychiatric symptoms.

The current study has several limitations. First, some of the data were collected in a retrospective manner, and therefore subject to recall-bias, especially given a notable time lapse between injury and patient interview (i.e., median of 286 days). It will be helpful for future endeavors to incorporate prospective, longitudinal clinical encounters with healthcare professionals in assessing psychiatric symptoms. Second, our operational definition of subclinical, long-term psychological symptoms was developed by our researchers. We understand that different definitions may have changed our results. However, given that 50^th percentile on any of the PROMIS measures represents the norm of the general population, we believed that a score ≥75^th on any of the PROMIS measures is clinically relevant. Furthermore, our operational definition of subclinical, long-term psychological symptoms relied on PROMIS measures, specifically in domains of anger, anxiety, depression, and stress. While we chose these assessments due to their relevance to typical psychological symptoms following concussion, employing a broader definition of psychological symptoms may have shown different findings. Third, given the design of our study, we were unable to obtain baseline, pre-injury PROMIS measures in our cohort for direct comparisons to post-injury values. Such comparison may have provided better context to our finding that a third of patients who had recovered from a SRC are experiencing subclinical psychological symptoms. Additionally, our sample, the majority of which was male and of White racial background, may be limited in generalizability. Finally, the current study was explorative in nature and thus no controls were recruited to compare both the prevalence of subclinical, long-term psychological symptoms, and the proportions of those who endorsed psychiatric symptoms. Future studies should utilize control groups, both with those who are healthy and those with orthopedic injuries, to better be able to answer whether or not the prevalence of long-term psychiatric symptoms was secondary to the concussion, an injury of any type, or is normal for this demographic.

Conclusion

In a cohort of adolescent and collegiate athletes with SRC, approximately one-third exhibited subclinical, long-term psychological symptoms. Predictors of such symptoms included orthopedic injuries and delayed RTP. Emotional disturbance following SRC may be strongly associated with subsequent orthopedic injuries, delayed sport participation, and overall physical inactivity.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data will be provided upon reasonable request to the requester.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.