Athletic Training and Sports Health Care

Original Research 

Patient, Treatment, and Cost Characteristics Associated With Sport-Related Ankle Sprains: A Report From the Athletic Training Practice-Based Research Network

Ashley N. Marshall, PhD, ATC; Teresa M. Kikugawa, DAT, ATC; Kenneth C. Lam, ScD, ATC

Abstract

Purpose:

To describe patient, treatment, and cost characteristics associated with complete ankle sprain patient cases managed by athletic trainers.

Methods:

Electronic patient records for complete ankle sprain cases documented within the Athletic Training Practice-Based Research Network were identified and reviewed. Summary statistics were calculated for patient, treatment, and cost characteristics. Treatment characteristics included type of athletic training service, duration of care, episodes of care, and amount of care. Direct costs of care were estimated by applying the Centers for Medicare and Medicaid Services Physician Fee Schedule for non-facility organizations.

Results:

One hundred thirty patient cases (male = 60%, secondary school setting = 101 [76.5%], age = 16.6 ± 1.9 years, height = 172.7 ± 9.9 cm, mass = 72.1 ± 15.5 kg) were identified. The most frequently used treatments were hot/cold pack (22.6%), therapeutic exercise (22.2%), and strapping (9.2%). The duration of care was 21.9 ± 18.5 days across 7.6 ± 5.0 episodes of care per case. The amount of care was 17.6 ± 12.6 services per case and 2.3 ± 1.3 services per episode of care. The estimated direct cost of care was $533.72 ± $508.88 per case and $70.73 ± $45.60 per episode of care.

Conclusions:

Athletic trainers appear to be underutilizing treatments that are effective in reducing recurrence and long-term complications, such as therapeutic activities, neuromuscular reeducation, and manual therapies. The estimated direct costs of care rendered from athletic training services for these injuries provide insight into the valuable role of athletic trainers in the management of ankle sprains.

[Athletic Training & Sports Health Care. 201X;XX(X):XX–XX.]

Abstract

Purpose:

To describe patient, treatment, and cost characteristics associated with complete ankle sprain patient cases managed by athletic trainers.

Methods:

Electronic patient records for complete ankle sprain cases documented within the Athletic Training Practice-Based Research Network were identified and reviewed. Summary statistics were calculated for patient, treatment, and cost characteristics. Treatment characteristics included type of athletic training service, duration of care, episodes of care, and amount of care. Direct costs of care were estimated by applying the Centers for Medicare and Medicaid Services Physician Fee Schedule for non-facility organizations.

Results:

One hundred thirty patient cases (male = 60%, secondary school setting = 101 [76.5%], age = 16.6 ± 1.9 years, height = 172.7 ± 9.9 cm, mass = 72.1 ± 15.5 kg) were identified. The most frequently used treatments were hot/cold pack (22.6%), therapeutic exercise (22.2%), and strapping (9.2%). The duration of care was 21.9 ± 18.5 days across 7.6 ± 5.0 episodes of care per case. The amount of care was 17.6 ± 12.6 services per case and 2.3 ± 1.3 services per episode of care. The estimated direct cost of care was $533.72 ± $508.88 per case and $70.73 ± $45.60 per episode of care.

Conclusions:

Athletic trainers appear to be underutilizing treatments that are effective in reducing recurrence and long-term complications, such as therapeutic activities, neuromuscular reeducation, and manual therapies. The estimated direct costs of care rendered from athletic training services for these injuries provide insight into the valuable role of athletic trainers in the management of ankle sprains.

[Athletic Training & Sports Health Care. 201X;XX(X):XX–XX.]

Ankle sprains are one of the most common musculoskeletal injuries associated with physical activity. An estimated 2.15 new injuries occur per 1,000 person-years in the United States,1 and 30% of those occur within organized sport.2 In the 2004–2005 secondary academic year alone, just over 7 million high school students participated in athletics, which increased to nearly 8 million by 2017.3 Of all recorded sport-related injuries during this time period, 50% of lower extremity injuries were ligament sprains and 40% of these sprains were to ligaments in the ankle.4 Similar statistics are reported in collegiate athletics, as lateral ligament complex ankle sprains have been the most commonly reported injury diagnosis.5 Although lateral ankle sprains are the most common injury in an athletic population,2,6,7 clinicians are also tasked with managing the less commonly diagnosed deltoid and tibiofibular ligament sprains.7

Ankle sprains are generally thought to be “mild” injuries, but they are associated with long-term consequences including diminished function,8 reduced physical activity,9 and deficits to health-related quality of life.10 Furthermore, these injuries have been associated with chronic conditions, such as chronic ankle instability11 and post-traumatic osteoarthritis.12 Due to the potential for poor outcomes13 and high risk of reinjury14 following an ankle sprain, there has been an increased focus on the proper management and treatment of these injuries. Recently, Simon et al.15 evaluated athletic training services provided for ankle sprain injuries in the high school setting through the National Athletic Treatment, Injury and Outcomes Network (NATION) database, and reported that athletic trainers are generally following treatment guidelines set forth by the National Athletic Trainers' Association position statement.16 For example, athletic trainers frequently provided therapeutic exercise and neuromuscular reeducation for both time-loss and non–time-loss ankle sprain injuries.15 This strategy is in line with best practice for prevention of recurrent sprain,16 addressing deficits to strength, balance, and function.

Although recent findings have evaluated the services athletic trainers are providing for ankle sprains,15,17 several gaps in the literature still exist. First, injury documentation is often cited as a limitation within athletic health care research,18 and limits the ability to observe the athletic training services provided over the entire duration of care. Simon et al.15 noted that their dataset may have been incomplete and, as a result, athletic trainers may not have reported all of the care provided for ankle sprain injuries. Incomplete documentation of athletic injuries is problematic and may lead to the underestimation or overestimation of findings. However, analyzing the services provided for complete patient cases from intake to discharge may provide a better estimation of treatment patterns at the point-of-care. Additionally, there has been limited evidence regarding the estimated direct costs associated with treatment and the care provided for these injuries. It has been proposed that athletic trainers reduce health care costs by limiting the number of referrals to other health care professionals15; however, the value of the athletic training services provided for these injuries has not been investigated. Both treatment strategy and estimated direct costs of care are important to the athletic training profession because they characterize and quantify the value of the care being provided to athletes. Therefore, the purpose of this study was to describe patient, treatment, and cost characteristics associated with complete ankle sprain patient cases managed by athletic trainers.

Methods

Design and Setting

This study was a retrospective analysis of de-identified patient electronic medical records (EMRs) collected within the Athletic Training Practice-Based Research Network (AT-PBRN). The AT-PBRN and its features, including its EMR system, infrastructure, clinician training, and data collection methods, have been described in previous studies.17,19 All patient records were created by the participating athletic trainer providing care within the secondary school or collegiate setting. For this study, there was a total of 43 clinical practice sites (secondary school = 39, college = 4) across 11 states (Arizona, Florida, Kansas, Massachusetts, Minnesota, Missouri, New Hampshire, New York, Utah, Virginia, and Wisconsin). Clinical practice sites were predominantly public high schools (83.7%), set in an urban area (41.9%), and employed one certified athletic trainer (48.8%).

Participants

A total of 113 athletic trainers practiced at these clinical practice sites during the study period. Most athletic trainers were female (60.2%) and held a master's degree (76.7%). On average, the athletic trainers were 30.0 ± 11.2 years old, certified for 3.9 ± 5.1 years, and employed at their current site for 0.7 ± 2.2 years, on a part-time (41.8%) or full-time (37.2%) basis. This study was deemed exempt by the university's institutional review board because it was a retrospective analysis of de-identified patient records.

Procedures

All data were collected by a participating athletic trainer within the AT-PBRN using the web-based CORE-AT EMR system.19 Patient records from each of the AT-PBRN clinical practice sites between 2009 and 2017 were reviewed. Patient cases were first identified using the International Classification of Disease, version 9 (ICD-9) diagnostic codes in the injury demographics form of the EMR, following standard procedures used in previous studies.17,19 Cases were retained if the ICD-9 code matched one of the following: 845.0 (ankle sprain/strain), 845.1 (deltoid ligament sprain), or 845.3 (tibiofibular ligament sprain). In an effort to ensure quality data, only complete patient cases were included, defined as injuries that had (1) a documented first encounter or injury demographics form, (2) injury evaluation, (3) daily treatment forms with at least one encounter per week for the duration of care, and (4) discharge form (the last documented session with the patient). These data were used to analyze patient characteristics, treatment procedures, and associated cost for each ankle sprain injury.

Patient characteristic variables extracted from the demographics form included sex, sport, activity during injury (ie, practice or competition), mechanism of injury, and diagnosis. Procedures obtained from the daily treatment forms consisted of all of the current procedural terminology codes (CPT) that the athletic trainer implemented during each episode of care (ie, documented patient encounter) (Table 1). Each CPT code was associated with a direct cost of care, estimated by implementing the Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule for non-facility (ie, non-hospital) organizations (Table 1).20 Direct cost was calculated based on the fee associated with the CPT code and the number of 15-minute increments documented. The estimated direct cost of care for each treatment and the number of services rendered were used to calculate the average total direct cost per ankle sprain case and average direct cost per episode of care.

Athletic Training Services Provided for the Management of Lateral Ankle Sprains

Table 1:

Athletic Training Services Provided for the Management of Lateral Ankle Sprains

Instrumentation

The CORE-AT ( www.core-at.com)19 uses four forms for full documentation of an injury from first contact with the athletic trainer through discharge. After a patient has been entered into the system, the athletic trainer completes the injury demographics (eg, sex, sport, age, height, and mass), initial evaluation, daily treatments (ie, procedural summaries), and discharge (ie, functional and special tests used for decision making regarding discharge from care) forms throughout the duration of the injury. Patient data were formatted as structured variables within the EMR and recorded using either a drop-down menu or radio buttons. In-depth features and functionality of the CORE-AT have been thoroughly described in previous studies generated through the AT-PBRN.17,19

Analysis

Summary statistics (frequency, percentage, and mean ± standard deviation) were calculated for all variables. Treatment characteristics included the type (CPT code), amount of care (number of services per case), and duration of care (number of days between intake and discharge). Direct cost characteristics included the number of services per case and procedural total cost per case and per episode of care. Additional calculations estimated the minimum, maximum, median, and interquartile range for the cost variables. All analyses were conducted using IBM SPSS Statistics software (version 24; IBM Corporation, Armonk, NY).

Results

Patient Characteristics

During the study period, 1,104 ankle sprains were documented, of which 130 patient cases were complete (males = 78 [60%]; secondary school setting = 101 [76.5%], age = 16.6 ± 1.9 years; height = 172.7 ± 9.9 cm; mass = 72.2 ± 15.5 kg). Of the complete cases, the most commonly documented diagnosis was sprain/strain (ICD-9 code: 845.0, n = 107, 82.3%), followed by tibiofibular ligament sprain (ICD-9 code: 845.1, n = 19, 14.6%) and deltoid ligament sprain (ICD-9 code 845.3, n = 4, 3.1%). Mechanism of injury included contact (n = 39, 39%), twisting (n = 37, 35.6 %), non-contact (n = 31, 23.8%), and falls (n = 23, 17.7%), and injuries were most likely to occur in football (n = 45, 34.6%), basketball (n = 22, 16.9%), soccer (n = 20, 15.4%), and volleyball (n = 11, 8.5%) (Table 2). Within each sport, in-season practices (n = 51, 39.2%) and in-season games (n = 51, 39.2%) were equally the most reported activities during injury (Table 3). Patients resumed full function 6.92 ± 14.39 days following injury.

Frequency of Ankle Sprain Cases According to Sport

Table 2:

Frequency of Ankle Sprain Cases According to Sport

Activity During Ankle Sprain Injury

Table 3:

Activity During Ankle Sprain Injury

Treatment Characteristics

A total of 2,292 procedures were documented for the treatment of patient cases, with 17.6 ± 12.6 services provided per case (range: 3 to 63 services). From first documented encounter to discharge, the duration of care lasted 21.5 ± 18.5 days (range: 1 to 88 days). The most commonly used procedures were hot/cold packs (n = 519, 22.6%), therapeutic exercise (n = 508, 22.2%), athletic trainer reevaluation (n = 382, 16.7%), and strapping (ie, taping and bracing; n = 210, 9.2%). The least used procedures were infrared (n = 1, < 0.1%), contrast bath (n = 6, 0.3%), and neuromuscular reeducation (n = 6, 0.3%) (Table 4). The average number of episodes of care per patient case was 7.55 ± 5.0 (range: 2 to 29), and patients received 2.3 ± 1.3 treatments per episode of care.

Athletic Training Services Provided During Patient Encounters

Table 4:

Athletic Training Services Provided During Patient Encounters

Cost Characteristics

Patients received a total of 18.6 ± 13.7 services per case, rendering a total procedural direct cost of $533.72 ± $508.88 (median = $359.17, range = $75.44 to $2,856.21, interquartile range = $145.90 to $572.45; Figure 1). Patients received 2.34 ± 1.3 services per episode of care, resulting in a procedural direct cost of $70.73 ± $45.6 per episode of care (median = $65.08, range = $0.00 to $280.32, interquartile range = $33.79 to $96.37).

Total direct costs of care for ankle sprain cases. Bee swarm box plot of all results. The box indicates the 25th and 7th quartiles and the central line is the median. The ends of the whiskers are the 2.5% and 97.5% values. Each dot represents the total cost of care for one entire ankle sprain case.

Figure 1.

Total direct costs of care for ankle sprain cases. Bee swarm box plot of all results. The box indicates the 25th and 7th quartiles and the central line is the median. The ends of the whiskers are the 2.5% and 97.5% values. Each dot represents the total cost of care for one entire ankle sprain case.

Discussion

To the best of our knowledge, this is the first study to describe patient, treatment, and cost characteristics specific to complete ankle sprain patient cases evaluated and managed by athletic trainers. The patient characteristics in this study were in line with previous point-of-care evidence17,19,21 because injuries occurred primarily within in-season practices and competitions during football, basketball, and soccer. Not only is the ankle the most commonly injured body part in sports, but it has also been reported that it is the most frequently treated by athletic trainers,21 highlighting the role that athletic trainers play in the athletic health care system. Although Simon et al.15 reported the number of episodes of care and athletic training services per injury, they did not report the duration of care for these ankle sprain injuries. In the current study, ankle sprain injuries were treated for an average of 3 weeks and, to our knowledge, this is the first study to report such data. Previous investigations have provided insight into practice characterization, explained treatment strategies, and described time from injury until return to sport22; however, limited information is available regarding the services provided by athletic trainers for ankle sprains over the duration of care and the value of these services.

In the current study, athletic trainers provided an average of 18 services over 3 weeks for each ankle sprain case. The most frequently documented services included hot/cold pack (22.6%), therapeutic exercise (22.2%), reevaluation (16.7%), and strapping (9.2%). Of these procedures, therapeutic exercise is supported with the best evidence,16,23 because it has been shown to consistently improve self-reported function and prevent recurrent injury following acute ankle sprains, particularly when prescribed in high doses (ie, > 900 minutes of therapeutic exercise).24 A recent consensus statement25 recommended that clinicians use a rehabilitation-oriented assessment to develop appropriate management strategies and effectively target mechanical and sensorimotor impairments during rehabilitation. Furthermore, combining functional rehabilitation with an external support (eg, bracing, taping) has also been identified as an effective strategy to improve function and reduce recurrent sprains.23 Although evidence suggests that cryotherapy provides a temporary improvement in secondary outcomes (eg, pain),26 there is disparity over whether it improves primary outcomes (eg, self-reported function and clinical outcomes).16 As a result, it is important to consider the context of how the clinician incorporates this modality when treating ankle sprain injuries. Ice, or some other form of cryotherapy, is often immediately applied to provide an analgesic effect, control excess swelling, and reduce the risk of secondary hypoxic tissue damage.26 Due to the popularity of cryotherapy in athletic health care following an acute injury, evidence is limited as to whether cryotherapy on its own will improve primary outcomes; however, treatment success has been noted when ice is combined with therapeutic exercise.23

Simon et al.15 reported that athletic trainers provided an average of 22 services per ankle sprain injury, listing therapeutic activities or exercises (47.4%), neuromuscular reeducation (16.6%), strapping (14.2%), and modalities (11.5%) as the most common services provided. In comparison, athletic trainers in the current study had a low use of neuromuscular reeducation (n = 6, 0.3%). It is possible that athletic trainers within the AT-PBRN may have been documenting this procedure under a different category, such as functional rehabilitation, or as a therapeutic activity. However, even if athletic trainers documented neuromuscular reeducation using the CPT code for therapeutic activities, there is a low prevalence of this treatment category being reported (n = 137, 6%). Although patients in the current study received an average of 3 weeks of care, the type of care provided may not have allowed for functional rehabilitation, strength, and sensorimotor deficits to be truly addressed and corrected. In addition, athletic trainers in the current study returned athletes to full sport participation approximately 1 week following injury. This finding is in line with previous evidence highlighting that there is a 95% probability that patients who suffer a first-time ankle sprain will return to full participation within 10 days.27 Nevertheless, a large proportion of patients who suffer an acute lateral ankle sprain experience prolonged mechanical and sensorimotor deficits following injury.11 This disparity between a seemingly not ideal rehabilitation progression and early return to sport is likely contributing to the high rate of injury recurrence and poor long-term outcomes following ankle sprain injuries.25,28 Moreover, previous investigations have identified that evidence-based rehabilitation reduces the risk of recurrent injury.29 Thus, it is imperative that clinicians assess mechanical and sensorimotor deficits on initial evaluation and throughout the rehabilitation process to appropriately manage these injuries and mitigate negative long-term consequences.25

The use of non-steroidal anti-inflammatory drugs, a treatment strategy supported by quality evidence,16 was not documented within this study or the study by Simon et al.15 Even over-the-counter medications require parental consent to be administered to minors, and the ability to obtain consent may hinder athletic trainers from providing non-steroidal anti-inflammatory drugs for the management of ankle sprains. However, parents or guardians may have been providing patients with these medications outside of the purview of the athletic trainer. Additionally, manual therapy was one of the least used services in both studies (approximately 3% of all treatments), although joint mobilizations are known to increase dorsiflexion range of motion and correct positional faults.30 Although additional research is warranted to determine the appropriate frequency and duration of this treatment, it is interesting that athletic trainers are generally not employing this type of intervention with athletes who have suffered an ankle sprain.

Methodologically, several differences exist between the current study and the study conducted by Simon et al.15 For instance, the AT-PBRN uses the CORE-AT EMR for all participating athletic trainers,19 whereas the NATION data collection tools are embedded into commercially available EMRs.31 The data are then sent to the Datalys Center for Sports Injury Research and Prevention, Inc., and combined across the numerous EMRs.15,31 Thus, variation may exist between how AT-PBRN participating athletic trainers and NATION participating athletic trainers are instructed to document injury treatment, and within the type of data analyzed (ie, structured vs unstructured variables).

Recently, there have been calls to highlight the value of athletic trainers in athletic health care. In a series of Value Models,32,33 the National Athletic Trainers' Association proposed that the value of the services provided must be established to eventually determine the value of those services, and ultimately demonstrate why athletic trainers are vital health care providers. Despite these calls, there is limited information regarding the estimated direct costs associated with services provided for ankle sprain injuries specifically by athletic trainers. In the United States alone, an ankle sprain averages $1,211.15 per emergency department visit,34 which typically consists of unnecessary imaging to rule out fracture and little to no follow-up treatment. In fact, approximately 80% to 90% of patients who report to the emergency department for an ankle sprain undergo imaging, but fewer than 15% of patients actually have a fracture.34 Feger et al.35 estimate the financial burden associated with the diagnosis and management of lateral ankle sprain injuries to be $152 million in the United States, with most of the cost related to physician evaluations and only 7.9% resulting from physical therapy.

According to our study, the median cost per case was $359.17, comprising only services provided by athletic trainers and not unnecessary imaging or potentially un-warranted referrals. Eleven of these cases were identified as outliers, for which the direct cost of care was substantially higher than the rest of the cases. On further investigation, it was determined that nine of the outliers were injuries that occurred and were treated in the collegiate setting. It is likely that the athletic trainers treating these patients had a greater number of resources than those treating patients in the secondary school setting, contributing to the increased cost. Further, according to the Centers for Medicare and Medicaid Services,20 the CPT code for hot/cold pack does not render a cost associated with the treatment. Similarly, athletic trainers are often reevaluating and reassessing the status of an injury throughout the treatment process to monitor progress, but evaluation and reevaluation CPT codes can only be billed every 14 days. Both of these circumstances contribute to a potential underestimation of the direct cost of care for the actual services rendered.

In the current study, only 11.77% of the ankle sprain injuries documented during the study period met the criteria to be considered a complete patient case. We opted to only evaluate complete patient cases in an effort to combat some of the issues regarding documentation habits within the athletic training profession18; however, complete and consistent documentation of all patient care provided by athletic trainers would deliver stable data for point-of-care research. Future investigations should focus on a cost savings analysis within athletic training practice. To truly measure cost savings to the health care system as a result of services provided by an athletic trainer, we must first determine the worth of the services rendered, assess the quality of these services through the incorporation of patient outcomes, and incorporate stakeholders to ultimately estimate the value the care provided. In addition, although this study provides an estimate of the direct costs of care for the management of ankle sprains, indirect costs (eg, time loss or follow-up care) add to the societal burden following these injuries.11 Future investigations should also seek to determine the indirect costs of these injuries and how they are influenced by management strategies.

Implications for Clinical Practice

Although athletic trainers are generally following recommendations for the management of ankle sprain injuries, they appear to be underutilizing treatments that are effective in reducing recurrence and long-term complications, such as therapeutic activities, neuromuscular reeducation, and manual therapies. The estimated direct costs of care rendered from athletic training services for these injuries provide insight into the valuable role of athletic trainers in the management of ankle sprains.

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Athletic Training Services Provided for the Management of Lateral Ankle Sprains

Treatment or ProcedureCPT CodeMean Fee (2009–2017)Fee Range (2009–2017)
Aquatic therapy97113$40.87$34.26 to $43.78
Athletic trainer evaluation97005$76.85$69.97 to $86.49
Athletic trainer reevaluation97006$45.39$37.51 to $58.74
Contrast bath97034$17.24$14.79 to $18.33
Electrical stimulation97014$18.42$16.23 to $19.40
Gait training97116$27.41$24.53 to $28.75
Hot or cold pack97010$0.00$0.00 to $0.00
Infrared97026$5.77$5.05 to $6.12
Iontophoresis97033$28.51$22.25 to $33.06
Manual therapy techniques97140$28.95$25.97 to $30.51
Massage97124$25.33$22.36 to $26.95
Neuromuscular reeducation97112$32.36$28.85 to $34.45
Physical performance test or measurement97750$32.20$28.85 to $33.67
Strapping: ankle29540$33.53$26.23 to $39.09
Strapping: knee29230$43.19$28.75 to $53.76
Therapeutic activities97110$33.66$29.57 to $35.53
Therapeutic exercises97530$31.11$28.13 to $33.02
Ultrasound97035$12.45$11.54 to $12.94
Vasopneumatic devices97016$18.29$15.15 to $19.74
Whirlpool97022$21.94$17.31 to $24.05

Frequency of Ankle Sprain Cases According to Sport

SportNo. (%)
Football45 (34.6)
Basketball22 (16.9)
Soccer20 (15.4)
Volleyball11 (8.5)
Track9 (6.9)
Tennis5 (3.8)
Gymnastics4 (3.1)
Baseball4 (3.1)
Lacrosse3 (2.3)
Field hockey3 (2.3)
Softball2 (1.5)
Cross-country1 (0.8)
Other1 (0.8)
Total130 (100)

Activity During Ankle Sprain Injury

SportNo. (%)
Pre-season conditioning4 (3.1)
Pre-season scrimmage5 (3.8)
In-season practice51 (39.2)
In-season game51 (39.2)
Post-season practice1 (0.8)
Post-season game0 (0.0)
Off-season conditioning1 (0.8)
Off-season practice5 (3.8)
Not sports related12 (9.2)
Total130 (100)

Athletic Training Services Provided During Patient Encounters

Treatment or ProcedureNo. (%)
Hot or cold pack519 (22.6)
Therapeutic exercise508 (22.2)
Athletic trainer reevaluation382 (16.7)
Strapping: ankle and/or foot210 (9.2)
Athletic trainer evaluation141 (6.2)
Therapeutic activities137 (6.0)
Electrical stimulation117 (5.1)
Massage91 (4.0)
Whirlpool86 (3.8)
Manual therapy techniques35 (1.5)
Ultrasound25 (1.1)
Vasopneumatic devices14 (0.6)
Physical performance test or measurement9 (0.4)
Contrast bath6 (0.3)
Neuromuscular reeducation6 (0.3)
Aquatic therapy3 (0.1)
Strapping: knee2 (0.1)
Infrared1 (0)
Total2,292 (100)
Authors

From the Department of Interdisciplinary Health Sciences, A.T. Still University, Mesa, Arizona (ANM, TMK, KCL); and Northwestern University Health Services, Evanston, Illinois (TMK).

The authors have no financial or proprietary interest in the materials presented herein.

The authors thank the participating members of the Athletic Training Practice-Based Research Network for their work to develop and promote the network. Clinicians interested in joining the network can find more information at www.atpbrn.org

Correspondence: Ashley N. Marshall, PhD, ATC, Department of Health and Exercise Science, Appalachian State University, ASU Box 32071, 1179 State Farm Road, Boone, NC 28608. E-mail: marshallan1@appstate.edu

Received: January 14, 2019
Accepted: March 01, 2019
Posted Online: July 26, 2019

10.3928/19425864-20190521-01

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