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VOLUME XVI OF THE ENCYCLOPEDIA OF SPORTS MEDICINE
AN IOC MEDICAL COMMISSION PUBLICATION
EDITED BY DENNIS J. CAINE, PhD
PETER A. HARMER, PhD, MPH, ATC and
MELISSA A. SCHIFF, MD, MPH
A John Wiley & Sons, Ltd., Publication This edition first published 2010, © 2010 International Olympic Committee Published by Blackwell Publishing Ltd Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has been merged with Wiley’s global Scientific, Technical and Medical business to form Wiley-Blackwell. Registered office: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www. wiley.com/wiley-blackwell The right of the author to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloging-in-Publication Data
Epidemiology of injury in Olympic sports / edited by Dennis J. Caine, Peter Harmer, and Melissa Schiff. p.; cm.—(Encyclopaedia of sports medicine;16) “An IOC Medical Commission publication.” Includes bibliographical references. ISBN: 978-1-4051-7364-3 1. Sports injuries—Epidemiology. 2. Olympics. I. Caine, Dennis John, 1949– II. Harmer, Peter. III. Schiff, Melissa. IV. IOC Medical Commission. V. Series. [DNLM: 1. Athletic Injuries—epidemiology. 2. Athletic Performance. 3. Sports Medicine— methods. QT 13 E527 2009 v.16] RD97.E65 2009 617.1Ј027—dc22 2008043615 A catalogue record for this book is available from the British Library. Set in 9/12 pt Palatino by Macmillan Publishing Solutions, Chennai, India Printed and bound in Malaysia 1 2009 Contents
List of Contributors, vii 9 Equestrian, 114 paul mccrory and michael turner Foreword, x 10 Fencing, 124 Preface, xi peter a. harmer
11 Field Hockey, 133 Part 1: Summer Sports karen murtaugh 1 Aquatics, 3 stasinos stavrianeas 12 Gymnastics, 144 gregory s. kolt and dennis j. caine 2 Archery, 18 john c. hildenbrand iv and 13 Judo, 161 ghazi m. rayan peter a. harmer
3 Athletics, 26 14 Modern Pentathlon, 176 mitchell j. rauh and caroline a. macera jens kelm
4 Badminton, 49 15 Rowing, 181 martin fahlström jane rumball
5 Baseball, 59 16 Sailing, 191 glenn s. fleisig, christopher s. vernon neville mcmichael and james r. andrews 17 Soccer (Football), 204 6 Basketball, 78 carolyn a. emery gaylene mckay and jill cook 18 Softball, 236 7 Boxing, 92 stephen w. marshall and tsharni zazryn and paul mccrory johna k. register-mihalik
8 Cycling, 107 19 Taekwondo, 249 andrew l. pruitt and todd m. carver willy pieter
v vi contents
20 Team Handball (Handball), 260 28 Ice Hockey, 411 grethe myklebust breda h.f. lau and brian w. benson
21 Tennis, 277 29 Snowboarding, 447 babette m. pluim and j. bart staal kelly russell, brent e. hagel and claude goulet 22 Triathlon, 294 veronica vleck Part 3: Paralympic Sports 30 Paralympic Sports, 475 23 Volleyball, 321 a.d.j. webborn evert verhagen
Part 4: Injury Prevention and Further 24 Weightlifting, 336 Research justin w.l. keogh 31 Injury Prevention in Sports, 491 25 Wrestling, 351 melissa a. schiff and rebekah dennis j. caine, kasey young and o’halloran warren b. howe 32 Conclusions and Further Research, 500 Part 2: Winter Sports peter a. harmer 26 Alpine Skiing, 371 Index, 509 tonje wåle flørenes and arne ekeland
27 Figure Skating, 393 caroline g. caine List of Contributors
JAMES R. ANDREWS, MD, American Sports GLENN S. FLEISIG, PhD, American Sports Medicine Institute, Birmingham, Alabama, USA Medicine Institute, Birmingham, Alabama, USA
BRIAN W. BENSON, MD, MSc, Faculty of CLAUDE GOULET, PhD, Department of Physical Kinesiology, Sport Medicine Centre and Department of Education, Faculty of Education, Laval University, Pavillon de Community Health Sciences, Faculty of Medicine, University l’Éducation Physique et des Sports, Québec, Canada of Calgary, Calgary, Alberta, Canada BRENT E. HAGEL, PhD, Department of Paediatrics and CAROLINE G. CAINE, PhD, Department of Community Health Sciences, Faculty of Medicine, University of Theatre Arts, University of North Dakota, Grand Forks, North Calgary, Alberta Children’s Hospital, Calgary, Alberta, Canada Dakota, USA PETER A. HARMER, PhD, MPH, ATC, Exercise DENNIS J. CAINE, PhD, Department of Physical Science – Sports Medicine, Willamette University, Salem, Education, Exercise Science and Wellness, University of North Oregon, USA Dakota, Grand Forks, North Dakota, USA JOHN C. HILDENBRAND IV, MD, Hand TODD M. CARVER, MS, The Boulder Center for Surgery Section, Department of Orthopedic Surgery, Baptist Sports Medicine, Boulder, Colorado, USA Medical Center, Oklahoma City, Oklahoma, USA
JILL COOK, PhD, Centre for Physical Activity and WARREN B. HOWE, MD, Student Health Services, Nutrition Research, Deakin University, Burwood, Australia Western Washington University, Bellington, Washington, USA
ARNE EKELAND, MD, PhD, Martina Hansen JENS KELM, MD, Klinik für Orthopädie und Hospital, Baerum, Norway Orthopädische Chirurgie, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany, and Chirurgisch-Orthopädisches CAROLYN A. EMERY, BScPT, PhD, Sport Zentrum, Illingen/Saar, Germany Medicine Centre, Faculty of Kinesiology, Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, JUSTIN W.L. KEOGH, PhD, Institute of Sport Alberta, Canada and Recreation Research, School of Sport and Recreation, Auckland University of Technology, Auckland, New Zealand MARTIN FAHLSTRÖM, PhD, MD, Department of Surgical and Perioperative Sciences, Sports Medicine, and GREGORY S. KOLT, PhD, School of Biomedical Department of Community Medicine and Rehabilitation, and Health Sciences, University of Western Sydney, Sydney, Rehabilitation Medicine, Umeå University, Umeå, Sweden New South Wales, Australia vii viii list of contributors
BREDA H.F. LAU, BSc, BKin, MSc(c), Faculty of MITCHELL J. RAUH, PhD, PT, MPH, Graduate Kinesiology, Sport Medicine Centre, University of Calgary, Program in Orthopaedic and Sports Physical Therapy, Rocky Calgary, Alberta, Canada Mountain University of Health Professions, Provo, Utah, and Graduate School of Public Health, San Diego State University, CAROLINE A. MACERA, PhD, Graduate School California, USA of Public Health, San Diego State University, California, USA GHAZI M. RAYAN, MD, Hand Surgery Section, STEPHEN W. MARSHALL, PhD, Departments Department of Orthopedic Surgery, Baptist Medical Center, of Epidemiology, Orthopedics, and Exercise and Sport Science, Oklahoma City, Oklahoma, USA University of North Carolina at Chapel Hill, North Carolina, USA JOHNA K. REGISTER-MIHALIK, MA, Department of Exercise and Sport Science, University of North PAUL MCCRORY, MBBS, PhD, Centre for Health, Exercise and Sports Medicine and the Brain Research Institute, Carolina at Chapel Hill, North Carolina, USA University of Melbourne, Melbourne, Victoria, Australia JANE RUMBALL, PhD, Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, GAYLENE MCKAY, PhD, Alphington Sports Ontario, Canada Medicine Clinic, Northcote, Australia
KELLY RUSSELL, MSc, Department of Community CHRISTOPHER S. MCMICHAEL, MPH, Health Sciences, Faculty of Medicine, University of Calgary, American Sports Medicine Institute, Birmingham, Alabama, USA Alberta, Canada
KAREN MURTAUGH, MSc, MD, Dip Sport Med, MELISSA A. SCHIFF, MD, MPH, Department of Levy Elliott Sports Medicine Clinic, Burlington, Ontario, Canada Epidemiology, University of Washington School of Public Health and Harborview Injury Prevention and Research GRETHE MYKLEBUST, PhD, PT, Oslo Sports Center, Seattle, WA, USA Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway J. BART STAAL, PhD, Department of Epidemiology and Caphri Research School, Maastricht University, VERNON NEVILLE, PhD, MSc, CSCS, School of Maastricht, The Netherlands Sport, Exercise & Health Sciences, Loughborough University, Loughborough, UK STASINOS STAVRIANEAS, PhD, Department of Exercise Science, Willamette University, Salem, Oregon, USA REBEKAH O’HALLORAN, BSc, Harborview Injury Prevention and Research Center, Seattle, Washington, USA MICHAEL TURNER, MD, Chief Medical Adviser, British Horseracing Authority, London, UK WILLY PIETER, PhD, Department of Physical Education, University of Asia and the Pacific, Pasig City, Philippines EVERT VERHAGEN, PhD, Department of Public and Occupational Health, EMGO-Institute, Amsterdam, The BABETTE M. PLUIM, MD, PhD, Royal Dutch Netherlands Lawn Tennis Association, Amersfoort, The Netherlands VERONICA VLECK, PhD, Faculty of Human ANDREW L. PRUITT,EdD, The Boulder Center Kinetics, Technical University of Lisbon, Cruz Quebrada, for Sports Medicine, Boulder, Colorado, USA Portugal list of contributors ix
TONJE WÅLE FLØRENES, MD, Oslo Sports Wellness, University of North Dakota, Grand Forks, North Trauma Research Center, Norwegian School of Sport Sciences, Dakota, USA Oslo, Norway TSHARNI ZAZRYN, PhD, Department of A.D.J. WEBBORN, MBBS, MSc, Chelsea School Health Social Science, School of Public Health and Preventive Research Centre, University of Brighton, Eastbourne, UK Medicine, Monash University, Caulfield Campus, Victoria, Australia KASEY YOUNG, MS Department of Physical Education, Exercise Science and Foreword
Throughout periods of conditioning and train- been given to the issues of the prevention of these ing by athletes and during actual competition, the injuries and the presentation of guidelines for potential for injury exists as a threat to successful future research. performance. The study of injury mechanisms and This volume of the Encyclopaedia of Sports the prevention of injuries rely on a comprehensive Medicine makes an important contribution to the knowledge base of injury statistics for each particu- total understanding of Olympic sports and it is lar sport and sports event. this understanding that exists as the major objec- For each Olympic sport and event, the injury sta- tive of the Encyclopaedia series. Professors Caine, tistics have been studied and analyzed by the co- Harmer, and Schiff, together with all of the contrib- editors and contributing authors of this volume in uting authors, are to be congratulated on the qual- terms of types of injuries, time and location, risk ity of the comprehensive coverage that they have factors, and inciting conditions. With the over- provided regarding the epidemiology of sport inju- all goal of decreasing the incidence of injuries for ries. We welcome this important addition to the athletes in the future, careful consideration has Encyclopaedia of Sports Medicine series.
Dr Jacques Rogge IOC President
x Preface
DENNIS J. CAINE,1 PETER A. HARMER2 AND MELISSA A. SCHIFF3 1 Department of Physical Education, Exercise Science and Wellness, University of North Dakota, Grand Forks, North Dakota, USA 2 Exercise Science – Sports Medicine, Willamette University, Salem, Oregon, USA 3 Department of Epidemiology, University of Washington School of Public Health and Harborview Injury Prevention and Research Center, Seattle, Washington, USA
In this age of highly specialized training and is known about the distribution and determinants intense competition, injuries are common and may of injury and injury rates as reported in the litera- sometimes prevent top performers from competing ture, and further to evaluate the current research on in national and international competitions. Younger injury prevention strategies and suggest directions athletes who aspire to Olympic participation may for further research. This book provides a state-of- also find progress towards top-level competition the-art account of the epidemiology of injury across compromised as a result of injury. Sport injuries a broad spectrum of Olympic sports. All sports and may also significantly impact quality of life. There events within sports, where there were a sufficient is epidemiological evidence that level of physical number of studies published to warrant a chapter, fitness is a significant predictor of all-cause mortal- are included in this book. ity, morbidity, and disease-specific morbidity and Epidemiology of Injury in Olympic Sports is sub- that physical activity patterns track from early to divided into four parts: Summer Sports, Winter later life. Injury or incomplete recovery from injury Sports, Paralympic Sports, and Injury Prevention affects the ability to participate in those sport and and Further Research. Whereas we have included recreational activities that would be beneficial to as many summer and winter sports as possible in health. Injuries may also contribute to the develop- the first two parts, only one part covering all para- ment of osteoarthritis. There is a significant pub- lympic sports has been presented, given the pau- lic health cost associated with these injuries, the city of epidemiological studies in these events. future development of osteoarthritis, and other dis- A common, uniform strategy and evidence- eases associated with decreased levels of physical based approach to organizing and interpreting the activity. literature is used in this book and applied across We wish to congratulate the Medical Commission all sport-specific chapters, each with the same basic of the International Olympic Committee (IOC) on headings so that the reader can easily find common their decision to dedicate an entire encyclopedia information across chapters: volume to the topic of Epidemiology of Injury in Olympic Sports. This choice no doubt reflects the • Introduction growing importance of injury prevention and pro- • Who is affected by injury? tecting the health of athletes to support the IOC • Where does injury occur? mission. The purpose of Epidemiology of Injury in • When does injury occur? Olympic Sports is to comprehensively review what • What is the outcome? xi xii preface
• What are the risk factors? Above all, we would like to thank Dr. Howard • What are the inciting events? Knuttgen and the IOC Medical Commission as • Injury prevention well as Cathryn Gates of Wiley-Blackwell for their • Further research assistance and patience during this challenging endeavor. Each chapter is amply illustrated with tables to make it easy to examine injury factors between Sport-Specific Chapter Outline studies within a sport and between sports. Most significantly, this book has limited the discussion In the Introduction for each chapter, authors were of risk factors and preventive measures to those asked to provide the following information: his- which have actually been scientifically tested. torical background of the sport in the context of The information in this book will benefit physi- the Olympics, relevant background information to cians, physical therapists, athletic trainers, sport establish the importance and need for the review, scientists, sports governing bodies, coaches, parents a well-defined problem statement (what is being and reference librarians. Physicians, physical thera- reviewed, the population of interest, and for what pists and athletic trainers will find Epidemiology of purpose), and a succinct comment on the methodo- Injury in Olympic Sports helpful in identifying prob- logical limitations of the literature reviewed. lem areas in which appropriate preventive meas- Search methods employed by the authors ures can be tested and ultimately implemented to involved four broad approaches: (1) academic reduce the incidence and severity of injuries. Some search engines; (2) World Wide Web and Google sports scientists as well as healthcare profession- Scholar; (3) privately owned and government sta- als will find the information in this book useful tistical sites; and (4) hand search of references lists as a basis for continued epidemiological study of (i.e., ancestry approach). injuries in various sports, while others may find it The most commonly used electronic data- beneficial as a course or reference text. We are opti- bases were EMBASE, PubMed, and Sport Discus. mistic that sports governing bodies and coaches Other search engines used included: AARP will use this information as an informed basis for Ageline, Academic Search Premier, Allied and the development of injury prevention programs Complementary Medicine (AMED), Biological related to such factors as exposure, training tech- Abstracts, Cumulative Index to Nursing and Allied niques, equipment modifications, and rules. Health Literature (CINAHL), Cochrane Central In closing, we would like to thank the authors for Register of Controlled Trials, Cochrane Database their outstanding contributions to this project. The for Systematic Reviews, Cumulative Index for the 32 chapters in this book have been written by pro- Physician and Sportsmedicine, Database of Review fessionals—including sports medicine physicians, of Effects (DARE), Health STAR, NHS Economic epidemiologists, and exercise scientists—who have Evaluation Database, Physical Education Index, expertise in sports injury epidemiology. Researching ISI Web of Science, Proquest, Proquest Dissertation and writing an epidemiologic overview of the liter- and Theses, Psych Info, SafetyLit, Social Science ature in each of the sports areas is a very meticulous Citation Index, Spotlit Scopus, and the Science and time-consuming endeavor. Increasingly, the Citation Index. professional rewards for chapter contributions are Privately owned and government statistical over-shadowed by those received for a successful sites used included: AUSPORT, AUSTROM, the research grant application or publishing an article Centers for Disease Control and Prevention (CDC), in a juried scholarly venue. We therefore view the National Center for Health Statistics (NCHS), contributions of the authors to this project as gener- the National Saftety Council (NSC) Fact Sheets ous donations of their time, effort, and expertise to Library, National Collegiate Athletic Association the IOC specifically and more generally to the field Injury Surveillance System (NCAA ISS), the of sports injury epidemiology. National Center for Catastrophic Sports Injury preface xiii
Research, the Royal Society for the Prevention of events. In the section on risk factors, only data on Accidents (RoSPA) Home and Leisure Accident risk factors that have been tested for correlation or Surveillance System (HLASS), and the US for predictive value are included. Analytical data Consumer Product Safety Commission National can point toward factors that contribute to the Electronic Injury Surveillance System (NEISS). occurrence of injury. Authors classified risk factors Sports injury epidemiology is concerned with the in terms of intrinsic and extrinsic. Intrinsic factors who, where, when, what, why, and how of injuries. are individual biologic or psychosocial characteris- To address the question of who is affected by injury, tics predisposing an athlete to the outcome of injury, each author presents a discussion of overall (com- such as previous injury or life stress. Extrinsic risk petition plus practice) rates of injuries and a tabu- factors are factors that have an impact on the ath- lar summary of injury rates by age/participation lete while he or she is participating in sport, such as level, gender, and position played. In many sports, training methods or coaching qualifications. incidence rate data are available (e.g., rate per 1000 In sports where data were available, authors hours, snowboard runs, skier days, races, etc.). discussed player-related inciting events leading to However, in others, authors had to report clinical the injury situation and which are reported across incidence (e.g., number of injures divided by the injuries rather than a description of biomechanical number of injured participants times some k value). aspects of specific injuries. Player-related aspects Each chapter includes a section on where the typically represent the action or activity leading injury occurred, providing detailed informa- to the injury (e.g., receiving or delivering a round- tion on anatomic and environmental location. house kick in taekwondo, collisions in snow-board- Anatomic information may include a breakdown ing, falls from a horse in equestrian, tackling in of injuries by region and/or specific body parts. soccer, body checking in ice hockey, etc.). Environmental location includes whether an injury Each chapter includes a section on injury preven- occurs in practice or competition, indoors or out- tion based on research that has attempted to deter- doors, by event, or by surface or terrain in which mine the effectiveness of sport-specific preventive the activity takes place. measures. This section might be broken down into The discussion of when injuries occur includes randomized and non-randomized studies where injury onset and chronometry. Injury onset preventive measures have been tested and/or addresses information related to the frequency implemented. In the latter case, for example, the and distribution of acute and overuse injuries. introduction of mandatory full face shield rules Chronometry may address such time-related fac- among the pediatric ice hockey population has dra- tors as time into practice, time of day, and time of matically reduced the frequency of facial and eye season when injury occurred. injuries. Each chapter addresses the question, “what is the Finally, authors provide suggestions for further outcome?”, through presentation of data concern- research which arose from their identification of ing injury type, time loss, clinical outcome, and eco- gaps and weaknesses in the epidemiology litera- nomic cost. Depending on the research available, ture. In these regards they were asked to consider the sections on clinical outcome include the follow- such factors as research questions arising from ing subsections: recurrent injury, catastrophic injury, the epidemiological review, injury definition most non-participation, and residual effects of injury. appropriate for the sport, study population and A discussion of the why and how of injury is sample size considerations, study design, and sta- presented in sections on risk factors and inciting tistical approaches. This page intentionally left blank PART 1
SUMMER SPORTS This page intentionally left blank Chapter 1
Aquatics
STASINOS STAVRIANEAS Department of Exercise Science, Willamette University, Salem, Oregon, USA
Introduction of available data-based evidence makes it difficult to assess the accuracy of this statement. Although aquatic sports have been part of the Water polo was played as “football in the water” Olympic Games since the 1896 Athens Games, the starting around 1870 in England; in 1900 it was the establishment of the International Amateur Swimming first team sport introduced in the Olympic Games. Federation (FINA) in 1908 provided much-needed The inclusion of women’s water polo at the 2000 structure to the aquatics competitive program. Sydney Games indicates that the sport remains Diving evolved from the early “plunging” (1904 popular and has successfully transcended the sex St. Louis Games) and “fancy diving” competitions barrier. Few studies have provided a systematic that first appeared over a century ago. Technological accounting of injuries in water polo, and much advances (i.e., water agitators, springboard metal remains to be investigated. alloys, video, etc.) have resulted in ostensibly safer This review summarizes existing knowledge and facilities but ever more complicated dives. However, provides guidance for future research regarding the few studies exist regarding injuries during training epidemiology of injuries in aquatic sports. In general, or competition for competitive diving (Anderson & multiple methodologic limitations were found in the Rubin 1994; Badman & Rechtine 2004). reviewed literature, including variable injury defini- Competitive swimming has been a constant tions, differences in the athlete population studied in the Olympic Games since 1896 for men and (age, sex, ability, and years of training), small num- since the 1912 Stockholm Olympics for women. bers of participants, and problematic data-collection Unfortunately, the injury profile for swimming is instruments (i.e., recording methods). The majority of unclear, as almost all studies on swimming injuries the studies were retrospective in design and injury are retrospective and do not account for exposure rates were not based on exposure data. This summary in determining injury rates. of the extant literature on injuries in aquatic sports Synchronized swimming is the most recent addi- should be viewed with these limitations in mind. tion to the aquatics competition program and has evolved from a mostly esthetic sport in the early Who Is Affected by Injury? 1900s to be included in the Olympic program for the first time in the 1984 Los Angeles Games. Although A summary of the studies reporting injury rates in Weinberg (1986) characterized synchronized swim- aquatic sports is shown in Table 1.1. All of the stud- ming as a sport “relatively free of injury,” the lack ies in this review were retrospective, with varying sample sizes (10 to 2496 subjects) and competitive levels, but both sexes were represented. It must also be noted that most of the studies only reported Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 injuries per 100 participants because of the lack of Blackwell Publishing, ISBN: 9781405173643 exposure data. 3 Table 1.1 Injury rates in aquatic sports.
Study Study a Method b No. Sex Level c Years of No. of Study Total No. of % of No. of Rate Rate design Training teams Duration No. of injured athletes injuries (injury / (injury (range) injuries athletes injured per 100 100 player- /1000 athletes** hours) athlete exposures)
Swimming Kennedy & RQ 2496 C 261 10.4 Hawkins 1974b Graham & RQ 78 F CT 1 year 8 10.2 Bruce 19772 Garrick & R I/ME 159 77M, C 6 2 years 8 8 5 5 Requa 19782 82F Kennedy et al. R ME/R 35 NT 43 122 1978 Richardson et al. R I/ME/Q 137 54M, E, NT 10 3 63 58 42 46 1980 83F Zaricznyj et al. RR 74 C 2 2 2.7 2.7 0.001 1980c,d Mutoh et al. RQ 19 9M, E, NT 8.5 Ϯ 2.6 37 19 100 194 19881 10F Bak et al. RQ 268 C 100 80 30 125 0.09 1989 Lanese et al. PR 57 36M, CT 2 1 year 29 22 38.5 51 0.12M, 19902 21F 0.08F Goldstein et al. R I/ME 19 F E, NT 3 3 15.8 15.8 1991 McFarland & R ME 68 F CT 56 2.12 Wasik 19963 Capaci et al. RQ 38 M C 5.13–6.34 23 23 60.5 60.5 2002 Diving Krejkova et al. R ME 40 1 to 30 33 33 82.5 82.5 1981 Rubin 19832 RQ 38 14M, E3284 24F Mutoh et al. RQ 10 5M, 5F E, NT 8 Ϯ 3.1 30 10 100 300 19881 Anderson et al. R ME/I 14 6F, 8M E 14.8F, 19 4F, 67F, 135 0.00004** 1993a1,3 14.4M 2M 25M Anderson & RQ 37 16M, E3492 Rubin 19942 21F Rubin et al. R Q/ME 20 10F, NT 11.8–12.7 35 8F, 80F, 175 19942 10M 9M 90M Baranto et al. R ME 18 14F, E 89 16 89 494 20061 6M Synchronized Swimming Mutoh et al. 19881 RQ 24 F E, NT 7.9 Ϯ 2.1 31 19 79 163 Kirkley 19912 RQ 85 F AG,E 9 51 38 45 134** Water Polo Biener & Keller RQ 147 M C,E 35 189 73 50 128** 0.93** 1985 Mutoh et al. RQ 13 M E, NT 27 12 92.3 225 19881 McLain & R ME 54 36M, C 8.5 Ϯ 1.5 2 1 year 2M, 0F 5M, Reynolds 19893 16F 0F Jerolimov & RQ 102 M C, E 8 329 322 Jagger 1997 Annett et al. R ME 77 M E, NT 13 years 278 361** 1.16** 20003 Junge et al. RR 156** M NT 17 17 10.9 10.8** 6.3 2.8** 20063)
1 pain; 2 medical problem that resulted in time loss, 3 any musculoskeletal complaint a RϭRetrospective b: IϭInterview; QϭQuestionnaire; MEϭMedical Exam; Rϭschool/accident report * Data for organized school teams only, ** Calculated from data Mϭ Males, FϭFemales c: CϭCompetitive, AGϭ Age Group, NTϭNational Team/Olympic/World Championships, EϭElite, MϭMasters, CTϭCollege team 6 chapter 1
Diving 26 years), 61% of whom reported upper-extremity injuries, 61% back injuries, and 40% neck problems. Only Mizel et al. (1993) examined injuries in groups Anderson, Gerard and Zlatkin (1993a) noted that other than elite or national team level, and all but 42% of elite divers experience neck pain. Others Mizel et al. (1993) and Anderson et al. (1993b) indi- have also noted frequent injuries (24% to 29%) at cated clinical injury rates in divers between 80% the hand and wrist (Anderson et al. 1993b, Mutoh, and 100%. Rubin and Anderson (1996) presented Takamoto & Miyashita 1988). Mizel et al. (1993) data from Zimmerman (1993), who reported 8.8 found that 45% of injuries in a sample of 120 com- injuries per 1,000 training hours, and Gabriel (1992), petitive divers were to the ankle and foot. who studied medical insurance carrier reports of injury over 3 years that indicated 6.5 injuries per 100 participants per year for divers. Swimming
Swimming A review of Table 1.3 reveals that the most fre- quent injury location for swimmers is the shoulder As shown in Table 1.1, available studies indicated (12% to 87%), followed by the knee and the lower a prevalence of overall injuries ranging from 2.7 to back. A multitude of investigators have exam- 194 injuries per 100 athletes. Only McFarland and ined the effects of swimming on shoulder inju- Wasik (1996) reported an exposure-based injury ries alone (i.e., Dominguez 1978b, Richardson et rate (2.12 injuries per 1,000 athlete exposures) for al. 1980, McMaster et al. 1989, McMaster & Troup “any musculoskeletal problem reported to medical 1993, Burchfield et al. 1994, Stocker et al. 1995, Bak personnel.” & Fauno 1997, Johnson et al. 2003) with similar results. Dominguez (1978b) reported that 22% of Water Polo swimmers 11 to 12 years of age and 65% of swim- Few studies have systematically examined inju- mers 13 to 18 years of age reported shoulder pain. ries in water polo, and all are retrospective, with The knee is the second most common injury site sample sizes ranging from 13 to 156, mostly using among swimmers, with prevalences ranging from male participants. Injuries are primarily reported 6% to 28%, although Hahn and Foldspang (1998) as prevalence, ranging from 5% to 92%. described 62.3% in 53 Danish swimmers. According to Vizsolyi et al. (1987), breaststrokers experienced Where Does Injury Occur? a higher prevalence of knee-related problems than non-breaststrokers (73% and 48%, respectively). Anatomical Location Rovere and Nichols (1985) added that 47% of swim- mers cited weekly knee pain, with 75% having knee A summary of the available data on percent distri- pain at least three times per season. bution of injuries by anatomical location for aquatic Capaci et al. (2002) concluded that 33.3% of but- sports is presented in Tables 1.2 (diving, synchro- terfliers and 22.2% of breaststroke swimmers expe- nized swimming, water polo) and 1.3 (swimming). rienced lower back injuries. Mutoh (1978) found Some studies also reported rates by specific body a 37% rate of injuries for butterfliers. Drori et al. location, which will be discussed below. (1996) reported a 50% rate of injuries for butterfli- ers and 47% for breaststrokers. Diving In a study of 45 cases of insertion tendonitis in In divers, most injuries involve the low back swimmers, Merino and Llobet (1978) conveyed that (18.8% to 89%), neck (10.3% to 65.7%), and shoul- 73% were shoulder-related (51% freestyle, 42% der (20.7% to 85%). Rubin (1983) cited an unpub- backstroke, and 6% butterfly), 13.5% were in the lished study by Mangine (1981) on 66 divers, 89% groin (17% each in breaststroke and backstroke and of whom experienced back pain on multiple occa- 66% in the butterfly), and 13.5% involved the knee sions. He then surveyed 37 elite divers (ages, 11 to (66% in breaststroke and 34% in the butterfly).
Table 1.2 Comparison of injury onset.
Synchronized Diving Swimming Water Polo
Mutoh Anderson Mutoh Kirkley Biener & Mutoh Jerolimov & Annett Junge Study et al. 1988 et al. 1993b* et al. 1988 1991 Keller 1985 et al. 1988 Jagger 1997 et al. 2000 et al. 2006
No. of athletes 10 113M, 138F 24 85 147 13 102 77 156 Total No. of 30 143M, 227F 31 51 189 27 329 278 17 injuries Head/face 3 10.6M, 11F 39 96.4 15.5 53 Neck 10.3 14.7M, 14F 6.5 7.4 4.7 Upper 10.5M, 9.2F 1 Extremity Shoulder 20.7 41 4 18.5 0.9 24.1 6 Elbow 3 8 3 4 0.3 11.5 6 Forearm Wrist/hand/ 24.1 25.8 28 8 1.2 19.7 18 finger Lower 18.2M, 8 Extremity 22.9F Hip/groin 10 7.1 Knee 7.1 14.7M, 12.9 33 25.9 0.3 3.6 13.2F Ankle 7.1 3 Foot 2 1.7 6 Toe 0.3 Trunk/Low 27.6 31.5M, 45.2 8 5 37 0.3 7.9 11 back 29.5F Other/Not 3 10 0.3 4.2 specified a Sex is reported when known. * Calculated from data. 8 chapter 1 13 Capaci et al. 2002 3 56.5 2 5 13 3 30.4 26 18 886 38 886 23 Richardson Richardson 1999 7 4 53 11 68 56 55 18 McFarland & 1996 Wasik 239 McMaster et al. 1989 2 13 4 2 8 3 18 Bak et al. 1989 3 3 5.7 a 19 268 473 31.4 38 87 Mutoh et al. 1988 2 2 6 20 6 4 37.1 22 47 10 10 Zaricznyj et al. 1980 35 43 51 37 28 19 13 16 Kennedy et al. 1978 8 12.5 12.5 12.5 Graham & 1977 Bruce 9.7 25 31 12.5 37 26.8 25 32.5 261 Kennedy & Hawkins 1974b When totals are greater than 100%, multiple injuries are involved. than 100%, multiple injuries are greater When totals are No. of athletes 2496 78 Total no. of injuries Total Head/face Neck Upper Extremity Shoulder Table 1.3 Table distribution of injuries in swimming by anatomical location. Percentage Study a Elbow Wrist/hand/finger Forearm Lower Extremity Hip/groin Knee Ankle Foot Toe back Trunk/Low Other/Not specified aquatics 9
Water Polo accounted for the majority of the cross-training injuries (running, 47%; running steps, 13%; pulling Water polo players suffer chronic shoulder injuries sleds, 9%), and weight training caused 24%. at varying rates (3% to 38%) (Rollins et al. 1985, Richardson (1999) found that 42% of injuries Webster et al. 2009). Knee injuries (3.6% to 25.9%), occurred in the water, 22% on the deck, 7% outside acute head and orofacial injuries (15.5% to 53%), the pool, 6% in the locker room, 5% on the bleach- and hand injuries (8% to 29%) are also common. ers, 3% on the starting blocks, 2% each for hallway Jerolimov and Jagger (1997) estimated 3.1 orofa- and gym, 1% on stairs; 10% were from unspecified cial injuries per player. The prevalence of shoulder causes, although these figures involved 91% athletes injury detailed by Colville and Markman (1999) and 9% nonathletes or guests. The author also noted approached 80%, and this remains the most current that 54% of injuries occurred during competition, estimate. Biener and Keller (1985) stated that 39% of 31% during practice, 8% at warm-up, 2% on dry all injuries were to the head and face and that 28% land, and 5% other. involved the wrist, hand, and fingers. Synchronized Swimming Environmental Location Most injuries affecting synchronized swimmers can be Diving attributed to activities in the water, although Kirkley Rubin and Anderson (1996) cited a study by Gabriel (1991) reported that 27% of shoulder injuries and 12% (1992) in which 60% of injuries in athletes 13 to 18 of knee injuries occurred during weight training. years of age and 43.3% of injuries in divers 19 to Water Polo 30 years of age occurred during practice. They also included work by Zimmerman (1993), in which 92% An analysis of injuries in team sports during the 2004 of the 37 recorded injuries took place during train- Olympic Games indicated that male water polo play- ing. Mizel et al. (1993) reported that springboard ers suffered 30 injuries per 1,000 matches, 63 injuries diving accounted for 55% of foot and ankle injuries, per 1,000 player-hours, or 2.8 injuries per 1000 ath- dry-land training (i.e., gymnastics, trampoline) for lete exposures (Junge et al. 2006). Biener and Keller 13%, platform diving for 4%, and other events (such (1985) reported injury rates differed between games as exiting the pool) for 28% of injuries in a sample (4.16 injuries per 100 games), practices or friendly of divers. In terms of the timing of injury within a games (1.64 injuries per 100 games), and practices dive from the springboard, 12% were related to the (2.7 per 1,000 hours of practice). The authors also approach, 35% to the hurdle, and 53% to the press reported that goaltenders suffered 43% of injuries phase just prior to take off. during training (mostly from shots from other play- ers), as opposed to 22% of field players. There are no Swimming reports of water polo injuries taking place in areas around the pool or in other training facilities. The available data suggested that most swimming injuries occur during training. For example, Garrick When Does Injury Occur? and Requa (1978) reported that 100% of injuries in male and 57% in female high-school swimmers Injury Onset occurred during practice; 4% of female swim- mers were injured during competition. McMaster Most injuries in aquatic sports are chronic in nature, et al. (1989) noted that 5.1% of males and 14.6% of and are associated with highly repetitive motions females aged 13 to 14 years found weight training (i.e., arm cycles in swimming or eggbeater kicks in painful. McFarland and Wasik (1996) detailed similar water polo). However, onset may also vary by ana- injury rates from swimming and cross training for tomical location and the mechanism of injury. For swimming (1.05 and 1.07 injuries per 1,000 athlete example, acute shoulder injuries are common in exposures, respectively). Weight-bearing activities divers during impact with the water (i.e., Anderson & 10 chapter 1
Rubin 1994, Rubin et al. 1993), whereas chronic and clinical examination and reported that 67% shoulder injuries are common in swimmers (see dis- suffered abnormalities in the thoracolumbar spine, cussion below). with the first incident of back pain coinciding with a growth period (median, 15 years), and 94% of the Diving injuries occurring when the athletes were 14 to 17 Rubin and Anderson (1996) cited a study by years of age. The authors also estimated that the Zimmerman (1993) in which 62.2% of injuries were probability of experiencing back pain within 1 year acute and 37.8% classified as “overuse.” Baranto was 45% after divers reached 13 years of age. et al. (2006) reported that the median age for the Swimming first episode of back pain in divers was 15 years old. Ciullo and Stevens (1989) cited data from Troup Swimming et al. (1987), who found that most injury refer- rals started around the age of 18, when swimmers Stulberg et al. (1980) reported that 82% of swimmers had been training for approximately 10 years and experienced knee pain within 3 years of beginning are entering a more intense training and com- the breaststroke. Rovere and Nichols (1985) sug- petition schedule. Of elite swimmers who expe- gested that knee pain in breaststroke may involve a rienced shoulder pain during swimming, 83% short-term problem characterized by overuse and a indicated that the pain was more prevalent dur- long-term progressive chronic condition. ing the early and middle section of the swimming season (Richardson et al. 1980). The authors also Water Polo noted an increase in injuries as swimmers move Annett et al. (2000) classified 73.4% of water polo from competitive (27%; males, 38%; females, 23%) injuries as acute, 26.6% as due to overuse, and to elite (52%; males, 47%; females, 57%) to cham- 20.5% as chronic in nature (lasting 6 weeks or pionship caliber (57%; males, 50%; females, 68%). longer) (Figure 1.1). Dominguez (1978b) studied three age groups (р8 years old, 9–12 years old, and 13–18 years old) Chronometry and reported a 2% prevalence of pain in 9-to-12- year-old swimmers, and 65% in 13-to-18-year-olds. Diving Richardson et al. (1980) found that 47% to 68% Baranto et al. (2006) studied 18 elite divers (average of elite swimmers experienced pain, as opposed age, 17 years) using magnetic resonance imaging to 23% to 38% of younger, nonelite swimmers.
Figure 1.1 In water polo, contact with the opponent is often a cause of acute shoulder injury. © IOC /Tsutomu KISHIMOTO. aquatics 11
Stulberg et al. (1980) and Hahn and Foldspang diagnoses included asymmetry in muscle develop- (1998) reported 82% of swimmers had knee pain ment (57% of divers), cervical-motion restriction within 3 to 4 years of beginning breaststroke. (15–50%), positive Spurling’s test (50%), facet-joint tenderness (79%), spasm of the trapezius (79%), Synchronized Swimming and bone spurs (57%; 50% of females and 62.5% Kirkley (1991) stated that 64% of all injuries occurred of males). Rubin et al. (1993) reported that 80% of during the conditioning part of the training season a group of 20 elite divers exhibited shoulder insta- (speed swimming, synchronized swimming, weight bility, inflammation, and acromioclavicular-joint training, and flexibility conditioning) and 36% occur- injury, including acute subluxations and disloca- red during the routine preparation phase (choreog- tions, and traction tendinitis. raphy, compulsory figures, and practice of routine). In an early report, Rossi (1978) noted that 25 of 30 divers (83.3%) exhibited isthmic modifications, with Water Polo 63.3% exhibiting spondylolysis and 15.8% spondy- lolisthesis. Rossi and Dragoni (2001) reported that Junge et al. (2006) found that 41% more injuries divers had the highest prevalence of spondylolysis occurred in the second half of games as compared (23 of 57 athletes, 40.35%) of 37 sports studied. with the first half. However, the timing of injury was not reported for 35% of recorded injuries. Swimming What Is the Outcome? Of age group swimmers who reported shoulder pain, Dominguez (1978a) identified 39% with co - Injury Type racoacromial ligament tenderness and another 10.9% This review included only reports that addressed with Class 3 symptoms (disabling pain during and injuries specific to aquatic sports. Illnesses in aquatic after the activity to the degree that it affects perform- athletes such as mononucleosis or anemia were ance). Mutoh (1978) reported that 22% of butterfliers ex cluded. For specific conditions such as otitis ex- suffered from spondylolysis and intervertebral-disk terna (swimmer’s ear), which is often attributed to narrowing. McMaster et al. (1989) found that 4% infections from Pseudomonas aeruginosa, readers are of age-group swimmers experienced shoulder dis- referred to several reviews (i.e., Calderon & Mood location or subluxation, and 13.5% of males and 1982, Gerrard 2004, Nichols 1999, Wang et al. 2005). 12% of females also experienced nonspecific neck pain. A variety of studies have established that Diving breaststrokers experience knee injury in significant numbers (54–100%), including medial and lateral Since the first reports of injuries in competitive collateral ligament sprains, medial femoral condyle divers (Groher 1973), several studies have discussed contusion, and synovitis of the medial compartment different types of injury outcomes such as dam- (Hahn & Foldspang 1998, Hawkins & Kennedy 1974, age to soft tissue or ligaments or both, interverte- Kennedy & Hawkins 1974a, Keskinen et al. 1980, bral disk protrusions and degeneration, and stress Rodeo 1999, Rovere & Nichols 1985, Stulberg et al. fractures (Carter 1994, Kimball et al. 1985, Rubin 1980, Vizsolyi et al. 1987). Finally, Soler and Calderon 1983). Mizel et al. (1993) reported that in 55 injuries (2000) found that spondylolysis developed in 10.2% suffered by 41 divers (age Ն 18 years) 33% were of swimmers, although a third were asymptomatic. ankle sprains, 31% fractures (all lower-extremity), 9% Achilles tendon contusions, 7% midfoot strains, Synchronized Swimming 5% cuticle injuries, and 15% miscellaneous injuries. Anderson et al. (1993b) noted that fractures were Kirkley (1991) conducted a cross-sectional study the most common injury for both male and female that showed that 71% of swimmers with shoulder junior Olympic divers (44.2% and 52.9%, respec- injury were diagnosed with rotator cuff tendinitis, tively). Anderson et al. (1993a) reported that specific 24% of swimmers presented with patellofemoral 12 chapter 1 pain syndrome (24%), and 100% of lumbar spine missed an average of 11.5 practices, and 21.5% of injuries were muscle strains. nonbreaststrokers missed an average of 6.9 practices (Grote et al. 2004). Hahn and Foldspang (1998) also Water Polo noted that 24.5% of swimmers missed time because Junge et al. (2006) recorded foot fracture (1 case), of breaststroke-related knee injury. McFarland and tympanic membrane rupture (2), eye contusion (1), Wasik (1996) stated that only 4 of 56 injuries in their у shoulder dislocation (1) and sternal fracture (1) dur- study resulted in 21 days away from participation ing the 2004 Athens Olympic Games water polo in practice. Lanese et al. (1990) reported 241.5 disabil- competition. In a retrospective study of 77 elite play- ity days for males and 63.5 for females (1.43 and 0.62 ers, Annett et al. (2000) found that frequent injury disability days per 100 person-hours, respectively) in types included finger and thumb sprains (8.3% of their 1-year study of a collegiate swim team. Merino total injuries) and supraspinatus tendinitis (7.9%), and Llobet (1978) concluded that tendinitis does not eye injuries (6.1%), and tympanic-membrane trauma adversely affect swimmers, as 84% returned to full (6.1%). Jerolimov and Jagger (1997) concluded that performance in 1 month or less, with only 3% not 96.4% of water polo injuries were orofacial, with being able to return to the sport. cuts to the lips accounting for 48%, followed by the tongue (12.8%) and cheek (9.1%). Finally, Merino Synchronized Swimming and Llobet (1978) reported shoulder and elbow Kirkley (1991) reported an average of 28 hours of insertion tendinitis in water polo players. practice time and 6% of synchronized swimming competitions lost due to injury, for an average of 1 Time Loss week without training over the course of one full Diving competitive season. Anderson and Rubin (1994) indicated that cervical injuries required 43% of elite divers (67% of females, Water Polo 25% of males) to miss at least 1 week of training. McLain and Reynolds (1998) noted that injuries in Similarly, Rubin et al. (1993) reported that 16 of 20 male high-school water polo players resulted in the national team divers missed at least 1 week of prac- athletes missing an average of 5 days of participation. tice at some point because of shoulder injury associ- Junge et al. (2006) reported that time away from par- ated with diving. Conversely, Rubin and Anderson ticipation because of injury ranged from 2 days (eye (1996) cited Zimmerman (1993), where 31 of 40 contusion) to Ն 30 days for a fractured sternum for divers (77.5%) who reported an injury missed 4 participants in the 2004 Olympic Games, with an inci- hours of practice or less, and 90% returned to prac- dence for time-loss injuries of 8.7 per 1,000 matches tice within 2 weeks. (19 injuries per 1,000 player-hours). Annett et al. (2000) noted that no acute water polo injury resulted Swimming in more than 6 weeks away from participation in their Dominguez (1978b) reported that at least 10% of age- 13-year study of elite male players. Finally, Biener and group swimmers (13–18 years) missed practice or Keller (1985) found that in a sample of 147 players, swimming meets. Richardson et al. (1980) indicated 48% did not miss practice or playing time because that 81% of swimmers with shoulder pain diminished of injury, whereas 24% missed unspecified time, 10% daily training and 40% had to stop training for a missed one practice, and 18% did not report. short period. Garrick and Requa (1978) found 71% of female high-school swimmers missed 5 days or more. Clinical Outcome Hip abductor injury caused 9.2% of breaststrokers Diving and 6.3% of individual medley swimmers to miss competition (an average of 2.2 and 2.6 missed com- Lebwohl (1996) reported two fatalities on record petitions, respectively), but 42.7% of breaststrokers worldwide due to impact of the head with the aquatics 13
platform during a complicated reverse somersault Synchronized Swimming dive. Rubin (1983) referenced a study by Groher Mutoh et al. (1988) reported that in their study, 19 (1973) on divers who trained for more than 5 years, of 24 participants (79%) experienced chronic pain; in which 33% experienced “unusual rigid attitude 73.7% of them required medical treatment. in their lumbar spine,” 55% demonstrated restricted flexion, and 40% had limited extension. Of these, Water Polo arthritis of the spinous processes developed in 50% , arthritis of the vertebral joints in 55%, and spondy- The NCCSI records indicated a total of four indirect lolysis in 20%. Krejcova et al. (1981) indicated that high-school fatalities in water polo and one at the 67% of divers exhibited reduced mobility of the college level from 1992 to 2007 (National Center for spine, 47% had rotation blockade, 23% had reduced Catastrophic Sport Injury Research 2008). Jerolimov mobility of the lumbosacral region, and 47.5% sco- and Jagger (1997) found that 33% of water polo inju- liosis, but the authors did not connect these out- ries required medical treatment, and Annett et al. comes to specific prior or current injuries. Baranto (2000) reported that 20.5% of acute and overuse water et al. (2006) reported that in a 5-year follow-up after polo injuries became chronic. Biener and Keller (1985) an initial examination, 12 of 17 divers (median age, noted that 36% of injuries required no treatment, 36% 17 years at baseline) experienced a total of 89 spinal were self-treated and 22% required a visit to a phy- abnormalities and 3 quit competing altogether. sician or hospital, mostly for dental injuries. Hame Krejcova et al. (1981) also found, from vestibular et al. (2004) described a total of 20 fractures (16 male and optokinetic examinations, evidence of vestibu- and 4 female) in collegiate Division I water polo play- lar disease in 75% of all divers (27.5% peripheral and ers during a review of fractures spanning 14 years. 47.5% central) and electroencephalogram examina- tion revealed abnormal patterns in 57.5% of divers. Economic Cost This literature review did not identify any studies Swimming that analyzed the economic costs associated with injuries in aquatic sports. A review of the National Center for Catastrophic Sport Injury Research (NCCSI) website indicated five indirect (systemic failure as a result of exertion What Are the Risk Factors? or complication secondary to nonfatal injury) and eight direct (caused by participation in the sport) Intrinsic Factors catastrophic injuries in high-school female swim- Swimming mers and one indirect fatality in a female college swimmer from 1982 through 2007 (National Center Gender differences: Sallis et al. (2001) concluded that for Catastrophic Sport Injury Research 2008). female swimmers at Pomona College sustained more Richardson (1999) indicated that among 886 acci- injuries than their male peers (47.08 vs. 12.37 injuries dents reported during USA Swimming–sanctioned per 100 participant years, P Ͻ 0.001). Specifically, dif- competitions, 78% were minor (i.e., minor contu- ferences in rates (injuries per 100 participant-years) sions, falls around the pool, small lacerations, etc.), existed in the shoulder (21.05 vs. 6.55, P Ͻ 0.01), knee 19% were major (undefined), and 3% were frac- (5.85 vs. 1.45, P Ͻ 0.01), back and neck (8.19 vs. 1.45, tures. Dominguez (1978a) presented a case series of P Ͻ 0.01), and hip (2.34 vs. 0.00, P Ͻ 0.01). three swimmers with debilitating chronic shoulder Age differences: Vizsolyi et al. (1987) concluded that pain who underwent successful coracoacromial lig- swimmers who were older and trained more had a ament resection, resulting in pain-free participation greater incidence of injury than younger, less expe- in swimming. McFarland and Wasik (1996) noted rienced swimmers (P Ͻ 0.001), but the authors did low rates of surgery for swimming and swimming not distinguish between age and training as causes cross-training injuries (4% and 5%, respectively). for injury. Bak et al. (1989) indicated that medley 14 chapter 1 swimmers had a significantly higher proportion of as the cause of all knee injuries in swimmers. injuries (54%) as compared with swimmers special- Stulberg et al. (1980) concluded that all 23 swim- izing in a single stroke (freestyle, 41%; backstroke, mers in their study experienced pain during 32%; breaststroke, 32%; and butterfly, 37%). the final thrust of the whipkick. Based on a 48% prevalence of knee pain in nonbreaststrokers, Water Polo Vizsolyi et al. (1987) concluded that the breast- stroke kick can generate pain even when used on a To date, no study has conclusively connected risk limited basis during training. Rovere and Nichols factors to specific injuries in water polo, although (1985) reported that the most notable event associ- Sallis et al. (2001) reported that female collegiate ated with the onset of knee pain in breaststrokers players experienced significantly more injuries than was an increase in breaststroke training distance their male peers (18.38% vs. 7.10%, P Ͻ 0.001), with (81%), followed by weight lifting (19%), and shoulder injury rates also significantly higher (8.09% running and inadequate warm-up (16% each). vs. 3.40%, P Ͻ 0.01). Hame et al. (2004) concluded Pain in the lower extremity has also been linked that male water polo players had a significantly to the use of the kickboard in 9% of females greater rate of fractures than female players (4.1 and 11% of males aged 13 to14 years (McMaster vs.1.3 injuries per 100 athlete-years of participation). et al. 1989). Capaci et al. (2002) indicated that 11 of 23 Extrinsic Factors swimmers experienced pain during and after Some studies have attributed injuries to specific workouts (P Ͻ 0.0001). Richardson et al. (1980) equipment, or lack thereof. For example, Burchfield reported that 81% of swimmers stated that hand et al. (1994) argued that the introduction of hand pad- paddles exacerbated their shoulder pain. In con- dles and pull buoys correlated temporally with the trast, Stocker et al. (1995) found no association onset of, and increases in, the prevalence of shoul- between paddle use and shoulder pain, but 50% der pain in age-group swimmers (33 of 56 swim- of the swimmers associated pain with increased mers aged 13 to 18 years, P Ͻ 0.001). In water polo, distance or intensity or both. McMaster et al. Jerolimov and Jagger (2007) concluded that the use of (1989) concluded that although 77% of females mouth guards would result in fewer orofacial injuries and 88% of males used paddles in training, only during water polo. However, there is a complete void 16.8% of females and 20.7% of males experi- of research describing the role of extrinsic factors in enced pain during swimming. However, shoulder the development of injuries in aquatic sports. pain was positively correlated (P Ͻ 0.05) with stretching, weight training, kickboard use, and What Are the Inciting Events? sleep (in females). Burchfield et al. (1994) indi- cated that 49 of 56 swimmers who incorporated Diving weight lifting in their training experienced shoul- der pain. Few researchers have presented information as to the inciting events of injuries in diving. According to several authors (i.e., Anderson & Rubin 1994, Synchronized Swimming Kimball et al. 1985, Rubin 1983), the acrobatic In the single study that provided data on the activi- nature of diving and the impact with the water are ties that resulted in injury during synchronized the inciting events associated with the anatomical swimming, Kirkley (1991) reported that the precipi- distribution of injuries in diving. tating events for shoulder injury were weight train- ing (29%), butterfly swimming (24%), and sculling Swimming (43%). For knee injury, the causes were eggbeater Kennedy and Hawkins (1974a) and Capaci et al. motion (70%), synchronized swimming in general (2002) identified the whipkick during breaststroke (18%), and weight training (12%). aquatics 15
Water Polo (i.e., medical insurance reports vs. reports to a coach), classification (i.e., chronic vs. acute, sprain Junge et al. (2006) found that all injuries reported vs. strain, etc.) and treatment of injuries, make iden- during the 2004 Olympics were due to contact with tification of injury characteristics (severity, type, another player. Biener and Keller (1985) indicated etc.) difficult. Above all, this review underscores the that 65% of injuries in field players were caused need for standardized injury surveillance systems by contact with an opponent (48% accidental and in all aquatic sports without which a comprehen- 17% intentional), whereas the ball caused 13% of sive understanding of injury risks and resolutions is injuries and players’ own mistakes caused 19% of not possible. For example, in examining sex as a risk injuries. In contrast, 74% of injuries sustained by factor, Troup et al. (1987) identified differences in goalkeepers were due to contact with the ball, with prevalence of pain between male and female swim- only 14% resulting from accidental contact with mers (70% vs. 65%, respectively) but Richardson another player. Annett et al. (2000) stated that kicks et al. (1980) reported the opposite effects of sex were the cause of chest and abdominal injuries in and shoulder injuries among elite and national water polo (9 of 334 injuries overall). team swimmers (47–50% for males and 57–68% for females). Lanese et al. (1990), however, found no Injury Prevention differences between the sexes. Few well-designed studies on the impact of injury- In a separate example in water polo injuries, the prevention strategies in aquatic sports exist. For single study that included longitudinal data (13 example, Rovere and Nichols (1985) reported that years) did not provide insights as to injury rates reducing breaststroke training was the most effec- across that time span (Annett et al. 2000). Similarly, tive treatment for knee-pain reduction in breast- Jerolimov and Jagger (1997) found that pivot players strokers (84%). Dominguez (1978b) stated that a experienced a higher rate of orofacial injuries (5.5 weight-lifting program diminished shoulder pain in injuries per player) than defensive/attacking play- 8.5% of male swimmers ages 13 to 18. Ciullo (1986) ers (3.5 injuries per player), attacking players (3.1 cited his earlier study, in which the initiation of a injuries per player), and goalkeepers (0.6 injury per stretching program decreased shoulder impinge- player), but these data were not evaluated for signif- ment in swimmers training over 12,000 yards per icance. There is a clear need for well-designed pro- day from 80% to approximately 14%. However, spective cohort studies to address these basic issues. none of these were controlled studies. Overall, this Questions that remain unanswered for each of the review revealed a dearth of prospective studies aquatic sports include the following: What training that examined injury-prevention protocols in any practices result in injuries? What can be done to mini- aquatic sports in a scientifically valid way. mize or eliminate these injuries? What is the relation- ship between growth rates and injury rates? When is Further Research it safe to introduce certain elements, such as weight training or paddles into the training schedule, and One consistent pattern that emerges from this how should these be introduced? What are the long- review was the difficulty of accurately describing term effects of injuries in aquatic sports? These exam- injury rates, causes of injury, or strategies that can ples of specific areas for future research in all the reduce the risk of injury, because of the lack of valid aquatic sports will enable coaches, medical person- studies. The small number of participants, lack of nel, researchers, and athletes to ensure safe and pro- controls, and diversity of data-acquisition methods ductive training and competition experiences for all.
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Archery
JOHN C. HILDENBRAND IV AND GHAZI M. RAYAN Hand Surgery Section, Department of Orthopedic Surgery, Baptist Medical Center, Oklahoma City, Oklahoma, USA
Introduction on its injury patterns. The purpose of this chapter is to present a comprehensive review of the research Archery was introduced as an official sport in literature on injury patterns in archery. These data the 1900 Paris Olympic Games and included in should communicate to researchers the need for the 1904, 1908, and 1920 Olympics. Women were an easily accessible universal data bank for storing allowed to participate in the 1904 and 1908 Games. information on, studying, and reporting injuries in Because of a lack of uniform rules, archery was this increasingly popular sport. dropped from the Olympic Games program after 1920. It reemerged in the 1972 Munich Olympic Games, and has been on the program since. Who Is Affected by Injury? Today, archery is popular as a competitive We located only two articles that reported preva- sport, with a 14.8% increase in the number of par- lence data for archery. Ertan and Tuzun (2000) ticipants in the United States from 2000 to 2006. In used a questionnaire to poll 88 archers at the 2000 у 2006, approximately 7.5 million individuals ( 6 Turkish Archery Championship, half of whom were years of age; males, 72.3%, females, 27.7%) par- novice competitors. Although the reported preva- ticipated in archery at least once (Sporting Goods lence of injury was high (56.8%), the definition of Manufacturers Association 2007), with 529,000 a reportable injury is unknown. Mann and Littke у archers practicing frequently ( 52 events/year). (1989) also used a retrospective questionnaire to Archery is governed by the International Archery study 21 archers who qualified for the Canadian Federation, which consists of member National World Championship team in 1987 and reported Governing Bodies, including USA Archery, which 38.1 injuries per 100 participants. supports developmental programs such as the Junior Olympic Archery Development for younger Where Does Injury Occur? archers and Paralympics organizations for archers with disabilities. Today, archery attracts athletes of Anatomical Location both sexes and of all ages with its easy-to-learn but challenging pursuit of mastery. Most reported archery injuries are in the upper Until recently, archery has been neglected by the extremities (Figure 2.1). Injuries are also described scientific community. The recent rise in popularity in the chest, neck, and back. Table 2.1 compares the has stimulated new but modest medical research percent distribution of injuries by location. Ertan and Tuzun (2000) identified the most frequently injured body part as the fingers, fol- lowed by the shoulder of the drawing arm. Chen Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 et al. (2005) studied 24 elite archers at the Tsoying Blackwell Publishing, ISBN: 9781405173643 National Sport Training Center and found the 18 archery 19
Figure 2.1 Most reported archery injuries involve the upper extremities © IOC / Tsutomu KISHIMOTO shoulder and the wrist to be most commonly males and females trained for 11 months per year. injured, with 15 of the 24 archers reporting an However, no studies have examined the distribution injury to each of these areas (62.5%). Renfro and of injuries between practice and competition. Fleck (1991) reference an archery injury report of musculoskeletal injuries at the Olympic Training When Does Injury Occur? Center in Colorado Springs, Colorado, over a 10- month period during which 16 of 33 reported inju- Injury Onset ries (48.5%) were to the shoulder, while 14 (42.4%) were in the upper back muscles. There was no There are no data available on the relative fre- mention of the remaining 3 injuries. quency or distribution of acute and chronic injuries Data collected from the National Electronic in archers. Table 2.2 lists published reports on acute Injury Surveillance System (NEISS; U.S. Consumer and chronic injuries in archery. Product Safety Commission 2007), which included numerous hunting-related archery injuries, indi- Chronometry cated that the most frequent site for injury was the fingers (35.4%), followed by the hand (15.7%). Only There are no published studies examining the influ- 10 (2.7%) of the 370 injuries were reported to affect ence of time in practice or time of the competitive the shoulder girdle. season on injury occurrence.
Environmental Location What Is the Outcome? We found no studies that commented on envi- ronmental influences and the impact on archery Injury Type injuries, although NEISS data indicate that the Acute majority of the archery injuries in the general pop- ulation (48.6%) occurred at home. Case reports and case series in the NEISS indicate We have suggested that archers are more likely a diverse range of acute injury types, including lac- to sustain an injury during practice rather than erations, fractures, contusions, and acute compres- competition, as the majority of an archer’s time in sion neuropathies (U.S. Consumer Product Safety the sport is spent practicing. For example, Mann Commission 2007). However, it is not possible to and Littke (1989) noted that, on average, both separate competition archery from hunting injuries 20 chapter 2
Table 2.1 Percentage comparison of injury location.
Mann & Whiteside & Sorenson Fingleton Fukuda & Littke Andrews Shimizu Renfro & (1978) (1987) Neer (1988) (1989) (1989) et al. (1990) Fleck (1991) Rayan (1992)
Injuries 1 13 2 21 1 1 33 7 Head, neck, or 100 100 100 42 chest Upper Extremities Shoulder 100 100 49 Arm Elbow 100 28.6 Forearm 14.3 Wrist 28.6 Hand 14.3 Fingers 14.3 Lower Extremities Pelvis Thigh Knee Leg Ankle Foot Toes Not Otherwise 9 Specified
Table 2.2 Comparison of injury onset.
Study Injury Onset Level of Evidence Number of Injuries Number of Participants
Fingleton (1987) Acute IV 13 13 Rayan (1992) Acute IV 3 5 Vogel & Rayan (2003) Acute IV 1 1 Sorenson (1978) Acute V 1 1 Fukuda & Neer (1988) Chronic IV 2 2 Shimizu et al. (1990) Chronic IV 1 1 Rayan (1992) Chronic IV 4 5 Naraen et al. (1999) Chronic IV 1 1 Whiteside & Andrews (1989) Chronic V Sicuranza & McCue (1992) Chronic V Rehak (2001) Chronic V Ciccotti & Ramani (2003) Chronic V Dimeff (2003) Chronic V Safran (2004) Chronic V Toth et al. (2005) Chronic V Mann & Littke (1989) Unknown III 8 21 Ertan & Tuzun (2000) Unknown III 50 88 Renfro & Fleck (1991) Unknown V 33 Unknown
Level III ϭ case–control study; Level IV ϭ case series; Level V ϭ expert opinion. archery 21
U.S. Consumer Naraen Ertan & Ciccotti & Vogel & Chen Toth Product Safety et al. Tuzun Ramani Rayan et al. et al. Commission (1999) (2000) Rehak (2001) (2003) Dimeff (2003) (2003) Safran (2004) (2005) (2005) (2007)
1 75 1 1 1 1 1 80 4 370 2.7 100 6.3 25 16.2
20 18.8 5.9 6.3 1.4 100 1.3 100 2.5 1.6 10.7 100 100 0 25 6.2 12 18.8 25 4.6 8 100 6.3 25 15.7 20 0 35.4
13.8 1.1 6.3 1.6 11.3 1.1 1.3 3.8 2.9 2.5 0.8 3.8 3.5 0 1.4 24 0.5
in these data. Ertan and Tuzun (2000) reported fin- 1991; Mann 1994). Compression neuropathies are ger blisters as the most frequent (20%) injury type also caused by repetitive compression, traction in 88 competitive archers surveyed, followed by and friction inflicted on these peripheral nerves abrasions and contusions to the soft tissue of the (Rayan 1992; Sicuranza & McCue1992; Rehak 2001; bow forearm (10.7%) caused by string touches or Dimeff 2003; Safran 2004; Toth, McNeil & Feasby “string slap.” 2005). Table 2.3 lists specific studies on types of injuries. Chronic Chronic injuries occur because of repetitive micro- Time Loss trauma, and are often referred to as “overuse” There are currently no studies in the published syndromes. In archery, they present as repetitive literature on time lost from competition, practice, concentric and eccentric loading on muscles caus- or work. ing fatigue and tendinitis of the surrounding mus- cles (Mann & Littke 1989; Whiteside & Andrews Clinical Outcome 1989; Renfro & Fleck 1991; Ciccotti & Ramani Vascular Injuries 2003). Archery-related overuse syndromes have also been reported as physeal injuries of immature Bow hunter’s stroke is a term coined by Sorensen archers (Naraen et al. 1999). There are also reports (1978) after he described a 39-year-old male with of recurrent shoulder instability due to repetitive neurologic symptoms from a stroke while practic- stresses created by the archer’s stance (Fukuda ing archery. Ischemic lesions developed in the ver- & Neer 1988; Mann & Littke 1989; Renfro & Fleck tebrobasilar system from head rotation that caused Table 2.3 Comparison of injury type.
Fukuda & Mann & Whiteside & Shimizu Renfro & Naraen Ertan & Ciccotti & Vogel & Sorenson Fingleton Neer Littke Andrews et al. Fleck Rayan et al. Tuzun Rehak Ramani Dimeff Rayan Safran Toth et al. Diagnosis (1978) (1987) (1988) (1989) (1989) (1990) (1991) (1992) (1999) (2000) (2001) (2003) (2003) (2003) (2004) (2005)
Vascular ϩ Nerve Compression Digitital nerve ϩϩ Median nerve ϩϩ at wrist Pronator ϩϩϩ ϩ syndrome Long thoracic ϩ ϩϩ nerve Overuse Tendinopathy de Quervain ϩ disease Medial ϩϩ epicondylitis Lateral ϩ epicondylitis Rotator cuff ϩϩ ϩ ϩ Upper back ϩ musculature Instability Shoulder ϩ Fracture Coracoid process ϩ Trauma Finger Blister ϩ Metacarpal ϩ fracture Forearm ϩϩ contusion Laceration ϩ Penetrating ϩ archery 23
Table 2.4 Comparison of the level of evidence with purported archery-related risk factors.
Study Level of Evidence Number Purported Risk Factor
Mann & Littke (1989) III 21 Age, sex Ertan & Tuzun (2000) III 88 Training time, experience Fukuda & Neer (1988) IV 2 Technique Shimizu et al. (1990) IV 1 Technique Rayan (1992) IV 5 Technique Naraen et al. (1999) IV 1 Training time Vogel & Rayan (2003) IV 1 Technique
Level III ϭ case–control study; Level IV ϭ case series; Level V ϭ expert opinion. stenotic changes in the vertebral artery. Sorensen to traction or compression of the long thoracic nerve detailed characteristics of the archer’s posture dur- during archery practice. Three systematic reviews of ing practice and correlated them with pathology. peripheral-nerve injuries in sports have identified The author suggested that archers experiencing archery as a potential cause for long thoracic nerve dizziness or facial tingling while shooting should palsy (Dimeff 2003; Safran 2004; Toth et al. 2005). end practice and seek medical care. Hanakita et al. The median nerve is also at risk during archery. (1988) have documented the same phenomenon. Sicuranza & McCue (1992), Rayan (1992), and Rehak (2001) all described median-nerve compres- Musculotendinous Injuries sion neuropathy from archery. Rayan (1992) also Fukuda and Neer (1988) examined shoulder insta- reported a radial sensory-nerve compression neu- bility among archers and noted posterior instability ropathy from misuse of the release mechanism. and recurrent dislocation, possibly due to improper posture and technique (although there is no evi- Miscellaneous Injuries dence that this contention is accurate). Skeletal injuries have been reported in skeletally Mann and Littke (1989) surveyed 21 elite arch- immature athletes. Naraen et al. (1999) pub lished a ers and found that most of their injuries occurred case report of an 11-year-old archer with epiphyseal in the drawing-arm rotator cuff, especially among injury of his coracoid process from overuse. They females, in the form of impingement tendinitis of the detailed the patient’s symptoms of pain in his supraspinatus and long head of the biceps tendons. nondominant shoulder during archery training. Renfro and Fleck (1991) reported similar findings. Rayan (1992) reported on a 38-year-old archer who Whiteside and Andrews (1989) and Frostick sustained an open small finger metacarpal fracture et al. (1999) have reported that the repetitive load- of the dominant hand, which occurred when the ing of the wrist extensors can produce lateral epi- patient mishandled the bow as he was drawing, condylitis in archers. Medial elbow tendinopathy allowing the bow to discharge onto his hand. has also been described (Whiteside & Andrews 1989; Rayan 1992; Frostick et al. 1999; Ciccotti & Economic Cost Ramani 2003). Rayan (1992) described a patient To our knowledge, the economic impact of sustain- with de Quervain tendinopathy from misuse of the ing an archery-related injury in competitive ath- release mechanism. letes has not been studied. Nerve-Compression Injuries What Are the Risk Factors? Shimizu et al. (1990) reported the case of a 20-year-old male in whom a winged scapula gradually developed There are no studies to date that have published on the side of his drawing arm. This was attributed analytical data on either intrinsic or extrinsic risk 24 chapter 2 factors. Table 2.4 lists purported risk factors and fired in one session, drawing technique to prevent the level of evidence associated with each article. median-nerve compression, and the impact of non- Rayan (1992) documented in two case reports compliance in using protective equipment have not injuries resulting from failure to use appropriate been examined (Sicuranza & McCue 1992; Naraen protective equipment. et al. 1999; Ertan & Tuzun 2000). Although Mann and Littke (1989) found no correlation with bow What Are the Inciting Events? weights and related injuries, several studies (Mann & Littke 1989; Rayan 1992; Naraen 1999; Ertan & Mann & Littke (1989) indicate that frequent neck Tuzun 2000) have reported an association between symptoms in the form of paracervical and upper hours practiced/arrows fired and different injury torso muscle stiffness and pain are due to the patterns. For example, Ertan and Tuzan (2000) asymmetrical head and neck position and torso/ reported a mean of 12.3 hours training per week upper extremity muscle imbalance during fir- (4.4 training sessions of 2.8 hours per day) with an ing posture. They noted that poor stance, posture, average of 168.5 arrows per session using a mean and firing technique may lead to stress and patho- bow weight of 39.8 lb in a sample of elite Turkish logic changes at the thoracolumbar junction of the archers. The authors calculated the estimated lower spine. However, no data are provided to weekly work of 13.5 tons to be a risk factor for confirm this. injury, but provide no data to demonstrate an asso- ciation. In addition, Mann and Littke (1989) studied shoulder injuries among elite athletes and found a Injury Prevention significant difference between daily practice hours Currently, there are no published studies examin- for males (3.3) and females (2.4), but noted that ing the effectiveness of injury-prevention measures women manifested more clinical signs of shoulder in competitive archers. injuries and reported higher number of prior inju- ries than males. However, explicit exploration of this proposed relationship is lacking. Further Research Archery deserves better awareness in the lit- There is a scarcity of evidence-based medicine and erature, and attention should be focused on more epidemiologic data on archery injuries. Issues such research related to the biomechanics and epidemi- as creation of an international surveillance system, ology of its injuries. Epidemiologic studies are the standardization of reporting injuries, identification foundation on which most clinical studies build of risk factors, and injury prevention need research their infrastructure. The challenge is for future sci- development. For example, recommendations on entists to develop research methods that would rec- injury prevention, including proper stretching ognize, prevent, and treat injuries and, ultimately, and warm-ups, weight-training, careful selection improve the well-being of archers and advance the of bow weights, limits on the number of arrows sport of archery.
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Angiographic examination and surgical Renfro, G.J. & Fleck, S.J. (1991) Preventing Sporting Goods Manufacturers treatment of bow hunter’s stroke. rotator cuff injury and reaching optimal Association (2007) Archery Participation Neurosurgery 23, 228–232. athletic performance in archery through Report 2007. SGMA, Washington, DC. Mann, D.L. (1994) Injuries in archery. resistance exercise. The US Archer Toth, C., McNeil, S. & Feasby, T. (2005) Sports-Specific Injuries. In: Clinical July–Aug, 194–195. Peripheral nervous system injuries Practice of Sports Injury Prevention Safran, M.R. (2004) Nerve injury about in sport and recreation, a systematic and Care (Xxxxx, X., ed.), Blackwell the shoulder in athletes, part 2. The review. Sports Medicine 35, 717–738. Scientific Publications, Osney, Oxford: American Journal of Sports Medicine 32, U.S. Consumer Product Safety pp. 665–675. 1063–1076. Commission (2007) National Electronic Mann, D.L & Littke, N. (1989) Shoulder Shimizu, J., Nishiyama, K., Takeda, K., Injury Surveillance System (NEISS). injuries in archery. Canadian Journal of Ichida, T. & Sakuta, K. (1990) A case of URL http://www.cpsc.gov/library/ Sports Science 14, 85–92. long thoracic nerve palsy, with winged neiss.html [accessed on 2007]. Naraen, A., Giannikas, K.A. & Livesley, scapula, as a result of prolonged Vogel, B.R. & Rayan, G.M. (2003) P.J. (1999) Overuse epiphyseal injury exertion on practicing archery. Clinical Metacarpal fracture from archery: a of the coracoid process as a result of Neurology 30, 873–876. case report. Journal of Oklahoma Medical archery. International Journal of Sports Sicuranza, M.J. & McCue, F.C. (1992) Association 96, 79–80. Medicine 20, 53–55. Com pression neuropathies in the upper Whiteside, J.A., & Andrews, J.R. (1989) Rayan, G.M. (1992) Archery-related extremity of athletes. Hand Clinics 8, Common elbow problems in the injuries of the hand, forearm, and elbow. 263–273. recreational athlete. The Journal of Southern Medical Journal. 85, 961–964. Sorensen, B.F. (1978) Bow hunter’s stroke. Musculoskeletal Medicine 6, 17–34. Rehak, D.C. (2001) Pronator syndrome. Neurosurgery 2, 259–261. Clinics in Sports Medicine 20, 531–540. Chapter 3
Athletics
MITCHELL J. RAUH1,2 AND CAROLINE A. MACERA2 1 Graduate Program in Orthopaedic and Sports Physical Therapy, Rocky Mountain University of Health Professions, Provo, Utah, USA 2 Graduate School of Public Health, San Diego State University, California, USA
Introduction and pole vault; (3) road events (marathon, 10-km race walk for women, 20 km and 50 km race walks Athletics, also known as track and field, is a group for men); and (4) combined events (heptathlon for of sport events that involve running, jumping and women, decathlon for men) (Official Olympic games throwing (Official Olympic games website 2009). website 2009). The name “athletics” is derived from the Greek While discontinued as an Olympic sport in 1924, word athlon, meaning “contest.” we included cross-country running in our review Track and field athletics was included in the first because (1) few studies have reported on competitive modern Olympic Games in 1896, and has been track and field distance running events, (2) many present at every Olympic Games. While the number runners who participate in collegiate or interscholas- and type of events have changed over time, the tic track and field also participate in cross-country, men’s program has become fairly standardized since either competitively or for fall training, (3) although 1932. From the original 46 track and field events, there is a difference in surface type, the biomechani- only 24 remain in the current games. Women were cal and training mechanisms for running are similar first allowed to participate in a few track and field for the two sports, and (4) cross-country continues to events at the 1928 Olympics (Official Olympic games be popular at multiple competitive levels. website 2009). Presently, women compete in 23 While participation in competitive track and field events. Thus, the only difference is that men compete and cross-country may include benefits such as in one more race walk (50 km) than women (Official medals, scholarships, and improved cardiovascu- Olympic games website 2009). Currently, track and lar health, it also carries the risk of musculoskeletal field athletics can be classified in to four areas: (1) injury. With the large number of participants and track events, including sprints (100 m, 200 m, 400 m), diverse events, the sport of track and field poses middle-distance running (800 m, 1500 m) and long- special problems for medical professionals and distance running (5000 m, 10,000 m), hurdling sports injury researchers who monitor, treat, and (110 m for women, 110 m and 400 m for men), relays recommend preventive measures to minimize inju- (110 m and 4 ϫ 400 m) and 3000-m steeple chase; (2) ries. Runners strike the ground approximately 800 field events, including long jump, triple jump, high to 1500 times per mile with forces of 1.5 to 5 times jump, shot put, discus, javelin, and hammer throw, body weight experienced by the foot, and that force is transferred up the kinetic chain (Cavanaugh & Lafortune 1980; Subtonick 1985; Hreljac 2004). Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 Because middle and distance (and cross-country) Blackwell Publishing, ISBN: 9781405173643 running events require more repetitious movements 26 athletics 27
during training and competition, these runners may competitive events in which each athlete or run- be more susceptible to overuse injuries than athletes ner participated. who participate in other events. Sprint and jump • The few studies examining injury patterns dur- events require fast and explosive musculoskeletal ing the season have reported the proportion of movements that may lead to acute muscle strains. athletes injured. Without adjusting for actual Pole-vaulters and high jumpers may be at risk for athlete exposure, the incidence of injury may traumatic injuries to the head and spine due to appear highest at the beginning of the season improper landings. Throwing events such as the because there may be more participants to report javelin, shot put, and discus are more likely to result an injury. As the season progresses, there may be in acute and overuse injuries to the upper extremi- fewer participants to report an injury because of ties than other track and field events (Snouse 2002). a season-ending injury or noninjury reason (e.g., The purpose of this chapter is to review the exist- quitting the sport). Thus, the risk of injury toward ing literature on the distribution and determinants the end of the season may be falsely minimized. of injury rates as reported in the elite/club, colle- • In track and field, few studies reported injury giate, and interscholastic track and field injury and rates and risk factors for specific events. Thus, cross-country running literature, and to suggest determining which events have the highest risk of measures for the prevention of injury and direc- injury is difficult for directing prevention efforts. tions for future research. We restricted our review • In general, information is limited for injury rates to studies covering events that were competitive by body location, injury type, injury severity, or in nature rather than recreational one-time spon- setting (practice vs. competitive event). In stud- sored running events. Incidence data as percent- ies of multiple sports, data for these rates were ages were summarized over the time frame of the usually not reported individually for track and individual study, which ranged from a few weeks field or cross-country. to several years. When available, incidence data • Few studies prospectively examined risk factors were reported as the number of injuries per athlete for injury at these competitive levels. exposure or person-years. Potential risk factors for injury were evaluated on cohort (prospective or ret- rospective) or case– control studies only. Who Is Affected by Injury? The literature on injuries among competitive elite/club, collegiate, and high-school track and Incidence of Injury field and cross-country runners presented in this Overall Comparisons chapter must be evaluated in light of the following methodologic limitations: A comparison of injury rates reported in prospec- tive and retrospective studies of club/elite, col- • Information for injury rates and risk factors legiate, and high-school track and field athletes among Olympic level athletes was not found. (n ϭ 17) and cross-country runners (n ϭ 15) is Thus, findings are limited to elite/club, colle- shown in Table 3.1. Most injury rates were deter- giate, and high-school populations. mined per 100 athlete-seasons, with a range of 1.3 • Some studies did not provide adequate data to to 147.9 injuries per 100 athlete-seasons in track and estimate overall sample injury rates, limiting field and 1.4 to 75.1 per 100 athlete-seasons in cross- comparisons of several studies. country. However, calculating injury rates per 100 • Comparability within and across competitive athlete-seasons does not account for individual dif- levels are difficult, as studies often use different ferences in exposure risk. When determining injury definitions of injury, data-collection methods, risk by exposure, only three studies reported injury and criteria to determine the population at risk. rates by athlete exposures (AEs), with a range of • Few studies used a more sensitive denomi- 1.1 to 29.9 per 1,000 AEs for track and field (Clarke nator (e.g., per 1,000 athlete exposures) that & Buckley 1980; Powell & Dompier 2004; Knowles accounted for the actual number of practices and et al. 2006). For cross-country, four studies reported 28 chapter 3 a a — — — — — — 30.0 29.7 18.9 15.7 29.9 17.2 Injury Rate/1,000 Athlete Exposures a a a a 7.9 —— — — 91.7 46.8 43.2 49.1 16.1 10.8 19.6 41.6 46.8 136.8 123.9 149.0 131.8 161.5 147.9 Injury Rate/100 Athlete-Seasons — — — 61.2 56.9 63.5 75.8 69.6 81.6 35.1 36.8 43.2 Percentage Percentage of Athletes Injured a a a a a 4 10.8 11 16.1 55 65.0 90 29 61 15 14.0 57 73 71 23 — 29 42 44 16 28 130 NANA — 4,977 2,737 2,514 2,463 No. of Injuries 60 F: 51 M: 96 93 F: 37 95 F: 46 M: 49 No. of Participants NA F: NA M: NA 48 F: 22 M: 26 289 NA M: 56 F: NAM : NA 1,329 1,408 94 F: 37 M: 57 F: NA M: NA oss-country runners. or competition for у 1 wk injury that caused altera- tion of normal training у 1 wk Definition evaluation required. ATC school/insurance acci- or medical dent reports treatment lost from practice or lost from competition visit ATC 12 mo Injury lasting у 1 wk 147 12 mo Musculoskeletal pain or Duration Injury Collection P ME/IRF 1 yr training Injuries affecting RI P AT 2 yr Restricted participation or Design Data PP ME/I 3 yr MR Any treatment 1 yr first aid, requiring Trauma P AT/MR 1 yr in time resulting Trauma Lysolm & Lysolm (1987) Wiklander D’Souza (1994) R Q Outdoor Elite/Club Track Bennell & (1996) Crossley Collegiate Track Powell & Dompier (2004) Indoor Study Table 3.1 Table Comparison of injury rates in track and field athletes cr Orava & Saarela (1978) Zaricznyj et al. (1980) Outdoor Lanese et al. (1990) Indoor Sallis et al. (2001) R AT 15 yr requiring Medical problem athletics 29 a A — — — — — — — — — 1.18 1.06 2.2 1.9 21.0 19.2 20.1 ( continued ) a a a a a a a a a a 0.7 1.7 1.2 1.4 1.1 1.6 1.3 1.4 1.3 35.1 32.8 33.7 — 7.7 — 34.5 31.4 — —N 70.9 73.0 68.0 —— —— — a a a a a a a — — — — — 7.2 7.1 7.4 14.1 50.2 18.5 10.0 17.5 14.1 19.2 12.0 10.0 a a a a a a a 9 50.0 2 4 7 8 6 11 33.0 15 44.0 26 38.8 22 14.2 11 73 19 36 90 74 12 28 41 30 959 NA NA 174 101 164 149 1,884 1,940 a a a a a F: 34 M: 33 NA 2736 F: NA M: NA 516 208 308 F: 167 M: 279 10,642 F: 4,235 48 2,823 127 F: NA M: NAF: NAM: NA 925 NA NA F: 1,266 M: 1,003 — F: 65 M: 70 M: 6,407 101 F: 1,141 M: 1,682 2,269 F: 1,531 1,120 52.0 M: 1,205 820234 F: 78 48.0 M: 156 135 446 18 ATC evaluation required ATC participation tice or game missed subsequent practice or game pete or practice in usual manner pete or practice in usual manner ATC visit ATC lowing day of injury or medical attention required Miss meet or у 2 practices, or cause change in training for у 2 practices tice or game missed subsequent practice or game or game 1 season leg pain Exercise-related 88 (77 days) PQ P AT 2 years Restricted participation or P AT 8 years Any symptom P AT 3 yr Injury cause у 1 wk missed P AT/IRF 2 seasons Unable to complete prac- P TC 1 season ability to com- Altered P TC 3 seasons ability to com- Altered P ME/QP 1.85 yr fracture Stress ME/IRF 1 season leg pain Exercise-related P IRF 3 seasons Limited participation fol- P exam AT P 1 season Unable to complete prac- I/Q 1 season b b,c Reinking (2006) Reinking et al. (2007) Powell & Dompier (2004) Beachy et al. (1997) Clarke & Buckley (1980) Requa & Garrick (1981) Shively et al. (1981) Chandy & Grana (1985) Sallis et al. (2001) R AT 15 years requiring Medical problem High-School Track Knowles et al. (2006) McLain & Reynolds (1989) & Watson DiMartino (1987) Lowe et al. (1987) P IRF/AT 1 season practice Miss an organized Collegiate Cross-Country Kelsey et al. (2007) 30 chapter 3 2.8 4.3 1.7 — — — — — 17.0 19.6 15.0 13.1 16.7 10.9 Injury Rate/1,000 Athlete Exposures a a a a a a a a a a a a a a a a a —— 1.6 1.6 1.6 1.4 1.6 1.1 1.5 0.0 2.3 —— 16.2 50.2 29.9 65.5 23.9 10.2 75.1 84.4 67.7 64.6 41.7 65.0 66.1 34.6 29.1 Injury Rate/100 Athlete-Seasons a a a a a a ϭ males; ME ϭ medical exam; MR ϭ medical — — — — 3.5 7.5 15.2 21.7 10.2 38.5 41.9 12.0 19.1 29.0 34.0 26.0 47.4 10.6 35.7 47.0 48.0 13.0 Percentage Percentage of Athletes Injured a a a a a 6 2 3 1 2 9 3 7 8 0 9 9 11 17 15 13 10 31 50 23 41 316 157 159 776 846 843 512 331 1,622 No. of Injuries a a a a 2,278 105 F: 46 M: 59 421 F: 186 M: 235 F: 68 M:57 1,288 188 F: 63 M: 125 3,233 F: 1,202 M: 2,031 576 167 94 F: 40 M: 54 No. of Participants F: 787 M: 501 F: 711 M: 1,567 F: 187 M: 389 F: 26 M: 141 unning clubs (competitive). pete or practice in usual manner Unable to complete prac- tice or game missed subsequent practice or game due to MTSS injury Unable to complete prac- tice or game missed sub- sequent practice or game Symptoms of MTSS 125 or game tice or game missed sub- sequent practice or game pete or practice in usual manner tice or game missed sub- sequent practice or game tice or game missed subsequent practice or game. Definition injury report form; M F ϭ females; injury report I ϭ interview; ϭ IRF ϭ case–control; (13 wk) (11 wk) (11 (8 wk) Duration Injury Collection P TC 3 seasons ability to com- Altered P IRF/AT 1 season P/CC I/ME 1 season P AT 8 seasons Any symptom PP TC AT/IRF 1 season 2 seasons ability to com- Altered Unable to complete prac- P exam AT 1 season Unable to complete prac- Design Data continued ) certified athletic trainer; CC ϭ ATC ϭ athletic trainer reports; Only women studied. Calculated from data presented in article. data presented Calculated from Forty-five percent collegiate cross-country runners, 55% postcollegiate r runners, collegiate cross-country Forty-five percent Chandy & Grana (1985) High-School Cross-Country Plisky et al. (2007) retrospective; TC ϭ telecommunication between coaches and MDs. ϭ retrospective; R Q ϭ questionnaire; ϭ prospective; ϭ data not available; P NA syndrome; MTSS ϭ medial tibial stress reports; Rauh et al. (2006) PBennett et al. (2001) IRF 1 season Beachy et al. (1997) Lowe et al. (1987) P IRF/AT 1 season practice Miss an organized Rauh et al. (2000) P IRF 15 seasons Unable to complete prac- Shively et al. (1981) Garrick & Requa (1978) McLain & Reynolds (1989) Study Table 3.1 ( Table AT a b c athletics 31 a a,b a a 3.4 Other ——— 6.4 11.1 3.9 after Practice a,b a,f a,f a,f 11.1 a,b —— 7.4 15.7 14.4 a a a Hurdles Shot Put Long Jump and Before High Jump ——— — — — — Vaulting a,c — — — 13.3 ——— — — — — — 14.1 — 1.1 15.7 — 12.8 32.7 Marathon Pole- a,b a,c a,e a,e a,e 11.1 27.8 29.1 23.1 33.3 Running unning. a a a a a 43.6 66.7 31.3 Sprinting Distance d d d 11 54.4 36.4 — — — — — — 9.1 — 55 38.2 27 51 4130 46.378 43.3 17.1 10.0 — — 9.8 13.3 4.9 6.7 2.4 3.3 — — — — 14.7 16.7 4.9 6.7 90 30.0 Injuries No. of Participants No. of F: 208 M: 308 F: 78 M: 156 147 Based on 44.8% (78/174 injuries) reported injuries specific to track events. Based on 44.8% (78/174 injuries) reported all throwing events. long jump ϭ all events; other multi-event; shot put throwing Distance ϭ middle and distance running; Calculated from data presented in article. data presented Calculated from Events Ͼ 400 yd. Distance ϭ middle distance; marathon both long distance and r Inclusive of all jumping activities. Table 3.2 Table or event types in track and field. comparison of injury by running Percentage Study (1987) & Wiklander Lysolm 60 specifically for discus or javelin events. reported No data were F ϭ females; M males. a b c d e f High School & DiMartino (1987)Watson 234 Requa & Garrick (1984) 516 Elite/Club D’Souza (1994) 32 chapter 3 injury rates by athlete exposure with a range of In summary, while the data suggest that injury 2.8 to 20.1 per 1,000 AEs (Rauh et al. 2000, 2006; risk is higher among runners as compared with Powell & Dompier 2004; Plisky et al. 2007). athletes competing in field events (Figure 3.1), several limitations must be noted. First, the data on field events is limited. Second, the definition Event Type in Track and Field of injury and number of athletes injured in a spe- Five studies provided information on injury occur- cific event is not standardized across the studies. rence by event type in track and field (Table 3.2). Third, none of the studies used a denominator that While Bennell & Crossley (1996) reported no accounted for varying exposures by event type to significant differences between injury risk by event adequately compare injury rates between event type (sprints/hurdles: 100 m, 200 m, 400 m; middle types. Finally, the definition of what is considered distance: 800 m 1500 m; distance: 3 km, 5 km, 10 km, a sprint or distance event (e.g., 100 m vs. 800 m) or marathon; jumps/multiple events: long, triple, the classification of the athlete (sprinter vs. distance high, heptathlon), they did not report injury esti- runner) when injured was variable and may have mates or provide data to calculate them; therefore, affected the risk estimate reported for that event. the study was not included in the table. Two stud- Thus, further research to provide accurate informa- ies provided data by event type among elite/club tion for each event type is needed, especially at the athletes. D’Souza (1994) reported data for running collegiate level, for which no reports were found. and field events and reported that most injuries occurred during sprinting and distance running Where Does Injury Occur? events. Lysolm & Wiklander (1987) restricted their report to running events only and also found that Anatomical Location the highest percent of injuries occurred during sprinting events. The percentage of injuries associated with Similar to the elite/club studies, data from two a natomical locations is presented in Table 3.3 for prospective high-school studies indicated that most elite/club and high-school track and field athletes injuries occurred during running, with the highest and high-school cross-country runners only. The cat- number reported during sprinting, followed by egorization of body regions are derived from those middle distance/distance running (Requa & commonly used in prospective and retrospective Garrick 1981; Watson & DiMartino 1987). studies of track and field and cross-country running.
Figure 3.1 Current evidence suggests that the injury risk among track and field athletes is higher among runners than those competing in field events. © IOC / Yo NAGAYA athletics 33 3 Lowe et al. (1987) d Rauh et al. (2000) High-School Cross-Country Rauh et al. (2006) a Requa & Garrick (1981) 6 174 316 1,314 Lowe et al. (1987) oss-country runners. High-School Watson & Watson DiMartino (1987) a,c 0.08.00.0 2.4 2.4 0.0 0.0 0.0 0.0 0.0 0.0 2.4 0.0 5.7 0.0 0.0 9.1 0.0 1.7 0.0 0.0 0.06.0 4.9 4.8 16.7 16.7 1.1 3.4 0.0 — 0.0 — — — 0.08.0 7.3 19.5 16.7 33.3 29.3 35.6 5.2 38.3 6.7 33.6 0.0 66.7 6.06.06.0 0.0 14.6 9.7 0.0 16.7 0.0 1.9 6.3 5.2 0.0 4.2 4.2 0.0 3.2 3.2 0.0 0.0 — PPPPPPP 50 41 Zaricznyj et al. (1980) a P 5.6 1.4 0.0 1.41.4 0.0 24.0 18.0 4.8 0.0 16.7 0.0 4.5 1.1 0.0 — 0.0 — 0.0 — 9.99.9 10.0 12.1 0.0 0.0 11.7 6.6 0.0 0.0 71 48 289 234 446 516 421 3,233 188 12.7 Orava & (1978) Saarela e a — Lysolm & Lysolm Wiklander (1987) a,b Elite/Club Track 7.3 12.7 D’Souza (1994) c 7.30.0 13.8 0.0 10.9 0.0 15.4 14.0 17.1 0.0 9.8 10.8 17.1 33.3 0.0 0.0 9.1 0.0 4.6 0.0 0.00.0 0.0 14.7 0.0 0.0 12.7 RRP — 1.8 — —— 14.7 — 14.6 10.1 12.7 11.3 16.2 11.0 12.7 19.7 24.0 19.5 16.7 12.6 21.7 22.0 0.0 95 147 60 21.527.7 20.2 18.3 18.2 23.7 12.7 13.0 130 90 55 100.0 80.7 100.0 84.5 64.0 80.3 66.7 87.3 95.8 95.1 100.0 Bennell & Crossley (1996) Percentage comparison of injuries by injury location among track and field athletes cr Percentage Only 80% of all reported injured body locations. injured Only 80% of all reported Percentages based on total number of injuries reported for each body part. based on total number of injuries reported Percentages Calculated from data presented in article. data presented Calculated from Reported as back/pelvis/hip. Based on organized school sport and physical education participation settings. Based on organized Ankle Other Foot/toes Upper extremity Shoulder/upper arm/elbowWrist/hand/fingers —Lower extremity 2.8 — Number of injuries Upper leg Knee/patella Lower leg Achilles tendon Pelvis/hip/groin Head Spine/trunk Back/spine Trunk/internal Table 3.3 Table a b c d e Study Design No. of participants 34 chapter 3
The percent of injury in some body regions may among cross-country runners than among track be incomplete because the data from some studies and field athletes. For cross-country runners, the could not be categorized accordingly in our classifi- lower leg was the most common location of injury, cation. Despite this limitation, data in Table 3.3 indi- followed by the knee and ankle. While the predom- cate that the lower-extremity body region incurred inant body site of lower-extremity injury among the greatest percentage of injuries, followed by the track and field athletes was also the lower leg, inju- spine/trunk and upper-extremity regions. Few inju- ries to the upper leg were slightly more frequent ries occurred to the head. than those to the knee. The higher percent of upper- leg injuries may reflect the explosive and dynamic Head nature of the sprinting/hurdling and jumping events and the additional requirement of quadri- Our review suggests that the incidence of head inju- ceps and hamstring muscles during speed running ries is rare and occurred only in young track and and plyometric activities (Bennell & Crossley 1996). field athletes (Zaricznyi et al. 1980; Requa & Garrick 1981). Neither study, however, specified the injury Environmental Location type or severity, event or cause of the head injuries. Practice versus Competitive Event Spine/Trunk Although few track and field and cross-country The proportion of spine/trunk injuries reported studies reported data on the setting in which the among track and field athletes was larger than that injury occurred, those that did reported more inju- reported in cross-country runners. The difference ries during practice (range, 1.1–75.3 injuries per may be because track and field has a variety of events 100 athletes) than in a competitive event (range, that may cause acute and overuse spine and trunk 0.2–20.0 injuries per 100 athletes) regardless of com- injuries, whereas cross-country runners are more petition level (Clark & Buckley 1980; Zarincznyi likely to incur overuse injuries only to the low back et al. 1980; Requa & Garrick 1981; Lowe et al. 1987; region, which absorbs high levels of force during the Watson & DiMartino 1987;D’Souza 1994; Rauh support phase of running and is acted on by strong et al. 2000, 2006; Knowles et al. 2006). When rates muscular contractions (Knutzen & Hart 1996). are calculated by athlete exposure, two stud- ies (Rauh et al. 2000, 2006) show that injury rates Upper Extremity in cross-country are greater during practice than during competition (P р 0.05). Although athlete Most upper-extremity injuries occurred at the shoul- exposures may not be as sensitive as athlete expo- der and elbow and were only reported in track and sure-hours in estimating the risk of injury during field studies (Watson & DiMartino 1980; Requa & practices and games (Caine et al. 2006), the higher Garrick 1981; Lowe et al. 1987; Sallis et al. 2001). This practice injury rates per athlete exposures found in seems plausible, as acute or overuse upper-extrem- cross-country may adequately reflect the effect of ity injuries are more likely to occur in track and field cumulative mileage or longer distances run during events that comprise throwing (e.g., javelin, discus, practices than in competitions. At present, no stud- shot put) or landing (pole-vault, high jump). ies have reported practice and competition injury- rate comparisons per athlete exposure-hours or per Lower Extremity miles in track and field or cross-country. Since all track and field events and cross-country running require a significant amount of lower- When Does Injury Occur? extremity use, it would be expected that most inju- ries occur at the lower limbs because of repeated Injury Onset loading cycles that may not be accommodated by the musculoskeletal system. Overall, a higher pro- In general, most injuries in track and field and cross- portion of lower-extremity injuries was reported country running are overuse in nature (injuries athletics 35 caused by repetitive microtrauma to the tendons, What Is the Outcome? bones, and joints that develop gradually over time). Only three studies differentiated between acute Injury Type and sudden onset injuries and overuse injuries. A percentage comparison of injury types by elite/ In a study of 95 elite/club track and field athletes, club track and field (Orava & Saarela 1978; Lysolm Bennell and Crossley (1996) reported that 71.6% of & Wiklander 1987; Bennell & Crossley 1996) and 111 lower-limb injuries were overuse in nature, espe- high-school track and field (Requa & Garrick 1981; cially for middle-distance and long-distance runners Lowe et al. 1987; Watson & DiMartino 1987), and (76% and 95%, respectively). Athletes participating cross- country (Lowe et al. 1987) is shown in Table in sprints/hurdles, and jumps/multi-events, how- 3.4. Overall, inflammations, muscle strains, and ever, were more likely to incur an acute or sudden sprains were the most common injury types for onset injury (50% and 55%, respectively). Orava and these athletes. Although not summarized in Table Saarela (1978) also reported a similar distribution of 3.4, the most common inflammation-type injuries acute and overuse injuries of young elite track and occurred at the lower leg (medial or posterior tibial field athletes over a 3-year period. Of the 71 inju- stress syndrome, “shin splints”) and knee (patel- ries reported, 52 (73.2%; 36.1 per 100 athletes/year) lofemoral pain syndrome, knee pain). The most were overuse injuries and 19 (26.8%; 13.2 per 100 common body sites for muscle strains and sprains athletes/year) acute injuries. In a study of 446 high- were at the hamstrings and ankle, respectively. school track and field athletes and 188 cross-coun- Tendinitis at the Achilles and patellar tendon were try runners, Lowe et al. (1987) reported that only 1 the most common types of tendinitis injuries. (16.7%; 0.22 per 100 participants) of the 6 track and field injuries was acute onset. The acute injury was Time Loss caused by a discus hitting a female athlete in an adjoining field. All (n ϭ 3) cross-country running Currently, there is no consensus on what constitutes injuries were overuse in nature. the severity of an injury. To provide some method of comparing the severity of injury across studies, the time lost as a result of injury has been used. In Chronometry general, time loss has been defined as any injury Only three studies provided information regard- that restricts the athlete from completing a practice ing injury patterns during the course of a competi- or competitive event or prevents the athlete from tive season. In a 1-year study of 147 elite track and returning to a subsequent practice or competi- field athletes, D’Souza (1994) reported that most tive event in an unrestricted participation status (53.4%) injuries occurred at the beginning of the (Rice, Schlotfeldt & Foley 1985; Rauh et al. 2006). season and the least (8.9%) toward the end of the While time-loss severity classifications of mild season. In a study of 3,233 high school cross-coun- (р7 days), moderate (8–21 days), or major (у22) try runners, Rauh et al. (2000) reported that most have been advocated to standardize injury severity injuries occurred during weeks 3 to 7 (68.7%) of a (Powell & Dompier 1994), others have used dif- 16-week season. In a 1-year study of track and field ferent classifications (Beachy et al. 1997; Rauh et athletes, Lysolm and Wiklander (1987) reported al. 2006; Plisky et al. 2007). Thus, these differences significant variations (P Ͻ 0.001 to 0.05) in the inci- in definitions make the comparability within and dence of injury over the 12 months with the highest across competitive levels difficult. frequency of injuries during the spring and sum- Data on injury severity from one high-school mer months when training and competition were track and field study and four cross-country stud- most intense. Among long-distance/marathon run- ies are summarized in Table 3.5. Using similar ners, a significant correlation (r ϭ 0.59) was found injury-severity classifications, all studies compar- between the injury rate during a given month ing severity per 1,000 athlete exposures (Rauh et and the distance covered during the preceding al. 2000, 2006; Plisky et al. 2007) or per 100 athletes month. (Garrick & Requa 1978; Requa & Garrick 1981; 36 chapter 3 25.5 — Tendonitis Other Fracture 25.0 75.0 — — — —— 16.7 — 66.6— 50.0 — 15.1— — 39.7—————— —— 33.3 — — — — 50.0 — — — — 19.2 — — — — — — 18.0 48.0 — — 20.0 4.0 15.8 50.5 — — 10.9 oss-country runners. prospective; R ϭ retrospective. ϭ prospective; P om report; Contusion Fracture Inflammation Laceration Sprain Strain Stress 62 16.7 50.0 — —31 — — — — 66.7 100.0 — — 11 — — 27.3 — 27.3 18.2 — 9.1 18.2 5571 — 2.8 — —41 43.6 — 39.4 — — 1.4 10.9 36.5 12.7 20.0 16.9 1.4 2.5 17.2 12.7 24.3 12.7 — 14.6 4.9 130 — — 25.2 —174 5.5 1.7 24.5 20.5 2.9 11.0 17.2 13.3 2.3 15.5 46.0 — — 14.4 No. of Injuries Participants F: 78 M: 156F: 167 M: 279 30F: 208M: 308 — 4 73 101F: 63 —M: 125 2.7 1.0 39.9 2 4.1 2.0 3.3 — 19.2 15.8 13.3 50.0 26.7 — — 16.7 — M: NA NA — 6.0 8.0 Design No. of RP 95 39 P 446 P 516 P 188 a a a a a Calculated from data presented in article. data presented Calculated from Elite/Club Track (1996) Bennell & Crossley Lysolm & Wiklander (1987) & Wiklander Lysolm Lowe et al. (1987) Requa & Garrick (1981) High-School Cross-Country Lowe et al. (1987) Table 3.4 Table comparison of injuries by injury type among track and field athletes cr Percentage ϭ data not available or able to be calculated fr F ϭ females; M males; NA a Study Collegiate Track Clarke & Buckley (1980) P F: NA NA — 20.0 6.0 — 16.0 26.0 — — 32.0 Orava & Saarela (1978)Orava & Saarela PHigh-School Track & DiMartino (1987) 48 Watson P 234 athletics 37
Rauh et al. 2006; Plisky et al. 2007) indicate that participants), the rates are higher for collegiate track most injuries are minor in nature. Although no data and field athletes. In general, rates for direct injuries were reported in terms of injury-severity classifi- are higher for male than for female track and field cation for elite/club athlete studies, Bennell et al. athletes. Pole-vaulting is responsible for most inju- (1996) reported that average time loss from training ries, with 19 fatal (18 high school, 1 college), 11 non- due to injury among club track and field athletes fatal permanent disability (8 high school, 3 college), was 9.0 days (standard deviation, 8.5). and 7 serious (5 high school, 1 college, 1 middle school) injuries. Being struck by a thrown discus, Clinical Outcome shot put, or javelin has also resulted in 23 direct Reinjury injuries to high-school track and field athletes. Few studies have reported on reinjury among track Economic Cost and field athletes and cross-country runners. Data from two track and field studies (Clarke & Buckley A review of the literature showed that only one 1980; Bennell & Crossley, 1996) and two cross-coun- prospective study reported the cost of injury try (Rauh et al. 2000, 2006) studies indicated that related to competitive track and field or cross-coun- reinjury rate per 100 athletes ranged from 19.6 to try running in elite/club, collegiate or interscholas- 46.3. The two cross-country studies also reported tic populations. Knowles et al. (2007) reported that reinjury rates of 37.6 and 43.3 per 1,000 athlete expo- the adjusted exponentiated mean medical, human sures, respectively (Rauh et al. 2000, 2006). Two stud- capital (medical costs ϩ loss of future earnings), ies indicated that the shin and knee had the highest and comprehen sive costs (medical costs ϩ loss of rates of reinjury, (Rauh et al. 2000, 2006). While future earnings ϩ reduced quality of life costs) information on time lost as result of reinjury among for boys’ track and field athletes were $452 (95% track and field athletes and cross-country runners is confidence interval [CI], 334–611), $1,641 (95% CI, limited, it constitutes important information for par- 1,308–2,060) and $8,620 (95% CI, 6,435–11,145), ticipants and coaches, since it represents an index of respectively. The mean estimated costs of injury the extent to which progress toward increased skill for girls’ track and field was lower—$377 (95% CI, and running levels can be compromised by injury. 320–445), $1,619 (95% CI, 1,381–1,897), and $7,637 Because the reasons are not clear for reinjury among (95% CI, 6,674–8,740), respectively. Even though track and field athletes and cross-country runners, most injuries resulted in less than 1 week’s loss of future studies should examine these factors to help sports participation, these relatively minor injuries explain this finding in these sports, particularly resulted in a substantial cost to society. Their find- among female athletes, for whom the reinjury rates ings suggest that using time lost from participation appear to be higher. rather than cost as the primary marker of severity may be misleading. Catastrophic Injury Catastrophic injuries are rare but severely debili- What Are the Risk Factors? tating events. Data on catastrophic injury among collegiate and high-school track and field and cross- A key to the cause, prevention, and treatment of country runners are monitored by the National injuries of competitive track and field athletes and Center for Catastrophic Sport Injury Research cross-country runners lies in an understanding (Mueller & Cantu 2006). During 24 years of observa- of the factors associated with injuries. A number tion (1983 through 2006), 68 direct catastrophic inju- of risk factors from cohort (prospective and retro- ries occurred in collegiate and high-school track and spective) and case–control studies were identified field. Direct injuries are those that occurred directly in elite/club, collegiate and high school popula- from participation in the skills of the sport. Most tions. These are summarized in Table 3.6, and high- direct injuries (n ϭ 58) occurred at the high-school lights for intrinsic and extrinsic factors are noted level, but when adjusted for exposure (per 100,000 below. 38 chapter 3 e e e e e e e Major Injury Rate/1,000 AEs Moderate Injury Rate/1,000 AEs 2.53.91.4 0.3 0.49.8 0.39.6 0.0 0.0 7.9 4.3 0.0 2.5 2.3 1.2 1.7 1.4 ——— 11.2 4.1 2.4 13.112.6 3.7 2.9 4.0 2.2 Minor Injury Rate/1,000 AEs c c c e c,e c,e c,e c,e c,e c,e ———— ———— ———— 5.04.65.4 — — —0.0 —0.0 0.0 — — 5.5 6.7 8.8 5.4 10.7 17.2 Major Injury Rate/100 Athletes c c c c c c c c c c c c c c c a 5.4 9.71.9 4.52.2 1.7 —9.7 8.8 — — 11.4 11.1 11.5 13.9 6.718.1 —16.1 19.6 —12.6 — 12.8 Moderate Injury Rate/100 Athletes c c c c c c c c c c c c c c c 8.5 16.9 49.6 56.5 44.3 37.0 49.0 29.9 Minor Injury Rate/100 Athletes c e e e e e e e oss-country runners. 28 —— 17.4 — 23.1 16.3 Major Injuries c c c c 3 59 2930 14 14 14.4 18.5 21 18 Moderate Injuries c c c c c c Injuries ϭ у 15 days lost. 11 days lost. ϭ у 11 2,5333,453 10 5 1 1 0 0 21.7 5,986 158,008 2 105 30 0 14.3 32 — 6 — NA— NA 87 NA — 7.0 — 29 — 30 18,608 209 76 45 1,24,063 1,197 313 215 No. of AEsNo. of Minor F: 46 M: 59 F: 26 M: 141 — 23 F: NA 516 105 421 F: 186 M: 2353233 F: 1202M: 2031 10,600167 104 46,572 77,491 589 608 46 134 179 13 106 109 F: 208 M: NA — No. of Participants M: 308 — 57 b f b d d d Minor ϭ р 4 days lost; moderate 5–14 major Minor ϭ Յ 5 days lost; moderate 6–10 major All studies used prospective designs. All studies used prospective Major and out-for-season injuries combined. Major and out-for-season Calculated from data presented in article. data presented Calculated from Minor ϭ р 5 days lost; moderate/major у 6 lost. Collegiate Track Clark & Buckley (1980) High-School Track Requa & Garrick (1981) Table 3.5 Table Comparison of injury rates by severity in track and field athletes cr Study Rauh et al. (2006) Rauh et al. (2000) Garrick & Requa (1978) report. ϭ data not available or able to be calculated from F ϭ females; M males; NA AEs ϭ athlete exposures; a b c d e f High-School Cross-Country Plisky et al. (2007) athletics 39
Intrinsic Factors as compared with those with a right–left Q-angle difference of 0 to 3 degrees (Rauh et al. 2007a). Demographics The relationship between injury and leg-length With respect to sex as a risk factor for injury, the discrepancy or greater navicular drop is less clear. data are equivocal. While female runners had a While a leg-length discrepancy Ͼ0.5 cm was found significantly greater occurrence of injuries than to be associated with stress fracture among elite male runners in three studies of high school cross- track and field athletes (Bennell et al. 1996), no country runners (Bennett et al. 2001; Rauh et al. association was found between a leg-length dis- 2006; Plisky et al. 2007) other studies found no sig- crepancy у0.5 cm among high-school cross-coun- nificant sex differences (Bennell & Crossley 1996; try runners (Rauh et al. 2006). For navicular drop, Reinking et al. 2007). a case–control study of high-school cross-country While younger age was significantly associated runners indicated that runners with a medial tibial with injury in a prospective study of elite runners stress syndrome injury had a greater mean navic- (Kelsey et al. 2007), other elite/club or high-school ular drop than noninjured runners (Bennett et al., studies did not find an association (Bennell et al. 2001). Conversely, two prospective studies of colle- 1995, 1996; Bennell & Crossley 1996; Rauh et al. giate and high-school cross-country runners found 2006). Grade level was not associated with injury no association between a navicular drop of Ͼ10 mm among high-school cross-country runners (Rauh and exercise-related leg pain or medial tibial stress et al. 2006; Plisky et al. 2007). syndrome (Plisky et al. 2007; Reinking et al. 2007). In a retrospective study of elite track and field Body Mass/Composition athletes, those with greater overall flexibility were more likely to sustain one or more injuries over a 12- In a prospective study of high-school cross-country month period (Bennell & Crossley 1996). An overall runners, Plisky et al. (2007) reported that runners flexibility index of the lower limb was determined by who had a higher body-mass index (20.2–21.6, summating z-scores for sit-and-reach, hip rotation, calculated as the weight in kilograms divided by the calf flexibility, and ankle dorsiflexion. Athletes with square of the height in meters) were more likely to a flexibility index in the highest tertile were consid- incur an injury than runners with a lower body-mass ered to have greater overall flexibility. The authors index (18.8–20.1). However, other studies reported suggested that the greater flexibility observed may no significant association (Bennell & Crossley 1996; reflect a greater amount of stretching in that group Rauh et al. 2006; Reinking 2006). Thus, more studies in an attempt to prevent a future injury. are needed to determine the impact of body-mass index on injuries in these sports. Menstrual Problems The relationship between menstrual history and Biomechanical/Alignment risk of injury was reported in female elite/club Malalignment or biomechanical insufficiencies have and collegiate populations only. Multiple studies been speculated as risk factors for running injury. found an association between a history of amenor- Of the malalignment and biomechanical factors rhea or oligomenorrhea and increased risk of stress identified, only four were found to be significantly fracture or other musculoskeletal injury (Myburgh associated with injury: quadriceps angle (Q-angle), et al. 1990; Bennell et al. 1995, 1996; Kelsey et al. leg-length discrepancy, navicular drop, and greater 2007). Because menstrual irregularities have been overall flexibility. In two prospective studies of associated with low serum estrogen concentrations, high-school runners, those with a large Q-angle the mechanism likely involves decreased bone den- (Ն20 degrees for the overall sample and girls; Ն15 sity secondary to hypoestrogenemia (Drinkwater et degrees for boys only) were approximately twice as al. 1990; Rencken et al. 1996). Studies are needed to likely to incur an injury (Rauh et al. 2006, 2007a). identify causes of menstrual irregularities (e.g., low Runners with a right left Q-angle difference у4 energy availability) and recommend appropriate degrees were also twice as likely to incur an injury interventions (Nattiv et al. 2007). 40 chapter 3 oss-country runners. 0.05) Corrected (OR, 4.1; P Ͻ 0.05) Corrected Age of menarche in) calf girth (OR, 4.0; P Ͻ 0.05) (decrease Later age of menarche Fewer menses in past year index (fewer menses/yr Lower menstrual since menarche) Lower total body BMC Lower lumbar spine BMD Lower foot BMD Lower fat intake per kilogram of body weight number of leg-length discrepancies Greater overall flexibility: OR ϭ 5.3 (p Ͻ 0.05) Greater Later age of menarche disturbance ( Ͻ 8 menses History of menstrual in any year since menarche) (OR, 6.0; P Ͻ 0.02) History of oligomenorrhea about body weight (OR, 8.0; Carefulness P Ͻ 0.03) Later age of menarche score (eating disorder) Higher EAT-40 Results (females only) fracture Associated with stress had signifi- fracture Female athletes with stress cantly ( P р 0.05) Associated with musculoskeletal injury: Female athletes with musculoskeletal injury had significantly (p р 0.05) (multivariable fracture Associated with stress logistic regression): had signifi- fracture Female athletes with stress cantly ( P р 0.05) Purpose Identify factors to predict fracture risk of stress increased Determine incidence, distribu- tion, types, and severity of mus- culoskeletal injuries history of stress-fracture Participants F: 46 M: 49 F: 46 M: 49 Design Duration Method No. of R 12 mo I 95 Table 3.6 Table Comparison of analytical epidemiologic injury studies female and male track field athletes cr Study Elite/Club Track Bennell et al. (1996) P 12 mo I 95 Bennell & Crossley (1996) Bennell et al. (1995) R Lifetime Q/MR F: 53 Determine incidence and nature athletics 41 ( continued ) Lower lumbar spine BMD ( P ϭ 0.02) Lower femoral neck BMD ( P Ͻ 0.005) triangle BMD ( P ϭ 0.01) Lower Ward BMD ( P ϭ 0.01) Lower trochanter femur BMD ( P ϭ 0.02) proximal Lower Total spine density Less than 90% of age-related ( P ϭ 0.01) Lower daily calcium intake ( P ϭ 0.02) of RDA) Lower daily intake (percent ( P ϭ 0.02) Lower weekly dairy intake ( P Ͻ 0.05) Oral contraceptive nonuse ( P Ͻ 0.05) or oligomenorrhea amenorrhea Current ( P Ͻ 0.005) Prior stress fracture fracture Prior stress (rate ratio, 6.4; 95% CI, 1.8–22.9) Lower whole-body BMC (rate ratio, 2.7; 95% CI, 1.3–5.9) Daily calcium intake (per 100-mg decrease) (rate ratio, 1.1; 95% CI, 1.0–1.3) age (rate ratio, 1.4; 95% chronologic Younger CI, 1.1–1.9) (rate ratio, 1.9; 95% age at menarche Younger CI, 1.2–3.2) Athletes with musculoskeletal injury had significantly (RR, 2.3, 95% CI, 1.0–5.4) History of ERLP Associated with stress fracture (Cox propor- fracture Associated with stress models) tional-hazards associated with any injury: Q-angle у 20 degrees sample (RR, 1.7; 95% CI, 1.2–2.4) Total Females (RR, 1.6; 95% CI, 1.1–2.5 Knee injury (RR, 5.7; 95% CI, 2.3–14.1) injuries (RR, 3.8; 95% CI, у 8 days lost from 1.1–13.3) Determine whether athletes with had lower bone fractures stress density or higher incidence of risk factors for osteoporosis Identify factors associated with incidence of ERLP stress fracture. stress Determine relationships of Determine relationships Q-angle as risk factor for overall lower injury and specific injured limb site F: 38 M: 12 F: 34 M: 33 F: 171 M: 222 ME/Q F: 127 Identify risk factors that predict IRF 393 1.85 yr (16 wk) CC 1 yr ME 50 P Average, a b Collegiate Cross-Country Reinking et al. (2007) PKelsey et al. (2007) 1 season Q 67 Myburgh et al. (1990) Myburgh High-School Cross-Country Rauh et al. (2007a) P 1 season 42 chapter 3 ϭ males; ME ϭ medical angle; R ϭ retrospective; incidence rate ratio; M ϭ Female sex (IRR, 1.3; 95% CI, 1.1–1.6) (HR, 2.4; 95% CI. 1.6–3.6) Q-angle у 20 degrees injury (females) summer running Previous (HR, 1.6; 95% CI, 1.1–2.6) injury (males) Any prior running (HR, 1.2; 95% CI, 1.0–1.5) Results with any injury (males Q-angle у 15 degrees only) (RR, 1.5; 95% CI, 1.1–2.3) with difference Q-angle right-left у 4 degrees any injury (RR, 1.8; 95% CI, 1.4–2.5) Shin injury (RR, 2.4; 95% CI, 1.3–4.4) Ankle/foot injury (males only) (RR, 3.7; 95% CI, 1.2–11.4) Associated with MTSS (multivariable logistic regression) High BMI (OR, 7.3; 95% CI, 1.2–43.5) Female sex (OR, 2.9; 95% CI, 1.1–9.6) Associated with injury (Cox proportional-haz- regression) ards analysis Logistic regression MTSS, 64%; (predicted navicular drop Greater P Ͻ 0.001) MTSS, 84%; P Ͻ 0.001) Female sex (predicted MTSS, 74%; (predicted Sex and navicular drop P Ͻ 0.003) ϭ body-mass index; CC ϭ case–control; CI ϭ confidence interval; ϭ Eating EAT-40 prospective; ϭ prospective; Q ϭ questionnaire; Q-angle ϭ quadriceps Purpose Determine whether navicular and other factors associated drop with MTSS Identify risk factors for running- injury related between Determine relationship and measures lower-extremity MTSS odds ratio, P odds ratio, P ϭ unning clubs (competitive). Participants F: 46 M: 59 F: 186 M: 235 F: 68 M: 57 bone mineral density; BMI ϭ IRF/AT 105 IRF 421 I/ME 125 ϭ females; HR ϭ hazard ratio; form; IRR I ϭ interview; injury report IRF ϭ (13 wk) (16 wk) (8 wk) bone mineral count; BMD ϭ Design Duration Method No. of exercise-related leg pain; F exercise-related ϭ continued ) ϭ medical OR syndrome; medial tibial stress reports; MTSS ϭ athletic trainer reports; BMC athletic trainer reports; ϭ Forty-five percent collegiate cross-country runners, 55% postcollegiate r runners, collegiate cross-country Forty-five percent Ninety-two percent of subjects were track or road runners. track or road of subjects were Ninety-two percent relative risk. RR ϭ relative exam; MR Attitudes Test-40; ERLP ERLP Attitudes Test-40; Table 3.6 ( Table Study AT a b High-School Cross-Country Plisky et al. (2007) PRauh et al. (2006) 1 season P 1 season Bennett et al. (2001) CC 1 season athletics 43
As studies have found an association between association between musculoskeletal injury in any of later age of menarche and low bone mineral den- the eight sites measured in a retrospective study of sity (BMD) and bone mineral content (BMC) track and field athletes. Thus, further study is needed (Bennell et al. 1996, 1999), it has been suggested on the role of muscle mass as a predictor of injury. that later age at menarche may increase the risk for stress fracture. Findings from prospective and ret- Diet and Behavioral Factors rospective elite track and field athlete studies sup- Of the multiple dietary factors examined as risk port this risk association (Bennell et al. 1995, 1996; factors, only lower daily calcium and daily fat Bennell & Crossley 1996). In contrast, Kelsey et al. intake levels were found to be associated with an (2007) reported an association between younger increased risk of stress fracture in two studies of age at menarche and higher rates of stress fracture. collegiate and elite/club track and field athletes However, they suggested that their finding may be (Myburgh et al. 1990; Kelsey et al. 2007). In a ret- related to some other aspect of bone strength asso- rospective study of elite/club track and field ath- ciated with later age at menarche in the decreased letes, Bennell et al. (1995) reported that athletes risk of stress fracture. with stress fractures scored significantly higher on the Eating Attitudes Test (EAT-40) (questionnaire Bone and Muscle Mass on bulimia, food preoccupation, and oral control, Garner and Garfinkel, 1979) and were more likely Associations between lower BMD or BMC and to engage in restrictive eating behavior patterns an increased risk of stress fracture were reported and dieting. Further, they found that athletes who in elite/club track and field athletes only. Bennell were careful about their weight were eight times et al. (1996) prospectively identified significantly more likely to have sustained a stress fracture. lower levels of BMD at the lumbar spine and foot and lower levels of total-body BMC among athletes Prior Injury with stress fracture as compared with athletes with- out stress fractures. In a case–control study of run- One of the strongest intrinsic risk factors for injury ners, Myburgh et al. (1990) also found significantly at any competitive level was previous injury (Rauh lower levels of lumbar-spine BMD among athletes et al. 2006; Kelsey et al. 2007; Reinking et al., 2007). with stress fracture. They also reported lower levels However, none of the studies reported on the of BMD at the femoral neck and Ward triangle and cause of prior injury. That is, they did not examine less than 90% of age-related spine density among whether the increased risk was due to returning athletes with stress fractures than among athletes to activity before complete healing or the effects of without stress fracture. another intrinsic (e.g., biomechanical) or extrinsic In a prospective study of elite track athletes, (e.g., returning to too much mileage too soon) factor. Bennell et al. (1996) found that women who incurred stress fractures had significantly less lean mass Extrinsic Factors than women without stress fractures. However, the Training effects of less lean mass may be regionally related. Although no significant differences were found for Training error and training experience have tradi- thigh-girth values between the two groups, women tionally been thought to increase the risk of injury with smaller corrected calf-girth values (skinfold in competitive track and field and cross-country thickness subtracted from girth measurement) were running. In a study of elite track and field athletes, at increased risk for stress fracture. The authors sug- Lysolm and Wiklander (1987) reported that 72% of gested that smaller calf muscles may be unable to the injuries were caused by training fault (exces- produce enough force to counteract the loading of sive distance, sudden change of training routines). the lower limb at ground contact and to decrease However, comparisons of these training factors bone strain. However, using the same girth meas- between injured and noninjured runners were not ures, Bennell & Crossley (1996) did not find an reported. Reports from cohort and case–control 44 chapter 3 studies in elite/club, collegiate, and high-school Injury Prevention populations indicate no associations between injury The purpose of this review was to evaluate the and the following training factors: average train- risk of injury and propose some considerations for ing hours, running distance, summer (preseason) prevention among competitive track and field ath- mileage, training type, running surface, training letes and cross-country runners. To date, only one intensity and frequency, and frequency of competi- randomized, controlled trial has been conducted tion (Myburgh et al. 1990; Bennell & Crossley 1996; to reduce injury in competitive runners. To deter- Bennell et al. 1995, 1996; Rauh et al. 2006; Kelsey mine the effect of oral contraceptives on bone mass et al. 2007; Reinking et al. 2007). In a prospective and stress fracture incidence, Cobb et al. (2007) ran- study of 421 high-school cross-country runners, domly assigned 150 competitive female distance running on concrete surfaces or flat, but irregular, runners (intercollegiate cross-country teams, post- terrain increased the risk of injury by 12% for each collegiate running clubs, and road races) to an oral mile; however, only nonsignificant statistical trends contraceptive (30 µg of ethinyl estradiol or 0.3 mg were found (Rauh et al. 2006). In addition, prospec- of norgestrel) or control (no intervention) group. tive studies of collegiate and high school cross- Although taking oral contraceptives was not signif- country runners found no association between icantly related to the incidence of stress fracture, the years of competitive experience and injury (Rauh direction of the effect was protective (hazard ratio, et al. 2006; Plisky et al. 2007; Reinking et al. 2007). 0.57; 95% CI, 0.18–1.83). Findings from a prospec- tive observational cohort in elite female track and Footwear field athletes also found no association between Like training error, inappropriate or poor footwear oral-contraceptive use and stress fracture (Bennell has been suggested as a risk factor for injury in et al. 1996). In contrast, a case–control study indi- running sports. However, several prospective and cated a protective effect of oral-contraceptive use on retrospective studies of competitive track and field the incidence of stress fracture among elite female athlete or cross-country runners were consistent in runners (Myburgh et al. 1990). Thus, further study reporting no significant association between foot- is needed on the benefits of oral contraceptives and wear and musculoskeletal injury (Myburgh et al. reduction of stress fractures. 1990, Bennell & Crossley 1996; Bennell et al. 1996). Our review did not identify any other nonrand- In sum, although current studies indicate that omized trials designed to decrease or prevent the training-related factors, surface, and footwear are not occurrence of injury in these competitive sports important in the cause of stress fracture or other mus- populations. Therefore, suggestions for the preven- culoskeletal injury in competitive track and field ath- tion of injury in competitive track and field athletes letes and cross-country runners, more studies with and cross-country runner are limited. larger number of participants, variation in length and type of training, actual exposure time on surfaces, Injury Rates and detail on how footwear was assessed are needed before definitive conclusions can be made. Subsequent Injury Although current methods of reporting injury rates What Are the Inciting Events? provide valuable information, they do not inform how injury rates might be partially skewed by a per- A review of the literature showed that no pub- centage of individual athletes who are injured repeat- lished data exist regarding inciting events leading edly. Our review indicated that few studies reported to injury in competitive track and field or cross- the distinction between athletes who incurred only country running in elite/club, collegiate, or inter- one injury versus athletes who incurred multiple scholastic populations. This may be because most injuries during the course of a season. Because an injuries are repetitive rather than acute traumatic important aspect of injury prevention is to minimize in nature. the risk of an athlete’s initial injury, an equal goal athletics 45
should be to minimize the occurrence of subsequent injury (Bennell et al. 1996; Rauh et al. 2006, 2007a). injuries to the same body location (reinjury) or addi- Although several reports have suggested preven- tional injuries to new body parts (Rauh et al. 2007b). tive interventions such as orthotic or heel-pad use Thus, more studies are needed to better understand to reduce these biomechanical imbalances or struc- the impact of subsequent injury. tural differences (McCaw 1992; Fredericson 1996; Kuhn et al. 2002; Gross & Foxworth 2003), no stud- Practice versus Competitive Events ies were identified that demonstrated their pro- More studies are needed comparing injury rates tective effects against injury in these sports. Thus, during practices and competitive events at all com- well-designed randomized, controlled trials or petitive levels using denominators that adjust for large prospective observational studies are needed the number of athletes at risk (per 1,000 athlete to determine whether these or other prophylactic exposures or 1,000 hours of exposure) or distance measures are effective in minimizing injury in these incurred (e.g., per mile) in each setting. competitive sport populations.
Rates for Individual Track and Field Events Prior Injury Few prospective studies exist that have examined Studies are needed to determine common causes injury rates by individual track and field events, of prior injury. Does returning to full training particularly for jump events (long, triple, high), and competition before an injury is fully healed pole vault, and throwing events (shot put, discus, increase the risk of reinjury? Does a prior injury hammer, javelin). No data were found for com- alter an athlete’s biomechanics enough to increase bined events (heptathlon, decathlon). Thus, more the likelihood of an injury at another body site? studies are needed to determine which events have Accordingly, education and preventive muscu- higher injury rates and to provide injury rate infor- loskeletal program studies should be implemented mation, by event type, for body location and injury and evaluated to determine their effectiveness in type and time lost (severity) due to injury. decreasing the recurrence of injury.
Body Location and Injury Type Nutrition, Menstrual, and Bone Health Overall, only half the studies provided informa- Low energy availability (with or without eating tion for injured body location and about one third disorders), amenorrhea, and osteoporosis, alone reported information for injury type. Further, most or in combination, pose significant health risks to studies classified or grouped specific body loca- female athletes, including stress fracture (Nattiv et tions into gross body regions. Because specific al. 2007). The potentially irreversible consequences body locations and injury types may have different of these clinical conditions emphasize the impor- causes of injury, future studies are recommended tance for prevention and for early diagnosis and to report rate information as least detailed catego- treatment. Our review indicates that several of rized as possible to help determine which areas these components were associated with stress frac- deserve more attention in terms of etiologic study ture among elite competitive female track and field or preventive-management purposes. Also, more athletes. Future studies are needed to determine information is needed to determine whether cer- the interaction of low energy expenditure, amenor- tain body location(s) or type of injuries have higher rhea, and low bone mass and their effect on injury rates of recurrence. at all competitive levels, especially among high- school athletes, for whom the period of bone-mass Risk Factor Assessment and Injury Prevention accrual is highest. Finally, interventions designed to increase knowledge and behaviors toward appro- Biomechanical/Alignment priate energy, calcium, and protein intake among Several studies indicate that a large Q-angle or athletes and coaches are needed to assess their leg-length discrepancy may increase the risk of effectiveness in reducing injuries. 46 chapter 3
Training prevention and management purposes prior to and during the season for all sports. However, our Although numerous reviews on the causes of run- review did not identify any reports that determined ning injuries over the past few decades suggest that whether using a health care team resulted in a training errors play a large part in these injuries reduction in injuries or medical costs in these sports. (Macera 1992; van Mechelen 1995; Knutzen & Hart Further, while many colleges and elite-professional 1996; Yeung & Yeung 2001; van Gent et al. 2007), teams have full-time sports medicine teams to take our review indicates that training error or experi- care of their athletes, many high schools may not ence were not associated with injury in competitive have the financial resources to employ a physician track and field athletes and cross-country runners. or athletic trainer (Rice et al. 1985; Aukerman et al. However, only a few prospective studies examined 2006). Thus, studies are needed to examine whether training errors in these competitive populations. injury-management/prevention programs designed Thus, additional large-scale prospective studies are for these sports are beneficial, especially at lower needed to determine whether the following factors levels of competition. increase the likelihood of injury in these sports: Track and field events usually require a large training distances per week, abrupt changes in fre- number of officials to monitor the events for safety quency or intensity of training, hard (e.g., concrete) purposes (Pendergraph et al.. 2005). Because it is or different surface types, terrain (e.g., banked, likely that many event officials are not sports medi- hills). It may be that some training error factors cine or health care professionals, studies are needed do not cause injury in isolation but only when in to determine whether educating these individu- the presence of another training error factor. Thus, als in appropriate safety protocols results in fewer future studies should also examine whether inter- injuries, especially in field events (shot put, discus, actions between two or more training error factors hammer, javelin, pole vault) in which the inju- increase the athlete’s risk of injury. ries may have more serious consequences (Boden While inappropriate shoe wear and manage- et al. 2001; Pendergraph et al. 2005; Mueller and ment have been suggested to increase injury among Cantu 2006). track and field athletes and runners (Snouse 2002; Fredericson 1996), little is known about these fac- tors in competitive populations. Studies are needed Further Research to determine whether certain foot type–shoe type combinations that adversely affect the athlete’s Standardization of Study Methods lower-limb alignment or biomechanics increase the At present, it is difficult to compare injury inci- athlete’s susceptibility to injury. When should shoes dence estimates among published track and field be replaced? Does spike length in certain events and cross-country studies for two main reasons: increase the risk of injury? Do certain shoes provide (1) investigators have used different methods for insufficient shock absorption for training and events? collecting injury data, different injury definitions, Finally, similar to findings in military recruits and different ways of defining and collecting data on other athletic populations (Yeung & Yeung 2001), the time at risk (exposure), and different ways of esti- evidence for the protective effects of stretching on mating incidence; and (2) investigators do not injury is unsubstantiated in competitive track and report their methods in sufficient detail. Definitions field and cross-country. Future studies should deter- range from any symptom (Beachy et al. 1997) to an mine whether certain types and frequency of stretch- occurrence that causes 1 or more weeks of missed ing, or when stretching is performed, are beneficial participation (Clarke & Buckley 1980). Clearly, a in reducing injury in these sports. standard operational definition of injury needs to be determined in order to make meaningful compari- Health Care Team/Event Management sons across studies (Zemper 2005). At a minimum, Rice et al. (1985) advocated the need for having an we suggest the use of a denominator that speci- appropriate health care system in place for injury fies actual daily practice and competitive events athletics 47
participated in without restriction of injury. This elite/club, collegiate, and high-school levels. will provide an injury rate (per 1,000 hours of expo- Second, there are few prospective cohort and sure) that will account for varying season lengths, case–control studies that have adequately exam- and allow for better comparisons of injury risk by ined potential risk factors for injury, especially for sex, athletic event, body location, and injury type. collegiate and high-school track and field athletes, This review has summarized the available litera- for whom no studies were found. Finally, there is a ture on injuries among competitive track and field lack of studies designed to determine the protective athletes and cross-country runners. Despite the pop- effects of factors suggested to reduce injuries in ularity of these sports, they have not received much these sports. Thus, there is a need for large-scale epi- attention from medical and epidemiologic research- demiologic observational and interventional stud- ers. First, it is clear from this review that there is ies at all competitive levels in both sports. Based on limited information on injury rates, injury loca- our review, we have identified important issues and tion, injury type, and injury severity, particularly at future research directions for these sports.
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Chapter 4
Badminton
MARTIN FAHLSTRÖM Department of Surgical and Perioperative Sciences, Sports Medicine, and Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden
Introduction self-reported injuries and symptoms to seeking medical care in emergency wards or sports medi- Badminton became a competitive indoor sport cine clinics. There are also differences in study pop- with national and international tournaments ulations, which are not always specified, playing toward the end of the 19th century (Levinson & level, sports habits in particular countries, available Christensen 1996). The first international federation sports medicine care, and whether injured players was founded in the United Kingdom in 1934. Since sought medical care. 2005, the office of the Badminton World Federation (BWF), comprising 164 member nations, has been Who Is Affected by Injury? located in Kuala Lumpur, Malaysia (BWF 2009). Badminton is currently played, either competitive Both on competitive and recreational levels, bad- or recreationally, by an estimated 200 million peo- minton is considered a low-risk sport. Jørgensen & ple worldwide (Chin et al. 1995). It became a full Winge (1987) found a lower injury incidence in medal Olympic sport at the 1992 Olympic Games in badminton (2.9 injuries per 1,000 hours) than in Barcelona, with singles and doubles events for both contact sports such as association football (4.1 inju- men and women. In the 1996 Games in Atlanta, ries per 1,000 hours), ice hockey (4.7 injuries per mixed doubles were also added (IOC Sports 2008). 1,000 hours), and handball (8.3 injuries per 1,000 Badminton requires considerable accelerating hours). An overview of injury rates in studies on and decelerating movements over the court, with badminton players is shown in Table 4.1. strokes played from extreme postural positions, Incidence rates in younger players are somewhat resulting in severe loading of the lower extremi- conflicting. Backx et al. (1989) examined injury inci- ties and the racket arm (Figure 4.1). Even though dences in 14 different sports in Dutch school pupils the sport is played on all levels worldwide, there aged 8 to 17 years, comparing the injury rates in the are relatively few specific studies on badminton- various sports with the total study population. The related injuries or epidemiology. The purpose of injury risk ratio in badminton (0.21) was the second this chapter is to describe the known epidemiology lowest of the examined sports, and lower than in of badminton-related injuries. other racket sports (tennis, 0.47), net sports (volley- There are limitations on the interpretability of ball, 0.56) and individual sports (swimming, 0.72; the data in this search, especially because of dif- club gymnastics, 0.82). However, a study by Weir ferences in injury definitions, which range from & Watson (1996) with 12-to-15-year-old Irish pupils showed that badminton had the highest injury rate (7.1 injuries per 1,000 hours) of 11 school sports examined. Both studies included contact sports as Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 well as individual sports. The difference may be Blackwell Publishing, ISBN: 9781405173643 related to experience, with the Dutch pupils being 49 50 chapter 4
Figure 4.1 Competitive badminton demands quick reactions, speed, coordination and stamina and places significant loads on shoulders and lower extremities. Photograph by Tobias Edbom.
Table 4.1 Injury rates in studies on badminton players.
Study Type of Study Player Level No. of Cases Injuries/1,000 Hours of Badminton
Jørgensen & Winge 1987a Prospective Competitive & recreational 229 2.9 Weir & Watson 1996b Retrospective Competitive school pupils 230 7.1 Kluger et al. 1999c Retrospective Competitive 179 1.5 Yung et al. 2007d Retrospective Competitive 253 5.4 a Self-reported injury that appeared in connection with badminton training or match, handicapped during play and/or required special treatment to play, or made playing impossible. b Self-reported injury that caused pain, discomfort, or incapacity, which was attributed to participation in sport and which necessitated curtailment or absence from training or competition for at least 2 days. c Self-reported injury that was connected with badminton play. d Injury that led to consultation with a sports medicine clinic.
beginners while the Irish pupils were all competi- Similarly badminton-related eye injury has been tive badminton players. associated with 2% (Vinger & Tolpin 1978) to 66% (Chandran 1974) of all sports-related traumatic Where Does Injury Occur? eye injuries in different countries (Chandran 1974; Vinger & Tolpin 1978; Barrell et al. 1981; Gregory 1986; MacEwen 1987; Fong 1994; Pardhan et al. Anatomical Location 1995; Leivo et al. 2007). However, the incidence In badminton, the lower extremities account for the of eye injury in badminton appears low, rang- majority of all injuries. Injury locations are shown ing from 0.04 injury per 1,000 playing sessions in Table 4.2. (Barrell et al. 1981) to 0.4 injury per 1,000 players Research indicates that some specific injuries are per year (Leivo et al. 2007). These values are com- more common in badminton than in other sports. parable to, or lower than, other racket sports, such For example, badminton has been shown to account as tennis (0.01 injury per 1,000 sessions [Barrell for 46% to 51% of all sports-related acute Achilles et al. 1981]; 0.4 per 1,000 players per year [Leivo tendon ruptures in Scandinavia (Möller et al. 1996; et al. 2007]) and squash (0.05 per 1,000 sessions; 1.3 Houshian, Tscherning & Riegels-Nielsen 1998). per 1,000 players per year), or contact sports like badminton 51
Table 4.2 Injury-location frequencies (%) in studies on badminton injuries.
Prospective Studies Retrospective Studies
Jørgensen Krøner Fahlström Hamid Hensley Klingler Chard & Fahlström Kluger Yung & Winge et al. & Patel 2007d & Paup & Lachmann et al. et al. et al. 1987a 1990b 2007c 1979e Biener 1987d 1998b 1999f 2007d 1986f
No. of 229g,h 217g,h 122h 469h 435h 339h 128g,h 81g,h 179h 253h injuries Head 1.3 4.1 4.0 5 4.8 Eye 0.9 2.3 1.6 4 Other 0.4 1.8 2.4 1 4.8 Spine/trunk 10.5 1.8 10.6 18.7 1 4.5 14 11.1 20.0 Neck 5.7 1.7 Thorax 4.0 Back 10.5 1.8 4.9 16.6 1 4.5 5 11.1 13.6 Abdomen 0.4 9 2.4 Upper 30.5 11.1 18.8 18.1 21 8 24 17.9 24.8 extremity Shoulder 8.7 1.4 9.0 2 2 8 3.9 12.0 Upper arm 9.6 6.9 2.2 Elbow 7.4 8.2 9 6 13 5.0 2.4 Lower arm 3.5 3.4 7.2 Hand/wrist 1.3 2.8 1.6 6 3 3.4 3.2 Not 18.1 4 specified Lower 57.7 82.9 66.5 59.9 56 67 43 85.9 71.0 50.4 extremity Hip/groin 4.8 8.2 4 2.4 Thigh 6.6 2.8 6.6 8.3 3 11.1 12.0 Knee 10.9 11.5 20.5 24.0 9 12 25 16.7 17.9 12.0 Crus 5.7 14.3 3.3 2 5.1 0.6 5.6 Ankle 9.2 44.2i 27.9j 17.0 43j 47 10 29.5 30.2 10.4 Heel/ 8.7 7.0 3 3 34.6 5.0 Achilles tendon Foot/toes 11.8 10.1i 27.9j 3.6 43j 5 6.2 8.0 Not 3.1 17 20.5 20 14.1 specified a Self-reported injury that appeared in connection with badminton training or match, handicapped during play and/or required special treatment to play, or made this impossible. b Injury that caused consultation in the emergency department. c Injury that caused medical consultation during ongoing badminton tournament. d Injury that led to consultation with sports medicine clinic. e Self-reported injury handicapping the player’s performance. f Self-reported injury connected with badminton play. g Recreational-level player. h Competitive-level player. i Of the injuries, 5.3% were Achilles tendon tears; however, the authors have not described whether these injuries were classified as ankle or foot injuries. j Ankle and foot injuries were not separated. 52 chapter 4 floorball (0.9 per 1,000 players per year) and rink acute Achilles tendon ruptures seem to occur late in bandy (0.8 per 1,000 players per year) (Leivo et al. playing sessions, even though no exact time frames 2007). are given (Inglis & Sculco 1981; Kaalund et al. 1989; Fahlström et al. 1998a,b). Environmental Location Jørgensen and Winge (1987) found the injury inci- What Is the Outcome? dence to be similar in training sessions and in match play in both elite players (3.1 and 2.3 injuries Injury Type per 1,000 hours of participation, respectively) and Acute badminton injuries consist mostly of soft- recreational players (3.1 and 3.2 per 1,000 hours, tissue injuries, with sprains and joint injuries the respectively). However, a study of elite players in most common injuries reported, followed by strains Hong Kong (Yung et al. 2007), reported a higher and tendon injuries and fractures and skin wounds. injury incidence in competition than in training for An overview of the injury types is shown in both elite seniors (3.8 vs. 2.6 per 1,000 hours) and Table 4.3. The most common eye injury is hyphema elite juniors (5.9 vs. 2.8 per 1,000 hours). (Chandran 1974; Vinger & Tolpin 1978; Gregory 1986; Kelly 1987; MacEwen 1987). When Does Injury Occur? Overuse injuries in badminton are most often described as different tendinopathies or soft-tissue Injury Onset injuries (Hensley & Paup 1979; Klingler & Biener 1986; Jørgensen & Winge 1987; Krøner et al. 1990; A majority (67–74%) of badminton injuries in com- Høy et al. 1994; Hamid 2007). petitive players are described as overuse injuries (Jørgensen & Winge 1987; Kluger et al. 1999), and in most cases (56–73%) symptoms start gradu- Time Loss ally (Fahlström et al. 2006; Fahlström & Söderman The Abbreviated Injury Scale (AIS) is a six-point 2007). Many injury studies focus on definitions that scale used in casualty units. The scale describes include seeking medical care or preventing par- the severity of injuries, where AIS 1 indicates ticipation. However, studies show that both com- minor injuries and AIS 6 is untreatable injury, petitive and recreational players remain active in which is always fatal (Jørgensen 1981). Fahlström badminton, even though they have ongoing symp- et al. 1998b reported that 51% of acute badminton toms or injuries, with reported prevalence ranging injuries treated in an emergency department in a from 16% to 20% for shoulder injuries (Fahlström Swedish hospital were classified as minor (AIS 1) et al. 2006; Fahlström & Söderman 2007), 17% to and 49% were moderate (AIS 2). Høy et al. (1994) 22% for Achilles tendon problems (Fahlström et al. studied 100 badminton players treated in an emer- 2002a,b) to 28% (location not specified; Jørgensen & gency department in a Danish hospital. The inju- Winge 1987). ries in that study were not specified, but according to the AIS scale, 17% were classified as minor (AIS Chronometry 1), 56% as moderate (AIS 2), and 27% as severe Acute badminton injuries have been shown to be (AIS 3). Only 4% of the injured players were able more frequent during midseason, with 69% to 81% to return to playing badminton within 1 week, and of all acute injuries occurring during the months 28% of the injured players stopped playing for at of October through March (Krøner et al. 1990; least 8 weeks. Fahlström et al. 1998a,b). In contrast, the occurrence However, most badminton injuries are not so of acute injuries is most often normally distributed severe that they require treatment in an emer- during playing sessions (Høy et al. 1994; Fahlström gency department. Hamid (2007) studied injured et al. 1998b), although some studies indicate that badminton players consulting a sports medicine badminton 53
Table 4.3 Frequency (%) of injury types described in studies on badminton-related injuries.
Klingler & Jørgensen & Krøner Høy Fahlström Kluger Hamid Yung Biener Winge et al. et al. et al. et al. 2007c,f et al. 1986a.b 1987c,d 1990c,e 1994c,e 1998ba,e 1999a,b 2007a,f
No. of injuries 339g 229g,h 217g,h 100g,h 78g,h 179g 469g 253g Injury Acute and Acute (26%) Acute Acute Acute Acute Acute New (49%)i classification overuse and overuse (64%) and and (74%) overuse recurrent (36%) (51%) Overuse 74 36 Sprains/joint 65.5 11 58.5 55 43.6 48 26 28 injuries Strains/ 18 12 28.6 23 39.7 51 30.9 64 tendon injuries Fractures 2 1.5 5.1 5 2.6 4.9 Skin wounds 1 5.1 Eye 1.0 2.3 3 contusions Contusions 0.5 2 (not eye) Not specified 13.5 0.5 14.1 1 2.2 6 a Retrospective study design. b Self-reported injury connected with badminton play. c Prospective study design. d Self-reported injury that appeared in connection with badminton training or match, handicapped during play, or required special treatment to play, or made playing impossible. e Injury that led to consultation with the emergency department. f Injury that led to consultation with sports medicine clinic. g Competitive-level player. h Recreational-level player. i The frequency figures are related to the new injuries. clinic and found that as many as 92% of the injured Clinical Outcome players were back on their ordinary playing level in 7 days or less, and only 7% had more than 21 days As mentioned above, while many badminton of absence from play or modified play. Jørgensen injuries may negatively affect players or require and Winge (1987) reported a mean duration of treatment, they usually do not prevent participa- time loss for injuries of 48 days, but that 92% of tion. However, Høy et al. (1994) reported that 12% injured players were still playing badminton. Thus, of the patients in their study had to stop playing. although many badminton injuries may interfere Although the injuries were not specified, they were with play or require treatment, they do not prevent treated in an emergency department and classified players from participating. Similar results were seen as moderate or severe in 83% of the cases. Achilles in prevalence studies on badminton-related ongo- tendon rupture seems to be the acute badminton ing shoulder pain, where the symptoms affected injury with the most severe consequences, since the activities of daily living in about one third of the it has been found that no players have returned cases and sleep in about one fourth of the cases, but to their previous activity level after being treated the players were still playing badminton (Fahlström conservatively for acute Achilles tendon rupture et al. 2006; Fahlström & Söderman 2007). (Fahlström et al. 1998a). Table 4.4 lists the outcomes 54 chapter 4
Table 4.4 Consequences at follow-up after acute badminton injuries in the lower extremities.
Diagnosis Absence from Remaining Return to Same Sports Work, in Days Symptomsa Sporta Activity Levela
Achilles tendon 49 (1–90)c 36% 54%d 36% rupture—surgically treated (n ϭ 22)b Achilles tendon 49% Ͼ42 Not 82%f 54% rupture—surgically 13% Ͼ90 specified treated (n ϭ 39)e Achilles tendon 75 (2–180)c 78% 22%d 0% ruptures—nonsurgically treated (n ϭ 9)b Ankle sprains/ 24 (0–65)c 56% 83%d 74% fractures (n ϭ 23)b Knee injuries (n ϭ 13)b 21 (0–90)c 62% 46%d 38% Gastrocnemius strains 26 (0–50)c 0% 100%d 75% (n ϭ 4)b
a The percentage in these columns are all related to all the injured players in each row. b Adapted from Fahlström et al. (1998a,b); mean follow-up, 36 months; range, 10–69 months. c Mean and range. d Badminton play. e Kaalund et al. (1989); mean follow-up, 23 months; range, 11–39 months. f Any sports activity. of different acute badminton injuries in the lower than 3 days and 23% more than 3 weeks, with a mean extremities. of 2.4 to 42.5 days (Klingler & Biener 1986; Jørgensen & Winge 1987; Høy et al. 1994; Fahlström et al. Economic Cost 1998a,b). However, most studies do not specify con- sequences according to different diagnoses. Table 4.4 Medical consultation is sought by 21% to 81% of shows the mean and range for work absences for injured players (Fahlström et al. 2006; Fahlström & four acute lower-extremity badminton injuries. Söderman 2007). Krøner et al. (1990) reported that Høy et al. (1994) reported some kind of financial 62% of acutely injured players who went to a hos- loss for 10% of injured players with injuries that pital outpatient department needed only a single needed acute care, 83% of which were classified as visit, while 7% were admitted. In a similar study, moderate or severe. Høy et al. (1994) found that 21% of acutely injured players were admitted. Retrospective self-report studies on badminton injuries have shown hospi- What Are the Risk Factors? talization frequencies of 6% (Hensley & Paup 1979) to 12% (Klingler & Biener 1986) for badminton inju- Intrinsic Factors ries that required medical consultation. Yung et al. (2007) calculated the cost of badmin- Few studies have examined sex differences in ton injuries and reported a mean of 4.8 physiother- injury characteristics in badminton. Jørgensen apy treatments with a cost of US$253 per injury. and Winge (1987) found no significant difference Elite senior players seemed to need more physi- in injury incidence in men and women (3.0 vs. otherapy treatments (5.1 per injury) than younger 2.8 injuries per 1,000 hours) and this finding has players (4.3 per injury). been reported in competitive players (Yung et al. Absence from work has been reported in 56% to 2007) and school pupils (Backx et al. 1989; Weir & 72% of injuries, with 40% of the cases being more Watson 1996). However, Klingler and Biener (1986) badminton 55
reported a higher frequency of ankle sprains in 1977; Jørgensen & Winge 1987; Kluger et al. 1999; women as compared with men (56% vs. 44% of all Hamid 2007), no scientific studies have specifically injuries) and Fahlström et al. (2006) found that the investigated them in badminton. Furthermore, frequency of players seeking medical consultations there are no studies examining technique or racket because of shoulder pain was significantly higher quality in relation to injuries. in female than male elite players (100% vs. 55%). Competition format is a risk factor for injury in Age has been proposed as a risk factor for injury badminton. Although most injuries (53–62%) have in badminton players, with older athletes at greater been documented during singles play (32–44% risk (Høy et al. 1994; Yung et al. 2007). A Danish during doubles; Hensley & Paup 1979; Jørgensen & study on recreational and competitive players (Høy Winge 1987), the risk for eye injury is higher in et al. 1994) reported a higher incidence of injuries doubles play, since being hit by the other player’s for players Ն18 years of age than for those Ͻ18 racket is responsible for 7% to 31% of eye injuries (Ͼ25 years ϭ 42 injuries per 1,000 players per year; (Hensley & Paup 1979; Barrell et al. 1981; Gregory 18–25 years ϭ 45 injuries per 1,000 players per year; 1986; Kelly 1987). Ͻ18 years ϭ 28 injuries per 1,000 players per year). However, the differences were not statistically veri- What Are the Inciting Events? fied. A similar pattern was reported by Yung et al. (2007) in a study from Hong Kong, with a higher Most acute injuries (62–65%) are related to players injury incidence (7.4 injuries per 1,000 hours) in falling or slipping on the court. The rest are due elite senior athletes (Ն21 years and in scholarship to collision or being hit by another player’s racket programs for intensive training), while elite junior during doubles play (Hensley & Paup 1979; Krøner athletes (Ͻ21 years recommended to join the elite et al. 1990). senior team) had an injury incidence of 5.0 inju- A shuttle causes a majority of the eye inju- ries per 1,000 hours. Younger potential athletes ries (69–83%), while a racket is responsible in the (Ͻ15 years and in systematic training in badmin- remainder of cases (Hensley & Paup 1979; Barrell ton) had an even lower incidence of 2.1 injuries et al. 1981; Gregory 1986; Kelly 1987). per 1,000 hours. Fahlström et al. (2002a) found that competitive players with Achilles tendon pain were Injury Prevention significantly older than players without pain. Wearing protective glasses seems to be effective Kluger et al. (1999) concluded that the incidence for eye-injury prevention in badminton, as no eye for acute injury in competitive badminton players injuries have been noted in players wearing protec- increased constantly from the first competition year tive glasses (Chandran 1974; Vinger & Tolpin 1978; (0.32 injury per 1,000 playing hours) to be threefold Barrell et al. 1981; Gregory 1986; MacEwen 1987; higher during competition years 5 to 7 (0.92 injury Fong 1994; Pardhan et al. 1995; Leivo et al. 2007). per 1,000 playing hours); however, the authors did However, there are no prospective studies to con- not report whether the differences were statisti- firm this. cally significant. Overuse injuries showed a similar Adolescent badminton players have been shown incidence during the first competition year as com- to have higher bone mineral density and size in pared with competition years 5 to 7 (0.95 vs. 0.75 weight-bearing sites as compared with ice hockey injuries per 1,000 playing hours). players, who are training on a significantly higher level, indicating a great osteogenic potential in bad- Extrinsic Factors minton play (Nordström et al. 1998, 2008).
Since a majority of badminton injuries are localized Further Research in the lower extremities, court surfaces and foot- wear are potentially of high importance. Although The true incidences of injuries related to age, playing several authors have discussed these factors (Mills level, amount and intensity of badminton activity, 56 chapter 4 and other risk factors is largely unknown and training for a mean of 5.2 hours per week and play- requires large-scale, long-term prospective studies ing matches 2.9 hours per week, as compared with and the development of appropriate definitions of the Hong Kong sample, in which both training time reportable injuries to uncover them. The BWF recom- (17.4–19.1 hours per week) and match time (1.8–4.3 mends injury registrations during major badminton hours per week) were higher. events. A registration form has been developed, in In addition, because research indicates that the which all injuries that cause medical contacts dur- majority of acute Achilles tendon ruptures occur ing a badminton competition are registered, but this toward the end of playing sessions, it has been form has not been used systematically to date. This suggested that fatigue and poor muscle coordina- kind of registration is well positioned to gather com- tion may be associated with a risk of tendon rup- prehensive data, on all levels of competition, to create ture (Kaalund et al. 1989; Fahlström et al. 1998b). a basis for research on injury patterns in badminton. However, methodologically sound research is Existing research has provided promising direc- needed to investigate this contention. tions for study. For example, the Danish study by Previous injury and inadequate rehabilitation Jørgensen and Winge (1987) indicated a higher have also been implicated as risk factors, with 9% injury incidence in recreational players (3.1 injuries to 26% of injured players reporting previous pain, per 1,000 playing hours) as compared with elite symptoms or injuries related to the subsequent players (2.8 injuries per 1,000 hours) but no sta- injury location (Kaalund et al. 1989; Høy et al. 1994; tistical comparisons were presented, and Krøner Fahlström et al. 1998a,b). Yung et al. (2007) found et al. (1990) reported a shorter warm-up time for 51% of the injuries in competitive players to be older players as compared with younger play- recurrent, with the frequency in elite senior ath- ers, although the relationship between warming letes being 62%, in elite junior athletes 32% and in up and stretching habits and injury has yet to be potential athletes 20%, yet no studies have been fully explored (Kaalund et al. 1989; Høy et al. 1994; conducted to examine this relationship. Fahlström et al. 1998a,b; Kluger et al. 1999). The badminton scoring system has been changed Poor muscle strength has been suggested to twice since 2001, which has led to more critical influence injury incidence. Couppé et al. (2006) points as well as shorter games and matches. It is found that female senior elite badminton play- not known whether these changes have influenced ers had weaker external rotation strength in the injury patterns. shoulder as compared with junior female players. There are few data and no specific studies on This could affect the incidence of shoulder injuries, injury prevention in badminton. As noted previ- since shoulder muscle imbalance of the external ously, because many injuries are recurrent or pre- rotator cuff muscles versus the internal rotator cuff ceded by local symptoms (Kaalund et al. 1989; muscles is suggested to be a primary risk factor for Høy et al. 1994; Fahlström et al. 1998a,b; Yung et al. glenohumeral-joint injuries in sports with overhead 2007), strength-training programs and adequate activity (Niederbracht et al. 2008). These data need rehabilitation of ongoing injuries are considered to be verified in epidemiologic studies of shoulder important measures to prevent injury. However, injury in badminton. there are no prospective studies to confirm this. Fatigue is also proposed to be a risk factor for In summary, there is a lack of knowledge about badminton injuries. The overall injury incidence badminton-specific risk factors, prevention, and in elite players reported by Jørgensen and Winge rehabilitation. Systematic research in these areas is (1987) was relatively low (2.8 injuries per 1,000 most appropriate for the development of badmin- hours) as compared with a study of elite players ton in the future and should be supported by the in Hong Kong, where the overall injury incidence BWF, even though prospective scientific studies in was 5.0 injuries per 1,000 hours (Yung et al. 2007). collaboration with coaches and badminton teams However, the total badminton-playing time in the may be best managed on a continental or national Danish study was relatively low, with elite players basis. badminton 57
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Baseball
GLENN S. FLEISIG, CHRISTOPHER S. MCMICHAEL AND JAMES R. ANDREWS American Sports Medicine Institute, Birmingham, Alabama, USA
Introduction rate of injury. However, because of the sheer num- bers of athletes participating, the number of injuries Millions of people worldwide participate in the in baseball is substantial, and prevention of these sport of baseball. In the United States alone, there are injuries should have the utmost priority (Lyman & approximately 2,850 professional players (including Fleisig 2005, Pasternack et al. 1996). both major and minor leaguers), 45,000 intercollegi- The purpose of this chapter is to comprehen- ate players, 433,684 high-school players, and nearly sively review the epidemiology of both overuse 2 million youth players (Seefeldt et al. 1993). and acute injuries in the sport of baseball. Baseball’s history as a medal sport in the Olympics Many previously published studies on base- has been brief, but its history as an Olympic exhibi- ball injuries suffer from methodologic problems, tion/demonstration sport dates back over 100 years. described by Walter and Hart (1990), which restrict The sport made its unofficial debut during the 1904 the potential to interpret and compare findings. Summer Olympics. In the years since, it has been a These include the following: recall bias, study- part of 12 additional Olympiads (as both an exhibi- population diversity, underestimation of injury, tion and a medal sport) allowing 17 different nations and lack of a uniform injury definition. In addition, to make appearances. Baseball was granted status injury rates are rarely calculated using the same rate as a full medal sport by the International Olympic denominator. Many studies calculate injury rates Committee for the 1992 Barcelona games. Since based on exposure, rather than on participation, then it has been a part of every Olympic Games. In disregarding the fact that exposure may differ for 2005, baseball and softball were voted out of the 2012 each participant. A majority of the studies on base- Summer Olympics in London, England, making ball-related injuries were retrospective case or case them the first sports eliminated from the games since series and few used a cross-sectional or prospective polo was removed from the 1936 games in Berlin, design. This chapter will focus solely on retrospec- Germany. The format of the sport during the games tive and prospective cohort studies. has changed very little. The only major change that has occurred was in 2000, when athletes were no longer required to be of amateur status, as previous Who Is Affected by Injury? games had required (Olympic Movement 2007). Baseball is characterized as a noncontact sport, and A comparison of injury rates reported in prospec- historically, it has not been considered to have a high tive and retrospective injury studies, among vary- ing levels of competition, are shown in Table 5.1. A majority of the reported rates, particularly those involving youth and high-school athletes, are Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 reported per 100 athletes and do not account for Blackwell Publishing, ISBN: 9781405173643 differences in exposure. However, comparison of 59 60 chapter 5 a 0.74 Injuries per 1,000 Population Injuries per 1,000 AE 0.17 0.18 2.9 Injuries per 100 Athletes 3 1.22 76 29 1.47 1381 9.5 2.8 810 5.4 21 15.0 19.4 No. of Injuries 15,444 2.0 117 4,233 0.062 46 861 13.2 133 c Require missing practice or Require game visit, hospitalization, or death in game or practice Require medical treatmentRequire first aid, medical Require attention, or insurance report 2missed time or position restriction 0.27 Require withholding athlete Require competition from to not returning Require immediate play seek medical atten- Require tion and/or miss one or more games Injury Definition and insurance claim—LL insurance partici- from removal Require pation, first aid, or an injury for which the coach was onto the field of play brought insurance missing practice or Require game Require stop participation Require day of onset or sub- through attention stantial professional 2,167 Injury Surveillance NATA Participants 771,810 medical attention Require 6,744,240 insurance claim—LL Require — system records records system R Survey 256 P ER records 64,075 room emergency Required R Insurance R Survey 1,969 participation altered Require PRP Survey Survey Survey 740 137 2,861 or medical care Require R Surveillance PP SurveyP Survey 148 P Survey 68 Surveillance 108 R Insurance Design Data Source Total P Survey 534 P Survey 249 b 2 1 1 2 2 3 3 Duration, in yr 2 2 Martin et al. (1987) Lowe et al. (1987) 2 Zaricznyj et al. (1980) Pasternack et al. (1996) Cheng et al. (2000) 2 McLain & Reynolds (1989) DuRant et al. (1992) Powell & Barber- Foss (2000) Youth Hale (1961) 5 Marshall et al. (2003) Grana (1979) 2 Table 5.1 Table Comparison of injury rates in baseball. Study Radelet et al. (2002) Chambers (1979) 1 High School Garrick & Requa (1978) College Whiteside (1980) 2 baseball 61 ’s 3.2 2.8 3.37 5.83 5.78 1.85 c e f prospective; R ϭ retrospective. ϭ prospective; om an external cause during sports). e that occurs, even though the athlete does National Collegiate Athletic Association ϭ — 277 5.83 1,049 54.5 4,453 games 3,893 practices 245,000 339,000 —63 9.2 71 ’s participation for observation. he current game or practice and prevents the player game or practice and prevents he current required medical attention by a team-certified athletic required e calendar days beyond the day of injury. d h i NHIS Require missing at least one Require game or practice participation altered Require in game or practice Require missing one or more missing one or more Require days or games medical attentionRequire 16 1.04 NCAA ISS NCAA NHAMCS Require miss 1 wk of Require participation injury evaluated by Require trainer National Athletic Training Association ; NCAA ISS Association ; NCAA Athletic Training National ϭ TA TA e f population — 93 — population 1,728 — 1,536 ganized intercollegiate practice or competition and (2) ganized intercollegiate ’s customary participation on the day after onset, (3) any fractur , and (5) any mild brain injury that requires cessation of a player , and (5) any mild brain injury that requires Ambulatory Medical Care Survey; NHIS ϭ National Health Interview P Ambulatory Medical Care Assuming a 24-man roster on each team, we calculated a new injury rate as 1.04 per 100 players. Assuming a 24-man roster system system reports system system R NHIS U.S. P Surveillance P Surveillance R R ED records U.S. P Surveillance R logs Trainers’ 88 3 1 12 P End-of-season 3 3 emergency ϭ emergency Little League Baseball; NA room; ϭ LL g The NCAA ISS defined injury as: (1) a result of participation in an or ISS defined injury as: (1) a result The NCAA NHAMCS defined injury as any visit to the emergency department in which a record of cause of injury, injury diagnosis, or any reason for visiting which injury was indicated. reason injury diagnosis, or any of cause injury, department in which a record NHAMCS defined injury as any visit to the emergency Includes data related to softball injuries. Includes data related Followed one high-school baseball tournament. Per 1,000 adolescents 10 to 19 years of age. Original rate was reported as 1.79 per 10 games. Assuming a 24-man roster on each team, we calculated a new injury rate as 54.5 per 100 players. Assuming a 24-man roster as 1.79 per 10 games. Original rate was reported The NATA Injury Surveillance system defines a reportable injury as: (1) any that causes cessation of participation in t Injury Surveillance system defines a reportable The NATA Original rate was reported as 29 per 1,000 player matches. Original rate was reported NHIS includes all medically attended sports-related injury episodes (any traumatic event during the past 3 months that caused an fr NHIS includes all medically attended sports-related McFarland & (1998) Wasik Dick et al. (2007) 16 P Surveillance Professional/ Olympic Chambless et al. (2000) Conn et al. (2003) 2 Clarke & Buckley (1980) Junge et al. (2006) 1 Mixed Burt & Overpeck (2000) athletic event; ER AE ϭ a b c d e f g h i Splain & Rolnick (1984) Duda (1987) 1 Injury Surveillance System; NHAMCS ϭ National Hospital return to that session, (2) any injury causes cessation of a player return scheduled session, (4) any dental injury not miss any regularly trainer or physician and (3) resulted in restriction of the student-athlete’s participation or performance for 1 mor in restriction trainer or physician and (3) resulted 62 chapter 5 these rates is difficult because of extreme differ- Compared with injuries in youth baseball, these ences in injury definitions. findings are very similar, using comparable meth- ods, to rates found by Radelet et al. (2002). Two Youth Baseball retrospective studies found injury rates of 1.2 to 1.47 For this review, youth baseball was categorized as per 100 athletes (Grana 1979; Lowe et al. 1987), and pre–high-school recreational league play. The first several prospective studies found rates from 5.4 (in known epidemiologic study of baseball injuries in a single tournament) to 19.4 per 100 athletes (Martin children was completed by Hale in 1961. The study et al. 1987; McLain and Reynolds 1989; DuRant was a retrospective review of insurance claims (spe- et al. 1992). Perhaps the best estimate of the true cifically, only claims filed through the Little League incidence of baseball injuries in high-school athletes Baseball insurance system) over a 5-year period and followed 2,167 high school players prospectively for reported an injury rate of 2.0 injuries per 100 partici- three seasons. Data were collected on any traumatic pants (Hale 1961). This rate is most likely an under- event that caused an injury requiring treatment and estimate of the true injury rate because it includes an injury rate of 13.2 per 100 athletes was calculated only injuries in which an insurance claim was filed (Powell and Barber-Foss 2000). with Little League Baseball. Many more youth were Prospective follow-up studies on high-school у likely injured without seeking medical care or sought players have found injury rates of 9 per 100 ath- care through additional insurance systems and were letes, while retrospective studies have found rates Ͻ not included in this study (Lyman & Fleisig 2005). 2 per 100 athletes. The large disparity between Smaller studies demonstrate a wide disparity of retrospective and prospective studies on high- injury rates in youth baseball ranging from 0.062 school baseball injuries suggests that a universally per 100 athletes to 9.5 per 100 athletes (Chambers accepted definition of injury must be identified. It 1979; Zaricznyj et al. 1980; Pasternack et al.1996; is also likely that retrospective studies are limited Marshall et al. 2003). The defining characteristics of by recall bias (Lyman & Fleisig 2005). an injury in each study can be found in Table 5.1. Cheng et al. (2000) reported 76 baseball-related Collegiate Baseball emergency-room visits in 2000 among adolescents Our literature search revealed five studies on base- during a 2-year study in Washington, DC. This ball-related injuries at the collegiate level. The first, translated to an injury rate of 0.74 per 1,000 adoles- by Clarke and Buckley (1980), examined injuries cents. However, not all DC youths played baseball, reported by the National Athletic Injury/Illness causing this rate to not be directly comparable to Reporting System between 1975 and 1978. They other rates presented here. reported an incidence of 9.2 significant injuries per Radelet et al. (2002) used athlete exposures (AEs), 100 athletes. A “significant injury” in this study rather than a person-based rate denominator, mak- was defined as an injury in which an athlete missed ing the results not directly comparable to the other at least 1 week of participation from that sport studies presented. Regardless, an injury rate of 0.17 (Clarke & Buckley 1980). per 1,000 AEs was found, with an injury defined as By following one collegiate team for 4 years, a player being removed from play, requiring first Splain and Rolnick (1984) found an injury rate of aid, or both, and is likely the most representative 71 per 100 athletes. This rate is much higher than all study of the true injury rate in youth baseball. other reported injury rates. A likely reason is that “injury” was defined as any evaluation done by an High-School Baseball athletic trainer, either on the field or in the train- The first known study of high-school baseball ing room, including very minor injuries (Splain & injuries was published by Garrick and Requa in Rolnick 1984). 1978 and used AE as a rate denominator rather McFarland and Wasik (1998) conducted a than counts of athletes or games. Garrick and 3-year prospective study on a single National Requa showed an injury rate of 0.18 per 1,000 AEs. Collegiate Athletic Association (NCAA) Division baseball 63
I team. The injury rate reported in this study was Injuries to Pitchers 5.83 per 1,000 AEs. In addition, through the NCAA The repetition of the high forces and torques in the Injury Surveillance System, Dick et al. (2007) shoulder and elbow experienced by pitchers can reported an injury rate during collegiate baseball eventually result in serious injury or arm-related games of 5.78 and during practices of 1.85 per 1,000 disability (Francis et al. 1978; Dillman et al. 1993; AEs from 1988 through 2004. These two studies Fleisig et al. 1995, 1996; Hutchinson & Ireland are very similar in their reported rates of injuries 2003). Based on our review, studies analyzing inju- in collegiate baseball and represent the most accu- ries to pitchers use self-reported pain or time lost rate estimate of the collegiate baseball injury rate or both as their injury definition. Pitchers have because of their large numbers and length of time the highest probability of injury (Redbook 2003). studied. Several studies have found high rates of pain in Studies of different levels of collegiate players the elbow and shoulder joints, which are thought have revealed higher injury rates, both in games to be a result of overuse (Figure 5.1). Summaries of and practices, at higher levels–in games: Division I, studies involving elbow and shoulder injuries in 6.64 per 1,000 AEs; Division II, 5.36; and Division pitchers can be found in Table 5.2. The first study III, 4.85; in practices: Division I, 2.34; Division II, on pitching-specific injuries compared three groups 1.47; and Division III, 1.59 (Dick et al. 2007).
Professional/Olympic Baseball
Few studies reviewed the epidemiology of injuries in professional baseball. In 2000, Chambless et al. published a 12-year (1985–1997) study on minor league baseball injuries. An “injury” was defined as an event that would cause a player to miss one or more days or games. The study showed an injury rate of 1.79 per 10 games. In addition, Junge et al. (2006) studied the 2004 Olympic Games in Athens, Greece and found an injury rate of 29 per 1000 player games, which translated to 0.5 injury per game. An injury in this study was any event that required medical attention. The paucity of published studies on injuries in professional base- ball may be due to the fact that the business aspect of professional sports often has a negative impact on the reporting of such injury information to the medical community (Oberlander et al. 2000). Chambless et al. (2000) studied injury events that required the athlete to miss one or more days or games, at the minor league level and found sig- nificantly greater injury rates at the minor league rookie level (2.4 per 10 games) than at higher minor league levels (1.62 per 10 games). These findings suggest that the rookie-level players are not condi- tioned enough for the professional level that they are now playing or that the players are now going Figure 5.1 Serious injuries to baseball batters and fielders are rare, but can be catastrophic. Pitchers are far more above and beyond what they are physically capable susceptible to injury, due to overuse and sometimes poor of in order to be successful in professional baseball. mechanics. © IOC / Hamish BLAIR. 64 chapter 5
Table 5.2 Studies of elbow and shoulder injury in pitchers at various levels of play.
Study Design N Age, in yr Affected Joint Frequency Percent Percent with Measure Reporting Changes on Pain Radiographs
Youth Leagues Adams (1965) Retrospective 80 9–14 Elbow Prevalence 45 95 Gugenheim (1976) Retrospective 595 11–12 Elbow Prevalence 18 28 Larson et al. (1976) Retrospective 120 11–12 Elbow Prevalence 18 95 Albright et al. (1978) Prospective 54 11–12 Both Incidence 44 Hang et al. (2004) Prospective 112 11–12 Elbow Incidence 69 65 Lyman et al. (2001) Prospective 298 9–12 Elbow Incidence 26 Shoulder 32 Lyman et al. (2002) Prospective 488 9–14 Elbow Incidence 28 Shoulder 35 Mixed Torg et al. (1972) Retrospective 49 9–18 Elbow Prevalence 29 4 Shoulder 29 High School Grana & Rashkin Prospective 73 15–18 Elbow Incidence 58 56 (1980) Ochi et al. (1994) Retrospective 130 15–18 Elbow Prevalence 38 43 Shoulder 38 Collegiate Albright et al. (1978) Prospective 18 18–23 Both Incidence 61 Professional Slager (1977) Retrospective 149 Major L. Elbow Prevalence 61 Shoulder 57 Conte et al. (2001) Prospective – Major L Elbow % of disabled 22a list days for all players Shoulder 28a a Percent reporting pain in this study is actually the percent of days on the Major League disabled list due to elbow and shoulder injuries
of male children: pitchers, baseball players who used a prospective design in which each pitcher did not pitch, and healthy boys who did not play was interviewed after each game, rather than at baseball (Adams 1965). The defining characteris- the end of a tournament or season. This was done tic of injury in this study was self-reported pain, in an effort to minimize recall bias. Again, pain which was highest in the boys who were pitchers. was used as the defining characteristic of injury, Further studies have found a prevalence of elbow and the study showed self-reported elbow pain of pain in youth and high-school pitchers between more than 25% in youth pitchers and self-reported 18% and 29%, respectively, and an incidence of shoulder pain of more than 30% in youth pitchers pain of 26% in youth and 58% in high-school pitch- (Lyman et al. 2001, 2002). ers. As shown in Table 5.2, shoulder pain has had Very few studies exist that specifically examine the less attention from the scientific community, with injuries of pitchers at elite levels of play. Albright et a prevalence of 29% (Torg et al. 1972) and an inci- al. (1978) studied 18 collegiate and 55 Little League dence of 32% to 35% (Lyman et al. 2001, 2002). pitchers in 1973. They found symptoms related to Perhaps the best estimates available for the true both elbow and shoulder injury (comprised of objec- incidence of youth pitching injuries were comple- tive findings such as swelling and limited range of ted by Lyman et al. in 2001 and 2002. The studies motion) in 61% of the collegiate pitchers and 44% baseball 65
of the Little League pitchers. A 1977 study sent a shoulder. While pain in the elbow or shoulder does questionnaire to every professional baseball player not necessarily represent a medical problem, it does during the 1975 spring training season. Based on cause discomfort and may be an early indicator of a 149 pitchers’ responses, an incidence rate of self- developing overuse injury (Lyman & Fleisig 2005). reported elbow soreness of 61% and self-reported shoulder soreness of 57% were found in professional Lower Extremity pitchers (Slager 1977). Lower-extremity injuries are relatively uncommon in youth baseball players, but become more com- Where Does Injury Occur? mon as age increases and the level of play becomes more competitive (Lyman & Fleisig 2005). Injuries to Anatomical Location the lower extremity ranged from 22.9% to 28.6% of Recognition of commonly injured anatomical sites total injuries for youth baseball players and 37.5% is essential because it alerts sports medicine pro- for high-school players. Similarly, intercollegiate and fessionals to areas in need of special attention. A professional baseball players were generally in the percentage comparison of injury location reported range of 32.0% to 67.3% of total injuries. Ankle and in youth, high-school, collegiate, and professional knee injuries are more frequent at higher ages and baseball players is shown in Table 5.3. A vast major- skill levels as a result of sliding (Janda et al. 1988). ity of injuries in baseball affect either the upper or the lower extremities, with the shoulder being one Head, Face, and Torso of the most injured anatomical locations in baseball. Although they represent a small proportion of the injuries involved in baseball, injuries to the head, Upper Extremity face, and torso often result in some of the most Injuries to the upper extremity are commonplace in severe outcomes seen in baseball. Injuries to these both pitchers and position players (Lyman & Fleisig areas can include fractures, concussions, traumatic 2005). Injuries to the upper extremity can occur as a brain injuries, and sudden death (Marshall et al. result of both overuse and an acute traumatic inci- 2003). Further discussion of traumatic brain injuries dent. However, the injury mechanism of a majority and sudden death (commotio cordis) appears in the of these injuries is overuse. Studies have found that “Catastrophic Injury” section of this chapter. upper-extremity injuries comprise approximately The face and eye are particularly vulnerable and 31.7% to 60.1% of all injuries (Table 5.3.) Between prone to penetration by fast-moving objects, such as 1999 and 2003, 73% of all players placed on the disa- baseballs. In a study by Napier et al. (1996), baseball bled list (DL) in Major League baseball had injuries was found to be the 10th leading cause of consumer classified as wear and tear or as caused by overuse product–related eye injuries in the United States or insufficient rest (Redbook 2003). and the underlying cause of most sports-related eye The best data source for injuries (including those injuries in the United States. Marshall et al. (2003) to the upper extremity) in Major League Baseball is reported a risk of facial injury in youths of 4.1 per the Redbook. It is an analysis of all professional base- 100,000 player-seasons based on insurance claims. ball players and their associated time on the Major It is not surprising that an inordinate number of League Disabled List (DL). Shoulder and elbow inju- baseball injuries involve younger athletes. This is ries account for more than half (53%) of all underly- because of the higher participation rates of children ing causes for Major League Baseball players to be versus adults. Vinger et al. (1999) showed that 45% placed on the disabled list (Redbook 2003; Conte of eye injuries involved youths 5 to 14 years of age. et al. 2001). The incidence of elbow and shoulder It was also observed that a majority of these eye inju- injury in youth baseball athletes is estimated to be 26 ries resulted from direct contact with the ball (Napier to 35 per 100 pitchers per season (Lyman et al. 2001, et al. 1996). Youth baseball teams can expect 2.3 ball 2002). These youth studies have focused primarily and player impacts per game, with 7.3% causing on a definition of injury as “pain” in the elbow or major or extreme discomfort (Seefeldt et al. 1993). 66 chapter 5
Table 5.3 Comparison of injury location and level of play in baseball by percent of occurrence.
Study No. of Head/Spine/Trunk (% of Injuries) Upper Extremity (% of Injuries) Injuries Head Face Neck Back Ribs Stomach Total Shoulder Arm Elbow Forearm Wrist Hand/ Total Finger
Youth Baseball Pasternack 66 4.5 27.2 0 1.5 0 0 32.3 3.0 0 4.5 7.5 0 21.2 36.2 et al. (1996) Zarincznyj 154 38.0 0 0 0 0 0 38.0 0.6 0.6 5.2 3.2 3.2 19.5 32.3 et al. (1980) Cheng et al. 76 37.0 — — 3.0a —— 40.0 ——————32.0 (2000)
High-School Baseball Powell and 861 0 8.9 1.9 5.4a 00 18.1 19.7 0 0 24.6 0 0 44.3 Barber-Foss (2000)
Collegiate Baseball Whiteside 133 8.8 1.0 1.0d 10.8 21.5b 28.0c 49.5 (1980) Clarke and ——————— 2.0 ——————— Buckley (1980) Splain and 63 0 0 0 7.9 0 0 7.9 12.7 6.3 6.3 0 4.8 1.6 31.7 Rolnick (1984) McFarland and 277 4.0 0 3.0 10.0 0 0 17.0 24.0 6.0 12.0 9.0 0 0 51.0 Wasik (1998)
Adult Amateur Baseball Lebrun et al. 33 — 3.0g 3.0 — — — 6.0 — 60.1 — — — — 60.1 (1986)
Professional/Olympic Baseball Garfinkel et al. 382 2.8j 2.1 4.2 0 1.8I 0.8 11.7 13.9 4.7 6.5 3.7 2.9 11.2 42.9 (1981) Chambless 942 7.1 0 0 8.2 2.1 0 17.4 24.0 0 12.6 19.0 0 0 55.6 et al. (2000) Junge et al. 16 0 0 0 0 0 0 0 6.0 25.0 13.0 0 0 13.0 57.0 (2006) Conte et al. % of DL 0 0 0 5.0 0 0 5.0 27.8 0 22.0 0 0 6.1 55.9 (2001) days
DL ϭ disabled list. a Unspecified spine/trunk. b Shoulder and arm combined. c Forearm and hand combined. d Injuries classified under “torso.” e Hip and leg combined.
When Does Injury Occur? et al. 1996). Injuries to fielders, batters, and base runners tend to have acute or traumatic injury Injury Onset mechanisms, or both, typically due to contact with Injuries in baseball fall into two categories: acute/ the ball, the bat, another player, the ground, a base, traumatic injuries and overuse injuries (typically or a fence or wall (Hale 1979). In comparison, pitch- seen in pitchers). In general, injuries are thought ing injuries tend to be the result of cumulative to occur in direct proportion to the intensity of microtrauma because of the repetitive throwing the competition and age of the athletes (Walk motion (Andrews & Fleisig 1998; Yen & Metzl 2000). baseball 67
No. of Lower Extremity Injuries Pelvis/Hips Thigh Knee Leg Ankle Heel/ Foot/Toe Total Achilles
66 1.5 0 13.6 4.5 9.0 0 0 28.6
154 1.2 0 9.0 0.6 9.0 0 3.1 22.9
76 — — —— — — — 26.0
861 14.5 — 10.5 — 12.5 — — 37.5
133 7.8e —16— 16— — 39.8
— 37.0 — 7.0 — — — — 44.0
63 6.4f 14.3 20.6 3.2 14.2 0 1.3 60.3
277 0 13.0 4.0 8.0 4.0 0 3.0 32.0
33 — — 6.1 9.1h —— —15.2
382 3.7 6.8 12.0 6.8 2.4 2.9 7.6 42.2
942 14.0 0 8.5 3.1 12.6 0 0 38.2
16 6.0 6.0 0 19.0 6.0 0 6.0 43.0
% of DL days 0 0 7.3 0 0 0 0 67.3
f Groin injuries (4.8%) included. g Neck and back combined. h Leg and ankle combined. i Refers to chest injuries. j Unspecified head (1.0%), ear (1.0%), and throat (0.8%) injuries combined.
Injury rates have been reported to be four times as opposed to 46% during practice. McFarland and higher during games than during practice for Wasik (1998) also reported the injury rate during youth players (Radelet et al. 2002) and three times preseason practice was twice as high as during higher during games than during practice in minor the regular season (2.97 and 1.58 per 1,000 AEs, league players (5.78 and 1.85 per 1,000 athlete respectively). This is most likely due to the high exposures, respectively) (Chambless et al. 2000). intensity of preseason practice and lack of physi- Of 277 orthopedic problems observed by McFarland cal conditioning that has accumulated during the and Wasik (1998), 54% occurred during game play off-season. Table 5.4 Comparison of injury types in baseball by percent of total injuries.
No. of No. of Level Subjects Injuries Abrasions Concussions Fractures Inflamations Laceration Strain Nonspecific Other 1 Other 2 Other 3 Sprain
Youth Hale (1961) 771,810 15,444 52.0a 3.0 19.0 10.0 3.0b 13.0 Heald (1991) 5,000,000 96,000 43.0a 2.0 19.0 10.0 5.0b 3.0c 18.0d Cheng at al. — 76 20.0 24.0f 17.0 32.0d 7.0g (2000)e High School Lowe et al. 256 3 33.3 33.3 33.3 (1987) Powell & 2,167 861 8.8 31.2 0.3 1.7h 30.7i 6.6j 20.6 Barber-Foss (2000) Collegiate Clarke & —— 10.0k 28.0 1.0h 5.0l 19.0c 37.0 Buckley (1980) Whiteside 133 3.4 26.1 6.7h 29.4i 34.5 (1980) Professional Garfinkel et al. — 382 16.7 0.5 0.5 11.6m 2.8 17.8 42.2a 0.5m 0.6o 0.4p 5.5 (1981) Martin et al. 148 8 25.0 37.5 12.5 12.5h 12.5 (1987) Junge et al. — 16 57.0q 19.0 19.0 19.0 (2006) a Includes contusions. b Dental injuries. c Other unspecified injuries. d Includes sprains. e Includes softball data. f Includes dislocations. g Intracranial injuries. h Neurotrauma. i General trauma. j Musculoskeletal injuries. k Combines dental fractures with other types of fractures. l Chronic orthopedic. m Combines blisters (4.9), epicondylitis/tendinitis (4.1), rotator cuff tendinitis (1.6), bursitis (0.2), myositis (0.2), myositis ossificans (0.2), synovitis (0.2), and paronychia (0.2). n Foreign body. o Combines effusion (0.2), fascial hernia (0.2), and thigh atrophy (0.2). p Combines nail avulsion and corns. q Includes contusions and lacerations. baseball 69
What Is the Outcome? Sometimes, players miss time, but are not put on the disabled list. During the 2002 and 2003 seasons, Injury Type players in this category included 410 players and 2495 missed days. These missed days ranged from Information from studies reporting distribution of a low of 23 days to a high of 163 (Redbook 2003). injuries by injury type is summarized in Table 5.4. Studies have reported that 25% of collegiate A majority of baseball-related injuries for levels baseball injuries result in the loss of р10 days (Dick from youth to professionals are not severe. et al. 2007). Similarly, after following a baseball Abrasions, followed by fractures, sprains/strains, team for three seasons, McFarland and Wasik and lacerations are the most common injury types (1998) found that injured players usually missed (Walk et al. 1996). The incidence of injuries, by Ͻ1 week or Ͼ21 days. type, provides a clear pattern of occurrences for Time lost from practice or games has been evalu- athletes at the youth, high-school, collegiate, and ated in only two studies of high school and youth professional levels. baseball. However, as compared with higher levels of play, similar results were found when studying Time Loss youth players. In 1978, Garrick and Requa found A commonly used measure of injury severity is the that 27% of those injured in youth baseball missed duration of time an injured athlete is kept from par- at least 5 days of practice or games. Powell and ticipating in their sport. Not all injuries in baseball Barber-Foss (1999) reported on the median time result in time loss. Those that do, however, can keep lost due to mild traumatic brain injury in youth an athlete out from just a few days to several months. baseball players. They found the median time A study of the 2004 Greece Olympic Games found missed was 3 days and no time loss was more than that 44% of injuries resulted in time loss (Junge et 3 weeks. Time lost to injuries requires further study, al. 2006). Garfinkel et al. (1981) reported that 94% of especially in conjunction with the specific type of professional athletes suffered injuries that prevented injury at specific levels of play (Walk et al. 1996). their participation for Ͻ8 days, 5% missed 8 to 28 days of activity, and 1% did not participate in activ- Clinical Outcome ity for Ͼ28 days. In Major League Baseball, there were an average of 371 players with 443 injuries per Studies of long-term clinical outcomes for baseball- year between 1999 and 2003, which resulted in a related injuries are severely lacking. Francis et al. total of 24,463 disability days during this 5-year span (1978) reported that 15% of 398 college students who (Redbook 2003). In addition, each Major League pitched as youth pitchers felt that their ability to team averaged 12 players on the DL, for a total of throw in college was hindered by pain, tenderness, 815 days, per season. During the same 5-year period, or limitation of movement as a result of their youth the average number of days spent on the DL per pitching. This study suggests that a potential for dis- injury was 66, an increase of 24% from the previous ability exists that is associated with youth baseball 5-year period (Redbook 2003). Approximately one pitching and continues into adulthood. No similar third of all injured players on the DL miss Յ30 days, study of the long-term effects of baseball partici- one third miss 31 to 90 days, and one third miss Ͼ91 pation has been conducted. In 1999, the American days. In addition, Chambless et al. (2000) reported Sports Medicine Institute began a 10-year prospec- that higher-level professional athletes (AAA, AA, A) tive study attempting to identify long-term effects of were out 1 to 3 days, while rookies were out 4 to 20 baseball pitching on youth pitchers. Each of the 476 days per injury. These results suggest that athletes youth pitchers in the study were identified and con- playing professional baseball for the first time are tacted every year. Four-year preliminary findings not in the best physical shape at the beginning of showed no significant relationship between number their careers and perform above their physical capa- of innings pitched, position played, types of pitches, bilities to be successful at the professional level. years pitched, and whether the athlete missed any 70 chapter 5 games and whether the athlete reported chronic Economic Cost arm pain (Childress 2003). However, analysis of the Lost wages and lost profit are seen only in pro- entire 10-year follow up will be needed in order to fessional baseball and do not apply to youth, make any final conclusions. high-school, or college players. According to the Redbook (2003), from 1999 through 2003, Major Catastrophic Injury League Baseball teams paid $1.4 billion to play- ers on the DL, which is more than double that of Although rare, catastrophic injuries in baseball the preceding 5-year period ($585 million from need to be identified and studied. A catastrophic 1994 through 1998). It was also determined that injury was defined as a “sport injury that resulted $11.9 million were lost per team to players being in a brain or spinal cord injury or skull or spinal on the DL in 2003. More than half of all DL days fracture” and a direct injury as an one that “resulted (59%) and dollars (57%) lost were due to injuries directly from participation in the skills of the resulting in surgery. For injuries requiring surgery, sport” (Mueller 2007). A study by Nicholls et al. a Major League team can expect a player to miss an (2004) noted that softball and baseball are respon- average of 105 days and cost his team $1.3 million sible for the highest sporting fatality rate among in lost wages (Redbook 2003). 5-to-14-year-olds in the United States–88 deaths from 1973 through 1995. The most common cause of fatality as a result What Are the Risk Factors? of playing baseball is commotio cordis (Lyman & Fleisig 2005). In clinical terms, commotio cordis is An important aspect in the epidemiology of base- cardiac arrest as a result of a blunt, nonpenetrating, ball injuries is the identification of factors that and usually innocent-appearing chest blow (Maron increase one’s risk of being injured. However, infor- et al. 2002). Maron et al.’s 2002 study found that 53 mation on these risk factors is relatively limited. of 128 commotio cordis events, entered into the U.S. Intrinsic risk factors are those associated with indi- Commotio Cordis Registry, were caused by chest viduals’ biologic and psychosocial characteristics blows from baseballs. Baseball has the lowest risk that predispose a baseball player to injury. Extrinsic of traumatic brain injuries in high-school athletes, factors are outside influences that have an impact 0.05 traumatic brain injury per 1,000 athlete expo- on the athlete while engaging in their sport – sures (Powell and Barber-Foss 1999). Spinal and for example, the equipment used and the playing severe head injuries have also been noted, but are environment. Our review of the literature revealed much less common than in contact sports such as a definite paucity of research on risk factors in football and hockey (Powell and Barber-Foss 1999). baseball athletes. The number of baseball-related fatalities is lower for high-school and college players than for youth Intrinsic Factors players. The National Center for Catastrophic Sport Nonpitcher Injury Research reports that between the fall of 1982 and the fall of 2006 there were nine reported Intrinsic risk factors for nonpitchers are very similar fatalities among high-school baseball players and to those for pitchers, but have not been researched three among collegiate baseball players (Mueller as extensively. Level of play is probably the most 2007). significant risk factor yet to be identified. As an Boden et al. (2004) studied the same National athlete progresses to higher levels of play the risk Center for Catastrophic Sport Injury Research data of injury increases. Bigger, stronger, and more and calculated a total direct catastrophic injury rate aggressive players tend to throw faster, hit harder, of 1.7 per 100,000 collegiate baseball players and a and run faster, which all lead to increases in the fatality rate of 0.86 per 100,000 collegiate baseball number of injuries (Lyman & Fleisig 2005). Higher- players. level athletes have a higher risk of injuring their baseball 71
lower extremities, mainly because poor mechanics Albright et al. (1978) found that pitchers who increase the risk of injury when sliding (Janda et al. threw with a sidearm motion were more likely to 1988). show symptoms of injury (presence and severity of pain, swelling, and decreased range of motion) Pitcher than those pitchers who did not throw sidearm. Physical characteristics Self-Satisfaction Perhaps the most persuasive evidence regarding the Psychology plays an important role in the self- association of injuries to intrinsic factors is related report of injury in pitchers and should be exam- to physical characteristics of the pitcher. Younger ined more closely, particularly in the youth athlete players are more likely to suffer from injuries to the (Lyman & Fleisig 2005). Lyman et al. (2001) asked upper extremities and from being hit by pitched pitchers to rate their performance in each game balls while batting (Hale 1979; Grana & Rashkin pitched. Results showed that the level of self- 1980). In addition, younger baseball athletes expe- satisfaction was inversely related to the claim of rience pain associated with the epiphyseal areas, experiencing arm pain. It is unknown whether this while older players experience injuries associated represented using pain as an excuse or as a reason with overuse that leads to ligament and tendon for performance (Lyman et al. 2001). tears (Walk et al. 1996). Lyman et al. (2001) observed 9-to-12-year-olds and found that the risk of elbow Extrinsic Factors pain was 2.9-fold greater among у12-year-old pitch- ers as compared with those Ͻ10 years of age. Elbow Nonpitcher pain was also increased 4.1-fold among pitchers 86 Extrinsic factors associated with baseball injuries to 100 lb and 5.4-fold among pitchers over 100 lb as vary greatly based on the position played by the compared with those Ͻ71 pounds. These findings athlete. Factors associated with injuries to non- are likely due to additional secondary ossification pitchers or position players are primarily attributed centers in the youth elbow (Lyman & Fleisig 2005). to the surrounding environment, including rigidity In comparison, greater height was associated with of the bases and protective equipment used while a decreased risk of elbow pain, with pitchers у61 batting, fielding, and base running. in. having a 65% decreased risk of elbow pain as compared with those Ͻ55 in., possibly indicating skeletal maturity with fusion of the secondary ossi- Fixed Bases fication centers. Age was not significantly associated One risk factor that affects players while running with a decreased risk of shoulder pain. In contrast the bases and sliding are the use of fixed bases. у to elbow pain, height 61 in. was associated with a Fixed bases have been found to cause contusions, 3.6-fold increased risk of shoulder pain as compared fractures, sprains, and ligamentous injuries to the Ͻ with pitchers 55 in. (Lyman et al. 2001). hands, feet, and knees (Janda et al. 1988). Most studies published on base running or sliding inju- Pitching Motion ries attempt to prove that breakaway bases are a Biomechanical research at the American Sports safer alternative to fixed, more rigid bases, rather Medicine Institute has found that improper pitch- than simply describing the incidence/prevalence ing mechanics leads to increased kinetics (i.e., forces of associated injuries. These studies may have and torques) which is thought to be an implication focused on breakaway bases as a safer alternative for injury (Fleisig et al. 1989; Dillman et al. 1993; because, while poor musculoskeletal conditioning, Fleisig 1994; Fleisig et al. 1995, 1996). However, poor technique, and late decisions to slide may be the relationship between mechanics and injury has risk factors for sliding and base-running injuries not yet been fully established, and no studies exist (Janda et al. 2001), it is much more difficult to alter identifying mechanics as a risk factor for injury. the behaviors of a player than to simply modify 72 chapter 5 his or her environment (Lyman & Fleisig 2005). cumulative pitch counts were those who stopped A simple environmental change, using breaka- pitching, or who reduced their pitching load to way bases, has proven to be an effective injury- avoid shoulder pain (Lyman & Fleisig 2005). prevention tool, and will be discussed further in the “Injury Prevention” section of this chapter. Pitch Type It is hypothesized that the use of the curveball by young pitchers causes increases in the forces and Pitchers torques of the pitching elbow and shoulder, thereby Extrinsic risk factors associated with pitching inju- increasing the risk of injury in this age group. ries primarily revolve around pitch counts and Olsen et al. (2006) found that compared to healthy types of pitches thrown by the athlete. pitchers, youth pitchers who had elbow or shoul- der surgery did not throw significantly more cur- Pitch Counts veballs, nor did they start throwing the curveball Two prospective longitudinal studies looked at the earlier in life. However, Lyman et al. (2002) found number of pitches thrown per game and during an 86% increased risk of elbow pain with throwing the season among adolescent pitchers (Lyman et al. sliders and a 52% increased risk of shoulder pain 2001, 2002). The first found no significant associa- with throwing curveballs as compared with fast- Ͻ tions between pitches thrown during a game and balls (P 0.05). Biomechanical research supports self-reported elbow pain. However, as game pitches the findings that breaking pitches put the athlete at increased, a highly significant dose–response rela- no more risk than fastballs (Dun et al. 2008). tionship was found for self-reported shoulder pain, with a 2.5-fold increased risk of shoulder pain asso- Other Risk Factors ciated with у75 pitches per game (Lyman et al. Lyman et al. (2001) identified additional risk factors 2001). The second study using the same methods in youth baseball pitchers. Weightlifting was asso- with a larger sample size, broader age range (9–14 ciated with a nearly 2-fold increased risk of elbow years), and athletes from a larger geographic area pain. The type and frequency of the youth play- found a similar association with increasing number ers’ workouts were unknown; therefore, it is not a of game pitches and risk of both elbow and shoul- sound conclusion that weightlifting is detrimental der pain (Lyman et al. 2002). to pitchers. Playing baseball outside of an organized In comparison, the relationship between the total league was associated with a 2.3-fold increased risk number of pitches thrown in a season (cumulative of elbow pain. This obviously increases a pitcher’s pitches) and risk of elbow and shoulder pain var- pitch count beyond those recorded in the study, lead- ied by study. Lyman et al., in the 2001 study, noted ing to further overuse (Lyman et al. 2002). Pitching a 53% decreased risk of elbow injury associated while fatigued was the most influential factor in with 300 to 599 pitches and a 3.4-fold increased risk pitching injuries. Lyman et al. (2001) and Olsen et al. of elbow injuries associated with у600 pitches as (2006) found that pitchers who continually pitched compared with Ͻ300 pitches. Pitchers in this study while fatigued (recorded as self-reported fatigue also had a decreased risk of shoulder injury with an while pitching) were at a 6 and 36 times increased increased cumulative number of pitches. This con- risk of being injured, respectively, as compared with trasts with an increased risk of elbow injury asso- those who did not pitch while fatigued. ciated with Ͼ200 cumulative pitches as compared with р200 pitches among pitchers in the Lyman What Are the Inciting Events? et al. 2002 study. Pitchers who threw a greater number of pitches were also found to have a Pitching Injuries decreased risk of shoulder pain (Lyman et al. 2001). The decreased risk of shoulder pain may be due Pitchers have the highest probability of injury as to survivorship, in which pitchers who had low compared with the other players (Redbook 2003). baseball 73
This increased risk is due to the repetitive pitching outfielders, 9.8%; runner, 21.7%; batters, 23.8%; and motion, causing cumulative microtrauma to the miscellaneous injuries, 1.1%. The issue of studying elbow and shoulder (Lyman & Fleisig 2005). In injuries in baseball by position has received little particular, youth pitchers are at the greatest risk attention and clearly is a topic for future research. of injury because of their immature skeletons. The cumulative trauma that began at a young age is Injury Prevention often the underlying cause of the severe pitching injuries seen in high-school, college, and profes- Nearly all injury-prevention studies are of the youth sional pitchers (Lyman & Fleisig 2005). and high-school level. Perhaps this is an effort to instill safe play practices at a young age that can be Batting Injuries maintained by athletes as they mature and advance in their baseball careers. Our review of the litera- Our review of the literature revealed no epide- ture revealed a great paucity of injury-prevention miologic studies focused on batting-related inju- studies in baseball. The few studies that have been ries. Danis et al. (2000) examined the rate of youth completed have examined injury-prevention tools batting injuries, but restricted the data to only for baseball players including, equipment and facial injury and the effect of players wearing face behavioral changes. As previously mentioned it is shields. In an effort to describe background inci- much easier to modify one’s environment rather dence, the study found that 5.3 per 100 athletes than a behavior; hence, a majority of injury preven- reported facial injury while batting. tion is done through equipment. Base-Running Equipment Base runners experience injury due to several mech- anisms: they are hit with balls both thrown in the Face Guards/Face Shields field and hit from the batter, they experience muscu- Although batting helmets have been mandatory in lar injuries while running, and they sustain contact Major League Baseball since the 1957–1958 season injuries while sliding. Hosey and Puffer (2000) exam- (Light 1996; Morris 2006; Major League 2007), they ined three NCAA Division I teams and found that have not been rigorously tested for their effective- collegiate players experience 6.01 injuries per 1,000 ness. A somewhat new and effective addition to slides. Feet-first slides (7.31 per 1,000 slides), dive batting helmets is face guards. Research has found backs (5.75 per 1,000 slides), and headfirst slides that the use of face guards while batting reduces (3.53 per 1,000 slides) are the three main sliding the risk of eye and facial injuries (Lyman & Fleisig mechanics and determine which anatomical loca- 2005). In a nonrandomized study of facial injuries tions are injured (Hosey & Puffer 2000). The major- in youth leagues, Marshall et al. (2003) found a ity of research on sliding injuries has focused on the 35% reduced risk of facial injury in leagues using comparison of breakaway bases versus traditional face shields as compared with those not using bases, which will be covered later in the chapter. the shields. The argument against the use of face shields in higher levels of baseball is that the ability Fielding to see high-velocity pitches and breaking pitches No studies on fielding injuries were available for effectively can be compromised. The use of face review. However, it is believed that these injuries guards decreases with an increase in level of com- occur because of contact with the ball, the ground, petition (Marshall et al. 2003) and should be an area another fielder, or a fence or wall (Hale 1979). of future improvement in baseball injury preven- Garfinkel et al. (1981) found an injury distribution tion. However, using protective equipment alone among professional baseball players as follows: may not be the answer to injury prevention, as the pitcher, 14.6%; catcher, 13.3%; first base, 1.8%; sec- proportion of injuries prevented would be less than ond base, 7.6%; third base, 3.4%; shortstop, 2.6%; 32% (Kyle 1996). 74 chapter 5
Safety Baseballs Our review of the literature found studies using a variety of definitions of “injury.” These definitions By reducing the hardness of the baseball, researchers ranged from self-reported pain, to injuries requiring hope to lower the frequency of contusions, fracture, missed games or practice, to injuries requiring sur- and most importantly, commotio cordis (Yamamoto gery, to emergency department visits, to insurance et al. 2001; Marshall et al. 2003). Laboratory stud- claims. Each one of these definitions encompasses a ies have shown that baseballs with a lower mass completely different collection of data, making them and less stiffness have a reduced potential for injury impossible to compare with each other. Therefore, a (Vinger et al. 1999; Yamamoto et al. 2001). In a non- clear and consistent definition of injury is needed to randomized study, Marshall et al. (2003) found that improve and better understand baseball injuries and safety baseballs exhibited an overall decreased risk their underlying characteristics. Perhaps time missed of injury of 23% as compared with regular hard from games and/or practice would be the best meas- baseballs. ure of injury for both pitchers and nonpitchers. Because of the deformity characteristics, softer Furthermore, “exposure” was found to be defined balls may penetrate the eye socket more deeply, in a variety of ways, from counting players, to causing more severe eye injuries. Therefore, the soft- counting games or practices, to counting pitches. est baseballs should be used only in very young ath- Most current sports injury surveillance systems use letes, for whom the speed of a pitched, thrown, or a measure of athlete exposures. This definition of batted ball is markedly slower (Vinger et al. 1999). exposure is best, and allows for future studies to be easily compared with previous studies. However, Breakaway Bases athlete-exposures work well for nonpitchers, but Improper technique may be the strongest risk not for pitchers. Starting pitchers and relief pitch- factor for sliding injuries; however, altering an ers have dramatically different levels of exposure athlete’s behavior is difficult. A simple and inex- throughout a game or season. Therefore, the number pensive solution is the use of breakaway bases. of innings pitched, batters faced, or pitches thrown Studies have shown that the utilization of breaka- would be the best measure of exposure for pitchers way bases has the potential to prevent up to 96% of (Lyman et al. 2005). sliding injuries, minimizing the occurrence of frac- Because of the paucity of risk-factor studies, par- tures, sprains, and strains (Janda et al. 1988). Sendre ticularly among elite baseball athletes, additional et al. (1994) studied breakaway bases and showed factors should be studied including muscle strength, the injury rate, in a nonrandomized study, among flexibility, ball hardness, and training regimens. college, high-school, and youth baseball and soft- The effectiveness of protective equipment such as ball players was 0.03 per 1,000 AEs, as compared face guards, safety baseballs, and breakaways bases with 1.0 per 1,000 AEs with standard stationary has been proven in numerous studies. Further bases. Similarly, injury rates using breakaway bases research should focus on redesigning this equip- in the NCAA was 0.41 per 100 games, as compared ment to make it more player-friendly to increase with 2.01 per 100 games for fixed bases (Dick et al. its widespread use and acceptability by players, 2007). The possibility of injury prevention by using coaches, and fans, while still providing protection breakaway bases is indisputable, and these should to the athlete. The effectiveness of several other be used at all levels of play (Sendre et al. 1994). types of protective equipment has not been proven. The development of the modern-day double-ear- flap batting helmet by Creighton Hale, Ph.D., has Further Research not been studied for its effectiveness in the preven- Currently the definition of both “injury” and tion of head injuries. Lightweight baseballs have “exposure” are the largest obstacles to overcome in been studied as an injury-prevention strategy. sports-injury-prevention research in general and in Fleisig et al. (2006) showed that throwing light- baseball injury research in particular (Lyman 2005). weight baseballs reduced shoulder and elbow loads baseball 75
in youth pitchers. Decreased loads are thought to Risk Factors” section of this chapter), Little League lead to fewer injuries in baseball pitching, although Baseball has changed from limits on the number additional studies are needed to document a reduc- of innings pitched to limits on pitches per game. tion of injuries with this type of baseball. Research on the success of these pitch-count limits Studies are needed to evaluate other potential is in progress. The challenge for researchers, base- injury-prevention strategies such as proper pitching ball organizations, and individuals is to prevent technique and pitch limits. It has been determined pitchers from pitching so much that they develop that throwing and pitching using improper overuse injuries but also allow pitchers to pitch mechanics produces more force and torque on the enough to develop strength, technique, and experi- elbow and shoulder (Fleisig 1994; Fleisig et al. 1995, ence. With the implementation of new pitch-count 1996). Future randomized, controlled trials compar- rules in Little League Baseball, it should be of the ing training pitchers in the use of proper technique utmost priority to study their effects on the injury are needed to prove effectiveness in reducing inju- rates in youth baseball. Similarly, the effects of pitch ries. No prevention studies on pitching limits exist counts at the high-school and college levels should yet. Based on studies such as those by Lyman et al. be studied to determine whether pitch count rules in 2001 and 2002 (described in the “What Are the should be implemented at those levels.
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Basketball
GAYLENE MCKAY1 AND JILL COOK2 1Alphington Sports Medicine Clinic, Northcote, Australia 2Centre for Physical Activity and Nutrition Research, Deakin University, Burwood, Australia
Introduction percentage of players), which reflects characteris- tics of specific surveillance methods and designs. Basketball was invented in 1891 by James Table 6.1 summarizes injury rates and design Naismith, a physical education teacher who rec- parameters (retrospective, prospective) of basket- ognized the need for an indoor sport during cold ball injury studies. winter months. From simple beginnings, basketball The definition of a reportable injury can influence has grown in popularity throughout the world. The the injury rate reported. Definitions comprised of International Basketball Federation is now com- “any injury receiving attention” capture minor inju- prised of 213 countries and reports that in 2006, 11% ries that do not result in time lost from participation of the world played basketball (2008). Basketball and produce higher injury rates as compared with was played for the first time at the Olympic Games definitions based on “time lost from participation.” on August 1, 1936, in Berlin. Women’s basketball These minor injuries cloud our understanding of joined the Olympic program in 1976. Traditionally, the risk associated with playing basketball. For basketball has been considered a noncontact sport, example, McKay et al. (2001b) used a definition of but there is now sufficient body contact to suggest “any injury receiving treatment” and found a rate of that it has evolved into a semicontact sport. 23 to 26.9 per 1,000 hours of participation. However, This chapter aims to provide a comprehensive applying a “time-loss” definition resulted in a rate review of the injury literature on adult basketball of approximately 6 per 1,000 hours. Definitions players from 1990 through 2007. For data on children, used in the studies listed in Table 6.1 are identified. youth, and adolescent players, see Harmer (2005). In general, most epidemiologic studies in basket- Who Is Affected by Injury? ball report a relatively low injury rate. The highest rate of injury is reported in professional American basketball (19–25 per 1,000 AEs). Other rates Overall Injury Rate reported in Table 6.1 vary from 1.4 to 9.9 injuries There is a wide range in the overall rate of injury in per 1,000 AEs, depending on the definition used basketball and considerable variation in how rates and the population sampled. are reported (hours of participation, athlete expo- sures (AEs), athlete per season, participant years, Where Does Injury Occur?
Anatomical Location Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 Basketball requires repetitive jumping interspersed Blackwell Publishing, ISBN: 9781405173643 with running and rapid change of direction, and this 78 basketball 79
Table 6.1 Overall injury rates in basketball.
Study Design Duration Sample Per 1,000 Hr Per 1,000 AE Other Rates
Agel et al. (2007) R 16 yr College Female 7.7a Dick et al. (2007) R 15 yr College Male 9.9a Deitch et al. (2006) R 6 seasons NBA and WNBA Male—game-related 19.3b Female—game- 24.9b related Meeuwisse et al. P 2 yr College (2003) Male 4.9b McKay et al. (2001b) P 17 mo Adults Male—elite 26.9b 26.9b Male—recreational 22.0b 14.7b Female—elite 23.0b 23.0b Female—recreational 25.7b 17.2b Sallis et al. (2001) R 15 yr College Male 126.9/100 players/yr Female 112.0/100 players/yr Stevenson et al. P 5 mo Adults— 15.1a (2000) recreational Starkey (2000) R 10 yr NBA Male 21.4a Arendt & Dick (1995) R 5 yr College Male 5.6a Female 5.2a Crawford & Fricker R 8 yr Elite (16 to (1990) 23 yr) Female 0.8 participant- yearsa Lanese et al. (1990) P 1 yr College Male 4.5b Female 4.8b
AE ϭ athlete exposure; NBA ϭ National Basketball Association; P ϭ prospective; R ϭ retrospective; WNBA ϭ Women’s National Basketball Association. a Any reported injury. b Time loss from reported injury.
pattern is indicated in the lower limb being more The most common specific injuries have been affected by injury than the upper limb. Table 6.2 detailed in several studies providing more infor- details the distribution of injuries by body region. mation about specific anatomical sites of injury. The lower limb accounts for 46.4% to 68.0% of inju- Studies reporting injury location-by-type data are ries, while head and neck injuries were responsible summarized in Table 6.3. for 5.8% to 23.7%. Upper-limb injuries account for The most common lower-limb injuries in basket- 5.6% to 23.2% of injuries, and spine and pelvis inju- ball occur at the ankle and knee. The prevalence of ries for 6.0% to 14.9%. ankle injuries varies between 10.7% and 76.0% of 80 chapter 6
Table 6.2 Percent distribution of injuries by anatomical location.
Study Head/Neck Spine/Pelvis Upper Limb Lower Limb Other %% % % %
Agel et al. (2007) 14.7 7.4 14.1 60.8 3.0 Dick et al. (2007) 13.9 11.4 14.1 57.9 2.7 Deitch et al. (2006) 65.0 Meeuwisse et al. (2003) 10.2 6.5 13.5 67.4 2.3 McKay et al. (2001b) 23.7 6.3 23.2 46.8 Starkey (2000) 8.5 9.5 12.1 46.4 23.5 Crawford & Fricker (1990) 9.6 14.6 5.6 66.0 2.2 all injuries, at rates between 1.5 to 4.3 per 1,000 AEs Location on the Court and 5.2 to 5.5 per 1,000 hours of participation. It has been reported that approximately half of all The rate of knee injury has been reported between basketball injuries occur in the key, where crowd- 1.5 and 4.4 per 1,000 AEs and is the most frequent ing, jumping, and body contact are common. For injury reported in professional American basketball example, Meeuwisse et al. (2003) found that inju- players, accounting for 20% of all injuries (Figure ries in this region accounted for 44.7% of reportable 6.1) (Deitch et al. 2006). Anterior cruciate ligament injuries, at a rate of 2.2 injuries per 1,000 AEs. (ACL) damage is a common knee injury, which is often season-ending or, at times, career-ending. Because of its serious nature, several studies have Competition versus Training specifically investigated the rates of ACL injuries in More injuries are sustained during competition basketball (Table 6.3), which vary from 0.03 per 1,000 than during training sessions. In a 16-year review AEs in a male sample (Agel et al. 2005) to 0.48 per of men’s college basketball in the USA, Dick et al. 1,000 AEs in a female sample (Gwinn et al. 2000). (2007) found that the rate of injuries in games was Knee-extensor injuries mostly affect the proximal two times greater than in practice (9.9 per 1,000 AEs end of the patellar tendon in basketball players and vs. 4.3 per 1,000 AEs; rate ratio, 2.3; 95% CI, 2.2– account for approximately 70% of patellar tendon 2.4). In a similar review of women’s college basket- injury (Blazina et al. 1973). ball, Agel et al. (2007) reported the same findings Although dental injuries are thought to account (7.7 per 1,000 AEs vs. 4.0 per 1,000 AEs; rate ratio, for only 1% of basketball-related injuries, they are of 1.9; 95% CI, 1.9–2.0). concern because they can be permanent, disfiguring, Meeuwisse et al. (2003) reported that 3.7 times and expensive (Labella et al. 2002). Cohenca et al. more serious injuries occurred in collegiate bas- (2007) conducted a retrospective review of records ketball games (1.9 per 1,000 AEs) as compared and reported the incidence of traumatic dental inju- with training sessions (0.5 per 1,000 AEs). Agel et ries for male and female college basketball players al. (2007) reports that female college players were as 10.6 and 5.0 per 100 athlete-seasons, respectively. more likely to sustain a concussion (rate ratio, 3.3; 95% CI, 2.8–4.0), knee internal derangement Environmental Location (rate ratio, 3.3; 95% CI, 2.9-3.7) and ankle sprain Basketball is played indoors, usually on wooden (rate ratio, 2.0; 95% CI, 1.8–2.2) in a game than in floors. Early studies suggested that harder floors training. may be implicated in overuse injuries, specifically In professional American basketball, (Deitch et al. patellar tendinopathy (Ferretti et al. 1984); how- (2006) reported that female players were injured ever, the move to better floor surfaces leaves little more frequently at practices as compared with variation in the basketball environment, and there games, while Starkey et al. (2000) reported that are no studies investigating how different environ- 43.2% of injuries in male players over a 10-year ments impact injuries (acute or overuse). period occurred during a game. basketball 81 1,000 AEs 3.7 Concussion % Per 1,000 AEs 0.03–0.13 Nose—Fracture Head— % Per AEs ϭ risk ratio. Lower Back Strain % Per 1,000 1,000 AEs 3.3 1.7 0.1 1.3 0.1 1.7 0.1 6.5 0.5 Upper-Leg Upper-Leg Contusion 6.9 1.5 4.4 0.9 0.8 0.2 3.9 0.33.52.6 0.7 2.2 0.7 0.2 4 2.8 0.8 0.7 1.7 1 0.2 1 3.6 0.3 0.2 0.3 1.2 2.4 0.2 0.6 % Per AEs 2.4 0.2 Tendon % Per 1,000 3.3 0.7 1.7/PY AEs Knee Patella or Patellar 1.5 0.119.122.5 2.5 4.4 2.4 0.2 4.3 4.7 0.8 1.2 13.7 2.5 rate per 1,000 person-days; PY ϭ rate per 1,000 participant-years; RR ϭ rate per 1,000 person-days; PY a a a a 0.45 0.07 0.03–0.13 0.20–0.37 0.09 0.48 For females RR, 3.0; P Ͻ 0.001 Knee Internal Derangement 1.45.2 0.08 0.28 1.9 1.25.7 0.07 0.29 %AEs Per 1,000 % Per 1,000 2.9/PY 5.5/Hrs 0.4/PD 1.9/PD Per 1,000 AEs Ankle Ligament Sprain 24.626.2 1.917.9 2.3 15.98.1 1.2 3.5 7.4 0.7 1.5 0.7 0.1 15.8 21.1 3.9 76.0 17.3 4.3 1.6 0.4 % 16.1 3.4 a b b b a a b b a b a a a a a a Time loss from any reportable injury. any reportable loss from Time Any reported injury. Any reported Dick et al. (2007) Sallis et al. (2000) Arendt & Dick (1995) Arendt Hr ϭ rate per 1,000 playing hours; PD AE ϭ athlete exposures; McKay et al. (2001b) Female & Collins (2006) Trojian African-American Agel et al. (2005) Female Starkey (2000) Table 6.3 Table and rates for common location-by-type injuries. Frequency Female Male Male Mihata et al. (2006) Male Caucasian Male Male Male Male Female Hosea et al. (2000) Male Female Leanderson et al. (1993) a b Beynnon et al. (2005) Female Meeuwisse et al. (2003) Deitch et al. (2006) Female McGuine & Keene (2006) Gwinn et al. (2000) Male Agel et al. (2007) 82 chapter 6
Chronometry
Few studies have investigated the time during a game at which injury occurs. McKay et al. (2001a) found no significant relationship between time during a game and ankle injuries. Three studies have investigated the time during a basketball season during which injury is most com- mon and shown have a higher rate in the presea- son as compared with later in the season for both practice and games. In men’s collegiate basketball, Dick et al. (2007) reported that the preseason injury rate in practice (7.5 per 1,000 AEs) was almost three times higher than the in-season practice injury rate (2.8 per 1,000 AEs) (rate ratio, 2.7, 95% CI, 2.6–2.8), which was, in turn, 50% greater than the postsea- son rate of training-related injuries (1.5 per 1,000 AEs) (rate ratio, 1.9; 95% CI, 1.5–2.3). For game- related injuries, the in-season rate (10.1 per 1,000 AEs) was 1.6 times higher than the postseason rate (6.4 per 1,000 AEs) (rate ratio, 1.6; 95% CI, 1.3–1.9). Comparable findings were documented in women’s college basketball. Agel et al. (2007) reported that the preseason training-related rate (6.8 per 1,000 AEs) was more than twice as high as during in- season training (2.8 per 1,000 AEs) (rate ratio, 2.4; 95% CI, 2.2–2.4), and the regular season game rate (7.7 per 1,000 AEs) was significantly greater than Figure 6.1 The dynamic running, jumping and cutting of that for the postseason (5.5 per 1,000 AEs) (rate modern basketball are associated with a high percentage of acute and chronic knee injuries. © IOC/Steve MUNDAY ratio, 1.4; 95% CI, 1.2–1.7). Stevenson et al. (2000) reported that the injury rate in Australian bas- ketball players was the highest at the start of the When Does Injury Occur? season (20 per 1,000 hours) and then significantly declined by the end of the fifth month (10 per 1,000 Injury Onset hours). Although few studies differentiate between acute Starkey (2000) reported that game-related inju- and overuse injuries it appears that overuse inju- ries in professional American basketball increased ries account for between 12.8% and 37.7% of all by 12.4% over a 10-year period. In contrast, Agel injuries. et al. (2005) showed that over a 16-year period the Tendinopathies, particularly patellar tendin- game injury rate in female collegiate players had opathy, are the most common overuse injury. All an average annual decrease of 1.8% (P ϭ 0.04), and players are vulnerable, particularly those that are the rate of injury in training sessions had an aver- aerial players by nature. Cook et al. (1998) reported age annual decrease of 1.3% (P ϭ 0.05). No changes a prevalence of patellar tendinopathy diagnosed were reported over the same period in men’s col- on imaging in basketball players of 50%. About one legiate basketball, either during games (0.8%, third of athletes with patellar tendon changes had P ϭ 0.28) or training sessions (0.0%, P ϭ 0.98) (Dick imaging abnormalities bilaterally. et al. 2007). basketball 83
What Is the Outcome? to ankle injuries, accounting for 43.3% of injuries for which Ͼ1 week was missed, with these injuries Injury Type occurring at a rate of 1.3 per 1,000 AEs. Meeuwisse Table 6.4 summarizes the percentage distribution et al. (2003) reported that ankle injuries caused, on of type of injury incurred by basketball players. average, 5.5 days to be missed, while McGuine and In general, sprains are the most common type of Keene (2006) reported a mean of 7.6 days. injury, often accounting for about half the injuries. In a largely recreational sample, in which 66.3% Other common injuries are contusions and strains. of the players were over the age of 25 years, McKay et al. (2001b) reported that calf injuries were second Time Loss to ankle injuries for time lost, accounting for 16.7% of injuries for which у1 week was missed, at a rate There is considerable variation in how time loss due of 0.5 per 1,000 AEs. to injury and the severity of injury are recorded in In professional American players, injuries to the basketball studies, making it difficult to give a clear lumbar spine were the third most common injury overview. Agel et al. (2007) reported that approxi- to cause days to be missed, accounting for 11.0% of mately 25% of game and training injuries caused у10 all time missed. days to be missed. In a study of elite and recreational Tendinopathy, once it progresses past self- Australian basketball players, McKay et al. (2001b) management, can result in extended periods during reported that 17.8% of injuries (2.9 per 1,000 AEs) which the player is unable to train or play. A study resulted in у1 week away from participation. of recovery from patellar tendinopathy indicated Other studies have assessed time loss and sever- that more than 33% of players were unable to play ity of injury in terms of the need for surgery or for more than 6 months and 18% for 12 months hospitalization. In professional American basket- (Cook et al. 1997). ball players, Starkey (2000) reported that 3.7% of players required surgery (1.8 per 1,000 AEs), which Clinical Outcome accounted for 28.4% of the total days missed. Knee injuries appear to be responsible for the Recurrent injuries are common in basketball. For most time lost, and they required surgery more often example, DuRant et al. (1992) reported that 66.7% than other injuries. In intercollegiate players, Agel of athletes who injured their ankles had a history of et al. (2007) reported that knee internal derangement ankle sprain, and follow-up of ankle injuries after 6 to injuries accounted for 41.9% of game-related and 18 months have shown that residual ankle symptoms 26.1% of training-related injuries in which Ͼ10 days occur in 40% to 50% of cases. Konradsen et al. (2002) of participation were lost and, on average, knee found that 7 years after injury, 32% of injured players injuries caused 18.3 days to be missed (Meeuwisse continued to report residual ankle symptoms. et al. 2003). In professional players, knee injuries Recurrent injuries in basketball also involve the were responsible for 13.6% of days lost, and the knee (DuRant et al. 1992; Meeuwisse et al. 2003), patellofemoral joint accounted for 13.1% of days elbow (Meeuwisse et al. 2003), shoulder (DuRant, lost (Starkey 2000). 1992), hand (Meeuwisse et al. 2003), lumbar spine/ Ankle injuries also cause substantial time to be pelvic region (Meeuwisse et al. 2003), leg (DuRant missed. Agel et al. (2007) reported that ankle inju- et al. 1992), and concussion (Meeuwisse et al. 2003). ries accounted for 13.2% of game-related and 11.5% Catastrophic injuries are defined by the National of training-related injuries, for which Ͼ10 days Center for Catastrophic Sports Injury Research participation were lost. McGuine and Keene (2006) (NCCSI 2004) in the United States as those that found that 29% of ankle injuries caused 8 to 21 days result in a brain or spinal cord injury or skull or to be missed and another 6.4% caused Ͼ21 days spinal fracture and subclassified as fatalities, non- to be missed. In a sample of Australian players, fatal (permanent severe functional disability) McKay et al. (2001b) noted most time lost was due and serious (no permanent functional disability 84 chapter 6 Injury Rate per 1,000 AEs Other 1.79.5 0.3 1.7 1.9 0.5 11.4 Injury Rate per 1,000 AEs % Dental % 0.9 0.2 Injury Rate per 1,000 AEs Overuse 16.9 % 3.9 Injury Rate per 1,000 AEs Contusion 6.7 9.1 18.1 25.3 4.6 % Injury Rate per 1,000 AEs Strain 7.1 % Injury Rate per 1,000 AEs Sprain 52.6 37.0 7.2 16.4 3.2 20.4 59.3 40.4 10.1 15.2 3.8 19.9 5.0 % Rechel et al. (2008) Male Deitch et al. (2006) Male McKay et al. (2001b) 51.6 9.4 Female Table 6.4 Table distribution and rate for injury type. Percent Female Starkey (2000) 20.9 7.4 16.2 4.1 11.8 4.5 Chan et al. (1993) 55.5 basketball 85
but severe injury). The NCCSI provides the most Treatment costs for dental injuries are invariably comprehensive data for catastrophic injuries in high. Labella et al. (2002) studied 50 college teams college basketball. Catastrophic injury rates for over one season and noted that 45 dental referrals male and female basketball players are detailed in were required, with a minimum cost estimate for Table 6.5. It appears that the risk of catastrophic serious dental injuries being US$1,000. injury in basketball is small. For college players, 36 catastrophic injuries (9 direct, 27 indirect) were recorded over a 24-year period (1982–1983 to 2005– What Are the Risk Factors? 2006). Intrinsic Factors
Economic Cost Intrinsic risk factors implicated in basketball inju- ries are detailed in the following section. The effect Economic cost is considered in terms of the cost of of these factors may be mediated by extrinsic fac- treatments, loss of earnings, and effect on quality of tors, particularly load, and there are few clear life. Knowles et al. (2007) found that for American cause-and-effect relationships with injury. high school athletes ankle and knee injuries were most commonly implicated in monetary costs and direct medical costs were higher for boys basket- Sex ball ($401: 95% CI ϭ 348–463) than girls basketball Although a number of studies have found a higher ($354; 95% CI ϭ 324–386) (p < 0.01)”. de Löes et al. overall rate of injury in female players as compared (2000) investigated the cost of knee injuries over a with male players (in professional American basket- 7-year period in a range of sports in Switzerland by ball, e.g., Deitch et al. 2006), most have reported no reviewing insurance data. Knee injuries in basket- significant differences (Arendt & Dick, 1995; Lanese ball players had a mean cost of US$1,427 per injury et al. 1990; McKay et al. 2001a; Sallis et al. 2001). for men and US$1,060 for women. Furthermore, However, specific sex-related injuries have been knee injuries were responsible for 30% of the costs noted. For example, Deitch et al. (2006) found that for all injuries in male basketball players (US$170 female professional American basketball play- per 1,000 hours of participation) and 34% for ers sustained significantly more sprains as com- female players (US$180 per 1,000 hours). pared with male players. More importantly, Agel The other concern with regard to substantial et al. (2005) determined that female players were economic cost in basketball is dental injuries. more than three times as likely to incur an ACL injury as compared with their male counterparts Table 6.5 Catastrophic injuries in basketball per 100,000 (rate ratio, 3.6; 95% CI, 3.0–4.2), and Gwinn et al. participations. (2000) showed a similar trend (ACL injury rates in Rate of Rate of women, 0.5 per 1,000 AEs as compared with 0.1 per Group and Rate of Nonfatal Serious 1,000 AEs in men; rate ratio, 5.4, P Ͼ 0.05). Mechanism Fatalities Injuries Injuries Previously presented sex-related sociocultural differences, including women having less experi- Male—college Direct 0.29 0.59 1.76 ence in organized sports or being less fit, do not Indirect 6.75 0.00 0.29 seem to be important. For example, Mihata et al. Female—college (2006) showed no change in the rate of ACL inju- Direct 0.00 0.00 0.00 ries per 1,000 AEs in male and female basketball Indirect 1.01 0.00 0.00 players over a 15-year period (1989–1994: women, Direct injuries resulted directly from participation in the skills of 0.29; men, 0.07; 1994–2004: women, 0.28; men, the sport. Indirect injuries were caused by systematic failure as 0.08) despite improvements in these characteris- a result of exertion while participating in a sport activity or by a complication secondary to a nonfatal injury. Most commonly, indi- tics. Similarly, Agel et al. (2005) showed no change rect fatalities are cardiac failures. in the rate of ACL injury over a 13-year period in 86 chapter 6 female (0.27 per 1,000 AEs) and male (0.08 per 1,000 Previous Injury AEs) basketball players. The most commonly documented intrinsic risk Cook and colleagues (1998, 2000) have found factor for ankle injury is a history of ankle sprain that men may be at greater risk for patellar tendi- (Table 6.6). In the earliest of these studies, Garrick nopathy, documenting considerable prevalence dif- and Requa (1973) reported a significantly higher ferences between men (42%) and women (18%). rate of ankle injury in those with a history of ankle injury (27.7 per 1,000 AEs) as compared with their Level of Competition previously uninjured counterparts (13.9 per 1,000 There is uncertainty regarding whether level of AE; P ϭ 0.025). McGuine and Keene (2006) docu- competition is a risk factor for injury in basketball. mented the risk of sustaining an ankle sprain to Dick et al. (2007) reported significantly higher game- be twice as high for players who had sustained an related injury rates in Division I men’s collegiate ankle injury in the previous 12 months (rate ratio, basketball (10.8 per 1,000 AEs) than in Division III 2.14; 95% CI, 1.3–3.7) and McKay et al. (2001a) (9.0 per 1,000 AEs) (rate ratio, 1.2; 95% CI, 1.1–1.3) reported that players with a history of ankle sprain but not for Division II. Agel et al. (2007) found were almost five times more likely to injure their differences between all three levels in collegiate ankle as those without a history of ankle injury women: Division I as compared with Division II (rate ratio, 4.9; 95% CI, 2.0–12.5). (8.9 vs. 7.4 per 1,000 AEs; rate ratio, 1.2; 95% CI, Evidence shows that combinations of intrinsic 1.1–1.3), and Division III (8.9 vs. 6.6 per 1,000 AEs; risk factors may have a cumulative effect on the rate ratio, 1.3; 95% CI, 1.3–1.5). risk of ankle injury. For example, overweight male In contrast, an Australian study reported no dif- athletes (body-mass index у95th percentile) with a ference in the game-related injury rate between elite previous ankle sprain were 9.6 times (McHugh et (men, 26.9 per 1,000 hours of participation; women, al. 2006) to 19 times (Tyler et al. 2006) more likely 23.0 per 1,000 hours) and recreational players (men, to sustain a noncontact ankle sprain as compared 22.0 per 1,000 hours; women, 25.7 per 1,000 hours) with normal-weight players without a history of (McKay et al. 2001a). ankle sprain.
Table 6.6 Intrinsic risk factors of ankle injury.
Risk Factor Study Results
Nonmodifiable Being female Beynnon et al. (2005) RR, 1.5; 95% CI, 0.8–2.9 Hosea et al. (2000) RR, 1.3; P Ͻ 0.001 Modifiable History of ankle injury Garrick & Requa (1973) 27.7 (history) vs. 13.9 per 1,000 AEs; P Ͻ 0.05 McGuine & Keene (2006) RR, 2.1; 95% CI, 1.3–3.7; P ϭ 0.005 McHugh et al. (2006) 1.2 vs. 0.3 per 1,000 AEs; P Ͻ 0.05 McKay et al. (2001a) RR, 5.0; 95% CI, 2.0–12.5; P Ͻ 0.001 Tyler et al. (2006) 2.7 vs. 0.4 per 1,000 AEs; P Ͻ 0.001 Abnormal body sway/balance McGuine et al. (2000) Injury rate, 2.7 (high sway) vs. 0.4 (low sway) per 1,000 AEs; P Ͻ 0.0002 Wang et al. (2006) Anteroposterior sway (RR, 1.2; P ϭ 0.01); mediolateral sway (RR, 1.2; P Ͻ 0.001) Weight (heavier athletes at McHugh et al. (2006) Injury rate for BMI у95th percentile, 3.0 per 1,000 AEs; increased risk) vs. Ͻ95th percentile, 0.8 per 1,000 AEs; P Ͻ 0.05 Tyler et al. (2006) 2.0 (overweight) vs 0.5 (normal weight) per 1,000 AEs; P ϭ 0.04
BMI ϭ body-mass index; RR ϭ rate ratio. basketball 87
Race/Ethnicity cells in the heel, were 4.3 times more likely to injure their ankle than those wearing less expensive shoes Trojian & Collins (2006) determined that white (rate ratio, 4.4; 95% CI, 1.5–12.4; P ϭ 0.01). female players were 6.6 times more likely to injure their ACL than were black female players (0.45 What Are the Inciting Events? per 1,000 AEs vs. 0.07 per 1,000 AEs; rate ratio, 6.6, 95% CI, 1.35–31.73). Player contact was responsible for 52.3% of game- related injuries in male collegiate players (Dick et al. Balance 2007) and 46.0% of injuries in female players (Agel et al. 2007) and was the most common mechanism Although balance has been examined as a risk fac- for ankle injuries in both. Meeuwisse et al. (2003) tor in youth and adolescent basketball injury (e.g., documented a ratio of 4:3 for contact to noncontact Plisky et al. 2006, Wang et al. 2006, McGuine et al. injuries also in college players. In an Australian 2000), no such studies have involved adult players. sample, McKay et al. (2001b) reported that 52.1% Injury Score of injuries were due to body contact but that almost half (45.0%) of the ankle injuries were incurred dur- Using a sample of 45 basketball players, ing landing and another 30% sustained while doing Shambaugh et al. (1991) showed that logistic- a cutting maneuver. regression analysis incorporating three structural ACL injuries have been reported as non-con- measures [weight imbalance (lateralization of tact injuries in 65.2 % of male college players and ϫ ϩ center of gravity) 0.36 abnormal right quadriceps 80.1% of female college players (Arendt & Dick ϫ ϩ ϫ angle 0.48 abnormal left quadriceps angle 1995). Although Krosshaug et al. (2007) found ϩ Ϫ 0.86 intercept ( 7.04)] correctly predicted the that a majority (71.8%) of ACL injuries were from injury status of 91% of players. However, Grubbs noncontact mechanisms, they reported pertur- et al. (1997) applied this injury equation to 62 high- bation of a movement pattern in the time before school basketball players and found it to have no injury for many cases. These researchers conducted predictive value. video analysis of 39 ACL injuries (22 in women, 17 in men) and found that one half (11 of 22) of the Extrinsic Factors ACL injuries in women involved the player being Playing Position pushed or collided with before the time of injury. A majority (71.8%) occurred while the injured player Limited research has investigated whether play- was in possession of the ball, and over half (56.4%) ing position is a risk factor for injury. Early studies occurred while attacking. For female players, were descriptive in nature but concluded no such 59.1% of ACL injuries occurred during single-leg relationship (Henry et al. 1982), which has been landings, while in male basketball players 35.3% supported by more recent research on both overall occurred during single-leg landing. injury rate (McKay et al. 2001a) and risk for ankle injury specifically (Leanderson et al. 1993; McKay Injury Prevention et al. 2001b). In contrast, Meeuwisse et al. (2003) showed As detailed previously, the two most problem- that centers had a higher injury rate for knee (rate atic injuries in basketball are related to the ankle ratio, 13.0), ankle (rate ratio, 4.5) and foot (rate ratio, and knee (ACL). As a result, greater emphasis 10.0) injuries as compared with forwards, who had on prevention of these injuries is evident in the the lowest rate. literature.
Shoes Ankle Injuries
McKay et al. (2001a) reported that basketball play- Injury-prevention strategies for the ankle have ers wearing more expensive shoes, which had air traditionally included the use of external ankle 88 chapter 6 supports (braces or tape), high-cut shoes and func- the lowest rate of ankle injury in players wearing a tional rehabilitation programs. combination of high-cut shoes and ankle tape (6.5 per 1,000 AEs). However, more recent evidence External Ankle Support suggests that the cut of shoe does not affect the The use of external ankle support as a protective fac- incidence of ankle injuries. For example, Barrett tor for ankle injuries is well documented in the lit- et al. (1993) studied 622 basketball players over a 2- erature. External ankle support includes the use of month period and reported no difference in ankle both ankle braces and ankle tape. Four systematic injury rates for three types of shoes—low-cut shoes, reviews, analyzing between 5 and 14 randomized, high-cut shoes, and high-cut shoes with inflatable controlled trials (RCTs) have concluded that ankle air chambers—and McKay et al. (2001a) found no braces decrease the incidence of ankle injuries association between cut of shoe (low, mid, and high (Handoll et al. 2001; Quinn et al. 2000; Thacker et cut) and ankle injuries in a sample of 40 players al. 1999; Verhagen et al. 2000). Handoll et al. (2001) with ankle injuries and 360 control players. conducted a meta-analysis using 14 RCTs (8,279 par- ticipants) and reported a reduction in the number of Functional Rehabilitation ankle sprains with the use of external ankle braces McGuine and Keene (2006) reported that a bal- (rate ratio, 0.53; 95% CI, 0.40–0.69). This reduction ance training program (balance board and single- was greatest in those with a history of ankle sprain leg functional exercises) significantly decreased (rate ratio, 0.33; 95% CI, 0.20–0.53). Handoll et al. the risk of ankle sprains in high-school basketball (2001) concluded that there is good evidence that players as compared with a control group (1.13 ankle braces provide protection for athletes involved per 1,000 AEs vs. 1.87 per 1,000 AEs; P ϭ 0.04). in sporting activities considered to present a high Beyond this study, there appears to be a lack of risk for ankle injuries, such as basketball. Garrick basketball-specific research to demonstrate func- and Requa (1973) documented the lowest rates of tional rehabilitation as a protective factor for ankle ankle injury in basketball players taping their ankles injuries. (ankle tape/high-cut shoes, 6.5 per 1,000 AEs; ankle tape/low-cut shoes, 17.6 per 1,000 AEs) as com- Anterior Cruciate Ligament Injuries pared with those not taping their ankles (no tape/ high-cut shoes, 30.4 per 1,000 AEs; no tape/low cut Hewett et al. (1999) used a 6-week preseason neu- shoes, 33.4 per 1,000 AEs). Sitler et al. (1994) studied romuscular training program that was completed 1,601 military cadets playing basketball over two three times per week for 60 to 90 minutes per ses- seasons and determined that the use of ankle braces sion to assess the impact on the rate of ACL inju- significantly decreased the incidence of ankle inju- ries. The rate of noncontact ACL injury decreased ries occurring due to player contact. by 72% in the intervention group (rate ratio, 0.50; Olmsted et al. (2004) calculated the number- 95% CI, 0.1–2.5). needed-to-treat statistic from the basketball injury data of Sitler et al. (1994) and concluded that for Dental Injuries one ankle sprain to be prevented in a single bas- ketball season in athletes with a history of sprain, Dental injuries, although infrequent, can be costly; 18 ankles would need to be braced. In athletes their incidence may be reduced by the use of mouth without a history of sprain, 39 basketball players guards. Labella et al. (2002) conducted a prospec- would need to wear a brace. tive study examining 70,936 AEs from 50 college basketball teams and showed that players wear- ing custom-made mouth guards had a significantly Shoes lower rate of dental injuries (0.12 per 1,000 AEs) as In basketball, high-cut shoes were advocated after compared with those not wearing mouth guards Garrick and Requa’s (1973) study, which reported (0.67 per 1,000 AEs). Despite this, Perunski et al. basketball 89
(2005) reported low use of mouth guards in Swiss Similarly, further research into ACL injuries basketball, with only four mouth guards worn in in basketball should include exploring and con- 302 players who reported 55 dental injuries. firming risk-factors (including race), determining whether the addition of unexpected changes to nor- mal movement patterns during training improved Further Research landing strategies, or whether neuromuscular train- ing programs can decrease the risk of ACL injury in Injury Surveillance Systems players of varying levels of experience, age groups, There is an ongoing need to develop more compre- and ethnic groups. For example, Krosshaug et hensive injury surveillance systems in basketball al. (2007) found that female players land with at all levels of participation with a standard defini- more hip and knee flexion and, as a result, were tion of a reportable injury and denominator data 5.3 times more likely to sustain a valgus col- (exposures) for expressing injury rates. Consistent lapse than male players (rate ratio, 5.3; P ϭ 0.002). injury surveillance systems would enable compari- In addition, Chandrashekar, Slauterbeck, and sons across studies to be readily made and provide Hashemi (2005) argued that the female ACL has a a clearer understanding of injuries in varying bas- smaller cross-sectional area (mean ϮSD: in female ketball populations around the world. players, 58.29 Ϯ 15.32 mm2, in male players, Further research also needs to examine factors 83.54 Ϯ 24.89; P ϭ 0.007), is shorter in length (in such as age, sex, level of experience, and position female players, 26.85 Ϯ 2.82 mm; in male players, played on the court, for not only the overall injury 29.82 Ϯ 2.51; P ϭ 0.01), and has a smaller volume profile but also to improve the understanding of (in female players, 1954 Ϯ 516 mm3; in male play- specific injuries. The reasons for injuries being more ers, 2967 Ϯ 886; P ϭ 0.003) as compared to the male prevalent in the preseason as compared with later in ACL. The association of these differences with ACL the season also need to be established, and whether injury has yet to be substantiated in the epidemio- a pattern exists as to when injuries occur during logic literature. Interestingly, Lombardo, Sethi, and games needs to be clarified. There also needs to be Starkey (2005) reported that an 11-year prospective more widespread reporting of catastrophic injuries study investigating 305 professional male players to enable risk factors and preventive strategies to be showed no significant difference in intercondylar developed for these life-changing events. notch width index between players with ACL inju- Regarding the major injury categories of ankle ries (0.235 Ϯ 0.031) and those without ACL injuries Ϯ ϭ Ϫ ϭ and knee injuries, further research of ankle inju- (0.242 0.041) players (t305 0.623; P 0.534). ries should include investigating the mechanisms Finally, although tendinopathy is currently sub- of ankle injuries and their role in preventing these ject to extensive research at molecular, histologic, injuries, identification of other risk factors for ankle and clinical levels, it would be reasonable to say injuries, the role of the sole of the basketball shoe that this research has not yet delivered substantial in respect to proprioceptive feedback, and the rate changes in management. For example, Gaida et al. of ankle injury (Robbins and coworkers found (2004) found that athletes who had patellar tendin- that the thickness and hardness of the soles of opathy trained for a mean (ϮSD) of 2.6 Ϯ 1.4 hours shoes affected foot position under dynamic condi- more than athletes without tendinopathy but the tions, with the thickest and softest soles causing importance of load, as measured by frequency or the greatest errors [Robbins et al. 1995; Robbins & volume of participation, has not been adequately Waked 1998]), the impact of functional rehabilita- explored. Better understanding of tendon pathol- tion programs in reducing the risk of ankle injury, ogy, improved exercise options, and understand- clarification of the specific role of ankle taping or ing those at risk are key to improving management. bracing in preventing ankle sprains, and the utility Most importantly, identifying the source of pain is of improving physical fitness/conditioning as an critical, followed by research that allows the matrix effective injury prevention strategy. to fully restructure after injury. 90 chapter 6
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Boxing
TSHARNI ZAZRYN1 AND PAUL MCCRORY2 1Department of Health Social Science, School of Public Health and Preventive Medicine, Monash University, Caulfield Campus, Victoria, Australia 2Centre for Health, Exercise and Sports Medicine and the Brain Research Institute, University of Melbourne, Melbourne, Victoria, Australia
Introduction be male and between 17 and 34 years of age on the first day of competition and the boxer’s country Boxing (also known as pugilism) is the physical skill must be affiliated with the Amateur International of fighting with the fists (Stening 1992). Boxing Boxing Association (AIBA). Of the 203 recognized was first included as an Olympic sport for the National Olympic Committee nations, 195 are affil- 23rd Ancient Olympic Games in 688 b.c., and was iated with the AIBA and use their rules to regulate largely a bare-knuckle activity at that time (Jordan the sport (International Boxing Association 2008). 1993, BBC 2007a). During ancient Roman times, Competitive bouts in Olympic boxing include boxing was seen as a spectator event, with slaves four rounds of 2 or 3 minutes each, with a one often forced to participate. Eventually, boxing in minute break in between (International Boxing Rome was banned by Caesar Augustus in a.d. 393, Association 2007). Boxers qualify for the Olympic after aristocrats who had been participating were Games based on regional qualifying tournaments being injured (BBC 2007a). with boxers paired off at random within each of the Boxing was not commonly practiced again until 11 weight divisions for participation in elimination the 17th century, and the rules in use today began bouts (International Olympic Committee 2008). to develop from standards established in Britain Compulsory protective equipment for this sport in the early 18th century (BBC 2007b). Organized includes headgear, 10-oz (284 g) gloves, and a cus- amateur boxing is thought to have begun around tom-fitted mouth guard (Figure 7.1). Scoring within 1880, although boxing was not a part of the mod- this sport uses a computerized system whereby two ern Olympiad until the 1904 Games (International of the three judges must award a point to the same Olympic Committee 2008). It was omitted from the boxer within 1 second of each other (International first two Games of the modern era because it was Boxing Association 2007). Points are awarded for considered too dangerous, and was again not a part blows that, without being blocked or guarded in of the 1912 Olympic Games in Stockholm because of any way, land with the knuckle part of the closed a national ban on the sport in Sweden (International glove on any part of the front or sides of the head Olympic Committee 2008). To be eligible to partici- or body above the hips (International Boxing pate in boxing at the Olympic Games, a boxer must Association 2007). The purpose of this chapter is to review the dis- tribution and determinants of injuries as reported Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 in the amateur boxing literature. The boxing lit- Blackwell Publishing, ISBN: 9781405173643 erature reviewed includes injuries both to boxers 92 boxing 93
Figure 7.1 Flyweight (over 45–51 kg) bout at the Athens Olympic Games in 2004. © IOC. participating under the rules and regulations of 2002; Loosemore et al. 2007, Knowles & Whyte the AIBA and military personnel who participate 2007; McCrory et al. 2007). in boxing as part of their training. Military boxing, while still a type of amateur boxing, does not nec- Who Is Affected by Injury? essarily comply with the rules and regulations of the AIBA. Both groups are discussed in the infor- A comparison of injury rates reported in the liter- mation provided below. ature is shown in Table 7.1. As there are only five studies in the amateur boxing literature that report Methodologic Limitations injury rates, wide variations in the range of results exists. In terms of injuries sustained during compe- Epidemiologic investigations of boxing injuries are tition, rates range from 9.5 to 25.0 per 100 bouts in limited both in methodologic quality and quan- competition (Estwanik et al. 1984; Porter & O’Brien tity. Injury surveillance has largely been limited to 1996; Zazryn et al. 2006). Within training, rates have poorly designed descriptive studies with many dif- been reported to be between 12.1 and 20.4 injuries ferent study designs and follow-up periods stud- per 100 boxers (Porter & O’Brien 1996; Welch et al. ied. This hinders the ability to compare studies or 1986; Zazryn et al. 2006). In terms of injury rates to determine injury risks and prevention strategies. based upon exposure time, in competition rate Other methodologic limitations common to many ranges of 920.9 to 1221.4 per 1000 hours has been of the studies include small sample sizes, inconsist- reported (Porter & O’Brien 1996; Zazryn et al. 2006; ent definitions of injury, selection bias for boxers Welch et al. 1986). In training, injury rates of 0.5 to and mismatching of controls (if used), limited use 22.1 per 1000 hours have been reported (Zazryn of the blinding of researchers, the cross-sectional et al. 2006; Welch et al. 1986) or retrospective nature (or both) of data collection in most studies, variations in the assessment tools Where Does Injury Occur? used and nonvalidation of assessment tools in a boxing cohort, and limited measurement or discus- Anatomical Location sion of possible confounders for the results seen (including age, sex, socioeconomic status, educa- Table 7.2 provides a percentage comparison of the tion, employment, injury sustained outside of box- anatomical locations of injuries sustained during ing, alcohol and drug use, etc.) (Kemp 1995; Jako amateur boxing. The head/face (10.3–100.0%) and 94 chapter 7 6.2 77.7 47.5 Rate per 1,000 Athlete Exposures 9.4 0.5 22.1 43.5 Rate per 1,000 hr of Exposure 9.5 15.5 22.8 920.9 Rate per 100 Bouts Rate per 100 Boxers No. of Injuries 10 days 85 Duration of Study 2 years 294 14.0 10 days 52 2 years 294 14.0 5 mo 64 12 mo5 mo 4 44.412 mo 29 25.0 20.4 1221.4 4 12.1 7 years 73 C Competition (C) or (T) Training C C T C & T 2 years 559 26.6 C C T T C sustained sustained sustained b c a sustained during c . Any event requiring medical Any event requiring attention for injuries sustained during competition Injury Definition (includ- ing participation type when injured) during competition Notable injuries Moderate injury during competition during training either competition or training Mild injury Necessitated early stoppage of competition Physical damage that required Physical damage that required con- or prevented treatment tinuation of competition Necessitated early stoppage of continuation prevented and/or of training Physical damage that required con- or prevented treatment tinuation of training Airmen off duty for у 48 hr Airmen off because of injury sustained during competition Moderate injury Medical records Data Collection records Medical records records Medical records records records (monthly) Medical records records Not reported Sample Size Not reported Not reported 147 Questionnaire Not reported Excusing a cadet from physical activity for a minimum of 1 day Excusing a cadet from Excludes minor injuries such as nosebleeds, black eyes and lacerations. Excusing a cadet from physical activity for у 7 days. Excusing a cadet from Amateur Estwanik et al. 1984 Table 7.1 Table comparison of injury rates in competition and training for amateur boxing. A Study a b c Estwanik et al. 1984 et al. 1986Welch 2100 Medical Welch et al. 1986Welch 2100 Medical Porter & O’Brien 1996 Zazryn et al. 2006 9Porter & O’Brien Medical 1996 Zazryn et al. 2006 33 Medical Military & Brennan O’Connor 1968 Welch et al. 1986Welch 2100 Medical boxing 95 T 2.0 Enzenauer et al. 1989 0.5 1.4 7.7 2.2 25.3 35.7 Welch Welch et al. 1986 0.2 0.7 0.7 0.5 3.9 1.8 5.7 2.3 1.4 0.7 42.8 19.0 Oelman et al. 1983 Military 5.5 0.5 4.5 1.4 5.5 5.9 10.8 9.6 6.4 10.0 4.1 1.4 11.0 13.7 47.9 2 yr 12 yr 2 yr 6 yr Welch Welch et al. 1986 CCTT Brennan & Brennan O’Connor 1968 24.5 19.2 Brennan & Brennan O’Connor 1968 0.8 5.1 Timm Timm et al. 1993 7.2 7.7 0.7 1.3 0.2 0.4 4.5 4.0 1.1 1.8 7.6 7.6 5.8 2.9 2.5 5.1 3.6 2.9 3.7 6.0 5.6 4.3 2.5 6.5 1.61.3 1.3 3.3 8.1 6.4 2.7 2.9 17.7 18.5 Jordan Jordan et al. 1990 25.0 0.9 1.3 25.0 3.6 3.6 25.0 3.8 3.8 Zazryn et al. 2006 b b 34.5 13.8 10.3 25.0 3.4 14.5 34.5 41.4 Porter & O’Brien 1996 Amateur 75.0 Zazryn et al. 2006 3.1 1.6 64 4 29 4 447 1,219 240 73 221 437 73 401 51.6 25.0 Porter & O’Brien 1996 a 1.9 4.7 1.9 1.9 3.81.9 0.0 0.0 0.0 25.0 16.1 8.6 0.0 0.0 0.0 4.6 1.0 7.2 5.8 5.8 3.8 5.8 3.8 4.7 0.0 41.4 0.0 23.9 21.9 0.0 0.0 5.5 4.8 3.6 6.2 1.9 1.6 1.9 1.6 C C C T T C & T C & T C 52 44.2 23.4 0.0 48.3 50.0 32.9 36.2 16.3 17.8 39.7 13.5 47.5 16.7 48.1 71.9 100.0 10.3 25.0 27.1 33.3 59.2 63.0 54.8 67.7 48.0 67.8 26.9 20.3 40.4 15.6 10 days 5 mo 12 mo 5 mo 12 mo 10 yr 15.5 yr 14 yr 7 yr Estwanik et al. 1984 Hand and wrist injuries reported as one category. Hand and wrist injuries reported Notable injuries (excluded minor such as nosebleeds, black eyes and lacerations). Upper arm Forearm Elbow Wrist Abdomen Upper extremity Shoulder Internal Other Ribs/chest Neck Not further specified/other Spine/trunk Upper back/cervical Lower back/lumbar Ear No. of injuries Nose Mouth/teeth Not specified Table 7.2 Table comparison of injury location during competition and training for amateur boxing. Percent a b Activity when injured Study time period Location of injuries Head Skull Intracranial Face/scalp Orbital region Hands/fingers Not further specified Lower extremity Pelvis, hips, groin Thigh Lower leg Foot/Toes Not further specified Ankle C ϭ competition; T training. Knee 96 chapter 7 the upper extremities (0.0–50.0%) were the most for a 2-year recall were sustained during training common regions of injury in all studies (Brennan activities (Tan et al. 2002). & O’Connor 1968; Oelman et al. 1983, Rose & The specific activities being undertaken at the Arlow 1983; Estwanik et al. 1984; Welch et al. 1986; time of injury have not been the focus of much Enzenauer et al. 1989; Jordan, Voy etl al. 1990 & research. While the sparring phase of training is Stone 1990; Timm et al. 1993; Porter & O’Brien 1996; largely considered to be the time at which most Zazryn et al. 2006). boxers are at an increased risk of injury, only one During competitive bouts, head injuries accounted study has reported sparring injuries separately for 48.1% to 100.0% of injuries sustained. In training, from other training injuries. That study was based however, the proportion of head injuries was lower, at on a 12-month follow-up of boxers with four train- 10.3% to 67.8% (Oelman et al. 1983; Welch et al. 1986; ing injuries reported (75% of these were sustained Enzenauer et al. 1989; Porter & O’Brien 1996; Zazryn during sparring). et al. 2006). Of the injuries to the head, the nose (5.8– 75.0%), face (10.3–26.9%), and intracranial region (6.5– When Does Injury Occur? 51.6%) are the most commonly reported injuries. For the upper extremity, injuries to the wrist Injury Onset (1.9–34.5%) and hands/fingers (6.4–40.4%) were commonly reported. Only one study collected data on both acute and chronic injuries resulting from boxing participation (Porter & O’Brien 1996). In that study of 147 Irish Environmental Location boxers, 37.9% of injuries sustained in training were As shown in Table 7.1, there were only five stud- reported as being of long-term onset. It was not ies in the amateur boxing literature that reported specified which injuries were of long-term cause. separate injury rates for training and competition All other studies in amateur boxing that report (Brennan & O’Connor 1968; Estwanik et al. 1984; chronic injuries have focused on the assessment Welch et al. 1986; Porter & O’Brien 1996; Zazryn of chronic neurologic injury. Despite this, one et al. 2006). Injury rates ranged from 9.5 to 25.0 per systematic review of the observational studies 100 bouts in competition to 12.1 and 20.4 injuries assessing chronic brain injury in amateur boxers per 100 boxers in training (Estwanik et al. 1984; concluded that there was little evidence based on Porter & O’Brien 1996; Zazryn et al. 2006). poorly constructed studies that chronic brain injury Three studies have determined injury rates is associated with participation in amateur boxing based on exposure time (Welch et al. 1986; Porter (Loosemore et al. 2007). & O’Brien 1996; Zazryn et al. 2006). In competition, an injury rate range of 920.0 to 1,221.4 per 1,000 Chronometry hours has been reported (Porter & O’Brien 1996; To date, no research has been conducted in box- Zazryn et al. 2006). In training, rates of 0.5 to 22.1 ing related to the time when injury occurred. What per 1,000 hours have been reported (Welch et al. may be relevant is the round (or amount of time 1986; Zazryn et al. 2006). into a bout) during which an injury is sustained. Two studies reported that over 90% of the expo- Again however, this has not yet been researched. sure time for a boxer is spent in training (Welch et al. 1986; Zazryn et al. 2006). However, both of these What Is the Outcome? studies showed that the majority of injuries (75.2% and 57.1%, respectively) occurred in the competi- Injury Type tive setting (Welch et al. 1986; Zazryn et al. 2006). This is in contrast to a self-report, cross-sectional A percent comparison of injury types reported survey of 276 amateur boxers in Australia, which for amateur boxing are summarized in Table 7.3. found that 61% of injuries reported by respondents Perusal of this table shows that the most commonly boxing 97
Table 7.3 Percent comparison of injury types in amateur boxing.
Amateur Military
Estwanik Timm Porter & Zazryn Zazryn Oelman Welch Welch et al. et al. O’Brien et al. et al. et al. et al. et al. Study 1984a 1993 1996 2006 2006 1983 1986 1986
No. of injuries 52 1219 64 4 4 437 73 221 Activity when injured C C & T C C T T C T Study time period 10 days 15.5 5 mo 12 mo 12 mo 12 yr 2 yr 2 yr yr Injury Types Concussion 6.1 51.6 25.0 26.3 5.5 8.1 Contusion/hematoma 23.1 24.9 3.1 3.0 32.9 20.8 Dislocation/subluxation 1.3 1.6 1.6 9.6 14.9 Fracture 17.3 4.9 14.1 25.0 25.0 28.1 26.0 21.7 Inflammation/tendinitis 1.9 10.0 4.7 2.7 3.6 Laceration/open wound/bleed 26.9 6.3 6.3 50.0 25.0 0.9 Sprain/strain 21.1 38.3 15.6 50.0 0.7 28.1 Other intracranial 16.5 Other 9.6 8.1 3.1 0.5 1.4 2.7 Not specified 22.4
C ϭ competition; T ϭ training. a Notable injuries (excluded minor injuries such as nosebleeds, black eyes, and lacerations). reported competitive injury types were lacerations et al. 2006). Porter and O’Brien (1996) reported that or other bleeding (6.3–50.0%), concussions (5.5– cerebral injury occurred in 11.7% of amateur fights. 51.6%), contusions or hematomas (3.1–32.9%), and Definitional issues exist for the reporting of con- fractures (14.1–26.0%) (Estwanik et al. 1984; Welch et cussion in boxing. A concussion could be reported al. 1986; Porter & O’Brien 1996; Zazryn et al. 2006). as a direct medical diagnosis by the ringside doc- The most commonly reported training injuries were tor or could be apparent as a knockout (KO), or as sprains and strains (0.7–50.0%) and fractures (21.7– the referee stopping the contest as a result of a head 28.1%). injury (RSC-H). The inclusion and exclusion of any Concussions (0.0–71.7%), fractures (particularly of these variables alters the concussion rate that is of the nose; 10.9–30.0%) and lacerations (generally reported. of the orbital region; 8.7–56.0%) are the most com- Studies reporting the proportion of bouts that mon head injury types sustained during competi- end in KO or RSC-H indicate that these outcomes tion bouts (Estwanik et al. 1984; Welch et al. 1986; occur in only 0.6% to 7.8% of bouts (Blonstein & Porter & O’Brien 1996; Zazryn et al. 2006). Upper- Clarke 1957; Schmidt-Olsen et al. 1990). Further, extremity injuries, however, tend to be sprains or information about Olympic bouts published since strains (0.0–100.0% of all upper-extremity injuries), 1980 shows a decreasing trend in the fights that are fractures (0.0–54.2%), contusions (0.0–47.8%), or ended by KO and RSC-H (Figure 7.2). dislocations (0.0–24.1%). In terms of acute neurologic injuries resulting Time Loss from amateur boxing, the most commonly reported type is concussion. Studies have reported the inci- Time loss from participation in boxing, other activi- dence of acute neurologic injury to be between ties, or work as result of a boxing injury has not been 6.5% and 51.6% of all injuries (Oelman et al. 1983; well studied. Table 7.4 displays the results of time Jordan et al. 1990; Porter & O’Brien 1996; Zazryn lost because of boxing injury. In military studies, 98 chapter 7
35
30
25
20
15
10
Proportion of All Bouts (%) 5
0 Moscow, Los Seoul, Barcelona, Atlanta, Sydney, 1980 angeles, 1988 1992 1996 2000 1984 Knock–out Figure 7.2 Proportion of all Referee stopped contest–head Olympic Games bouts ended prematurely since 1980. Referee stopped contest–injury Total ended prematurely
a wide variety of measures of time lost hinder the hard blows during a bout, they may require boxers ability to compare results. to discontinue competing or sparring for 4 weeks. Only one study in a nonmilitary population has At the end of any exclusion periods, a boxer is attempted to measure the effect of boxing injury on required to get medical certification before return- participation levels. In their cohort of 142 amateur ing to competitive boxing or sparring (International boxers, Porter and O’Brien (1996) reported that on Boxing Association 2007). average a boxing injury sustained during training resulted in 1.2 days of submaximal training. Clinical Outcome Injuries sustained during competition in amateur boxing that result in time loss are more difficult to Clinical outcomes as a result of amateur boxing measure because: (a) a mandatory exclusion time injury have only been studied in relation to deaths exists for AIBA boxers who have been knocked out and brain injury. Fortunately, fatalities appear to during a bout; and (b) many boxers do not return to be relatively uncommon, with only about one third training in the week following a fight, thus meas- (190) of the 645 boxing fatalities reported between ures of time lost could be biased toward a higher 1918 and June 1983 occurring in amateur box- figure. According to AIBA rules, boxers who have ers (Ryan 1983). No more recent data on fatalities had one KO or RSC-H, may not compete in a bout exist. Fatalities in military boxers have also been or sparring for a period of 4 weeks (International reported in the literature, although at low incidence Boxing Association 2007). If a boxer has had two (Enzenauer et al. 1989). Thus, with the exception KOs or RSC-Hs in a 3-month period, then a man- of discharges from the various military groups datory exclusion period from bouts and sparring of (Brennan & O’Connor 1968; Oelman et al. 1983; Ross 3 months exists, and if a boxer has three KOs or et al. 1999), and a few case reports of deaths (Cantu RSC-Hs within a 12-month period, he may not & Voy 1995; Ross et al. 1999; Constantoyannis & compete or spar for 1 year (International Boxing Partheni 2004), clinical outcomes of injury includ- Association 2007). In addition, if a boxing asso- ing the frequency of reinjury, residual symptoms, ciation considers that a boxer has received a lot of and nonparticipation are not known. boxing 99 8.1 11.1 11.4 Enzenauer et al. 1989 401 T 6 yr Average no. of sick days ( continued ) 7.5 4.6 6.2 Military Enzenauer et al. 1989 401 T 6 yr length Average of stay in hospital (days) 8.0 11.0 11.0 15.0 14.0 18.0 14.0 1986 73 T 2 yr Median no. of days excused from physical activity Hand, 11.0; Hand, 11.0; 15.0; finger, thumb, 16.0 b b b b b Contusions, 8.0 Fractures, 8.9; Fractures, contusions, 8.0 4.5 18.3 13.3 Fracture, 16.0; open Fracture, wound, 88.5 Oelman et al. 1983 et al. Welch 437 T 12 yr no. of days Average of inpatient stay (for service personnel admitted for у 2 days) wound, 88.5 subdural hemorrhage, hemorrhage, subdural cerebral 59.3; laceration & contusion, 242.0; 8.6 other, 8.8 12.5 Fracture, 21.0 Fracture, 7.0 12.2; open Fracture, 7.0 Open wound, 88.5 10.0 10.0 15.0 Concussion, 3.9; 20.0 Welch et al. Welch 1986 221 C 2 yr Median no. of days excused physical from activity a 9.0 12.0 Brennan & Brennan O’Connor 1968 240 C 14 yr no. of Average working days lost (for those off duty for у 48 hr) b b 0.0 4.9 4.9 14.2 Amateur Porter & O’Brien 1996 29 of days submaximal or missed training Neck Face/scalp Nose Not further specified/other Spine/trunk Ribs/chest Upper extremity Forearm Hands/fingers Table 7.4 Table of boxing injuries. lost as a result Time Study Wrist No. of injuries Activity when injuredStudy time period T of time lostMeasure 5 mo no. Average Location of injuries Head Intracranial Shoulder Upper arm Elbow 100 chapter 7 2.8 8.9 10.8 Enzenauer et al. 1989 5.9 2.8 5.1 Military Enzenauer et al. 1989 14.0 11.0 1986 b b 5.5 6.2 10.4 Oelman et al. 1983 et al. Welch 6.1 Dislocation,27.6 50.7 sprain/strain, Dislocation, 35.4; 50.7 sprain/strain, fracture, 45.3 fracture, ged). 19.0 Welch et al. Welch 1986 11.0 16.0 Brennan & Brennan O’Connor 1968 b b b 6.4 1.2 6.4 6.4 10.0 Amateur Porter & O’Brien 1996 continued ) An additional 3 airmen did not return to work (2 deaths, 1 invalided and dischar An additional 3 airmen did not return Reported as the one category. Lower leg All injuries Table 7.4 ( Table Study Not further specified C ϭ competition; T training. a b Not further specified/other Not further specified Lower extremity Knee Foot/Toes Ankle boxing 101
Nonfatal brain injury is the most severe injury of amateur boxers. Neuropsychological testing reported in the amateur boxing literature. These also shows conflicting results, with no correlation include case reports of acute intracranial injuries computed during a cross-sectional study but with (including subdural hematomas) (Cruikshank et al. increasing age being significantly correlated with 1980). However, one military article reports that reductions in neuropsychological test scores over a these represent only 0.3% of boxing injuries. This 9-year period (Brooks et al. 1987; Porter 2003). same article reported a rate of serious head injury of 1 per 60,000 boxing participants (Ross et al. 1999). Extrinsic Factors Catastrophic injuries of other types (e.g., perma- Exposure nent disability) have not been reported in the ama- teur boxing literature. Two case reports of cervical The published literature provides conflicting infor- spine fractures that were treated, with both boxers mation on whether or not any exposure variable having favorable outcomes (one with no recurrent is a risk factor for injury. McLatchie et al. (1987) neurologic deficits, and one with persistent head- have reported significant correlations between an aches), have also been reported (Place et al. 1996, increasing number of fights and a boxer having Ecklund & Enzenauer 1996; Strano & Marais 1983). an abnormal neurologic examination (P Ͻ 0.05). In univariate analyses, Kemp et al. (1995) showed an Economic Cost inverse relationship between reaction time and pat- tern recognition between low-bout (р40 fights) and There is no published research on the economic high-bout (Ͼ40 fight) boxers (P Ͻ 0.05). Significant costs of boxing injuries. reductions in finger-tapping speed between boxers with Ͼ30 fights and other athletic controls, includ- What Are the Risk Factors? ing lower-bout boxers, have also been shown in the literature (Murelius & Haglund 1991). Epidemiologic evidence of risk factors for injury in No study reports a significant difference between amateur boxing is not well established. Although the number of bouts participated in and the results many authors have hypothesized about factors that of any neuropsychological tests (Brooks et al. 1987; may lead to an increased injury risk, only evidence- Butler et al. 1993; Porter & Fricker 1996; Porter based assessment of factors related to neurologic 2003; Matser et al. 2000). This includes follow- injury in amateur boxers has been undertaken. up studies of boxers of periods from 3 days to 9 Table 7.5 shows a summary of intrinsic and extrin- years after baseline data-collection measurements sic risk factor research related to neurologic injury (Porter & Fricker 1996; Porter 2003; Moriarity et al. in amateur boxers. 2004). However, one study reported a significant trend result at baseline (based on increasing odds Intrinsic Factors ratios—all of which had nonsignificant 95% confi- dence intervals) for the parameters of perceptual/ Age motor function, memory, and visuoconstriction, The three aspects of a boxer’s age that are consid- although this trend was not shown at follow-up 2 ered important for injury development include age years later (Stewart et al. 1994). In addition, a study at commencement of boxing, current age, and the reporting EEG results, brainstem auditory evoked age at which they retire from competition (Jordan potentials, and auditory evoked P300 potentials 1996; Scott et al. 2001). In active amateur boxers, have not shown any significant correlations with McLatchie et al. (1987) found that decreasing age the number of bouts (Haglund & Persson 1990). was a risk factor for abnormal electroencepha- Haglund and Bergstrand (1990) report a sig- logram (EEG) results. In contrast, Haglund and nificant correlation between an increasing career Persson (1990) reported that EEG deviations were length and the occurrence of a cavum septum pel- not significantly correlated with age in a group lucidum (P Ͻ 0.05). In this same study, a correlation 102 chapter 7 11 fights were fights were Boxers who had у 11 likely to have reduced more memory function (OR, 2.23 [95% CI,0.94–5.27]), perceptual/motor skills (OR, 2.21 [95% CI, 0.89–5.43]) abilities (OR, and visuoconstructional 2.20 [95% CI, 0.97–5.02]), as compared with baseline. No changes based on bouts during the follow-up period found of sparring were or as a result ( P Ͼ 0.05). No significant difference between No significant difference novice and experienced boxers or as of no. bouts on any test a result head blows in fights ( P Ͼ 0.05). More lead to a significantly faster speed of ( P Ͻ 0.0001). information processing High match boxers ( Ͼ 30 fights) had significantly lower ( P Ͻ 0.05) finger- tapping performance than other but was still within “normal” groups, range. No other exams had signifi- ( P Ͼ 0.05). cant results based on number of KOs, wins, losses, RSC-Hs, length of career). Abnormal neurologic exam correlated exam correlated Abnormal neurologic no. of fights ( P Ͻ 0.05). with increasing with Abnormality on EEG correlated younger age ( P Ͻ 0.05). No variable was significantly associated ( P Ͼ 0.05) with abnormal (no. of fights, fights lost, test results KOs, length of career) Findings brainstem auditory evoked potentials, EEG, ataxia/ inter- vestibular test battery, views, and urine samples. Completed at baseline and then at 2-yr follow-up. Neurologic exam, tests of Neurologic cognitive function, brainstem EEG, CKBB evoked response, and ophthalmologic exam. within 6 days Done pre-bout, of a bout and at 2-yr follow-up. CT post-bout and at 2 yr. Clinical neurologic, physical, Clinical neurologic, exam, and neuropsychological MRI, and EEG. CT, Neuropsychological exam.Neuropsychological ( P Ͼ 0.05) No significant differences ropsychological exam, EEG ropsychological and CT Clinical neurologic and neu- Clinical neurologic exam, EEG. ropsychological Assessments a 365 active amateurs exam, Neuropsychological 86 active amateur union boxers; 47 rugby players; 31 water polo players 50 retired amateurs; 25 50 retired soccer players; 25 track and field athletes 29 active amateurs; (no amateur controls 11 sparring); 8 others 20 active amateurs and neu- Clinical neurologic 53 retired amateurs; 53 retired 53 former football players Participants without a parallel c ontrol group Interrupted time series Interrupted group with a control Case–control, Case–control, retrospective retrospective retrospective retrospective Design Stewart et al. 1994 time series Interrupted Butler et al. 1993 Haglund & Bergstrand Haglund & Bergstrand 1990; Haglund & Persson 1990; & Haglund Murelius 1991 Brooks et al. 1987Brooks Case–control, McLatchie et al. 1987 Cross-sectional, Thomassen et al. 1979 Case–control, Table 7.5 Table injury in amateur boxers. Risk factors for neurologic Study boxing 103 ϭ odds An improvement in learning per- An improvement formance was seen between boxers who had 3 bouts and their baseline to ( P Ͻ 0.05). Compared results baseline, boxers with RSC-H had times significant declines in reaction ( P Ͼ 0.01) and boxers with epistaxis time had a slowing of choice reaction ( P Ͻ 0.01). No significant correlations ( P Ͼ 0.05) No significant correlations between performances in any test no. of bouts with sparring frequency, of wins. or KOs/RSC-H percentage education age and lower Increasing test levels significantly reduced of greater (coefficients scores than 0.5). Greater weight and number of Greater punches in the fight significantly short-term memory reduced ( P ϭ 0.02). Lower ranked boxers (won fewer than 3 fights) showed slower attention test in the direct response ( P ϭ 0.01). Boxers who had a KO performed better at the puncture test with their nondominant hand ( P ϭ 0.04). No statistical differences existed based on winning, losing, or drawing ( P Ͼ 0.05). There was no significant associa- There tion ( P Ͼ 0.05) between tests scores baseline or follow-up for length at of no. of bouts, percentage of career, losses, weight division or education level. Low-bout boxers ( Ͻ 40 bouts) performed better than high-bout time and pattern boxers for reaction ( P Ͻ 0.05). recognition . ϭ computed imaging; OR magnetic resonance tomography; MRI ϭ Physical and computer- ized neuropsychological exam. Done 2 wk prior to a tournament and within 2 hr of a bout competed in at that tournament. Neuropsychological exam. Neuropsychological Done at baseline; 18 mo; 4 yr; 7 yr & 9 yr. Neuropsychological exam Neuropsychological and after a bout. before Neuropsychological exam. Neuropsychological Done at baseline and 15–18 mo later. Psychometric exam and perfusion measured cerebral SPECT. HMPAO by Tc-99m 82 active amateurs; 30 age-matched university controls students were 39 active amateurs; 28 age-matched males training at a gym or living in same suburb controls were having a fight; 28 active amateurs not having a fight but asked to controls were exercise 20 active amateurs; matched for 20 controls age and socioeconomic status 41 boxers; 34 service- controls men were opyleneamineoxime single-photon emission computed tomography with a control group with a control Interrupted time series Interrupted group with a control with a control group with a control Case–control, Case–control, retrospective While studies that included control groups are reported here, only the results for the boxing groups are shown; results comparing boxers with control groups have been omitted. groups boxers with control comparing shown; results are for the boxing groups only the results here, reported are groups While studies that included control Moriarity et al. 2004 time series Interrupted Porter 2003 Matser et al. 2000 before–after Controlled 38 active amateurs Porter & Fricker 1996 time series Interrupted ratio;Tc-99m HMPAO SPECT ϭ technetium-99m hexamethylpr HMPAO ratio;Tc-99m Kemp et al. 1995 EEG ϭ electroencephalogram; CI ϭ confidence kinase isoenzyme BB; CT creatine interval; CKBB ϭ a 104 chapter 7 with the number of fights lost by a boxer and the of headgear use, glove weight, and hand bandages) number of KOs or RSC-H were also significantly were in place for amateur competition. No signifi- associated with cavum septum pellucidum find- cant change in the number of bouts ended early was ings (P Ͻ 0.05) (Haglund & Bergstrand 1990). Other seen in the later years in which headgear was worn, studies, however, have reported that an increasing glove weight was increased, and hand bandaging number of KO, TKO, or RSC-H results have been was allowed (Schmidt-Olsen et al. 1990). correlated with improvements between baseline and post-bout measurements for simple and choice reac- Further Research tion times (P Ͻ 0.01) and nondominant hand punc- Informed decisions regarding injury-prevention ture (P ϭ 0.04) tests (Matser et al. 2000; Moriarity practices in amateur boxing require accurate and et al. 2004). Two studies have found no differences reliable data on the distribution and determinants of between injury outcome and the number of KO/TKO injury. The amateur boxing literature is replete with or RSC-H results (Murelius & Haglund 1991; Porter case series and case–control studies, mainly related 2003). No significant results either at baseline or at to neurologic injury, but is lacking in basic epidemi- up to a 9-year follow-up have been shown in relation ologic description and cohort studies for prospective to sparring exposure or win/loss percentages and longitudinal follow-up of boxers. As such, the details neuropsychological test results (Brooks et al. 1987; regarding injury risks that could be used to inform Stewart et al. 1994; Matser et al. 2000; Porter 2003). injury prevention are not yet known. Therefore, the establishment of larger-scale surveillance systems to What Are the Inciting Events? document current and reliable data on injury trends and risk factors for amateur boxing are needed. Only one study has reported inciting events leading to An international surveillance system that boxing injuries (Tan et al., 2002). In this study, factors includes all AIBA countries and uses a standard- thought to contribute to head injuries included a loss ized injury definition would help correct many of of concentration (40.0%), poor technique (27.3%), mis- the methodologic limitations of past research. In matching of opponents (14.6%), not using headgear particular, this surveillance system should aim to (3.6%), and illegal blows by an opponent (foul; 3.6%). include the following information:
Injury Prevention • demographic details of boxers (including date of birth, country of origin, year of boxing registra- A number of measures have been put in place in ama- tion, etc); teur boxing over the past few decades to decrease the • medical reports (details obtained from preregis- likelihood of poor outcomes associated with partici- tration, annual, and prefight and postfight medi- pation in the sport (Jako 2002). These include: cal checks); • careful medical control • fight details (including date, weight at weigh-in, • use of protective equipment opponent name, opponent’s weight at weigh- • improved refereeing; and in, venue, number of scheduled and completed • mandatory exclusion rounds, fights results, etc); • injury details from competition (including date No randomized, controlled trials have been con- of injury, specific body region injured, injury ducted to evaluate the efficacy of any injury-preven- nature, specific mechanism of injury, any con- tion techniques for amateur boxing. The only study tributing factors, use of protective equipment, in which the potential effectiveness of injury-preven- medical diagnosis, treatment given, measure of tion strategies in boxing was a retrospective analysis impact—time off sport/work, and date of return of the number of bouts ended by KO or RSC-H in to training/sparring/competition); Denmark (Schmidt-Olsen et al. 1990). Throughout • weight difference between competitors at the each of the 3 years studied, different rules (in terms time of a competitive bout; boxing 105
• details of any exclusion periods imposed and strength, biomechanics), boxing skill/technique/ compliance with these; performance, preexisting medical conditions, pre- • training exposure (including amount of training vious injury, genetics, psychological factors, the and sparring, activities undertaken, etc); and equipment used (including the ring, gloves, hand • training injuries (including date of injury, spe- bandages, groin protectors, and headgear), varia- cific body region injury, injury nature, spe- tions in rules and regulations, the medical support cific mechanism of injury, any contributing given, and the training practices and injury treat- factors, use of protective equipment, medical ment and prevention knowledge of trainers and diagnosis, treatment given, measure of impact— boxers. time off sport/work, and date of return to This review of the amateur boxing injury litera- training/sparring/competition). ture highlights the need for larger-scale, prospec- tive surveillance systems to be developed and Risk factors yet to be studied within the amateur implemented. Such surveillance is needed to deter- boxing literature include sex, weight (either at the mine the risk factors for injury development for time of the fight, differences between competitors, this sport as the current available literature fails to or loss in the lead up to a fight), the physical provide evidence for injury prevention strategies to condition of the boxer (including conditioning, be developed.
References
BBC. (2007a) Early Boxing History. BBC case report from Greece. British Journal http://www.aiba.org [accessed on Co. URL http://www.bbc.co.uk/ of Sports Medicine 38, 78–79. January 10, 2008] london/sport/boxing/early_history. Cruikshank, J., Higgens, C. & Gray, J. International Olympic Committee (2008) shtml [accessed on April 14, 2007] (1980) Two cases of acute intracranial Boxing. Official website of the Olympic BBC. (2007b) A London Revival—Part 1. haemorrhage in young amateur boxers. Movement. URL www.olympic.org/ BBC Co. URL http://www.bbc.co.uk/ The Lancet 1, 626–627. uk/index_uk.asp [accessed on May london/sport/boxing/london_revival. Enzenauer, R., Montrey, J., Enzenauer, R. & 12, 2008] shtml [accessed on April 14, 2007] Manning Mauldin, W. (1989) Jako, P. (2002) Safety measures in amateur Blonstein, J. & Clarke, E. (1957) Further Boxing-related injuries in the US boxing. British Journal of Sports Medicine observations on the medical aspects of Army, 1980 through 1985. Journal of 36, 394–395. amateur boxing. British Medical Journal the American Medical Association 261, Jordan, B. (1993) General concepts. In: 1, 362–364. 1463–1466. Medical Aspects of Boxing (Jordan, B., Brennan, T. & O’Connor, P. (1968) Estwanik, J., Boitano, M. & Ari, N. ed.), CRC Press, Boca Raton, FL, Incidence of boxing injuries in the (1984) Amateur boxing injuries at the pp. 4–10. Royal Air Force in the United Kingdom 1981 and 1982 USA/ABF national Jordan, B. (1996) Boxing. In: Epidemiology 1953–1966. British Journal of Industrial championships. The Physician and of Sports Injuries (Caine, D., Caine, C. & Medicine 25, 326–329. Sportsmedicine 12, 123–128. Lindner, K., eds.), Human Kinetics Brooks, N., Kupshik, G., Wilson, L., Haglund, Y. & Bergstrand, G. (1990) Does Publishers, Inc., Champaign, IL, Galbraith, S. & Ward, R. (1987) A Swedish amateur boxing lead to chronic pp. 113–123. neuropsychological study of active brain damage? 2. A retrospective study Jordan, B., Voy, R. & Stone, J. (1990) amateur boxers. Journal of Neurology, with CT and MRI. Acta Neurologica Amateur boxing injuries at the Neurosurgery, and Psychiatry 50, Scandinavica 82, 297–302. US Olympic Training Center. The 997–1000. Haglund, Y. & Persson, H. (1990) Does Physician and Sportsmedicine 18, Butler, R., Forsythe, W., Beverly, D. & Swedish amateur boxing lead to chronic 81–90. Adams, L. (1993) A prospective brain damage? 3. A retrospective Kemp, P. (1995) A critique of published controlled investigation of the cognitive clinical neurophysiological study. Acta studies into the effects of amateur effects of amateur boxing. Journal of Neurologica Scandinavica 82, 353–360. boxing: Why is there a lack of Neurology, Neurosurgery, and Psychiatry International Boxing Association (2007) consensus? Journal of the Royal Naval 56, 1055–1061. Rules for International Competitions Medical Service 81, 182–189. Cantu, R. & Voy, R. (1995) Second impact or Tournaments. Maison du Sport Loosemore, M., Knowles, C. & Whyte, G. syndrome: A risk in any contact sport. International. URL http://www.aiba. (2007) Amateur boxing and The Physician and Sportsmedicine 23, org [accessed on January 10, 2008] risk of chronic traumatic brain 27–34. International Boxing Association. (2008) injury: systematic review of Constantoyannid, C. & Partheni, M. Affiliated National Federations: Directory. observational studies. British Medical (2004) Fatal head injury from boxing: A Maison du Sport International. URL Journal. 335, 809. 106 chapter 7
Matser, E., Kessels, A., Lezak, M., Troost, Porter, M. (2003) A 9-year controlled Randall, R. (1994) Prospective study J. & Jordan, B. (2000) Acute traumatic prospective neuropsychologic of central nervous system function in brain injury in amateur boxing. The assessment of amateur boxing. amateur boxers in the United States. Physician and Sportsmedicine 28, 87–92, Clinical Journal of Sport Medicine 13, American Journal of Epidemiology 139, 95–96. 339–352. 573–588. McCrory, P., Zazryn, T. & Cameron, Porter, M. & Fricker, P. (1996) Controlled Strano, S. & Marais, A. (1983) Cervical C. (2007) The evidence for chronic prospective neuropsychological spine fracture in a boxer—a rare but traumatic encephalopathy in boxing. assessment of active experienced important sporting injury: a case Sports Medicine 37, 467–476. amateur boxers. Clinical Journal of Sport report. South African Medical Journal 63, McLatchie, G., Brooks, N., Galbraith, S., Medicine 6, 90–96. 328–330. Hutchison, J., Wilson, L., Melville, I. & Porter, M. & O’Brien, M. (1996) Incidence Tan, S., Ghougassian, D., Baker, W. & Teasdale, E. (1987) Clinical neurological and severity of injuries resulting from Johnson, P. (2002) Profile of head examination, neuropsychology, amateur boxing in Ireland. Clinical injuries in NSW amateur boxing. electroencephalography and computed Journal of Sport Medicine 6, 97–101. Advanced Sports Research Institute, tomographic head scanning in active Ross, R., Ochsner, M. & Boyd, C. (1999) New South Wales Australia. amateur boxers. Journal of Neurology, Acute intracranial boxing-related Timm, K., Wallach, J., Stone, J. & Ryan Neurosurgery, and Psychiatry 50, 96–99. injuries in U.S. Marine Corps recruits: III, E. (1993) Fifteen years of amateur Moriarity, J., Collie, A., Olson, D., report of two cases. Military Medicine boxing injuries/illnesses at the United Buchanan, J., Leary, P., McStephen, 164, 68–70. States Olympic Training Center. Journal M. & McCrory, P. (2004) A prospective Ryan, A. (1983) Eliminate boxing gloves. of Athletic Training 28, 330–334. controlled study of cognitive function The Physician and Sportsmedicine 11, 49. Thomassen, A., Juul-Jensen, P., De during an amateur boxing tournament. Schmidt-Olsen, S., Kallund Jensen, S. & Fine Olivarius, B., Braemer, J. & Neurology 62, 1497–1502. Mortensen, V. (1990) Amateur boxing in Christensen, A. (1979) Neurological, Murelius, O. & Haglund, Y. (1991) Denmark: the effect of some preventive electroencephalographic and Does Swedish amateur boxing measures. The American Journal of Sports neuropsychological examination of 52 lead to chronic brain damage: 4. A Medicine 18, 98–100. former amateur boxers. Acta Neurologica retrospective neuropsychological study. Scott, I., Finch, C., Ozanne-Smith, J., Eime, Scandinavica 60, 352–362. Acta Neurologica Scandinavica 83, 9–13. R., Staines, C. & Clapperton, A. (2001) Welch, M., Sitler, M. & Kroeten, H. Oelman, B., Rose, C. & Arlow, K. (1983) Counting Injuries Out of Boxing. Monash (1986) Boxing injuries from an Boxing injuries in the Army. Journal of University, Melbourne, Australia. instructional program. The Physician and the Royal Army Medical Corps 129, 32–37. Stening, W. (1992) Boxing. The Medical Sportsmedicine 14, 81–89. Place, H., Ecklund, J. & Enzenauer, Journal of Australia 156, 76–77. Zazryn, T., Cameron, P. & McCrory, P. R. (1996) Cervical spine injury in a Stewart, W., Gordon, B., Selnes, O., (2006) A prospective cohort study of boxer: Should mandatory screening be Bandeen-Roche, K., Zeger, S., Tusa, R., injury in amateur and professional instituted? Journal of Spinal Disorders Celentano, D., Shechter, A., Liberman, boxing. British Journal of Sports Medicine 9, 64–67. J., Hall, C., Simon, D., Lesser, R. & 40, 670–674. Chapter 8
Cycling
ANDREW L. PRUITT AND TODD M. CARVER The Boulder Center for Sports Medicine, Boulder, Colorado, USA
Introduction Athens. This discipline of cycling still exists, but Cycling was included in the first modern Olympic many other forms have become recognized as Games in 1896. For almost a century, road racing at an Olympic sport. Of them, track racing was the the Olympics was a male-dominated sport. It was next to be introduced as an Olympic sport in 1924. not until 1984 that women competed in the first- During track events, riders race around in circles ever Women’s Olympic road race. During the 2008 on a 42-degree-banked track. Olympic-level track Beijing Olympic Games both men’s and women’s racing is comprised of many subcategories, includ- road races comprised the events that made up the ing Individual Pursuit, Points, Sprint races, Kierin, Olympic road-racing category. Madison, and Team Pursuit races. Of these, women In the early years, competitive cycling was lim- do not compete in the first four of these events. ited to open-road, mass-start style racing. Figure 8.1 At the 1996 Atlanta games the Time Trial was is an image from the 2004 Olympic road race in introduced. Riders were chosen from their respective
Figure 8.1 This is an image taken during the Cycling Individual Road Race at the 2004 Olympic games in Athens. © IOC/Shiniciro TANAKA.
Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 Blackwell Publishing, ISBN: 9781405173643 107 108 chapter 8 countries to compete individually, against the studies, cross-sectional surveys, and case–control clock, in time-trial fashion. Time trials are open- designs. Each of these methods of data collection road style racing, but have an individual-start for- has inherent inaccuracies, mainly in the form of mat. Racers typically start at 90-second intervals subjective self-reporting and low response rates. and race on a course designed to be completed in Thus, there is concern regarding the representative under an hour. quality of the studies reviewed. Also in Atlanta, MTB racing was first repre- sented in the Olympic Games. Olympic MTB racing Who Is Affected by Injury? consists of cross-country (CC) and downhill (DH) racing. During a CC event racers compete on very Cycling, apart from competition, is thought by hilly, sometimes mountainous courses. The race is many to be a relatively safe form of aerobic exer- a test of their riding skill and pedaling endurance cise. By way of eliminating repeated foot-to-ground against other racers. These races begin as mass- contact, the sport is a great means of developing start events but because of the variable terrain, cardiovascular fitness without the impact of large the pack of riders usually break into small groups forces in the musculoskeletal system. However, the quickly after the start. During a DH event, racers sport of competitive cycling requires much higher race against the clock in time-trial format, mostly speeds and much higher muscle and joint loads down the mountain. The typical race duration is than recreational cycling. This predisposes the com- quite short, lasting anywhere between 2 and 10 petitive cyclist to increased risk of injury during the minutes. considerable time spent training and racing. The BMX races were included for the first time typical Olympic-level cyclist races 50 to 80 days a in the 2008 Olympic games in Beijing, China. season and trains 20 to 40 hours/wk in preparation BMX races are held on dirt tracks with abundant (Olympic Movement 2008). banked turns and jumps. The track is usually While many studies have shown injury rates around 350 m long. The riders compete in “heats” and characteristics of recreational cycling (Chow (qualifying rounds, quarter-finals, semifinals, and et al 1993), as meant very few have studied the finals), with the top four qualifying for the next competitive population. Because of the high speeds round. associated with competitions the sport experiences The purpose of this chapter is to review the epi- significant and frequent crashes and subsequent demiology of the injuries that occur in the Olympic injuries. Table 8.1 shows a comparison of injury rates events of cycling. The specific cycling disciplines across cycling disciplines gathered from mainly include Road Racing, Track Racing, Mountain retrospective, survey-based studies. The MTB dis- Biking (MTB), and BMX. These disciplines were cipline of competitive cycling has been the most introduced to the Olympic Games at different times heavily studied in terms of injury rates. This interest throughout the last century. is not surprising, considering that this sport experi- There are very few published studies in the med- ences a relatively high rate of injury because of the- ical or cycling literature concerning the epidemiol- variable terrain on which the mountain biker races. ogy of injury in cycling. The sport itself is wrought The first-ever study analyzing injury rates with tradition, superstition, and folklore, none of in competitive mountain biking was published which relates well to the scientific investigation of by Kronisch and Rubin (1994). Of the 265 rac- sports injuries. To our knowledge, this is the first ers surveyed, 86% reported at least one injury attempt to create a review of the published litera- in the previous year. These results suggest that ture on the epidemiology of cycling injuries as they Olympic-level MTB racing is quite dangerous. relate to Olympic-level competition. But, on further analysis, it was obvious that some Notably, none of the studies reviewed in this of the injuries reported were very minor. Of the chapter are prospective cohort studies. The limited reported injuries, only 20.4% required medical research that does exist is mainly in the form of case attention. cycling 109
Table 8.1 Published studies on injuries in competitive cycling.
Study Type of Design/Data No. of Participants Duration of Data Results Cycling Collection (surveys received/ Collection surveys sent)
Kronisch & MTB R/Q 265 surveys sent 1 yr 85.7% of the 265 Rubin (1994) studied were injured in the year 1992; 20.4% required medical attention. Pfeiffer (1993) MTB R/Q 63 1 yr 90.5% of the 63 surveyed were injured in the year 1991. Pfeiffer (1994) MTB R/Q 61 1 yr 88.5% of the 61 surveyed were injured in the year 1992. Krosnich et al. MTB Observational 4027 3 days of off- Overall injury rate of (1996) road racing, one 0.49% for CC and 0.51% for single event DH; 0.37 injuries/100 hr racing for CC, 4.34/100 hr for DH. Pfeiffer & MTB Observational/I 8,804 3 different events Overall injury rate of Kronisch (1995) on NORBA 0.45%, with no differences calendar between DH and CC. Callaghan & Rd, Tr, MTB R/Q 92/71 1990–1995 Low back pain was Jarvis (1996) reported in 60% of racers, 33% reported knee pain.
BMX ϭ BMX; CC ϭ cross country; DH ϭ downhill; MTB ϭ mountain; I ϭ interview; NORBA ϭ National Off-Road Bicycle Association; P ϭ prospective; Q ϭ questionnaire; R ϭ retrospective; Rd ϭ road; Tr ϭ track.
Using riders from the National Off-Road Bicycle sections of the course in either the cross-country, Association (NORBA) racing series, Pfeiffer (1993, downhill, or eliminator event. 1994) collected data on the rates of injury in the Pfeiffer and Kronisch (1995) prospectively stud- pro/elite category. During 1993, 57 of the 63 riders ied injuries occurring during three off-road cycling surveyed reported an injury and in 1994, 54 of the events. The overall injury rate was 0.45% (or 40 of 61 racers reported at least one injury. the 8,804 racers observed). No difference was found It was clear that a new criterion for “injury” between the cross-country and downhill events. was needed. In 1996, Kronisch went to Mammoth No effects of sex were found for cross-country and Lakes, CA, for the NORBA series final and reported downhill, but interestingly, women appeared more on the frequency of injuries across the five events: likely than men to sustain an injury during the cross-country, downhill, dual slalom, hill climb and eliminator event (2.17% vs. 1.61%). eliminator (Kronisch, R.L., Pfeiffer, R.P. & Chow, T.K. (1996). A criterion for injury documentation Where Does Injury Occur? was that medical attention was required. In total, 4,027 racers competed in Mammoth Mountain for Anatomical Location the 1996 study. Of these, 16 were injured. The over- all injury rate, for all events, was 0.40%. However, Callaghan and Jarvis (1996) studied the relative of the 16 injuries, 13 occurred during downhill frequency of injuries sustained to various areas of 110 chapter 8 the body in a group of 71 competitive racers injured What Is the Outcome? during 1990–1995. They reported that low back pain was the leading site of injury among their studied Injury Type population of cyclists. Of the 71 questionnaires re - In the recreational population of riders, the knee turned for analysis, 60% reported low back pain, ac counts for more overuse injuries (Bassett et al. 33% knee pain, and 30% neck or shoulder pain or 1978; Hannaford et al. 1989; Holmes et al. 1991; both. Quite surprisingly, only 5.6% reported any Burke 1990). But, among the competitive popu- groin pain, which commonly affects recreational lation of cyclists, back pain (Callaghan & Jarvis cyclists (Dettori & Norvell 2006). 1996) appears to be the most prevalent condition. The data generated by Callaghan and Jarvis In the British study between the years of 1993– (1996) would seem contradictory to research 1995, the prevalence of back injury, classified collected in the United States, which sug- as requiring medical care, was 60% (Callaghan gests that the knee is the most injured area of & Jarvis, 1996). The comparable figure for knee the body during competitive cycling (Holmes pain was 33%. However, the results indicate et al. 1991). However, Holmes et al. (1991) found that Callaghan and Jarvis (1996) considered only that the knee was the most commonly injured patellofemoral knee pain. This restriction would body part in the lower extremity, not in the severely underestimate the true injury rate of the entire body. total knee joint. Environmental Location Knee injuries are classified as anterior, pos- terior, medial, and lateral in location. Holmes The only published data regarding environmental et al. (1991) studied 354 cyclists and categorized location arise from the sport of mountain biking. their knee injuries by the location of the injury Kronisch et al. (1996) reported that 81% of accidents and the level of the cyclist. As shown in Table 8.2, occur during downhill sections of the course when the anterior knee is the most commonly injured speed is speculated to be at its peak. area across all levels of cyclists in their study. The diagnoses include chondromalacia, patellar tend- When Does Injury Occur? initis, quadriceps tendinitis, and patellofemoral disease. Injury Onset Friction and pressure at the interface between the saddle and the perineum cause considerable There are no published data on the relative problems for the cyclist. The most benign of the pro-portions of injury related to injury onset. problems are termed “saddle sores” by the vast However, it is reported that overuse injuries of the majority of cyclists. These sores can be very prob- low back and the pelvis are very common in elite lematic for the elite cyclist and may even progress cyclists (Callaghan & Jarvis, 1996). They can range into a cyst, which can end a cyclist’s season from a simple muscle strain of the gluteals to bur- prematurely. sitis, peritoneal/genital compression injury. and Perineal/genital conditions may also affect the arteriosclerosis in the groin region (Holmes et al. cyclist and include painful urination, prostatitis, 1991, 1995). urinary tract infections, and sexual dysfunction (Dettori & Norvell, 2006). Iliac artery endofibro- sis is also a concern among competitive cyclists Chronometry (Chevalier et al. 1985). Urinary strictures have also Specific data on the incidence rates and timing been identified in BMX athletes (Delaney & Carr of injuries sustained by racers are currently not 2005). However, no data exist on the frequency of available. these conditions among competitive cyclists. cycling 111
Table 8.2 Incidence of overuse knee injuries in 354 cyclists (may have more than one diagnosis).
Level I (elite) Level II (competitive) Level III (recreational)
Number of cyclists 58 122 174 Anterior Chondromalacia 15 56 87 Patellar tendinitis 17 15 21 Quadriceps tendinitis 8 4 6 Patellofemoral disease — 1 12 % of Cyclists 68.9 62.3 72.4 Medial Medial capsule/plica 7 18 6 Medial retinaculum/patellofemoral 57 12 ligament Plica and medial patellofemoral 83 2 ligament Pes anserinus — 3 5 % of Cyclists 34.5 25.4 14.4 Lateral Iliotibial band syndrome 13 26 46 % of Cyclists 22.4 21.3 26.4 Posterior Hamstring 10 3 2 Posterior capsule — 4 3 % of Cyclists 17.2 5.7 2.9
From: Holmes, J.C., Pruitt, A.L., & Whalen, N.J. (1991) Cycling overuse injuries. Cycling Science 3(2), 11.
Ulnar- and medial-nerve palsy at the wrist has important races for the Olympic selection process been called “cyclist’s palsy” and has long been could be missed. Surprisingly, no data were found identified as a cycling-specific injury affecting com- on the amount of time that is lost because of vari- petitive cyclists because the nerves are compressed ous injuries sustained in competitive cycling. for long periods of time. The results of one prospec- tive study indicate that the incidence of cyclist’s Clinical Outcome palsy is highest among mountain bikers but equal among all other levels of cyclists (Patterson No data exist regarding the long-term or residual et al. 2003). effects of injuries occurring during competitive cycling–related injuries. Time Loss Economic Cost As in any professional sport, time loss due to injury can have a significant effect on a cyclist. During the The economic cost of an injury can vary dramati- time spent recovering from an injury, cardiovascu- cally according to the severity and location of the lar fitness is usually lost, which places the racer at a trauma. No data exist on the economic cost to a disadvantage on returning to the sport. In addition, racer. 112 chapter 8
What Are the Risk Factors? wearing a helmet during competition are sparse, a significant decline has been reported in race-related Although it is believed that such factors as skill, head injuries in the United States (McLennan et al. sex, previous injury, and concentration may relate 1988; Runyan et al. 1991; Chow et al. 1993) since to the risk of cycling injury, there are currently no the advent of the helmet law. No such data are studies that have tested these factors. available for Europe. But, since competitive cyclists spend the majority of the time training on the open What Are the Inciting Events? roads, outside competition (where the helmet law does not apply), it is also important to study com- During training, racer accidents are unpredictable. pliance with the helmet rule. Most often, injuries sustained by competitive cyclists while outside competition are caused by collisions with motor vehicles. During competition, racer acci- Further Research dents can be caused by poor road or trail conditions, The epidemiology literature on cycling injuries is collision with a race-related automobile or motorcy- greatly lacking. There are few prospective stud- cle, or direct bicycle-to-bicycle contact. However, no ies that provide descriptive information on rate data exist on the types or frequencies of events that of injury, injury location, environmental location, lead to accidents and subsequent injury. injury onset, chronometry, injury type, time loss, It is currently thought that bike fit, or the rela- clinical outcome, economic cost, or the risk fac- tive positioning of the rider’s contact points to the tors associated with injury susceptibility. Similarly, bicycle (feet, pelvis, hands), has potential effects studies on preventive measures are sparse. on the likelihood of injury. However, no such data This chapter has reviewed the literature, limited exist. as it may be, on injuries among cyclists competing at the Olympic level. It is clear that a need exists for Injury Prevention larger-scale observational and intervention studies The use of a helmet is the most effective means of investigating the distribution and determinants of preventing bicycle-related head and facial injuries injuries encountered during competitive cycling. during recreational cycling (Rivera et al. 1994; Pitt One area, in particular, with a large deficit of et al. 1994; Carr et al. 1995). However, helmets have knowledge regarding injury is in the field of cycling only recently been required for competitive cyclists. biomechanics. Because of the high incidence rate of In the United States, helmet use has been manda- overuse injuries, it is clear that further research is tory during competition since 1986. And in Europe needed to study the clinical incidence of overuse the competitive cyclist was free to race without a cycling injuries and related risk factors and inciting helmet until 2003. While the data on the efficacy of events.
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Equestrian
PAUL MCCRORY1 AND MICHAEL TURNER2 1Centre for Health, Exercise and Sports Medicine, University of Melbourne, Victoria, Australia 2Chief Medical Adviser, British Horseracing Authority, London, UK
Introduction In 682 b.c., a chariot race was run at Greece’s 25th Olympiad, marking the earliest recorded date in equestrian sports history. From that early begin- ning, both team and individual equestrian events developed and in the modern era, equestrian as a competitive sport first began in 1868 at the Royal Dublin Horse Show. By the latter part of the 19th century, there were regular international events and competitions. Although individual show jumping was part of the Paris Olympics of 1900, the full equestrian program of dressage, show jumping, and 3-day eventing was introduced at the Stockholm Olympics in 1912, see Figure 9.1. Very quickly, the need for standardized interna- tional rules was recognized, and in May 1921 dele- gates from 10 national equestrian organizations met in Lausanne, Switzerland, to discuss the formation of an international federation in order to harmonize regulations governing the sport. The Fédération Equestre Internationale (FEI), founded in the same year remains the international body governing equestrian sport recognized by the International Olympic Committee (IOC). The FEI is the sole controlling authority for all international events in dressage, jumping, eventing, driving, endurance, vaulting, reining and para-equestrian. It establishes Figure 9.1 Olympic equestrian sport—3-day event. the regulations and approves the equestrian pro- © IOC / Yasuo YUBA. grams at championships, continental and regional Equestrian Sports in the Ancient Olympics games as well as the Olympic games. The ancient Olympics were rather different from the modern Games. Beginning in 776 b.c. with a Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 single foot race, these games became the preemi- Blackwell Publishing, ISBN: 9781405173643 nent games in ancient times. Equestrian sports 114 equestrian 115
were introduced at the 25th Olympiad in 682 b.c. with 70 horses involved in the competitions. Since The original stadium was too small for the four- 1928, the six key events (team and individual com- horse chariot race, so all horse-racing events were petition in the three disciplines) have remained rel- held at the hippodrome, adjacent to the main sta- atively constant. dium. Over time, the events expanded to encom- From 1952 onward, equestrian sports became pass both two-horse chariot and four-horse chariot one of the very few Olympic events in which men races, with separate races for chariots drawn by and women (civilian as well as military) com- foals. Another known Olympic event was a race pete directly against one another. In team com- between carts drawn by a team of two mules, petition, teams may have any blend of male and somewhat reminiscent of the “chuck wagon” races female competitors, and are not required to have seen at modern-day rodeos. The course for all char- minimum numbers of either sex; countries are iot events was 12 laps around the stadium track free to choose the best riders, irrespective of sex. (ϳ9 miles). For races with single riders, the course Equestrian disciplines and the equestrian compo- was 6 laps around the track (ϳ4.5 miles), and there nent of the Modern Pentathlon are also the only were separate races for full-grown horses and foals. Olympic events that involve animals. The horse Jockeys rode without stirrups. Only wealthy people is considered as much an athlete as the human could afford to pay for the training, equipment, and rider. feed of both the driver (or jockey) and the horses. Additional events sanctioned by the FEI as inter- As a result, the owner received the olive wreath of national disciplines include combined driving, victory instead of the driver or jockey. reining, equestrian vaulting, endurance riding, and Paralympic competitions. While these events are recognized internationally and are all part of Equestrian Sports in the Modern Olympics the FEI World Equestrian games, none are yet part Equestrian events were first included in the mod- of the Summer Olympics, though some, such as ern Olympic Games in 1900 at the Paris Olympics, vaulting and reining, are potentially on track to be with individual show jumping, high jumping, and added. long jumping. At the 1906 IOC meeting, Baron Pierre de Coubertin, the founder of the modern Recreational Equestrian Sports Olympics, requested that a Swedish cavalry officer Count Clarence Von Rosen draft a more detailed The vast majority of horse riders are amateurs who Olympic equestrian program. This was then sub- ride for recreation. The demographics of injury at sequently presented to the Olympic Congress at this level are largely unknown, although some the Hague in 1907 and was accepted for the 1908 information is available in specific subgroups of Games to be held in London. However, when the riders, such as professional jockeys, rodeo riders, Organising Committee received the entries from and polo participants. (Turner & McCrory, 2002). 88 riders from 8 nations, it was overwhelmed and In broad terms, the approximate numbers of unable to organize the full program. Fortunately, horse riders is known. In the United States, over the 1912 Games were awarded to Stockholm, 30 million people ride on a regular basis, with and the equestrian Olympic program proposed more than 2 million of these being under the age by Count Van Rosen was readily accepted. In the of 19 (Bixby-Hammett & Brooks 1990; Bixby- autumn of 1911, the invitations were sent out to the Hammett 1992; Nelson & Bixby-Hammett, 1992, military departments and to the National Olympic Nelson et al. 1994a, Nelson et al. 1994c). In the Committees. The three-day event (eventing) was United Kingdom, this figure is estimated to be 3 limited to officer entries, but the jumping and dres- million regular participants, with one third being sage competitions were open to civilians. The first children. (Silver & Parry, 1991) In Australia, there Equestrian participation at the Olympics saw 62 are over 250,000 people actively engaged in rec- competitors (all military officers) from 10 nations, reational horse riding, with 74,000 registered 116 chapter 9 child participants in events run by pony clubs exposure information to suggest that injured rid- and the Equestrian Federation of Australia ers’ represent the typical horse-riding population. (Cripps 2000). Although numerous case series have reported specific injury occurrences, such as catastrophic Methods and Aims head or spinal injury, the common thread miss- ing throughout all these studies is information on This chapter seeks to define the scope and epidemi- exposure. (Ball et al. 2007; Gabbe et al. 2005) Similar ology of injuries seen in equestrian sports and their criticisms can be made about electronic injury sur- nature and risk factors. It must be noted that little veillance systems, such as the U.S. national injury or no specific injury information exists with regard surveillance system (http://www.nyssf.org/sta- to Olympic equestrian competition and as a result, tistics1998.html) or the North American CHIRPP information has been sought from the wider spec- database (http://www.hc-sc.gc.ca/pphb-dgspsp/ trum of equestrian sport. publicat). The limited available data on equestrian injury Injury information from retrospective and case are largely a reflection of the way horse riding is series studies of injuries affecting equestrian rid- conducted. Namely, the sport is mostly amateur, ers are summarized in Table 9.1. A review of this variably supervised, and, apart from limited com- table provides a demographic breakdown by age petitive situations, is not subject to administrative and sex. where reported, and by the most frequent control that would enable the compilation of injury injures. It is important to note that in line with the data. Injuries, especially minor injuries, are seldom majority of epidemiologic data in this sport, infor- reported, and there are no regulatory requirements mation is derived mostly from postal surveys, ret- anywhere in the world that compel formal injury rospective questionnaires of hospitalized patients, notification for this sport other than in professional and hospital inpatient data (where no exposure horseracing in some countries. This lack of detailed information is recorded) and are biased toward information is somewhat surprising, given that acute injuries. Nevertheless, it can be seen that horse riding is one of the most popular participa- young (Ͻ 15 years) female riders predominate and tion sports with tens of millions of active riders in that fractures are the most common injury noted. most Western countries. In addition, there are articles specifically exam- ining acute recreational equestrian participation Who Is Affected by Injury? and pediatric injuries (Grossman et al. 1978; Lloyd 1987; Bixby-Hammett & Brooks 1990; Horse racing is considered to be one of the most Bixby-Hammett 1992; Chitnavis et al. 1996; Moss dangerous sports in the world, as it involves two et al. 2002; McCrory & Turner 2005). This area different species functioning together as a team, has been reviewed and the findings are similar with the horse being able to act autonomously and findings to those found in Table 9.1 (McCrory & unpredictably. The fully grown horse can weigh up Turner 2005). to 550 kg and travel at speeds of 60 km/hr, putting the rider, who is at up to 3 m above ground, at sig- nificant risk of injury (Thomas et al. 2006). Professional Jockeys Professional jockeys are a group at high risk of Recreational Riders injury because of their occupational exposure to All published studies of recreational equestrian horses as part of training as well as competitive injuries report acute injuries only. Both Gierup et race situations. In the United Kingdom, the top al. (1976) and Williams et al (1995) have reported rank of jockeys competes over 900 times per season a one-third incidence of previous injuries in rid- and have the highest injury rates of any competi- ers presenting to hospital with a new acute injury, tive sport (Turner & McCrory, Balendra 2002 et al. although no details were provided, nor was any 2008). equestrian 117
Table 9.1 Retrospective and case series studies.
Study Reference Patient Source Total No. of No. of Injuries Ͻ15 yr Demographics Equestrian Injuries old (% of total)
Bernhang & Winslett Horse Shows 290 62 (21%) 85% female (1983) Association survey, 34% falls United States 15% fractures Bernhang & Winslett Pony club survey, 31 19 (61%) No analysis performed (1983) United States Barone and & Rodgers Hospital admissions, 136 NS 76% female (1989a) United States 75% falls 62% fractures Sahlin (1990) Pediatric hospital, 23 23 (100%) 90% female Norway 60% falls 50% fractures Bixby-Hammett & National Electronic 167,578 48,822 (29%) 65% female Brooks 1990) Injury Surveillance System, United States Buckley et al. (1993) National injury data- 827 315 (38%) 74% female base, New Zealand 46% fractures Nelson et al. (1994b) Postal survey, United 589 (27% of total 46 (8%) Injury rate, 0.4/per States surveyed) 1,000 hr Sorensen et al. (1996) Paediatric Hospital 516 95% female data, Sweden 27% fractures Injury rate, 14/1000 hrs Campbell-Hewson Pediatric emergency 41 41 (100%) 95% female et al. (1999) department, United 66% falls Kingdom 26% fractures Ghosh et al. (2000) National Pediatric 720 276 (38%) 62% female Trauma Registry, United 64% falls States 35% fractures Cripps 2000) Australian Bureau of 64 Statistics data, Australia Moss et al. (2002) Emergency department, 260 (10% of all 62 (23%) 80% female United Kingdom sports injuries) 80% falls 60% fractures Ball et al. (2007) Questionnaire of 151 Not stated Sex not stated emergency patients 54% Chest injuries Canada
Where Does Injury Occur? and hence are recorded more accurately. Head injuries are responsible for the majority of serious Anatomical Location equestrian injuries and deaths. (Bixby-Hammett Injuries to the extremities comprise the largest 1983, 1987, 1992, 2006; Lloyd 1987; Silver & Parry group of injuries. They are predominantly soft- 1991; Nelson & Bixby-Hammett 1992; Nelson tissue injuries and long-bone fractures (Watt & et al. 1994c; Silver 2002) Such injuries are almost Finch 1996; Lim et al. 2003) Patients with such invariably related to falls. Injuries to the thorax, injuries are not routinely admitted to the hospi- abdomen, and pelvis are also often severe and tal, and they may be underrepresented in pub- account for a smaller but substantial number of lished studies. Patients with equestrian-related hospitalizations (Bixby-Hammett 1983, 1987, 1992, head injuries are typically admitted to hospital, 2006). 118 chapter 9
There are very few published studies that record as most, if not all, reported injuries are acute inju- the anatomical location of injury in any detail. ries presenting to hospital emergency departments. Ball et al. (2007), in a Canadian study of 151 surgi- cal patients, reported that 54% of injuries were to Chronometry the chest, 48% to the head, 22% to the abdomen One study reports injuries occurring more fre- and 17% to the extremities. Although these figures quently during school holidays (Silver & Parry seemingly contradict other studies, they reflect the 1991) and on weekends; however, this more likely nature of the study population. Studies that have represents the most frequent type of riding con- looked at rates of acute injuries in professional jock- ducted rather than suggests that holidays represent eys have found that soft-tissue injuries are the most a particular threat of injurious situations. common injuries overall (varying between 32% and 84% of injuries), whereas upper-limb fractures are What Is the Outcome? the most common significant injury, followed by concussion and upper-limb joint dislocation. ( Press Injury Type et al. 1995; Turner & McCrory 2002; McCrory et al. 2006; Balendra et al. 2007). There are no data available from prospective stud- ies or where the exposure incidence is known that Environmental Location enable injury-rate calculation. The published ret- rospective and case series studies are outlined in The majority of equestrian injuries occur during lei- Table 9.1 and are presented as a percentage of total sure riding rather than in competition (Whitlock et al. injuries. Although the broad categories of anatomi- 1987; MMWR 1996) Unfortunately, no published cal injuries are commonly reported, the widely var- studies provide any specific breakdown of either the ied methods make comparison impossible. proportion of leisure-related injuries or more precise Furthermore, in studies (such as in professional information in this regard. Equestrian injuries tend to jockeys) in which detailed injury information is occur when the rider is mounted (Barone & Rodgers prospectively recorded, there is enormous varia- 1989; Nelson & Bixby-Hammett 1992; Hobbs et al. tion in the same injury across different countries. 1994; Nelson et al. 1994c), during riding lessons This is shown in Table 9.2, illustrating differences (Bixby-Hammett 1987), on farms, or in paddocks. in fracture rates. It is speculated that this disparity When Does Injury Occur? reflects intrinsic differences (e.g., low bone density and increased fracture risk) between individuals rather than a difference in horse-riding techniques Injury Onset (McCrory et al. 2006). In the same study, the most As noted previously, the majority of published stud- common type of injury was a soft-tissue injury and ies report little information regarding injury onset, the frequency varied between 32% and 84% of all
Table 9.2 Fractures by race category and country of origin in professional jockeys
Country Flat racing Jumps Racing
Fractures as % of Fractures per Fracture as % of Fractures per Total Falls 100,000 Rides Total Falls 100,000 Rides
France 19.6 60.5 6.60 603.2 Ireland 9.8 36.1 3.37 159.9 Great Britain 3.3 14.6 2.51 169.8
Data are from McCrory et al. (2006). equestrian 119
injuries depending on the country of origin of the The same is true with catastrophic spinal cord injured jockey. injuries—data from hospital spinal cord services have been published (Roe et al. 2003). Given the Time Loss relatively small numbers of these injuries and the selection bias inherent in hospital data, the strength Limited published information exists, and the time of any preventative recommendations (e.g., body lost reported in published studies generally refers protectors) in this setting is limited. to either chronic injuries or those severe enough to In professional sport, specific information exists warrant hospital presentation. There are no pro- as to career-ending injuries; however, it must be spective data available for acute injuries. understood that these represent the minority of There is one published paper detailing time lost injuries to professional jockeys (Balendra et al. from racing and insurance payments to profes- 2008) In the published study, 45 such injuries were sional jockeys in the United Kingdom (Turner et al. recorded over a 15-year time frame. The distribu- 2008) The findings are summarized in Table 9.3. No tion of these injuries in shown in Figure 9.2. other published data exist for recreational riding Various case series and recommendations and time loss. have been reported detailing catastrophic head and spinal injury from equestrian par- Clinical Outcome ticipation (Ingermarson et al. 1989; CDC 1990; No published prospective information exists. There Nicholl et al. 1991, 1995; Silver & Parry 1991; are a variety of case series and retrospective question- Buckley et al. 1993; Christey et al. 1994; Bond naire-based studies reporting long-term outcome and et al. 1995; MMWR 1996; Committee on Quality time lost from equestrian injuries. In general terms, Improvement 1999; Cripps 2000; Moss et al. 2002; all of these papers suffer from selection bias, given Silver 2002). In general, the rate of fatal head the population from which injuries are obtained injuries from horse riding is relatively low both in in addition to the methodologic limitations of the general terms and in comparison with other sports study design (Nelson & Bixby-Hammett 1992; Giebel (Nicholl et al. 1991, 1995). In one of the few prospec- et al. 1993; Nelson et al. 1994c; Campbell-Hewson tive estimates, this horse riding–related mortality et al. 1999; Ghosh et al. 2000; Sorli 2000; Dekker et al. risk was put at 0.08 per 100,000 population (Cripps 2003, 2004). 2000) This risk estimate includes all age groups.
Table 9.3 Days off of racing in professional jockeys in the United Kingdom
Days off Racing (maximum ϭ 546) No. of Claims % of Total
1–7 214 16.1 8–14 213 16.1 15–21 158 11.9 22–28 132 9.9 29–60 317 23.9 61–90 107 8.0 91–120 60 4.5 121–150 34 2.5 151–180 22 1.7 181–365 38 2.9 366–546 33 2.5 Total 1,328 100.0%
Data are from Turner et al. (2008). 120 chapter 9
Head, 20%
Shoulder, 13.3% Neck, 6.7%
Elbow, 4.4% Chest, 2.2%
Spinal cord, 6.7% Hand, 4.4% Abdomen, 4.4% Back, 13.3%
Pelvis, 4.4%
Thigh, 4.4%
Knee, 4.4%
Leg, 6.7%
Ankle, 2.2% Figure 9.2 Anatomical site Other, 2.5% of injury in professional jockeys.
Economic Cost What Are the Risk Factors? The only study examining the economic cost of Intrinsic Factors injury (or at least insurance costs for injuries) was in professional jockeys in the United Kingdom There are relatively few intrinsic factors that pre- (Balendra et al. 2008). In that study, approximately dispose a rider to injury. with none that have been 1,328 injuries were reported to the insurer during validated scientifically. In general, a rider requires the 11-year period from 1996 to 2006, and the total a sense of balance, reasonable physical fitness, and cost of these injures was almost £4,500,000 (approx- alertness to ride. Clearly, anything that impairs imately US$8.9 million). A large percentage of the these functions would be a contraindication to rid- injuries were minor ones and received relatively ing. In the same manner, avoidance of alcohol and small payouts. The most common injuries suffered drugs that may impair riding should be mandatory. by jockeys were fractures, more specifically, c lavicle Horse-riding experience has been proposed with fractures. However, dislocations were the most the recommendation that a minimum of 100 hours of serious injury, accounting for the longest time out riding experience is required before injury reduction of racing and the highest payouts. No breakdown occurs (Mayberry et al. 2007) The evidence for this was reported in terms of the nature of treatment was based on a mail survey of pony clubs in the required or the indirect economic costs of injury. United States, in which novice riders’ reported greater equestrian 121
injury rates than more advanced riders. However, no or even that the current helmet test standards are exposure data were collected. The broad recommen- adequate to prevent head injury (Watt & Finch, dation, however, that injury prevention efforts need 1996). There is some anecdotal evidence, however, to focus on novices seems reasonable. suggesting a benefit for helmet use in preventing or lessening the severity of head injuries (Nelson & Extrinsic Factors Bixby-Hammett 1992; Bond et al. 1995). Similarly, the benefits of other safety equipment, such as There are many potential factors that have an body protectors and safety-release stirrups remain impact on the athlete and injury prevention, such unproven. as protective equipment, coaching, rules, and envi- Most equestrian organizations have regulations ronmental risks. However, none of these have been governing the conduct of the sport and include spe- analytically studied in equestrian sport. cific equestrian safety issues. In professional horse racing, and to a lesser extent in amateur racing, What Are the Inciting Events? there are strict licensing requirements, supervision Although falling from horses or being kicked are of race courses, veterinary assessment of horses, the most familiar mechanisms of injury, horses medical assessment of jockeys, and enforcement can also inflict injuries by biting, pulling, kicking of riding and safety rules. Pony clubs and similar the rider, standing or rolling on the rider, and hit- groups in the pediatric age group have specific ting the rider with a sudden movement of the head safety standards for supervisors and riders, and (Regan et al. 1991). It is also noted that in riders, strict requirements for helmet use. approximately 15% of equestrian injuries occur during nonriding activities, such as grooming, Further Research feeding, handling, shoeing, and saddling (Bixby- Hammett 1987; Barone & Rodgers 1989; Hobbs The major challenges facing equestrian sports is et al. 1994; McCrory & Turner 2005) the accurate understanding of injury rates across a No published information exists regarding the wide spectrum of sports participation coupled with specific activities being performed at the time of the formal scientific demonstration that the various the injury, with the possible exception of where an proposed injury-prevention measures are effective. injury results from a collision between horse and Ideally, this should be performed before they are car while road riding (Silver & Parry 1991). implemented or promoted. In addition, the barri- ers to the adoption of injury-prevention measures Injury Prevention should be studied. Given the high participation in organized instruc- There are no published data on injury prevention tional programs such as a pony club, an assess- that have been subjected to formal analysis. The ment of the effectiveness of rider (and supervisor) use of other protective equipment, like body pro- training should be undertaken. Rider and public tectors and safety stirrups has been made compul- education may assist in informing riders about spe- sory in recent years so as to reduce the incidence cific risks with riding and, hence, alter behavior to of injuries; however, the efficacy of many of these avoid dangerous situations as well as encouraging interventions has never been validated (Turner & the use of protective equipment. Although laud- McCrory 2002; Ceroni et al. 2007). able, such campaigns need to be validated against Protective equestrian helmets are widely recom- defined outcomes (Thompson 1994; Northey 2003). mended. Such helmets need to be certified to an Ensuring that riding instructors are certified, appropriate material testing standard, and a variety experienced, and have a good knowledge of horses of impact standards exist in different countries. are all reasonable measures, although no formal There have been no formal prospective or control- analysis has correlated injuries with instruction, and led studies conclusively demonstrating a benefit any certification needs to be formally evaluated. 122 chapter 9
Horse selection may have a role, whereby instruc- in the safe approach to horses, and avoidance of tors can match suitable horses with the level of situations in which other animals or vehicles may rider experience. As with all primary prevention frighten a horse, have all been proposed but not measures, the efficacy depends on both whether evaluated (Watt & Finch 1996). Specific “tuck-and- the regulations are enforced and whether the safety roll” techniques if unmounted have been suggested requirements are themselves effective (Mayberry as a means, albeit unproven, of reducing injuries et al. 2007). in falls. Some authors have suggested specific neurologic Appropriate and well-maintained equipment contraindications to riding, including unstable spi- (e.g., tack or saddlery) is important to prevent nal cord lesions, permanent sequelae from head falls. The checking of equipment as part of a pre- injury, and repeated painful injury to the cervical mounting and predismounting routine is criti- and lumbar spine (Bixby-Hammett & Brooks 1990). cal, although it has not been rigorously assessed. None of these have been validated prospectively, Similarly, appropriate clothing, such as riding boots and would need to be individually assessed. and gloves are important. Horse behavior is also a significant factor in With the majority of equestrian injuries hap- many equestrian injuries. In U.S. Pony Club sur- pening during unsupervised leisure riding, the veys, it has been estimated that up to 80% of likelihood of preventing injury is reduced. Rider- injuries resulted from the behavior of the horse education campaigns to ensure adequate training, (Bixby-Hammett 1987). Although horses are by maintenance and inspection of equipment, and their very nature unpredictable, some basic prin- wearing appropriate clothing and helmets may all ciples are important and may be taught as part of assist in reducing injuries. Because there is so little basic horse-riding instruction. Warm-up procedures knowledge of injury demographics or the efficacy for the horse, rider training, supervisor awareness of prevention countermeasures in this field, it is of aberrant horse behavior, specific instruction likely that injuries will continue to occur.
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(2008) Payments to injured professional Grossman, J.A., Kulund, D.N., Miller, Nicholl, J., Coleman, P. & Williams, C. jockeys in British horse racing (1996– C.W., Winn, H.R. & Hodge, R.H., Jr. (1991) Injuries in Sport and Exercise. 2006). British Journal of Sports Medicine (1978) Equestrian injuries: results of a Medical Care Research Unit, 42, 763–766. prospective study. Journal of the American Department of Public Health Medicine, Turner, M. & McCrory, P. (2002) Medical Association 240, 1881–1882. Sheffield University Medical School, Horseracing injuries: injuries resulting Hobbs, G.D., Yealy, D.M. & Rivas, J. Sheffield, UK,. from professional horseracing in Great (1994) Equestrian injuries: a five-year Nicholl, J., Coleman, P. & Williams, B. Britain and Ireland during the period review. Journal of Emergency Medicine (1995) The epidemiology of sports and 1992–2000. British Journal of Sports 12, 143–145. exercise related injury in the United Medicine 36, 403–409. Ingermarson, H., Grevsten, S. & Thoren, Kingdom. British Journal of Sports Watt, G. M. & Finch, C. F. (1996) L. (1989) Lethal horseriding injuries. Medicine 29, 232–238. Preventing equestrian injuries: locking Journal of Trauma 29, 25–30. Northey, G. (2003) Equestrian injuries in the stable door. Sports Medicine 22, Lim, J., Puttaswamy, V., Gizzi, M., New Zealand, 1993–2001: knowledge 187–197. Christie, L., Croker, W. & Crowe, P. and experience. New Zealand Medical Whitlock, M. R., Whitlock, J. & (2003) Pattern of equestrian injuries Journal 116, U601. Johnston, B. (1987) Equestrian injuries: presenting to a Sydney teaching Press, J.M., Davis, P.D., Wiesner, S.L., a comparison of professional hospital. Australian and New Zealand Heinemann, A., Semik, P. & Addison, and amateur injuries in Berkshire. Journal of Surgery 73, 567–71. R.G. (1995) The national jockey British Journal of Sports Medicine Lloyd, R.G. (1987) Riding and other injury study: an analysis of injuries to 21, 25–26. equestrian injuries: considerable professional horse-racing jockeys. Clinical Williams F. & Ashby K. (1995) Horse severity. British Journal of Sports Journal of Sports Medicine 5, 236–240. related injuries, HAZARD Edition Medicine 21, 22–24. Regan, P., Roberts, J., Feldberg, L. & 23 (June 1995). Melbourne, Australia, Mayberry, J.C., Pearson, T.E., Wiger, Roberts, A. (1991) Hand injuries from Victorian Injury Surveillance System/ K.J., Diggs, B.S. & Mullins, R.J. (2007) leading horses. Injury 22, 124–126. Monash University Accident Research Equestrian injury prevention efforts Roe, J.P., Taylor, T.K., Edmunds, I.A., Centre, 1–13. need more attention to novice riders. Cumming, R.G., Ruff, S.J., Plunkett- Journal of Trauma 62, 735–739. Cole, M.D., Mikk, M. & Jones, R. F. Chapter 10
Fencing
PETER A. HARMER Exercise Science—Sports Medicine, Willamette University, Salem, Oregon, USA
Introduction percentage of fencers recorded as injured in spe- cific competitions (20–27.5%; Majorano & Cesario Fencing is one of only four sports to have been 1991; Naghavi 2000) or self-reported as sustaining included in every Olympiad of the modern era. an injury in their fencing careers (59–77.8%; Nye Olympic competition has basically consisted of 1967; Carter et al. 1993) appears high, exposure- events for men in the standard three weapons since based injury rates, especially for time-loss injuries its inception (individual foil and sabre from 1896, (i.e., those significant enough to necessitate an individual epee from 1900; team epee and sabre athlete withdrawing from competition) indicate from 1906; team foil from 1920) (Fencing 2008). that the majority of fencing injuries are minor. For The first event for women (individual foil) was example, in a review of 15 years of sports-insurance introduced in 1924, with a team foil event being data in Germany, Raschka et al. (1999) estimated an added in 1960. Individual and team épée for injury rate of 0.12 per 1,000 persons/yr for fencing, women were included in the Olympic program for which was the lowest, with aikido, of eight combat the first time in 1996 with women’s saber added in sports analyzed. Studies in Table 10.1 indicate con- 2004. The martial origins of fencing and the use of sistent findings of a time-loss rate of 0.0 to 0.3 per weaponry in individual combat impart the impres- 1,000 athlete exposures (AE) across a wide variety sion of high risk to modern competitive fenc- of competition and training settings. By compari- ing. The purpose of this chapter is to examine the son, soccer and basketball have been found to have veracity of this belief by evaluating the extant lit- ϳ50 times and 31 times higher rates of time loss erature on fencing-related injury. The focus was on from competition because of injury, respectively, data-based studies, although case reports and case than fencing (Harmer 2008a). series were included for a fuller understanding of clinical outcomes, particularly for catastrophic and complicated injuries. Overall, the paucity of well- Where Does Injury Occur? designed, data-driven studies was evident. Anatomical Location Who Is Affected by Injury? The percent distribution of injury by anatomical A summary of studies reporting injury rates in location is presented in Table 10.2. Although several fencing is presented in Table 10.1. Although the studies have found that the highest proportion of injuries involved the wrist, hand, and fingers (range, 54.6–61.3%), the majority of research has shown the Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 lower extremities to be the most common site of Blackwell Publishing, ISBN: 9781405173643 injury (mean ϭ 59%; range, 42.9–77.3%), specifically 124 fencing 125 a,c b,d b,d a,d b,d b,c b,c a,e a,d b,d b,d b,d b,d b,d b,d 1.0 0.1 1.8 0.2 0.0 Other — — — 0.25 — 27.5 — 0.42 b 00 0.0 0.22 3.1 0.2 0.270.36 0.2 0.3 0.0 20.0 0.2 0.33 0.0 0.3 0.2 AE per 1,000 Time-loss Time-loss Injury Rate a — — — — — — — — — — — — 2.1 4.3 25.4 1,000 AE Overall per 0 5 3 2 2 0 11 58 49 31 100 No. of Injuries (competi- tion only) ϭ 801 F ϭ 64 n ϭ 358 M ϭ 18 F ϭ 6 n ϭ 1365 n ϭ 178 M ϭ 47,483F ϭ 30,740 98 86 Participants M ϭ 155 M ϭ 892 F ϭ 506 USA Italy USA Italy n England Clubs ϭ 18 25 Location No. of Iran International n ϭ 1398 United States n ϭ 78,223 184 direct monitor; I ϭ interview; M male; F female e; DM ϭ direct University fencing teams (1 yr) competitions (1 yr) (1 yr) (1 competition) fencers (1 yr)Milan-area Italy Community fencing clubs (1 yr) competition (1 competition) Championships (5 yr) Data Source (Duration of Data Source Study) Collection PQPP DMP DM Regional youth P DM/I Regional competitions (1 yr)PQ DM Italy University fencing team National competition PQ Design Data Per 100 participants. Any injury that resulted in withdrawal from competition, inability to practice after the or both. in withdrawal from Any injury that resulted Any injury for which medical assistance was sought. Per 100 participants/yr. Per 1,000 hours of participation. Table 10.1 Table Comparison of fencing injury rates. Study Graham & Bruce (1977) Roi & Fasci (1986) Roi & Fasci (1988) Lanese et al. (1990) Majorano & Cesario (1991) Gambaretti et al. (1992) Naghavi (2000)Harmer (2007) P DMHarmer (2008a) P DM P International Junior Q ϭ questionnair ϭ prospective; P AE ϭ athlete exposure; a DMb World Veterans c d e National competitions (5 yr) Weightman & Weightman (1975) Browne 126 chapter 10 3.3 15.2 wrist) (2008a) Harmer — 2.7 — 1.6 —— 11.4 (inc. in 5.9 3.3 hip) ankle) (inc. in (inc. in — 7.7 3.8 ——— — 8.7 8.7 hip) wrist) ankle) elbow) (n ϭ 732) (n ϭ 481) (2003) Jäger (2003) Kelm et al. (2001) Wild et al. Wild (2000) Naghavi (1992) 1.8 16.3 58.1 — 7.3 (inc. in 9.2 6.1 3.2 20.3 17.1 6.8 34.7 19.6 9.8 14.3 — — — 4.0 — — — — — — — 2.2 — — — — 4.9 — — 3.2 7.9 29.2in (inc. — — 3.2 8.7 2.4 Gambaretti et al. Gambaretti (n ϭ 164) (n ϭ 49) — — — 3.2 — — — — 2.2 — 12.2 10.2 — 3.3 — 16.3 8.3 3.8 — 1.8 4.1 16.1 3.3 — 2.3 — — — 3.2 — — 19.0 2.0 8.0 6.0 (2.0) (0.0) (0.0) (3.2) (0.0) (0.0) (0.0) (0.0) (4.4) — 23.0 15.2 12.2 6.5 24.1 9.8 22.6 9.1 9.2 18.0 10.0 21.0 23.2 22.5 3.2 25.8 14.6 29.0 25.6 13.0 (20.0) (6.6) (20.4) (77.4) (9.9) (26.9) (21.3) (7.7) (19.5) (55.0) (68.4) (53.1) (12.8) (66.0) (63.3) (42.1) (77.3) (63.6) Bierner (1991) Müller-Strum & Müller-Strum — — 1.0 3.0 (inc. in trunk) 3.0 — — 6.6 4.9 4.0 2.0 4.0 4.0 2.0 9.0 shoulder) Majorano & Cesario (1991) — — — — — — — — 60.0 — (inc. in elbow) — — — — — 9.8 (inc. in — — (inc. in ankle) (inc. in ankle) 23.8 14.3 — — — (inc. in 9.1in (inc. 9.1 9.1 (0.0) (1.0) 18.2 11.0 (1986) Roi & Fasci Head/spine/trunk Table 10.2 Table comparison of injury location in fencing. Percent Head/skull Arm Neck/throat Shoulder Elbow Trunk/back Upper extremity (63.7) (67.0) Wrist Thigh Lower extremity Pelvis/hips (27.3) (23.0) Forearm Hand/fingers 54.6 (inc. in wrist) 12.0 Leg Knee Ankle Other Foot/toes fencing 127
the ankle and knee (Figure 10.1). In addition to pro- that 77% of recorded injuries occurred in practice spective studies with this outcome, in the largest and 23% in competition. It is not clear from these retrospective self-report study to date (1,603 respond- data, however, whether the rate of injury (i.e., rela- ents), Carter et al. (1993) reported that the knee (17– tive to exposure units) would be greater in practice 19%) and ankle (14–14.5%) were cited as the locations than competition. of both the worst injury suffered in the previous year and the worst injury suffered in a fencing career. When Does Injury Occur? In the largest prospective, exposure-based study of fencing injury (78,223 participants), Harmer Injury Onset (2008a) noted that while the knee was the most commonly injured region (19.6%), a wide variety To date, only two prospective studies have pre- of pathologies were involved. Of particular concern sented data on injury onset in fencing. From a were injuries to the anterior cruciate ligament (ACL). 1988–1990 study of fencers in the United States, Mountcastle et al. (2007) reported that in a 10-year Moyer & Konin (1992) found that 55.2% of the study of sports-related injury at the U.S. Military reported injuries were acute and 44.8% were over- Academy at West Point, fencing ranked the second use or chronic. Similarly, in a 5-year study of 293 lowest of six club sports for which an incidence fencers at the German Olympic Training Center in rate for males was recorded (0.06 per 1,000 AE). No Tauberbischofsheim, Jäger (2003) classified 60.3% ACL ruptures occurred in females during the study of the injuries as acute and 39.7% as overuse. A ret- period. Majewski et al. (2006) examined the cause rospective study conducted by Carter et al. (1993) of knee injuries in a 10-year study of patients at an in the United States found that of the self-reported orthopedic clinic in Switzerland and found a rate of cases of “worst injury in the previous year,” 67% 1.5 per 1,000 participants per 10 years for fencing. were acute and 33% overuse or of gradual onset.
Environmental Location Chronometry
Few studies have examined the distribution No research on the chronometry of injuries in fencing, of injury between competition and practice. such as the distribution of injuries over a competitive However, Gambaretti et al. (1992), in a 1-year study season or the relative rate of injury during different of 178 fencers (youth through elite level), found phases of a fencing tournament, was located.
Figure 10.1 Rapid change of direction and strong lunging place the knee and ankle at risk for injury. Photo by Serge Timacheff. Reprinted with permission. 128 chapter 10
What Is the Outcome? & Bierner (1991) surveyed 105 male and female fencers from Germany and Switzerland and noted Injury Type that 148 reported injuries resulted in 64 days in the hospital and 203 days missed from work or fenc- The distribution of injury types in fencing derived ing. Carter et al. (1993) found that 22% of injuries from the extant literature is detailed in Table 10.3. sustained in the previous year did not result in Three general patterns are evident: (a) studies in any time loss, but 15% were reported as having an which abrasions/blisters and contusions predomi- extreme impact on participation. However, no other nate, (b) those in which sprains and strains are most details were provided. Finally, Naghavi (2000), who common, and (c) the low proportion of puncture reported the highest overall injury rate of any study injuries. Taken together, the data indicate that fenc- in this review, emphasized that there were no time- ing injuries tend to be minor, whether surface trauma loss injuries and that all injuries were treated with (abrasions, contusions) or musculoskeletal derange- standard first aid. ment (sprains, strains) common to any activity with rapid change of direction activity. For example, in Clinical Outcome addition to the data in Table 10.3, in an early eco- logic study of fencing clubs in England, Weightman Catastrophic Injury & Browne (1975) noted that 28% of reported inju- Despite the impression of high risk for signifi- ries were sprains and strains, while Moyer & Konin cant injury from the powerful use of the various (1992) found that 33% of 323 acute injuries were weapons in fencing, there have been few fatali- sprains and 24% were strains in a 2-year study in ties recorded in the literature. Since 1937, only ten the United States. The consistently low proportion deaths worldwide have resulted from penetrating of puncture wounds underscores the fact that this wounds in fencing: all have been in men; 3 in foil, type of “fencing-specific” injury is not common and 6 in épée, 1 in saber; 6 occurred in competition, studies that reported a high percentage of lacerations 3 in practice, 1 unknown; 7 resulted from a broken (e.g., Naghavi 2000) indicated that these were prin- blade, 2 from an intact blade, 1 unknown; 7 penetra- cipally minor cuts to the hand, readily treated with tions were in the chest, 1 through the neck, 1 in the standard wound care such as a bandaid. face, 1 unknown) (Parfitt 1964; Safra 1982; Crawfurd 1984, 1991; “Fencing match” 1990; “Fencer’s tragic” Time Loss 1994; “Ukrainian fencer” 2004; “Fencer dies” 2005; In the earliest fencing injury study found in the lit- “Smierc szermierza 2009”). erature, Nye (1967) classified 32.7% of injuries (17 of Although mortal injuries are very rare, non- 52) as severe (resulted in x-ray examination, medi- fatal penetrating injuries are more frequent but cal treatment, or time lost from work; no further still uncommon. For example, Carter et al. (1993) breakdown), but indicated that 48% of all injuries found that approximately 5% of 1,246 fencers sur- required no treatment. In their 1-year study of clubs veyed reported a puncture wound (variously to in northern England, Weightman & Browne (1975) face, neck, chest, abdomen, arms, and legs) as their noted that 68% involved no time lost from partici- worst injury during their fencing career but Harmer pation but did not provide any data on time loss (2008a) indicated that only 0.006% of participants for injuries that involved some time loss. Lanese et in national-level competitions in the United States al. (1990), the only study to date to quantify time over a 5-year period suffered a puncture or pen- loss, reported that eight time-loss injuries in a uni- etrating wound that resulted in time loss. Wild et versity fencing team resulted in 21.5 disability days al. (2001) noted only one pneumothorax and two for men (4.3 per 1,000 hours of participation) and lacerations from broken blades in a 15-year study 3.5 disability days for women (2.1 per 1,000 hours in Germany. Harmer et al. (1996) detailed a distant- of participation). Fencing had the lowest rate of entry pneumothorax from a broken épée in an elite time loss of the eight sports studied. Müller-Strum fencer, and a pneumohemothorax was reported fencing 129 — — Other/ Unknown Abrasion/ Blister Spasm — — — 6.9 10.3 25.9 — — 46.3 — — —— — 2.0 — 6.0 — — 46.0 — 7.0 30.0 — — — — — 58.2 3.0 3.3 2.4 — — 39.3 Fracture Laceration Puncture Rupture Cramp/ — — 11.0 — — — 10.0 9.0 — — 9.1 — — — 45.5 7.6 4.4 0.5 2.7 3.3 4.9 — 13.0 Dislocation Sprain Strain Contusion Subluxation/ ? 23.9 26.0 — — 2.1 41 12.2 12.2 24.4 — 2.4 100148 22.0 24.0 6.0 17.0 18.0 8.0 — Inc. in Other 2.0 1.0 213 23.0 10.8 — 2.4 5.6 No. of Injuries a b Self-reported worst injury in previous 5 years. worst injury in previous Self-reported Self-reported worst injury in the previous year. worst injury in the previous Self-reported Azémar (1999)Naghavi (2000)Kelm et al. (2003) 132 31 26.0 6.5 — 3.2 44.0 25.8 — — 38.7 — — — 19.3 6.5 Harmer (2008a) 184 25.5 26.1 12.0 Table 10.3 Table comparison of injury types in fencing. Percent Study a b Roi & Fasci (1986)Roi & Facsi (1988)Majorano & Cesario 11(1991) 58 & Müller-Strum Bierner (1991) 18.2 8.6 — — 27.3 48.3 — — Gambaretti et al. Gambaretti (1992) Carter et al. (1993) 130 chapter 10
(also from a broken épée) in a practice session for interval [CI], 0.20–0.35), young adult (ϳ18–30 years the 2007 Pan American Games (“Brazilian fencer” old; 0.31; 95% CI, 0.22–0.44), and veteran (у50 2007). In addition, penetrating injuries have been years old; 0.21; 95% CI, 0.10–0.39) fencers. reported in various locations, including the neck (Harmer 2008c) and abdomen (Matloff 1985). Sex However, the incidence of significant penetrating In the first study to examine the influence of sex on wounds has not been well researched. In the only injuries in fencing, Lanese et al. (1990) found no sig- study to document the incidence of penetrating nificant difference in the rate of disability days per wounds resulting in a time loss, Harmer (2008a) 1,000 hours of participation for time-loss injuries noted an overall rate of 0.008 per 1,000 AE (any between men and women (P ϭ 0.47). Similarly, in a penetrating injury resulting in time loss) and a rate 10-year study of cadets at the U.S. Military Academy of 0.0016 per 1,000 AE for penetration wounds to at West Point, Mountcastle et al. (2007) noted no the trunk. significant difference in the rate of complete ACL ruptures between men and women (1 case in 16,964 Other Outcomes AE vs. 0 in 12,148). However, in their 15-year study In addition to serious injuries, a variety of unique of 93 elite German fencers, Wild et al. (2001) con- clinical presentations related to fencing have been cluded that women had a rate of ankle injury that introduced in the literature. Borelli et al. (1992) des- was three times higher than that for men, but no cribed an intravascular papillary endothelial hyper- statistical analysis was done. In the largest study of plasia, possibly an organized thrombus, in the hand of fencing injuries to date, Harmer (2008a) found that a female fencer, postulated to be related to “the con- women had 35% higher risk for a time-loss injury tinuous microtrauma to which the hand of a fencer is in competition than men (relative risk, 1.35; 95% CI, exposed.” Gray and Bassett (1990) detailed a case of 1.01–1.81). osteochondritis dissecans in an 18-year-old elite épée fencer, which was surgically repaired without com- Extrinsic Factors plications. Kelm et al. (2004) presented an instance of The only extrinsic risk factor that has been reported is acute tibialis anterior rupture in an elite veteran fencer. event (i.e., foil, épée, saber). Examining data from the 1991 Italian national competition, Majorano & Cesario Economic Cost (1991) noted that twice as many foil fencers (18.6%) No studies were located that examined the economic sustained some injury as compared with either épée impact of fencing injuries on individual athletes, (8.9%) or saber (9.2%), but the significance of these clubs, National Governing Bodies, or the Fédé- differences was not tested. Harmer (2008a) found that ration Internationale d’ Escrime (FIE). although foil and épée were not significantly different in the rate of time-loss injuries, saber had a statistically What Are the Risk Factors? significantly higher risk (62%) for time-loss injury as compared with foil and épée (relative risk, 1.62; 95% Intrinsic Factors CI, 1.2–2.2), and this increased risk was evident for both men (relative risk, 1.61; 95% CI, 1.06–2.44) and Age women (relative risk, 1.63; 95% CI, 1.05–2.54).
Jäger (2003) argued that poor strength and muscle What Are the Inciting Events? imbalance in young athletes (р16 years old) were responsible for injuries in this population, but no Inciting events have not been extensively exam- data were provided to support this contention. ined, but from the available information, three Harmer (2008b), in an analysis involving approxi- major factors emerge: (a) trauma directly from an mately 42,000 participants, found no significant dif- opponent’s weapon, (b) poor technique (both the ference in the rate of time-loss injury (per 1,000 AE) opponent’s and that of the injured athlete), and between youth (8–17 years old; 0.27; 95% confidence (c) injuries from the piste. fencing 131
An injury resulting from direct impact of the (e.g., enforcement of rules on dangerous fencing, opponents’ blade is the most common inciting enhanced medical coverage). None of these factors event: Carter et al. (1993) found 4.5% of self- has been tested in any prevention intervention. reported worst injuries in a career were due to the opponent’s weapon. Nye (1967) indicated that this Further Research mechanism was responsible for 10% of injuries. However, when injury is defined as any request Despite the long history, international scope, and for care, a significantly greater proportion of inju- perceived risk of modern competitive fencing, ries are attributable to the blade. Roi & Fasci (1986) remarkably few well-designed injury studies have and Naghavi (2000) reported that 55% to 64.5% of been conducted. However, the research that has injuries were caused by opponent’s weapon (prin- been completed indicates that, contrary to popu- cipally minor contusions and abrasions). lar belief, fencing is very safe. The rate of time-loss Gambaretti et al. (1992) ascribed 63% of ankle injuries has been shown to be significantly lower injuries to poor foot position, while Carter et al. than that for more popular sports such as basketball (1993) cited an athlete’s poor technique (12.2–14.7% and soccer, but the majority of fencing injuries are of injuries) and the opponent’s dangerous actions similar to these sports, principally involving sprains (8.5–9.0%) as important inciting events. Jäger (2003) and strains in the lower extremities. Although concluded that both acute and overuse injuries “fencing-specific” injuries, including penetrating were a result of technical errors, but provided no wounds, are rare, they remain a major concern. data to support this claim. Given the current dearth of comprehensive epide- Slipping, tripping, or stepping on the edge of the miologic data, there are numerous options for future piste has been identified as responsible for between research. However, the first step in this process is 9.6% (Carter et al. 1993) and 37% (Gambaretti et al. to develop broadly implemented surveillance sys- 1992) of injuries. tems, which use a standard definition of a reportable injury, appropriate exposure metric(s), and qualified data recorders, such as medical personnel, and which Injury Prevention are directed toward answering a coordinated set of Although participant safety is presented as a high research questions. Principal among these are con- priority in fencing, no injury prevention studies firming injury rates for various subpopulations (chil- have been instituted. To date, FIE-mandated changes dren, youth, veterans, women, wheelchair) across all to equipment and rules related to safety have been three events, and expanding analyses to explore spe- based on face validity. For example, the plastron cific risk factors (sex, age, training/experience, etc). was introduced as a consequence of a fatal penetrat- Most urgent is the need to explore the antecedents of ing injury in the 1951 World Championships, where significant penetrating injuries and fatalities and to it was determined that the fencer’s jacket was of institute, and test, meaningful prevention programs inadequate thickness (Parfitt 1964). However, no to reduce or eliminate rare but catastrophic injuries. research has been conducted to determine the actual With the plethora of local, regional, and international efficacy of this or any other change. competitions available, an important database could Similarly, numerous recommendations for be achieved in a short period and strengthened decreasing injury have been presented in the lit- with the addition of longitudinal data. Information erature (Carter et al. 1993; Zemper & Harmer 1996; related to the rate and risk factors of practice/train- Roi & Bianchedi 2008) based on descriptive stud- ing-related injuries will require additional research ies, face validity or first principles, covering behav- design efforts to accurately capture rate-based data. ioral characteristics (e.g., improving conditioning The continuing growth of fencing indicates its and technical expertise), equipment and facilities enduring appeal as an athletic endeavor and places (e.g., improved composition and construction of on researchers and medical personnel the onus to the piste, increased integrity of blades and cloth- uncover the intricacies of fencing injury to allow ing), and administration of fencing competitions participants to enjoy their sport for life. 132 chapter 10
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Research Quarterly 48(1), Medicina dello Sport 44(3), 281–289. accident. (2004) Deutsche Presse- 21–220. Matloff, M. (1985) Fencing gentlemanly Agentur, March 15. Gray, W. & Bassett, F. (1990) but still dangerous. Reuters, Barcelona, Weightman, D. & Browne, R. (1975) Osteochondritis dissecans of the patella July 18. Injuries in eleven selected sports. British in a competitive fencer: a case report. Mountcastle, S.B., Posner, M., Kragh, J.F. & Journal of Sports Medicine 9(3), 136–141. Orthopedic Review 19(1), 96–98. Taylor, D.C. (2007) Gender differences Wild, A., Jaeger, M., Poehl C., Werner, A., Harmer, P. (2007) Minimal risk of time- in anterior cruciate ligament injury Raab, P. & Krauspe, R. (2001) Morbidity loss injury in Masters fencing: USA vary with activity: epidemiology of profile of high-performance fencers. National and World Championship anterior cruciate ligament injuries in a Sportverletzung Sportschaden 15, 59–61. data 2002–2006. Medicine & Science in young, athletic population. American Zemper, E. & Harmer, P. (1996) Fencing. In: Sports & Exercise 39(5), S412 (abstract). Journal of Sports Medicine 35(10), Epidemiology of Sports Injuries (Caine, D., Harmer, P. (2008a) Incidence and 1635–1642. Caine, C. & Lindner, K., eds.) Human characteristics of time-loss injuries in Moyer, J. & Konin, J. (1992) An overview Kinetics, Champaign, IL, pp. 186–195. competitive fencing: A prospective, of fencing injuries. American Fencing 5-year study of national competitions. 42(4), 25. Chapter 11
Field Hockey
KAREN MURTAUGH Levy Elliott Sports Medicine Clinic, Burlington, Ontario, Canada
Introduction 62.6 injuries per 1,000 occasions of participation for hockey, compared to 64.4 injuries per 1,000 occa- Field hockey continues to be one of the most sions for soccer. In the National Collegiate Athletic popular team sports played by men and Association (NCAA) in the United States, during women throughout the world. According to the 2004–2005, the overall game injury rate for women International Hockey Federation (FIH), it currently was 11.4 injuries per 1,000 athlete exposures (AEs) consists of five continental federations and a total for field hockey and 15.7 injuries per 1,000 AEs for of 122 member associations (FIH 2006). Since the lacrosse (NCAA 2008). At the high-school level, 1976 Olympics in Montreal, Quebec, Canada, when Powell & Barber-Foss (1999) documented 3.7 field the first Olympic competition was held on artificial hockey injuries per 1,000 AEs versus 5.3 soccer inju- turf, all international matches have been played on ries per 1,000 AEs. During the 2004 Olympic Games this surface. in Athens, Greece, field hockey injuries (men, 55 The purpose of this chapter is to review the injuries per 1,000 game exposures; women, 17 per research on injury in field hockey and to use this 1,000) occurred at a lower rate than in basketball information to suggest methods for injury preven- (men, 64 per 1,000; women, 67 per 1,000) or soccer tion and to guide future investigations. (men, 109 per 1,000; women, 105 per 1,000) (Junge et al. 2006). However, Backx et al. (1989) found that Who Is Affected by Injury? field hockey had the highest rate of injury for girls (risk ratio, 2.6) but the second highest rate for boys Injury is common in field hockey, and up to 75% (risk ratio, 1.3) when comparing the observed to the of field hockey players have sustained at least one expected rate of injury across 14 school sports. The acute injury during a game or practice (Murtaugh relative injury rate was determined by comparing 2001). Table 11.1 summarizes the published rates the injury rate for each of 14 sports to the rate for of acute injury by gender and level of competi- the total study population (106 injuries per 1,000 tion. Most studies suggest that injury rates in participants). In Ireland, hockey was second only hockey are comparable to, or lower than, the rates to rugby in the number of injuries to children that in other team sports, such as basketball, soccer, and presented to the emergency room (ER) (Abernethy lacrosse. For example, Nicholl et al. (1995) evalu- & MacAuley 2003). ated injury in recreational sport and found a rate of Unfortunately it is difficult to compare values between studies since different methods have been used and players of different levels or age groups are rarely included in the same sample. A key fac- Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 tor that influences the injury rate in any research Blackwell Publishing, ISBN: 9781405173643 study is the injury definition. For instance, some 133 134 chapter 11
Table 11.1 Injury rates in men’s and women’s field hockey.
Study Population No. in Injury Definition Study Rate of Injury Sample Design
WOMEN Powell & Barber-Foss High school 442 Medical attention P 3.7/1,000 AEs (1999) and restricted participation Murtaugh (2001) High school, college, 158 Self-reported R 0.4/athlete-year and elite Fuller (1990) Recreational NA Medical attention P 1,340/1,000 hr match (100.2 hours of match play play) Dick et al. (2007) College NA Medical attention P 7.9/1,000 AEs (game) and restricted participation Graham & Bruce College 275 Debilitating to P 0.3/player/season (1977) performancea Lindgren & Maguire Elite 10 NA P 6/player/year (1985) Freke & Dalgleish Elite 40 Medical attention R 2.4/player/career (1994a) Freke & Dalgleish Elite 62 Medical attention P 1.9/player/4 (1994c) tournaments Westbrook (2000) Elite 24 Medical attention P 34.0/1,000 player-hours Junge et al. (2006) Elite (29 matches) NA Medical attention P 17/1,000 player-matches MEN Lindgren & Maguire Elite 16 NA P 3.1/player/yr (1985) Junge et al. (2006) Elite (42 matches) NA Medical attention P 55/1,000 player-matches BOTH Nicholl et al. (1995) Recreational NA Self-reported R 62.6/1,000 AEs Roberts et al. (1995) Recreational 50 Self-reported R 1.4/player/yr 50 Self-reported P 2.4/player/season Jung et al. (1998) Recreational 130 Self-reported R 1.7/player/year Finch et al. (2002) Recreational 393 Self-reportedb P 15.2/1,000 hr
AE athlete exposure; NA not available; P prospective; R retrospective. a The player’s coach or athletic trainer completed the forms stating whether the injury was debilitating to the athlete’s performance. b The injury definition of Finch et al. (2002) included that the injury must have required medical attention or restricted participation, whereas the other studies included any self-reported injury. studies asked athletes to report any injuries with- some component of time loss from activity (Powell out specifying severity or time loss (Fuller 1990; & Barber-Foss 1999; Dick et al. 2007). A review of Nicholl et al. 1995; Roberts et al. 1995; Jung et al. the injury rates reported Table 11.1 reveals that 1998; Murtaugh 2001), while others used any studies with a broader injury definition tend to medical attention as the threshold for detecting report higher rates because more minor injuries are an injury (Freke & Dalgleish 1994a, 1994c; Junge detected. The main advantage of a more rigorous et al. 2006). A more strict injury definition involves injury definition is that it allows researchers to rep- both the diagnosis of the injury by a certified medi- licate methods between studies, thereby enabling cal professional, such as an athletic trainer, and more-valid comparisons between these studies. field hockey 135
Table 11.2 Site of injury as a percent of the total injuries in men’s and women’s field hockey.a
Study Population No. in Head/ Upper Back/ Lower Other/Not Sample Face Limb Torso Limb Reported
WOMEN Powell & Barber-Foss High school 442 16.6 15.8 4.9 58.8 3.3 (1999) Murtaugh (2001) High school, college, 158 34.0 14.0 1.0 51.0 0.0 and elite Fuller (1990) Recreational NA 10.4 20.0 8.9 60.7 0.0 Rose (1981) College NA 11.1 4.9 4.9 79.0 0.0 Dick et al. (2007) Game 25.3 20.7 7.1 43.2 3.8 College NA Practice 8.4 8.1 16.2 60.2 7.1 Lindgren & Maguire (1985) Elite 10 1.7 5.0 16.7 76.7 0.0 Freke & Dalgleish (1994a) Elite 40 0.0 11.6 21.1 65.3 2.1 Freke & Dalgleish (1994c) Elite 62 4.3 13.0 23.2 59.4 0.0 Westbrook (2000) Elite 24 7.3 10.1 21.1 61.5 0.0 Junge et al. (2006) Elite NA 27.0 20.0 9.0 47.0 0.0 MEN Lindgren & Maguire (1985) Elite 16 6.1 8.2 12.2 69.4 4.1 Junge et al. (2006) Elite NA 22.0 20.0 8.0 50.0 0.0 BOTH Eggers-Ströder & Hermann Recreational 322 19.0 62.0 19.0b (1994) Yard & Comstock (2006) ER presentations 1356 28.0 39.4 0.0 28.2 4.4 (2–18 y) Sherker & Cassell (1998) ER presentations— 292 32.8 31.7 NA 12.7 22.8 all ages
ER emergency room; NA not available. a The highest value for each study is in bold type. b Eggers-Ströder & Hermann (1994) combine head and trunk injuries.
Where Does Injury Occur? The next most common site of injury is the upper limb. It is difficult to determine whether field Anatomical Location hockey has a higher rate of upper-limb injury than other sports because there is limited information The majority of researchers have found that the lower on the overall rate of upper-limb injury in athletes. limb is the most frequently injured site of the body However, a review by Rettig (1998) suggests that (Table 11.2). A more detailed breakdown of the site of hand and wrist injuries comprise 3% to 9% of all lower-limb injuries is presented in Table 11.3. sports injuries and that most incidents are associ- There is also a significant risk of damage to the ated with competition. Most of the hockey stud- head and face in field hockey. Graham and Bruce ies cited in Table 11.2 indicate a higher range than (1977) found that field hockey had the highest rate Rettig’s (1998) values (4.9–39.4%). of head and face injuries of the nine sports they studied. Many athletes (42–62%) have had at least Environmental Location one facial injury (Bolhuis 1987; Murtaugh 2001). Field hockey also had the second highest incidence Although 60% to 70% of all women’s hockey injuries of dental injury for women and accounted for occur during practice (a finding that is consistent 1.3% of the total dental injuries at the 1989 Canada for all levels of hockey; Powell & Barber-Foss 1999; Games (Lee-Knight et al. 1992). Westbrook 2000; Dick et al. 2007), the rate of injury 136 chapter 11
Table 11.3 Site of lower limb injury as a percent of the total injuries in men’s and women’s field hockey.a
Study Population No. in Hip/Thigh Knee Leg Ankle/Foot Sample
WOMEN Powell & Barber-Foss (1999) High school 442 21.8b 13.7 NA 23.3 Fuller (1990) Recreational NA 17.0 24.4 5.2 14.1 Rose (1981) College NA 13.6 11.1 8.6 40.8 Dick et al. (2007) Game 9.9 17.6 2.9 18.1 College NA Practice 26.9 17.3 7.9 16.7 Lindgren & Maguire (1985) Elite 10 11.7 11.7 6.7 18.3 Freke & Dalgleish (1994a) Elite 40 15.0 16.0 8.0 26.0 Freke & Dalgleish (1994c) Elite 62 17.0 13.0 13.0 17.0 Westbrook (2000) Elite 24 22.9 14.7 6.4 16.5 Junge et al. (2006) Elite NA 0.0 0.0 0.0 13.0 MEN Lindgren & Maguire (1985) Elite 16 22.4 22.4 8.2 10.2 Junge et al. (2006) Elite NA 0.0 22.0 3.0 17.0
NA not available. a The highest value for each study is in bold type. b Powell & Barber-Foss (1999) combine hip, thigh, and leg injuries.
is much higher during matches. The relative risk of (Lindgren & Twomey 1988; Freke & Dalgleish 1994a, 1.5 to 2.1 of sustaining injury during a game as com- 1994b; Jung et al. 1998). Reinking (2006) followed a pared with during practice (4.9 vs. 3.2 per 1,000 AEs group of female collegiate players over one season for high school [Powell & Barber-Foss 1999]; 7.9 vs. and reported that 89% had exercise related-leg pain. 3.7 for college [Dick et al. 2007]; 22.0 vs. 10.0 for elite The most common chronic knee injuries have been players [Westbrook 2000]). Furthermore, Dick et al. reported as patellofemoral pain, patellar tendinitis, (2007) found that players were more likely to sus- and iliotibial band friction syndrome (Devan et al. tain severe injuries, such as concussions, facial inju- 2004). Most shin pain has been related to exertional ries, and knee internal derangements during games. compartment syndrome or medial tibial stress syn- Unfortunately, there are no data that compare prac- drome (Reinking 2006). Freke & Dalgleish (1994a, tice and game injury rates in men’s hockey. 1994c) found that 7% of their athletes were diag- nosed with medial tibial stress syndrome. When Does Injury Occur? Chronometry Injury Onset Few studies have reported on what time of the The prevalence of chronic injury in field hockey game or season injury occurs. Westbrook (2000) ranges from 12% to 55% of total injuries (Fuller found that 58% of acute injuries occurred during 1990; Freke & Dalgleish 1994a, 1994c; Westbrook the second half of games. However, Junge et al. 2000) and may be more common in elite athletes (2006) reported the same rate of injury during both (Lindgren & Maguire 1985; Sherker & Cassell 1998; halves of the matches at the 2004 Olympics. It is also Westbrook 2000). unclear whether the time of the season influences The majority of these chronic injuries affect the injury rates. Finch et al. (2002) studied community- lower back and lower limb. Chronic back pain, or level hockey, and the highest rate of injury occurred treatment for previous lumbar spinal conditions has during the first 4 weeks of the first season studied been found in 45% to 78% of field hockey players (24.4 injuries per 1,000 exposure-hours). However, field hockey 137
this result was not replicated in the second play- Time Loss ing season (11.7 injuries per 1,000 exposure-hours), Most hockey injuries do not limit participation. For when the highest rate of injury was during the example, when nine sports were studied in school- fourth month of competition (21.0 injuries per children, field hockey had the lowest proportion of 1,000 exposure-hours). Finch et al. (2002) suggest injuries that caused over a week of nonparticipation that newly recruited subjects may have reported (Powell & Barber-Foss 1999), with 79.6% of injuries more injuries in the first month of the study, creat- resulting in 8 days away from participation, 13.6% ing a reporting bias during the first season of the of injuries requiring 8 to 21 days off, and 7.1% study. At the college level, the practice-injury rate needing 21 days away. Dick et al. (2007) reported has been found to be highest in the preseason (6.4 that 15% of game injuries and 13% of practice inju- injuries per 1,000 AEs) as compared with in-season ries in the NCAA restricted participation for 10 (2.21 injuries per 1,000 AEs) or postseason practice days. The rate for injuries causing 7 days of time (1.63 injuries per 1,000 AEs). In contrast, game inju- loss was 3.0 per 1,000 AEs during the 2004–2005 ries have been found to be highest in-season (8.0 season (NCAA 2008). The study by Junge et al. injuries per 1,000 AEs) versus preseason (6.5 inju- (2006) is the only one that attempted to evaluate ries per 1,000 AEs) or postseason (7.2 injuries per overall time loss among elite athletes. Although 1,000 AEs) (Dick et al. 2007). there was no follow-up after the 2004 Olympic Games, team physicians estimated the duration What Is the Outcome? of each injured player’s absence from training or matches. It was reported that 45% of injured ath- Injury Type letes expected to miss matches or training and 89% of these time-loss injuries were expected to cause The majority of field hockey injuries are minor an absence of up to 1 week. On average, a time-loss sprains and strains (Table 11.4) followed by contu- injury occurred every third match and the incidence sions and wounds or lacerations. The wide range of time-loss injuries was 16 (95% CI, 9–23) per 1,000 of values in each category in Table 11.4 reflects the player-matches. methodologic differences between studies, includ- There is limited information on which injuries ing different injury definitions. affect participation the most. Up to 12% of female Finch et al. (2002) found that hockey had the field hockey players have been found to miss a highest proportion of community-level athletes game or take time off from school or work because who sustained a contusion (79.5%) or laceration of back pain (Murtaugh 2000). However, Rose (15.2%). Many of these injuries required medical (1981) found that second-degree ankle sprains attention. For example, the most common hockey- caused the most disability (as determined by the related ER diagnosis in Australia is an open wound team physician). In elite players, over half of the (20.5% of injuries) (Sherker & Cassell 1998). In the dental injuries sustained have been found to require United States, contusions and abrasions accounted a visit to a physician, a dentist, or both (Elliott & for 79.5% of hockey-related ER visits by children Jones 1984; Bolhuis 1987; Sherker & Cassell 1998; (Yard & Comstock 2006). Yard & Comstock 2006). As indicated in Table 11.3, most injuries affect the lower limb, and the most common specific injury Clinical Outcome is an ankle sprain (Graham & Bruce 1977; Rose 1981; Dick et al. 2007). Beynnon et al. (2005) stud- Powell & Barber-Foss (1999) reported that only 1.2% ied a cohort of female high-school and college field of field hockey injuries require surgery. However, hockey players (n 138) and reported a first-time Roberts et al. (1995) revealed that recreational ath- ankle-injury rate of 0.9 (95% confidence interval letes are playing and training at less than full capac- [CI], 0.4–1.9) injuries per 1,000 person-days, which ity during 10.7% of the season. Recurrent injury was lower than for basketball players but not sig- also contributes significantly to ongoing disability. nificantly different from soccer or lacrosse. In schoolchildren, 10.5% of the acute injuries have 138 chapter 11 29.3 30.0 25.0 63.4 — 30.0 4.0 36.4 1.6 6.2 3.4 11.4 34.7 48.4 Reported — — — — — 0.9 7.7 — 3.7 3.4 — Concussion Other/Not 32.5 Laceration 11.0 — —8.0 25.016.4 19.0 25.0 — —— 1.24.5 6.2 — 5.9 — a . 22.03.0 23.010.1 2.437.0 3.0 2.7 2.4 42.0 9.0 1.8 26.3 32.1 — 24.4 32.0 32.0 13.8 17.5 17.5 2.5 7.5 8.118.5 17.116.9 19.857.9 16.4 15.4 9.4 11.2 9.4 20.2 — 14.7 — 25.0 39.7 32.1 23.9 22.8 25.5 Sprain Strain Contusion Fracture Wound/ 10406224 19.5 NA 24.0 8.0 16 7.3 13.0NA — 50 19.0292 8.0 23.7 15.3 158 NA NA 442 No. in Sample Elite Elite Elite Recreational ages High school, college, and elite College College Population The highest value for each study is in bold type (excluding “Other/Not Reported” injuries). Lindgren & Maguire (1985) & Maguire Lindgren & Dalgleish (1994a)Freke Elite & Dalgleish (1994c)Freke (2000) Westbrook Elite Junge et al. (2006) Elite MEN (1985) & Maguire Lindgren Junge et al. (2006) Elite BOTH Roberts et al. (1995) Sherker & Cassell (1998) ER presentations—all Murtaugh (2001) Rose (1981) Dick et al. (2007) Game Practice WOMEN (1999)Powell & Barber-Foss High school 11.4 of the total injuries in men’s and women’s field hockey Table of acute injury as a percentage Types Study not available. NA room; ER emergency a field hockey 139
been found to be reinjuries, and this proportion rises Maguire 1985; Finch et al. 2002). For example, in to 27% in recreational players and 44% in elite ath- Australia, more men are registered as field hockey letes (Graham & Bruce 1977; Fuller 1990; Powell & players, with a ratio of 1.3 male player to every Barber-Foss 1999). female player. However, men presented to the Victorian hospital ER (1996–1997) 1.7 times more Catastrophic Injury than women for hockey injuries (n 292 field hockey-related presentations) (Sherker & Cassell There have been no reported fatalities in hockey. 1998). The injury rates reported at the 2004 Olympic However, field hockey was shown to have the Games suggest that elite men have 3.2 times greater fourth highest incidence of eye injuries among risk than elite women of sustaining any injury in the 16 sports followed by the NCAA Injury a game and are six times more likely to sustain a Surveillance System from 2000 to 2004 (Cyr 2006), time-loss injury in a match (odds ratio, 6.0; 24 inju- with 11% of head and facial injuries also affect- ries per 1,000 player-matches [95% CI, 12–36] vs. ing the eye (Elliott & Jones 1984). The National 4 [95% CI, 0–10]). Overall, 75% of women versus Center for Catastrophic Sport Injury Research only 52% of men were able to continue participat- (2007) has studied serious injury in U.S. scholas- ing, without interruption, after an injury (Junge tic and collegiate sport since 1982 and has docu- et al. 2006). mented two eye injuries and three head injuries (two skull fractures) due to the impact of a hockey ball. Concussions account for 1.7% to 7.7% of acute Extrinsic Factors injuries (Murtaugh 2001; Finch et al. 2002; Covassin The playing surface, equipment, rules and other et al. 2003; Dick et al. 2007). Head injuries have athletes may influence the pattern of injuries in been shown to account for 5.1% of ER presenta- hockey, although only limited research as been tions in hockey, with a 10.5% admission rate, while conducted. Spedding (1986) surveyed players and intracranial injuries (e.g., concussion, subdural coaches in Australia. They thought that the game hematoma) had a 25.0% admission rate (Sherker & had become safer due to improvements in umpir- Cassell 1998). ing interpretations and the introduction of artificial turf. Since that time, there have been additional rule Economic Cost changes, including the elimination of the offside There are no data available on the economic cost of rule, and now most matches are played on artifi- field hockey injuries. cial turf. Dick et al. (2007) compared injury patterns in the NCAA before and after 1996, when many of these changes occurred and found a statistically sig- What Are the Risk Factors? nificant decrease in game injury rates between the early years (8.7; 95% CI, 8.03–9.28 injuries per 1,000 Intrinsic Factors AEs for 1988–1989 to 1995–1996) and the later years Multiple anatomical, physiologic, and psychological (6.9; 95% CI, 6.29–7.53 for 1996–1997 to 2002–2003). factors may influence injury in hockey players. For The decrease was due to declines in ankle, knee, example, Murtaugh (2001) reported that injured play- and finger injuries. However, the rate of head inju- ers (n 40) were significantly younger (mean SD, ries (concussions and lacerations) increased. It is 18.0 2.6 vs. 20.4 3.2 years) and had less experi- unclear which factor(s) may be responsible for the ence (5.4 3.5 vs. 7.4 3.3 years) than uninjured changes. players (n 118) in a study of female players. In terms of field position, Murtaugh (2001) Sex has also been found to affect the rate and re ported that goalkeepers had the highest rate of type of injury in hockey. In particular, male players injury (0.6 per athlete-year vs. 0.5 for midfield appear to sustain injury more often and to suffer players and 0.4 for forwards and defense players) more severe injuries than female players (Lindgren & and 16.7 times more back and torso injuries than 140 chapter 11 field players. Midfielders had the highest rate of during the shot, and the closest players must stop injuries to the head and face and upper limb, and or avoid a fast-moving ball. Most of these high-risk defenders had a higher rate of lower limb injury activities in hockey occur inside the 25-yard line (0.3 vs. 0.2 injuries per athlete-year). Dick et al. and, consequently, two thirds of game injuries occur (2007) found a similar trend. Unfortunately, neither in this area. This rate includes the 26% of injuries Dick et al. (2007) nor Murtaugh (2001) evaluated that occur around the goal (Dick et al. 2007). these data for statistical significance. Disregarding the rules may also increase injury. Team physicians at the 2004 Olympic Games con- cluded that 19% of recorded injuries were caused What Are the Inciting Events? by foul play (Junge et al. 2006). The situations that lead to the most injuries in hockey are tackling and set plays. Tackling, which Injury Prevention accounts for 17% to 20% of injuries, is an attempt to gain possession of the ball. Players may come Using protective equipment is the most obvious in contact with the turf, the stick, the ball, or each method of reducing injury in sport. It is widely other (Figure 11.1) (Graham & Bruce 1977; Hume accepted that shin guards reduce injuries to the et al. 2003). The most common set plays are free lower leg in soccer; however, to the author’s knowl- hits and short corners. Intention is often disguised edge, no data on the benefits of shin guards in field hockey have been published. Similarly, there are no known data on how the development of light and resilient foams in goalkeeping equipment has affected injury patterns for goalkeepers or the sur- rounding field players.
Further Research Most of the available research on hockey inju- ries focuses on describing their nature and rate. Unfortunately, it is difficult to compare studies because they use different injury definitions and varied study designs. In addition, many authors focus only on elite athletes eventhough a review of Australian ER data found that players 11 to 19 years of age accounted for 50% of the hockey injuries (Sherker & Cassell 1998). The sport would benefit from an in-depth study of injury patterns at all levels. The research team should involve coaches and athletic trainers, physicians to confirm each diag- nosis, and epidemiologists to develop the study design and analyze the data. The best injury defini- tion would incorporate a time-loss component (e.g., no participation on the day of the injury and the fol- lowing day), which would minimize the inclusion Figure 11.1 A player is engaged in an attempted tackle, during which he risks contact with the turf, the ball, of minor injuries that do not have serious conse- the stick, or the other player. Photo courtesy of Hockey quences. The FIH has a medical section that pro- Australia. Reprinted with permission. duces forms for match-injury and medical-incident field hockey 141
reporting. This association, along with local hockey association with specific injuries and their predic- associations, is ideally positioned to help provide tive value. This information can be used to develop the infrastructure needed for injury surveillance. evidence-based guidelines for prevention. Data The largest gap in hockey injury information should also be collected prospectively as new rules involves how injuries occurs and the effectiveness and new equipment are introduced into the game of preventive strategies. Although the literature to evaluate the effects of these changes. Other indicates that adhering to and enforcing the rules related issues include, whether children or inex- of the game, a commitment to physical prepara- perienced players are at greater risk, whether cur- tion, and the use of appropriate protective equip- rent protective equipment is effective, and whether ment will reduce injuries (Fox 1981; Rose 1981; specific training programs can prevent injury. For Spedding 1986; Moore 1987; Sherker & Cassell example, it has been demonstrated in other settings 1998), there is little research to support these sug- that balance training and ankle bracing reduce the gestions. Therefore, the focus of new research rate of recurrent ankle sprains and may reduce first should be on identifying the situations that lead time injuries (Verhagen et al. 2000). to injury and the specific mechanisms of injury. Given that over 78% of head and face injuries For example, Lindgren & Maguire (1985) argued are from stick or ball contact (Jung et al. 1998; that unaccustomed high-intensity training on arti- Murtaugh 2001; Dick et al. 2007) and, in Australia, ficial turf was the major contributing factor to the two thirds of hockey-related ER visits are due to high incidence of overuse injuries in their wom- injuries caused by the stick (Sherker & Cassell en’s squad, and Reinking (2006) suggested that 1998), the almost universal absence of facial protec- differences in the incidence of exercise-related leg tion needs to be examined (Elliott & Jones 1984). pain between teams he studied were related to the Several authors have advised hockey associations training surface. However, no one has investigated to require eye or face protection or both (Jones 1989; these claims. Similarly, although deliberate physical Cyr 2006; Yard & Comstock 2006). Recently, the contact is not permitted in field hockey, incidental FIH rules were modified to allow the use of a face contact seems to be contributing to a larger pro- or head protector if there are documented medical portion of injuries in more recent studies. Twenty concerns (FIH 2006). The NCAA has extended this years ago, contact was responsible for only 2.2% option to all field players. These changes acknowl- of injuries, but in a 2007 review of NCAA players, edge the issue of facial and head injury, but there it caused 13% of injuries (Fuller 1990; Dick et al. is no known research on the appropriate design or 2007). It is unclear whether this discrepancy is due effectiveness of the proposed devices. It should be to changes in the game or differences in the study the priority of the hockey administrators to ensure populations. Fox (1981) suggested that experience, that this equipment is safe. In addition, hockey position, and psychological factors were the most associations and governing bodies should drive the important injury risk factors. Kolt and Roberts development of policies that incorporate evidence- (1998) collected injury data and a self-esteem based guidelines into the initial management of inventory over a 20-week season from 50 players. head and brain injury, and return-to-play deci- Multiple-regression analysis indicated that the fre- sions following head and brain injury (McManus quency of more severe injuries significantly pre- 2006). dicted self-esteem scores (P 0.01) and Rose (1981) Finally, a meta-analysis has indicated that the identified an inverse relationship between success overall risk of an orofacial injury is 1.6 to 1.9 times and injury. Further work is needed to understand higher if a mouth guard is not worn during sports the importance of these characteristics and how with a risk of facial injury (Knapik et al. 2007). they may be manipulated to decrease injury rates. Consequently, the American Dental Association As risk factors are identified and confirmed, and the International Academy of Sports they should be evaluated statistically for their Dentistry recommend mouth-guard use for hockey 142 chapter 11
(American Dental Association 2004). A survey of studies suggest that players do not wear mouth 359 American parents cited field hockey, along guards consistently because of discomfort or inter- with football, boxing, ice hockey, wrestling, and ference with breathing (Bolhuis et al. 1987). It is karate as sports in which mouth-guard use ought clear that studies to determine the effectiveness of to be mandatory (Diab & Mourino 1997). However, mouth-guard use in hockey are required.
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Gymnastics
GREGORY S. KOLT1 AND DENNIS J. CAINE2 1School of Biomedical and Health Sciences, University of Western Sydney, Sydney, New South Wales, Australia 2Department of Physical Education, Exercise Science and Wellness, University of North Dakota, Grand Forks, North Dakota, USA
Introduction part in six events (pommel horse, vaulting, rings, horizontal bar, parallel bars, and rope climb). By Gymnastics is a broad term used to describe a 1932, floor exercise was also included. range of physical activities dating back to the The 1928 Olympic Games saw the introduction Egyptians in 2000 b.c. Several other ancient socie- of a team event for women, and by the Games of ties (e.g., Greeks, Romans, Chinese) have also doc- Helsinki in 1952, individual Olympic events for umented various types of gymnastics in relation to women were introduced, and they have remained conditioning and health. For example, the Chinese ever since. In 1932 the Federation International de participated in gymnastics as mass displays of free Gymnastique conducted the first Artistic Men’s exercises. The more modern competitive gym- World Championships in Paris, which included nastics is based on the work of Freidrich Jahn, events for vaulting, bars, and beam, as well as who developed apparatus including rings, paral- other disciplines, including long jump and jave- lel bars, pommel horse, and horizontal bar, with lin. The first participation of women in the World the primary purpose of developing and training Championships occurred in 1934 in Budapest. Also strength. in Budapest (in 1963), the first World Champion- Gymnastics developed further to the point in ships in Modern Gymnastics (to become Rhythmic 1881 at which representatives from France, Holland, Sportive Gymnastics in 1975) was held. It was not and Belgium formed the European Gymnastics until 1984 that this gymnastics discipline was intro- Federation, an organization that ran regular duced to the Olympic Games. world championship competitions. In 1921, this Gymnastics has developed to include several organization changed its name to the Federation disciplines. Aside from the better-known men’s International de Gymnastique, which currently artistic gymnastics, women’s artistic gymnastics, remains the world governing body representing and rhythmic sportive gymnastics, the Federation approximately 130 member nations. Gymnastics International de Gymnastique also oversees gym- was included in the first modern Olympic Games in nastics for all (a noncompetitive discipline), tram- Athens in 1896. Although women were not included poline gymnastics (since 1998), aerobic gymnastics at this stage, 18 gymnasts from five countries took (since 1996, and formerly known as sport aerobics), and sports acrobatics (since 1999). Current-day Olympic Games include men’s gymnastics, wom- Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 en’s gymnastics, rhythmic gymnastics, and tram- Blackwell Publishing, ISBN: 9781405173643 poline gymnastics. 144 gymnastics 145
Gymnastics is a sport that is well known for information on the epidemiology of artistic gym- its intense training, relatively young age of par- nastics injury as reported in the literature. The ticipants, psychological demands, and physical majority of the emphasis of this chapter will be on requirements in terms of strength, power, and flex- the cross sectional, retrospective, and prospective ibility. From a biomechanical perspective, a small, epidemiologic studies, as they provide very useful lean, and muscular physique provides an advan- information on the distribution and determinants tage in the complex maneuvers that characterize of injury. Case studies (of which there are a large modern-day gymnastics. As such, many perform- number in the literature) will be drawn on only to ers are entering gymnastics at increasingly younger discuss particular aspects of injuries, as in general, ages to take advantage of such body shape before they do not represent overall gymnastic popula- the onset of puberty. Added to this is the intense tions, and cannot be used to identify injury risk. training at such ages, often for up to 20 to 40 hours Much of the extant literature on injury in gym- per week (Caine et al. 1989; Dixon & Fricker 1993; nastics has dealt with female gymnasts, with only a Kolt & Kirkby 1995). In men’s gymnastics, train- few studies addressing male gymnasts. In review- ing will often commence at older ages, but training ing existing literature, several methodologic limi- intensity will be equally as demanding as for wom- tations are apparent, often making comparison en’s gymnastics. Usually men will endure such between studies difficult (Caine, 2003): training levels for longer periods of time given that their peak performance is often of a later onset • Diversity of study populations in aspects such as because of the requirement for greater levels of age, level of performance, and type of training strength that occur well after puberty. environment (e.g., club-based vs. college-based, A further important change in gymnastics in elite vs. subelite and recreational). past years has been the complexity and range of • In many cases, data collection has covered less skills that have come into the sport. With changes than a full-year cycle of training and competi- in equipment design (e.g., introduction of sprung tion. With differences in injury incidence between floors), the variety of skills, as well as the difficulty training and competition (Bak et al. 1994; Caine and risk associated with such skills (e.g., with a et al. 1989, 2003; Kerr & Minden 1988; Lindner greater number of rotations and twists, and with & Caine 1990a; Marshall et al. 2007; Pettrone & a higher amplitude) has increased dramatically. Ricciardelli 1987), comparing different periods of Given these factors of intense training during peri- an annual performance and training cycle is dif- ods of growth and development, and the increased ficult and can be seen as problematic. risk of more contemporary maneuvers, it is perhaps • Many studies have an insufficient sample size to not surprising that concern has often been raised carry out risk-factor analysis regarding the rate and severity of injury in competi- • Frequent use of self-report questionnaires that tive artistic gymnastics (Caine et al. 2008). may not capture accurate details on the diagno- Several comprehensive reviews of gymnastics inju- sis and exact nature of injury. Self-report meth- ries (Caine 2003; Caine & Nassar 2005; Caine et al. ods also allow gymnasts to present themselves in 1996) and injury countermeasures (Daly et al. 2001) a way that provides a reason for poor perform- have been published. It is the intent of this chapter ance (e.g., exaggerate their injuries as a way of not to simply provide a further review of the same accounting for performance) material, but rather to extend on those previous • The use of retrospective data collection, a method reviews with more recently published work. To dependent on memory recall and thus the risk build the overall picture, however, material previ- of “retrospective contamination.” It has been ously reviewed will be included to a lesser degree to shown that retrospectively collected data tend to provide a complete picture. The predominant focus miss the more minor injuries, thereby resulting in of the chapter will be on competitive men’s and lower overall injury rates (Kolt & Kirkby 1999). women’s artistic gymnastics, and we will provide • Variability in injury definition across studies. 146 chapter 12
• The use of convenience samples or nonrandom injury rates across studies is difficult, given that selection, resulting in the possibility that the most authors have not taken into account the expo- gymnastic programs most concerned with injury sure to injury risk, but rather reported injury rates will be overrepresented. per season. Those who did report injury based • The dearth of studies on populations from out- on exposure found rates ranging from 0.5 injury side North America. With different training meth- per 1,000 hours of participation (Lindner & Caine ods across countries, findings from one country 1990a) to 5.3 injuries per 1,000 hours of participa- may not be generalizable to other countries. tion (Kolt et al. 2004) for female club gymnasts. • With significant changes in gymnastics train- One study of male and female gymnasts in ing (including increased difficulty of skills being Sweden (Harringe et al. 2007a) found a rate of performed), equipment, and rules over the years, 2.2 injuries per 1,000 hours of exposure with no comparing results from different periods should sexdifferences. It should be noted that participants be done with caution. For example, every 4 in this study were gymnasts involved in “team- years, rule changes are made in accordance with gym,” a variation of artistic gymnastics involv- the Federation International de Gymnastique ing teams of 6 to 12 members participating in Code of Points. tumbling, trampette, and the floor program. Only two studies have reported data relative to athletic It is important for the reader to interpret the findings exposures (i.e., one AE equals one athlete par- of gymnastics injury research in light of these limita- ticipating in a competition or practice) with Caine tions, while at the same time recognizing the diffi- et al. (2003) finding 8.5 injuries per 1,000 athletic culty of collecting such data in more controlled ways. exposures (AEs) in club-level gymnasts and Sands et al. (1993) reporting 90.9 injuries per 1,000 AEs in college-level gymnasts. Who Is Affected by Injury? Marshall et al. (2007) reported on female gym- Gymnastics has always been seen as a sport with nastics injuries recorded on the National Collegiate a high risk of injury, given the nature of the skills Athletic Association Injury Surveillance System being undertaken, as well as the intensity and from 1988–1989 through 2003–2004. They found a number of hours of training being undertaken significant annual decrease in injury rates during by participants. Defining injury in gymnastics is competition (Ϫ4% annually) over this period, but problematic, however, because of the tendency for not during practice. Interestingly, in their retrospec- gymnasts to train “around” injuries. For example, tive analysis of gymnastics-related injuries treated a gymnast with an ankle injury will often train on in U.S. hospital emergency departments, Singh et bars and avoid mounts and dismounts to protect al. (2008) reported a 25% decrease in the number of the ankle. As a result, a commonly recommended injuries between 1990 and 2005. definition of injuries in gymnastics studies has There is a dearth of injury data for participants been “any gymnastics-related incident that resulted in rhythmic gymnastics and trampoline gymnas- in the gymnast missing any portion of a workout tics. Cupisti et al. (2007b) carried out an 8-month or competitive event” (Caine et al. 1989, 2003). prospective study with 70 club-level rhythmic However, there is no published consensus state- gymnasts 13 to 19 years of age. They reported 49 ment endorsing this definition. As a result, there significant injuries over the survey period, equating remains considerable variability across studies. to a rate of 1.08 injuries per 1,000 hours of training. Table 12.1 shows a comparison of injury rates across a large number of prospective and retro- Where Does Injury Occur? spective studies in men’s and women’s artistic gymnastics. It is clear that that the majority of epi- Anatomical Location demiologic research on gymnastics injury has been carried out in the 1980s and 1990s, with very little Understanding the anatomical location of injury primary research since that time. Comparison of is important for coaches and sports medicine staff gymnastics 147 d 2.5 2.0 3.7 3.6 0.5 3.3 5.3 1.4 ( continued ) No. of Injuries per 1,000 hr of Exposure e 1.6 5.3 0.1 4.2 2.9 12.4 28 70.3 54.5 33 45.8 12.8 24.9 22.2 89 39.8 56.0 840.5 200 198 294 364 No. of Injuries per 100 Participant- Seasons a b c 42 24 50 64 20 72 46 79 98 162 542 370 268 162 221 220 725 362 766 3042 2,016 5,929 No. of Participants 7 11 33 29 73 93 57 16 41 95 325 260 321 147 128 349 192 No. of Injuries 10 yr 7 mo 3 seasons7 mo 353 11 mo 11 1 yr 1 season Duration of Data Collection 2nd 1 yr 1 yr 2 seasons 146 1 season 11 mo 11 1 yr 7 mo 9 mo 1 season 3 seasons 90 1 yr 3 yr 18 mo 2 seasons 39 9 mo 9 1st I Q I Q Q Q Q Data-Collection Method Q Q I Q I Q Q Q Q Q Q and I Q I Q and I Q I R P R R P Design of Study P P P R R P R P P P P P and RP Q P P P Table 12.1 Table Injury rates in women’s and men’s artistic gymnastics. Study Dixon & Fricker (1993) 1974–1975 Female gymnasts Recreational (1987) & Ricciardelli Pettrone P (1986) Vergouwen (1987) & Ricciardelli Pettrone P Lowry & LeVeau (1982) Lowry & LeVeau Kolt & Kirkby (1995) Garrick & Requa (1980) Goodway et al. (1989) Caine et al. (2003) Steele & White (1983) Backx et al. (1991) McLain & Reynolds (1989) P Kolt et al. (2004) Lowry & LeVeau (1982) Lowry & LeVeau Goodway et al. (1989) Club Garrick & Requa (1980) Lindner & Caine (1990a) P Bak et al. (1994) Caine et al. (1989) High school Garrick & Requa (1980) 1973–1975 Weiker (1985) Weiker Kolt & Kirkby (1999) 1973–1974 148 chapter 12 5.33 2.2 No. of Injuries per 1,000 hr of Exposure i 0.3 9.3 40 76.2 13.9 93 204 275 100 254 No. of Injuries per 100 Participant- Seasons n the publication or calculations were not pos- n the publication or calculations were a g h j f 20 42 21 18 24 162 121 377 107 185 per yr No. of Participants 8 1 5 10 42 16 61 151 247 509 2,739 1,380–1,550 No. of Injuries 12 mo 9 mo 10 yr 8 seasons 536 1 season 11 mo 11 Duration of Data Collection 1 season mo 11 16 yr 8 mo 2 seasons 5 yr e no figures are reported, data were not available withi data were reported, are e no figures I Q I Q I Q Data-Collection Method by Recorded physiotherapist Q Q Q I Q P P R P R Design of Study P R R P P P continued ) Rates include data from 25 male participants. Rates include data from This sample includes 70 recreational gymnasts. This sample includes 70 recreational This sample includes 16 male gymnasts. This sample included 477 recreational gymnasts. This sample included 477 recreational 1 participant ϭ gymnast participating in one season. This rate includes a high incidence of trampoline injuries. Total number of participants during 3 yr (mean duration, 17.5 mo). Total Range of approximate number of participants each year. Range of approximate This sample includes data from 8 female gymnasts. This sample includes data from This sample includes 79 female gymnasts. Kirialanis et al. (2003) College (1994) NCAA Club (1985) Weiker Dixon & Fricker (1993) McLain & Reynolds (1989) P Male gymnasts Recreational (1982) Lowry & LeVeau Table 12.1 ( Table Study Harringe et al. (2007) (1982) Lowry & LeVeau R ϭ retrospective; ϭ questionnaire; Q ϭ prospective; I ϭ interview; P Caine (2003) and Nassar (2005). Wher Adapted and updated from a b c d e f g h i j sible from the available data. sible from College or equivalent Marshall et al. (2007) Kerr (1991) High school Garrick & Requa (1980) Sands et al. (1993) gymnastics 149
Table 12.2 Anatomical location of injury in club, high-school, and college artistic gymnastics.
Study Head (%) Spine/Trunk (%) Upper extremity Lower extremity (%) (%)
Female club gymnasts Prospective studies Garrick & Requa (1980) 6.0 0.0 25.0 69.0 Weiker (1985) 3.2 7.5 18.1 70.2 Caine et al. (2003) 0.7 15.0 20.5 63.7 Lindner & Caine 4.1 16.7 22.9 54.1 (1990a) Bak et al. (1994) 2.4 9.8 17.1 61.0 Kolt & Kirkby (1999) 1.1 17.2 20.9 59.0 Caine et al. (1989) 1.6 19.2 21.4 57.8 Harringe et al. (2007) 26.9 7.7 65.4 Retrospective studies Steele & White (1983) 1.4 13.7 14.4 69.1 Kerr & Minden (1988) 13.0 56.0 Dixon & Fricker (1993) 1.5 22.3 21.7 55.3 Kolt & Kirkby (1995) 0.6 17.8 22.7 57.3 Homer & Mackintosh 2.0 24.4 18.3 54.9 (1992)
Female high school and college gymnasts Garrick & Requa (1980) 3.0 13.0 36.0 48.0 (mixed) Garrick & Requa (1980) 7.7 43.6 12.8 35.9 (interscholastic) Sands et al. (1993) 0.8 18.1 22.2 58.9 Marshall et al. (2007) 5.6 (practice)a 19.1 (practice) 17.8 (practice) 52.8 (practice) 6.7 (competition) 9.5 (competition) 11.5 (competition) 69.3 (competition)
Male gymnasts Weiker (1985) 18.2 9.1 36.4 36.4 Kerr (1991)b 20.0 23.0 47.0 Dixon & Fricker (1993) 0.4 13.4 53.4 32.8 Lueken et al. (1993 3.2 17.1 39.3 43.1 Kirialanis et al. (2003)c 0.0 7.9 19.9 72.2 Harringe et al. (2007) 0.0 31.3 12.5 56.2
Adapted and updated from Caine (2003) and Caine and Nassar (2005). Where no figures are reported, data were not available within the publication or calculations were not possible from the available data. a This study combined head and neck injuries into a single category. b This sample combines 16 men and 8 women. c This sample combines 83 men and 79 women.
alike. Such information highlights the body parts in gymnastics report injury by anatomical location, most likely to be injured, and can point to preventive and given the relatively low rates of injury in rec- measures, including technique changes and physical reational gymnasts, no classification by anatomical conditioning programs. Table 12.2 shows injury by location is provided for these participants. anatomical location for female and male gymnasts at As shown in Table 12.2, the lower extremity is club level and college level. Not all studies of injury the most commonly injured body region for both 150 chapter 12
competition injuries and 10.6% of all practice inju- ries in the 16-year longitudinal study of Marshall et al. (2007) involved the knee. With respect to the ankle, Kerr (1991) found that it accounted for 29.0% of injuries, Garrick and Requa (1980) 25.0%, Kolt and Kirkby (1999) 31.2% (com- bined ankle and foot), Kirialanis et al. (2003) 45.7% (combined ankle and foot and men and women), and Marshall et al. (2007) 18.8% in competition and 15.2% in practice. The lower back accounted for 12.2% to 20.3% of injuries in four studies of club- level gymnasts (Homer & Mackintosh 1992; Sands et al. 1993; Kolt and Kirkby 1999; Caine et al. 2003), yet only 3.2% of all competition injuries and 7.7% of all practice injuries among college-level gym- nasts (Marshall et al. 2007). Only six studies reported injury to male gym- nasts by anatomical location. These included five prospective studies (Weiker 1985; Lueken et al. 1993; Kerr 1991; Kirialanis et al. 2003; Harringe et al. 2007a) and one retrospective study (Dixon & Fricker 1993). Similar to the rate for female gym- nasts, the lower extremity appeared to be the most injured region (32.8–72.2% of injuries) followed by the upper limb (12.5–53.4%) and trunk and spine (7.9–31.3%). The Dixon and Fricker (1993) study, Figure 12.1 The ankle is one of the most commonly injured however, which examined injuries over a 10-year body parts in gymnasts. © IOC/Hiroki SUGIMOTO period, found the upper extremity (53.4% of inju- ries) to incur more injuries than the lower extremity (32.7%). When examining specific anatomical loca- club-level gymnasts and high-school and college tions, the shoulder joint was a commonly injured gymnasts (35.9–70.2% of injuries), with the majority body part, ranging from 4.6% in a small study of of studies finding proportions above 50%. The next 16 male gymnasts (Kirialanis et al. 2007) to 19.1% most frequently injured region appears to be the (Dixon & Fricker 1993). The wrist was also a com- upper extremity (7.7–36.0%), the trunk and spine monly injured body part, with up to 13.8% of inju- (0–43.6%), and the head (up to 7.7%). There do not ries (Dixon & Fricker 1993), as was the ankle, with appear to be any obvious differences between the a range from 9.8% (Dixon & Fricker 1993) to 25.0% proportions reported in prospective and retrospec- (Harringe et al. 2007a) and 27.0% (Kerr 1991). In tive studies. the Kerr (1991) study, the lower back accounted for A more specific look at these body regions high- 20.0% of injuries. The parts of the upper extremity lights that injuries to the knee are the most common, (e.g., shoulder, wrist) in male gymnasts are more followed by those to the ankle (Fig. 12.1) and the commonly injured than in female gymnasts (in lower back. For example, knee injuries ranged from whom ankle and lower back injuries predominate), 13.5% to 24.5% of all reported injuries in four stud- is likely indicative of the different types of appara- ies (Steele & White 1983; Weiker 1985; Lindner & tus used in men’s gymnastics. Caine 1990a; Kolt & Kirkby 1999), and comprised Data on the anatomical location of injury 26.5% of combined knee and thigh injuries in the in rhythmic gymnastics is limited. Cupisti et al. Kirialanis et al. (2003) study. Over one-quarter of all (2004) carried out a cross-sectional study of the gymnastics 151
prevalence of low back pain in 67 club-level rhyth- between gymnastic event and injury. In one study mic gymnasts. They found that only 10.5% of gym- that did report exposure-based acute injury data, nasts reported low back pain, as compared with Caine et al. (2003) found that the floor exercise was 26.0% of matched controls (nongymnasts). The the event most likely to lead to injury in club-level timing within the season during which the survey female gymnasts. This supported an earlier find- was administered may have contributed to what ing that floor exercise had the highest frequency of appears a very low prevalence of low back pain injury at international competitions in the period in this sample. In a later study, Cupisti et al. (2007) from 1983 to 1998 (Leglise 1998). investigated 70 club-level rhythmic gymnasts over In men’s gymnastics, few data are available. an 8-month period. The most prevalent anatomi- Kirialanis et al. (2003) found that 52.9% of all knee cal sites for injury were the foot (38.3%), knee and injuries and 43.8% of all ankle injuries occurred on lower leg (19.1%), and back (17.0%). floor exercise, and that 37.5% of ankle injuries were incurred during work on the parallel bars. In an Environmental Location earlier study, Lueken et al. (1993) found that from 15 years of injury data taken from the U.S. Olympic Practice versus Competition Training Center, floor exercise contributed most to Gymnastics is a sport characterized by a large injury (24.9%), followed by rings (19.2%), horizon- number of hours dedicated to training and very tal bar (16.9%), parallel bars (16.4%), pommel horse few hours spent in competition. It is not unusual (14.7%), and vault (7.9%). NCCA data for 1987 for some gymnasts, despite training up to 40 hours through 1994 (NCCA 1994) also show floor exercise per week, to participate in only 5 to 10 competitions as having the highest percent of injuries (27.9%), per year. With this differential in time spent in train- followed by high bar (22.1%) and pommel horse ing versus competition, it is expected that a larger (27.6%). proportion of injuries would occur in a training environment. Although not all studies report dis- When Does Injury Occur? tribution of injuries by practice versus competition, several studies of female gymnasts have found that Injury Onset 71.0% to 96.6% of injuries occur in practice and 3.4% to 21.0% in competition (Garrick & Requa 1980; In gymnastics, in which a high number of train- Pettrone & Ricciardelli 1987; Kerr & Minden 1988; ing hours are required for high-level performance Caine et al. 1989, 2003; Lindner & Caine 1990a; Bak and a number of high-risk skills are performed, et al. 1994; Harringe et al. 2007a). However, when it is expected that both sudden-onset and grad- exposure is accounted for, the rate of injury has ual-onset injuries will occur. Studies reporting been shown to be two to three times greater in com- on injury onset for female gymnasts indicate a petition (Caine et al. 2003; Marshall et al. 2007). range of 21.9% to 55.8% for gradual-onset and 44.2% to 82.3% for sudden-onset injuries (Steele & White 1983; Weiker 1985; Pettrone & Ricciardelli Gymnastic Events 1987; Goodway et al. 1989; Caine et al. 1989, 2003; With gymnasts participating in a wide variety of Lindner & Caine 1990a; Jones 1992; Dixon & Fricker events or apparatus (six for men, four for women, 1993; Mackie & Taunton 1994; Bak et al. 1994; Kolt and many other nonapparatus training drills), & Kirkby 1995, 1999; Harringe et al. 2007b). In all it is important to understand where the greatest but one study (Caine et al. 1989), the greatest pro- risk of injury lies. However, much of the injury portion of injuries were of sudden onset. Studies of data reported for gymnastics fail to differentiate male gymnasts also show a greater proportion of between sudden-onset and gradual-onset injuries, sudden- versus gradual-onset injuries (Kerr 1991; and also does not take into account exposure time Dixon & Fricker, 1993; Kirialanis et al. 2003). on each apparatus; these combined factors make it Some studies also suggest that higher-level difficult to accurately understand the relationship gymnasts tend to have a greater proportion of 152 chapter 12 gradual-onset or chronic injuries. For example, gymnastics-related injuries presenting to U.S. hos- Kolt and Kirkby (1995) in their retrospective study pital emergency departments during October and showed that 55.0% of injuries to elite gymnasts March, months that are associated with the compet- were of gradual onset, as compared with only itive seasons for club gymnastics and high-school 34.3% for their subelite counterparts. In a later lon- gymnastics, respectively. The most comprehensive gitudinal study, Kolt and Kirkby (1999) found that study in this area demonstrated that in-season com- 49.7% of elite gymnasts’ injuries were of gradual petition rates were higher than postseason injury onset, as compared with only 25.0% for the sub- rates (15.6 vs. 10.8 injuries per 1,000 AEs) (Marshall elite group. This supports earlier findings from et al. 2007). highly competitive and trained gymnasts, in which 55.8% of injuries were gradual in onset (Caine et al. 1989). What Is the Outcome?
Injury Type Chronometry Injury types in gymnastics have been categorized When examining injury chronometry in gymnas- differently across studies, making comparison dif- tics, both timing within a practice session and ficult. Table 12.3 shows a percent comparison of timing during a year-long season are important. injury types across a range of studies of female Although not many studies have reported this level gymnasts. It can be seen from the table that sprains of detail in describing injury, it does provide very (15.9–43.6%) are the most common type of injury, useful information for designing practice sessions followed by strains (6.4–31.8%). Other types of inju- and outlining annual training programs. Several ries that are common in some studies include con- studies have reported that the early part of a train- tusions (Garrick & Requa 1980; Lowry & LeVeau ing session is a period during which a higher fre- 1982), fractures (Garrick & Requa 1980; Pettrone quency of injury can occur (Caine et al. 1989, 2003; & Ricciardelli 1987), and inflammatory conditions Lindner & Caine, 1990a). In a more recent study of (Kolt & Kirkby 1995, 1999). The main difficulties male and female gymnasts, Harringe et al. (2007a) in comparing the proportions across studies are reported that 26% of all training injuries occurred differences in understanding and definition of the at the beginning of the session, 24% at midsession, injury types, and the self-report nature of data col- 33% toward the end of the session, and 17% with lection in some studies. a gradual increase throughout the whole session. We found one report on injury types for One study investigated the time into a competition male gymnasts. In the 1993–1994 NCAA Injury when injury occurred (Caine et al. 2003) and found Surveillance System Report for Gymnastics, the that 58.3% of such injuries occurred during the first top three injury types during 1986 through 1994 half-hour of a competition. were sprain (22–35%), strain (12–26%), contusion A number of studies have also followed the time (7–17%), and fracture (7–12%) (NCAA 1994). into the season for injury occurrence in women’s For rhythmic gymnastics, only one study has gymnastics (Caine et al. 1989, 2003; Kerr & Minden reported injury type (Cupisti et al. 2007). They 1988; Dixon & Fricker 1993; Marshall et al. 2007). found that of the 46 injuries recorded, 26.1% were The findings of these studies vary, but it appears strains, 15.2% sprains, 17.4% contusions, 6.5% frac- that injury rates can increase following periods of tures, 2.2% dislocations, and 32.6% other. decreased training (Caine et al., 1989, 2003), during the practice of competitive routines (Caine et al. Time Loss 1989; Sands et al. 1993), and during weeks just prior to and during competition (Kerr & Minden Most studies that recorded this level of data have 1988; Sands et al., 1993; Caine et al. 2003). Similarly, found that mean time loss per injury is greater for Singh et al. (2008) reported a peak frequency of advanced than for lower-level gymnasts (Kolt & gymnastics 153 43.6 17.9 17.9 39.7 31.5 16.4 29.6 20.6 21.4 15.9 16.2 18.7 29.719.3 23.3 14.3 31.8 29.2 0.0 41.9 20.6 21.4 0.0 41.9 6.4 0.0 0.0 32.0 21.0 0.0 11.8 19.4 11.8 9.7 n the publication or calculations were not pos- n the publication or calculations were 0.0 1.1 1.6 0.0 40.1 19.0 17.7 4.1 0.0 2.3 3.1 6.5 8.1 0.0 8.2 8.4 15.3 8.31.6 17.9 8.1 13.8 4.8 3.4 10.2 3.0 11.7 31.2 e no figures are reported, data were not available withi data were reported, are e no figures 4.1 3.1 1.6 6.08.9 0.6 0.5 6.5 4.3 4.1 0.7 9.7 6.4 27.4 0.0 20.5 34.2 1.5 27.3 1.6 0.00.5 0.0 0.0 0.5 0.0 2.2 0.0 0.0 0.7 0.0 0.0 0.0 0.0 a (interscholas- tic study) study) Includes data for recreational as well club-level gymnasts. Includes data for recreational 2 year 2 High school Prospective studies Garrick & Requa (1990) 1 year (mixed Pettrone & Pettrone Ricciardelli (1987) Kolt & Kirkby (1995) Kolt & Kirkby (1999) Caine et al. (2003) Retrospective Lowry & (1992) LeVeau Lindner & Caine (1990a) Caine et al. (1989) Club Prospective studies Garrick & Requa (1980) Table 12.3 Table club, high-school, and college female artistic gymnastics. of injury in recreational, Type Level/Study AbrasionRecreational Retrospective Concussionstudies ContusionLowry & Dislocation (1992) LeVeau Fracture Inflammation Laceration Nonspecific Sprain Strain Other Caine (2003) and Nassar (2005). Wher Adapted and updated from a sible from the available data. sible from 154 chapter 12
Kirkby 1995, 1999; Caine et al. 2003). For example, of the primary injury (Kolt & Kirkby 1999). The Kolt and Kirby (1999) reported that female elite repetitive nature of training for many gymnastic gymnasts missed 0.5 training session and modi- skills is also likely a reason for the predominance of fied 23.1 training sessions per injury, whereas their recurrent injuries. Several cohort studies of female subelite counterparts missed 2.0 and modified 7.0 competitive gymnasts found that between 24.5 and training sessions for each injury. When viewing 32.3% of all injuries were reinjuries (Linder & Caine this impact from an annual perspective, Kolt and 1990; Kolt & Kirkby 1999; Caine et al. 2003). It has Kirkby (1999) found that elite gymnasts spent 21% also been shown that club-level (2.1 reinjuries per of their total annual training time participating at 1,000 AEs; Caine et al. 2003) and college-level (2.19 a reduced capacity because of injury, with subelite reinjuries per 1,000 AEs; NCAA 1994) gymnasts (although competitive) gymnasts reducing their show similar rates of reinjury. No recent published training capacity by 16.5%. In an earlier study, data are available on rates of recurrent injury, nor Sands et al (1993) did not comment directly on the are there any data available for male gymnasts. time lost due to injury but did find that female col- lege gymnasts were training with an injury during Catastrophic Injury approximately 71% of training sessions. Other studies that have looked at the number of There is concern in gymnastics regarding cata- days lost due to injury have found that advanced- strophic injury given the high-risk skills being level participants experience a greater proportion trained and competed. There have been some of severe injuries (у 21 days time loss) than begin- highly publicized spinal cord injuries to gymnasts ning-level female gymnasts (17% vs. 3%; Fisher’s from China (Cowley & Westly 1998) and the United exact P ϭ 0.003) (Caine et al. 2003) and that com- States (Ryan 1995). The national spinal cord injury petition injuries resulted in a greater proportion of registry in Japan identified seven catastrophic inju- severe injuries than those that occurred in practice ries to female gymnasts from 1990 to 1992 (Katoh (37.5% vs. 10.2%; Fisher’s exact P ϭ 0.007) (Caine et al. 1996), and Schmitt and Gerner (2001) reported et al. 2003). Kirialanis et al. (2003), in a sample of six female gymnasts with spinal cord injuries over male and female gymnasts, found that 29% of inju- the period 1985 to 1997. ries resulted in absence from training and compe- Data arising from studies of club-level gymnasts tition for Ͼ1 month, and a further 44% of injuries indicate an infrequent occurrence of catastrophic resulted in absence for between 1 week and 1 injury. Dixon and Fricker (1993), in a retrospective month. Perhaps the strongest data in this area come study of 116 male and female elite gymnasts train- from the 16-year study of injuries in female college ing at the national sports institute in Australia, gymnasts (Marshall et al. 2007). Over this 16-year found no catastrophic (life-threatening) injuries period, 39% of competition injuries and 32% of over the 10-year period of interest. These findings training injuries resulted in a time loss у10 days. are supported by other longitudinal studies of club- For competitive rhythmic gymnasts, Cupisti level gymnasts (Caine et al. 1989, 2003; Lindner & et al. (2007) found that for each injury sustained, 4.1 Caine 1990a; Kolt & Kirkby 1999) showing no cata- training sessions were missed and 32 were modified. strophic injuries. Unfortunately, there are currently no national injury surveillance systems that track Clinical Outcome injuries, including catastrophic injuries, among club-level gymnasts. Recurrent Injury Other available data have shown a relatively Gymnastics is a sport in which participants experi- small number of catastrophic injuries relative to ence recurrent injuries for several reasons including the number of participants. The National Center premature return to activity, inadequate rehabilita- for Catastrophic Sports Injury Research (2007) has tion, and possibly an underestimation of the severity tracked catastrophic injuries in high-school and gymnastics 155
college settings since 1982. In the period 1982 to these, Wadley and Albright (1993) surveyed former 2007, there were 19 catastrophic injuries occurred collegiate gymnasts and found that 45% of previous among more than 147 million high-school and 8 injuries (low back, ankle, great toe, shoulder, knee) million college gymnast participants. In compari- still had symptoms. Two studies focused on back son to other sports, direct injury rates for nonfatal pain and associated radiologic changes in former (i.e., permanent, severe functional disability such top-level gymnasts (Tsai & Wredmark 1993; Lundin as quadriplegia) were highest for male and female et al. 2001). These studies found no differences gymnasts at both the high-school and college between the former gymnasts and control groups levels. (nongymnasts) in back pain, but reported a higher prevalence in radiologic changes (e.g., degenera- tive changes) in the gymnastic groups. Maffulli et Nonparticipation al. (1992) carried out long-term follow-ups (mean, Injury is often a reason for dropping out of 3.6 years) of elbow joint articular surface lesions in sport. Dixon and Fricker (1993) in their study of 12 (6 male and 6 female) gymnasts. They found a Australian elite gymnasts over 10 years found that high frequency of osteochondritic lesions, signs of 9.5% retired as a result of injury. The sorts of inju- joint aging, loose intraarticular bodies, decreased ries that were involved in the decision to drop out range of elbow extension, and mild residual pain at included anterior cruciate ligament rupture, osteo- full extension. chondritis of the elbow, knee meniscus lesions, navicular stress fracture, and chronic rotator-cuff conditions. Some published case studies have also What Are the Risk Factors? reported injuries that led to withdrawal from gym- nastics. These included injuries to the low back For injury-intervention and rehabilitation programs (Katz & Scerpella, 2003) and elbow (Jackson et al. to be effective, an in-depth knowledge of injury 1989; Maffulli et al. 1992; Singer & Roy 1984). risk factors is paramount. Other studies that have examined the relationship between injury and dropping out of a sport have Intrinsic Factors found that between 16.3% and 52.4% of those who dropped out of club-level gymnastics had an injury Some studies showed that body size (height and at the time of withdrawing from the sport (Caine weight), age, and body fat were all greater in et al. 1989, 2003; Lindholm et al. 1994). Although injured or high-injury-risk gymnasts (Steele & this could suggest that injury may have played a White 1983; Lindner & Caine 1990a, 1993; DiFiori role in the withdrawal, there are several other fac- et al. 2002a). It is possible, however, in these stud- tors, such as age or transition to other sports that ies that factors such as greater height and weight could have influenced this decision. Notably, data characterized older gymnasts who were competing on 80 youths who had dropped out of club-level at higher levels of competition. gymnastics within the previous month indicated Results of a study of gymnastics-related injuries that being injured was the least important factor in presenting to U.S. hospital emergency departments their decision to drop out (Kolt 1996). suggests an age effect with regard to distribution of injuries. Singh et al. (2008) reported that upper- extremity injuries were more common in the 6-to- Residual Effects 11-year age group than in the 12-to-17-year age Despite the high rates of injury in gymnasts and group (risk ratio, 1.46; 95% confidence interval the severity of a large proportion of those injuries, [CI], 1.37–1.56; P Ͻ 0 .0001) and that lower-extrem- very few studies have examined the residual or ity injuries were more common in the 12-to-17- longer-term effects of such injuries. In the earliest of year age group (risk ratio, 1.69; 95% CI, 1.56–1.83; 156 chapter 12
P Ͻ0.0001). Also, the 6-to-11-year-olds were more rate (Caine et al. 1989, 2003; Kolt & Kirkby 1995, likely to be admitted than the 12-to-17-year-olds 1999). Two of these studies indicate lower injury (risk ratio, 1.69; 95% CI, 1.23–2.32; P Ͼ 0.001). rates for elite than for subelite gymnasts (Kolt & Some research also indicates that a rapid period Kirkby 1995, 1999). Using the proportion of time of growth is associated with increased risk of injury loss and injury rate as criterion variables (Caine (Caine & Lindner 1985; Micheli 1983). Caine et al. et al. 1989), competitive level was the best dis- (1989) found that rapid growth (as indicated by criminator between high- and low-risk gymnasts. Tanner stages) was associated with increased risk Caine et al. (2003) showed that advanced gymnasts of injury (P Ͻ 0.05). Caine et al. (2006) also reported were at increased risk of injury as compared with previous injury (incidence rate ratios [IRR], 1.55; beginning-level gymnasts (risk ratio, 1.47; 95% CI, 95% CI, 1.79–2.0), injury to other sites (incidence 0.92–2.33). This difference was even greater for rate ratios [IRR], 155; 0.74; 95% CI, 0.65–0.85), and competition (risk ratio, 4.22; 95% CI, 1.33–13.36) positive musculoskeletal assessment (i.e., symp- than for practice (risk ratio, 0.97; 95% CI, 0.34–2.75). tomatic during preseason musculoskeletal assess- The 16-year study by Marshall et al. (2007) also ment; IRR, 1.49; 95% CI, 1.24–1.79) to be predictors found that competition injury rates were higher in of overuse but not acute injury among highly com- those competing in higher-level versus lower-level petitive female gymnasts. divisions (16.6 injuries per 1,000 AEs vs. 7.6). Motor characteristics such as less speed, poorer balance, higher endurance, and higher flexibility What Are the Inciting Events? have been implicated as significant injury predic- tors in female gymnasts (Lindner & Caine 1990b). Very few studies provide information on the action Steele and White (1983) suggested that high lum- or activity leading to injury in gymnastics. Harringe bar flexibility and low shoulder flexibility were et al. (2007a) reported that 52% of injuries occurred associated with risk of injury. These joint ranges during landing and 21.5% during takeoff for tum- of motion were, however, taken after injury, so the bling and vaulting. In a different form of classifi- direction of the association cannot be determined. cation, a study of 16 years of data (Marshall et al. An interesting but underresearched area of injury 2007) showed that for competition injuries, 70.7% risk in gymnastics is the role played by psychoso- resulted from either landings in floor exercise or cial factors. Kerr and Minden (1988) and Kolt and from dismounts from other apparatus. Marshall Kirkby (1996) showed that increased levels of life et al. (2007) also reported that the majority of inju- stress were associated with the number of injuries ries in practice (54%) and competition (70.7%) and their severity. The retrospective nature of these involved other contact—contact with items such as studies, however, means that the direction of the the floor, the mat, or equipment. relationship between life stress and injury cannot In their 3-year study of Canadian gymnasts, be accurately determined. Petrie (1992), in a pro- Lindner and Caine (1990) reported that the most spective study of 193 female gymnasts, found that frequent mechanism of sudden-onset injuries was a those who were injured reported higher negative missed move followed by contact with or fall from life stress than their noninjured counterparts. apparatus. They did not, however, specify whether the missed move involved contact with apparatus or floor. Extrinsic Factors
Training and competition exposure is the most Injury Prevention common extrinsic risk factor for injury. The results of research are still somewhat inconclusive as to A summary of suggested preventive measures has whether advanced or lower levels of training and been provided in several reviews on gymnastics competition pose the greatest risk for highest injury injuries (Daly et al. 2001; Caine 2003; Caine & gymnastics 157
Nassar 2005). Most of these measures emerged studies have looked at injury in light of the from clinical practice or descriptive research, and amount of time gymnasts spend in training and some from risk factor analyses, but none of them competition. have actually been tested to determine their effec- • Much of the injury research occurred in the 1980s tiveness. In contrast, there has been promising and 1990s, with very little since that time. With research in other sports areas (e.g., team handball, significant changes in gymnastics over the past soccer, basketball) supporting the use of injury- 10 to 15 years (including equipment changes and prevention strategies that include preseason con- rule changes), data on current-day gymnasts are ditioning, functional training, education, and required. In this regard, nationally organized strength and balance programs that are contin- injury surveillance programs are needed. ued throughout the playing season (Heidt et al. • Research on injury in male gymnasts is 2000; Wedderkopp et al. 2003; Olsen et al. 2005; clearly lacking and needs attention. This should McGuine & Keene 2006; Mickel et al. 2006; Emery specifically include epidemiologic and analytic et al. 2007). risk-factor studies. The results of prevention studies in women’s • Research on injury in rhythmic gymnastics is gymnastics are encouraging. Although not sta- clearly lacking and needs attention. With very tistically evaluated, one study using a three-step different physical demands on artistic gymnas- protocol involving postural, proprioceptive, and tics, relying on generalization of findings across postural components, shows promise in reduc- disciplines is not advised. Both epidemiologic ing ankle and low back pain in young elite female and risk-factor studies are required. gymnasts (Mirca et al. 2008). In addition, Harringe • There is an absence of research specifically et al. (2007) conducted an 8-week lumbar stabiliz- on trampoline gymnastics. As this discipline ing intervention (nonrandomized) involving 51 becomes more popular, research findings from gymnasts, 11 to 16 years of age. Gymnasts in the epidemiologic studies will be required to help intervention group reported significantly few days guide training and injury prevention and with back pain at completion as compared with rehabilitation. baseline (P ϭ 0.02). • Further research is required on the residual Given the numerous causes of injury in gymnas- effects of injuries later in life. With many gym- tics, preventive measures are no doubt complex. nastics injuries being significant or long-term in To be effective, it is clear that input is needed nature, it is important to ascertain the longer- from the gymnast, coach, policy and rule makers, term effects of such events. equipment manufacturers, and a multidisciplinary • More accurate research on predictors and risk medical support team (including athletic trainers, factors of injury in gymnastics is needed. This physical therapists, physicians, psychologists, and research should be done prospectively and nutritionists). should encompass modifiable risk factors that could be developed into injury-prevention strat- egies. Risk factors of particular interest include Further Research injury history, pain history, coaching qualifica- In an extensive review such as this, it is often tions, periods of rapid growth, and psychosocial the case that a greater number of areas needing factors. research are exposed than the amount of research • Because most of the research to date has relied carried out to date. Several critical areas of research on self-report of injury, medical evaluation of have been identified for gymnastics. injury is required to more accurately categorize and diagnose injuries. • Further work on injury in relation to expo- • There is a pressing need for studies designed to iden- sure-time data is required. To date, only a few tify and determine the effect of injury-prevention 158 chapter 12
measures on reducing the rate of injury among Future research will be successful in its outcomes gymnasts. Injury-prevention measures of par- and applications only if truly collaborative efforts ticular interest include neuromuscular training are put in place. Potential contributors of effective programs, preseason conditioning, programs to research teams include the coach, physician, physi- enhance landing and skill mechanics, and use of cal therapist, athletic trainer, epidemiologist, and taping and bracing to prevent ankle injuries. research academicians.
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Judo
PETER A. HARMER Exercise Science—Sports Medicine, Willamette University, Salem, Oregon, USA
Introduction of the overall rate per 1,000 athlete exposures (AE) can be attributed to the variety of definitions Judo (“the gentle way”) was initially derived from used for a reportable injury (e.g., “any request for various styles of traditional Japanese jujitsu by medical assistance”; “injury resulting in with- Jigoro Kano, who opened the first dojo (training hall) drawal from competition”), and the short duration for Kodokan judo in 1882. Although judo was to be (e.g., one competition) and the small sample sizes a demonstration sport in the 1940 Tokyo Games of many of the studies. Research that presents time- (Amateur Athletic Foundation of Los Angeles 2005), loss injury data is more cohesive, with rates rang- it was not actually included in the Olympic program ing from ϳ4 to 10 per 1,000 AE. Frey et al. (2004) until 1964 (male-only events); then it was dropped have completed the largest and most comprehen- for the 1968 Olympic Games and reinstated for the sive study to date, with a 9-year study involving 1972 Olympiad, and it has remained on the Olympic more than 150,000 male and female participants, program ever since. Events for women were intro- from 11 years old to у21 years old, competing at duced in the 1992 Games in Barcelona. local through international level. Their findings Judo is an extremely physically demanding indicated a rate of 44 per 1,000 AE for “any request combat sport consisting of techniques done from a for medical assistance” and a time-loss injury rate standing position (tachiwaza), principally throws of 5.7 per 1,000 AE. (nagewaza), or on the ground (newaza), such as Various researchers have reported the number grappling (katamewaza), arm-locks (kansetsu- or percentage of judo-related injuries in com- waza), and choking techniques (shimewaza), and it parison to other sports in an array of settings. For has a high potential for injury. The purpose of this example, Kujala et al. (1995) used national sports chapter is to examine the extant literature on judo- injury insurance data to compare injury rates for related injury. Overall, a paucity of well-designed, six sports (soccer, ice hockey, volleyball, basketball, data-driven studies was evident. judo, karate) in Finland over a 5-year period and found that judo had the second highest injury rate Who Is Affected by Injury? (after karate). Similarly, Parkkari et al. (2004) com- pleted a large community-based study of randomly A comparison of studies reporting injury rates in recruited adults who played sports in Finland. Judo shown in Table 13.1. The wide range (25.2–148) (n ϭ 11) had the second fewest number of partici- pants (after wrestling) but the second highest self- reported injury rate (after squash) of 31 sports: 16.3 Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 (95% confidence interval [CI], 9.8–27.0) per 1,000 Blackwell Publishing, ISBN: 9781405173643 hours of participation. Velin et al. (1994) found 161 162 chapter 13 a,c a,c a,d a,d a,c a,f b,c b,c a,e b,c 2.5 Other 22.2 2.0 17.0 25.8 – 5.42 15.0 1.1 117 1.9 b Time Loss Time per 1,000 AE 9.8 8.2 Injury Rate a Overall per 1,000 AE 122.6 130.6 16 – – 57 81.4 8.6 33 – – 1163 – – No. of Injuries 3,941 350 Female ϭ 43 49 – – female ϭ NA Participants Female ϭ 1,099 Ivory Coast n ϭ 120 87 115.0 4.0 Japan Men ϭ 7,520 1672 – – Finland Male/ Australia n ϭ 62 Poland NA Location No. of FranceGermany Male ϭ 16,496 Men ϭ 100Germany Male ϭ 199 542Belgium 285 NA – – – – Osaka Police Department (1938–1942) (10 yr) (1978–1984) 9 competitions (1986–1987) National Insurance Competition & (1987–1991) Training Australian University Games (1994) Championships Data Source Data Source (Duration of Study) (1980) (1980–1982/3?) Regional competitors (1 yr) NA Physical Education Institute DM RR DM DM (NA) 6th Student World Data-Collection Method Q Q DM (NA) 154 competitions NA DM P R P Design of Study R R NA RR P Nakata & Shirata (1943) Dah & Djessou (1989) Kujala et al. (1995) Cunningham & Cunningham (1996) Table 13.1 Table Comparison of judo injury rates. Study (1981)Sterkowicz P Rabenseifner (1984) & Biener Perren (1985) Sturbois et al. (1987) Barrault et al. (1983) judo 163 a,c a,c a,c a,c a,c a,g a,c a,c a,c a,c a,c a,c a,c a,c a,c a,c b,c 12.0 0.21 10.7 100 7.0 14.3 1.5 28.3 13.8 25.0 16.7 13.0 14.1 22.5 238.0 29.5 10.3 18.9 41.3 40.9 44 – – 5 34.314 13.7 – 10.9 – 10 48.5 4.9 40 13 17,618 44.0 5.7 ϭ 210 62 148.0 – Women ϭ 84Women 9 41.3 9.2 Men ϭ 70 ϭ 46 Women Girls ϭ 60Men ϭ 29 ϭ 8Women 17 4 2 104.9 51.3 125.0 – Girls ϭ 270 – – 45 52.1 – Boys ϭ 417 54 39.8 – Men ϭ 284 ϭ 108 Women Boys ϭ 111 25 77.2 – United Kingdom Germany NA United Kingdom United Kingdom United Kingdom Germany n ϭ 800 1907 –South Africa n – (3 yr) State Insurance Company (1981–1995) 1 competition (1996) (1997) (9 yr) University Team(2006) 3 competitions (2005) Philippines n ϭ 14 1 competition (1996) 800 judoka Asian Championships Phillippines7th All Africa Games Men ϭ 100(1999) 1 competition 7 Judo FederationFrench France 25.2 n ϭ 150, 007 3.6 RR DM DM DM/Q DM Q DM DM DM DM R P P P P P P Per 100 participants/yr. Per 1,000 insured persons. Per 1,000 insured Any injury which resulted in withdrawal from competition and/or inability to practice after the in withdrawal from Any injury which resulted Any injury for which medical assistance was sought Per 1,000 hr of participation. Per 1,000 Per 100 participants. Per 1,000 person-years. Raschka et al. (1999) James & Pieter (1999) Atlas et al. (2007) P et al. Green (2007) Pieter & De Crée Pieter & De Crée (1997) Ganschow (1998) R Pieter et al. (2001) Phillips et al. (2001) James & Pieter (2003) et al. (2004)Frey P AE ϭ athlete exposures. review; RR ϭ record ϭ questionnaire; monitor; Q DM ϭ direct R ϭ retrospective; ϭ prospective; in the cited study; P ϭ information is not provided NA a b c d e f g 164 chapter 13 that judo ranked 11th of 25 sports represented in a Environmental Location 1-year study of emergency-department treatment Few studies have examined the relative distribution of children in Nice, France, and accounted for 2.9% of judo injuries sustained in practice versus competi- of all sports-related injuries treated. Cunningham tion. However, the majority of those that have indi- and Cunningham (1996) reported that judo ranked cated that more injuries occur during practice. For seventh in the percentage of athletes injured of 19 example, although Atlas et al. (2007) reported that sports at the 1994 Australian University Games 57% of injuries were from competition in a group of (25.8% of judo athletes required some medical 14 Philippine university judoka, and in a recall sur- assistance). vey of 181 competitive judoka, Ransom & Ransom (1989) found that 55.9% of injuries were sustained in Where Does Injury Occur? practice and 44.1% in competition. Kujala et al. (1995) noted that 70% of injuries occurred in practice and Anatomical Location 30% in competition. Ganschow (1998) conducted a retrospective survey of 800 German judoka and iden- The percent distribution of anatomical location of tified 45.3% of injuries in practice, 30.2% in competi- injuries is presented in Table 13.2. Overall, it appears tion, 15% in warm-up, and 9.5% in technical training. that the upper extremities (mean, 39.3%; range, Barsottini et al. (2006) completed a 1-year study of 21.3–62.9%), specifically the shoulder (mean, 15.2%; city clubs (São José dos Campos) and regional com- range, 4.6–37.1%), are injured most frequently, with petitions in Brazil and reported that 71% of injuries the knee (mean, 14.7%; range, 4.3–27.8%) typically occurred in practice with 29% in competition. Finally, the most frequently injured location in the lower Souza et al. (2006) also used a 1-year recall survey extremities. but found slightly fewer (43.6%) injuries in practice However, given the costs and complica- than competition (49.1%), with 7.3% in conditioning tions associated with knee injuries, a number of or not specified. Busnel et al. (2006) reported that researchers have specifically examined this area. de 58.8% of ACL ruptures in their study occurred in Loës et al. (2000), in a 7-year study in Switzerland, competition versus 41.2% in practice. calculated an incidence of knee injuries in 14-to- 20-year-old male judoka of 0.2 (95% CI, 0.06–0.33) per 10,000 hours of participation and 0.19 (95% When Does Injury Occur? CI, 0.05–0.32) for female judoka. Majewski et al. (2006) completed a 10-year study of knee injuries Injury Onset in patients at an orthopedic clinic in Switzerland All of the available injury literature for judo has and found a rate of 2.7 per 1,000 participants per focused on acute injuries. To date, no studies have 10 years for judoka. Medial collateral ligament examined the frequency or distribution of acute and anterior cruciate ligament (ACL) damage, versus chronic injuries. with approximately equal distribution, comprised 83% of all knee trauma in this population. Busnel Chronometry et al. (2006) noted an ACL rupture rate of 12.4 per 100 athletes per 6 years, whereas Mountcastle No studies have been located that examined the et al. (2007) found an ACL injury rate of 0.17 per relationship between periods in a competitive sea- 1,000 AE for men (n ϭ 5) and 0.22 per 1,000 AE for son or time within a competition and injury. women (n ϭ 1). Sterkowicz (1980) studied head injuries in What Is the Outcome? regional, national, and international competitions in Poland (1,920 bouts) and reported a rate of 2.9 Injury Type per 1,000 AE for head injuries requiring medi- cal attention, and 1.3 per 1,000 AE for time-loss The percent distribution of injury types is pre- head injuries. sented in Table 13.3. Overall, sprains (mean, 30.7%; judo 165
range, 10.0–56.6%) and contusions (mean, 23.8%; fracture/dislocation after being thrown, one to range, 4.6–56.8%) are the most common types of soft-tissue neck injury, and one myocardial rupture. injury, indicating that most judo injuries are not Hoshi & Inaba (2002) conducted a 13-year retro- serious. For example, in Frey et al. (2004), the most spective study of sports-related deaths in Japanese comprehensive study to date, 52.1% of time-loss schoolchildren and reported 51 trauma-associated injuries were sprains. However, in several studies, judo deaths and 7 heat-related judo deaths. fractures, and dislocations are prominent. Katoh et al. (1996) conducted a 3-year (1990– 1992) nationwide survey of sports-related spi- Time Loss nal-cord injuries in Japan and found that judoka (n ϭ 26) accounted for 4.9% of the total, although Few studies examined the severity of judo inju- there was no bony involvement in 69.2% of judoka ries as reflected by time loss from participation. with spinal-cord injuries. Lannuzel et al. (1994) Overall, it appears the risk is low. Barrault et al. reported on an 11-year-old boy with ischemic (1983) noted that although 31.4% of withdrawals stroke caused by dissection of the left vertebral from competition were sent to the hospital, this artery following cervical trauma in judo prac- represented only 0.6% of all competitors. Parkkari tice. Delattre et al. (2005) noted partial left-sided et al. (2004) reported 60% of self-reported injuries nerve deficits following a cervical facet fracture in ϭ (n 12) did not result in any time loss and only competition. ϭ 5% (n 1) resulted in missing work or activity for Closed head injuries have also been reported. de at least 1 day. James and Pieter (2003) estimated Vera Reyes (1970) detailed a case series (n ϭ 3) of у time loss of 21 days for a male competitor with subdural hematoma from judo practice in which all р a shoulder dislocation but 7 days for two female recovered. However, in the Nishimura et al. (1988) competitors with elbow sprain. In a larger sample, case series of subdural hematoma (n ϭ 4), only Green et al. (2007) documented a mean of 21 days one recovered. Of the remaining three, one died for 10 time-loss injuries in male judoka (not includ- and two were left in a permanent vegetative state. ing a fractured clavicle) and a mean of 29 days for Hirakawa et al. (1971) studied sports-related head 6 time-loss injuries in female judoka (not including injuries and noted that subdural hematoma (n ϭ 4) a medial collateral ligament rupture). was found only in judoka. Finally, Kujala et al. (1995) reported that 0.17% of Clinical Outcome judo injuries (two cases) in their study resulted in у Because of its physically demanding, high-impact 5% permanent disability. nature (Figure 13.1), fatal and catastrophic injuries, in addition to a wide variety of other injuries with Shimewaza-Related clinically important outcomes, have been reported Owens & Ghadiali (1991) reported a case of an in judo. experienced judoka with signs of anoxic brain damage and suggested that frequent shimewaza Fatal and Catastrophic Injuries was the cause. However, Rodriguez et al. (1991, 1998) studied both the acute and chronic effects In one of the earliest available studies on fatalities of shimewaza through electroencephalogram and in judo, Koiwai (1981) surveyed member nations regional cerebral blood flow studies in 10 competi- of the International Judo Federation and found 19 tive Italian judoka and concluded that there is no deaths (from 20 official responses plus personal evidence to indicate a risk to central nervous sys- communication data) prior to 1981. However, tem function from shimewaza. Koiwai argued that only 10 could be specifically attributed to judo (the others were due to preex- Musculoskeletal Injuries isting cardiac or other pathologies). Of the judo- attributable deaths, four were due to cerebral Kurosawa et al. (1996) reported on two cases of com- hemorrhage after being thrown, four to cervical plete hamstring rupture (one each from uchimata 166 chapter 13
Table 13.2 Percent comparison of injury location in judoka.
Nakata & Sasa Koiwai Sterkowicz Sturbois Horiyasu Barrault Rabenseifner Perren & Shirata et al. et al. et al. Biener (1943) (1958) (1965) (1980) (1980) (1982) (1983) (1984) (1985) Location (n ϭ 1672) (n ϭ 1598) (n ϭ 70) (n ϭ 57) (n ϭ 593) (n ϭ 115) (n ϭ 1,790) (n ϭ 542) (n ϭ 334)
Head and 6.6 5.4 10 19.3 — 4.3 22.2 0.7 8.7 neck Head/ 1.4 — 5.7 — — — 9.2 0.7 — skull Neck 1.9 — 4.3 — — 4.3 4.2 ——
Face 0.7 0.6 — — — — — —— Eye ——————— —— Ear 1.2 — — — — — — ——
Mouth/ — 4.8 — — — — — —— teeth Nose 1.4 — — — — — 8.8 ——
Trunk and 25.9 5.5 1.4 10.5 — 11.4 8.4 8.9 31.4 back Upper 32.2 25.9 62.9 31.6 52.8 33.0 38.4 39.7 21.3 extremity Shoulder 20.1 15.1 37.1 7.0 28.9 12.2 14.5 7.6 — Arm 0.6 0.2 2.9 — 3.2 — — ——
Elbow 6.0 5.8 12.9 19.3 7.4 12.1 13.5 2.2 — Forearm 0.9 0.4 2.9 — 4.7 — — ——
Wrist 1.4 — — — 1.8 6.1 1.8 14.4 — Hand 0.9 2.6 2.9 5.3 1.8 — 8.6 ——
Fingers 2.3 1.8 4.2 — 5.0 2.6 — 15.5 —
Lower 35.3 52.3 24.3 38.6 47.2 48.7 27.8 50.7 38.6 extremity Pelvis/ — 2.0 — 1.8 — —- 2.3 —— hips Thigh 2.2 0.5 — — 1.2 — (inc. in —— hip) Knee 9.4 21.8 4.3 14.0 18.5 27.8 9.2 15.5 — Leg 7.5 6.1 5.7 7.0 2.0 — 0.9 20.1 — Ankle 6.9 19.9 2.9 7.0 14.9 17.4 6.4 10.3 — Foot/toes 9.3 2.0 11.4 8.8 10.9 3.5 9.0 4.8 — Other/ — 10.9 1.4 ——2.6 3.2 —— unreported judo 167
Dah & Kujala Carazzato Pieter & Ransom & Ganschow James & Raschka Phillips Djessou et al. et al. De Crée Ransom Pieter et al. et al. (1989) (1995) (1996) (1997) (1989) (1998) (1999) (1999) (2001) (n ϭ 35) (n ϭ 1163) (n ϭ 721) (n ϭ 48) (n ϭ 495) (n ϭ 1907) (n ϭ 99) (n ϭ 44) (n ϭ 62)
14.3 9.9 16.7 6.3 12.4 7.1 34.3 27.3 3.2
— 6.3 — 2.1 2.2 1.2 11.2 6.8 3.2
8.6 (inc. in — 4.2 — — 2.0 — — head) — —— — — — 3.0 — — 5.7 0.9 — — 0.8 5.9 — 2.3 — — —— — 2.4 (inc. in 2.0 2.3 — eye) — 2.7 — — 3.0 — 6.0 13.6 —
— —— — 4.0 (inc. in 10.1 2.3 — eye) 8.5 12.1 12.5 27.1 5.7 4.4 8.1 2.3 14.5
42.9 35.6 36.3 31.2 46.1 40.3 37.4 27.3 51.6
17.1 20.0 — 10.3 20.6 16.9 10.1 4.6 — — (inc. in — — 1.0 — 1.0 2.3 — shoulder) 2.9 7.7 — 8.3 7.9 5.3 10.1 11.3 — 14.3 (inc. in — 6.3 — — 1.0 — — elbow) 2.9 3.4 — 2.1 6.1 — 4.0 2.3 — — (inc. in — 2.1 10.5 18.1 1.0 — — wrist) 5.7 4.5 — 2.1 — (inc. in 10.1 6.8 — hand) 34.3 39.3 34.5 31.2 35.8 32.0 20.2 38.5 30.6
— 0.7 — 2.1 — — ———
2.9 1.9 — 2.1 1.6 — 2.0 — —
5.7 20.2 — 20.7 8.9 13.7 9.1 13.6 — 5.7 2.0 — — — — — 2.3 — 2.9 8.3 — 4.2 7.3 9.3 5.1 15.8 — 17.1 6.2 — 2.1 18.0 9.0 4.0 6.8 — — 3.0 — 4.2 — 16.2 — 4.6 —
(continued) 168 chapter 13
Table 13.2 (continued)
Pieter et al. James & Frey et al. Barsottini Souza et al. Green et al. Yard et al. Pieter et al. (2001) (2003) (2004) (2006) (2006) (2007) (2007) Location (n ϭ 16) (n ϭ 15) (n ϭ 1749) (n ϭ 78) (n ϭ 110) (n ϭ 53) (n ϭ 451)a
Head and neck 18.9 40.0 — 1.0 0.9 18.9 23.4 Head/skull 6.3 —— — 0.9 — 6.6 Neck — —— — — 3.8 9.7 Face — 6.7 — — — 7.5 7.1 Eye — 6.7 — — — —— Ear — 6.7 — — — —— Mouth/teeth 6.3 13.2 — — — 3.8 — Nose 6.3 6.7 — 1.0 — 3.8 — Trunk and 12.1 — 10.7 9.0 5.5 9.4 6.9 back Upper 43.7 33.4 50.1 37.0 45.5 41.5 45.3 extremity Shoulder 18.7 6.7 — 19.0 21.8 11.3 19.1 Arm — — — 1.0 1.8 — (inc. in shoulder) Elbow — 13.3 — 3.0 (inc. in 9.4 14.9 all arm) Forearm — 6.7 — — — — (inc. in elbow) Wrist 18.7 — — 4.0 — — 11.3 Hand 6.3 — — — 4.6 — (inc. in wrist) Fingers — 6.7 — 10.0 17.3 20.8 — Lower 31.2 26.6 27.1 53.0 46.4 28.3 24.4 extremity Pelvis/hips — —— 3.0 — —— Thigh — 6.7 — — 5.5 — 8.4 Knee 12.5 6.7 — 23.0 26.4 13.3 (inc. in thigh) Leg — 6.7 — 1.0 0.9 — 16.0 Ankle — 6.7 — 14.0 10.0 7.5 (inc. in leg) Foot/toes 18.7 — — 12.0 3.6 7.5 (inc. in leg) Other/unre- 6.3 — 12.1 1.0 1.8 1.9 0.0 ported a Annual estimate from National Electronic Injury Surveillance System database. Values in bold print are the percent totals for each body region.
and tai otoshi) and recommended surgical repair Frey and Muller (1984) noted Heberden nodes in in such incidents because one patient treated con- 30% (9 of 30) members of the Swiss national judo servatively still had a 20% to 40% deficiency on team who were classified as having severe osteoar- isokinetic strength testing as compared with the thritis of the distal interphalangeal joints and most contralateral side 7 years after the injury. Although also had proximal interphalangeal joint involve- magnetic resonance imaging showed nonunion of ment. Strasser et al. (1997) completed a 16-year lon- the hamstring with the ischial tuberosity, the ath- gitudinal case study of eight judoka, all of whom lete remained active in competition. had radiologic changes indicative of osteoarthritis of judo 169 18.7 Unknown — 1.9 — 6.5 — 9.3 — 15.9 — 15.2 — 5.9 — 2.6 6.2 — 1.5 10.6 8.0 22.0 14.5 7.4 14.3 — c c c 38.6 52.1 39.0 56.6 31.3 38.1 38.6 56.5 35.0 59.8 72.6 — — —— 38.0 — 0.1 — — — 10.0 — 10.0 —— 22.8 7.0 12.3 ——— 40.4 24.0 — 3.0 0.6 17.0 — 10.0 10.0 3.3 30.0 28.0 luxations) — 1.9 17.0 17.0 22.6 7.5 — 1.5 3.9 11.3 1.5 27.6 8.0 24.1 5.2 13.5 2.12.0 — 1.0 4.26.7 8.1 12.5 21.2 8.3 — 19.2 16.6 13.3 12.1 20.0 20.0 6.7 5.3 7.0 38.8 23.3 6.7 b b — 14.8 17.9 — 21.7 19.2 4.6 15.9 11.4 6.8 8.0 12.9 (inc. in 6.3 6.3 12.5 6.3 12.5 12.5 5.7 11.9 7.0 30.4 23.1 15.5 18.2 2.7 2.7 42.6 13.5 14.3 10.1 25.0 12.5 —19.0 — 28.6 — — 34.0 25.4 45.9 23.2 26.6 38.6 56.8 13.0 4.0 18.0 46.7 Contusion Luxations Fracture Laceration Sprain Strain Other/ — — 6.1 neurologic neurologic injury Abrasion Concussion/ 49 — — 285 — 2.0 14.0 12.0 No. of Injuries ? 1163 —? — 44 — 6.8 ? 410 — 4.1 ?? 70 593 — — 5.7 — ? 57 7.0 — 93 110 — — 62 16 25.042 — 42 — — 458 1598 — — 184 16 25 392 53 — — 208 48 8.3 2.1 7520 1672 — 0.6 150,007 1977 — — Men: 199 No. of Participants Women: 43 Women: a a a d Time-loss injuries only. Time-loss Includes wounds. Includes practice and competition. Includes strains. a b c d Sasa (1958) Nakata & Shirata (1943) Table 13.3 Table comparison of injury types in judoka. Percent Study Cunningham & Cunningham (1996) dos Santos et al. (2001) Phillips et al. (2001) 210 62 — — Pieter et al. (2001) Souza et al. (2006) et al. (2007) Green et al. (2007) Yard Koiwai (1965) Sturbois (1980) Pieter & De Crée Pieter & De Crée (1997) James & Pieter (1999)Raschka et al. (1999) 687 99James & Pieter (2003) et al. (2004) Frey 7.1 116 15 6.7 Sterkowicz (1981) Horiyasu et al. (1982) 52 115 — — Rabenseifner (1984) & Biener Perren (1985) 100 542 — 0.7 Dah & Djessou (1989)Kujala et al. (1995) 120 30 — — 170 chapter 13
Figure 13.1 Well-timed attacks generate high-velocity throws and high-impact forces. © IOC/Yo NAGAYA.
the finger joints. Although symptoms were reported of perirenal hematoma, possibly developed over as mild, the “degenerative changes were progres- 30 years of judo training, that required surgical sive and more pronounced” in active judoka. removal. Other reported unique acute traumatic muscu- Fati et al. (1980) studied the acoustic function loskeletal injuries in judo include dislocation of the of 15 experienced young adult judoka and found proximal tibiofibular joint (Cossa et al. 1968), nerve consistent hearing loss in the frequency of 6,000 damage secondary to shoulder dislocation (Jerosch to 8,000 Hz, which was possibly due to damage et al. 1990), distal radio-ulnar dislocation (Russo & to the organ of Corti and the auditory ossicles Maffulli 1991) and knee dislocation with arterial from ukemi. damage (Witz et al. 2004). Dermatologic Ukemi-Related Dermatologic infections related to close contact are The significant impact associated with individual common in wrestling, and various studies have and accumulated nagewaza has raised a variety noted the same issue in judo. For example, Poisson of concerns, including damage to the renal and et al. (2005) detailed the outbreak of tinea corporis auditory systems. Norton et al. (1967) conducted gladiatorum in 49 of 131 members of a French judo extensive urinalysis of 204 active male judo play- team. Hirose et al. (2005) found that 35% (11 of ers (pretraining and posttraining) and determined 31) of members of a Japanese university judo club that judo resulted in no significantly different val- were dermatophyte carriers for Tinea tonsurans ues than for other sports (i.e., not a risk to the renal and Suganami et al. (2006) reported a prevalence system). De Meersman and Wilkerson (1982) in of 9.1% of T. tonsurans among 496 male and female a controlled biomechanical study of nine judoka middle-school judoka at a national tournament in found that hematuria depended principally on the Japan. “severity of the mechanical trauma” rather than on the exercise per se (i.e., ukemi) and concluded Dental that the quality of the tatami/competition surface may reduce the risk of athletic pseudonephritis in Dental injuries in judo are also reported in the lit- judoka. Fujita et al. (1988) presented a case report erature (Legrand et al. 1980; Parzeller et al. 1999; judo 171
Beachy 2004). However, the incidence appears it would be supported by further research has not low. For example, in a 15-year study of high- been determined. school judoka, Beachy (2004) reported an incidence In addition, in studies in other sports, being of 0.19 of 1,000 AE (95% CI, 0–3.6) and Legrand female has been associated with an increased risk of et al. (1980) noted that dental injuries were sus- sustaining an ACL injury. However, data from judo tained by 0.05% of Ͼ800,000 participants in a studies have not supported this finding. For exam- 3-year study. However, 86% of these injuries were ple, although Wang and Ao (2001), in a 9-year retro- broken teeth. spective study of hospital patients in China, found 9 times as many ACL injuries in female judoka as Economic Cost in male judoka (18 vs. 2), Ao et al. (2000) reported no difference (although no rate data are provided). Few data are available on the economic costs asso- Similarly, although de Loës et al. (2000) noted an 80% ciated with judo-related injuries. Carazzato et al. higher risk for cruciate injuries in females, the dif- (1996) reported in a retrospective study of 129 ference was not statistically significant, nor was the high-level judoka in Brazil that only 5% of injuries incidence of overall knee injuries (rate ratio, 1.0). A required surgery. de Loës et al. (2000) found an prospective 6-year study of 151 adolescent elite judo average cost of judo-related knee injuries in young players (107 male; 44 female) by Busnel et al. (2006) male judoka (14–20 years) of US$950 (US$90 per came to the same conclusion. Finally, in a 10-year 1,000 hours of participation) and US$797 (US$60 study of cadets at the U.S. Military Academy at West per 1,000 hours) for female judoka. Point, Mountcastle et al. (2007) found no significant difference in the rate of complete anterior cruciate ruptures between men and women (incidence rate What Are the Risk Factors? ratio, 1.3; 95% CI, 0.15–11.13). The importance of age as a risk factor is also Intrinsic Factors uncertain, especially as it may interact with expe- Several intrinsic risk factors have been examined rience as a causal factor. Barrault et al. (1983) first in the literature, including sex, age, skill level, and presented data on the significant discrepancy weight. Although conclusions should be viewed between the time-loss rate (per 1,000 AE) between with caution given the methodologic limitations, children (15.9) and other age categories (seniors, including inadequate power, some general obser- 9.7; juniors, 8.7; cadets, 9.0). However, Kujala et al. vations may be possible. (1995) reported a significantly greater rate for those The role of sex as a risk factor is unclear. For 20 to 34 years old than for other age groups (183.7 example, Pieter & De Crée (1997) found women vs. 72.1 per 1,000 person-years). Sterkowicz (1997) to have a significantly greater rate of injury used a 4-year study of national insurance data in than men (106.7 per 1,000 AE vs. 72.1 per 1,000; Poland and reported judoka р17 years old to be at PϽ0.01) but James & Pieter (2003) reported men potentially greater risk for upper-extremity injury to be at greater risk (48.5 per 1,000 AE vs. 34.3 per (especially clavicular fracture) than those у18 years 1,000; PϽ0.001). However, Barrault et al. (1983), of age. in the second largest judo injury study conducted Several studies have examined the role of experi- to date, found no significant difference in the rate ence/expertise and weight in injury risk. Barrault et of time-loss injury between men and women (9.8 al. (1983) found that regional (12.7) and local (10.3) vs. 8.2 per 1,000 AE), which was supported by the competitions had almost double the rate of time- findings of Green et al. (2007). James and Pieter loss injuries (per 1,000 AE) as national competitions (1999) indicated girls to have a significantly higher (6.2). However, dos Santos et al. (2001) conducted a rate than boys (52.1 per 1,000 AE vs. 39.8 per 1,000; 1-year study of 42 judoka (beginners—dan grades) P ϭ 0.047) but whether this difference is related to and found no relationship between injury and judo sex, age, or interaction between the two or whether experience/expertise. Similarly, Barsottini et al. 172 chapter 13
(2006) and Green et al. (2007) reported no differ- wrists and ankles, were banned. With the develop- ence in injury rates between dan and kyu grades. ment of international competition, articles defin- Although Barsottini et al. (2006) and Green et al. ing prohibited acts (specific techniques considered (2007) found no differences in injury rates across unsafe) and identifying violation of rules against weight categories, Green et al. did note that losing actions “that are dangerous to the opponent” as a у5% of body weight before competition was signif- basis for disqualification were codified and have icantly associated with being injured (P ϭ 0.02) and been in place for more than 50 years (International Okada et al. (2007) found weight a risk for lum- Judo Federation 1955, 2003). However, the efficacy bar radiologic abnormalities and nonspecific low of these regulations has been based on face valid- back pain in a study of 82 elite collegiate Japanese ity, and no studies have been published indicating judoka (lumbar radiologic abnormalities preva- the actual validity, efficacy, or success of these rules lence in lightweight judoka, 65.5% vs. ϳ 90% for to prevent injury. Moreover, no data-based injury- middleweights and heavyweights (PϽ0.05)). The prevention studies of any kind have been located prevalence of nonspecific low back pain with lum- in the judo literature. bar radiologic abnormalities in lightweights was 50%, in middleweights 100%, and in heavyweights Further Research 88.9% (PϽ0.05). Despite the long history and physical nature of Extrinsic Factors judo, relatively little well-designed injury research has been conducted. Indeed, the Kodokan-based No research was located that reported analysis of Association for the Scientific Study on Judo has extrinsic risk factors in judo. not published an injury study in its Bulletin for 50 years (Sasa 1958), and Norton et al. (1967) included What Are the Inciting Events? a plea that their study be the impetus for more “rigorously conducted scientific investigations” It is clear that tachiwaza is the primary source of in judo. Although substantially more research has judo injuries (mean, 72.2%; range, 42.4–90%), with been conducted since then on a wide variety of seoi nage (mean, 28.4%; range, 23–33.8%) and tai judo-related topics, adequate large-scale and long- otoshi (mean, 19.5%; range, 16.9–22.0%) being term epidemiologic work is still lacking. particularly problematic (Koiwai 1965; Horiyasu If any significant progress is to be made in et al. 1982; James & Pieter 1999, 2003; Pieter et al. understanding the determinants of injury in judo, 2001; Souza et al. 2006, Green et al. 2007). However, researchers have to use appropriate epidemiologic aspects of attacking (throwing) and defending methods, including prospective designs, unam- (being thrown) appear to be the inciting event in biguous definitions of reportable injuries (overall approximately equal proportions (Sterkowicz 1981; and time loss) and denominator data (exposure Horiyasu et al. 1982; James & Pieter 1999, 2003; dos information). Incorporating trained medical pro- Santos et al. 2001; Pieter et al. 2001; Green et al. fessionals with standardized recording systems to 2007). collect the data for analysis within a coordinated series of regional and national databases is essen- tial. The work of the Medical Commission of the Injury Prevention French Judo Federation (Barrault et al. 1983; Frey et Over the years, a number of regulations designed to al. 2004) is the most extensive and well-structured prevent injury in judo have been implemented. For currently available and is a good model for other example, participant safety has been a major con- groups, particularly national governing bodies and sideration in judo as reflected in rules specifically the International Federation, to follow. Hopefully, designed to prevent injury. More than 100 years a 10-year study by USA Judo Sports Medicine ago, locks on small joints, such as the fingers, toes, that has been reported (Nishime 2007) but not yet judo 173
published will be a useful addition to the paucity was shown to effectively reduce talar tilt both in the literature. before and during practice more than traditional In addition to clarifying the rate of injury asso- bandaging. However, no epidemiologic studies ciated with judo participation, further work is have been undertaken to determine risk reduction needed to understand the nature and extent of with this type of prophylactic taping. time-loss injuries and the economic costs associated Judo is a highly regarded, widely practiced with injury in judo, variation in injury rates within sport throughout the world but with an appar- competitions and across seasons and competitive ently high inherent risk for injury. Research to date careers, the impact of chronic injury, and risk and indicates that the perception of injury risk due to protective factors such as age, level of competition, the dynamic physicality of judo may be greater conditioning, rules modifications, previous injury, than the actual risk, but additional epidemiologic and prophylactic taping. For example, the often studies are needed to substantiate these findings repeated but unsubstantiated claim that judo is the and to identify ways to reduce injury rates. The safest contact sport for preadolescents (р13 years medical commissions of national federations and old) (Nishime 2007) should be addressed. Similarly, the International Judo Federation as well as the Yamamoto, Kigawa & Xu (1993) compared tradi- International Association of Judo Researchers need tional judo taping of ankles with functional tap- to act as the coordinators of large-scale research ing to determine the effect on ankle stability via projects to provide this information. radiographic talar tilt measures. The functional taping
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adult judo athletes. In: Proceedings of The Rodriguez, G., Vitali, P. & Nobili, F. (1998) Sturbois, X., Ramyead, R. & Noens, C. Second Annual Congress of the European Long-term effects of boxing and judo- (1987) Incidence des lésions dues à College of Sport Science, Copenhagen, choking techniques on brain function. l’enseignement du judo dans un institut Denmark. August 20–23, 1997. Italian Journal of Neurological Sciences 19, d’éducation physique (in French). Pieter, W., Talbot, C., Pinlac, V. & 367–372. Cinésiologie 112(March/April), 67–71. Bercades, L.T. (2001) Injuries at the Russo, M. & Maffulli, N. (1991) Dorsal Suganami, M., Hirose, N., Shiraki, Y., Konica Asian Judo Championships. dislocation of the distal end of the Hiruma, M. & Ikeda, S. (2006) Acta Kinesiologiae Universitatis Tartuensis ulna in a judo player. Acta Orthopaedica [Trichophyton tonsurans infection 6, 102–111. Belgica 57(4), 442–446. among judo practitioners who Poisson, D.M., Rousseau, D., Defo, D. & Sasa, T. (1958) Various forms of injury attended the National Junior High Esteve, E. (2005) Outbreak of tinea caused by judo. Bulletin of the School Judo Tournament in Japan corporis gladiatorum, a fungal Association for the Scientific Study on (2005): incidence and therapeutic infection due to Trichophyton tonsurans, Judo, Kodokan 1, 99–104. response] (in Japanese). Nippon Ishikin in a French high level judo team. Souza, M., Monteiro, H., Del Vecchio, F. Gakkai Zasshi 47(4), 319–24. EuroSurveillance 10(9), 187–190. & Gonçalves, A. (2006) Referring to Velin, P., Four, R., Matta, T. & Dupont, D. Rabenseifner, L. (1984) Sportverletzungen judo’s sports injuries in Sao Pãulo State (1994) Évaluation des traumatismes und sportschäden im judosport [Sports Championship. Science & Sports 21, sportifs de l’enfant et de l’adolescent injuries and sports damage in judo] 280–284. (in French). Archives de Pédiatrie 1(2), (in German). Unfallheilkunde 87(12), Sterkowicz, S. (1980) W sprawie 202–07. 512–516. zapobiegania urazom glowy u judoków Wang, J. & Ao, Y. (2001) Epidemiological Ransom, S.B. & Ransom, E.R. (1989) [On protection against head injuries study of anterior cruciate ligament The epidemiology of judo injuries. in judo players] (in Polish). Sport injury (in Chinese). Chinese Journal of Journal of Osteopathic Sports Medicine Wyczynowy 18(18–9), 62–65. Sports Medicine 20(4), 380–82. 3(1), 12–14. Sterkowicz, S. (1981) Wypadkowosc na VI Witz, M., Witz, S., Tobi, E., Shnaker, A. & Raschka, C., Parzeller, M. & Banzer, W. Akademickich Mistrzostwach Swiata w Lehmann, J. (2004) Isolated complete (1999) 15jährige versicherungsstatistik judo (Wroclaw 1980) [Injury rate at the popliteal artery rupture associated with zu inzidenzen und unfallhergangstypen 6th Students World Championships in knee dislocation. Knee Surgery, Sports von kampfsportverletzungen im judo (Wroclaw 1980)] (in Polish). Sport Traumatology, Arthroscopy 12, 3–6. Landessportbund Rheinland-Pfalz [15 Wyczynowy 19(10), 48–52. www.judoinfo.com/olympics.htm years of actuarial statistics concerning Sterkowicz, S. (1997) Body injuries in [accessed on May 12, 2008] insurance-related trauma incidences youth training in judo. URL http:// www.judoresearch.org [accessed on and accident types in the combat www.judoinfo.com/research4.htm February 23, 2008] sports in the Rhineland-Palatinate [accessed on November 11, 2007] Yamamoto, T., Kigawa, A. & Xu, T. (1993) sports association] (in German). Strasser, P., Hauser, M., Hauselman, H.J., Effectiveness of functional ankle taping Sportverletzung Sportschaden 13, 17–21. Michel, B.A., Frei, A. & Stucki, G. for judo athletes: a comparison between Rodriguez, G., Francione, S., Gardella, M., (1997) [Traumatic finger polyarthrosis judo bandaging and taping. British Marenco, S., Nobili, F., Novellone, G., in judo athletes: a follow-up study] (in Journal of Sports Medicine 27(2), 110–112. Reggiani, E. & Rosadani, G. (1991) Judo German). Zeitschrift fur Rheumatologie Yard, E.E., Knox, C.L., Smith, G.A. & and choking: EEG and regional cerebral 56(6), 342–350. Comstock, R.D. (2007) Pediatric martial blood flow findings.Journal of Sports Sturbois, X. (1980) Pathologie traumatique arts injuries presenting to Emergency Medicine and Physical Fitness 31(4), du licencié de judo en Belgique (in Departments, United States 1990–2003. 605–610. French). Médecine du Sport 54(S2), 13–14. Journal of Science and Medicine in Sport 10, 219–226. Chapter 14
Modern Pentathlon
JENS KELM Klinik für Orthopädie und Orthopädische Chirurgie, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany Chirurgisch-Orthopädisches Zentrum, Illingen/Saar, Germany
Introduction lacking (Schmitz 1985). Currently, only two studies (Schmitz 1985; Kelm et al. 2003) have denominator- Modern pentathlon is a sports contest consisting based data on trauma associated with the modern of five events—shooting (4.5-mm air pistol), fenc- pentathlon. However, the Schmitz (1985) data were ing (epee, one hit), swimming (200-m freestyle), collected before the introduction of the current riding (jumping course, with randomly chosen 1-day competition format and may not accurately horse), and—until 2008—a final cross-country run reflect contemporary conditions. Although the two (3000 m). At the beginning of 2009, the single com- studies use similar definitions for acute and chronic ponents shooting and running have been joined injuries (see the section “What Is the Outcome?”), together to a so-called “combined event”, similar Schmitz (1985) does not include sports-induced as in biathlon, and is performed either as a final illness or diseases in her analysis. The considera- cross-country run or on a track. Thus, athletes must tion of these additional health problems related have very different physical qualities from those of to multidiscipline events is important because of athletes in single component contests (Frohberger their high negative impact in training (Kelm et al. et al. 1987; Minder 1987; Parisi et al. 2001; Brodani & 2003). Krajcovic 2007). The modern pentathlon became an Olympic dis- cipline at the 1912 Olympic Games in Stockholm Who Is Affected by Injury? at the instigation of Pierre de Coubertin, but it was not an Olympic event for women until the 2000 Neither Schmitz (1985) nor Kelm et al. (2003) docu- Games in Sydney. Initially, modern pentathlon ment time-loss injuries, but they report overall competitions were held over 5 days, with one event injury rates based on any incidents requiring treat- each day; however, since 1993, competitions have ment by medical staff. Nonetheless, the incidence been conducted as 1-day-events (i.e., all five disci- of pentathlon-related health problems appears to plines on a single day) at all international competi- be quite low. tions (Kelm & Kirn 1997). In her study of 219 pentathletes, Schmitz (1985) Because of the limited public profile of modern found the following rates of injury for each disci- pentathlon, sports medicine research in this area is pline per 10,000 hours of participation: 8.6 in riding, 5.6 in running, 1.4 in fencing, and 0.8 in swim- ming. No injuries were reported for shooting. Kelm et al. (2003) recorded 224 health incidents in 108 ath- letes over one competition year, resulting in a rate Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 of 2.07 incidents per athlete per year. Acute injuries Blackwell Publishing, ISBN: 9781405173643 occurred at a rate of 0.5 per athlete per year. 176 modern pentathlon 177
Table 14.1 Percentage distribution by anatomical location of reportable incidents (Kelm et al. 2003).
Location Acute Injuries Chronic Injuries Illness Others Total
Head/neck 4% 1% 92% 3% 40% Pelvis/lower 39% 51% 8% 2% 37% extremity Shoulder/upper 38% 58% 0% 4% 13% extremity Torso 11% 14% 50% 25% 10%
Where Does Injury Occur? Table 14.2 Percentage distribution of injury type by spe- cific event (Kelm et al. 2003).
Anatomical Location Events Acute Chronic Illness Others Total With respect to anatomical location, the head and injuries injuries neck region (40%) is the most frequently affected Running 18% 47% 32% 3% 36% part of the body (principally because of upper Fencing 26% 46% 23% 5% 23% respiratory tract infections), followed by the pelvis Swimming 6% 28% 61% 5% 19% and lower extremities (37%), the shoulder girdle Riding 40% 13% 33% 14% 15% Shooting 0% 42% 58% 0% 7% and upper extremities (13%), and the torso (10%) (Table 14.1). The majority of affected structures are the mucous membranes of the respiratory system, ϭ ϭ followed by muscles (n 40), bones (n 36), ten- Chronometry dons (n ϭ 32), and ligaments (n ϭ 23) (Kelm et al. 2003). Schmitz (1985) reported a similar distribution. With respect to the distribution of incidents through- out a season, more occurred preseason (60%) than in-season (40%). Nevertheless acute injuries (38%) Environmental Location occurred significantly more frequently (P Ͻ 0.01) According to Kelm et al. (2003) the majority (84%) of in-season than preseason (18%) (Kelm et al. 2003). reportable incidents happen during training, but the proportion of acute injuries was significantly higher (P Ͻ 0.01) in competition. As noted previously, What Is the Outcome? Schmitz (1985) reported that riding had the highest Schmitz (1985) and Kelm et al. (2003) defined rate of injuries of the five pentathlon events. Kelm reportable incidents in the modern pentathlon as et al. (2003) found that riding, fencing, and running follows: (a) acute injury: acute traumatic dysfunc- accounted for 40%, 26%, and 18% of acute injuries tion during sports due to a disproportion between but no exposure data are provided (Table 14.2). physical strain and maximum stress (Krahl & Steinbrück 1980); (b) chronic injury: chronic dys- function as direct result of mechanical (over)use When Does Injury Occur? due to sports, or chronic dysfunction resulting from incomplete healing after an acute sports injury Injury Onset (Groh & Groh 1975); (c) illness: physical impair- Of the 224 reportable incidents in Kelm et al. ment due to sports that cannot be ascribed to an (2003), the majority were illness (41%) or chronic acute or chronic injury (Kirn-Jünemann 1998); and injuries (33%), followed by acute injuries (23%). (d) other: health impairment that cannot be clearly The remaining 3% could not be clearly assigned to ascribed to one of the above-mentioned categories a specific category. (Kirn-Jünemann 1998). 178 chapter 14
Table 14.3 Percentage distribution by type of reportable incidents (Kelm et al. 2003).
Acute Chronic Illness Others Injuries Injuries
Total 23% 33% 41% 3% Contusions 26% Strains 23% Sprains 15% Ruptures 11% Fractures 10% Abrasions 6% Luxation 5% Others 4% Stress fractures 10% Tendinitis Fasciitis 72% Periostitis Existing sprains 4% Existing luxations 2% Others 12% Otitis Pharyngitis 91% Laryngitis Others 9%
Injury Type Figure 14.1 The final event, running, causes The majority of world-class athletes studied suf- predominantly chronic injuries (47%). fered from illness (41%) and chronic injuries (33%) © IOC/Wataru ABE (Table 14.3). Acute injuries (23%) were not frequent (Kelm et al. 2003). The majority of illnesses were otitis and pharyngitis, with principal chronic inju- acute injuries (40%). Shooting (7%) had few report- ries being tendinditis and periostitis. Although the able incidents and no acute injuries (Kelm et al. majority of acute injuries were contusions, strains, 2003). and sprains, there was a high proportion of stress fractures (chronic [overuse] injury) in the lower Time Loss extremities (n ϭ 7; 5 distal tibia, 2 metatarsal) in relation to a total of 13 fractures. Kelm et al. (2003) reported that a majority (67%; The distribution of incident categories by event 150/224) of reportable incidents led to cancellation are listed in Table 14.2. The majority of incidents of training or competition or both, with an aver- were associated with running (36%), with chronic age of 10 days of nonparticipation during the pre- injuries accounting for 47% of running-related season. Approximately 16% (36/224) of time-loss problems (Figure 14.1), as compared with 18% events occurred during a competition but only 3 for acute injuries. Fencing injuries (23%), ranked of these 224 events resulted in more than 1 week of second, were also predominantly chronic injuries nonparticipation (Kelm et al. 2003). Schmitz (1985) (46%), whereas riding (15%) was dominated by reported a case in her cohort that required cessation modern pentathlon 179
of all sports activities for 2.5 years, but no details Extrinsic Factors are provided. However, the athlete returned to par- There are currently no studies that have examined ticipation, and there have been no reports in which the association between extrinsic factors and the the pentathlon had to be given up after an injury risk of injury. (Schmitz 1985).
Clinical Outcome What Are the Inciting Events?
Most reportable incidents in the modern pentath- Little research is available on causative events in lon appear to be minor. However, serious injury can pentathlon injuries. However, 81% of acute injuries occur, particularly in riding. Kelm et al. (2003) docu- in riding are associated with falling from the horse mented a posterior cruciate ligament rupture and a (Kelm et al. 2003). scapula fracture, both sustained during riding, and Schmitz (1985) reported a complex femoral frac- Injury Prevention ture with an arterial vascular injury, also sustained No intervention studies to address injuries in the during riding. modern pentathlon have been conducted. Economic Cost Further Research Because of the small number of athletes and injury incidents, the economic impact of modern pen- Currently, the research literature on the epidemiol- tathlon-related injuries is not significant for health ogy of the modern pentathlon is very poor and con- insurance systems. Kelm et al. (2003) found no sists of only limited retrospective data. Because all instances of inability to work caused by the mod- competitive modern pentathletes are registered with ern pentathlon. both the world association and national associa- tions, physicians and coaches should be recruited to develop prospective surveillance systems of at least What Are the Risk Factors? one contest year (but, preferably more) to examine the problem of injury in this multidiscipline event Intrinsic Factors more precisely. This will require standardized defini- Sex tions of both acute and chronic injuries, as well as of the sports-induced illness. In addition, research on Although Kelm et al. (2003) noted no sex differ- preseason and in-season injuries and the risk asso- ences in the frequency of acute and chronic inju- ciated with the participation of children and young ries, there was a significant (P ϭ 0.025) difference adults is vital. Specifically, the impact of regular clin- with respect to the frequency of illness, which was ical examinations, especially of young athletes, in more common in women than in men (average. promoting the early treatment of acute injuries and 1.32 vs. 0.67 incidents per person per year). In addi- reducing chronic problems of the locomotor system tion, women were more likely to sustain ligament needs to be examined (Szekelly 1996). Equipment pathologies than men (13% vs. 3%; P ϭ 0.002). modification, especially footwear for running and However, men had more muscle-related injuries fencing, and efficient training protocols must also than women (21% vs. 10%; P ϭ 0.013). be carefully examined in controlled research. Finally, prospective, comparative studies with athletes from Age specialized disciplines could finally shed light on Frequency of illness has been found to be nega- pentathlon-specific acute and chronic injuries and tively correlated with age, irrespective of sex injury patterns so that effective prevention programs (r ϭ Ϫ0.28; P ϭ 0.0034) (Kelm et al. 2003). can be developed to eliminate them. 180 chapter 14
References
Brodani, J. & Krajcovic, J. (2007) Struktura Kelm, J., Ahlhelm, F., Pitsch, W., Kirn- Minder, P. (1987) Moderner Fünfkampf. sportveho vykonu v modernom Jünemann, U., Engel, C., Kohn, D. & Sportinformation 10, 14–16. pätЈboji muzov. Telesna Vychova a Sport Regitz T. (2003) Sports injuries, Parisi, A., Masala, D., Cardelli, G. & 17, 22–24. sports damages and diseases of Di Salvo, V. (2001) Il pentathlon Frohberger, U., Schmitz-Losem, J. & world class athletes practicing moderno. Medicina dello Sport 54, Rieden, H. (1987) Leistungssport modern pentathlon. Sportverletzung— 243–246. Moderner Fünfkampf. Praktische Sportschaden 17, 32–38. Schmitz I. (1985) Sportschäden und Sport-Traumatologie und Sportmedizin Kirn-Jünemann U. (1998) Sportverletzungen bei Modernen 1, 4–10. Sportverletzungen, Sportschäden Fünfkämpfern. Dissertation. Rheinische Groh, H. & Groh, P. (1975) und Erkrankungen bei Modernen Friedrich—Wilhelm Universität, Sportverletzungen und Sportschäden. Fünfkämpfer(inne)n der Weltklasse. Bonn. Luitpold-Werk, München. Dissertation. Universität des Szekelly, G. (1996) A “Sydney 2000” Kelm, J. & Kirn, U. (1997) Zur Saarlandes, Homburg/Saar. programban reszt vevoe sportolok Entwicklung des Modernen Krahl, H. & Steinbrück, K. (1980) klnikai viszgalata. Hungarian Review of Fünfkampfes. Sportorthopädie— Traumatologie des Sports. Sports Medicine 37, 5–10. Sporttraumatologie 13, 177–179. Grundbegriffe und Analysen. Orthopädische Praxis 14, 28. Chapter 15
Rowing
JANE RUMBALL Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, Ontario, Canada
Introduction the United States. This regulation requires equal Competitive rowing has a long and storied tradi- proportions of male and female athletes in colle- tion dating back several hundred years, and the giate sports, and women’s rowing was one of the International Federation of Rowing Associations sports that profited from a need to balance out the (FISA; founded in 1892) is the oldest sporting fed- numbers on male football teams. eration in the Olympic movement. There are two The increase in participation is encouraging, as types of rowing: sculling (using two oars), and rowing confers several important health benefits, sweeping (using one oar as in Figure 15.1). In scull- including lower rates of cardiovascular disease, ing, there are three boat classes: the single, double, diabetes, and obesity (Seiler 2004). Rowing also and quadruple sculls. In sweep, there are also three exerts a protective effect on bone mineral den- classes: the pair, four (with or without coxswain), sity in the spine, because of the load placed on and eight (always with coxswain). the vertebrae during each stroke (Wolman et al. Numbers in collegiate rowing participation have 1990). However, the demanding training regimen increased steadily in recent years, with a large and repetitive nature of the movement can predis- rise occurring because of the advent of Title IX in pose the rower to various musculoskeletal injuries.
Figure 15.1 Sweep rowers use one oar each. Photo credit: Dr. Volker Nolte
Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 Blackwell Publishing, ISBN: 9781405173643 181 182 chapter 15
Although rowing ranks among the most aerobically Who Is Affected by Injury? strenuous of sports, life-threatening or permanent Rowing injury research typically focuses on the col- injury is extremely rare. Acute deaths occurring in legiate and elite rowing population. International the sport can usually be attributed to undiagnosed competition begins at the junior level ( 19), while cardiomyopathy or abnormal cardiac function most senior World Championship competitors (McNally et al. 2005). are in their 20s and 30s. Masters rowing is a divi- Because rowing is also a highly technical sport, sion for rowers not currently training at the World errors in technique can easily lead to injury; as Championship level and who are 27 years of age. improperly supported forces approaching 1000 N are placed on the lumbar spine and supporting structures. Although many injuries stem from over- Overall Injury Rates use and can be treated successfully with conserva- The vast majority of studies investigating rowing- tive treatment, there are a few injuries incurred from specific injury do not report the rate of injury rowing that can be debilitating and unresponsive relative to time or athlete-exposures, making com- to conservative therapy. Preventive strategies can parison difficult. be difficult to implement, as the reason for onset of Weightman and Browne (1975) documented certain rowing injuries is still not fully understood. injury rates for 11 selected sports and reported an Although several review articles on rowing inju- injury rate of 1.4 per 10,000 person-hours for rowing ries exist (Karlson 2000; McNally et al. 2005; Rumball (the highest rate was 36.5 for football). However, it et al. 2005), there has not yet been an extensive epi- was unclear whether all of these injuries were row- demiologic overview of the rowing injury literature. ing-induced. For example, two rowers suffered The purpose of this chapter is to comprehensively broken ankles, although there is no mechanism of review the existing epidemiologic data on injuries as onset stated and nowhere else in the literature is reported in the rowing injuries literature, and to rec- this type of injury reported. The authors concluded ommend important areas for further research. that rowing is “a very safe sport.” The vast majority of studies are descriptive Hickey et al. (1997) conducted a retrospective and theoretical in nature, and case study reports analysis during a 10-year period (1985 through abound. There are several methodologic limitations 1994) on the injuries of male and female rowers at in the existing research, which include differences the Australian Institute of Sport (AIS). During that in subject characteristics (experience level, fitness time, 320 injuries were documented by 172 rowers. level, age, and sex), instability of results due to short An earlier retrospective survey also from the periods of data collection, low sample size, variabil- AIS by Reid et al. (1989) focused on 40 female rowers ity in injury definition, and bias due to retrospective on AIS scholarships between 1985 and 1989. During questioning and analysis. There is also a large dif- that time, 25 of the 40 presented for rowing-related ference between rowing-specific injury and injury injuries, accounting for 61 rowing injuries in total. occurring to rowers (which may have resulted from More recently, a survey study of Irish row- other training, such as lifting weights or running), ers by Wilson et al. (2004) reported a history of and this fact is not always reported. Furthermore, injury by 66.5% of male and 69.6% of female changes in equipment over the years have theoreti- rowers. In this study, 227 questionnaires were cally led to different injury patterns, severity, and analyzed, representing 18.7% of the total rowing risk. Rules of racing have changed; women’s rowing population of Ireland. was not introduced at the Olympic level until 1976, and lightweight rowing in 1996 (lightweight men’s Sex Differences double and four, lightweight women’s double). With these factors in mind, there still continues to There is evidence suggesting a sex difference in be a strong and consistent pattern to injury onset, rowing injury rate and location. In an extensive cause, and prognosis within the sport of rowing, report by Hickey et al. (1997), 84 females accounted which is detailed herein. for 204 injuries, while 88 males accounted for 116 rowing 183
injuries. Female rowers had an average of 1.58 inju- However, Hickey et al. (1997) demonstrated that inju- ries per scholarship-year, and male rowers had an ries sustained by rowers are mostly overuse in nature. average of 0.85. Of 320 injuries observed over a 10-year period, 92 were acute (29%), while 228 were overuse (71%). The Where Does Injury Occur? ratio of acute to overuse injuries in female rowers was 1:2.58, and in male rowers was 1:2.31. Respondents to An overall percentage comparison of injury location a 2004 survey of rowing injuries in Ireland described across studies is shown in Table 15.1. A review of the majority of injury onset as “slow progression” the data in this table indicates that the spine was the during rowing (43.6%) or “sudden onset” during most frequently injured region for rowers (range, rowing (18.5%) (Wilson et al. 2004). 23.1–59.0%), followed by the chest area (range, 6.0–22.6%) and the forearm/wrist region (range, Chronometry 2.3–15.5%). The region of the spine most frequently Time of Day injured was the lumbar spine (range, 9.8–45.0%). It has been postulated that there is a higher risk When Does Injury Occur? for back injury while practicing during an early- morning hour (Adams et al. 1987; Urban & McMullin 1988; Reid & McNair 2000), when disks Injury Onset are still imbibed with fluid and more prone to There is a lack of reporting on the number of acute injury. However, there are no prospective data to and overuse injuries in the rowing literature to date. confirm this theory.
Table 15.1 Percent comparison of overall injury location in club and elite rowing.
Elite Mixed Club
Hickey Hickey Reid Wajswelner Coburn & Wilson Wajswelner et al. (1997) et al. (1997) et al. (1989) et al. (1995) Wajswelner et al. (2004) et al. (1995) (1993)
Study Design RRRNSNSRNS No. of injuries 204 116 (male) 61 (female) 132 54 NS 90 (female) (227 surveys) Head/Face 1 0.9 — — — — — Spine Cervical 1 1.7 4.9 12.9 8 6 — Thoracic 6.9 1.7 9.8 11.4 6 10.5 5.6 Lumbar 15.2 25 9.8 28 45 27 44.4 Shoulder/Upper Arm 5.4 5.2 4.9 9.8 9 5 — Elbow 3.4 1.7 — 1.5 — — — Forearm/wrist 14.7 15.5 15 2.3 — 8.5 10 Hand 4.9 8.6 4.9 1.5 — — — Trunk/abdomen 1 0.9 11.4 — — — — Chest 22.6 6 21.3 6.1 11 5.8 20 Hip/pelvis/groin/buttock/thigh 6.9 10.3 6.6 9.1 9 —— Knee 9.3 12.9 9.8 4.5 6 9 6.7 Lower leg 0.5 1.7 — — 6 —— Foot/ankle 6.4 6.9 — 6.1 — — — Other 1 0.9 4.9 (disc) 8.3 — 8.4 (disc) 13.8
NS not specified; P prospective; R retrospective. 184 chapter 15
Time of Season costovertebral joint subluxation (Thomas 1988; Rumball et al. 2005); however, rib stress fractures Rates of injury are much higher during the transi- account for the vast majority of injuries to this tional period between dry land and on-water train- region. Typically, the posterolateral angle of ribs 5 to ing, as well as during heavy training periods that 9 is the area most frequently affected (Karlson 2000). emphasize a large volume of work coupled with The rate of stress fractures of the ribs is reported high intensity. Hickey et al. (1997) observed two to be between 6.1 and 22.6% (Hickey et al. 1997; peak times for injury presentation in both women Warden et al. 2002), with a higher reported and men in Australia: May–June (high volume) and proportion in women. Of note, is the finding that the summer racing period of November–February injuries to the chest area comprise 26% of overuse (high intensity). July had the lowest reported fre- injuries in women but only 9% in men (Hickey et al. quency, but the authors postulated that it may be 1997), supporting other reports that female rowers due to the fact that athletes were away competing experience a higher rate of stress fractures of the ribs in the northern hemisphere. (Wajswelner 1995; Karlson 2000). However, other Data collected on the Canadian national team data suggest no sex difference (Hannafin 2000). during the years 1991 through 1996 substantiate Furthermore, data collected during the years 1991 these findings, as the majority of rib stress frac- through1996 on the Canadian National Rowing tures occurred during the high-volume months team indicate no difference in the proportion of (December–February) and race preparation months stress fractures of the ribs between lightweight (March–May) (R. Backus, Canadian team physician: and heavyweight rowers, scullers and sweep- unpublished observations). ers, or men and women (Table 15.2) (Backus, R.: unpublished observations). What Is the Outcome? Shoulder Injury Type Anecdotal reports suggest that a rower may com- No epidemiologic studies provide an overall monly exhibit a combination of an anteriorly description of injury types incurred during rowing. placed glenohumeral head, tight posterior shoulder Instead, reports have focused on the frequency and capsule, tight latissimus dorsi, and weak rotator- severity of injury types believed to be common in cuff muscles (Richardson & Jull 1995), which may rowing. These include injuries involving the low lead to nonspecific shoulder pain. back, rib and chest, shoulder, forearm and wrist, and knee. Forearm and Wrist Injury to the forearm and wrist can include exer- Back tional compartment syndrome (Chumbley 2000), The prevalence of injuries to the spine appears to be sculler’s thumb (Williams 1977), de Quervain dis- on the increase (Teitz et al. 2002). Although rowers ease and intersection syndrome (Hanlon & Luellen who do not have back pain during collegiate years 1999), and lateral epicondylitis (Karlson 2000). The have a lower incidence of back pain than the gen- most common rowing-specific injury appears to be eral population (Roy et al. 1990; Hickey et al. 1997; tenosynovitis due to excessive wrist motion and Teitz et al. 2003; McNally et al. 2005), those who repeated rotation of the oar twice during each stroke experience back pain causing 1 weeks of lost prac- cycle (McNally et al. 2005, Rumball et al. 2005). tice will likely have a recurrence (Teitz et al. 2003). Knee Rib and Chest Although women may be predisposed to patellar There are reports of injuries to the chest, includ- tracking problems due to anatomical considera- ing costochondritis, intercostal muscle strain, and tions (Karlson 2000), both male and female rowers rowing 185
Table 15.2 Incidence of rib stress fractures in Canadian national rowing team members from 1991 to 1996.a
Year 1991–1992 1992–1993 1993–1994 1994–1995 1995–1996 Overall
Rib fractures 11 0 4 4 4 23 No. training 39 43 43 44 54 223 Incidence 0.28 0.00 0.09 0.09 0.07 0.10
1991–1996 Women Men
With rib fractures 716 No. training 88 135 Incidence 0.08 0.12
1991–1996 Heavyweight Lightweight
With rib fractures 20 3 No. training 184 39 Incidence 0.11 0.08
1991–1996 Scull Sweep
With rib fractures 419 No. training 39 184 Incidence 0.10 0.10
Data provided by Dr. Richard Backus, Canadian team physician a Incidence refers to the number of fractures per athlete. may have iliotibial band syndrome, due to full knee latter group and the eumenorrheic rowers. These compression at the catch coupled with varus knee findings may relate to an increased risk of fractures alignment. in this population.
Other Time Loss Dermatologic issues, including infected blisters, Because many elite rowers train and compete hand warts, sculler’s knuckles, slide bites, and full-time, time lost due to injury can have a major rower’s rump can commonly develop in the rower impact (Wilson et al., 2004). However, there are (Rumball et al. 2005). few data on rowing injury outcomes. Existing data Issues surrounding body composition and the focuses primarily on back injury, with a few studies Female Athlete Triad can arise in the lightweight- documenting the most time lost from training and rowing population (Sykora et al. 1993; Pacy et al. competition resulting from rib stress fractures 1995). The Triad is composed of disordered eating, (O’Sullivan et al. 2003). Coburn and Wajswelner menstrul dysfunction, and lowered bone mineral (1993) documented 54 consecutive rowing injuries density, and can often present in elite and recrea- over a 12-month period and observed that overall, tional atheletes with devastating consequences if only 20% of injuries kept rowers out of the boat for left untreated (Lebrun & Rumball, 2002) Wolman longer than 1 week. More recently, Wilson et al. et al. (1990) studied 26 elite female rowers, half of (2004) found a mean land-training time loss of 1 to whom were amenorrheic, and observed significant 2 weeks (23.3%) and a rowing training time loss of differences in bone mineral density between the 1 to 2 weeks (29.1%) overall. 186 chapter 15
With respect to low back pain (LBP), Sys et al. Motor Characteristics (Flexibility, Endurance, (2001) reported that of athletes with spondylolysis, Balance, Speed) 89.3% returned to sport within an average of 5.5 Because of the highly technical nature of the rowing months after the onset of treatment, and that non- stroke, there are many elements of motor coordina- union did not compromise overall outcome. O’Kane tion, balance, and flexibility that may contribute to et al. (2003) noticed a difference in time lost from the development or prevention of rowing injury. training with athletes who had preexisting back McGregor et al. (2002) studied 20 elite oarsmen pain before their collegiate rowing careers. Of sub- with and without LBP and observed different mobil- jects who had preexisting back pain, 79% missed 1 ity trends in those with current or previous symp- week and 6% missed 1 month. For subjects without toms. Those with pain demonstrated hypomobility preexisting back pain, 62% missed 1 week and 18% in their lumbar spines, which resulted in increased missed 1 month. This led the authors to conclude: pelvic rotation. Given the cross-sectional study “While rowers with preexisting back pain are more design, the authors did not know whether these dif- likely to have back pain in college, they are less likely ferences in mobility were a result or a cause of LBP. to miss extended periods of practice time or end their In a study of LBP in 17 elite lightweight women college rowing careers because of back pain.” (Howell 1984), a high positive correlation was found Stress fractures of the ribs may result in the most between hyperflexion of the lumbar spine and the time lost from on-water training and competition incidence of LBP, as well as a high negative correla- (Warden et al. 2002), and an estimated 10% to tion between adherence to a regular stretching pro- 15% of elite rowers will sustain a stress fracture gram and incidence of LBP (P 0.005). of a rib at some point in their competitive careers (Hannafin 2000), although these theories have not Extrinsic Risk Factors yet been confirmed in the epidemiologic research. Coaching, Rules What Are the Risk Factors? Two of the risk factors that Teitz et al. (2002) observed while studying LBP in 1,632 college row- Very few studies have tested possible risk fac- ers were related to training methods modifiable by tors for injury in rowing. To date, the research has coaches: the use of a rowing ergometer for 30 min- focused on height and weight, hypomobility and utes at a time (P 0.001), and increased training vol- hyperflexion in the lumbar spine, and training ume using multiple training methods (P 0.001). volume. What Are the Inciting Events? Intrinsic Factors The nature of rowing is that from one stroke to the Physical Characteristics (Height, Weight, Age) next, different firing patterns, balance issues, timing Rowers are typically tall and lean, with an average within the crew, load on the blade, level of fatigue, height approaching 6’ (women) and 6’6” (men). and many other factors can make it very difficult to Although greater height can contribute to longer pinpoint the precise mechanism of injury. stroke lengths (through longer levers), it may However, while the term rowing injury implies also predispose a rower to a higher risk of injury. that the injury was sustained during time spent on Teitz et al. (2002) studied 1,632 college rowers the water, this is not always the case, making com- and observed that greater height and weight, and parison of studies all the more difficult. There are beginning the sport prior to 16 years of age, were reports that up to 50% of injuries in elite rowers are significant risk factors (P 0.03) for developing due to land-based training, including ergometer LBP. Higher mean college height and weight were and weight training (Bernstein et al. 2002; Hickey significant risk factors in both men (P 0.007 and et al. 1997), and these factors must be taken into P 0.02) and women (both P 0.001). consideration. Wilson et al. (2004) observed that rowing 187
running accounted for 14.1% of slow progression Vinther et al. (2006) observed differences in stroke and 5.7% of sudden onset injuries. mechanics in rowers with a history of stress frac- With respect to weights, Stallard (1980) observed tures of the ribs and those without. Rowers with that all cases of back pain in his sample of rowers a history of these fractures showed a higher veloc- could be accounted for by weightlifting. Others ity of the seat in the initial drive phase (sequential have also noted a higher incidence of injury in movement), greater cocontraction of serratus ante- rowers due to weightlifting (Karlson 2000, Warden rior and trapezius muscles, and a reduced leg/arm et al. 2002). Coburn and Wajswelner (1995) noted strength ratio. that of 54 observed rowing injuries, 65% of them occurred from rowing itself and 28% in the weight Injury Prevention room, and that weights were the cause of a larger number of lumbosacral injuries (40%) than inju- Although many researchers propose preventive ries to the rest of the body (27.8%). More recently, strategies, there are very few who actually provide Wilson et al. (2004) reported that 17.2% of injuries evidence of such strategies working. were due to weightlifting. Koutedakis et al. (1997) noted significant negative Ergometer training has also been implicated. correlation coefficients between knee-flexion-to- There is often heavy initial loading at the catch on extension peak torque ratios and days off due to the rowing ergometer, and elite rowers will often low-back injury in both female and male rowers. train with low drag factor settings to mimic the The authors retested a subgroup of 22 female row- feeling inside the boat and to prevent low back ers after introducing a 6- to 8-month hamstring- injury (McNally et al. 2005). As rowers become strengthening program, and observed a reduction fatigued at the end of a long session, the stability of of the incidence of low-back injury in the female the low back may be impaired (Caldwell et al. 2003; rowing population. Holt et al. 2003). Further Research Effect of Sculling and Sweeping Future research should focus on longitudinal, Controversy exists surrounding the issue of injury prospective data collection involving detailed as it relates to the type of rowing. Sculling, which injury reporting on all rowing-specific injuries and requires two oars, is generally considered a sym- their outcomes. This could come from a variety of metrical motion. Sweeping uses one oar, and angles: athlete exposure, equipment changes, risk requires a slight to extreme rotation of the trunk factors, and sex differences. either to the right or left to achieve adequate stroke With respect to exposure, future studies could length. Although injury occurs in both populations, follow a group of novice rowers over the course some researchers have postulated an increased of several seasons to gather data concerning how incidence of stress fractures of the ribs in the latter exposure and advancing levels of training and population (Holden & Jackson 1985; Christiansen & competition affect injury rates and type. Novice Kanstrup 1997; Bojanic & Desnica 1998), while rowers may be predisposed to injury because the others do not observe any increased risk (Hannafin boat can often be off-balance, and power applica- 2000; Backus R.: unpublished observations). tion is compromised as a result (McNally et al. Sacroiliac joint dysfunction, however, may be more 2005). More experienced rowers learn to selectively common in sweep rowers (66%) than scullers (34%) recruit muscle groups that aid in moving the boat (Timm 1999). and relaxing those that do not (Yoshiga et al. 2003). Over time, sweep rowers usually specialize on one Stroke Mechanics particular side, which may lead to back pain related Few articles exist that document the effect of to asymmetric muscle development (Stallard 1980; movement pattern on injury. However, a study by Secher 1993). 188 chapter 15
In addition, future research could focus on vari- A lack of flexibility and strength is implicated in ous equipment changes and subsequent forces on the development of stress fractures of the ribs as anatomical models in controlled environments. well (Holden & Jackson 1985). Equipment could include different blade designs Theoretical strategies to prevent back and rib (such as in Figure 15.2), rigging changes (adjusting injury that need to be tested include stretching of load by shortening and lengthening oars or changing hamstring and gluteal muscles and core stability the span of the riggers), changes in angle of the foot work (McGregor et al. 2002), breathing out during stretchers and boat design (some hull shapes, while the drive (Manning et al. 2000), anterior rotation of fast, also tend to be less stable than others and could the pelvis (Caldwell et al. 2003), inspiratory muscle predispose certain rowers to injury). training (Voliantis et al. 2001), use of the ergometer There are several theories on risk factors that for cardiovascular and not strength training, with remain hypothetical and need to be substantiated lower load (Teitz et al. 2003), coaching rowers to with sound epidemiologic evidence. These include avoid stretching loose muscles and having rowers theories for LBP risk factors such as low hamstring- assume positions of lordosis or extension during to-quadriceps strength ratio (Koutedakis et al. rest periods (Howell 1984), modifying technique 1997), strength imbalances in the left and right erec- for longer rows (Karlson 2000), and switcing sides tor spinae muscles during extension (Parkin et al. for injured sweep rowers (McNally et al. 2005). 2001), increased demand on the respiratory system All risk factors related to stroke mechanics and (Loring & Mead 1982), and hip muscle imbalances other injury also remain theoretical. Stallard (1980) (particularly in female athletes) (Morris et al. 2000). proposed that the great loads placed on the lower
Figure 15.2 Differences in blade shape over the years (most recent at top). L large; M medium. Image credit: Dr. Volker Nolte and Concept2 (Morrisville, Vermont). rowing 189
back at the catch may cause injury, and the amount be beneficial (Vinther et al. 2006). The heavy and of lumbar flexion at this part of the stroke cycle may acute load on the spine that results from a power- further compound the problem (Bull & McGregor ful catch may be lessened with a lighter catch and 2000, O’Sullivan et al. 2003, McNally et al. 2005). rapid but steady acceleration of the oar (McNally Poor stroke mechanics have been named as a poten- et al. 2005). In addition to technical advice, coaches tial cause for stress fractures of the ribs (Karlson are usually also responsible for the rigging of the 2000; McKenzie 1989; Read 1994), and repetitive boat, and improper foot angle or placement may strain through excessive wrist motion may lead to contribute to knee injuries (Karlson 2000). forearm and wrist injury (McNally et al. 2005). There are obviously significant gaps in the epi- Further research is needed to determine whether demiologic literature of rowing injury to date, there are certain positions during the stroke cycle which encompass overall incidence, outcome, that predispose the rower to increased rates of risk factors, and prevention. The vast majority of injury. The rowing stroke is divided into four main the existing research is anecdotal or retrospective, phases: the catch (blade of the oar enters the water, without a clear definition of injury, its duration, or legs and back are fully flexed while arms are fully mechanism for onset. In particular, injuries must extended); the drive (power phase of stroke, duing be reported as whether they were acute or chronic which legs and back are extending and arms are and whether they were sustained during rowing or beginning to engage); the finish or release (blade cross-training. In addition, low back pain should be is taken out of the water, legs and back are fully further defined, which will be alleviated by more extended, arms are fully flexed); and the recovery and better imaging studies in the future. Further (relaxation phase, rower begins to move up in studies on the cause of stress fractures of the ribs reverse order toward the catch position). are also eagerly anticipated. A better understanding Coaching style at the catch position varies of the mechanisms underlying the onset of rowing considerably. Some coaches advise a sequential injury will decrease the incidence of debilitating strategy of initiating the drive phase with the legs injury in the future as well as ensuring a faster (knee extension) followed by extension of the hip return-to-sport for the athletes, allowing the sport and back, while research suggests that a more of rowing to become an even safer and more enjoy- synchronous movement of the legs and trunk may able activity for all involved.
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Sailing
VERNON NEVILLE School of Sport, Exercise & Health Sciences, Loughborough University, Loughborough, UK
Introduction to the extent that today there are more participants in windsurfing than all other types of sailing com- The sport of sailing has evolved from one of the bined. Windsurfing first joined the Olympic Games oldest means of transport, dating back over 5,000 in 1984 and is regarded as one of the most athleti- years. Today, sailing is enjoyed worldwide from the cally demanding and exciting sailing events. occasional recreational enthusiast to elite Olympic- There are currently nine one-design class boats class competitors and professional big-boat sailors. for the 11 Olympic-class sailing events. The term It is estimated that more than 16 million people one-design implies that the boats in each class are participate in sailing activities worldwide. The identical, having been manufactured under strict earliest record of modern-day sailboat racing was International Sailing Federation (ISAF) specifica- the first America’s Cup challenge around the Isle tions, ensuring that the skill of the athlete is tested of Wight in 1851 (Whiting 2007). In fact, the rather than the design of the boat. America’s Cup is the oldest competing trophy in Many Olympic-class sailors go on to become pro- modern sport, predating the Modern Olympics by fessional big-boat sailors in prestigious elite team 45 years. events such as the America’s Cup and the Volvo Sailing was included in the inaugural Modern Ocean Race (formerly the Whitbread Round-the- Olympic Games in Athens in 1896, but the regatta World Race). The increased interest in competitive was canceled because of adverse weather condi- sailing has led to a rise in commercialization and tions. Hence, the first Olympic medals for sail- professionalism at the elite levels of competition, ing were awarded at the 1900 Olympic Games. with clear increases in the physiological and psy- The design or class of boats has changed over the chological demands placed on competitive sailors. years, with the Star class being the oldest current The demands and technical requirements of sail- Olympic-class boat; first introduced for the 1932 ing at all levels depend largely on the class of boat, Games. The first women’s Olympic sailing event the sailors role on board, the level of competition, was introduced for the 1988 Olympic Games in and the weather conditions. As with most other Seoul with the 470 two-person Dinghy; an addi- athletes, sailors are at risk of injury (Neville et al. tional two women’s classes were added in 1992. 2006) and an understanding of the risks is impor- Windsurfing originated in the late 1960s, and has tant in helping to reduce the burden of sailing inju- been one of the fastest-growing sports in the World, ries (whether it be financial, performance, health, or otherwise). The aim of this chapter is to review the literature Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 on sailing and to provide a detailed report on the Blackwell Publishing, ISBN: 9781405173643 risks, distribution, and mechanisms of injury, as well 191 192 chapter 16 as suggested injury-prevention strategies and direc- Position tions for future research. Most studies reviewed The physiological demands of sailing are position- were descriptive in nature, with few reports hav- and boat-specific (Legg et al. 1997a; Bernardi et al. ing quantitatively measured sailing exposure. Thus, 2007), and the risk of injury is associated with the incidence rates are mostly estimated or based on specific activities performed. In elite Olympic- data collected from retrospective questionnaires. class sailing, the positions that predominantly In addition, the considerable variation in research involve hiking are at greatest risk of injury. This methods, particularly with respect to the definition is the helmsman in the one-person classes such as of injury, the specificity of cohorts, the classification the Laser, Finn, Laser Radial, and NeilPryde RS:X of injury, and the clarity of injury diagnosis, makes and the crew in two- or three-person classes, such comparison between studies difficult. Moreover, the as the 470, Star, Yngling, and 49er. In novice sail- dearth of data on Olympic-class sailing injuries is ing (Schaefer 2000), however, it is the helmsman surprising, considering the interest there has been who is at greatest risk of impact with the boom or in the physiological and biomechanical demands of mainsheet. In America’s Cup sailing (Allen 1999; Olympic-class sailing in recent years (Mackie et al. Allen 2005; Neville et al. 2006), the bowmen and 1999; Bojsen-Moller et al. 2007; Cunningham & Hale the grinders are at greatest risk of injury. Neville 2007; Vangelakoudi et al. 2007). et al. (2006) reported an incidence of 3.2 and 3.1 injuries per 1,000 hours of sailing for bowmen and Who Is Affected by Injury? grinders, respectively. These results are not surpris- ing, considering the high frequency of activities The incidence of injury varies according to the performed by the bowmen along the narrow fore- class of sailing; Olympic-class (McCormick & deck and the high intensity and volume of grind- Davis 1988; Legg et al. 1997b; Nathanson & ing performed by the grinders (Miller 1987, Neville Reinert 1999; Schaefer 2000; Dyson et al. 2006), et al. 2003, 2006). Helmsmen, on the other hand, recreational sailing (Nathanson et al. 2006), and have few physical stressors other than neck, big-boat sailing (Price et al. 2002; Spalding et al. shoulder, and lower back fatigue, resulting from 2005; Neville et al. 2006) are shown in Table 16.1. prolonged standing and concentration, which is evi- Most studies are based on retrospective ques- dent in the relatively low risk of injury (0.4 per 1,000 tionnaires, with few having accurately measured hours of sailing) (Neville et al. 2006). Conversely, exposure. In fact, there is only one prospective off-shore racing helmsmen have a higher risk of study in the literature to date that has compre- injury (2.6 injuries per race leg) (Spalding et al. 2005) hensively reported incidence data for injuries in because of the arduous nature of steering in heavy sailing (Neville et al. 2006). However, some stud- weather conditions. Most positions in off-shore rac- ies have included the frequency of injuries over ing have a similar risk of injury; ranging from 1.7 to a specific period of time, such as during a par- 3.1 injuries per leg of the race (Spalding et al. 2005). ticular competition (Price et al. 2002; Spalding et al. 2005) or over a year (Legg et al. 1997b; Sex Schaefer 2000; Dyson et al. 2006; Nathanson et al. 2006). Based on these data it seems that profes- There is little evidence to suggest any difference in sional big-boat sailors are at greater risk of injury the risk of injury between male and female sailors. (3.1 to 3.2 injuries per year) (Spalding et al. 2005; Of the 238 minor injuries incurred by novice Dinghy Neville et al. 2006) than other classes of sailing (0.2 sailors, Schaefer (2000) reported that the risks of to 2.0 injuries per year) (Legg et al. 1997b; Dyson injury in men and women were similar, as were the et al. 2006; Nathanson et al. 2006; Schaefer 2000). nature and type of injuries. In windsurfing, Ullis & However, these large differences may be due to the Anno (1984) reported similar types of injuries for wide variations in methods and definitions used in men and women, although men had a greater inci- injury surveillance studies. dence of serious injuries. McCormick and Davis sailing 193 1.5 No. of Injuries per per Year Athlete 0.2 0.4 1.1 2.0 1.2 — 0.7 3.1 3.2 0.37 No. of Injuries per 1,000 Hr of Exposure — 0.29 — — — — 0.22 — 5.70 — Injuries per 1,000 Days of Sailing Duration No. of 299 10 mo — No. of Injuries 489 — 1.0 a 28 203643 3 yr 76 173 — 2 yr 2 yr — — No. of Athletes Elite Elite Elite Recreational 28 67 2 yrProfessional 35Professional — 97Amateur 220 365 (195) 312 2 yr 9 mo — — Standard of Standard Competition ew positions. 470, Europe, 470, Europe, Tornado, Mistral (Race–board) (2003) Race Challenge (Wave–slalom) (Boardsail) Class Description RQRQ Windsurfing Windsurfing RQ DinghyWebS NoviceRQ Windsurfing 536 Mixed Windsurfing 238 Mixed 294 1 yr 73 — 104 Career — Design of Study During the race, 365 sailors were rotated in and out for the 195 cr rotated During the race, 365 sailors were Olympic Class Legg et al. (1997b) RQ Schaefer (2000) Dyson et al. (2006) Finn, Laser, RQ Nathanson & Reinert Windsurfing (1999) McCormick & Davis (1988) Sailing Recreational Nathanson et al. (2006)Big-Boat Sailing WebS Neville et al, (2006) Mixed classes Spalding et al. (2005) P Recreational Price et al. (2002) RQ 1431 America’s Cup Ocean Volvo RQ 1756 — Global 18.9 Table 16.1 Table Comparison of injury rates by sailing class. Study Internet survey. WebS prospective; P questionnaire; RQ retrospective a 194 chapter 16
(1988), however, reported that during strong wind contact with the center board or skeg (Ullis & Anno conditions, female windsurfers had a greater inci- 1984; Allen & Locke 1989; Nathanson & Reinert dence of injury (0.37 per 1,000 hours; n 22) than 1999). Lower-back injuries in windsurfing are male windsurfers (0.17 per 1,000 hours; n 51). thought to be due to maintaining lumbar extension Unfortunately, big-boat sailing reports that have (lordotic posture) for prolonged periods and pos- included data on injuries in women (Allen 1999; sibly the lumbar compression involved when sail- Spalding et al. 2005) have failed to include inci- ing without the use of a harness, which attenuates dence or comparative data; hence, it is difficult to the force transmitted through the spine (Locke & determine any difference in risk. Allen 1992; Rosenbaum & Dietz 2002). The anatomical location of injury in big-boat sail- ing seems consistent, regardless of the sailing class. Where Does Injury Occur? The spine and torso are at greatest risk of injury (21–43%), followed by the upper limbs (22–39%) Anatomical Location (Allen 1999, 2005; Neville et al. 2006; Spalding et al. The distribution of injuries by anatomical location 2005, Price et al. 2002). appears to be specific to the sailing class (Table 16.2). In elite-level Olympic-class sailing (Legg et al. 1997b; Environmental Location Moraes et al. 2003), the body parts most frequently injured are the spine, followed by the knee. A ret- In professional sailing, land-based strength and rospective questionnaire on 28 elite New Zealand conditioning training plays a major role in prepar- Finn, Tornado, Laser, Europe, 470 and Mistral sail- ing athletes for the high physical demands of racing ors during preparation for the 1996 Olympic Games (Bernardi et al. 2007). Hence, the intensity of training (Legg et al. 1997b) identified the lumbar spine as is often higher than that of sailing (Neville et al. the most commonly injured body part during the 2006). It is not surprising, then, that in one report previous 3 years, followed by the knee, shoulder, on the America’s Cup, the incidence of injury dur- and upper limb. Experienced Dinghy and Keelboat ing strength and conditioning training was greater sailors “hike” (lean) out of the boat for prolonged than that during sailing (8.6 vs. 2.2 injuries per periods to counterbalance the heel force exerted 1,000 hours) (Neville et al. 2006). Furthermore, con- by the wind (Figure 16.1). The force exerted on the trary to many other sports, the incidence of injury foot strap of Laser sailors while hiking in 15 knots during the America’s Cup competition period was of wind can be in excess of 800 N (Mackie & Legg lower than during the training periods (4.7 vs. 6.2 1999). This force is translated mainly to the knee and injuries per 1,000 hours) (Neville et al. 2006). This lumbar spine (Newton 1989; Mackie & Legg 1999), lower risk may be due to the reduced volume and thereby increasing the stress and associated risk of intensity of training during the competition period. injury to these structures. In contrast, novice Dinghy Environmental conditions, particularly wind sailors are typically less proficient at hiking and speed, have been reported to affect the risk of have a greater percentage of upper-limb, mainly the injury (Vogiatzis et al. 1995; Schaefer 2000). In rec- hand, and head injuries as a result of impact with reational sailing, 18% (316 of 1,756) of injuries and use of equipment (Schaefer 2000). Windsurfing reported in an Internet-based survey (Nathanson injuries occur predominantly to the lower limbs et al. 2006) occurred as a direct result of high wind and lower back (Ullis & Anno 1984; Allen & Locke speeds. Schaefer (2000) Thirty-four percent of inju- 1989; Nathanson & Reinert 1999; Dyson et al. 2006). ries in novice sailors (81 of 238) occurred when Dyson et al. (2006) reported the lower limbs to be wind speeds were above 17 knots, and less than 9% the most frequently injured body region (39%), spe- (21 of 238) occurred at wind speeds below 7 knots, cifically, the thigh and calf and the ankle and foot, even though the percentage exposures was similar followed by the lumbar spine and shoulder. Most (22% and 24%, respectively) (Schaefer 2000). During lower-limb injuries in windsurfing are the result off-shore racing, the stages covering the southern of falling with the feet caught in the foot straps or ocean, where the roughest sea conditions were sailing 195 – – 12 Price (2002) Off–Shore Racing Off–Shore Spalding et al. (2005) 43 4238 21 39 13 18 Allen (1999) 16 16 15–––––10 –– 6 11 – 5 8 5 – 9 8 – 86–––– 1316 –– 30 11– 10– 217 – –– 11 – – – 11 13 – – – 16 Allen (2005) 206–– – 54 312 229 America’s Cup America’s Neville et al. (2006) 11 18 217416 6 6 5 8 22 30 7 8 35311 11 33 6 2 12 26 9539 8 7 19 Dyson et al. (2006) 2627 220 2 – – – – – 16 – – – – – 19 – – 45 Nathanson & Reinert (1999) 489 18 Windsurfing a 40 – 78 40 95 61 51 – 40 79 30 49 Ullis & Anno Ullis & (1984) 511 56 centage of injuries. a –– –– –– – Moraes et al. (2003) 13–– 27 –– 2 –––– 24 40 41 33526 21 – 32 Schaefer (2000) Olympic-Class Sailing – 22 12 34 18 –– 24 – 15 2 21 – – – – – – Legg et al. (1997) Values expressed as percentage of all athletes as opposed to per as percentage expressed Values Arm Leg Knee Ankle and foot – Shoulder Hip Spine and Torso Neck spine Thoracic Ribs spine – Lumbar Upper Extremity 45 Elbow Hand and fingers –Lower Extremity – 53 Table 16.2 Table distribution of injuries by anatomical location. Percentage a Head and Face No. of Incidents 20 238 – 196 chapter 16
Figure 16.1 Helmsman and crew hiking off the side of a two-person Olympic class keelboat (Star) showing the position of the knee during prolonged hiking. Courtesy of Getty Images. experienced, had significantly more injuries than thirds of injuries (148 of 220) in a 2-year America’s other stages (P 0.02; Price et al. 2002). In wind- Cup campaign were acute. However, the severity surfing the risk of injury is greater when sailing in of chronic injuries (predominantly tendinopathies) “hurricane” conditions of 40 knots (McCormick & was significantly greater than acute injuries (6.1 Davis 1988). Interestingly though, chronic lower vs. 3.4 days absent per injury), which was attrib- back pain in windsurfers occurs predominantly uted to the demands of high-repetition activities. during lighter wind conditions (Locke & Allen In contrast, a pilot study on an all-female team 1992), because of maintaining a prolonged lordotic (America3) competing in the 1995 America’s Cup posture. (Allen 1999), showed a greater percentage of over- use injuries and muscle strains than an all male When Does Injury Occur? crew (overuse, 68% vs. 33%; strains, 33% vs. 12%; female vs. male, respectively). These differences are postulated to be the result of differences in experi- Injury Onset ence and the high absolute demands of this sailing Most sailing injuries can be characterized as either class subjecting females to higher relative loads, but acute or chronic in nature, as a result of macro- they could also be due to discrepancies in injury traumatic or micro-insidious forces. Acute injuries, definition and data-collection methods. resulting from a sudden trauma, include contusions, Unfortunately, there are few data available on the fractures, strains, and sprains, whereas chronic nature of injury in Olympic-class sailing. It appears injuries, resulting from prolonged or repetitive that the type of injury may be related to the skill overloading, include tendinopathies, sprains, neu- level of the athlete. Elite Olympic-class sailors ropathies, and bursitis (Peterson & Renstrom 2001). appear to be at greater risk of overuse injuries The nature of injury seems to be specific to the sail- (Legg et al. 1997b), whereas novice Dinghy sailors ing class (Allen 1999, 2005; Allen & Locke 1989; are predominantly at risk of acute trauma (95% of Nathanson & Reinert 1999; Neville et al. 2006). Most all injuries) (Schaefer 2000). This may be related windsurfing injuries (ϳ70%) are acute (Allen & to a number of factors, including the level of con- Locke 1989; Nathanson & Reinert 1999), mainly as a ditioning and skill development (Vangelakoudi result of impact with equipment. In professional big- et al. 2007), the risk of contact with hardware, and boat sailing, Neville et al. (2006) reported that two the highly repetitive nature of specific activities. sailing 197
In some sailing classes, the nature of injury may neuropathies also appear to be common for helms- vary according to crew position; for example, off- men in this class (Spalding et al. 2005). shore racing helmsmen experience mostly over- use injuries to the upper limb, whereas mastmen Injury Severity and bowmen are at greater risk of acute injuries Few studies have discussed the severity of injury in (Spalding et al. 2005). relation to training or competition time lost. The severity of injury is often specific to the class What Is the Outcome? of boat or the role of the athlete. For example, patel- lofemoral pain syndrome may prevent a Finn or Injury Type Laser sailor from sailing (Newton 1989; Cockerill The type of injury sustained is related to the sailing 1999), but this is not necessarily the case for an class, as well as the level of sailing experience. In a America’s Cup afterguard. The severity of injury study of 536 novice Dinghy sailors (Schaefer 2000), is therefore related to the demands of the specific contusions and bruises were the most common activities performed. In recreational sailing, only injuries (61% [146 of 238]), followed by abrasions half of all injuries reported by Nathanson et al. and lacerations (32% [75 of 238]). Similar findings (2006) required first-aid or medical care. Similarly, have been confirmed by an online survey of recrea- Schaefer (2000) reported an incidence of 17.1 injuries tional sailors using a variety of boats (Nathanson per 1,000 hours in novice Dinghy sailors; however, et al. 2006). In contrast, elite Olympic-class sailors when minor injuries (234 of 238) were excluded, experience more strains and sprains, considered the incidence of severe injuries was just 0.29 injuries to be as a result of repetitive and prolonged activi- per 1,000 hours. Therefore, focusing attention on the ties such as hiking and trimming (Legg et al. 1997b; risks of these 2% of injuries may be most effective Moraes et al. 2003), although these reports failed to in attenuating the impact of injury. There seems to include quantitative data. be a relatively high risk of severe injuries in wind- In windsurfing, the types of injuries are similar surfing (Ullis & Anno 1984), with 21% (9 of 43) of between elite (Allen & Locke 1989) and recreational one cohort of competitive male windsurfers having boardsailors (McCormick & Davis 1988), with abra- been admitted to the hospital for treatment at some sions (23–63% of athletes), lacerations (29–59%), point in their career. These severe injuries included and strains (19–59%) being most frequent. One sur- knee ligament sprains, vertebral fractures and disk vey of 107 windsurfers over a 2-year period (Dyson herniations, lacerations, ruptured knee ligaments, et al. 2006), reported muscle strains as the most shoulder dislocations, elbow epicondylitis, infected common injury in wave-slalom (32%), race-board- wounds, pneumothorax, carpal tunnel syndrome, ers (45%), and recreational windsurfers (30%). and eardrum perforation and were frequently asso- Lacerations and abrasions were also common for ciated with advanced maneuvers of wave-jumping wave-slalom windsurfers and ligament sprains for and wave-sailing (Dyson et al. 2006). In contrast, a recreational windsurfers. Forearm neuropathies study by McCormick and Davis (1988) found that (Ciniglio et al. 1990; Jablecki 1999) have also been of the 76% of recreational windsurfers with injuries reported in windsurfers, as a result of prolonged who were questioned, only 15% of the injuries were and repeated elbow flexion and forearm pronation severe (i.e., required medical treatment). Overuse (Dyson et al. 1996). neuropathies, such as lateral antebrachial cutane- During elite America’s Cup sailing, Neville ous syndrome (Jablecki 1999) and radial tunnel et al. (2006) found contusions, sprains, and tendi- syndrome (Ciniglio et al. 1990) have also been docu- nopathies to be the most frequent injury types. mented as severe windsurfing injuries. In off-shore racing (Bugge 1986; Price et al. 2002), Neuropathies and tendinopathies are not uncom- the majority of injuries are impact injuries, such mon in big-boat sailing (Neville et al. 2003, 2006; as contusions and lacerations (38–47%), fractures Molloy et al. 2005; Spalding et al. 2005). Neville (11–18%) and sprains (9–23%). Tendinopathies and et al. (2003) reported two incidents of posterior 198 chapter 16 interosseous-nerve entrapment (PINE) in one team are available on the risks of injuries in sailing, par- of 35 professional sailors during the 2-year prepa- ticularly relating to intrinsic factors such as sex, ration for the 31st America’s Cup (0.1 per 1,000 age, sailing experience, and conditioning. For the hours), with a mean consequence of 13 days absent extrinsic risk factors, apart from the class of boat from sailing and 37 days absent from weight-train- and the role of the athlete, the wind conditions ing for each incident. Similarly, wrist tenosynovitis have been shown to play an influential part in resulted in 15 days’ absence from sailing per inci- the physical and technical demands (Vogiatzis dent (Neville et al. 2006). Injuries resulting in the et al. 1995) and subsequent injury risk. greatest absence from America’s Cup sailing were chronic overuse injuries: cervical spine degenera- tion (21%), PINE (7%), lumbar spine abnormali- What Are the Inciting Events? ties (6%), and biceps tendinopathy (4%) (Neville et Identifying the inciting mechanisms of sailing al. 2006). Spalding et al. (2005) also reported that injuries is important in determining preventive- off-shore helmsmen were at risk of severe overuse reatment strategies. Although some activities in injuries (shoulder rotator-cuff impingement, wrist sailing are similar regardless of the class of boat, tenosynovitis, carpal tunnel syndrome), all of which many are specific, such as “hiking” (Olympic class affected their performance or participation. sailing) (Figure 16.1), “pumping” (Olympic-class sailing and windsurfing), “grinding,” and “steer- Sailing Fatalities ing” (big-boat sailing). In elite Olympic-class sail- ing (Legg et al. 1997b; Shephard 1997; Newton Although relatively uncommon, fatal incidents have 1989), prolonged hiking is the main cause of knee been reported in both elite and recreational sailing. injury, particularly when the knee is in sustained A total of five fatalities have occurred during the past flexion (Newton 1989). A substantial number of nine Volvo Ocean Races (formerly, the Whitbread cases (23) of radial-nerve syndrome were reported Ocean Race), mostly as a result of being washed by Ciniglio et al. (1990) as a result of prolonged overboard in rough sea conditions. The Canadian elbow flexion and forearm pronation while pump- national boating fatalities report between 1996 and ing the sail when windsurfing. A similarly complex 2000 (LifesavingSociety 2003) reported that 4% insidious elbow injury, termed “grinder’s elbow” (32 of 888) of all water-related deaths were due to by Miller (1987) and later diagnosed as PINE sailing, whereas an Australian national analysis of by Neville et al. (2003), appears to be the result fatal boating incidents reported that 36% (86 of 241) of excessive repetitive grinding and top-handle of fatalities occurred while Dinghy sailing (O’Connor winching on America’s Cup–class boats. Steering 2008). ISAF recently legislated on the use of quick- or “helming” is typically regarded as one of the release harnesses during competition after several least-demanding activities in most sailing classes; entrapment incidents and three fatalities involving however, in off-shore racing, particularly in heavy Dinghy trapeze harnesses (Thorn 2007). weather conditions of the Southern Ocean, it is one of the more arduous activities, predisposing helms- What Are the Risk Factors? men (89%) to upper-limb overuse injuries (Spalding et al. 2005). In sailing, the causal factors predisposing an ath- lete to injury are often difficult to determine, as a Equipment large proportion of injuries are insidious and occur as a result of complex interactions of various risk As sailing relies on the interaction between ath- factors. Most often, the risk of injury is the result lete and hardware, and often in unstable and of an interaction between an athlete’s physical and unpredictable conditions, it is not surprising that psychological characteristics and the environment equipment is a major contributing factor to many (van Mechelen et al. 1992). Very few analytical data injuries. In particular, recreational and novice sailors sailing 199
(Schaefer 2000; Nathanson et al. 2006) are at greatest knee to injury (Newton 1989; Legg et al. 1997b; risk of injury as a result of impact with hardware Shephard 1997; Bojsen-Moller et al. 2007). In certain (22–51%), most notably, the boom or mainsheet classes, such as Finn sailing it is extremely difficult (31%) (Schaefer 2000). Other severe but less com- to maintain a straight-leg position when hiking, mon injuries occur during lowering of the keel in which results in greater forces being exerted on the the boat (hand/finger lacerations and fractures). knee joint (Newton 1989). In other classes, in which Hence, it is these areas in which the greatest invest- straight-leg hiking is predominantly performed, ment of preventive resources should be allocated. such as in Laser sailing, greater loads are placed on Adverse interactions with equipment are also the quadriceps muscles and on the lumbar spine responsible for a high proportion (45%) of windsurf- (Newton 1989; Cockerill 1999; Mackie et al. 1999; ing injuries (Nathanson & Reinert 1999)— for exam- Bojsen-Moller et al. 2007). However, there are few ple, falling with feet caught in the foot straps, or data to suggest any increased risk of quadriceps impact with the center board, skeg or mast (Ullis & injury in sailors. Foot placement is also impor- Anno 1984; Allen & Locke 1989; Nathanson & tant when hiking, as internal rotation of the leg Reinert 1999; Dyson et al. 2006). The boom shape promotes overdevelopment of the vastus lateralis and diameter has also been suggested to contribute muscle (Cockerill & Taylor 1998), increasing lateral to forearm overuse injuries in windsurfing (Ciniglio tracking of the patella and predisposing the athlete et al. 1990; Jablecki 1999). Depending on hand size to chronic knee pain (e.g. chondromalacia patella). and grip strength, a larger-diameter boom requires In big-boat sailing, incorrect grinding technique greater grip strength, which could prematurely has been postulated as a risk factor for upper-limb fatigue forearm muscles. Athletes’ trapeze har- overuse injuries (Neville et al. 2003; Molloy et al. nesses have also been associated with a number of 2005), particularly if the upper extremity, rather fatalities and entrapment incidents in Dinghy sail- than the lower extremity and trunk, is relied on as ing (Thorn 2007). the force generator. Similarly, off-shore helmsmen In America’s Cup sailing (Neville et al. 2006), who steer with the upper arm in shoulder flexion impact with boat hardware accounts for 15% of and abduction are at greater risk of supraspinatus all injuries, with pulling and lifting sails account- impingement injury, where as those adopting an ing for a further 5%. Low grinding pedestals have adducted shoulder position with elbow flexion are also been suggested to increase the risk of lumbar at greater risk of wrist tenosynovitis (Spalding et al. spine injuries in grinders (Allen 1999; Neville et al. 2005). Furthermore, most activities performed 2006). A third of all off-shore racing injuries occur in big-boat sailing require forward flexion of the below deck (Price et al. 2002; Spalding et al. 2005), spine with repetitive lumbar rotation and often because of the greater volume of time spent below during strenuous exercise and high load conditions deck and the violent and sudden movements of the (Neville et al. 2006), thereby placing the structures yachts during heavy weather. In addition, Spalding of the lumbar spine under tremendous strain and et al. (2005) reported that all helmsmen with carpal increased risk of injury (Bono 2004). tunnel syndrome (17% of helmsmen) used polished carbon steering wheels, as opposed to fabric-grip wheels as were used by the noninjured helms- Injury Prevention men. The smooth surface requires the helmsmen to One of the most important topics in sport is that of grip the wheel harder, particularly when wet, thus injury prevention. The literature on sailing-injury increasing forearm stress. prevention is restricted to a few informative descrip- tive reports and expert opinions (Blackburn 1994; Cockerill & Taylor 1998; Cockerill 1999; Scott 2001; Technique Crafer 2004), with no published intervention stud- In elite Olympic-class sailing, poor hiking tech- ies. Hence, there is a need for well-controlled stud- nique and inadequate strength can predispose the ies on injury-prevention measures to understand 200 chapter 16 the effectiveness of proposed interventions. A injuries can enable prudent distribution of preven- number of proposed injury-prevention strategies tive resources. requiring further research are discussed in the fol- With the notable risk of overuse injuries in sail- lowing section. ing, consensus as to the definition of acute and chronic injuries is also required. In the classifica- tion of sprains and strains, the nature of injury Further Research should be based on the inciting events, regard- The aim of this chapter has been to identify the less of the type of injury. For example, an acute incidence, distribution and risk factors of sailing injury should be defined as an injury resulting injuries. The scarcity of analytical studies, espe- from a specific, single traumatic event, whereas a cially of Olympic-class sailing, is of concern. Little chronic injury should be defined as resulting from has changed in the past decade, since Allen (1999) a gradual development of symptoms through over- called for sports medicine clinicians to collect use or prolonged exposure (Peterson & Renstrom injury data from Olympic sailors. In fact, to date, 2001). there have been no prospective analytical stud- The risk of injury in sailing is largely unknown, ies published in the English language literature on as only one prospective study to date has competitive Olympic-class sailing injuries. included exposure data (Neville et al. 2006). This review of the sailing injury literature under- Researchers are therefore encouraged to accu- scores the necessity for injury surveillance at all rately collect exposure data so as to determine the levels, from junior through to the elite Olympic actual risk and incidence of injury (Knowles et al. classes. In particular, prospective data collection is 2006). Sailing exposure should be reported as required, in which the diagnosis of injury is con- the total number of hours of sailing, from when firmed by sports medicine clinicians rather than by the first sail is hoisted until when the last sail is the athlete or coach. A major issue highlighted by dropped. this review is the variation in methods and defini- A number of questions have been highlighted tion of injury used by studies. by this literature review, which may help to direct Neville et al. (2006) used an injury defini- future research: tion similar to that adopted by other professional sports—“any incident occurring as a direct result of • What are the distribution, incidence, and sever- scheduled sailing or training causing pain, disability ity (in terms of time loss) of injuries in Olympic- or tissue damage, resulting in at least one treatment class sailing? from a medical officer”—thereby precluding minor • What, if any, are the differences in rates and ailments, medical advice, consultations, soft-tissue characteristics of injuries between the Olympic massage, and nonspecific treatments that did not classes? meet this criterion. • Are there differences in the incidence and nature Sailing-injury surveillance should avoid incor- of training and competition injuries? porating mixed definitions of injury; hence, a sail- • What are the long-term health effects of sailing ing injury should be defined as either a “medical injuries? In particular, is there any evidence of attention injury,” requiring medical attention from chronic lumbar spine degeneration as a result of a qualified medical practitioner, or a “time-loss sailing activities? injury,” resulting in a specified number of days’ • What are the risks and nature of injuries in junior absence from sailing participation. Severity statistics sailors? should be included when possible to identify • Do psychological stress, personality, and atti- the injuries at greatest risk of affecting perform- tude (Halliwell 1989; May 2000) influence sail- ance, participation, or health (van Mechelen 1997). ing injury during repeated races or regatta Moreover, an understanding of the severity of formats? sailing 201
• Do body composition and somatotype (which ᭺ protective clothing, such as helmets, gloves, are specific to the class and position of the athlete shoes or booties (McCormick & Davis 1988; (Legg et al. 1997a; Bojsen-Moller et al. 2007; Dyson et al. 2006). Shephard 1990) correlate to injury risk? ᭺ effective mechanism of foot-strap release • Is there any evidence of hyperthermia, hypother- (Dyson et al. 2006) mia, or dehydration affecting performance and ᭺ smaller boom grip size for female windsurfers injury rates in sailing? (Allen & Locke 1989) • Do strength, fitness, flexibility, or muscle imbal- ᭺ windsurfing harness with a quick-release sys- ances influence injury, in particular, hamstring: tem and a polychloroprene lower back brace to quadriceps strength ratio deficit (Bojsen-Moller provide additional trunk support (Dyson et al. et al. 2007), weak abdominal muscles and short- 2006) ened hip flexor muscles (Blackburn 1994), poste- ᭺ improved design and friction on the grip of off- rior:anterior shoulder strength imbalance (Kibler shore steering wheels (Spalding et al. 2005) & Garrett 1997; Neville et al. 2003, 2006)? ᭺ improved ergonomics below deck on off-shore • Is there any evidence of intrinsic injury- racing yachts (Spalding et al. 2005) prevention strategies reducing the risk of inju- ᭺ higher grinding pedestals to reduce the degree ries? With particular reference to the following: of lumbar flexion (Allen 1999; Neville et al. 2006; ᭺ the position of the feet during hiking (Cockerill Neville Pain & Folland 2009). 1999) ᭺ the frequency and amplitude of pumping in The success of injury prevention in sports windsurfing (Guevel, Hogrel & Marini 2000) is largely due to the level of support given to ᭺ the contribution of the lower-limbs for force the athlete, which includes coaching, sports generation during grinding (Neville et al. 2003; science, medical, psychological, and social Molloy et al. 2005) support. Multidisciplinary support staff struc- ᭺ the dynamic use of the whole body when off- tures are common in professional sailing teams shore steering (Spalding et al. 2005) (Neville et al. 2006); however, sailors at all lev- ᭺ adopting a supinated hand-grip position on els would benefit from the support of informed the boom to relieve forearm neuropathy syn- personnel in the prevention of injuries (Allen & dromes in windsurfing (Ciniglio et al. 1990) De Jong 2006). A greater amount of medical ᭺ increasing the resilience of high-risk body support should be directed toward injury pre- regions through specific strength training vention and not limited to the treatment of (Zelhof 1990), prime examples are: the forearms acute trauma. of grinders and off-shore racing helmsmen, the In conclusion, sailors of all classes of sailing and shoulders of Olympic-class and big-boat sail- level of ability seem to be at risk of injury, and thus ors, the knees of hiking sailors and the lower to maximize the enjoyment and competitive level of back and abdominals of all sailors (Rovere the sport, there is an irrefutable need for informa- 1987; Blackburn 1994). tive scientific research of sailing injuries and injury- ᭺ monitoring sailing volume and intensity in mana- prevention strategies. Successful research requires ging recovery (Neville et al. 2008). a multidisciplinary team including coaches, sports ᭺ the role of nutrition and hydration in prevent- scientists, and sports physicians, as well as the ing fatigue and dehydration (Burke 2003; Slater athletes. The research process should be driven by & Tan 2007; Tan & Sunarja 2007; Neville, Gant ISAF, the National Governing Bodies of sailing, as & Folland 2009). well as local yacht clubs, parents, and the athletes. • Is there any evidence of extrinsic injury- Only through increasing our knowledge of the prevention factors reducing the risk of injuries? sport will athletes be free to achieve their quest for With particular reference to the following: sailing enjoyment and success. 202 chapter 16
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Soccer (Football)
CAROLYN A. EMERY Sport Medicine Centre, Faculty of Kinesiology, Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
Introduction soccer and includes 208 national associations (FIFA 2008a). Soccer is the world’s most popular organized sport, Soccer was introduced as an exhibition sport and with an estimated 265 million players (90% male, the first team sport included in the Olympic Games 10% female) participating worldwide in 2006 (FIFA sport in 1900 and 1904 respectively (IOC 2008). 2007). This is an overall 10% increase in participa- Since 1908, soccer has been played in every summer tion since 2000, with the greatest increases in par- Olympic Games. By the 1920s, however, professional ticipation in youth (32%) and girls (19%) over 6 leagues had evolved so that the Olympic Games, years of age (FIFA 2007). In some countries, such as then restricted to amateur athletes, no longer repre- Canada, the increase in soccer participation over 20 sented the highest level of competition in the world years of age has been as much as 300% (Canadian (FIFA 2008a). The first FIFA World Cup was held Soccer Association 2007). in Uruguay in 1930 and is held every 4 years (FIFA The game of soccer evolved during the late 19th 2008a). century in England from a variety of ball games Participants in organized soccer cross all age involving both handling and kicking the ball. In groups, levels of play from recreational to profes- 1863, the London Football Association officially sional, ethnicities, and socioeconomic levels. Soccer split the game of football into rugby football, in is a sport that requires little equipment and offers which handling and carrying the ball was allowed, numerous potential benefits related to physical- and association football, which banned the use of activity participation and resultant health outcomes, the hands. The Football Association established both physical and psychosocial. Soccer is, however, a the first set of official rules for soccer (FIFA 2008b). collision/contact sport, and its participants are sus- In 1888, 12 clubs from England founded the ceptible to the risk of injury. The incidence of injury Football League, the first professional league com- in soccer is high, with reported rates of 10 to 35 petition (FIFA 2008b). In 1904, with representation injuries per 1,000 game-hours in adult men’s soccer from seven European soccer associations (France, (Dvorak & Junge 2000) and 10–70 injuries per 1000 Belgium, Denmark, the Netherlands, Spain, game hours in adult women’s soccer (Steffen 2008). Sweden, and Switzerland), a governing body Consistently, lower extremity injuries account for the for the sport was organized in Paris, called the majority of injuries in soccer at all levels ( 80%). Fédération Internationale de Football Association Soccer injuries may significantly impact qual- (FIFA). Now FIFA is the world governing body for ity of life. Reduction of soccer injury would have a major impact on quality of life through the main- tenance and promotion of active living. For exam- Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 ple, it is estimated that 8% of youths drop out of Blackwell Publishing, ISBN: 9781405173643 sport and recreational activities because of injury 204 soccer (football) 205
(Grimmer et al. 2000). There is epidemiologic evi- Games. This comprehensive review of the literature dence that level of physical fitness is a significant will examine injury incidence, descriptive epidemi- predictor of all-cause mortality, morbidity, and ology, mechanisms of injury, outcomes of injury, disease-specific morbidity (Blair 1993; Blair et al. risk factors for injury, and injury-prevention stra- 1995; Jebb & Moore 1999; Paffenbarger et al. 1994) tegies in competitive soccer. This review will in- and that physical-activity patterns track from early clude a summary of recommendations for future to later life (Must et al. 1992; Nieto et al. 1993). The research examining risk factors and prevention prospect of injury or incomplete recovery from strategies for injury in soccer. These recommenda- injury affects the ability to participate in sport and tions will include methodologic considerations for recreational activities that would be beneficial to future research. health. Injuries have also been documented to be a The most challenging element in comparing re- leading cause of the development of osteoarthritis search in this area is the inconsistency in injury in later life (Roos et al. 1998; Drawer & Fuller 2001; definitions and injury-severity definitions. A meth- Englund et al. 2003; Lohmander 2004; von Prat odologic consensus statement was published in et al. 2004; Koh & Dietz 2005; Myklebust & Bahr 2006 to identify definitions and methods to ensure 2005; Roos 2005). There is a significant public health consistency and comparability of results in studies cost associated with these injuries, the future devel- examining injury in soccer (Fuller et al. 2006). For opment of osteoarthritis, and other diseases asso- the purpose of this review, a consensus statement ciated with decreased levels of physical activity on injury definitions and data-collection procedures (Angus et al. 1998). in studies of soccer injuries will be considered in the There are previous comprehensive reviews of evaluation of the epidemiologic literature reviewed the literature examining the epidemiology of inju- (Fuller et al. 2006). To facilitate comparisons between ries in soccer. Inklaar (1994a, 1994b) concluded that studies, an attempt will be made to use the pro- the epidemiologic evidence regarding soccer injury posed definitions based on this consensus statement is inconsistent and far from complete. Larsen et al. when possible. As such, an injury will be defined as (1996) also concluded that the evidence reported any physical symptom sustained by a player that was inconsistent because of inconsistencies in results from a football match or football training, injury definitions and surveillance methods. Olsen irrespective of the need for medical attention or time et al. (2004) examined strategies for prevention of lost from football. An injury that results in a player soccer injuries and concluded that while some receiving medical attention by a qualified medical strategies to prevent injuries in elite soccer look practitioner is referred to as a “medical-attention” promising, weak research design has led to inad- injury. An injury that results from a player being equate evaluation. Steffen (2008) has examined unable to take full part in future football training or the epidemiology of injury in women’s soccer and match play is referred to as a “time-loss” injury. concluded that there are few prospective studies examining risk factors, mechanisms of injury, and Who Is Affected by Injury? prevention strategies for injury. In addition, she suggested that a multivariate approach to risk was The estimated 265 million players participating in rarely examined. Despite the significant contribu- soccer worldwide in 2006 (FIFA 2007) represent tion of these epidemiologic reviews of the litera- players from recreational through elite and interna- ture, a comprehensive review of the literature has tional professional players. Organized soccer begins not been completed examining all aspects of epide- as young as age 3 in some countries. Few data exist miology of injury in soccer in the past 10 years. on injury for this very young age group; however, As such, the purpose of this chapter is to exam- with soccer participation comes the potential for ine the epidemiology of injury in competitive soccer injury. Soccer injuries can occur in any par- adult levels of soccer. The focus will remain on ticipant, regardless of age, sex, or level of play. The outdoor soccer, which is played in the Olympic overall rates of injury by sex, age group, regular Table 17.1 Incidence of injury in elite male, female, and tournament soccer players.
Study Study Design Population (sex, age, Sample Size or Injury Definition (country, yr) level of play, other) Denominator Data
Adult Male Agel et al. (2007) Descriptive (USA, Male college (NCAA) 22,000 G and Medical attention 1988–2003) 15 yr 62,000 P (physician or certified athletic trainer) and time loss or restricted performance 1 day any dental injury Albert (1983) Descriptive (USA, Male professional 56 players Medical attention 1979–1981) (ages 19–38) 3 outdoor (physician) or seasons time loss Arnason (1996) Cohort (Iceland, 1991) Men’s elite (ages 84 players Time loss 18–34) 1 season
Drawer & Fuller Cohort (Britain, Male professional 87,529 player-hr Time loss (2002) 1994–1997) 2.5 yr
Engstrom et al. (1990) Cohort (Sweden) Male (elite) 1 season 64 Time loss
Hawkins et al. (2001) Cohort (Britain, Male (91 professional n 2,376 Time loss 1997–1999) football clubs) 2 yr 2 days
Hagglund et al. Cohort (Sweden, Male (ages 17–38, top n 525 Time loss (2006) 2001–2002) elite divisions) 1 year
Inklaar et al. (1996) Cohort (The Netherlands Adult youth (male, n 477 Time loss 1986–1987) elite amateur, ages (adult 245, 13–60) 1 season youth 232)
Luthje et al. (1996) Cohort (Finland, 1993) Adult (male, elite, ages n 263 Medical attention 17–35) 1 season Nielsen et al. (1989) Cohort (Denmark) Youth adult (male, Adult, 93 Youth, Time loss ages 16–adult. Club 30 soccer various levels) 1 season Peterson et al. (2000) Cohort (Switzerland) Adult youth (age n 264 All groups: adult, 16–18, 14–16; all levels: high through low) 1 yr Poulsen et al. (1991) Cohort (Denmark 1986) Adult (male, 21–30, n 55 Time loss varying levels ) 1 yr
Walden et al. (2005) Cohort (Europe, Professional (male; n 266 Time loss 2001–2002) mean age, 26) 1 season Data-Collection No. of Injuries Game Incidence Practice Incidence Total Incidence Rate Method Rate (95% CI) [no. Rate (95% CI) [no. of (95% CI) [no. of of injuries per injuries per 1,000 hr or injuries per 1,000 hr 1,000 hr unless AEs] or AEs] specified AEs]
Injury surveillance G 6,693 P 6,281 18.75 (18.3 –19.2) 4.34 (4.24–4.45) [AE] system (athletic [AE] trainer)
Injury surveillance Outdoor 106 1981 outdoor season system (athletic 10.1 (6.48–14.99) trainer) [AE] Injury surveillance 85 34.8 5.9 (physical therapist, physician or coach) Injury surveillance 744 8.5 (club senior physiotherapist) Injury surveillance 85 24 7 (athletic trainer) Injury surveillance 6,030 25.9 3.4 (team medical practitioner) Injury surveillance 1,189 (2001) 25.9 (22.8– (2001) 5.1 (4.6–5.6) (2001) 7.6 (7.1–8.3) (physician or physical 29.2) (2002) 22.7 (2002) 5.3 (4.7–5.8) (2002) 7.6 (7.0–8.3) therapist) (20.0–25.8) Interview 83 13–14 yr, 12.8 15–16 yr, 16.1 17–18 yr, 28.3 Adult, 15.8 Injury surveillance 236 (outdoor only) 16.6 1.5 (physician) Injury surveillance Adult 82 High-level adult, High-level adult, 2.3 (physician) 18.4 Lower-level Lower-level adult, 5.6 adult, 11.9
Injury surveillance 558 Adult high to Adult high to low Adult high to (physician) low level, range: level, range: 6.5–28.5 low level, range: 18.6–29.3 18.6–29.3
Interview biweekly 56 Highest division, Highest division, 4.07 (study physician) 19.76 Middle Middle divisions, 5.69 divisions, 20.69 Injury surveillance 658 30.5 (23.1–37.9) 5.8 (3.6–6.4) 9.4 (7.3–11.5) (physician) (continued) Table 17.1 (continued)
Study Study Design Population (sex, age, Sample Size or Injury Definition (country, yr) level of play, other) Denominator Data
Adult Female Dick et al. (2007) Descriptive (USA, Women’s college 20,447 G and Medical 1988–2003) (NCAA) 54,750 P attention 15 yr (physician or certified athletic trainer) and time loss or restricted performance 1 day any dental injury (1994 onward) Engstrom et al. (1991) Cohort (Sweden) Female (age 21 yr, elite) n 41 Time loss 1 yr
Faude et al. (2005) Cohort (Germany, Female (ages 17–27, n 165 Time loss 2003–2004) elite, national league) 11 mo Giza et al. (2005) Cohort (USA 2001–2003) Female (age not n 202 Time loss reported, elite) 2 5 mo Jacobson & Tegner Cohort (Sweden, 2000) Female (ages 16–36, n 269 Time loss (2007) premiere league) 10 mo Ostenberg & Roos Cohort (Sweden, 1996) Female (ages 14–39) n 123 Time loss (2000) 7 mo
Soderman et al. Cohort (Sweden, 1998) Female (ages 20–25, n 146 Time loss (2001) elite) 7 mo
Tournament Dvorak et al. (2007a) Cohort (Germany, 2006) Male (FIFA World Cup, 2111 tournament Medical attention tournament) player hours (team physician)
Junge (2004c) Cohort (international, Male female 10,155 player-hr Medical 1998–2001) tournament (12 attention time international) loss
Junge (2004b) Cohort (international, Male (international 2,111 player-hr Medical attention 2002) tournament) Junge et al. (2006) Cohort (international, Male and female Medical attention 2004) Olympic Games
Junge & Dvorak Cohort (international, Female tournament 5742 player-hr Medical attention (2007) 1999–2006) (7 international) Walden et al. (2007) Cohort (Europe, MS Championship, WS MS 368 Medical attention 2004–2005) Championship, MU WS 160 MU Championship 144
AE athlete-exposure; G player-games; MS Men’s Senior; MU Men’s U-19; P player-practices; WS Women’s Senior. Data-Collection No. of Injuries Game Incidence Practice Incidence Total Incidence Rate Method Rate (95% CI) [no. Rate (95% CI) [no. of (95% CI) [no. of of injuries per injuries per 1,000 hr or injuries per 1,000 hr 1,000 hr unless AEs] or AEs] specified AEs]
Injury surveillance G 5,373 P 5,836 16.44 (16.0 –16.88) 5.23 (5.09–5.36) [AE] system (athletic [AE] trainer)
Injury surveillance 78 24 7 system (medical student) Injury surveillance 241 23.3 2.8 6.8 system (physical therapist, physician) Injury surveillance 173 12.6 1.2 1.9 system (physician)
Interview by primary 237 13.9 2.7 4.6 investigator weekly
Injury surveillance 65 14.3 3.7 6.6 system (physical therapist) Injury surveillance 80 Acute. 10.0 Acute. 1.3 Acute. 5.5 system (physical therapist)
Injury surveillance 145 68.7 (57.5–79.9) (team physician)
Injury surveillance 901 All, 88.7 (physician) Time loss, 35 Men, 53–191 Women, 39–64 Injury surveillance 171 81.0 (physician) Injury surveillance Men, 77 Women, 45 Men, 73 (57–89) (physician) Women, 70 (50–90) Injury surveillance 387 67.4 (60.7–74.1) (physician) Injury surveillance MS, 40 WS, 17 MS, 36.0 MS, 2.1 (physician) MU, 16 WS, 36.0 WS, 2.5 MU, 30.4 MU, 2.9 210 chapter 17
Figure 17.1 Women’s elite soccer is gaining in popularity. © IOC / Steve MUNDAY.
season and tournament play, session type (i.e., with men’s competition. In practice (training) practice, game) are summarized in Table 17.1. Only the rates of injury reported are similar for men studies reporting injury rates per 1000 player-hours and women. In men’s elite tournament play, the or 1000 athlete exposures are reported. In addition, injury rates reported range from 36 to 89 injuries studies relying solely on self report have not been per 1,000 player-hours (Junge 2004b,c; Junge et al. included. Only studies in which a method of injury 2006; Walden et al. 2007). In women’s elite tour- surveillance is in place are reported. In addition, nament play, the reported injury rates range from only studies which identify injuries as “time loss” 36 to 70 injuries per 1,000 player-hours (Junge, or “medical attention” injuries as per consensus 2004c, 2006; Walden et al. 2007). These data sug- definition will be included (Fuller et al. 2006). gest that in tournament play, injury rates are higher The reported incidence of injury in elite ama- than in regular season play for both men and teur (including college) and professional men’s women. soccer ranges from 17 to 35 injuries per 1,000 player-hours in regular season game play and Where Does Injury Occur? 2 to 7 in regular season practice (Nielsen et al. 1989; Engstrom et al. 1990; Poulsen et al. 1991; Anatomical Location Arnason 1996; Luthje et al. 1996; Peterson et al. 2000; Hawkins, Hulse & Wilkinson 2001; Hagglund Lower-extremity injuries accounted for 67% to et al. 2006; Walden et al. 2005; Agel et al. 2007). In 88% of all injuries reported in men’s and women’s elite amateur (including college) women’s soc- soccer, regardless of whether it was regular-season cer (Figure 17.1) the reported incidence of injury or tournament play (Table 17.2). Upper-extremity ranges from 13 to 24 injuries per 1,000 player-hours injuries, on the other hand, accounted for only in regular season game play and 1 to 7 in regu- 2% to 15% of all injuries in all age groups in both lar season practice (Engstrom et al. 1991; Faude men’s and women’s leagues. Consistently, the most et al. 2005; Giza et al. 20052007; Ostenberg & frequently injured body parts were the ankle, knee, Roos 2000; Soderman et al. 2001; Dick et al. 2007; and thigh across all age groups and both sexes Jacobson & Tegner). Overall, the reported rates of (Table 17.2). By sex, it appears that in elite women’s injury in regular-season game play are slightly regular season play, the proportion of total injuries lower in elite women’s competition as compared accounted for by knee injuries typically exceeds soccer (football) 211 that of groin and thigh injuries (Engstrom et al. When Does Injury Occur? 1991; Ostenburg & Roos 2000; Soderman et al. 2001; Giza et al. 2005), whereas the opposite is true for Injury Onset male elite players (Albert 1983; Poulsen et al. 1991; Given the nature of the sport (i.e., speed, pivot- Luthje et al. 1996; Peterson et al. 2000; Drawer & ing, jumping, collisions) it is not surprising that Fuller 2002; Walden et al. 2005; Haglund et al. the majority of soccer injuries reported in relevant 2006). The same is true for elite men’s tournament studies were acute in nature. In the studies that play (Junge et al. 2004b; Dvorak et al. 2007; Walden defined overuse injuries specifically, they were cat- et al. 2007); however, in elite women’s tournament egorized as a pain syndrome of the musculoskel- play, groin and thigh injuries appear to account etal system with insidious onset and without any for a similar proportion of injuries as knee injuries known trauma or disease that might have caused (Junge 2006, 2007). previous symptoms (Walden et al. 2005; Hagglund Head and neck injuries accounted for 3% to 18% et al. 2007). In men’s elite soccer, acute-onset inju- of all injuries in elite men’s soccer (Albert 1983; ries accounted for 63% to 94% of injuries (Arnason Luthje et al. 1996; Peterson et al. 2000; Hawkins 1996; Luthje et al. 1996; Peterson et al. 2000; Walden et al. 2001; Walden et al. 2005; Hagglund et al. 2006; et al. 2005; Hagglund et al. 2006). In women’s elite Agel et al. 2007) and 7% to 18% in elite women’s soccer, acute-onset injuries accounted for 69% to soccer (Faude et al. 2005, Giza et al. 2005, Dick et 84% of injuries (Engstrom et al. 1991; Ostenberg & al. 2007; Jacobson & Tegner 2007) during the regu- Roos 2000; Soderman et al. 2001; Faude et al. 2005; lar season. In tournament play, head and neck inju- Giza et al. 2005; Jacobson & Tegner 2007). ries accounted for up to 21% and 33% in men and women, respectively (Maehlum et al. 1999; Junge et al. 2004c). Head and neck injury rates reported in Chronometry men’s and women’s elite soccer were 1 to 1.8 inju- Time in Game ries per 1,000 player-hours (Hawkins & Fuller 1999; Elias 2001; Faude et al. 2005; Agel et al. 2007; Dick Walden et al. (2007a) reported a significantly et al. 2007). It should be noted, however, that con- higher proportion of noncontact injuries in the cussion often goes unreported. Delaney et al. (2002) second half of elite tournament play. Tscholl et al. reported that while 63% of varsity soccer and foot- (2007a), however, found no significant differences ball players reported signs and symptoms related between the 1st and 2nd half of the game in elite to a concussion, only 20% realized that they had tournament play; however, non-contact injury was sustained a concussion. not reported in this regard. Tscholl et al. (2007a) also reported a 2.5-fold increased risk of injury in the last 15 minutes of the second half of knock-out matches in tournament play. Junge & Dvorak 2007a did not Environmental Location find any difference in injury risk in the first as com- Overwhelmingly, the incidence of injury reported pared with the second half of elite women’s tourna- in soccer is clearly much higher during games than ment play; however, they did report fewer injuries in practice at all levels of play (Table 17.1). The in the first 15 minutes of play in both the first and increased risk of injury in games as compared with second half of tournament games. training ranges from 3- to 1-fold in studies across both sexes and all age groups. Time of Season Some studies have examined the risk of injury on natural grass as compared with artificial turf. Agel et al. (2007) reported the greatest rates of These findings will be discussed further, along injury across 15 years of men’s collegiate soccer in with other risk factors, in the “What Are the Risk the preseason as compared with the regular season Factors” section. (Incidence Rate Ratio, [IRR] 3.3; 95% confidence 212 chapter 17
Table 17.2 Anatomical location of injury (%) in elite male, female, and tournament soccer players.
Study Study Design Population (sex, age, Sample Injury Definition (country, yr) level of play, other) Size or Denominator Data
Adult Male Agel et al. (2007) Descriptive (USA, Male college (NCAA) 22,000 G Medical attention (physician 1988–2003) 15 yr and 62,000 or athletic trainer) and P time lost or restricted performance 1 day any dental injury Albert (1983) Descriptive (USA, Male Professional (ages 56 players Medical attention (physician) 1979–1981) 19–38) 3 outdoor seasons or time loss Arnason (1996) Cohort (Iceland, Men’s elite (ages 18–34) 84 players Time loss 1991) 1 season
Drawer & Fuller Cohort (Britain, Male Professional 87,529 Time loss (2002) 1994–1997) 2.5 yr player-hr Hawkins et al. Cohort (Britain, Male (91 professional n 2376 Time loss 2 days (2001) 1997–1999) football clubs) 2 yr Hagglund et al. Cohort (Sweden, Male (ages 17–38, top n 525 Time loss (2006) 2001–2002) elite divisions) 2 yr Luthje et al. (1996) Cohort (Finland, Adult (male, elite, ages n 263 Medical attention 1993) 17–35) 1 season Nielsen et al. Cohort (Denmark) Youth adult (male, Adult 93 Time loss (1989) ages 16–adult. Club Youth 30 soccer various levels) 1 season Peterson et al. Cohort Adult Youth (age n 264 All (2000) (Switzerland) groups: adult, 16–18, 14–16, all levels: high through low) 1 yr Poulsen et al. Cohort (Denmark Adult (male, 21–30, n 55 Time loss (1991) 1986) varying levels) 1 yr Walden et al. Cohort (Europe, Professional (male, mean n 266 Time loss (2005) 2001–2002) age 26) 1 season Adult Female Dick et al. (2007) Descriptive (USA, Women’s college 20,447 G and Medical attention (physician 1988–2003) (NCAA) 15 yr 54,750 P or athletic trainer) and time lost or restricted perform- ance 1 day any dental injury (1994 onward) Engstrom et al. Cohort (Sweden) Female (21 yr, elite) n 41 Time loss (1991) 1 yr Faude et al. (2005) Cohort (Germany, Female (ages 17–27, elite, n 165 Time loss 2003–2004) national league) 11 mo Giza et al. (2005) Cohort (USA Female (age not n 202 Time loss 2001–2003) reported, elite) 2 5 mo Jacobson & Tegner Cohort (Sweden, Female (ages 16–36, n 269 Time loss (2007) 2000) premiere league) 10 mo soccer (football) 213
Anatomical Injury Location (game/practice when known)
Head/Neck Trunk/Back Upper Hip/Groin Thigh Knee Lower Leg Ankle Foot Other Extremity
12.8/4.8 10.5/13.9 6.8/5.3 67.3/70.7 NA NA NA NA NA 2.6/5.3 (all LE injury)
8.5 7.6 5.7 10.4 21.7 17 4.7 24.5
16 13 hamstring ankle sprain 10.8 22.2 15.2 13 16
7 ( spine) 2 ( spine) 3 12 23 17 12 17 6 20
2001/2002 7/9 2/2 7/9 23/22 15/18 16/10 10/9 7/8 3/3 9 9 6 2 22 19 8 17 8
14.8 22.2 37 7.4 18.5
3.6 head 5.9 back 5.4 7.3 groin 14.5 17.7 9.5 20.4 10 5.6
10.5 17.5 22.8 1.8 19.3 21.1 7
3 6 12 23 20 11 14 5.5 5.5
13.8/3.9 8.4/13.2 6.3/4.2 67.8/ 72 NA NA NA NA NA 3.7/6.7 (all LE injury)
3.8 6.4 15.4 23 9 25.6 9 7.7
6.6 7.5 5.3 6.2 18.3 18.7 8.2 17.8 11.2
10.4 12.8 7.5 5.5 6.9 31.8 6.5 9.3 9.3
4.7 12.7 0.34 4.8 11.4 15.3 12.2 28.4 10.5
(continued) 214 chapter 17
Table 17.2 (continued)
Study Study Design Population (sex, age, Sample Injury Definition (country, yr) level of play, other) Size or Denominator Data
Adult Female Ostenberg & Roos Cohort (Sweden, Female (ages 14-39) 7 n = 123 Time loss (2000) 1996) months Soderman et al. Cohort (Sweden, Female (ages 20–25, elite) n 146 Time loss (2001) 1998) 7 mo Tournament Dvorak et al. Cohort (Germany, Male (FIFA World Cup, 2,111 Medical attention (team (2007) 2006) tournament) tournament physician) player-hr Junge et al. (2004c) Cohort Male female 10,155 player Medical attention time loss (International, tournament hours 1998–2001) (12 international) Junge (2004b) Cohort Male (international 2,111 player Medical attention (International, tournament) hours 2002) Junge et al. (2006) Cohort Male and female Medical attention (International, Olympic Games 2004) Junge & Dvorak Cohort Female tournament 5,742 Medical attention (2007) (International, (7 international) player-hr 1999–2006) Walden et al. Cohort (Europe, MS Championship, MS 368 Medical attention (2007) 2004–2005) WS Championship, WS 160 MU Championship MU 144
AE athlete-exposure; G player-games; LE xxxxx; MS Men’s Senior; MU Men’s U-19; NA not available; P player-practices; interval [CI], 3.1–3.5) and in the regular season as are muscle strains, ligament sprains and contusions. compared with the postseason (Incidence Rate Ratio, There is some indication that the greatest propor- [IRR] 1.3; 95% CI, 1.1–1.5)]. Dick et al. (2007) reported tion of injuries was ligament sprain (33–66%) in similar findings across 15 years of women’s collegiate most studies in women’s soccer (Engstrom et al. soccer, with the greatest rates of injury in the presea- 1991; Soderman et al. 2001; Faude et al. 2005; Junge son as compared with the regular season (Incidence et al. 2007). In other women’s studies, muscle strains Rate Ratio, [IRR] 1.19; 95% CI, 1.04–1.36) and in the accounted for the greatest proportion of injuries regular season as compared with the postseason (Ostenberg & Roos 2000; Giza et al. 2005; Jacobson & (Incidence Rate Ratio, [IRR] 1.4; 95% CI, 1.22–1.65). Tegner 2007,). In men’s elite soccer, muscle strains accounted for the greatest proportion of injuries in What Is the Outcome? the majority of studies (Albert 1983; Arnason 1996; Hawkins et al. 2001; Drawer & Fuller 2002; Walden et al. 2005; Hagglund et al. 2006; Dvorak et al. 2007). Injury Type Contusions are consistently among the three most Studies examining injury type are summarized in common injury types reported across both sexes. Table 17.3. The most common injury types reported In tournament play, contusions accounted for the soccer (football) 215
Anatomical Injury Location (game/practice when known)
Head/Neck Trunk/Back Upper Hip/Groin Thigh Knee Lower Leg Ankle Foot Other Extremity
10.8 7.7 17 26.2 6.2 10.8 12.3 9.2
3.3 16.4 24.6 4.9 45.9 4.9
12 head 6.6 6.3 5.7 16.1 12.7 18.7 15.5 6.3 0.3
8–33 3–33 0–13 8–22 8–23 0–23 0–23 0–25
14.6 head 3.5 4.7 6.4 17.5 12.9 17 14.6 8.2 0.6
M/F 8/9 6/7 5/2 17/16 16/11 18/13 12/20 4/7 14/16
18 9 8 3.1 12 11 11 24 3.1
1.3 5 6.5 8.8 21.3 13.8 12.5 18.8 12.5
WS Women’s Senior. greatest proportion of injuries in the majority of player-hours in men’s, women’s, and youth elite studies across sex and age groups (Junge 2004b,c; levels of play (Agel et al. 2007; Dick et al. 2007; Junge et al. 2006; Dvorak et al. 2007; Junge & Dvorak Kofotolis et al. 2007). 2007). Fractures accounted for 1% to 12% of injuries Anterior cruciate ligament (ACL) injury has in most studies (Albert 1983; Engstrom et al. 1991; become one of the most significant concerns in elite Poulsen et al. 1991; Inklaar et al. 1996; Hawkins et levels of soccer because of the inability of some al. 2001; Soderman et al. 2001; Drawer & Fuller 2002; players to return to their preinjury level of partici- Faude et al. 2005; Giza et al. 2005; Hagglund et al. pation, in addition to the long-term sequelae asso- 2006; LeGall et al. 2006; Walden et al. 2005; Jacobson ciated with osteoarthritis (Myklebust & Bahr 2005). & Tegner 2007). Concussions accounted for 2% to ACL injury rates are reportedly 2 to 6 times higher 7% of injuries (Albert 1983; Junge 2004b,c; Giza in female as compared with male athletes (Bjordal et al. 2005; Junge et al. 2006; Junge & Dvorak 2007; & Arnoy 1997, Hewett et al. 2006, Griffin et al. 2005, Jacobson & Tegner 2007). Mihata et al. 2006). Injury rates estimated in wom- By specific injury type, the most common inju- en’s and girl’s soccer range from 0.07 to 0.5 inju- ries reported at all levels of play is ankle sprains, ries per 1,000 player-hours (Bjordal & Arnoy 1997; with reported rates of 1.5 to 3 injuries per 1,000 Faude et al. 2005; Giza et al. 2005; Mandelbaum et al. 216 chapter 17
Table 17.3 Injury type (%) in elite male, female, and tournament soccer players.
Study Study Design Population (sex, age, level of Sample Size or (country, yr) play, other) Denominator Data
Adult Male Albert (1983) Descriptive (USA, Male professional (ages 19–38) 3 56 players 1979–1981) outdoor seasons Arnason (1996) Cohort (Iceland, 1991) Men’s elite (ages 18–34) 1 84 players season Drawer & Fuller (2002) Cohort (Britain, Male Professional 2.5 yr 87,529 player-hr 1994–1997) Hawkins et al. (2001) Cohort (Britain, Male (91 professional football n 2376 1997–1999) clubs) 2 yr Hagglund et al. (2006) Cohort (Sweden, Male (ages 17–38, top elite divi- n 525 2001–2002) sions) 2 yr Poulsen et al. (1991) Cohort (Denmark 1986) Adult (male, 21–30, varying n 55 levels) 1 yr Walden et al. (2005) Cohort (Europe, Professional (male, mean age n 266 2001–2002) 26) 1 season Adult Female Engstrom et al. (1991) Cohort (Sweden) Female (21 yr, elite) 1 year n 41 Faude et al. (2005) Cohort (Germany, Female (ages 17–27, elite, n 165 2003–2004) national league) 11 mo Giza et al. (2005) Cohort (USA Female (age not reported, elite) n 202 2001–2003) 2 5 mo Jacobson & Tegner Cohort (Sweden, 2000) Female (ages 16–36, premiere n 269 (2007) league) 10 mo Ostenberg & Roos Cohort (Sweden, 1996) Female (ages 14–39) 7 mo n 123 (2000) Soderman et al. (2001) Cohort (Sweden, 1998) Female (ages 20–25, elite) 7 mo n 146 Tournament Dvorak et al. (2007) Cohort (Germany, Male (FIFA World Cup, 2,111 tournament 2006) tournament) player-hr Junge (2007) Cohort (international, Female tournament (7 5,742 player-hr 1999–2006) international) Junge et al. (2004c) Cohort (international, Male female tournament (12 10,155 player-hr 1998–2001) international) Junge (2004b) Cohort (international, Male (international tournament) 2,111 player hours 2002) Junge et al. (2006) Cohort (international, Male and Female Olympic 2004) Games soccer (football) 217
Injury Definition Injury Type (game/practice when known)
Sprain Strain Contusion Concussion Fracture Dislocation Other
Medical attention 27.4 34 16 1.9 4.7 2.8 (physician) or time loss Time loss 22 29 20 28
Time loss 19.3 40.6 19.8 3.8
Time loss 2 days 19 37 13 4
Time loss 2001/2002 23/19 15/15 3/3 1/ 1 5/6 15/17 Time loss 42.1 29.8 12.3 7 0 8.8
Time loss 21 26 16 2 1
Time loss 33.3 10.3 15.3 1.2 15.3 Time loss 46.5 17.4 23.7 5.4 16.1
Time loss 19.1 30.7 16.2 2.9 11.6
Time loss 24.5 28.7 8.4 3.8 1.3 0.8 1.7
Time loss 18.5 32.2 16.9 3.1 7.8
Time loss 65.6 16.4 18
Medical attention 14 15 51 (team physician) Medical attention 26 8 45 3.1 2.3 2.1
Medical atten- 5–24 3–25 35–76 0–7 0–10 0–3 tion time loss Medical attention 14 15 50 2.3 1.8
Medical attention M/F 9/29 6/9 71/36 0/4 1/2 0/4 218 chapter 17
2005; Mihata et al. 2006; Ostenberg & Roos 2000; than age-matched controls (Larsen, Jensen & Jensen Steffen et al. 2008). 1999). The National Centre for Catastrophic Sport Injury Research (2007) reported 16 direct cata- Time Loss strophic injuries between 1982 and 2007 in high- Based on the recent consensus statement on injury school and college soccer. A catastrophic injury definitions and data-collection procedures in stud- directly resulting from participation in soccer was ies of soccer injuries, time-loss categories esti- categorized as a fatality, a nonfatality (i.e., perma- mating severity of injury include slight (0 days), nent severe functional disability), or serious (i.e., no minimal (1–3), mild (4–7) , moderate (8–28), and permanent functional disability but severe injury severe ( 28) if these are reported (Fuller et al. such as a fractured cervical vertebrae with no 2006). Proportion of injuries by time-loss catego- paralysis). ries are summarized in Table 17.4. The majority of injuries in men’s, women’s, and youth soccer are Economic Cost categorized as mild (4–7 days time loss) or mod- erate (8–28). Severe injuries ( 28 days time loss) There is a significant public health cost associ- accounted for 10% to 25% of all injuries across ated with soccer injuries, the future development sexes, youth, and tournament soccer. of osteoarthritis, and other diseases associated with decreased levels of physical activity (Angus et al. 1998). Dvorak & Junge 2000 suggested a con- Clinical Outcome servative estimate of $150 for the primary medical Many studies examining reinjury rates in either costs associated with each soccer injury, suggest- men’s or women’s soccer reported 20% to 46% ing $30 billion annually for primary medical costs of injuries as recurrent (Nielsen & Yde 1989; for soccer injuries based on players in the United Inklaar 1994b; Arnason et al. 1996; Hagglund et al. States actively registered with FIFA. One of the 1996; Hawkins & Fuller 1999; Dvorak et al. 2000; most costly injuries associated with soccer is likely Ostenberg & Roos 2000; Soderman et al. 2001; ACL injury. In an economic evaluation of youth Faude et al. 2005; Walden et al. 2007) In soccer, basketball injuries completed alongside a rand- there is a greater risk of injury reported for players omized, controlled trial (RCT) examining a preven- with a history of injury in many prospective cohort tion strategy for injury in youth basketball (Emery studies. These results will be discussed further in et al. 2007), McAllister (2007) estimated a range of the “What Are the Risk Factors” section. direct health care costs (1-year time horizon) asso- Injuries have also been documented to be a lead- ciated with ACL injury of $7,000 to $9,000 in 1994 ing cause of the development of osteoarthritis in Canadian dollars. later life. There is evidence that knee and ankle injuries, specifically, resulted in an increased risk What Are The Risk Factors? of early development of osteoarthritis (Roos et al. 1998; Drawer & Fuller 2001; Englund et al. 2003; Causality associated with injury is both extremely Lohmander 2004; von Prat et al. 2004; Koh & Dietz complex and dynamic in nature. Meeuwisse (1994) 2005; Myklebust & Bahr 2005; Roos 2005). Long- initially developed a multifactorial model of cau- term follow-up studies provide evidence that 12 sation that attempted to account for the interac- to 20 years after knee injury (meniscus and or ACL tion of multiple risk factors. Risk factors in soccer injury), 50% of those injured will have knee oste- are any factors that may increase the potential for oarthritis, as comparison with 5% in the uninjured injury. Risk factors may be extrinsic (i.e., weather, population (Myklebust & Bahr 2005; Roos 2005). field conditions) or intrinsic (i.e., age, conditioning) Specifically, soccer players have been shown to to the player. Modifiable risk factors refer to those have a higher incidence of ankle and knee arthritis that can be altered by injury-prevention strategies soccer (football) 219
to reduce injury rates (Meeuwisse 1991; Emery play for both men and women. In addition, the rates 2003). Nonmodifiable risk factors, which cannot be of injury in tournament play are more similar for altered, may affect the relationship between modi- men and women. fiable risk factors and injury. By specific injury type, there is some indica- tion that the greatest proportion of all injuries is Nonmodifiable Intrinsic Risk Factors ligament sprain (33–66%) in most studies in wom- en’s soccer (Engstrom et al. 1991; Faude et al. 2005; Previous Injury Junge et al. 2007). In other women’s studies, muscle Previous injury is the most consistently reported strains accounted for the greatest proportion of all risk factor for injury in soccer and other sports injuries in women’s soccer (Ostenberg & Roos 2000; (Emery 2003). It has been suggested that this may Giza et al. 2005; Jacobson & Tegner 2007). In men’s be a result of inadequate rehabilitation (Emery elite soccer, muscle strains accounted for the great- 2003). In soccer, there is a greater risk of injury est proportion of injuries in the majority of studies reported for players with a history of injury in (Albert 1983; Arnason 1996; Drawer & Fuller 2002; many prospective cohort studies. Hagglund et al. Hawkins et al. 2001; Walden et al. 2005; Hagglund (2006) reported a greater risk of all injuries (hazard et al. 2006; Dvorak et al. 2007). When examining ratio, 2.7; 95% CI, 1.7–4.3). By specific injury type, the risk of ACL injury alone, the risk of injury in Hagglund et al. (2006) found that players with women’s soccer was twofold to eightfold higher a previous hamstring, groin, or knee joint injury than that for men’s (Arendt & Dick 1995; Bjordal & were at two to three times the risk of a recurrent Arnoy 1997; Mihata et al. 2006). injury specific to that structure the following sea- son. Kucera et al. (2005) reported an increased risk Age of ankle and knee injuries in youth soccer play- By age, higher rates of injury are typically found in ers who had sustained one previous injury to the the older age groups (Arnason 2004a; Kucera et al. same site (ankle injury rate ratio [IRR], 4.19; 95% 2005; Ostenberg & Roos 2000). Other studies exam- CI, 2.97–5.92), knee IRR, 5.84; 95% CI, 4.04–8.44) ining female soccer players found no difference in and an even greater risk in players who reported injury rate by age group; however, the age range in multiple ankle injuries (ankle IRR, 8.16; 95% CI, these studies examining young female adult soc- 4.89–13.61). Arnason et al. (1996) report the pro- cer players was tighter than in other studies (Faude portion of all muscle strain injuries and ligament et al. 2005; Soderman et al. 2001). sprain injuries to be 44% and 58%, respectively. For ankle sprain injuries specifically, studies have Anthropometrics reported 61% to 69% as recurrent sprains (Arnason et al. 1996; Kofotolis et al. 2007). Faude et al. (2005) Arguably, weight is a modifiable risk factor, but report a fivefold increased risk of ACL injury in it will be considered in combination with anthro- players with a previous ACL injury (IRR, 5.24; 95% pometrics including height. Faude et al. (2005) CI, 1.42–19.59)]. demonstrated a ninefold increased risk of injury in female soccer players who are taller than 1 stand- ard deviation above the mean height (IRR, 9.64; Sex 95% CI, 1.96–58.52). Weight was not a risk factor Sex has been previously discussed. In summary, the in this study. Other studies have not found height, rates of injury in regular season game play reported weight, or body-mass index to be risk factors for are slightly lower in elite women’s competition as injury in soccer (Arnason et al. 2004a; Hagglund compared with men’s competition (Table 17.1). In et al. 2006; Kucera et al. 2005; Ostenberg & Roos practice (training) the rates of injury reported are 2000; Witvrouw et al. 2003). Dvorak et al. (2000) similar for men and women. In tournament play, found elite male players with 7.7% body fat to be injury rates reported are higher than regular season at a greater risk of injury (χ2 9.31; P 0.002). 220 chapter 17
Table 17.4 Severity of injury by time-loss categories (% of all injuries).
Study Study Design Population (sex, age, level of play, other) Sample Size or (country, yr) Denominator Data
Adult Male Agel et al. (2007) Descriptive (USA, Male college (NCAA) 15 yr 22,000 G and 1988–2003) 62,000 P
Arnason (1996) Cohort (Iceland, 1991) Men’s elite (ages 18–34) 1 season 84 players Drawer & Fuller Cohort (Britain, Male Professional 2.5 yr 87,529 player-hr (2002) 1994–1997) Engstrom et al. Cohort (Sweden) Male (elite) 1 season 64 (1990) Hawkins et al. (2001) Cohort (Britain, Male (91 professional football clubs) 2 yr n 2,376 1997–1999) Hagglund et al. Cohort (Sweden, Male (ages 17–38, top elite divisions) 1 yr n 525 (2006) 2001–2002) Luthje et al. (1996) Cohort (Finland, 1993) Adult (male, elite, ages 17–35) 1 season n 263 Peterson et al. (2000) Cohort (Switzerland) Adult youth (age groups: adult, 16–18, n 264 14–16; all levels: high through low) 1 yr Poulsen et al. (1991) Cohort (Denmark 1986) Adult (male, 21–30, varying levels) 1 year n 55
Walden et al. (2005) Cohort (Europe, Professional (male, mean age 26) 1 season n 266 2001–2002) Adult Female Dick et al. (2007) Descriptive (USA, Women’s dollege (NCAA) 15 yr 20,447 G and 54,750 P 1988–2003)
Engstrom et al. Cohort (Sweden) Female (21 yr, elite) 1 year n 41 (1991) Faude et al. (2005) Cohort (Germany, Female (ages 17–27, elite, national league) n 165 2003–2004) 11 mo Jacobson & Tegner Cohort (Sweden, 2000) Female (ages 16–36, premiere league) 10 mo n 269 (2007) Ostenberg & Roos Cohort (Sweden, 1996) Female (ages 14–39) 7 mo n 123 (2000) Soderman et al. Cohort (Sweden, 1998) Female (ages 20–25, elite) 7 mo n 146 (2001b) Tournament Dvorak et al. (2007) Cohort (Germany, 2006) Male (FIFA World Cup, tournament) 2111 tournament player-hr Junge et al. (2004c) Cohort (International, Male female tournament (12 international) 10,155 player-hr 1998–2001) Junge (2004b) Cohort (International, Male (international tournament) 2,111 player-hr 2002) Junge et al. (2006) Cohort (international, Male and female Olympic Games 2004) Kibler (1993) Cohort (USA, 1987–1990) Male female (ages 12–19, invitational 74,900 player-hr tournament) Walden et al. (2007) Cohort (Europe, MS Championship, WS Championship, MU MS 368 WS 60 2004–2005) Championship MU 144
G player-games; MS Men’s Senior; MU Men’s U-19; P player-practices; WS Women’s Senior. soccer (football) 221
Injury Definition Time Loss, 0 Time Loss, 1–3 Time Loss, 4–7 Time Loss, Time Loss, Days, Slight Days, Minimal Days, Mild 8–28 Days, 28 Days, Moderate Severe
Medical attention and time ( 10 days) 83.3 ( 10 days) loss or restricted performance 16.7 1 day any dental injury Time loss Time loss 14.1 35.4 38 12.4
Time loss
Time loss 2 days (2–3 days) 10 23 45 23
Time loss 33.1 27.6 28.8 10.5
Medical attention ( 1 week) 50 35.6 14.4 All 52.2 32.4 15.4
Time loss ( 1 game) 28 (1 to 5 games) ( 5 games) 54 18 Time loss 28 28 29 15
Medical attention and time- ( 10 days) 81 ( 10 days) loss or restricted performance 19 1 day any dental injury (1994 onward) Time loss (1–6 days) 49 (7–30 days) ( 30 days) 36 15 Time loss (1–6 days) 51 (7–30 days) ( 30 days) 36 13 Time loss 17 22 39 22
Time loss (1–6 days) 31 (7–30 days) ( 30 days) 51 18 Time loss (1–6 days) 34 (7–30 days) ( 30 days) 49 18
Medical attention (team 2002/2006 37/33 17/15 11/18 2/5 physician) 33/30 Medical attention time loss 48–70 17–36 1–18 2–17 0–3
Medical attention 32.9 36.7 17.1 11.4 1.9
Medical attention M/F 32/25 4/13 3/8 3/3 58/53 Medical attention or time loss (0–7 days) 62.5 ( 7 days) (season) 8.6 28.8 Medical attention MS/WS/U19 47/44/47 13/0/18 13/22/29 27/17/6 0/17/0 222 chapter 17
Female Hormones P 0.049) in female players who subsequently sus- tained an overuse injury only. Inklaar et al. (1994b) In the examination of risk factors specifically for found a correlation between decreased adductor ACL injuries in female athletes, Shultz et al. (2005) muscle flexibility and subsequent adductor mus- reported an association between hormone fluctua- cle injury. A similar association between hamstring tions through the menstrual cycle and anterior knee muscle flexibility and hamstring muscle injury was joint laxity. The only epidemiologic evidence found not found. As such, based on few studies, there in women’s soccer specifically, demonstrated higher are insufficient data to conclude that there is a rates of acute injury during the premenstrual and clear relationship between flexibility and injury in menstrual phases as compared with the rest of the soccer. cycle (Moller-Nielsen & Hammar 1989). Myklebust General joint laxity and knee hyperextension et al. (1998) also found European handball players were both found to be predictive of traumatic injury to be more susceptible to injury during the men- in female soccer players (laxity: OR, 3.1; P 0.03; strual phase. On the other hand, Wojtys et al. (2002) hyperextension: OR, 2.5; P 0.03) (Soderman et al. found female athletes to be more susceptible to 2001). Consistent with these findings, Ostenberg & ACL injuries during the ovulation phase. As such, Roos (2000) also found generalized joint laxity to the relationship between the phase of the menstrual be predictive of injury in female players (OR, 4.3; cycle in which a female athlete is more susceptible P 0.001). Arnason et al. (1996) found medial knee to ligament injury is inconclusive to date. instability to be associated with knee injuries in male soccer players; however, there was no asso- Modifiable Intrinsic Risk Factors ciation found between ankle instability and ankle injury in the same study. With few studies exam- Fitness Level and Endurance ining joint laxity or instability as a risk factor for There is some evidence that poor endurance is injury in soccer, firm conclusions cannot be drawn. a risk factor for sport injury in male and female army trainees (male IRR, 2.8; 95% CI, 1.2–6.7); Strength female IRR, 1.69; 95% CI, 1.45–7.92)] (Jones et al. 1993). In soccer, study findings in men’s and Female soccer players with a lower hamstring: women’s soccer have not found endurance based quadriceps strength ratio (i.e., based on concentric- on estimated Maximal oxygen consumption, muscle-strength testing using an isokinetic
VO2max to be associated with injury risk (Arnason dynamometer) have been shown to be at a greater et al. 2004c; Ostenberg & Roos 2000). This find- risk of injury (Soderman et al. 2001, Knapik et al. ing may be related to the homogeneity of overall 1991). Orchard et al. (1997) also demonstrated an higher fitness levels in soccer athletes. increased risk of hamstring injury in players with lower hamstring strength and decreased ham- string:quadriceps ratio. In contrast, Ostenberg and Flexibility and Joint Laxity Roos (2000) were unable to demonstrate an associa- Witvrouw et al. (2003) found decreased levels of tion between isokinetic concentric muscle strength preseason hamstring and quadriceps flexibility in and injury in female soccer players. Ostenberg and male professional soccer players who subsequently Roos (2000) examined vertical jump as a functional sustained a hamstring or quadriceps strain injury. lower-extremity strength measure and found no Arnason et al. (1996), however, were unable to association with injury in adult female soccer play- demonstrate a significant association between mus- ers. Despite these nonsignificant findings examin- cle flexibility and muscle strain injury. Soderman ing all injury risk, there is certainly a trend toward et al. (2001) demonstrated greater side-to-side dif- increased risk associated with low hamstring: ferences in ankle dorsiflexion (odds ratio [OR], quadriceps ratio for lower extremity and hamstring 7.06; P 0.02) and hamstring flexibility (OR, 3.56; strain injury in soccer. soccer (football) 223
Neuromuscular Control and Balance demonstrated a significantly increased risk of injury in female youth soccer players with a high Soderman et al. (2001) found low postural sway level of perceived life stress as compared with to be predictive of injury in female soccer play- those with a perceived low level of life stress (OR, ers. Osterberg and Roos (2000) found higher 1.67; 95% CI, 1.3–2.18). In addition, players with a performance on the square-hop test to also be pre- high perceived “mastery climate” were also at an dictive of injury in female soccer players. In addi- increased risk of injury (P 0.026). Schwebel et al. tion, neuromuscular training programs including a (2007) findings suggest that inhibition, risk taking balance-training component have been consistently and aggression are not predictive of injury in youth effective in decreasing the risk of injury in soccer male soccer players. It should be noted, however, players (Caraffa et al. 1996, Emery & Meeuwisse that the small sample size (n 60), few injuries 2008, Hewett et al. 1999, Mandelbaum et al. 2005, (n 6), and multiple comparisons lead to a likeli- McGuine & Keene 2006). hood of low study power associated with a type II There are very few studies including soccer play- statistical error. ers that examine biomechanical risk factors for injury using a prospective design. Soderman et al. (2001) did not find static measures of alignment Nonmodifiable Extrinsic Risk Factors including quadriceps angle, knee or foot alignment Level of Play and Experience to be predictive of injury. Hewett et al. (2005) pre- screened 205 female athletes (including soccer play- In most studies examining level of play, there is ers) and were able to determine that athletes who consistently a greater risk of injury reported in subsequently sustained an ACL injury had a 2.5- higher levels of play. By division of play in elite fold greater knee abduction moment, 20% greater adult soccer, Agel et al. (2007) report the greatest ground reaction force, and 16% shorter stance time rates of game injury across 15 years of men’s colle- than noninjured athletes on a drop vertical jump giate soccer in Division I as compared with Division test. In fact, knee abduction moment had a sensi- III (RR, 1.4; 95% CI, 1.3–1.5) and in Division II as tivity of 78% and a specificity of 73% in predicting compared with Division III (RR, 1.3; 95% CI, 1.2– ACL injury. A linear regression model including 1.4). These differences were consistent for practices. the most highly significant predictors (knee abduc- Dick et al. (2007) reported similar findings across 15 tion angles, knee abduction moments, and side-to- years of women’s collegiate soccer, with the great- side differences in these measures) of ACL injury est rates of game injury in Division I as compared showed a predictive r2 value of 0.88. These findings with Division III (RR, 1.2; P 0.01). There were no are monumental in the understanding of dynamic significant differences found in practices by divi- neuromuscular factors associated with injury that sion of play. Contrary to these findings, Poulsen will lead to further refinement of neuromuscular et al. (1991) found a 1.8-fold increased risk of injury training prevention strategies in soccer. in lower-skilled players. Kucera et al. (2005) found a 38% to 48% reduced risk of injury with a greater Psychological and Social Factors number of years of soccer experience, as compared with players with 2 years of soccer experience. Dvorak et al. (2000) confirmed previous findings in other sports that life-event stress and poor reaction Position of Play time were associated with injury in male soccer players. Is has been hypothesized that life-event Tscholl et al. (2007a) examined injury rates by stress reduces attention and mental performance, player position during six women’s top level tour- which in turn reduces reaction time in an athletic naments and find no difference in overall injury situation, leading to injury (Junge 2000). Taimela rates or time-loss injury rates between forwards, et al (1990) also found poor reaction time to midfielder, defenders and goalkeepers. LeGall et al. be predictive of injury in soccer. Steffen (2008) (2006), however, report greater rates of injuries 224 chapter 17 sustained per player in defenders (2.2), followed by male ACL injuries in soccer to be the result of tack- goalkeepers (2.0), midfielders (1.6), and forwards ling. For men, 64% were tackles from the side and (1.5) in elite youth players over 10 seasons. Kucera for women 44% and 32%, respectively, were related et al. (2005) found the greatest risk of injury in to tackles from the side and front. Andersen et al. defenders as compared with midfielders (IRR, 1.23; (2004a) examined how violations of the rules of the 95% CI, 1.00–1.51). Consistent with these findings, game contributed to injury through video analysis Faude et al. (2005) also found the greatest risk of of 174 matches in professional men’s football. They injury in defenders, with strikers a close second as reported that less than one third of the injuries iden- compared with goalkeepers and midfielders. tified on video and 40% of the incidents with a high risk of injury resulted in a free kick being awarded. Modifiable Extrinsic Risk Factors Only one tenth of these situations led to a yellow or red card. In addition, the agreement between the Playing Surface match referee and the expert referee panel review- Some studies have examined the risk of injury ing the video was 85%. Clearly, foul play accounts on natural grass as compared with artificial turf. for a significant portion of injury in all studies Ekstrand et al. (2006) found no difference in injury reporting these findings. Given the support for risk on artificial turf as compared with natural accuracy of penalties assigned, clearly a review of grass in professional men’s soccer. Arnason et al. fair play is required to protect players from injury. (1996), however, demonstrated a greater than two- fold increased risk of injury on artificial turf as Equipment compared with natural grass. Steffen et al. (2007) Shin guards were introduced as mandatory equip- finds no difference in the incidence of overall ment in 1991 in U.S. collegiate soccer to reduce injury or acute onset injury on artificial turf and the risk of lower-leg injuries (Agel et al. 2007). In grass in female youth players over a season of play. a biomechanical study, Boden (1998) demonstrated However, the incidence of serious injury ( 21 days a 41% to 77% reduction in load force with shin of time lost) was greater on artificial turf (relative guards, depending on the type. Evidence is lack- risk, 2.0; 95% CI, 1.3–3.1)]. Further examination of ing, however, to support the effectiveness of shin shoe type and shoe-surface interface is critical. guards in soccer. Agel et al. (2007) demonstrate no difference in the rates of lower leg and ankle Rules fractures and contusions in the two seasons prior Penalties including a free kick or yellow or red card to this mandate and the 13 years following this are intended to modify unsafe acts such as foul change. tackles (including tackles from behind) that poten- tially increase the risk of unnecessary injury in soc- What Are the Inciting Events? cer. Junge et al. (2007) reported 29% of injuries to be caused by foul play, but only 50% of these resulted Player-to-player contact injuries accounted for in a penalty sanctioned by the referee. Walden et al. 32% to 61% of all injuries in studies relying on self- (2007) reported foul play injuries in male, female, reporting mechanism of injury (Nielsen & Yde 1989; and U-19 European Championships to account for Arnason et al. 1996; Luthje 1996; Hawkins et al. 37%, 17%, and 29% of all injuries, respectively. In 2001; Emery et al. 2005, Faude et al. 2005; Agel et al. regular season play, 23% of match injuries in men’s 2007; Dick et al. 2007). Agel et al. (2007) reported elite soccer were a result of foul play. Fuller et al. 16% of all injuries to be related to a slide tackle in (2004) report that foul challenges accounted for 30% men’s collegiate soccer. Hawkins et al. (2001) report of head and neck injuries analyzed in international 32% of all match injuries to be related to tackling. soccer matches. Bjordal & Arnoy (1997)reported Junge et al. (2007) reported 29% of injuries to be 58% of all women’s ACL injuries and 42% of all caused by foul play, but only 50% of these resulted soccer (football) 225
in a penalty sanctioned by the referee. Walden et al. heading duels with attention focused on the ball (2007) reported foul play injuries in male, female, in the air (13%). The authors concluded that player and U-19 European Championships to account for attention and ball control may be important factors 37%, 17%, and 29% of all injuries, respectively. In in the prevention of injuries. regular season play, 23% of all match injuries in In examining mechanism of injury in women’s men’s elite soccer were a result of foul play. soccer, Tscholl et al. (2007b) identified 86% to be Some studies have examined mechanism of a result of direct contact with another player. Of injury through video analysis (Giza et al. 2003; these, 52% resulted from tackles from the side, Andersen et al. 2004a, 2004b, 2004c, Arnason et al. 38% tackles from the front, and 11% tackles from 2004a, Fuller et al. 2004; Tscholl et al. 2007a, 2007b). behind. One-footed (65%) and upper body (21%) Andersen et al. (2004b) examined ankle sprain tackling actions were the most common. This study injuries and identified the primary mechanisms of highlighted some differences in mechanisms of injury to be tackling (53.8%), clearing, or shooting, injury as compared with similar studies examin- during which there was forced plantar flexion asso- ing elite men’s soccer. Tackles from behind were ciated with contacting the opponent’s foot (15.4%), rarely seen in women’s soccer, and slide-in tackles running (15.4%), landing after heading (7.7%), and resulting in injury were much more common. In other (7.7%). Giza et al. (2003) further examined addition, the use of elbows in aerial challenges was the mechanism of ankle injury in four world soccer rarely a cause of injury in women’s soccer. competitions and reported weight bearing of the injured limb 54% of the time. Injury Prevention Andersen et al. (2004c) further examined through video analysis the mechanism of 192 head contact To date, there have been 17 prospective studies incidents that involved stoppage in play because of examining the effectiveness of injury-prevention a suspected injury. Sixteen of these resulted in head programs specifically in soccer (Table 17.5). injuries causing time loss. The most common play- The majority of the prevention strategies (12 of ing action for these was heading duel (58%). The 15) examined include a neuromuscular train- body part that hit the player was the elbow, arm, or ing program aimed at reducing injuries. These hand (41%), followed by the head (32%), and foot programs consistently include various specific (13%). In cases in which there was contact of the components of balance, agility, endurance, and elbow, arm, or hand, the elbow was above shoulder strength training (Ekstrand et al. 1983; Tropp et level 85% of the time, active 77% of the time, and al. 1985; Caraffa et al. 1996; Hewett et al. 1999; intentional 20% of the time. The authors suggest a Heidt et al. 2000; Soderman et al. 2000; Junge potential rule change related to elbow use. Fuller et et al. 2002; Askling et al. 2003; Mandelbaum et al. al. (2004) further report through video analysis that 2005; McGuine & Keene 2006; Hagglund et al. foul challenges account for 30% of head and neck 2007; Emery & Meeuwisse 2008; Engebretsen et injuries analyzed in international soccer matches. al. 2008; Steffen 2008;) (Table 17.5). Other inter- Arnason et al. (2004a) examined 95 incidents vention studies have examined an educational from 52 matches captured on video and identified video-based awareness program (Arnason et based on referee stoppage in play because of a sus- al. 2005), ankle braces (Tropp et al. 1985; Surve pected injury. Duels caused 88% of the incidents, of et al. 1994) and cognitive behavioral training which 64% were tackling duels. The player sustain- (Johnson et al. 2005). All studies demonstrated a ing the incident was reportedly focused away from protective effect of the intervention with a reduc- the opponent 93% of the time. The primary mecha- tion of injury in the intervention group ranging nisms observed were breakdown attacks, tackling from 38% to 88% reduction (Ekstrand et al. 1983; from the front or side with attention focused on the Tropp et al. 1985; Surve et al. 1994; Caraffa et al. ball (24%), defensive tackling duels with attention 1996; Heidt et al. 2000; Askling et al. 2003; Johnson focused on the ball or low ball control (20%), and et al. 2005; Mandelbaum et al. 2005; McGuine & 226 chapter 17
Table 17.5 Injury-prevention studies.
Study Study Design (country Population (sex, age, Type of Study (no. of players/no. follow-up period) level of play, other) of teams)
Neuromuscular training interventions Askling et al. (2003) RCT Elite male Intervention (15/2) Sweden Mean age 24 Control (15/2) 11 mo Premier league Division 1
Caraffa et al. (1996) Quasi-experimental Semi-professional amateur Total (600) Italy Age unknown Intervention (20) 3 yr Control (20)
Ekstrand et al. (1983) RCT Amateur male Total (180/12) 6 mo Ages 17–37 Intervention (6) Control (6)
Emery & Meeuwisse RCTa Youth club soccer Intervention (380/32) (2008) Canada Ages 13–18 Control (364/28) 6 mo Premier
Engebretsen et al. (2008) RCT Elite male Total (508/31) Norway Previous injury or reduced HR control (195) 8 mo function in the ankle, knee, HR intervention (193) hamstring, or groin LR control (120)
Hagglund et al. (2007) RCT Amateur male Intervention (241/10) Sweden Age 15–46 yr Control (241/10) 10 mo 4th Division
Heidt et al. (2000) Quasi-experimental Female youth Intervention (42) USA High school Control (258) 1 year Ages 14–18
Hewett et al. (1999) Quasi-experimental Youth (male female) Intervention (366/15) [girls] USA Age 14–18 yr Control 1 1 yr Soccer, basketball, and (463/15) [girls] volleyball Control 2 (434/13) [boys] soccer (football) 227
Targeted Injuries Intervention Injury Rates (no. of Effect of Intervention injuries/1,000 player-hr, unless otherwise stated)
Hamstring strains Preseason concentric and Intervention: 3 injuries IRR (estimate), eccentric hamstring Control: 10 injuries 0.3 70% reduction in injury strengthening program (16 sessions-10 wk) ACL injury Preseason and in season Intervention (10 injuries): IRR (estimate), proprioceptive training program 0.15 injuries/team/season 0.13 87% reduction in injury (balance) (30 days preseason, Control (60 injuries): 1.15 3x/wk in season) injuries/team/season All injury Multifaceted program (training, equipment, ankle IRR (estimate), taping, rehabilitation, 0.25 70% reduction in injury exclude if severe knee instability, education, disciplined play, correction and supervision by doctor(s) and physiotherapist(s). All injuries, Neuromuscular training Intervention: IRR (all), 0.67 (95% CI, 0.43–1.04) n.s. acute-onset injury, program (balance, agility, jump All, 3.35 (95% CI, 2.65–4.17) IRR (acute onset), 0.62 (95% CI, ankle and knee technique, eccentric quads/ Acute, 3.05 (95% CI, 0.39–0.96) sprains hamstrings, core stability) 2.39–3.84) IRR (ankle sprain), 0.57 (95% CI, All, 2.08 (95% CI, 1.54–2.74 0.28–1.16) [NS]. Acute,1.75 (95% CI, Control: 1.26–2.34) IRR (knee sprain), 0.38 (95% CI, 0.08–1.86) [NS] 38% reduction in acute-onset injury Ankle and knee Targeted neuromuscular HR intervention, 4.9 (95% HR intervention vs. HR control: sprains, hamstring (balance) and/or strength CI, 4.3–5.6) IRR, 0.94 (95% CI, 0.77–1.13) [NS] and groin strains training (eccentric, core) program HR control, 5.3 (95% CI, No effect dependent on previous injury 4.6– 6.0) LR control vs. HR intervention: and/or function LR control, 3.2 (95% CI, IRR, 0.65 (95% CI, 0.51–0.85) 2.5–3.9) LR control vs. HR control: IRR, 0.61 (95% CI, 0.48–0.79) All injury Education regarding risk factors Intervention: Practice: for reinjury, rehabilitation Practice 3.3 (95% CI,2.6–4.2 IRR (estimate) 1.22 (P 0.05) n.s. principles, and a 10-step Game 10.5 (95% CI, 8.3–13.2) Game progressive rehabilitation Reinjury 2.3 (95% CI, IRR (estimate) 0.85 (P 0.05) n.s. program including return-to-play 1.4–3.9) Reinjury: criteria. Control: Hazard ratio (all reinjury), 0.34 (95% Practice 2.7(95% CI, 2.1–3.5) CI, 0.16–0.72) Game 12.3 (95% CI, 9.9–15.3) Hazard ratio (LE reinjury), 0.25 (95% Reinjury 8 (95% CI, 5.9–11) CI, 0.11–0.57) 66% reduction in all reinjury 74% reduction in LE reinjury All injury Preseason conditioning (CV, Intervention: IRR (estimate) 0.47 plyometrics, agility, strength, 16.7 injuries/100 players 53% reduction in all injury flexibility) Control: 7-weeks; 1–2x/wk 35.3 injuries/100 players Serious injury Neuromuscular training Intervention (girls): Intervention vs. Control (girls) ACL/MCL program (flexibility, jump 0.22 injuries/1,000 IRR (estimate) 0.42 (P 0.11) n.s. training, agility) exposures Intervention vs. Control (boys) 60–90 minutes 3x/week, 6 mo Control (girls): IRR (estimate) 2.47 (P 0.46) n.s. 0.52 injuries/1,000 Control (girls) vs. Control (boys) exposures IRR (estimate) 5.78 (P 0.08) n.s. Control (boys): No effect. Trend toward reduction in 0.09 injury/1,000 exposures intervention group (continued) 228 chapter 17
Table 17.5 (continued)
Study Study Design (country Population (sex, age, Type of Study (no. of players/no. follow-up period) level of play, other) of teams)
Junge et al. (2002) Quasi-experimental Male youth Total 194 Switzerland Age 14–19 yr 2 seasons
Mandelbaum et al. (2005) Cohort Female youth Year 1: USA 12–18 yr Intervention (1,041/52) 2 yr Control (1,905/95) Year 2: Intervention (844/45) Control (1,913/112) McGuine & Keene (2006) RCT Male female Intervention (473/27) USA High school soccer and Control (458/28) 1 season basketball Mean age 16 Soderman et al. (2000) RCT Female amateur Intervention (121/7) Sweden Mean age 20 Control (100/6) 7 mo
Steffen (2008) RCTa Female youth Intervention (1,073/58) Norway Ages 14–16 Control (947/51) 8 mo
Other Intervention Studies Arnason et al. (2005) RCT Elite male Intervention (127/7) Iceland Age unknown Control (144/8) (6 mo) Divisions 1 and 2
Johnson et al. (2005) RCT Elite male female high Intervention (16) Sweden injury risk Control (16) 6 mo Mean age: Men, 22.9 Women, 20.1 Surve et al. (1994) RCT Senior male Previous ankle sprain (258) South Africa No previous sprain (246) 1 season
Tropp et al. (1985) RCT Amateur male Total (439/25) Sweden 6 mo
ACL anterior cruciate ligament; CI confidence interval; F-MARC FIFA Medical Assessment and Research Centre; HR high-risk; ratio; RCT randomized controlled trial. aeffect estimates adjusted for effect of clustering. soccer (football) 229
Targeted Injuries Intervention Injury Rates (no. of Effect of Intervention injuries/1,000 player-hr, unless otherwise stated)
All injury Multifaceted program Intervention: IRR (estimate), 0.79 [NS] (warm-up, cool down, taping 6.71 No effect. Trend toward reduction in unstable ankles, rehabilitation, fair Control: intervention group play, F-MARC bricks-flexibility, 8.48 strength, agility, coordination, endurance) ACL injury Neuromuscular training program Intervention: IRR, 0.181 (P 0.0001) (warmup including flexibility, 0.09 injuries/1,000 AEs 82% reduction in ACL injury strength, plyometrics, agility) Control: 0.49 injuries/1,000 AEs
Ankle sprains Balance training program Intervention: IRR, 0.56 (95% CI, 0.33–0.95) (wobble board) 1.13 44% reduction in ankle sprains 5x/wk for 4 wk, preseason Control: 3x/wk in-season 1.87 Acute-onset lower- Home-based wobble board Intervention IRR, 1.24 (95% CI, 0.74–2.06) extremity injury balance training program (daily 4.75 No effect for 30 days, 3x/wk for rest of Control season) 3.83 All injury F-MARC 11 warm-up (core Intervention IRR 0.99 (95% CI, 0.83–1.19) stability, balance, plyometrics, 3.6 (95% CI, 3.2–4.1) No effect strength) Control 3.7 (95% CI, 3.2–4.1) IRR, 1.0 Acute-onset injury Educational video-based (15 min) Intervention No effect awareness program (i.e. injuries, 6.6 0.7 risk factors, mechanisms of injury) Control 6.6 0.7 All injury Cognitive behavioural training Intervention IRR (estimate) 0.17 (p 0.005) (relaxation, stress management, 0.22 injuries/player 83% reduction in injury goal setting, self confidence Control training, critical incident diary) 1.31 injuries/player 6–8 inseason sessions Ankle sprain injury Semirigid ankle brace Previous: Previous Sprain (Sport-Stirrup) Intervention: 0.14 IRR 0.16 Control: 0.86 84% reduction in ankle sprains in No previous: intervention group (previously Control: 0.46 injured) No effect in players without previous sprain Ankle sprain injury Ankle brace or balance training 71–82% reduction in players with previous sprains No effect in players without previous sprains
IRR Incidence Rate Ratio; LE Lower Extremity; LR low-risk; MCL medial collateral ligament; NS not significant; OR odds 230 chapter 17
Keene 2006; Hagglund et al. 2007; Emery & 2008). The precision of estimates of effect in the Meeuwisse 2008; Engebretsen et al. 2008). The excep- other studies should thus be interpreted with cau- tion are five studies that demonstrated no effect of tion (Emery 2007). Limitations of some of the intervention (Hewett et al. 1999; Soderman et al. 2000; studies examined, particularly nonrandomized Junge 2002; Arnason et al. 2005; Steffen 2008) (Table designs, include potential selection bias and bias- 17.5). It should be noted that compliance with inter- associated confounding variables (Caraffa et al. vention, particularly in the case of a home-program 1996; Hewett et al. 1999; Heidt et al. 2000; Junge component, may be the key factor in studies show- et al. 2002; Mandelbaum et al. 2005). Measurement ing no effect or a smaller effect size (Soderman et al. bias is also certainly of concern in many of the stud- 2000; Steffen 2008). In the case of Hewett et al. (1999), ies reviewed in which injury surveillance had not the outcome measure was all serious knee injury. been previously validated (Xxxxx et al. 1985; Caraffa There were only 14 injuries, limiting the power to et al. 1996; Heidt et al. 2000). In some studies, the detect a significant difference but a significant trend sample size was small and nonsignificant findings was observed. may be related to low power (Hewett et al. 1999; Four of the intervention studies have focused Junge et al. 2002). Compliance is not assessed in on female youth soccer players (Hewett et al. most of the studies examined and is reportedly 1999; Heidt et al. 2000; Mandelbaum et al. 2005; poor in two RCTs that examined prevention strate- Steffen 2008) and one on adult female soccer play- gies in youth soccer (Emery 2008; Steffen 2008). ers (Soderman et al. 2000). Emery et al. (2008)and Many of the intervention studies including mul- Johnson et al. (2005) and McGuine & Keene tifaceted training programs were effective in reduc- (2006)targeted male and female youth soccer play- ing injury in soccer. It remains unclear in many ers. The remaining nine studies targeted prevention studies precisely which components are critical to in male soccer players, one of which targeted youth prevention (Ekstrand et al. 1983; Hewett et al. 1999; (Ekstrand et al. 1983; Tropp et al. 1985; Surve et al. Heidt et al. 2000; Junge et al. 2002; Mandelbaum 1994; Caraffa et al. 1996; Junge et al. 2002; Askling et al. 2005; Hagglund et al. 2007; Emery et al. et al. 2003; Arnason et al. 2005; Hagglund 2007; 2008). Some of these comprehensive and effective Engebretsen et al. 2008). programs were also very time- and supervision- Some studies reviewed targeted prevention of intensive. For example, Hewett et al. (1999) devel- all injuries (Ekstrand et al. 1983; Heidt et al. 2000; oped a 60- to 90-minute supervised program that Soderman et al. 2000; Junge et al. 2002; Arnason et al. was implemented for 6 months. Programs such as 2005; Hagglund 2007; Emery 2008; Engebretsen et al. these may not be sustainable in some levels of soccer. 2008; Steffen 2008). Other studies were targeting Regardless of program components, it is impor- specific injury types, including ACL injury (Hewett tant to engage all stakeholders, including play- et al. 1999), hamstring strains (Askling et al. ers, parents, trainers, coaches, and organizations 2003), and ankle sprains (Tropp et al. 1985; Surve in order to maximize uptake of prevention strat- et al. 1994). The study design used to examine the egy and optimize benefit. Finch (2006) supports effectiveness of interventions in 11 of 16 studies this notion in proposing a sports-injury research was an RCT (Ekstrand et al. 1983; Tropp et al. 1985; framework-the Translating Research into Injury Surve et al. 1994; Soderman et al. 2000; Askling Prevention Practice (TRIPP)-which builds on et al. 2003; Arnason et al. 2005; Johnson et al. 2005; the fact that only research that can, and will, be Hagglund 2007; Emery 2008; Engebretsen et al. adopted by sports participants, their coaches, and 2008; Steffen 2008). sporting bodies will prevent injuries. As such, it is Despite the design of most studies, in which critical that performance benefits of the program individual players were targeted for prevention are also considered. Comprehensive training pro- in the context of a team intervention, only two grams, including components of balance, strength, studies adjusted for the effect of team (cluster) plyometrics, and agility training may improve per- appropriately in the analysis (Emery 2008; Steffen formance in addition to biomechanical measures soccer (football) 231
that have been demonstrated to be risk factors for Research examining precise injury mechanisms injury in soccer (Myer et al. 2005, 2006; Pollard through video analysis has added substantially to et al. 2006). the understanding of injury risk in soccer and will contribute to the ongoing research in injury preven- tion in soccer. For example, it is clear that elbowing Further Research in elite men’s soccer requires further examination Worldwide participation rates in soccer are high. with regard to potential rule changes that may fur- High rates of injury in this population have a sub- ther penalize such intentional contact. stantial impact on the player, the parents in the Although there is limited RCT evidence sup- case of youth participants, and the health care sys- porting preventive training programs in soccer to tem. Sports injury in soccer may also potentially reduce the risk of injury, there are several studies affect future ability to participate and may have that support the protective effects of a neuromuscu- long-term health costs related to decreased lev- lar training program in reducing the risk of injury els of physical activity and osteoarthritis related or reinjury (Ekstrand et al. 1983; Caraffa et al. 1996; to some injuries. Given these facts, it is critical to Heidt et al. 2000; Askling et al. 2003; Mandelbaum further evaluate the economic impact of injury et al. 2005; McGuine & Keene 2006; Hagglund 2007; in the most popular sport participated in world- Emery 2008; Engebretsen et al. 2008). The consist- wide. This would facilitate the greater participation ency of the findings between youth and adult stud- of policy makers in the prevention of injuries in ies is also encouraging. These programs all contain soccer. some element of balance, strength, agility, core sta- Consistently, the majority of injuries in all stud- bility (or some combination of these) training. It ies examining injury across all age groups, levels remains unclear what the optimal components and of play, and both sexes are acute-onset lower- duration of neuromuscular training are essential to extremity injuries. Injury-prevention strategies provide a protective effect soccer. The studies dem- should clearly target ankle and knee sprains and onstrating no effect have smaller sample sizes, are thigh and groin strains. Concussions and ACL inju- targeting specific injury types with lower injury ries are also of particular concern because of poten- rates, report poor compliance, or do not report tial long-term health outcomes. compliance with the program. The consistency of the evidence based on pro- Although there has been little attention to date on spective study designs for nonmodifiable risk fac- the prevention of overuse injuries in soccer, this may tors, including previous injury and sex for specific reflect the lack of knowledge and consistency related injury types such as ACL injuries for women is to overuse-injury definitions and surveillance to strong. These findings support targeting players capture these injuries. Further attention is required with a history of injury for injury prevention. The to develop consistent definitions, evaluate risk fac- strength of the evidence for potentially modifiable tors, and implement and evaluate prevention strate- risk factors is weaker, based on fewer studies exam- gies targeting overuse injuries in soccer players. ining these factors prospectively. In addition, there Future studies examining prevention strate- are few studies that use a multifactorial approach gies in soccer must further examine strategies for to examining risk factors for injury in soccer, and program delivery in order to optimize compliance hence lack of control for other potentially con- and have the greatest effect on reducing injury in founding variables threatens the internal validity soccer. The analysis strategy used to examine the of many of these studies. Future research examin- effectiveness of interventions must consider cluster ing potentially modifiable risk factors for injury effects of teams in the analysis. It is also critical to in soccer must take a multifactorial approach and continue to integrate basic science, laboratory, and further should consider the dynamic and recursive epidemiologic research to maximize the under- nature of injury risk as proposed by Meeuwisse standing of mechanisms of injury, risk factors for et al. (2007). injury, optimal prevention strategies, complete and 232 chapter 17 appropriate treatment (i.e., medical, surgical, reha- participation and the implications for the future bilitation) and long-term effects of injury in soccer. health of our population (i.e., the development of Long term follow-up studies should be part of the osteoarthritis and other disease morbidity and mor- future plan for research in injury prevention in soc- tality). What we learn from research in elite levels cer. These studies will be critical in quantifying the of soccer will certainly impact future research in long-term impact of soccer injuries on future sports more recreational populations.
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Journal of in women’s elite football tournaments. rate as predictors of adult mortality. Sports Medicine & Physical Fitness 45, British Journal of Sports Medicine American Journal of Epidemiology 136, 594–603. 41(suppl. 1), i15–i19. 201–213. Soderman, K., Alfredson, H., Pietila, T. & von Prat, A., Roos, E.M. & Roos, H. (2004) Olsen, L., Scanlan, A., MacKay, M., Werner, S. (2001) Risk factors for leg High prevalence of osteoarthritis 14 Babul, S., Reid, R., Clark, M. & injuries in female soccer players: a years after ACL tear in male soccer Raina, P. (2004) Strategies for prospective investigation during one players—a study of radiographic and prevention of soccer related injuries: outdoor season. Knee Surgery Sports patient relevant outcomes. Annals of a systematic review. British Journal of Traumatology and Arthroscopy 9, 313–321. Rheumatological Disease 63, 269–273. Sports Medicine 38, 89–94. Soderman, K., Werner, S., Pietila, T., Walden, M., Hagglund, M. & Ekstrand, J. 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(2002) Incidence of football injuries and Medicine 41(suppl.), i33–i37. The effects of the menstrual cycle on complaints in different age groups and Steffen, K., Andersen, T.E. & Bahr R. anterior cruciate ligament injuries in skill-level groups. American Journal of (2008) Self-reported injury history and women as determined by hormone Sports Medicine 28, S51–S57. lower limb function as risk factors levels. American Journal of Sports Pollard, C.D., Sigward, S.M., Ota, S., for injuries in female youth players. Medicine 30, 182–188. Langford, K. Powers, C.M. (2006) The American Journal of Sport Medicine 36, influence of in-season prevention 700–708. Chapter 18
Softball
STEPHEN W. MARSHALL1 AND JOHNA K. REGISTER-MIHALIK2 1Departments of Epidemiology, Orthopedics, and Exercise and Sport Science, University of North Carolina at Chapel Hill, North Carolina, USA 2Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, North Carolina, USA
Introduction and consequently had a focus on sliding-related injuries (Meyers et al. 2001). This early softball The purpose of this chapter is to critically examine literature includes some of the most thorough the literature reporting injury rates and potential risk factors in softball. We also discuss and suggest possible prevention measures and directions for future investigation. There are two types of softball – slow-pitch and fast-pitch. Slow-pitch softball is a hugely popu- lar sport, enjoyed by millions of recreational ath- letes in the United States as a weekend pastime. In addition, fast-pitch softball is also a popular and highly competitive sport for women at the club, high-school, collegiate, and Olympic levels. The difference lies in the pitching style and ball speeds, which are much higher in fast-pitch (Figure 18.1). Young women who play fast-pitch softball in high school—and boys who play baseball—often transition into slow-pitch recreational leagues in adult life. Little is known about this transition and the epidemiology of injury in these recreational leagues. Although the rules and many elements of the game are very similar between fast-pitch and slow- pitch softball, the stresses imposed on the athletes (especially the pitchers) are quite different. Early epidemiologic research in softball—studies pub- lished in the 1980s—largely addressed slow-pitch
Epidemiology of Injury in Olympic Sports. Edited by Figure 18.1 The fast-release under arm pitching style D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 used in fast-pitch softball places significant stress on the Blackwell Publishing, ISBN: 9781405173643 shoulder and upper arm. © IOC. 236 softball 237
intervention trials ever done in sports medicine War II, eventually leading to the formation of the (Janda et al. 1988). International Softball Federation in 1965. Fast-pitch As fast-pitch softball became more popular, the softball for women was admitted to the Olympics kinetic energies exchanged during on-field injury from 1996 to 2008. events in softball increased (Meyers et al. 2001), Despite the popularity of fast-pitch and slow- as did the biomechanical forces on pitchers’ arms pitch softball, we located very few recent epidemi- and shoulders (Werner et al. 2005). This has led ologic studies that specifically addressed softball. to the need for additional research, particularly In particular, there are no recent epidemiologic on interventions to prevent softball injury, that studies of recreational softball participants and remains largely unmet at this point (Meyers et al. younger softball players (high-school age and 2001). In fact, the current line of softball research younger). There are also no prospective studies has retreated from the early groundbreaking work identifying risk factors for softball injury and no on safety bases, becoming increasingly diffuse and recent evaluations of injury prevention programs in descriptive in nature. slow-pitch or fast-pitch softball. Finally, review of Softball is a popular sport that is widely played the literature is complicated by the fact that some in the United States and throughout the world. studies fail to clearly distinguish between slow- Over 16,600 women played collegiate (fast-pitch) pitch and fast-pitch softball (Pollack et al. 2005). softball in the 2005–2006 academic year, mak- ing it the fourth most popular college sport for Who Is Affected by Injury? women, based on the number of participants (National Collegiate Athletic Association 2007). National data from the Centers for Disease Control Fast-pitch softball is also the fourth most popu- and Prevention on emergency department (ED)– lar sport for girls at the high-school level (based attended sports injuries provides some insight on the number of participants), with over 373,000 into the significance of softball injury on a popula- participants (National Federation of State High tion basis. For girls 15 to 19 years of age, softball School Associations 2007). Beyond the high-school is the fourth most common sports activity result- and college settings, many more people play rec- ing in an ED-attended injury (Centers for Disease reational slow-pitch and competitive fast-pitch Control and Prevention 2002). By comparison, the softball in youth and adult leagues. The Sporting most common activities resulting in ED-attended Goods Manufacturers Association (2007) reports injury for girls 15 to 19 years are basketball, gym- there were a total of 10.5 million frequent, regular, nastics, and soccer (Centers for Disease Control and and casual softball participants in 2006. For the Prevention 2002). purposes of comparison, baseball has 16.1 million From 10 through to 44 years of age, softball is frequent/regular/casual participants (Sporting consistently one of the top five activities resulting Goods Manufacturers Association 2007). Thus, in sports-related injuries resulting in ED visits for baseball accounts for approximately two thirds of female participants. Across all age groups, softball participants in the batted-ball sports, with softball accounts for 5% of sports-related injuries resulting contributing the remaining one third. in ED visits for female participants. For male par- Softball was invented in 1887 by George ticipants, it is one of the top five activities resulting Hancock. Originally called mushball or kittenball, in a sports-related injury resulting in an ED visit in the name “softball” was not coined until the 1920s. the 25-to-44-year age group (Centers for Disease The sport was originally played by men and did Control and Prevention 2002). However, these not become popular with women until the forma- national data on ED-attended injuries cannot be tion of the Amateur Softball Association of America used to estimate injury incidence, since they do not in the 1930s. The sport gradually spread through- include data on the number of softball participants out the world, fueled in part by the enthusiasm at risk. Nevertheless, it is clear that softball injuries of deployed American servicemen during World in girls and women have considerable public health 238 chapter 18 year year 2003–2004 academic year year 1990 1987–1988 academic year 2.7 (practice) 3.5 (overall) 0.07 (practice) 0.10 (overall) 2.67 (practice) 0.79 (practice) 1.13 (overall) Rate/1,000 Athlete- Exposures Data Collected Year — (game) 0.11 —— 1999–2000 seasons 0.96 (overall) 1996–1999 academic 4.30 (game)— 1988–1989 through 1.78 (game) 2005–2006 academic Risk/1,000 Athletes 9 0.91 — 9 1.30 — 37 71 910 1.67 5.9 (game) 1995–1997 academic 153 No. of Injuries — — 5336 — — 99 54 No. of Participants 2 yr 3 yr 829 1 yr Prospective High school 3 yr Prospective High school 1 yr Prospective High school 1 yr Design Age Group Duration Marshall et al. 2007 Prospective College 16 yr Radelet et al. 2002Knowles et al. 2006 Prospective Community Prospective High school Rechel et al. 2008 Prospective High school Powell & Barber-Foss Powell & Barber-Foss 1999 DuRant, 1992 McLain & Reynolds 1989 Table 18.1 Table Injury risks and rates in softball. Study softball 239 significance—of a magnitude comparable to that Where Does Injury Occur? for soccer and basketball. The epidemiologic studies that met our criteria— Anatomical Location quantify both the number of softball injuries and the The frequency of injury to various anatomical size of the population at risk—for providing a reli- locations is summarized in Table 18.2. The col- able incidence estimate are listed in Table 18.1. For lege study (Marshall et al. 2007) and one of the two of these studies, the data are nearly 20 years old high-school studies (Rechel et al. 2008) disaggre- (DuRant 1992; McLain & Reynolds 1989). They are gated the data by games and practices, while the included in Table 18.1 in the interest of complete- other high-school study pooled game and practice ness, but will not be discussed further. data (Powell & Barber-Foss 1999). Irrespective of High-school data from the Reporting Injury these methodologic differences, it is clear that the Online system based at Nationwide Children’s lower extremity is the most commonly injured site, Hospital indicates an overall injury rate of 1 per 1,000 accounting for between 40% and 50% of injuries. athlete-exposures (AEs) in high-school (fast-pitch) This is followed by the upper extremity, accounting softball (Rechel et al. 2008). This agrees well with for 30% to 40% of injuries. much-older high-school data from North Carolina (Knowles et al. 2006). The incidence estimates from Rates in Games versus Practices a previous National Athletic Trainers Association (NATA) sponsored national high school injury sur- In college fast-pitch, the rate of injury was 1.6 veillance system (Powell & Barber-Foss 1999) were times higher in games than in practices, although much higher, for reasons that are unknown. the absolute numbers of game and practices inju- In relation to other high-school sports, two of ries were similar (52% practices and 48% games) the three high-school studies agreed that softball (Marshall et al. 2007). Two high-school studies has the lowest injury rate (per 1,000 AEs) of all (Powell & Barber-Foss, 1999; Rechel et al. 2008) girls’ sports that have been studied. These include report a twofold higher rate in games than in prac- volleyball, soccer, basketball (Knowles et al. 2006; tices and agree that the majority of injuries (56% to Rechel et al. 2008) track and cheerleading (Knowles 65%) occur in practice. et al. 2006). The third high school study reported that volleyball had a much lower injury rate than When Does Injury Occur? softball (Powell & Barber-Foss 1999). At the college level, softball has the lowest game Injury Onset injury rate, and the fourth lowest practice injury rate, of the 16 sports monitored by the National Because of the limited number of studies, there are Collegiate Athletic Association (NCAA) (Hootman no data on the proportion of acute versus chronic et al. 2007). Based on the college data, base runners injuries. It has been reported that very significant account for over one fourth of the injuries in fast- biomechanical forces are generated on the arm and pitch softball (29%), followed by basemen (14%), shoulder by the “windmill” technique used by batters (13%), pitchers (11%), catchers (9%), and fast-pitch pitchers (Werner et al. 2005, 2006) but, shortstops (7%) (Marshall et al. 2007). surprisingly, the epidemiology of chronic elbow The injury rate in community league slow-pitch and shoulder conditions has never been studied in softball appears to be about one tenth the rate in these athletes. high school fast-pitch, based on a study of commu- Chronometry nity-based sports in the greater Pittsburgh area in children 7 to 13 years of age (Radelet et al. 2002). There are few published data on chronometry. On the other hand, the injury rate in fast-pitch soft- However, descriptive analysis of NCAA softball ball is two to three times higher at the college level data suggests nonsignificant annual decreases (Marshall et al. 2007) than at the high-school level. in game (Ϫ0.2%; P ϭ 0.74) and practice (–0.8%; 240 chapter 18
Table 18.2 Percentage of injuries by body part injured.
Study Body Part % of Injuries
Game and Practice Combined Powell 1999 Head/neck/scalp 3.2 Face/scalp 8.0 Shoulder/arm 16.3 Forearm/wrist/hand 22.9 Trunk 5.5 Hip/thigh/leg 18.0 Knee 10.8 Ankle/foot 14.8 Other 0.5 Game Practice Marshall et al. 2007 Head/neck 13.4 9.6 Upper extremity 33.1 33.0 Truck/back 7.2 12.3 Lower extremity 43.3 40.8 Other 3.0 4.4 Game Practice Rechel et al. 2008 Head/face/neck 17.1 22.4 Lower extremity 49.1 35.0 Upper extremity 32.3 40.7 Trunk 1.5 1.9 Lower extremity 49.1 35.0
P ϭ 0.43) injury rates from 1988 to 2004. (Marshall Fractures of the hand and fingers also account for et al. 2007) These numbers suggest that despite 6% of college-game injuries. advancements in care, softball injury rates remain Note that the college study (Marshall et al. 2007) relatively unchanged. With regard to time in sea- presented combined body part and injury type son (preseason, in-season, postseason), this same combined into a single variable (i.e., this study study suggested injury rates in NCAA softball for reported on ankle sprains), whereas body part preseason practices (3.65 per 1,000 AEs) and in-sea- and injury type have been reported separately for son games (4.53) were the highest, followed by pre- the two high-school studies (i.e., sprain and ankles season games (2.65) and postseason games (2.39). were disaggregated). In-season (1.68) and postseason (0.81) practices had the lowest injury rates for time of season. (Marshall Time Loss et al. 2007) Softball injuries, on average, appear to be simi- lar and perhaps slightly less severe than injuries What Is the Outcome? in other sports, based on the distribution of time lost. The data from Reporting Injury Online at Injury Type Nationwide Children’s Hospital indicates that At the high-school level, sprains and strains are softball has a smaller proportion of injuries, with a the predominant type of injury, accounting for 40% time loss of Ͼ3 weeks higher than that of any of the to 50% of injuries (Table 18.3). At the college level, eight other study sports (Rechel et al. 2008), but this ankle sprains alone account for one tenth of total difference may simply reflect statistical fluctuation. injuries (Marshall et al. 2007). In addition, con- The previous national high-school study reported cussions account for 6% of college-game injuries. that 8% of softball injuries resulted in a time loss softball 241
Table 18.3 Percentage of injuries by type of injury.
Study % of Injuries
Powell & Barber-Foss 1999 Injury Type Game and Practice Combined General trauma 27.6 Sprains 23.8 Strains 32.2 Fractures 8.4 Musculoskeletal 3.8 Neurotrauma 3.2 General Stress 1.0 Marshall et al. 2007 Body Part and Injury Type Game Practice Ankle sprain 10.3 9.5 Knee derangement 8.7 5.4 Concussion 6.0 2.8 Upper-leg strain 5.1 8.5 Hand/digit fracture 5.9 1.6 Rechel et al. 2008 Injury Type Game Practice Sprains/strains 42.0 43.7 Contusions 19.1 11.3 Fractures 18.3 16.6 Concussions 0.4 8.9 of Ͼ3 weeks—the third lowest of the 10 sports tears and ruptures of the anterior cruciate ligament studied (Powell & Barber-Foss, 1999). The NCAA and shoulder rotator-cuff injuries clearly have a study reported that 25% of game injuries and 22% high rate of reinjury in softball. of practice injuries resulted in у10 days of time Data on cardiac deaths due to chest-wall impacts loss. This was similar to rates for women’s soccer, have been reported for softball. Maron et al. (1995) women’s lacrosse, volleyball, and women’s basket- reported two deaths over the period 1977 to 1995. ball. Gymnastics had a much greater proportion of One was of a 4-year-old girl and the other was to injuries resulting in у10 days of time loss (39% of a 16-year-old boy. Both resulted from recreational game and 32% of practice injuries), whereas field play in the family’s home or a public park. hockey had a lower proportion (15% of game and 13% of practice injuries). In a study of injury pat- Economic Cost terns among female high-school athletes, softball A high-school study from North Carolina reported resulted in the highest proportion of subsequent that the average medical cost, in 1999 U.S dollars, у injuries, causing 8 days lost, as compared with of a high-school softball injury was $416. In total, similar new injuries causing time lost when com- the average comprehensive cost for high-school pared with four other high-schools sports. (Rauh softball injury was $5,550 per injury (Knowles et al. 2007) et al. 2007). Comprehensive costs include medi- cal costs, loss of earnings, and lost quality of life. Clinical Outcome Interestingly, the average comprehensive cost of injury in softball was lower than in any of the other A study of reinjuries in girls’ high-school sports 11 sports studied (Knowles et al. 2007). (Knowles et al. 2007) noted that softball had a lower proportion of multiple injuries (19%) than What Are the Risk Factors? soccer or basketball (27% and 26%, respectively). This analysis, using the same data reported by Risk factors for injury should ideally be identified Powell and Barber-Foss (1999), demonstrated that from analytic studies, typically using prospective 242 chapter 18 cohort or case–control designs. Only a small sliding is safer than head-first sliding and number of studies have been conducted within the has no performance cost to the player (Flyger past decade for fast-pitch or slow-pitch prospec- et al. 2006). Based on this, we would recommend tively identifying risk factors for injury using corre- that the baseball studies of sliding performance lations or predictive values. Only type of base has (Hosey et al. 2003) be replicated in softball and been addressed in a series of epidemiologic stud- that this line of research be expanded to test the ies (Janda et al. 1988, 1990, 2001; Sendre et al. 1994) hypothesis that feet-first slides in softball provide (see “Injury Prevention” section). There is evidence an injury-prevention advantage with no perfor- from one study that level of play is an extrinsic mance cost. risk factor, because injury rates in the NCAA rise The downside to the increased use of the feet- slightly with advancement of competitive level. first slide is impact with the base, leading to ankle Division I has the highest injury rates (game. 4.45 sprains. In college softball, 9% of all game injuries per 1,000 AEs; practice, 2.98) followed by Division II were due to contact with a fixed (traditional) base, (game, 4.32; practice, 2.85) and Division III (game, and 43% of all game injuries due to contact with a 4.14; practice, 2.28). base were ankle sprains (Marshall et al. 2007). This suggests that increased use of the feet-first slide in combination with increased use of safety bases may What Are the Inciting Events? be the most effective injury-prevention strategy. Janda (2003) describes three types of inciting events Although 9% of all game injuries were due to in slow-pitch softball: sliding, collisions, and falls. contact with a fixed (traditional) base, only 1% In addition, injuries related to pitching and throw- of injuries involved contact with a safety base. ing are a concern in fast-pitch. However, the prevalence of safety bases in college softball is unknown. Collection of data on preva- lence of the use of safety bases would be an inex- Sliding pensive and highly useful means of verifying the In college softball, sliding accounts for 23% of inju- injury-prevention capacity of safety bases. ries in games, a rate of 0.89 injury per 1,000 AEs. By comparison, sliding accounts for only 13% of base- Pitching and Throwing ball injuries, although the rate is approximately sim- ilar (0.75 injury per 1,000 AEs). However, there are The pitching technique in softball involves three more slides per game in baseball (7.7) than in soft- phases: windup and stride, delivery, and follow- ball (5.3) (Hosey & Puffer 2000). Thus, when rates through (Flyger et al. 2006). Arm strength is an are computed using slides as the denominator, it important determinant of successful pitching, as becomes clear that the sliding-injury rate is twice as is timing, coordination, and contributions from high in softball as in baseball (12 injuries per 1,000 the trunk and rotator muscles (Flyger et al. 2006). slides vs. 6 per 1,000 slides) (Hosey & Puffer 2000). Underarm pitching is an ergonomically stressful It is important to note that, in softball, injury motion, with high loads on the arm and shoulder rates are higher for head-first slides (19.46 per 1,000 during the downward phase of arm swing (Flyger slides) than for feet-first slides (10.04 per 1,000 et al. 2006). In windmill pitchers, the loads placed slides) or divebacks (7.49 per 1,000 divebacks) on the elbow and shoulder, and the resulting dis- (Hosey & Puffer 2000). Furthermore, in a high- traction stress, are comparable to those experienced speed video analysis of 20 college baseball players, by baseball pitchers (Werner et al. 2005, 2006). it was found that performance (as measured by time Stresses on the arm and shoulder due to throw- to reach the base) was almost identical for feet-first ing are also assumed to be significant in softball. and head-first slides (3.67 seconds for feet-first vs. Axe et al. (2002) observed 220 half-innings of col- 3.65 for head-first) (Hosey et al. 2003). Thus, one lege softball and reported that pitchers threw review of the literature, concluded that feet-first an average of 89.61 pitches per game, infielders softball 243
threw the ball up to 6.30 times per game, and been evaluated (Table 18.4). The discussion below outfielders threw distances of up to 175 feet. focuses on three areas that we consider to have Based on their data, the authors developed particular importance for injury prevention and a series of off-season conditioning/rehabilitative future research. Note, however, that only safety programs. However, the effectiveness of these pro- bases have been proven effective in epidemiologic grams has never been studied. studies of softball injury. The sections on “Other Equipment Modifications” and “Throwing and Contact with Other Players and Objects Pitching” reflect our informed opinion, drawing on (Collisions and Falls) biomechanical research and baseball studies.
Over half the game injuries in college softball are Safety Bases due to contact with inanimate objects, including balls (14%), the ground (14%), bases (10%), and Softball is distinguished by an early series of stud- dugouts, walls, and railings (2%) (Marshall et al. ies that addressed safety bases (Janda et al. 1988, 2007). The use of safety balls and safety bases and 1990; Sendre et al. 1994). These studies demon- padding of walls and railings have the potential to strated the effectiveness of safety bases, with over reduce some of these injuries (Meyers et al. 2001). 90% of sliding injuries prevented (Table 18.5). It is clear from these studies that the use of safety bases Injury Prevention should be encouraged at all levels of the game. It is curious, however, that the line of research address- There has been a long-standing interest in the med- ing safety bases petered out in the 1990s. Typically, ical community in reducing the risk of injury to a positive evaluation of an effective intervention children and adolescents playing baseball and soft- would generate additional follow-up research, ball (American Academy of Pediatrics Committee addressing how best to effect behavioral change on Sports Medicine and Fitness 1994). However, in an effort to have the intervention adopted by as as is the case for many sports, the few scientific many users as possible. studies that have focused on the effectiveness of These studies are also interesting from a meth- preventive measures and the majority of the inter- odologic standpoint. Softball and baseball fields ventions that have been suggested have never were fitted with the safety bases and teams rotated
Table 18.4 Proposed, promising, and proven interventions for softball injury.
Intervention Supporting Literature
Proven Safety bases Janda 1990; Janda et al. 1992; Sendre 1994 Promising but Unevaluated Throwing and pitching conditioning programs Meyers et al. 2001; Axe et al. 2002; Flyger et al. 2006 Suggested but Unevaluated Coaching and player education Meyers et al. 2001; Radelet et al. 2002 Padding of walls, backstops, rails, and dugouts Meyers et al. 2001; Janda 2003 Pitch counts Werner et al. 2005 Well-maintained fields, facilities, and equipment Meyers et al. 2001; Janda 2003 Return-to-play guidelines for concussions, neck/back injuries, Radelet et al. 2002 fractures, and dislocations Reduced-impact balls Flyger et al. 2006 Face guards Radelet et al. 2002 Feet-first slides instead of head-first slides Flyger et al. 2006 Ineffective Chest protectors Flyger et al. 2006 244 chapter 18 Study Conclusion “Use of breakaway bases … could potentially achieve of a … reduction injuries.” bases “Breakaway …. safer than are stationary standard bases.” “Use of the Hollywood Impact Base in baseball and softball sig- nificantly reduced the possibility of injury.” b Proportion Proportion of Sliding Injuries Prevented 96% (95% CI, 82–99) gRR ϭ 0.04 (95% CI, 0.01–0.18) 97% (95% CI, 89–99) gRR ϭ 0.03 (95% ,CI: 0.01–0.11) 92% (95% CI, 27–99) gRR ϭ 0.08 (95% CI, 0.01–0.73) No. of Sliding Injuries 2 on break- away; 45 on traditional 2 on breakaway 1 on Hollywood; 4 on traditional Exposure Exposure Data 633 games played with breakaway bases; 627 games played with standard bases 1035 games played with breakaway bases 472 games and 33,153 AEs on Hollywood bases; 155 games and 3,999 AEs on tradi- tional bases Injury Data Source emergency stu- rooms, dent health clinic, orthopedic surgeons Janda 1988 medicine person- nel and umpires Duration 2 yr Field staff, 2 yr Same as 2 yr Sports Base Study Rogers Break-Away Base Rogers Break-Away Base Hollywood Impact Base a Study Population softball league (Ann Arbor summer league), 18–55 men and yr, women Same popula- tion as Janda 1988 softball, collegiate (varsity/junior varsity/intra- mural) baseball and softball, high-school and club baseball, men 15–48 yr, and women Controlled trialControlled Recreational Preintervention/ postintervention trialControlled Recreational Defned as 1 – gRR, or (injury risk per game using safety bases/injury traditional bases). A similar table appears in Pollack et al (2005). A Table 18.5 Table Safety bases in softball. Study Design CI ϭ confidence interval; gRR game risk ratio. AE ϭ athlete-exposure; a b Janda et al. 1988 Janda et al. 1990 Sendre et al. 1994 softball 245
between the fields with traditional bases and the to induce injury. Pitch-count programs are designed safety bases, so that all teams played on both types to limit the number of pitches thrown in games and of base. However, none of studies describe a proce- practices by a single individual. A severe limita- dure for randomizing teams to fields, and none of tion of these programs is that they apply only to them provide a clear study definition of a “sliding” the number of pitches thrown in a specific setting, injury. In one study (Sendre et al. 1994), the recrea- such a given league. A child who plays in multiple tional softball teams played on both traditional and leagues, or who throws a lot of practice pitches in safety bases, whereas the college, high-school, and an informal setting (such as at home), could easily club softball and baseball teams played only on exceed the recommended pitch count. safety bases, creating the potential for confound- ing by sport and level of competition. The other Further Research two studies used games played as the denomina- tor (Janda et al. 1988, 1990), rather than the more As has been noted by other reviewers (Meyers et al. nuanced measure of athlete-exposures. Despite 2001; Pollack et al. 2005; Flyger et al. 2006) the scien- these limitations, the studies were highly influential tific literature on softball is sporadic and episodic. and are widely regarded as landmark publications. From a public health perspective, the amount of research effort devoted to softball is woefully insuf- Other Equipment Modifications ficient, relative to its overall popularity in the com- munity and at the high school and college level. In Laboratory studies of protective eyewear indicate particular, there is a dearth of analytical epidemio- that polycarbonate lenses provide excellent protec- logic risk-factor studies and rigorous intervention tion for batters from the risk of being hit in the eye studies addressing injury prevention in softball. by a pitched ball (Vinger et al. 1997). Two baseball The overwhelming preponderance of the research studies have indicated that face guards reduce the effort in the batted-ball sports is directed toward risk of facial injury by 23% to 35% (Danis Hu & baseball, despite that fact that softball accounts for Bell 2000; Marshall et al. 2003). Reduced-impact over one third of participants in these two sports balls (also known as safety balls or sof-tee balls) combined. Although some of the knowledge have been found to be effective in preventing injury gleaned from baseball research can be assumed to in youth baseball (Marshall et al. 2003; Pasternack be applicable to fast-pitch softball, there are suffi- et al. 1996). These balls deform on impact and dis- cient differences between the games (especially in sipate the kinetic energy of the ball over a wider terms of pitching mechanics) that there is a pressing area, thereby reducing impact force. need for more epidemiologic research on softball. Chest or “heart” protectors are commercially There are few (if any) epidemiologists conduct- available for batters and fielders. They consist of ing research specifically targeting softball injury. padding worn over the sternum and chest wall. We located only one epidemiologic study within Although it is claimed that these devices prevent the past decade that addressed solely softball commotio cordis, they appear to be completely (Marshall et al. 2007); however, even this paper was ineffective (Viano et al. 2000; Weinstock et al. 2006; part of a special journal supplement addressing Doerer et al. 2007). multiple sports. In contrast, three review papers calling for more softball research were published Throwing and Pitching between 2001 and 2006 (Meyers et al. 2002; Pollack Repeatedly pitching and throwing a softball is an et al. 2005; Flyger et al. 2006). It seems that softball ergonomically stressful activity. Youth pitchers who has the dubious distinction of having more pub- throw a large number of pitches in a short span lished calls for epidemiologic research than actual of time are potentially at risk of incurring repeti- epidemiologic research papers. tive overuse syndrome (Werner et al. 2005, 2006). It is clear that the current epidemiologic research Repetitive throwing of the ball also has the potential in this area is limited and needs to be strengthened 246 chapter 18 through additional studies of youth and recreational in the United States—outside the high-school and populations, the use of analytic cohort and case–con- college settings—that is almost completely under- trol studies designed to identify and quantify risk studied. Conditioning programs specific to softball factors for injury, and a return to intervention studies developed for off-season or rehabilitative purposes (such as the safety-base studies) evaluating injury- (Axe et al. 2002) have never been evaluated. Pitch- prevention initiatives. Some calls for future research count limits appear to be successful in baseball along these lines include those emphasizing the need (Lyman et al. 2002) but have never been studied in for descriptive studies and injury surveillance data softball. The use of face guards in softball has been (Meyer et al. 2001; Pollack et al. 2005), analytic stud- recommended (Radelet et al. 2002) but never studied. ies aimed at identifying risk factors (Pollack et al. Concerns have been noted about the biomechan- 2005) and specific research initiatives including the ics of pitching in elite fast-pitch softball. Literature effect of surfacing on injury risk (Meyers et al. 2001), indicates there is excessive distraction at the shoul- conditioning and rehabilitation programs (Meyers der as a result of muscle force used to produce et al. 2001; Flyger et al. 2006), the effectiveness of delivery of the pitch. (Janda et al. 1992; Loosli institutional-level injury-prevention programs et al. 1992; Werner et al. 2005, 2006) This distrac- (Meyers et al. 2001), and the effect of plyometric tion, force, and torque presumably predisposes the training programs on injury risk (Flyger et al. 2006). softball pitcher to overuse injury, but no prospec- In addition to the areas for future research identi- tive cohort studies have been conducted to quan- fied by previous authors (Table 18.4), there is also a tify their incidence of overuse injury. Likewise, need for a comprehensive prospective cohort study sliding mechanics presumably also predispose soft- aimed at identifying a variety of intrinsic (e.g., age, ball athletes to injury (Corzatt et al. 1984), but has skill, sliding technique, pitching mechanisms, physi- never been addressed in rigorous analytical epide- cal characteristics) and extrinsic (e.g., experience, miologic study such as a prospective cohort study. level of competition, coach factors, equipment, types Finally, more research on safety interventions is of bases used) risk factors. There is a pressing need needed. In particular, more research on safety bases to study the effect of the stresses placed on the upper is needed, in order to identify who is currently not extremity by pitching in fast-pitch softball, particu- using them, whether they would benefit from using larly with a view to the identification of particular them, and to identify barriers to adoption of safety movement patterns, pitching styles, or anatomical bases. It is also important to replicate the studies characteristics of arm and shoulder, that would pre- that demonstrated that the bases were effective in dispose these athletes to acute or overuse injury. preventing injury (especially since the most recent Research should be done to distinguish the injury of those studies is nearly 20 years old). Research differences between slow- and fast-pitch softball. on sliding is also needed, with a view to determin- Research should also focus on the recreational slow- ing whether feet-first slides provide an injury pre- pitch population that forms the majority of softball vention without a performance cost, as has been players. Little research exists for the youth popula- suggested (Flyger et al. 2006). We suggest that the tion, in which a great number of athletes participate feet-first slide in combination with the safety base in softball at various levels. There is also a large (Ͼ1 would be an important injury-prevention strategy million participants) amateur fast-pitch population to target in future research.
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Taekwondo
WILLY PIETER Department of Physical Education, University of Asia and the Pacific, Pasig City, Philippines
Introduction below national. One A-E refers to one athlete being exposed to the possibility of incurring an injury Taekwondo is a modern sport that originated in when engaged in a bout. Korea in the 1950s. It was based on Japanese karate Perusal of Table 19.1 indicates that most of the inju- using non-contact rules for competition (Capener ries in taekwondo competition in adults are not seri- 1995) and was internationally unified under the ous—that is, do not lead to time away from practice International Taekwondo Federation in 1966. In or competition. The total competition injury rate for 1973, a full-contact version eventually emerged in men ranges from 20.6 to 139.5 per 1,000 A-E, while Korea under the banner of the World Taekwondo their time-loss injury rate ranges from 6.9 to 33.6 per Federation (WTF). It is this form of taekwondo that 1,000 A-E. For women, the total injury rate ranges appears at the Olympic Games. from 25.3 to 105.5 per 1,000 A-E, while their time-loss The purpose of this chapter was to review inju- injury rate ranges from 2.4 to 23.8 per 1,000 A-E. ries in adult taekwondo athletes according to WTF rules. For a review of taekwondo injuries in youth, children and adolescents, see Pieter (2005). Where does injury occur?
Anatomical location Who is affected by injury? The prospective studies included in Table 19.2 indicate Table 19.1 shows comparative competition injury the lower extremities to be the body region injured rates per 1,000 athlete exposures (A-E) in adult most often in taekwondo competition for all reported taekwondo-in (taekwondo athletes). An injury was injuries, which is consistent with the almost exclusive defined as any circumstance for which the athlete use of kicking techniques in competition and training. sought the assistance of the on-site medical per- The range of the percent distribution of all reported sonnel, while a time-loss injury was defined as one injuries to the lower extremities is from 0.0% to 45.7% that prevented the competitor from completing the in men and from 50.0% to 100.0% in women. The present bout or subsequent bouts or both, and from instep of the foot is especially susceptible to injury participating in taekwondo for a minimum of 1 (Pieter & Zemper 1995; Kazemi & Pieter 2004). day thereafter. Elite is defined as competing at the What is of more concern, however, is that in com- (inter)national level, while recreational is anything petition, the head-and-neck area is the second most frequently injured body region, with 22.2% to 75.0% of all reported injuries in men and 7.9% to 25.3% in women (Table 19.2). Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 In a prospective training study by Kim et al. Blackwell Publishing, ISBN: 9781405173643 (1994), the lower limbs were reported to be the 249 250 chapter 19
Table 19.1 Distribution of injury rates per 1,000 athlete-exposures (95% confidence interval) in adults.
Study Study Level Competition Sample Total Injury Time-Loss Injury Design Size Ratea Rateb
Zemper & Pieter P Elite Team Trials M ϭ 48 127.4 (79.3–175.4) 23.6 (5.1–52.3) (1989) F ϭ 48 90.1 (50.6–129.6) 13.5 (1.8–28.8) Pieter & Lufting P Elite World M ϭ 273 — 22.9 (9.9–35.9) (1994) Championship F ϭ 160 9.7 (1.3–20.6) Pieter (1995) P Elite National M ϭ 1,665 — 33.5 (27.3–39.6) Championships F ϭ 742 23.0 (15.7–30.4) Pieter et al. (1995) P Elite European Cup M ϭ 67 139.5 (94.0–185.1) 27.1 (7.0–47.2) F ϭ 30 96.5 (39.5–153.5) 8.8 (8.4–26.0) Pieter et al. (1998)a P Recreational Open M ϭ 46 51.3 (1.0–101.5) 25.6 (9.9–61.2) tournament Pieter & Bercades F ϭ 24 47.6 (18.4–113.6) 23.8 (22.9–70.5) (1997)b Pieter & Zemper P Elite National M ϭ 1,665 95.1 (84.7–105.4) — (1999) Championships F ϭ 742 105.5 (89.8–121.1) Koh et al. (2001) P Elite World M ϭ 330 120.8 (92.9–148.7) 33.6 (18.9–48.3) Championship F ϭ 233 90.1 (61.4–118.7) 14.22 (2.8–25.6) Beis et al. (2001b)a P Elite National M ϭ 533 20.6 (11.8–29.3) 6.9 (1.8–11.9) Championship Beis et al. (2007)b F ϭ 216 36.4 (18.0–54.8) 2.4 (2.3–7.2) Kazemi & Pieter P Elite National M ϭ 219 79.9 (53.4–106.4) — (2004) Championship F ϭ 99 25.3 (3.2–47.4)
F ϭ female; M ϭ male; P ϭ prospective. a Any circumstance for which the athlete sought treatment from the on-site medical personnel. b Any injury that prevented the competitor from completing the present bout or subsequent ones or both and from participating in taekwondo for a minimum of 1 day thereafter.
body region most often affected, followed by the When does injury occur? trunk. In a retrospective study, Kazemi et al. (2005) confirmed the lower extremities (46.5% of all inju- Injury onset ries) to be most often injured in taekwondo train- Most analyses of taekwondo injuries have been ing, followed by the upper extremities (18.0%) as concerned with acute injuries, and few studies have did Zetaruk et al. (2005) in their retrospective train- detailed a gradual onset of taekwondo competition ing study on time-loss injuries: 57.1% and 40.8% for injuries. For instance, Pieter and Zemper (1999) the lower and upper extremities, respectively. reported gradual onset of injuries in both men (0.6 per 1,000 A-E; 95% confidence interval [CI], 0.2–1.4) Environmental location and women (0.6 per 1,000 A-E; 95% CI, 0.6–1.8). The literature search revealed that most stud- Information implicated in the gradual onset of ies included all reported taekwondo injuries that competition injuries, such as frequency, duration, occurred at competitions. Few are available on such and intensity of training, however, is lacking (Ohta- injuries sustained during training. Fukushima et al. 2002). taekwondo 251 —— Kazemi & Pieter (2004) Beis et al. (2001) ———2.9 Koh et al. (2001) 2.22.23.9 — 1.2 2.2 5.6 — 1.4 — 6.7 9.5 4.8 — — — 14.3 2.8 1.2 — — — 6.7 — 11.1 4.6 7.0 6.7 14.3 6.7 17.1 — Pieter & Zemper (1999) a —— taekwondo-in. Pieter et al. (1998) 9.1 50.0 50.0 7.2 6.9 8.5 2.6 9.5 — 11.4 9.1 — — 2.5 3.9 7.0 26.7 — — — ——— 25— — — — — — — 7.4 — 7.4 4.6 2.9 3.7 4.6 4.0 8.5 6.9 2.8 — 5.3 4.2 — — — — 4.8 — 4.8 14.3 6.7 — 8.6 6.7 2.9 2.9 8.6 ——— — 25.0 — — — — 4.9 2.8 1.8 7.5 2.9 1.2 5.6 11.3 2.8 6.7 6.7 14.3 6.7 — 13.3 4.8 — — — 8.6 — 2.8 2.8 18.2 2.8 — Pieter et al. (1995) 3.7 3.77.43.7 5.0 3.7 — — 10.0 7.4 3.7 5.0 3.7 3.7 3.7 5.0 — — — — 13.1 14.4 1.4 15.8 9.5 6.7 22.9 40.0 — — — 15.0 8.3 27.3 — — 2.8 2.9 5.6 5.3 — 6.7 — — — — — — — — — — 1.2 — — — 11.111.1 5.0 15.0 8.3 — 27.3 — — — — 50.0 4.4 9.0 11.5 4.0 8.5 9.9 13.2 10.5 9.5 4.8 — 13.3 5.7 — — — 11.1 — 8.3 18.2 MF MF M F M F27 MF MF MF 22.2 20 20.0 36 33.3 9.1 11 75.0 4 50.0 2 30.3 25.3 324 23.9 174 7.9 71 33.3 38 13.3 34.3 21 — 15 35 5 22.2 —14.8 — 9.144.4 25.0 80.018.5 41.7 — 40.0 63.6 12.0 25.0 — 15.5 9.1 50.0 26.8 — 45.7 46.8 — 19.1 52.3 13.3 16.4 42.3 8.6 71.1 19.5 33.3 16.9 — 66.7 26.3 40.0 9.5 100 40.0 11.4 60.0 Zemper & Pieter (1989) Injury rates per 1,000 athlete-exposures (95% CI) for all studies combined. Injury rates per 1,000 athlete-exposures —Groin —Other —Face —Mouth —Nose —Other Trunk M, 9.0 (6.6–11.4) 4.3 (2.0–6.6) F, —Ribs Total no. of injuries Total Head and neck M, 24.9 (20.9–29.3) 17.2 (12.5–21.9) F, —Head —Pelvis/hips —Other M, 11.0 (8.4–13.7) M, 11.0 14.2 (10.0–18.5) F, —Hands M, 44.2 (38.1–48.7) 53.0 (44.6–61.2) F. —Foot —Lower leg —Knee —Upper leg Other Upper extremities —Fingers —Wrist —Other Lower extremities Table 19.2 Table injuries by location in distribution of all reported Percent F ϭ females; M males. a 252 chapter 19
Chronometry (Pieter & Zemper 1995; Koh, de Freitas & Watkinson 2001). Lacerations range from 3.7% to 25.0% when Only Beis et al. (2001a) have reported the time dur- collapsed over sex. ing competition when an injury occurred. They Regardless of the definition used to classify the found that rates were highest in the preliminary injury, early and recent research has highlighted rounds and decreased as competition progressed. the cerebral concussion as an area of concern in the Specifically, men incurred 52.3% of all injuries in epidemiology of taekwondo injuries (e.g., Pieter & the first match (10.8 per 1,000 A-E; 95% CI, 4.4– Zemper 1998; Koh & Watkinson 2002a; 2002b). 17.1), followed by 23.8% (4.9 per 1,000 A-E; 95% CI, Table 19.4 depicts the percent distribution and 0.6–9.2) in the semifinals, and 19.1% (3.9 per 1,000 competition injury rates for cerebral concussions A-E; 95% CI, 0.1–7.8) in the finals. in adults. Zemper and Pieter (1994) estimated that The women sustained 33.3% of all injuries in the there was about one concussion for every 100 jun- first match (12.1 per 1,000 A-E; 95% CI, 1.5–22.8), ior and senior competitors combined. followed by 26.7% in the semifinals (9.7 per 1,000 A-E; 95% CI, 3.0–16.4) and 20.0% in the finals (7.3 Time loss per 1,000 A-E; 95% CI, 1.0–15.5). Table 19.5 displays rates (with 95% confidence What is the outcome? intervals) for overall and specific competition time- loss injuries in taekwondo as well as the estimated days lost. Overall time-loss injuries refer to any time- Injury type loss injury. Specific time-loss injuries refer to days Table 19.3 displays the percent distribution of away from taekwondo due to injury to a specific injury types sustained in competition. The contu- body region or body part or time away from taek- sion was the most often occurring type of injury, wondo as a result of a specific injury type, such as across all studies summarized in the table. a cerebral concussion. Collapsed over sex, fractures range from 7.9% Table 19.5 shows that the majority of competi- to 22.5% of all reported injuries. The foot has been tion time-loss injuries led to Յ1 week of restricted found to be especially susceptible to fractures taekwondo participation. In men, the rate for
Table 19.3 Percent distribution of all reported injuries by type in taekwondo-in.
Zemper & Pieter Pieter & Kazemi & Pieter Pieter et al. et al. Zemper Koh et al. Beis et al. Pieter (1989) (1995) (1998) (1999) (2001) (2001) (2004)
MFMFMFM FMFMF MF
Abrasion 3.7 — — — — — 1.9 2.3 4.2 — — 33.3 2.9 — Concussion 3.7 5 11.1 9.1 25 — 7.4 2.3 8.5 5.3 4.8 — 8.6 — Contusion 63 75 50 90.9 50 50 48.5 53.5 28.2 50 52.4 46.7 14.3 60 Dislocationa — 5 — — — — 0.6 2.3 2.8 — 4.8 6.7 — — Epistaxis — — 5.6 — — — 1.9 5.2 — — 4.8 6.7 2.9 — Fractureb 14.8 — 11.1 — — — 10.5 8.1 22.5 7.9 14.3 — — — Laceration 3.7 — 8.3 — 25 — 10.8 8.6 4.2 5.3 14.3 6.7 14.3 — Sprain 3.7 5 11.1 — — — 11.1 8.6 14.1 23.7 4.8 — 28.6 20 Strain 3.7 5 — — — — 1.5 3.5 9.9 7.9 — — 11.4 20 Other 3.7 5 2.8 — — 50 5.8 5.6 5.6 — — — 17.1 —
F ϭ females; M ϭ males. a Includes subluxation. b Includes suspected fractures. taekwondo 253
head-and-neck time-loss injuries leading to Յ7 The technique that led to the fatal injury in the days of restricted activity was significantly higher adolescent practitioner was a roundhouse kick to than those leading to Ն21 days away from taek- the celiac plexus while sparring with an advanced wondo participation: 7.6 per 1,000 A-E (95% CI, student. No protective equipment was worn. The 4.7–10.6) versus 2.1 per 1,000 A-E (95% CI, 0.5–3.6) cause of death was believed to be cardiac arrest as (Pieter & Zemper 1997). a result of vagal stimulation secondary to the kick. The death of the adult male was a result of a spinning back kick to the left lower lateral aspect Clinical outcome of the anterior chest while sparring with his Scant data are available on fatal injuries in taek- instructor. No protective equipment was worn. wondo training or competition. Two deaths (one The cause of death was suggested to be aspiration male adolescent and one adult) that occurred dur- and asphyxia as a result of the spinning back kick ing training were described by Schmidt (1975). (Schmidt 1975).
Table 19.4 Percent distribution and injury rates per 1,000 athlete-exposures (95% confidence interval) of cerebral concussions in adults.
Study Males Females
% Rate % Rate
Zemper & Pieter (1989) 3.7 4.7 (4.5–14.0) 5.0 4.5 (4.3–13.3) Pieter & Lufting (1994) Not available 15.3 (4.7–25.9) Not available 3.2 (3.1–9.6) Pieter et al. (1995) 11.1 15.5 (0.3–30.7) 9.1 8.8 (8.42–26.0) Pieter et al. (1998) 25.0 12.8 (12.3–38.0) — — (—) Pieter & Zemper (1998) 7.4 7.0 (4.2–9.9) 2.3 2.4 (0.0–4.8) Koh et al. (2001) 8.5 10.1 (6.0–26.2) 5.3 4.5 (2.1–11.0) Beis et al. (2001b) 4.8 1.0 (0.9–2.9) — — (—) Koh & Watkinson (2002a) Not available 55.2 (27.2–83.1) Not available 49.3 (12.8–85.8) Kazemi & Pieter (2004) 8.6 6.9 (0.9–14.6) — — (—)
Table 19.5 Overall and specific time-loss injury rates per 1,000 athlete-exposures (95% confidence interval) in adults by sex and days lost.
Study/Body Men, Time Lost Women, Time Lost part Յ7 days 8–20 days Ն21 days Յ7 days 8–20 days Ն21 days
Pieter & 2.1 (0.5–3.6) 0.6 (0.2–1.4) 1.5 (0.2–2.8) 1.2 (0.5–2.9) — 1.2 (0.5–2.9) Zemper (1995) (foot) Pieter & 7.6 (4.7–10.6) 2.9 (1.1–4.8) 2.1 (0.5–3.6) 5.5 (1.9–9.0) 1.8 (0.2–3.9) 1.2 (0.5–2.9) Zemper (1997) (head & neck) Pieter & 25.6 (9.9–61.2) — — 23.8 (22.9–70.5) — — Bercades (1997) (overall) Pieter & 3.2 (1.3–5.1) 0.9 (0.1–1.9) 1.2 (0.0–2.3) 1.8 (0.2–3.9) — — Zemper (1998) (concussion) 254 chapter 19
A more recent case study reported the death of males also sustained the higher grades of concussion an adult female practitioner as a result of arrhyth- (Pieter & Zemper 1998; Zemper & Pieter 1994). mogenic cardiomyopathy (Aguilera et al 1999). No further information was provided for this particu- Age differences—total injuries lar case. Based on the data reviewed in this chapter, men are In a prospective study, Oler et al (1991) revealed at a higher risk of incurring any injury as compared one fatal injury secondary to a spinning hook kick with boys: relative risk, 1.6 (95% CI, 1.4–1.8; PϽ0.001), to the head at a national competition. The authors and women are at a higher risk than girls: relative did not provide any demographic details, but the risk, 2.0 (95% CI, 1.6–2.3; PϽ0.001). athlete died within 24 hours after receiving the kick. The post-mortem examination showed the fol- Age differences—time-loss injuries lowing: occipital skull fracture (the hardwood floor Ն was not matted), bilateral acute subdural hemato- Zetaruk et al (2005) reported that older ( 18 years) mas, contusions of the frontal and temporal lobes, students of karate, taekwondo, aikido, and kungfu hemorrhage, and herniation of the brainstem. were more at risk of incurring training time-loss injuries (i.e., those that require time off from train- What are the risk factors? ing or competition for Ͻ7 days) than their younger counterparts (odds ratio, 4.0; 95% CI, 1.5–9.5). Intrinsic factors Based on the data reviewed in this chapter, men were at a higher risk than boys (relative risk, 1.5; 95% Although skill level has been suggested to be CI, 1.2–1.9; PϽ0.001), while women were more likely implicated in total taekwondo competition injuries to sustain a time-loss injury in competition than girls (Zandbergen n.d.), published research to establish (relative risk, 4.3; 95% CI, 3.1–5.8; PϽ0.001). this relationship is lacking (Pieter 1996). Zetaruk et al (2005) found that skill level (belt rank) was Age differences—cerebral concussions not a predictor of time-loss training injuries of Ͻ7 days away from practice in a group of karate, taek- Based on the data reviewed in this chapter, boys wondo, aikido, and kungfu athletes. were more likely to sustain a cerebral concus- sion than men (relative risk, 1.9; 95% CI, 1.5–2.6; Ͻ Sex Differences—Overall Time-Loss Injuries and P 0.001) and girls were at higher risk than women Ͻ Cerebral Concussions (relative risk, 3.6; 95% CI, 2.1–6.2; P 0.001).
Based on the data reviewed in this chapter, men Experience—time-loss injuries were at a higher risk than women of sustaining Zetaruk et al (2005) revealed that those with у3 competition time-loss injuries (relative risk, 1.5, years of experience were at a greater risk of time-loss 95% CI, 1.1–2.1; P ϭ 0.006). They were also at a injuries of Յ7 days as compared with their less expe- higher risk of incurring a cerebral concussion: rela- rienced colleagues (odds ratio, 2.5; 95% CI, 1.5–4.0). tive risk, 1.9 (95% CI, 1.1–3.4, P ϭ 0.020). Table 19.4 indicates that there are differences Age/experience—time-loss injuries between men and women in competition injury rates for concussions based on the point estimates, An interaction between age and experience was but not when the 95% confidence intervals are taken found for time-loss injuries of Ն7 days away into account. The small sample sizes in each indi- from practice or competition as well as multiple vidual study may have precluded any significant instances of time-loss injury. For those who were differences However, when the data in Table 19.4 younger than 18 years, regardless of years of expe- were combined, the men recorded an injury rate for rience, the probability of time-loss injuries of Ն7 concussions of 9.4 per 1,000 A-E (95% CI, 7.1–11.7), days was less than 1%. Those who were Ͼ18 years which is significantly higher than that for the women of age and had Ͻ3 years of experience had a prob- (4.6 per 1,000 A-E; 95% CI, 2.6–6.5). More adult ability of 12% to sustain a time-loss injury of Ն7 taekwondo 255
days, while those of the same age with Ն3 years of subscales. In the men who lost and were depressed, experience had a probability of 35% to sustain such 62.5% were correctly classified (P ϭ 0.035) as time-loss injuries (Zetaruk et al 2005). injured or not injured based on fatigue; those who were injured were more fatigued. Previous injury Extrinsic factors Koh and Cassidy (2004) reported that those who had a history of receiving a head blow leading to Although it has been suggested that rule changes a concussion were at a reduced risk of getting one that came into effect in 2002, awarding more at the competition covered during the study period points for head blows, might have contributed to (odds ratio, 0.6; 95% CI, 0.5–0.8). This is contrary an increase in cerebral concussions in competition to what previous research showed (e.g., Barnes (Koh & Watkinson 2002a), no analytical data are et al. 1998). It might be that those who had a history currently available to confirm this. of receiving head blows were more cautious and Zetaruk et al (2005) found that taekwondo-in were adopted defensive techniques or evasive maneu- at higher risk than karateka (karate athletes) to incur vers and may also have improved their anticipa- time-loss injuries of Ͻ7 days (odds ratio, 3.3; 95% tory skills (Koh & Watkinson 2002b). CI, 1.5–7.3). They were also at higher risk to sustain time-loss injuries requiring Ն7 days away from Technique training or competition as compared with karateka (odds ratio, 3.7; 95% CI, 1.9–7.4). When collapsed over age group, those who used blocking skills were less likely to receive a head blow in competition (odds ratio, 0.7; 95% CI, 0.5–0.9) What are the inciting events? or sustain a concussion (odds ratio, 0.6; 95% CI, Table 19.6 shows the percent distribution of tech- 0.4–0.9) (Koh & Cassidy 2004). niques that led to any competition injury, and Table 19.7 displays the exact circumstances that Psychological profile led to time-loss injuries. Beis et al. (2007) found the Pieter et al. (2005b) revealed a relationship between roundhouse and spinning hook kicks implicated in pre-competition mood and total injury. Pre- time-loss injuries (Figure 19.1). competition mood was assessed approximately 1 Table 19.6 shows that when collapsed over sex, hour prior to competition. In women who lost and the roundhouse kick is involved in 20.0% to 66.7% were depressed, 83.0% were correctly classified of total injuries, followed by the spinning back kick (P ϭ 0.004) as injured or not injured based on anger, with 1.5% to 36.4%. In terms of overall time-loss fatigue, and confusion—that is, those who were injuries, the roundhouse kick was the predominant injured scored higher on the aforementioned mood technique, at 14.3% to 100.0%.
Table 19.6 Percent distribution of inciting events (frequency of techniques) involved in injury in adults.a
Pieter et al (1995) Pieter et al (1998) Koh et al (2001) Beis et al (2001b)
Men Women Men Women Men Women Men Women
Roundhouse kick 66.7 63.6 25.0 50.0 56.5 65.8 47.6 20.0 Spinning hook kick 2.8 — — — 1.5 5.3 9.5 — Spinning back kick 8.33 36.4 — — 1.5 2.6 9.5 6.7 Axe kick 2.8 — — — 2.9 2.6 4.8 6.7 Side kick — — — — 11.6 7.9 — — Other 19.37 — 75.0 50.0 26.0 15.8 28.6 66.6 a Any circumstance for which the athlete sought treatment from the on-site medical personnel. 256 chapter 19
Table 19.7 Percent distribution of inciting event characteristics involved in time-loss injuries.a
Pieter et al (1995) Pieter & Bercades (1997)
MFM F
Receiving roundhouse kick 42.9 — — — Receiving spinning hook kick 14.3 — — — Delivering roundhouse kick 14.3 100.0 Receiving spinning back kick — 100.0 — — Simultaneous roundhouse kicks — — 50.0 — Simultaneous punches — — 50.0 — Other 28.6 — — — a Any injury that prevented the competitor from completing the present or subsequent bout, or both, and from participating in taekwondo for a minimum of 1 day thereafter.
Figure 19.1 Spinning kicks are a common inciting event of injury. © IOC/Steve MUNDAY.
Table 19.8 presents inciting events involved in heterogeneous sample of beginning to advanced head blows in competition with and without con- practitioners ranging in age from 18 to 66 years. cussion. Collapsed over gender, the axe kick was Punches and kicks to the face were not allowed. involved in most of the head blows without concus- Comparisons were subsequently made with stud- sion (41.5% to 56.8%), followed by the roundhouse ies in which full-contact taekwondo injuries were kick (40.0% to 51.2%). When head blows were fol- investigated in homogeneous samples of mostly lowed by concussions, the roundhouse kick was elite athletes. The conclusion was that the imple- involved in 42.9% to 75.0%. mentation of preventive measures resulted in a sig- nificantly lower injury rate. Injury prevention However, the study has several methodologi- cal flaws. For example, the researchers focused on As far as is known, only Burke et al (2003) have “light contact” taekwondo as opposed to the full- investigated intervention measures to prevent contact version that appears at the Olympic Games, taekwondo-related injury. The authors set out to and in the absence of injury data before the imple- investigate the effect of preventive measures in a mentation of preventive measures, any reported taekwondo 257
Table 19.8 Percent distribution of inciting events (frequency of techniques) involved in head blows or cerebral concussions.
Koh & Pieter et al. Koh & Watkinson (2002a) Watkinson (1995)— cerebral (2002b)— Concussions Head Blows with- Head Blows with Head Blows out Concussion Concussion
Men F Men Women Men Women Men Women
Roundhouse kick 46.7 40.0 75.0 — 51.2 40.9 53.3 42.9 Spinning back kick 5.0 — 100.0 4.9 2.3 13.3 14.3 Axe kick 46.7 55.0 — — 41.5 56.8 26.7 28.6 Other 6.7 — 25.0 —— — — 14.3 effects of these measures seem premature. Finally, the United States (http://www.ncaa.org/wps/ the calculation of injury rates per 1,000 A-E resulted ncaa?ContentID=1126) or the Injury Information from dividing the number of total injuries by the System in The Netherlands (https://bis.pgdata.nl). total number of athletes, with one exposure being The latter already has an entry for martial arts. equal to one tournament. The investigators arrived These national governing bodies could subse- at their injury rate per 1,000 A-E for the one time- quently feed into an international taekwondo loss injury reported by dividing the total number injury surveillance system coordinated by the WTF. of participants (2,498) by 1,000 as the denominator, Before the effectiveness of any interventions resulting in a time-loss injury rate of 0.4 per 1,000 can be evaluated, there is a need to establish base- A-E. Given the design issues highlighted above, line data. Van Mechelen et al. (1992) suggested a the findings are considered problematic and cau- model on which future (longitudinal) intervention tion is warranted in concluding that the preventive research could be based. The model may be sum- measures had any effect on reducing injuries in marized as follows: Step 1: assess the injuries; Step taekwondo. 2: establish the inciting events; Step 3: introduce preventive measures; and Step 4: repeat Step 1 to Further research assess the effectiveness of Step 3. McLatchie et al (1994) have so far conducted the Future research should use a uniform definition of only martial arts study known to this author in injuries (Hodgson Phillips, 2000). In line with the which, over a 10-year period, the preceding model current International Olympic Committee position was used by first collecting baseline karate injury (Junge et al. 2008), a reportable injury should be data, subsequently introducing preventive measures, defined as “any musculoskeletal complaint newly and finally studying the incidence of injuries again. incurred due to competition and/or training dur- Preventive measures suggested in the litera- ing the tournament that received medical atten- ture that should be investigated in future research tion regardless of the consequences with respect include determination of (Koh & Watkinson 2002a; to absence from competition or training” (p. 414). 2002b; Oler et al 1991; Pieter & Lufting 1994; Pieter This definition allows injuries to be recorded that et al 1995; Zemper & Pieter 1989):: include all reported injuries as well as those that lead to time loss, so that comparisons may be made • the effect of regular testing of protective equip- with studies cited in this chapter (e.g., Pieter et al ment (since its lifespan is limited), 1998; Zetaruk et al. 2000; Beis et al. 2001b). • the potential improvements in the headgear, Each taekwondo national governing body especially the temporal area, and could develop its own injury surveillance system • the effect of blocking skills, evasive maneuvers akin to the NCAA Injury Surveillance System in and awarding points for defensive techniques. 258 chapter 19
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Team Handball (Handball)
GRETHE MYKLEBUST Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
Introduction demands are characterized by intermittent sprinting. Modern handball was first played toward the The match level of play includes high-speed running end of the 19th century in Denmark, Germany, forward, backward, and sideways, plant and cut and Sweden. The first World Championship was fakes, jumps, landings, turns, and repeated accelera- played in Germany in 1938. Handball has been an tion and deceleration movements. Most of the play Olympic Sport since 1972. Women’s handball was in handball involves balancing on one or two legs introduced at the 1976 Olympic games in Montreal while catching, bouncing (dribbling), or throwing and has become one of the most highly attended the ball with one hand. Because of the play with Olympic sports (Figure 20.1). Today, handball or hard tackling and body checking, a risk of injuries is team handball is a sport played in 183 countries, quite obvious in handball. by both sexes and in different age groups. There The purpose of this chapter is to review the hand- are 31 million players, trainers, officials, and ref- ball literature, presenting injury incidences, injury erees worldwide acting with 1,130,000 teams types and locations, injury mechanisms and the (International Handball Federation 2007). consequences of an injury. Finally, prevention stud- Handball is a high-intensity sport with frequent ies will be presented, as will suggestions for future physical contact between players. The physical handball research.
Figure 20.1 Women’s handball match from the Sydney 2000 Summer Olympics © IOC/Steve MUNDAY.
Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 Blackwell Publishing, ISBN: 9781405173643 260 team handball (handball) 261
There are some methodologic issues that make it and 20.2, respectively. Most studies report injury challenging when presenting the data from the hand- rates relative to match or training. Few studies ball literature. First, the definition of a sports injury report overall injury rates in handball. This lack is not the same in the literature. The time-loss defini- of information makes it difficult to compare the tion is used in most of the literature, but some inves- overall rates across competitive levels, sexes, and tigators studying injuries in handball have included sports. Two studies among male players show an injuries that are not necessarily time-loss injuries. overall injury risk between 2.5 and 8.3 per 1,000 Jørgensen (1984) included injuries that handicapped playing hours (Jorgensen 1984; Seil et al. 1998). the player, required special treatment in order to The only study reporting injuries among male and play, or both, while Wedderkopp et al. (1997, 2003) female players show 0.9 and 0.5 injury per match included injuries that caused the player to participate per player (Asembo & Wekesa 1998). Among ado- with “considerable discomfort” but did not necessar- lescents, the injury risk was low and similar among ily stop the play or require medical follow-up. girls and boys, with 0.7 injury per 1,000 playing Second, the definition of injury severity differs hours (de Loes 1995). among the different studies. Van Mechelen et al. 1992, Wedderkopp et al. (1997) showed that back play- Hlobil & Kemper (1992) have described the severity ers had the highest overall incidence of injuries and of injuries based on the following criteria: nature and the highest number of acute noncontact lower-limb duration of the injury, type of treatment, sporting injuries as compared with other player positions time lost, working time lost, permanent damage, and among young female players. This high incidence costs. In the literature presented in this chapter, we of injuries among back players was also reported found different criteria used. The most-used injury by Fagerli et al. (1990). classification is minor (absence of 1–7 days), mod- erate (8–21 days), and major (Ͼ21 days). But non- Where Does Injury Occur? time-loss injuries are also included in some studies. Third, the injury-registration level and methods Anatomical Location vary between studies. In some studies, injuries are registered from hospital records or large national sur- Table 20.3 summarizes the available data on per- veys (Fagerli et al. 1990; de Loes 1995). Recordings of cent distribution of injuries by location in men’s injuries from hospital records or insurance companies and women’s handball. Although sample sizes are will probably present a large number of more serious small, a picture of where injuries occur in handball and most of these acute injuries. Minor injuries and is provided. overuse injuries will, on the other hand, be missed. Other registration methods used are questionnaires Head Injuries and telephone or in-person interviews. This in addi- Asembo and Wekesa (1998) found that 43% of the tion to whether the registration is done prospectively injuries among males involved the head and neck, or retrospectively make the safety of the data ques- while the numbers among females were substan- tionable. The methodologic issues related to recall tially lower, at 16%. These results are similar to bias, overestimation or underestimation of sports those reported by Langevoort et al. (2007). There participation, incomplete responses, nonresponse, seems to be few concussions among these injuries drop-out, invalid injury description and problems (Table 20.3), and one might expect that most of related to the duration and cost of research are clearly these injuries are blows to the face, nose, or possi- of great importance when comparing the results of ble damage to the teeth. studies (Bahr & Holme 2003).
Upper Extremities Who Is Affected by Injury? Acute injuries to the upper extremities are frequent Studies reporting the incidence of injury in adoles- and different studies report them to constitute cent and adult handball are shown in Tables 20.1 from 7% to 50% of the total numbers of injuries 262 chapter
Table 20.1 Epidemiologic studies on incidence of handball injuries among adolescents.
Study Study Design Country and Population Injury definition No. of Injuries /1,000 hr
Period Players/ 20 Injuries Match Training Total
Nielsen & Prospective Denmark, 1 club, youth division An incident occurring during B: 40/15 B: 8.9 B: 1.7 Yde (1988) cohort September Youth players Age: a game and practice in the club G: 54/22 G: 11.4 G: 2.2 1985–May 7–18 yr causing the player to miss at least 1986 one game or practice session Backx et al. Longitudinal The Selected schoolchildren Any physical damage caused by B ϩ Ga B ϩ G: 14 B ϩ G: (1991) Netherlands, Boys and girls an accident during physical 4.3 November Age: 8–17 yr education or in any sports 1982–June activities outside of school, both 1983 organized and nonorganized de Loes Insurance Switzerland, Selected participants in All acute injuries occurring M: M: 0.72 (1995) records 1987–1989 the Swiss Organization during the activities in “Youth 30,876/1,052 F: 0.76 “Youth and Sports” and Sports” F: 10,357/371 Age: 14–20 yr Wedderkopp Retrospective Denmark, 22 teams, youth elite, Any injury occurring during a F: 217/211 F: 40.7 F: 3.4 et al. (1997) cohort 1994–1995 intermediate, and scheduled game or practice and (1 season) recreational causing the player to either miss Female youth players the next game or practice session, Age: 16–18 yr or being unable to participate without considerable discomfort Wedderkopp RCT (of Denmark, 22 teams, youth elite, Any injury occurring during a F: 126/66 F: 23.4 F: 1.2 et al. (1999) teams) August 1995– intermediate and scheduled game or practice and May 1996 recreational causing the player to either miss (1 season) Female youth players the next game or practice session, Age: 16–18 yr or being unable to participate without considerable discomfort team handball (handball) 263 F: 1.0 IG: 0.4 CG: 0.6 M. 0.6 F: 1.0 F: 52 F: 10.4 IG: 4.7 CG: 10.3 M: 8.3 F: 10.4 a F: 321/48 M ϩ F: 1,837/298 M: 107/13 F: 321/48 F: 163/ Any injury occurring during a scheduled match or training ses- sion, causing the player to require or to miss at medical treatment least part of the next match or training session Any injury occurring during a scheduled match or training ses- sion, causing the player to require or to miss at medical treatment least part of the next match or training session Any injury occurring during a scheduled game or practice and causing the player to either miss the next game or practice session, or being unable to participate without considerable discomfort 120 teams (1837 players) Female and male youth players Age: 15–17 yr 34 teams (428 players) Female (25 teams) and male (9 teams) youth players Age: 15–18 yr 16 teams, youth elite, intermediate and recreational Female youth players Age: 14–16 yr Female (25 teams) and male (9 teams) youth players Age: 15–18 yr Norway, Norway, September 2002–April 2003 (1 season) Norway, Norway, September 2001–March 2002 (1 season) Denmark, 1997–1998 (1 season) Prospective Prospective cohort Retrospective Retrospective cohort RCT b Data from the coach report are presented. are the coach report Data from Number of players and number injuries not reported. Wedderkopp Wedderkopp et al. (2003) trial. B ϭ boys; G girls; M males; F females; RCT randomized, controlled a b Olsen et al. (2006) Olsen et al. (2005) 264 chapter 20 a a a a a a M: 0.9 M: 8.3 F: 0.5 M: 1.2 F: 2.0 Time loss: M: 0.6 F: 0.5 M: 2.4 F: 0.7 Women’s World World ϭ Women’s c c M: 13.3 F: 13.8 Injuries/1,000 hr Total Match Training F: 13–36 F: 84–145 loss: Time M: 31–40 /478 M: 89–129 b /62 M: 12.1 M: 2.6 b M: 52 injuries F: 15 injuries M: 186/91 M: 14.3 M: 0.6 M: 2.5 M: 69/44 F: 58/24 M: 288/282 No. of Players/ Injuries M: M ϩ F: Injuries leading to temporary stop- page of the game or substitution for player the injured An injury occurring during handball practice or competition leading to nonparticipation in at least one practice session or game An injury occurring during a game or practice causing the player to miss at least one game or practice session Any injury occurring in connection with the game or in training that handicaps the player during special treatment game or requires (i.e. special bandaging or medical or to play, attention) or both in order the player from completely prevents playing An injury occurring during a game or training session causing the player to miss part of the training or match, or leading to absence for at least sev- eral days of activities Any physical symptom incurred Any physical symptom incurred medical during a match receiving the team physician attention from of the consequences with regardless match or to absence from respect training 14 teams elite 9 male teams 5 female teams 406 players Total: 16 teams, divi- sion III–IV Male players Mean age: 25.8 yr 1 club, division I and II lower division Male and female players Age Ͼ 18 yr Selected players division from I–III Male players Age: 17–37 yr Population Injury Definition 1 team, division III Male players Age not reported National team players Male and female ϭ females; M ϭ males; tournaments for men and women during the Olympic Games 2004; WC OG ϭ Africa club championship April 9–17, 1995 Germany, July Germany, 1995–May 1996 Denmark, September 1985–May 1986 Denmark, 1981–1982 40 wk Period Aug. Germany, 2001–May 2002 EC, WC & OG Men & women Prospective Prospective cohort cohort Prospective Prospective cohort Retrospective Retrospective cohort Study Design Country and Prospective cohort Prospective Prospective cohort Number of players or injuries not reported. Data were presented as injuries per match player. presented Data were This is injuries/1000 hours. Asembo & (1998) Wekesa Seil et al. (1998) Prospective Nielsen & Yde Nielsen & (1988) Jørgensen Jørgensen (1984) Cup 2003 and Men’s World Cups 2001 and 2003. Cup 2003 and Men’s World Table 20.2 Table Epidemiologic studies on incidence of handball injuries among adults. Study Petersen et al. (2002) Handball Championship 2002; F Europe Women’s EC ϭ a b c Langevoort et al. (2007) Table 20.3 Absolute numbers, percent comparisons, or both of injury locations among female and male handball players.
Body Seil Olsen et al. Wedderkopp Part/Type Fagerli et al. Jørgensen et al. Asembo & Langevoort et al. (2006), Junior Nielsen & Yde Nielsen & Yde et al. (1997), of Injury (1990)a (1984) (1998) Wekasa (1998) (2007)b Datac (1988), Senior Data (1988), Junior Data Junior Data
Women Men Men Men Women Men Men Women Women ϩ Men Women Men Women Men Women
No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) Injured body part Head, 9.6 — 4 (2) 11 (16) 29 (43) 68 (31) 8 (29) 5 (5) neck Trunk 3.5 — 2 (1) 2 (3) 13 (18) 36 (15) 2 (7) 8 (9) Upper extremities 2 (3) 3 (5) Shoulder 13 23 (8) 13 (7) 5 (2) 11 (5) 4 (4) 12 (27) 1 (5) 2 (13) 2 (1) Arm 11 (4) 3 (1) 5 (2) 2 (2) (upper/ lower) Elbow 18 (6) 3 (2) 7 (3) 13 (4) 4 (4) 10 (5) Hand, 36.7 17 (6) 20 (11) 18 (7) 22 (9) 16 (18) 9 (20) 5 (23) 1 (7) 2 (1) includ- ing wrist, finger Lower 36.5 0 8 (12) extremi- ties Hip/groin 1 (2) 5 (3) 3 (2) 9 (3) 2 (2) Thigh 7 (16) 19 (10) 17 (6) 3 (3) 2 4 (9) 0 2 (13) (including (including leg) leg) Knee 25 (9) 18 (10) 27 (12) 35 (13) 24 (27) 2 3 (7) 4 (18) 1 (7) 31 (15) Lower leg 52 (18) 9 (5) 9 (6) 17 (7) 2 (2) Ankle 45 (16) 14 (8) 22 (9) 28 (12) 22 (24) 9 12 (27) 10 (45) 4 (27) 56 (27) (foot/ankle) Foot/toe — 3 (2) 5 (2) 6 (2) 1 (1) 1 (0.5) Others 20 (7) 1 4 (9) 2 (9) 2 (13) 0 a The numbers presented represents data on all age groups. b The numbers for the three men and women tournaments have been merged, gives one column for female tournaments and one for male. c Data from the coach report is presented. 266 chapter 20
(Jorgensen 1984; Nielsen & Yde 1988; Fagerli et al. 1988; Seil et al. 1998; Petersen et al. 2002). The 1990; Wedderkopp et al. 1997; Seil et al. 1998; Olsen number of injuries is related to whether they report et al. 2006; Langevoort et al. 2007). Shoulder and time-loss injuries or all injuries (Table 20.2). The hand and finger injuries are most common. Finger study reporting the highest incidence of time-loss injuries are more often observed among youth injuries is the one among national team players players (Table 20.3). in international tournaments, with incidence as high as 40 injuries per 1,000 match-hours for men Lower Extremity and 36 injuries per 1,000 match-hours for women (Langevoort et al. 2007). For the rest of the stud- The majority of acute injuries in handball are ies among senior players the injury incidence is located to the lower extremity, regardless of the age described to be at the same level as among youth and gender (Nielsen & Yde 1988; Fagerli et al. 1990; players (Table 20.2). Seil et al. 1998; Wedderkopp et al. 1997, 1999, 2003; When looking at time-loss injuries, a sex differ- Petersen et al. 2002; Reckling et al. 2003, Zantop & ence is found at the national level (Langevoort Petersen 2003). et al. 2007), but minimal sex differences are The most frequent injuries reported in handball described in other studies (Nielsen & Yde 1988; are ankle injuries (8–45%), while the most serious Olsen et al. 2006) (Table 20.2). injuries are knee injuries (7–27%), including the anterior cruciate ligament (ACL) injury. Match—Training Environmental Location There is no doubt that the injury incidence is Tables 20.1 and 20.2 present data on injury incidence higher in matches than during training sessions in match and training among adolescent and adult for all injuries (Nielsen & Yde 1988; Backx et al. handball players, respectively. In the first prospec- 1991; Seil et al. 1998; Wedderkopp et al. 1997, 1999, tive study on handball injuries, Nielsen and Yde 2003; Petersen et al. 2002; Olsen et al. 2006) (Tables (1988) reported time-loss injuries among 7-to-18- 20.1 and 20.2). The high incidence of injuries in year-old players in one Danish sport club. They Olympic tournaments and World Championships reported an injury incidence of 10 injuries per 1,000 indicate a high injury risk in matches, especially at match-hours (11 in girls and 9 in boys). In contrast, the top level (Langevoort et al. 2007). This picture is Wedderkopp et al. (1997), based on a retrospective approximately the same for adults and adolescents, study in Danish handball, found that the young and there is no sex difference identified. female players had the highest injury incidence, with up to 41 injuries per 1,000 match-hours. In their When Does Injury Occur? later prospective intervention study Wedderkopp et al. (1999) report that the incidence in the control Injury Onset group (the same players as in the previous retrospec- tive study) was 23 injuries per 1,000 match-hours. Injuries are often divided into acute injuries and However, since both studies include all injuries, overuse injuries. Acute injuries occur suddenly and not just time-loss injuries, the apparent difference have a clearly defined onset or cause, while over- in injury incidence may be caused by methodologic use injuries occur gradually. The majority of inju- differences. Since Wedderkopp et al. (1999) did not ries reported in handball, both among adolescents report time-loss injuries separately, their injury inci- and adult players are acute injuries located in the dence estimates cannot be directly compared with lower extremity (Table 20.3). those of Nielsen and Yde’s (1988) study (Table 20.1). In studies reporting both acute and overuse inju- Among senior (adult) players, we see similar ries the distribution of overuse injuries is between injury rates as among young players, with 12 to 7% and 21% (Nielsen & Yde 1988; Wedderkopp 14 injuries per 1,000 playing hours (Nielsen & Yde et al. 1997; Olsen et al. 2006). Knowledge of overuse team handball (handball) 267
injuries in the upper extremities is sparse, but a study Wedderkopp et al. 1997; Seil et al. 1998; Olsen et al. among German male players showed that 40% of 2006; Langevoort et al. 2007), and contusions 25 examined players had been handicapped during (2–36%) (Jorgensen 1984; Nielsen & Yde 1988; training and play during the past 6 months because Fagerli et al. 1990; Wedderkopp et al. 1997; Seil of shoulder pain (Gohlke et al. 1993). These results et al. 1998; Asembo & Wekesa 1998; Olsen et al. have been confirmed in a study among elite female 2006; Langevoort et al. 2007). Fractures and dis- Norwegian players (Hasslan, L., Norwegian School locations are usually less common, except in the of Sport Sciences, Oslo, Norway, pers. comm.). studies of Fagerli et al. (1990) and Asembo and Among the 178 players tested, 57% reported previ- Wekesa (1998), which showed high numbers of ous or present shoulder pain. Forty-nine (67%) of fractures—19% to 22% and 31%, respectively. In the those players who had reported pain suffered from study by Fagerli et al. (1990), patients were treated reduced training performance, and 24 (34%) could at an emergency department, which could explain not play matches because of pain. the high numbers of fractures, while Asembo and Seil et al. (1998) reported overuse symptoms Wekesa’s (1998) study was done among elite-level among male nonprofessional-level players and male players. The latter study’s high number of showed that the three most dominant anatomic fractures was not found in Langevoort et al.’s areas with overuse symptoms were the shoulder, (2007) data among national players, where the lower back, and the knee. number of fractures was only 1% to 2%. Few studies report overuse injuries, but in a Chronometry study by Olsen et al. (2006), lower-leg pain (perios- titis) was reported to be the most common problem. Few studies report time of injury. However, Some studies report injury data based on a specific Langevoort et al. (2007) reported that 45% of the diagnosis. A study of jumper’s knee showed that the injuries occurred in the middle 10 minutes of each prevalence was 10% among female handball play- half, and decreased toward the end. Asembo & ers and 30% among male players (Lian et al. 2005 Wekesa (1998) reported that 57% of injuries Engebretsen & Bahr et al. 2005). Tyrdal and Bahr occurred in the second half. Since we do not know (1996) described elbow problems among goalkeep- anything about when the players sustained an ers and found that 41% of 729 players experienced injury in relation to the exact time (minutes played), elbow problems. The injury mechanism appeared to it is not possible to draw any conclusions from this be repeated hyperextension trauma, and the condi- information. One might suspect that players play- tion was called “handball goalies elbow.” ing a full match are the ones who get most of the Table 20.5 presents the incidence of ACL injury injuries but we do not know if this is the case. in handball. In a retrospective study published in 1990, Strand et al. found that the incidence of ACL injury was highest among women playing at the What Is the Outcome? top level, with 0.82 ACL injury per 1,000 playing hours, as compared with male players, with 0.31 Injury Type injury per 1,000 playing hours. The relatively high The results of studies reporting absolute num- incidence of ACL injuries among female players, bers, percent distribution of injuries by injury particularly among elite players, was later con- type, or both are summarized in Table 20.4. This firmed by several prospective studies (Myklebust table shows that the most common types of acute et al. 1997, 1998, 2003). The highest ACL incidence injuries in handball are muscle and ligament is described with elite female handball in Norway, sprains (2–68%) (Jorgensen 1984; Nielsen & Yde with 2.29 ACL injuries per 1,000 match-hours 1988; Fagerli et al. 1990; Wedderkopp et al. 1997; (Myklebust et al. 2003). The incidence is lower Seil et al. 1998; Olsen et al. 2006; Langevoort et al. among adolescents and among players in the lower 2007), muscle strains (6–26%) (Jorgensen 1984; divisions. Table 20.4 Absolute numbers and/or percent comparison of injury type among female and male handball players.
Type of Injury Fagerli et al. Jørgensen Seil Asembo & Langevoort Olsen et al. Nielsen & Yde Nielsen & Yde Wedderkopp (1990) (1984) et al. Wekasa et al. (2007)a (2006), Junior (1988), Senior (1988), Junior et al. (1997), (1998) (1998) Datab Data Data Junior Data
Women Men Men Men Women Women Men Women ϩ Men Women Men Women Men Women
No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%)
Concussion 1 6 (4) 6 (2) 0 0 4 (2) Fracture 19 22 9 (10) 68 (31) 2 (1) 4 (2) 0 1 (2) 0 3 (20) 9 (4) Dislocation — 5 (6) 36 (15) 2 (1) 7 (3) 1 (0.5) Tendon/liga- 2 — 0 12 (5) 12 (6) 4 (2) mentous rup- ture, meniscus lesion Sprain (9) 13 (29) 42 (46) 0 5 (2) 32 (13) 42 (15) 38 14 (58) 30 (68) 15 (68) 5 (25) 129 (61) Strain/muscle — 4 (9) 24 (26) 18 (9) 16 (6) 6 25 (12) fiber rupture Contusion 23 29 16 (36) 6 (7) 7 (3) 13 (4) 127 (60) 130 (54) 16 6 (25) 1 (2) 2 (9) 2 (13) 18 (9) Laceration/ 2 9 0 18 (7) 22 (9) 10 (3) 9 (3) 4 (2) abrasion/blister Others 5 4 7 (16) 13 (5) 19 (7) Only specified for 3 (13) 0 1 (5) 3 (20) 17 (8) three types a The numbers for the three men’s and women’s tournaments have been merged, giving one column for women’s tournaments and one for men’s. b Data are from the coach report. team handball (handball) 269 Women: Women: 0.31 All divi- sions: 0.14 Elite: 0.19 0.03 All divi- sions: 0.03 Elite: 0.03 Injuries/1,000 hr Match Training Total Match Training Divisions I–III Male: 0.31 Male ϩ Female: 0.20 Male ϩ Female: 0.08 Division I Male: 0.54 Female: 1.62 Division II Male: 0.84 Female: 1.82 Division III Male: 0.27 Female: 0.72 All divisions: 1.48 Elite: 2.79 players/injuries Divisions I–III 7 Male: 111/ Female: 98/18IV–VIIDivisions Female: 0.82 Divisions IV–VII Male ϩ Female: 1,060/24 Youth divisionYouth Male ϩ Female: division Youth 1,200/12 Male: 1696/33 Female: 1696/54 Male: 144/5Female: 144/23 Female: 1.60 Male: 0.23 Women: All divisions: Men: 0.03942/29 Men: 0.06 Elite: 225/13 Injury Definition No. of Total ACL ACL ruptures Total occurring during hand- ball games or play Total ACL ACL ruptures Total occurring during handball games or play ACL ruptures Total occurring during handball organized training or games ACL ruptures Total occurring during handball organized training or games Selected players from Selected players from western Norway division I–III Male and female Division I–VII Age not reported Youth division Youth Age: 14–16 yr 212 teams, top three 212 teams, top three divisions Male and female players Mean age for injuries: 23.8 yr (16–36) for men and 21.3 (16–34) for women 24 teams, elite division male and female players Mean age for injuries 23.4 yr for men and 21.9 for women 60 teams, top three division Female players Mean age for injuries 22 yr Norway, Norway, 1979–1989, 10 seasons Norway, Norway, 1989–1991 2 seasons Norway, 1993–1996 3 seasons Norway, August 15 1998– May 31 1999, 10.5 mo Study Design Period Population hospital records Prospective Prospective cohort Prospective cohort Prospective cohort Table 20.5 Table injuries in handball. ACL Epidemiologic studies on incidence of Study Design, country and period Strand (1990) Retrospective, Myklebust et al. (1997) Myklebust et al. (1998) Myklebust et al. (2003) ligament; M ϭ Male; F Female ϭ anterior cruciate ACL 270 chapter 20
Some handball studies have reported a possible Nielsen and Yde (1988) found that 41% of the play- association between age and ACL injuries. Strand ers who incurred injuries during the study period et al. (1990) reported that 35% and 25% of ACL inju- still had symptoms 6 months after the end of the ries occurred in the 15-to-19- and 20-to-24-year age season. One might assume that many minor or groups, respectively. Reckling et al. (2003) reported moderate injuries are not followed by a complete that of 12 ACL tears recorded in 100 adolescent and rehabilitation, which could be a risk factor for new youth handball players (ages 8–18), 11 were in the age injury or reinjury. A study among handball play- group 15 to 18, 1 was in 12 to 14, and none were in 8 ers showed that the risk of a reinjury of a recon- to 12). However, these studies were retrospective and structed ACL was 13% after returning to match they have no comparable data on noninjured play- play (Myklebust et al. 2002). ers. The high number of injured players may, rather, Osteoarthritis (OA) is a possible consequence after reflect the high number of participants in these age an ACL injury, whether the patient has had surgery groups, so prospective studies are needed before age or has been treated conservatively. Persons with can be identified as a potential risk factor for ACL knee OA suffer from swelling and pain, loss of range injury among handball players (Olsen 2005a). of motion, and often altered function with dimin- ished muscle strength (Gillquist & Messner 1999). Time Loss Myklebust et al. (2002) showed that the prevalence of OA was 42% among surgically treated patients Some studies have reported details regarding time- and 46% among nonsurgically treated patient 6 to loss injuries. Twenty percent of the players in one 11 years after ACL injury. These high numbers were study (Nielsen & Yde (1988) reported absence from confirmed in the study conducted by von Porat handball because of injury for Ͼ4 weeks. In a study et al. (2004) among soccer players. L’Hermette et al. reported by Langevoort et al. (2007), 23% of the (2006) found that 60% of retired male handball play- injuries prevented the player from participating in ers were diagnosed with premature hip OA, as com- a match or training for р1 week and 5% of the inju- pared with 13% of the control subjects. ries led to longer absences. Ankle, knee, and head injuries most frequently led to absences. In addi- tion, Langevoort et al. (2007) found that signifi- Economic Cost cantly more noncontact than contact injuries were Some studies have evaluated the costs of severe knee expected to result in absence from handball. injuries; predominantly ACL injuries. The cost of this In a study of youth players Olsen et al. (2006) injury is not easy to estimate. A sum of US$17,000 reported that 56% of the acute match injuries per injury has been estimated when including and 50% of acute training injuries were moderate only surgical and rehabilitation costs. Engebretsen (Յ8 days lost) or major (Ն21 days lost) injuries. (Ullevål University Hospital and Faculty of Medicine Notably, 64% of the overuse injuries in this study University of Oslo, pers. comm.) estimated the total were either moderate or major injuries. costs to be approximately 500,000 NOK (US$91,000) over the athlete’s life span when including long-term Clinical Outcome disability, sick leave, and the possibility of additional Studies have shown that 5% to 36% of the injuries surgical procedures. are major (absence from team activities Ͼ3 or 4 Forssblad et al. 2005, Weidenhielm, and Werner weeks), and that reinjuries are common (Nielsen & (2005) looked at health care costs for knee surgery Yde 1988; Seil et al. 1998; Wedderkopp et al. 1999, directly related to participation in different sports in 2003; Myklebust et al. 2002; Olsen et al. 2006; Sweden. They found that the overall cost per player Langevoort et al. 2007). More serious injuries could was estimated to be SEK 108 (US$18). They con- affect the athlete’s physical fitness and the team’s clude that sports participation can lead to injuries, performance. In addition, it could influence other but in relation to the costs of an inactive lifestyle, the aspects, such as time lost from school and work. costs of sports injuries are low. team handball (handball) 271
In one study looking at socioeconomic costs lower-limb injuries in general are contradictory of sports injuries in Flanders, Cumps et al. (2008) (Murphy et al. 2003). The picture is more apparent found that the highest direct medical costs were when studying ACL injuries. Strand et al. (1990) found for ACL injuries (US$1889 per injury) and reported that female players in the three top divi- the lowest for foot injuries (US$72 per injury). sions have a higher incidence of ACL injury than players playing at lower levels. This has been con- What Are the Risk Factors? firmed by Myklebust et al. (1998, 2003), who found the highest incidence of ACL injuries among female The combination of intrinsic and extrinsic factors, elite players. The same pattern is found among soc- and the interaction between them, could make cer players (Roos et al. 1995; Bjordal et al. 1997). the athlete vulnerable to injury (Bahr & Maehlum 2004). For a successful rehabilitation and to make effective prevention programs, it is important to Competition versus Practice know the athletes’ relevant risk factors. There is no doubt that injury incidence is higher in matches than during training sessions for all inju- Intrinsic Factors ries (see Tables 20.1 and 20.2). The overall incidence Sex in handball has been found to be 4 and 24 times higher in matches (Nielsen & Yde 1988; Backx et al. Studies of team handball players have shown that 1991; Wedderkopp et al. 1997, 1999, 2003; Seil et al. women have an incidence of ACL injuries 3 to 5 times 1998; Petersen et al. 2002). It appears to be approxi- higher than that of men (Ferretti et al. 1992; Lindenfeld mately the same for adolescents and adults, and no et al. 1994; Arendt & Dick 1995; Hutchinson & sex difference has been identified. Regarding ACL Ireland 1995; Bjordal et al. 1997; Myklebust et al. injuries there is an 8 times higher match incidence 1997, 1998; Powell & Barber-Foss 2000). among men and a 53 to 93 times higher match inci- dence among women (Myklebust et al. 1998, 2003). Previous Injury Although two studies of handball players have Player Position shown that 30% to 35% of injuries were injuries of As presented in the section on “Who Is Affected the same type and location as those that occurred by Injury,”, several studies (Jorgensen 1984; Fagerli in the previous season (Nielsen & Yde 1988; et al. 1990; Wedderkopp et al. 1997) have shown a Wedderkopp et al. 1997), and one study showed higher incidence of injuries among back players. a propensity for players to reinjure their ACLs Several studies have shown that the relative risk (Drogset & Grontvedt 2002), only one study actu- of ACL injury is also higher among back players ally tested this relation. Myklebust et al. (2002) (Myklebust et al. 1997, 1998, 2003). Another trend found that 13% of players who continued to play is that the proportion of back players injured is handball after their ACL reconstruction reruptured even higher when studying the elite level only their ACL, but there was no difference between this (Myklebust et al. 1998). One reason for this could be group and players who ruptured their previously that the back players perform most of the plant and uninjured ACL, which indicates that previous ACL cut movements and the jump shots; in addition, injury is not a risk factor for having a new ACL they have more ball contact than players at other injury to the same knee (Myklebust et al. 2002). positions.
Extrinsic Factors Shoe–Floor Interaction Level of Play Shoe–surface interaction has been studied as an ACL Several studies have analyzed the relation between injury risk factor in different sports. In handball, level of play and injury; however, the findings for it has been shown that the risk of ACL injury is 2.4 272 chapter 20 times greater when competing on artificial floors reduced acute lower-extremity injuries among (with an increased coefficient of friction) as com- players in the intervention group. In this study, pared with wooden floors (Olsen et al. 2003). There the teams were highly compliant with the pro- is little doubt that the shoe–playing surface interface gram—87% of the teams performed the program is important to consider when developing interven- as intended. In addition, the sample size was high tion strategies to reduce the incidence rate of serious enough to detect a difference between the interven- knee injuries. tion and control groups. In some of the studies pre- sented in Table 20.6, the number of teams or players What Are the Inciting Events? is too low to detect a difference between the groups. In the prospective cohort study by Myklebust Most injuries in handball occur in a contact situa- et al. (2003), a five-phase neuromuscular training tion. Studies report contact injuries to be between program was tried out among female players. The 40% and 84% (Nielsen & Yde 1988; Fagerli et al. intervention significantly reduced ACL injuries 1990; Langevoort et al. 2007). Some studies have from the control season to the second intervention reported information regarding the mechanism of season among the elite players who completed the an ACL injury. In approximately 90% of the cases, program, and they also found a significant reduc- the injury is a noncontact injury in the attacking tion in the risk of noncontact ACL injuries. A video phase of the play while the players are doing a plant presentation of the prevention programs of Olsen and cut or a landing after a jump shot (Myklebust et al. and Myklebust et al. studies is found at www. et al. 1997, 1998, 2003). ostrc.no and www.skadefri.no. Despite the relatively sparse number of studies, Injury Prevention we can conclude that it is possible to prevent acute Prevention is the ultimate goal of sports injury epi- ankle and knee injuries in handball. Studies from demiology (Bahr et al. 2002, Kannus & van Mechelen comparable sports, such as soccer (Mandelbaum 2002), and as soon as there is evidence that points et al. 2005) and basketball (Hewett et al. 1999) have to an association between certain risk factors and confirmed that it is possible to prevent this injury. injury it is natural to test this through an interven- For more details on ACL injury prevention, the tion (Caine et al. 1996). The number of preventive reader is referred to the results of an ACL consen- studies in sports is not impressive. Nevertheless, sus meeting (Griffin et al. 2006). handball is one of the sports in which injury- prevention interventions have been performed, and these studies are presented in Table 20.6. Further Research As shown, there have been six studies, including The review of the handball injury literature has one case–control study, two prospective cohort clearly shown that there are gaps and weaknesses studies, and three randomized, controlled trials. in the epidemiology literature. In 1999, Wedderkopp et al. showed that a 10–15 min program with balance-board training and a spe- • First, there is a need for an injury surveillance sys- cial warm-up and training program for all muscle tem to obtain information of all kind of injuries, groups yielded a significant reduction of both over- both overuse and acute injuries. It should be car- use and acute injuries among youth female players. ried out throughout the whole season, including This is the only study that has shown a reduction of the preseason. This knowledge will help to target overuse injuries. In the other studies presented in an age group or an injury type if the incidence Table 20.6 the goal has been to reduce acute ankle of injury changes. This will also help us to know and knee injuries. where the preventing efforts must be focused In a randomized, controlled trial among youth and to see whether there is a need for a change female and male players, Olsen et al. (2005) showed to the rules of the play. In addition, it will make that a structured warm-up program significantly it possible to point out possible seasonal changes Table 20.6 Injury-prevention studies in handball.
Study Study Design Type of Level and Study Group Injury Definition and Comparison of Follow-up Results (RR or OR Intervention Country Registration Interventions provided if ade- quate information provided)
Wedderkopp RCT (of Warm-up, bal- Youth elite, 237 female players Acute and overuse; IG: 10–15 min balance- 10 mo Significant reduc- et al. (1999) teams) ance board, intermediate 11 teams in each Time loss or partici- board training and a spe- (August–May) tion of both strength, play, recreational group pate with “consider- cial warm-up and training overuse and acute cool-down, Denmark (IG ϭ 111 players; able discomfort” program for all major injuries in IG, stretching, CG ϭ 126 players) Coach; injury form muscle groups (upper and including ankle primary Age: 16–18 yr (every 10 days) lower limbs) at all practice sprains sessions RR, 0.17; 95% CI, CG: Train and play as 0.09–0.32 usual Petersen et al. Prospective Balance board, Divisions Male playersa Acute; Time loss or IG: A program including 10 mo Lower number of (2002) cohort jump training, II–III 1 division II (18 play- interruption information on injury (August–May) knee and ankle primary Germany ers) in the IG Team PT; injury mechanisms, and proprio- injuries in IG 1 Division III teama in form (frequency not ceptive and jump training (P ϭ NS) the CG reported) at every practice session Age not reported (10 min) in the 8 wk pre- season, then propriocep- tive training 1–2 times (5 min) per week during season) CG: Train and play as usual Myklebust Prospective Neuromuscular Divisions 2,647 female players ACL CS: Baseline data on the 3 seasons A significant et al. 2003 cohort training I–III 60 teams (942 play- Coach and/or team incidence and mechanism. (10.5 mo reduction in the (balance, Norway ers) in CS PT; injury form (tel- Train and play as usual each season; incidence of ACL polymetric) 58 teams (855 in ephone every 1–2 mo Introduction of an ACL August injuries from first IS injury prevention pro- 15–May 31) CS to second IS 52 teams (850 players) gram: 15 min balance among elite play- in second IS exercises (floor, mat and ers who completed Mean age at injury board) 3 times weekly the intervention 22 yr during 5–7 week in the program preparatory period, and OR, 0.06; 95% CI, then 1 times per week 0.01–0.54 during the season Second IS (intervention section): Modifying the ACL prevention program to make it more chal- lenging and specific to handball
(continued) Table 20.6 (continued)
Study Study Design Type of Level and Study Group Injury Definition and Comparison of Follow-up Results (RR or OR Intervention Country Registration Interventions provided if ade- quate information provided)
Wedderkopp RCT (of Warm-up, bal- Youth elite, 163 female players Acute and overuse; AD: Functional strength 9 mo Significantly fewer et al. 2003 teams) ance board, intermediate 8 teams in each group Time loss or partici- and 10–15 min balance- (August– acute injuries in the strength, play, recreational (AD ϭ 77 players; pate with “consider- board training at all prac- April) AD group. cool-down. Denmark NAD ϭ 86 players) able discomfort” tice sessions No reduction of Stretching pri- Ages 14–16 yr NAD: Functional strength lower-limb injuries mary, rehabilita- only (non–balance board) in AD tion, secondary at all practice sessions OR, 0.21; 95% CI, 0.09–0.53 Multivariate analy- sis, but no control of cluster randomi- zation in analysis Petersen et al Prospective Information Senior female IG: 134 female play- Acute: Time loss IG: An 8-week preseason One season IG: reduced risk 2005 case–control about injury players ers (10 teams) Weekly contact with program; proprioceptive of ankle or ACL study mechanism Two teams CG: 142 players (10 each team and jump training three injury compared to Balance board, semiprofes- teams) times a week (10 min), CG (P ϭ NS) jump training sional, four then once a week during Ankle: OR, 0.55; teams supe- the season 95% CI, 0.22–1.43 rior amateur CG: Train and play as ACL: OR, 0.17, 95% level, four usual CI, 0.02–1.5 teams lower amateur level Germany Olsen et al. RCT cluster Structured Youth players 120 teams Time-loss injuries. PT IG: Introduction of a 8 mo The number of 2005 randomized warm-up Norway 1837 male and female blinded regarding IG structured warm-up (September– ankle and knee program players or CG; called teams program to improve run- April) injuries was signifi- IG ϭ 958 players; (808 every month ning, cutting, and landing cantly reduced in women and 150 men) techniques as well as the IG (50% reduc- CG ϭ 879 players neuromuscular control, tion of acute ankle (778 women and 101 balance, and strength and knee injuries, men) CG: Train and play as even higher reduc- Ages: 15–17 yr usual tion among severe injuries) Intervention versus control group: RR, 0.53; 95% CI, 0.35–0.81
AD ϭ ankle disk group; CG ϭ control group; CS ϭ control season; IG ϭ intervention group; IS ϭ intervention season; NAD ϭ non–ankle disk group; NS ϭ not significant; PT ϭ physical therapist; RCT ϭ randomized, controlled trial; RR ϭ rate ratio. a Number of players not reported. team handball (handball) 275
in injury risk—for example, injuries related to the necessary. A video study of matches could point preseason—before the match season starts. out risk factors. • Agreement and clarification of injury defini- • Exploration of the risk of reinjury in relation to tion is necessary to be able to compare studies rehabilitation of the first injury is necessary. within the sport of handball as well as with other • There is a need to study long term-consequences sports. of severe injuries, such as ACL injuries, in relation • There is a special need for research regarding to quality of life and personal and social economic overuse injuries. Coaches report that overuse costs. injuries are a problem for the continuity of the • The shoe–floor friction interaction should be training. More precise information about shoul- explored more closely. der and back injuries is needed. These are mostly • Taping and bracing should be performed to overuse injuries, for which injury mechanisms avoid new injuries while an injury is being are more difficult to investigate. rehabilitated. • An effort should be made to gain consistent • For young athletes playing at a high level, it is knowledge on injury mechanisms. These are nec- necessary to test the effectiveness of a rule limit- essary to understand before introducing the best ing the number of matches or competitions that and most effective prevention measures. can be played per unit time. • There is a need for risk-factor studies to help us • The use of protective equipment in hand- to make the prevention strategies more specific. ball needs to be standardized. Research is also • A closer look at the increased risk of head inju- needed to determine the effectiveness of padded ries, injury type, and injury mechanisms is knee and elbow protection to avoid injury.
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Tennis
BABETTE M. PLUIM1 AND J. BART STAAL2 1Royal Dutch Lawn Tennis Association, Amersfoort, The Netherlands 2Department of Epidemiology and Caphri Research School, Maastricht University, Maastricht, The Netherlands
Introduction with significant health benefits. A positive associa- tion has been shown between regular tennis par- The modern game of tennis (“lawn tennis”) origi- ticipation and positive health benefits, including nated in Europe in the late 19th century, with its improved aerobic fitness, a leaner body, a more roots going back to the ancient game of real tennis. favorable lipid profile, improved bone health and a Tennis spread first throughout the English-speak- reduced risk of cardiovascular morbidity and mor- ing world (Great Britain and the United States), tality (Pluim et al. 2007). particularly among the upper classes. Today, tennis Injury has been identified as an important rea- is played by millions of people, and more than 200 son why participants drop out of tennis (Otis countries are affiliated with the International Tennis et al. 2006). Like many other sports, playing tennis— Federation. Tennis is also a very popular spectator at either a recreational, college, or professional sport, especially the four Grand Slam tournaments: level—places participants at risk of injury. Tennis Australian Open, French Open, Wimbledon, and injuries are a common cause of disability and, in the U.S. Open. some cases, absence from work. This can have sub- Tennis was part of the Summer Olympic Games stantial socioeconomic consequences, both on a per- program from the very beginning, in 1896. At the sonal and a societal level, and reduces the chances 1896 Summer Olympics two tennis events were for someone to enjoy tennis as a lifetime sport. played, both for men. Tennis was dropped from For these reasons, it is important to develop the Olympic program after 1924 as a result of dis- effective measures for the prevention of tennis inju- cussions over amateurism and professionalism. ries. The aim of this chapter is to provide an over- However, tennis returned as a demonstration sport view of the available scientific knowledge on the to the 1984 Summer Olympics in Los Angeles. At occurrence, causes, risk factors, and prevention of the next Games in 1988, tennis was once again an tennis injuries. official sport and has continued as a part of the Games since then. Olympic medals can be won in Methodologic Limitations men’s and women’s singles and doubles. But tennis is more than a sport to watch and a In order to identify risk factors in tennis, the pre- sport to enjoy. Playing tennis is also associated ferred study design is a prospective longitudinal cohort study of players at risk for injury, controlled for possible confounders. However, the majority of the retrieved studies had a cross-sectional design, excluding the possibility of establishing a causal Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 relationship. Furthermore, most studies did not Blackwell Publishing, ISBN: 9781405173643 adequately correct for confounding factors. Very 277 278 chapter 21 few cohort studies were identified that estimated a medical problem that required physical or medi- measure of association between risk factors and the cal assistance” (Hutchinson et al. 1995; Safran et al. occurrence of tennis injuries, and no randomized, 1999) and “any consultation and/or treatment given controlled trials on preventive measures in tennis to a player during a tournament on site” (Silva were identified. et al. 2003). Using these definitions, injuries that may not have had any effect on tennis play, time loss, or work were also included. Kühne et al. Who Is Affected by Injury? (2004) addressed this problem by making a sepa- The studies reporting incidence rates are summa- rate category for “Bagatellverletzungen” (minor rized in Table 21.1. A review of this table shows injuries), which included sunburns, abrasions, and that incidence rates in tennis vary from 0.0003 to blisters. 2.9 injuries per player per year, and from 0.11 injury to 5.0 injuries per 1,000 hours of play. The variation Where Does Injury Occur? in the reported incidence rates of tennis injuries reflects variation in injury definition, study design, Anatomical Location populations under study, methods of data collec- Identification of the most commonly injured ana- tion, and duration of follow-up or recall period. tomical sites in tennis is an important indication of The lowest injury rates (0.3 injury per 1,000 play- areas that should be targeted for preventive meas- ers per year and 0.5 injury per 1,000 hours of play) ures. A percentage comparison of injury location were reported in the Victorian Injury Surveillance of reported studies in tennis players is shown in System (VISS) (Routley & Valuri 1993) and the Table 21.2. A review of these studies shows that Letsel Informatie Systeem (Oldenziel & Stam 2008; the lower extremity is the most frequently injured Stam 2004; Schoots et al 1999, Ten Hag & Toet region in tennis players (range, 39–65%), followed 1999) studies, respectively. Injuries in these stud- by the upper extremity (range, 24–46%) and the ies included only those for which the player was head/trunk (range, 8–22%). The retrospective data treated at a hospital emergency department. This show a fairly similar distribution over the lower implies that predominantly more acute and seri- extremity (range, 31–61%), upper extremity (range, ous injuries would be reported, as players with less 22–48%), and head/trunk (range, 8–20%). serious and chronic injuries were more likely to The most frequently injured parts of the lower visit their general practitioner, physiotherapist, or body were the lower leg, ankle, and thigh, with sports physician or to self-treat. the ankle sprain and thigh muscle strain as most The other study with a relatively low injury frequent injuries. Upper-extremity injuries were rate (0.11 injury per 1,000 hours of play) was by most frequently located in the elbow and shoul- Weijermans et al. (1998). In that study, injuries sus- der, with tendon injuries of the shoulder and tennis tained by tennis players at a club had to be reported elbow (lateral epicondylitis) as the most frequent to a contact person in order to be recorded. This injuries. may have resulted in underreporting of inju- ries. Biener and Caluori (1976a, 1976b, 1976c) also When Does Injury Occur? reported a relatively low injury rate—0.05 injury per player per year—which can be explained by Injury Onset their long recall period of 17.5 years. The highest injury rates, ranging from 6.9 medi- With the exception of one study (Jayanthi et al. 2005), cal treatments per 1,000 games played to 37 injures all of the studies reporting injury onset report that per 1,000 athlete-exposures (AEs), were reported in the majority of injuries were of a sudden nature, three studies (Hutchinson et al. 1995; Safran et al. ranging from 55% to 75% of all injuries sustained 1999; Silva et al. 2003), This is undoubtedly related (Reece, 1986; Baxter-Jones et al. 1993, Maffulli & to their rather inclusive injury definitions: “any Helms 1993; Weijermans et al. 1998; Kühne et al. Table 21.1 A comparison of injyury rates in tennis.
Studya Country Study Data Duration No. of Injuries Study Population Injury Definition No. of No. of Other Rates Design Collection of Injury Injuries/ Injuries/ Surveillance 1,000 hr of Player/yr Exposure
Juniors Spinks, 2006 Australia P I 12 mo 10 744 pre-school and Any incident which 1.2 school children (407 M, occurred during physical 1.3 M 337 F), aged 5–12 years activity and for which first 1.1 F aid treatment was given Silva, 2003 Brazil P DM 13 tournaments 280 258 participants in the Any consultation and/or 1.8 treatment/ national circuit in the treatment given to a injured player; under 12, 14, 16, and 18 player during a 6.9 evaluations/ age categories tournament on site 1,000 games played Safran, 1999 United P DM 6 tournament 137 M 720 M and 539 F All injuries that required 18.5/100 players States (3 M, 3F) 96 F participants at USTA physical or medical 37/1,000 AEs Boys and Girls National assistance Champions, 1996–1998 Beachy, 1997 United R MR 8 yr 146 291 M and 297 F high Every time an athlete 0.1 M States school players sought help it was consid- 0.4 F ered a reportable injury Hutchinson, United P DM 6 tournaments 304 1440 participants at the Any medical problem 21.5/1,000 AE; 1995 States in 6 yr USTA Boys National, requiring physical or 9.9/100 players Championships medical assistance 1986–1988; 1990–1992. Baxter-Jones, United PI 2 yr 162 156 elite players, 8–16 y Any injury resulting in 0.5 1993 Kingdom discontinuation of training and/or medical treatment Backx, 1991 Netherlands P Q 7 mo 399 (all 1818 school children Any physical damage 1.5 0.1 sports) 8–17 y; caused by an accident 198 tennis players during physical education or in any sports activi- ties outside of school, both organized and non-organized Backx, 1989 Netherlands R Q 6 wk 791 (all 7468 school children Physical damage caused All sports sports) 8–17 y; 690 tennis by a sports-related inci- 10.6/100 players dent and reported as such participants by the respondent RR tennis 0.47 RR 0.4 M RR 0.6 F Reece, 1986 Australia R MR 4 yr 176 24 M 21 F elite Any injury that required 2.5 M players at Australian attention from the medical 2.9 F Institute of Sport, aged officer or physiotherapist 16–20 y, mean 17.6 (continued) Table 21.1 (continued)
Studya Country Study Data Duration No. of Injuries Study Population Injury Definition No. of No. of Other Rates Design Collection of Injury Injuries/ Injuries/ Surveillance 1,000 hr of Player/yr Exposure
Garrick, 1978 United PC 2 yr 13 114 M and 136 F high A medical problem 0.01 M States school tennis players resulting from tennis 0.04 F participation necessitating removal from a practice or competitive event and/or resulting in missing a subsequent practice or competitive event Adults Veijgen (2007) The PQ 13 wk 283 1,009 amateur tennis Any physical symptom of 3.0 1.0 Netherlands players a player resulting from a tennis match, practice, or unorganized tennis activ- ity, as a result of which the player was not able to take full part in tennis for 3 consecutive days Jayanthi et al. United RQ 1 yr 299 140 M, 388 F Any injury or pain the 3.0 Prevalence, 52.9 (2005) States recreational-league player had experienced in 3.8 M injuries /100 players (ITN 3 to 8); the past 12 mo preventing 2.8 F players mean age 46.9 yr play for 7 days or more Kühne et al. Germany P Q 2 yr 335 60 competitive play- The injuries and problems 1.5 (2004) ers, mean age 25 yr; 50 that the player experi- recreational players, enced during tennis mean age 53 yr LIS—Oldenziel The P MR Continuous 2,331, extrap- Tennis players from Injuries requiring 0.05 & Stam (2008); Netherlands registration olated to 4,000 general population treatment at an emergency injury/yr (2002–2006) department Stam (2004); Extrapolated Tennis players from 0.05 to 5,200 general population injury/yr (1998–2002) Schoots et al. Extrapolated Tennis players from 0.06 (1999) to 7200 general population injury/yr (1992–1996) OBiN— The RI 3.5 mo Outdoor, 91 Tennis players from All acute and chronic 1.1 (range, Oldenziel & Netherlands Indoor, 37 general population injuries or ailments that 0.9–1.3) Stam (2008); Unknown, 3 (2000–2005) developed as a result 0.9 outdoor Schmikli et al. of or during sports 1.6 indoor (1995, 2001); participation van Galen & Diederiks (1990) 3 mo Outdoor, 27 Tennis players from 0.5 Indoor, 17 general population Outdoor (1997–1998) 1.0 Indoor 4 wk Outdoor, 42 Outdoor, 1,216 players Injuries or ailments newly 1.2 Outdoor Indoor, 24 Indoor, 573 players developed as a result of or 2.9 Indoor (1992–1993) during sports participation; chronic injuries not recorded 4 wk Outdoor, 35 Tennis players from 1.2 Outdoor Indoor, 28 general population 1.8 Indoor (1986–1987) Sallis et al. R MR 15 yr College players; range, Medical problem as a 0.5 M (2001) 18–22 yr; 3,767 result of sport 0.4 F participants in all participation requiring sports, including tennis visit to training room Weijermans et The PQ 6 mo (outdoor 179 179 club players from Tennis-related problem 0.1 al. (1998) Netherlands season) 46 tennis clubs resulting in loss of practice or match time, need for medical consultation, or negative social/economic consequences (absence from school/work) Routley & Australia P MR 1 and 2 yr 90 General population; Injuries requiring 0.0003 Valuri (1993) 338,400 tennis players treatment at the emer- gency department Larsen (1991) Denmark P Q 6 mo 33 109 M, 51 F members Injury was self-defined 5.0 10.9 injury/ of a Danish tennis club as any lesion occurring 5.4 M player/season (303 members); mean as a result of tennis play 4.1 F age 26.8 yr (range, 9–59) (whether or not the person was able to continue play) Lanese et al. United P DM 1 yr 10 12 M, 11 F college Traumatic medical 1.4 0.4 (1990) States players, age 18–22 yr problem due to sports 1.6 M 0.50 M participation resulting in 1.0 F 0.4 F time loss from practice or competition Winge et al. Denmark P Q 6 mo (outdoor 46 Elite players: 61 M, Every problem that 2.3 0.5 injury/ (1989) season) mean age 28 yr; 28 F, appeared in connection 2.7 M player/season mean age 22 yr with tennis, handicapped 1.1 F the player during play, and/or required special treatment Krause & Germany R Q 1 yr 88 78 M 49 F elite All tennis-related injuries 0.7 Pottinger (1988) players, age 15 to 46 yr from the year before (1985) Biener & Switzerland R Q Tennis career 225 203 M, 72 F high-level Not reported 0.05 Caluori (1976a, competitive players; 1976b, 1976c) mean age 28 yr
AE athlete-exposure; DM direct monitor; F female; I interview; i/d indoor tennis; ITN international tennis number; LIS letsel informatie systeem; M male; MR medical records; OBiN Ongevallen en Bewegen in Nederland (Injuries and physical activities in the Netherlands ) o/d outdoor tennis; P prospective; Q questionnaire; R retrospective. a Results of the LIS and OBiN studies in different time periods have been reported by different authors. 282 chapter 21
Table 21.2 Percent comparison of injury location in tennis.
P
Oldenziel & Veijgen Kühne et al. Sallis et al. Safran et al. Hutchinson Winge et al. Stam (2008) (2007) (2004) (2001) (1999) et al. 1995 (1989)
2331 283 335 1874 (all 233 304 46 sports) Head/trunk 11 10 11.3 7.9 19.9 22 11 Head/neck 9 1.1 4.2 7 Back 12.1 12 Upper back/chest 1 1.1 11.3 7.9 11 Lower back 1 7.8 Abdomen 3.6 3 Upper extremity 29 36.7 24.9 23.9 27.7 27 45.8 Shoulder 4 12 11.8 13.9 10.7 9 17.4 Arm 1 2.8 5.9 5.0 4.4 Elbow 2 13.1 4.4 8.5 8 10.9 Forearm 1 2.8 5.1 2.2 Wrist/hand 21 6.0 3.6 4.1 3.5 10 10.9 Lower extremity 60 53.3 63.6 65.2 52.5 51 39 Pelvis/hip 1 3.5 27.1 6.4 8 Thigh/groin 2 8.5 13.9 9.9 21 4.3 Knee 10 12.7 7.8 12.0 5.0 2 6.5 Lower leg 10 18.0 14.6 13.2 2 4.3 Calf/Achilles tendon 7 9.2 4.3 Ankle 25 8.5 6.9 16.7 8.5 7 10.9 Foot/toes 5 2.1 7.2 9.4 13.5 11 8.7 Other 1 3.0 4.3 Total 100 100 99.8 100 100.1 100 100.1
P prospective; R retrospective. a Refers to the total number of overuse injuries.
2004; Veijgen 2007). The pattern of injury onset varies occurred within a few minutes of starting play. by injury location. Most acute injuries are found in However, this was an overall figure for all three rac- the lower extremities and most gradual-onset, more quet sports and not specified for tennis. chronic injuries are located in the upper extremities. This is not surprising, as most acute trauma such What Is the Outcome? as ankle sprains, knee sprains, and muscle ruptures originate in the lower extremity. The more grad- Injury Type ual-onset chronic repetitive strain injuries tend to A percent comparison of injury types sustained affect the tendons of the shoulder, elbow, and wrist, by tennis players is shown in Table 21.3. A strain located in the upper extremity. is consistently the most common injury type for tennis players, whereby the severity of the injury Chronometry can vary from a slight muscle strain to chronic Very little information is available related to the time tendinopathy. A sprain is the second most common when injuries occurred, such as time into practice, injury type. We added a column for cramps, as the time of day, or time of season. In a study on badmin- number of cramps was quite high in one study, and ton, squash, and tennis players, Chard & Lachmann it is debatable whether or not cramps should be (1987) reported that in 20% of the players, injury classified as an injury (under strains). tennis 283
R
Jayanthi et al. Krause & Chard & Reece et al. von Krämer. & Biener and Caluori (2005) Pöttinger (1988) Lachmann (1987) (1986) Schmitz-Beuting (1979) (1976a, 1976b, 1976c)
299 88 131 176 225 15
10 19.3 20 19.3 16.6 8 2 2.8 3.8 6 10 2 19.3 16 2.3 12.8 10.2 4 41 36.2 35 19.9 48.2 43.4 15 27.2 9 9.1 5.7
20 4.5 14.5 7.4 41 1.1 6 4.5 7 2.3 1.5 39 39.8 45 60.8 31.1 48.6 5.7 5.7 3.4 5 3.4 9.7 12 9.1 19 13 4.9 1 4.5 15.1 5 2.3 4 5.7 8 19.3 5.5 14.2 8 4 8 7.7 3 4.5 (19)a 93 99.8 100 100 95.9 100
Tennis Elbow interpreted with caution, as they are difficult to com- pare with more recent studies, in which elbow inju- A percentage comparison of injury rates for tennis ries are presented as either a yearly incidence or as a elbow is shown in Table 21.4. The reported injury percentage of all injuries (range, 2–20%; Table 21.2). rates for tennis elbow are quite high, with percent- ages ranging from 37% to 57%. However, the injury Knee definitions used were either quite broad (“Have you ever had pain on either side of the elbow which has Three studies specifically examined anterior cruciate caused discomfort or disability when playing ten- ligament (ACL) injuries in tennis players. Majewski nis?”) or tennis elbow was self-reported, without the et al. 2006, Susanne & Klaus (2006) reviewed the use of an injury definition. Furthermore, all studies epidemiology of 7,769 athletic knee injuries that had presented cumulative incidence rates by reporting been treated in their clinic over a 10-year period. Of the career incidence: the percentage of players who these, 295 were directly related to tennis. Of the 129 currently suffered from tennis elbow (or elbow pain) patients who underwent arthroscopic evaluation, 33 or had suffered from it in the past. Only one study (11.3%) were found to have an ACL injury. Powell (Carroll 1981) reported the yearly incidence and et al. (1988) reported 222 racket-sport–related knee prevalence of tennis elbow (9.1% and 14.1%, respec- injuries. One hundred twenty-one players under- tively). These cumulative injury rates should be went arthroscopy, and 28 (13%) were diagnosed Table 21.3 Percent comparison of injury type.
Study No. of Abrasions/ Contusions Cramps Dislocations Fractures Inflammation Miscellaneous Overuse (not Strains Sprains Unspecified Injuries Lacerations specified)
Oldenziel & 2331 28 — — 3 21 — 1 — 19 26 2 Stam (2008) Veijgen (2007) 283 0.7 0.7 0.4 1.8 5.4 (eye, 0.4; 13.8 59.3 15.1 2.8 nerve, 1.1) Kühne et al. 335 — 7.2 28.7 0.3 0.6 2.1 0.3 46.6 13.7 (2004) Silva et al. (2003) 399 4 27.1 17.7 39.6 4.3 Safran et al. 233 0 5.0 0.71 0.7 18.4 12.1 54.6 8.5 (1999) Hutchinson et 304 8.6 3.8 0.5 1 10 3.8 55 17.1 al. (1995) Winge et al. 46 5 2 5 (blisters) 14 17 (1989) Reece et al. 176 1.1 0.6 0.6 3.5 7.0 1.2 69.2 16.9 (1986) Biener & Caluori 225 3.1 0.8 11.3 21.3 (1976a, 1976b, 1976c) tennis 285
Table 21.4 Comparison of tennis elbow injuries.
Study Study Data Study Population Injury Definition Injury Rate Severity Design Collection
Kamien (1989) R Q and I 260 (187 M, 73 F) Have you ever 57% career 36% (33% M, active club had pain on either incidence 42% F) could not members, age 10 to side of the elbow use arm in daily 70 yr which has caused life; 59% had discomfort or to stop playing disability when tennis playing tennis? Kitai et al. Q Q and DM 150 M members of 4 Any reported 51% career Single episode (1986) tennis clubs, mean elbow pain was incidence 41 wk; if more ( SD) age 41.5 noted as tennis episodes: first 13 11.3 yr elbow and most recent 18 wk Carroll (1981) R Q and I 74 local league Self-reported 35% career 1 player had players, age 17–54 yr tennis elbow incidence surgery sufferers; no injury definition given Priest et al. RQ 2,633 (1,343 M, 1,290 Experienced 31% career 130 players (1980a, 1980b) F) participants of a elbow pain from incidence received a tennis school, playing tennis cortisone 9–69 yr injection Gruchow & RQ 532 (278 M, 254 F) Self-reported Incidence, 9.1%; 3 players had Pelletier (1979) members of a tennis elbow prevalence, surgery private tennis club, sufferers; no 14.1%; Career aged 20 to 50 y injury definition incidence, 39.7% given
Career incidence percentage of players that currently suffered from tennis elbow or had suffered from it in the past;.DM direct moni- toring; F female; I interview; M male; Q questionnaire; R retrospective; SD standard deviation.
with an ACL injury. Of the 19 knee injuries reported ruptures due to sports injuries, 12 occurred during by Kühne et al. (2004), only two were ACL ruptures tennis play (10 in men, 2 in women). (10.5%). Even though ACL injuries are not as com- mon in tennis as they are in contact sports, they do Back occur, and risk factors need to be identified. The motions required in tennis include flexion, Tennis Leg extension, and rotation of the spine, and intense tennis play is generally held to be a risk factor for Millar (1979) reviewed 720 cases of calf-muscle low back pain (Figure 21.1). This was examined in strain, also known as “tennis leg.” In 16.2% of several studies. the cases, the injury occurred during tennis play. Saraux et al. (1999) interviewed 633 spectators Unfortunately, no data regarding the population at at an international tennis competition and divided risk were presented. them into 388 tennis players (281 men, 107 women) and 245 non–tennis players (140 men, 105 women). Achilles Tendon Rupture Among the male tennis players, 17.4% reported low Möller et al. (1996) examined 153 cases of total back pain during the past week, as compared with Achilles tendon rupture. Of the 98 Achilles tendon 18.7% of the non–tennis players. Corresponding 286 chapter 21
13-year follow-up period correlated significantly to low back pain (P 0.005). Alyas et al. 2007, Turner & Connell (2007) studied the spine of 33 asymptomatic elite adolescent tennis players (mean [ SD] age, 17.3 1.7 years). Five play- ers (15.2%) had a normal magnetic resonance imag- ing examination, and 28 (84.8%) had an abnormal examination. Nine players showed 10 pars lesions (3 complete fractures) and 23 patients showed signs of early facet arthropathy. In conclusion, there is no evidence that playing tennis involves a higher risk of low back pain (with or without sciatica). However, radiologic abnor- malities are common, and the disk is the structure at risk for future back pain in former players.
Stress Fractures Maquirriain & Ghisi (2006) performed a retrospec- tive study of the 139 players designated by the Argentine Tennis Association for medical care at their High Performance Center. The elite tennis players in their study had a 12.9% absolute risk of stress fracture during a 2-year period. The tarsal navicular bone, the spine, and the metatarsals were the most affected bones. Goldberg & Pecora (1994) found a clinical inci- dence of 8% in tennis (2 injuries in 24 players) when Figure 21.1 The motions required in serving include they reviewed the medical records of stress fractures flexion, extension, and rotation of the spine. © IOC / Steve MUNDAY. in collegiate athletes over a 3-year period. In a case series of 196 stress fractures, Iwamoto & Takeda figures in women were 18.7% and 27.6%. Sciatica (2003) found five fractures (2.6%) related to tennis. was not more common in tennis players than in The proportion of stress fractures of all tennis inju- non–tennis players (men, 7.1% vs. 4.3%; women, ries (n 363) was 1.7%. Reece et al. 1996, Fricker, 7.5% vs. 9.5%). None of these differences were sta- and Maguire (1986) reported five stress fractures (of tistically significant. The volume of play was simi- 176 injuries) among 45 elite junior tennis players lar in tennis players with and without pain. followed for 4 years. Lundin et al. (2001) investigated back pain and radiologic changes in the thoracolumbar spine in Eye Injuries 134 former top athletes, including 28 tennis play- ers, and 28 nonathletes of comparable age. Among Of a total of 80 athletes with sport-related eye inju- the tennis players, 14 had no back pain, 5 had mod- ries who presented to a hospital emergency depart- erate back pain, and 9 had severe back pain. Of the ment, 12.6% were caused by tennis (Pardhan, nonathletes, 11 had no back pain, 8 had moderate Shacklock & Weatherill 1995). Most injuries were back pain, and 9 had severe back pain. No correla- caused by contact with the ball, and all patients tion was found between back pain and the number required follow-up treatment or hospital admit- of types of radiologic abnormalities in either group. tance. A study by Barr et al. (2000) of 52 sport- However, a decrease in disk height during the related eye injuries showed that 10% were related tennis 287
to tennis. Of all injuries, macroscopic hyphema was of chronic injuries required surgery (Kühne et al. the most common reason for admission (87.5%). 2004). These included two ACL reconstructions, three partial meniscectomies, one meniscus repair, Time Loss one Achilles tendon repair (a second Achilles ten- In the reported studies, time loss ranged from 5.9 to don rupture was treated conservatively, with a cast), 48.5 days per injury (Biener & Caluori, 1976a, 1976b, and one lateral ankle ligament reconstruction. This 1976c; Winge et al. 1989; Lanese et al. 1990) and was a rerupture; three other lateral ankle ligament from 5.7 to 24.2 days per 1,000 hours of play (Lanese ruptures were treated conservatively. et al. 1990). Time lost from work was much less, as Osteoarthritis of the Lower Extremities people are often able to continue working despite having a shoulder or ankle injury, ranging from 0 Spector et al. (1996) retrospectively studied a cohort to 5 days per injury, with 16% to 20% of all injuries of 81 female former elite athletes (67 middle- and resulting in time lost from work (Weijermans et al. long-distance runners, and 14 tennis players), 40 to 65 1998; Kühne et al. 2004; Oldenziel & Stam 2008). In years of age, recruited from original playing records, the LIS study (Breedveld 2003), 5% of all players vis- and 977 age-matched female controls from London, iting an emergency department from 1997 to 1999 United Kingdom. Osteoarthritis was defined by were hospitalized for an average of 5 days. From radiologic changes (joint-space narrowing and osteo- 2002 to 2006, the percentage of players who were phytes) in hip joints, patellofemoral joints, and tibi- hospitalized after visiting an emergency department ofibular joints. The former athletes had a greater risk was 6%, and the average number of days in the hos- of radiologic osteoarthritis at all sites. This associa- pital was 3.5 days (Oldenziel & Stam 2008). tion was strongest for the presence of osteophytes at the tibiofibular joints (odds ratio, 3.6; 95% confidence Clinical Outcome interval [CI], 1.9–6.7), at the patellofemoral joints (odds ratio, 3.5; 95% CI, 1.8–6.8), narrowing at the Medical Treatment patellofemoral joints (odds ratio, 3.0; 95% CI, 1.2–7.7), Injuries sustained while playing indoors tended to femoral osteophytes (odds ratio, 2.5; 95% CI, 1.0–6.3), be more severe than outdoor injuries, with a higher and hip joint narrowing (odds ratio, 1.6; 95% CI, 0.7– percentage (range, 57–66% vs. 27–53%) requiring 3.5), and was weakest for narrowing at the tibiofibu- medical treatment (van Galen & Diederiks 1990; lar joints (odds ratio, 1.2; 95% CI, 0.7–1.9)). The tennis Schmikli et al. 1995, 2001; Oldenziel & Stam 2008). players tended to have more osteophytes at the tibi- The percentage of injuries requiring medical treat- ofibular joints and hip. It was concluded that weight- ment ranged from 27% to 60% (Biener & Caluori, bearing sports-activity in women is associated with a 1976a, 1976b, 1976c; Breidveld 2003; Kühne et al. twofold to threefold increased risk of radiologic oste- 2004; Stam 2004; Oldenziel & Stam 2008). oarthritis (particularly the presence of osteophytes) In two studies of junior tennis players (Reece et of the knees and hips. al. 1986; Hutchinson et al. 1995) injuries were rela- Maquirriain & Ghisi (2006) studied 18 asymp- tively minor. Hutchinson et al. (1995) reported that tomatic tennis players (17 men; mean age, 57.2 only 1 of 1440 players required transport to the hos- years; range, 51–76) and 18 age- and sex-matched pital (heat exhaustion). Reece et al. (1986) reported controls (59.8 years; range, 51–76). Changes in the 176 injuries during a 4-year period, of which only 2 dominant shoulder occurred in 33% of the play- required surgical intervention. The first was a pain- ers, versus 11% of the controls (P 0.04 by the ful bipartite patella, in which the offending piece Wilcoxon test). The group with osteoarthritis was of bone was surgically removed. The second con- significantly older than the players without degen- dition was a lateral meniscus injury, treated with a erative changes (P 0.0008). It was concluded that partial meniscectomy. prolonged intensive tennis practice may be a pre- Injuries were more serious in a study of 110 disposing factor for mild degenerative articular competitive tennis players: 3.3% of acute and 2.2% changes in the dominant shoulder. 288 chapter 21
Economic Cost Previous Injury The direct medical costs per year in the It has not been reported in tennis studies whether a Netherlands for patients treated for a tennis injury previous injury is a risk factor for another injury. at an emergency department were calculated in the LIS study (Schoots et al. 1999; Stam 2004; Oldenziel Extrinsic Factors & Stam 2008). The average costs per patient Extrinsic risk factors for tennis injuries include vol- increased from 690 USD per year in the period 1997 ume of play, skill level, match play, playing surface, to 1999 to 1800 USD in the period 2002 to 2006. The shoes, and equipment (rackets, string and balls). total direct medical costs increased from 4.1 mil- lion USD (1997–1999) to 6.9 million USD (2002– Volume of Play 2006). Further study is warranted on direct and indirect medical costs for tennis injuries in other Veijgen (2007) found that those who played 3 countries. hours per week had a significantly higher risk for tennis injury than those who played 3 hours per week. Weijermans et al. (1998) reported that What Are the Risk Factors? the injured group played an average of 4.9 hours per week, whereas the noninjured group played Intrinsic Factors an average of 2.1 hours per week. This difference Age was statistically significant in the 30-to-39-year age group (P 0.05) and the 40-to-49-year age group The association between age and injury rate has (P 0.005). been investigated in two studies (Jayanthi et al. 2005; Two studies on tennis elbow noted a higher risk Veijgen 2007). Injury rates appeared to be independ- with an increased volume of play. Kitai et al. (1986) ent of age. reported that the “average” tennis-elbow sufferer has played 8 hours weekly before the onset of pain, Sex whereas the average pain-free player plays 5.5 hours a week. Gruchow & Pelletier (1979) noted Studies examining the relation between injury risk that recreational players practicing 2 hours a day and gender are presented in Table 21.5. were at significantly higher risk for elbow pain Four prospective cohort studies (Winge et al. than those playing 2 hours a day. In contrast, 1989; Lanese et al. 1990; Safran et al. 1999; Sallis Jayanthi et al. (2005) reported that the total inci- et al. 2001) compared injury rates between male and dence and prevalence of all tennis-related injuries female tennis players, and showed that the injury were not different among recreational players who rate was higher for the male players, but in only played 4 hours a week, 4 to 6 hours a week, or two studies (Winge et al. 1989; Safran et al. 1999) 6 hours a week. was this difference statistically significant. In the LIS These studies suggest that an increased volume study, there was no significant difference in the of play is likely to be a risk factor for tennis injury, number of men as compared with women who pre- but the association between volume of play and sented with a tennis injury at an emergency depart- injury risk should be studied in greater detail. ment (Oldenziel & Stam 2008). The male-to-female ratio was 55:45, which is similar to the tennis par- Skill Level ticipation rates of men and women in tennis in the Netherlands (Hildebrandt et al. 2004). We were able to identify only three studies that These results suggest that injury rates in male compared injury rates between players of different and female players are fairly similar, but that there ability. Jayanthi et al. (2005) described the incidence might be a slight preponderance of injuries in male and prevalence of injuries in recreational players players. of different skill levels, ranging from International tennis 289 0.05 Not reported 0.001 NS P Value (M)(F) 2.5 M and 3.0 F injuries/player/yr 41/1,000 AEs (M) 32/1,000 AEs (F) 0.456 M and 0.425 F injury/player/year Injury Rate, Other 0.37 P 0.05 0.64 injury/season NS 0.62 OR (F), 0.7 (95% CI 0.6–1.0), P 0.053 ns Value or P Value Odds Ratio 1.6 M 1.0 F 1.1 F 2.78 F 19/100 athletes (M)(F) (55%M:45%F) Injury rate per 1000 h 176 6 M 4 F 46 2.7 M 137 M 96 F 2991874 all 3.75 M sports 2,331 0.05 No. of Injuries 24 M 21 F 61 M 12 M 11 F 28 F 3767 all 720 M 539 F 140 M 388 F sports 2,331 registered registered cases No. of Subjects 1 yr tournaments 1 yr 13 wk 1009 283 3.0 Study Duration Data collection PQ Study Design Reece et al. (1986) R MR 4 yr Winge et al. (1989)Winge R MR 6 mo Lanese et al. (1990) P E Safran et al. (1999) P DM 6 Sallis et al. (2001) R MR 15 yr Jayanthi et al. (2005) R Q Veijgen (2007) Veijgen Oldenziel & Stam (2008) P MR Continuous Table 21.5 Table Sex as a risk factor for tennis injuries. Study R retrospective. prospective; F female; M male; NS not significant; OR odds ratio; P AE athlete-exposure; 290 chapter 21
Tennis Number 3 to 8. Despite trends, there were Playing Surface no statistical differences in overall injury inci- Bastholt (2000) reported on the number of medical dence and prevalence rates across all skill levels. treatments given to professional tennis players on There were trends of increasing prevalence of inju- the ATP Tour from 1995 to 1997. The relative risk of ries in players with higher ranking. Veijgen (2007) having to receive treatment while playing on a hard reported that experience ( 5 years of play) was court as compared with grass was 0.80 (P 0.01), a protective factor for tennis injuries (odds ratio, whereas the risk of playing on a hard court as 0.7; 95% CI, 0.5–0.9; P 0.010). Maquirriain & compared with clay was 2.3 (P 0.001). The risk Ghisi (2006) reported that junior elite players had was lowest on clay as compared with grass (0.35; a higher incidence of stress fractures than profes- P 0.0001). Thus, playing on either grass or hard sional adults (20.3%; 95% CI, 11.4–33.2; vs. 7.5%; court resulted in a higher number of treatments 95% CI, 2.8–15.6; P 0.045). than playing on clay. Although “treatment” is not the same as “injury,” these results suggest that the Match Play injury risk is lowest on clay, followed by grass and Veijgen (2007) identified playing matches as a risk hard court. This may be related to the ability to factor for tennis injury (tournament player: odds slide on clay, which has been suggested to be more ratio, 4.1; 95% CI, 2.3–7.3; P 0.01). Because experi- important than the cushioning effect of grass for ence was identified as a protective factor (see “Skill the reduction of load on the locomotor system of Level” section, above), this resulted in the highest tennis players, because of the longer braking phase injury rates in competitive players that have played and the resulting lower peak force (Nigg et al. 1986; 5 years of tennis as compared with recreational Nigg & Segesser 1988). players with 5 years of tennis experience. Weijermans et al. (1998) compared injured play- Shoes ers with noninjured players of the same age and Llana et al. (2002) examined the discomfort asso- found that significantly more injured than non- ciated with footwear worn in tennis matches; injured players played tennis competition, club 128 male and 18 female recreational tennis play- championships, and tournaments (all P 0.01). ers (mean age [ SD], 26 8.2 years) were per- Furthermore, injured players considered winning sonally interviewed and had their tennis shoes and performing to be significantly more important tested. The most important finding was the sig- than noninjured players (P 0.05) and having fun nificant correlation (r 0.19; P 0.02) between and relaxing significantly less important (P 0.01). perceived incorrect arch support and plantar Winge et al. (1989) found fairly similar injury rates discomfort. during practice (2.2 injuries per player per 1,000 hr In a prospective short study with 2 months of of training) and competition (2.4 injuries per player follow-up, Nigg et al. (1986) studied 171 mem- per 1,000 hr of match; P not significant). bers of tennis clubs. Sixty-one (50 men, 18 women) These findings suggest that injury rates may be reported pain and completed a medical question- slightly higher during competition than during naire. Shoe, temperature, type and duration of practice. match play, subjective assessment of shoe comfort, sole grip, and lateral stability were assessed. It was Equipment concluded that stiffness of the shoe and subjective Although some descriptive studies point to a relation evaluation of frictional properties of the shoe were between certain types of equipment (rackets, strings, significantly associated with pain. and balls) and injury (Brody 1989; Tomosue et al. Although “discomfort” and “pain” are not 1995; Wilson & Davis 1995; Stone et al. 1999, Vught equivalent to “injury,” it does suggest that a correct & Safran 1999), there have been no analytical longi- design of the shoe and outsole adapted to the sur- tudinal studies that have tested this relationship. face may reduce the risk of a tennis injury. tennis 291
What Are the Inciting Events? Researchers should, if possible, choose a pro- spective study design in order to decrease the risk Very little scientific information is available regard- of recall bias. A comparison of injury rates across ing the inciting events for tennis injuries. An ankle studies will be facilitated when similar definitions injury often occurs when sliding into the backhand, of injuries are used and are clearly stated in the particularly if the foot is suddenly stopped (high studies. The injury definitions in the studies in this friction between shoe and surface [e.g. high court review can be categorized as “time loss,” “medi- temperature, loose clay, line sticking out, outsole cal assistance,” and “tissue injury” definitions with high friction]). In the study by Weijermans (Orchard & Seward 2002; Hägglund et al. 2005). et al. (1998) one of four ankle sprains was caused Each definition has advantages and disadvantages by a player stepping on a ball; in 42% of the cases and delivers its own scope of the problem of tennis the player was hitting a backhand at the moment injuries. A clear benefit of using a “time-loss” defi- the injury occurred. nition is that it will generally result in the record- ing of injuries that substantially affect the player’s Injury Prevention health or performance or both. Based on the current literature review, we were Few studies have been carried out on the reli- unable to identify measures proven to prevent ten- ability of injury recording systems, and this nis injuries. There are no randomized, controlled tri- should therefore be a priority for future research als or nonrandomized preventive studies available, (Meeuwisse & Love 1998; McManus 2000; and the limited results of the studies on risk factors Hägglund et al. 2005). To improve the reliability for tennis injuries fail to provide a clear perspective. of data collection it would be recommended to develop instruction manuals that can be used by the observers. Further Research Another important characteristic is exposure The aim of the present literature review was to pro- time, which is a measure of participation time in vide an overview of available knowledge on the training and matches during which the player is epidemiology of tennis injuries. By presenting stud- at risk of injury. The exposure time should, if pos- ies with different study designs, a picture emerges sible, be recorded individually for each player that represents the current base of knowledge in and should be taken into account when studying this field. It is clear from the results that further risk factors for tennis injuries (van Mechelen et al. studies on distribution and rate of injuries, risk fac- 1996). However, because of practical limitations in tors, inciting events, and prevention of tennis inju- many cases—especially in large cohort studies— ries are needed. In particular, risk factors for injuries estimates of exposure time may have to be used. to the spine should be identified, particularly in the Finally, in order to obtain optimal results in future growing athlete. In addition, further research into studies, we recommend that a consensus statement volume of play, match play, skill level, and the rela- on injury definitions and data-collection procedures tionship between age and injury risk is warranted. in studies of tennis injuries be produced.
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Triathlon
VERONICA VLECK Faculty of Human Kinetics, Technical University of Lisbon, Cruz Quebrada, Portugal
Introduction Although at least two longitudinal prospective studies of more than 6 weeks duration have been Triathlon made its Olympic debut as the opening conducted (Vleck 2003; J. Tennant, University of event of Sydney 2000 only 19 years after first being North Carolina, Chapel Hill, unpublished results), officially recognized by the International Olympic both they and the largest database thus far com- Committee. The Olympic triathlon involves a 1.5-km piled (Hiller et al. 1989, for 2,438 Olympic distance lake, ocean, or river swim (Figure 22.1), a 40-km cycle [OD] triathletes) are largely unpublished. Most of ride (conducted under `drafting´ conditions where the available work is based on retrospective ques- the athlete is allowed to `slipstream´ behind another tionnaires, and possesses the following methodo- rider), and a 10-km run. Competitions are also held logic limitations: over a variety of other distances, formats, and 5 year age-groups (see Bentley et al., 2002 and www. • Nonrandom samples, small survey samples, low triathlon.org for details). response rates, and response bias (Egermann Although triathlon is increasing in popularity et al., 2003; Scott 2004). (O’Toole et al. 2001; Burns et al. 2003; Gosling et al. • Variation in the duration of retrospective recall 2007), this has not been matched by a concomitant required and consequent time dependent mem- increase in the quantity and quality of triathlon ory loss (Gabbe et al. 2003). injury research (Gosling et al. 2008a). It is the aim • Inconsistent definitions or methods of recording of this chapter to summarize the current state of injury or both (Gregory 2002; Vleck 2003; Junge & knowledge about the distribution and determinants Dvorak 2008) and lack of injury validation of injury and the efficacy of preventive measures against medical records. in triathlon. Recommendations for the design of • Lack of differentiation in the study sample future triathlon injury research, such that the results between draft-legal and draft-illegal special- arising from it may be more easily transferable into ists; between different athlete abilities, ages, or real-world (health and safety) gains (Finch 2006) in sexes;and between athletes specializing in train- training and race course design, are also provided. ing for different event distances. Fewer than 50 peer-reviewed publications on • Inadequate allowance within the study design triathlon injury were obtained by our search. for the effects of cross-training. • Inadequate quantification of risk factors (particu- larly extrinsic, training-related, ones). Epidemiology of Injury in Olympic Sports. Edited by D.J. Caine, P.A. Harmer and M.A. Schiff. © 2010 • Lack of follow-up data for nonparticipants or Blackwell Publishing, ISBN: 9781405173643 drop-outs. 294 triathlon 295
Figure 22.1 Prerace swim training by the Portuguese National Squad, European Triathlon Championships, Lausanne, CH, August 19, 2006. Photograph by Nigel Farrow.
Data comparison between studies is also limited (Williams et al. 1988; Vleck et al., in press), as well by the fact that injury patterns and risk of injury in as between sexes (Vleck et al. 2007c) in each of triathlon may have changed over time along with these events (Vleck 2003). However, neither these changes in both the rules (International Triathlon differences nor whether injury rates differ with Union [ITU] Competition rules, 2006–2008) and levels ability level (Vleck & Garbutt 1998) or between of performance (Vleck et al. 2008). The most noticea- draft-legal and draft-illegal triathlon have been suf- ble change was the divergence of racing formats used ficiently investigated. The data-collection methods within age group, and elite OD triathlon, at the 1995 for the prospective studies differ, and the retrospec- ITU World Championships, from both having a non- tive data do not account for differences in individ- drafted-cycle section to the current situation of age- ual athlete exposure. It should be noted, moreover, group cycling remaining draft-illegal and elite OD from Table 22.1 that data regarding the extent of triathlon cycling having become draft-legal. injury in youth and junior triathletes, athletes with a disability, or different senior age groups are entirely absent from the literature. The long-term impli- Who Is Affected by Injury? cations of triathlon participation for pulmonary, A summary of the published data on injury occur- musculoskeletal, or cardiac health (Tulloh et al. rence in triathlon is presented in Table 22.1. The 2006; Hassan et al. 2006; Knez et al. 2007; Knez table indicates that injury causing cessation of et al. 2008) are not clear. training for 1 day, reduction of training, or seek- ing medical aid could affect between 29% (Vleck Where Does Injury Occur? 2003) and 91% (O’Toole et al. 1989) of athletes. Incidence rates of 10 to 27.6 (for OD triathletes, Anatomical Location depending on period of the year), 27.1 and 4.6 for short-distance triathletes, and 0.71 11 per 1,000 A percent comparison of the anatomical locations (in hours of exposure for Ironman (IR) triathletes, terms of the number of total injuries, and, in brack- respectively, were obtained through longitudinal ets, the number of athletes in the study) is shown in prospective survey by Vleck (2003), and by retro- Table 22.2 and illustrates that the studies vary both spective recall by Burns et al. (2003) and Gosling in the locations surveyed and the grouping of data. et al. (2007), respectively, as well as by Egermann When the data of Villavicencio et al. (2006) and et al. (2003) (data not shown). Table 22.1 indicates Clements et al. (1999) (who assessed only neck and that differences in the extent of injury may exist lower back pain, and knee injury, respectively) are between long-course and short-course triathletes omitted, however, it is clear that most injuries occur 296 chapter 22
Table 22.1 Injury occurrence.a
Study Study Injury Definition Subjects Event Distance Design Men Women
Levy (1986a, 1986b) R ↓Tr, CTr, Dr, Med 31 0 Not clear
Ireland & Micheli (1987) R Unclear 117 51 88.3% S and OD
Murphy et al. (1986) D Unclear Unclear IR (possibly same as Massimino et al. 1998) O’Toole et al. (1987) R Unclear 35 11 IR (Hawaii 1984)
Massimino et al. (1988)b R Med 58 23 IR (Hawaii 1985)
Williams et al. (1988) R CTr; “Felt really 251 81 134 OD, 83 L, 115 S uncomfortable in training and racing.” Collins et al. (1989)c R ↓Tr, CTr, Dr, Med, Non-T 197 60 OD, S, IR race finishers
O’Toole et al. (1989) R Athlete’s judgment 75 20 IR Given list of common OU injuries Jackson (1991) C Clinical case study 1 0 Mixed Migliorini (1991) R, D OU; clinical diagnosis 21 3 OD (2 IR)
Korkia et al. (1994) P CTr 1 day, CRace, CDF, 124 31 9% M and 0.6% W long; T/OU 65.2% M and 5.1% W, short Wilk et al. (1995) R TR, SB, or Ru specific 41 31 Unclear overuse or traumatic injury Manninen & Kallinen R Unclear (mainly lower back 70 22 57% IR/HM; 43% S OD (1996)d pain) Cipriani et al. (1998) R Unclear (CTr, Med?); worst 44 8 Unclear (probably mixed) injuries Vleck & Garbutt (1998)e R ↓TR, CTr, Dr, Med 12 0 OD 17 0 87 Clements et al. (1999) R (in Knee injury; ↓Tr, CTr 2 46 12 Not stated race) days; clinical diagnosis in 18 subjects Fawkner et al. (1999) P ↓Tr, CTr 1 day, Dr, Med. 27 29 — Wilk et al. (2000) C Clinical examination 1 0 MD Hiller et al. (1989) R Unclear 1968 470 OD triathlon 297
Ability Level Study Returns (%) % Group Affected by Injury Duration All Traumatic/ Overuse Temp./ Acute Fluid-Related/ Injury
Triathlon club 1 yr Unclear 90.3 — — — members—unclear 29% novice, 58% Unclear Unclear 64 — — — average, 22% expert Mixed Unclear Unclear — 21 — —
Age group—elite Race medical 4.6 M, 76; W, 73 M, 22; W, 18 M, 78C; W, 82 Unclear report 1 yr (1 yr) (1 yr) (1 yr) retrospectively Intermediate Unclear 8 — (22) 15 (M, 78; W, 82) 53.5 DH; 1 85 hypother.; 1 hyperther. Age group—elite Unclear 59.3 50.6 — — —
38.9% beginners, 1 yr and 1 race 45.0 — Excluded 49 (2.5/1,000 — 49.4% intermediate, hrPS, 4.6/1,000 11.7% elite hrC) Age group—elite 1 year 0.20 91 — 91 — (15% professional)
Age group 8 wk — — — 100 — Elite— 3 yr NA Unclear — — — international squad Age group—elite 8 wk 21.0 37 22 41% of cases —
Age group 1 yr 48.0 75 (75%TR, 27.8%C) 33.3 78.9 —
1 elite 1 yr 55.0 72MS Not differentiated between —
Mainly intermediate Ever? 52.0 64 Unclear, but 37.5 most injuries — were related to overtraining Elite 5 yr 71.0 41.2 75.0 — Subelite 78 37.5 75 .0 — Age group 66 56.3 56.3 — 7 novice, 17 club, 3 yr 58 34 (34.5) — 27.8 — 26 age group, 7 elite
— 18 wk Unclear 39 — — — Age group Case study NA — — 100 — — Ever NA No overall —— — incidence (continued) 298 chapter 22
Table 22.1 (continued)
Study Study Injury Definition Subjects Event Distance Design Men Women
Richter et al. O Clinical examination 0 1 IR (2007) Burns et al. (2003)e R/P ↓Tr, CTr 1 day, Dr, Med, 91 40 Competitors, Australian OU/T domestic series
Egermann et al. (2003) R CTr/Race 588 68 IR Europe 2000
Vleck (2003) Re ↓Tr, CTr, Dr, Med 7 OD 11 OD 7 IR P53OD Sharwood (2004) O Clinical examination 293 IR (2001) 579 IR (2002)
Shaw et al. (2004) R ↓Tr, CTr, Dr, Soc/Ec 190 68 —
Burns et al. (2005)e R ↓Tr, CTr 1 day, Dr, Med 44 8 As in Burns et al. 2003
Villavicencio et al. R Acute event leading to 131 56 Unclear (2006) CTr 1 day, Dr, Med Gosling et al. (2007) O race Damage due to physical 213f/ 6 “fun”; Mixed activity (race data) 10, 173 5 S, 1 OD Tennant (2007) R Not clear 969 11 S, 3 OD, 2 ½ IR Gosling et al (2008b) O Heat casualty 1,844 S Race 1 2,000 Race 2 Vleck et al. (in press)e R ↓Tr, CTr, Dr, Med 12 OD 18 IR
C competition-related; CDF cessation of daily function; CRace cessation of racing; CTR cessation of training; CTR/Race cessation hr hours; hyponat hyponatremia; hypother. hypothermia; IR Ironman distance; L long distance; M men; MD middle dis- observational; OD Olympic distance; P prospective; PS preseason; R retrospective; Ru Running; S sprint; SB swimming W women; wk week; yr year; ½ IR ½ Ironman Superscripts refer to percentages of injuries attributed to 1 discipline. a Data from Chateau et al. (1 case of hypothermia), Charle (1997) (1 hand fracture in the swim). Moehrle et al. (2001), (ultraviolet potential myocardial damage (La Gerche et al. 2004) are not included. b In addition, 1.0, 3.9, 6.3, 10.3, 8.2, and 10.2% of starters received postrace intravenous fluids from 1981 to 1986. c Rates estimated retrospectively and unlikely to be strictly comparable because of differing recall periods. d Nonsignificant tendency (P 0.052) for women to exhibit more low back pain than men. e Same methods of retrospective data collection & analysis used in both papers from this group. f Number of race starters who presented themselves for medical assistance. triathlon 299
Ability Level Study Returns (%) % Group Affected by Injury Duration All Traumatic/ Overuse Temp./ Acute Fluid-Related/ Injury
Unclear Case study 1 — — — hyponat
Novice to elite 6 mo PS; 10 Unclear 50.4PS 37.5C 32 78 PS,2.5/1,000 international wk C hr, 78C, 4.6/1,000 hr 10, 10–12, and Since start? 35 74.8, 12 hr 0.71 1.11/1,000 hr Elite 5 yr 48.1–91.7 29–50 Subelite Age group Elite 7 mo 22–84 80.4 Mixed Race All? 12 2 hyponat clinical diagnosis 62% competitive, rest 3 seasons and 55 62 — mainly lower level recall for 1 season Novice to elite 6 mo PS; 10 Unclear 50.4PS Unclear — wk C Lifetime Ϸ2.2/1,000 31–67.8 13.6–62.7 31–67.8 — hr Race series 2.71/1,000 2.3% 28 6 7 DH, 6 race-hr starters temp.-related
Mixed 3 yr 24.2 90.3
Mixed 2 races Unclear — — 0.8
Elite 5 yr 75% — 43.1 72.2 — 95% of training or racing; D descriptive; DH dehydration; Dr seeking medical aid; HM half-marathon; hyperther. hyperthermia; tance; Med taking medication; MO month; MS musculoskeletal; NA not applicable; OU overuse; Non-T nontraumatic; O and cycling; Soc/Ec social or economic cost; T traumatic; temp. temperature; TR training-related; ↓TR decreased training; exposure), Mollica (1998) (case study: chronic foot compartment syndrome), or relating to muscle cramps (Lopez & Chateau 1997) or Table 22.2 Percent comparison of injury location in triathlon.
No. of Injuries Ireland & Massimino Williams et al. Micheli (1987) et al. (1988) (1988) Collins et al. (1989)
All Elite Women 40 Yr Retro Retro Retro Retro Discipline attributed to 7S, 17B, 71R, 5S, 20B, 58R 11S, 50B, 53R 11S, 12.5B, overall 5O 62R, 8R O, 4.1R B, 6.5O
Head/neck/ cervical —— 6 — ——— region Upper back (5) — — — ———