HEALTH CARE FOR RURAL HIGH SCHOOL ATHLETES:
INJURY RATES, RISK FACTORS, AND IMPLICATIONS:
A PRELIMINARY ANALYSIS
A thesis presented to
the faculty of
the College of Health and Human Services of Ohio University
In partial fulfillment
of the requirements for the degree
Master of Science
Erin M. Driscoll
August 2007
2
This thesis titled
HEALTH CARE FOR RURAL HIGH SCHOOL ATHLETES:
INJURY RATES, RISK FACTORS, AND IMPLICATIONS: A PRELIMINARY
ANALYSIS
by
ERIN M. DRISCOLL
has been approved for
the School of Recreation and Sport Sciences
and the College of Health and Human Services by
Chad Starkey
Visiting Professor of Recreation and Sport Sciences
Gary S. Neiman
Dean, College of Health and Human Services
3 Abstract
DRISCOLL, ERIN M., M.S., August 2007, Athletic Training Education
HEALTH CARE FOR RURAL HIGH SCHOOL ATHLETES:
INJURY RATES, RISK FACTORS, AND IMPLICATIONS: A PRELIMINARY
ANALYSIS (74 pp.)
Director ofThesis: Chad Starkey
Objective: To determine the rate and risk of injury associated with high school athletic participation and assess the licensed athletic trainer’s (LAT) role as the point of
first contact for non-athletic orthopedic and nonorthopedic conditions suffered by
nonathletes and athletes. Participants: Eight southeastern Ohio high schools with 2,202
athletes, ranging in age from 13 to 19 (15.8±1.2). Methods: Injury information was
submitted to the researchers by the LAT. Main Outcome Measures: Frequency, clinical
incidence rates, and injury rates. Results: Over 3 seasons 651 orthopedic and 41
nonorthopedic conditions were reported. Twenty-one of the 651 orthopedic injuries were
non-athletic related. Football sustained the most injuries. Strains (24.7%) were the most
common orthopedic injury. Influenza (14.6%) was the most common nonorthopedic
condition. Conclusion: Injury rates were higher than previous literature. Lower extremity
was consistent with literature for most frequently injured body area. Nonorthopedic
conditions were reported higher than other research. Key Words: Epidemiology, High
School, Injuries
Approved: ______
Chad Starkey
Visiting Professor of Recreation and Sports Sciences
4 Acknowledgments
I would like to acknowledge and thank my committee members, Dr. Starkey, Dr.
Seegmiller, and Dr. White, for their support, insight, and wisdom over the past year.
Without your help this would still be just an idea.
I would specifically like to thank Dr. Starkey for everything he has done in this project. He has spent countless hours editing my writing and helping me run the statistics on this thesis.
I would also like to thank Megan Lindley for her help with the data collection and helping me to get our collection instruments finalized before football started in the fall.
And finally thank you to all the Ohio University graduate assistants at the eight high schools used in this study. Your dedication to this project is truly appreciated.
Without your help there would have been no data to analyze.
5 Table of Contents ABSTRACT...... 3 ACKNOWLEDGMENTS...... 4 LIST OF TABLES ...... 7 CHAPTER 1: INTRODUCTION...... 8 Introduction ...... 8 Problem Description...... 9 Purpose Statement ...... 9 Research Questions ...... 9 Purpose of the Study...... 10 Delimitations of the Study...... 10 Limitations of the Study ...... 11 Definition of Terms ...... 11 Athletic exposure ...... 11 Athletic trainer...... 11 Clinical incidence rate...... 11 Incidence rate ...... 12 Injury rate (IR)...... 12 Injury risk ...... 12 Prevalence ...... 12 CHAPTER 2: LITERATURE REVIEW...... 13 Injury Surveillance in the High School Setting ...... 14 Measure of Injury Frequency...... 15 Athletic Exposure...... 15 Injury Rate ...... 16 Incidence Rate ...... 16 Injury Risk...... 17 Clinical Incidence...... 17 Time-Lost Injury Rate ...... 17 Prevelance ...... 18 Measure of Injury Severity...... 18 Subject Populations ...... 19 Injury Definitions ...... 19 Injury Analysis ...... 22 Catastrophic Events...... 23 Orthopedic Injuries...... 25 General Medical Conditions...... 29 Summary ...... 29 CHAPTER 3: METHODS ...... 30 Subjects ...... 30 Instrumentation...... 30 Procedures ...... 31 Statistical Analysis ...... 32 CHAPTER 4: RESULTS ...... 33 Introduction ...... 33 Research Question One: What is the distribution of injuries per sport? ...... 33 Research Question Two: What are the most commonly diagnosed orthopedic injuries?...... 36 Research Question Three: What is the distribution of injury by body area?...... 38
6
Research Question Four: What is rate of injury-by-injury type (contact or noncontact)?...... 39 Time-Loss...... 40 Research Question Five: What kind of time loss is associated with different sports and different orthopedic injuries?...... 40 Research Question Six: Is there a difference in the rate of injury between sexes in this study?...... 44 Nonorthopedic Conditions...... 45 Research Question Seven: What role does the licensed athletic trainer play in the identification and management of nonorthopedic (general medical) conditions?...... 45 CHAPTER 5: DISCUSSION ...... 48 Introduction ...... 48 Injuries by Sport ...... 50 Injury Type...... 50 Body Area...... 52 Mild Traumatic Brain Injury ...... 52 Knee Injuries ...... 54 Ankle Injuries ...... 57 Athletic Trainer’s Role as Point of First Contact...... 60 Non-athletic Related Conditions...... 61 Recommended Procedural Modifications...... 62 Conclusion...... 63 REFERENCES...... 65 APPENDIX A ...... 71 APPENDIX B ...... 72 APPENDIX C ...... 73
7 List of Tables
Table Page
1: Injury Definitions ...... 20 2: High School Athletic Injury Rates and Risks ...... 22 3: Most Common Reported Injury Location and Type ...... 26 4: Demographic Profile ...... 31 5: Frequency and Rate of Injury and Illness by Sport ...... 34 6: Orthopedic Injuries by Sport ...... 35 7: Type of Orthopedic Injuries ...... 37 8: Frequency of Injury by Body Area ...... 38 9: Injury by Type (Contact versus Noncontact) ...... 39 10: Time Lost to Injury by Sport ...... 41 11: Orthopedic Time-Loss Injuries ...... 42 12: Frequency and Rate of Injury and Illness by Sex ...... 44 13: Nonorthopedic Conditions ...... 46 14: Nonorthopedic Conditions by Sport ...... 47 15: Comparison of High School Athletic Injury Rates ...... 49 16: Concussion by Sport ...... 53 17: Concussion by Type of Injury ...... 53 18: Knee Injuries by Activity ...... 55 19: ACL Injury by Sex ...... 56 20: Knee Structures Injured ...... 56 21: Ankle Sprains by Activity ...... 58 22: Ankle Sprain by Mechanisms of Injury ...... 59
8 Chapter 1: Introduction
Introduction
Injuries are commonplace in high school athletics. The high injury rate stems from several factors including improper equipment, poor coaching, inappropriate technique, strength deficits, and improper training (Guskiewicz, Weaver, Padua, &
Garrett, 2000; Turbeville, Cowan, Owen, Asal, & Anderson, 2003). A 2001 report revealed that approximately four million sports or recreational injuries were seen in
American emergency rooms, exceeding that for motor vehicle accidents (Burt &
Overpeck, 2001). A study on sports and recreational injuries and their impact on rural agricultural operations reported that 93% of boys and 92% of girls that were injured
required some health care ranging from a physician’s office to care at the scene of the
injury (Kurszewski et al., 2006).
An estimated 30 million minors each year participate in organized sports (Gotsch,
Annest, & Holmgreen, 2002). The potentially fatal consequences of trauma to the brain, cervical spine, and cardiovascular system require prompt medical attention. If the
athlete’s parents cannot afford the medical costs, the athletic trainer assumes a role of
heightened importance in triaging those injuries that do – and do not – require medical
referral.
The availability of epidemiological information regarding the frequency of high-
risk injuries provides insight to the potential risks for secondary school athletes (Powell,
2001). From this information proper recommendations can be made for the needed
emergency supplies and staff hired to manage emergency situations.
9 Problem Description
In 1908 President Theodore Roosevelt identified the “rural problem” in America
by stating that rural areas of the country were not developing at the same rate as the rest
of the nation. After almost a century and trillions of dollars spent on federal health care
programs, the rural problem still remains very much an issue (Fluharty, 2002). An
Oregon State study identified the problems associated with rural adolescent health care,
concluding that students in rural areas less likely to visit a physician or nurse practitioner.
Students in this study also more likely to never have received care for an injury or
accident they sustained (Zimmer-Gembeck, Alexander, & Nystrom, 1997). These
findings provide evidence that rural areas of the country are still very much in need of
adequate health care.
Purpose Statement
This thesis investigated high school athletic injuries and illnesses in a rural
population in southeastern Ohio and describes the athletic trainer’s role in providing
services for nonorthopedic and non-athletic related injuries. A secondary purpose of this study was to collect baseline data for future research studies.
Research Questions
This descriptive epidemiological study specifically examines the following questions:
1. What is the distribution of injuries per sport?
2. What are the most commonly diagnosed orthopedic injuries?
3. What is the distribution of injury by body area?
4. What is the rate of injury-by-injury type (contact or noncontact)?
5. What kind of time loss is associated with different sports and different
10 orthopedic injuries?
6. Is there a difference in the rate of injury between sexes in this study?
7. What role does the licensed athletic trainer play in the identification and
management of nonorthopedic (general medical) conditions?
Purpose of the Study
The purpose of this study was to determine the rate and risk of injury associated with high school athletic participation and describes the nature, type, and severity of athletic related trauma. This study also assessed the role of the athletic trainer as the point of first contact for athletic, non-athletic, orthopedic, and general medical conditions for athletes and those in the general population (e.g., the student body as a whole, teachers, parents, community members). The patient’s compliance with the referral recommendation will also be examined.
Another purpose was to maintain a dataset on this population for further research to be conducted in the future and a concurrent research project examining the financial costs associated with high school athletic injuries.
Delimitations of the Study
Delimitations of this study include:
1. Adolescents participating in rural high schools that employed graduate
assistant athletic trainers.
2. The data analyzes was for thee athletic seasons.
11 Limitations of the Study
Limitations of this study include:
1. The data collection instruments lack of detailed practice and game exposure
information for each athlete.
2. An injury definition that was more inclusive than studies found in other
literature.
3. There was an assumption that all data reported was accurate.
4. Variability in reporting compliance between the various high school athletic
trainers.
Definition of Terms
Athletic exposure
Chance an athlete has to sustain an injury. One athletic exposure equals one practice or one game.
Athletic trainer
Certified and licensed athletic trainers are health care professionals who specialize in preventing, recognizing, managing and rehabilitating injuries that result from physical activity. As part of a complete health care team, the athletic trainer works under the direction of a licensed physician and in cooperation with other health care professionals, athletics administrators, coaches and parents (National Athletic Trainer’s Association
[NATA], 2007b).
Clinical incidence rate
Number of athletes divided by the number of athletes at risk (Knowles, Marshall,
& Guskiewicz, 2006).
12 Incidence rate
Number of times a disease occurs new during a specified period of time (Knowles
et al., 2006).
Injury rate (IR)
Chance that an athlete will experience an injury found by dividing the number of injuries sustained by the total amount of time the athlete is at risk (Knowles et al., 2006).
Injury risk
Injury risk is the probability of injury per athlete found by dividing
the number of injured athletes by the number of athletes at risk (Knowles et al., 2006)
Prevalence
A proportion of how many athletes are injured during a specific period of time
(Knowles et al., 2006).
13 Chapter 2: Literature Review
An Oregon study that investigated adolescent health care reported students attending a rural school or a school with a lower socioeconomic status had a decreased likelihood of having recently visited a physician compared to students at urban schools or schools with a higher socioeconomic standing (Zimmer-Gembeck et al., 1997). A book published in 2004, Critical Issues in Rural Health, identified a geographic isolation factor that may serve as a barrier to adolescents receiving adequate health care (Glasgow,
Wright Morton, & Johnson, 2004). In rural areas the delivery of health care services is affected by a more expensive cost of providing services to a dispersed demographic, the patient’s sense that confidentiality is lacking in small towns, and an overall decreased access to public health programs (Glasgow et al., 2004).
A study published in The Journal of Clinical Epidemiology measured physical activity differences by sex and socioeconomic status. They found that boys reported engaging in significantly more vigorous activity outside of school and had a higher rate of participation on sports teams than females, estimating that boys average 860 minutes of activity per-week compared to 489 minutes per week for girls. Boys reported spending the most time weight lifting, playing baseball and basketball, jogging, and biking. Girls spent the most time dancing, walking, performing calisthenics, aerobic dance, and playing baseball (Sallis, Zakarian, Hovell, & Hofstetter, 1996).
A yearlong injury surveillance study was performed in Hawaii’s 38 public schools. Of the total 2,718 injuries reported, 1,140 treatments rendered were contraindicated, a fact that can be attributed to over 40% of the schools using unqualified individuals to care for athletic injuries. The study also found that 64% of the time the
14 coach served as the school’s athletic trainer and had education limited to first aid, CPR, and/or a 3 hour educational coaching class. Eighty-four percent of the time the coach was
responsible for prevention, care, and the rehabilitation of athletic injuries (Buxton,
Okasaki, Ho, & McCarthy, 1995).
In the late 1970s the Athletic Health Care and Training Program was developed as
a pilot and implemented in Seattle Public Schools to improve the quality of health care in
secondary schools. The participants underwent basic athletic training lectures and labs.
To determine the efficacy of this program the participants and the sites were evaluated
throughout the year. This study demonstrated that implementing such a program can
improve preparedness for an emergency or injury; evaluation and management of
injuries; and improved record keeping of athletic injuries in high schools. Improvements
were noted after the school nurse or athletic training students (ATS) had only 27 hours of
lectures, demonstrations, and laboratories as training (Rice, Schlotfeldt, & Foley, 1985).
The National Collegiate Athletic Association (NCAA) Injury Surveillance System
(ISS) has provided evidence to support the need for rule changes in NCAA sports. A review of this database resulted in the NCAA adopting a no spearing and a no clipping rule in football and NCAA hockey enforces a no hitting from behind rule (Hootman,
Dick, & Agel, 2007).
Injury Surveillance in the High School Setting
There have been several national and local secondary school-based injury surveillance systems. A study presented in the Free Communications section of the
Journal of Athletic Training used an internet-based surveillance site. The investigators recruited high schools that employed athletic trainers affiliated with the NATA from
15 across the country. A total of 425 schools agreed to participate. A total of 84 reporters
submitted weekly exposure reports and injury reports. The study resulted in 4,350 injuries
with 2,240 occurring during competitions and 2,110 injuries during practice. Their overall injury rate was 2.5 injuries per 1,000 athletic-competitions among the nine sports
being studied. Competitions had a higher injury rate (4.6 injuries per 1,000 athletic
competitions) than practices (1.7 injuries per 1,000 athlete-practices). This study
concluded with a statement demonstrating the distinct possibility of managing a high
school injury surveillance system across the country (Comstock, Yard, & Collins, 2007).
Measure of Injury Frequency
Two means of assessing injury in athletics are risk and rate. The risk is the average probability of injury per athlete. Rate is the raw number of injuries that occur per
unit of time (Knowles, Marshall, & Guskiewicz, 2006).
Athletic Exposure
An athletic exposure (AE) is used to determine the injury risk. The athletic exposure describes the number of times an athlete is placed at risk to sustain an injury.
The NCAA injury surveillance system (ISS) defines athletic exposure as one athlete participating with a chance of injury in either one practice or game (Hinton, Lincoln,
Almquist, Douoguih, & Sharma, 2005). Risk is commonly described as gross exposures
or may be based on time, such as game hours played or minutes of exposures.
This can be divided into game and practice athletic exposures to determine where
the most risk occurs, as in a study done in eight high schools in the Oklahoma City
School District. The researchers determined game athletic exposures by multiplying the
number of players on the team by the number of games in the season. Practice athletic
16 exposures were calculated by multiplying the total number of players on the team by
the total number of practices each week for the entire season. The advantage of
separating the two rates is being able to compare the two in a game-to-practice ratio
(Turbeville et al., 2003). Once the injury data has been calculated injury rates per 1000
AEs can be found (Powell & Dompier, 2004).
Injury Rate
Injury rate provides an estimate of the chance that an athlete will experience an
injury during a specified time or exposure interval. Most parents of athletes want to know
their child’s “risk” of getting injured playing a specific sport. Generally what they want to know is the injury rate for that sport. Injury rate can be determined by dividing the number of injuries sustained by the total amount of time the athlete is at risk (Knowles et al., 2006). The injury rate can be an estimate of players that would play in each game if the exact numbers were unknown.
Injury Rate for Sport = Number of Injuries______Total Amount of Time the Athlete is at Risk
Incidence Rate
The incidence rate describes the incidence of injury divided by a unit of time.
This measurement takes into consideration the varying playing times for different athletes. The unit of time for this study will be an AE. This calculations accuracy depends on how precisely data was collected on playing times (minutes or hours) for each athlete.
This calculation can result in a minimum of zero and has no maximum value (Knowles et al., 2006).
Incidence Rate = Number of Injuries * Sum of person-time Athletic Exposures
17 Injury Risk
Injury risk is the probability of an athlete sustaining an injury. The formula consists of dividing the number of athletes that were injured by the total number of athletes. This can be performed for individual teams or for all sports combined. This calculation cannot produce a value greater than one or less than zero (Knowles et al.,
2006).
Injury Risk = Number of Injured Athletes Number of Athletes
Clinical Incidence
Clinical incidence is a combination of the injury rate and risk. This formula uses
the numerator of the rate formula and the denominator of the injury risk formula. Clinical
incidence is a better measure of resources used (Knowles et al., 2006).
Clinical Incidence = Number of Injuries Number of Athletes at Risk
Time-Lost Injury Rate
In 1998 the NATA developed the Appropriate Medical Coverage in
Intercollegiate Athletics (AMCIA) task force to establish guidelines that collegiate
institutions could use to help evaluate their own current medical coverage. Time-loss
injuries, non-time-loss injuries, and the rehabilitation provided for each were a few of the
factors investigated. The task force was faced with very little data that included
rehabilitation treatments provided for injuries that did not require time-loss. Recently the
NCAA has been investigating time-loss injury rates; however there is a lack of data for non-time-loss injuries (Powell & Dompier, 2004). Studies show that 10% of injuries at
18 the 1985 Junior Olympic Games resulted in time-loss (Martin, Yesalis, Foster, &
Albright, 1987).
A study at Michigan State University used the Sports Injury Monitoring System
(SIMS) to monitor athletic injuries occurring at thirty collegiate schools at varying levels
of competition over two seasons of play. Of the 68,497 injuries reported, football
represented the most, 52.1% non-time loss and 57.9% time-loss injuries in men’s sports.
Soccer had the highest for women’s sports representing 17.9% of non-time-loss and 22%
of time-loss injuries (Powell & Dompier, 2004).
Prevelance
Prevalence is a proportion of how many athletes are injured during a specific
period of time. The injuries could have occurred before the season began or during the
season. This is different from the measure of incidence, which only takes into account the
new cases of injury during a period of time, such as the beginning of the season.
Measure of Injury Severity
The NCAA ISS defines injury severity by the amount of time lost or if surgery is necessary. Each method has its own limitations. Basing severity on time lost is limited by the fact that injuries that result in time lost in one sport may not result in time loss in another. A second limitation using the time loss method is injuries occurring at the end of the season. Time lost for those injuries must be estimated due to the season ending. The method of classifying injury severity by the need for surgery also has its own unique limitations. Concussion can be classified as severe though the patient may never require surgery. A further limitation is that surgical techniques and their applications are ever
19 changing. The fact that every team and every athlete has the same quality of medical
care can be a limiting factor (Klossner, 2007).
Buxton et al. (1995) used a time loss scale to determine injury severity. Their scale classified mild injuries as those causing the student athlete to miss one to seven
days; minor injuries required 8 to 21 days of time loss; and major injuries resulted in
more than 21 days of time loss.
Subject Populations
Subjects for epidemiological investigations vary relative to the population being
studied. However, there remain differences in populations even within high school
epidemiologic studies. Powell and Barber-Foss (1999a) limited their subjects to varsity
high school athletes. Another study included every football player, grades nine through
twelve, in eight high schools in Oklahoma City (Turbeville et al., 2003).
Injury Definitions
Defining an athletic injury can be a daunting task. Currently there is no agreement
in the definition used to classify an injury by epidemiologists. This creates a problem when researchers attempt to compare injury rates between studies (Hodgson Phillips,
2000). Injuries are classified several different ways (see Table 1).
20 Table 1
Injury Definitions Study Injury Definition Comstock An injury resulting from the athlete’s participation in a sanctioned practice et al., 2007 or competition, which necessitated the medical attention of an ATC or a
physician, and that resulted in at least one day of restricted athletic activity.
Hinton et High school: injury was defined as an event that necessitated medical al., 2005 attention by the school’s AT and restricted on their playing for at least one
day. Lost playing time started on the day of injury. Summer Camps:
anytime medical attention was sought regardless if playing time was lost.
Hootman, NCAA Injury Surveillance System Definition of Injury: et al., 2007 Injury occurred during an organized intercollegiate practice or competition
and medical attention by the AT or physician was required and restricted
participation in athletics for at least one day beyond the initial injury date.
Powell & Any injury that causes cessation of participation in the current game or Barber- Foss, 1999a practice and prevents the player’s return to that session.
Any injury that causes cessation of a player’s customary participation
following the day of onset.
Any fracture that occurs, even though the athlete does not miss any
regularly scheduled sessions.
Any dental injury, including fillings, luxations, and fractures.
Any mild brain injury that requires cessation of the athlete’s participation
for observation before returning, either in the current session or the next.
21
Table 1 (continued). Study Injury Definition Rice et al., A medical problem that occurred from athletic participation that caused the 1985 athlete to be removed from practice or a game or that resulted in lost
playing time the next day.
Starkey, Anything that necessitated a physician’s referral or prescription 2000 medication, resulted in a loss of playing time in either a practice or game,
or caused emergency care to be given to the athlete.
Turbeville Anything that caused a football player to miss at least one practice or game et al., 2003 or a head injury that caused a loss of consciousness and forced the player
to stop playing in either a practice or a game.
22 Injury Analysis
Injuries can be researched in many different ways: body area, specific structure involved, specific injury, mechanism, sport participation, and different levels of competition. Injury rates and risks among common high school athletics found in previous research are presented in Table 2. Table 2 also presents the increased rate of
injury during camp play as opposed to injury rates during the regular season. The
different definition – and therefore reporting criteria – makes comparing different
epidemiological studies difficult.
Table 2
High School Athletic Injury Rates and Risks Sport Injury Rate per 1000 AEs Source Football 3.2 Turbeville, 2003 8.1 Powell & Barber-Foss, 1999a Girl’s 4.4 Powell & Barber-Foss, 1999a Basketball 3.6 Messina et al., 1999 Boy’s 4.8 Powell & Barber-Foss, 1999a Basketball 3.2 Messina et al., 1999 Baseball 2.8 Powell & Barber-Foss, 1999a Boy’s Soccer 4.6 Powell & Barber-Foss, 1999a Girl’s Soccer 5.3 Powell & Barber-Foss, 1999a Softball 3.5 Powell & Barber-Foss, 1999a Volleyball 1.7 Powell & Barber-Foss, 1999a Boy’s Lacrosse 2.89 (Season) Hinton et al., 2005 14.71 (Camp) Girl’s Lacrosse 2.54 (Season) Hinton et al., 2005 13.27 (Camp) Wrestling 5.6 Powell & Barber-Foss, 1999a
23 Catastrophic Events
Brain Injury.
A 1983 study conducted by the National Federation of State High School
Associations reported an average of 12 deaths per year between 1970 and 1980, with head trauma – presumably injury to the brain – being the most frequent cause of death
(National Federation of State High School Associations, 1981).
Concussions, or “mild traumatic brain injuries” (MTBI), accounted for 21% percent of injuries in a pilot study in Minnesota high schools (Gerberich, 1977). A retrospective study performed in 1977 found that 24% of all injuries reported by 103
Minnesota secondary school football teams were MTBI. Ninety percent of the 112 athletes that reported a loss of consciousness were questioned about their diagnostic procedure; 41% were examined by coaches, 33% by physicians, and 18% by athletic trainers (Gerberich, Priest, Boen, Straub, & Maxwell, 1983). Early detection of concussions can result in improved management (Powell, 2001). Since the severity of concussion is graded on patient symptoms it is important an athletic trainer be present for the event to improve early recognition of a concussion. In 1994 the Journal of Athletic
Training published its position statement on sport-related concussion. The goal of the
NATA position statement was to provide information to those caring for MTBI on any level of participation. Thanks in part to rule changes outlawing spearing, improved athlete education on the dangers of concussions, better safety equipment, and more effective assessment tools the number of fatalities in 1990 was zero in high school and college football. Since then the average death due to brain injuries has been approximately five per year (Guskiewicz et al., 2004). In the NCAA the frequency of
24 concussions has increased an average of 7% annually over the last 16 years despite rule
changes put into effect to decrease the amount of head and neck injuries. The authors of this study have attributed part of the annual increase to improved detection and management of MTBI (Hootman et al., 2007).
In examining the epidemiology of concussions in high school football,
Guskiewicz et al. (2000, p.648) noted “the motivation to participate in competitive, aggressive sports has led to bigger, faster, and stronger athletes, and has subsequently increased the velocity of collisions and the severity of head injuries”. One study found that 20% of the reported injuries occurring in high school football were concussions
(Gerberich et al., 1983). A study of a 1999 high school football season found concussions to account for 9% of all injuries (Turbeville et al., 2003). A 1999 study published in the
Journal of the American Medical Association focused on MTBI in high school athletes.
They reported that 5.5% of the 23,566 injuries, approximately 1,300 cases, reported were
MTBI. Football incurred the highest percentage of MTBI of all sports studied with 63.4%
(822) of the injuries; wrestling was a distant second with 10.5% (136). The authors noted that MTBI occurred in all sports they studied (Powell & Barber-Foss, 1999b). Hootman
et al. (2007) reported similar findings with football accounting for 55% of all concussions
diagnosed in the NCAA ISS. Women’s hockey had the highest rate of injury (0.91
concussions per 1000 athletic exposures). A subsequent finding in this study was that
women’s soccer, a noncontact sport traditionally had a rate of 0.41 concussions per 1000
athletic exposures.
25 Cervical Spine.
During a 2-year prospective study of the Oklahoma City School District (eight
high schools total) investigators examined the incidence of injury in high school football.
Six percent of the total injuries seen were cervical spine injuries (Turbeville et al., 2003).
A non-displaced cervical spine fracture was reported in a yearlong study of high schools in Hawaii’s public school system (Buxton et al., 1995).
Cardiovascular.
During a one-season study of Texas high school basketball injuries, one death was
reported from pulmonary complications after being hospitalized for a thigh contusion
(Messina, Farney, & DeLee, 1999). The Hawaii study reported one athlete died because
of a cardiac aneurysm (Buxton et al., 1995).
Orthopedic Injuries
An overview of the most commonly reported orthopedic injuries by location and type is presented in Table 3.
26 Table 3
Most Common Reported Injury Location and Type Most Often Most Often Most Injured Body Injured Body Frequent Sport Area Part Injury Source High School Upper Forearm/Wrist/ Strains Powell & Barber- Baseball Extremity Hand Foss, 1999a Boy’s High Lower Ankle Sprain Messina et al., School Basketball Extremity 1999 Lower Ankle/Foot Sprain Powell & Barber- Extremity Foss, 1999a Girl’s High Lower Ankle Sprain Messina et al., School Basketball Extremity 1999 Lower Ankle/Foot Sprain Powell & Barber- Extremity Foss, 1999a High School Lower Ankle Sprain/ Turbeville et al., Football Extremity Strain 2003 Lower Hip/Thigh/Leg Sprain Powell & Barber- Extremity Foss, 1999a High School Lower Ankle Sprain/ Hinton et al., Lacrosse Extremity Strain 2005 Camp Lacrosse Lower Knee Contusion Hinton et al., Extremity 2005 High School Lower Ankle/Foot Sprain Powell & Barber- Boy’s Soccer Extremity Foss, 1999a Girl’s High Upper Forearm/Wrist/ Strain Powell & Barber- School Softball Extremity Hand Foss, 1999a Girl’s High Lower Ankle/Foot Sprain Powell & Barber- School Volleyball Extremity Foss, 1999a High School Upper Shoulder/Arm Sprain Powell & Barber- Wrestling Extremity Foss, 1999a NBA Basketball Lower Ankle Sprain Starkey, 2000 Extremity
27 Upper Extremity.
In selected sports the upper extremity often accounts for the most injured body area. In a three-year high school injury study, baseball, wrestling, and softball all incurred the majority of upper extremity injuries. Baseball and softball had 22.6% and 22.9% of injuries occurring at the forearm/wrist/hand while wrestling had 18.4% of injuries at the shoulder/arm (Powell & Barber-Foss, 1999a).
The upper extremity typically falls second in the most injured body area category in basketball and football. In a study of the National Basketball Association (NBA) and the Women’s National Basketball Association (WNBA) the upper extremity (excluding the head, cervical spine, and chest) was second in overall injuries accounting for 14.8 and
15.1% respectively (Deitch, Starkey, Walters, & Moseley, 2006). In a study assessing the risk factors for high school football players the upper extremity (which included the head, neck, face, abdomen, back, and chest/ribs) accounted for 38% of overall injuries, behind the lower extremity, which accounted for 62% (Turbeville et al., 2003).
Lower Extremity.
A report published in the Journal of Athletic Training summarizing injury trends over 16 years and 15 teams in the NCAA states the majority of injuries occurring at the lower extremity with 53.8% and 53.7% occurring in games and practices respectively
(Hootman et al., 2007).
Turbeville et al. (2003) reported that 20% of all football injuries involved the knee. Twenty-three percent of those injuries involved an anterior cruciate ligament
(ACL) tear, with females having a statistically significant higher rate of injury than males. Incidence of knee injury was 0.71 for girls and 0.31 per 1000 player hours for
28 boys. Another study also reported that girls had a 3.8 times higher risk of sustaining an
injury to the ACL than boys (Messina et al., 1999). Hootman et al., (2007) reported
football as sustaining the highest frequency of ACL injuries (approximately 5,000 over
16 years) but women’s gymnastics had the highest injury rate (0.33 per 1000 athletic
exposures) among the 15 sports studied.
A Wisconsin 5-year retrospective study examined ACL injury data from 14
different colleges and university’s basketball teams. The women’s programs had an average of 1.86 ACL injuries while the men’s programs had an average of 0.93 ACL
injuries. This study also discusses the possible link between the level of competition and
injury rate. Using the NCAA Injury Surveillance System report men and women’s
basketball for the 1993-1994 season, Oliphant and Drawbert (1996) identified that the
injury rate for Division I female athletes was higher than that in Division III. Also there
was a greater difference in injury rate between males and females at the Division III level
(3.7 times) than at the Division I level (2.6 times).
Currently ACL injuries in the NCAA have shown a 1.3% average annual increase
over the last 16 years (Hootman et al., 2007). Further research on individuals at higher
risk of sustaining an ACL injury will allow athletic trainers to implement prevention
programs, which is one of the foremost goals of athletic trainer (Ireland, 1999).
Turbeville et al. (2003) also reported the ankle as one of the most frequently
injured body parts accounting for 27% of the total injuries. An article published in 2000
by the Journal of Athletic Training reported that the ankle was the most common site for
musculoskeletal injury supports this data. Ankle sprains, with the majority of sprains
occurring on the lateral side, were the most frequent injury reported (Starkey, 2000).
29 Messina et al. (1999) also found the ankle to be the most injured body part. The ankle
accounted for 32% of male basketball injuries and 31% of female basketball injuries.
General Medical Conditions
There is very little literature about the amount of general medical illnesses an
athletic trainer sees as the point of first contact. A study comparing the NBA and the
Women’s National Basketball Association (WNBA) noted that 0.3% of the injuries
occurring in the NBA over 6 years were systemic illnesses, including heat exhaustion,
dehydration, and general fatigue. The WNBA had a slightly higher rate of systemic injuries accounting for 1.1% (Deitch et al., 2006).
A 10-year prospective study of the National Basketball Association showed a much higher rate of general medical issues resulting from a difference in reporting
criteria. Of the 9,904 injuries and illnesses seen over the 10 years, 2,131 (21.5%) were general medical in nature. Of those general medical conditions reported upper respiratory conditions accounted for 16.7% of all cases. Others included gastrointestinal problems, dermatologic conditions, and local and systemic infections (Starkey, 2000).
Summary
Generally most epidemiology studies find the lower extremity to be the most commonly injured body area with the ankle incurring the most injuries followed closely
by the knee (Starkey 2000; Turbeville et al., 2003). When distinguished, sprains usually
occur more often than strains (Messina et al., 1999; Powell & Barber-Foss, 1999a;
Starkey, 2000).
30 Chapter 3: Methods
Subjects
Eight rural high schools in southeastern Ohio receiving the services of a licensed athletic trainer (LAT) were included in this study. Population size included all athletes on each of the schools’ various athletic teams for the 2006-2007 academic year. The athletes ranged in age from 13 to 19 years.
Prior to data collection the Ohio University Institutional Review Board approved this study. An administrator from each school consented to this record review.
Instrumentation
Data collection was completed using standardized instruments in Microsoft Word
Forms format. Ohio University’s Institutional Review Board approved the study. A
School Information Sheet (see Appendix A) identified the number of teams, team size, the number of practices and games, zip code of townships in the school district, and school enrollment (see Table 4). The Athlete Profile Sheet (see Appendix B) assigned a unique six-digit code for each athlete, blinding his or her personal identity from the researchers. This instrument also collected other demographic information including the sport(s) of participation and positions on each team.
The LAT completed an Initial Report Form (see Appendix C) for each reportable event. This form collected pertinent epidemiological information for orthopedic, general medical and psychosocial conditions. Referral information, including the difficulty of the referral decision was also collected. Included with the Initial Report is the Procedures
Performed Form, that indicated how many days of practice, games, or school was missed as a result of the injury.
31 Table 4
Demographic Profile Schools that Number of Number of Number of Sport had Teams Athletes Games Played Practices Baseball 8 198 317 559 Basketball Cheerleading 8 131 315 452 Boy’s Basketball 8 225 353 995 Girl’s Basketball 8 161 311 952 Boy’s Cross Country 8 46 67 438 Girl’s Cross Country 7 37 61 408 Football 8 352 147 1080 Football Cheerleading 8 127 125 450 Golf 3 28 33 83 Boy’s Soccer 2 58 67 172 Girl’s Soccer 1 32 31 50 Softball 8 178 309 461 Tennis 1 13 15 50 Track & Field 8 285 178 710 Girl’s Volleyball 8 229 284 788 Wrestling 5 102 91 395 Total 99 2202 2704 8043 Note. Includes Varsity, JV, and freshman teams
All data were submitted electronically at the end of each athletic season.
Procedures
The LATs were instructed on the procedures to complete each form before practice started for the fall 2006 season. The researchers held group and individual meetings with the LATs to provide an overview of the policies and procedures and answer any questions regarding system. A reportable injury was defined in this study as one that required the examination by a physician or LAT regardless of any loss of playing time or any non-athletic related condition in which the advice of a licensed athletic trainer was sought. When either of these conditions is met the LAT electronically filled out the
Initial Report and Procedures Performed Form. Forms were submitted at the close of the
32 fall, winter, and spring athletic seasons for the duration of the 2006-2007 academic year. As the forms were submitted a case number was assigned, by the researcher, to distinguish each injury from another, in the case that there were multiple injuries for the same athlete. Procedures Performed Forms were resubmitted at the close of the athlete’s rehabilitation, if not closed in the same season, updating the researcher on further diagnoses, practices, games, or days of school missed.
Statistical Analysis
Data was analyzed using Microsoft Excel and SPSS (SPSS Inc, Chicago, IL) statistical software (version 14.0). Data was first entered into Microsoft Excel
Spreadsheets upon submission.
Data analysis included frequencies and cross tab calculations. Injury rates were calculated by dividing the number of injuries by the total number of athlete exposures.
Game injury rates and practice injury rates were calculated by using injuries that occurred in only that time frame. The total number of exposures was estimated based on how many athletes typically participate in a practice or a game. Injury risks were calculated by dividing the number of injured athletes by the number of athletes at risk. Clinical incidence was calculated by dividing the total number of injuries by the number of athletes participating in that sport.
33 Chapter 4: Results
Introduction
Of the total 692 reports submitted during the course of the 2006-2007 academic
year 651 were orthopedic injuries and 41 were nonorthopedic conditions. Of the
orthopedic conditions 630 were athletic related and 21 were non-athletic related. This
identifies 62 reports filed by LATs that is outside of the traditional role of evaluating and
treating athletic related orthopedic injuries.
Research Question One: What is the distribution of injuries per sport?
Football had the greatest number of reportable injuries, followed by girl’s basketball, softball, track and field (both boy’s and girl’s combined), boy’s basketball, and baseball (see Table 5).
Football had the highest game injury rate (25.4 injuries per 1000 AEs) and the most orthopedic injuries (163) (see Table 6). Track and field had the highest practice injury rate (9.5 injuries per 1000 AEs).
34 Table 5
Frequency and Rate of Injury and Illness by Sport Practice Game IR Practice IR per Game per 1000 Sport Total Injuries 1000 AEs Injuries AEs Football 170 (24.6%) 63 (23.2%) 1.3 100 (34.8%) 25.4
Girl’s Basketball 97 (14.0%) 26 (9.6%) 1.4 53 (18.4%) 21.5
Softball 74 (10.7%) 34 (12.5%) 3.3 37 (12.9%) 7.1
Track and Field 74 (10.7%) 49 (18.1%) 9.5 18 (6.3%) 2.9
Boy’s Basketball 72 (10.4%) 41 (15.1%) 1.5 28 (9.8%) 10.1
Baseball 55 (7.9%) 22 (8.1%) 1.5 28 (9.8%) 6.4
Girl’s Volleyball 25 (3.6%) 13 (4.8%) 0.6 12 (4.2%) 4.7
Wrestling 22 (3.2%) 12 (4.4%) 1.4 7 (2.4%) 5.5
Girl’s Cross 8 (1.2%) 4 (1.5%) 2.0 1 (0.3%) 3.2 Country
Boy’s Soccer 5 (0.7%) 2 (0.7%) 0.4 2 (0.7%) 1.9
Boy’s Cross 4 (0.6%) 3 (1.1%) 1.2 0 (0.0%) 0.0 Country
Basketball 2 (0.3%) 0 (0%) 0.1 1 (0.3%) 0.2 Cheerleading
Girl’s Soccer 1 (0.1%) 1 (0.4%) 0.0 0 (0.0%) 1.8
Tennis 1 (0.1%) 1 (0.4%) 1.5 0 (0.0%) 0.0
Football 0 (0.0%) 0 (%) 0.0 0 (0.0%) 0.0 Cheerleading
Golf 0 (0.0%) 0 (%) 0.0 0 (0.0%) 0.0
Total 692 (100.0%) 271 (100.0%) 1.5 287 (100.0%) 7.4
35 Table 6
Orthopedic Injuries by Activity Game IR per Practice IR Sport Total Percent (%) 1000 AEs per 1000 AEs Football 163 25.0 25.37 1.21 Girl’s Basketball 85 13.1 20.68 1.36 Softball 73 11.2 7.10 3.30 Track and Field 70 10.8 2.90 9.31 Boy’s Basketball 69 10.6 10.10 1.38 Baseball 53 8.1 6.42 1.47 Non-Sanctioned Athletic Activity 29 4.5 * * Girl’s Volleyball 24 3.7 4.73 0.54 Non-Athletic Related 21 3.2 * * Wrestling 17 2.6 4.74 1.24 Off Season Strength & Conditioning 17 2.6 * * Physical Education 10 1.5 * * Girl’s Cross Country 7 1.1 3.16 1.51 Boy’s Soccer 5 0.8 1.89 0.41 Boy’s Cross Country 4 0.6 0.0 1.19 Basketball Cheerleading 2 0.3 0.19 0.0 Girl’s Soccer 1 0.2 1.79 0.0 Tennis 1 0.2 0.0 1.54 Total 651 100.0 7.36 1.40 Note. * Cannot be determined
36 Research Question Two: What are the most commonly diagnosed orthopedic injuries?
Strains were the most commonly reported orthopedic injury in the study accounting for 24.9% of all cases (see Table 7). Sprains were a close second with 24.1% of all cases. This study distinguishes between the two, unlike other studies, but combined they total 319 injuries and 49% of all cases seen by LATs in high schools. Contusions represented 14.7% of all orthopedic conditions and concussions 6.1%. There were 40 concussion sustained in the 2006-2007 school year by athletes in various sports.
37 Table 7
Type of Orthopedic Injuries Injury Frequency Percentage (%) Strain 162 24.9 Sprain 157 24.1 Contusion 96 14.7 Concussion 40 6.1 Gross Fracture 26 4.0 Tendinopathy 20 3.1 Inflammation 17 2.6 Bursitis 14 2.2 Dislocation 14 2.2 Laceration 14 2.2 Abrasion 11 1.7 Subluxation 11 1.7 Medial Tibial Stress Syndrome 10 1.5 Sprain & Torn Cartilage 6 0.9 Fracture 5 0.8 Neuropathy 5 0.8 Patellar Femoral Dysfunction 5 0.8 Torn Cartilage 5 0.8 Stress Fracture 4 0.6 Friction Syndrome 3 0.5 Spasm 3 0.5 Epicondylitis 2 0.3 Hairline Fracture 2 0.3 Nondisplaced Fracture 2 0.3 Avulsion Fracture 1 0.2 Blister 1 0.2 Bone Spur 1 0.2 Burn 1 0.2 Epistaxis 1 0.2 Hematoma 1 0.2 Hip Pointer 1 0.2 Hyphema 1 0.2 Impingement 1 0.2 Instability 1 0.2 Narrowing of Foremen 1 0.2 Osgood Slaughters 1 0.2 Pes Planus 1 0.2 Piriformis Syndrome 1 0.2 Soreness 1 0.2 Spermatic Cord Torsion 1 0.2 Tooth Luxation 1 0.2
38 Table 7 (continued). Injury Frequency Percentage (%) Unknown 1 0.2 Total 651 100.0
Research Question Three: What is the distribution of injury by body area?
The majority injuries were at the lower extremity, accounting for 50.1% of all submitted reports. The upper extremity ranked second as the most commonly injured body area with 23.0% of all injuries (see Table 8).
Table 8
Frequency of Injury by Body Area Body Area Frequency Percentage (%) Lower Extremity 347 53.3 Upper Extremity 159 24.4 Head 66 10.1 Torso 48 7.4 Cervical 28 4.3 Hip 2 0.3 Genitals 1 0.2 Total 651 100.0
39 Research Question Four: What is rate of injury-by-injury type (contact or noncontact)?
In this study the majority of injuries were noncontact injuries (57.9%). Contact injuries, which were strictly contact with another player, either on the same or opposing team, accounted for 36.7% of injuries (see Table 9).
Table 9
Injury by Type (Contact versus Noncontact) Injury Type Frequency Percentage (%) Clinical Incidence Noncontact 401 57.9 0.18 Contact 254 36.7 0.12 Not Applicable 37 5.3 0.02 Totals 692 100.0 0.31
40 Time-Loss
Research Question Five: What kind of time loss is associated with different sports and different orthopedic injuries?
Football accounted for 1,1161 total practices missed. Boy’s basketball (171) was second, followed by track and field (104), and girl’s basketball (102). Football was the sport in which the most games (159) were missed due to illness or injury. Athletes missed sixty games followed by 51 missed games in boy’s basketball (see Table 10).
Table 11 presents the orthopedic injuries that were responsible for athletes missing games and practices. Sprains, which were the second most common injury, were responsible for the most games missed (89) in high school athletics. Gross fractures (79) which ranked fifth in frequency was the second leading cause of a student athlete missing competition time. Sprains and gross fractures were again the first and second leading cause of practice time lost with 415 and 279 practices missed respectively.
41 Table 10
Time Lost to Injury by Sport Sport Practices Missed Games Missed Football 1161 159 Boy’s Basketball 171 51 Track and Field 104 17 Girl’s Basketball 102 20 Softball 97 40 Baseball 84 60 Wrestling 51 1 Girl’s Cross Country 44 6 Girl’s Volleyball 37 15 Boy’s Soccer 34 0 Boy’s Cross Country 11 2 Girl’s Soccer 10 0 Basketball Cheerleading 0 0 Football Cheerleading 0 0 Golf 0 0 Tennis 0 0 Total 1906 371
42 Table 11
Orthopedic Time-Loss Injuries Games Percentage Practices Percentage Orthopedic Injury Total Missed (%) Missed (%) Strain 161 43 10.4 254 13.8 Sprain 157 89 21.5 415 22.6 Contusion 96 8 1.9 74 4.0 Concussion 40 37 8.9 179 9.7 Gross Fracture 26 78 18.8 279 15.2 Tendinopathy 20 0 0.0 13 0.7 Inflammation 17 3 0.7 18 1.0 Bursitis 14 2 0.5 25 1.4 Dislocation 14 30 7.2 90 4.9 Laceration 14 1 0.2 1 0.1 Abrasion 11 0 0.0 0 0.0 Subluxation 11 29 7.0 111 6.0 MTSS 10 0 0.0 6 0.3 Sprain & Torn Cartilage 6 15 3.6 129 7.0 Fracture 5 29 7.0 24 1.3 Neuropathy 5 1 0.2 8 0.4 Patellar Femoral Dysfunction 5 1 0.2 2 0.1 Torn Cartilage 5 6 1.4 20 1.1 Stress Fracture 4 16 3.9 60 3.3 Friction Syndrome 3 4 1.0 39 2.1 Spasm 3 0 0.0 0 0.0 Epicondylitis 2 0 0.0 0 0.0 Hairline Fracture 2 3 0.7 5 0.3 Nondisplaced Fracture 2 0 0.0 0 0.0 Avulsion Fracture 1 13 3.1 67 3.6 Blister 1 0 0.0 0 0.0 Bone Spur 1 0 0.0 0 0.0 Burn 1 0 0.0 0 0.0 Epistaxis 1 0 0.0 0 0.0 Hematoma 1 0 0.0 0 0.0 Hip Pointer 1 3 0.7 5 0.3 Hyphema 1 3 0.7 2 0.1 Impingement 1 0 0.0 0 0.0 Instability 1 0 0.0 1 0.1 Narrowing of Foremen 1 0 0.0 4 0.2 Osgood Slaughters 1 0 0.0 2 0.1 Pes Planus 1 0 0.0 0 0.0 Piriformis Syndrome 1 0 0.0 0 0.0 Soreness 1 0 0.0 0 0.0 Spermatic Cord Torsion 1 0 0.0 2 0.1
43 Table 11 (continued). Games Percentage Practices Percentage Orthopedic Injury Total Missed (%) Missed (%) Tooth Luxation 1 0 0.0 2 0.1 Unknown 1 0 0.0 0 0.0 Total 651 414 100.0 1837 100.0
44 Research Question Six: Is there a difference in the rate of injury between sexes in this study?
An independent t-test performed on practice- and game-related injury rate for boys and girl’s sports, excluding cheerleading, golf, tennis, and track and field, demonstrated no significant difference between the two groups (see Table 4). The male clinical incidence rate of all injuries was slightly higher between the two groups, but was not significantly different (see Table 12).
Table 12
Frequency and Rate of Injury and Illness by Sex Sex Frequency Percentage (%) Clinical Incidence Male 328 61.5 0.36 Female 205 38.5 0.32 Total 533 100.0 0.34 Note. Excludes cheerleading, golf, tennis, and track and field.
45 Nonorthopedic Conditions
Research Question Seven: What role does the licensed athletic trainer play in the identification and management of nonorthopedic (general medical) conditions?
A range of nonorthopedic conditions were reported (see Table 13). Of the total
692 reports submitted, 41 (5.92%) were general medical conditions. Influenza was the most common at 14.6% of the 41 cases reported. Nutritional guidance (7.3%) was the second most frequent reason someone sought the advice of the LAT. Of the 41 conditions, 15 were systemic illnesses, 13 were skin conditions, 4 were dietary/disordered eating issues, 4 were cardiorespiratory conditions, 2 gynecological, 2 psychosocial, and 1 condition was classified as “other.”
Table 14 categorizes the nonorthopedic conditions by sport. Girl’s basketball accounted for the most nonorthopedic conditions seen by an athletic trainer with 29.3%, followed by of football (17.1%), and student athletes or non-athletes (12.2%).
46 Table 13
Nonorthopedic Conditions Condition Frequency Percentage (%) Influenza 6 14.6 Nutritional Guidance 3 7.3 Boil 2 4.9 Eczema 2 4.9 Exercise Induced Asthma 2 4.9 Mononucleosis 2 4.9 Ovarian Cyst 2 4.9 Tinea Corpus 2 4.9 Acid Reflux 1 2.4 Allergic Reaction 1 2.4 Benign Lymphomas 1 2.4 Burn 1 2.4 Chest Pain 1 2.4 Conjunctivitis 1 2.4 Drug Abuse 1 2.4 Depression 1 2.4 Dermatitis 1 2.4 Disordered Eating 1 2.4 Hypertension 1 2.4 Infection 1 2.4 Ingrown Toenails 1 2.4 Kidney Stones 1 2.4 Lymph Inflammation 1 2.4 MDA 1 2.4 Pneumonia 1 2.4 Reaction to Medication 1 2.4 Skin Disease 1 2.4 Urticaria 1 2.4 Total 41 100.0
47 Table 14
Nonorthopedic Conditions by Sport Sport Frequency Percentage (%) Girl’s Basketball 12 29.3 Football 7 17.1 Non-Athletic Related 5 12.2 Wrestling 5 12.2 Track and Field 4 9.8 Boy’s Basketball 3 7.3 Baseball 2 4.9 Girl’s Cross Country 1 2.4 Softball 1 2.4 Volleyball 1 2.4 Total 41 100.0
48 Chapter 5: Discussion
Introduction
This was an epidemiological study of eight high schools in a rural area of Ohio.
Each school employed a licensed graduate assistant athletic trainer through Ohio
University. These LATs provided a service for over 2,200 athletes. The study followed
football, volleyball, boy’s and girl’s basketball, softball, baseball, track and field, tennis,
golf, wrestling, and cheerleading at these schools. The LATs submitted 692 reports (651
orthopedic and 41 nonorthopedic). Of the 651 orthopedic injuries, 21 were non-athletic
related injuries.
Table 15 is a comparison of the game and practice injury rates of the schools in
the study and injury rates found in published articles. The game injury rates, with the
exception of boys and girl’s soccer, and wrestling are all higher than the literature states.
All of the practice injury rates are less than the published articles’ findings. I feel this
could be due to a number of factors. Due to the limited exposure data the athletic
exposures had to be estimated. The practice exposures could have been overestimated.
We feel that the game injury rates are higher due to the fact that many of the studies
published did not collect illness data as well as orthopedic data.
An Oregon State study identified the problems associated with rural adolescent health care, students in rural areas less likely to visit a physician or nurse practitioner.
Students in this study also more likely to never have received care for an injury or accident they sustained (Zimmer-Gembeck et al., 1997). These findings are compounded by the findings of our study that students in this population are also sustaining injuries at
49 a higher rate. The medical shortages associated with a rural setting compounds the medical problems suffered by athletes.
Table 15
Comparison of High School Athletic Injury Rates Published Studies Our Results Injury Rate per 1000 AEs Sport Injury Rate per 1000 AEs Source Game Practice Football 3.2 Turbeville, 2003 25.4 1.3
8.1 Powell & Barber-Foss, 1999a Girl’s 4.4 Powell & 21.5 1.4 Basketball 3.6 Barber-Foss, 1999a Messina et al. 1999 Boy’s 4.8 Powell & 10.1 1.5 Basketball 3.2 Barber-Foss, 1999a Messina et al. 1999 Baseball 2.8 Powell & 6.4 1.5 Barber-Foss, 1999a Boy’s 4.6 Powell & 1.9 0.4 Soccer Barber-Foss, 1999a Girl’s 5.3 Powell & 1.8 0.0 Soccer Barber-Foss, 1999a Softball 3.5 Powell & 7.1 3.3 Barber-Foss, 1999a Volleyball 1.7 Powell & 4.7 0.6 Barber-Foss, 1999a Wrestling 5.6 Powell & 5.5 3.2 Barber-Foss, 1999a
50 Injuries by Sport
The results found in this study are similar to others. Football had the highest
frequency of injury and illness combined, (170) accounting for 24.6%, followed by girl’s
basketball with 14.0% (97) of injuries reported.
The majority of injuries occurred in games (290 injuries, 41.9%). Practices accounted for 277 injuries (40.0%). Injuries were also reported as chronic (3.8%), having occurred in physical education class (1.4%), and “not applicable” (9.2%) or “other”
(3.6%). These statistics differ from those reported by Powell and Barber-Foss (1999a) who found that the majority of high school injuries occurred during practices (55.5%).
This difference can be due to a potentially inflated practice exposure rate, which can
decrease the practice injury rate. This could also be due to the fact that I did not log every injury as either having occurred in practice or a game. This is due to chronic injuries and injuries that occurred outside of practice and competition.
Powell and Barber Foss (1999a) did find that when they compared the rates per
1000 athletic exposures that games showed a higher injury rate. These findings are similar to the findings in this study. I found that all sports, with the exception of track and
field, boy’s cross country, and tennis had higher game injury rates (see Table 6). In this
study the overall game injury rate was 7.36 injuries per 1000 athletic exposures and 1.40 injuries per 1000 practice athletic exposures.
Injury Type
Strains accounted for the most frequently reported injury (162, 24.9%), followed
by sprains (157, 24.1%). This finding does not agree with most literature where the
authors distinguish between the two types of injuries. Sprains were reported as the most
51 common injury sustained in a variety of sports (Messina et al., 1999; Powell & Barber-
Foss, 1999a). Powell and Barber-Foss (1999a) found that sprains were the most common type of injury in boy’s baseball, basketball, football, soccer, wrestling, girl’s basketball, field hockey, softball, soccer, and volleyball. Strains were most frequent in softball and baseball. During the course of this study there were no catastrophic injuries that occurred
from which to draw data.
52 Body Area
The lower extremity accounted for the majority (53.3%) of reported injuries while the upper extremity accounted for just less than one quarter of reported injuries (24.4%).
The head, which included concussions and injuries to the face and scalp, experienced
10.1% of all orthopedic injuries. This finding supports the findings by Hootman et al.,
(2007) which states that the majority of injuries sustained in 15 sports over 16 seasons were at the lower extremity.
Mild Traumatic Brain Injury
During the study of one academic year of athletics in eight high schools a total of
40 MTBI (5.8% of total cases) were reported. The percentage of MTBI cases reported in this study was well below that of a pilot study run in Minnesota high schools, which found that 21% of all injuries were MTBI (Gerberich, 1977). The reason for this may be related to this study calling for general medical reports as well as orthopedic and a result of this study having a much broader definition of injury.
A retrospective study performed in 1977 found that 24% of all injuries reported by
103 secondary football teams were MTBI. Ninety percent of the 112 athletes that reported a loss of consciousness were questioned about their diagnostic procedure; 41% were examined by coaches, 33% by physicians, and 18% by athletic trainers (Gerberich et al., 1983). In this study a team physician on the sidelines or a LAT examined all 40
MTBI. This finding is an improvement over the results of Gerberich et al. (1983) in which coaches examined 41% of concussions and only 51% were examined by either a
LAT or physician.
53 Football reported 23 of the 40 (57.5%) MTBI reported (see Table 16). Girls and
boy’s basketball and baseball each came in second reporting four (10%) MTBI each.
Seventy percent of these MTBI were sustained during competition. Contact with another person resulted in 82.5% of the reported concussions (Table 17).
Table 16
Concussion by Sport Game IR Practice IR Percentage per 1000 per 1000 Clinical Sport Total (%) AEs AEs Incidence Football 23 57.5 4.56 0.10 0.07 Boy’s Basketball 4 10.0 1.08 0.04 0.02 Baseball 4 10.0 0.69 0.07 0.02 Girl’s Basketball 4 10.0 0.81 0.05 0.02 Non-Athletic Related 2 5.0 * * * Girl’s Cross Country 1 2.5 0.0 0.50 0.03 Softball 1 2.5 0.19 0.0 0.01 Wrestling 1 2.5 0.79 0.0 0.01 Total 40 100.0 0.72 0.05 0.02 Note. * Not applicable
Table 17
Concussion by Type of Injury Type of Injury Frequency Percentage (%) Contact 33 82.5 Non Contact 7 17.5 Total 40 100.0
54 These concussions overall accounted for 179 practices missed, 37 games missed, and 8 absences from school. The LAT referred the athlete to a physician 25 times
out of 40. In 23 cases (57.5%) the athlete complied, two cases (5%) declined the referral,
and two cases (5%) saw a physician without being referred by the LAT.
Knee Injuries
Knee injuries accounted for 16.6% of injuries (see Table 18). Football sustained
the highest number of knee injuries (29, 26.9%) and track and field (15, 13.9%) and girl’s
basketball (14, 13.0%) came in second and third. Of the 148 knee injuries, 49 (45.4%)
happened in a game and 70 (64.8%) were non-contact injuries. The most commonly
reported mechanism of injury was “unknown” (20, 18.5%) by the athlete. Where there
was a known mechanism a valgus stress was identified as the cause in 18 cases (16.7%).
The medial collateral ligament (MCL) was injured in 19 (17.6%) of the 108 knee injuries.
The ACL was involved in 10 (9.3%) of knee injuries. Only four (3.7%) of all total knee
injuries were isolated to the ACL. The most common type of injury at the knee was a
sprain (27, 25.0%) and six of those included a secondary injury of torn cartilage.
55 Table 18
Knee Injuries by Activity Game IR Practice Percentage per 1000 IR per Activity Total (%) AEs 1000 AEs Football 29 26.9 4.31 0.24 Track and Field 15 13.9 0.81 1.75 Girl’s Basketball 14 13.0 3.24 0.21 Softball 11 10.2 1.53 0.29 Boy’s Basketball 10 9.3 1.08 0.21 Non-Sanctioned Athletic Activity 7 6.5 * * Baseball 4 3.7 0.92 0.0 Wrestling 4 3.7 1.58 0.23 Girl’s Cross Country 3 2.8 0 0 Off Season Strength and Conditioning 3 2.8 * * Volleyball 3 2.8 0.39 0.09 Boy’s Cross Country 2 1.9 0.0 0.40 Girl’s Soccer 1 0.9 1.80 0.0 Non-Athletic Related 1 0.9 * * Physical Education Class 1 0.9 * * Total 108 100.0 1.27 0.21 Note. * Cannot be determined.
An interesting finding was that in this study all six of the male ACL involved knee injuries occurred during football (see Table 20). Softball accounted for 75% of the girl’s four ACL involved knee injuries. One ACL injury occurred in girl’s basketball.
Tuberville et al. (2003) stated that girl’s have a statistically higher chance of knee injury than boys while Messina et al. (1999) stated that girl’s had a 3.79 times higher risk of sustaining an injury to the ACL than boys. Data collected in this study does not support these previous findings.
56 Table 19
ACL Injury by Sex Injury Gender Female Male Isolated ACL 2 2 ACL, MCL 0 2 ACL, MCL, Medial Meniscus 0 2 ACL, Meniscus 2 0 Total 4 6
Table 20
Knee Structures Injured Structure Frequency Percentage (%) MCL 19 16.1 Patella 17 14.4 Patellar Tendon 16 13.6 Bursa 12 10.1 Meniscus 11 9.3 ACL 10 8.4 IT Band 7 5.9 Unknown 6 5.1 Hamstring 4 3.4 Skin 4 3.4 Medial Aspect General 3 2.5 LCL 2 1.7 Pes Anserine 2 1.7 Fat Pad 1 0.8 Femoral Growth Plate 1 0.8 Lateral Aspect General 1 0.8 Lateral Femoral Condyle 1 0.8 Nerve 1 0.8 Total 118 100.0
57 Ankle Injuries
An article published in 2000 by the Journal of Athletic Training reported that the
ankle was the most common site for musculoskeletal injury. Ankle sprains, with the
majority of sprains occurring on the lateral side, were the most frequent injury reported in
a review of the NBA (Starkey, 2000). Ninety-nine (15.2%) of the reported injuries involved the ankle joint. Turbeville et al. (2003) reported the ankle as accounting for 27%
of the total injuries and one of the most frequently injured body parts. Messina et al.
(1999) also found the ankle to be the most injured body part. The ankle accounted for
32% of male basketball injuries and 31% of female basketball injuries.
Eighty-six (13.2%) of the reported injuries were ankle sprains. Boys (19) and
girl’s (18) basketball sustained the most ankle sprains, 22.1% and 20.9% respectively
(see Table 21).
58 Table 21
Ankle Sprains by Activity Percentage Game IR per Practice IR Sport Total (%) 1000 AEs per 1000 AEs Boy’s Basketball 19 22.1 3.25 0.35 Girl’s Basketball 18 20.9 4.87 0.31 Football 13 15.1 1.78 0.10 Track and Field 8 9.3 0.32 1.16 Softball 7 8.1 0.94 0.192 Volleyball 5 5.8 1.57 0.04 Baseball 4 4.7 0.46 0.07 Non-Sanctioned Athletic Activity 4 4.7 * * Physical Education Class 3 3.5 * * Boy’s Cross Country 1 1.2 0.0 0.40 Boy’s Soccer 1 1.2 0.94 0.0 Non-Athletic Related 1 1.2 * * Off Season Strength & 1 1.2 * * Conditioning Wrestling 1 1.2 0.0 0.11 Total 86 100.0 1.08 0.18 Note. * Cannot be determined.
Game ankle sprains accounted for 48.8% of total ankle sprains and practice
39.5%. Inversion ankle sprains were the most common mechanism (69, 80.2%). Second most common mechanism of injury was a player stepping on another player’s foot (see
Table 22).
59 Table 22
Ankle Sprain by Mechanisms of Injury Mechanism Frequency Percentage (%) Inversion 69 80.2 Stepped on Opponent’s Foot 9 10.5 Eversion 5 5.8 Fell 1 1.2 Rotation 1 1.2 Unknown 1 1.2 Total 86 100.0
The majority (72.1%) of ankle sprains were non-contact injuries. Most frequently the ankle sprain was isolated to the anterior talofibular (ATF) ligament (80.2%) but overall 91.5% sprains included the ATF ligament.
60 Athletic Trainer’s Role as Point of First Contact
The licensed athletic trainers in this study reported a total of 692 cases. Twenty-
six (3.8%) cases were non-athletic related. Forty-one (5.9%) of the 692 cases were
nonorthopedic in nature. This finding is higher than the data found in the NBA and the
WNBA. A study comparing the NBA and the WNBA noted that 0.3% of the injuries
occurring in the NBA over 6 years were systemic illnesses, including heat exhaustion,
dehydration, and general fatigue. The WNBA had a slightly higher rate of systemic injuries accounting for 1.1% (Deitch et al., 2006). A study of the NBA showed higher rates of general medical issues. Of the 9,904 injuries and illnesses seen over the 10 years,
2,131 (21.5%) were general medical in nature. Of those general medical conditions reported upper respiratory conditions accounted for 16.7% of all cases. Others included gastrointestinal problems, dermatological conditions, and local and systemic infections
(Starkey, 2000).
The most common illness reported in this study was influenza (6 illnesses,
14.6%). The second most common reason outside of orthopedic conditions a licensed athletic trainer’s services were sought was for nutritional counseling (3, 7.3%).
61 Non-athletic Related Conditions
Of the 692 reports 29 (4.2%) were during non-sanctioned athletic activity, 26
(3.8%) were non-athletic related, and 10 (1.4%) were during physical education class.
This is a combined total of 65 (9.4%) cases that a LAT evaluated that were outside the
realm of organized high school athletics. Of these 65 cases some were referred to physicians by the LAT and others were not.
Of the 29 reports of injuries during non-sanctioned athletic activity 7 were
referred to a physician, 20 were not, and 2 went to a physician’s office or the emergency
room on their own accord.
The 26 non-athletic injuries resulted in 8 physician referrals, 4 self-referrals (the athlete went on their own), 1 case refused the referral, and 13, which were not referred.
Of the physical education injuries only three were referred to a physician and seven were not.
We feel that having the LAT in high schools to evaluate athletic related injuries as well as these 65 cases outside of organized athletics results in time and money saved by needless visits to the emergency rooms or doctor’s appointments.
62 Recommended Procedural Modifications
The analysis of data from this study was significantly limited by the inability to calculate confidence intervals for individual athlete injury risks. This was based partly on the data collection forms used and the quality and quantity of responses received from participating schools. The following recommendations, if implemented, should help to improve the validity and reliability of our sample.
1. Modify data collection procedures to identify individual athlete exposures.
2. Reconsider the reporting criteria to decrease the number of reports thereby
lessening the workload placed on the athletic trainers.
3. Electronic data submission such as a web-based or computer-based reporting
mechanism will streamline data collection and analysis.
4. Reconsider the need to monitor activities such as cheerleading, golf, and
tennis. The athletic training coverage of cheerleading significantly varies from
school to school. A relatively low number of schools offer golf and tennis.
63 Conclusion
Injuries in rural parts of the country are occurring at higher rates. With decreased
access to health care the problem of high school injuries is growing. The evidence found
in this study supports the need for a licensed athletic trainer in every high school. Rice et
al. (1985) suggested that it would be impractical for every high school to employ an
athletic trainer because at the time there were only 5,000 certified athletic trainers and
over 20,000 US secondary schools. In 2007 there are over 30,000 certified athletic trainers and 4, 014 are singularly employed in high schools and another 2,327 are affiliated with high schools via a clinic, physician, or hospital based outreach program
(NATA, 2007a). If the numbers of athletic trainers keep increasing, the goal of having an athletic trainer at every high school in the country can be achieved.
The athletic training profession is becoming increasing aware of the need to establish injury surveillance systems to monitor injury trends and to help develop evidence-based prevention programs to aid in the reduction of the number of injuries seen in high school athletics (Comstock et al., 2007). It has also been published that the optimal way to minimize the risk of injury is to provide prevention programs to young
athletes (Powell & Barber-Foss, 1999a).
The purpose of this study was to collect baseline data for future study. As the
database is expanded and data collection procedures are streamlined, these data will
provide the epidemiological data required to identify the long-term risks of athletic
participation. Concurrent and future studies will attach a financial and human price tag
(time lost from school, surgery, and long-term disability) on the costs of these injuries
and, hopefully, substantiate the efficacy of various injury prevention and injury
64 rehabilitation techniques. Students in the Graduate Athletic Training Program at Ohio
University should be encouraged to use this database and population to determine the efficacy of injury prevention and rehabilitation techniques.
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71 APPENDIX A
72
APPENDIX B
73 APPENDIX C
74