Christy L. Collins

Epidemiology of High School and Collegiate Football Injuries in the United States, 2005–2006

Background Football, one of the most popular sports among male high school students in the United States, is a leading cause of sports-related injuries, with an injury rate almost twice that of basketball, the second most popular sport. Hypothesis Injury patterns will vary between competition and practice exposures and between levels of play (ie, high school vs. National Collegiate Athletic Association [NCAA]). Study Design Descriptive epidemiology study. Methods Football-related injury data were collected over the 2005-2006 school year from 100 nationally representative high schools via High School RIO™ (Reporting Information Online) and from 55 Division I, II, and III colleges via the NCAA Injury Surveillance System. Results Nationally, an estimated 517 726 high school football-related injuries (1881 unweighted injuries) occurred during the 2005-2006 season. The rate of injury per 1000 athlete-exposures was greater during high school competitions (12.04) than during practices (2.56). The rate of injury per 1000 athlete-exposures was also greater during collegiate competitions (40.23) than during practices (5.77). While the overall rate of injury per 1000 athlete-exposures was greater in the NCAA (8.61) than in high school (4.36), high school football players sustained a greater proportion of fractures and concussions. Running plays were the leading cause of injury, with running backs and linebackers being the positions most commonly injured. Conclusion Patterns of football injuries vary, especially by type of exposure and level of play. Future studies should continue to compare differences in injury patterns in high school and collegiate football, with particular emphasis placed on high-risk plays (running plays) and positions (running backs and linebackers).

Epidemiology of Severe Injuries Among United States High School Athletes: 2005-2007

Background Over 7 million students participate in high school athletics annually. Despite numerous health benefits, high school athletes are at risk for injury. Hypothesis Severe injury rates and patterns differ by gender and type of exposure. Study Design Descriptive epidemiology study. Methods Sports-related injury data were collected during the 2005-2007 academic years from 100 nationally representative United States high schools via RIO (Reporting Information Online). Severe injury was defined as any injury that resulted in the loss of more than 21 days of sports participation. Results Participating certified athletic trainers (ATCs) reported 1378 severe injuries during 3 550 141 athlete-exposures (0.39 severe injuries per 1000 athletic exposures). Football had the highest severe injury rate (0.69), followed by wrestling (0.52), girls’ basketball (0.34), and girls’ soccer (0.33). The rate in all boys’ sports (0.45) was higher than all girls’ sports (0.26) (rate ratio [RR], 1.74; 95% confidence interval [CI], 1.54-1.98; P < .001). However, among directly comparable sports (soccer, basketball, and baseball/softball), girls sustained a higher severe injury rate (0.29) than boys (0.23) (RR, 1.28; 95% CI, 1.08-1.52; P = .006). More specifically, girls’ basketball had a higher rate (0.34) than boys’ basketball (0.24) (RR, 1.43; 95% CI, 1.10-1.86; P = .009). Differences between boys’ and girls’ soccer and baseball/softball were not statistically significant. The severe injury rate was greater in competition (0.79) than practice (0.24) (RR, 3.30; 95% CI, 2.97-3.67; P < .001). Nationally, high school athletes sustained an estimated 446 715 severe injuries from 2005-2007. The most commonly injured body sites were the knee (29.0%), ankle (12.3%), and shoulder (10.9%). The most common diagnoses were fractures (36.0%), complete ligament sprains (15.3%), and incomplete ligament sprains (14.3%). Of severe sports injuries, 0.3% resulted in medical disqualification for the athletes’ career, and an additional 56.8% resulted in medical disqualification for the entire season. One in 4 (28.3%) severe injuries required surgery, with over half (53.9%) being knee surgeries. Conclusion Severe injury rates and patterns varied by sport, gender, and type of exposure. Because severe injuries negatively affect athletes’ health and often place an increased burden on the health care system, future research should focus on developing interventions to decrease the incidence and severity of sports-related injuries.

The Epidemiology of United States High School Soccer Injuries, 2005–2007

Background United States high school soccer participation increased 5 fold over the last 30 years. With increased participation comes increased injury incidence. Hypothesis High school soccer injury patterns will vary by gender and type of exposure. Study Design Descriptive epidemiologic study. Methods Soccer-related injury data were collected over the 2005–2006 and 2006–2007 school years from 100 nationally representative United States high schools via Reporting Information Online (RIO, an Internet-based sports-related injury surveillance system). Results Participating certified athletic trainers reported 1524 soccer injuries during 637 446 athlete exposures (AEs), for an injury rate of 2.39 per 1000 AEs, corresponding to a nationally estimated 807 492 soccer-related injuries during the 2005–2006 and 2006–2007 seasons. The injury rate per 1000 AEs was greater during competition (4.77) than practice (1.37) (rate ratio [RR] = 3.49; 95% confidence interval [CI], 3.15–3.87). Overall, the most frequent diagnoses were incomplete ligament sprains (26.8%), incomplete muscle strains (17.9%), contusions (13.8%), and concussions (10.8%). The most commonly injured body sites were the ankle (23.4%), knee (18.7%), head/face (13.7%), and thigh/upper leg (13.1%). Similar proportions of boys (57.9%) and girls (53.9%) returned to activity in <1 week. During competition, girls sustained complete knee ligament sprains requiring surgery at a rate of 26.4 per 100 000 AEs, higher than the rate among boys during competition (1.98 per 100 000 AEs) (RR = 13.3; 95% CI, 3.15–56.35) and among girls during practice (2.34 per 100 000 AEs) (RR = 11.3; 95% CI, 4.31–29.58). Player-to-player contact was more common among competition injuries (injury proportion ratio [IPR] = 2.42; 95% CI, 2.01–2.92), while noncontact mechanisms were more common among practice injuries (IPR = 2.39; 95% CI, 1.90–3.01). Conclusions High school soccer injury patterns vary by gender and type of exposure. Identifying such differences in injury patterns is the important first step in the development of evidence-based, targeted injury prevention efforts.

National High School Athlete Concussion Rates From 2005-2006 to 2011-2012

Background: High school athletes are at risk for concussions. Although a previously published study showed an increase in concussion rates for a single school district, it remains unknown if the rate of concussions among high school athletes is increasing nationally. Purpose: To investigate national high school athlete concussion rates over time. Study Design: Descriptive epidemiologic study. Methods: The rate of concussions per 1000 athlete-exposures was calculated for academic years 2005-2006 through 2011-2012 using the High School Reporting Information Online sports injury surveillance system. Results: During the 7-year period of this study, High School Reporting Information Online captured 4024 concussions with overall concussion diagnosis rates increasing significantly from 0.23 to 0.51 (P = .004). Concussion diagnosis rates increased for each of the 9 sports studied, with 5 sports having statistically significant increases over this 7-year period. Conclusion: The study analysis indicates that national concussion diagnosis rates for high school sports have increased significantly over time.

The epidemiology of new versus recurrent sports concussions among high school athletes, 2005–2010

Objectives To compare new versus recurrent concussions with respect to constellation of symptoms, symptom severity, symptom resolution; evaluate potential subset differences with respect to gender and sport; and to compare mechanisms and activities associated with new versus recurrent concussions. Methods Sports-related injury and exposure data were collected for nine sports from 2005 to 2010 from 100 nationally representative US high schools. Results Nationally, an estimated 732,805 concussions occurred. Of these reported concussions, 13.2% were recurrent. The rate of new concussions was 22.2 per 100,000 athletic exposures while the rate of recurrent concussions was 3.1 per 100,000 athletic exposures (RR 7.23, 95% CI 6.39 to 8.17, p<0.001). While 0.6% of new concussion symptoms took >1 month to resolve, 6.5% of recurrent concussion symptoms took >1 month to resolve (IPR 10.35; 95% CI 4.62 to 23.16; p<0.001). Loss of consciousness was reported more often with recurrent (7.7%) than new concussions (4.4%) (IPR 1.76; 95% CI 1.02 to 3.03; p=0.043). A greater proportion of athletes sustaining recurrent concussions returned to play in >3 weeks (7.5%) or were medically disqualified (16.2%) than athletes sustaining new concussions (3.8%; IPR 1.95; 95% CI 1.01 to 3.77; p=0.047 and 2.9%; IPR 5.58; 95% CI 3.50 to 8.88; p<0.001, respectively). The majority of new and recurrent concussions resulted from contact with another person (73.4% and 77.9%, respectively). Conclusions Athletes sustaining recurrent concussions had longer symptom resolution times, were kept out of play longer and reported loss of consciousness more frequently than athletes sustaining new concussions. With the possibility of long-term impairment and other negative sequelae, proper management and prevention of concussions at the high school level is imperative.

Assessment and Management of Sport-Related Concussions in United States High Schools

Background: Little existing data describe which medical professionals and which medical studies are used to assess sport-related concussions in high school athletes. Purpose: To describe the medical providers and medical studies used when assessing sport-related concussions. To determine the effects of medical provider type on timing of return to play, frequency of imaging, and frequency of neuropsychological testing. Study Design: Descriptive epidemiology study. Methods: All concussions recorded by the High School Reporting Information Online (HS RIO) injury surveillance system during the 2009 to 2010 academic year were included. χ2 analyses were conducted for categorical variables. Fisher exact test was used for nonparametric data. Logistic regression analyses were used when adjusting for potential confounders. Statistical significance was considered for P < .05. Results: The HS RIO recorded 1056 sport-related concussions, representing 14.6% of all injuries. Most (94.4%) concussions were assessed by athletic trainers (ATs), 58.8% by a primary care physician. Few concussions were managed by specialists. The assessment of 21.2% included computed tomography. Computerized neuropsychological testing was used for 41.2%. For 50.1%, a physician decided when to return the athlete to play; for 46.2%, the decision was made by an AT. After adjusting for potential confounders, no associations between timing of return to play and the type of provider (physician vs AT) deciding to return the athlete to play were found. Conclusion: Concussions account for nearly 15% of all sport-related injuries in high school athletes. The timing of return to play after a sport-related concussion is similar regardless of whether the decision to return the athlete to play is made by a physician or an AT. When a medical doctor is involved, most concussions are assessed by primary care physicians as opposed to subspecialists. Computed tomography is obtained during the assessment of 1 of every 5 concussions occurring in high school athletes.

Epidemiological features of high school baseball injuries in the United States, 2005-2007.

OBJECTIVES. The goals were to calculate injury rates among high school baseball players and to characterize the general epidemiological features of high school baseball injuries and, more specifically, injuries attributed to being hit by a batted ball. METHODS. We analyzed baseball exposure and injury data collected over the 2005–2006 and 2006–2007 school years from a nationally representative sample of 100 US high schools by using an injury surveillance system, Reporting Information Online. RESULTS. Nationally, an estimated 131555 high school baseball-related injuries occurred during the 2005–2006 and 2006–2007 academic years, for an injury rate of 1.26 injuries per 1000 athletic exposures. The most commonly injured body sites were the shoulder (17.6%), ankle (13.6%), head/face (12.3%), hand/finger (8.5%), and thigh/upper leg (8.2%). The most common injury diagnoses were ligament sprains (incomplete tears) (21.0%), muscle strains (incomplete tears) (20.1%), contusions (16.1%), and fractures (14.2%). Although the majority of injuries resulted in a time loss of <7 days, 9.7% resulted in medical disqualification for the season, and 9.4% required surgery. Of the 431 reported baseball injuries, 50 (11.6%) were attributed to being hit by a batted ball. Greater proportions of injuries attributed to being hit by a batted ball were to the head/face (48.0%) and mouth/teeth (16.0%), compared with injuries not attributed to being hit by a batted ball (8.2% and 1.3%, respectively). A greater proportion of injuries attributed to being hit by a batted ball required surgery (18.0%), compared with other baseball-related injuries (6.8%). CONCLUSIONS. Although high school baseball is relatively safe, targeted, evidence-based interventions could reduce the rate of high school baseball-related injuries. On the basis of our findings, we strongly recommend that helmets with face shields or at least mouth guards and eye protection be used by pitchers, infielders, and batters at the high school level.

An Epidemiologic Comparison of High School and College Wrestling Injuries

Background Wrestling holds worldwide popularity, and large numbers of United States high school and college males participate. However, the sports arduous nature results in high injury rates. Hypothesis Wrestling injury rates and patterns will differ between high school and college practice and match exposures. Study Design Descriptive epidemiology study. Methods Wrestling-related injury data were collected during the 2005–2006 academic year from 74 nationally representative high schools via High School Reporting Information Online (RIO) and from 15 Division I, II, and III colleges via the National Collegiate Athletic Association Injury Surveillance System. Results Certified athletic trainers reported 387 injuries among participating high school wrestlers during 166 279 athlete-exposures, for an injury rate of 2.33 injuries per 1000 athlete-exposures. Nationally, high school wrestlers sustained an estimated 99 676 injuries and 8741 skin infections during the 2005–2006 season. In college, 258 injuries occurred among participating wrestlers during 35 599 athlete-exposures, for an injury rate of 7.25 injuries per 1000 athlete-exposures. The injury rate per 1000 athlete-exposures was higher in college than high school (rate ratio [RR] = 3.11, 95% confidence interval [CI]: 2.66–3.64) and was higher in matches than in practice in high school (RR = 2.12, 95% CI: 1.73–2.59) and college (RR = 5.07, 95% CI: 3.96–6.50). Diagnoses in greater proportions of college wrestlers included lacerations (injury proportion ratio [IPR] = 5.98, 95% CI: 2.27–15.74) and cartilage injuries (IPR = 2.69, 95% CI: 1.26–5.74). Body parts injured in greater proportions of high school wrestlers included elbow (IPR = 3.90, 95% CI: 1.66–9.14) and hand (IPR = 2.59, 95% CI: 1.21–5.54). Almost half of all injured high school (44.9%) and college (42.6%) wrestlers resumed wrestling within <1 week. Skin infections represented 8.5% and 20.9% of all reported high school and college events, respectively, and frequently affected the head/face/neck (50.0%). Conclusions Rates and patterns of wrestling injury differ between high school and college and between practice and matches.

Computerized neurocognitive testing for the management of sport-related concussions.

Objectives: To describe the prevalence of computerized neurocognitive testing for the assessment of high school athletes who sustain concussions, and to describe associations between using computerized neurocognitive tests, timing of return-to-play, and medical provider managing the athlete. Methods: Concussions recorded in the High School Reporting Information Online injury surveillance system during the 2009–2010 academic year were included. Measures of association between use of computerized neurocognitive testing and outcomes were analyzed. A questionnaire was sent to athletic trainers (ATs) querying the use of computerized neurocognitive testing. χ2 analyses were conducted for categorical variables. Logistic regression analyses were used to adjust for potential confounders. Statistical significance was set at P < .05. Results: High School Reporting Information Online recorded 1056 concussions. Athletes who underwent computerized neurocognitive testing were less likely to be returned to play within 10 days of injury (38.5% vs 55.7%, P < .001) and more likely to be returned to play by a physician (60.9% vs 45.6%, P < .001). We had a response rate of 97.3% for the survey. Of respondents, 39.9% used computerized neurocognitive testing; 93.0% of those used ImPACT. Tests were most often interpreted by ATs (78.9%) and/or physicians (78.8%), as opposed to neuropsychologists (16.9%). Conclusions: Approximately 40% of US high schools that employ an AT use computerized neurocognitive tests when managing sport-related concussions. Tests are most often interpreted by ATs and physicians, as opposed to neuropsychologists. Computerized neurocognitive tests are significantly associated with the timing of return-to-play.

Epidemiology of 6.6 Million Knee Injuries Presenting to United States Emergency Departments From 1999 Through 2008

BACKGROUND While knee injuries are treated by a wide range of clinicians, patients with knee injuries frequently present to emergency departments (EDs). The knee is the most commonly injured joint by adolescent athletes with an estimated 2.5 million sports-related injuries presenting to EDs annually. OBJECTIVES The objective was to examine the epidemiology of knee injuries presenting to EDs in the United States from 1999 through 2008. METHODS The Consumer Product Safety Commission National Electronic Injury Surveillance System database (NEISS) was used to examine causes of knee injuries treated in U.S. EDs from 1999 through 2008. RESULTS An estimated 6,664,324 knee injuries presented to U.S. EDs from 1999 through 2008, for a rate of 2.29 knee injuries per 1,000 population. Those 15 to 24 years of age had the highest injury rate (3.83), while children younger than 5 years had the lowest rate (0.55). The most common diagnoses were strains and sprains (42.1%), contusions and abrasions (27.1%), and lacerations and punctures (10.5%). The most common general product categories causing injury were sports and recreation (49.3%), home structures (30.2%), and home furnishings (13.6%). Several sex and age group differences were identified. For example, males sustained a higher proportion of basketball-related injuries (11.1%) than females (3.6%; injury proportion ratio [IPR] = 3.11, 95% confidence interval [CI] = 2.79 to 3.46, p < 0.001). Additionally, individuals 65 years and older sustained a higher proportion of injury due to stairs, ramps, landings, and floors (42.0%), compared to all other ages (20.1%; IPR = 2.09, 95% CI = 1.95 to 2.23, p < 0.001). CONCLUSIONS Rates and patterns of knee injuries vary by sex and age. Although knee injuries will likely continue to occur most frequently among youth and young adult athletes, anticipating and responding to trends such as an increase in the incidence of knee injuries among adult and senior patients will enable clinicians to better anticipate caseloads, allocate resources, and determine best practices for diagnosis and treatment of knee injuries in different age groups.