Thomas P. Dompier

National Collegiate Athletic Association Injury Surveillance System: Review of Methods for 2004–2005 Through 2013–2014 Data Collection

BACKGROUND Since 1982, the National Collegiate Athletic Association has used the Injury Surveillance System (ISS) to collect injury and athlete-exposure data from a representative sample of collegiate institutions and sports. At the start of the 2004-2005 academic year, a Web-based ISS replaced the paper-based platform previously used for reporting injuries and exposures. OBJECTIVE To describe the methods of the Web-based National Collegiate Athletic Association ISS for data collection as implemented from the 2004-2005 to 2013-2014 academic years. DESCRIPTION The Web-based ISS monitored National Collegiate Athletic Association-sanctioned practices and competitions, the number of participating student-athletes, and time-loss injuries during the preseason, regular season, and postseason in 25 collegiate sports. Starting in the 2009-2010 academic year, non-time-loss injuries were also tracked. Efforts were made to better integrate ISS data collection into the workflow of collegiate athletic trainers. Data for the 2004-2005 to 2013-2014 academic years are available to researchers through a standardized application process available at the Datalys Center Web site. CONCLUSIONS As of February 2014, more than 1 dozen data sets have been provided to researchers. The Datalys Center encourages applications for access to the data.

Incidence of concussion during practice and games in youth, high school, and collegiate American football players

IMPORTANCE A report by the Institute of Medicine called for comprehensive nationwide concussion incidence data across the spectrum of athletes aged 5 to 23 years. OBJECTIVE To describe the incidence of concussion in athletes participating in youth, high school, and collegiate American football. DESIGN, SETTING, AND PARTICIPANTS Data were collected by athletic trainers at youth, high school, and collegiate football practices and games to create multiple prospective observational cohorts during the 2012 and 2013 football seasons. Data were collected from July 1, 2012, through January 31, 2013, for the 2012 season and from July 1, 2013, through January 31, 2014, for the 2013 season. The Youth Football Surveillance System included 118 youth football teams, providing 4092 athlete-seasons. The National Athletic Treatment, Injury and Outcomes Network program included 96 secondary school football programs, providing 11 957 athlete-seasons. The National Collegiate Athletic Association Injury Surveillance Program included 24 member institutions, providing 4305 athlete-seasons. EXPOSURES All injuries regardless of severity, including concussions, and athlete exposure information were documented by athletic trainers during practices and games. MAIN OUTCOMES AND MEASURES Injury rates, injury rate ratios, risks, risk ratios, and 95% CIs were calculated. RESULTS Concussions comprised 9.6%, 4.0%, and 8.0% of all injuries reported in the Youth Football Surveillance System; National Athletic Treatment, Injury and Outcomes Network; and National Collegiate Athletic Association Injury Surveillance Program, respectively. The game concussion rate was higher than the practice concussion rate across all 3 competitive levels. The game concussion rate for college athletes (3.74 per 1000 athlete exposures) was higher than those for high school athletes (injury rate ratio, 1.86; 95% CI, 1.50-2.31) and youth athletes (injury rate ratio, 1.57; 95% CI, 1.17-2.10). The practice concussion rate in college (0.53 per 1000 athlete exposures) was lower than that in high school (injury rate ratio, 0.80; 95% CI, 0.67-0.96). Youth football had the lowest 1-season concussion risks in 2012 (3.53%) and 2013 (3.13%). The 1-season concussion risk was highest in high school (9.98%) and college (5.54%) in 2012. CONCLUSIONS AND RELEVANCE Football practices were a major source of concussion at all 3 levels of competition. Concussions during practice might be mitigated and should prompt an evaluation of technique and head impact exposure. Although it is more difficult to change the intensity or conditions of a game, many strategies can be used during practice to limit player-to-player contact and other potentially injurious behaviors.

College sports-related injuries - United States, 2009-10 through 2013-14 academic years.

Sports-related injuries can have a substantial impact on the long-term health of student-athletes. The National Collegiate Athletic Association (NCAA) monitors injuries among college student-athletes at member schools. In academic year 2013-14, a total of 1,113 member schools fielded 19,334 teams with 478,869 participating student-athletes in NCAA championship sports (i.e., sports with NCAA championship competition) (1). External researchers and CDC used information reported to the NCAA Injury Surveillance Program (NCAA-ISP) by a sample of championship sports programs to summarize the estimated national cumulative and annual average numbers of injuries during the 5 academic years from 2009-10 through 2013-14. Analyses were restricted to injuries reported among student-athletes in 25 NCAA championship sports. During this period, 1,053,370 injuries were estimated to have occurred during an estimated 176.7 million athlete-exposures to potential injury (i.e., one athletes participation in one competition or one practice). Injury incidence varied widely by sport. Among all sports, mens football accounted for the largest average annual estimated number of injuries (47,199) and the highest competition injury rate (39.9 per 1,000 athlete-exposures). Mens wrestling experienced the highest overall injury rate (13.1 per 1,000) and practice injury rate (10.2 per 1,000). Among womens sports, gymnastics had the highest overall injury rate (10.4 per 1,000) and practice injury rate (10.0 per 1,000), although soccer had the highest competition injury rate (17.2 per 1,000). More injuries were estimated to have occurred from practice than from competition for all sports, with the exception of mens ice hockey and baseball. However, injuries incurred during competition were somewhat more severe (e.g., requiring ≥7 days to return to full participation) than those acquired during practice. Multiple strategies are employed by NCAA and others to reduce the number of injuries in organized sports. These strategies include committees that recommend rule and policy changes based on surveillance data and education and awareness campaigns that target both athletes and coaches. Continued analysis of surveillance data will help to understand whether these strategies result in changes in the incidence and severity of college sports injuries.

Comprehensive Coach Education and Practice Contact Restriction Guidelines Result in Lower Injury Rates in Youth American Football

Background: Research evaluating the effect of comprehensive coach education and practice contact restriction in youth football injury rates is sparse. In 2012, USA Football released their Heads Up Football coaching education program (HUF), and Pop Warner Football (PW) instituted guidelines to restrict contact during practice. Purpose: To compare injury rates among youth football players aged 5 to 15 years by whether their leagues implemented HUF and/or were PW-affiliated. Study Design: Cohort study; Level of evidence, 2. Methods: Athletic trainers (ATs) evaluated and tracked injuries at each practice and game during the 2014 youth football season. Players were drawn from 10 leagues across 4 states. The non–Heads Up Football (NHUF) group consisted of 704 players (none of whom were PW-affiliated) from 29 teams within 4 leagues. The HUF+PW group consisted of 741 players from 27 teams within 2 leagues. The HUF-only group consisted of 663 players from 44 teams within 4 leagues. Injury rates and injury rate ratios (IRRs) were reported with 95% CIs. Results: A total of 370 injuries were reported during 71,262 athlete-exposures (AEs) (rate, 5.19/1000 AEs). Compared with the NHUF group (7.32/1000 AEs), the practice injury rates were lower for the HUF+PW group (0.97/1000 AEs; IRR, 0.13; 95% CI, 0.08-0.21) and the HUF-only group (2.73/1000 AEs; IRR, 0.37; 95% CI, 0.26-0.53). Compared with the NHUF group (13.42/1000 AEs), the game injury rate was lower for the HUF+PW group (3.42/1000 AEs; IRR, 0.25; 95% CI, 0.15-0.44) but not for the HUF-only group (13.76/1000 AEs; IRR, 1.02; 95% CI, 0.73-1.43). Also, the HUF+PW game injury rate was lower than that of HUF-only (IRR, 0.20; 95% CI, 0.12-0.36). Higher injury rates were typically found in those aged 11 to 15 years compared with those aged 5 to 10 years. However, stronger effects related to HUF implementation and PW affiliation were seen among 11- to 15-year-olds. When restricted to concussions only, the sole difference was found between the practice concussion rates among 11- to 15-year-olds in the HUF+PW (0.14/1000 AEs) and NHUF groups (0.79/1000 AEs) (IRR, 0.18; 95% CI, 0.04-0.85). Conclusion: These findings support comprehensive coach education and practice contact restrictions as effective methods of injury mitigation. Future research should continue evaluating similar programming within other levels of competition and sports.

Sex Differences in the Incidence of Anterior Cruciate Ligament, Medial Collateral Ligament, and Meniscal Injuries in Collegiate and High School Sports 2009-2010 Through 2013-2014

Background: Previous research has noted sex-based differences in anterior cruciate ligament (ACL) injury rates in young athletes, while little is known about medial collateral ligament (MCL) and meniscal injury rates in this population. The objective of this study was to compare injury rates for traumatic knee injuries (ie, ACL, MCL, and meniscal injuries) in collegiate and high school (HS) varsity student-athletes across multiple sports. Hypothesis: Knee injury rates vary by sex and across different sports and levels of competition. Study Design: Descriptive epidemiology study. Methods: Injury and athlete-exposure data were utilized from the National Athletic Treatment, Injury and Outcomes Network (NATION) and National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP) during the 2009-2010 to 2013-2014 academic years. Analyses focused on ACL, MCL, and meniscal injuries. Injury rates and injury rate ratios (IRRs) with 95% CIs were calculated for basketball, ice hockey, lacrosse, soccer, and baseball/softball. Results: The ACL injury rate was higher for female than male athletes at the collegiate (IRR, 2.49; 95% CI, 1.81-3.41) and HS (IRR, 2.30; 95% CI, 1.67-3.18) levels. At the collegiate level, the highest ACL IRR comparing female to male athletes was reported in softball/baseball (IRR, 6.61; 95% CI, 1.48-29.55). At the HS level, the highest ACL IRR was reported in basketball (IRR, 3.68; 95% CI, 1.91-7.10). The MCL injury rate was higher for female than male athletes at the HS level (IRR, 2.11; 95% CI, 1.25-3.56) but lower for female than male athletes at the collegiate level (IRR, 0.73; 95% CI, 0.59-0.92). The meniscal injury rate was lower for female than male athletes at the HS level (IRR, 0.47; 95% CI, 0.31-0.71), while no differences by sex were seen at the collegiate level (IRR, 1.35; 95% CI, 0.90-2.02). Conclusion: Knee injury rates varied by sex across 5 different sports in the HS and collegiate settings. Female athletes sustained ACL injuries at a higher rate than male athletes at both the HS and collegiate levels in these 5 sports; however, there was not a distinct sex disparity in MCL and meniscal injuries. Future studies should examine the rates of concomitant and recurrent injuries to inform injury prevention and rehabilitation programs.

Concussion Symptoms and Return to Play Time in Youth, High School, and College American Football Athletes

IMPORTANCE To our knowledge, little research has examined concussion across the youth/adolescent spectrum and even less has examined concussion-related outcomes (ie, symptoms and return to play). OBJECTIVE To examine and compare sport-related concussion outcomes (symptoms and return to play) in youth, high school, and collegiate football athletes. DESIGN, SETTING, AND PARTICIPANTS Athletic trainers attended each practice and game during the 2012 to 2014 seasons and reported injuries. For this descriptive, epidemiological study, data were collected from youth, high school, and collegiate football teams, and the analysis of the data was conducted between July 2015 and September 2015. The Youth Football Surveillance System included more than 3000 youth football athletes aged 5 to 14 years from 118 teams, providing 310 team seasons (ie, 1 team providing 1 season of data). The National Athletic Treatment, Injury, and Outcomes Network Program included 96 secondary school football programs, providing 184 team seasons. The National Collegiate Athletic Association Injury Surveillance Program included 34 college football programs, providing 71 team seasons. MAIN OUTCOMES AND MEASURES We calculated the mean number of symptoms, prevalence of each symptom, and the proportion of patients with concussions that had long return-to-play time (ie, required participation restriction of at least 30 days). Generalized linear models were used to assess differences among competition levels in the mean number of reported symptoms. Logistic regression models estimated the odds of return to play at less than 24 hours and at least 30 days. RESULTS Overall, 1429 sports-related concussions were reported among youth, high school, and college-level football athletes with a mean (SD) of 5.48 (3.06) symptoms. Across all levels, 15.3% resulted return to play at least 30 days after the concussion and 3.1% resulted in return to play less than 24 hours after the concussion. Compared with youth, a higher number of concussion symptoms were reported in high school athletes (β = 1.39; 95% CI, 0.55-2.24). Compared with college athletes, the odds of return to play at least 30 days after injury were larger in youth athletes (odds ratio, 2.75; 95% CI, 1.10- 6.85) and high school athletes (odds ratio, 2.89; 95% CI, 1.61-5.19). The odds of return to play less than 24 hours after injury were larger in youth athletes than high school athletes (odds ratio, 6.23; 95% CI, 1.02-37.98). CONCLUSIONS AND RELEVANCE Differences in concussion-related outcomes existed by level of competition and may be attributable to genetic, biologic, and/or developmental differences or level-specific variations in concussion-related policies and protocols, athlete training management, and athlete disclosure. Given the many organizational, social environmental, and policy-related differences at each level of competition that were not measured in this study, further study is warranted to validate our findings.

Epidemiology of Hamstring Strains in 25 NCAA Sports in the 2009-2010 to 2013-2014 Academic Years

Background: The epidemiology of hamstring strains among student-athletes has been extensively researched. However, there is a paucity of recent data describing patterns of hamstring strains. Purpose: To describe the epidemiology of hamstring strains in 25 National Collegiate Athletic Association (NCAA) championship sports. Study Design: Descriptive epidemiology study. Methods: Hamstring strains data were analyzed from the NCAA Injury Surveillance Program during the 2009-2010 to 2013-2014 academic years. Hamstring strain injury rates, rate ratios (RRs), and injury proportion ratios were reported with 95% CIs. Results: During the study period, 1142 hamstring strains were reported, leading to an injury rate of 3.05 per 10,000 athlete-exposures (AEs). Most hamstring strains occurred during practices (68.2%). However, the competition rate (5.24 per 10,000 AEs) was larger than the practice rate (2.56 per 10,000 AEs; RR = 2.05; 95% CI, 1.81-2.32). A slight majority occurred during the regular season (52.9%). However, the preseason rate (5.00 per 10,000 AEs) was larger than the regular season/postseason rate (2.34 per 10,000 AEs; RR = 2.14; 95% CI, 1.90-2.40). Men’s football, men’s soccer, and women’s soccer contributed the greatest proportion of hamstring strains (35.3%, 9.9%, and 8.3%, respectively). Most hamstring strains were due to noncontact (72.3%). Of all hamstring strains, 12.6% were recurrent, 37.7% resulted in a time loss of <24 hours, and 6.3% resulted in a time loss >3 weeks. Variations in hamstring strain patterns existed by sport. The hamstring strain rate was larger in men than in women in soccer (RR = 1.60; 95% CI, 1.22-2.11), baseball/softball (RR = 1.66; 95% CI, 1.07-2.59), and indoor track (RR = 1.88; 95% CI, 1.26-2.78). In addition, proportions of hamstring strains that were recurrent were higher among men in most sex-comparable sports, but this difference was not significant. Conclusion: Hamstring strain rates were higher in the preseason and in competition. Student-athletes should be acclimatized to the rigors of preseason participation. Meanwhile, further surveillance should investigate the effectiveness of prospective prevention programs in an effort to reduce the prevalence of initial and recurrent hamstring strain injuries.

The Epidemiology of Lateral Ligament Complex Ankle Sprains in National Collegiate Athletic Association Sports

Background: Ankle sprains are a common injury in collegiate sports. Few studies have examined the epidemiology of individual ligament injuries, specifically the lateral ligament complex (LLC) of the ankle. Purpose: To describe the epidemiology, including the estimated yearly national incidence, of LLC sprains among National Collegiate Athletic Association (NCAA) athletes. Study Design: Descriptive epidemiology study. Methods: Injury surveillance data for 25 sports from the NCAA Injury Surveillance Program (NCAA-ISP) for the academic years 2009-2010 to 2014-2015 were used for analysis. All injuries included for analysis had a diagnosis of an LLC sprain. LLC sprain rates and rate ratios (RRs) with 95% CIs were calculated. From the sample, national estimates of the annual incidence of LLC sprains across the entire student-athlete body from these 25 sports were also calculated. Results: During the 2009-2010 to 2014-2015 academic years, 2429 LLC sprains were reported, for a rate of 4.95 per 10,000 athlete-exposures (AEs). LLC sprains comprised 7.3% of all reported collegiate sports injuries in the NCAA-ISP. Also, an estimated 16,022 LLC sprains occurred annually among the 25 sports. The sports with the highest LLC sprain rates were men’s basketball (11.96/10,000 AEs) and women’s basketball (9.50/10,000 AEs). Most LLC sprains occurred during practices (57.3%); however, the LLC sprain rate was higher in competitions than in practices (RR, 3.29; 95% CI, 3.03-3.56). Also, 11.9% of LLC sprains were identified as recurrent injuries, with the largest proportions of recurrent LLC sprains being found within women’s basketball (21.1%), women’s outdoor track (21.1%), women’s field hockey (20.0%), and men’s basketball (19.1%). In 44.4% of LLC sprains, the athlete returned to play in less than 24 hours; in 3.6%, the athlete required more than 21 days before returning to play (including those who did not return to play at all). Conclusion: LLC sprains were the most commonly reported injury diagnosis among United States collegiate student-athletes. Continued examination of interventions that aim to reduce the incidence, severity, and recurrence of LLC sprains, specifically in women, is warranted.

Development and Validation of a Movement and Activity in Physical Space Score as a Functional Outcome Measure

OBJECTIVE To develop and validate a functional measure, the Movement and Activity in Physical Space (MAPS) score, that encompasses both physical activity and environmental interaction. DESIGN Observational matched-pair cohort with 2-month follow-up. SETTING General community under free-living conditions. PARTICIPANTS Adult participants (N=18; n=9 postsurgical, n=9 matched control; mean age ± SD, 28.9 ± 12.0y) were monitored by an accelerometer and global positioning system receiver for 3 days within 1 week (4.1 ± 2.8d) after knee surgery (T=0) and 2 months later (T+2). The healthy controls were matched for age, sex, smoking, perceived physical activity level, and occupation of a postsurgical participant. Correlation, t test (with Bonferroni adjustment: α=.05/2), analysis of variance, and intraclass correlation coefficient were used to establish validity and reliability evidence. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE MAPS scores. RESULTS MAPS scores were moderately correlated with the Knee Injury and Osteoarthritis Outcome Score (P<.05). There was a significant group difference at T = 0 for MAPS (t(9.9)=-3.60; P=.01). Analysis of variance results for the MAPS indicated a time and group interaction (F(1,12)=4.60, P=.05). Reliability of 3 days of MAPS scores ranged from 0.75 to 0.81 (postsurgical and control), and 2-month test-retest reliability in the control group was 0.94. CONCLUSIONS The results provide a foundation of convergent and known-group difference validity evidence along with reliability evidence for the use of MAPS as a functional outcome measure.

Epidemiology of National Collegiate Athletic Association men's and women's swimming and diving injuries from 2009/2010 to 2013/2014

Background Recent injury data for collegiate-level swimming and diving are limited. This study describes the epidemiology of mens and womens swimming and diving injuries reported by the National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP) during the 2009/2010 to 2013/2014 academic years. Methods Injuries and athlete-exposure (AE) data reported within 9 mens and 13 womens swimming and diving programmes were analysed. Injury rates, injury rate ratios (IRR), and injury proportions by body site, diagnosis and mechanism were reported with 95% CIs. Results The ISP captured 149 and 208 injuries for mens and womens swimming and diving, respectively, leading to injury rates of 1.54/1000 and 1.71/1000 AEs. Among females, divers had a higher injury rate (2.49/1000 AEs) than swimmers (1.63/1000 AEs; IRR=1.53; 95% CI 1.07 to 2.19). Injury rates for male divers (1.94/1000 AEs) and swimmers (1.48/1000 AEs) did not differ (IRR=1.33; 95% CI 0.85 to 2.31). Most injuries occurred to the shoulder, resulted in strains and were classified as overuse or non-contact. Female swimmers had a higher overuse injury rate (1.04/1000 AEs) than male swimmers (0.66/1000 AEs; IRR=1.58; 95% CI 1.14 to 2.19). Overuse injury rates for female divers (0.54/1000 AEs) and male divers (0.46/1000 AEs) did not differ (IRR=1.16; 95% CI 0.40 to 3.34). Injury rates in 2012/2013–2013/2014 were lower than those in 2009/2010–2011/2012 for womens swimming (IRR=0.70; 95% CI 0.52 to 0.95) and diving (IRR=0.56; 95% CI 0.30 to 1.08), respectively. No time trends existed for mens swimmers or divers. Conclusions Shoulder, strain and overuse injuries were common in collegiate mens and womens swimming and diving. Female swimmers were more likely to suffer an overuse injury than male swimmers. In addition, divers may have higher injury rates than swimmers, although small reported numbers warrant additional research.