Epidemiology of Sports Injuries Among High School Athletes in the United States: Data From 2015 to 2019

Background

Nearly 8 million high school students in the United States participate in sports each year. With the lack of recent population data, an update to previous studies on US high school athletes is needed.

Purpose

To update the epidemiology of sports injuries in high school athletes in the United States.

Study Design

Descriptive epidemiology study.

Methods

The data from the National Health School Sports-Related Injury Surveillance Study, including 100 nationally representative high schools, were obtained for 9 high school sports (boys' football, soccer, basketball, wrestling, and baseball and girls' soccer, basketball, volleyball, and softball) between the 2015 and 2019 academic years. Injury rates were calculated as the ratio of injuries per 1000 athlete exposures (AEs), defined as 1 athlete participating in 1 practice or competition. Data on injured body area, injury type (sprains/strains, concussions, contusions, and fractures), time loss, and need for surgery were also obtained. Rate ratios (RRs) with 95% CIs and P values were calculated.

Results

Athletic trainers reported 15,531 injuries during 6,778,209 AEs, with an overall rate of 2.29 injuries per 1000 AEs. Injury rates were highest in football (3.96), girls' soccer (2.65), and boys' wrestling (2.36). The overall injury rate was lower in girls' sports (1.86) compared with boys' sports (2.52) (RR, 0.74 [95% CI, 0.71-0.76]; P < .001) and was higher in competition compared with practice (RR, 3.39 [95% CI, 3.28-3.49]; P < .001). The most commonly injured body areas were the head/face (24.2%), ankle (17.6%), and knee (14.1%). Sprains/strains (36.8%) and concussions (21.6%) were the most common diagnoses. Overall, 39.2% and 34% of injuries resulted in a time loss of <1 week and 1 to 3 weeks, respectively. Surgery was required in 6.3% of injuries, with wrestling (9.6%), girls' basketball (7.6%), and boys' baseball (7.4%) being the sports with the highest proportion of injuries needing surgery.

Conclusion

Study findings demonstrated that boys' football, girls' soccer, and boys' wrestling had the highest injury rates, with boys' sports overall having higher injury rates than girls' sports. Sprains/strains and concussions were the most common diagnoses. Few injuries required surgery.

Concussion Symptomology By Symptom Resolution Time in US High School Athletes: Findings From The National Athletic Treatment, Injury and Outcomes Network (NATION) High School Surveillance Program

CONTEXT

Concussions incurred during high school athletics are a significant health concern, and studies examining concussions with symptom resolution time (SRT) of 15-28 days have been limited.

OBJECTIVE

To compare concussions that had a SRT of 15-28 days with concussions that had a SRT of >28 days among US High School athletes.

DESIGN

Descriptive epidemiology study.

SETTING

Secondary school athletic training clinics.

PATIENTS OR OTHER PARTICIPANTS

Secondary school athletes.

MAIN OUTCOME MEASURE(S)

Concussion frequency, symptom number, and symptom prevalence.

RESULTS

Among all 917 reported concussions (of which 50.8% had missing SRT), 88 had SRT recorded as 15-28 days and 29 had SRT recorded as >28 days. Greater frequencies of concussions with SRT >15 days were reported among boys' sports (n= 78) than girls' sports (n= 39). Boys' football (51.7%) and girls' basketball (11.5%) accounted for the largest proportions of all reported concussions with SRT of 15-28 days; boys' football (58.6%) accounted for the greatest proportion of concussions reported with SRT >28 days. The average number of symptoms in concussions with SRT of 15-28 days was 6.3±3.4 and 7.2±3.8 in those with SRT >28 days. The most frequently reported symptoms in concussions with both SRT of 15-28 days and >28 days were headache, dizziness, sensitivity to light, and difficulty concentrating. The prevalence of irritability was higher in concussions with SRT of 15-28 days as compared to concussions with SRT >28 days (26.1% vs. 13.8%); visual problems (48.3% vs. 35.2%) and hyperexcitability (24.1% vs. 15.9%) were more prevalent in concussion with SRT >28 days, although differences were not statistically significant.

CONCLUSIONS

Symptom prevalence and total count were comparable between concussions with SRT of 15-28 days and >28 days with no statistically significant difference, suggesting symptom burden within these groups are more similar than they are different.

Visuo-vestibular and cognitive connections of the vestibular neuromatrix are conserved across age and injury populations

BACKGROUND AND PURPOSE

Given the prevalence of vestibular dysfunction in pediatric concussion, there is a need to better understand pathophysiological disruptions within vestibular and associated cognitive, affective, and sensory-integrative networks. Although current research leverages established intrinsic connectivity networks, these are nonspecific for vestibular function, suggesting that a pathologically guided approach is warranted. The purpose of this study was to evaluate the generalizability of the previously identified "vestibular neuromatrix" in adults with and without postconcussive vestibular dysfunction to young athletes aged 14-17.

METHODS

This retrospective study leveraged resting-state functional MRI data from two sites. Site A included adults with diagnosed postconcussive vestibular impairment and healthy adult controls and Site B consisted of young athletes with preseason, postconcussion, and postseason time points (prospective longitudinal data). Adjacency matrices were generated from preprocessed resting-state data from each sample and assessed for overlap and network structure in MATLAB.

RESULTS

Analyses indicated the presence of a conserved "core" network of vestibular regions as well as areas subserving visual, spatial, and attentional processing. Other vestibular connections were also conserved across samples but were not linked to the "core" subnetwork by regions of interest included in this study.

CONCLUSIONS

Our results suggest that connections between central vestibular, visuospatial, and known intrinsic connectivity networks are conserved across adult and pediatric participants with and without concussion, evincing the significance of this expanded, vestibular-associated network. Our findings thus support this network as a workable model for investigation in future studies of dysfunction in young athlete populations.

Prevalence of stress amongst high school athletes (v2)

Objective

This study sought to 1) ascertain the severity of the stress experienced by high school athletes due to playing a sport, 2) understand how these athletes deal with their stress, and if these athletes desire help from someone and 3) determine whether athletes consider their stress a debilitating factor.

Methods

200 high school athletes between the ages of 16 and 17 were surveyed using an anonymous online survey platform to discover the relationship between stress and sports. The survey examined both male and female athletes from a variety of sports, different locations, and different ethnicities.

Results

Approximately 91% of all the cohort experienced some level of stress due to sports. Interestingly, about a third claimed stress positively affected performance. Fear of failure and self-pressure were the most common causes of stress. About 27% who were experiencing moderate to extreme stress wanted, but did not receive, help from a medical professional. However, of all the participants who experienced some level of stress, only 18% believed that receiving help from a medical professional would not be beneficial for them.

Conclusion

While it is easy to overlook and minimize the stress of a high school athlete, doing so may cause future problems such as anxiety and depression, both of which have been steadily increasing among that same population. It is important that, if needed, these athletes have access to medical professionals to adequately manage their stress.

Secondary School Athletic Trainers' Strategies and Barriers to Overuse Injury Treatment in Adolescent Athletes

CONTEXT

Studies have illustrated that overuse injuries occur in adolescent athletes more often than previously reported. The general purpose of this study was to provide a thorough report of secondary school athletic trainers encounters, practices, and perceptions of overuse injury in adolescent athletes.

DESIGN

Cross-sectional.

METHODS

An anonymous online questionnaire was distributed via email to athletic trainers in the secondary school setting. The questionnaire was sent to participants during the summer of 2021 and 430 participants (highest educational degree earned: master's degree = 66%) completed the survey. Various survey methods were used to evaluate athletic trainers (1) demographics, (2) estimations about what percentage of injuries evaluated and treated were classified as overuse, (3) methods for treating overuse injuries, (4) confidence in treating overuse injuries and the complete implementation of their treatment plan, (5) perceptions of various barriers to treating overuse injuries, and (6) perception as to why patients did not want to reduce activity to treat their overuse injuries.

RESULTS

Participants reported that about half of all evaluations and treatments in a year were overuse injuries and they were "fairly" or "completely" confident (90%) in their ability to treat these injuries. The most common treatments cited were stretching (91%) and reducing activity (90%). Only 61% of participants were "fairly" or "completely" confident in the complete implementation of their treatment plan. Participants believed that patients' reluctance to reduce sport activities (82% "moderate" or "extreme" barrier) was the most significant barrier to treatment. Participants cited athletes' avoidance of missing games as the most common reason athletes were reluctant to reduce sporting activity.

CONCLUSIONS

Participants felt confident in treating overuse injuries yet faced significant barriers in treating these injuries. Clinicians should be prepared to have conversations about the importance of reducing sporting activity to allow proper healing for overuse injuries in adolescent athletes.

The Initiation and Developmental Course of Prescription Drug Misuse Among High School Athletes During the Transition Through Young Adulthood

The objective of this study was to examine the extent to which involvement in high-contact, semicontact, or noncontact sports during the 12th grade is associated with the initiation and developmental course of prescription drug misuse (PDM) between ages 17/18 years and 27/28 years. Data were collected from a national multicohort panel sample of US 12th-graders (cohorts 2006-2017; n = 4,772) from the Monitoring the Future Study who were followed for a decade, through age 27/28 years. Approximately 31% of high school seniors indicated PDM at baseline (age 17/18 years). While past-year PDM remained relatively stable between ages 17/18 years and 27/28 years, participation in both noncontact (adjusted odds ratio = 1.40, 95% confidence interval: 1.02, 1.91) and contact (adjusted odds ratio = 1.57, 95% confidence interval: 1.08, 2.28) sports in the 12th grade increased the odds of initiating prescription stimulant misuse during the 10 years following high school as compared with respondents who did not participate in these types of sports in the 12th grade. To our knowledge, this is the first national study to have assessed how sports participation during high school is associated with the initiation and developmental course of PDM from adolescence to young adulthood. These findings reinforce the need for PDM screening during adolescence, as nearly 1 in 3 high school seniors engage in PDM. Increased prescription stimulant misuse following high school warrants ongoing monitoring during young adulthood, especially among athletes.

The Effect of COVID-19 Lockdown on PHQ Depression Screening Scores for High School Athletes

Adolescent behavioral health was in crisis before COVID-19. The shutdown and reopening of in-person learning and extracurricular activities may have worsened this crisis. We examined high school athletes’ depression before and during the pandemic. Data were collected as part of a pilot program incorporating Patient Health Questionnaire (PHQ) screenings during high school sports physicals before the COVID-19 lockdown and three timepoints after. Statistical comparisons were made using logistic regression. A total of 927 individual scores were analyzed: 385 from spring 2020; 145 from fall 2020; 163 from fall 2021; and 234 from spring 2022. Fall 2020 students were 3.7 times more likely to have elevated PHQ-2 scores than spring 2020 students (95% CI = 1.8, 7.6). Fall 2021 and spring 2022 scores did not differ significantly from pre-pandemic, although trends of elevated scores persisted (OR = 1.6; 95% CI = 0.7, 3.5, and OR = 1.2; 95% CI = 0.6, 2.4, respectively). A significant difference in PHQ-9 depression severity classification was detected over time (p < 0.01). Elevated PHQ scores were found after the onset of the COVID-19 pandemic. After the initial peak in fall 2020, scores decreased but did not reach pre-pandemic levels.

Association Between Design Elements of Concussion Laws and Reporting of Sports-Related Concussions Among US High School Athletes, 2009-2017

OBJECTIVES

Studies that evaluate the effectiveness of concussion laws often use only a single variable (ie, presence of the law), failing to account for law complexity. We examined the association between multiple design elements of state concussion laws and rates of sports-related concussion reporting among US high school athletes.

METHODS

We derived 3 design elements of concussion laws from the 2009-2017 LawAtlas database: (1) strength of law, (2) number of law revisions, and (3) speed of law adoption. We examined the association between these design elements and rates of new and recurrent sports-related concussion reporting from the 2009-2010 through 2016-2017 academic years in a nationally representative sample of high school athletes participating in High School Report Information Online, an online data collection tool.

RESULTS

A total of 7064 sports-related concussions (6332 [89.6%] new and 732 [10.4%] recurrent concussions) were reported during the study period, with an overall rate of 39.7 sports-related concussions per 100 000 athletic exposures (eg, game or practice). Rates of new concussion reporting were higher among high schools in states with medium- or high-strength concussion laws than in states with low-strength concussion laws and in states with at least 1 concussion law revision than in states with no concussion law revisions. Rates of recurrent concussion reporting were lower among high schools in states with ≥2 concussion law revisions than in states with <2 concussion law revisions. Early law adoption was associated with higher rates of new and recurrent concussion reporting, and late law adoption was associated with lower rates of new and recurrent concussion reporting.

CONCLUSION

Our findings may help inform legislators of the public health effect of concussion laws.

Prevalence of exercise-induced bronchoconstriction and laryngeal obstruction in adolescent athletes

OBJECTIVES

To study the prevalence of exercise-induced bronchoconstriction (EIB) and exercise-induced laryngeal obstruction (EILO) in adolescent athletes.

METHODS

All adolescents (n = 549) attending first year at a sports high school in 2016 and 2017, were invited to answer a questionnaire on respiratory symptoms. The 367 responding participants were divided into two groups based on whether they reported exercise-induced dyspnea (dyspnea group) or not (nondyspnea group). Randomly selected participants in each group were invited to undergo two standardized exercise tests, an EIB test and a continuous laryngoscopy exercise (CLE) test, to investigate EILO.

RESULTS

In total, 98 participants completed an EIB test, 75 of whom also completed a CLE test. Positive EIB tests: eight of 41 in the dyspnea group and 16 of 57 in the nondyspnea group. Positive CLE tests: 5 of 34 in the dyspnea group and three of 41 in the nondyspnea group. The estimated prevalence of EIB was 23.1% (95% confidence interval [CI]: 14.5-33.8) and of EILO 8.1% (95% CI: 2.5-18.5) in the whole study population. No differences in prevalence of EIB or EILO were found between the dyspnea and the nondyspnea groups.

CONCLUSION

EIB was highly prevalent in this cohort of adolescent athletes. EILO was less prevalent, but represents an important differential diagnosis to EIB. Self-reported exercise-induced dyspnea is a weak indicator for both EIB and EILO and standardized testing should be provided.

Concussion Knowledge, Attitudes, and Self-Reporting Intentions in Youth Athletes

CONTEXT

Although it has been suggested that developmental and sociological factors play a role in concussion reporting, the empirical evidence related to this is limited.

OBJECTIVE

To examine the influences of sex, school level, school location, concussion-reporting history, and socioeconomic status on concussion-related knowledge, attitudes, and reporting intentions among middle school and high school athletes.

DESIGN

Cross-sectional study.

SETTING

Master students and High School athletes attending pre-participation examinations (PPEs) were asked to complete paper-based surveys.

PATIENTS OR OTHER PARTICIPANTS

Overall, 541 athletes representing 18 sports returned fully completed surveys.

MAIN OUTCOME MEASURE(S)

Outcomes were concussion-related knowledge, perceived seriousness, positive feelings about reporting, and self-reporting intentions. We examined group differences in these outcomes across levels of the explanatory variables of sex, school level (middle school versus high school), school location (urban versus rural), concussion self-reporting history (yes or no), and socioeconomic status (free or reduced-price lunch versus no free or reduced-price lunch) using Wilcoxon rank sum tests. Then we used multivariable ordinal logistic regression models to identify predictors of higher score levels for each outcome. Odds ratio (OR) estimates with 95% confidence intervals (CIs) excluding 1.00 were deemed significant.

RESULTS

Odds of higher levels of knowledge were higher in urban versus rural school student-athletes (ORAdjusted = 1.81; 95% CI = 1.03, 3.17), and lower in student-athletes on free or reduced-price lunch versus those not on free or reduced-price lunch (ORAdjusted = 0.52; 95% CI = 0.36, 0.77). Similarly, odds of higher levels of seriousness were lower in male versus female student-athletes (ORAdjusted = 0.48; 95% CI = 0.32, 0.72). Further, odds of higher levels of self-reporting intentions were lower among male versus female student-athletes (ORAdjusted = 0.53; 95% CI = 0.37, 0.75).

CONCLUSIONS

Developmental and sociological factors were differentially associated with concussion-related knowledge, attitudes, and self-reporting intentions. These results can inform medical providers, parents, and coaches with regard to context-specific clinical assessments of concussion symptoms.

Compliance With the National Athletic Trainers' Association Inter-Association Task Force Preseason Heat-Acclimatization Guidelines in High School Football

CONTEXT

In 2009, the National Athletic Trainers' Association Inter-Association Task Force (NATA-IATF) released preseason heat-acclimatization guidelines for gradually acclimatizing high school (HS) athletes to the environment during the first 2 weeks of the preseason and reducing the risk of exertional heat illness. However, researchers who studied the 2011 preseason found a low level of overall compliance.

OBJECTIVE

To assess compliance with the NATA-IATF guidelines during the 2017 preseason and compare the findings with 2011 preseason data and between states mandating and not mandating the guidelines.

DESIGN

Cross-sectional study.

SETTING

Preseason HS football, 2017.

PATIENTS OR OTHER PARTICIPANTS

A total of 1023 athletic trainers working with HS football (14.2% response rate).

MAIN OUTCOME MEASURE(S)

Using a survey, we acquired information from athletic trainers on their HS football programs, including location and compliance with 17 NATA-IATF guidelines during the 2017 football preseason. The outcome measures were full compliance with all 17 NATA-IATF guidelines and compliance with ≥10 NATA-IATF guidelines. Prevalence ratios (PRs) with 95% confidence intervals (CIs) compared findings between (1) the 2017 and 2011 preseasons and (2) states whose HS athletic associations imposed a full or partial or no mandate to follow the NATA-IATF guidelines.

RESULTS

Overall, 3.9% reported full compliance with NATA-IATF guidelines; 73.9% complied with ≥10 guidelines. The proportion reporting full compliance was higher in 2017 than in 2011 but not statistically different (3.9% versus 2.5%; PR = 1.54; 95% CI = 0.96, 2.46). However, the proportion reporting compliance with ≥10 guidelines was higher in 2017 (73.9% versus 57.9%; PR = 1.28; 95% CI = 1.20, 1.36). The proportion of respondents reporting their HSs were fully compliant was highest among the with-mandate group (9.4%), followed by the partial-mandate group (4.6%) and the without-mandate group (0.6%). Group differences retained significance when we examined compliance with ≥10 guidelines.

CONCLUSIONS

Although full compliance with NATA-IATF guidelines remained low, many HS football programs complied with ≥10 guidelines.

Healthcare professional involvement and RTP compliance in high school athletes with concussion

OBJECTIVES

To describe concussion rates in high school athletes and involvement of healthcare professionals in concussion diagnosis, management and compliance with return to play (RTP) guidelines.

METHODS

Data were analysed from injury reports in the National High School Sports-Related Injury Surveillance System between 2009/2010 and 2012/2013 to identify student athletes with concussion and determine compliance with RTP guidelines. Compliance with RTP guidelines was examined using logistic regression, adjusting for sport and injury-related variables.

RESULTS

There were 5611 concussions recorded during 15 712 475 athlete exposures (AEs), a rate of 3.6 concussions per 10 000 AEs. Rates were higher during competition and among girls compared to boys in gender equitable sports. Healthcare professionals were less likely to be present at the time of concussion for girls' sports, lower competition levels and practices. Compliance with RTP guidelines was higher for athletes with recurrent concussions, those sustained in collision sports, for athletes reporting more symptoms and when a physician made the RTP decision.

CONCLUSIONS

Presence of healthcare professionals and compliance with RTP guidelines varied by sport, gender, level of play and exposure type. High school athletes with concussion are best served by assessment teams with athletic trainers and physicians working together to manage concussions and contribute to RTP decisions.

A School-Based Neuromuscular Training Program and Sport-Related Injury Incidence: A Prospective Randomized Controlled Clinical Trial

CONTEXT

  An estimated 40 million school-aged children (age range = 5-18 years) participate annually in sports in the United States, generating approximately 4 million sport-related injuries and requiring 2.6 million emergency department visits at a cost of nearly $2 billion.

OBJECTIVE

  To determine the effects of a school-based neuromuscular training (NMT) program on sport-related injury incidence across 3 sports at the high school and middle school levels, focusing particularly on knee and ankle injuries.

DESIGN

  Randomized controlled clinical trial.

SETTING

  A total of 5 middle schools and 4 high schools in a single-county public school district.

PATIENTS OR OTHER PARTICIPANTS

  A total of 474 girls (222 middle school, 252 high school; age = 14.0 ± 1.7 years, height = 161.0 ± 8.1 cm, mass = 55.4 ± 12.2 kg) were cluster randomized to an NMT (CORE; n = 259 athletes) or sham (SHAM; n = 215 athletes) intervention group by team within each sport (basketball, soccer, and volleyball).

INTERVENTION(S)

  The CORE intervention consisted of exercises focused on the trunk and lower extremity, whereas the SHAM protocol consisted of resisted running using elastic bands. Each intervention was implemented at the start of the season and continued until the last competition. An athletic trainer evaluated athletes weekly for sport-related injuries. The coach recorded each athlete-exposure (AE), which was defined as 1 athlete participating in 1 coach-directed session (game or practice).

MAIN OUTCOME MEASURE(S)

  Injury rates were calculated overall, by sport, and by competition level. We also calculated rates of specific knee and ankle injuries. A mixed-model approach was used to account for multiple injuries per athlete.

RESULTS

  Overall, the CORE group reported 107 injuries (rate = 5.34 injuries/1000 AEs), and the SHAM group reported 134 injuries (rate = 8.54 injuries/1000 AEs; F_1,578 = 18.65, P < .001). Basketball (rate = 4.99 injuries/1000 AEs) and volleyball (rate = 5.74 injuries/1000 AEs) athletes in the CORE group demonstrated lower injury incidences than basketball (rate = 7.72 injuries/1000 AEs) and volleyball (rate = 11.63 injuries/1000 AEs; F_1,275 = 9.46, P = .002 and F_1,149 = 11.36, P = .001, respectively) athletes in the SHAM group. The CORE intervention appeared to have a greater protective effect on knee injuries at the middle school level (knee-injury incidence rate = 4.16 injuries/1000 AEs) than the SHAM intervention (knee-injury incidence rate = 7.04 injuries/1000 AEs; F_1,261 = 5.36, P = .02). We did not observe differences between groups for ankle injuries ( F_1,578 = 1.02, P = .31).

CONCLUSIONS

  Participation in an NMT intervention program resulted in a reduced injury incidence relative to participation in a SHAM intervention. This protective benefit of NMT was demonstrated at both the high school and middle school levels.

Competition-Level Differences on the Lower Quarter Y-Balance Test in Baseball Players

CONTEXT

Decreased performance in dynamic balance has previously been associated with a history of ulnar collateral ligament injury in baseball players. Previous research on dynamic balance in soccer players has shown that test performance depends on competition level. However, dynamic balance has yet to be examined in baseball players.

OBJECTIVE

To understand normative values and determine differences in dynamic balance, as measured by the Lower Quarter Y-Balance Test, across competition levels in baseball players.

DESIGN

Cross-sectional study.

SETTING

Preseason physical examinations.

PATIENTS OR OTHER PARTICIPANTS

Dynamic balance was measured in 88 high school (HS), 78 collegiate (COL), and 90 professional (PRO) baseball players.

MAIN OUTCOME MEASURE(S)

All participants completed the Lower Quarter Y-Balance Test using the standard protocol. In unilateral stance, they reached with 1 foot in the anterior, posteromedial, and posterolateral directions. We calculated 1-way analyses of variance to compare performance, composite score, and reach asymmetry for each direction as well as the sum of the asymmetry values (P < .05). Composite score was calculated by averaging the maximum normalized reach scores. Reach asymmetry was determined by calculating bilateral differences in reach ability.

RESULTS

In comparison with the HS and COL groups, the PRO players exhibited greater posteromedial (P < .01; effect size index [ESI]_HS = 1.06, ESI_COL = 0.95) and posterolateral reach (P < .01; ESI_HS = 0.82, ESI_COL = 0.84) as well as a greater composite score (P < .01; ESI_HS = 0.60, ESI_COL = 0.87). In contrast, HS baseball players exhibited increased anterior reach (P < .01; ESI_COL = 0.60, ESI_PRO = 0.39) compared with the COL and PRO cohorts. No significant differences in reach asymmetry were observed among groups.

CONCLUSIONS

Lower extremity dynamic balance performance differed based on the baseball players' competition level. These baseline data may be helpful in identifying low-performing athletes who might benefit from neuromuscular interventions.

A Comparison of Women's Collegiate and Girls' High School Volleyball Injury Data Collected Prospectively Over a 4-Year Period

BACKGROUND

There is a relative paucity of research examining the sport-specific injury epidemiology of high school and collegiate volleyball athletes. Moreover, differences in study methodology frequently limit our ability to compare and contrast injury data collected from selected populations.

HYPOTHESIS

There are differences between the injury patterns characteristic of high school and collegiate female volleyball athletes.

STUDY DESIGN

Retrospective clinical review.

LEVEL OF EVIDENCE

Level 3.

METHODS

We statistically analyzed injury incidence and outcome data collected over a 4-year interval (2005-2006 to 2008-2009) by 2 similar injury surveillance systems, the National Collegiate Athletic Association's Injury Surveillance System (NCAA ISS) and the High School Reporting Injuries Online (HS RIO). We compared diagnoses, anatomic distribution of injuries, mechanisms of injury, and time lost from training or competition between high school and collegiate volleyball athletes.

RESULTS

The overall volleyball-related injury rate was significantly greater among collegiate athletes than among high school athletes during both competition (injury rate ratio, 2.9; 95% CI, 2.5-3.4) and practice (injury rate ratio, 3.5; 95% CI, 3.1-3.9). Collegiate athletes had a higher rate of ankle sprain, knee injury, and shoulder injury. Concussions represented a relatively high percentage of injuries in both populations (5.0% of total NCAA ISS injuries vs 4.8% of total HS RIO injuries, respectively).

CONCLUSION

The data suggest that although similar, there were distinct differences between the injury patterns of the 2 populations. Compared with high school volleyball players, collegiate athletes have a higher rate of acute time loss injury as well as overuse time loss injury (particularly patellar tendinosis). Concussions represented a significant and worrisome component of the injury pattern for both study populations.

CLINICAL RELEVANCE

The injury data suggest that important differences exist in the injury patterns of female high school compared with collegiate volleyball athletes. Consideration of the specific injury patterns may be helpful in future prevention efforts.

Ice hockey injuries among United States high school athletes from 2008/2009-2012/2013

BACKGROUND

The popularity of ice hockey has grown in recent years and injuries are a concern given the physical nature of the sport. We sought to report the rates, mechanisms, and severity of boys' US high school ice hockey injuries. We hypothesized that body checking would be a major source of injury and that concussions would be common. We also expected to find that competition would have a higher rate of injury than practice.

DESIGN

Descriptive epidemiology study.

METHODS

Boys' US high school ice hockey injury data from 2008/2009 through 2012/2013 academic years were obtained from the National High School Sports-Related Injury Surveillance System, High School Reporting Information Online database. The primary outcome was rate of injury per 10,000 athlete exposures (AEs).

RESULTS

Overall, 724 boys ice hockey injuries occurred during 311,817 AEs for an injury rate of 23.2 per 10,000 AEs. Injury rates were significantly higher during competition compared to practice (rate ratio = 7.8, 95% confidence interval: 6.5-9.4). Concussion was the most frequent injury reported at a rate of 6.4 per 10,000 AEs. Body checking was the mechanism of injury in over 46% of injuries. The head/face/neck region (33.8%) and upper arm/shoulder region (20.6%) were the most commonly injured body sites. Just over 6% of injuries resulted in surgical intervention.

CONCLUSION

Injuries among high school ice hockey athletes are common. Increases in the number of high school ice hockey injuries will likely parallel the increase in high school ice hockey participation in the United States.

Effects of Two Concussions on the Neuropsychological Functioning and Symptom Reporting of High School Athletes

To assess the effects of two sports-related concussions on neuropsychological functioning and symptom reporting, the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) was administered to 483 high school athletes. Three groups of athletes were determined based on the number of previous concussions: no concussion (n = 409), 1 concussion (n = 58), and 2 concussions (n = 16). The results showed that the three groups did not differ in terms of their ImPACT composite scores (Verbal Memory, Visual Memory, Reaction Time, and Processing Speed) and the Total Symptom Score. As there are only a few studies that have reported the sequelae of 2 concussions in high school athletes, it is premature to declare that a repeated concussion does not have persistent neurocognitive effects on high school athletes.

High School Athletes' Perceptions of Concussion

BACKGROUND

The perception high school athletes have regarding concussions may influence their injury-reporting behavior, and if their perceptions are based on incorrect or incomplete information, they may be at risk for subsequent head injuries.

PURPOSE

To determine whether the recent influx of concussion information has had a positive impact on high school athletes' knowledge of concussions, to determine their perceptions regarding the severity of a concussion injury, and to determine whether receiving correct information will potentially alter their future reporting behavior.

STUDY DESIGN

Cross-sectional study; Level of evidence, 4.

METHODS

A total of 454 high school athletes (212 females, 242 males; mean age, 15.7 ± 1.15 years) from 6 different schools participated in an anonymous survey. The researchers met with teams individually at their high schools to collect data and provide an educational intervention regarding sports-related concussions. The survey questions assessed the athletes' personal injury histories and perceptions and knowledge of the severity of concussion injuries.

RESULTS

There was a difference in the number of athletes who reported having their "bell rung" (n = 297) versus the number of athletes reporting at least 1 concussion (n = 172) (t (453) = -11.60, P = .000, d = -0.54). There was also a difference in the number of athletes who reported a history of at least 1 concussion at the beginning of the study session (n = 172) versus the number of athletes who reported at least 1 concussion at the end of the session (n = 292) (t (453) = -12.018, P = .000, d = 0.732). Fifty percent of athletes also stated that the importance of a game/event should dictate when they return to play.

CONCLUSION

High school athletes continue to fail to realize when they have sustained a concussion. Additionally, athletes lack understanding regarding the severity and seriousness of a concussion. A better effort at formalized education must be made if the culture of sports is to change.

CLINICAL RELEVANCE

Allied health care professionals need to continue to put forth a great effort in educating all student athletes on what a concussion is and the dangers of a concussion injury. Preseason meetings should be used as an opportunity to provide formalized education to all student athletes.

Neuropsychological test performance of Hawai'i high school athletes: updated Hawai'i immediate post-concussion assessment and cognitive testing data

The present study reviewed the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) baseline test scores of 247 high school athletes ages 13 to 18 from a private school in Hawai'i. The aim of the research was to update a prior exploratory investigation conducted in 2008 that compared the test scores of Hawai'i public high school athletes with the normative data provided by the ImPACT publishers. The results of this study provide assurance that the present ImPACT scores of the Hawai'i high school athletes are similar to the general ImPACT norms. The present study is a rare effort to compare the ImPACT scores of high school athletes from an ethnically diverse region with the ImPACT norms. The findings offer further support for the use of the ImPACT norms when evaluating high school athletes from Hawai'i. Future research in various regions of the United States and with other sociocultural backgrounds is encouraged.

Shoulder injuries among US high school athletes, 2005/2006-2011/2012

OBJECTIVES

The objective of this study was to describe shoulder injuries in a nationally representative sample of high school athletes playing 9 sports. A national estimate of shoulder injuries among high school athletes was subsequently calculated.

METHODS

Injury data were collected in 9 sports (boys' football, soccer, basketball, wrestling, and baseball; girls' soccer, volleyball, basketball, and softball) during the 2005-2006 through 2011-2012 academic years from a nationally representative sample of high schools via High School Reporting Information Online.

RESULTS

During the 2005-2006 through 2011-2012 academic years, high school athletes in this study sustained 2798 shoulder injuries during 13,002,321 athlete exposures, for an injury rate of 2.15 per 10,000 athlete exposures. This corresponds to a nationally estimated 820,691 injuries during this time period. Rates of injury were higher in competition as compared with practice (rate ratio = 3.17 [95% confidence interval: 2.94-3.41]). The highest rate of injury was in football (4.86) and the lowest in girls' soccer (0.42). The most common types of injury were strain/sprain (37.9%) and dislocation/separation (29.2%). Boys were more likely than girls to sustain their injuries after contact with another person or with the playing surface. Surgical repair was required for 7.9% of the injuries. Time loss from athletic participation varied among sports, with 40.7% of athletes returning within 1 week, whereas 8.2% were medically disqualified for their season/career.

CONCLUSIONS

High school shoulder injury rates and patterns varied by sport and gender. Prospective epidemiologic surveillance is warranted to discern trends and patterns to develop evidence-based interventions to prevent shoulder injuries.

Exertional heat stroke management strategies in United States high school football

BACKGROUND

The 5-year period of 2005-2009 saw more exertional heat stroke-related deaths in organized sports than any other 5-year period in the past 35 years. The risk of exertional heat stroke appears highest in football, particularly during the preseason.

PURPOSE

To estimate the incidence of exertional heat stroke events and assess the utilization of exertional heat stroke management strategies during the 2011 preseason in United States high school football programs.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A self-administered online questionnaire addressing the incidence of exertional heat stroke events and utilization of exertional heat stroke management strategies (eg, removing athlete's football equipment, calling Emergency Medical Services [EMS]) was completed in May to June 2012 by 1142 (18.0%) athletic trainers providing care to high school football athletes during the 2011 preseason.

RESULTS

Among all respondents, 20.3% reported treating at least 1 exertional heat stroke event. An average of 0.50 ± 1.37 preseason exertional heat stroke events were treated per program. Athletic trainers responding to exertional heat stroke reported using an average of 6.6 ± 1.8 management strategies. The most common management strategies were low-level therapeutic interventions such as removing the athlete's football equipment (98.2%) and clothing (77.8%) and moving the athlete to a shaded area (91.6%). Few athletic trainers reported active management strategies such as calling EMS (29.3%) or using a rectal thermometer to check core body temperature (0.9%). Athletic trainers in states with mandated preseason heat acclimatization guidelines reported a higher utilization of management strategies such as cooling the athlete through air conditioning (90.1% vs 65.0%, respectively; P < .001), immersion in ice water (63.0% vs 45.4%, respectively; P = .01), or fans (54.3% vs 42.0%, respectively; P = .06) and monitoring the athlete's temperature (60.5% vs 46.2%, respectively; P = .04).

CONCLUSION

Preseason exertional heat stroke events, which are likely to be fatal if untreated, were reported by one fifth of all athletic trainers in high school football programs. The standard of care is (and should be) to treat proactively; therefore, treatment is not a perfect proxy for incidence. Nevertheless, there is an urgent need for improved education and awareness of exertional heat stroke in high school football. Areas of improvement include the greatly increased use of rectal thermometers and immersion in ice water.

Epidemiology of cheerleading stunt-related injuries in the United States

CONTEXT

Cheerleading-related injuries are on the rise. To date, no epidemiologic studies of cheerleading stunt-related injuries have been published.

OBJECTIVE

To describe and compare cheerleading stunt-related injuries by type of cheerleading team (All Star, college, high school, middle school, or recreation league) and event (practice, pep rally, athletic event, or cheerleading competition).

DESIGN

Prospective injury surveillance study.

SETTING

Participant exposure and injury data were collected from US cheerleading teams via the Cheerleading RIO (Reporting Information Online) surveillance tool.

PATIENTS OR OTHER PARTICIPANTS

Athletes from enrolled cheerleading teams who participated in official, organized cheerleading practices, pep rallies, athletic events, or cheerleading competitions.

MAIN OUTCOME MEASURE(S)

The numbers, types, and rates of cheerleading stunt-related injuries during a 1-year period (2006-2007) are reported.

RESULTS

Stunt-related injuries accounted for 60% (338/567) of the injuries sustained by US cheerleaders who participated in the study and 96% (22/23) of the concussions and closed head injuries (CHIs) reported during the study. Collegiate cheerleaders were more likely to sustain a concussion or CHI than were cheerleaders on other types of teams (P = .02, odds ratio = 3.10, 95% confidence interval = 1.20, 8.06). Most injuries occurred while the cheerleader was spotting or basing another cheerleader (34%, 115/338), and these injuries comprised 32% (51/161) of all stunt-related strains and sprains. Four cheerleaders (1.2%, 4/335) were admitted to the hospital, and 9 cheerleaders (2.7%, 9/335) required surgery.

CONCLUSIONS

Cheerleading stunts pose an increased risk for injury, especially in terms of sustaining a concussion or CHI. Spotters and bases were most likely to be injured during the performance of cheerleading stunts and were at risk for sustaining strain and sprain injuries. The ankle, lower back, and wrist were the sites most likely to be reinjured while performing cheerleading stunts.

Epidemiology of cheerleading fall-related injuries in the United States

CONTEXT

Over the past several decades, cheerleaders have been performing fewer basic maneuvers and more gymnastic tumbling runs and stunts. As the difficulty of these maneuvers has increased, cheerleading injuries have also increased.

OBJECTIVE

To describe the epidemiology of cheerleading fall-related injuries by type of cheerleading team and event.

DESIGN

Prospective injury surveillance study.

SETTING

Participant exposure and injury data were collected from US cheerleading teams via the Cheerleading RIO (Reporting Information Online) surveillance tool.

PATIENTS OR OTHER PARTICIPANTS

Athletes from 412 enrolled cheerleading teams who participated in official, organized cheerleading practices, pep rallies, athletic events, or cheerleading competitions.

MAIN OUTCOME MEASURE(S)

The numbers and rates of cheerleading fall-related injuries during a 1-year period (2006-2007) are reported.

RESULTS

A total of 79 fall-related injuries were reported during the 1-year period. Most occurred during practice (85%, 67/79) and were sustained by high school cheerleaders (51%, 40/79). A stunt or pyramid was being attempted in 89% (70/79) of cases. Fall heights ranged from 1 to 11 ft (0.30-3.35 m) (mean = 4.7 + or - 2.0 ft [1.43 + or - 0.61 m]). Strains and sprains were the most common injuries (54%, 43/79), and 6% (5/79) of the injuries were concussions or closed head injuries. Of the 15 most serious injuries (concussions or closed head injuries, dislocations, fractures, and anterior cruciate ligament tears), 87% (13/15) were sustained while the cheerleader was performing on artificial turf, grass, a traditional foam floor, or a wood floor. The fall height ranged from 4 to 11 ft (1.22-1.52 m) for 87% of these cases (13/15).

CONCLUSIONS

Cheerleading-related falls may result in severe injuries and even death, although we report no deaths in the present study. The risk for serious injury increases as fall height increases or as the impact-absorbing capacity of the surfacing material decreases (or both).

Dental Injuries in Intermediate and High School Athletes: A 15-Year Study at Punahou School

OBJECTIVE: To determine the rate, type, and severity of dental injuries recorded for intermediate and high school interscholastic athletic participants. DESIGN AND SETTING: A longitudinal study (1988-2003) of intermediate and high school athletes utilizing the same certified athletic trainers to evaluate and record all injury data. SUBJECTS: Sports participation included 123 teams in 19 female, 18 male, and 2 coed sports. Of 2445 Punahou School intermediate and high school students, on average, 1340 students (623 females, 717 males) annually participated in interscholastic athletics. MEASUREMENTS: Dental injuries were defined as injuries to the jaw, teeth, and oral soft tissue (lip, mouth, cheek, and tongue). Soft tissue injuries requiring physician or dentist referral were recorded. Other soft tissue injuries were treated as skin abrasions and were not recorded. Actual days lost from activity were recorded. The estimated injury rate was determined (injuries/1000 athlete-sessions). Mouth-guard use was recorded. RESULTS: During the 15-year study, 19 492 injuries were reported, with 56 (0.2%) recorded as dental injuries (23 tooth, 20 jaw, and 13 soft tissue). Injury rates were highest for girls' wrestling (0.243, confidence interval = 0-2.3), boys' judo (0.189, confidence interval = 0-3.6), and boys' soccer (0.127, confidence interval = 0.4-1.4). The football injury rate was 0.029 (confidence interval = 0.04-0.29), with no tooth injuries. CONCLUSIONS: The incidence and injury rate of dental injuries was extremely low for all reported sports. A universal definition of dental injuries must be established to facilitate injury data collection and analysis.