Characteristics of Water Skiing–Related
and Wakeboarding-Related Injuries
Treated in Emergency Departments
in the United States, 2001-2003
Sarah Grim Hostetler,* Todd L. Hostetler,† MD, Gary A. Smith,* MD, DrPH,
‡
and Huiyun Xiang,* MD, MPH, PhD
From the *Center for Injury Research and Policy, Columbus Children’s Research Institute,
Children’s Hospital, The Ohio State University College of Medicine and Public Health,
†
Columbus, Ohio, and the Department of Internal Medicine/Pediatrics, Ohio State University
Medical Center and Children’s Hospital, Columbus, Ohio
Background: Water skiing and wakeboarding are popular sports with high potential for injury due to rapid boat acceleration,
lack of protective gear, and waterway obstacles. However, trends in water skiing– and wakeboarding-related injuries in the
United States have not been described using national data.
Hypothesis: The number of injuries, injury diagnoses, and body regions injured vary by sport.
Study Design: Descriptive epidemiology study.
Methods: Data regarding water skiing– and wakeboarding-related injuries presenting to 98 hospital emergency departments in
the United States between January 1, 2001, and December 31, 2003, were extracted from the National Electronic Injury
Surveillance System. Data included demographics, injury diagnosis, and body region injured.
Results: Data were collected for 517 individuals with water skiing–related injuries and 95 individuals with wakeboarding-related
injuries. These injuries represent an estimated 23 460 water skiing– and 4810 wakeboarding-related injuries treated in US emergency departments in 2001 to 2003. Head injuries represented the largest percentage of injuries for wakeboarders (28.8% of all
injuries) and the smallest percentage for water skiers (4.3%) (P < .01; relative risk [95% confidence interval], 6.73 [3.89-11.66]).
Analysis of injury diagnosis was consistent as wakeboarders had significantly more traumatic brain injuries (12.5% of all injuries)
than did water skiers (2.4%) (P < .05; relative risk [95% confidence interval], 5.27 [2.21-12.60]). Strains or sprains were the leading injury diagnoses for water skiing (36.3% of all injuries), and the majority (55.7%) were to the lower extremity. Lacerations
were the most common diagnoses for wakeboarders (31.1% of all injuries), and the majority (59.6%) were to the face.
Conclusion: The analyses of water skiing– and wakeboarding-related injuries treated in US emergency departments in 2001 to 2003
highlight the differences in injury patterns for these 2 sports. The substantial number of head and facial injuries among wakeboarders underscores the need for research on the potential role of helmets or other protective gear to reduce these common injuries.
Keywords: water skiing; wakeboarding; athletic injuries; National Electronic Injury Surveillance System (NEISS)
Water skiing is a sport of established popularity with an
estimated 8.4 million participants.30 Wakeboarding, a relatively new water sport combining water skiing and snow-
boarding, has experienced a 49% increase in participation
during the past 5 years to an estimated 3.4 million participants.30 The risk for injury is high in both sports, with
rapid acceleration up to 35 mph, lack of protective gear,
and waterway obstacles such as towlines, boat propellers,
and other skiers. To date, the majority of research has
focused on water skiing and has shown an association with
multiple injury types, including contusions, abrasions, lacerations, fractures, strains, sprains,§ ruptured tympanic
membranes,14,27 vaginal lacerations,9,14,15,18,19,24,28,36 enema
‡
Address correspondence to Huiyun Xiang, MD, MPH, PhD, Center for
Injury Research and Policy, Columbus Children’s Hospital, 700 Children’s
Drive, Columbus, OH 43205 (e-mail: [email protected]).
No potential conflict of interest declared.
The American Journal of Sports Medicine, Vol. 33, No. 7
DOI: 10.1177/0363546504271748
© 2005 American Orthopaedic Society for Sports Medicine
§
1065
References 1, 2, 6, 13, 17, 23, 26, 27, 32.
1066
Hostetler et al
injury,3,16 infections,14,25,27 cardiac trauma,12 and spinal
cord damage.11,23,32 These water skiing–related injuries
typically differ by level of experience, as novices are
injured most frequently while submerged during takeoff
with douche and enema injuries, while experts most commonly injure their knees, backs, or shoulders while
falling.5,14,29,35 Some of these common injuries can result in
significant rehabilitation time, a mean of 7 weeks in one
study29 and up to 4 months in another case report.2 Little
research has been done on wakeboarding-related injuries,
although one pioneering study showed that ACL tears and
shoulder dislocations are the most common wakeboardingrelated injuries treated by orthopaedic surgeons.4
To our knowledge, no study has evaluated water skiing–
or wakeboarding-related injuries using a nationally representative sample. Previous studies date back to 1962 and
consist of case reports, convenience samples with up to 89
patients, or surveys with response rates as low as 12%.||
The purpose of this article is to examine water skiing– and
wakeboarding-related injuries using a national US database to determine the age distribution of total injuries,
injury types, and body regions injured for each sport. We
hypothesized that the differences in the goals and equipment of water skiing and wakeboarding would yield very
different injury profiles for each sport. The new information from this study will inform participants, product manufacturers, and policy makers about the patterns of water
skiing– and wakeboarding-related injuries in the United
States and will assist in the development of effective prevention strategies.
The American Journal of Sports Medicine
Variables
Injury. Water skiing– and wakeboarding-related injuries
were identified using the consumer product code for water
skiing, which captures injuries associated with water skiing, wakeboarding, kneeboarding, tubing, and other water
sports. We defined a water skiing– or wakeboarding-related
injury as an injury event that occurred to an individual
while water skiing or wakeboarding, respectively. The narrative description of the incident in the NEISS database
was used to distinguish injuries associated with water skiing and wakeboarding from those related to other water
sports and to exclude cases in which water sport equipment was involved but the patient was not water skiing or
wakeboarding at the time of injury (eg, a water ski was
used as a fighting tool at home). We deleted 25 kneeboarding, tubing, and other water sport–related injury cases
because there were not enough cases to allow meaningful
comparisons. We also deleted 18 “water board” injury cases
because we could not differentiate if they were associated
with a kneeboard, wakeboard, or other water sport device.
Body Region. The body part injured provided by NEISS
was classified into broader body regions in our study to
allow for meaningful comparison. “Upper extremity”
includes the upper arm, elbow, lower arm, wrist, hand, and
finger. “Lower extremity” includes the upper leg, knee,
lower leg, ankle, foot, and toe. “Head” refers to the head
only. “Face” captures the face, ear, eyeball, mouth, and
neck. “Trunk” encompasses the shoulder, upper trunk, and
lower trunk. “Other” includes the NEISS categories not
specified, all parts of the body, and 25% to 50% of the body.
MATERIALS AND METHODS
Data Source
The National Electronic Injury Surveillance System (NEISS)
is operated by the US Consumer Product Safety Commission
(CPSC) to provide timely data on consumer product–related
and sports activity–related injuries treated in emergency
departments (EDs) in the United States and its territories.
The NEISS receives data from a network of 98 hospitals
representing a stratified probability sample of 6100 hospitals with at least 6 beds and a 24-hour ED.22 At all 98 hospitals, every ED medical record is reviewed by a professional NEISS coder, and data regarding patients treated
for injuries are entered into the NEISS database. The
database is updated daily and includes information
regarding the patient’s age, sex, race, injury diagnosis,
body part injured, product(s) involved, treatment received,
and a brief narrative describing the incident. Each year,
NEISS provides data on a projected 500 000 injury-related
ED visits and allows estimation of the number and epidemiology of such events for the entire nation. Data used
in this study were water skiing– and wakeboarding-related
injury cases treated in EDs of NEISS hospitals between
January 1, 2001, and December 31, 2003.
||
References 1-7, 9, 11-20, 23-29, 32, 35, 36.
Injury Diagnosis. Injury diagnoses presented in this
study are the injury diagnosis codes provided by NEISS
with the following exceptions. “Traumatic brain injury”
includes the NEISS injury diagnosis codes for concussions
and for internal organ injuries with the “head” as the body
part injured. “Fracture” represents both fractures and
avulsions. “Laceration” includes both lacerations and
punctures. “Contusion or abrasion” represents contusions,
abrasions, and hematomas.
Statistical Analysis
Data analyses were conducted using SAS software (version 8.02, SAS Institute Inc, Cary, NC)33 and SUDAAN
(version 8.0.2, Research Triangle Institute, Research
Triangle Park, NC)31 to account for the weighting structures of NEISS. The SAS program was used primarily to
calculate frequencies and percentages, whereas the
SUDAAN was used to calculate the confidence intervals
(CIs) for all percentages. Experts at the CPSC provided
statistical weights for the NEISS data that adjust for the
inverse probability of selection for each injury episode
based on the volume of the specific ED involved and other
factors built into the complex surveillance system
design.22 The NEISS was designed to project national estimates of injuries related to specific types of products.22 The
actual sample size is an unweighted number and is speci-
Vol. 33, No. 7, 2005
fied when presented in this article; all other numbers are
national estimates calculated using the statistical
weights. National estimates of water skiing– and wakeboarding-related injuries were calculated by age, gender,
race, and treatment outcome. For total national estimates,
95% CIs were calculated using the estimated generalized
coefficient of variation for NEISS data as advised by
experts at the CPSC.22 National estimates, percentages,
and 95% CIs were calculated by injury diagnosis and body
region injured for each sport. Relative risks (RRs) and P
values were calculated to further quantify statistically
significant differences. Lower extremity injuries were further detailed by specific body part injured for each sport
because these injuries represent a significant percentage
of injuries in both sports. Injury diagnosis–specific information is provided only for categories representing at least
5% of total injuries for at least 1 sport. Diagnosis-specific
groups totaling less than 5% (dislocation, crushing, amputation, foreign body, dental injury, nerve damage, burn,
and internal organ injury to lower and upper trunk) were
moved into the “other” category and detailed in a footnote.
Ethical Considerations
This study was approved by the Institutional Review
Board of the Columbus Children’s Research Institute.
RESULTS
Number of Injuries
The NEISS collected data on 517 individuals with water
skiing–related injuries and 95 individuals with wakeboardingrelated injuries treated in NEISS EDs between January 1,
2001, and December 31, 2003 (Table 1). Based on these
data, an estimated 23 460 individuals with water skiing–
related injuries and 4810 individuals with wakeboardingrelated injuries were treated in US EDs in 2001 to 2003
(95% CI, 20 240-26 680 for water skiing; 4150-5470 for
wakeboarding). The distributions of the patients’ ages,
gender, races, and treatment outcomes are shown by sport
in Table 1. For water skiing, injuries demonstrated a
bimodal peak in young adulthood and middle age (n =
3639 for ages 20-24 years and n = 3202 for ages 40-44
years, compared with only 1881 for ages 30-34 years). In
contrast, wakeboarding injuries peaked during late adolescence (n = 1278 for ages 15-19 years with a steady
decline to n = 136 for ages 40-44 years). Men accounted for
the majority of injuries in both sports (72.2% of individuals injured while water skiing and 86.1% of individuals
injured while wakeboarding). Among persons with recorded
race (69.9%), white participants experienced 98.4% of
injuries.
Body Region Injured
The number and percentage of injuries by body region and
sport are presented in Table 2 and Figure 1. Head injuries
represented the largest percentage of injuries among
Water Skiing and Wakeboarding Injuries
1067
TABLE 1
Demographics of Water Sports–Related Injuries for
Actual Sample and National Estimatesa
Total persons
Age, y
14 and younger
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50 and older
Gender
Male
Female
Race
White
Minority
Unknown
Treatment outcome
Treated and
released
Hospitalized
Water Skiing
Wakeboarding
Actual
National
Sample Estimatesb
Actual
National
Sample Estimatesb
517
23 462
95
4806
40
74
85
69
49
59
66
35
40
1420
3568
3639
3437
1881
2791
3202
1893
1631
10
23
19
19
14
7
2
0
1
398
1278
1006
943
732
296
136
0
17
379
138
16 947
6514
84
11
4139
666
363
13
141
15 523
254
7685
77
3
15
3938
58
810
502
15
22 893
569
92
3
4725
80
a
Data are from the National Electronic Injury Surveillance
System, 2001-2003.
b
National estimates are calculated with statistical weights as
advised by experts at the Consumer Product Safety Commission
to account for the inverse probability of selection for each injury
episode.
wakeboarders (28.8% of all injuries) and the smallest percentage of injuries among water skiers (4.3%), a statistically significant difference (P < .01). The RR for this relationship was 6.73 (95% CI, 3.89-11.66). Wakeboarders also
had a high percentage of facial injuries (28.4%). In contrast, water skiers had a significantly higher percentage of
injuries to the upper extremity (13.0%) and trunk (27.1%)
than did wakeboarders (2.9% and 14.4%, respectively). The
lower extremity was the most frequently injured body
region for water skiers (34.0% of all injuries). Among lower
extremity injuries (Table 3), water skiers most frequently
injured their knees or upper legs (30.8% and 25.7% of all
water skiing–related lower extremity injuries, respectively),
whereas wakeboarders most frequently injured their ankles
or feet (32.0% and 24.9% of all wakeboarding-related lower
extremity injuries, respectively).
Injury Diagnosis
Table 2 also highlights statistically significant differences
in injury diagnosis by sport. Consistent with the body
region injured, wakeboarders had a significantly higher
percentage of traumatic brain injuries (12.5% of all
injuries) compared with water skiers (2.4%) (P < .05; RR
1068
Hostetler et al
The American Journal of Sports Medicine
TABLE 2
Characteristics of Water Sports–Related Injury by Sporta
Water Skiing
n
Total injuries
Body region injured
Upper extremity
Lower extremity
Head
Face
Trunk
Otherb
Injury diagnosis
Laceration
Contusion or abrasion
Fracture
Strain or sprain
Traumatic brain injury
c
Other
%
Wakeboarding
95% CI
n
23 462
%
95% CI
4806
3042
7967
1004
4872
6365
212
13.0
34.0
4.3
20.8
27.1
0.9
9.4-16.6
28.8-39.1
2.3-6.3
16.2-25.3
21.9-32.4
0-1.8
137
1231
1384
1363
691
0
2.9
25.6
28.8
28.4
14.4
—
0-5.9
16.9-34.4
22.7-34.9
19.0-37.7
8.2-20.5
—
4001
3937
2108
8515
558
4343
17.1
17.1
9.0
36.3
2.4
18.5
12.7-21.4
13.7-20.5
6.1-11.9
30.9-41.7
1.0-3.8
14.8-22.2
1493
282
722
884
602
823
31.1
5.9
15.0
18.4
12.5
17.1
16.7-45.4
1.2-10.5
7.9-22.1
13.0-23.8
6.1-19.0
10.2-24.1
a
Data are from the National Electronic Injury Surveillance System, 2001-2003. All percentages and confidence intervals (CIs) use statistical weights in calculations as advised by experts at the Consumer Product Safety Commission to account for the inverse probability of
selection for each injury episode; thus, there are slight variations from what would be calculated directly from the actual numbers.
b
Other (body region) refers to injuries with the body part not specified, all of the body, and 25% to 50% of the body.
c
Other (injury diagnosis) refers to dislocation, crushing, amputation, foreign body, hematoma, dental injury, nerve damage, burn, and
internal organ injury to the lower and upper trunk.
TABLE 3
Specific Body Part Injured in Water Skiing– and
Wakeboarding-Related Lower Extremity Injuriesa
Water Skiing
n
Upper leg
Knee
Lower leg
Ankle
Foot
Toe
Total
2044
2457
1105
1067
1172
122
7967
%
25.7
30.8
13.9
13.4
14.7
1.5
100.0
Head
4.3%
n=1004
Face
20.8%
n=4872
Head
28.8%
n=1384
Wakeboarding
n
%
130
256
145
393
307
0
1231
10.5
20.8
11.8
32.0
24.9
—
100.0
a
Data are from the National Electronic Injury Surveillance
System, 2001-2003. All national estimates and percentages use
statistical weights in calculations as advised by experts at the
Consumer Product Safety Commission to account for the inverse
probability of selection for each injury episode; thus, there are
slight variations from what would be calculated directly from the
actual numbers.
Upper
Extremity
13.0%
n=3042
Face
28.4%
n=1363
Upper
Extremity
2.9%
n=137
Trunk
27.1%
n=6365
Trunk
14.4%
n=691
Lower
Extremity
25.6%
n=1231
Lower
Extremity
34.0%
n=7967
WATER SKIING
vs
WAKEBOARDING
Figure 1. Body region injured by water sport. Data are from
the National Electronic Injury Surveillance System, 20012003.
statistically significant differences in injury diagnoses by
age for either sport.
DISCUSSION
[95% CI], 5.27 [2.21-12.60]). Water skiers had a significantly higher percentage of contusions or abrasions
(17.1%) and strains or sprains (36.3%) than did wakeboarders (5.9% and 18.4%, respectively) (P < .05 for both;
RR [95% CI], 2.60 [1.28-5.28] for contusions or abrasions;
1.97 [1.44-2.71] for strains or sprains). The majority
(55.7%) of water skiing strains or sprains were to the lower
extremity. Lacerations were the most common diagnoses
for wakeboarders (31.1% of all injuries), and the majority
(59.6%) of these lacerations were to the face. There were no
Our analyses of water skiing– and wakeboarding-related
injuries treated in NEISS hospital EDs in 2001 to 2003
highlight the differences in injury patterns for these 2
sports. Water skiing–related injuries peaked during young
adulthood and middle age and were most commonly
strains or sprains to the lower extremity. In contrast,
wakeboarding-related injuries peaked during adolescence.
Lacerations were the most common wakeboarding-related
diagnoses, and the head and face were the most frequently
Vol. 33, No. 7, 2005
injured body regions. For both sports, men represented the
vast majority of all injuries.
Overall, wakeboarders were 6.7 times more likely than
were water skiers to be treated in the ED for a head injury.
The head was the body region most frequently injured for
wakeboarders and the body region least frequently injured
for water skiers. This finding is consistent with injury
diagnosis; wakeboarders were 5.3 times more likely to be
treated for a traumatic brain injury than were water
skiers. Previous studies on water skiing confirm the low
incidence of head injuries in this sport.11,13,29,32
Superficially, these sports appear similar as both involve
the athlete balancing on a thin board while being towed
along the surface of the water by a motorboat.20 However,
the goal of each sport differs greatly, which results in the
very different head injury profiles observed in our data.
Water skiers strive for sharp, quick turns and crisp cuts
across the wake. In contrast, the goal of the wakeboarder
is often more daring and includes extreme jumps and
tricks, such as flips, inverts, and spins with a small margin
of safety.4,7,20 If the wakeboarder attempts but does not
complete an inverted rotation, his or her head will often be
closest to the water and strike first. If the athlete finishes
a rotation or spin yet does not have a clean landing, the
edge of his or her board will catch the surface of the water,
creating a whip-like effect on the head and body before
impact. Further, in most instances, the speed of the wakeboarder relative to the water is enhanced by the rotational acceleration of the trick, unlike water skiing. These factors predispose the wakeboarder to an increased risk of
head injury, as evidenced by our data.
The most common diagnosis for wakeboarding-related
injuries was lacerations. More than half of these lacerations were to the face, which was significantly different
from water skiing. We suspect that the majority of these
lacerations were inflicted by the towrope, wakeboard, or
water debris. Wakeboarders must strategically position
the towrope in close proximity to the body and often switch
hands while rotating; any timing error or fall could result
in contact with the rope. Further, unlike water skiing, the
wakeboarder’s feet remain securely attached to the board
during a fall.20 Thus, the wakeboard will be in close proximity to the person throughout the fall, in contrast to
water skis that are discarded from the skier more easily.
Our national data for water skiing were consistent with
previous regional studies13,23,26 demonstrating that the
lower extremity was the most commonly injured body
region and strains/sprains were the most common injury
diagnoses. The majority of these water skiing–related
lower extremity injuries were to the knee or upper leg.
This fact is likely related to the lower extremity exertion
required for takeoff, cuts across the wake, sharp turns, and
maintaining balance through choppy water. Lastly,
although many case studies on water skiing–related
injuries highlight vaginal and rectal douche injuries,¶ our
ED data contained no injuries to the pubic region for
either sport. It is possible that these injuries occurred, but
individuals may not have sought ED treatment.
¶
References 3, 9, 14-16, 18, 19, 24, 28, 36.
Water Skiing and Wakeboarding Injuries
1069
Wakeboarding-related injuries peaked dramatically
during adolescence. This finding is consistent with international research demonstrating that adolescents consistently have higher rates of injury than do other age
groups.8,10,21,34 In addition, we suspect it reflects the age
distribution of person–hours of exposure among participants in this sport. Water skiing–related injuries showed a
bimodal age distribution, peaking during the early 20s and
early 40s. The peak during the early 20s is also likely
explained by the aforementioned factors for adolescents.
The second peak during the 40s may result from increased
participation in this activity among persons in this age
group because these individuals are more likely to have
the financial resources to purchase a boat, the family
incentive with children old enough to water ski, and a
propensity toward injury due to a greater prevalence of
decreased conditioning and flexibility compared with
younger age groups.
Several methodological limitations exist in our study.
First, NEISS only tracks injuries treated in EDs. Our findings may not be representative of injuries treated in other
medical facilities or injuries in which no care was sought
at all. Second, NEISS did not capture information regarding the proximal cause of injury, the detailed outcome of
treatment, the skill level and physical condition of the participant, the condition of the equipment involved, the experience level of the boat operator, or whether alcohol was
involved. Further research is needed for both sports, investigating these and other important variables, to gain a
clearer picture of the mechanisms of injury and strategies
for prevention. In addition, NEISS only includes a code for
the most severe injury. Particularly for wakeboarding,
which has a large number of head injuries, the frequency
of additional more minor injuries might be underrepresented. Last, we could not calculate injury rates because
we could not find accurate national estimates of the number of participants or their sport-specific exposure time.
The Sporting Goods Manufacturer’s Association’s “Sports
Participation Topline Reports” round sport participant
estimates to the nearest thousand, making rate estimation
subject to wide CIs. Furthermore, these estimates are
available only as a total and are not detailed by age or sex.
Despite these limitations, NEISS provides nationally representative data that can identify product- or sports
activity–specific injury patterns for the entire United States.
In summary, the striking differences in injury patterns
between water skiing and wakeboarding point to key
interventions to prevent injury. Our findings regarding
wakeboarding-related injuries underscore the need for
research on the potential role of helmets or other protective head gear for wakeboarders to reduce the number of
head and face injuries. The substantial number of lacerations also warrants evaluation of a plastic or foam coating
for towropes to decrease the likelihood of injury during
falls and tricks. For water skiing, the high percentage of
strains and sprains emphasizes the need for physical conditioning and education for participants new to the sport
regarding techniques for getting up out of the water,
strategies to minimize the force exerted by the towrope
(avoid pulling the rope in toward the body, keeping the
1070
Hostetler et al
rope taut when outside the wake), and the importance of
letting go of the rope when they fall. Both sports require
attentive boat operators, knowledgeable of the acceleration and top speeds appropriate to each sport, and a
focused observer in the boat to monitor the skier and communicate between the skier and boat operator. Water skiing and wakeboarding are water sports that are fun and
can contribute to physical fitness when attention is paid to
the prevention of injuries associated with these activities.
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