THEMATIC ISSUE
Incidence and Distribution of Pediatric
Sport-Related Injuries
Dennis Caine, PhD,* Caroline Caine, PhD, and Nicola Maffulli, MD, MS, PhD†
Objective: To provide a critical review of the available literature
on the descriptive epidemiology of pediatric sport-related injuries.
Key Words: epidemiology, sports, injury, athletic injuries, children,
adolescents
(Clin J Sport Med 2006;16:500–513)
Data Sources: MEDLINE (1966 to 2006) and SPORTDiscus
(1975 to 2006) were searched to identify potentially relevant articles.
A combination of medical subject headings and text words was used
(epidemiology, children, adolescents, athletic injuries, sports, injury,
and injuries). Additional references from the bibliographies of retrieved articles were also reviewed.
Study Selection: Published research reports on the incidence and
distribution of injury in children’s and youth sports. Specific emphasis was placed on reviewing original studies, which report incidence
rates (rate of injuries per unit athlete time). Forty-nine studies were
selected for this review.
Data Extraction: Data summarized include incidence of injury
relative to who is affected by injury (sport, participation level, gender,
and player position), where injury occurs (anatomical and environmental location), when injury occurs (injury onset and chronometry),
and injury outcome (injury type, time loss, clinical outcome, and
economic cost).
Data Synthesis: There is little epidemiological data on injuries
for some pediatric sports. Many of the studies retrieved were characterized by methodological short-comings and study differences
that limit interpretation and comparison of findings across studies.
Notwithstanding, the studies reviewed are encouraging and injury
patterns that should be studied further with more rigorous study
designs to confirm original findings and to probe causes of injury and
the effectiveness of preventive measures.
Conclusions: Incidence and severity of injury are high in some
child and youth sports. This review will assist in targeting the relevant
groups and in designing future research on the epidemiology of
pediatric sports injuries. Well-designed descriptive and analytical
studies are needed to identify the public health impact of pediatric
sport injury.
From the *Department of Physical Education, Health and Recreation, Western
Washington University, Bellingham, Washington; and †Department of
Trauma and Orthopedic Surgery, Keele University School of Medicine,
Stoke on Trent, England.
Reprints: Dennis Caine, PhD, Department of Physical Education, Health and
Recreation, Western Washington University, Bellingham, WA (e-mail:
[email protected]).
Copyright ! 2006 by Lippincott Williams & Wilkins
500
P
articipation in child and youth sports is increasingly
popular and widespread in Western culture. Many of these
youngsters initiate year-round training and specialization in
their sports at a very early age. It is not uncommon for teens
to train at regional centers in gymnastics or tennis for 20 or
more hours a week or for youngsters as young as 6 years
to play organized hockey or soccer and travel with select
teams to other towns and communities to compete on a regular
basis. Many of these young athletes play in multiple leagues
throughout the school year, attend sports summer camps, and
enroll in training clinics during school vacation.
Engaging in physical activity has many health benefits
but also involves a risk for injury. The magnitude of pediatric
sports-, recreation-, and exercise-related (SRE) injury has been
shown in several recent US regional and national surveys
of injury-related visits to hospital emergency departments
(ED) and primary-care office settings.1–6 For example, in a
recent report,2 65% of all SRE-related injury visits to ED in
2000 and 2001 (out of 4.3 million visits) are sustained by
individuals 19 years of age or younger. SRE injuries were the
most common cause of pediatric injuries in other surveys,
accounting for 19% to 29% of all injuries in this population.1,4,5
The economic burden of SRE injuries is substantial, especially
among children and youth. In addition to the immediate
healthcare costs, these injuries may have long-term consequences on the musculoskeletal system, resulting in reduced levels of
physical activity.
Pediatric sports-related injuries are bound to occur;
however, every effort must be made to prevent the occurrence
of unnecessary injuries. To this end, epidemiological techniques have been increasingly applied to sports injury problems since the early 1960s.7 Epidemiological data have been
used to reduce injury rates by driving the development and
implementation of injury prevention programs. Examples of
data-driven changes in policies and practices include the
prohibition of !spearing" in football and rules regarding water
depth and the racing dive in swimming.8
There are two interrelated types of epidemiological
research–descriptive and analytical. Quantifying injury occurrence (how much) with respect to who is affected by injury,
where and when injuries occur, and what is their outcome is
referred to as descriptive epidemiology. Explaining why and
Clin J Sport Med ! Volume 16, Number 6, November 2006
Clin J Sport Med ! Volume 16, Number 6, November 2006
how injuries occur and identifying strategies to control and
prevent them is referred to as analytical epidemiology.9
We have limited our overview to descriptive epidemiology as it applies to pediatric sport-related injuries. Our
search was limited to published studies, including recent epidemiological reviews of pediatric sports injuries,10–12 which
report incidence rates (number of injuries/1,000 participation
hours or 1,000 athlete exposures) for males and females.
Literature searches were conducted using MEDLINE (1966 to
2006) and SPORTDiscus (1975 to 2006) and restricted to
English-language articles. Medical subject headings and text
words included epidemiology, children, adolescents, athletic
injuries, sports, injury, and injuries. Each title was searched
manually for any focus on the epidemiology of pediatric sports
injuries. The reference lists of selected articles were searched
using the same criteria. Forty-nine studies were selected for
this review.
Many of the studies retrieved were characterized by
methodological shortcomings and study differences that limit
the interpretation and comparison of findings across studies
and sports. These included diversity of study populations; short
periods of data collection and small sample sizes in some
studies; low response rates, recall bias, and response motivation
bias associated with use of questionnaires; non-random selection; extremely variable injury definitions and methods of
data collection; and limited or no information on exposure of
participants to risk of injury. The epidemiological literature on
pediatric sports injuries reviewed in this article should be
evaluated in light of these limitations.
DESCRIPTIVE EPIDEMIOLOGY
Descriptive epidemiology is by far the most common type
of epidemiological research in the pediatric sports injury
literature. Although there has been a transition to approaches
that are etiologically based rather than descriptive, there remain
Pediatric Sport-Related Injuries
large gaps in the available descriptive epidemiological literature
on pediatric sports injuries. For example, competitive swimming and figure skating attract large numbers of youth
participants, yet there are almost no published epidemiological
studies for these sports. A diagram illustrating important aspects
of the descriptive epidemiology of pediatric sports-related
injuries is shown in Figure 1. These components are discussed
below with the purpose of highlighting their various contributions to the epidemiology of pediatric sports injuries.
HOW MANY INJURIES?
In descriptive epidemiology, the researcher attempts
to quantify the occurrence of injury, but the researcher must
first define injury. A review of the pediatric sports injury literature reveals that no common operational definition exists.
Definitions include such criteria as presence of a new symptom
or complaint, decreased function of a body part or decreased
athletic performance, cessation of practice or competition
activities, and consultation with medical or training personnel.
If injury is defined differently across studies, a meaningful
comparison of injury rates is difficult because of different
criteria for determining numerator values.
Injury Occurrence
The most basic measure of injury occurrence is a simple
count of injured persons. However, frequency data alone have
very limited epidemiologic utility and should not be confused
with rates.13 To investigate the incidence and distribution
of injuries it is necessary to know the size of the source
population from which the injured individuals were derived, or
the population at risk. As applied to sports injury epidemiology, the prevalence of injury is the proportion of athletes in
a population-at-risk who have an existing injury at any given
point in time. Injury incidence is the number of new injuries
that occur in population-at-risk over a specific period of time,
FIGURE 1. Important aspects of the descriptive epidemiology of pediatric sports-related injuries.
q 2006 Lippincott Williams & Wilkins
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Clin J Sport Med ! Volume 16, Number 6, November 2006
Caine et al
such as from the start of the season. The focus of this review is
on injury incidence given space restrictions and the obvious
limitations of prevalence data in providing an accurate representation of all injuries in a population.
Incidence data are necessary to answer questions such
as, ‘‘Is the rate of injury greater in some sport activities, or
level of activity, than in others?’’ The 2 most common
approaches to reporting injury incidence in the sports injury
literature are incidence rates and clinical incidence. Clinical
incidence refers to the number of incident injuries divided by
the total number of athletes at risk and is usually multiplied by
some k value (eg, 100).14 Historically, clinical incidence has
been widely reported in the pediatric sports injury literature.10,11 However, while it may serve as an indicator of clinical
or resource utilization, it does not account for the potential
variance in exposure of participants to risk of injury.14
Incidence rate refers to the number of incident injuries
divided by the total time-at-risk and is usually multiplied by
some k value (eg, 1000). It is the preferred measure of
incidence in research studies because it can accommodate
variations in the time exposure of individual athletes. Different
units of time-at-risk, varying in precision, have been used to
calculate incidence rates. These include athlete exposures [an
athlete-exposure (AE) is defined as one athlete participating in
1 practice or game where there is the possibility of sustaining
an athletic injury], time-exposures (1 time-exposure is defined
as 1 athlete participating in 1 minute, hour, or day of activity in
which there is the possibility of the athlete sustaining an
athletic injury), and element-exposures (1 element-exposure is
defined as 1 athlete participating in 1 element of activity in
which there is the possibility of sustaining an athletic injury).
Examples of element-exposures include vaults, pitches, plays,
and bike trips.
In determining incidence rates, exposure data are ideally
recorded prospectively for each individual athlete as precisely
as possible. However, the logistics of acquiring the appropriate
data are usually an important factor in determining what the
unit of risk will be and whether it will represent actual or
estimated exposure. Due to space restrictions, the focus of this
review is on incidence rates (ie, number of injuries/1000
participation hours or 1,000 athletic exposures). These are also
the most commonly reported exposure-based incidence rates.
Having addressed the how much (injury rates) of descriptive epidemiology, we now turn to distribution of injury.
Injury distribution relates to person factors (who), place factors
(where), time factors (when), and injury outcome (what), and
these provide the descriptive characteristics of injuries.
WHO IS AFFECTED BY INJURY?
As might be expected, person factors are most often
categorized according to sport affiliation, participation level
(eg, grade level, age, skill level), gender, and player position.
Sport Affiliation
A summary of studies reporting separate overall (ie,
practice and competition combined) incidence rates for
girls’ and boys’sports is shown in Tables 1 and 2, respectively.
Boys’ incidence rates per 1000 hours and/or per 1000 AE’s
502
exposure are shown for baseball,15,16 basketball,16,17 crosscountry running,18,19 football,15,16,20–22 gymnastics,23 ice
hockey,24–25 rugby,26–28 soccer,15,16,29–33 and wrestling.16,34,35
Studies reporting incidence rates for girls’ sports include
basketball,16,17,36 cross-country running,18,19 field hockey,16
gymnastics,23,37–41 soccer,15,16,29–33,42 softball,15,16 and volleyball.16 Notably, few studies provide confidence levels for
measures of incidence.
In Tables 1 and 2, the highest rates of injury per 1000
hours exposure are reported for boys in ice hockey (range, 5
to 34.4), rugby (range, 3.4 to 13.3), and soccer (range, 2.3 to
7.9), and for girls in soccer (range, 2.5 to 10.6), basketball
(range, 3.6 to 4.1), and gymnastics (range, 0.5 to 4.1). When
AE’s are used, cross-country running (range, 10.9 to 15.0),
soccer (range, 4.3 to 17.0), and baseball (range, 2.8 to 17.0)
show the highest incidence rates for boys, and cross-country
running (range, 16.7 to 19.6), softball (range, 3.5 to 10.0), and
gymnastics (8.5) report the highest rates for girls. Most of
these sports involve a high rate of contact, jumping, sprinting,
or pivoting activities, which are often involved in the mechanism of sports injury.43 The relatively high incidence of
injuries in cross-country running and baseball perhaps relates
to the repetitive nature of motor patterns performed in these
activities.
Given the study differences that may restrict the interpretation and comparison of findings across sports, it is of
particular interest to compare incidence rates within multiplesport studies. In 1 such study,16 football had the highest overall
injury rate per 1000 AE’s for boys followed by wrestling,
basketball, soccer, and baseball. Among girls, soccer had
the highest injury rate, followed by basketball, field hockey,
softball, and volleyball.16
Participation Level
Several studies among those summarized in Tables 1
and 2 provide a breakdown of incidence rates across age or
competitive levels. In this regard, older boys reportedly experience higher rates of injury compared with younger boys in
football,20 rugby,27 and in soccer.29,31 Older boys are faster,
heavier, and stronger, and they generate more force on contact,
perhaps relating to greater risk of injury.
In girls’ soccer, 1 study reports higher rates of injuries
among younger relative to older players.32 In contrast, 2
studies report higher injury rates for older, more advanced
gymnasts.37,41 Advanced gymnasts train longer hours, perhaps
relating to increased risk of overuse injury. Two studies
compared injury rates among same age, elite and sub-elite
female gymnasts,38,39 with sub-elite gymnasts suffering higher
injury rates. The authors hypothesized that differences in such
factors as coaching, skill technique, and conditioning may
explain the higher rates among the sub-elite girls.38,39
Gender
Several studies among those summarized in Tables 1 and
2 report incidence rates for both males and females allowing
cross-gender comparisons within a sport. Higher incidence
rates are reported for girls compared with boys in crosscountry running [(IRR = 1.3, CI = 1.0,1.6);18 (IRR = 1.5, CI =
1.4, 1.7)19], gymnastics,25 and soccer (IRR = 1.54, CI = 1.06,
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Clin J Sport Med ! Volume 16, Number 6, November 2006
Pediatric Sport-Related Injuries
TABLE 1. A Summary of Exposure-based Incidence Rates in Boys Sports
Study
Baseball
Radelet15
Powell16
Basketball
Powell16
Messina17
Cross-Country Running
Rauh18
Rauh19
Football
Malina20
Turbeville21
Turbeville22
Radelet15
Powell16
Gymnastics
Bak23
Ice Hockey
Smith24
Gerberich25
Rugby Union
Garraway26
Duration of
Study
Data
Injury
Design Collection Surveillance
Team Type
or Age(s)
No.
No. of
of
Exposures
Injuries
(hours)
No. of
Exposures
(AEs)
Rate
(Injuries
per
1000 hr)
Rate
(Injuries
per
1000 AEs)
95%
Confidence
Intervals
(Low/High)
P
P
Q
Q
2 yrs
3 seasons
7–13 yr
High school
128
861
—
—
6913
311,295
—
—
17
2.8
—
—
P
P
DM
DM
3 seasons
1 season
High school
High school
1933
543
—
169,885
444,338
—
—
3.2
4.8
—
—
—
P
P
DM
DM
1 season
15 seasons
High school
High school
159
846
—
—
10,600
77,491
—
—
15
10.9
—
—
P
DM
2 seasons
P
P
P
P
DM
DM
Q
DM
2
2
2
3
Youth
4th–5th grade
6th grade
7th grade
8th grade
High school
Middle school
7–13 yrs
High school
259
58
61
90
50
132
64
129
10,557
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
8462
1,300,446
—
—
—
—
—
—
—
—
—
10.4
6.6
9.8
13.4
16.2
3.2
2
15
8.1
P
Q
26
—
—
1
—
—
P
R
seasons
seasons
yrs
seasons
1 yr
Club
DM
Q
1 season
1 season
High school
High school
27
—
—
—
—
—
34.4
5
—
—
—
—
P
—
1 season
26
72
495
—
—
—
—
—
—
3.4
8.7
7
—
—
1.6
2.1/4.8
6.5/10.8
—
—
—
—
8.74/1000
skier days
—
—
14,340
(half days)
—
7.1/1000
(half days)
—
Roux27
Skiing
Garrick28
P
Q
1 season
under 16
16–19
High school
R
Q
2 yrs
,18 yrs
Snowboarding
Machold29
R
Q
1 week
Secondary
School
Soccer
Le Gall30
P
DM
10 seasons
Kucera 31
Emery32
P
P
Q
DM
3 yrs
1 season
P
P
P
Q
DM
Q
2 yrs
3 seasons
1 week
All
U16
U15
U14
U12–18
Overall
U18
U16
U14
7–13 yrs
High school
6–17 yrs
1152
371
361
420
467
—
16
16
7
47
1765
—
—
—
—
—
—
—
2030
2817
2177
—
—
—
—
—
—
—
109,957
—
—
—
—
2799
385,443
—
4.8
5.2
4.6
4.9
—
5.5
7.9
5.7
3.2
—
—
—
—
—
—
—
4.3
—
—
—
—
17
4.6
7.3
P
P
P
I, Q
DM
DM
1 season
3 seasons
2 seasons
—
High school
—
219
2910
—
—
522,608
—
—
—
36,262
—
—
—
6
5.6
7.6
Radelet15
Powell16
Backous33
Wrestling
Pasque34
Powell16
Hoffman35
9.2/11.8
5.1/8.6
7.6/12.7
10.8/16.5
12.2/21.5
2.7/3.8
—
—
—
—
102
—
—
—
—
3.9/4.7
—
—
—
—
—
—
—
—
—
—
P, prospective cohort; R, retrospective cohort; DM, Direct Monitor; IR, Insurance Records; RR, Record Review; Q, Questionnaire.
An athletic exposure (AE) is one athlete participating in one practice or game in which the athlete is exposed to the possibility of athletic injury.
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Caine et al
TABLE 2. A Summary of Exposure-based Incidence Rates in Girls Sports
Rate
(Injuries
per
1000 hr)
Rate
(Injuries
per
1000 AEs)
95%
Confidence
Interval
(Low/High)
394,143
120,751
—
—
3.6
4.1
4.4
—
—
—
—
—
Data
Collection
P
P
P
DM
DM
DM
3 seasons
1 season
1 yr
High school
High school
High school
1748
543
436
P
P
DM
DM
1 season
15 seasons
High school
High school
157
776
—
—
8008
46,572
—
—
19.6
16.7
P
DM
3 seasons
High school
510
—
138,073
—
3.7
—
—
—
—
P
DM
3 yrs
Kolt38
PR
Q
18 months
Kolt39
R
Q
1 yr
Bak23
Lindner40
Caine41
P
P
P
Q
QI
I
1 yr
3 seasons
1 yr
All levels
Top
Beginning
All levels
Elite
Sub-elite
All levels
Elite
Sub-elite
Club
Club
All levels
Top
Middle
192
125
67
349
151
198
321
111
210
41
90
147
83
64
76,919.5
36,040.0
40,879.5
105,583
57,383
48,200
163,920
—
—
—
173,263
40,127
22,536
20,591
22,584
—
—
—
—
—
—
—
—
—
—
—
—
—
2.5
3.5
1.6
3.3
2.6
4.1
2.0
1.6
2.2
1.4
0.5
3.7
3.7
3.1
8.5
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
Skiing
Garrick28
R
Q
2 yrs
,18 yrs
—
—
—
—
11.6/1000
skier days
—
Snowboarding
Machold29
R
Q
1 week
Secondary
school
—
5598
(half days)
—
14.8/1000
(half days)
—
Soccer
Kucara31
Emery32
P
P
Q
DM
3 seasons
1 season
P
P
P
P
DM
Q
DM
Q
1
2
3
1
season
yrs
seasons
week
12–18 yrs
Overall
U14
U16
U18
14–19 yrs
Community
High school
6–17 yrs
320
20
14
5
—
79
16
1771
—
60,166
2526
2440
1976
—
—
—
—
—
—
—
—
—
—
—
1637
355,512
—
5.3
5.6
7.9
5.7
2.5
6.8
—
—
10.6
—
—
—
—
—
—
23
5.3
—
4.7/6
—
—
—
—
—
—
—
—
P
P
Q
DM
2 yrs
3 seasons
Community
High school
37
910
—
—
3807
—
—
—
10
3.5
—
—
P
DM
3 seasons
High school
601
—
359,547
—
1.7
—
Basketball
Powell16
Messina17
Gomez36
Cross-Country
Running
Rauh18
Rauh19
Field Hockey
Powell16
Gymnastics
Caine37
Soderman42
Radelet15
Powell16
Backous33
Softball
Radelet15
Powell16
Volleyball
Powell16
Team Type
or Age(s)
No.
of
Exposures
(AEs)
Study
Design
Study
No.
of
Injuries
No.
of
Exposures
(hrs)
Duration of
Injury
Surveillance
50
—
—
107,353
P, prospective cohort; R, retrospective cohort; DM, Direct Monitor; IR, Insurance Records; RR, Record Review; Q, Questionnaire.
An athletic exposure (AE) is one athlete participating in one practice or game in which the athlete is exposed to the possibility of athletic injury.
1.5430).15,30 One study15 of basketball participants reported
a higher incidence rate for boys, while another showed a higher
but nonsignificant incidence rate for girls (P = 0.11). Gender
differences in injury rates are particularly evident when rates
504
for specific locations are compared. For example, a greater
incidence rate of knee injuries affecting girls has been reported
in several studies.16,17,19,31 Possible explanations for the
difference between genders include hormonal differences,
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Clin J Sport Med ! Volume 16, Number 6, November 2006
increased joint laxity in female athletes, anatomical differences, and differences in motor control of knee function which
may predispose them to knee injuries in cutting and jumping
sports.31
Player Position
Several studies summarized in Table 1 report distribution of injuries by player position.22,27,30 In these studies, as
well as several others reporting clinical incidence,44–46 injury
distribution was reported as a proportion of all injuries
sustained. Unfortunately, this approach does not account for
the differential exposure of players to risk of injury. In child
and youth sports, starters and experienced players may have
more playing time than non-starters and less experienced
players during games.47 In addition to more time at their
position, some young athletes may also play at more than 1
position, thus also increasing their exposure to risk of injury.
These findings underscore the importance of using exposure
units for individual athletes, for example on-ice player-game
minutes,48 which capture the actual exposure of the players to
risk of injury.
WHERE DOES INJURY OCCUR?
The where of injury distribution involves identifying the
anatomical and environmental location of injury. Anatomical
locations include body region of injury (eg, upper extremity),
as well as specific body parts (eg, shoulder, elbow). Environmental locations include whether an injury occurs during
practice or competition; surface or terrain on which the activity
takes place; event, such as the balance beam in gymnastics;
geographical location; and weather conditions.9
Anatomical Location
Identification of commonly injured anatomical sites is
important because it alerts sports medicine personnel to injury
sites in need of special attention during pre-participation
musculoskeletal screening. Information on high injury risk sites
and related inciting factors (events leading to the situation where
the injury took place, eg, high sticking in hockey) are also
important targets for preventive strategies. For example, the
introduction of mandatory full face shield rules dramatically
reduced the rate of facial and eye injuries in youth ice hockey.49
For brevity, Table 3 shows percent range values for the
most common injury locations as reported in recent sportspecific reviews on the epidemiology of pediatric sport-related
injuries.44–46,49–56 Most injuries are to the lower extremity.
With few exceptions, the ankle and knee are the most common
injury sites to the lower extremity, except for taekwondo in
which injuries occur primarily to the foot and toes.
Upper extremity injuries are more common in sports such
as baseball, judo, gymnastics, and snowboarding. Table 3 shows
that shoulder, elbow, and wrist injuries are the most common
locations for upper extremity injury in these sports, although
the rank order varies by sport. Sports with the highest frequency
of injuries involving the head and/or face include high school
ice hockey, karate, and taekwondo. In one multi-sport study,16
injuries to the head/neck/spine were more common in football
and wrestling than other boys’ high school sports.
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Pediatric Sport-Related Injuries
In addition to reporting injury location as a percent or
proportion of all injuries sustained, some recent research
reports incidence rates for specific body locations,17–19,26,32,37
thus permitting comparison of (location) rates across such
factors as gender, sport, and so forth. For example, Messina
et al17 reported a significantly higher rate of lower extremity
(P = 0.008) and knee (P = 0.0001) injury in girls compared
to boys in high school basketball.
Environmental Location
Much of the limited literature on environmental location
has focused on injury frequency in practice and competition.
Studies reporting competition and practice incidence rates for
boys15–17,19–22,30,32,34,57–63 and girls15,16,19,32,37,42,58,60,61 are summarized in Tables 4 and 5, respectively. In most sports, the
proportion of injuries is greater in practice than competition due
simply to the larger amount of exposure time. On a practical
basis, this relationship implies the need for a strong program of
early recognition and management of practice-related injuries.16
Yet, in reality, incidence rates are actually higher in competition
than training in most boys (IDR = 1.7 to 5.0; RR = 2.57 to
10)16,20,21,30,32 and girls (IDR = 2.2 to 3.7; RR = 1.7 to
4.22)16,19,32,37 sports. Competitors are more likely to be playing
at greater intensity and speeds in competition and tournaments than in practice, increasing the risk of sustaining an
injury.64
In football, higher rates of injury have been reported
on artificial turf,48,65,66 on ‘‘wet or muddy’’ or ‘‘good’’ field
conditions,47,67 and during ‘‘foggy’’ weather conditions.47 One
study of youth soccer reported a higher incidence rate for indoor
compared to outdoor soccer,68 yet another study reported no
significant difference except at the elite level, where incidence
rate was greater in outdoor soccer (RR = 3.22; CI = 1.8 to
6.12).69 The data on slope characteristics suggest a greater risk
of skiing injury on groomed runs compared with powder70 and
easy compared with more difficult runs.71 For snowboarders, the
injury risk may be greater on the half-pipe compared with
marked runs, and on hard, icy or slushy terrain compared with
prepared slopes.29 In girls’ gymnastics, the event associated
with the highest incidence of injury is floor exercise.37 This is
not an unexpected finding given the multiple landings
performed in floor routines.
WHEN DOES INJURY OCCUR?
The next component of injury distribution is the when
of injury occurrence (Figure 1). This includes onset and
chronometry of injury. There are 2 broad categories of injury
onset: injuries that occur suddenly, or acute injuries (eg,
fractures and sprains); and injuries that develop gradually, or
overuse injuries (eg, stress fracture and tendinitis). Examples
of chronometry include time into practice, time of day, and
time of season when injury occurs.
Injury Onset
Very few studies provide a breakdown of incidence
rate by nature of injury onset. In fact, several studies reviewed
in Tables 1 to 5 report only acute injuries. This finding raises
concern for several reasons. First, as training has become
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Caine et al
TABLE 3. Percent Comparison of Most Common Injury Locations (Adapted from Caine and Maffulli (eds.)10 and Maffulli and
Caine (eds.)11
Study
Sport
Participation Level
Gender
Injury Region (%)
Harmer49
Basketball
—
—
LE (35.9–92)
Stuart44
Gridiron Football
—
Caine and Nassar50
Girls’ Gymnastics
HS
Yth
—
—
LE (21–34)
LE (36–51)
LE (54.1–70.2)
Benson and Meeuwisse51
Ice Hockey
Jr level (16–20 yrs old)
—
LE (24.9–33.7)
HS level (14–19 yrs old)
Mnr level (,14 yrs old)
Pieter52
Martial Arts:
Judo
Karate
Taekwondo
ankle/foot (16.6–44)
knee (5–20)
—
—
ankle (12–29)
knee (7–24.5)
knee (4.2–13.3)
thigh (4–12.8)
face (14.8–31)
shoulder (11.6–22)
arm (3.9–23)
HD (14.8–31)
UE (23–55)
—
—
—
M
F
M/F
UE (28–37)
S/T (8.9–47.1)
UE (28–37.8)
—
—
—
—
—
—
—
M
F
M/F
M
F
M/F
M
HD (51.3–90.9)
HD (40.6)
HD (28.0–40.6)
LE (36.7–65)
LE (41.4–85.7)
LE (36.7–85.7)
LE (25.3–43.4)
McIntosh45
Rugby
Hagel53
Skiing and
Snowboarding
Soccer
—
M/F
—
—
Skiing: LE (21.7–72.1)
Snowboarding: UP (5–80.0)
LE (58–85.1)
Kibler and Safran54
Tennis
(acute injuries only)
—
—
—
—
LE (39.1–59)
UE (20–45.7)
Zemper55
Track and Field
—
—
LE (64–87.4)
Hewett et al56
Wrestling
(acute injuries only)
—
—
—
—
S/T (11.2–28.5)
HD (3.6–28.6)
Giza and Micheli46
Body Part(s) Most
Commonly Injured
shoulder (12–14.8)
torso (6.7–29.4)
hand/wrist/fingers (4–17.8)
shoulder (4.4–12)
face/teeth (46.1–87.9)
face/teeth (37.5)
face/teeth (37.5–87.9)
foot/toes (16.1–50)
foot/toes (11.5–42.9)
foot/toes (16.1–50)
thigh (8.1–15.9)
ankle (7.5–14.6)
Skiing: knee, lower leg
Snowboarding: forearm, wrist
knee (10.1–26)
ankle (13–37)
ankle (16.7–27.8)
thigh (11.1–29.4)
shoulder (25–47.2)
elbow (17.9–44.6)
lower leg (8–35.8)
upper leg (8–35.8)
ankle (10.2–17.1)
neck (3.5–28.5)
rib/chest (4.1–16.1)
lower back (1.2–18.6)
ear (0.9–23.4)
HS, High school; Jr, Junior level; MS, Middle school; Yth, Youth; Mnr, Minor level; M, male; F, female; M/F, male and female; LE, lower extremity; UE, upper extremity;
S/T, spine/trunk (includes pelvis/hips); HD, head.
Most of the injury data for skiing and snowboarding came from case series reports.
so sport-specific and nearly continuous, overuse injuries are
becoming more common in pediatric sports.72–74 In fact, nearly
half of all pediatric sports injuries are overuse injures.75 In
some sports, overuse injuries may actually constitute the
majority of all injuries incurred.41,55,76 A second concern is that
overuse injuries may be associated with substantial time loss
and risk of reinjury.41 Finally, injury risk factors may relate
differently to the categories on injury onset,8,77,78 a possibility
not accounted for in many of the analytical studies on pediatric
sports injury epidemiology.
506
Chronometry
A relationship between time into competition and
increased frequency of injury has been reported in basketball,
gymnastics, rugby, taekwondo, and wrestling. Fatigue seems
a likely cause of basketball injuries according to two studies
that reported most injuries occurred in the last quarter or
second half of games.79,80 In gymnastics, several studies report
a relatively high frequency of injuries early in practice,
perhaps due to inadequacy of warm-up prior to attempting
difficult skills.37,40,41 In taekwondo, more injuries occurred in
q 2006 Lippincott Williams & Wilkins
Clin J Sport Med ! Volume 16, Number 6, November 2006
Pediatric Sport-Related Injuries
TABLE 4. A Summary of Exposure-based Game/practice Incidence Rates in Boys Sports
Team Type
or Age(s)
Practice Rate
(Injuries per
1000 hr)
Game Rate
(Injuries per
1000 hr)
Practice Rate
(Injuries per
1000 AEs)
Comp. Rate
(Injuries per
1000 AEs)
2 yrs
3 seasons
7–13 yrs
High school
—
—
—
—
6
1.8
24
5.6
P , 0.05
IDR = 3.1
(SD = 0.20)
DM
3 seasons
High school
—
—
3.4
7.1
P
DM
1 season
High school
1.8
16.9
—
—
IDR = 2.1
(SD = 0.09)
P , 0.0001
P
DM
1 season
High school
—
—
P
P
DM
DM
2 seasons
2 seasons
Grades 4–8
High school
—
—
—
—
8.7
1.3
18.6
13.1
Turbeville22
P
DM
2 seasons
Youth
—
—
0.97
8.8
Radelet15
Powell16
P
P
Q
DM
2 yrs
3 seasons
7–13 yrs
High school
—
—
—
—
7
5.3
43
26.4
Stuart57
Ice Hockey
Roberts58
Roberts59
Rugby
Pringle60
P
DM
1 season
Grades 4–8
—
—
—
8.8
IDR = 2.1
RR = 10.0
(CI = 6.5; 16.2)
RR = 9.11
(CI = 4.3; 18.9)
P = ,0.05
IDR = 5.0
(SD = 0.08)
—
P
P
DM
DM
Tournament
Tournament
12–19 yrs
High school
—
—
117.3
135.6
—
—
26.4
25.9
—
—
P
DM
4 weeks
Bird61
Soccer
Le Gall30
P
DM
1 season
6–15 yrs
R. Union
R. League
,19 yrs
—
—
—
—
—
15.5
24.5
—
—
—
—
0.9
—
—
—
6.2
—
—
—
—
P
DM
10 seasons
U14–U16
3.9
11.2
—
—
Emery32
P
DM
1 season
U14–U18
2.94
—
—
Peterson62
P
DM
1 yr
16–18 yrs
(high skill)
16–18 yrs
(low skill)
14–16 yrs
(high skill)
14–16 yrs
(low skill)
High school
7.9
38.4
—
—
RR = 2.9
(CI = 2.3; 3.5)
RR = 2.57
(CI = 1.2; 6.2)
P = 0.0088
—
17.4
63.8
—
—
—
35
—
—
—
14.1
59.4
—
—
—
—
—
2.5
10.2
Study
Design
Data
Collection
Baseball
Radelet15
Powell16
P
P
Q
Q
Basketball
Powell16
P
Messina17
Cross-Country
Running
Rauh19
Football
Malina20
Turbeville21
Study
Duration of
Injury
Surveillance
7.2
7.57
15
15
Powell16
P
DM
3 seasons
Inklar63
P
Q
1 season
13–14 yrs
15–16 yrs
17–18 yrs
—
—
—
12.8
16.1
28.3
—
—
—
—
—
—
Wrestling
Pasque34
Powell16
P
P
DM
DM
1 season
3 seasons
High school
High school
—
—
—
—
5
4.8
9
8.2
Level of
Significance
and Ratios
—
IDR = 4.1
(SD = 0.17)
—
—
—
—
IDR = 1.7
(SD = 0.06)
P, prospective cohort; R, retrospective cohort; DM, Direct Monitor; IR, Insurance Records; RR, Record Review; Q, Questionnaire; RR, relative risk.
An athletic exposure (AE) is one athlete participating in one practice or game in which the athlete is exposed to the possibility of athletic injury.
Ratio: Incidence density ratio (IDR) = game injury rate over practice injury rate.
q 2006 Lippincott Williams & Wilkins
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Caine et al
TABLE 5. A Summary of Exposure-based Competition/practice Incidence Rates in Girls Sports
Duration of
Injury
Surveillance
Team Type
or Age(s)
Practice Rate
(Injuries per
1000 hr)
Game Rate
(Injuries per
1000 hr)
Practice Rate
(Injuries per
1000 AEs)‡
Comp. Rate
(Injuries per
1000 AEs)
DM
3 seasons
High school
—
—
3.2
7.9
P
DM
1 season
High school
—
—
P
DM
1 season
High school
—
—
21.1
12.5
Field Hockey
Powell16
P
DM
3 seasons
High school
—
—
3.2
4.9
IDR = 1.5
(SD = 0.14)
Gymnastics
Caine37
P
DM
3 yrs
All levels
Beginning
Advanced
2.35
1.67
3.13
7.43
0.78
17.36
—
—
—
—
—
—
RR = 2.69
RR = 0.97
RR = 4.22
P
DM
1 season
PeeWee
—
50.5
—
11.2
—
P
DM
4 weeks
6–15 yrs
—
13
—
—
—
P
DM
1 season
,18 yrs
—
—
0
4.7
—
P
DM
1 season
U14–U18
2.62
8.55
—
—
P
P
P
Q
DM
DM
2
1 season
3 seasons
7–13 yrs
14–19 yrs
High school
9
1.5
—
41
9.1
—
—
—
3.1
—
—
11.4
RR = 3.26
(CI = 1.51; 7.81)
—
—
IDR = 3.7
(SD = 0.16)
P
DM
3 seasons
High school
—
—
2.7
5.9
P
Q
2 yrs
7–13 yrs
—
—
7
P
DM
3 seasons
High school
—
—
2.8
Study
Basketball
Powell16
Messina17
Cross-Country
Running
Rauh19
Ice Hockey
Roberts58
Netball
Pringle60
Rugby
Bird61
Soccer
Emery32
Radelet15
Soderman42
Powell16
Softball
Powell16
Radelet15
Volleyball
Powell16
Study
Design
Data
Collection
P
2
16
11
1.2
Level of
Significance
and Ratios#
IDR = 2.5
(SD = 0.11)
P , 0.0001
RR = 1.7
(CI = 1.0; 3.0)
IDR = 2.2
(SD = 0.14)
—
IDR = 0.4
(SD = 0.18)
P, prospective cohort; R, retrospective cohort; DM, Direct Monitor; IR; Insurance Records; RR, Record Review; Q, Questionnaire; RR, relative risk.
An athletic exposure (AE) is one athlete participating in one practice or game in which the athlete is exposed to the possibility of athletic injury.
Ratio: Incidence density ratio (IDR) = game injury rate over practice injury rate.
the first tournament match, possibly because of a larger variety
of skill levels in the early rounds.79 In rugby, two studies
found injuries distributed equally throughout the game,61,82 but
another83 noted more injuries in the first and fourth quarters.
Global and regional changes in the management of player
substitution encompassed in these studies may explain this
difference.45 Most wrestling injuries occur in the second and
third periods, perhaps related to fatigue.34,84
Although count data are sufficient to explore the relation
between injury frequency and time into practice or competition
for most sports, exposure time is necessary for a meaningful
comparison of incidence rates relative to time of season. Two
studies of female gymnasts indicate a higher injury rate
following periods of reduced training such as a short vacation,
during competitive routine preparation, and during the weeks
508
prior to competition.37,41 Possible causes could be stress,
fatigue, or lack of skill readiness.51
Studies of rugby injuries also report a higher incidence
of injury at the beginning of the season,26,27 and after winter
vacation,27 suggesting a lack of ‘‘match fitness’’ may predispose to injury.27 Similarly, one study of elite youth soccer
players noted the incidence rate was highest at the outset of the
competitive season.30 These findings suggest the importance
of pre-season training in reducing the incidence of lower
extremity injuries.
WHAT IS THE OUTCOME?
Injury outcome relates to the severity of injury. Injury
severity can span a broad spectrum from abrasions to fractures
q 2006 Lippincott Williams & Wilkins
Clin J Sport Med ! Volume 16, Number 6, November 2006
to injuries that result in severe permanent functional disability
or even death. Injury severity is typically expressed by 1 or
more of the following: injury type, time loss, clinical outcome,
and economic cost. Assessment in each of these areas is
important in identifying the extent of the injury problem.
Injury Type
Identification of common injury types is important
because it alerts sports medicine personnel to injuries in need
of special attention (eg, ACL injuries), and it directs
researchers in identifying and testing related risk factors and
preventive measures. Most studies report injury types in
general terms, such as contusion or fracture, with unfortunately few specifics on type of fracture, grade of injury, and
so forth. The more common types of injuries reported across
sports are sprains and/or strains and contusions followed
in different rank order – depending on sport, participation
level, and gender – by lacerations, fractures, and inflammation.44–46,49–56 Most studies report these injury types as a
percentage of all injuries sustained, although several recent
studies26,32,37 report incidence rates for injury types, thus
permitting comparison of rates across descriptive components.
For example, football had the highest overall and game incidence rate for concussion in a recent study of high school
athletes.85 Cheerleading had the highest concussion rate for
practice followed by football.
Time Loss
A useful measure of injury severity and one often used
in the literature on pediatric sports injuries is the duration of
restriction from athletic performance.86 However, it should be
recognized that subjective factors such as personal motivation,
peer influence, or coaching staff reluctance may determine if
and when players return to play. Additionally, as shown in
Table 6, the amount of time loss corresponding to each severity
category (ie, mild, moderate, severe) may vary both within and
between sports,18,22,30,41,42 making cross-study comparisons
difficult at best. Notwithstanding these limitations, the available data indicate that most pediatric sports injuries are relatively minor, as indicated by time loss. For example, Powell
et al16 report that the majority (67.4% or greater) of injuries
in both boys’ and girls’ high school sports required fewer than
8 days of time loss.
Several studies have analyzed time loss relative to other
descriptive factors. Two studies report a significantly greater
proportion or incidence rate of severe competition relative to
practice injuries in gymnastics37 and soccer,30 respectively.
Pediatric Sport-Related Injuries
One study reports a significantly greater proportion of severe
injuries for advanced-level compared with beginning-level
gymnasts,37 and another reported a significantly greater
incidence rate of major injuries affecting young relative to
older age group soccer players.30 Finally, among cross-country
runners, girls had significantly higher rates of disabling
injuries (ie, 15 or more days of time lost) than boys (RR = 1.5;
CI = 1.0, 2.2).19
Clinical Outcome
Clinical outcome includes such factors as residual symptoms, re-injury, catastrophic injuries, and non-participation
subsequent to injury. With the exception of catastrophic injuries affecting high school athletes, there are surprisingly
few published studies that report on clinical outcome of pediatric sports injuries.
Residual Symptoms
The possibility of sport-related physeal injury and
subsequent growth disturbance has elicited considerable
concern in the sports medicine literature.72–74 A recent review
suggests that 1% to 10% of pediatric sports injuries are physeal
injuries and that growth disturbance may occur in as many as
1 out of 6 cases.74 Of additional concern were the many reports
of stress-related physeal injuries, including those resulting in
growth disturbance.74
Two follow-up studies of former top-level female
gymnasts revealed no significant differences in back pain
between gymnast and control groups. However, the prevalence
of radiological abnormalities was greater in gymnasts.87,88 In
a follow-up study (mean = 3.6 years) of gymnasts who initially
presented with a lesion of the articular surface of the elbow,
there was a high frequency of osteochondritic lesions, intraarticular loose bodies, pain, and reduced range of motion.89 Arm
pain associated with pitching or throwing during youth league
baseball has been reported to persist into adulthood as pain,
tenderness, or limited movement.90 And follow-up (1 to 3 years)
of children who suffered lower leg fractures from skiing
revealed residual pain on exercise, shortening of the leg,
outward rotation of the foot, and angulation of the lower leg.91
Re-injury
A persisting problem in child and youth sports is
inadequate treatment and rehabilitation for injuries31,73 It is
believed that unresolved residual symptoms from previous
injury predispose the athlete to re-injury at the same and
TABLE 6. Examples of Studies Reporting Injury Severity by Different Measures of Time Loss
Study
Sport
Rauh18
Turbeville22
Le Gall30
Cross-country running
Football
Soccer
Caine41
Soderman42
Gymnastics
Soccer
q 2006 Lippincott Williams & Wilkins
Mild (definition
and % value)
1–4 d (66.1)
,1 game (61)
2–3 d (minor/31);
4–7 d (mild/29.3)
,8 d (40.8)
,7 d (32.0)
Moderate
(definition and % value)
Severe
(definition and % value)
5–14 d (24.1)
1 or 2 games (28)
1–4 weeks (29.9)
$15 d (9.8)
$3 games (11)
.4 wks (9.9)
8–21 d (33.3)
7–30 d (52.0)
.21 d (25.9)
.30 d (14.0)
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Clin J Sport Med ! Volume 16, Number 6, November 2006
Caine et al
different sites.92–94 Some recent research shows history of
injury to be a significant risk factor for incident injury in
several pediatric sports.31,32,78,85 However, there are surprisingly few data that illuminate the incidence rate of re-injury
in pediatric sports. Existing percent estimates for re-injury
to the same body part (from previous and/or present season)
representing a variety of sports and participation levels range
from 6.4% to 49.0%.16,19,34,37,40,41,43,60 Incidence rates range
from 2.08 to 37.6 re-injuries per 1000 AEs.19,37,47,52
Catastrophic Injury
The worst-case scenario in pediatric sports is catastrophic injury. Unfortunately, catastrophic injuries occur in
most child and youth sports.44–46,49–51,53,55,56,95 Most data on
catastrophic sports injuries arise from case report and case
series studies. The most comprehensive picture of catastrophic
injuries in pediatric sports comes from the National Center
for Catastrophic Sports Injuries (NCCSI),96 which has been
tracking these incidents in high school sports in the United
States since 1982.
According to NCCSI, a catastrophic injury may be direct
(brain/spinal cord injury or skull/spinal fracture) or indirect
(systemic failure as a result of exertion or by a complication
secondary to a non-fatal injury). These injuries are further
categorized as fatalities, non-fatal injuries (permanent severe
functional disability), and serious injuries (no permanent
disability but significant initial injury, for example vertebral
fracture without paralysis).
In the 23rd Annual report, NCCSI found that, during the
period 1982 to 2005, gymnastics and ice hockey are associated
with the highest clinical incidence (ie, number of incident
injuries divided by the total number of athletes at risk) of
catastrophic injuries in both male and female participants.96
However, football was the sport associated with the greatest
number (ie, count data) of catastrophic injuries overall. Of
particular concern in football is the number of preventable
indirect catastrophic injuries due to heat stroke.96 Also of
concern, is the high frequency of catastrophic injuries in
cheerleading. Between 1982 and 2005, high school cheerleading accounted for 52.1% of all girl’s high school direct
catastrophic injuries in the United States.96
Non-participation
Aside from catastrophic injury, which is usually careerending, the frequency and nature of injuries that force
retirement from sport are also of interest. Unfortunately, few
studies report on frequency of season- or career-ending
injuries. In cross-country running19 and high school football21
studies, 1.67% and 6.35% of injuries, respectively, were
season-ending injuries. In gymnastics, 16.3% to 52.4% of
dropouts37,41,97 were injured when they withdrew from the
sport. However, in addition to injury, reasons for leaving
gymnastics may also include having other things to do, not
liking the pressure, not having enough fun, and too timeconsuming.98 In a 10-year study of Australian elite gymnasts,
9.2% of female gymnasts (ages 9 to 19 yrs) retired as a result
of injury.99
TABLE 7. Sports Injuries for Youth Age 0–14 Yrs in 1998 USD. Statistics Include: Doctor/clinic, Emergency Department,
Ambulatory Surgery, Hospital Admissions via Emergency Department, and Hospital Admissions Direct*
Baseball
Basketball
Boxing
Diving
Football
Golf
Gymnastics
Hockey
Field Hockey
Ice Hockey
Horseback Riding
Martial Arts
Skiing (snow)
Soccer
Softball
Swimming
Tennis
Track & Field
Volleyball
Weight Lifting
Wrestling
Estimated
Wtd Cases
Medical
Work Loss (USD)
Pain and
Suffering (USD)
Legal &
Liability (USD)
Average Total
Cost (USD)
232,020
526,359
1,798
11,074
413,431
25,696
63,677
37,669
5,478
20,877
31,911
15,077
30,140
205,475
67,238
49,708
10,380
18,566
45,293
25,781
41,962
228,417,849
431,257,018
1,885,339
17,902,034
442,392,827
32,701,777
60,747,152
36,699,949
3,405,098
17,155,492
70,669,289
9,921,896
42,012,615
170,808,524
54,479,698
54,446,660
9,014,759
16,123,740
27,771,395
19,935,927
36,010,463
476,281,548
1,211,396,382
4,764,160
24,004,634
1,290,349,210
43,288,950
184,381,597
67,921,352
8,831,084
41,944,697
187,296,475
33,402,857
135,597,521
564,646,350
121,950,548
105,864,039
28,353,458
50,228,438
80,172,528
43,314,614
122,157,588
2,302,335,951
4,913,716,473
24,674,719
133,881,019
4,873,510,305
249,405,387
681,580,233
353,711,565
37,396,538
207,350,630
526,493,482
141,589,283
412,375,431
2,125,337,301
519,099,229
362,729,916
95,582,827
205,214,459
356,601,757
244,952,518
489,888,598
10,438,322
22,759,127
108,736
610,212
22,932,284
1,129,548
3,216,885
1,591,011
172,290
924,931
2,723,093
641,892
2,048,017
9,930,668
2,414,391
1,815,631
461,513
942,689
1,612,577
1,069,865
2,249,599
3,017,473,669
6,579,129,000
31,432,954
176,397,899
6,629,184,627
326,525,662
929,925,868
459,923,877
49,805,010
267,375,750
787,182,339
185,555,928
592,033,584
2,870,722,842
697,943,867
524,856,246
133,412,556
272,509,326
466,158,258
309,272,924
650,306,247
*Source: U.S. Consumer Product Safety Commission.
510
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Clin J Sport Med ! Volume 16, Number 6, November 2006
Economic Cost
Injury costs go well beyond the cost of a visit to the emergency room or family physician. The economic impact involves
medical, financial, and human resources at many levels.100
Indeed, as Miller et al101 delineate in their analysis of injury
costs to the public, the cost of an injury can include (1) such
direct costs as emergency medical services, physician, hospital,
physical therapy, medicine, and possibly funeral/coroner costs;
and (2) such indirect costs as parents’ lost wages and fringe
benefits, employers’ lost productivity, and administrative costs
for processing a myriad of insurance or public welfare programs. Unquantifiable costs are the harmful effects of a sports
injury on the psychosocial life of the individual or family owing,
for example, to economic dependence or social isolation.100
Even though most injuries are not severe, their economic
burden to the public (see Table 7), according to the National Youth Sports Safety Foundation,102 mounted up to almost
USD 26 billion for SRE-related injuries to youth ages 0 to 14
years in 1998! Clearly, more than simply the injured child is
affected by childhood injuries.
There are few investigations into the costs associated
with specific sports or with specific injury types. Several
studies report on the number of injuries requiring surgery
(range = 1.2% to 5.9%) but did not include estimates of
economic costs.16,17,34,36,41,85 In 1999, hospital costs associated
with skiing injuries were estimated as high as USD 22,000 to
28,000 per patient103,104 with additional outpatient costs
around USD 15,243 per patient and financial impact to the
family at USD 1500 per patient.104 In snowboarders, by comparison, the average hospital costs were USD 10,000.105
In 2000, de Loës et al106 reviewed data from 1987 to
1993 on knee injuries across 12 sports in male and female
Swiss youth ranging in age from 14 to 20 years. They found
the mean medical costs for males to be USD 1097 per knee
injury and USD 1131 per knee injury for females; these figures
reflect the Swiss insurance program. In the United States
system, an ACL rupture in a female high school basketball
player can cost around USD 17,000 for reconstruction and
rehabilitation and a total direct impact of approximately USD
119 million per year for this population alone.56
Obviously, the ‘‘cure’’ for such high costs has to lie in
preventing as many pediatric injuries as possible. To do that,
we need to continue showing how high the economic impact
is on public resources in order to win much-needed funds
for research into effective injury prevention measures. For
example, Newsome et al107 reported that the lifetime dental
costs of a tooth avulsion that is not properly preserved or
transplanted can be more than USD 10,000, but custom-fitted
mouth guards that can reduce the risk significantly can be
made available for less than USD 10.
CONCLUSIONS
This review has shown that good injury data can help
to identify the nature and extent of injury problems. Reliable
descriptive data also provide a basis from which causes
of injury can be probed and the effectiveness of preventive
measures evaluated. In the past, data on the incidence and
distribution of pediatric sports injuries have led directly to
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Pediatric Sport-Related Injuries
suggestions for injury prevention that, once implemented, have
helped to control and prevent the occurrence of severe sports
injuries such as eye injuries in hockey and spinal injuries in
football. However, the most reliable suggestions for prevention
are still believed to emerge from analytical epidemiological
studies.
Above all, our overview of the pediatric injury literature
underscores the need for well-designed descriptive epidemiological studies to determine the nature and extent of the
public health burden imposed by pediatric sport-related injuries. The lack of quality descriptive epidemiological data on
pediatric sports injuries is difficult to understand given the
increased levels of participation and training which characterize child and youth sports today. Coordinated and welldesigned research programs can eliminate many of the
methodological shortcomings and study differences in the
current literature that were identified throughout this review.
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