Eye Protection and Risk of Eye Injuries
in High School Field Hockey
Peter K. Kriz, MDa, David Zurakowski, PhDb, Jon L. Almquist, VATL, ATCc, John Reynolds, VATL, MS, ATCc, Danielle Ruggieri, BAd,
Christy L. Collins, PhDe, Pierre A. d’Hemecourt, MDf, R. Dawn Comstock, PhDg
OBJECTIVE: To determine if injury rates among female field hockey players differ before and after
abstract
implementation of a national mandate for protective eyewear (MPE).
METHODS: We analyzed girls’ field hockey exposure and injury data collected from national (High
School Reporting Information Online [RIO]) and regional (Fairfax County Public Schools) high
school sports injury databases in 2 seasons before (2009/10 and 2010/11) and 2 seasons after
(2011/12 and 2012/13) a national MPE.
RESULTS: The incidence of eye/orbital injuries was significantly higher in states without MPE (0.080
injuries per 1000 athletic exposures [AEs]) than in states with MPE (before the 2011/12 mandate) and
the postmandate group (0.025 injuries per 1000 AEs) (odds ratio 3.20, 95% confidence interval
1.47–6.99, P = .003). There was no significant difference in concussion rates for the 2 groups (odds ratio
0.77, 95% confidence interval 0.58–1.02, P = .068). After the 2011/12 MPE, severe eye/orbital injuries
(time loss .21 days) were reduced by 67%, and severe/medical disqualification head/face injuries were
reduced by 70%. Concussion rates for field hockey (0.335 per 1000 AEs) rank third among girls’ sports
included in the High School RIO surveillance program.
CONCLUSIONS: Among female high school field hockey players, MPE is associated with a reduced
incidence of eye/orbital injuries and fewer severe eye/orbital and head/face injuries. Concussion
rates did not change as a result of the national MPE. Concussion remains the most common injury
involving the head and face among female field hockey players, prompting further inquiry into
potential effects of adopting protective headgear/helmets.
a
Division of Sports Medicine, Departments of Orthopedics and Pediatrics, Warren Alpert Medical School, Brown
University, Rhode Island Hospital/Hasbro Children’s Hospital, Providence, Rhode Island; bDepartments of
Anesthesia and Surgery and fDivision of Sports Medicine, Boston Children’s Hospital, Harvard Medical School,
Boston, Massachusetts; cFairfax County Public Schools, Falls Church, Virginia; dProvidence College, Providence,
Rhode Island; eOhioHealth Research and Innovations Institute, Columbus, Ohio; and gColorado School of Public
Health and University of Colorado School of Medicine, Aurora, Colorado
Dr Kriz conceptualized and designed the study; Drs d’Hemecourt and Comstock assisted with study
design; Mr Almquist, Dr Collins, and Dr Comstock designed the data collection instruments;
Mr Almquist, Mr Reynolds, Dr Collins, and Dr Comstock coordinated and supervised data collection
at one of the two sites; Dr Kriz and Ms Ruggieri collected and analyzed data from the two databases
and drafted the initial manuscript; Dr Zurakowski carried out the statistical analyses; Drs Kriz and
Zurakowski contributed tables and figures; Drs Zurakowski, d’Hemecourt, and Comstock reviewed
and revised the manuscript; and all authors approved the final manuscript as submitted.
The content of this report is solely the responsibility of the authors and does not necessarily reflect
the official views of Prevent Blindness America or the Centers for Disease Control and Prevention.
www.pediatrics.org/cgi/doi/10.1542/peds.2015-0216
DOI: 10.1542/peds.2015-0216
WHAT’S KNOWN ON THIS SUBJECT: A previous
national study conducted over 2 seasons by this
group of authors demonstrated the effectiveness
of mandated protective eyewear in reducing eye/
orbital, concussive, and head/facial injuries in
high school girls’ field hockey.
WHAT THIS STUDY ADDS: Data collected from
regional/national high school sports injury
surveillance databases by certified athletic
trainers over 4 seasons has shown that
nationally mandated protective eyewear results
in a greater than 3-fold reduced risk of eye/
orbital injuries in girls playing high school field
hockey.
Accepted for publication June 1, 2015
Address correspondence to Peter Kriz, MD, 2 Dudley St, Ste 200, Providence, RI 02905. E-mail:
[email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2015 by the American Academy of Pediatrics
PEDIATRICS Volume 136, number 3, September 2015
ARTICLE
Field hockey remains a popular high
school (HS) sport for girls in the
United States, with participation rates
increasing by 28% from 1990 to
2014.1 Although they are infrequent,
serious eye injuries can occur, most
commonly resulting from players
being struck by the stick or ball.2–4
On occasion, eye injuries can be
catastrophic, resulting in vision loss
and permanent disability.5 In 2011,
the National Federation of State High
School Associations (NFHS) issued
a protective eyewear mandate (MPE)
requiring all HS field hockey players
to wear protective eyewear in
NFHS-sanctioned competitions.6 In
contrast, protective eyewear remains
voluntary in non-NFHS sanctioned
competitions and other field
hockey–related play, as USA Field
Hockey, the National Collegiate
Athletic Association (NCAA), and the
International Hockey Federation have
not yet endorsed eye protection
among their players.7,8
Developmental, college, and nationallevel field hockey coaches and
programs have voiced concern that
MPEs will jeopardize international
recruitment efforts (as no other
country mandates eyewear
protection) and the ability of the US
national teams to remain competitive
internationally.9 Previous studies
have shown that MPE in female HS
lacrosse players results in a virtual
elimination of eye/orbital injuries.10
METHODS
The primary objective of this study
was to compare eye/orbital injuries
during practices and games for US
players of HS girls’ field hockey for 2
seasons before and 2 seasons after
a national MPE. Secondary objectives
included examining differences
between cohorts for (1) all eye/
orbital, concussive, and head/face
injuries; (2) concussive injuries only;
(3) head/face injuries only (excluding
eye/orbital and concussive injury);
and (4) head/face and eye/orbital
injuries resulting in delayed return to
522
activity (time loss [TL] .21 days
and/or medical disqualification [DQ]
for remainder of season). These
secondary objectives were chosen
because critics of protective eyewear
have cited concerns that it obscures
peripheral vision and can lead to more
aggressive play, and thus may result in
players sustaining more concussions
or head/face injuries owing to
increased player-player contact.
A prospective cohort study was
conducted during 2 seasons of play
immediately before (fall 2009 and fall
2010) and immediately after (fall
2011 and fall 2012) a national MPE in
girls’ field hockey exercised by the
NFHS (effective fall 2011). The study
population was US players of HS girls’
field hockey. Before the national MPE,
cohorts were defined by their
participation in a state interscholastic
league either with or without
a protective eyewear mandate. As of
fall 2011, all US girls’ HS field hockey
players were mandated to wear
protective eyewear. Inclusion criteria
were HS field hockey; play occurring
during HS-sanctioned seasons; and
participating HS covered by a certified
athletic trainer (AT). Exclusion criteria
were injuries sustained during field
hockey play unrelated to practice or
competition; off-season field hockey
practices or competitions; or activities
unrelated to field hockey practices or
games (eg, injury in recreational
soccer, locker room horseplay).
Given the nature of the study design
(retrospective data analysis captured
by prospective longitudinal
surveillance programs, no intervention
performed, no personal data collected),
informed consent was not obtained
from study participants. Institutional
review board approval was granted
from Rhode Island Hospital.
Injury surveillance systems used in this
study included (1) High School
Reporting Information Online (RIO),
a validated, Internet-based data
collection tool developed and used by 1
author (RDC) for tracking sports injury
epidemiologic data including athlete
exposure and injury information, and (2)
Fairfax County (Virginia) Public Schools
(FCPS) Athletic Training Program,
a large public school system with 25
member high schools. High School RIO’s
quality measures are reported
annually in on-line reports (http://www.
ucdenver.edu/academics/colleges/
PublicHealth/research/
ResearchProjects/piper/projects/RIO/
Pages/Study-Reports.aspx). The FCPS
database, captured via a districtmandated electronic medical recordkeeping program for injury surveillance,
was maintained by 2 authors (JLA
and JR).
ATs collected field hockey–related
athletic exposure and injury
information throughout the study. In
addition to standard variables captured
by the HS RIO and FCPS surveillance
systems, a variable was added to the
data collection: whether MPE was in
effect in the injured player’s state of HS
attendance (before fall 2011). An
athletic exposure (AE) was defined as 1
athlete participating in 1 practice or
competition. A reportable injury was
defined as one that (1) occurred as
a result of an organized HS athletic
practice or competition, (2) required
medical attention from a team AT or
physician, and (3) resulted in
restriction or alteration of the athlete’s
participation status. For each injury, the
AT completed a detailed report that
included date of injury, exposure (eg,
practice versus competition), injury
characteristics (eg, body site, diagnosis,
severity, TL), and circumstances
leading to injury (eg, mechanism,
specific activity at time of injury). Both
databases were monitored regularly
by the authors’ research teams (RDC,
JLA, and JR) to maximize compliance
and ensure data quality.
As the primary objective in this
prospective cohort study was to
ascertain whether athletes who have
exposure to MPE are less likely to
sustain eye/orbital injuries compared
with those without MPE, incidence
rates and odds ratios (ORs) were
calculated, using the z-test to
KRIZ et al
determine whether MPE led to
a significantly reduced injury rate.
Because the injury data represent
rates per 1000 AEs, generalized
Poisson log-linear regression modeling
was used to compare incidence rates
of total injuries and specific injury
types between MPE and no-MPE
groups, with the likelihood ratio test to
assess significance and ORs and 95%
confidence intervals (CIs) to estimate
the effect of MPE on the risk of
injury.11 Statistical analysis was
performed using PROC GENMOD in
SAS version 9.2 (SAS Institute, Cary,
NC). Two-tailed values of P , .05 were
considered statistically significant.
RESULTS
Overall, 206 high schools participated.
HS field hockey players sustained 415
eye/orbital, concussion, and head/facial
injuries during 624 803 athletic
exposures (0.664 injuries per 1000
AEs). Table 1 summarizes the study
population characteristics. Players from
16 of 19 states that sanction HS field
hockey were represented. Of 206
participating high schools, 148 (72%)
were large schools ($1000 students).
Of 415 injuries, 234 (56%) were
reported in the MPE group during
361 488 AEs, and 181 were reported
in the no-MPE group in 263 315 AEs.
Cohort-specific injury rates and
corresponding ORs for total injuries
(including eye/orbital and
concussion), concussive injuries,
head/face injuries (excluding eye/
orbital and concussion), eye/orbital
injuries only, and severe injuries are
summarized in Table 2.
Eye/orbital injuries recorded during
the study period included eyebrow/
eyelid lacerations, periorbital
contusions, and corneal abrasions.
Eye/orbital injuries occurred 3 times
more frequently in players from noMPE states compared with MPE
states (before the 2011/12 mandate)
and the postmandate group (0.080
injuries vs. 0.025 injuries per 1000
AEs; OR 3.20, 95% CI 1.47–6.99, P =
.003). The incidence of total injuries
PEDIATRICS Volume 136, number 3, September 2015
including eye/orbital and concussion
was 0.687 injuries per 1000 AEs in
the no-MPE group compared with
0.647 injuries per 1000 AEs in the
MPE group (OR 1.06, 95% CI
0.87–1.29, P = .54).
Regarding concussion, 116
concussions were diagnosed during
the 2 seasons after the national MPE
mandate (2011/12 and 2012/13),
compared with 93 in the 2 seasons
preceding the mandate (2009/10 and
2010/11). The concussion incidence
in the group without MPE was 23%
lower than that of the group with
MPE overall (OR 0.77, 95% CI
0.58–1.02, P = .068) during the 4season study, but this result was not
statistically significant, although it
suggests a statistical trend. The
concussion rate for field hockey
players during the 4-season study
was 0.335 injuries per 1000 AEs
(Table 1), compared with 0.392 per
1000 AEs for the 2 seasons after the
national MPE mandate and 0.282
injuries per 1000 AEs for the 2
premandate seasons. Concussions
were the most common injury,
representing 209 of 415 (50.4%)
total eye, orbital, and head/facial
injuries collected during the 4-season
study. Head/face injuries (excluding
eye/orbital and concussions)
occurred .25% more frequently in
the group without MPE compared
with the group with MPE (0.323 vs
0.252 injuries per 1000 AEs; OR 1.28,
95% CI 0.95–1.72, P = .099). After the
2011/12 mandate, severe eye/orbital
TABLE 1 Characteristics of the Study Population, 2009/10, 2010/11, 2011/12, and 2012/13 Seasons
Characteristic
Total injuries (eye/orbital, concussion, head/facial)
Total AEs
MPE
No MPE
High School RIO
FCPS
High schools
HS-RIO
FCPS (25 schools/season)
Large schools ($1000 students)
High School RIO
FCPS
Small schools (,1000 students)
High School RIO
FCPS
States participating
High School RIO
FCPS (Virginia)
Age range, y
Injuries
Eye/orbital
Concussion
Head/face (excluding eye and concussion)
Severe (TL .21 d)
Eye/orbital
Concussion
Head/face
Medical DQ
Eye/orbital
Concussion
Head/face
Concussion incidence rate ratio (includes MPE,
no MPE, and AEs)
2009 to 2011
2011 to 2013
2009 to 2013
212
329 601
66, 286
263 315
213 240
116 361
180
130a
50b
68c
18
50b
42d
42
0
14
13
1
14–18
203
295 202
295 202
–
158 810
136 392
117
67
50
82
32
50
35
35
0
13
13
1
14–18
415
624 803
361 488
263 315
372 050
252 753
206
106
100
148
48
100
58
58
0
16
16
1
14–18
22
93
97
16
3
9
4
11
0
5
6
0.282
8
116
79
19
1
15
3
10
0
10
0
0.392
30
209
176
35
4
24
7
21
0
15
6
0.335
Values are expressed as n unless noted otherwise.
a 39 MPE, 91 no MPE.
b All no MPE.
c 10 MPE, 58 no MPE.
d 20 MPE, 22 no MPE.
523
TABLE 2 Injuries and Risk of Injury Stratified by MPE or No MPE
Injury
Total
2009 to 2011
2011 to 2013
Concussive
2009 to 2011
2011 to 2013
Head/face
2009 to 2011
2011 to 2013
Eye/orbital
2009 to 2011
2011 to 2013
Severeb and medical DQ
2009 to 2011
2011 to 2013
a
b
MPE
No MPE
n
Incidence per 1000 AEs
n
Incidence per 1000 AEs
234
31
203
134
18
116
91
12
79
9
1
8
30
1
29
0.647
0.467
0.687
0.371
0.272
0.393
0.252
0.181
0.267
0.025
0.015
0.027
0.083
0.015
0.098
181
181
—
75
75
—
85
85
—
21
21
—
26
26
—
0.687
0.687
—
0.285
0.285
—
0.323
0.323
—
0.080
0.080
—
0.099
0.099
—
Incidence Rate Ratio (95% CI)
z-Test P Value
1.06 (0.87–1.29)
1.47 (1.00–2.15)
—
0.77 (0.58–1.02)
1.05 (0.63–1.75)
—
1.28 (0.95–1.72)
1.78 (0.97–3.26)
—
3.20 (1.47–6.99)
5.33 (0.71–39.30)
—
1.19 (0.70–2.01)
6.60 (0.89–48.23)
—
0.544
0.048a
—
0.068
0.856
—
0.099
0.061
—
0.003a
0.104
—
0.517
0.065
—
Statistically significant.
Injury requiring time off from play for .21 days.
injuries (TL .21 days) were reduced
by 67% (3 injuries during 2009/10
and 2010/11 vs 1 injury during
2011/12 and 2012/13), and severe/
medical DQ head/face injuries were
reduced by 70% (10 injuries during
2009/10 and 2010/11 vs 3 injuries
during 2011/12 and 2012/13).
TL injuries were compared between
the 2 seasons premandate, the 2
postmandate seasons, and the entire 4season study period (Table 3). No
statistically significant differences
between the MPE and no-MPE groups
were identified for each of the TL
intervals. Compared with the
premandate (2009–2011) results, there
was a relative increase in TL injuries
lasting 10 to 21 days and seasonending injuries in the postmandate
(2011–2013) seasons, with the
majority (86%) of these injuries
resulting from concussion (Table 1). In
comparison, concussive injuries made
up only 52% of severe (TL .21 days)
and medical DQ injuries in the 2
premandate seasons (2009–2011).
Table 4 compares injury mechanisms
for eye/orbital, concussion, and
head/face injuries for seasons 2009
to 2011 and 2011 to 2013, as well as
the cumulative injuries for all 4
seasons. Contact with the ball and stick
remained the most common injury
mechanism among both the MPE and
524
no-MPE groups, accounting for
a collective 36% and 28% of eye/
orbital, concussion, and head/face
injuries, respectively. Overall, playerplayer contact injuries were similar
between the MPE and no-MPE groups
(25% vs 19% of total injuries,
respectively). No statistical trends or
statistically significant differences were
identified for any injury mechanisms
between the MPE and no-MPE groups.
DISCUSSION
Evidence from our study confirms
that a national mandate for protective
eyewear among girls participating in
US HS field hockey is associated with
a 3-fold reduction in the rate of eye/
orbital injuries, without significantly
increasing frequency of player-player
contact head and facial injuries,
including concussion. Head/face
injuries (excluding eye/orbital and
concussion) occurred .25% more
frequently in the no-MPE group
compared with the MPE group.
Concussions were the most common
injury, representing 50% of all
injuries involving the head and face.
Although concussion rates increased
during the 4 seasons of data
collection, concussion rates for MPE
and no-MPE groups did not
demonstrate a statistically significant
difference. Additionally, the number of
reported severe eye/orbital and head/
face injuries decreased by 67% and
70%, respectively, when comparing
data from a 2-season time period
before and after a national MPE.
Mandated protective eyewear for HS
field hockey players is an important
injury prevention development. As in
girls’ lacrosse,10,12 epidemiologic
studies support the effectiveness of
protective eyewear mandates in
reducing eye/orbital injuries in HS
field hockey. More than 64 000 HS
athletes participate in NFHSsanctioned field hockey.1 Additionally,
.5000 athletes participate in NCAA
women’s field hockey.13 In contrast,
only 31 athletes are currently
members of the US Women’s National
Team.14 Despite the discrepancies in
these numbers, there is 1
commonality among all 3 groups:
they are all amateur athletes at risk
for sports-related injury.
Micieli et al15 recently reported on
the impact of visors on eye/orbital
injuries in professional athletes,
demonstrating an incidence of eye/
orbital injuries in the National Hockey
League (NHL) of 0.248 per 1000 AEs
during 2002/13, 3 times higher than
that among HS field hockey players in
states without MPE. Unlike the
reluctance to endorse eye protection in
amateur elite field hockey, professional
KRIZ et al
TABLE 3 Time to Return to Field Hockey After Injury
Injury
2009 to 2011
MPE
n
TL
31
,1 d
1–2 d
3–6 d
7–9 d
10–21 d
$22 d
Medical DQ
Season ending
Missing data, n
6.7
16.7
26.7
30
16.7
0
3.3
0
1
2011 to 2013 (All MPE)
No MPE
2009 to 2013
MPE
181
203
17.2
13.3
22.2
10.6
18.3
8.9
5.6
2.8
1
234
11.9
12.4
10.4
12.9
28.4
9.5
5
9.5
2
11.3
13.0
12.6
15.2
26.8
8.2
4.8
8.2
3
No MPE
181
17.2
13.3
22.2
10.6
18.3
8.9
5.6
2.8
1
Values are expressed as % unless noted otherwise.
ice hockey at various levels including
the NHL has made significant strides
in implementing mandated visor use
over the past decade.16–18 Another
study showed that 73% of NHL
players wore visors as of the 2012/
13 season, and in a relatively short
time, there will be 100% compliance
with mandatory visor use among
NHL players, based on the current
NHL grandfathering rule.19
Although one could argue that the
risk of eye/orbital injury in amateur
field hockey is one-third the risk in
professional men’s ice hockey, the
financial burden to amateur athletes
who sustain an eye/orbital injury and
their families may be substantially
higher compared with a professional
athlete because an amateur player’s
disability insurance policy (if she has
one) is unlikely to provide much
financial compensation for life- or
career-altering loss of vision.
Furthermore, because only 37% of US
public secondary schools employ
a full-time AT and only 47% of US
public secondary school athletes have
full-practice AT coverage every
afternoon,20 timely access to medical
care, as well as the level of medical
care, available to HS athletes is in
stark contrast to the tertiary levels of
medical care that professional
athletes commonly have at their
disposal. Despite the significant
strides made regarding protective
eyewear mandates in US HSsanctioned field hockey competitions,
protective eyewear remains voluntary
in practices, non–NFHS-sanctioned
competitions, showcases, tournaments,
and other field hockey–related play.
This includes large numbers of middle
school, high school, collegiate, and
national team field hockey players in
the United States. The eyesight of
nearly 70 000 US players is currently at
risk for serious injury, to allow a select
few elite amateur field hockey players
to remain competitive internationally
or to allow collegiate field hockey
teams to competitively recruit
international players.
Although concussion assessment in
US HS field hockey players was
a secondary study objective, there
were many significant findings and
trends pertaining to concussive
injury. It is important to note that in
our 4-year study, there were no
statistically significant differences in
concussion rates between groups
with and without MPE. Similarly, in
the 2-year study performed before
the national mandate, there were no
significant differences in concussion
rates between the 2 groups (OR 1.05
95% CI 0.63 to 1.75, P = .86).21
After the NFHS protective eyewear
mandate in fall 2011, the incidence
rate for concussions sustained in HS
field hockey increased from 0.285
concussions per 1000 AEs (seasons
2009/10 and 2010/11) to 0.393
concussions per 1000 AEs (2011/12
and 2012/13). At first glance, one
might infer that an eyewear protection
mandate, and perhaps the
accompanying criticisms of protective
eyewear (eg, reduced peripheral
vision), were responsible for this
increase, but a closer examination of
concussion epidemiology provides
a more likely explanation. Rosenthal
et al22 reported that during the time
period 2005/06 through 2011/12,
concussion rates reported by ATs for 9
HS sports increased from 0.23 to 0.51
concussions per 1000 AEs, with 5
sports having statistically significant
increases over this period. The authors
hypothesized that several factors
potentially contributed to this trend:
(1) concussion incidence actually
increased; (2) increased athlete
TABLE 4 Injury Mechanism for Eye/Orbital, Concussion, and Head/Face Injuries
Contact With
2009 to 2011 (n = 212)
Total Injuries, %
Ball
Stick
Player
Ground
Goal
Other
Missing data
Total
36.3
30.7
19.3
2.4
0.5
1.4
9.4
100
2011 to 2013 (n = 203)
MPE
No MPE
Total Injuries, %
n
%
n
%
Total Injuries, %
n
11
11
6
2
0
1
0
31
35.5
35.5
19.4
6.5
0.0
3.2
0.0
100
66
54
35
3
1
2
20
181
36.5
29.8
19.3
1.7
0.6
1.1
11.0
100
35.0
25.1
25.6
4.4
0.5
3.4
5.9
100
71
51
52
9
1
7
12
203
PEDIATRICS Volume 136, number 3, September 2015
2009 to 2013 (n = 415)
35.7
28.0
22.4
3.4
0.5
2.4
7.7
100
MPE
No MPE
n
%
n
%
82
62
58
11
1
8
12
234
35.0
26.5
24.8
4.7
0.4
3.4
5.1
100
66
54
35
3
1
2
20
181
36.5
29.8
19.3
1.7
0.6
1.1
11.0
100
525
monitoring by coaches, medical
personnel, parents, and athletes
themselves occurred secondary to
increased concussion awareness; and
(3) increased coverage of games/
practices by ATs occurred.22
Concussion legislation enacted in all
US states between 2009 and 201423
has inevitably led to increased
concussion education and reporting
among student-athletes, coaches,
parents, and school nurses: several
authors in our study cited a significant
increase in total number of
concussions reported after concussion
laws went into effect in their
respective states. Similarly, with evergrowing numbers of primary care
sports medicine fellowships
nationally24 and a subsequent greater
availability of sports medicine–trained
physicians for game coverage and
concussion clinic staffing, it is likely
that physician reporting of sportsrelated concussion has also increased
over the past few years. Echlin et al
reported a significantly higher
incidence of concussion with
physician-observed games compared
with games not covered by physicians
in collegiate men’s and women’s
varsity ice hockey, suggesting an
underestimation of sports concussion
in the scientific literature.25
Our study has some limitations.
Randomization was not part of the
study design, since enrollment in MPE
and no-MPE groups was
predetermined by established state
mandates for protective eyewear in
effect during the 2009/10 and 2010/
11 seasons. Additionally, small event
frequencies in specific injury
subcategories (such as severe eye/
orbital injuries [TL .21 days] and
severe/medical DQ head/face injuries
in the MPE and no-MPE groups)
prevented attaining statistically
significant results. However, clinical
significance was achieved regarding
reduction of these injury
subcategories with implementation of
MPE. Furthermore, no catastrophic
injuries were recorded during our 4season study period. Based on
526
calculations performed during our
prior publication,21 a catastrophic
injury in HS field hockey occurs every
8.3 seasons, making the likelihood of
capturing such an injury in
a relatively small sample of the total
number of national athletic exposures
in HS field hockey exceedingly rare.
Performing a prospective,
longitudinal study that collects both
injury and exposure data among all
HS field hockey participants
nationally in an effort to capture
catastrophic eye/orbital, concussion,
and head/facial injuries would be
costly and resource prohibitive.
Additionally, whereas we were able to
capture injuries and determine which
injuries occurred in states with and
without MPE, incomplete data
collection by ATs for the variable
“was the athlete wearing eye
protection at time of injury?”
prevents us from determining
whether players were wearing
protective eyewear at the time of
injury in MPE and no-MPE states.
Finally, data on the number of fouls
incurred during competition is not
captured by High School RIO, FCPS
Athletic Training Program, or any
other national database. Although it is
feasible that players were more
aggressive when playing with eye
protection, we saw no difference in
athlete-athlete contact injury rates
during our study period, which would
have been expected if play became
more aggressive over time.
Despite some limitations, our study
was able to pool and analyze data
from national and regional HS sport
injury surveillance databases from
2 seasons before and 2 seasons
after implementation of a national
protective eyewear mandate in HS
girls’ field hockey, resulting in the
largest prospective national study
examining the effectiveness of MPE
in reducing eye/orbital, concussive,
and head/facial injuries performed
to date. Future research evaluating
the performance of athletes
wearing and not wearing protective
eyewear (eg, goals, assists, fouls
committed) may be warranted to
determine the impact of protective
eyewear on skill level and player
development.
CONCLUSIONS
Among female US HS field hockey
players, a national MPE is
associated with a .3-fold reduced
risk of eye/orbital injuries and
a decreased incidence of severe
eye/orbital and head/face injuries.
Given the scientific evidence
demonstrating that mandatory
protective eyewear effectively
reduces eye injuries in field hockey
players without increasing
concomitant injury such as
concussion, research now exists to
support a policy change regarding
mandatory protective equipment in
field hockey at all amateur levels.
ACKNOWLEDGMENTS
We thank the ATs who assisted with
data collection in this study and Vito
Perriello, MD, for his lifelong
contributions to the fields of
pediatrics, sports medicine, and
injury prevention before his
unexpected death in 2009.
ABBREVIATIONS
AE: athletic exposure
AT: athletic trainer
CI: confidence interval
DQ: disqualification
FCPS: Fairfax County Public
Schools
High School RIO: High School
Reporting
Information
Online
MPE: mandate for protective
eyewear
NCAA: National Collegiate Athletic
Association
NFHS: National Federation of State
High School Associations
NHL: National Hockey League
OR: odds ratio
TL: time loss
KRIZ et al
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Funded in part by Prevent Blindness America grant 701-5215 and Centers for Disease Control and Prevention grant R49/CE001172-01. The authors also
acknowledge the generous research funding contributions of the National Operating Committee on Standards for Athletic Equipment.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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