1. Epidemiology of High School Competition and Practice Injuries
Julie Rechel
University of Richmond
My mentor, Dr. Dawn Comstock, coordinated the collection of a significant amount of nationally representative data on high school sports injuries during the school year. From her database of sports injuries, I was able to analyze injury rates, injury proportion ratios, and overall trends of p and c related injuries. She introduced me to the methodologic techniques in the field of injury epidemiology and discussed with me the significance of my results.
Ellen Yard, Dr. Comstock’s research assistant, guided me in the process of writing a scientific paper and proofread numerous drafts of my manuscript.
Mentors: R. Dawn Comstock, PhD; Ellen Yard, MPH

2. Introduction
7 million high school athletes competed in interscholastic sports during the school year
Increase of 16.1% over the past decade
1.4 million injuries
Objective: Compare practice and competition related injuries, leading to recommendations for injury prevention
According to the National Federation of State High School Associations, over 7 million high school athletes across the nation competed in interscholastic athletics during the school year, ; the number of high school athletes has increased 16.1% over the last decade.
Although athletes benefit in many ways from their participation in high school sports, including higher grade point averages, fewer school absences, and better behavior they are also at high risk of incurring sports injuries resulting from their participation in athletics.
According to the Centers for Disease Control, high school athletes sustained an estimated 1.4 million injuries during the school year.
The objective of my study was to compare the epidemiology of practice and competition injuries in high school athletes participating in nine sports. Specifically, I aimed to calculate rates of high school practice and competition injuries and describe and compare the body site, diagnosis, and severity of injuries between practice and competition.

3. Methods High School RIOTM Definition of Injury
100 nationally representative schools with ATCs
Football, soccer, basketball, wrestling, baseball, softball, and volleyball
Definition of Injury
Occurring from participation in practice or competition
Requiring medical attention
Resulting in restriction of participation for ≥ one day
Analyzed using EpiInfo and SPSS
I analyzed data from High School RIO, an internet based injury surveillance system that collected injury and exposure data from 100 nationally representative schools with certified athletic trainers. All eligible schools were categorized by geographic location and high school size. Schools were then randomly selected from each substratum to obtain 100 study schools. The certified athletic trainers at participating schools reported injury and exposure data weekly through High School RIO
The sports studied were football, boys’ and girls’ soccer, boy’s and girls’ basketball, wrestling, baseball, softball, and girls’ volleyball.
An athlete exposure was defined as one athlete participating in one practice or competition. An injury was defined as a condition occurring from participation in organized interscholastic practice or competition, requiring medical attention and resulting in the restriction of the athlete’s participation for one or more days.
Data was analyzed using EpiInfo version 6.0 and SPSS software, version Rate ratios and injury proportion rations were calculated with 95% confidence intervals and p-values.

4. RRs vs. IPRs Rate Ratio Injury Proportion Ratio
RR = (# Competition Injuries/# Competition AE)*1,000
(# Practice Injuries/ # Practice AE)*1,000
Injury Proportion Ratio
IPR = (# competition concussions/# total competition injuries)
(# Practice concussions/# total practice injuries)
Numerator – Subgroup of denominator
Magnitude of Association
Same tests for statistical significance

5. Injury Rates
4,350 injury reports correlating to an estimated 1.4 million injuries nationwide
Rates of injury per 1,000 athlete exposures
Total: 2.51
Competition: 4.63
Practice 1.69
RR=2.73, 95% CI:
Highest rates of injury in competition:
Football: 12.09
Girls’ soccer: 5.21
Boys’ soccer: 4.22
During the school year, high school athletes participating in the nine sports studied at the 100 nationally representative schools sustained 4,350 injuries. This correlates to an estimated 1.4 million injuries nationwide.
Slightly more injuries occurred in competition than in practice.
The total injury rate was 2.51 injuries per 1,000 athlete exposures, and the rate of injury was significantly higher in competition compared to practice.
Football and girls’ and boys’ soccer had the highest rates of injury in competition, while baseball, softball, and volleyball had the lowest rates of injury in competition. The highest rates of injury in practice were seen in football, wrestling and boys’ soccer.

6. Body Site Head/Face/Neck (competition vs. practice)
Body site injured differed by sport but was fairly consistent by gender.
Looking at the graphs, you can see that the majority of injuries in both practice and competition affected the lower extremities. Specifically, the most frequently injured body sites were the ankle, the head and face, and the thigh, respectively.
In most sports, Lower extremity injuries occurred in similar proportions among practice and competition injuries. However, practice related injuries in boys’ soccer players were significantly more likely to be to the lower extremities than competition related injuries. The opposite trend was seen in baseball and softball players.
Upper extremity injuries also occurred in similar proportions among practice and competition injuries. The largest difference as seen in girls’ basketball, where upper extremity injuries made up a significantly greater proportion of practice injuries compared to competition injuries. An opposite trend was seen in both boys’ and girls’ soccer, with cri more likely to be to the upper extremities than pri.
Injuries to the head/face/neck made up a higher proportion of injuries occurring in competition than in practice. Specifically, competition related injuries were over 6 times more likely to be to the head/face/neck than practice related injuries in boys’ soccer players and girls’ volleyball players.
Head/Face/Neck (competition vs. practice)
Overall; IPR=1.61, 95% CI:
Boys’ Soccer; IPR=7.74, 95% CI:
Girls’ Basketball; IPR=6.03, 95% CI:

7. Diagnosis
Sprains/strains: Higher proportion of practice injuries; IPR=1.23, 95% CI:
Fractures: Higher proportion of competition injuries; IPR=1.30, 95% CI:
Concussions:
Higher Proportion of Competition Injuries
Overall; IPR=2.02, 95% CI:
Boys’ soccer; IPR=6.94, 95% CI:
Girls’ basketball: IPR=5.83, 95% CI:
Higher Proportion of Practice Injuries
Girls’ softball; IPR=20.26, 95% CI:
Injury diagnosis differed by sport and gender.
The majority of injuries were sprains/strains, which made up a larger proportion of practice injuries than competition injuries. This trend was magnified in boys’ and girls’ soccer.
Competition related injuries were more likely than practice related injuries to be contusions, especially in soccer players of both genders.
CRI were also more likely than PRI to be fractures, particularly in boys’ soccer and volleyball players. This trend was not seen in girls’ basketball players.
Competition related injuries were more likely than practice injuries to result in concussions; this was especially true for participants of boys’ soccer and girls’ basketball. An interesting exception to this trend was seen in girls’ softball players, whose practice related injuries were 20 times more likely to be concussion than competition related injuries. Volleyball players also contracted a greater proportion of concussions during practice.

8. Severity
Injury severity was quantified as time loss, and the majority of all injuries resulted in time loss of less than a week.
CRI were more likely than PRI to cause at least 3 weeks of time loss and an end to the athlete's season or career.
5.3% of all injuries required surgery, and competition related injuries were more likely to require surgery in more sports, especially volleyball, and boys’ and girls’ soccer. This trend was not seen in girls’ softball players, whose PRI more often required surgery.
>3 Weeks or End of Season/Career; IPR=1.28, 95% CI:
End of Season/Career; IPR=1.73, 95% CI:
Surgery; IPR=1.62; 95% CI:

9. Limitations
Only high schools with NATA-affiliated athletic trainers were eligible for participation
Definition of injury as resulting in time loss of one day restricted number of reported injuries
Definition of an athlete exposure as a single competition or practice is less precise than a definition based on minutes of exposure
As with all studies, this study had limitations
Only high schools with NATA-affiliated athletic trainers were eligible for participation, but this increased quality and consistency of reported data
Definition of injury as resulting in time loss of one day restricted number of reported injuries but reduced burden on participating athletic trainers
The definition of an athlete exposure as a single competition or practice is less precise than a definition based on minutes of exposure but a more precise definition was not logistically practical.

10. Injury Prevention
Incorporate drills of high-risk situations into practice
Enforce wearing of safety equipment in practice as well as competition
Focus attention on reducing sprains/strains
Educate coaches and players on symptoms of concussion to increase reporting
Because of the increased rate and severity of competition related injuries, players must be prepared for the increased intensity of competition by incorporating drills of high-risk situations encountered in competition into practice.
Many injuries can be prevented through wearing safety equipment, and officials and coaches often enforce these prevention measures in competition more than in practice. The wearing of safety equipment in practice as well as competition may reduce many practice related injuries that result from simple negligence.
Softball Players Example
Since sprains and strains make up the majority of injuries, attention should be focused on reducing these types of injuries through more appropriate preseason neuromuscular training and increased vigilance during this conditioning.
Concussions occur seemingly more often among female athletes, possibly because many male players believe their symptoms are not serious enough to be reported or because coaches and parents of females are more cautious when dealing with potential concussions. Therefore, all coaches, players, and athletic trainers, must made aware of concussion symptoms and be encouraged to report them.
Contrary to popular belief, sports injuries are not “just a regular part of playing the game”. Sports injuries occur in predictable patterns that, when analyzed in epidemiological injury studies such as mine, can be prevented through appropriate intervention techniques. Not only coaches and athletic trainers, but also injury epidemiologists, doctors of sports medicine, and parents of student athletes need to play a role in studying injuries in order to recognize these predictable patterns and implement methods to decrease injury rates in high school athletes.

11. Conclusion
Rates and patterns of high school sports injuries differ between practice and competition
Sport-specific studies will help coaches develop targeted techniques to lower injury rates
Reducing injury rates should be a priority
Injury rates and patterns of body sites injured, severity, and diagnosis of high school sports injuries differ between competition and practice.
Sport-specific studies should investigate the mechanisms of injuries in both competition and practice in order to educate coaches and athletic trainers on techniques to lower injury rates in both practice and competition among high school athletes
As previously stated, participation in high school athletics is rising, and the benefits of such participation are well documented. Meanwhile, an obesity epidemic is raging in our nation. As public health officials promote exercise among teens in order to promote a healthy lifestyle and curb this epidemic, injury epidemiologists, coaches, and athletic trainers must do their part to make athletics as safe as possible for all athletes.

12. The Importance of Injury Epidemiology