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Objectives: Limited research exists describing youth football injuries, and many of these are confined to specific regions or communities. The authors describe U.S. pediatric football injury patterns receiving emergency department (ED) evaluation and compare injury patterns between the younger and older youth football participants.
Methods: A retrospective analysis of ED data on football injuries was performed using the National Electronic Injury Surveillance System–All Injury Program. Injury risk estimates were calculated over a 5-year period (2001–2005) using participation data from the National Sporting Goods Association. Injury types are described for young (7–11 years) and adolescent (12–17 years) male football participants.
Results: There were an estimated total of 1,060,823 visits to U.S. EDs for males with football-related injuries. The most common diagnoses in the younger group (7–11 years) were fracture/dislocation (29%), sprain/strain (27%), and contusion (27%). In the older group (ages 12–17 years), diagnoses included sprain/strain (31%), fracture/dislocation (29%), and contusion (23%). Older participants had a significantly higher injury risk of injury over the 5-year study period: 11.0 (95% confidence interval [CI] = 9.2 to 12.8) versus 6.1 (95% CI = 4.8 to 7.3) per 1,000 participants/year. Older participants had a higher injury risk across all categories, with the greatest disparity being with traumatic brain injury (TBI), 0.8 (95% CI = 0.6 to 1.0) versus 0.3 (95% CI = 0.2 to 0.4) per 1,000 participants/year.
Conclusions: National youth football injury patterns are similar to those previously reported in community and cohort studies. Older participants have a significantly higher injury risk, especially with TBI.
American football is a popular sport, with an estimated 11.9 million participants in 2006 and 5 million frequent (40 + days/year) participants.1 Young and adolescent (ages 7–17 years) football participants comprise an estimated 53.4% of this total, or approximately 6.35 million participants.1 Young athletes, when compared to older athletes, have a higher body surface–to–mass ratio, open physes, and immature motor skills, all of which can contribute to greater injury.2 Injuries in the young athlete can have significant consequences in later life based on the unique physiology of rapidly growing children,3,4 including limb length discrepancies and early osteoarthritis.5
Previously published research on football injuries has been primarily focused on injuries of high school6–11 or collegiate athletes.10,12,13 Several prospective cohort studies have examined injuries in the youth football programs of individual communities over one or two seasons.3,4,14–18 Most of these were smaller studies, with the largest including 5,128 young football participants.3 Currently, there is very limited information about youth football injuries on a national scale. Furthermore, to our knowledge there are no studies that directly compare the youngest participants to adolescent and high school participants. These deficits are compounded by problems with generalizability due to large variations in injury reporting between studies. This is due in part to the challenge of defining what constitutes an injury in this group.9 The classification of “injured participants” in the literature is varied and has been defined in terms of the sport (missed all or a portion of a game or practice), by self-assertion, by testament of an athletic trainer or coach, or by seeking medical treatment. Additionally, the amount of exposure has been calculated in varying manners including any participation, by number of games, by number of game minutes, or by number of plays. Given the increasing levels of participation in football and the lack of nationwide data on youth football injuries, we examined national injury patterns in youth and adolescent football participants who underwent emergency department (ED) evaluation and compared injury patterns of very young participants with those of adolescents.
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From 2001 to 2005, there were an estimated 1,111,917 ED visits for children aged 7 through 17 years for football-related injuries occurring at school or sport/recreation (Table 1). Males represented the large majority of these injuries (n = 1,060,823). The number of injuries in male 12- to 17-year-old participants was approximately four times that of younger participants during the study period. The overall male injury risk over the 5-year study period for ages 7–17 was approximately 9.5 per 1,000 participants/year (95% CI = 7.9 to 11.1). The annual injury risk during the study years for the older participants group (12–17 years) and the younger participants (7–11 years) is depicted in Figure 1.
Table 1. Demographics of Football Injuries in Athletes Presenting to EDs, United States, 2001–2005
|7–11 years old|
|12–17 years old|
Figure 1. Annual injury risk for male football participants presenting to emergency departments (EDs), by age group, United States, 2001–2005.
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The younger male participants had an injury risk of approximately 6.1 per 1,000 participants/year (95% CI = 4.8 to 7.3; Table 2). Fracture was the most common diagnosis, followed closely by sprain/strain and contusion. Commonly injured body parts in the younger participants included arm/hand (43.0%), followed by leg/foot (23.7%) and head/neck (19.0%).
Table 2. Football Injury Characteristics of Male Participants Presenting to EDs by Age Group, United States, 2001–2005
|Characteristic||Males||Injury Risk Ratio‡|
|Age 7–11 years||Age 12–17 years|
|n*||Injury Risk† (95% CI)||n*||Injury Risk† (95% CI)|
|Total injuries||206,149||6.1 (4.8, 7.3)||854,674||11.0 (9.2, 12.8)||1.8|
|Injuries by diagnosis|
| Fracture/dislocation||60,411||1.8 (1.4, 2.2)||248,940||3.2 (2.6, 3.8)||1.8|
| Sprain/strain||56,499||1.7 (1.3, 2.5)||261,084||3.3 (2.8, 3.9)||1.9|
| Contusion||55,833||1.7 (1.3, 2.5)||196,569||2.5 (2.1, 3.0)||1.5|
| Laceration||13,393||0.4 (0.3, 0.5)||47,139||0.6 (0.5, 0.7)||1.5|
| TBI||10,977||0.3 (0.2, 0.4)||64,458||0.8 (0.6, 1.0)||2.7|
| Other||8,977||0.3 (0.1, 0.4)||36,290||0.5 (0.3, 0.7)||1.7|
|Injuries by mechanism|
| Struck by/against||100,414||3.0 (2.3, 3.6)||410,438||5.3 (4.3, 6.2)||1.8|
| Overexertion||35,583||1.1 (0.8, 1.3)||184,266||2.4 (2.0, 2.2)||2.2|
| Fall||37,272||1.1 (0.8, 1.4)||112,209||1.4 (1.1, 1.8)||1.3|
| Unknown/unspecified/other||32,881||1.0 (0.7, 1.3)||147,762||1.9 (1.5, 2.3)||1.9|
The overall injury risk over the 5-year study period for the older male participants’ group was 11.0 per 1,000 participants/year (95% CI = 9.2 to 12.8; Table 2). The most common diagnoses were sprain/strain, fracture, and contusion. The most common body part injured was arm/hand, with 37.4% of all injuries. Other common sites of injury included leg/foot (27.4%) and head/neck (17.4%).
In examining the injury risk ratios of the two groups (Table 2), the overall injury risk ratio for the 5-year period between groups was 1.8, with the older age group demonstrating a higher risk of injury across all types of injuries. When examining the injuries by ED diagnosis, older participants were 2.7 times more likely to have a TBI, almost twice as likely to suffer a strain or sprain (1.9), and 1.8 times more likely to experience a fracture when compared with the younger participants. Fracture, which was the leading diagnosis in the younger group, was replaced by sprain/strain as the leading diagnosis in the older group. Younger participants had a higher proportion of arm/hand injuries (43.0% vs. 37.4%), but injury site distribution was fairly similar in both groups (Table 3).
Table 3. Proportions for Body Parts by Age Group of Football Injuries Presenting to U.S. EDs, 2001–2005
|Injuries by Body Part||Age 7–11 Years||Age 12–17 Years|
|National Estimate*||% of Total|| 95% CI||National Estimate*||% of Total|| 95% CI|
|Head/neck||39,225||19.0||16.8, 21.3||148,955||17.4||16.1, 18.8|
|Arm/hand||88,509||43.0||40.6, 45.3||319,074||37.4||36.2, 38.5|
|Upper trunk||21,194||10.3||8.7, 11.9||117,561||13.8||13.0, 14.5|
|Lower trunk||8,015||3.9||3.0, 4.8||30,791||3.6||3.1, 4.1|
|Leg/foot||48,745||23.7||21.9, 25.4||233,599||27.3||26.1, 28.6|
|Other|| 316†||0.1||0.0, 0.4||4,294||0.5||0.3, 0.7|
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Previous research describing football injuries has been largely confined to examining cohorts over one or two seasons, usually from a single community or region. To our knowledge, our study is the first to use a nationally representative data set to describe injuries to young football participants that require ED evaluation and then compare them to older adolescent football participants.
Previous research has identified that many injuries incurred by football participants are minor.3,16 Our finding that fractures are the most common injury diagnosis in the younger age group and second most common in the older age group most likely reflects the increased level of acuity with this database of injuries receiving ED evaluation. It should be noted, however, that using ED-treated injuries does create some difficulty in comparing our findings with previous research on youth football injuries.
Over the 5-year study period, we found that older youths (ages 12–17 years) appear to have an increasing annual injury risk, while the younger participants had a relatively constant injury risk. We do not have an explanation for this, but can speculate that over this 5-year period, adolescent football participants may have been at increasing risk of injury due to less conditioning, increased weight resulting in more force, increased length of playing seasons, or playing more aggressively or because of adolescent football rule modifications. This worrisome trend in the older age group encompasses high school football programs, programs that already have been reported to have the highest injury rate for high school athletics.25 Additional research will be needed to determine if this trend continues and whether more focused analysis for its causative factors is warranted.
In comparing injury diagnoses in the older group with the younger group, we found that TBI, sprain/strain, and fracture/dislocation were significantly more common in the older age group. This is troublesome given that TBI and fracture/dislocation are two of the most serious injury diagnoses. Others have also reported that increasing age is associated with increasing risk of fracture,17,18 and Shankar et al.10 have noted that injured high school football participants have a greater proportion of fractures and concussions than collegiate football athletes. Furthermore, this is consistent with Powell and Barber-Foss,26 who found that high school football accounts for the majority (63%) of mild TBI in all high school athletics.
Arm/hand was the location with the highest proportion of injuries in our study in both age groups. This is consistent with previous studies of younger participants,3,14,18,27 but conflicts with the findings of several high school football studies that reported the lower extremity to be the most common site.6,7,9–11 Again, this may reflect the difference in our data set, which includes only injuries resulting in an ED evaluation, so does not include injuries treated only on the field.
Our findings support the need for continued efforts in injury prevention and control directed at youth football. Radelet et al.27 asserted that “youth football should be a priority for injury studies,” and we concur. Furthermore, these findings suggest the need to direct further prevention efforts within the sport. Others have made recommendations regarding mechanisms for reducing sports injuries including preparticipation physicals, sporting event medical coverage, adequate training of coaches, adequate hydration, enforcement of game rules, and proper equipment.2,28 Although these approaches have already been used with some success in football,25,28 these interventions need to be continually modified and then tested specifically within this age group to further reduce injury risk in young athletes.
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Our estimates of injury involve some potential biases associated with the use of NEISS-AIP for injury frequency and NSGA’s participation data. By examining NEISS-AIP ED data, we underestimate minor football injuries that are not treated in an ED setting. Although these minor injuries have less serious medical consequences, they still may restrict participation, as well as cause pain. Similarly, other significant injuries might be evaluated primarily by a specialist or in an office-based practice or by an on-field physician and not be evaluated in the ED.
The NEISS-AIP allows for only the most severe injury to be coded in the case of multiple injuries and thus may underreport less serious injuries. Conversely, extreme injuries resulting in fatalities are not fully captured in NEISS-AIP (patients who were dead on arrival or died in the ED are excluded) and were excluded from our analysis. Thus, we cannot make any inference from our data on the incidence of fatal injury occurrence in the study population. All of these factors would lead to an underestimation of the frequency of injuries and injury rate.
By restricting location codes to school and place of recreation or sport, we attempted to minimize the potential for including injuries not occurring in organized football settings. While it is likely that we nevertheless included some nonorganized football injuries, and this would lead to overestimation of the problem, it is also possible that we missed organized football injuries that were not coded as football related. This possibility could offset any overestimation, although we cannot be sure where the balance lies.
The participation data are a self-reported mail survey of a nationally representative sample. A participant was included if reporting participation at least one time over the past 12 months. Thus, the numbers may overestimate the number of participants, causing a bias of underreporting rates. In addition, using the NSGA’s data for participation for participants 7–17 years in calculating injury rates has the limitation of not accounting for sampling error. Our denominator was not considered a random variable; it was assumed that the denominator was our population parameter or, simply, our sample size. We recognize that this is an assumption of utilizing an ecologic study design, but currently there is no better way to estimate the number of adolescents playing football in the United States. All of our analyses were done using visits to an ED by young and adolescent male football participants and are not necessarily extrapolated to female participants in these age groups.