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Acceptable Level of Injury Risk

Risk of athletic injury is problematic at all levels, from youth to professional sport. Sport sociologists frequently discuss why people select sports in which to participate. Is it based on likes and dislikes or skill level? For many parents, allowing their child to participate or not may be based on risk. The relative safety of one sport over another may deter parents from allowing their sons or daughters to participate in any given sport. Perhaps the rationale for sport selection varies as a child ages and matures. Parents may allow some sports at a certain age and allow different sports at a more mature age. USA Football, a national governing body for youth football (partially funded by the National Football League), recently reported that participation among players ages 6 to 14 years fell from 3 to 2.8 million in 2011, a 6.7% decline.26 The nation’s largest youth football program, Pop Warner, saw participation drop 5.7% from 2010 to 2011 and another 4% drop between 2011 and 2012.26 Concussion risk and awareness may play a part in parents’ reluctance to allow their children to participate in football. Although concussion has occurred in other sports, the IR is significantly higher in American football than other sports. However, when looking at injuries beyond concussion, female cross country running has the highest IR/1000 AEs (15.9).7


Prevention programs can be developed once injury mechanisms and risk factors are well understood. Many times, ISS provides necessary data to identify injury clusters and trends with sport. Moreover, it can ascertain if longstanding assumptions are facts or misconceptions. A 5-year study of NCAA ISS data published in 19 9 527 revealed a significant increased risk of ACL injury in female collegiate soccer and basketball athletes when compared to male soccer and basketball athletes. This large sample over a 5-year period supported the anecdotal evidence that women were at higher risk of ACL tears, at least in basketball and soccer. This information then led to a surge in research trying to explain the root cause of the gender difference and determine how to reduce the risk for female athletes. A critical component in determining the effectiveness of prevention interventions is for data to be collected pre- and postintervention. Early prevention interventions only had the postintervention incidence data and, thus, do not have the ability to confirm positive findings.1,2 In order for ISS to truly impact prevention intervention procedures, ongoing prevention studies will need to use several epidemiology and surveillance techniques to assess the effectiveness of these programs.

Staffing and Coverage

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For athletic trainers working at a middle school, high school, or a college, staffing and proper coverage are always areas of concern. Athletic trainers can use ISS data to identify sports that are of higher risk for injury and adjust coverage plans accordingly. Also, by tracking injury occurrence over several years, athletic trainers can identify the time of year or type of events that are associated with higher rates of injury. For example, do multiday events, such as a wrestling tournament, warrant more staff than a single match?

The NATA Recommendations and Guidelines for Appropriate Medical Coverage of Intercollegiate Athletics (AMCIA) were established in 2000 to create a more justifiable and objective system for determining the health care needs of each institution. The most up-to-date injury information provided by the NCAA ISS further supported AMCIA Recommendation and Guidelines amendments in 2003, 2006, and 2010. These empirical data informed changes in calculating health care units and were dictated by increased participation opportunities and IR changes as reported by NCAA ISS.28

Appropriate medical coverage, as determined by the NATA Committee of College and University Athletic Trainers involves basic emergency care during sports participation and other health care services for student-athletes. This includes27 but is not limited to the following:

• Determination of athletes’ readiness to participate

• Injury prevention

• Evaluation of athletic injuries/illnesses

• Immediate treatment of athletic injuries/illnesses

• Rehabilitation and reconditioning of athletic injuries.

These recommendations are for collegiate level athletics and are not requirements. Sports that are considered lower risk include baseball, softball, cross country, swimming, outdoor track, and tennis, must have an individual physically present who possesses the minimum qualifications as stated in the NCAA Sports Medicine Handbook (cardiopulmonary resuscitation, first aid, automated external defibrillator, and bloodborne pathogen training). Sports considered moderate risk, including women’s basketball, field hockey, lacrosse (men’s and women’s), soccer (men’s and women’s), indoor track, and volleyball, should have a certified athletic trainer or a designated staff member with minimal qualifications. If the athletic trainer is not present, he or she must be able to respond in less than 5 minutes. Sports with increased risk include football, ice hockey (men’s and women’s), wrestling, men’s basketball, and gymnastics should have a certified athletic trainer physically present for all practices.27 Some institutions may determine from their own ISS data that sports considered lower risk outside may be at a higher risk during their indoor season (ie, baseball in a gymnasium) and, therefore, justify having a certified athletic trainer at these practice events. Overall, AMCIA recommendations can be critical to determining if staffing is limited and provide factual information to justify additional staffing.

Bringing It Together

Sports injury surveillance has formed the backbone of injury epidemiology research, serving to highlight the types and patterns of injury that warrant additional investigation. Injury surveillance has been integral in guiding rule changes, improving equipment, and developing training regimens that decrease modifiable risk factors. Limited by definitions and methodology, ISS is not entirely uniform across collectors, agencies, or sports. With this broad scope, ISS can, at times, lack context. Specific issues revolve around a lack of standardized nomenclature (definition of a reportable injury, selection criteria [new injury, recurrent injury], severity [time lost]), lack of standardized exposure rates (definition for exposures [events, hours]; varying denominator variables [100 or 1000 AEs]), and data collection procedures (reporting time [monthly, weekly], personnel [trained, medical background]). Overall athlete participation is a critical component of surveillance because the actual number of players that participated in any given sport or event is used to calculate AE. Although attempts have been made to create consistency across databases, the most critical factor for all injury data is hindered by the exposure denominator. Although it is recommended to use AE 1000, it is not universally reported this way. Therefore, sport injury specialists will continue to review each study as separate case reports, limiting their abilities to make interstudy comparisons or to generalize across types of populations.

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