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When Did the Injury Occur?

Most surveillance systems require a time frame for the injury, based on when the activity occurred. This is typically the season (pre-, post-, or offseason). If the injury occurred during a tournament, the surveillance systems may request information regarding the round, heat, or group.14 For example, a swimmer suffered a bicipital strain in the quarter final heat of a postseason competition. This information allows researchers to consider the role of fatigue in risk of injury. Designating time frames for injury has advanced the understanding of when injuries are more likely to occur.

Cause of Injury

The mechanism of injury is consistently reported.2,7,8,12,14 Typically, one focuses on the extrinsic risk factors. The primary classifications are overuse, noncontact trauma, contact with opponent/teammate, contact with object (moving or stationary), and recurrent/previous injury.14 Overuse is an injury that occurs due to repeated microtrauma with an insidious onset, meaning there was no single, identifiable event that caused the injury. Traumatic injuries are caused by a single, identifiable event, such as a collision with an opponent. Mechanisms can be further defined as noncontact, meaning there was no contact with another person or object, or contact, which are categorized as some degree of collision with another person, moving, or stationary object. The ISS may ask whether the action causing the injury was a violation of a sport rule.8,14 These data allow people to track how well rules are implemented and followed and if they are effective in limiting injury. The type of surface played on or other environmental variables may be requested because they may have contributed to the mechanism. Playing surfaces can include types of grass, artificial grass or turf, or types of indoor playing surfaces or floor materials. Some surveillance systems may have a location for reporting hazards or worn surfaces (uneven surfaces) and weather if considered a factor (slippery surface).

Additional challenges arise when attempting to use surveillance data to research specific injuries, such as comparing noncontact and contact anterior cruciate ligament (ACL) injuries. These are additional terms, specific to an ACL injury, that appear to be inconsistent in the literature.11 This focus in epidemiology is more on mechanism of injury or cause of injury. Most databases do not use these terms. Therefore, if epidemiologists want to investigate noncontact and contact anterior cruciate ligament injuries, this information would need to be added to the reporting information.

What Is a Definable Injury?

Clinically, definitions of injury often overlap with a diagnosis. An athletic trainer may evaluate and diagnose a basketball player with an injury based on the following:

• Location (ankle)

• Onset (acute [traumatic, macrotrauma] or chronic [insidious, overuse, microtrauma])

• Type of injury (sprain)

• Mechanism of injury (inversion)

• Severity (second degree)

This same clinician may determine severity of the injury by the following:

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• Need for medical attention (evaluated and immediate treatment provided)

• Length of disability (restricted from practices and games for 3 days)

• Recurrence of injury (third ankle sprain in 8 months)

If the injury is a newly incurred injury, it should be reported. However, a recurrent or preexisting injury may be reported in some surveillance systems but not in others. The surveillance systems for international soccer records only new injuries.14 There is much discrepancy regarding recurrent injury definitions and how they should be reported within ISS. Subsequent sport injuries may be coded23 in ISS as the following:

• New injury = different location

• Local injury = same location but different type

• Recurrent injury = same location and same type

A clearer, standardized definition is needed for injury surveillance purposes. Within the international soccer ISS, an injury is defined as “any musculoskeletal complaint newly incurred due to competition or training that received medical attention.”8,14 This definition has several key variables that must be explored. First, it establishes all new injuries and excludes recurrent or preexisting injuries. Second, it excludes all nonmusculoskeletal injuries and illness. Third, it identifies all injuries requiring medical attention (not just injuries that resulted in time lost). However, medical attention is defined differently across surveillance systems (care provided by an athletic trainer vs referral to a physician). Fourth, it identifies when the injury occurred (training/ practice or competition). Although competition is clearer and standard, training can be defined differently. Missing from this definition is a precise understanding of medical attention and training. One variable not included is time lost, meaning that an injury does not require missed participation to be counted.

As a result of surveillance systems, the term reportable injury7-9,14 has been coined. Many systems define reportable differently and may link it to severity or time lost. There are several options for defining severity, including the following: by days of practice missed, games missed, or if a referral or hospitalization was required. Many ISSs arbitrarily base severity as days missed. Injuries resulting in restricted participation of 10+9 days vs 30+4 days have been reported as indicators of severity. The NCAA ISS requires time lost and needing medical attention in their definition of a reportable injury. The NCAA is more specific in its definition of an injury. Since 1995, a reportable injury has been defined as one that occurred as a result of participation in an organized intercollegiate event (practice or game, required medical attention (athletic trainer or physician), and restricted participation for more than 1 calendar day.9

A meaningful definition of injury should incorporate time lost from participation to reduce the bias associated with estimates of incidence.1 However, systems that report all injuries are beneficial because studies of injury sequences support that minor injuries are often followed by moderate or major injuries, and acute complaints are a predictor of subsequent injuries.23 The advantage of a broad definition of injury is that it allows for the assessment of the full spectrum of activities. A more narrow definition may assess musculoskeletal only, concussion only, or all dental injuries regardless of time lost but will likely exclude any chronic conditions, illnesses, or diseases. A clear definition within ISS decreases any misinterpretation by those collecting the data.

For best practice, a reportable injury should include the following multiple components:

• The injury occurred in a game or practice.

• The injury required medical attention.

• The injury resulted in a restriction or exclusion from participation for 1 or more days.6-9,14