Journl of Athletic Trining 2015;50(8):870 878 doi: 10.4085/1062-6050-50.7.02 Ó y the Ntionl Athletic Triners Assocition, Inc www.ntjournls.org originl reserch Epidemiology of Ntionl Collegite Athletic Assocition Women s Gymnstics Injuries, 2009 2010 Through 2013 2014 Zchry Y. Kerr, PhD, MPH*; Ross Hyden, MS*; Megn Brr, ATC*; Dvid A. Klossner, PhD, ATC ; Thoms P. Dompier, PhD, ATC* *Dtlys Center for Sports Injury Reserch nd Prevention, Inc, Indinpolis, IN; Mrylnd Athletics, University of Mrylnd, College Prk Context: Recent injury-surveillnce dt for collegite-level women s gymnstics re limited. In ddition, reserchers hve not cptured non time-loss injuries (ie, injuries resulting in restriction of prticiption,1 dy). Ojective: To descrie the epidemiology of Ntionl Collegite Athletic Assocition (NCAA) women s gymnstics injuries during the 2009 2010 through 2013 2014 cdemic yers. Design: Descriptive epidemiology study. Setting: Aggregte injury nd exposure dt collected from 11 women s gymnstics progrms providing 28 sesons of dt. Ptients or Other Prticipnts: Collegite student-thletes prticipting in women s gymnstics during the 2009 2010 through 2013 2014 cdemic yers. Intervention(s): Women s gymnstics dt from the NCAA Injury Surveillnce Progrm (ISP) during the 2009 2010 through 2013 2014 cdemic yers were nlyzed. Min Outcome Mesure(s): Injury rtes; injury rte rtios; injury proportions y ody site, dignosis, nd pprtus; nd injury proportion rtios were reported with 95% confidence intervls (CIs). Results: The ISP cptured 418 women s gymnstics injuries, rte of 9.22/1000 thlete-exposures (AEs; 95% CI ¼ 8.33, 10.10). The competition injury rte (14.49/1000 AEs) ws 1.67 times the prctice injury rte (8.69/1000 AEs; 95% CI ¼ 1.27, 2.19). When considering time-loss injuries only, the injury rte during this study period (3.62/1000 AEs) ws lower thn rtes reported in erlier NCAA ISP surveillnce dt. Commonly injured ody sites were the nkle (17.9%, n ¼ 75), lower leg/ Achilles tendon (13.6%, n ¼ 57), trunk (13.4%, n ¼ 56), nd foot (12.4%, n ¼ 52). Common dignoses were ligment sprin (20.3%, n ¼ 85) nd muscle/tendon strin (18.7%, n ¼ 78). Overll, 12.4% (n ¼ 52) of injuries resulted in time loss of more thn 3 weeks. Of the 291 injuries reported while studentthlete used n pprtus (69.6%), most occurred during the floor exercise (41.9%, n ¼ 122) nd on the uneven rs (28.2%, n ¼ 82). Conclusions: We oserved lower time-loss injury rte for women s gymnstics thn shown in erlier NCAA ISP surveillnce dt. Sfety inititives in women s gymnstics, such s sting mts, pdded equipment, nd redesigned vult tle, my hve contriuted to minimizing the frequency nd severity of injury. Key Words: incidence, sports, injury surveillnce Key Points The time-loss injury rte for women s gymnstics ws lower thn tht demonstrted in erlier Ntionl Collegite Athletic Assocition Injury Surveillnce Progrm surveillnce dt. Lower extremity injuries composed the lrgest proportion of injuries. Injury distriutions vried y pprtus, with the floor exercise ccounting for the lrgest proportion of injuries. Reserchers should monitor nd evlute the use of injury-prevention strtegies. When the Ntionl Collegite Athletic Assocition (NCAA) conducted its first ntionl chmpionship in women s gymnstics during the 1981 1982 cdemic yer, 179 tems nd 2063 thletes prticipted. 1 However, over the pst 30 yers, prticiption hs decresed. In the 2012 2013 cdemic yer, 82 tems nd 1488 thletes prticipted, ut the verge squd size per tem incresed from 11.5 in 1981 1982 to 18.1. 1 Despite the decrese in the overll numer of student-thletes prticipting nnully, collegite women s gymnstics progrms continue to recruit student-thletes who egn specilized trining t n erly ge. Erly speciliztion, coupled with high-impct upper nd lower extremity movements, my plce student-thletes t incresed risk of injury in college, prticulrly if they ignore signs of overuse. 2,3 Therefore, exmining the incidence of injuries sustined during women s gymnstics will help drive the development of trgeted injury-prevention interventions. Numerous reserchers hve exmined the epidemiology of women s gymnstics t multiple levels, including clu sports, 4,5 high school, 6 college, 7,8 nd elite. 9,10 Investigtors 4 12 hve predominntly reported tht lower extremity injuries, sprins, strins, nd overuse injuries composed the lrgest proportions of injuries tht femle gymnsts sustined. In ddition, reserchers 7 hve highlighted the lower ck s n re of concern for femle gymnsts. Most injuries were reported to hve occurred during the floor 870 Volume 50 Numer 8 August 2015
exercise nd on the uneven rs. 4 7 Vrying pprtusspecific mechnisms of injury occur. 7,13 Such findings hve contriuted to the implementtion of equipment modifictions, such s using sting mt to soften lndings nd sor lnding impcts 14 ; dding pdding to lnce ems; nd using new vulting tle, which fetures lrger nd cushioned push-off surfce. However, few reserchers hve exmined women s gymnstics-relted injuries over the pst decde. Smples from recent reserch hve een smll 13 or hve focused on younger gymnsts, whose injuries my differ from those of collegite-level student-thletes who hve fully developed physiclly. 4,11 From 2009 2010 through 2013 2014, the NCAA Injury Surveillnce Progrm (ISP) hs monitored ll injuries occurring in smple of women s gymnstics vrsity tems. Unlike pst reserch 7 exmining NCAA women s gymnstics, this study cptured non time-loss (NTL) injuries (ie, injuries resulting in restriction of prticiption,1 dy) to optimlly summrize the types of injuries tht thletic triners (ATs) mnge nd tret. Therefore, the purpose of our study ws to use dt from the NCAA ISP to descrie the epidemiology of women s gymnstics injuries occurring within the NCAA competition level during the 2009 2010 through 2013 2014 cdemic yers. METHODS Dt were otined from the NCAA ISP, which is mnged y the Dtlys Center for Sports Injury Reserch nd Prevention, Inc, n independent, nonprofit reserch orgniztion. 15 The ISP depends on convenience smple of mteur vrsity sport tems with ATs reporting injury dt. More in-depth informtion out the methods of the NCAA ISP during the 2009 2010 through 2013 2014 cdemic yers is ville in previous puliction 15,* ut is lso summrized in this section. Dt Collection The ATs from prticipting progrms reported injuries in rel time through their electronic helth record pplictions throughout the cdemic yer. They lso hd the option to use the Dtlys Center s in-house Injury Surveillnce Tool (Dtlys Center, Indinpolis, IN) to provide dt. Common dt elements tht included injury nd exposure informtion from the electronic helth record pplictions nd the Injury Surveillnce Tool were deidentified, recoded, nd exported to n ggregte dtse. In ddition to unintentionl injuries, the surveillnce system cptured other sport-relted dverse helth (ie, illness) events, such s het-relted conditions, generl medicl conditions, nd skin infections. Only vrsity-level prctice nd competition events were included in the ISP dt sets. Junior vrsity progrms nd ny individul weight-trining nd conditioning sessions were excluded. For ech event, the ATs completed detiled report on the injury or condition (eg, site, dignosis) nd the * Portions of the Methods section re reprinted with permission. Kerr ZY, Dompier TP, Snook EM, et l. Ntionl Collegite Athletic Assocition Injury Surveillnce System: review of methods for 2004 2005 through 2013 2014 dt collection. JAthlTrin. 2014;49(4): 552 560. circumstnces (eg, ctivity, mechnism, event type [ie, competition or prctice]). They could view nd updte previously sumitted informtion s needed during the course of seson. When n thlete ws le to return to prticiption, ATs provided the dte of return, which generted the numer of dys of time loss (clculted s the difference etween the return dte nd the injury dte). For injuries tht restricted prticiption eyond the end of the seson, ATs used the dte on which thletes were le to sfely return to sport-specific ctivity s the dte of return. They lso provided the numer of student-thletes prticipting in ech prctice nd competition. Before rriving t the Dtlys Center, the dt were stripped of ny identifiers nd personlly identifile informtion (eg, nme, dte of irth, insurnce informtion) nd retined only relevnt vriles nd vlues. 15 Exported dt pssed through n utomted verifiction process tht conducted series or rnge of consistency checks. Dt were reviewed nd flgged for invlid vlues. The utomted verifiction process would notify the ATs nd dt qulity-control stff, who would help the ATs resolve the concern. Dt tht pssed the verifiction process were plced into sport-specific ggregte dt sets used for nlysis. Dt provided to the reserchers for this study used the women s gymnstics ggregte dt set. Definitions A reportle injury in the ISP ws defined s n injury tht (1) occurred s result of prticiption in n orgnized intercollegite prctice or competition nd (2) required ttention from n AT or physicin. Multiple injuries occurring from 1 injury event could e included. As opposed to the previous 25 yers of NCAA-reported dt tht reported only time-loss (TL) injuries, this 5-yer dt set ws uniquely different ecuse NTL injuries were included. A reportle thlete-exposure (AE) ws defined s 1 student-thlete prticipting in 1 NCAA-snctioned prctice or competition in which he or she ws exposed to the possiility of thletic injury, regrdless of the time ssocited with tht prticiption. Only student-thletes with ctul plying time in competition were included in competition exposures. Sttisticl Anlysis Dt were nlyzed to ssess rtes nd ptterns of collegite women s gymnstics injuries. Body prts were ctegorized s hed/fce, neck, shoulder/clvicle, rm/ elow, hnd/wrist, trunk (including chest, domen, upper ck, nd lower ck), hip/thigh/upper leg, knee, lower leg/ Achilles tendon, nkle, foot, nd other. No injuries were recorded for the upper leg. Dignoses were ctegorized s ligment sprin, muscle/tendon strin, inflmmtion (including ursitis nd tendinitis), entrpment/impingement, contusion/rsion, concussion, frcture, stress frcture, disloction/suluxtion, nd other. In ddition, knee internl derngement included ny isolted or comined nterior crucite ligment, posterior crucite ligment, collterl ligment (medil or lterl, not differentited), or meniscus (medil or lterl, not differentited) injury. The numer of dys tht injuries restricted prticiption ws ctegorized s NTL injuries, resulting in restricted Journl of Athletic Trining 871
Tle 1. Injury Rtes nd 95% Confidence Intervls y Time in Seson nd Type of Athlete-Exposure in Ntionl Collegite Athletic Assocition Women s Gymnstics, 2009 2010 Through 2013 2014 Prctice Competition Totl Rte (95% Confidence Injuries in Smple, No. Rte (95% Confidence Injuries in Smple, No. Rte (95% Confidence Injuries in Smple, No. Injuries All Preseson 257 25 014 10.27 (9.02, 11.53) 0 0 Not pplicle 257 25 014 10.27 (9.02, 11.53) Regulr seson 88 12 917 6.81 (5.39, 8.24) 55 3627 15.16 (11.16, 19.17) 143 16 544 8.64 (7.23, 10.06) Postseson 13 3278 3.97 (1.81, 6.12) 5 515 9.71 (1.20, 18.22) 18 3793 4.75 (2.55, 6.94) Totl 358 41 209 8.69 (7.79, 9.59) 60 4142 14.49 (10.82, 18.15) 418 45 351 9.22 (8.33, 10.10) All time loss Preseson 91 25 014 3.64 (2.89, 4.39) 0 0 Not pplicle 91 25 014 3.64 (2.89, 4.39) Regulr seson 37 12 917 2.86 (1.94, 3.79) 29 3627 8.00 (5.09, 10.91) 66 16 544 3.99 (3.03, 4.95) Postseson 4 3278 1.22 (0.02, 2.42) 3 515 5.83 (0.00, 12.42) 7 3793 1.85 (0.48, 3.21) Totl 132 41 209 3.20 (2.66, 3.75) 32 4142 7.73 (5.05, 10.40) 164 45 351 3.62 (3.06, 4.17) All severe Preseson 36 25 014 1.44 (0.97, 1.91) 0 0 Not pplicle 36 25 014 1.44 (0.97, 1.91) Regulr seson 8 12 917 0.62 (0.19, 1.05) 6 3627 1.65 (0.33, 2.98) 14 16 544 0.85 (0.40, 1.29) Postseson 1 3278 0.31 (0.00, 0.90) 1 515 1.94 (0.00, 5.75) 2 3793 0.53 (0.00, 1.26) Totl 45 41 209 1.09 (0.77, 1.41) 7 4142 1.69 (0.44, 2.94) 52 45 351 1.15 (0.83, 1.46) 2013 2014. Includes injuries tht resulted in time loss.3 weeks or the student-thlete premturely ending his or her seson. prticiption for less thn 1 dy; injuries, resulting in time loss of 1 to 21 dys; nd severe injuries, resulting in time loss of more thn 3 weeks. Dt were nlyzed using SAS Enterprise Guide softwre (version 4.3; SAS Institute Inc, Cry, NC). Sttisticl nlyses included clcultion of rte rtios (RRs), injury proportion rtios (IPRs), nd v 2 tests. The overll injury rte ws clculted s the rtio of injuries per 1000 totl AEs. Injury rtes were lso clculted s the rtio of prctice injuries per 1000 prctice exposures nd the rtio of competition injuries per 1000 competition exposures. Injury rtes were lso clculted per NCAA division. The following is n exmple of n RR compring competition nd prctice injury rtes: numer of competition injuries RR ¼ = numer of competition AEs numer of prctice injuries numer of prctice AEs The following is n exmple of n IPR compring the proportion of shoulder injuries sustined on the uneven rs pprtus nd ll other pprtuses: numer of shoulder injuries on the uneven rs IPR ¼ = numer of totl injuries on the uneven rs numer of shoulder injuries on ll other pprtuses numer of totl injuries on ll other pprtuses All 95% confidence intervls (CIs) not contining 1.0 were considered different. This study ws pproved y the Reserch Review Bord of the NCAA. RESULTS Overll Frequencies nd Rtes During the 2009 2010 through 2013 2014 cdemic yers, ATs reported 418 college women s gymnstics injuries cross 28 tem sesons from 11 progrms. A totl of 358 injuries (85.6%) occurred during prctice, nd 60 (14.4%) occurred during competition. Most injuries (61.5%, n ¼ 257) occurred in the preseson, 34.2% (n ¼ 143) in the regulr seson, nd 4.3% (n ¼ 18) in the postseson. Overll, 12.4% (n ¼ 52) of injuries resulted in time loss of more thn 3 weeks. Of these severe injuries, 46.2% (n ¼ 24) returned to sport prticiption fter 3 weeks, nd 53.8% (n ¼ 28) resulted in student-thletes premturely ending their sesons. Of ll injuries, 6.7% (n ¼ 28) required surgery, nd 16.3% (n ¼ 68) were recurrent injuries. These 418 injuries occurred during 45 351 AEs, for n injury rte of 9.22/1000 AEs (95% CI ¼ 8.33, 10.10; Tle 1). However, when considering only injuries resulting in time loss of t lest 1 dy (39.2%, n ¼ 164), the injury rte ws reduced to 3.62/1000 AEs (95% CI ¼ 3.06, 4.17). During the 5-yer period, the injury rte remined stedy, with the highest nd lowest rtes occurring in the 2009 2010 (9.81/1000 AEs) nd 2013 2014 (8.22/1000 AEs) cdemic yers (Figure). The competition injury rte (14.49/1000 AEs) ws 1.67 times the prctice injury rte (8.69/1000 AEs; 95% CI ¼ 1.27, 2.19). However, injury rtes for competition (11.94/ 1000 AEs) nd prctice (11.45/1000 AEs) did not differ 872 Volume 50 Numer 8 August 2015
Figure. Injury rtes per 1000 thlete-exposures y competition, prctice, nd cdemic yer for women s gymnstics from 2009 2010 through 2013 2014. Note tht ll injuries, regrdless of the time restriction from prticiption, re included. within Division I (RR ¼ 1.04; 95% CI ¼ 0.70, 1.56). In ddition, the injury rte ws higher in Division I (11.50/ 1000 AEs) thn in Divisions II nd III (7.10/1000 AEs; RR ¼ 1.62; 95% CI ¼ 1.33, 1.97). Among prctices, the preseson injury rte (10.27/1000 AEs) ws 1.65 times the rte of injury during the regulr seson nd postseson comined (6.24/1000 AEs; 95% CI ¼ 1.31, 2.07). However, this RR ws not different when considering only TL injuries (RR ¼ 1.44; 95% CI ¼ 1.00, 2.07). Body Sites Injured nd Dignoses Commonly injured ody sites included the nkle (17.9%, n ¼ 75), lower leg/achilles tendon (13.6%, n ¼ 57), trunk (13.4%, n ¼ 56), nd foot (12.4%, n ¼ 52; Tle 2). Among ody prts, the knee hd the lrgest proportion of severe injuries (30.2%, n ¼ 13) nd injuries requiring surgery (20.9%, n ¼ 9). The severe knee injuries requiring surgery were mostly ters to the nterior crucite ligment. Among ody prts, the shoulder (29.6%, n ¼ 8), nkle (26.7%, n ¼ Tle 2. Distriution of Body Prts Injured in Ntionl Collegite Athletic Assocition Women s Gymnstics, 2009 2010 Through 2013 2014 Body Prt Injuries in Smple, Rte (95% Confidence Non Time-Loss Injuries, Severe Injuries, Requiring Surgery, Recurrent Injuries, Hed/fce 20 (4.8) 0.44 (0.25, 0.63) 5 (25.0) 3 (15.0) 1 (5.0) 0 (0.0) Neck 3 (0.7) 0.07 (0.00, 0.14) 1 (33.3) 0 (0.0) 0 (0.0) 0 (0.0) Shoulder/clvicle 27 (6.5) 0.60 (0.37, 0.82) 16 (59.3) 2 (7.4) 2 (7.4) 8 (29.6) Arm/elow 35 (8.4) 0.77 (0.52, 1.03) 20 (57.1) 10 (28.6) 2 (5.7) 5 (14.3) Hnd/wrist 14 (3.4) 0.31 (0.15, 0.47) 10 (71.4) 0 (0.0) 2 (14.3) 2 (14.3) Trunk 56 (13.4) 1.23 (0.91, 1.56) 33 (58.9) 7 (12.5) 3 (5.4) 8 (14.3) Hip/thigh/upper leg 29 (6.9) 0.64 (0.41, 0.87) 23 (79.3) 1 (3.5) 0 (0.0) 2 (6.9) Knee 43 (10.3) 0.95 (0.66, 1.23) 21 (48.8) 13 (30.2) 9 (20.9) 4 (9.3) Lower leg/achilles tendon 57 (13.6) 1.26 (0.93, 1.58) 43 (75.4) 4 (7.0) 3 (5.3) 12 (21.1) Ankle 75 (17.9) 1.65 (1.28, 2.03) 41 (54.6) 5 (6.7) 2 (2.7) 20 (26.7) Foot 52 (12.4) 1.15 (0.83, 1.46) 31 (59.6) 7 (13.5) 2 (3.9) 6 (11.5) Other 7 (1.7) 0.15 (0.04, 0.27) 5 (71.4) 0 (0.0) 0 (0.0) 1 (14.3) Totl 418 (100.0) 9.22 (8.33, 10.10) 249 (59.6) 52 (12.4) 26 (6.2) 68 (16.3) Includes injuries tht resulted in time loss.3 weeks or the student-thlete premturely ending his or her seson. Journl of Athletic Trining 873
Tle 3. Distriution of Injury Dignoses in Ntionl Collegite Athletic Assocition Women s Gymnstics, 2009 2010 Through 2013 2014 Injury Dignosis Injuries in Smple, Rte (95% Confidence Non Time-Loss Injuries, Severe Injuries, Requiring Surgery, Recurrent Injuries, Ligment sprin 85 (20.3) 1.87 (1.48, 2.27) 33 (38.8) 14 (16.5) 5 (5.9) 8 (9.4) Muscle/tendon strin 78 (18.7) 1.72 (1.34, 2.10) 52 (66.7) 5 (6.4) 6 (7.7) 8 (10.3) Inflmmtion c 47 (11.2) 1.04 (0.74, 1.33) 41 (87.2) 0 (0.0) 0 (0.0) 8 (17.0) Entrpment/impingement 13 (3.1) 0.29 (0.13, 0.44) 10 (76.9) 0 (0.0) 0 (0.0) 4 (30.8) Contusion/rsion 32 (7.7) 0.71 (0.46, 0.95) 25 (78.1) 1 (3.1) 0 (0.0) 3 (9.4) Concussion 12 (2.9) 0.26 (0.11, 0.41) 1 (8.3) 3 (25.0) 0 (0.0) 0 (0.0) Frcture 15 (3.6) 0.33 (0.16, 0.50) 4 (26.7) 9 (60.0) 5 (33.3) 3 (20.0) Stress frcture 16 (3.8) 0.35 (0.18, 0.53) 9 (56.3) 2 (12.5) 1 (6.3) 3 (18.8) Disloction/suluxtion 14 (3.4) 0.31 (0.15, 0.47) 2 (14.3) 9 (64.3) 3 (21.4) 3 (21.4) Other d 106 (25.4) 2.34 (1.89, 2.78) 72 (67.9) 9 (8.5) 6 (5.7) 28 (26.4) Totl 418 (100.0) 9.22 (8.33, 10.10) 249 (59.6) 52 (12.4) 26 (6.2) 68 (16.3) Includes injuries tht resulted in time loss.3 weeks or the student-thlete premturely ending his or her seson. c Includes ursitis nd tendinitis. d Includes injuries with counts,10. Injuries in this ctegory with multiple reports included spsms (n ¼ 6), synovitis (n ¼ 4), chondromlci (n ¼ 3), noseleed (n ¼ 3), hyperextension (n ¼ 3), cpsulitis (n ¼ 3), tendinosis (n ¼ 2), one spur (n ¼ 2), spinl stenosis (n ¼ 2), nd disc injury (n ¼ 2). In ddition, injuries included those coded for dignosis s miscellneous. 20), nd lower leg/achilles tendon (21.1%, n ¼ 12) hd the lrgest proportion of recurrent injuries. Common dignoses included ligment sprin (20.3%, n ¼ 85) nd muscle/tendon strin (18.7%, n ¼ 78; Tle 3). Dignoses with the lrgest proportions of severe injuries were disloctions/suluxtions (64.3%, n ¼ 9) nd frctures (60.0%, n ¼ 9). In ddition, disloctions/suluxtions nd frctures hd the gretest proportions of surgeries (21.4%, n ¼ 3, nd 33.3%, n ¼ 5, respectively). Entrpments/ impingements (30.8%, n ¼ 4) nd disloctions (21.4%, n ¼ 3) hd the lrgest proportions of recurrent injuries. The most common injuries were nkle sprins (11.2%). These 47 nkle sprins included 31 lterl ligment complex sprins nd 12 medil (deltoid) ligment sprins. Other common injuries included hip/thigh/upper leg strins (4.8%, n ¼ 20), lower leg/achilles tendon inflmmtions (4.3%, n ¼ 18), nd internl knee derngements (4.1%, n ¼ 17). In ddition, 6 lower ck strins were reported, ut 4 resulted in time loss of less thn 1 dy. The competition injury rte of internl knee derngements (1.45/1000 AEs) ws 5.43 times tht of prctice (0.27/1000 AEs; 95% CI ¼ 2.01, 14.67). In ddition, the competition injury rte of medil (deltoid) ligment sprins (1.45/1000 AEs) ws 9.95 times tht of prctice (0.15/1000 AEs; 95% CI ¼ 3.21, 30.85). Internl knee derngements lso composed the lrgest proportion of severe injuries (47.1%, n ¼ 8) nd injuries requiring surgery (41.2%, n ¼ 7). Mechnism of Injury nd Apprtuses Of the 383 (91.6%) injuries with known mechnism, most were sustined from contct with the surfce (33.7%, n ¼ 129) or overuse (29.8%, n ¼ 114; Tle 4). Few overuse injuries were severe (2.6%, n ¼ 3), nd none required surgery. However, 20.9% (n ¼ 27) nd 7.8% (n ¼ 10) of injuries due to contct with the surfce were severe nd required surgery, respectively. Of the 291 (69.6%) injuries reported during n pprtus event, most occurred during the floor exercise (41.9%, n ¼ 122) nd on the uneven rs (28.2%, n ¼ 82). Differences existed mong pprtuses y ody site, dignosis, nd Tle 4. Distriution of Mechnisms of Injury in Ntionl Collegite Athletic Assocition Women s Gymnstics, 2009 2010 Through 2013 2014, Mechnism of Injury Injuries in Smple, Rte (95% Confidence Non Time-Loss Injuries, Severe Injuries, c Requiring Surgery, Recurrent Injuries, Contct with nother person 6 (1.6) 0.13 (0.03, 0.24) 1 (16.7) 0 (0.0) 0 (0.0) 0 (0.0) Contct with surfce (ie, mt) 129 (33.7) 2.84 (2.35, 3.34) 58 (45.0) 27 (20.9) 10 (7.8) 19 (14.7) Contct with pprtus 63 (16.5) 1.39 (1.05, 1.73) 34 (54.0) 10 (15.9) 4 (6.4) 7 (11.1) Contct with out-of-ounds oject 2 (0.5) 0.04 (0.00, 0.11) 0 (0.0) 1 (50.0) 0 (0.0) 0 (0.0) No pprent contct d 62 (16.2) 1.37 (1.03, 1.71) 35 (56.5) 7 (11.4) 7 (11.3) 11 (17.7) Overuse/grdul 114 (29.8) 2.51 (2.05, 2.98) 95 (83.3) 3 (2.6) 0 (0.0) 22 (19.3) Illness/infection 7 (1.8) 0.15 (0.04, 0.27) 5 (71.4) 0 (0.0) 0 (0.0) 0 (0.0) Includes the 383 injuries with known mechnism of injury (91.6% of ll injuries). c Includes injuries tht resulted in time loss.3 weeks or the student-thlete premturely ending his or her seson. d Includes injuries tht were not cused y contct ut not considered overuse/grdul or illness/infection, such s sustining n nkle sprin while running or lower leg strin while decelerting. 874 Volume 50 Numer 8 August 2015
Tle 5. Body Prt Injured, Dignosis, Severity of Injury, nd Surgery Needs y Apprtus in Ntionl Collegite Athletic Assocition Women s Gymnstics, 2009 2010 Through 2013 2014 Apprtus Vrile Blnce Bem, No./48 (%) Floor Exercise, No./122 (%) Uneven Brs, No./82 (%) Vult, No./39 (%) Body prt Hed/fce 3 (6.3) 5 (4.1) 6 (7.3) 0 (0.0) Neck 0 (0.0) 0 (0.0) 2 (2.4) 1 (2.6) Shoulder/clvicle 0 (0.0) 2 (1.6) 15 (18.3) 0 (0.0) Arm/elow 4 (8.3) 2 (1.6) 14 (17.1) 6 (15.4) Hnd/wrist 2 (4.2) 0 (0.0) 9 (11.0) 1 (2.6) Trunk 5 (10.4) 8 (6.6) 11 (13.4) 5 (12.8) Hip/thigh/upper leg 5 (10.4) 5 (4.1) 5 (6.1) 3 (7.7) Knee 5 (10.4) 22 (18.0) 5 (6.1) 4 (10.3) Lower leg/achilles tendon 1 (2.1) 34 (27.8) 1 (1.2) 6 (15.4) Ankle 10 (20.8) 33 (27.1) 3 (3.7) 10 (25.6) Foot 13 (27.1) 11 (9.0) 11 (13.4) 3 (7.7) Other 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Dignosis Ligment sprin 15 (31.3) 32 (26.2) 12 (14.6) 8 (20.5) Muscle/tendon strin 5 (10.4) 19 (15.6) 18 (22.0) 11 (28.2) Inflmmtion c 1 (2.1) 15 (12.3) 5 (6.1) 5 (12.8) Entrpment/impingement 0 (0.0) 5 (4.1) 4 (4.9) 1 (2.6) Contusion/rsion 11 (22.9) 7 (5.7) 10 (12.2) 2 (5.1) Concussion 2 (4.2) 4 (3.3) 4 (4.9) 0 (0.0) Frcture 2 (4.2) 2 (1.6) 6 (7.3) 0 (0.0) Stress frcture 0 (0.0) 6 (4.9) 0 (0.0) 2 (5.1) Disloction/suluxtion 2 (4.2) 2 (1.6) 7 (8.5) 1 (2.6) Other 10 (20.8) 30 (24.6) 16 (19.5) 9 (23.1) Injury severity nd surgery needs d Non time-loss injuries 26 (54.2) 70 (57.4) 42 (51.2) 27 (69.2) Severe injuries e 5 (10.4) 19 (15.6) 15 (18.3) 4 (10.3) Requiring surgery 2 (4.2) 9 (7.4) 9 (11.0) 1 (2.6) Recurrent injuries 5 (10.4) 21 (17.2) 7 (8.5) 7 (17.9) Does not include 20 generl conditioning injuries, nd 7 competition nd 100 prctice injuries with unknown or missing pprtus dt. c Includes ursitis nd tendinitis. d Does not include injuries with unknown or missing mechnism injury. Percentges re clculted from only those injuries with known injury mechnism. e Includes injuries tht resulted in time loss.3 weeks or the student-thlete premturely ending his or her seson. mechnism of injury (Tles 5 nd 6). Shoulder injuries composed lrger proportion of injuries on the uneven rs (18.3%, n ¼ 15) thn on other pprtuses (1.0%, n ¼ 2; IPR ¼ 19.1; 95% CI ¼ 4.5, 81.74). Lower leg/achilles tendon injuries were responsile for lrger proportion of injuries in the floor exercise (27.8%, n ¼ 34) thn on other pprtuses (4.7%, n ¼ 8; IPR ¼ 5.89; 95% CI ¼ 2.83, 12.28). In ddition, contusions ccounted for lrger Tle 6. Mechnism of Injury y Apprtus in Ntionl Collegite Athletic Assocition Women s Gymnstics, 2009 2010 Through 2013 2014 Apprtusc Mechnism of Injury Blnce Bem, No./44 (%) Floor Exercise, No./111 (%) Uneven Brs, No./77 (%) Vult, No./38 (%) Contct with nother person 0 (0.0) 0 (0.0) 1 (1.3) 1 (2.6) Contct with surfce (ie, mt) 8 (18.2) 54 (48.7) 32 (41.6) 16 (42.1) Contct with pprtus 27 (61.4) 1 (0.9) 26 (33.8) 6 (15.8) Contct with out-of-ounds oject 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) No pprent contct d 5 (11.4) 19 (17.1) 10 (13.0) 1 (2.6) Overuse/grdul 4 (9.1) 37 (33.3) 8 (10.4) 14 (36.8) Illness/infection 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Does not include injuries with unknown or missing mechnism of injury. c Does not include 20 generl conditioning injuries nd 7 competition nd 100 prctice injuries with unknown or missing pprtus dt. d Includes injuries tht were not cused y contct ut not considered overuse/grdul or illness/infection, such s sustining n nkle sprin while running or lower leg strin while decelerting. Journl of Athletic Trining 875
Tle 7. Most Common Injuries Associted With n Apprtus in Ntionl Collegite Athletic Assocition Women s Gymnstics, 2009 2010 Through 2013 2014 Apprtus Most Common Injury Injuries Associted With Apprtus, No. % Most Frequent Mechnism of Apprtus Injury (No.) Blnce em (n ¼ 48) Ankle sprin 8 (16.7) Contct with surfce (ie, mt) (5) Hip/thigh/upper leg contusion 4 (8.3) Contct with lnce em (2) Foot sprin 4 (8.3) Contct with lnce em (4) Floor exercise (n ¼ 122) Ankle sprin 20 (16.4) Contct with surfce (ie, mt) (16) Lower leg inflmmtion 11 (9.0) Overuse (11) Knee internl derngement 11 (9.0) Contct with surfce (ie, mt) (7) Uneven rs (n ¼ 82) Concussion 4 (4.9) Contct with surfce (ie, mt) (3) Shoulder muscle/tendon strin 4 (4.9) No pprent contct (2) Hnd/wrist sprin 4 (4.9) Contct with uneven rs (3) Vult (n ¼ 39) Ankle sprin 5 (12.8) Contct with surfce (ie, mt) (3) Arm/elow muscle/tendon strin 3 (7.7) Overuse (2) Lower leg/achilles tendon inflmmtion 3 (7.7) Overuse (3) proportion of injuries on the lnce em (22.9%, n ¼ 11) thn on other pprtuses (7.8%, n ¼ 19; IPR ¼ 2.93; 95% CI ¼ 1.49, 5.76). Overuse injuries composed lrger proportion of injuries for the floor exercise nd vult (31.7%, n ¼ 51) thn the lnce em nd uneven rs (9.2%, n ¼ 12; IPR ¼ 3.43; 95% CI ¼ 1.91, 6.16). Ankle sprins were responsile for lrge proportions of injuries on ll pprtuses (Tle 7). Contct with the surfce ccounted for mny of these injuries, followed y contct with the pprtus (ie, lnce em, uneven rs). Wheres only 10 concussions occurred on gymnstics pprtuses (plus 2 tht occurred during generl prctice), 4 (40.0%) occurred on the uneven rs nd composed one of the lrgest proportions of injuries reported with tht pprtus. An dditionl 4 (40.0%) occurred during the floor exercise, nd the remining 2 (20.0%) occurred on the lnce em. DISCUSSION We used injury-surveillnce dt to descrie the epidemiology of women s gymnstics t the NCAA level over 5 yers. The study is the most roust ssessment of women s gymnstics injuries to our knowledge, using surveillnce dt tht hve een checked thoroughly for vlidity nd reliility nd including NTL injuries. Such dt cn potentilly drive the development of trgeted interventions for prevention nd helth cre relted to those injuries in women s gymnstics. Wheres much reserch exists regrding the epidemiology of women s gymnstics, only smll proportion of reserchers hve focused on the collegite level. 7,8 The overll injury rte in our study from 2009 2010 through 2013 2014 (9.22/1000 AEs) ws greter thn tht of previous NCAA surveillnce dt from 1988/1989 through 2003/2004 (6.07/1000 AEs). 7 This rte increse is due in prt to the chnge in our dt-collection method tht resulted in n dditionl 254 NTL injuries tht otherwise would not hve een cptured. When excluding these injuries, the TL injury rte ws 3.62/1000 AEs, which is decrese in the TL injury rte from previous yers. This decrese my suggest tht sfety inititives in women s gymnstics, such s sting mts, pdded equipment, nd redesigned vult tle, hve contriuted to minimizing the frequency nd severity of injury. 14 A lrger proportion of injuries occurred during the preseson. In ddition, the rte of injuries in the preseson ws higher thn tht in the regulr seson nd postseson comined. Mrshll et l 7 speculted tht this oservtion my e ttriutle to student-thletes lerning new skills during the preseson. In ddition, thletes not fully recovered from injuries my rest minor injuries nd ply through them during the regulr seson nd postseson. This my e prticulrly true given the smller difference in rtes when restricted to TL injuries. As seen in previous studies, 4,6 10,12 lower extremity injuries composed more thn hlf of ll reported injuries. In prticulr, the knee hd the lrgest proportion of severe injuries nd injuries requiring surgery, wheres the nkle nd lower leg/achilles tendon hd lrge proportions of recurrent injuries. At the sme time, overuse injuries ccounted for pproximtely 3 in 10 of ll reported injuries. Given tht gymnstics is high impct, requiring upper nd lower ody kinetic chin lod ctivity, interventions should focus on the kinesthesi nd proprioception needed to perform the technicl skills for ech of the 4 pprtuses. At the sme time, interventions should include exmining vritions of conditioning nd corrective exercises tht cn reduce the incidence nd severity of injury. Reserchers 7,9,10 hve lso noted the need to further exmine lower ck injuries. Authors using erly NCAA ISP dt hve oserved tht lower ck strins ccounted for 6.1% of ll prctice injuries nd 3.2% of competition injuries. 7 However, from 2009 2010 through 2013 2014, only 2 lower ck strins resulting in time loss of t lest 1 dy were reported. At the sme time, low numer of concussions were reported (n ¼ 12). Yet one-third of reported concussions occurred during use of the uneven rs, ll of which were sustined ecuse of contct with the mt/floor. This oservtion my suggest tht gymnsts either fell during their routines, possily ecuse of filed ctch-relese moves, or did not lnd properly during their dismounts. Given the low prticiption from sponsoring schools (pproximtely 6 tems per yer), we emphsize the need for continued surveillnce to etter scertin the incidence of lower ck strins nd concussions. 876 Volume 50 Numer 8 August 2015
Our exposures did not distinguish prticiption y pprtus, so we could not clculte pprtus-specific injury rtes. Such pprtus-specific exposure informtion would lso llow us to etter decipher the disproportionte numer of injuries occurring during the floor exercise. Reserchers 4 7 hve highlighted the higher frequency of floor-exercise relted injuries, prticulrly to the knee nd nkle. However, our oservtions my hve een ised ecuse of mesurement error relted to exposure scertinment. Overuse injuries my e sustined ecuse of cumultive exposure on pprtuses rther thn the pprtus itself. Thus, future reserch my enefit from the collection of cumultive exposure dt tht cn e strtified ppropritely y pprtus to etter determine the effectiveness of such interventions. A lrge proportion of known injuries during the floor exercise ffected the nkle nd lower leg/achilles tendon. Mny injuries to these ody prts were lso recurrent. This high frequency of injury my e ttriutle to the mechnics of the floor exercise. The force on the lower extremities due to tkeoffs nd lndings from repetitive tumling my contriute to the incidence nd severity of injury. 7,16 In ddition, s student-thletes lnd from tumles, they my not rech sufficient rottion (ie, underrotte), cusing the ngle of inclintion in the nkle to e more cute (ie, shrper ngle to the floor) nd thus mking it stretch frther thn it should. A points ceiling exists in the collegite scoring system ( perfect 10), nd studentthletes my not e rewrded more points for more difficult vritions of skills (eg, doule-twisting Yurchenko vult compred with Yurchenko full). Still, Mrshll et l 7 rgued tht recent judging my fvor rewrding skills with higher degrees of difficulty s opposed to rtistic spects. Such focus on difficult tumling routines my pressure gymnsts to perform high-risk skills in repetitive fshion, in ftigued stte, or efore mstering the skill. Therefore, Mrshll et l 7 recommended greter deduction for flls to reinforce performing skills only when the gymnst hs mstered them. Future reserchers should provide more indepth exmintions of skills performed to determine if degree of difficulty is ssocited with injury risk. Mrshll et l 7 noted tht previous injury-surveillnce dt my not hve fully cptured the injuries occurring in women s gymnstics, s the methods did not cpture or ccount for NTL injuries. Wheres injuries my restrict prticiption, student-thletes lso my lter prticiption. 17 For exmple, gymnst who sustins n nkle sprin still my trin on the uneven rs ut not lnd on the injured leg. Altered prticiption my result in risk of more severe future injury. 17 For exmple, continued prticiption with pinful inflmmtion in the Achilles tendon my led to rupture. 8 To our knowledge, few investigtors 18,19 hve reported NTL injuries in generl. The only reserchers to study collegite femle student-thletes hve reported tht 84% of injuries were not ssocited with time loss. 18 However, gymnstics ws not included. We re the first to our knowledge to exmine NTL injuries in collegite women s gymnstics, oserving tht lmost 2 in 3 injuries seen y ATs did not restrict prticiption for t lest 1 dy. Including NTL injuries will help to scertin the true urden of injury sustined y collegite student-thletes nd mnged y ATs. Our study hd limittions. First, tem prticiption in dt collection ws low, ut the Dtlys Center is mking efforts to increse prticiption. Therefore, our oservtions my not e generlizle to the other collegite women s gymnstics progrms. In ddition, AEs were unit sed rther thn time sed. Thus, we could not report injury rtes y minute or hour of prctice nd competition. This recording method provides consistency for comprisons cross vrious sport-injury surveillnce reserch outcomes. This limittion ws lso necessry to reduce reporter urden. As mentioned, our exposures were not strtified y pprtus, so we were unle to estimte pprtus-specific injury rtes. We lso did not collect informtion out whether gymnsts were ll-round competitors or pprtus specilists, oth of which potentilly my plce student-thletes t risk for different types of injuries. All-round competitors my sustin injuries tht my e prtilly ttriutle to previous events on different pprtuses. Prctice routines nd equipment (eg, fom lnding pits, flooring, mts) lso were not monitored. CONCLUSIONS We oserved lower TL injury rte for women s gymnstics thn in erlier NCAA ISP dt. 7 In ddition, our results were consistent with previous reserch in which investigtors found tht lower extremity injuries composed the lrgest proportion of injuries. Injury distriutions vried y pprtus, with the floor exercise responsile for the lrgest proportion of injuries. Sport-relted injury-surveillnce dt cn help drive the development of trgeted reserch nd injury-prevention interventions in women s gymnstics. These include etter scertinment of pprtus-specific exposures nd thlete types (ie, ll-round versus pprtus specilist). In future studies, reserchers should lso monitor nd evlute the use of injuryprevention strtegies, including fom pits, low-impct crdiovsculr routines, limited-impct routines, yers in competitive gymnstics, prticiption with pin when injured, core stility progrms, nkle rces nd prophylctic tpe, nd equipment with pdding to sor shock. ACKNOWLEDGMENTS The Ntionl Collegite Athletic Assocition (NCAA) Injury Surveillnce Progrm dt were provided y the Dtlys Center for Sports Injury Reserch nd Prevention. The Injury Surveillnce Progrm ws funded y the NCAA. We thnk the thletic triners who volunteered their time nd efforts to sumit dt to the NCAA Injury Surveillnce Progrm. Their efforts hve hd tremendously positive effect on the sfety of collegite studentthletes. REFERENCES 1. Student-thlete prticiption 1981 1982 2012 2013. Ntionl Collegite Athletics Assocition We site. http://www.ncpulictions. com/productdownlods/pr2014.pdf. Accessed Mrch 9, 2015. 2. Mlin RM. Erly sport speciliztion: roots, effectiveness, risks. Curr Sports Med Rep. 2010;9(6):364 371. 3. Kllus KW, Kellmnn M. Burnout in thletes nd coches. In: Hnin YL, ed. Emotions in Sport. Chmpign, IL: Humn Kinetics; 2000: 209 230. Journl of Athletic Trining 877
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