MODULE 10

Wilson1982

Week10CanadianSportOverallinjuryStudy.pdf

44  July 2015 international Journal of athletic therapy & training

Original CliniCal researCh

ollegiate athletes belong to a special cohort commonly examined in sports medicine research. Conducting epidemiological stud- ies on both the risks and rates of injury are important to address gaps in injury pre-

vention and sport safety.1–3 In 2007 an epidemiological review of collegiate injuries across 15 different sports governed by the National Collegiate Athletic Association (NCAA) in the United States was conducted.1 Although the review noted some important findings in regard to injury rates, it lacked information on injury severity risk

(the risk of sustaining a severe injury in comparison with a nonsevere injury). Furthermore, sex and sport were looked at independently, and therefore comparisons cannot be made.1 While knowledge of injury rates plays a key role in injury prevention strategies, it is also import- ant to understand the risk of sustaining a severe injury. Possible risk factors for severe injury in sport may include the nature of the sport itself (contact or noncontact), age, competition level, and sex.1,2,4,5

Previous results have shown that males have a higher rate of injury, calculated by number of injuries

Johanna M. Hurtubise, MA, CAT(C), Cheryl Beech, MA, CAT(C), and Alison Macpherson, PhD • York University

Comparing Severe Injuries by Sex and Sport in Collegiate-Level Athletes: A Descriptive Epidemiologic Study

context: There is a lack of research on sex differences for severe injuries across a variety of sports at the collegiate level. objective: To compare differences in injury severity and concussion between sexes and collegiate sports. Design: Descriptive epidemiological study. participants: 1,657 injuries were analyzed from collegiate teams at York University. Data collection and analysis: Injuries were assessed by a certified or student athletic therapist and were categorized based on degree of tissue and/or joint damage as either severe or nonsevere. Severe injuries included those with third degree damage, while all others were classified as nonsevere. Injury severity was compared between the sexes and across different sports using Pearson chi- square analysis. Logistic regression was used to assess the relative contribution of each covariate. results: Males sustained 1,155 injuries, with 13.3% of them being severe, while females sustained only 502 injuries, 17.7% of which were severe. The odds of sustaining severe injuries among female athletes are 1.4 times the odds of male athletes (OR: 1.40, CI 1.05–1.86). Eleven percent of all female injuries were concussions— significantly more than males (χ2 = 11.03, p = .001). The odds of female athletes having a concussion are 1.9 times the odds of a male athlete (OR: 1.85, CI 1.28–2.67). conclusion: Based on our analysis, females are at an increased risk of sustaining a severe injury, particularly concussions. These findings highlight the need for future research into sex and sport-specific risk factors. This may provide information for health care professionals, coaches, and athletes for the proper prevention, on-field care, and treatment of sport injuries. Key Words: injury severity, sex differences, concussions, collegiate sports

international Journal of athletic therapy & training July 2015  45

per unit of exposure. Females, however, have a greater number of injuries per athletes, indicating that females have a greater risk of injury than males.2,4–6 The major drawback of these studies is that their findings are spe- cific to either one sport or to high school sports, and therefore cannot be compared with the collegiate-level athletes in Canada. Our study looks at a wide variety of sports to compare both sex and sport difference regarding injury severity risks.

We also chose to compare concussion risk between sex and sport. There has been an increase in the number of reported concussions over the past two decades, either due to increased reporting and detection of concussions, or due to an increase in the number of concussive impacts occurring.1,7,8 Although the effects of concussion are still under investigation, it is known that concussions may lead to long-term consequences, and as such require diligence in their prevention and care.8,9 Hootman et al. found that women’s hockey had the highest rate of concussions compared with all other sports.1 Meanwhile, Daneshvar et al. found that concussions represented a greater proportion of total injuries in females compared with males in basketball, ice hockey, and soccer.7 In our study we will look at the risk of concussion associated with both sex and sport to add further evidence to this area of research.

The purpose of our study is to determine if a differ- ence in injury severity risk exists between males and females in sex-matched sports at the collegiate level. Information regarding types of injuries sustained by sport will also be included. To our knowledge, there is no existing research looking at this risk across a variety of sports at the collegiate level in Canada. We hypothesize that females will have a higher percentage of severe injuries and a greater percentage of reported concussions.

Methods Study Design

This is a descriptive epidemiologic study using previ- ously collected data from York University’s Gorman/ Shore Sport Injury Clinic sport injury database. Data were de-identified before collection and therefore exempt from ethical approval. The outcome variable was injury severity for the first analysis and concussion for the second analysis. Exposure variables were sex and sport.

Participants

Participants were student-athletes on the York Univer- sity Lions’ varsity teams, as determined by the Ontario University Athletics (OUA) association. These athletes were treated at the Gorman/Shore Sport Injury Clinic at York University (Toronto, Ontario, Canada) from August 1, 2008 through July 31, 2012. The York University Lions collegiate men’s and women’s teams included in this study were as follows: soccer, ice hockey, vol- leyball, basketball, cross-country, and track and field. Men’s football and women’s rugby were also included. Data excluded from this study were injuries sustained by athletes not on one of the aforementioned sport teams or athletes injured outside of collegiate events, including recreational activities, intramurals, or activity courses as part of an academic program.

Injury Information

A sport injury was defined as any physical complaint sustained by an athlete during competition or training, which required medical attention by an athletic thera- pist or medical doctor.2,3,10 An injury assessment form was completed by a certified athletic therapist (CAT) or athletic therapy certificate student therapist, which was subsequently entered into Injury Zone, an Inter- net-based sports medicine database (https://sports1. injuryzone.com/iZoneWeb/) monitored by Presagia (Montreal, Quebec, Canada). Injuries were categorized as severe or nonsevere based on the degree of tissue damage as determined during the initial assessment. Injuries involving first aid treatment, in which assess- ment forms were not completed, were excluded. Severe injuries included those defined as third degree joint or tissue damage in which there is gross instability and complete tear or rupture of the involved tissues.11 Concussions were included as a severe injury as all athletes with concussions were seen by a medical doctor and removed from game play for a minimum of five days, as per the current international concussion protocol.9 All other injuries, including first and second degree tissue damage, were considered nonsevere. See Table 1 for a complete list of injuries in this study. Injury data that was incomplete or inconsistently reported were excluded from analysis.

Statistical Analysis

Statistical analysis was conducted using SPSS 19.0.0 (IBM, Armonk, NY). The exposure variables were sex and sport, and the outcome variables were injury

46  July 2015 international Journal of athletic therapy & training

severity and concussion. Chi-square analyses, with an a priori level of significance set at p = .05, were per- formed to examine the association between exposure and outcome variables. Further logistic regression anal- yses, with an a priori level of significance set at p = .05 and a 95% confidence interval, were used to quantify the associations between sex and severe injury and sex and concussion. Concussions were analyzed as a proportion of both all injuries and severe injuries. We were limited by the data available, however the power calculation based on unequal groups revealed a 1-β of 80%.

Results Injuries

There were 1,657 injuries included in the study, of which 1,414 (85.3%) were nonsevere and 243

(14.7%) were severe (Table 1). Overall, the most common injuries were nonsevere strains (22.9%) and sprains (23.0%) (Table 1). Concussions (7.7%), fractures (1.9%), and subluxations (1.6%) were the most common severe injuries (Table 1). Of the 243 severe injuries reported, approximately half (52.3%) were concussions.

Sex Differences

The number of reported male injuries outnumbered female injuries threefold: 1,155 (69.7%) and 502 (30.3%), respectively (Table 2). Of these, males had 154 severe injuries, while females had 89; however, females had a significantly higher proportion of severe injuries (17.7%) compared with males (13.3%) (Table 2; χ2 = 5.40, p = .02). These results show that female athletes have 1.4 times the odds of severe injury than males (OR: 1.40, CI: 1.05–1.86).

Table 1. Frequency of Type of injury by sex among Collegiate athletes at York University,

august 2008–July 2012

Type of Injury M a l e s ( n = 1 , 1 5 5 ) ,

n ( % ) Fe m a l e s ( n = 5 0 2 ) ,

n ( % )

To t a l ( n = 1 , 6 5 7 ) ,

n ( % ) Severe

Concussion 72 (6.2) 55 (11.0) 127 (7.7)

Fracture 19 (1.6) 13 (2.6) 32 (1.9)

Subluxation 19 (1.6) 7 (1.4) 26 (1.6)

Dislocation 16 (1.4) 6 (1.2) 22 (1.3)

Rupture/tear 12 (1.0) 4 (0.8) 16 (1.0)

Other–surgical repair 16 (1.4) 4 (0.8) 20 (1.2)

Total 154 (13.3) 89 (17.7) 243 (14.7)

Nonsevere

Sprain 263 (22.8) 118 (23.5) 381 (23.0)

Strain 280 (24.2) 100 (19.9) 380 (22.9)

Tendinitis 88 (7.6) 40 (8.0) 128 (7.7)

Tightness/spasm 85 (7.4) 39 (7.8) 124 (7.5)

Contusion 88 (7.6) 22 (4.4) 110 (6.6)

PFPS 25 (2.2) 17 (3.4) 42 (2.5)

Impingement 25 (2.2) 11 (2.2) 36 (2.2)

Joint irritation 13 (1.1) 6 (1.2) 19 (1.1)

Bursitis/fasciitis 11 (1.0) 7 (1.4) 18 (1.1)

Cartilaginous 15 (1.3) 0 (0.0) 15 (0.9)

Other 108 (9.4) 53 (10.6) 161 (9.7)

Total 1,001 (86.7) 413 (82.3) 1,414 (85.3) Abbreviations: PFPS = patellofemoral pain syndrome.

international Journal of athletic therapy & training July 2015  47

Concussions

Eleven percent of all female injuries were concus- sions—significantly more than in males (6.2%) (Table 3; χ2 = 11.03, p = .001). Female athletes were at greater odds of sustaining a concussion than male ath- letes (OR: 1.85, CI: 1.28–2.67). Similarly, concussions made up 61.8% of all female severe injuries and 46.8% of male severe injuries (Table 3; χ2 = 4.47, p = .03). Within severe injuries, female athletes had significantly higher odds of sustaining a concussion compared with males (OR: 1.86, CI: 1.07–3.23).

Sport Differences

Women’s hockey (23.9%), rugby (21.3%), and soccer (20.3%) had the highest percentage of severe injuries (Table 2). Nearly all women’s sports reported a higher proportion of severe injuries when compared with males of the same sport; however, the only statistical significance was found when comparing men’s football to women’s rugby (Table 2; χ2 = 3.90, p = .05). The only exception to this was volleyball, in which males showed a slightly higher proportion of severe injuries

(Table 2). Women’s ice hockey (19.6%), rugby (13.9%), and basketball (13.3%) had the highest proportion of concussions compared with all other teams (Table 3). Although females typically had a higher proportion of concussions compared with males in the same sport, this was only significant in ice hockey and rugby/foot- ball (Table 3; χ2 = 5.42, p = .20; χ2 = 12.02, p = .001). When looking at the proportion of concussions to severe injuries, it is important to note that in both soccer and cross-country/track and field, males had a higher proportion of concussions to severe injury than females (Table 3).

Discussion Our results show that males generally incur more injuries, but females had a significantly higher pro- portion of severe injuries. Furthermore, females had a significantly higher proportion of concussions. Some sports of interest include: volleyball, which was the only sport that males had the greater proportion of severe injuries; soccer, where females had a lower proportion of concussions compared with males; and ice hockey,

Table 2. injury severity by sport and sex among Collegiate athletes at York University,

august 2008–July 2012 S e v e r e, n

( % ) N o n s e v e r e, n

( % ) To t a l P -Va l u e Sex

Male 154 (13.3) 1,001 (86.7) 1,155

Female 89 (17.7) 413 (82.3) 502 .020

Total 243 (14.7) 1,414 (85.3) 1,657

Sport

Football (M) 74 (14.1) 450 (85.9) 524

Rugby (F) 26 (21.3) 96 (78.7) 122 .048

Basketball (M) 20 (14.6) 117 (85.4) 137

Basketball (F) 12 (20.0) 48 (80.0) 60 .344

Volleyball (M) 13 (19.7) 53 (80.3) 66

Volleyball (F) 13 (18.3) 58 (81.7) 71 .836

Soccer (M) 10 (10.6) 84 (89.4) 94

Soccer (F) 14 (20.3) 55 (79.7) 69 .086

Ice hockey (M) 29 (18.0) 132 (82.0) 161

Ice hockey (F) 22 (23.9) 70 (76.1) 92 .260

Cross country/track & field (M) 5 (3.0) 161 (97.0) 166

Cross country/track & field (F) 5 (5.3) 90 (94.7) 95 .362 Abbreviations: M = male; F = female.

48  July 2015 international Journal of athletic therapy & training

where females had a significantly higher proportion of concussions than males.

Although the injury incidence rate is an import- ant factor to consider when looking into possible injury prevention and treatment protocols, the risk of sustaining a severe injury is also essential to study. Previous studies have found similar results to ours, in that females are at a higher risk for sustaining a severe injury.2,4 Powell and Barber-Foss concluded that major injuries in females occur more often than in males in high school basketball and soccer.4 Similarly, Darrow et al. found that severe injuries accounted for 14.9% of all injuries sustained in high school and, among sports that were comparable (soccer, basketball, and baseball/softball), females sustained a higher rate of severe injury that males.2 Future research on females and sport-specific risk factors is important to better understand causes of injury and ways to prevent them.

It is interesting to note that both men and women volleyball players sustained a low, but similar percent- age of severe injuries. This emphasizes the importance

of understanding risk factors associated with each sport to apply prevention and coaching programs for improved sport safety. In an epidemiology study of female collegiate volleyball players, it was found that 23% of all injuries sustained were considered severe.12 Of these, 44% were ankle ligament damage resulting from contact with a teammate or opposing player. This study did not look at men’s volleyball injuries, so a comparison between the sexes cannot be made.12 However, we can speculate that the low risk of severe injuries in volleyball is perhaps attributed to rules and regulations that enhance player safety for both sexes, such as the center line rule which was introduced to the NCAA in 1998.12,13 This rule permits the encroach- ment of the opposing team’s side as long as there is no safety hazard present or does not interfere with the opponent’s play, thus eliminating this particular risk factor.12 Further investigation into the reasons behind the low risk of severe injury in volleyball is needed to implement possible rules or prevention programs throughout other female sports.

Table 3. Proportion of Concussions among all injuries and severe injuries among Collegiate athletes

at York University, august 2008–July 2012

To t a l C o n c u s s i o n s

To t a l I n j u r i e s

( n )

P r o p o r t i o n o f C o n c u s s i o n s

( % ) p - Va l u e

S e v e r e I n j u r i e s

( n )

P r o p o r t i o n o f C o n c u s s i o n s

( % ) p -Va l u e Sex

Male 72 1,155 6.2 154 46.8

Female 55 502 11.0 .001 89 61.8 .024

Sport

Football (M) 27 524 5.2 74 36.5

Rugby (F) 17 122 13.9 .001 26 65.4 .011

Basketball (M) 10 137 7.3 20 50.0

Basketball (F) 8 60 13.3 .176 12 66.7 .358

Volleyball (M) 5 66 7.6 13 38.5

Volleyball (F) 7 71 9.9 .637 13 53.8 .431

Soccer (M) 7 94 7.4 10 70.0

Soccer (F) 7 69 10.1 .544 14 50.0 .327

Ice hockey (M) 15 161 9.3 29 51.7

Ice hockey (F) 18 92 19.6 .020 22 81.8 .026

Cross country/track & field (M)

4 166 2.4 5 80.0

Cross country/track & field (F)

2 95 2.1 .875 5 40.0 .197

Abbreviations: M = male; F = female.

international Journal of athletic therapy & training July 2015  49

Females have 1.9 times the odds of sustaining a concussion as compared with males, and this finding is consistent with current research.1,7,8,14–17 In previous epidemiology studies of sports in the NCAA, it was found that 5% of all injuries were concussions and that females had a higher percentage of concussions than males in basketball, ice hockey, soccer, and lacrosse.1,7 Likewise, Gessel et al. found that 8.9% of all high school injuries and 5.8% of all collegiate injuries were concussions.14 Females were found to have a higher rate of concussions, and a higher proportion of con- cussions compared with all injuries in sports played by both sexes.14 Sex differences and concussions are highly scrutinized in present sports medicine research in an attempt to discover the reasons behind such disparities.14,16,18 Some proposed explanations for sex differences with concussions include: (1) biomechani- cal—females have weaker neck muscles and therefore greater angular acceleration of neck and head;14,18 (2) psychosocial—some suggest males are socially encouraged to play through injuries, while females are more concerned with long-term effects on health and therefore may be more honest about symptoms;14,18 and (3) hormonal—estrogen, which maintains normal cerebral blood flow16,18 plays a protective role in males while increasing mortality in females.14,18 The values found in our study suggest that research focusing on the risk factors of concussions, as well as on prevention strategies targeted at female athletes, should be of high priority in concussion research. This is necessary to help decrease the risk of concussion in female athletes, which will allow for safer participation in sport.

There were some noteworthy sport-specific differ- ences when looking at concussion risk and sex. For instance, we noted that in some sports, such as soccer, the risk of concussion when compared with other severe injuries was higher in males than in females. This may be due to the high risk of other severe injuries to females in soccer, but requires further investigation into sport-specific risk factors. Current literature has found that females are more likely to sustain an ankle or knee injury than males, and are three times more likely to tear their anterior cruciate ligament.5 A study looking at men’s and women’s soccer injury rates found that 44% of severe injury in females was due to knee derangement, while this only accounted for 11% of severe injuries in males.19,20

In addition, the differences between concussion risk in male and female ice hockey players are essen-

tial to highlight. Women’s ice hockey not only had the highest proportion of concussions compared with all other teams, but was also significantly higher than men’s ice hockey. This holds true when comparing the proportion of concussions to all injuries, or to severe injuries only. This strengthens the fact that sex-specific risk factors in this sport need to be better understood to implement prevention programs. Women’s ice hockey, although similar to men’s, has an important rule distinction, in which intentional body checking is not allowed.18 In theory, this should reduce the number of concussions as player contact should also be reduced, however this does not seem to be the case.18 In an epidemiological study on collegiate-level ice hockey players in the United States, it was found that concussions were the most common injury seen in female hockey players (21.6%), while concussions constituted only 9% of injuries sustained for males.21,22 Furthermore, this study found that over 40% of concus- sions were due to contact with another player.21 Schick and Meeuwisse found that 96% of injuries sustained by females are due to contact with either an opponent or the boards, whereas males received 79% of their injuries from contact.23 It has been suggested that unanticipated body checking in women’s hockey may lead to increased player contact and thus an increased concussion risk.21,23 This unanticipated checking and player contact may be caused by variability in play seen in women’s ice hockey. This variability may be influenced by coaching styles during player develop- ment, as some females may play with male leagues and may be more comfortable with contact, while others may not. Moreover, inconsistent enforcement of the body checking rule increases variability between games.21,23 The results found in both our study, as well as throughout the literature, suggest the need for further investigation into the effectiveness of current rules in hockey to prevent the potential severity and morbidity associated with concussion.

The measure of severity of injury is a limitation to this study. We were unable to confirm interrater reliabil- ity of those evaluating injuries due to the surveillance nature of our data. Furthermore, although degrees of injury are a common method of determining tissue damage in the medical field, this was not confirmed through actual imaging of the tissue itself. While time lost due to injury is the leading measure of injury severity in the literature,24 this information was not available in the database and may have strengthened

50  July 2015 international Journal of athletic therapy & training

the criteria of severe and nonsevere injuries, thereby increasing accuracy in categorizing the injuries. Finally, this study was conducted among collegiate-level ath- letes, and therefore may not be generalizable to other populations.

Conclusion This study highlights sex differences of severe injury in Canadian collegiate sport. Females, when compared with males, have higher odds of incurring a severe injury, as well as higher odds of sustaining a concussion in collegiate sport participation. This emphasizes the need for further research on risk factors which may influence these results. A better understanding of both injury epidemiology, as well as potential risk factors, may allow sport medicine personnel, coaches, trainers, and athletes to implement proper injury prevention, education, and management to improve sport safety for female athletes.

Acknowledgments

We thank Dr. Frances Flint who supervised and guided us and Tracy Meloche of the Gorman/Shore Sport Injury Clinic at York University for coordination of data collection.

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Johanna M. Hurtubise and Alison Macpherson are with the York University Sports Medicine Team, York University, Toronto, ON.

Cheryl Beech is with York University, Toronto, ON.

Matthew Hoch, PhD, ATC, Old Dominion University, is the report editor for this article.

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