Abstract
Background:
Research on catastrophic injuries and medical conditions among majority girls’ and women’s sports are underrepresented. In this study, we describe the incidence, characteristics, and mechanisms of severe softball injuries/medical conditions between 2014 and 2021.
Hypothesis:
Catastrophic injury and illness patterns will be observed with a higher incidence rate at the collegiate level.
Study Design:
Descriptive epidemiologic study.
Level of Evidence:
Level 3.
Methods:
Events from the National Center for Catastrophic Sport Injury Research (NCCSIR) and National Electronic Injury Surveillance System (NEISS) were included. NCCSIR included catastrophic injuries during participation in high school (HS) or college sponsored girls’/women’s softball resulting in death, temporary or permanent disability, or life-threatening injury. NEISS included severe girls’/women’s softball injuries (product code 5034) among 13- to 17- and 18- to 24-year-olds among severe dispositions. National estimates were derived using a weighted sample for NEISS. Counts (%) and incidence rates (IR) per 100,000 participants overall and by age level, injury/medical event, and outcome were reported.
Results:
NCCSIR captured 0.3 events per 100,000 participants (95% confidence interval, 0.1-0.5), and incidence was higher in college (IR, 2.5; 0.9-6.6) compared with HS (IR, 0.1; 0.1-0.4). Sudden cardiac arrest was the most common event (5, 63%), and 2 (25%) fatalities were reported. NEISS captured 10.2 events per 100,000 participants (9.7-10.8). Incidence was higher in 18- to 24-year-olds (IR, 8.9; 8.3-9.6) compared with 13- to 17-year-olds (IR, 4.2; 3.8-4.6), and no fatalities were captured.
Conclusion:
Collegiate and 18- to 24-year-old athletes demonstrated a higher incidence of severe injuries than HS and 13- to 17-year-old athletes across both surveillance systems. NEISS captured a higher incidence of catastrophic events than NCCSIR. NCCSIR observed more cardiac events, whereas NEISS observed more head/face injuries.
Clinical Relevance:
Continued monitoring of severe injuries and medical events in softball is necessary to support response and prevention measures.
Keywords: Softball, catastrophic injuries, head injuries, cardiac arrest
Softball is a popular throwing sport in the United States (US) with participants of all ages and levels. More than 2 million youth and adolescent players participate in fastpitch softball at the recreational, high school (HS), and travel ball levels of play, 26 with nearly 20,500 athletes participating at the collegiate level. 17 Among slowpitch softball, >6 million athletes participate in leagues across the country. 30 Previous injury epidemiology literature has focused primarily on documenting the incidence and mechanisms of acute and chronic injuries,13,28-30 with overuse mechanisms of the upper extremity being described more predominantly.19,21 Although softball is not considered a contact sport that predisposes participants to a high risk of severe or catastrophic injuries, contact injuries do occur via sliding, collisions with other players, and ball contact. 29 Furthermore, catastrophic, severe medical events can occur. Catastrophic injuries and medical events are defined as injuries or medical conditions that result in death, permanent functional disability, or serious injuries that result in temporary disability. 16 These injuries and medical events include spinal cord injuries, traumatic brain injuries, internal organ injuries, commotio cordis, exertional heat stroke, and cardiovascular events. 16
Among comparable bat and ball sports, previous literature estimated 0.43 catastrophic injuries per 100,000 participants from 1982 to 2002 among baseball players at the adolescent and collegiate levels, with severe head injuries (ie, traumatic brain injuries, skull fracture) being the diagnosis reported most commonly. However, sparse information among softball players is available. 3 In addition, under-representation of women’s sport research participants may fail to highlight differences in individual, team, and economic levels that may inform prevention measures specific to these populations that are often under resourced compared with men’s sports. Given the increased popularity of girls’ and women’s softball in the last 3 decades,17,26,30 further knowledge is needed to determine the incidence of catastrophic injuries to inform response, treatment, and prevention of these potentially life-altering injuries.
Injury surveillance is the first step in a systematic approach to sports injury prevention and mitigation. 27 As described in 1992 by van Mechelen et al, 27 injury surveillance describes the burden and incidence of sports-related injuries to inform future policy and intervention strategies. Surveillance is ongoing or repeated, and serves as the first and the final step in evaluating policy or intervention strategies. In the context of sport, catastrophic injuries resulting in long-term disability or death are a high priority to prevent due to the significant long-term impacts, including the psychological toll on families, communities, and societal impacts such as years of life lost when a fatality occurs.4,31 Injury surveillance supports clinicians and policy makers to understand mechanisms, clinical diagnosis, and outcomes and mitigate the occurrence of these injuries.
The purpose of this study is to address the knowledge gap in women’s/girls’ sports and describe the incidence, characteristics, and mechanisms of catastrophic and severe sport-related softball injuries and medical conditions among HS- and college-aged athletic participants captured by 2 national injury surveillance systems from 2014 to 2021.
Methods
Study Design and Data
This study is a descriptive epidemiological study inclusive of data from 2 national injury surveillance systems. The National Center for Catastrophic Sport Injury Research (NCCSIR) is a surveillance system that provides continuous collection and reporting on catastrophic sport-related injuries in the US. 16 NCCSIR conducts catastrophic injury and severe medical condition surveillance for middle school, HS, collegiate, professional/semiprofessional, and youth league sports. 16 NCCSIR captures events through routine searches of publicly available media sources (ie, online media reports, news articles, social media, blogs) and individual reports provided by members of the public, sport or medical organizations, and researchers to an internet-based portal (https://www.sportinjuryreport.org/). This portal allows anyone (ie, athletes, coaches, parents, athletic trainers) to report the basic details about a catastrophic injury or medical condition. Once an event is captured, athletes, parents, and schools are contacted to acquire more detailed information about the athlete, details about the event and injury, medical care provided, and the outcome. All information captured for each event is reviewed by NCCSIR staff to determine case eligibility.
A second injury surveillance system, the National Electronic Injury Surveillance System (NEISS), is a publicly available database of consumer product and sport or recreation injuries reporting to US hospital emergency departments. 25 NEISS was founded by the US Consumer Product Safety Commission and has been operational for >45 years. This surveillance system collects data on consumer product-related injuries by sampling approximately 100 hospitals across the US that are weighted to create a nationally representative probability sample. 25 Emergency department (ED) staff review ED department records for demographic, injury, and disposition information logged by an assigned and trained NEISS coordinator into the NEISS database. Data collected from the sample can be weighted to produce national estimates. 24
Injury Definition
NCCSIR defines a catastrophic injury as a severe injury or medical condition event incurred during participation in a HS- or college-sponsored sport that resulted in temporary, semipermanent or permanent disability, or fatality. Injuries and medical conditions that were included in this study and captured by NCCSIR include girls’ and women’s softball traumatic injuries (traumatic brain injuries, spinal fracture, commotio cordis, internal organ injury, spinal cord injury), heat or exertional illness (rhabdomyolysis with hospitalization, exertional sickling, heat stroke), environmental injury (lightning injury, drowning), and sudden cardiac arrest. Injuries captured by the NEISS database were defined as injuries with the product code for softball relating to the activity, apparel, or equipment (code 5034). To ensure comparable injury severity with NCCSIR, cases were included if the participant was admitted to the hospital (disposition codes 2, treated and transferred; 4, treated and admitted/hospitalized; 5, held for observation) or the incident included fatalities (disposition code 8). Cases that listed a disposition of treated and released were excluded due to potential for inclusion of nonsevere nature of events. Narrative reviews of NEISS data were conducted by a research investigator and crosschecked with a second investigator to (1) exclude events that did not meet NCCSIR catastrophic injury case definitions, and (2) crosswalk injury types to NCCSIR injury case classifications. NEISS events based on narrative review were excluded if the following were reported without a secondary severe catastrophic injury: (1) a concussion was listed with no secondary severe injury (ie, facial/skull fracture, traumatic brain injury, or closed head injury); and (2) upper or lower extremity fractures (ie, wrist, ulna/radial, tibia/fibula, foot fracture). Once eligibility was established, NEISS severe injury and medical events were crosswalked to NCCSIR definitions by category such as a “head injury” (ie, head/face fractures, brain bleed, subdural hematoma, closed head injuries), “spinal cord injury” (ie, spinal cord injury with or without a vertebrae fracture), “sudden cardiac arrest” (ie, hypertrophic cardiomyopathy, arrythmia, commotio cordis), or “other traumatic injury” (ie, internal organ injury, spinal fracture) diagnosis code, body region, and information provided in the narrative field. Table 1 provides a detailed description of how attributes are used to define events (ie, level, sport, sample, athlete exposure, injury definitions, exclusion criteria) by each surveillance system. For the NEISS database, all deidentified event narratives abstracted by included and excluded cases are provided in the Online Appendix with event narratives provided in Tables A3 and A4.
Table 1.
Attributes and Injury Definitions for 2 Surveillance Systems
| Attribute | NCCSIR | NEISS |
|---|---|---|
| Level | HS and collegiate | HS aged (13-17 years), College aged (18-24 years) a |
| Sport | HS softball (female and fastpitch only)Collegiate Softball (female and fastpitch only) | Softball (male and female, slow pitch and fastpitch) |
| Coverage and sample information | National | Nationally representative sample |
| Event capture (direct/indirect; reporter; reporting method) | Indirect: searches of publicly available sources (media, news articles);Direct: paper and web-based reporting from schools, athletes, parents, researchers, and sport organizations | Direct: Publicly available dataset that samples from 100 ED electronic medical records |
| Athlete exposure capture and definition | Estimated via annual participation statistics from NFHS and NCAA1,2Athlete exposure = 1 AS | Estimated via youth sport participation estimates by age from SBRNet.comAthlete exposure = 1 AS |
| Injury definition | An injury resulting in semipermanent or permanent disability or death | Softball injuries relating to the activity, apparel, or equipment (code 5034) and one of the following dispositions: (1) admitted, treated and transferred, (2) admitted, treated, and hospitalized, (3) admitted, held for observation, (4) Fatality |
| Included injury types | Spinal cord injuries, spinal fractures, traumatic brain injuries (ie, brain bleeds), skull fractures, heat stroke, sudden cardiac arrest, internal organ injuries, exertional sickling, rhabdomyolysis, and commotio cordis that occurred during softball related participation | Narrative reviews were queried for each case for the following: spinal cord injuries, spinal fractures, traumatic brain injuries (ie, brain bleeds), closed head injuries, skull fractures, heat stroke, sudden cardiac arrest, internal organ injuries, exertional sickling, rhabdomyolysis, and commotio cordis that occurred during softball related participation |
| Exclusions | Cases outside of study timeframe (2014-2021)Sport level of “sand lot,” “recreational,” or “slowpitch” due to denominator match. Reviewed by 2 research investigators | Cases outside of study timeframe (2014-2021)Excluded the following dispositions: (1) not admitted, no injury; (2) not admitted, treated/examined and releasedConcussions with no secondary listing of facial/skull fracture, traumatic brain injury, or closed head injury; distal fractures (ie, wrist, ulna/radial, tibia/fibula, foot fracture without a secondary severe catastrophic injury no concomitant severe. Identified following narrative review by 2 research investigators |
AS, athlete-season; ED, emergency department; HS, high school; NCAA, National Collegiate Athlete Association; NCCSIR, National Center for Catastrophic Sport Injury Research; NEISS, National Electronic Injury Surveillance System; NFHS, National Federation of High Schools.
Ages are categorized as 13 to 17 years, and 18 to 24 years to allow for denominator match.
Athlete Participation
Athlete participation was defined as an athlete-year for each database using publicly available annual participation statistics. Annual participation statistics from the National Federation of High Schools (NFHS) and the National Collegiate Athlete Association (NCAA) were utilized to attain population estimates of participation by type of play (fastpitch, slowpitch) and level (HS, college) for NCCSIR data.11,18 No recreational cases were captured and included for HS and collegiate athlete participants. The Sports Business research Network (SBRN), 22 which abstracts participation statistics from the Sports and Fitness Industry Association (SFIA), 23 was utilized for NEISS data. SFIA examines participation in team sports by age in the US. 23 Participation statistics included girls’ and women’s softball and were grouped by age categories (13-17 years old, 18-24 years old) and type of play (all participation: fastpitch, slowpitch). Following narrative review of the NEISS events, discernment of fastpitch and slowpitch related cases was not possible; thus, participation statistics for both fastpitch and slowpitch were aggregated.
Statistical Analysis
Descriptive statistics included counts and percentages for participant characteristics (age group and/or level of play), sport-related factors (level of play, position), location (home, public park, sport/competition, school, unknown), and injury (type, location, severity or disposition). Sport related factors (position, mechanism of injury) were reported exclusively from NCCSIR data, as NEISS data does not report this information. Incidence rates per 100,000 athlete-season (AS) and 95% confidence intervals (CIs) were calculated overall and stratified by sport level/age group. Incidence rate (IR) ratios and 95% CIs were reported comparing incidence rates of college to HS (referent category) participants. All data management and statistical analyses were performed in SAS Version 9.4 (SAS Institute). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were used for reporting. 1
Results
From 2014 to 2021, NCCSIR captured 8 injuries among HS and collegiate girls’/women’s softball athletes for a combined incidence of 0.26 injuries per 100,000 AS (95% CI, 0.08, 0.44) (Tables 2 and 3). Among collegiate players, IR was 18 times the rate among college players (IR, 2.48; 95% CI, 0.05, 4.91) compared with HS players (IR: 0.14, 95% CI: 0.00, 0.27) (Table 3). Half of injury events occurring during competition (4, 50%) (Table 2) with the position played most frequently at the time of injury being baserunner (3, 38%) (Table 2); 62% (5) of events were due to sudden cardiac arrest, followed by head injuries (2, 25%) (Table 3), and 25% (2) of events resulted in death (Table 2). Online Appendix Table A1 provides more specific diagnosis categorizations for each event.
Table 2.
Athlete, event, and injury characteristics of severe and catastrophic injuries during girls’ and women’s softball participation across 2 surveillance systems from 2014 to 2021.
| Characteristic | NCCSIR | NEISS (Sample) a | NEISS (National estimate) a | NEISS (National estimate 95% CI) a |
|---|---|---|---|---|
| Overall | 8 (100%) | 23 (100%) | 657 (100%) | (314, 999) |
| Age, y [mean (SD)] | 17.5 (2.6) | 16.3 (2.8) | 17.1 (14.7) | – |
| Level | ||||
| HS or aged 13-17 years | 4 (50%) | 20 (59%) | 337 (51%) | (90, 549) |
| College or aged 18-24 years | 4 (50%) | 14 (41%) | 320 (49%) | (56, 618) |
| Session | ||||
| Competition | 4 (50%) | – | – | – |
| Scrimmage | 1 (13%) | – | – | – |
| Practice | 1 (13%) | – | – | – |
| Other | 2 (25%) | – | – | – |
| Location | ||||
| Home | 2 (25%) | – | – | – |
| Public park | 1 (13%) | – | – | – |
| Sport/competition | 5 (63%) | 19 (83%) | 626 (95%) | (309, 942) |
| School | 2 (9%) | 21 (3%) | (–12, 54) | |
| Unknown | 2 (9%) | 10 (2%) | (–3, 23) | |
| Mechanism | ||||
| Contact with player | 1 (13%) | – | – | – |
| Contact with apparatus/object | 2 (25%) | – | – | – |
| Infection or illness | 5 (63%) | – | – | – |
| Contact with other | ||||
| Sport position | ||||
| Baserunner | 3 (38%) | – | – | – |
| Pitcher | 2 (25%) | – | – | – |
| Other, unknown | 3 (38%) | – | – | – |
| Outcome | ||||
| Death | 2 (25%) | – | – | – |
| Temporary disability (trauma related) | 4 (50%) | – | – | – |
| Serious (Nontrauma survivor) | 2 (25%) | – | – | – |
| Disposition | ||||
| Admitted, treated, transferred | – | 4 (17%) | 224 (34%) | (–34, 483) |
| Admitted, treated, and hospitalized | – | 18 (78%) | 418 (64%) | (167, 669) |
| Admitted, held for observation | – | 1 (4%) | 15 (2%) | (–14, 43) |
| Death | – | – | – | – |
CI, confidence interval; HS, high school; NCCSIR, National Center for Catastrophic Sport Injury Research Surveillance System; NEISS, National Electronic Injury Surveillance System.
NEISS includes both sample counts and national estimates. NEISS sample sizes <20, or national estimates <1200 may be unstable and interpreted with caution.
Table 3.
NCCSIR injury rates per 100,000 ASs of severe catastrophic injuries during girls’ and women’s softball participation from 2014 to 2021
| NCCSIR (overall) a | NCCSIR (HS) a | NCCSIR (college) a | |||||
|---|---|---|---|---|---|---|---|
| n; AS | IR (95% CI) | n; AS | IR (95% CI) | n; AS | IR (95% CI) | IR ratio (95% CI) | |
| Total | 8; 3088, 860 | 0.26 (0.08, 0.44) | 4; 2927,493 | 0.14 (0.00, 0.27) | 4; 161, 367 | 2.48 (0.05, 4.91) | 18.14 (4.53, 72.54) |
| Injury category | |||||||
| Head injury | 2; 3088, 860 | 0.06 (–0.02, 0.15) | – | – | 2; 161, 367 | 1.24, (–0.48, 2.96) | – |
| Spinal cord injury | 1; 3088, 860 | 0.03 (–0.03, 0.10) | – | – | 1; 161, 367 | 0.62 (–0.59, 1.83) | – |
| Sudden cardiac arrest | 5; 3088, 860 | 0.16 (0.02, 0.30) | 4; 2927, 493 | 0.14 (0.00, 0.27) | 1; 161, 367 | 0.62 (–0.59, 1.83) | 4.53 (0.51, 40.58) |
| Other traumatic injury (ie, internal organ injury) | – | – | – | – | – | – | – |
| Fatality | 2; 3088, 860 | 0.06 (–0.02, 0.15) | 2; 2927, 493 | 0.07 (–0.03, 0.16) | – | – | – |
| Nonfatality | 6; 3088, 860 | 0.19 (0.04, 0.35) | 2; 2927, 493 | 0.07 (–0.03, 0.16) | 4; 161, 367 | 2.48 (0.05, 4.91) | 36.28 (6.65, 198.10) |
AS, athlete-season; CI, confidence interval; HS, high school; IR, incidence rates; NCAA, National Collegiate Athlete Association; NCCSIR, National Center for Catastrophic Sport Injury Research Surveillance System; NFHS, National Federation of High Schools.
Includes fastpitch softball, female athletes only based on cases (male = 0), and denominator match; HS participation from NFHS (Anon n.d.) and college participation from NCAA (Anon n.d.). Rates with counts <5 should be interpreted with caution.
NEISS captured 23 severe girls’ and women’s softball injuries (national estimate 657 95% CI, 314, 999), with an overall incidence of 5.13 injuries per 100,000 AS (95% CI, 4.74, 5.52) (Tables 2 and 4). Incidence was nearly 2 times the rate among 18- to 24-year-olds (IR, 8.90; 95% CI, 8.25, 9.55) compared with 13- 17-year-olds (IR, 4.14; 95% CI, 3.75, 4.52) (Table 4). Head injuries were the most common injury reported (95.6%, 628; 95% CI, 311, 944) (Tables 2 and 4); 64% (N = 418, 95% CI, 167, 669) resulted in hospital admission, treatment, and hospitalized. No deaths were captured in the NEISS data (Table 2). Incidence of head injuries was over 2 times the rate among players aged 18 to 24 years old at 8.71 (95% CI, 8.07, 9.35) per 100,000 AS, compared with players aged 13 to 17 years old at 5.36 (95% CI, 5.02, 5.69) per 100,000 AS. Tables 2 and 3 and Online Appendix Table A2 provide further information on diagnosis, body part, codes, and event narratives.
Table 4.
NEISS injury rates per 100,000 ASs of severe catastrophic injuries during girls’ and women’s softball participation from 2014 to 2021
| NEISS (overall) a | NEISS (aged 13-17) a | NEISS (aged 18-24) a | |||||
|---|---|---|---|---|---|---|---|
| n; AS | IR (95% CI) | n; AS | IR (95% CI) | n; AS | IR (95% CI) | IR ratio (95% CI) | |
| Total | 657; 12,802, 940 | 5.13 (4.74, 5.52) | 320; 8174, 690 | 7.28 (6.51, 8.06) | 337; 4628, 250 | 7.28 (6.51, 8.06) | 1.86 (1.60, 2.17) |
| Injury category | |||||||
| Head injury | 628; 12,802,940 | 4.90 (4.52, 5.29) | 290; 8174, 690 | 3.55 (3.15, 3.96) | 337; 4628, 250 | 7.28 (6.51, 8.06) | 2.05 (1.75, 2.40) |
| Spinal cord injury | 20; 12,802,940 | 0.15 (0.09, 0.22) | 20; 8174, 690 | 0.24 (0.13, 0.35) | – | – | – |
| Sudden cardiac arrest | 5; 12,802,940 | 0.04 (0.00, 0.07) | 5; 8174, 690 | 0.06 (0.00, 0.11) | – | – | – |
| Other traumatic injury (i.e., internal organ injury) | 5; 12,802,940 | 0.04 (0.00, 0.07) | 5; 8174, 690 | 0.06 (0.01, 0.11) | – | – | – |
AS, athlete-season; CI, confidence interval; HS, high school; IR, incidence rates; NEISS, National Electronic Injury Surveillance System.
Includes fastpitch and slow pitch softball for cases and denominator match from Sports Business research Network 22 ; NEISS sample sizes <20, or national estimates <1200 may be unstable and interpreted with caution. National weighted sample used to calculate incidence rates and 95% CIs. Slight discrepancies due to rounding; includes slowpitch, fastpitch softball participation based on NEISS code 5304.
Discussion
This study provides initial insight into catastrophic injuries among girls’ and women’s softball, where there is a paucity of literature to direct preventative measures. The highest overall incidence of severe or catastrophic softball injury was among college level (NCCSIR) and 18- to 24-year-old softball players (NEISS), with NEISS demonstrating a greater number of cases compared with NCCSIR. NCCSIR data indicated that most events occurred during competition among baserunners. Sudden cardiac arrest represented the highest incidence overall, with 80% of those events occurring at the HS level. In contrast, NEISS data, which captures both fastpitch and slowpitch at all levels of play, demonstrated a higher incidence of injuries across all categories and age groups compared with NCCSIR, except for cardiac arrest.
NCCSIR Surveillance Findings
By level of play, the highest incidence was observed at the collegiate level, with 50% of these events occurring during competition, and 38% being baserunners. A high incidence of severe catastrophic injuries at collegiate or higher levels of play across myriad sports has been demonstrated consistently, regardless of the contact nature of the sport. 10 The highest injury incidence among collegiate players was severe head injuries. Irrespective of severity, Veillard et al 28 found 11.2% of all injuries among collegiate softball athletes were head/face injuries, the third most common injury location reported from 2014 to 2019. Reasons for a high incidence of head injuries at the collegiate level may be related to greater exposure due to a greater density of games in a season (ie, more games played per week during the collegiate season compared with the HS season), and higher pitch and bat exit velocities, predisposing the athlete to potential for traumatic forces from ball contact.3,8 Softball athletes have reported the highest incidence rate of ball contact injuries at 8.82 per 10,000 athlete exposures, with 27% of injuries occurring to the head and face. 8 However, these studies did not differentiate severity of the injury, making direct comparisons with the current study difficult. To mitigate risk of severe head injuries, previous studies among youth baseball players demonstrated a 35% reduction in risk of facial injuries from 1997 to 1999 due to the implementation of safety balls and face guards. 14 A paucity of research is available specific to softball athletes in discerning the efficacy of protective equipment to prevent severe head injuries; however, analysis of softball faceguard performance with different materials indicated that metal masks performed better at attenuating forces compared with plastic masks. 15 Nonetheless, although facemask regulations at the HS level have not been enacted, encouragement of faceguard use for vulnerable positions (ie, pitchers, first and third base), as well as for batters, may mitigate severe head injuries due to ball-contact-related injuries.
Among HS softball players, a majority of events were related to cardiac arrest, 3 (38%) of which resulted in a death. In total, 80% of sudden cardiac arrest events occurred among HS players, none due to blunt trauma (commotio cordis), which is surprising given this is a common mechanism for sudden cardiac arrest in baseball players. 3 Currently, no data have been published on discerning potential mechanisms for this difference between the sports. Potential contributors may be related to difference in ball diameter or exit velocity if due to contact with a ball, but no research is available to confirm this hypothesis. Approximately 25% of sudden cardiac deaths are due to hypertrophic cardiomyopathy, 12 similar to the frequencies displayed in the current study. Younger athletes may have an increased likelihood of underlying cardiac conditions such as hypertrophic cardiomyopathy, myocarditis, Marfan syndrome, or nonstructural-related causes such as inherited arrhythmia syndromes, which may go undetected in adolescence due to being asymptomatic.12,20 Management strategies for sudden cardiac arrest, including early activation of emergency medical services, chest compressions, and defibrillation, have been well reported. 5 Ensuring that an automated external defibrillator (AED) is near all fields of play (ideally within 3 minutes) and easily located by coaches and support staff are proven prevention strategies that can increase the chance of survival among athletes who participate in bat and ball sports. 5
NEISS Surveillance Findings
The NEISS surveillance system encompassed fastpitch and slowpitch girls’ and women’s softball participants that included both organized and recreational forms of softball, resulting in a broader case capture. Similar to NCCSIR surveillance findings, the highest incidence rate of catastrophic injuries in NEISS was among 18- to 24-year-old participants at 7.3 per 100,000 AS. Head injuries were the most common injuries among participants admitted to the ED with 18- to 24-year-old participants demonstrating over 2 times the incidence of 13- to 17-year-old participants. Previous research utilizing the NEISS surveillance system between 1994 and 2010 found 23.6% of injuries treated in EDs among softball participants aged >18 years were to the head/face region irrespective of severity of the injury. 2 Similarly, among softball players aged 7 to 21 years old from 2010 to 2019, head/neck/face injuries represented the third highest proportion 30.15% (95% CI, 28.16%, 32.22%) of all injuries by body region. 8 However, across both studies, the majority of these injuries were treated and released, indicating that less severe injuries were captured, making direct comparisons with our study challenging based on injury severity despite similarities in injury mechanism.2,7
The NEISS surveillance system did not capture any deaths among softball participants admitted to the ED over this 8-year period. Although the number of events were similar for cardiac arrest (NCCSIR, N = 4; NEISS, n = 1 sample, N = 5 national estimate), the incidence was lower in the NEISS data source due to the differences in target population by including both fastpitch and slow pitch and recreational play participants. The single case used to estimate the national estimate indicated that cardiopulmonary resuscitation was provided, and an AED was applied (Online Appendix). Receiving bystander cardiopulmonary resuscitation and AED improves chances of survival upon admission to hospital and resultant discharge.6,9
Strengths and Limitations
The strengths of this study are that 2 large surveillance systems were used that are a national representations of severe sport injuries in organized scholastic, league, and recreational softball. Women’s and girls’ softball is growing in popularity, yet these athletes often remain understudied. This study is the first to provide initial insight into a girls’ and women’s bat and ball sport that has not been solely investigated in previously literature. However, this study is not without limitations. First, the NCCSIR surveillance system relies predominantly on media reports for event capture and reports to an online portal (https://www.sportinjuryreport.org/); therefore, all not events nationally may be captured, leading to a potential underestimation of the incidence rate for NCCSIR cases. Second, misclassification of severe catastrophic injuries is possible for NEISS cases; although procedures to identify severe catastrophic sports injuries were consistent with NCCSIR definitions. However, narrative fields were not always detailed enough to discern specific diagnostic details (ie, injuries described as ‘closed head injuries’ or ‘CHI’). All case narratives have been provided in the Online Appendix from the NEISS database abstraction to improve transparency. To address this potential misclassification, criteria based on dispositions (ie, admission to hospital) were used to exclude cases that may not constitute a severe injury to mitigate inclusion of less severe injuries. Third, due to differences in target populations reported, different denominators were used to estimate the incidence rates for each data source, preventing direct comparisons between the data sources. Fourth, investigators were not able to differentiate the style of play (ie, fastpitch, slowpitch) or type of play (school, league, or recreational) in the NEISS narrative fields; therefore, fastpitch and slowpitch participation were combined and used, limiting comparisons between style of play. Fifth, for both data sources sample sizes for these catastrophic and severe injuries were small, resulting in wide CIs for incidence rates. NEISS considers a national estimate unstable when the estimate is <1200 or the number of records is <20, and therefore should be interpreted with caution for low count estimates.
Conclusion
Severe catastrophic injuries are a rare but consequential and can result in severe outcomes among softball players. Across both surveillance systems, collegiate and 18- to 24-year-old athletes demonstrated a higher incidence of severe injuries compared with HS and 13- to 17-year-old athletes across both surveillance systems. The high incidence of cardiac arrest among HS players observed supports the need for access to AEDs, along with level, venue, and sport (ie, slow pitch versus fastpitch) specific emergency action plans to increase survival. Finally, given the high incidence of head injuries across 18-24 year olds and college-level play, further considerations on equipment protections related to head injuries for vulnerable positions should be encouraged to mitigate severe catastrophic head injuries.
Clinical Recommendations
Due to the frequent underrepresentation and potentially decreased resources in a majority girls’ and women’s sports, further engagement of sport organizations, coaches, and medical staff is needed to encourage reporting to discern injury and sport characteristics for response and prevention programs. Given the higher proportion of cardiac events at the HS level, continued easy access and training to implement an AED is necessary across all fields of play. In addition, given the higher incidence of severe head injuries among the collegiate and 18- to 24-year-old age groups, considerations for protective equipment options for vulnerable positions may be an option for potential mitigation of these injuries.
Supplemental Material
Supplemental material, sj-docx-1-sph-10.1177_19417381251314019 for Catastrophic Severe Injuries and Medical Conditions in Girls’ and Women’s Softball: An 8-Year Epidemiologic Study by Chelsea Martin, Kathryn Osterhout, Erin Shore, Randi Delong, Johna Mihalik and Kristen Kucera in Sports Health
Acknowledgments
The authors acknowledge the significant contributions of Frederick O. Mueller, who directed the National Center for Catastrophic Sport Injury Research (NCCSIR) from 1982 to 2013. They thank all the athletes, families, coaches, athletic trainers, medical providers, school staff, state associations, researchers, journalists, and others who have participated in this research and have shared information with the NCCSIR.
Footnotes
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: the National Center for Catastrophic Sport Injury Research is funded by the following organizations: the American Football Coaches Association, the National Athletic Trainers’ Association, the National Collegiate Athletic Association, the National Federation of State High School Associations, the National Operating Committee on Standards for Athletic Equipment, and the American Medical Society for Sports Medicine.
The authors report no potential conflicts of interest in the development and publication of this article.
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Associated Data
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Supplementary Materials
Supplemental material, sj-docx-1-sph-10.1177_19417381251314019 for Catastrophic Severe Injuries and Medical Conditions in Girls’ and Women’s Softball: An 8-Year Epidemiologic Study by Chelsea Martin, Kathryn Osterhout, Erin Shore, Randi Delong, Johna Mihalik and Kristen Kucera in Sports Health