Analysis of Injury Rates and Treatment Patterns for Time-Loss and Non–Time-Loss Injuries Among Collegiate Student-Athletes

Abstract

Objective:

To compare the injury rates for time-loss and non–time-loss injuries among selected intercollegiate athletic programs and to describe the number of treatments associated with these injuries.

Design and Setting:

A volunteer, cross-sectional cohort study of 50 collegiate athletic programs representing the 3 National Collegiate Athletic Association divisions, the National Association of Intercollegiate Athletics, and the National Junior College Athletic Association during the 2000–2002 academic years.

Subjects:

Individuals listed on the team rosters for the participating institutions and representing the sports associated with the institution's athletic programs.

Measurements:

The athletic training staff and students recorded the injury and treatment data for the participating institutions. The data included information for time-loss and non– time-loss injuries, daily treatments, and daily athlete-exposures.

Results:

Non–time-loss injury rates were 3.5 (confidence interval = 3.4, 3.6) times the time-loss rate for men and 5.1 (confidence interval = 4.9, 5.2) times the time-loss rate for women. Non–time-loss injuries required more treatments over the course of the year than did time-loss injuries. For men's sports, 22% of the injuries resulted in loss of participation time, with 47% of the treatments associated with these injuries. For women's sports, 16% of the injuries and 34% of the treatments were associated with time-loss injuries.

Conclusions:

Throughout the sports medicine year, athletic training staff and students spent more time delivering treatments to athletes who were not missing participation time than to athletes who were missing time. A noteworthy difference in the workforce available to provide health care among the various levels of intercollegiate athletics may contribute to the frequency of injury and treatments reported.

During the 2000–2001 academic year, nearly 450 000 athletes participated in the athletics programs of the 5 major college athletic associations¹: approximately 150 000 in the National Collegiate Athletic Association (NCAA) Division I, 74 000 in NCAA Division II, 137 000 in NCAA Division III, 42 000 in the National Association of Intercollegiate Athletics (NAIA) (NAIA national office, personal communication, November 2002), and 45 000 in the National Junior College Athletic Association (NJCAA) (NJCAA national office, personal communication, November 2002). During the same time period, the National Athletic Trainers' Association (NATA) membership totalled nearly 23 000 certified athletic trainers, with about 20% (4585) identified as employed by colleges and universities.² Athletic trainers fill the role of primary health care providers in these collegiate athletic programs. Comparing the number of athletes with the number of available certified athletic trainers demonstrates a ratio of nearly 100 athletes per certified athletic trainer.

In recent years, many collegiate programs have experienced an increase in the participation time of their athletes. This increase in participation results in greater exposure (chance for injury) and places a greater demand for service on the athletic health care team, especially the athletic trainers. With longer seasons, concern has arisen that some athletic programs are not adequately staffed to meet the changing medical coverage needs of the student-athletes. In response to these trends, the NATA established a task force to describe the Appropriate Medical Coverage in Intercollegiate Athletics (AMCIA) in 1998. Its charge was to develop recommendations and guidelines by which institutions could evaluate the medical coverage currently available to their student-athletes and to make these recommendations sensitive to the different levels of participation. The guidelines had to take into account a number of factors, including both time-loss and non–time-loss injuries, the number of treatments provided for the injuries, an identified potential for catastrophic injury, the team size, team travel requirements, and other administrative duties.³ To develop its recommendations, the task force turned to existing literature and interviews with athletic trainers from the different levels of collegiate athletic programs. As the task force began to assemble its recommendations, it was faced with limitations in available information regarding those injuries requiring treatment even when the player did not lose participation time.

During the past decade, a number of investigators have identified the injury rates for selected collegiate sports. The NCAA Injury Surveillance System (NCAAISS) has described time-loss injury rates for selected sports⁴ and provided invaluable data for the task force as it addressed the relative risk associated with time-loss injuries. Unfortunately, the existing NCAAISS data did not address considerations for non–time- loss injury rates. In addition, the existing literature was designed to evaluate the relative risk of injury among selected sports and did not include consideration for health care services, including treatments that were required to manage these injuries.

In reviewing the literature, we identified only a few studies that included descriptions of non–time-loss injury rates. During the 1985 Junior Olympic Games, Martin et al⁵ found that only 10% of the 1113 reported injuries required time lost from competition. Additionally, Cunningham and Cunningham⁶ found that 66% of the injuries at the Australian University Games were non–time-loss injuries, whereas only 34% required time loss. Other researchers examining individual sports such as baseball, softball, track and field, volleyball, and wrestling found non–time-loss injury rates between 72% and 95%.^7–11 The information gained from the descriptions of time-loss injuries and the limited data for non–time-loss injuries was still missing the critical element concerning the amount of health care services required to manage both categories.

With the paucity of injury treatment data available in the literature, it is important to describe treatment rates provided by athletic trainers in the collegiate setting. Preliminary data from 2 universities that collected treatment-related data provided evidence that non–time-loss injuries required much more athletic trainer time for assessment, treatment, and rehabilitation than had been anticipated.³ Non–time-loss injury rates and treatment rates for both classifications of injury are important because these issues are often overlooked when coverage and personnel decisions are made. Our purpose was to provide injury and treatment rates for time-loss and non–time-loss injuries for a multitude of sports in 5 major collegiate divisions.

METHODS

Project Design

The participants included 10 volunteer schools from each of the 3 NCAA divisions, 10 from the NAIA, and 10 from the NJCAA in each of the 2 seasons (2000–2001, 2001–2002). Collected data included information regarding the different levels of participation, the time-loss and non–time-loss injuries, athlete-exposures, and treatment frequencies by sport. The data were maintained in such a manner that no athlete or institution was identified with specific injury or treatment-related information.

We used the Sports Injury Monitoring System (SIMS-Med Sports Systems, Dimondale, MI) as a uniform program for the documentation of information regarding the daily activities of the athletic training program as it managed the health care of collegiate student-athletes. The software program allowed the recorders to include data from all athletic training service areas regarding daily contact with student-athletes for the identification, evaluation, treatment, and management of sport-related injuries. Several of the volunteers were very familiar with the SIMS program because it was their documentation system of choice. The new schools were provided training over the phone and one on one at the national and regional conventions. The certified athletic trainers at the volunteer institutions were responsible for the training of their personnel regarding the needs of the projects. The head athletic trainers were responsible for maintaining the project. All members of the institutional staff (athletic trainer, graduate assistant, or athletic training student) had immediate availability of research staff through a toll-free help line available 24 hours per day, 7 days per week, 365 days per year.

Participation

The athletic director, team physician, and athletic training staff members were required to complete informed consents for their participation in the study. The project and the materials used during the study period were reviewed and approved by the university's institutional review board. Mutually exclusive code numbers for institutional data were used in the central database. The athletic training staff had to be willing to record data for all the sports offered by the institution. In addition, the athletic training staff had to commit to participate, and the institution had to demonstrate that it had the computer technology available to ensure consistent documentation from all athletic training service areas.

The research staff recruited volunteers from athletic training staffs using announcements in the NATA News, available Internet listservs, and personal contacts. Each volunteer was thoroughly informed of the commitment necessary to complete the study requirements. From among the volunteers, the final participants were selected based on the level of participation, the commitment of the athletic training staff to complete the study, the diversity of the sports offered by the institution, and the technology available at the institution to meet the study requirements.

The research staff manually reviewed all incoming information for clarity and accuracy. Questions regarding the data were verified through follow-up contacts with recorders before the data were included in the study analysis.

In the event a school could not complete the required documentation, the research staff recruited and included comparable schools to replace the schools that withdrew. During the first year of the study, when a school was unable to comply with the requirements of the study, the research staff was able to replace it, especially because the new school could continue in the second year. When a school had to drop out in the second year, it was replaced only if it dropped out before October. In the second year, 4 schools were unable to complete the requirements for participation. Participation is represented as team seasons (Appendix A).

The project software protocol automatically aggregated data from within the master system at each institution and prepared it for e-mail transmission to the central database. The variables included in the transfer were institution number, player number, player information, injury/illness data, daily exposure data, and daily treatment data. At the end of each recording year, schools that completed the data requirements were awarded a stipend as prescribed by the research design. The stipends were distributed according to individual institutional policy.

Each participating school was asked to submit specific information regarding the numbers of full-time certified athletic trainers, graduate assistant athletic trainers, and athletic training students who would be identified as “data recorders.” These data were used to identify the relationship between available workforce and the number of treatments provided by the program. As a model for analysis, full-time-equivalents (FTEs) were assigned to each applicable person at participating institutions. A certified athletic trainer represented 1 FTE, whereas a graduate assistant represented 0.5 FTE and an athletic training student, 0.25 FTE.

Operational Definitions

To compare data among the participating institutions, each participating school was provided a project manual that included specific operational definitions related to the research design. The operational definitions were uniform and had to be adopted by each institution, at least for the duration of the project. The definitions focus on the general guidelines for the system and the specific definitions for documentation (Table). The operational definitions used in the study were derived from the AMCIA Task Force's initial recommendations.³

Operational Definitions

Exposure Data

Each participating school was required to complete a daily activity calendar that identified the number of participants in any session for that day (eg, the number of players at a practice or game). These calendar data were aggregated to create the number of athlete-exposures (AEs) for each sport. Coupled with the injury data, injury rates per 1000 AEs were calculated.

Analysis

Data analysis was conducted using SPSS statistical software (version 10; SPSS Inc, Chicago, IL). Injury rates were calculated per 1000 AEs by dividing injury frequencies by exposures. The treatments per injury rates were calculated by dividing the number of treatments by the number of injuries. Treatment rates per 100 AEs were calculated to provide perspective on the work load associated with different sports. This treatment-per-exposure rate allows for comparison of the different amounts of treatment required by different sports as they might be compared with football, in that an average football team with 100 players would create 100 AEs each day. Rates were calculated for cumulative male and female sports, by level of participation, and within the sports (Appendices B–F). The confidence intervals for the individual rates were calculated using a binomial distribution identified by Motulsky.¹²

For the comparison of data among the levels and within the sports, we used injury rates per 1000 AEs, treatments per injury, and treatment rates per 100 AEs to create a ratio between the 2 components of the relationship. For example, non–time- loss injury rates divided by time-loss injury rates produced an incidence density ratio (IDR).¹³ This allowed us to make judgments concerning the magnitude of difference between the conditions under consideration. An IDR of 1.0 would represent no difference between the 2 conditions.

The study captured data for a variety of sports among the various levels of participation that represented 22 states. Among the 5 levels of participation, 10 sports were common for all levels for both men's and women's sports. The data for wrestling and field hockey were also included, although data were not recorded at all levels for these sports. Their inclusion allows for comparisons with existing literature regarding these 2 sports. The following data analysis reflects only this group of common sports for the 5 levels.

RESULTS

The project data were aggregated from 20 school seasons (1 school in 1 season) for NCAA Division I, 20 for NCAA Division II, 19 for NCAA Division III, 18 for the NAIA, and 19 for the NJCAA. The participating schools represented 9 of the 10 NATA Districts. Districts 4 and 5 included 48% of the participating schools; followed by District 2 (12%); Districts 7, 8, and 9 with 10% each; and Districts 3, 6, and 10 with 4% each. During the first data-recording year, 5 of the initial volunteers had to be replaced. Between the 2 recording years, 6 schools had to be replaced. The reasons for these replacements included difficulties with staff changes and technology problems. Within the 96 school seasons, we included data for men's sports and women's sports for 1253 team seasons (614 men's and 639 women's team seasons).

Athlete-Exposures

The institutions reported 2 358 197 opportunities to be injured (AEs) during practices and games. The men's teams accounted for 63.7% (1 502 824) of the AEs. For the men's sports, the 3 NCAA divisions accounted for 72.2% of the total reported AEs. The NCAA Division I data accounted for the largest proportion of AEs (37.9%), whereas NCAA Division II (19.7%) and NCAA Division III (14.6%) were similar to the NAIA (14.3%) and the NJCAA (13.7%).

For the women's sports, the 3 NCAA divisions accounted for 75.0% of the total reported AEs, with Division I reporting 37.8%, Division II producing 22.0%, and Division III accounting for 15.3%. The NAIA produced 13.9% and the NJCAA accounted for 11.1% of the AEs.

All Reported Injury Frequencies

A total of 68 497 injuries were reported, with 79.7% (54624) resulting in no time loss from participation. Non– time-loss injuries accounted for 77.7% (34 760) of the men's injuries and 83.6% (19 864) of the women's injuries (see Appendix A). Non–time-loss injury rates per 1000 AEs were 23.1 (confidence interval [CI] = 22.9, 23.4) for men and 23.2 (CI = 22.9, 23.5) for women. The time-loss injury rates were 6.6 per 1000 AEs (CI = 6.5, 6.8) for men and 4.6 per 1000 AEs (CI = 4.4, 4.7) for women.

Among the men's sports, football accounted for the largest proportion (52.1%) of the non–time-loss and 57.9% of the time-loss incidents. For the women's sports, soccer accounted for the largest proportion (17.9%) of the non–time-loss and 22.0% of the time-loss incidents.

Using the IDR reported in Appendix A (the ratio of non– time-loss to time-loss injury rates per 1000 AEs), the men's sports showed a 3.5 (CI = 3.4, 3.6) times higher injury rate for non–time-loss injuries (23.1, CI = 22.9, 23.4) than for time-loss injuries (6.6, CI 6.5, 6.8). The women's sports showed the non–time-loss injury rate (23.2, CI = 22.9, 23.5) was 5.1 times higher (CI = 4.9, 5.2) than for the time-loss injuries (4.6, CI = 4.4, 4.7).

A closer examination of the data in Appendix A shows that men's tennis (IDR = 6.9, CI = 5.6, 8.3) and swimming/diving (IDR = 6.7, CI = 5.7, 7.9) had a non–time-loss injury rate that was nearly 7 times the injury rate for time-loss injuries. This is in contrast to sports such as wrestling (IDR = 3.5, CI = 3.2, 3.7) and football (IDR = 3.1, CI = 3.1, 3.2), in which the non–time-loss injury rates were more than 3 times the injury rates for time-loss injuries. The only sport among the women's teams to have a 7-fold difference between non–time- loss and time-loss injury rates was volleyball (IDR = 7.1, CI = 6.5, 7.7). Swimming/diving (IDR = 6.1, CI = 5.4, 6.9) and indoor track and field (IDR = 6.3, CI = 5.7, 6.9) had a 6- fold difference. For basketball, the men's IDR was 3.6 (CI = 3.4, 3.9) and the women's was 4.1 (CI = 3.9, 4.5). Most sports played by both sexes have similar IDRs except for outdoor track (men, 3.3, CI = 3.0, 3.8; women, 5.1, CI = 4.5, 5.8) and golf (men, 2.3, CI = 1.7, 3.3; women, 4.4, CI = 3.2, 6.0).

All Reported Treatment Frequencies

The project participants recorded 779 065 treatments associated with the injuries they encountered during the study period. Treatments for those injuries for which the player lost no time accounted for 57.9% (450 742). Within the men's sports, the non–time-loss treatments represented 52.6% (251 131) of the treatments recorded. For the women's sports, 66.1% (199 611) of the treatments were for non–time-loss injuries. The average number of treatments per reported injury for men's sports was 10.7, with the average number of treatments for non–time-loss injuries of 7.2 (CI = 7.2, 7.3) and for time- loss injuries of 22.7 (CI = 21.9, 23.5). The women's sports showed an average of 12.7 treatments per injury, with the average number of treatments for non–time-loss injuries at 10.0 (CI = 9.6, 10.5) and the time-loss injuries at 26.2 (CI = 24.8, 27.6). The men's sports showed an average number of treatments per 100 AEs as 31.7 (16.7, CI = 16.7, 16.8 for non– time-loss injuries; 15.0, CI = 15.0, 15.1 for time-loss injuries), whereas the women's sports showed an average of 35.3 treatments per 100 AEs (23.4, CI = 23.2, 23.4 for non–time-loss injuries; 12.0, CI = 11.9, 12.0 for time-loss injuries).

Summary Injury Data by Level of Participation

We grouped the data by level of participation to provide comparisons of incidence rates and treatment rates among levels. Appendices B through F show the data partitioned by level for men's and women's sports. The injury rate for men's sports and non–time-loss injuries showed a consistent decrease from NCAA Division I to NCAA Division II to NCAA Division III, with NAIA lower than NCAA Division III and higher than NJCAA. For women's sports and non–time-loss injuries, the rates decreased from NCAA Division I to NJCAA, with NCAA Division III and NAIA being the same. When time- loss injuries were examined, the injury rates for the men's sports by level ranged from a high of 7.7 (CI = 7.5, 7.9) for NCAA Division I to a low of 5.7 (CI = 5.4, 6.0) for NAIA. The injury rates for women by level of participation ranged from 5.4 (CI = 5.1, 5.6) in NCAA Division I to 3.1 (CI = 2.8, 3.4) in NAIA. The injury rate for men's non–time-loss incidents was nearly 4 times higher (IDR =3.5, CI = 3.4, 3.6) than for time-loss incidents and more than 5 times higher (IDR =5.1, CI = 4.9, 5.2) for time-loss injuries in the women's sports across levels of participation.

Summary of Treatment Data by Levels of Participation

The summary data in Appendices B through F show the distribution of injury and treatment data for the men and women's sports and among the 5 levels of participation. Within these data across the levels, football accounted for 51.2% of the treatments for men's sports, followed by baseball (10.7%), basketball (10.5%), and soccer (7.3%). Basketball represented 23.9% of all treatments provided for women's sports. Soccer (17.6%) and volleyball (16.1%) were very similar in their numbers of treatments.

For both men's and women's sports, the treatment per injury rate for time-loss injuries was approximately 3 times that for non–time-loss injuries: IDR = 3.1 (CI = 3.1, 3.2) and 2.6 (CI = 2.5, 2.7), respectively. From these data, it appears that 22.3% of the injuries in men's sports and 16.4% of the injuries in women's sports were time-loss injuries and that these required nearly 3 times the amount of treatments per injury than the non–time-loss injuries.

National Collegiate Athletic Association Division I

Participation by NCAA Division I schools resulted in 893 116 (63.8% = men's) exposures and 34 269 injuries (68.0% = men's) (see Appendix B). The men's sports had a higher overall injury rate per 1000 AEs (40.9, CI = 40.4, 41.4) than did the women's sports (33.9, CI = 33.3, 35.9), with the non–time-loss injury rate of 33.2 (CI = 32.8, 33.7) for the men and 28.5 (CI = 28.0, 29.1) for the women. The time-loss injury rate was higher for the men's sports (7.7, CI = 7.5, 7.9) than for the women's sports (5.4, CI = 5.1, 5.6). The women's sports showed an injury rate for non–time-loss cases that was more than 5 times higher (IDR = 5.1, CI = 4.9, 5.2) than for the time-loss injuries. For the men's sports, the non– time-loss injury rate was more than 4 times higher (IDR = 4.3, CI = 4.2, 4.5) than for time-loss injuries.

Among the men's sports, football showed the highest injury rate per 1000 AEs for non–time-loss injuries (42.2, CI = 41.5, 43.0), followed by tennis (40.5, CI = 37.0, 49.1), indoor track and field (37.5, CI = 35.7, 39.3), and wrestling (34.3, CI = 32.6, 36.0). In the time-loss injury category, the highest injury rate was for wrestling (10.7, CI = 9.8, 11.7), followed by football (9.3, CI = 8.9, 9.7), indoor track and field (7.8, CI = 7.0, 8.7), and basketball (7.8, CI = 6.9, 8.6).

For the women's sports, basketball accounted for the highest non–time-loss injury rate per 1000 AEs (37.6, CI = 35.6, 39.5), followed by tennis (36.9, CI = 33.5, 40.2), field hockey (34.3, CI = 30.6, 37.9), and soccer (33.6, CI = 31.8, 35.3). The category of time-loss injuries showed the highest injury rate for soccer (8.2, CI = 7.3, 9.1). The time-loss injury rate for tennis (8.1, CI = 6.5, 9.7) was similar to that of soccer and was followed by basketball (7.3, CI = 6.4, 8.1) and field hockey (7.2, CI = 5.5, 8.9).

A total of 448 438 treatments were provided, with 63.6% of the treatments associated with men's sports. The average number of treatments per injury for men's sports was 12.2 (CI = 11.8, 12.6), and the women's sports produced 14.9 (CI = 14.2, 15.6) treatments per injury. When the non–time-loss and time- loss groups were examined, the men's sports showed 8.1 (CI = 8.0, 8.1) treatments per non–time-loss injury and 30.3 (CI = 29.0, 32.0) treatments per time-loss injury. The women's sports showed average treatments per injury of 11.9 (CI = 11.2, 12.5) and 31.0 (CI = 28.8, 53.2), respectively.

The number of treatments provided for each injury group among the study sports showed a relatively consistent finding of more than 30 treatments per time-loss injury for football (33.8, CI = 31.9, 35.7), basketball (33.7, CI = 28.4, 39.0), baseball (32.9, CI = 28.1, 37.8), and soccer (30.6, CI = 21.8, 39.50). Among the remaining sports, tennis (29.1, CI = 17.6, 40.5) and indoor track and field (28.0, CI = 23.1, 32.9) approached the level of nearly 30 treatments per time-loss injury. Among the women's sports, volleyball and basketball had the highest treatment per time-loss injury rate at 48.6 (CI = 40.6, 56.6) and 45.4 (CI = 39.4, 51.4), respectively, followed by soccer (30.0, CI = 25.1, 34.9) and softball (30.9, CI = 24.7, 37.2).

Among the men's sports, football (60.0, CI = 59.8, 60.2), soccer (59.8, CI = 59.1, 60.4), indoor track and field (59.1, CI = 58.6, 59.6), and basketball (58.2, CI = 57.6, 58.6) showed the highest frequency of treatments per 100 AEs. It is noteworthy to consider the similar findings for football and indoor track and field, the large number of athletes in these sports, and the relatively small number of participants per team.

The comparison of women's sports shows a very high number of treatments per 100 AEs for basketball (97.6, CI = 97.9, 97.8) and volleyball (71.4, CI = 70.9, 71.8) . Other sports, such as soccer (57.4, CI = 56.9, 57.9), field hockey (53.9, CI = 52.9, 54.9), and indoor track and field (50.7, CI = 50.3, 51.2), showed comparable treatments per 100 AEs with several of the men's sports.

National Collegiate Athletic Association Division II

Participation by NCAA Division II schools is shown in Appendix C. Total AEs were 484 238; total injuries were 12 584, with men's teams accounting for 61.2% of the exposures and 62.1% of the injuries. The men's sports had a higher overall injury rate per 1000 AEs (26.3, CI = 25.8, 26.9) than the women's sports (25.4, CI = 24.7, 26.1), with the non–time- loss injury rate nearly the same for both groups: 20.5 (CI = 20.0, 21.0) and 21.3 (CI = 20.7, 27.0), respectively. The time- loss injury rate was higher for the men's sports (5.8, CI = 5.5, 6.1) than for the women's sports (4.1, CI = 3.8, 4.4). The women's sports showed an injury rate for non–time-loss cases that was more than 5 times higher (IDR = 5.2, CI = 4.8, 5.6) than that for the time-loss injuries. For the men's sports, the non–time-loss injury rate was more than 3 times higher (IDR = 3.5, CI = 3.4, 3.7) than that for time-loss injuries.

Among the men's sports, soccer showed the highest injury rate per 1000 AEs for non–time-loss injuries (34.7, CI = 32.7, 37.3), followed by football (28.8, CI = 27.8, 29.8), and basketball (28.0, CI = 26.1, 30.0). In the time-loss injury category, the highest injury rate was for football (10.2, CI = 9.6, 10.8), followed by wrestling (5.9, CI = 4.8, 6.9), basketball (5.7, CI = 4.8, 6.6), and soccer (5.3, CI = 4.2, 6.3).

For the women's sports, soccer accounted for the highest non–time-loss injury rate per 1000 AEs (35.7, CI = 33.3, 38.0), followed by volleyball (28.6, CI = 26.4, 30.8), basketball (26.1, CI = 24.2, 28.0), and field hockey (26.0, CI = 22.8, 29.3). The category of time-loss injuries showed the highest injury rate for soccer (7.7, CI = 6.6, 8.8), followed by basketball (6.6, CI = 5.6, 7.6) and volleyball (5.5, CI = 4.5, 6.5).

Treatments totaled 109 688, with 54.3% of the treatments associated with men's sports. The average number of treatments per injury for men's sports was 7.6 (CI = 7.0, 8.2) and for women's sports, 10.5 (CI = 9.6, 11.4). The men's sports showed 5.0 (CI =4.5, 5.6) treatments per non–time-loss injury and 16.8 (CI = 15.0, 18.5) treatments per time-loss injury. The women's sports showed average treatments per injury of 7.8 (CI = 7.0, 8.7) and 24.3 (CI = 21.3, 27.3), respectively.

The number of treatments provided for each time-loss injury among the men's sports varied from a high in soccer (29.0, CI = 20.1, 37.9) to a low in tennis (3.9, CI = −7.1, 14.9). For the women's sports, the highest number of treatments existed for basketball (31.7, CI = 24.9, 38.6), followed by field hockey (28.6, CI = 13.7, 43.6), soccer (26.5, CI = 20.1, 32.8), and volleyball (24.8, CI = 17.1, 32.6).

Among the men's sports, the treatments per 100 AEs showed soccer (39.1, CI = 38.4, 39.7) with the highest treatment rate, followed by basketball (29.3, CI = 28.7, 29.8), football (27.1, CI = 26.9, 27.4), and wrestling (22.6, CI = 22.0, 23.1). The data for Division II programs showed no drop from those of Division I.

The comparison of women's sports shows the highest number of treatments per 100 AEs for basketball (51.9, CI = 51.3, 52.5) and volleyball (43.3, CI = 42.6, 44.0). Other sports, such as soccer (44.6, CI = 44.0, 45.2), field hockey (30.4, CI = 29.4, 31.3), and softball (21.5, CI = 20.9, 22.0) showed comparable treatments per 100 AEs with several of the men's sports, especially men's basketball with field hockey and softball with wrestling.

National Collegiate Athletic Association Division III

Appendix D displays the participation by NCAA Division III schools that resulted in 350 203 (62.6% = men's) exposures and 8439 injuries (60.3% = men's). The men's sports had a slightly lower overall injury rate per 1000 AEs (23.2, CI = 22.6, 23.8) than did the women's sports (25.6, CI = 24.7, 26.4), with the women's non–time-loss injury rate (20.9, CI = 20.1, 21.6) higher than the men's (16.7, CI = 16.2, 17.3). The time-loss injury rate was higher for the men's sports (6.5, CI = 6.4, 6.8) than for the women's sports (4.7, CI = 4.4, 5.1). The women's sports showed an injury rate for non– time-loss cases that was more than 4 times higher (IDR = 4.4, CI = 4.1, 4.8) than for the time-loss injuries. For the men's sports, the non–time-loss injury rate was more than twice as high (IDR = 2.6, CI = 2.4, 2.7) as for time-loss injuries.

Among the men's sports, wrestling had the highest injury rate per 1000 AEs for non–time-loss injuries (44.7, CI = 40.9, 48.5), followed by basketball (22.5, CI = 20.7, 24.4), football (18.1, CI = 17.1, 19.1), and soccer (17.5, CI = 15.6, 19.4). In the time-loss injury category, the highest injury rate was for football (10.4, CI = 9.7, 11.2), followed by soccer (8.5, CI = 7.1, 9.8), wrestling (7.8, CI = 6.1, 9.4), and basketball (7.0, CI = 5.9, 8.0).

For the women's sports, volleyball accounted for the highest non–time-loss injury rate per 1000 AEs (67.0, CI = 62.7, 71.2), followed by basketball (23.8, CI = 21.7, 25.9), soccer (23.4, CI = 20.8, 26.0), and field hockey (19.4, CI = 14.7, 24.0). The category of time-loss injuries showed the highest injury rate for soccer (10.0, CI = 8.3, 11.7), followed by field hockey (8.2, CI = 5.2, 11.7) and basketball (7.6, CI = 6.4, 8.8).

Of the 70 361 treatments provided, 55.4% were associated with men's sports. The average number of treatments per injury for men's sports was 7.7 (CI = 6.9, 8.4), and the women's sports produced 9.4 (CI = 8.4, 10.3) treatments per injury. The men's sports showed 6.1 (CI = 5.9, 6.2) treatments per non–time-loss injury and 11.8 (CI = 10.1, 13.5) treatments per time-loss injury. The women's sports showed average treatments per injury of 7.3 and 18.2, respectively.

The number of treatments provided for each time-loss injury group among the men's sports varied from highs in indoor track and field (29.1, CI = 29.1, 44.1) and basketball (20.7, CI = 14.6, 26.8) to a low in cross-country (8.1, CI = −2.3, 18.6). For the women's sports, the highest number of treatments for each time-loss injury was for basketball (24.4, CI = 17.6, 31.1), followed by volleyball (21.6, CI = 12.6, 31.1), soccer (17.4, CI = 10.9, 23.9), swimming and diving (17.0, CI = 1.6, 32.4), and softball (17.0, CI = 8.7, 25.2).

Among the men's sports, the treatments per 100 AEs showed basketball (29.6, CI = 29.0, 30.14) with the highest treatment rate, followed by wrestling (26.1, CI = 25.3, 26.9), football (20.5, CI = 20.2, 20.7), soccer (19.6, CI = 19.0, 20.1), and indoor track and field (17.8, CI = 17.1, 18.5). The data for Division III programs were comparable with those for Division II.

Women's sports showed the highest number of treatments per 100 AEs for basketball (45.6, CI = 45.0, 46.3) and volleyball (42.2, CI = 41.4, 43.1). Other sports, such as soccer (36.8, CI = 35.9, 37.6), field hockey (25.8, CI = 24.4, 27.3), and indoor track and field (20.1, CI = 19.3, 20.9), had treatments per 100 AEs comparable with several of the men's sports, especially field hockey and wrestling.

National Association of Intercollegiate Athletics

Participation by NAIA schools resulted in 330 625 exposures and 7376 injuries, with the men's teams accounting for most of the exposures (64.4%) and injuries (62.5%; Appendix E). The men's sports had a lower overall injury rate per 1000 AEs (21.5, CI = 20.9, 22.1) than the women (23.3 CI = 22.5, 24.2), with the women's non–time-loss injury rate (20.2, CI = 19.4, 21.0) higher than the men's (15.8, CI = 15.3, 16.3). The time-loss injury rate was higher for the men's sports (5.7, CI = 5.0, 6.4) than for the women's (3.1, CI = 2.8, 3.4). The women's sports showed an injury rate for non–time-loss cases that was more than 6 times higher (IDR = 6.5, CI = 5.9, 7.2) than for the time-loss injuries. For the men's sports, the non– time-loss injury rate was nearly 3 times higher (IDR = 2.8, CI = 2.6, 3.0) than for time-loss injuries.

Among the men's sports, football had the highest injury rate per 1000 AEs for non–time-loss injuries (19.1, CI = 18.2, 20.1), followed by indoor track and field (18.7, CI = 14.9, 22.5), cross-country (16.4, CI = 13.0, 19.9), and basketball (13.6, CI = 12.3, 14.8). In the time-loss injury category, the highest injury rate was for football (9.2, CI = 8.5, 9.8), followed by soccer (6.2, CI = 5.2, 7.2), and basketball (4.8, CI = 4.1, 5.6).

Among the women's sports, soccer accounted for the highest non–time-loss injury rate per 1000 AEs (31.3, CI = 29.0, 33.6), followed by indoor track and field (29.9, CI = 25.1, 34.8), field hockey (26.8, CI = 16.0, 37.6), and volleyball (23.5, CI = 21.4, 25.7). The category of time-loss injuries showed the highest injury rate for field hockey (7.0, CI = 1.4, 12.6), followed by soccer (5.2, CI = 4.3, 6.2) and volleyball (3.4, CI = 2.6, 4.3).

Of the 104 405 treatments provided, 63.5% were associated with men's sports. The average number of treatments per injury for men and women's sports was similar at 14.4 (CI = 13.4, 15.4) and 13.8 (CI = 12.5, 15.0), respectively. The men's sports showed 16.6 (CI = 15.3, 17.8) treatments per non–time- loss injury and 24.6 (CI = 22.2, 27.0) treatments per time- loss injury. The women's sports show average treatments per injury of 10.8 and 33.2, respectively.

The number of treatments provided for each time-loss injury among the men's sports varied greatly, with highs of 73.5 (CI = 56.5, 90.5) for outdoor track and lows of 10.0 (CI = −23.9, 40.9) and 12.7 (CI = −13.9, 39.3) for golf and tennis, respectively. For the women's sports, the highest number of treatments for time-loss injuries occurred in basketball (53.4, CI = 41.8, 65.0), followed by soccer (33.9, CI = 23.5, 42.5) and outdoor track and field (30.7, CI = 8.8, 52.6). Field hockey (6.7, CI = −13.3, 26.6) showed the lowest number of treatments for time-loss injuries among women's sports.

Among the men's sports, the treatments per 100 AEs showed football (41.9, CI = 41.5, 42.2) had the highest treatment rate, followed by soccer (39.5, CI = 38.9, 40.1), baseball (26.7, CI = 26.3, 27.2), and basketball (24.4, CI = 24.0, 24.9). The data for NAIA football are comparable with those for NCAA Division I football; however, NAIA soccer players required fewer treatments than those in NCAA Division I.

Among women's sports, the highest number of treatments per 100 AEs was for soccer (43.3, CI = 42.6, 43.9) and softball (37.0, CI = 36.4, 37.7). Other sports, such as volleyball (31.7, CI = 31.0, 32.4), basketball (31.6, CI = 31.0, 32.2), and indoor track and field (20.4, CI = 19.3, 21.6) showed a different pattern in the order of sports compared with the NCAA programs.

National Junior College Athletic Association

Participation information by NJCAA schools resulted in 300 015 (68.4% = men's) exposures and 5829 injuries (67.0% = men's). The men's sports had a lower overall injury rate per 1000 AEs (19.0, CI = 18.4, 19.6) than the women's (20.3, CI = 19.4, 21.2), with the women's non–time-loss injury rate (15.9, CI = 15.1, 16.7) higher than the men's (13.0, CI = 12.6, 13.6). The time-loss injury rate was higher for the men's sports (5.7, CI = 5.6, 6.3) than for the women's (4.4, CI = 4.0, 4.8). The women's sports showed an injury rate for non– time-loss cases that was more than 3 times higher (IDR = 3.6, CI = 3.3, 4.0) than for the time-loss injuries. For the men's sports, the non–time-loss injury rate was more than twice as high (IDR = 2.2, CI = 2.1, 2.4) as for time-loss injuries.

Among the men's sports, football showed the highest injury rate per 1000 AEs for non–time-loss injuries (17.6, CI = 16.6, 18.6), followed by soccer (16.4, CI = 14.4, 18.5) and basketball (14.6, CI = 13.2, 16.0). In the time-loss injury category, the highest injury rate was for football (11.1, CI = 10.3, 11.9), followed by soccer (7.1, CI = 5.7, 8.5) and basketball (4.5, CI = 3.7, 5.3).

For the women's sports, soccer accounted for the highest non–time-loss injury rate per 1000 AEs (29.2, CI = 26.0, 32.5), followed by indoor track and field (25.5, CI = 21.2, 29.8), softball (16.3, CI = 14.7, 18.0), and basketball (16.2, CI = 14.6, 17.8). The category of time-loss injuries showed the highest injury rate for soccer (8.3, CI = 6.6, 10.1), followed by basketball (5.9, CI = 4.9, 6.8) and softball (4.5, CI = 3.6, 5.3).

Of the 46 401 treatments provided, 58.4% were associated with men's sports. The average number of treatments per injury for men's sports was lower (6.9, CI = 6.1, 7.7) than for women's sports (10.1, CI = 8.7, 11.4). The men's sports showed 6.2 (CI = 5.3, 7.2) treatments per non–time-loss injury and 8.5 (CI = 6.9, 10.0) treatments per time-loss injury. The women's sports showed average treatments per injury of 8.5 (CI = 7.1, 9.9) and 15.5 (CI = 12.0, 19.0), respectively.

The number of treatments provided for each time-loss injury among the men's sports varied from a high in swimming and diving (23.7, CI = −21.4, 74.8) and indoor track and field (23.5, CI = 2.0, 42.9) to a low for cross-country (4.4, CI = −5.1, 13.9). For the women's sports, the highest number of treatments for time-loss injuries existed for swimming and diving (56.7, CI = −9.4, 112.7), followed by indoor track and field (29.7, CI = 6.5, 52.8) and soccer (21.6, CI = 13.0, 30.2). Cross-country (5.7, CI = −12.8, 24.2) and tennis (5.7, CI = −9.4, 26.1) showed the lowest number of treatments among the women's sports.

Among the men's sports, the treatments per 100 AEs showed indoor track and field had the highest treatment rate (20.6), followed by football (17.0, CI = 15.3, 18.7), soccer (16.0, CI = 12.1, 19.9), and basketball (14.4, CI = 11.4, 17.3). The data for the NJCAA reflect lower treatment frequencies than for either the NCAA or the NAIA.

For women's sports, the highest number of treatments per 100 AEs was for indoor track and field (53.0, CI = 51.6, 54.4), followed by soccer (41.7, CI = 40.8, 42.7) and basketball (23.1, CI = 22.5, 23.6). The treatment frequency patterns for indoor track and field and soccer were comparable with those found in NCAA Division I programs. Other sports produced a pattern of lower treatment frequencies.

Personnel Resources

One of the challenges of this research project was to supply information for the process of identifying workforce relationships necessary for providing medical coverage to collegiate athletes. We assumed that a full-time staff member equals 1 FTE. A graduate assistant staff member equals 0.5 FTE, and an undergraduate athletic training student equals 0.25 FTE.

Using this model, the estimated number of FTEs available for providing treatments to athletes during the 2-year study period was highest in NCAA Division I (276), with NCAA Division II (134) and NCAA Division III (132) quite similar. When we examined the available workforce for the NAIA and NJCAA, we found similar numbers at 94 and 62, respectively. It is interesting to note that a comparison of NCAA Divisions II and III with NAIA and NJCAA showed that the former had more than 50% additional workforce available to provide treatments for injured student-athletes.

Using the available FTE numbers for the 5 divisions and the total treatments rendered by each division in the current analysis, we noted that NCAA Division I recorded 1625 treatments per FTE, NCAA Division II recorded 819, and NCAA Division III recorded 533. For the NAIA, the number of treatments per FTE was 1110 and for the NJCAA, 748.

DISCUSSION

Our study was limited to 2 collegiate participation years, 2000–2001 and 2001–2002. Fifty institutions were included per project year based on the limitation of stipends available for participants. The individual sports teams and seasons available depended on the nature of the programs that volunteered to participate in the study. As with other multisite research models, the data-collection process relied on the professionalism and dedication of the data recorders at each study site.

One of our most important findings is the difference between non–time-loss and time-loss injury rates. Traditionally, when the risk of injury is established for a collegiate sport, it is based on data from the NCAAISS that used time lost from participation as a component of the definition of a reportable event.⁴ The time-loss injury rates establish the potential for injury for only those injuries that require the player to be restricted from participation. From the data we report, injury rates across all men and women's sports were consistently higher for the non–time-loss injury category when compared with the time-loss injury rate. The athletic training staffs evaluated and managed about 3 times the number of injuries, compared with those injuries that were traditionally reported in the literature. In the daily athletic training room experiences, the early recognition and management of injuries (all types) may prevent many from becoming time-loss cases and, thus, minimize player time loss from participation. Further research using more specific study designs would be required to clearly identify the impact of early recognition and early management of the injuries identified by the athlete to the athletic trainer.

Our results show that 77.5% of the men's injuries and 83.3% of the women's injuries were in the non–time-loss category. These findings support the research of Martin et al,⁵ who identified 90% of Junior Olympics injuries as non–time loss, and Cunningham and Cunningham,⁶ who identified 60% of reported injuries as non–time loss in Australian University Games.

Regardless of whether the injury was non–time loss or time loss, it required some number of treatments to complete full recovery. The designation of the 2 injury categories reflects injury severity, the assumption being that time-loss injuries are more serious than non–time-loss injuries because they affect the player's ability to perform. Intuitively, one would expect that the majority of treatments would be associated with time- loss injuries. Our data show that 57.9% of the reported treatments were associated with non–time-loss injuries. These injuries accounted for 52.8% of the treatments provided in men's sports and 65.4% in women's sports. The total number of treatments was higher for non–time-loss injuries, but the treatment per injury rate was higher in the time-loss category.

Among the sports, differences existed in the injury rates and treatments for the 2 categories. Some of the variation is due to the relatively small number of schools with a particular sport and the differences in the natures of the different sports. For example, the non–time-loss injury rates for football across divisions varied between 42.2/1000 AEs in NCAA Division I and 17.6/1000 AEs in NJCAA. The time-loss injury rates, on the other hand, were more consistent and varied between a high of 11.1/1000 AEs in the NJCAA schools and 9.2/1000 AEs in the NAIA schools. Among the women's sports, basketball showed a similar finding with the non–time-loss injury rates varying between a high of 37.6/1000 AEs in the NCAA Division I schools and 15.7/1000 AEs in the NAIA schools. The time-loss injury rates varied from 7.6/1000 AEs in NCAA Division III and 2.5/1000 AEs in NAIA schools. These data demonstrate a similar pattern of injury rates per 1000 AEs reported by the NCAAISS in its 2000–2001 report, both reflecting a definition of reportable injury as one that loses participation time.⁴

Within specific sports and among the different levels of participation, some data cells reflect relatively infrequent injuries, small numbers of AEs, or small numbers of participating programs (or a combination of these). The evaluation of the injury rates for non–time-loss and time-loss injuries may be considered to be less reliable in part because of the small numbers for these sports.

We also examined injury rates for sports that are not traditionally recorded in the NCAA data (ie, tennis, cross-country, track and field, swimming/diving, and golf). Although these sports had lower time-loss injury rates than those usually reported, their non–time-loss injury rates approached those being reported for sports such as basketball, soccer, and volleyball. When the treatments per injury data were examined, treatment frequencies were similar, regardless of the sport across divisions. Collegiate sports, regardless of their perceived level of risk, required similar amounts of workforce to care for the injured players, especially in the category of injuries that required no loss of player participation time.

One way of evaluating the relationship between the amount of treatment provided for non–time-loss and time-loss injuries is to look at the number of treatments per exposure rather than injury. The exposure is a measure of the number of players and the number of participation sessions and can be equated to “participation time.” When the treatments per injury were aggregated, sports such as swimming/diving, tennis, cross- country, and golf recorded the lowest number of treatments per 100 AEs. It is interesting to note that indoor track and field would be ranked third for men's sports and tied with field hockey in fourth place for the women's sports. The perception may be that these sports are of lesser risk, yet the participants require a substantial number of treatments in order to continue to participate.

The reported workforce available to provide treatment to collegiate athletes was quite different for the different levels in the study. The NCAA Division I program had twice the workforce available to provide treatment for injured athletes than did NCAA Divisions II and III. It had nearly 3 times the workforce available as the NAIA schools and more than 4 times the workforce available for the NJCAA schools. It is not surprising that NCAA Division I had the highest number of treatments per FTE, followed by the NAIA schools. The NCAA Division II and NAIA were similar, and the NJCAA displayed the lowest number of treatments for their workforce. These variations in the available workforce among the various divisions may contribute to the frequency of injury and treatments reported within each division.

In summary, our study included 311 certified athletic trainers, 106 graduate assistant athletic trainers, and 1601 athletic training students, and we documented in excess of 2.3 million opportunities for the injuries to occur (exposures), 68 497 injury encounters with athletes, and nearly 780 000 treatments. The findings from these data are reflected in the following summary points:

1. Injury rates for non–time-loss problems were 3.5 times higher for men and 5 times higher for women than for time- loss injuries among collegiate athletic programs.

2. Non–time-loss problems required as many or more treatments over the course of the year as the time-loss injuries.

3. For men's sports, 22% of the injuries resulted in loss of participation time, with 47% of treatments associated with these time-loss injuries. For women's sports, 16% of the injuries resulted in loss of participation time, with 34% of treatments associated with time-loss injuries.

4. The largest proportion of treatments, the highest number of treatments per injury rates, the highest number of treatments per exposures, and the largest available workforce available to provide treatment existed for the NCAA Division I schools.

5. The NCAA Divisions II and III, NAIA, and NJCAA programs experienced similar injury rates, especially for time- loss injuries, as those of the NCAA Division I schools.

6. There was no difference in the available workforce to care for the injuries among the divisions.

Throughout the sports medicine year, athletic training staff and students spend as much or more time delivering treatments to athletes who are not missing participation time than on the injuries requiring time loss from participation. These numbers reflect the nature of care and management patterns of injuries so that players continue to compete. The process of identifying workforce needs for specific collegiate sports, regardless of the level of participation, should take into consideration the numbers of non–time-loss problems and the treatments associated with these injuries, along with the relative risk of significant trauma, team travel patterns, and administrative requirements.

Appendix A: Study Data for Men's and Women's Sports for All Levels

Appendix B: Summary of Study Data for Men's and Women's Sports for National Collegiate Athletic Association Division I

Appendix C: Summary of Study Data for Men's and Women's Sports for National Collegiate Athletic Association Division II

Appendix D: Summary of Study Data for Men's and Women's Sports for National Collegiate Athletic Association Division III

Appendix E: Summary of Study Data for Men's and Women's Sports for National Association of Intercollegiate Athletics

Appendix F: Summary of Study Data for Men's and Women's Sports for National Junior College Athletic Association