Abstract
Background:
The inclusion of clinical practice factors, beyond epidemiologic data, may help guide medical coverage and care decisions.
Hypothesis:
Trends in injury and treatment characteristics of sport-specific injuries sustained by secondary school athletes will differ based on sport.
Study Design:
Retrospective analysis of electronic patient records.
Level of evidence:
Level 4.
Methods:
Participants consisted of 3302 boys and 2293 girls who were diagnosed with a sport-related injury or condition during the study years. Injury (sport, body part, diagnosis via ICD-9 codes) and treatment (type, amount, and duration of care) characteristics were grouped by sport and reported using summary statistics.
Results:
Most injuries and treatments occurred in football, girls’ soccer, basketball, volleyball, and track and field. Sprain or strain of the ankle, knee, and thigh/hip/groin and concussion were the most commonly documented injuries across sports. The injury pattern for boys’ wrestling differed from other sports and included sprain or strain of the elbow and neck and general medical skin conditions. The most frequently reported service was athletic training evaluation/reevaluation treatment, followed by hot/cold pack, therapeutic exercise, manual therapy techniques, electrical stimulation, and strapping of lower extremity joints. Most sports required 4 to 5 services per injury. With the exception of boys’ soccer and girls’ softball, duration of care ranged from 10 to 14 days. Girls’ soccer and girls’ and boys’ track and field reported the longest durations of care.
Conclusion:
Injury and treatment characteristics are generally comparable across sports, suggesting that secondary school athletic trainers may diagnose and treat similar injuries regardless of sport.
Clinical Relevance:
Subtle sport trends, including skin conditions associated with boys’ wrestling and longer duration of care for girls’ soccer, are important to note when discussing appropriate medical coverage and care.
Keywords: medical coverage, practice characteristics, adolescent athletes
Because of an increase in participation24 and the potential for sport-related injuries in interscholastic athletics,9 identifying appropriate medical coverage and care for secondary school athletes has become an important topic within the sports medicine community.10 Recommendations for medical coverage and care have historically been based primarily on injury risk data from epidemiologic investigations. However, while epidemiologic studies have provided an abundance of data regarding the incidence and rates of injury between the sexes,17,19,20 in different sports,1-4,11-13,15,20,34 and across different levels of play,18,29,33 these investigations often exclude many tasks performed by the athletic medicine staff, including injury prevention and rehabilitation, that are essential elements of high-quality medical coverage and care. As a result, sports medicine organizations such as the National Athletic Trainers’ Association (NATA),23 American Orthopaedic Society for Sports Medicine,6 and American Medical Society for Sports Medicine10 have recently highlighted the need to include the wide variety of tasks associated with assessing, treating, and managing sport-related injuries and illnesses when determining appropriate medical coverage for secondary school athletes, including clinician demands for the development of injury and illness strategies and the treatment and rehabilitation of time loss and non–time loss injuries in various sports.5,10,22
The inclusion of other clinical practice factors beyond injury incidences and rates is important in determining appropriate medical coverage and care because many duties provided by the athletic medicine staff include preventative measures and treatment for non–time loss injuries (eg, overuse injuries) and may be unaccounted for, by definition, in epidemiologic studies.14,28 However, without adequate clinical data of preventative, treatment, and rehabilitation efforts for all types of sports and injuries, determining appropriate medical coverage and care for secondary school athletes can be difficult. However, these investigations were broad in scope considering typical practice patterns31 and an aggregate of all documented injuries32 and did not account for injuries sustained in different sports. Specific attention toward injuries grouped by sports as well as an understanding of the treatment characteristics associated with these injuries is needed to aid in medical coverage recommendations and patient care decisions. Therefore, the purpose of this study was to describe the injury and treatment characteristics of injuries sustained by patients participating in various interscholastic sports as recorded through a national practice-based research network.
Materials and Methods
Design and Setting
This study was a retrospective analysis of de-identified patient records within a Web-based electronic medical record (EMR). The A.T. Still University Institutional Review Board exempted the study because the study was deemed to be a retrospective analysis of de-identified patient records. All records were created by an athletic trainer (AT) who was a member of the Athletic Training Practice-Based Research Network (AT-PBRN)32 and was providing patient care in a secondary school. The ATs practiced in 62 secondary schools across 14 different states (Arizona, California, Connecticut, Florida, Kansas, Massachusetts, Minnesota, Missouri, New Hampshire, New York, Utah, Virginia, Vermont, Wisconsin). Most schools were public (85%) and coeducational (95%) institutions, set in an urban area (71%), and employed 1 certified AT (77%). On average, ATs collected data over 16.1 ± 12.5 months (range, 1-48 months). To ensure data quality, all ATs completed a formal, 2-hour EMR training session prior to joining the AT-PBRN, and the administrative team of the AT-PBRN routinely reviewed the clinical data entered into the EMR relational database.32
Participants
Patients who were diagnosed with a sport-related injury between October 1, 2009 and October 31, 2013 and participated in an interscholastic sport were included in this report (Table 1). A sport-related injury was defined as that diagnosed by a health care provider (eg, AT, physician) and required at least 1 AT service, such as an initial evaluation. A Certification of Honest Broker System/Processes provided by the EMR developer (Essentialtalk) ensured that patient data obtained by the AT-PBRN research team were void of all federally defined personal identifiers (ie, protected health information).25
Table 1.
Injuries and athletic training services documented within the AT-PBRN grouped by sport
| Injuries, n (%) | Athletic Training Services, n (%) | |||
|---|---|---|---|---|
| Sport | Boys | Girls | Boys | Girls |
| Badminton | 5 (0.2) | 36 (1.6) | 4 (0.0) | 102 (1.2) |
| Baseball | 132 (4.0) | 0 (0.0) | 528 (4.3) | 0 (0.0) |
| Basketball | 302 (9.1) | 416 (18.1) | 1079 (8.8) | 1345 (15.4) |
| Cheerleading | 3 (0.1) | 121 (5.3) | 6 (0.0) | 269 (3.1) |
| Cross-country | 62 (1.9) | 122 (5.3) | 208 (1.7) | 421 (4.8) |
| Field hockey | 1 (0.0) | 23 (1.0) | 1 (0.0) | 73 (0.8) |
| Football | 1934 (58.6) | 33 (1.4) | 7340 (60.2) | 139 (1.6) |
| Golf | 1 (0.0) | 5 (0.2) | 0 (0.0) | 17 (0.2) |
| Gymnastics | 0 (0.0) | 4 (0.2) | 0 (0.0) | 20 (0.2) |
| Hockey | 28 (0.8) | 4 (0.2) | 104 (0.9) | 44 (0.5) |
| Lacrosse | 26 (0.8) | 67 (2.9) | 108 (0.9) | 373 (4.3) |
| Other | 49 (1.5) | 72 (3.1) | 103 (0.9) | 165 (1.9) |
| Soccer | 238 (7.2) | 484 (21.1) | 705 (5.8) | 2188 (25.1) |
| Softball | 2 (0.1) | 188 (8.2) | 5 (0.0) | 595 (6.8) |
| Swimming | 9 (0.3) | 23 (1.0) | 12 (0.1) | 68 (0.8) |
| Tennis | 5 (0.2) | 61 (2.7) | 14 (0.1) | 198 (2.3) |
| Track | 221 (6.7) | 303 (13.2) | 1075 (8.8) | 1435 (16.5) |
| Volleyball | 20 (0.6) | 328 (14.3) | 85 (0.7) | 1264 (14.5) |
| Wrestling | 264 (8.0) | 3 (0.1) | 816 (6.7) | 2 (0.0) |
| Total | 3302 (100.0) | 2293 (100.0) | 12,193 (100.0) | 8718 (100.0) |
AT-PBRN, Athletic Training Practice-Based Research Network.
Instrumentation
Clinical data were recorded in a Web-based EMR previously described by Valovich McLeod et al.32 AT services were recorded as International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT)27 codes within the EMR.
Statistical Analysis
All variables of interest were grouped based on sport and reported using summary statistics. Patient demographics included age, sex, height, and weight of the patient, while injury characteristics were represented by sport, body part, and diagnosis (ICD-9 code). The most frequent injuries were reported for each sport. Treatment characteristics included the type (CPT code), amount (number of services for the duration of care), and duration (number of days between the initial evaluation to the last documented episode of care) of care for each injury.
Results
Injury Characteristics
A total of 5595 sport-related injuries (boys, 3302; age, 16.3 ± 1.5 years and girls, 2293; age, 16.0 ± 1.4 years) were documented during the study period. The 10 sports reporting the most injuries during the study years accounted for 84% of all documented injuries (Table 1). In general, concussions and a sprain or strain of the ankle, knee, and thigh/hip/groin were the most documented injuries, in varying rank order, across most sports (Table 2).
Table 2.
Common injuries documented for the top 10 sports reporting the most injuries in the AT-PBRNa
| Diagnosis | ICD-9 Code | Boys’ Football (n = 1934), n (%) | Girls’ Soccer (n = 623), n (%) | Girls’ Basketball (n = 416), n (%) | Girls’ Volleyball (n = 328), n (%) | Girls’ Track and Field (n = 302), n (%) |
|---|---|---|---|---|---|---|
| Concussion | 850.9, 850.0, 850.5 | 409 (21.1) | 80 (12.8) | 72 (17.3) | 30 (9.1) | 9 (3.0) |
| General medical: skin | 684, 110.9, 54.9, 704.8 | 6 (0.3) | 1 (0.1) | 0 (0.0) | 1 (0.3) | 0 (0.0) |
| Pain (general): knee | 719.46 | 31 (1.6) | 22 (3.5) | 22 (5.3) | 10 (3.0) | 25 (8.3) |
| Sprain/strain: ankle | 845, 845.01, 845.03, 845.09 | 225 (11.6) | 87 (14.0) | 78 (18.8) | 75 (22.9) | 41 (13.6) |
| Sprain/strain: elbow | 841.1, 841.9 | 23 (1.2) | 4 (0.6) | 1 (0.2) | 4 (1.2) | 2 (0.7) |
| Sprain/strain: hand/finger | 842.1 | 53 (2.7) | 6 (1.0) | 19 (4.6) | 21 (6.4) | 0 (0.0) |
| Sprain/strain: low back | 846.00, 846.10, 847.90 | 39 (2.0) | 13 (2.1) | 3 (0.7) | 14 (4.2) | 7 (2.3) |
| Sprain/strain: knee | 844, 844.1, 844.2, 844.9 | 148 (7.7) | 45 (7.2) | 29 (7.0) | 12 (3.7) | 24 (7.9) |
| Sprain/strain: neck | 847 | 34 (1.8) | 6 (1.0) | 4 (0.6) | 5 (3.0) | 5 (1.7) |
| Sprain/strain: shoulder | 831.00, 840 | 87 (4.5) | 4 (0.6) | 5 (1.2) | 5 (1.5) | 1 (0.3) |
| Sprain/strain: thigh/hip/groin | 843.9, 843.90 | 94 (4.3) | 65 (10.4) | 33 (7.9) | 12 (3.7) | 47 (15.6) |
| Tendinitis: Anterior/posterior tibialis | 726.72 | 8 (0.4) | 13 (2.1) | 5 (1.2) | 10 (3.0) | 39 (12.9) |
| Diagnosis | ICD-9 Code | Boys’ Basketball (n = 271), n (%) | Boys’ Wrestling (n = 264), n (%) | Boys’ Soccer (n = 238), n (%) | Boys’ Track and Field (n = 221), n (%) | Girls’ Softball (n = 188), n (%) |
| Concussion | 850.9, 850.0, 850.5 | 33 (10.9) | 27 (10.2) | 30 (12.6) | 4 (1.8) | 40 (21.3) |
| General medical: skin | 684, 110.9, 54.9, 704.8 | 0 (0.0) | 12 (4.5) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| Pain (general): knee | 719.46 | 5 (1.6) | 7 (2.7) | 9 (3.8) | 9 (4.1) | 1 (0.5) |
| Sprain/strain: ankle | 845, 845.01, 845.03, 845.09 | 107 (35.4) | 19 (7.2) | 40 (16.8) | 22 (10.0) | 27 (14.4) |
| Sprain/strain: elbow | 841.1, 841.9 | 0 (0.0) | 17 (6.4) | 0 (0.0) | 1 (0.5) | 9 (4.8) |
| Sprain/strain: hand/finger | 842.1 | 14 (4.6) | 4 (1.5) | 3 (1.3) | 0 (0.0) | 5 (2.7) |
| Sprain/strain: knee | 844, 844.1, 844.2, 844.9 | 24 (7.9) | 15 (5.7) | 15 (6.3) | 15 (6.8) | 9 (4.8) |
| Sprain/strain: low back | 846.00, 846.10, 847.90 | 15 (5.0) | 10 (3.8) | 8 (3.4) | 6 (2.7) | 3 (1.6) |
| Sprain/strain: neck | 847 | 3 (1.0) | 11 (4.2) | 4 (1.7) | 5 (2.3) | 2 (1.1) |
| Sprain/strain: shoulder | 831.00, 840 | 8 (2.6) | 11 (4.2) | 10 (4.2) | 6 (2.7) | 1 (0.5) |
| Sprain/strain: thigh/hip/groin | 843.9, 843.90 | 13 (4.3) | 0 (0.0) | 29 (12.2) | 47 (21.2) | 13 (6.9) |
| Tendinitis: anterior/posterior tibialis | 726.72 | 2 (0.7) | 0 (0.0) | 4 (1.7) | 23 (10.4) | 4 (2.1) |
AT-PBRN, Athletic Training Practice-Based Research Network; ICD-9, International Classification of Diseases, Ninth Revision.
Boldfaced values indicate the top 5 injuries for each sport.
Treatment Characteristics
A total of 20,911 services were recorded during the study period. Across all sports, the most frequently reported service was AT evaluation or reevaluation, followed by hot or cold pack, therapeutic exercise or activities, manual therapy techniques or massage, electrical stimulation, and strapping of lower extremity joints (ankle, foot, hip knees, toes) (Table 3). The only exceptions were reported for football, in which more strapping of the upper extremity was reported than manual therapy or massage; boys’ basketball, in which more whirlpool treatments were reported than electrical stimulation treatments; and boys’ wrestling, in which more strapping of the upper extremity was reported than electrical stimulation (Table 4). Girls’ soccer, boys’ track and field, and girls’ track and field reported the highest number of services per injury (Table 5). Boys’ track and field reported the longest average duration of care (18.1 ± 72.9 days), while girls’ softball reported the shortest average duration of care (6.2 ± 10.8 days).
Table 3.
Athletic training services recorded during study period
| Treatment or Procedures | CPT Codes | n (%) |
|---|---|---|
| Athletic trainer evaluation or reevaluation | 97005, 97006 | 9608 (45.9) |
| Hot or cold packs | 97010 | 4120 (19.7) |
| Therapeutic activities or exercise | 97110, 97530 | 3206 (15.3) |
| Strapping: Lower extremity (ankle/foot, hip, knee, toes) | 29540, 29520, 29230, 29550 | 1278 (6.1) |
| Electrical stimulation | 97014 | 778 (3.7) |
| Manual therapy techniques or massage | 97140, 97124 | 746 (3.6) |
| Strapping: Upper extremity (elbow or wrist, hand or finger, shoulder) | 29280, 29260, 29240 | 401 (1.9) |
| Whirlpool | 97022 | 318 (1.5) |
| Physical performance test or measurement | 97750 | 141 (0.7) |
| Ultrasound | 97035 | 118 (0.6) |
| Neuromuscular re-education | 97112 | 82 (0.4) |
| Vasopneumatic devices | 97016 | 53 (0.3) |
| Gait training | 97116 | 36 (0.2) |
| Contrast bath | 97034 | 14 (0.1) |
| Infrared | 97026 | 7 (0.0 |
| Aquatic therapy | 97113 | 3 (0.0) |
| Iontophoresis | 97033 | 2 (0.0) |
| Total | 20,911 (100.0) |
CPT, Current Procedural Terminology.
Table 4.
Common athletic training services documented for the top 10 sports reporting the most injuries, n (%)
| Boys’ Football | Girls’ Soccer | Girls’ Track and Field | Girls’ Basketball | Girls’ Volleyball | |
|---|---|---|---|---|---|
| Athletic trainer evaluation or reevaluation | 3547 (48.3) | 882 (40.3) | 588 (41.0) | 667 (49.6) | 521 (41.2) |
| Electrical stimulation | 295 (4.0) | 100 (4.6) | 57 (4.0) | 41 (3.0) | 47 (3.5) |
| Hot or cold pack | 1493 (20.3) | 427 (19.5) | 306 (21.3) | 231 (17.2) | 226 (17.9) |
| Manual therapy or massage | 132 (1.8) | 99 (4.5) | 68 (4.7) | 59 (4.4) | 76 (6.0) |
| Therapeutic exercise or activities | 1041 (14.2) | 427 (19.5) | 238 (16.6) | 194 (14.4) | 246 (19.5) |
| Strapping of the lower extremities | 369 (5.0) | 175 (8.0) | 118 (8.2) | 86 (6.4) | 81 (6.4) |
| Boys’ Basketball | Boys’ Track and Field | Boys’ Wrestling | Boys’ Soccer | Girls’ Softball | |
| Athletic trainer evaluation or reevaluation | 489 (45.3) | 428 (39.8) | 427 (52.3) | 338 (47.9) | 259 (43.5) |
| Electrical stimulation | 18 (1.7) | 38 (3.5) | 21 (2.6) | 24 (3.4) | 28 (4.7) |
| Hot or cold pack | 186 (17.2) | 271 (25.2) | 173 (21.2) | 152 (21.6) | 118 (19.8) |
| Manual therapy or massage | 36 (3.3) | 60 (5.6) | 24 (2.9) | 31 (4.4) | 32 (5.4) |
| Therapeutic exercise or activities | 174 (16.1) | 177 (16.5) | 105 (12.9) | 72 (10.2) | 85 (14.3) |
| Strapping of the lower extremities | 75 (7.0) | 42 (3.9) | 22 (2.7) | 63 (8.9) | 40 (6.7) |
Table 5.
Amount and duration of care per injury for the top 10 sports reporting the most injuries
| Boys’ Football | Girls’ Soccer | Girls’ Track and Field | Girls’ Basketball | Girls’ Volleyball | |
|---|---|---|---|---|---|
| Amount of care (number of services) | 4.7 ± 6.6 | 5.4 ± 9.9 | 5.2 ± 5.1 | 4.1 ± 4.2 | 4.6 ± 5.5 |
| Duration of care (days of service) | 11.8 ± 31.3 | 14.4 ± 25.6 | 10.1 ± 30.0 | 14.7 ± 36.7 | 11.5 ± 19.3 |
| Boys’ Basketball | Boys’ Track and Field | Boys’ Wrestling | Boys’ Soccer | Girls’ Softball | |
| Amount of care (number of services) | 4.3 ± 4.3 | 5.3 ± 5.9 | 3.6 ± 4.1 | 3.6 ± 3.2 | 4.1 ± 4.1 |
| Duration of care (days of service) | 11.1 ± 27.4 | 18.1 ± 72.9 | 12.6 ± 18.7 | 6.6 ± 5.8 | 6.2 ± 10.8 |
Discussion
Our findings are similar to previous epidemiologic7,8,16,19,21,26,29,30,33,34 and clinical practice characteristics investigations32 and suggest that secondary school ATs tend to diagnose similar injuries and use similar methods to treat these injuries, regardless of sport. While the injury characteristics were generally similar across sports, there were a few trends noted between sports. For example, boys’ wrestling included diagnoses related to general medical skin conditions (ie, tinea, folliculitis, herpes simplex) and sprain or strain of the neck, while boys’ wrestling and girls’ softball were the only sports where sprain or strain of the elbow was documented as a common injury. It appears that the types of injuries suffered during girls’ soccer, girls’ track and field, and boys’ track and field tend to require more time and effort to provide treatment and care than other sports. Girls’ soccer and basketball required longer durations of care when compared with boys’ soccer and basketball, respectively. In contrast, boys’ track and field required longer durations of care when compared with girls’ track and field.
The basis of determining appropriate medical coverage and care, as described by the NATA’s Appropriate Medical Coverage of Intercollegiate Athletics (AMCIA)22 document, is the relative workload of each sport. To calculate the relative work load for each sport, AMCIA guidelines recommend multiplying the injury risk (based on multiyear injury surveillance data) with the average number of treatments per injury. As a result, certain sports may require increased coverage because of increased risk of injury. Contact sports like football and soccer often require daily on-field practice and game coverage because of the increased risk of catastrophic injuries. In contrast, noncontact sports such as track and field may not require on-field event coverage but may require the same or greater amount of time to care for chronic, overuse, and recurrent injuries that may linger for a large portion of a season. While our inclusion of the type, amount, and duration of care offers a more comprehensive perspective on the demands on ATs, our data set likely does not provide a complete picture in terms of all of the treatments delivered in the secondary school setting. To continue the discussion related to appropriate medical coverage and care within the context of AMCIA22 and Appropriate Medical Coverage for Secondary School Athletes summary document,5 future studies should aim to capture data for services that are associated with non–time loss injuries and preventative services in the secondary school setting.
This study is not without its limitations. We analyzed injuries based on ICD-9 coding which, at times, did not allow us to identify a specific diagnosis for an injury. Our analyses may have been more informative if we were able to differentiate between sprain and strain injuries, for example.
Conclusion
Secondary school ATs tend to diagnose similar injuries and use similar treatment methods, regardless of sport. ATs covering wrestling should pay special attention to skin conditions and should be well prepared to prevent and treat these conditions.
Acknowledgments
The authors would like to thank the participating members of the Athletic Training Practice-Based Research Network for their work to develop and promote the network.
Footnotes
The following authors declared potential conflicts of interest: Alison R. Snyder Valier, PhD, ATC, has grants/grants pending from the National Athletic Trainers’ Association Research and Education Foundation. Tamara C. Valovich McLeod, PhD, ATC, FNATA, was a paid legal consultant for 2 cases this past year related to sports concussions.
References
- 1. Agel J, Evans TA, Dick R, Putukian M, Marshall SW. Descriptive epidemiology of collegiate men’s soccer injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2002-2003. J Athl Train. 2007;42:270-277. [PMC free article] [PubMed] [Google Scholar]
- 2. Agel J, Olson DE, Dick R, Arendt EA, Marshall SW, Sikka RS. Descriptive epidemiology of collegiate women’s basketball injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004. J Athl Train. 2007;42:202-210. [PMC free article] [PubMed] [Google Scholar]
- 3. Agel J, Palmieri-Smith RM, Dick R, Wojtys EM, Marshall SW. Descriptive epidemiology of collegiate women’s volleyball injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004. J Athl Train. 2007;42:295-302. [PMC free article] [PubMed] [Google Scholar]
- 4. Agel J, Ransone J, Dick R, Oppliger R, Marshall SW. Descriptive epidemiology of collegiate men’s wrestling injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004. J Athl Train. 2007;42:303-310. [PMC free article] [PubMed] [Google Scholar]
- 5. Almquist J, Valovich McLeod TC, Cavanna A, et al. Summary statement: appropriate medical care for the secondary school-aged athlete. J Athl Train. 2008;43:416-427. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. American Orthopaedic Society for Sports Medicine. Principles for selecting team medical coverage. http://www.nata.org/sites/default/files/SecondarySchool.pdf Accessed January 7, 2014.
- 7. Badgeley MA, McIlvain NM, Yard EE, Fields SK, Comstock RD. Epidemiology of 10,000 high school football injuries: patterns of injury by position played. J Phys Act Health. 2013;10:160-169. [DOI] [PubMed] [Google Scholar]
- 8. Borowski LA, Yard EE, Fields SK, Comstock RD. The epidemiology of US high school basketball injuries, 2005-2007. Am J Sports Med. 2008;36:2328-2335. [DOI] [PubMed] [Google Scholar]
- 9. Comstock RD, Collins CL, Currie DW. National High School Sports-Related Injury Surveillance Study: summary report (2012-2013). http://www.ucdenver.edu/academics/colleges/PublicHealth/research/ResearchProjects/piper/projects/RIO/Documents/2012-13.pdf Accessed January 10, 2014.
- 10. Courson R, Goldenberg M, Adams KG, et al. Inter-association consensus statement on best practices for sports medicine management for secondary schools and colleges. http://www.nata.org/sites/default/files/SportsMedicineManagement.pdf Accessed January 7, 2014. [DOI] [PMC free article] [PubMed]
- 11. Dick R, Ferrara MS, Agel J, et al. Descriptive epidemiology of collegiate men’s football injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004. J Athl Train. 2007;42:221-233. [PMC free article] [PubMed] [Google Scholar]
- 12. Dick R, Hertel J, Agel J, Grossman J, Marshall SW. Descriptive epidemiology of collegiate men’s basketball injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004. J Athl Train. 2007;42:194-201. [PMC free article] [PubMed] [Google Scholar]
- 13. Dick R, Putukian M, Agel J, Evans TA, Marshall SW. Descriptive epidemiology of collegiate women’s soccer injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2002-2003. J Athl Train. 2007;42:278-285. [PMC free article] [PubMed] [Google Scholar]
- 14. Difiori JP, Benjamin HJ, Brenner J, et al. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Clin J Sport Med. 2014;24:3-20. [DOI] [PubMed] [Google Scholar]
- 15. Dragoo JL, Braun HJ, Durham JL, Chen MR, Harris AH. Incidence and risk factors for injuries to the anterior cruciate ligament in National Collegiate Athletic Association football: data from the 2004-2005 through 2008-2009 National Collegiate Athletic Association Injury Surveillance System. Am J Sports Med. 2012;40:990-995. [DOI] [PubMed] [Google Scholar]
- 16. Fernandez WG, Yard EE, Comstock RD. Epidemiology of lower extremity injuries among U.S. high school athletes. Acad Emerg Med. 2007;14:641-645. [DOI] [PubMed] [Google Scholar]
- 17. Frommer LJ, Gurka KK, Cross KM, Ingersoll CD, Comstock RD, Saliba SA. Sex differences in concussion symptoms of high school athletes. J Athl Train. 2011;46:76-84. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and collegiate athletes. J Athl Train. 2007;42:495-503. [PMC free article] [PubMed] [Google Scholar]
- 19. Ingram JG, Fields SK, Yard EE, Comstock RD. Epidemiology of knee injuries among boys and girls in US high school athletics. Am J Sports Med. 2008;36:1116-1122. [DOI] [PubMed] [Google Scholar]
- 20. Krajnik S, Fogarty KJ, Yard EE, Comstock RD. Shoulder injuries in US high school baseball and softball athletes, 2005-2008. Pediatrics. 2010;125:497-501. [DOI] [PubMed] [Google Scholar]
- 21. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40:747-755. [DOI] [PubMed] [Google Scholar]
- 22. National Athletic Trainers’ Association. Recommendations and guildelines for appropriate medical coverage of intercollegiate athletics. http://www.nata.org/sites/default/files/AMCIA-Revised-2010.pdf Accessed January 10, 2014.
- 23. National Athletic Trainers’ Association. Secondary school official statement. http://www.nata.org/sites/default/files/SecondarySchool.pdf Accessed January 9, 2014.
- 24. National Federation of State High School Associations. 2012-2013 High School Athletics Participation Survey results. http://www.nfhs.org/content.aspx?id=3282 Accessed January 7, 2014.
- 25. National Institutes of Health. Research repositories, databases, and the HIPAA privacy rule. http://privacyruleandresearch.nih.gov/research_repositories.asp Accessed January 7, 2014.
- 26. Nelson AJ, Collins CL, Yard EE, Fields SK, Comstock RD. Ankle injuries among United States high school sports athletes, 2005-2006. J Athl Train. 2007;42:381-387. [PMC free article] [PubMed] [Google Scholar]
- 27. Rindal DB, Gordan VV, Litaker MS, et al. Methods dentists use to diagnose primary caries lesions prior to restorative treatment: findings from The Dental PBRN. J Dent. 2010;38:1027-1032. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28. Roos KG, Marshall SW. Definition and usage of the term “overuse injury” in the US high school and collegiate sport epidemiology literature: a systematic review. Sports Med. 2014;44:405-421. [DOI] [PubMed] [Google Scholar]
- 29. Shankar PR, Fields SK, Collins CL, Dick RW, Comstock RD. Epidemiology of high school and collegiate football injuries in the United States, 2005-2006. Am J Sports Med. 2007;35:1295-1303. [DOI] [PubMed] [Google Scholar]
- 30. Swenson DM, Collins CL, Best TM, Flanigan DC, Fields SK, Comstock RD. Epidemiology of knee injuries among U.S. high school athletes, 2005/2006-2010/2011. Med Sci Sports Exerc. 2013;45:462-469. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31. Valovich McLeod TC, Bliven KC, Lam KC, Bay RC, Valier AR, Parsons JT. The National Sports Safety in Secondary Schools Benchmark (N4SB) study: defining athletic training practice characteristics. J Athl Train. 2013;48:483-492. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32. Valovich McLeod TC, Lam KC, Bay RC, Sauers EL, Snyder Valier AR. Practice-based research networks, part II: a descriptive analysis of the athletic training practice-based research network in the secondary school setting. J Athl Train. 2012;47:557-566. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33. Yard EE, Collins CL, Dick RW, Comstock RD. An epidemiologic comparison of high school and college wrestling injuries. Am J Sports Med. 2008;36:57-64. [DOI] [PubMed] [Google Scholar]
- 34. Yard EE, Schroeder MJ, Fields SK, Collins CL, Comstock RD. The epidemiology of United States high school soccer injuries, 2005-2007. Am J Sports Med. 2008;36:1930-1937. [DOI] [PubMed] [Google Scholar]