TABLE 1.
Sports-specific nomenclature of the cutaneous lesion resulting from the impact of a high velocity contact of the ball to the skin [a,b]
| Floorball [c] Floorball ecchymotic patches [1,2] Floorball purpura [current report] |
| Paintball Paintball purpura [5–7] Paint pellet erythema [d] [4] Paint pellet purpura [e] [3] |
| Ping pong Ping pong patches [f] [8] |
| Racquetball Annular erythematous (and occasionally purpuric) patches [g] [9] Annular lesion [8] RATE (racquetball-associated targetoid erythema) sign [current report] |
| Squash Annular erythematous (and occasionally purpuric) patches [h] [9] Annular lesion [8] TEAS (targetoid erythema associated with squash) sign [current report] |
The term “sports purpura” has been used by some authors to describe the observed clinical lesions. However, erythema may: (1) only develop, or (2) concurrently present with purpura, or (3) initially appear and be followed subsequently by purpura [11].
The “ball SITE (sports-induced targetoid erythema) sign” is a proposed new unifying terminology—regardless of the specific ball sport—to define the unique and pathognomonic cutaneous lesion resulting from high velocity impact contact of the ball to the skin.
Floorball is also referred to as either innebandy (in Sweden and Norway), salibandy (in Finland) and unihockey (in Germany and Switzerland); “bandy” refers to a team winter sport played on ice in which the skaters use sticks to hit a ball into the opposing team’s goal and “inne” and “sali” translates to “indoor”. The floorball ball is white, 72 mm in diameter, and 23 grams in weight and made of plastic; it is hollow and has 26 holes each of 11 mm in diameter. The fastest ball speed has been recorded at a velocity of 204 kilometers per hour (which is equivalent to 127 miles per hour) [1,2,10].
Impact-associated injuries from the floorball were recorded in 3% of 172 injuries (occurring in 4 of 133 injured women) among a study group of 374 female floorball players [16]. Ecchymotic patches of purpura occur at the cutaneous impact site of the ball in floorball players [1,2]. The patch is initially annular, confluent, and corresponds to the diameter of the holes in the ball; in some circumstances, the lesion enlarges and displays a Swiss cheese-like pattern with discrete white-round areas within the patch [1,2,10].
Rahbari and Nabai described “paint pellet erythema” in a 19-year-old man with “three nonpruritic, annular, erythematous lesions [on the upper back] . . . that developed after the patient was hit by several paint pellets two days earlier” [4].
Seigel et al described a “targetoid lesion” on both the arm and back of a 32-year-old woman that occurred at the “sites in which she was hit on bare flesh by paint bullets while enjoying a survival game outing two days previously”. The individual “irislike lesions had an ecchymotic margins surrounding a central clear zone and a ‘bullseye’superficial erosion” [3].
Scott and Scott observed that the lesions “are uniformly circular, 12 to 15 mm in diameter, with clear centers and an annular 3 mm border that is generally erythematous but may be purpuric”. They also included a figure of an “annular popliteal lesion from a racquet ball” [8].
Barazi and Adams, in a correspondence titled “sports purpura,” include an accompanying figure legend that describes a “large, erythematous, annular patch created by the impact of a racquet ball.” The authors comment, “initially, the lesions demonstrate an annular, urticarial plaque, but progress to exhibit purpura” and that “the purpura may take one week to resolve [9].
Subsequent to the high velocity impact of a squash ball with the skin there is a central ecchymosis surrounded by a white ring and then an erythematous targetoid zone [12,13]. In some patients, additional zones of white (normal-appearing skin) and purpura are observed [14]. Indeed, two brothers—Camaron and Morgan Pilley—decided to confirm the clinical consequence to a participant’s back following contact of a high velocity squash ball with the skin. Cameron, at a distance of 2 meters, served a squash ball directed toward his brother Morgan’s back; an ecchymosis-lined erosion resulted at the point of contact that was surrounded by a white ring (or normal appearing skin) and a broad annular target of erythema [15].