Clinics in Sports Medicine

Clin Sports Med 27 (2008) 19–50
CLINICS IN SPORTS MEDICINE
Epidemiology of Injury in Child

and Adolescent Sports: Injury Rates,
Risk Factors, and Prevention
Dennis Caine, PhDa,*, Nicola Maffulli, MD, MS, PhD, FRCS
(Orth)b, Caroline Caine, PhDc
a
Department of Physical Education, Exercise Science and Wellness,
University of North Dakota, Hyslop Sports Center, Room 114, 2751 2nd Avenue North Stop 8235,
Grand Forks, ND 58202–8235, USA
b
Department of Trauma and Orthopedic Surgery, Keele University School of Medicine,
Thornburrow Drive, Hartshill, Guy Hilton Research Centre, Stoke on Trent,
ST4 7QB Staffordshire, England
c
Department of Theatre Arts, University of North Dakota, 5 Chandler Hall,
3280 Davis Drive Stop 8136, Grand Forks, ND 58202-8136, USA
T
he benefits of engaging in physical activity are well known and docu-
mented, and the participation of children and adolescents in organized
sports is increasingly popular and widespread internationally. Indeed,
many of these youngsters specialize in their sports beginning at an early age,
training year-round at regional centers in gymnastics or tennis for 20 or more
hours a week in Western countries. Furthermore, youngsters as young as 6 to
8 years of age play organized hockey or soccer and travel with select teams to
other towns and communities to compete on a regular basis. In some countries,
children as young as 5 or 6 years of age may be selected to attend government-
funded sports schools. In China, for example, there are 3000 government
sports schools, of which approximately 100 are boarding schools, at which chil-
dren aged 5 to 16 years train long hours in the hope of being chosen to attend
one of China’s Olympic training centers [1].
This increased sports involvement of children from an early age through the
years of growth raises concern about the risk and severity of injury. Young ath-
letes of all ages and everyone who works with them need to know answers to
questions, such as the following. What is the risk for injury in children’s and
youth sports? Is the risk for injury greater in some sports or levels of participation
compared with other sports? Are some physical, psychologic, or sport-related fac-
tors associated with an increased risk for injury? Can injury be prevented and, if
so, how? How effective are the injury countermeasures? These are all questions
that sports medicine personnel and coaches should be prepared to respond to,
*Corresponding author. E-mail address: denniscaine@mail.und.nodak.edu (D. Caine).
0278-5919/08/$ – see front matter Crown Copyright ª 2008 Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.csm.2007.10.008 sportsmed.theclinics.com
20 CAINE, MAFFULLI, & CAINE
and the information should be made readily available to them [2]. Providing this
information is an important objective of sports injury epidemiology.
There are two interrelated types of epidemiologic research: descriptive and an-
alytic. Quantifying injury occurrence (how much) with respect to who is affected
by injury, where and when injuries occur, and what is their outcome is referred to
as descriptive epidemiology. Explaining why and how injuries occur and identi-
fying strategies to control and prevent them is referred to as analytic epidemiology
[3], and this is where answers to many of our previous questions can materialize.
The purpose of this article is to review the analytic aspects of child and adolescent
sports injury epidemiology, with particular emphasis on injury risk factors and
preventive measures. Our review begins with a discussion of injury rates.
INJURY RATES
The most basic expression of risk is incidence, which is defined as the number
of new cases of disease (or injury) that occur in a defined population during
a given period of time [4]. Clinical incidence, which refers to the number of
incident injuries divided by the total number of athletes at risk and usually
multiplied by some k value (eg, 100) [5], is commonly reported in the pediatric
sports injury literature [6–8]. Although it may serve as an indicator of clinical or
resource use, however, it does not account for the potential variance in expo-
sure of participants to risk for injury [5].
Incidence rate, which refers to the number of incident injuries divided by the
total time-at-risk and usually multiplied by some k value (eg, 1000), is the pre-
ferred measure of incidence in research studies because it can accommodate
variations in the exposure time of individual athletes. Different units of time-
at-risk, varying in precision, have been used to calculate incidence rates [6].
Given space limitations, however, the authors have focused on incidence rates
calculated as the number of injuries per 1000 participation hours or per 1000
athletic exposures (AEs). These are also the most commonly reported expo-
sure-based incidence rates and provide an important basis for studying predict-
ability of risk factors and the effectiveness of preventive measures.
A summary of studies reporting separate overall (ie, practice and competition
combined) incidence rates for boys’ and girls’ sports is shown in Tables 1 and 2,
respectively. Boys’ incidence rates per 1000 hours, or per 1000 AEs, are shown
for baseball [9–12], basketball [9,10,12,13], cross-country running [14,15], foot-
ball [9–12,16–18], gymnastics [19], ice hockey [20–22], rugby [23–25], soccer
[9–12,26–30], and wrestling [9,10,12,31,32]. Studies reporting similar incidence
rates for girls’ sports include basketball [9,10,12,13,33], cross-country running
[14,15], field hockey [12], gymnastics [19,34–38], soccer [9–12,27,28,39], softball
[9–12], and volleyball [10,12].
In Tables 1 and 2, the highest rates of injury per 1000 hours of exposure are
reported for boys in ice hockey (range: 5 to 34.4), rugby (range: 3.4 to 13.3),
and soccer (range: 2.3 to 7.9) and for girls in soccer (range: 2.5 to 10.6), basketball
(range: 3.6 to 4.1), and gymnastics (range: 0.5 to 4.1). When AEs are used, how-
ever, cross-country running (range: 10.9 to 15.0), football (range: 3.54 to 16.2),
EPIDEMIOLOGY OF INJURY IN CHILD AND ADOLESCENT SPORTS 21
and soccer (range: 2.43 to 17.0) show the highest incidence rates for boys, and
cross-country running (range: 16.7 to 19.6), soccer (range: 2.35 to 23.0), and
gymnastics (8.5) report the highest rates for girls. Most of these sports involve
a high rate of contact, jumping, sprinting, or pivoting activities, which are often
involved in the mechanism of sports injury [40]. A relatively high incidence of
injuries in cross-country running and baseball perhaps relates to the repetitive
nature of motor patterns performed in these activities.
These comparisons of incidence rates across studies should be viewed cau-
tiously in light of methodologic shortcomings and study differences. These in-
clude diversity of study populations, short periods of data collection and small
sample sizes in some studies, low response rates and recall bias associated with
the use of questionnaires, and variable injury definitions and methods of data
collection. Given that these study shortcomings may restrict the interpretation
and comparison of findings, it is useful to compare incidence rates across sports
within a multiple-sport study that has used the same injury definition and data
collection methods across sports studied. In three multisport studies involving
US high-school athletes [9,10,12], football had the highest overall injury rate
per 1000 AEs for boys and soccer was associated with the highest incidence
of injury for girls, followed by basketball and softball. Baseball was consistently
associated with the lowest injuries in boys’ studies.
INJURY RISK FACTORS

Risk factors in sport are any factors that may increase the risk for injury [41].
These factors may be classified as intrinsic or extrinsic [42]. Intrinsic factors are
individual biologic and psychosocial characteristics predisposing an athlete to
the outcome of injury, such as previous injury or life stress. They are viewed
as factors that predispose the athlete to react in a specific manner to an injury
situation. Once the athlete is predisposed, extrinsic or ‘‘enabling’’ factors may
facilitate manifestation of injury [43]. Extrinsic risk factors are factors that have
an impact on the athlete while he or she is participating in sport, such as train-
ing methods or equipment.
Risk factors can also be divided into modifiable and nonmodifiable factors
[44]. Modifiable risk factors refer to those that can be altered by injury preven-
tion strategies to reduce injury rates. Nonmodifiable risk factors, which cannot
be altered, may affect the relation between modifiable risk factors and injury.
Although nonmodifiable risk factors, such as gender and age, may be impor-
tant considerations in many studies of injury prediction, it is clearly important
to study factors that are potentially modifiable through physical training or be-
havioral approaches, such as strength, balance, or flexibility [44]. Risk factors
that have been subjected to statistical tests for correlation or for predictive value
in studies of children’s and youth sports injuries are discussed next.
Adolescent Growth Spurt

It is believed that the adolescent growth spurt is associated with an increased
risk for injury attributable to such factors as increased muscle-tendon tightness
22
Table 1
Summary of incidence rates in boys’ sports
Study Duration Team No. No. Rate: no. Rate: no.

designa/ Data of injury type or No. exposures exposures injuries per injuries per 95% CI
Study country collectionb surveillance age(s) injuries (hours) (AEs)c 1000 hours 1000 AEs (low/high)
Baseball
Knowles P (United DM 3 years HS 94 0.95 0.61/1.47
et al [9] States)
Comstock P (United DM 1 year HS 1.19
et al [10] States)
Radelet P (United Q 2 years 7–13 128 6913 17.0
et al [11] States) years
Powell and P (United Q 3 seasons HS 861 311,295 2.8
Barber-Foss States)
[12]
Basketball
et al [9] States)
CAINE, MAFFULLI, & CAINE

et al [10] States)
Powell and P (United DM 3 seasons HS 1933 444,338 4.8
Barber-Foss States)
[12]
Messina P (United DM 1 season HS 543 169,885 3.2
et al [13] States)
Cross-country running
Rauh P (United DM 1 season HS 159 10,600 15.0
et al [14] States)
Rauh P (United DM 15 seasons HS 846 77,491 10.9
et al [15] States)
Football
EPIDEMIOLOGY OF INJURY IN CHILD AND ADOLESCENT SPORTS

et al [9] States)
et al [10] States)
Malina P (United DM 2 seasons Youth 259 10.4 9.2/11.8
et al [16] States)
4th–5th 58 6.6 5.1/8.6
grades
6th grade 61 9.8 7.6/12.7
7th grade 90 13.4 10.8/16.5
8th grade 50 16.2 12.2/21.5
Turbeville P (United DM 2 seasons HS 132 3.2 2.7/3.8
et al [17] States)
Turbeville P (United DM 2 seasons MS 64 2.0
et al [18] States)
Radelet P (United Q 2 years 7–13 129 8462 15.0
et al [11] States) years
Powell and P (United DM 3 seasons HS 10,557 1,300,446 8.1
Barber-Foss States)
[12]
Gymnastics
Bak et al P (Denmark) Q 1 year Club 26 1.0
[19]
Ice hockey
Emery and P (Canada) DM 1 season All minor 296 4.13 3.67/4.62
Meeuwisse
[20]
Atom 14 1.12 0.61/1.87
Pee Wee 53 3.32 2.49/4.34
Bantam 73 4.16 3.26/5.23
296 Midget 156 6.07 5.16-7.1
23
(continued on next page)
24
Table 1
(continued)
Study Duration Team No. No. Rate: no. Rate: no.
designa/ Data of injury type or No. exposures exposures injuries per injuries per 95% CI
Study country collectionb surveillance age(s) injuries (hours) (AEs)c 1000 hours 1000 AEs (low/high)
Smith P (United DM 1 season HS 27 34.4
et al [21] States)
Gerberich R (United Q 1 season HS 5
et al [22] States)
Rugby
McManus and P (Australia) DM 1 season Junior Elite 84 13.3
Cross [23]
Garraway and P (United 1 season Less than 26 3.4 2.1/4.8
Macleod [24] Kingdom) 16 years
16–19 72 8.7 6.5/10.8
years
Roux et al [25] P (France) Q 1 season HS 495 7.0 1.6
Soccer

et al [9] States)
et al [10] States)
Le Gall P DM 10 seasons All 1152 4.8
et al [26]
U16 371 5.2
U15 361 4.6
1152 U14 420 4.9
Kucera P (United Q 3 years U12–18 467 109,957 4.3 3.9/4.7
et al [27] States)
Emery P (Canada) DM 1 season Overall 5.5
et al [28]
U18 16 2030 3.2
U16 16 2817 5.7
16 U14 7 2177 7.9
Radelet P (United Q 2 years 7–13 years 47 2799 17
et al [11] States) Alsace
Junge P (Europe) DM 1 year 14–18
et al [29] years
Czech Republic 57 2.3
14–18 130 2.6
years
Barber-Foss States)
[12]
Backous P (United Q 1 week 6–17 years 7.3
et al [30] States)
Wrestling
et al [9] States)
Comstock P(United DM 1 year HS 2.5
et al [10] States)
Pasque and P (United I, Q 1 season 219 6.0
Hewett [31] States)
Barber-Foss States)
[12]
Hoffman and P (United DM 2 seasons 36,262 7.6
Powell [32] States)
a
Design: P, prospective cohort; R, retrospective cohort.
b
Data collection: DM, direct monitor; HS, high school; IR, insurance records; MS, middle school; Q, questionnaire; RR, record review.
25
c
AE is one athlete participating in one practice or game in which the athlete is exposed to the possibility of athletic injury.
Adapted from Caine D, Caine C, Maffulli N. Incidence and distribution of pediatric sport-related injuries. Clin J Sport Med 2006;16:503; with permission.
26
Table 2
Summary of incidence rates in girls’ sports
Duration No. No. Rate: no. Rate: no.
Study Data of injury Team type No. exposures exposures injuries per injuries per 95% CI
Study designa collectionb surveillance or age(s) injuries (hours) (AEs)c 1000 hours 1000 AEs (low/high)
Basketball
et al [9] States)
et al [10] States)
Barber-Foss States)
[12]
Messina P (United DM 1 season HS 543 120,751 3.6
et al [13] States)
Gomez P (United DM 1 year HS 436 107,353 4.1
et al [33] States)
Cross-country running
Rauh P (United DM 1 season HS 157 8008 19.6
et al [14] States)
Rauh P (United DM 15 seasons HS 776 46,572 16.7

et al [15] States)
Field hockey
Barber-Foss States)
[12]
Gymnastics
Caine P (United DM 3 years All levels 192 76,919.5 22,584 2.5 8.5
et al [34] States)
Top 125 36,040.0 3.5
Beginning 67 40,879.5 1.6
Kolt and PR (Australia) Q 18 months All levels 349 105,583 3.3
Kirkby [35]
Elite 151 57,383 2.6
Subelite 198 48,200 4.1
Kolt and R (Australia) Q 1 year All levels 321 163,920 2.0
Kirkby [36]
Elite 111 1.6
Subelite 210 2.2
Bak et al [19] P (Denmark) Q 1 year Club 41 1.4
Lindner and P (Canada) QI 3 seasons Club 90 173,263 0.5
Caine [37]
Caine P (United I 1 year All levels 147 40,127 3.7
et al [38] States)
Top 83 22,536 3.7
Middle 64 20,591 3.1
Soccer
et al [9] States)
et al [10] States)
Kucara P (United Q 3 seasons 12–18 years 320 60,166 5.3 4.7/6.0
et al [27] States)
Emery P (Canada) DM 1 season Overall 20 2526 5.6
et al [28]
U14 14 2440 7.9
U16 5 1976 5.7
U18 2.5
Soderman P (Sweden) DM 1 season 14–19 years 79 6.8
et al [39]
Radelet P (United Q 2 years Community 16 1637 23.0
et al [11] States)
27
28
Table 2
(continued)
Duration No. No. Rate: no. Rate: no.
Study Data of injury Team type No. exposures exposures injuries per injuries per 95% CI
Study designa collectionb surveillance or age(s) injuries (hours) (AEs)c 1000 hours 1000 AEs (low/high)
Barber-Foss States)
[12]
Backous P (United Q 1 week 6–17 years 10.6
et al [30] States)
Softball
Knowles P (United DM 3 years HS 71 .96 0.61/1.42
et al [9] States)
et al [10] States)
Radelet P (United Q 2 years Community 37 3807 10.0
et al [11] States)
Powell and P (United DM 3 seasons HS 910 3.5
Barber-Foss States)
[12]

Volleyball
et al [10] States)
Barber-Foss States)
[12]
a
Design: P, prospective cohort; R, retrospective cohort.
b
Data collection: DM, direct monitor; HS, high school; IR, insurance records; Q, questionnaire; RR, record review.
c
AE is one athlete participating in one practice or game in which the athlete is exposed to the possibility of athletic injury.
Adapted from Caine D, Caine C, Maffulli N. Incidence and distribution of pediatric sport-related injuries. Clin J Sport Med 2006;16:504; with permission.
[45] and decreased physeal strength [46–48]. In addition, bone mineralization

may lag behind linear bone growth during the pubescent growth spurt, thus
rendering the bone temporarily more porous and more prone to injury during
this period [49]. Studies of fracture occurrence show an increase in epiphyseal
fractures during pubescence, an association between periods of rapid growth
and peak fracture rate [50–56], and a noteworthy association between peak
height velocity and peak fracture rate [49,53].
Caine and colleagues [38] reported higher injury rates associated with injury
in peripubertal female gymnasts (Tanner stages 2 and 3) compared with gym-
nasts characterized by stages 1, 4, and 5, regardless of competitive level
(P<.05). DiFiori and colleagues [57] reported that adolescent gymnasts between
10 and 14 years of age were significantly more likely to have chronic wrist pain,
even when adjusted for training intensity, age of initiation of training, years of
training, and gender, than those who were older or younger than this age group.
The findings in both of these studies await confirmation from an analysis of in-
dividual longitudinal growth records with individual injury rates, however.
Age
In boys’ sports, it is generally believed that the risk for injury would be greater
among older boys because they are faster, heavier, and stronger and they gen-
erate more force on contact. The relation between age/grade/competitive levels
and injury rates seems to be sport-specific, however. For example, perusal of
Table 1 shows that the incidence of injury increases with grade or age level
in boys in gridiron football [16], rugby [24], and soccer [26,28], although these
relations were not tested statistically. In minor hockey, compared with the
youngest age group, Atom, the risk for injury increased significantly through
Pee Wee, Bantam, and Midget age groups [20].
Emery and colleagues [28] also report a significantly higher rate of injury
among U14 relative to U18 female soccer players (relative risk [RR] ¼ 3.13,
95% confidence interval [CI]:1.14–10.67; P ¼ .01) [28]. In contrast, Caine
and colleagues [34] reported that the RR for injury among US gymnastics level
7 through 9 girls was 1.47 times greater than that of level 4 through 6 female
gymnasts. This difference was even greater (RR ¼ 4.22) for competition than
for practice (RR ¼ 0.97). The generally older advanced-level gymnasts attempt
more complex and difficult skills and accumulate greater exposure to training,
thus perhaps related to increased incidence of injury.
Biologic Maturity
Children of the same chronologic age may vary considerably in biologic matu-
rity status, and individual differences in maturity status influence measures of
growth and performance during childhood and adolescence [58]. The concern
is that competition between early- and late-maturing boys in contact sports,
such as gridiron football and ice hockey, contributes to at least some of the se-
rious injuries in these sports.
Several studies have attempted to examine the relation between biologic
maturity, as determined by Tanner stages or estimation of Tanner stages,
and injuries in sports. Violette [59] investigated 466 junior and senior high-
school football players. He found that junior high-school players were less
likely than senior high-school players to be injured, even though both levels
had a wide variation in sexual maturation. The injured junior high-school
players were lighter and less mature than noninjured teammates.
Backous and colleagues [30] investigated the relation between biologic ma-
turity, as estimated from grip strength and height, and injury among 681
male soccer players aged 6 to 17 years. The proportion of injured athletes
was not significantly greater for strong boys compared with weak boys
playing with age-matched groups in the same division. There was a signifi-
cantly higher proportion of injuries among the tall/weak boys compared
with the immature (short/weak) and mature (tall/strong) boys (P <.05),
however.
Linder and colleagues [60] examined the relation between sexual maturity
(Tanner stage) and injury in junior high-school football players. Injuries
were more prevalent (P ¼ .03) among players characterized by Tanner stages
3, 4, and 5 as compared with those who were less physically mature (Tanner
stages 1 and 2). Unfortunately, individual variation in exposure to risk for
injury was not accounted for in this or the other studies mentioned. It is
therefore possible that the more mature athletes were exposed to a greater
risk for injury because they played more.
Body Size
The concern, particularly in sports in which grouping for competition is by age
or grade level, is that of a mismatch between smaller and larger boys. In
hockey, for example, Roy and colleagues [61] evaluated the morphologic
and strength differences between small and large Pee Wee hockey players.
The average weight and height differences were 37.2 kg and 31.5 cm, respec-
tively. Similarly, marked differences in grip strength and impact force distin-
guished these groups. Brust and colleagues [62] noted similar differences in
a sample of Bantam hockey players and found that the lighter players were
more likely to be injured. It is noteworthy that biologic maturation was not
accounted for in these studies.
Although there is some evidence of a similar relation between injury and
body size in American football [59], several studies have instead reported an
increased rate of injury among heavier players [63–66] or players with
a high body mass index (BMI) [65]. Heavier weight produces greater forces,
which are absorbed through soft tissue and joints [67], thus perhaps related
to increased risk for injury. This would seem especially true for overweight
football players or among ‘‘oversized’’ athletes in sports like gymnastics [68–
70], in which a small body size is related to success in the sport. It also seems
to be true with regard to specific injuries. For example, two studies report a re-
lation between overweight, as indicated by the BMI, and increased risk for an-
kle sprains in high-school football players [71,72].
Coaching
Intuition suggests that poor coaching may be a predictor for injury. The
National Center for Catastrophic Sport Injury (NCCSI) reports that one half
of catastrophic injuries to female athletes are from high-school and college
cheerleading [73]. The NCCSI implicates inexperienced and untrained coaches
who try to teach stunts that they neither have the knowledge nor ability to
teach or are too difficult with regard to the skill and capabilities of the team.
Schulz and colleagues [74] tested a coaching experience/qualification/training
(EQT) variable in their 3-year prospective cohort study and found a protective
effect. Higher levels of coach EQT accounted for a 50% reduction in injury risk
over a lower coach EQT. Conversely, Knowles and colleagues [9] tested a sim-
ilar coach EQT across 12 sports and found it not to be a predictor of injury
rates when subjected to multivariate analysis.
Fitness
Few studies examine the impact of fitness (proprioceptive ability, strength,
endurance, flexibility, and adiposity) on injuries. McGuine and colleagues
[75] found a positive linear relation between balance and rate of ankle injuries
among high-school basketball players. Similarly, Plisky and colleagues [76] re-
ported that a dynamic balance test was predictive of lower extremity injury in
high-school basketball players. Additionally, Wang and colleagues [77] report
that high variations of postural sway correspond to occurrence of ankle injuries
(P ¼ .01; odds ratio [OR] ¼ 1.22) in high-school basketball players. In contrast,
McHugh and colleagues [71] found that balance was not a significant indicator
for noncontact ankle sprains in high-school football players.
In gymnastics, two studies [78,79] report greater endurance as a significant
(P <.05) injury predictor among club-level gymnasts. Lindner and Caine [79]
also report evidence of an association between poor flexibility and injury among
female gymnasts; however, this association was not significant at all age and com-
petitive levels studied. In wrestlers, Pasque and Hewett [31] found that increased
shoulder ligament laxity was related to increased risk for shoulder injury.
Adiposity was shown to be a risk factor for injury in one study of gymnasts,
but gymnastics is the only sport in which this was demonstrated to be the case
[79]. In football, despite the high incidence of obese players on high-school
teams, Kaplan and colleagues [66] found no increased injury risk in their study
of 98 players, but adiposity was associated with increased risk for lower
extremity injuries in a study of 216 players by Gomez and colleagues [65].
Gender
Of the available pediatric basketball literature, girls are at greater risk for sus-
taining a knee injury (P <.001) [80] ([incidence density ratio ¼ 1.44, 95% CI:
1.2–1.71] [81], [incidence density ratio ¼ 1.7, P <.05] [82], [RR ¼ 1.92,
P <.0001] [83], and [RR ¼ 2.29, P <.001] [13]), and the knee injury is more
likely to require surgery (P <.05) [81] ([incidence density ratio ¼ 2.65, 95%
CI: 1.64–4.29] [81] and [P <.047] [13]) or to involve the anterior cruciate liga-
ment (ACL) (RR ¼ 9.0; P ¼ .05) [84] ([RR ¼ 3.79; P <.024] [13], [P <.01] [85],
and [incidence density ratio ¼ 4.14, 95% CI: 2.18–7.9] [81]). Girls also seem to
be at greater risk than boys for sustaining an ankle injury (RR ¼ 1.24; P <.05)
[83] and being reinjured (P ¼ .002) [81].
In one multi-sport study [81], high school girls showed significantly higher in-
jury rates than boys for knee injuries, knee surgeries, and for ACL injuries. It
should be noted, however, that rates were reported in terms of number of injuries
per 100 players, ie, clinical incidence. In high-school cross-country running, girls
have significantly higher injury rates than boys for overall injuries (P <.0001); ini-
tial injuries (P <.0001); subsequent injuries (P <.0001); shin injuries (P <.0001);
hip and foot injuries (P <.01); and reinjury to the knee, calf, and foot (P <.05) [15].
The potential reasons for these gender differences include femoral notch var-
iation [86], cross-sectional diameter of the ACL [87], hormonal influences on
injury risk [88], variations in lower extremity strength and flexibility [89], neu-
romuscular factors [90], and lower skill levels [67]. Of these factors, variations
in strength and flexibility and the neuromuscular factors are considered poten-
tially modifiable [90].
Previous Injury
Previous injuries can lead to fibrosis, with adhesions and limited joint motion and
function, thus predisposing to further injury at the same site [15]. Restricted joint
motion leads to muscle atrophy and increased compensatory stress on other
areas, thus predisposing to injury at other sites. The limited studies evaluating
the relation between previous injury and new injury at the same site have shown
that a history of concussion is an important predictor of future concussions
among high-school football players (injury rate ratio [IRR] ¼ 2.28, 95%
CI: 1.24–4.19) [91] and that previous injury is a significant predictor of overuse
injuries among female gymnasts (IRR ¼ 2.12, 95% CI: 1.61–2.78) [92]. Rauh and
colleagues [14] reported that once injured, a high-school cross-country runner
had a four- to fivefold increased likelihood of reinjury at the same body site.
Previous injury in the past year increased the risk for injury in soccer players
(RR ¼ 1.74, 95% CI: 1.0–3.1) [28], high-school football players (OR ¼ 1.83, 95%
CI: 1.09–3.07) [17], and high-school cheerleaders (IRR ¼ 2.0, 95% CI: 0.8–4.7)
[74]. These findings may relate to persistent symptoms underlying physiologic
deficiencies resulting from the initial injury (ie, ligamentous laxity, muscle
strength, endurance, proprioception) or inadequate rehabilitation [42].
Psychologic Characteristics
In the general sport and recreational literature, life stress has been shown as
a strong predictor of injury [93,94]. This link has also been demonstrated in
club gymnasts [95,96], high-school football players [97], and ice hockey [21].
The findings may have been influenced by the retrospective nature of injury
data collection in some studies and the relatively short periods over which in-
jury and psychosocial variables were monitored, however.
INJURY PREVENTION
Participation in children’s and youth sports is not without risk. Sports injuries
may cause significant discomfort and disabilities, may reduce productivity, and
are responsible for significant medical expenses. In some cases, the injury may
be catastrophic, causing lifelong disability. Other less severe injuries may also
have long-term effects, because there is evidence that knee and ankle injuries
may result in an increased risk for osteoarthritis later in life [98]. Although it
is impossible to eliminate all injuries, attempts to reduce them are obviously
warranted [99].
Epidemiologic data have been used to reduce injury rates by driving the de-
velopment and implementation of injury prevention programs. Examples of
data-driven changes in policies and practices include the prohibition of ‘‘spear-
ing’’ in football and rules regarding water depth and the racing dive in swim-
ming [100]. In karate, strict judging and heavy penalties for uncontrolled blows,
particularly for the youngest competitors, have been shown to decrease the risk
for injury [101]. Other preventive measures supported by research include
improved training for high-school wrestling coaches, increased awareness of
pathogenic weight control in wrestling and gymnastics, and rules against push-
ing or checking from behind in ice hockey [100].
Until recently, relatively little research has been designed to determine the
effectiveness of injury prevention measures in children’s and youth sports. A
summary of results of the nonrandomized studies is shown in Table 3 [102–
113]. Study results indicate a protective effect of landing skills training in reduc-
ing injuries in elite junior Australian football players [102], of a sport-specific
balance training program in reducing ACL injuries in female team handball
players [107], of a rehabilitation and conditioning program in reducing
incidence of injury among youth soccer players [108], and of a total body pre-
season conditioning program in reducing early-season knee injuries among
high-school football players [113].
In one study [111], half-time warm-up and stretching exercises were not
shown to decrease injuries among high-school football players; however, signif-
icantly fewer third-quarter sprains and strains per game were reported. The
results of two plyometric-based interventions are mixed, with one study involv-
ing in-season intervention showing no significant difference in ACL injury rates
[103] and another that included a preseason intervention showing a significant
reduction in serious knee injuries, including ACL injuries [109].
Several studies have investigated the protective effects of safety equipment,
with mixed results [104,106,110,112]. One study demonstrated the use of
safety balls and face guards in reducing risk for injury in youth baseball
[106], and another study showed a protective effect of eyewear in reducing
the rate of head/face injuries among female scholastic lacrosse players [110].
Two studies showed an increase in lower extremity injuries associated with
the use of knee or ankle bracing [104,112].
The results of the nonrandomized studies must be viewed cautiously, how-
ever, because risk factors or interventions assessed may not be the only
34
Table 3
Summary of non-RCT studies examining prevention strategies for injury in child and adolescent sport
Results (RR or OR,

Study design (country provided if adequate
Author (year) and time frame) Participants (age) Prevention strategy Injury definition information provided)
Scase et al [102] Non-RCT (two seasons) 723 Australian rules 1. Intervention: eight Any incident occurring Players in the
(Australia) football players 30-minute sessions during game or intervention group
(less than 18 years) on landing, falling, training that resulted were significantly less
and recovery skills in a player missing likely to sustain an
2. Control group one or more games injury during the
competitive season
than the control group

(RR ¼ 0.72, 95%
CI: 0.52–0.98)
Pfeiffer et al [103] Non-RCT (USA) 765 female HS athletes 1. Intervention: ACL injury confirmed on 1. Incidence of
(soccer, basketball, plyometric-based the basis of history at noncontact ACL
and volleyball) exercise program time of surgery or MRI injuries was
two times per week 0.167/1000
during the season player-exposures
2. Control group versus 1.87/1000
player-exposures in
the control group
(P>.05)
Yang et al [104] Stratified cluster sample 19,728 athlete seasons 1. Intervention and use Lower 1. Lower extremity
non-RCT (United (M/F) (12 sports) of lower extremity extremity injury discretionary
States) (3 years) 1,104,354 AEs procedure equipment use
equipment resulted in lower rate
2. Control group of lower extremity
injury (RR ¼ 0.91,
95% CI: 0.72–1.15)
2. Kneepad use (RR ¼
0.44, 95%
CI: 0.27–0.74)
3. Knee brace (RR ¼
1.61, 95%
CI: 1.08–2.41)
4. Ankle brace (RR ¼
1.74, 95%
CI: 1.11–2.72)
Mandelbaum et al Non-RCT (United States) Year 1: 2946 female 1. Intervention ACL injury During year 1, there
[105] (2 years) soccer players warm-up consisting was an 88% decline
Year 2: 2756 female of education, in ACL injury
soccer players stretching, compared with
strengthening, age- and skill-matched
plyometrics, and controls
sports-specific agility In year 2, there was
drills a 74% reduction in
2. Control group ACL injury compared
with age- and
skill-matched controls
35
36
Table 3
(continued)
Results (RR or OR,
Marshall et al [106] Non-RCT Little league 1. Reduced-impact 1. RR (safety ball) ¼ 0.72
(United States) baseball (5–18 years) safety ball versus (95%
(three seasons: traditional ball CI: 0.57–0.91)
1997–1999) 2. Face guard versus 2. RR (face guard) ¼ 0.65
no face guard (95%
CI: 0.43–0.98)
Myklebust Non-RCT over Female European 1. Control year ACL injury (>1 week OR (first) ¼ 0.87, 95%
et al [107] three seasons team handball 2. First intervention time loss ¼ CI: 0.5–1.52
(60, 58, and 52 players season: floor, balance suspected) OR (second) ¼ 0.64,
teams/season) (16–18 years) matt and wobble board as assessed 95% CI: 0.35–1.18
(Norway) exercises (15 minutes), by physical OR elite division
and handout (videotape therapy (second) ¼ 0.37,
plus coach delivered) 95% CI: 0.13–1.05
(three times per week for
5–7 weeks and one time
per week for season)

3. Second intervention
season: same as
previous intervention,
with PT delivered
at every practice (15
minutes) (three times
per week for 5–7
weeks and one time
per week for season)
Junge et al [108] Non-RCT (Switzerland) 194 soccer players 1. Intervention (I) Injury resulting in 1. RR ¼ 0.82, 95%
(mean ¼ 16.5 years) included coach and physical complaint for CI: 0.58–1.15
player education, longer than 2 weeks 2. RR (high-skilled
rehabilitation, and or missed session divisions) ¼ 0.94,
conditioning 95% CI: 0.58–1.5
program 3. RR (low-skilled
(cardiovascular, divisions) ¼ 0.63,
strength, flexibility, 95% CI: 0.42–0.94
and plyometrics
training)
2. Control: ill-defined
Hewett et al [109] Non-RCT (United States) 1263 HS (soccer, 1. Intervention: 366 Serious knee injury 14 serious knee injuries
volleyball, and girls (6-week jump (ligament sprain) seen (2 intervention,
basketball) training 60–90 by athletic therapist 2 male control,
minutes three times (>5 days time loss) 10 female control)
per week) (includes RR ¼ 0.42 (male)
flexibility, strength, RR ¼ 0.17 (female)
plyometrics, weight Significant based on
training, and landing v2 analysis (P ¼ .05)
techniques) No control for sport type
2. Control 1: 463 girls or factors other than
3. Control 2: 434 boys gender
Webster et al [110] Non-RCT (2-year) 700 varsity and junior 1. Intervention All reported injuries Overall, head/face
varsity female protective eyewear (to trainer), including injury rate (no. injuries
lacrosse players (goggles) face, scalp, skull, per 1000
(aged 13–18 years) 2. Control group ears, and jaw AEs) was 16.5%
lower in goggle
wearers compared
with nonusers
(RR ¼ 0.49)
37
38
Table 3
(continued)
Results (RR or OR,
Bixler and Jones [111] Non-RCT (United States) HS football players 1. Intervention: Injury requiring Injury rates between
(five teams: three half-time warm-up medical attention groups not statistically
intervention, two and stretching significant (insufficient
control) exercises data to calculate RR)
2. Control: no exercises
Grace et al [112] Non-RCT (United States) 580 HS football players, 1. Intervention: Lower extremity Significantly more
(two seasons) varsity and junior (n ¼ 330) single- injuries injuries of the knee in
varsity and double-hinged group that wore
knee braces single-hinge
2. Control group: (P<.001); also,
(n ¼ 250) nonbraced significantly more
ankle and foot injuries
in athletes who wore
braces compared with
those who did not
wear braces (P<.01)

Cahill and Non-RCT HS football players 1. Intervention: preseason Reduction in number
Griffith [113] (United States) conditioning program and severity of knee
2. Control: record injuries (no exposure
of injuries before data were collected)
preseason conditioning
program
Abbreviation: HS, high school.
Adapted from Emery CA. Injury prevention and future research. In: Caine DJ, Maffulli N, editors. Epidemiology of pediatric sports injuries. Individual sports. Med Sports Sci,
vol. 49. Basel (Switzerland): Karger; 2005:187–91; with permission.
difference between groups. The lack of measurement and control for poten-
tially confounding variables (eg, those relating to coaching technique, warm-
up routine, equipment) may result in an overestimation of association between
exposure and injury rates [67]. Additionally, not all studies accounted for expo-
sure time in estimating injury rates between treatment and control groups.
The randomized controlled trial (RCT) studies summarized in Table 4
[114–122] demonstrate a protective effect of a home-based balance training pro-
gram in reducing acute-onset injuries in high-school basketball players [114]
and in reducing all injuries, including ankle injuries, among high-school phys-
ical education students [118]. Two studies [119,122] involving female adoles-
cent team handball players and using a multifaceted training program that
included proprioceptive balance training demonstrated a protective effect for
all injuries. Another study [117] that also involved adolescent team handball
players demonstrated a protective effect of a structured warm-up program to
improve motor performance and neuromuscular control, balance, and strength
in decreasing the risk for acute ankle and knee injuries. A multifaceted presea-
son training program involving female high-school soccer players was also
shown to be effective in reducing injury [121]. McGuine and Keene [116] re-
ported a significantly lower rate of ankle sprains among high-school basketball
and soccer players exposed to both pre- and in-season balance training
programs.
Two RCT studies focused on the use of protective equipment in reducing
the risk for injury. Mickel and colleagues [115] compared groups of high-school
football players exposed to prophylactic ankle taping or ankle bracing during
a regular football season. There was no statistically significant difference in
ankle sprains between the two groups. Notably, the average cost to tape
each ankle during an entire season was greater than the cost of the commer-
cially available brace. McIntosh and McCrory [120] reported no significant
difference between concussion rates in rugby players younger than 15 years
of age with and without headgear.
SUGGESTIONS FOR FURTHER RESEARCH

The epidemiology of sports injuries in children and youth is an important area
of research that has been largely overlooked in the medical and sport science
literature. The overview of pediatric injury literature presented here under-
scores the need to establish large-scale injury surveillance systems designed
to provide current and reliable data on injury trends in sports for boys and
girls. This is especially important for sports like gymnastics, in which the rules
change every 4 years, or like swimming or resistance training, in which there is
a dearth of descriptive epidemiologic studies. Reliable descriptive data, in turn,
provide an effective basis for the identification and testing of risk factors and
preventive measures.
As this review indicates, few modifiable injury risk factors have been statis-
tically evaluated. Compared with boys, girls have been shown to be at greater
risk for injury, particularly knee injury, in several sports. There is also some
40
Table 4
Summary of RCT studies examining prevention strategies for injury in child and adolescent sport
Study design Results (RR or OR,
(country and provided if adequate
Author (year) time frame) Participants (age) Prevention strategy Injury definition information provided)
Emery et al [114] Cluster RCT (Canada) 920 secondary school 1. Intervention: Required medical 1. Intervention was
basketball players standard warm-up, attention or caused protective of
(12–18 years old, additional a player to be acute-onset injuries
25 schools) warm-up, and removed from the (RR ¼ 0.71, 95%
home-based current session or to CI: 0.5–0.99) but
balance training miss a subsequent not with respect to
using a wobble session all injury (RR ¼ 0.8,
board 95% CI: 0.57–
2. Control: standard 1.11), lower
warm-up extremity injury
(RR ¼ 0.83, 95%

CI: 0.57–1.19),
and ankle sprain
injury (RR ¼ 0.71,
95% CI: 0.45–
1.13)
Mickel et al [115] RCT (United States) 83 HS football players 1. Intervention: Ankle sprain There was no
(one season) prophylactic ankle statistically
taping significant
2. Prophylactic ankle difference in ankle
bracing sprains between the
two groups
McGuine and RCT (each member 765 HS soccer and 1. Intervention: Ankle sprain: defined Rate of ankle sprains
Keene [116] of a team was basketball players balance training as trauma that (1) was significantly
randomly assigned (523 girls and 242 before season and disrupted the lower in the
to the same boys) in-season ligaments of the intervention group
intervention or maintenance ankle; (2) occurred (P ¼ .04). Athletes
control group 2. Control group during a with history of an
(United States) coach-directed ankle sprain had
competition, a twofold increased
practice or risk for sustaining
conditioning a sprain, whereas
session; and athletes who
(3) caused the performed the
athlete to miss the intervention
rest of a practice or program decreased
competition or to their risk for reinjury
miss the next (RR ¼ 0.56).
scheduled
coach-directed
practice or
competition
Olsen et al [117] Cluster RCT (Norway) 1837 team handball 1. Intervention: Acute injuries RR intervention versus
one season players aged structured warm-up involving the control group ¼
(8 months) 15–17 years, to improve running, knee and ankle 0.53, 95%
120 clubs cutting, and CI: 0.35–0.81
landing technique
and neuromuscular
control, balance,
and strength
2. Control: no
treatment
41
42
Table 4
(continued)
Emery et al [118] Cluster RCT 127 HS students 1. Intervention: daily Injury occurring during RR ¼ 0.20, 95%
(Canada) (14–18 years old, progressive home a sporting activity, CI: 0.05–0.88)
10 schools) program using which required RR (ankle sprain) ¼
wobble board medical attention or 0.14, 95%
2. Control: no loss of at least 1 day CI: 0.18–1.13
treatment of sporting activity Multivariate analysis
plus control for
cluster randomization
Greatest effect in those
with previous injury
Also demonstrated
dose response effect
based on
improvements in
timed static and
dynamic balance

Wedderkopp et al [119] Cluster RCT 16 teams of female 1. Intervention: practice Injury requiring OR ¼ 0.21, 95%
(Denmark) European team session included 10–15 player to miss CI: 0.09–0.53
handball players minutes’ use of next session or Multivariate analysis but
(16–18 years old) individual ankle disk unable to no control of cluster
and warm-up with two participate randomization in
or more functional large- without considerable analysis
muscle group exercises discomfort Increased risk with
as in previous study increased time in
2. Control group: match play
no ankle disk
McIntosh and RCT (Australia) 294 rugby union 1. Intervention: Concussion Nine concussions
McCrory [120] players less than Headgear of occurred during
15 years of age any choice study period; 7 of
(1179 player 2. Control group the players wore
exposures with headgear and 2 did
headgear, 357 not. Headgear did
without headgear) not significantly
(one season) reduce concussion
injury rate in rugby
(z ¼ 0.0648, 95%
CI: 0.0092 to 0.0086)
Heidt et al [121] RCT (United States) 300 female HS soccer 1. Intervention: 7-week Injury requiring RR ¼ 0.42, 95%
players (14–18 preseason Frappier missing at least CI: 0.2–0.91
years old) acceleration program one game or
(cardiovascular, practice
plyometrics,
strength, and
flexibility)
2. Control: no
preseason program
43
44
Table 4
(continued)
Wedderkopp et al [122] RCT (Denmark, 237 female European 1. Intervention: practice Injury requiring RR ¼ 0.17, 95%
1995/1996) team handball session training program player to miss CI: 0.09–0.32
players (16–18 (warm-up with two next session or
years old) or more functional unable to participate
large-muscle group without considerable
exercises and discomfort
proprioceptive ankle
disk activity)
2. Control: nonspecific

practice session training
Abbreviation: HS, high school.
Adapted from Emery CA. Injury prevention and future research. In: Caine DJ, Maffulli N, editors. Epidemiology of pediatric sports injuries. Individual sports. Med Sports Sci,
vol. 49. Basel (Switzerland): Karger; 2005:187–91; with permission.
evidence that periods of rapid growth, poor coaching, poor dynamic balance,
and previous injury are associated with an increased risk for injury. Exposure
patterns in injured and uninjured athletes were not consistently identified as
a basis for determining reasons for injury occurrence, however. Additionally,
risk factors for injury may interact differently with the categories of injury on-
set, a possibility that was not accounted for in many of the risk factor studies
reviewed. Future studies on risk factors need to account for the multivariate
nature of sports injuries by including sufficient sample size and as many rele-
vant risk factors as possible [44].
Although few studies have been published that were designed to determine
the effect of injury prevention measures, initial results are promising. There is
evidence supporting the use of injury prevention strategies in children and
adolescents that includes preseason conditioning, functional training, educa-
tion, and strength and balance programs that are continued throughout the
playing season. Surprisingly, however, there have been no preventive trials
that have focused specifically on measures to reduce the risk for overuse in-
juries. Children’s and youth sports are associated with significant potential
for acute injury. With the advent of sports specialization and year-round train-
ing, however, overuse injuries are becoming increasingly prevalent in chil-
dren’s and youth sports [123].
Examples of questions that have arisen from this review of the pediatric
sports injury literature that may help to direct further analytic research include
the following. Do some psychosocial factors, for example, attitudes toward
safety gear, increase the risk for injury, particularly during competition? Can
an increased risk for sport injury during rapid growth be confirmed with refer-
ence to growth velocity data? What factors are associated with the increased
frequency of chronic injuries experienced by many young athletes? What are
the nature and incidence of growth plate injuries, including those that are stress
induced? Can standard preparticipation musculoskeletal screening, combined
with follow-up and rehabilitation as needed, provide a protective effect against
injury? Finding answers to these important questions is an essential task for the
new generation of sports injury epidemiologists. In the future, sports injury
epidemiologists also need to expend more collaborative effort to ensure that
important research findings are successfully implemented and evaluated.
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Clin Sports Med 27 (2008) 19–50

CLINICS IN SPORTS MEDICINE

Epidemiology of Injury in Child

*Corresponding author. E-mail address: denniscaine@mail.und.nodak.edu (D. Caine).

INJURY RISK FACTORS

Adolescent Growth Spurt

Study Duration Team No. No. Rate: no. Rate: no.

CAINE, MAFFULLI, & CAINE

EPIDEMIOLOGY OF INJURY IN CHILD AND ADOLESCENT SPORTS

CAINE, MAFFULLI, & CAINE

CAINE, MAFFULLI, & CAINE

CAINE, MAFFULLI, & CAINE

[45] and decreased physeal strength [46–48]. In addition, bone mineralization

Results (RR or OR,

CAINE, MAFFULLI, & CAINE

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CAINE, MAFFULLI, & CAINE

CAINE, MAFFULLI, & CAINE

SUGGESTIONS FOR FURTHER RESEARCH

CAINE, MAFFULLI, & CAINE

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CAINE, MAFFULLI, & CAINE

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CAINE, MAFFULLI, & CAINE

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