Findings From the Preparticipation
Athletic Examination and Athletic Robert H. DuRant,
PhD; Robert A. Pendergrast, MD, MPH; Carolyn Seymore, MD; Gregory Gaillard; Josh Donner,
study investigated the relationships between the findings from a standardized preparticipation athletic examination, the sport played, and athletic injuries requiring treatment by a physician and/or requiring the athlete to miss one or more games. Of public high school students receiving a preparticipation athletic examination during the 1989-1990 academic year, 674 (56%) either completed a telephone interview or returned a mailed questionnaire at the end of the academic year. The sample consisted of 408 (60.5%) blacks \s=b\ This
and 243 (36.1%) whites; 470 (69.7%) of the subjects were males. The subjects ranged in age from 13 to 20 years (mean \m=+-\SD, 16.1 \m=+-\1.2 years), and participated in at least 10 school sports. Injuries were reported by 29.5% of the athletes. The highest proportion of athletes injured occurred among male football (36.3%), female basketball (33.3%), male baseball (19.4%), male soccer (17.2%), and female track and field (15.8%) participants. Responses by the athletes and their parents on the standardized health history were significantly associated with injuries in several specific areas. Knee injuries were associated with previous knee injuries, knee surgery, and history of injuries requiring medical treatment. Ankle injuries were associated with previous ankle injuries and previous injuries requiring medical treatment. Both arm and other leg injuries were associated with previous fractures. Male athletes with either abnormal knee or ankle findings. from the physical examination were more likely to injure the knee or ankle, respectively. However, the sensitivities and positive predictive values of these relationships are weak. These data suggest that the preparticipation athletic examination may not predict certain athletic injuries and that additional prevention efforts for specific body areas of injury are needed in certain sports.
(AJDC. 1992;146:85-91)
activities
and other recreational among the of nonfatal Sports leading injuries among adol¬ have consistently escents.13 school football
High players experienced higher injury rates than other athletes,
but
Accepted for publication September 24,
1991. From the Section of General Pediatrics and Adolescent Medicine, Department of Pediatrics, The Medical College of Georgia, Au-
gusta.
MD
high injury rates also occur among track and field, base¬ ball, basketball, gymnastics, wrestling, and field hockey participants.1,4"6 Methodologie differences in study design
make intersport comparisons of injury rates difficult. It has been difficult to accurately predict which athletes are at risk of injury from sports participation because of vari¬ ations in the definition of athletic injuries, the training of the individual diagnosing and recording injuries, the methods of injury detection, how the injury rates are cal¬ culated, the time frames of the studies, and the popula¬ tions studied. Several investigators have proposed that the purpose of the preparticipation athletic examination (PAE) is to iden¬ tify athletes who are at risk of injury, illness, or death from sports participation.712 However, evidence that abnormal findings on the PAE predict an increased risk of athletic injury is inconsistent.13"25 Most studies have reported that increased joint flexibility, ligamentous laxity, and previ¬ ous injuries were associated with increased sprains, dis¬ locations, and reinjuries.15'25 Unfortunately, many of these studies were poorly designed and/or controlled, had low statistical power because of small sample sizes, or did not use appropriate statistical tests. In a well-controlled study, Lysens et al26 conducted extensive physical examinations and psychological and behavioral tests on 185 college freshman physical education students in Belgium and monitored injuries for a period of 1 year. Although they found that several physical and psychological character¬ istics were associated with injuries, they pointed out that their sample was a self-selected population who were not likely to have experienced previous injuries that would have inhibited their participation in a highly demanding physical education program. Because their PAE protocol
are
causes
Presented at the Southern Society for Pediatric Research, New Orleans, La, January 31,1991, and the Society for Adolescent Medicine, Denver, Colo, March 15, 1991.
Reprints
Injuries
Department Editors.— William B. Strong, MD, Augusta, Ga; CarlL. Stanitski, MD, Pittsburgh, Pa; Ronald E. Smith, PhD, Seattle, Wash; Jack
H. Wilmore, PhD, Austin, Tex section provides current information re¬ lated to the medical needs of young athletes, as pertinent to counseling young athletes and their parents regarding sports participation and practices contributing to the health maintenance of the athlete, as well as current concepts in the prevention, diagnosis, and treatment of sports-related illnesses and injuries.
Purpose.—This
not available.
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hip to 90° and held there by the athlete's hand. The leg was then extended slowly as far as possible without moving the thigh. If the leg could be extended completely, the hamstring was
Table 1.—Athletes Participating and Injured in Each Sport Stratified by Gender No. (%)
No. (%)
of
Participants -·Sport
Females (N=470) (N = 204)
of Injuries
Males
Males
P*
Football
300 (63.8)
Basketball Baseball/ softballt
132(28.1) % (47.1)
20(15.2) 32(33.3) .0004
108 (22.9)
21 (19.4)
9 (9.1)
10 (17.2)
0
2(10.0) 11(10.7) 2(7.7)
2(7.7) 9(15.8)
Soccer
58 (12.3)
Tennis 20(4.3) Track and field 103(21.9) Golf 26(5.5) 0 Cheerleading Rifle
1 (0.2)
109 (36.3)
Females
0
99 (48.5) 0
26(12.7) 57(27.9) 4(1.9) 15 (7.4) 0
0
were
0
0
1
0
0
.05
considered normal. Spine.—First, the athlete was examined for scoliosis, kyphosis, or increased lumbar lordosis. Next, the athlete was placed in a sitting position with the knees flexed between 60° and 90°. The athlete was then asked to bend forward as far as possible, put¬ ting his or her head between the legs. Flexibility was then recorded as normal, tight, or very tight. Knees.—Each knee was examined for alignment, effusion, active and passive range of motion, ligament integrity, and ro¬ tatory stability. A meniscus test was then done and specific joints
NS
NS NS
(6.6)
.
.
.
"Kruskal-Wallis analysis of variance. NS indicates no statistical sig¬ nificance. tBaseball and softball are played by only males and females,
respectively.
far more comprehensive than is presently used in scholastic athletic programs in the United States, the gen¬ eral applicability of the findings is limited. Although these studies suggest that a standardized PAE might be able to detect adolescent athletes at increased risk of sports-related injuries, no prior research has specifically addressed this detail. In three previous studies, we have described and evaluated the PAE program in our public school system.7"10 The purposes of this study were to test whether findings from the PAE were predictive of athletic injuries and to examine other factors associated with ath¬ letic injuries among high school students during the 19891990 academic year. was
SUBJECTS AND METHODS PAE
The study protocol was approved by the Medical College of Georgia's Human Assurance Committee and the Athletic De¬ partment of the Richmond County Board of Education. All 1204 public high school students in Richmond County, Georgia, who planned to participate in interscholastic sports during the 19891990 academic year were required to undergo a physical exam¬ ination at the beginning of the sports season. Students could choose between an examination by a physician of their choice or a station examination provided by volunteer physicians, den¬ tists, and physical therapists from the local community. How¬ ever, all PAEs were recorded on the standardized Preparticipa¬ tion History and Physical Examination Form previously recommended by the American Academy of Pediatrics' Com¬ mittee on Practice and Ambulatory Medicine.8-9'27 We did not record who performed the examination on each athlete. The station examination was performed in the outpatient department of a community hospital. On scheduled evenings, groups of 50 to 100 students were evaluated. At the first station, the health history was reviewed with the student; the height, weight, pulse rate, and blood pressure were mea¬ sured; and vision screening was completed. The students then circulated through seven other examination stations. The content of all components of the station examination has been previously described.8·28 Briefly, the following procedures were used when examining each joint and muscle group. Hamstrings. —The athlete was placed in a supine position on the examining table. The leg being tested was then flexed at the
palpated.
Ankles. —Ankles were tested for heel cord tightness, range of motion, muscle strength in plantar flexion, dorsiflexion, inver¬ sion, eversión, and lateral and medial stability. Shoulders.—The shoulders were examined for range of mo¬ tion, joint stability, and muscle strength in flexion, extension, abduction, and internal rotation. The history and physical examination results were then re¬ viewed by one physician, and a recommendation was made con¬ cerning athletic participation. The students were either cleared for athletic participation without reservation, recommended not to participate after discussion with them and their coaches and/or parent(s), or cleared contingent on further evaluation, treatment, or conditioning. At the time of the examination, no examiner was aware of the purpose of the study.
Survey Design design
used in this study has been previously described.29 The standardized PAE form includes parental consent, biographical data, and home addresses and tele¬ phone numbers. In April 1990, letters were sent to the par¬ ents of all athletes explaining the purpose of the study. Using the telephone numbers provided by the students on the PAE forms, we attempted to contact by telephone all students who participated in interscholastic athletics during the academic year. All telephone contacts were made between 5 and 9 PM and were conducted during April and May 1990. Only 242 adolescents were at home during the period that the tele¬ phone calls were made. No parents or adolescents refused to be interviewed. In May 1990, all adolescents (n 962) not interviewed by telephone were mailed an identical question¬ naire with a stamped, self-addressed return envelope. Four hundred thirty-two adolescents returned the questionnaire, resulting in 674 (56%) completing either the maUed question¬ naire or the telephone interview. There were no differences between the interviews conducted by telephone and the mailed questionnaires in any variables measured. The survey
=
Subjects The subjects ranged in age from 13 to 20 years (mean±SD, 16.1±1.2 years). The sample consisted of 470 (69.7%) males, 408 (60.5%) blacks, and 243 (36.1%) whites, and was slightly skewed toward the 9th grade (36.6%), with fewer 12th grad¬ ers (14.5%). The demographic data of the sample of 674 did not differ from those of the 530 adolescents receiving PAEs who were not interviewed.
Questionnaire The questionnaire was designed to measure athletic injuries and attrition from scholastic sports.29 The questionnaire was first pretested on a small group of male and female adolescents, and revisions were made in the wording of ambiguous items. The questionnaire obtained information about demographic vari¬ ables, the sport for which the initial PAE was conducted (Table 1), attrition from any sport, and the reasons for attrition, and whether an injury was sustained during participation in schoolsponsored sports that either required them to seek medical care from a physician and/or caused them to miss one or more games.
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Table 2. —Injuries
Occurring Among Athletes Participating in
Male- and
No. of Athletic
Female-Specific Sports
Injuries
Males
Females
Mean ± SD
Mean Rank
0.50 ±0.68 0.24 ±0.75
251.82 197.20
0.32 ±0.84 0.44 ±0.66
210 .47 246 .40 J
.0083
0.44±0.76 0.16±0.44
111.28 92.64
.002
0.55 + 0.75 0.36 ±0.71
256.93 224.69
.008
0.34 ±0.64 0.25 ±0.62
105.29 97.93
.021
Mean ± SD
Mean Rank
Football Yes No
Basketball Yes No
.0001
|
Baseball/softball Yes No
*Kruskal-Wallis
Table
analysis
of variance.
3.—Self-reported Athletic Injuries to Specific Areas of the Body No. (%) of
Location Neck
Back Knee
Ankle Foot
Leg,
Injuries*
12(1.8) 7(1.0) 13 (1.9) 61 (9.1) 54 (8.0) 7(1.0) 27 (4.0) 22 (3.3) 5 (0.7) 11 (1.6) 26 (3.9) 3 (0.4) 2 (0.3) 3 (0.4)
Head
other than above
Shoulder Elbow Wrist
Arm, other than above
Kidney* Ribst Heartt Total
253
'Percentages based on tRepresents those who responded
674 athletes. to mailed
questionnaires.
This definition of injury is more conservative than has been used in either population-based studies5 or prospective stud¬ ies,4-6'25'26 and was chosen because adolescents are not likely to accurately recall injuries that are not significant enough to require medical care or missing a game.30 Athletes recorded the number of injuries sustained, the sport in which the injury(or injuries) occurred, and the part or area of the body injured. Because of a lack of knowledge of anatomy or ath¬ letic injuries, the adolescents were not asked to provide the medical diagnosis of their injury.
Statistical
Analysis
For the purpose of this study, the outcome variables were as follows: experiencing an athletic injury, area of the body injured, and the total number of injuries sustained by each athlete. As¬ sociations among categorical variables were analyzed with 2 tests and the strengths of the associations were determined with coefficients. Significant relationships between findings from the health history or physical examination and athletic injuries were then assessed for sensitivity, specificity, and positive and negative predictive value. Because of deviations from normality in the distribution of the number of athletic injuries by each athlete, this variable was analyzed with Kruskal-Wallis analysis of variance.
experienced
RESULTS
Among male athletes, a greater proportion of football players (36.3% ) were injured than other athletes, followed in order by basketball, baseball, and soccer players (Table 1). The percentage of female basketball players (33.3%) experiencing athletic injuries was approximately the same as that of male football players (36.3%). A higher per¬ centage of female than male athletes were injured partic¬ ipating in basketball (P=s.0004) and track and field (P>.05), and a higher percentage of male baseball players than female softball players (P=s.05) were injured (Table 1). No significant ethnic or age differences were found in injury rates within each sport. Injury rates did not vary by school. None of the schools employed certified trainers,
and information was not collected on variations among coaches in training techniques. Male adolescents experienced a significantly greater mean number of injuries (mean±SD, 0.41±0.72) than fe¬ males (mean±SD, 0.29±0.63) (Pss.011). The mean num¬ ber of injuries sustained by football and baseball players was significantly greater than for other male athletes (Table 2). In contrast, male basketball players experienced a significantly lower mean number of injuries than other male athletes. Among female athletes, basketball and softball players sustained a greater mean number of inju¬ ries than other female athletes (Table 2). The knee was the most frequently injured body part, followed in order by injuries to the ankle, leg, arm, and shoulder (Table 3). When injuries to specific areas of the body were examined within each sport and by gender, an increased risk of injury to the knee occurred among male football players (11.7% vs 7.0%) (Table 4). Female basket¬ ball players and male baseball players were at higher risk of ankle injuries. Male baseball players were also more likely to experience leg and arm injuries. Shoulder inju¬ ries were more likely to occur among male football, bas¬ ketball, and soccer players, and head injuries occurred more frequently among male baseball players. Among the 57 female track and field participants, 15.8% experienced a knee injury, compared with 6.8% of other female athletes (P=s.048). More of the items on the standardized health history were significantly associated with athletic injuries than findings from the physical examination. Athletes experi¬
encing dizziness, fainting, frequent headaches, or con¬ slightly more likely to report a head injury during sports participation (Table 5). Having previously
vulsions were
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Table 4.—Associations Between Athletic Injuries to Football No
Yes
No
(n = 228)
(n = 446)
Yes (n = 108)
No (n = 566)
(n = 58)
(n 616)
35(11.7)
26(7.0)
19(8.3)
42(9.4)
12(11.1)
49(8.7)
4(6.9)
57(9.3)
2(0.9)
27(9.0)
27(7.2) NS NS
Leg
No. (%)
16 (5.3)
11
(2.9)
(%)
P*
11
(3.7)
9 (3.9)
NS NS
'Controlling for males. NS indicates tP>.05 for females. tP= .017 for females only. §P>.05 for female softball.
statistical
0(0)
18
(3.2)
4
(6.9)
.012
17
(3.8)
8 (7.4)
23 (3.7)
NS NS 18 (3.2)
.0366 NS
12(1.9) NS NS
.035§ 5
21 (3.4)
(8.6) .049 NS
significance.
a knee injury or having undergone knee surgery was significantly associated with knee injuries during the subsequent sports season. Similarly, previous ankle injuries and previous injury requiring treatment by a physician were associated with ankle injuries during sports participation. Athletes who had previously broken a bone were more likely to injure a leg or arm during the sports season. Shoulder injuries were significantly associated with other serious joint injuries in the past. However, based on coefficients, the strength of each of these statistically significant relationships was weak (Table 5). When the sensitivities and positive predictive values of these relationships were analyzed, the informa¬ tion contained in the health history was insufficient for the physician to predict those athletes who would be injured (Table 6). Athletes who had previously broken a bone or had experienced other injuries requiring treat¬ ment by a physician had a significantly greater mean number of injuries than other athletes (Table 7). Adolescents with either abnormal knee or ankle find¬ ings during the physical examination were more likely to experience an athletic injury to the knee or ankle, respec¬ tively (Table 8). However, when gender was controlled, these relationships were only significant for male athletes and the relationships were weak. The sensitivities were also low for these relationships. The positive predictive value of the ankle component of the PAE was higher than
experienced
(8.3)
NS NS no
5(0.9)
.012§ 9
51(8.3) NS NS
.0003
NS NS 15 (4.0)
3(5.2)
.0003
15 (3.4)
16(2.6) .002 .007
36(6.4)
7(6.5)
=
6(10.3)
.0002§ 9(2.0)
12 (5.3)
20(3.5)
18(16.7)
NS NS
NS NS
P*
29(6.5)
No
NS NS
NS NS
3(1.3)
NS NS
P*
2(1.9)
.044 NS
6(1.6)
6(2.0)
20(4.5)
25(11.0)
Yes
NS NS
.024 .011t
.0008 .009
P*
Arm No.
NS NS
4(1.1)
18(6.0)
P*
Head No. (%)
Soccer
(n = 374)
.034 .006
Ankle injury No. (%)
Baseball
Basketball
Yes
P*
Shoulder injury No. (%)
=
(n 300) =
Knee injury No. (%)
Specific Areas of the Body and Sport Played by the Athlete (N 674)
that of the knee examination. This was partly due to there four males found to have abnormal ankles, three of whom were later injured. In comparison, 15 males were diagnosed as having abnormal knees, five of whom were later injured. No other variable had an effect on the relationships between findings on the PAE and athletic injuries.
being only
COMMENT The identification of risk factors for athletic injuries among adolescents has been difficult, partly due to the lack of a uniform definition of reportable injuries.31 Some investigators have classified injuries by severity while others categorize injuries by class or time lost from participation.617 For example, Prager et al6 defined injury as an event causing an inability of the player to return to practice or the field of play for 48 hours. McLain and Rey¬ nolds4 and Lanese et al32 defined injury as any traumatic medical problem due to sports participation that results in a loss of time from practice or competition. However, they compute the number of days lost using different methods. Injury was defined by Lysens et al26 as any event causing at least a 3-day absence from sports. When applied to the same group of athletes, these definitions will result in different injury rates. Consequently, comparisons of sport-specific injury rates among different studies are problematic. We chose a conservative definition of ath-
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Table 5.—Associations Between Positive
Finding From the Health History and Self-reported Injuries to Areas of the Body Findings From the
Location of
Injury During Sports Season
the
Head
Item/Area
No, No. (%)
1 (6.3) 15 (93.8)
11 (1.7) 636 (98.3)
2 (13.2) 13 (86.7)
10 I(1.5) 1 638 (98.5) 1
History Coefficient
Concussion
Yes No
Head Yes No
Dizziness, fainting, frequent
Neck Yes
Neck
headaches,
or
convulsions
injury
0(0) 1 (100.0)
No Knee Yes No
Knee
Knee Yes No
Knee surgery
Ankle Yes No
Ankle
Ankle Yes No
Injuries requiring treatment
Leg,
Broken bones
injury
Shoulder Yes No
Other serious
Arm Yes
Broken bones
joint injuries
6.—Sensitivity, Specificity, and
Positive and
.02
.13
.01
.0001
.22
56 (8.6) 598 (91.4) J
.026
.11
8 (16.7) 40 (83.3)
45 (7.3) 569 (92.7)
.022
.09
11 (15.7) 59 (84.3)
550 (92.9)
.012
.10
9 (7.2) 116 (92.8)
16 (3.0) 521 (97.0)
.026
.09
2 (20.0) 8 (80.0)
20 (3.1) 632 (96.9)
.003
.12
15(2.8) 1 522 (97.2) J
.017
.09
/
44(7.2) 570 (92.8)
J
\
42(7.1)
9 (7.2) 116 (92.8)
No
.05
NS
3 (37.5) 5 (62.9)
injury
NS
7(1.1) 1 648 (98.9)
15 (30.6) 34 (69.4)
by a physician
other Yes No
Table
Yes, No. (%)
Health
\J
Negative Predictive Values for the Associations History and Athletic Injury
From the Health
Between
Findings
Predictive Value, %
History
Injury
Sensitivity,
%
Specificity, %
Positive
Negative
97.7
6.3
98.3
98.0
13.3
98.5
0.0
98.9
Concussion
Head
Dizziness, fainting
Head
injury Knee injury Ankle injury
Neck Knee
25.4
99.8 94.4
15.1
93.4
30.6 16.7
92.8
Ankle
Knee surgery
Knee
5.1
99.2
37.5
91.4
20.8 36.7
90.3
15.7
92.9
82.5 98.8
14.4
94.2
20.0
96.9
Neck
Injury requiring
treatment
by physician a
Ankle
Broken bone
Leg or arm
Joint injury
Shoulder
letic injury to maximize the internal validity of the study. Because we were relying on adolescents' self report, we were only interested in the injuries that were traumatic enough to require the athlete to seek medical care from a physician and/or caused the athlete to miss one or more games. We assumed that adolescents would be likely to accurately recall injuries of this degree of severity. In agreement with previous studies,1-4"6 we found that football players were more likely to be injured (36.3%)
8.3 16.7 0.0
9.1
92.7
than athletes in any other sports, but the proportion in¬ jured was lower than has been previously reported. McLain and Reynolds4 reported that 61% of the 179 foot¬ ball players in a Maywood, 111, high school were injured during a single sports season. In an investigation of foot¬ ball injuries from 1982 to 1985, Prager et al6 found that the proportions of athletes injured were 45.3%, 60.7%, 35.9%, and 27.0%, respectively. Powell33 estimated that among the 1 million athletes participating in interscholastic foot-
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ball, 28% had mild injuries, 5.9% had moderate injuries,
and 3.3% had major injuries. Football injury rates in other studies vary considerably based on the definition of injury.15"17 Our more conservative definition of injury may account for these differences. It also may be that our larger sample of football players (within one sports season) from a greater number of high schools provides a more accu¬ rate estimate of football injuries. When compared with data reported in a study by McLain and Reynolds,4 our athletes also had a lower rate of injuries in boys' basketball (37% vs 15.2%), girls' softball (13% vs 9.1%), and girls' track (18% vs 15.8%). How¬ ever, we found slightly higher injury proportions in girls' basketball (33.3% vs 31%), boys' baseball (19.4% vs 15%), boys' soccer (17.2% vs 13%), boys' and girls' tennis (10.0% vs 0% and 7.7% vs 3%, respectively), and boys' golf (7.7% vs 0.0%). As was reported earlier for football injuries, in¬ jury rates reported in other studies vary substantially by
injury definition, making comparisons difficult.415'34,35 Nicholas14 and Godshall13 have reported contradictory
orthopedic findings on the predictive of athletic in¬ preparticipation jury in high school students. Neither study, however, was well controlled and neither study included appropri¬ ate statistical analysis of the data. Lysens et al25 reported data
as
to whether abnormal
examination
Table
are
7.—Injuries Associated With Findings Health From the
History
No. of Athletic
Finding from the health history Injuries requiring treatment by a physician Yes No
Broken bones Yes No *Kruskal-Wallis
analysis
Injuries
Mean ± SD
Mean Rank
.
...
365.44 1 322.53 J
.025
0.54 ±0.93 0.32 ±0.62
368.75 317.31
.0006
of variance.
Table 8.—Associations Between
Physical
Examination
Knee injury Yes No
Total
only
injury
Total
5 (29.4) 12 (70.6) 17
.0032
4 (26.7) 11 (73.3) 15
Ankle injury Yes No Total
452 50
.
Males only ankle Yes No Total
(7.5)
injury
Sensitivity, %
Specificity, %
Positive
Negative
.12
8.2
98.0
29.4
91.4
.049
.11
9.5
97.4
27.7
91.6
.001
.20
7.4
99.7
66.7
92.5
.001
.22
7.7
99.8
75.0
92.2
No. (%)
(66.7) (33.3)
663
4 2 6
36 (7.8) 427 (92.2) 463
3 (75.0) 1 (25.0) 4
613 (92.5)
Injuries Predictive Value, %
56 (8.6) 596(91.4)
38 (8.4) 414(91.6)
Examination and Athletic
Findings
Abnormal,
652
knee
Findings From the Physical
Normal, No. (%)
Males Yes No
physical
P*
0.58 ±1.12 0.34±0.62
J
that muscle tightness found during the preparticipation examination was not associated with muscle strains. However, increased joint flexibility and ligamentous lax¬ ity were associated with increased sprains and disloca¬ tions. The finding by Lysens et al25 confirms previous ob¬ servations by Ekstrand and Gillquist,18 Grana and Moretz,20 and Kirby et al.21 Lysens et al25 also reported that abnormalities in feet configuration found during the preparticipation examination were associated with shin splints, chondromalacia patellae, Achilles tendon prob¬ lems, and plantar fascitis during athletic competition. In contrast, we found that only two items on the physical examination component of the PAE were associated with athletic injuries and that the association applied only to male athletes. Male athletes with either abnormal knee or ankle findings on the PAE were more likely to injure the knee or ankle, respectively. However, these associations were weak, and the sensitivity and positive predictive values were low, indicating that the utility of the physical examination to predict these injuries was limited. We found that more of the items on the health history portion of the PAE were predictive of athletic injuries than were findings from the physical examination. Consider¬ ing that the most frequently injured body areas were the knee, ankle, leg, arm, and shoulder, the fact that each of these injuries was associated with findings on the health history is helpful. Specifically, previous injuries or having undergone surgery on a particular body area were asso¬ ciated with injuries during the subsequent sports season. examination However, as was found with the portion of the PAE, the associations between findings from the health history and actual injuries were weak and the sensitivities and positive predictive values were low. Previous studies also support the finding that athletes who report previous injuries are at higher risk of reinjury during athletic competition.13"17'22"25 Data from the US Mil¬ itary Academy, West Point, NY, suggest that the major¬ ity of leg and knee injuries are reinjuries.24 Lysens et al25 reported that sprain, dislocations, and stress injuries showed the highest probability of recurrence. From an epidemiologie viewpoint, the PAE can be
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viewed as a screening test for previously undetected risk of injury or disease. As such, it fulfills the widely accepted criteria for a screening test for large populations: specifi¬ cally, it is relatively inexpensive, rapid, and noninvasive.36 Our data indicate that the validity of the PAE in predicting risk of injury may be fairly low. As the data for this study were collected in a well-organized station examination that has been established and refined for more than 10 years,710 it seems unlikely that further refinement of our screening tool will significantly improve the sensitivity or positive predictive value for injuries. If so, the majority of injuries in high school athletes will continue to occur in young men and women who have demonstrated no ab¬ normalities during the history or physical examination portion of the PAE. This necessarily moves the focus of in¬ jury prevention in high school athletics away from the in¬ dividual athlete and to the environmental and social fac¬ tors contributing to injury risk. Factors such as the pairing of athletes for size and strength, selection of proper safety equipment, rules for fair play, and adequate preseason conditioning need to be addressed. Despite the need to broaden the scope of interest for injury prevention beyond the individual athlete, one cannot ignore the significance of a positive finding on the PAE. For example, our data suggest that almost 31% of young athletes who report a history of knee injury will in the subsequent athletic season sustain another knee
injury significant enough to cause inability to participate in at least one game or a visit to a physician. We can only speculate as to how many of those reinjuries could have been prevented by intensive physical therapy and athletic training, but we expect it would be a sizable proportion. While we recognize that the majority of athletic injuries can
only
be addressed
by
broader environmental
con¬
cerns, those athletes who demonstrate an abnormality on
the PAE form a high-risk group whose need for preven¬ tive therapy must not be ignored. In summary, our data suggest that the PAE is a useful screening tool in identifying a small group of athletes at high risk of athletic injury. However, it also has demon¬ strated the importance of looking beyond the level of the individual athlete into the broader environment in which athletic events occur to address the greater scope of ath¬
letic
injuries.
References
Runyan CW, Gerken EA. Epidemiology and prevention of adolescent injury. JAMA. 1989;16:2273-2279. 2. Rivara FP, Calonge N, Thompson RS. Population-based 1.
of unintentional injury incidence and impact during childhood. Am J Public Health. 1989;79:990-994. 3. Gallagher SS, Finison K, Guyer B, Goodenough S. The incidence of injuries around 87000 Massachusetts children and adolescents: results of the 1980-81 statewide childhood injury prevention program surveillance system. Am J Public Health.
study
1984;74:1340-1347. 4. McLain LG, Reynolds S. Sports injuries in a high school. Pediatrics. 1989;84:446-450. 5. Backx FJG, Erich WBM, Kemper ABA, Verbeek ALM.
Sports injuries in school-aged children: an epidemiologic study. Am J Sports Med. 1989;17:234-240. 6. Prager Bl, Fitton WL, Cahill BR, Olson GH. High school football injuries: a prospective study and pitfalls of data collection. Am J Sports Med. 1989;17:681-685. 7. DuRant RH, Linder CW, Sanders JM, Jay S, Brantley G, Bedgood R. Adolescent females' readiness to participate in sports: sex and race differences in the preparticipation athletic
examination. J Adolesc Health Care. 1988;9:310-314. 8. DuRant RH, Seymore C, Linder CW, Jay S. The preparticipation examination of athletes: comparison of single and multiple examiners. AJDC. 1985;139:657-661. 9. Linder CW, DuRant RH, Seklecki DO, Strong WB. Preparticipation health screening of young athletes: results of 1268 examinations. AmJ Sports Med. 1981;9:187-191. 10. Strong WB, Linder CW. Preparticipation health evaluation for competitive sports. Pediatr Rev. 1982;4:113-122. 11. Tennant ES, Sorenson K, Day CM. Benefits of preparticipation sports examinations. J Fam Pract. 1981;13:287-288. 12. Kibler WB, Chandler TJ, Uhl T, Maddux RE. A musculoskeletal approach to the preparticipation physical examination: preventing injury and improving performance. Am J Sports Med. 1989;17:525-531. 13. Godshall RW. The predictability of athletic injuries: an
eight-year study. J Sports 14. Nicholas
Med. 1975;3:50-54. to knee ligaments.
J. Injuries 1970;112:2236-2239.
JAMA.
15. Garrick JG, Reque RK. Injuries in high school sports. Pediatrics. 1978;61:465-469. 16. Blyth CS, Mueller FO. Football injury survey: parts 1 to 3. Phys Sportsmed. 1974;2:45-50. 17. Olson OC. The Spokane study: high school football in-
juries. Phys Sportsmed. 1979;7:75-82. 18. Ekstrand J, Gillquist J. Soccer injuries and their mechanisms: a prospective study. Med Sci Sports Exerc. 1983;15:267-270. 19. Ekstrand J, Gillquist J. The avoidability of soccer injuries. Int J Sports Med. 1983;4:124-128. 20. Grana WA, Moretz JA. Injuries to knee ligaments: relationship to looseness and tightness in football players. JAMA.
1978;240:1975-1976. 21. Kirby RL, Simms FC, Symington VD, Garner JB. Flexibility and musculoskeletal symptomatology in female gymnasts and age-matched controls. Am J Sports Med. 1981;9:160-164. 22. Cahill BR, Griffith EH. Effect of preseason conditioning
the incidence and severity of high school football knee inAm J Sports Med. 1978;6:180-184. 23. Brooks WH, Young AB. High school football injuries: prevention of injury to the central nervous system. South Med
on
juries.
J. 1976;69:1258-1260.
24. Abbott H, Kress J. Preconditioning in the prevention of knee injuries. Arch Phys Med Rehabil. 1969;50:326-333. 25. Lysens R, Steverlynck A, van den Auweele Y, et al. The predictability of sports injuries. Sports Med. 1984;1:6-10. 26. Lysens RL, Ostyn MS, Auweela YV, LeFevre J, Vuylsteke M, Renson L. The accident-prone and overuse-prone profile of the young athlete. Am J Sports Med. 1989;17:612-619. 27. Saltzman EJ, Shea DW, eds. Management of Pediatric Practice. Elk Grove Village, Ill: American Academy of Pediat-
rics; 1986:59-60. 28. Linder CW, DuRant RH, Seklecki DO. Response to Blackburn and Hunter. Am J Sports Med. 1981;9:192-193. 29. DuRant RH, Pendergrast RA, Donner J, Seymore C, Gaillard G. Adolescents' attrition from
AJDC. 1991;145:1119-1123.
school-sponsored sports.
30. Fienberg SE, Loftus EF, Tanur JM. Recalling pain and other symptoms. Milbank Q. 1985;63:582-597. 31. Risser WL. Epidemiology of sports injuries in adolescents. Adolescent Medicine: State of the Art Reviews.
1991;2:109-123. 32. Lanese RR, Strauss RH, Leizman DJ, Ratondi AM. Injury and
disability
in matched men's and women's
intercollegiate
sports. Am J Public Health. 1990;80:1459-1462. 33. Powell J. 636 000 injuries annually in high school football. Athletic Training. 1987;22:19-22. 34. McCarroll JR, Meaney C, Sieber JM. Profile of youth soccer injuries. Phys Sportsmed. 1984;12:113-117.
35. Whiteside PA. Men's and women's injuries in comparable sports. Phys Sportsmed. 1980;8:130-140. 36. Mausner JS, Kramer S. Mausner and Bahn Epidemiology: An Introductory Text. Philadelphia, Pa: WB Saunders Co; 1985:217.
Downloaded From: http://archpedi.jamanetwork.com/ by a Oakland University User on 06/09/2015
Athletic Examination and Athletic Robert H. DuRant,
PhD; Robert A. Pendergrast, MD, MPH; Carolyn Seymore, MD; Gregory Gaillard; Josh Donner,
study investigated the relationships between the findings from a standardized preparticipation athletic examination, the sport played, and athletic injuries requiring treatment by a physician and/or requiring the athlete to miss one or more games. Of public high school students receiving a preparticipation athletic examination during the 1989-1990 academic year, 674 (56%) either completed a telephone interview or returned a mailed questionnaire at the end of the academic year. The sample consisted of 408 (60.5%) blacks \s=b\ This
and 243 (36.1%) whites; 470 (69.7%) of the subjects were males. The subjects ranged in age from 13 to 20 years (mean \m=+-\SD, 16.1 \m=+-\1.2 years), and participated in at least 10 school sports. Injuries were reported by 29.5% of the athletes. The highest proportion of athletes injured occurred among male football (36.3%), female basketball (33.3%), male baseball (19.4%), male soccer (17.2%), and female track and field (15.8%) participants. Responses by the athletes and their parents on the standardized health history were significantly associated with injuries in several specific areas. Knee injuries were associated with previous knee injuries, knee surgery, and history of injuries requiring medical treatment. Ankle injuries were associated with previous ankle injuries and previous injuries requiring medical treatment. Both arm and other leg injuries were associated with previous fractures. Male athletes with either abnormal knee or ankle findings. from the physical examination were more likely to injure the knee or ankle, respectively. However, the sensitivities and positive predictive values of these relationships are weak. These data suggest that the preparticipation athletic examination may not predict certain athletic injuries and that additional prevention efforts for specific body areas of injury are needed in certain sports.
(AJDC. 1992;146:85-91)
activities
and other recreational among the of nonfatal Sports leading injuries among adol¬ have consistently escents.13 school football
High players experienced higher injury rates than other athletes,
but
Accepted for publication September 24,
1991. From the Section of General Pediatrics and Adolescent Medicine, Department of Pediatrics, The Medical College of Georgia, Au-
gusta.
MD
high injury rates also occur among track and field, base¬ ball, basketball, gymnastics, wrestling, and field hockey participants.1,4"6 Methodologie differences in study design
make intersport comparisons of injury rates difficult. It has been difficult to accurately predict which athletes are at risk of injury from sports participation because of vari¬ ations in the definition of athletic injuries, the training of the individual diagnosing and recording injuries, the methods of injury detection, how the injury rates are cal¬ culated, the time frames of the studies, and the popula¬ tions studied. Several investigators have proposed that the purpose of the preparticipation athletic examination (PAE) is to iden¬ tify athletes who are at risk of injury, illness, or death from sports participation.712 However, evidence that abnormal findings on the PAE predict an increased risk of athletic injury is inconsistent.13"25 Most studies have reported that increased joint flexibility, ligamentous laxity, and previ¬ ous injuries were associated with increased sprains, dis¬ locations, and reinjuries.15'25 Unfortunately, many of these studies were poorly designed and/or controlled, had low statistical power because of small sample sizes, or did not use appropriate statistical tests. In a well-controlled study, Lysens et al26 conducted extensive physical examinations and psychological and behavioral tests on 185 college freshman physical education students in Belgium and monitored injuries for a period of 1 year. Although they found that several physical and psychological character¬ istics were associated with injuries, they pointed out that their sample was a self-selected population who were not likely to have experienced previous injuries that would have inhibited their participation in a highly demanding physical education program. Because their PAE protocol
are
causes
Presented at the Southern Society for Pediatric Research, New Orleans, La, January 31,1991, and the Society for Adolescent Medicine, Denver, Colo, March 15, 1991.
Reprints
Injuries
Department Editors.— William B. Strong, MD, Augusta, Ga; CarlL. Stanitski, MD, Pittsburgh, Pa; Ronald E. Smith, PhD, Seattle, Wash; Jack
H. Wilmore, PhD, Austin, Tex section provides current information re¬ lated to the medical needs of young athletes, as pertinent to counseling young athletes and their parents regarding sports participation and practices contributing to the health maintenance of the athlete, as well as current concepts in the prevention, diagnosis, and treatment of sports-related illnesses and injuries.
Purpose.—This
not available.
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hip to 90° and held there by the athlete's hand. The leg was then extended slowly as far as possible without moving the thigh. If the leg could be extended completely, the hamstring was
Table 1.—Athletes Participating and Injured in Each Sport Stratified by Gender No. (%)
No. (%)
of
Participants -·Sport
Females (N=470) (N = 204)
of Injuries
Males
Males
P*
Football
300 (63.8)
Basketball Baseball/ softballt
132(28.1) % (47.1)
20(15.2) 32(33.3) .0004
108 (22.9)
21 (19.4)
9 (9.1)
10 (17.2)
0
2(10.0) 11(10.7) 2(7.7)
2(7.7) 9(15.8)
Soccer
58 (12.3)
Tennis 20(4.3) Track and field 103(21.9) Golf 26(5.5) 0 Cheerleading Rifle
1 (0.2)
109 (36.3)
Females
0
99 (48.5) 0
26(12.7) 57(27.9) 4(1.9) 15 (7.4) 0
0
were
0
0
1
0
0
.05
considered normal. Spine.—First, the athlete was examined for scoliosis, kyphosis, or increased lumbar lordosis. Next, the athlete was placed in a sitting position with the knees flexed between 60° and 90°. The athlete was then asked to bend forward as far as possible, put¬ ting his or her head between the legs. Flexibility was then recorded as normal, tight, or very tight. Knees.—Each knee was examined for alignment, effusion, active and passive range of motion, ligament integrity, and ro¬ tatory stability. A meniscus test was then done and specific joints
NS
NS NS
(6.6)
.
.
.
"Kruskal-Wallis analysis of variance. NS indicates no statistical sig¬ nificance. tBaseball and softball are played by only males and females,
respectively.
far more comprehensive than is presently used in scholastic athletic programs in the United States, the gen¬ eral applicability of the findings is limited. Although these studies suggest that a standardized PAE might be able to detect adolescent athletes at increased risk of sports-related injuries, no prior research has specifically addressed this detail. In three previous studies, we have described and evaluated the PAE program in our public school system.7"10 The purposes of this study were to test whether findings from the PAE were predictive of athletic injuries and to examine other factors associated with ath¬ letic injuries among high school students during the 19891990 academic year. was
SUBJECTS AND METHODS PAE
The study protocol was approved by the Medical College of Georgia's Human Assurance Committee and the Athletic De¬ partment of the Richmond County Board of Education. All 1204 public high school students in Richmond County, Georgia, who planned to participate in interscholastic sports during the 19891990 academic year were required to undergo a physical exam¬ ination at the beginning of the sports season. Students could choose between an examination by a physician of their choice or a station examination provided by volunteer physicians, den¬ tists, and physical therapists from the local community. How¬ ever, all PAEs were recorded on the standardized Preparticipa¬ tion History and Physical Examination Form previously recommended by the American Academy of Pediatrics' Com¬ mittee on Practice and Ambulatory Medicine.8-9'27 We did not record who performed the examination on each athlete. The station examination was performed in the outpatient department of a community hospital. On scheduled evenings, groups of 50 to 100 students were evaluated. At the first station, the health history was reviewed with the student; the height, weight, pulse rate, and blood pressure were mea¬ sured; and vision screening was completed. The students then circulated through seven other examination stations. The content of all components of the station examination has been previously described.8·28 Briefly, the following procedures were used when examining each joint and muscle group. Hamstrings. —The athlete was placed in a supine position on the examining table. The leg being tested was then flexed at the
palpated.
Ankles. —Ankles were tested for heel cord tightness, range of motion, muscle strength in plantar flexion, dorsiflexion, inver¬ sion, eversión, and lateral and medial stability. Shoulders.—The shoulders were examined for range of mo¬ tion, joint stability, and muscle strength in flexion, extension, abduction, and internal rotation. The history and physical examination results were then re¬ viewed by one physician, and a recommendation was made con¬ cerning athletic participation. The students were either cleared for athletic participation without reservation, recommended not to participate after discussion with them and their coaches and/or parent(s), or cleared contingent on further evaluation, treatment, or conditioning. At the time of the examination, no examiner was aware of the purpose of the study.
Survey Design design
used in this study has been previously described.29 The standardized PAE form includes parental consent, biographical data, and home addresses and tele¬ phone numbers. In April 1990, letters were sent to the par¬ ents of all athletes explaining the purpose of the study. Using the telephone numbers provided by the students on the PAE forms, we attempted to contact by telephone all students who participated in interscholastic athletics during the academic year. All telephone contacts were made between 5 and 9 PM and were conducted during April and May 1990. Only 242 adolescents were at home during the period that the tele¬ phone calls were made. No parents or adolescents refused to be interviewed. In May 1990, all adolescents (n 962) not interviewed by telephone were mailed an identical question¬ naire with a stamped, self-addressed return envelope. Four hundred thirty-two adolescents returned the questionnaire, resulting in 674 (56%) completing either the maUed question¬ naire or the telephone interview. There were no differences between the interviews conducted by telephone and the mailed questionnaires in any variables measured. The survey
=
Subjects The subjects ranged in age from 13 to 20 years (mean±SD, 16.1±1.2 years). The sample consisted of 470 (69.7%) males, 408 (60.5%) blacks, and 243 (36.1%) whites, and was slightly skewed toward the 9th grade (36.6%), with fewer 12th grad¬ ers (14.5%). The demographic data of the sample of 674 did not differ from those of the 530 adolescents receiving PAEs who were not interviewed.
Questionnaire The questionnaire was designed to measure athletic injuries and attrition from scholastic sports.29 The questionnaire was first pretested on a small group of male and female adolescents, and revisions were made in the wording of ambiguous items. The questionnaire obtained information about demographic vari¬ ables, the sport for which the initial PAE was conducted (Table 1), attrition from any sport, and the reasons for attrition, and whether an injury was sustained during participation in schoolsponsored sports that either required them to seek medical care from a physician and/or caused them to miss one or more games.
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Table 2. —Injuries
Occurring Among Athletes Participating in
Male- and
No. of Athletic
Female-Specific Sports
Injuries
Males
Females
Mean ± SD
Mean Rank
0.50 ±0.68 0.24 ±0.75
251.82 197.20
0.32 ±0.84 0.44 ±0.66
210 .47 246 .40 J
.0083
0.44±0.76 0.16±0.44
111.28 92.64
.002
0.55 + 0.75 0.36 ±0.71
256.93 224.69
.008
0.34 ±0.64 0.25 ±0.62
105.29 97.93
.021
Mean ± SD
Mean Rank
Football Yes No
Basketball Yes No
.0001
|
Baseball/softball Yes No
*Kruskal-Wallis
Table
analysis
of variance.
3.—Self-reported Athletic Injuries to Specific Areas of the Body No. (%) of
Location Neck
Back Knee
Ankle Foot
Leg,
Injuries*
12(1.8) 7(1.0) 13 (1.9) 61 (9.1) 54 (8.0) 7(1.0) 27 (4.0) 22 (3.3) 5 (0.7) 11 (1.6) 26 (3.9) 3 (0.4) 2 (0.3) 3 (0.4)
Head
other than above
Shoulder Elbow Wrist
Arm, other than above
Kidney* Ribst Heartt Total
253
'Percentages based on tRepresents those who responded
674 athletes. to mailed
questionnaires.
This definition of injury is more conservative than has been used in either population-based studies5 or prospective stud¬ ies,4-6'25'26 and was chosen because adolescents are not likely to accurately recall injuries that are not significant enough to require medical care or missing a game.30 Athletes recorded the number of injuries sustained, the sport in which the injury(or injuries) occurred, and the part or area of the body injured. Because of a lack of knowledge of anatomy or ath¬ letic injuries, the adolescents were not asked to provide the medical diagnosis of their injury.
Statistical
Analysis
For the purpose of this study, the outcome variables were as follows: experiencing an athletic injury, area of the body injured, and the total number of injuries sustained by each athlete. As¬ sociations among categorical variables were analyzed with 2 tests and the strengths of the associations were determined with coefficients. Significant relationships between findings from the health history or physical examination and athletic injuries were then assessed for sensitivity, specificity, and positive and negative predictive value. Because of deviations from normality in the distribution of the number of athletic injuries by each athlete, this variable was analyzed with Kruskal-Wallis analysis of variance.
experienced
RESULTS
Among male athletes, a greater proportion of football players (36.3% ) were injured than other athletes, followed in order by basketball, baseball, and soccer players (Table 1). The percentage of female basketball players (33.3%) experiencing athletic injuries was approximately the same as that of male football players (36.3%). A higher per¬ centage of female than male athletes were injured partic¬ ipating in basketball (P=s.0004) and track and field (P>.05), and a higher percentage of male baseball players than female softball players (P=s.05) were injured (Table 1). No significant ethnic or age differences were found in injury rates within each sport. Injury rates did not vary by school. None of the schools employed certified trainers,
and information was not collected on variations among coaches in training techniques. Male adolescents experienced a significantly greater mean number of injuries (mean±SD, 0.41±0.72) than fe¬ males (mean±SD, 0.29±0.63) (Pss.011). The mean num¬ ber of injuries sustained by football and baseball players was significantly greater than for other male athletes (Table 2). In contrast, male basketball players experienced a significantly lower mean number of injuries than other male athletes. Among female athletes, basketball and softball players sustained a greater mean number of inju¬ ries than other female athletes (Table 2). The knee was the most frequently injured body part, followed in order by injuries to the ankle, leg, arm, and shoulder (Table 3). When injuries to specific areas of the body were examined within each sport and by gender, an increased risk of injury to the knee occurred among male football players (11.7% vs 7.0%) (Table 4). Female basket¬ ball players and male baseball players were at higher risk of ankle injuries. Male baseball players were also more likely to experience leg and arm injuries. Shoulder inju¬ ries were more likely to occur among male football, bas¬ ketball, and soccer players, and head injuries occurred more frequently among male baseball players. Among the 57 female track and field participants, 15.8% experienced a knee injury, compared with 6.8% of other female athletes (P=s.048). More of the items on the standardized health history were significantly associated with athletic injuries than findings from the physical examination. Athletes experi¬
encing dizziness, fainting, frequent headaches, or con¬ slightly more likely to report a head injury during sports participation (Table 5). Having previously
vulsions were
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Table 4.—Associations Between Athletic Injuries to Football No
Yes
No
(n = 228)
(n = 446)
Yes (n = 108)
No (n = 566)
(n = 58)
(n 616)
35(11.7)
26(7.0)
19(8.3)
42(9.4)
12(11.1)
49(8.7)
4(6.9)
57(9.3)
2(0.9)
27(9.0)
27(7.2) NS NS
Leg
No. (%)
16 (5.3)
11
(2.9)
(%)
P*
11
(3.7)
9 (3.9)
NS NS
'Controlling for males. NS indicates tP>.05 for females. tP= .017 for females only. §P>.05 for female softball.
statistical
0(0)
18
(3.2)
4
(6.9)
.012
17
(3.8)
8 (7.4)
23 (3.7)
NS NS 18 (3.2)
.0366 NS
12(1.9) NS NS
.035§ 5
21 (3.4)
(8.6) .049 NS
significance.
a knee injury or having undergone knee surgery was significantly associated with knee injuries during the subsequent sports season. Similarly, previous ankle injuries and previous injury requiring treatment by a physician were associated with ankle injuries during sports participation. Athletes who had previously broken a bone were more likely to injure a leg or arm during the sports season. Shoulder injuries were significantly associated with other serious joint injuries in the past. However, based on coefficients, the strength of each of these statistically significant relationships was weak (Table 5). When the sensitivities and positive predictive values of these relationships were analyzed, the informa¬ tion contained in the health history was insufficient for the physician to predict those athletes who would be injured (Table 6). Athletes who had previously broken a bone or had experienced other injuries requiring treat¬ ment by a physician had a significantly greater mean number of injuries than other athletes (Table 7). Adolescents with either abnormal knee or ankle find¬ ings during the physical examination were more likely to experience an athletic injury to the knee or ankle, respec¬ tively (Table 8). However, when gender was controlled, these relationships were only significant for male athletes and the relationships were weak. The sensitivities were also low for these relationships. The positive predictive value of the ankle component of the PAE was higher than
experienced
(8.3)
NS NS no
5(0.9)
.012§ 9
51(8.3) NS NS
.0003
NS NS 15 (4.0)
3(5.2)
.0003
15 (3.4)
16(2.6) .002 .007
36(6.4)
7(6.5)
=
6(10.3)
.0002§ 9(2.0)
12 (5.3)
20(3.5)
18(16.7)
NS NS
NS NS
P*
29(6.5)
No
NS NS
NS NS
3(1.3)
NS NS
P*
2(1.9)
.044 NS
6(1.6)
6(2.0)
20(4.5)
25(11.0)
Yes
NS NS
.024 .011t
.0008 .009
P*
Arm No.
NS NS
4(1.1)
18(6.0)
P*
Head No. (%)
Soccer
(n = 374)
.034 .006
Ankle injury No. (%)
Baseball
Basketball
Yes
P*
Shoulder injury No. (%)
=
(n 300) =
Knee injury No. (%)
Specific Areas of the Body and Sport Played by the Athlete (N 674)
that of the knee examination. This was partly due to there four males found to have abnormal ankles, three of whom were later injured. In comparison, 15 males were diagnosed as having abnormal knees, five of whom were later injured. No other variable had an effect on the relationships between findings on the PAE and athletic injuries.
being only
COMMENT The identification of risk factors for athletic injuries among adolescents has been difficult, partly due to the lack of a uniform definition of reportable injuries.31 Some investigators have classified injuries by severity while others categorize injuries by class or time lost from participation.617 For example, Prager et al6 defined injury as an event causing an inability of the player to return to practice or the field of play for 48 hours. McLain and Rey¬ nolds4 and Lanese et al32 defined injury as any traumatic medical problem due to sports participation that results in a loss of time from practice or competition. However, they compute the number of days lost using different methods. Injury was defined by Lysens et al26 as any event causing at least a 3-day absence from sports. When applied to the same group of athletes, these definitions will result in different injury rates. Consequently, comparisons of sport-specific injury rates among different studies are problematic. We chose a conservative definition of ath-
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Table 5.—Associations Between Positive
Finding From the Health History and Self-reported Injuries to Areas of the Body Findings From the
Location of
Injury During Sports Season
the
Head
Item/Area
No, No. (%)
1 (6.3) 15 (93.8)
11 (1.7) 636 (98.3)
2 (13.2) 13 (86.7)
10 I(1.5) 1 638 (98.5) 1
History Coefficient
Concussion
Yes No
Head Yes No
Dizziness, fainting, frequent
Neck Yes
Neck
headaches,
or
convulsions
injury
0(0) 1 (100.0)
No Knee Yes No
Knee
Knee Yes No
Knee surgery
Ankle Yes No
Ankle
Ankle Yes No
Injuries requiring treatment
Leg,
Broken bones
injury
Shoulder Yes No
Other serious
Arm Yes
Broken bones
joint injuries
6.—Sensitivity, Specificity, and
Positive and
.02
.13
.01
.0001
.22
56 (8.6) 598 (91.4) J
.026
.11
8 (16.7) 40 (83.3)
45 (7.3) 569 (92.7)
.022
.09
11 (15.7) 59 (84.3)
550 (92.9)
.012
.10
9 (7.2) 116 (92.8)
16 (3.0) 521 (97.0)
.026
.09
2 (20.0) 8 (80.0)
20 (3.1) 632 (96.9)
.003
.12
15(2.8) 1 522 (97.2) J
.017
.09
/
44(7.2) 570 (92.8)
J
\
42(7.1)
9 (7.2) 116 (92.8)
No
.05
NS
3 (37.5) 5 (62.9)
injury
NS
7(1.1) 1 648 (98.9)
15 (30.6) 34 (69.4)
by a physician
other Yes No
Table
Yes, No. (%)
Health
\J
Negative Predictive Values for the Associations History and Athletic Injury
From the Health
Between
Findings
Predictive Value, %
History
Injury
Sensitivity,
%
Specificity, %
Positive
Negative
97.7
6.3
98.3
98.0
13.3
98.5
0.0
98.9
Concussion
Head
Dizziness, fainting
Head
injury Knee injury Ankle injury
Neck Knee
25.4
99.8 94.4
15.1
93.4
30.6 16.7
92.8
Ankle
Knee surgery
Knee
5.1
99.2
37.5
91.4
20.8 36.7
90.3
15.7
92.9
82.5 98.8
14.4
94.2
20.0
96.9
Neck
Injury requiring
treatment
by physician a
Ankle
Broken bone
Leg or arm
Joint injury
Shoulder
letic injury to maximize the internal validity of the study. Because we were relying on adolescents' self report, we were only interested in the injuries that were traumatic enough to require the athlete to seek medical care from a physician and/or caused the athlete to miss one or more games. We assumed that adolescents would be likely to accurately recall injuries of this degree of severity. In agreement with previous studies,1-4"6 we found that football players were more likely to be injured (36.3%)
8.3 16.7 0.0
9.1
92.7
than athletes in any other sports, but the proportion in¬ jured was lower than has been previously reported. McLain and Reynolds4 reported that 61% of the 179 foot¬ ball players in a Maywood, 111, high school were injured during a single sports season. In an investigation of foot¬ ball injuries from 1982 to 1985, Prager et al6 found that the proportions of athletes injured were 45.3%, 60.7%, 35.9%, and 27.0%, respectively. Powell33 estimated that among the 1 million athletes participating in interscholastic foot-
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ball, 28% had mild injuries, 5.9% had moderate injuries,
and 3.3% had major injuries. Football injury rates in other studies vary considerably based on the definition of injury.15"17 Our more conservative definition of injury may account for these differences. It also may be that our larger sample of football players (within one sports season) from a greater number of high schools provides a more accu¬ rate estimate of football injuries. When compared with data reported in a study by McLain and Reynolds,4 our athletes also had a lower rate of injuries in boys' basketball (37% vs 15.2%), girls' softball (13% vs 9.1%), and girls' track (18% vs 15.8%). How¬ ever, we found slightly higher injury proportions in girls' basketball (33.3% vs 31%), boys' baseball (19.4% vs 15%), boys' soccer (17.2% vs 13%), boys' and girls' tennis (10.0% vs 0% and 7.7% vs 3%, respectively), and boys' golf (7.7% vs 0.0%). As was reported earlier for football injuries, in¬ jury rates reported in other studies vary substantially by
injury definition, making comparisons difficult.415'34,35 Nicholas14 and Godshall13 have reported contradictory
orthopedic findings on the predictive of athletic in¬ preparticipation jury in high school students. Neither study, however, was well controlled and neither study included appropri¬ ate statistical analysis of the data. Lysens et al25 reported data
as
to whether abnormal
examination
Table
are
7.—Injuries Associated With Findings Health From the
History
No. of Athletic
Finding from the health history Injuries requiring treatment by a physician Yes No
Broken bones Yes No *Kruskal-Wallis
analysis
Injuries
Mean ± SD
Mean Rank
.
...
365.44 1 322.53 J
.025
0.54 ±0.93 0.32 ±0.62
368.75 317.31
.0006
of variance.
Table 8.—Associations Between
Physical
Examination
Knee injury Yes No
Total
only
injury
Total
5 (29.4) 12 (70.6) 17
.0032
4 (26.7) 11 (73.3) 15
Ankle injury Yes No Total
452 50
.
Males only ankle Yes No Total
(7.5)
injury
Sensitivity, %
Specificity, %
Positive
Negative
.12
8.2
98.0
29.4
91.4
.049
.11
9.5
97.4
27.7
91.6
.001
.20
7.4
99.7
66.7
92.5
.001
.22
7.7
99.8
75.0
92.2
No. (%)
(66.7) (33.3)
663
4 2 6
36 (7.8) 427 (92.2) 463
3 (75.0) 1 (25.0) 4
613 (92.5)
Injuries Predictive Value, %
56 (8.6) 596(91.4)
38 (8.4) 414(91.6)
Examination and Athletic
Findings
Abnormal,
652
knee
Findings From the Physical
Normal, No. (%)
Males Yes No
physical
P*
0.58 ±1.12 0.34±0.62
J
that muscle tightness found during the preparticipation examination was not associated with muscle strains. However, increased joint flexibility and ligamentous lax¬ ity were associated with increased sprains and disloca¬ tions. The finding by Lysens et al25 confirms previous ob¬ servations by Ekstrand and Gillquist,18 Grana and Moretz,20 and Kirby et al.21 Lysens et al25 also reported that abnormalities in feet configuration found during the preparticipation examination were associated with shin splints, chondromalacia patellae, Achilles tendon prob¬ lems, and plantar fascitis during athletic competition. In contrast, we found that only two items on the physical examination component of the PAE were associated with athletic injuries and that the association applied only to male athletes. Male athletes with either abnormal knee or ankle findings on the PAE were more likely to injure the knee or ankle, respectively. However, these associations were weak, and the sensitivity and positive predictive values were low, indicating that the utility of the physical examination to predict these injuries was limited. We found that more of the items on the health history portion of the PAE were predictive of athletic injuries than were findings from the physical examination. Consider¬ ing that the most frequently injured body areas were the knee, ankle, leg, arm, and shoulder, the fact that each of these injuries was associated with findings on the health history is helpful. Specifically, previous injuries or having undergone surgery on a particular body area were asso¬ ciated with injuries during the subsequent sports season. examination However, as was found with the portion of the PAE, the associations between findings from the health history and actual injuries were weak and the sensitivities and positive predictive values were low. Previous studies also support the finding that athletes who report previous injuries are at higher risk of reinjury during athletic competition.13"17'22"25 Data from the US Mil¬ itary Academy, West Point, NY, suggest that the major¬ ity of leg and knee injuries are reinjuries.24 Lysens et al25 reported that sprain, dislocations, and stress injuries showed the highest probability of recurrence. From an epidemiologie viewpoint, the PAE can be
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viewed as a screening test for previously undetected risk of injury or disease. As such, it fulfills the widely accepted criteria for a screening test for large populations: specifi¬ cally, it is relatively inexpensive, rapid, and noninvasive.36 Our data indicate that the validity of the PAE in predicting risk of injury may be fairly low. As the data for this study were collected in a well-organized station examination that has been established and refined for more than 10 years,710 it seems unlikely that further refinement of our screening tool will significantly improve the sensitivity or positive predictive value for injuries. If so, the majority of injuries in high school athletes will continue to occur in young men and women who have demonstrated no ab¬ normalities during the history or physical examination portion of the PAE. This necessarily moves the focus of in¬ jury prevention in high school athletics away from the in¬ dividual athlete and to the environmental and social fac¬ tors contributing to injury risk. Factors such as the pairing of athletes for size and strength, selection of proper safety equipment, rules for fair play, and adequate preseason conditioning need to be addressed. Despite the need to broaden the scope of interest for injury prevention beyond the individual athlete, one cannot ignore the significance of a positive finding on the PAE. For example, our data suggest that almost 31% of young athletes who report a history of knee injury will in the subsequent athletic season sustain another knee
injury significant enough to cause inability to participate in at least one game or a visit to a physician. We can only speculate as to how many of those reinjuries could have been prevented by intensive physical therapy and athletic training, but we expect it would be a sizable proportion. While we recognize that the majority of athletic injuries can
only
be addressed
by
broader environmental
con¬
cerns, those athletes who demonstrate an abnormality on
the PAE form a high-risk group whose need for preven¬ tive therapy must not be ignored. In summary, our data suggest that the PAE is a useful screening tool in identifying a small group of athletes at high risk of athletic injury. However, it also has demon¬ strated the importance of looking beyond the level of the individual athlete into the broader environment in which athletic events occur to address the greater scope of ath¬
letic
injuries.
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