Preventing Injuries in Sports, Recreation, and Exercise

Public Health Burden

Participation in sports, recreation, and exercise (SRE) is increasingly popular and widespread in American culture. SRE activities include organized sports (school or club) and unorganized sports (backyard or pick-up), such as basketball, football, and hockey; recreational activities, such as boating, biking, skiing, swimming, and playground activities; and exercise and training activities, such as weight-lifting, aerobics, and jogging.

Participation in SRE activities contributes to health-related fitness; however, the risk of injury is inherent in any physical activity. Drowning is the second leading cause of injury death among children ages 1 to 14 and kills more than 4,000 Americans annually. More than 10,000 people receive treatment in the nationís emergency departments (ED) each day for injuries sustained in SRE activities. At least one of every five ED visits for an injury results from participation in sports or recreation. In 1999, Americans made an estimated 1.5 million ED visits for injuries sustained while playing basketball, baseball, softball, football, or soccer. Approximately 715,000 sports and recreation injuries occur each year in school settings alone. Injuries are also a leading reason people stop participating in potentially beneficial physical activity.

Risk of injury varies by many factors, including specific activity and participant age. Children younger than 15 account for 25% of all drownings and about 40% of all SRE-related ED visits. They may be at risk because of immature or undeveloped coordination, skills, and perception. Adolescents and young adults under age 25 have high participation rates in SRE activities and experience almost one third of all SRE-related injuries. The population of older adults is increasing, and little is known about their injury risk during participation in SRE. In 1996, EDs treated more than 53,000 SRE_related injuries among people 65 and older, a 54% increase from 1990.

Few data exist about injury incidence and prevalence, costs, relative risks of injury from different activities, risk and protective factors, and effective programs to prevent SRE injuries. While some ED surveillance data are available, they lack exposure information and exclude the large proportion of SRE injuries that are treated in primary care settings, sports medicine clinics, orthopedic clinics, and chiropractic clinics.

The Injury Centerís Niche in Sports, Recreation, and Exercise Safety

CDCís mission includes both promoting physical activity and preventing injuries. While another center at CDC has an active research program in physical activity, the Injury Center includes a focus on sports, recreation, and exercise injury prevention. Although the scope and depth of this research has been limited, the Injury Center is uniquely positioned to provide epidemiologic and prevention research about SRE-related injuries. Few other federal agencies or national organizations consistently fund broad-based research into SRE injuries. Examples of federal agencies with interest in SRE include the National Institutes of Health (NIH), the U.S. Coast Guard, and the U.S. Consumer Product Safety Commission (CPSC). NIH supports some foundational research in SRE-related trauma and injury prevention and the Coast Guard supports boating safety programs and some surveillance. CPSC provides excellent ED surveillance; however, its information does not include data about participation rates (exposure data) that could facilitate comparisons. CPSC traditionally focused on product-based research to protect consumers from hazardous products; with Injury Center funding, CPSC recently expanded its ED surveillance to include all injuries treated in the ED, regardless of cause.

Working with other agencies, nonprofit organizations, and professional organizations, the Injury Center can provide complementary research to facilitate safe sporting environments and identify risk and protective behaviors. The Injury Center has convened two working groups related to surveillance and research methodologies in SRE, and it continues to play a coordinating role in the field. Through its connections with organizations such as the National Collegiate Athletic Association, National Athletic Trainers Association, and the American Academy of Orthopaedic Surgeons, the Injury Center can foster collaborations to leverage maximum benefit from scarce funding for SRE injury prevention research. Other important and appropriate activities include developing new surveillance methods to capture exposure data; providing linkages to medical care, emergency department, and other public healthĖoriented data bases; and developing and effectively disseminating science-based interventions.

The Injury Centerís Research Priorities in Sports, Recreation, and Exercise

Every research priority in this agenda is important. After considering input from experts in the field, Injury Center staff identified the four most important priorities, those that warrant the greatest attention and intramural and extramural resources from the Injury Center over the next three to five years. They are designated with asterisks.


A.* Evaluate strategies to increase dissemination and use of effective interventions to prevent SRE injuries.

Effective interventions exist to prevent SRE injuries, but they frequently are not used. Examples include bike helmets and other protective equipment, break-away bases, impact-reducing playground surfacing, and isolation pool fencing. Research should assess factors that hinder and encourage individualsí and organizationsí adoption of these effective interventions, including sociocultural and environmental influences, organizational leadership and infrastructure, community engagement, and coalition building. Studies should also assess different methods to increase awareness of effective interventions, tailor programs to local circumstances, and maintain fidelity to intervention guidelines. CDCís strength in program implementation, evaluation, and health communication makes research in this area a natural opportunity, and advances will be broadly applicable to other health promotion areas. Research would benefit current interventions and programs in drowning prevention, playground safety, bicycle safety, and any SRE activity with efficacious interventions.

B.* Evaluate environmental, behavioral, and legislative or regulatory interventions to prevent SRE injuries.

Many promising interventions exist but have not been evaluated. These include modifications of physical play environments, use of current and newly designed safety gear, and gender- and age-specific equipment requirements. The importance of the presence and training of coaches and certified athletic trainers should be examined, as should be the roles of parents and physicians in preventing injury in organized sports. Finally, research is needed to assess the effects of policies and practices about the use of safety gear, practice guidelines and rules of play, and informed officiating. Tools to evaluate interventions in these areas may include impact biomechanics and epidemiologic research.

C.* Evaluate existing and develop new methods to obtain exposure and injury incidence data for SRE.

Recent reports estimate that approximately 3.7 million ED visits occur each year for injuries related to participation in sports and recreation. However, without reliable methods for estimating frequency and duration of participation in these physical activities (i.e., exposure data to calculate denominators), researchers cannot determine injury rates and compare them across activities. Population-based SRE injury information may be obtainable from a variety of sources. Several population-based participation surveys exist and, if validated, may serve as sources of denominator data for such studies. Accurate estimates of numbers of injuries combined with injury rates will enable researchers to examine risk and protective factors and explore prevention strategies. These findings will facilitate more effective, programmatic decision making.

D.* Determine the short-term economic costs of injuries related to SRE.

SRE injuries are not a major source of mortality, but they do place a large burden on the health care system for both initial care and rehabilitation. They also result in costs related to lost productivity and other factors. Despite the large number of ED visits for these injuries, most medically treated SRE-related injuries are treated by health care providers outside of the emergency setting, indicating that the magnitude of the problem is much greater than ED statistics suggest.

For example, in the U.S., anterior cruciate ligament (ACL) knee injuries are usually sports related, and the vast majority occur in active, healthy 15- to 24-year-olds. ACL rupture can be debilitating in the short term, preventing continued physical activity. The cost of ACL reconstruction alone, not including initial evaluation or rehabilitation, is just under $1 billion per year in the U.S. Data from other countries also suggest that the cost of other SRE-related injuries is quite high. Quantifying health care and other economic costs to society of SRE-related injuries and delineating the sources of those costs will provide an important foundation for documenting the public health burden of these injuries.

E. Identify risk and protective factors and evaluate interventions for injuries related to open-water recreation.

Submersion injuries and drownings in lakes, canals, rivers, and oceans are a growing problem, accounting for one quarter to one third of all drownings (or 1,200 drownings in 1998). While open-water drowning fatalities represent only about 12% of drownings among children ages 14 and younger, they account for more than 30% of drownings among adolescents over age 14 and among adults. Ninety-one percent of open-water drowning victims are men. Much of the problem can be attributed to unsafe boating. In fact, in 1999, 734 people died and another 4,300 required medical care as a result of boating activities.

To design effective interventions, it is necessary to identify modifiable risk factors. Research is needed to assess the role of cultural factors responsible for ethnic and gender disparities in drowning rates; the role of alcohol in drownings and in boating-related injuries and deaths; the importance of swimming ability, supervision, and lifeguarding services; and the contribution of drowning prevention skills in preventing open-water submersions in various environments.

Although many safe boating programs, policies, and recommendations are in effect, few have been rigorously evaluated. Research about the components of safe boating should investigate the efficacy and effectiveness of boating safety education courses, personal flotation devices (PFD), and various laws and policies aimed at improving boating safety. To further reduce the number of boating-related injuries, the effectiveness of these and other interventions as they relate to size and type of boat, water environment type, and operator characteristics must be improved. CDC can supplement the Coast Guardís injury surveillance and educational efforts by evaluating promising interventions and programs.

F. Evaluate residential pool safety measures for children.

About 4,000 Americans drown each year; approximately 1,000 are children under age 15. A majority of child drownings occur in residential, backyard pools. While some drowning prevention interventions have been evaluated, further delineation and evaluation of their risks and benefits is necessary. Interventions to be evaluated may include those that address either physical/environmental factors such as pool alarms, pool covers, and door alarms or behavioral factors such as PFD use, CPR training, supervision, and swimming lessons.

G. Identify ways to minimize injury risk among people initiating or increasing physical activity.

Many factors influence recommendations for starting and increasing physical activity, including age, gender, fitness level, nutritional status, anthropometry, and injury history. Research should identify strategies to improve physical fitness of participants at all fitness levels while minimizing the risk of injury. Knowledge about differences in human tolerance by age, fitness level, and gender is an important prerequisite for prevention, as is knowledge about the biomechanics and injury tolerances of tissue, bone, and other human structures. Ideally, researchers should develop science-based guidelines for choosing an activity and recommend the frequency, intensity, and duration of participation given a prospective participantís current fitness level and past injuries. Research should also evaluate personal protective devices and training programs. Special populations, including children, older adults, women, and people who are obese or undernourished, should receive particular attention.

H. Identify risk and protective factors for and evaluate interventions to prevent injuries from outdoor recreation.

Little is known about the risk factors for, and prevention of, injuries in common outdoor recreational activities, such as riding personal watercraft, snowmobiles, and all-terrain vehicles; hiking and climbing; skiing; and participating in equestrian activities. Approximately 73,000 ED visits annually are related to participation in equestrian activities alone, and many thousands of people are injured each year while using personal recreational vehicles. Other injuries from outdoor recreation result from recreational fires, avalanches, and insect, snake, and other animal bites. Studies should address education, protective equipment, vehicle design, the role of alcohol, and posted warnings as well as promising public policy and legislative interventions.

I. Evaluate the effectiveness of interventions to improve bicycling safety.

Approximately 81 million people ride bicycles, and each year, more than 600,000 visit the ED for bicycle-related injuries. Many of these injuries occur in traffic. Research should examine the traffic interaction of bicycles and motor vehicles to identify ways to improve road sharing and increase safety for bicyclists. It should evaluate safety training, bike skills classes, and bike maintenance as components of bicycle safety programs. Additionally, biomechanics research can contribute to improved bike and helmet design.

J. Evaluate how injuries are affected by changing the physical environment to increase physical activity while promoting and preserving safety.

A 1994 survey reported that 20% of adults (38 million) rode bicycles outdoors and 73% (138 million) walked for exercise in the 30 days before the survey. During this time period, 1% to 1.5% reported that they had been injured while doing these activities. As efforts increase to promote walking and bicycling for improved health and for transportation, the potential for injury may also increase. Research is needed to assess the health and safety effects of environmental changes designed to increase physical activity in a community, such as community exercise facilities, sidewalks and bike trails, bike lanes, pedestrian malls, sports parks, and skate parks. It is important to study the effects of these dedicated spaces on injury rates, use rates, and exercising behavior to help identify and promote safe environments for physical activity.

K. Quantify the injury risks of physical activity among older Americans.

In 1996, people ages 65 and older made 53,000 sports-related ED visits. This represented an increase of 54% since 1990, while the population grew by only 8% in the same time period. As Americans live longer, they will likely remain active longer, increasing the need for effective injury prevention strategies for active older adults. Additionally, research suggests that exercise is important for older Americans to maintain physical and mental health and independence. Research in this area should focus on understanding the risks of various SRE activities in this population and, where possible, examine risk in the context of research about the benefits of these activities.

L. Determine the effect of playground design on injury patterns.

Approximately 200,000 children each year visit EDs for playground-related injuries. Injury prevention efforts should focus on identifying environmental and supervisory modifications. Research should begin by studying the components of the problem: developmental and other characteristics of children, physical aspects of indoor and outdoor equipment and play spaces, and the balance between safety and the level of challenge the equipment poses. Effective prevention strategies will address each component, as well as the relationships among them. Research may also help define the role of supervision in various settings.

About 60% to 80% of playground-related injuries involve falls. Research should include testing of indoor and outdoor playground surfaces to determine which ones protect children from injury and which ones increase the likelihood of injury. Researchers should study childrenís behavior, human tolerances or impact biomechanics, and ideal surface characteristics.

Research should also address how best to combine injury prevention and requirements of the Americans with Disabilities Act (ADA). ADA requirements are intended to ensure that children with disabilities have equal access to appropriate play spaces. However, common playground surfaces that lessen injury-producing forces may hamper the mobility of children with disabilities, and pathways that allow easy access are frequently tripping hazards. Research should identify materials and mechanisms that will accomplish both safety and accessibility needs.




This page last reviewed September 07, 2006.

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