Community-level football injury epidemiology: traumatic injuries treated at Swedish emergency medical facilities

Community-level football injury epidemiology: traumatic injuries treated at Swedish emergency... Abstract Background Despite the popularity of the sport, few studies have investigated community-level football injury patterns. This study examines football injuries treated at emergency medical facilities using data from three Swedish counties. Methods An open-cohort design was used based on residents aged 0–59 years in three Swedish counties (pop. 645 520). Data were collected from emergency medical facilities in the study counties between 1 January 2007 and 31 December 2010. Injury frequencies and proportions for age groups stratified by sex were calculated with 95% confidence intervals (95% CIs) and displayed per diagnostic group and body location. Results Each year, more than 1/200 person aged 0–59 years sustained at least one injury during football play that required emergency medical care. The highest injury incidence was observed among adolescent boys [2009 injuries per 100 000 population years (95% CI 1914–2108)] and adolescent girls [1413 injuries per 100 000 population years (95% CI 1333–1498)]. For female adolescents and adults, knee joint/ligament injury was the outstanding injury type (20% in ages 13–17 years and 34% in ages 18–29 years). For children aged 7–12 years, more than half of the treated injuries involved the upper extremity; fractures constituted about one-third of these injuries. Conclusions One of every 200 residents aged 0–59 years in typical Swedish counties each year sustained a traumatic football injury that required treatment in emergency healthcare. Further research on community-level patterns of overuse syndromes sustained by participation in football play is warranted. Introduction Football (soccer) is the most popular sport in the world. According to the 2006 FIFA Big Count, 265 million people are involved in football world-wide, the majority (>85%) being unregistered players.1 In Sweden, football and other sports are an important part of daily life, both in organized leagues and as recreational activities. The Swedish Sports Confederation (RF) estimates that about a third of the population participate in organized sports.2 Only a small proportion compete at the professional stage; the clear majority participate in sports activities and games organized at the community level. 3184 football clubs registered with the Swedish Football Association account for about 1 000 000 members, corresponding to more than one-tenth of the overall population.3 While a large body of research on football injuries is available, descriptive and intervention studies mainly address injuries occurring during organized games and practices.4 Furthermore, although the body of literature related to the benefits of informal football play is growing,5 few studies document football injury incidences in the general population. Understanding the aggregated impact of football injury in a community requires population based data that capture all unintentional injury cases. Previous studies in Scandinavian settings have showed that sports injuries constitute the largest category of injuries requiring medical care, and that football is the most commonly represented sport in this category.6–8 This study examines the epidemiology of community-level football injuries treated at emergency medical facilities using data from three Swedish counties. The specific aims are to describe the overall incidence of football injuries treated in emergency medical care over a 4-year study period and to analyse sex and age differences in injury proportions regarding body location and injury types. Methods This study uses an open-cohort design. The primary outcome measure is football injuries treated at emergency medical facilities. Data were collected at the study emergency rooms over a 4-year study period running from 1 January 2007 through 31 December 2010. A football injury was defined as an acute injury sustained while the injured party was engaged in football activities. Football activity was defined as organized play, play during school or work hours, or play during leisure time. The study excludes injuries occurring during transportation to or from football activities. Further, dental injuries were excluded, as this type of injury is not documented in the registry used in this study. Data collection The primary study populations consisted of residents aged 0–59 years, living in catchment areas for four hospitals in Skaraborg county (Skövde, Lidköping, Mariestad, Falköping), the three hospitals serving Värmland county (Karlstad, Arvika, Torsby) and Norrlands University Hospital in Umeå serving six of the municipalities in Västerbotten county. The total populations in these catchment areas, which averaged 645 520 residents over the study period, comprised about 7% of the total Swedish population. The data were retrieved from the Swedish subset of the Injury Data Base (IDB Sweden), which is administered by the Swedish Board of Health and Welfare.9 The data that comprise IDB Sweden reflect unintentional injuries that have been sustained in discrete events. Overuse ‘injuries’ arising from causes extended in time or inflammatory processes are not included in the database. IDB records are based on injuries sustained by community-dwelling individuals, regardless of wherever these occur; at work, at home or during leisure time activities. IDB Sweden is constructed to allow for parallel categorisation of certain types of injury events. For example, football injuries occurring in school settings can be classified as school injuries and also, as sports injuries. Data on the setting where the injury was sustained are obtained by patient self-report and includes only data from the first emergency visit and not follow-up visits. Additional data on injury circumstances are entered by clinical staff, including the time period when the patient received care for the injury. These clinical data are recorded by trained coders. Data on clinical interventions and injury consequences are also reported by the clinical staff. The quality of the data in IDB Sweden is regularly evaluated. The data collection procedures are standardized to allow detailed international comparisons. The combined number of incomplete records is controlled by relating the number of cases listed in IDB Sweden to administrative healthcare databases on randomly selected days. The proportion of incomplete records in IDB Sweden average about 10–15% annually for all emergency medical facilities combined. A free text field is included with each injury record in IDB Sweden, briefly summarizing the patients’ descriptions of injury circumstances, which was also reviewed in this study to verify that the injury cause involved football play. The study design was based on data obtained from databases established for the purpose of systematically and continuously developing and securing the quality of health services. All personal identification data had been removed from the records before analyses. According to Swedish legislation, no review by a research ethics board was required for this study. Data analysis Descriptive statistics were employed to calculate and display injury frequencies and proportions, and the associated 95% confidence intervals (95% CIs) according to the matrix representation (diagnostic group—body location) for age groups stratified by sex. To tabulate injury type (diagnostic group) and body location of injury, the matrix representation of sports injuries developed by Jacobsson et al.10 was used (Supplementary table S1). The descriptive statistical analyses were conducted using the general populations of the study area. A basis for statistical inferences at the population level was provided by computation of 95% CIs showing overlaps or not.11 The analyses of injury patterns focused primarily on injuries to people between the ages of 7–29 years using three age group categories: children (7–12), adolescents (13–17) and young adults (18–29 years of age). However, to give a complete picture of the patterns, in the initial analyses other age groups were also included. Results About 25% (n = 8096) of all sports injuries registered during the study period had been sustained during participation in football activities. Each year, more than 1 of every 200 persons aged 0–59 years sustained at least one traumatic injury during football play that required emergency healthcare. Characteristics of study subjects Adolescents and young adults accounted together for 72% of the injury episodes (table 1). The highest injury incidence was observed among adolescent boys [2009 injuries per 100 000 population years (95% CI 1914–2108 injuries)] and adolescent girls [1413 injuries per 100 000 population years (95% CI 1333–1498 injuries)]. While ∼50% more males were treated for football injuries in ages 7–17 (male/female incidence ratio (IR) 1.50, 95% CI 1.41–1.59), the ratio was noticeably higher among those aged 18–59 (IR 4.36, 95% CI 4.01–4.73) and 0–6 (IR 4.25, 95% CI 1.97–9.18). Table 1 Numbers of football injuries per 100 000 population annually requiring emergency medical healthcare in study counties (total population 645 520) between 1 January 2007 and 31 December 2010 displayed by age group and sex Age (years)  Football injuries treated in emergency medical healthcare  Males  Females  Total  n  Injuries per 100 000 and year (95% CI)  n  Injuries per 100 000 and year (95% CI)  n  Injuries per 100 000 and year (95% CI)  0–6  34  35 (25–49)  8  9 (4–18)  42  12 (8 – 18)  7–12  800  996 (928–1069)  544  698 (641–760)  1344  850 (804–897)  13–17  1792  2009 (1914–2108)  1189  1 413 (1333–1498)  2981  1720 (1657–1785)  18–29  2287  1098 (1053–1145)  564  295 (271–320)  2851  713 (687–740)  30–59  746  148 (138–159)  132  27 (23–32)  878  89 (83–95)  Total  5659  579 (564–595)  2437  263 (253–274)  8096  425 (416–435)  Age (years)  Football injuries treated in emergency medical healthcare  Males  Females  Total  n  Injuries per 100 000 and year (95% CI)  n  Injuries per 100 000 and year (95% CI)  n  Injuries per 100 000 and year (95% CI)  0–6  34  35 (25–49)  8  9 (4–18)  42  12 (8 – 18)  7–12  800  996 (928–1069)  544  698 (641–760)  1344  850 (804–897)  13–17  1792  2009 (1914–2108)  1189  1 413 (1333–1498)  2981  1720 (1657–1785)  18–29  2287  1098 (1053–1145)  564  295 (271–320)  2851  713 (687–740)  30–59  746  148 (138–159)  132  27 (23–32)  878  89 (83–95)  Total  5659  579 (564–595)  2437  263 (253–274)  8096  425 (416–435)  Football injury patterns among children For the age group 7–12 years, injuries to the upper extremity (shoulder, upper arm, wrist, hand and fingers) accounted for >50% of all recorded football injuries for both boys and girls (figure 1; Supplementary table S1). Fractures were the most common injury type for both sexes (34%), closely followed by contusions (32%). Concussions accounted for 2–3% of all football injuries in this age group. No statistically verified difference in the distribution of injuries between the sexes was observed regarding body location or type. Figure 1 View largeDownload slide Distribution of football injuries requiring emergency medical healthcare in the study counties from January 1, 2007 through December 31, 2010 displayed by injury type, affected body part, sex, and age group Figure 1 View largeDownload slide Distribution of football injuries requiring emergency medical healthcare in the study counties from January 1, 2007 through December 31, 2010 displayed by injury type, affected body part, sex, and age group Football injury patterns among adolescents For the age group 13–17 years, the injury patterns differed between the sexes (figure 1; Supplementary table S2). Larger proportions of injuries to the lower extremity in the younger age group were observed for both boys and girls, with the proportions of knee injury among girls [20.4% (95% CI 18.1–23.8)] being larger than among boys [14.5% (95% CI 12.9–16.2)]. A similar distribution was observed for ankle injury [girls 21.3% (95% CI 19.0–23.7); boys 16.3% (95% CI 14.6–18.1)]. While fractures were the most common injury type for boys (30%), the most common injury for girls was joint/ligament injury (39%) reflecting a pattern similar to the younger age group. Concussions accounted for 4–5% of all football injuries in this age group. Football injury patterns in young adults For young adults (ages 18–29 years), the distribution of injury proportions differed between the sexes (figure 1; Supplementary table S3). Injuries to the lower extremity dominated among both men and women, and the sex differences in knee injury proportions was even larger with young adults [women 33.5% (95% CI 29.6–37.6); men 19.0% (95% CI 17.4–20.7)] than among adolescents. In contrast, men were diagnosed with more injuries to the shoulder and upper arm [men 8.6% (95% CI 7.8–9.8); women 4.4% (95% CI 2.9–6.5)]. Joint/ligament injuries were the most common injury type in both sexes, but the proportion of joint/ligament injuries was more common for women [47.7% (95% CI 43.5–51.9)] than for men [35.4% (95% CI 33.5–37.4)] as the leading injury type. Concussions accounted for 3–4% of all football injuries in this age group. Discussion We found that about 1 of every 200 residents aged 0–59 years residing in the study populations sustains a football injury that requires emergency healthcare each year. Recalculating these numbers to the national level (population 9.5 million at the time of the study), the annual burden of traumatic football injuries on health services in Sweden can be estimated at 29 500 cases (95% CI 28 200–30 800 cases). In female adolescents and young adults, knee joint/ligament injury was in this study found to be the predominant football injury type (20% in ages 13–17 years and 34% in ages 18–29 years). Multiple studies have documented elevated risk for knee injuries in females participating in organized football.12,13 Our results confirm that injuries to the knee in female football players comprise a serious challenge for the healthcare services in communities where football is popular, and the large proportion of knee joint/ligament injuries in females aged 18–29 years is particularly worrisome. Although an accurate initial assessment is vital for effective treatment and rehabilitation of knee injuries, the rate of correct diagnoses in routine emergency healthcare has been reported poor.14 Diagnostic delays lead to unnecessary suspension of efficient treatment and increases the risk of secondary injury to the knee. The results of this study suggest that liberal use of specific diagnostic procedures, such as magnetic resonance imaging (MRI), is warranted when female football players present to emergency rooms with knee injuries. Moreover, managers of football clubs should discuss the actions that can be taken to prevent injuries during play in this group of athletes. “Knäkontroll” (Knee Control) is a Swedish injury prevention exercise programme specifically designed for prevention of traumatic knee injuries for which the efficacy has been established in several studies.15,16 A preliminary follow-up study focusing on implementation showed a high reach and adoption of the program among girls’ football coaches17 but the preventive effectiveness on acute knee injuries remains to be evaluated. In the age group 7–12 years, more than half of the recorded injuries involved the upper extremity. It is notable that fractures constituted about one-third of these injuries. This injury pattern is concordant with the general pattern of childhood injuries; the typical and costliest injury among children is a forearm fracture.18 In Sweden, forearm fractures account for about one-third of child fractures presented at emergency departments.19 Large proportions of injuries to the upper extremity, and in particular fractures, among children have previously been reported from football activities,20,21 but have seldom been highlighted as a noteworthy problem requiring systematic response measures. Clinical guidelines specific for child football players having suffered fractures to the upper extremity are therefore missing. Regarding preventive measures, it has been established that fall-related mechanisms account for ∼80% of injuries sustained during participation in sports during childhood.22 There is therefore a need for development of fall-related injury prevention programs for young children participating in football. A school-based educational programme to improve falling skills in children based on martial arts techniques has shown promising results.23 Such programs need to be modified for seamless integration into football activities and also be adapted to children with pre-participation risk factors, e.g. high body mass index and low self-reported general health.24 The proportion of ankle injuries rose steadily with age to comprise about 20% of all injuries for both sexes in the ages 18–29 years; joint/ligament injury was here the outstanding injury type. At the initial presentation, there are many injuries that can mimic an ankle sprain. Particularly in the skeletally immature athlete, bone injuries are more likely to occur than a ligamentous injury.25 Correct diagnosis in an early stage is therefore of importance to provide effective treatment and prevents relapses. Knowledge of relevant anatomy, physical examination, and appropriate imaging can assist in diagnosing the ankle injuries. Using physiotherapy expertise already at the emergency department has been showed to manage a great deal of this type of musculoskeletal caseload safely and time efficiently.26 Like other injuries to joints, ankle injuries that reoccur can lead to joint instability.27 Regarding prevention, there is good evidence that taping, bracing and neuromuscular training are all effective for the avoidance of ankle–sprain recurrences.28 With instructions on such preventive measures and distribution of a home-based training programme to patients suffering an ankle sprain the risk of injury recurrences could be reduced substantially.29 In addition, while return to football training and play after injury poses a considerable risk of injury recurrence, this risk can be lowered by as much as 75% after the occurrence of lower extremity injuries by following a simple return-to-play protocol that could be easily distributed to patients in the emergency department.30 Concussions represented ∼3% of the football injures treated at emergency healthcare facilities observed in this study. As in any patient group, concussion among football players should be considered a clinical diagnosis made by medical practitioners familiar with the evaluation of trauma to the head.31 The assessment can be guided by a symptoms checklist, but should also contain a cognitive evaluation, balance tests and further neurological physical examination, while imaging should be reserved for situations when intracerebral bleeding is suspected.32 Regarding prevention, concussions have in football primarily been reported to be consequential to elbow/arm-to-the-head incidents and head-to-head impacts.33 This injury mechanism may be related to participation in organized football in the older age groups as opposed to school/leisure time play and younger football players. To date, there is no conclusive evidence of a preventive effect of, for instance, helmet use or strength training of the neck muscles on concussion risk.34 The design of this study is relatively unique in that the population-level burden of traumatic football injuries on healthcare seldom has been established using rigorous methods for collection and coding of clinical data, validation, and control of missing data. Meanwhile, it should be recognized that the current sports injury reporting systems suffer from conceptual issues,35 as ‘one size does not fit all’.36 The analyses in the study were limited to injuries that were attended to emergency healthcare. Data on clinically significant traumatic injuries managed by coaches, sideline team medical staff, or self-treatment were not included. Also, information on exposure to football activities was not obtained, which excludes the possibility to assess injury risk at different levels of participation in the sport. Similarly, data were not collected on overuse injuries with gradual onset that are not treated in emergency healthcare. To establish the burden on healthcare from this injury category, which has been reported to constitute 10–40% of all football injuries among children and adolescents,37 wide-spread adoption of health information systems that support use of detailed cause and location codes, such as the ICD-10-AM, are needed for case identification.38 Furthermore, descriptive study was performed for the purpose of systematically and continuously developing and securing the quality of healthcare services, and thus, no statistical testing was employed. Instead, an estimation approach was used that aimed to quantify the descriptor of interest as an estimate of a relevant quantity and to quantify the uncertainty in this estimate by means of a CI. The CIs obtained provide the ranges of uncertainty due to the sampling variation to indicate the precision of the sample study results as estimates of the population values, and thus to allow for corresponding inferences about the population values to be made. In summary, football is the most popular physical activity game world-wide, and its popularity both as sport and as recreational activity is steadily growing in both genders. In addition to primary prevention programs, health service providers need to develop clinical guidelines for diagnosing players presenting with knee injuries and management of children having suffered injuries to the upper extremity. Further research on community-level patterns of overuse syndromes sustained during football participation is also warranted. Supplementary data Supplementary data are available at EURPUB online. Funding This research was supported by grant P2013-0153 from the Swedish Centre for Sports Research (CIF). Conflicts of interest: None declared. Key points This study, based on the residents in three Swedish counties (pop. 645 520), set out to examine the epidemiology of community-level football injuries treated in emergency medical healthcare during a 4-year period. Each year, about 1 in every 200 persons aged 0–59 years sustained at least one injury during football play that required emergency medical care with the highest injury incidences among adolescent boys and girls. In female adolescents and adults, knee joint/ligament injury was the outstanding injury type, while for children aged 7–12 years, more than half of the treated injuries involved the upper extremity; fractures constituted about one-third of these injuries. References 1 FIFA. Big Count 2006: Statistical Summary Report, FIFA. Communications Division, 2007. Available at: Http://www.fifa.com/mm/document/fifafacts/bcoffsurv/bigcount.summaryreport_7022.pdf (08 April 2016 date last accessed, from http://www.sciepub.com/reference/42441) 2 Riksidrottsförbundet. Idrotten i siffror. Stockholm: Riksidrottsförbundet. 2013. Available at: Http://www.rf.se/ImageVaultFiles/id_48735/cf_394/2013_-_Idrotten_i_siffror_-_RF.PDF (08 April 2016 date last accessed). 3 Fogis, the footbalĺs common information system. 2015. (Available at: http://fogis.se/om-svff/ 3 June 2016, date last accessed). 4 Bizzini M, Dvorak J. FIFA 11: an effective programme to prevent football injuries in various player groups worldwide—a narrative review. Br J Sports Med  2015; 49: 577– 9. Google Scholar CrossRef Search ADS PubMed  5 Blatter JS, Dvorak J. Football for health—science proves that playing football on a regular basis contributes to the improvement of public health. Scand J Med Sci Sports  2014; 24: 2– 3. Google Scholar CrossRef Search ADS PubMed  6 Lindqvist KS, Timpka T, Bjurulf P. Injuries during leisure physical activity in a Swedish municipality. Scand J Public Health  1996; 24: 282– 92. 7 Ytterstad B. The Harstad injury prevention study: The epidemiology of sports injuries. An 8 year study. Br J Sports Med  1996; 30: 64– 8. Google Scholar CrossRef Search ADS PubMed  8 Timpka T, Lindqvist K. Evidence based prevention of acute injuries during physical exercise in a WHO safe community. Br J Sports Med  2001; 35: 20– 7. Google Scholar CrossRef Search ADS PubMed  9 The National Board of Health and Welfare. Skadehändelser som föranlett läkarbesök vid akutmottagning. Statistik från Socialstyrelsens Injury Database (IDB) Sverige, 2010. 2011. Stockholm. (Available at: http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/18491/2011-11-18.pdf, 8 April 2016, date last accessed). 10 Jacobsson J, Timpka T, Kowalski J, et al.   Prevalence of musculoskeletal injuries in swedish elite track and field athletes. Am J Sports Med  2011; 40: 163– 9. Google Scholar CrossRef Search ADS PubMed  11 Altman DG. Why we need confidence intervals. World J Surg  2005; 29: 554– 6. Google Scholar CrossRef Search ADS PubMed  12 Waldén M, Hägglund M, Werner J, et al.   The epidemiology of anterior cruciate ligament injury in football (soccer): a review of the literature from a gender-related perspective. Knee Surg Sports Traumatol Arthrosc  2010; 19: 3– 10. Google Scholar CrossRef Search ADS PubMed  13 Hägglund M, Waldén M. Risk factors for acute knee injury in female youth football. Knee Surg Sports Traumatol Arthrosc  2015; 24: 737– 46. Google Scholar CrossRef Search ADS PubMed  14 Arastu MH, Grange S, Twyman R. Prevalence and consequences of delayed diagnosis of anterior cruciate ligament ruptures. Knee Surg Sports Traumatol Arthrosc  2014; 23: 1201– 5. Google Scholar CrossRef Search ADS PubMed  15 Walden M, Atroshi I, Magnusson H, et al.   Prevention of acute knee injuries in adolescent female football players: cluster randomised controlled trial. BMJ  2012; 344: e3042. Google Scholar CrossRef Search ADS PubMed  16 Hägglund M, Atroshi I, Wagner P, et al.   Superior compliance with a neuromuscular training programme is associated with fewer ACL injuries and fewer acute knee injuries in female adolescent football players: secondary analysis of an RCT. Br J Sports Med  2013; 47: 974– 9. Google Scholar CrossRef Search ADS PubMed  17 Lindblom H, Walden M, Carlfjord S, et al.   Implementation of a neuromuscular training programme in female adolescent football: 3-year follow-up study after a randomised controlled trial. Br J Sports Med  2014; 48: 1425– 30. Google Scholar CrossRef Search ADS PubMed  18 Collard DC, Verhagen EA, Mechelen WV, et al.   Economic burden of physical activity-related injuries in Dutch children aged 10–12. Br J Sports Med  2011; 45: 1058– 63. Google Scholar CrossRef Search ADS PubMed  19 Hedström EM, Svensson O, Bergström U, et al.   Epidemiology of fractures in children and adolescents. Acta Orthop  2010; 81: 148– 53. Google Scholar CrossRef Search ADS PubMed  20 Leininger RE, Knox CL, Comstock RD. Epidemiology of 1.6 million pediatric soccer-related injuries presenting to US Emergency Departments from 1990 to 2003. Am J Sports Med  2006; 35: 288– 93. Google Scholar CrossRef Search ADS PubMed  21 Rössler Junge A, Chomiak J, et al.   Soccer injuries in players aged 7 to 12 years: a descriptive epidemiological study over 2 seasons. Am J Sports Med  2016; 44: 309– 17. Google Scholar CrossRef Search ADS PubMed  22 Nellans KW, Kowalski E, Chung KC. The epidemiology of distal radius fractures. Hand Clin  2012; 28: 113– 25. Google Scholar CrossRef Search ADS PubMed  23 Nauta J, Knol DL, Adriaensens L, et al.   Prevention of fall-related injuries in 7-year-old to 12-year-old children: a cluster randomised controlled trial. Br J Sports Med  2013; 47: 909– 13. Google Scholar CrossRef Search ADS PubMed  24 Dahlström Ö, Backe S, Ekberg J, et al.   Is “Football for All” safe for all? Cross-sectional study of disparities as determinants of 1-year injury prevalence in youth football programs. PLoS ONE  2012; 7: e43795 Google Scholar CrossRef Search ADS PubMed  25 Halstead ME. Pediatric ankle sprains and their imitators. Pediatr Annal Pediatr Ann  2014; 43: e291-6[CrossRef]. 26 de Gruchy A, Granger C, Gorelik A. Physical therapists as primary practitioners in the emergency department: six-month prospective practice analysis. Phys Ther  2015; 95: 1207– 16. Google Scholar CrossRef Search ADS PubMed  27 Doherty C, Bleakley C, Hertel J, et al.   Recovery from a first-time lateral ankle sprain and the predictors of chronic ankle instability: a prospective cohort analysis. Am J Sports Med  2016; 44: 995– 1003. Google Scholar CrossRef Search ADS PubMed  28 Verhagen EA, Bay K. Optimising ankle sprain prevention: a critical review and practical appraisal of the literature. Br J Sports Med  2010; 44: 1082– 8. Google Scholar CrossRef Search ADS PubMed  29 Hupperets MD, Verhagen EA, Mechelen WV. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ  2009; 339: b2684. Google Scholar CrossRef Search ADS PubMed  30 Hägglund M, Walden M, Ekstrand J. Lower reinjury rate with a coach-controlled rehabilitation program in amateur male soccer: a randomized controlled trial. Am J Sports Med  2007; 35: 1433– 42. Google Scholar CrossRef Search ADS PubMed  31 Echemendia RJ, Giza CC, Kutcher JS. Developing guidelines for return to play: consensus and evidence-based approaches. Brain Inj  2015; 29: 185– 94. Google Scholar CrossRef Search ADS PubMed  32 Harmon KG, Drezner J, Gammons M, et al.   American medical society for sports medicine. American Medical Society for Sports Medicine position statement: concussion in sport. Clin J Sport Med  2013; 23: 1– 18. Google Scholar CrossRef Search ADS PubMed  33 Andersen TE, Arnason A, Engebretsen L, et al.   Mechanisms of head injuries in elite football. Br J Sports Med  2004; 38: 690– 6. Google Scholar CrossRef Search ADS PubMed  34 Benson BW, Mcintosh AS, Maddocks D, et al.   What are the most effective risk-reduction strategies in sport concussion? Br J Sports Med  2013; 47: 321– 6. Google Scholar CrossRef Search ADS PubMed  35 Timpka T, Jacobsson J, Bickenbach J, et al.   What is a sports injury? Sports Med  2014; 44: 423– 8. Google Scholar CrossRef Search ADS PubMed  36 Clarsen B, Bahr R. Matching the choice of injury/illness definition to study setting, purpose and design: one size does not fit all!. Br J Sports Med  2014; 48: 510– 2. Google Scholar CrossRef Search ADS PubMed  37 Faude O, Rößler R, Junge A. Football injuries in children and adolescent players: are there clues for prevention? Sports Med  2013; 43: 819– 37. Google Scholar CrossRef Search ADS PubMed  38 Finch CF, Shee AW, Clapperton A. Time to add a new priority target for child injury prevention? The case for an excess burden associated with sport and exercise injury: population-based study. BMJ Open  2014; 4: e005043. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The European Journal of Public Health Oxford University Press

Community-level football injury epidemiology: traumatic injuries treated at Swedish emergency medical facilities

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Oxford University Press
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© The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
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1101-1262
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Abstract

Abstract Background Despite the popularity of the sport, few studies have investigated community-level football injury patterns. This study examines football injuries treated at emergency medical facilities using data from three Swedish counties. Methods An open-cohort design was used based on residents aged 0–59 years in three Swedish counties (pop. 645 520). Data were collected from emergency medical facilities in the study counties between 1 January 2007 and 31 December 2010. Injury frequencies and proportions for age groups stratified by sex were calculated with 95% confidence intervals (95% CIs) and displayed per diagnostic group and body location. Results Each year, more than 1/200 person aged 0–59 years sustained at least one injury during football play that required emergency medical care. The highest injury incidence was observed among adolescent boys [2009 injuries per 100 000 population years (95% CI 1914–2108)] and adolescent girls [1413 injuries per 100 000 population years (95% CI 1333–1498)]. For female adolescents and adults, knee joint/ligament injury was the outstanding injury type (20% in ages 13–17 years and 34% in ages 18–29 years). For children aged 7–12 years, more than half of the treated injuries involved the upper extremity; fractures constituted about one-third of these injuries. Conclusions One of every 200 residents aged 0–59 years in typical Swedish counties each year sustained a traumatic football injury that required treatment in emergency healthcare. Further research on community-level patterns of overuse syndromes sustained by participation in football play is warranted. Introduction Football (soccer) is the most popular sport in the world. According to the 2006 FIFA Big Count, 265 million people are involved in football world-wide, the majority (>85%) being unregistered players.1 In Sweden, football and other sports are an important part of daily life, both in organized leagues and as recreational activities. The Swedish Sports Confederation (RF) estimates that about a third of the population participate in organized sports.2 Only a small proportion compete at the professional stage; the clear majority participate in sports activities and games organized at the community level. 3184 football clubs registered with the Swedish Football Association account for about 1 000 000 members, corresponding to more than one-tenth of the overall population.3 While a large body of research on football injuries is available, descriptive and intervention studies mainly address injuries occurring during organized games and practices.4 Furthermore, although the body of literature related to the benefits of informal football play is growing,5 few studies document football injury incidences in the general population. Understanding the aggregated impact of football injury in a community requires population based data that capture all unintentional injury cases. Previous studies in Scandinavian settings have showed that sports injuries constitute the largest category of injuries requiring medical care, and that football is the most commonly represented sport in this category.6–8 This study examines the epidemiology of community-level football injuries treated at emergency medical facilities using data from three Swedish counties. The specific aims are to describe the overall incidence of football injuries treated in emergency medical care over a 4-year study period and to analyse sex and age differences in injury proportions regarding body location and injury types. Methods This study uses an open-cohort design. The primary outcome measure is football injuries treated at emergency medical facilities. Data were collected at the study emergency rooms over a 4-year study period running from 1 January 2007 through 31 December 2010. A football injury was defined as an acute injury sustained while the injured party was engaged in football activities. Football activity was defined as organized play, play during school or work hours, or play during leisure time. The study excludes injuries occurring during transportation to or from football activities. Further, dental injuries were excluded, as this type of injury is not documented in the registry used in this study. Data collection The primary study populations consisted of residents aged 0–59 years, living in catchment areas for four hospitals in Skaraborg county (Skövde, Lidköping, Mariestad, Falköping), the three hospitals serving Värmland county (Karlstad, Arvika, Torsby) and Norrlands University Hospital in Umeå serving six of the municipalities in Västerbotten county. The total populations in these catchment areas, which averaged 645 520 residents over the study period, comprised about 7% of the total Swedish population. The data were retrieved from the Swedish subset of the Injury Data Base (IDB Sweden), which is administered by the Swedish Board of Health and Welfare.9 The data that comprise IDB Sweden reflect unintentional injuries that have been sustained in discrete events. Overuse ‘injuries’ arising from causes extended in time or inflammatory processes are not included in the database. IDB records are based on injuries sustained by community-dwelling individuals, regardless of wherever these occur; at work, at home or during leisure time activities. IDB Sweden is constructed to allow for parallel categorisation of certain types of injury events. For example, football injuries occurring in school settings can be classified as school injuries and also, as sports injuries. Data on the setting where the injury was sustained are obtained by patient self-report and includes only data from the first emergency visit and not follow-up visits. Additional data on injury circumstances are entered by clinical staff, including the time period when the patient received care for the injury. These clinical data are recorded by trained coders. Data on clinical interventions and injury consequences are also reported by the clinical staff. The quality of the data in IDB Sweden is regularly evaluated. The data collection procedures are standardized to allow detailed international comparisons. The combined number of incomplete records is controlled by relating the number of cases listed in IDB Sweden to administrative healthcare databases on randomly selected days. The proportion of incomplete records in IDB Sweden average about 10–15% annually for all emergency medical facilities combined. A free text field is included with each injury record in IDB Sweden, briefly summarizing the patients’ descriptions of injury circumstances, which was also reviewed in this study to verify that the injury cause involved football play. The study design was based on data obtained from databases established for the purpose of systematically and continuously developing and securing the quality of health services. All personal identification data had been removed from the records before analyses. According to Swedish legislation, no review by a research ethics board was required for this study. Data analysis Descriptive statistics were employed to calculate and display injury frequencies and proportions, and the associated 95% confidence intervals (95% CIs) according to the matrix representation (diagnostic group—body location) for age groups stratified by sex. To tabulate injury type (diagnostic group) and body location of injury, the matrix representation of sports injuries developed by Jacobsson et al.10 was used (Supplementary table S1). The descriptive statistical analyses were conducted using the general populations of the study area. A basis for statistical inferences at the population level was provided by computation of 95% CIs showing overlaps or not.11 The analyses of injury patterns focused primarily on injuries to people between the ages of 7–29 years using three age group categories: children (7–12), adolescents (13–17) and young adults (18–29 years of age). However, to give a complete picture of the patterns, in the initial analyses other age groups were also included. Results About 25% (n = 8096) of all sports injuries registered during the study period had been sustained during participation in football activities. Each year, more than 1 of every 200 persons aged 0–59 years sustained at least one traumatic injury during football play that required emergency healthcare. Characteristics of study subjects Adolescents and young adults accounted together for 72% of the injury episodes (table 1). The highest injury incidence was observed among adolescent boys [2009 injuries per 100 000 population years (95% CI 1914–2108 injuries)] and adolescent girls [1413 injuries per 100 000 population years (95% CI 1333–1498 injuries)]. While ∼50% more males were treated for football injuries in ages 7–17 (male/female incidence ratio (IR) 1.50, 95% CI 1.41–1.59), the ratio was noticeably higher among those aged 18–59 (IR 4.36, 95% CI 4.01–4.73) and 0–6 (IR 4.25, 95% CI 1.97–9.18). Table 1 Numbers of football injuries per 100 000 population annually requiring emergency medical healthcare in study counties (total population 645 520) between 1 January 2007 and 31 December 2010 displayed by age group and sex Age (years)  Football injuries treated in emergency medical healthcare  Males  Females  Total  n  Injuries per 100 000 and year (95% CI)  n  Injuries per 100 000 and year (95% CI)  n  Injuries per 100 000 and year (95% CI)  0–6  34  35 (25–49)  8  9 (4–18)  42  12 (8 – 18)  7–12  800  996 (928–1069)  544  698 (641–760)  1344  850 (804–897)  13–17  1792  2009 (1914–2108)  1189  1 413 (1333–1498)  2981  1720 (1657–1785)  18–29  2287  1098 (1053–1145)  564  295 (271–320)  2851  713 (687–740)  30–59  746  148 (138–159)  132  27 (23–32)  878  89 (83–95)  Total  5659  579 (564–595)  2437  263 (253–274)  8096  425 (416–435)  Age (years)  Football injuries treated in emergency medical healthcare  Males  Females  Total  n  Injuries per 100 000 and year (95% CI)  n  Injuries per 100 000 and year (95% CI)  n  Injuries per 100 000 and year (95% CI)  0–6  34  35 (25–49)  8  9 (4–18)  42  12 (8 – 18)  7–12  800  996 (928–1069)  544  698 (641–760)  1344  850 (804–897)  13–17  1792  2009 (1914–2108)  1189  1 413 (1333–1498)  2981  1720 (1657–1785)  18–29  2287  1098 (1053–1145)  564  295 (271–320)  2851  713 (687–740)  30–59  746  148 (138–159)  132  27 (23–32)  878  89 (83–95)  Total  5659  579 (564–595)  2437  263 (253–274)  8096  425 (416–435)  Football injury patterns among children For the age group 7–12 years, injuries to the upper extremity (shoulder, upper arm, wrist, hand and fingers) accounted for >50% of all recorded football injuries for both boys and girls (figure 1; Supplementary table S1). Fractures were the most common injury type for both sexes (34%), closely followed by contusions (32%). Concussions accounted for 2–3% of all football injuries in this age group. No statistically verified difference in the distribution of injuries between the sexes was observed regarding body location or type. Figure 1 View largeDownload slide Distribution of football injuries requiring emergency medical healthcare in the study counties from January 1, 2007 through December 31, 2010 displayed by injury type, affected body part, sex, and age group Figure 1 View largeDownload slide Distribution of football injuries requiring emergency medical healthcare in the study counties from January 1, 2007 through December 31, 2010 displayed by injury type, affected body part, sex, and age group Football injury patterns among adolescents For the age group 13–17 years, the injury patterns differed between the sexes (figure 1; Supplementary table S2). Larger proportions of injuries to the lower extremity in the younger age group were observed for both boys and girls, with the proportions of knee injury among girls [20.4% (95% CI 18.1–23.8)] being larger than among boys [14.5% (95% CI 12.9–16.2)]. A similar distribution was observed for ankle injury [girls 21.3% (95% CI 19.0–23.7); boys 16.3% (95% CI 14.6–18.1)]. While fractures were the most common injury type for boys (30%), the most common injury for girls was joint/ligament injury (39%) reflecting a pattern similar to the younger age group. Concussions accounted for 4–5% of all football injuries in this age group. Football injury patterns in young adults For young adults (ages 18–29 years), the distribution of injury proportions differed between the sexes (figure 1; Supplementary table S3). Injuries to the lower extremity dominated among both men and women, and the sex differences in knee injury proportions was even larger with young adults [women 33.5% (95% CI 29.6–37.6); men 19.0% (95% CI 17.4–20.7)] than among adolescents. In contrast, men were diagnosed with more injuries to the shoulder and upper arm [men 8.6% (95% CI 7.8–9.8); women 4.4% (95% CI 2.9–6.5)]. Joint/ligament injuries were the most common injury type in both sexes, but the proportion of joint/ligament injuries was more common for women [47.7% (95% CI 43.5–51.9)] than for men [35.4% (95% CI 33.5–37.4)] as the leading injury type. Concussions accounted for 3–4% of all football injuries in this age group. Discussion We found that about 1 of every 200 residents aged 0–59 years residing in the study populations sustains a football injury that requires emergency healthcare each year. Recalculating these numbers to the national level (population 9.5 million at the time of the study), the annual burden of traumatic football injuries on health services in Sweden can be estimated at 29 500 cases (95% CI 28 200–30 800 cases). In female adolescents and young adults, knee joint/ligament injury was in this study found to be the predominant football injury type (20% in ages 13–17 years and 34% in ages 18–29 years). Multiple studies have documented elevated risk for knee injuries in females participating in organized football.12,13 Our results confirm that injuries to the knee in female football players comprise a serious challenge for the healthcare services in communities where football is popular, and the large proportion of knee joint/ligament injuries in females aged 18–29 years is particularly worrisome. Although an accurate initial assessment is vital for effective treatment and rehabilitation of knee injuries, the rate of correct diagnoses in routine emergency healthcare has been reported poor.14 Diagnostic delays lead to unnecessary suspension of efficient treatment and increases the risk of secondary injury to the knee. The results of this study suggest that liberal use of specific diagnostic procedures, such as magnetic resonance imaging (MRI), is warranted when female football players present to emergency rooms with knee injuries. Moreover, managers of football clubs should discuss the actions that can be taken to prevent injuries during play in this group of athletes. “Knäkontroll” (Knee Control) is a Swedish injury prevention exercise programme specifically designed for prevention of traumatic knee injuries for which the efficacy has been established in several studies.15,16 A preliminary follow-up study focusing on implementation showed a high reach and adoption of the program among girls’ football coaches17 but the preventive effectiveness on acute knee injuries remains to be evaluated. In the age group 7–12 years, more than half of the recorded injuries involved the upper extremity. It is notable that fractures constituted about one-third of these injuries. This injury pattern is concordant with the general pattern of childhood injuries; the typical and costliest injury among children is a forearm fracture.18 In Sweden, forearm fractures account for about one-third of child fractures presented at emergency departments.19 Large proportions of injuries to the upper extremity, and in particular fractures, among children have previously been reported from football activities,20,21 but have seldom been highlighted as a noteworthy problem requiring systematic response measures. Clinical guidelines specific for child football players having suffered fractures to the upper extremity are therefore missing. Regarding preventive measures, it has been established that fall-related mechanisms account for ∼80% of injuries sustained during participation in sports during childhood.22 There is therefore a need for development of fall-related injury prevention programs for young children participating in football. A school-based educational programme to improve falling skills in children based on martial arts techniques has shown promising results.23 Such programs need to be modified for seamless integration into football activities and also be adapted to children with pre-participation risk factors, e.g. high body mass index and low self-reported general health.24 The proportion of ankle injuries rose steadily with age to comprise about 20% of all injuries for both sexes in the ages 18–29 years; joint/ligament injury was here the outstanding injury type. At the initial presentation, there are many injuries that can mimic an ankle sprain. Particularly in the skeletally immature athlete, bone injuries are more likely to occur than a ligamentous injury.25 Correct diagnosis in an early stage is therefore of importance to provide effective treatment and prevents relapses. Knowledge of relevant anatomy, physical examination, and appropriate imaging can assist in diagnosing the ankle injuries. Using physiotherapy expertise already at the emergency department has been showed to manage a great deal of this type of musculoskeletal caseload safely and time efficiently.26 Like other injuries to joints, ankle injuries that reoccur can lead to joint instability.27 Regarding prevention, there is good evidence that taping, bracing and neuromuscular training are all effective for the avoidance of ankle–sprain recurrences.28 With instructions on such preventive measures and distribution of a home-based training programme to patients suffering an ankle sprain the risk of injury recurrences could be reduced substantially.29 In addition, while return to football training and play after injury poses a considerable risk of injury recurrence, this risk can be lowered by as much as 75% after the occurrence of lower extremity injuries by following a simple return-to-play protocol that could be easily distributed to patients in the emergency department.30 Concussions represented ∼3% of the football injures treated at emergency healthcare facilities observed in this study. As in any patient group, concussion among football players should be considered a clinical diagnosis made by medical practitioners familiar with the evaluation of trauma to the head.31 The assessment can be guided by a symptoms checklist, but should also contain a cognitive evaluation, balance tests and further neurological physical examination, while imaging should be reserved for situations when intracerebral bleeding is suspected.32 Regarding prevention, concussions have in football primarily been reported to be consequential to elbow/arm-to-the-head incidents and head-to-head impacts.33 This injury mechanism may be related to participation in organized football in the older age groups as opposed to school/leisure time play and younger football players. To date, there is no conclusive evidence of a preventive effect of, for instance, helmet use or strength training of the neck muscles on concussion risk.34 The design of this study is relatively unique in that the population-level burden of traumatic football injuries on healthcare seldom has been established using rigorous methods for collection and coding of clinical data, validation, and control of missing data. Meanwhile, it should be recognized that the current sports injury reporting systems suffer from conceptual issues,35 as ‘one size does not fit all’.36 The analyses in the study were limited to injuries that were attended to emergency healthcare. Data on clinically significant traumatic injuries managed by coaches, sideline team medical staff, or self-treatment were not included. Also, information on exposure to football activities was not obtained, which excludes the possibility to assess injury risk at different levels of participation in the sport. Similarly, data were not collected on overuse injuries with gradual onset that are not treated in emergency healthcare. To establish the burden on healthcare from this injury category, which has been reported to constitute 10–40% of all football injuries among children and adolescents,37 wide-spread adoption of health information systems that support use of detailed cause and location codes, such as the ICD-10-AM, are needed for case identification.38 Furthermore, descriptive study was performed for the purpose of systematically and continuously developing and securing the quality of healthcare services, and thus, no statistical testing was employed. Instead, an estimation approach was used that aimed to quantify the descriptor of interest as an estimate of a relevant quantity and to quantify the uncertainty in this estimate by means of a CI. The CIs obtained provide the ranges of uncertainty due to the sampling variation to indicate the precision of the sample study results as estimates of the population values, and thus to allow for corresponding inferences about the population values to be made. In summary, football is the most popular physical activity game world-wide, and its popularity both as sport and as recreational activity is steadily growing in both genders. In addition to primary prevention programs, health service providers need to develop clinical guidelines for diagnosing players presenting with knee injuries and management of children having suffered injuries to the upper extremity. Further research on community-level patterns of overuse syndromes sustained during football participation is also warranted. Supplementary data Supplementary data are available at EURPUB online. Funding This research was supported by grant P2013-0153 from the Swedish Centre for Sports Research (CIF). Conflicts of interest: None declared. Key points This study, based on the residents in three Swedish counties (pop. 645 520), set out to examine the epidemiology of community-level football injuries treated in emergency medical healthcare during a 4-year period. Each year, about 1 in every 200 persons aged 0–59 years sustained at least one injury during football play that required emergency medical care with the highest injury incidences among adolescent boys and girls. In female adolescents and adults, knee joint/ligament injury was the outstanding injury type, while for children aged 7–12 years, more than half of the treated injuries involved the upper extremity; fractures constituted about one-third of these injuries. References 1 FIFA. Big Count 2006: Statistical Summary Report, FIFA. Communications Division, 2007. 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The European Journal of Public HealthOxford University Press

Published: Feb 1, 2018

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