Sport injuries in adolescents

Abstract

In spite of the wide range of injuries in adolescents during sports activities, there are only a few studies investigating the type and frequency of sport injuries in puberty. However, this information may help to prevent, diagnose and treat sports injuries among teens. 4468 injuries in adolescent patients were treated over a ten year period of time: 66,97% were boys and 32.88% girls. The most frequent sports injuries were football (31.13%) followed by handball (8.89%) and sports during school (8.77%). The lower extremity was involved in 68.71% of the cases. Knee problems were seen in 29.79% of the patients; 2.57% spine and 1.99% head injuries. Injuries consisted primarily of distortions (35.34%) and ligament tears (18.76%); 9,00% of all injuries were fractures. We found more skin wounds (6:1) and fractures (7:2) in male patients compared to females. The risk of ligament tears was highest during skiing. Three of four ski injuries led to knee problems. Spine injuries were observed most often during horse riding (1:6). Head injuries were seen in bicycle accidents (1:3). Head injuries were seen in male patients much more often then in female patients (21:1). Fractures were noted during football (1:9), skiing (1:9), inline (2:3), and during school sports (1:11). Many adolescents participate in various sports. Notwithstanding the methodological problems with epidemiological data, there is no doubt about the large number of athletes sustain musculoskeletal injuries, sometimes serious. In most instances, the accident does not happened during professional sports and training. Therefore, school teachers and low league trainer play an important role preventing further accidence based on knowledge of individual risk patterns of different sports.
It is imperative to provide preventive medical check-ups, to monitor the sport-specific needs for each individual sports, to observe the training skills as well as physical fitness needed and to evaluation coaches education.

Full text

[page 82] [Orthopedic Reviews 2011; 3:e18]
Sport injuries in adolescents
Susanne Habelt,1Carol Claudius Hasler,2
Klaus Steinbrück,3Martin Majewski1
1Department of Orthopaedic Surgery,
University Hospital of Basel, Basel;
2Department of Orthopaedic Surgery,
University Children’s Hospital of Basel,
Switzerland; 3Clinic of Orthopaedic
Surgery, Stuttgart-Botnang, Germany
Abstract
In spite of the wide range of injuries in ado-
lescents during sports activities, there are only
a few studies investigating the type and fre-
quency of sport injuries in puberty. However,
this information may help to prevent, diagnose
and treat sports injuries among teens. 4468
injuries in adolescent patients were treated
over a ten year period of time: 66,97% were
boys and 32.88% girls. The most frequent
sports injuries were football (31.13%) followed
by handball (8.89%) and sports during school
(8.77%). The lower extremity was involved in
68.71% of the cases. Knee problems were seen
in 29.79% of the patients; 2.57% spine and
1.99% head injuries. Injuries consisted prima-
rily of distortions (35.34%) and ligament tears
(18.76%); 9,00% of all injuries were fractures.
We found more skin wounds (6:1) and frac-
tures (7:2) in male patients compared to
females. The risk of ligament tears was high-
est during skiing. Three of four ski injuries led
to knee problems. Spine injuries were
observed most often during horse riding (1:6).
Head injuries were seen in bicycle accidents
(1:3). Head injuries were seen in male
patients much more often then in female
patients (21:1). Fractures were noted during
football (1:9), skiing (1:9), inline (2:3), and
during school sports (1:11). Many adolescents
participate in various sports. Notwithstanding
the methodological problems with epidemio-
logical data, there is no doubt about the large
number of athletes sustain musculoskeletal
injuries, sometimes serious. In most
instances, the accident does not happened dur-
ing professional sports and training.
Therefore, school teachers and low league
trainer play an important role preventing fur-
ther accidence based on knowledge of individ-
ual risk patterns of different sports.
It is imperative to provide preventive med-
ical check-ups, to monitor the sport-specific
needs for each individual sports, to observe the
training skills as well as physical fitness need-
ed and to evaluation coaches education.
Introduction
When we think of sports, we usually think
about professional sports. We think about foot-
ball, skiing or athletic competitions being per-
formed by adults. Most sports are performed,
however, by children and adolescents.1In the
United States over 25-30 million children and
adolescents take part in school sports activities
and 20 million are members of sport clubs.2,3
The number of young athletes is continually
increasing.1,4 Parallel to this increase of partic-
ipants, the number of acute and over use
injuries is raising.5,6
Children and adolescents are at a special
risk for injuries because most sports are not
adapted to the motor skills of their specific age
group.6,7 Thus, adolescents play according to
the rules of adults and the apparatuses are not
adjusted to their sizes.6,7 For example, the bas-
ketball baskets are just available in one height
and almost all sports have only one ball size,
the one used for adults.6However, particularly
adolescents may sustain injuries, which can
impair their growth with potential lifelong
effect.8
The aim of the following study was to pro-
vide epidemiologic data, which can aid to pre-
vent, diagnose and treat sports injuries among
adolescents.
Materials and Methods
Over a ten year period of time, all patients
with sports injuries treated in the sports clinic
were documented in a specially designed com-
puter program. Since the implementation of
the computerized case history, 17,397 patients
with 19,530 injuries have been analyzed: 4468
injuries (25.68%) were related to patients
between 10 and 19 years of age; 66,97% of the
patients were male, 32.88% were female and
the remaining 0.16% were of ambiguous gen-
der (Table 1).
Patient’s sex, kind of injury, localisation of
injury and type of sports, as well as the treat-
ment were documented. All patient examina-
tions during outpatient clinic were performed
either by, or under the supervision of, a senior
consultant.
All patients were examined clinically regard-
ing pain, swelling, range of motion, and stabil-
ity. The clinical examination was followed by a
radiographic evaluation (anterior-posterior
and lateral view) depending on the type of
injury. If the clinical and radio logic findings
remained doubtful or required further investi-
gation, the patients were transferred for ultra-
sound or MRI examination.
Sports injuries occurring during warm-up
were not included in the study.
Results
Sports
Most injuries occurred while engaging one
popular European sports, soccer. Soccer was
involved in 31.13% of all injuries followed by
handball (8.89%), sports during school
(8.77%), skiing (5.95%), and biking (5.71%)
(Table 2).
Location
The upper extremities were involved in
25.27% of the injuries, the lower extremities in
68.71%, the spine in 2.57% and the head in
1.99% of the cases. Injuries of the upper extrem-
ity were seen on all locations with an especially
high number of injuries at fingers (8.12%),
metacarpus (3.13%) and wrist (3.54%). The
knee (29.79%) and ankle joint (24.02%) were
most often involved during injuries of the lower
leg. Compared to knee and ankle joint, the
shoulder (5.42%) and elbow (2.84%) were not
often injured (Table 3).
Type of injury
Over all, injuries consisted primarily of dis-
tortions (35.34%) as well as ligament tears
(18.76%); 9,00% of all injuries were fractures.
(Table 3)
Gender
More than half of the male patients played
ball games such as soccer (1311 patients),
handball (222 patients) and basketball (168
patients). Girls skied (156 patients), danced
(79 patients), and did gymnastic (123
patients). However, 175 girls played handball
or had their accident during school sports (167
patients).
Orthopedic Reviews 2011; volume 3:e18
Correspondence: Martin Majewski, Department
of Orthopaedic Surgery and Traumatology,
University of Basel, Spitalstrasse 21, 4031 Basel,
Switzerland.
Tel: +41.61.265.25.25 - Fax: +41.61.328.78.03.
E-mail: majewski01@yahoo.de
Key words: epidemiology, sport injury, adolescent.
Received for publication: 13 September 2011.
Accepted for publication: 16 October 2011.
This work is licensed under a Creative Commons
Attribution NonCommercial 3.0 License (CC BY-
NC 3.0).
©Copyright S. Habelt et al., 2011
Licensee PAGEPress, Italy
Orthopedic Reviews 2011; 3:e18
doi:10.4081/or.2011.e18

[Orthopedic Reviews 2011; 3:e18] [page 83]
Type of injury
Looking at the over all distribution of boys
and girls (2:1) we found more skin wounds
(6:1) and fractures (7:2) in male patients. Girls
showed more ligament tears (3:2).
Sex and location
Compared to the overall distribution of male
and female patients (2:1) head injuries were
seen more often in male patients than in female
patients (21:1). Shoulder, hand and lower leg
injuries showed a boy-girl distribution of 4:1.
We found a boy-girl distribution of 5:4 of spine,
elbow and knee problems (Table 1).
Sports and location
In contrast to the overall relative number of
head injuries (1:50), head injuries during bicy-
cle accidents were seen much more often
(1:10); 1:3 head injuries have been bicycling
injuries. Spine injuries were observed in gen-
eral with a distribution of 1:40. During horse
riding 1 of 3 injuries affected the spine and 1:6
of all spine injuries were related to horse rid-
ing. Shoulder injuries were seen in 1:17 cases,
shoulder injuries during skiing were seen with
a distribution of 1:10. The overall hand and
elbow injury rate was 1:30 and 1:35 respective-
ly. During biking the hand (1:9) and elbow
(1:8) were injured much more often. In gener-
al, finger injuries were seen in 1:12 patients.
School sports primarily led to ankle sprains,
nevertheless, every 5th accident during sports
in school was located at the fingers. One third
of all injuries were been related to the knee,
3:4 ski injuries led to knee problems (Table 4).
Sports and type of injury
The highest number ligament tears (279
patients) and joint sprains (500 patients) were
the results of accidents during soccer. The per-
centage of ligament tears compared to the
overall number of accidents (1:5) was highest
during skiing; 1:3 skiing injuries were liga-
mentous injuries. Approximately the same dis-
tribution was seen while playing handball
(1:3). Fractures were noted among football
(1:9), skiing (1:9), inline skating (2:3), and
during school sports (1:11). The overall frac-
ture rate was 1:11. Wrestling (1:5) and snow-
boarding (1:6) had a high number of disloca-
tions compared to all dislocations that were
seen (1:20). Wounds were seen most often
after bike falls (1:5) (Table 2).
Location and type of injury
The injuries of the lower extremities con-
sisted primarily of ligament tears: 1:5 injuries
at the lower extremity were ligament tears and
approximately all ligament tears occurred in
the legs. Fractures were mostly seen at the
upper extremity (Table 3).
Discussion
Little is known about sports-related injuries
to the locomotor system in children and adoles-
cents. However, these groups are the ones who
are most likely to sustain injuries because they
are constantly in motion. This is surely a suffi-
cient motivation to gather epidemiological
data to discuss the basics of their injuries.
Article
Table 2. Sports specific diagnosis, sorted by number of injuries.
Skin Contusion Distortion Muscle Ligament Tendon Dislocation Fracture Cartilage Total
wound injury injury injury Total lesion
Football 26 271 500 31 279 4 66 154 60 1391
Handball 16 53 168 2 83 14 15 22 24 397
Scholl Sport 0 88 188 12 52 1 11 36 4 392
Ski 6 16 96 0 86 1 22 30 9 266
Biking 75 85 28 0 24 07 18 18 255
Basketball 2 17 112 2 70 0 10 13 9 235
Gymnastics 1 34 49 4 25 16 17 29 166
Volleyball 0 16 75 3 40 0 12 36155
Trek and Field 6 24 45 12 23 03 6 31 150
Tennis 99 38 3 20 05 6 38 128
Ice skating 3 24 27 5 11 17 10 9 97
Dance 0 14 38 7 12 07 4 8 90
Judo 2 23 21 68 0 9 5 5 79
Swimming 2 16 8 10 108311 59
Jogging 02 27 6 13 11 2 3 55
Horse riding 0 29 504 0 1 8 2 49
Badminton 05 11 0 25 02 1 1 45
Wrestling 0 10 11 16 0 9 7 1 45
Inline skating 28 10 10 0 1 15 0 37
Skateboard 03 16 05 1 3 8 0 36
Table 1. Gender specific location within
4468 sports injuries.
No specificationMale Female Total
Head 0 85 4 89
Chest 0 16 3 19
Pelvis 0 38 8 46
Spine 0 65 50 115
Shoulder 2 199 53 254
Upper arm 0 14 5 19
Elbow 0 72 55 127
Forearm 0 51 17 68
Wrist 1 114 43 158
Hand 0 110 30 140
Finger 0 224 139 363
Hip 0 16 2 18
Thigh 0 130 58 188
Knee 1 773 557 1331
Lower leg 1 149 35 185
Ankle 1 756 316 1073
Foot 1 123 72 196
Toes 0 57 22 79
Total 7 2992 1469 4468

[page 84] [Orthopedic Reviews 2011; 3:e18]
Adolescent are subjected to many stresses,
strains and injuries. An increase in the num-
ber of injuries has been seen.1,4 In the United
States alone, sports related injuries in children
and adolescents cost more than 1.8 billion dol-
lars per year.2
The actual incidence of injuries in children
and adolescents is difficult to determine.
Between 3-11% of schoolchildren are injured
each year.8-10 Children and adolescents may be
particularly at risk for sports-related injuries
as a result of improper technique, muscle
weakness and poor proprioception.7,11,12
Boys sustain twice as many injuries as girls.
In accordance with the literature two third of
our patients were male.8-11,13 Males participat-
ing in sport may be at greater risk of injury as
they tend to be more aggressive, have larger
body mass, and experience greater contact
compared with girls in the same sports and
they more involved in contact sports and foot-
Article
Table 3. Location specific diagnosis within 4468 sports injuries.
Skin Contusion Distortion Muscle Ligament Tendon Dislocation Fracture Cartilage Total
wound injury injury injury Total lesion
Head 50 26 000 0 0 13 0 89
Chest 0 18 000 0 0 0 1 19
Pelvis 5 25 300 0 0 1 12 46
Spine 1 37 35 10 000131 115
Shoulder 5 41 46 12 1 100 40 18 254
Upper arm 54 420 0 0 3 1 19
Elbow 15 52 20 07 0 11 8 14 127
Forearm 2 17 200 0 1 42 4 68
Wrist 2 38 87 10 0 1 23 6 158
Hand 7 39 29 02 0 1 56 6 140
Finger 6 89 156 0 22 15 11 64 0 363
Hip 67 100 2 0 0 2 18
Thigh 3 46 58 67 010310 188
Knee 20 153 441 0 460 1 103 20 133 1331
Lower leg 19 53 0 39 14055 14 185
Ankle 3 56 611 1 342 11 36 22 1073
Foot 12 80 58 02 0 0 23 21 196
Toes 1 32 28 00 0 1 14 3 79
Total 162 813 1579 121 838 25 230 402 298 4468
Table 4. Sports specific location, sorted by number of injuries.
Head Chest Pelvis Spine Shoulder Upper Elbow Fore Wrist Hand Finger Hip Tight Knee Lower Ankle Foot Toes Total
arm arm leg
Football 30 2 14 15 41 1823 66 40 80 9 82 473 48 353 71 35 1391
Handball 11 010 23 670328 57 04117 1 126 11 2 397
Scholl Sport 65 3 6 17 1918477 1 10 78 18 134 13 1 392
Ski 00 0 0 29 1012116 08196 10 200266
Biking 27 461 16 0 33 8 28 23 65347 25 6 17 0 255
Basketball 22 0 3 7 0 200 6 42 0348 2 116 20235
Gymnastics 11 1 18 10 1 12 8 15 390934 9 25 91166
Volleyball 10 0 3 9 0 403 3 28 0121 1 76 50155
Trek and Field 00 8 13 3010270119 34 19 37 33150
Tennis 00 2 9 9 2 1190 30034 9 35 86128
Ice skating 21 6 2 6 0 2137 16 0334 373197
Dance 00 0 0 2 0 1001 1210 21 2 29 19 2 90
Judo 20 0 1 9 0 12 010 30721 0211 10 79
Swimming 10 0 3 9 2 11 200 002812 12659
Jogging 00 0 0 1 0 000 0 10113 7 25 2555
Horse riding 00 0 19 10000000613 144149
Badminton 00 1 2 0 0 010 0 00035 060045
Wrestling 02 1 1 16 1 10 11 1 3003 3 20045
Inline skating 10 1 0 2 0 2555 301 5 1 60037
Skateboard 00 0 5 3 0 0041 5003 1 14 0036
Total 10 1 0 2 0 255 5 301 5 1 60037

[Orthopedic Reviews 2011; 3:e18] [page 85]
ball.11,13 All of these factors may lead to
increased forces in running, jumping, pivot-
ing, and contact, which may increase suscepti-
bility to injury.11 Underlining this, we found
more skin wounds and fractures as well as
head and shoulder injuries in males.
Therefore, paediatric orthopaedic patients
fall into two groups: obese patients or young
athletes.14 On one hand, due to our technolog-
ical environment, adolescents tend not be as
active anymore and through this do not have
the level of coordination that one would sus-
pect.6,14 On the other hand, youths tend to have
reduced perception of risk and boundless ener-
gy.15 In addition, the sports apparatuses are
rarely tailored to the needs of the adoles-
cent.7,16 Skiing is one of the only sports where
the height and weight of each individual is
taken into consideration when giving out
equipment. Adolescents play according to the
rules of adults and the apparatuses are not
adjusted to their sizes.7
However, most sports are not adapted to the
motor skills and size of adolescents.6,7
Adolescents play according to the rules of
adults.6,7 Almost all sports have only one ball
size, the one used for adults.6However, partic-
ularly adolescents may benefit from sports
equipment adapted to there needs.8
Teachers deal with all kind of problems,
because the school population is not specially
selected or trained. Therefore they have to
simultaneously handle obese patients, young
athletes, low level of coordination, and reduced
perception of risk, as well as adult sports
equipment.17 Playing with adult-sized balls,
sports injuries account for a significant mor-
bidity with frequent finger injuries among ado-
lescents during sports in school. 8.77% of all
injuries we have seen were caused during
school sports. School sports primarily led to
ankle sprains and every 5th accident was locat-
ed at the fingers; 9% of those injuries were
fractures.
The province of Quebec does not allow ado-
lescents to body check until the age of 14,
whereas in Ontario they are already allowed to
at the age of 10 to 12 years. Analysis of hockey
injuries in the two provinces showed a higher
incidence of injury when checks were allowed,
with a higher proportion of head injuries and
fractures. A simple change in regulation could
prevent many injuries among adolescents play-
ing hockey.18
The Toronto District School Board abruptly
removed playground equipment from 136
schools because it was dangerously non-com-
pliant with standards. After the equipment was
removed and replaced with safe equipment,
the injury rates dropped down by 50%. The
same number of children did the same playing,
but in a safe environment. Therefore the
injury risk was substantially reduced.19
The examples of playground and ice hockey
are not exhaustive for formal and organized
sports and leisure activities. We found a high
number of head injuries during bicycle acci-
dents and spine injuries were observed during
horse riding. These injuries might be reduced
by wearing a helmet or and spinal protection
even during leisure bike rides or horse riding.
Elevated speed and falls from greater
heights are the cause of severe injuries.10 The
most dangerous sports are today's most popu-
lar sports such as snowboarding, carving and
inline skating.20-22 In his study Diamond found
that skiing poses an especially high risk for
head injuries in children.23 Accidents are due
to balance problems and collisions.20
Beginners have more injuries of the forearm
(46%) and the most advanced tend to suffer
from head and neck injuries (30%).22 A situa-
tion possible to changed by better protection of
the head. Out of our personal experience
coaches appear to have a specific perception
concerning the causes of sports accidents.
They somehow believe that factors like meth-
ods or organization of the game do not have an
effect on accidents.7In addition, adolescents
are under intense pressure, with a higher level
of training, to meet the expectation from the
coach and their parents.3
On the other hand there are exogenous fac-
tors such as apparatuses, which are not adapt-
ed to the adolescents’ size, as well as endoge-
nous factors such as the individual level of per-
formance that are important for the cause of
injuries. Potential factors adapted from Emery
were listed in Table 5.11
Beside the above mentioned, the type of
sport is a deciding factor and determines the
rate of injury as well as the localisation and the
resulting diagnosis.13,22,24 In our study ball
games like soccer, handball and basketball in
boys and school sports, handball and skiing in
girls accounted for the highest number of
injuries. An American study showed that injury
occurred most often during basketball, soccer,
baseball, football and roller blading.13 62% of
sports injuries take place in athletic clubs, 21%
in school sports, and 17% during leisure sports.
Abernethy reported an even higher percent of
schools sports injuries with 51%.25,26
It is quite noticeable that adolescents have
the same types of injuries that adults have.13, 27
Patel stated in his work on sport injuries in
adolescents, that most common types of
injuries are soft tissue injuries as sprains,
strains, and contusions.28 However, in our
study 9% of all injuries had been fractures.
Our unique description of epidemiological
data of adolescents sport injuries, showed the
highest number ligament tears and joint
sprains as a result of accidents during soccer.
Never less, the risk of ligament injury was
highest during skiing and handball. Fractures
were noted among soccer, skiing, inline-skat-
ing, and during school sports and dislocations
were seen during wrestling. Injuries of the
lower extremities consisted primarily of liga-
ment tears and fractures were mostly seen at
the upper extremity.
In conclusion school teachers and coaches
play an important role preventing further acci-
dents based on knowledge of individual risk
patterns of individual sports. Risk factors may
be extrinsic (sport, position, level, weather) or
intrinsic (previous injury, sex) to the individ-
ual participating in sports. Modifiable risk fac-
tors refer to those with the potential to be
altered by injury prevention strategies such as
education or behavioural intervention (rules,
playing time), environmental interventions
(playing surface, equipment), and legislative
interventions.11
However, a reduction of the incidence of
injuries should not only be confined to a modi-
fication of rules and apparatuses. It is impera-
tive to provide preventive medical check-ups,
to monitor the sport-specific needs for each
individual sports, to observe the training skills
as well as physical fitness needed and to eval-
uation coaches education. This is an important
duty for each paediatrician or family physician
who is interested in sports medicine.
Article
Table 5. Potential risk factors for injury in adolescent sport.
Extrinsic risk factors Intrinsic risk factors
Non-modifiable Kind of sport Age
Level of sport Previous injury
Position Sex
Time of season
Weather
Potential modifiable Equipment Coordination
Playing surface Fitness level
Playing time Flexibility
Rules Participation in sport-specific training
Time of day Proprioception
Psychological factors
Strength

[page 86] [Orthopedic Reviews 2011; 3:e18]
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