Methods

The first author observed outdoor skaters from July through September 1996 and April to August 1997 at 33 locations in Boston's affluent Back Bay neighborhood. This neighborhood has many professionals, few children, and many college students, especially during the academic year.⁹

Four dichotomous variables record use of helmets, wrist guards, elbow and kneepads. The age of skaters is estimated as youngest to age 12, 13–17, 18 –50, and 51 and over. Although finer age gradations are typically examined, the goal here is to distinguish between children, teens, adults, and older adults by observation. The wide age categories meet the goal and minimize misclassification errors. Skaters were coded as beginner, average, or advanced. Beginners are easily recognized by their comparative lack of control and poor technique. They lack balance (especially when trying to stand still), flail their arms, fall down occasionally, clutch railings, go slower, tend not to stride correctly, and become nervous when confronting bumps, inclines, or other skaters. Advanced skaters appear to be in full control, sometimes skating backwards, doing stunts, or speed skating. They are able to stop quickly and gracefully. The majority of skaters who could not be classified as beginner or advanced skaters were coded as average.

Skating locations were classified as street, sidewalk, or bicycle path, as has been done in other studies of skate safety.⁶ Although this was mainly a study of in-line skaters, because injuries of roller skaters are so similar,^3,4 the three observed roller skaters were included. Our exclusion criteria specify that the same skater not be coded twice in the same data collection block, or in contiguous data collection blocks at the same location. However, the same skater could be recorded again later on the same day.

Results

Table 1 shows demographic and background data on the sample. Table 2 shows the percentage of skaters wearing helmets (5.7%), elbow (10.0%) and kneepads (22.8%), and wrist guards (60.5%). Females were significantly more likely to wear wrist guards and kneepads. Not only were more males skating, with less protective gear, but table 2 also shows that males were nearly twice as likely as females to skate on streets (13.3% v 7.6%).

Table 3 shows the percentage of skaters using the four types of protective equipment by skill level. Skaters in the beginner group were significantly more likely to wear all four types of gear. Use of helmets, elbow pads, and kneepads dropped for average skaters and then increased for advanced skaters. Use of wrist guards was highest among beginners, then declined for average skaters, and declined further for advanced skaters.

In table 4, the four types of protective gear are considered together. The two largest categories are comprised of skaters who wore no protective gear (n = 824) and those who wore only one type of gear (n = 839); 539 skaters wore two to four types of gear. Only independent variables that were significantly related to use of protective gear are depicted in the table. Females, skaters age 0–12 and 50+, beginners, and skaters on bicycle paths wore the most protective gear.

Results not reported in tables show that among street skaters none were in the beginner category, compared with 9.2% beginners on sidewalks, and 8.7% on bicycle paths (p<0.001). Use of protective gear was not significantly related to the weekday or weekend, number of passing skaters per hour, temperature, or month observed.

Discussion

Males are at higher risk for all types of injuries,¹⁰ including skating related injuries.^4,5 Ellis reports that, “Approximately twice as many boys as girls were injured in sports-related activities as compared to a 4 to 1 ratio in in-line skating”.⁵ Schieber and Branche-Dorsey hypothesized this may be due to (1) more males skating than females; (2) lesser ability of males; or (3) more risky behavior among males (p429).⁴

Our data support two out of three of these explanations.⁴ In Boston, one would expect more male skaters to be injured because males comprise about 70% of skaters and they take greater risks. Not only do they wear less protective equipment, they are also more likely to skate on streets with traffic. Our data do not support the notion, however, that more males are injured because they are less skilled.

There is some evidence that beginners are at higher risk for sustaining skating related injuries. In their case series of 57 injured skaters in New York and Chicago, Callé and Eaton report that 60% were novice skaters and 30% were intermediate.³ Similar findings have been reported for roller skaters.^11,12 However, a recent study claims that advanced skaters are at higher risk of injury.¹³ More experienced skaters tend to skate at more dangerous locations such as on the street, perform tricks, and skate more hours, making them more prone to injury than novice skaters. The conventional wisdom that novice skaters are at higher risk of injury may be a dangerous myth encouraging skaters to stop wearing protective equipment when they become more proficient.

This study is based on observation of 2210 skaters in one section of Boston in 1996 and 1997. Percentages of skaters wearing various types of protective gear would likely differ in other cities, as would the percentage wearing gear in Boston over time. Generalizability is limited given the geographic and time bound nature of these data.

Implications for prevention

The low percentage of skaters observed wearing helmets (5.7%) is appalling. Two papers by Schieber and colleagues focus on head injury.^4,14 Although the incidence of head injury is much lower than other types of skating injuries, head injuries can result in serious long term disabilities. It is important to dispel popular myths that helmets are uncomfortable, unnecessary at certain times (for example, when skating on paths away from motorists), or unnecessary for certain individuals (for example, experienced skaters).

According to our data, young males are at highest risk of skating related injuries because they skate more, are more likely to skate in dangerous locations, and wear less protective gear than females. Given the higher risks for males, clinicians and public health experts need to target males for prevention efforts. Convincing males to follow the “rules of the road” and to wear protective gear would reduce the number and severity of injuries.

Along with males, moderately skilled and expert skaters should also be targeted for injury prevention efforts. These data show that moderately skilled skaters are less likely to wear protective gear than either beginning or advanced skaters. Motivating these average skaters to emulate more safety conscious advanced skaters would be a major public health accomplishment. Convincing average and expert skaters to always wear all the gear would prevent many head and extremity injuries.