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Abstract
Background/aim Recent rule changes regarding the safety of basketball athletes necessitate up-to-date reports of injury incidence. This study describes the epidemiology of injuries in men's and women's National Collegiate Athletic Association (NCAA) basketball during the 2009/2010–2014/2015 seasons.
Methods Basketball injury data originate from the 2009/2010–2014/2015 academic years from the NCAA Injury Surveillance Program (NCAA-ISP) from 78 men's and 74 women's NCAA basketball programmes which provided 176 and 181 team-seasons, respectively. A reportable injury occurred during organised practice or competition and required attention from an athletic trainer (AT) or physician. Injury rates, injury proportions and rate ratios (RRs) were calculated. All 95% CIs not containing 1.0 were considered statistically significant.
Results A total of 2308 and 1631 injuries were reported in men's and women's basketball, respectively, for injury rates of 7.97 and 6.54/1000 athlete-exposures (AEs). The rate was higher in men than women (RR=1.22; 95% CI 1.15 to 1.30). Non-time-loss (NTL) injuries (resulting in participation restriction time under 24 hours) accounted for 64.8% and 53.6% of men's competition and practice injuries, respectively, and 53.9% and 51.3% of women's competition and practice injuries, respectively. Injuries to the lower extremity were the most common in competitions (men: 54.9%; women: 59.0%) and practices (men: 62.4%; women: 67.3%). The most common injury in men's and women's basketball was ankle sprain (17.9% and 16.6%, respectively).
Conclusions NTL injuries account for over half of all injuries in basketball. Most injuries were lower extremity injuries, specifically ankle sprains. While rule changes have been implemented to make basketball safer, continued research is needed to assess the effectiveness of these changes.
- Basketball
- Sporting injuries
- Ankle
- Concussion
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Introduction
Over 34 000 student-athletes play men's and women's collegiate basketball in the National Collegiate Athletic Association (NCAA).1 The NCAA has a long history sponsoring basketball, with the first men's and women's championships held in 1939 and 1982, respectively.2 ,3 Two comprehensive analyses explored the epidemiology of injuries in men's and women's collegiate basketball from 1988/1989 to 2003/2004,2 ,3 with additional research addressing ankle and knee injury incidence and prevention.4–8
Although more recent publications have discussed basketball injuries at the high school9 and elite levels,10 more recent data on the epidemiology of collegiate basketball injuries are needed. Previous research2 ,3 also did not account for non-time-loss (NTL) injuries, or those resulting in time loss under 24 hours. Such exclusion does not account for the full breadth of injuries sustained by basketball athletes. Additionally, new rules and policies have been implemented related to gameplay.11 In 2010, the NCAA introduced concussion policies requiring mandatory education, immediate removal from play, elimination of same-day return to play and clearance by a medical professional after a concussion.12 Furthermore, the NCAA Rules Committee has emphasised safety points, including mitigating excessive elbow swinging, ball handler contact and player control fouls related to blocking or charging.11 Men's basketball extended the three-point line in 2008 and implemented a restricted area arc under the basket in 2011; Division I men's and women's basketball also introduced a 30 s shot clock.12–14 Rule changes support the need for updated reporting of injury rates to evaluate any improvements in game safety.
Given the paucity of current epidemiological data, alongside recent safety and rule changes, this study describes the incidence of injuries sustained in men's and women's NCAA basketball in the 2009/2010–2014/2015 seasons.
Methods
Data originate from the NCAA Injury Surveillance Program (NCAA-ISP), which is managed by the Datalys Center for Sports Injury Research and Prevention (Datalys Center). Data on men's and women's basketball injuries are from the 2009/2010 to 2014/2015 academic years. The NCAA-ISP methodology has been previously described15 and is summarised below.
Data collection
The NCAA-ISP depends on a convenience sample of NCAA varsity sport teams with athletic trainers (ATs) reporting injury and exposure data. Participating ATs reported injuries in real time through their electronic health record application throughout the academic year. Common data elements, including injury and exposure information, are de-identified, recoded and exported to an aggregate database. Only varsity-level practice and competition events were included in the NCAA-ISP data sets. Junior varsity programmes, as well as any individual weight-lifting and conditioning sessions, were excluded. Programmes can choose to participate on a voluntary basis, and participation varies by sport and year.
For each event, the AT completed a detailed event report on the injury or condition (eg, body part, diagnosis) and the circumstances (eg, activity, mechanism, event type (ie, competition or practice)). ATs were able to view and update previously submitted information as needed. Additionally, ATs provided the number of student-athletes participating in each practice and competition. Final diagnoses were used for each injury—for example, an ankle sprain initially that was later confirmed to be a fracture was coded as a fracture. Injury mechanism was ascertained through a combination of self-report and external partner. The player and trainer assisted in forming the final mechanisms. In times of uncertainty, collateral information was obtained from players, coaches and video when available.
Prior to arriving to the Datalys Center, data were stripped of any identifiers and personally identifiable information (eg, name, date of birth, insurance information), retaining only relevant variables and values.15 Exported data passed through an automated verification process that conducted a series of range and consistency checks. Data were reviewed and flagged for invalid values. The automated verification process would notify the AT and data quality assurance staff, who would assist the AT in the resolution of questionable values. Data that passed the verification process were then placed into sport-specific aggregate datasets for use by researchers.
Definitions
A reportable injury in the NCAA-ISP was defined as an injury that (1) occurred as a result of participation in an organised intercollegiate practice or competition and (2) required attention from an AT or physician. Multiple injuries occurring from one injury event could be included. Time-loss (TL) injuries were those injuries that resulted in participation restriction for at least 24 hours. In particular, severe injuries16 resulting in time loss over 3 weeks, or injuries where the student-athlete or medical professional chose to prematurely end their season were examined. NTL injuries defined as those injuries resulting in participation restriction for <24 hours were also included.
A reportable athlete-exposure (AE) was defined as one student-athlete participating in one NCAA-sanctioned practice or competition in which he or she was exposed to the possibility of athletic injury, regardless of the time associated with that participation. Athletes listed on the game roster for each competition were included in competition AE. If an athlete warmed up prior to a game but did not play, this was counted as an AE. This method is known as the ‘athlete-participation’ method and has potential to underestimate injury rates, which is elaborated on in the Discussion section.17 ,18 In addition, if an injury took place during pregame warm-ups, this was counted as a competition-related injury.
Body parts injured were categorised as head/face, neck, shoulder, arm/elbow, hand/wrist, trunk (including chest, abdomen, upper back and lower back), hip/groin, upper leg, knee, lower leg, ankle, foot and other. Diagnoses were categorised as sprain, strain, contusion, concussion, fracture, dislocation, inflammation, laceration, spasm, tendonitis and other. In addition, ‘knee internal derangement’ included any isolated or combination of anterior cruciate ligament (ACL), posterior cruciate ligament, collateral ligament (medial or lateral, not differentiated) or meniscus (medial or lateral, not differentiated) injury.
Statistical analysis
Data were analysed using SAS Enterprise Guide software (V.5.1; SAS Institute, Cary, North Carolina, USA) for statistical analyses, including the calculation of injury rates and proportions, rates, rate ratios (RRs) and injury proportion ratios (IPRs). The injury rate was calculated as the number of injuries per 1000 AEs. All 95% CIs not containing 1.0 were considered statistically significant. This study was approved by the (name removed for blind review).
Results
Overall incidence and rates
Men's basketball
ATs reported 2308 injuries across 176 team-seasons from 78 programmes over 6 years. A total of 1454 (63.0%) occurred during practice; 854 (37.0%) occurred during competition (table 1). Most injuries occurred in the regular season (68.2%, n=1573); 28.1% (n=649) and 3.7% (n=86) occurred in the preseason and postseason, respectively. In total, 57.7% (n=1332) were NTL injuries, 39.9% (n=921) were TL injuries and 2.4% (n=55) were missing this information. Additionally, 5.1% (n=117) of all injuries were severe; 3.7% (n=86) resulted in surgery. These injuries occurred during 289 406 AEs, for an injury rate of 7.97/1000 AEs (95% CI 7.65 to 8.30). Competition rates were higher than practice rates among all injuries (RR=2.12; 95% CI 1.95 to 2.31), NTL injuries (RR=2.56; 95% CI 2.30 to 2.86) and TL injuries (RR=1.63; 95% CI 1.41 to 1.87).
Injury rates and 95% CIs by time in season and type of athlete-exposure (AE) in NCAA men's and women's basketball, 2009/2010–2014/2015*
Women's basketball
ATs reported 1631 injuries across 181 team-seasons from 74 programmes over 6 years. A total of 1021 (62.6%) occurred during practice; 610 (37.4%) occurred during competition (table 1). Most injuries occurred in the regular season (69.4%, n=1132); 27.7% (n=452) and 3.8% (n=62) occurred in the preseason and postseason, respectively. In total, 52.3% (n=853) were NTL and 43.9% (n=716) were TL injuries, with 3.8% (n=62) missing this information. Additionally, 9.4% (n=154) of all injuries were severe; 5.0% (n=81) resulted in surgery. These injuries occurred during 249 506 AEs, for an injury rate of 6.54/1000 AEs (95% CI 6.22 to 6.85). Competition rates were higher than practice rates among all injuries (RR=1.96; 95% CI 1.77 to 2.16), NTL injuries (RR=2.06; 95% CI 1.79 to 2.36) and TL injuries (RR=1.87; 95% CI 1.60 to 2.18).
Sex differences
Basketball injury rates were higher in men than women except in preseason competitions and postseason practices (table 1). TL injury rates were higher in men versus women in practice, and overall. The severe injury rate in women was larger than that in men (RR=1.93; 95% CI 1.24 to 2.99). However, the rate of injuries requiring surgery did not differ between men and women (0.30 vs 0.32/1000 AE; RR=0.92; 95% CI 0.68 to 1.24).
Body sites injured
The lower extremity comprised the largest proportion of injuries in competitions (men: 54.9%, n=469; women: 59.0%, n=360) and practices (men: 62.4%, n=908; women: 67.3%, n=683; table 2). Additionally, the knee had the largest proportion of severe injuries.
Injury counts, percentages and rates per 1000 athlete-exposures (AEs) by body part injured and type of event in NCAA men's and women's basketball, 2009/2010–2014/2015*
Many body part-specific injury rates were higher in men than in women. For example, compared with women, men had higher injury rates for the hip/groin in competitions (RR=3.22; 95% CI 1.74 to 5.96) and the ankle in practices (RR=1.53; 95% CI 1.27 to 1.85). The sole instance where the body part-specific injury rate was larger for women than men was for lower leg injuries in practices (RR=1.74; 95% CI 1.33 to 2.27).
Diagnoses
Sprains, strains and contusions comprised the largest proportion of injuries; fractures had the largest proportion of severe injuries (table 3). Many diagnosis-specific rates varied by sex. For example, compared with women, men had higher injury rates for fractures in competitions (RR=1.81; 95% CI 1.02 to 3.19) and sprains in practices (RR=1.69; 95% CI 1.39 to 1.90). Meanwhile, compared with men, women had higher injury rates for concussions in competitions (RR=1.92; 95% CI 1.26 to 2.95) and inflammation in practices (RR=2.04; 95% CI 1.37 to 3.02).
Injury counts, percentages and rates per 1000 athlete-exposures (AEs) by diagnosis and type of event in NCAA men's and women's basketball, 2009/2010–2014/2015*
Injury mechanisms
Player contact, followed by non-contact, surface contact and overuse, comprised the largest proportion of injury mechanisms (table 4). In men's basketball, other contact (comprising contact with the backboard, rim or any out-of-bound object) comprised the largest proportion of severe injuries (23.1% and 12.5% in competitions and practices, respectively). In women's basketball, non-contact comprised the largest proportion of severe injuries (14.7% and 14.0% in competitions and practices, respectively). Compared with women, men had higher injury rates for player contact in competitions (RR=1.46; 95% CI 1.26 to 1.70), and in practices (RR=1.72; 95% CI 1.50 to 1.97), and surface contact in practices (RR=1.48; 95% CI 1.16 to 1.89). Meanwhile, compared with men, women had a higher injury rate for overuse in practices (RR=1.66; 95% CI 1.35 to 2.05).
Injury counts, percentages and rates per 1000 athlete-exposures (AEs) by injury mechanism and type of event in NCAA men's and women's basketball, 2009/2010–2014/2015*
Common injuries
The most common injury in men's and women's basketball was an ankle sprain (17.9% and 16.6% of all injuries, respectively; table 5). Other common injuries in both sports included concussion, knee internal derangement and hip/groin strain. The ankle sprain rate was higher in men than women (RR=1.32; 95% CI 1.13 to 1.54).
Common injuries in NCAA men's and women's basketball, 2009/2010–2014/2015*
Among men and women, 79 and 92 knee internal derangements were reported. The knee internal derangement rate was higher in women than men (RR=1.35; 95% CI 1.00 to 1.82), and was primarily due to the difference in ACL tears (men: n=18; women: n=44). The ACL rate was higher in women than men (RR=2.84; 95% CI 1.64 to 4.91).
Discussion
Our study updated previous research regarding the descriptive epidemiology of collegiate basketball injuries.2 ,3 It includes NTL injuries to better describe the breadth of injuries diagnosed and managed by ATs and team medical staff. The results support prior findings and add insight into the profile of collegiate basketball injuries.
We found that 57.7% of men's and 52.3% of women's basketball injuries were NTL. The inclusion of NTL injuries in injury surveillance provides a better understanding of the continuum of injuries detected and managed by ATs and team medical staff. However, data from Powell and Dompier19 reported larger proportions of injuries reported as NTL (78.3% and 80.6% for men and women, respectively), which led to higher injury rates compared with our study (27.8 and 31.2/1000 AEs for men and women, respectively). The manner in which ATs report NTL injuries may vary across medical record systems and studies. The extent to which ATs monitored NTL injuries may have also varied. Furthermore, research at the high school level also noted variations in the reporting of NTL injuries among ATs employed in different settings (full time vs outreach).20 These findings highlight the need for continued exploration of NTL injuries as well as other conditions causing unspecified pain, but not participation restriction time.21
Compared with previous studies examining NCAA men's and women's basketball injuries, our study reported TL injury rates are lower.2 ,3 During the 1988/1989–2003/2004 academic years, TL injury rates in men's basketball were reported as 9.9 and 4.3/1000 AEs for competitions and practices, respectively,2 and 7.7 and 4.0/1000 AEs for women's competitions and practices, respectively.3 Our TL injury rates are also lower than rates reported by Powell and Dompier19 that included NCAA, National Association of Intercollegiate Athletics (NAIA) and National Junior College Athletic Association (NJCAA) data from the 2000/2001–2001/2002 academic years (6.0 and 6.1/1000 AEs overall for men and women, respectively). The reduction in TL injuries is a noteworthy finding and may represent improved safety in NCAA basketball, possibly due to recent rule changes. Another explanation is that previously recorded TL injuries may in fact have been NTL injuries, which led to falsely inflated representation of TL injuries. Overall, it is our hope that further description of TL and NTL injuries more accurately depicts the nature of injuries in NCAA basketball and provides baseline information for future research studies.
The NCAA has made efforts to ensure player safety through rule changes such as the extension of the three-point line and the restricted arc under the basket.12–14 As our study does not specifically examine injuries directly related to shooting or playing within those specific areas on the court, more specific research regarding these playing activities is recommended. Also, our findings may differ from previous findings due to changes in data collection; data collection prior to 2004 used paper-and-pencil reports that were faxed to the NCAA.2 ,3 ,15 As current data collection relies on pre-existing electronic health record applications that are used in day-to-day clinical practice, we believe these data may better capture injuries than seen in previous efforts.22
Studies in the National Basketball Association (NBA) and Women's NBA (WNBA) have found competition injury rates inclusive of TL and NTL injuries (19.1 and 24.9/1000 AEs for men and women, respectively) that exceed those reported in our study.23 ,24 TL injury rates in high school athletes (2.08 and 1.83/1000 AEs for boys and girls, respectively) were lower than those reported in our study.9 Our findings, in the context of these studies, may suggest that injury rates increase with higher competition levels. This increase may be due to the higher intensity of gameplay in more elite athletes. Nevertheless, because varying injury rates may also be the result of varying methodologies, more research is needed to be able to more validly compare injury incidence and severity across levels and within athletes across time. It is unknown whether the numbers of athletes that play in a collegiate versus professional game are similar or different. Furthermore, the difference in game length of 40 vs 48 min provides another potential source of bias.
Compared with women, men had a higher injury rate for all injuries (TL and NTL) and TL injuries only; however, women had a higher severe injury rate than men. These findings were consistent in strata of all injuries, practice injuries and competition injuries. This is also consistent with the previous epidemiological studies of basketball injuries,2 ,3 where ∼25% of women's game and practice injuries, and ∼18% of men's game and practice injuries restricted participation for at least 10 days.
Our findings may also suggest there is increased physicality of men's basketball compared with women's basketball. Compared with women, men had higher injury rates related to player contact in competitions and practices and surface contact in practices. Additionally, player contact was the most common injury mechanism involved in ankle sprain, hand/wrist sprain, concussion and head/face laceration. Better enforcement of rules and coaching that emphasises less intentional fouls may mitigate the incidence of falls and other unintentional contact with the floor, potentially limiting injury incidence related to floor surface. Furthermore, the court layout may present safety issues that can be addressed by individual schools, as evidence by the proportion of men's injuries that were ‘severe’ and classified as ‘other contact’.
The ankle was the most commonly injured body part in men and women, which parallels previous findings from 15 NCAA sports,25 as well as individual sports such as soccer and volleyball from high school to the professional level.3 ,26 ,27 Ankle injury prevention strategies have included improvements in shoe design, orthoses, taping, neuromuscular training and muscular strengthening.5 ,28 ,29
Concussions comprised 4.6% and 8.1% of all injuries reported in men's and women's basketball, respectively. In 2010, the NCAA Executive Committee adopted a new concussion policy,12 which mandated immediate removal of play of individuals suspected of being concussed and eliminated same-day return to play.30 In the NCAA-ISP data, a number of concussions were returned to play in <24 hours. This may be the result of athletes presenting with delayed concussion symptoms. The need for sufficient recovery time from all injuries is important, but even more crucial when managing concussions. While recent research has found that in general, concussed collegiate athletes are being held out longer than previously,31 the same data from 2009/2010 to 2013/2014 found a near-significant trend of increasing concussions in men's basketball.32 In a group of elite female basketball players, the per cent of injuries that were concussions doubled in 2005 and quadrupled in 2006, compared with 2000.10 Although these increases are likely the result of better education and knowledge, leading to increased reporting and detection of concussion, it is imperative to continue to educate athletes, ATs, parents, coaches and officials associated with collegiate basketball on recognition and management of concussion, with a focus on proper return to play.
Compared with men, women had higher injury rates related to overuse in practices. This is consistent with existing studies of injuries in college athletes.33 This may be due to sex differences in healthcare usage, biomechanics, joint laxity, the physiological response to microtrauma associated with overuse injuries, and differences in coaching and training.33 Alteration in practice and conditioning programmes may mitigate the impact of these injuries.33 Most importantly, these interventions should be used in men's and women's basketball to reduce the impact of injuries to all basketball athletes.
Limitations
The NCAA-ISP uses a convenience sample of NCAA men's and women's basketball programmes and may not be generalisable to non-participants, or other levels of competition. Moreover, the rigor and physicality of team practice or warm-up is an important factor that could not be quantified nor controlled for. Variations in rules, substitutions and warm-up patterns between men's and women's basketball, and different divisions of NCAA basketball, may have confounded reported injury rates. Last, the AE also does not account for the amount of time that each individual athlete participates in each event; thus, an athlete that plays for an entire game provides 1 AE just as an athlete that only participates in warm-ups. As previously stated, this method for quantifying AE, known as the athlete-participation method, has potential to underestimate game injury rates as it may overestimate exposure time.17 This methodological aspect of our analysis must be recognised to accurately interpret injury patterns.17 In this scenario, as aptly pointed out in an editorial highlighting sports epidemiological principles, the magnitude of the underestimation will depend on the ratio of athletes on the field to the number of athletes who played in that game.17 Furthermore, it should be noted that this method helps to reduce reporting burden placed on the AT who can simply make a player count at the beginning of the game rather than having to keep track of substitutions during the game. Nevertheless, future research should aim to find consensus in the most valid and reliable method for tracking at-risk exposure time in basketball.
Conclusion
NTL injuries account for over half of all injuries in NCAA men's and women's basketball. Most injuries were to the lower extremity injuries, specifically ankle sprains. TL injury rates reported in this study are lower than those previously reported.2 ,3 Although rule changes may explain such lower rates, continued research is needed to assess the effectiveness of these changes. Continued longitudinal surveillance will also detect trends in injury rates, particularly related to NTL injuries and specific diagnoses such as concussion and ankle sprains.
What are the findings?
The study updated previous findings related to US collegiate basketball players by examining time-loss (TL) and non-time-loss (NTL) injuries.
NTL injuries account for over half of all injuries in basketball.
Most injuries were to the lower extremity injuries, specifically ankle sprains.
Men sustain injury more commonly from contact with another player, while women sustain injury more commonly from overuse and non-contact.
How might it impact on clinical practice?
Athletic trainers and coaches can encourage reporting of NTL injuries to ensure player safety.
Healthcare professionals can more closely monitor contact injuries among men and overuse and non-contact injuries among women.
Though lower extremity injuries and ankle sprains are the most common, ATs and coaches should continue to monitor closely for concussions, given recent legislation.
Acknowledgments
The NCAA Injury Surveillance Program data were provided by the Datalys Center for Sports Injury Research and Prevention. The Injury Surveillance Program was funded by the NCAA. The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the NCAA. The authors thank the many ATs who have volunteered their time and efforts to submit data to the NCAA Injury Surveillance Program. Their efforts are greatly appreciated and have had a tremendously positive effect on the safety of collegiate athletes.
References
Footnotes
Contributors ZYK led the creation of the study. ZYK, SLZ and AMW led the analysis of the study and drafting of the manuscript. The remaining authors, KGR, AD and TPD, assisted with editing and revision of the manuscript. All authors approved the final manuscript as presented.
Funding The NCAA Injury Surveillance Program data were provided by the Datalys Center for Sports Injury Research and Prevention. The Injury Surveillance Program was funded by the NCAA.
Competing interests None declared.
Ethics approval Ethics approval was given by the National Collegiate Athletic Association Research Review Board.
Provenance and peer review Not commissioned; externally peer reviewed.