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J Athl Train. 2007 Apr-Jun; 42(2): 202–210.
PMCID: PMC1941290

Descriptive Epidemiology of Collegiate Women's Basketball Injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 Through 2003–2004

Julie Agel, MA, ATC,* David E Olson, MD, CAQ Primary Care Sports Medicine,* Randall Dick, MS, FACSM, Elizabeth A Arendt, MD,* Stephen W Marshall, PhD, and Robby S Sikka§

Abstract

Objective: To review 16 years of National Collegiate Athletic Association (NCAA) injury surveillance data for women's basketball and to identify potential areas for injury prevention initiatives.

Background: The number of colleges participating in women's college basketball has grown over the past 25 years. The Injury Surveillance System (ISS) has enabled the NCAA to collect and report injury trends over an extended period of time. This has allowed certified athletic trainers and coaches to be more informed regarding injuries and to adjust training regimens to reduce the risk of injury. It also has encouraged administrators to make rule changes that attempt to reduce the risk of injury.

Main Results: From 1988–1989 through 2003–2004, 12.4% of schools across Divisions I, II, and III that sponsor varsity women's basketball programs participated in annual ISS data collection. Game and practice injury rates exhibited significant decreases over the study period. The rate of injury in a game situation was almost 2 times higher than in a practice (7.68 versus 3.99 injuries per 1000 athlete-exposures, rate ratio = 1.9, 95% confidence interval = 1.9, 2.0). Preseason-practice injury rates were more than twice as high as regular-season practice injury rates (6.75 versus 2.84 injuries per 1000 athlete-exposures, rate ratio = 2.4, 95% confidence interval = 2.2, 2.4). More than 60% of all game and practice injuries were to the lower extremity, with the most common game injuries being ankle ligament sprains, knee injuries (internal derangements and patellar conditions), and concussions. In practices, ankle ligament sprains, knee injuries (internal derangements and patellar conditions), upper leg muscle-tendon strains, and concussions were the most common injuries.

Recommendations: Appropriate preseason conditioning and an emphasis on proper training may reduce the risk of injury and can optimize performance. As both player size and the speed of the women's game continue to increase, basketball's evolution from a finesse sport to a high-risk contact sport also will continue. The rates of concussions and other high-energy trauma injuries likely will increase. The NCAA ISS is an excellent tool for identifying new risk factors that may affect injury rates and for developing consistent injury definitions in order to improve the research and provide a source of clinically relevant data.

Keywords: athletic injuries, injury prevention, ankle sprains, knee injuries, anterior cruciate ligament injuries, stress fractures, concussions

The National Collegiate Athletic Association (NCAA) conducted its first women's basketball championship in 1982. In the 1988–1989 academic year, 766 schools were sponsoring varsity women's basketball teams, with 10 345 participants. By 2003–2004, the number of varsity teams had increased 34% to 1026, involving 14 596 participants. 1 Participation growth during this time has been apparent in all 3 divisions but particularly in Divisions II and III.

SAMPLING AND METHODS

Over the 16-year period from 1988–1989 through 2003– 2004, an average of 12.4% of schools sponsoring varsity women's basketball programs participated in annual NCAA Injury Surveillance System (ISS) data collection ( Table 1). The sampling process, data collection methods, injury and exposure definitions, inclusion criteria, and data analysis methods are described in detail in the “Introduction and Methods” article in this special issue. 2

Table 1
School Participation Frequency (in Total Numbers) by Year and National Collegiate Athletic Association (NCAA) Division, Women's Basketball, 1988–1989 Through 2003–2004*

RESULTS

Game and Practice Athlete-Exposures

The average annual numbers of games, practices, and athletes participating for each NCAA division, condensed over the study period are shown in Table 2. Division I annually averaged 10 more practices than Division II and 24 more than Division III. Divisions I and II annually played 2 to 3 more games than Division III. Mean numbers of participants per practice and per game were similar in all divisions.

Table 2
Average Annual Games, Practices, and Athletes Participating by National Collegiate Athletic Association Division per School, Women's Basketball, 1988–1989 Through 2003–2004

Injury Rate by Activity, Division, and Season

Over the 16 years of the study, the rate of injury in a game situation was almost 2 times higher than in a practice (7.68 versus 3.99 injuries per 1000 athlete-exposures [A-Es], rate ratio = 1.9, 95% confidence interval [CI] = 1.9, 2.0; Figure 1). There were statistically significant decreasing linear trends in the injury rates in games (average annual change: −1.8%, P = .04) and practices (average annual change: −1.3%, P = .05) over the sample period.

Figure 1
Injury rates and 95% confidence intervals per 1000 athlete-exposures by games, practices, and academic year, women's basketball, 1988–1989 through 2003–2004 (n = 3556 game injuries and 6655 practice injuries). Game time trend, ...

The total number of games and practices and associated injury rates, condensed over the study period, by division and season (preseason, in season, postseason) are presented in Table 3. During this time, 3556 injuries from more than 45 000 games and 6665 injuries from more than 134 000 practices were reported. Game injury rates were higher in Division I than in Division II (8.85 versus 7.43 injuries per 1000 A-Es, rate ratio = 1.2, 95% CI = 1.1, 1.3, P = .01) and Division III (8.85 versus 6.62 injuries per 1000 A-Es, rate ratio = 1.3, 95% CI = 1.3, 1.5, P < .01). Across all divisions, preseason-practice injury rates were more than twice as high as regular-season practice rates (6.75 versus 2.84 injuries per 1000 A-Es, rate ratio = 2.4, 95% CI = 2.2, 2.4, P < .01), and regular-season game injury rates were significantly higher than those in the postseason (7.74 versus 5.52 injuries per A-Es, rate ratio =1.4, 95% CI = 1.2, 1.7, P < .01).

Table 3
Games and Practices With Associated Injury Rates by National Collegiate Athletics Association Division and Season, Women's Basketball, 1988–1989 Through 2003–2004*

Body Parts Injured Most Often and Specific Injuries

The frequency of injury to 5 general body areas (head/neck, upper extremity, trunk/back, lower extremity, and other/system) for games and practices with years and divisions combined is shown in Table 4. More than 60% of all game and practice injuries were to the lower extremity. Approximately 15% of all game injuries involved the head and neck and another 14% involved the upper extremity.

Table 4
Percentage of Game and Practice Injuries by Major Body Part, Women's Basketball, 1988–1989 Through 2003–2004

The most common body part and injury type combinations for games and practices with years and divisions combined are displayed in Table 5; all injuries that accounted for at least 1% of reported injuries over the 16-year sampling period were included. In games, ankle ligament sprains (24.6%), knee internal derangements (15.9%), concussions (6.5%), and patellar problems (2.4%) accounted for the majority of injuries. In practices, ankle ligament sprains accounted for 23.6% of all reported injuries, whereas knee internal derangements (9.3%) and patellar injuries (4.0%) together accounted for another 13.3%; upper leg muscle-tendon strains (5.0%) and concussions (3.7%) were other common injury categories. Thirty percent of ankle ligament injuries were identified as recurrent sprains. In a game versus a practice, participants were more than 3 times more likely to sustain a concussion (0.50 versus 0.15 injuries per 1000 A-Es, rate ratio = 3.3, 95% CI = 2.8, 4.0), more than 3 times as likely to sustain a knee internal derangement (1.22 versus 0.37 injuries per 1000 A-Es, rate ratio = 3.3, 95% CI = 2.9, 3.7), and twice as likely to sustain an ankle ligament sprain (1.89 versus 0.95 injuries per 1000 A-Es, rate ratio = 2.0, 95% CI = 1.8, 2.2).

Table 5
Most Common Game and Practice Injuries, Women's Basketball, 1988–1989 Through 2003–2004

Mechanism of Injury

The 3 primary injury mechanisms—player contact, other contact (eg, balls, standards, floor), and no contact—in games and practices with division and years combined are presented in Figure 2. Most game injuries (46%) resulted from player contact. The remaining game injuries were distributed approximately equally between no contact (29%) and other contact (24%). The majority of practice injuries (47%) involved no contact.

Figure 2
Game and practice injury mechanisms, all injuries, women's basketball, 1988–1989 through 2003–2004 (n = 3556 game injuries and 6655 practice injuries). “Other contact” refers to contact with items such as balls, standards, ...

Severe Injuries: 10+ Days of Activity Time Loss

The most common injuries that resulted in at least 10 consecutive days of restricted or total loss of participation and their primary injury mechanisms combined across divisions and years are reported in Table 6. For this analysis, time loss of 10+ days was considered a measure of severe injury. Approximately 25% of both game and practice injuries restricted participation for at least 10 days. In both games and practices, lower extremity (knee, lower leg, ankle, and foot) problems accounted for most of these more-severe injuries. Noncontact mechanisms were associated with the majority of severe knee injuries, whereas most severe ankle ligament sprains were associated with player contact. Concussions accounted for 3.4% of severe game injuries, most of which were contact injuries. Stress fractures associated with the foot and lower leg accounted for 15.0% of severe practice injuries.

Table 6
Most Common Game and Practice Injuries Resulting in 10+ Days of Activity Time Loss, Women's Basketball, 1988–1989 Through 2003–2004

Game Injuries

Game injury mechanisms are shown in more detail in Figure 3. Contact with another player and no contact were the most commonly reported game injury mechanisms accounting for more than 50% of injuries. Contact with the floor accounted for 19.2% of game injuries. Very few injuries were associated with contact with the standard or rim or running into an out-of-bounds apparatus.

Figure 3
Sport-specific game injury mechanisms, women's basketball, 1988–1989 through 2003–2004 (n = 3556)

The mechanisms of anterior cruciate ligament (ACL) injuries in games are displayed in Figure 4. Injuries to the ACL accounted for 8% of all game injuries in women's basketball (0.66 injuries per 1000 A-Es); of these, 64% occurred as a result of noncontact injury mechanisms.

Figure 4
Game anterior cruciate ligament injury mechanisms, women's basketball, 1988–1989 through 2003–2004 (n = 265)

Stress Fractures

Stress fractures were recorded in a variety of anatomic areas; 50% affected the foot, with an additional 39% affecting the lower leg. A total of 80% of stress fractures required at least 10 days of time lost from activity; 25% of all stress fractures reported were classified as recurrent injuries, with 75% of these requiring at least 10 days of time loss. The stress-fracture injury rate (ie, any stress fracture during any exposure) increased from 0.10 per 1000 A-Es in 1988–1989 to 0.19 per 1000 A-Es in 2003–2004. The rate peaked in 2001–2002 at 0.34 per 1000 A-Es but has been higher than 0.16 per 1000 A-Es since 1994–1995 (data not shown). This was a significant increase over time ( P < .01).

COMMENTARY

Participation in women's sports has increased since the advent of Title IX in the 1970s and, according to the NCAA, more colleges sponsored women's soccer, basketball, and lacrosse teams than corresponding men's teams in 2003. 3 Because women's participation at all levels of athletics has increased dramatically in recent years, attention has shifted to the characterization of injuries in female athletes. Although not considered a collision sport, basketball is a fast and aggressive sport that has been shown to have a high frequency of injury. 4

Despite increases in the number of schools reporting to the ISS over the 16-year time period, the overall injury rates have decreased in both the game and practice environments. Game rates were consistently higher than their comparable practice rates; however, when compared with game injury rates in women's professional basketball (24.9 per 1000 A-Es, 95% CI = 22.9, 26.9, P < .05), 5 all women's collegiate rates were substantially lower. The overall men's NCAA basketball game injury rate of 9.9 per 1000 A-Es (95% CI = 9.7, 10.2) was also consistently and significantly higher than the overall women's NCAA basketball game injury rate of 7.7 per 1000 A-Es (95% CI = 7.4, 7.9). 6

Division I preseason games had the highest overall rate of injury. Division I preseason practice rates demonstrated the highest injury rate of all practice categories. However, these data do not allow us to determine why these Division I preseason game and practice rates were high and why overall preseason injury rates were higher than in-season and postseason rates.

Games, Practices, and Seasons

As expected, the rate of injuries was higher during games than during practices. Player-to-player contact, increased intensity, and uncontrolled game situations are likely factors contributing to this increased injury rate. The injury rate in regular-season games (7.74 per 1000 A-Es) was 1.4 times higher than in postseason games (5.52 per 1000 A-Es). This finding suggests that players may be more prone to injury earlier in the season. However, this result could also be due to selection bias, as teams that have high injury rates may not reach the postseason.

Preseason practice rates (6.75 per 1000 A-Es) were also more than twice (rate ratio = 2.38) as high as in-season practice injury rates (2.84 per 1000 A-Es). During the preseason, deconditioning from the off-season, increased intensity as players try to earn starting positions, and early season fatigue are all factors associated with an increased risk of injury. Many colleges have athletic trainers, nutritionists, and conditioning coaches who work with the athletes and help them to maintain good conditioning during the season. Yet with year-round training, players often train in the off-season, and when they are not in school, they make their own decisions about frequency of play, what court surface to play on, and what equipment to use. This uncontrolled environment may lead to early season injuries when players return to regular practice at school and may help to explain the increasing number of injuries such as stress fractures.

Preseason conditioning should be carefully planned because it can optimize performance and may reduce the risk of injury. Strength, agility, and flexibility should be emphasized both in the preseason and during the season, with stretching and warm-ups preceding all intensive practices and games. Injury prevention should be emphasized by coaches as much as individual and team skills and basic principles taught to athletes. During practices and games, coaches must be sensitive to the effects of fatigue, recognizing that not only is performance compromised in tired players but also that fatigue may raise the risk of injury. 7

The most common region of injury, accounting for nearly two thirds of injuries in both games and practices, was the lower extremity. Most of these injuries were ankle ligament sprains caused by player contact. Knee internal derangements were the second most common injury, with the primary mechanism for ACL and meniscal injuries being no apparent contact and the primary mechanism for collateral ligament injuries being player-to-player contact. The distribution of occurrence of the 3 injuries was relatively equivalent (data not shown).

Ankle Ligament Sprains

The ankle is the body part most susceptible to injury during basketball games and practices. Ankle sprains are the most frequent injury associated with basketball at all levels of play. 5, 8 Hosea et al 9 reported that women collegiate basketball players had a 25% greater risk of sustaining a grade I ankle sprain than men collegiate basketball players had, but no difference was noted in the rates for grade II and III sprains. The NCAA database does not allow for reporting of grade I, II, and/or III with any degree of confidence, so data in this report include all grades of injury. However, in the ISS data, women basketball players had a lower ankle sprain injury rate than their male counterparts in both games and practices. 6

In 1973, Garrick and Requa 10 showed a protective effect of taping and high-top shoes on the rate of ankle sprains. The combination was particularly effective in players with prior injuries, although the protective effect was also significant among players without a history of ankle injury. McKay et al 11 and Thacker et al 7 confirmed that ankle taping decreased the risk of ankle injury in players with a history of ankle injury. However, changes in shoe technology may limit the practical uses of these findings. 10 A semirigid orthosis protected the ankle in patients with prior ankle injuries (1.6 sprains per 1000 A-Es versus 5.2 per 1000 A-Es in the unprotected ankle), but did not seem to reduce the rate of new sprains. 7, 10 Identifying inversion versus eversion mechanisms of injury and whether players were taped or untaped at the time of injury may be helpful in further defining risk factors as well as monitoring the success of preventive measures.

McKay et al 11 also noted that almost half (45%) of ankle injuries were sustained during landing; another third (30%) occurred during a cutting or twisting maneuver. The NCAA data do not record cutting or twisting maneuvers, but 45% of the reported ligamentous injuries in games and practices combined resulted from the injured player coming down on another player. Players with a history of ankle injury were almost 5 times as likely to sustain another injury as were those without such a history. Published reports suggest ankle-sprain recurrence rates in basketball may be as high as 70%, which is substantially higher than the 30% reported in this population. 12 Thus, athletes with a history of ankle sprains should be educated as to the increased risk after an initial injury, should undergo proper rehabilitation, and should pursue preventive strategies (eg, taping or bracing, balance training).

Other modifiable factors beyond the athlete's control also can influence the incidence of ankle injuries. These include rules to limit and minimize unnecessary or hazardous contact with other players, appropriate officiating, responsible coaches who train athletes safely and prepare them appropriately for competitive activities, and safe, hazard-free facilities.

Meeuwisse et al 4 described the “lane” as the court zone in which the most, as well as the most severe, injuries occurred. Centers tended to be at greatest risk for injury. Increasing the size of the lane from the current NCAA and Women's National Basketball Association regulation size to international regulation size may reduce congestion in the lane and may force players to spread out on the court, thereby decreasing the risk of certain injuries. Also, calling consistent fouls in the lane may decrease the risk of particular injuries. However, increasing the lane size may increase the risk of other injuries, because spread on the court may lead to more cutting, pivoting, and jumping, raising the risk of knee and ankle injuries. Thus, careful studies of modifications in the lane size are needed to help improve our understanding of how rule changes might affect injury rates.

Anterior Cruciate Ligament Injuries

Anterior cruciate ligament injuries accounted for 8% of game injuries in women's collegiate basketball players. The ISS data indicate that 64% of these injuries in games resulted from noncontact mechanisms, 27% from contact, and 8% from other nonplayer contact. However, what constitutes a noncontact injury is not standardized. For example, when a player is jostling for position, has brief contact with another player, and falls to the ground, should this mechanism be classified contact, no contact, or other non-player contact? Observer bias also can play a role. Most ACL injuries likely arise from a combined mechanism, so more rigorous definitions may be helpful and improve accuracy in reporting and, thus, help in the development of preventive regimens.

In 1995, Arendt and Dick 13 reported a higher rate of ACL injuries in female soccer and basketball players compared with male athletes in those sports. Agel et al 14 observed a similar effect in men's and women's basketball over a 13-year period. Deitch et al 5 noted that although the overall frequency of knee ligament injuries in Women's National Basketball Association and National Basketball Association players was low, the women's ACL injury rate was 1.6 times that of the men. Interestingly, the rate of ACL injuries in women was higher at the collegiate level than at the professional level. Deitch et al 5 suggested that this may be a result of attrition and the premature termination of careers that might otherwise include the professional rank.

The neuromuscular system is currently generating the most enthusiasm in the research community, because it may be one of the easiest risk factors to change. Neuromuscular training programs have been developed and implemented to reduce ACL injury risk, and the results have been promising. 15–19

Stress Fractures

The ISS data show an increasing trend in the rate of lower extremity stress fractures. The most common sites reported for stress fractures in female basketball players reported were the lower leg (39%) and foot (50%). These stress fracture results need to be interpreted with caution, as awareness surrounding the injury, diagnostic tools associated with the injury, and treatments of the injury have undergone major changes during the time period of this report, so changes in rates over time may reflect either better diagnostic skills or true increases in rates. Arendt et al 20 reported that the tibia was the bone incurring the largest number of stress injuries in women's basketball players at one institution, but, as in other sports, the foot as an anatomic region accounted for the greatest number of stress injuries. Hame et al 21 noted that women were more susceptible to stress fractures in the foot, whereas their male counterparts were more susceptible to stress fractures about the ankle.

Arendt et al 20 also found that in their population of collegiate athletes, nearly half of the stress injuries (30 of 61) were associated with a change in training regimen. Not only changes in the total volume of training but other specific components of training (eg, increased activities that put torsional stress on the lower extremity skeletal system, such as pivoting) may play a role in the increase in stress fractures over time. 22 The military has had some success in preventing lower extremity stress fractures in basic training recruits using a modified, reduced-running training protocol. 23

In addition, traditional basketball court shoes for women are basically pared-down versions of men's shoes. Because women's lower extremity biomechanical alignment is often different than men's, shoes and/or foot orthotics designed specifically for women may help to disperse stress through the lower kinetic chain in a more efficient manner. The use of shock-absorbing boot inserts among military trainees has shown some injury-reduction benefit. 24

Other potentially modifiable risk factors for stress fractures among physically active females include low cardiorespiratory fitness, lack of resistance training, poor nutrition (eg, low calcium intake, negative energy balance), and menstrual dysfunction. 25–27

Off-season workouts are another area of concern with regard to stress fractures. Today's collegiate athlete has less time to recover and to rest after the end of the season than athletes in the past. Year-round training can result in players being overtrained for the preseason and not having sufficient time to heal from injuries. Addressing these factors with better and more appropriate training techniques and enhanced monitoring of summer workout regimens may help to decrease the risk of injury.

Concussions

Another injury of concern in women's collegiate basketball players is concussion. Although it can be argued that male athletes may be at greater risk for concussions due to their aggressive natures and the faster pace of their sports, female athletes actually may be at greater risk due to their smaller size and weaker neck strength. 28 Covassin et al 29 reported that the concussion injury rate in women's collegiate basketball games increased from 0.54 per 1000 A-Es in the 1997–1998 season to 0.89 per 1000 A-Es in the 1999–2000 season. The ISS data showed a significant average annual increase in the concussion rate of 7.0% ( P < .01) across all sports over time. Although this may reflect a true increase in occurrence over time, it may also reflect increased awareness of concussion symptoms and better diagnostic tools. At the time of data collection, the ISS did not have a standard definition of concussion or a minimum set of required symptoms, so a broad range of injuries may be included in these numbers. Concussions occurred more often in women's collegiate basketball players than in their male counterparts in both games and practices and in the ISS data as well. 29 Deitch et al 5 noted that Women's National Basketball Association players had a concussion rate 3 times that of the National Basketball Association players.

Mouth guards significantly reduce the incidence of dental injuries but have not been shown to substantially decrease the risk of concussions. 28, 30 Although basketball is considered a noncontact sport, the increasing use of elbows during participation heightens the risk of injury for athletes. As the size of players and the speed of the women's game continue to increase, basketball will complete the evolution from a finesse sport to more of a high-risk contact sport. Thus, we expect the incidence of concussions to continue increasing over time.

Areas for Future Research

Young female athletes are participating in more organized sports and are achieving improved levels of fitness. Yet despite these changes in the experience, participation, and fitness of female athletes over the past 10 years, a decreasing trend in injury cannot be identified. Thus, the presumed increased fitness and skill of today's female athletes has not translated into a significant decrease in the risk of injury in women's basketball. 3, 31

We need to better understand further the risk factors that may predispose athletes to injury. Anatomic variations (eg, genu recurvatum, below-normal hamstrings-to-quadriceps strength ratio) and environmental and sport-specific factors that may lead to an increased risk for injury must be identified. 32, 33

Neuromuscular control and balance training may help to reduce the frequency of lower extremity injuries, including ankle sprains and ACL injuries in basketball players. Data from randomized controlled trials designed to address the effectiveness of an intervention are limited, and no specific risk factor has been identified yet. The best age for interventions that effect the most lasting change in neuromuscular function is just beginning to be studied. Compliance with these programs is another concern that rarely has been measured. Ultimately, the training programs that will receive the greatest acceptance by athletes, coaches, and teams are those that demonstrate both performance enhancement and injury reduction.

Improving training techniques and providing athletes with more supervised training programs for the off-season can help us to diminish some suspected, specific risk factors associated with stress fractures. Additionally, further research on the effects of hormone therapy is a promising area that may help to reduce the incidence of stress fractures. 20, 22, 34, 35

Exploring the effects of specific rule changes on injury rates can help us to identify risk factors in games that may predispose players to injury. Exploring the effect of an increased size of the lane in either Division II or Division III and comparing those results with Division I and international basketball competition can help us determine if rule modification will reduce the risk of injury.

Use of the information database provided by the ISS must be improved. As we identify new risk factors that may predispose athletes to injury, the ISS should be flexible enough to add variables to capture more information on these risk factors, leading to possible ways to reduce injury. Consistent definitions of injury should be maintained, and injury mechanisms should be specified accurately to improve the research value and clinical value of the NCAA ISS data. Additionally, in calculating rates of injury, consideration must be given to the choice of denominators (eg, hours of participation versus number of games). If we fail to improve the collection database, we will not take full advantage of this excellent resource.

Conclusions

The ISS data provide information on the general risk and specific types of injuries associated with women's college basketball players over a 16-year period. Overall game and practice injury rates have significantly decreased during this time. Efforts to improve conditioning and training and rule changes designed to decrease the risk of specific injuries have not shown the intended change. Thus, efforts to reduce the injury rate should take on a multifaceted approach. A series of rule and training changes may be more likely than a single specific rule change or training improvement to lead to a long-term decrease in the overall injury rates. It is likely, however, that several specific rule changes, training modifications, and equipment changes can affect the risk of specific injuries in female basketball players.

DISCLAIMER

The conclusions in the Commentary section of this article are those of the Commentary authors and do not necessarily represent the views of the National Collegiate Athletic Association.

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