Pediatr Clin N Am 49 (2002) 769 – 792

Major international sport profiles$

Dilip R. Patel, MDa,*, Bernhard Stier, MDb,
Eugene F. Luckstead, MDc
a
Michigan State University Kalamazoo Center for Medical Studies, 1000 Oakland Drive,
Kalamazoo, MI 49008, USA
b
Pediatrics and Adolescent Medicine, Wetzlarer, Str 25, D-35510 Butzback, Germany
c
Texas Tech Medical School-Amarillo, 1400 Wallace Blvd., Amarillo, TX 79106-1788, USA

Sports are part of the sociocultural fabric of all countries. Although different
sports have their origins in different countries, many sports are now played
worldwide. International sporting events bring athletes of many cultures together
and provide the opportunity not only for athletic competition but also for socio-
cultural exchange and understanding among people. This article reviews five major
sports with international appeal and participation: cricket, martial arts, field hockey,
soccer, and tennis. For each sport, the major aspects of physiological and
biomechanical demands, injuries, and prevention strategies are reviewed.

Cricket
Cricket is one of the most popular sports in the world; its English origin dates
back to 1150 [1]. Marylebone Cricket Club in England is the official governing
body for cricket. Cricket is a ball and bat field sport played by two opposing
teams with 11 players each. The bat is made of wood, the length of which does
not exceed 38 inches. The ball is hard, and has a cork foundation covered with
leather. There are two wickets, one at either end of the pitch, consisting of three
stumps, each 28 inches high, placed side by side. Each team can play two
innings, and tournament matches last for 3 or 5 days. One-day matches with
limited overs are also popular. In many countries it is a national pastime, and is
played in organized tournaments, or recreationally by children and adults in

$
Cricket and martial arts sections are adapted from: Patel DR. Cricket injuries in youth:
a short review. Asian Journal of Paediatric Practice 2000;3:9; and from: Robertson AL, Patel DR.
Medical aspects of martial arts: an overview. Asian Journal of Paediatric Practice 2000;4:23; used
with permission.
* Corresponding author.
E-mail address: patel@kcms.msu.edu (D. Patel).

0031-3955/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 1 - 3 9 5 5 ( 0 2 ) 0 0 0 1 8 - 4
770 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792

streets and parks. Despite the popularity of cricket, especially among children and
adolescents, only limited data have been published regarding injuries, especially
in youths.

Demands of the sport

Cricket is a noncontact sport, with moderate dynamic and low static demands on
the energy systems. Depending upon the level of competition, many cricketers
sustain high level of stress, especially during the season, accounting for an
increased incidence of overuse injuries [2]. It is mostly an outdoor sport, although
indoor cricket is especially popular in New Zealand and Australia. Energy
expenditure in college players has been estimated to range from 700 to1000 kJ/
m2/h [3]. During the play of the game there are repeated periods of short (lasting less
than 20 seconds), high-intensity activity utilizing anaerobic energy pathways [3].
Many children and adolescents begin to play cricket at an early age, and
continue to participate for a number of years, with increasing levels of intensity [2].
The most common and significant overuse injury reported is to the thoraco-lumbar
spine in fast bowlers [1,4 – 9]. This is a result of repetitive rotation, extension, and
lateral flexion movements used during bowling. The peak ground reaction forces
(when the foot hits the ground during running) can be as high as four to nine times
the body weight of the bowler; this load is transmitted to the spine [10]. Fast
bowlers are particularly prone to developing back pain and lumbar stress injury
leading to spondylolysis and other spine abnormalities [4,5,7,8,10 – 12,] Bartlett
et al in a recent review of the biomechanics of fast bowling, presented a detailed
analysis of the three types of fast bowling techniques: side-on, front-on, and mixed
types [10]. This and other studies suggest that the mixed type technique used by
many fast bowlers is the most stressful to the spine, leading to back pain and
thoraco-lumbar abnormalities. Other factors contributing to back and spine overuse
injuries in bowlers include bowling too many overs, poor lumbar and hamstring
flexibility, poor lower body strength, poor bowling technique, greater release
height, obesity, and poor preseason conditioning [13].
Stretch has recently reviewed the biomechanics, kinematics, and kinetics of
batting in cricket [3]. Batting requires highly developed neuromotor skills,
dynamic interceptive abilities, and visual-spatial processes.

Injuries
Perhaps the first documented cricket injury that resulted in death was that of
Frederick, Prince of Wales, who died of complications in 1751 after a ball hit his
head [13 – 15]. Fortunately, fatalities are very rare in cricket. Stretch [16] reported
on the seasonal incidence and nature of musculoskeletal injuries in schoolboy
cricketers in South Africa. The author noted that the seasonal incidence of
injuries in all players was 49%. In this study, common injuries were to the back
and trunk (33.3%), upper extremities (24.6%), and lower extremities (22.8%).
Bowlers were the most likely to be injured (47.6%) compared with batsmen
 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792 771

(29.8%) and fielders (22.8%). There was no difference in the number of injuries
sustained during practice or a match. A significant number of injuries were
recurrent injuries (36.8%). Back injuries were most common in bowlers, upper
extremity injuries were most common in fielders, and head and face injuries were
most common in batsmen. The injuries in schoolboy cricketers were similar to
those sustained by club and provincial cricketers [16,17].
Finch reported that cricket accounted for 4% of all sports-related injuries seen
in the hospital emergency departments in Australia, making it the eighth most
common type of sports-related injury seen in the emergency departments [13].
These were acute musculoskeletal injuries requiring an emergency visit; the vast
majority of cricket injuries are not severe enough to require a trip to the hospital.
Acute injuries can result from the direct impact of a ball or bat, collision with
another player, or hitting the ground [13,16,17]. Some of the risk factors that
contribute to increased likelihood of acute direct impact trauma include young
age, low level of skill, lack of experience, and failure to use appropriate
protective equipment [13]. The incidence of recurrent injuries ranges from
20% to 30% in some studies, suggesting a need for the proper rehabilitation of
initial injuries [16,18]. The recovery time for the majority of typical muscu-
loskeletal injuries ranges from 1 to 7 days [16]. More injuries occur early in the
season, when players are not yet at peak condition, and toward the end of the
season, when too many matches are scheduled in a short period of time [16].
A wide range of injuries, from acute to overuse, and mild to severe, has been
recognized in cricket. Overuse injuries, especially in fast bowlers, have been
studied most extensively; most other types of injuries have been described largely
as case reports (Table 1).

Table 1
Cricket injuries
Acute Overuse Other
Rotator cuff tear Lumbar spondylolysis Blunt chest trauma
Finger and hand injuries and spondylolisthesis Head trauma
(contusions, lacerations, Disc degeneration Facial fractures
finger fractures and dislocations) Nonspecific anterior knee pain Temperomandibular
Fracture of forearm (radius or ulna) Patellar tendinitis dislocation
Shoulder dislocation Tibial stress syndrome Splenic rupture
Acute musculotendionus tears (shin splints) Pneumomediatinum
(quadriceps, hamstrings, Stress fractures Splitting or wearing of
supraspinatus, gastrocnemius) (tibia, fibula, metatarsals) the finger skin
Eye injuries (detached retina, orbital Talotibial exostoses Osteoarthritis of finger
fracture, ruptured globe, traumatic Heel contusions joints and knee
iritis, hyphaema, corneal abrasion, Shoulder impingement
laceration, eyeball contusion, Glenohumeral instability
chronic glaucoma) Rotator cuff tendinitis
Biceps tendinitis
Elbow overuse injuries
Data from Refs. [1,4 – 9,13,16 – 30,141,142].
772 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792

Lumbar spondylolysis, commonly seen in fast bowlers, can be career-limiting

or career-ending. It is more significant in adolescent players during their growth
period. Many authors have reported on lumbar spondylolysis and other spinal
abnormalities in fast bowlers [1,4,6 – 9,19]. Hardcastle studied a group of 16 to 18
year-old fast bowlers, and found a high incidence of back pain associated with
radiological abnormality, pars interarticularis defect (54%), and disc degeneration
(63%) [19]. Annear examined former fast bowlers and found a significantly
higher incidence of spondylolysis and disc degeneration that was detected on
radiological imaging [4].
Bowling also stresses the shoulder, and many players develop an overuse injury
often referred to as the ‘‘thrower’s shoulder’’ [11]. The underlying pathophysiology
involves rotator cuff inflammation, edema, and impingement, often associated with
glenohumeral instability. The bowler complains of activity-related shoulder pain,
particularly during throwing or other overhead activity. There is a loss of throwing
length, and overarm throwing may be too painful to continue [11].
Other overuse injuries are less common. Overuse injuries of the lower
extremities, such as shin splints, anterior knee pain, patellar tendinitis, and stress
fractures of the tibia, fibula, or metatarsals, may result from the considerable
amount of running involved [13,20]. The wicketkeeper may develop knee pain,
tendinitis, and patellofemoral syndrome from spending many hours in a squatting
position, as well as chronic injury to the hands from catching the balls [20].
Splitting or chronic abrasive injury of the skin on the fingers has been described
in spin bowlers; this is the result of repeated friction and pressure from the seam
of the ball [13,21].
Acute injuries can occur from impact with another player, the ground, ball, or
bat. Head injury, eye injury, facial fractures, and dental injuries can result from
direct impact with the ball [22 – 25]. The batsman is especially vulnerable to these
types of injuries. Eye injury, though uncommon, is one of the most serious,
particularly in indoor cricket [5,22,24,26]. Blunt impact to the chest has caused
death from cardiac arrhythmia and myocardial infarction [27]. Ball impact with
the abdomen resulting in intra-abdominal injuries, and traumatic splenic rupture
from impact with the ground or the ball can occur [28]. Injury to testes can occur
from ball impact. Finger injuries, including contusions, abrasions, lacerations,
fractures, and dislocations are more common in indoor cricket [29]. Acute
musculotendionus strains (such as hamstring, quadriceps, gastrocnemius) can
occur while running between wickets or when stopping suddenly [13]. Acute
sprains of ankle and knee ligaments are associated with running. These injuries
are more common in indoor cricket. Rare case reports of pneumothorax and
pneumomediastinum have been found in the literature [30].

Injury prevention
General, nonspecific preventive measures, which are applicable to many
sports and exercise activities, should also be followed by cricketers. These
include maintaining overall conditioning, including cardiovascular, muscular
 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792 773

strength, flexibility, and endurance [31]. Proper warm-up and stretching should
be done routinely. The appropriate development of skills is especially
important for young cricketers. Robertson described a special program for
children, developed in Australia, called Kanga cricket [32]. This type of
cricket is modified to suit the needs of children who are beginners. The ball is
softer and smaller, and the bat and stumps are lightweight. The rules have also
been modified.
Preventive measures, specifically for fast bowlers, should include correct
bowling technique, limitation of number of overs during a specified time,
avoiding the mixed style of bowling, and early and prompt recognition and
treatment of back pain or underlying spinal problem. The appropriate use of
mouthguards, visors, boxes, gloves, helmets, padding, and testicular cups is
recommended to prevent injuries. Children and adolescents playing cricket in
an informal setting are less likely to use protective equipment and, therefore,
are more vulnerable to preventable injuries; proper awareness and education
is recommended.

Martial arts
Millions of children and adults participate in martial arts, and they are
increasing in popularity. Between 1.5 and 2 million Americans participate in
martial arts; approximately 20% are children [33,34]. The many styles of martial
arts have had their origins in different countries, and their popularity varies in
different parts of the world (eg, tae kwon do and hap ke do in Korea, judo in
Japan, and kung fu in China). Tae kwon do is very popular among youth; the
average age of competitors is 16 to 17 years [35]. The many reasons cited for
training in the varied disciplines include self defense, cardiovascular fitness,
flexibility, improved self-esteem, and concentration.

Demands of the sport

Most martial arts have some physiologic, neuromuscular, and biomechanical
demands in common. Aerobic and anaerobic energy pathways are important. In
typical tournament settings each round can last 2 (tae kwon do) or 3 (karate)
minutes with either single or double elimination fights. There may also be three
consecutive rounds, each of which lasts 2 or 3 minutes [36,37]. Martial arts
demand extensive practice and disciplined training. Concentration, speed, visual
perceptual abilities, flexibility, and neuromuscular coordination are necessary
attributes for martial arts participants.

Injuries
Martial arts injuries have been documented in the medical literature since the
1960s. Streeton [38] reported a case of hemoglobinuria after karate exercises that
caused considerable trauma to the hands. Potential causes of injuries in the
 774
Table 2
Martial arts injuries
Uncommon injuries
Common injuries Head, neck, and face Upper extremity Lower extremity Chest, abdomen, and groin
Minor head injuries Severe head and Fractures of thumb and Metatarsal fractures [42] Anterior chest impact and
or concussions neck injuries [143] fingers [45,57,145] death [45,46]

D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792

Acute soft tissue Scalp lacerations, Nail avulsions [41] Growth plate injuries Abdominal contusions
contusion of skull fractures
extremities
Overuse tendinitis Epistaxis Displaced type I coronoid Sequential stress fractures Winding blow to the solar
fracture of left elbow [147] of tibia [155] plexus [65]
Sprains and Tooth avulsions Coracoid process fracture [148] Complete avulsion of Liver laceration [159]
dislocations hamstring tendons [179]
of fingers
Abrasions Corneal abrasions Segmental perineural and Osteochondral fracture of Posttraumatic recurrent hepatic
interfascicular fibrosis of the lateral femoral condyle [156] alveolar echinococcosis [160]
dorsal branch of the ulnar nerve
Stroke from neck-holding ‘‘Karate-kid finger’’ [149] Pelvic fracture [157] Spleen rupture [46]
maneuver [49]
Carotid artery occlusion Dorsal dislocation of the Calcaneal apophysitis [158] Total transection of the
following a punch [48] distal end of the ulna [150] pancreas [161]
Blinding choroidal rupture [144] Long thoracic nerve and dorsal Anterior compartment syndrome Costochondritis
scapular nerve injuries [151]
Orbital blowout fractures [65] Shoulder dislocation [151] Peroneal nerve injury Rib fractures
Malar fractures Multiple aneurysms of Pneumothorax
both hands [152]
Kienbock’s disease [153] Mediastinal emphysema [162]
Lateral epicondylitis and Superficial thrombophlebitis of
overuse syndromes [154] the chest wall [163]
Testicular injury
 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792 775

martial arts include: lack of appropriate supervision, inadequate and incorrect

training, inappropriate aggression, male sex, younger age, inexperience, and
improper use of equipment [17,33,35,37 –45]. In his study of trauma epidemi-
ology in the martial arts, Birrer [45] made several observations. Minor con-
tusions of the upper and lower extremities, particularly the digits, are the most
common; lower belt ranks and younger ages are associated with increased risk of
injury; the use of protective equipment reduces the number and severity of
injuries; and men have higher injury rates and severity than women. His data
included injuries from all types of martial arts activities, including supervised
and informal unsupervised sparring.
Fatal injuries, though rare in youth, have been reported in adults. The first
reported deaths occurred in three trainees secondary to anterior chest wall trauma
[46]. Since that time several fatalities have been documented [41,47]. A number
of life-threatening injuries have also been reported, including some associated
with prolonged disability [48 –50]. Several unusual acute and chronic injuries are
listed in Table 2 [56,144,146,151,157,178].
Injuries occur more frequently and are more severe in tournaments [13,42,
44,51 –53]. Injuries occur in nearly one of every four matches in the competition
setting, but preventive techniques have been shown to reduce this rate [54,55].
Zemper estimated that the magnitude of severity increased from three to 20 times
in tournaments [44]. In tournament matches, head and neck injury rates increase
dramatically, equaling and often outnumbering injuries to the extremities and
trunk [42,45,51,53,55,56,181]. This injury pattern is the opposite in nontourna-
ment settings where extremity injury, especially lower extremity, predominates
[35,45,57,181]. Some studies suggest that the risk for significant head injury in
competitive situations approaches or exceeds the rate for other sports, such as
American football [44,58]. A clear association exists between repeated concus-
sion-type head injuries and a decline in the ability to process information
efficiently; the full significance of these findings on the adolescent or prepubes-
cent athlete has not been made clear [35,59 –62].
Several investigators have identified younger age and inexperience as risk
factors for injury in the martial arts [41,45,47,51,53,63,175]. Injuries are more
common and more severe during the first 2 years of participation [45].
The incidence of injuries varies across studies, and studies are difficult to
compare, primarily because of methodological differences. In 1988, Birrer [33]
reported that martial arts were responsible for 16.9 injuries per 100,000
participants per year, placing them eighth among sports (basketball, 188;
American football, 16; aquatics, 46; lacrosse, 39.5; wrestling, 26; sledding,
24.6; dancing, 18.8). In 1996, Birrer again suggested that martial arts injury
rates compare favorably with other sports, with injury rates less than those of golf
or common exercise [45]. The average injury rate in the martial arts (3.5 injuries
per 1000 participants per year) was less than golf (5.4), general exercise (6.9),
gymnastics (15.6), wrestling (22.9), and American football (74.6) [45]. Zemper
and Pieter [44] found that the ‘‘time loss’’ injury rates among college students
placed tae kwon do third for both males and females.
776 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792

In the United States, data from the National Electronic Injury Surveillance
System (NEISS), which is collected from emergency facilities, show the
incidence of martial arts injury to be 8.2 per 100,000 per year [47]. Peak injury
rates occurred in postpubertal males, and in females in the 5 to 14 year (16.5
injuries/100,000 population/y) and 15 to 24 year (19.2 injuries/100 000 popu-
lation/y) age groups. Birrer and the NEISS collected surveillance data that
included all forms of martial arts [45,47].

Injury prevention
Recommendations for prevention of injuries in the martial arts have focused on
two areas, namely, protective equipment and improved training techniques. As
early as 1977, McLatchie showed that the appropriate use of protective equipment
reduced the frequency of injury from one in four to 1 in 22 [55,178]. The use of
extensive equipment has been considered by some to be too restrictive for the
participants and less appealing to the spectators [54]. Over the past two decades
numerous studies on protective equipment have shown them to be highly effective
in reducing the number and severity of injuries to martial arts participants
[45,51,54,55]. In fact, most injuries occur while neither the attacker nor the
defender is wearing protective gear [45]. As a result, some types of protective
equipment have become standard, while the use of others remains optional for the
individual participant. At the 1989 and 1990 United States National Junior Tae
kwon do Championships, head and chest protection, arm and shin pads, and a groin
cup were required for participation; mouthguards were frequently optional [41,42].
Protective equipment changes the character of injuries sustained in the martial
arts; for example, use of knuckle pads reduced finger and hand injuries, decreased
the severity of head injuries, and increased the frequency of minor head injuries
[54]. In 1986, Schwartz reported that padded extremities may promote an
increased use of force by the attacker [61]. Based on this finding, a number of
authors have raised the concern that protective equipment such as gloves and foot
pads may protect the attacker more than the defender [35,41,45].
The use of headgear seems to protect the soft tissues and bones of the face
[45,51,54]. One of the largest insurers of the martial arts in the United States
requires the use of headgear during free-sparring [43]. Head contact is not
recommended in children because repeated head trauma, even apparently minor,
can have lasting neuropsychological consequences [41,42].
Other suggestions offered to reduce martial arts injuries include the use of
padded floors and mandatory mouth protectors. Mouth protectors reduce internal
mouth and tooth injuries, as well as the severity of concussions from blows to the
mouth and jaw [40 – 42,65,66]. Two methods of improved foot and ankle taping
have also been reported [31].
Several studies suggest that inexperience (especially less than one year) and
younger age are associated with the highest rates and severity of injury
[41,42,45,53,54]. Inexperience is thought to increase the risk of injury for several
reasons, including poor attacking and blocking techniques [42].
 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792 777

Other factors influence injury rates during informal sparring and competitions.
Unsupervised activity is associated with increased injuries. Improved medical
care, including prefight clearance guidelines, standards for return to activity after
injury, and required medical coverage for tournaments would maximize safety.
Uniform standards for instructors, referees, and physicians have also been
recommended [45].

Field hockey
Field hockey is a popular field sport believed to have its origins in ancient
Asia, Egypt, and Greece [36]. In modern times, it became a highly popular sport
in England and later in the British Commonwealth. The popularity of field
hockey was so great that in the fourteenth century King Edward III banned it
because it was believed to interfere with other national duties of men [67,70]. In
the United States field hockey is very popular with girls According to the
National Federation of State High School Associations (NFSHA), there were
58,372 female participants in 1528 high schools and 213 male participants in
eight high schools during the 1999– 2000 school year [68]. According to the
National Collegiate Athletic Association (NCAA) participation data there were
5203 women participants on 239 teams [69].
Field hockey is played by two teams on a 90  55-m field; each team has 11
players [36,70]. A match consists of two, 35-minute halves with an approximately
10-minute break separating them. It is a stick and ball sport, the object of which is
to score a point by sending the ball into the opposing team’s goal. The stick, which
is made of wood or wood and synthetic material, is curved at one end, has one flat
surface and is made for use as a right-sided stick to propel the ball [36,67,70].

Demands of the sport

Field hockey is a limited contact sport, with high-to-moderate dynamic and
low static demands [67,70,72]. It is a field invasive sport with more aerobic
(60%) than anaerobic (40%) energy system demands [67]. The maximal oxygen
uptake for an elite male and female hockey player is estimated to be between 48
and 68 mL/kg/min and 45 and 59 ml/kg/min, respectively [67,73 – 75,176]. It also
requires a high level of specific skill development. During a game the players
cover considerable distances (5– 9 km) [74] and the estimated energy expenditure
is high, ranging from 30 to 50 kJ/min [67,176]. The intermittent running,
accelerating, and decelerating increases the overall effort needed. The average
play time and touches per possession increase, and game interruptions decrease
on an artificial turf, thus adding to physiological demands [75 –77]. There is
decreased shock absorption on artificial turf [67,76]. The position played may
have some bearing on the player’s physique and somatotype [67,78 – 80]. The
body fat percentage for male and female high level players is between 11% and
15% and 16% and 26%, respectively [67,81,82]. Dribbling in a semicrouched
778 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792

position places significant compressive stress on the thoraco-lumbar spine.

Troupe et al noted that during an experimental 7-minute period of dribbling
there was a loss of height at a rate of 0.44 mm/min [83].

Injuries
The NCAA data show an injury rate for women’s field hockey of 9.4 (games)
and 4.2 (practice) per 1000 athlete exposures [84]. The rate of injury is 10.5 on
artificial surfaces and 9.3 on natural turf. Most injuries occur in the lower
extremities including the ankle, knee, and upper leg. Injuries include ankle
sprains, medial tibial stress syndrome, musculotendinous strains, and contusions;
more significant but uncommon injuries include ankle fractures, knee ligament
sprains, meniscus injury, and patellar contusion and fracture [71,84]. Most
injuries are noncontact injuries such as minor sprains and strains. Contact injuries
from collision with another player are less common, and contact injuries from the
stick, ball, and playing surface are rare. Lower back pain, acute strain, and
chronic disk changes are common in hockey players; this has been attributed to
playing in a semicrouched position [71,83]. Hand and finger injuries can occur
from contact with the stick or ball. Severe head and face injuries, including those
to the eyes and mouth, can occur from direct hit by a ball or collision with
another player. Mathews and Yurkofsky note that most injuries are likely to occur
during ball handling, shooting, and going after loose balls [71].

Injury prevention
Prevention strategies focus on enforcement of the rules, sport specific training
and conditioning, and timely rehabilitation of injuries. Mouth and shin guards are
required, but headgear is not. Rules of the game do not allow deliberate body or
stick contact between players; no deliberate checking is allowed; no high sticking
is allowed; the height of driven shots is specified; and an obstruction rule makes it
illegal for a player to deliberately come in the way of a driven shot. All of these
measures have been shown to be effective in preventing injuries [71].
Aerobic training should be done using high intensity interval sessions.
Anaerobic conditioning is also important, especially utilizing sprint training
regimens. Flexibility, strength, and endurance of the lower extremities are
especially important.

Soccer
Association football, known as soccer in the United States, has its origins in
early 19th century England [36,85]. It is played on a field 100 yards long by
50 yards wide, with a goal post on each end; each team has 11 players. Soccer is
the most popular team sport in the world, with more than 200 million participants
of both genders, and from all age groups [36,70]. In the United States, there are
3 million players in high school or youth soccer associations; 6 million children
 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792 779

under age 12 play soccer [86,88 – 90]. It is the fastest growing youth sports in the
United States, with an annual increase ranging from 11% to 20% [86,89].
According to 1999 – 2000 NCAA participation data, there were 18,188 women
participants on 811 teams, and 18,221 men participants on 715 teams [69].

Demands of the sport

Soccer is a contact and collision sport with high-to-moderate dynamic and
low static demands [85,90]. It is a rather continuous sport with few inter-
ruptions; significant running and jogging demands are placed on the aerobic
energy systems [73,90]. Typically, a player spends 70% to 80% of the time
engaged in this type of activity with the remaining time spent in short periods
of high intensity sprinting. Soccer players also require a high level of motor
coordination and agility with which to move the ball quickly. The ball is
predominantly controlled by use of the lower extremities and head. Lower
extremity muscle strength, endurance, flexibility, and neck muscle strength are

Table 3
Soccer injuries
Head and neck [86,87,110 – 116]
Concussions (1% – 3% of injuries, most grade 1, uncommon in under 12 age group)
Long term sequelae in those with past history of head injuries
Acute neck sprains, disk herniations, fracture/dislocation, central cord compression (all rare)
Maxillofacial [96,97,111,118,164 – 167]
Nasal, mandibular, zygomatic fractures (uncommon)
Dental injuries (tooth avulsions and fractures)
Orbital blow out fractures (30% of sports-related blow out fractures)
Hyphaema, corneal abrasions, retinal injuries
Upper extremity [85,86,95,167] (3% – 30% of injuries)
Fractures (rare, most due to fall)
Thumb-ulnar collateral ligament sprains (in goal keepers)
Groin injuries [94,168] (5% – 8% of injuries, most musculotendinous strains)
Hip and pelvis [85,95,167]
Osteitis pubis
Iliac apophysitis/hip pointer
Avulsion fractures
Femoral neck stress fractures
Lower extremity [90,105,107,167] (60% – 90% of injuries)
Thigh contusions (10% – 45% of players)
Knee injuries (most common injuries; MCL is most common, ACL sprain is twice as common in
females as in males
Ankle injuries (second most common injuries; inversion ankle sprains, chronic pain)
Plantar fasciitis, foot sprains, turf toe
Stress fracture of 2nd and 5th metatarsal (most common stress fractures in soccer players)
Subluxation of peroneus brevis, tibialis posterior
Increased incidence of calcaneal apohysitis
Increased incidence of cervical, hip, knee, and ankle osteoarthritis in adults [169 – 171]
780 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792

essential. There are significantly increased amounts of stress placed on the hips,
knees, and abdominal muscles as a result of running, changing directions, and
being tackled [85].

Injuries
Numerous studies have reported injury rates, trends, and patterns in youth
soccer (Table 3). Most of these are from Europe and a few are from the United
States. Many of the studies were done on youth because of its popularity [86,92 –
104] Reported injury rates vary depending upon the age of the participant, level
of competition, level of exposure, and definition of injury. Nonfatal injury rates
range from 0.6 to 19.1 injuries per 1000 playing hours [86]. A widely quoted
study by Nilsson et al of injuries (including all minor injuries such as abrasions
and contusions) in 11- to 18-year-olds (n = 25,000), reported injury rates of 14 for
boys and 32 for girls per 1000 playing hours [104]. Sullivan, using a definition of
injury as ‘‘requiring medical attention and prevented further participation’’,
reported rates of 0.5 for boys and 1.1 for girls per 1000 playing hours, in those
under 18 years of age (n = 1272) [106]. Schmidt-Olsen et al’s study (n = 496) of
12- to 18-year-old males revealed an injury rate of 3.7 per 1000 playing hours
[146]. They defined an injury as ‘‘acquired during game or practice, causing one
or more of the following: reduction in activity, the need for treatment or medical
advice, and/or negative social or economic consequences’’ [146]. A recent review
by Metzl indicates that injury rates for soccer are similar to that for American
football in children less than 12 years of age. In high school players, the injury
rate in soccer is significantly lower than in American football [88].
Despite the limitations of epidemiologic studies, several observations can be
made regarding soccer injuries: (1) injuries are uncommon in the under-12 age
group, less than 5% annually; (2) the incidence of injury increases tenfold by
high school; (3) injuries are twice as common in girls in the under 12-age
group; (4) boys and girls have the same injury rate during adolescent years,
except for knee injuries, which are twice as common in girls; (5) the goal
keeper is at higher risk; (6) in all age groups, common injuries include minor
sprains, strains, contusions, and abrasions; (7) 60% to 80% of injuries involve
the lower extremities; (8) knee injuries are the most common with medial
collateral ligament injury being the most common knee injury; (9) anterior
cruciate sprains are twice as common in females; (10) ankle sprain is the
second most common injury; (11) fractures are uncommon (3.5% – 9% of
injuries) but most fracture involve the upper extremities; (12) injuries are six
times more common in indoor soccer; (13) injury rates in adults are higher on
artificial surface; (14) fatal injuries are very rare, reported from falling goal-
posts; and (15) overall injuries are higher in games than in practice [85 – 87,89,
90 – 98,100 – 103,108 –110].
Heading the ball, concussion, and its long-term effects have been the subject
of much discussion in the literature [64,87,88,96,110– 115]. Evidence suggests
that heading the ball is not a common cause of concussion; concussion is more
 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792 781

likely to be the result of a collision with another player or a fall to the ground.
Although the long-term effects of repeated concussions are known, the effects
of heading the ball in the absence of concussion have not been clearly studied.
According to an American Academy of Pediatrics (AAP) policy statement, data
are insufficient to restrict soccer players from heading the ball; however, the
player must learn and use correct techniques for heading the ball, and to
prevent head and neck injuries, players should avoid heading a water-soaked
ball [86,117].

Injury prevention
The prevention of injuries in soccer focuses on training, conditioning, and
specific skill development, especially in younger players. Other factors that
play lesser roles in injury prevention include equipment, rules, and field
conditions [95,107,108,117 –119]. Preparticipation evaluation should delineate
the baseline fitness and deficiencies. Aerobic endurance is important. Lower
extremity muscle strength, flexibility, and endurance must be adequately
addressed. Proper techniques for heading the ball must be learned. Ekstrand
noted the importance of consistent practice in reducing acute injuries; this is
probably the result of improved neuromuscular coordination and motor control
[86,94]. Rehabilitation of injuries, especially for ankle sprains, is critical in
order to prevent chronic pain and impingement. Some studies suggest that
fewer anterior cruciate ligament injuries follow proprioceptive training
[95,107].
Shin guards may reduce the severity of leg injuries. Proper shoes are very
important; molded cleats for natural grass turf are recommended [85]. Mouth
guards may help reduce the incidence of dental injuries and the severity of
concussions; AAP recommends eyewear with polycarbonate lenses [86]. Goal-
posts must be secured properly. Smaller balls, reduced field size, and downsized
goals for players under 12 help reduce injuries [85,108]. Heat related illness can
be prevented by maintaining adequate hydration.

Tennis
Tennis, also known as lawn tennis, is a racket and ball sport played by
either two or four players on a court divided by a net. It is believed to have
its origins in ancient Egypt and Persia [36,70]. The modern version is
attributed to Major Clopton Wingfield of England, who in 1874 patented ‘‘a
portable court for playing the ancient game of tennis’’ [120]. In 1875, the
Marylebone Cricket Club and All-England Croquet Club delineated the rules
of lawn tennis. According to NFSHA participation data, 139,507 boys and
159,740 girls played at the high school level in the United States during the
1999 –2000 school year [68]. Worldwide, an estimated 50 million individuals
782 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792

of all ages and both genders play tennis; 18 million of those are in the United
States [120].

Demands of the sport

Tennis is a noncontact, high-to-moderate dynamic and low static energy
system demand sport. Both aerobic and anaerobic energy systems are utilized at
different points [121]. Konig et al noted that in professional tennis players the
overall intensity ranged between 60% and 70% of maximum oxygen uptake,
mainly provided by the aerobic energy system [122 – 124]. They further noted
that the energy for intermittent high intensity muscular activity during tennis is
derived from anaerobic glycolysis. The metabolic demands in tennis may be
influenced by the age and skill level of player, level of competition, and style
of play [123]. The anaerobic energy system is utilized for short bursts of high
intensity activity. Konig et al noted that after many years of playing profes-
sionally, tennis players had specific cardiovascular and metabolic adaptations
including: increased heart size, higher oxygen uptake capacity, improved
muscular oxidative enzyme activities, reduced baseline catecholamine levels,
and lower resting heart rates.
Tennis places high biomechanical demands on the musculoskeletal system
and requires a great deal of neuromuscular coordination, speed, agility, and
power. Kibler and other investigators have studied the biomechanics of tennis
and analyzed the tremendous amounts of loads, forces, and motions generated
in the upper and lower extremities as well as in the torso and spine [121 –
123,125– 132]. Large motions are associated with very high velocities in the
scapular and shoulder regions. There is significant flexion and extension at
elbow and wrist, and large, high velocity rotational motions are seen in the
back, hip, and trunk. Large amounts of motions and high velocities generate
racket speeds of 70 –80 miles per hour and ball speeds of 80– 115 miles per
hour in high-level competitions [120,123]. Studies by Kibler and other
investigators have shown that tennis players, including adolescents, exhibit
positive and negative musculoskeletal adaptations affecting flexibility and
muscle strength. Positive adaptations include increased bone density, increased
tendon size, increase endurance, and increased muscle strength. Negative
adaptations (maladaptations) include decreased flexibility in the hips, low
back, elbow, and shoulder internal rotation, forearm pronation contracture,
and muscle strength imbalance in the back and shoulders [122,123,125,126,
128,130,133,134].
Nirschl and Sobel noted that the serve and overhead strokes eccentrically
load the shoulder external rotators and scapular stabilizers, and concentrically
load the shoulder internal rotators [132]. This leads to muscle strength
imbalance with relatively less strength in the external rotator compared with
the internal rotators. Similarly, wrist extensors are eccentrically loaded with a
backhand stroke leading to relatively less strength when compared with flexors.
Nirschl and Sobel further note that contralateral abdominal muscles are
 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792 783

Table 4
Tennis injuries
Shoulder
Rotator cuff tendinosis
Elbow
Lateral and medial tennis elbow
Medial collateral ligament sprain
Medial epicondyle apophysitis
Ulnar neuropathy
Wrist
Triangular fibrocartilage complex injury
Distal radioulnar joint injury
Back and spine
Acute strains
Lumbar disk herniation/degeneration
Spondylolysis
Knee
Patellar tendinitis
Anterior knee pain syndrome
Thigh and Leg
Hamstring strains
Gastrocnemius strain/tennis leg
Achilles tendinitis
Stress fracture of tibia
Ankle and foot
Ankle sprain
Stress fracture of metatarsal
Plantar fasciitis
Data from Refs. [120,123,131 – 138,172 – 174].

eccentrically loaded during serve; this is accompanied by lumbar hyperexten-

sion. [132].

Injuries
Most injury data collected are from high-level, competitive tennis players
(Table 4). Musculoskeletal injuries are common at all levels in tennis; 50% to 90%
of players report having had an injury in the past 12 months [123]. Most injuries are
mild, resulting in minimal time loss from play, and the number of overuse injuries
(75%) far exceeds the number acute injuries. Kibler and Safran reported that low
back pain was the most common complaint (31% boys, 47% girls) that kept junior
championship players out of play [134]. Safran and Hutchinson noted that in
adolescent boys, excluding back pain, elbow injury (22%), dominant wrist injury
(19%), pain in front of shoulder (17%), and pain in back of shoulder (15%) were
the most prevalent. In adolescent girls, excluding back pain, pain in front of
shoulder (31%), dominant wrist injury (29%), nondominant wrist injury (25%),
and elbow pain (25%) were most prevalent [135,136].
Many factors contribute to overuse injuries [138,177]. These include
baseline deficits in strength and flexibility, lack of muscle endurance, poorly
784 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792

rehabilitated previous injury, inadequate recovery periods, high level of expo-

sure, improper racket size, grip, string tension, incorrect stroke techniques,
rapid progression, and hard court surface [131 – 134,138,177]. In addition, the
musculoskeletal maladaptations noted above also contribute to injury.

Injury prevention
Baseline evaluation plays an important role in the identification of muscu-
loskeletal deficits that can be corrected by a properly designed conditioning
program [123,139,180]. One method of evaluation, described by Nirschl, is
presented in Box 1. Kibler and Chandler have described the following goals of a

Box 1. Nirschl Orthopaedic and Sports Medicine Clinic tennis

fitness evaluation protocol

History assessment
Musculoskeletal durability
Varus – valgus elbow angle
Shoulder slope angel—scapular insufficiency
Spinal postural alignment
Q angles (knees)
Tibial os-calcis alignment
Foot posture
Flexibility: shoulder, back, hip, knees, ankle
Manual strength testing: shoulders, hip groups
Grip strength
Grip (hand) size

Performance tests
Upper body anaerobics (medium-ball toss)
Vertical jump
Reaction time
Hexagon test
Shuttle run
20-yard dash

Baseline conditioning tests

Submaximal aerobics (VO2 max)
Timed sit-ups
Timed push-ups
 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792 785

Sit-reach flexibility
Lean body mass

Isokinetic testing
Cybex 340 knee
Cybex 340 shoulder
Cybex 340 testing of clinically indicated areas

From: Nirschl R, Sobel J. Tennis. In: Reider B, editor. The high-

school aged athlete. Philadelphia: W.B. Saunders; 1996. p. 731;
with permission.

conditioning program in tennis: (1) improve internal rotation of dominant

shoulder, (2) improve shoulder external rotation strength and endurance, (3)
improve the strength of the scapular stabilizers, (4) improve low back and

Fig. 1. Racket grip size. Measure distance from proximal palmar crease between the long and ring
finger to the tip of the ring finger. (From Nirschl R, Sobel J. Tennis. In: Reider B, editor. The high
school-aged athlete. Philadelphia: W.B. Saunders; 1996. p. 733; with permission.)
786 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792

hamstring flexibility, and (5) correct individual weaknesses in strength and range
of motion [123,126]. Other components of a conditioning program include
resistive training, sprint training, footwork, and speed training [123,180]. For
competitive players who play year-round, conditioning is best accomplished by
periodization, in which the intensity, volume, and progression of exercise is
planned and controlled. This allows a player to peak at competition time and
avoid overtraining [120,126,131,140]. Correct stroke techniques must be learned.
A properly designed conditioning program should focus on preventing the
development of musculoskeletal maladaptations.
Equipment requirements are minimal in tennis. Shoes must allow side-to-side
stability as well as flexibility. Counterforce bracing is useful. Rackets must be
selected properly. Nirschl recommends a midsize, graphite frame with medium
flexibility and medium to soft string tension [132]. The Nirschl technique is
useful in assessing the correct grip size (Fig. 1).

Acknowledgments
The authors thank Amy Gandy for her superb technical assistance in the
preparation of the manuscript.

References
[1] Hardcastle P. Lumbar pain in fast bowlers. Aust Fam Physician 1991;20:943.
[2] Patel DR. Cricket injuries in youth: a short review. Asian Journal of Paediatric Practice
2000;3:9.
[3] Stretch RA, Bartlett R, Davids K. A review of batting in men’s cricket. J Sports Sci 2000;
18:931.
[4] Annear PT, Chareka TMH, Foster DH, Hardcastle PH. Pars interarticularis stress and disc
degeneration in cricket’s potent strike force: the fast bowler. Aust N Z J Surg 1992;62:768.
[5] Bell PA. Spondylolysis in fast bowlers: principles of prevention and a survey of awareness
among cricket coaches. Br J Sports Med 1992;26:273.
[6] Burnett AF, Khangure MS, Elliott BC, et al. Thoracolumbar disc degeneration in fast bowlers in
cricket: a follow up study. Clin Biomech (Bristol, Avon) 1996;11:305.
[7] Elliot B, Burnett A, Stockill N, et al. The fast bowler in cricket: a sports medicine perspective.
Sports Exercise Injury 1995;1:201.
[8] Elliott B, David JW, Khangure MS, et al. Disc degeneration and the young fast bowler in
cricket. Clin Biomech 1993;8:227.
[9] Foster D, John D, Elliott B, et al. Back injuries in fast bowlers in cricket: a prospective study.
Br J Sports Med 1989;23:150.
[10] Bartlett RM, Stockill NP, Elliot BC, et al. The biomechanics of fast bowling in men’s cricket: a
review. J Sport Sci 1996;14:403.
[11] Crisp T. Cricket: fast bowler’s back and thrower’s shoulder. In Pract 1989;233:790.
[12] Elliott BC. Back injuries and the fast bowler in cricket. J Sports Sci 2000;18:983.
[13] Finch CF, Elliot BC, McGrath AC. Measures to prevent cricket injuries. Sports Med
1999;28:263.
[14] Belliappa PP, Barton NJ. Hand injuries in cricketers. J Hand Surg 1991;116B:212.
[15] Brasch R. How sports begin. Longman (UK): Camberwell; 1971.
 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792 787

[16] Stretch RA. Seasonal incidence and nature of injuries in schoolboy cricket. S Afr Med J
1995;85:1182.
[17] Stretch RA. The incidence and nature of injuries in first-league and provincial cricketers. S Afr
Med J 1993;83:339.
[18] Smith C. Sports injuries encountered on a first class international cricket tour. Sports Med
1991;6:10.
[19] Hardcastle P, Annear P, Foster DH, et al. Spinal abnormalities in young fast bowlers. J Bone
Joint Surg 1992;74B:421.
[20] Corrigan AB. Cricket injuries. Aust Fam Physician 1984;13:558.
[21] Agosta J. Epidemiology of podiatric sports medicine clinic. Australian Podiatrist 1994;28:93.
[22] Aburn N. Eye injuries in indoor cricket at Wellington Hospital: a survey from January 1987 to
June 1989. N Z Med J 1990;103:454.
[23] Fong LP. Sports-related eye injuries. Med J Aust 1994;160:743.
[24] Forward GR. Indoor cricket injuries. Med J Aust 1988;148:560.
[25] Lim LH, Moore MH, Trott JA, et al. Sports-related facial fractures: a review of 137 patients.
Aust N Z J Surg 1993;63:784.
[26] Jones NP, Tullo AB. Severe eye injuries in cricket. Br J Sports Med 1986;20:178.
[27] Heymann TD. It’s not cricket! Myocardial infarction following non-penetrating blunt chest
trauma. Br J Clin Pract 1994;48:338.
[28] Du Toit DF, Rademan F. Splenic rupture caused by a cricket ball: a case report. S Afr Med J
1987;71:796.
[29] Sadleir LG, Horne G. Indoor cricket finger injuries. N Z Med J 1990;103:3.
[30] Clements MR, Hamilton DV. Pneumomediastinum as a complication of fast bowling in cricket.
Postgrad Med J 1982;58:435.
[31] Luckstead EF, Greydanus DE. Medical care of the adolescent athlete. Los Angeles: PMIC; 1993.
[32] Robertson I. Aussie sports and organised sport. Canberra (Australia): Australian Sports Com-
mission; 1982.
[33] Birrer RB, Halbrook SP. Martial arts injuries: the results of a five year national survey. Am J
Sports Med 1988;16:408.
[34] Robertson AL, Patel DR. Medical aspects of martial arts: an overview. Asian Journal of
Paediatric Practice 2000;4:23.
[35] Feehan M, Walker AE. Precompetition injury and subsequent tournament performance in full-
contact tae kwon do. Br J Sports Med 1995;29:258.
[36] Encyclopedia Britannica. Martial arts, field hockey, soccer, tennis. www.britannica.com.
Accessed 2001.
[37] Wilkerson LA. Martial arts. In: Garrett WE, Kirkendall DT, Squire DL, editors. Principles and
practice of primary care sports medicine. Philadelphia: Lippincott Williams & Wilkins; 2001.
p. 525 – 30.
[38] Streeton JA, Melb MB. Traumatic hemoglobinuria caused by karate exercise. Lancet 1967;
2:191.
[39] Chuang TY, Lieu DK. A parametric study of the thoracic injury potential of basic tae kwon do
kicks. J Biomech Eng 1992;114:346.
[40] Kujala UM, Taimela S, Antti-Poika I, et al. Acute injuries in soccer, ice hockey, volleyball,
basketball, judo, and karate: analysis of national registry data. BMJ 1995;311:1465.
[41] Oler M, Tomson W, Pepe D, et al. Morbidity and mortality in the martial arts: a warning.
J Trauma 1991;31:251.
[42] Pieter W, Zemper ED. Incidence of reported cerebral concussions in adult tae kwon do athletes.
J R Soc Health 1998;118:272.
[43] Wilkerson LA. Martial arts injuries. J Am Osteopath Assoc 1997;97:221.
[44] Zemper ED, Pieter W. Injury rates during the 1988 U.S. Olympic team trials for tae kwon do.
Br J Sports Med 1989;23:161.
[45] Birrer RB. Trauma epidemiology in the martial arts: the results of an eighteen-year international
survey. Am J Sport Med 1996;24:S72.
788 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792

[46] Schmidt RJ. Fatal anterior chest trauma in karate trainers. Med Sci Sport Exerc 1975;7:59.
[47] National Electronic Injury Surveillance System. Washington, DC: United States Consumer
Safety Commission. Volumes 2 – 18, 1979 – 1994.
[48] Blumenthal DT, Riggs JE. Carotid occlusion following a karate punch to the neck. Mil Med
1996;161:562.
[49] McCarron MO, Patterson J, Duncan R. Stroke without dissection from a neck holding man-
uevre in martial arts. Br J Sports Med 1997;31:346.
[50] Wos W, Puzio J, Opala G. Traumatic internal carotid artery thrombosis following karate blow.
Pol Przegl Chir 1977;49:1271.
[51] McLatchie GR. Analysis of karate injuries sustained in 295 contests. Injury 1976;8:132.
[52] Siana JE, Borum P, Kryger H. Injuries in tae kwon do. Br J Sports Med 1986;20:165.
[53] Stricevic MV, Patel MR, Okazaki T, et al. Historical perspective and injuries sustained in
national and international tournament competitions. Am J Sports Med 1983;11:320.
[54] Johanssen HV, Noerregaard FOH. Prevention of injury in karate. Br J Sports Med 1988;
22:113.
[55] McLatchie GR, Morris EW. Prevention of karate injuries: a progress report. Br J Sports Med
1977;11:78.
[56] Tuominen R. Injuries in national karate competitions in Finland. Scand J Med Sci Sports
1995;5:44.
[57] Hirata K. Injuries of karate in Japan. Jpn J Educ Med 1967;3:123.
[58] Zemper ED, Pieter W. Injury rates in junior and senior national tae kwon do competition.
Proceedings of first IOC World Congress in Sports Science. Colorado Springs: USOC; 1989.
p. 219 – 20.
[59] Gronwall D, Wrightson P. Delayed recovery of intellectual function after minor head injury.
Lancet 1974;2:605.
[60] Rimel RW, Giordani JT, Barth JT, et al. Disability caused by minor head injury. Neurosurg
1981;9:221.
[61] Schwartz ML, Hudson AR, Fernie GR, et al. Biomechanical study of full-contact karate con-
trasted with boxing. J Neurosurg 1986;64:248.
[62] Zemper ED, Pieter W. Cerebral concussions in tae kwon do athletes. In Hoerner EF, editor.
Head and neck injuries in sports. Philadelphia: American Society for Testing Materials; 1994
[63] Birrer RB, Birrer CD. Unreported injuries in martial arts. Br J Sports Med 1983;17:131.
[64] Zaricznyi B, Shattuck LJM, Mast TA, et al. Sports-related injuries in school-aged children. Am
J Sports Med 1980;8:318.
[65] McLatchie GR. Karate and karate injuries. Br J Sports Med 1981;15:84.
[66] Nieman EA, Swann PG. Karate injuries. BMJ 1971;1:233.
[67] Reilley T, Borrie A. Physiology applied to field hockey. Sports Med 1992;14:10.
[68] National Federation of State High School Associations. Participation Study 1971 – 2000. Avail-
able at www.nfshsa.org. Accessed 2001.
[69] National Collegiate Athletic Association. NCAA Participation Data: 1982 – 2000. Available at
www.ncaa.org. Accessed 2001.
[70] Barnes AS. Encyclopedia of sports. South Brunswick, New Jersey; 1975.
[71] Mathews LS, Yurkofsky JB. Lacrosse and field hockey. In: Garrett WE, Kirkendall DT, Squire
DL, editors. Principles and practice of primary care sports medicine. Philadelphia: Lippincott,
Williams & Wilkins; 2001. p 513 – 23.
[72] Hargreaves A. Fitness profiles of the British Olympic men’s team. 1978 – 80. Hockey Digest
1983;10:68.
[73] Reilley T, Ball D. The net physiological cost of dribbling a soccer ball. Res Quarterly Exercise
Sports 1984;55:267.
[74] Reilley T, Seaton A. Physiological strain unique to field hockey. J Sports Med Phys Fitness
1990;30:142.
[75] Jamison S, Lee C. The incidence of female hockey injuries on grass and synthetic playing
surfaces. Aust J Sci Med Sport 1989;21:15.
 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792 789

[76] Malhotra MS, Gosh AK, Khanna GL. Physical and physiological stresses of playing hockey on
grassy and astroturf fields. Soc Natl Inst Sports J 1983;6:13.
[77] Stanitski CL, McMaster JH, Ferguson RJ. Synthetic turf and grass: a comparative study. Sports
Med 1984;2:22.
[78] Bale P, McNaught-Davis P. The physiques, fitness and strength of top class women hockey
players. J Sports Med Phys Fitness 1983;23:80.
[79] Bhanot JL, Sindhu LS. Maximal anaerobic power in national level Indian players. Br J Sports
Med 1981;15:265.
[80] Wilsmore RG. The body type of female hockey players involved in different playing positions
and levels of competition. Austr J Sci Med Sports 1982;19:76.
[81] Sidhu BS, Singh J, Chugh OP, et al. Physique and body composition of Indian national police
players of team games. Ind J Sports Sci 1989;1:29.
[82] Withers RT, Roberts RGD, Davies GJ. The maximum aerobic power, anaerobic power and
body composition of South Australian male representatives in athletics, basketball, field hock-
ey, and soccer. J Sports Med Phys Fitness 1977;17:391.
[83] Troupe JDG, Reilley T, Eklund JAE, Leatt P. Changes in stature with spinal loading and their
relation to perception of exertion or discomfort. Stress Medicine 1985;1:303.
[84] National Collegiate Athletic Association. Injury Surveillance System: 1996 – 1997. Overland
Park (KS): National Collegiate Athletic Association; 1996.
[85] Lohnes JH, Garrett WE. Soccer. In: Reider B, editor. High-school aged athlete. Philadelphia:
W.B. Saunders; 1996. p. 715 – 27.
[86] American Academy of Pediatrics. Injuries in youth soccer: a subject review. Pediatrics
2000;105:659.
[87] Barnes BC, Cooper L, Kirkendall DT, et al. Concussion history in elite male and female soccer
players. Am J Sports Med 1998;26:433.
[88] Metzl J. Soccer injuries in youth. Pediatr Emerg Care 1999;15:130.
[89] Metzl J, Micheli LJ. Youth soccer: an epidemiological perspective. Clin Sports Med 1998;
17:663.
[90] Kirkendall DT. The applied sport science of soccer. Physician Sportsmed 1984;13:53.
[91] Arendt E, Dick R. Knee injury patterns among men and women in collegiate basketball and
soccer. NCAA data and review of the literature. Am J Sports Med 1995;23:694.
[92] Backous DD, Friedl KE, Smith NJ, et al. Soccer injuries and their relation to physical maturity.
Am J Dis Child 1988;142:839.
[93] Ekstrand J, Gillquist J. Soccer injuries and their mechanisms: a prospective study. Med Sci
Sports Exerc 1983;15:267.
[94] Ekstrand J, Hilding J. The incidence and differential diagnosis of acute groin injuries in male
soccer players. Scand J Med Sci Sports 1999;9:98.
[95] Golusinksi Jr. LL. Soccer. In: Garrett WE, Kirkendall DT, Squire DL, editors. Principles and
practice of primary care sports medicine. Philadelphia: Lippincott Williams & Wilkins; 2001.
p. 568 – 9.
[96] Hoff GI, Martin TA. Outdoor and indoor soccer: injuries among youth players. Am J Sports
Med 1986;14:231.
[97] Hoy K, Lindblad BE, Terkeslsen CJ, et al. European soccer injuries: a prospective epidemio-
logical and socioeconomic study. Am J Sports Med 1992;20:318.
[98] Hunt M, Fulford S. Amateur soccer: injuries in relation to field position. Br J Sports Med
1994;24:265.
[99] Inklaar H, Bol E, Schmikli SL, et al. Injuries in male soccer players: team risk analysis. Int J
Sports Med 1996;17:229.
[100] Inklaar H. Soccer injuries: incidence and severity. Sports Med 1994;18:55.
[101] Kibler WB: Injuries in adolescent and preadolescent soccer players. Med Sci Sports Exerc
1993;25:1330.
[102] Luthje P, Nurmi I, Kataja M, et al. Epidemiology and traumatolgy of injuries in elite soccer: a
prospective study in Finland. Scand J Med Sci Sports 1996;6:180.
790 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792

[103] Nielsen AB, Yde J. Epidemiology and traumatology of injuries in soccer. Am J Sports Med
1989;17:803.
[104] Nillson S, Roass A. Soccer injuries in adolescents. Am J Sports Med 1978;6:358.
[105] Sullivan JA, Gross RH, Grana WA, et al. Evaluation of injuries in youth soccer. Am J Sports
Med 1980;8:325.
[107] Caraffa A, Cerulli G, Projetii M, et al. Prevention of anterior cruciate ligament injuries in
soccer. A prospective controlled study of proprioceptive training. Knee Surg Sports Traumatol
Arthrosc 1996;4:19.
[108] Center for Disease Control and Prevention. Injuries associated with soccer goalposts: United
States, 1979- 1993. MMWR 1994;43:153.
[109] Lindenfeld TN, Schmitt DJ, Hendy MP, et al. Incidence of injury in indoor soccer. Am J Sports
Med 1994;22:364.
[110] Boden BP, Kirkendall DT, Garrett WE. Concussion incidence in elite college soccer players.
Am J Sports Med 1998;26:238.
[111] Jordan SE, Green GA, Galanty HL, et al. Acute and chronic brain injury in United States
national team soccer players. Am J Sports Med 1996;24:205.
[112] Matser EJ, Kessels AG, Lezak MD, et al. Neuropsychological impairment in amateur soccer
players. JAMA 1999;282:971.
[113] Matser JT, Kessels AG, Jordan BD, et al. Chronic traumatic brain injury in professional soccer
players. Neurology 1998;51:791.
[114] Sortland O, Tysvaer AT. Brain damage in former association football players. Neuroradiology
1989;31:44.
[115] Tysvaer AT, Storli OV. Soccer injuries to the brain: a neurologic and electroencephalographic
study of active football players. Am J Sports Med 1989;17:573.
[116] Tysvaer AT. Head and neck injuries in soccer. Sports Med 1992;14:200.
[117] Barfield WR, Gross RH. Injury prevention. In: Sullivan AJ, Anderson SJ, editors. Care of the
young athlete. Elk Grove Village (IL): American Academy of Pediatrics and American Acad-
emy of Orthopedic Surgeons; 2000. p. 121 – 30.
[118] Inklaar H. Soccer injuries II: aetiology and prevention. Sports Med 1994;18:81.
[119] Surve I, Schwellnus MP, Noakes T, et al. A fivefold reduction in the incidence of recurrent
ankle sprains in soccer players using the Sport-Stirrup orthosis. Am J Sports Med 1994;
22:601.
[120] Otis C. Tennis. In: Drinkwater B, editor. Women in sports. Oxford: Blackwell Science; 2000.
p. 550 – 63.
[121] Bergerson MF, Maresh CM, Kraemer WJ, et al. Tennis: a physiological profile during match
play. Int J Sports Med 1991;12:474.
[122] Groppel JL, Roetert EP. Applied physiology of tennis. Sports Med 1992;14:260.
[123] Kibler WB, Chandler TJ. Tennis. In: Garrett WE, Kirkendall DT, Squire DL, editors. Principles
and practice of primary care sports medicine. Philadelphia: Lippincott Williams & Wilkins;
2001. p. 577 – 89.
[124] Konig D, Huonker M, Schmid A, et al. Cardiovascular, metabolic, and hormonal parameters in
professional tennis players. Med Sci Sports Exerc 2001;33:654.
[125] Chandler TJ, Kibler WB, Kiser AM, et al. Shoulder strength, power, and endurance in college
tennis players. Am J Sports Med 1992;20:455.
[126] Chandler TJ. Exercise training for tennis. Clin Sports Med 1995;14(1):33.
[127] Giangarra CE, Conroy B, Jobe FW, Pink M. EMG and cinematographic analysis of elbow
function in tennis players. Am J Sports Med 1993;21:394.
[128] Kibler WB. Biomechanical analysis of the shoulder during tennis activities. Clin Sports Med
1995;14:79.
[129] Kibler WB. The role of scapula in throwing activities. Am J Sport Med. 1998;26:325.
[130] Kibler WB. Clinical biomechanics of the elbow in tennis: implications for evaluation and
diagnosis. Med Sci Sports Exerc 1994;26:1203.
[131] Lehman RC. editor. Racquet Sports. Clin Sports Med 1995;14(1).
 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792 791

[132] Nirschl R, Sobel J. Tennis. In Reider B, editor. High-school aged athlete. Philadelphia: W.B.
Saunders; 1996. p. 729 – 39.
[133] Kibler WB, Chandler TJ. Racquet sports. In: Fu F, Stone R, editors. Sports Injuries. Baltimore:
Williams Wilkins; 1994. p. 531 – 50.
[134] Kibler WB, Safran MR. Musculoskeletal injuries in the young tennis player. Clin Sports Med
2000;19:781 – 92.
[135] Safran MR, Hutchinson MR, Moss R, et al. A comparison of injuries in elite boys and girls
tennis players: Transactions of the Ninth Annual Meeting of the Society of Tennis Medicine and
Science. Indian Wells (CA): Society of Tennis Medicine and Science; 1999.
[136] Safran MR, Hutchinson MR. 1998 USTA Boys’ National Championships: injuries or pain that
prevented the player from playing, practicing, or competing in tennis for at least 7 days
(unpublished data, 1998).
[137] Bylak J, Hutchinson MR. Common sports injuries in young tennis players. Sports Med 1998;
26:119.
[138] Marx RG, Sperling JW, Cordasco FA. Overuse injuries of the upper extremity in tennis players.
Clin Sports Med 2001;20(3):439 – 51.
[139] Kibler WB. The sport preparticipation examination. Champaign (IL): Human Kinetics; 1990.
[140] Sobel J, Pettrona F, Nirschl R. Prevention and rehabilitation of racquet sports injuries. In:
Nicholas JA, Hershman EB, editors. The upper extremity in sports medicine. Philadelphia:
Mosby; 1990. p. 843 – 60.
[141] Bell P. Cricket: injury in long trousers. Br J Sports Med 1999;33:151.
[142] Murthy P, Bandasson C, Dhillon RS. Temperomandibular joint dislocation and deafness from
cricket ball injury. J Laryngol Otol 1994;108:415.
[143] Aotsuka A, Kojima S, Furamoto H, et al. Punch drunk syndrome due to repeated karate kicks
and punches. Rinsho Shinkeigaku 1990;30:1243.
[144] Mars JS, Pimenides D. Blinding choroidal rupture in karate. Br J Sports Med 1995;29:273.
[145] Crosby AC. The hands of karate experts: clinical and radiological findings. Br J Sports Med
1985;19:41.
[146] Schmidt-Olsen S, Jorgensen U, Kaalund S. Injuries among young soccer players. Am J Sports
Med 1991;19:273.
[147] Liu SH, Henry M, Bowen R. Complications of type 1 coronoid fractures in competitive athletes:
a report of two cases and review of the literature. J Shoulder Elbow Surg 1996;5:223.
[148] Cottalorda J, Allard D, Dutour N, et al. Fracture of the coracoid process in an adolescent. Injury
1996;27:436.
[149] Chiu DTW. ‘‘Karate kid’’ finger. Plast Reconstr Surg 1993;91:362.
[150] Russo MT, Maffulli N. Dorsal dislocation of the distal end of the ulna in a judo player. Acta
Orthop Belg 1991;57:442.
[151] Jerosch J, Castro WHM, Geske B. Damage of the long thoracic and dorsal scapular nerve after
traumatic shoulder dislocation: case report and review of literature. Acta Orthop Belg 1990;
56:625.
[152] Vayssairat M, Priollet P, Capron L, et al. Does karate injure blood vessels of the hand? Lancet
1984;2:529.
[153] Szabo RM, Grennspan A. Diagnosis and clinical findings of Kienbock’s disease. Hand Clin
1993;9:399.
[154] Tondeur M, Haentjens M, Piepsz A, et al. Muscular injury in a child diagnosed by 99mTc-MDP
bone scan. Eur J Nuc Med. 1989;15:328.
[155] Ariyoshi M, Nagata K, Kubo M, et al. Three stress fractures at different sites in the same tibia: a
case report. Acta Orthoped Scand. 1997;68:406.
[156] Mbubaegbu CE, Percy AJL. Femoral osteochondral fracture: a non-contact injury in martial
arts? A case report. Br J Sports Med 1994;28:203.
[157] Birrer RB, Robinson T. Pelvic fracture following karate kick. NY State J Med 1991;11:503.
[158] Wirtz PD, Vito GR, Long DH. Calcaneal apophysitis (Sever’s disease) associated with tae kwon
do injuries. Am J Podiatr Med Assoc 1988;78:474.
792 D.R. Patel et al / Pediatr Clin N Am 49 (2002) 769–792

[159] Cantwell JD, King Jr. JT. Karate chops and liver lacerations. JAMA 1973;224:1424.
[160] Sato N, Namieno T, Takahashi H, et al. A long surviving patient with recurrences of hepatic
alveolar echinococcosis after traumatic intra-abdominal rupture. J Gastroent 1996;31:885.
[161] Nielsen TH, Jensen LS. Pancreatic transection during karate training. Br J Sports Med
1986;20:82.
[162] Matsushima T, Yoneyama H, Yano T. Spontaneous mediastinal emphysema caused by strained
utterance: is it characteristic of the Japanese? Chest 1995;108:885.
[163] Schlueter AJ, Al-Jurf AS, Lentz SR. Kung fu phlebitis: an unusual presentation of Mondor’s
disease. Am J Hematol 1996;52:66.
[164] Jones NP. Orbital blow out fractures in sport. Br J Sports Med 1994;28:272.
[165] Orlando RG. Soccer-related eye injuries in children and adolescents. Physican and Sports-
medicine 1988;16:103.
[166] Putukian M, Knowles WK, Swere S, et al. Injuries in indoor soccer: the Lake Placid Dawn to
Dark Soccer Tournament. Am J Sports Med 1996;24:317.
[167] Putukian M. Soccer. In: Drinkwater B, editor. Women in sports. Oxford: Blackwell Science;
2000. p. 575 – 99.
[168] Gilmore J. Groin pain in the soccer athlete: fact, fiction, and treatment. Clin Sports Med
1998;17:787.
[169] Lindberg H, Ross H, Gardsell P: Prevalence of coxarthrosis in former soccer players: 286
players compared with matched controls. Acta Orthop Scand 1993;64(2):165 – 7.
[170] Roos H, Lindberg H, Gardsell P, et al. The prevalence of gonarthrosis and its relation to
meniscectomy in former soccer players. Am J Sport Med 1994;22:219.
[171] Sortland O, Tysvaer AT, Storli OV. Changes in cervical spine in association football players. Br
J Sports Med 1982;16:80.
[172] Hutchinson MR, Laprade RF, Burnett QM. Injury surveillance at the USTA boys’ tennis
championships: a six year study. Med Sci Sports Exerc 1995;7:826.
[173] Kibler WB. Musculoskeletal injuries in the young tennis player. Clin Sports Med 2000;19:4.
[174] Winge S, Jorgenson J, Nielson L. Epidemiology of injuries in Danish championship tennis. Int J
Sport Med 1989;10:368.
[175] Pieter W, Zemper ED. Injury rates in children participating in tae kwon do competition.
J Trauma 1997;43:89.
[176] Scott PP. Morphological characteristics of elite male field hockey players. J Sports Med Phys
Fitness 1991;31:57.
[177] Meeuwisse WH. Assessing causation in sport injury: a multi-factoral model. Clin J Sport Med
1994;4:166.
[178] McLatchie GR, Davies JE, Caulley JH. Injuries in karate: a case for medical control. J Trauma
1980;20:956.
[179] Kurosawa H, Nakasita K, Nakasita H, et al. Complete avulsion of the hamstring tendons from
the ischial tuberosity: a report of two cases sustained in judo. Br J Sports Med 1996;30:72.
[180] Kibler WB, Chandler TJ. Sports specific conditioning. Am J Sports Med 1994;22:424.
[181] Noerregaard FOH, Johannsen HV. Pattern of injuries in Danish karate championships. Ugeskr
Laeger 1986;148:1785.