Lacrosse began as a Native American tradition and is now one of the fastest growing sports in the United States.1,2 Modern women's lacrosse began in 1890 in Scotland and was brought to the United States in 1926, with first recorded play occurring at the collegiate level.3 By the end of 2013, the United States had an estimated 278 000 female lacrosse players, with half of those participating at the youth level.4 For the youth players, this represents a 43% increase in 5 years. Thus, lacrosse is the fastest growing team sport for girls, and female participation at the high school level has increased 126.6% in the last 10 years.4 Not surprisingly, the explosive growth at the youth level has led to increased collegiate play. Four hundred sixteen colleges and universities now sponsor women's lacrosse as a team sport (38.2% growth from 2008 to 2013). In 2013, US Lacrosse experienced record numbers of members and regional chapter applicants.4 Expanding media coverage will also likely add to the sport's popularity and participation.5
The growth in women's lacrosse participation has in turn increased the total number of lacrosse-related injuries.6 Indeed, although the women's game only allows stick-to-stick contact and minimal incidental body contact, injury rates are still on the rise. Dick et al7 showed that at the women's collegiate level, game injury rates had substantially increased from 1988/1989 to 2003/2004 (a 16-year period).
The purpose of this clinical literature review is to aggregate and analyze the existing literature relating to injuries associated with women's lacrosse participation. Women's injury data were collected at the youth, high school, and collegiate levels and were organized to compare injury rates, location, type, severity, setting (game vs practice), and player position. This detailed analysis of cumulative lacrosse injury data helped identify injury risk factors in the women's game and has implications for injury prevention efforts.
Literature Search Strategy
A comprehensive literature search was performed in PubMed, High Wire Press, SPORTDiscus, Google Scholar, and Ovid using the keywords “Lacrosse Injuries,” “Epidemiology Lacrosse Injuries,” “Lacrosse Injury,” “Lacrosse,” and “Injury.” The electronic search included material published during or after 1950. In addition, all bibliographies of electronically found sources were cross-referenced to identify any additional publications that were not produced in the electronic searches. All articles with data on women's injury rates were categorized by overall injury rates, rates by session (competition vs practice), nature of injury, location, type, severity, and player position.
The data gathered on injury rates in women's lacrosse are summarized in Table 1. Rates of injury varied from 0.03 to 3.9 injuries/100 athletes. Several studies examined anterior cruciate ligament (ACL) injury rates in women's lacrosse and other sports and found that women's lacrosse had lower incidence rates (0.18) than women's soccer (0.32) and basketball (0.28).8–10 Cantu et al11 looked at fatalities and catastrophic injuries in college and high school sports over a 15-year period. The researchers found that the relative incidence level of suffering a catastrophic injury or fatality in lacrosse is much lower than for other collision sports.11
Injury Rates by Age
Injury rates increase with age: from youth leagues to high school and finally to the collegiate level.12,13 The increased injury rates are likely due to multiple factors, including more intense play and anthropometric differences between players.12
Game Versus Practice Injury Rates
Athlete exposures (AEs) are units of susceptibility to injury which is defined as one athlete participating in one game or practice in which she is exposed to the possibility of athletic injury. The game and practice injury rates for women's lacrosse are summarized in Table 2. Women's game injury rates are consistently higher than practice injury rates (ranging from 0.2 to 7.1 vs 0.01 to 3.3). Yard and Comstock14 did not differentiate between men and women or practice and game at the youth level. Lincoln et al, Goldenberg and Hossler,15 Matz and Nibbelink,16 Hootman et al,17 and Covasin et al18 all found increased rates of injury during game activity.15–19 McCulloch and Bach2 did not study game injury numbers, showed a higher rate per 1000 AEs during games (11.5/6.1) when compared with practice injury rates. The disparity between practice and game sessions could be due to different intensity of competition, as practice sessions tend to involve less aggressive play, more frequent breaks, and fewer collisions.
Nature/Mechanism of Injury
Not much empirical information is available on the nature of lacrosse injuries. Women's lacrosse is classified as an incidental contact sport.20 Purposeful body-to-body contact is not allowed, and the playing field is larger than that of the men's game (120 yards long and 70 yards wide), which creates more open space and likely reduces the probability of contact. For these reasons, injuries in the women's game occur most frequently from stick-to-player or player-to-ball contact, rather than player-to-player contact.7,12,20,21
Because of the lower collision rates compared with men's lacrosse, minimal protective equipment is required in the women's game. Women wear mouth guards and protective eyewear mandated in 2004. However with the exception of goalies, neither helmets nor padding are worn.22 Light protective gloves are optional but are infrequently worn. Soft headgear is allowed.
Contusions, fractures, lacerations, concussions, sprains, and strains were the most common injuries recorded.23 Injuries displayed as gradual onset included overuse injuries and stress fractures, but were seldom listed. Kang et al24 studied stress fractures, which would likely account for a larger gradual onset (7) than sudden onset (0).
Injury Site Location (Body Area)
There is an abundance of information provided in the literature on injury site location, as displayed in Supplemental Digital Content 1 and 2 (see Tables S1A and S1B, http://links.lww.com/JSM/A144 and http://links.lww.com/JSM/A145). Most data provided on women have centered on head and facial injuries. Women sustain a higher percentage of head and facial injuries relative to male lacrosse players.19,25 Risk factors for these injuries may be attributed to 3 categories: (1) lack of protective equipment, (2) improper use of equipment, and (3) lack of enforcement of the rules.15,26,27 Women are required to wear eye protection (mandated at all levels in 2004) and mouth guards, but helmets, body padding, and hand protection are not mandated for nongoalie female players.22
In the youth game, the most common injuries for females are to the ankle (26%), hand (24%), and face (21%).14 Goldenberg showed that the largest number of injuries occur to the lower extremities (56%) in female high school lacrosse players.15 The lack of mandatory protective glove wear increases their risk for injuries to the hands and fingers; although as mentioned earlier, some players choose to wear light fabric gloves that offer substantially less protection than the padded gloves common to the men's game. Many accidental injuries are also likely due to lack of skill development and unfamiliarity with the sport, leading to poor control of stick check and movement. Novice players especially should wear additional protective equipment.
Lincoln et al19 compared the rate of head injuries at the high school level between boys and girls over a 4-year period, for 46 teams (23 males and 23 females) and found that girls had significantly higher rate of injury (0.54/1000 AE) than did boys (0.38/1000 AE). Goldenberg15 showed a high rate of injury to the eye (1.3 per 100 athletes), but this study was done in 1995, before the mandatory use of protective eyewear implemented for the women's game in 2004.15 Lincoln et al28 compared eye injury rates in girls' scholastic lacrosse before and after the eyewear rule change and found a reduction from 0.10/1000 AE to 0.016/1000 AE (See Tables S1A and S1B, Supplemental Digital Content 1 and 2, http://links.lww.com/JSM/A144 and http://links.lww.com/JSM/A145).
The women's game does not currently use helmets for nongoalie players. However, women tend to carry the head of the stick closer to their heads and faces during cradling as a result of the technique needed for maximum ball control with sticks that lack a pocket in the mesh. Holding their stick close to their face while possessing the ball may increase the probability of injury to face and head from purposeful or incidental contact. In the women's game, most injuries occur to the head and facial areas, which are left exposed, except for the mandated protective eyewear.22 The regulation for head and face protection in the women's game continues to be an evolving improvement process. US Lacrosse (the national governing body of lacrosse) is currently working with leading manufacturers to develop lacrosse-specific head protection. New protective equipment for women needs to specifically address common injury mechanisms of women's lacrosse and not merely adopt currently available protective equipment from the men's game or other similar sports.21
The most common types of injuries for women are (in order from most frequent to least frequent) concussions, sprains, contusions, and lacerations. These injuries are summarized in Table 3. Males experienced more concussions (nearly 2:1) in all studies, whereas females experienced contusions, abrasions, sprains, and strains in greater numbers. For women, the lack of protective equipment is perhaps the number one cause of contusions and lacerations. Studies on concussion injuries have provided the overall number of concussion occurrences, but most studies have not listed the severity or time lost from each concussion.29 Similarly, regarding sprains, current research lists only the number of sprains, but future data collection could improve research by including the area of the body where the sprain occurred (specific: ie, ACL, MCL, and ATF; or general: ie, ankle or knee). More detailed data on injury type are warranted for future lacrosse studies.
The severity of injuries in women's lacrosse varies in the literature. According to the current literature, more than 50% of injuries are in the mild category resulting in players missing practice and games for 1 to 7 days.12,16,30,31 Table 4 summarizes the data on injury severity. The most common injuries in the mild category were contusions and lacerations.32 The moderate category involves player absence from 8 to 21 days, with the primary injuries being ankle sprains and muscle strains.12,16,30,31 The severe category requiring 22 or more days lost was attributed to ACL injuries and was documented by Hinton et al12 and Matz and Nibbelink.12,16
The definition of a catastrophic injury in the literature ranges from the loss of one or more vital functions to the complete loss of life.2,16 Commotio cordis, a sudden cardiac episode secondary to blunt, nonpenetrating but forceful chest blows are very rare in sports. There have been recorded incidents of commotio cordis in baseball, hockey, and lacrosse, with and without protective equipment over the heart area.14,33 There are approximately 18 cases of lacrosse-related commotio cordis in the literature, all of which come from the high school or collegiate levels. Of these 18 cases, half occurred in goalies who were wearing chest protection.11,16,32
Injury by Position
The injury-by-position data are presented in Table 5. Offensive players had the most injuries, followed by defensive players and then midfielders.24,31,34 Goalies had fewer injuries, which may be due to the rules which limit players' ability to make physical contact with the goalie.15 Risk seems to be greater for players who do more ball handling (more exposure to body and stick contact) and who perform more running, cutting, and stopping maneuvers, compared with goalies. Further research should include player position when documenting injuries to better track what types of injuries are associated with particular field positions. These data can help researchers, officials, coaches, and medical professionals develop improved protective equipment and regulations for gameplay to decrease injury risk.
Risk Factors for Injury During Lacrosse Participation
Risk factor data are displayed in Table 6 and are divided into intrinsic and extrinsic risk factors. Intrinsic risk factors for youth and collegiate players include hypermobility of joints, age, skill level, and sex.35,36 Extrinsic risk factors include rules of the game (body and stick contact),18,29 equipment (or lack thereof for females),9,25,34,37 position played,15 and game versus practice participation.17
This clinical review of women's lacrosse-related literature is intended to offer insight to the types of injuries that a provider of medical services to lacrosse players may expect. Women tend to have injuries to the lower extremity and exposed body parts of the hand and face because of limited protective equipment coverage and incidental stick and body contact.7,12,13,15,16,19 The overall women's lacrosse injury rate is lower compared with other female collision sports such as soccer, but it is higher than the rate for basketball.7,14,17
Facemasks and goggles limit the exposure of the face to the stick and ball, so as to reduce injuries to the eyes, nose, and mouth. Rule enforcers should continue to ensure that players are using protective equipment appropriately to cover at-risk body areas, despite the effects on mobility. In addition, officials and rule makers can continue to improve the safety of the game by developing and enforcing rules to limit players' risk to injury while still maintaining the integrity of the game. Specifically, continuing research on developing effective protection for those at risk for commotio cordis is urgently needed to reduce the chances of this catastrophic injury to players of lacrosse and other collision sports.11,38,39
A summary of recommended injury prevention suggestions is provided in Table 7. These suggestions range from wearing the right equipment, adopting youth specific rules, and promoting health and safety rules. However, the largest focus on injury prevention must be on the education of officials, coaches, players, parents, and the community concerning rules, game integrity, and sportsmanship. An extensive certification process for coaches and officials is available through US Lacrosse (http://www.uslacrosse.org/participants/coaches/coaching-education-program.aspx and http://www.uslacrosse.org/participants/officials/womens-officials-information/womens-training-and-certification-process.aspx). US Lacrosse spent numerous years focused on developing rules specific to youth lacrosse. These rules are available through US Lacrosse and were developed with a multidisciplinary panel with best practices and consideration of physiology, growth and development, injury prevention, and functional status based on age. They significantly limit contact, prioritize skills and team development concepts, focus on sportsmanship, game integrity, and positive game experience.20,40
Rule changes have been implemented for injury prevention. US Lacrosse emphasizes injury prevention through adequately educating and certifying coaches and officials to ensure that the rules are known, understood, and enforced and to instruct youth on the ethics of the game.
Most lacrosse protective equipment comes in varying shapes and models that provide a range of body protection.5 Many players will sacrifice the protection provided by large, heavier equipment for greater ranges of motion and less resistance facilitated by smaller, lighter equipment that offers less protection. However, choosing to use minimal equipment places athletes' bodies at greater risk for contact injuries. Likewise, for the sake of enhanced mobility and speed, many players elect to not use optional equipment such as rib pads. Most women's mandated equipment is lighter than male counterparts. Women are only required to wear a mouth guard and protective eye goggles. Goalies in women's lacrosse are required to wear throat protectors and chest pads. No protective equipment is mandated for the back, chest, ribs, abdomen, hips, or lower extremities for all nongoalie players. Mandating the use of protective equipment for all lacrosse players may help mitigate injury risk to these areas. However, women may be against more equipment mandates. Finally, game and duration may pose injury risk factors as a result of play intensity and exposure to injury risk. Tournament play may present a higher level of risk because of fatigue and greater exposure to risk.
With current increasing trends of participation in lacrosse at all levels of play, efforts to enhance safety and decrease potential injury risk are warranted. Improvements to rules, equipment, and gameplay that consider the well-being of participants can have a tremendous positive influence on players' health, our healthcare system, and future generations of lacrosse players. Healthcare professionals are in a position to improve athletes' well-being by making recommendations to the sport's governing body to address limitations in rules or equipment to reduce injury risk. Although the rate of injury in lacrosse is lower than the rates in many other collision sports, stricter rules on contact and protective equipment are recommended as the sport grows. Also, we need to ensure appropriate development of fundamental movement skills for youth players before being allowed to check or make stick-to-stick contact in a competitive environment. In addition, ongoing monitoring of the types and rates of injury can help to determine the efficacy of rules and equipment and to recommend modifications to improve safety for participants.
Suggestions for Further Research
Further research is warranted to better classify and predict lacrosse injury factors and mechanisms. More complete and thorough data are needed for women to classify injuries based on position, age, level of play, type of injury, severity of injury, mechanism of injury, and time point in game/practice when injury occurred. Injury data among females at the postcollegiate levels, including amateur, professional, and international play, should be collected, as well as injury data distinguished by cause, either intrinsic or extrinsic factors. Longitudinal studies and meta-analyses to assess lacrosse injuries across all levels of play are recommended. Researchers are advised to implement thorough statistical analyses and conduct more epidemiological studies across all levels of play. In future research, it would be helpful if documentation of the onset of injuries was included to further glean the incidence of injury patterns, especially given the exponential growth in participation.
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