The passage of Title IX of the Education Amendments of 197221 assured a dramatic increase in the number of females who participate in athletics. Subsequently, reports detailing injury pattern of female and male athletes were published.1,4,5,7-10,14,16,18-20,23-25 In 1976, an initial report by Haycock and Gillette12 showed similar overall injury rates between the genders, although a higher injury rate affecting the patella was identified. Subsequent reports identified a striking difference in the incidence of knee injuries, knee injuries for which the athlete required surgery, and anterior cruciate ligament injuries.1,4,9,10,14,19,23,25 However, except for the knee, studies have not revealed any significant gender specific injury patterns; rather only sport specific patterns.
The most common injuries in athletes who play basketball affect the ankle and knee.8,20 Although most attention recently has been focused on knee injury patterns, especially the anterior cruciate ligament, initial studies comparing the incidence of gender related injuries of the ankle in basketball players have not defined the relative risk of an ankle injury based on gender or level of competition.5,7,14,20,24 The current study was undertaken to determine the relative risk of ankle injuries in scholastic and collegiate, male and female basketball players.
MATERIALS AND METHODS
One hundred twenty-five high schools, colleges, and universities in New Jersey that have male and female basketball teams were selected for the current study. All participating schools had a common practice facility, a certified athletic trainer, and a team physician. The athletic trainers were instructed carefully in the study protocol and proper data acquisition. Data sheets were distributed to document each injury affecting the ankle and knee during the 2-year study period. An injury was defined as a traumatic event suffered by the athlete that required evaluation and treatment by the athletic trainer, team physician, or both. Information included the diagnosis and severity of the ankle injury, whether the injury occurred during a practice or a game, and the time the athlete missed playing basketball. The data were collated, and the relative risk as defined as the incidence of injuries in female athletes versus male athletes, and injuries in collegiate athletes versus injuries in scholastic athletes was determined. Statistical analysis was performed using Fisher's exact two-tail probability test with a significance level of 0.05.
Ninety-five institutions participated in the current study. Fourteen were college or university basketball programs and 81 were high school programs. Eleven thousand seven hundred eighty athletes participated in this study, 6840 males and 4940 females. The female athletes included 364 collegiate and 4576 scholastic players whereas there were 504 and 6336 male collegiate and scholastic athletes, respectively. The relative discrepancy in the number of players of each gender related to an increased number of male athletes participating on freshman or junior varsity teams. During the 2-year period, 1384 injuries to the knee and ankle were documented. One thousand one hundred seventy-one injuries occurred in the scholastic athletes and 213 injuries occurred in collegiate athletes. Seventy-six percent of the injuries involved the ankle. Four hundred ninety-four of the ankle injuries were in female athletes and 558 ankle injuries were in male athletes. Of the documented ankle injuries, Grade I ankle sprains accounted for 72% of the injuries for male and female athletes (Table 1).2,6
Overall, the relative risk for suffering an ankle injury was significantly greater for the female athlete than the male athlete (1.25:1). However, this risk was essentially attributable to the increased incidence of Grade I ankle sprains (1.26:1; p = 0.0001). Females who participated in athletics at the scholastic level had a statistically significant (24% greater) relative risk for overall ankle injuries and Grade I ankle injuries compared with the males. Females who participated in basketball at the collegiate level had a relative risk of 1.33:1 for overall ankle injuries, which was significant p = 0.059 (Table 2). There was not a significant increase in the relative risk for Grade II or Grade III ankle sprains, syndesmosis injuries, or ankle fractures for the female athletes compared with the male athletes.
The current study revealed an increased risk of suffering a knee injury of 1.92:1 (p = 0.00009) for the female athletes compared with the male athletes. The anterior cruciate ligament injury risk was more than three times greater for the female players (p = 0.00003), compared with the male players.
However, the relative risk of suffering an ankle injury significantly increased with an increased level of competition from scholastic to collegiate. The relative risk for an ankle injury doubled in both genders, 2.19:1 for the females and 2.05:1 for the males (Table 3). Compared with their scholastic counterparts, female collegiate athletes had an increased relative risk of 3.66:1 (p = 0.00623) for the anterior cruciate ligament injuries, whereas the male basketball players did not have an increased risk of anterior cruciate ligament injury with the increased level of competition.11
The basic physiologic and strength differences between the genders have been well-described.13,14,15,17 The current study, in which the relative risk of ankle injuries was assessed, showed an increased risk for a mild or Grade I ankle sprain among the female athletes compared with the male athletes. A potential flaw of the current study relates to the grading of ankle sprains by the certified athletic trainers and team physicians. However, it is thought that this particular diagnosis is so common that there is relative uniformity in the assessment of this problem, especially the mild or Grade I sprain.
Ankle sprains have been shown by several authors to be a common injury associated with basketball.3,7,8,18,20,22,24 The current study showed the increased incidence of mild ankle injuries among female scholastic and collegiate basketball players in New Jersey. The relative risk for a serious injury to the ankle is the same for males and females. The relative risk for an ankle injury with an increased level of competition also doubles for both genders. This is unlike the findings reported for an anterior cruciate ligament injury, in which the incidence significantly increases with increased competition for women only.11
Injury risk patterns in sporting activities generally are the result of intrinsic and extrinsic factors. The extrinsic factors in basketball include the level of competition, equipment, playing time, and the practice and game facilities. In the current study, playing time was not specifically accounted for, but matched programs in the same institution with the same facilities were used to account for the other factors. Intrinsic factors such as age, limb alignment, strength, joint stability, and generalized joint laxity previously have been considered for explaining the differences in injury rates between the genders.3
In their prospective study of intrinsic ankle injury risk factors, Baumhauer et al3 reported that generalized joint laxity, foot and ankle anatomic alignment, and ankle ligament stability were not significant risk factors for an ankle injury. Their study included a relatively small subject group of outdoor athletes, who participated in soccer, lacrosse, and field hockey. They did not observe a significant difference for height, weight, gender, or sport. Instead they found that a muscle imbalance with an elevated eversion-to-inversion ratio was associated with a greater incidence of an inversion ankle injury, as did a smaller dorsiflexion-to-plantar flexion strength ratio. Huston and Wojtys reported that some female athletes rely on a different muscle recruitment order than their male counterparts in response to provocative tests.15 Female athletes activate their quadriceps mechanism in response to anterior tibial translation, whereas the male athletes relied on their hamstrings for initial stabilization. Although this specific muscle activation pattern may have significant implications in the development of training techniques to prevent anterior cruciate ligament injuries, it raises the issue that perhaps there are similar differences involving the muscles stabilizing the ankle, which should be evaluated in the future.
In addition, Hewitt et al13 showed that a plyometric training program focusing in landing mechanics and lower extremity strength decreased landing impact forces, increased hamstring strength, and increased vertical jump in female volleyball players. They postulate that this program may have a positive effect on knee stabilization and prevention of serious knee injury. The current study, in which an increased risk for mild ankle sprains among female basketball players was shown, identifies the need to assess a similar training program designed to strengthen and prevent injuries about the ankle.
The current epidemiologic study identified an increased relative risk for female players of sustaining a Grade I ankle injury while playing basketball. The risks for Grade II and Grade III ankle sprains, syndesmosis sprains, and fractures were not different for the two genders. Male and female players doubled their risk of suffering an ankle injury when participating in athletics at the college level. Additional research is needed to define the intrinsic factors associated with this injury pattern and to develop appropriate training protocols.
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