NBSIR 77-1218

Risks Associated with Certain

Sports Activites

William B. Beine

Performance and Safety Analysis Section

Product Systems Analysis Division

Center for Consumer Product Technology

Institute for Applied Technology

January 1977

Final Report

Prepared for Bureau of Engineering Sciences

Consumer Product Safety Commission

5401 Westbard Avenue

Bethesda, Maryland

NBSIR 77-1218

RISKS ASSOCIATED WITH CERTAIN

SPORTS ACTIVITIES

William B. Beine

Performance and Safety Analysis Section

Product Systems Analysis Division

Center for Consumer Product Technology

Institute for Applied Technology

January 1977

Final Report

Prepared for Bureau of Engineering Sciences

Consumer Product Safety Commission

5401 Westbard Avenue

Bethesda, Maryland 20207

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U.S. DEPARTMENT OF COMMERCE, Juanita M. Kreps, Secretary

Dr. Betsy Ancker-Johnson. Assistant Secretary for Science and Technology

NATIONAL BUREAU OF STANDARDS. Ernest Ambler. Acting Director

SUMMARY

There are substantial risks associated with many sports

activities. This conclusion is supported by the U.S. Consumer

Product Safety Commission's Consumer Product Hazard Index

which ranks 367 product categories. Many sports rank high

on this index, for example, football activity and related

equipment is ranked #4, baseball #5, basketball #12, snow

skiing #17, hockey #34, and gymnastics #47.

The purpose of this study is to provide the Commission

with recommendations for assigning priorities to tasks

associated with reducing the incidence and severity of sports

related injuries.

This study was limited to sports activities related to

football, baseball, basketball, snow skiing, ice hockey,

gymnastics, and trampolines. Tasks of identifying hazards

associated with these activities and formulating subsequent

recommendations were accomplished primarily as a result of

reviewing the published literature. Data provided by the

National Electronic Injury Surveillance System (NEISS) are

also utilized.

The availability of literature regarding hazards in

many sports is not consistent with their ranking on the

Commission's Hazard Index. Further, the utility of many

reports is limited because of the fragmented approach and

compartmentalized views of athletic injury research. This

precludes a comprehensive statistical assessment of risks

associated with sports activities.

An analysis of the literature and NEISS data resulted

in the following recommendations:

• Expand data collection activities based upon a systems concept.

• Encourage development of standardized terminology

applicable to sports research.

• Determine the feasibility of an institute to initiate

and coordinate sport injury research and to disseminate

results to the athletic community.

• Improve the surveillance capabilities of NEISS.

• Stimulate research to resolve the controversy and

problems associated with helmet test procedures.

ii
• Determine the potential and alternatives for

promulgating hockey face guard standards.

• Stimulate research to reinforce theories pertaining

to knee injury prevention and provide for disseminating

results to the athletic community.

• Allocate resources to areas of ski-boot-binding testing,

adjusting, maintenance, and establish equipment

performance criteria.

• Determine the feasibility of establishing a ski-bootbinding safety performance standard.

Formulation of these recommendations incorporated an

assessment of the frequency and severity of specific injuries

and the literatures capacity to identify essential factors

for determining appropriate remedial action.

iii
Table of Contents

Page

Summary ii

Abstract 1

1. Introduction 1

2. Comments on the Data Sources 3

2.1 Published Literature ..... 3

2.2 NEISS 5

3. Discussion 7

3.1 NEISS 7

3.1.1 Projected National Emergency Room

Injuries 7

3.1.2 Major Injuries 9

3.1.3 Projected Injury Trends 10

3.2 Fatalities 11

3.2.1 Death Certificate Project 11

3.2.2 Annual Survey of Football Fatalities . 11

3.3 Published Literature 13

3.3.1 Distribution of Injuries by Sport . . 13

a. Football 13

b. Ice Hockey 17

c. Snow Skiing 19

d. Baseball 21

e. Basketball 22

f. Gymnastics 23

3.3.2 Specific Issues 23

a. Head Injuries - Concussions ... 23

b. Facial Injuries 28

c. Neck Injuries 29

d. Lower Leg Injuries (Knee) .... 32

e. Lower Extremity Equipment Related

Skiing Injuries 40

f. Natural versus Synthetic Playing

Surfaces 44

3.4 Rules and Standards Activity 52

4. Conclusions and Recommendations 55

Appendix A. Projected Number of Hospital Emergency

Room Treated Injuries 61

Appendix B. Wayne State Tolerance Curve 70

List of References 71

iv
List of Tables

Table No. Title Page

1 NEISS emergency room injury projections

for FY 76 by product category and age

group 8

2 Numbers of participants in recreational

programs of member institutions of the

National Federation of State High School

Association (322) and the National

Collegiate Athletic Association (321) ... 8

3 NEISS major injury projections for FY 76

by product category 10

4 Average annual percentage change in

projected injuries by sport—July 1972

through June 1976 10

5 Summary of death certificates collected by

CPSC as of October 1976 by sport, year of

death, and location of related injury ... 12

6 Comparison of head injury (concussions)

reported by various studies 25

7 NEISS data—average annual number of

projected emergency room injuries involving

the neck by sport (FY 1973-76) 30

8 Extent of knee and ankle injuries reported

by different studies 33

9 Projected number of lower leg injuries

annually incurred by the general populace

based on the NEISS sample 34

10 Severity versus type of surface - incidence

per game (Martin, et al. (28)) 45

11 Injuries versus type of surface - incidence

per game - 1970 (Bramwell, Requa, and

Garrick (223)

)

46

12 Injuries versus type of surface - incidence

per game - 1971 (Adkison, Requa, and

Garrick (214)) 47

v
List of Tables (continued)

Table No. Title Page

13 Injury rates for grass and four synthetic

surfaces - incidence per game - 1971

(Adkison, Requa, and Garrick (214)) .... 47

14 Knee and ankle injury rates for schools with

fields resurfaced and maintained and those

with no change - 1971-1972 (Blyth and

Mueller (9) Table LXXIII) . . 48

15 Frequency of injury versus turf as

reported in the three NFL studies 49

16 Summary of injuries per game for Gradient 2

through 7 versus various surfaces 50

17 NFL "Playable" injuries versus turf

1973-74 50

18 NFL injuries on turf versus field types

1973-74 (incidence per game) 51

A-l Categories for injury diagnosis and body

parts used in NEISS 62

A2

Football Activity and Related Equipment

(PC-1211) 63

A-3 Baseball Activity and Related Equipment

(PC-1204) 64

A-4 Basketball Activity and Related Equipment

(PC-1205) 65

A-5 Snow Skiing and Associated Equipment

(PC-1216) 66

A-6 Ice Hockey and Related Equipment (PC-1279) . 67

A-7 Gymnastics and Associated Equipment

(PC-1272) 68

A-8 Trampolines (PC-1233) 69

vi
'

.
RISKS ASSOCIATED WITH CERTAIN SPORTS ACTIVITIES

William B. Beine

This study provides the Consumer Product

Safety Commission with recommendations for assigning

priorities to tasks associated with reducing the

incidence and severity of sports related injuries.

Recommendations were derived from an analysis of

published literature and NEISS data. They emphasize

the need for collecting additional data, improving

surveillance capabilities, stimulating research, and

developing and promulgating equipment safety standards.

Key words: Accident; associated factors; injuries;

literature; NEISS, recommendations; review; sports;

safety

1. INTRODUCTION

The evolution of sport has primarily been the result

of advances in technology. Technology has opened the way

for new activities such as snowmobiling and has changed the

complexion of more firmly rooted sports. Often, these changes

place new demands on the athlete. The rigid hard-shelled

helmet was introduced to increase head protection. However,

it gave the football athlete a sense of added security and

permitted the involvement of head and helmet in blocking and

tackling. This practice increases the risk of serious injury.

Communications have popularized sport. As a result,

greater numbers of youths are participating in sports activitie

Many of these persons may be unaware of the risk they are

taking as a result of inadequate or poorly fitted and

maintained equipment and playing surfaces, or inadequate

training and supervision.

The athlete is the core of the person-equipment-sport

mix and it is the athlete's physical welfare that is of

concern. That risks in sports are not at a minimum is apparent

by the high ranking of many sports activities on the U.S.

Consumer Product Safety Commission's (CPSC) most recent

Consumer Product Hazard Index (314). For example, the
Hazard Index 1 ranks the product categories of football activity

and related equipment #4, and similar classifications of

baseball 2 #5, basketball #12, snow skiing #17, hockey #34,

and gymnastics #47.

Viewed in its entirety, the subject of risk in sports

is complex, involving equipment, facilities, supervision,

physical maturity, ability, attitude, conditioning, and the

environment as contributing factors. Within the context of

sports as systems and given the nature of associated accidents

and injuries, it is necessary for the Consumer Product Safety

Commission (CPSC) to identify those issues and conditions in

the person-equipment-sport mix which can be effectively

regulated through voluntary or mandatory standards.

This report is the third and final report to the Consumer

Product Safety Commission (CPSC) . It provides recommendations

for assigning priorities to tasks associated with reducing

the incidence and severity of sports related injuries, and

recommendations to improve data acquisition and analysis.

These recommendations are primarily the result of an analysis

of previous athletic injury studies appearing in the published

literature. Data obtained through the Commission's National

Electronic Injury Surveillance System (NEISS) were also

utilized

.

The usual resource limitation precluded a comprehensive

review of all sports activities. Furthermore, it would have

been pointless to include activities which were not included

in the literature. This criterion resulted in the selection

of several product categories: football, baseball, basketball,

snow skiing, ice hockey, gymnastics, and trampolines. Specific

safety issues related to these activities were not delineated

at the outset of the study. Rather, the issues presented in

this report, as well as the depth which these were researched,

developed as a consequence of the available literature.

1 The "Hazard Index" lists 367 product categories. These

product categories were derived by consolidating the National

Electronic Injury Surveillance System (NEISS) listing of

approximately 1000 categories. Categories are ranked by

multiplying the estimate number of injuries treated in

emergency rooms by weights for severity and age, then dividing

by one million and truncating.

2 For convenience, the name of the sport associated with each

product classification is used throughout the report to

identify the actual classification; e.g., football will be

used in lieu of football activity and related equipment.

- 2 -
Two earlier memorandum reports were submitted to the

Commission. The first report (May 1976) provided a "first

cut" assessment of risks associated with these sports and

subsequent recommendations. The second report (September

1976) provided an analysis of three years (July 1972 through

June 1975) of NEISS data. This report draws from these

earlier reports and includes a more thorough analysis of

specific issues.

This report is divided into several sections. The next

section includes a number of pertinent comments about the

data sources. Analyses are provided in the following section.

This is followed by a discussion of rules and standards

activities, and finally, the conclusions and recommendations.

A list of nearly 400 references and tables of injuries

projected by NEISS are included at the end of this report.

2. COMMENTS ON THE DATA SOURCES

2 . 1 Published Literature

In 1967, Haddon (269) authored a paper discussing

principles in sports research. He comments, "good basic

data on incidence and prevalence (i.e., the numbers of cases

existing at a given time per unit population) have not yet

been obtained for the effects of most organized and unorganized

sports, whether beneficial or injurious." Shortly thereafter,

Clarke (258) commented that, "research activity in sports may

be prevalent, but there is little evidence to support or deny

respective opinions on most legitimate arguments." More

recently, Blyth and Mueller (9) in a unique attempt to apply

methods of epidemiology to problems of football injuries

observed that, "There is relatively little data available on

the extent of problems of football injuries, or other sports

injuries, particularly at the high school level and below--

even though football accounts for most of the sports injury

research." As recently as 1974, Hayes (274) pointed out,

"Because of the approach to recording the incidence, nature,

and severity of sports injuries, it is very difficult to

assess statistically the risk factors of individual activities.

Without this knowledge, one cannot isolate the many variables,

both overt and covert, which contribute to injurious situations."

Sports injury research has yet to assess the extent,

severity, and nature of athletic injuries. Consequently,

basic input to decision processes affecting safety in athletics

has been and will be based upon perceived need rather than

valid statistical measures. Past studies have addressed a subset of these problems but their utility is limited, because

- 3 -
they lack commonality of purpose and design. Traditionally

such studies are limited to a geographical sector, to a specific population, and to demonstrating the extent and

severity of injuries resulting from a specific set of factors.

Further they lack universally accepted basic definitions,

such as, reportable injury, injury classifications, injury

rate, severity rating, etc.

As with the injurious aspects of sports, research has

not provided evidence to demonstrate the beneficial aspects

of sports (283, 284) making it impossible to assess the risk

of participation, particularly, if a definition of risk is

adopted as proposed by Clarke (16): "Calculated risk is an

assessment of the hazards in the sports being offered relative

to the sports' purported benefits."

Given that an equation in terms of benefits and injuries

can be developed, it would be impossible, according to Hayes

(274), to apply the results universally to a population of

participants with multifaceted motivations and participating

in sports at all levels of competition. The approach

suggested by Hayes may be more appropriate: "A risk factor

may be defined as the susceptibility of a participant to

injury. The susceptibility is determined by the state of the

man, machine, and environment, and the interactions among them."

By any definition, an assessment of the risks in sports

implies the availability of data. In particular, the latter

definition implies statistical knowledge of the system.

A system is characterized by a set of objects, their

descriptive attributes, and relationships between these objects

and attributes. In general, these objects or entities may be

physical or abstract. In sport, these entities might be

the athlete, protective equipment, playing surface, coach,

etc. The attributes are properties of each entity, for

example, the athlete's age, weight, aggressiveness, motivation,

muscular strength, or a ski binding's release tolerance,

corrosive resistance, tolerance to friction, etc. Relationships between entities and attributes tie the system together.

Small changes in one parameter may alter the system dramatically.

Application of the systems concept to sport injury research

is a topic discussed by Fraser (266). He writes, "...consideration of the interactions that occur within a man-machineenvironment complex that cause or contribute to the occurrence

of accidents, allows a clearer analysis,..., of the different

components that make up the system, .... Until this approach

becomes more widespread among all those involved, we cannot

even verge on the optimal in recreational system safety.

- 4 -
In sport injury research, the systems concept has had

infrequent application. Most studies isolate one or two

variables and assume the effects of others to be negligible.

The efficacy of this "piecemeal approach" is obviously limited.

The literature provides very little information on sports

injuries related to activities of basketball, trampolines,

gymnastics, and to some extent, baseball. Conversely, football

and snow skiing activities account for most of the literature.

This disproportionate treatment by the literature could

properly reflect hazards encountered in these sports. However,

this would probably be an erroneous assumption in view of the

numbers of basketball and baseball injuries projected by NEISS.

Unfortunately, it is beyond the scope of this study to fill

the void where data are lacking.

2.2 NEISS

The National Electronic Injury Surveillance System (NEISS)

was implemented to collect injury surveillance data on a wide range of products and activities from a sample of 119

participating hospital emergency rooms. These 119 hospitals

are a sample of all hospital emergency rooms in the contiguous

United States. (The 96th Edition of the Statistical Abstract

of the United States indicates that there were almost 6000

nonfederal "short-term" hospitals in the United States in 1973.)

NEISS broadens the scope of this study since it provides

data on the general population, whereas the literature

principally addresses a subset of this population--those

engaged in organized activities. The structure of the NEISS

precludes distinguishing between the many activities loosely

referred to as sport related activities and those activities

defined as sport. Only that activity which pulls together

elements of personnel, supervision, officiating, equipment,

and rules best characterizes sport. On the other hand, sport

related activities are not well defined and are potentially

related to sport only in a most obscure sense. NEISS treats

these two classes of activities as one when they are, from the

standpoint of this study, essentially dissimilar.

The need for distinction is also evident when approaches

are considered for reducing the risks associated with these

activities. Obviously, elements unique to organized activities

(rules, supervision, equipment, etc.) can serve as vehicles

for mitigating the incidence and severity of injuries. On the

other hand, problems of reducing the incidence and severity

of injuries resulting from unorganized activities, where these

common elements are missing, must be addressed in other ways.

Reducing the risks encountered by this population could be

- 5 -
accomplished through information and education programs, or

possibly through improving the safety characteristics of

essential equipment.

The utility of NEISS, in view of the project objective,

is limited for other reasons.

First, it is impossible to establish statistically valid

injury rates from NEISS data, because the number of exposures

experienced by those in the NEISS sample is not known.

Typical measures of exposure are the number of participants

(injured and noninjured) , games, ski-man-days, hours, etc.

Without exposure data any comparative analysis of the NEISS

data assumes that each product category is equally represented

in the NEISS sample.

It should not be inferred that rates (injuries per

exposure) alone are sufficient for establishing priorities.

The magnitude of a problem, in terms of numbers of injuries

is equally important. Both statistics must be incorporated

into the analysis of risks. NEISS provides an estimate of

the number of emergency room treated injuries. Whether or

not 1000 injuries are incurred by a population of 1000

participants or 1 million participants is unknown.

Second, the system does not include provisions for

identifying any of the elements of the accident sequence.

Hence, inferences concerning the relative importance of

various elements in accident causation cannot be made.

Third, any rationale for establishing an optimum set

of priorities for mitigating the hazards of sports must

include measures of severity. Sufficiently detailed measures

are lacking because severity ratings are not an integral part

of the recording format. As a result, measures of severity

must be based on arbitrary ratings and derived in secondary

analysis. Such measures may be misleading if used for

establishing priorities. Furthermore, these data are

limited to immediate consequences. Data on long term or

late effects of trauma, critical to an accurate assessment

of severity (202), are not recorded.

Because it is impossible to identify circumstances

related to injuries and the relative risks incurred by

various groups, the utility of the NEISS data is limited.

- 6 -
3. DISCUSSION

This section begins with an analysis of data collected

by NEISS. Injuries and major injuries are discussed. A

discussion of sports fatalities follows. This section

closes with a discussion and analysis of material obtained

from the published literature.

3.1 NEISS

NEISS 3 provides data over a four year period, from

July 1972 through June 1976, providing a multi-year and

relatively consistent base of surveillance data about the

distribution of injuries treated in the sample of hospital

emergency rooms by type of injury, affected body part, age,

sex, and disposition. The numbers of injuries presented in

this report are in terms of national projections of hospital

emergency room treated injuries. 4 These projections are

derived by multiplying the number of injuries reported by

each hospital and summing the results for all hospitals.

The weight factor assigned to each hospital is determined

by the nature and number of similar hospitals in the country.

These are standard weights developed and used by CPSC in

their analyses. 5

3.1.1 Projected National Emergency Room Injuries

As indicated by table 1, 85% of the injuries are related

to football, baseball, and basketball activities. The

percentages of injuries distributed between these activities

differs only slightly. However, when only those injuries

incurred by youths 20 years or less are considered, these

differences become more pronounced. Football activities

clearly account for the greatest number of injuries. Although

the number of injuries related to gymnastics and trampoline

activities are low, practically all injuries are incurred

by youths 20 years old or less. In general, this age group

accounts for 73% of all injuries.

3 NEISS data presented in this report were extracted from data

tapes prepared for NBS by CPSC.

4 See appendix A for data pertaining to specific injury types.

5 Obtained from the Bureau of Epidemiology, CPSC.

- 7 -
Table 1. NEISS emergency room injury projections

for FY 76 by product category and age group

Product

Category

All Ages Age Group < 20 Years

projected

injuries

June '75 - July ' 76

% of

all

injuries

Projected

injuries

June '75 - July 1 76

'% of corresponding

injury projections

for all ages

Football 386 944 31% 331 748 86 %

Baseball 351 073 28 207 575 59

Basketball 329 637 26 235 965 72

Snow skiing 85 807 7 54 292 63

Ice hockey 25 919 2 18 441 71

Gymnastic 54 105 4 50 814 94

Trampoline 18 465 1 17 642 96

1 251 940 100 % 916 477 73%

For the most part, this predominance of football,

basketball, and baseball injuries is the result of greater

numbers participating in these activities. This conclusion

is supported by data presented in table 2 on sports participation in institutions of the National Collegiate Athletic

Association (NCAA) (321) and the National Federation of State

High School Associations (NFSHSA) (322). The participation

pattern for various activities parallels the results indicated

by table 1. To extend this analysis further would be misleading

Table 2. Numbers 3 of participants in recreational programs

of member institutions of the National Federation of

State High School Association (322) and the National

Collegiate Athletic Association (321)

Interscholastic Intercollegiate Intramural Total All

Sport high school athletics sports (college) levels

Tackle football 1 113 106 42 187 4 341 i 493 101

Other football 19 066 — 314 401

-L activities

Baseball 426 424 19 487 8 198 973 537 Softball 155 552 3 185 360 691

Basketball 1 127 797 22 937 412 246 -1 562 980

Skiing 19 510 1 324 2 855 — 23 689

Ice hockey 30 065 2 851 15 074 47 990

Gymnastics 116 764 4 202 3 763 124 729

a) These data do not account for all sports participants.

- 8 -
since the participation data provide only partial estimates.

Participation data for pre-secondary school and non-scholastic

sports are not included. In addition, the unknown numbers

participating in sports related activities would increase

participation estimates tremendously, particularly, for

sports such as football, basketball, and baseball.

In view of the project objective, it would be desirable

to express injuries in terms of rates for comparative analysis.

Risks of participation might be expressed in terms of injuries

per unit of exposure. Obviously, NEISS provides input for

estimating numbers of injuries, but exposure estimates for

the broad base of participants sampled by NEISS are unmeasurable.

A more realistic measure of the risks incurred in sports

activities may be in terms of injuries per unit of participation.

However, satisfactory estimates of participation for all groups

have not been obtained. Even if these data were available, it

may be inappropriate to establish rates without further adjustments for geographic factors. Establishing priorities on the

basis of numbers of injuries alone suggests that football,

basketball, and baseball should receive the greatest priority

for further investigation.

Relative to other NEISS product categories, only two,

"Stairs, Ramps and Landings" and "Bicycles and Bicycle Equipment,"

account for more emergency room injuries (324) during this

period, than football, baseball, or basketball.

3.1.2 Major Injuries

All injuries reported through the NEISS are classified

according to one of four disposition codes:

1. Treated and released or examined and not treated;

2. Treated and transferred for hospitalization;

3. Admitted for hospitalization;

4. DOA or expired in emergency room.

Major injuries will be defined as those injuries classified

according to code 2, 3, or 4.

As indicated in table 3, football accounts for the

greatest number of major injuries, followed by baseball and

snow skiing. Snow skiing 6 accounts for the highest ratio of

6 Ski injuries may be misrepresented by the NEISS. See

discussion, page 19.

- 9 -
major to all injuries —1 out of every 13 injuries is a major

injury. Conversely, basketball suggests the lowest ratio.

The incidence of major injuries incurred by youths less than

20 years old is similar to that indicated by table 1 —72% of

all major injuries compared to 73% of all injuries are

incurred by this age group.

Table 3. NEISS major injury projections for FY 76

by product category

Product

Category

All Ages Age Group <20

Major injury

projections

June '75 - July ' 76

% of 1 all

major

injuries

Ratio of

major

injuries to

all injuries

Major

injuries

June ' 75 - July '76

% of corresponding

major injury

projections for

all ages

Football 11 938 37% 1/32 10 613 89%

Baseball 8 063 25 1/44 4 639 58

Basketball 2 919 9 1/113 1 921 66

Snow skiing 6 608 21 1/13 3 622 55

Ice hockey 343 1 1/76 211 62

Gymnastics 1 417 4 1/38 1 361 96

Trampoline 911 3 1/20 805 88

Total 32 199 100% 23 172 72%

3.1.3 Projected Injury Trends

Table 4 provides the average annual percent changes in the

projected number of injuries treated in hospital emergency

rooms. As indicated, only activities related to ice hockey

show a decline in the projected number of injuries.

Table 4. Average annual percentage change in projected

injuries by sport—July 1972 through June 1976.

Activity

Average

Annual

% change

Football 19.1

Baseball 22.7

Basketball 20.4

Snow skiing 4.0

Ice hockey -3.4

Gymnastics 51.1

Trampoline 3.9

Based on two years of data July 1974 through June 1976.

- 10 -
Injuries resulting from gymnastic activities have increased

at the greatest rate. However, given the greater numbers of

injuries in activities related to football, baseball, and

basketball, the increases corresponding to these activities

are of greater consequence.

3 . 2 Fatalities

Data pertaining to fatalities in sports come from two

sources —the CPSC's Death Certificate Project and the Annual

Survey of Football Fatalities.

3.2.1 Death Certificate Project

The Death Certificate Project was initiated by the CPSC

to "provide additional information concerning hazard patterns."

(324) The project is designed to collect certificates from

54 health jurisdictions, New York City, the District of

Columbia, Puerto Rico, and the Virgin Islands. At this time,

not all jurisdictions have reported. Thus, these data do not

reflect the totality of sports fatalities. It should also

be noted that these fatalities are the result of a broad

range of sports activities (from recreational to competitive

activities) and no inferences can be made regarding the role

of protective equipment.

The seven product categories emphasized in this study

have accumulated 126 certificates of death since 1973.

Table 5 provides a summary of these certificates. They are

primarily distributed in the categories related to football,

baseball, and snow skiing activities. These fatalities are

associated primarily with head injuries.

3.2.2 Annual Survey of Football Fatalities

Another source of information on fatalities in sports

has been .the Annual Survey of Football Fatalities initiated

in 1931 by the American Football Coaches Association. Since

then, a study has been conducted each year with the exception

of 1942. The 1975 report (5) indicates 1221 fatalities have

been recorded during the past 43 years as a result of football

activities. Of these, 821 have been classified as "direct"

and 400 as "indirect."

The criteria for making these classifications are as

follows: Direct-- "Those deaths which resulted directly from

participation in football"; Indirect-- "Those which are caused

by systematic failure as a result of exertion while participating

in football activity or by a complication which was secondary

to a non-fatal injury.

- 11 -
Table 5. Summary of death certificates collected by

CPSC as of October 1976 by sport, year of

death, and location of related injury

(These data were extracted from the certificates by CPSC staff.)

Yr

.

Head

injury

Neck/

spine

Trunk

internal Other Total

Football

(Prod. Code 1211)

73 10 1 2 13

51

(40%)

74 13 2 2 3 20

75 9 3 1 4 17

76 1 1

Baseball

(1204)

73 4 2 6

35

(28%)

74 11 2 3 16

75 5 2 7

76 4 2 6

Basketball

(1205)

73 1 1

8

(6%)

74 2 1 3

75 1 1 1 3

76 1 1

Snow skiing

(1216)

73 1 1 2

23

(18%)

74 4 2 1 7

75 5 2 7

76 4 1 1 1 7

Ice hockey

(1279)

73 0

1

(1%)

74 0

75 0

76 1 1

Gymnastics

(1272)

73 0

2

(2%)

74 1 1

75 1 1

76 0

Trampoline

(1233)

73 0

6

(5%)

74 2 2 4

75 1 1 2

76 0

Total

(%)

77

(61%)

14

(11%)

14

(11%)

21

(17%)

126

(100%)

- 12 -
The majority of all football-related fatalities have

occurred in high school football (60.5%), followed by sandlot

(20.9%), college (11.1%) and pro and semipro football (7.5%).

Direct fatalities were primarily the result of head

injuries (60.6%), followed by injuries to the spine (18.3%)

and injuries to the abdominal or internal organs (17.0%).

In 1975, there were 15 direct fatalities, 13 involving

the head and 2 involving the spinal cord. There have been

57 direct fatalities recorded in the four seasons between

1971 and 1975 (2-5)

.

Fifty-three of these fatalities

resulted from injuries to the head, neck, and spinal cord.

The incidence of fatalities in sports appears to be low.

For example, Blyth and Arnold (5) calculate the average

number of fatalities directly related to football to be

1.09 per 100 000 players annually.

3 . 3 Published Literature

There are no comprehensive studies that examine injury

patterns across all sports. Most of the literature concerns

specific problems within individual sports. A direct comparison

of these reports is usually impossible because each employs a different definition of reportable injury, different definitions

of severity, and focuses on different problems and populations.

The literature can be grouped into that material concerning

the distribution of injuries within a sport and reports

emphasizing specific issues. Specific issues are discussed

in the latter portion of this section. However, to place

these issues in proper perspective a review of the distribution

of injuries is presented first.

3.3.1 Distribution of Injuries by Sport

a. Football

Football has been the principal target of most athletic

injury research. As a result, reports on football injuries

are numerous. Those presented were chosen because they are

the more recent reports available or they illustrate a particular approach to research and reflect the literature

regarding the overall distribution of injuries encountered

within this sport.

Garrahan (21)

,

in a study of the 1960-65 high school

football seasons in Rhode Island, obtained injury data from

insurance claim forms. Of 11 020 football athletes participating in this 6-year period, 2191 were injured. This

- 13 -
injury rate (19.9 injuries per 100 participants) is one of

the lowest reported for football and is typical of rates

based upon insurance claims.

Most injuries involved the

shoulder, and

back

.

knee

,

hand

ankle

,

13.4%

12.7%

8.4%

7.4%

7.2%

The types of injuries were

strains and

sprains

,

fractions

concussions, and

lacerations

.

61.0%

15.2%

4 . 9 %

4.7%

A study by Allen (1) of 465 football players, constituting

5 teams participating in league play during the 1965 and 1966

season at Clarke Air Force Base, recorded 200 injuries for

a rate of 62.4 injuries per 100 participants. This is the

highest reported injury rate for any population of football

players. Also, the severity of these injuries exceeds that

usually reported.

One hundred and eleven (38%) injuries were graded as major

injuries; 22% "resulted in the player being out for the

season"; and 13% resulted in hospitalization. There was

a total of 711 days of hospitalization resulting in an

average of 2.45 hospitalized days per injury. The body

parts most frequently injured were the

The knee also accounted for 30% of the 111 major injuries.

knee

,

ankle

,

f ore arm-wri st-hand

,

shoulder girdle,

upper arm-elbow,

thigh

,

spine-back-neck, and

foot

.

21.4%

15.9%

12 .4%

11.4%

5.5%

5.2%

4.1%

4.1%

14 -
The most common type of injuries were

contusions

,

sprains (injuries to

29.7%

the ligaments)

,

strains (injuries to

27 .

6

o

o

the musculotendinous

structures

)

fractures

,

abrasions and

14.5%

6 . 2 %

lacerations, and

dislocations

.

5.5%

3.4%

Sprains and strains also accounted for 40.5% of the 111 major

injuries

.

The National Football Injury Report (28) represents a joint effort by the National Collegiate Athletic Association

Committee on Medical Aspects and Competitive Safeguards of

Sports and the U.S. Public Health Service, to provide nationwide data at the college level on the incidence and causes of

football injuries. The report is plagued by what the authors

refer to as "some confusion as to what constituted a reportable

injury." Data were drawn from 40 schools participating in

National Collegiate Athletic Association (NCAA) football

during the 1970 season.

There were 2782 injuries reported and classified according

to three degrees of severity: "Active Participation" (those

injuries without time lost from participation) ; "Partial

Participation" (injuries with time lost from games or practice)

and "Hospitalized." The 2782 injuries involved 1468 players.

These were classified as "Active Participation" injuries in

37.5% of the 2782 injuries; "Partial Participation" injuries

(56.0%); and "Hospitalized" (6.5%).

The principal types of injuries reported were

sprains

,

contusions

,

strains

,

concussions, and

fractures

.

31.1%

25.4%

17.1%

6.5%

4.7%

The most frequently injured body part was the

knee

,

ankle

,

head and face

thigh, and

shoulder

.

18.2%

12 . 0 %

10 . 6 %

5.7%

5.3%

- 15 -
Of the 179 hospitalized cases, 40.8% were the result of

knee injuries and 20.7% the result of head and face injuries.

Probably the most comprehensive study of high school

football injuries is one conducted in North Carolina between

1968 and 1972 by Blyth and Mueller (9)

.

This study included

43 high schools selected on the basis of size, and for

logistic reasons, within a 100-mile proximity of Chapel Hill,

North Carolina. As a result, 8776 participants were included

in the study. A reported injury was "one occurring as a result

of participation in an organized football program at the high

school level, for which professional treatment was received,

and/or which resulted in restriction or modification of the

boy's usual activity for one day beyond the day of injury."

There were 4287 injuries recorded in four years resulting

in an average injury rate of 488 injuries per 1000 players.

Data on these injuries were the result of interviews with

coaches, injured players, and fellow players.

The major types of injuries were

sprains

,

- 20.4%

contusions

,

- 17.7%

fractures

,

- 10.6%

pulled muscles. - 8.8%

strains

,

- 7.4%

lacerations, and - 5.8%

concussions

.

— 5.4%

Injuries were distributed in the following

lower leg, knee, and ankle. 38.0%

trunk

,

- 13.2%

head and neck, - 12 . 9%

shoulder

,

- 8. 3%

hand, fingers, and thumb, - 8.0%

lower arm, including wrist

and elbow. - 6.7%

upper leg, - 5.4%

back

,

- 4.7%

foot and toe, and - 2.9%

upper arm. - 1.4%

The most frequently injured body part was the lower leg

(including knee and ankle) with 38.0% of the reported injuries.

Over one half (50.8%) the lower leg injuries involved the knee,

followed closely by the ankle (40.3%).

- 16 -
A severity classification for specific groupings of

injuries was not given. However, the overall severity of

the 4287 injuries was assessed. Of these injuries, 34.7%

resulted in "seven or more days lost from participation by

injured participants."

The frequency of injuries resulting from a "blow from

object" accounted for 31.2% of all injuries. The "objects"

were recorded as helmets causing 38.8% of these injuries,

shoes (23.1%), shoulder pads (15.2%), and knees (11.9%).

Injuries involving helmets and shoulder pads as the "objects,"

accounted for 16.8% of the total number of injuries.

Other major classifications of causes include:

collision with another person, - 20.1%

torsion or twisting, - 10.8%

collision with object,

contact with sharp, hard, or

- 8.6%

rough object. - 4.0%

illegal act. - 3.7%

stepped in or on object, - 2.6%

improper technique, and

ill fitting, broken, or

- 1.9%

defective equipment - 1.7%

Summary

Injuries occurring in football are primarily distributed

about the

knee and ankle,

hand and arm, trunk, and

shoulder.

The principal types of injuries are

sprains and strains,

contusions, and

fractures

.

Since football is a contact sport, it is not surprising that

most injuries result from impacts with objects and collisions

with other persons.

b. Ice Hockey

Ice hockey, like football, is a contact sport involving

forces which are potentially injurious. These forces are

transmitted through body checks, stick, puck, skate blades

and contact with boards, surface, or goal posts.

-17-
An early survey (1963-64 season) by Toogood and

Love (111), collected injury data from insurance claims on 85

reported injuries from a population of 2469 participants

(ages 7-18 years) in the Toronto Township Hockey League.

Although the report implies mouthpieces and headgear were

worn (the extent to which these were worn is not mentioned)

,

65.9% of the injuries were injuries to the head or face. The

mouth and teeth accounted for 24.7% of these injuries. The

majority of head and face injuries were due to being hit by

the hockey stick (18.8%), puck (.12.9%), or skate (7.1%).

A survey (109) of hockey injuries during the 1969-70

season "within the greater Edmonton metropolitan area,"

collected data on 446 injuries involving 345 players. The

survey included 6890 players, ages 9 through "18 plus," from

461 teams. Again, the majority of injuries were to the head

and face (55.5%). Injuries were distributed to the

head and face,

shoulder

,

knee

,

hand

,

ankle, and

wrist

.

The typical injuries were

lacerations

,

bone/muscle bruise,

fractures

,

sprains/strains

,

teeth

,

concussions, and

dislocations

.

The "causes of injury" were attributed to the

stick

,

- 32.7%

puck

,

- 17.7%

boards

,

- 15.9%

body check,

accidental collisions

- 12.1%

between players. - 7.4%

fall or trip. - 5.8%

skates

,

- 3.6%

fights, and - 2.5%

goal posts. - 1.8%

- 55.5%

- 7.4%

- 7.4%

- 4.9%

- 4.7%

- 3.6%

- 34.8%

- 19.5%

- 12 . 8 % - 12 . 6 % - 8.7%

- 4.3%

- 3.6%

Inadequate or faulty equipment was named in 0.2% of the total

injuries. The extent to which helmets and intra-oral mouth

protectors were worn by all players cannot be determined.

- 18 -
However in 90% of the injuries involving teeth, the players

were not wearing a mouth protector. Ninety- three percent

of the lacerations were to the facial area. Of the 19 players

suffering concussions, 17 were wearing hockey helmets.

Hayes (102) collected ice hockey injury data during the

1970-71 season from 21 Canadian and 9 American universities

conducting intercollegiate hockey programs. The 328 injuries

were distributed about the

The distribution of these injuries "relative to the cause

included

Hayes also noted that most injuries were contusions or

lacerations

.

c. Snow Skiing

Unlike hockey and football, ski-accident research has

emphasized noncompetitive populations engaged in recreational

activities. Associated with this population are wide

differences in participant age, physical condition, ability,

experience, exposure, training, among other factors.

Shealy (75), in reviewing the literature, estimates that

there are between 3 and 5 million skiers in the U.S. and

165 000 to 600 000 injuries annually. Most of these injuries

involved the lower extremity.

The incidence of skiing injuries estimated by Shealy

is much greater than that suggested by the NEISS data. A

possible explanation is that ski areas frequently provide

emergency medical facilities or first-aid stations at the

base of the slopes. As a result, many injured skiers are

treated locally and may not require emergency room treatment.

Since NEISS reflects only those cases treated in the emergency

rooms of participating hospitals, these injuries are not

recorded

.

head and face,

knee

,

neck and shoulders,

trunk

,

ankles and feet,

arms and hands, and

upper leg.

45.1%

10.4%

9.2%

8 . 8 %

8 . 2 %

7.9%

5.5%

body contact,

stick

,

puck

,

ice surface, and

skates

.

38 . 3%

29 . 1%

15.2%

13.9%

3.5%

- 19 -
Arnold and Ackman (45) in a study of ski injuries in

Canada, indicate approximately 39.0% of all injuries are

sprains followed in frequency by

The lower extremity was injured in approximately 70% of the

cases. In commenting on the effectiveness of release bindings

the authors indicate, "approximately half the injured skiers

felt that their bindings failed to function properly at the

time of their injuries."

Snow conditions were indicated as factors contributing

to the "causes of accidents" in 30% of the cases, closely

followed by "carelessness" (27.5%); "faulty equipment" was

indicated in 10% of the cases.

In an analysis of ski injuries encountered during the

1972-73 season at a Vermont ski area and treated at the

emergency medical care facility at the base of the slope,

Gutman (59), et al., recorded 792 injuries. Sprains were

the most frequently reported injuries, accounting for 43%

of the total. Fractures were second with 31% of the total.

Thus sprains, strains, and fractures represented 74% of all

injuries in that survey. These 584 injuries involved the

upper extremity (including trunk) in 33.9% of the cases and

lower extremity in 65.8% of the cases.

These statistics compared with a similar and earlier

study of the 1960-61 season by the same authors, show little

change in the overall injury rate and similar distributions

of specific types of injuries. However, this comparison shows

the number of upper extremity sprains and fractures have

increased from 49 in 1960-61 to 198 in 1972-73 while lower

extremity sprains and fractures have decreased from 476 in

1960-61 to 384 in 1972-73. Total sprains and fractures

increased from 539 to 584 for the same period. The authors

hypothesize that modern equipment, "hard-plastic boots,"

and "improved release binding" may be the reason for this

slight shift in the injury pattern.

The changing patterns of ski injuries was the subject

of a report by Tapper and Moritz C78) . They compare data

collected at one ski area during the 1969-72 skiing seasons

with injury records of earlier seasons. The rate of ski

injuries, according to the authors, has declined from 7.4

per 1000 skiing days in 1960-61 to 3.2 injuries per 1000

skiing days in 1971-72. The most "significant factors" in

fractures

,

cuts

,

dislocations, and

frostbite

.

32 . 0%

15.0%

4.0%

1 . 0 %

- 20 -
the declining injury rate, according to the authors, have

been "the slope grooming and continued expansion" of the

skiing area.

The most pronounced change in injuries has been a decline

in ankle sprains and fractures and foot injuries and an

increase in tibial shaft fractures. Of the tibial shaft

fractures occurring during the 1971-72, 30% were in children

under the age of 10. Injuries involving the knee, tibia,

ankle, and foot accounted for 45% of the injuries during the

1969-72 seasons.

In most accidents, injured skiers blamed slope conditions,

bindings, collisions, or ski poles as the "cause" of their

injury—37% directly blamed malfunction of their bindings.

Garrick and Kurland (58)

in a study assessing the

methods of collecting ski injury data, suggest that "data

from ski patrol reports may not represent accurately the

number of injured skiers or the characteristics of all the

injured as a group."

In a controlled experiment to determine the extent that

injuries are not reported, they found that characteristics

of sex, age, and skill level were significant in determining

who would and who would not report injuries. Of the injured

seen in this experiment, 45% had not reported their injuries

to the local ski patrol. The importance of this result

should be emphasized. First, reports using data collected

by the ski patrol or at the ski-area first-aid station

apparently underestimate the extent of the injury problem.

Second, such studies may be misleading since young,

inexperienced, or female skiers are most likely to report

their injuries while their counterparts are least likely.

A study by Shealy, et al. (75) supports this finding.

Their study population consisted of 2071 members (primarily

students - 90%) of a ski club in Buffalo, New York. Data

were collected through questionnaires sent to members. When

comparing results with those of the ski patrol for the same

period, the authors found that 58% of all fractures and 84%

of all non-fractures and 80% of all injuries had not been

reported to the ski patrol. In addition, the same reporting

biases in age, sex, and experience were observed as in the

study by Garrick and Kurland.

d. Baseball

The published literature offers very little regarding

injuries related to baseball activities. A report by Polk (96)

was published in 1968 and provides data on the frequency and

causes of baseball injuries incurred by professional and

- 21 -
college baseball players. The principal types of injuries

reported in this survey were

These injuries accounted for 82.5% of all injuries.

Sprains were primarily due to sliding and running between

bases. Strains were predominantly the result of throwing,

followed in frequency by running between the bases. Contusions

were primarily the result of a batter being hit by the pitched

ball or as a result of collisions between players. Pulled

muscles were predominantly due to running between bases or

throwing. The causes of fractures were distributed evenly

between sliding and the batter being hit by the pitched ball.

e. Basketball

Few reports were obtained describing injuries and related

factors associated with basketball. There is a paucity of

published literature regarding this sport.

Basketball injuries, according to the authors of a University of Toronto study (288), are primarily sprains

and strains. This type of injury accounted for 58.3% of

all intercollegiate and intramural athletic injuries. The

most frequently occurring injuries were

sprains

,

strains

,

contusions

,

pulled muscles, and

fractures

.

27.3%

18.7%

16.9%

11.3%

8.3%

sprains and strains,

contusions

,

fractures, and

abrasions/ lacerations

58.3%

14.0%

5.1%

4.6%

Injuries were distributed about the

ankles

,

hands/wrists/fingers/

31.6 o,

*o thumbs

,

knees

,

head/face, and

elbows/shoulders

.

20 . 1 %

11.4%

6.7%

4.3%

- 22 -
f. Gymnastics

Gymnastics includes a variety of activities. The sport

encompasses the events of floor exercise, vaulting, rings,

horizontal bar, parallel bars, pommel fside) horse, and

includes activities of trampolining and tumbling.

Bozdech (.361, pp. 541-542), in surveying the literature

of European countries, indicates the relative injury rate

(number of injuries in 100 athletes per year) is between

0.8 and 2.07 percent. According to Bozdech "the greatest

number of injuries occur on the parallel bars; then follow

the horizontal bar, rings, and horse. But the most dangerous

apparatus is the horizontal bar: Of all fatal injuries,

36 percent occur on this apparatus as opposed to only 18 percent

on the rings." Most of the injuries in gymnastics, he claims,

are the result of a wrong execution of the exercise. Defects

in the apparatus is second in causing injuries, but he adds

"this is far less common."

The reasons why the horizontal bar is the more hazardous

apparatus are not given by Bozdech. However, the increased

risk is probably due to the height of the apparatus (102 3/8 in

(40.31 cm) from floor to bar) (125, p. GY10, Rule 1) and the

requirement for executing maneuvers. In the latter case the

performer must release and regrasp the bar, providing opportunity

for falls.

The published literature provides no additional injury

statistics regarding trampoline activities. However, according

to Piscopo (121, p. 34-37) "the element of risk sharply

increases when somersault turns are introduced."

3.3.2 Specific Issues

Several of the more frequently occurring or severe sports

injuries are emphasized by the literature. These include

head and facial injuries, lower leg, spinal injuries, lower

extremity equipment related ski injuries, and injuries

related to playing surfaces. These are discussed in the

following sections.

a. Head Injuries - Concussions

Injuries involving the head have created greater concern

than injuries to any other parts of the body. It is not

because these injuries occur more frequently, but because

of their potential severity. Although there are limited

data available to quantify the extent of serious head injuries

- 23 -
in sports, many studies have been published which provide

insight into this problem. Probably the most notable of

these studies are the annual surveys of football fatalities

(2-5)

.

According to the Forty-Fourth Survey (5) 819 deaths

resulted directly from participation in football over the

past 44 years. Sixty-one percent of the recorded deaths

resulted from head injuries (66% as a result of high school

football, 20% from "sandlot" football, 7% from college

and 7% from "pro and semipro" football activities) . Unfortunately, similar studies for other sports have not developed.

Recently the CPSC began collecting death certificates.

These data do not reflect the totality of sports fatalities

nor at this time are they relevant to statistical analysis.

However, the certificates provide additional information on

the severity of head injuries in sports. As indicated in

table 5 (page 12), head injuries account for 61% of the

certificates on record for the seven sports. It should be

noted that these fatalities are the result of a broad range

of sports activities (from recreational to competitive

activities) and no inferences can be made regarding the role

of protective equipment. They do emphasize, however, the

importance and need for adequate head protection in sports.

Concussions, according to NEISS, 7 account for approximately 1% or less of all injuries reported for each sport.

However, when only major injuries (those requiring hospitalization) are considered, concussions become more apparent

accounting for

11.8% of major football injuries,

8.7% of major basketball injuries,

11.6% of major baseball injuries,

2.5% of major snow skiing injuries,

9.5% of major gymnastic injuries, and

5.4% of major trampoline injuries.

Again, it must be noted that these data are drawn from the

general population and the specific role of protective equipment is unknown.

Many studies have emphasized particular populations and

show the incidence of head injury in relation to other injuries.

The study of North Carolina High School football injuries

discussed earlier (9), surveyed 45 schools over a 4-year

7 See appendix A.
period--l 9 6 9- 19 72 . Two hundred and thirty-one concussions

were recorded for 8776 football participants in the sample

schools. Assuming other regions of the country experienced

similar rates (2.6 concussions per 100 athletes), the

resulting projection is substantial —28 941 concussions

annually occurring in interscholastic high school football

alone

.

In relation to other injuries, the North Carolina study

showed concussions accounted for 5.4% of all reported injuries.

This is comparable to rates reported in other studies conducted

by Garrahan (21), Martin, et al. (28), and Grippo (25).

Table 6. Comparison of head injury (concussions)

reported by various studies.

% of all

Source injuries Population

Garrahan 4.9 High School Football

1960-1965

Martin, et al

.

6.5 College Football

1970

Grippo

(SRI)

4.5 Professional Football

1974

Blyth, et al.

N.C. Study

5.4 High School Football

1969-72

There is no argument as to the etiology of head injuries.

As Snook (175) suggests, "...the etiology is a blow to the

head,..." The injuries that follow may be "...cerebral

concussion, intracerebral hemorrhage, craniocerebral hematoma,

either epidural and subdural, and cerebral hemorrhage." Thus,

the prime objective of a helmet is to provide a "smooth ride

for the brain" (163) by attenuating the forces of impact (158).

But the characteristics of these impacts depends upon the

sport (143, 156). In hockey and baseball these impacts are

characterized by high velocity low mass impacts (puck, ball,

stick) , whereas the reverse holds true for football.

The head injury problem has attracted the attention of

two groups currently developing standards in athletic

equipment—the National Operating Committee on Standards for

Athletic Equipment (NOCSAE) and the ASTM Committee F-8.

NOCSAE has prepared and implemented a "Standard Method of

Impact Test and Performance Requirements for Football Helmets"

(348) based on work done at Wayne State University. As of

August 1976, a total of 93 helmet models have passed the

- 25 -
NOCSAE standard (327). ASTM will soon follow with a football

helmet test procedure. Both are preparing and considering

standards for ice hockey helmets and NOCSAE will soon present

a baseball batting helmet standard (330)

.

The NOCSAE standard is a significant document in that

it has established the minimum level of performance helmet

manufacturers must attain if their helmets are to be used

in high school and college football programs throughout the

nation. This is the result of recent decisions by the rules

committees making the wearing of NOCSAE approved helmets mandatory

for college football players in 1978 and high schools in 1980

(174, 37)

.

Considerable controversy has surrounded the differences

between the NOCSAE test methods and the ASTM method of testing

helmets, particularly with respect to the headform—NOCSAE

using a resilient headform and ASTM favoring a rigid metal

headform. 8 The extent of these differences, particularly

regarding the ability to reflect safety performance characteristics, is not known. Some proclaim a distinct difference

exists. Hodgson (147) commenting on this difference notes,

"...some comparative drop tests were made using human cadavers.

The data revealed that the MHF (metal headform) was not only

unrealistic in response characteristics, but also distorted

the comparison between helmets, thus making a more realistic

head model essential to progress." On the other hand, Newman

(158) cites recent work "with both cast magnesium and soft

headforms" where results indicated that "the physical

properties of the headform have little influence on helmet

response .

Recent tests, in which NBS participated (129, 130, 131),

indicate the existence of "substantial differences in the

measured values of maximum accelerations transmitted to the

headform when using the NOCSAE and ASTM test systems" and "poor

correlation between the two test methods." If in fact the

results differ substantially between two relatively simple

drop tests, what differences prevail when playing field

conditions are substituted for laboratory conditions?

Of further concern has been the failure to demonstrate

interlaboratory reproducibility of test results. This was

indicated by Andrews (129, 130) and more recently suggested

by the results of the "NOCSAE Round Robin" presented at

the ASTM meeting of January 1977.

8 Several reports are available that examine in considerable

detail the difficulties of evaluating protective headgear,

for example, reports by Berger (134) and Newman (158).

- 26 -
Another controversial point concerns the criteria for

determining failure, i.e., "at what point the output

exceeds that, which, from a biomechanical point of view,

would be injurious to the wearer of the helmet" (158). Data

needed to confirm or dispute this argument do not exist.

The criteria used in the NOCSAE test is based on an

approximation of the Wayne State Tolerance (WST) curve: 9

SI = /

T

a

2 ’ 5 dt

.

. o

Portions of the WST curve were derived from tests using

human cadavers, animals, human volunteer studies and accidental

free falls (158) . This curve has never been verified for

living humans (158) , nor is there convincing evidence in the

published literature showing correlation between the severity

index and tolerance to impact conditions encountered on the

playing field.

Studies to determine the characteristics of impacts

encountered under playing conditions are practically nonexistent. Radio telemetry has been attempted (163) but

the results are questionable. That differences in the two

environments exist is obvious. In the laboratory the helmet

absorbs most of the impact. On the field the helmet becomes

an element of the system absorbing part of the impact and the

physiologic response of the athlete dissipating the rest (163)

.

Further, current test methods for helmets simulate only the

translational component of acceleration. Obviously, head

impacts in sports result in both translational and rotational

motions. The importance of the rotational component relative

to the translational component has not been conclusively

demonstrated

.

Still to be resolved is the question as to how long a certified helmet maintains its certified condition. This

is a complicated problem that depends on several factors

including type of helmet, age, usage pattern, and if it

will be reconditioned periodically.

Research in helmet testing is in its first generation

and it is apparent in reviewing the published literature

that current testing methods are embedded in considerable

controversy. These problems can only be resolved by

stimulating and encouraging research.

9 See appendix B.

- 27 -
b. Facial Injuries

Facial injuries have also attracted the interest of

those concerned with sport safety. These injuries occur

with greatest frequency as a result of ice hockey activities.

Of the ice hockey data collected through NEISS over the

past two years, 10 almost 56% involve an injury to the head,

ear, eye, face, or mouth. The face alone accounts for

38.9% of all injuries.

The survey of ice hockey injuries (1963-64 season) by

Toogood and Love (111), of the Toronto Township Hockey League

support these data. Of the 85 injuries, 65.9% were injuries

to the head or face. The mouth and teeth accounted for 24.7%

of these injuries. The majority of head and face injuries

resulted from being hit by the hockey stick, puck, or skate.

The survey (108) of hockey injuries during the 1969-70

season "within the greater Edmonton metropolitan area,"

also indicates that the majority of injuries involve the

head and face (55.5%). Injuries involving the head were

distributed about the

mouth

,

- 16.4%

eyes

,

- 13.7%

nose - 8.1%

head (not face)

,

- 4.7%

forehead

,

- 4.5%

cheek, and - 4.3%

j aw. - 3.8%

Typical injuries were

lacerations

,

bone/muscle bruises,

fractures

,

sprain/strains

,

teeth

,

concussions, and

dislocations

.

34 . 8%

19.5%

12 . 8 %

12 . 6 %

8.7%

4.3%

3.6%

The study of ice hockey injuries during the 1970-71 season

by Hayes (102) shows similar findings. Of 328 injuries

encountered in 280 collegiate games, slightly more than 45%

involved the head and face.

10 See appendix A, table A. 6.

- 28 -
It is apparent from the available literature that over

45% of hockey injuries involve some part of the face. This

is substantiated by the Massachusetts Medical Society's

recent findings and recommendations.

"A Committee of the Massachusetts Medical Society

finds a startling increase in eye and facial

injuries in hockey at all levels and recommends

every player—not just goalies--wear full masks." (113)

Face shields are becoming increasingly popular in hockey

and will be mandatory for all Ameteur Hockey Association (AHA)

players up to age 16 starting this season and for Massachusetts

secondary school players in 1978 (115)

.

Goalie masks are worn by practically all goalies. The

performance of these masks was the subject of a clinical test

by Sze, et al. (110) Their test apparatus consisted of a rigid headform. The location, magnitude, and direction of

puck impact was controlled by a puck suspended on three guy

wires. A heavier than normal puck was used to enable the

investigators "to extrapolate the findings to higher velocities

for which the momentum of the modified puck is comparable

to the momentum of an actual puck traveling between 80 and

100 miles per hour." The results indicate, "...two serious

design weaknesses in all of the masks tested. None were

able to distribute a blow which impacted on a support point.

Secondly, blows away from support points caused the mask to

'bottom out' in critical regions at forces well below those

commonly developed in a game."

ASTM is developing a standard for eye and face protection

for hockey players. This standard which will be completed

in the near future does not include contour masks for goalies.

NOCSAE is in the preliminary stage of developing a face mask

standard (330). The potential and alternatives for promulgating

these standards should be evaluated.

c. Neck Injuries

Spinal injuries, particularly those to the cervical region

also have resulted in sports. A recent study of spinal cord

injuries in high school and college programs by Clarke (139)

,

estimates that 68 permanent cases* 1 occur annually (54 in

high school programs, 4 in 2-year college and 10 in 4-year

college programs)

.

1

Defined as hemiplegia-monoplegia, paraplegia, quadriplegia

,

or death.

- 29 -
Of the 86 permanent cases reported in that 3-year study,

football accounted for 46 (or 54%)

,

gymnastic activities for

22 (26%), baseball for 3, and basketball for 1. Trampoline

activity accounted for 36% of the permanent cases resulting

from participating in gymnastic activities.

Most of the spinal injuries in gymnastics were attributed

to "improper landings on the apparatus" leading that

investigator to emphasize the need for "...competent supervision more to protect the participant from premature attempts

to execute advanced maneuvers than to serve as a spotter for

off-apparatus landings."

Annual surveys of football fatalities (.2-5) have

collected data over a 43-year period. The most recent

survey (5) provides data on 819 fatalities directly related

to football activities--18 . 3% of these were the result of

spinal injuries, primarily injuries involving the cervical

spine. Since 1970, spinal injuries have accounted for

17.9% of all direct football fatalities.

The incidence of neck injuries, however, appears to be

low. The North Carolina Study (9) of high school injuries

showed 2.6% of all injuries were neck injuries. The "National

Football League 1974 Injury Study" found 2.8% of all injuries

involved the neck. The NEISS data provides rates for the

general population. These are shown in table 7. The incidence

of neck injury is less than 5% for any category.

Table 7. NEISS data--average annual number of projected

emergency room injuries involving the neck

by sport (FY 1973-76)

Average annual

projected

number

oo

Injuries requiring

hospitalization

o.

'o Football 3779 (1.2) 4., 6

Basketball 791 (0.3) 3., 4

Baseball 1661 (0.6) 0 ., 8

Snow skiing 537 (0.6) 7., 4

Gymnastic 1086 (3.0) 11., 3

Trampoline 813 (4.4) 4.. 0

Ice hockey 202 (0.8) 0 ., 0

Although gymnastic and trampoline activities produce more

neck injuries per 100 reported injuries, football activities

provide the greatest number of neck injuries. Gymnastic

activities also produce the greatest rate of major injuries.

- 30 -
The principal factor in the production of neck injuries

"...is a forceful displacement of the neck in one direction

or, less commonly, in a twisting action." (175)

Liedholt (154) suggested that the "forces that produce

injuries of the spine can be divided into compression, flexion,

extension, lateral flexion, rotation and horizontal shear."

Of these, flexion, extension, and lateral flexion are

primarily associated with severe neck injuries in sports.

In an early study of head and neck injuries published

in 1961, Schneider (171) reviewed 14 football fatalities.

He noted that, "Often the unyielding plastic face guard was

found to have been forced upward, throwing the neck into

hyper-extension. ...The posterior rim of the helmet,..., was

driven against the back of the neck and frequently caused severe

injury to the cervical vertebrae and spinal cord."

Alley (128) , a few years later, in a study of head and

neck injuries in high school football reached the opposite

conclusion and noted that, "the vast majority of neck injuries

were sustained in flexion, and the faceguard was found not

culpable in the production of those injuries." He further

indicated that many of these injuries were the result of

a technique known as "spearing.

More recently, Snook (175) commented, "...that such

hyper-f lexion injury is relatively rare," and noted that,

"By far, the most common type of neck injury that we have

seen is the lateral-f lexion neck injury in which the head

is sharply laterally flexed to one side." He also suggests

that "high shoulder-pads" or "neck collars" protect against

these injuries.

The face mask probably contributes to neck injury.

Considering the observed mechanisms of neck injury, the

protruding face mask serves as a lever for increasing the

effective load applied to the cervical spine. In recognition

of this fact, some have encouraged the removal of the mask.

However, as Torg has been quoted (187), "due to playing

techniques and attitudes inculcated in players today, I think to remove the face mask would be sheer folly." The

face mask and helmet have become integral parts of techniques

employed in blocking and tackling. As one investigator notes,

"...improved headgear makes it possible for a good tackier to

stop a runner cold with a head-on tackle." (184)

Recently, the National Football Alliance, realizing

the hazards of using the head in blocking and tackling,

implemented rules making illegal the techniques of butt

blocking and face tackling. Butt blocking is defined as

- 31 -
"a technique involving a blow with the face mask, frontal

area, or top of the helmet, driven directly into an opponent

as the primary point of contact, either in close line play

or in the open field." (186) Face tackling is defined as

"driving the face mask, frontal area, or top of the helmet

directly into the runner." (186) The NCAA made similar rule

changes, making it illegal for a player to "deliberately use

his helmet to butt or ram an opponent" and to "intentionally

strike a runner with the crown or the top of his helmet." (37)

Because of these changes the hazards of serious neck

injuries in football may be substantially reduced. However,

rules have little effect unless they are enforced. According

to a recent publication published by the NFSHSA "it would

be difficult to remove head contact from all blocking and

tackling because such a rule would be so difficult to

administer that it would be unenforceable." (40)

Of greater consequence may be the positions adopted by

the American Football Coaches Association and the National

Athletic Trainers' Association "...opposing the use of

tackling and blocking techniques with the helmet and/or

face mask as the initial point of contact." (181, 30)

The effectiveness of these recent changes will have to

be demonstrated. Unfortunately, good historical baseline

data to aid such an analysis are limited.

d. Lower Leg Injuries (Knee)

The knee in sports is most susceptible to injury. To

some "the knee was not well designed" —its strength dependent

upon surrounding "large and strong muscles and strong

ligaments." (203) To others the "knee is remarkable in

its ability to encompass the two seemingly incompatible

properties of stability and mobility and in order to

accomplish this many subtle anatomic mechanisms are

necessary." (367, p. 52) Therefore, it is not surprising

that knee injuries account for the greatest proportion of

sports injuries.

That the injuries involving the knee pose a substantial

problem was suggested by Torg, et al. (230): "Each season

there are an estimated 100 000 to 130 000 (football) knee

injuries among professional, collegiate, scholastic, and

sandlot players, with 30 000 to 50 000 of these requiring

surgery .

Table 8 presents a summary of findings of recent reports

with respect to knee and ankle injuries. As indicated, the

knee in football is the most frequently injured body part,

- 32 -
Table

8.

Extent

of

knee

and

ankle

injuries

reported

by

different

studies.

H3 0 d 3 0 3 3 -r- cr d 0 X3

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oood£ X

<Ts d

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aj os -33 -
accounting for approximately one out of every five injuries.

Basketball, ice hockey, and baseball account for fewer knee

injuries. The inconsistency reported in the incidence of

ice hockey knee injuries shown by the Toronto study Q-8.1%)

compared to the results of studies by Reeves and Hayes

is probably due to the nature of that study. The Toronto

study is based on injury records and emphasizes a dynamic

activity over an extended period of time (1951-1969)

Knee and ankle injuries are both frequently occurring

injuries in skiing (lower leg injuries related to skiing

activities will be discussed in the next section) . Interestingly,

in instances where the knee does not account for the greatest

number of injuries, the ankle predominates. (The exception is

the ice hockey studies.)

A summary of lower leg injuries reported through NEISS 12

is shown in table 9. The knee and ankle are included in

one classif ication--lower leg. The results are comparable

to table 8. The lower leg is the most frequently injured

body part in sports. Ice hockey is the exception, here

head and facial injuries predominate.

Table 9. Projected number of lower leg injuries

annually incurred by the general populace based

on the NEISS sample

Sport activity

Average number ...of lower leg

3. injuries per year

% of

Total

Most frequent

body part

injured

Football 74 321 23.9% yes

Basketball 105 427 41.2% yes

Baseball 66 653 24.5% yes

Snow skiing 47 754 58.5% yes

Gymnastics 8 587 23.6% yes

Trampoline 4 433 24.4% yes

Ice hockey 3 472 13.2% no

Total 310 647 31.5%

a) Derived by summing projections for each of four fiscal

years and dividing by four.

12 See appendix A.
According to the "National Football Injury Report —1970"

(28) , knee injuries appear to be among the most severe injuries

"with a hospitalization rate of 14.5%" The overall hospitalization rate for that study was 6.5% of all injuries reported.

In Allen's study Cl) of Air Force football injuries,

30% of the 111 major injuries involved the knee. Thirteen

of these players required surgery.

In the "1976 Spring Football Injury Study," C15) Clarke

notes: "The knee definitely was the body part most frequently

receiving a significant injury." Significant injuries are

defined as "those causing absence for at least one week and/or

dental injuries."

Because the knee in sports is the most vulnerable joint

in the body, it has been studied by many researchers. Their

findings regarding factors contributing to knee injuries

can be divided into four groups:

i) susceptibility to injury,

ii) physical conditioning,

iii) previous injury, and

iv) shoe-turf interface.

i. Susceptibility to Injury. In a study of 139 professional football players, Nicholas (199), suggests there are

differences between athletes which account for various

injuries. He devised procedures to determine the looseness

or tightness of the body. These tests comprise the following

indices

• palms to floor, knees extended,

• knee recurvatum,

• rotation of the knee and ankle,

• rotation of the hip, and

• upper extremity laxity.

Thirty-nine professional football players out of 139 examined

had at least three indices of looseness, and of these 72%

ruptured their knee ligaments. Of the remaining 100 players

with two or less indices of looseness, 9% ruptured their

ligaments. In view of these findings, he concluded that,

"independent of many factors responsible for injury in

football, an increased likelihood of ligamentous rupture

of the knee occurred in loose jointed football players and

of muscle tears in tight jointed football players."

- 35 -
In his paper, "Muscular Strength and the Knee" (197),

Klein notes that the "ligaments are responsible for

maintaining the integrity of the joint structure." He

reasons that, if these ligaments are loose "an increased

amount of torque results before the stretch reflex response

for muscle action, and the knee itself may try to prevent

abnormal movement." The high incidence of knee injuries

in high school football players he notes, occurs at a time

when ligaments are "more flexible because of the normal

pubertal growth pattern."

However, the findings of Godshall (268) do not agree

with those of Nicholas or Klein. In an 8-year study yielding

2800 examinations of high school athletes the author states

that "We certainly could not find any definite correlation

between loose- jointedness and major injuries in our patients."

ii. Physical Conditioning. Proper conditioning is

recognized by most to be a key factor in injury prevention

(206, 197, 367, 248). Allman (248) comments, "The proper

utilization of exercise is undoubtedly the single most

important factor for the prevention of sports injuries."

Sinton (206) agrees, and encourages year-round conditioning

of the leg musculature, as "the best method of preventing

knee and ankle injuries in athletes."

It is questionable that year-round conditioning programs

are adhered to. In their analysis of injuries reported

during the first three days of 1975 football practice,

Powell, Carey, and Clarke (31) note that "the advent of the

special rules for the first three days (of football practice)

may have lulled some athletes into neglecting a well rounded

preseason conditioning program...:" These "special rules"

limit the first three days of NCAA preseason football practice

to non-contact conditioning drills.

iii. Previous Injury. Studies have shown that players

with a history of injury sustain higher rates of re-injury.

The North Carolina study, for example, (9) shows injury

rates of 624 per 1000 for those with a history of injury

while only 437 per 1000 for those without a previous injury.

Of course, these rates include all types of injuries, not

only those involving the knee. Unfortunately, there are

no studies to show the effect of previous injury on the

incidence of knee injuries. However, the literature suggests

that athletes with a history of injury should concern themselves with proper rehabilitating conditioning (367, Ch. V)

(197); that bracing and taping is effective in preventing

re-injury (213, 203); that in certain instances individuals

with previous damage should be screened from competition (213)

- 36 -
iv. Shoe-Turf Interface. The likelihood of a knee

or ankle injury increases as the foot becomes more rigidly

attached to the surface (209, 215, 25, 196, 8). In the

presence of torque resulting from upper trunk rotation or

a force applied to the lower extremity in a "plane other

than that of normal joint motion" (209), an injury may

occur

.

This problem has been studied by many and solutions

have emphasized cleat design. Hanley, in 1963, (196, 298),

introduced shoes with flat cleatless heels and shorter front

cleats. This was later modified by Smith and described by

Hi rata (196) as a cleat "somewhat oval in shape" and "lower

in profile." A swivel football shoe is discussed by Cameron

and Davis (191) . It features a "metallic forefoot turntable

within a molded sole which are mounted four football cleats."

The turntable is capable of rotating 360°. It also features

a cleatless heel "which contains a beveled notch."

Cleat configuration relative to injury rates has been

investigated by some studies. Such a study was conducted by

Torg and Quendenfeld (209) of two high school leagues (public

and Catholic leagues) in the Philadelphia area. All reported

injuries were examined by an orthopedic surgeon and graded

for severity. The public high school league consisted of

18 teams for a total of 594 players per season. The Catholic

league had 18 teams for a total of 704 players per season.

Players in both leagues wore conventional football shoes

having seven 3/4 inch (1.9 cm) cleats with tips 3/8 inch

(0.95 cm) in diameter 13 during the first year of the study

(1968 for the public league and 1969 for the Catholic league)

.

For subsequent years (1969, 70, 71), the players in the public

school league were required to wear "shoes with molded soles,

each containing fourteen 3/8 inch (0.95 cm) cleats for both

practice and games." Similarly, players in the Catholic

league, for the 1970 and 1971 seasons, were "required to

wear the soccer type shoe for both practice and games." All

games were played on natural turf and the authors assumed

that "any differences in the incidence and severity of knee

and ankle injuries were due to differences in shoe type and

cleat length.

In the first year, with the conventional shoe, the Catholic

league encountered 93 knee injuries and 72 ankle sprains. With

the soccer type shoe, the number of injuries declined to 38

knee injuries and 36 ankle sprains in 1970, and 35 knee injuries

1

3

The NCAA and NFSHSA now require shoes with a maximum cleat

length of 1/2 inch (1.27 cm) . - 37 -
and 39 ankle sprains in 1971. In addition, the authors

report "a decrease in the number of knee injuries requiring

surgery from 32 in 1969, to four in 1970, and five in 1971."

Shoe

In j

Knee

ur ies

Ankle

Requiring

Surgery (knee)

Conventional (1969) 93 72 32

Soccer (1970) 38 36 4

Soccer (1971) 35 39 5

During 1968, 51 knee injuries were reported for the

public school league using the conventional shoe. During the

following years, with the required shoe the number of injuries

dropped to 24 in 1969, 30 in 1970, and 29 in 1971. The

number of cases where surgery was performed or indicated was

24 in 1968, 4 in 1969, 7 in 1970, and 2 in 1971.

Requiring

Shoe Knee injuries Surgery

Conventional (1968) 51 24

Soccer (1969) 24 4

Soccer (1970) 30 7

Soccer (1971) 29 2

The authors concluded "that the conventional football

shoe with seven long cleats is the major factor responsible

for the epidemic of knee injuries at all levels of organized

football." Further, they recommended the use of a soccer

type shoe with:

(1) synthetic molded soles,

(2) minimum of 14 cleats per shoe,

(3) 1/2 inch (1.27 cm) minimum cleat tip diameter, and

(4) 3/8 inch (0.95 cm) maximum cleat length.

A number of laboratory studies emphasize the need for

matching shoes with types of surfaces to minimize the risk

of lower extremity injuries. These tests attempt to describe

the traction typical of various shoe-surface combinations.

Torg, Quendenfeld, and Landau (210) attempted to quantify

the "shoe-surface interface release coefficient" for various

combinations. Their test device consisted of a prosthetic

foot for mounting shoes with different cleat types. Attached

to the prosthetic foot was a perpendicular rod with a torque

wrench attached to the opposite end. The shoe/surface could

be engaged to a prescribed load and torque applied. A

measurement could be taken directly from the torque wrench.

- 38 -
On the basis of their "experience," they classified the

shoe-turf combinations as "not safe" if the release coefficient

exceeded 0.49 and "safe" if the release coefficient was less

than 0.31. The midpoint between these extremes was chosen

to define the two categories of "probably not safe" and

"probably safe."

The results of that study indicate that the conventional

football shoe with 1/2 inch Cl. 27 cm) cleats "required by

NCAA and NFSHSA is probably not safe on grass." In addition,

all shoes with exception of the 1/2 inch (1.27 cm) by 3/8 inch

(0.95 cm) soccer cleats tested on the Astroturf sample were

classified as "safe" or "probably safe" when tested on various

synthetic turf samples.

Two points should be noted in interpreting these results.

The criteria for classifying different types of shoe surface

combinations was established on the basis of their "experience.

It was assumed that conditions of the test, e.g., shoe position

and weight distributions, adequately simulated the actual

conditions when injuries occur.

A study by Bonstingel, Morehouse, and Niebel (215)

investigated the effects of shoe types and playing surfaces.

Their findings are in agreement with Torg ' s knee injury

statistics. However, their conclusions are tempered by

observations that the study was "only a simulation of what

occurs under actual playing conditions," and "that many knee

injuries are a result of positional vulnerability and could

occur regardless of the shoe or playing surface."

Unfortunately, until relationships between the shoeturf interface and the occurrence of injuries are more

thoroughly researched and injury threshold criteria are

established, the utility of such laboratory studies is

limited

.

From the preceding discussions the basis for mitigating

lower leg injuries is apparent or in some instances within

grasp through additional research. However, the real obstacle

may not lie in obtaining the solutions but in disseminating

the results to coaches, athletes, and administrators so that

the solutions will become routine practice. For example,

attempts to gain acceptance of specifications for "safe"

cleated or cleatless shoes will be met with resistance if

performance appears to be affected.

- 39 -
e. Lower Extremity Equipment Related Skiing Injuries

Shealy (75) estimates that between 165 000 and 600 000

skiing injuries occur annually. The lower extremity is

involved in 60% to 70% of these injuries (62, 45, 59).

Typically ski injuries are sprains and fractures ( 62 . 45,

59). Factors of age, sex, skill, ability, physical condition,

slope conditions, crowds, equipment, equipment adjustment

and maintenance, and prior injury have been associated with

the occurrence of skiing injuries. Their ralative importance

is disputed. However, the role of equipment, specifically

the ski-boot-binding system, is considered to be one of the

most significant factors associated with the occurrence of

skiing injuries. Johnson, et al. (62) classified 44% of

the injuries investigated in their study as "lower extremity

equipment related" (LEER) injuries. Tapper and Moritz (78)

note of the injuries investigated during the 1971-72 season,

that "37% of those injured directly blamed malfunction

(release failure or premature release) of their bindings."

The ski bindings function is twofold: (1) it serves to

couple the skier to his skis, and (2) in the event of an

accident, allows the skier and skis to separate before the

forces "exceed the failure loads of the leg." (48, 56)

Ski bindings according to Shealy, et al. (75) employ

the same basic mechanical design —"a spring loaded cam or

lever detent. The cam or lever requires some predetermined

force to be displaced; once the displacement exceeds the

detent value, the spring ceases to exert any retentive force."

The differences in bindings lie in the application of this

principle

.

' Should the binding fail in its first function, the

phenomenon is known as "inadvertent release." Shealy, et al.

(75) found the advanced skier was encountering a large number

of upper extremity injuries relative to the intermediate and

beginner classes. These injuries, they suggest, "are typical

of what one would expect from what is known as an inadvertent

release," and estimate perhaps as much as one-third of the

skiing population is at risk.

Should the binding not release in the event of a fall,

the ski acts as a "lever in twist," "as a lever in bending,"

or as both "a lever in twist and bending." (62) The result

may be a knee or ankle sprain, or a fracture of the tibia,

ankle, or fibula (62, 47, 65).

- 40 -
Some binding types are apparently more effective than

others in protecting the lower leg. This was pointed out by

Shealy, et al. (75) They classified bindings as:

(1) cable bindings (used by approximately 9% of the

study population)

,

(2) bindings with "two release modes" (54% of the

population)

,

(3) bindings with "more than two release modes" (14%

of the population)

.

The cable release binding consists of a "forward throw-handle"

which pulls the cable snug over the heel of the boot, forcing

the boot forward into the "toe piece" of the binding. The

two release modes bindings enable the release of the toe in

a "twisting fall" preventing "torsion at the tibia," and an

upper release in a forward fall preventing a "levered break

of the tibia." The third category of bindings is simply

described as bindings that release in other ways, e.g., an

upward or rolling release at the toe.

The resulting overall accident rates per 1000 man-skidays were 13.07 for cable bindings, 8.60 for two-release

modes bindings, and 6.75 for those with more than two release

modes

.

Their analyses suggested that "the more-than-two release

mode binding is superior, for every skill level except

beginner, where there is no apparent advantage over the

two-release mode binding.

That bindings perform to their theoretical potential

is dependent upon many factors. These factors can be grouped

as follows:

i) binding release settings,

ii) friction, and

iii) environmental factors.

i. Binding Release Settings. Ski binding release

settings are based upon skier parameters of age, weight,

sex, ability, and proximal tibia width (352, p. 221) (56).

In practice, weight and ability are the two principal

parameters. A study by Johnson, et al. (62) examined

binding release settings of injured and non-in jured skiers.

They found the average setting exceeded the recommended value

by 45% for the uninjured group. The average setting of the

injured groups exceeded the recommended value by as much as

- 41 -
85%--85% for the LEER injuries of a flexural nature,

75% for the LEER injuries produced by torque, and 55% for

all other injuries.

A release setting too high negates the release protection

afforded by the binding. Conversely, a low release setting

could permit the binding to release prematurely. However, it

is questionable whether release settings adequately indicate

the value at which release occurs. Bahniuk, et al., (47) in

laboratory conditions, tested seven bindings previously

"set in the pure torsion mode (toe release) at approximately

58 newton meters." When a load was applied to the ski, the

torques required for release varied up to 104 newton- meters

.

It is interesting to note that Johnson, et al. (62)

found that the skier "who more recently has adjusted and

tested his bindings for release and who has more recently

had his equipment set up for release by a ski shop professional"

was more often found in the group with lower extremity injuries

than in the control group of uninjured skiers. Similar

findings were reported by Young, et al. (83)

ii. Friction. The binding's ability to function

properly can be affected by friction between the top of

the ski and boot sole (68, 62, 74) . This force depends on

the weight of the skier and effective coefficient of friction

between the boot sole and ski surface. Friction can be

reduced by placing a pad or lubricant between the ski top

and boot sole. Material for this pad, called an antifriction device (AFD) , can be metal, plastic, polyethylene,

teflon, or a mechanical device.

The efficacy of these devices has been demonstrated

by Johnson, et al. (62) Particularly effective were the

teflon and mechanical devices. Laboratory studies by

Bahniuk, et al. (48, 64) support these findings.

iii. Environment. The effects of environmental factors

on "the efficacy of modern ski bindings" was the subject of

a clinical study by Bahniuk and Izant (47)

.

That study

was designed to measure changes in release values after the

bindings were exposed to different simulated environmental

conditions. These conditions included an initial, test to

determine the baseline release value followed by exposure

to vibration, use, salt, ice, and dirt.

A number of weaknesses in the test procedures limit

conclusions based on the results. For example, although

each of the seven bindings was set to release at 58 newtonmeters (toe-release) in the "pure torsion mode," the baseline

- 42 -
release value obtained in the initial test varied up to 104

newton-meters. The accumulated effects of exposure were

discounted. The simulated tibia, according to the authors,

did not possess the same mechanical properties as the human

tibia

.

However, the results of the study provide some important

observations. Each of the seven bindings was affected

differently by the tests. For example, the second and most

severe "dirt test" caused a 16% decrease in the "maximum

torsional moment at release" in one binding and a 30% increase

in another.

The ice test adversely affected all bindings. Each

binding was tested after exposure to water spray and

temperatures of 5°C for 48 hours. When tested, the increase

in the "maximum torsional moment at release" varied from 56%

in one binding to 270% in another. When compared to the

"tibia failure criteria" suggested by the authors, each

of the bindings exceeded the failure criteria.

The study of environmental factors under actual conditions

has received little attention. However, Johnson, et al. (62)

observed that corrosion of the binding mechanism and improper

lubrication of the binding was more frequently found in

the group encountering "lower extremity equipment related

injuries" than in a control population of uninjured skiers.

The "typical fracture" found in skiing injuries has

risen from the area of ankle to the lower third of the

tibia (52, 78, 56). This shift has been attributed to

the modern rigid ski boot.

A ski boot, according to Bahniuk, et al. (49), is a mechanical device coupling the ski-boot-binding system and

foot of the skier. The modern boot is a hard, rigid or

hinged, plastic boot which functions in two ways to prevent

injury. First, the boot enables a skier "to control his skis

and thus avoid a fall" and subsequent possibility of injury.

Second, if a fall should occur, the boot can absorb energy

and thus prevent or reduce injury. In their clinical study

of ten boots (one leather and nine versions of the plastic

type)

,

they concluded that the ability of a boot to absorb

energy is inversely correlated with the boot's stiffness.

Hence, the potential for injury appears to be greater for

the stiffer boot.

However, the stiffer boot enables the skier to be more

closely coupled to his skis, thereby providing the potential

for increased controllability and, as a result, decreasing

- 43 -
the number of falls. On the basis of that study, it is

impossible to "assess the relative importance of energy

absorption and boot stiffness."

The population of recreational skiers is not typified

by the properly conditioned athlete. As such, recreational

skiers rely primarily upon their equipment for protection

against lower extremity injuries. This equipment, in

laboratory conditions, performs with a great deal of variability. In actual use conditions, reliability is influenced

by the interactions of several variables of which little

has been documented. Many skiers are skiing with improperly

adjusted bindings, evidenced by the number of skiers reported

by Johnson (62) and Young (83) who had their bindings

adjusted just prior to encountering a lower extremity injury.

In summary, the literature suggests several discrepancies

relative to the occurrence of lower extremity ski injuries.

Procedures for testing the ski-boot-binding system are not

optimal, performance criteria have not been established,

guidelines are needed to aid in properly adjusting bindings,

and finally, the skier must be educated in equipment

maintenance

.

f. Natural versus Synthetic Playing Surfaces

The safety issue concerning natural versus synthetic

playing surfaces has been controversial since synthetic

surfaces were first introduced. It has stirred the interest

of manufacturers, players, sport safety researchers and,

during 1971 and 1972, was a subject before the Congressional

Subcommittee on Commerce and Finance (226). More recently

the National Football League Players Association petitioned

the Consumer Product Safety Commission to, "...commence a proceeding to issue a consumer product safety rule for

synthetic turf used as a surface cover for athletic playing

fields." (238, 237) Those petitions were subsequently denied.

Among the first studies to investigate possible differences

in injury rates on natural and synthetic surfaces was the

"National Football Injury Study--1970" by Martin, et al. (28)

The intent of that study was to provide national data at

the college level on the incidence and causes of football

injuries. Data were drawn from 40 schools participating in

National Collegiate Athletic Association (NCAA) football

during the 1970 season. However, the report is plagued by

what the authors refer to as "some confusion as to what

constituted a reportable injury," thereby limiting the

reliability of these data.

- 44 -
There were 2782 injuries reported and classified according

to three degrees of severity: "Active Participation" (injuries

without time lost from participation) ; "Partial Participation"

(injuries with time lost from games or practice) ; and

"Hospitalized." Game injuries accounted for 1178 injuries.

Table 10 shows the distribution of these injuries by severity

and the type of playing surface associated with each injury.

Table 10. Severity versus type of surface - incidence

per game (Martin, et al. (28))

Partial Active

Surface Hospitalized Participation Participation Combined

Grass 0.19 1.58 0.96 2.73

Turf A 0.27 1.70 0.66° 2.63

Turf B 0.17 1 • 24 b 1.10,

1.46 d 2.51

Turf C 0.15 3. 15 b 4.76

a) Turf designations were taken from Martin's report.

b) Significant: p < .01 Chi-square.

c) Significant: p < .05 Chi-square.

d) Significant: p < .10 Chi-square.

One by two Chi-square analysis to determine the statistical

significance of injury rates (injuries per game) associated

with synthetic surfaces compared to grass, shows that "Active

Participation" injuries associated with Turf A

14 to be

significantly lower than the rate associated with grass.

The rate of "Active" and "Partial Participation" injuries

associated with Turf C significantly exceeded that of

grass. The difference in rates between Turf B and grass

are not significant. Finally, the rates of "Hospitalized"

injuries do not differ significantly between grass and

synthetic surfaces. However, only 2 "Hospitalized" injuries

were reported for Turf C.

Another study, of the 1970 football season was conducted

by Bramwell, Requa, and Garrick (223). The principal

objective of that study was to determine if any differences

existed in injury rates sustained on synthetic and natural

surfaces at the high school level. Their study included

26 high schools in the greater Seattle area. These schools

participated in 228 games: 80 games played on 1 artificial

surface and 148 on 12 different grass fields.

1

Tur f A, B, and C were designations used by Martin (28) for

the three brands of synthetic surfaces.

- 45 -
An injury was defined as one "that resulted in not

finishing a game and/or missing 2 or more subsequent

practices and/or any subsequent game or games." Injuries

resulting in 2 or more missed games were considered severe.

Table 11 shows the rates of injuries and severe injuries

for the two types of surfaces. There were 139 injuries

reported, yielding overall injury rates of 0.52 injuries

per game on grass fields and 0.76 injuries per game on the

synthetic surface. The higher rate on the synthetic

surface was statistically significant (p < .05 Chi-square).

Table 11. Injuries versus type of surface - incidence

per game - 1970 (Bramwell, Requa , and Garrick (223))

"Severe"

Surface Injury rate Injury rate

Grass 0.52 0.18

Synthetic 0.76 a 0.24

a) Significant: p < .05 Chi-squares.

Of the 139 injuries, 32.4% were classified as serious.

The overall serious injury rate for the synthetic surface

was 0.24 injuries per game and 0.18 injuries per game for

grass fields. This difference was not statistically

significant

The second year of the study by Adkison, Requa, and

Garrick (214) was expanded to ".include participation on

additional brands and generations of synthetic turf as well

as additional games played on grass." That portion of the

study included 73 high schools in the Seattle and Spokane,

Washington, and Portland, Oregon, areas. The playing surfaces

studied consisted of "over 50 different grass fields" and

four synthetic surfaces —one three-year-old Tartan Turf and

"two generations" (3 fields) of Astroturf.

Results for the second year are provided in table 12

and show Astroturf to be associated with a significantly

higher injury rate. Tartan Turf, however, is associated

with a significantly lower injury rate.

- 46 -
Table 12. Injuries versus type of surface - incidence

per game - 1971 (Adkison, Requa , and Garrick (214))

Surface

Injuries

per game

Severe

injuries per game

Grass

Astroturf

Tartan Turf

0.51

0.63

0.28'

0.19

0.25

0.17

a) Significant: p < .05 Chi-square.

b) Significant: p < . 10 Chi-square.

Severe injuries were defined as those resulting in a "player missing two or more subsequent games." The pattern

of severe injury rates is similar to that of all injuries.

However, these differences are not statistically significant.

If the injury rates for synthetic surfaces are considered

in aggregate, the resulting injury rate is 0.55 injuries per

game and does not differ significantly from that of grass at

0.51 injuries per game. This difference, as pointed out by

authors, "underscores the fallacy of considering all brands

of synthetic turf in aggregate when comparing their safety

characteristics to grass."

Extending the results of the preceding studies to the

population of synthetic and natural surfaces must be based

on the assumption that factors other than the type of surface

contribute negligibly to the results. That this is a valid

assumption is questionable. For example, in the latter

study by Adkison, Requa, and Garrick (214), the differences

in injury rates between the three Astroturf surfaces were

greater than the differences in rates between grass, Tartan

Turf, and the aggregate rate for Astroturf (see table 13).

Differences in rates between Astroturfs A and B, and B and C

are statistically significant (p < .05 Chi-square).

Table 13. Injury rates for grass and four synthetic

surfaces - incidence per game - 1971

(Adkison, Requa, and Garrick (214))

Surface Incidence per game

GrassAstroturf

ABCTartan Turf0.71

0.37-

0.81

0.51

0.63

0.28

- 47 -
As another example that the assumption of uniformity

among surfaces of a particular type may be invalid, consider

the study of high school football injuries by Blyth and

Mueller (9)

To remove the possibility that field conditions

were influencing rates of knee and ankle injuries, 9 of the 43

study schools were randomly selected and "their game and

practice fields were completely resurfaced and maintained

in good condition for the final two years of the study,

1971-72." Table 14 provides the injury rates (knee and

ankle only) for the two groups. As indicated by the

differences in these rates, knee and ankle injury rates

are, in part, determined by the condition of the playing

field

Table 14. Knee and ankle injury rates for schools with

fields resurfaced and maintained and those with no

change - 1971-1972 (Blyth and Mueller (9) Table LXXIII)

Significant: p < .01 Chi-square.

That possible differences within a class of surfaces

affect the results of comparative studies of synthetic and

natural surfaces is apparent, however, the extent of this

influence is not so obvious.

One comparative study where variability in field

conditions is expected to be at a minimum is the ' multi-year

National Football League Injury Study conducted by the

Standard Research Institute (SRI) (23, 24, 25). The most

recent of three reports emphasizes the 1974 professional

football season. Two earlier reports cover the period

from 1969 to 1973.

The analysis of "turf injuries" is "separated into

gradients of injury severity":

Frequency - [Gradient 1: Incidence of injury

Schccls

Percent of

Injury rate population

Fields resurfaced and maintained

Schools with no change

0.142

0.213

19.1

80.9

Severity

Gradient 2: Incidence of re-injury

Gradient 3: Injuries causing two or more

missed games

Gradient 4: Injuries requiring

hospitalization

Gradient 5: Injuries requiring surgery

Gradient 6: Third degree injuries

II [Gradient 0:

- 48 - Punishment Playable injuries
The first of these gradients, the incidence of injury

associated with playing on synthetic surfaces and natural

turf for 1970-1974, is provided in the 1974 NFL report.

A comparison of this result and those of the two previous

NFL studies is provided in table 15. As the NFL data indicate,

the three types of synthetic surfaces have consistently been

associated with higher accumulated rates (incidence per game)

of injury than natural turf. After five seasons of data,

the differences in rates beween each type of synthetic surface

and natural turf is statistically significant.

Table 15. Frequency of injury versus turf as reported

in the three NFL studies

Incidence per game

Tur f a 1970-72 b 1970-73° Turf 1970-74 d

Natural A 2.0 2.08 Natural 2.23

2.2 2.28 Poly 2.53 g

„ p „ TMf „ _ f Synthetic B

2

2 .

8

2 . 89 Tartan 3.05

B

3

2.

8

e

2 . 77

f Astro 2. 93

f

a) The first two NFL injury reports designates playing surfaces

as A, B^, B

2

, and B^

.

b) Figure 33 of the 1972 NFL study (23).

c) Table 15 of the 1973 NFL study (24).

d) Table 27 of the 1974 NFL study (25).

e) Significant (computed by SRI)

.

f) Significant at the .001 level (computed by SRI)

g) Significant at the .05 level (computed by SRI).

Gradients 2 through 7 are all measures of major 15 or

serious injuries. Gradient 2 is included because the report

notes that "reinjuries were more severe than new injuries

(in terms of recovery rates)." When minor injuries are excluded,

which is the case in table 16, only the incidence of third

degree injuries per game (Gradient 6) associated with Tartan

Turf is significantly greater than that recorded for natural

turf. In fact, only those rates associated with Tartan Turf

suggest a pattern of greater rates than those of natural turf.

1

5

A major injury is defined "as one causing two or more

missed games."

- 49 -
Table 16. Summary of injuries per game for Gradient 2

through 7 versus various surfaces

Turf Gradient

2

1970

3

Incidence per

-1974

4 5

game

1973-

6

1974

7

Natural 0.36 1.00 0.37 0.29 0.33 0.37

Poly 0.31 0.97 0.29 0.25 0.35 0.45

Tartan 0.45 1.04 0.40 0.25 0. 55

a 0.49

Astro 0,35 0.94 0.44 0.29 0.40 0.36

a) Significant at the .05 level (computed by SRI).

Also included in that study is an analysis of "playable"

injuries (gradient zero) which are not considered an injury as

defined in the NFL study. Data for these rates "were collected

in logs by NFL medical personnel after each of the 20 games

played during 1973 and 1974." The rates for each type of

playing surface are presented in table 17. As indicated,

synthetic surfaces were associated with significantly greater

rates of playable injuries than those recorded on natural

surfaces

.

Table 17. NFL "Playable

Turf

Natural

Poly

Tartan

Astro

injuries versus turf 1973-74

Incidence per game

5.60

7. 56 a

6 . 4 6

b

7. 75

a

a) Significant at the .001 level (computed by SRI).

b) Significant at the .01 level (computed by SRI).

Previously it was mentioned that basic differences in

generic classes of surfaces limit the reliability of many

comparative studies of playing surfaces and that these

differences may be at a minimum with fields used by the NFL.

However, in the NFL study the question also arises concerning

the appropriateness of comparing each generic class of

synthetic surface with natural turf. Synthetic surfaces of

a particular brand will have different characteristics if

- 50 -
some are football fields and some are converted baseball

fields , because , as stated in the 1974 NFL study, "a football

field is crowned or peaked in the center and supposedly,

has better drainage, converted baseball fields have more

obstructions in that pitchers mounds, base paths, and the

like, must be converted; the synthetic baseball fields also

have different shock pads (to make the ball livelier) than

those on football fields." These differences were only

superficially analyzed in the report. However, differences

are apparent as shown in table 18. When converted baseball

fields are excluded, the differences between natural and

synthetic surfaces do not appear to be great, but no

mention is made of statistical significance. 16

Table 18. NFL injuries on turf versus field types

1973-74 (incidence per game)

Converted

Turf Football fields baseball fields

1973

Natural 1.73 1.65

Synthetic 1.84 2.43

1974

Natural 2.23 1.97

Synthetic 2.57 3.00

The results of the NFL studies show significantly more

NFL injuries have been recorded per game played on each of

three synthetic surfaces over the five seasons between 1970

and 1974. The differences in injury rates are primarily

due to the incidence of minor injuries, since each measure

of severity (Gradient 2 through 7) shows no significant

differences exist, with exception of third degree injuries

(Gradient 6 versus Tartan Turf) , between natural turf and

each of the three synthetic surfaces. The significant

differences in "playable" injuries tends to support the

predominance of minor injuries occurring on synthetic

surfaces

.

In general, the findings of natural/synthetic surface

studies suggest that synthetic surfaces are associated with

higher rates of injury when compared to rates associated

with natural surfaces. However, these results cannot be

16 It is impossible to compute the statistical significance

of these differences using the data presented in the study.

- 51 -
extended to show that a particular type of turf is a cause

of injury. At most, they indicate that the type of turf

is a parameter in an unspecified set of elements which may

be responsible for different rates of injury. It may well

be that one turf brings together elements of equipment,

personnel, environmental factors, styles of play, and other

unknowns, which ultimately contribute to different rates of

injury (e.g., football versus converted baseball fields,

cleat selection versus type of turf, physical changes due

to aging of surfaces and underpads, etc.).

If questions concerning safety implications of playing

surfaces are to be answered on the basis of turf related

studies, additional data are required. These studies must

incorporate controls to account for the many factors

influencing the incidence and severity of turf related

injuries.

3.4 Rules and Standards Activity

The recent decisions by the National Federation of

State High School Associations (NFSHSA) and the National

Collegiate Athletic Association (NCAA) to incorporate a rule change intended to eliminate the use of the head as

the initial point of contact in blocking and tackling promises

to be a significant step in reducing the number of serious

football injuries. More important may be the positions

taken by the National Athletic Trainer's Association (181)

"opposing the use of tackling and blocking techniques with

the helmet and/or face mask as the initial point of contact,"

and that taken by the American Football Coaches Association

to discourage the teaching of head tackling and blocking (186).

The incorporation, enforcement, and effectiveness of

rules and rule changes targeted for enhancing participant

safety is an area that could be explored further. As a study

entity, it has not been emphasized. However, there are

indications that organized competition at the college level

and below is becoming more regulated in the use of specific

items of protective equipment. The NCAA Football Rules

(37, p. FR-16 ) require all players to wear knee pads, head

protectors, shoulder pads, and mouth protectors. Four point

chin straps were mandatory in 1976 and all helmets used in

1978 must comply with the National Operating Committee on

Standards for Athletic Equipment (NOCSAE) standard. Further,

the rules prohibit the use of certain equipment such as shoe

cleats more than 1/2 inch (1.27 cm) in length or exceeding

a specified minimum cleat diameter.

- 52 -
The NCAA Baseball Rules (101, p. BA-14) require players

to wear protective helmets (double ear flap helmet preferably)

while batting and running the bases.

The NCAA Hockey Rules (114, pp. IH-9-10) require goalkeepers to wear protective face masks. All players must

wear dental guards and head guards with chin straps fastened.

Skates must be equipped with approved safety heel tips.

The NCAA Basketball Rules (126, p. BR-56) include recommendations for court specifications, padding for back boards,

and lighting.

The NCAA Gymnastic Rules (125, pp. CY-5-14) contain

dimensions and safety specifications for the pommel horse,

rings, vaulting board, parallel bars, horizontal bar, and

mat dimensions and placement.

Some schools have minimum medical qualifications for

participation (140, 66) or incorporate other safety procedures

in attempting to reduce the risk of participating in sports.

One such experiment (306) was conducted in New York State

where "junior high football rules were changed to eliminate

the kickoff, deflate the ball to a lower pressure, and allow

coaches to point out dangerous practices to officials at

any time." They claim to have reduced their injury rate by

almost 100%.

Also in New York, there is an ongoing experiment based

upon what is called the Selection Classification Age Maturity

Program (SCAM) "aimed at grouping athletes (ages 12-19) on

the basis of physical fitness, skills and physical maturity"

(267) in hopes of reducing injury to participants in sports.

The usual mechanism for grouping athletes is by chronological

age and sometimes also by weight.

There are two principal groups in the U.S. currently

involved with developing standards for athletic equipment:

NOCSAE and the American Society for Testing and Materials

( ASTM) Committee F-8 on Protective Equipment for Sports.

NOCSAE, formed in 1969 "for the purpose of making

competitive sports (147) , as free from injury as possible

through protective equipment standards" has developed a method and requirements for testing football helmets (348)

.

As of August 10, 1976, "93 helmet models have passed the

NOCSAE football helmet standard." (327) A preliminary

baseball batting helmet standard may be the second NOCSAE

standard (329)

.

In addition this group is conducting

preliminary studies on ice hockey protective headgear and

soft-shell football helmets (330)

.

- 53 -
In June 1969, ASTM entered the sports field, according

to Hale (270) , because of the number of participants seriously

injured "owing to the lack or the inadequacy of protective

equipment." In the Committee's seven years of existence,

they have produced two standards:

1. Designation: F381-74 Standard Consumer Safety

Specification for Components, Assembly, and Use

of a Trampoline.

2. Designation: F355-72 Standard Method of Test for

Shock Absorbing Properties of Playing Surface Systems.

A number of standards are currently in various stages of

development. These include proposed standards for football

and hockey helmets, knee pads for football, mouth protectors

for all contact sports, and eye and face protection for

forwards and defensemen in hockey. The Skiing Safety Subcommittee is developing standards for determining the

longitudinal and torsional stiffness of Alpine skis, and a standard for measuring the static release moments of adult

ski bindings.

The American National Standards Institute (ANSI) has

also been engaged in sports standards activities. They

approved a standard entitled "American National Standard

Safety Requirements for Aerial Passenger Tramways," designated

ANSI B77. 1-1973. This standard includes provisions for

tramways, lifts, and tows used in ski areas. (These devices

are under the jurisdiction of the U.S. Forest Service in

those instances where the ski site is built on land designated

as part of the national forest.. There are 129 such sites in

the U.S.) 17

A number of groups have been involved with developing

standards for helmets in general. These standards are the

forerunners of standards for helmets in sports and include:

The ANSI Z-90. 1-1966 and a revision Z-90. 1-1971 which address

safety helmets; the Snell Memorial Foundation 1968 and 1970

standards; a number of military specifications for aviators

helmets; and a number of foreign standards including:

(British) BSI 2011 1956 (motorcycle helmets

)

BSI 1869 1960 (motorcycle helmets

)

(Canadian) CSA D230 1970 (motorcycle helmets

)

(Australian) AS E33 1968 (motorcycle helmets

)

AS E43 1968 (motorcycle helmets

)

(New Zealand) - NZS 1214 1969 (motorcycle helmets

)

17 Telephone conversation with Mr. P. Wingelman

,

U.S. Forest

Service, March 1976. -54-
The International Organization for Standardization (ISO) has

issued a standard on helmets for "road users" designated

ISO/R 1511-1970. ISO has also issued standards for gymnastic

equipment

ISO/R 378-1964 (E)

ISO/R 379-1964 (E)

ISO/R 380-1964 (E)

ISO/R 381-1964 (E)

ISO/R 382-1964 (E)

Parallel Bars

Horizontal Bars

Rings

Vaulting Horse and Pommel Horse

Balancing Beam

However, these standards primarily address equipment dimensions

and specifications. ISO is also developing a standard on ski

boots (75)

.

4. CONCLUSIONS AND RECOMMENDATIONS

• Expand data collection activities based upon a systems

concept

.

From the preceding discussion it is evident that

risks in sports cannot be quantified on the basis of existing

data. The published literature provides an incomplete and

inconsistent assessment of the risks associated with sports.

Some activities (baseball, basketball, and gymnastics)

account for a great number of hospital emergency room

injuries, but have rarely been the subject of injury

research.

The assessment of risks for a particular sport and

population of participants must include more than an

analysis of the occurrence of injury. The assessment

must also include measures of severity, immediate

diagnosis, and long term effects of injuries.

Furthermore, risks can be altered. Consequently,

the analysis must include provisions for addressing

factors which might potentially influence risks. These

factors include supervision, officiating, physiological

characteristics of participants, conditioning, experience,

ability, skill, facilities, protective equipment, the

environment, and use and fit of protective equipment.

The relationships among these factors and their specific

roles in influencing injury must be quantified. Data

collection activities based upon the systems concept

must be expanded. Otherwise, as noted by Fraser "...we

cannot even verge on the optimal in recreational system

safety. " (.266

)

- 55 -
Expansion of data collection activities does

not necessarily require development of data collection

methods. For example, the National Athletic Injury/

Illness Reporting System (NAIRS) , when fully implemented,

may provide injury data related to a variety of sports

activities

.

• Encourage development of standardized terminology applicable

to sports research.

The results of most sport injury investigations are

not compatible because of the use of nonuniform terminology.

For example: What is an injury? Sports injury studies

employ a variety of definitions comprising various

intervals of lost participation time, need or perceived

need for professional treatment, specific kinds of

trauma regardless of lost participation time, or

incidents resulting in insurance claims. Similar

variations are observable in definitions of injury

severity. The formulation of standardized terminology

applicable to sports research should be encouraged.

• Determine the feasibility of an institute to initiate and

coordinate sport injury research and to disseminate results

to the athletic community.

In recognition of the fragmented approaches to

football injury research, the lack of injury research

in other athletic activities, and the futility of most

research efforts, Blyth and Mueller in their report of

1972 (9), recommended the establishment "of a 'Sports

Trauma Institute' through which efforts could be made

to coordinate research ventures, provide adequate medical

specialist consultation, and disseminate research findings

to the athletic community. " The concept of a "Sports

Trauma Institute" was also suggested by Grippo (25).

Although Grippo' s recommendation is limited to a "safety

committee" within the National Football League, it serves

to emphasize the desire and need for centralized control

to initiate, coordinate, and monitor research activities

over a complex base of sports safety issues.

At the Second National Conference on Sports Safety,

October 1976, the need for such an organization was

again emphasized. This "Umbrella Organization" would

be entrusted with establishing priorities, coordinating

research activities, and disseminating information to the

athletic community.

- 56 -
Millions of injuries occur annually as a result

of recreational and competitive sports activities.

Research has been sporadic, producing results of

limited value. The concept of a "Sports Trauma Institute"

to initiate and coordinate research activities and

disseminate the results to the athletic community

appears to be a logical alternative to attaining the

optimum in sports safety. The CPSC should jointly

explore the feasibility of establishing such an

institute

.

• Improve the surveillance capabilities of NEISS.

The NEISS system is a surveillance tool intended to

serve "...as a springboard for action to combat productrelated injuries." (325) Currently, the system provides

data which are manipulated to form the Age Adjusted

Frequency Severity Index (AFSI) . Many categories of

the general class "Sports and Recreational Equipment"

rank high on this index. However, because each sportrelated product category includes a broad base of

activities (e.g.. Basketball Activity and Related

Equipment —Product Code (PC-1205), the nature of specific

injury problems cannot be identified. Consequently,

the ability to plan and implement injury prevention

programs is reduced. Efforts to limit the scope of

some categories is evident by the inclusion of single

product categories (e.g., Ice Skates--PC-1245) . However,

this results in ambiguous categories (e.g., Ice Hockey

and Related Equipment--PC-1279 and Ice Skates--PC-124 5 )

.

A second function of NEISS is to provide surveillance

data for measuring the success or failure, of programs

to reduce the frequency and severity of injuries. Many

sport-related categories, because of their broad scope,

may be insensitive to changes in injury patterns resulting

from injury prevention programs, or it may be impossible

to associate effective programs with identifiable changes

(e.g., consider the decline in projected number of

ice hockey injuries from FY 75 to FY 76. Is this the

result of an effective program or due to a decline in

the number of participants (or exposures))?

To improve the surveillance capabilities of NEISS,

the "Sport and Recreational Equipment" categories should

be reviewed and appropriately altered to correct

ambiguities and the lack of specificity. Additionally,

if NEISS is to provide useful surveillance data a common

unit of exposure must be incorporated and measured.

- 57 -
• Stimulate research to resolve the controversy and problems with helmet test procedures.

Documented reports indicate that head injuries are

associated with most sports fatalities. Many fatalities

could possibly be prevented with adequate head protection.

Standards groups are active in developing helmet standards.

The NOCSAE standard has been recognized by the two

organizations (NCAA and NFSHSA) representing the majority

of participants in organized football, in effect making

NOCSAE approved helmets compulsory items in the near

future. A youth headform has been developed, and these

helmet designs are being tested. Further, the NCAA

and NFSHSA have passed rule changes which are intended

to reduce the potential for serious head and neck injury.

The impact that these developments will have on serious

head injury remains to be evaluated.

Also, the ASTM standard for testing helmets will

soon be available. At that time, both manufacturer

and those professionally involved will have to choose

the method which better reflects their respective needs.

This becomes an inconsequential decision if both methods

are equally valid. However, there exists considerable

controversy regarding the differences between the two

methods. Recent tests, in which NBS participated (129,

130, 131), indicate the existence of "substantial

differences in the measured values of maximum accelerations

transmitted to the head-form when using the NOCSAE and

ASTM test systems" and "poor correlation between the two

test methods." The apparent controversy concerning the

appropriateness of drop test methods and derived injury

tolerance criteria relative to conditions encountered

in a playing field environment can be resolved only

through additional research. Finally, the useful

certification period of certified helmets remains to

be determined.

The implication that these issues have on participant

safety is a matter of speculation. Historical data are

not adequate to serve as baseline data for comparative

studies intended to resolve conflicting views. Only by

stimulating and encouraging research to assess these

issues directly will the optimum in head protection be

realized. Such research may have considerable value in

developing head protection standards for other sports.

- 58 -
• Determine the potential and alternatives for promulgating

hockey face guard standards.

Over 40% of the projected emergency room injuries

(FY 76) related to ice hockey activities involve some

part of the face.

ASTM is developing a standard for eye and face

protection for hockey players. NOCSAE has conducted

tests on ice hockey protective headgear "in order to

establish conclusive data for the formation of a safety standard." (330) The potential and alternatives

for promulgating these standards should be considered.

• Stimulate research to reinforce theories pertainig to

knee injury prevention and provide for disseminating results

to the athletic community.

The knee is the most frequently injured body part

in sports. The most damaging of these is an injury

involving the surrounding ligaments. The literature

suggest that the extent of knee injuries could be

minimized through

1. proper conditioning programs,

2. in certain instances screening individuals

with a previous injury or those susceptible

to injury, and

3. selecting the best combinations of shoe, cleats,

and surface to minimize the chance of injury

resulting from cleat/surface "lock-up."

Research needed to reinforce these concepts and

obtain an efficient method of disseminating the results

(of other sports injury research as well) to coaches,

administrators, athletes, trainers and physicians

should be encouraged.

• Allocate resources to areas of ski-boot-binding testing,

adjusting, maintenance, and establish equipment performance

criteria

.

Fractures, sprains, and strains of the lower leg

are typical snow skiing injuries. Such injuries have

been associated with release failure of the binding

system. Injuries have also been attributed to premature

binding releases.

- 59 -
Conditioning programs are usually routine to

athletes engaged in competitive activities. Thus, these

athletes avoid many injuries. The recreational skier,

however, usually does not have access to formal conditioning programs. As such, recreational skiers depend

on their equipment for protection against injury. The

bindings' ability to afford this protection is influenced

by friction, release setting, environmental factors,

corrosion and type of binding.

The literature suggests four tasks to reduce the

risks associated with recreational skiing.

1. Develop guidelines to aid proper binding

adjustments

.

2. Educate the skier on the importance and

procedures for proper equipment maintenance.

3. Improve procedures for testing the ski-bootbinding system.

4. Establish minimum equipment performance criteria.

• Determine the feasibility of establishing a ski-bootbinding safety performance standard.

The ASTM Subcommittee on Skiing is developing standards

for skis and binding mountings. Currently, a binding

safety performance standard is not included. The

feasibility of developing a safety performance standard

on bindings, or possibly the ski-boot-binding system

should be evaluated.

The preceding recommendations constitute a set of first

priority tasks for reducing the incidence and severity of

sports related injuries. These recommendations address only

a small set of potential hazards in sports. There are

indications that different types of playing surfaces are

associated with different rates of football injuries. The

trunk, shoulder, and hands were shown to be frequently injured

in football. According to NEISS, basketball and baseball

activities pose as great a problem, in terms of numbers of

injuries, as football. However, in view of study constraints,

the absence of information precludes consideration of these

and other aspects as priority sports safety issues.

Several organizations are committed to pursuing safer

participation in sports. Some are actively engaged in tasks

related to the preceding recommendations. Coordinating with

these groups would minimize redundant efforts and ally

substantial resources.

- 60 -
Appendix A. Projected Number of Hospital Emergency

Room Treated Injuries

These projections are based on the National Electronic

Injury Surveillance System data collected from 119 hospitals

from July 1972 through June 1976. Projections are derived

by multiplying the number of injuries reported by each

hospital by the weight factor associated with that hospital

and summing the results for all hospitals.

Table A-l provides a listing of diagnostic and body

part categories used in NEISS. The remainder of this appendix

is divided into seven parts according to the following NEISS

Product Categories (PC)

:

Table A-2 : Football Activity and Related Equipment

(PC-1211)

Table A- 3 : Baseball Activity and Related Equipment

(PC-1204)

Table A-4 : Basketball Activity and Related Equipment

(PC-1205)

Table A- 5

:

Snow Skiing and Associated Equipment

(PC-1216)

Table A- 6 : Ice Hockey and Related Equipment (PC-1279)*

Table A- 7 : Gymnastics and Associated Equipment (PC-1272)

Table A- 8 : Trampolines (PC-1233).

Within these subdivisions the data are arranged by injury

diagnosis and affected body part. These data are also arranged

according to the most frequently occurring injuries (e.g.,

sprain/strain-lower leg)

.

*Ice hockey data are available for FY 75 and 76 only.
Table A-l: Categories for injury diagnosis

and body parts used in NEISS

Injury Diagnosis

Amputation

Anoxia

Avulsion

Burns (not specified)

Burns (scald from hot liquids)

Burns (thermal)

Burns (chemical, caustics, etc.)

Cell damage by radiation,

except thermal (radiation

burns by ultraviolet, x-rays,

radioactive materials, etc.)

Concussion

Contusions/Abrasions

Crushing

Dermatitis, Con j untivi tis

Dislocation

Electric Shock

Foreign Body

Fracture

Hematoma

Internal Organ Injury

Laceration

Nerve Damage

Poisoning

Puncture

Strain or Sprain

Submersion (including drowning)

Other

Not stated

Ingested foreign object

Aspirated foreign object

Body Part

Head

Ear

Eyeball

Face (including nose)

Mouth (lips, tongue, teeth)

Neck

Upper trunk (including

shoulders

Lower trunk (including hips)

Upper arm

Lower arm (including wrist

and elbow)

Hand

Finger

Upper leg

Lower leg (including knee

and ankle)

Foot

Toe

25-50% of Body

All parts of body

Other

Not stated

- 62 -
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Table

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69

Total
Appendix B.

Wayne State Tolerance Curve

TIME-MILLISECONDS

Fiqure 3. Wayne State Concussion

Tolerance Curve.

(Courtesy of R. E. Berger (134 , p. 31, figure 3))

- 70 -
List of References

The List of References is arranged alphabetically

according to several topics. Because these topics reflect

a great deal of overlap, the assignment of each reference to

a topic was determined by a simple hierarchial classification

scheme —topics grouped as Level 1 were considered first,

then Level 2, and finally. Level 3. Each entry appears only

once in the list.

Level 1. Page

Head and Neck 81

Lower Extremity (excludes snow skiing) 85

Synthetic Playing Surfaces 87

Environmental Heat 89

Standards and Specifications 95

Books 98

Level 2.

Football 72

Snow Skiing 75

Baseball 78

Ice Hockey 79

Other Sports 80

Level 3.

General 90
LIST OF REFERENCES

Football

1. Allen, M. L. , "Air Force Football Injuries," The American

Medical Association 206, 5 (October 28, 1968) pp. 1053-

1058 .

2. Blyth, C. S. and Arnold, D. C., The Forty-First Annual

Survey of Football Fatalities : 1931-1972, Chapel Hill,

North Carolina, February 1973.

3. Blyth, C. S. and Arnold, D. C., The Forty-Second Annual

Survey of Football Fatalities: 1931-1973 , Chapel Hill,

North Carolina, February 1974.

4. Blyth, C. S. and Arnold, D. C., The Forty-Third Annual

Survey of Football Fatalities: 1931-1974 , Chapel Hill,

North Carolina, February 1975.

5. Biytn, C. S. and Arnold, D. C., The Forty-Fourth Annual

Survey of Footoall Fatalities: 1931-1975 , Chapel Hill,

North Carolina, February 1976.

6. Blyth, C. S. and Mueller, F. 0., "Football Injury Survey:

Part 1-When and Where Players Get Hurt," The Physician

and Sports Medicine 2, 9 (September 1974) pp . 45-52 .

7. Blyth, C. S. and Mueller, F. 0., "Football Injury Survey:

Part 2-Indentify ing the Causes," The Physician and Sports

Medicine 2, 10(October 1974) pp. 71-78.

8. Blyth, C. S. and Mueller, F. 0., "Football Injury Survey:

Part 3-Injury Rates Vary with Coaching," The Pnysician and

Sports Medicine 2, 11 (November 1974) pp. 45-50.

9. Blyth, C. S. and Mueller, F. 0., An Epidemiologic Study of

High School Football Injuries in North Carolina- 1968 - 1972 , U. S. Consumer Product Safety Commission under

Contract CPSC-C-74-18

.

10. Bowerman, J. W. and McDonnell, E. S., "Football Injuries

Reflect Position Played, Gear Worn," Radiology News Digest

October 1975.

11. Bowers, Jr., K. D., "Let's Make High School Football Safer,"

The West Virginia Medical Journal 70, 8 (August 1974)

pp. 180-182.

12. Brown, R. B., "Personality Characteristics Related to Injuries

in Football," Research Quarterly 42, 2(1971) pp. 133-138.

- 72 -
Football

13. Castellanos, A. and Greer, P., "Tackle Football in Pre-High

School Children," Sports Medicine and Physical Fitness 6,

3 (September 1966) pp. 187-190.

f 14. Chandler, J. V. ; Langley, T. D. ; and Blair, S. N. , "Movement

Times for Jab and Cross-Over Steps by High School Football

Players," Research Quarterly 45, 2 (May 1975) pp. 149-152.

15. Clarke, K. S. , 1976 Spring Football Injury Study , NCAA

Committee on Competitive Safeguards and Medical Aspects of

Sports, 1976.

16. Clarke, K. S., "Calculated Risk of Sports Fatalities," The

American Medical Association 197, 11 (September 12, 1966)

pp. 172-174.

17. Conrad, R. W. , A Survey of the Pre-Season Football Coaching

Techniques , Tri-State Area School Study Council, University

of Pittsburgh, June 1966.

18. Diamond, P. E. and McMaster, J. H. , "Tackier' s Exostosis,"

Sports Medicine 3, 5(1975) pp. 238-242.

19. Eastwood, F. R. , "Hazards to Health," New England Journal of

Medicine 271, 8 (August 20, 1964) pp. 411-413.

20. Edmunds, G. B. , "Football: The Last Hurrah?", Sports

Merchandiser (March 1976) pp. 41-42.

21. Garrahan, W. F. , "The Incidence of High School Football

Injuries," Rhode Island Medical Journal (August 17, 1967)

pp. 833-835.

22. Godshall, R. W. "Junior League Football: Risks vs. Benefits,"

Sports Medicine 3, 3 (May/June 1975) pp. 139-144.

23. Grippo, J. , National Football League Injury Study 1969-72 , Prepared for The National Football League, New York, New York,

Stanford Research Institute Project MSD-1961.

24. Grippo, J. , National Football League 1973 Injury Study , Prepared for The National Football League, New York, New York,

Stanford Research Institute Project MSD-1961.

25. Grippo, J. , National Football League 1974 Injury Study , Prepared for The National Football League, New York, New York,

Stanford Research Institute Project MSD-1961.

26. Hibbert, Jr., R. W. , "High School Football Injuries," The

Rocky Mountain Medical Journal 47, (April 1950) pp. 276-

279.

- 73 -
Football

27. Himmelwright , G. 0., "Field Decisions-Diagnosis In Football,"

Maryland State Medical Journal (October 1967) pp. 50-58.

28. Martin, G. L. and Costello, D. F., The 1970 Intercollegiate

Tackle Football Injury Surveillance Report , The Joint

Commission on Competitive Safeguards and Medical Aspects

of Sports.

29. Mueller, F. O. and Blyth, C. S., "North Carolina High School

Football Injury Study: Equipment and Prevention," Sports

Medicine 2, 1 (January/February 1974).

30. Murray, B. and Herbert, D. , A Coach's Guide to Safe Football , Prepared for the American Football Coaches Association.

31. Powell, J. W. ; Carey, R. C.; and Clarke, K. S., "Injury Patterns

During the First Three Days of Football Practice Among Big

Ten Schools," Athletic Training 11, 1 (March 1976) pp. 40-45.

32. Rachun, A. and Kavanagh, F. J., "Protective Football Equipment,"

American Journal of Surgery 98, (September 1959) pp. 363-367.

33. Robey, J. M. ; Blyth, C. S.; and Mueller, F. 0., "Athletic

Injuries," The American Medical Association 217, 2 (July 12,

1971) pp. 184-189.

34. Tomlins, F. I., "The Prevention of Athletic Injury," The

Medical Society of New Jersey 63, 9 (September 1966) pp . 414-

415.

35. Williams, D. J. and Dayries, J. L., A Critical Analysis of

the 1969 Little Grizzly Football Program in Missoula, Montana , The Bureau of Research on Physical Activity and Sport, University of Montana (September 1970).

36. "A Modified Junior-High Plan Shows Football Injury Decline,"

Medical Tribune (January 6, 1964).

37 . The Official National Collegiate Athletic Association Football

Rules-1976 , The NCAA Publishing Service, P. O. Box 1906,

Shawnee Mission, Kansas.

38. "The House That Nicholas Built," Physician and Sports Medicine

1, 3 (November 1973) pp. 73-79.

39. "Searching for Loose and Tight Joints," The Physician and

Sports Medicine 2, 10 (October 1974) pp. 80-82.

4 0 . National Federation of State High School Associations: Facts

of Football Safety, Elgin, Illinois , National Federation

Publications, 1975.

-74
Football/Snow Skiing 41.

"October: Football Injuries," Applied Therapeutics

(October 1963) pp. 833-841, 920.

42 . Hazard Analysis-Football: Activity and Related Equipment , U. S. Consumer Product Safety Commission, July 1974.

43 . Fact Sheet-No. 42: Football and Football Equipment , U. S. Consumer Product Safety Commission, October 1974.

44. NEISS News , U. S. Consumer Product Safety Commission 4, 3

(December 1975)

Snow Skiing

45. Arnold, I. M. F. and Ackman, C. F. D. , "Skiiny Injuries in

Canada-A Coast-to-Coast Study," Sports Medicine (January/

February 1973) pp. 31-33.

46. Bahniuk, E., "The Right Ski Bindings for Safety," Consumers 1 Research 60, 1 (January 1977).

47. Bahniuk, E. and Izant, T. , "The Effects of the Environment

on Some Ski Bindings," Safety Research 8, 1 (March 1976)

pp. 30-37.

48. Bahniuk, E.; Mack, R. P.; Burstein, A. H. ; and Frankel, V. H.,

"The Biomechanics of Contemporary Ski Bindings," Safety

Research 4, 4 (December 1972) pp. 160-171.

49. Bahniuk, E.; Mack, R. P.; Burstein, A. H. ; and Frankel, V. H.,

"The Biomechanics of Ski Boots," Safety Research 6, 1

( March 1 9 7 4 ) pp . 2 4 - 3 3 .

50 . Bodine, K. G. , "Boots and Bindings," The American Podiatry

Association 62, 1 (January 1972) pp. 33-34.

51. Casewit, C., "Ski Safely," The California Highway Patrolman

(December 1975) pp . 14-16, 58, 59.

52. Erskine, L. A., "Recent Changes in the Pattern of Skiing

Injuries," Trauma 14, l(January 1974) pp . 92-93.

53. Ettlinger, C. F., "Five Steps to Skiing Safety," Vermont

Ski Safety Equipment , n.d.

54. Ettlinger, C. E., "Bindings Performance Report: The Gertsch

Line," Skiing 28, 7 (Spring 1976) pp. 82-85.

55. Fagan, C. A. and Tapper, E. M. , "The Ski "Safety" Strap: A

Misnomer," Sports Medicine 3, 2 (March-April 1975) pp . 95-

96

- 75 -
Snow Skiing

56. Garrick, J. G. , "The Mythology of Ski Injuries," The Physician

and Sports Medicine 1, 3 (November 1973) pp. 35-38.

57. Garrick, J. G. , "The Epidemiology of Ski Injuries," Minnesota

Medicine 54 (January 1971) pp. 17-18.

58. Garrick, J. G. and Kurland, L. T. , "The Epidemiologic Significance of Unreported Ski Injuries," Safety Research 3, 4

(December 1971) pp. 182-187.

59. Gutman, J.; Weisbuch, J.; and Wolf, M. , "Ski Injuries in 1972-

1973," The American Medical Association 230, 10 (December 9,

1974) pp. 1423-1425.

60. Harwood, M. R. and Strange, G. L., "Othopedic Aspects and

Safety Factors in Snow Skiing," New York State Journal of

Medicine (November 1966) pp. 2899-2907.

61. Hoffmann, P., "Take the High Boots from Skiing Children,"

The Physician and Sports Medicine 2, 12 (December 1974)

pp . 58-59.

62. Johnson, R. J. ; Pope, M. H.; and Ettlinger, C., "Ski Injuries

and Equipment Function," Sports Medicine 2, 6 (November/

December 1974) pp . 299-307.

63. Leach, R. E., "Medicine and Skiing," Skiing 28, 7 (Spring 1976)

pp . 14-16 .

64. Mack, R. P.; Bahniuk, E.; Burstein, A. H.; and Frankel, V. , "The Biomechanics of Children's Ski Bindings," Sports

Medicine 2, 3 (May/June 1974) pp. 154-162.

65. Marshall, J. R. ; Warren, R. ; and Fleiss, D. J., "Ligamentous

Injuries of the Knee in Skiing," Clinical Orthopaedics and

Related Research 108 (May, 1975) pp. 196-199.

66. McAlister, R. ; Brody, J. A.; Hammes, L. M. ; Feltz, E. T.;

Duncan, D. L. ; and Williams, M. L. , "Epidemiology of Ski

Injuries in the Anchorage Area," Archives of Environmental

Health 10, pp. 710-714.

67. Outwater, J. O. , "On the Friction of Skis," Medicine and

Sports 2, 4 (May 1970) pp. 231-235.

68. Outwater, J. 0.; Mastro, G. N. ; and Ettlinger, C. F., "The

Engineering Problem of Ski Safety," Biomechanics 2, 3

(1969) pp. 209-216.

Outwater, J. O. and Ettlinger, C. F., "The Engineering of

Ski Bindings," Medicine and Science in Sports 1, 4

(December 1969) pp. 200-206.

-76-

69 .
Snow Skiing

TS~. Piziali , R. L. and Mote, Jr., C. D. , "The Snow Ski as a Dynamic System," Dynamic Systems, Measurement and Control

94 (Series G) , 2 (June 1972) pp. 133-138 .

71. Pope, M. H.; Johnson, R. J.; and Ettlinger, C. F., "Ski Binding

Settings Based on Anthropometric and Biomechanical Data,"

Human Factors 18, 1(1976) pp. 27-32.

72. Prokop, L. , "Non-traumatic Incidents During Skiing," Sports

Medicine and Physical Fitness 12, 4 (December 1972) pp . 219-

223.

73. Reynolds, P. C., "Safety Strong at Ski Mechanics Seminars,"

Selling Sporting Goods (November 1975) pp . 52-53.

74. Shealy, J. E. , "Effectiveness of Anti-Friction Devices in SnowSkiing as a Function of Years Use," Human Factors Society , 19th Annual Meeting Proceedings (October 14-16, 1975)

pp. 125-129.

75. Shealy, J. E.; Geyer, L. H.; and Hayden, R. , "Epidemiology of

Ski Injuries: Effect of Method of Skill Acquisition and

Release Binding Accident Rate," Human Factors 16, 5, pp . 459-

473.

76. Spademan, R. , "Lower-Extremity Injuries as Related to the Use

of Ski Safety Binding," The American Medical Association 203,

7 (February 12, 1968) pp. 103-108.

77. Subotnick, S. I., "The Biomechanical Basis of Skiing

(Preliminary Report)," The American Podiatry Association

64, l(January 1974).

78. Tapper, E. M. and Moritz, J. R. , "Changing Patterns in Ski

Injuries," The Physician and Sports Medicine 2, 12

(December 1974) pp. 39-47.

79. Tucker, R. C., "Skiing Down Through the Years," Minnesota

Medicine 54 (January 1971) pp. 61-69.

80. Ungersma, J. A.; Mason, L. G. ; O'Keefe, M. A.; and Walker,

O. R. , "Helicopter Fracture," Sports Medicine 3, 3 (May/

June 1975) pp. 122-131.

81. Van Der Linden, W. ; Sunzel, H.; and Larsson, K. , "Fractures

of the Tibial Shaft after Skiing and Other Accidents,"

The Journal of Bone and Joint Surgery 57-A, 3 (April 1975)

pp. 321-327.

82. Voorhees, R. L., "Injury Prevention," Minnesota Medicine 54

(January 1971) pp. 19-23.

- 77 -
Snow 83. Skiing/Baseball

Young , L. R. ; Oman, C. M. ; Crane, H.; Emerton, A.; and Heide,

"The Etiology of Ski Injuries: An Eight Year Study of the

Skier and His Equipment," Orthopedic Clinics of North

America 7, 1 (January 1976) pp . 17-29.

R. ,||

84. Young, L. R. and Crane, H. , "The Influence of Equipment and

Skier Factors on Ski Injuries: A Nine Year Study,"

(Unpublished Paper January 1976)

.

85 . Summary Analysis of Snow Skiing and Associated Equipment (1216) , U. S. Consumer Product Safety Commission, September 4, 1973.

86.

"Ski-ing Safely," New Zealand Road Safety (August-September 1975)

pp. 13-15.

Baseball

87. Adams, J. E., "Injury to the Throwing Arm," California Medicine

102, 2 (February 1965) pp. 127-129.

88. Brogdon, B. G. and Crow, N. E., "Little Leaguer's Elbow,"

American Journal of Roentgen 83, 4 (April 1960) pp. 671-675.

89. Cahill, B. R. ; Tullos, H. S.; and Fain, R. H., "Little League

Shoulder," Sports Medicine 2, 3 (May/June 1974) pp. 150-153.

90. Diveley, R. L. and Meyer, P. W. , "Baseball Shoulder," The

American Medical Association 171, 12 (November 1959) pp. 135-

137 .

91. Dworkin, C., "Baseball Fever: An Occupational Hazard,"

The Canadian Nurse 70, (July 1974) pp. 24-26.

92. Ewing, J. D., "Little League Elbow," Nebraska Medical Journal

(March 1972) pp . 73-75.

93. Larson, R. L. and McMahan, R. O. , "The Epiphyses and the

Childhood Athlete," The American Medical Association 196,

7 (May 1966) pp. 99-104.

94. Newell, K. M. , "Decision Processes of Baseball Batters,"

Human Factors 16, 5 (October 1974) pp. 520-527.

95. Hirschl, R. P., "Etiology of Tennis Elbow," Sports Medicine

3, 5 (September/October 1975) pp. 261-264.

96. Polk, R. G. , "The Frequencies and Causes of Baseball Injuries,

The Athletic Journal (1968) pp . 18-20.

97. Woods, G. W. ; Tullos, H. S.; and King, J. W. , "The Throwing

Arm: Elbow Joint Injuries," Sports Medicine 1, 4(1973)

pp. 43-47.

- 78 -
Baseball /Ice Hockey

98. "Better Baseball Mit Pads Could Avoid Hand Trauma," Medical

Tribune and Medical News 17, 18 (May 12, 1976) pp. 43.

99. "Catchers Need More than a Mitt," Medical World News (April

5, 1976).

100 . Summary Analysis of Baseball Activity and Related Equipment

(1204) , U. S. Consumer Product Safety Commission, Bureau of

Epidemiology, September 4, 1973.

101 . The Official National Collegiate Athletic Association Baseball

Guide-1976 , NCAA Publishing Service, Shawnee Mission, Kansas.

Ice Hockey

102. Hayes, D., "The Nature, Incidence, Location and Causes of

Injury in Intercollegiate Ice Hockey," Application of Science

and Medicine to Sport, Pub. C. C. Thomas 1975 , pp . 292-300.

103. Hornof, Z. and Napravnik, C., "Analysis of Various Accident

Rate Factors in Ice Hockey," Medicine and Science in Sports

5, 4(1973) pp. 283-286.

104. Hussey, H. H. , "Ice Hockey Injuries," Editorial, The American

Medical Association 236, (July 12, 1976) p. 187.

105. Merrifield, H. H. and Cowan, R. F. J. , "Groin Strain Injuries

in Ice Hockey," Sports Medicine (January/February 1973)

pp. 41-42.

106. Nagobads, V. G., "Hockey Injuries: The Pro Is Hit the Hardest,"

The Physician and Sports Medicine 1, 3 pp. 55-57.

107. Ramey, M. R. , "Force Plate Designs and Applications," Exercise

and Sport Science Reviews 3, (1975) pp. 303-319.

108. Reeves, J. S. and Mendryk, S. W. , "A Study of the Incidence,

Nature, and Cause of Hockey Injuries in the Greater Edmonton

Metropolitan Area," Application of Science and Medicine to

Sport , Pub. C. C. Thomas 1975, pp. 301-308.

109. Reeves, J. S., "Recommendations for the Reduction of Hockey

Injuries," The Canadian Association for Health Physical

Recreation and Education 38, (March-April 1972) pp. 18-21.

110. Sze, Y.; Thompson, J. C.; Norman, R. W. ; and Hayes, D.,

"Procedures for the Evaluation of Hockey Goaltender's Face

Masks," Mechanics and Sport ed. Jeffrey Bleustrin (The

American Society of Mechanical Engineers) p. 315.

111. TooGood, T. and Love, W. G. "Jerry", "Hockey Injury Survey,"

The Canadian Association of Health, Physical Education and

Recreation 32, (1966) pp. 20-23.

- 79 -
Ice Hockey /Other Sports

112. Special Analysis of Hockey Equipment (1214 ) , U. S. Consumer

Product Safety Commission, Bureau of Epidemiology, April 26,

1973 .

113. "Sports," The Washington Post , March 10, 1976, Section D, p. 5.

114 . The Official National Collegiate Athletic Association Ice

Hockey Guide-1977 , NCAA Publishing Service, Shawnee Mission,

Kansas

.

115. Vinger, Paul F., Letter to ASTM Membership, February 24, 1976.

Other Sports

116. Fink, R. A. and Monge , J. J., "Snowmobiling Injuries,"

Minnesota Medicine (January 1971) pp. 29-32.

117. Hinrichsen, K. W. , "Medical Aspects of Football," The Medical

Journal of Australia 1, (April 27, 1963) pp. 608-611.

118. Kraus, J. F. and Gullen, W. II., "An Epidemiologic Investigation

of Predictor Variables Associated with Intramural Touch Football Injuries," American Journal of Public Health 59, 12

pp. 2144-2156.

119. Kruger, H., "Playing Safe: Progressive Spotting," Physical

Education and Recreation 47, 4 (April 1976) pp. 31-33.

120. Lok, V. and Yuceturk, G., "Injuries of Wrestling," Sports

Medicine 2, 6 (November/December 1974) pp . 324-328 .

121. Piscopo, J. and Hennessy, J., "Playing Safe: Trampoline

Safety," Physical Education and Recreation 47, 4 (April

1976) pp. 33-36.

122. Priest, J. D.; Jones, H. H.; and Nagel, D. A., "Elbow Injuries

in Highly Skilled Tennis Players," Sports Medicine 2,

3(1974) pp. 137-149.

123. Fact Sheet No. 85 Trampolines , U. S. Consumer Product Safety

Commission, February 1976.

124. Summary Analysis of Trampolines (1233 ) , U. S. Consumer Product

Safety Commission , (July 19, 1973) pp . 1-5.

125. The Official National Collegiate Athletic Association Gymnastics

Rules-197

6

, NCAA Publishing Service, P. O. Box 1906 , Shannee Mission, Kansas.

126 . Official National Collegiate Athletic Association Basketball

Rules-1977, NCAA Publishing Service, Shawnee Mission, Kansas,

1976 . - 80 -
I,

Head and Neck

127. Albright, J. P.; Moses, J. M. ; Feldick, H. G.; Dolan, K. D., and

Burmeister, L. F., "Nonfatal Cervical Spine Injuries in

Inter scholastic Football," Journal of the American Medical

Association 236, ll(September 13, 1976), pp. 1243-1245.

128 .

129.

130 .

131.

132 .

133.

134 .

135.

136 .

139 .

137

138

Alley, Jr., R. H., "Head and Neck Injuries in High School

Football," Journal of American Medical Association 188, 3

(May 4, 1964), pp. 118-122.

Andrews, L. M. , Football Helmet Tests: Round Robin Using

NOCSAE Recommended Test Method , National Bureau of Standards

Letter Report to the U. S. Consumer Product Safety Commission,

March 3, 1976.

Andrews, L. M. , Football Helmet Tests: Round Robin Using ASTM

Recommended Test Method , National Bureau of Standards Letter

Report to the U. S. Consumer Product Safety Commission,

March 3, 1976.

Andrews, L. M. , Football Helmet Tests: Comparison of Data

Using Both NOCSAE and ASTM Recommended Test Methods , National

Bureau of Standards Letter Report to the U. S. Consumer

Product Safety Commission, March 3, 1976.

Baldwin, K. , "Standards Meeting Focuses on Head Safety,"

Selling Sporting Goods (March, 1976) pp. 86-87.

Bellow, D. G. ; Mendryk, S., and Schneider, V., "An Investigation

into the Evaluation of Hockey Helmets," Medicine and Science

in Sports 2, l(Spring, 1970) pp. 43-49.

Berger, R. E., Considerations in Developing Test Methods For

Protective Headgear , National Bureau of Standards Report: NBSIR

76-1107, August 1976.

Bishop, P. J., "Head Protection in Sport with Particular

Application to Ice Hockey," Ergonomics 19, 4(1976) pp. 451-

464.

Bolitho, N. , "Head Injuries in Ice Hockey at the Amateur Level,"

Journal of the Canadian Association of Health Physical

Education and Recreation 37 (November-December 1970) pp. 29-

34 . Burstein, F., "Ocular Injuries in Sports," Sports Medicine 3,

1 ( January-February 1975) pp. 25-34.

Chrisman, O. D.; Snook, G. A.; Stanitis, J. M. , and Keedy, V. A.,

"Lateral-Flexion Neck Injuries in Athletic Competition,"

The American Medical Association 192, 7 (May 17, 1965)

pp. 117-120.

Clarke, K. S., Sport-Related Spinal Cord Injuries in Schools

and Colleges, 1973-75 , Prepared for the NCAA Committee on

Competitive Safeguards and Medical Aspects of Sports, 1976.

- 81 -
Head and Neck

140. Collins, H. R. and Johnson, C., "Heads Up! Protect Neck, Head

from Serious Football Injuries," Texas Medicine 63 (November

1967) pp. 40-41.

141. Duff, J. F., "Spearing: Clinical Consequences in the Adolescent,"

Sports Medicine 2, 3(1974) pp. 175-177.

142. Gibbs, R. W. , "Unsafe Headgear Faulted in Critical HockeyInjuries, " Physician and Sports Medicine 2, 1 (February, 1974)

pp. 39-42.

143. Gurdjian, E. S.; Hodgson, V. R. ; Hardy, W. G.; Patrick, L. M.

;

and Lissner, II. R. , "Evaluation of the Protective Characteristics

of Helmets in Sports," Trauma (1964) pp. 309-324.

144. Hardy, C. H. and Marcal, P. V. , "Elastic Analysis of a Skull,"

Applied Mechanics 27 (December, 1973) pp . 838-842 .

145. Heintz, W. D., "Mouth Protectors: A Progress Report," The

American Dental Association 77 (September 1968) pp. 632-636.

146. Heintz, W. D. , "The Case for Mandatory Mouth Protectors," The

Physician and Sports Medicine (April 1975) pp . 61-63.

147. Hodgson, V. R. , "National Operating Committee on Standards for

Athletic Equipment Football Helmet Certification Program,

Medicine and Science in Sports (1975) pp. 225-232.

148. Hodgson, V. R. and Thomas, L. M. , "Biomechanical Study of

Football Head Impacts Using a Human Head Model," Prepared for

The National Operating Committee on Standards For Athletic

Equipment (April 19, 1973) pp. 3-24.

149. Hughes, J. R. and Hendrix, D. E., "Telemetered EEG from a Football Player in Action," Electroencephalography and

Clinical Neurophysiology 24 (1968) pp. 183-186.

150. Jagger, R. G. and Clarke, D. A., "Mouthguards for Contact

Sports," Dental Technician 27, 10 (October 1974) pp. 88-90.

151. Kindt, G. W. ; Schneider, R. C .

,* and Robinson, J. L. , "A

Method of Comparing the Impact Absorption Characteristics of

Football Helmets," Medicine and Science in Sports 3, 4(1971)

pp. 203-209.

152. King, J. H., "Evaluating Head Protecting Devices," Institute

of Environmental Sciences 1973 Proceedings , Anaheim, California, April 2-5, 1973.

153. Krans, J. F.; Anderson, B. D.; and Mueller, C. E., "The

Effectiveness of a Special Ice Hockey Helmet to Reduce Injuries

in College Intramural Hockey," Medicine and Science in Sports

2, 3(1970) pp. 162-164.

- 82 -
cs

Head and Neck

154. Leidholt, J. D., "Spinal Injuries in Sports," Surgical Clinics

of North America 43 (April 1963) pp. 351-361.

155. Liu, Y. K. and Chandran, K. B., "Package Cushioning for the

Human Head," Applied Mechanics 42, 2 (September 1975)

pp. 541-546 .

156. Mahajan, B. M. , Standards for Athletic Helmets —State of the

Art and Recommendations, National Bureau of Standards Report:

NBSIR 73-276 (April, 1974).

157. Melvin, W. J. S.; Dunlop, H. W. ; Hetherington , R. F.; and

Kerr, J. W. , "The Role of the Faceguard in the Production of

Flexion Injuries to the Cervical Spine in Football," The

Canadian Medical Association Journal 93 (November 20, 1965)

pp. 1110-1119.

158. Newman, J. A., On the Use of the Head Injury Criterion (HIC ) in Protective Headgear Evaluation , 1974 Stapp Car Conference,

(November 17-19) pp. 615-640.

159. Okihiro, M. M. ; Taniguchi, R. ; and Goebert, H. W. , "Football

Injuries of the Cervical Spine and Cord," Hawaii Medical

Journal 34, 5 (May 1975) p. 171-175.

160. Ommaya, A. K. , "Surgical Management of Head Injuries in

Athletes," The Physician and Sports Medicine 2, 4 (April 1976)

pp . 56-62

161. Pashby, T. J.; Pashby, R. C.; Chisholm, L. D. J.; and Crawford,

J. S., "Eye Injuries in Canadian Hockey," Canadian Medical

Association Journal 113 (October 4 , 1975), pp . 663-666 .

162. Pizzi, F. J. , "Late Effects of Craniospinal Injuries," The

Physician and Sports Medicine 2, 4 (April, 1976) pp. 74-79.

163. Reid, S. E.; Epstein, H. M. ; and Louis, M. W. , "Brain Trauma

Inside a Football Helmet," The Physician and Sports Medicine

2, 8 (August 1974) pp. 32-35.

164. Robey, J. M. , "Contribution of Design and Construction of

Football Helmets to the Occurrence of Injuries," Medicine

and Science in Sports 4, 3(1972) pp. 170-174.

165. Robinson, R. I., "NCAA Football Head and Neck Injuries in

Eastern Colleges-197 2 and 1974 Seasons," Physical Education

and Recreation Journal 46, 6(1975) pp . 45-46.

167. Rontal, E. and Rontal, M. , "Maxillofacial Injuries in Football Players. An (Evaluation of Current Facial Protection,"

Sports Medicine and Physical Fitness 11, 4 (December 1971)

pp. 241-245.

- 83 -
Head and Neck

168. Rose, K. D. ; Stone, F.; Fuenning, S. I.; and Williams, J.,

"Cardiac Contusion Resulting from "Spearing" in Football,"

Archives of Internal Medicine (August 1966) pp . 129-131.

169. Ryan, A. J., "On-Field Diagnosis of Head Injuries," The

Physician and Sports Medicine (April 1976) pp . 82-84 .

170. Schmidek, H. H., "Complications May Arise in Seconds-or

Months," The Physician and Sports Medicine (April 1976)

pp. 68-70

.

171. Schneider, R. C.; Reifel, E.; Crisler, H. O.; and Oesterbaan,

B. G. , "Serious and Fatal Football Injuries Involving the

Head and Spinal Cord," The American Medical Association

(August 12, 1961) pp. 362-367.

172. Schneider, R. C. and Antine, B. E., "Visual-field Impairment

Related to Football Headgear and Face Guards," The American

Medical Association 192, 7 (May 17, 1965), pp . 616-618.

173. Schneider, V. E., "Protection of the Head in Hockey," The

Canadian Association of Health Physical Education and

Recreation 37 (May-June 1971) pp. 35-36.

174. Schwank, W. C. and Ryan, A. J., "Stopping Spear Tackling,"

Physical Sports Medical Journal 3, 9 (September 1975) pp. 72-

78.

175. Snook, G. A., "Head and Neck Injuries in Contact Sports,"

Medicine and Science in Sports 1, 3 (September 1969) pp. 117-

123.

176. Torg, J. S.; Quedenfeld, T. C.; Thieler III, E. R. ; and

Lignelli, G. J., "Collision with Spring-Loaded Football

Tackling and Blocking Dummies," The American Medical

Association 236, ll(September 13, 1976) pp. 1270-1271.

177. Vinger, P. F., "Ocular Injuries in Hockey," Archives of

Ophthalmology 94, 1 (January 1976) pp. 74-76.

178. Wirtz, P. D. , "Head and Neck Injuries in Football," Iowa

Medical Society 66, 3 (March, 1976) pp. 89, 102.

179. Wood, A. W. S., "Search for Safety," The Canadian Dental

Association 40, 5 (May 1974) p. 338.

180. Yeager, B., "More Experience, More Neck Injury," The Physician

and Sports Medicine (April 1975) p. 20.

181. Press Release: Opposing the Use of Certain Tackling and

Blocking Techniques, National Athletic Trainers Association,

June 11, 1975.

- 84 -
Head and Neck/Lower Extremity

182 . "Injuries to the Neck and Upper Extremity in Sports,"

Special Meeting Report, Sports Medicine 1, 2 (JanuaryFebruary 1973) pp. 38-40.

183. "Brain Damage in Sports," The Lancet (February 21, 1976)

pp. 401-402.

184 . "Helmets, Face Guards, and Better Football," Sportspages,

The Physician and Sports Medicine 1, 3 (November 1973) p. 32.

185.

186.

187 .

188.

"Concussion and Hedd Injuries," The Physician and Sports

Medicine 2, 10 (October 1974) pp . 46-54.

"Football Rules Seek to Curb Head Blocking," Sportspages,

The Physician and Sports Medicine 4, 3 (March 1976) pp . 23-24

"Head, Neck Injuries Discussed at Meeting," Sportspages,

The Physician and Sports Medicine 4, 6 (June 1976).

"Boxing Produces Most Severe Head Injuries," Discussion,

The Physician and Sports Medicine (April 1976) pp. 87-89.

Lower Extremity

189.

Ill

Abbott, H. G. and Kress, J. B., Preconditioning in the

Prevention of Knee Injuries," Archives of Physical Medicine

and Rehabilitation 50, (June 1969) pp. 326-333.

190. Andrish, J. T.; Bergfeld, J. A.; and Walheim, J., "A

Prospective Study on the Management of Shin Splints,"

Journal of Bone and Joint Surgery 56A, 8 (December 1974)

pp. 1697-1700.

191. Cameron, B. M. and Davis, 0., "The Swivel Football Shoe:

A Controlled Study," Sports Medicine (January/February 1973)

192.

193.

pp. 16-27.

Conway, D. H., "An Introduction to Podiatric Sports Medicine,"

American Podiatry Association 65, 5 (May 1975) pp. 495-499.

Conway, D. H. , "A Modified Athletic Shoe with Adjustable

Midfoot Sling," American Podiatry Association 60, 3 (March

1970) pp. 118-121.

194 . DiStefano, V. J. and Nixon, J. E., "Ruptures of the Achilles

Tendon," Sports Medicine (January/February 1973) pp. 34-37.

195. Ferguson, Jr., A. B., "The Case Against Ankle Taping,"

Sports Medicine (January/February 1973) pp. 46-47.

196. Hirata, Jr., ISAO, "The Hanley Cleat and the Ivy LeagueA Progress Report," The American College Health Association

17, (April 1969) pp. 369-370.

- 85 -
Lower Extremeity

197. Klein, K. K. , "Muscular Strength and the Knee," The Physician

and Sports Medicine 2, 12 (December 1974) pp. 29-31.

198. McKinney, D. ; McKinney, P.; Overman, S.; and Stringfellow, M.

,

"Investigation of a Training Shoe as a Supplemental

Conditioning Device," Research Quarterly 46, 4 (December

1975) pp. 422-427.

199. Nicholas, J. A., "Injuries to Knee Ligaments Relationship to

Looseness and Tightness in Football Players," The American

Medical Association 212, 13 (June 29, 1970) pp. 2236-2239.

200. Peterson, T. R. , "The Cross-Body Block, the Major Cause of

Knee Injuries," The American Medical Association 211, 3

(January 19, 1970) pp. 449-452.

201. Peterson, T. R. , "Blocking at the Knee, Dangerous and Unnecessary," The Physician and Sports Medicine 1, 2 (September

1973) pp. 47-50.

202. Rail, K. L. ; McElroy, G. L. ; and Keats, T. E., "A Study of

Long Term Effects of Football Injury to the Knee," Missouri

Medicine 61, 6 (June 1964) pp. 435-438.

203. Reahl, Jr., G. E., "Soft Tissue Injuries of the Knee and

Ankle," Maryland State Medical Journal (October 1967)

pp. 66-71.

204. Rowe, M. L. , "Varsity Football Knee and Ankle Injury,"

New York State Journal of Medicine 69, (December 1, 1969)

pp. 3000-3003.

205. Ryan, A. J. , "Taping Prevents Acute and Repeated Ankle Sprains,

The Physician and Sports Medicine 1, 3 (November 1973) pp. 40-

46.

206. Sinton, W. A., "Knee Injuries Part II: Prevention," Sports

Medicine 1, 2 (January/February 1973) pp . 49-52.

207. Slocum, D. B. and Larson, R. L. , "Indirect Injuries to the

Extensor Mechanism of the Knee in Athletes," American

Journal of Orthopedics (November/December 1964) pp. 249-

259 .

208. Steingard, P. M. , "Foot Failures in Basketball," The Physician

and Sports Medicine 2, 3 (March 1974) pp. 64-69.

209. Torg, J. S. and Quedenfeld, T., "Knee and Ankle Injuries

Traced to Shoes and Cleats," The Physican and Sports

Medicine 1, 2 (September 1973) pp. 39-43.

- 86 -
Lower Extremity/Synthetic Playing Surfaces

210. Torg, J. S.; Quedenfeld, T. C.; and Landau, S., "The ShoeSurface Interface and Its Relationship to Football Knee

Injuries," Sports Medicine 2, 5 (September/October 1974)

pp . 261-269

211. Wiechec, F. J., "Examination, Treatment and Conditioning of

Athletic Injuries of the Lower Extremities," The American

Podiatry Association 57, 11 (November 1967) pp. 509-514.

212. Wells, J., "The Incidence of Knee Injuries in Relation to

Ankle Taping," The National Athletic Trainer's Association

4, 4 (Winter 1969) pp. 10-13.

213. "Prevention of Knee Injuries in Athletes with Knee Joint

Laxity," The American Medical Association 231, 2 (January

1975) p. 207.

Synthetic Playing Surfaces

214. Adkison, J. W. ; Requa , R. K. ; and Garrick, J. G. , "Injury

Rates in High School Football-A Comparison of Synthetic

Surfaces and Grass Fields," Clinical Orthopaedics and

Related Research 99 (March-April 1974) pp. 131-136.

215. Bonstingl, R. W. ; Morehouse, C. A.; and Niebel, B. W.

"Torques Developed by Different Types of Shoes on Various

Playing Surfaces," Medicine and Science in Sports 7, 2

(1975) pp. 127-131.

216. Bowers, Jr., K. D. and Martin, R. B., "Impact Absorption,

New and Old Astro-Turf at West Virginia University,"

Medicine and Science in Sports 6, 3 (March 1974) pp. 217-221.

217. Bowers, Jr., K. D. and Martin, R. B., "Aging Astro Turf: A

Threat to Safety and Performance?," The Physician and

Sports Medicine (October 1975) pp. 65-67.

218. Bowers, Jr., K. D. and Martin, R. B. , "Cleat-Surface Friction

on New and Old Astroturf," Medicine and Science in Sports

7, 2(1975) pp. 132-135.

219 . Carew, J., "Synthetic Grass," Horticulture 48, (January 1970)

p . 38 .

220. Carry, P., "A Surface Case of Bugs in the Rugs," Sports

Illustrated 33, (September 14, 1970) pp. 40-42, 45.

221. Clarke, K. S., Artificial Surface: College Football and

Soccer In juries-1975 , Report to the U. S. Consumer

Product Safety Commission, (September 8, 1976).

222. Dreiske, P., "Artificial Turf: Pro and Con," Family Safety

(Fall 1972) pp. 12-15.

- 87 -
Synthetic Playing Surfaces

223. Garrick, J. G. and Bramwell, S. T. , "High School Football

Injuries: A Comparison of Playing Surfaces," Medicine and

Science in Sports 4, (1972) pp. 166-169.

224. Howard, M. K.; Koon, J. L. ; and Rochester, E. W. , "Effect of

Artificial Turf on Player Environment," The National Athletic

Trainer’s Association 6, 4 (Winter, 1971) pp. 157-159.

225. Kandelin, W. W. ; Krahenbuhl , G. S.; and Schacht, C. A.,

"Athletic Field Microclimates and Heat Stress," Safety

Research 8, 3 (September 1976) pp. 106-111.

226. McGuire, B. J. and Toner, S. D. , Evaluation of Synthetic Turf

Safety Test Programs , National Bureau of Standards Technical

Report to Subcommittee on Commerce and Finance, January 24, 1972

227. Morehouse, C. A. and Morrison, W. E., "The Artificial Turf

Story," Penn State HPER Series No. 9, The Pennsylvania State

University, 1975.

228. Patrick, C. and Barton, B., "Astroturf or Grass as Related to

Temperature Relative Humidity," National xAthletic Trainer's

Association 7, 2(1972) pp. 47-48.

229. Stanitski, C. L. ; McMaster, J. H.; and Ferguson, R. J.,

"Synthetic Turf and Grass: A Comparative Study," Sports

Medicine 2, 1 (January/February 1974) pp . 22-26.

230. Torg, J. S.; Quedenfeld, T. C.; and Landau, S., "Football Shoes

and Playing Surfaces: From Safe to Unsafe," The Physician

and Sports Medicine 1, 3 (November 1973) pp . 51-54.

231. Whitehurst, J. R. , "The Astrodome Turf and Lower Extremeity

Injuries," American College Health Association 17, (December

1968) pp. 136-137.

232. "New "Grass" Improves Bowl Playing Surface," Adhesives Age

15, (1972) p. 29.

233. "Artificial Turf: Pros and Cons," Round Table, The Physician

and Sports Medicine (February 1975) pp. 41-50.

234. "NFL Players: Give Us Grass (to Play on)," The Physician and

Sports Medicine 2, 1 (January 1974) pp . 20-21.

235. "Synthetic Turf and Grass," Letters, Sports Medicine 2, 3

(May/June 1974) pp. 178-179.

236. "Researchers Test Shoes Used on Artificial Turf," Parks and

Recreation 9, 11 (January 1975) pp. 2-3.

- 88 -
Synthetic Playing Surfaces/Environmental Heat/General Topics

237. "National Football League Players Association-Denial of

Petition Regarding Artificial Turf Covering," Federal

Register 38, 239 (December 13, 1973) pp. 34361-34362.

238. "National Football League Players Association Denial of

Petition Regarding Artificial Turf Covering," Federal

Register 41, 179 (September 14, 1976) pp . 39068-39069.

239. "A Farewell to Grass," Sports, Newsweek 75, (May 11, 1970).

Environmental Heat

240. Blyth, C. S. and Burt, J. J., "Effect of Water Balance on

Ability to Perform in High Ambient Temperatures,"

Research Quarterly (American Association of Health Physical

Education and Recreation) 32, 3 (October 1961) pp . 301-307 .

241. Murphy, R. J., "The Problems of Environmental Heat in

Athletics," Ohio State Medical Journal 59, 8 (August 1963)

pp. 799-804.

242. Murphy, R. J. and Ashe, W. F., "Prevention of Heat Illness

in Football Players," The American Medical Association

194, 6 (November 8, 1965) pp. 180-184.

243. Spickard, A., "Heat Stroke in College Football and Suggestions

for Prevention." Southern Medical Journal 61, (August 1968)

pp. 791-796.

244. Westerman, R. L. and Martin, C., "The Case Against Fluid

Restriction," The Physician and Sports Medicine 2, 7

(July 1974) pp. 25-28.

245. "Dog Days and Siriasis," Commentary, The American Medical

Association 233, 6 (August 1975) pp . 513-515.

246. "Water Deprivation and Performance of Athletes," American

Journal of Clinical Nutrition 27, 10 (October 1974) pp. 1096-

1097 .

247. "American College of Sports Medicine: Position Statement on

Prevention of Heat Injuries During Distance Running,"

The American Osteopath Association 74, (June 1975) pp . 158-

159.

General Topics

248. Allman, F., "Competitive Sports for Boys Under Fifteen

Beneficial or Harmful?" The Medical Association of Georgia

55 (November 1966) pp. 464-468.

249. Allman, F., "Prevention of Sports Injuries," Athletic Journal

65 (March 1976) p. 74.

- 89 -
General Topics \ & 250. Ball, D. W. , "Control Versus Complexity-Continuities in the

Scalinq of Gaming," Pacific Sociological Review 17, 2

(April 1974) pp. 167-183.

251. Blasco , E. A., "Sporting Goods Industry Meeting," Selling

Sporting Goods 29, 6 (June 1976) pp. 44-45.

252. Blonstein , J. L. , "Injuries in Sport," Medical Society of

London Transactions 90 (1974) pp. 20-30.

253. Bramwell, S. T. ; Masuda, M. ; Wagner, N. W. ; and Holmes, T. H.

,

"Psychosocial Factors in Athletic Injuries: Development

and Application of the Social and Athletic Readjustment

Rating Scale," Human Stress 1, 2 (June 1975) pp. 6-20.

254. La Cava, G., "Sport and Puberty," Sports Medicine and

Physical Fitness 14, 3 (September 1974) pp. 163-164.

255. Christophe, K. and Leard, S., "A Follow-Up Study of Athletic

Injuries," The American College Health Association 18

(February, 1970) pp. 210-212.

256. Clarke, K. S., "Safeguarding the Health of the Athlete,"

The West Virginia Medical Journal 60, 10 (October 1964)

pp. 286-290.

257. Clarke, K. S., "Sports Medicine in Perspective," The West

Virginia Medical Journal 66, 2 (February 1970) pp. 44-47 .

258. Clarke, K. S., "Accident Prevention Research in Sports,"

Journal of Health, Physical Education and Recreation 45,

(1969) pp. 45-48.

259. Clement, Jr., J. D.

;

Graves, R. A.; Lane, R. M. ; and Weisz, H.,

"Minimum Standards of Physical Fitness Required of

Candidates for Collision Sports at the University of Maine,"

Maine Medical Association Journal 58, 6 (June 1967) pp. 121-

123 .

260 . Corbitt, R. W. ; Erickson, D. J. ; Thornton, M. L. ; Kriss, F. C.;

Cooper, D. L. ; and Crais, T. T. , The American Medical

Association

—

228, 10 (June 3, 1974) pp. 1266-1277.

261. Cownie, A. R. , "An Operational Game for the Study of Decision

Making in a Hazardous Activity," Accident Analysis and Prevenation 2, (1970) pp. 1-10.

262. DePalma, A. F. and Flannery, G. F., "Acute Anterior Dislocation

of the Shoulder," Sports Medicine 1, 2 (January/February 1973)

pp. 6-15.

- 90 -
General Topics

263. Dotson, C. 0. and Stanley, W. J., "Values of Physical Activity

Perceived by Male University Students," The Research

Quarterly 43, 2(1972) pp. 148-156.

264. Duncan, K. S., "Prevention of Sports Injury," Royal Society

of Medicine Proceedings 62, (September 1969) pp. 918-921.

265. Ellison, K. and Freischlag, J., "Pain Tolerance, Arousal, and

Personality Relationships of Athletes and Nonathletes ,

The Research Quarterly Journal 46, 2 (May 1975) pp . 250-255.

266. Fraser, T. M. , "Recreation, Technology, and System Safety,"

Human Factors 16, 5 (October 1974) pp. 447-453.

267. Gerber, S., "Are Kids Too Yound to Avoid Sports Injuries?",

Science Digest 78, (October 1975) pp . 44-52.

268. Godshall, R. W. , "The Predictability of Athletic Injuries:

An Eight-Year Study," Sports Medicine 3, 1 (January/February

1975) pp. 50-54.

269. Haddon, Jr., W. , "Principles in Research on the Effects of

Sports on Health," The American Medical Association 197,

ll(September 12, 1966) pp. 163-166.

270. Hale, C. J., "Significant Trends and Complex Barriers in the

Engineering of Protective Sports Equipment," Materials

Research and Standards (October 1971) pp . 8-12.

271. Hall, W. K. , "A Probabilistic Framework For Accident Data

Analysis," Accident Analysis and Prevention 1, (1969)

pp. 159-165.

272. Harris, M. B. and Ramsey, S., "Stereotypes of Athletes,"

Perceptual and Motor Skills 39, 2 (October 1974) pp . 705-

706.

273. Haycock, C. E. and Gillette, J. U., "Susceptibility of Women

Athletes to Injury," The American Medical Association 236,

2 (July 12, 1976) pp. 163-165.

274. Hayes, D., "Risk Factors in Sport," Human Factors 16, 5

(October 1974) pp. 454-458.

275. Hendry, L. B., "Human Factors in Sports Systems: Suggested

Models for Analyzing Athlete-Coach Interaction," Human

Factors 16, 5(1974) pp. 528-544.

276. Hinkamp, J. F., "High School Athletic Injuries," Illinois

Medical Journal 148, 2 (August 1975) pp. 127-129.

277. Hoffman, S. D., "In Search of Unreasonable Risk of Injury,"

Lab Data (Fall 1975) pp. 10-16.

- 91 -
General Topics

278 . Hogan, J. c.

,

"Sports in the Courts," Phi Delta Kappan 56,

2 (1974) pp. 132-135 .

279. Hullemann , K. D.; List, M. ; Matthes, D.; Wiese, G . ; and

Zika, D., " Spiroergometr ic and Telemetric Investigations

During The XXI International Stroke Mandeville Games 1972

In Heidelberg," Journal of Paraplegia 13, 2 (August 197b)

pp. 109-123.

2 8 0. Hurwitz, S., "Medical Aspects of Adolescents," Western

Journal of Medicine 121, 5 (November 1974) pp. 443-447.

281. Johnson, C. J.; Moran, J. C.; Paine, S. C.; Anderson, H. W. ; and Breysse, P. A., "Abatement of Toxic Levels of Carbon

Monoxide in Seattle Ice-Skating Rinks," American Journal

of Public Health 65, 10 (October 1975) pp. 1087-1090.

282. King, R. J., "It's the Law-Seller's Liability," Minnesota

Medicine (January 1971) pp. 49-50.

283. Klein, D., "Body-Contact Sports: Catharsis or Reinforcement?

Accident Analysis and Prevention 6, (1974) pp. 85-91.

284. Kniker, C. R. , "The Values of Athletics in Schools: A

Continuing Debate," Phi Delta Kappan 56, 2 (October 1974)

pp. 116-120.

285. Lane, R. M. , "Uniform Code of Medical Qualifications for

Participants in Interscholastic Athletics in Maine,"

The Maine Medical Association (November 1969) pp. 247-254.

286. Ley, K. "The New York State Experiment," Sports Medicine

1, 3 (March-April 1973) pp . 42-44.

287. Lingard, D. A., "The Impact of Sports Injuries in Winter

on Medical Services," New Zealand Medical Journal 82,

549 (October 1975) pp. 229-232.

288. Macintosh, D. L. ; Skrien, T.; and Shephard, R. J., "Athletic

Injuries at the University of Toronto," Medicine and

Science in Sports 3, 4 (March 1971) pp. 195-199.

289. Macintosh, D. L.; Skrien, T.; and Shephard, R. J., "Physical

Activity and Injury," Sports Medicine and Physical Fitness

12, 4 (December 1972) pp. 224-237.

290. Mather, B. S., "Correlations Between Strength and Other Properties of Long Bones," Journal of Trauma 7, 5(1967)

pp. 633-638.

- 92 -
General Topics

291. McBryde, A. M. , "Stress Fractures in Athletes," Sports

Medicine 3, 5(1976) pp . 212-217.

292. McGuigan , R. A., "Sports for Children," The Iowa State

Medical Society 50, 10 (October 1960 pp. 601-604.

293. Nicholas, J. A., "Risk Factors, Sport Medicine and The

Orthopedic System: An Overview," Sports Medicine 3,

5 (September/October 1975) pp . 243-259.

294. Ogilvie, B. C. and Tutko , T. A., "If You Want to Build

Character, Try Something Else," Psychology Today 5,

(October 1971) pp . 61-63.

295. Polednak, A. P., "Secular Trend in Body Size Among College

Athletes," American Journal of Physical Anthropology 42,

(May 1975) pp. 501-506.

296 . Reid, S. E.; Epstein, H. M. ; Louis, M. W. ; and Reid, Jr.,

S. E., "Physiologic Response to Impact," Journal of

Trauma 15, 2 (February 1975) pp. 150-152.

297.

Renick, J. A., "The Use and Misuse of College Athletics,"

Journal of Higher Education XLV, 7 (October 1974) pp . 545-

552.

298. Ryan, A. J., "Technological Advances in Sports Medicine and

in the Reduction of Sports Injuries," Exercise and Sport

Sciences Review 1(1973) pp . 285-312.

299. Ryan, A. J., "Medical Aspects of Sports," The American

Medical Association 194, 6 (November 8 , 1965) pp . 173-175 .

300.

Sayre, B. M. , "The Need to Ban Competitive Sports Involving

Preadolescent Children," Pediatrics 55, 4 (April 1975)

pp. 564-565

301.

Sherman, M. A., "Information Retrieval in Sport and Physical

Activity," Exercise and Sport Sciences Review 3, (1975)

pp. 321-349.

302. Smith, M. D., "Aggression in Sport: Toward a Role Approach,"

Canadian Association For Health Physical Education and

Recreation 37, ( January-February 1971) pp . 22-26.

303. Spring, J., "Athletics and the Modern Industrial State,"

Phi Delta Kappan 56, 2 (October 1974) pp . 114-115.

304 . Steinhaus, A. H. "Aims

and Physical Fitness

and Perspectives," Sports Medicine

6, 3(1966) pp. 191-197.

- 93 -
General Topics

305. Thorndike, A., "Prevention of Injuries in College Athletics,"

The American Medical Association 169, 13 (March 28, 1959)

pp . 1405-1409.

306. Thornton, M. L. , "Pediatric Concerns about Competitive

Preadolescent Sports," The American Medical Association

227, 4 (January 28, 1974) pp. 418-419.

307. Watt, E. W. ; Buskirk, E. R. ; and Plotnicki, B. A., "A

Comparison of Single vs. Multiple Daily Training Regimens:

Some Physiological Considerations," Research Quarterly 44,

1 (March 1973) pp. 119-123.

308. White, G. , "How to Save Intercollegiate Athletics," Phi Delta

Kappan 56, 2 (October 1974) pp. 106-109.

309. Zoller, G. W. , "Hazards in School Sports," The Physician and

Sports Medicine 1, 2 (September 1973) pp. 69-71.

310. "Anabolic Steroids: Doctors Denounce Them, but Athletes

Aren't Listening," News and Comment, Science 176, (June 1972)

pp. 1399-1401.

311. "Problems in Matching Competitors," Clinical Pediatrics 8,

8 (August 1969) pp. 434-436.

312. "How to Enjoy Sports-and Avoid Injury," U. S. News & World

Report (December 29, 1975) pp . 37-39.

313. "Instant Information on Sports • In juries , " Sportspages,

The Physician and Sports Medicine (April 1975) pp . 22.

314. Consumer Product Hazard Index, Fiscal Year 1975 , U. S.

Consumer Product Safety Commission, December 1975.

315. "The Shoulder in Sports," Report, Sports Meaicine 2,

1 (January/February 1974).

316. "The Referee and Sports Injuries," The Physician and Sport s Medicine 1, 2 (September 1973) p. 105.

317. "Medical Care for Young Athletes: 'Pretty Barbaric, But That's

the Way It is'," The Physician and Sports Medicine 2, 11

(November 1974) pp. 75-80.

318. "Council Fights for Fitness-and Existence," The Physician

and Sports Medicine (April 1976) pp . 106-109.

Proceedings of the 3rd Special Convention and 70th Annual

Convention , The National Collegiate Athletic Association,

St. Louis, Missouri, January 14-17, 1976.

-94-

319 .
General Topics / Standards and Specifications

! 320. "What's the Story on Sports Equipment?", The Physician and

Sports Medicine (March 1976) pp . 117-125.

321 . The Sports and Recreational Programs of the Nation's

Universities and Colleges ^ The National Collegiate Athletic

Association, Report Number Four-August 1974.

322. 1975-1976 Sports Participation Survey , The National Federation

of State High School Associations, Elgin, Illinois.

j 323. National Athletic In j ury/Illness Reporting System Sport - Related Incidence Charts, 1975-1976 , Report to the U.S.

Consumer Product Safety Commission, September 4, 1976.

I 324. NEISS NEWS , U.S. Consumer Product Safety Commission 5, 1

(July/August 1976).

325. NEISS NEWS , Bureau of Product Safety, (October 1972)

326. National Operating Committee on Standards for Athletic Equipment, News Release, June 13, 1976.

• rv

‘ 327. National Operating Committee on Standards for Athletic Equipment, News Release, August 16, 1976.

328. National Operating Committee on Standards for Athletic Equipment, News Release, September 17, 1976.

329. National Operating Committee on Standards for Athletic Equipment, News Release, October 11, 1976.

330. National Operating Committee on Standards for Athletic Equipment, News Release, November 12, 1976.

331. National Operating Committee on Standards for Athletic Equipment, News Release, December 14, 1976.

332. The Consumer Product Safety Act, Public Law 92-573 92nd Congress,

S. 3419 , October 27 , 1972.

I Standards and Specifications

333American National Standard Safety Requirements for Aerial

Passenger Tramways , ANSI B77. 1-1973 (New York: American

National Standards Institute, Inc. 1973).

334. Canadian Standards Association, Hockey Helmets-Supplement No . 1

CSA Standard Z262 . 1-1975 .

335. Canadian Standards Association, Hockey Helmets, CSA Standard

Z262. 1-1975.

- 95 -
Standards and Specifications

336. ISO Recommendation R37 8, Gymnastic Equipment-Parallel Bars , ISO/R 378-1964, International Organization for Standardization,

(December 1964).

337. ISO Recommendation R379, Gymnastic Equipment-Horizontal Bars , ISO/R 378-1964, International Organization for Standardization,

(December 1964).

338. ISO Recommendation R38Q, Gymnastic Equipment-Rings , ISO/R 380-1964, International Organization for Standardization

,

(December 1964).

339 . ISO Recommendation R381, Gymnastic Equipment-Vaulting Horse

and Pommelled Horse , ISO/R 381-1964, International

Organization for Standardization, (December 1964).

340. ISO Recommendation R382, Gymnastic Equipment-Balancing Beam , ISO/R 382^1964, International Organization for

Standardization, (December, 1964).

341. ISO Recommendation R1511 Protective Helmets for Road Users , ISO/R 1511-1970, International Organization for

Standardization, 1970.

342 . Japanese Industrial Standard: Protective Helmets for

Vehicular Users , JIST 8133-1970, Japanese Standards

Association,- 1970.

343. Military Specification-Binding, Ski, All Terrain , MIL-B43504A, U.S. Government Printing Office (February 21, 1972).

344. Military Specification-Ski, Military, All-Terrain , MIL-S43190B, U. S. Government Printing Office, (December 17,

1974) .

345. "Motorcycle Helmets, Federal Motor Vehicle Safety Standard

FMVSS No. 218 National Highway Traffic Safety Administration,"

Federal Register (August 20, 1973) p. 22390.

346. Specifications for Protective Headgear for Vehicular Users , ANZI Z90. 1-1971, American National Standards Institute, Inc.,

New York (1971) .

347. Standard Consumer Safety Specification for Components, Assembly , and Use of a Trampoline, ASTM: F 381-74, American Society

for Testing and Materials, Philddelphia (1974).

348

.

Standard Method of Impact Test and Performance Requirements

For Football Helmets , National Operating Committee on

Standards for Athletic Equipment, September 1973.

349. Standard Method of Test for Shock Attenuation Characteristic s of Protective Headgear for Football , ASTM F429-75,

American Society for Testing and Materials, Philadelphia (1975)

- 96 -
Standards and Specif ications/Books

350

Standard Method of Test for Shock Absorbing Properties of

Playing Surface Systems, ASTM F355-72 , American Society

for Testing and Materials, Philadelphia (1972).

Books

351. Baitsch, H., The Scientific View of Sport (New York: SpringerVerlag Berlin Heidelberg, 1972).

352. Bleustein, J., Mechanics and Sport (New York: The American

Society of Mechanical Engineers) AMD- Vol. 4.

353. Boone, W. T., Illustrated Handbook of Gymnastics Tumbling

and Trampolining (New York: Parker Publishing Co., Inc.,

1976) .

354. Brown, B., Complete Guide to Prevention and Treatment of

Athletic Injuries (New Jersey: Prentice-Hall, 1972).

355. Craig, T. T., Current Sports Medicine Issues (Ohio:

Proceedings of the National Sports Safety Congress,

February 15-17, 1973).

356. Dolan, J. P. and Holliday, L. J., Treatment and Prevention

of Athletic Injuries (Danville: Interstate Printers and

Publishers, Inc., 1976).

357. Grupe, 0.; Kurz, D.; and Teipel, J. M. , Sport in the Modern

World-Chances and Problems (Berlin: Springer-Verlag , 1973).

358. Hay, J. G. , The Biomechanics of Sports Techniques (New Jersey:

Prentice-Hall, Inc., 1973).

359. Komi, P. V. , Biomechanics V-A , Proceedings of the Fifth

International Congress of Biomechanics (Finland: University

Park Press, 1976).

360. Komi, P. V. , Biomechanics V-B , Proceedings of the Fifth

International Congress of Biomechanics (Finland: University

Park Press, 1976).

361. Encyclopedia of Sport Sciences and Medicine , ed. Leonard

A. Larson, (New York: MacMillan Company, 1971).

362. MacMahon, B.; Pugh, T. F.; and Ipsen, J., Epidemiologic

Methods (Boston: Little, Brown and Co., 1960).

363. Miller, D. I. and Nelson, R. C., Biomechanics of Sport

(Philadelphia: Lea and Febiger, 1973).

364. O'Donoghue, D. H., Treatment of Injuries to Athletes

(Philadelphia: W. B. Saunders, Co., 1962).

- 97 -
Books

365. Singer, R. N . , Coaching, Athletics, and Psychology (New York:

McGraw-Hill, 197 2) .

366. Taylor, A. W. , ed .

,

Application of Science and Medicine to

Sport (Illinois: Charles C. Thomas, publisher, 1975).

367. Taylor, A. W. , ed., The Scientific Aspects of Sports Training

(Illinois: Charles C. Thomas, Publisher, 1975).

368. Yost, C. P., ed.

,

Sports Safety (Prepared under Contract

PH 86-67-260, Department of Health, Education, and Welfare).

369. Selected Problems in Sports Safety (Washington, D.C.: AAPHER

American Alliance for Health, Physical Education and

Recreation Publications, 1975)

.

370. Athletic Handbook (St. Louis, Missouri: Rawlings Sporting

Goods Company, 1974).

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NBS-1 14A (REV. 7-73)

U.S. DEPT. OF COMM. BIBLIOGRAPHIC DATA

SHEET

1. PUBLIC A 1 ION OR KEPOR 1 NO. 77-1218

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3. Recipient's Accession No.

4. I l l 11 AND SUBTITLE

RISKS ASSOCIATED WITH CERTAIN SPORTS ACTIVITIES

5. Publication Date

6. Performing Organization Code

7. A UTHOR(S)

William B. Beine

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Bureau of Engineering Sciences

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16. ABSTRAC T (A 200-word or less factual summary of most significant information. If document includes a significant

bibliography or literature survey, mention it here.)

This study provides the Consumer Product Safety Commission

with recommendations for assigning priorities to tasks associated with reducing the incidence and severity of sports related injuries. Recommendations were derived from an analysis of the published

literature and the NEISS data. They emphasize the need for

collecting additional data, improving surveillance capabilities, stimulating research, and developing and promulgating equipment

safety standards.

17. KEY WORDS (six to twelve entries; alphabetical order; capitalize only the first letter of the first key word unless a proper name; separated by semicolons

Accident; Associated factors; Injuries; Literature; NEISS; Recommendati Review; Sports; Safety.

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