Sports-related eye injuries: floorball endangers the eyes of young players

The objectives of this study were to determine the distribution of different sports-related eye injuries and to identify injury types to enable recommendations to be made about the use of protective eyewear. The study population comprises all 565 eye trauma patients examined at the Ophthalmology Emergency Clinic of the Helsinki University Central Hospital over a 6-month period. Data were collected from patient histories and questionnaires. In addition, three severe floorball eye injury cases are presented. Of the 565 eye traumas, 94 (17%) were sports related. Of these, 42 (45%) were associated with floorball. Countrywide, in Finland, estimated over 300 (+95% CI 228-415) floorball eye injuries occur annually. The mean age of floorball patients was 22 years. The most common finding (55%) in sports injury patients was hyphema. Clinically severe eye injuries during this period accounted for one-fourth of all cases. During the study period, no eye injury was found in an organized junior ice hockey, where facial protection is mandatory. Floorball is estimated to belong to the highest risk group in sports, and thus, the use of protective eyewear is strongly recommended. We conclude that national floorball federations should make protective eyewear mandatory.     

Sports injuries in women: a one-year prospective follow-up study at an outpatient sports clinic.

A one-year prospective follow-up study of all patients visiting Tampere Research Station of Sports Medicine (TRSSM) was carried out in order to determine the specific features of women's sports injuries compared to those of men. During this period 334 women (31%) and 745 men (69%) visited the station. Women were significantly younger than men and the ten most usual sports events causing the injury differed from those of men. In women acute dislocations, contusions, and fractures were significantly less common in men, while women had more frequent stress-related sports injuries. In both sexes the most common sites of trouble were knee, ankle, and lower back, but in women as opposed to men, the metatarsal area, the toes, and the sole were among the ten most usual sites of the injury. Fourteen women (4%) and 49 men (6%) required operative treatment of the injury. The knee was the most common site of operation in both sexes, in women significantly more frequently than in men.     

Epidemiology and risk factors of sports injuries--multivariate analyses using German national data

Representative data on the incidence of sports injuries and the risk groups involved is extremely rare. The data generated by the "First National Health Survey for the Federal Republic of Germany", conducted between October 1997 and March 1999, included information on the incidence of sports injuries requiring medical care and the associated sick leave, fitness indicators, and potential risk factors. The data was collected on the basis of a standardised cross-sectional questionnaire. The net sample comprised 6687 subjects aged 18 to 79. 3.1 % of adult Germans sustained a sports-related injury within the foregoing year. The annual incidence of injury among those actively engaging in sports is 5.6 %. 62 % of all sports injuries result in sick leave. The period off work was longer than 30 days in only one out of five cases. Three out of four injured recreational athletes are male. The incidence declines significantly in the more senior population. These differences apply even if the specific sporting profile is factored in. Analysis of incidence rates on their own is misleading for some population groups. For instance, although individuals of normal weight and a good fitness display more than twice the average incidence of sports injuries, our study shows that these figures do not reflect the actual risk of injury, as bivariate calculation of incidence does not take account of the specific extent of sporting activity. When specific participation rates and the intensity of training are taken into account, no significant differences in the risk of injury are apparent. Our representative data also shows that future injury prevention strategies should focus on the highest risk group of young male recreational athletes.     

Impact of social standing on sports injury prevention in a WHO safe community: intervention outcome by household employment contract and type of sport

Objectives: As physical activity is promoted as part of a healthy lifestyle, sports injuries are becoming an important public health concern in many countries. The objective of this study is to investigate rates of sports injuries before and after implementation of a WHO Safe Community program.

Methods: Sports injury data were collected pre- and post-implementation from all individuals below 65 years of age during 1 year in the targeted municipality (population 41 000) and in a control municipality (population 26 000). A quasi-experimental design was used and individuals were divided into three categories based on household relationship to the labour market.

Results: There were no differences between socio-economic categories regarding pre-intervention injury rates. No statistically significant post-intervention changes in injury rate were observed in the control area or among any females in either area. In the intervention area, a statistically significant (p = 0.011) decrease in injury rate was observed among male members of households in which the vocationally important member was employed. A statistically significant decrease was observed in injuries sustained in team sports among male members of households in which the vocationally important member was employed (p = 0.001) and among members of households in which the vocationally important member was self employed (p<0.05).

Conclusions: The study indicates areas for improvement in the civic network based WHO Safe Community model. The results show that females, participants in individual sports, and members of non-vocationally active households were less affected by the interventions. These facts have to be addressed in planning future community based sports injury prevention programmes and their evaluations.

     

Sports related injuries in Scottish adolescents aged 11-15

OBJECTIVES: To measure the age and sex distribution of self reported sports and leisure injuries in a 12 month retrospective recall period among a representative national sample of Scottish adolescents, and to examine the characteristics (gender, age, handedness, and level of sports participation) of sports related injuries in relation to injuries sustained during other activities. DESIGN/SETTING: Self completion questionnaire survey administered in schools during April- June 1994. SUBJECTS: 4710 pupils aged 11, 13, and 15 years drawn from a representative sample of 270 classes with returns from 224 classes (83% completion rate). RESULTS: 42.1% of the sample reported a medically attended injury. These were significantly more frequent among boys but there were no significant age differences in overall frequency of injury. Sport related injuries accounted for 32.2% of all medically attended injuries. As with all injuries, frequency was greater in boys than girls at all ages, and there are differences in the pattern of lesions in sports and nonsports injuries. Lower limb injuries were more frequent than upper limb injury in sports (57.6 v 23.9%), whereas there were no differences in non-sports injuries (31.5 v 31.3%). Age and handedness differences in sports injury rates were also identified. High sports participation was significantly associated with a higher risk of injury in general and sports related injury in particular. CONCLUSION: Age, gender, handedness, and level of sports participation have been shown to be implicated in differential risk of sports related injury. Reducing sports injury among adolescents should be a priority, but research into the injury profiles of different sports is needed before detailed injury prevention strategies can be developed.     

Trends in sports injuries, 1982-1988: an in-depth study on four types of sport.

In this study, we analyzed the records of both inpatients and outpatients which were treated for acute sports injuries in the Trauma Department of the University of Groningen (The Netherlands) during the years 1982 to 1988. We examined whether there was a trend in sports injuries in this time period. The study comprised four types of sports, i.e., soccer, volleyball, gymnastics, and martial arts. The absolutely highest rates of injuries across the seven years were found in soccer, followed by gymnastics, volleyball, and martial arts. Injuries sustained at participating in soccer, volleyball, and gymnastics involved for the major part the lower extremities, followed by injuries of the upper extremities, whereas the reverse pattern was observed for patients who participated in martial arts. For all four types of sport, the ankle and foot were the most frequently site of injury of the lower extremities. Sprains and strains were the major types of injury. Most injuries were seen at ages between 10 and 30 years. The ratio of male to female patients within age groups did not differ significantly across the seven years. We concluded that, except for martial arts, the increased participation in sports in the last decade was not accompanied with a change in the patterns of sports injuries by the patients' age, sex, and number and nature of the injury. This consistency in results can be used to guide the development of prevention programs aimed at a reduction of injuries in specific sports.     

Helmets,head injury and concussion in sport

Research on the mechanism of concussion in recent years has been focused on the mechanism of injury as well as strategies to minimize or reverse injury. Sports-related head injury research has led to the development of head protective gear that has evolved over the years. Headgears have been designed to protect athletes from skull fractures, subdural hemorrhages and concussions. Over the years, through experience of athletes and continued scientific research, improvements in helmet design have been made. Although these advances have decreased the number of catastrophic injuries throughout sports, the effects on concussions are promising, but largely unproven. In this review, we will discuss development of helmets and studies analyzing their level of protection for both concussion and head injury. This will help us understand what future developments are still needed to minimize the risk of concussion among athletes in various forms of sports.     

Trend in sports injuries among young people in Finland

The main purpose of this study was to explore how the number of home, sports, and other leisure time injuries among young people aged 15 - 25 years has developed in Finland in 1988 - 2003. In 1988, 2559 people aged 15 - 25 years were interviewed by Statistics Finland. In 1993, 1997 and 2003 those amounts were 751, 1638 and 1382. The subjects were asked in a telephone interview to report the injuries in which they had been involved during the previous 12 months. The crude injury incidence in 2003 was 364 per 1000 person years in men and 246 in women. The total number of injuries increased 49 % between the years 1988 and 2003. The number of sports injuries increased the most. The increase was greater among men than women, and the injury rate was higher among both men and women aged 15 - 19 years than those aged 20 - 25 years. More research is needed on whether and how exercise and time at home have changed and become riskier among young people. It is also essential to find out which prevention methods are the most effective among young people and implement these measures in a well-planned and targeted manner.     

Non-fatal sports and recreational violent injuries among children and teenagers, United States, 2001–2003

BACKGROUND: An estimated 2.7 million non-fatal unintentional sports and recreational injuries are treated in U.S. hospital emergency departments (EDs) annually. However, little is known about the number of sports and recreational injuries resulting from violent behavior. METHODS: Data for 2001-2003 on sports and recreational injuries were obtained from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP)-a national sample of 66 U.S. EDs. National estimates and rates of persons treated for violence-related sports and recreational injuries in EDs are compared to those treated for unintentional sports and recreational injuries. Types of injuries and injury circumstances are described. RESULTS: During the study period, an estimated 6,705 (8.3 per 100,000; 95% confidence intervals (CI), 6.3-10.3) children and teenagers with violence-related sports and recreational injuries were treated in U.S. EDs annually, compared to 2,698,634 children and teenagers with unintentional sports and recreational injuries. Thus, violent behavior accounted for 0.25% of sports and recreational injuries. The highest incidence rate (13.6 per 100,000) for violence-related sports and recreational injuries was for children aged 10-14 years. Most patients with violence-related sports and recreational injuries were treated and released from the ED. A majority of those with violence-related sports and recreational injuries were injured to the head/neck region (52.2%), of which 24.1% were treated for traumatic brain injuries. Most violent injuries resulted from being pushed or hit (65.6%); the most common sports and recreational activity varied by age: playground (65.2%) for children < or =9 years; bicycling (26.7%) for 10-14-year-olds; basketball (45.3%) for 15-19-year-olds. CONCLUSIONS: National ED surveillance systems can provide useful information pertaining to prevention programs designed to reduce sports and recreational injuries resulting from violent behavior and unintentional causes.     

The incidence of injury in Texas high school basketball. A prospective study among male and female athletes.

Recent publications have reported differences in the incidence, rate, risk, and type of sports injury among men and women. We undertook a prospective study to determine the incidence of injury among high school basketball players and to examine the differences in injury type, incidence, rate, and risk between male and female athletes. During a single basketball season, an injury survey of girls' varsity teams at 100 class 4A and 5A high schools in Texas was conducted. These data were previously reported. We surveyed the same 100 high schools during a subsequent season to gather injury data from the boys' varsity teams. The athletic trainer collected data on each reportable injury and reported the data weekly to the University Interscholastic League. A reportable injury was defined as one that occurred during a practice or a game, resulted in missed practice or game time, required physician consultation, or involved the head or the face. The boys' and girls' data were compared and statistically analyzed. The rate of injury was 0.56 among the boys and 0.49 among the girls. The risk of injury per hour of exposure was not significantly different between the two groups. In both groups, the most common injuries were sprains, and the most commonly injured area was the ankle, followed by the knee. Female athletes had a significantly higher rate of knee injuries including a 3.79 times greater risk of anterior cruciate ligament injuries. For both sexes, the risk of injury during a game was significantly higher than during practice.     

Injuries treated at a sports injury clinic compared with a neighbouring accident and emergency department.

Previous reports relating to sports injuries treated at hospital Accident and Emergency departments (A&E) or Sports Injury Clinics (SIC) indicate differences between the groups. This study compared directly the sports injuries treated during overlapping time periods at an A&E department (n = 2490) and a SIC (n = 340) set within the same geographical area. The two populations were found to differ significantly in age, sport, injury and injury site. Hospital patients tended to be younger, with an acute injury to the upper body or head which occurred during participation in sports where contact is likely. SIC patients tended to be older, with chronic or overuse injuries to the back or lower limb. It was found that there are significant differences between the sports injuries treated at the sports injury clinic and the hospital casualty department. It is concluded that demand is clearly shown for both types of treatment site when both are available in the same geographical area.     

Likelihood of knee replacement surgery up to 15 years after sports injury: A population-level data linkage study

ObjectivesKnee injury is strongly associated with the development of knee osteoarthritis. While there is preliminary evidence for an increased risk of knee replacement (KR) surgery after sports injury, no studies have investigated this at a population level. This population-level study aimed to quantify the likelihood of KR surgery and direct healthcare costs 10–15 years after sports injury.DesignStatewide population-based cohort study.MethodsThe cohort was established by linking two key administrative datasets capturing all hospital admissions and emergency department (ED) presentations in Victoria, Australia. Sports injury presentations from 2000–2005 and KR admissions from 2000–2015 were identified using ICD-10-AM codes. A Cox proportional hazards model estimated likelihood of KR using time to surgery admission data, adjusting for potential confounders. KR costs for the sports-injured cohort were estimated from the health system perspective using diagnosis codes and national hospital cost weights.ResultsOver the study period there were 64,038 sports injuries (including 7205 knee injuries) resulting in ED presentation or hospitalisation, and 326 KR procedures. Multivariate analysis showed that having a knee injury more than doubled the hazard of subsequent KR (hazard ratio 2.41, 95%CI 1.73–3.37), compared to all other sports injuries. Direct healthcare costs for KR totaled $AUD7.93 million for the cohort, with 21% of costs attributable to the knee injury group.ConclusionsSports-related knee injury manifests in a significantly greater likelihood of KR, at considerable cost to society. Targeted health policy and effective interventions are needed to prevent sports-related knee injuries and contain this substantial burden.     

The Harstad injury prevention study: the epidemiology of sports injuries. An 8 year study.

OBJECTIVE--To describe the epidemiology of sports injuries occurring in a community during 8 years and to evaluate the outcome of an intervention implemented against injuries occurring in downhill skiing. METHODS--Hospital treated sports injuries occurring in Harstad, Norway (population 22 600) were recorded prospectively during an 8 year period. A prevention programme targeting downhill skiing injuries was evaluated. RESULTS--2234 sports injuries accounted for 17.2% of recorded unintentional injuries. Two out of three injuries occurred in team sports. Soccer accounted for 44.8% of all sports injuries. Downhill skiing injuries had higher mean score on the abbreviated injury scale than all other sports analysed combined (P < 0.01). Postintervention injury rates for downhill skiing were reduced by 15% when adjusting for exposure (P = 0.24). Further observations are needed for assessing the effectiveness of the downhill skiing safety programme. CONCLUSIONS--Strategies for future sports injury prevention include community involvement, particularly sports organisations. Local data analysis seems to justify some priorities, for example, promotion of helmet use in downhill skiing for young adolescents and prevention of lower limb fractures in male soccer players 15+ years old. Prospective hospital recording of injuries provides a tool for the design and outcome evaluation of sports injury intervention research.     

Badminton injuries.

In a one year period, from 1 January 1986 to 31 December 1986, 4303 patients with sports injuries were treated at Aarhus Amtssygehus and Aarhus Kommunehospital. The mean age was 21.6 years (range 7-72 years) and 2830 were men. Two hundred and seventeen badminton injuries occurred in 208 patients (136 men) with a mean age of 29.6 years (range 7-57 years), constituting 4.1 percent of all sport injuries in Aarhus. Joints and ligaments were injured in 58.5 percent of the patients, most frequently located in the lower limb and significantly more often among patients younger than 30 years of age. Muscle injury occurred in 19.8 percent of the patients. This type of injury was significantly more frequent among patients older than 30 years of age. Most injuries were minor. However, 6.8 percent of the patients were hospitalized and 30.9 percent received additional treatment by a physician. As the risk of injury varies with age, attempts to plan training individually and to institute prophylactic measures should be made.     

Injuries presenting to Army physiotherapy in north Queensland, Australia

OBJECTIVE: To analyze archival physiotherapy records at a major military base in North Queensland, Australia, to investigate the epidemiology of injuries associated with sports and training, examining for possible risk factors for military training injury. METHODS: A retrospective study was undertaken during a 62-month period, from 1987 to 1992, at Lavarack Barracks, Townsville, Australia, which services a dynamic population base of some 5,000 uniformed staff. Sociodemographic basic data, as well as treatment-related data (treatment area, number and type, interval between onset and initial treatment, reported cause), were used. Admission records were recoded according to the Orchard Sports Injury Classification System (version 2.0) standard. RESULTS: During the 62-month period from 1987 to 1992, 4,993 personnel, 96.2% (4,803/4,993) males and 3.7% (190/4,993) females, were referred for 5,025 physiotherapy treatments. The incidence of injuries requiring physiotherapy was 80.4 new patients per 5,000 personnel per month, and the incidence rate of injury was 19.3% per year or 0.19 injuries per person per year. The mean age of patients was 25.7 +/- 6.2 (SD) years, and the median age was 24 years, with a range of 17 to 59 years. Injuries were related to military training (29.3%, 1,471/5,025), diverse causes (21.2%, 1,072/5,025), sports (13.8%, 694/5,025), insidious onset (11.8%, 589/5,025), football (11.7%, 586/5,025), manual handling (4.2%, 211/5,025), motor vehicle crashes (4.1%, 206/5,025), and surgery (3.9%, 196/5,025). The four major body areas treated by physiotherapists were the knee joint (37.0%, 1,321/3,612), lumbar spine (29.8%, 1,075/3,612), ankle (19.9%, 719/3,612), and shoulder joints (13.8%, 497/3,612), which accounted for nearly three-quarters of all admissions. Of these, most were referred without definitive diagnosis (71.1%, 2,572/3,612), with the remainder comprising joint injuries (17.5%, 634/3,612), other types of pathology such as chest infections or neurological involvement, soft-tissue injuries (3.5%, 128/3,612), and bone damage (1.0%, 38/3,612). Most injuries (59.0%, 2,959/5,019) occurred during the 6 months between April and September referred to as the winter season, during which 71.8% of all football and 66.8% of all sports-related referrals were made. Significant associations were found between gender and injury cause (p < 0.001), gender and injury type (p < 0.01), body area affected and injury type (p < 0.00001), body area affected and injury cause (p < 0.00001), injury cause and injury type (p < 0.00001), and season and injury cause (p < 0.00001). Pretreatment interval was significantly associated with cause of injury (p < 0.00001), body area affected (p < 0.0001), and type of injury (p < 0.0001). Total number of consecutive treatments provided was significantly associated with both body area affected (p < 0.05) and injury type (p < 0.001). CONCLUSIONS: This study has used archival physiotherapy records for the purpose of exploring injury reporting patterns associated with a military population. The incidence profile for injuries using physiotherapy admissions is likely to be conservative because the patients are a group of injured military personnel selected by medical officers for physiotherapy treatment. This selection process needs further study, particularly because the majority of injuries referred for physiotherapy treatment are undiagnosed. This may be attributable in part to the cumulative and diverse nature of some injuries. Injury prevention needs to focus on activities relating to military training and football and other sports. Improved systems for recording detailed and accurate physiotherapy admission, treatment, and follow-up information are needed.     

Prevalence of injuries among young adults in sport centers: relation to the type and pattern of activity

The rate of injuries resulting from physical exercise in sport centers as well as related factors has not yet been described. The aims of this study were to describe the prevalence of self‐reported activity‐specific injuries, to identify the relations between injury profile and different types and patterns of physical activity and to assess whether gender is a modifying variable in that connection. Four hundred and fifty‐seven men and women aged 20–35 years participated in this cross‐sectional study. A questionnaire was used to evaluate the types and patterns of physical activity performed in the 12 months preceding the study and sports injuries sustained during that time. One hundred and ninety of the 457 subjects reported an injury as a result of exercising (41.6%). A relationship was found between weight training and injuries of the upper extremity (UE) for men and between spinning classes and knee injuries for women. Among those who participated in weight‐training exercises, more frequent and longer duration exercise was associated with UE injury, and among those who participated in spinning classes more frequent exercise was associated with knee injury. Future injury prevention programs in sport centers should pay special attention to men who participate in weight training and to women who participate in spinning classes.     

Pancreatic injury in the athlete

Pancreatic injuries in the athlete are seldom reported in the literature. These injuries can result from atraumatic etiologies and blunt abdominal trauma. Atraumatic pancreatic injuries in the athlete are diagnosed and treated in a similar manner to the nonathletic patient. Fluid replacement, analgesic support, metabolic stabilization, and minimization of gastric stimulation are the primary management methods for this type of pancreatic injury. Athletically related traumatic pancreatic injury is associated with a high morbidity and mortality. The consequences of a delayed diagnosis make this type of injury an important diagnostic consideration in an athlete with abdominal pain. Initial clinical, radiologic, and laboratory findings of direct injury to the pancreas are often equivocal, and require clinical suspicion and further investigation. Current evidence suggests that pancreatic duct injury is the primary cause of the morbidity and mortality associated with the direct trauma. A conservative or surgical management plan should be based on a combination of serial clinical examinations, pancreatic enzyme levels, and either magnetic resonance retrograde choleopancreatogram or endoscopic retrograde chloangiopancreatography investigations to rule out ductal injury. The prevention of pancreatic and other intra-abdominal injuries is an evolving area of sports medicine research. Sports specific epidemiologic data collection and analysis are important elements in the development of evidencebased interventions.     

Evidence based prevention of acute injuries during physical exercise in a WHO safe community

OBJECTIVE: To evaluate a community based programme for evidence based prevention of injuries during physical exercise. DESIGN: Quasi-experimental evaluation using an intervention population and a non-random control population. PARTICIPANTS: Study municipality (population 41,000) and control municipality (population 26,000) in Sweden. MAIN OUTCOME MEASURES: Morbidity rate for sports related injuries treated in the health care system; severity classification according to the abbreviated injury scale (AIS). RESULTS: The total morbidity rate for sports related injuries in the study area decreased by 14% from 21 to 18 injuries per 1,000 population years (odds ratio 0.87; 95% confidence interval (CI) 0.79 to 0.96). No tendency towards a decrease was observed in people over 40. The rate of moderately severe injury (AIS 2) decreased to almost half (odds ratio 0.58; 95% CI 0.50 to 0.68), whereas the rate of minor injuries (AIS 1) increased (odds ratio 1.22; 95% CI 1.06 to 1.40). The risk of severe injuries (AIS 3-6) remained constant. The rate of total sports injury in the control area did not change (odds ratio 0.93; 95% CI 0.81 to 1.07), and the trends in the study and control areas were not statistically significantly different. CONCLUSION: An evidence based prevention programme based on local safety rules and educational programmes can reduce the burden of injuries related to physical exercise in a community. Future studies need to look at adjusting the programme to benefit all age groups.     

Quantifying the risk of sports injury: a systematic review of activity-specific rates for children under 16 years of age

Injuries caused by sports and other forms of physical activity in young children constitute a significant public health burden. It is important to quantify this risk to ensure that the benefits of sport participation are not outweighed by the potential harms. This review summarises the literature reporting exposure-based injury rates for various forms of physical activity in children aged 15 years and younger. Forty eight studies were found, of which 27 reported injury rates per hourly based exposure measured and 21 reported injury rates according to some other measure. Fourteen different sports and activities were covered, mostly team ball sports, with soccer being the most widely studied. Injury definition and the method of ascertaining and measuring injuries differed between studies, which created a large variation in reported injury rates that did not necessarily represent actual differences in injury risk between activities. The highest hourly based injury rates were reported for ice hockey, and the lowest were for soccer, although the range of injury rates for both of these activities was wide. Very few studies have investigated sports-related injuries in children younger than 8 years or in unorganised sports situations.     

A new look at horse-related sport and recreational injury in New Zealand

Although equestrian injury studies to date have provided useful information for injury prevention, these studies have not been detailed enough or inclusive enough, to identify and characterise all sub-populations that may be at risk. One study has reported injury rates for the population-at-risk. The present study was carried out to determine, more precisely, who is injured in horse-related activities in New Zealand, what sorts of injuries they sustain, the circumstances of injury and the cost of treatment. A novel search of linked hospital discharge and compensation claim data for 2002 and 2003 was carried out. Of 716 newly hospitalised cases, 29% were in the 5–19-year and 28% in the 35–49-year age groups. Incidence rates for regular riders peaked at 13–15 years (900/100 000) and 50+ years (880/100 000). Where the ‘place of occurrence’ was specified only 12% of cases sustained injury in a ‘sports and athletics area’. This new study has highlighted injuries occurring in farm and other ‘open’ locations such as mountains and forest, injuries to older riders and injuries to bystanders/handlers during non-organised recreational activity. Attention was drawn to the high in-patient cost of hospitalised injuries in persons >40 years and the need for injury information relating to specific riding activities. Current equestrian injury prevention tends to target young females and organised riding; in focusing on these, other significant population groups and injury mechanisms may be overlooked and opportunities for injury prevention missed.