Participation in any sport or recreational activity may result in a catastrophic
sports injury, particularly if unsupervised or if engaged with little or no protection. Direct fatalities in sport are rare, as most sport fatalities are indirect and associated with non-sport cardiovascular problems. In the United States,
American football has the greatest incidence of catastrophic injury per population, whereas
cheerleading is associated with the greatest incidence of direct catastrophic injury at both the interscholastic and intercollegiate levels. Cervical spine trauma is most common in sports and activities involving contact and collision, particularly American football,
rugby,
ice hockey,
gymnastics,
skiing,
wrestling, and
diving. A 2005 report by the National Center for Catastrophic Sport Injury Research in the United States stated that sports requiring attention for potential catastrophic injuries are American football, ice hockey,
baseball, wrestling, gymnastics, and
track and field. The incidence of catastrophic injury is four times higher in college than in high school in the United States. Sport accounts for between 5% and 10% of all cervical spine and
spinal cord injuries in the United States, and 15% in Australia. The incidence of catastrophic injury for all sports is low, less than 0.5 per 100,000 participants. A study in the
province of
Ontario in
Canada based on
epidemiological data from 1986, 1989, 1992, and 1995 states that the greatest incidence of catastrophic injuries occurred in
snowmobiling,
cycling, ice hockey, and
skiing. Of the 2,154 reported catastrophic injuries, 1,756 were sustained by males and 368 by females. The only activity in the study in which female casualties outnumbered males was
equestrianism. The study also stated that
field and floor sports had a relatively low incidence of catastrophic injury, and that July had the highest incidence of injury.
Drowning was the cause of 357 fatalities, and there were 640 head and 433 spine injuries. The study found 79.2% of the injuries were preventable; from over 1,500 responses, 346 involved
alcohol consumption, and 1,236 were not supervised. Most alcohol-related injuries were sustained in snowmobiling (124),
fishing (41), diving (40), boating excluding canoeing (31), swimming (31), riding an
all-terrain vehicle (24), and cycling (23). Other studies have concluded that alcohol consumption is a common
risk factor "associated with all types of exposure" (that is, activities) for
traumatic brain injury.
Classification of sports by contact The
American Academy of Pediatrics has classified sports based on the likelihood of collision and contact. It recommends against participation in
boxing. Those classified as
contact and collision sports include
basketball, boxing, diving,
field hockey, football, ice hockey,
lacrosse,
martial arts,
rodeo, rugby,
ski jumping,
soccer,
team handball,
water polo, and wrestling. Those classified as
limited contact include baseball,
bicycling, cheerleading, whitewater
canoeing and
kayaking,
fencing,
floor hockey,
flag football, gymnastics,
handball,
horseback riding,
racquetball, skating (
ice skating,
inline skating,
roller skating),
skiing (
cross-country skiing,
downhill skiing,
water skiing),
skateboarding,
snowboarding,
softball,
squash,
ultimate frisbee,
volleyball, and
windsurfing or
surfing, and the track and field events
high jump and
pole vaulting. Sports classified as
non-contact include
archery,
badminton,
body building,
bowling, flatwater
canoeing and
kayaking,
curling,
dancing,
golf,
orienteering,
power lifting,
race walking,
riflery,
rope jumping,
rowing,
running,
sailing,
scuba diving,
swimming,
table tennis,
tennis,
weightlifting and
weight training, the track and field events
discus,
javelin, and
shot put and all track events.
American football From 1945 to 2005, there were 497 fatalities, of which 69% were a result of brain injury and 16% from spinal cord injury. Today, the most common catastrophic injury in American football is cervical spinal cord injury, which is also the "second leading cause of death attributable to football". The 84% reduction in head injuries and 74% reduction in fatalities is directly attributable to the implementation of
NOCSAE standards for
football helmets and rule changes for tackling. Football has the highest incidence of cervical spinal cord injuries in the United States per population. From 1977 to 2001, the incidence of cervical spinal cord injury amongst high school, college, and professional participants was 0.52, 1.55, and 14 per 100,000 participants, respectively. From 1982 to 1988, 75% of direct fatalities and 40% of indirect fatalities in college sports were associated with football; for high school athletes, the rates were 75% and 33%, respectively. Indirect fatalities were usually caused by
cardiac failure or heat exhaustion. Indirect fatalities in high school and college football have been attributed to
heat stroke, heart-related conditions,
viral meningitis, and even
lightning strikes. The most common mechanism for catastrophic cervical spinal cord injury in American football is axial loading or compression resultant from
spear tackling, in which a player uses the crown of the helmet as the initial point of contact for striking another player. This form of tackling was banned in 1976 for high school and college football, resulting in a significant reduction in catastrophic injuries of this type. For example, incidence of
quadriplegia decreased from 2.24 and 10.66 per 100,000 participants in high school and college football in 1976, to 1.30 and 2.66 per 100,000 participants in 1977. Since 1977, about 67% of all catastrophic injuries in football were the result of a player making a tackle. In the paper
Catastrophic Football Injuries: 1977-1998 published in 2000 by the journal
Neurosurgery, Robert Cantu and Frederick Mueller recommend that "players should use the shoulder for blocking and tackling" instead of "using the head as a battering ram". The purpose of rules against spearing, ramming, and butting is to protect both the tackler and the opponent from head trauma or catastrophic injury. Mueller also suggests that coaches remove players from a game if they exhibit symptoms of
concussion, such as dizziness, headaches, nausea, or sensitivity to light.
Baseball Baseball has a high incidence of catastrophic injury, the most common being cranial injuries usually sustained during a collision between a
baserunner diving head first and a fielder, resulting in an axial compression injury to the baserunner. Other causes included collisions, such as between a
catcher and baserunner, or being struck by a pitched, thrown, or batted ball.
Canoeing In a 2008 study, all catastrophic injuries recorded for recreational
canoeing were fatal, and accounted for 4.3% of all sport and recreation fatalities in the province. Of the 27 cases, 24 fatalities resulted from drowning, and the others from cerebral contusions, cerebral lacerations, and skull fractures. Canoeing drowning fatalities are "often correlated with alcohol consumption", as it increases the probability of submersion and decreases the probability of recovery from submersion. They are often associated with young males inexperienced in canoeing.
Cheerleading The primary cause of increased incidence of catastrophic injuries to cheerleaders is the "evolution of cheerleading to a gymnastic-like activity". It is the leading cause of catastrophic injuries to females, representing over 65% of the catastrophic injuries occurring in high school and college female athletes in the United States. High-risk activities include the construction of pyramids, which result in several catastrophic injuries each year, the 'basket toss', and tumbling, all of which are usually performed over hard surfaces. Cheerleader pyramids are banned in
Minnesota and
North Dakota. Other causes include inadequate supervision, poorly trained coaches, and the equipment used.
Fishing In the Ontario study, fishing resulted in 126 catastrophic injuries, of which 117 were fatal, 110 from drowning. Of these, 119 events were associated with males, of which 112 were fatalities. Fishing had the highest rate of catastrophic injuries to all injuries for any activity in Ontario, as 2.54% of all fishing injuries were catastrophic. Catastrophic injuries in fishing may be related to equipment, fish, alcohol, or the environment. Equipment issues generally involve penetrative injuries from the use of
hooks and
harpoons, but may also be caused by the
fishing rod,
lure,
sinker, or
bait. Fish-related injuries result from mishandling, poisoning, and contamination from consumption. Environmental causes may include
overexposure to solar radiation, lightning strikes,
hypothermia during
ice fishing,
snakebites, and viral
infection spread by
mosquitoes.
Gymnastics Gymnastics has a relatively low incidence of catastrophic injury, that is the number of catastrophic injuries with respect to the number of participants. In the United States from 1982 to 2007, nineteen catastrophic injuries were reported from 147 million high school and 8 million college participants. Club-level injury surveillance data in Australia indicate no catastrophic injury to elite participants from 1983 to 1993. Elite gymnast catastrophic injuries to the spinal cord have been recorded in China, Japan, and the United States, the most notable being to
Sang Lan and
Julissa Gomez. There is an "absence of research reporting rate data" for catastrophic injury to club-level gymnasts in the United States.
Ice hockey The most common catastrophic injury occurring in
ice hockey is cervical spinal cord injury, which most often occur at
C5,
C6, or
C7. The most common cause is
checking from behind, resulting in a player falling headfirst into the glass or boards. Such checking was banned from hockey in 1985, which has resulted in a decreased incidence of catastrophic spinal injuries and a reduction of head and neck injuries. Increased standards for
hockey helmets and the requirement that they be worn in competitive play has resulted in a decrease of serious head injury and fatalities. Although full facial protection (helmet with cage) did not reduce the incidence of catastrophic injuries or concussion compared to a standard helmet, it reduced the incidence of facial injuries and lacerations.
Porting Porters who carry loads on their heads are subjected to axial strains that exacerbate degenerative change in the cervical spine, and has an
etiological role in
spondylosis. In a 1968 study, Laurence Levy recorded six catastrophic injuries to porters at Harare Central Hospital in
Harare,
Zimbabwe. Of these, one died instantaneously, and five became quadriplegic, one as a result of a herniated intervertebral disc and four from fractures or fracture-dislocations.
Rugby For
rugby union, the incidence of catastrophic injury from 1952 to 2005 in England was 0.84 per 100,000 per year. In all other countries, from 1970 to 2007 the incidence was 4.6 per 100,000 per year. For
rugby league, it was 2 per 100,000 per year. In
rugby union in France, the incidence of catastrophic cervical spine injuries decreased from 2.1 per 100,000 in the 1996–1997 season to 1.4 per 100,000 in the 2005–2006 season, which has been attributed to rule changes regarding the
scrum. The most common causes are the
scrum, the
ruck or
maul, and the
tackle. Research from Australia states that injury prevention in youth rugby should focus on the scrum and the tackle, and that risk factors are level of play (age group) and
player position. It also indicated that "neck injuries in the scrum and to the front row are of great concern". The use of a
scrum cap or other padded headgear does not reduce the incidence of concussion or other head or neck trauma.
Skiing and snowboarding In a survey of scientific literature from 1990 to 2004, 24 studies covering 10 countries indicated an increasing incidence of traumatic brain injury (TBI) and spinal cord injury amongst
alpine skiers and
snowboarders. The most common cause of death is head injuries, which can be mitigated by 22–60% by the use of
helmets. The increased incidence coincides "with the development and acceptance of acrobatic and high-speed activities". Most deaths are attributed to massive head, neck, or thoracoabdominal injury, of which TBI accounted for between 50% and 88% and spinal cord injury between 1% and 13%. Ski fatalities occur between 0.050 and 0.196 per 100,000 participants. Head injuries represent 28.0% of all injuries in skiers and 33.5% for snowboarders.
Snowmobiling In the Ontario study, snowmobiling had the highest incidence and prevalence of recreational catastrophic injuries of any activity (290 incidents, 120 fatalities). It had the second-highest incidence of catastrophic injury per participant (88.2 per 100,000), the greatest incidence per 100,000 population (0.706), and the greatest incidence of fatality per 100,000 population (0.292). It was also the activity in which alcohol consumption was most prevalent in catastrophic events (124), representing more than one third of all events for which alcohol was a factor. Other contributing factors include "poor lighting, young age and inappropriate terrain".
Track and field The majority of
track and field-related fatalities in the United States is associated with
pole vaulting. Other fatalities and catastrophic injuries in track and field occur by a participant or bystander being struck by a discus, shot put, or javelin.
Water sports Most catastrophic injuries related to diving and swimming in the United States occur when an individual dives into shallow water. It is the cause of 2.6% of all cervical spine injury admissions, and are chiefly sustained by recreational divers. The most common cause is diving into shallow water, inexperience, inadequate supervision, and alcohol consumption. Catastrophic swimming injuries in the Ontario study were four times as prevalent in males than females. The incidence of catastrophic injury in
competitive swimming is very low, and almost all such injuries occur in recreational and non-competitive swimming.
Wrestling From 1981 until 1999 in the United States, 35 catastrophic injuries related to wrestling were reported, one in college and the others in high school, an incidence of 1 per 100,000 per year. They were caused by three positions: defensive position during takedown (74%), down position (23%), and lying position (3%). Most occurred in the lower
weight classes, and 80% were incurred during a match. In
Iran from 1998 to 2005, the incidence of catastrophic injury was 1.99 per 100,000 participants per year. Most injuries were cervical fracture or major cervical ligament injuries. One of the athletes died, one third became
tetraplegic, one
paraplegic, and six others had residual neurologic deficits. Catastrophic wrestling injuries are preventable, and associated risk factors include incorrectly performing a manoeuvre, lack of supervision by the coach, and inappropriate injury management.
Other activities In the United Kingdom, the incidence of catastrophic injury per year for work-related situations is 0.9 per 100,000. The incidence is highest in agriculture (6.0 per 100,000) and construction (6.0 per 100,000), and lowest in the service sector (0.4). The incidence is 3.7 per 100,000 for pedestrians, 2.9 per 100,000 for automobile occupants, and 190 per 100,000 for motorcyclists. Vehicular accidents account for 43% of catastrophic spinal injury in the United States and 45% in Australia. In the Ontario study, recreational catastrophic injuries were most prevalent in snowmobiling (290 incidents, 120 fatalities), bicycling (289 incidents, 67 fatalities), fishing (126 incidents, 117 fatalities), boating (excluding canoeing, 112 incidents, 72 fatalities), diving (105 incidents, 5 fatalities) and swimming (100 incidents, 86 fatalities). The greatest incidence per participant was recorded for diving (511.0 per 100,000), snowmobiling (88.2 per 100,000),
parachuting (62.9 per 100,000),
tobogganing or sledding ( 37.7 per 100,000),
hang gliding (29.4 per 100,000),
water polo (24.5 per 100,000), scuba diving (12.2 per 100,000),
hunting (12.2 per 100,000),
horseback riding (11.6 per 100,000),
archery (11.1 per 100,000), and fishing (11.0 per 100,000). The greatest incidence per 100,000 population were recorded for snowmobiling (0.706), cycling (0.701), ice hockey (0.462), fishing (0.307), boating excluding canoeing (0.273), diving (0.256), swimming (0.243) and baseball (0.217). The greatest incidence of fatality per 100,000 population were recorded for snowmobiling (0.292), fishing (0.285), swimming (0.200), boating excluding canoeing (0.175), cycling (0.163), canoeing (0.066), riding an all-terrain vehicle (0.039), hunting (0.037), and horseback riding (0.024). Catastrophic cycling injuries were most prevalent in cities, particularly
Toronto (64),
Ottawa (21), and
London (7). Drowning represented more than half of sport and recreation fatalities in the Ontario study. In the United States, the
Consumer Product Safety Commission (CPSC) recorded nearly 1,000 fatalities between 1967 and 1987 as a result of riding an all-terrain vehicle, more than half of which were individuals less than 16 years old. This led to a filing of an action per the
Consumer Product Safety Act in 1987, which effectively ended the sale of three-wheeled ATVs. Since then, 35% of deaths were individuals less than 16 years old. The
American Academy of Pediatrics and CPSC recommend that individuals less than 16 years old should not ride ATVs. ==Effects and management==