SPECIAL POPULATIONS

Injury Prevention in Youth Sports

Jake D. Veigel1 and Michael D. Pleacher2
1

University of Massachusetts Primary Care Sports Medicine Fellowship, Fitchburg, Massachusetts; and
University of New Mexico School of Medicine, Department of Pediatrics, Albuquerque, New Mexico

VEIGEL, J.D. and M.D. PLEACHER. Injury prevention in youth sports. Curr. Sports Med. Rep., Vol. 7, No. 6, pp. 348Y352,
2008. Sport is the principal cause of injury in children and adolescents. Youth participation in organized athletics is estimated to be
45 million in the United States alone. These injuries influence health and fitness and have socioeconomic impact. Many injuries can be
prevented. This article outlines the efficacy of current injury prevention strategies in youth sports through the use of educational programs,
rule changes in baseball and hockey, safety equipment, and conditioning programs.

INTRODUCTION

EDUCATIONAL PROGRAMS AND RULE CHANGES

With an estimated 45 million children and adolescents

involved in organized athletics in the United States, it is
not surprising that sport is the primary cause of injury in
young people (1,2). The majority of injuries are mild strains,
sprains, and contusions, with few severe enough to require
hospitalization. Despite the relatively low severity of these
injuries, they can have a significant impact. Injuries may
lead to reduced participation in sport and fitness activities,
thus contributing to the childhood obesity epidemic. Injury
also may disrupt potential benefits of sport, including
increased self-esteem, community involvement, and
increased fitness. Injury has direct costs from evaluation,
treatment, and rehabilitation, and indirect costs of parental
sick leave and lost productivity if parents miss work to tend
to an injured child.
Many youth sport-related injuries can be prevented.
Prevention strategies include educational programs, rule
changes, safety equipment, and preseason and in-season
conditioning programs. An excellent review discussing
youth sports injury prevention was published in Current
Sports Medicine Reports in 2003 (3). Since the publication of
that review, a number of new youth injury prevention
programs have been evaluated; this article reviews this
recent research.

Specific rules have been established to ensure the safety

of athletes. Spearing in American football, crosschecking in
ice hockey, and tackling from behind in soccer are examples
of activities limited by rules designed to protect athletes.
Another component of ensuring athlete safety is providing
proper sport fundamental instruction. Several educational
programs have been adopted by sport-governing bodies to
reinforce the importance of adhering to rules, to teach
proper fundamentals, and to reduce injury related to poor
technique.
Violation of existing rules appears to be a major risk
factor for injury. A recent study evaluated nine high school
sports to determine the number of sports-related injuries
sustained as a result of illegal activity. This study revealed
that 6.4% of overall injuries were related to rules transgressions. It was estimated that 98,066 injuries occur
nationally on an annual basis as the result of illegal activity.
By enforcing existing rules strictly, and by educating
athletes about the dangers of rules infractions, a high
percentage of injuries potentially could be prevented (4).
Ice hockey is a fast-paced sport with a high rate of injury.
A policy statement published in 2000 by the American
Academy of Pediatrics (AAP) called for the limitation of
body checking, the adoption of fair-play policies, and
educational programs emphasizing following the rules and
safe play (5). Several recent articles have looked at the
effect of implementing these injury prevention practices.
Body checking clearly exposes athletes to injury. Youth
leagues with younger participants typically restrict body
checking. A recent study examined checking related injuries,
confirming that leagues that allowed checking had a higher
injury rate than leagues where checking was not allowed.
Some hockey experts feel that teaching checking at earlier

Address for correspondence: Michael D. Pleacher, M.D., UNM School of Medicine,

Department of Pediatrics, MSC10 5590, 1 University of New Mexico, Albuquerque,
NM 87131-0001 (E-mail: pleacherm@hotmail.com).

1537-890X/0706/348Y352
Current Sports Medicine Reports
Copyright * 2008 by the American College of Sports Medicine

348

Copyright @ 2008 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

ages would allow for more time to perfect proper checking

technique, and therefore be protective against future injury.
However, this study found evidence to the contrary. Players
at the bantam level who had learned checking legally at
an earlier age had higher odds of sustaining an injury due
to checking than the bantam players who were not allowed
to check at age 10 and 11. The authors concluded that the
early acceptance of body checking raised the injury rate
substantially in younger and older athletes (6).
Some hockey governing bodies have adopted fair play
policies. Teams can earn standings points through victories
and ties, but additional standings points may be earned if
a team does not accumulate a large number of penalties.
Prior studies of fair play programs have shown a reduction
in numbers of penalties and injuries (7). The Fair-Play
Program (FPP) adopted by Hockey Quebec was recently
examined. In games played under the FPP rules, the number
of penalties was significantly lower than the number of
penalties in the games not played under the FPP. Despite
this disparity, there was no difference in the injury rate.
There was a statistically insignificant trend toward lower
injury severity in the FPP games, but the study was limited
by small sample size (8). Further study of the FPP used by
Hockey Quebec is warranted to determine whether these
rule changes reduce injury rates or severity.
USA Hockey and Hockey Canada have extensive educational programs regarding player safety and injury prevention. USA Hockey implemented its Heads Up Hockey
initiative in 1996; this program focuses on reducing head
and spinal cord injury through player and coach education.
Instructional tools and a DVD are available through USA
Hockey. However, there is no recently published literature
evaluating the effectiveness of this program (9).
Hockey Canada has provided a similar safety program
since 1995 with a focus upon injury prevention and first aid
(10). ThinkFirst Canada, a brain and spinal cord injury
prevention foundation, has produced a video titled Smart
Hockey, which teaches youth players about the causes,
symptoms, and prevention of head and spinal cord injury
(11). The effectiveness of this program was evaluated in a
2003 study. Players who viewed the video were more
familiar than controls with the causes of concussion and
spinal cord injury, and they were better able than controls
to identify symptoms of concussion. There was a significant
reduction in the number of crosschecking and checking
from behind penalties in athletes who watched the video.
This suggests that preseason educational programs can
improve players knowledge of brain and spinal cord injury,
and that such programs can reduce the number of certain
high-risk penalties. Further study is warranted to determine
whether this program reduces injuries (12).
In summary, studies support the implementation of the
recommendations made by the AAP in its 2000 policy
statement on ice hockey. Limiting body checking, using fair
play policies, and educating athletes have been shown to be
effective strategies in youth ice hockey injury prevention.
In an effort to reduce the number of shoulder and elbow
injuries in youth baseball pitchers, the USA Baseball
Medical and Safety Advisory Committee released a revised
position statement in May 2006 addressing pitch counts,
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Number 6

November/December 2008

pitch types, and appearances made by youth pitchers (13).

These recommendations are summarized in the Table. In
October 2007, Little League implemented revised rules to
limit the number of pitches made by Little League pitchers
(14). Both the USA Baseball and Little League position
statements outline age-specific pitch count limits. Additionally, USA Baseball advises players to refrain from
participating in multiple leagues, participating in year-round
baseball, and participating in scouting showcases. Both sets
of recommendations are based on a recent paper reporting
the results of a case-control study. Pitchers with a history of
a significant pitching-related shoulder or elbow injury were
more likely than uninjured counterparts to have pitched
more months per year, more innings per year, more pitches
per game, and more pitches per year. Injured pitchers were
more likely to have participated in scouting showcases,
and were more likely to have pitched through arm pain or
fatigue (15). It is hoped that implementation of rule changes
such as pitch count limitations will prevent a significant
number of youth pitching-related injuries.

SAFETY EQUIPMENT
A variety of safety devices have been designed for athletes
in nearly every sport. Many recent studies have evaluated
the efficacy of safety devices in preventing injury. Unfortunately, despite the availability of existing safety devices,
some athletes choose not to use the equipment. There is an
evolving body of literature looking at the effectiveness of
promotional campaigns to increase the use of safety devices.
Helmets and Headgear
Helmet use is mandatory in certain sports, but remains
optional for many other sports despite significant risk for
head injury. Headgear use has increased in soccer, as players
are more aware of the potential for traumatic brain injury.
A recent study evaluated the effectiveness of three brands
of soccer headgear at reducing forces transmitted to the
head as the result of heading or direct head-to-head contact.
None of the equipment tested showed any attenuation in
mechanical forces due to heading, but there was a 33%
reduction in acceleration forces from head-to-head impact
when the headgear was used (16). Further study is warranted
in soccer to evaluate the effectiveness of headgear at
preventing injury.
Alpine skiing and snowboarding are popular winter
activities that carry a significant risk for head injury.
TABLE. USA baseball pitch count recommendations.
Pitches
per Game

Pitches
per Week

Pitches
per Season

Pitches
per Year

9Y10

50

75

1000

2000

11Y12

75

100

1000

3000

13Y14

75

125

1000

3000

Age (Yr)

Adapted from USA Baseball Medical and Safety Advisory Committee

(13).
Injury Prevention in Youth Sports

Copyright @ 2008 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

349

Helmets are mandatory equipment for Federation Internationale de Ski (FIS) ski events, but helmet use is optional
for the recreational skier or boarder. A recent case-control
study of recreational skiers and snowboarders revealed a
60% reduction in risk for head injury among skiers using
helmets compared with a control group (17). Efforts have
been made to increase helmet use among skiers and
snowboarders through promotional campaigns. A multifaceted helmet promotion campaign entitled It Aint Brain
Surgery has been evaluated in Colorado. This program used
numerous media outlets to promote helmet use. Another
component of the program involved a helmet loaner
program. Stores offering free loaner helmets with ski rental
packages noted a 10-fold increase in helmet acceptance and
use. This multi-faceted campaign resulted in an obvious
increase in helmet use, although data on injury prevention
have yet to follow (18).
Eye Protection
In 2004, the AAP Committee on Sports Medicine and
Fitness published a policy statement promoting the use of
protective eyewear for athletes. Specific manufacturing
standards exist for protective eyewear, and protective
goggles and glasses meeting these standards were recommended by the committee for specific sports. It was further
recommended that functionally one-eyed athletes should
wear eye protection for all sports. Functionally one-eyed
athletes were recommended to avoid boxing, martial arts,
and wrestling due to the significant risk of eye injury in
these sports (19).
Squash is a particularly high-risk sport for eye injury because
of its rapidly moving, small hard projectile and the close
quarters of the competitors wielding long hard rackets. A multifaceted eyewear promotion strategy similar to the previously
mentioned helmet campaign has been evaluated. Promotional
and educational materials about eye injury and eye protection
were provided at squash venues. Appropriate protective
eyewear was available for players to try or purchase. Compared
with controls, those players exposed to the promotional
program had a 2.4 times increased odds for wearing appropriate eyewear (20). This study, as does the helmet study,
shows the potential for increased use of safety equipment
when multi-faceted promotional campaigns are undertaken.
Faceguards, Safety Balls, and Chest Protectors
Baseball has a high rate of injury as the result of being
struck by the ball. Numerous safety devices are used in
youth baseball to reduce the risk of injury. Many youth
baseball organizations support the use of faceguards, safety
balls, and chest protectors.
In 2001, USA Baseball recommended that youth baseball
organizations use reduced-impact safety balls in leagues with
young players. This recommendation was made based on the
high incidence of injuries related to being struck with the
baseball (21). In a recent 3-yr study of Little League
Baseball, the injury rate was reduced by 23% when safety
balls were used. The use of faceguards reduced the risk
of facial injury by 35% (22). Safety balls and faceguards
appear to be effective injury prevention strategies when
implemented in youth baseball.
350 Current Sports Medicine Reports

Commotio cordis is a rare but devastating event in

sport. A recent report revealed that, of 85 recent cases
of commotio cordis occurring during organized sport
participation, 32 (38%) occurred in athletes wearing chest
protectors (23). This report follows another study in which
youth baseball and lacrosse chest protectors were evaluated
for their ability to prevent commotio cordis. None of the
chest protectors were effective at lowering the risk of
commotio cordis when compared with wearing no protection at all (24). These studies suggest that wholesale
reevaluation of the design and use of chest protectors is
necessary to lower the risk of commotio cordis.
BRACES
A variety of braces are available, with wide variations in
price and design. Many athletes elect to use braces for
purposes of protection or injury prevention. A recent
epidemiologic study revealed that previous lower extremity
injury increases the rate of sustaining future lower extremity
twofold (25). Those athletes with previous leg injury appear
justified in implementing an injury prevention strategy,
although bracing may not be the most effective method.
Several recent studies have been published examining
ankle braces in volleyball players. An ankle brace ideally
would prevent injury without compromising performance or
impairing normal ankle function. One case-series examining
ankle bracing among volleyball players revealed a significant reduction in ankle injuries among athletes using an
ankle brace. The authors reported an injury rate of 0.07
injuries per 1000 athlete exposures, compared with a rate of
0.98 per 1000 exposures reported by the NCAA Injury
Surveillance System (26). The Yang study demonstrated
that the overall lower extremity injury rate was reduced by
use of lower extremity protective equipment, but the modest
reduction was attributed entirely to the use of kneepads.
When the kneepad data were excluded, it appeared that the
use of knee and ankle braces actually increased rates of
lower extremity injury (25).
A recent study of athletes with chronic ankle instability
found no detrimental impact on agility testing when semirigid or soft ankle braces were used. This same study
demonstrated a significant subjective difference in terms
of comfort, with soft braces being more acceptable than
semi-rigid braces (27). The use of external ankle braces
in volleyball players over the course of a season does
not appear to have a detrimental effect upon dynamic
ankle restraint mechanisms (28). In summary, the use of
ankle braces may be an effective strategy for preventing ankle
injury, although recent data are mixed. There appears to be
no measurable adverse impact upon either performance or
function based upon recent studies.

CONDITIONING PROGRAMS
Traditional warm-up and cool-down stretching exercises
have been a standard routine in competitive and recreational sports. The utility of these exercises has been
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extensively studied, but findings are inconclusive. A systematic review suggests there is not sufficient evidence to
support or discontinue routine stretching before or after
exercise to prevent injury (29). Although there is little
evidence for injury prevention, nearly all coaches surveyed
believe that warm-up stretching routines do, in fact, prevent
injury (30).
Several recent injury prevention studies have focused on
preseason and in-season neuromuscular training, proprioceptive training, and sport-specific skill interventions. Many
of these studies have shown beneficial effect with regards to
injury prevention.
Neuromuscular Interventions
Neuromuscular training programs have been a mainstay
in physical therapy for treatment of injuries. There is
evidence that neuromuscular training programs also may be
effective in injury prevention, especially with regards to
female anterior cruciate ligament (ACL) injuries. A
prospective cohort study found that a structured warm-up
including strengthening, stretching, plyometrics, and soccer
specific skill sets was more effective in reducing ACL
injury in adolescent female soccer players than traditional
warm-up stretching exercises (31). Another study showed
that it is possible to prevent ACL injuries with a neuromuscular program in female handball athletes (32). A metaanalysis of six studies relating to ACL injury prevention in
female athletes concluded that neuromuscular training
programs may reduce the risk of ACL injury (33). This
study recommends training programs that also emphasize
performance enhancement as a means to motivate compliance in athletes.
It is unknown whether any one training program is
superior to other training regimens for preventing ACL
injuries. One study compared a basic resistance training
program with a plyometric training program in high
school female athletes. Both regimens induced favorable
mechanics, but outcome data regarding injuries were not
reported (34).
Myrick performed a small study of one basketball team
using performance enhancement and an injury prevention
training program with positive results (35). However, this
study was limited by small sample size and lack of a control
group. The results suggest that programs incorporating
performance enhancement to motivate athlete compliance
may produce lower injury rates, but further study is
warranted.
Proprioception
Proprioceptive balance training, like neuromuscular
training, is used frequently for treatment of sports-related
injuries and has been studied as an element in injury
prevention. Emery et al. studied the effectiveness of a homebased wobble board program. Initial studies were promising
in reducing sports-related injuries among healthy adolescents (36). In a follow-up wobble board study, no statistically significant results were observed, but self-reported
compliance was low. However, a potentially clinically
relevant trend in favor of reducing lower extremity injuries
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Number 6

November/December 2008

was observed (37). McGuine et al. studied the effect of a

balance training program on the risk of ankle sprains in
adolescents. The rate of ankle sprains was 6.1% in those
athletes who underwent the training program compared
with 9.9% in the control group (38). Those with a previous
history of ankle sprains in the intervention group decreased
their risk of having an ankle sprain by one-half. In summary,
the evidence suggests balance training programs are effective in preventing ankle sprains, especially in those athletes
with a history of previous ankle sprains.
Sports-Specific Skills
Sports with frequent jumping, landing, and high-speed
running with rapid directional change have a higher rate of
injury. The influence of preseason and in-season skillspecific injury prevention programs has been studied. Scase
et al. studied the effectiveness of a preseason physical
training program geared at improving landing skills in elite,
under 18, male Australian football players. It was found
that the intervention resulted in an overall improvement
in landing skills, with a subsequent reduction in injury
risk (39).
Researchers also have studied the influence of in-season
injury prevention training upon hip and knee kinematics
specific to landing in female soccer players. The training
program induced significant changes in biomechanics that
may play a role in ACL injury (40). Replacement of
traditional warm-up and cool-down routines with structured
warm-up programs can prevent injury, especially to the knee
and ankle. Efforts should be made to incorporate such injury
prevention training programs into youth sports (41).

CONCLUSION
Based upon the recent available data, there are numerous
strategies that can be implemented in youth sports to
effectively prevent injuries. Enhancing the safety of
athletes may lead to greater enjoyment of and longer
participation in sports. Given the recent pediatric obesity
epidemic, it stands to reason that medical professionals
should promote safe and enjoyable physical activities for
our youth. Strong evidence exists that supports the
implementation of altered rules, use of safety equipment,
and participation in specific conditioning programs.
Enforcement of rules designed to protect athletes should
be uniform. Education of parents and coaches must
continue regarding evolving injury prevention methods.
Sports medicine providers who care for young athletes are
in a unique position to stay abreast of new literature on
injury prevention and to educate athletes, parents, and
coaches of new ways to protect our young athletes.
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