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Injuries and Illnesses in the Women's National Basketball Association (WNBA)

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Title:
Injuries and Illnesses in the Women's National Basketball Association (WNBA)
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WALTERS, SHERI L. ( Author, Primary )
Copyright Date:
2008

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Ankle ( jstor )
Anterior cruciate ligament ( jstor )
Basketball ( jstor )
Diseases ( jstor )
Eye injuries ( jstor )
Physical trauma ( jstor )
Professional sports ( jstor )
Sprains and strains ( jstor )
Women ( jstor )
Womens studies ( jstor )

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University of Florida
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University of Florida
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Copyright Sheri L. Walters. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Embargo Date:
5/1/2005
Resource Identifier:
82904580 ( OCLC )

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INJURIES AND ILLNESSES IN THE WOMEN’S NATIONAL BASKETBALL ASSOCIATION (WNBA) By SHERI L. WALTERS A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN EXERCISE AND SPORT SCIENCES UNIVERSITY OF FLORIDA 2003

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Copyright 2003 by Sheri L. Walters

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ACKNOWLEDGMENTS I would like to take this opportunity to thank the many people who assisted in the completion of my thesis. First, I would like to extend thanks to Laura Ramus, Head Athletic Trainer for the Detroit Shock; Mike Abdenour, Head Athletic Trainer for the Detroit Pistons; and Arnie Kander, Physical Therapist for the Detroit Pistons, for helping me to generate the idea for this project and pointing me in the right direction to get it started. Jamin Dershowitz, NBA and WNBA legal counsel, and Tracey Ellis-Ward, Assistant Director of WNBA Operations, must be recognized for their support of this project. I would also like to thank my parents who have always been there when I needed them. Their love and support have helped to guide me throughout my life and have helped me to obtain the goals that I have set for myself. The guidance and friendship provided to me from Trish Bare-Grounds, Amy Stephenson, and Amiee Gunnoe will never be forgotten. Last, but not least, I would like to thank Dr. MaryBeth Horodyski, who no matter the situation was never more than a cell phone call or page away. The many hours she spent in assisting me in this project and in becoming a better certified athletic trainer are too numerous to count but along with her friendship will not be forgotten. iii

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TABLE OF CONTENTS Page ACKNOWLEDGMENTS.................................................................................................iii LIST OF TABLES............................................................................................................vii ABSTRACT.....................................................................................................................viii CHAPTER 1 INTRODUCTION........................................................................................................1 Statement of the Problem..............................................................................................1 Research Hypotheses....................................................................................................2 Definition of Terms......................................................................................................4 Assumptions.................................................................................................................6 Limitations....................................................................................................................7 Significance..................................................................................................................7 2 REVIEW OF LITERATURE.......................................................................................9 Definition of Injury.....................................................................................................10 Injury Rates in High School Basketball......................................................................10 Injury Rates in Collegiate Basketball.........................................................................11 Injury Rates in Professional Basketball......................................................................12 Lower Extremity Injuries............................................................................................13 Ankle...................................................................................................................14 Knee.....................................................................................................................15 Anterior cruciate ligament (ACL)................................................................15 Patellofemoral pain syndrome (PFPS).........................................................16 Hamstring............................................................................................................17 Stress fracture......................................................................................................18 Other Injuries and Health Concerns...........................................................................18 Eye.......................................................................................................................19 Illnesses...............................................................................................................19 Pregnancy............................................................................................................20 Injury by Position.......................................................................................................20 Time of Injury Occurrence.........................................................................................21 Contributing Factors to Increased Injury Risk in Females.........................................22 Physiological Characteristics......................................................................................23 iv

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Recommendations for Decreasing the Injury Rate.....................................................24 Conclusion..................................................................................................................26 3 MATERIALS AND METHODS...............................................................................27 Subjects.......................................................................................................................27 Instruments.................................................................................................................27 WNBA Injury and Illness Report Form..............................................................27 Official WNBA Guide and Register....................................................................28 WNBA’s Web Site..............................................................................................28 Procedures...................................................................................................................28 Design.........................................................................................................................29 Analysis......................................................................................................................29 4 RESULTS...................................................................................................................31 Accuracy of the Coding..............................................................................................31 Descriptive Analysis...................................................................................................31 Subject Participation............................................................................................31 Injury and Illness Rates.......................................................................................32 Injury and Illness Nature.....................................................................................32 Anatomical Site of Injury....................................................................................33 Mechanism and Activity at Time of Injury.........................................................37 Injuries and Illnesses by Player Position.............................................................39 Practice versus Game..........................................................................................40 Injuries by Half of Game.....................................................................................40 Injuries by Time in Season..................................................................................40 Days Missed From Basketball.............................................................................41 Other Points of Interest........................................................................................41 Chi Square Analyses...................................................................................................42 Ankle Versus Knee Injuries.................................................................................42 Chronic Versus Acute Knee Injuries...................................................................43 Time in Game and Time in Season.....................................................................43 Player Position and ACL Injuries........................................................................44 5 DISCUSSION.............................................................................................................45 Discussion...................................................................................................................45 Injury and Illness Nature.....................................................................................47 Anatomical Site of Injury....................................................................................48 Mechanism of Injury...........................................................................................52 Player Position.....................................................................................................52 Half of the Game.................................................................................................53 Time in Season....................................................................................................53 Practice versus Game Participation.....................................................................54 Days Missed From Basketball.............................................................................54 Conclusion..................................................................................................................55 v

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Implications for Future Research................................................................................57 APPENDIX A WNBA INJURY AND ILLNESS REPORT FORM..................................................58 B IRB EXEMPTION APPROVAL...............................................................................60 LIST OF REFERENCES...................................................................................................62 BIOGRAPHICAL SKETCH.............................................................................................67 vi

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LIST OF TABLES Table page 1. Injured Player Demographics.......................................................................................31 2. Injury Frequency Classified by Nature.........................................................................32 3. Injury Frequency Classified by Nature.........................................................................33 4. Injury Frequency Classified by Body Area..................................................................33 5. Injury Frequency Classified by Body Area..................................................................34 6. Injury Frequency by Structure......................................................................................34 7. Injury Frequency by Structure......................................................................................35 8. Injury Frequency by Specific Structure........................................................................36 9. Injury Frequency by Specific Structure........................................................................37 10. Injury and Illness Frequency by General Mechanism................................................38 11. Injury and Illness Frequency by Specific Mechanism................................................38 12. Injury and Illness Frequency by General Activity......................................................39 13. Injury and Illness Frequency by Specific Activity.....................................................39 14. Injuries and Illnesses by Player Position....................................................................40 15. Frequency of Injuries and Illnesses by When (Game versus Practice).......................40 16. Frequency of Injuries and Illnesses by When in Game..............................................40 17. Rate of Game-Related Conditions by Time in Season...............................................41 18. Frequency and Percentage of Time Loss....................................................................41 19. Frequency of Injuries and Illnesses by Season...........................................................42 vii

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Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science in Exercise and Sport Sciences INJURIES AND ILLNESSES IN THE WOMEN’S NATIONAL BASKETBALL ASSOCIATION (WNBA) By Sheri L. Walters May 2003 Chair: MaryBeth Horodyski Major Department: Exercise and Sport Sciences Extensive information is available on the incidence of injury in the various levels of competitive basketball; however, a lack of research exists for women’s professional basketball. The purpose of this study was to examine the frequency of injuries and illnesses in the WNBA. Data were reviewed retrospectively for six consecutive WNBA seasons. Certified athletic trainers collected information regarding injury occurrence using a standardized injury report form. Data were analyzed using descriptive and inferential statistics. Analyses were completed on body part, injury nature, mechanism of injury, and total time lost. Subjects (N=813, age 26.5.9 years, height 182.5.48 cm, weight 76.0 .3 kg) participated in official league activities, totaling approximately 25,330 game-related athlete exposures (AE) and 524,550 competition minutes (CM). An overall injury rate of 23.5 injuries/1,000 AE or 11.5 injuries/10,000 CM was documented. In the WNBA, the lower extremity was the most frequently injured area (60.1%) viii

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resulting in the most total time lost. The most frequently injured body parts were the knee (15.2%), ankle (14.3%), and patella (6.8%). General medical conditions accounted for 8.2% of all reported cases. Sprains (28.4%) were the most frequent type of injury, with the ankle sustaining the most sprains (49.4%). Additional injuries sustained included tendonitis (19.6%), strains (18.6%), contusions (13.3%), and fractures (4.8%). Concussions occurred at a rate of 0.55 per 1,000 AE (n=14, 1.3%), while the anterior cruciate ligament was torn at a rate of 0.32/1,000 AE (n=8, 0.8%). Chi square analysis revealed no significant difference in game-related injuries among guards (26.7/1,000 AE), forwards (22.0/1,000), and centers (21.9/1,000 AE). Excluding overuse/chronic injuries, activities at time of injury with highest injury incidence were defensive rebounding (9.1%), offensive rebounding (6.0%), and driving (5.5%). Overuse/chronic injuries accounted for the highest percentage (20.2%). Athletes were placed on the injured reserve list in 18.4% of the cases. Injuries which resulted in the player being out for the remainder of the season accounted for 4.6% of all injuries, while 3.9% of the injuries required surgical intervention during the time of this investigation. A medication was prescribed in 48.1% of the reported cases. As these results suggest female professional basketball players may become injured at a rate higher than their male counterparts with respect to CM, and while the focus is often on prevention of acute injuries, attention also should be directed towards overuse/chronic conditions. ix

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CHAPTER 1 INTRODUCTION Interest and participation in women’s athletics have grown since the early 1970’s. As this growth has occurred, a corresponding increase in the interest of gender-related sports injuries has also developed. Many epidemiological studies have been completed analyzing the injury rates of males and females in various sports at the high school and collegiate levels. 9,14,30,31,57,65 As the growth of women’s athletics in general has occurred, basketball has emerged as one of the most popular sports for female athletes culminating into the formation of the Women’s National Basketball Association (WNBA). The WNBA, which originally consisted of eight teams in 1997, has grown to its present 16 by adding two teams in both 1998 and 1999 and four teams in 2000. The popularity of basketball and the belief that female basketball players may be predisposed to certain types of injuries, namely the anterior cruciate ligament (ACL) sprain, has led to even more consideration from researchers. Statement of the Problem The incidence of injury in male and female high school and collegiate athletics has been investigated extensively. 9,14,30,31 However, few studies have examined the incidence of injury in elite or professional athletics. 57,65 Women’s professional sports, in particular, have been neglected primarily because of the lack of opportunity to investigate them. The only known study that analyzed professional women’s basketball was completed in 1982 by Zelisko et al. 65 They compared the injury rates of one professional women’s team to one professional men’s team for two years. This study obviously does not 1

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2 account for the change in skill level and intensity of play demonstrated by today’s female athletes. It is suggested that due to an increased skill level and intensity of today’s female athletes, the frequency and severity of injuries have increased. Currently, comparing various studies is difficult because the authors use inconsistent definitions of injury and athletic exposure. 9,45,47,48 The definitions of injury range from “an accident that was debilitating to the player” 22:218 to “medical problems arising as a direct result of interscholastic sport participation that required a participant to be withdrawn from a practice or competitive event or miss participation in a subsequent event.” 21:2246 The present study has defined injury and illness, according to the WNBA’s “Guidelines to Reporting” set forth by the National Basketball Trainers’ Association (NBTA), as any injury or illness that (1) resulted in a player missing one or more practices; or (2) resulted in a player missing one or more games; or (3) required medical attention (i.e., a doctor’s visit, medication, x-rays, sutures). Similar to the variations in the definition of injury, injury rates are reported in a variety of ways. Most commonly, rates are reported per athletic exposure. In this study, two types of exposure were used: athletic exposure (AE) and competition minutes (CM). 57 The purpose of this investigation was to determine the frequency of injuries and illnesses in the WNBA. This study was designed to investigate the most common types of injuries, mechanisms of injury, activities leading to the injury, time and place of injury occurrence, and the time lost to the injury. Research Hypotheses Based on the review of literature and the nature of this study the following have been identified as research hypotheses:

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3 1. Significantly more ankle injuries will occur in the WNBA as compared to any other specific injury. 2. Those who have been taped or braced will have significantly fewer ankle sprains than those who were not taped or braced. At all levels and in both genders, ankle injuries are the most common injuries in basketball. 1,9,48,49,57,65 Prophylactic ankle bracing/taping is believed to decrease the frequency of injuries to this structure. 43,56 3. Significantly more injuries to the knee will be chronic. 4. The majority of time loss due to knee injuries will be from acute knee sprains. Patellofemoral inflammation was the leading cause of time loss in the NBA, but the time loss came in small, often reoccurring, increments whereas knee sprains, usually result in a long time loss event. 57 Because of the short duration of the WNBA season, players may try to play through such inflammatory conditions. 5. Significantly more injuries will occur during the first half of the regular season than in the second. 6. Significantly more injuries will occur during the second half of competition than the first half. According to Apple et al., 3 46.7% of all injuries in the NBA occurred before the first 27 games of an 82-game regular season were played. Broken down, 17.8% of those occurred during the 30-day preseason and 28.9% during the first 26 games. The middle third of the season produced 19.6% of the injuries while the final third provided 15.4%. The playoffs, in which only a limited number of teams participate for a 1-5 week period, resulted in 11.4% of the injuries. This distribution of injuries may also occur in the WNBA for two primary reasons. First, the athletes who play internationally are just finishing their season overseas and may be fatigued. Second, those who did not play internationally may not be properly conditioned.

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4 Sixty percent of game related injuries occur during the second half. 17 It was suggested that this is a result of fatigue, staleness after half time, improper warm-up after half time, and improper strength and conditioning during the preseason. 6 7. Guards will sustain significantly more anterior cruciate ligament injuries than forwards or centers. Apple et al. 3 indicated that guards and forwards in the NBA were more likely to sustain a knee injury. In a 1985 study, 15 out of 24 ACL sprains occurred in guards while nine occurred in centers. Different mechanisms were indicated for ACL injury for these two positions. A jumping and landing mechanism was three times more common in centers while the most common mechanism of ACL rupture in guards involved a twisting or pivoting action. 23 Definition of Terms The following are definitions of terms that were used in the study. Acute injury was defined as an injury with sudden onset and short duration. 6 Athlete exposure was defined as one athlete appearing in one game. 57 Chronic injury was defined as an injury with long onset and long duration. 6 Competition minute was defined as one athlete playing one minute in a game. 57 Dynamic overload was defined as an injury to the muscle as it generates more forces than it is capable of withstanding. 58 Eversion was defined as turning the foot outward. 6 Extrinsic factor was defined as an agent arising from outside of the body that may increase risk of injury 58 Hyperextended was defined as extreme stretching of a body part. 6

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5 Injury was defined for the purposes of this study as an injury/illness that resulted in (i) a player missing one or more practices; (ii) a player missing one or more games; or (iii) a player sustaining an injury requiring medical attention (e.g., a doctor’s visit, medication, x-rays, sutures). Injury rate was defined as the number of injuries sustained divided by the total number of athlete-exposures and competition minutes. The injury rates were expressed per 1,000 athlete-exposures and 10,000 competitions minutes. Insidious was defined as a gradual onset with respect to symptoms, an injury or illness having no apparent cause. 58 Intrinsic factor was defined as an agent arising from inside of the body that may increase risk of injury 58 Inversion was defined as the movement of the plantar aspect of the calcaneus toward the midline of the body. 58 Overuse was defined as accumulated microtraumatic stress placed on a structure or body area. 58 Previous injury was defined for the purposes of this study as an injury/illness that occurred outside of league sanctioned activities. These injuries will be tracked, noted, and not used in data collection. Re-injury was defined for the purposes of this study as any injury/illness that is a re-occurrence of a prior injury. In cases in which a re-injury occurs of previous injury it will still be classified as a re-injury for the purposes of this study as long as the re-injury occurred during league activities.

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6 Sprain was defined as the stretching or tearing of ligamentous or capsular tissues. 58 Grade 1 was defined as a stretched ligament with little or no tearing of its fibers. 58 Grade 2 was defined as a partial tearing of some of the fibers. 58 Grade 3 was defined as a ligament that had been completely ruptured. 58 Strain was defined as an injury to the musculotendinous unit resulting from excessive stretch or tension. 58 Grade 1 was defined as the stretching and limiting tearing of the musculotendinous fibers. 58 Grade 2 was defined as the actual tearing of some of the fibers. 58 Grade 3 was defined as the complete rupture of the muscle. 58 Valgus was defined as the position of a body part that is bent outward. 6 Varus was defined as the position of a body part that is bent inward. 6 Assumptions Six assumptions were made for the purposes of this investigation. 1. The use of NATABOC certified athletic trainers and licensed team physicians ensured the accurate evaluation and diagnosis of injuries. 2. The WNBA injury and illness report was filled out accurately by a certified athletic trainer and/or physician. 3. Information provided by the athletes to complete the WNBA injury and illness report was accurate. 4. All previous injuries and illnesses were noted as such on the injury and illness report form so that they may be excluded from this investigation. 5. The care received by the athletes was similar since a certified athletic trainer treated all.

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7 6. The style of play, in games and practices, at the professional level is similar throughout the league. Limitations There are certain limitations present in epidemiological studies. Such limitations are listed below. 1. A Medical Injury and Illness Report Form was completed for all athletes who are put on the WNBA’s Injured List. The Injured List was designed to include only players who are unable to render playing services due to injury and illness. Unfortunately, some teams use the list to create roster space for other players which is prohibited by the league. If the league suspects a violation it is investigated. If it is determined that such an incidence has occurred, the team and player are penalized. 2. Not all athletes wore a prophylactic ankle brace or tape during all practices and games. Due to differences in the personal preferences of the athletes, coaches, and athletic trainers involved, the use of prophylactic ankle support varied and was not controlled. Significance In order to provide adequate medical coverage and to design effective injury prevention programs at any level of sport, one needs sufficient knowledge of the type, mechanism, and frequency of injuries associated with the specific sport. A clear definition of injury was used in order for the types, frequencies, and mechanisms of injuries to be reported and monitored. In providing data concerning the incidence of injury, frequency of injuries, and mechanism of injury, this study in turn provided avenues through which injury prevention can be investigated.

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8 The present study has helped to update the injury rates occurring in women’s professional basketball. The data that are currently available were reported in 1982 and the injury rates were presented only per athletic exposure (AE). Even though AE is the most common method for reporting injury rates, it is not sensitive to the length of time the athlete was participating. To obtain a more sensitive injury rate the number of game-related AE and competition minutes (CM) were calculated. In past studies, researchers have usually given injury rates for general anatomical sites and conditions. 9,21,47,48,60,67 For example, instead of reporting a given number of hamstring strains, researchers report the number of injuries to the thigh and the number of strains. This lack of specificity does not allow the data to be used effectively in the development of prevention programs. Knowledge of the circumstances under which an injury occurs provides the athletic trainer with the basis for developing effective rehabilitation, strength and conditioning programs. The trends that are identified in this study can help to develop injury prevention programs.

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CHAPTER 2 REVIEW OF LITERATURE Since the passage of Title IX, participation and interest in female sports has risen exponentially. As a result of this increased interest, women’s professional sports leagues have been formed. Thus far the most successful league in terms of longevity has been the Women’s National Basketball Association (WNBA), a part of NBA Enterprises Inc. Along with the increased interest in women’s sports has also come an increased awareness in women’s health issues, especially those issues related to sport. It has been recognized for quite some time that female participants in various sports may be at a higher risk for certain injuries than their male counterparts. 1 Many theories as to why this increased risk for injury exists have been suggested. For example, Albohm 1 predicted that if females received better training and proper facilities their injury rate would be decreased. However, many of the factors, including those suggested by Albohm, 1 would seem to be eliminated at the elite levels of sport. Despite this fact, many believe that elite female athletes, professional basketball players in particular, may still demonstrate the increased risk of injury reported in the lower levels of the sport. When investigating the incidence of injury in basketball many factors need to be examined. These factors include, but are not limited to, injury rates to male and female basketball players at the high school, collegiate, and professional level; type of injury sustained; injury by position; and time of injury occurrence. In addition to these factors, contributing factors to injuries, physiological characteristics, and recommendations for decreasing the injury rate will be discussed. 9

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10 Definition of Injury When examining the incidence of injury, the term “injury” must be defined. Currently, comparing various studies is difficult because the authors use inconsistent definitions of injury. 9,45,47,48 The definitions of injury range from “an accident that was debilitating to the player” 9 to “medical problems arising as a direct result of interscholastic sport participation that required a participant to be withdrawn from a practice or competitive event or miss participation in a subsequent event.” 21 The need for a common definition is necessary to accurately compare injury rates between studies. Injury Rates in High School Basketball In a study examining high school sports, basketball was reported to have one of the highest rates of injury. 45 Much debate has occurred in the literature as to what differences, if any, exist between the injury rates and types in female versus male high school basketball players. Haycock and Gillette 27 suggested that injuries of female athletes were no different from those of men and that well-trained female athletes were not more susceptible to injury. However, the authors of one two-year study in high school basketball demonstrated that the girls’ injury rate was 0.72 per player and the boys’ was 0.16 per player. 45 In a three-year study completed by Chandy and Granna, 9 the girls’ injury rate was 77.5 per 1,000 athletic exposures (AE) compared to the boys’ 56.0 per 1,000 AE. More recently than the previous studies however, Powell and Barber-Foss 51 reported 4.8 cases per 1,000 AE for males and 4.4 cases per 1,000 AE for females at the high school level. Chandy and Grana 9 also reported that the girls’ injuries were much more severe. Major injury occurred in 43.9 of the 1,000 athletic exposures for the girls compared to only 24.7 per 1,000 exposures for the boys. Also, significantly more girls were out for

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11 the season and required surgery. 9 Similarly, Powell and Barber-Foss 51 reported during the three year study period 52 females required knee surgery while only 22 males did. It is important to note that while the Moretz and Granna, 45 Chandy and Grana, 9 and Shively et al. 54 studies are three of the most frequently cited references concerning female and male injury rates in high school basketball, the studies were completed in Oklahoma at a time when female basketball players were still competing in six-on-six basketball. It should also be noted that this style of play is very different from the traditional five-on-five basketball. Injury Rates in Collegiate Basketball Injury rates in basketball vary between levels of competition. 14 While the same types of injuries caused by similar mechanisms occur in both high school and college basketball players, the injuries do not occur at the same rate. The higher injury rate in high school athletes may be because adolescents are less likely to have reached musculoskeletal maturity at the beginning of high school competition. 21 Physical maturity, increased skill level, better conditioning, and better coaching may serve to reduce the rate of injury in four-year college athletes. 21 Like the literature concerning the injury rates in high school basketball players, there are many conflicting reports concerning the injury rates in female versus male basketball players at the collegiate level. In the late 1970’s and early 1980’s Whiteside 60 and Clarke and Buckley 12 reported that women had an increased relative frequency of injury, especially in the frequency of injuries to the lower extremity. Contrary to these findings, no statistically significant gender difference in the pattern of injury for basketball was reported in a 15 year study at a NCAA Division III university that was

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12 completed in 2000. 53 Similar results were reported in a one year study at a Division I institution that was completed in 1990. 38 The NCAA Injury Surveillance System listed the 1998-1999 basketball injury rates per gender. 47,48 The women studied sustained 5.1 injuries per 1,000 athletic exposures during practice and 9.2 injuries per 1,000 athletic exposures during games. The men sustained 3.8 injuries per 1,000 athletic exposures during practice and 10.2 per 1,000 AE during games. While absolute differences exist between the males and females, no mention of significance was provided. Injury Rates in Professional Basketball In 1982, Zelisko et al. 65 reviewed and compared the injuries from two consecutive seasons in a Women’s Professional Basketball League (WPBL) team and a National Basketball Association (NBA) team. The study noted that the women sustained 60% more injuries than the men. Females were injured at a rate of 51.2 per 1,000 AE compared to 32.0 per 1,000 AE for males. While the type of injuries sustained by both men and women followed a similar pattern with contusions, strains, muscle cramps/spasms, and acute tenosynovitis/tendonitis being the most common, women sustained significantly more sprains, strains, and contusions. 65 The majority of the studies that have been completed on the injury rates in professional basketball have looked exclusively at either females or males. A study examining the injury rates of women at the Australian Institute of Sport (AIS) from 1990-1995 concluded that on average one injury occurred per 3.9 months or 3.1 injuries per player per 12 months on scholarship. When comparing the injury rate at the AIS from the 1982-1989 period (0.8 injuries per basketball player per year) to the injury rate from 1990-1995 (3.1 injuries per basketball player per year), a statistically significant

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13 difference was reported. The AIS study, as do others, 2,49 suggests that the incidence of injury in female basketball players is increasing. 30 Unfortunately, the AIS’s unique arrangement does not allow for comparison with other studies because the athletes live and train extensively at the institute the entire year. However, the increase in the injury rate may not be limited to females. A study analyzing the injuries and illnesses in the NBA over a 10 year period, the 1988-1997 seasons, showed a 12.4 % increase in conditions during the study period. 57 Of the study’s 9,904 usable reports, 75.2% were athletic related while 24.8% were non-athletic or general medical. Throughout the ten year study a total of 200,012 athletic exposures resulted in a game-related injury rate of 21.4 injuries per 1,000 AE. Per 1,000 AE sprains (7.4), contusions (4.5), and strains or spasms (4.1) were the most common injuries. 57 Injury rate comparisons can be made between the NBA and the NCAA. NBA players experienced an injury rate of 21.4 injuries per 1,000 AE which was twice that experienced by the collegiate players whose injury rate was 10.9/1,000 AE. Comparably speaking, the majority of the injuries sustained by the NBA players were to the ankle (14.3%), patellofemoral complex (12.5%), and the lumbar spine (9.1%) where as the collegiate players sustained most of their injuries to the ankle (28.8%), knee (12.0%), and hip/pelvis (2.7%). The most common types of injury in the NBA were sprains (27.8%), strains (21.5%), and inflammatory conditions (20.4%). In the NCAA, sprains (37.1%), strains (16.4%), and contusions (12.6%) were the most common types of injury. 57 Lower Extremity Injuries The majority of injuries in basketball are lower extremity injuries 28,57 and result in the greatest number of days lost. 57 In a retrospective study in intercollegiate athletics in two colleges over a two-year period, 51.4% of all injuries occurred to the lower

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14 extremity. The percentage was higher in basketball, soccer, track, and wrestling possibly because of the twisting, acceleration, and deceleration motions involved in these sports. 35 Ankle At all levels and in both genders, ankle injuries are the most common injuries. 1,9,27,53,57,60,65 In the NBA, ankle sprains were the most frequent game-related injury, occurring at a rate of 3.4 per 1,000 AE. Ankle sprains represented 9.4% of all orthopedic conditions reported. 57 Researchers at the high school and collegiate level also reported similar results. 1,9,45,47,48,54,60 One study suggested that the majority of time lost (53.7%) is due to ankle injury. 43 In a comparison of professional female and male basketball players, ankle injuries were the most common injury occurring at a rate of 9.2 per 1,000 AE and 6.5 per 1,000 AE, respectively. 65 Females were reported to have sustained four times as many ankle injuries in one high school study. 45 Hosea et al. 31 stated that females had a 25% greater risk of sustaining a Grade I ankle sprain. The risk of sustaining an ankle injury was doubled for both men and women at the intercollegiate level as compared to the interscholastic. 31 Previous researchers have considered several factors for increased risk of ankle injury. The three major predictors of ankle injury are previous ankle injury, air cells in the heels of shoes, and the lack of a general stretching program as part of the warm up. 43 The overall general joint laxity that is believed to be a factor in the disparity of ACL injuries in the female athletic population may also be a factor in the risk of sustaining an ankle sprain. 31

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15 Knee Anterior cruciate ligament (ACL) The disparity in the ACL injury rate between males and females has been well documented at all levels of competition. 4,9,24,26,31,36,48 It has been reported that the increased predisposition is two to eight times higher in females. 32,33,65 During the 1988 Olympic basketball trials, a survey was completed that clearly demonstrated the disparity of ACL injuries between males and females. Thirty-four of 64 women had a history of knee injury, compared to 11 of 80 men. Of these, the three males and 13 females had ACL tears and the men and eight females underwent ACL reconstruction. 32 The disparity may not only be between genders but also between levels of play. Female collegiate players were indicated to be 3.66 times at a greater risk of sustaining an ACL injury than scholastic females. 31 Many factors have been postulated as contributing to ACL injury. Intrinsic factors such as joint laxity, hormonal influences, limb alignment, notch dimensions, and ligament size tend to be more sex specific and may not be modifiable. Conditioning, experience, skill, strength, muscle recruitment patterns, and landing techniques are extrinsic factors that are to an extent modifiable. 26,32,36 Exercise may predispose the female athlete to ACL injury by way of increased joint laxity. In a study of 11 semi-professional females, anterior knee laxity was measured six times a day. Laxity did not change during sedentary work in the morning or during a warm-up, but significantly increased with game style practice. At one and one-half hours post practice normal laxity measures had not been reached. Five hours post practice the amount of laxity had returned to normal. 52

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16 As mentioned previously, hormones may influence the incidence of ACL injury. Estrogen and progesterone receptors have been found on the ACL in men and women. 26 During the ovulatory phase of the menstrual cycle, a surge in estrogen production occurs. An increased incidence of ACL injury in women during the ovulatory phase is believed to exist but has not been demonstrated significant (P=0.09). 61,62 Further, it has also been reported that the cyclic rise and fall of estrogen may play an important role in the collagen production of fibroblasts and the tensile strength of the ACL. Other female sex hormones may also impact the ACL. Relaxin has a direct effect on collagen remodeling and is associated with ligament relaxation during pregnancy. Progesterone directly antagonizes the effects of relaxin. 61 Estrogen and progesterone also affect the neuromuscular system. The ability of women to perform motor skills may be adversely affected by the fluctuation of hormones, especially in those that have premenstrual symptoms. During the premenstrual and menstrual periods, female athletes may be more susceptible to injury because of the changes in the neuromuscular system. 61 The effects of estrogen and progesterone on tensile strength of tissues and changes in the neuromuscular system may not only make females more susceptible to ACL injury but also to various other injuries, including hamstring stains. Patellofemoral pain syndrome (PFPS) While anterior cruciate ligament (ACL) injuries are the most often publicized injury of the knee, Starkey 57 wrote that in the NBA “Patellofemoral inflammation may be the silent endemic among professional basketball players.” This statement was based on his findings that the tibiofemoral and patellofemoral complex was the most common site of orthopedic trauma (13.8%), resulted in the greatest amount of time lost (26.6%), and is

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17 second only to the ankle in game-related injuries and incidence rates. 57 Similarly in a study involving the British Columbia Sports Medicine Clinic University, 72% of the basketball related injuries seen at the clinic involved the knee. Forty-four percent of the knee injuries seen were diagnosed as PFPS and 25% were ACL sprains. 24 Hamstring Unfortunately, most epidemiological studies divide the body into areas (i.e., thigh or femur) and not into more specific parts (i.e., hamstring and quadriceps). 2,45,47,48,57,65 Because of this categorization of injury location, it is impossible to determine the incidence of hamstring injury from these studies. While popular belief holds that since females are generally considered to have greater flexibility they should sustain fewer muscle strains, some research has reported otherwise. A comparison of injuries in the WPBL and the NBA indicated that women suffered more strains than the men, especially in the thigh. The difference in the rate of strains (13.8 per 1,000 AE for the women and 7.9 per 1,000 AE for the men) was statistically significant. 65 Similarly, in a study of high school basketball players, 11 females had muscle strains while the men had none. 45 Generally, poor strength and flexibility, improper warm-up, and fatigue are cited as the primary causes of hamstring injuries. 7,63 Bilateral imbalance of hip-joint flexibility, inadequate hamstring to quadriceps strength ratio, and strength imbalances between the left and right leg have also been suggested to be possible risk factors for the increased incidence of hamstring strain. 39 With the female population, an inadequate hamstring to quadriceps strength ratio has also been cited as a major risk factor for ACL injury. 26 Also of significance to the female athletic population is what effect do female

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18 sex hormones play in muscular injury; these hormones are believed to affect the structure and composition of a variety of tissues. 61 Stress fracture In general, basketball players are at a high risk of sustaining stress fractures because of repetitive running, cutting, and jumping. 8 In a study conducted at the Australian Institute of Sport, the authors indicated that 9.0% of all injuries were stress fractures. 30 While not broken down into types of fractures, Starkey 57 reported that 3.0% of all injuries in the NBA were fractures. Women are possibly at a higher risk than men of sustaining a stress fracture because of differences in bone mass, musculoskeletal fitness, endocrine factors, and biomechanically unfavorable conditions. 44 Certain dietary factors and menstrual history also may have an affect on the incidence of stress fractures in females. 5 Musculoskeletal fitness becomes an important factor when fatigue of muscles causes more force to be transmitted to the bone resulting in an increased mechanical load being placed on the bone during high repetition (i.e., distance running) or high-intensity loading (i.e., sprinting, jumping) activities. Therefore, those who are weaker or lack muscular endurance are at a greater risk for suffering stress fractures. 5,40 The tibia is the most common site of stress fracture for both men and women. 5,30 However, women tend to have more femoral, metatarsal, and pelvic stress fractures than men. 5 Other Injuries and Health Concerns In the NBA, one quarter of the reported conditions were not orthopedic. 57 These conditions involved the eye and various illnesses.

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19 Eye The International Federation of Sports Medicine has designated basketball as being a high risk sport for eye injuries. 24 It has been suggested that basketball is second only to baseball in number and severity of occular trauma. 24,42 In the NBA, 5.4% of all injuries were to the eye and adnexa. 64 A ten-year study at a Division I university indicated that 10.7% of all basketball competitors sustained eye injuries each year and that the injuries were four times more likely to occur in practice than games because 4 to 5 times more time was spent in practice. 42 Contrary to these findings, Zagelbaum 64 reported that 88.1% of eye injuries in the NBA occur during regular and postseason games. During the regular season 1.44 eye injuries occurred per 1,000 athletic exposures. The rate significantly increased to 2.48 per 1,000 AE during the post-season. 64 It has been suggested that college and professional basketball players are more at risk for severe eye injuries because of the strength and speed associated at these levels. 24 A small majority (50.9%) of eye injuries in the NBA were abrasions/lacerations of the eyelid. Twenty-eight point eight percent of the injuries were contusions to the eyelid or periorbital region, 11.9% were corneal abrasions, and 5.1% were orbital fractures. 64 Of those sustaining eye injuries, 15.3% missed games and 8.5% missed practices as a result. 64 Several mechanisms have been cited as causes of these injuries. 24,42,64 Fingers (35.6%) and elbows (28.8%) to the eye while rebounding (30.5%) and playing offense (27.1%) produced the most eye injuries. 64 In most cases (96.6%), protective eyewear was not being worn. 64 Illnesses Systemic conditions were the most prevalent illnesses in the NBA representing 21.6% of all reports, of these upper respiratory infections were the most common

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20 conditions (16.7%). 57 In a study of Division I athletes a similar high incidence of upper respiratory infection was attributed to the long season which takes place during the winter months. It was suggested that the incidence was probably no different than that from the general population. 19 Gastrointestinal problems (3.5%), local and systemic infections (0.9%), and dermatological conditions (0.9%) were other frequently treated conditions in the NBA. 57 Pregnancy While the issue of pregnancy in elite female athletes is an interesting topic, it also brings up several concerns for both the mother and the fetus, 10,13,15,16,20,25,34,46 which is beyond the scope of this project. However, it should be noted that pregnancy in the WNBA presents a large time loss factor since the collective bargaining agreement treats pregnancy as an injury for which the athlete receives pay and benefits. Injury by Position Though today’s style of basketball often blurs player positions, 18.9% of all injuries in the NBA occurred in centers, 40.7% in forwards, and 40.3% in guards. Per 1,000 athletic exposures, forwards had the highest injury rate at 21.7, followed by guards 21.3 and centers 21.0. The differences were not significant. 57 Apple 3 indicated that guards and forwards in the NBA were more likely to sustain a knee injury while centers were more likely to injure their backs. In a 1985 study, 15 out of 24 ACL sprains occurred in guards while nine occurred in centers. 22 Different mechanisms were indicated for ACL injury for these two positions. A jumping and landing mechanism was three times more common in centers while the most common mechanism of ACL rupture in guards involved a twisting or pivoting action. 22 These mechanisms are more prominent in the associated position.

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21 Centers appear to be at a greater risk for eye injury. 64 Most eye injuries have been reported to occur while rebounding and while on offense. 64 Since centers are closer to the basket they tend to be involved in more rebounding opportunities. Centers also tend to be more closely guarded than do other position players. Time of Injury Occurrence Studies that have looked at time of injury occurrence have demonstrated that the absolute number of injuries in practice is higher than that found in competition. In 1978, while looking at injury rates in high school basketball, Moretz and Grana 45 reported that 39 out of 43 girls’ injuries and 6 out 8 boys’ injuries occurred during practice. However, Garrick and Requa 21 suggested that the higher number of injuries during practice is due to the fact that the entire team is at risk simultaneously while competition limits the number at risk at a given moment; also because time in practice exceeds the time in competition. Similarly, Whiteside 60 suggested that the relative frequency of injury in practice was proportional to the time the athlete was at risk. It was also proposed that per unit of exposure, competition presents the highest risk. 60 More cases occurred for males (58.0%) and females ( 53.2%) at practice than at games. However per 1,000 AE, two times as many cases occurred during games than practices for both males and females. 51 In a study completed in 1980 that looked at women’s injuries in collegiate sports, 22% of basketball AE were game related, but 35% of the significant injuries occurred in games. 12 Also of concern is when during the course of the game do injuries tend to occur. According to a study presented in 1987 at the National Athletic Trainers’ Association convention, 60% of game related injuries occur during the second half. 17 It was suggested that this is a result of fatigue, staleness after half time, improper warm-up after half time, and improper strength and conditioning during the preseason. 6

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22 Another factor associated with game injury rates is whether the injury occurs at home or on the road. In the NBA, 43.2% of the injuries were game related. Of these, 55.1% occurred at home while 44.9% occurred on the road. 57 As for injury rates per body part, most followed the same patterns for injury in general. The most significant variant was the eye injury rate. In a study that examined the eye injury rate in the NBA, it was stated that 88.1% of eye injuries occur during regular and postseason games. During the regular season 1.44 eye injuries occurred per 1,000 athletic exposures. The rate significantly increased to 2.48 per 1,000 AE during the post-season. 64 When considering time of injury occurrence, one must also consider the time in the season or year. According to Apple et al. 3 , 46.7% of all injuries in the NBA occurred before the first 27 games of an 82-game regular season were played. Broken down, 17.8% of those occurred during the 30-day preseason and 28.9% during the first 26 games. The middle third of the season produced 19.6% of the injuries while the final third provided 15.4%. The playoffs, in which only a limited number of teams participate for a 1-5 week period, resulted in 11.4% of the injuries. An additional 7% of the injuries occurred during the off-season. Similarly to these findings, the majority of high school basketball injuries occurred during the first half of the season. 45 Contributing Factors to Increased Injury Risk in Females In 1976, it was suggested that the mechanisms of injury appear to be similar in men and women. Differences in the overall rate of injury in athletic programs existed due to the different sport activities that people chose and was not related to structural or physiological differences. 1 The extrinsic factors for injury associated with basketball include level of competition, equipment, playing time, facilities, and coaching. 9,31 At any

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23 given level of basketball, these should be equal between the sexes. However, on some occasions not all extrinsic factors are equal between the sexes. However, when looking at comparable sports (i.e., men’s and women’s basketball), a higher incidence of injury in the women’s sport does often appear. The higher incidence of injury in the female athletic population has been attributed most frequently to a lack of or improper conditioning. 12,27,45 Intrinsic factors such as limb alignment, strength, strength imbalances, joint stability, and generalized joint laxity have also been suggested to increase the risk of injury for female athletes. 9,31 Of the intrinsic factors, limb alignment plays an important role because in basketball two of the most common mechanisms of injury are landing on the foot of another player after a rebound or jump shot and quick changes of direction or cutting. 19 Both of these mechanisms involve the lower extremity. This is of particular concern for the athlete who has a biomechanically unfavorable condition in the lower extremity. The primary condition of concern in the female athletic population is a wider pelvis. A wider pelvis results in a greater Q angle. 37 An increased Q angle has been suggested to predispose athletes to patellar dislocations/subluxations, chondromalacia of the patella, and ACL tears. 14,26,37 Physiological Characteristics In 1979, two studies were published that analyzed the physiological characteristics of elite basketball players. 11,59 One evaluated females 59 while the other assessed males. 11 Overall the elite collegiate female basketball players were taller and heavier than the average female and former basketball players. These elite athletes also had above normal pulmonary function, were significantly stronger, and had significantly less fat than the average female and former basketball players. The authors suggested

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24 that this reflected a trend toward an increase in the intensity of training and conditioning programs. They stated that at that time women’s basketball was a skill oriented game with emphasis on shooting, passing, and dribbling. They hypothesized that the increased emphasis on women’s basketball at that time would lead to maximal refinement of those skills, thus increasing the importance of aerobic capacity and strength. 59 When comparing the physiological characteristics of the males and females, the elite male basketball players had greater muscular endurance, strength, aerobic capacity, and less relative body fat. The males were also significantly taller and heavier than the female athletes. 11,59 Recommendations for Decreasing the Injury Rate For prevention of specific injuries, prophylactic and protective equipment is often suggested. To reduce the number and severity of eye injuries, protective eye wear made of 3 mm thick polycarbonate lens with unbreakable frames is recommended. 24,42,64 Prophylactic knee and ankle bracing/taping is believed to decrease the frequency of injuries to these structures. 43,55,56 As was mentioned previously, a lack of or improper conditioning is often cited as a primary cause of injury in female athletes, particularly in muscular injuries. While strains were the most common injury for both males and females in the NBA and WPBL, 65 the incidence was so low at the Australian Institute of Sport that it was not even listed. 30 The low incidence of strains at the AIS may be attributed to the fact that the athletes train intensely year round. During the preseason, the athletes complete 20 training sessions per week. Each session at the institute lasts from 1-2 hours. In the competitive season, they partake in 16 sessions and 2-3 games per week. During the

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25 postseason, the athletes participate in 9 sessions per week, in an overseas tour, and compete in the Under-18 National Championship. 30 Besides improper conditioning, improper technique could be a significant factor for injury in female athletes. For example, females tend to cut in a more erect posture with less knee and hip flexion and more knee valgus. This position combined with the greater relative quadriceps activation puts the knee joint in a position that gives the quadriceps a mechanical advantage over the hamstrings which often results in a quadriceps-induced anterior drawer. 36 A study has been presented in which NCAA Division I female basketball players were trained to perform cuts in a three-step pattern in which the knee was flexed and the feet were kept under the hips. During a two-year period, ACL injuries were reduced by 89% in the study group. 36 Poor landing mechanics may also influence the incidence of injury in female athletes. A relationship between high landing forces and an increased rate of knee injury has been established. 18 A plyometric training program designed to decrease landing forces by teaching neuromuscular control of the lower limb during landing was tested in a group of high school volleyball players. After training, it was observed that landing forces decreased 22% and knee adduction and abduction moments decreased approximately 50%. Previous research has indicated that abduction and adduction movements greater than 35 N-m during landing elicited pain. 50 The collateral ligaments were reported to be at risk for injury at 29 N-m. 41 Pre-training Hewett et al. 29 indicated that the abduction and adduction forces on landing were 42 N-m and 36 N-m, respectively. After training, the forces were reported to be 20 N-m and 22 N-m. 29

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26 Additionally, the hamstring-to-quadriceps peak torque ratios increased on both the dominant and non-dominant side and the side-to-side imbalance between the two were corrected with the training program. As mentioned previously, this imbalance of strength between the hamstring and quadriceps and between the dominant and non-dominant sides could pose an increased risk of both ACL sprains and hamstring strains. Also of significance was that the mean vertical jump increased 10% and hamstring power increased 21% on the non-dominant side and 44% on the dominant side. 29 The increased risk for females of sustaining an ACL injury has also been attributed to female sex hormones. 61 Women taking birth control pills had a lower ACL injury rate in one study, suggesting a protective effect of hormone level stabilization. 61 Conclusion Since a common definition of injury has not been used in most of the studies, it is impossible to compare the statistics accurately to determine at which level of play more injuries occur per athletic exposure. However, several generalizations can be made. The greatest number of injuries appear to occur to the lower extremity. 28,35,57 Several intrinsic and extrinsic factors may predispose female athletes to a higher injury rate. 26,32,36,44 More research needs to be completed on the types of injuries sustained by athletes at all levels of competition. Along with injury rates, the mechanism of injuries and specific factors associated with injury should be examined. The ability to decrease the injury rates in male and female basketball players alike through the various techniques mentioned should also be further examined for there effectiveness.

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CHAPTER 3 MATERIALS AND METHODS Subjects All subjects were participants in the Women’s National Basketball Association (WNBA). As of the 2002 season, the WNBA consisted of a total of 16 teams. When the league was founded in 1997, it consisted of only eight teams. In 1998 and 1999 two teams were added to the league. While in 2000, the league added four more teams bringing the total to 16. In the league’s six years a total of 813 women have appeared on a team’s roster, or an average of 135.5 players in the league per year. Instruments Data were collected by using the WNBA’s injury and illness report form (Appendix A), the Official WNBA Guide and Register, and the WNBA’s web site ( http://www.wnba.com ). A similar injury and illness report form was used in Starkey’s 57 study that analyzed injuries and illnesses in the NBA. Starkey 57 also used a similar register and web site for his study. The specific injury and injury nature from the WNBA’s injury and illness report form was coded using the National Athletic Injury/Illness Reporting System (NAIRS). All data were entered into SPSS-PC, version 10.0 (SPSS, Inc, Chicago, IL). WNBA Injury and Illness Report Form The WNBA injury and illness report form was completed by the team’s certified athletic trainer when an athlete became injured or ill. The data collected consisted of player position, age, experience, height, weight, where and when injury occurred, quarter, 27

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28 general and specific body part, specific structure and injury or illness, side, onset, injured list status, practices and games missed, seen by physician, required hospitalization and/or surgery, mechanism, activity, medication, taping or bracing, cut of shoe, and eyewear used. Official WNBA Guide and Register The Official WNBA Guide and Register is the WNBA’s official statistical publication. It provides a record of the total number of game related athletic exposures (AE) and competition minutes (CM) per athlete for each completed season. The register is published yearly. WNBA’s Web Site The WNBA’s official web site ( http://www.wnba.com ) also provides a record of the total number of game related AE and CM. The web site contains the current season’s statistics and was used only to obtain the 2002 regular and postseason statistics. Procedures Permission to study injuries and illnesses in the WNBA was granted by the league’s legal counsel after a formal proposal was reviewed and accepted. Following approval from the University of Florida Institutional Review Board, the injury and illness report forms obtained from the WBNA were coded by the primary investigator, using the NAIRS coding system for the specific injury and injury nature. Using the Official WNBA Guide and Register and the WNBA’s official web site, total game-related AE and CM were determined. To compare the data from this study with similar studies, game-related injury rate was calculated per 1,000 AE. 57 One athlete appearing in one game equals one AE. In the WNBA, the maximum AE would be 22 if all 11 players from each team participate in the contest. Incidence rates for AE were calculated using the formula:

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29 number of injuries (group)/total game exposures (group) X 1,000. While AE is the most common way to report injury rates, it lacks sensitivity by not taking into account the amount of time the athlete was participating. 57 As such, CM were also calculated for this study. Each regulation game represents 400 total minutes of participation (10 players on the court for 40 minutes). Incidence rates for CM were calculated using the formula: number of injuries (group)/total game minutes played (group) x 10,000. Following coding of the injuries/illness and collection of other pertinent data, the data were entered into a computerized database. The accuracy of the coding was tested by randomly selecting 10% of the forms (n= 230) and recoding them to test consistency of the primary investigator. Design The study design was a retrospective epidemiological study. The study examined the frequencies, means, standard deviations, and frequency rates of injuries and illnesses in the WNBA as related to player position, age, where and when the injury occurred, mechanism, activity, and time lost. The dependent variables were rate of injury and time lost from participation. The independent variables were player position, age, injury type, time and place of occurrence, protective taping and/or bracing, cut of shoe, and eyewear used. Analysis In order to determine if any significant differences exists between the dependent and independent variables, descriptive and inferential statistics were used to assess the frequencies and severity of injuries.

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30 Descriptive analysis included frequencies, percentages, and ratio assessments to assess the variables of playing situation (game vs. practice), injury nature, injury severity, player position, specific site of injury, injury mechanism, and amount of time lost. A comparative analysis was conducted in order to determine if a statistically significant difference between the injury natures, general and specific sites of injury, mechanism of injury, player position, and time and place of injury occurrence existed. Pearson’s chi-square tests were used to test for significant differences between the variables of interest (i.e., ankle injury versus other anatomical structures, ankle tape/brace versus no tape/brace, chronic versus acute knee injuries, time of play in game and season, and player position). An alpha level of .05 was established a priori. The Statistical Package for Social Sciences (SPSS) was used to analyze the data.

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CHAPTER 4 RESULTS The purpose of this investigation was to determine the frequency of injuries and illnesses in the WNBA. This study was designed to investigate the most common types of injuries, mechanisms of injury, activities leading to the injury, time and place of injury occurrence, and the time lost to the injury. Data for this study were gathered during the 1997-2002 WNBA seasons. Accuracy of the Coding The accuracy of the coding was tested by randomly selecting 10% of the forms (n= 191) and recoding them to test consistency of the primary investigator. The accuracy of the coding was found to be 97.9%. Descriptive Analysis Subject Participation Subjects (N=813) participated in official league activities, totaling approximately 25,330 game-related athlete exposures (AE) and 524,550 competition minutes (CM). A total of 1,903 injuries and illnesses were reported for 407 subjects. Injured athlete demographics are presented in Table 1. Table 1. Injured Player Demographics n=407 Minimum Maximum Mean SD Age (years) 18.0 39.0 26.5 3.9 Height (cm) 152.4 218.4 182.5 9.5 Weight (kg) 49.8 126.7 76.0 11.3 31

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32 Injury and Illness Rates A total of 1,747 injuries were sustained during practices and games. An overall game-related injury rate of 23.5/1,000 AE or 11.5/10,000 CM was documented. General medical conditions (n=156) accounted for 8.2% of all reported cases. Injury and Illness Nature Injury and illness nature frequencies are displayed in Tables 2 and 3. Sprains (25.7%) were the most common type of injury, with the ankle sustaining the most (49.4%) sprains. Additional injuries sustained included inflammation (21.1%), strains (15.4%), contusions (11.0%), and fractures (3.9%). Table 2. Injury Frequency Classified by Nature All Injuries and Illnesses (n=1,903), All injuries (n=1,747) Injury/Condition Frequency(%) Days Missed(%) Sprain 490(25.7%) 1523(16.5%) Inflammation 382(21.1%) 1694(18.4%) Strain 294(15.4%) 1271(13.8%) Contusion 209(11.0%) 358(3.9%) Fracture 75(3.9%) 531(5.8%) Skin Wound 56(2.9%) 55(0.6%) Spasm 44(2.3%) 127(1.4%) Neurologic 31(1.6%) 89(1.0%) Upper Respiratory Infection 25(1.3%) 1(0.0%) Gastrointestinal 24(1.3%) 17(0.2%) Eye 24(1.3%) 8(0.0%) Dental 22(1.2%) 21(0.2%) Meniscal 16(0.8%) 157(1.7%) Note : Injuries representing less than 1.0% of the total were excluded from this table, except those of special interest to this investigation

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33 Table 3. Injury Frequency Classified by Nature Game-Related Injuries and Illnesses (n=615) Injury/Condition Frequency (% of type) Game Injuries (%) Rate per 10,000 CM A Rate per 1,000 AE B Sprain 227(46.3%) 36.9% 4.3 9.0 Inflammation 55(14.4%) 8.9% 1.0 2.2 Strain 90(30.6%) 14.6% 1.7 3.2 Contusion 119(56.9%) 19.3% 2.3 4.7 Fracture 32(42.7%) 5.2% 0.6 1.3 Skin Wound 28(50.0%) 4.6% 0.5 1.1 Spasm 10(22.7%) 1.6% 0.2 0.4 Neurologic 17(54.8%) 2.8% 0.3 0.7 URI 0(0.0%) 0.0% 0.0 0.0 Gastrointestinal 1(4.2%) 0.2% 0.0 0.0 Eye 13(54.2%) 2.1% 0.2 0.5 Dental 8(36.4% 1.3% 0.2 0.3 Meniscal 5(31.3%) 0.8% 0.0 0.2 Note : Injuries representing less than 1.0% of the total were excluded from this table, except those of special interest to this investigation A CM, competition minute B AE, Athletic Exposure Anatomical Site of Injury The summaries of injuries to general and specific body parts are presented in Tables 4 through 9. The lower extremity was the most frequently injured area (60.1%) resulting in the most total time lost. The most frequently injured body parts were the knee (15.2%), ankle (14.4%), and patella (6.8%). Table 4. Injury Frequency Classified by Body Area All Injuries and Illnesses (n=1,903) Body Area Frequency (%) Days Missed (%) Head 186(9.8%) 161(2.8%) Neck 27(1.4%) 67(1.2%) Upper Extremity 252(13.2%) 492(8.8%) Torso 138(7.3%) 556(10.0%) Lower Extremity 1144(60.1%) 4171(74.8%) General Medical 156(8.2%) 131(2.4%) Total 1903(100%) 5578(100.0%)

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34 Table 5. Injury Frequency Classified by Body Area Game-Related Injuries and Illnesses (n=615) Body Area Frequency (% of area) Game Injuries (%) Rate per 10,000 CM A Rate per 1,000 AE B Head 90(48.4%) 15.1 1.7 3.6 Neck 7(25.9%) 1.2 0.1 0.3 Upper Extremity 114(45.2%) 19.1 2.2 4.5 Torso 39(28.3%) 6.6 0.8 1.5 Lower Extremity 335(29.3%) 56.3 6.4 13.2 General Medical 10(6.4%) 1.7 0.3 0.4 Total 595(31.3%) 100.0% 11.5 23.5 A CM, competition minute B AE, Athletic Exposure Table 6. Injury Frequency by Structure All Injuries and Illnesses (n=1,903) Structure Frequency(%) Days Missed(%) Knee 290(15.2%) 1360(14.8%) Ankle 274(14.4%) 970(10.5%) General Medical 155(8.1%) 71(0.8%) Patella 130(6.8%) 286(3.1%) Foot 120(6.3%) 418(4.5%) Lumbar 86(4.5%) 439(4.8%) Fingers 79(4.2%) 123(1.3%) Shoulder 63(3.3%) 206(2.2%) Eye 38(2.0%) 21(0.2%) Mouth 31(1.6%) 13(0.1%) Neck 27(1.4%) 67(0.7%) Note : Injuries representing less than 1.0% of the total were excluded from this table, except those of special interest to this investigation

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35 Table 7. Injury Frequency by Structure Game-Related Injuries and Illnesses (n=615) Structure Frequency (% of area) Game injuries (%) Rate per 10,000 CM A Rate per 1,000 AE B Knee 90(31.0%) 14.6% 1.7 3.6 Ankle 123(45.3%) 20.0% 2.3 4.9 General Medical 10(6.5%) 1.6% 0.2 0.4 Patella 27(20.8%) 4.4% 0.5 1.1 Foot 29(24.2%) 4.7% 0.6 1.1 Lumbar 21(24.4%) 3.4% 0.4 0.8 Fingers 34(43.0%) 5.5% 0.6 1.3 Shoulder 26(41.3%) 4.2% 0.5 1.0 Eye 20(52.6%) 3.3% 0.4 0.8 Mouth 15(48.4%) 2.4% 0.3 0.6 Neck 7(25.9%) 1.1% 1.3 0.3 Note : Injuries representing less than 1.0% of the total were excluded from this table, except those of special interest to this investigation A CM, competition minute B AE, Athletic Exposure

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36 Table 8. Injury Frequency by Specific Structure All Injuries and Illnesses (n=1,903) Specific Injury Frequency(%) Days Missed(%) Ankle Sprain 216(11.4%) 690(7.5%) Patellar Tendonitis 95(5.0%) 209(2.3%) Knee Sprain 72(3.8%) 505(5.5%) ACL rupture 16(0.8%) 177(1.9%) Knee Inflammation 72(3.8%) 157(1.7%) Finger Sprains/Dislocation 57(3.0%) 19(0.2%) Hamstring Strain 50(3.0%) 126(1.4%) Knee/Patella contusion 48(2.5%) 183(2.0%) Plantar Fascitis 48(2.5%) 168(1.8%) Head/Face Lacerations 39(2.0%) 17(0.2%) Lumbar Strain 38(2.0%) 230(2.5%) Quadriceps Strain 36(1.9%) 120(1.3%) Meniscus C 32(1.7%) 254(2.8%) Lumbar Spasm 30(1.6%) 113(1.2%) Hip Flexor Strain 29(1.5%) 123(1.3%) Thumb Sprain 28(1.5%) 14(0.2%) Adductor Strain 28(1.5%) 101(1.1%) Quadriceps Contusion 26(1.4%) 14(0.2%) URI 25(1.3%) 1(0.0%) Concussion 25(1.3%) 74(0.8%) Gastrointestinal 24(1.3%) 17(0.2%) Eye Abrasion/Laceration 23(1.2%) 4(0.0%) Chondromalacia 20(1.1%) 20(0.2%) Gastrocnemius 20(1.1%) 98(1.1%) Note : Injuries representing less than 1.0% of the total were excluded from this table, except those of special interest to this investigation C Includes meniscal tears associated with ligament sprains

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37 Table 9. Injury Frequency by Specific Structure Game-Related Injuries and Illnesses (n=615) Specific Structure Frequency (% of area) Game Injuries (%) Rate per 10,000CM A Rate per 1,000 AE B Ankle Sprain 107(49.5%) 17.4% 2.0 4.2 Patellar Tendonitis 9(9.5%) 1.5% 0.2 0.4 Knee Sprain 36(50.0%) 5.9% 0.7 1.4 ACL rupture 8(50.0%) 1.3% 0.2 0.3 Knee Inflammation 9(12.5%) 1.5% 0.2 0.4 Finger Sprain/Dis 12(21.1%) 2.0% 0.2 0.5 Hamstring Strain 15(30.0%) 2.4% 0.3 0.6 Knee/Patella contusion 21(43.8%) 3.4% 0.4 0.8 Plantar Fascitis 10(20.8%) 1.6% 0.2 0.4 Head/Face Lacerations 21(53.8%) 3.4% 0.4 0.8 Lumbar Strain 10(26.3%) 1.6% 0.2 0.4 Quadriceps Strain 0(0.0%) 0.0% 0.0 0.0 Meniscus C 10(31.3%) 1.6% 0.2 0.4 Lumbar Spasm 10(33.3%) 1.6% 0.2 0.4 Hip Flexor Strain 3(10.3%) 0.5% 0.1 0.1 Thumb Sprain 14(50.0%) 2.3% 0.3 0.6 Adductor Strain 4(14.3%) 0.7% 0.1 0.2 Quadriceps Contusion 12(46.2%) 2.0% 0.2 0.5 URI 0(0.0%) 0.0% 0.0 0.0 Concussion 14(56.0%) 2.3% 0.3 0.6 Gastrointestinal 1(4.2%) 0.2% 0.0 0.0 Eye Abrasion/Lac 8(34.8%) 1.3% 0.2 0.3 Chondromalacia 0(0.0%) 0.0% 0.0 0.0 Gastrocnemius 9(45.0%) 1.5% 0.2 0.4 Note : Injuries representing less than 1.0% of the total were excluded from this table, except those of special interest to this investigation A CM, competition minute B AE, Athletic Exposure C Includes meniscal tears associated with ligament sprains Mechanism and Activity at Time of Injury Excluding chronic, overuse, and insidious conditions (22.6%), mechanisms at time of injury with highest incidence were non-athletic (9.1%), dynamic overload (6.9%), elbowed (6.4%), stepped on the foot of another (6.1%), and fell on the floor (5.3%). Non-athletic conditions were typically general medical conditions. Conditions by mechanism are presented in Tables 10 and 11.

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38 Table 10. Injury and Illness Frequency by General Mechanism Mechanism Frequency % of Mechanism Contact-Player 482 28.2% General Mechanism 572 33.4% Contact-Object 170 9.9% Other 488 28.5% Table 11. Injury and Illness Frequency by Specific Mechanism Note : Specific mechanisms with a frequency less than 50 were grouped into the other category for its general mechanism Mechanism Frequency % of Mechanism Contact-Player Elbowed 110 6.4% Stepped on Foot 104 6.1% Kneed/Kicked 74 4.3% Other 196 11.4% Con-Object Fell on Floor 91 5.3% Hit by Ball 67 3.9% Other 9 0.5% Gen Mechanism Overuse 215 12.6% Dynamic Over. 118 6.9% Overstretched 75 4.4% Inversion 63 3.7% Other 89 5.2% Other Chronic/Insid 206 12.0% Non-athletic 156 9.1% Unknown 72 4.2% Other 43 2.5% Excluding chronic and insidious conditions, activities at time of condition with highest incidence were defensive rebounding (9.1%), offensive rebounding (6.0%), and driving (5.5%). Chronic and insidious conditions accounted for the highest percentage (22.2%). Conditions by activity are presented in Tables 12 and 13.

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39 Table 12. Injury and Illness Frequency by General Activity Activity Frequency % of Activity Offense 385 24.4% Defense 361 22.9% Loose Ball 156 9.9% General 677 42.8% Table 13. Injury and Illness Frequency by Specific Activity Activity Frequency % of Activity Offense Rebounding 114 7.2% Driving 106 6.7% Shooting 50 3.2% Other 108 6.8% Defense Rebounding 174 11.0% Other 116 7.3% Loose Ball Running 57 3.6% Collision 51 3.2% Other 41 2.6% General Chronic/Ins 350 22.2% Non-athletic 173 11.0% Weight/Con 55 3.5% Other 54 3.4% Note : Specific mechanisms with a frequency less than 50 were grouped into the other category for its general activity Injuries and Illnesses by Player Position Presented in Table 14 is a summary of injuries and illnesses by player position. Chi square analysis revealed no significant difference in game-related injuries among guards (24.2/1,000 AE), forwards (20.6/1,000 AE), and centers (20.2/1,000 AE).

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40 Table 14. Injuries and Illnesses by Player Position Position Freq of All(%) Freq of Game-Related(%) Rate per 10,000 CM A Rate per 1,000 AE B Guard 766(40.2%) 271(44%) 12.9 26.7 Forward 750(39.3%) 223(37.6%) 10.6 22.0 Center 391(20.5%) 111(18.4%) 10.6 21.9 A CM, competition minute B AE, Athletic Exposure Practice versus Game Table 15 presents frequency of injuries/illnesses by when they occurred with regards to game or practice. Table 15. Frequency of Injuries and Illnesses by When (Game versus Practice) When Frequency Percent Days Missed Days Missed per Injury Game 615 36.5% 1679 2.73 Practice 658 39.0% 2446 3.72 Chronic 233 13.8% 810 3.48 Other 181 10.7% 154 0.85 Injuries by Half of Game Frequencies of conditions by when they occurred during the course of the game are presented in Table 16. Table 16. Frequency of Injuries and Illnesses by When in Game When Frequency Percent Pre-Game 14 2.6% 1 st Half 207 38.8% 2 nd Half 244 45.7% Overtime 5 0.9% Post Game 8 1.5% Other 56 2.9% Injuries by Time in Season Frequencies of game-related conditions by when they occurred during the course of the season are presented in Table 17.

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41 Table 17. Rate of Game-Related Conditions by Time in Season Time in Season Freq CM AE Exposures/10,000 CM Exposures/1,000AE Preseason 33 --------1 st Half 275 247,575 12,018 11.1 22.9 2 nd Half 248 247,575 12,018 10.0 20.6 Postseason 55 29,400 1,294 18.7 42.5 Days Missed From Basketball A partial breakdown of days missed from participation is presented in Table 18. The majority of reported injuries (n=928, 53.7%) resulted in no time loss. Season ending injuries/illnesses accounted for 4.6% (n=88) of all conditions. Ankle injuries resulted in the greatest time loss at 7.5%. Table 18. Frequency and Percentage of Time Loss # of Days Missed Frequency Percent 0 928 53.7% 1 215 12.4% 2 121 7.0% 3 77 4.5% 4 57 3.3% 5 39 2.3% 6 35 2.0% 7 36 2.1% 8-20 153 8.8% 21-57 68 4.4% Other Points of Interest Athletes were placed on the injured reserve list in 18.4% of the cases. During the time of this investigation, 3.9% of the injuries required surgical intervention. A medication was prescribed in 48.1% of the reported cases. Concussions occurred at a rate of .55 per 1,000 game related AE (n=14, 2.3%) with 56.0% of the total concussions occurring in games. The anterior cruciate ligament was torn at a rate of .32/1,000 AE

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42 (n=8, 1.3%) with 50.0% of the total ACL ruptures (n=15) occurring in games. The frequency of injuries throughout the league’s history appears consistent (See Table 19). Table 19. Frequency of Injuries and Illnesses by Season Year Freq Game Freq Total CM Total AE Rate per 10,000 CM A Rate per 1,000 AE B 1997 137 53 46,500 2,142 11.4 24.7 1998 263 86 63,650 3,157 13.5 27.2 1999 257 84 82,250 4,059 10.2 20.7 2000 450 149 110,050 5,341 13.5 27.9 2001 382 116 111,350 5,349 10.4 21.7 2002 421 127 110,750 5,282 11.5 24.0 A CM, competition minute B AE, Athletic Exposure Chi Square Analyses Descriptive techniques are not the only methods that were used to analyze the injury data. Inferential statistics were used to determine statistical significance. Pearson’s Chi square ( 2 ) tests were completed for differences between ankle and knee injuries, chronic versus acute knee injuries, time in game, time in season, and player position at time of ACL injury. A p value of 0.05 was used to determine significance. Adjustments were made for athletic-exposure comparisons for player position based on number of players occupying the position during the game [guard (2/5), forward (2/5), and center (1/5)]. Ankle Versus Knee Injuries While the number of injuries occurring to the knee (n=290) compared to those occurring to the ankle (n=274) was not significantly different ( 2 =0.45, df=1, p=0.5), the ankle was sprained (n=216) significantly ( 2 =72, df=1, p<0.01) more often than the knee (n=72). Ankle sprains also resulted in significantly ( 2 =28.64, df=1, p<0.01) more time lost from participation (n=690 missed) than did knee sprains (n=505 missed). Of the 216

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43 ankle sprains reported, it was also reported that 65 of the ankles were taped, 24 braced, and 43 had neither. Chronic Versus Acute Knee Injuries Athletes in the WNBA suffered more chronic knee injuries (n=167) than acute (n=152) but the difference was not significant ( 2 =0.46, df=1, p=0.50). Specifically, they acquired more patellar inflammatory conditions (n=95) than acute knee sprains (n=72) but again the difference was not statistically significant ( 2 =2.44, df=1, p=0.12). However, acute knee injuries required significantly ( 2 =253.7, df=1, p<0.01) more days missed (n=942) than did chronic injuries (n=366). Likewise, acute knee sprains (n=505) resulted in significantly more time loss ( 2 =122.7, df=1, p<0.01) than did inflammatory conditions about the patella (n=209). Time in Game and Time in Season More injuries occurred in the second half of the game (n=244) than the first (n=207), but the difference was not significant ( 2 =3.04, df=1, p=0.08). Significantly more injuries occurred in the first half (n=764) of the regular season than in the second (n=493) ( 2 =58.43, df=1, p<0.01). During the first half of the season (n=275) injuries occurred at a rate of 11.1/10,000 CM (22.9/1,000 AE). The rate was 10.4/10,000 CM (20.6/1,000 AE) during the second half and 18.7/10,000 CM (42.5/1,000 AE) during the post-season (n=55). Athletes in the WNBA sustained 1,246 injuries at or before the first half of the season was completed compared to only 664 in the second half. Again, significance cannot be determined without practice exposure rates. As mentioned previously, injury rates for practices versus games cannot be compared because exposure rates were not kept for practices. However, 615 injuries occurred in games while 658 occurred in practices.

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44 Player Position and ACL Injuries Sixteen ACLs were ruptured during league activities through the WNBA’s first six seasons. Guards sustained 8 ruptures, forwards 6, and centers 2. Due to the fact that typically, two guards, two forwards, and one center are at play at any given time and thus rosters are adjusted for this, the Chi Square was thus calculated relatively. As such, the differences between the guards, forwards, and centers in ACL injury rate were not significant ( 2 =0.875, df=2, p=0.65). Eight or 50.0% of the ACL injuries occurred in games at a rate of 0.32 per 1,000 AE or 0.2 per 10,000 CM.

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CHAPTER 5 DISCUSSION Research has been completed examining and comparing overall and specific injury rates for male and female athletes at the high school and collegiate level. Except for the article by Zelisko et al. 65 comparing injury rates of a team in the WPBL to one in the NBA, no research has been completed on the injury and illness rates in women’s professional basketball. Based on this previous research many coaches, physicians, researchers, and athletic trainers believe that female athletes sustain a greater number of injuries as compared to their male counterparts. This study was conducted due to the lack of current data available on injuries and illnesses in women’s professional basketball. The purpose of this investigation was to determine the frequency of injuries and illnesses in the WNBA. This study was designed to investigate the most common types of injuries, mechanisms of injury, activities leading to the injury, time and place of injury occurrence, and the time lost to the injury. Data for this study were gathered during the 1997-2002 WNBA seasons. Discussion A total of 1,903 injuries/illnesses were sustained by 50.1% (n=407) of the 813 subjects included in this study. The overall game-related injury rate for the study was 23.5 injuries/1,000 AE or 11.5 injuries/10,000 CM. The injury per exposure rate is similar to their male counterparts in the NBA who experienced an injury rate of 21.4 injuries per 1,000 AE. 57 However, when expressed as rate per CM, the WNBA players experienced 30% more injuries as compared to the NBA (8.8 per 10,000 CM 57 ). When 45

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46 comparing the injury rates in the WPBL to those in the NBA Zelisko et al. 65 noted that the women sustained 60% more injuries than the men. Females were injured at a rate of 51.2 per 1,000 AE compared to 32.0 per 1,000 AE for males. 65 The NCAA Injury Surveillance System listed the 1998-1999 basketball injury rates per gender. 47,48 The women studied sustained 5.1 injuries per 1,000 athletic exposures during practice and 9.2 injuries per 1,000 athletic exposures during games. The men sustained 3.8 injuries per 1,000 athletic exposures during practice and 10.2 per 1,000 AE during games. 47,48 Thus, the injury rate in this study was higher. However, one must be cautious in comparing these studies because of several factors. First, official WNBA activities occur May through the first week of September. The athletes could be returning to camp in a deconditioned state. Second, many of the athletes play overseas during the league’s off season. Many of these athletes return to camp immediately following the completion of these seasons and could be fatigued. Thirdly, when comparing AE the amount of time the athlete was participating in each exposure should be taken into account. For example, games in the NBA are 48 minutes compared to only 40 minutes in the WNBA. The frequency of injuries throughout the WNBA’s history appears consistent unlike that reported in other studies. The CM injury rates per year ranged from 10.2 to 13.5. However, no consistent pattern was noted that would suggest the injury rate was increasing. Athletes in the WNBA were injured at a rate of 2.1 injuries per basketball player per year. When comparing the injury rate at the AIS from the 1982-1989 period (0.8 injuries per basketball player per year) to the injury rate from 1990-1995 (3.1 injuries per basketball player per year), a statistically significant difference was reported. The AIS study, as do others, 2,49 suggests that the incidence of injury in female basketball

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47 players is increasing. 30 However, the increase in the injury rate may not be limited to females. A study analyzing the injuries and illnesses in the NBA over a 10 year period, the 1988-1997 seasons, showed a 12.4 % increase in conditions during the study period. 57 Injury and Illness Nature Sprains were the most common injury sustained in the WNBA accounting for 25.7% of all injuries, with the ankle sustaining the most sprains (49.4%). Additional injuries sustained included inflammation (21.1%), strains (15.4%), contusions (11.0%), and fractures (3.9%). In comparison, the most common types of injury in the NBA were sprains (27.8%), strains (21.5%), and inflammatory conditions (20.4%). In the NCAA, sprains (37.1%), strains (16.4%), and contusions (12.6%) were the most common types of injury. 57 Starkey 57 reported that per 1,000 game-related AE sprains (7.4), contusions (4.5), and strains or spasms (4.1) were the most common injuries. Comparably the rates per 1,000 game-related AE in the WNBA were sprains (9.0), contusions (4.7), and strains or spasms (3.6). While the type of injuries sustained by both men and women in the Zelisko et al. 65 study followed a similar pattern with contusions, strains, muscle cramps/spasms, and acute tenosynovitis/tendonitis being the most common, it was reported that women sustained significantly more sprains, strains, and contusions during that study period. General medical conditions (n=156) accounted for 8.2% of all reported cases. Upper respiratory illnesses were the most common reported illnesses and accounted for 1.3% of all injury/illness cases. Systemic conditions were the most prevalent illnesses in the NBA representing 21.6% of all reports, of these upper respiratory infections were the most common conditions (16.7%). 57 Gastrointestinal problems (3.5%), local and systemic infections (0.9%), and dermatological conditions

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48 (0.9%) were other frequently treated conditions in the NBA. 57 The observed difference in the rates of general medical conditions may be attributed to a few factors. First, the NBA season takes place during the winter months when colds and other systemic conditions are generally more common. Second, the NBA season is approximately twice as long as the WNBA season and the athletes in the NBA may become more fatigued and thus more susceptible to systemic conditions. Thirdly, while entering the data from the WNBA injury reports into the database, it was noted that some teams reported no general medical conditions while others reported several. Therefore, a possible limitation of this study is that some of the athletic trainers may not have reported general medical conditions. Anatomical Site of Injury The majority of injuries in basketball are lower extremity injuries 28,57 and result in the greatest number of days lost. 57 In a retrospective study in intercollegiate athletics in two colleges over a two-year period, 51.4% of all injuries occurred to the lower extremity. 35 The lower extremity was also the most frequently injured area in the WNBA (60.1%) resulting in the most total time lost (74.8%). The most frequently injured body parts were the knee (15.2%), ankle (14.4%), and patella (6.8%). Comparably, the majority of the injuries sustained by the NBA players were to the ankle (14.3%), patellofemoral complex (12.5%), and the lumbar spine (9.1%) where as the collegiate players sustained most of their injuries to the ankle (28.8%), knee (12.0%), and hip/pelvis (2.7%). 57 At all levels and in both genders, ankle injuries are the most common injuries in basketball. 1,9,27,53,57,60,65 In the WNBA, ankle sprains were the most frequent game-related injury, occurring at a rate of 4.2 per 1,000 AE. In comparison, ankle sprains were also

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49 the most frequent game-related injury in the NBA, occurring at a rate of 3.4 per 1,000 AE. 57 In a comparison of professional female and male basketball players in 1982, ankle injuries were the most common injury occurring at a rate of 9.2 per 1,000 AE and 6.5 per 1,000 AE, respectively. 65 When comparing this study to previous studies of professional basketball the results suggest that the rate of ankle injuries for both genders may have decreased over time. The disparity in the ACL injury rate between males and females has been well documented at all levels of competition. 4,9,24,26,31,36,48 It has been reported that the increased predisposition is two to eight times higher in females. 32,33,65 In the WNBA, the anterior cruciate ligament was torn at a rate of .32/1,000 AE (n=8, 1.3%) with 50.0% of the total ACL ruptures (n=16) occurring in games. The game-related injury rate for ACL ruptures were not published for the NBA, presumably because they did not occur at a rate significant enough to merit report. However, it was reported that during the ten year period 13.2% of all knee sprains were ACL sprains (n=35). 57 While ACL injuries are the most often publicized injury of the knee, Starkey 57 stated that in the NBA the patellofemoral inflammation may be a more important factor to be considered. The statement was based on his findings that the tibiofemoral and patellofemoral complex was the most common site of orthopedic trauma (13.8%), resulted in the greatest amount of time lost (26.6%), and is second only to the ankle in game-related injuries and incidence rates. 57 The same pattern was observed in the WNBA with the tibiofemoral and patellofemoral complex being the most common site of orthopedic trauma (22.0%), resulting in the greatest amount of time lost (17.9%), and being second only to the ankle in game-related injuries rate. In the WNBA, the athletes

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50 suffered more chronic knee injuries than acute but the difference was not significant (p=0.50). Specifically, they acquired more patellar inflammatory conditions than acute knee sprains although the difference was not statistically significant (p=0.12). However, acute knee injuries required significantly more days missed than did chronic injuries (p<.01). Likewise, acute sprains resulted in significantly more time loss than did inflammatory conditions about the patella (p<.01). In the NBA, The difference between the NBA and WNBA in amount of days lost in acute versus chronic injuries may be the result of the different lengths in the season. The NBA season is much longer than the WNBA season. As such, more chronic conditions may develop in the NBA and in an attempt to be effective towards the end of the season and playoffs the males may take time off through out the season while since the WNBA season is comparably so short the females may often attempt to play through the pain. Injuries to the eye and adnexa accounted for 2.1% of all conditions in the WNBA. In the NBA, 5.4% of all injuries were to the eye and adnexa. 64 Sixty-four percent of all eye injuries in the WNBA were abrasions and lacerations of the eyelid or periorbital region. The other most common eye injuries were iris contusion (11%), corneal lacerations (8.1%), and globe contusions (8.1%). A small majority (50.9%) of eye injuries in the NBA were abrasions/lacerations of the eyelid. Twenty-eight point eight percent of the injuries were contusions to the eyelid or periorbital region, 11.9% were corneal abrasions, and 5.1% were orbital fractures. 64 A majority (58.8%) of the eye injuries in the WNBA occurred in games. The game-related eye injury rate for the regular season was 0.8 per 1,000 AE and no game related eye injuries were reported in the postseason. Contrary to the findings of when the injury occurred in the WNBA,

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51 Zagelbaum 64 reported that 88.1% of eye injuries in the NBA occur during regular and postseason games. During the regular season 1.44 eye injuries occurred per 1,000 AE. The rate significantly increased to 2.48 per 1,000 AE during the post-season. 64 The most common mechanism of eye injury in the WNBA (45.9%) was by being elbowed. The second most common fell into the other category of contact with another, which included fingers (43.2%). Rebounding (offensive and defensive) accounted for 46.9% of all activities at time of eye injury. Driving while on offense accounted for 18.8%. Only 12 reported on protective eyewear use or nonuse and in all reported instances it was not in use. In the NBA, fingers (35.6%) and elbows (28.8%) to the eye while rebounding (30.5%) and playing offense (27.1%) produced the most eye injuries. 64 In most cases (96.6%), protective eyewear was not being worn. 64 Other conditions of interest were hamstring strains, stress fractures, concussions and pregnancy. Hamstring strains accounted for 3.0% of all conditions in the WNBA, occurred at a rate of 0.6 per 10,000 CM, and resulted in 126 days lost (1.4% of total days missed) from participation. In the NBA, hamstring strains were 2.5% of all injuries, occurred at a rate of 0.3 per 10,000 CM, and resulted in 1,878 days lost (2.8% of total days missed) from participation. 57 A comparison of injuries in the WPBL and the NBA indicated that women suffered more strains than the men, especially in the thigh. The difference in the rate of strains (13.8 per 1,000 AE for the women and 7.9 per 1,000 AE for the men) was statistically significant. 65 In the WNBA, stress fractures accounted for 0.8% of all injuries and resulted in 273 days lost from participation at a rate of 0.3 per 10,000 CM or 0.6 per 1,000 AE. The sites of the stress fractures and their frequency were: 6 in the foot, 3 of the sacrum, 2 of

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52 the tibia, 2 of the fibula, 1 of the ankle, and 1 of the hip/pelvis. While not broken down into types of fractures, Starkey 57 reported that 3.0% (n=302) of all injuries in the NBA were fractures with a rate of 0.4 per 10,000 CM. In the WNBA, 3.9% (n=75) of all injuries were fractures with a rate of 1.4 per 10,000 CM. Concussions occurred at a rate of .55 per 1,000 game related AE (2.3%) with 56.0% of the total concussions occurring in games. Pregnancy (n=5) resulted in the athletes missing 123 games. Absence from practice was not reported for the pregnancies and thus total time lost from league activities related to pregnancy can not be determined. Mechanism of Injury Excluding chronic, overuse, and insidious conditions (24.6%), mechanisms at time of condition with highest incidence were non-athletic (9.1%), dynamic overload (6.9%), elbowed (6.4%), stepped on the foot of another (6.1%), and fell on the floor (5.3%). Non-athletic conditions were typically general medical conditions. Chronic and insidious conditions accounted for the highest percentage (22.2%) of activities at time of condition. Others with highest incidence were defensive rebounding (9.1%), offensive rebounding (6.0%), and driving (5.5%) Player Position Though today’s style of basketball often blurs player positions, 18.9% of all injuries in the NBA occurred in centers, 40.7% in forwards, and 40.3% in guards. Per 1,000 athletic exposures, forwards had the highest injury rate at 21.7, followed by guards 21.3 and centers 21.0. The differences were not significant. 57 Analysis of player position in the WNBA revealed no significant difference in game-related injuries among guards (24.2/1,000 AE), forwards (20.6/1,000 AE), and centers (20.2/1,000 AE).

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53 Apple 3 indicated that guards and forwards in the NBA were more likely to sustain a knee injury while centers were more likely to injure their backs. The differences between the WNBA guards, forwards, and centers in ACL injury rate were not significant (p=0.65). However, a Chi Square analysis revealed that a significant difference exists between the positions in the incidence of low back injury, with the greatest incidence occurring in centers ( 2 =6.6, df=2, p=0.038). Half of the Game According to a study presented in 1987 at the National Athletic Trainers’ Association convention, 60% of game related injuries occur during the second half. 17 This did not hold true in the WNBA. More injuries occurred in the second half of the game (n=244, 45.7%) than the first (n=207, 38.8%), but the difference was not significant (p=0.08). Time in Season According to Apple et al., 1 46.7% of all injuries in the NBA occurred before a third (27) of the 82 games in a regular season had been played. Broken down, 17.8% of those occurred during the 30-day preseason and 28.9% during the first 26 games. The middle third of the season produced 19.6% of the injuries while the final third provided 15.4%. The playoffs, in which only a limited number of teams participate for a 1-5 week period, resulted in 11.4% of the injuries. In the WNBA significantly more injuries occurred in the first half (n=764) of the regular season (practices and games) than in the second (n=493) (p<.001). During the first half of the season (n=275) injuries occurred at a rate of 11.1/10,000 CM (22.9/1,000 AE), 10.4/10,000 CM (20.6/1,000 AE) during the second half (n=248), and 18.7/10,000 CM (42.5/1,000 AE) during the post-season (n=55). Athletes in the WNBA sustained 1,246 injuries at or before the first half of the

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54 season (preseason and first half of the regular season) was completed compared to only 664 in the second half (second half of the regular season and postseason). The higher injury rate in the first half of the season may be attributed to a couple of factors. First, since official league WNBA activities only run from May through the first week of September, many of the athletes may be returning to camp out of condition and more susceptible to injury. Second, as a result of the short season many athletes travel overseas to compete in non-league games and may return to the WNBA fatigued. Practice versus Game Participation Whiteside 60 suggested that the relative frequency of injury in practice was proportional to the time the athlete was at risk. It was also proposed that per unit of exposure, competition presents the highest risk. 60 Injury rates for practices versus games cannot be compared in the WNBA because exposure rates were not kept for practices. However, 615 injuries occurred in games (36.5%) while 658 occurred in practices (39.0%). Generally speaking teams spend more time in practice than in competition. Therefore, it could be hypothesized that relative to exposure, athletes are injured significantly more often in competition. Days Missed From Basketball The majority of reported injuries in the WNBA (53.7%) resulted in no time loss from participation. Of all cases, 4.6% were season ending injuries/illnesses (n=88), 18.4% resulted in the athlete being placed on the injured reserve list, and 3.9% of the cases required surgical intervention. In the NBA, 47.7% of reported injuries resulted in no time loss from participation with 12.3% being placed on injured reserve and 3.7% of all cases requiring surgery. 57

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55 Conclusion Regarding research hypothesis number one: Significantly more ankle injuries will occur in the WNBA as compared to any other specific injury. The following conclusions were made: 1. While the knee was not injured significantly more often than the ankle, the ankle did sustain significantly more sprains than did the knee. 2. Ankle sprains also resulted in significantly more time lost from participation than did knee sprains. Regarding research hypothesis number two: Those who have been taped or braced will have significantly fewer ankle sprains than those who were not taped or braced. The following conclusion was made: Since record is not kept of the exposure rates of the athletes with regard to total practice exposure or ankle taping/bracing exposure, the effectiveness of these prevention measures couldn’t be determined. Regarding research hypothesis number three: Significantly more injuries to the knee will be chronic. The following conclusions were made: 1. Athletes in the WNBA did not suffer significantly more chronic knee injuries than acute. 2. They did not acquire significantly more patellar inflammatory conditions than acute knee sprains. Regarding research hypothesis number four: The majority of time loss due to knee injuries will be from acute knee sprains. The following conclusions were made: 1. Acute knee injuries required significantly more days missed than did chronic injuries. 2. Likewise, acute knee sprains resulted in significantly more time loss than did inflammatory conditions about the patella. Regarding research hypothesis number five: Significantly more injuries will occur during the first half of the regular season than in the second. The following

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56 conclusion was made: Significantly more injuries occurred in the first half of the regular season than in the second. Regarding research hypothesis number six: Significantly more injuries will occur during the second half of competition than the first half. The following conclusion was made: More injuries occurred in the second half of the game than the first, but the difference was not significant. Regarding research hypothesis number seven: Guards will sustain significantly more anterior cruciate ligament injuries than forwards or centers. The following conclusion was made: The differences between the guards, forwards, and centers in ACL injury rate were not significant ( 2 =0.875,df=2, p=0.65). With professional athletics becoming more and more intense, there is a need to understand what type of injuries women athletes are most likely to experience and under what circumstances they occur. We noted that injuries sustained by WNBA players normally resulted in minimal time lost from participation. Lower extremity injuries were the most frequent, specifically injuries to the ankle and knee, and resulted in the most time lost. Previous results 3,8,9,11,12 suggesting that female professional basketball players are injured at a rate higher than their male counterparts were replicated. Our results also suggest that whereas the focus is often on prevention of acute injuries, attention also should be directed towards overuse/chronic conditions. The data from this study provides information concerning injuries important to sports medicine practitioners who work with basketball and/or female athletes. The data also serves as a foundation for future research in women’s professional athletics.

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57 Implications for Future Research Future epidemiological research in the area of incidence of injury and illnesses of female professional athletes, especially basketball players, is definitely necessary. It is recommended that future studies: 1. Examine time in menstrual cycle at time of injury. 2. Examine the use of oral contraceptives at the time of injury. 3. Examine off-season activities in the WNBA and how they may relate to injury incidence during the WNBA season. 4. Examine injuries relative to the total amount of time in practices. 5. Examine the effectiveness of ankle taping and bracing as compared to total amount of time in play. 6. Examine the injury rates as in this study, but communicate with the athletic trainers prior to the start of the season to better explain the forms and reporting procedures. 7. Compare injury rates in the WNBA with those in the NBA with inferential statistics. 8. Continue the use of computerized injury surveillance systems.

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APPENDIX A WNBA INJURY AND ILLNESS REPORT FORM

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59

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APPENDIX B IRB EXEMPTION APPROVAL

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BIOGRAPHICAL SKETCH Sheri L. Walters was originally from Wapanucka, Oklahoma. She received a Bachelor of Science in Education with a concentration in athletic training from East Central University in 2000. As a student athletic trainer at East Central, she worked with a variety of sports including football, women’s basketball, cross country, and softball. She was a member of Chi Omega sorority. In her junior year, she became a member of Alpha Chi and Phi Epsilon Kappa, honor fraternities. In November of 2000, she passed the National Athletic Trainers’ Association BOC exam and was certified in February of 2001. She has served as an assistant athletic trainer with the United States Taekwondo Union since 2001. During the 2001 WNBA season, she worked as the assistant athletic trainer for the Detroit Shock. In the fall of 2001, she began working towards a master’s degree in the graduate athletic training program at the University of Florida. In her first year in the graduate program, she worked as the head athletic trainer at Buchholz High School. In her second year, she worked as a graduate intern with the University of Florida football program and as the head athletic trainer for women’s golf. Upon receiving her master’s degree, she plans to work an additional year with the University of Florida football program and as the head athletic trainer for women’s golf while starting the PhD program in the Department of Rehabilitation Science. After completing the graduate intern position, she plans to attend UF’s physical therapy program and then complete her PhD. 67