Overuse injuries in youth basketball and floorball

This is an elec onic ep in o he o iginal a icle. This ep in may di e om he o iginal in pagina ion and ypog aphic de ail. Au ho (s): Ti le: Yea : Ve sion: Please ci e he o iginal e sion: All ma e ial supplied ia JYX is p o ec ed by copy igh and o he in ellec ual p ope y igh s, and duplica ion o sale o all o pa o any o he eposi o y collec ions is no pe mi ed, excep ha ma e ial may be duplica ed by you o you esea ch use o educa ional pu poses in elec onic o p in o m. You mus ob ain pe mission o any o he use. Elec onic o p in copies may no be o e ed, whe he o sale o o he wise o anyone who is no an au ho ised use . O e use inju ies in you h baske ball and loo ball Leppänen, Ma i; Pasanen, Ka i; Kujala, U ho; Pa kka i, Ja i 2015 © 2015 Leppänen e al. This wo k is published by Do e Medical P ess Limi ed, and licensed unde C ea i e Commons A ibu ion – Non Comme cial (unpo ed, 3.0) License. The ull e ms o he License a e a ailable a h p://c ea i ecommons.o g/licenses/by-nc/3.0/. 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In o ma ion on how o eques pe mission may be ound a : h p://www.do ep ess.com/pe missions.php Open Access Jou nal o Spo s Medicine 2015:6 173–179 Open Access Jou nal o Spo s Medicine Do ep ess submi you manusc ip | www.do ep ess.com Do ep ess 173 O iginAl eSeA ch open access o scien i ic and medical esea ch Open Access Full Tex A icle h p://dx.doi.o g/10.2147/OAJSM.S82305 O e use inju ies in you h baske ball and loo ball Ma i leppänen1 Ka i Pasanen1 U ho M Kujala2 Ja i Pa kka i1 1Tampe e esea ch cen e o Spo s Medicine, UKK ins i u e o heal h P omo ion esea ch, Tampe e, 2Depa men o heal h Sciences, Uni e si y o Jy äskylä, Jy äskylä, Finland co espondence: Ma i leppänen Tampe e esea ch cen e o Spo s Medicine, UKK ins i u e o heal h P omo ion esea ch, PO Box 30, 33501 Tampe e, Finland Tel +358 3 282 9111 Fax +358 3 282 9200 email [email p o ec ed] Backg ound: The popula i y o eam spo s is g owing among young people. High aining olume and in ensi y may p edispose young a hle es o o e use inju ies. Resea ch o da e has ended o ocus on acu e inju ies a he han o e use inju ies. The pu pose o his s udy was o examine he occu ence, na u e, and se e i y o o e use inju ies in you h baske ball and loo ball, wi h he hypo hesis ha o e use inju ies a e equen in you h eam spo s. Me hods: The s udy comp ised a o al o 401 Finnish eam spo s a hle es (207 baske ball and 194 loo ball playe s). The da a we e collec ed using a de ailed ques ionnai e. The pa icipan s (mean age 15.8±1.9 yea s) esponded o he ques ionnai e co e ing in o ma ion on o e use inju ies du ing he p e ious 12 mon hs. Resul s: A o al o 190 o e use inju ies was epo ed (97 in baske ball and 93 in loo ball). In bo h spo s, mos o he inju ies in ol ed he lowe ex emi ies (66% and 55% o all inju ies in baske ball and loo ball, espec i ely). In baske ball, he mos commonly inju ed si e was he knee (44 cases, 45%). In loo ball, he mos commonly inju ed si es we e he lowe back/pel is (36 cases, 39%) and knee (32 cases, 34%). O e use inju ies caused an a e age ime loss om ull pa icipa ion o 26±50 (median 7) days in baske ball and 16±37 (median 5) days in loo ball. Conclusion: O e use inju ies a e a common p oblem in you h eam spo s, and o en cause long- e m absence om ull pa icipa ion. The indings sugges ha inju y educ ion and ain- ing load moni o ing s a egies a e needed in he ield. Mo e esea ch using explici p ospec i e da a collec ion is needed o be e unde s and he p oblem. Keywo ds: o e use inju ies, spo s inju ies, epidemiology, adolescence, eam spo s In oduc ion Spo s pa icipa ion among he young is associa ed wi h mul iple heal h bene i s.1,2 Howe e , compa ed wi h less physically ac i e adolescen s, highly ac i e adoles- cen s seem o su e mo e musculoskele al pain,3 such as a highe incidence o Osgood–Schla e disease4 and low back pain.5 O e use inju ies in you h spo s a e o pa icula conce n because hey may cause long- e m disabili y, nega i ely a ec spo s pa icipa ion, and impac on pe o mance and e en daily ac i i ies.6 Fu he - mo e, epe i i e physical o e loading o he physis may in some cases esul in g ow h dis u bances and de o mi ies.7 In ensi e aining wi h a high aining olume a an ea ly age may p edispose young a hle es o o e use inju ies.8 O e use inju ies a e common in endu ance spo s9–11 and echnical spo s12 ha equi e long mono onous aining sessions o epe i ious mo emen pa e ns. Howe e , o e use inju ies may also be a subs an ial p oblem in eam spo s due o he high aining olume and compe i- ion load.13–15 Al hough in e es in spo s inju y esea ch has inc eased o e he pas Numbe o imes his a icle has been iewed This a icle was published in he ollowing Do e P ess jou nal: Open Access Jou nal o Spo s Medicine 22 May 2015 Open Access Jou nal o Spo s Medicine 2015:6 submi you manusc ip | www.do ep ess.com Do ep ess Do ep ess 174 leppänen e al decade,16 he e is li le esea ch on he incidence, p e alence, and p e en ion o o e use inju ies.12 Baske ball is a globally popula eam spo .17 Se e al ea lie s udies ha e in es iga ed he epidemiology o baske ball inju ies in a ious popula ions, mainly among adul ,17 p o essional,18–20 collegia e,21,22 and high school23,24 baske ball playe s, bu also mo e ecen ly among child en.25–27 Rega dless o he la ge numbe o s udies published, analyses on he incidence and na u e o o e use inju ies in baske - ball a e sca ce. In addi ion, mos o he s udies published ha e been conduc ed ou side Eu ope, and knowledge abou baske ball- ela ed inju ies in Eu ope is s ill insu icien .17 Floo ball is a eam spo ha has become e y popula in Eu ope, and is also one o he mos popula eam spo s among he you h o Finland. In 2009–2010, he e we e 144,000 leisu e- ime loo ball playe s among Finnish adoles- cen s aged 3–18 yea s.28 Floo ball is a o m o hockey played indoo s on a cou (20×40 m) su ounded by a low boa d. The playe s use s icks o g aphi e compounds o sco e goals wi h a hollow, dimpled plas ic ball. A eam usually consis s o 15–20 playe s, and six playe s (a goalkeepe and i e ou ield playe s) a e on he cou a he same ime. The playing ime is h ee pe iods o 20 minu es. While he goalkeepe wea s a helme and padded clo hes, he o he playe s usually wea no p o ec ion o eye p o ec ion only. Al hough ough body con ac is no allowed, loo ball is associa ed wi h sudden accele a ions, s ops and u ns, uncon olled con ac s wi h he boa ds, and s ikes by s icks o he ball.2 Thus a , only a ew s udies ha e in es iga ed loo ball inju ies,29–34 and hese s udies ha e ocused mos ly on adul playe s. Mo eo e , li le in o ma ion exis s on o e use inju ies in his spo . Baske ball and loo ball a e popula spo s among young people in Finland. These spo s a e bo h played indoo s and include simila mo emen s, such as apid u ns, s ops, and accele a ions. Mos epidemiological s udies on baske - ball and loo ball ha e ocused on acu e inju ies. Thus, he pu pose o his e ospec i e s udy o young baske ball and loo ball playe s was o examine he occu ence, na u e, and se e i y o o e use inju ies. The s udy hypo hesis is ha al hough mos o he inju ies in hese spo s a e acu e in na u e, o e use inju ies a e common and o en es ic no mal aining and playing o a long ime. Ma e ials and me hods Pa icipan s S udy pa icipan s we e ec ui ed om baske ball and loo - ball eams o he Tampe e egion. Al oge he , 20 eams (wi h 475 junio playe s) we e in i ed ( en baske ball and en loo ball eams), and 18 eams (nine baske ball and nine loo ball eams) ag eed o pa icipa e in he s udy. O he pa icipa ing eams, 37 playe s e used o ake pa in he s udy. Playe s we e included i hey we e o icial membe s o he pa icipa ing eams and had played o icial junio games (U16–U20) du ing he p e ious season. Playe s we e excluded (n=3) i hey had no pa icipa ed in aining and games du ing he p e ious season. A o al o 401 playe s (207 baske ball playe s and 194 loo ball playe s) ag eed o pa icipa e in he s udy. Pa icipa ion in he s udy was based on w i en in o med consen om each playe , and he consen o a pa en o subjec s younge han 18 yea s was equi ed. The s udy was app o ed by he e hics commi ee o he Pi kanmaa Hospi al Dis ic , Tampe e, Finland (ETL code R10169). Da a collec ion This e ospec i e analysis is pa o a la ge 3-yea (2011– 2014) ollow-up s udy on spo s inju y isk ac o s. Inju y occu ence in his epo was analyzed e ospec i ely o e a p eceding 12-mon h pe iod. The da a used a e based on a de ailed ques ionnai e, which subjec s comple ed when hey en e ed he s udy (baseline). The ques ionnai e was based on a p e ious s udy o spo s inju ies,32 and co e ed in o ma ion on pe sonal da a, spo s pa icipa ion, and he his o y o spo s inju ies. The a hle es we e asked o e alua e as p ecisely as possible he numbe o weekly aining ses- sions, he numbe o hou s spen pe session, and he numbe o games hey played du ing he p e ious season. One pa o he ques ionnai e conce ned inju y occu ence du ing pa icipa ion in he playe ’s spo . This pa was comple ed i he a hle e had sus ained a spo s inju y in he p eceding 12 mon hs. Fo each inju y ha had occu ed o e he pe iod o in e es , he ana omic loca ion, ype o inju y, he na u e o inju y (acu e o o e use), con ex (con ac o non-con ac , aining o compe i ion), da e o occu ence, and eco e y ime we e egis e ed. The collec ed da a we e sys ema ically c oss-checked wi h he a hle e ace- o- ace o ensu e he accu acy o he comple ed ques ionnai e. Inju y de ini ions and se e i y An inju y was de ined as any physical complain ela ed o a game o p ac ice ha esul ed in he playe being unable o ake ull pa in a game o p ac ice session o a leas one day. Any signi ican pain o discom o ha es ic ed no mal aining was aken in o conside a ion. An o e use inju y was de ined as being caused by epe i i e mic o auma wi hou a single, iden i iable e en being esponsible o inju y. Open Access Jou nal o Spo s Medicine 2015:6 submi you manusc ip | www.do ep ess.com Do ep ess Do ep ess 175 O e use inju ies in you h eam spo s The se e i y o he inju ies was de ined acco ding o Fulle e al,35 using ime loss om ull pa icipa ion in he usual aining p og am o compe i ion: a minimal inju y, an inju y causing an absence om ull pa icipa ion o 1–3 days; a mild inju y, an inju y causing an absence om ull pa icipa ion o 4–7 days; a mode a e inju y, an inju y causing an absence om ull pa icipa ion o 8–28 days; and a se e e inju y, an inju y causing an absence om ull pa icipa ion o 29 o mo e days. exposu e hou s To al hou s o exposu e we e calcula ed as he sum o aining and game hou s pe yea . The o al aining hou s pe yea o each playe we e calcula ed by he indi idually epo ed weekly aining hou s o e he 45-week ac i e pe iod. To al exposu e ime du ing he games was calcula ed using an a e age o 60 minu es’ ac i e exposu e ime (including ime spen in wa m-up, playing, and cool-down) pe game. inju y a e and inju y incidence The inju y a e was calcula ed as he numbe o inju ed playe s di ided by he numbe o exposed playe s. Inju y incidence pe 1,000 hou s o exposu e was calcula ed by di iding he numbe o inju ies by he o al numbe o hou s o exposu e and hen mul iplying ha igu e by 1,000. S a is ical analysis Means ± s anda d de ia ions we e calcula ed o desc ibe con- inuous a iables, and equencies and pe cen ages we e used o ca ego ical a iables. Di e ences in inju y occu ence, inju ed body si e, and inju y se e i y be ween he boys and gi ls we e analyzed using he chi-squa ed es . The indepen- den samples - es was used o compa e g oup di e ences in cha ac e is ics o he pa icipan s. P- alues ,0.05 we e conside ed o be s a is ically signi ican . Resul s cha ac e is ics o he pa icipan s A o al o 401 junio playe s (213 boys and 188 gi ls) comple ed he ques ionnai e in he yea hey en e ed he s udy. The s udy popula ion consis ed o 207 baske ball playe s (101 boys and 106 gi ls) and 194 loo ball playe s (112 boys and 82 gi ls). The cha ac e is ics o he pa ici- pan s a e shown in Table 1. The mean age o he pa icipan s a he ime hey en e ed he s udy was 15.8±1.9 ( ange 12–21) yea s. The boys we e signi ican ly olde han he gi ls (P=0.001). The boys epo ed ha ing s a ed playing a a signi ican ly (P,0.001) younge age han he gi ls (8.1±2.6 yea s e sus 9.1±2.7 yea s, espec i ely). The a e - age aining olume pe week was signi ican ly (P=0.001) highe o he boys (10.2±3.9 hou s pe week) han he gi ls (9.0±3.0 hou s pe week). O e all inju y cha ac e is ics In all, he 401 playe s included in he s udy epo ed a o al o 629 inju ies, comp ising 439 acu e inju ies (70%) and 190 o e use inju ies (30%). In baske ball, he p opo ion o o e use inju ies was 31% and in loo ball he p opo - ion was 30%. The incidence o o e use inju y was 1.0 pe 1,000 hou s o exposu e in bo h spo s. The inju ed popula- ion consis ed o 91 (60%) male playe s and 61 (40%) emale playe s, o whom 80 (53%) we e baske ball playe s and 72 (47%) we e loo ball playe s. In addi ion, playe s epo ed a o al o 150 o e use condi ions ha caused no ime loss om aining o compe i ion; hese we e no included in he p esen analysis. Table 1 cha ac e is ics o he pa icipan s Baske ball (n=207) Floo ball (n=194) All (n=401) P- alue† Boys (n=101) Gi ls (n=106) Boys (n=112) Gi ls (n=82) Boys (n=213) Gi ls (n=188) Age (yea s) 15.2±1.6 14.6±1.6 16.9±1.3 16.6±2.0 16.1±1.7 15.5±2.0 0.001** heigh (cm) 17.3±9.4 168.5±6.7 178.6±6.5 166.5±5.7 179.0±8.0 167.6±6.3 ,0.001** Weigh (kg) 68.9±13.2 61.1±9.9 70.4±8.9 61.2±7.5 69.7±11.1 61.2±8.9 ,0.001** BMi (kg/m2)21.3±3.1 21.5±2.9 22.0±2.4 22.1±2.6 21.7±2.7 21.7±2.8 0.848 Age when s a ed o play (yea s) 7.9±2.3 8.1±2.3 8.2±2.9 10.4±2.6 8.1±2.6 9.1±2.7 ,0.001** e e played in adul eli e league le el Yes (%) 4.0 1.9 7.1 30.5 5.6 14.4 no (%) 96.0 98.1 92.9 69.3 94.4 85.6 T aining sessions/week 4.5±1.4 4.1±1.2 4.1±1.5 3.5±1.0 4.3±1.5 3.8±1.2 ,0.001** T aining hou s/week 9.8±3.2 8.9±3.0 10.6±4.4 9.1±3.1 10.2±3.9 9.0±3.0 ,0.001** games/season 32.7±14.8 38.1±17.5 37.4±15.4 35.7±15.0 35.2±15.3 37.1±16.5 0.237 No es: Values a e p esen ed as mean ± s anda d de ia ion; †P- alues o sex di e ences among all pa icipan s; **P- alue ,0.05 conside ed o be s a is ically signi ican . Abb e ia ion: BMi, body mass index. Open Access Jou nal o Spo s Medicine 2015:6 submi you manusc ip | www.do ep ess.com Do ep ess Do ep ess 176 leppänen e al Table 2 F equency (n) and ana omical dis ibu ion o o e use inju ies acco ding o game and sex, wi h dis ibu ion o o e use inju ies acco ding o inju y se e i y Baske ball (n=97) Floo ball (n=93) Boys (n=44) Gi ls (n=53) To al Boys (n=65) Gi ls (n=28) To al All 44 (16/6/6/16) 53 (21/11/10/11) 97 (37/17/16/27) 65 (30/12/16/7) 28 (11/4/11/2) 93 (41/16/27/9) head/neck 0 (0/0/0/0) 0 (0/0/0/0) 0 (0/0/0/0) 0 (0/0/0/0) 0 (0/0/0/0) 0 (0/0/0/0) Uppe body 0 (0/0/0/0) 1 (1/0/0/0) 1 (1/0/0/0) 0 (0/0/0/0) 2 (1/1/0/0) 2 (1/1/0/0) T unk 15 (10/2/1/2) 17 (11/2/2/2) 32 (21/4/3/4) 32 (17/4/7/4) 8 (6/0/2/0) 40 (23/4/9/4) Uppe back/ches 0 (0/0/0/0) 1 (1/0/0/0) 1 (1/0/0/0) 0 (0/0/0/0) 0 (0/0/0/0) 0 (0/0/0/0) lowe back/pel is 11 (7/2/1/1) 16 (10/2/2/2) 27 (17/4/3/3) 29 (16/4/6/3) 7 (5/0/2/0) 36 (21/4/8/3) hip/g oin 4 (3/0/0/1) 0 (0/0/0/0) 4 (3/0/0/1) 3 (1/0/1/1) 1 (1/0/0/0) 4 (2/0/1/1) lowe ex emi ies 29 (6/4/5/14) 35 (9/9/8/9) 64 (15/13/13/23) 33 (13/8/9/3) 18 (4/3/9/2) 51 (17/11/18/5) Thigh 0 (0/0/0/0) 1 (0/1/0/0) 1 (0/1/0/0) 6 (4/1/1/0) 0 (0/0/0/0) 6 (4/1/1/0) Knee 22 (5/2/4/11) 22 (7/4/6/5) 44 (12/6/10/16) 25 (8/7/7/3) 7 (2/2/2/1) 32 (10/9/9/4) Shin/cal 4 (1/1/0/2) 7 (1/2/2/2) 11 (2/3/2/4) 1 (1/0/0/0) 6 (0/0/5/1) 7 (1/0/5/1) Ankle 1 (0/1/0/0) 4 (1/1/0/2) 5 (1/2/0/2) 1 (0/0/1/0) 2 (1/0/1/0) 3 (1/0/2/0) Foo 2 (0/0/1/1) 1 (0/1/0/0) 3 (0/1/1/1) 0 (0/0/0/0) 3 (1/1/1/0) 3 (1/1/1/0) No e: n, numbe o inju ies (minimal/mild/mode a e/se e e). Baske ball O he 207 baske ball playe s pa icipa ing in he s udy, 80 (39%) had sus ained a leas one o e use inju y in he p eced- ing 12 mon hs. The boys had sus ained 44 (45%) o e use inju ies and he gi ls 53 (55%), gi ing a o al o 97 o e use inju ies among he baske ball playe s. The inju y a e was 0.47 o e use inju ies pe a hle e pe yea . Mos o he o e use inju ies in baske ball in ol ed he lowe ex emi ies (64 cases, 66%), wi h he knee being he mos commonly inju ed si e (44 cases, 45%, Table 2). O e use inju ies caused an a e age ime loss om ull pa ici- pa ion o 26±50 (median 7) days. The se e i y o inju ies is p esen ed in Table 3. In baske ball, he e we e no di e ences o he ana omic loca ion (Figu e 1) o se e i y o o e use inju ies be ween he boys and he gi ls. Floo ball O he 194 loo ball playe s, 72 (37%) epo ed ha ing had a leas one o e use inju y in he p eceding 12 mon hs. Signi ican ly mo e boys (51 playe s) epo ed o e use inju y/ inju ies han gi ls (21 playe s, P=0.005). Floo ball playe s sus ained a o al o 93 o e use inju ies, o which he boys sus ained 65 (70%) o e use inju ies and he gi ls 28 (30%) o e use inju ies. The inju y a e in loo ball was 0.48 o e use inju ies pe a hle e pe yea . Mos o he o e use inju ies in ol ed he lowe ex emi- ies (51 cases, 55%). The mos commonly inju ed si e was he lowe back/pel is (36 cases, 39%), and he second mos common si e was he knee (32 cases, 34%, Table 2). The e we e di e ences in ana omic loca ion o o e use inju ies be ween he boys and gi ls; he boys epo ed signi ican ly mo e lowe back and knee o e use inju ies compa ed wi h he gi ls (P,0.001, Figu e 2). Mos o he inju ies we e classi ied as minimal (Table 3). The e was no di e ence in se e i y o o e use inju ies be ween he boys and gi ls (P=0.544). The a e age ime loss om ull pa icipa ion due o an o e use inju y was 16±37 (median 5) days. Discussion The main inding o his e ospec i e s udy was ha 39% o baske ball playe s and 37% o loo ball playe s epo ed ha ing had a leas one o e use inju y du ing he p eceding 12-mon h pe iod. O e use inju ies caused long absences om ull pa icipa ion in aining and playing in bo h spo s. Mos o he o e use inju ies in hese spo s a ec ed he lowe ex emi ies, wi h he knee and lowe back/pel is being he mos commonly inju ed si es. Epidemiological s udies o o e use inju ies in eam spo s a e sca ce, especially among young people. P e ious s udies in olde popula ions o loo ball playe s ha e epo ed ha app oxima ely 17%–24% o all loo ball inju ies a e o e use inju ies.30,31 In a s udy o emale playe s only,33 he pe cen age o o e use inju ies was 30%. In ou s udy, he p opo ion o o e use inju ies among young loo ball playe s was simila (30%). Acco ding o p e ious s udies among p o essional baske ball playe s,18,19,36 o e use inju ies and in lamma o y condi ions accoun o 15%–27% o all inju ies. In ou s udy, 31% o all baske ball inju ies we e o e use inju ies. Howe e , Cla sen e al37 ecen ly ound ha o e use inju ies end o be unde epo ed, so he ac ual p opo ion o o e use Open Access Jou nal o Spo s Medicine 2015:6 submi you manusc ip | www.do ep ess.com Do ep ess Do ep ess 177 O e use inju ies in you h eam spo s Knee Lowe back/pel is Shin/cal Ankle Hip/g oin Foo Thigh Uppe back/ches Uppe body Head/neck 0510 15 Numbe o inju ies 20 25 Boys Gi ls Figu e 1 O e use inju ies in baske ball acco ding o ana omic loca ion and sex. Knee Lowe back/pel is Shin/cal Ankle Hip/g oin Foo Thigh Uppe back/ches Uppe body Head/neck 0510 15 Numbe o inju ies 20 25 30 35 Boys * * Gi ls Figu e 2 O e use inju ies in loo ball acco ding o ana omic loca ion and sex. No e: *Signi ican di e ence a P,0.001. Table 3 Se e i y o o e use inju ies (n=190) acco ding o spo s and sex Inju y se e i y Baske ball Floo ball Boys Gi ls To al Boys Gi ls To al Minimal, 1–3 days 16 (36) 21 (40) 37 (38) 30 (46) 11 (39) 41 (44) Mild, 4–7 days 6 (14) 11 (21) 17 (18) 12 (19) 4 (14) 16 (17) Mode a e, 8–28 days 6 (14) 10 (19) 16 (17) 16 (25) 11 (39) 27 (29) Se e e, $29 days 16 (36) 11 (21) 27 (28) 7 (11) 2 (7) 9 (10) To al 44 (100) 53 (100) 97 (100) 65 (100) 28 (100) 93 (100) No e: Values a e p esen ed as numbe o inju ies (% ounded). inju ies is p obably much highe han hese a es sugges . Ou esul s, which show ha he mos common inju y loca ion causing long- e m losses in playing ime was he knee, a e in acco dance wi h p e ious indings ha g owing a hle es commonly su e om Osgood–Schla e disease,4 pa ello emo al pain, o o he long-las ing bu sel -limi ing unspeci ied knee pain.38 When desc ibing he occu ence o o e use inju ies, he de ini ion used o eco d hese inju ies is impo an . We used he de ini ion “ ime los om ull pa icipa ion in he usual aining p og am o compe i ion” and ound an o e use inju y incidence o 1.0 inju ies pe 1,000 hou s o exposu e in bo h spo s. Un o una ely, we we e no able o ind a e e ence incidence o ei he you h spo . In hei p ospec i e coho s udy o senio baske ball playe s, Cumps e al17 used an inju y de ini ion based on physical discom o a he han ime loss, and ound an o e use inju y incidence o 3.8 pe 1,000 hou s o exposu e, which is conside ably highe han he incidence in you h baske ball in ou s udy. Al hough hese a es a e no compa able due o di e en s udy designs and me hods, i can be specula ed ha he inju y de ini ion we used may ha e unde es ima ed he ue ex en o o e use inju ies. S anda d inju y su eillance me hods ( ime loss) a e no able o egis e all o e use inju ies because o e use p oblems o en ha e a g adual onse and a hle es end o ain and compe e despi e hei symp oms.37 I is wo h no ing ha playe s in ou s udy epo ed 150 o e use condi ions ha caused no ime loss and hence we e no de ined as inju ies, bu i is mos likely ha hese inju ies we e s ill ha m ul. Including hese condi ions in he p esen analysis would gi e an o e use inju y incidence o 1.8 pe 1,000 hou s o exposu e. The p esen inding ha mos o he o e use inju ies in bo h baske ball and loo ball a e loca ed in he lowe ex emi ies, wi h he knee being he mos common si e o an o e use inju y, is consis en wi h p e ious esea ch.17,30,31,33 The e is e idence in he li e a u e ha o e use knee con- di ions, such as pa ello emo al pain, a e common, espe- cially in eli e-le el baske ball.17,19,20,36 In eam spo s ha equi e jumping ( olleyball, baske ball), he high aining load is commonly epo ed as a isk ac o o pa ella endinopa hy.15,17,39 Fu he mo e, ecen indings indica e ha smalle endon c oss-sec ional a ea migh also be ela ed o pa ella endinopa hy.40 While adolescen a hle es apidly inc ease hei muscle s eng h, endon s i ness and c oss-sec ional a ea a e no simila ly de eloped, and his may p edispose adolescen a hle es o endon o e use inju ies.41 Pains in he endon inse ions and associa ed endon- ela ed p oblems a e common in you h eam spo s ha in ol e epe i ious impac mo emen s such as landing Open Access Jou nal o Spo s Medicine 2015:6 submi you manusc ip | www.do ep ess.com Do ep ess Do ep ess 178 leppänen e al om a jump and sudden s ops.4 Su p isingly, acco ding o ou esul s, o e use condi ions o he lowe back we e almos as common as knee p oblems in baske ball, and in loo ball hey we e e en mo e common. In loo ball, a plausible explana ion o his migh be he low playing posi ion, which causes s ain o he lowe back. I is well known ha inju y p o iles a y by spo ,10 bu he e is insu icien e idence ega ding whe he male and emale eam spo a hle es ha e di e en isks o o e use condi ions. Many au ho s ha e ound ha pa ella endi- nopa hy is a mo e common in male a hle es han in emale a hle es.13,15,42 Howe e , his is no he case in all spo s and o e use condi ions. Cumps e al17 epo ed ha emale bas- ke ball playe s a e a a highe isk o all o e use inju ies and o pa ello emo al pain. Snellman e al32 epo ed o e use inju ies in loo ball being mo e common in emales, whe eas Wiks öm and Ande sson31 ound he opposi e. In he cu - en s udy, he e we e no sex di e ences in baske ball, bu in loo ball he boys seemed o ha e sus ained o e use inju ies mo e o en han he gi ls. Sex di e ences migh pa ly be explained by di e ences in aining olumes.43 Mo e s udies a e he e o e needed o de e mine he possible ole o sex as a isk ac o o o e use inju ies in eam spo s as well as in o he spo s. This s udy has some limi a ions. Fi s , he e is ecall bias a ec ing he eliabili y o he e ospec i ely collec ed inju y his o y. In addi ion, we we e no able o con i m de ailed diagnoses. Second, we calcula ed exposu e hou s based on indi idually epo ed da a and by using a e age alues o aining and playing. Thus, i is possible ha some playe s played less and some mo e han ou es ima ion. Fu he , he inju y de ini ion based on ime loss, al hough emphasizing ime loss om ull pa icipa ion in aining o compe i ion, migh ha e le aside inju ies ha caused no ime loss o we e ansien in na u e. I is possible ha his migh ha e esul ed in unde es ima ion o he equency and se e i y o o e use inju ies. These esul s should he e o e be in e - p e ed wi h cau ion. In addi ion, in ou s udy, he age o he pa icipan s anged om 12 o 21 yea s, and hese indings canno be ex apola ed o imma u e adolescen a hle es o o adul a hle es. The s eng hs o his s udy a e he accu acy o he comple ed ques ionnai e and he high esponse a e. We collec ed he da a on he day he playe en e ed he s udy, and comple ed he ques ionnai e on he spo , meaning ha a s udy esea che was able o ca e ully check he comple ed ques ionnai e wi h he playe . All pa icipa ing playe s com- ple ed he ques ionnai e. Conclusion O e use inju ies among g owing a hle es in you h eam spo s ha e no been well s udied. The p esen indings p o ide e idence ha o e use inju ies a e qui e a common p oblem among you h baske ball and loo ball playe s, and o e use inju ies o en ha e a long- e m inju ious e ec on he playe ’s abili y o p ac ice and compe e a ull capaci y. No wi hs and- ing he limi a ions o e ospec i ely collec ed da a, ou ind- ings sugges ha de elopmen o inju y educ ion and aining load moni o ing s a egies is needed in he ield. P ospec i e analyses o isk ac o s o o e use inju ies in popula you h eam spo s a e also needed. In o de o unde s and he ue ex en o he p oblem, u u e s udies should use s anda dized me hods o egis e o e use p oblems. Acknowledgmen s The s udy was suppo ed by he Finnish Minis y o Educa ion and Cul u e and he Medical Resea ch Fund o Tampe e Uni e si y Hospi al. We hank he playe s and hei coaches o hei coope a ion wi h ou esea ch. Disclosu e The au ho s decla e ha he e a e no con lic s o in e es s ega ding he publica ion o his pape . Re e ences 1. Pa e RR, T os SG, Le in S, Dowda M. Spo s pa icipa ion and heal h- ela ed beha io s among US you h. A ch Pedia Adolesc Med. 2000;154:904–911. 2. Bäckmand H, Kujala U, Sa na S, Kap io J. 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