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In-Line Skating Injuries: Epidemiology and Recommendations for Prevention

Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention as published in "Sports Medicine" 19 (6):427-432, 1995 authored by Richard A. Schieber and Christine M. Branche-Dorsey

Publication date: 01/01/1995


Table of Contents

Summary

Introduction

1. Demographical Characteristics of In-Line Skaters

2. Why the Sport Is So Popular

3. Injury Epidemiology

4. Discussion and Recommendations
4.1 Protective Gear
4.2 Special Considerations for Novice Skaters
4.3 Trails
4.4 General Measures

5. Conclusions

References

POINT OF CONTACT FOR THIS DOCUMENT:

Tables
Estimated annual incidence and demography of participants & injury

Figures
Anatomical distribution of injuries sustained during in-line skating


Summary

In 1993 there was an estimated 12.6 million in-line skaters in the US. In-line skating is popular because of its affordability and its exercise and recreational value. The main risk factors for injury include speed, obstacles and hard surfaces. Using the National Electronic Injury Surveillance System in US hospitals, 31,000 skaters were reported injured over a 12 month period. Fractures, dislocations, sprains, strains and avulsion made up 67% of all injuries. It is recommended that skaters wear protection equipment including helmet, wrist guards, knee-pads and elbow-pads. Although head injuries from skating appear low in numbers, helmet protection is also recommended. Further studies are required that assess risk factors for injury and environmental and behavioral aspects.


Introduction

Since the development of modern in-line skates in 1980, in-line skating has become the fastest growing recreational sport, particularly in the US. More than 100 models of skates are manufactured by over 33 companies, (1) and at least 3 publications and 3 national or international associations exist. Yet, until recently, no data have been published on the incidence of injuries or the risk factors and exposure associated with in-line skating. We have summarized the body of knowledge on in-line skating injuries and make recommendations for safe participation.


1. Demographical Characteristics of In-Line Skaters

Data from recent surveys on sports participation in the US indicate that there were an estimated 12.6 million in-line skaters in the US in 1993, an increase of 37% over the previous year. (2) In total, 44% of these were first-year skaters, and 29% of all participants skated more than 25 times annually. Most in-line skaters were young: in 1993, 77% were younger than 25 years of age, and 39% were between 6 and 11 years old. The number of men participating approximately equaled the number of women. About one-third of all American skaters lived in the North Central states. 37% of participants lived in households with an annual income exceeding $US50,000.


2. Why the Sport Is So Popular

The popularity of in-line skating can be attributed to several factors: the quality and affordability of equipment, the potential for aerobic exercise, and the value of the sport for both recreation and transportation. Regarding quality, the rigid polyurethane boot and wheels of even recreational level in-line skates will withstand greater stress loads than traditional 'quad' roller-skates. Furthermore, the single row of very low friction polyurethane wheels allows in-line skaters, even novices, to move faster and manoeuver better than the traditional roller-skater. The dramatic decrease in the price of in-line skates has also added to their popularity.

As with cycling, the durability of the equipment, coupled with the ability to travel fairly great distances, encourages long-duration workouts. Physiological responses measured during in-line skating indicate that individuals with average fitness levels can achieve appropriate exercise training on flat terrain, although highly fit people might need to skate uphill more or skate quite fast to achieve the same benefit. The minimal ballistic forces involved result in a low-impact endurance work. (3,4)

The skates can be used for other forms of recreation, including in-line hockey and cross-training for other sports, especially ice hockey, alpine and cross-country skiing, ice skating and roller-skating. Many children use them as a method of transportation, much as they would use a bicycle. For some, speed-skating is popular, and amateur races are now held. (5) Some participants practice extreme or artistic skating, which emphasizes jumps, spins, cartwheels and other tricks. Because of its diversity of expression, the sport is not likely to be just a fad.


3. Injury Epidemiology

Until recently, pertinent injury risk factors and the likelihood of injury were largely unknown. Three apparent risk factors are speed, obstacles and hard surfaces. Cruising speeds of 10 to 17 miles/hour (16 to 27 km/h) are commonly reached, (6) and anecdotal reports cite speeds in excess of 70 miles/hour (112 km/h), especially when 'skitching', the undesirable practice of holding onto a fast-moving motor vehicle while skating. (7) Furthermore, when skating outdoors (the presumed practice of most in-line skaters), participants must share the roadway with motor vehicles, cyclists, pedestrians and pets, as well as negotiate defects in the pavement and road debris.

Epidemiological studies of skating injuries are prone to at least 2 flaws in study design: lack of generalisability and absence of good exposure data. First, because very few databases representatively sample or register all nonfatal injuries in a large population, the reliability (generalisability) of any findings may be limited. For example, a case series of injured skaters from a given hospital may be heavily influenced by the hospital referral pattern, and thus not relate to the larger geographical region or the nation. The second problem is related to the lack of good exposure data. It would be more meaningful to calculate the risk of injury per hour skated or per skater than to tally the total number of skaters injured. However, such denominator data are rarely available in the same injury database. For example, a 1992 survey estimated that in-line skaters had 211.5 million participant-days (9.4 million participants engaged for an average 22.5 days of participation per person per year), but it did not include any injury information. (2)

In an effort to overcome these design problems, we recently investigated the nature and body site distribution of injuries to in-line skaters. (8) We used the National Electronic Injury Surveillance System (NEISS), to obtain a probability sample of individuals treated for product-related injuries in emergency departments of US hospitals. (9) This database is maintained by the US Consumer Product Safety Commission to identify potentially significant hazards resulting from the use of consumer products. We used the NEISS database to estimate the number of in-line skaters in the US who were injured severely enough to require an emergency department visit during the 12-month period beginning 1 July 1992. Approximately 31,000 skaters were so injured. They ranged in age from 5 to 71 years (mean 19.7 years, median 15 years). The male: female ratio of all injured in-line skaters was 1.3:1, with a ratio of 1.9:1 for teenagers. The reason that more males are injured than females is unknown; we speculate that it may be caused by more males skating than females, lower ability or a greater propensity to take risks. In this study, in-line skating injuries occurred more frequently during the spring (45%) and summer (28%) months; 39% of all injuries occurred on a Saturday or Sunday.

Musculoskeletal injuries were the most frequent type of injury noted. Fractures, dislocations, sprains, strains and avulsions constituted 63% of all principal injuries. The wrist area, including the wrist and lower arm, was the site most frequently injured (Figure 1): 37% of all injured skaters had a wrist injury; about two-thirds of them sustained a fracture and/or dislocation. Head injuries were sustained by 5% of injured subjects. Hospital admission was required for 3.5% of all injured in-line skaters. Calle (10) recently substantiated these findings. Using NEISS for the period from 1987 to 1992, he found a similar age and sex distribution, as well as a high incidence of wrist fractures.

Using the same database for this 12-month period, we compared the frequency of in-line skating injuries with those of injured roller-skaters and skateboarders (Table 1). We chose this comparison because, in all of these sports, the legs are used for self-propulsion, the sport is a type of transportation, and the fall is from a similar height and occurs against a similar surface. For every injured in-line skater reported, about 1.1 skateboarders and 3.0 roller-skaters were injured. Skateboarding injuries were much more likely to occur among men, while roller-skating injuries were more likely to occur in women. The age distributions were similar, even though statistical differences did exist. As a point of reference, during this period nearly 600,000 bicycle-related injuries were reported through NEISS.

Our general findings have been substantiated by several other reports. One study (11) indicated that, in a small case series of skaters who sought medical attention, the relative age distribution for the 3 sports was similar. It was noted that injuries were commonly caused by loss of control, skating over an obstacle or going too fast.

A study in Victoria, Australia (2) indicated that forearm and wrist injuries constituted 43% of all injuries to in-line skaters of all ages. Half the injuries were incurred in areas used by transport, especially footpaths. A call-back survey of 24 such injured people indicated that 11 (46%) were first-time skaters who simply lost control and fell. Others were experienced skaters who were injured while performing a trick, often at considerable speed. Only 14% of those skaters whose injuries were serious enough to warrant hospital admission wore any protective gear. None of the 24 wore wrist guards before the injury occurred; 58% wore them afterwards. For every in-line skater injured, there were 1.0 injured skateboarders and 1.8 injured roller-skaters.


4. Discussion and Recommendations

4.1 Protective Gear

The International In-line Skating Association recommends that skaters always wear full protective gear: helmet, wrist guards, and knee and elbow pads. (6) Although use of wrist guards has been estimated at 46% in one affluent Michigan county, (13) use in other geographical regions has been considerably lower. (12) For all in-line skaters, roller-skaters and skateboarders, the wrist appears to be particularly vulnerable to injury, as might be expected in sports that commonly result in falling on outstretched arms with hyperextension of the wrist. By holding the wrist firmly against 1 or 2 stiff plastic or metal plates, wrist guards protect against such sudden hyperextension. They also provide a barrier to direct contact of the wrist with the hard skating surface. Until recently, the relative degree of effectiveness of wrist guards in preventing wrist injuries was not known. However, preliminary results of our case-control study of injured in-line skaters indicate that wrist guards are virtually completely protective against lacerations, sprains and strains, and that they reduce the overall odds of sustaining any wrist injury more than 6-fold. (14) Because the wrist is at such high risk and because it is so readily protected, wrist guards should be worn by all in-line skaters (and probably by skateboarders and roller-skaters as well). Elbow- and knee-pad protectors might also help prevent local injuries, but their degree of effectiveness is unknown. Further evaluation of the effectiveness of wrist, knee and elbow pads in reducing or eliminating injuries is warranted.

The issue of protection against head injury is particularly important because of the potential for long term disability. Although the percentage of injured in-line skaters who sustain a head injury appears low (only about 5% in our study), (8) any such event has the potential to cause enormous and long-lasting medical, social and financial consequences. Approved cycle helmets and multipurpose helmets are effective in reducing the incidence of serious head injuries to cyclists, (15) and should offer similar protection to in-line skaters. Consequently, we recommend that in-line skaters also wear a helmet while skating.

4.2 Special Considerations for Novice Skaters

Novice skaters appear to be at particularly high risk of injury. Besides wearing protective gear, novices should avoid roadways with traffic, uneven surfaces, hills (even small ones) and obstacles. They should avoid roadways shared by cyclists and pedestrians until they are capable of steering away from them successfully. Skating instruction may reduce the likelihood of injury, and safe skating practices are likely to improve skills, especially in the early phases of learning.

4.3 Trails

Although more experienced skaters might be able to safely share the road with cyclists and pedestrians, separate trails are advisable where possible. (6) Trail designs have been published, including recommendations for design speed, drainage, trail width, sight distances and surface materials. Trails should be kept free of sand, dirt, leaves and twigs, which can become trapped between the wheels and cause a sudden change in velocity with loss of balance. Good drainage is needed so that puddles do not form; water also changes the coefficient of friction and results in a sudden change in velocity. Trails should also flatten for at least 30 feet (9m) before intersections.

4.4 General Measures

Equipment, especially wheels, should be maintained in good condition. Skaters should skate according to local bicycle traffic regulations and give way to pedestrians. 'Skitching', the practice of holding onto a moving motor vehicle for propulsion while on skates, should be strongly prohibited. This practice potentially endangers the skater if the vehicle suddenly slows, stops or turns. If a skater falls for any reason, their enhanced momentum will result in a greater impact force with the roadway (or another vehicle), and is likely to cause a more severe injury.


5. Conclusions

In-line skating is a popular sport that provides an excellent recreational outlet for adults, adolescents and children. Although in the US the frequency of bicycle-related injuries far exceeds that of injuries from in-line skating, more studies of exposure to risk are needed to determine the relative safety of this sport. Subsequent studies should be conducted to assess the risk factors for injury, especially the relative importance of environmental and behavioural aspects. Certain groups of participants also warrant additional study, particularly those who might be exposed to greater risk because they spend more time skating than other individuals, skate at higher speeds or at higher performance levels (such as speed-skating and trick-skating), or have greater exposure to bodily contact (e.g. in-line hockey players). Meanwhile, full protective gear is recommended.


References

  1. Biemesderfer D. Fast track. Northwest/Airlines World Traveller 1993; 25:20-6
  2. American Sports Data, Inc. American sports analysis report. Hartsdale: American Sports Data, Inc., 1994
  3. Hoffman MD, Jones GM, Bota B, et al. In-line skating; physiologic responses and comparison with roller skating. Int J Sports Med 1992; 13:137-44
  4. Snyder AC, O'Hagan KP. Clifford PS, et al. Exercise responses to in-line skating: comparisons to running and cycling. Int J Sports Med 1993;14:38-42
  5. Annual in-line skating events. In-line: the skate magazine 1995 Mar; 4 (2): 100-2
  6. International In-line Skating Association. Guidelines for establishing in-line skate trails in parks and recreational areas. Minneapolis International In-line Skating Association, 1992
  7. Martin D. Skating by -at 72 M.P.H. New York Times 1993 Nov 24; Sect B: 1 (col 1-4)
  8. Schieber RA. Branche-Dorsey CM. Ryan GW. Comparison of in-line skating injuries with rollerskating and skateboarding injuries. JAMA 1994; 271:1856-8
  9. US Consumer Product Safety Commission. The NEISS sample (design and implementation). Bethesda: US Consumer Product Safety Commission. 1992
  10. Calle SC. In-line skating injuries, 1987 through 1992 (letter). Am J Public Health 1994;84:675
  11. Orenstein JB. Bladerollers. American Academy of Pediatrics Section Injury and Poison Prevention {abstract}. 1993 Spring Session, American Academy of Pediatrics, Section on Injury and Poison Prevention; 1993 Mar 23; Chicago, 6
  12. Heller D. Rollerblading injuries, Hazard, Victoria, Australia 1993;10:11-6
  13. Jacquet JB, Grzesiak E. Personal protective equipment use by In-line roller skaters. J Fam Pract 1994;38:486-8
  14. Schieber RA, Branche-Dorsey CM. Effectiveness of wrist Guards in preventing wrist injuries to in-line skaters {abstract} In: Abstract of the 122nd Annual Meeting and Exhibition, American Public Health Association; 1994 Oct 30-Nov 4: Washington, D.C., Washington, D.C.: American Public Health Association, 1994:360
  15. Thompson RS, Rivara FP, Thompson DC. A case-control study of the effectiveness of bicycle safety helmets. N Engl J Med 1989;320:1361-7

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Table 1

Table I.    Estimated annual incidence and demography of participants and
            injuries, by sport, from the National Electronic Injury
            Surveillance System, 1 July 1992 to 30 June 1993 (8)
===========================================================================
Variable        Sport
                ---------------------------------------------------
                in-line skating     roller-skating  skateboarding
-------------------------------------------------------------------
Estimated
injury
incidence+      30 863              92 963          34 938
(95% confidence
interval)       (23 073-38 653) (70 371-115 555)    (26 252-43 624)

Mean age
(years)&        19.7                16.6            13.6

Median age
(years)%        15                  12              13

Age range
(years)         5-71                2-75            2-72

Male:Female
ratio           1.3:1               0.4:1           4.6:1

-------------------------------------------------------------------
+   p<0.0001 pairwise comparison of the 3 sports by multiple range
    test (Fisher's lease significant difference method).

&   x(superscript2)=132.2, p<0.0001 pairwise comparison of the 3
    sports by Kruskal-Wallis test.

%   x(superscript2)=81.2, p<0.0001 pairwise comparison of the 3
    sports by median one-way analysis.
====================================================================

Figure 1

Anatomical distribution of injuries sustained during in-line skating

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