[18] 
An injury is a general term referring to damage to the body, and can be caused by accidents, falls, weapons, sports, and other incidents. Injuries may affect many parts of the body, including the brain, the extremities, and internal organs. Wounds are injuries that break the skin or other body tissues, and include cuts, scrapes, and punctured skin. This document is focused on injuries to the extremities and spine, referred to as musculoskeletal injuries throughout this document.
Injuries are reported for six different categories, with each having a somewhat different focus and data source(s) specific to the category of injury. To address the broadest picture, this chapter includes the following sections.
Self-reported Injuries [1]: Data for this topic is based primarily on the National Health Interviews Survey (NHIS), conducted annually since 1957 by the National Center for Health Statistics, Centers for Disease Control and Prevention, US Department of Health and Human Services. The survey includes self-reported questions on medical conditions, health insurance, doctor’s office visits, and physical activity and other health behaviors. Because of small sample sizes for some conditions, data is often merged for three years, the result being an average across the time period.
Traumatic Injuries [2]: Traumatic injuries are unintentional physical injuries of sudden onset and severe enough to require immediate medical attention. Causes of traumatic injuries include moving vehicle accidents (i.e., car, bicycle, motorcycle), gunshot injuries, sports, and falls. A major trauma is an injury that has the potential to cause prolonged disability or death. Data on traumatic injuries is based on national health care databases compiled annually by the Agency for Healthcare Research and Quality (AHRQ) and the National Center for Health Statistics (NCHS) of discharges and visits to hospitals, emergency rooms, outpatient clinics, and physician offices.
Falls [3]: Unintentional injury deaths and deaths due to falls are tracked by the Centers for Disease Control (CDC). Falls are a major cause of traumatic injury and death to the aging population.
Workplace Injuries [4]: Workplace injuries are compiled annually by the US Department of Labor, Bureau of Labor Statistics, Injuries, Illnesses and Fatalities Program. Musculoskeletal injuries are classified as musculoskeletal disorders (MSD) that affect muscles, tendons and connective tissue, and comprise a substantial portion of all workplace injuries.
Sports Injuries [5]: Sports injuries occur to children at playgrounds ranging all the way to professional sports. There is no single database that addresses sports injuries for all ages and activities. BMUS 4th Edition includes data from the US Consumer Product Safety Commission, National Electronic Injury Surveillance System (NEISS); the University of Colorado, Colorado School of Public Health High School Sports-Related Injury Surveillance Study (RIOTM); and data from the National Collegiate Athletic Association published in the Journal of Athletic Training. Access to raw databases used in any of these sources, as well as data from professional sports injuries, is not available.
Military Injuries [6]: Military injuries include injuries that occur in both nonactive and active duty personnel, and across the five major branches of military duty: Army, Navy, Air Force, Marine Corps, and Coast Guard. Data is compiled from annual summaries published by the Armed Forces Health Surveillance Branch.
Musculoskeletal injuries represent the majority of injuries treated. Using the national healthcare databases and ICD-9-CM codes for comparison basis, the share of injuries treated classified as musculoskeletal rose from 61% to 89% of all injuries between 2006/2007 and 2013.
Musculoskeletal injuries may be specific to the category of injury (e.g., MSDs as described in Workplace Injuries above), but for the most part fall into five major groups, plus a group of less common injuries. These categories are based on ICD-9-CM diagnostic codes used primarily in national healthcare databases.
Fractures: Fractures occur when a bone is broken. Fractures fall into six types which are not exclusive of one another.
Dislocations: Dislocations are joint injuries that force the articular surfaces of bones out of position. An acutely dislocated joint is painful, swollen, and often visibly out of place. Movement becomes limited. Immediate medical attention is needed to reposition the bones, relieve pressure on soft tissue structures, and provide proper support for healing.
Sprains & strains: A sprain is a stretched or torn ligament, while a strain is a stretched or torn muscle or tendon. A strain can be caused by twisting or pulling tissues. The difference between a sprain and a strain is that a sprain injures the bands of tissue that connect two bones together, while a strain involves an injury to a muscle or to the band of tissue that attaches a muscle to a bone.
Contusions: A contusion, also referred to as a bruise, is damage to the body that doesn't break the skin but ruptures the blood capillaries beneath, resulting in discoloration to the injured area. Most contusions are minor and heal quickly, but they can be serious enough to cause deep tissue damage, swelling, lead to internal “degloving (a significant soft-tissue injury), and limit joint range of motion near the injury. Bruises do not only occur under the skin, but also in deeper tissues, organs, and bones. While these deeper bruises may not show visible signs of bleeding, they can cause pain. They are the second most common sports injury.
Open wounds:
Other musculoskeletal injuries:
On average 2013-2015, 8.83 million persons reported seeking medical care for an injury during the prior three months, a number that extrapolates to 35.3 million per year (Reference Table 5A.1.1 PDF [7] CSV [8]), a number slightly higher than reported by the Centers for Disease Control (CDC) for nonfatal unintentional injuries. Even so, the number of self-reported annual injuries is much lower than the number of healthcare visits to physicians, emergency departments, outpatient clinics, and hospitals reported during the course of a year (Reference Table 5B.2.1 PDF [9] CSV [10]), suggesting that self-reported injuries are under reported.
The proportion of self-reported total injuries that were musculoskeletal was similar to that reported by the national healthcare databases for injury-related healthcare visits, 80% and 87% respectively. (Reference Table 5A.1.1 PDF [7] CSV [8]; Table 5B.2.1 PDF [9] CSV [10])
Self-reported injuries are reported by male and female individuals in the same proportion they are found in the population. Using age as the comparison variable, older people report more injuries than younger. Among racial/ethnic groups, non-Hispanic whites report more injuries while non-Hispanic others report fewer. Using the four geographic regions of the US, injuries are reported higher in the Midwest region. (Reference Table 5A.1.1 PDF [7] CSV [8]; Table 5A.1.2 PDF [11] CSV [12]; Table 5A.1.3 PDF [13] CSV [14]; Table 5A.1.4 PDF [15] CSV [16])
[18] When reporting the cause of their injury, respondents are asked about six specific causes and an “other” cause. Approximately one-half of respondents reply with the “other” response, which includes accidents around the home and while conducting activities of daily living. In compiling data on the cause of injury, only three categories are used. “Falls” is one of the six specific causes; “vehicle or sports-related” injuries include being in a motor vehicle collision or as a pedestrian hit by a vehicle, accidents while in a boat, train or airplane, and accidents while on a scooter, bike, skateboard, horse, etc. Burns are included in the “other” cause category.
The cause of all injuries reported by male and female individuals is 11% each for vehicle or sports-related injuries. However, women report more falls than men (43% versus 30%) and fewer other causes (46%, 60%). (Reference Table 5A.1.1 PDF [7] CSV [8])
[20] By age, persons age 18 to 44 report higher incidence of vehicle and sport-related injuries (15.6%), while those age 65 and over report only 5% from this cause. However, the 65 and over population reports the highest incidence of falls (58.4%). (Reference Table 5A.1.2 PDF [11] CSV [12])
[22] Using race/ethnicity as the comparison variable, there is less variation between groups with only vehicle or sport-related injuries varying. Black non-Hispanics report vehicle or sport-related injuries as a cause 15.2% of the time while non-Hispanic whites report only 9.7% of injuries caused by vehicle or sport-related causes. (Reference Table 5A.1.3 PDF [13] CSV [14])
[24] Geographic regional areas report only minor differences by cause of injuries, with vehicle and sport-related accidents slightly higher in the South and West regions than in the Northwest and Midwest regions. (Reference Table 5A.1.4 PDF [15] CSV [16])
[26] It has long been known that most injuries occur in or around the home, in part because of the time spent at home versus other locations. In 2013-2015, persons self-reporting injuries reported one-half of the injuries for which they sought medical treatment occurred in the home (32%) or outside the home or farm (17%). Female individuals are more likely to report an injury occurring inside the home than are male individuals (37% versus 22%). Other common places of injuries to occur are public buildings (13%) and public streets (12%). Male individuals report injuries occurring in public buildings more than do female ones (22%, 13% respectively). Age is also a factor in where injuries occur, with 75% of injuries reported by persons age 65 and over occurring in or around the home while those age 18 or younger have more injuries at school (28%) or in a public facility (22%). Race/ethnicity and geographic region are not factors in where injuries occur. (Reference Table 5A.2.1 PDF [27] CSV [28])
[30] The type of activity engaged in does not differ significantly as a cause of musculoskeletal injuries. Sports, non-sport leisure activities, and working in and around the home or workplace are the cause of similar numbers of injuries for which medical care is sought. There are slight differences between male and female individuals, but age is a greater factor, with those age 65 and older reporting working at home (27%) or an “other” activity (42%) while young people under 18 are more likely to be injured during sport activities (41%). Race/ethnicity and geographic region are neither one a factor in the type of activity engaged in when injuries occur. (Reference Table 5A.2.1 PDF [27] CSV [28]; Table 5A.2.2 PDF [31] CSV [32]; Table 5A.2.3 PDF [33] CSV [34]; Table 5A.2.4 PDF [35] CSV [36])
[38] The type of self-reported injury reported showed small variations by demographic group, particularly with respect to age and race/ethnicity. Overall, the most common type of musculoskeletal injury for which medical attention was sought was a sprain or strain (37%). This was particularly true for non-Hispanic blacks (42%) and non-Hispanic others (43%), and persons age 18 to 44 (43%). Persons age 65 and older were most likely to report a scrape or bruise (contusion) for which they sought medical attention (28%). Fractures were most common among those 18 and younger (27%). (Reference Table 5A.3.1 PDF [39] CSV [40]; Table 5A.3.2 PDF [41] CSV [42]; Table 5A.3.3 PDF [43] CSV [44]; Table 5A.3.4 PDF [45] CSV [46])
[48] Injuries to the lower extremity were the most common injury site, accounting for 45% of all musculoskeletal injuries for which medical attention was sought. Female individuals reported lower extremity injuries more than male (52% and 39% of all injuries, respectively) while 42% of injuries reported by male individuals were to the upper extremity. Persons age 18 to 64 years were most likely to have a back injury, but injuries to the neck/back/spine accounted for only 13% of reported injuries. Spine injuries were reported in the West region (19%) more than other regions. Race/ethnicity was not a factor is anatomic site of injuries for which medical attention was sought. (Reference Table 5A.3.1 PDF [39] CSV [40]; Table 5A.3.2 PDF [41] CSV [42]; Table 5A.3.3 PDF [43] CSV [44]; Table 5A.3.4 PDF [45] CSV [46])
[50] Sprains and strains accounted for 64% of injuries for which medical attention was sought when the neck/back/spine were involved, and 41% of lower extremity injuries. Scrapes and bruises accounted to 49% of torso injuries. Injuries to the upper extremity were distributed across all types of injuries. Fractures occurred more frequently from a fall, while sprains and strains were more common with vehicle or sport-related injuries. Cuts and other types of injuries occurred from other causes. (Reference Table 5A.4.1 PDF [51] CSV [52]; Table 5A.4.2 PDF [53] CSV [54])
[56] Just over 6% of self-reported medically-consulted musculoskeletal injuries resulted in hospitalization of one night or longer. Fractures were most likely to result in hospitalization (16%), with sprains and strains least likely (2%). Injuries to the torso were more likely to result in hospitalization (10%) than injuries to other anatomic sites. Injuries resulting from falls (10%) also had a greater likelihood of hospitalization. (Reference Table 5A.4.3 PDF [57] CSV [58])
The annual National Health Interview Survey asks participants if they are limited in activities of daily living (ADL), such as the ability to dress oneself, to get in or out of bed or a chair, or to work, due to health issues. Depending on the NHIS dataset used, the specific limitation items are different. The Person file includes activities such as dressing, eating, and working. The Injury file focuses on ability to socialize, walk, and lift/carry items. Both include only persons age 18 and over, and both are based on a “yes” response to “fracture or bone/joint injury” as the cause of the limitation.
In the Injury file, one in four or five persons report limitations with all activities included unless special equipment is available. Reaching over the head is the most limited activity (30%), while grasping small objects the least limited (20%). (Reference Table 5A.5.1 PDF [59] CSV [60])
[62] Inability to work at all (52%) or limited in kind of work (27%) is the major limitation for adults in the Person file reporting a fracture or bone/joint injury. While one in three (31%) reported needing help with routine needs, the specific ADL varied. Women reported higher levels of need than men, and age was also a factor. One in four (25%) of persons age 65 and over reported needing help with personal care after a fracture or bone/joint injury. (Reference Table 5A.5.2 PDF [63] CSV [64])
[66] In addition to needing help with activities, persons suffering a fracture or bone/joint injury report high levels of bed days and lost work days. A bed day is defined as 1/2 or more days in bed due to injury or illness in past 12 months, excluding hospitalization. A mean of 28 bed days were reported by 4.5 million persons with a fracture or bone/joint injury, for a total of 122.6 million days. Mean bed days were slightly higher for women (28 days), persons aged 45 to 64 years (30 days), non-Hispanic whites (30 days), and persons living in the Midwest (35 days).
A missed work day is defined as absence from work due to illness or injury in the past 12 months, excluding maternity or family leave. A mean of 23 lost work days were reported by 2.5 million persons with a fracture or bone/joint injury, for a total of 55.9 million days. Mean lost work days were similar between sexes, by age, and regionally, but considerably higher for Hispanic persons with a fracture or bone/joint injury (33 days) and much lower for non-Hispanic others (10 days).
The share of bed days and lost work days reported by a demographic group is impacted by both the mean days reported and their share of the total population. However, variations can be seen. For example, non-Hispanic whites accounted for 80% of bed days but only 60% of lost work days, while Hispanics were 10% and 17%, respectively. Female injured had a higher share of bed days (59%), while lost work days were evenly split between female and male individuals. Persons age 45 to 64 reported half (49%) of total bed days, with the balance split between younger and older persons. However, due to a representing a small share of the workforce, persons age 65 and over accounted for only 4% of lost work days. (Reference Table 5A.5.3 PDF [67] CSV [68])
[70]
Traumatic injury is a term which refers to physical injuries of sudden onset and severe enough to require immediate medical attention. Traumatic injuries are the result of a wide variety of blunt, penetrating, and burn mechanisms. They include motor vehicle collisions, sports injuries, falls, natural disasters, and a multitude of other physical injuries which can occur at home, on the street, or while at work and require immediate care. Persistent pain and psychological distress lasting several years are common after traumatic musculoskeletal injury (TMsI).1
Accidents resulting in traumatic injury and requiring medical attention are treated in all levels of care sites, including physician’s offices, outpatient clinics, hospital emergency departments, and if severe enough, hospitalization. In 2013, more than 72 million patient visits for injuries were recorded for all levels of care, with 87% of these visits (62.7 million) involving a musculoskeletal injury. Visits for musculoskeletal injuries represented 5% of all healthcare visits for any cause. Visits to a physician’s office accounted for the largest share of total musculoskeletal injury healthcare visits (58%), while the 18.9 million emergency department visits for a musculoskeletal injury represented the highest share of visits for any cause (14%). (Reference Table 5B.0.1 PDF [71] CSV [72])
[74] Records of patient visits for treatment of injuries often include a general cause of injury. In 2013, 28.3 million injury healthcare visits to hospitals and emergency departments were recorded, of which 73% (20.5 million) were musculoskeletal injuries. More than one-half ( 52%) of musculoskeletal hospital injuries were due to falls, with approximately one-fourth each due to trauma events (auto, train, boat, plane, motorcycle) or machinery, moving objects, other types of traumatic injury and other/undefined causes. Only a small proportion (3%) were due to sports injuries. Due to some admissions with multiple causes listed, percentages total more than 100%. Among emergency department visits, more than one-half of musculoskeletal injury visits were due to trauma events (51%), followed by falls as the cause of injury (36%), other/undefined cause (14%) and sports injuries (8%). (Reference Table 5B.1.1 PDF [76] CSV [77])
[79] By sex, women are more likely to suffer a musculoskeletal injury for which healthcare is sought due to a fall, while men are more likely suffer an injury from a traumatic event or a sports injury. Age is a clear factor related to musculoskeletal injuries where hospitalization occurs, with 71% of hospitalization discharges due to an injury from a fall among those age 65 and over. Injuries from falls treated at emergency departments are spread among all age groups. Persons age 18 to 44 years represent the largest share of trauma injuries treated in both the hospital (36%) and emergency department (47%). (Reference Table 5B.1.2 PDF [80] CSV [81]and Table 5B.1.3 PDF [82] CSV [83])
[85]
[87] The most frequent type of injury treated as a result of a fall is a fracture, accounting for 80% of hospitalizations and 33% of emergency department visits. Fractures are also the most frequent traumatic injury seen in hospital cases (63%), but open wounds (28%) and sprains/strains (25%) are treated more frequently in the emergency department as a result of a traumatic injury. Sports injuries are tracked in the ED setting, but not the hospital. Sprains and strains accounted for 35% of sports injuries treated in the emergency department in 2013. (Reference Table 5B.1.4 PDF [88] CSV [89])
[91]
[93] The Centers for Disease Control (CDC) also provides data on the cause of injuries in their Web-based Injury Statistics Query and Reporting System [94] (WISQARS). Again, falls are the leading cause of unintentional nonfatal injuries (32%), with a rate of 29.2 injuries per 1,000 persons in 2015. The rate rises to 63.6/1,000 among those age 65 and over. Other common causes of unintentional injuries are struck by/against (14%) and overexertion (11%). (Reference Table 5B.1.5 PDF [95] CSV [96] and Table 5B.1.6 PDF [97] CSV [98])
[100]
[102]
Healthcare visits for treatment of musculoskeletal injuries include hospital discharges, emergency department visits, outpatient clinic visits, and physician’s office visits. Overall, 1 out of every 15 healthcare visits (6.8%) is for treatment of a musculoskeletal injury. In 2013, sprains and strains and fractures were the most frequently treated type of musculoskeletal injury. (Reference Table 5B.2.1 PDF [9] CSV [10])
[104] Female injured are slightly more likely to be treated in a hospital than male (55% vs 51% of the population). Persons age 65 and over are far more likely to be treated for a musculoskeletal injury in the hospital, while those aged 45 to 64 are more likely to visit a physician’s office. Non-Hispanic whites are treated for musculoskeletal injuries in all healthcare settings more than other racial/ethnic groups. Residents of the Midwest region visit outpatient clinics for injury treatment more than residents of other regions, while those living in the West are most likely to visit a physician’s office for injury healthcare. (Reference Table 5B.2.1 PDF [9] CSV [10]; Table 5B.2.2 PDF [105] CSV [106]; Table 5B.2.3 PDF [107] CSV [108]; Table 5B.2.4 PDF [109] CSV [110])
Nearly 6 in 10 ( 58%) of musculoskeletal injuries for which healthcare treatment was sought were treated in a physician’s office. An additional 3 in 10 were treated in an emergency department and another 1 in an outpatient clinic. Less than 3% were severe enough to require hospitalization. (Reference Table 5B.2.5 PDF [111] CSV [112])
[114] Three out of four (74%) fracture injuries admitted to the hospital are the admitting (first) diagnosis, while one in five other injuries are diagnosed as the admitting diagnoses. The ratio is much higher as the first diagnosis when treated in the emergency department. (Reference Table 5B.3 PDF [115] CSV [116])
[118] Fractures are one of the most common musculoskeletal injuries, and can have long-term impact, particularly among the elderly. In 2013, one in five (24%) musculoskeletal injuries treated in a healthcare facility was for a fracture, with 1 in 20 persons in the population receiving care for a fracture. Data are based on visits in multiple settings and do not represent unique cases. (Reference Table 5B.2.1 PDF [9] CSV [10])
Trends in the number of fractures treated between 1998 and 2013 show relatively stable numbers. Around 3 million fractures of the upper and lower limbs are treated in emergency rooms each year, another 9 million in physician’s offices, with about 900,000 upper and lower limb fracture patients hospitalized each year. (Reference Table 5B.5.1 PDF [119] CSV [120])
[122] Fractures of the radius and ulna (lower arm) are the most frequently treated fracture, with 2.7 million treated in 2013. These fractures are usually treated in the emergency department (ED) or a physician’s office, with a third (33%) occurring in the under 18 years of age population. Fractures of the ankle, humerus (upper arm), hand, and foot each account for 1.2 million to 1.6 million of fractures treated. These fractures occur at all ages, but more often in the middle ages of 18 to 64 years. Fracture of the neck of the femur, a serious injury with 77% occurring to persons over age 65 and more often among women, accounting for 68% of first line visits in the hospital or emergency department. Nearly 1.2 million neck of femur fractures visits were treated in 2013, with more than one-half (56%) seen initially in the ED or the hospital. (Reference Table 5B.5.2 PDF [123] CSV [124])
[126] In 2013, fractures of the lower limb first treated in the ED had a higher rate of transfer to the hospital (35%) than did upper limb fractures (10%). This is likely due to neck of femur fractures in the older population, as 66% of lower limb fractures for persons age 65 and older treated in the ED were transferred to the hospital. However, fractures to the trunk were the most serious, and 42% treated in the ED were transferred to the hospital. When hospitalized fracture patients were discharged, more than 1 in 2 (58%) with a lower limb fracture were discharged to skilled nursing, intermediate care, or another facility, while another 11% had home healthcare. Among discharged patients age 65 and over, 80% with a lower limb fracture went to additional care while 8% had home healthcare. (Reference Table 5B.5.3 PDF [127] CSV [128]; Table 5B.5.4 PDF [129] CSV [130])
[132] Sprains and strains are the most common musculoskeletal injuries treated in any healthcare facility. In 2013, one in five (26%) musculoskeletal injuries treated in a healthcare facility was for a sprain or strain, with 1 in 18 persons in the population receiving care for a sprain or strain. (Reference Table 5B.2.1 PDF [9] CSV [10]) Sprains and strains occur on a wide continuum of severity, and while mild sprains can be successfully treated at home, severe sprains sometimes require surgery to repair torn ligaments.
In 2013, sprains and strains of the back and sacroiliac joint comprised nearly one-third (30%, 7.1 million treatment episodes) of all sprains and strains for which healthcare treatment was given. Most were seen in a physician’s office (71%), with nearly all the remaining persons seen in an emergency department. Approximately 11,000 sprains and strains of the back and sacroiliac joint required hospitalization. Slightly more than 5 million sprains and strains of the shoulder and upper arm were seen by healthcare providers, as were 4.2 million sprains and strains of the ankle and foot. All totaled, more than 24 million persons with sprains and strains received medical care for these injuries in 2013. (Reference Table 5B.6.1 PDF [133] CSV [134])
[136] When evaluated by age, in 2013 more sprains and strains were treated in persons aged 18 to 44 years than other age groups, followed by the 45 to 64 years of age group. Although there is some difference by sex, overall sprain and strain injury treatments reflect the distribution of male and female individuals in the population. The one exception is the 58% of hospital treatment for sprains and strains of the knee and leg which affect more male individuals. (Reference Table 5B.6.2 PDF [137] CSV [138])
[140] Penetrating trauma is an injury caused by a foreign object piercing the skin, which damages the underlying tissues and results in an open wound. The most common causes of such trauma are gunshots, explosive devices, and stab wounds. Depending on the severity, it can be a puncture wound (sharp object pierces the skin and creates a small hole without entering a body cavity, such as a bite), a penetrating wound (a sharp object pierces the skin, creating a single open wound, AND enters a tissue or body cavity, such as a knife stab), or a perforating wound (object passes completely through the body, having both an entry and exit wound, such as a gunshot wound).
The most common causes of penetrating trauma in the US are gunshots and stabbings. One recent study found approximately 40% of homicides and 16% of suicides by firearm involved injuries to the torso.1 As recently as 2003, the US led in firearms-related deaths in all economically developed countries.2
A 2010 study of 157,045 trauma patients treated at 125 US trauma centers found the incidence of penetrating trauma to be significantly less than blunt trauma. Only 6.4% of all injuries were gunshots, while 1.5% were stab wounds.3 Yet, significant geographic variations and racial differences in the incidence of penetrating trauma exist. In a Los Angeles study of 12,254 trauma patients, 24% of patients treated had sustained penetrating trauma. In a similar Los Angeles study, penetrating trauma accounted for 20.4% of trauma cases, yet resulted in 50% of overall trauma deaths—most of which were due to gunshot wounds.4 Hence, the precise incidence of penetrating chest injury varies depending on the urban environment and the nature of the review. Overall, reported findings show penetrating chest injuries account for 1% to 13% of trauma admissions, and acute exploration is required in 5% to 15% of cases; exploration is required in 15% to 30% of patients who are unstable or in whom active hemorrhage is suspected.5
Although hospital and emergency department visits for penetrating injuries are a small proportion of total visits (<1%), in 2013 there were 76,000 hospital discharges and 290,400 emergency department (ED) visits with an external cause of injury defined as assault by firearms, explosives, or cutting/piercing instrument. Cutting/piercing instruments were identified for about two-thirds of the injuries (45,500 hospital discharges and 19,300 ED visits). Most of the remaining cases listed a firearm cause. (Reference Table 5B.7.1 PDF [141] CSV [142])
Males constituted a majority of persons with penetrating injuries, particularly when caused by firearms (88%) and explosives (80-85%). Two-thirds of penetrating injuries (66%-67%) occurred to persons age 18-44, even though this age group represents on 36% of the population. Residents in the South region had slightly higher rates of penetrating injuries than representative of its population. (Reference Table 5B.7.1 PDF [141] CSV [142])
[144]
[146] Looking at a five-year trend for penetrating injuries by race shows black, non-Hispanics carry a larger share of firearms injuries than expected for the population share, but only a slightly higher share of injuries caused by explosives or cutting/piercing instruments. (Reference Table 5B.7.3 PDF [147] CSV [148])
[150] Hospital charges to treat injuries from firearms ($102,300) and explosives ($12,600) are much higher, on average, than the cost for all musculoskeletal injuries or all hospital discharges. Average charges for stabbing injuries ($35,400) are lower than for other causes of hospital stay. Overall in 2013, penetrating injuries accounted for $4.8 million in hospital charges. (Reference Table 5B.7.2 PDF [151] CSV [152])
The average hospital length of stay for musculoskeletal injuries in 2013 was 5.4 days, nearly a full day longer than for hospital discharges for any diagnoses (4.6 days). Persons age 45 to 64 had a slightly longer average stay (5.6 days), while those under 18 years of age had the shortest stay (4.3 days).
[155] Dislocation injuries serious enough to require hospitalization had the longest average length of stay in 2013, nearly six days. However, except for serious sprains and strain injuries, with an average stay of just under five days (4.8), all musculoskeletal injuries had an average hospital stay of five to five-and-one-half days.
[157] Average charges to treat musculoskeletal injuries provide a comparison between injury type and groups, but do not necessarily reflect actual cost as these are usually negotiated between providers and payors. By age, the highest average charges are for persons age 18 to 44 years ($64,700 per stay). The lowest charges are for the youngest patients (under 18 years, $47,400) and those age 65 and over ($51,000). By type of injury, dislocations have the highest average charges ($74,000 per episode), followed by fractions ($61,900). Musculoskeletal injuries have average hospital charges of $15,000 more than hospital stays for any diagnoses ($55,700 vs. $39,500). (Reference Table 5B.4.1.2 PDF [158] CSV [159])
[161]
[163] In general, the average length of stay and average charges for persons hospitalized with a musculoskeletal injury are longer/higher for men than for women, with the exceptions of fractures and contusions. Overall, non-Hispanic blacks have slightly longer hospital stays for musculoskeletal injuries, while Hispanics have higher average charges. By geographic region, the Northeast and South have slightly longer average stays, but the highest average charges are in the West. Fractures account for more than half the total charges for musculoskeletal injuries. (Reference Table 5B.4.1.1 PDF [164] CSV [165]; Reference Table 5B.4.1.3 PDF [166] CSV [167]; Reference Table 5B.4.1.4 PDF [168] CSV [169])
[171] Total charges for all persons hospitalized with a musculoskeletal injury diagnoses (6.3%) comprise a larger share of total hospital charges for all discharges with any diagnoses than the comparative share of patients (4.5%). The discrepancy from 0.5% to 4.1% and is greatest for persons age 45 to 64. (Reference Table 5B.4.1.1 PDF [164] CSV [165]; Reference Table 5B.4.1.2 PDF [158] CSV [159]; Reference Table 5B.4.1.3 PDF [166] CSV [167]; Reference Table 5B.4.1.4 PDF [168] CSV [169])
[173] Musculoskeletal injuries treated in an emergency department (ED) are usually discharged to home (90%), but nearly one in ten is admitted to the hospital (8%). This is half the rate seen for all other diagnoses presenting to the ED (16%). However, persons treated in a hospital for a musculoskeletal injury are more likely to be discharged to additional care (55%), including short-term, skilled nursing/intermediate care, or home health care, than are hospital discharges for any diagnoses (30%). (Reference Table 5B.4.2 PDF [174] CSV [175]; Table 5B.4.3 PDF [176] CSV [177])
[179] The type of musculoskeletal injury impacts whether additional care is likely to be required, with fracture injuries more often discharged to additional care than other types of musculoskeletal injuries. One in for (25%) of persons with fracture injuries seen in the ED are admitted to the hospital.
[181]
[183] Age is a significant factor related to additional care. Among those under the age of 18, 91% are discharged from the hospital to home. By the age of 65 and over, 81% are discharged to skilled nursing/intermediate care or home health care with a fracture. This compares to 25% of hospital discharges for any diagnoses.
[185]
Falls are a major cause of unintentional musculoskeletal injuries, particularly fractures, and often the contributing cause of death within a year of the fall in older persons. Between 2000 and 2015, the age-adjusted rate of death per 100,000 persons due to falls rose from 4.8 to 9.0, nearly doubling. At the same time, the proportion of total unintentional injury deaths that were due to falls rose from 14% to 23%. (Reference Table 5C.1 PDF [186] CSV [187])
[189] Most deaths due to falls were associated with older age, with the elderly person with already compromised health never fully recovering from their injuries, leading to death.The rate of deaths per 100,000 due to falls rose from 62.3 among persons age 75 to 84 years to 250.1 in the 85 and older age group. However, the share of deaths due to falls did not rise as steeply, accounting for 56% of total unintentional injury deaths in the 75 to 84 age group, compared with 69% in those 85 and older. Persons who fall in their mid-80s or older have a higher likelihood of dying from that fall. (Reference Table 5C.2 PDF [190] CSV [191])
[193] Falls are also the leading cause of unintentional injuries resulting in hospitalization for most age groups. Exceptions are persons age 15 to 24 (4th ranking cause), 25 to 34 (5th), and 35 to 44 (3rd). On average, for the years 2010 to 2016, falls accounted for between 8% and 77% of all hospitalized injuries, depending on the age group, and 43% overall for all ages.1 The estimated lifetime medical and work-loss costs for all unintentional hospitalized nonfatal injuries in 2013 was $253 billion.2
One in eight (13%) unintentional injuries incurred from a fall that was severe enough to be treated in an emergency department and resulted in hospitalization in 2015. Age was a strong mitigating factor, as only 2% of these injuries among children and adolescents under 18 years of age were hospitalized, while in the 85 and older age group, 35% were hospitalized. (Reference Table 5C.3 PDF [194] CSV [195])
[197] Workplace injuries are tracked by the US Department of Labor, Bureau of Labor Statistics [200], with data published annually on these injuries. Musculoskeletal workplace injuries include fractures, bruises/contusions, and amputations, as well as musculoskeletal disorders (MSDs). MSDs are often cumulative and include repetitive motion injuries that occur when the body reacts to strenuous repetitive motions (i.e., bending, climbing, crawling, reaching, twisting) or overexertion. MSD injuries include sprains, strains, tears, back pain, soreness, carpal tunnel syndrome, hernia, and musculoskeletal system and connective diseases. MSD cases are more severe than the average nonfatal workplace injury or illness, typically involving an average of several additional days away from work. In 2016, the median number of days away from work for all workplace injuries was 8 days;1 for MSD injuries, the median was 12 days. (Reference Table 5D.1 PDF [201] CSV [202])
The rate of nonfatal occupational injuries and illnesses has significantly decreased during the past 25 years, potentially due in part to heightened attention to workplace safety. In 1992, more than 2.3 million cases of work-related injuries and illnesses were reported by the Bureau of Labor Statistics. By 2016, the number had dropped to 892,000. A similar decline occurred in the number of MSDs. However, the relative ratio of MSDs to all workplace injuries has remained relatively steady at approximately one-third (29% to 35% range) of all workplace injuries. (Reference Table 5D.1 PDF [201] CSV [202])
[204] Men sustain workplace injuries at a higher incidence than women, with rates of 103.9 and 89.4/10,000 full-time workers, respectively, in 2016. They also are away from work an average of two days longer than women after a workplace injury. It is likely that at least a portion of the reason for this difference is the type of work involved, with men working more frequently in industries where a workplace injury is more common. Aging is a factor in median days away from work; workers less than 44 years of age had a median of less than 10 days away, while workers age 65 and over had a median of 15 days away in 2016. (Reference Table 5D.2.1 PDF [205] CSV [206] and Table 5D.2.2 PDF [207] CSV [208])
[210] The type of workplace injury incurred is a major factor in defining the median number of associated days away from work. Fractures have historically been, and remain, the injury associated with the highest number of days away from work. In the late 1990s, a median of 20 to 21 days away from work were reported for a fracture; since the early 2000s, the median days away has been about 30. Over the last few years, days away from work has risen to the mid-30s. In past years, carpal tunnel syndrome was identified as a close second in terms of days away from work (ranging from 21 to 32 days over the years 1997 to 2010), it was not listed as a condition in the latest reports. Amputations and tendonitis are the other two injury types that are associated with a median of greater than 10 days away from work.
Traumatic injuries to muscles, tendons, and ligaments account for 2 in 5 (39%) injuries resulting in days away from work. Sprains and strains have an incidence per 10,000 full-time workers, which is twice that of the next listed injury (36.3/10,000 versus 16.8) in 2016. Workers between the ages of 25 and 54 sustain the largest number of nonfatal occupational injuries that involve days away from work, possibly reflecting the ages found in the workforce. (Reference Table 5D.3.1 PDF [211] CSV [212]; Table 5D.3.2 PDF [213] CSV [214]; and Table 5D.4 PDF [215] CSV [216])
[218] Overexertion, either in combination with bodily reaction or involving outside sources, is the most common cause of nonfatal injuries resulting in days away from work. Together, the two types of overexertion resulted in an incidence of 51.0 per 10,000 full-time workers in 2016, with a median of 11 to 12 days away from work. For median days away from work, repetitive motions involving microtasks had the highest median days away from work (24) but had an incidence of only 2.1 per 10,000 full-time workers. (Reference Table 5D.5 PDF [219] CSV [220])
Workers often sustain injuries that affect multiple parts of their body. However, injuries to the upper extremities (shoulder, arm, wrist, hand), trunk (including the back), and lower extremities (knee, ankle, foot, toe) far outnumber injuries to the head, neck, other body systems, and multiple parts. In 2016, about one-third of workplace injuries involving days away from work involved the upper extremities (32%), with hand injuries the most common. Trunk and lower extremity injuries each account for about a fourth of all injuries (23% each). Knee injuries are the most common lower extremity injury. Back injuries account for three-fourths of trunk injuries. (Reference Table 5D.6 PDF [221] CSV [222])
[224]
Sports are integrally woven into the fabric of American society. From being a fan, through participation in recreational athletics, all the way to participation in competitive club, high school, collegiate, and professional athletics, sports are an important facet of our lives. Participation in sports and physical activities have several noted health and psychological benefits; however, over the past few decades, an increase in participation in both youth sports as well as recreational activity has been noted – with a resultant increase in both acute and chronic musculoskeletal injuries.
The goal of this section is to provide an overview of the epidemiology of athletic injuries in the United States population. As we ascend the athletic ladder from recreational activities to professional sports, we note an increase in participation and injury data available. However, we have poor mechanisms and infrastructure to study injuries among those engaged in the lowest levels of athletic participation. For example, there is limited data on the middle-aged person who begins jogging for fitness or the 12-year old who rides a bicycle. Similarly, as youth sports club participation has become more popular in the United States there are few resources to study injuries in this setting. We will attempt to provide an overview of these less organized athletic injuries from available data. We will also focus on higher levels of organized sports, primarily scholastic sports (high school level) and intercollegiate sports.
It is estimated that 30 million children and adolescents participate in organized sports. In addition, some 150 million adults participate in physical activity and recreational activities that are not related to their employment.1 However, both these large at-risk populations lack a systematic mechanism for tracking musculoskeletal injuries and conditions.
While professional, collegiate, and even high school athletics have epidemiologic systems in place to track injury patterns, recreational athletics lack any type of surveillance system. However, the US Consumer Product Safety Commission established the National Electronic Injury Surveillance System [226] (NEISS) in 1997 to track emergency room visits and injury patterns associated with specific products. This database has also been helpful as a means of documenting injuries associated with athletic, physical activity, and recreational endeavors. However, a major limitation of this data is that injuries not significant enough to require an emergency room visit, or injuries that are seen in other healthcare settings (e.g., athletic training room, primary care clinic, specialty clinic) may not be documented and reported. Regardless, the NEISS probably provides the best available nationwide estimates on recreation related and physical activity injuries significant enough to require an emergency room visit.
Using the data from the NEISS, a 2002 CDC report detailed 4.3 million sports and recreation related injuries that were treated in US emergency departments.1 The injury rate was highest for boys ages 10-14. A more recent paper documented that an estimated 600,000 knee injuries present annually to emergency rooms in the United States. Of these, 49.3% resulted from participating in sports and recreation activities.2
More recent data from the NEISS for the years 2014 through 2016 reveal similar patterns. During this time period a total of 4.2 million emergency room visits were documented for injuries related to sports participation, physical activity, and recreational endeavors. Of those, 1.5 million were due to participation in team sports and 2.8 million injuries resulted from individual sports and recreational activities, of which 61% impacted the musculoskeletal system. Two out of three musculoskeletal injuries occur to males, with the proportion lower for individual sports (57%) than for team sports (77%). Of the estimated 2.8 million injuries resulting from individual sports that present annually to emergency rooms in the US, 57% impact the musculoskeletal system. Two out of three musculoskeletal injuries (65%) occur to males, with the proportion being slightly smaller among males for individual sports than for team sports. (Reference Table 5E.1.1 PDF [227] CSV [228])
[230]
Cycling and wheeled sports account for 19.9% of all recreational sports injuries and musculoskeletal injuries serious enough to warrant a visit to the ED. Fitness training results in an additional 16.3% of the total number of musculoskeletal injuries seen. Musculoskeletal injuries account for more than 50 percent of all injuries in all sports, with the exception of water sports. (Reference Table 5E.1.1 PDF [227] CSV [228])
[232] Musculoskeletal injuries treated in the ED as a result of a recreational sport injury occur in the highest proportion in kids ages 2 through 18. According to the latest data, nearly 60% of all musculoskeletal injuries due to participating in individual and team sports and recreational activities occur in this age range. This is, in part, due to the high number of playground injuries, as well as biking and other wheeled equipment, such as skateboards and scooters, but kids account for a higher proportion of treated sports injuries in all but a few sports that are more adult focused. Adults between the ages of 19 and 44 also account for a substantial proportion (29%) of treated musculoskeletal injuries, but they are also a larger share of the population and more likely to be active in recreational sport activities. (Reference Table 5E.1.2.1 PDF [233] CSV [234])
[236] Sprains and strains, primarily affecting the joints and muscles, are the most common reason for seeking care in the emergency department for sports and physical activity related injuries. An estimated 41.2% of musculoskeletal injuries seen in emergency departments due to participating in recreational sports and physical activities result in sprains or strains, followed by bone fractures (30.4%), contusions (24.3%), and joint dislocations (3.8%). (Reference Table 5E.1.3 PDF [237] CSV [238])
[240] Injuries from team and individual sports to the extremities are the most common, with 41.3% occurring in the upper extremity compared with 37.5% in the lower extremity. The trunk sustains most of the remaining injuries (14.4%), with less than 6% involving the head, although head injuries are often unreported. (Reference Table 5E.1.4 PDF CSV) Among team sports, kids age 2 to 12 are the most likely to injure the upper extremity in all except those playing hockey, where participation numbers in this age range are low. (Reference Table 5E.1.7 PDF [241] CSV [242])
[244] Nearly all (96%) musculoskeletal injuries due to sports and recreational activities seen in the ED are treated and released. This compares to just over 81% for all emergency department visits. Only 3% of recreational activity and sports injuries seen in EDs result in hospitalization. Among individual sports, 4.1% of musculoskeletal injuries seen in the ED resulted in hospitalization with the highest proportion of injuries from mountain climbing (12.1%), all-terrain vehicles and motorized bikes (8.1%), and bicycle/wheeled activities (bicycles, skateboards, scooters, etc.) (6.1%). Among team sports only 1.1% of injuries seen in the ED resulted in hospitalization, with the highest proportion reported in soccer (1.5%), followed by hockey (1.4%) and football (1.3%). (Reference Table 5E.1.5 PDF [245] CSV [246])
[248] It is not surprising that the majority of injuries treated in emergency departments due to sports participation and recreational physical activities occur on sports fields (37.5%), with 50.9% of team sports injuries and 29.2% of individual sports injuries occurring in this setting. (Reference Table 5E.1.6 PDF [249] CSV [250])
[252] Scholastic sports have nearly doubled from an estimated 4.0 million participants in 1971-1972 1 to 7.98 million participants in 2017-2018.2 These high school athletes experienced an estimated 1.4 million injuries in 2017-2018.3 Data from the National High School Sports-Related Injury Surveillance System [253] using RIO (Reporting Information Online) as a surveillance system, was used to examine injury rates and trends. This data provides quality epidemiologic information entered by athletic trainers associated with participating high schools and provides nationwide estimates for injury incidence rates in common high school sports.
Using the National High School Sports-Related Injury Surveillance Study, it was estimated that more than 17 million injuries resulted from participation in team sports at the high school level during the 13 years studied between the 2005-2006 and 2017-2018 school years. On average, of the total injuries documented during the surveillance period, strains/sprains accounted for 44%, concussions represented 18%, contusions comprised 11%, and fractures were documented in 9% of cases. Injuries categorized as “other” comprised 18% of all injuries. Overall, the majority of injuries from participating in high school athletics impacted the musculoskeletal system.4
[255] Football had the highest injury incidence rate for musculoskeletal injuries among all team sports at the high school level, followed by girls’ soccer and boys’ wrestling. In 2017-2018, football also had the greatest number of total injuries as well. In every sport besides girls’ volleyball and boys’ wrestling, more injuries occurred during competition when compared to practice.
Musculoskeletal injuries occur at numerous different sites throughout the body. On average, between 2012 and 2018, 21% of all injuries were to the head/face, 17.5% impacted the ankle, 14.5% occurred in the knee, 9.5% affected the hip/thigh/upper leg, 7.5% affected the shoulder, 8% were to the hand/wrist, 5% to the trunk, 5% to the lower leg, 4% to the arm/elbow, 4% affected the foot, and 2% of all injuries were to the neck. Injuries categorized as “other” comprised 2% of all injures. The ankle and knee, two of the most injured joints accounted for a combined total of 32% of all musculoskeletal injuries among high school athletes.5 This is consistent with the most recent data available for the 2017-18 academic year.6
[257] Musculoskeletal injuries also account for substantial time loss from playing a sport. On average, between 2012 and 2018, 17% of all injuries resulted in 1-2 days of time loss; 24% resulted in 3-6 days of time loss; 16% resulted in 7-9 days of time loss; 19% resulted in 10-21 days of time loss; and 23% resulted in greater than 21 days of time loss or medical disqualification for the season, medical disqualification for the career, or an injury that did not resolve prior to the end of the season permitting return to play. One in four (24%) resulted in 3-6 days of time loss, which can equate to missing an entire week of practice and games, but nearly as many (23%) injuries resulted in missing 22 or more days or not returning to sport during the same season.7 During the same time period, between 5.3% and 8.2% of injuries annually required surgical intervention to repair.8
Though nearly 95% of all sports-related injuries seen in emergency departments are treated and released, as noted in the discussion of recreational athletics above, emergency medical system (EMS) transport among high school athletes is relatively uncommon. The overall rate of EMS transport among high school athletes participating in organized sports is 0.29 transports per 10,000 athlete exposures, according to a recent report.9 Nearly 60% of the injuries requiring EMS transport impacted the musculoskeletal system, with the most common injuries including fractures (24%), strains (12%), dislocations (11%), and sprains (10.3%).
Trends in annual injury incidence rates for high school athletes over time are presented in Graphs 5E.2.3a thru 5E.2.3h and the total annual number of injuries among high school athletes over time based on the RIO data are presented in Graph 5E.2.4. Overall, these data have remained relatively stable between 2005-2006 and 2017-2018. Annual incidence rates over time for specific high school sports during this time period are also presented. Some significant trends have been reported.10 Specifically, there have been statistically significant decreases in the annual injury incidence rate for boys’ high school soccer and basketball during practice sessions; however, there has also been a significant increase in the annual incidence rate for girls’ high school soccer in competitions.
[259]
[261]
[263]
[265]
[267]
[269]
[271]
[273]
[275]
[277]
[279] While less data is available on long term health impacts of musculoskeletal injuries in scholastic athletes, one such study by McLeod and colleagues offers insight into the significant impact of athletic injury in this large population.11 The research team studied a convenience sample of 160 uninjured and 45 injured scholastic athletes with health-related quality of life measures. They found significantly lower scores among the injured athletes for the following subscores of the Quality of Life Short Form Questionnaire (SF-36):12 physical functioning, limitations due to health problems, bodily pain, social functioning, and the physical composite score. These findings suggest that physical injuries in our young athletes affect not only their physical function and risk for future musculoskeletal injury and disability, but also extend beyond the physical aspects of overall health. Limited data is available on the long-term health related impact of musculoskeletal injuries experienced by high school athletes.
The National Collegiate Athletic Association [283] (NCAA) is a non-profit association that regulates athletes of more than 1,200 institutions, conferences, organizations, and individuals that organize athletic programs of many colleges and universities in the United States and Canada. Athletic programs of more than 1,100 member schools that compete are divided into three levels or divisions.1 Nearly a half-million student-athletes participate in NCAA sports that offer national championships annually, and this number continues to grow. During the 2018-2019 academic year, the number of teams competing in NCAA championship sponsored sports reached an all-time high of 19,750. However, only about 6% of high school athletes will participate in NCAA intercollegiate sports.2
While there are numerous benefits associated with participating in collegiate athletics, there is also an increased risk of injury associated with participating in many types of sports. These injuries primarily affect the musculoskeletal system, in general, and the lower and upper extremities specifically. Though awareness of risk of injury associated with participating in collegiate athletics is growing, there is little known about the long-term impact of injuries sustained while participating in collegiate athletics. Recent injury data from the NCAA Injury Surveillance System [284], as well as reports for specific joint injuries sustained by NCAA athletes and emerging data on the potential long-term impact of these injuries on health related quality of life, is presented.
For over 30 years, the NCAA and the Datalys Center [285] (since 2009) has been engaged in active injury surveillance within the unique population of college athletes. Collaborative efforts between the NCAA and the National Athletic Trainers’ Association [286] (NATA) have yielded rich injury surveillance data used to inform important rule changes to protect player safety.3 In a 2007 special issue of The Journal of Athletic Training, data from the NCAA injury surveillance system from the 1988-89 academic year through the 2003-2004 academic year were reviewed for 15 collegiate sports.4 With permission from the publisher, data from this study is included in this site. To read the full article, click here [287].
The 15 sports examined included five fall sports (men’s football, women’s field hockey, men’s soccer, women’s soccer, and women’s volleyball), six winter sports (men’s basketball, women’s basketball, women’s gymnastics, men’s gymnastics, men’s ice hockey, and men’s wrestling), and five spring sports (men’s baseball, men’s football, women’s softball, men’s lacrosse, and women’s lacrosse). Data for men’s spring football were only included in the analysis of practice injuries. These data provided an overall summary of the NCAA data from the years 1988-1989 through 2003-2004, made recommendations for injury prevention initiatives, and provided insight into the burden of musculoskeletal injury experienced by collegiate athletes. Some of these data are highlighted in this section. More recently, a series of papers on the first decade of web-based injury surveillance in high school and collegiate athletes have been published.5,6,7,8,9,10,11 These data are also briefly integrated here, as appropriate, as they provide further insight into the incidence and burden of musculoskeletal injuries in collegiate athletes. Overall, musculoskeletal injuries to the upper and lower extremity account for approximately 80% of all injuries among NCAA athletes; however, injury patterns vary slightly by sport. The CDC, which estimates 2.6 million children ages 0 through 19 years are treated in emergency departments each year for sports and recreation related injuries12, provides tips on how to prevent sports-related injuries in their Protect the Ones You Love Initiative [288]. Other professional societies and associations such as the American Orthopaedic Society for Sports Medicine’s (AOSSM) At Your Own Risk [289]and Stop Sports Injuries [290], and the National Athletic Trainers Association (NATA) Position Statements [291] also provide recommendations for injury prevention.
Overall, incidence rates for the 15 sports examined range from a high of 35.9 per 1,000 game athlete-exposures for men’s football to a low of 1.9 for men’s practice basketball. Among men, the highest injury rates were observed in football, wrestling, soccer, and ice hockey. Among women, the highest injury rates were experienced in soccer, gymnastics, ice hockey, and field hockey. (Reference Table 5E.3.2 PDF [292] CSV [293])
[295]
[301] The majority of injuries resulted from contact with another player, regardless of whether or not injuries were sustained in practices or games. (Reference Table 5E.3.4 PDF [302] CSV [303])
[305] The majority of injuries documented during the study period affected the musculoskeletal system, with 72% of all injuries in games and 75% of all injuries in practices affecting the extremities. Regardless of whether injuries occurred in practices or games, over half of all injuries reported across the 15 sports examined during the study period were to the lower extremity. (Reference Table 5E.3.5 PDF [306] CSV [307])
[309] The NCAA injury surveillance system has also been used to examine the incidence and injury patterns of specific injuries among collegiate athletes.13,14These studies have primarily focused on those injuries that likely have the greatest burden in terms of time loss from sport, the need for surgical intervention, and the potential for long-term impact on health. Specifically, joint injuries have been a primary concern as it is well documented that these injuries can lead to chronic instability and increase the risk of osteoarthritis and degenerative joint disease.
Acute traumatic anterior cruciate ligament (ACL) injuries in the knee often lead to chronic pain and instability, and generally require surgical repair to restore function and stability. There is also substantial evidence to suggest that acute traumatic knee joint injuries such as ACL tears significantly increase the risk for post-traumatic osteoarthritis. Several studies have focused on the rate of ACL injuries among collegiate athletes.4,11,15,16,17 estimated that approximately 2,000 athletes participating in 15 different men’s and women’s NCAA sports sustain an ACL tear annually. The average annual rate of ACL injury during the 16-year study period examined was 0.15 per 1,000 athlete-exposures. Arendt and Dick16 first reported that there were disparities in ACL injury incidence rates between males and females participating in the NCAA gender matched sports of soccer and basketball. This observation was confirmed in a follow-up study that examined data from 1990 through 2002.15 The authors reported that the rate of ACL injuries was 3 times higher in female soccer players (0.33) when compared to male soccer players (0.11). Similarly, they reported that the rate of ACL injuries was 3.6 times higher in female basketball players (0.29) when compared to males (0.08). Regardless of sport, the rates in females were significantly higher when compared to males. They also reported that ACL injury rates declined significantly in male soccer players during the study period but remained constant among female soccer players. (Reference Table 5E.3.6 PDF [310] CSV [311])
[313] Despite the decreases in ACL injury rates observed by Agel et al15 in male soccer players, Hootman et al4 reported that ACL injury rates among males and females combined, participating in 15 different NCAA sports, significantly increased during the 16-year study period. On average, they reported a 1.3% annual increase in the rate of ACL injury over time (P=0.02). (Reference Table 5E.3.7 PDF [298] CSV [299])
[315] Dragoo et al13 compared ACL injury rates between NCAA football players participating on artificial turf and those participating on natural grass. They reported that the rate of ACL injury on artificial surfaces was significantly higher (1.39 times higher) than the injury rate on grass surfaces. A more recent study reports the injury rate on artificial turf 1.63 times higher than on grass surfaces.18 They also noted that non-contact injuries occurred more frequently on artificial turf surfaces (44%) than on natural grass (36%).
Ankle sprains are also common among NCAA athletes and they frequently lead to chronic pain, instability, and functional limitations. Hootman et al4 estimated that approximately 11,000 athletes participating in 15 different men’s and women’s NCAA sports sustain an ankle sprain annually. The average annual rate of ankle sprain injury during the 16-year study period examined was 0.86 per 1,000 athlete-exposures. They also examined the annual injury rates for ankle sprains among males and females participating in these sports combined between 1988 and 2004. They reported that injury rates remained constant during the 16-year study period. On average, there was a non-significant 0.1% (P=0.68) annual decrease in the rate of ankle sprains during the study period. (Reference Table 5E.3.6 PDF [310] CSV [311])
[317] Shoulder injuries, especially those that result in instability, also impact a significant number of NCAA athletes and can lead to chronic pain, recurrent instability, and functional limitations. Recurrent shoulder instability has also been associated with the increased risk of osteoarthritis in the shoulder. Surgical reconstruction is common following shoulder instability in young athletes. Owens et al14 examined the injury rates and patterns for shoulder instability among NCAA athletes over the 16-year period from 1988 through 2004 in the same 15 sports described previously. The overall injury rate for shoulder instability during the study period was 0.12 per 1,000 athlete-exposures. On average, this is comparable to just under 2,000 shoulder instability events experienced annually in NCAA athletes. Injury rates for shoulder instability were significantly higher in games when compared to practice. Overall, NCAA athletes were 3.5 (95% CI: 3.29-3.73) times more likely to experience shoulder instability events in games when compared to practices. Just over half (53%) of the shoulder instability events documented during the study period were first time instability events, with the remaining injuries being recurrent instability events (47%). Most shoulder instability events were due to contact with another athlete (68%) and other contact (20%). Nearly half (45%) of all shoulder instability events experienced by NCAA athletes during the study period resulted at least 10 days of lost playing time, with the remainder returning to play within 10 days of injury.
While we still have a rudimentary understanding of the impact that musculoskeletal injuries sustained by collegiate athletes have on long-term health outcomes, studies have recently begun to examine health-related quality of life in current and former NCAA athletes. McAllister et al1 evaluated health-related quality of life in NCAA Division I athletes using the SF-362 and examined the association between scores, injury history and severity. Collegiate athletes who reported a history of mild injury had significantly lower physical component summary scale scores, role physical scores, bodily pain scores, social function scores, and general health scores on the SF-36 when compared to those with no history of injury. Collegiate athletes who reported a serious injury had significantly lower scores on all SF-36 component scores when compared to athletes with no history of injury. Similar results were observed in a separate study that examined NCAA Division I and Division II athletes.3
More recently, studies have examined health-related quality of life in former NCAA athletes. Sorenson et al4 reported that former NCAA Division I athletes were significantly more likely to have joint-related health concerns when compared to non-athletes and were 14 times more likely to seek professional treatment for their symptoms. They also reported that the prevalence of joint related health concerns was significantly higher in older former athletes when compared to younger former athletes.
In a similar study, Simon et al5 examined health-related quality of life in former NCAA Division I athletes and former non-athletes using the Patient-Reported Outcomes Measurement Information System (PROMIS).6 They reported that former collegiate athletes report significantly worse scores for 5 of the 7 PROMIS scales examined when compared to non-athletes. Specifically, former athletes reported poorer scores on the physical function, depression, fatigue, sleep disturbances, and pain interference scales. There were no differences noted between former NCAA athletes and non-athletes for the anxiety and satisfaction with participation in social roles scales. The authors also noted that former collegiate athletes reported significantly more major injuries, chronic injuries, daily limitations, and physical activity limitations when compared to non-athletes.
Overall, these studies suggest that NCAA athletes who sustain injuries during their college years have significantly lower health-related quality of life scores, and that these scores may get worse with time, particularly for joint-related health issues and long-term major and chronic injuries. Decreased health-related quality of life in former college athletes may also contribute to greater daily activity and physical activity limitations when compared to non-athletes and may lead to significant chronic health comorbidities. Further research is needed to determine which factors contribute to the poorer health-related quality of life outcomes observed among former collegiate athletes in these studies.
The burden of musculoskeletal issues on the military population cannot be overstated. Further, the impact of these injuries does not stop when the service member transitions out of the military. Musculoskeletal injuries and conditions are one of the greatest threats to our military’s readiness and troops ability to deploy and as such, bear a substantial significance for our society as a whole.1,2 Further, inability to return to full duty due to musculoskeletal injury or pre-existing musculoskeletal condition is the most common reason for medical discharge from the Armed Services across all branches,3,4 with almost 78% of male Army personnel and 85% of females with a disability discharge discharged due to a musculoskeletal injury or condition.4 There is anecdotal and some scientific evidence on medical discharges from the British armed forces that females in military service experience an excess of work-related injuries, compared with males.5
During Fiscal Year 2016, there were nearly 1.3 million active duty service members (enlisted plus officers) and an additional 860,000 Reserve and National Guard members. Among all branches of the Department of Defense enlisted personnel (1.06 million), 84% are male and 16% female. Female personnel were slightly younger, with 86% under the age of 35, compared to 83% of male personnel under 35 years of age. This is nearly double the percentage of the civilian population under age 35, years where in both male and female persons only 44% is under 35 years of age. The Marine Corps has the highest proportion of personnel under the age of 35 years, with 92.5% of the enlisted component of the Marine Corps less than 35 years. The young age and high activity level of the active duty military population brings about a unique set of musculoskeletal conditions. (Reference Table 5F.0.1 PDF [320] CSV [321] and Table 5F.0.2 PDF [322] CSV [323]) (G5F.0.1, G5F.0.2, G5F.0.3)
[325]
[327]
[329] The military summary data presented here is largely derived from the Defense Medical Surveillance System (DMSS) from the Medical Surveillance Monthly Report (MSMR) annual reports on non-deployed, Active Duty United States military personnel. The DMSS examines total numbers of hospitalizations and ambulatory visits broken down by a defined set of diagnostic categories based on ICD-9-CM, and in the most recent years the ICD-10-CM, codes. In general, musculoskeletal injuries and conditions are compiled into two major diagnostic classifications, “injury and poisoning” or “musculoskeletal system” conditions. Typically, diagnoses included in the “injury and poisoning” category are more acute in nature (i.e. fractures, ligament tears, shoulder dislocations, etc.), while more chronic conditions (i.e. osteoarthritis, tendinitis, stress fractures, etc.) are included in the “musculoskeletal system” category.
Excluding pregnancy-related visits, ”injury and poisoning” and “musculoskeletal system” are consistently amongst the top causes for hospitalization and consistently ranked second and fourth most frequent diagnoses across all military personnel. Mental disorders and digestive systems are commonly ranked first and third. This illustrates the significant overall burden of musculoskeletal problems in relation to all other medical conditions treated at Military Treatment Facilities (MTFs). (Reference Table 5F.1.1.1 PDF [332] CSV [333])
[335] Broken down by service branch, the rate of hospitalization per person-year for all diagnostic categories is higher for Army personnel than for other service branches. Since the Army has more than double the number of personnel in other branches, the absolute number of hospitalizations is much higher and therefore not a valid comparison point. (Reference Table 5F.1.1.2 PDF [336] CSV [337])
[339] The total morbidity burden (hospitalizations plus ambulatory visits) for injury/poisoning events ranks as the number one cause of medical treatment received at MTFs. More than 540,000 service members were treated annually for an injury/poisoning event each year from 2012 to 2017. This accounted for roughly 25% of all encounters at military hospitals over that time frame. Additionally, injury/poisoning events resulted in 12% of hospital bed days and ultimately almost 25% of lost work time. (Reference Table 5F.1.1.3 PDF [340] CSV [341])
[343] Musculoskeletal injuries in the military encompass a wide range of pathology from chronic overuse conditions to acute injuries from training accidents to high energy blast injuries sustained on deployments. Given the overall young age of military cohorts, injuries sustained are often sports or training related and not unlike what would be seen in a civilian Sports Medicine practice; however, these injuries often occur at a higher incidence when compared with their civilian counterparts. The high energy blast injuries that we grew accustomed to during the heights of the Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) conflicts have decreased over the last decade yet still remain a significant cause for morbidity and mortality amongst the military population.1
In 2012, battle injuries comprised 7% of hospitalization due to injury but fell to 1% or less in subsequent years. The overall rate of hospitalization for injuries/poisoning events has fallen over the last five years from 7.7 per 1,000 person-years in 2012 to 5.0 per 1,000 person-years in 2017. The most common cause of hospitalized injuries reported was falls. In recent years, however, the cause of more than half of hospitalizations due to injury was not identified, which makes a direct comparison challenging. (Reference Table 5F.1.2.1 PDF [344] CSV [345])
[347] The rate of hospitalization for injuries per person-year is consistently highest in the Army and lowest in the Air Force. Based on the 2016 distribution of Armed Forces by sex (84% male; 16% female), females are slightly less likely to be hospitalized for an injury/poisoning event across all branches. (Reference Table 5F.1.2.2 PDF [348] CSV [349] and Table 5F.1.2.3 PDF [350] CSV [351])
[353] The most common reason for ambulatory visits within the military has consistently been the “musculoskeletal system,” and the rate per person year has steadily increased over the 2012 to 2017 time period. Additionally, injury and poisonings are the 5th most common cause of ambulatory healthcare visits in the US Armed Forces, which also increased over the time period between 2012 and 2017. While the absolute number of visits is impacted by the annual end strength of the Armed Forces, the rate of ambulatory visits has not changed considerably between 2012 and 2017 despite fluctuations in total number of personnel. Overall, more than half the active component of the Armed Forces personnel had an ambulatory visit for an injury event each year resulting in an annual per person rate of 0.6-0.7, or roughly two in three personnel.
The direct care system (DCS) includes military treatment facilities (MTF) comprised of medical centers, hospitals, and clinics found at military bases and posts in the US and around the world dedicated to providing healthcare to DoD-eligible beneficiaries and staffed and run by DoD personnel. In addition, the military health system (MHS) provides purchased care contracted outside of an MTF that provides or supplements care to beneficiaries that is either unavailable in the DCS or falls outside the MTF market area.
For personnel treated at a MTF, disposition (ie, full, light or limited duty) of patients are tracked closely. In 2017, the illness-and injury-related diagnostic categories with the highest proportions of “limited-duty” dispositions were injuries and poisonings (17.5%) and musculoskeletal disorders (13%).1 However, treatment visits in purchased care facilities are not always identified. (Reference Table 5F.1.3.1 PDF [354] CSV [355] and Table 5F.1.3.3 PDF [356] CSV [357])
[359] Unlike hospitalizations for injury/poisoning events, where females are slightly less likely to be hospitalized, they are slightly more likely to have an ambulatory visit. (Reference Table 5F.1.3.2 PDF [360] CSV [361])
The diagnostic cause of ambulatory visits for injury/poisoning events is also provided in the MSMR Annual Summary Edition. While the proportion of visits varies somewhat by year and by sex, injury causes are consistent overall with the top two injuries being ankle sprains and sprains of the cruciate ligament of the knee. Between 8% and 10% of all ambulatory injuries are a sprain of the ankle, with foot injuries sometimes included in this diagnosis category depending on coding. Sprains of the cruciate ligament (knee) is the second most common, accounting for 3% to 4% of injuries. Sprains and strains of the shoulder and upper arm are more common among males, while females are more often diagnosed with sprain of the hip. (Reference Table 5F.1.3.4 PDF [362] CSV [363])
Routine, repetitive physical training and job requirements place service members at risk for common overuse conditions throughout the body. Prolonged overhead activities combined with routine physical training involving push-ups and pull-ups place this population at risk of developing common chronic conditions of the upper extremity. Some of the most common conditions include shoulder impingement, rotator cuff tendinopathy, medial and lateral epicondylitis, and degenerative wrist conditions like scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC). Patellofemoral syndrome, patellar tendinitis, and iliotibial band syndrome are among the common overuse injuries affecting the knee in activity duty military populations. Ankle sprains leading to chronic ankle instability are also a common cause of disability in this cohort and occur at a rate 5-6 times higher than in the general population.2 Finally, chronic back and neck issues are a significant cause of morbidity and can ultimately result in the inability of the patient to perform the duties required of them to remain on Active Duty.
Stress fractures have long been a subject of interest in the military population given the treatment cost and significant time lost to injury this condition has. A recent epidemiological study found 31,758 lower extremity stress fractures occurred over a three-year time period, with 40% occurring in the tibia/fibula, 16% in the metatarsals, 9% in the femoral neck, 6% in the femoral shaft, and 30% in other unspecified bones.3 Females had a significantly increased risk of suffering from a stress fracture in any bone compared to their male counterparts; nearly 3-fold in this study. This gender difference has been repeatedly demonstrated and is attributed to anatomic, physiologic, and endocrinologic differences between males and females.4,5,6 Given the significant burden this condition has on troop readiness, identifying those at risk for stress fractures and improving prevention strategies should be a primary research focus going forward.
Acute injuries in the Active Duty population occur most commonly as a result of training accidents or sporting injuries. Causes of injury hospitalizations are coded according to the coding scheme outlined in the North Atlantic Treaty Organization (NATO) Standardization Agreement (STANAG) No. 2050, ed. 5.7
Falls and land transport consistently rank as the top unintentional causes for injury hospitalizations. Among all medical encounters for injuries and poisoning events (both hospitalization and ambulatory), musculoskeletal injuries to the knee, arm and shoulder, and foot and ankle all consistently rank in the top 10 out of 142 disease conditions. This is true both in total number of encounters and individuals affected, comprising at least two-thirds of medical encounters and more than one-half of individuals affected attributable to injuries and poisoning. (Reference Table 5F.1.4.1 PDF [364] CSV [365] and Table 5F.1.4.2 PDF [366] CSV [367])
[369] Among the most common acute injuries managed in the military population are fractures, ligamentous or meniscal knee injuries, and shoulder dislocations. Fractures can occur anywhere in the body but most often are seen in the hand and wrist (metacarpals, scaphoid, distal radius), ankle, and clavicle in the active duty population, and occur at a higher incidence than their civilian counterparts.8,9,10 These fractures often require operative fixation resulting in significant lost duty time and an increased likelihood that the patient is unable to return to full duty.
Multiple studies have shown an almost 10-fold higher incidence of anterior cruciate ligament and meniscal injuries in active duty service members compared to the general population.11,12,13 In contrast to injury patterns seen in civilians, men were at increased risks of sustaining these injuries compared to females; this may be attributable to differences in occupational tasks and activities between men and women in the military.
Shoulder dislocations and resultant shoulder instability are ubiquitous in the Active Duty population; a 7 to 21 times higher incidence of shoulder dislocation injury has been reported compared to the general population.14,15 These injuries often require surgical repair in this population with approximately 9% of those who require surgery being discharged for disability due to their injury.16
Identifying those at risk of sustaining these debilitating injuries and implementing preventive strategies should be of utmost importance in attempting to curb the resultant costly disability to our military members.
The true cost of military injuries is difficult to define due to the complexity of injuries and the long-lasting implications on the service member. In addition to actual treatment costs of the index injuries, we must take into account the added financial burden associated with time away from duty, long-term care for severely injured, and the effects of war trauma. In recent years (2012 to 2017), injuries and poisoning events cost a morbidity burden of 40,000 to 68,000 bed days among active category Armed Forces personnel. (Reference Table 5F.1.4.3 PDF [370] CSV [371])
[373] The Army has estimated the cost of Basic Combat Training (BCT) injuries to be $22 million annually for treatment of the 40% of men and 61% of women who sustain BCT-related injuries annually. The most common types of injuries were sprains, strains, joint pain, and back pain.1
Injury costs associated with the ongoing conflicts in Iraq and Afghanistan will be staggering for decades to come. One out of every two veterans from these two conflicts has already applied for permanent disability benefits. Higher survival rates for amputees and other catastrophic injuries that require life-long care further add to the economic burden of these disability costs associated with musculoskeletal injuries. The present value of the expected total medical care for Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans already committed to be delivered over the next forty years is projected to be $288 billion.2
The impact of musculoskeletal injuries on the service member does not stop when they leave the military. Degenerative conditions have been shown to plague the aging military population. Fragility fractures are less common in the active duty population, but certainly have a profound effect on the Veteran community. The years of consistent physical demands placed on the bodies of Active Duty service members results in life-long musculoskeletal issues, particularly post-traumatic arthritis, as well as psychological disturbances from chronic pain.
It has been shown that US military personnel develop osteoarthritis of the knee at rates up to 50% higher than age matched civilian counterparts.1 A recent retrospective review of total knee arthroplasty in active duty service members under age 50 years, found that nearly 75% of the knees had experienced prior ligamentous, meniscal, or chondral injury prior to arthroplasty, compared to 9.8% observed in a high volume civilian adult reconstruction practice.2 They reported an average of 17.2 years from injury to arthroplasty in this population.3 There is a paucity of data examining the prevalence of post-traumatic osteoarthritis of other major joints, including the hip, shoulder, and ankle, in the military population, but is believed to be significant.
Chronic pain and opioid abuse are endemic in our country; the military and veteran communities are not immune from these issues. Traumatic brain injuries, post-concussive syndrome, post traumatic stress disorder, and behavioral health disorders, combined with the stigma attached to these issues, complicates the diagnosis and treatment of chronic pain in this patient group. Chronic pain due to musculoskeletal pain and combat-related polytrauma pain has been reported in up to 50% of the Veteran community and 44% among US service members after combat deployment compared to 26% in the general population.4
Extremity trauma resulting from high-energy explosives in Iraq and Afghanistan was common; 54% of evacuated wounded service members had extremity injures. More than one-quarter (26%) of all extremity war injuries involved fractures; 82% were open.5 The Military Extremity Amputation/Limb Salvage (METALS) Study found that participants with a unilateral or bilateral amputation had significantly better SMFA functional outcomes than those whose limbs had been salvaged. This is contrary to what was found in the civilian LEAP study, where there were no significant differences in outcomes at two or seven years post injury.5 Amputees were nearly three times as likely to be engaged in a vigorous sport or recreational activity. However, the percentage working/on active duty or in school was the same, as were the rates of depression.5 Future key challenges in this population after discharge from military service include: access to care, prosthetic maintenance, activities of daily living, vocational rehabilitation, and quality of life.
The burden of musculoskeletal disease on the military population is vast and spans across the service member’s lifetime. The physical nature demanded by military requirements places its Active Duty and Reserve members at risk of suffering from acute, chronic, and life-long musculoskeletal conditions. Great strides have been made in developing ways to prevent and identify these issues sooner, but much work remains to be done.
Falls are the major cause of musculoskeletal injury among the elderly, with a rate in 2015 per 1,000 persons that was more than twice that for all ages (63.6/1000 versus 29.1/1000). Falls are also a major cause of death among the oldest old, those 85 and over. (Reference Table 5B.1.6 PDF [97] CSV [98])
[377]
[379] While persons aged 65 and older account for only 14% of the total U.S. population, they represent more than one-half (53%) of patients admitted to the hospital with a musculoskeletal injury. Among the 65 and over population, fractures account for 57% of injuries with a hospital stay and 28% of emergency department visits. (Reference Table 5B.2.1 PDF [9] CSV [10])
[381] More than three out of four (77%) fractures of the neck of femur, commonly known as a hip fracture, were treated for persons age 65 and over in 2013. Fractures of the humerus (upper arm) were also highest among the 65+ population, with 40% treated in this age group. (Reference Table 5B.2.2 PDF [105] CSV [106])
[383] In 2013, the proportion of hospital discharge patients age 65 and over with a musculoskeletal injury who were transferred to a skilled nursing, intermediate care or other long-term care facility was nearly three in four (71%). This compares to 48% of fracture patients among all ages, and only 14% for all ages, all diagnoses. Another 10% are discharged with home healthcare. (Reference Table 5B.4.2 PDF [174] CSV [175])
[385] With current average life expectancies of persons in their 40s, 50s, and 60s in the United States well beyond the age of 80, the risk of incurring a musculoskeletal injury, and, in particular, a fracture, is significant.
Between the years 1996-1998 and 2012-2014, the number of persons in the population reporting a musculoskeletal injury rose only slightly, from 23.4 million to 26.3 million, resulting in a slight decline in the proportion of the population with a musculoskeletal injury (8.6% to 8.3%). However, the distribution of the population with a musculoskeletal injury, by age group, showed a consistent shift upward as the population ages, reflecting the overall aging of the U.S. population. Persons in the 44 to 64-year age group showed the sharpest increase, but there was a jump in the 65 and over population as the Baby Boomers cohort ages. (Reference Table 8.1.5 PDF [386] CSV [387])
[389] Healthcare treatments and visits contribute to the burden of musculoskeletal injuries. Ambulatory nonphysicians are showing the fastest rise in the number of healthcare visits for musculoskeletal injuries (130%) between the years 1996-1998 to 2012-2014, from 54 million to 124 million visits, and are starting to approach physician office visits, which averaged 145 million visits per year 2012-2014. Hospital discharges for musculoskeletal injuries remain a very small proportion of overall treatment visits (< 3 million), indicating that most musculoskeletal injuries are not serious enough to require hospitalization. Prescription medications for musculoskeletal injuries more than doubled over the time frame, jumping from 201 million prescriptions to 423 million between 1996-1998 and 2012-2014, an increase of 111%. (Reference Table 8.2.5 PDF [390] CSV [391])
[393] In recent years, ambulatory care visits account for the largest share of per person direct cost for persons with a musculoskeletal injury, with the share increasing while inpatient costs share drops. In 2014 dollars, the average cost per person in 2012-2014 for ambulatory care was $2,949, an increase of 109% from 1996-1998, although the share of total costs increased only 3% (33% to 36%). The share of mean per person cost for inpatient care dropped from 34% to 28% between 1996-1998 and 2012-2014, but the mean cost in 2014 dollars rose from $1,421 to $2,283, an increase of 61%. At the same time, the average per person cost for prescriptions rose from $444 to $1,569, an increase of 253%. (Reference Table 8.4.5 PDF [394] CSV [395])
[397] Total direct per person healthcare cost for persons with a musculoskeletal injury were $8,135, an increase of 93% since 1996-1998, in 2014 dollars. Incremental direct per person costs, those costs most likely attributable to a musculoskeletal injury, rose from $1,261 to $2,022, in 2014 dollars, an increase of 60%. Total aggregate direct costs for persons with a musculoskeletal injury were $214 billion in 2012-2014, a rise of 117% from the $98 billion in 1996-1998, in 2014 dollars. Incremental aggregate direct costs increased from $29 billion in 1996-1998 to $53 billion in 2012-2014, an increase of 80%. (Reference Table 8.6.5 PDF [398] CSV [399])
[401]
[403] Indirect costs associated with lost wages for persons ages 18 to 64 are not calculated for persons with a musculoskeletal injury. However, musculoskeletal injuries are a primary cause of lost work days by persons in the labor force. Since 1992, musculoskeletal disorders (MSD) have accounted for nearly one-third of workplace injuries involving days away from work. In addition, MSD injuries consistently across the years result in more median days away from work than all workplace injuries. In 2016, MSDs had a median of 12 days away from work compared to a median of 8 days for all injuries, which includes the MSDs in this median. (Reference Table 5D.1 PDF [201] CSV [202] and Table 5D.2.2 PDF [207] CSV [208])
Musculoskeletal workplace injuries are a major concern, accounting for a large proportion of all nonfatal injuries that result in days away from work. Even though long-term trends show significant reductions in the total number of worker injuries each year, the proportion that are musculoskeletal related (MSD, which include fractures, bruises/ contusions, and amputations) continues to account for more than one-half of all worker nonfatal injury cases involving days away from work. In addition to the cost of medical care for these injuries, the cost of lost wages and the potential for long-term impairment negatively impacting worker productivity are enormous.
Even with improved and improving understanding and documentation of injuries, there are numerous unmet needs that represent challenges for the future. These range from logistical challenges brought about by the complexity of our healthcare system to the actual improvement of the provision of care for members of our society. While a comprehensive discourse cannot be provided here, we propose some timely thoughts.
While ICD-10 coding of diagnoses will provide greater resolution of the types of injuries sustained, it represents a challenge to the longitudinal tracking of injuries as we fully transition from one to the other. Discrepancies between providers, coders, healthcare and payment systems need to be recognized, minimized, and resolved.
Also, despite the availability of some very robust data systems, we still lack the ability to track many common injuries in our societies; those include injuries during pregnancy, due to domestic violence, due to animals, that are self-inflicted, and of great recent interest, due to gunshot / ballistic violence. Greater granularity regarding common injuries such as fall in the elderly (e.g., home, facilities, circumstances of fall) and motor vehicle crashes (e.g., under the influence, phones/devices) may help formulate interventions and policies to prevent injuries.
On the outcome side, the US still lacks comprehensive and mandatory treatment and outcomes registries that will allow us to understand the spectrum of treatment rendered and the outcomes obtained. We also have an opportunity to understand the relationship between treatment and outcomes.
The link between opioid use and injuries will also be important to understand and study. The current opioid "crisis" and the utilization of medications to treat injury-related pain drives the need for both ways to prevent injury and offer alternatives for treatment. For example, not only is there greater availability and use of cannabis-based products and medications, there has been increasing interest in substituting them for opioids. These changes should be carefully monitored so the epidemiologic and care implications are understood.
As we move forward, there will be a continued need to reflect on the data we have and how we can enhance that data to improve the prevention, evaluation and treatment of injuries.
Analysis includes all 5-digit codes within each three-digit category.
Fractures
Trunk and Multiple Site Fractures
Fracture of rib(s) sternum, larynx, and trachea: 807
Fracture of pelvis: 808
Ill‐defined fractures of bones of trunk: 809
Multiple fractures involving both upper limbs and upper limb with rib(s) and sternum: 819
Multiple fractures involving both lower limbs lower with upper limb and lower limb(s) with rib(s) and sternum: 828
Fracture of unspecified bones: 829
Upper Limb Fractures
Fracture of clavicle: 810
Fracture of scapula: 811
Fracture of humerus: 812
Fracture of radius and ulna: 813
Fracture of carpal bone(s): 814
Fracture of metacarpal bone(s): 815
Fracture of one or more phalanges of hand: 816
Multiple fractures of hand bones: 817
Ill-defined fractures of upper limb: 818
Multiple fractures involving both upper limbs and upper limb with rib(s) and sternum: 819
Lower Limb Fractures
Fracture of neck of femur: 820
Fracture of other and unspecified parts of femur: 821
Fracture of patella: 822
Fracture of tibia and fibula: 823
Fracture of ankle: 824
Fracture of one or more tarsal and metatarsal bones: 825
Fracture of one or more phalanges of foot: 826
Other multiple and ill‐defined fractures of lower limb: 827
Derangement
Internal derangement of knee: 717
Other derangement of joint: 718
Dislocation
Upper Limb Dislocation
Dislocation of shoulder: 831
Dislocation of elbow: 832
Dislocation of wrist: 833
Dislocation of finger: 834
Lower Limb Dislocation
Dislocation of hip: 835
Dislocation of knee: 836
Dislocation of ankle: 837
Dislocation of foot: 838
Other Site Dislocation
Other multiple and ill‐defined dislocations: 839
Sprains/Strains
Upper Limb Sprains/Strains
Sprains and strains of shoulder and upper arm: 840
Sprains and strains of elbow and forearm: 841
Sprains and strains of wrist and hand: 842
Lower Limb Sprains/Strains
Sprains and strains of hip and thigh: 843
Sprains and strains of knee and leg: 844
Sprains and strains of ankle and foot: 845
Back and Spine Sprains/Strains (also included in Spine Chapter)
Sprains and strains of sacroiliac region: 846
Sprains and strains of other and unspecified parts of back: 847
Other Site Sprains/Strains
Other and ill‐defined sprains and strains: 848
Contusions
Contusion of trunk: 922
Contusion of upper limb: 923
Contusion of lower limb and of other and unspecified sites: 924
Crushing Injuries
Crushing injury of trunk: 926
Crushing injury of upper limb: 927
Crushing injury of lower limb: 928
Crushing injury of multiple and unspecified sites: 929
Open Wound
Open Wound of Trunk and Chest
Open wound of neck: 874
Open wound of chest (wall): 875
Open wound of back: 876
Open wound of buttock: 877
Open wound of other and unspecified sites except limbs: 879
Open Wound of Upper Limb
Open wound of shoulder and upper arm: 880
Open wound of elbow forearm and wrist: 881
Open wound of hand except finger(s) alone: 882
Open wound of finger(s): 883
Multiple and unspecified open wound of upper limb: 884
Open Wound of Lower Limb
Open wound of hip and thigh: 890
Open wound of knee leg (except thigh) and ankle: 891
Open wound of foot except toe(s) alone: 892
Open wound of toe(s): 893
Multiple and unspecified open wound of lower limb: 894
Traumatic Amputation
Traumatic amputation of Upper Limb
Traumatic amputation of thumb (complete) (partial): 885
Traumatic amputation of other finger(s) (complete) (partial): 886
Traumatic amputation of arm and hand (complete) (partial): 887
Traumatic amputation of Lower Limb
Traumatic amputation of toe(s) (complete) (partial): 895
Traumatic amputation of foot (complete) (partial): 896
Traumatic amputation of leg(s) (complete) (partial): 897
Late Effect of Injury
Injury to other nerve(s) of trunk excluding shoulder and pelvic girdles: 954
Injury to peripheral nerve(s) of shoulder girdle and upper limb: 955
Injury to peripheral nerve(s) of pelvic girdle and lower limb: 956
Injury to other and unspecified nerves: 957
Injury other and unspecified: 959
Ecodes-Penetrating Injuries
Firearms: 965.0-965.4, 922.0-922.9, 955.0-955.4, 970.0, 985.0-985.4
Explosives: 965.5-965.9, 923.0-923.9, 955.5-955.9, 971.0, 985.5-985.7
Stabbing device: 956.0, 966.0, 974.0, 986.0
Links:
[1] https://www.boneandjointburden.org/fourth-edition/va0/self-reported-injuries
[2] https://www.boneandjointburden.org/fourth-edition/vb0/traumatic-injuries
[3] https://www.boneandjointburden.org/fourth-edition/vc0/falls
[4] https://www.boneandjointburden.org/fourth-edition/vd0/workplace-injuries
[5] https://www.boneandjointburden.org/fourth-edition/ve0/sports-injuries
[6] https://www.boneandjointburden.org/fourth-edition/vf0/military-injuries
[7] https://bmus.latticegroup.com/docs/bmus_4e_5a.1.1.pdf
[8] https://bmus.latticegroup.com/docs/bmus_4e_5a.1.1.csv
[9] https://bmus.latticegroup.com/docs/bmus_4e_5b.2.1.pdf
[10] https://bmus.latticegroup.com/docs/bmus_4e_5b.2.1.csv
[11] https://bmus.latticegroup.com/docs/bmus_4e_5a.1.2.pdf
[12] https://bmus.latticegroup.com/docs/bmus_4e_5a.1.2.csv
[13] https://bmus.latticegroup.com/docs/bmus_4e_5a.1.3.pdf
[14] https://bmus.latticegroup.com/docs/bmus_4e_5a.1.3.csv
[15] https://bmus.latticegroup.com/docs/bmus_4e_5a.1.4.pdf
[16] https://bmus.latticegroup.com/docs/bmus_4e_5a.1.4.csv
[17] https://bmus.latticegroup.com/file/bmuse4g5a10png
[18] https://bmus.latticegroup.com/docs/bmus_e4_g5a.1.0.png
[19] https://bmus.latticegroup.com/file/bmuse4g5a111png
[20] https://bmus.latticegroup.com/docs/bmus_e4_g5a.1.1.1.png
[21] https://bmus.latticegroup.com/file/bmuse4g5a112png
[22] https://bmus.latticegroup.com/docs/bmus_e4_g5a.1.1.2.png
[23] https://bmus.latticegroup.com/file/bmuse4g5a113png
[24] https://bmus.latticegroup.com/docs/bmus_e4_g5a.1.1.3.png
[25] https://bmus.latticegroup.com/file/bmuse4g5a114png
[26] https://bmus.latticegroup.com/docs/bmus_e4_g5a.1.1.4.png
[27] https://bmus.latticegroup.com/docs/bmus_4e_5a.2.1.pdf
[28] https://bmus.latticegroup.com/docs/bmus_4e_5a.2.1.csv
[29] https://bmus.latticegroup.com/file/bmuse4g5a121png
[30] https://bmus.latticegroup.com/docs/bmus_e4_g5a.1.2.1.png
[31] https://bmus.latticegroup.com/docs/bmus_4e_5a.2.2.pdf
[32] https://bmus.latticegroup.com/docs/bmus_4e_5a.2.2.csv
[33] https://bmus.latticegroup.com/docs/bmus_4e_5a.2.3.pdf
[34] https://bmus.latticegroup.com/docs/bmus_4e_5a.2.3.csv
[35] https://bmus.latticegroup.com/docs/bmus_4e_5a.2.4.pdf
[36] https://bmus.latticegroup.com/docs/bmus_4e_5a.2.4.csv
[37] https://bmus.latticegroup.com/file/bmuse4g5a122png
[38] https://bmus.latticegroup.com/docs/bmus_e4_g5a.1.2.2.png
[39] https://bmus.latticegroup.com/docs/bmus_4e_5a.3.1.pdf
[40] https://bmus.latticegroup.com/docs/bmus_4e_5a.3.1.csv
[41] https://bmus.latticegroup.com/docs/bmus_4e_5a.3.2.pdf
[42] https://bmus.latticegroup.com/docs/bmus_4e_5a.3.2.csv
[43] https://bmus.latticegroup.com/docs/bmus_4e_5a.3.3.pdf
[44] https://bmus.latticegroup.com/docs/bmus_4e_5a.3.3.csv
[45] https://bmus.latticegroup.com/docs/bmus_4e_5a.3.4.pdf
[46] https://bmus.latticegroup.com/docs/bmus_4e_5a.3.4.csv
[47] https://bmus.latticegroup.com/file/bmuse4g5a123png
[48] https://bmus.latticegroup.com/docs/bmus_e4_g5a.1.2.3.png
[49] https://bmus.latticegroup.com/file/bmuse4g5a124png
[50] https://bmus.latticegroup.com/docs/bmus_e4_g5a.1.2.4.png
[51] https://bmus.latticegroup.com/docs/bmus_4e_5a.4.1.pdf
[52] https://bmus.latticegroup.com/docs/bmus_4e_5a.4.1.csv
[53] https://bmus.latticegroup.com/docs/bmus_4e_5a.4.2.pdf
[54] https://bmus.latticegroup.com/docs/bmus_4e_5a.4.2.csv
[55] https://bmus.latticegroup.com/file/bmuse4g5a125png
[56] https://bmus.latticegroup.com/docs/bmus_e4_g5a.1.2.5.png
[57] https://bmus.latticegroup.com/docs/bmus_4e_5a.4.3.pdf
[58] https://bmus.latticegroup.com/docs/bmus_4e_5a.4.3.csv
[59] https://bmus.latticegroup.com/docs/bmus_4e_5a.5.1.pdf
[60] https://bmus.latticegroup.com/docs/bmus_4e_5a.5.1.csv
[61] https://bmus.latticegroup.com/file/bmuse4g5a131png
[62] https://bmus.latticegroup.com/docs/bmus_e4_g5a.1.3.1.png
[63] https://bmus.latticegroup.com/docs/bmus_4e_5a.5.2.pdf
[64] https://bmus.latticegroup.com/docs/bmus_4e_5a.5.2.csv
[65] https://bmus.latticegroup.com/file/bmuse4g5a132png
[66] https://bmus.latticegroup.com/docs/bmus_e4_g5a.1.3.2.png
[67] https://bmus.latticegroup.com/docs/bmus_4e_5a.5.3.pdf
[68] https://bmus.latticegroup.com/docs/bmus_4e_5a.5.3.csv
[69] https://bmus.latticegroup.com/file/bmuse4g5a133png
[70] https://bmus.latticegroup.com/docs/bmus_e4_g5a.1.3.3.png
[71] https://bmus.latticegroup.com/docs/bmus_4e_5b.0.1.pdf
[72] https://bmus.latticegroup.com/docs/bmus_4e_5b.0.1.csv
[73] https://bmus.latticegroup.com/file/bmuse4g5b01png
[74] https://bmus.latticegroup.com/docs/bmus_e4_g5b.0.1.png
[75] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3555553/pdf/jpr-6-039.pdf
[76] https://bmus.latticegroup.com/docs/bmus_4e_5b.1.1.pdf
[77] https://bmus.latticegroup.com/docs/bmus_4e_5b.1.1.csv
[78] https://bmus.latticegroup.com/file/bmuse4g5b11png
[79] https://bmus.latticegroup.com/docs/bmus_e4_g5b.1.1.png
[80] https://bmus.latticegroup.com/docs/bmus_4e_5b.1.2.pdf
[81] https://bmus.latticegroup.com/docs/bmus_4e_5b.1.2.csv
[82] https://bmus.latticegroup.com/docs/bmus_4e_5b.1.3.pdf
[83] https://bmus.latticegroup.com/docs/bmus_4e_5b.1.3.csv
[84] https://bmus.latticegroup.com/file/bmuse4g5b121png
[85] https://bmus.latticegroup.com/docs/bmus_e4_g5b.1.2.1.png
[86] https://bmus.latticegroup.com/file/bmuse4g5b122png
[87] https://bmus.latticegroup.com/docs/bmus_e4_g5b.1.2.2.png
[88] https://bmus.latticegroup.com/docs/bmus_4e_5b.1.4.pdf
[89] https://bmus.latticegroup.com/docs/bmus_4e_5b.1.4.csv
[90] https://bmus.latticegroup.com/file/bmuse4g5b131png
[91] https://bmus.latticegroup.com/docs/bmus_e4_g5b.1.3.1.png
[92] https://bmus.latticegroup.com/file/bmuse4g5b132png
[93] https://bmus.latticegroup.com/docs/bmus_e4_g5b.1.3.2.png
[94] https://webappa.cdc.gov/sasweb/ncipc/nfirates.html
[95] https://bmus.latticegroup.com/docs/bmus_4e_5b.1.5.pdf
[96] https://bmus.latticegroup.com/docs/bmus_4e_5b.1.5.csv
[97] https://bmus.latticegroup.com/docs/bmus_4e_5b.1.6.pdf
[98] https://bmus.latticegroup.com/docs/bmus_4e_5b.1.6.csv
[99] https://bmus.latticegroup.com/file/bmuse4g5b141png
[100] https://bmus.latticegroup.com/docs/bmus_e4_g5b.1.4.1.png
[101] https://bmus.latticegroup.com/file/bmuse4g5b142png
[102] https://bmus.latticegroup.com/docs/bmus_e4_g5b.1.4.2.png
[103] https://bmus.latticegroup.com/file/bmuse4g5b211png
[104] https://bmus.latticegroup.com/docs/bmus_e4_g5b.2.1.1.png
[105] https://bmus.latticegroup.com/docs/bmus_4e_5b.2.2.pdf
[106] https://bmus.latticegroup.com/docs/bmus_4e_5b.2.2.csv
[107] https://bmus.latticegroup.com/docs/bmus_4e_5b.2.3.pdf
[108] https://bmus.latticegroup.com/docs/bmus_4e_5b.2.3.csv
[109] https://bmus.latticegroup.com/docs/bmus_4e_5b.2.4.pdf
[110] https://bmus.latticegroup.com/docs/bmus_4e_5b.2.4.csv
[111] https://bmus.latticegroup.com/docs/bmus_4e_5b.2.5.pdf
[112] https://bmus.latticegroup.com/docs/bmus_4e_5b.2.5.csv
[113] https://bmus.latticegroup.com/file/bmuse4g5b212png
[114] https://bmus.latticegroup.com/docs/bmus_e4_g5b.2.1.2.png
[115] https://bmus.latticegroup.com/docs/bmus_4e_5b.3.pdf
[116] https://bmus.latticegroup.com/docs/bmus_4e_5b.3.csv
[117] https://bmus.latticegroup.com/file/bmuse4g5b213png
[118] https://bmus.latticegroup.com/docs/bmus_e4_g5b.2.1.3.png
[119] https://bmus.latticegroup.com/docs/bmus_4e_5b.5.1.pdf
[120] https://bmus.latticegroup.com/docs/bmus_4e_5b.5.1.csv
[121] https://bmus.latticegroup.com/file/bmuse4g5b511png
[122] https://bmus.latticegroup.com/docs/bmus_e4_g5b.5.1.1.png
[123] https://bmus.latticegroup.com/docs/bmus_4e_5b.5.2.pdf
[124] https://bmus.latticegroup.com/docs/bmus_4e_5b.5.2.csv
[125] https://bmus.latticegroup.com/file/bmuse4g5b512png
[126] https://bmus.latticegroup.com/docs/bmus_e4_g5b.5.1.2.png
[127] https://bmus.latticegroup.com/docs/bmus_4e_5b.5.3.pdf
[128] https://bmus.latticegroup.com/docs/bmus_4e_5b.5.3.csv
[129] https://bmus.latticegroup.com/docs/bmus_4e_5b.5.4.pdf
[130] https://bmus.latticegroup.com/docs/bmus_4e_5b.5.4.csv
[131] https://bmus.latticegroup.com/file/bmuse4g5b513png
[132] https://bmus.latticegroup.com/docs/bmus_e4_g5b.5.1.3.png
[133] https://bmus.latticegroup.com/docs/bmus_4e_5b.6.1.pdf
[134] https://bmus.latticegroup.com/docs/bmus_4e_5b.6.1.csv
[135] https://bmus.latticegroup.com/file/bmuse4g5b521png
[136] https://bmus.latticegroup.com/docs/bmus_e4_g5b.5.2.1.png
[137] https://bmus.latticegroup.com/docs/bmus_4e_5b.6.2.pdf
[138] https://bmus.latticegroup.com/docs/bmus_4e_5b.6.2.csv
[139] https://bmus.latticegroup.com/file/bmuse4g5b522png
[140] https://bmus.latticegroup.com/docs/bmus_e4_g5b.5.2.2.png
[141] https://bmus.latticegroup.com/docs/bmus_4e_5b.7.1.pdf
[142] https://bmus.latticegroup.com/docs/bmus_4e_5b.7.1.csv
[143] https://bmus.latticegroup.com/file/bmuse4g5b531png
[144] https://bmus.latticegroup.com/docs/bmus_e4_g5b.5.3.1.png
[145] https://bmus.latticegroup.com/file/bmuse4g5b532png
[146] https://bmus.latticegroup.com/docs/bmus_e4_g5b.5.3.2.png
[147] https://bmus.latticegroup.com/docs/bmus_4e_5b.7.3.pdf
[148] https://bmus.latticegroup.com/docs/bmus_4e_5b.7.3.csv
[149] https://bmus.latticegroup.com/file/bmuse4g5b533png
[150] https://bmus.latticegroup.com/docs/bmus_e4_g5b.5.3.3.png
[151] https://bmus.latticegroup.com/docs/bmus_4e_5b.7.2.pdf
[152] https://bmus.latticegroup.com/docs/bmus_4e_5b.7.2.csv
[153] https://www.jems.com/articles/print/volume-37/issue-4/patient-care/penetrating-trauma-wounds-challenge-ems.html
[154] https://bmus.latticegroup.com/file/bmuse4g5b31png
[155] https://bmus.latticegroup.com/docs/bmus_e4_g5b.3.1.png
[156] https://bmus.latticegroup.com/file/bmuse4g5b32png
[157] https://bmus.latticegroup.com/docs/bmus_e4_g5b.3.2.png
[158] https://bmus.latticegroup.com/docs/bmus_4e_5b.4.1.2.pdf
[159] https://bmus.latticegroup.com/docs/bmus_4e_5b.4.1.2.csv
[160] https://bmus.latticegroup.com/file/bmuse4g5b33png
[161] https://bmus.latticegroup.com/docs/bmus_e4_g5b.3.3.png
[162] https://bmus.latticegroup.com/file/bmuse4g5b34png
[163] https://bmus.latticegroup.com/docs/bmus_e4_g5b.3.4.png
[164] https://bmus.latticegroup.com/docs/bmus_4e_5b.4.1.1.pdf
[165] https://bmus.latticegroup.com/docs/bmus_4e_5b.4.1.1.csv
[166] https://bmus.latticegroup.com/docs/bmus_4e_5b.4.1.3.pdf
[167] https://bmus.latticegroup.com/docs/bmus_4e_5b.4.1.3.csv
[168] https://bmus.latticegroup.com/docs/bmus_4e_5b.4.1.4.pdf
[169] https://bmus.latticegroup.com/docs/bmus_4e_5b.4.1.4.csv
[170] https://bmus.latticegroup.com/file/bmuse4g5b35png
[171] https://bmus.latticegroup.com/docs/bmus_e4_g5b.3.5.png
[172] https://bmus.latticegroup.com/file/bmuse4g5b36png
[173] https://bmus.latticegroup.com/docs/bmus_e4_g5b.3.6.png
[174] https://bmus.latticegroup.com/docs/bmus_4e_5b.4.2.pdf
[175] https://bmus.latticegroup.com/docs/bmus_4e_5b.4.2.csv
[176] https://bmus.latticegroup.com/docs/bmus_4e_5b.4.3.pdf
[177] https://bmus.latticegroup.com/docs/bmus_4e_5b.4.3.csv
[178] https://bmus.latticegroup.com/file/bmuse4g5b41png
[179] https://bmus.latticegroup.com/docs/bmus_e4_g5b.4.1.png
[180] https://bmus.latticegroup.com/file/bmuse4g5b42png
[181] https://bmus.latticegroup.com/docs/bmus_e4_g5b.4.2.png
[182] https://bmus.latticegroup.com/file/bmuse4g5b43png
[183] https://bmus.latticegroup.com/docs/bmus_e4_g5b.4.3.png
[184] https://bmus.latticegroup.com/file/bmuse4g5b44png
[185] https://bmus.latticegroup.com/docs/bmus_e4_g5b.4.4.png
[186] https://bmus.latticegroup.com/docs/bmus_4e_5c.1.pdf
[187] https://bmus.latticegroup.com/docs/bmus_4e_5c.1.csv
[188] https://bmus.latticegroup.com/file/bmuse4g5c11png
[189] https://bmus.latticegroup.com/docs/bmus_e4_g5c.1.1.png
[190] https://bmus.latticegroup.com/docs/bmus_4e_5c.2.pdf
[191] https://bmus.latticegroup.com/docs/bmus_4e_5c.2.csv
[192] https://bmus.latticegroup.com/file/bmuse4g5c12png
[193] https://bmus.latticegroup.com/docs/bmus_e4_g5c.1.2.png
[194] https://bmus.latticegroup.com/docs/bmus_4e_5c.3.pdf
[195] https://bmus.latticegroup.com/docs/bmus_4e_5c.3.csv
[196] https://bmus.latticegroup.com/file/bmuse4g5c13png
[197] https://bmus.latticegroup.com/docs/bmus_e4_g5c.1.3.png
[198] https://webappa.cdc.gov/cgi-bin/broker.exe
[199] https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6438a5.htm?s_cid=mm6438a5_w
[200] https://www.bls.gov/data/#injuries
[201] https://bmus.latticegroup.com/docs/bmus_4e_5d.1.pdf
[202] https://bmus.latticegroup.com/docs/bmus_4e_5d.1.csv
[203] https://bmus.latticegroup.com/file/bmuse4g5d11png
[204] https://bmus.latticegroup.com/docs/bmus_e4_g5d.1.1.png
[205] https://bmus.latticegroup.com/docs/bmus_4e_5d.2.1.pdf
[206] https://bmus.latticegroup.com/docs/bmus_4e_5d.2.1.csv
[207] https://bmus.latticegroup.com/docs/bmus_4e_5d.2.2.pdf
[208] https://bmus.latticegroup.com/docs/bmus_4e_5d.2.2.csv
[209] https://bmus.latticegroup.com/file/bmuse4g5d12png
[210] https://bmus.latticegroup.com/docs/bmus_e4_g5d.1.2.png
[211] https://bmus.latticegroup.com/docs/bmus_4e_5d.3.1.pdf
[212] https://bmus.latticegroup.com/docs/bmus_4e_5d.3.1.csv
[213] https://bmus.latticegroup.com/docs/bmus_4e_5d.3.2.pdf
[214] https://bmus.latticegroup.com/docs/bmus_4e_5d.3.2.csv
[215] https://bmus.latticegroup.com/docs/bmus_4e_5d.4.pdf
[216] https://bmus.latticegroup.com/docs/bmus_4e_5d.4.csv
[217] https://bmus.latticegroup.com/file/bmuse4g5d13png
[218] https://bmus.latticegroup.com/docs/bmus_e4_g5d.1.3.png
[219] https://bmus.latticegroup.com/docs/bmus_4e_5d.5.pdf
[220] https://bmus.latticegroup.com/docs/bmus_4e_5d.5.csv
[221] https://bmus.latticegroup.com/docs/bmus_4e_5d.6.pdf
[222] https://bmus.latticegroup.com/docs/bmus_4e_5d.6.csv
[223] https://bmus.latticegroup.com/file/bmuse4g5d14png
[224] https://bmus.latticegroup.com/docs/bmus_e4_g5d.1.4.png
[225] https://www.bls.gov/news.release/archives/osh_11092017.pdf
[226] https://www.cpsc.gov/Research--Statistics/NEISS-Injury-Data
[227] https://bmus.latticegroup.com/docs/bmus_4e_5e.1.1.pdf
[228] https://bmus.latticegroup.com/docs/bmus_4e_5e.1.1.csv
[229] https://bmus.latticegroup.com/file/bmus4eg5e11png
[230] https://bmus.latticegroup.com/docs/bmus_4e_g5e.1.1.png
[231] https://bmus.latticegroup.com/file/bmus4eg5e12png
[232] https://bmus.latticegroup.com/docs/bmus_4e_g5e.1.2.png
[233] https://bmus.latticegroup.com/docs/bmus_4e_5e.1.2.1.pdf
[234] https://bmus.latticegroup.com/docs/bmus_4e_5e.1.2.1.csv
[235] https://bmus.latticegroup.com/file/bmus4eg5e13png
[236] https://bmus.latticegroup.com/docs/bmus_4e_g5e.1.3.png
[237] https://bmus.latticegroup.com/docs/bmus_4e_5e.1.3.pdf
[238] https://bmus.latticegroup.com/docs/bmus_4e_5e.1.3.csv
[239] https://bmus.latticegroup.com/file/bmus4eg5e14png
[240] https://bmus.latticegroup.com/docs/bmus_4e_g5e.1.4.png
[241] https://bmus.latticegroup.com/docs/bmus_4e_5e.1.7.pdf
[242] https://bmus.latticegroup.com/docs/bmus_4e_5e.1.7.csv
[243] https://bmus.latticegroup.com/file/bmus4eg5e15png
[244] https://bmus.latticegroup.com/docs/bmus_4e_g5e.1.5.png
[245] https://bmus.latticegroup.com/docs/bmus_4e_5e.1.5.pdf
[246] https://bmus.latticegroup.com/docs/bmus_4e_5e.1.5.csv
[247] https://bmus.latticegroup.com/file/bmus4eg5e16png
[248] https://bmus.latticegroup.com/docs/bmus_4e_g5e.1.6.png
[249] https://bmus.latticegroup.com/docs/bmus_4e_5e.1.6.pdf
[250] https://bmus.latticegroup.com/docs/bmus_4e_5e.1.6.csv
[251] https://bmus.latticegroup.com/file/bmus4eg5e17png
[252] https://bmus.latticegroup.com/docs/bmus_4e_g5e.1.7.png
[253] http://www.ucdenver.edu/academics/colleges/PublicHealth/research/ResearchProjects/piper/Pages/default.aspx
[254] https://bmus.latticegroup.com/file/bmus4eg5e21png
[255] https://bmus.latticegroup.com/docs/bmus_4e_g5e.2.1.png
[256] https://bmus.latticegroup.com/file/bmus4eg5e22png
[257] https://bmus.latticegroup.com/docs/bmus_4e_g5e.2.2.png
[258] https://bmus.latticegroup.com/file/bmus4eg5e23apng
[259] https://bmus.latticegroup.com/docs/bmus_4e_g5e.2.3a.png
[260] https://bmus.latticegroup.com/file/bmus4eg5e23bpng
[261] https://bmus.latticegroup.com/docs/bmus_4e_g5e.2.3b.png
[262] https://bmus.latticegroup.com/file/bmus4eg5e23c1png
[263] https://bmus.latticegroup.com/docs/bmus_4e_g5e.2.3c1.png
[264] https://bmus.latticegroup.com/file/bmus4eg5e23c2png
[265] https://bmus.latticegroup.com/docs/bmus_4e_g5e.2.3c2.png
[266] https://bmus.latticegroup.com/file/bmus4eg5e23dpng
[267] https://bmus.latticegroup.com/docs/bmus_4e_g5e.2.3d.png
[268] https://bmus.latticegroup.com/file/bmus4eg5e23e1png
[269] https://bmus.latticegroup.com/docs/bmus_4e_g5e.2.3e1.png
[270] https://bmus.latticegroup.com/file/bmus4eg5e23e2png
[271] https://bmus.latticegroup.com/docs/bmus_4e_g5e.2.3e2.png
[272] https://bmus.latticegroup.com/file/bmus4eg5e23fpng
[273] https://bmus.latticegroup.com/docs/bmus_4e_g5e.2.3f.png
[274] https://bmus.latticegroup.com/file/bmus4eg5e23gpng
[275] https://bmus.latticegroup.com/docs/bmus_4e_g5e.2.3g.png
[276] https://bmus.latticegroup.com/file/bmus4eg5e23hpng
[277] https://bmus.latticegroup.com/docs/bmus_4e_g5e.2.3h.png
[278] https://bmus.latticegroup.com/file/bmus4eg5e24png
[279] https://bmus.latticegroup.com/docs/bmus_4e_g5e.2.4.png
[280] https://www.nfhs.org/articles/high-school-sports-participation-increases-for-29th-consecutive-year/
[281] http://www.ucdenver.edu
[282] http://www.ucdenver.edu/academics/colleges/PublicHealth/research/ResearchProjects/piper/projects/RIO/Documents/2017-18.pdf
[283] http://www.ncaa.org/
[284] http://www.ncaa.org/sport-science-institute/ncaa-injury-surveillance-program
[285] https://datalyscenter.org/index.php
[286] https://www.nata.org/
[287] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1941297/
[288] https://www.cdc.gov/safechild/nap/index.html
[289] https://www.atyourownrisk.org/
[290] https://www.stopsportsinjuries.org/
[291] https://www.nata.org/news-publications/pressroom/statements/position
[292] https://bmus.latticegroup.com/docs/bmus_4e_5e.3.2.pdf
[293] https://bmus.latticegroup.com/docs/bmus_4e_5e.3.2.csv
[294] https://bmus.latticegroup.com/file/bmus4eg5e31png
[295] https://bmus.latticegroup.com/docs/bmus_4e_g5e.3.1.png
[296] https://bmus.latticegroup.com/docs/bmus_4e_5e.3.1.pdf
[297] https://bmus.latticegroup.com/docs/bmus_4e_5e.3.1.csv
[298] https://bmus.latticegroup.com/docs/bmus_4e_5e.3.7.pdf
[299] https://bmus.latticegroup.com/docs/bmus_4e_5e.3.7.csv
[300] https://bmus.latticegroup.com/file/bmus4eg5e32png
[301] https://bmus.latticegroup.com/docs/bmus_4e_g5e.3.2.png
[302] https://bmus.latticegroup.com/docs/bmus_4e_5e.3.4.pdf
[303] https://bmus.latticegroup.com/docs/bmus_4e_5e.3.4.csv
[304] https://bmus.latticegroup.com/file/bmus4eg5e33png
[305] https://bmus.latticegroup.com/docs/bmus_4e_g5e.3.3.png
[306] https://bmus.latticegroup.com/docs/bmus_4e_5e.3.5.pdf
[307] https://bmus.latticegroup.com/docs/bmus_4e_5e.3.5.csv
[308] https://bmus.latticegroup.com/file/bmus4eg5e34png
[309] https://bmus.latticegroup.com/docs/bmus_4e_g5e.3.4.png
[310] https://bmus.latticegroup.com/docs/bmus_4e_5e.3.6.pdf
[311] https://bmus.latticegroup.com/docs/bmus_4e_5e.3.6.csv
[312] https://bmus.latticegroup.com/file/bmus4eg5e35png
[313] https://bmus.latticegroup.com/docs/bmus_4e_g5e.3.5.png
[314] https://bmus.latticegroup.com/file/bmus4eg5e36png
[315] https://bmus.latticegroup.com/docs/bmus_4e_g5e.3.6.png
[316] https://bmus.latticegroup.com/file/bmus4eg5e37png
[317] https://bmus.latticegroup.com/docs/bmus_4e_g5e.3.7.png
[318] http://A: Estimated probability of competing in college athletics
[319] https://www.cdc.gov/safechild/sports_injuries/index.html
[320] https://bmus.latticegroup.com/docs/bmus_e4_5f.0.1.pdf
[321] https://bmus.latticegroup.com/docs/bmus_e4_5f.0.1.csv
[322] https://bmus.latticegroup.com/docs/bmus_e4_5f.0.2.pdf
[323] https://bmus.latticegroup.com/docs/bmus_e4_5f.0.2.csv
[324] https://bmus.latticegroup.com/file/bmuse4g5f01png
[325] https://bmus.latticegroup.com/docs/bmus_e4_g5f.0.1.png
[326] https://bmus.latticegroup.com/file/bmuse4g5f02png
[327] https://bmus.latticegroup.com/docs/bmus_e4_g5f.0.2.png
[328] https://bmus.latticegroup.com/file/bmuse4g5f03png
[329] https://bmus.latticegroup.com/docs/bmus_e4_g5f.0.3.png
[330] https://www.gov.uk/government/collections/medical-discharges-among-uk-service-personnel-statistics-index
[331] https://www.researchgate.net/publication/11401381_Does_military_service_damage_females_An_analysis_of_medical_discharge_data_in_the_British_armed_forces
[332] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.1.1.pdf
[333] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.1.1.csv
[334] https://bmus.latticegroup.com/file/bmuse4g5f11png
[335] https://bmus.latticegroup.com/docs/bmus_e4_g5f.1.1.png
[336] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.1.2.pdf
[337] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.1.2.csv
[338] https://bmus.latticegroup.com/file/bmuse4g5f12png
[339] https://bmus.latticegroup.com/docs/bmus_e4_g5f.1.2.png
[340] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.1.3.pdf
[341] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.1.3.csv
[342] https://bmus.latticegroup.com/file/bmuse4g5f13png
[343] https://bmus.latticegroup.com/docs/bmus_e4_g5f.1.3.png
[344] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.2.1.pdf
[345] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.2.1.csv
[346] https://bmus.latticegroup.com/file/bmuse4g5f21png
[347] https://bmus.latticegroup.com/docs/bmus_e4_g5f.2.1.png
[348] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.2.2.pdf
[349] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.2.2.csv
[350] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.2.3.pdf
[351] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.2.3.csv
[352] https://bmus.latticegroup.com/file/bmuse4g5f22png
[353] https://bmus.latticegroup.com/docs/bmus_e4_g5f.2.2.png
[354] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.3.1.pdf
[355] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.3.1.csv
[356] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.3.3.pdf
[357] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.3.3.csv
[358] https://bmus.latticegroup.com/file/bmuse4g5f31png
[359] https://bmus.latticegroup.com/docs/bmus_e4_g5f.3.1.png
[360] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.3.2.pdf
[361] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.3.2.csv
[362] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.3.4.pdf
[363] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.3.4.csv
[364] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.4.1.pdf
[365] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.4.1.csv
[366] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.4.2.pdf
[367] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.4.2.csv
[368] https://bmus.latticegroup.com/file/bmuse4g5f41png
[369] https://bmus.latticegroup.com/docs/bmus_e4_g5f.4.1.png
[370] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.4.3.pdf
[371] https://bmus.latticegroup.com/docs/bmus_e4_5f.1.4.3.csv
[372] https://bmus.latticegroup.com/file/bmuse4g5f51png
[373] https://bmus.latticegroup.com/docs/bmus_e4_g5f.5.1.png
[374] http://www.dtic.mil/dtic/tr/fulltext/u2/1050457.pdf
[375] https://www.hks.harvard.edu/publications/financial-legacy-iraq-and-afghanistan-how-wartime-spending-decisions-will-constrain
[376] https://bmus.latticegroup.com/file/bmuse4g5g01png
[377] https://bmus.latticegroup.com/docs/bmus_e4_g5g.0.1.png
[378] https://bmus.latticegroup.com/file/bmuse4g5g02png
[379] https://bmus.latticegroup.com/docs/bmus_e4_g5g.0.2.png
[380] https://bmus.latticegroup.com/file/bmuse4g5g03png
[381] https://bmus.latticegroup.com/docs/bmus_e4_g5g.0.3.png
[382] https://bmus.latticegroup.com/file/bmuse4g5g04png
[383] https://bmus.latticegroup.com/docs/bmus_e4_g5g.0.4.png
[384] https://bmus.latticegroup.com/file/bmuse4g5g05png
[385] https://bmus.latticegroup.com/docs/bmus_e4_g5g.0.5.png
[386] https://bmus.latticegroup.com/docs/bmus_e4_T8.1.5.pdf
[387] https://bmus.latticegroup.com/docs/bmus_e4_T8.1.5.csv
[388] https://bmus.latticegroup.com/file/bmuse4g5h01png
[389] https://bmus.latticegroup.com/docs/bmus_e4_g5h.0.1.png
[390] https://bmus.latticegroup.com/docs/bmus_e4_T8.2.5.pdf
[391] https://bmus.latticegroup.com/docs/bmus_e4_T8.2.5.csv
[392] https://bmus.latticegroup.com/file/bmuse4g5h02png
[393] https://bmus.latticegroup.com/docs/bmus_e4_g5h.0.2.png
[394] https://bmus.latticegroup.com/docs/bmus_e4_T8.4.5.pdf
[395] https://bmus.latticegroup.com/docs/bmus_e4_T8.4.5.csv
[396] https://bmus.latticegroup.com/file/bmuse4g5h11png
[397] https://bmus.latticegroup.com/docs/bmus_e4_g5h.1.1.png
[398] https://bmus.latticegroup.com/docs/bmus_e4_T8.6.5.pdf
[399] https://bmus.latticegroup.com/docs/bmus_e4_T8.6.5.csv
[400] https://bmus.latticegroup.com/file/bmuse4g5h12png
[401] https://bmus.latticegroup.com/docs/bmus_e4_g5h.1.2.png
[402] https://bmus.latticegroup.com/file/bmuse4g5h13png
[403] https://bmus.latticegroup.com/docs/bmus_e4_g5h.1.3.png