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American Journal of Epidemiology Advance Access originally published online on November 23, 2005
American Journal of Epidemiology 2006 163(2):151-159; doi:10.1093/aje/kwj022
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American Journal of Epidemiology Copyright © 2005 by the Johns Hopkins Bloomberg School of Public Health All rights reserved; printed in U.S.A.

Original Contribution

Epidemiology of Musculoskeletal Injuries among High School Cross-Country Runners

Mitchell J. Rauh1, Thomas D. Koepsell2,3, Frederick P. Rivara2,3,4, Anthony J. Margherita5 and Stephen G. Rice6

1 Graduate Program in Orthopaedic and Sports Physical Therapy, School of Rehabilitation Sciences, Rocky Mountain University of Health Professions, Provo, UT
2 Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle, WA
3 Harborview Injury Research and Prevention Center, Seattle, WA
4 Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA
5 West County Spine and Sports Medicine and Radiant Research Inc., St. Louis, MO
6 Department of Pediatrics, Jersey Shore University Medical Center, Neptune, NJ

Correspondence to Dr. Mitchell J. Rauh, Graduate Program in Orthopaedic and Sports Physical Therapy, Rocky Mountain University of Health Professions, 1662 West 820 North, Provo, UT 84601 (e-mail: mrauh{at}rmuohp.edu).

Received for publication May 18, 2005. Accepted for publication September 1, 2005.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
To determine the incidence of lower-extremity injury among high school cross-country runners and to identify risk factors for injury, the authors prospectively monitored a cohort of 421 runners competing on 23 cross-country teams in 12 Seattle, Washington, high schools during the 1996 cross-country season. Collected were daily injury and athletic exposure (AE) reports, a baseline questionnaire on prior running and injury experience, anthropometric measurements, and coaches' training logs. The overall incidence rate of injury was 17.0/1,000 AEs. Girls had a significantly higher overall injury rate (19.6/1,000 AEs) than boys did (15.0/1,000 AEs) (incidence rate ratio = 1.3, 95% confidence interval: 1.0, 1.6). Compared with boys, girls had significantly higher rates of injuries resulting in ≥15 days of disability. For the overall sample and for girls, Cox regression revealed that a quadriceps angle of ≥20° and an injury during summer running prior to the season were the most important predictors of injury. For boys, a quadriceps angle of ≥15° and a history of multiple running injuries were most associated with injury. Results suggest that the incidence of lower-extremity injuries is high for cross-country runners, especially girls. Preseason screening to determine risk factors should be examined as a preventive approach for identifying high-risk runners.

adolescent; athletic injuries; female; prospective studies; risk factors; running; schools; sports

Abbreviations: AE, athletic exposure; Q-angle, quadriceps angle


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Over 364,000 athletes participated in high school cross-country running in the United States during the 2003–2004 school year (1Go). Both boys' (196,428 participants) and girls' (166,287 participants) cross-country ranked as the seventh most popular high school sports nationally (1Go). Data on injury rates among high school cross-country runners are limited, however. Previous studies have reported a cumulative seasonal incidence of injury for cross-country runners ranging from 1.1 percent to 47 percent (2Go–10Go), but these studies are difficult to compare because they used different definitions of injury, data collection methods, and criteria to determine the population at risk, injury severity, and exposure setting (practice vs. meets). To our knowledge, only one study used a denominator that accounted for the actual number of practices and meets in which each runner participated, which may affect the reported incidence of injury (9Go).

Recent reviews of running injuries have suggested various possible risk factors (11Go–15Go). However, most data come from clinical case series (16Go, 17Go) and cohort studies of adult and recreational runners (18Go–23Go). Limited evidence has been reported on risk factors for injury among high school cross-country runners (24Go).

The objectives of this investigation were 1) to ascertain the incidence, recurrence, severity, body site, and exposure setting of running-related lower-extremity injuries prospectively among a cohort of high school cross-country runners; and 2) to identify anthropometric and training-related risk factors associated with these injuries.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
Study population
The study followed 12 male and 11 female cross-country teams in 12 Seattle, Washington, high schools during the 1996 cross-country season. Of the 491 runners who competed during the 1996 season, 421 (86 percent; 186 girls and 235 boys) agreed to participate. Comparison of participants and nonparticipants revealed no important differences by gender. The study was approved by the University of Washington Human Subjects Division and the Seattle School District. Parental consent was obtained for each subject prior to participation.

Data collection
Injuries.
Prior to the 1996 cross-country season, coaches were trained on using the Athletic Health Care System Daily Injury Report form (25Go). From the first official day of practice until the last regular or postseason competition, coaches recorded each runner's daily participation in practices and meets as well as absences and limitations to participation because of injury. A running injury was defined as any reported muscle, joint, or bone problem/injury of the back or lower extremity (i.e., hip, thigh, knee, shin, calf, ankle, foot) resulting from running in a practice or meet and requiring the runner to be removed from a practice or meet or to miss a subsequent one (9Go). Injuries that did not occur during participation, or were unrelated to running, were excluded. A day lost to injury was any in which the runner was not able or permitted to participate in an unrestricted manner. For injured runners, coaches recorded the body part injured (e.g., knee) and injury type (e.g., tendonitis). The Daily Injury Report required 5 minutes or less per day to complete.

Injuries were subdivided into initial or subsequent ones. An initial injury was the runner's first injury during the season (9Go). Subsequent injury was any injury to the same or different body part that occurred after the runner's initial injury (9Go).

Anthropometric evaluation.
At the beginning of the season, the quadriceps angle (Q-angle) and lengths of both legs were measured by the same experienced physical therapist (M. J. R.) using standard methods (26Go, 27Go). For Q-angle, runners were instructed to stand comfortably (without shoes) with knees extended and quadriceps muscles relaxed, feet facing anteriorly approximately shoulder-width apart, and with body weight distributed evenly across both legs (26Go). A standard full-circle goniometer with lengthened stationary arms was used. The borders of each patella were palpated, and a small dot was marked on the skin overlying the center of the patella. The anterior superior iliac spines and tibial tuberosities were then located by careful palpation and were then marked. The fulcrum was placed in the center of the patella and the longer and shorter arms directed at the anterior superior iliac spine and the tibial tuberosities, respectively (26Go).

While supine, each runner's absolute leg length was measured from the anterior superior iliac spine to the medial malleolus (27Go).

Questionnaire.
At the time of anthropometric evaluation, all subjects completed a questionnaire on baseline characteristics. Included were gender, grade level, height, weight, previous high school cross-country running experience, preseason (summer 1996) running, and prior running-related injuries.

Coaches' training logs.
Throughout the season, coaches recorded the distance, intensity (pace), surface, and terrain for each run performed during a practice or meet.

Data analysis
We calculated several injury incidence rates. The total injury rate was considered the total number of injuries divided by the total number of athletic exposures (AEs). An AE was any practice or competitive event where a runner was at risk of sustaining an injury (9Go, 25Go). For the initial injury rate, the numerator was restricted to the initial injury for each runner and the denominator to AEs up to the initial injury (9Go). For the subsequent injury rate, the numerator was restricted to injuries after the initial one for each runner and the denominator to exposures after the initial injury (9Go). Four time-loss classifications were used to assess injury severity: 1) 1–4 days missed, 2) 5–14 days missed, 3) ≥15 days missed, and 4) out-for-the-season injuries (9Go, 25Go). Injury rates were compared between boys and girls and between practices and meets (28Go).

Injury rate ratios with 95 percent confidence intervals were calculated to compare the incidence of injury in an exposed group with that in a baseline or referent group (28Go). From the baseline questionnaire, risk factors examined included grade level, preseason running (number of weeks, days per week, and miles per week run (1 mile = 1.609 km)), and previous injury experience (any previous running injury, 1996 summer running injury, 1995 cross-country running season, and cumulative number of previous running injuries); the definition of injury described earlier was used.

We analyzed the risk of injury by Q-angle by taking the average Q-angle of the right and left legs. We analyzed average Q-angle as a simple dichotomy (<20°/≥20°) and in four ordered categories (<10°/≥10–<15°/≥15–<20°/≥20°) to evaluate dose-response using the third group (≥10–<15°) as the reference category. Leg-length discrepancy was the difference between the right and left leg lengths (≤0.5 cm/>0.5–1.0 cm/>1.0–1.5 cm/>1.5 cm). Chi-square tests for trend were conducted to determine whether the risk of injury increased with increasing leg-length difference.

Body mass index was calculated from weight (kilograms) and height (meters) as weight divided by height squared (21Go). Those in the highest and lowest quartiles were compared with those between the 25th and 75th percentiles, as calculated separately for boys and girls (21Go).

We used Cox proportional hazards regression analysis to examine the association between risk of initial injury and the independent variables of interest (29Go). Three categories (pace, surface, terrain) of training variables were analyzed as time-dependent covariates whose values could change with each daily practice or meet during the season. These exposures were expressed as number of miles run on a given day at each level of exposure. Cox proportional hazards regression models were also used to assess the combined effect of baseline risk factors and training practices. Since the number of injuries was too small to allow simultaneous study of all training factors, separate models were fitted for each of three main training categories (pace, surface, terrain).

All analyses were conducted with Stata (version 5.0; Stata Corporation, College Station, Texas) and Epi-Info (version 5.10; USD Inc., Stone Mountain, Georgia) software.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
Selected baseline characteristics of the study sample are summarized in table 1. Girls and boys were similar with regard to grade level and high school running experience. Overall, 60 percent of runners reported running sometime during the preceding summer (72 percent of girls vs. 51 percent of boys (p < 0.001)). While little difference was found between boys and girls in the average number of weeks or days per week of running, boys reported running significantly more miles per week (p < 0.01). A larger proportion of girls than boys had a Q-angle of ≥20°. Few runners had a leg length difference of more than 1.5 cm, with similar distributions between boys and girls. More than one third of the runners reported at least one previous running-related injury that limited or caused them to stop running, with a higher proportion of girls than boys reporting such an injury (p < 0.05).


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  		TABLE 1. Baseline characteristics of high school cross-country runners who competed during the 1996 cross-country season, Seattle, Washington

 
During the 11-week season, 162 runners (38.5 percent) incurred 316 running-related injuries. Table 2 summarizes initial, subsequent, and overall injury rates (per 1,000 AEs) during the 1996 cross-country season. Girls had a significantly higher overall injury rate than boys did. Injuries that resulted in 1–4 days lost from participation occurred most frequently, while out-for-the-season injuries were least common. Compared with boys, girls had significantly higher total injury rates for all injuries except those resulting in 5–14 days lost. The initial injury rate for ≥15 days lost was four times greater for girls than for boys. The cumulative incidence of injury during the entire season was greater for girls than for boys, with injuries occurring earlier among girls (figure 1). Ten percent of runners did not complete the entire season. Of these, 6.7 percent stopped competing for noninjury reasons, and the percentages among girls and boys were similar.


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  		TABLE 2. Injury risk by time loss among high school cross-country runners who competed during the 1996 cross-country season, Seattle, Washington

 


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  		FIGURE 1. Cumulative incidence of initial injury among girl and boy high school cross-country runners during the 1996 cross-country season, Seattle, Washington.

 
Overall, higher rates of initial injuries and total injuries were reported during practices than during meets (table 3). By gender, a similar pattern was observed, but the difference in risk for total practices versus meets was statistically significant for girls only. Compared with boys, girls had higher initial and total injury rates during practices, but the difference was statistically significant for total injury rates only.


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  		TABLE 3. Injury risk during practices and meets among high school cross-country runners who competed during the 1996 cross-country season, Seattle, Washington

 
The shin was the most common body part initially injured (3.6/1,000 AEs), followed by the knee (2.5/1,000 AEs) and ankle (1.2/1,000 AEs). Girls had a significantly higher initial injury rate (5.8/1,000 AEs) than boys did (2.0/1,000 AEs) for shin injury (incidence rate ratio = 2.5, 95 percent confidence interval: 1.4, 4.6). Among injured runners, the overall rate of reinjury of the same body part was highest for the shin (73.6/1,000 AEs), hip (53.8/1,000 AEs), and knee (41.8/1,000 AEs).

Gender-adjusted univariate associations between lower-extremity injury and baseline risk factors were statistically significant for previous history of running-related injury, especially for those with four or more running injuries; 1996 summer preseason injury; and running for 5–8 weeks during the 1996 summer preseason (table 4). Runners with a Q-angle of ≥20° were almost twice as likely to be injured than runners whose Q-angle was <20°. Similarly, runners with Q-angles of ≥15–<20° and ≥20° were more likely to incur an injury compared with runners whose Q-angles were ≥10–<15°. Within gender groups, similar patterns were observed, with somewhat stronger associations among girls for past injury and preseason running habits and among boys for a Q-angle of ≥15–<20°.


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  		TABLE 4. Selected potential risk factors for initial injury among high school cross-country runners who competed during the 1996 cross-country season, Seattle, Washington

 
In the final Cox proportional hazards regression models that included both baseline risk factors and training practices, the only statistically significant predictors of injury were a Q-angle of ≥20° and a running injury during the preceding summer (table 5). By gender, the findings were similar for girl runners and, for boy runners, only a Q-angle of ≥15°. For training practices and risk of running injury during the 1996 cross-country season, the hazard ratios shown reflect the amount by which the risk of injury on a given day is multiplied for each mile of running of the type indicated, adjusting for number of miles run at each level of the other exposures. For example, the Cox regression model for pace includes three continuous, time-dependent exposures: miles run at an easy pace, miles run at a moderate pace, and miles run at a hard pace at a given practice or meet. The hazard ratio of 1.06 for easy pace implies a 6 percent increase in the incidence of injury for every mile of easy running at a given practice or meet, adjusted for distance run on each of the various surfaces and terrains listed. No significantly increased injury risks were found in relation to overall mileage, mileage by running pace, surface, or terrain for the overall sample or within gender.


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  		TABLE 5. Cox proportional hazards regression results for the combined effects of significant risk factors and training practices on initial running injury among high school cross-country runners who competed during the 1996 cross-country season, Seattle, Washington

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
The results of this study suggest that the incidence of injuries among cross-country runners is high, with girls at significantly higher risk. Compared with boys, girls were also at higher risk of injuries causing greater disability from participation. Injury rates among girls were higher during practices than meets. For both the overall sample and for girls, the rates of initial and reinjury at the same body site were highest for the shin. Runners with large Q-angles and a previous running injury had a greater risk of lower-extremity running injuries.

The study's prospective design allowed the risk profile of each runner to be established before injuries occurred, reducing the likelihood of measurement and recall bias (30Go). The study size was large enough to enable analysis of several risk factors simultaneously and by gender. During the season, 38.5 percent of the runners were reported to have at least one running-related injury to the lower extremities that was severe enough to result in their removal from or nonparticipation in a practice or meet. This result supports other recent reports that high school cross-country runners have high annual-season injury rates (3Go, 9Go). When we accounted for actual number of practices or meets in which the runner participated, our overall injury rate of 17.0/1,000 AEs was higher than the 13.1/1,000 AEs we reported in a previous study (9Go). The increased rate may be related to more frequent (weekly) contact with coaches about incidents of injuries. That girls had a significantly higher overall injury rate than boys and were three times more likely than boys to have an injury lasting ≥15 days confirms our earlier findings that, compared with boys, girls may be at greater risk of running injury and longer disability (9Go).

For the overall sample, injury risk was higher during practices than in meets, as previously reported (5Go, 9Go). Unlike our previous finding, however, no significant differences in injury risk were found between practices and meets when we controlled for actual participation (9Go). Also in contrast to previous findings (5Go, 9Go), girls had a significantly higher total incidence of injury during practice than in meets. Finally, our findings concur with previous running studies in that the shin and knee were the most frequently injured body sites: the shin for girls and the knee for boys (9Go, 17Go, 22Go).

Several studies have identified large Q-angle (31Go, 32Go) and previous injury (21Go, 23Go, 33Go, 34Go) as risk factors for running injury. The Q-angle is the angle formed between the vectors for the combined pull of the quadriceps femoris muscle and the patellar tendon, thus providing an estimate of the vector force between the quadriceps muscle and the patellar tendon (35Go). Theoretically, a large Q-angle (>15–20°) increases the lateral pull on the patella against the lateral femoral condyle, thus contributing to patellar subluxation and other patellofemoral pain disorders (35Go). Associations between large Q-angle and other lower-extremity injuries have been reported in other sports and military populations (36Go–38Go). Our findings suggest that coaches may want to screen runners for large Q-angle and previous injury at the beginning of the season. For runners with large Q-angles, preventive interventions and/or orthotics that may reduce biomechanical imbalances or structural inequities might be implemented (13Go, 39Go, 40Go). For runners identified with prior injury, it is important to ensure that appropriate rehabilitation and modification of training methods are incorporated, because these runners may be more prone to injury.

The number of weeks of running during the summer was predictive of risk, but not when we adjusted for other risk factors. Years of high school cross-country experience, leg-length difference, body mass index, preseason running practices, and all training practice variables, which have been thought to increase risk of injury (e.g., hills, concrete, hard pace), were not significantly associated with risk in our study. While several of these factors have been shown to be predictive in other studies and may cause some individual injuries, their effects were not as important within the range of experience of most runners. Because running injuries are likely multifactorial, other factors (e.g., competitive level, inappropriate stretching or warm-up, muscle imbalance, increased pronated or supinated feet, inappropriate running shoe wear, weather conditions) that we did not examine, or interactions between these other factors and training variables, may also be involved. In addition, there may have been other training issues (e.g., coaching styles) that led to a higher risk of injury on one team compared with others, but small team sizes limited our ability to compare across teams.

Other limitations of the study should be noted. First, it is possible that risk factor associations specific to a body site or injury type escaped detection. Although we felt that the coaches' reports regarding injured body site were accurate because of the education they received about running injuries and how to report them (9Go), we were less sure about the accuracy of their reports on injury type without a clinician's diagnosis to confirm them. Thus, we did not report results regarding injury type because there was an increased likelihood of misclassification (9Go). Additionally, we did not examine risk factors separately by body site because of small numbers of injury events for many sites. Second, coaches were instructed to report the intensity of each run as one of three intensity (pace) categories, but coaches may have judged running intensity differently. This source of measurement error may have obscured an association with injury risk. Finally, the absence of association between body mass index and injury may have resulted in part from our assessment of body mass index from self-reported height and weight rather than from direct observation.

It is anticipated that the popularity of high school cross-country will continue. Although our results confirm recent findings that high school cross-country runners experience high injury rates, especially girls, we were able to identify only a few significant risk factors. Furthermore, the generalizability of our findings is unknown. The characteristics and training practices of our high school cross-country teams may differ from those for high school cross-country teams in other geographic regions. Thus, additional epidemiologic studies in other settings and focusing on other risk factors may be worthwhile.


   ACKNOWLEDGMENTS
 
This research was supported in part by the Foundation for Physical Therapy Research, American Physical Therapy Association.

The authors thank the high school athletic directors, coaches, and runners for their cooperation and participation in the study.

Conflict of interest: none declared.


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 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
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