AT 715 Epidemiology
Dr. Rauh

Ed Le Cara, DC, ATC, CCSP, CSCS, NASM-CES
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90 Mission Drive, Suite B
Pleasanton, CA 94566
FAX 925-462-5560

Please direct all correspondence to Ed Le Cara at the email address above.

A Comprehensive Review of Men’s and Women’s Lacrosse Injuries

ABSTRACT

Objective: The purpose of this literature review is to collect all available published data on
injuries that occur in the sport of lacrosse. Of particular interest is the risk of injury based on
level of play, gender, and position. Data Sources: A comprehensive literature search was
performed in PubMed, High Wire Press, SPORTDiscus, Google Scholar, and Ovid using the
keywords Lacrosse Injuries, Epidemiology Lacrosse Injuries, Lacrosse Injury, Lacrosse AND
Injury. Years searched were from 1950 until 2008. Data Synthesis: Injury Rates; Injury Rates
in games compared to practice; Injury Onset; Injury Site Location; Injury Type; Injury Severity;
Injury by position; and Case Reports; Conclusions/Recommendations: Although there is such a
large increase in participation, there is relatively little data on the injuries that do occur. There is
no data at the professional level or the indoor game. Overall, the rate and severity of injuries per
Athlete Exposure is relatively low compared to other collision sports like football and hockey.
In females because the rules and equipment used are so drastically different then men, face and
hand injuries are of most prevalence. Increased efforts to identify key factors on the most
common cause of death in Lacrosse, Commodio Cordis, needs to be made so preventative
measures can be made to reduce the incidence of catastrophic injuries. Medical professionals
who cover lacrosse need to understand the injury types and injury rates. Knowledge of the types
of injuries they should expect to encounter will better prepare them for injuries they will need to
treat leading to better care for the athletes.

Key Words: Commodio Cordis, Epidemiology, Athlete Exposure Rate

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INTRODUCTION

Lacrosse (LAX) has been one of the fastest-growing team sports in the Country. In the
US Lacrosse 2007 participation survey, extensive growth has been displayed at all levels from
youth to professional.1

Youth LAX has seen a 94 percent increase in participation over the past six years and in
2007 the youth movement rose over nine percent.1 Over the last six years the high school
segment has grown nearly 100 percent and shows no signs of slowing down. Only 18 state
associations have sanctioned high school LAX.1 Youth and high school participation are
influencing increased opportunities at the collegiate level.

In a span of 10 years there have been 152 new programs added to college institutions. In
2008 there were 27 new varsity programs and 23 more teams are scheduled to begin play in the
2009 and 2010 seasons. The collegiate level has received some significant public attention from
CSTV and ESPN with over sixty televised games both locally and nationally.1 As expected, with
an increase in participation at the collegiate level, the opportunities to be a male professional
LAX player are growing as well.

 In the 2005 there were only 150 participants and 21 teams at the professional level and in
the 2007 season it has grown to 300 participants and 22 teams. An increase in participants is not
as apparent as at the other levels but the popularity of the sport is becoming much more visible.
Coverage of 60 Major League Lacrosse (MLL) games on ESPN and ESPN2 occurred in the
2008 season. The MLL is the professional outdoor league in the United States and Canada.
According to the National Lacrosse League (NLL) website, this year NBC will have television
coverage of over 30 games. The NLL is the Professional Indoor League of the United States and
Canada.

There haven’t been many reasons to explain why LAX is such a rapidly growing sport.
Perhaps it is the US Lacrosse Association that has provided the infrastructure to support and
nurture youth participants with exciting action, stylish equipment, and increased exposure. Both
boys and girls are fueling the demand for additional playing opportunities.1 It is exciting to see
the oldest sport in the United States experiencing such a large growth. However, with additional
participation in a contact (women’s) and collision (men’s) sport creates possibilities of more
injuries.2

The purpose of this literature review is to collect all available data that provides
information on injuries associated with playing lacrosse. Men’s and Women’s data will be
collected at all levels of play. The characteristics and components from each study will be
displayed in tables with a summary of those tables. Additionally, there will be suggestions for
injury prevention and future research based upon the findings.

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INJURY CHARACTERISTICS

Injury Rates

The data gathered on injury rates in men’s and women’s lacrosse are summarized in Table 1.
Rates of injury are different based upon each of the researcher’s interest (from .0000068 – 3.8
injuries/100 athletes). The disparity occurs because different researchers were looking at
different types of injuries and different severities of injuries at different levels. Cantu, et al3
looked at fatalities and catastrophic injuries in college and high school sports over a 15 year
period. Cantu found that the relative incidence level of suffering a catastrophic injury or fatality
in LAX is much lower than in other collision sports. Prodromos, et al4 and Mihata5 and Arendt6
studied ACL injury rates in Men’s and Women’s Lacrosse and found correlation between each
others findings and much lower incidence rates compared to soccer and basketball (.17men/.18
women versus .28/.32 in soccer and .13/.28 in basketball) Diamond and Gale7 limited their
research to head injuries in men’s and women’s lacrosse with much higher incidence in the
women’s game (.77/.44).

Yard8 found almost a 4:1 boys to girls injury rate in youth players (4577/1250) with similar
number of teams and players involved. Overall, the injury rates are higher in males at all levels
and the rates increase with age and level of play.

Men’s rate of injury should be higher because of the nature of the game is more physical and the
rules allow for more body and stick contact.9, 10 The studies also displayed higher numbers as
the level increased, i.e., college displayed higher game and practice injury rates than high school,
and the high school level had higher levels than the youth level.11 The increase in age and level
may be due to the intensity is higher and the athletes are bigger, faster, and stronger as the higher
the level, less of the participation is for plain leisure as competition gets higher. In future
research, time of injury should be included during assessment, i.e. first or second half of game or
practice, or quarters, when applicable, to better understand the type of injury.

There was no data for those players who participate at the professional level or Indoor Lacrosse,
known as Box Lacrosse.

I would tend to believe that indoor lacrosse, with much closer confines, would have a larger
incident rate of head and face injuries in women who wear no helmet or facemask and hand
injuries because no gloves are worn.12 Further research to break down the differences in the
games is necessary to further evaluate risk of injury.

Game vs. Practice Injury Rates

The game verses practice injury rates for both men’s and women’s lacrosse is typical of other
sports that have participation by both genders as summarized in Table 2. The information
provided by the literature showed that game injury rates appear higher across the board.
Depending on what type of injuries the researchers were studying made the numbers appear
much higher or lower when compared to one another. Yard, et al8 did not differentiate between
men/women and practice/game at the youth level. Lincoln, et al13, Goldenberg, et al14, Matz, et

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al15, Hootman et al, 16, Covasin, et al17 all showed increased rate of injury during game activity.
McCulloch, et al18 did not study game injuries but showed a higher rate during games between
men and women per 1000 AE (11.5/6.1). The reason for the disparity between the practice and
game sessions could be attributed to the lack of intense competition during practice, as well as
the types of activities and drills performed during practice. The decreased time spent during
practice in high impact or scrimmage situations when the athletes are at greater risk.

Injury Onset

There wasn’t an overwhelming amount of published studies involving injury onset. However,
from the type of injury, the onset could be assumed. This data is summarized in Table 3. The
majority of the information provided by Hinton, et al19 (104/873 IPR/1000 AE), Mayer, et al20
(0/2 IPR/1000 AE), Matz, et al15 (0/104 IPR/1000AE), and Lincoln, et al13 (16/348) listed acute,
or sudden, injuries as the most common. Injuries occur most often in the men’s game from player
to player contact resulting in immediate injuries such as concussions, contusions, and lacerations.
The nature of the women’s game has injuries occurring most frequently from stick to player, or
player to ball contact, rather than player-to-player contact.

Risk factors that contribute to injury onset in the women’s game include the lack a head and
hand protection, as well as lack of strict enforcement of the rules by the officials. Contusions,
fractures, lacerations, concussions, sprains, and strains were the most common injuries
recorded.21 Injuries displaying as gradual onset included overuse injuries and stress fractures,
but were seldom listed. Kang, et al22 studied stress fractures which would account for a larger
gradual onset than sudden onset (7/0 gradual versus sudden). In future research studies,
documentation of the onset of injuries should be included.

Injury Site Location

There is an overwhelming amount of information provided in the literature on injury site location
as listed in Table 4. The majority of data provided on the women centered on head and facial
injuries. Women displayed a higher percent of head and facial injuries compared to anything
else surveyed or observed, while male lacrosse players displayed a higher number of
concussions, shoulder, and lower extremity injuries.13, 23 Risk factors for these injuries can be
attributed to lack of appropriate equipment or the incorrect use of equipment or lack of
enforcement of the rules that are already in place.7, 14, 24 Women only wear eye protection
(mandated at all levels in 2004), but no helmet or face or hand protection.25

In the youth game, Yard8 found the highest amount of injuries occur to females in the face
(21%), hand (24%), and ankle (26%). Ankle injuries come in at the highest percentage of injury
sites is also expected as ankle sprains are one of the most common injuries in running sports.19
Yard8 also found a high number of injuries in boys to the hand (23%) which is somewhat
surprising considering the boys do wear gloves. The boys are able to strike the player that is
carrying the ball with their own stick that may account for a lot of stick to hand contact that
could lead to injury.

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Lincoln 13 showed the exact number of head injuries at the high school level between boys and
girls over a four year period involving 23 teams but this was the only study that showed similar
rates of injury. The lack of a helmet in the women’s game made up for the aggressive style and
rules of the men’s game. Goldenberg14 showed a high rate of injury to the eye (1.4 IPR) but this
study was done in 1995, before the mandatory use of eyewear in women in 2004. In the
women’s game, the majority of injuries occur to the head and facial area, which is left
unprotected, except for the mandated protective eyewear. The eyewear does well to protect the
eyes, but leaves the rest of the face vulnerable to being hit by the stick and ball.25 Women tend
to carry the head of the stick closer to their head and face because of a smaller basket to carry the
ball compared to the men. Lack of protective glove-wear for females also increases their risk for
injuries to the hands and fingers. Goldenberg14 also showed largest number of injuries occur to
the lower extremity (ankle 3.5, knee 1.9, thigh 1.7) in female high school lacrosse players.

In the men’s game the protective helmet they wear does well to protect against eye injuries,
lacerations, and other injuries in like nature, however when tested for protection against
concussions, lacrosse helmets did not provide consistent protection.16 Lincolns13 data provides a
clear pattern of occurrence in the men’s game (84.2% HS and 88.6% College aged men of
injuries to the head area) compared to females (58% HS and 49% College) respectively, as well
as a need for further research on protective equipment. The high incidence of facial injuries
displayed at all levels of women’s plays needs some sort of alterations, whether it is the addition
of protective equipment or changes in rules or enforcement.

Injury Type

The current research has information on several different types of injuries, concussions, sprains,
contusions, and lacerations seemed to occur most frequently. These injuries are summarized in
Table 5. Males experienced more concussions (nearly 2:1) in all studies, while females
experienced contusions, abrasions, sprain/strains. Risk factors for these injuries are virtually the
same throughout each table. For women, their lack of protective equipment is perhaps the
number one cause of their contusions and lacerations. Since the majority of the articles covered
head and facial injuries in women, had these players been wearing helmets, they would have
been protected from such forces. In future research, more detailed injury tracking would be
useful. Current research lists the number of sprains, but future research could include the area of
the body the sprain occurred, i.e. ACL, MCL, ATF, or even just ankle or knee. Another detail
that should be included is concussion severity. Current research provided the overall number of
concussions occurring throughout the study, but the majority of the studies fail to list the severity
or time lost from each concussion.26

Injury Severity

Injury severity in the current lacrosse literature has over 50 percent of injuries caused the
participants to be out of game or practice between one and seven days. Table 6 summarizes the
data on injury severity. The most common injuries that were in the mild category were
contusions and lacerations.27 The moderate category was anywhere from eight to 21 days, with
the primary injuries being mild ankle sprains and muscle strains. 22+ days lost were attributed to
ACL reconstructions and were documented by Hinton19 and Matz.15 Catastrophic injuries are

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very rare and they only occurred in the men’s game at the collegiate level and high school

levels.3, 15, 27

The literature wasn’t specific in regards to the type of catastrophic injuries. A search in Google
on the World Wide Web provided some insight. There have been eight documented cases of
death by Commotio Cordis in Lacrosse at the Men’s college level. Commotio Cordis, sudden
cardiac death secondary to blunt non-penetrating chest blows in sports, does not appear to have
any type of treatment or prevention.28-30 There have been incidences of Commotio Cordis in
baseball, hockey, and lacrosse with and without protective equipment over the heart.8, 30
Treatment by onsite emergency responders with AED’s did not have any ability to prevent death
in the four cases in lacrosse.27-29 Future research in injury severity requires additional
information regarding catastrophic injuries should be provided, i.e. type of catastrophic injury
that occurred and the exact definition of a catastrophic injury. Commotio Cordis needs further
study for prevention and treatment. The type and severity varied within the current literature. A
catastrophic injury may be defined as the loss of vital functions or complete loss of life, that
definition wasn’t always clear.15, 18 Injury severity needs to be included in more studies; the
current research didn’t include it as one of the criterion for injury tracking.

Injury by Position

There hasn’t been much information on injury by position in any sport and that includes lacrosse.
The data that is available is summarized in Table 7. Offensive players had the most injuries,
followed by defensive players, and then midfielders.12, 22, 31 Goalies had a low rate of injury
which may be due to the amount of protective equipment that they wear and the rules that do not
allow any contact by other players.14 Risk appears to be greater in those players that may do
more ball handling (more exposure to body and stick contact) and who do more running, cutting,
stopping. Further research should include player position when documenting injuries to better
track what type of injuries occur per position. This data can help rules officials develop
requirements for different protective equipment and rules preventing certain activities to reduce
the risk of injury.

Risk Factors

Risk factor data is displayed in Table 8 and is divided into intrinsic and extrinsic risk factors.
Intrinsic risk factors for youth and collegiate are displayed and include hypermobility of joints,
age, and skill level, and gender. 32, 33

Extrinsic risk factors includes rules of the game (body/stick contact)17, 26, equipment or lack of
equipment in females5, 10, 23, 31, possibly position played,14 and game versus practice
participation0.16

Further research needs to address indoor versus outdoor playing environments, fields (field turf
versus grass), and possibly game times or tournament play. A risk may be that after a one or two
day tournament, an increase in injury will occur in the latter games due to fatigue. Night games
may pose a larger risk because of limited visibility of the ball. Information like this would allow

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tournament directors to design the games to be played with longer or shorter times between
games, less games (i.e. wrestler’s are limited to 5 matches in day) to be played, or possibly no
night games.

There was no data to compare grass fields versus field turf (artificial turf). An interesting
comparison would be the indoor game on field turf versus outdoor on field turf. Comparing the
two environments may decipher if it is the inside or outside game that may produce more injuries
or the type of field the game is played on.

Injury Prevention:

I have provided a summary table of recommended injury prevention from the researchers and the
supporting evidence in Table 9.

Suggestions For Further Research:

In addition to further research per subsection, I have provided a summary of suggestions in Table

10.
Case Reports:

As a courtesy for the reader, I have included a summary of the case reports available in regards
to LAX injuries in Table 11. Case reports included clavicle fractures34, 35, isolated rib fracture36,
eye/orbit injuries 23, hand injuries24, 31, 37, stress fracture of the femoral shaft22, and internal organ
derangement. 38

DISCUSSION

As expected, this review of the literature provided insight into the types of injuries to expect
when covering lacrosse events as a medical provider. Not surprisingly, men have an increased
incidence to all injuries and catastrophic injury. Women tend to have injuries to the lower
extremity and exposed body parts of the hand and face because of their lack of protective
equipment and incidental stick and body contact.

Overall, in the men’s game, Lacrosse players have a decreased likelihood of injuries of all
severities when compared to other collision sports like football and hockey. Women’s injury
rate in Lacrosse is also low compared to other contact sports like soccer but is higher than in
basketball.

Although there are quality studies to fall back on when preparing for coverage of a LAX season,
further research is needed. There is no available research in regards to the professional game
that occurs both indoors and outdoors. Considering that each successive level of play induces
higher injury rates, I would expect that the professional level would have the highest rate of
injury compared to the youth, high school, and collegiate. In addition, the indoor game because
of the aggressive nature, ability to cross check using one’s stick, and fighting that is permissible
by the rules, would lead to higher injury rates as well.

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Coaches, referees, athletes, protective equipment manufactures, researchers, rules makers, and
medical professionals can use this literature review when preparing for LAX practices and
games. For example, knowing that the men’s game involves the use of helmets, it would be
appropriate to have a electric screw driver in both the coaches and athletic training bag so that
one is prepared to remove a face mask for airway access in case of emergency. Training of
coaches and medical personnel is also paramount prior to the season. A high rate of lacerations
and abrasions would clue the athletic trainer to have the most evidence based approach to
debridement and cleaning of these wounds with proper wound coverage to reduce the chance of
infection. The strength and conditioning coach should use the high rate of lower extremity
injuries in females as a clue to include neuromuscular training in warm-up to help prevent non-
contact injuries to the knee and ankle. Referees can be clued to have strict adherence to the rules
for not only proper outcome of the game but referees play a vital role in limiting injury exposure
by not allowing stick and body contact during a women’s game. Equipment manufacturers can
continue to increase the safety of the game by enhancing the helmet for reduction in concussions.
Facemasks must limit the exposure of the face to the stick and ball to reduce injuries to the eyes,
nose, and mouth. Rules makers must continue to enhance the game by enforcing rules to limit
the exposure of injury to the players. Researchers can look at the void that needs to be filled by
continuing research on Commotio Cordis to reduce the chances of catastrophic injury to the
players of Lacrosse and other sports that blunt trauma to the chest can occur.

With large increases in participation at all levels, efforts need to be made to enhance the safety
and decrease the injuries that can have long term consequences on the players’ health, our health
care system, and future generations of Lacrosse players.

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