This study demonstrates the burden of hand and wrist injuries on NCAA student athletes distributed among the athletic divisions. Many of these injuries are minor and can be managed conservatively, though more severe injuries require surgical intervention and incur significant time away from participation in the sport. Hand and wrist injuries are more likely to occur during competition as compared to practice due to the increased intensity and the less controlled environment.(6–8) The hand and wrist injury rates were significantly higher for division I student athletes compared to the other divisions. Male and female division I student athletes sustained significantly higher incidence of hand and wrist injuries compared to athletes in divisions II and III, which could be attributed to the higher intensity of division I sports. While our study cannot prove these differences in intensity, it is generally accepted that there is an increasing level of skill, athletic training, and time investment in the sport as one progresses to a higher division of play. However, this assumption does not explain the higher injury rate for division III compared to division II. Interestingly, other studies using the ISP database have revealed a similar pattern of higher injury rates in division III vs. other divisions.(12–15) This could be explained by differences in athleticism and skill such that division III athletes could lag behind in these traits compared to division I and II athletes, placing themselves and other athletes at greater risk for injury.(12) Furthermore, division III programs may trail the other divisions in available resources and coaching experience that could be directed towards improved strength, conditioning, and injury prevention programs.(13)
The NCAA student athlete spends approximately 40 hours per week, or the same amount of time as a full-time job, participating in their sport during practice and competition. The motivation for this dedication varies by the student athlete. When an injury occurs, this may be devastating to the team and to the student athlete. Narratives of victory on the playing field, respect for toughness and sacrifice and the redemptive value of athletic participation are motivating factors to return to play following an injury.(9) As we hypothesized, division I student athletes tended to miss fewer days compared to division II and III student athletes. This trend remained true in male athletes, where division I male student athletes returned to their sport approximately three days faster than their division II and division III counterparts. Interestingly for female student athletes, division III female student athletes missed the fewest days from participation in their sport. Due to the nature of the dataset, we are unable to analyze particular causality of the hand and wrist injuries. The decision for a player to miss more time may vary based on the player position or the time of competition within the season. Contact sports, including ice hockey, football, volleyball, lacrosse, basketball, and field hockey, have higher rates of hand and wrist injuries in NCAA sports and are generally evenly accessible for both genders; this would not explain the discrepancy in time loss injuries between division I male and female student athletes.(6)
The NCAA is committed to the safety of its student athletes. In order to reduce injury rates, the Sports Science Institute and the College Athletic Trainers’ Society have recommended eliminating twice daily practices and limiting the number of live practices during the preseason to 3 per 7-day period.(16) In general, these societies are working to reduce player-on-player contact to make collegiate athletics safer. While only speculative, such efforts to reduce injuries may be exemplified by the difference between the rate of hand and wrist injuries in NCAA athletes and the general population. Approximately 25% of all sports-related injuries in NCAA athletes involve the hand and wrist,(2, 3) while 47% of acute sporting injuries in the general population involved the hand and wrist.(4)
Time away from athletic participation due to injury can negatively affect the student athlete as well as the team dynamic. Most hand and wrist injuries can be treated conservatively, requiring time missed from athletics. Fifty percent of all hand and wrist injuries sustained by male and female NCAA student athletes required less than one day away from the respective sport. At the same time, approximately 1%-2% of all hand and wrist injuries across male and female athletics result in a loss of greater than 60 days away from their sport. Some sports have limited seasons that last only a few months, such as basketball or hockey. Any loss of time will alter team dynamics and can dramatically affect the outcome of a season. Hand and wrist injuries that cause student athletes to miss more than one day can dramatically affect a team and an entire season.
More severe injuries to the hand and wrist require surgical intervention. We hypothesized that division I student athletes, those playing at the highest collegiate level, would have higher rates of surgical intervention for their hand and wrist injuries. While the surgical intervention rate is relatively low at 3.65% across all genders and divisions, we found a statistically significant increased surgical intervention rate in division I student athletes compared to division II and division III athletes. This difference was more apparent when evaluating the different surgical intervention rates in male and female student athletes such that male student athletes had higher rates of surgical intervention compared to female student athletes across all divisions. It is possible that differences in surgical rates could suggest variability among treating hand surgeons regarding management of common sports-related hand and wrist injuries in collegiate student athletes. A study polled 37 consultant hand surgeons for teams in the National Football League (NFL), the National Basketball Association (NBA) and Major League Baseball (MLB). The surgeons completed a survey regarding the management of ten common hand injuries and there was variability in their responses regarding initial management, return to protected play and return to unprotected play.(17) These variances are likely due to differences in injury, player position, time of year within the season, or surgeon preference. However, it is difficult to elicit these differences in the NCAA-ISP database because these variables are not reported.
There are several limitations of this study. Because we examined sports injuries collected in the NCAA-ISP database, our findings may not be generalizable to other sports or non-collegiate level athletics. We did not separate athletes based on which sport they played, nor by seniority, pre-, regular or post-season activity, player position or by playing surface. We did not look at specific injury mechanisms. When reporting the types of injuries sustained, we chose to present the general categories of injuries rather than the details of each fracture (e.g. 1st vs. 5th metacarpal fracture) or ligamentous injury (e.g. ulnar collateral ligament injury) as we felt this would provide a level of granularity that is beyond the scope of this manuscript. The data reported is from the NCAA-ISP database, which is based on voluntary reports from athletic trainers. This manner of data collection is vulnerable to reporting bias because we can’t definitively conclude that each injury was accurately reported, however, our large sample size would help mitigate this bias. While this will continue to be a limitation for studies using this dataset, validation studies show that the NCAA-ISP captured 88.3% of all time-lost events across all divisions(10, 18); this was then integrated into the weighting of the data provided by the ISP.(10) While using both eras of the dataset allowed us to increase our sample size, it should be noted that non-time-loss injuries were not recorded until the later era beginning in 2009. This change in data recording methodology affected all sports and divisions thus should not impact our general findings. In the future, we would like to evaluate hand and wrist injury rates in collegiate athletes over time to see if they are reduced, as the focus of the NCAA is on student athlete safety. It would also be interesting to look at surgical intervention rates over time in NCAA student athletes. Surgeons have become more aggressive about pursuing surgical management of hand and wrist injuries in some sports. In NCAA football in 2008, 6% of UCL injuries to the thumb underwent surgical intervention; in 2016, 10% were treated surgically.(8) The focus should be on individualized treatment of collegiate athletes, emphasizing student athlete safety and preventing long-term complications. This is always kept in balance by the amount of time away from athletics, as days lost can have a significant impact on student athlete and team performance.