Journal of Athletic Training 2007;42(3):381–387

 by the National Athletic Trainers’ Association, Inc

www.journalofathletictraining.org

Ankle Injuries Among United States High School

Sports Athletes, 2005–2006
Alex J. Nelson, BA*; Christy L. Collins, MA†; Ellen E. Yard, MPH†;
Sarah K. Fields, JD, PhD*; R. Dawn Comstock, PhD*†
*The Ohio State University, Columbus, OH; †Columbus Children’s Research Institute, Children’s Hospital,
Columbus, OH

Context: Ankle injuries are the most common sport-related a significantly higher rate during competition (9.35 per 10 000
injuries. To date, no studies have been published that use na- athlete-exposures) than during practice (3.63) (risk ratio ⫽ 2.58;
tional data to present a cross-sport, cross-sex analysis of ankle 95% confidence interval ⫽ 2.26, 2.94; P ⬍ .001). Boys’ bas-
injuries among US high school athletes. ketball had the highest rate of ankle injury (7.74 per 10 000
Objective: To investigate the incidence rates of ankle injuries athlete-exposures), followed by girls’ basketball (6.93) and
by sex, type of exposure, and sport. boys’ football (6.52). In all sports except girls’ volleyball, rates
Design: Descriptive epidemiologic study. of ankle injury were higher in competition than in practice. Over-
Setting: One hundred US high schools. all, most ankle injuries were diagnosed as ligament sprains with
Patients or Other Participants: United States high school incomplete tears (83.4%). Ankle injuries most commonly
athletes. caused athletes to miss less than 7 days of activity (51.7%),
Main Outcome Measure(s): We reviewed ankle injury data followed by 7 to 21 days of activity loss (33.9%) and more than
collected over the 2005–2006 school year from a nationally rep- 22 days of activity loss (10.5%).
resentative sample obtained by High School RIO, an injury sur- Conclusions: Sports that combine jumping in close proximity
veillance system. Specific sports studied were boys’ football, to other players and swift changes of direction while running
boys’ and girls’ soccer, girls’ volleyball, boys’ and girls’ basket- are most often associated with ankle injuries. Future research
ball, boys’ wrestling, boys’ baseball, and girls’ softball. on ankle injuries is needed to drive the development and im-
Results: An estimated 326 396 ankle injuries occurred na- plementation of more effective preventive interventions.
tionally in 2005–2006, yielding an injury rate of 5.23 ankle in- Key Words: injury surveillance, injury epidemiology, lower
juries per 10 000 athlete-exposures. Ankle injuries occurred at extremity injuries

Key Points
• This is the first study to compare the epidemiology of ankle injuries across sports and between sexes among US high
school athletes using nationally representative data.
• Among US high school athletes participating in 9 sports during the 2005–2006 school year, ankle injuries accounted for
22.6% of all injuries, with a total ankle injury rate of 5.23 injuries per 10 000 athlete-exposures.
• Of the high school sports studied, the 4 that involve jumping in close proximity to other players and swift changes of
direction while running (football, basketball, soccer, and volleyball) were those with the highest rates of ankle injury.
• Studies are needed to enhance our understanding of ankle injuries in high school athletes and to drive the development
and implementation of more effective targeted preventive interventions.

I organized high school athletics,11 the ankle is the most com-

n the 2005–2006 school year, more than 7.1 million stu-
dents in the United States (US) participated in high school monly reported body site of injury.1,2,4–8,10–17 The high rate
athletics.1 This represents an all-time high of 53.5% of of ankle injuries among athletes has driven researchers to at-
enrolled students and demonstrates the 17th straight year of tempt to identify risk factors2–6,8,10–12,17,18 and preventive
growth in high school athletic participation. Although athletics methods.16,19–21 Prior reports of ankle injuries among athletes
play an important role in an adolescent’s adoption of a healthy have included single sports in a limited population,5,6,15,17
lifestyle, including physical fitness, participation in any sport evaluation of risk or preventive factors,16,19,20,21 and general
carries an inherent risk of injury. As high school athletic par-
ticipation continues to grow, the incidence of sport-related in- sport-related injury studies in which the ankle was only one
jury is also expected to increase. of many injured sites.2–4,8–13,16,18,22 None of these authors
Patterns of sports-related injury vary by sport,2–4 sex,2,3,5–7 have presented a comparative epidemiology of ankle injuries
age,2,3,8,9 and type of athletic exposure (eg, competition or across sports and between sexes among high school athletes
practice).6,10 Despite sport-specific patterns, one fact is con- using nationally representative data. Well-designed surveil-
sistent: of the nearly 2 000 000 injuries that occur yearly in lance systems are needed to collect the accurate exposure and

Journal of Athletic Training 381

injury data required to determine ankle injury rates across RR ⫽ (number of competition ankle injuries/number of com-
sports and between sexes. petition A-Es) ⫻ 10 000
Our goal was to describe the ankle injuries that occurred
among high school athletes participating during the 2005–
(number of practice ankle injuries/number of practice
2006 academic year in 9 different sports using data drawn
A-Es) ⫻ 10 000
from a nationally representative sample of high schools.
The following is an example of how PRs were calculated:

METHODS PR ⫽ [(national estimated No. girls’ basketball ankle injuries

while rebounding)/(national estimated total No. girls’
Certified athletic trainers (ATs) who possessed current Na- basketball ankle injuries)]
tional Athletic Trainers’ Association (NATA) membership and
Board of Certification certification, provided care to high
school athletes, and had valid e-mail addresses were invited to [(national estimated No. boys’ basketball ankle inju-
participate in the study as data reporters (n ⫽ 4120). Schools ries while rebounding)/(national estimated total No.
with ATs willing to participate (n ⫽ 425) were stratified into boys’ basketball ankle injuries)].
8 sampling groups by 4 US Census geographic locations23 and
2 school size categories (⬍1000 versus ⱖ1000 students). A Statistical significance was assessed using 95% confidence in-
random sample of schools from each stratum (12 schools from tervals (CIs) and P values, with P ⬍ .05 considered signifi-
4 strata and 13 schools from the other 4 strata) was selected cant. All data presented reflect national estimates, unless oth-
to obtain a representative study sample of 100 schools. To erwise stated. This study was approved by the Columbus
maintain the representativeness of the study sample, if a school Children’s Research Institute’s Institutional Review Board. We
dropped out of the study, another school from the same stra- were granted a waiver of the informed consent/assent require-
tum was randomly selected for replacement. ment under the Institutional Review Board Latitude to Ap-
The ATs at participating high schools reported data weekly prove a Consent Procedure that Alters or Waives Some or All
throughout the 2005–2006 academic year using an Internet- of the Elements of Consent, §46.116.
based injury surveillance system, High School RIO (Reporting
Information Online, Columbus Children’s Research Institute, RESULTS
Columbus, OH), which collected athlete-exposures (A-Es) and
In the 2005–2006 school year, athletes from the 9 sports of
injury and injury event information for all injuries sustained
interest sustained 905 ankle injuries during 1 730 764 A-Es,
by high school athletes participating in 5 boys’ sports (11-man
for an ankle injury rate of 5.23 ankle injuries per 10 000
football, soccer, basketball, wrestling, and baseball), and 4
A-Es. This number represents an estimated 326 396 ankle in-
girls’ sports (soccer, volleyball, basketball, and fast-pitch soft-
juries sustained nationally (22.6% of all high school sports-
ball). The RIO system, which has been used in several other
related injuries). Ankle injury rates by sport, type of exposure
studies of rugby and summer camp injuries,24 has been de-
(competition versus practice), and sex are presented in the Ta-
scribed in detail previously.25 The RIO system is closely mod-
ble. Overall, ankle injury rates were higher in competitions
eled after the National Collegiate Athletic Association Injury
than in practices (RR ⫽ 2.58; 95% CI ⫽ 2.26, 2.94; P ⬍
Surveillance System, which has collected high-quality data on .001). This finding was consistent in all sports except volley-
injuries, A-Es, and risk factors since 1982 and has been used ball (Table). Overall, girls had an ankle injury rate that was
to develop preventive interventions that have had proven suc- similar to boys (5.39 versus 5.15 per 10 000 A-Es). In sports
cess in reducing injuries among collegiate athletes.26 A re- played by both sexes (soccer, basketball, and baseball or soft-
portable injury was defined as one that occurred as a result of ball), boys had higher rates of practice-related ankle injuries,
an organized high school athletic practice or competition, re- but girls had higher rates of competition-related ankle injuries.
quired medical attention by a team AT or a physician, and Despite having a lower ankle injury rate than both boys’ and
resulted in restriction of the athlete’s participation for 1 or girls’ basketball, football accounted for the greatest portion of
more days beyond the day of injury. An A-E was defined as all high school ankle injuries (24.1%), followed by boys’ and
1 athlete participating in 1 practice or competition. Each week, girls’ soccer (Figure 1). Wrestling, baseball, and softball will
reporters received an e-mail reminding them to log into the not be discussed further as each had an ankle injury rate of
Internet-based surveillance system. Reporters who failed to log less than 2.0 injuries per 10 000 A-Es, and combined, they
in to complete the weekly exposure and injury report received accounted for less than 10% of all ankle injuries.
an e-mail or phone call reminding them to do so. As shown in Figure 2, injuries to the ankle constitute a
We used SPSS with the Complex Samples module (version higher proportion of all injuries sustained by female athletes
14.0; SPSS Inc, Chicago, IL) for data analysis. To calculate (32.5%) than by male athletes (18.4%) (PR ⫽ 1.77; 95% CI
national estimates of the number of injuries, we assigned each ⫽ 1.53, 2.05; P ⬍ .001). Ankle injuries occurred slightly more
reported injury a sample weight based on the inverse of the often among seniors (29.7%) than among juniors (25.2%),
probability of the school’s selection into the study (based on sophomores (26.0%), or freshmen (19.1%). No significant dif-
the total number of US high schools in each of the 8 sampling ferences were noted in proportions of ankle injuries by height,
strata). Statistical analyses inclyded the ␹2 test with Yates cor- weight, or body mass index of injured high school athletes.
rection and t tests. We used rate ratios (RRs) and injury pro- Ankle injuries were most frequently diagnosed as ligament
portion ratios (PRs) as measures of the magnitude of asocia- sprains with incomplete tears (83.4%), followed by diagnoses
tions. The following is an example of the RR calculation of fractures (5.2%), ligament sprains with complete tears
comparing the rate of competition ankle injuries to the rate of (4.0%), and contusions (2.0%) (Figure 3). A total of 81.8% of
practice ankle injuries: ankle injuries were new, 9.4% were recurrent injuries incurred

382 Volume 42 • Number 3 • September 2007

 Soccer
Soccer accounted for 33.6% of all ankle injuries (boys ⫽
15.7%, girls ⫽ 17.9%) (Figure 1). Injuries to the ankle were
the most frequent injury in both boys’ and girls’ soccer, but
the proportion of ankle injuries to total soccer injuries was
higher among girls (31.5%) than it was among boys (23.5%;
PR ⫽ 1.35; 95% CI ⫽ 1.00, 1.81; P ⬍ .05) (Figure 2). Frac-
tures made up a higher proportion of soccer injuries among
girls (11.3%) than among boys (2.0%), although the difference
was not statistically significant (PR ⫽ 5.55; 95% CI ⫽ 0.70,
43.93; P ⫽ .06). A total of 77.3% of boys’ soccer ankle in-
juries and 85.2% of girls’ soccer ankle injuries were new in-
juries. None of the boys who sustained ankle injuries were
wearing ankle braces, whereas 2.5% of the girls who sustained
ankle injuries were wearing ankle braces.
Injury mechanisms related to a higher proportion of ankle
injuries in boys’ soccer than in girls’ soccer included contact
with another person (47.1% versus 40.8%, respectively; PR ⫽
1.16; 95% CI ⫽ 0.78, 1.72; P ⫽ .48) and contact with the
playing surface (41.1% versus 31.4%, respectively; PR ⫽
Figure 1. Ankle injuries by high school sport, High School Sports- 1.31; 95% CI ⫽ 0.82, 2.09; P ⫽ .28). Conversely, a higher
Related Injury Surveillance Study, United States, 2005–2006 school
proportion of ankle injuries in girls’ soccer than in boys’ soc-
year.
cer was due to contact with the playing apparatus (eg, ball,
goalpost) (11.7% versus 4.1%, respectively; PR ⫽ 2.84; 95%
CI ⫽ 0.70, 11.62; P ⫽ .12) and no contact (ie, rotation around
during the same season as the initial injury, 8.1% were recur- a planted foot, etc) (11.3% versus 4.1%, respectively; PR ⫽
rences of injuries initially incurred during a prior season, and 2.30; 95% CI ⫽ 0.89, 8.50; P ⫽ .07), although these sex
0.7% were unknown or other. The athlete was wearing an an- differences were not statistically significant. A higher propor-
kle brace when 7.8% of ankle injuries occurred. tion of ankle injuries in boys’ soccer than in girls’ soccer were
The outcome of ankle injuries, measured as the length of due to general play (22.4% versus 12.6%, respectively; PR ⫽
time an athlete was unable to participate in practice or com- 1.78; 95% CI ⫽ 0.85, 3.73; P ⫽ .12) and heading the ball
petition (or both), is presented in Figure 4. Ankle injuries most (4.4% versus 1.1%, respectively; PR ⫽ 3.98; 95% CI ⫽ 0.41,
commonly caused athletes to miss less than 7 days of activity 38.86; P ⫽ .20), although these sex differences were not sta-
(51.7%), followed by 7 to 21 days of activity (33.9%), more tistically significant. A greater proportion of boys’ soccer an-
than 22 days of activity (10.5%), and ‘‘other/unknown’’ kle injuries sustained in competition were ruled illegal or foul
(3.9%). By multiplying the median of the days lost in each play than in girls’ soccer (8.5% versus 6.0%, respectively; PR
category by the number of athletes in each category, we cal- ⫽ 1.41; 95% CI ⫽ 0.63, 3.15; P ⫽ .32), although, again, the
culated that ankle injuries were responsible for an estimated difference was not statistically significant.
2 287 536 days of activity lost. Of those ankle injuries that
occurred during competition (n ⫽ 172 118), 5.3% were di- Volleyball
rectly related to action that was ruled as illegal or as foul play
by a referee or disciplinary committee. Girls’ volleyball accounted for 10.6% of all high school
ankle injuries (Figure 1). Of the sports described in this study,
volleyball had the highest proportion of ankle injuries (42.4%;
Football Figure 2). The most common mechanisms associated with an-
kle injuries in volleyball were contact with another person
Football accounted for 24.1% of all ankle injuries (Figure (48.7% of total volleyball ankle injuries) and contact with the
1). The most common mechanism of football ankle injury was playing surface (41.6%). More specifically, ankle injuries most
contact with another person (61.2% of football ankle injuries), often occurred during blocking (51.0%), spiking (14.2%),
followed by contact with the playing surface (28.2%). More passing (13.0%), and general play (6%). Ankle injuries most
specifically, ankle injuries most often occurred while tackling frequently occurred to the middle blocker (40.2% of all ankle
(45.8%), blocking (18.6%), and being stepped on (12.6%). injuries). The court locations at which the highest proportions
The types of plays most frequently associated with ankle in- of ankle injuries took place were middle forward (32.5%),
juries were running plays (61.9%), followed by passing plays right forward (20.7%), and left forward (14.4%). A total of
(15.5%), special teams plays (11.9%), and general play or con- 91.4% of volleyball ankle injuries were new injuries. In 10.4%
ditioning (6.4%); 4.3% were other/unknown. Ankle injuries of volleyball ankle injuries, the athlete was wearing an ankle
were most commonly sustained by running backs (26.4% of brace.
all football ankle injuries), followed by wide receivers and
flankers (11.6%). Less than 1% of football ankle injuries sus-
tained in competition (0.7%) resulted from illegal or foul play. Basketball
A total of 81.8% of football ankle injuries were new injuries. Basketball accounted for 23.8% of all ankle injuries (boys
The athlete was wearing an ankle brace in 10.8% of football ⫽ 12.2%, girls ⫽ 11.6%; Figure 1). Boys’ basketball had the
ankle injuries. highest ankle injury rate per 10 000 A-Es of all sports studied

Journal of Athletic Training 383

Ankle Injury Rates per 10 000 Athlete-Exposures by Sport, Sex, and Type of Exposure: High School Sport-Related Injury Surveillance
Study, United States, 2005–2006 School Year
Injury Rates
Ankle Injuries, per 10 000
Sport Exposure Type No. Athlete-Exposures Athlete-Exposures

Boys’ sports
Football Practice 130 349 183 3.72
Competition 151 82 059 18.40
Totals 281 431 242 6.52
Soccer Practice 40 104 106 3.84
Competition 43 49 294 8.72
Totals 83 153 400 5.41
Basketball Practice 101 156 679 6.45
Competition 68 61 663 11.03
Totals 169 218 342 7.74
Wrestling Practice 19 126 059 1.51
Competition 12 40 220 2.98
Totals 31 166 279 1.86
Baseball Practice 11 115 564 0.95
Competition 16 63 871 2.51
Totals 27 179 435 1.50
Girls’ sports
Soccer Practice 32 98 166 3.26
Competition 58 43 415 13.36
Totals 90 141 581 6.36
Volleyball Practice 49 75 544 6.49
Competition 25 43 691 5.72
Totals 74 119 235 6.21
Basketball Practice 62 132 836 4.67
Competition 67 53 325 12.56
Totals 129 186 161 6.93
Softball Practice 8 88 362 0.91
Competition 13 46 727 2.78
Totals 21 135 089 1.55
Boys’ total Practice 301 851 591 3.53
Competition 290 297 107 9.76
Totals 591 1 148 698 5.14
Girls’ total Practice 151 394 908 3.82
Competition 163 187 158 8.71
Totals 314 582 066 5.39
Combined totals Practice 452 1 246 499 3.63
Competition 453 484 265 9.35
Totals 905 1 730 764 5.23

(7.74), and although the sex difference was not statistically ankle injuries was sustained by forwards (the primary re-
significant, boys’ basketball players had a higher ankle injury bounding position) than in girls’ basketball (46.2% versus
rate than did girls’ basketball players (6.93). Ankle injuries 26.0%, respectively; PR ⫽ 1.78; 95% CI ⫽ 1.21, 2.62; P ⬍
represented a slightly higher proportion of all injuries in boys’ .01). Conversely, in girls’ basketball, a greater proportion of
basketball than in girls’ basketball (39.7% versus 36.5%, re- ankle injuries tended to occur to guards than in boys’ basket-
spectively). ball (49.2% versus 41.8%, respectively; PR ⫽ 1.18; 95% CI
A greater proportion of ankle injuries in boys’ basketball ⫽ 0.88, 1.58; P ⫽ .29). Although the sex differences were not
tended to be related to contact with another person than in statistically significant, a greater proportion of ankle injuries
girls’ basketball, although this difference was not significant tended to occur in the inside lane (where most rebounding
(60.1% versus 53.6%, respectively; PR ⫽ 1.12; 95% CI ⫽ occurs) in boys’ basketball than in girls’ basketball (67.7%
0.88, 1.43; P ⫽ .38). Although rebounding was the activity versus 56.5%, respectively; PR ⫽ 1.20; 95% CI ⫽ 0.96, 1.50;
associated with the greatest proportion of ankle injuries in both P ⫽ .10), and a greater proportion of ankle injuries tended to
boys’ and girl’s basketball (47.1% and 31.9%, respectively), occur between the 3-point arc and the lane (where guards play)
the sex difference was significant (PR ⫽ 1.47; 95% CI ⫽ 1.04, in girls’ basketball than in boys’ basketball (22.5% versus
2.10; P ⫽ .03). Additional activities associated with ankle in- 15.0%, respectively; PR ⫽ 1.50; 95% CI ⫽ 0.84, 2.68; P ⫽
juries in boys’ and girls’ basketball were shooting the ball .17). Although no girls’ basketball injuries were related to il-
(12.1% versus 8.0%, respectively), ball handling/dribbling legal or foul play, 2.5% of boys’ basketball ankle injuries sus-
(7.3% versus 14.0%, respectively), defending (12.2% versus tained in competition were related to illegal or foul play. A
12.8%, respectively), and general play (10.5% versus 18.1%, total of 78.1% of boys’ and 74.3% of girls’ basketball injuries
respectively). In boys’ basketball, a greater proportion of all were new injuries. In 12.6% of the boys’ injuries, the athlete

384 Volume 42 • Number 3 • September 2007

Figure 2. Ankle injuries as a proportion of total high school injuries by sport, High School Sports-Related Injury Surveillance Study,
United States, 2005–2006 school year.

Figure 3. Diagnosis of ankle injuries by high school sport, High School Sports-Related Injury Surveillance Study, United States, 2005–
2006 school year. *‘‘Other’’ includes diagnoses such as stress fracture, muscle strain, tendinitis, etc.

was wearing an ankle brace, compared with 18.6% of the girls’ US high school athletes participating in boys’ football, girls’
injuries. and boys’ soccer, girls’ volleyball, girls’ and boys’ basketball,
boys’ wrestling, boys’ baseball, and girls’ softball during the
2005–2006 school year, ankle injuries accounted for 22.6% of
DISCUSSION
all injuries, with a total ankle injury rate of 5.23 injuries per
Ankle injuries are the most common injuries sustained by 10 000 A-Es. Incidence rates of ankle injuries varied by sport,
high school athletes. As participation in high school athletics sex, and type of athletic exposure (competition versus prac-
continues to increase, so will the number of athletes who sus- tice). This study is the first to present ankle injury data from
tain ankle injuries. In this surveillance study of injuries among a nationally representative sample of US high schools by sport,

Journal of Athletic Training 385

 explanation. Furthermore, our data demonstrate that certain lo-
cations on the playing field/court were associated with higher
rates of ankle injuries. For example, a greater percentage of
ankle injuries occurred in the lane in basketball and at the net
in volleyball.
The fact that jumping in close proximity to other players
and changing direction while running are major components
of both boys’ and girls’ basketball likely explains our findings
that these sports had the highest ankle injury rates. These re-
sults are consistent with those of previous authors, who noted
that rebounding was the activity most often associated with
ankle injuries in high school basketball players10 and that bas-
ketball players were most likely to sustain ankle inju-
ries.10,16,21
Past investigators8,9 have suggested that an adolescent is
more likely than a prepubescent to sustain an ankle injury,
given the development of greater body mass and strength dur-
ing this period of maturation. The body mass and strength of
many student-athletes continue to increase throughout high
school, which may account for our findings that the fewest
ankle injuries occurred among freshmen and the greatest num-
ber occurred among seniors. However, based on our data, an-
kle injuries did not seem to vary significantly by height,
weight, or body mass index. An alternative explanation may
Figure 4. Time loss for ankle injuries by high school sport, High
be that the older students were involved in more intense com-
School Sports-Related Injury Surveillance Study, United States,
2005–2006 school year. *‘‘Other’’ includes medical disqualification
petitions (ie, varsity versus junior varsity or freshman games).
for the season, situations in which the athlete chose not to contin- Additional studies are needed to further examine differences
ue, etc. in ankle injuries based on age, height, weight, and body mass.
As do all studies, this study has its limitations. Given that
eligible schools had to have an AT who was a member of the
sex, and exposure type. Because we used the same definition NATA on staff, our results may not be generalizable to all
of injury, units of exposure, and reporting system, we can schools in the US. The immediate attention to injury that an
directly compare ankle injuries across sports and between sex- AT provides could aid in diagnosis, treatment, and prevention
es, a task that has been difficult in the past because of vari- of further injury, thus reducing injury rates. Alternatively, the
ability of injury definitions and units of exposure across stud- presence of the AT may result in an increase in reported injury
ies. rates from enhanced diagnosis and reporting. However, we felt
Ankle injuries were more common in the sports that in- this potential limitation was outweighed by the increased qual-
volved both running and jumping, with the highest rates oc- ity of data provided by these medically trained professionals.
curring in football, basketball, soccer, and volleyball. This Additional socioeconomic differences may exist between
finding is consistent with the results of prior studies.5,6,15,17,19 schools with and without the services of ATs, which could
Activities that involve jumping in close proximity to other result in differences involving other potential risk factors, such
players were also associated with ankle injuries (ie, rebound- as field condition or quality of equipment.
ing and shooting in basketball and spiking and blocking in Despite the current movement to use a more quantitative,
volleyball). Other types of activity that were related to ankle time-based unit of A-E (such as minutes or hours),27 our def-
injury involved swift changes of direction while running: for inition of 1 athlete participating in 1 practice or competition
example, the activities required of the running back and wide was the most feasible definition of A-E for our study, given
receiver positions in football and the general play of all po- that our data reporters, high school ATs, could not necessarily
sitions in soccer and basketball. be present to time the participation of every athlete in every
Prior authors have reported varied results regarding sex dif- sport. Additionally, we contend that every athlete is at risk for
ferences in ankle injuries. Some have noted higher rates injury during every practice and competition in which he or
among male athletes,6,10 whereas others have reported higher she participates. Other limitations of this study relate to our
rates among female athletes.2,7 We found a similar ankle injury inability to track individual athletes across several seasons to
rate per 10 000 A-Es among high school girls and boys. Ankle capture recurrent injuries, as well as the limited usefulness of
injuries represented a greater proportion of all body sites in- the information we collected on protective equipment, when
jured among girls than among boys (31.7% versus 18.3%). past authors19,20 have shown that ankle braces and taping may
However, this sex difference varied by type of athletic expo- protect athletes from ankle-related injuries.
sure. Girls had higher rates of practice-related ankle injuries It is often assumed that ankle injuries are an unavoidable
than did boys (3.82 versus 3.53 per 10 000 A-Es), but boys part of sport participation because of their high frequency. The
had higher rates of competition-related injuries (9.76 versus prevalent morbidity and burden on health care that results from
8.71 per 10 000 A-Es). ankle injuries have been discussed in many publica-
In all sports except girls’ volleyball, rates of ankle injury tions.7,20,21,28–32 Such negative outcomes could be reduced by
were greater during competition than during practice, which is identifying those athletes most at risk for ankle injuries and
consistent with the results of previous studies.6,10 The inherent by implementing targeted preventive measures. Of the high
increase in intensity in competition situations is one logical school sports studied, the 4 that involve activities of jumping

386 Volume 42 • Number 3 • September 2007

in close proximity to other players and swift changes of di- 13. Centers for Disease Control and Prevention (CDC). Nonfatal sports- and
rection while running (football, basketball, soccer, and volley- recreation-related injuries treated in emergency departments: United
ball) were those most often associated with injuries to the an- States, July 2000–June 2001. MMWR Morb Mortal Wkly Rep. 2002;51:
kle. To enhance our understanding of ankle injuries in high 736–740.
14. Anandacoomarasamy A, Barnsley L. Long term outcomes of inversion
school athletes, future researchers could combine the reporting
ankle injuries. Br J Sports Med. 2005;39:e14.
power of High School RIO with the preseason studies and 15. Greene JJ, McGuine TA, Leverson G, Best TM. Anthropometric and per-
tracking that have been used in prior studies, such as preseason formance measures for high school basketball players. J Athl Train. 1998;
evaluation of postural sway,21 ankle strength and flexibility,21 33:229–232.
preseason compilation balance scores,16 and presence of par- 16. McGuine TA, Greene JJ, Best T, Leverson G. Balance as a predictor of
ticular types of ankle braces and their resultant effective- ankle injuries in high school basketball players. Clin J Sport Med. 2000;
ness.19,20 Future research will add to our growing knowledge 10:239–244.
of the patterns of ankle injuries and, thus, will drive the de- 17. Verhagen EA, Van der Beek AJ, Bouter LM, Bahr RM, Van Mechelen
velopment and implementation of more effective preventive W. A one season prospective cohort study of volleyball injuries. Br J
Sports Med. 2004;38:477–481.
interventions.
18. Cheng TL, Fields CB, Brenner RA, Wright JL, Lomax T, Scheidt PC.
Sports injuries: an important cause of morbidity in urban youth. District
ACKNOWLEDGMENTS of Columbia Child/Adolescent Injury Research Network. Pediatrics.
2000;105:E32.
The lead author was funded by the Samuel J. Roessler Scholarship
from the Landacre Honor Society at The Ohio State University Col- 19. Kinzey SJ, Ingersoll CD, Knight KL. The effects of selected ankle ap-
lege of Medicine. This study was funded by the Centers for Disease pliances on postural control. J Athl Train. 1997;32:300–303.
Control and Prevention (CDC), grant R49/CE000674. The content of 20. Pienkowski D, McMorrow M, Shapiro R, Caborn DN, Stayton J. The
this report is solely the responsibility of the authors and does not effect of ankle stabilizers on athletic performance: a randomized pro-
necessarily represent the official views of the CDC. spective study. Am J Sports Med. 1995;23:757–762.
21. Wang HK, Chen CH, Shiang TY, Jan MH, Lin KH. Risk-factor analysis
of high school basketball-player ankle injuries: a prospective controlled
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Alex J. Nelson, BA, contributed to analysis and interpretation of the data and drafting, critical revision, and final approval of the article.
Christy L. Collins, MA, contributed to conception and design; acquisition and analysis and interpretation of the data; and drafting, critical
revision, and final approval of the article. Ellen E. Yard, MPH, contributed to conception and design, acquisition of the data, and critical
revision and final approval of the article. Sarah K. Fields, JD, PhD, contributed to conception and design and drafting, critical revision,
and final approval of the article. R. Dawn Comstock, PhD, contributed to conception and design; acquisition and analysis and interpretation
of the data; and drafting, critical revision, and final approval of the article.
Address correspondence to Christy L. Collins, MA, Center for Injury Research and Policy, Columbus Children’s Hospital, 700 Children’s
Drive, Columbus, OH 43205. Address e-mail to [email protected].

Journal of Athletic Training 387