Characteristics of Injuries Occurring During Cross-Country: A Report from the Athletic Training Practice-Based Research Network

Running is a popular physical activity, particularly in adolescent athletes. In fact, cross-country running was ranked as the fourth and fifth most popular sport among American high school boys and girls, respectively.¹ Furthermore, approximately half a million adolescent athletes are estimated to participate in high school cross-country annually.¹ As with all sport activities, running is associated with many health benefits, but the risk of injury is also a concern.

For example, researchers who conducted a retrospective study² of musculoskeletal injuries in high school cross-country runners reported an overall incidence of 17.0/1000 athlete-exposures, with a higher rate in girls (19.6/1000 athlete-exposures) versus boys (15.0/1000 athlete-exposures). According to comparative data from collegiate and high school injury-reporting systems, the highest rates of overuse injuries were among womens' and girls' cross-country, followed by mens' and boys' cross-country.³ Unlike acute injuries that may limit participation in sport, many athletes with overuse injuries continue to train, resulting in non–time-loss injuries that require ongoing evaluation and treatment by medical providers.

Despite the number of epidemiologic studies^3–5 in which researchers described injury rates in cross-country runners, data are limited regarding the treatment of these injuries, particularly in adolescent athletes. The few investigations of medical services have focused on those used by elite track and field athletes participating in an Olympic trial.⁶ These medical services were reported generally and provided for a relatively short time (ie, 2 weeks), but athletes were treated for 3 ± 1.13 visits and most often obtained medical services from massage therapists or chiropractors, with athletic trainers (ATs) being the least used medical providers. In the secondary school setting, running athletes have greater access to ATs and may seek athletic training services for injuries and preventive treatments. In other studies from the Athletic Training Practice-Based Research Network (AT-PBRN), cross-country athletes accounted for 2.1% of daily patient encounters⁷ and 4.8% and 1.7% of athletic training services provided to girl and boy runners, respectively.⁸ Although cross-country athletes make up a relatively small percentage of all athletes who receive medical treatment, an understanding of the types of injuries and treatment characteristics associated with these injuries may offer insight into the athletic training services needed for adolescent athletes participating in cross-country. The purpose of our study was to describe the injury and treatment characteristics of injuries sustained during cross-country participation by high school athletes.

METHODS

RESULTS

Injury Characteristics

A total of 681 patient cases (girls = 415, age = 15.2 ± 1.2 years, and boys = 266, age = 15.4 ± 1.3 years) were recorded during the study period. The number of exposed clinical practice sites (ie, high schools with student-athletes participating in cross-country and at risk for injury) was not different between sexes for each academic year (mean ± SD: girls = 19.2 ± 14.9, boys = 18.0 ± 14.0, P = .86). A detailed summary of injury demographics, including participation level, time of injury, and mechanism of injury, is provided in Table 1. Most injuries were non–time loss (69.3%, n = 472), reported by varsity-level athletes (72.7%, n = 495), sustained during in-season practice (67.4%, n = 459, Table 2), and the result of a noncontact (42.0%, n = 286) or insidious or unknown (41.6%, n = 283) mechanism of injury. The most commonly injured body parts were the knee (21.4%, n = 146), ankle (20.4%, n = 139), and calf (17.5%, n = 119). More than 70% of all injuries were recorded as a sprain or strain (43.6%, n = 297), tendinopathy (18.5%, n = 126), or general pain (9.5%, n = 65). The 5 most frequently recorded ICD-10 diagnoses were S73.109A (sprain/strain of the thigh/hip/groin: 13.7%, n = 93), S93.409A (sprain/strain of the ankle: 9.3%, n = 63), S83.90XA (unspecified thigh sprain/strain [distal end]: 8.8%, n = 60), M76.8 (anterior/posterior tibialis tendinitis: 8.1%, n = 55), and M25.569 (knee pain: 5.7%, n = 39). In general, injured body parts (Table 3) and diagnosis types (Table 4) were similar between girls and boys.

Table 1 Injury Demographics by Sex

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Table 2 Diagnosis Type According to Time of Injury, n (%)

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Table 3 Injured Body Part by Sex and Time Lost Due to Injury, n (%)

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Table 4 Diagnosis Type by Sex and Time Lost Due to Injury, n (%)

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Treatment Characteristics

A total of 3621 athletic training services were documented across 2641 episodes of care. The most commonly used procedures were therapeutic activities or exercises (n = 1039, 28.7%), hot or cold packs (n = 945, 26.1%), and athletic training evaluation or reevaluation (n = 848, 23.4%; Table 5). The least used procedures were upper extremity strapping (ie, elbow or wrist, hand or finger, shoulder; n = 2, 0.1%), contrast bath (n = 5, 0.1%), and gait training (n = 5, 0.1%; Table 5). An overwhelming majority of athletic training services were administered to patients whose injuries occurred in-season (n = 3096, 85.5%; Table 6) and to varsity-level athletes (n = 2639, 72.9%; Figure). Additionally, patients with non–time-loss injuries received more athletic training services (n = 2396, 66.2%) than those with time-loss injuries (n = 1225, 33.8%; Table 7). Across all patient cases, the average amount and duration of care were 5.5 ± 15.1 (median = 2, IQR = 1–4) episodes of care and 27.8 ± 87.5 (median = 1, IQR = 1–14) days, respectively. Patients received an average of 7.4 ± 17.4 (median = 3; IQR = 2–6; range, 1–206) total athletic training services, with 1.9 ± 1.0 (median = 2; IQR = 1–2; range, 1–8) services per episode of care. According to the mean, the diagnosis types with the greatest amount of care, duration of care, and total number of services were dislocations/subluxations (n = 3; 21.3 ± 33.5 visits, duration = 24.7 ± 22.6 days, services = 21.7 ± 19.2), contusions (n = 30; 14.8 ± 48.7 visits, duration = 32.0 ± 88.5 days, services = 23.1 ± 13.7), and tendinopathy (n = 126; 6.5 ± 14.2 visits, duration = 44.1 ± 114.8 days, services = 8.8 ± 1.7; Table 8). Based on the median and IQR, the amount of care, duration of care, and total number of services were similar across diagnosis types (Table 8). Median values for the amount (non–time loss = 2.0 [IQR = 1–4] visits, time loss = 2.0 [IQR = 1–5.5] visits) and duration of care (non–time loss = 0.0 [IQR = 0.0–18.25] days; time loss = 1.0 [IQR = 0.0–17.5] days) were not different between groups (amount: P = .08; duration: P = .46); however, patients with time-loss injuries received more total athletic training services than patients with non–time-loss injuries (time-loss = 4.0 [IQR = 2–8] services, non–time-loss = 3.0 [IQR = 2–6] services, P = .001).

Table 5 Athletic Training Services Recorded for Patients With Cross-Country Injuries

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Table 6 Athletic Training Services According to Time of Injury

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Table 7 Athletic Training Services by Time Lost Due to Injury

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Table 8 Amount and Duration of Treatment for Cross-Country Injuries by Diagnosis Type

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DISCUSSION

To our knowledge, this is the first study to describe the injury and treatment characteristics related to cross-country injuries in adolescent athletes and provide insight into the workloads of ATs treating these patients. Previous investigations of athletic injuries have been specific to population (eg, youth,¹⁴ adolescents,¹⁵ college students¹⁶), joint (eg, ankle,^13,17 knee¹⁸) injury (eg, concussion,¹² anterior cruciate ligament injury¹⁹) or sport (eg, basketball,²⁰ football²¹). However, a focus on injury and treatment patterns specific to adolescent cross-country student-athletes has not existed until now.

Our findings suggest that ATs were predominantly treating patients with lower extremity (ie, knee, ankle, calf) injuries, most of which appeared to be musculotendinous or ligamentous, as indicated by diagnoses of a sprain or strain or tendinopathy. Grooms et al¹⁸ reported that although knee abrasions, contusions, sprains, and strains were all documented as occurring in cross-country athletes, strains resulted in the greatest number of athletic training services per injury (boys: mean = 21, median = 6, IQR = 2–14; girls: mean = 17, median = 7, IQR = 3–32). Patients with several injury types received a greater number of visits (sprain or strain: mean = 5.6, median = 2, IQR = 1–5 visits; tendinopathy: mean = 6.5, median = 2, IQR = 1–5 visits; contusion: mean = 14.8, median = 2, IQR = 1–2 visits; dislocation or subluxation: mean = 21.3, median = 2, IQR = 2–2 visits) and total number of services (sprain or strain: mean = 3.0, median = 3, IQR = 2–2 services; tendinopathy: mean = 8.8, median = 4, IQR = 2–8 services; contusion: mean = 21.3, median = 3, IQR = 2–5 services; dislocation or subluxation: mean = 21.7, median = 3, IQR = 2–3 services) than sprains or strains, yet these categories had fewer documented injuries (n = 126, 30, and 3 injuries, respectively) than sprains or strains (n = 297). As a result, the medians and IQRs for these categories aid in the interpretation of potentially skewed data due to small sample sizes.

On average, patients required between 7 and 8 athletic training services over approximately 1 month, most often therapeutic activities or exercises. In recent studies of treatment characteristics of ankle^13,17 and knee¹⁸ injuries, researchers cited therapeutic exercise as one of the most frequently documented athletic training services. Furthermore, both Simon et al¹⁷ and Marshall et al¹³ reported that while ATs generally used good practice patterns when treating ankle sprains, they were still underusing services with high Strength of Recommendation Taxonomy evidence, such as therapeutic exercise/activities (grade A evidence)²² and manual therapies (grade B evidence).²²

Authors^2,23 of epidemiologic studies have described the most common injuries related to running activities as lower extremity sprains, strains, tendinitis, and inflammation. Our findings were similar in the most frequent diagnoses of lower extremity sprain or strains (thigh or hip/groin, ankle, distal thigh), anterior or posterior tibialis tendinitis, and knee pain, providing validity to our dataset. With recent research indicating an increased risk of overuse injury related to sport specialization²⁴ and the potential for distance runners to overtrain, injury-prevention programs targeting student-athletes may be a logical next step. In particular, programs that incorporate such components as monitoring training volume, eccentric exercises, improving muscle imbalances (eg, hip-abduction weakness versus medial quadriceps strength), proprioception and balance exercises, and intrinsic foot muscle strengthening may help reduce the injury risk.⁵ Additionally, biomechanical alterations were present in runners with chronic lower extremity musculoskeletal conditions,²⁵ and gait retraining was an effective rehabilitation strategy for these types of injuries (eg, patellofemoral pain,²⁶ exercise-related leg pain,²⁷ lower limb stress fractures²⁸). However, gait retraining was one of the least documented treatment strategies in this study. Based on the evidence, ATs should consider incorporating this treatment into rehabilitation protocols for cross-country patients, especially those with chronic or overuse injuries.

We were able to identify the amount of care, duration of care, and total number of athletic training services provided for the various injuries experienced by adolescent runners. Musculotendinous or ligamentous injuries occurred most often and required the greatest amount of care, longest duration of care, and largest total number of athletic training services. Nonetheless, the results for dislocations and subluxations should be taken with caution as only 3 patients were diagnosed with this type of injury in our study. Lam et al⁸ reported these variables by sport for more than 5500 injuries in high school student-athletes. Although the authors⁸ did not identify the amount and duration of care provided for cross-country athletes, they determined that injured girls' track-and-field athletes received care at an average of 5.2 ± 5.1 visits over 10.1 ± 30.0 days, and injured boys' track-and-field athletes received care at an average of 5.3 visits over 18.1 ± 72.9 days. When we combined all injury types, cross-country athletes received a similar amount of care (5.5 ± 15.1 visits, median = 2, IQR = 1–4) from an AT; however, their average duration of care was 1.5 to 3 times as long (27.8 ± 30.0 days, median = 1, IQR = 1–14). Additionally, these variables did not differ between patients with non–time-loss injuries and those with time-loss injuries, indicating that the frequencies and lengths of treatment were comparable between groups. Patients with time-loss injuries received a greater number of total athletic training services than those with non–time-loss injuries, yet the difference between groups was only 1 procedure. Thus, this finding may not be meaningful from a clinical perspective. Continued participation by these adolescent cross-country athletes after injury (ie, non–time-loss injuries) may play a role in lengthening the time spent receiving care.

Interestingly, the most common injuries sustained by track and field athletes⁸ (ie, ankle sprain or strain, thigh sprain or strain, anterior/posterior tibialis tendinopathy, and knee pain) were similar to those experienced by the cross-country athletes in our study. This leads us to believe that other factors may have contributed to the long duration of care provided for these injuries: eg, the cross-country season is usually in the fall and not all athletes train over the summer,²⁹ these athletes compete in longer races and likely have greater training volumes than those who compete solely in track events, and overuse injuries typically do not restrict participation but frequently need ongoing rehabilitation and management.³⁰

Often ATs play a role in maintaining an athlete's sport participation, even when the athlete has an injury. Not only was the injury rate higher for non–time-loss injuries than time-loss injuries in youth,¹⁴ interscholastic,³¹ and intercollegiate¹⁶ athletics, but some authors^17,31 estimated that ATs also spent more time seeing patients (ie, athletic training facility visits) with non–time-loss injuries. Furthermore, in a recent study,¹⁵ the non–time-loss injury rate was higher in high school athletes than in collegiate athletes. These trends were also evident for runners in particular. Grooms et al¹⁸ observed that more than 90% of athletic training facility visits for knee injuries sustained by high school cross-country student-athletes were for non–time-loss injuries, indicating that these student-athletes were continuing to run even though they were still receiving treatment for their injuries. Similarly, Rauh et al² noted that injuries resulting in 1 to 4 days lost from participation occurred most frequently, suggesting that most patients returned to sport relatively quickly. We found that more than two-thirds (n = 472, 69.3%) of high school cross-country injuries were non–time loss, which agrees with these previous results.^2,15,18 It was notable that even though the number of non–time-loss injuries was larger and these patients sought a greater amount of care, they were typically receiving the same types of treatments as patients with time-loss injuries (Table 7). Decisions regarding whether to allow patients to continue to participate while receiving treatment are likely contributing to ATs' overall demand as health care providers because cross-country patients with non–time-loss injuries currently represent most of the workload for that sport.

The National Athletic Trainers' Association's (NATA) document³² on appropriate medical coverage of intercollegiate athletics (AMCIA) recommended that the appropriate medical coverage of each sport should be determined based on the relative workload (ie, injury risk × average number of treatments per injury) calculated for each sport. Traditionally, cross-country is considered a low-risk sport, but our results, in conjunction with the findings of the aforementioned studies,^2,18 provide more insight into the demands placed on ATs who provide care for cross-country teams. The AMCIA identified a base health care index for each sport according to injury risk, injury rates (from multiyear sport injury-surveillance data), and the volume of care provided for injuries in each sport. This base health care index is then adjusted for site-specific data (ie, number of athletes, days in season). Although these estimates help colleges and universities to make appropriate decisions regarding medical coverage, similar calculations do not exist for secondary school athletics. Our work contributed cross-country–specific data for high school athletes and indicated that the demand on ATs to manage non–time-loss injuries in the sport is high. Furthermore, the NATA's AMCIA recommendations and guidelines are focused on the evaluation and adjustment of medical coverage for the safety of collegiate student-athletes. However, researchers^33,34 have identified that approximately 30% of high schools in the United States lack access to athletic training services. Our results also demonstrate the level of care that high school cross-country student-athletes are not receiving when they lack access to an AT.

This study was not without limitations. The use of ICD-10 codes aligns with best practices within the health care community; still, we were unable to specify the exact diagnoses of some injuries. For example, we were unable to distinguish between a sprain and a strain in the combined diagnostic codes, determine whether a sprain or strain to the thigh involved the quadriceps or hamstrings muscles, or identify certain conditions such as medial tibial stress syndrome because it is often grouped with ankle tendinopathy. Additionally, our ability to accurately evaluate athletic training practice was limited by the documentation of the ATs participating in point-of-care research. Given the retrospective nature of this study and its focus on patient records, any misdiagnosis of injuries by ATs may have influenced our findings. Patient care documentation data compiled from a diverse collection of clinical practice sites can vary, and therefore, outliers are expected. Accordingly, we chose to report the median as it provides a better estimate of the average case. Finally, despite the compilation of data from more than 100 clinical sites across 22 states and Washington, DC, this group of high schools may not represent all high schools throughout the country.

CONCLUSIONS

We characterized the injury and treatment characteristics for injuries sustained by high school cross-country student-athletes. Specifically, our results suggested that high school cross-country student-athletes experience injuries for which they continue to seek treatment even though their participation has not been restricted. Considering early restriction of participation and refining treatment strategies to include such interventions as gait retraining may help shorten the duration of care for these patients. To our knowledge, we are the first to describe these treatment characteristics related to the sport of cross-country. These findings provide insight into the demands of the sport when determining appropriate medical coverage. Future researchers should evaluate the influence of training volume and other performance variables on the duration of care and injury recovery. Furthermore, a high school equivalent of the NATA's AMCIA document³² would be a valuable resource for ATs. Our cross-country–specific data regarding the volume of care supplied by ATs to these student-athletes could help with the development of a base health care index for cross-country at the secondary school level.