Descriptive Epidemiology of Game-Related Youth Flag Football Injuries

METHODS

We conducted a prospective epidemiologic study at 1 regional and 2 national-level youth flag football tournaments between December 2021 and February 2022. The tournaments involved both male and female athletes of ages 6 to 12 years. All injury and exposure data were observed and collected by 1 certified athletic trainer (AT; K.D.B.F.) with experience in injury epidemiology. Injury documentation was entered on site into an electronic medical record. The AT was present for all games during the tournaments and evaluated all injuries on the field or the sideline. The AT was located in a central medical tent visible and with access to all fields. Injuries were captured when athletes were seen directly by the AT, when the AT was called onto the field of play, and when athletes reported to the medical tent. Because the teams traveled to the tournament location, injury follow-up was not possible, so all injuries were acute in nature. This study was approved by the Institutional Review Board of Emory University. Operational definitions are presented in Table 1.

Table 1 Operational Definitions

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RESULTS

A total of 1939 athletes (1744 boys and 195 girls) of ages 6 to 12 years participated in this study. A total of 47 injuries to unique individuals in 1939 athletes with 9228 AEs were recorded (Table 2). The overall injury risk was 2.4% (95% CI = 1.8%, 3.2%) with an injury rate of 5.1 per 1000 AEs (95% CI = 3.7, 6.8). Of the 47 injuries, 36 occurred in boys (8365 AEs) and 11 in girls (863 AEs). Girls displayed a significantly higher risk for both the injury risk ratio (2.73; 95% CI = 1.41, 5.30) and injury rate ratio (2.96; 95% CI = 1.51, 5.82) based on the Fisher exact test. No other differences were noted between boys and girls.

Table 2. Summary of Injury and Exposure Data

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Head/face/neck injuries accounted for the largest proportion (n = 15, 31.9%) of all reported injuries (girls = 6, 54.5%; boys = 9, 25.0%), followed by the ankle/foot (19.1%), thigh (10.6%), and wrist/hand (10.6%). The most common types of injury overall were contusion (55.3%), sprain/subluxation (14.9%), and general trauma (10.6%; Table 3).

Table 3. Injury Characteristics

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Almost three-quarters (74.5%) of all injuries were from direct impact to the player (boys = 77.8%, girls = 63.6%), followed by torsion in boys (13.9%) and stretch in girls (18.2%). No overuse injuries were reported. More injuries occurred during defensive team activities (46.8%) than during offensive activities (40.4%), with “going for the flag” cited as the most frequent defensive player activity for both boys (38.9%) and girls (27.3%). The most often injured position defensively was defender (40.4%) and offensively was wide receiver (25.5%). Offensively, most injuries to girls occurred while going for a pass (45.5%), which was the same for boys (16.7%), followed by running the ball (13.9%) and going for the ball (5.6%).

DISCUSSION

This is the largest study to date to prospectively describe the incidence of youth flag football injuries by observing 1939 athletes across 3 tournaments. Despite the increasing participation rates, a paucity of research exists on flag football injuries, particularly at the youth level. The minimal information available is sourced from aggregated data on emergency department visits or the National Electronic Injury Surveillance System database, which may not accurately portray on-field injury epidemiology.^19,20 The authors¹⁷ of only 1 study to date have directly compared youth tackle and flag football. A strength of our study was that all injury data were collected by a certified AT; ATs have been shown to be highly reliable sources of injury reporting.²¹

The overall game-related injury rate in this study was 5.1 per 1000 AEs. This injury rate appears to fall within the range of the game-only injury rates in youth tackle football, from 4.3 to a high of 36.2 per 1000 AEs (Figure 1), as well as close to the overall rate of injury of 5.77 per 1000 AEs reported in youth flag football.^17,22–27 It was interesting to note that the tackle football study with the lowest injury incidence rate of 4.3 was the single investigation in which injury information was obtained from coaches. A similar potential for underreporting was present in the youth flag football study by Peterson et al,¹⁷ in which injury reporters included coaches, parents, and ATs. By contrast, other studies,^17,23–25 including ours, all relied on certified ATs. Thus, injuries may be underreported by coaches and not a true reflection of actual injury incidence. If the Radelet et al data²² are removed from the comparison due to different data-collection methods (depending on coaches instead of certified ATs), then our injury rate (5.1) was less than the lowest tackle injury rate (8.8), providing objective epidemiologic evidence that flag football is a safer alternative. Although no individual type of injury or body part injured was statistically different between males and females, there was a statistically significant difference (P < .001) for both overall injury risk and injury rate between boys (2.1%, 4.3) and girls (5.6%, 12.8), respectively, with girls being 3 times more likely to be injured. This finding is similar to that of Collins et al,²⁸ who noted that females had a higher match injury rate than males in adolescent rugby. These data contribute to the body of literature also showing that females have a higher injury risk in same-sex sports such as lacrosse,^29,30 soccer,^31,32 and baseball or softball.^31,33 Future research is warranted to determine why females are at increased risk of injury not only in these previously reported sports but also in flag football.

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Injuries to the head/face/neck accounted for almost one-third (31.9%) of all reported injuries. Most of these injuries were contusions (10), nose epistaxis (2), or laceration (1). Only 1 concussion injury (female) was described. Consistent findings of the head/face/neck being the most often injured have been shown in youth tackle football^23,24 and in patients with football injuries who presented to emergency rooms.³³ Head/face/neck injuries were followed by ankle/foot (19.1%), thigh (10.6%), and wrist/hand (10.6%) injuries. Contusion was the predominant type of injury, accounting for more than half of all injury types, followed by sprains and general trauma, similar to the results of Kerr et al^23,34 among youth tackle athletes. Boys and girls did not differ in the body parts injured or types of injury.

An interesting finding from this study was that all hip- and trunk-related contusion injuries involved impact of a hard plastic flag attachment fixture against the body surface when a player fell to the ground (Figure 2). This result highlights a possible design flaw in the equipment as a direct contributor to athlete injury. Either using compressible or deformable material that collapses when impact occurs between the player and the ground or moving the attachment of the flags so that they are not located near the bony portions of the hip may decrease the incidence of hip and trunk contusion injuries. Similar equipment-related correlations with injuries were observed when flag football players wore shorts that contained pockets; hand and finger injuries increased.^35,36 The simple uniform change of eliminating pockets reduced the number of finger and thumb injuries.³⁶ As a direct result of this finding, players are not allowed to wear shorts with pockets during play.³⁷

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In a sport considered to have less contact, it was interesting to note that 75% of all injuries were due to direct contact with either another player or the ground, evenly split between offense and defense. Direct impact was the primary mechanism of injury in both boys (77.8%) and girls (63.6%), followed by torsion in boys (13.9%) and stretch in girls (18.2%). In youth tackle football, 80% of injuries in youth tackle football were due to contact,²³ and in nontackle football, most injuries still occurred from contact with another player.²⁰ Among collegiate-aged flag football athletes, 50% of all injuries were attributed to contact with another player, 18% to contact with the ground, and 8% to contact with another object; therefore, 76% of all injuries were contact in nature.³⁸ This factor may be one of the most critical areas to address for injury prevention. If three-quarters of all injuries are related to contact, considering some form of protective equipment, especially for youths, may be beneficial. Although all injuries in our research would be classified as minor, implementing even minimal protective equipment or padding may significantly reduce the most common injury, contusions.

Most injuries occurred through the player activity of going for the flag, highlighting the need for education of both coaches and players on technique. Many youths launch themselves toward the offensive player in an attempt to pull the flag, often resulting in injury. Tackle football organizations have implemented various forms of coach and player education modules to teach better tackling technique and reduce the injury risk.^39,40 Coach education on proper tackling technique has been shown to reduce injuries in high school⁴¹ and youth⁴² tackle football. The development of similar flag football technique education may have a similar effect in reducing the injury risk in flag football and perhaps also in those players advancing to tackle football.

Our work was not without limitations. First, only information on game-related injuries was collected. Most sports report higher game injury rates than practice injury rates; therefore, not monitoring season-long practice exposures may have played a role in the lack of reported overuse injuries. In addition, most sports generally produce more injuries during practices in terms of frequency, even though injury rates during practices are generally lower (given increased exposures). Hence, it is possible that some athletes sustained an injury in a practice and did not participate in the tournaments. Although we focused on game-related injuries, because injuries most likely occurred in practices, and some of these practice-injured athletes may not have participated in the tournaments, the overall frequency of injuries in this age group may be underreported. Future research would benefit from longitudinal data collection of players across entire seasons. A second limitation was the lack of complete anthropometric and demographic data on participants aside from sex and age. Age, height, and body mass index have not been shown to influence the injury incidence in youth tackle football,^24,34,43 yet determining if this also holds true for youth flag football would be helpful. Given that girls represented only about 10% of the total study population, this lack of balance between sexes was also a possible limitation. The smaller sample size for girls means that the CIs were wider than those for boys, creating more uncertainty. Thus, the estimates for boys were more likely to be closer to the true rates than those for girls. In this case, as the sample size did not reflect dropouts etc, the female participants most likely represented the population of females playing flag football and not a biased group. However, the smaller sample size in 1 group increases the risk of not observing differences and committing a type II error. We did observe a higher injury risk in girls than in boys. Finally, injuries may have been underreported. Although the AT was present and available to all fields and athletes and coaches were instructed by the tournament directors to report all injuries to the AT, some injuries may not have been recorded.

Although the injury incidence rate for youth flag football was lower than that for youth tackle football, the body parts affected, types of injury, and mechanisms were similar between youth flag and youth tackle football. Despite being considered a noncontact sport, 76% of all injuries were the result of contact mechanisms. Additional rule changes and equipment modifications should be evaluated to minimize the injury risk in flag football at the youth level.