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Obstructing the goal? Hospitalisation for netball
injury in New Zealand 2000–2005
Pam Smartt, David Chalmers
Netball is a fast, demanding team game characterised by
sudden direction changes, rapid acceleration, pivots, and elevating
leaps.1,2 Injury is common and is reported to
be one of the main reasons for young people dropping out of the
sport.3,4 Reducing the risk of injury in
netball is therefore an important goal for the sport, for New Zealand’s
Accident Compensation Corporation (ACC) and, more generally, for public
health.5
For the sport, injury affects performance and participation,
for ACC it results in compensation claims, and for public health injury can
negate the health benefits of physical
exercise.6
Netball is the most popular team sport for women in New
Zealand (NZ) and is played widely by women of all ages. Participation continues
well into the childbearing years when active involvement by females in other
sports is generally declining.7 Netball is
popular with Māori who make up 26% of netball
participants.7 The game is also played by a
growing number of males,8 with 81% of male
participants involved in the indoor game.7
In 1989–1990 there were an estimated 100,000 netball
participants in NZ.9 According to Netball New
Zealand, there are now an estimated 200,000 participants: 120,000 registered
members and a further 80,000 playing in social competitions
nationwide.8 This estimate is likely to be
conservative as in 2003 SPARC7 estimated that
255,700 New Zealanders (club and non-club members/informal participation) aged 5
years and over played netball.
The last descriptive epidemiological study of netball
injuries in NZ was published in 1993 (data from
1988).9 There have been several significant
changes in the sport in that period. Netball became a recognised Olympic sport
in 1995 (making its inclusion in future Olympics possible), and has grown in
popularity in NZ both as a participant and a spectator sport. It is acknowledged
that netball today is a faster, more physical game and that there is a closer
contest for the ball. Attitudes toward sports injury have also changed and there
has been a national netball injury preventive programme NetballSmart in
place since 2005.10
The aim of this study was to examine the current profile of
hospitalised netball injury and identify any the changes that have occurred
since 1988. We have limited the study to injury treated in the public hospital
system because our main focus is serious acute injury.
MethodsStudy design and
definitions—This study was undertaken as part of a larger study
of hospitalised injury across 187 sporting and recreational
activities.11 A novel search procedure was
developed to identify injury cases associated with specific activities. The
procedure comprised a search of both coded and narrative information in a linked
hospital discharge and ACC entitlement claim dataset.
Sporting and recreational activity was defined as any
pastime or game requiring physical effort undertaken for “amusement,
diversion or fun” (Concise Oxford Dictionary). NZ’s National Minimum
Dataset (NMDS) changed from ICD version 9 to ICD version 10-AM in 1999, with the
first full year of implementation in 2000. There were subsequent updates in 2001
and 2004. With no single year likely to be free from the effect of coding
changes, all of the available data coded to ICD version 10-AM was used to obtain
proportions for comparison with the earlier study.
Datasets—NZ’s National
Minimum Dataset (NMDS) for 2000–2005, coded to three editions of ICD-10-AM
(ICD-10-AM-1-3), was the primary data source. The ability to identify
sport/recreational injury cases directly from these data varied according to the
edition of ICD-10-AM applying at the time (e.g. individual sports were not
recognised in ICD-10-AM-112), and the hospital
providing the data (e.g. narratives describing the circumstances of injury were
not available for some hospitals).
To improve case ascertainment and sport-specific injury
information, the NMDS data were linked to ACC sport/recreational injury
entitlement claims data (2000-2005). The probabilistic linkage program
AUTOMATCH13 was used to link the two datasets.
Data were blocked into subsets of similar records and the records in each block
matched on common variables which included National Health Index number,
surname, first name, injury day and second initial. After each pass, successful
matches were removed and the procedure repeated using a new set of match
variables on the residual.
Approval for the use of these datasets in this way was
provided by the Lower South Island Regional Ethics Committee (ref. OTA/99/02/008
& OTA/01/07/049) and the ACC Research Ethics Committee (ref.45).
Cases—Cases comprised discharges
from public hospitals in the period 2000–2005 with an e-code in the
discharge record. For the purposes of injury prevention, reporting is commonly
restricted to diagnoses in ICD-10-AM Chapter XIX “Injury poisoning and
certain other consequences of external causes” (diagnoses
S00-T98).12, 14, 15 Because a number of sport
and recreational injury diagnoses fall outside this chapter (e.g.
musculoskeletal injuries, M00-M99), this restriction was not applied. However,
injury diagnoses in the range A00-R99 (Chapters I-XVIII) are reported
separately.
Although our original intention was to include injury
arising from sports-specific paid-work, limited recording of occupation in the
NMDS dataset precluded this and so cases coded as “paid work” were
excluded. Other exclusions included
day-patients (these are inconsistently recorded in the NMDS),
readmissions for the same injury, cases of poisoning, self-harm, assault, and
complications of medical and surgical care. ICD-10-AM classification groupings
were used in the reporting of cases by body region, diagnosis and procedure. So
for example, cases with “knee and lower leg” injury comprised all
injuries with an ICD-10-AM diagnosis code in the range S80-S89. Where cases were
reported according to medical procedure type, the first recorded procedure was
used to group cases according to the invasiveness of the procedure. This
classification separates cases undergoing ligament and tendon
”repair” from those undergoing more invasive
“reconstruction” procedures.
Identification and assignment of
cases—The linked NMDS/ACC dataset, comprising 328,802 first-time
admissions for injury, was the starting point for the search.
Separate searches were undertaken which identified
cases with:
A total of 56,144 new cases of sport and
recreational injury were identified using these procedures. Cases were assigned
to sport/recreational activities according to ICD-10-AM-3 activity codes
U50-U72.14 Two netball codes are available in
this classification: “Indoor Netball” (six players and excluding
traditional netball played indoors) and “Netball, other and
unspecified”.14
For the current study, cases classified to these two
codes were extracted from the master dataset of 56,144 new sport and
recreational injury in-patient cases. Conflicts between the datasets in the
identification and assignment of cases were resolved by applying a hierarchy of
preferences with (a) as the highest priority and (d) as the lowest.
Injury rates—Population
estimates were obtained from Statistics New Zealand for the calculation of
age-specific population rates. There were no reliable estimates of current
participation in netball by age and gender. Participation was therefore
estimated by applying the proportions of netball participants reported in the
New Zealand National Surveys of Sport and Physical Activity (NZPAS),
1997–2001,16 to the average
usually-resident population for 2001. These surveys were carried out by the
National Research Bureau (NRB) for SPARC and gathered information about
participation in sport and leisure activities through household surveys of NZ
residents.
Thus the estimates used for calculating incidence rates
were for participation in netball activity, not membership of netball
clubs/associations; the former being likely to have come from the same
population as the hospitalisation data which makes no distinction between
members and non-members of clubs/associations.
Injury severity—For the purpose
of this study a serious non-fatal injury case was defined as a case with an
ICD-based Injury Severity Score (ICISS) of less than or equal to
0.941,17 i.e. cases whose injuries at admission
give them a survival probability of 94.1% or worse (probability of death in
hospital of at least 5.9%). The ICISS score for each case was computed as the
product of the survival risk ratio (using survival probabilities based on
1999–2001 mortality data) for each of their injuries individually
derived.18
Results56,144 (17%)
of all injury cases were attributable to sport or recreation; 1126 (3%) of these
cases were attributable to netball: 911 (81%) female and 215 (19%) male. The
average age at injury was 29 years (range 5–82 years); males were slightly
older (31 years, 7–59 years) than females (29 years, 5–82 years).
Europeans comprised the largest ethnic group (61%), followed by Māori
(26%). Pacific Island peoples accounted for 5% of cases.
Almost all cases (99%, N=1113) occurred in the 5–54
year age-range, with frequencies peaking in the 30–34 year age-group for
both sexes (208 cases: 163 female, 45 male); see Figure 1. There was also a
notable peak for females in the 10–14 year age-group (129 cases).
Figure 1. Incident hospitalisations due to
netball by age-group and gender (New Zealand
2000–2005)
 Assuming a participation rate of 7% and an average annual
population of 3,974,483 for the period (2000–2005), the crude participant
injury rate for regular players (i.e. adults and children who had played netball
in the last 4 weeks) was 123 per 100,000 per year.
The highest injury rate was 325 per 100,000 participants per
year for the 35–49 year age-group. The participant injury rate increased
with age. The population injury rate was 5.0 per 100,000.
Body region and nature of
injury—Across all diagnoses, the lower leg/knee (683 cases, 61%),
forearm/elbow (151 cases, 13%), wrist/hand (91 cases, 8%), and the ankle/foot
(73 cases, 6%), were the most commonly injured regions; see Table 1.
As far as could be determined from the coded data, injuries
coded as lower leg/knee (S80-S89) included 73 cases (6% of all 1126 cases) with
primary diagnoses relating to the knee.
Table 1. Incident hospitalisations due to
netball injury by body region and nature of injury (New Zealand
2000–2005)
† This group includes
injury to the distal areas of the radius and ulna; ‡ This group includes
injury to the maleolus or ‘ankle bone” and injury to the Achilles
tendon; * Including avulsion and traumatic rupture of joint cartilage, capsule,
and ligament; a Includes connective
tissue; b Includes abnormal clinical and
laboratory findings NEC.
The most common diagnoses were ACL rupture (22 cases),
various disorders of the patella (17 cases), derangement and tears of the
meniscus (12 cases), sprains and strains of collateral and other unspecified
ligaments of the knee (9 cases), and chronic instability of the knee (5 cases).
The remaining 8 cases had general or nonspecific conditions. Lower leg/knee
injuries also included 500 cases of injury to the Achilles tendon (S86.0). A
number of other strains and sprains and ruptures (22 cases) of the ankle area
were coded as ankle/foot (S90-S99).
The distribution of cases by body region was similar for
males and females except for the forearm/elbow (4% of all male vs. 15% of all
female cases) and the ankle and foot (9% of all male vs. 5% of all female
cases). For cases with a diagnosis in the range S00-T98, muscle and tendon
injuries were the most common (46%, 518/1126 cases), followed by fractures (32%,
363/1126 cases); see Table 1.
Injury to the Achilles tendon (S86.0) was the most common
individual diagnosis (500/1126 cases, 44.4%); followed by fractures of the
proximal phalanx (34/1126, 3.0%), lower end of the radius (29/1126 cases, 2.6%)
and lateral malleolus (29/1126 cases, 2.6%).
Five of the top 10 primary diagnoses were fractures of the
distal radius. For cases with primary diagnosis codes in the range A00-R99 (67
cases), 35 cases (52%) had musculoskeletal injuries (M00-M99) including chronic
instability and derangements of the ligaments of the knee, recurrent
dislocations, nonunion/malunion of fractures; a further 12 cases (18%) had post
trauma deep vein thrombosis of the lower extremities.
Age and the nature of injury—The
distribution of injuries across age-groups by body region (detailed for injury
diagnoses, S00-S99) is shown in Table 2. Injury to the forearm/elbow was the
most common injury in the 0–14 year age-group (83 of 158 cases, 53%),
while knee/lower leg injury was the most common injury in the 15–24 year
age-group (98 of 201 cases, 49%), 25–54 age-group (523 of 753 cases, 69%)
and the 55+ age-group (6 of 13 cases, 46%).
Wrist/hand injuries were relatively constant throughout the
age-groups at 8–9%. The proportion of “non-injury” primary
diagnoses varied across the age-groups, and (leaving aside 2 cases in the 55+
age- group), peaked at 9% in the 15–24 age-group.
The distribution of injury types across age-groups is shown
in Table 3. Fractures dominated in the 0–14 year age-group (123/158 cases,
78%), in particular, fracture of the forearm (82 cases). Injury to the muscle
and tendon dominated in the 25–54 year age-group (455 of 754 cases, 60%)
and these were predominantly to the Achilles tendon (439 cases). Injury in the
15-24 year age-group was more evenly distributed between fractures (59 cases,
29%), muscle/tendon injury (57 cases, 28%) and strains/sprains (34 17%).
Overall, the most common diagnoses were Achilles tendon
injury (S86.0, 470 cases) with a median age of 34 years, and forearm fracture
(S52, 147 cases) with a median age of 13 years.
Table 2. Incident hospitalisations due to
netball by age group and body region (New Zealand
2000–2005)
Table 3. Incident hospitalisations due to
netball by age-group at admission and nature of injury (New Zealand
2000–2005)
† Primary diagnoses in the range
A00-R99
Operations and procedures—168 cases
(15%, and including 31 cases of injury to the Achilles tendon) had no coded
procedures (standard procedures such as X-rays
and plaster applications are not usually coded)
The remaining cases (958) underwent 166 different
procedures.12,14,15 The type of first
recorded procedure (usually the procedure performed for treatment of the
principal diagnosis), by body region is shown in Table 4.
Table 4. First recorded procedures performed in
new inpatient cases hospitalised for netball injury (New Zealand
2000–2005)
a The ICD-10-AM
classification includes injury to the Achilles tendon in this group;
b 97% (437 cases) of repairs were to the
Achilles tendon; c 52% (160 cases) open
reduction with or without fixation, 42% (130 cases closed reduction, 5% (14
cases) fixation only, unspecified 2 (1%).; d 27
reconstructions of the knee (22 with a primary diagnosis involving the ACL), 11
reconstruction of the Achilles tendon. Note: average number of procedures in
cases with operations is 2 (1-8), (958 cases), 168 cases had no coded
procedures; application of plaster is not a coded procedure.
Surgical repair was the first recorded procedure in 452
(40%) cases, mostly (437 cases) to the Achilles tendon. A further 324 (29%)
cases had open or closed reduction and/or fixation of a fracture to the forearm
(134 cases), lower leg/ankle (90 cases), wrist/hand (72 cases) or other areas
(28 cases). “Other procedures” (77 cases) included wound drainage,
removal of loose bodies in the joint, aspiration and other open procedures.
Forty-two cases (4%) received more invasive reconstructive surgery to the knee
(27 cases), Achilles tendon (13 cases), and hand and orbit (2 cases).
Of the remaining 140 cases, 32 had a CT or MRI scan, 17 had
an arthroscopic washout and/or debridement, 11 had immobilisation or
stabilisation procedures, and 3 cases had a discectomy.
Mechanism of
injury—“Overexertion and strenuous or repetitive
movements” was the most common mechanism of injury (517 cases, 46%),
followed by a fall (314 cases, 28%); see Table 5. Narrative information
suggested that falls were often the result of a heavy or bad landing after a
jump and that “overexertion” was also associated with leaping,
jumping and landing; there are no ICD-10-AM codes that adequately capture these
“pre-fall” incidents or underlying mechanisms of injury.
Table 5. Incident hospitalisations due to
netball injury by mechanism of injury (New Zealand
2000–2005)
Injury severity and length of stay
(LOS)—Netball injury posed no “threat-to-life”
(ICISS=1) in 669 cases (59%), while in 422 cases (37%) there was a
threat-to-life of between 0.05% and 13.44% (ICISS scores 0.995-0.942); an ICISS
score could not be calculated for 35 cases; see Figure 2.
The “threat-to-life” was less than 5.9% (ICISS
score >0.941) in 416 cases. In the remaining 6 cases the injury sustained was
deemed as a “serious threat to life” (ICISS score <=0.941 i.e.
cases whose injuries at admission gave them a survival probability of 94.1% or
worse or a probability of death in hospital of at least
5.9%), using the NZIPS definition of serious
injury.17 These 6 cases all sustained
fractures, 3 to the head/neck region and 3 to the femur; 5 were the result of a
fall. The average age of players with a “serious injury” was 41
years, the gender split was even and the average length of stay (LOS) was 4.8
days. The average LOS for all 1126 cases was 2.3 days (range 1–21
days).
Figure 2. Incident hospitalisation due to
netball injury by ICISS score (New Zealand 2000–2005)
 DiscussionWhile injury incidence rates are lower in netball than in
many other sports, the popularity of the game and its ability to keep females
actively engaged in sport make it an important target for injury prevention.
The last descriptive epidemiological study of netball
injuries in NZ, for injury data in 1988, was published in
1993.9 In that study, hospitalised injury per
100,000 population per year was 4.3, the hospitalised injury per 100,000
participants per year was 143, the gender split was 89.5% female to 10.5 % male,
the commonest sites of injury reported were the ankle (52.4%) and knee (18.9%),
and the commonest ages at injury were 26, 25 and 17 years. The modal length of
stay in hospital was 2 days and the proportion of serious injuries (AIS≥3)
was 9%. Netball accounted for 3.1% of hospitalised sports injury and cost ACC
$1.7 million. These results were based on day and inpatient cases hospitalised
in 1988.
There are several notable points of difference between the
earlier study9 and the current report. The
proportion of male netball players hospitalised increased from 10% (1988) to 19%
(2000-2005). This increase is consistent with an increase in the proportion of
male participants; the SPARC physical activity survey of 1997–2001
reported that 21% of netball participants were male. A recent study of netball
hospitalisation in Australia19 reported that
12% of hospitalised injury cases were male (participation rate 13.4%).
The importance of differentiating indoor from outdoor
netball injury was acknowledged in the earlier study by Hume but injury coding
at the time did not allow this distinction to be made. ICD-10-AM-3 (introduced
July 2004) distinguishes “indoor” 6-player netball from “other
netball” (including “traditional” netball played indoors). In
2005, the first full year of discharges coded to ICD-10-AM-3 which distinguished
different types of netball, “indoor” netball accounted for 27% of
cases, with an even gender split and an average age at injury of 34 years. In
“other netball” females predominated (84%) and the average age of
injury was 26 years.
Hume reported that 17, 25, and 26 year-olds were the most
frequently hospitalised ages (5.6%), whereas in the current study 30, 31, and 32
year-olds were most frequently hospitalised ages (3.8-4.4%). One possible
explanation for the apparent difference is the inclusion of day-cases in the
earlier study—a recent Australian
study,19 however, reported the peak age for
netball hospitalisations as 25–34 years lending support to the impression
that the average age of hospitalised injury cases may be increasing.
Netball has been characterised as a game prone to knee and
ankle injury, with knee injury highlighted because of the high cost and
associated disability.5,9,20,21 Only 6% of
hospitalised injury in the current study involved the knee, compared to 19%
reported by Hume. It is not possible to determine if knee injury (and in
particular ACL rupture) has become less common or if differences between studies
are due to changes in treatment and management since 1988. There is anecdotal
evidence to suggest that same-day arthroscopic reconstruction of the knee
carried out in private hospitals under ACC cover may account for the difference.
There also appear to be large differences between the two
studies in the proportion of ankle injuries reported. The most likely
explanation is that Achilles tendon injury was classified as “ankle
injury” in the earlier study and as “Injury to the knee and lower
leg” in the current study. Because the mechanisms of injury are likely to
be very different for Achilles injury and ankle sprain/strain, reporting
specific diagnoses is arguably more important than general “body
areas” or injury “type” for targeted injury prevention.
Forearm fractures were much less frequent in the earlier
study (5 cases, 3.5%) than the present study (149 cases, 13%); with the young
median age (12 years) of cases in the current study being of concern. There was
also a notable overall injury peak (129 cases) for females in the 10-14 year
age-group in the current study that was not observed in the earlier study. There
are a number of possible reasons for the increases. It has been argued elsewhere
that children are starting competitive sport too young, increasing their risk of
injury;22 70% of children presenting to
Australian emergency departments with a netball injury sustained the injury
during formal competition.
Changes in the tempo and physicality of the game since 1988,
and the increase in indoor netball and the type of game played on indoor courts,
may also have increased the risk of injury. However, it is also possible that
the success of the national netball team, the silver ferns, in the 2000s has
increased the popularity of the sport with young females and the observed number
of injuries in this group.
Injury rates varied between the studies but not appreciably.
Census data were used in both studies to calculate population injury rates.
Participant injury rates were calculated using estimates from two physical
activity surveys—i.e. the Life in New Zealand (LINZ) study and the New
Zealand Sport and Physical Activity Survey (NZSPAS). A slightly higher
population injury rate (5.0 vs. 4.3 per 100 000) was reported in the current
study but a slightly lower participant injury rate (123 vs. 143 per 100 000).
Netball injury accounted for only 3% of all sports injury in
both studies. There were few cases in either study where injury posed a high
threat to life and the most frequent LOS was 2 days in both studies. The
proportion of “serious” injuries was 9% in the earlier study
compared to <1% in the current study, however, different severity measures
and thresholds were used in each study. A case-by-case examination of injuries
in the current study suggested that approximately 90% of players with lower leg
injuries could be “out of action” for 3-6 months. In the sports
injury setting, a severity measure based on a “threat of disability”
rather than “threat to life” is required.
There were a number of study limitations. In restricting
eligible cases to in-patients our population is not representative of all
netball-related injury cases; however, it is likely to represent cases with the
greatest consequences for the health system and the individual. Routinely
collected census and sport participation data were used to estimate injury
incidence rates in both studies. However, although the sport participation
surveys (LINZ, NZSPAS) were conducted in a similar manner and were funded by the
same organisation (Hillary Commission/SPARC) they were conducted at least 10
years apart and were subject to the limitations associated with such
surveys;23, 24 the reported rates therefore
should be interpreted with caution.
ConclusionNetball is a relatively safe
sport;2 however, the physical demands of the
game and its popularity have grown. The differences highlighted in this study,
between hospitalised netball injury in the late 1980s and the present, suggest
that (a) the average age of hospitalised netball injury cases may be increasing,
(b) forearm fractures in young netball players are a cause for concern, (c)
Achilles tendon injuries and/or the surgical repair of these injuries appears to
have increased while knee ligament injuries requiring hospital
admission/surgical repair appear to have decreased, and (d) the indoor version
of the game and male players may be important targets for injury prevention.
Competing interests: None known.
Author information: Pam Smartt, Research
Fellow; David Chalmers, Deputy Director; Injury Prevention Research Unit,
Department of Preventive and Social Medicine, Dunedin School of Medicine,
University of Otago, Dunedin
Acknowledgements: The New Zealand Accident
Compensation Corporation (ACC) funded this research. Data for the study was
supplied by the New Zealand Health Information Service, ACC, and the New Zealand
Sport and Recreation Association. Helpful comments on an earlier draft of this
paper were received from ACC, and Chris Lewis (Information Analyst, New
Zealand Health Information Service) provided very helpful comments on the final
manuscript.
Correspondence: Pam Smartt, Injury
Prevention Research Unit (IPRU), Department of Preventive and Social
Medicine, PO Box 913, Dunedin, New Zealand. Fax: +64 (0)3 4798337; email: pam.smartt@ipru.otago.ac.nz
References:
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