The incidence, prevalence, nature, severity and mechanisms of injury in elite female cricketers: A prospective cohort study

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ContentslistsavailableatScienceDirect

Journal

of

Science

and

Medicine

in

Sport

jou rn al h om ep a ge :w w w . e l s e v i e r . c o m / l o c a t e / j s a m s

Original

research

The

incidence,

prevalence,

nature,

severity

and

mechanisms

of

injury

in

elite

female

cricketers:

A

prospective

cohort

study

Nirmala

Kanthi

Panagodage

Perera

a,b,c,d,e,∗

_,

_Alex

_Kountouris

f

_,

_Joanne

_L.

_Kemp

d

_,

Corey

Joseph

g

_,

_Caroline

_F.

_Finch

h

a_School_of_Health_and_Life_Sciences,_Federation_University_Australia,_Australia

b_Division_of_{Physiotherapy,}_Department_of_Medical_and_Health_Sciences,_Linköping_University,_Sweden c_Botnar_Research_Centre,_Nufﬁeld_Department_of_{Orthopaedics,}_University_of_Oxford,_United_Kingdom

d_Latrobe_Sports_and_Exercise_Medicine_Research_Centre,_College_of_Science,_Health_and_Engineering,_Latrobe_University,_Australia e_Centre_for_Sport,_Exercise_and_{Osteoarthritis}_Research_Versus_Arthritis,_United_Kingdom

f_Cricket_Australia,_Melbourne,_Australia g_Monash_Health,_Melbourne,_Australia

h_School_of_Medical_and_Health_Sciences,_Edith_Cowan_University,_Australia

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received12December2018 Receivedinrevisedform16May2019 Accepted20May2019

Availableonline25May2019 Keywords: Female Athleticinjuries Injuryrates Cricketepidemiology Bat-and-ballsports Sportsmedicine

a

b

s

t

r

a

c

t

Objectives:Incidence,prevalence,nature,severityandmechanismsofinjuryinelitefemalecricketers overtwoseasonsfromMarch2014toMarch2016,inclusive.

Design:Prospectivecohortstudy.

Methods:InjurydatacollectedviaCricketAustralia’sAthleteManagementSystemonallelitefemale playersovertwoseasonswereanalysed.Proﬁlesofthenature,anatomicallocationandmechanismof injurieswerepresentedaccordingtodominantplayerposition.Injuryincidencerateswerecalculated basedonmatchplayinghours.

Results:Therewere600medical-attentioninjuries;with77.7%playersreporting≥1injury.Therewere 79.5%acuteinjuriescomparedtogradualonsetinjuries.Oftheallmedical-attentioninjuries,20.2%ledto time-loss;34.7%werematch-time-lossinjuries.Matchinjuryincidencewas424.7injuries/10,000hfor allinjuriesand79.3injuries/10,000hfortime-lossinjuries.Ofalltheinjuries,31.8%weremuscleinjuries and16.0%jointsprains.Wristandhand(19.8%),lumbarspine(16.5%)andknee(14.9%)injurieswerethe mostcommontime-lossinjuries.Sixplayerssustainedlumberspinebonestressinjurythatresultedin themostdaysmissedduetoinjury(average110.5days/injury).

Conclusions:Thereisaneedtofocusonspeciﬁcinjuriesinfemalecricket,includingthigh,wrist/handand kneeinjuriesbecauseoftheirfrequency,andlumbarspineinjuriesbecauseoftheirseverity.

Practicalimplications

• Mostcostlytime-lossinjuryinwomen’scricketattheelitelevel

waslumbarspinebonestressinjury.Thereisaneedforenhanced

lumbarspineinjurypreventionstrategies bycorrecting

bowl-ingtechnique,overallloadmanagement(e.g.CricketAustralia’s

BowlingWorkloadGuidelines)andbackstabilityprogrammesto

reduceinjuryrisk.

• Time-lossfromhandand wristinjuries are more commonin

femaleplayersthantheirmalecounterpartsandshouldbeafocus

forpreventionstrategiessuchasskillstraining.

∗ Correspondingauthor.

E-mailaddress:Perera.nk@outlook.com(N.K.PanagodagePerera).

• Theawarenessoftheincreaseinjuryrisksinpace-bowlersand

pace-bowlingall-roundersmayassist withworkload

manage-ment, match scheduling, training programs to minimise the

injuryrisk.

• Themostcommoninjurymechanismswereinsidiousand

work-loadmanagement,increasingcapacity(physicalpreparedness),

tournamentschedulingisimportanttomitigatetheriskofthese

injuries.

1. Introduction

Injurypreventionisanimportantfocusforelitesporting

organ-isations,becausesportsinjuriesresultinmissedgametime1_and

mayimpairplayerperformance.2_Injury_surveillance_is_the_ﬁrst_step

ofprevention3 _and_Cricket _Australia_has_had _a _{well-established}

https://doi.org/10.1016/j.jsams.2019.05.013

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injury surveillance program for over 20-years for elite men’s

cricket.4–7_Other_cricket_playing_nations_such_as_England,8 _South

Africa9_and_New_Zealand10_have_also_published_injury_surveillance

reportsformen’scricket.Ofthe1.4millionAustraliancricket

par-ticipantsin the2016–2017season,more than27%(n=400,000)

werefemale,andthiswasapproximately80,000morefemale

play-ersthaninthepreviousseason.11_Further,_the_2017–2018_season

sawfemalecricketparticipationincreasedto30%ofallplayers.12

However,despite the recent growthof women’s cricket atthe

national and international level, there are no published injury

reportsspeciﬁctofemaleplayers.

To help prevent injuries in female cricket players, targeted

injurysurveillanceisrequired.Inmen’scricket,injurysurveillance

overthepastdecadehasidentiﬁedthatlumbarspinebonestress

injuriesandhamstringinjurieshaveresultedinthemost

game-time missed due to injury.6,7 _Injury_prevention _strategies _have

thereforefocussedonthesespeciﬁcinjuriesformen’scricket.For

example,theannualinjuryincidenceofhamstringstrainschanged

from3.1 inthe2006–2007season,increasingupto11.0during

the2011–2012season,andthengraduallyreducedto7.7inthe

2015–2016season.13_Changing_injury_proﬁles_reﬂect_the_changes

tothematchschedulewithagradualincreaseinthenumberof

T20gamesfrom2006–2007to2011–2012season,whilethe

num-berof50-over andFirst-classgamesstayed constant.6 _Through

surveillance,theincreasingworkloadwasidentiﬁedasa

signiﬁ-cantriskfactorforinjury6_which_then_enabled_successful_workload

managementandteampreparation.Inaddition,duetoscheduling

improvements,alldomestic50overmatcheswereplayedatthe

startoftheseasontominimiseﬂuctuationofplayersworkloads

andthisalsocontributedtoadeclineinannualhamstringstrain

incidence.13_In_addition_to_{physiological}_differences_between_male

andfemaleathletes,femalecricketplayersalsohavesigniﬁcantly

differentmatchloadsduetominimaltestmatchescomparedto

menwhichislikelytoresultindifferentriskfactorsforinjury.

How-ever,itisunknowniffemaleplayershavethesameinjuryproﬁlesas

theirmalecounterparts.Thisstudyaimstoprovideadetailed

pro-ﬁleofmedicalattentioninjuriesincludingmatch-time-lossinjuries

sustainedbyelitefemalecricketersovertwoseasonsfromMarch

2014toMarch2016,inclusive.Speciﬁcally,itaimstodescribethe

incidence,nature,anatomicallocationandmechanismsofmedical

attentioninjuriessustainedbyAustralianelitefemaleplayersto

provideafocusforinjurypreventionstrategies.

2. Methods

TheAthleteManagementSystem(AMS)(FairPlayAMS2016)14

isacricket-speciﬁcinjurysurveillancesystemwith100%coverage

inelitecricketplayers(bothmaleandfemale)inAustralia.TheAMS

injurydatawerecollectedprospectivelybythetreatingmedical

teammember(doctororphysiotherapist)whocodedthemtothe

OrchardSportsInjuryClassiﬁcationSystem(OSCICS-10).15_When

eachinjurywasloggedontheAMS,theimpactoftheinjurywas

assignedoneofthefollowinginjurycategoriesbytheteammedical

staff:

1available—notinjured,andcouldplay/trainunrestricted,

2modiﬁed—availabletoplaybutrestrictedfromsomematchor

trainingactivitiesduetotheinjury(e.g.shoulderimpingement

—canbat/bowl/ﬁeldina matchbutlimitedtothrowingover

shorterdistancethanusual),

3unavailable — not available to play a match due to injury

(e.g.shoulderdislocation—unabletobat,ﬁeldand/orbowlas

requiredinamatch).

ItisimportanttonotethatinjurydatacollectedthroughtheAMS

donotcapturethenumberofgamesmissedduetoeachinjury,as

doneintraditionalinjurysurveillanceprograms.16_However,_it_can

automaticallygeneratethenumberofdaysinayearforwhichthe

playerwasinjuredandunavailable,knownastheplayerinjury

sta-tus.Wheneachinjurytreatmentconsultationisenteredontothe

AMSbythemedicalteam(eitherataneworsubsequent

consul-tation),theplayer’sinjurystatusisupdated(available,modiﬁed

orunavailable).Typically, playerstransitionbetweeninjury

sta-tuscategoriesastheirinjuriesimproveordeteriorate.Eachinjury

could,therefore,beanalysedforthenumberofdaysthattheplayer

wasin each of the injury status categories (injuryprevalence).

Whilethisstudybeganbeforepublicationoftheupdatedversion

oftheinternationalconsensusdeﬁnitioninmid-2016,17_the_data

wereadjustedretrospectivelytoconformtotheinjurydeﬁnition

aligningwithcontemporarydatacollectionmethodsacrossCricket

Australia,althoughitcouldmakeadirectcomparisonwith

histori-calstudiesofmen’scricketdatamorechallenging.Theinternational

consensusdeﬁnitionformedicalattentioninjury17_was_used_and

includedanyinjurythat:requiredattentionfrommedicalstaffand

wouldpotentiallyaffectcrickettrainingorplaying(includeboth

time-lossandnon-time-lossinjuries).Withinthemedical

atten-tioninjuries,match-time-lossinjuriesweredeﬁnedasaninjury

that resulted(orwould result)ina player beingunabletobat,

bowlorwicketkeepduringamatchifamatchwasscheduled.17

Theremainingmedicalattentioninjurieswereconsideredas

non-match-time-lossinjuries

InjurydataforfemaleplayerscompetinginAustraliannational

andinternationalleveltournamentsovertwoconsecutivecricket

seasons(23March2014to22March2016)wereextractedfrom

theAMSbyCricketAustraliatoanExcel®(MicrosoftOfﬁceExcel

2013)spreadsheetandthenconvertedintoSPSS®22.0(IBMSPSS

Statistics2015).Injurydatathatdidnotconformtotheabove

def-initionand/orwerenotrelatedtoinjuriesduringtrainingforand

playingcricket(e.g.injuredplayingfootball)wereexcluded.

Toenablecomparisonswithpreviouscricketinjurysurveillance

studiesformaleplayers,datawerefurtherdividedintotwo

12-monthcricketseasons.

Injuryseveritywasdeﬁnedasthenumberofdays(fromwhen

theinjurywassustained)thattheplayerremainedinthe

‘unavail-able’category(i.e.injuriesincurringtime-loss)inaccordancewith

thenewinternationalcricketinjurydeﬁnition.17_Time-loss_injuries

(bothtraining andmatch)weregradedusinganinjury severity

scale18_:

1minor(1–7days),

2moderate(8–28days),

3serious(29days–6months)and

4longterm(>6months).

Playerswereclassiﬁedaseitheranall-rounder, batter,

pace-bowler,spin-bowlerorwicketkeeperbasedontheirdominantskill,

identiﬁedontheAMSbyCricketAustraliaadministrators.Itshould

benotedthatplayerskillscouldoverlap(e.g.allplayersﬁeldand

bat,butnotallplayerswouldbowl,orwicketkeep).All-rounders

weredeﬁnedbyCricketAustraliaadministratorsasplayerswho

weresimilarlyproﬁcientinmorethanonerole(e.g.bowlingand

batting,orbattingandwicket keeping).Toenablecomparisons,

injurieswerecategorisedbytheplayerroleandtheactivityatthe

timeoftheinjuryandmodeofinjuryonsetbasedonthe

interna-tionalconsensusdeﬁnition.17

Descriptivestatisticswereusedtodescribetheplayer

demo-graphicdata,injurytype,bodyregion,natureandmechanismof

theinjuriesreported.Theinjuryincidenceproportion(injuryIP)

forSeason1,Season2andthetotal2-yearperiodwascalculated

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Injuryincidenceproportion= numberofinjuries

numberofplayers

Nationalandinternationalmatchesplayedbyelitefemale

play-ersoverthe2-yearsurveillanceperiodwereusedtoestimatethe

exposureintermsofhoursandovers(deliveries)playedtocalculate

thematchincidence.17 _Three_different_cricket_formats_currently

existandwereusedtocalculateexposure.Twenty-twenty(T20)is

theshortestversionplayedoverthreehours,with20overs(120

deliveries)bowledby eachteamwithamaximum limitoffour

overs(24deliveries)perbowler.One-day(OD)cricketisplayed

oversevenhours,with50overs(300deliveries)bowledbyeach

team,withamaximumlimitoftenovers(60deliveries)perbowler.

Testcricket,themulti-dayformatofthegame,isplayedoverfour

daysinwomen’scricket(ﬁvedaysinmen’scricket),withno

lim-itationsonbowlerworkloads.Therefore,eachformofthegame

hasdifferencesintermsofexposureandthephysicaldemandson

players.Matchesplayedineachseasonacrossthedifferentgame

formatsinadomesticandinternationaltournament(AppendixA

inSupplementarymaterial)wereusedtocalculatematchinjury

incidenceusingthefollowingformulainaccordancewiththe

inter-nationalconsensusforcricketinjurydeﬁnition:20

Matchinjuryincidence= numberofinjuries

numberofplayerhoursx10,000hours

Thenumberofplayerhours(exposure)foranODmatchwas

consideredtobe43.3playerhoursperteampermatchand14.7

playerhoursperteamperT20match.17

AllstatisticalanalyseswereperformedusingSPSS® 22.0(IBM

SPSSStatistics2015).

Ethics approval was granted by the Federation University

AustraliaHumanResearchEthicsCommittee(Projectnumber

C16-002).Toprotectplayerprivacy,alldatacellscorrespondtocountsof

≥5.21_In_cases_where_the_injury_categories_could_not_be_broadened

inameaningfulwaytoensure≥5cases,thevaluewasreplacedby

anasterisk(*)inthepresentationofresults.

3. Results

Themeanageofthe121includedplayerswas24.2±4.5years.

Season1included89 players;96playerswereincludedin

Sea-son2,and64playerswereinvolvedinbothseasons.Ofthe121

players,113playerssustained600medical-attentioninjuries,and

94outofthe113(77.7%)playerssustained>1injuryduringthe

2-yearstudyperiod.Amongthemedical-attentioninjuries,therewas

ahigherincidenceofnewinjuries(73.2%)comparedtorecurrent

injuries(26.8%),and acuteinjuries(79.5%) comparedtogradual

onsetinjuries (20.5%).Of theallmedical-attention injuries,121

(20.2%)weretime-lossinjuries,and42oftheseinjuriesto

match-time-loss. Total match injury incidence was 424.7 injuries per

10,000playerhours(Table1).

Whentheinjuriesweregroupedintoplayerroleandactivityat

thetimeoftheinjury,17_the_majority_of_the_wrist_and_hand_injuries

(13.7%)andshoulderinjuries(9.1%)weresustainedduring

ﬁeld-ing.Similarly,muscleinjuries(9.4%)andjointsprains(7.4%)were

sustainedduringﬁelding.Further,catching(10.7%)andthrowing

(10.7%)werethemostcommoninjurymechanismswhen

play-ersare ﬁelding where sudden-onset non-contact injury (24.9%)

andimpact/traumaticinjury(17.1)werethemostcommonmode

ofinjury onset duringﬁelding. Oftheinjuries sustainedduring

batting,4.8%werethighinjuries,and9.7%wereinjuriesto

mus-cle.Therewere6.3%muscleinjuriesduringbowlingwithbowling

deliverybeingthecommon injury mechanism(16.5%). Further,

16.5%oftheinjuriessustainedduringbowlingweresudden-onset

non-contactinjuryonset(Table2).Whentheplayersweregrouped Table

1 Match injury incidence per 10,000 player hours in Australian elite female cricketers in the 2014–2015 and 2015–2016 seasons. Twenty-twenty (T20) match One-day (OD) match Multi-day match Total No of matches Total exposure Numberof injuries Match injury incidence for

10,000 player hours Number of matches Total exposure Number of injuries

Match injury incidence for

10,000 player hours Season 1 59 865.4 41 473.8 32 1386.7 37 266.8 1 78 2 256.4 92 2330.1 80 343.3 Season 2 75 1100.0 77 700.0 35 1516.7 62 408.8 3 351 6 170.9 113 2967.7 145 488.6 Time-loss 134 1965.4 24 122.1 67 2903.3 14 48.2 4 429 4 93.2 205 5297.7 42 79.3 Non-time-loss 134 1965.4 94 478.3 67 2903.3 85 292.8 4 429 4 93.2 205 5297.7 183 345.4 Total a 134 1965.4 118 600.4 67 2903.3 99 341.0 4 429 8 186.5 205 5297.7 225 424.7 Number of player hours per team per match 11,15 : T20 = 14.7 h, OD = 43.3 h, multiday = 39 h per day. a Medical-attention injuries.

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Table2

Anatomicallocation,nature,mechanismandmodeofonsetofallinjuriescategorisedbyplayerroleandactivityatthetimeofinjury.

Playerroleandactivityatthetimeofinjury(%) Total(%) Batting Bowling Fielding Wicketkeeping

Anatomicallocationoftheinjury(n=351)

Wristandhand 2.8 1.7 13.7 2.0 20.2

Shoulder 2.0 * 9.1 * 12.5 Thigh 4.8 * 4.0 1.4 11.4 Knee 2.3 2.3 3.7 * 9.1 Lumbarspine 2.8 3.1 2.0 – 8.0 Ankle 1.7 2.0 2.8 * 6.8 Lowerleg 2.6 1.4 2.6 – 6.6 Foot 1.4 2.3 – * 4.0 Head * – 1.4 * 3.1

Trunkandabdominal * 2.3 * – 3.1

Pelvis/buttock 1.4 – 1.4 – 2.8

Thoracicspine * * * – 2.6

Elbow * – 1.4 – 2.6

Hipandgroin * * * * 2.6

Neck * * * * 2.3

Forearm * – * – *

Upperarm * * – – *

Unspeciﬁed * – – * *

Chest – – * – *

Natureoftheinjury(n=351)

Muscleinjury 9.7 6.3 9.4 1.4 26.8

Jointsprains 5.4 3.4 7.4 1.4 17.7

Bruising/haematoma 3.1 2.0 7.1 * 13.4

Synovitis,impingement,bursitis 2.8 2.8 5.4 * 11.4

Tendoninjury 1.4 1.4 3.7 * 6.8 Fracture * – 3.4 – 4.6 Otherwiseunspeciﬁed * * 2.0 * 4.5 Jointdislocations – * 2.3 * 2.8 Laceration/abrasion * * 2.0 * 2.8 Nerveinjury * * 1.4 * 2.8 Cartilageinjury * * * * 2.3 Stressfracture * * – * 1.4 Chronicinstability * – * – *

Otherstress/overuseinjury * * * – *

Arthritis * – – – * Injurymechanism(n=346) Bowlingdelivery – 16.5 – – 16.5 Insidious 8.1 2.9 1.7 2.0 14.7 Diving 4.0 – 9.2 * 13.6 Running 6.6 * 5.8 * 13.3 Catching – – 10.7 2.3 13.0 Throwing * – 10.7 – 11.0 Ballcollision 5.8 – 3.8 * 10.1 Fall/slip/lunge/changedirection 2.0 – 4.0 * 6.9 Playercollision * * * * * Modeofonset(n=346)

Sudden-onsetnon-contactinjury 6.4 15.9 24.9 2.6 49.7

Impact/traumaticinjury 12.1 – 17.1 2.0 31.2

Insidious(gradualonsetandnoidentiﬁablemodeofonset) 5.8 3.5 * 1.7 12.1

Gradualonsetassociatedwithbowling/running/throwing/batting practice/weighttraining

3.2 * 2.9 * 6.9

*Injurycountis<5.

TerminologyusedforanatomicallocationsandnatureofinjuriesarebasedontheOSICS-10.15

Analyseswereperformedoncompletedata,discrepanciesbetweentotalsamplesize(n=600injuries)andvariablecountareduetomissingdata.

intotheirdominantskill,all-roundersandpace-bowlerssustained

38.5% and 28.9% of all medical-attention injuries respectively.

More speciﬁcally, pace-bowlers and pace-bowling all-rounders

sustainedmoreinjuriesthanotherplayersinthesquadaccounting

for47.8%ofallinjuries(AppendixAinSupplementarymaterial).

Ofallmedical-attentioninjuries,thigh(n=84,14.0%),wristand

hand(n=77,12.8%)andknee(n=68,11.3%)werethemost

fre-quentlyinjuredregions.Therewere191(31.8%)muscleinjuries

and35.7%(n=30)ofallthighinjuriesweretothehamstring.

Therewere121(20.2%)time-lossinjuries(94newand27

recur-rent)withatotalof3638days(average60days,SD±47.38per

injury)unavailableoverthe2-yearsofthestudy.Theincidence

oftime-lossinjuries duringmatcheswas79.3injuries/10,000 h

(Table1). Injuriestothe wristand hand(19.8%), lumbar spine

(16.5%)andknee(14.9%)werethemostcommontime-lossinjuries.

Sixplayers(includingﬁvepace-bowlers)sustainedlumbarspine

bonestressinjuriesthatresultedinthemostdaysmissedofany

injury(average110.5daysperinjury)(Table3).

4. Discussion

This prospective cohort study investigate the incidence,

natureandmechanismsofinjuriessustainedbyAustralianelite

female cricketers. Match injury incidence (time-loss) of 79.3

injuries/10,000hwashigherinelitefemalecricketerscompared

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Table3

Theanatomicallocationandnatureofmostcommonmedical-attention,time-lossinjuriesandmatch-time-lossinjuriesanddaysunavailabletoplay.

Allinjuries n=600(%) Time-lossinjuries n=121(%) Match-time-loss injuriesn=61(%)

Totaldaysunavailabletoplay** (averagedaysperinjury)s

Lumbarspine(L) 10.5 16.5 16.4 898(44.9)

Lumberspinebonestressinjury(LS) 4.9 * 663(110.5)

Kneeinjuries(K) 11.3 14.9 11.5 759(42.2)

Synovitis,impingement,bursitis(KG) 4.9 * 93(15.5)

Cartilageinjury(KC) 4.1 * 262(52.4)

Wristandhand(W) 12.8 19.8 21.3 531(22.1)

Wristandhandfractures(WF) 9.9 * 416(34.7)

Thighinjury(T) 14.0 15.7 11.5 368(19.4)

Hamstringinjury(TM) 14.0 11.5 307(18.1)

Shoulderinjuries(S) 11.0 5.8 8.2 (51.7)

Ankle(A) 5.8 6.6 8.2 154(19.3)

*Injurycountis<5. **Generaltime-lossdays.

TerminologyusedforanatomicallocationsandnatureofinjuriesarebasedontheOSICS-10.15

10-years.6_The_difference_could_be_explained_by_the_injury

deﬁni-tionsused,withpreviousstudiesinmen’scricketusingatime-loss

deﬁnitionthatstrictlyincludedonlyinjuriesresultinginmatches

missed due toinjury,17 _consequently_{under-reporting} _the_total

numberofinjuriesthuslowerinjuryrates.Incomparison,the

cur-rentstudycountedthenumberofdaysthattheplayerwouldhave

beenunavailabletoplay, irrespectiveofwhethermatcheswere

scheduled,andthus,capturingthedurationthatplayerswere

inca-pacitatedduetoinjuryratherthansimplymatchesmissed(e.g.

off-seasoninjuries).

Mostinjuries (73.2%) inthisstudywerenewinjuries, which

is similar to ﬁndings reported in men’s cricket (80–92% new

injuries).7 _{Additionally,} _77.7% _of _players _sustained _multiple

injuries;26.8%of allmedical-attentioninjuries and22.3% ofall

time-lossinjurieswererecurrent,whichisanimportantﬁnding

becausethepreviousinjury is a risk factor for re-injury.22 _The

majority(57.1%)ofallinjuries(medicalattentionandtime-loss)

occurredinpace-bowlersorpace-bowlingall-rounders,asis

simi-lartoinjurydatainmalecricketers.7_The_unnatural_and_repetitive

actionofpace-bowlingarelikely topredisposepace-bowlersto

greaterinjuryriskincomparisontootherplayerroles.

Addition-ally,inelitemen’scrickethighsustainedbowlingworkloadsand

workloadspikeshavebeenidentiﬁedasriskfactorsforcricket

pace-bowlers.5_It_is_likely_that_elite_female_pace-bowlers_may_be_exposed

tothesame risksastheirmalecounterparts.However, females

arenotlikelytoexperiencethesameworkloadspikesand

pos-siblytheveryhighsustainedbowlingloadsasmenbecausethey

wouldnothavethesamematchscheduling.Further,comparedto

themaleplayers,femalecricketersplayveryfewtestmatches.It

is,therefore,difﬁculttoconcludethatthesameworkloadfactors

driveinjuryriskin femalepace-bowlersbut doeshighlightthat

pace-bowlinginvolvesrepetitivehighimpactforcesthat

predis-poseallplayerstoinjury.23_Another_possible_explanation_could_be

thatwithmoretraining/preparationperiodsthanmatches,female

playersmaynotreach‘match’intensityattraining,andpossibly

sustaininjuriesastheytransitionfromthetrainingenvironmentto

competitivematches.Futureresearchshouldfocusontheimpact

thatincreasingmatchschedulingandincreasingworkloadscould

haveoninjuriesinwomen’scricket.

Therelativelylargenumberandrankingofthighinjuriesmay

bemechanisticallyexplainedbyburstsofrunning,catching,diving

andbowling.Forexample,sprinting,24_where_sudden_high-speed

accelerationordeceleration(suchasrunningbetweenwicketsor

chasingaballduringﬁelding)maycauseahamstringinjury.The

bowlingdeliverystride,beingoneofthemostcommon

mecha-nisms,highlightstheriskassociatedwiththebowlingaction25_and

mightalsoexplainthekneeinjuriesreportedinpace-bowlersand

pace-bowlingall-rounders.

Thewristandhandregionwasassociatedwiththemost

com-montime-lossinjuryaveraging22daysunavailabletoplaycricket.

Thisappearstobeoverrepresentedinwomencomparedtomen.6,7

Lacrosseisanothersportwherefemaleplayershavehighratesof

wristandhandfractures,26_with_both_sports_involving_the_risk_of

ahardballstrikingthehandandﬁngers.Incricket,playersareat

riskofﬁngerandhandinjuriesbecauseﬁeldersmustcatchorstop

afast-movinghardballwithoutgloves(exceptthewicketkeeper).

Fingerinjuriesalsooccurbybeingstruckbytheballwhilebatting,

irrespectiveofprotectivegloves.Althoughthesizeandweightof

ballsusedinwomen’scricketissmallerthanballsusedinmen’s

cricket,27_and_the_peak_delivery_speeds_up_to₁₂₀_km/h,28_there_is

signiﬁcantpotentialfortheballstocauseinjury.Despitethesmaller

ballsandslowerbowlingspeeds,comparedtomen,theseinjuries

still occur.It is possiblethat duetotheinfancy ofprofessional

women’scricket,someplayersmayhavecatchingandﬁelding

tech-niquesthatpredisposethemtohandandﬁngerinjuries.

Lumbarspineinjuries werethesecond mostcommon

time-lossinjury.Importantly,thereweresixlumbarspinebonestress

injuries (including stressfractures)recorded, predominantly on

pace-bowlersresultinginthemostgamedaysmissedperinjury

(average 110.5days unavailable per injury). Thisstudy

demon-strates that elite femalecricketers develop lumbar bone stress

injuries,similartotheirmalecounterparts.7_In_elite_men’s_cricket,

thisinjuryhasattractedmuchresearch,becausetheinjuriesrequire

longrecoveryperiods.23_Workload,4,5_and_technique_factors_such

asexcessiveshoulder counter-rotationandtrunklateralﬂexion

associatedwithside-on,front-onormixedbowlingactions25_;_and

theassociated repetitivelumbarloading23_have_been_associated

withincreasedriskoflumbarbonestressinjuriesinmaleplayers.

Thesefactorswerenotconsideredinthecurrentstudybutcould

alsobeanimportantfactorforfemaleplayers.Althoughfemale

cricketerscurrentlydo notexperiencesameacuteworkloadsas

malesduetodifferencesinmatchscheduling,itispossiblethat

theincreasedprofessionalismof femaleplayersin recent years

mayhaveresultedinrelativelyhighertrainingandmatch

bowl-ingloads.Theseincreasedworkloadsmightpredisposeplayersto

lumbarbonestressinjuries.Futureresearchshouldfocusonfemale

player’sbowlingtechniqueandworkloadtoprovideinformation

relatingtoinjuryriskfactors,aetiologyandmechanismsofinjuries.

Epidemiological data collected through injury surveillance

provideastrongbasisforthedevelopmentofappropriately

tar-geted and evidence-based injury prevention programs, as well

asprovidingabaselineagainstwhichtoevaluatethesuccessof

suchprograms.3_In_particular,_the_number_of_lumbar_spine_bone

stressinjuriesreportedsuggeststhatsimilartomen,increasing

workloadsmayincreasetheriskofinjuryinfemalecricketers,

(6)

bowlingguidelines.Further,bowlingkinematicsandkineticsneed

tobeinvestigatedinfemaleplayers.Forexample,femaleshavea

greaterlumbarlordosiscurvatureextendsacrossthreevertebrae

comparedtolordosiscurvesacrosstwovertebrae’sinmalesand

femaleshaveacaudallylocatedlordoticpeak,andgreatercranial

peakheight.29_Therefore,_given_the_differences_in_structure,_it_is

uncertainwhetherthesameriskfactorsthatpredisposemale

play-erstoinjuryalsoaffectfemaleplayers,butintheabsenceofany

otherevidence,theseshouldbeconsidered.

Bonestressinjuriesarethoughttorepresenttheinabilityofthe

skeletontowithstandrepetitiveboutsofmechanicalloading

caus-ingstructuralfatigue.Previousstudiesindicatethatfemaleathletes

aremorevulnerabletobonestressinjuriesthantheirmale

coun-terparts,andapproximately30%offemalecollegiateathleteswere

atmoderate(25.5%) orhigh(3.8%) riskforbonestressinjury.30

TheRelativeEnergyDeﬁciencyinSport(RED-S),31_may_explain_the

largerthanexpectedlumbarbonestressinjuriesandwhysomeof

theseinjuriesoccurredinbatters.TheRED-Sconsidersthe

relation-shipbetweenenergyavailability,menstrualfunctionandchanges

tothebonemineraldensityinresponsetotrainingloads,the

inten-sityoftraining,stresslevelsandnutritionstatus.31_However,_this

needsconﬁrminginfuturestudies.

Severallimitationsinthisstudyshouldbeaddressed.Wedidnot

recordgamesmissed,andtherefore,themeasureofinjury

preva-lencecannotbeaccuratelycomparedtopreviousstudiesinmen’s

cricketthatusedgamesmissedtodeﬁnetime-loss.Matchinjury

incidencewascalculatedbasedonmatchﬁxturestoenable

com-parisonwithpreviousmen’scricketinjuryepidemiologyresearch.

The exposurehours wereestimated based onaverages for the

numberofmatchesplayed,ratherthancollectingindividualmatch

exposure.However,exposureintermsofhoursofplaywas

cal-culatedinaccordancewiththeinternationallyrecognisedcricket

injurydeﬁnition.17,20_Injury_types_were_not_deﬁned_using_uniform

diagnosticcriteria and thereforethe coding of the injury

diag-nosismightnotbeconsistentbetweenthemedicalprofessionals

inputtingthedataintoAMSmedicalnotes,limitingtheaccuracyof

thedata.Thedatawascollectedfrom2014to2016.Asthewomen’s

gamecontinuedtogrow,workloadsoffemalecricketersincreased

from2017to2018andincreasingworkloadslikelytohave

inﬂu-ence the current injury proﬁles. However, as women’s cricket

develops,appropriatephysicalpreparedness,workload

manage-mentandeffectivemonitoringmaymitigatetheinjuryrisks.

5. Conclusion

Thisprospectivecohortstudyinvestigatedinjuriessustainedby

Australianelitefemale cricketplayers.Thereis a needtofocus

onspeciﬁcinjuriesinfemalecricket,includingthigh,wrist/hand

andkneeinjuries becauseoftheirfrequency,and lumbarspine

injuriesbecauseoftheirseverity.Importantly,thisstudy

demon-stratedthatelitefemalecricketersdeveloplumbarspondylolysis,

liketheirmalecounterparts.Theﬁndingsofthisstudymayprovide

abasisforinjurypreventionprogramsinelitewomen’scricket.

Financialsupport

NKPP was supported by a Federation University Australia

Postgraduate Scholarship and Centre for Sport, Exercise and

OsteoarthritisResearchVersusArthritis-SportsGrant(HFR02510).

Contributorship

AllauthorscontributedtoallitemsintheICMJEcontributorship

guidelines.

Acknowledgements

TheauthorswishtoacknowledgeCricketAustraliafortheir

sup-port.

AppendixA. Supplementarydata

Supplementarymaterialrelatedtothisarticlecanbefound,in

theonlineversion,atdoi:https://doi.org/10.1016/j.jsams.2019.05.

013.

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