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Importance of Injury Surveillance in High School Athletics

By Michael Koester, M.D., and Christy Collins, Ph.D. on December 16, 2020 hst Print

For nearly eight million high school students in the United States,1 competitive athletics plays an important role in the adoption and maintenance of a physically active lifestyle. Beyond increasing strength, endurance and flexibility, and helping to maintain a healthy weight,2,3 regular physical activity can also improve psychological well-being, increase self-esteem, reduce depression and anxiety, and improve academic performance.2,4

Along with the numerous health benefits comes the potential risk of injury. Injury prevention in this population is often overlooked as many sports-related injuries are thought to be “part of the game.” In reality, these injuries are largely preventable. However, prevention efforts rely on collecting accurate data through injury surveillance. Simply put, it’s impossible to attempt to fix a problem if we don’t know the cause of the problem, or even if a problem exists!

By collecting the who, what, why, where and how of injuries, injury surveillance studies, like High School RIO, provide the data needed to make recommendations on how to help sports to be as safe as possible for student-athletes. High School RIO data are used to help minimize the risk of injury for athletes who play sports which, in turn, will increase physical activity, improve physical fitness levels, and lead to life-long healthy behaviors.

It is important to note that all levels of sports participation have unique demands, participants and myriad variables affecting injury risk. Thus, injury rates and patterns vary greatly among youth sports, high schools, colleges and pro teams. Making high school basketball rules changes based on NCAA injury rates would be unhelpful at best, and at worst, could actually increase injury risk at the high school level.

Contrary to what many people may believe, accurate and scientifically rigorous sports injury data collection is difficult. The National High School Sports-Related Injury Surveillance Study, otherwise known as High School RIOTM, is the only surveillance study of all time-loss injuries in a national sample of U.S. high school athletes. Funded by the National Federation of State High School Associations (NFHS), High School RIO collects vital injury and illness data from hundreds of high schools across the nation. These data benefit the entire high school sports community of student-athletes, parents, pediatric sports medicine clinicians, high school athletic directors, local/state high school athletic associations/ administrators, and the NFHS by describing the rates, patterns and trends of high school sports-related injuries. Of note, there are no similar injury surveillance systems utilized for club sports anywhere in the United States.

For nearly two decades, the NFHS Sports Medicine Advisory Committee (SMAC) has used High School RIO data to inform rules changes and further risk minimization issues in every sport. Not only is the NFHS able to compare general injury rates in sports over time, but the SMAC can look at specific injury patterns such as concussion by position in football, or lacerations related to metal cleats in softball.

Data collection and reporting is driven by an athletic trainer at each participating high school. To allow the best analysis of the information, a wide variety of data points are collected, including how many athletes were practicing and competing each week and specific information about injuries and injury events (practice or competition, position played, mechanism of injury, etc.). As healthcare professionals who specialize in sports injuries and illnesses, athletic trainers are in a unique position to collect the information needed to develop data-driven interventions.

Given the importance of accurate injury data collection, athletic administrators and coaches should encourage their school’s athletic trainer to participate in High School RIO. An added bonus to a school’s participation is an annual injury surveillance report generated for each participating school, allowing coaches to review injury rates and patterns with the athletic trainer and team physician.

While the NFHS SMAC has encouraged schools to participate in High School RIO for many years, we believe the next couple years represents an unprecedented opportunity to expand the fields of sports injury and risk-minimization. High school sports are facing extraordinary challenges related to the coronavirus pandemic. Athletes are returning to play after extended absences, training schedules have been altered, and seasons have been shortened or shifted.

The increasing popularity of club sports, specialization and year-round training has led to concern that many high school athletes are at increased risk for injury due to “overuse” injuries.5 The 2020-21 and 2021-22 athletic seasons will give researchers an opportunity to see what effects a prolonged time away from competitive sports has on injury rates. Of particular interest to the NFHS SMAC, is that there is the potential for about 12 states to play football in the spring of 2021 and then in the fall season a few months later. Through diligent injury surveillance, the risk of injury during and after the pandemic can be measured and then potentially reduced through subsequent injury prevention efforts.

High School RIO is managed by the Datalys Center for Sports Injury Research and Prevention, an independent nonprofit organization that furthers the efforts of researchers, public health officials, associations, policy-makers and the public by collecting and translating sport injury and treatment data.

For more information on how to participate in High School RIO, please email the High School RIO staff at highschoolrio@datalyscenter.org.


1National Federation of State High School Associations. 2018-19 High School Athletics Participation Survey. 2019. Available at: https://www.nfhs.org/sports-resource-content/high-school-participation-survey-archive.

2Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC: U.S. Department of Health and Human Services, 2008.

3Janssen I, Leblanc AG. Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. Int J Behav Nutr Phys Ac. 2010;7:40.

4Centers for Disease Control and Prevention. The association between school based physical activity, including physical education, and academic performance. Atlanta, GA: U.S. Department of Health and Human Services. 2010.

5Bell DR, Post EG, Biese K, Bay C, Valovich McLeod T. Sport Specialization and Risk of Overuse Injuries: A Systematic Review With Meta-analysis. Pediatrics. 2018 Sep;142(3):e20180657. doi: 10.1542/peds.2018-0657. Epub 2018 Aug 22.