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·       United States Consumer Product Safety Commission Study of June 4, 1997
·       Oklahoma Report of Traumatic Brain Injuries in Baseball 1992-1994
·       The Physician and Sports Medicine Journal Article – Sept. 1999
·       University of Minnesota – Public Health Article – Injury Prevention – 2004
CPSC Releases Study of Protective Equipment for Baseball
June 4, 1996
Release # 96-140




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For Immediate Release;
Contact: Kathleen Begala
(301) 504-0580 Ext. 1193

"We want kids outside in the sunshine, not inside in an emergency room," said CPSC Chairman Ann Brown.
WASHINGTON, D.C. The U.S. Consumer Product Safety Commission (CPSC) announced today that safety equipment for baseball could significantly reduce the amount and severity of 58,000 (or almost 36 percent of) baseball-related injuries to children each year.
Baseball, softball, and teeball are among the most popular sports in the United States, with an estimated 6 million children ages 5 to 14 participating in organized leagues and 13 million children participating in non-league play. In 1995, hospital emergency rooms treated 162,100 children for baseball-related injuries.
At a press conference at Camden Yards stadium, home of the Baltimore Orioles, CPSC released the findings from its one-year study on the ability of protective equipment, including softer-than-standard baseballs, safety release bases, and batting helmets with face guards, to reduce injuries to children playing baseball.
"CPSC is the federal agency responsible for overseeing the safety of 15,000 different types of consumer products, including sports equipment and products claiming to reduce injuries and increase safety," said CPSC Chairman Ann Brown. "Parents need to know what options they have in protective equipment so they can make the best decisions for their children playing baseball."
Nick Senter, executive director of the Dixie Baseball League, an organization based in 11 Southern states, and Richard Bancells, trainer of the Baltimore Oriole's baseball team, joined Chairman Brown for today's announcement.
Senter said, "Since we began using batting helmets with face guards in the Dixie League, we've seen a drop in both injury rates and insurance rates."
CPSC collected and analyzed data on baseball, softball, and teeball-related deaths and injuries to children to determine specifically how these children were injured and what safety equipment could prevent such injuries. CPSC also studied voluntary safety standards and reviewed published scientific literature evaluating currently available protective equipment.
CPSC analyzed the 88 reports it received of baseball-related deaths of children between 1973 and 1995. It found that 68 of the deaths were caused by ball impact and 13 were caused by bat impact. Of the 68 ball impact deaths, 38 resulted from blows to the chest while 21 deaths were caused by a ball hitting a player's head.
Of the 162,100 hospital emergency-room-treated injuries in 1995, most of the injuries (almost 75 percent) occurred to older children ages 10 to 14. This age group represents about half of the total number of children playing baseball.
Of the total number of injuries to children, CPSC considers about 33 percent severe, including fractures, concussions, internal injuries, and dental injuries. The remaining 67 percent less severe injuries include contusions, abrasions, lacerations, strains, and sprains. More than 50 percent of the children under age 11 who were injured while playing baseball sustained injuries to the head and neck area, while a larger percentage of older children sustained injuries to their arms and legs.
Based on its analyses, CPSC found that three pieces of safety equipment will help reduce injuries. Softer-than-standard baseballs and softballs, which have a softer, spongier core than standard baseballs and softballs, can reduce ball impact injuries. Face guards that attach to batting helmets and protect the face can reduce injuries to batters.
Safety bases that release from their anchor can reduce sliding injuries. Safety release bases that are based on age, gender, and skill levels of the players provide the best protection.
Conclusions from the CPSC Study:
  • Baseball protective equipment currently on the market may prevent, reduce, or lessen the severity of more than 58,000 injuries or almost 36 percent an estimated 162,100 hospital emergency-room-treated, baseball-related injuries occurring to children each year.
  • Softer-than-standard balls may prevent, reduce, or lessen the severity of the 47,900 ball impact injuries to the head and neck.
  • Batting helmets with face guards may prevent, reduce, or lessen the severity of about 3,900 facial injuries occurring to batters in organized play.
  • Safety release bases that leave no holes in the ground or parts of the base sticking up from the ground when the base is released may prevent, reduce, or lessen the severity of the 6,600 base-contact sliding injuries occurring in organized play.

Study Overview on Baseball Deaths, Injuries, and Protective Equipment
The U.S. Consumer Product Safety Commission (CPSC) is releasing the results of a one-year study on the ability of safety equipment to reduce baseball injuries and deaths. The study found that injuries to children playing baseball could be reduced by the use of softer-than-standard baseballs, face guards on batting helmets, and safety release bases. CPSC's baseball project found that protective equipment could significantly reduce the number and severity of 58,000 or almost 36 percent of baseball-related injuries to children each year.
Baseball, softball, and teeball are among the most popular youth team sports in the United States. CPSC estimates that 6 million children ages 5 to 14 participate each year in organized leagues, while another 13 million children participate in non-league play.
Baseball leads team sports in deaths to children with three to four deaths each year. The sport ranks third in annual injuries to children following basketball and football. In 1995, hospital emergency rooms treated an estimated 162,100 children for baseball-related injuries.


CPSC is the federal agency responsible for overseeing the safety of 15,000 different types of consumer products, including sports equipment and products claiming to reduce injuries and increase safety.
CPSC collected and analyzed data on baseball, softball, and teeball-related deaths and injuries to children ages 5-14 to determine specifically how these children were injured and what safety equipment could prevent such injuries. CPSC also studied voluntary safety standards and reviewed published scientific literature evaluating currently available protective equipment, including softer-than-standard baseballs and softballs, face guards for batting helmets, and modified safety bases. This study analyzed injuries to children playing baseball in organized league play and informal recreational backyard, school, and neighborhood play.

Analysis of Death and Injury Data
CPSC collected information on deaths from death certificates, the agency's Medical Examiners and Coroners Alert Project, consumer complaints, and news clips.
From 1973 to 1995, CPSC received reports of 88 baseball-related deaths to children.
  • 68 deaths or 77 percent from ball impact
  • 13 deaths or 15 percent from bat impact
  • 7 deaths or 8 percent cause unknown
The 68 ball impact deaths break down as follows:
  • 38 deaths or 56 percent to the chest
  • 21 deaths or 31 percent to the head
  • 9 deaths or 13 percent to other areas
To obtain information on how baseball-related injuries to children occur, CPSC used injury data from April 1995 to August 1995 from hospital emergency rooms collected by the agency's National Electronic Injury Surveillance System also know as NEISS. CPSC completed a telephone survey of 348 NEISS cases of injured children answering questions (with parental permission) or with parents answering questions about their children's injuries and use of protective equipment.
Hospital emergency rooms treated about 162,100 children ages 5 to 14 for baseball-related injuries in 1995. Most of the injuries, almost 75 percent, occurred to the older children ages 10 to 14, representing about half of the total number of children in this age group.
Of the total number of injuries to children, CPSC considers about 33 percent as severe, including fractures, concussions, internal injuries, and dental injuries. The remaining 67 percent of the less severe injuries include contusions, abrasions, lacerations, strains, and sprains. More than 50 percent of the children under age 11 who were injured while playing baseball sustained injuries to the head and neck area, while a larger percentage of older children sustained injuries to their shoulders, arms, and legs.
  • 162,100 hospital emergency-room-treated, baseball-related injuries to children ages 5-14
  • Almost 75 percent of injuries occur to children ages 10-14
  • 33 percent of injuries were severe
Based on the telephone survey of 348 hospital emergency-room cases, CPSC identified the causes of the 162,100 baseball-related injuries to determine whether protective equipment could prevent injuries.
Injury Cause
Approximate Number
Hit by ball
Hit by bat

Analysis of Baseball Protective Equipment
Softer-than-Standard Baseballs and Softballs
Ball impact injuries to the head and chest are the most severe and frequent of all baseball injuries. Ball impact to the chest accounted for 38 deaths, while ball impact to the head accounted for 21 deaths. Of the 88,700 ball impact injuries, which account for 55 percent of all hospital emergency-room-treated baseball injuries, 54 percent (or 47,900 ball impact injuries) were to the head and neck. 35,200 ball-impact injuries to the face occurred during organized play.
Official major and youth league standard baseballs have a core of cork or rubber, which is wound with natural or synthetic fibers, such as wool or cotton, and covered with two pieces of leather sewn together with 108 stitches. Softer baseballs have a much larger core made of soft, spongy natural or synthetic substances, such as soft polyurethane, rubber, or kapok, with no winding, and a cover. Softer-than-standard softballs have a spongier core than standard softballs.
Softer-than-standard baseballs and softballs may reduce the risk and severity of 47,900 hospital emergency-room-treated injuries to children being hit by the ball, particularly to the head and neck. CPSC found that 97 percent of ball impact injuries where the child identified the type of ball involved a standard ball. The percent of hospital emergency-room-treated injuries involving softer balls were lower than their share of the market, and injuries from softer balls were less severe than those from standard balls. Softer-than-standard baseballs and softballs are available nationwide at prices that are competitive with standard baseballs and softballs.
CPSC studied all available scientific literature on the softer-than-standard baseball, including published articles suggesting that softer balls may increase the risk of death from ball impact to the chest. CPSC commissioned expert reviews of these articles, which found that the biological and biomechanical models used to mimic chest impact deaths in children were not accurate representations of the way death occurs to children on the baseball field. The agency has found no convincing evidence that softer balls increase the risk of chest impact death. In contrast, an expert review determined that softer-than-standard baseballs can reduce head injuries.
Face Guards for Batting Helmets
In 1995, children received an estimated 3,900 hospital emergency-room-treated injuries to the face while at bat. Face guards attach to batting helmets to protect the face, including the eyes, nose, mouth, jaw, and cheeks.
The face guards currently on the market must be installed or attached to a batting helmet. They are made from clear polycarbonate plastic or plastic coated wire and retail for about $10. CPSC found that none of the injured players it studied received facial injuries while wearing batting helmets with face guards.
CPSC has determined that the current ASTM voluntary standard for face guards is effective in preventing facial injuries. According to the standard, the face guard must prevent the ball from touching the face. Although youth leagues generally require children to use batting helmets, only one league requires batting helmets with face guards.
Safety Release Bases
In 1995, sliding injuries accounted for about 13,000 hospital emergency-room-treated injuries or 8 percent of the total number of injuries to children playing baseball. Of these sliding injuries, about 8,200 or 63 percent were caused when children slid into the base with 80 percent or 6,600 of these base-contact sliding injuries occurring during organized play. Girls appear to be at a higher risk of injury from base-contact sliding injuries than boys.
CPSC studied several styles of modified safety bases to determine which would reduce the risk of injury from sliding into the base. For reducing the risk of sliding injuries, CPSC recommends one style of a safety base with the following characteristics: releases from its anchoring system upon impact; leaves no holes in the ground or parts of the base sticking up from the ground when the base is released. Since girls appear to be at higher risk, models based on age, gender, and skill levels of the players may provide the greatest level of protection.
The list price for a set of safety release bases ranges from $300 to $595 compared with $150 for a standard three-base set, although these safety bases tend to outlast regular bases. In addition, currently available safety release bases with the recommended characteristics require permanent installation in the ground.

  • Baseball protective equipment currently on the market may prevent, reduce, or lessen the severity of more than 58,000 injuries or almost 36 percent of an estimated 162,100 hospital emergency-room-treated, baseball-related injuries occurring to children each year.
  • Softer-than-standard balls may prevent, reduce, or lessen the severity of the 47,900 ball impact injuries to the head and neck.
  • Batting helmets with face guards may prevent, reduce, or lessen the severity of about 3,900 facial injuries occurring to batters in organized play.
  • Safety release bases that leave no holes in the ground or parts of the base sticking up from the ground when the base is released may prevent, reduce, or lessen the severity of the 6,600 base-contact sliding injuries occurring in organized play.

1. Viano, D.C., McCleary, J.D., Andrzejak, D.V., and D.H. Janda, "Analysis and Comparison of Head Impacts Using Baseballs of Various Hardness and a Hybrid III Dummy", Clinical Journal of Sport Medicine 3: 217-228, 1993.
2. Janda, D.H., Wojtys, E.M., Hankin, F.M., and M.E. Benedict, "Softball Sliding Injuries: A Prospective Study Comparing Standard and Modified Bases", Journal of the American Medical Association 259: 1848-1850, 1988.
3. Sendre, R.A., Keating, T.M., Hornak, J.E., and P.A. Newitt, "Use of the Hollywood Impact Base and Standard Stationary Base to Reduce Sliding and Base-Running Injuries in Baseball and Softball", American Journal of Sports Medicine 22: 450-453, 1994.
4. Viano D.C., Andrzejak, D.V., and A.I. King, "Fatal Chest Injury by Baseball Impact in Children: A Brief Review", Clinical Journal of Sport Medicine 2: 161-165, 1992.
5. Viano, D.C., Andrzejak, D.V., Polley, T.Z., and A.I. King, "Mechanism of Fatal Chest Injury by Baseball Impact: Development of an Experimental Model", Clinical Journal of Sport Medicine 2: 166-171, 1992.
6. Janda, D.H., Viano, D.C., Andrzejak, D.V., and R.N. Hensinger, "An Analysis of Preventive Methods for Baseball-Induced Chest Impact Injuries", Clinical Journal of Sport Medicine 2: 172-179, 1992.
7. Estes, N.A.M., "Sudden Death in Young Athletes (editorial)", New England Journal of Medicine 333: 380-381, 1995.
8. Maron, B.J., Poliac, L.C., Kaplan, J.A., and F.O. Mueller, "Blunt Impact to the Chest Leading to Sudden Death from Cardiac Arrest During Sports Activities", New England Journal of Medicine 333: 337-341, 1995.

Lyle J. Micheli, M.D., Director, Sports Medicine, The Children's Hospital, 300 Longwood Ave., Boston, MA 02115; (617) 355-6534
Barry J. Maron, M.D., Director, Cardiovascular Research Division, Minneapolis Heart Institute Foundation, 920 East 28th St., Suite 40, Minneapolis, MN 55407-3984; (612) 863-3996/3984
Flaura Winston, M.D., Ph.D., The Children's Hospital of Philadelphia, 34th Street & Civic Center Blvd., Room 2426, Philadelphia, PA 19104; (215) 590-5208
Christine Branche-Dorsey, Ph.D., Epidemiologist, National Center for Injury Prevention and Control, Centers for Disease Control, 4770 Buford Highway, NE, Chamblee, GA 30341;
(770) 488-4652


Centers for Disease Control and Prevention



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Each year, more than 125,000 baseball and softball players under age 15 are injured badly enough to seek treatment in hospital emergency departments. Hundreds of thousands of adults receive minor injuries in these sports. Many of the injuries can be prevented if players wear safety gear and if additional safety measures are added to the game.Bike crashes can result in serious injury. In 1997, more than half a million persons were injured badly enough to need emergency department care as a result of bike crashes in the United States. Wearing a bike helmet reduces the risk of brain injury from a bike crash by as much as 88%.

Tips for Preventing Baseball and Softball Injuries
To help your child avoid injuries while playing baseball or softball, follow these safety tips from the American Academy of Pediatrics, the Centers for Disease Control and Prevention (CDC), the Consumer Product Safety Commission, and other sports and health organizations. (Note: These tips apply to adult ball players, too.)
  • Before your child starts a training program or plays competitive baseball or softball, take him or her to the doctor for a physical exam. The doctor can help assess any special injury risks your child may have.
  • Make sure your child wears all the required safety gear every time he or she plays and practices. Insist that your child wear a helmet when batting, waiting to bat, or running the bases. Helmets should have eye protectors, either safety goggles or face guards. Shoes with molded cleats are recommended (most youth leagues prohibit the use of steel spikes). If your child is a catcher, he or she will need additional safety gear: catcher's mitt, face mask, throat guard, long-model chest protector, and shin guards.
  • If your child is a pitcher, make sure pitching time is limited. Little League mandates time limits and requires rest periods for young pitchers.
  • Insist that your child warm up and stretch before playing.
  • Teach your child not to play through pain. If your child gets injured, see your doctor. Follow all the doctor's orders for recovery, and get the doctor's OK before your child returns to play.
  • Make sure first aid is available at all games and practices.
  • Talk to and watch your child=s coach. Coaches should enforce all the rules of the game, encourage safe play, and understand the special injury risks that young players face. Make sure your child's coach teaches players how to avoid injury when sliding (prohibits headfirst sliding in young players), pitching, or dodging a ball pitched directly at them.
  • Above all, keep baseball and softball fun. Putting too much focus on winning can make your child push too hard and risk injury.
Encourage your league to use breakaway bases. These bases, which detach when someone slides into them, can prevent many ankle and knee injuries in both children and adults. Leagues with players 10 years old and under should alter the rules of the game to include the use of adult pitchers or batting tees. Remember, you don't have to be on a baseball diamond to get hurt. Make sure your child wears safety gear and follows safety rules during informal baseball and softball games, too.

Who Is Affected?
In the United States, more than 33 million people participate in organized baseball and softball leagues. Nearly 6 million of these players are 5 to 14 years old. Even though these sports are not considered contact sports, they are associated with a large number of injuries. Hospital emergency departments treat more than 95,000 baseball-related injuries and 30,000 softball-related injuries among players under age 15 each year. The number of injuries among adults is also high, with as many as 8 percent of players sustaining injuries each year.
The majority of injuries in baseball and softball are minor, consisting mostly of abrasions (scrapes), sprains, strains, and fractures. Many of these injuries are to the ankle and knee. Eye injuries are also common in baseball. In fact, baseball is the leading cause of sports-related eye injuries in children. Catastrophic injuries in baseball and softball are rare. They occur most often when players are struck in the head or chest with a ball or a bat. On average, 3 children under age 15 die each year from baseball-related injuries.
Baseball can lead to injuries caused by overusing a certain body part. Pitchers commonly suffer overuse injuries in their elbows or shoulders. As many as 45 percent of pitchers under age 12 have chronic elbow pain, and among high school pitchers, the percentage rises to 58 percent. To prevent these injuries, Little League Baseball, Inc., has set a limit of six innings of pitching per week and requires pitchers to rest between appearances. Teaching proper pitching mechanics can also prevent serious overuse injuries.
Helmets and safety equipment for catchers have brought about reductions in injuries. Little League Rule 1.7 says, A Catcher's helmet must meet NOCSAE specifications and standards.@ Other safety gear has been added more recently, including eye protectors and face masks on helmets. Chest protectors and softer balls are also being studied for their protective effect.
Making changes to the playing field and the rules of the game can also prevent injuries. Sliding into the base causes more than 70 percent of recreational softball injuries and nearly one-third of baseball injuries. Using bases that break away upon impact can prevent 1.7 million injuries per year. Adding screens or fencing to the dugout and eliminating the on-deck circle protects players from wild pitches, foul balls, and flying bats.

Safety Resources
  • American Academy of Orthopaedic Surgeons
Through the public information link on the AAOS home page (www.aaos.org), you can access fact sheets on injury prevention for many popular sports, including baseball. AAOS's phone number is 1-800-346-2267.
  • American Academy of Pediatrics
Review AAP's policy statement, A Risk of Injuries from Baseball and Softball in Children 5 to 14 Years of Age @ (www.aap.org/policy/00161.html). AAP's phone number is 847-228-5097.
  • American Red Cross
If you coach a youth sports team, get advice from the American Red Cross on conditioning young athletes (http://www.crossnet.org/news/inthnews/98/05-09-98.html). ARC's phone number is 703-248-4222.
  • Brain Injury Association
BIA's fact sheet about sports and concussion safety (www.biausa.org/sportsfs.htm) provides data on brain injuries for several sports, including baseball. Call BIA at 1-800-444-6443.
  • U.S. Consumer Product Safety Commission
The Summer 1996 issue of CPSC's Consumer Product Safety Review (http://www.cpsc.gov/cpscpub/pubs/cpsr_nws1.pdf) featured an article on reducing baseball injuries with protective equipment. CPSC's phone number is 1-800-638-2772.
  • Little League Baseball, Inc.
Link to the Little League home page (www.littleleague.org) to access facts on health and safety.
  • National SAFE KIDS Campaign
Visit the SAFE KIDS home page (www.safekids.org) to access fact sheets on sports and recreation injuries, or call 202-662-0600.

The data and safety tips in this fact sheet were obtained from the following sources:
  • American Academy of Orthopaedic Surgeons. Baseball. Available at http://www.aaos.org/wordhtml/pat_educ/baseball.htm. Accessed July 8, 1999.
  • American Academy of Orthopaedic Surgeons Seminar (Sullivan J, Grana W, editors). The Pediatric Athlete. Park Ridge, IL: The Academy, 1990:141,149-151,259.
  • American Academy of Pediatrics. Risk of injury from baseball and softball in children 5 to 14 years of age. Pediatrics 1994;93(4):690-692.
  • American Academy of Pediatrics. Sports Medicine: Health care for young athletes. Elk Grove Village, IL: The Academy, 1991:148-150.
  • American Red Cross. Red Cross gears up to help prevent sports injuries this spring: coaches advised on proper conditioning of young athletes. News release, May 7, 1998. Available at http://www.crossnet.org/news/inthnews/98/05-09-98.html. Accessed July 6, 1999.
  • Caine D, Caine C, Lindner K, editors. Epidemiology of Sports Injuries. Champaign, IL: Human Kinetics, 1996:63-85.
CDC. Sliding-associated injuries in college and professional baseball B1990-1991. Morbidity and Mortality Weekly Report 1993;42(12):223,229-230.
  • Institute for Preventative Sports Medicine. Softball injuries: Phase I of a study on the costs, causes and prevention of recreational softball injuries. Available at http://users.aol.com/wwwipsm/pubs/softball_I.html. Accessed July 7, 1999.
  • U.S. Consumer Product Safety Commission. Baseball safety. CPSC publication #329. Washington, DC: The Commission.
U.S. Consumer Product Safety Commission. Reducing youth baseball injuries with protective equipment. Consumer Product Safety Review 1996;1(1):1-4.

Developed by the Centers for Disease Control and Prevention. Visit them at http://www.cdc.gov
This page last updated by the CDC on September 16, 1999



Getting to the Heart of the Softer-Baseball Debate
Softer baseballs are used in an effort to reduce the severity of impact injuries to the brain, face, and heart, but debate on their efficacy, along with hesitance within baseball, has hindered their widespread adoption.
Recent reports on baseball impact injuries bring the issues into sharper clinical focus, including new information about the etiology of commotio cordis and conflicting reports about whether softer baseballs reduce the risk of that event. Another study addresses the risk of eye injuries with softer baseballs (see "Researchers Weigh In on Eye Issues, below).
Lance Van Auken, director of publications and media relations for Little League Baseball, says several models of softer baseballs are approved for play in various Little League divisions. Each local league's board of directors determines which balls the league will use. "We do know that a majority of the very youngest divisions [5- to 8-year-olds] use some type of softer baseballs. However, in the divisions that include players ages 9 to 18, the softer baseballs are rarely used," he says.
New Information on Commotio Cordis
Commotio cordis, sudden death from relatively minor chest wall impact in the absence of structural cardiac injury or abnormality, is rare in sports. Each year two to four commotio cordis deaths are reported in baseball (1). Maron et al (2) recently published information on 70 cases contained in the US Commotio Cordis Registry. The victims were most likely to be boys younger than 16, and the most common sports involved were baseball, softball, and hockey.
In 1998, Link et al (3) narrowed the proposed mechanism of commotio cordis by showing that impacts that occurred 30 to 15 msec before the peak of the T wave produced ventricular fibrillation in young pigs.
In a separate report, Link et al (4) described the high frequency of heart block and ST-segment elevation after resuscitation, which may explain why resuscitation is often difficult in patients with commotio cordis.
Do Softer Baseballs Reduce the Risk of Commotio Cordis?
In 1992, Janda and colleagues (5,6), using a computerized model, anesthetized pigs, and crash test dummies, suggested that softer baseballs did not decrease and perhaps increased the risk of commotio cordis. In their most recent study (7), Janda's group assessed 9 soft-core baseballs as they struck a three-rib biomechanical surrogate at three speeds (40, 50, and 60 mph). A standard Major League baseball served as a control. Janda says the study determined the "viscous criterion" (VC) for each baseball. VC was developed by the automotive industry during crash testing to measure how far and how fast the chest caves in during impact, says Janda, an orthopedic surgeon in Ann Arbor, Michigan, and director of the Institute for Preventative Sports Medicine (ISPM). Baseballs with higher VC values could carry a greater injury risk.
The study found that one of the softer baseballs had a significantly lower VC value than the standard baseball at all three speeds, six had a lower VC at 60 mph, four had a lower VC at 50 mph, and one had a lower VC at 40 mph. One of the softer baseballs had a higher VC at 60 mph. The researchers say the study shows that not all softer baseballs significantly reduce the risk of chest impact injuries. "We also determined that the weight of the ball was critically important," Janda says. The two lightest baseballs were among the group that had a significantly lower VC. (The standard baseball was the fourth lightest baseball.)
In a 1996 review of protective equipment in youth baseball (8), the US Consumer Product Safety Commission (CPSC) analyzed the impact of softer baseballs. The type of baseball involved was recorded in 94% of 88,700 baseball impact injuries recorded in 1995. The CPSC reported that the softer baseballs were involved in fewer and less severe injuries than were the standard baseballs. In its discussion of the apparently contradictory studies (5,6) from Janda's group, the CPSC notes that it commissioned an independent review of the articles by six scientific and medical experts. The reviewers questioned the ability of the biological and biomechanical models to mimic chest impact injuries in children. The CPSC concluded that softer baseballs can reduce the number and severity of youth baseball injuries.
Meanwhile, Link et al (3) also evaluated the effect of softer baseballs as a component of their pig study. They tested three softer balls and a standard Little League baseball on 48 pigs, timing impacts to occur with the up slope of the T wave. Each ball weighed the same and was propelled at 30 mph.
Researchers noted a relationship between baseball hardness and the likelihood of ventricular fibrillation. The lowest risk was for the softest baseball; although a reduced risk of death was seen with medium-soft and least-soft baseballs, the difference did not reach statistical significance. The authors concluded that though the softest baseball may not be practical for competitive play by older youths because of ball performance, it may be useful for T-ball or recreational play.
Link and Janda are critical of each other's studies. Link says that Janda's most recent study (7) deemphasizes the finding that the balls used in T-ball were safer. He also notes that the 1998 Janda study (7) evaluates both weight and softness, which obscures the qualities that make a ball safer. "The data with safety baseballs in both our and Janda's experiments show there is little doubt that safety baseballs will reduce the risk of both cardiac and other injuries in youth baseball," says Link, who is assistant professor of medicine and director of the Cardiovascular Center for the Evaluation of Athletes at New England Medical Center in Boston.
Janda says the 30-mph speed used by the Link group is slower than actual Little League play, particularly when kids are using aluminum or titanium bats. Link counters that his group's latest study (9) yielded the same results using a 40-mph velocity. Janda also notes that his group looked at nine baseball models, whereas Link's group evaluated three.
Link says he is concerned that the public's perception of Janda's studies could lead to underutilization of the softer baseballs, which he believes could increase the risk of sudden death and other injuries.
J.J. Crisco, PhD, research director of the National Operating Committee on Standards for Athletic Equipment (NOCSAE), says part of the problem with interpreting the data about softer baseballs and developing standards for protective equipment is that the dynamics of chest impact injuries are more complicated than for head injuries or muscle contusions. "We know why softer baseballs decrease those injuries: accelerators and stress. But we don't yet have a mechanical variable to decrease for commotio cordis," he says.
There is no widely accepted standard for baseball hardness, though Crisco notes that the American Society for Testing and Materials is working on proposed standards. He adds that the baseballs used in Little League—made from cheaper materials—have been found to be harder than those used in Major League Baseball. NOCSAE has published a voluntary standard for baseballs that are designed to reduce head injuries. Crisco says the group is presently updating the standard to address a greater spectrum of injuries, including commotio cordis.
What's the Prevention Message?
Though Janda and Link disagree on the safety of softer baseballs, they do agree that the devices are not magic bullets for preventing commotio cordis and that good coaching can help young players avoid baseball impact injuries.
"We believe kids should be taught how to get out of the way," Janda says. "I've heard eyewitness reports of kids panicking and walking right into the ball, but if you watch Cal Ripken, he tucks his head and rolls his shoulder so that his scapula takes the blow." He says that kids also need to learn how to avoid chest impact injuries by sliding into base with their back toward the catcher. Janda says some recreational leagues seek to avoid baseball impact injuries among younger players by having the coach of the batting team do the pitching; a few use mechanical pitching machines.
The research jury is still out on how well chest protectors prevent chest impact injuries. Eleven (16%) of the players in the US Commotio Cordis Registry were wearing commercially available protective gear when the incidents occurred. Janda says the ISPM is conducting a study on chest protectors.
Van Auken says that Little League Baseball is in the third year of a 3-year study to determine the protective value of equipment (ie, softer baseballs, batting vests, face masks, breakaway bases) used by various divisions.
1.    Kyle SB: Youth Baseball Protective Equipment Project: Final Report. Washington, DC, US Consumer Product Safety Commission, 1996
2.    Maron BJ, Link MS, Wang PJ, et al: Clinical profile of commotio cordis: an under appreciated cause of sudden death in the young during sports and other activities. J Cardiovasc Electrophysiol 1999;10(1):114-120
3.    Link MS, Wang PJ, Pandian NG, et al: An experimental model of sudden death due to low-energy chest-wall impact (commotio cordis). N Engl J Med 1998;338(25):1805-1811
4.    Link MS, Wang PJ, Pandian NG, et al: Resuscitation in a biological model of commotio cordis, sudden death from low energy chest wall impact, abstracted. J Am Coll Cardiol 1998;31(2):403A
5.    Janda DH, Viano DC, Andrzejak DV, et al: An analysis of preventive methods for baseball-induced chest impact injuries, abstract. Clin J Sport Med 1992;2(3):172-179
6.    Viano DC, Andrzejak DV: Mechanism of fatal chest injury by baseball impact: development of an experimental model. Clin J Sport Med 1992;2(3):166-171
7.    Janda DH, Bir CA, Viano DC, et al: Blunt chest impacts: assessing the relative risk of fatal cardiac injury from various baseballs. J Trauma 1998;44(2):298-303
8.    Kyle SB, Adler P, Monticone RC Jr: Reducing youth baseball injuries with protective equipment. Consumer Prod Safety Rev 1996;1(1):1-4
9.    Link MS, Wang PJ, VanderBrink BA, et al: Reduced risk of death with safety balls in an experimental model of commotio cordis: sudden death from low energy chest wall impact, abstracted. J Am Coll Cardiol 1999;33(2):534A

Researchers Weigh In on Eye Issues
Baseball is the leading cause of sports-related eye injuries in children aged 5 to 14 (1,2). One of the concerns among physicians and coaches has been that a softer baseball could increase the risk of eye injury because the softer material might protrude farther into the eye orbit.
To investigate those suspicions, a recent investigation by Vinger et al (1) had two objectives: (1) to measure the intrusion of baseballs of 6 different hardnesses launched at several speeds into an artificial eye orbit, and (2) to determine if baseball players could tell the difference between harder and softer balls when catching, throwing, and batting.
Researchers found that the softest of the six baseballs intruded significantly into the orbit, and recommended that this ball be used only among players younger than age 6 who have little grip strength. They found that orbital intrusions of the next two softest balls were not clinically meaningful and, because they had a lesser peak force and onset rate than Major League baseballs, should not cause an increase in eye injuries.
When the researchers evaluated whether softer baseballs changed the feel of the game for participants, they found that children younger than age 14 could detect a difference only when using the softest baseball and that adults could not differentiate between the hardest "soft" baseball and standard baseballs.
While advocating the use of softer baseballs in youth baseball to prevent brain injury and commotio cordis, the researchers note the best way to decrease eye injuries in baseball is to use protective eyewear that conforms to American Society of Testing and Materials (ASTM) standards for batters, base runners, and fielders.
1.    Vinger PF, Duma SM, Crandall J: Baseball hardness as a risk factor for eye injuries. Arch Ophthalmol 1999;117(3):354-358
2.    Kyle SB: Youth Baseball Protective Equipment Project: Final Report. Washington, DC, US Consumer Product Safety Commission, 1996

Lisa Schnirring
University of Minnesota – Publich Health Article – Injury Prevention - 2004

Sports participation is on the rise for children and adolescents in the United States. Each year, more than 20 million American youth participate in school or community sports (Damore). This results in approximately one million serious sports-related injuries occurring annually, requiring hospitalization, surgery, missed school, or at least a half-day in bed (School Health Guidelines to Prevent Unintentional Injuries and Violence). The social, as well as economic consequences related to sports injury incidents are quite substantial, and are estimated to cost thousands of millions of dollars in the U.S. each year (Kelm).
In a recent study, sports-related injuries accounted for 41 percent of musculoskeletal injury treated in emergency rooms in 5 to 21 year olds (Damore). As shown in Table 1, basketball accounts for the most sports-related injuries, followed by football, and then baseball and softball
Table 1.
Table 2 shows that the most sports-related injuries occur in early adolescence, with 13-year old children experiencing the highest number of sports-related injuries. These children and adolescents are anatomically, physiologically, and psychologically immature, which may make their bodies more susceptible to damage (Franklin).

Table 2 Sports-related injury distribution by age.
Source: Journal of Pediatric Orthopaedics, March/April 2001

Types of Injuries

There are many different types of sports-related injuries, from mild events to severe and life-threatening incidents. Although brain and spinal injuries are the most serious sports-related injuries, they account for relatively small percentages of the total injuries reported. According to a study by Michigan State University, in boys’ baseball and girls’ softball, forearm, wrist, and hand injuries were the most common type of injuries, with head, neck, and spine injuries accounting for 2-3% of all injuries. Ankle and foot injuries were the most frequent type of injuries in basketball, soccer, and volleyball. Football players had the highest prevalence of head, neck, and spine injuries at 13.3% of the total injury problem (Powell 282).

In order to decrease the frequency and incidence of these and all types of sports-related injuries, we must first understand the nature of these events.
  • Overstretching and stress to a ligament is called a sprain.
  • Ligament damage is most common in sports, such as basketball, football, and soccer, where there is a high frequency of twisting and cutting movements.
  • Sprains and tearing of ligaments are some of the more common injuries in adolescent and adult athletes
  • Sprains occur less frequently in younger athletes because their epiphyseal plates tend to be the “weak link” in an injury event.
  • Joint dislocations are the most severe form of ligament damage, and can lead to long-term disability in the child athlete (Hutchinson).
  • A strain is damage to the muscle, as a result of forceful contraction.
  • Common strains resulting from sports injuries occur in the hamstrings, quadriceps, and calf muscles.
  • Children and adolescents who have recently gone through a growth spurt are at higher risk of suffering from a tprain (Hutchinson).
  • Fractures are usually a result of acute mechanical overload.
  • The incidence of fractures is significantly higher in collision activities.
  • The growth plate in the developing tissues of long bones is affected in 15% of all pediatric fractures with 15% of these injuries leading to growth arrest requiring surgery (Oeppen).
  • Stress fractures, caused by excessive exercise without proper rest time, occur most commonly in the tibia, fibula, and tarsal bones.
Overuse Injuries
  • All types of overuse injuries are becoming more prevalent in young athletes.
  • Competitive year-round participation and specialization in one sport can lead to these chronic injuries to young bodies.
  • Damage to the muscles, tendons, and ligaments commonly occur in the shoulder and elbow in sports involving throwing, whereas running and jumping sports may cause injuries to the leg, knee, ankle, or foot.
  • Baseball, basketball, running, gymnastics, and swimming are the most common sports cited for contributing to overuse injuries (Sports Injuries a Growing Problem in Kids).
Brain Injuries
  • Annually, approximately 300,000 mild to traumatic brain injuries are classified as sports-related (School Health Guidelines to Prevent Unintentional Injury and Violence).
  • Twenty percent of all high school football players sustain brain injuries (Head Injury Fact Sheet).
  • When an individual has a brain injury, depending on the severity, it may result in a concussion or a coma.
  • A concussion results from shaking the brain within the skull, and usually results in a short loss in consciousness (Head Injury Fact Sheet).
  • Concussions are graded according to severity, which is a helpful tool in providing safe guidelines to return to activity.
    • Grade I
      • Usually no loss of consciousness
      • Return to play after one week if asymptomatic
    • Grade II
      • Unconscious for < 5 minutes
      • Return to play after one week if asymptomatic
    • Grade III
      • Unconscious for > 5 minutes
      • Memory loss for more than 24 hours
      • Return to play after one month or longer
  • Repeated Concussions
    • “Second Impact Syndrome” increases likelihood of permanent brain damage
  • Comas are a much more severe brain injury than concussions.
  • A coma is a deep state of unconsciousness, where the individual will not respond to stimuli.
  • Recovery from a coma usually takes a long period of time and may result in permanent impairments.
Spinal Cord Injuries
  • Approximately 55 percent of all spinal cord injuries occur between the ages of 16 and 30.
  • 8 percent result from sports injuries (UA National Spinal Cord Injury Statistical Center)
  • When the chin is flexed as little as 30 degrees, causing the natural curve of the neck to significantly lessen, the forces on the top of the head are directly transmitted to the cervical vertebrae.
  • Football players using the tops of their helmets to “spear” opponents are at high risk for serious cervical spine injury (Lawrence).
  • Athletes should be instructed to block and tackle with the head up to reduce the risk of head and spinal injuries.
Although only a small percentage of sports injuries involve the spinal cord, their significance should not be taken overlooked. These incidents may result in life-long paralysis or death. Spinal cord injured individuals are have an average hospitalization of 16 days, followed by stay in a rehabilitation unit for approximately 44 days (UA National Spinal Cord Injury Statistical Center).

Heat Stress Injuries
  • From 1995 through the 2002 football season there have been 15 high school heat stroke deaths in football (Heat Stress and Athletic Participation).
  • Heat injuries are classified from the least dangerous heat cramps, to heat exhaustion, to heat stroke, which is a life-threatening emergency.
  • Children thermoregulate effectively in normal weather conditions with rehydration and proper clothing, but have a decreased ability to adapt to temperature extremes.
  • Children acclimate to heat more slowly and show less heat dissipation than adults in a hot environment because of a lower sweat rate.
  • Cold temperatures are another cause for concern, as the high surface area-to-body mass ratio can cause excessive heat loss, increasing the risk of hypothermia (Franklin 222).
  • Games and practices should be suspended, delayed, or postponed during extreme weather conditions to prevent heat related injury and illness (Gerberich).

Prevention/Control Strategies

When developing injury prevention and control approaches, it is best to use a variety of methods. William Haddon Jr. developed ten technical strategies for controlling injuries (Robertson 16-19). Strategies one, four, six, eight, nine, and ten work particularly well in prevention and control on sports-related injuries in children and adolescents.

1. Prevent the creation of the hazard in the first place.

One way this can be accomplished is through pre-participation physical examinations, which should include screenings for neurological and cardiovascular disorders (Gerberich). By identifying individuals with congenital and other existing health problems, serious health incidents could be avoided.

Another way to prevent hazards is to reduce aggressive physical contact. Intentional spearing in football should be strongly discouraged by coaches and officials and blocking below the waist should be minimized in practice. Body checking in youth hockey has been shown to account for 86% of all injuries that occurred during games (American Academy of Pediatrics). Limiting checking in younger players and enforcing rules in all ages of players, such as lengthy penalties for pushing or checking from behind, can reduce injuries. Coaches should emphasize good sportsmanship and fair play at all times.

4. Modify the rate or spacial distribution of release of the hazard

According to the American College of Sports Medicine, injury risks can be significantly decreased by ensuring athletes are matched by size, maturation, or skill level (222). If competitors have large differences in speed and strength, the rate of injury may increase dramatically based on the applied forces and acceleration. A recent US study on youth hockey injuries found that size differences among the bantam players ages 14 and 15 had body weight variances of 53 kg from the smallest to largest players and also differed in a height of 55 cm (American Academy of Pediatrics).

6. Separate the hazard and that which is to be protected by interposition of a material barrier.

Effective prevention strategies for youth athletes may includes properly fitted helmets, face shields, pads, mouth guards, and other protective properly fitting equipment.

Source: Parmet: JAMA, Volume 289(5).February 5, 2003.652

8. Make what is to be protected more resistant to damage from the hazard.

By ensuring proper skills development, a number of sports injuries may be avoided. According to the chart below, motor skills cause the majority of injuries in young athletes. Coaches should ensure that athletes have learned skills involved in sports-specific tasks before moving on to more advanced motor movements.
Reasons for Injuries

Source: Journal of Pediatric Orthopaedics, March/April 2001

Another way to make young athletes more resistant to injury events is to have them participate in an overall fitness program, including muscular strength and endurance, cardio-respiratory endurance, and flexibility. By training and strengthening the entire body, imbalances may be identified and remedied.

9. Begin to counter the damage already done by the environmental hazard.

Injured athletes should seek prompt medical care where a licensed physician can assess the damage. Athletes should then rest until sufficient healing has taken place before returning to play.

10. Stabilize, repair, and rehabilitate the object of the damage.

Proper rehabilitative care should be provided to the injured athlete. Also, a physician may prescribe the use of a stabilization device, such as a knee brace or ankle brace.

Haddon’s Matrix
Another method of injury prevention and control developed by William Haddon Jr. is known as Haddon’s Matrix. This can serve as a guide to realizing the factors contributing to injuries and their severity, as well as the timing of these factors. As shown in the table below, there are many different factors involved in controlling injuries.
Vehicles & Equipment
Physical Environment
SocioEconomic Environment
Pre-Injury Phase
*Train athletes properly on following rules and playing safely.
*New skills should be mastered before moving on and learning more.
*Ensure athletes have adequate and properly fitting safety equipment.
*Encourage less physical play in practice.
*Make sure playing surfaces are safe.
*Check weather, i.e. temperature, humidity, storm conditions
*Athletic trainer or physician should be at all practices and games. If this is not possible, coaches should devise emergency response procedures.
Injury Phase
*Ensure players do not exceed abilities and fitness level.
*Emphasize fair play and following rules.
*Athletes must wear protective equipment.
*Athletes must always be supervised in practice.
*Emergency response system ready, i.e. phone, first aid equipment, etc.
Post-Injury Phase
*Give prompt and appropriate first aid.
*First aid kit utilized.
*Athlete should seek prompt medical care.
*Athlete should participate in physical therapy or other means of rehabilitation.

There are many limitations to injury prevention and control in youth sports. Funding coaches, trainers, and proper safety equipment can be costly, but the long-term economic and physical consequences of injury may rationalize these expenses. I believe more research and education is needed in the area of the training and conditioning principles. For example, the long-term effects of repeatedly throwing a baseball from age 8 to age 18 may undoubtedly cause long term arm and shoulder pain. Strict guidelines in regards to use of safety equipment, as well as the frequency, intensity, and duration of competitive athletes’ conditioning programs may prove to nearly diminish these chronic injuries. Also, comprehensive education to the athletes, parents, coaches, and officials is needed to share the importance of injury prevention and control.
In conclusion, the growing number injuries in youth sports and recreational activities will only continue to rise as participation increases. Coaches, parents, athletes, and athletic trainers and physicians must work together to decrease the likelihood and seriousness of sports-related injuries. A multi-factoral approach must be used to combat the many issues involved in preventing the incidence and severity of sports-related injuries.


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