I have written many articles and discussed many times on my podcast a number of tips to decrease injuries in youth sports. In baseball, recommendations to decrease amounts of pitching, avoiding showcase events, and correcting pitching mechanics have received tremendous attention. In soccer and other sports with large number of female athletes, ACL injury prevention programs have been emphasized. And generally, efforts to discuss the risks of single-sport specialization in any sport at a young age have spread in recent years.

If there is a risk factor in any sport that can be shown to cause a significant number of injuries, then it seems worthwhile to identify it and try to correct it, right? A study by Collins et al published in the journal Injury Prevention highlights a risk that we rarely hear discussed when we try to promote youth sports safety measures.

We must eliminate dirty play in youth sports.

Injuries related to fouls and other dirty play in sports

The authors used the RIO (Reporting Information Online), an injury surveillance system, to collect data on injuries in high school sports in the United States. For the 2005–06 and 2006–07 academic years, they captured injuries in boys’ football, soccer, basketball, wrestling, and baseball and girls’ soccer, volleyball, basketball, and softball. They attempted to compare differences between sports (boys’ and girls’) for injury rates, and in particular, the proportions of those injuries related to illegal activities and fouls.

The study offers some surprising findings:

The authors estimated that 98,066 injuries occurred nationwide during those years as the result of an action that was ruled illegal activity by a referee/official or disciplinary committee. They calculated an injury rate of 0.24 injuries related to illegal activity per 1000 athletic competition-exposures.

  • Boys’ and girls’ soccer had the highest rates of injury related to illegal activity.
  • Girls’ volleyball, girls’ softball, and boys’ baseball had the lowest rates of injury related to illegal activity.
  • Boys’ and girls’ sports overall had similar rates of injuries related to illegal activity.
  • Of all injuries in these sports, 6.4% were related to illegal activity.
  • The highest proportions of injuries related to illegal activity were found in girls’ basketball, girls’ soccer, and boys’ soccer (in that order).
  • The lowest proportions of injuries to illegal activity were found in girls’ softball, boys’ football, and girls’ volleyball. The head and face, ankle, and knee were the body parts most often reported as injured during illegal activity.
  • Almost 1/3 of injuries related to illegal activity affected the head and face areas. In fact, a much higher percentage of injuries related to illegal activity were to the head and face (32.3%) than injuries that occurred from non-foul activities (13.8%). Over 1/4 of the injuries related to fouls and similar activity were concussions.
  • In terms of the severity of the injuries related to illegal activity, 5.7% required surgery. 10.5% resulted in the player being held out for the rest of the season.

Head injury in soccer from dirty play

Take home points about dirty play in youth sports

Every sport has rules created to keep play and competition fair between athletes and teams. However the rules also serve to prevent or decrease the chances of athletes getting hurt from unsafe plays, moves, and activities.

This study shows that at the high-school level, injuries from fouls and dirty play caused more than 10% of all injuries in four of the nine sports (boys’ soccer, girls’ soccer, boys’ basketball, and girls’ basketball). The authors argue – and I agree with them – that any risk factor that causes such a high percentage of injuries should be examined for ways to modify that risk.

In that sense, better rule enforcement and punishment of players guilty of fouls and other illegal activity might actually decrease a sizable portion of youth sports injuries. Since over 5% of these injuries needed surgery and 10% were season-ending injuries, it seems to be an especially important effort.

Furthermore, with an ever-increasing focus on concussions and their long-term effects, cutting down foul-related injuries is a no-brainer. The authors showed a huge discrepancy between concussions (and head and face injuries in general) caused by illegal activity and injuries that occurred in sports naturally.

In theory, cutting down on injuries related to dirty play and fouls makes sense. It probably would be harder to actually achieve. But better rule enforcement and punishment by referees and education of athletes, parents, coaches, and referees by sports medicine healthcare providers might be a much needed first step.

Soccer player receiving a yellow card for dirty play

Collins CL, Fields SK, Comstock RD. When the rules of the game are broken: what proportion of high school sports-related injuries are related to illegal activity? Injury Prevention. 2008;14:34-38.