Report 19 of the Council on Scientific Affairs (A-99)
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In-line Skating

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Resolution 404, introduced by the Young Physicians Section at the 1997 Interim Meeting and referred to the Board of Trustees, asked: "That the American Medical Association (AMA) work with the Federation to encourage state and local governments to adopt legislation requiring that children use appropriate safety gear when in-line skating and skateboarding." 

Current AMA Policy H-10.975 (AMA Policy Compendium) strongly recommends use of protective equipment for in-line skating, encourages skating safety education, encourages that safety equipment be available where in-line skates are purchased or rented, and encourages the design and manufacture of appropriate safety equipment. This report reviews in-line skating injuries and the effectiveness of protective equipment in preventing these injuries. Because data and studies on skateboarding are limited, this report focuses on in-line skating.

Methods

The MEDLINE database was searched for English-language articles published from 1980 to April 1998 using the MeSH key word skating (that key word includes skateboarding, rollerskating, and in-line skating). The Lexis-Nexis database was searched for legislation mandating protective equipment used while skating. Also, national medical societies, professional organizations, public health organizations, and in-line skating organizations were contacted for data and policy on in-line skating.

Design of In-line Skates

The design of in-line skates, 3 to 5 low-friction wheels in a straight line, allows skaters more maneuverability and greater speeds than with traditional roller skates. In-line skaters frequently travel at 10 to 17 miles per hour, and competitive skaters can sustain speeds of 25 miles per hour.¹ In-line skating can be used as aerobic exercise,² independent transportation, competitive sport, and training for other sports. 

National Trends in In-line Skaing

In-line skating has become one of the fastest growing sports since its introduction into the United States in 1980. Recent surveys indicate that about 22.5 million Americans participated in in-line skating in 1995.³ This is a 79% increase over the number of 1993 participants.

Epidemiology of In-line Skating Injuries

The number of injuries associated with in-line skating has increased as the number of skaters has grown. In 1996, the Consumer Product Safety Commission (CPSC) reported almost 105,000 in-line skating injuries. This ranked as the eighth leading cause of injury in sports and recreational activities.^4,5 There were 25 deaths attributed to in-line skating from 1992 through 1995; 20 of these deaths were the result of collisions with motor vehicles. A study using National Electronic Injury Surveillance System (NEISS) data from a probability sample of US hospital emergency departments estimated that 31,000 skaters in the United States were injured severely enough to require an emergency department visit during a 12-month period beginning July 1992.⁶  Musculoskeletal injuries were the most frequent, with fractures, dislocations, sprains, strains, and avulsions accounting for 63% of all principal injuries. Of injured skaters in that study, 37% had a wrist injury, making the wrist area (including the wrist and lower arm) the most common site of injury. Two-thirds of wrist injuries were fractures or dislocations. Among the injured patients seen in emergency departments, only 5% sustained a head injury, and only 3.5% of all injured skaters were admitted to a hospital.^6,7

There is growing interest and participation in in-line hockey, both in an unorganized "street" version and in a supervised and regulated form. National statistics do not yet identify in-line skating injuries due to participation in hockey but street hockey players may be especially injury prone. USA Hockey InLine is one organization promoting responsible skating with trained coaches, supervised games, training, regulations, and concern for adequate protective equipment. 

Risk Factors for In-line Skating Injuries

Studies have shown that age, gender, and skating experience are risk factors for in-line skating injuries. Although the age range of injured skaters in one study was broad (5 to 71 years of age), children and adolescents were at greatest risk, with the mean age of injury at 19.7 years and the median age of injury at 15 years.⁷ A study using NEISS- reported in-line skating injuries in 1992 and 1993 found that pediatric injuries were most common among children 11 and 12 years old, with 52% of injuries among skaters 7 to 15 years of age.⁸  Boys had 68% of the reported injuries related to in-line skating. 

The most common causes of injury, according to 35 in-line skaters who were interviewed in a public park and who said they had previously been injured in-line skating, were loss of balance (95%) caused by road defect, debris, excess speed, inability to stop, and performing tricks.⁹ A case-control study using NEISS-reported in-line skating injuries between December 1992 and July 1993 found that the most typical fall involved a novice, inexperienced skater wearing little or no safety gear who lost his or her balance while skating or fell after striking a road defect or debris.¹⁰ Falls typically occurred on outstretched arms without any attempt to stop. In this study, the wrist was the most common site of primary injury, with 25% of all injuries being wrist fractures.¹⁰

Loss of balance can result in direct wrist or elbow impact. The injuring force is a combination of the fall from a height and the skater s momentum. This produces a large number of forearm fractures, in contrast to bicycle injuries from deceleration where the head is the point of impact.¹¹

Protective Equipment

The CPSC studied 41 cases of in-line skating injuries reported to NEISS in March 1995.¹² Interviews with injured skaters or parents indicated that 67% of those injured were not wearing any protective equipment. According to the International In-Line Skating Association, currently there are no manufacturing standards for kneepads, elbow pads, or wrist guards (Gil Clark, Executive Director, International In-Line Skating Association, personal communication, June 24, 1998). By contrast, for bicycle and multisport helmets there are standards established by the American National Standards Institute (ANSI), the American Society for Testing and Materials (ASTM), and the Snell Foundation. By 1999, bicycle and multisport helmets will be required to meet a standard set by the CPSC.¹³

Wrist Guards. Wrist guards consist of two hard volar and dorsal plates over a fingerless glove. There are conflicting data on the effectiveness of these wrist guards in preventing injuries. A report of four unusual in-line skating injuries observed in an emergency department suggests that wrist guard splints might have caused these forearm fractures.¹⁴ The authors of this report suggest that wrist guards might displace the fracture from the distal radius to the proximal end of the wrist splint resulting in a more serious injury in some falls. A study of 20 pairs of cadaver arms, one with a wrist brace and one without a brace, demonstrated more fractures with the braced arm when the sliding arms-out motion of a falling skater was simulated.¹⁵ Another study using 20 pairs of cadaveric arms measured the force necessary to fracture the arm with a standard wrist guard compared to the arm without a guard.¹⁶ There was no significant difference in the fracture patterns. The authors concluded that wrist guards were not effective in preventing wrist fractures. A third study of 15 pairs of cadaver arms, one with a wrist guard and one without a guard, using the force of a drop to simulate a skater accident found that more force was necessary and fewer fractures occurred in the protected arm.¹⁷  There are research design questions in a biomechanical approach, especially in choice of methods to simulate a fall, just as there are concerns with epidemiological approaches such as case-control studies.^18-20

A case-control study of injured in-line skaters reported to NEISS between December 1992 and July 1993 determined that wrist guards could have prevented an estimated 87% of the wrist injuries.¹⁰ From June through November 1991, data on in-line skating injury cases were solicited from emergency room physicians in California, New York City, and Chicago and from 60 randomly selected members of the American Society of Hand Surgery.²¹ A retrospective analysis of these 57 injured patients indicated that 80% did not wear wrist protection. Wrist injuries were more common in skaters without wrist protection but fractures of the distal radius, radial head, and proximal phalanx of the thumb did occur to skaters with wrist protection, leading the authors to call for mandatory wrist protection and possible redesign of wrist protection equipment. 

Knee and Elbow Pads. Kneepads and elbow pads consist of a hard outer shell of plastic with stiff foam rubber cushioning the knees and elbows, and are secured by elasticized straps. This protective equipment decreases sliding friction injuries and cushions the impact of a fall.²² A case-control study of injured in-line skaters reported to NEISS between December 1992 and July 1993 determined that kneepads could prevent an estimated 32% of knee injuries, and elbow pads could prevent an estimated 82% of elbow injuries.¹⁰ 

Helmets. The International In-Line Skating Association encourages in-line skaters to wear bicycle helmets or multisport helmets. These helmets have a hard outer shell and interior padding. Design and construction have been based on standards from the Snell Foundation, the ANSI, or the ASTM. There are specialized in-line skating helmets that cradle the back of the head, and extend to the nape of the neck. For the helmet to be maximally protective, the helmet should fit snugly with straps fastened so that the helmet stays on top of the head.

In a study of 161 in-line skating injuries, the number of head injuries was not sufficient to determine the effectiveness of helmets in reducing injuries.¹⁰ Head injuries from bicycle accidents, which are more frequent, provide one approach to evaluate helmet protection. A study of bicyclist injuries found that a bicycle helmet prevented 85% of head injuries and 88% of brain injuries.¹¹ Bicycle helmets appear to protect bicyclists from head injuries in situations similar to those skaters encounter.²³ Reviews of the effectiveness of helmets in the prevention of head injuries in bicycle accidents and other recreational sports are available.^24,25 AMA Policy H-10.985 supports the use of bicycle helmets for bicycling, encourages physicians to educate their patients on helmet safety, and supports state and local legislation on bicycle helmets. The Centers for Disease Control and Prevention similarly recommend use of helmets that meet recognized standards when bicycling, as well as legislation, education, promotion, and evaluation of helmet use.²⁴ 

Studies of helmets used by bicyclists and equestrians suggest barriers to the use of helmets and other safety equipment, including lack of knowledge of the importance of protective equipment, discomfort wearing equipment, perceived unattractiveness of equipment, and cost.^26,27 These barriers tend to be most prevalent in youths.

Protective Gear Policy

The current challenges are to determine the effectiveness of protective gear and to increase use of protective equipment for in-line skating. A March 1995 CPSC study found that 67% of emergency room-treated in-line skaters wore no protective equipment.¹² According to a study of 63 in-line skating-injured patients treated in a trauma center, 59% owned protective equipment, but only 25% were using the equipment at the time of injury.²⁸

Wrist guards, kneepads, and elbow pads seem to protect skaters from soft-tissue injuries in a fall or collision.^10,22 Approved helmets that are worn properly may prevent head and facial bruises, abrasions, concussions, and severe brain injury. While the number of head injuries in in-line skating is small, these are the most serious injuries sustained in in-line skating.

Everyone should be encouraged to wear safety equipment while in-line skating, but it is especially important that children be protected because they are over-represented among injured skaters.²² A policy statement of the American Academy of Pediatrics encourages legislation requiring helmet use while skating but use of helmets by child and adolescent skaters is required by law only in New York and Oregon.²⁹ The American Academy of Pediatrics recommends that physicians offer the following advice to patients and families concerned with in-line skating.²⁹

• Full protective gear should be worn at all times. This should include wrist guards, elbow pads, kneepads, and a helmet. The helmet should be certified by the ASTM, the ANSI, or the Snell Foundation.  
• Unsafe and dangerous activities such as hitching or truck surfing, which is latching onto a speeding vehicle, should be discouraged.   
• Training for beginners should be encouraged, and novice skaters should start in an indoor or outdoor rink rather than on the street.   
• Skaters should not skate in the dark, and should learn to look for road debris or defects that could cause them to lose their balance.   
• Skaters, especially children with balance problems, physical disabilities, or uncorrected vision or hearing problems, should skate in a rink where everyone moves in the same direction or in another protected place. 

Conclusions

In-line skating is a fast-growing sport. Along with the increase in participants, there is an increase in injuries. Children are the largest group of participants injured in in-line skating. Retrospective studies show that in-line skaters who wear protective gear have fewer injuries. Existing AMA policy encourages the use of protective equipment, including wrist guards, kneepads, elbow pads, and helmets. Several in-line skating researchers have decried the lack of prospective studies on the effectiveness of in-line skating protective equipment. Such data would assist legislators to determine the most appropriate actions to protect in-line skaters. Increased public awareness of in-line skating safety and education of in-line skaters on the value of protective equipment remain appropriate. Protective equipment that is easier to use, less cumbersome to wear, and that affords maximal protection might also enhance public acceptance and use of this gear.

The AMA can assist in raising public awareness of in-line skating protective equipment. Physicians and hospitals as well as sporting goods stores, manufacturers, and the media, can increase public awareness about safety issues regarding in-line skating. As health advocates, physicians have a key role in raising awareness because of their role in counseling patients and in the community. An educational brochure, such as that of the Massachusetts Medical Society, is one prevention approach. 

RECOMMENDATIONS

The following statements, recommended by the Council on Scientific Affairs, were adopted by the AMA House of Delegates as AMA policy at the 1999 AMA Annual Meeting: 

1. Th AMA reaffirms existing Policy H-10.975,  
2. The AMA encourages federal agencies and industries to support research on patterns of equipment use and frequency of protective equipment use for in-line skating.  
3. The AMA will work with the Consumer Product Safety Commission, Centers for Disease Control and Prevention, national in-line skating organizations, and medical specialty societies, Alliance and Federation to encourage in-line skaters to wear protective equipment.  
4. The AMA encourages physicians to counsel patients, and their parents when appropriate, that full protective equipment should be worn and appropriate safety measures be taken to prevent in-line skating injuries. Consistent with recommendations of the American Academy of Pediatrics, prevention efforts should include the following:   
   1. Full protective gear should be worn at all times. This would include wrist guards, elbow pads, kneepads, and a helmet. The helmet should be certified by the ASTM, the ANSI or the Snell Foundation.  
   2. Unsafe activities such as hitching or truck surfing, which is latching onto a moving vehicle, should be avoided.  
   3. Training for beginners should be encouraged, and novice skaters should start in an indoor or outdoor rink rather than on the street.  
   4. Skaters should not skate in the dark and should learn to look for road debris or defects that could cause them to lose their balance.  
   5. Skaters, especially children with balance problems, physical disabilities, or uncorrected vision or hearing problems who skate should do so in a rink or another protected place. 
5. The AMA encourages medical specialty societies and state and local medical societies to advocate for state and local legislation to improve the safety of in-line skating through: