The American Journal of Sports

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Shoulder Injuries in Men's Collegiate Lacrosse, 2004-2009

Elizabeth C. Gardner, Wayne W. Chan, Karen M. Sutton and Theodore A. Blaine
Am J Sports Med published online May 3, 2016
DOI: 10.1177/0363546516644246
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AJSM PreView, published on May 3, 2016 as doi:10.1177/0363546516644246

Shoulder Injuries in Mens Collegiate

Lacrosse, 2004-2009
Elizabeth C. Gardner,*y MD, Wayne W. Chan,y MD, PhD,
Karen M. Sutton,y MD, and Theodore A. Blaine,y MD
Investigation performed at the Department of Orthopaedic Surgery,
Yale University School of Medicine, New Haven, Connecticut, USA
Background: Mens lacrosse has been one of the fastest growing team sports in the United States, at both the collegiate and
high school levels. Uniquely, it combines both continuous overhead and contact activity. Thus, an understanding of its injury epidemiology and mechanisms is vital. Shoulder injuries have been shown to be common in the sport, but thus far there has been no
dedicated analysis of these injuries with which to better inform injury prevention strategies.
Study Design: Descriptive epidemiology study.
Methods: All athlete exposures (AEs) and shoulder injuries reported to the National Collegiate Athletic Association (NCAA) Injury
Surveillance System for intercollegiate mens lacrosse athletes from 2004-2005 through 2008-2009 were collected. Type of injury
was documented and the injury incidence per 1000 AEs was calculated. Event type, injury mechanism, specific injury, outcome,
and time lost were recorded. Statistical analysis was performed using 95% CIs, calculated based on a normal approximation to
Poisson distribution.
Results: There were a total of 124 observed shoulder injuries during 229,591 monitored AEs. With weights, this estimates 1707
shoulder injuries over 2,873,973 AEs, for an incidence of 0.59 per 1000 AEs (95% CI, 0.56-0.62). The incidence of shoulder injury
during competition was 1.89 per 1000 AEs (95% CI, 1.76-2.02), compared with 0.35 per 1000 AEs (95% CI, 0.33-0.38) during
practice. Acromioclavicular joint injuries were most common (0.29 per 1000 AEs; 95% CI, 0.27-0.31). Labral injuries and instability
events were also frequent (0.11 per 1000 AEs; 95% CI, 0.10-0.13). Player-to-player contact caused 57% of all shoulder injuries,
with 25% due to contact with the playing surface. The average time lost was 11.0 days, with 41.9% of all shoulder injuries requiring 10 days. Clavicle fractures and posterior shoulder dislocation were particularly severe, with no athletes returning to play during the same season.
Conclusion: Shoulder injuries are common in NCAA mens lacrosse and are an important source of lost playing time. Acromioclavicular injuries were the most frequent injury in this series, but labral and instability injuries were also common. In this increasingly popular contact sport, an understanding of the epidemiology and mechanism of shoulder injuries may be used to improve
protective equipment and develop injury prevention.
Keywords: lacrosse; shoulder; injury prevention; epidemiology

The first mens lacrosse National Collegiate Athletic Association (NCAA) championship game was played in 1971.

Since then, the popularity of and access to the sport has

grown substantially. In 1988-1989, there were 150 schools
sponsoring varsity mens lacrosse teams with 4805 participants. By 2013-2014, the number increased to 391 with
13,857 participants,2 making lacrosse one of the fastest
growing sports in the United States. Players are involved
at a younger age, and the sport has been made more popular throughout the country and around the world.
The rapidly increasing popularity of this unique overhead, contact sport mandates an understanding of the
injury profile of mens lacrosse. Thus far, data have been
reported on eye injuries,15 anterior cruciate ligament injuries,17 overall epidemiology,7,10,11,23 and concussion3-5,9;
however, no epidemiologic study has been reported specifically on shoulder injuries. Notably, shoulder injuries
account for 6.5% of reported injuries at the high school
level.23 Professional mens lacrosse shows a similar trend,
with 14% of all injuries affecting the shoulder (J. Parsons
and P. Stull, unpublished data, 2015). To better inform

*Address correspondence to Elizabeth C. Gardner, MD, Department

of Orthopaedic Surgery, Yale University School of Medicine, 800 Howard
Avenue, 1st Floor, New Haven, CT 06519, USA (email: elizabeth.gardner
@yale.edu).
y
Department of Orthopaedic Surgery, Yale University School of Medicine, New Haven, Connecticut, USA.
The content of this manuscript is solely the responsibility of the
authors and does not necessarily represent the official view of the Datalys
Center or the National College Athletic Association.
One or more of the authors has declared the following potential conflict of interest or source of funding: The NCAA Injury Surveillance Program data were provided by the Datalys Center for Sports Injury
Research and Prevention. The Injury Surveillance Program was funded
by the National College Athletic Association (NCAA).
The American Journal of Sports Medicine, Vol. XX, No. X
DOI: 10.1177/0363546516644246
2016 The Author(s)

1
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Gardner et al

The American Journal of Sports Medicine

TABLE 1
Mens Lacrosse Athlete Estimated Exposures per Year and Division
Athlete Exposures by Year

Division I
Division II
Division III
Total

2004-2005

2005-2006

2006-2007

2007-2008

2008-2009

Total

197,762
36,165
169,325
403,252

327,932

352,665
680,597

315,343

145,409
460,752

305,086

205,286
510,372

428,514
52,810
337,676
819,000

1,574,637
88,975
1,210,361
2,873,973

injury prevention measures, it is important to understand

these common injuries and their mechanisms. The purpose
of the current study was to describe the incidence and
mechanism of shoulder injuries in the game of mens collegiate lacrosse.

METHODS
Institutional review board approval (exemption) was obtained
for this study. Approval of methods and to conduct the study
was also received from the NCAA.

Data Collection
Data for this study were collected by the NCAA via its Injury
Surveillance System (ISS). The data were obtained from
Datalys, the nonprofit organization responsible for the collection, organization, and maintenance of the database. The
data were obtained for the most recent 5-year period available, 2004-2005 through 2008-2009, to reflect the current
state of the game. The details of the system have been well
described previously by Dick et al6 and Kerr et al.13 It is
a convenience sample in which volunteer certified athletic
trainers from NCAA-sponsored institutions submit information related to the type of injury, body part injured, measures
of injury severity (time loss and the need for surgery), and
sport-specific details related to the mechanism of injury
and player position via a web-based system. The NCAA ISS
has repeatedly been used for the purposes of calculating incidence and describing the epidemiology of injury in American
collegiate athletics.1,7,8,19,20
With the provided data for the sport code Mens
Lacrosse, an exposure data set was extracted from the
5-year period from 2004-2005 through 2008-2009 (Table
1). One athlete exposure is defined as 1 student-athlete
participating in 1 game or practice, no matter the duration.
Using the sport code Mens Lacrosse and the body part
code Shoulder, an injury data set was extracted for these
years. A reportable injury is one that (1) occurred as
a result of participation in an intercollegiate practice or
competition and (2) required medical attention by an athletic trainer or physician and (3) resulted in restriction of
participation or performance for one or more calendar
days beyond the day of injury.6 The exported data set
passes through an automated verification process, and
any data flagged for invalid values are addressed by the
athletic trainers and data quality assurance staff.

Statistical Methods
For each athlete exposure (AE) and injury reported in the
data set, the NCAA has provided a sampling weight to
allow extrapolation of the data from the small convenience
sample to the entire NCAA population. These sampling
weights have been included in all analyses.
The incidence of injury was calculated as the number of
injuries divided by the number of AEs. This is reported per
1000 AEs to allow comparison with previously reported
data.7,10,23 The 95% CIs were calculated for the incidence
rates based on assumptions of a normal approximation to
Poisson distribution.
Within the provided data, there is no descriptive information regarding injury severity. For each injury, however,
the time lost, defined as the duration from the initial index
injury to return to play, from activity was reported. This
was used as a surrogate for severity of injury. Here, injuries
with 10 days lost, including season-ending injuries, are
considered particularly severe.7
Further analysis described the mechanism of injury and
evaluated for factors affecting the incidence of injury, such
as the event type or activity during which the injury occurred.

RESULTS
A total of 7087 events were recorded, each with between 4
and 55 athletes participating, yielding a total of 229,591
observed AEs. Data collection each year began on the first
day of preseason and ran through the final day of competition, including any postseason games or practices if applicable. Of the 2,873,973 estimated AEs, 2,417,650 were
practice AEs and 456,323 were game AEs. There were no
participating Division II schools from 2005-2006 through
2007-2008.
These results represent the incidence of injuries. This
allows the results of the sampled population to be better
extrapolated to all NCAA mens lacrosse participants during the 2004-2005 through 2008-2009 seasons.
There were a total of 124 observed injuries during the collection period. When weighted to an estimated 2,873,973
AEs, there were an estimated 1707 shoulder injuries, yielding an incidence of 0.59 per 1000 AEs (95% CI, 0.56-0.62).
When evaluated according to event type, the incidence of
shoulder injuries during practice was 0.35 per 1000 AEs
(95% CI, 0.33-0.38) and during competition, 1.89 per 1000
AEs (95% CI, 1.76-2.02).

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Shoulder Injuries in Mens Lacrosse

TABLE 2
Specific Injury Incidencea
Injury
AC joint sprain grade 1/2
Shoulder contusion
Anterior subluxation
RTC injury
Anterior dislocation
Posterior subluxation
Impingement
SLAP tear
Rhomboid partial tear
Labrum (non-SLAP)
Scapular fracture
Clavicle fracture
Otherb
Synovitis
Calcific bursitis
Deltoid partial tear
Trapezius partial tear
SC subluxation
AC joint sprain grade 3
Posterior dislocation
All shoulder injuries
All labrum/instability eventsc

Observed Injury
Occurrence

Weighted Injury
Occurrence

61
10
10
9
7
4
3
3
2
2
2
2
2
1
1
1
1
1
1
1
124
22

833.48
155.11
137.42
144.93
90.62
42.58
57.75
23.81
35.40
30.29
23.91
22.33
15.87
18.28
16.63
16.63
15.98
10.58
7.94
7.94
1707.48
332.66

Incidence per 1000

AE (95% CI)
0.29
0.05
0.05
0.05
0.03
0.01
0.02
0.01
0.01
0.01
0.01
0.01
0.01
0.01
0.01
0.01
0.01
\0.01
\0.01
\0.01
0.59
0.11

(0.27-0.31)
(0.05-0.06)
(0.04-0.06)
(0.03-0.07)
(0.03-0.04)
(0.01-0.02)
(0.02-0.03)
(0.01-0.01)
(0.01-0.02)
(0.01-0.02)
(0.01-0.01)
(0.01-0.01)
(\0.01-0.01)
(\0.01-0.01)
(\0.01-0.01)
(\0.01-0.01)
(\0.01-0.01)
(\0.01-0.01)
(\0.01-\0.01)
(\0.01-0.01)
(0.57-0.62)
(0.09-0.13)

Percentage of All Observed

Shoulder Injuries
49.2
8.1
8.1
7.3
5.7
3.2
2.4
2.4
1.6
1.6
1.6
1.6
1.6
0.8
0.8
0.8
0.8
0.8
0.8
0.8
100.0
21.8

AC, acromioclavicular; AE, athlete exposure; RTC, rotator cuff tear; SC, sternoclavicular; SLAP, superior labral anterior and posterior.
Includes superficial abrasions.
c
Combination of anterior and posterior dislocation/subluxation, labrum, and SLAP injuries.
b

Table 2 presents the weighted incidence of each specific

shoulder injury during the collection period. Acromioclavicular (AC) joint injuries were the most common, accounting for 50.0% of all shoulder injuries. Labral injuries
(including anterior, posterior, superior labral anterior
and posterior [SLAP] tears) and those associated with
anterior/posterior instability events combine to account
for over 20% of all shoulder injuries (21.8%). The incidence
of posterior dislocation/subluxation was rare (0.01 per 1000
AEs; 95% CI, 0.01-0.02). The rate of fracture about the
shoulder, including the clavicle and scapula, was 0.02 per
1000 AEs (95% CI, 0.01-0.02).
Most shoulder injuries occurred by player-player contact (57%). Contact with the playing surface caused 25%
of the injuries. The balance comprised acute noncontact
injury (8.7%), contact with apparatus (4.6%), and overuse
injuries (4.6%).
For those athletes able to return to play that season, the
average time loss for shoulder injuries in this cohort was
11.0 days. Not surprisingly, fractures were severe injuries,
with all athletes with clavicle fracture remaining out for
the remainder of the season and those with scapular fractures missing an average of 42.5 days (Table 3). Grade 1 or
2 AC joint injuries resulted in significant loss of time (10.5
days), with the number rising significantly (26.0 days) for
grade 3 injuries and 1 season-ending injury. Anterior
subluxation/dislocation events also resulted in extended
loss of time (16.8 days) and 2 season-ending injuries. Posterior subluxations and dislocations led to fewer missed

days (7.2 days) but also resulted in 1 season-ending injury.

Other injuries that led to 10 days of time lost include
SLAP tears (13.7 days) and presumed non-SLAP labral
tears (12 days). Overall, 41.9% of all shoulder injuries
reported resulted in 10 days lost.
Several specific injuries were further analyzed to better
understand their mechanism. Injuries to the AC joint
represented the largest subset of shoulder injuries; almost
all (99%) were partial sprains. Injuries to the AC joint were
primarily related to player-to-player contact (67.7%) and
player-to-surface contact (28.9%). Most players sustaining
AC joint injuries returned to play within 1 week (44.5%) or
2 weeks (24.4%). Still, 9.5% of players had not returned to
play after 4 weeks, and 2.0% of players sustained
season-ending injuries (all grade 1 or 2 injuries).
Labral injuries (anterior, posterior, SLAP) and those
associated with instability events accounted for 20% of all
shoulder injuries. The primary injury mechanism for these
injuries was player contact (44.3%), with contact with the
playing surface accounting for most other injuries (37.8%).
The average time lost for these athletes was 16.9 days.

DISCUSSION
For more than a decade, lacrosse has been one of the fastest growing team sports in the United States. According to
the US Lacrosse 2013 Participation Survey,21 nearly
750,000 players participated in lacrosse on organized

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Gardner et al

The American Journal of Sports Medicine

TABLE 3
Season-Ending Shoulder Injuries With Average Time Loss of 10 Daysa
Shoulder Injuryb
Clavicle fracture (n = 2)
Posterior shoulder dislocation (n = 1)
Scapular fracture (n = 2)
AC joint sprain grade 3 (n = 1)
Anterior shoulder dislocation (n = 7)
Anterior subluxation (n = 10)
Labrum (SLAP) (n = 2)
Labrum (non-SLAP) (n = 3)
AC joint sprain grade 1 or 2

Average Time Loss, d

Percentage of Injuries That Were Season Ending

All were season ending

All were season ending
42.5
26.0
18.0
16.0
13.7
12.0
10.5

100
100

28.6

1.6

AC, acromioclavicular; SLAP, superior labral anterior and posterior.

n = number of observed injuries.

teams at some level in 2013, an increase of nearly 25,000

players from just 1 year prior. At the collegiate level, the
growth is particularly astounding. In this era of downsizing of college athletics, lacrosse has defied the odds, with
60 new college programs beginning play in 2013, with 39
more starting in 2014.21
The mens game is unique in that it is an overhead contact sport more similar to American football than to sports
using sticks such as ice hockey. This exposes the athlete to
the typical injuries encountered in overhead sports, collision sports, and sports using handheld equipment (sticks
or crosses).
Common maneuvers that occur in mens lacrosse may
lead to unique mechanisms of injury. Body contact, or
checking, is permissible if the contact is above the waist
and below the shoulder of the opponent, and the opponent
is in possession of or within 5 yards of the ball. It is similar
to ice hockey and typically involves a collision at the shoulder level with both hands on the stick. If a player falls or is
driven into the ground, a direct blow to the top of the shoulder may occur. If the fall occurs with the arm in an abducted
and externally rotated position, the shoulder may dislocate
in an anterior-inferior direction. Finally, during a face-off,
rotational force in the shoulder, combined with a posteriorly
directed shearing force, may lead to labral injury.
The NCAA mandates that all players, except the designated goalkeeper, wear shoulder and arm pads.18 Although
shoulder pads have become more robust in recent years,
they remain significantly thinner and lightweight than
those used in ice hockey or football. Lacrosse shoulder
pads have a noncantilever design, sitting directly on top
of the shoulder. With the purpose of not restricting motion,
these pads offer less protection.
In a limited report of the NCAA ISS,12 mens lacrosse
had the fifth-highest overall game injury rate (15.7 injuries
per 1000 AEs) among mens sports, falling below football
(39.1 per 1000 AEs), wrestling (23.8 per 1000 AEs), soccer
(19.1 per 1000 AEs), and ice hockey (17.7 per 1000 AEs)
during the 2004-2005 season. In this same report, the
shoulder was the most commonly injured body part during
a game during the 2003-2004 season.
Hinton et al10 conducted a 3-year prospective study of
high school lacrosse players in Fairfax County, Virginia,

reporting the types, mechanisms, and circumstances of

lacrosse injuries in this population. The overall injury
rate was 2.89 per 1000 AEs. Shoulder injuries accounted
for 8.5% of all injuries (0.24 per 1000 AEs).
Similarly, Xiang et al23 used the High School Reporting
Information Online (RIO) database to describe the epidemiology of high school boys lacrosse from 2008-2009
through 2011-2012. They found an overall injury incidence
rate of 2.26 per 1000 AEs. Shoulder injury accounted for
6.5% of all injuries and ranked seventh of 10 body sites
for frequency of injury.
Dick et al7 reported on the epidemiology of all mens
lacrosse injuries at the collegiate level, using data from
the NCAA ISS from 1988-1989 through 2003-2004. With
an incidence of 1.56 injuries per 1000 AEs, the shoulder
was the second most commonly injured body part during
a game. The practice shoulder injury incidence was reported
to be 0.23, making it the fourth most common practice
injury in their series.
In the present study, the overall incidence of shoulder
injury in intercollegiate mens lacrosse players was found to
be 0.59 per 1000 AEs (95% CI, 0.56-0.62). The incidence of
shoulder injuries during practice was 0.35 per 1000 AEs
(95% CI, 0.33-0.38) and 1.89 per 1000 AEs (95% CI, 1.762.02) during competition, comparable although slightly
increased compared with the rates in the series by Dick
et al.7 These data indicate that with the increased participation in mens lacrosse, the rates of shoulder injuries have
increased modestly (from 1.56 to 1.89 per 1000 AEs). Both
our data and that of the prior NCAA study report an
increased rate of shoulder injury in the collegiate population
compared with that of high school players. This may be
explained by the increased physicality of play in the older
age group. The fact that in this cohort 86.7% of shoulder injuries were due to contact (player contact, contact with playing
surface, and contact with apparatus) supports this conjecture.
These data also provide important information on the
specific types of shoulder injuries that occur in mens
lacrosse. Of the 21 specific types of injuries coded (Table
2), the most common injury was to the AC joint (50.0%),
and the second most common injury was to the labrum
(21.8%). This high incidence of labral injuries in mens
lacrosse has not been previously reported and is an

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Shoulder Injuries in Mens Lacrosse

important consideration in diagnosing and treating these

injuries.

AC Joint Injuries
With an incidence of 0.29 per 1000 AEs (95% CI, 0.27-0.31),
AC joint injuries are the most common shoulder injury in
intercollegiate mens lacrosse. In the report by Dick et al7
of NCAA mens lacrosse players from 1988-1989 through
2003-2004, the incidence of AC joint injuries during games
was 0.64 per 1000 AEs, and the incidence of the same injuries during practices was 0.06, 10-fold less. In our updated
group, a similar trend holds true, but the incidence has
increased to 1.14 per 1000 AEs (95% CI, 1.05-1.24) and
0.13 per 1000 AEs (95% CI, 0.11-0.13) for games and practices, respectively.
The most common mechanism of AC joint injury in our
group was contact with another player (body checking),
accounting for 67.7% of injuries. In the typical body check,
the player lowers and drives the top of the shoulder into
the other players body. This forces the shoulder girdle
downward and away from the clavicle, leading to potential
injury to the acromioclavicular and/or coracoclavicular ligaments. Contact with the playing surface was responsible
for nearly all of the remaining AC joint injuries (28.9%).
A similar mechanism occurs when a player falls and is
driven into the ground, leading to a direct blow to the top
of the shoulder and separation of the AC joint.
Less than half of all players who sustained an AC joint
injury were able to return to play within 1 week (44.5%),
with 30.2% out for at least 2 weeks. Of athletes with AC
joint injuries, 49% would meet the study definition by
Dick et al7 of 101 days lost as a marker of a severe injury,
attesting to the morbidity of the injury.
As previously mentioned, the required shoulder pads in
mens lacrosse are noncantilevered and rest on top of the
shoulder. The above data suggest that their design does
not adequately protect the shoulder. This may be due to
their mobility or insufficient padding. Further attention
to their design, including a better padded and less mobile
structure, may help to decrease the incidence of these
injuries.

Labral Injuries (Superior, Posterior, Anterior) and

Instability Events (Subluxations and Dislocations)
Particularly notable in this report and previously underrecognized is the high incidence of shoulder labral injuries
and instability events. In aggregate, they account for
21.8% of all shoulder injuries in NCAA mens lacrosse,
occurring with an incidence of 0.11 per 1000 AEs (95%
CI, 0.09-0.13).
Some typical maneuvers that occur in mens lacrosse
lead to unique mechanisms of labral injury. Body checking
typically involves contact at the shoulder level with both
hands on the stick, followed by pushing forward of both
arms, extending the elbows, flexing the shoulders, and protracting the scapula. This constellation of forces, like blocking by football linemen, leads to a net posterior force on the
shoulder and, as in football, may lead to posterior labral

injury. The face-off is another unique event that may

also be associated with labral injury. The face-off player
crouches with both hands on the stick, which is positioned
flat on the ground. The player then pushes both arms forward to clamp the ball, while twisting the stick to gain possession. This maneuver leads to both a rotational force in
the shoulder and a posteriorly directed force; this shearing
may also lead to labral injury.
Posterior shoulder injury has previously been reported
in athletes who subject their shoulders to repeated posteriorly directed shear forces. Mair et al16 described posterior
labral injuries in a series of 9 contact athletes, a group
composed of 8 football linemen and 1 lacrosse player. In
the Mair et al16 series, the lacrosse athlete recalled the
moment of injury to have occurred when holding his stick
in front of his body. He then suffered a posteriorly directed
blow with the shoulder forward-flexed and the elbow
locked in extension. At surgery, he, along with all of the
football linemen, had posterior labral detachment.22
The current study found that posterior shoulder subluxation/dislocation was a rare event, with an incidence of
0.02 per 1000 AEs (95% CI, 0.01-0.02). In accordance
with that proposed by Mair et al,16 the most common mechanism of posterior instability was contact with another
player, accounting for 47.1% of these injuries. Contact
with the playing surface and shooting were the cause of
the remaining injuries. Most players with a posterior
shoulder injury were able to return to play within 1 week
(52.9%). However, 31.4% required more than 2 weeks; of
these, 15.7% did not return to play during that season.
This attests to the potential severity of these injuries.
The mechanism of anterior-inferior labral tear with
shoulder subluxation/dislocation occurs in most collision
sports and has been well described. An anteriorly directed
force with the arm in abduction and external rotation leads
to tearing/avulsion of the anterior-inferior glenohumeral
ligament and capsulolabral complex. If a player is checked
and makes contact with the ground with the arm in an
abducted and externally rotated position, the shoulder
may dislocate in an anterior-inferior direction, leading to
anterior and inferior labral injury. In our population, anterior labral injuries (dislocation, subluxation, and labral
tear) had a combined incidence of 0.09 per 1000 AEs
(95% CI, 0.08-0.10). These results are similar to the overall
incidence of instability events occurring in collegiate
sports, reported by Owens et al.19 In their series, a total
of 4080 glenohumeral instability events were documented,
resulting in an incidence rate of 0.12 injuries per 1000 AEs.

Fractures
In its classification of shoulder injuries, the NCAA includes
fracture of the scapula, proximal humerus, and clavicle. Of
note, it is unknown whether the scapular fractures are
those of the body or glenoid fractures associated with an
instability event (bony Bankart). In our cohort, there
were no reported humerus fractures. The incidence of
each scapular and clavicle fracture was 0.01 per 1000
AEs (95% CI, \0.01-0.01) in this population. Hinton
et al10 reported the incidence of all fractures in boys

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Gardner et al

The American Journal of Sports Medicine

high school lacrosse to be 0.27 per 1000 AEs, but they did
not classify them according to the site of the fracture. Similarly, Xiang et al23 reported the incidence of any fracture
in boys high school lacrosse to be 0.25 per 1000 AEs.
The mechanism of injury for these injuries in our study
was similar to that seen with AC joint injuries. Most were
due to contact with another player, whereas the remainder
were due to contact with the playing surface. As with AC
joint injuries, clavicle fractures are due to a direct blow
to an area protected by shoulder pads. Thus, it is likely
that improvements to shoulder pads could help to decrease
this injury rate. Neither of the athletes who suffered a clavicle fracture was able to return to play during that season.
Both players with scapular fractures returned to play;
however, it was after 20 and 65 days, respectively.

Game Versus Practice

Dick et al7 found that, overall, athletes were 4 times more
likely to have an injury during a game than in a practice
(12.58 vs 3.24 injuries per 1000 AEs for games and practice
exposures, respectively). Similarly, in the high school population, Hinton et al10 found the overall rate of injury to be
4.44 per 1000 AEs, whereas the rate of injury during practice was 1.40 per 1000 AEs. In the series of collegiate athletes reported by Owens et al,19 athletes sustained more
glenohumeral instability events during games than practices (incidence rate ratio [IRR], 3.50; 95% CI, 3.29-3.73).
Similar to prior reports, we found that shoulder injuries
were 5 times more common during games than in practices.
Dick et al7 hypothesized that this finding was to be expected,
due to the sustained elevated intensity of game play. Athlete
exposure during practice likely involves periods of instruction, conditioning, and noncontact drills, in addition to drills
and scrimmages that are similar to game play. This is substantiated by the findings of an NCAA ISS report of all
mens lacrosse injuries reported during the 2005-2006 season, which found that in a practice environment, a noncontact
mechanism was responsible for 49% of all reported injuries,
whereas contact with another player was causative in
25%.12 However, during competition, noncontact injuries
accounted for only 25% of those reported, while contact
with another athlete was the listed mechanism for 52%.

Mechanism of Injury
In his study of high school boys lacrosse, Xiang et al23
found that 40.9% of all injuries were due to contact with
another player. Dick et al7 reported that 45.9% of all
game injuries resulted from player contact. Owens et al19
also found that male collegiate athletes were more likely
to sustain a glenohumeral instability event from player
contact (IRR, 2.74; 95% CI, 2.31-3.25) than other mechanisms. Our findings corroborate these studies, with
57.5% of all shoulder injuries caused by contact with
another player. Nearly 25% of the remaining shoulder
injuries were reported to be due to contact with the playing
surface. Whether a change in playing surface could potentially affect the incidence of shoulder injury is unknown
and deserves further study.

Time Loss
Due to limitations in the data collected, neither the NCAA
ISS nor other similar injury databases have specific details
regarding the severity of injuries. As such, it is necessary to
use surrogate markers. Time loss has been previously used
for this purpose.7,10 A threshold of 10 days of time loss was
chosen to allow for comparison with prior studies.7,19
In our study, 41.9% of all injuries necessitated 10 days
of recovery prior to return to play. This is comparable with
that reported by Owens et al,19 in which time lost to sport
(.10 days) occurred in 45% of glenohumeral instability
events. Shoulder injuries are particularly limiting in
mens lacrosse, since shoulder braces are poorly tolerated
and may restrict motion in a sport where overhead activity
is necessary. Table 3 lists the shoulder injuries for which
the average time loss was 10 days. This information is
useful to help advise players, coaches, and medical professionals when handling these injuries during the season.
Only 3.7% of all shoulder injuries in this series were
season ending. Table 3 includes the percentage of each specific injury that was season ending. This, too, is very useful
in counseling athletes regarding their likelihood of returning to play.

Limitations
While it has been consistently used as a source of quality
epidemiologic data for American collegiate athletics, the
NCAA ISS does have limitations. While they collect data
from a convenience sample of institutions sponsoring
intercollegiate mens lacrosse and assign weights to injuries and exposures to allow extrapolation to the entire
NCAA population, many sponsoring schools are not sampled. This introduces the possibility for either overestimation or underestimation of the incidence of injury. In
a validation study, Kucera et al14 found that the NCAA
ISS captured 88.2% of all time-loss injuries in mens and
womens soccer. Division II schools are particularly underrepresented in this population, with no data collected for 3
of the 5 years studied. This could raise concerns about the
applicability of these data to that specific population.
Another limitation of a database study such as this is
that all injury data are reported by athletic trainers and
are not further validated by a sports medicine physician.
The athletic trainers are also limited to the confines of
the designed system. For example, when reporting AC joint
injuries, there are only 2 categories: partial (Rockwood 1 or
2) and complete (Rockwood 3). This is a simplified system, with no allowance for free text comments. As such,
some of the details of specific injuries may be lost. Furthermore, clinical follow-up and treatment decision making are
not captured in this database. This limits our ability to
judge injury severity, beyond time loss. The use of time
loss as a surrogate for injury severity is also limited, as
this is subject to great variability at the hands of different
medical providers. In addition, the use of season ending
also does not provide specific information regarding the
timing of the injury within the season. Thus, season ending
could mean any number of actual days lost. Despite these

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AJSM Vol. XX, No. X, XXXX

Shoulder Injuries in Mens Lacrosse

limitations listed above, this method of data collection has

been previously validated in epidemiologic studies of
American collegiate athletics. Therefore, we believe that
this method allows the most current and representative
presentation of shoulder injuries within the sport of American intercollegiate mens lacrosse.

Areas of Future Research

Similar to prior reports of mens collegiate lacrosse injuries,7 we found injuries to the AC joint to be common and
an important area of future research. The efficacy of current shoulder pads has not been investigated and may
reveal the potential for significant injury prevention. In
our study, we also found a high incidence of labral injuries
in mens lacrosse. This is an area that has not been emphasized previously and deserves further study.

CONCLUSION
Mens lacrosse is one of the fastest growing sports in the
United States, including at the intercollegiate level. It is
a unique sport, with injury risks factors commonly associated with both contact and overhead sports. As such, it is
essential to understand the epidemiology of mens lacrosse
shoulder injuries.
We found that AC joint injuries continue to be particularly common, despite shoulder pads, which are meant to
protect this area. For the first time, we demonstrated the
high incidence of labral and instability injuries in mens
lacrosse. Finally, this study emphasizes the potentially
serious nature of shoulder injuries in mens lacrosse,
with 41.9% of all shoulder injuries necessitating at least
10 days of time loss. This information will also help to
guide future injury prevention programs, including alterations to equipment and rules, to protect the athletes.

ACKNOWLEDGMENT
The authors thank the many athletic trainers who have
volunteered their time and efforts to submit data to the
NCAA Injury Surveillance Program. Their efforts are
greatly appreciated and have a tremendously positive
effect on the safety of collegiate athletes.
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