The Current State of Head and Neck

Injuries in Extreme Sports

Vinay K. Sharma*, Juan Rango,* MD, Alexander J. Connaughton,* MD,
Daniel J. Lombardo, MD, and Vani J. Sabesan, MD
Investigation performed at the Homer Stryker MD School of Medicine,
Western Michigan University, Kalamazoo, Michigan, USA
Background: Since their conception during the mid-1970s, international participation in extreme sports has grown rapidly. The
recent death of extreme snowmobiler Caleb Moore at the 2013 Winter X Games has demonstrated the serious risks associated
with these sports.
Purpose: To examine the incidence and prevalence of head and neck injuries (HNIs) in extreme sports.
Study Design: Descriptive epidemiological study.
Methods: The National Electronic Injury Surveillance System (NEISS) was used to acquire data from 7 sports (2000-2011) that
were included in the Winter and Summer X Games. Data from the NEISS database were collected for each individual sport per
year and type of HNI. Cumulative data for overall incidence and injuries over the entire 11-year period were calculated. National
estimates were determined using NEISS-weighted calculations. Incidence rates were calculated for extreme sports using data
from Outdoor Foundation Participation Reports.
Results: Over 4 million injuries were reported between 2000 and 2011, of which 11.3% were HNIs. Of all HNIs, 83% were head
injuries and 17% neck injuries. The 4 sports with the highest total incidence of HNI were skateboarding (129,600), snowboarding
(97,527), skiing (83,313), and motocross (78,236). Severe HNI (cervical or skull fracture) accounted for 2.5% of extreme sports
HNIs. Of these, skateboarding had the highest percentage of severe HNIs.
Conclusion: The number of serious injuries suffered in extreme sports has increased as participation in the sports continues to
grow. A greater awareness of the dangers associated with these sports offers an opportunity for sports medicine and orthopaedic
physicians to advocate for safer equipment, improved on-site medical care, and further research regarding extreme sports injuries.
Keywords: extreme sports; head and neck injuries; concussions; epidemiology

Over the past few decades, extreme sports has become a

widely used phrase to describe a variety of nontraditional
and adventure sports. The label has evolved to denote
activities such as bungee jumping, snowboarding, extreme
skiing, canyoning, surfing, skateboarding, skydiving, paragliding, rock climbing, and mountain bicycling.2,7,14,16,22
Several epidemiological studies have shown that since the

conception of extreme sports in the 1960s, participation has

grown exponentially.5,6 Extreme sports have been accepted
as a separate and organized entity, as evidenced by the
advent and rising popularity of the X Games, the introduction of slope-style snowboarding events into the Winter
Olympics in 2014, and an increasing number of nationally
televised events over the past decade. Extreme sports are
believed to have a greater risk of injury compared with traditional sports. Currently, little evidence exists describing
the injury rates for extreme sports due to their nontraditional, independent participation and lack of official regulation.5 Our preconception of an increased risk of injury and
death with extreme sports necessitates the need to better
understand injury rates and trends.3-5,22
Injury characteristics of extreme sports vary extensively
due to their high-energy, high-risk nature.8,13 Specifically,
head and neck injuries (HNIs) are of growing concern
because of increased awareness of short- and long-term consequences reported in the literature.2,9,14,17,19 HNIs include
concussions, fractures, and traumatic brain injuries (TBIs),

Address correspondence to Vani J. Sabesan, MD, Department of

Orthopaedic Surgery, Wayne State University School of Medicine, Suite
305, 18100 Oakwood Boulevard, Detroit, MI 48124, USA (e-mail:
vsabesan@med.wayne.edu).
*Homer Stryker MD School of Medicine, Western Michigan University,
Kalamazoo, Michigan, USA.

Department of Orthopaedic Surgery, Wayne State University School

of Medicine, Detroit, Michigan, USA.
The authors declared that they have no conflicts of interest in the
authorship and publication of this contribution.

The Orthopaedic Journal of Sports Medicine, 3(1), 2325967114564358

DOI: 10.1177/2325967114564358
The Author(s) 2015

This open-access article is published and distributed under the Creative Commons Attribution - NonCommercial - No Derivatives License (http://creativecommons.org/
licenses/by-nc-nd/3.0/), which permits the noncommercial use, distribution, and reproduction of the article in any medium, provided the original author and source are
credited. You may not alter, transform, or build upon this article without the permission of the Author(s). For reprints and permission queries, please visit SAGEs Web site
at http://www.sagepub.com/journalsPermissions.nav.

1
Downloaded from ojs.sagepub.com by guest on February 7, 2015

Sharma et al

The Orthopaedic Journal of Sports Medicine

which can result in outcomes such as chronic depression,

headaches, paralysis, and death.9 Several articles have
described injuries associated with extreme sports; however,
they have primarily focused on mainstream activities such
as snowboarding, snow skiing, and skateboarding. The objective of this study was to examine the epidemiology of HNI
in 7 extreme sports over the past decade (2000-2011). The
sports were selected based on their popularity and active
status in the X Games (both winter and summer) and other
major televised extreme sporting events. Our hypothesis
was that there would be an increased rate of HNI over
the 12-year time period and that concussions would be the
most common HNI reported among the 7 extreme sports.

METHODS
The National Electronic Injury Surveillance System
(NEISS) of the Consumer Product Safety Commission
(CPSC) was used to acquire data for this study from
2000 to 2011. The CPSC conducts yearly sampling frames
of all active emergency departments in the United States,
including information regarding the total number of
emergency department visits. The NEISS is a national
probability sample of 100 hospitals in the United States
and its territories.1 Patient information is collected from
each NEISS hospital for every emergency visit involving
an injury associated with consumer products, such as
sporting equipment. Data are updated on a daily basis,
and any missing information is obtained by telephone
interviews with patients within the first week after
injury. From this sample, the total number of injuries
treated in hospital emergency rooms nationwide can be
estimated. The sampling procedure and the statistical
basis for calculation of national estimates based on the
NEISS data are validated approaches and described on
the CPSC website. The derivation of sampling weights
used by the NEISS is well established and used by researchers and government agencies.18 Sampling weights were
applied to the NEISS data to account for selection, for number of annual emergency department visits for each hospital, and for hospitals that do not respond. After being
weighted, the NEISS data provides estimates for the total
number of specific consumer productrelated sports injuries in the United States. Variables included in the standard NEISS case report are treatment date, sex, race,
diagnostic category, body part injured, patient disposition, and location of injury. As a part of the Consumer
Product Safety Mission, the NEISS database serves as a
reliable and reproducible source for a wide range of epidemiological subjects.
Injuries associated with 7 extreme sports were identified
and examined using the NEISS consumer product codes in
this study: snowboarding (5031), snowmobiling (1290),
surfing (1261), mountain biking (5033), motocross (5036),
skateboarding (1333), and snow skiing (3283). Because of
the way the NEISS categorizes their product codes, motocross included 2-wheeled, powered, off-road vehicles such
as dirt bikes and trail bikes; mopeds and mini-bikes were
excluded. Surfing included injuries related to windsurfing.

Figure 1. Head and neck injuries in 7 extreme sports between

2000 and 2011.
Snow skiing included injuries related to downhill skiing,
cross-country skiing, ski jacks, ski lifts, and snowshoes.
Four types of head injuries and 4 types of neck injuries
were recorded for each extreme sport during the 12-year
span. Concussion, contusions/abrasions, fractures, and
lacerations were recorded for head injuries. Contusions/
abrasions, fractures, lacerations, and strains/sprains were
recorded for neck injuries.
The risk of concussion, neck fracture, and skull fracture
were calculated using participation rates for extreme sports
from the 2013 Outdoor Foundation Participation Report,
which contained data from 2007 to 2012.15 The Outdoor
Foundation is a not-for-profit organization focused on
encouraging and enhancing the experiences of people in the
outdoors. Annually, the organization conducts a series of
online interviews and surveys to assess the participation
in various outdoor sports. Similar to the NEISS database,
a weighting technique was used to balance the data and
accurately reflect the entire US population. For this study,
we used participation figures from 2007 to 2011 for all
Americans older than 6 years; limited data are available
prior to 2007 for the 7 extreme sports.15 Of note, there were
no data recorded by the Outdoor Foundation study for
motocross.
For each NEISS injury case report, the activity and
sampling weight were recorded. National estimates for
extreme sports injuries were calculated by summing the
sampling weights for all injury case reports within a specific sport. This was done for the different types of HNIs
for each year from 2000 to 2011. Incidence rates and ratios

Downloaded from ojs.sagepub.com by guest on February 7, 2015

The Orthopaedic Journal of Sports Medicine

Head and Neck Injuries in Extreme Sports

TABLE 1
Common Head and Neck Injuries in Extreme Sports (2000-2011)
Summer Sports, n (%)
Surfing
Head injuries
Concussion
Contusion/abrasion
Fracture
Laceration
Total
Neck injuries
Contusion/abrasion
Fracture
Laceration
Strain/sprain
Total
Other head and neck injuries
Total, summer sports

3242 (8.2)
2097 (5.3)
173 (0.4)
14,990 (37.7)
20,502 (51.6)
344
1209
187
10,112
11,852
7404
39,758

(0.9)
(3.0)
(0.5)
(25.4)
(29.8)
(18.6)
(100)

Mountain Biking

Motocross

Skateboarding

4530 (29.7)
1080 (7.1)
115 (0.8)
1182 (7.8)
6907 (45.3)

22,788 (29.1)
5164 (6.6)
961 (1.2)
3211 (4.1)
32,124 (41.1)

28,328 (21.9)
14,703 (11.3)
3544 (2.7)
17,189 (13.3)
63,764 (49.2)

221 (1.5)
527 (3.5)
69 (0.5)
2059 (13.5)
2876 (18.9)
5450 (35.8)
15,233 (100)

1321 (1.7)
1452 (1.9)
825 (1.1)
10,626 (13.6)
14,224 (18.2)
31,888 (40.8)
78,236 (100)

442 (0.3)
42 (0.0)
151 (0.1)
6637 (5.1)
7272 (5.6)
58,564 (45.2)
129,600 (100)

Winter Sports, n (%)

Snowboarding
Head injuries
Concussion
Contusion/abrasion
Fracture
Laceration
Total
Neck injuries
Contusion/abrasion
Fracture
Laceration
Strain/sprain
Total
Other head and neck injuries
Total, winter sports

Snowmobiling

Snow Skiing

42,811 (43.9)
6963 (7.1)
403 (0.4)
6514 (6.7)
56,691 (58.1)

4054 (24.6)
1290 (7.8)
162 (1.0)
992 (6.0)
6498 (39.5)

34,897 (41.9)
4488 (5.4)
625 (0.8)
5507 (6.6)
45,517 (54.6)

375 (0.4)
784 (0.8)
88 (0.1)
13,645 (14.0)
14,892 (15.3)
25,944 (26.6)
97,527 (100)

581 (3.5)
206 (1.3)
349 (2.1)
3886 (23.6)
5022 (30.5)
4928 (30.0)
16,448 (100)

230 (0.3)
1039 (1.2)
181 (0.2)
14,009 (16.8)
15,459 (18.6)
22,337 (26.8)
83,313 (100)

were calculated only from years 2007 to 2011 using the

injury statistics from the NEISS and the participation
rates from the 2013 Outdoor Foundation report. Incidence
rates and incidence rate ratios were calculated for all
extreme sports except motocross, since the Outdoor Foundation does not include participation figures for motocross. A single simple linear regression analysis was
used to assess the relationship between time and participation in the 7 extreme sports over the 12-year span. Student t tests were used to compare injury rates between
sports. All statistical analyses were performed using R
statistical software version 3.0.1, with a 0.05.

RESULTS
A total of 4,083,691 injuries were reported for all 7
extreme sports between 2000 and 2011, of which 460,115
(11.3%) were HNIs. Of the total reported HNIs, 381,760
(83%) were head injuries and 78,355 (17%) were neck injuries. The average number of HNIs was 38,385 per year.
Regression analysis demonstrated a significant increase

(P .001) in the occurrence of HNIs over the studied time

period (Figure 1). Although the incidence of injuries in
extreme sports HNIs increased from the year 2000
(34,565) to 2011 (40,042), this trend was not consistent
from year to year. Additionally, there was no significant
increase in the total number of participants from year to
year (P .08). Furthermore, when combined, there was
no significant difference (P .67) in the occurrence of
HNIs between the 3 winter and 4 summer extreme sports
during the 12 years (Table 1).
There was a wide range of injury rates for HNI between
individual extreme sports (Figure 2). The 4 sports with the
highest total number of reported HNIs during the 12-year
period were skateboarding (129,600), snowboarding
(97,527), skiing (83,313), and motocross (78,236) (Table
1). The sports with the lowest reported number of HNIs
were mountain biking (15,233), snowmobiling (16,448),
and surfing (39,758). There were 140,650 concussions
(31% of HNIs, 3.4% of all injuries) reported over the
12-year period for extreme sports. Snowboarding had the
most concussions (42,811), accounting for 30% of all
reported concussions, while snow skiing had the second

Downloaded from ojs.sagepub.com by guest on February 7, 2015

Sharma et al

The Orthopaedic Journal of Sports Medicine

Snowboarding had the greatest calculated incidence of

concussions (535.7 per 1,000,000 person-years), followed
by skateboarding (414.9 per 1,000,000 person-years)
(Table 3). Furthermore, a snowboarder was 3.5 times more
likely to suffer a concussion compared with a snow skier
(152.5 per 1,000,000 person-years). There was a 54 times
greater calculated risk of a skull fracture for skateboarding (54.7 per 1,000,000 person-years) compared with
snowboarding (0.98 per 1,000,000 person-years) (Table 4).
Similarly, there was a 38 times greater risk of suffering a
neck fracture while surfing (38.09 per 1,000,000 personyears) compared with skateboarding (1.00 per 1,000,000
person-years) (Table 4). Mountain biking was the second
riskiest sport with respect to neck fractures, with an incidence rate of 12.8 per 1,000,000 person-years.

DISCUSSION

Figure 2. Distribution of injuries in individual extreme sports

from 2000 to 2011.

most occurrences (34,897), accounting for 25% of all

reported concussions (Figure 3). Snowmobiling and surfing had the fewest reported concussions (2.9% [4054] and
2.3% [3242], respectively).
Severe HNI (classified as either a cervical or skull fracture) had a total occurrence of 11,242, which accounted
for 2.4% of HNIs. Skateboarding and motocross had the
greatest number of severe HNIs (3586 and 2413, respectively) (Figure 3). Furthermore, skateboarding had
the highest reported number of skull fractures (3544),
accounting for 59.2% of all reported skull fractures for
extreme sports, and motocross had the highest incidence
of neck fractures (1452), which accounted for 27.6% of all
reported neck fractures.
The risk of an extreme sport participant suffering an
HNI over a 1-year period was 5.16 per 10,000 personyears (motocross was excluded from risk analysis). The
average injury incidence rates for the summer and winter
extreme sports were 6.10 per 10,000 person-years and 4.23
per 10,000 person-years, respectively, with a calculated
incidence rate ratio (IRR) of 1.44 for the summer sports,
with the winter sports as the referent group. Skateboarding had the highest risk of HNI for extreme sports participants (10.21 per 10,000 person-years), while mountain
bicycling had the lowest risk (1.08 per 10,000 personyears) (Table 2). The HNI incidence rates for snowboarding were much higher than snow skiing (8.6 and 2.45 per
10,000 person-years, respectively), with a calculated IRR
of 3.5 for snowboarding compared with snow skiing as the
referent group (Table 2).

This study presents previously unknown data and establishes incidence rates of HNIs in extreme sports. Between
2000 and 2011, over 4,000,000 injuries occurred in
extreme sports, of which 11.3% were HNIs. Although the
risk of HNI while participating in extreme sports was low,
there was a significant increase in the number of HNIs
from 2000 to 2011. Furthermore, as participation grows
in these nontraditional sports, physicians need to be
aware of the distribution of injuries specific to extreme
sports to implement optimal treatment and prevention
programs.
Concussions were the most common HNI among
extreme sports participants (Table 1). The risk of suffering
a concussion was highest in snowboarding and skateboarding. Recently, there has been a lot of media attention
placed on the long-term sequelae of concussions suffered
in mainstream sports. It is well known that permanent
neurological deficits are related to severe and recurrent
concussions.12 Most professional and collegiate sports
and many high school organizations have adopted timeeffective concussion policies12 and implemented use of
tools like the SCAT 2 on the sidelines. One of the medical
challenges with extreme sports is patient accessibility.
Many extreme sports take place in environments where
medical care may not be readily available on site, with the
exception of participation in professional competitions.
Because of these challenges, greater emphasis needs to
be placed on proper helmet and safety strategies to prevent participant concussions.
In addition to concussions, severe injuries are another
concern in extreme sports. Skateboarders were found to
have the highest risk of skull fractures compared with the
5 other extreme sports. Surfers had the highest risk
of neck fracture, with a surprising 38 times increased risk
compared with skateboarders. While the incidence of severe
injuries was low for the studied extreme sports, skull and
neck fractures can have devastating effects on quality of life.
Physicians need to be aware of these trends in activities with
high rates of severe injuries, such as skateboarding, so that
they can provide proper patient advice, prevention care, and
safety equipment. Additionally, our study found that 12% of

Downloaded from ojs.sagepub.com by guest on February 7, 2015

The Orthopaedic Journal of Sports Medicine

Head and Neck Injuries in Extreme Sports

Figure 3. Distribution of severe injuries and concussions in individual extreme sports. (A) Occurrence of concussions and (B)
occurrence of severe injuries.

TABLE 2
Risk of Head and Neck Injuries in Extreme Sports
Sport
Mountain biking
Snowmobiling
Snow skiing
Surfing
Snowboarding
Skateboarding

Incidence Rate per

10,000 Person-Years

Incidence
Rate Ratio

1.08
1.64
2.46
7.00
8.60
10.21

1
1.51
2.28
6.49
7.97
9.46

TABLE 3
Incidence Rate of Concussions in Extreme Sports
Sport
Mountain biking
Snowmobiling
Surfing
Snow skiing
Skateboarding
Snowboarding

Incidence Rate per

1,000,000 Person-Years

Incidence
Rate Ratio

50
60
103
152
415
534

1
1.2
2.06
3.04
8.3
10.68

motocross injuries were HNIs, similar to previously published studies (14%).11

Head and neck injuries pose serious economic and social
threats. The overall cost associated with an HNI in
extreme sports has been described in 3 phases.20 The first
phase is the cost of the evacuation (transport, acute medical care, etc), the second phase is the cost of rehabilitation
(therapy, treatment, etc), and the third phase is the cost to

TABLE 4
Incidence Rate of Skull and Neck Fractures
in Extreme Sports

Skull fractures by sport

Snowboarding
Mountain biking
Snow skiing
Snowmobiling
Surfing
Skateboarding
Neck fractures by sport
Skateboarding
Snow skiing
Snowmobiling
Snowboarding
Mountain biking
Surfing

Incidence Rate per

1,000,000 Person-Years

Incidence
Rate Ratio

1
2
2
4
9
55

1
2
2
4
9
55

1
5
6
7
13
38

1
5
6
7
13
38

the community (social support, future medical care, etc).

The cumulative cost of all 3 phases for HNI for an individual patient can range from $30,000 to $2 million, depending on the severity of the injury.4 Furthermore, the
consequences of HNI are not restricted to economics; they
can also negatively alter quality of life and interpersonal
relationships. Severe concussion or repeat concussion can
lead to chronic traumatic encephalopathy, a syndrome
that results in a high rate of depression, drug dependence,
and possibly, suicide attempt or completion.1 Studies have
shown that HNIs have resulted in deteriorated marital
relationships, decreased income, and a feeling of loneliness resulting from a lack of social interaction.10,21

Downloaded from ojs.sagepub.com by guest on February 7, 2015

Sharma et al

The Orthopaedic Journal of Sports Medicine

Limitations were present in this study. The NEISS database obtains information from only emergency room visits,
thus excluding patients who go untreated or are treated in outpatient settings. Furthermore, NEISS data are restricted to
the product-code system. The combination of these 2 factors
limits how accurately we can predict rates and trends in the
general population. Additionally, the population of the study
includes both recreational and competitive sports participation; therefore, it may not accurately reflect the risk of individuals participating in an extreme sport. A study using a
database that tracks injuries in organized extreme sports competitions (eg, X Games) would be a useful area of future focus.

CONCLUSION
This study helps educate participants and physicians about
the types of HNIs associated with the growing arena of
extreme sports. This study offers important data regarding
the trends of HNI in extreme sports. HNIs can greatly alter
a persons quality of life, and as participation in these sports
increases, understanding the incidence of HNI will assist in
implementing effective medical prevention programs and
proper safety equipment practices. More research regarding
the long-term outcomes of HNI in extreme sports needs to
be done to provide sports medicine physicians with a comprehensive clinical picture of these devastating injuries.
REFERENCES
1. (CPSC) USCPSC. The NEISSThe National Electronic Injury Surveillance
System: a tool for researchers. US Consumer Product Safety Commission. http://www.cpsc.gov/en/ResearchStatistics/NEISS-Injury-Data/.
Accessed February 13, 2013.
2. Ackery A, Hagel BE, Provvidenza C, Tator CH. An international review
of head and spinal cord injuries in alpine skiing and snowboarding. Inj
Prev. 2007;13:368-375.
3. Balthrop PM, Nyland J, Roberts CS. Risk factors and musculoskeletal
injuries associated with all-terrain vehicle accidents. J Emerg Med.
2009;36:121-131.
4. Bergeron MF, Engebretsen L. Protecting elite athletes in extreme and
challenging environments: advancing the dialogue. Br J Sports Med.
2012;46:769.
5. Brymer E, Schweitzer R. Extreme sports are good for your health: a
phenomenological understanding of fear and anxiety in extreme
sport. J Health Psychol. 2013;18:477-487.

6. Caine DJ. The epidemiology of injury in adventure and extreme

sports. Med Sport Sci. 2012;58:1-16.
7. de Jong P. The health impact of mandatory bicycle helmet laws. Risk
Anal. 2012;32:782-790.
8. Goulet C, Hagel BE, Hamel D, Legare G. Self-reported skill level and
injury severity in skiers and snowboarders. J Sci Med Sport. 2010;13:
39-41.
9. Graves JM, Whitehill JM, Stream JO, Vavilala MS, Rivara FP.
Emergency department reported head injuries from skiing and
snowboarding among children and adolescents, 1996-2010. Inj
Prev. 2013;19:399-404.
10. Jennum P, Kjellberg J, Ibsen R, Bendix T. Health, social, and economic consequences of neck injuries: a controlled national study
evaluating societal effects on patients and their partners. Spine (Phila
Pa 1976). 2013;38:449-457.
11. Larson AN, Stans AA, Shaughnessy WJ, Dekutoski MB, Quinn MJ,
McIntosh AL. Motocross morbidity: economic cost and injury distribution in children. J Pediatr Orthop. 2009;29:847-850.
12. Ma R, Miller CD, Hogan MV, Diduch BK, Carson EW, Miller MD.
Sports-related concussion: assessment and management. J Bone
Joint Surg Am. 2012;94:1618-1627.
13. Ogawa H, Sumi H, Sumi Y, Shimizu K. Skill level-specific differences in snowboarding-related injuries. Am J Sports Med. 2010;
38:532-537.
14. Osberg JS, Schneps SE, Di Scala C, Li G. Skateboarding: more dangerous than roller skating or in-line skating. Arch Pediatr Adolesc
Med. 1998;152:985-991.
15. The Outdoor Foundation. 2013 Outdoor Recreation Participation
Report. http://www.outdoorfoundation.org/research.participation.
2013.html. Accessed February 13, 2013.
16. Pikora TJ, Braham R, Mills C. The epidemiology of injury among surfers, kite surfers and personal watercraft riders: wind and waves. Med
Sport Sci. 2012;58:80-97.
17. Rice MR, Alvanos L, Kenney B. Snowmobile injuries and deaths in
children: a review of national injury data and state legislation. Pediatrics. 2000;105:615-619.
18. Schroeder T, Ault K. The NEISS sample design and implementation.
http://www.cpsc.gov//PageFiles/106617/2001d011-6b6.pdf. Accessed
September 29, 2013.
19. Sulheim S, Holme I, Ekeland A, Bahr R. Helmet use and risk of
head injuries in alpine skiers and snowboarders. JAMA. 2006;
295:919-924.
20. Tator CH, Duncan EG, Edmonds VE, Lapczak LI, Andrews DF. Complications and costs of management of acute spinal cord injury. Paraplegia. 1993;31:700-714.
21. Wedcliffe T, Ross E. The psychological effects of traumatic brain
injury on the quality of life of a group of spouses/partners. S Afr J
Commun Disord. 2001;48:77-99.
22. Willig C. A phenomenological investigation of the experience of taking
part in extreme sports. J Health Psychol. 2008;13:690-702.

Downloaded from ojs.sagepub.com by guest on February 7, 2015