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Vol. 57. Issue 214.
(April - June 2022)
Review
Open Access
Injury incidence and patterns in rink hockey: A systematic review
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Bernat De Pabloa,b,c,
Corresponding author
bernatdepablo@gmail.com

Corresponding author at: Medical Department, Futbol Club Barcelona, Barça Innovation Hub, C/ Sant Pere n°1 08173, Sant Cugat del Vallés, Barcelona 08028, Spain.
, Javier Peñad,e, Daniel Morenoe, Gil Rodasc,f, Martí Casalsc,d,e,g
a Hospital Universitari Mutua Terrassa, Barcelona 08221, Spain
b Doctoral program in Medicine and Biomedical Sciences, University of Vic - Central University of Catalonia (UVic-UCC), Barcelona 08500, Spain
c Medical Department, Futbol Club Barcelona, Barça Innovation Hub, C/ Sant Pere n°1 08173, Sant Cugat del Vallés, Barcelona 08028, Spain
d Sport and Physical Activity Studies Centre (CEEAF), University of Vic - Central University of Catalonia, Vic, Barcelona 08500, Spain
e Sport Performance Analysis Research Group (SPARG), University of Vic - Central University of Catalonia, Vic, Barcelona 08500, Spain
f Sports Medicine Unit, Hospital Clinic & Hospital Sant Joan de Déu, Barcelona 08950, Spain
g Faculty of Medicine, University of Vic - Central University of Catalonia (UVic-UCC), Barcelona 08500, Spain
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Abstract

This systematic review aims to analyze studies on the extent of injuries in rink hockey athletes. Quality of the reported information was also analyzed. A literature search was performed from January 1992 until August 2020 using the main databases The search terms were: “rink hockey” or the synonym “roller hockey” and “injur*”.

A total of 11 studies were considered eligible and included. Of these, nine were cross-sectional or descriptive. All samples were non-random, and only one study used a standardized consensus classification of injuries.

Muscle strains were the most frequent injuries and lower limbs the most affected body regions. Moreover, overuse was the most common cause, and injury severity was primarily moderate. Injury burden was not reported, and the incidence rate ranged from 3.23–9.7 injuries/1000 h.

We conclude that the quality of the reports has room for improvement in terms of study design, outcome, epidemiology measures, and investigation of injury characteristics.

Keyword:
Injury surveillance
Injury prevention
Roller hockey
Epidemiology
Team sports
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Introduction

Rink hockey (RH), also known as roller hockey, quad hockey, or hardball hockey, is an international team sport played for the first time in England in the late 19th Century.

Spain, Italy, Portugal, and Argentina are the countries with a higher number of RH licenses, and their national teams gather the majority of international trophies. The most mediatic moment for this sport was in 1992 when RH was included in the Barcelona Summer Olympic Games as a demonstration sport.

RH is a collective sport, played on four-wheeled quad roller skates with a wooden stick used as an extension of the arm to propel a round hardball.1 The game is played by two teams of five players (four outfield players and one goalkeeper). It is considered dynamic, with repeated intermittent bouts of high intensity skating.2 Therefore, players need to develop many sport-specific skills, such as coordination, endurance, power, and speed, to optimize their match performance.3

RH is a contact sport, with potential collision elements, either static (fences, goals) or dynamic (hockey sticks and ball).4 Nevertheless, the use of protective equipment, such as helmets or mouthguards, is not mandatory nor frequent (unlike in other similar sports, such as ice hockey and inline hockey).

Over recent decades, knowledge about the epidemiology of injuries has become one of the main trends in sports medicine to decrease injury risk through specific prevention strategies. Indeed, injury studies have been carried out in sports such as soccer,5 basketball,6,7 and ice hockey.8,9

As a sport with important similarities to RH (contact, speed, use of skates and stick), ice hockey can be used as a reference point for the investigation. Many studies focusing on ice hockey injury surveillance have been released in recent years, including male, female, and youth athletes.10,12 Furthermore, studies on the application of injury prevention programs have been carried out.10

This systematic review aims to identify and describe the study design, outcome, objective, population, injury epidemiology measures, and characteristics (type, body region, mechanism, and severity) of injuries sustained in RH athletes while analyzing the quality of the reported information.

MethodsSources of information

A computer-based literature search was conducted within electronic databases from 1990 to August 2020 (the lower limit was set in 1990 because of an increase in the scientific literature in that period due to the inclusion of male RH as a demonstration sport in the 1992 Olympic Games).

The consulted databases were PubMed, Web of Science, SportDiscus, Google Scholar, Scielo, and Semantic Scholar, according to the recommendations from the preferred reporting items for systematic and integrative reviews and meta-analysis statement (PRISMA).11

Search strategy

The search terms were: (rink-hockey OR roller hockey OR quad hockey) AND (injury OR injuries OR pathology) that were included in the title, abstract, or keywords of a paper.

Selection of the studies included in the review

To increase research accuracy, two authors (BDM and MCT) separately screened citations and abstracts to identify the publications relevance for inclusion. Only studies focused on injuries of RH were included.

Afterwards, full texts were obtained to ascertain whether the publications satisfied the inclusion criteria. Besides, the reference sections of the selected articles were searched to identify other relevant papers.

Data were collected and stored in a database and checked by both authors in order to find possible discrepancies that were solved by consensus after reviewing the conflictive articles again.

Inclusion criteria

Any research item about rink hockey injuries was included. Articles in English, Spanish, Portuguese, and Italian were accepted. PhD dissertations, final projects for master's and bachelor's degrees were incorporated.

Exclusion criteria

Manuscripts about other team sports with a formal structure similar to RH were not considered (e.g., inline hockey, also referred to in the literature as roller hockey).

Case reports, abstracts, congress posters, and communications in conferences or workshops were excluded.

Selection process

Fig. 1 uses the PRISMA flowchart to summarize all stages of the process for selecting the papers to review.12

Fig. 1..

Flow chart of the selection of articles to review.

(0.23MB).

The first identification phase revealed 78 research items through database searching and one from another source (directly from the author).

Fifty-four duplicated items were eliminated in the screening phase.

The remaining 25 were then screened for relevance based on their title and full text.

Fourteen items were excluded according to the following criteria: other sports (n = 9), case reports (n = 3), congress posters (n = 2).

Finally, 11 items were included in the review.

Statistical analysis

We performed a descriptive study of some variables analyzed in the different studies, computing absolute and relative frequencies for categorical variables and central tendency and statistical dispersion measures for continuous variables. All analyzes were performed with the R statistical package (The R Foundation for Statistical Computing), version 3.3.3.

ResultsStudy design, primary outcome, and objectives

The 11 reviewed items comprised nine cross-sectional or descriptive studies15–18,21–24 and two experts’ opinions.17,18

Following the description of the study design, the evidence level19 was evaluated as III in nine items (81.8%)13,14,16,20–24 and V in two (18.2%).17,18

Nine studies were specific about RH (13–18,21–23), while two studies included RH among other sports or injury evaluation reporting as the primary objective.20,24 Four studies were conducted in Portugal,14,15,21,22 four in Spain,17,20,23,24 one in Italy,18 one in Argentina,13 and one in Germany.16

The primary outcome was described as injury patterns in five of the 11 studies (45.4%);17,18,20,22,23 injury patterns and incidence in two (18.2%) 14,16; injury incidence in one (9.1%);21 and specific incidence of tendinopathy and craniofacial injuries in the last three studies (27,3%).13,15,24

The objective was defined as descriptive in seven of the 11 studies (63.6%),14–16,20,22–24 analytical in two (18.2%),17,18 non-reported in one (9.1%),21 and unclear in one (9.1%).13

All the information in this subsection is summarized in Table 1.

Table 1.

Characteristics of the studies included in the systematic review.

First author, year Country (Reference)  Study design (evidence level)  Main outcome measured  Objective  Sample size  Num of injuries  Injury definition  Injury data collection  Occurrence measures  Association measures  CI provided 
Pons, 1991Spain17  Experts’ opinion (V)  Injury patterns  Analytical  NR  NR  NR  NR  NR  NR  NR 
Egocheaga, 2004Spain20  Descriptive (III)  Injury patterns  Descriptive  N = 22 male professional SP  48  NR  Prospective study during two seasons. Injured players visited in a Sport Medicine Unit.  Incidence rate  NR  NR 
Marques, 2007Portugal21  Descriptive (III)  Injury incidence  NR  N = 30 male international YPMean age: 15.2 ± 0.44  13  Fuller et al. 200614  Prospective study for 8 months.Injuries recorded by coaches in a predesigned template.  Incidence rate  NR  NR 
Pelaez, 2008Argentina13  Cross-sectional (III)  Craniofacial injuries (any head/neck damaged tissue during a RH game)  Unclear  All players participating in 119 games  85  Craniofacial injuries (any head/neck damaged tissue during a RH game)  Prospective study for 18 months. All games in 2 clubs. Injuries recorded by coaches in a predesigned template.  Incidence rate? Unclear  NR  NR 
Gonçalves, 2008Portugal14  Descriptive (III)  Injury incidenceInjury patterns  Descriptive  N = 63 male YP32 international YPMean age 14.9 ± 0.631 Regional YPMean age 15.4 ± 0.4  8128 injuries (international)53 injuries (regional)  Fuller et al. 200614  Prospective study for 8 months.Injuries recorded by coaches in a predesigned template.  Incidence rate  NR  NR 
Pereira, 2013Portugal22  Descriptive (III)  Injury patterns  Descriptive  N = 289 225 male SP64 male YPMean age: 24.3 ± 5.5    NR  Retrospective questionnaire about injuries during the last season.  Incidence prevalence  NR  Yes 
Durigon, 2014Italy18  Experts’ opinion (V)  Injury patterns  Analytical  NR  NR  NR  NR  NR  NR 
Reverter, 2018Spain23  Descriptive (III)  Injury patterns  Descriptive  N = 23 male SP10 Professional 13 AmateursMean age: 30.48 ± 7.98 years  88 48 amateur team40 professional team  Fuller et al.200614  Prospective study for 2 seasons. Injuries recorded by coaches in a predesigned template.  Incidence proportion?Unclear  NR  Yes 
Lopes, 2019Portugal15  Cross sectional (III)  Orofacial injuries  Descriptive  117 YP (116 male, 1 female) Mean age 15.3 years.    Orofacial injuries  Retrospective questionnaire about mouth/tooth injuries during the whole career  Incidence prevalence  NR  NR 
Florit, 2019 Spain24  Descriptive (III)  Tendinopathy incidence  Descriptive  8 seasons.N = 131 RH playersMean age 29.5 ± 6.7 years.  7447 professional team 27 YP  Tendon injuries according OSIICS classification15  Retrospective revision of clinical history in a multisport elite club.  Incidence proportion  NR  Yes 
Husen, 2020Germany16  Cross sectional (III)  Injury patternsInjury Incidence  Descriptive  108 (69 male, 39 female). 65% German 1st division  2947  NR  Retrospective questionnaire about injuries during the whole career.  Incidence rate  NR  NR 

NR: Non-reported; RH: Rink Hockey; SP: Senior Players; YP: Youth Players

Population and collection, number, and definition of injuries

Eight of the 11 studies (72.7%) stated their sample size, ranging from 22 to 289 athletes, with a median of 85.5 (Q1 = 28.2; Q3 = 120.5). All samples were reported as non-randomized.

Five studies (45.4%) prospectively collected injuries through predetermined templates reported by coaches/physical trainers/physiotherapists (n = 4) or by medical staff (n = 1). Three studies (27,2%) used retrospective questionnaires answered by the athletes, two (18,2%) were experts’ opinion, and one (9.1%) was based on a retrospective review of medical records.

Seven of the 11 studies (63.6%) reported the number of injuries, ranging from 13 to 2947, with a median of 81 (Q1 = 61; Q3 = 86.5). Five (45.4%) did not report the injury classification and three (27.3%) used as an injury definition the Junge's formula.25 Finally, three studies (27.3%) focused on specific injuries (two in craniofacial injuries and one in tendon injuries), and only one (9.1%) used a standardized by consensus injury classification (OSIICS).26

Table 1 summarizes all the data reported above.

Epidemiological measures of occurrence

Seven of the 11 studies (63.6%) reported measures of occurrence, such as: incidence rate (n = 4), proportion (n = 1), and prevalence (n = 2). In two studies, measures were unclear (Table 1).

None used association measures, and only one calculated the confidence intervals.

Measures of injury incidence

Two of the 11 studies14,21 presented the injury incidence rate calculated following standardized formulas.25 Both studies were conducted among Portuguese youth players. The total rate was 3.2321–9.714/1000 exposure hours (EH). The match rate was 17.514–36.721(21)/1000 EH, and the training rate was 1.7721–7.514/1000 EH.

Other studies presented injury incidence rates using non-standardized formulas. In Egocheaga's study20 the rate was 7.1 injuries/500 EH, and the formula was not specified.

The Husen study reported 9.4 ± 12.3 injuries/1000 AE (9.8 ± 11.1/1000 AE in men and 8.9 ± 14.3/1000 h AE in women).16 In Husen's study, the AE was defined as the “number of athletes participating in a game or practice regardless of duration or type of exposure”.

In Florit's study,24 the injury incidence proportion of tendinopathy was 64.4 and 19.6 injuries/100 athletes/season, respectively, for professional RH players and youth RH players.

In the specific studies about orofacial injuries, 45/117 (25.4%) of the interviewed players reported at least one orofacial trauma during their career(15) and the incidence rate of craniofacial injuries in Pelaez's study was reported as 85 injuries/100 match hours.13

Although two studies reported an injury incidence rate or proportion during matches and training sessions,16,23 none of them calculated the athletic exposure. The Reverter study23 reported 88 injuries; 26.1% (n = 23) occurred during training sessions and 73.9% (n = 65) during matches. In the Husen study,16 the athletes reported in the injury surveillance questionnaire that 53.3% of their injuries occurred during practice and 46.7% during matches, but these observations were not confirmed or registered by any medical staff.

None of the studies calculated the injury burden. Table 2 summarizes injury incidence.

Table 2.

Injury incidence in RH studies.

First author, year Country (Reference)  Population  Total incidence  Training incidence  Match incidence  Incidence formula  Injury burden 
Pons, 1991 Spain17  NR  NR  NR  NR  NR  NR 
Egocheaga, 2004 Spain20  Professional  7.1 injuries / 500 h  NR  NR  NR  NR 
Marques, 2007 Portugal21  International YP  3.23 injuries / 1000 h  1.77 / 1000 h  18.45 /1000 h  Junge et al. 200614  NR 
Pelaez, 2008 Argentina13  NR  NR  NR  85 / 100 h  Craniofacial injuries / 100 match hours*  NR 
Gonçalves, 2008 Portugal14  International YPRegional YP  4.9 injuries / 1000 h9.7 injuries / 1000 h  3.7 / 1000 h7.5 / 1000 h  17.5 / 1000 h36.7 / 1000 h  Junge et al. 200614  NR 
Pereira, 2013 Portugal22  Senior & YP  NR  NR  NR  NR  NR 
Durigon, 2014 Italy18  NR  NR  NR  NR  NR  NR 
Reverter, 2018 Spain23  Professional & amateur senior players  NR  NR  NR  Junge et al. 200614  NR 
Lopes, 2019 Portugal15  YP  NR  NR  NR  NR  NR 
Florit, 2019 Spain24  Professional YP  64.4 **19.6 **  NR  NR  Injuries / 100 players / season  NR 
Husen, 2020 Germany16  MenWomen  9.8 ± 11.1/1000 AE8.9 ± 14.3/1000 AE  NR  NR  AE definition = n of athletes participating in a game or practice regardless of duration or type of exposure.  NR 

*Craniofacial injuries: any damage in head/neck tissues. **Tendinopathy injuries. AE: Athlete Exposure, YP: Youth Players, NR: Non-Reported

Injury characteristicsType of injuries

Muscle strain was the most frequent injury in two of the studies in Spanish RH players,20,23 followed by tendon/ligament injuries in Egocheaga's study20 and by fractures in Reverter's study.23

In young Portuguese athletes, articular injuries were the most frequent, followed by muscle/tendon injuries.14

In the Pelaez study, 10% of the reported craniofacial injuries were fractures.13

The type of injuries reported in the reviewed research is shown in Table 3.

Table 3.

Injury characteristics in RH studies.

First author, year Country (Reference)  Population  Total injuries  Type of injury  Mechanism of injury 
Pons, 1991 Spain17  NR  NR  NR  NR 
Egocheaga, 2004 Spain20  Professional SP  48  Muscle injuries n = 21 (43.7%), tendon/ligament injuries n = 13 (27.1%), bone injuries n = 5 (10.4%), others n = 9 (18.8%).  9 (18.8%) direct trauma, 22 (45.8%), overuse (including muscle injury), 17 (35.4%) acute injury. 
Marques, 2007 Portugal21  International YP  13  NR  NR 
Pelaez, 2008 Argentina13  NR  85  Fractures n = 8 (9.4%).  39% contact with stick, 24% elbow, 21% ball, 5% skate, 4% hand, 4% fences, 3% others 
Gonçalves, 2008 Portugal14  International YPRegional YP  2853  Joint injuries n = 36 (44.4%), muscle/tendon injuries n = 25 (30.9%), contusions n = 17 (21%), fractures n = 3 (3.C7%).   
Pereira, 2013 Portugal22  SP and YP  NR  NR  242 (45.1%) acute, 294 (54.9%) overuse. 
Durigon, 2014 Italy18  NR  NR  NR  NR 
Reverter, 2018 Spain23  Professional SPAmateur SP  4048  Muscle injuries n = 22 (25%), fracture n = 20 (22.7%), wound n = 16 (18.2%), sprain n = 6 (6.8%), contusion n = 6 (6.8%), dislocation n = 4 (4.5%), concussion n = 4 (4.5%), others n = 10 (1,4%)  Professional SP: n = 16 (40%) traumatic, n = 24 (60%) overuseAmateur SP: n = 32 (66,7%) traumatic, n = 16 (33,3%) overuse 
Lopes, 2019 Portugal15  YP  NR  NR  71.9% impact with equipment, 28.1% impact with other athletes. 
Florit, 2019 Spain24  Professional SPRegional YP  4727  Senior: Adductor tendinopathy n = 8 (17%), hamstring n = 5 (10.6%), shoulder n = 3 (6.4%)YP: Adductor tendinopathy n = 5 (18.5%), shoulder n = 3 (11.1%), hamstring n = 1 (3.7%).  NR 
Husen, 2020 Germany16  Men and women RH players  2947  Abrasion (23.4%), wrist contusion (7.9%), thigh muscle strain (6.2%), knee contusion (5.4%), cervical muscle strain (5.1%).  NR 

NR: Non-Reported; SP: Senior Players; YP: Youth Players.

Body region affected

The lower limbs were the body regions with the highest proportion of injuries, followed by the upper limbs and head and neck. Trunk and back injuries were only reported in one study.

No detail about the specific regions (thigh, calf, shoulder, forearm) or affected muscles, tendons, or ligaments were reported, except for the Florit study.24 In this latter study, the most frequent tendinopathy in professional and young RH players involved the adductor muscles, followed by the hamstring in professional players and shoulder tendinopathy in young players.

Two studies presented specific data about craniofacial injuries. Lopes study reported orofacial injuries in 117 Portuguese youth players; 38.5% of the subjects referred an RH-related orofacial trauma. Only four out of the 45 affected athletes (8.9%) were using a mouthguard at the moment of the accident.15 Pelaez study reported craniofacial injuries during 119 games of the Argentinean League: in 54 games (45.4%), at least one craniofacial injury was reported. The facial area was the most commonly affected (lips 37%, nose 21%, orbit 21%, chin 11%).13

In Husen's study,16 the knee was the location most likely to cause time-loss injuries (38.5%), followed by foot (14.5%) and hand (13.7%).

The most frequent injured body regions are shown in Fig. 2.

Fig. 2..

Most affected body regions reported in RH injury research.

(0.14MB).
Mechanism of injury

Four studies reported the mechanism of injury. Overuse was the most frequent mechanism of injury in Egocheaga's study20 (20) (45.8%), followed by an acute presentation (35.4%).

In Reverter's study,23 the leading cause of injury was contact with the stick (22.7%), whereas 13.6% of injuries occurred with no contact. On the contrary, in the German questionnaire,16 the primary causes of reported injuries were ball contact among men (35.7%) and collisions among women (32.1%).

In Pelaez's study,13 craniofacial injuries were caused by contusion with a stick (39%), other players’ elbow (24%), ball (21%) or skate (5%). Finally, in Lopes’ study (25), most of the impacts were with mobile equipment (71.9%), other athletes (28.1%)

The reported mechanisms of injury are shown in Table 3.

Injury severity

The Husen questionnaire16 detected a median time loss due to injuries of 0.9 ± 1.4 weeks per player per season and 12.7 ± 20.3 weeks per player career.

In Pereira's questionnaire,22 athletes reported that ankle/feet injuries caused an average time-loss of 13.7 ± 24.2 days, followed by knee injuries (11.1 ± 24.3 days) and groin/hip injuries (10.1 ± 29.9 days).

Pelaez's study13 showed that 3% of the 85 craniofacial injuries led to a loss of consciousness, and 16% required a transfer to the hospital, with 9.4% causing fractures.

In the Florit study,24 64% of the tendinopathies reported did not cause the players to miss practices or matches.

Moderate injuries (7–28 days) were the most frequent in the three studies, following the Junge classification about severity.27 The injury severity is summarized in Table 4.

Table 4.

Injury severity in RH studies.

First author, year Country (Reference)  Population  Total injuries  Time loss (days) average ± SD (range)  Mild (1–7 days)  Moderate (7–28 days)  Severe (>28 days) 
Pons, 1991 Spain17  NR  NR  NR  NR  NR  NR 
Egocheaga, 2004 Spain20  Professional SP  48  NR  NR  NR  NR 
Marques, 2007 Portugal21  International YP  13  4.63 ± 9.43 (1–33)  5 (38.5%)  7 (53.8%)  1 (7.7%) 
Pelaez, 2008 Argentina13  NR  85  NR  NR  NR  NR 
Gonçalves, 2008 Portugal14  International YPRegional YP  2853  31.1 ± 35.2 (1–115)38.9 ± 27.2 (4-79)  11 (39.3%)28 (52.8%)  13 (46.4%)22 (41.5%)  4 (14.3%)3 (5.7%) 
Pereira, 2013 Portugal22  SP & YP  NR  Ankle/feet injuries 13.8 ± 24.2 Knee injuries 11.1 ± 24.3Groin/hip injuries 10.1 ± 29.9  NR  NR  NR 
Durigon, 2014 Italy18  NR  NR  NR  NR  NR  NR 
Reverter, 2018 Spain23  Professional SPAmateur SP  4048  NRNR  6 (15%)8 (16.7%)  26 (65%)18 (37.5%)  8 (20%)22 (45.8%) 
Lopes, 2019 Portugal15  YP  NR  NR  NR  NR  NR 
Florit, 2019 Spain24  Professional SPRegional YP  4727  NR  NR  NR  NR 
Husen, 2020 Germany16  Men and women RH players  2947  0.9 ± 1.4 weeks per player per season12.7 ± 20.3 weeks per player career.  NR  NR  NR 

SD: Standard Deviation; SP: Senior Players NR: Non-Reported; YP: Youth Players.

Experts’ opinions

Two articles with experts’ opinions on RH hockey were found. The first article17 was released during the 1992 Olympic Games. The Medical Staff of the Spanish National Team stated that the most frequent injuries were strains in adductor muscles, overuse injuries in anterior tibial muscles, ankle sprains, and wrist injuries in RH players; and knee articulation injuries (the meniscus tear being the most frequent) and hamstring strains in goalkeepers. The quality score of the study was 19% (Table 1).

The Medical Staff of the Italian National Team18 also released an article in 2014 describing muscle strains in the adductor area and articular injuries in the ankle and knee as the most frequent injuries in RH. Moreover, lower back pain and shoulder tendinopathy were the most frequent overuse injuries. Finally, this study concurred with the Spanish article that the most frequent injury in goalkeepers was the knee articulation injury (meniscus).

Neither studies presented epidemiological data to support these arguments. The quality score of the study was 12,5% (Table 1).

Discussion

Despite a growing scientific interest in RH over the last few years (several studies on physical performance2,28,29 or match analysis30,31 have been carried out), there are few studies regarding injury profiles or surveillance. Moreover, the articles found in our research had high methodological heterogenicity and small samples. To our knowledge, this is the first systematic review that summarizes the injury profiles of RH players. Our analysis may set a starting point in the study of RH injuries, allowing us to assess real problems and tailor specific prevention programs.32,33

Study design, primary outcome, and objectives

Even though most of the analyzed research is descriptive, design and objective are not reported in five of the 11 studies. According to Nielsen et al.34 failure to be clear about goals may lead to inappropriate, misleading, and flawed conclusions in sports injury research. Therefore, we must encourage that in future research about RH, an optimal study design description must be stated.

Furthermore, none of the included studies presented a high level of evidence, and there were no randomized cohort studies or case-control studies.

Population and definition, collection, and number of injuries

The majority of analyzed studies included male professional RH players. Male youth players were also involved in several reports.14,15,21,22,24 On the contrary, female athletes were only incorporated in one study.16 Moreover, the sample size was generally small and comprehended heterogeneous age groups.

The injuries classified by player position were unavailable in epidemiological studies (despite the goalkeepers’ specific injuries mentioned in two experts’ opinion articles). Only three studies used standardized injury definition, and data collection sources were heterogeneous (conducted by athletic therapists, athletic trainers, physicians using injury registry databases). Also, all the included articles except for one did not use injury classification tools such as OSIICS,35 and this may cause a lack of homogeneity in the categorization of injuries. Thus, better consistency and homogenization in the definitions and methodologies may help compare data across studies.26

Finally, more exhaustive studies, including all ages and female athletes, should be performed to obtain better information about RH's actual injury patterns.

Epidemiological measures of occurrence

Standard measures used to describe the frequency of injury are incidence proportion and incidence rate.36 In a sport-injury context, the numerator is generally the number of injuries or number of injured athletes, while the denominator is often the total number of athletic exposures or hours played during the follow-up period.37

In our systematic review, only two studies used standardized formulas to report injury incidence.14,21 That can be a limitation for further investigations because equivalent formulas allow a comparison between populations and data.

The results obtained in the studies involving Portuguese international youth players showed an overall injury rate between 3.2321–9.714/1000 exposure hours (EH). The match injury incidence ranged from 17.514–36.721/1000 EH and the training incidence from 1.7721 to 7.514/1000 EH. The results can be compared with professional sports, such as ice hockey (15.6/1000 h overall incidence);38 futsal (6.8/1000 h overall incidence, and 44.9/1000 h match incidence);39 handball (6.5/1000 h overall incidence, and 22.2/1000 h match incidence).7 Nevertheless, we should consider that there might be differences between senior players and youth players, so the comparison of the results should be made with caution. In a study conducted on American basketball youth players, the overall incidence was 1.94/1000 EH, and the match incidence was 3.27/1000 EH.7

As shown, results from other sports demonstrated that injury incidence during matches is higher than during training because of several factors (e.g., the higher physical and physiological demands required in matches compared to training sessions.40

Further research must be carried out to confirm this trend in RH with studies on senior players, including female athletes. The final goal will be to implement injury prevention programs.

Despite injury incidence is widely used, injury burden has now been suggested as the most accurate measure to evaluate the impact of injuries in athletes.26 The injury burden should consider the injury and the exposure and time-loss in the equation.41 Nevertheless, none of the evaluated research in our review calculated the injury burden.

Characteristics of injury (type, body region, mechanism, and severity)

Muscle injuries seem to be the most frequent injury in RH players. None of the studies described the affected muscle groups. Joint injuries seem to be frequent in youth players20 Nevertheless, only in one study, the injuries were surveilled by medical staff.20

Lower limbs were the most affected body regions, and moderate injuries (7-28 days) were the most frequent.

High prevalence of head injuries

Specific studies have been carried out about injuries in the craniofacial area in RH players since these types of injuries have become a reason of relevant concern in all sports in the last decade.42,43 At the moment, no helmet nor mouthguard is mandatory for RH players, although some countries, such as Italy, recommend the use of a helmet in youth players. The Spanish RH Federation (Real Federación Española de Patinage) has presented the project to implement a protective helmet in different categories over the 2021–2022 season.44 This implementation is supported by Lopes22 and Pelaez23 studies concluding that more effective protection gear must be considered for all players to prevent craniofacial injuries. Also, data from other sports support this implementation. Indeed, a helmet is mandatory in ice hockey, where the head is the most reported injured body area.45,46 In inline hockey, the helmet is also mandatory, and the reported head injuries are lower.47

Groin pain

We found two articles about groin pain in RH players.48,49 We excluded them from this systemic review because they did not investigate the epidemiology of RH injuries. Besides, none of them sustained any epidemiological data about groin pain in RH players to justify an investigation about this matter. We think that it is relevant to mention these studies because in a field that is hardly explored, such as RH injuries, the existence of two articles focused on a specific injury reveals a concern.

Limitations

In addition to the limitations of the included studies, there were also limitations in the review process. The search strategy was deliberately broad to identify all original RH-related studies, including reference searches and knowledge from authors with extensive RH research backgrounds. However, it is still possible that large studies reporting on other sports or injuries could have reported on RH within a subgroup analysis.50

Despite all limitations, our study sets a starting point in the injury surveillance in RH players, willing to understand the physical implications of this sport better.

Conclusions

Our systematic review revealed that research on RH injuries is spare and presents high methodological heterogenicity. The studies present relevant methodological issues that do not draw valid comparisons and evaluations to reach conclusions or patterns.

According to the studies included in this review, the most frequent injury was muscle strain; the most frequent mechanism was acute; the most affected body regions were the lower limbs, and the severity was mainly moderate (7–28 days of return-to-play).

Head and neck injuries are reported as a concerning issue, suggesting that further investigations on the effect of appropriate protective equipment are needed.

According to this systematic review, the quality of the reports on injury surveillance has room for improvement. Finally, more research on injury incidence and burden should be performed to implement specific prevention programs and adopt the best countermeasures.

Funding

MC acknowledges the financial support from the Ministry of Science and Innovation and the Ministry of Universities of the Government of Spain (Ref: PID2019-104830RB-I00/AEI DOI: 10.13039/501100011033).

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