Michigan Governor’s Council on Physical Fitness, Health and Sports
Position Statement:
The Prevention of Injuries In
In-line Skating
In-line skating is one of the fastest-growing amateur sports in the United States.1 Due to the relatively high rate of injuries associated with in-line skating, the members of the Governor’s Council on Physical Fitness, Health and Sports believe that specific measures of intervention are essential for the safety and enjoyment of those who participate in in-line skating. Research has shown that education and the use of appropriate equipment can drastically reduce the incidence and severity of injuries sustained during in-line skating. We believe that the inherent healthful benefits of in-line skating make the current high level of participation in the sport a valuable social trend. However, we believe that attitudes and use of protective equipment must be improved. In order to sustain the present popularity of in-line skating, and concurrently, to reduce the unacceptable level of associated injuries we recommend the following:
Recommendations Regarding Education
• Master the basic skills of striding, stopping, and turning before skating in open terrain. Skaters should maintain control at all times by skating at a pace commensurate with their skill level.
• Learn and obey all traffic regulations. Skaters should consider themselves under the same obligations as the rider of a bicycle or the driver of an automobile when skating on paths, sidewalks or roads.
• Skate on the right side of a lane and pass on the left. Skaters should announce their intention to pass by stating “passing on your left” as they approach pedestrians.
• Yield to pedestrians at all times.
• Learn the laws and ordinances that apply to in-line skaters in your community and obey them. Destruction of public property and inconsiderate actions have resulted in various venues throughout the United States being declared off-limits to in-line skaters. Courteous and thoughtful skaters are the best insurance against further restrictions.
• Seek instruction from a certified in-line skating instructor. The International In-Line Skating Association (IISA) hosts local clinics and regional test sites for the certification (three levels) of in-line skating instructors. Most of the serious injuries to in-line skaters occur among beginners who have had no instruction in the basics of in-line skating.
Recommendations Regarding Equipment
• Wear protective equipment. This equipment should be in place before the skates are placed on the feet. Protective equipment includes a fitted helmet, wrist guards, and elbow and knee pads.
• Keep equipment in proper working order to maintain maximum control. Proper maintenance includes replacing worn wheels or bearings, adjusting or replacing worn brake pads, and aligning wheels that are loose or misaligned.
• Do not skate in water, sand or oil, or over sewer drains. Such surfaces can interfere with proper functioning of skates.
• Use only certified equipment that is individually fitted to the skater. Helmets should meet the standards of recognized certifying organizations such as the American National Standards Institute (ANSI), American Society for Testing and Materials (ASTM), the Snell Memorial Foundation (SMF), or the U.S. Consumer Product Safety Commission (CPSC).
Recommendations Regarding the Environment
• Do not wear earphones or use any devices that will impair hearing or distract you from attending to traffic, pedestrians, or the skating surface.
• Avoid skating in darkness. If unavoidable, wear reflective clothing and carry a light to illuminate you and your path.
• Skate with caution in unfamiliar environments or on foreign or novel surfaces.
• Select environments that you know are safe. Avoid uneven surfaces, roads and paths with debris, and neighborhoods where safe passage cannot be ensured.
• Avoid crowds, traffic, and uneven surfaces if you are a beginning skater. Beginning skaters should also be accompanied by an experienced skater.
In-line skating has been the fastest-growing amateur sport in the United States during the past seven years, increasing from an estimated three million to 27 million participants-an increase of 798% between 1989 and 1996.27 Michigan ranks sixth among active participants in in-line skating, outdistanced only by the more populous states of California, Texas, New York, Florida, and Ohio. With slightly over one million of Michigan’s residents involved with in-line skating (one-half million in the metro Detroit area), it is prudent to consider the benefit/cost ratio of the sport, with a view toward increasing health-related benefits and reducing the injuries and commercial costs of participating in in-line skating.
Definition
In-line skating is defined as a sport wherein locomotion is achieved by traveling on skates with wheels (generally four per skate) in line with each other. In-line skating has attracted a wide audience, including recreational skaters, fitness enthusiasts, athletes in cross-training, hockey players, cross-country and alpine skiers, stunt competitors, racers, artistic performers, and extreme skaters.
History of In-line Skating
In-line skating evolved from roller skating, which, as legend has it, was developed to occupy ice hockey players during the months when there was no ice in northern Europe.42 The first in-line skate, featuring three in-line wheels attached to a wooden plate, was patented in Paris, France, in 1819.42 Numerous renditions appeared over the next century, but it was not until 1984 when a comfortable skate with a reliable brake revolutionized in-line skating and introduced millions of Americans to skating as a means of recreation, competition, fitness, training, or transportation.
Today, children under 12 represent the largest group of in-line skaters (38%), while teenagers account for an additional 25%.25 Fifty-five percent of adult skaters have been skating for two years or less. The in-line skating population in the United States is nearly equally divided between males (54%) and females (46%). Marketing analyses indicate that in 1995 72% of skate sales were to first-time buyers. These statistics reveal that in-line skating is a new activity for most Americans. The wide range in ages and its appeal to both genders from a variety of occupations suggests that in-line skating has an enduring place in the American world of leisure and sports.
INJURIES RESULTING FROM
IN-LINE SKATINGOverview
The recent emergence of in-line skating as a popular American pastime also brought with it reports of injuries and deaths that many believe could have been prevented through programs of education and knowledge of the epidemiology related to in-line skating injuries.3,5,6,13,17 The staff of the Consumer Product Safety Commission (CPSC) concluded that almost one-third of the injuries associated with in-line skating treated by emergency room personnel in the United States occurred to bodily areas for which protective equipment was available to prevent or lessen the severity of the injury.18
Prior to 1990, injuries associated with in-line skating received little national attention. Of the 42 reports pertaining to in-line skating injuries available for this review, all but one appeared after 1990. The first death associated with in-line skating was reported to CPSC in 1992.18 Since January, 1992, CPSC has received reports of 52 deaths associated with in-line skating, two-thirds of which involved a motor vehicle. Forty-two of the reported dead were males and 31 were children under 15 years of age.
The estimated number of injuries due to in-line skating that were treated in emergency rooms has increased from 37,000 in 1993, to 76,000 in 1994, to 99,500 in 1995 and to 103,000 in 1996.32 However, the number of injuries from 1995 to 1996 increased by only 3%, while participation numbers increased by approximately 17%. Although such data do not dispel the concern about injuries, they may indicate that educational programs and protective equipment are having an influence on in-line skaters.
How In-line Skating Injuries Occur
The rapid emergence of in-line skating as a popular recreational activity introduced millions of participants to a sport for which they had neither any fundamental movement skills, nor the time to acquire the rudiments of balance, striding, turning, or stopping-all essential skills for safely participating in in-line skating.22 In less than a decade of experience with in-line skating, the scientific literature has provided a clear indication of the types of injuries associated with the sport, their frequency and severity, and the circumstances under which they occur.2,9,10,14,36,40 However, at this time there is not complete evidence concerning the effectiveness of certain types of equipment in preventing injuries. It is also not known how many injuries could be avoided through developmentally appropriate instructional programs.
The nature of in-line skating places the participant in a precarious position from the moment that the skates are worn. The participant is required to balance, while moving, on narrow wheels that offer little resistance to hard surfaces. Although roller skating and ice hockey require many of the skill components that are essential to in-line skating, many in-line skaters have no previous experience with skating of any type.13,32
Most in-line skating injuries occur when beginning skaters fall on a hard surface. Attempting to stop or turn are the movement objectives most often associated with the injuries. Although falling forward is the most common reaction to the loss of balance, in-line skaters frequently fall backward when upright balance is disrupted.13
Frequency, Severity, and Sites of Injuries
Injuries associated with in-line skating have been sufficiently documented since the early 1990s so that trends in the frequency, severity, and epidemiology are available. Numerous circumstances involving in-line skating contribute to the high rate of severe injuries. The rapid rise in popularity of in-line skating has created a void in developmentally appropriate instructional programs.11,22,26 The wide appeal of in-line skating to both genders within the 5- to 70-year age range has contributed to the unmet needs for safe places for participants to practice. High-risk behaviors common in extreme skating may also contribute to the injury rate. Lack of regulations in many states regarding protective equipment permits skaters to ignore suggestions regarding apparel that may prevent or reduce the severity of injuries. The need for smooth surfaces has sent many skaters to the roads, paths, and sidewalks inhabited by pedestrians, cyclists, and motorists.3,9,13 This combination of circumstances has led to an unacceptable frequency and severity of injuries associated with in-line skating.10
The most comprehensive data on injuries associated with in-line skating has been compiled by the U.S. Consumer Product Safety Commission’s National Electronic Injury Surveillance System (NEISS).25 Data from NEISS and independent investigations2,6,10,13 confirm that the upper extremity is the most common site for injuries associated with in-line skating. Data amalgamated by NEISS for the year 1994 showed involvement of the wrist in 24% of the injuries, followed by the lower leg-knee-ankle in 19%, the lower arm and elbow in 18%, and the head and face in 14%.
Injuries in in-line skating are relatively severe,10,29,38 with 40% involving fractures.3 The remaining types are: abrasions and contusions - 22%, sprains and strains - 18%, lacerations - 13% and unclassified - 7%.3,18 Motor vehicles impose the greatest danger to in-line skaters,13 contributing to 19 of the sport’s 25 fatalities between 1992 and 1995.3
The emerging literature on injuries associated with in-line skating is sufficiently abundant for the formulation of public policy regarding the rules under which skaters should function. Public policies could address the use of protective equipment; fundamental skill development; protective qualities of attire; and the responsibilities of sharing sidewalks, paths, and roads with pedestrians, cyclists, and motor vehicles. Initiation of public educational programs, such as those implemented to promote the use of helmets by cyclists, could greatly reduce the frequency and severity of injuries to in-line skaters.
Experience
Most in-line skaters attempt to skate without any previous instruction. Although the skills involved in sports such as ice hockey, figure skating, roller skating, skiing and skateboarding are common to in-line skating, many of those injured while in-line skating either have no previous experience with these compatible sports or have not participated in them recently.2,10 Banas2 reported that two of eight persons were injured in their very first attempt to skate. The database from NEISS25 revealed that 15 of 101 persons were injured on their first or second attempts at skating.
Protective Equipment
The short history of documented injuries associated with in-line skating and the evolution of designs in skates, helmets and wrist protection precludes a definitive statement regarding the cost/effectiveness of using specific articles of protective equipment.32,33,35 However, preliminary evidence overwhelmingly suggests that (a) protective equipment-including wrist guards, elbow and knee pads, and helmets-would result in a significant reduction in injuries associated with in-line skating, and (b) protective equipment is vastly underused by in-line skaters.10,12,13,17,18,28,31,32
The proposition that protective equipment could reduce the frequency and severity of injuries associated with in-line skating prompted several investigators to study the frequency and patterns of use by skaters. Young and Mark41 noted that of the 1,548 skaters observed by them, 31.7% wore no protective equipment, 64.5% wore only wrist guards, and only 2.6% wore helmets. Overall, adolescent males, children under 12 years of age, and advanced-level skaters were the least likely to wear protective equipment.
Data from NEISS confirms the efficacy of protective equipment in preventing injuries associated with in-line skating.32,18 Schieber and associates32 found that of subjects drawn from a national probability sample of those injured while in-line skating, only 7% wore the four recommended articles of protective equipment, 46% wore no protective equipment, 45% wore knee pads, 33% wore wrist guards, and 20% wore helmets. Schieber et al.32 estimated that failure to wear wrist guards increased the possibility of wrist injuries ten-fold, and failure to wear elbow pads increased the risk of elbow injury by a factor of 9.5.
The rapid increase in total injuries associated with in-line skating and the reluctance of skaters to wear appropriate protective equipment prompted the Consumer Product Safety Commission,3,11,18 the National Youth Sports Safety Foundation,12 and the International In-Line Skating Association42 to initiate national campaigns to promote the use of proper equipment. Kyle18 estimated that almost one-third of the injuries associated with in-line skating that were treated in hospital emergency rooms occurred to body parts where protective equipment was available to prevent or lessen the severity of the injury.
Despite the general consensus among physicians, epidemiologists, educators, and manufacturers that specific protective equipment could reduce the incidence and severity of injuries to in-line skaters, there is some evidence that wrist guards, as currently designed, may transfer the location of the injuries instead of preventing them. Scalone31 reported that if wrist guards are to fulfill their function of causing the skater to skid, rather than fall on the wrist, the impact will be transferred to the torso, thereby necessitating the use of a helmet to protect the head. Broida4 stated that although wrist guards prevented abrasions and contusions, they did not necessarily prevent fractures. Cheng et al.8 reported the occurrence of fractures to the forearm adjacent to the proximal border of the wrist guards, suggesting that the wrist guard may have transferred the impact to the proximal border of the splint. Thus, the design of some protective equipment may be associated with its own specific injury pattern.
Although injuries to the head occur less frequently than other injuries associated with in-line skating, they most frequently rank among the most severe.3,9,18,23,24 Weinberger and Selesnick39 reported that falls from in-line skating have resulted in a new cause for fractures of the temporal bone. The aversion of in-line skaters to wearing helmets suggests that an educational campaign similar to the one initiated to promote the wearing of helmets by bicycle riders is in order.
Barriers to wearing protective equipment during in-line skating are numerous, but not insurmountable. Young and Mark41 reported that although teenage skaters were the least likely to wear protective equipment, they were also the most susceptible to peer pressure. Therefore, promotional campaigns are likely to have the greatest influence on this age group.
Wearing protective equipment seems to be influenced by convenience, cost, image, and comfort.35,41 Children frequently wear helmets and knee pads used in other sports. The cost of helmets may equal or exceed the cost of the skates and the design of helmets may dissuade adolescents from wearing them.35 Manufacturers must ensure that the style of the helmet is attractive, while retaining its protective properties. The medical community must join with community groups in educational programs that promote the use of appropriate equipment.
The adoption of in-line skating as a means to achieve aerobic fitness has accentuated its health-related benefits. Mahar et al.19 reported that the impact shock wave that is customarily transmitted to the entire body when walking or running was attenuated by 50% during in-line skating. Thus, the lower impact of in-line skating may reduce the likelihood of degenerative diseases of the joints, while maintaining the necessary impact that is necessary for remodeling of bone. The reduced impact shock of in-line skating is attributed to a low change in the vertical velocity as the skate contacts the surface. Minimal acceleration of the head during the impact of in-line skating should also provide a more stable visual field, reduce vestibular excitation, and allow for a more stable gravitation reference than the locomotor skills of walking and running.
The physiological and biomechanical demands of in-line skating, compared to the more conventional modes of achieving aerobic fitness, have been the topics of numerous investigations.15,16,20,21,30 A typical protocol for assessing the physiological demands of aerobic activities is to compare their requirements in oxygen uptake and heart rate and to assess the build-up of lactic acid. Carroll et al.7 noted that in-line skating produced significantly greater heart rates and absolute oxygen uptake values than ice skating in collegiate ice hockey players. Thus, the metabolic cost of in-line skating was greater than ice skating at three velocities commonly experienced in game conditions. Snyder et al.34 reported that across the spectrum of oxygen uptakes studied, heart rates were higher with in-line skating than with cycling or running. However, when a criterion of lactic acid concentration was used as a measure of training effect in highly fit individuals, the in-line skating activity was less effective than running in achieving a significant training effect.
The substitution of in-line skating for running or cycling in order to achieve aerobic fitness or to enhance body composition has appealed to many adult fitness enthusiasts. Wallick et al.37 found that at comparable intensities the absolute maximal oxygen consumption (VO2 max) in in-line skating was approximately 5% lower than for treadmill running, but the metabolic load was similar. Furthermore, at comparable levels of oxygen consumption, the subjects perceived the effort to be identical in the two exercise conditions.
The training effects of in-line skating have been of interest to ice hockey players, skiers, and speed skaters. Hoffman et al.15,16 corroborated the report of Snyder et al.34 that highly trained individuals may have to resort to greater velocities or inclined surfaces in order to achieve a significant training effect through in-line skating.
Comparisons of metabolic energy requirements of in-line skating with walking, running, speed skating, skiing, and ice hockey skating demonstrate that in-line skating is a suitable alternative for achieving aerobic fitness among individuals. Highly trained individuals may have to increase their speed or the degree of the skating incline to receive a significant training effect.