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Online Surveillance Aids in Examining High School Sports Injury

Dawn Comstock, PhD, has made a career of sports statistics. Yet you won’t find her providing play-by-play color commentary or being asked to debate which team is more likely to advance to the playoffs. She’s not as interested when a player breaks a record as she is when a player breaks a bone.

Dr. Comstock is a leading authority on pediatric sports injury. She heads the only team in the country collecting sports injury surveillance data in a national sample of high school athletes.

The centerpiece of Dr. Comstock’s injury surveillance research is an internet-based software called RIOTM. Short for “Reporting Information Online,” RIOTM was developed by Information Technology experts at Nationwide Children’s in 2004. “There was not a commercially available tool that could do the internet-based data collection that we needed to do year after year,” said Dr. Comstock. “So, they created RIOTM.”

Modeled after the NCAA’s injury reporting system, High School RIOTM allows Dr. Comstock to capture injury data in 20 high school sports, from about 175 high schools throughout the country. “Every week, athletic trainers log in to our system to tell us what sports are in session, how many kids are practicing, how many kids are playing and how many kids have sustained an injury,” said Dr. Comstock. “For every injury, trainers include a very detailed report that tells us about the injured athlete, the injury sustained and about the injury event itself so we can start looking at risk factors.”

In a 2009 study of athletic trainers and varsity coaches, Dr. Comstock found that although athletic trainers lacked more responses for demographic questions when completing RIOTM, they were much more likely to participate and better at following directions for reporting. Participating athletic trainers submitted 338 injury reports; participating coaches submitted only 55. “Any U.S. high school with a National Athletic Trainer’s Association certified athletic trainer on staff is eligible to participate in High School RIOTM,” said Dr. Comstock.

An email requesting participation is sent at the beginning of the academic school year to every high school athletic trainer who is a member of the National Athletic Trainer’s Association and provides care to high school athletes. Participating schools are chosen at random. “The reason for the random sampling is so we can apply weighting factors to calculate national estimates of injuries,” said Dr. Comstock. “It allows us to use a relatively small, relatively inexpensive sample and still calculate national estimates.”

Dr. Comstock’s use of RIOTM has led to 22 manuscripts with findings such as: more than six percent of studied high school sports injuries were related to illegal activity; although boys have a higher overall rate of knee injury, girls are twice as likely to sustain knee injuries requiring surgery; and in gender comparable sports, including basketball, soccer, and baseball/softball, girls had a significantly higher rate of concussion than boys.

Some of the most notable findings are those related to concussion, which have caught the attention of national media including Time, the New York Times and People. A 2007 study showed that girls have a higher incidence of concussion than boys in basketball, soccer, and baseball/softball. Most recently, Dr. Comstock found that from 2005 to 2008, 41 percent of concussed athletes in 100 high schools across the United States returned to play too soon, against the guidelines set out by the American Academy of Neurology.  Sixteen percent of high school football players who lost consciousness during a concussion returned to the field the same day.

As Dr. Comstock examines data, she provides her findings to organizations like the National Federation of State High School Associations to help inform policy. “They are using our data to drive their decision making as to whether or not rules should be changed and whether additional education should be required,” said Dr. Comstock. “Currently there is a push to try to have legislation in every state across the country that would put specific requirements on when and how a student athlete can return to play following a concussion. They are using our data to try to push that legislation through.”

In addition to annual injury surveillance, RIOTM is also used for sentinel surveillance to help predict anticipated injuries, such as skin infections in wrestling. “During the course of the year we create a weekly report of the number of skin infections by region so we can monitor cases to see if we have any outbreaks.” Two years ago, Dr. Comstock’s team identified a skin infection outbreak in Minnesota two weeks before it became apparent to sports authorities. In response, the entire wrestling season was suspended.

Since RIOTM is similar to the NCAA’s injury surveillance system, Dr. Comstock can directly compare injuries that happen among high school athletes to those among collegiate athletes. “In every sport we have studied, injury rates in collegiate athletes are significantly higher than injury rates in high school athletes,” she said. “This information is important from an injury prevention standpoint. We’re learning that the same rules and education that are appropriate at the collegiate level aren’t always appropriate at the high school level.”

Dr. Comstock says her hope is to maintain High School RIOTM for the next 10 years so that she can examine trends over time. With the baseline data they have now collected, they can begin to examine the impact clinical interventions have on sports injury. “We recently received a grant to try to identify student athletes that might be at high-risk for concussion because of their neck strength,” said Dr. Comstock. “If we can make a correlation between neck strength and concussion, we can then enroll these kids in a simple neck strengthening training program and see whether or not it reduces the rate of concussion. What’s more, we have the ongoing surveillance to evaluate interventions to see how effective they are.”

How does High School RIOTM work? Access the demo site at

Yard EE, Collins CL, Comstock RD. A comparison of high school sports injury surveillance data reporting by certified athletic trainers and coaches. J Athl Train. 2009 Nov-Dec;44(6):645-52.

Collins CL, Fields SK, and Comstock RD. When the Rules of the Game are Broken: What Proportion of High School Sports-Related Injuries are Related to Illegal Activity? Inj Prev. 2008;14(1);34-38.

Yard EE, Comstock RD. Compliance with return to play guidelines following concussion in US high school athletes, 2005-2008. Brain Inj. 2009 Oct;23(11):888-98.

Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and collegiate athletes. J Athl Train. 2007 Oct-Dec;42(4):495-503.

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