1 Introduction

Lacrosse is one of the fastest-growing team sports in North America, with increasing participation at high school and collegiate levels. In a survey reported in The National Federation of State High School Associations 2024–2025 Handbook, 115,001 boys and 101,204 girls participated in lacrosse,¹ while 16,030 men and 13,481 women played at the collegiate level.² As participation increases, so does the incidence of lacrosse-related injuries, particularly those affecting the upper extremity. The biomechanics of lacrosse contribute significantly to these injuries, as high-velocity stick swings, frequent hand contact, and ball impact increase the risk of metacarpal fractures, ligamentous sprains, and contusions.³

Despite the growing body of research on lacrosse injuries, significant gaps remain in the literature, limiting a comprehensive understanding of upper extremity injuries in lacrosse. Most prior studies rely on single-institution or small-cohort analyses, restricting the generalizability of their findings.⁴ Few studies distinguish between high school and collegiate athletes, despite differences in physicality, protective equipment, and rule enforcement.^5,6 While concussions and lower extremity injuries have been extensively studied, injuries involving the shoulder, elbow, forearm, wrist, hand, and fingers remain underreported despite their significant impact on athletic performance, return to play, and long-term musculoskeletal function.^3,5,7 Given the sport's reliance on grip strength, fine motor control, and rapid stick-handling movements, these injuries present unique challenges for healthcare providers treating athletes.⁷

The current study aims to contribute to the development of evidence-based injury prevention strategies by providing a nationally representative analysis of lacrosse-related upper extremity injuries among high school and college-aged athletes. By utilizing data from the National Electronic Injury Surveillance System (NEISS), this study will identify injury patterns based on age, sex, and injury distribution. Our goal is to establish risk, injury, and re-injury profiles that can be used to guide athletic trainers, coaches, and healthcare providers in counseling patients about lacrosse participation.

2 Methods

2.2

2.2 Patient selection

This retrospective analysis examined lacrosse-related injuries over a 20-year period, from 2004 to 2023, to allow for a robust evaluation of long-term injury trends. Cases were identified using the NEISS product code specific to lacrosse (1215). To ensure the relevance of injury contexts, cases occurring outside designated sports and recreational settings (NEISS location code: 9) were excluded. To maintain data consistency and avoid confounding factors, cases from 2020 to 2021 were omitted. These years were marked by significant disruptions to organized sports, including widespread season cancellations and altered participation patterns due to the COVID-19 pandemic, rendering the injury data from this period anomalous and not comparable to other years.^20–23 Additionally, cases involving multiple associated product codes were excluded to improve specificity and accurately isolate lacrosse-related injuries. The study focused on patients aged 14 to 23, categorized into two cohorts: the high school-age group (14–18 years) and the college-age group (19–23 years). Then, the analysis was narrowed to focus exclusively on upper extremity injuries, defined as those affecting the shoulder, upper arm, elbow, lower arm (forearm), wrist, hand, and fingers (Fig. 1).

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Fig. 1 Inclusion exclusion criteria.

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3 Results

In total, N = 140,694 patients in the high school-age (14–18 years) and college-age (19–23 years) (n = 4820 unweighted records) presented to the ED for a lacrosse-related injury from 2004 to 2023 (all future figures were calculated using weighted injury counts). Of these cases, N = 50,042 (35.35 %) patients presented to the ED with injuries in the upper extremity, constituting our study population. The overall incidence rate (IR) of upper extremity injuries over the study period was 14.61 injuries per 1000 athlete exposures (AEs) (95 % CI: 8.58–20.64). Fractures had the highest overall IR (5.61; 95 % CI: 3.54–7.68), followed by contusions (3.77; 95 % CI: 1.91–5.62) and strains or sprains (2.64; 95 % CI: 1.56–3.73). Among body regions, the shoulder had the highest overall incidence rate (4.51; 95 % CI: 2.68–6.34), followed by the finger (3.40; 95 % CI: 1.85–4.96) and the wrist (2.38; 95 % CI: 1.40–3.35). Fig. 2 shows the trend of IRs for the high school-age and college-age groups for upper extremity lacrosse injuries.

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Fig. 2 Line Graph Demonstrating Yearly Incidence Rate.

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4 Discussion

This study provides a comprehensive analysis of upper extremity injuries in lacrosse among high school and college-aged players, offering valuable insights for healthcare providers treating lacrosse athletes. The findings highlight significant patterns in injury distribution and reveal important differences based on sex and age group.

Between 2004 and 2023, an estimated 140,694 high school and college athletes sought emergency department care for lacrosse-related injuries. Of these cases, 50,042 (35.35 %) involved the upper extremities, emphasizing the substantial incidence of upper extremity injuries among lacrosse athletes. Notably, these figures appear higher than those reported in previous literature. For instance, Dick et al. found that upper extremity injuries accounted for only 26.2 % of in-game injuries and 16.9 % of practice injuries.²⁴ However, their study focused solely on men's varsity college lacrosse and used the NCAA Injury Surveillance Program, which does not distinguish between outpatient and inpatient treatments. These limitations may contribute to the observed discrepancy. Furthermore, the overall incidence rate (IR) of upper extremity injuries was 14.61 injuries per 1000 athlete exposures (AEs). Studies report varying rates of upper extremity injuries, with incidence ranging from 4.9 per 1000 AEs during general play to as high as 19.6 per 1000 AEs in tournament settings.^24–26 This study's incidence rate of upper extremity injuries appears to approach that of tournament settings, once again suggesting that incidence rates for high school and female athletes are higher than previously published studies. These studies, however, focused solely on men's lacrosse at high-competition levels with smaller sample sizes (NCAA or the World Lacrosse Championship), which may contribute to the discrepancies in results. In contrast, this study examined athletes across age groups and sexes, providing a broader perspective on injury trends. The inclusion of a more diverse population may help capture a more accurate representation of upper extremity injury patterns, suggesting that injury risk could be influenced by factors such as skill level, style of play, and physical demands at different levels of competition.

Despite the increasing popularity of lacrosse, the incidence of upper extremity injuries in lacrosse has decreased over the years (Fig. 2). This may be attributed to the addition of stricter rules to prevent unnecessary injuries, such as increased penalties for intentional hits, banning body checking on players in a defenseless position, and requiring increased protective equipment such as chest protectors.^27–29 Fractures were the most common upper extremity injury, with a particular concentration in the hand and wrist. This aligns with previous research indicating that fractures account for up to 45 % of hand/wrist injuries in lacrosse.³⁰ In addition, shoulder injuries were particularly common, especially among male players, where body checking is regularly permitted. According to Gardner et al., acromioclavicular joint and labral injuries are the most common, with 57 % of shoulder injuries caused by player-to-player contact and 25 % resulting from impact with the playing surface.³¹

This study revealed distinct, sex-specific patterns in upper extremity injuries. Male athletes demonstrated significantly higher rates of upper extremity injuries compared to females across all injury types, outside of hematomas which showed no significant difference (p = 0.1657). Specifically, men were 7.45 times more likely to experience a fracture and 13.23 times more likely to experience a dislocation. This disparity is consistent with previous studies, attributing the increased risk of high-impact injuries in males to the physical nature and rule differences in men's lacrosse. In women's lacrosse, body checking is prohibited, and stick checking is limited to below the shoulders, with contact allowed only on the pocket of the stick. In contrast, men's lacrosse permits body checking, and stick checks can target both the opponent's hands and the stick's shaft.³² Additionally, the men's game features a faster pace of play and higher shot velocities.³³ The combination of these factors leads to a higher overall incidence of injuries across all body parts, as well as an increased risk of more severe injuries in male lacrosse players compared to their female counterparts. Research supports these differences in injury profiles based on differences in gameplay, with studies indicating that 45.9 % of injuries in men's lacrosse result from player-to-player contact, while in women's lacrosse, 42.1 % of injuries are attributed to contact with the ball or stick.^24,34

Age-related trends revealed that high-school lacrosse athletes were more likely to sustain a fracture when compared to their collegiate counterparts (IRR = 0.81; 95 % CI, 0.78–0.86). This is likely due to the ongoing skeletal maturation in young individuals.³⁵ Additionally, studies show that nearly one-third of children experience a fracture before the age of 17, with fractures accounting for 9 % of all childhood injuries.³⁶ Conversely, collegiate lacrosse players have a 2.37 times higher risk of dislocation and are more likely to sustain an injury of the hand, wrist, and shoulder compared to high school athletes. This may be explained by the increased intensity and physicality of collegiate play as well as cumulative exposure to repetitive stress over time. Several studies suggest that older athletes tend to compete more aggressively and intensely, often possessing greater body mass and speed; these factors may contribute to a heightened risk of injury in contact sports.^37–41 Roos et al. found that the rate of overuse injuries in college sports was 3.28 times higher than in high school sports.⁴² Similarly, Yerr et al. reported that among youth, high school, and collegiate lacrosse players, the rate of time-loss injuries (defined as participation restriction exceeding 24 h) per 1000 athlete exposures was highest at the collegiate level.^41,43 This highlights the potential correlation between higher levels of competition and increased injury severity.

When further analyzing the population by age and sex, college males exhibited the highest incidence rates (IRs) for most injury types. However, fractures, hemorrhages, and dermatitis were most common among high school males, while hematomas were highest among college females. Additionally, both collegiate and high school males had the highest IRs across all body regions. This suggests that sex plays a larger role than age in lacrosse-related upper extremity injuries, likely due to the distinct differences in rules and style of play.

The predominance of fractures and shoulder injuries can largely be attributed to the biomechanics of lacrosse, including high-velocity stick swings, player-to-player contact, and falls, creating significant forces on the upper extremities. To mitigate these risks, several recommendations emerge from the findings. Improved design and enforcement of protective gear standards, particularly for gloves with enhanced padding, are critical for reducing fracture risks. Coaches should emphasize proper falling techniques and stickhandling to minimize injuries from falls onto outstretched hands (FOOSH). Implementation of injury prevention programs focusing on strengthening exercises for the shoulder girdle could help reduce dislocation risks.

These findings have important implications for athletes, coaches, and healthcare providers involved in lacrosse. The high incidence of upper extremity injuries, particularly fractures and dislocations, underscores the need for enhanced protective measures and targeted prevention strategies. Moreover, this information can be valuable in counseling patients about their risk of injury should they choose to participate in lacrosse, setting expectations on the likelihood of injury and re-injury. By addressing these challenges proactively, stakeholders can promote safer participation while preserving the integrity of this growing sport.

5 Conclusion

This study provides a comprehensive analysis of upper extremity injuries in lacrosse among high school and college-aged players, offering valuable insights for athletes, coaches, and healthcare providers involved in lacrosse. The findings highlight significant patterns in injury distribution and reveal important differences based on sex and age group. These findings can help guide continued research, improved protective equipment, and tailored injury prevention strategies to ensure the long-term health and safety of lacrosse athletes at all levels of play.

Statement of informed consent

Due to the nature of the study, informed consent was not required.

Author contributions

All authors contributed to the design, drafting, editing, and final approval of this work.

Ethical approval

As the NEISS database contained deidentified information only, no institutional review board approval was required.

Credit author statement

Jacob M. Johnson: Conceptualization, Methodology, Validation, Formal Analysis, Investigation, Resources, Data Curation, Writing-Original Draft, Writing-Review & Editing, Project Administration, Visualization Peter V. Dinh: Conceptualization, Methodology, Data Curation, Writing-Original Draft, Writing-Review & Editing Timothy Reiad: Conceptualization, Methodology, Visualization, Validation, Formal Analysis, Data Curation, Writing-Original Draft, Writing-Review & Editing Simbarashe J. Peresuh: Conceptualization, Methodology, Writing-Original Draft, Writing-Review & Editing Stephen Wendolowski: Conceptualization, Methodology, Writing-Original Draft, Writing-Review & Editing David F. Bruni: Writing-Original Draft, Writing-Review & Editing Michel A. Arcand: Writing-Review & Editing, Project Administration Joseph A. Gil: Conceptualization, Methodology, Validation, Writing-Review & Editing, Project Administration, Supervision.

Consent lacrosse

Consent was not required for this study, as all data and results were obtained from a publicly available national database.

Statement of human and animal rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, revised in 2008. No informed consent was obtained for this study.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.