Sports Exercise and Injury (1997) 3, 31-42

ORIGINAL ARTICLE

 

 

Time-loss injuries in Junior Olympic taekwondo athletes

 

W. Pieter and E. D. Zemper*

Department of Exercise and Movement Science, University of Oregon, *Exercise Research Associates of Oregon (ExRA), Eugene, Oregon, USA

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SUMMARY. The purpose of this study was to assess the time-loss injuries in Junior Olympic taekwondo athletes. Data were collected at two national tournaments and one international meet. Injury data were collected by project staff and tournament medical personnel with simple check-off forms that describe the athlete and nature, site, circumstances and severity of the injury. Non-parametric procedures were used to determine the differences between boys and girls relative to total time-loss injury rate, body part injured within each gender, as well as estimated days lost. The boys (25.54/1000 athlete-exposures) sustained a lower total time-loss injury rate than the girls (29.91/1000 athlete-exposures) (P = 0.021). No other significant differences were found, although the head and neck ranked second in time-loss injuries in both boys (8.57/1000 athlete-exposures) and girls (9.10/1000 athlete-exposures).

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Address correspondence to: W. Pieter PhD, School of Life Sciences, University of North London, 166-220 Holloway Road, London N7 8DB, UK. Phone: +44 171 753 7023 (Ext 2357); Fax: +44 171 753 5081

INTRODUCTION

Epidemiological studies on injuries in young athletes participating in martial sports in general and in taekwondo in particular are scarce. For instance, Von Apel (1) conducted a case study on 28 young male judo athletes (14-18 years) and concluded that judo is not necessarily related to injuries to the spine of these youngsters, although 17.86% of them were found to have spinal abnormalities such as osteochondrosis. Menge and colleagues (2) did a cross-sectional study on 28 young male fencers (no age available) and although the fencers showed a higher prevalence (21.40%) for scoliosis in the range 11-15 compared to a control group (11.43%), no differences were found between the two groups in injuries to the spine. In a case study on French young athletes (4-16 years), male judo athletes sustained 9.26% of all injuries reported and their female colleagues, 4.55% (3). Unfortunately, the distribution of injuries by body part was not presented by gender. Wirtz et al (4) reported three cases of calcaneal apophysitis in young taekwondo athletes (9, 11 and 12 years old) as a result of repeated breaking of boards in the month prior to the injury.

Other investigators have focused their attention on injuries in general in young combative athletes. For instance, Oler et al (5) used a prospective design to assess the injuries sustained at one US Junior Olympic national taekwondo championship. The authors found that about 54% of all reported injuries were to the head and neck. Unfortunately, this proportion is for the combined sample of boys and girls. No separate data were provided by gender.

Although researchers have included young martial sport athletes in their sample, they have likewise failed to distinguish them from their adult counterparts in reporting the injuries (6-8). Only one study was located in which the authors reported on time-loss injuries in taekwondo. Martin et al (9) recorded the injuries at one national tournament and found that the boys incurred 8.2 time-loss injuries per 100 athletes and the girls, 8.3. This rate was much higher than that found in young wrestlers (6-16 years) for which 4.65 time-loss injuries per 100 participants were recorded (10).

In view of the paucity of data, the purpose of this study was to assess the time-loss injuries in Junior Olympic taekwondo athletes. Time-loss injury is defined as any injury that would keep the athlete from finishing the present bout and/or continuing with subsequent bouts and that would prevent him or her from returning to practice or competition for at least one day. In addition to type of time-loss injury, the location, situation and mechanism of injury were recorded. This study is part of a larger project, the Oregon Taekwondo Research Project (OTRP), that was initiated by the first author (WP) during his tenure at the University of Oregon, USA.

DEFINITION OF SERIOUS INJURY

A serious injury is defined as any injury that keeps an athlete from participating in training or competition for three weeks or more.

METHODS

Data were collected at the 1989 and 1990 US National Junior Taekwondo Championships and the unofficial Junior Taekwondo World Championships in 1989. The two US National Championships involved a total of 3274 boys and 865 girls (6-16 years old), and the World Championships involved 67 boys and 52 girls (13-16 years old). All tournaments were single elimination competitions.

Injury data were collected by project staff and tournament medical personnel with simple check-off forms that describe the athlete and nature, site, circumstances, and severity of the injury. These forms are a variation of forms used by the Athletic Injury Monitoring System (AIMS), a national sports injury data collection system designed and operated by one of the authors (EDZ). A form was completed for every injury for which treatment was sought by the competitors, referees or coaches from the medical staff at the competition site.

Exposure data for calculating injury rates were gathered from records of bouts actually fought. Injury rates were calculated from matches fought and minutes fought using the basic rate formula:

(# injuries # athlete-exposures (or minutes of exposure)) x 1000 = # injuries per 1000 athlete-exposures or per 1000 minutes of exposure.

One athlete-exposure (A-E) refers to one individual competing in one bout where he or she is exposed to the possibility of being injured.

The Mann-Whitney U test was used to determine the difference in total injury rate per 1000 A-E between boys and girls. The Kruskal-Wallis test was employed to assess the difference in injury rate per 1000 A-E within each gender relative to the following body parts: head and neck, upper extremities, trunk, and lower extremities. The Kruskal-Wallis test also was used to determine the difference between boys and girls relative to estimated days lost due to time-loss injuries All analyses were performed with a = 0.05.

RESULTS

Table 1 shows the total injury rates for time-loss injuries per 100 competitors, 1000 athlete-exposures and per 1000 minute-exposures. The time-loss injury location, type, situation, mechanism and estimated days lost are displayed in Tables 2-6.

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Table 1 Injury rates of time-loss injuries in young taekwondo athletes

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Boys

Girls

No. of athletes

3341

917

No.of A-E

6068

1538

No. of minutes exposed

21894

5855

No. of time-loss injuries

155

46

Total injury rates

 

 

-- time-loss/100 competitors

4.64

5.02

-- time-loss/1000 A-E

25.54

29.91

-- time-loss/1000 minutes

7.08

7.86

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Table 2 Distribution of time-loss injuries by body part* per 1000 AE

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_____Boys____

 

 

____Girls____

 

Body part

Number

Injury rate

Body part

Number

Injury rate

Head

28

4.61

Head

5

3.25

Face

5

0.82

Face

2

1.30

Mouth

3

0.49

Nose

2

1.30

Jaw

1

0.17

Eyes

1

0.65

Eyes

4

0.66

Jaw

1

0.65

Nose

3

0.49

Neck

1

0.65

Neck

6

0.99

Larynx

2

1.30

Larynx

2

0.33

Elbow

1

0.65

Shoulder

2

0.33

Wrist

1

0.65

Elbow

1

0.17

Hand

1

0.65

Wrist

3

0.49

Thumb

3

1.95

Hand

6

0.99

Fingers

4

2.60

Thumb

6

0.99

Ribs

2

1.30

Fingers

5

0.82

Pelvis, hips

1

0.65

Ribs

3

0.49

Groin

2

1.30

Stomach

2

0.33

Upper leg

1

0.65

Pelvis, hips

3

0.49

Hamstrings

1

0.65

Groin

4

0.66

Knee

3

1.95

Testicles

3

0.49

Ankle

7

4.55

Buttocks

1

0.17

Heel

1

0.65

Upper leg

6

0.99

Foot

3

1.95

Hamstrings

3

0.49

Toes

1

0.65

Knee

9

1.48

 

 

 

Patella

3

0.49

 

 

 

Lower leg

8

1.32

 

 

 

Ankle

10

4.65

 

 

 

Foot

6

0.99

 

 

 

Toes

15

2.47

 

 

 

Other

4

0.66

 

 

 

Total

155

25.54

Total

46

29.91

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* Body parts not listed in the Table were not involved in any recorded time-loss injuries.

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Table 3 Distribution of time-loss injuries by type of injury* per 1000 AEs

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_____Boys__

 

 

____Girls____

 

Injury type

Number

Injury rate

Injury type

Number

Injury rate

Contusion

52

8.57

Sprain

15

9.75

Fracture?

31

5.11

Contusion

12

7.80

Sprain

28

4.61

Fracture?

9

5.85

Concussion

25

4.12

Fracture

5

3.25

Fracture

20

3.30

Concussion

5

3.25

Strain

7

1.15

Strain

4

2.60

Other

7

1.15

Abrasion

1

0.65

Laceration

4

0.66

Epistaxis

1

0.65

Dislocation

3

0.49

Hyperextension

1

0.65

Subluxation

3

0.49

Laceration

1

0.65

Ligament: complete tear

2

0.33

Tendinitis

1

0.65

Abrasion

1

0.17

 

 

 

Bursitis

1

0.17

 

 

 

Epistaxis

1

0.17

 

 

 

Nerve injury

1

0.17

 

 

 

Total

155

25.54

Total

46

29.91

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* Injury types not listed in the Table were not involved in any recorded time-loss injuries.

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Table 4 Distribution of time-loss injuries by situation per 1000 AEs

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_____Boys____

 

 

____Girls____

 

Situation

Number

Injury rate

Situation

Number

Injury rate

Unblocked attack

75

12.36

Unblocked attack

20

13.00

Attacking-kick

46

7.58

Attacking-kick

11

7.15

Blocking a kick

16

2.64

Blocking a kick

6

3.90

Fall

13

2.14

Fall

4

2.60

Attacking-punch

3

0.49

Attacking-punch

2

1.30

Other

2

0.33

Other

2

1.30

 

 

 

Blocking a punch

1

0.65

Total

155

25.54

Total

46

29.91

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Table 5 Distribution of time-loss injuries by mechanism per 1000 AEs

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___Boys__

 

 

____Girls____

 

Mechanism

Number

Injury rate

Mechanism

Number

Injury rate

Receiving a blow

92

15.16

Receiving a blow

27

17.56

Delivering a blow

35

5.77

Delivering a blow

10

6.50

Impact with surface

16

2.64

Impact with surface

6

3.90

Other

6

0.99

Other

2

1.30

Simultaneous blows

5

0.82

Overuse/gradual

1

0.65

No evidence of contact

1

0.17

 

 

 

Total

155

25.54

Total

46

29.91

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Table 6 Distribution of days lost owing to time-loss injuries per 1000 AEs

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_____Boys____

 

 

____Girls____

 

Time-loss

Number

Injury rate

Time-loss

Number

Injury rate

7 days

85

14.01

7 days

22

14.30

8-20 days

44

7.25

8-20 days

16

10.40

2l days

26

4.29

21 days

8

5.20

Total

155

25.54

Total

46

29.91

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There was a significant difference (P = 0.021) between boys and girls in total time-loss injury rate per 1000 A-E (Mann-Whitney U = 199, 1 df) with the girls incurring a higher rate than the boys. No differences were found within gender in injury rate by body part (P > 0.05) or by days lost (P > 0.05). The injury rates per 1000 A-E by body part for the boys were: 8.57 for the head and neck, 3.79 for the upper extremities, 2.64 for the trunk and 9.89 for the lower extremities. For the girls the values were: 9.10, 6.50, 3.25, and 11.05 for the head and neck, upper extremities, trunk, and lower extremities, respectively.

DISCUSSION

Although the absolute number of time-loss injuries in the girls was lower than that in the boys, the time-loss injury rate per 1000 A-E was higher for the girls. It is not clear why the injury rate for the girls is higher. It may be that the girls are more inclined to report injuries than the boys as was also suggested by Barrault et al (11) for young and adult female judo athletes. Birrer & Birrer (l2) have found that most injuries (more than 60%) are not reported, including time-loss injuries. The boys who participated in the tournaments that were investigated and/or their coaches might not have been willing to seek medical treatment for an injury incurred.

Table 7 shows comparative data for total time-loss injury rates in various (combative) sports. All sports involved adult competitors, except for the young wrestlers and girls' soccer. Unfortunately, there is a paucity of data regarding time-loss injury rates in Junior Olympic athletes gained from prospective studies. Barrault et al (11) found a time-loss injury rate of 10.90/1000 A-E in French Junior Olympic judo athletes, but this is a combined rate for both boys and girls. In the present study, the combined time-loss injury rate for boys and girls in taekwondo would be 26.43/1000 A-E.

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Table 7 Comparative data for time-loss injury rates per 1000 A-Es in combative and other sports

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Girls______

Injury rate

Boys________

Injury rate

Taekwondo (this study)

29.9

Amateur boxing (17)*

 

College gymnastics (l8)

21.5

Adult non-contact karate (19)*

 

College soccer (20)

16.6

College football(20)

 

Adult judo (11)*

9.7

College wrestling (18)

 

College field hockey (l8)

8.4

Adult non-contact karate (21)*

 

College basketball (18)

8.1

Taekwondo (this study)

 

College lacrosse (22)

7.2

College soccer (20)

 

College volleyball (20)

5.2

College gymnastics (18)

 

College softball (22)

5.1

College lacrosse (22)

 

Girls' soccer (18

2.1

Boys' wrestling (10)*

 

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* Calculation based on data provided by the authors.

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A small pilot study on youth soccer (6-14 years old) during a 5-week season with 38 teams that was carried out by one of us (EDZ) showed game time-loss injury rates of 3.73 and 3.92/1000 A-E for boys and girls, respectively. Young wrestlers (6-16 years) incurred 5.63 time-loss injuries per 1000 A-E (10). Expressed per 100 participants, the boys in taekwondo sustained 4.64 time-loss injuries and the girls, 5.02; which are similar to that found by Lorish et a1 (10) (4.65) but lower that those found by Martin et al (9). It should be realized, however, that Martin et al's study was done at one tournament with only 49 boys and 12 girls participating. The wrestling study was done at two tournaments with 1742 competitors (10). However, since the exposure to injury is not taken into account, expressing injuries relative to number of participants is not as accurate as representing them in terms of A-Es. At one national semi-contact karate tournament, the girls (715 years) did not incur any time-loss injuries, while the time-loss injury rate for the boys (7-15 years) was found to be 2.63/1000 A-E (W Pieter, unpublished data). There were 218 boys and 84 girls participating.

Although the area of the head and neck sustained the second highest time-loss injury rate in both the boys and girls, the head itself sustained by far most of the injuries in the boys and ranked second after the ankle in the girls. Oler et al (5) reported one fatal injury as a result of a spinning hook kick to the head, but no age or gender was specified. The serious medical, social, economic and other ramifications of head injuries (13-15) warrant a re-evaluation of the rules that permit kicks to the head to score a point in full-contact taekwondo. Earlier (5, 16), it was recommended to exclude kicks to the head, especially when dealing with youngsters, but as of this writing, the international governing body (World Taekwondo Federation), and some of the national governing bodies have not yet implemented changes.

If suspected fractures would turn out to be fractures after all, this type of injury would be the second most often occurring injury leading to time-loss in boys and girls alike. Table 8 shows the distribution of (suspected) fractures by body part. The toes in the boys incurred most suspected fractures, and together with the fingers, most of the confirmed fractures. In an earlier study (16), it was pointed out that engaging in a bout with open hands would invite injuries, including fractures, to this body part. By the same token, kicking without dorsiflexing the toes when it is called for, such as in the side and spinning back kicks, may lead to injuries (fractures?). Another possibility is that the athletes did not perform the kick correctly. For instance, when executing the round kick, the most often used kick in competition (23), the instep of the foot should hit the target while the toes are in plantarflexion. Alternatively, the round kick can be executed with the ball of the foot hitting the target with the toes in dorsiflexion. It might very well be that the athletes, in both cases, hit the target with their toes instead of the instep or the ball of the foot, respectively.

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Table 8 Distribution of fractures by body part* per 1000 AEs

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____Boys___

 

 

____Girls____

 

Body part

Number

Injury rate

Body part

Number

Injury rate

Face

1

0.17

Hand

1

0.65

Wrist

1

0.17

Fingers

2

1.30

Hand

2

0.33

Foot

1

0.65

Fingers

5

0.82

Toes

1

0.65

Pelvis, hips

2

0.33

 

 

 

Ankle

1

0.17

 

 

 

Foot

3

0.49

 

 

 

Toes

5

0.82

 

 

 

Total Confirmed

20

3.30

Total Confirmed

5

3.25

Nose

2?

0.33?

Nose

2?

1.30?

Jaw

1?

0.17?

Wrist

1?

0.65?

Larynx

1?

0.17?

Thumb

2?

1.30?

Shoulder

1?

0.17?

Fingers

1?

0.65?

Elbow

1?

0.17?

Knee

1?

0.65?

Wrist

2?

0.33?

Ankle

1?

0.65?

Hand

2?

0.33?

Foot

1?

0.65?

Thumb

5?

0.82?

 

 

 

Fingers

1?

0.17?

 

 

 

Lower leg

1?

0.17?

 

 

 

Ankle

1?

0.17?

 

 

 

Foot

5?

0.82?

 

 

 

Toes

8?

1.32?

 

 

 

Total Suspected

31

5.11

Total Suspected

9

5.85

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* Body parts not listed in the Table were not involved in any recorded (suspected) fractures.

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The injury situation and mechanism confirm earlier observations about technical skill and game tactics in preventing (time-loss) injuries (5, 24,25). Coaches and athletes are advised to work on blocking skills, on anticipating attacks, evasive manoeuvres and the proper execution of techniques. Attacking with a kick as the second dominant injury situation and delivering a blow as the second dominant injury mechanism strongly suggest that athletes are not trained to choose the right moment or even the right technique to launch an attack. Preliminary research seems to indicate that attacking with and delivering a roundhouse kick are the dominant situation and mechanism, respectively, leading to injuries in adult taekwondo athletes (26). Zandbergen (27) also found the round kick to be predominantly involved in the occurrence of time-loss injuries in adult male taekwondo athletes. This technique, if executed at an inopportune moment, may lead to (time-loss) injuries to the (instep of the) foot as a result of hitting the elbow. Elsewhere (28), padding was recommended to help decrease injuries, including fractures, to the foot.

When broken down into days lost owing to time-loss injury, the girls showed higher rates than the boys for each category ( 7 days, 8-20 days, 21 days) distinguished, although these differences were not significant. It is not clear why this phenomenon occurred. Above, it was mentioned that the boys and/or their coaches might not have been inclined to report time-loss injuries as opposed to the girls. If so, even the more serious among these injuries, requiring an estimated time-loss of 8-20 days or 21 days remain underreported. Earlier (16), it was suggested that the tournament physicians were more conservative with the Junior Olympic athletes compared to their adult counterparts regarding estimated days lost owing to injury. The physicians might also have been more conservative when dealing with girls as opposed to boys. A third possibility is that the present sample size was too small, implying that a larger one would eliminate the differences between boys and girls.

More data need to be collected to confirm the results regarding serious injuries in Junior taekwondo competition and to allow more detailed analyses. However, these preliminary findings indicate that the US Taekwondo Union Sports Medicine Committee, in cooperation with other committees, should begin consideration of ways to reduce the numbers and severity of these serious injuries.

ACKNOWLEDGEMENTS

This study was funded by the United States Olympic Committee and supported by the United States Taekwondo Union.

Gratefulness is extended to Samuel Pejo MD, Jenny Stone ATC, MS and her staff at the US Olympic Training Center in Colorado Springs as well as to Marianette Bailey RN, Charles Bailey, Eric Wegner MA and Luigi T. Bercades MS for their assistance in data collection. Thank you also to the attending physicians at the various tournaments for their cooperation.

REFERENCES

1. Von Apel J. Wirbelsäulebefunde bei jugendlichen Judokas nach mehrjährigem Training Med u Sport 1978; 18 (10):310-314.

2. Menge M, Neuiand H, Rech R. Auswirkungen asymmetrischer Belastungen auf die Wirbelsaüle jugendlicher Fechter. In: Kindermann W Hort W eds. Sportmedizin für Breiten- und Leistungssport, Gräfelfing: Demeter Verlag, 1980: 439-441.

3. Villecrose N. Les traumatismes sportifs chez l'enfant et l'adolescent. A propos de 103 observations. Méd Sport 1991; 65 (3): 153-156.

4. Wirtz PD, Vito GR, Long DH. Calcaneal apophysitis (Sever's disease) associated with taekwondo injuries. J Am Pod Med Assoc 1988; 78 (9): 474-475.

5. Oler M, Tomson W, Pepe H, Yoon D, Branoff R, Branch J. Morbidity and mortality in martial arts: a warning. J Trauma 1991; 31 (2): 251-253.

6. Buckley T Karate injuries. A compilation of 1000 kumite matches. Unpublished report, Everett, WA: USA Karate Federation of Washington 1990.

7. Poirier E. Traumatologie du karaté en competition. Unpublished thesis, Paris, Université Paris Val-De-Marne 1990.

8. Von Steinbriick K. Judo - ein Sport von der Jugend bis ins Alter? Med u Sport 1984; 24(1): 24-30.

9. Martin RK, Yesalis CE, Foster D, Albright JP Sports injuries at the 1985 Junior Olympics. An epidemiological analysis. Am J Sp Med 1987; 15(6): 603-608.

10. Lorish TR, Rizzo TD, Ilstrup DM, Scott SG. Injuries in adolescent and preadolescent boys at two large wrestling tournaments. Am J Sp Med 1992; 20 (2): 199-202.

11. Barrault D, Achou B, Sorel R. Accidents et incidents survenus au cours des compétitions de judo. Symb 1983; 15 (3):144-152.

12. Birrer RE, Birrer CD. Unreported injuries in the martial arts. Br J Sports Med 1983; 17 (2): 13-14.

13. Bijur PE, Haslum M, Golding J. Cognitive and behavioral sequelae of mild head injury in children. Pediatrics 1990; 86(3): 337-344.

14. Greenspan AI, MacKenzie EJ. Functional outcome after pediatric head injury. Pediatrics 1994; 94 (4): 425-432.

15. Rappaport M, Herrero-Backe C, Rappaport ML, Winterfield KM. Head injury outcome up to ten years later. Arch Phys Med Rehabil 1989; 70 (12): 885-892.

16. Zemper ED, Pieter W A two-year prospective study of taekwondo injuries at national competitions, presented at the International Congress and Exposition on Sports Medicine and Human Performance, Vancouver BC, Canada, 1991; April 1620.

17. Estwanik JJ, Boitano M, Ari N. Amateur boxing injuries at the 1981 and 1982 USA/ABF National Championships. Phys Sportsmed 1984; 12(10): 123-128.

18. Zemper ED. Epidemiology of athletic injuries. In: McKeag DB, Hough D, Zemper ED, eds. Primary Care Sports Medicine. Dubuque, IA: Brown and Benchmark 1993: 6373.

19. McLatchie GR. Analysis of karate injuries sustained in 295 contests. Inj: Brit J Acc Surg 1976; (2) 8: 132-134.

20. Soccer injury rates continue five-year climb. NCAA NEWS 1993; 30(5): 2930.

21. Stricevic MV, Patel MR, Okazaki T Swain BK. Karate: historical perspective and injuries sustained in national and international tournament competitions. Am J Sp Med 1983; 11 (5): 320-324.

22. Game injuries up for women's lacrosse. NCAA NEWS 1993; 30(29): 5-6.

23. Scheirman G. A temporal and frequency analysis of the 1985 Taekwondo World Championships, Unpublished report, Colorado Springs: US Olympic Committee, 1985.

24. Pieter W LuftingR. Injuries at the 1991 Taekwondo World Championships. J Sp Traum Rel Res 1994; 16(1): 4957.

25. Zemper ED, Pieter W Injury rates during the 1988 US Olympic Team Trials for taekwondo. Br J Sports Med 1989; 23 (3): 161-164.

26. Pieter W Van Rijssegem G, Lufting R, Heijmans J. Injury situation and injury mechanism at the 1993 European Taekwondo Cup. J Hum Mov Stud 1995; 28 (1): 124.

27. Zandbergen A. Taekwondo Blessures en Fysiotherapie. Unpublished thesis, Enschede: Twentse Akademie voor Fysiotherapie, no date.

28. Pieter W, Zemper ED. Foot injuries in taekwondo. In: Varnes JW Gamble D, Horodyski MB, eds. 1995 ICHPER. SD 38th World Congress Proceedings, Gainesville: The University of Florida College of Health and Human Performance, 1995; P165-P166.