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Abstract

Background:

Flag football, a noncontact variant of American football, has gained significant interest in the United States and globally, which has been attributed to its accessibility, low cost, and perceived safety compared with traditional tackle football.

Purpose:

To identify the trends, primary mechanisms, and distributions of American flag football injuries among female athletes to better inform prevention and safety measures.

Study Design:

Descriptive epidemiology study.

Methods:

Data analyzed in this study were extracted from the National Electronic Injury Surveillance System (NEISS), a public database representing approximately 100 US emergency departments (EDs) that provides national injury estimates. NEISS was queried for all flag football injuries in female patients from January 1, 2014, to December 31, 2023. Descriptive statistics were used to analyze the distribution of injury by age, mechanism, diagnosis, and body region. Linear regression was used to analyze changes in injury rates over time.

Results:

Across the study period, 605 female patients with flag football injuries were evaluated at US EDs, extrapolating to a national estimate (NE) of 22,666 injuries from 2014 to 2023. The highest frequency of injuries occurred in 2023 (NE = 3531; 15.6%) and the lowest in 2020 (NE = 436; 1.9%). The most common injury diagnosis was found to be strain/sprain (NE = 6835; 30.2%), with adolescents aged 11 to 20 years sustaining the greatest number of injuries across all diagnoses. The most commonly affected body part was the finger (NE = 137; 22.6%). When analyzing the mechanism of injury, the most common cause was fall, including fall on an outstretched hand (NE = 4321; 19.1%). In addition, the majority of patients were treated and released (NE = 22,253; 98.2%).

Conclusion:

This study demonstrated that from 2014 to 2023, female flag football injuries reported to US EDs remained relatively stable, dropping in 2020 during the COVID-19 pandemic and peaking in 2023. The most common injuries sustained by female athletes playing flag football were strains/sprains and fractures. Given the high prevalence of injuries sustained in the adolescent population, the use of appropriate protective gear should be emphasized to prevent a precipitous rise in injuries as the sport continues to grow in popularity throughout the country.

Keywords

football (American)flag football epidemiology

Flag football is a version of American football that has become increasingly popular both in the United States and worldwide.²¹ The rules of the game are similar to those of American tackle football; however, instead of tackling opposing players to the ground, the defensive team aims to remove a flag or flag belt from the ball carrier to end a down.⁷ The sport has become increasingly popular given the low cost for participation, minimal equipment requirements, and easy accessibility of organized and unorganized games.²¹ Furthermore, flag football is perceived as safer than similar sports: Zendler et al²¹ found that among youth athletes, flag football resulted in fewer injuries than did basketball, soccer, and tackle football, and additionally found that tackle football resulted in head injury rates 18 times higher than those of flag football.

However, paramount among likely reasons for flag football’s popularity is the perceived safety of this sport in comparison with tackle football.²¹ Although the sport is presumed to be safe because of rules against tackling other players, there are limited data on injuries sustained by players in flag football. Kaplan et al⁷ found 0.14 time-loss injuries (an injury that prevented a player from returning to the current game or future training) per 1000 athlete-exposures (1 athlete participating in 1 game) for adult recreational flag football. Twelve percent of injuries among adults have been estimated to affect the head and neck,² while 5% have been attributed to concussions.⁷ McElveen et al¹¹ found 1.82 injuries requiring medical attention per 100 athletes for collegiate intramural flag football. Zendler et al²¹ found that the most common injuries among youth nontackle football players were lacerations and concussions, although head injuries among these athletes occurred at a lower rate than in basketball, soccer, and tackle football.

Flag football continues to rise in popularity, particularly among female athletes: 22 colleges reported nonvarsity female flag football teams in the 2023-2024 season. Furthermore, the National Collegiate Athletic Association Division III Atlantic East Conference has announced that it will introduce female flag football to the varsity level, with an anticipated start in spring 2025. Additionally, the sport will make its Olympic debut at the 2028 Los Angeles games.⁵ There is a paucity of literature specifically describing the nature of flag football injuries among female athletes. The purpose of this study was to identify the trends, primary mechanisms, and distributions of American flag football injuries among female athletes to better inform prevention and safety measures. We hypothesized that injuries would increase over the investigated study period and that injuries would be most common in adolescent/young adult athletes.

Methods

National Electronic Injury Surveillance System Database

This retrospective study used the National Electronic Injury Surveillance System (NEISS) database to capture flag football injuries sustained by female patients between 2014 and 2023. NEISS, which is operated by the US Consumer Product Safety Commission, contains publicly available and de-identified data. This database is commonly used in epidemiological studies characterizing the nature of sports injuries.^{1,8,14,15,17,20} The database contains data for emergency department (ED) visits from a stratified probability sample of approximately 100 US hospitals (which include trauma centers of differing levels). All included hospitals have a minimum of 6 beds and a 24-hour operating ED.

Each ED is assigned a statistical sample weight based on the inverse of the probability of selection. This allows for the calculation of national estimates (NEs) of injuries across the United States using the sample of NEISS cases.

Data Extraction

There were 605 female flag football injuries that were evaluated at US EDs from January 1, 2014, to December 31, 2023. Product code 1211, describing injuries related to football, was used. The narrative for each football injury was evaluated, and only injuries caused by flag football and sustained by a female patient were included in the present study. For each injury case, the patient’s demographic data (eg, age and sex), date of visit, diagnosis, and body area involved were available.

Statistical Analysis

Data analyses were performed using IBM SPSS Statistics Version 28.0 (IMB). Descriptive statistics were used to analyze the distribution of injury by age, mechanism, diagnosis, and body region. Linear regression was used to analyze changes in injury rates over time, such that the number of injuries was the dependent variable and the year was the independent variable. The P value and regression coefficient (β) are reported for statistically significant (P < .05) data.

Results

There were 605 cases of female patients with flag football injuries that were evaluated at US EDs from January 1, 2014, to December 31, 2023. When weighted, there were 22,666 NE female flag football injuries that were included in the analysis. When analyzing aggregate data from all extreme sports, injuries were most common among adolescents ages 11 to 20 years (Table 1). A total NE of 22,253 (98.2%) patients were treated and released, an NE of 23 (0.1%) were treated and transferred to another hospital, an NE of 114 (0.5%) were treated and admitted at the same facility, and an NE of 244 (1.1%) left before receiving treatment.

Table 1

Characteristics of Female Flag Football NEISS Cases and Nationally Estimated Injuries From January 1, 2014, to December 31, 2023 ^a

Category	NEISS Cases, n	NE (%)
Year
2014	59	2332 (10.3)
2015	66	2412 (10.6)
2016	69	2737 (12.1)
2017	56	2240 (9.9)
2018	44	1927 (8.5)
2019	71	2539 (11.2)
2020	12	436 (1.9)
2021	52	2192 (9.7)
2022	72	2321 (10.2)
2023	104	3531 (15.6)
Age, y
0-10 (child)	43	1509 (6.7)
11-20 (adolescent)	434	16,131 (71.1)
21-30 (young adult)	78	2622 (11.6)
31-45 (adult)	47	2220 (9.8)
≥46 (older adult)	3	183 (0.8)

NE, national estimate; NEISS, National Electronic Injury Surveillance System.

Mechanism of Injury

The most commonly documented cause of injury was a fall, including a fall on an outstretched hand (NE = 4321; 19.1%). Player collisions were the next most common cause of injury (NE = 2182, 9.6%). Overuse muscle strains and pulls were the third most common cause of injury (NE = 2022; 8.9%). Twisting injuries were the fourth most common cause of injury (NE = 2182; 9.6%). The mechanisms of the remaining injuries were classified as other/not stated (NE = 12,327; 54.4%). Adolescents sustained the greatest number of injuries across all mechanisms (Figure 1).

Figure 1.

Mechanism of female flag football injuries by age group.

Injury Diagnosis

The most common injury diagnosis was strain/sprain (NE = 6835; 30.2%). The next most common diagnosis was fracture (NE = 4720; 20.8%). The third most common diagnosis was concussion (NE = 1815; 8.0%). Adolescents sustained the greatest number of injuries across all diagnoses (Figure 2).

Figure 2.

Diagnosis of female flag football injuries by age group.

The most commonly affected body part was the finger (NE = 137; 22.6%). The second most commonly affected body part was the head (NE = 95; 15.7%). The third most commonly affected body part was the knee (NE = 89; 14.7%) (Table 2).

Table 2

Nationally Estimated Female Flag Football Injuries by Affected Body Part ^a

Affected Body Part	Frequency, NE	Percent
Finger	137	22.6
Head	95	15.7
Knee	89	14.7
Ankle	65	10.7
Wrist	31	5.1
Face (including eyelid, eye area, and nose)	30	5.0
Shoulder (including clavicle and collarbone)	25	4.1
Trunk, upper (not including shoulders)	22	3.6
Trunk, lower	20	3.3
Hand	15	2.5
Foot	14	2.3
Arm, lower (not including elbow or wrist)	13	2.1
Leg, lower (not including knee or ankle)	11	1.8
Neck	8	1.3
Elbow	7	1.2
Mouth (including lips, tongue, and teeth)	7	1.2
All parts of body (>50% of body)	5	0.8
Eyeball	4	0.7
Leg, upper	2	0.3
Not recorded	2	0.3
Toe	2	0.3
Ear	1	0.2

NE, national estimate.

Longitudinal Injury Trends

Linear regression analysis of the frequency of total female flag football injuries revealed an insignificant change (P = .864; β = 0.06) (Figure 3). The highest injury frequency was in 2023 (NE = 3531; 15.6%). The lowest injury frequency was in 2020 (NE = 436; 1.9%).

Figure 3.

Nationally estimated flag football injury frequencies from 2013 to 2022.

Linear regression analysis of the frequency of total female flag football concussions revealed an insignificant change (P = .131; β = −0.511) (Figure 4). The highest concussion frequency was in 2015 (NE = 299; 16.5%). The lowest injury frequency was in 2020 (NE = 0; 0.0%). Concussions were most common in adolescents ages 11 to 20 years (NE = 1411; 77.7%).

Figure 4.

Nationally estimated flag football concussion frequencies from 2013 to 2022.

Discussion

We analyzed injury data from a representative sample of US EDs to describe flag football injuries sustained by female patients ages 6 to 47 years from 2014 to 2023. During this time period, there were 22,666 NE flag football injuries sustained by female athletes. Notably, female flag football injuries reported to US EDs remained relatively stable, with linear regression demonstrating an insignificant change in injury rates (P = .864; β = 0.06). Our findings reveal that the fewest number of injuries occurred in 2020. Similarly, we found that there was an NE of 0 concussions during 2020. This trend corresponds with the COVID-19 pandemic, during which all Americans spent more time at home due to school closures, activity cancellations, and stay-at-home orders. These stay-at-home orders had a particular effect on the injuries sustained by children and adolescents, who were unable to participate in organized sports activities and who comprise the majority of injured female flag football players. Since the COVID-19 pandemic, we note an increase in injuries to greater than prepandemic levels, with the highest frequency in 2023.

With regard to location of injury, we found that the head, face (including eyes, eyeballs, mouth, and ears), and neck comprised 24.1% of injuries. Although Burnham et al² estimated that 12% of flag football injuries affect the head and neck, our cohort focuses only on female athletes (as opposed to those of both sexes) and focuses on all ages of athletes (as opposed to only adults). We additionally found that concussions only comprised 8.0% (NE = 1815) of injuries in the present study, similar to the finding of Kaplan et al⁷ that 5% of flag football injuries are due to concussions. We found that concussions were most prevalent in 2015 and least prevalent in 2020, during the COVID-19 pandemic. We also found that concussions were most common among adolescents ages 11 to 20 years when compared with other age groups. It is important to compare these data with tackle football: Mehta et al¹² found that the sport resulted in nearly 100,000 visits for head and neck injuries annually, of which the most common diagnosis was concussion (comprising 39% of injuries). Given a growing landscape of evidence on the dangers of concussion and efforts to prevent concussions among tackle football players,^6,16,18 our findings suggest that types of nontackle football, such as flag football, continue to provide safer alternatives. Nevertheless, given that concussions were the third most likely cause of injury, that they occurred most commonly among adolescents, and that Lempke et al⁹ found that high linear and rotational acceleration magnitudes among youth flag football players may increase risk of concussion, we echo calls for the use of helmets and other protective equipment among youth flag football players in particular to help reduce rates of concussion.

Regarding type of injury, Zendler et al²¹ previously found that lacerations, followed by concussions, were the most common injuries among nontackle football players of both sexes. Interestingly, our findings differ and indicate that strains/sprains were the most common injury among female flag football athletes, and that these injuries most commonly occurred in the knee and ankle. The meta-analysis by Mason et al¹⁰ demonstrated that female athletes are at a higher risk of strains/sprains, particularly of the ankle, given differences in body composition and mechanics, including weight, body mass index, joint laxity, and joint range of motion. Specifically, female athletes may have a higher risk of strains/sprains because of reduced concentric dorsiflexion strength.¹⁰ While further investigation is necessary to demonstrate if and why female athletes may be at greater risk of sustaining strains/sprains than male athletes, our findings do suggest that female flag football players should focus on strength and stretching regimens directly targeted at preventing this type of injury.

Aside from strains/sprains, fractures were the second most common injury among female flag football players. This is particularly notable given evidence that female athletes are at an increased risk of sustaining stress fractures in comparison with their male counterparts.^4,19 Given the high risk of stress fractures in female athletes, along with traumatic fractures, it is important to develop prevention strategies, including early screening for the female athlete triad (which describes how periods of low energy availability and undernutrition can lead to an amenorrheic state, estrogen deficiency, and the dysfunction of other hormones required for bone health),¹³ promotion of activities that improve bone health (eg, diet rich in vitamin D/calcium and strength training), and gait modification.³

Finally, regarding mechanism of injury, while Zendler et al²¹ found that the most common mechanism of injury for all nontackle football players was collision with another player, the most common mechanism of injury for female flag football players was a fall, followed by player collisions. We hypothesize that this may be the result of stylistic differences between males and females who play flag football (eg, male players may be more likely to collide with teammates or opponents than female players). Although it is difficult to determine the cause of players’ falls, our findings suggest that precautionary measures may be taken to ensure that athletes are playing on even fields and that referees enforce rules against tripping or pushing other players.

Limitations

Given that this was a retrospective study that relied solely on information from the NEISS data set, limitations were inherent. First, we could only include details of injuries that were reported to NEISS as occurring from “flag football.” We were unable to capture injuries that did not have “flag football” in the description written by the provider, which means we may not have captured all injuries from the sport. Second, the classification of injury mechanisms relied on the narrative reported by ED clinicians, and as such, there was variability in the level of detail provided. Indeed, as a result, 12,327 cases (54.4%) did not have a stated mechanism, which was a large flaw in this study. Third, the setting of the injury (eg, school team, recreational game, etc) and the surface on which players were injured could not be determined. We worked to mitigate such pitfalls by using a large national database that likely covered a wide range of settings, although estimates from NEISS NE extrapolations may not be an entirely accurate representation of national female flag football injuries. Fourth, we could not determine specific details about types of injuries (ie, if fractures were acute, chronic, traumatic, or related to stress injuries). Future studies should explore injury characteristics in further detail. Fifth, we could not account for the patients with injuries who were evaluated in health care settings other than EDs (eg, urgent care centers and orthopaedist/sports medicine physicians’ offices). As such, our findings may have been biased toward the most extreme injuries sustained by flag football players. Sixth, the exact number of female flag football players in each of the 10 years in the present study is not known, and this may have affected annual trends in injury rates.

Conclusion

Our study demonstrated that from 2014 to 2023, female flag football injuries reported to US EDs remained relatively stable, dropping in 2020 during the COVID-19 pandemic and peaking in 2023. The most common injuries sustained by female athletes playing flag football were strains/sprains and fractures. Given the high prevalence of injuries sustained in the adolescent population, the use of appropriate protective gear should be emphasized to prevent a precipitous rise in injuries as the sport continues to grow in popularity throughout the country.

Footnotes

Final revision submitted March 25, 2025; accepted April 21, 2025.

One or more of the authors has declared the following potential conflict of interest or source of funding: R.M.F. is a board or committee member of AAOS; American Orthopaedic Society for Sports Medicine; American Shoulder and Elbow Surgeons; Arthroscopy Association of North America; International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; and International Cartilage Restoration Society; is a paid consultant for AlloSource, Arthrex, and JRF; is a paid presenter or speaker for AlloSource, Arthrex, JRF, and Ossur; has received publishing royalties and financial or material support from Elsevier; is on the editorial or governing board of Journal of Shoulder and Elbow Surgery and Orthopedics Today; and has received research support from Smith & Nephew and Arthrex. L.K.C. is a fiduciary officer of American College of Surgeons, Southeast Fracture Consortium, Orthopaedic Trauma Association, MSOS, Ruth Jackson Orthopaedic Society, and Association of Women Surgeons and is involved in Speak Up Ortho and AAOS. R.L.P. is a board or committee member of American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Eastern Orthopaedic Association, ISHA: The Hip Preservation Society, New England Orthopaedic Society, and Society of Military Orthopaedic Surgeons; has received financial or material support from Arthrex; and is on the editorial or governing board of Arthroscopy, Journal of Cartilage & Joint Preservation, and Journal of Sport Rehabilitation. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Ethical approval was not sought for the present study.

ORCID iD

Auston Locke

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