Abstract
Background:
Softball is among the most widely played sports for women in the United States (US). However, contemporary comparisons of injury epidemiology between high school- and college-aged athletes are limited.
Purpose:
To provide an updated, comparative assessment of the epidemiology of softball-related injuries among female high school- and college-aged athletes and to characterize the burden of these injuries on emergency departments (EDs) across the United States.
Study Design:
Descriptive epidemiological study.
Methods:
The National Electronic Injury Surveillance System (NEISS) was queried for softball-related injuries in female athletes aged 14 to 23 years from 2015 to 2024. Patients aged 14 to 18 years were categorized as high school-aged, and those aged 19 to 23 years as college-aged. Weighted national estimates were calculated using NEISS sampling weights. Participation data from the National Federation of State High School Associations and the National Collegiate Athletic Association were used to derive population-based incidence per 100 at-risk participants. Incidence rate ratios (IRRs) with 95% CIs compared high school- and college-aged athletes for incidence, injury patterns, and disposition.
Results:
A total of 3385 NEISS cases corresponded to a weighted national estimate of 376,295 softball-related injuries in female athletes aged 14 to 23 years treated in US EDs between 2015 and 2024. College-aged athletes had a higher overall injury incidence than high school-aged athletes (22.44 vs 9.35 per 100 at-risk persons; IRR, 2.40 [95% CI, 2.38-2.42]). Both groups exhibited a sharp decline in injury incidence in 2020, corresponding with the onset of the coronavirus disease 2019 pandemic. The head, ankle, knee, and face were the most frequently injured body regions. When expressed per 100 at-risk persons, college-aged athletes had significantly higher injury rates to the upper leg, ear, eye, foot, and mouth, as well as higher rates of nearly all diagnosis categories, including avulsions, dental injuries, and lacerations. Most injuries were treated and discharged, but college-aged athletes had higher rates of admission/transfer, observation, and leaving against medical advice.
Conclusion:
Our study showed that from 2015 to 2024, college-aged female softball athletes were more than twice as likely as high school-aged athletes to present to the ED with a softball-related injury, with higher incidence across most body regions, diagnoses, and ED dispositions. These findings highlight a substantial, level-specific injury burden and support targeted preventive strategies.
Keywords
Softball is among the most widely played organized sports for adolescent and young adult females in the United States (US), with more than 345,000 high school-aged and over 20,000 college-aged participants competing annually10,11 in 2024. Participation provides substantial physical, psychosocial, and educational benefits; however, the sport's combination of high-velocity ball and bat impacts, rapid accelerations and decelerations while running bases, windmill pitching, and frequent sliding exposes players to both acute traumatic and overuse injuries.6,8,20 Injury surveillance studies consistently identify ankle sprains, concussions, and contusions as the most common softball injuries, with the lower extremity and head/face among the most frequently affected regions.1,8,12,20 However, few directly compare high school versus collegiate athletes, limiting level-specific context for injury prevention strategies and emergency department (ED) resource planning.
Limited comparative work suggests that collegiate softball athletes have higher overall injury rates, more overuse and shoulder injuries, and greater injury severity, whereas high school athletes experience more hand and finger injuries and minor contusions.15,20,21 Although mechanisms, such as being hit by a ball, sliding, running bases, and player-player collisions, are broadly similar across levels, the intensity of play, training volume, and consequences of injury appear to differ between high school and college. 14 However, few studies directly compare high school and collegiate softball athletes, and the most recent large-scale comparison reported data from the 2004-2014 seasons and drew from dedicated high school and collegiate injury surveillance programs rather than an ED-based, nationally representative dataset. 21 Subsequent epidemiologic studies have largely narrowed their focus to specific anatomic regions or diagnoses rather than evaluating the full spectrum of softball-related injuries across levels of play.1,8,12,20 An updated cross-level comparison is warranted, particularly across 2015-2024, a period that spans the coronavirus disease (COVID-19) pandemic and potential shifts in sport participation and care-seeking behavior.
The National Electronic Injury Surveillance System (NEISS) is a nationally representative, ED-based injury surveillance system that samples US hospitals to generate weighted national estimates of consumer product– and sports-related injuries. 19 In contrast to organized-sport surveillance programs, NEISS captures ED-treated injuries regardless of team affiliation or onsite medical coverage and includes diagnosis, body region, and ED disposition, allowing evaluation of injury patterns and ED resource utilization across levels of play.
The purpose of this study was to provide an updated, ED-based comparison of softball-related injuries among female high school- and college-aged athletes using a nationally representative database. Specific aims were to compare incidence, anatomic location, diagnoses, and mechanisms of injury and to characterize their burden on US EDs. We hypothesized that collegiate athletes would exhibit higher injury incidence and greater ED resource utilization than high school-aged athletes, with differences in injury patterns between competition levels.
Methods
Database and Query
This cross-sectional epidemiologic study used NEISS data to evaluate softball-related injuries treated in US EDs between 2015 and 2024. NEISS samples approximately 100 hospitals and generates national estimates of consumer product-related injuries using a stratified probability design. Trained coders abstract data from ED medical records and, when necessary, follow-up telephone interviews. Because NEISS data are de-identified and publicly available, institutional review board approval was not required for this study.
Data Collection
Injuries were included if the patient was female, aged 14 to 23 years, and the incident was classified under NEISS softball product codes. Patients aged 14 to 18 years were categorized as high school-aged, and those aged 19 to 23 years as college-aged. Recorded variables included patient and injury characteristics, anatomic location, diagnosis, and ED disposition (ie, the patient's status at ED discharge, such as treated and released, admitted, transferred, or held for observation). Cases with missing age, sex, or disposition were excluded from analysis; missingness for each variable was rare (<1%).
Statistical Analysis
Weighted national estimates and 95% CIs were calculated using NEISS sample weights, which reflect the inverse probability of selection of the reporting hospital within NEISS strata and are adjusted for hospital nonresponse and changes in national ED visit volumes. Softball participation data were obtained from the National Federation of State High School Associations (NFHS) and the National Collegiate Athletic Association (NCAA) to define at-risk populations.10,11 Because the NEISS does not specify whether injuries occurred during NFHS/NCAA-sanctioned participation versus recreational or informal play, incidence rates in this study represent ED-treated softball injuries per 100 female participants and may overestimate injury incidence within organized competition. Incidence rates were reported per 100 at-risk persons. Incidence rate ratios (IRRs) with corresponding 95% CIs were calculated to compare rates between high school- and college-aged athletes. IRRs were estimated using Poisson approximations, and CIs were constructed with mid-P exact methods. All statistical analyses were performed using R, Version 4.4.1 (R Foundation for Statistical Computing), and statistical significance was set as α≤ .05.
Results
A total of 3385 NEISS cases corresponded to a weighted national estimate of 376,295 softball-related injuries among female athletes aged 14 to 23 years treated in US EDs between 2015 and 2024. College-aged softball players sustained significantly higher injury rates than high school-aged players, with an overall incidence of 22.44 versus 9.35 per 100 at-risk persons. The corresponding incidence rate ratio (IRR) was 2.40 (95% CI, 2.38-2.42), indicating that college-aged athletes were more than twice as likely to present to the ED for softball-related injuries than their high school-aged counterparts (Table 1).
Comparative Characteristics of Female Softball Injuries by Age Group a
Data are presented as n (%), unless otherwise indicated. NEISS cases, n are unweighted case counts. National estimate reflects weighted national injury estimates; percentages in parentheses are row percentages. HS, high school; IR, incidence rate; IRR, incidence rate ratio; NEISS, National Electronic Injury Surveillance System.
Between 2015 and 2024, the incidence of softball-related injuries among high school-aged athletes ranged from 4.1 to 13.2 injuries per 100 at-risk persons (difference of 9.2 injuries per 100 at-risk persons). In contrast, college-aged athletes demonstrated higher and more variable incidence, ranging from 14 to 36.4 injuries per 100 at-risk persons (a difference of 22.4 injuries per 100 at-risk persons). Both groups exhibited a sharp decline in injury incidence in 2020, coinciding with the onset of the COVID-19 pandemic (Figure 1).
Incidence rates among high school and collegiate athletes by year. Shaded bands represent 95% CIs.
Injury Patterns
The most frequently injured body parts among female softball athletes aged 14 to 23 years were the head, ankle, knee, and face, while strain or sprain remained the most commonly reported diagnosis (Table 2; Figure 2). Complete reporting of unweighted counts, denominators, and 95% CIs for all incidence rates is provided in Supplementary Tables S1 and S2. Weighted estimates showed that strain or sprain accounted for 70% (n = 36,178) of ankle injuries, 64% (n = 2,369) of upper leg injuries, and 53% (n = 3443) of neck injuries among female softball athletes aged 14 to 23 years between 2015 and 2024.
Injury Characteristics and Incidence Rates per 100 At-Risk Persons by Age Group a
Data are presented as n (%), unless otherwise indicated. National estimate reflects weighted national injury estimates. At-risk person denominators were derived from annual participation counts summed across 2015-2024: high school = 3,527,364 at-risk persons; college = 207,375 at-risk persons. Unweighted case counts and complete 95% CI reporting are provided in Supplementary Tables S1 and S2. IR, incidence rate.
Incidence rates among female softball athletes evaluated in the emergency department. Bolded text indicates the top 5 injury sites by region. IR, incidence rate; IRR, incidence rate ratio; NA, not available.
Although high school-aged athletes represented 88% of ED visits for softball-related injuries, incidence rates per 100 at-risk persons were consistently higher among college-aged athletes. College players had significantly elevated rates of injuries to the upper leg (IRR, 6 [95% CI, 5.58-6.46]), ear (IRR, 4.50 [95% CI, 3.66-5.54]), eye (IRR, 4.07 [95% CI, 3.64-4.54]), foot (IRR, 3.72 [95% CI, 3.50-3.94]), and mouth (IRR, 3.43 [95% CI, 3.24-3.64]) (Figure 2). They also demonstrated higher rates across nearly all diagnosis categories, including avulsions (IRR, 12 [95% CI, 6.17-23.35]), dental injuries (IRR, 5.56 [95% CI, 3.20-9.66]), and lacerations (IRR, 3.99 [95% CI, 3.32-4.79]).
Disposition
Most softball-related injuries were treated and discharged from the ED, accounting for 98.4% of high school-aged and 96.2% of college-aged athletes (IR, 9.20 vs 21.59 per 100 at-risk persons). College-aged athletes experienced significantly greater rates of hospital admission/transfer (IRR, 4.78; 95% CI, 4.44-5.15), observation (IRR, 6.99 [95% CI, 5.66-8.63]), and leaving against medical advice (IRR, 7.20 [95% CI, 6.61-7.84]). Overall, college-aged athletes were more than twice as likely to present to the ED for a softball-related injury as high school-aged athletes (IRR, 2.40 [95% CI, 2.38-2.42]).
Discussion
The major finding of this national analysis of the 2015-2024 NEISS data was that college-aged female softball athletes had approximately 2.4-fold higher incidence of ED-treated softball-related injuries than high school-aged athletes. High school-aged athletes accounted for the majority of ED visits; however, incidence per 100 at-risk persons was higher at the collegiate level. Injury distributions were broadly similar across levels, with the head, ankle, knee, and face most frequently involved, and strains or sprains representing the most common diagnosis. The majority of patients were treated and released; however, college-aged athletes were more likely to be admitted, require short-term observation, or leave against medical advice.
These findings align with, but also extend, previous surveillance work in girls’ and women's softball. The NCAA Injury Surveillance Program and High School Reporting Information Online data have consistently shown higher injury rates at the collegiate level, with a larger proportion of time-loss and injuries requiring surgery in college compared with high school softball.9,20,21 By leveraging a nationally representative, ED-based dataset across a contemporary time frame, the present study corroborates these level-specific differences while capturing a broader spectrum of acute injuries and care-seeking patterns.
The regional injury patterns observed in this study are consistent with previous reports on softball and combined baseball-softball. Reviews of fastpitch softball identify the head/face and lower extremity as common injury sites, often attributed to ball contact, sliding into bases, and baserunning collisions.5,20 Pediatric NEISS analyses likewise report that head and neck injuries account for roughly one-third of softball ED presentations, with foot and ankle injuries frequently linked to sliding and abrupt changes in direction. 8 In the present cohort, college-aged athletes demonstrated disproportionately higher rates of injuries to the upper leg, foot, mouth, ear, and eye compared with high school-aged athletes. This pattern is consistent with faster game speed, more aggressive sliding and baserunning, and greater ball velocity at the collegiate level, all of which increase the energy of impacts to the face and lower extremities.9,21
The predominance of strain or sprain diagnoses in this NEISS cohort is clinically plausible, given the movement demands of fastpitch softball, including rapid acceleration and deceleration, cutting, base running, and sliding, which disproportionately load the ankle and other lower-extremity soft tissues.6,8,20 These patterns align with previous softball surveillance literature in high school and collegiate cohorts, where lower-extremity injuries, including ankle sprains and related soft-tissue diagnoses, account for a substantial share of injuries and are frequently linked to running, fielding, and sliding mechanisms.1,8,12,20 In the ED setting, sprain and strain presentations may also be overrepresented because acute pain, swelling, perceived instability, or difficulty bearing weight often prompts evaluation to exclude fracture or other structural injury, even when the ultimate diagnosis is ligamentous or muscular injury. 18 Ultimately, these findings support sprain and strain injury patterns as a key driver of ED-treated softball injuries and highlight the importance of prevention strategies emphasizing neuromuscular control, proprioception, and sport-specific technique training for high-risk actions (eg, cutting and sliding).3,9,21
The temporal trend observed in this study, characterized by a marked decline in injury rates across both groups in 2020, is consistent with broader work on ED utilization and youth sports during the COVID-19 pandemic. The NEISS and other national data sets have documented substantial reductions in sports-related ED visits around 2020, followed by a rebound toward prepandemic levels as organized play resumed.17,22 For softball, this likely reflects a combination of cancelled seasons, shortened schedules, and shifts in care-seeking toward outpatient or telehealth management for some injuries.
ED disposition findings in this cohort provide an indirect signal of comparative injury severity. College-aged athletes were more likely than high school-aged athletes to be admitted or held for observation and more likely to leave against medical advice. Although the absolute proportions of admission/transfer and observation were low, this pattern suggests that injuries in college-aged athletes were more severe or complex, or that clinicians had a lower threshold for advanced imaging and short-term monitoring in this group.2,7 Previous multisport ED and transport studies have reported similar trends, with collegiate athletes more likely than high school athletes to undergo advanced imaging, receive procedural interventions, or require hospital admission.2,7 These differences may relate to higher collision forces, expectations around expedited return to play, and ready access to team-based follow-up care, all of which can influence ED decision-making.
From a prevention and policy perspective, several targets emerge. First, the elevated rates of facial and dental-region injuries among college-aged athletes underscore the importance of facial protection in softball. The NCAA and dental society guidance support the use of mouthguards and orofacial protection to reduce the incidence and severity of dentofacial trauma in contact and high-velocity sports, including softball, yet adherence is often suboptimal.4,16 Second, the high incidence of lower-extremity injuries, particularly at the ankle, knee, and upper leg, aligns with evidence supporting neuromuscular training, strength programs, and technique-focused instruction to reduce noncontact and sliding-related injuries in team sports.13,18,21 Finally, given that most injuries were treated and discharged, standardized ED discharge instructions, sport-specific return-to-play counseling, and coordinated outpatient follow-up with athletic trainers and sports medicine clinicians may help reduce premature return and reinjury risk at both levels of play.
Limitations
This study is not without limitations. The NEISS is an ED-based surveillance system; injuries managed in athletic training rooms, primary care, urgent care, or team physician clinics are not captured. Thus, the dataset reflects only the subset of softball injuries that result in ED evaluation. This likely selects for more acute or concerning presentations and underestimates the overall burden of overuse and minor injuries. The NEISS records visits rather than unique athletes, preventing assessment of recurrent injuries or cumulative burden at the individual level. Age-based categorization into “high school-aged” and “college-aged” groups is an approximation and may misclassify some athletes, particularly those participating in club, recreational, or non-school-affiliated leagues. Additionally, the NEISS does not allow determination of whether a softball injury occurred during NFHS- or NCAA-sanctioned participation versus recreational or informal play. NFHS and NCAA participation counts were used as denominators to approximate populations at risk, but recreational softball participants and athletes outside of sanctioned school or collegiate programs are not included in these counts, even though their injuries may appear in the NEISS numerator. Accordingly, absolute incidence rates may be overestimated and should be interpreted as ED-based injury burden per participant rather than injury risk per athlete-exposure; therefore, they are not directly comparable to exposure-based rates from organized-sport surveillance systems. Finally, the 10-year study period spans the COVID-19 pandemic, during which both participation patterns and care-seeking behavior changed substantially, complicating direct comparison of incidence across years despite consistent analytic methods.
Conclusion
Our study showed that from 2015 to 2024, college-aged female softball athletes were more than twice as likely as high school-aged athletes to present to the ED with a softball-related injury, with higher incidence across most body regions, diagnoses, and ED dispositions. These findings highlight a substantial, level-specific injury burden and support targeted preventive strategies.
Footnotes
Appendix
Diagnosis-specific weighted national estimates and incidence rates (per 100 at-risk persons) by age group, NEISS 2015–2024
| Diagnosis | HS n | HS weighted estimate | HS weighted estimate 95% CI | HS IR per 100 At-Risk Persons | HS IR 95% CI | College n | College weighted estimate | College weighted estimate 95% CI | College IR per 100 At-Risk Persons | College IR 95% CI | IRR | IRR 95% CI |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Strain or sprain | 731 | 93475.5 | 89929.5–97021.5 | 2.650 | 2.549–2.751 | 89 | 12875.5 | 11782.3–13968.7 | 6.209 | 5.682–6.736 | 2.34 | 2.13–2.57 |
| Contusions, Abrasions | 533 | 72291.8 | 69173.4–75410.2 | 2.049 | 1.961–2.138 | 75 | 9989.1 | 9026.2–10952.0 | 4.817 | 4.353–5.281 | 2.35 | 2.12–2.61 |
| Other/Not Stated | 566 | 49798.9 | 47210.7–52387.1 | 1.412 | 1.338–1.485 | 71 | 6413.8 | 5642.2–7185.4 | 3.093 | 2.721–3.465 | 2.19 | 1.92–2.50 |
| Fracture | 401 | 40457.1 | 38124.3–42789.9 | 1.147 | 1.081–1.213 | 36 | 5110.6 | 4421.8–5799.4 | 2.464 | 2.132–2.797 | 2.15 | 1.86–2.49 |
| Internal organ injury | 241 | 23909.3 | 22115.9–25702.7 | 0.678 | 0.627–0.729 | 37 | 3607.1 | 3028.5–4185.7 | 1.739 | 1.460–2.018 | 2.56 | 2.15–3.06 |
| Concussions | 261 | 19779.9 | 18148.7–21411.1 | 0.561 | 0.515–0.607 | 18 | 2089.4 | 1649.0–2529.8 | 1.008 | 0.795–1.220 | 1.80 | 1.43–2.25 |
| Laceration | 145 | 15641.0 | 14190.5–17091.5 | 0.443 | 0.402–0.485 | 32 | 3662.0 | 3079.0–4245.0 | 1.766 | 1.485–2.047 | 3.99 | 3.32–4.79 |
| Dislocation | 63 | 6798.1 | 5841.8–7754.4 | 0.193 | 0.166–0.220 | 9 | 1330.2 | 978.8–1681.6 | 0.641 | 0.472–0.811 | 3.32 | 2.46–4.48 |
| Hematoma | 30 | 3131.1 | 2482.1–3780.1 | 0.089 | 0.070–0.107 | 3 | 252.8 | 99.6–406.0 | 0.122 | 0.048–0.196 | 1.37 | 0.72–2.60 |
| Dental injury | 27 | 1362.5 | 934.4–1790.6 | 0.039 | 0.026–0.051 | 2 | 451.0 | 246.4–655.6 | 0.217 | 0.119–0.316 | 5.56 | 3.20–9.66 |
| Avulsion | 5 | 601.0 | 316.7–885.3 | 0.017 | 0.009–0.025 | 2 | 422.7 | 224.6–620.8 | 0.204 | 0.108–0.299 | 12.00 | 6.17–23.35 |
| Hemorrhage | 7 | 589.5 | 307.9–871.1 | 0.017 | 0.009–0.025 | 1 | 86.6 | 0.0–176.3 | 0.042 | 0.000–0.085 | 2.47 | 0.79–7.73 |
Unweighted counts reflect the number of NEISS cases. At-risk person denominators were derived from annual participation counts summed across 2015-2024: high school = 3,527,364 at-risk persons; college = 207,375 at-risk persons. CI, confidence interval; HS, high school; IR, incidence rate; IRR, incidence rate ratio; NA, not available.
Final revision submitted January 10, 2026; accepted February 22, 2026.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. 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.
This study used publicly available, de-identified data from the National Electronic Injury Surveillance System (NEISS) and was deemed exempt from institutional review board oversight.
