The Epidemiology of Sports and Recreation Related Toe Fractures in the United States

Abstract

Background:

Fractures of the toes are among the most frequently diagnosed lower extremity fractures. In sports, toe fractures may present after diverse mechanisms of injury, varying severity, and varying implications for management. This study aimed to discern trends in toe fractures presenting to US emergency departments (EDs) particularly in association with sports and recreational activities. An additional aim of the study was to identify if rates of toe fracture presentation significantly decreased during the year 2020 at the height of the COVID-19 pandemic.

Methods:

We queried the National Electronic Injury Surveillance System (NEISS) database to identify toe fractures presented to US EDs from 2013 to 2022. The data outputs were analyzed by age group, sex, sport/recreational activity, and year. US Census data were used for calculation of incidence rates (IR) in 100,000 person-years. χ² tests and regression analyses were performed to determine significance. Grubbs’s test was performed to determine significant yearly outliers with particular attention to the year 2020.

Results:

A total of 921,033 toe fractures were identified across US EDs, with 175,864 cases associated with sports and recreation. Exercise (IR = 140.3) had the leading IR among sports/recreation followed by cycling (IR = 136.8), basketball (IR = 136.8), and football (IR = 94.9). Males accounted for 40.8% of fractures (IR = 23.0), whereas females contributed 59.2% (IR = 32.8). Toe fractures peaked in the 10- to 14-year-old age group in both males and females. Sports- and recreation-related toe fractures did not significantly decrease from 2013 to 2022, although all-cause toe fractures did significantly decrease as shown by a P value of .0037 from linear regression analysis of yearly trend in all toe fractures. The year 2020 was a significant outlier with a decrease in sports-related toe fractures though there was no significant decrease in all-cause toe fractures in 2020.

Conclusion:

Sports- and recreation-related toe fractures did not significantly decrease from 2013 to 2022, although a significant decrease in all-cause toe fractures was observed. Toe fractures continue to peak in the pediatric age groups, particularly 10-14 year-olds. Youth sports and recreation officials should be aware of the risks of toe fractures to aid in prevention.

Level of Evidence: Level III, epidemiologic database, retrospective cohort studies.

Introduction

Toe fractures rank among the most frequently diagnosed lower extremity fractures by physicians. In athletics, foot injuries, especially toe fractures, occur through various injury mechanisms, differing in severity and management implications. Previous studies demonstrated that toe fractures make up 5% to 6% of all fractures presenting to the emergency department (ED). ¹ Mechanisms of toe injuries are diverse but can be categorized into direct and indirect trauma. Studies on mechanisms of injury show that sports and recreation are the leading cause of injury among younger patients, whereas falls are the primary cause among older patients. ² Management of toe fractures varies based on displacement, pattern of injury, the surrounding soft tissue envelope, and the load across the fracture site during weightbearing. ³ Understanding the epidemiologic patterns of toe fractures can inform clinical decision making and improve patient outcomes. The National Electronic Injury Surveillance System (NEISS) is a well-established database used to study the epidemiologic trends of injuries presenting to EDs in the United States.^4,5 This study aimed to discern trends in toe fractures presenting to US EDs stratified across parameters such as sex, age, age group, and sports activities. Additionally, we sought to explore how the COVID-19 pandemic affected trends in toe fracture presentations to EDs in the year 2020.

Methods

NEISS is a publicly accessible database managed by the US Consumer Product Safety Commission (CPSC). It collects data from ED reports at approximately 100 hospitals nationwide. NEISS applies statistical weights to injury data from a nationally representative sample of hospitals, with weights based on factors like hospital size, type, and geographic region. This ensures the extrapolated injury estimates accurately represent national trends by adjusting for the proportion of hospitals in the sample compared to the overall US hospital population.

These data are then extrapolated to generate nationwide estimates of injury trends. Using diagnosis code 57 (fracture) and body part code 93 (toe), NEISS was queried to identify toe fractures that presented to US EDs from 2013 to 2022. Toe fracture rates were assessed by age, sex, location, activity/product, and patient disposition. Estimates of the population by age and sex were made using United States Census Data.

Product groups provided by the NEISS database represent various activities, sports, and scenarios linked to different types of injuries presented to EDs across the United States. In this study, injuries related to sports and recreation were identified using specific product codes from the NEISS database, including those for basketballs (1311), bicycles (1181), skateboards (1243), soccer balls (1344), baseballs (1222), footballs (1336), tennis rackets (1335), hockey equipment (1346), and exercise equipment (1111), with each code characterizing injuries associated with relevant sports and recreational products. In our study, these product groups served as a means of identifying the mechanisms of injury associated with toe fractures in our data set. By categorizing injuries within these product groups, we were able to analyze trends and identify specific activities or products that contributed to toe fractures, allowing us to better understand the factors influencing these injuries in the context of sports and recreational activities.

Incidence rates were reported in 100 000 person-years. χ² tests were performed to compare observed toe fractures with expected occurrences based on population data and NEISS toe fracture data. Regression analysis was performed to determine significance and trends among 10-year age groups from 2013 to 2022 (significance set at P value <.05). Additionally, Grubbs statistics were calculated to identify years that were significant outliers for the incidence of toe fractures. The Grubbs test formula is the absolute value of the (data point in question – average of the data set) / (standard deviation of the data set). Given that there were 10 years in the study period, the corresponding Grubbs statistic to identify an outlier with a P value of .05 was 2.18. Thus, any year with a Grubbs statistic >2.18 was deemed a statistically significant outlier.

Results

From 2013 to 2022, there were a total of 921,033 toe fractures presenting to US EDs, with an incidence rate (IR) of 27.9 per 100 000 person-years (95% CI 23.2-32.6). Of these, 175 864 cases, or 19.0%, were directly linked to sports and recreation, with an IR of 5.3 (95% CI 4.1-6.5).

Home furnishings/fixtures/accessories, home structures/construction materials, and sports and recreation were the leading product groups in consumer-related injuries associated with toe fractures during the study period. Home furnishings, fixtures, and accessories accounted for 34% of the national estimate with an IR of 9.5 (95% CI 7.56-11.02). Home structures and construction materials accounted for 30.1% of the national estimate with an IR of 8.5 (95% CI 7.15-9.9). Sports and recreation accounted for 23.5% of the national estimate with an IR of 5.32 (95% CI 4.11-6.54).

Yearly Trend

All-cause toe fractures did significantly decrease as shown by P value of .0037 from linear regression analysis of yearly trend in all toe fractures. There was also no significant trend in sports-related toe fractures (P > .05). The year 2020 was identified as a significant outlier for sports-related toe fractures, with a Grubbs statistic of 2.28, although it was not a significant outlier for all-cause toe fracture incidence (Grubbs statistic: G = 0.75). There was an average annual decrease of 2742.8 toe fractures over the study period (R² = 0.3885 [all-cause] vs R² = 0.673 [sports-related]) (Figures 1 and 2).

Figure 1.

Sports-related toe fractures (y = −2742.8x + 6E+06, R² = 0.6727). The regression analysis for Figure 2 resulted in a P value of 0.0037, demonstrating statistical significance.

Figure 2.

All-cause toe fractures (y = −458.72x + 943057, R² = 0.3885). The regression analysis for Figure 2 yielded a P value of 0.0542, indicating that the independent variable is not statistically significant.

Sex

Males accounted for 40.8% of fractures (n = 375 732), whereas females contributed 59.2% (n = 545 301). The overall incidence of toe fractures is 27.9 per 100 000 person-years (95% CI 23.2-32.6). When broken down by gender, the incidence rate is 23.0 per 100 000 person-years (95% CI 18.9-27.0) in males and 32.8 per 10 000 person-years (95% CI 27.2-38.3) in females. Among males, the top 3 product groups by National Estimate were sports and recreation, home furnishings/fixtures/accessories and home structures/construction, respectively. For females, the top 3 product groups were: home furnishings/fixtures/accessories, home structures/construction, and sports and recreation, respectively. See Figure 3 for leading product groups by Sex.

Figure 3.

Leading product groups associated with toe fractures by sex.

Age

The 5-year age group with the highest incidence rates for both males and females was 10-14 years, with IRs of 57.65 for males and 56.73 for females. The adult working population sustained the greatest number of toe fractures, with an IR of 18.3. This was followed by an IR of 6.44 for those aged 0-18 years and 3.15 for those aged ≥65 years. When stratified by sports and recreational activities among the 10-14-year-old age group over the study period, soccer was found to be the leading cause of toe fractures in this cohort.

Sports-Related Injuries

Among all sports, injuries that occurred as a cause of injuries caused by exercise equipment had the highest IR at 140.34, closely followed by bicycle and accessories, with an IR of 136.8. Among team sports, basketball had the highest injury incidence, with a similar IR of 136.8. The sport with the lowest incidence of injury was soccer, with a substantially lower IR of 58.6. See Table 1 for the breakdown by Sport.

Table 1.

Incidence of Sports and Recreation From 2013 to 2022.

Sports/Recreational Activity	Incidence Rate
Exercise and equipment	140.3
Bicycles and accessories	136.8
Basketball	136.8
Football	94.9
ATVs, mopeds, minibikes, etc	65.7
Playground equipment	65.4
Soccer	58.6

Abbreviation: ATVs, all-terrain vehicles.

Discussion

Our study found that although all-cause toe fractures showed a statistically significant decrease over time, sports- and recreation-related toe fractures did not demonstrate a significant trend in the overall incidence reported in US EDs over the past decade. However, the largest number of toe fractures were associated with home furnishings, fixtures, and accessories. Females represented nearly 60% of all toe fracture cases, and the highest fracture rates were observed in the 10-14-year age group.

In addition, the decreased incidence of sports-related toe fractures in 2020 may be attributed to several factors. Most notably, the COVID-19 pandemic led to a reduction in participation in sports activities, which likely contributed to decreased exposure to fracture risk. ⁸ However, further evaluation is needed to understand how CDC restrictions and broader public health guidelines during a global crisis influence patient behavior and healthcare-seeking patterns.

A 2000 study by Schulze et al ¹⁰ also found that furniture was the leading cause of toe fractures, particularly incidents involving dropping heavy objects onto the forefoot. Their finding aligns with our study, which identified home furnishings as the product group most commonly associated with toe fractures. It follows that home furnishings could contribute significantly to toe fractures, as people are more likely to be without shoes and thus less protected in their homes than in public. Without footwear, striking the forefoot against furniture is likely to increase the risk of toe fractures in the home setting.

Furthermore, we found that adolescents aged 10-14 years experience the highest incidence rate with an IR of 6.44. This could likely be attributed to increased physical activity in the younger population. ⁶ Parents receiving education on injury prevention for their children can help mitigate the number of injuries among children. ⁷

Among sports and recreational activities, exercise and exercise equipment were most commonly associated with toe fractures. Zemper et al ¹³ previously reported that mishandling of equipment was a leading cause of exercise-related toe fractures. This is suggestive of a crush mechanism from falling equipment. Another mechanism potentially implicated in toe fractures is axial load when striking the ground during high-impact activity. In all, proper training in the use of exercise equipment and wearing protective footwear can significantly reduce the risk of toe fractures. ⁹

In regard to soccer, a foot-dominant sport having the lowest IR of toe fractures among other sports, it must be highlighted that athletes in this sport often acquire more protective footwear, which prevents mechanisms of injury that may elicit a toe fracture. ¹⁰

In addition to female predominance in fracture cases the average age of incidence is 37.4 years old. This average age of incidence among females calls for the need to explore the potential role that hormonal differences play in increasing fracture risk. In particular, postmenopausal women experience a decline in estrogen levels, which leads to a decrease in the structural integrity of osteoporotic bone. ¹¹ Additionally, female feet may structurally differ from male feet, as they tend to have narrower heels and have a broader forefeet, which may result in increased forces on the forefoot. ¹² The increased forces seen by the forefoot may contribute in part to the greater number of toe fractures in women.

Limitations

This study is not without limitations. One of the primary limitations, inherent to the NEISS database, and thus this study, lies in the need for more detailed documentation about the individual-reported injury cases. Additionally, reliance on International Classification of Diseases (ICD) and product codes introduces potential misclassification, as diagnostic accuracy may vary across demographics and settings. Future studies should clarify whether coding validation was performed or whether multiple encounters were required to confirm fracture diagnoses. We do not report information such as other associated injuries, medical treatment of injury, severity of injury, presence of an open fracture, time to reduction, rates of neurovascular compromise, and operative vs nonoperative treatment. Additionally, this study only includes toe fractures that presented to EDs, so it does not account for fractures treated in urgent care centers, by primary care physicians, or elsewhere. We would presume that based on our collective clinical experience that this would account for a large number of fractures occurring in the United States. Additionally, some individuals with toe fractures may not have sought evaluation from a medical professional at all. Lastly, the diagnosis of a toe fracture is nonspecific. It does not distinguish between nondisplaced phalangeal fractures, typically managed conservatively with an orthotic, and displaced fractures, which may involve multiple toes and require operative fixation. Future research should consider assessing the rates of toe fractures in the NEISS database, which ultimately proceeds to operative fixation and/or hospital admission.

Conclusion

During the decade from 2013 to 2022, sports- and recreation-related toe fractures did not significantly decrease, although a significant overall decrease in all-cause toe fractures was observed. However, the year 2020 was a significant outlier in sports-related toe fractures in the wake of the COVID-19 pandemic. Home furnishings, home structures, and sports/recreation accounted for the greatest portion of toe fractures. Additionally, the 10-14-year-old age group had the greatest incidence of toe fractures. Further research is needed to investigate methods to mitigate the risk of toe fractures in adolescents.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114251342797 – Supplemental material for The Epidemiology of Sports and Recreation Related Toe Fractures in the United States

Supplemental material, sj-pdf-1-fao-10.1177_24730114251342797 for The Epidemiology of Sports and Recreation Related Toe Fractures in the United States by Dogerno Norceide, Gabriel I. Onor, Oluwatomi Akingbola, William Justice, Nana F. Amponsah, Abimbola Okulaja, Ifeanyichukwu Onor, Michael Okoronkwo, Chibuikem Nwizu and David Pedowitz in Foot & Ankle Orthopaedics