Sport-specific injury overview Cricket is riskier than you may realise. This article surveys the evidence and offers advice on injury avoidance
Cricket is a major international sport played in more than 60 countries. The laws of cricket were drawn up by the London Club in 1744, formalising a game that had been played for a hundred years before. While its popularity spread throughout the countries of the British Empire and western Europe, it was not until the mid-19th century that cricket gained its international status and regular international matches were played between touring teams.
The first recorded international took place in 1844, at St George’s Park, New York, between the United States and Canada. Canada won. The inaugural test match was played between Australia and England at the Melbourne Cricket Ground in 1877(1). Professionalisation and more recently, media coverage have led to a huge expansion and popularisation of the game as we know it today. Ten nations are full members of the International Cricket Conference, and 45 more are associated or affiliated members.
Although strictly a non-contact sport, injuries in cricket are common, and have been documented as far back as 1751, when Frederick, Prince of Wales (son of George II), expired suddenly from an abscess in his head as a consequence of a blow he’d received from a cricket ball(2). For one of the widely popular team sports, there have been relatively few publications in the medical literature on cricket injuries. This article reviews the injuries occurring commonly in cricket and describes measures to prevent or minimise them.
In the 1970s cricket was regarded as a sport of ‘moderate-risk injuries’. These days cricketers are more susceptible to higher-risk injuries and cricket ranks fifth among causes of non-fatal accidents. Elite cricketers are expected to train longer, harder, and earlier in life to excel in their chosen sport. The repetitive nature of the game and the need often to be out on the field of play for long periods further predispose cricketers to a wide range of injuries. Injury can occur during any phase of the game – bowling, batting or fielding – and can involve any part of the body.
Statistics on the incidence, nature and severity of injuries in cricket have only become recently available through research from Britain, South Africa and Australia(3,7,8,18).
Incidence: A British Council sports survey has reported 2.6 injuries per 10,000 hours played. Among Australian players the figure is reported to be 24.2 per 10,000 hours played. In South African surveys, 49% of all players injure themselves at some point in the season. Recent studies show that injuries are on the rise, with 28.4% to 71.6% of cricketers(7) sustaining between 1.61 and 1.91 injuries per season(8). The UK average rate of fatality among participants has been estimated at 2 per 100m adults.
Sites: Various studies have reported injury sites. Injuries to the lower limbs varied from 22.8% to 50% of total injuries, while upper-limb injuries accounted for 19.8% to 34.1%(3,7,8,10-12), with the fingers found to be the most vulnerable site(3,8,10). Back and trunk injuries accounted for about 18% and 33.3% respectively (7,8,10-12). Head, neck, and face account for anything from 5.4% to 25%(3,7,8,10-12), mainly concussions, contusions and lacerations. The Australian Cricket Board (ACB) survey reported that injuries to players missing a first-class game in the 1998 and 1999 seasons divided into: lower limb 47.3%, trunk 32.6%, and upper limb 18.9%(18).
Actions: Both the South African and ACB studies have shown that bowlers are most likely to sustain an injury that causes them to miss a match, followed by batsmen and then fielders(7,11). Among schoolboy bowlers injuries ranged from 38%(13) to 47.4%(11); among provincial bowlers it was 33% to 65.7%(8). Spondylolysis is often encountered in Australian fast bowlers playing first-class cricket(13), as are stress fractures at other sites including the metatarsal bones, fibula and tibia(4). The most common batting injuries are muscle strains and impact injuries(10).
Age: Among adult professionals, most injuries occurred during match play (69.3%), whereas at school level the distribution was equal between matches (45.6%) and practice (47.4%). Most injuries occurred at the start of the season, and in 22.7% of adult and 29.8% of schoolchild cases they were recurrent injuries from the previous season(7, 18).
Younger players tend to be at greatest risk(7,8,10,11), with bowlers (mean age 16.8 years) showing increased vulnerability when their growth process is not complete(13). Among Australian children, cricket contributed 4% of all sports-related injuries and ranked eighth out of sports-related child emergency-department presentations(19) – mainly for facial and head injuries (44.2%)(19).
There are three broad categories: direct impact, indirect, and overuse(20).
Direct blow injuries occur when a player is struck by the ball, collides with another player, or crashes into the boundary fence(4,19,20). For example, bowlers and fielders can be exposed to balls of very high speed and are at risk from a misjudgement of the ball or unanticipated bounce. A cricket ball is a leather-covered solid cork sphere weighing 160g and measuring 22.4cm to 22.9cm in circumference. As the ball is propelled down the pitch at speeds of up to 150km/h(20), the batsman must make a series of very quick decisions, including determining the line and length of the ball, whether to move forwards or backwards, whether to play a stroke and which stroke to play. Any misjudgement creates a visual inadequacy which could cause the ball to ricochet off the bat’s edge or the batsman to miss the ball completely, either of which might end up with the cricket ball colliding with a body (21). The batsman’s feet are vulnerable to being struck by a ball and lightweight batting shoes offer little protection against such impact(4).
Wicket-keepers can experience great trauma, especially on the receiving end of a fast delivery. Fielders are susceptible both to direct blows from the ball and running and sliding into the boundary fence.
Despite batsmen and close-in fielders wearing protective equipment, reports of head and eye injuries are common(19,22). Other frequently reported impact injuries are fractures of the arm, hands and toes, and soft-tissue injuries to the upper arm and thigh, thorax, abdomen and testicles(4,19,23). Splenic rupture has been reported both because of a blow from a cricket ball and collision with the boundary fence, and at the extreme, there was a report of fatal cardiac arrest after a player was hit in the chest by a cricket ball(4,17).
Indirect injuries are muscle, ligament and tendon damage sustained while attempting to perform a specific activity. These injuries are most prevalent at the start of a season and in players who pay less attention to warming up and their general level of fitness(20).
Overuse can produce a range of injuries secondary to running (eg lower limb), throwing (eg shoulder and elbow) and bowling (eg lower back). But the most common overuse injury is associated with fast bowling. Bowling involves repetitive twisting, extension and rotation of the trunk in a short period, while body tissues and footwear must absorb large ground reaction forces of 4.1 to 9 times the bowler’s body weight. It is the speed of the delivery, and thus the force of the action, that makes the fast bowler more injury prone(26), particularly to bony abnormalities (eg spondylolytic incidences, spondylolisthesis, spondylolysis, pedicle sclerosis and pars defect), disc degeneration, stress fracture at various sites, primarily in the metatarsal bones, fibula and tibia, muscle and other tissue tears, and pain (unpublished data)(4,27,28,29). The other overuse injury is splitting or wearing of the finger skin as spin bowlers repeatedly drag their skin across the seam of the ball to impart spin(4). The laws of the game prohibit the use of protective strapping, and the skin may only partially heal between matches. The end or middle finger joints are often traumatised repeatedly by the bowling action, and sometimes the consequent osteoarthritic changes can be severe enough to end a bowler’s playing career(4).
A wicket-keeper may also experience osteoarthritic changes in the knees (because of the action of repeated squatting), and in the joints of the hand, from repeatedly catching the ball(4).
Other overuse injuries are related to throwing, catching or running. Repetitious throwing can result in instability, impingement syndrome, degenerative changes in the rotator cuff, and tendinitis in the biceps or a tear of the supraspinatus tendon(4). Running long distances during matches predisposes the player to stress fractures, shin pain, patellar tendinitis and muscle tears(4).
Finch et al(30) described three types of injury prevention measures: pre-event, during the event and post-event.
Primary measures (pre-event): In the past the need to be physically fit was a low priority among players. These days players and coaches at all levels appreciate the benefits of a good stretching programme before and after play, and understand that comprehensive conditioning and technique programmes are vital injury-prevention measures.
While senior and junior players alike participate in pre-season training camps(31), non-elite cricketers may still rate conditioning and general fitness as a low priority, because of the lack of research into its effect on cricket performance – and so may be increasing their injury risk.
Good coaching guidelines can reduce the incidence of lower back injuries. Instruction on good technique and the adoption of either a front-on or side-on approach to the wicket reduces the rotational stress on the lower back and the risk of spondylolysis and facet joint arthrosis(24, 32). There are also recommendations available on how long a young bowler should spend at practice and how many overs they should bowl in a match(32).
Cricketers rely heavily on the quality of the whole playing field, not just the pitch. Excessively wet or uneven playing surfaces can be dangerous to all players and play should be suspended until the field is safe. Umpires and team captains should inspect the pitch and field. In some countries, such as New Zealand, a national standard has been set for the construction and maintenance of cricket pitches(31).
Secondary measures (during the event): Cricket is predominantly played in summer, which increases the risk of dehydration, heat exhaustion, heat stroke and skin cancer. In general cricketers are required to wear white shirts, trousers and, if desired, a hat; and use sun-screen protection, all of which help to protect the eyes and skin from the damaging effects of the sun. A regular intake of fluids will reduce the risk of heat illness and maintain physical performance (30).
Batsmen and in-fielders need to wear well-fitting helmets with visor, especially against fast bowlers, to prevent eye and facial injuries. Proper shoes can minimise damage to feet being struck by the ball. At all levels it is important that appropriate first aid be available at the match.
Tertiary measures (post-event): Injuries need to be properly managed to restrict the possibility of further damage. Overall, the treatment goals are pain relief, promotion of healing, decreased inflammation and a return to functional and sports activities as soon as possible.
Accurate diagnosis of any injury and correct treatment and rehabilitation allow a prompt return to activity. The coach should ensure that the risk of further injury is minimised.
Cricket today demands greater physical effort from players at vital stages during their careers and predisposes them to a greater risk of injuries. It is the duty of those involved in the treatment of injuries to have a better understanding of the principles of the game and players’ specific requirements, to help them reach their full potential. Improved coaching and monitoring of injuries has increased our knowledge in this field and has led to international recommendations to prevent the injuries commonly seen in cricket.
Pradeep Moonot and Shilpa Jain