Konda M, Mangal R, Daniel A, Stead TS, Ganti L.

Archery-Related Musculoskeletal
Injuries: An Epidemiological Study Revealing Injury Sites, Risk Factors, and Implications
for Prevention. Orthopedic Reviews. 2023;15. doi:10.52965/001c.88933

General

Archery-Related Musculoskeletal Injuries: An Epidemiological

Study Revealing Injury Sites, Risk Factors, and Implications for
Prevention
Meghana Konda, Rohan Mangal1, Anjali Daniel2, Thor S. Stead3, Latha Ganti3
1 Miller School of Medicine, University of Miami, 2 Emory University, 3 The Warren Alpert Medical School of Brown University
Keywords: archery, National Electronic Injury Surveillance System
https://doi.org/10.52965/001c.88933

Orthopedic Reviews
Vol. 15, 2023

Objective
While generally considered a safe sport, archery injuries are often the result of overuse or
penetration and largely affect the upper extremities. Studies have shown that during
training periods the average risk of injury is 4.4%. By studying mechanisms of injury and
their prevalence nationally, this study aims to educate coaches, athletes, and equipment
manufacturers on ways the sport can be safer from a clinical perspective.

Methods and Materials

The National Electronic Injury Surveillance System Database was queried to analyze
archery-related musculoskeletal injuries that occurred between 2013 and 2022.

Results
Approximately 43,083 injuries were recorded over a 10-year span, of which 8,038 were
women and 35,367 were men. Men were thus 4.4 times more likely to experience injury
during archery. Injury sites in men included the finger (66.2%), hand (17.1%), face (6.2%),
shoulder (5.4%), and foot (5.1%). All reported injuries in women were finger-related. The
most common diagnoses for men were lacerations (58.1%), fractures (12.7%), contusions
and abrasions (7.5%), foreign body (5.9%), punctures (4.9%), and strains/sprains (4.9%).
Women exclusively experienced lacerations, accounting for 100% of their injuries.

Conclusion
The study identifies that lacerations were the most common archery-related injury that
was treated in the ED. Additionally, the fingers were the most common site of injury.
Findings from this study suggest that improved safety equipment, such as reinforced
gloves, finger tabs, and forearm braces should be used by athletes to practice the sport
more safely. Future research could involve studying injury rates in archers who use each
combination of these safety precautions to investigate which gear is most protective.

INTRODUCTION injuries when using the compound bow.3,4 For a well-bal-

anced performance, an archer must focus on the strength
Archery is a constantly developing sport that has become and endurance of their forearm and shoulder girdle muscles
increasingly popular among a variety of age groups. as they are key to executing the technique properly.5
Archery is composed of different phases including aiming, Despite being a non-contact sport, archery commonly
release, and follow through.1 From drawing to releasing, an results in injuries with the impingement of soft tissues.
archer is constantly pulling against an enormous amount Tendons, ligaments, and nerves are most prone to such
of pressure from the tension of the string (9-18 kgs) as injuries.6 Soft tissue injuries may cause chronic pain and
they extend their non-dominant hand to the target while inflammation, and can contribute to the development of
the dominant hand engages in a dynamic pulling and re- bone spurs, which cause further microtrauma to tissue.7
leasing of the bowstring.2 Depending on the different types Acute injuries may also include lacerations, typically in
of bows such as olympic, recurve, and compound, the site cases where an arrow pierces the forearm and causes severe
of injury tends to vary. For example, for archers using an bruising or desensitization of the affected area if severe.6
olympic bow, hypertrophy of the finger flexor tendons is Both of these injuries are common even in archers who take
common, whereas the upper arm and shoulder are prone to precautions such as wearing a finger tab, or a forearm brace
 Archery-Related Musculoskeletal Injuries: An Epidemiological Study Revealing Injury Sites, Risk Factors, a…

due to the continuous and rapid act of extending and re- (code 59), punctures (code 63), strains/sprains (code 64),
leasing the bowstring to the target. and other (code 71). Patients’ dispositions were also ana-
Due to the overuse of shoulder and rotator cuff muscles, lyzed to determine if they were admitted to the hospital,
shoulder and back injuries are also common in archers. treated and released (code 1), treated and transferred (code
However, wrist and hand injuries have also been becoming 2), treated and admitted for hospitalization (code 4), or left
more common due to the misuse and mishandling of the without observation (code 6).
equipment. While shoulder injuries have been previously
studied, current literature does not include a large segment STATISTICAL ANALYSIS
of injuries, including the fingers, wrists, and hands. This
retrospective study aims to characterize archery injuries Gender, anatomic locations, age groups, and diagnoses re-
and report on their epidemiology over the past ten years. lated to archery injuries were assessed in this study.
Anatomic locations were also grouped into 6 broad cate-
gories for subanalysis: (1) head/neck, (2) upper extremi-
METHODS AND MATERIALS
ties, (3) lower trunk/pubic region, (4) lower extremities, (5)
STUDY DESIGN 25% or more of body, and (6) upper trunk. NEISS data-
base outputs were analyzed using JMP Pro 15. Through this
National Electronic Injury Surveillance System (NEISS), an study, the authors examined whether males or females were
electronic, publicly available database, was queried and an- more prone to archery injuries, how injuries were distrib-
alyzed to perform a retrospective study of musculoskeletal uted among various age groups, the types of injuries that
injuries resulting from archery. The NEISS database is for- were most common in affected individuals, and the neces-
mulated by the United States Consumer Product Safety sity of follow-up care for affected individuals.
Commission, which closely tracks and records various trau-
matic injuries that have occurred due to consumer products
RESULTS
and have resulted in emergency department visits. In this
study, archery was chosen from the Sports and Recreation
A total of 43,083 archery-related injuries were identified
Equipment section of the product group to analyze all in-
through the NEISS database over a ten-year span. Males
juries that resulted in emergency department visits.
incurred 82% of the injuries (n=35,367), an injury rate 4.4
STUDY POPULATION times higher than in females (n=8,038).
Figure 1 depicts the frequency distribution of archers
The NEISS database has transcribed and recorded data from among different age groups suffering from archery-related
approximately ~100 emergency departments throughout injuries. Injury rates peaked at ages 10-19 years in males
the United States In this study, NEISS data over a ten-year and 30-39 years in females, with a peak incidence at age
span from 2013 to 2022 was queried. The patient popula- 15 in men and a peak incidence at age 36 in women. Injury
tion was not filtered by age, sex, or race. Participants were rates declined as individuals grew from adolescence until
required to have experienced an archery-related injury in middle age in their fifties, where numbers peaked again for
the aforementioned time interval to meet the inclusion cri- both genders. Thereafter, the number of injuries declined
teria. with age where reported cases were less than 1,200 for both
To analyze injuries specifically related to archery, prod- males and females in their 80s.
ucts in the sports and recreation equipment group with This cohort was also analyzed by race. White patients
archery as the subgroup were searched. In the archery sub- (~78%) were the most affected by archery-related injuries.
group, all equipment, apparel, and activity-related injuries Additionally, the graph shows that the Black population
were included in the study (code 1235). All body parts were made up a small percentage (~2%), while some patients
searched in the study including head/neck injuries: the did not report their race. Additionally, some patients were
head (code 75), face (code 76), eyeball (code 77), mouth recorded as identifying with multiple races, indicating that
(code 88), neck (code 89), and ear (code 94). Upper extrem- they did not identify into a single category presented to
ity body parts including the shoulder (code 30), the elbow them. This category made up approximately 4% of the in-
(code 32), the lower arm (code 33), the wrist (code 34), the jured population.
upper arm (code 80), the hand (code 82), and the finger With regards to anatomic location, archery-related in-
(code 92) were searched in the study. Lower trunk/pubic re- juries most commonly affected the fingers. Injuries were
gion body parts including: the pubic region (code 38) and distributed as follows in men: 66.2% finger (n=23,342),
the lower trunk (code 79) were also searched in the study. 17.1% hand (n=6,012), 6.2% face (n=2,122), 5.4% shoulder
Lower extremity body parts including: the knee (code 35), (n=1,909), and 5.1% foot (n=1,803). In contrast, in women,
the lower leg (code 36), the ankle (code 37), the upper leg 100% of all reported injuries were of the finger. Figure 3
(code 81), the foot (code 83), and the toe (code 93) were all represents the distribution of anatomic injuries in men.
queried in the study. In men, the most common diagnosis was lacerations
In terms of diagnosis codes, all codes were queried, but (58.1%). Other frequently encountered diagnoses include
only diagnoses that had numerical data were used for fracture (12.7%), contusions/abrasions (7.5%), foreign body
analysis. These diagnoses included contusions (code 53), (5.9%), puncture (4.9%), and strains/sprains (4.9%), while
foreign bodies (code 53), fractures (code 57), lacerations the remaining injuries were classified as other (6%) as rep-

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 Archery-Related Musculoskeletal Injuries: An Epidemiological Study Revealing Injury Sites, Risk Factors, a…

Figure 1. Number of archery-related injuries by 10-year age groups from the NEISS database.

Figure 2. Distribution of race in archery related

injuries from the NEISS database.

resented in Figure 4. In women, all archery injuries in the Figure 3. Distribution of archery-related injuries by
database were reported as lacerations (100%). the affected body part in men.
In terms of disposition, all individuals who suffered from
archery-related injuries and went to the ED were treated, injuries. Based on the National Safety Council, 3.2 million
examined, and then released. Additional hospitalization people were treated in the ED for sports and recreational
was not needed for the reported visits. By the data queried activities annually.8 This data suggests that about 1 in
from the database, 33,769 males were treated/examined, every 670 sports injuries in the United States are archery-
and then released, while 7,692 females were treated/exam- related injuries. Given this frequency, expanding on risk
ined, and then released. prevention and mitigation strategies in archery is worth-
while.
DISCUSSION With over 23 million Americans aged 18 and older par-
ticipating in archery, the United States is a leading country
While partly understated, archery-related visits to the where archery is increasingly popular; this is due to the va-
emergency department are relatively common. After a re- riety of training facilities and programs available.9 In the
view of the NEISS database, approximately 43,083 archery- United States, archery participants are more often males
related injuries resulted in ED visits between 2013 and than females by a 3:1 margin.10 Most archers come from
2022. This represents an average annual incidence of 4,308 rural backgrounds, usually from the Midwest, and begin

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 Archery-Related Musculoskeletal Injuries: An Epidemiological Study Revealing Injury Sites, Risk Factors, a…

Figure 4. Most common diagnoses of archery-related injuries in emergency departments in men.

their archery journey from a young age.10 As participation continuous and excessive pressure inflicted on it as the
gradually increased in males throughout the years, partic- archer shoots the arrow. By misplacing the arrow or bend-
ipation rates for females are declining.10 Overall, young ing the finger in an improper manner, an archer is prone to
males, ages 15-29, make up more than 55% of all archers.10 being injured even with the finger brace, leading to lacera-
Efforts to dispel the gender disparity and provide an oppor- tions of the skin. Traumatic lacerations to the skin, which
tunity for the sport to be available to all, regardless of gen- are often painful and occur near the joints, remain a com-
der, can be beneficial to counter this trend. mon reason for patients to seek emergency care.13
Analysis of the database corroborates previous epidemi- In addition to traumatic lacerations, fractures such as
ological findings that males suffer significantly higher rates open metacarpal fractures are common diagnoses in
of archery-related injuries than women.11 Specifically, it archers. During the aiming phase, fractures due to im-
was determined that males suffer archery-related injuries proper placement of the hand are predominant, given the
4.4 times more than women. Therefore, there are more extensive amount of stress placed on the upper extremi-
recorded cases of males visiting the ED for archery-related ties.14 Other chronic injuries included bilateral medial epi-
injuries than women.12 Thus, in terms of injuries, although condylitis and median nerve compression, affecting the
males suffer higher rates of injuries, it can not be concluded wrist in most archers.15,16 As tension is concentrated at the
that men are more susceptible to injuries than women be- wrist and fingers when pulling the bowstring, prolonging
cause archery is a sport predominantly played by males. the time of exposure with the string, even after the release
The highest frequency of injuries occurred during ado- of the arrow, can cause these chronic injuries, in addition
lescence in both men and women. These occurred at the to tendonitis, blistering, and bruising.17 Overuse type of
highest rates in the 10-19 year age group in men, peaking at tendon injuries and strains such as de Quervain’s tenosyn-
15 years, suggesting that male archers are most susceptible ovitis, extensor tendon tenosynovitis are among the most
to injury during this stage of life. Most archers begin their common musculoskeletal injuries in competitive archers
archery experience with no past experience and therefore, and occur when the tendons and rotator cuff muscles are
need to be thoroughly trained to handle the heavy bow and overused with repetitive load bearing, putting enormous
arrow. With just a slip of the finger, the position of the ar- amounts of stress on the body and leads to early degener-
row can be drastically altered, allowing more room for in- ative changes.18,19 As most of these injuries are caused by
juries to occur. Since most of the injuries in both genders poor technique, overuse, and limited recovery time, it is im-
occurred during the adolescent period, these findings sug- portant to provide archers with comprehensive training to
gest that more focus should be given to properly training prevent further injuries.20
and accurately guiding novice archers to prevent injuries. This study has limitations worth noting. The total num-
The most common injury site was the finger in both gen- ber of archery-related injuries is likely to be underreported
ders with lacerations being the most common diagnosis. in the NEISS database as it only includes individuals who
Although safety gear is worn by archers to protect the fin- reported to the ED for treatment, and excludes individuals
ger, it is still extremely vulnerable to injuries due to the who have been injured but did not seek emergency care. As

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 Archery-Related Musculoskeletal Injuries: An Epidemiological Study Revealing Injury Sites, Risk Factors, a…

archery is a sport that is predominantly played by males, White, Black/African American, and other. This other cat-
there is limited data for women. In the NEISS database, all egory is a combination of cases where the ED record in-
reported injuries for women were lacerations of the finger dicates more than one race or where none of the above
- not accounting for a variety of injuries that likely affect applies. Due to this characterization, the database fails to
women. This limits the ability to further analyze gender as capture the full diversity of the US population and cannot
it relates to archery injuries by location and wound type. provide an accurate representation of injuries associated
In the NEISS database, there is limited data on geo- by race. Additionally, while diagnoses of injuries were pro-
graphical location of where archery-related injuries oc- vided, the severity of each injury was not taken into con-
curred. The database includes information regarding the sideration in the database and therefore, could not be an-
specific incident sites of injuries such as home, farm/ranch, alyzed. Finally, as this is a retrospective study, the study
school, and industrial place but does not have records of design limits the ability to draw causative conclusions, but
the distribution of injuries among the states/territories in rather suggests correlations.
the United States. This limits the ability to further analyze This study’s objectives were to provide an overview of
if location, rural or urban, has an effect on archery-related archery-related injuries and their trends in demographics,
injuries and visits to the ED. Further research should focus diagnosis, and disposition. Future studies may include bet-
on considering location as a component of analysis to es- ter characterizing archery injuries in both genders and in-
tablish if differences in geographic location has an effect on jury rates in athletes with various protective gear in use.
training methods or the use of safety gear to help prevent This work would help contribute to the growing body of lit-
further injuries. erature that advocates for the implementation and use of
Additionally, a portion of injury types in the NEISS data- protective gear in the sport.
base were recorded as “other”. The “other” category limited
our analysis as the mechanism of injury could not be con-
cretely stated. In the NEISS database, race is categorized as

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 Archery-Related Musculoskeletal Injuries: An Epidemiological Study Revealing Injury Sites, Risk Factors, a…

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