I would like to post this paper that I
started to write on Ultimate Frisbee. It s unfinished but I ran
into difficulties in writing it. The worst being the erasure of
all my original questionnaires by my computer provider. I left it
in unfinished because I felt the lack of data makes it hard
to justify any quantitative conclusions, but this still contains
some qualitative observations that I still feel were worth discussing,
History of Ultimate
Ultimate is a relatively new sport, having just celebrated its 31st
anniversary. Frisbee football was developed at Columbia High school
in Maplewood, New Jersey during 1968 and originally allowed tackling
(reference 1). Tackling was abandoned after the large number
of significant injuries. The rules have undergone several revisions
and ultimate is played today according to the 9th edition rules
(reference 1-4, appendix 1).
Purpose of this Study
Ultimate players were surveyed about their self reported injuries
to find out what type of injuries they are having so that possible
causes could be determined and recommendations on injury prevention
could be made.
Rules of Ultimate
The game involves two teams of seven players. At least three or four players
of both gender are on the field at one time per team. No more than four males
or females are on the playing field at one time. If a team is short players
of one sex they would be limited to having less than seven players on the
The Ultimate disc weighing 165g is harder and flatter than a Frisbee disc
and will fly farther and more accurately because of this design. One team
gains possession of the disc at the beginning of the game after an agreed
flip of the disc before the game. The defensive team starts with the disc
and has one player throw the disc towards the opposing offensive team who
may begin play by catching or picking up the disc. Successful
passes must then move the disc to members of the offensive team. Players group
in formations known as 'stacks' so that they may maximize the use of the playing
field. At the same time the defensive team may guard each member of the offensive
team including the thrower. If the thrower is unable to complete a pass or
runs out of time then the disc turns over to the other team. A goal occurs
when a pass is completed behind the other teams goal line. A disc that hits
the ground is dead. Play is further complicated by the dynamics of using a
disc instead of a ball, because the wind may significantly influence the curve
of the disc passes do not have to be straight but may curve around players.
Stalls or updrafts that make the disc linger too long in the air predispose
players for injuries since too many players from both the offense and defense
enter the area making collision more likely. Badly thrown or planned plays
are hence called "hospital plays".
Such dangerous plays as well as fouls or picks (cutting off other players)
are self-reported by players. Any violation of the rules that is felt to have
occurred is discussed and agreed on before play resumes. This is felt by many
to be an integral part of the game because referees are not used. One of the
central aspects of ultimate is its casual atmosphere and the ' spirit of the
game'. The spirit of the game assumes fair play, self-calling of fouls, courtesy
and respect of other players.
Comparison of Ultimate
with Other Similar Sports
Other disc sports include disc golf, freestyle throwing, and guts (reference
1,2,3). They use discs of different sizes, shapes, and weight that give all
different flight characteristics. They will not be discussed further as they
are distinct from ultimate and do not involve the same playing skills or injury
patterns.Comparison of ultimate with other similar sports.
Ultimate involves sudden
bursts of speed often played continuously over 90 minutes with half time and
breaks allowed. The Bethesda Conference (reference 5) classified sports based
on their static and dynamic components. Ultimate is similar to sports like
basketball, ice hockey, and lacrosse all being high dynamic and low static
activities (figure 1)
Dynamic forces involve movement and change in a muscle length with low intramuscular
forces. Bowling would be a sport with low dynamics while squash would be high.
Static exercises cause large intramuscular forces with little or no change
in muscular length. Isometric resistance training is an example of high static.
Ultimate compared to other sports on the basis of dynamic and static forces
Soccer, or Squash
Football, Team Handball or Ultimate
or Rock climbing
Cycling, or Kayaking
is grouped as a class IIc sport but does share similarities with both soccer
The Bethesda conference
also stratified the risk for participants with heart disease to play (FIGURE
2). Ultimate would have restrictions similar to other IIa sports (reference
Ultimate may also be described as a contact/collision after the American Association
of Pediatrics Classification of Sport (reference 6, figure 2). Risk of participation
in sports is stratified according to level of contact for athletes with specific
medical conditions. (figure 3)
Comparison of ultimate with other sports on the basis of contact
contact / Impact
Summary of limitations for contact /collision sport
needs individual assessment
Absence or loss of one
eye guards may allow play
head trauma Repeat concussions
unless poorly controlled
compete following stress test
impetigo, Herpes, scabies
compete but no contact
use protective cup
There is very little published
in the sports medicine or orthopedic literature about Ultimate. Marfleet (reference
7) studied injuries among high-level players attending a series of tournaments.
This study looked at the incidence of injuries among experienced players.
In Winnipeg personal observation is that there are a high incidence of significant
injuries in the spring and early summer among ultimate players corresponding
to the beginning of the Ultimate season locally. Injuries occur in the beginner
and the elite players. Athletes have had injuries such as ACL tears, ankle
fractures and shoulder dislocations similar to the patterns of injuries seen
in contact sports such as hockey, rugby, and football. This is unexpected
from the popularized image of Ultimate as a carefree sport. This survey was
designed to look at what types of injuries are common in Ultimate and how
they can be eliminated or minimized.
The ultimate player must also be proficient in catching and throwing a disc
using a variety of techniques (reference 1,2,3). One unique skill is "going
ho" or horizontal where a player dives while simultaneously catching an out
of reach disc. Leaping forward with extended arms and legs, catching the disc,
rolling sideways to diminish the forces, and standing again to pass the disc,
best does this. Marfleet (reference 7) has shown that if done incorrectly
with flexed limbs there is a higher likelihood of injury. (see diagrams)
Protective equipment is neither enforced nor banned. Many to increase their
grip during pivoting and cutting wear cleats. Torque generated on the ankles
places excessive forces at the ankle and knee. Extrinsic factors also have
a role in the occurrence of injuries. The quality of the fields played on
is often not optimal and can be hard or uneven. Weather, heat and ultraviolet
light are also a concern.
A survey questionnaire (both in French and English) was distributed through
the Manitoba Organization of Disc Sports (MODS) for all players whether injured
or not to complete. (see appendix 2) Surveys were also distributed at games,
sports medicine clinics, athletic therapy clinics, and at a local schools
teaching Junior Ultimate. The Canadian Ultimate Players Association and other
provincial bodies were also contacted to distribute copies to their members.
A modified version of the survey was also sent out to touring teams attending
the World Ultimate Championships in Minneapolis in 1998. Due to the unknown
number of people reached by the survey it is unknown what the actual prevalence
of injuries is but patterns of injuries based on the returned surveys are
All respondents were asked about their injuries. Diagnoses were either self
reported or diagnosed by physiotherapists, physicians or others and not verified
further. When some answers were imprecise they were contacted to clarify.
All information was volunteered and not altered after being received. Results
were organized using Microsoft Excel.
This study found a high rate of knee and lower limb injuries. Leg injuries
were the most common at 29%. The main injuries were 1% MCL, < 1% PCC, 2% quadriceps,
4% hamstrings, 4% leg, 15% knee, and 3% ACL. Not all players gave specifics
as to what type of knee injury they sustained but both men and women reported
3% had ACL tears.
On the comment portion of the survey women reported a greater portion of non-contact
mechanisms of injury. Ankle injuries were reported in 20% of the players.
Other notable injuries involved shin splints 6%, shoulders 6%, and groin,
back, fingers, ribs, clavicles and concussions that together accounted for
5% or less. (see diagram)
Other significant injuries were concussions 1%, and eye injuries 1% (see figures
showing female and male injury rates, overall injuries)
This study found a high rate of significant knee injuries involving the
meniscus cartilage and ACL tears. ACL tears cause a significant morbidity
(reference 8). Female players have a higher rate of ACL injuries than males
in many sports especially those involving landing, stopping, and sudden direction
Women have been found to have an ACL injury rate 2.229 times in soccer and
2.89 times in basketball when compared with men (reference 9)
Many reasons have been postulated and not all are physical
1) A weaker hamstring and quadriceps ratio. Women tend to activate their
quadriceps before their hamstrings as opposed to men who do the opposite.
Women have their quadriceps fire before the hamstrings as compared with men.
Training with a BAPS board improved proprioception and led to a seven-fold
reduction in ACL injuries.
2) Women are speculated to be more susceptible during days 10-14 of their
menstrual cycle because of increased laxity when the estrogen and progesterone
level is peak. One study by Dicaprio and Khodiguian (reference 10) suggest
a protective effect from oral contraceptives.
3) Women have different anatomic features such as, an increased Q angle
of the knee, increased pronation and increased laxity of joints that may contribute
4) Women historically have had decreased levels of encouragement and opportunities
to be coached, to practice skills and to play sports. A lack of expert training
could potentially lead to an increased number of injuries in women as compared
to men. Attitudes are changing toward gender roles in sports (reference 11).
Ireland (reference 12)describes
a position of no return. This disadvantageous posture often leads to non contact
ACL tears and may be clearly identified on videotaped athletes (reference).
Injury is less likely when an athlete assumes a safe position (see figure)
Contrast between "Position of no Return" and " Safe Position"
After Ireland (reference 12)
Position of no return
Back in foreward flexion and rotated to opposite side
Hips in adduction and internal rotation
Knee less flexed and in valgus position
Tibia in external rotation
Back in normal lordosis
Hips flexed and in neutral abduction/adduction
Tibia in neutral position with no rotation
Landing pattern on both feet and in Control
Weight balanced in center with mid foot stance
13) describes the coactivation of the hamstrings to reduce ACL strain. The
hamstrings stabilize the knee best at >15-30 degrees of flexion and that better
hamstring coactivation occurs when the trunk is positioned over the knees.
A bad position for the athlete is when an anterior pelvic tilt increases the
genu valgus with increased exaggeration of the Q angle. Rozzi also suggests
using a tensor wrap to increase knee proprioception, which leads to decreased
After a player has had an ACL reconstruction 5-7% of players will injure their
other leg. This is felt to be due to either incomplete rehabilitation or persistent
neuromuscular weakness that has not been addressed
Knee braces are divided into 3 categories including, prophylactic, rehabilitative,
and functional braces.
Prophylactic knee bracing is bracing an uninjured knee to prevent an
injury from occurring is controversial. It has been extensively scrutinized
in American football. Grace et al 8.(reference 14) showed that football players
wearing a single hinged brace had an increased incidence of foot and ankle
injuries. Rovere, Haught and Yates (reference 15) found an increase in knee
injuries when a brace was used. Albright and Powell (reference 16) showed
a decreased injury rate in offensive and defensive football players in practices
yet an increase in knee injuries for skill position players (backs and kickers)
during games. Ultimate resembles football in many ways. Experience with football
suggests against the use of prophylactic braces. (reference16b)
Rehabilitation knee braces are designed to allow protected motion of a
knee after an injury whether surgery is planned or not. Rehab braces are usually
given for MCL injuries and are meant to be a temporary aid in recovery. They
do not give enough support or flexibility for playing ultimate. An athlete
who requires the use of a Rehab brace should not play until their rehabilitation
has advanced enough that they no longer require a brace.
Functional knee braces are designed to improve stability for unstable
or postoperative knees in daily activities or sports. They are best used in
individuals with low-grade instability such as a partial ligament tear or
reconstructed ACL rather than more unstable injuries including damage to the
menisci or chondral surfaces and excessive joint laxity. The player must also
be knowledgeable in its use, fitting, and care. A thin build also gives a
better fit with less slipping. (reference 13,17) Much of the benefit from
wearing a functional brace is felt to be due to improvement of the proprioceptive
sensing in the injured knee as well as psychological reassurance. Colville
et al (reference 18) showed that athletes felt much better wearing braces
even if very little improvement in stability occurred. Krister et al (reference
19) demonstrated that wearing a simple elastic compression also increased
proprioception in an ACL injured group.
Functional braces generally do not tolerate pivoting sports well and ultimate
may be a relative contraindication for their use depending on the person's
level of playing and expectations. An objective degree of proprioception and
strength should be present before return to play.
ACL tears are significant injuries where the treatment (surgical repair) is
expensive and must be followed by a long period of rehabilitation. Correcting
predisposing factors that lead towards injury might be more effective.
Some suggestions for the prevention of non-contact ACL injuries include:
1) Developing lateral hip strength by doing lunges, side steps and
plyometrics. Begin with simple routines and gradually work up to more complex
drills. (reference 2) A woman with a trendelenberg gait should definitely
do these exercises as this type of walk already suggests a significant lateral
2) Six weeks of pre-training prior to practicing ultimate related skills.
Given the short playing season of ultimate, players who begin the activity
suddenly are susceptible to injury.
3) Retrograde treadmill running is a useful rehabilitation tool. Having
the athletes walking backwards teaches effective co contraction of the hamstrings,
quadriceps, and triceps surae.
4) Plyometric drills are used to teach players to land correctly. It
is best to land with the knee flexed at 20-30 degrees. It is also important
to land softly to avoid excess impact on knees and ankles.
5) Teach eccentric control of the knee by practicing eccentric hamstring
curls that in turn help control loads during play.
6) Encourage three step stops rather than sudden stops. The rules of
ultimate allow this. This method of deceleration is gentler on the knees.
7) Maintain the ready position - straight back, knees slightly flexed,
avoid a rolled back, rounded shoulders and hyper-extended knees. Integrate
the proper drills to incorporate the ready position ideally at the beginning
and end of drills.
8) For patients recovering from an ACL operation improved neuromuscular
control should be demonstrated. All injured patients will tend to favor the
uninjured knee. Any limping behavior should be discouraged from the beginning
and weight should be distributed evenly.If
the player is aware of these limits playing may be resumed. Changing the pattern
of play such as adapting a neutral ready position or taking three step turns
can change the forces on the knees and lessen the likelihood of re-injury
as recommended by Ireland. (reference 12) The UPA rules do allow for three
steps after receiving a disc. Players should develop their skills to habitually
use their three steps to come to a full stop.
Any knee requiring functional bracing should be evaluated for surgical repair
and adjunct physiotherapy as well.
Ankle strains are common and account for about 10-15 % of sports related injuries
(reference 20). In soccer ankle injuries have been higher (17-20% of all injuries)(reference
21) and even higher in futsbal or indoor soccer (23%) (Reference 22). This
study made no distinction between Outdoor and Indoor Ultimate the latter being
more similar to futsbal. One would expect indoor ultimate to share a higher
rate of ankle injury as with futsbal since both involve a smaller playing
area with more pivoting. The most common mechanism of injury involves a plantar
flexion inversion stress. The anterior talofibular ligament is most commonly
injured as a first or second-degree strain. In this survey ankle injuries
were reported at 20%. Ankles injuries common in ultimate are often due to
a sudden change of direction during play. Players wear a variety of footwear
including soccer shoes, cross trainers, and cleats (although metallic cleats
are banned on many playing fields).
Similar to knees, ankles may also be braced after injury or prophylacticly.
Prophylactic bracing has been shown to be effective (reference 23) however
high-topped boots may be enough. Ultimate shares similarities with football,
basketball, and soccer all having a high incidence of inversion ankle strains.
Athletic taping or ankle braces are commonly used and both give good support
although taping loses its strength after a short amount of time (reference
24). One suggestion is to wear a low cut soccer cleat with an internal lace
up brace that can be periodically adjusted.
After an injury has occurred some form of functional support will aid in returning
function and the ability to play. There is no good evidence on how long to
wear a protective brace post injury. Although dependant on the severity of
the injury wearing a protective support throughout the phases of healing after
inflammation has resolved, muscular strength has returned, and proprioception
has also normalized (reference 23). After those parameters are returned any
further wearing of support would now be prophylactic. Since some propioceptive
deficits may persist in an improperly rehabilitated individual protection
is important. The player should also train in gradually increasingly difficult
cutting drills so a brace is never used as a substitute for adequate conditioning.
Taping gives support but tape has been known to lose support after as little
as ten minutes of playing (reference24).
Many players with ankle inversion injuries reported using cleats. A high coefficient
of friction between the ground and a player's foot has been associated with
a greater risk of injury. (reference 25) Using cleats, although providing
better control and performance during a game also increases the risk of injury.
One suggestion is to wear good shoes that provide some grip but not quite
as much as indoor soccer or football shoes. Cleats if used at all should be
used in wet, muddy conditions to provide extra traction. Similarly hard, dry
playing fields also provide a high coefficient of friction and should be avoided.
The ideal playing field should be level, grassy with soft earth and no stones
Discussion of other injuries
'Laying out' for the reception of a pass is a necessary skill that should
be carefully taught to new players
The use of Equipment
Ultimate does have some concussions but there is insufficient evidence
to support that wearing a type of helmet would be beneficial in preventing
or decreasing the severity of sustained injuries. Education of players on
the proper management of concussions and avoiding dangerous play would be
more effective. Other equipment such as padding for knees, shin guards, and
gloves may be left up to the players discretion for comfort since relatively
few injuries developed to support their use to prevent injuries.
There is no evidence that this is greater in ultimate. As with many other
amateur sports there is likely a lower incidence of alcohol, drug, and nicotine
abuse than in the general non-athletic population.(personal observation and
opinion). Likewise no one volunteered the use of any performance enhancing
substances on the survey.
This is difficult to assess. Respondents were aged 13-44 and composed of many
young professionals, and university and high school students. Locally ultimate
does not appear to be played in the inner city. Players who tour must have
free time and money to afford to tour.
This was not specifically assessed and one volunteered any disabilities. Disabled
This was not specifically assessed and one volunteered any disabilities.
Ultimate clothing and shoes closely resemble soccer equipment. Soccer jerseys
are commonly worn but during pick-up games colored versus white t-shirts distinguish
teams. Arms and knees are frequently abraded. Cleats of varying types are
used the most common being soccer the football. Metallic cleats are banned
on most fields.
Abrasions are common in ultimate and were not counted as injuries on the survey
since they occur frequently and are self-limited. The risk of HIV transmission
has been reported in sports and remains controversial (reference 24) but is
of very real concern. The Canadian Academy of Sport Medicine, American College
of Sport Medicine, and United States Olympic Committee have implemented guidelines
to address this issue (figure 4).
Recommendations towards Blood in Sport
Different sports have different risks of exposure Greatest risk: boxing, tae
kwon do, and wrestling Moderate risk: basketball, field hockey, judo, hockey,
soccer, football, team handball. Lowest risk: all others. Ultimate involves
frequent abrasions with the ground and incidental contact with other players
would be a moderate risk sport.
1. All athletes are warned of the risk with sexual contact and IV drug
2. Potentially infectious skin infections are covered.
3. Injured athletes should perform his or her own wound care.
4. Other athletes should not handle the athletes' blood.
5. Lacerations with substantial bleeding should be resolved before
return to play.
6. Clothing soaked with blood should be removed and all exposed parts
washed before return to play.
7. Only disposable towels and bandages are used.
8. Universal precautions be taken with any athlete
9. Disposable gloves be used and changed for each individual.
Individual with HIV should have access to play and do not present a risk to
other players. The risk is felt to be very small or negligible. Hepatitis
B is more transmissible than HIV and has been transmitted in hot tubs that
athletes have shared with open sores. Players should be knowledgeable in taking
universal precautions when they have open wounds.
Since there are no formalized referees in ultimate games, team captains should
have first aid kits available.
Ultimate is a very young and growing sport with a significant number of
injuries related to play. Many of these injuries may be prevented with proper
conditioning, training, conduct and equipment. Players with any medical illnesses
should receive a physical exam conducted by a medical doctor prior to participating.
Players should also be familiar with blood borne infection precautions.
Equipment should include comfortable clothes and shoes. Cleats are not recommended
although they may help to improve performance since they have been shown to
increase injuries in similar sports. Ankle braces have been shown to reduce
injuries although knee braces do not.
Players should know the rules well prior to playing and have the necessary
skills to play well. Skills specific to ultimate should not be assumed but
taught since the game is distinct from other sports. A pre-season conditioning
program should be encouraged. Injury programs have been shown to reduce the
occurrences of injuries in the similarly high risk sports of skiing and basketball
(reference 12) and a similar intervention could be done in ultimate.
The spirit of the game should be maintained though serious consideration should
be given to referees.
Appendix 1. Rules of Ultimate
Appendix 2. Survey
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1999 McGraw-Hill 1st ed. New York
22.Johnson DL, Neef RL: Soccer: outdoor pp604-605 Handbook of Sports Medicine
1999 McGraw-Hill 1st ed. New York. Sittler et al: The efficiency of a semirigid
ankle Stabilizer to Reduce Acute Ankle Injuries in Basketball- Arandomized
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24b.When Sport and HIV share the Bill, the smart money goes on common sense.
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