research on sports injuries

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Article Contents

Introduction, literature search, physeal injuries and growth disturbance, residual problems after injury in athletes, outcomes of operative management of common sports injuries, conclusions.

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Sport injuries: a review of outcomes

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Nicola Maffulli, Umile Giuseppe Longo, Nikolaos Gougoulias, Dennis Caine, Vincenzo Denaro, Sport injuries: a review of outcomes, British Medical Bulletin , Volume 97, Issue 1, March 2011, Pages 47–80, https://doi.org/10.1093/bmb/ldq026

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Injuries can counter the beneficial aspects related to sports activities if an athlete is unable to continue to participate because of residual effects of injury. We provide an updated synthesis of existing clinical evidence of long-term follow-up outcome of sports injuries. A systematic computerized literature search was conducted on following databases were accessed: PubMed, Medline, Cochrane, CINAHL and Embase databases. At a young age, injury to the physis can result in limb deformities and leg-length discrepancy. Weight-bearing joints including the hip, knee and ankle are at risk of developing osteoarthritis (OA) in former athletes, after injury or in the presence of malalignment, especially in association with high impact sport. Knee injury is a risk factor for OA. Ankle ligament injuries in athletes result in incomplete recovery (up to 40% at 6 months), and OA in the long term (latency period more than 25 years). Spine pathologies are associated more commonly with certain sports (e.g. wresting, heavy-weight lifting, gymnastics, tennis, soccer). Evolution in arthroscopy allows more accurate assessment of hip, ankle, shoulder, elbow and wrist intra-articular post-traumatic pathologies, and possibly more successful management. Few well-conducted studies are available to establish the long-term follow-up of former athletes. To assess whether benefits from sports participation outweigh the risks, future research should involve questionnaires regarding the health-related quality of life in former athletes, to be compared with the general population.

Participation in sports is widespread all over the world, 1 with well-described physical, psychological and social consequences for involved athletes. 2–5 The benefits associated with physical activity in both youth and elderly are well documented. 2 , 6–8 Regular participation in sports is associated with a better quality of life and reduced risk of several diseases, 1 , 9 allowing people involved to improve cardiovascular health. 10 , 11 Both individual and team sports are associated with favourable physical and physiological changes consisting of decreased percentage of body fat 12 and increased muscular strength, endurance and power. 13 , 14 Moreover, regular participation in high-volume impact-loading and running-based sports (such as basketball, gymnastics, tennis, soccer and distance running) is associated with enhanced whole-body and regional bone mineral content and density, 14 , 15 whereas physical inactivity is associated with obesity and coronary heart disease. 16 Sports are associated with several psychological and emotional benefits. 7 , 17 , 18 First of all, there is a strong relationship between the development of positive self-esteem, due to testing of self in a context of sport competition, 19 reduced stress, anxiety and depression. 20 Physical activities also contribute to social development of athletes, prosocial behaviour, fair play and sportspersonship 21 and personal responsibility. 22

Engaging in sports activities has numerous health benefits, but also carries the risk of injury. 7 , 23 , 24 At every age, competitive and recreational athletes sustain a wide variety of soft tissue, bone, ligament, tendon and nerve injuries, caused by direct trauma or repetitive stress. 25–35 Different sports are associated with different patterns and types of injuries, whereas age, gender and type of activity (e.g. competitive versus practice) influence the prevalence of injuries. 7 , 36 , 37

Injuries in children and adolescents, who often tend to focus on high performance in certain disciplines and sports, 24 include susceptibility to growth plate injury, nonlinearity of growth, limited thermoregulatory capacity and maturity-associated variation. 9 In the immature skeleton, growth plate injury is possible 38 and apophysitis is common. The most common sites are at the knee (Osgood-Schlatter lesion), the heel (Sever's lesion) and the elbow. 39 Certain contact sports, such as rugby, for example, are associated with 5.2 injuries per 1000 total athletic exposures in high school children (usually boys). These were more common during competition compared with training and fractures accounted for 16% of these injuries, whereas concussions (15.8%) and ligament sprains (15.7%) were almost as common. 40

Sports trauma commonly affects joints of the extremities (knee, ankle, hip, shoulder, elbow, wrist) or the spine. Knee injuries are among the most common. Knee trauma can result in meniscal and chondral lesions, sometimes in combination with cruciate ligament injuries. 37 Ankle injuries constitute 21% of all sports injuries. 41 Ankle ligament injuries are more commonly (83%) diagnosed as ligament sprains (incomplete tears), and are common in sports such as basketball and volleyball. Ankle injuries occur usually during competition and in the majority of cases, athletes can return to sports within a week. 42 Hip labral injuries have drawn attention in recent years with the advent of hip arthroscopy. 43 , 44 Upper extremity syndromes caused by a single stress or by repetitive microtrauma occur in a variety of sports. Overhead throwing, long-distance swimming, bowling, golf, gymnastics, basketball, volleyball and field events can repetitively stress the hand, wrist, elbow and shoulder. Shoulder and elbow problems are common in the overhead throwing athlete whereas elbow injuries remain often unrecognized in certain sports. 45 Hand and wrist trauma accounts for 3–9% of all athletic injuries. 46 Wrist trauma can affect the triangular fibrocartilage complex 47 or cause scaphoid fractures, 48 whereas overuse problems (e.g. tenosynovitis) are not uncommon. 49 Spinal problems can range from lumbar disc herniation, 39–42 to fatigue fractures of the pars interarticularis, 50 and ‘catastrophic’ cervical spine injuries. 51

Thus, in addition to the beneficial aspects related to sports activities, injuries can counter these if an athlete is unable to continue to participate because of residual effects of injury. Do injuries in children, adolescents and young adults have long-term consequences? What are the outcomes of the most commonly performed surgical procedures? The aim of this review is to provide an updated synthesis of existing clinical evidence of long-term follow-up outcome of sports injuries.

An initial pilot Pubmed search using the keywords ‘sports’, ‘injury’, ‘injuries’, ‘athletes’, ‘outcome’, ‘long term’, was performed. From 1467 abstracts that were retrieved and scanned we identified the thematic topics (types of injury, management, area of the body involved) of the current review, listed below:

Then a more detailed search of PubMed, Medline, Cochrane, CINAHL and Embase databases followed. We used combinations of the keywords: ‘sport’, ‘sports’, ‘youth sports’, ‘young athletes’, ‘former athletes’, ‘children’, ‘skeletally immature’, ‘adolescent’, ‘paediatric’, ‘pediatric’, ‘physeal’, ‘epiphysis’, ‘epiphyseal injuries’, ‘hip’, ‘knee’, ‘ankle’, ‘spine’, ‘spinal’, ‘shoulder’, ‘elbow’, ‘wrist’, ‘football players’, ‘football’, ‘soccer’, ‘tennis’, ‘swimmers’, ‘swimming’, ‘divers’, ‘wrestlers’, ‘wrestling’, ‘cricket’, ‘gymnastics’, ‘skiers’, ‘baseball’, ‘basketball’, ‘osteoarthritis’, ‘former athletes’, ‘strain’, ‘contusion’, ‘distortion’, ‘injury’, ‘injuries’, ‘trauma’, ‘drop out’, ‘dropping out’, ‘attrition’, ‘young’, ‘ youth’, ‘sprain’, ‘ligament’, ‘ACL’, ‘cruciate ligament’, ‘meniscus’, ‘meniscal’, ‘chondral’, ‘labrum’, ‘labral’, ‘reconstruction’, ‘arthroscopy’, ‘throwing’, ‘overhead’, ‘rotator cuff’, ‘TFCC’, ‘scaphoid’, ‘osteoarthritis’, ‘arthritis’, ‘long term’, ‘follow-up’ and ‘athlete’. The most recent search was performed during the second week of November 2009.

Osteoarthritis (OA) in former athletes

Spine problems in former athletes

Knee injury and OA

Ankle ligament injury and OA

Residual upper limb symptoms in the ‘overhead’ athlete

Meniscectomy and oa, meniscal repair in athletes.

Anterior cruciate ligament (ACL) reconstruction and OA

ACL reconstruction in children

Ankle arthroscopy in athletes, hip arthroscopy in athletes.

Operative management of shoulder injuries in athletes (focusing on surgery for instability and labral tears)

Operative management of wrist injuries in athletes (focusing on triquetral fibrocartilage complex, TFCC, injuries and scaphoid fractures)

Given the different types of sports injuries in terms of location in the body, several searches were carried out. The search was limited to articles published in peer-reviewed journals.

From a total of 2596 abstracts that were scanned, 1247 studies were irrelevant to the subject and were excluded. The remaining studies were categorized in the topics identified earlier. We excluded from our investigation case reports, letter to editors and articles not specifically reporting outcomes, as well as ‘kin’ studies (studies reporting on the same patients' population). The most recent study or the study with the longest follow-up was included. In some topics of particular importance, such as the effect of knee injuries (given their frequency), we included long-term studies reporting not only on athletes, but also on the general population (usually in these studies a very high proportion on sports injuries is included). Regarding knee injuries in adults, we included articles with follow-up more than 10 years.

Given the linguistic capabilities of the research team, we considered publications in English, Italian, French, German, Spanish and Portuguese.

A concern regarding children's participation in sports is that the tolerance limits of the physis may be exceeded by the mechanical stresses of sports such as football and hockey or by the repetitive physical loading required in sports such as baseball, gymnastics and distance running. 52 Unfortunately, what is known about the frequency of acute sport-related physeal injuries is derived primarily from case reports and case series data. In a previous systematic review on the frequency and characteristics of sports-related growth plate injuries affecting children and youth, we found that 38.3% of 2157 acute cases were sport related and among these 14.9% were associated with growth disturbance. 24 These injuries were incurred in a variety of sports, although football is the sport most often reported. 53

There are accumulating reports of stress-related physeal injuries affecting young athletes in a variety of sports, including baseball, basketball, climbing, cricket, distance running, American football, soccer, gymnastics, rugby, swimming, tennis. 24 Although most of these stress-related conditions resolved without growth complication during short-term follow-up, there are several reports of stress-related premature partial or complete distal radius physeal closure of young gymnasts. 25–29 These data indicate that sport training, if of sufficient duration and intensity, may precipitate pathological changes of the growth plate and, in extreme cases, produce growth disturbance. 24 , 32

Disturbed physeal growth as a result of injury can result in length discrepancy, angular deformity or altered joint mechanics and may cause significant long-term disability. 33 However, the incidence of long-term health outcome of physeal injuries in children's and youth sports is largely unknown.

Based on the previously selection criteria, 20 studies 54–73 were retained for analysis (Table  1 ). Injury to the physis can result in limb deformities and leg-length discrepancy, the latter being more common after motor vehicle accidents, rather than sports participation.

Evidence on acute physeal injury with subsequent adverse affects on growth.

OA in former athletes

Two studies investigated former top-level female gymnasts for residual symptoms (back pain) and radiographical changes. 74 , 75 Both studies reported no significant differences in back pain between gymnast and control groups; however, the prevalence of radiographical abnormalities was greater in gymnasts than controls in one study. 74

Lower limb weight-bearing joints such as the hip and the knee are at risk of developing OA after injury or in the presence of malalignment, especially in association with high impact sport. 76 Varus alignment was present in 65 knees (81%) in 81 former professional footballers (age 44–70 years), whereas radiographic OA in 45 (56%). 77 Others showed that prevalence of knee OA in soccer players and weight lifters was 26% (eight athletes) and 31% (nine athletes), respectively, whereas it was only 14% in runners (four athletes). 78 By stepwise logistic regression analysis, the increased risk is explained by knee injuries in soccer players and by high body mass in weight lifters. A survey in English former professional soccer players revealed that 47% retired because of an injury. The knee was most commonly involved (46%), followed by the ankle (21%). Of all respondents, 32% had OA in at least one lower limb joint and 80% reported joint pain. 79 Another study examined the incidence of knee and ankle arthritis in injured and uninjured elite football players. The mean time from injury was 25 years. 80 Arthritis was present in 63% of the injured knees and in 33% of the injured ankles, whereas the incidence of arthritis in uninjured players was 26% in the knee and 18% in the ankle. Obviously, it should be kept in mind that radiographic studies can only ascertain the presence of degenerative joint disease, which is just one of the features of OA. Clinical examination is always necessary to clarify the diagnosis, and formulate a management plan.

Ex-footballers also had high prevalence of hip OA (odds ratio: 10.2), 81 whereas in another study the incidence of hip arthritis was 5.6% among former soccer players (mean age: 55 years) compared with 2.8% in an age-matched control group. In 71 elite players it was higher (14%). Female ex-elite athletes (runners, tennis players) were compared with an age-matched population of women, and were found to have higher rates (2–3 fold increase) of radiographic OA (particularly the presence of osteophytes) of the hip and knee. 82 The risk was similar in ex-elite athletes and in a subgroup from the general population who reported long-term sports activity, suggesting that duration rather than frequency of training is important. An older study 83 is runners associated degenerative changes with genu varum and history of injury. A cohort of 27 Swiss long-distance runners was at increased risk of developing ankle arthritis compared with a control group. 84 Similarly elite tennis players were at risk of developing glenohumeral OA, 85 whereas handball players of developing premature hip OA, 86 and former elite volleyball players had marginally increased risk for ankle OA. 87 Interestingly a study that investigated the health-related quality of life (HRQL) in 284 former professional players in the UK found that medical treatment for football-related injuries was a common feature, as was arthritis, with the knee being most commonly affected. Respondents with arthritis reported poorer outcomes in all aspects of HRQL. 88

In summary, OA is more common among former athletes, compared with the general population. The lower limb joints are commonly affected, in association with high impact and injury.

Evidence from follow-up studies on spine of former athletes

Heavy physical work and activity lead to degenerative changes in the spine. Studies on different athletic disciplines and heavy workers have given variable degenerative changes and abnormalities in the lumbar spine. Even though sporting activity is regarded as an important predisposing factor in the development of spinal pathologies, 89–99 there are few studies on the late spinal sequelae of competitive youth sport. Any comparison in terms of back pain between top athletes and the general population is difficult. Experience of pain may be influenced by factors such as susceptibility, motivation and physical activity. Minor pain may be provoked by vigorous body movements that hamper athletic performance, thereby ascribing the pain a greater impact than in the general population. On the other hand, a well-motivated athlete may ignore even severe pain to maintain or improve his/her athletic performance. Also, varying rate/prevalence of osteophytosis has been reported in players associated with various disciplines of sports.

Efforts should be made to understand the aetiology of injuries to the intervertebral discs during athletic performance and thereby prevent them. 74

Based on the previously selection criteria, seven studies 74 , 89 , 98 , 100–103 were retained for analysis (Table  2 ). In summary, spine pathologies are associated more commonly with certain sports (e.g. wresting, heavy-weight lifting, gymnastics, tennis, soccer). Degenerative changes in the athlete's spine can occur, but they are not necessarily associated with clinically relevant symptoms of OA. Therefore, it cannot be determined whether it threatens the athlete's career, or whether it has a worse impact on athletes compared with the general population.

Evidence from follow-up studies on spine of former athletes.

Knee injury and OA in athletes

A population-based case-control study investigated the risk of knee OA with respect to sports activity and previous knee injuries of 825 athletes competing in different sports. They were matched with 825 controls. After confounding factors were adjusted, the sports-related increase risk of OA was explained by knee injuries. 104 Another study leads to the same conclusion: 23 American football high-school players were compared with 11 age-matched controls, 20 years after high-school competition. No significant increase in OA could be demonstrated clinically or radiographically. However, a significant increase in knee joint OA was found in the subgroup of football players who had sustained a knee injury. 105

A cohort of 286 former soccer players (71 elite, 215 non-elite) with a mean age of 55 years was compared with 572 age-matched controls, regarding the prevalence of radiographic features of knee arthritis. Arthritis in elite players, non-elite players and controls was 15%, 4.2% and 1.6%, respectively. In non-elite players, absence of history of knee injury was associated with arthritis prevalence similar to the controls. 106

An interesting study involved a cohort of 19 high-level athletes of the Olympic program of former East Germany. They sustained an ACL tear between 1963 and 1965. None were reconstructed, and all were able to return to sports within 14 weeks. Subsequent meniscectomies were necessary in 15/19 (79%) athletes at 10 years and 18/19 (95%) at 20 years, when in 18 of the 19 knees, arthroscopy was performed, 13 patients (68%) had a grade four chondral lesion. By year 2000 (more than 35 years after ACL rupture), 10/19 knees required a joint replacement. 107

The incidence of radiographic advanced degeneration (Kellgren–Lawrence grade 2 or higher) was 41% in a cohort of 122 Swedish male soccer players (from a total of 154) who consented to radiographic follow-up, 14 years after an ACL rupture. No difference was found between players treated with or without surgery for their ACL rupture. The prevalence of Kellgren–Lawrence grade 2 or higher knee OA was 4% in the uninjured knees. 108

Similar results were evident among Swedish female soccer players who were injured before the age of 20. The prevalence of radiographic OA was 51%, compared with 8% only in the uninjured knee, 12 years later. The presence of symptoms was documented in 63 of 84 (75%) athletes who answered the questionnaire, and was similar ( P = 0.2) in the two management groups (operative versus non-operative). The presence of symptoms did not necessarily correlate with radiographic OA ( P = 0.4). 109

In summary, knee injury is a recognized risk factor for OA. Injured athletes develop OA more commonly than the general population in the long term. Approximately half of the injured knees could have radiographic changes 10–15 years later. It is not clear whether radiographic changes correspond to presence of symptoms.

Ankle ligament injuries and OA in athletes

Ankle sprains are common sporting injuries generally believed to be benign and self-limiting. However, some studies report a significant proportion of patients with ankle sprains having persistent symptoms for months or even years. Nineteen patients with a mean age of 20 years (range: 13–28), who were referred to a sports medicine clinic after an ankle inversion injury, were followed for 29 months (average), and compared with matched controls. Only five (26%) injured patients had recovered fully, whereas 74% had symptoms 1.5–4 years after the injury. Assessments of quality of life using the short form-36 questionnaires revealed a difference in the general health subscale between the two groups, favouring the controls ( P < 0.05). 110

Similar conclusions were drawn from another study, regarding ankle injuries in a young (age range: 17–24 years) athletic population. 111 There were 104 ankle injuries (96 sprains, 7 fractures and 1 contusion), accounting for 23% of all injuries seen. Of the 96 sprains, 4 were predominately medial injuries, 76 lateral and 16 syndesmosis sprains. Although 95% had returned to sports at 6 weeks, 55% reported pain or loss of function. At 6 months, 40% had not fully recovered, reporting residual symptoms. Syndesmosis injuries were associated with prolonged recovery.

The association between ligamentous ankle injuries has been highlighted in a study that, retrospectively, reviewed data from 30 patients (mean age: 59 years, 33 ankles) with ankle osteoarthritis. 112 They found that 55% had a history of sports injuries (33% from soccer), and 85% had a lateral ankle ligament injury. The mean latency time between injury and OA was 34.3 years. The latency period for acute severe injuries was significantly lower (25.7 years), compared with chronic instability (38 years). Varus malalignment and persistent instability were present in 52% of those patients.

In summary, ankle ligamentous injuries in athletes can result in considerable morbidity, residual symptoms and arthritis 25–30 years later.

Shoulder injuries account for 7% of sports injuries and often limit the athlete in his or her ability to continue with their chosen sport. 113 Repetitive overhead throwing imparts high valgus and extension loads to the athlete's shoulder and elbow, often leading to either acute or chronic injury or progressive structural change and long-term problems in the overhead athlete. 45

Schmitt et al . 102 examined 21 elite javelin throwing athletes at an average of 19 years after the end of their high-performance phase (mean age at follow-up was 50 years). Five athletes (24%) complained about transient shoulder pain and three (16%) about elbow pain in their throwing arm affecting activities of daily living. All dominant elbows had advanced degeneration (osteophytes).

Elbow intra-articular lesions are recognized as consequences of repetitive stress and overuse. Shanmugam and Maffulli 9 reported follow-up (mean 3.6 years) of lesions of the articular surface of the elbow joint in a group of 12 gymnasts (six females and six males). This group showed a high frequency of osteochondritic lesions, intra-articular loose bodies and precocious signs of joint ageing. Residual mild pain in the elbow at full extension occurring after activity was present in 10 patients and all patients showed marked loss of elbow extension compared with their first visit.

Glenoid labral tears require repair, and shoulder instability is currently approached operatively more often. A review article found that conservative management of traumatic shoulder dislocations in adolescents was associated with high rates of recurrent instability (up to 100%). Therefore, surgical shoulder stabilization is recommended. The outcomes of surgical management are presented in the next section.

A distinct clinical entity is the ‘little league shoulder’, which is characterized by progressive upper arm pain with throwing and is more commonly seen in male baseball pitchers between ages 11 and 14 years. It is thought to be Salter-Harris type I stress fracture. Activity modification, education to improve throwing mechanics and core muscle training are recommended. It is not known how this condition behaves in the long term, regarding structural damage and development of degenerative changes.

Overhead athletes are plagued by shoulder and elbow injuries or overuse syndromes that can affect their performance and cause degeneration and pain in the long term.

The association between knee OA and meniscectomy has been well documented. In former athletes 114 – 116 it is associated with OA (Table  3 ). Meniscectomy in children and adolescents 117 – 123 has been associated with unfavourable results and radiographic arthritic changes in the long term (Table  4 ). However, radiographic criteria were not always clearly defined. To assess the long-term outcomes of meniscectomy, we also evaluated studies with a minimum follow-up of 10 years in the adult general population 106 , 124 – 129 (Table  5 ). Many of the ‘older’ studies providing the long-term outcomes represent results of open total meniscectomies. The overall message is that radiographic degeneration is common in meniscectomized knees, and patients are at risk of developing OA. The condition of the articular cartilage is a prognostic factor. However, clinical and radiographic findings do not always correlate. Resection should be limited to the torn part of the meniscus.

Menicectomy and osteoarthritis in athletes.

Menicectomy in children and adolescents.

Meniscectomy in adults / general popaltion—long-term outcomes.

Given the long-term problems associated with meniscectomies, preservation of the substance of the meniscus after injury is currently advocated. Based on this concept, arthroscopic meniscal repair techniques have been developed. 125 In the general population, encouraging clinical results with failure rates of 27–30% at 6–7 years follow-up have been reported. 130–132 One study 133 evaluated 45 meniscal repairs in 42 elite athletes followed for an average of 8.5 years. In 83% of them an ACL reconstruction was performed as well. Return to their sport was possible in 81% at an average of 10 months after surgery. They identified 11 failures (24%), seven of which were associated with a new injury. The medial meniscus re-ruptured more frequently compared with the lateral (36.4 versus 5.6%, respectively).

Mintzer et al . 134 retrospectively reviewed the outcome of meniscal repair in 26 young athletes involved in several sports at an average follow-up of 5 years (range: 2–13.5). No failures were reported, with 85% of patients performing high level of sports activities.

In general, the results of meniscal repairs in the general population, as well as in athletes, are encouraging.

ACL reconstruction and OA

Knee injuries can result in ligament ruptures and/or meniscal tears and are recognized as a risk factor of OA. A systematic review on studies published until 2006 135 reported on the prognosis of conservatively managed ACL injuries showed that there was an average reduction of 21% at the level of activities (Tegner score evaluation). ACL reconstruction is therefore a procedure frequently performed in athletic individuals, as they desire to maintain a high level of activities. However, does ACL reconstruction affect the incidence of knee degeneration and symptoms in the long term? We identified three studies 108 , 109 , 136 comparing operative versus non-operative management of ACL ruptures specifically in athletes, in regard to OA.

Two studies from Sweden investigating the prevalence of OA after ACL rupture in male 108 and female 109 soccer players were discussed earlier. Both found no difference in the incidence of radiographic arthritis between surgically and conservatively treated players, more than 10 years after their injury.

A comparative study 136 on high-level athletes with ACL injury showed no statistical difference between the patients treated conservatively or operatively (patella tendon graft) with respect to OA or meniscal lesions of the knee, as well as activity level, objective and subjective functional outcome. The patients who were treated operatively had a significantly better stability of the knee at examination.

Several studies present outcomes of ACL injuries in the general population. A recent systematic review included 31 studies (seven were prospective) reporting radiographic outcomes regarding OA, with more than 10 years follow-up after ACL injury. 137 The prevalence of OA in the injured knee varied from 1 to 100%, whereas in the contralateral knee it was 0–38%. Isolated ACL tears were associated with low OA incidence between 0 and 13%, whereas in the presence of additional meniscal injury, it was 21–48%. Meniscal injury and meniscectomy were the most frequently reported risk factors for OA. The authors scored the quality of the studies and found that studies scoring high reported low incidence of OA. Data extraction indicated that ACL reconstruction as a single factor did not prevent the development of knee OA. 137

There is lack of evidence to support a protective role of reconstructive surgery of the ACL against OA, both in athletes as well as in the general population.

ACL reconstruction in skeletally immature patients is a relatively new trend. 138 The concern is intra-operative epiphysis damage and growth disturbance, a complication which has been avoided in several studies. 139–143

The earliest published study 144 compared non-operative versus operative management of ACL ruptures in 42 skeletally immature athletes (age range: 4–17 years) followed for a mean of 5.3 years. They used a composite knee score based on clinical examination and a patient questionnaire and found superior results in the operatively treated patients. Age and growth plate maturity did not influence results. They recommended ACL reconstruction for active athletic children.

One of the early reports showed that there were no growth disturbances at a mean of 3.3 years after surgery in 9 children, however, with two re-ruptures. Those children could not return to athletic activities. 139

In a series of 57 ACL reconstructions, 15 patients had reached completion of growth when examined at follow-up, none had signs of growth disturbance, whereas clinical scoring was good or excellent in all patients. 142

Another study compared the outcomes of two management strategies in 56 children with ACL ruptures, namely ligament reconstruction in the presence of open physis, or delayed reconstruction after skeletal maturity. The ‘early’ reconstruction group had evidence of less medial meniscal tears (16 versus 41%), and no evidence of growth disturbances, at 27 months mean follow-up. 140

After 1.5–7.5 years follow-up of 19 ACL reconstructions in 20 athletic teenagers (age range: 11.8–15.6 years), all but one had returned to sports, none had tibiofemoral malalignment or a leg-length discrepancy of more than 1 cm, and the modified Lysholm score was 93 out of 95. 143

Finally, 55 children (ages 8 to 16 years, mean 13 years) were followed for a mean of 3.2 years (range: 1–7.5 years) after ACL reconstruction, with no evidence of growth disturbances. Clinical scores showed normal or almost normal values (higher than 90 out of 100 possible points) and 88% of the patients went back to normal or almost normal sports according to the Tegner score. 141

Overall, the clinical results are encouraging and iatrogenic epiphysis damage does not seem to be a problem, possibly because physeal sparing procedures were used. The study designs, however, are inadequate to answer the question of whether early or delayed ACL reconstruction results in the best possible outcome in skeletally immature patients.

Anterior impingement syndrome is a generally accepted diagnosis for a condition characterized by anterior ankle pain with limited and painful dorsiflexion. The cause can be either soft tissue or bony obstruction. Arthroscopic debridement is currently considered a routine procedure, and chondral lesions are now more frequently identified as causes of ankle pain. Few reports specifically in athletes are available 145–149 (Table  6 ). Short-term outcomes only are available. It is not known whether arthritis is a long-term consequence.

Ankle arthroscopy in athletes.

Only recently has the hip received attention as a recognized site of sports injuries, possibly as a result of the evolution of hip arthroscopy which allowed recognition of intra-articular pathology. 150 Acetabular labrum and chondral lesions can be addressed arthroscopically, and patients' satisfaction rates up to 75% have been reported. 44 One study evaluated the outcome of hip arthroscopy in 15 athletes (mean age: 32 years, range: 14–70) followed for 10 years. Nine were recreational athletes, four high school and two intercollegiate athletes. Diagnoses included cartilage lesion (8), labral tear (7), arthritis (5), avascular necrosis (1), loose body (1) and synovitis (1). The median improvement in the modified Harris hip score was 45 points (from 51 preoperatively to 96, on the 100-point scale), with 13 patients (87%) returning to their sport. All five athletes with arthritis eventually underwent total hip arthroplasty at an average of 6 years. 43 Long-term outcomes regarding progression of joint degeneration after traumatic chondral or labral damage are not available.

Operative management of shoulder injuries in athletes

Labral tears require repair, whereas shoulder instability is currently approached operatively more often. Conservative management of traumatic shoulder dislocations in adolescents is associated with high rates of recurrent instability (up to 100%), whereas recurrent dislocations were reported in up to 12%, at an average of 3 years after arthroscopic stabilization. Shoulder dislocations are particularly common in rugby, the characteristic mechanism of injury being tackling, whereas labral tears are common in the ‘overhead’ athlete'. Published results in athletes 151 – 162 (Table  7 ) show that operative stabilization of the shoulder is initially successful, but instability and pain can recur in the long term. Results of arthroscopic techniques in the management of intra-articular pathologies are promising, but long-term outcomes are unknown (Table  7 ).

RCT, randomized controlled trial; VAS, visual analogue scale.

Operative management of elbow injuries in athletes

Elbow ulnar collateral ligament (UCL) insufficiency is one of the frequently recognized injuries in the overhead athlete, as a result of excessive valgus stress. It constitutes a potentially career threatening injury and requires surgical repair. 163 The use of a muscle-splitting approach, avoiding handling of the ulnar nerve, and the use of the docking technique for stabilization is recommended 164 , 165 (Table  8 ). Recent advantages in arthroscopic surgical techniques and ligament reconstruction in the elbow have improved the prognosis for return to competition for highly motivated athletes. The results of arthroscopic debridement 150 , 166 (Table  7 ) need to be evaluated in the long term.

Operative management of elbow injuries in athletes.

UCL, ulnar collateral ligament.

Operative management of wrist injuries in athletes

A review of the literature shows that 3–9% of all athletic injuries occur in the hand or wrist, and are more common in adolescent athletes than adults. 46 In this article, we focused on TFCC injuries and acute scaphoid fractures in athletes.

TFCC injuries are an increasingly recognized cause of ulnar-sided wrist pain, and can be particularly disabling in the competitive athlete. Advances in wrist arthroscopy made endoscopic debridement and repair of the TFCC possible. McAdams et al . 47 treated arthroscopically TFCC tears in 16 competitive athletes (mean age: 23.4 years). Repair of unstable tears was performed in 11 (69%) and debridement only in 5 (31%). Return to play averaged 3.3 months (range: 3–7 months). The mean duration of follow-up was 2.8 years (range: 2–4.2 years). Clinical scores (mini-DASH and mini-DASH sports module) improved significantly. No long-term outcomes are available.

Operative management of scaphoid fractures in athletes, even if undisplaced, is recommended if early return to sports is desired. One study followed 12 athletes treated operatively for a scaphoid fracture. They were able to return to sports at 6 weeks. At an average follow-up of 2.9 years, 9 of 12 athletes had range of motion equal to the uninjured side, and grip strength was equal to the unaffected side in 10 of 12 athletes. 49

Participation in sports offers potential benefits for individuals of all ages, such as combating obesity and enhancing cardiovascular fitness. 1 On the other hand, negative consequences of musculoskeletal injuries sustained during sports may compromise function in later life, limiting the ability to experience pain-free mobility and engage in fitness-enhancing activity. 167 Increasingly, successful management of sports-related injuries has allowed more athletes to return to participation. The knee is the joint most commonly associated with sports injuries, and therefore is most at risk of developing degenerative changes. It is not clear whether radiographic OA always correlates with symptoms and reduced quality of life. Furthermore, even effective management of meniscal or ACL injury does not reduce the risk of developing subsequent OA. 137 , 168 OA in an injured joint is caused by intra-articular pathogenic processes initiated at the time of injury, combined with long-term changes in dynamic joint loading. Variation in outcomes involves not only the exact type of injury (e.g. ACL rupture with or without meniscal damage), 137 but also additional variables associated with the individual such as age, sex, genetics, obesity, muscle strength, activity and reinjury. A better understanding of these variables may improve future prevention and treatment strategies. 169

In many of the long-term studies (the majority being retrospective case series), several methodological flaws have to be highlighted. A recent systematic review on OA after ACL injuries 137 suggested that some studies may overestimate the prevalence of long-term OA. The authors in several studies mention that a proportion of the index group of injured athletes were available for follow-up or consented for radiographic examination. One can argue that these patients were the ones with symptoms, therefore the prevalence of OA (after ACL rupture for example) may appear higher than it really is. Presentation of outcomes was not always based on robust criteria. Different clinical scores and radiographic classifications have been used, and therefore results between studies are not directly comparable. In the majority of the studies, it was not clarified whether radiographic appearance correlated with symptoms, and how important these were for the quality of life of the patients. Disabling arthritis requiring intervention may actually be delayed for more than 20–30 years. 107 , 112 Furthermore, long-term studies present outcomes of older techniques, not used any more in clinical practice (e.g. primary ACL repair or total meniscectomy). Evolution in surgical or rehabilitation techniques might have improved outcomes of certain injuries. Therefore, currently known ‘long-term outcomes’ may only reflect the results of techniques used in the past and not what we should expect in the future. Increasing awareness of athletes and trainers, new diagnostic and musculoskeletal imaging modalities, improved surgical and rehabilitation methods, but also analysis of injury patterns in different sports and development of injury prevention strategies might be beneficial to minimize the effects of sports injuries in the years to come.

What is the true incidence of arthritis in the long term? Will it be a disabling condition for the former athlete, in the coming decades? Currently, joint preserving procedures (e.g. microfractures, 145 mosaicplaty, 170 autologous chondrocyte implantation, 171 , 172 realignment osteotomies 173 and implant arthroplasties 174 ) have evolved and allow middle aged or older patients to live without pain and maintain an active life style. Meniscal transplantation shows encouraging results. 175 Should therefore an increased risk for developing musculoskeletal problems prevent children and adults from being active in sports? 176 Do the benefits of participating in sports outweigh the risks?

A survey in Sweden showed that 80% of former track and field athletes with an age range of 50–80 years felt they were in good health, compared with 61% of the referents, despite higher prevalence of hip arthritis in former athletes. Low back disorders were similar in the two groups, shoulder and neck problems were lower in former athletes, and knee arthritis was similar in the two groups. 177

No definite answer can be given to the previously addressed questions, based on available evidence. Future research should involve questionnaires assessing the HRQL in former athletes, to be compared with the general population. 27 , 178–181

Physical injury is an inherent risk in sports participation and, to a certain extent, must be considered an inevitable cost of athletic training and competition. Injury may lead to incomplete recovery and residual symptoms, drop out from sports, and can cause joint degeneration in the long term. Few well-conducted studies are available on the long-term follow-up of former athletes, and, in general, we lack studies reporting on the HRQL to be compared with the general population. Advances in arthroscopic techniques allow operative management of most intra-articular post-traumatic pathologies in the lower and upper limb joints, but long-term outcomes are not available yet. It is important to balance the negative effects of sports injuries with the many social, psychological and health benefits that a serious commitment to sport brings. 9

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• Correction: Youth sport injury research: a narrative review and the potential of interdisciplinarity - May 01, 2022

• http://orcid.org/0000-0002-3762-2976 Solveig Elisabeth Hausken-Sutter 1 ,
• http://orcid.org/0000-0002-1487-8987 Richard Pringle 2 ,
• http://orcid.org/0000-0001-8436-7149 Astrid Schubring 1 ,
• http://orcid.org/0000-0002-9742-527X Stefan Grau 1 ,
• http://orcid.org/0000-0002-3918-7904 Natalie Barker-Ruchti 1 , 3
• 1 Department of Food and Nutrition, and Sport Science , University of Gothenburg , Gothenburg , Sweden
• 2 Faculty of Education , Monash University , Melbourne , Victoria , Australia
• 3 School of Health Sciences , Örebro University , Örebro , Sweden
• Correspondence to Solveig Elisabeth Hausken-Sutter; solveig.sand.hausken{at}gu.se

To prevent sports injuries, researchers have aimed to understand injury aetiology from both the natural and social sciences and through applying different methodologies. This research has produced strong disciplinary knowledge and a number of injury prevention programmes. Yet, the injury rate continues to be high, especially in youth sport and youth football. A key reason for the continued high injury rate is the development of injury prevention programmes based on monodisciplinary knowledge that does not account for the complex nature of sport injury aetiology. The purpose of this paper is to consider and outline an interdisciplinary research process to research the complex nature of sport injury aetiology. To support our proposition, we first present a narrative review of existing youth football and youth sport injury research demonstrating an absence of paradigmatic integration across the research areas’ main disciplines of biomedicine, psychology and sociology. We then demonstrate how interdisciplinary research can address the complexity of youth sport injury aetiology. Finally, we introduce the interdisciplinary process we have recently followed in a youth football injury research project. While further research is necessary, particularly regarding the integration of qualitative and quantitative sport injury data, we propose that the pragmatic interdisciplinary research process can be useful for researchers who aim to work across disciplines and paradigms and aim to employ methodological pluralism in their research.

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https://doi.org/10.1136/bmjsem-2020-000933

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What is already known?

Youth athletes sustain injuries.

Youth sport injuries have been researched from multiple scientific disciplines.

There is growing support for the application of a complexity approach to sport injury research.

What are the new findings?

An overview of youth football and youth sport injury research from the scientific disciplines of biomedicine, psychology and sociology.

Paradigmatic distinctions in youth football and youth sport injury research create scientific differences between bodies of injury research.

Youth football and youth sport injury research lacks integration across disciplines and paradigms.

Our proposed interdisciplinary research process consists of five phases that demonstrates the working process of a project researching youth football injuries.

The five-phase process can be considered a response to the call for interdisciplinarity in sport injury research as well as a practical guide.

Introduction

Youth sport injury research has during the past years produced important knowledge concerning injury aetiology and injury prevention. Most of this scholarship has emerged from research conducted in specific scientific disciplines, primarily biomechanics, sport medicine, exercise physiology, sport psychology and sport sociology. 1 Broadly speaking, researchers of these disciplines follow distinctive assumptions of what an injury is and what research questions, ethical stances, research methods and interpretations and explanations of results are most appropriate to study this phenomenon. 2 3 These constellations of beliefs, values and methodologies are referred to as scientific paradigms . Existing youth sport injury research can be categorised by three paradigms: positivism, postpositivism and interpretivism. The positivist paradigm is closely related to reductionism, and reality and truth are understood as singular and identifiable. Positivist sport injury research has specifically focused on identifying and separating risk factors. 4 Methodologically, objectivity is paramount, which requires researchers to detach themselves from the study object. In analysis, the identified risk factors are used to generalise causality. 3 5 In the postpositivist paradigm, reality and truth are understood alike positivism. However, researchers adopt diverse research methods to establish causality, including through qualitative methodology. 3 In the interpretivist paradigm, reality and truth are understood as multiple and relative. 2 3 Researcher objectivity is not considered possible as it is assumed that truth is constructed between researchers and the researched. The overall aim is to gain a deeper understanding of what an injury means, and how it is experienced and made sense of.

Scientific paradigms guide researchers and research, 2 3 5 and they have shaped research on youth sport injury aetiology. The existing body of knowledge is comprehensive, however, seldom brought together to understand sport injury and sport injury aetiology from the perspectives presently adopted. Thus, an interdisciplinary understanding that is interparadigmatic is missing. Recently, a number of sport injury researchers have critiqued the reductionist methodology that characterises most research on sport injury aetiology and suggested a turn to complexity to account for the multidimensional nature of sport injury aetiology. 4 6–9 At present, however, relatively few researchers adopt a complexity approach and scholarship is only at the conceptual level. Moreover, current discussions have not included ways to integrate the influence socio-cultural context has.

The purpose of this paper is to advance existing youth sport injury aetiology scholarship by considering and outlining an interdisciplinary research process to research the complex nature of youth sport injury aetiology. In our view, an interdisciplinary approach that is interparadigmatic has potential to generate data that can address the complexity of an injury. To support our proposition for interdisciplinarity, the paper aims to: (1) present the results of a narrative review that examined multidisciplinary literature on youth sport injury aetiology; (2) discuss interdisciplinary research to consider how such an approach can address the complexity of youth sport injury aetiology and (3) introduce an interdisciplinary research process that we have adopted in a research project on youth football injury aetiology.

To achieve the above aims, we draw on the research context of the ongoing project ‘Injury free children and adolescents: towards best practice in Swedish football’ (FIT project). 10 The purpose of the FIT project is to provide evidence-based interdisciplinary injury prevention strategies. To achieve this, the project aims to produce a comprehensive picture of injury aetiology in a sample of male and female Swedish football players aged 10–19 years through integrating natural and social science and producing quantitative and qualitative data. The research team includes scholars from biomechanics, sport medicine, sociology and sport coaching. The project started in January 2017 and involved a prospective questionnaire to record incidence and prevalence of injuries over a 5-month period, one-time biomedical testing (clinical examination, isometric strength measurements, running analysis and knee stability), a 5-month analysis of training protocols, observation of training sessions of players and their coaches and interviews with players and coaches. At present, the project is working towards the integration of collected quantitative and qualitative data.

Narrative review of youth football and sport injury research

We conducted a narrative review of literature relevant to youth football injury aetiology to provide a critical synthesis of existing literature and to specifically identify paradigmatic and methodological assumptions, research approaches, research methods and data analysis procedures. The focus on existing literature’s paradigmatic distinctions is an important first step in interdisciplinary work. 3 According to Phoenix et al 3  (p. 220), a ‘step back’ to understand underlying assumptions can advance knowledge and awareness of the respective research field as a way to ‘move beyond debates about right or wrong ways of approaching research’.

The first author has from January 2017 to May 2020 searched for literature on youth football injuries in the databases PubMed, Scopus, PsycINFO and Web of Science. Search terms included various combinations of ‘youth’, ‘soccer’, ‘football’, ‘injury’, ‘aetiology‘ and ‘risk’. Inclusion criteria were set to youth football players aged approximately 10–19 years and injury aetiology, injury prevention and/or injury risk factors. The search revealed a paucity of sociological youth football injury research. Thus, the search was broadened to sociological injury research in different sports and age groups, which identified research in biathlon, figure skating, rhythmic gymnastics, rugby and softball. To identify assumptions underlying paradigmatic distinctions, we predefined three analytic areas: body and injury perspective (state of the art regarding how an injury is explained and defined); paradigmatic assumptions (reality/truth/knowledge) and research approaches (methodology). Based on how these categories were approached in the literature included in the review, as well as discussions in the FIT project team and a presentation at a scientific conference, 11 we placed the literature in the three paradigms dominant for youth sport injury research: positivism, postpositivism and interpretivism. Furthermore, five dominant disciplines of youth sport injury research were identified based on the reviewed literature; biomedicine (biomechanics, sport medicine and exercise physiology), sport psychology and sport sociology. Table 1 summarises key findings of the narrative review.

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Distinctions of youth football and sport injury aetiology research

Biomedical research

Biomedical research on injuries in youth football has mostly focused on individual injury risk factors relating to kinematics, kinetics and spatiotemporal variables, physical development and amount of training and competitions. Key findings from our literature search show that age, growth and biological maturation contribute to an increased risk of injuries, especially during the year of peak height velocity. 12–14 Possible risk factor for injuries in youth football players during this period include muscle strength, 15 familial disposition, 16 previous injury, 17 physical stress (ie, training and match duration and perceived exertion) 18 and match playing. 12 16 Furthermore, external factors such as playing turf and type of shoes are associated with injuries among youth football players. 19 Findings from the biomedical discipline have resulted in the development of injury prevention interventions applied to youth through programmes such as the Nordic hamstring strengthening exercise, 20 the FIFA 11+ exercise programme 21 and a neuromuscular warm-up programme called ‘Knee control’. 22 These exercise-based programmes include multiple training components, such as agility, balance, mobility, running and strength activities.

In addition to identifying risk factors, biomedical research has contributed with a number of sport-general models on injury causation, including the Sequence of Prevention model, 23 and the Multifactorial Model of Athletic Injury Aetiology, 24 which was later revised and updated to a more dynamic model. 25 McIntosh 26 also proposed a multifactorial model of injury causation but with a biomechanical focus on tissue properties and injury. Furthermore, sport injury research frameworks such as the Translating Research into Injury Prevention Practice framework, 27 and the extension of the Reach; Effectiveness; Adoption; Implementation; Maintenance framework 28 have been developed in order to close the gap between research and implementation of interventions. These models and frameworks have, in general, been used by youth football injury aetiology researchers.

Biomedical youth football injury research reviewed in this paper is situated in the positivist paradigm. Given its assumptions of a singular and identifiable reality and truth, an injury is objectively defined as a specified damage to the physical body. Injury aetiology is often linear and related to identifiable individual physical factors. Methodologically, researchers are required to stay objective and abstain from interacting with research participants. A hypothetic-deductive reasoning leads the research from broad hypotheses to testing using quantitative methods (eg, physical testing, questionnaires), often in isolation and through manipulation of typical risk factors, often in a laboratory setting.

Psychological research

Psychological research on injuries in youth football players has mainly focused on psychosocial dimensions. Main risk factors identified in this research are personality traits (eg, high level of trait anxiety; low level of mistrust; ineffective coping), 29 history of stressors (eg, negative life event, daily hassles), 30 mental and physical fatigue 31 and team climate (eg, lack of support from coach and teammates). 31 32

Findings from the psychological discipline have resulted in prevention and research focusing on stress management techniques and goal setting skills. 33–35 Furthermore, the Model of Stress and Athletic Injury, 36 37 which demonstrates how the magnitude of stress and athletes’ appraisal of the situation may be influenced by the interplay between various psychosocial factors (eg, personality, history of stressors, coping resources), has become one of the most cited research models. In extending this model through the Biopsychosocial Model of Stress Athletic Injury and Health, the authors suggest that behavioural mechanisms associated with stress response (eg, impaired self-care; poor sleep quality) should also be addressed. 38 Moreover, emotions and environmental factors have been included in the Biopsychosocial Sport Injury Risk Profile, 39 as important risk factors related to sport injury.

Psychological youth football injury research reviewed in this paper is mainly situated in the positivist paradigm, with some research fitting into the postpositivist paradigm. Like the positivist paradigm, injury and injury aetiology definition is specific and related to the physical body, but adds the mind. Methodologically, researchers keep interaction with athletes to a minimum, and similar to positivist researchers, tend to follow a hypothetic-deductive reasoning as a method to gain knowledge. Assuming that establishing truth requires diverse sets of data, some researchers test the hypotheses by using qualitative methods, such as questionnaires and in-depth interviews.

Sociological research

Sociological research on youth sport injury has examined injuries from the perspective of athletes and by analysing the sporting culture athletes are immersed in. Key findings from our search show that sociocultural values (eg, sporting success; discipline and striving for perfection), social norms (eg, femininity; masculinity; power; being on time; respecting the coach), 40–43 pressure to play through injury and pain (especially socialisation to accept training/competing with pain; silence around pain and injury), 41 44 45 medical support (eg, lack of medical support; information being withheld) 44 46 and coach-athlete relationships, 42 47 can influence injury aetiology among athletes.

Sociological injury researchers do not use models to conceptualise injury aetiology, but employ theoretical frameworks such as sport ethic (a set of ideas and beliefs that together comprise norms of traditional athleticism), 42 narratives of self, 47 culture of risk, 48 social control (eg, individuals become inscribed and normalised by particular dominant standards) and masculinity theories, 49 in order to understand and explain sport injury aetiology.

Sociological youth sport injury research reviewed in this paper tends to be situated in the interpretivist paradigm. An injury and its aetiology are interpreted by athletes and researchers and can be explained or understood by examining athletes’ sociocultural context. To examine injury aetiology, researchers interact with athletes and the context. Methodologically, sociological researchers sometimes use deductive reasoning as described above, but they also use inductive reasoning, where the process of creating insight develops from empirical data towards a theory (ie, patterns, themes and categories of analysis emerge out of the data). Researchers in the interpretivist paradigm apply qualitative methods such as observation and interviews, and interpretive analysis techniques such as thematic, content, discourse and narrative analysis.

Reflections on distinctions of youth football and youth sport injury research

The narratively reviewed literature on youth football and youth sport injury research shows two paradigmatic distinctions. First, the literature is monoparadigmatic and tends to focus on one subdiscipline of sport science. Most of the literature is biomedical, sport psychological and sport sociological, and often based on either quantitative or qualitative research techniques. The French philosopher and sociologist Edgar Morin 50 argues that by approaching research from single disciplines, complexity becomes invisible. The disintegration of complexity through monodisciplinarity is not due to the discipline in itself, but as Morin 50  (p. 2) emphasises, because ‘of the discipline as it is conceived, non-communicating with the other disciplines, closed to itself’. Monodisciplinarity in research reduces the phenomenon into separate parts, thus making the whole as well as interactions between parts and between parts and the whole, invisible. 7 50 Second, and related to monodisciplinarity, there is no integration of research across the three paradigms.

These limitations can be clearly seen in our narratively reviewed literature included in table 1 . Thus, current youth sport injury research can be seen to shield off—or in other words leave out—possibly important aspects, creating a picture that is not actually representative of the complex phenomenon under study (eg, injury aetiology). 51 For example, biomedical and psychological disciplines, by mainly focusing on athletes’ physical bodies and minds, leave out their interaction with and in the larger sociocultural context the athletes participate in. Similarly, sociological research, by focusing on sociocultural context, often ignores how the physical body and mind interact with and influence athletes.

Researchers operating in these paradigms and disciplines can and do apply different research approaches and methods, thus, paradigms do not confine. Indeed, researchers have adopted approaches to be more inclusive, such as an ‘ecological’, ‘integrated’ or more ‘real-world’ approach to sport injuries. 52–54 However, these approaches either miss to account for multiple and complex interactions between different ‘parts of the whole’, 7 or do not attempt to integrate disciplines across paradigms or use multiple quantitative and qualitative research methods.

The complexity approach to sport injury research

The recognition that sport injury aetiology involves numerous interactions between various variables across multiple dimensions has led some researchers to explore the potential of a complex systems approach for understanding and researching sport injury aetiology. 4 6–9 Although researchers understand and apply complexity to sport injury research differently, three elements characterise current discussions. First, a complexity approach embraces an understanding of context as open systems consisting of components that are actively connected through mostly non-linear relationships. 4 7 8 A non-linear relationship between components in the system implies that A plus B does not necessarily equal C. For example, a weak muscle plus psychological stress does not necessarily result in an injury. Second, these non-linear relationships between the components can induce dramatic new effects giving rise to unexpected structures and events, also known as emergence. 55 56 Emergence can, for example, be certain tendencies, powers or complex phenomena such as a sport injury. Emergence, or the injury and its aetiology is constantly evolving, and not strictly predictable. 55 In other words, emergence is self-organising, meaning a complex system can transform over time, either growing or shrinking. 55 Emergence should be accounted for when researching sport injury aetiology, for example, through longitudinal studies. Finally, and what Newell 55 argues is typically overlooked in the understanding of complex systems, is the importance of ‘local knowledge’, or knowledge of specific parts of the system. An athlete can, for example, be stressed over an upcoming exam at school and is injured right before the exam. The athlete might believe exam stress caused the injury. A closer examination may, however, show that it was the way the coach had changed behaviour towards the athlete that affected the injury aetiology. When applying a complex systems approach to injury research, the focus moves from identifying single risk factors for injuries to recognising patterns of interaction among multilevel components, acknowledging that these components interact in unpredictable ways and may be moderated by a number of individual and contextual factors. 4 6 8

Researchers are currently discussing how the implementation of complex systems thinking can advance sport injury research, specifically through statistical mathematical models and computer-based simulations guided by equations, rules and laws. Complex models 4 and statistical procedures such as the Agent-Based Modelling (ABM) and Systems Dynamics (SD) modelling 9 are recent examples. According to Bekker 6  (p. 80), however, this development represents an “overemphasis on the epistemological question of how multifactorialism is accounted for in research and a corresponding underemphasis on the ontological considerations and assumptions we make about the world”, which reflects a dissonance in how complexity is understood and applied to sport injury research. The current argument for complexity assumes a reductionist positivist/postpositivist view where complexity is understood as emerging from the rule-based interactions of simple agents/elements and explored through agent-based modelling. 56 Consequently, it tends to ignore that there is more to emergence than the product of interactions of agents; athletes are themselves complex systems, and more complex than agents in agent-based simulations. 56 Thus, the current argument for complexity is limited in recognising the importance of understanding athletes’ interactions with and in a certain context; hence, it is ignoring the significance of incorporating sociocultural conditions that researchers from the interpretivist paradigm have identified as relevant. Bekker further argues that injury researchers’ focus should not be on methodological preferences, but rather on ‘understanding system goal behaviour using methodological pluralism’ 6 (p. 81). We agree. A complexity approach requires alternative research methodologies. One such approach, which we have found to have potential in the FIT project to account for the multiple dimensions of injury aetiology, is an interdisciplinary research process that includes scientific disciplines from different paradigms and integrates qualitative and quantitative research methods.

The potential of interdisciplinary sport injury research

Drawing on research by Klein and Newell, 57 we understand interdisciplinarity as a research process aiming to address a topic that is too broad or complex to be dealt with adequately by a single discipline. Furthermore, an interdisciplinary research process integrates disciplinary perspectives through construction of a more comprehensive perspective. 57 Both Newell 55 and sports researchers such as Buekers et al 58 argue that complex systems and phenomena are a necessary condition for interdisciplinary studies. The rationale for this argument lies in the way complex phenomena can be understood and studied. If an injury is to be understood as complex, then this would mean, as argued earlier, that the phenomenon is multidimensional. Seeing it from one single angle, such as from biomedicine or sociology, only, the phenomenon appears different than from another angle. Since the overall pattern of behaviour is non-linear and dynamic, an effective method for modelling such a phenomenon must offer insight into the separate parts as well as the complex pattern produced by their overall interactions. 55 An interdisciplinary research process, which draws insights from relevant disciplines and integrates these insights into a more comprehensive understanding, is thus proposed to have potential to study sport injury aetiology. 1

The benefits of interdisciplinarity have been pointed out in a recent Nature editorial. 59 The editor specifically endorsed the incorporation of social sciences, cautioning that ‘[i]f social, economic and/or cultural factors are not included in the framing of the questions’ then ‘a great deal of creativity can be wasted’. Recently, sports sociologists Pringle and Falcous 60 have also advocated a collaboration between the social and natural sciences. They argue that a collaboration between biomedical researchers and sport sociologists, which they refer to as methodological border crossing, could improve the political impact of research from the sociology of sport. Regarding sport injury research, Burwitz et al 1 argued for the benefits of interdisciplinarity over two decades ago. Despite their call, however, very little empirical work has been conducted to this end. Reasons provided for this reservation have been related to various obstacles that prevent high quality, truly integrated interdisciplinary work, as well as practical difficulties relating to gaining funding and publishing. 1 58 Philosophical obstacles relating to paradigmatic differences may also result in a lack of shared understandings, research approaches and methods, 61–63 preventing researchers from adopting such an approach. Nevertheless, our research in the FIT project has demonstrated that interdisciplinarity has potential for sport injury research.

The interdisciplinary research process of the FIT project

The interdisciplinary research process of the FIT project consisted of five phases depicted in figure 1 . The five-phase research process was developed based on key interdisciplinary research steps outlined by interdisciplinary researchers such as Alan Repko, Rick Szostak and William H. Newell. 55 64 While presented sequentially, the five-phase research process is an iterative and non-linear process. At times it was necessary to move back to an earlier phase or forward towards later phases, which is common and reflects the complexity of the interdisciplinary research process. 55 64

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The interdisciplinary research process of the FIT project. The figure illustrates the five-phase interdisciplinary research process adopted for the study of youth football injury aetiology. 10 The blue boxes present the main theme of each of the five phases of the process. The green boxes entail research actions. The interdisciplinary research process was not linear, but involved the researchers moving back to an earlier phase or forward towards later phases during the process.

In the first phase of the process, the FIT project research group came together from multiple scientific disciplines and agreed on researching injury aetiology in youth football using an interdisciplinary approach. In the second phase, the project team members decided which scientific disciplines to draw on to study the problem, a process that took place through meetings, discussions, reviewing literature and presentations of research within and outside of the project group. In phase III, we conducted research applying the following research methods to study youth football injury aetiology: questionnaire; measures of weight and height; injury diagnostics; clinical examinations; strength testing; running analyses; knee laxity measurements; examination of training protocols; field observations and interviews. Research methods were chosen based on knowledge gained from project team members’ disciplinary expertise, existing literature, internal meetings and discussions with experts outside of the research group. Additionally, phase III entailed recruitment of research participants.

In the final two phases, data were analysed through measurement-specific analyses (eg, three-dimensional kinematics to analyse movement-specific characteristics; isometric strength to analyse muscle weakness and/or muscle imbalance; content analysis of field notes and interview transcripts) and an analytic procedure was prepared that makes integrated analysis of measurement-specific analysis possible.

During the FIT project’s five-phase interdisciplinary research process, the research group encountered paradigmatic challenges typical of working interdisciplinarily. 61 One example is sample size and recruitment. Where positivist paradigmatic distinctions require a statistically powerful sample size, the interpretivist paradigm demands possibilities for in-depth and detailed examination of one or a few cases. A further challenge was the lack of an integrated data analysis procedure that would allow us to integrate the measurement-specific analysis referred to above. As we could not locate a suitable analytical procedure, we needed to spend time and effort to develop and test such a procedure. Finally, we have found that presenting the FIT project research in multiple cases resulted in misunderstanding and scientific criticism. As a result, we had to place extra effort in considering the communication of the FIT project’s scientific rationale, methodology and results. Indeed, while we have not struggled to respect our different paradigmatic worldviews and demands, it has been challenging to find and communicate what interdisciplinary researchers like Repko and Szostak 64 and Welch 65 call the ‘space in between’ scientific paradigms and disciplines we have been trying to create. The key measure that helped us to move forward in the interdisciplinary research process was a negotiation process that entailed regular meetings.

The purpose of this paper was to consider and outline an interdisciplinary research process to research the complex nature of youth sport injury aetiology. To facilitate this proposal, our narrative review of existing biomedical, sport psychological and sociological literature summarised youth football and youth sport injury research and demonstrated paradigmatic distinctions and methodological assumptions, research approaches, research methods and data analysis procedures. The narrative review has shown a paucity on youth football injury research in the sociological discipline as well as a dominance of monodisciplinary research and a lack of integration across research disciplines and paradigms.

Our paper has further shown that to advance youth sport injury research, specifically considering complexity, an interdisciplinary research process, such as proposed in figure 1 , has potential to integrate disciplinary knowledge and measurement-specific data across research paradigms. The integrated potential is particularly promising for research aiming to examine the interactions of components proposed vital to understand the complexity of injury aetiology. We recognise, however, that to advance this potential, additional research is necessary. We particularly see a need to develop and trial analytical procedures that integrate qualitative and quantitative injury aetiology data to produce complex injury aetiology findings, and to explore interdisciplinary research teams’ pragmatic negotiation of the challenges of melding seemingly opposing paradigms in the interests of better understanding the complexities of sport injury processes.

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Contributors NB-R and SG conceptualised the FIT project, which is the basis for this paper. NB-R acquired the funding. AS, NB-R, SG and SEH-S contributed with the preparation of tools and data production for the FIT project. SEH-S is the PhD student in the FIT project. NB-R and SEH-S were responsible for the initial preparation and writing of the manuscript. RP, AS and SG contributed to the accurate and critical revision of the manuscript as well as approval of the final version. All authors were involved in the preparation and editing of the manuscript.

Funding This study was funded by The Swedish Research Council for Sport Science.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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• Published: 03 May 2023

Interdisciplinary sport injury research and the integration of qualitative and quantitative data

• S.E Hausken-Sutter 1 ,
• K Boije af Gennäs 2 ,
• A Schubring 1 , 3 ,
• J Jungmalm 1 &
• N Barker-Ruchti 1 , 4  

BMC Medical Research Methodology volume  23 , Article number:  110 ( 2023 ) Cite this article

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To understand and prevent sport injuries, scholars have employed different scientific approaches and research methods. Traditionally, this research has been monodisciplinary, relying on one subdiscipline of sport science and applying qualitative or quantitative research methods. Recently, scholars have argued that traditional approaches fail to address contextual components of sport and the nonlinear interactions between different aspects in and around the athlete, and, as a way forward, called for alternative approaches to sport injury research. Discussion of alternative approaches are today taking place, however, practical examples that demonstrate what such approaches entails are rare. Therefore, the purpose of this paper is to draw on an interdisciplinary research approach to (1) outline an interdisciplinary case analysis procedure (ICAP); and (2) provide an example for future interdisciplinary sport injury research.

We adopt an established definition and application of interdisciplinary research to develop and pilot the ICAP for interdisciplinary sport injury teams aiming to integrate qualitative and quantitative sport injury data. The development and piloting of ICAP was possible by drawing on work conducted in the interdisciplinary research project “Injury-free children and adolescents: Towards better practice in Swedish football” (the FIT project).

The ICAP guides interdisciplinary sport injury teams through three stages: 1. Create a more comprehensive understanding of sport injury aetiology by drawing on existing knowledge from multiple scientific perspectives; 2. Collate analysed qualitative and quantitative sport injury data into a multilevel data catalogue; and 3. Engage in an integrated discussion of the collated data in the interdisciplinary research team.

The ICAP is a practical example of how an interdisciplinary team of sport injury scholars can approach the complex problem of sport injury aetiology and work to integrate qualitative and quantitative data through three stages. The ICAP is a step towards overcoming the obstacles of integrating qualitative and quantitative methods and data that scholars have identified.

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Introduction

Traditionally, sport injury researchers study injury aetiology in youth athletes from the perspective of one scientific discipline (e.g., exercise physiology, biomechanics; sport psychology; sport sociology). Broadly speaking, researchers of these disciplines follow distinctive assumptions of what an injury is and what research questions, ethical stances, research methods and interpretations and explanations of results are most appropriate to researching injury aetiology in youth athletes [ 1 , 2 , 3 ]. Biomedical scholars, for instance, often regard an injury to be related to identifiable individual physical factors and apply quantitative methods to test if components such as muscle strength previous injury, and growth and maturation are related to injury aetiology [ 4 , 5 , 6 ]. Sport sociologists often understand sport injury as a socially constructed phenomenon and apply qualitative methods to interview youth athletes about the coach-athlete relationship and/or observe contextual aspects such as the training environment [ 7 , 8 ]. To study aspects such as injury experiences, consequences and perceptions, sport psychology researchers oftentimes use either quantitative [ 9 ], qualitative [ 10 ] or mix qualitative and quantitative methods [ 11 ].

The predominant monodisciplinary approach to sport injury research has provided extensive knowledge on injury aetiology in youth athletes. In recent years, however, several sport injury scholars have critiqued the traditional monodisciplinary approach and suggested a turn to complexity approaches to account for the multifaceted nature of sport injury aetiology [ 12 , 13 , 14 , 15 , 16 , 17 ]. The key argument is that contemporary research has not been accounting for the nonlinear interactions between different components across different dimensions, such as interactions between people and the physical and social environments, and thus, does not consider the unpredictable, fluid, and flux nature of sport injuries. Instead, the scholars suggest a framework away from risk factors towards identifying risk patterns and looking deeper into the complex nature of sport injury aetiology [ 12 , 13 , 15 , 16 , 17 ]. To achieve this goal, however, scholars consider how to best address complexity differently, and best practice examples are a work in progress for sport injury research. To address this gap and to contribute to the current discussion on alternative approaches we propose that interdisciplinarity offers potential. We have adapted and applied the definition of interdisciplinarity based on Julie Klein and William H. Newell [ 18 ], who have significantly influenced the field of interdisciplinary research in the past 40 years. These scholars define interdisciplinarity as a research process that addresses a complex phenomenon that cannot be dealt with adequately by a single scientific discipline. To fit Klein and Newell’s definition to the team context within which we conducted interdisciplinary research, we adapted Klein and Newell’s [ 18 ] definition which in this article involves collaboration of researchers specialising in different scientific disciplines and methodological approaches, and the application of both qualitative and quantitative methods.

The need for interdisciplinarity in sport injury research was first called for by Burwitz et al. [ 19 ] in the 1990s. Since then, several sport science scholars have argued that research on athlete health and wellbeing requires a holistic and multidimensional approach, where scholars from different disciplines collaborate [ 20 , 21 , 22 ]. The rationale is that different scientific perspectives and research methods have established important insight into sport injury aetiology and can thus address a greater range of components that influence sport injury aetiology. The different disciplinary insights offer a means to facilitate an integrated understanding and discussion of sport injuries in relation to individual players’ context and situation, which has the potential to extend existing insights [ 19 , 22 , 23 ]. For example, and as demonstrated by sport science scholars Schofield, Thorpe, and Sims [ 24 ], their bringing of qualitative sociological data into dialogue with quantitative physiological data helped the team to draw novel conclusions as to which athletes were struggling with health problems, which eventually led to new insight and a return to the empirical data for a second stage of analysis. Such new and integrated insight into athlete health is necessary to develop prevention strategies that are more effective in addressing the components of sport injury aetiology. To that end, this paper contributes with a piloted procedure on how to work in an interdisciplinary team with qualitative and quantitative data in sport injury research. Specifically, the purpose of this paper is to draw on an interdisciplinary research approach to (1). outline an interdisciplinary case analysis procedure (ICAP); and (2). provide an example for future interdisciplinary sport injury research.

Interdisciplinary research and implications for data analysis

Interdisciplinary scholars Klein and Newell [ 18 ] define interdisciplinary research as:

a process of answering a question, solving a problem, or addressing a topic that is too broad or complex to be dealt with adequately by a single discipline or profession … [interdisciplinary research] draws on disciplinary perspectives and integrates their insights through construction of a more comprehensive perspective [ 18 p3].

Interdisciplinarity thus constitutes both a research approach and a process that is developed for the study of complex systems [ 23 ]. A key aspect of interdisciplinary research is integration: “…crafting an integrated synthesis of the separate parts that provide a larger, more holistic understanding of the question, problem or issue at hand” [ 18  p12; emphasis in original]. Detailing this definition, interdisciplinarians Repko, Szostak and Buchberger [ 25 ] outline that integration is a cognitive process, where the researcher(s) evaluate disciplinary knowledge from multiple scientific perspectives and create a more comprehensive understanding of the problem under study based on the disciplinary knowledge. The common ground is, according to several interdisciplinary scholars, necessary for integration of disciplinary insight to be possible [ 25 , 26 ]. For interdisciplinary sport injury research, we took this to mean that a team of disciplinarians, could collaborate, share, and integrate disciplinary knowledge, and engage in a discussion during which qualitative and quantitative data could be integrated.

The interdisciplinary research approach outlined above may seem familiar to scholars conducting mixed methods research in, for example, health research and sport psychology [ 27 , 28 ]. Mixed methods research does indeed often aim to integrate qualitative and quantitative methods and data to gain broad and deep understanding and to generate unique insight into multifaceted phenomena [ 27 , 29 , 30 ]. However, the type of interdisciplinarity proposed in this paper differs from the mixed methods research approach by involving strategies for dealing with an array of ontological, epistemological, and contextual challenges that often exist or emerge when a team of disciplinarians collaborate. For example, interdisciplinary teams in sport science research can experience, and have experienced problematic power relationships, language barriers, and misunderstandings that complicate the integration of qualitative and quantitative data if these issues are not dealt with in the team [ 22 , 24 , 31 ]. Such teamwork and related onto-epistemological differences have received sparse attention in mixed methods research [ 32 , 33 , 34 ]. Therefore, to account for these differences, interdisciplinarity does not only involve strategies for integrating methods and data, but also for integrating disciplinary knowledge to create a more comprehensive understanding of the problem under study, which is necessary for integration to be successful [ 26 ].

With the potential and challenges of interdisciplinary research in mind, how can qualitative and quantitative data be integrated in an interdisciplinary research team context? As we could not locate established procedures for interdisciplinarity in sport science and sport injury research, we draw on suggestions of an applied interdisciplinary process developed by Newell and colleagues [ 26 , 35 ], which constitutes integrative steps to guide researchers through the decisions made in the interdisciplinary process. According to these scholars, integration cannot follow an algorithm; rather, integration requires analytical reasoning and creative thinking as the interdisciplinary research process and its steps are iterative and complex [ 26 , 35 ]. Moreover, being humble, respectful of, and acknowledging each other’s perspectives has been recognised as valuable cognitive skills when aiming to integrate knowledge and data across disciplinary borders [ 22 , 36 ]. To successfully conduct integrated research, then, efforts beyond those associated with conducting high-quality disciplinary research and mixed methods approaches are necessary [ 26 ]. First, researchers need to understand a problem from different perspectives and disciplines. Second, researchers need to consider different disciplinary views and the methodological toolkits that the disciplines constitute. Finally, it is important that researchers embrace a holistic approach – an understanding of how disciplinary ideas and information relate to a problem and to each other. In sum, as the holistic thinking involved in interdisciplinary research opposes the traditional reductionist disciplinary strategy, interdisciplinary research is not “business as usual” [ 26 p262].

To develop an interdisciplinary case analysis procedure, which became the ICAP, we draw on research conducted in the interdisciplinary research project “Injury-free children and adolescents: Towards better practice in Swedish football (the FIT project) [ 37 ]. The purpose of the FIT project was to provide evidence-based interdisciplinary injury prevention strategies. The project aimed to produce a comprehensive and integrated picture of injury aetiology in a sample of male and female Swedish football players aged 10 to 19. The research team consisted of scholars from four scientific disciplines—biomechanics, sport medicine, sport sociology, and sport coaching. Based on the four scholars’ respective scientific expertise, qualitative data was generated through interview and observation-studies and quantitative data through biomedical measurements (kinematics/movement; strength; joint range of motion/flexibility; Peak Height Velocity (PHV)) and a longitudinal questionnaire study implementing an adapted version of the OSTRC-H questionnaire [ 38 ]. Upon completion of the studies, qualitative and quantitative data were analysed according to their respective disciplinary data analysis methods and quality standards (e.g., thematic analysis for qualitative interview and observation-data; statistical procedures for biomedical data). The next step was to perform integrated data analysis, which led us to the development of the ICAP.

The Interdisciplinary Case Analysis Procedure (ICAP)

The ICAP is a flexible, circular, and iterative procedure entailing three stages (see Fig.  1 ). The stages reflect the research process of a team of disciplinary researchers aiming to integrate data through an interdisciplinary data analysis procedure. In stage 1 and taking seriously the need for integration of disciplinary insights early in the research process, the aim is to create a comprehensive understanding of the phenomenon/a that the project team aims to study based on the scientific disciplines included in a project. In stage 2, qualitative and quantitative data, analysed according to their respective disciplinary standards, are brought together. Finally, in stage 3, the collated data is discussed through a team meeting consisting of the researchers representing the data included in step 2.

The three stages of the Interdisciplinary Case Analysis Procedure (ICAP)

Stage 1: Creation of comprehensive understanding

In stage 1, the aim is to create a comprehensive understanding of the problem that the project team intends to study based on the scientific disciplines included in the project [ 23 ]. To create comprehensive understanding, it is necessary that the team members find a common language, recognise conflicts and their unique strengths, and the disciplinary knowledge each member brings to the study [ 23 ]. In this stage, the either/or disciplinary thinking is replaced by both/and thinking requiring the disciplinarians to “think outside of the box” [ 26  p260].

For the FIT project to create comprehensive understanding of sport injury, we held several team meetings to discuss and reflect upon our different research approaches and understandings of sport injury aetiology. The meetings were carefully planned and led by the project leader, who aimed to be inclusive in type of language and making room for all disciplinary perspectives. We also reviewed diverse disciplinary literature relevant to sport injury, with a particular focus on youth football, to critically reflect upon onto-epistemological differences in sport injury research for the narrative review article we published together [ 39 ]. Through reviewing literature, we also considered the basic assumptions of complexity thinking, especially in relation to nonlinear interactions between different components in the athlete’s context. Moreover, the project was presented within and outside of academia to gain additional knowledge on disciplinary research approaches and sport injury aetiology in youth athletes. The planning and implementation of the FIT project’s four sub-studies also taught us more about the differences in qualitative and quantitative methods in relation to concepts such as recruitment, validity, and reliability. Finally, all researchers had the opportunity to participate in the respective studies, where, for example, the sport coaching researchers participated in the biomedical testing.

Stage 2: Collation of qualitative and quantitative data

The aim of Stage 2 is to bring together qualitative and quantitative data in preparation for stage 3’s integrated discussion of injury aetiology.

For the FIT project, we focused on one single case of a female player aged 14 that had participated in all four studies included in the FIT project. This entailed two steps: First, individual analysis of the different datasets using suitable data analysis methods (i.e., thematic analysis for qualitative interview and observation-data; statistical procedures for biomedical data). Second, collation of the analysed data per research participant in a multilevel data catalogue in the form of an Excel document (see supplemental online file ). The idea of this catalogue is to visualise and collate in a common “space” qualitative and quantitative data to provide a foundation for the integrated discussion in stage 3. The multilevel data catalogue entails six levels of information (see Table 1 for a simplified overview; for a more comprehensive description of the six levels, see the supplementary file ).

In level 1, to demonstrate the FIT project’s disciplinary perspectives, the multilevel data catalogue is divided into one biomedical (biomechanics, sport medicine) and one sociological (sociology, sport coaching) section. The purpose of level 2 is to show the different types of measurement and research methods employed under each disciplinary perspective. The columns in level 2 are divided into different biomedical- and sociology-themes (e.g., strength measurements; observation, interview). Level 3 specifies the type of data measured and generated for each of the themes. For example, for the strength theme, the hip abduction/adduction ratio is listed in separate columns. For the interview theme, topics such as “knowledge about injury and injury prevention” are listed. Level 4 contains data excerpts to demonstrate the type of qualitative and quantitative data from the individual analyses of the injured football player. Quantitative data is represented in numeric form (for example results from the strength measurements) while qualitative data is represented in textual form (for example quotes from the interview). Level 5 shows the reference value for qualitative and quantitative data. For the former, codes were given through a qualitative thematic analysis procedure [ 41 ]. For the latter, individual biomedical data was calculated and compared to the mean values of one reference group “females aged 14–19”. Finally, level 6 contains interpretation and evaluation of the qualitative and quantitative data in relation to reference values and literature. This level lays the most important groundwork for the team discussion and continuation of data integration for stage 3.

Stage 3: Team meeting and discussion

In stage 3, the aim is for the researchers from the different disciplines included in the interdisciplinary project to meet and discuss the collated qualitative and quantitative data. According to Newell [ 26 p261], the goal of this interdisciplinary stage is to “achieve a balance among disciplinary influences on the more comprehensive understanding”, i.e., no disciplinary perspective should dominate the discussion. The qualitative and quantitative data about the complex problem (i.e., sport injury) is in this stage examined to “identify patterns of behaviour” [ 26 p261], or relationships (interactions) between different components in the system that influence injury aetiology.

For the FIT project, stage 3 was conducted through a team meeting consisting of researchers representing the scientific disciplines included in the project. The discussion was moderated by one of the researchers in the team, who had experience from the FIT project’s four sub-studies and knowledge of interdisciplinary research. The data catalogue containing analysed data served as the basis for the two-step discussion: First, each researcher presented interpretations of the analysis of data relevant to their disciplinary expertise. Their interpretations were related to the FIT project’s overarching aim and were not yet specific to a specific case/research participant. During each researcher’s statement of the analysed data, the other team members were invited to ask questions, which is argued to enable a deeper understanding of the problem at hand [ 42 ]. Second the different perspectives and data were related to the 14-year-old female player’s injury in a joint discussion. The integrated discussion was also a way to identify different patterns in the empirical data.

Implications for interdisciplinary injury data analysis

As part of the process of developing and piloting the ICAP, we have encountered four issues that have implications for the use of the procedure and future research.

First, to facilitate the collation of qualitative and quantitative sport injury data in interdisciplinary research, we experienced that the different assumptions regarding disciplinary perspectives and qualitative and quantitative data require consideration early in the interdisciplinary research process. We propose that this consideration is vital as underlying ontological, epistemological, and methodological assumptions can complicate interdisciplinary research and integration due to misunderstandings and difficulties in reflecting and verbalizing these assumptions among members of interdisciplinary research teams. Therefore, the ICAP was, and needs to be part of a purpose-driven interdisciplinary research process that focuses on integration of disciplinary perspectives and research methods already in the planning and designing-phase of a project.

Second, as differences in assumptions influence how researchers define and research a phenomenon, it is necessary to facilitate collation through three circular, iterative, and pragmatic stages that enable teamwork across disciplinary borders. Indeed, working interdisciplinarily requires spaces, or “a community of research practice” [ 3 p56] within and through which the team can explore, negotiate, and reflect upon their commonalities and differences in scientific perspectives [ 43 ]. We have therefore found that it was of great importance that the team followed a procedure through which we met on a regular basis and had a team leader that supported methodological flexibility throughout the process. Such regular team meetings have indeed been found to facilitate the development of strategies that can help bring qualitative and quantitative materials together [ 24 ]. Following such a procedure does not, however, mean that working interdisciplinary is a strict and linear process. On the contrary, we did, for example, experience that we had to go back to stage 1 and learn more about concepts such as reliability, validity, credibility, generalisability, and transferability in relation to qualitative and quantitative methods [ 44 ] when interpreting the data in stage 3.

Third, and to further facilitate collation of qualitative and quantitative data in an interdisciplinary research team context, we noticed that the team benefitted from including a researcher with knowledge of interdisciplinary research and the different disciplines included in the project. We found this particularly important in stage 3 of the ICAP, when the team discussed the compiled data in relation to the injured player. When the discussion reached a dead-end, or when the disciplinarians misunderstood each other or the data, the interdisciplinary researcher moderator could clear up misunderstandings by, for example, pointing out how the different disciplines understand and interpret concepts differently and helping the team to find a common language. It occurs, for instance that qualitative and quantitative data contradict, which can be seen as a problem and an obstacle for integration [ 31 ]. Including an interdisciplinarian in the integration phase can, however, help the team use the contradictions in data to create new insight into the problem under study [ 31 ], which is key in Newell’s interdisciplinary process [ 26 ]. The idea of the interdisciplinarian , [ 26 ] or interlocutor , [ 30 ] as someone in the middle, who takes part in dialogue and conversation with the disciplinarians, can help the team see beyond their disciplinary borders, create unity, and refocus the team’s efforts towards constructive engagement in knowledge production [ 43 ]. Although the interdisciplinarian might not be able to eliminate possible power inequalities between the disciplinarians, paying attention to these boundaries and engaging the team in conversation can facilitate a common and interdisciplinary understanding of sport injury aetiology. For the FIT project, the interdisciplinarian helped the team to establish several aspects that needed further development, such as a need for a larger quantitative data set to be able to finalise the quantitative analysis as well as a need for additional cases to find patterns between cases. The team also realised the need for discussing the qualitative data in relation to findings and interpretations from similar qualitative research.

Fourth, we have noticed that successful integration requires a common understanding of what integration means in the team and where in the research process integration should take place. For the FIT project, integration involved a comprehensive understanding of sport injury aetiology in stage 1 [ 39 ], the collation of qualitative and quantitative data in one common space in stage 2 (the multilevel data catalogue), and an integrated discussion in stage 3 which together facilitated our interdisciplinary understanding of sport injury aetiology. There are, however, differences in degrees of integration [ 45 ]. Sometimes, for example, integration of knowledge and the collaborative process includes actors outside of academia and can lead to the creation of a new framework, which can generate a fundamental epistemological shift [ 36 , 43 ]. Being clear in the beginning of a project on what, when, and how to integrate is key for sucessful collaboration across disciplinary boarders.

Finally, some methodological limitations need to be considered before conducting an integrated analysis procedure such as the ICAP. First, the ICAP is a complex procedure to carry out and requires more time, resources, and expertise than traditional analysis procedures. Second, there is a lack of research on the integration of qualitative and quantitative data in the interdisciplinary research context, and more research is needed on the integrated potential of such an approach and process. Finally, in the interest of better understanding the complexity of sport injury aetiology, there is a need to explore the pragmatic negotiations that an interdisciplinary research team needs to make when integrating seemingly opposing worldviews, methods, and data.

The purpose of this paper was to draw on an interdisciplinary research approach to (1) outline an interdisciplinary case analysis procedure (ICAP); and (2) provide an example for future interdisciplinary sport injury research. The Interdisciplinary Case Analysis Procedure (ICAP) consists of a three-stage process that allowed us to create a more comprehensive understanding of sport injury aetiology, collate qualitative and quantitative data in a multilevel data catalogue and engage in an integrated discussion to identify patterns in the empirical data. Working interdisciplinarity is not business as usual and requires researchers to adopt certain cognitive skills that might be outside of their disciplinary comfort-zone. Creativity, flexibility, and openness are key such skills.

While we have developed the ICAP specifically for an interdisciplinary youth sport injury research project, the procedure is generic and can be applied in interdisciplinary research addressing other complex phenomena. For researchers who aim to adopt (and adapt) the ICAP, it is important to keep in mind that the procedure is not “just” about mixing or integrating qualitative and quantitative data, it includes strategies to integrate disciplinary knowledge and consider onto-epistemological differences throughout the whole research process. In so doing, the ICAP is a step towards overcoming the obstacles of integrating qualitative and quantitative methods and data that scholars have identified. It is our hope that sport science and other researchers will consider and apply ICAP in the interest of better understanding the complexities of a phenomenon under study.

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

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Hausken-Sutter, S., Boije af Gennäs, K., Schubring, A. et al. Interdisciplinary sport injury research and the integration of qualitative and quantitative data. BMC Med Res Methodol 23 , 110 (2023). https://doi.org/10.1186/s12874-023-01929-1

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A Research and Clinical Framework for Understanding Achilles Injury in Female Collegiate Gymnasts

Fryar, Caroline MD; Tilley, Dave DPT; Casey, Ellen MD; Vincent, Heather PhD, FACSM

1 Department of Physical Medicine and Rehabilitation, University of Florida College of Medicine, Gainesville, FL

2 Champion Physical Therapy & Performance, Watham, MA

3 Department of Physiatry, Hospital for Special Surgery, New York, NY

4 University of Florida College of Medicine, UF Physical Medicine & Rehabilitation

Address for correspondence : Caroline Fryar, MD, University of Florida College of Medicine, Department of Physical Medicine and Rehabilitation, Gainesville, FL 32611; E-mail: [email protected] .

Gymnastics is a popular sport with a high injury rate, particularly at the collegiate level. Achilles tendon rupture is a catastrophic injury with career-changing impact. Over the last decade, there has been a growing incidence of Achilles tendon ruptures, especially in female gymnasts. Currently, neither the effects of contributing risk factors on Achilles tendon rupture nor the research frameworks to guide future intervention strategies have been well described. This article reviews the functional anatomy and mechanical properties of the Achilles tendon, provides precollegiate and collegiate intrinsic and extrinsic risk factors for Achilles tendon rupture, and proposes a research framework to address this injury from a systemic perspective. Potential clinical interventions to mitigate Achilles tendon injury are proposed based on currently available peer-reviewed evidence.

Proposed risk factors include personal training history, cultural expectations regarding training type and volume, and environmental factors such as takeoff and landing surfaces. Future research should focus on identifying risk factors and implementing changes early in a gymnast’s career.

An error was reported in the author byline of “A Research and Clinical Framework for Understanding Achilles Injury in Female Collegiate Gymnasts.” The corrected author list should read:

Caroline Fryar, MD; Dave Tilley, DPT; Ellen Casey, MD; and Heather K. Vincent, PhD, FACSM

Current Sports Medicine Reports. 22(9):340, September 2023.

Introduction

Gymnastics is a sport with one of the highest injury rates in the National Collegiate Athletic Association (NCAA) ( 1 ). Unique biomechanical stresses, extreme joint ranges of motion required, and early sport specialization may be among the important contributors to injury ( 2 ). Female gymnasts tend to suffer more lower extremity injuries than their male counterparts and have the highest rate of severe Achilles-related injuries of all collegiate athletes ( 3,4 ). Achilles tendon (AT) rupture is a devastating injury that may stop training and competition for up to a year and may impair long-term performance with explosive plantarflexion demand, even after surgical repair ( 4,5 ). The state of the evidence of individual and interrelated effects of contributing risk factors on AT rupture has not yet been well-coalesced, or organized as a framework from which research, practice guidelines for injury prevention, and interventional strategies may be developed. This paper aims to provide a conceptual research and clinical framework based on available evidence to help inform multidisciplinary efforts to combat AT injury in women’s gymnastics.

Injury Prevalence and Mechanisms of Injury

Achilles injury prevalence.

Current data regarding prevalence of injury in female collegiate gymnasts is based on cross-sectional epidemiological studies, the NCAA Injury Surveillance Program (ISP), and anecdotal reports. Using NCAA-ISP data, the total rate of AT injuries in female college gymnasts was 16.73 per 1000 athlete exposures (AE); men’s and women’s basketball were the sports with the second and third highest total AT injury rates of 4.26 and 3.32 per 1000 AE, respectively ( 4 ). While NCAA-ISP data did not distinguish between injury types (tendinopathy vs partial vs complete tear), a “severe injury” group was created based on time lost from sport and operative rate that was considered a proxy for athletes suffering a rupture. Women’s gymnastics had the highest rate of severe injuries (defined as in-season/career-ending, injuries with >30-d time loss, or operative injuries), with 7.87 per 1000 AE. Another cross-sectional study of Division I to III of female gymnasts (N = 581) reported an overall incidence rate of 17.2% ( 5 ). While minimal up-to-date peer-reviewed evidence is available across all NCAA divisions, less formal tracking of Achilles tendon ruptures in college gymnastics through publicly available web sites like www.collegegymnews.com demonstrate consistently high numbers of AT ruptures per season with 20 and 16 reported in the 2020 and 2022 seasons respectively ( 6 ). Thus far, in the 2023 season 112 injuries have been reported, including 15 Achilles tears (13.4%) ( 6 ). These data are limited by their reliance on social media posts from both athletes and official accounts and may not fully capture the number of ruptures in a given season.

Healthy Tendon Structure and Function

The AT is the strongest, largest, and thickest tendon in the human body ( 7 ) and primarily functions to plantar flex the foot via the gastrocnemius and soleus ( 7–9 ). This AT complex also is an important stabilizer of the foot ( 8 ). The tendon has a large, crescent-shaped insertional footprint at the posterior calcaneus, which helps dissipate stress. Tendon fibers spiral 90° upon approach to the insertion with lateral fibers inserting medially and medial fibers inserting laterally ( 8,9 ). While this spiral may decrease fiber buckling during deformation, it also is thought to create a potential stress riser in the midportion of the tendon ( 9 ). The midportion of the tendon is further weakened by its blood flow; the posterior tibial artery supplies the proximal and distal portions of the tendon while the midportion is supplied by the smaller peroneal artery, creating a watershed area.

The tendon can withstand loads of 12 times the body weight during running and tolerate loads of 15 times body weight during tumbling ( 10–12 ). This is in part due to the parallel and in-series arrangement of collagen fibers, which allows for high tensile strength and the capacity to store and dissipate stress ( 8–10 ). The ability of the AT to stretch is another important function. Stretching of 4% in length is the approximate physiologic limit. Microscopic fibril failure begins at 6% to 8%, and macroscopic failure begins at 8% ( Fig. 1 ) ( 8 ). Elongation, coupled with other factors such as high eccentric plantarflexion force, mechanical position at landing, and landing surface may excessively strain the tendon — particularly if stiffness has not adapted sufficiently to appropriately dissipate stress ( 13 ). Younger gymnasts may begin accruing undetected tendon damage early in their careers. In one study of preadolescent gymnasts training 20 h·wk −1 over a 6-d period for 6 months, participants were found to perform squat jumps with 25% higher plantarflexion moments. These gymnasts were twice as likely to reach the 8.5% tendon strain level compared with nongymnast controls, with no differences in AT stiffness ( 14 ). Additional research in developing athletes, including prospective study design, would add essential understanding of pathology development.

Adaptation and Transition to Tendon Injury

Up to 95% of the AT tendon is composed of type 1 collagen with small amounts of type 3 collagen, elastin, and fibroblasts ( 8 ). When the tendon is repetitively stressed beyond its ability to repair, changes at the genetic and cellular level lead to tendinopathy ( 15 ). Compared with healthy tendons, tenocytes from damaged tendons show differential expression of genes related to collagen production and extracellular matrix remodeling, and changes in cellular morphology. For example, tendinopathic ATs have been found to produce more type 3 collagen, which is less resistant to tensile forces ( 7 ). In addition to weakening the tendon, these collective cellular changes contribute to tendon thickening, which may negatively impact its ability to glide through the paratenon, which has been proposed as a possible risk factor for acute AT rupture ( 7 ).

Ultrasound imaging can detect changes in the AT; however, the relationship between AT symptomology and ultrasound abnormalities is not yet clear ( 16 ). Even while asymptomatic, elite gymnasts have greater longitudinal thickness at the mid-AT and calcaneal junction ( 16,17 ) and greater prevalence of ultrasound abnormalities, including focal tendon thickening, hypoechoic areas, neovascularization, and paratenon blurring compared with nongymnast controls ( 16 ). Hypoechogenicity may be related to tendinopathy as it represents a disruption and separation of collagen fibers within the tendon and chaotic attempts at self-healing ( 7,9 ). The predictive role of neovascularization and the presence of inflammatory cells in tendinopathic tendons on future tendon rupture are still being investigated ( 7,18 ).

In other athletes, 45% of asymptomatic tendons with ultrasound abnormalities progressed to symptomatic tendinopathy ( 17 ). Compared with rhythmic gymnasts (who use clubs, ribbons, balls, hoops and streamers with limited tumbling movements), artistic gymnasts (who perform more explosive aerial skills at greater heights with higher landing forces) demonstrate higher neovascularization values ( 17 ). In other nongymnast athletes with acute AT rupture, neovascularization on ultrasound was present in the contralateral uninjured AT ( 18 ). More research is needed to determine if changes seen on ultrasound are occurring in truly asymptomatic tendons or are indicators of presymptomatic changes, especially in younger, developing gymnasts. An important advancement in this area will be to determine how both microscopic and macroscopic changes in the AT relate to the training load, muscle strength changes and symptom onset over time, as well as risk for future rupture.

Gymnastics-Specific Biomechanics

Landings with optimal biomechanics can help dissipate ground reaction forces appropriately along the kinetic chain ( 12 ). However, the sport of gymnastics has historically promoted suboptimal landing strategies for aesthetic reasons, leading to biomechanically appropriate landings receiving deductions ( Fig. 2 ). Intentionally training skills to land with mechanics linked to lower limb injury to limit deductions ultimately requires forces to be absorbed by passive structures. Gymnasts who consistently land short (with excessive, forced dorsiflexion) will sustain increased stretch-loading stimulus at the AT and may accelerate tendon breakdown ( 19,20 ). Slater et al. ( 20 ) found that greater hip flexion, knee flexion, and ankle flexion range of motion during landing from back somersaults and drop landings had smaller peak ground reaction forces (GRF) and rate of GRF development in artistic gymnasts. These authors encouraged a revisiting of judging criteria of lower limb positions to promote safer landings ( 20 ).

Gymnastics is one of the few, if not only, sports requiring athletes to land on their feet, onto solid ground, from heights of three meters or more across various landing surfaces ( 21 ). GRFs during tumbling are estimated to range from 9 to 17 times body weight, with GRFs of 1800 N during basic tumbling skills ( 12,22 ). Over a 2-wk period of 46 practice hours a gymnast may perform up to 900 landings ( 23 ), and increased load from suboptimal landing mechanics may promote tendon injury. Anecdotal observations of landing positions using high-speed filming have shown that gymnasts commonly make asymmetric foot contact, which results in one limb momentarily absorbing the entire GRF instead of adequate distribution. In addition, repetitive eccentric loading on the gastrosoleus and AT complex occurs during the landing phase of a back-handspring as the gymnast transfers their horizontal trajectory into a vertical one for their primary tumbling skill. Eccentric contractions have been established as a risk factor in tendon rupture, and the high volume of eccentric loading through a gymnast's Achilles likely is a contributor to Bonanno's findings that 91% of AT ruptures in female gymnasts occur during floor exercise, the majority of which happen during back-tumbling takeoffs ( 5,24 ).

A healthy tendon is normally able to withstand high physiologic forces, including those produced during high-level gymnastics ( 25 ). Therefore, the relatively high rate of AT rupture in collegiate gymnasts likely involves underlying tendon pathology not yet identified and/or a combination of nonmodifiable and modifiable risk factors. These proposed risk factors are presented in Table 1 .

Potential Risk Factors for AT Tendon Ruptures in Women's Gymnastics

Determination of personal and training factors is necessary to identify athletes at higher injury risk and to develop future research agendas to establish safe guidelines. While many of the risk factors are relevant in male and female collegiate gymnasts, female gymnasts have a much higher rate of AT rupture than males, and acknowledgment of differences in biology, timing of sport specialization, and number of lower-versus upper-body dominant events is important in risk identification.

Personal Risk Factors

Several features increase the overall risk of injury in collegiate gymnastics including older age, increased height and weight, higher competitive level, competition environment, and longer training duration ( 5,26 ). Precollegiate elite competition and performance of difficult vault and floor skills at a young age increased AT rupture risk ( 5 ). Identifying as African-American was related to heightened rates of AT rupture, especially during the collegiate experience ( 5 ). Aggressive training during and around puberty and peak growth velocity is a well-established injury risk in many sports ( 27,28 ). Relatively smaller injuries, such as Sever's disease, ankle sprains, and stress fractures may modify motion patterns. If smaller injuries are not rehabilitated properly alterations in mechanics may persist, leading to increased loading and potentially greater injury risk through the AT long term ( 29 ). In addition, inflammatory responses around periods of growth may chronically damage the AT ( 29 ). Lifetime use of retinoids also was related with higher rates of rupture, possibly because of its contribution in tendon elastic properties and onset of tendinopathy ( 5 ). Medications that are commonly used, such as nonsteroidal anti-inflammatory drugs (NSAIDs), could potentially impact acute and chronic inflammatory processes, including tendon healing ( 30,31 ). Medical conditions, such as relative energy deficiency syndrome, polycystic ovary syndrome, and related menstrual dysregulation conditions that negatively impact estrogen levels could alter normal tendon recovery and predispose an athlete to increased tendon damage throughout their career ( 28 ). It also is possible that changes in endogenous estradiol and progesterone across the menstrual cycle, as well as exogenous ethynil estradiol and progestin, might influence risk of tendon injury, as has been observed in anterior cruciate ligament injury ( 32 ).

For collegiate gymnasts, other factors like change of BMI throughout their career, when coupled with physical function features, such as plantar flexor strength, endurance and power, ankle flexibility, and foot type may influence the magnitude and rate of force development in the AT. As such, higher BMI may increase risk for tendon rupture. Plantar flexion is arguably one of the most important motions in gymnastics, as the sport requires high volumes of weight-bearing dorsiplantar flexion motions at ranges that most other athletes are unable to achieve ( 29 ). If active and passive dorsiflexion strength is mismatched with high plantarflexion strength, the resultant strength imbalance about the ankle may increase AT strain during landings, especially those involving underrotation and greater dorsiflexion. Pes planus is relatively common in gymnasts and itself produces excessive pronation, which elevates risk of overuse injury in the AT ( 33–36 ). The downstream mechanical impact is compounded by ligamentous laxity at the ankle that develops after multiple ankle sprains, which are the most common injury among gymnasts older than 10 years ( 37,38 ).

Training Risk Factors

Training history-related factors include age of sport specialization, training volume and frequency, and exposure to varied floor tumbling surfaces ( 5 ). It is well established that early sport specialization increases an athlete's injury risk throughout their career, with multiple consensus statements and recommendations available for high level training of young children ( 39–42 ). Gymnasts specialize in their sport earlier than almost any other athlete with a median age of 8 years, and athletes who advance to the NCAA have commonly practiced upwards of 20 h·wk −1 prior to puberty ( 2,5 ). Prior to college, competition season can last up to 7 months if an athlete qualifies to the available postseason competitions. At this level, there is no cultural expectation to decrease training hours after competition season ends in the late spring, even for a short 2-wk period. Training hours typically increase in the summer as athletes focus on strength training and new skill development. Preparation of routines for the next competition season usually starts in the fall with some continued skill development, and in late fall or early winter competitions are starting again. Logistically, this year-round training cycle forces gymnasts into early specialization, and there is no true off-season in gymnastics that could allow participation in other sports to develop alternative dynamic strength and tissue-loading patterns. One recent study found no differences in injuries sustained while competing in college between gymnasts who specialized before age 14 years and those who specialized later. However, a greater proportion of the early specializer group sustained injuries that required surgery during their college career, possibly indicating that these athletes sustained more severe injuries ( 2 ). While there is a strong body of research regarding early sport specialization, more information is needed specific to gymnastics.

Current recommendations for youth sports suggest weekly practice hours should not exceed the athlete's age in years due to increased injury risk ( 43,44 ). Despite these evidence-based recommendations, many precollegiate gymnasts practice upwards of 20 h·wk −1 ( 5 ). While lack of knowledge regarding these guidelines may be a contributing factor, coaches who are aware may feel that additional practice hours beyond age recommendations are necessary to gain a competitive advantage, without recognizing the importance of varying training load patterns in prevention of gradual-onset injuries ( 43 ). In addition, a club team prior to college may have athletes of varying ages competing at the same level. Practice groups and training plans are typically arranged for the whole group based on skill and competition level, despite having athletes with varying ages, growth status, social, and emotional development. Logistical challenges, including equipment and facility availability also may limit a coach’s ability to create training plans that are specific to both an athlete’s development and skill level. This could lead to a situation where a younger, prepubescent athlete is training the same high-level skill as their postpubertal teammate, whose tissues have had time to adapt to the high forces seen during these skills. This situation may contribute to Bonanno et al.'s ( 5 ) findings that college gymnasts who suffered AT rupture were more likely to have trained higher level tumbling skills at a younger age. This was the first study we are aware of that associates high level tumbling skill development with an athlete's age, and more research is needed on developmentally appropriate methods of training the high-level tumbling skills required at the collegiate level.

Environmental Factors

Floor surfaces have different mechanical properties that allow gymnasts to focus on different aspects of the skill, such as the takeoff or the aerial portion, while limiting the number of hard surface landings. Landing mat properties such as stiffness, dampness and friction coefficients significantly affect internal loads at the ankle; when mat stiffness or dampness increases by 30%, ankle loading rates increase by 26%, and ankle muscles would need to dissipate more energy with increased mat friction ( 45 ). Modeling studies predict reductions with vertical and horizontal ground reaction forces after landing with 272% increase in mat dampening ( 46 ). While softer impacts may reduce landing forces while learning a skill, an unintended consequence could be more exposure to exaggerated dorsiflexion if the skill is underrotated and variability in ankle stabilization after foot placement. As training volume increases, coaches and athletes may choose to place 1-inch thick soft mats in the takeoff area for a skill to help dampen repetitive forces on the lower limb. While the initial takeoff force may be dampened, an athlete with preexisting proximal kinetic chain weakness could theoretically create higher forces through the AT as they stabilize the foot in suboptimal patterns. Imperfect landing mechanics coupled with soft surfaces also may transfer high ground reaction force stresses suboptimally through the AT. The surface under the floor (concrete, court, or podium), brand and type of floor surface, and use of alternative equipment all likely contribute to the cumulative loading on the tendon and systematic study of these effects on AT stress could significantly advance this area.

Additional Training Exposure

While overtraining is associated with injury, undertraining also can amplify injury risk ( 47 ). Slow, safe progression to a high training load devoid of large spikes in training load may best prepare the gymnast for physical demands of a long competitive season ( 48 ). While many NCAA teams work with strength and conditioning coaches for formalized weight-lifting programs, calisthenics are typically emphasized instead of weight training prior to college. While calisthenic exercises are valuable in the context of sport-specific movements, the amount of loading understimulates the musculoskeletal system relative to actual loads experienced during tumbling and landings. Strength training may be a realistic and controlled way to load tissues to 17 times body weight and promote connective tissue, muscle, and bony adaptations ( 48 ). Early focus on neuromotor control and execution, followed by gradual development of heavier loads as an athlete grows is prudent. Despite evidence that strength training benefits youth athletes there is resistance within the gymnastics community to implement for fear of developing “bulkiness” and that altered strength-to-weight ratios can impair aerial mechanics of a skill ( 48 ). Fear of losing flexibility also is common, even though building strength through full range of motion is widely accepted as one of the best ways to maintain mobility ( 48–51 ). Fears also may exist that strength training causes injury, despite research that shows it can be an effective component of injury prevention programs for youth athletes ( 50 ).

Potential Risk Factor Intersections

We fully acknowledge that some risk factors may intersect with others and may not be uniquely independent. For example, a college freshman who recently had a change in BMI associated with growth and improved energy availability after meeting with their team’s dietician, who has a preexisting plantar-dorsiflexor strength mismatch, and recently increased their training volume of high-level tumbling skills may rapidly increase mechanical loading to the Achilles tendon over a period of months, predisposing a previously healthy tendon to asymptomatic damage and increased rupture risk. Alternatively, a highly skilled prepubescent athlete who introduced high-level tumbling skills at a young age who is training with older teammates at a similar volume with history of multiple ankle sprains also may have a heightened risk of Achilles rupture. Alternatively, this same athlete may have adequate capacity to repair microdamage to the Achilles tendon until starting retinoids as a treatment for acne when they begin puberty. Identifying the significance of individual risk factors along with their timing related to puberty and development of high-level tumbling skills may provide significant insight to the high rate of Achilles tendon ruptures in female college gymnasts.

Setting a Research Agenda

There are significant gaps in available literature surrounding AT injuries in gymnasts and the factors that contribute to the injury. In Table 2 , we propose a research framework systematically determines: 1) which personal, training, and environmental processes are needed to limit tendon damage early in an athlete’s career, 2) which athletes are at higher risk prior to symptom development, 3) which management strategies and rehabilitation protocols optimize tissue healing once damage has been identified. To address these points, research efforts also should include development of methods to monitor and manage workload across the age spectrum, methods to quantify cumulative mechanical loading, and identify load pattern differences by skill level and interaction with equipment and flooring. Ideally, these studies should be prospective in nature; however, we acknowledge difficulties in this study design, including a relatively small number of athletes compared with other sports that could make sufficiently powered studies difficult, loss to follow up, and that information on early career risks for future tendon damage involves collecting data on minors. Use of remote monitoring methods, body-worn biomechanical sensors, easy-to-use hand-held ultrasound imaging and careful documentation of physiological changes of the athlete would provide insight to address the points above. Success of this agenda is dependent on participation from all stakeholders, including the athlete, parents, coaches, athletic trainers, and other medical providers. Finally, large scale analysis of risk factors and their intersection across the age spectrum can help produce predictive algorithms that identify specific athlete profiles most prone to Achilles rupture and windows of time to detect the beginning of damage accumulation.

What Strategies Could Be Promising for Injury Prevention

Given the significant knowledge gaps that currently exist regarding AT injuries in gymnasts, significant change in injury rates may take many years. Even once risk factors are properly identified, there will likely be a delay in improvement in injury rate as coaches adopt new training methods and young athletes are given a chance to properly train their entire pre-NCAA career. This process can be more than 10 years. In the meantime, we suggest the following approaches:

• Lower-extremity soft-tissue prehabilitation, focusing on dynamic stability of the ankle and hip, and active + passive dorsiflexion of the ankle ( 49 ).
• Continued advocacy for the Code of Points to reward, not deduct, biomechanically appropriate landing.
• A yearly period of rest from gymnastics after the competitive season with a slow increase in volume and intensity prior to collegiate competition.
• Monitoring impact loads per session, including type of surface and height from which routines, takeoffs, and landings are performed ( 34 )

The Achilles tendon is one of the strongest tendons in the human body. However, long-term damage and poor healing can predispose an athlete to acute rupture. NCAA level gymnasts may be at increased risk due to a variety of personal and sport-specific factors, ranging from training volume around puberty to equipment variations. Future research should identify early risk factors to limit cumulative damage throughout a gymnast’s career, optimize the unique biomechanical demands of the sport, and develop training approaches to minimize overuse, improve tissue durability, and dynamic movement control.

The authors declare no conflict of interest and do not have any financial disclosures.

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Catastrophic injuries are defined as: fatalities, injuries that result in permanent functional disability, and serious injuries that result in temporary functional disability with full recovery. Examples include spinal cord injuries, brain bleeds, skull fractures, heat stroke, sudden cardiac arrest, internal organ injuries, exertional sickling, rhabdomyolysis, and commotio cordis. We monitor sudden cardiac arrest/death in athletes even if not directly related to athletics.

We monitor all of the above events at all level of any sport or physical activity.  However, our primary focus is middle school, high school, collegiate, and professional athletes.

For more information on what qualifies as a catastrophic sport injury, please see   NCCSIR Eligible Events Definition. 

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How the Olympics Break Athletes’ Bodies

With years of fractures, surgeries, hardware and pain, Olympians can list their injuries as readily as their achievements.

Mariana Pajón, a Colombian BMX rider, showing a scar from among her many surgeries. Credit... Federico Rios for The New York Times

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By James Wagner

Reporting from Mexico City and Paris

• Aug. 1, 2024

Mariana Pajón is one of the world’s most accomplished BMX riders, and she can quickly recount some of her career totals: 18 world championships, two Olympic gold medals in racing (in 2012 and 2016) and one silver, in Tokyo in 2021.

But Pajón, a Colombian, can also rattle off the much more painful totals of the cost of so much riding: 25 fractures, 12 screws, eight surgeries and countless tears of ligaments and tendons. The medical hardware in her left arm and knee included so much metal that she used to travel with her X-rays. Opening a door or serving a glass of water hurts.

“My joints are of an 80-plus-year-old,” Pajón said with a laugh. She is 32.

Pajón, who has been racing competitively since she was 4, wasn’t lamenting her injuries during a recent conversation. They are simply a fact of life for an athlete.

Wear and tear naturally degrades human bodies, even the most talented ones. But performing at the elite level, especially in high-impact Olympic sports such as wrestling, rugby or gymnastics, inherently has more risks. Shoulders give out. Ligaments tear. And, for some, metal screws and titanium plates become just more hardware in the lifelong pursuit of gold, silver and bronze.

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The Impact of Daylight Exposure on Injured Athletes: Implications for Rehabilitation

• Marc Niering Nordic Science Institute of Biomechanics and Neurosciences, Hannover, Germany
• Johanna Seifert Hannover Medical School, Hannover, Germany

During injury rehabilitation and return to competition, various factors impact outcomes, such as psychological parameters, sleep quality, and vitamin D levels. Studies have demonstrated that both natural and artificial daytime lighting can enhance these variables, as well as human health and performance. However, research into therapeutic methods is predominantly restricted to physical or psychological interventions that are costly and time-consuming, rather than integrated solutions. Research on the impact of daylight on injury rehabilitation among athletes is limited. Objective evaluation is necessary to establish effective recovery protocols, providing the rationale for this review. Therefore, this study analyzes existing research and theoretical explanations regarding the effects of daylight on athletes in the rehabilitation process. The results suggest that the underlying mechanism can be organized into sun-induced vitamin D synthesis, cognitive-behavioral processes, the circadian mechanism, and the visual processing of light stimuli. For practical implementation, we propose a cost-effective and time-saving artificial daylight intervention that can serve as an accompanying therapy for injuries. This intervention could be integrated into therapy facilities and sports clubs, for both competitive and recreational sports.

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• Why psychological factors are still being sidelined in sport-related concussion treatment and what we can do about it
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• http://orcid.org/0000-0001-9417-739X Kate N Jochimsen 1 , 2 ,
• Jeffrey G Caron 3 , 4 ,
• Ana-Maria Vranceanu 1 , 2 ,
• Jonathan Greenberg 1 , 2
• 1 Center for Health Outcomes and Interdisciplinary Research , Massachusetts General Hospital , Boston , Massachusetts , USA
• 2 Department of Psychiatry , Harvard Medical School , Boston , Massachusetts , USA
• 3 School of Kinesiology and Physical Activity Sciences , Université de Montréal , Montréal , Quebec , Canada
• 4 Center for Interdisciplinary Research in Rehabilitation of Greater Montréal , Montréal , Quebec , Canada
• Correspondence to Dr Kate N Jochimsen; kjochimsen{at}mgh.harvard.edu

https://doi.org/10.1136/bjsports-2024-108090

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• Rehabilitation
• Brain Concussion

Growing research supports the central role of psychological factors, including anxiety and depression, in recovery from sport-related concussion (SRC). 1 Indeed, mental health is among the most robust predictors of concussion outcomes, including SRC. 1 This is reflected in the recent Consensus Statement on Concussion in Sport, 2 which explicitly recommends consideration of anxiety, depression and psychological response to injury in assessment and treatment, including referrals for psychological evaluation as needed.

However, these recommendations often fail to trickle down to clinical practice. Psychological factors remain under-addressed, 3 and programmes specifically addressing psychological factors after SRC (eg, dealing with anxiety, teaching coping skills) remain scarce. In this commentary, we identify four challenges impeding the integration of psychological care into the treatment of SRC, and we propose strategies to ‘tackle’ these challenges.

Challenge 1: the importance of assessing psychological needs following SRC

Despite considerable support for a biopsychosocial approach in SRC assessment and treatment as well as recommendations to monitor and address anxiety and depression symptoms in concussion treatment guidelines (eg, Ontario Living Concussion Guidelines), 4 the majority of SRC measures neither require robust psychological health screening nor typically include metrics to assess coping skills. The most highly recommended screening and assessment tools, including the most recent Consensus Statement on Concussion in Sport, the Sport Concussion Assessment Tool 6, the Sport Concussion Office Assessment Tool (SCOAT6), Post-Concussion Symptom Scale and the Rivermead Post Concussion Symptoms Questionnaire, are limited to a gross and non-specific assessment of psychological factors. 2 5–8 The recently released SCOAT6 covers more psychological factors than previous measures, yet these are classified as ‘optional’. Despite acknowledging psychological factors, these tools and recommendations remain discordant with the mounting evidence supporting the importance and prognostic value of psychological factors in recovery from SRC. 1 9 This likely results in under-identifying emotional and psychological needs important …

X @katejoch

Contributors KNJ led the conceptional design, prepared the manuscript and critically reviewed the manuscript. JG assisted with the conceptional design, manuscript preparation and critically reviewed the manuscript. JC and A-MV assisted with manuscript preparation and critically reviewed the manuscript. All authors are the guarantors, accepting full responsibility for the finished work and approving the final manuscript.

Funding This study was supported by National Center for Complementary and Integrative Health (K23AT01065301A1, K23AT01192201A1).

Competing interests KNJ and JG report funding from the NCCIH (K23AT01192201A1 and K23AT01065301A1) and JC reports funding from the Social Sciences and Humanities Research Council of Canada, Canadian Institutes of Health Research and Fonds de recherche du Québec – Société et culture and royalties/licences from Routledge.

Provenance and peer review Not commissioned; externally peer reviewed.

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Sports Injuries: Diagnosis, Treatment, and Steps to Take

• Overview, Symptoms, & Causes
• Diagnosis, Treatment, & Steps to Take

Diagnosis of Sports Injuries

To diagnose your sports injury, your doctor will likely:

• Ask about the injury and how it happened.
• Ask about any recreational or occupational activities you do and if you recently changed the intensity level of these activities.
• Examine the injured area.
• Order imaging tests such as x-ray or magnetic resonance imaging (MRI) scans to evaluate the bones and soft tissues.

Treatment of Sports Injuries

You should not try to “work through” the pain of an injury, regardless of whether it is an acute or overuse injury. When you have pain from a particular movement or activity, you should stop right away.Continuing the activity may cause further harm.

The goals of treatment for a sports injury are recovery of the injured part of the body and prevention of future injuries.

Treatment for Serious Injuries

You should see a health care provider if you have symptoms of a serious injury. These symptoms include:

• Severe pain, swelling, or bruising.
• Pain and swelling that do not go away after a few days.
• Being unable to tolerate any weight on the area.
• An obvious deformity.

Treatment for serious injuries may include:

• Slings, to immobilize the upper body, including the arms and shoulders.
• Splints, braces, and casts, to support and protect injured bones and soft tissue. Splints and braces generally offer less support and protection than a cast, so they are not always a treatment option.
• Surgery. Surgery is needed in some cases to repair torn connective tissues or to realign fractured bones. The vast majority of musculoskeletal sports injuries do not require surgery.

Treatment of Minor Injuries

If you do not have any symptoms of a serious injury, it is probably safe to treat the injury at home—at least at first. If pain or other symptoms persist or worsen, you should check with a health care provider. Use the R-I-C-E method to relieve pain and inflammation and to speed healing:

• Rest.  Limit activities that involve using the injured area for at least a day or two. Try to avoid putting weight on or using the injured joint or limb.
• Ice.  Apply an ice pack to the injured area for 20 minutes at a time, four to eight times a day. Use a cold pack, ice bag, or plastic bag filled with crushed ice and wrapped in a towel. To avoid cold injury and frostbite, do not apply the ice for more than 20 minutes. (Note: Do not use heat immediately after an injury. This tends to increase internal bleeding or swelling. Heat can be used later to relieve muscle tension and promote relaxation.)
• Compression.  Keeping pressure on the injured area may help reduce swelling. An elastic bandage works well, but do not wrap it so tightly that it cuts off the circulation.
• Elevation.  If possible, keep the injured ankle, knee, elbow, or wrist elevated on a pillow, above the level of the heart, to help decrease swelling.

Other treatments may include over-the-counter anti-inflammatory and, rarely, medications, which can help treat pain and swelling.

Rehabilitation

After the injury has healed, you may need to complete a rehabilitation program before returning to the activity that caused the injury. A physical therapist or physiatrist will make a plan aimed at rebuilding strength and range of motion of the injured part of the body, and easing any residual pain. Most rehabilitation plans include exercises that you do at home, in addition to those you do in the therapist’s office. The therapist may also treat the injured area with cold, heat, ultrasound, aquatic, or massage therapy. A rehabilitation program can help you return to your previous level of activity and reduce the chance of reinjury.

Who Treats Sports Injuries?

Sports injuries are usually initially seen and treated by:

• Emergency physicians, who care for patients in emergency rooms (for serious injuries).
• Primary health care providers, including family doctors, internists, and pediatricians, who treat problems as they arise and coordinate care between the different specialized health care providers (for non-serious injuries). Many of these individuals may have obtained additional specialty training in the nonsurgical management of sports injuries.

You may also see:

• Orthopaedic surgeons, doctors who specialize in diagnosing and treating injuries to bones, joints, ligaments, tendons, muscles, and nerves.
• Pain management specialists, physicians who are trained in the evaluation and treatment of pain.
• Physiatrists, doctors who specialize in nonsurgical management of musculoskeletal conditions and can develop a plan of care, including rehabilitation.
• Develop a rehabilitation program.
• Strengthen muscles and joints.
• Prevent further injury.
• Sports medicine specialists, specialists who work with athletes and others with musculoskeletal injuries.

Living With Sports Injuries

Most sports injuries respond well to treatment and rehabilitation, enabling you to return to normal activities. But if pain persists, seek help. Your primary health care provider can manage most injury-related problems and he or she may refer you to an orthopaedic surgeon, a sports medicine specialist, or a pain management specialist.

Once an injury heals, it is important to continue some type of regular exercise.

• Take some simple steps to avoid injury, such as choosing an activity appropriate for your fitness level and gradually increasing the intensity, and using the proper equipment and technique.
• Learn how to spot injuries early on, and how to treat the minor ones at home.
• Seek medical care when you need it.

By following these steps, you can gain the health benefits of regular exercise while lowering the chance of a serious injury.

Learn About Research

View/download/order publications, news related to this health topic, fewer hip fractures may be associated with reductions in smoking, heavy drinking.

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What's the most dangerous sport in the world?

It's hard to compare sports head-to-head, but some stand out in terms of their risk of causing injury or death.

Sports offer a variety of benefits, from lowering stress and boosting self-esteem to improving heart and bone health. But they can also pose risks.

In extreme cases, elite athletes complete seemingly death-defying stunts at major sporting events, such as the Olympics. But which sports are the most dangerous to participants? And which pose the highest risk of death?

Which sports cause the most injuries?

These are tricky questions to answer because sports aren't always studied in the same way, making them difficult to compare. Let's start by looking at nonfatal-injury statistics.

In the U.S., the sports and recreational activities most frequently associated with injuries are "exercise," cycling and basketball, according to the National Safety Council . These statistics come from injuries that resulted in emergency department visits in 2023. Here, exercise isn't defined, but there's no separate category for running and the category covers injuries related to exercise equipment, so it appears to be broad.

Related: Extreme workouts: The nutritional needs of elite athletes

American football comes in fourth on the National Safety Council's list, behind basketball. That said, football produces the most injuries of any sport per 1,000 hours of participation, according to Ohio State University (OSU). Alongside basketball, it's also a strong contender for the most injury-riddled sport.

Football players' risk of concussions and subsequent brain damage has also been highlighted in recent years. Similar attention has fallen on other high-impact, collision sports, such as rugby, in which players routinely collide at all levels of the game.

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Carolyn Emery , a professor and chair of the Sport Injury Prevention Research Centre at the University of Calgary, studies collision sports as part of her work in trying to prevent injuries in Canadian youth sports. "Collision sports are our highest risk for concussion, as well as all injury that leads to time loss," meaning time spent away from sports to heal, she said.

Statistically, there's a higher rate of concussions in girls' sports than in boys' sports, Emery noted. At the youth level in Canada, female rugby produces the highest rate of concussions, followed by ice hockey and football. It's unclear why girls seem to get more concussions than boys, but Emery said she suspects it may be related to both biological factors and the fact that "girls are more likely to report baseline symptoms."

There's a link between sports with a high incidence of head impacts and long-term neurological impairment and neurodegenerative diseases , such as Alzheimer's, according to a 2024 study in the journal Sports Medicine - Open . Such sports include football, rugby and boxing — up to 20% of professional boxers experience a chronic traumatic brain injury. One example is chronic traumatic encephalopathy (CTE), a progressive disease with no available treatment.

It's not just collision sports that pose a risk of head injury. Equestrian sports — such as horse racing, show jumping and polo — are the most common cause of sports-related traumatic brain injury in U.S. adults, according to OSU. A 2024 study in JAMA Network Open also found that horseback riding was the most common cause of sports-related concussion in Europe.

Related: Why is exercise important, according to science?

What's the deadliest sport?

Fatalities in sports are rare, but they seem more likely in activities that pose a risk to an athlete's head and neck.

For instance, a 2021 study documented 320 horse-related fatalities in the U.S. over a decade, or an average of 32 per year. In 2023, PBS News reported that about two jockeys die, and 60 become paralyzed, from horse racing each year.

Boxing is another contender for the world's deadliest sport. A 2010 study found that there are about 10 boxing deaths every year, worldwide. However, the authors noted that this figure is likely higher, due to incomplete record-keeping. A 2011 survey estimated an average of 13 boxing deaths per year, CNN reported . These figures include amateur and professional boxing, but most boxing fatalities occur at the professional level.

The National Center for Catastrophic Sport Injury Research documents football fatalities at all levels of the game with its Annual Survey of Football Injury Research , and in 2023, three people died from traumatic injuries. In addition, there were 10 indirect exertional or medical fatalities, which included sudden cardiac arrests and conditions like heat stroke.

This survey highlights that not all sports-related deaths stem from collisions. Notably, only two athletes — a marathon runner and a cyclist — have ever died during competition at the Olympic Games. In both cases, the deaths were attributed to heat stroke or heat exhaustion, Quartz reported .

The death of a cyclist during competition at the 2016 Paralympics was attributed to cardiac arrest following a crash. Other Olympic athletes, including those competing in luge and downhill skiing , have died during practice sessions held in the lead-up to the games.

Sports and recreational activities that take place in water come with a risk of drowning, even at elite levels. Drowning is a leading cause of death for children in the U.S., where there are an average of 11 fatal drownings per day. And although it's rare, adult athletes can sometimes faint underwater, leading to near-fatalities and the occasional death .

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Studies and reports often present sports fatalities as total numbers across several years or per year rather than rates based on the number of participants. Most figures don't account for the long-term impact of sports with high-impact collisions, which can shorten life spans . Thus, it's challenging to directly compare fatalities in what appear to be the deadliest sports, such as boxing and horse racing.

However, if you also consider animal health, then horse racing is by far the deadliest sport, given that hundreds of horses die or are euthanized due to racing-related illnesses and injuries in the U.S. each year.

Ever wonder why some people build muscle more easily than others or why freckles come out in the sun ? Send us your questions about how the human body works to [email protected] with the subject line "Health Desk Q," and you may see your question answered on the website!

Patrick Pester is a freelance writer and previously a staff writer at Live Science. His background is in wildlife conservation and he has worked with endangered species around the world. Patrick holds a master's degree in international journalism from Cardiff University in the U.K.

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Velocity at what cost? MLB's hardest throwers keep succumbing to Tommy John surgery

From little league to mlb, baseball's never-ending quest for velocity runs parallel to the 'astronomical' frequency of tommy john surgery..

The road to a 100 mph fastball is littered with ruptured ulnar collateral ligaments. And it’s also a significantly dangerous destination upon arrival for Major League Baseball’s top flamethrowers.

So much remains unknown about pitcher health – why some get hurt, while others enjoy decades of incident-free hard throwing – and through countless studies, trials and one 384-page bible on the subject, best practices have emerged but not definitive answers.

Yet it’s hard to ignore a correlation between extremely hard throwers and major elbow injuries. This year’s velocity kings bear the evidence.

Of the top 64 hardest throwers this season based on average fastball velocity calculated by Statcast, 30 – nearly half – have undergone reconstructive Tommy John surgery on their pitching elbows or are expected to undergo the procedure soon, according to USA TODAY Sports research.  

That population is headlined by two pitchers at the bottom of this ultra-velocity club – Los Angeles Angels two-way superstar Shohei Ohtani and Tampa Bay Rays ace Shane McClanahan , who each averaged 96.8 mph with their fastballs this season and recently blew out their UCLs a second time.

McClanahan became the eighth Rays pitcher to undergo Tommy John surgery since 2020 and the third member of their rotation to suffer a season-ending elbow injury, though at 81-52, they retain the second-best record in the American League.

Ohtani is mulling whether to undergo a second procedure - he suffered his first UCL failure in 2018 - and has continued to serve as the Los Angeles Angels’ designated hitter, with hundreds of millions of dollars in free agency at stake this winter.

While Ohtani’s Angels had faded from serious playoff contentions before he walked off the mound in pain Aug. 23, the postseason will be greatly affected by hard throwers shelved by a failed elbow.

Baltimore Orioles closer Felix Bautista, who averaged 99.5 mph on his fastball and struck out 110 in 61 innings, exited Friday’s game one strike away from his 34 th save. The Orioles announced Saturday he has a UCL injury but have not revealed if surgery will be required.

And like McClanahan, two-time Cy Young Award winner Jacob deGrom – who gassed his fastball up to 98.7 mph in this, the first year of a $185 million deal with Texas – underwent his second elbow reconstruction procedure in June.

These high-profile, debilitating injuries, while representing a small sample, have nonetheless mirrored the frustrations of orthopedists and biomechanical experts who have seen reconstructive surgeries rise along with fastball velocity as pitchers young and old are convinced big velo is the overriding factor in getting scouted, signed and paid.

“It’s very frustrating to me and my colleagues,” says Dr. Glenn Fleisig, biomechanics research director at the pioneering American Sports Medicine Institute in Birmingham. “Frankly, the number of Tommy John injuries in minor league and major league baseball continues to rise.

“If you chart the rates of Tommy John injuries compared to the average fastball velocity, it’s scary how the graphs look the same.”  

The average fastball velocity in MLB increased from 90.5 in 2008 to 93.9 in 2022. And from 2016 to 2022, the number of pitches registering 100 mph leaped 72%, from 1,948 to 3,356.

It used to be that pitchers would go as hard as they can as long as they can – as in, innings in a given start. Now, length too often is measured in how long their elbow survives, leaving teams to reap the benefits in the short term but ultimately ponder a phrase more often associated with football.

Next man up.

“It’s astronomical,” Stan Conte, a senior medical director for the Miami Marlins and consultant to MLB, told USA TODAY Sports. “Part of the reason is because the damn surgery works. In MLB, 84% get back to their previous performance. Ninety percent get back to pitching competitively.

“To me, it’s funny guys aren’t afraid of Tommy John surgery. The question is, what’s causing it?”

'To get to the next level, you gotta throw 97-99'

To Conte, a longtime trainer for the Giants and Dodgers who also operates a sports performance clinic in Arizona, it is not purely the quest for velocity. Advances made in weight- and weighted-ball training have cleared a path to an upper-90s fastball that may supplant or enhance the natural ability gifted in a pitcher’s arm.

Certainly, there are safe ways to build velocity, and hundreds of professional pitchers have healthy elbows and mid-90s fastballs to show for it.

Yet the failure of baseball’s most important ligament is a multi-factorial puzzle, with mechanics and fatigue likely the most crucial – and potentially compromised by throwing hard.

A survey Conte conducted of more than 6,000 major- and minor league players in 2012 revealed that 13% of minor league pitchers had undergone Tommy John surgery in either their amateur or pro careers. By 2018, a similar survey revealed that the percentage of minor league pitchers who had Tommy John soared to 19%; 26% of major league pitchers had undergone the reconstructive surgery.

Nowadays, the chase for velocity begins not on a spring training backfield or minor league complex but at a private training facility or college campus, the pitcher likely still in their teens.

That creates a significant variance in quality of instruction compared to the caliber an athlete might enjoy at the game’s highest level.

“Nobody is really teaching good mechanics,” says Conte. “What they’re saying in college is, you want to get to the next level, you gotta throw 97-99. It doesn’t matter if you hit the bull or can’t throw a strike.”

Of our 30 pitchers with reconstructed or compromised UCLs atop the Statcast velocity leaderboard, 16 underwent Tommy John surgery either as amateurs or in Class A or lower professional ball, according to statistical analyst Joe Roegele’s database .

McClanahan, Marlins starter Jesús Luzardo and Rays reliever Pete Fairbanks each had surgery in high school, with Fairbanks going under the knife again in A ball. Trevor Megill, Spencer Strider and Jeff Hoffman had surgery in college, while Fairbanks and 10 others had elbow reconstruction before even surviving the Darwinist world of the low minors.

Just two suffered injuries in AA or AAA ball, with the rest at the major league level.

Load management

Grayson Rodriguez’s locker is just a few stalls down from All-Star closer Bautista in the Baltimore Orioles’ clubhouse, the positioning a cruel reminder of the vagaries of elbow health. The Orioles are bound for the playoffs, but while Rodriguez is pitching his way into the postseason rotation as a rookie, Bautista likely will miss the proceedings.

Even if he avoids surgery, Bautista probably won’t have an onramp to rest and rehab the injury. At 99.5 mph, Bautista threw the sixth-hardest fastball in the majors this year, and in a memorable nine-pitch battle with Houston’s Kyle Tucker that culminated in a grand slam on Aug. 8, Bautista threw six pitches that exceeded 100 mph, topping out at 102.

As a starting pitcher, Rodriguez doesn’t quite live in that rent district; his fastball tops out at 97.4 mph, 40 th on the list but fifth among starters. What makes him special is hitting 98.4 mph on his 93 rd pitch, as he did Monday in the greatest start of his young career, throwing six shutout innings against the Chicago White Sox.

Perhaps more notably, Rodriguez, 23, has survived the crucible of amateur ball and the minor leagues without major injury, an outcome for which he credits his parents – who watched his pitch counts and usage warily as a youth – and the Orioles for handling his workload as a pro.

“I was very fortunate my parents cared a lot about my health when I was younger, and really just being adamant about if I’d thrown too many pitches, or hadn’t had enough rest,” says Rodriguez, who recounts games of long toss with his father on their Texas street, a young Rodriguez envisioning the day he’d someday reach a certain light pole from his driveway.

“This organization does a really good job managing pitcher workloads. I think they really have our health in mind.”

Rodriguez, a true horse at 6-5, 230 pounds, works out with weighted balls to improve velocity, but only in the offseason to avoid further strain during the year. In a sense, Rodriguez represents the potentially modern ideal of a pitcher – one who can throw 100 mph, repeat his mechanics, leverage his natural ability but enhance his velocity.

And hold it for 100 pitches.

Veteran pitcher Michael Lorenzen says he believes the future will bring a generation of “guys sitting 99 (mph) and throwing 210 innings.” Yet he, too, believes the radar gun is a modern ill, forcing pitchers to compromise their health when the readings are suboptimal.

“Back in the day, guys like Nolan Ryan, if they didn’t feel great that day, could throw 87 mph and just say, ‘I didn’t have my best fastball that day,” says Lorenzen, 31, an All-Star this season. “But if I were to go out there and throw seven fastballs at 88 mph, the trainers would be out on the mound.

“So what does that do in my mind? If I have 88 mph in the tank, to me that tells me I have to throw 95. Say I throw 50 fastballs at 95 when I should be throwing 88 because my body doesn’t feel great, it’s all because I don’t want to spark any red flags. It’s extremely compromising on the body.

“So what do you do? You say, ‘I need to be up at 95. I have more in the tank.’ So you’re fatigued, you do it again, you do it enough times, you’re going to go down.”

Speed vs. safety

Indeed, in an ideal setting, Conte says three elements are working to protect the UCL, each bearing roughly equal responsibility: The bones (ulna, radius, humerus), the flexor tendon and the ligament itself.

Fatigue can compromise the flexor tendon, which is why a flexor strain sets off red flags and, in some cases, be a precursor to a torn UCL.

Maximum velocity does not help the cause, either.

Fleisig helped conduct a 2019 study on fastball velocity and torque on the elbow. While it did not find that harder throwers placed greater torque on their elbows than softer tossers, it did conclude that “within-subjects analyses suggested a deliberate reduction in velocity will reduce the load on an individual pitcher’s elbow.”

For practical purposes, Conte points to Marlins right-hander and reigning Cy Young Award winner Sandy Alcantara as the gold standard for varying velocity. Alcantara’s fastball ranks 30 th in average velocity, at 97.9 mph, although his sinking fastball can touch 101 mph.

More important, his four-pitch mix lessens the importance on what Conte calls the most dangerous pitch for a hurler: The maximum-effort fastball.

Alcantara is closing in on his fourth consecutive full season of making at least 30 starts and pitching at least 197 innings. That makes him a rarity during a period Conte said was MLB's most tumultuous period of injuries - with more than 800 players going on the injured list in 2022.

A literal arms race

The fight to curtail lost years due to elbow failures is happening on two fronts.

First is repair. It will soon be five years since Dallas-based orthopedist Keith Meister began using an extra-large tightening suture on Tommy John repairs, hoping to result in a stronger graft that can better withstand the stress of a 100-mph fastball. Orthopedist Jeffrey Dugas, one of Fleisig’s co-authors on elbow torque research, pioneered the internal brace procedure that has become increasingly popular for two-time Tommy John patients, in part because it offers a potentially shorter recovery time than the standard 18 months for a starting pitcher.

And the second is prevention. The biomechanics space is growing more crowded and in an effort to share information and unify best practices, the American Baseball Biomechanics Society was born in 2020. While proprietary information remains the artillery of modern warfare in baseball – and injury prevention is no different – Fleisig says the group aims to leverage technology and information to the greater good of the industry.

Beyond that, the injury prevention space is not holding its collective breath awaiting a paradigm shift. Velocity – the quest for it, its deployment to get outs and get paid – won’t be diminishing anytime soon.

Only the industry can decide how many injuries are too much, and whether availability, still, is the best ability.

“I think as the word gets out there, as the mindset changes, I’m hopeful there will be a shift in what teams are looking for and therefore what players are trying to do to move forward,” says Fleisig. “Every team wants to be the World Series champion. To do that, they need pitchers who are excellent and stay healthy.

“You’re not excellent if you’re here rehabbing in Birmingham.”

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• v.5; 2018 Dec

Injury prevalence across sports: a descriptive analysis on a representative sample of the Danish population

A. m. bueno.

1 Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus, Denmark

M. Pilgaard

2 The Danish Institute of Sports Studies, Frederiksgade 78B, 8000 Aarhus, Denmark

3 Centre of Human Factors and Sociotechnical Systems. University of the Sunshine Coast, Queensland, Australia

P. Forsberg

4 The Danish Institute of Sports Studies, Kanonbådsvej 4A, 1437 København K, Denmark

5 Department of Physiotherapy, University College Northern Denmark, 9000 Aalborg, Denmark

6 Section for Sport Science, Department of Public Health, Aarhus University, Dalgas Avenue 4, 8000 Aarhus, Denmark

R. O. Nielsen

Physical activity plays an important role in public health, owing to a range of health-related benefits that it provides. Sports-related injuries are known to be an important barrier to continued physical activity. Still, the prevalence of injuries on a general population level has not yet been explored in a descriptive epidemiological investigation. The purpose of the questionnaire-based study, therefore, was to describe the prevalence of injury in a representative sample of the Danish population.

Two samples of 10,000 adults (> 15 years) and 6500 children and adolescents (7–15 years) were invited to respond to a web-based questionnaire. Of these, 3498 adults (35.0%) and 3221 children (49.6%) responded successfully. The definition of sports injury was time-loss and medical attention-based, inhibiting participants from sports activity for at least 7 days, and/or involved contact with a healthcare professional, respectively.

Amongst adults, 642 (18.4% [95%CI: 17.1%; 19.6%]) reported to have had an injury within the past 12 months. Males reported significantly more injuries than females (difference in prevalence proportion: 9.2%-points [95%CI: 6.7%-points; 11.8%-points]). The prevalence of injuries was greatest in running (n inj  = 198), football (n inj  = 94) and strength training (n inj  = 89).

Amongst children, 621 (19.3% [95%CI: 17.9%; 20.6%]) had been injured. No difference in injury prevalence proportion existed between boys and girls. The prevalence of injuries was greatest in football (n inj  = 235), handball (n inj  = 86) and gymnastics (n inj  = 66).

Conclusions

Sports injuries seem to be very frequent in Denmark, since a total of 18.4% of the adults and 19.3% of the children reported having had one or more injuries within the past 12 months, equal to either time lost with physical activity and/or contact to the health care system.

The health benefits associated with physical activity are well accepted in the scientific literature, particularly since physical activity plays an important role in both the prophylaxis and treatment of a number of lifestyle diseases (Klarlund & Andersen, 2011 ). To counteract the deleterious effect of inactivity, which is reportedly the second biggest risk factor for death in Denmark (Eriksen et al., 2016 ), at least 30 min of physical activity per day has been recommended for adults by The Danish Health Authority (Klarlund & Andersen, 2011 ). Likewise, amongst children and adolescents, a minimum level of 90 min per day of physical activity has been recommended. In 2011, the prevalence proportion of physically active children and adults in Denmark was 86% and 64%, respectively (Laub, 2013 ). Children aged 7–9 years had the greatest level of physical activity, whereas adults aged above 70 years had the least.

Owing to the health-related benefits from being physically active, it is important to shed light on the barriers for becoming physically active, including those that also prevent individuals from maintaining a physically active lifestyle. Various barriers exist, including a lack of motivation having limited health literacy, time constraints, or being physically impaired (Klarlund and Andersen 2011 ; Rosenbaum et al. 2016 ). Another barrier is sports injury, which can lead to a temporary or permanent break from the chosen activity of interest. Nielsen et al. (Nielsen et al., 2014 ) found a median time-to-recovery of almost 3 months amongst injured novice runners, thus leading to reduced health-related benefits due to less activity.

According to the TRIPP model (Finch, 2006 ), the first step in injury research is to understand the extend of the problem. The prevalence and prevalence proportion of sport injuries has been widely investigated across sports. Unfortunately, such studies have only included groups selected by either one or more criteria, such as specific sport (Jacobsson et al., 2012 ), level (Hall et al., 2013 ), age (Scase et al., 2012 ) or injury type (Maselli et al., 2015 ). The recruitment of selected groups has further limited the external validity of study results to the general population. In addition, knowledge about the prevalence of sports injuries on a general population level is, alongside injury severity and treatment costs, important in order to identify whether sports injuries are a public health burden, as well as to identify whether certain sports contribute to a larger number of injuries than others (Finch, 2006 ). To our knowledge, no studies have yet investigated the total prevalence of sport injuries in a general population-based sample, and subsequently compared the prevalence and prevalence proportion of sports injuries between different sports.

Therefore, the primary aim of this study was to add to the literature the prevalence proportion of sport injuries in a representative sample of the general Danish population. The secondary aim was to describe the prevalence and prevalence proportion of injuries in different sports.

The study was designed as a questionnaire-based study. The Danish Data Protection Agency approved the study and in accordance with Danish law, approval from the local ethics committee is only required in studies with an intervention. In primo January 2016, questionnaires were distributed via postal mail by a local company (Rambøll, Denmark, using SurveyXact) to a representative sample of the general Danish population.

The Danish Civil Registration System (CRS), an administrative register established on April 2, 1968, which contains individual-level information on all persons residing in Denmark (and Greenland as of May 1, 1972), was used to identify: (i) a sample of adults consisting of 10.000 persons above 15 years; and, (ii) a sample of children and adolescents consisting of 6.500 persons between 7 and 15 years. A unique ten-digit Civil Personal Register number was assigned to all persons in the CRS which allowed for the identifications of birth date and gender (Schmidt et al., 2014 ). All 10.000 adults and 6.500 children were randomly selected from CRS.

Data-collection

The study sample was provided with a written letter by postal mail. For the children and adolescents, the letter was forwarded to the parent who was encouraged to help with the questionnaire. The letter contained a short introductory text about the survey history, method and aim, and contained a person-specific code, which was then used to access a web-based questionnaire. The recipients were encouraged to access the web-based questionnaire through a standard tablet or computer, and informed to complete all questions.

In January 2016, non-responders received a reminder by postal mail. In cases of no response, they were contacted by phone. In March, they received a second postal mail reminder.

A flow-chart is presented in Fig.  1 .

Recruitment Flowchart

Questionnaire

The questionnaire, “Habits of Activities and Sports of the Danes”, consisted of 42 questions focusing on activity habits in every aspect. Similar versions of the survey had previously been distributed to the Danish population on eight previous occasions, starting in the sixties. However, the questionnaire distributed in 2016 was the first to include questions pertaining to sports injury. In the questionnaire, a sport-related injury, dichotomized into “yes” or “no”, was defined as “an injury sustained in relation to sport/exercise, which has prevented you from participating in sport/exercise for at least seven days, and/or which required contact with health professionals (doctor, physiotherapist or other)”, pooling single and multiple injuries together. The injury definition including “and/or” in regard to time loss and medical attention was chosen to keep the questionnaire as short as possible but still comparable to definitions used in other studies. The injury had to be present within the past 12 months, but could have been sustained before this period, however it was unknown whether prevention from activity or contact to health professionals, or both, was the reason.

The responders had to report gender, age, activity in general, activity-specific participation, injury status, and the specific activity causing the injury (the latter four categories focused on the past 12 months). Only activities with regular participation were mentioned, and multiple activities could be noted as having caused the injury. The length of 12 months was used to avoid the influence of seasonal variation in affecting changes to sports participation levels. The activity options in the questionnaire were based on knowledge from previous questionnaires, and included the most frequently played sports and activities in Denmark (IDAN Rapport 2011). An option to add an activity under the label “others” was included.

In the descriptive analysis, an injury prevalence (IP) was calculated representing the number of individuals reporting an injury, while the injury prevalence proportion (IPP) was the number of individuals reporting injuries divided by total number of respondents.

In the comparative analyses, prevalence proportion ratio was used to describe the association between injury prevalence proportion and age-groups, solely in the adult group. Prevalence proportion difference, by binomial regression, was used to compare the association between injury prevalence proportion and gender, both among adults and children.

An uneven distribution of multiple age and gender existed between responders and non-responders, including gender and age among adults, thus the adult group were analytically weighted so that each unit was inversely proportional to the variance of the observation. The weight reduced the discrepancy in age and gender in the responders compared with non-responders. No weight was used amongst children due to even response proportions between gender and age groups.

In the calculations focusing the “active” part of the sample, the persons who reported sports-related injuries within the past 12 months without reporting regular participation in any sports activity the past 12 months, were excluded, showing in the different number of injuries among all compared to the active part. This accounts for the calculations of injuries among “active”, “injuries across sports” and comparative analysis of age-groups, for both children and adults. The wording “active” in the present paper, refers to a participant answering to have been regularly participating in at least one activity within the past 12 months.

The data management and statistical analyses were handled in Stata (Stata/IC 14.0 for Mac, College Station, TX, USA), while Excel (Microsoft Excel for Mac, version 15.19.1) was used to compute Tables.

Of the 10,000 adults receiving a questionnaire, 3498 (35.0%) responded. After weighting the data, the sample consisted of 1719 males and 1779 females, of which 82.4% reported regularly being physically active, within the past year. A total of 642 (IPP = 18.4% (95% CI: 17.1%; 19.6%)) reported to have been injured at least once within the past 12 months. Males reported significantly more injuries (9.2%-points (95% CI: 6.7%-points; 11.8%-points)) than females, since the prevalence and prevalence proportion of injuries amongst males were 396 (23.1% (95% CI: 21.1%; 25.0%)) and amongst females 246 (13.8% (95% CI: 12.2%; 15.4%)).

Of the 2884 active adults, 620 persons reported an injury, equivalent to a prevalence proportion of 21.5% (95% CI: 20.0%; 23.0%). Among active adults, 27.4% (95% CI: 25.1%; 29.7%) and 15.9% (14.0%; 17.8%) of the males and females, respectively, reported injuries.

Of the 6500 children receiving a questionnaire, 3221 (49.6%) responded, of which 95.2% were regularly active within the last year. Injuries were presented in 621 (19.3% (95% CI: 17.9%; 20.6%)) children in the past 12 months. The injury prevalence proportion was similar amongst boys (19.5% (95% CI: 17.5%; 21.4%)) and girls (19.1% (95% CI: 17.1%; 21.0%)). Amongst physically active children, 19.9% (95% CI: 18.5%; 21.3%) reported an injury.

Both adults (Table  1 ) and children (Table  2 ) reported in which activities they regularly participated and in case of an injury, which activity had been related to the injury. Amongst adults, running was the sport contributing with the most injuries (n inj  = 198), followed by football (n inj  = 94) and strength training (n inj  = 89). Amongst children, football (n inj  = 235), handball (n inj  = 86) and gymnastics (n inj  = 66) were the sports with the highest prevalence of injuries.

Injuries across sports among adults

Adults sport	participation			IP			IPP
	a	95%	CI	n	95%	CI	n /a	95%	CI
running	1032	979	1085	198	173	223	0,19	0,17	0,22
football	248	218	278	94	79	109	0,38	0,32	0,44
strength	1047	994	1100	89	71	107	0,09	0,07	0,10
handball	87	69	105	34	25	43	0,39	0,29	0,49
badminton	193	167	219	24	15	33	0,12	0,08	0,17
gymnastics	295	263	327	18	10	26	0,06	0,03	0,09
hiking	896	845	947	18	10	26	0,02	0,01	0,03
road biking	275	244	306	15	8	22	0,05	0,03	0,08
tennis	79	62	96	14	7	21	0,18	0,09	0,26
mount. Biking	211	183	239	13	6	20	0,06	0,03	0,09
cross fit	144	121	167	12	5	19	0,08	0,04	0,13
skiing	267	236	298	10	4	16	0,04	0,01	0,06
aerobic	246	216	276	10	4	16	0,04	0,02	0,07
martial arts	56	41	71	9	4	14	0,16	0,06	0,26
golf	143	120	166	9	3	15	0,06	0,02	0,10
bike spinning	374	338	410	9	3	15	0,02	0,01	0,04
swimming	514	473	555	7	2	12	0,01	0,00	0,02
riding	61	46	76	7	2	12	0,11	0,03	0,19
skateboarding	24	14	34	7	3	11	0,29	0,11	0,47
basketball	25	15	35	6	2	10	0,24	0,07	0,41
volleyball	47	34	60	5	1	9	0,11	0,02	0,19
canoe / kayak	82	64	100	4	0	8	0,05	0,00	0,10
orientering	32	21	43	4	0	8	0,13	0,01	0,24
dance	154	130	178	4	0	8	0,03	0,00	0,05
hockey	27	17	37	3	–	–	0,11	–	–
parkour	13	6	20	2	–	–	0,15	–	–
yoga	303	270	336	2	–	–	0,01	–	–
sailing	35	23	47	2	–	–	0,06	–	–
boy scout	25	15	35	2	–	–	0,08	–	–
climbing	28	18	38	1	–	–	0,04	–	–
bowling	82	64	100	1	–	–	0,01	–	–
petanque	40	28	52	1	–	–	0,03	–	–
athletics	8	2	14	1	–	–	0,13	–	–
triathlon	23	14	32	1	–	–	0,04	–	–
roller skating	58	43	73	1	–	–	0,02	–	–
table tennis	35	23	47	1	–	–	0,03	–	–
wind- kite surf	15	7	23	1	–	–	0,07	–	–
hurting	105	85	125	1	–	–	0,01	–	–
handicap sport	9	3	15	1	–	–	0,11	–	–
open water	13	6	20	0	–	–	0,00	–	–
billiard	52	38	66	0	–	–	0,00	–	–
nordic walking	72	56	88	0	–	–	0,00	–	–
pilates	106	86	126	0	–	–	0,00	–	–
diving	33	22	44	0	–	–	0,00	–	–
rowing	26	16	36	0	–	–	0,00	–	–
wave surf	4	0	8	0	–	–	0,00	–	–
shooting	51	37	65	0	–	–	0,00	–	–
fishing	143	120	166	0	–	–	0,00	–	–
role playing	10	4	16	0	–	–	0,00	–	–

Participation, “a” number of participants

IP , injury prevalence, “n inj ” number of injuries

IPP , injury prevalence proportion in different activities of adults, n inj /a the proportion

CI , confidence interval

Data are sorted by injury prevalence in descending order from highest to lowest

Injuries across sports among children

Children sport	participation			IP			IPP
	a	95%	CI	n	95%	CI	n /a	95%	CI
football	1177	1123	1231	235	208	262	0,20	0,18	0,22
handball	415	378	452	86	70	102	0,21	0,17	0,25
gymnastics	762	715	809	66	51	81	0,09	0,07	0,11
running	574	531	617	37	25	49	0,06	0,04	0,08
badminton	288	256	320	21	12	30	0,07	0,04	0,10
ridning	257	227	287	21	12	30	0,08	0,05	0,12
swimming	1132	1079	1185	17	9	25	0,02	0,01	0,02
dancing	381	345	417	16	8	24	0,04	0,02	0,06
strength training	377	341	413	15	8	22	0,04	0,02	0,06
trampoline	544	502	586	14	7	21	0,03	0,01	0,04
martial arts	208	181	235	14	7	21	0,07	0,03	0,10
basketball	81	64	98	10	4	16	0,12	0,05	0,20
kick scooter	478	438	518	9	3	15	0,02	0,01	0,03
parkour	100	81	119	8	3	13	0,08	0,03	0,13
skateboarding	196	169	223	7	2	12	0,04	0,01	0,06
boy scouting	345	311	379	7	2	12	0,02	0,01	0,04
tennis	117	96	138	6	1	11	0,05	0,01	0,09
athletics	65	49	81	5	1	9	0,08	0,01	0,14
hiking	190	164	216	4	0	8	0,02	0,00	0,04
bmx	45	32	58	4	0	8	0,09	0,01	0,17
volleyball	56	41	71	3	–	–	0,05	–	–
mountain biking	111	91	131	3	–	–	0,03	–	–
roller skating	268	237	299	3	–	–	0,01	–	–
aerobic teams	37	25	49	3	–	–	0,08	–	–
shooting	77	60	94	2	–	–	0,03	–	–
hockey	42	29	55	1	–	–	0,02	–	–
bike spinning	66	50	82	1	–	–	0,02	–	–
golf	43	30	56	1	–	–	0,02	–	–
table tennis	75	58	92	1	–	–	0,01	–	–
canoe / kayak / rowing	22	13	31	1	–	–	0,05	–	–
sailing	28	18	38	1	–	–	0,04	–	–
surfing	7	2	12	1	–	–	0,14	–	–
ice skating	75	58	92	1	–	–	0,01	–	–
road biking	34	23	45	0	–	–	0,00	–	–
role playing game	58	43	73	0	–	–	0,00	–	–
yoga	48	35	61	0	–	–	0,00	–	–
fishing	81	64	98	0	–	–	0,00	–	–

IP injury prevalence, “n inj ” number of injuries

IPP injury prevalence proportion in different activities of adults, n inj /a the proportion

CI confidence interval

Table  3 shows the injury prevalence proportion in different age-groups amongst adults and adolescents. These estimates focus only “physically active”. The prevalence proportion ratio is calculated with the youngest group, 16–19 years, as reference. The prevalence proportion of injured is continuously decreasing from the youngest to the oldest with only one plateau at 20–29 and 30–39.

Comparative analysis of prevalence proportions in different age groups (adults only), with the 16–19 years as the reference group

Adults age	participants			IP			IPP			IPP-ratio
	a	95%	CI	n	95%	CI	n /a	95%	CI	IPP/IPP	95%	CI
16–19	197	170	224	76	63	89	0,39	0,32	0,45	1
20–29	467	428	506	138	119	157	0,30	0,25	0,34	0,76	0,60	0,95
30–39	410	373	447	114	96	132	0,28	0,23	0,32	0,71	0,58	0,88
40–49	494	454	534	124	105	143	0,25	0,21	0,29	0,64	0,52	0,80
50–59	465	426	504	97	80	114	0,21	0,17	0,25	0,53	0,42	0,68
60–69	425	388	462	49	36	62	0,12	0,08	0,15	0,30	0,22	0,41
70+	426	389	463	23	14	32	0,05	0,03	0,08	0,14	0,09	0,22

IPP -ratio prevalence proportion-ratio, IPP/IPP the ratio between injury proportions

To our knowledge, no peer-reviewed articles have examined the injury prevalence and prevalence proportion of physically active persons in Denmark on a population level. The present study is therefore novel in the sense that contributes to the overall identification of the extent of the injury problem (Finch, 2006 ). The data presented in this study also suggest that sports injuries are frequent in Denmark, since a total of 18.4% of the adults and 19.3% of the children reported having had one or more injuries within the past 12 months, equal to either time lost with physical activity and/or contact to the health care system. We found more injuries amongst males than amongst females. The reason for this difference may be due to gender-specific differences in both physical aspects like anatomy but also psychologically aspects as mentality and behaviour when participating in certain sports. In addition, different preferences may exist between gender in the type of preferred physical activity and the exposure time of these activities, which, may be higher in males, which is detectable in the data set, and could be focused in future studies.

The consequences associated with sports-related injuries in Denmark are still largely unknown. For example, information about injury severity and recovery, potential absenteeism of work, use of therapeutic or surgical interventions, or time before returning to play (which may be equal to absenteeism from the health benefits of physical activity) are needed to understand the full impact from a population-level perspective.

According to Table ​ Table1, 1 , running was the sport which contributed to the most injuries (n inj  = 198) among adults, followed by football (n inj  = 94) and strength training (n inj  = 89). Accordingly, a reduction in the total number of sports injuries in the adult Danish population would benefit from a focus on preventing injuries sustained when running, playing football and engaging in strength training. Similarly, prevention of injuries in children and adolescents may require increased focus on preventing injuries associated with football (n inj  = 235), handball (n inj  = 86) and gymnastics (n inj  = 66) (Table ​ (Table2). 2 ). Importantly, no consequences in terms of absenteeism from work, surgery or time-to-recovery were reported. Therefore, some sports with a low injury prevalence, such as riding (7 injuries reported) amongst adults, may lead to severe injuries, such as spinal cord trauma etc., while the impact of injuries in other sports are less severe. This is not shown in the present data. Consequently, this is a major limitation that limited the possibility for evaluating the consequences of injuries across sports.

Table ​ Table3 3 shows the injury prevalence proportion ratio between age groups amongst active. The injury prevalence proportion continuously decrease from the youngest to the oldest, with only one plateau at 20–29 and 30–39. This observed trend could be explained by behavioural changes over time including changes to activity preference, as well as “the healthy athletes bias/effect” which is based on the rationale that only previously uninjured persons will continue to be active into older age.

The sample of the present study was recruited through CRS. Therefore, the 10.000 adults and 6.500 children and adolescents were representative of the population of Denmark in a number of variables, such as gender, age, education, ethnicity and demography. The response proportion among adults of 35% was lower than similar data collection in 2007 (43%) and 2011 (47%). Although the response proportion of 35% was low, the generalizability to the Danish population is presumably better than other studies examining the epidemiology of injury in specific target-populations such as elite athletes or members of certain sports clubs. However, the results in the present study may be affected by selection- and information bias. Owing to the response proportion of 35.0% amongst adults and 50% amongst children, it is reasonable to question whether the responders differed from the non-responders, (i.e. non-responders are hypothesized to be less active compared with responders). This selection problem was unsuccessfully handled by inviting the non-responders to answer a few questions describing their characteristics, but only 711 (10.9%) responded the phone call and the questions answered described the sub-sample insufficiently.

Amongst children, selection bias was less of a problem because of the higher proportion of persons responding, though the level of activity amongst responders may still be higher than non-responders. In summary, the selection problems addressed above may lead to selection bias amongst both adults and children leading to an overestimation of the proportion being injured in this sample altogether. The proportion of injured amongst active in general or across each sport may, however, be unaffected as it is unreasonable to believe that injury either motivates or prevents answering the questionnaire.

Injury definition

The definition of injury used in the present study is almost similar to the consensus definition for runners, proposed by Yamato et al. (Yamato et al., 2015 ). It is well known that different injury definitions will find different injury prevalence in the same population. Similar definitions must be used before comparing results produced in epidemiological studies. In the present study, time-loss was used as the first component, since it is commonly used to define injury in many team sports given that it is easier to identify cases of injury (Clarsen & Bahr, 2014 ) In individual sports, however, it can be difficult to distinguish between reduced, modified, and/or not participating or participating with pain, thus “time-loss” will appear differently between sports and individuals, and 7 days of inhibition may not appear before severe physical complaint is present. Therefore, injury definition, as second component, also comprised a component: “and/or professional health care attention” which classifies a person as injured, irrespective of whether there has been activity time-loss. The use of “time-loss” has the disadvantage that it is very individual-dependent whether to stop training or just modify it. “Medical attention”, on the other hand, is very level-dependent, as people at high level of sports may see physiotherapists regularly to avoid losing valuable training time or important competitions, where less trained persons or beginners may take some time off instead of seeing health care. Thus the use of “and / or” will cover some of this discrepancy and may thereby give a more valid picture of the injury proportions.

Perspective

Translating Research into Injury Prevention Practice (TRIPP) (Finch, 2006 ) is a framework to enhance prevention of sports-related injuries in a population. Injury surveillance studies must be conducted to identify if sports injuries are a public-health burden. The prevalence of injuries was demonstrated in the present study. Still, the consequences of these injuries require further investigation to fully understand the burden on public health.

The TRIPP framework highlights the importance of determining aetiology and mechanisms of injury. Bittencourt et al. (Bittencourt et al., 2016 ) promoted that the value of identifying single or multiple risk factors is limited in a prevention-perspective. In contrast, recognition of complex injury pattern as explanation of injury may be a new beneficial analytical approach (Bittencourt et al., 2016 ). If the injury pattern is recognized, next step is to develop preventive measures and test of the efficacy of the measures, first in ideal conditions, then implemented a in real world as guidelines for athletes and coaches (Soligard et al., 2016 ). Finally, additional epidemiological studies will be needed frequently to observe a potential effect of preventive interventions and a decline in injury prevalence on population level. Therefore, similar data collection on the prevalence and prevalence proportion of sports injuries in a sample representative of the Danish population will be conducted in the future. The next investigation made by the Danish Institute for Sports Studies will be in 2019/2020.

According to the present study, sports injuries seem to be very frequent in Denmark, since a total of 18.4% of the adults and 19.3% of the children reported having had one or more injuries within the past 12 months, equal to either time lost with physical activity and/or contact to the health care system.

Authors’ contribution

CD, DR and RON designed the study. MP and PF collected the data. AB, MP, PF and RON completed the data management and statistical analyses. AB, RON, CD, DR and AH interpreted the data. AB drafted the manuscript and all remaining authors revised it for important intellectual content. All authors approved the final version to be published.

Ethics approval and consent to participate

The study design and its procedures have been presented to the local ethics committee who, according to the Danish law, did not consider the study for ethical approval, owing to the observational nature of the study.

Competing interests

The authors declares that they have no competing interests.

Contributor Information

A. M. Bueno, Phone: +45 87168179, Email: moc.liamtoh@oneub_saerdnA .

M. Pilgaard, Phone: +45 29217036, Email: [email protected] .

A. Hulme, Phone: +61 4 8822 5006, Email: ua.ude.csu@emluha .

P. Forsberg, Phone: +45 40885279, Email: [email protected] .

D. Ramskov, Phone: +4587168179, Email: [email protected] .

C. Damsted, Phone: +4587168179, Email: kd.ua.hp@ammac .

R. O. Nielsen, Phone: +4587168179, Email: kd.ua.hp@neor .

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