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Epidemiology of Sports-Related Injuries and Associated Risk Factors in Adolescent Athletes: An Injury Surveillance
1 Health and Physical Education Department, Prince Sultan University, Riyadh 11586, Saudi Arabia; as.ude.usp@oteirpp
Jose Luis Martínez-Castillo
2 Nuestra Señora de las Mercedes School, Tarancón, 16400 Cuenca, Spain; moc.liamtoh@87ablasiul
Luis Miguel Fernández-Galván
3 Education Faculty, Autonomous University of Madrid, 28049 Madrid, Spain; moc.liamg@alecupedsiul
4 Center for Sport studies, Rey Juan Carlos University, 28028 Madrid, Spain; [email protected]
5 ITV Secondary School, Santa Rosa, La Pampa 6300, Argentina; moc.liamg@ikroposoigres
6 Performance and Sport Rehabilitation Laboratory, Faculty of Sport Sciences, University of Castilla-La Mancha, 45071 Toledo, Spain
The present study aimed to determine the epidemiology of sport-related injuries in amateur and professional adolescent athletes and the incidence of different risk factors on those injuries. Four hundred ninety-eight athletes aged 14 to 21 voluntarily participated in this prospective injury surveillance, conducted from 1 January 2019 to 31 December 2019. The information collected included: personal data, sports aspects, characteristics of the injuries, and lifestyle. Forty point four percent of the participants suffered an injury in 2019 (39% of them in a previously injured area). The average injury rate was 2.64 per 1000 h. Soccer presented the highest rate (7.21). The most common injuries were: lumbar muscle strains (12.24%), ankle sprains (11.98%), and bone fractures (9.31%). Ankles (36.12%), knees (19.32%), and shoulders (6.47%) concentrated the highest number of injuries. Fifty-nine point twenty-eight percent of the injuries occurred during practices, and 40.72% during competition or peri-competition. Higher injury rates were associated (in this order) with the following factors: (a) Greater number of hours of practice per week. (b) Not performing warm-ups. (c) Using inadequate sports facilities. (d) Being aged 14–17. (e) Not performing physical preparation. (f) Inappropriate training load. (g) Not performing injury-preventive activities. (h) Performing sports technique without the supervision of one sports coach. (i) Inadequate sports equipment. In conclusion, since most injury risk factors are modifiable, it is imperative to implement strategies to reduce amateur and professional adolescent athletes’ injury rates.
The practice of sport by adolescents generates physiological, psychological, and social benefits. These include improved health conditions, self-esteem, social interactions, and decreased risk of depression [ 1 ]. However, sports practice is inevitably linked with the appearance of injuries [ 2 ]. Moreover, this circumstance is aggravated by the increasing sports participation among adolescents in recent years [ 3 ].
Only in the United States, it was reported that 3.5 million youth under the age of 15 years old received medical care each year for injuries that occurred during sports practice. In addition, two-thirds of those injuries required care in emergency units [ 4 ]. LeBrun et al. [ 5 ] estimated that 23 million adolescents suffer sports injuries annually on the African continent. Similarly, Merkel [ 4 ] indicates that the estimated annual cost derived from sports injury management amounts to two billion dollars in the United States healthcare system. Furthermore, Knowles [ 6 ] mentions a prospective study conducted in the United States, wherein the annual statewide cost estimated of high school athletes was $9.9 million in medical expense, $44.7 million in human capital, and $144.6 million in total cost. In the case of Spain, no recent studies have analyzed the total cost of sports-related injuries in adolescents.
Similarly, an increase in the injury rates was observed in recent years in soccer [ 7 ]. This higher incidence is often attributed to a greater level of sports specialization and more intense practice at an early age [ 8 ]. This theory is supported by the fact that young athletes’ injury patterns seen in recent years are similar to those observed in mature athletes [ 8 ]. Under these circumstances, it is urgent to design strategies to reduce the incidence of sports injuries in adolescents due to their high cost in economic terms and the overload of health systems [ 7 ].
Likewise, reducing the risk of suffering injuries in such a significant population group will reduce youth sports attrition, promote lifetime participation in sports, and produce improvements in public health associated with the regular practice of sports [ 7 ]. In this regard, it is essential to highlight that there is a clear tendency to abandon sports practice during adolescence due to intrapersonal, interpersonal, and structural constraints [ 9 ].
Merkel [ 4 ] states that the sports drop-out rate of 15-year-olds is between 70% and 80%. Therefore, since adolescence is divided into three phases (early: 10–13 years; middle: 14–17; late: 18–21) [ 10 ], the highest drop-out rate occurs in middle adolescence. Moreover, according to the current evidence, one of the main reasons for sport drop-out is the occurrence of injuries [ 11 ]. Therefore, an in-depth review of the youth sports programs to make sports practice safer.
Importantly, promoting the design of strategies aimed at preventing injuries, protecting young athletes’ health, and increasing sports safety requires continuous surveillance of sports injury prevalence and patterns [ 12 ]. However, comparing the epidemiological results of existing research is complicated due to the different characteristics between studies [ 3 , 13 ]. Significant discrepancies in incidence rates among different research are common. Those discrepancies result from the differences in the target population, sports studied, country, competitive level, age group, and study type [ 3 ]. Thus, more epidemiological studies that consider all these variables are required to improve scientific knowledge about sports injuries and facilitate preventive interventions [ 14 ].
As for the current scientific research available related to sports injuries epidemiology and patterns in adolescents, the number of studies available is limited in the case of Spain. Moreover, most of them focused on specific sports (soccer, basketball, skateboarding, martial arts, padel), adult population, or recreational sports [ 15 , 16 , 17 , 18 , 19 , 20 ]. There is only one recent study on sports injuries in adolescents. However, it is a cross-sectional retrospective study focused on school sports [ 21 ].
In this context, it is necessary to know the sports-related injury epidemiology and patterns in adolescent athletes. It must be clarified which sports present the highest injury rates, the most frequent injuries, in what context the injuries occur, and if males suffer more injuries than females, and professional athletes more injuries than their amateur counter partners [ 14 ]. It is also important to determine the impact of different injury risk factors such as training load, sports technique, age, BMI, weekly hours of practice, sports equipment and facilities, performing injury-preventive activities, physical preparation, nutrition, and stress. Knowing this data is crucial for estimating the extent and cost of sports injuries. It will also increase the athletes’ safety and will be helpful to design more effective injury prevention strategies in the future.
It is important to highlight that injury prevention programs reduce the incidence of injuries in adolescent athletes. However, these programs are multifaceted and imply the adoption of numerous preventive measures, the development of different fitness components, and the modification of sports technique or lifestyle habits. Therefore, it is unknown precisely which aspects of the preventive programs are crucial to prevent sports injuries [ 22 ]. Therefore, the objective of the present study was twofold: (i) to determine the epidemiology of sport-related injuries in amateur and professional athletes in the Autonomous Community of Castilla-La Mancha (Spain); and (ii) to analyze the incidence of different risk factors on those injuries.
The current research data collection process was organized based on the checklist items for reporting observational studies on injury and illness in sports designed by the International Olympic Committee Consensus Statement [ 23 ]. The following steps were taken.
2.1. Study Design
A prospective injury surveillance was conducted from 1 January 2019 to 31 December 2019.
The study was carried out in the Autonomous Community of Castile-La Mancha (Spain). It is an inland region located in the southern half of the Iberian Peninsula. In 2020, it had a population of 2,045,211 inhabitants [ 24 ].
Of a total of 1547 subjects invited to participate in the present study, 945 met the inclusion criteria, and finally, 498 completed it (flow chart for selection of study participants is shown in Figure 1 ). The inclusion criteria were as follows: (a) Being aged between 14 and 21 years old. (b) Being a professional or amateur athlete. (c) Practice one sport for at least five hours a week within a sports club, and have practiced that sport for at least two years. (d) Do not suffer any injury or disease incompatible with their sport’s practice at the beginning of the study.
Flow Chart for selection of study participants.
Study participants received precise information about the objectives, benefits, and risks associated with their inclusion in the present study. All subjects signed an informed consent form declaring their willingness to be included in it. Additionally, the parents of the participants under 18 years signed an informed consent authorizing their children to participate in the study.
Athletes and their coaches and physical trainers were invited to participate in the study through the athletes´ Physical Education and Sports teachers. They were recruited from 10 Educational Institutions. Eight were Secondary Schools (four public and four private) located in rural and urban areas. The two other educational institutions were one public University (with campuses in six different cities of the Autonomous Community) and one private University.
Once the six leading researchers defined the study outcomes, an injury surveillance form was created to address all variables. The leading researchers listed and subsequently valued the items that could be included in the study from 0 to 10. Next, the Item-Level Content Validity Index (I-CVI) was calculated using the following formula:
where I-CVI: content Validity Index; Ne: number of experts giving a rating of “very relevant”; Nt: the total number of experts. Only the items with a score higher than 0.8 were included. As for reliability, the consistency of the results collected by the research assistants in quantitative variables was analyzed with Cronbach’s alpha. The value obtained was α = 0.84, which reflects a very good level of consistency.
Thereupon, the checklist was created. This document consisted of 24 items, grouped in four dimensions, as described in Table 1 :
Items included in the checklist used to collect the data.
To facilitate the registration of non-categorical and non-quantitative variables (i.e., appropriate sports injury prevention programs, adequate warm-up, adequate sports equipment), a scale ranging from 1 to 5 was used. A value of 1 corresponded to absolutely appropriate/adequate, and 5 absolutely inappropriate/inadequate. Injury severity was also rated from 1 to 5, being 1 recovery without rehabilitation or medical advice, and 5 undergoing surgical intervention. Similarly, the stress level was rated from 1 to 5, with 1 being no stress and 5 being severe stress.
2.5. Data Sources and Measurement
Ten research assistants collected data. All of them were qualified Physical Education and Sports teachers working at the educational centers that voluntarily participated in the study.
Three online theoretical sessions were held to unify criteria to avoid the potential risk of biased and to guarantee the consistency of the information collected. Six researchers and 10 research assistants attended the meetings. Firstly, the concept of injury was clarified. To be included in the present study, an injury was defined as “any event that occurred during an organized competition or practice and requires attention from a health care provider” [ 25 ]. Similarly, a professional athlete was defined as “the subject who, by virtue of a relationship established on a regular basis, voluntarily practice sport within the scope of one organization, sports club or entity in return for remuneration” [ 26 ]. Then, the meaning of the 24 items that make up the injury surveillance was explained in detail, and precise instructions were given to the research assistants regarding the data collection. Once this process was completed, the researchers met with the research assistants to rectify the errors before sending the data for further statistical analysis if the information collected was flagged and incomplete. Research assistants were also required not to interfere with the athletes’ competition and practice to avoid altering their study involvement.
2.7. Study Size
The sample size was estimated with the following formula [ 27 ]:
where n = sample size, N = population size, Z = confidence level, p = probability of success, q = probability of failure, e = confidence interval.
The confidence level was set at 95%, the confidence interval at 5%, and the probability of success at 50%. After performing the calculation, it was determined that the minimum number of individuals required to have a representative sample of the studied population within the Autonomous Community of Castile-La Mancha was 364.
2.8. Ethical Clearance
The present study was conducted in accordance with the principles set out in the Helsinki Declaration. Moreover, it was also approved by the Institutional Review Board of the Bioethics Committee at Prince Sultan University in Riyadh, Saudi Arabia (approval no. PSU IRB-2018-010017).
3. Statistical Analysis
The normality of the data was assessed using the Kolmogorov–Smirnov test and homoscedasticity with the Levene’s tests. To establish comparations between two samples, Student’s t -test was used when the data followed a normal distribution. For more than two cohorts or conditions, one-way ANOVA with Tukey´s post hoc test was conducted. In cases where the homogeneity of variance was violated, comparisons between two data samples were performed using Mann–Whitney U, whereas comparisons between more than two cohorts or conditions were conducted using Kruskal Wallis H, applying the Dunn–Bonferroni post hoc test for pairwise comparisons. When the data followed a normal distribution, the η2 parameter was used to estimate the effect size (ES). In addition, when the data did not follow a normal distribution, after conducting the Mann–Whitney U test, the ES was calculated using the following formula:
where Z: Z-score; N: number of observations. The ES was interpreted as follows: 0.2 small effect, 0.5 moderate effect, and 0.8 large effect. The association between dependent and independent variables was examined using the Pearson product–moment correlation coefficient, and the results were interpreted as follows: r = 0 null correlation; 0.01 ≤ r ≤ 0.09 very weak, 0.10 ≤ r ≤ 0.29 weak, 0.30 ≤ r ≤ 0.49 moderate, 0.50 ≤ r ≤ 0.69 strong, and r ≤ 0.70 very strong. The injury rate was reported as the number of injuries per 1000 athlete-exposures (practice and competition) [ 28 ]. The significance level was set at 0.05. Data are presented as mean ± SEM. Statistical analysis was performed using SPSS, version 22.0 (SPSS, Inc., Chicago, IL, USA).
Sample characteristics and epidemiological aspects are shown in Table 2 . The 10 most practiced sports by the study participants were respectively: soccer, swimming, weight training, athletics, basketball, tennis, judo, paddle tennis, volleyball, and cycling. Of these 10 sports, soccer, judo, and basketball presented respectively the highest injury rate, and weight training, cycling, and swimming the lowest. The total number of injuries was 529. Seventy-five-point ninety-eight percent of them occurred to participants of three sports modalities: 68.81% footballers, 10.96% basketball players, and 7.75% Judokas. The average injury rate was 2.64 per 1000 h. The percentage of injured subjects in 2019 was 40.4% (38.8% were amateur and 46.4 professional). Thirty-nine percent of the subjects suffered an injury in a previously injured area. The injury recurrence was 5.11% higher in professional athletes. The most common injuries were, in this order, lumbar muscle strains, ankle sprains, and bone fractures. The most common body regions were, respectively, ankles, knees, and shoulders. More than two-thirds of the injuries occurred in the lower limbs. Fifty-nine point two eight percent of the injuries occurred during athletic training, and 40.72% while competing or performing peri-competition activities. The most common injury mechanisms were, in this order: (a) No identifiable single event (repetitive transfer of energy, overuse). (b) Acute non-contact trauma. (c) Direct contact with an object.
Sample characteristics and epidemiological aspects.
BMI: Body mass index; X bar, x ¯ : Mean.
Comparisons between different conditions and subgroups within the sample are shown in Table 3 . In this regard, it was observed that injury severity ((IS), injury severity score (ISS), and injury rate (IR) was significantly higher in the 14-to-17-year-old cohort than in the 18- to 21-year-old age group [(ID: p < 0.001; ES = 1.45); (ISS: p < 0.001; ES = 0.72); (IR: p < 0.001; ES= 0.76)]. The Kruskal–Wallis H revealed a significant main effect of BMI ( p < 0.001). In addition, the Dunn–Bonferroni post hoc showed that normal-weight individuals presented an ID and an ISS significantly lower than overweight subjects [(ID: p < 0.001; ES = 1.14); (ISS: p = 0.029; ES = 1.16). No significant differences were found in ID and ISS between the underweight and normal-weight individuals and underweight and overweight subjects. Furthermore, no significant differences were found in IR between BMI categories.
Injury duration, injury severity score, and injury rate as a function of different factors and conditions.
ID: Injury duration (expressed in weeks). ISS: Injury severity score (rated from 1 to 5, with 1 being minor injury and 5 severe injury. IR: Injury rate (reported as the number of injuries per 1000 athlete-exposures: practice and competition). * Significant differences observed. BMI: Body mass index. UW: Underweight. NW: Normal weight. OVW: Overweight.
The ID, ISS and IR of the individuals who practiced sports less than 10 h a week were significantly lower than those who practiced sports for more than 10 h [(ID: p < 0.001; ES = 1.13); (ISS: p < 0.001; ES = 0.84); (IR: p < 0.001; ES = 1.03)]. The subjects who perform an individualized and sport-specific physical preparation presented also a significantly lower ID, ISS and IR than those who did not [(ID: p < 0.001; ES = 1.59); (ISS: p < 0.017; ES = 0.49); (IR: p < 0.001 Es =1.58)]. Similarly, the athletes who perform specific activities aiming to prevent injuries presented a significantly lower ID ( p < 0.001; ES = 1.12), ISS ( p < 0.001; ES = 1.14), and IR ( p < 0.001; ES = 1.10). Furthermore, the individuals who perform warm-ups adapted to their abilities and specific characteristics of the session had a significantly lower ID ( p < 0.001; ES = 1.14), ISS ( p < 0.001; ES = 1.18) and IR ( p = 0.019; ES = 0.103).
The subjects who used sports equipment in good condition that was frequently inspected presented a significantly lower ID ( p < 0.001; ES = 2.71), ISS ( p = 0.020; ES = 0.685), and IR ( p < 0.001; ES= 2.32) than those subjects who did not. In the same vein, a significantly lower ID, ISS and IR was observed among the athletes who used sports facilities in good condition that were free of obstructions, well-lit, ventilated, and possessed adequate flooring compare with those who did not [(ID: p < 0.001; ES = 2.32); (ISS: p < 0.001; ES = 2.37); (IR: p < 0.001; ES = 2.27)]. The individuals whose training load was adapted to their abilities also presented a significantly lower ID ( p < 0.001; ES = 2.01), ISS ( p < 0.001; ES = 0.27), and IR ( p < 0.001; ES = 2.01) than those who did not. Finally, the athletes who performed the sports techniques under the supervision of a sports coach had a significantly lower ID ( p < 0.001; ES = 1.61), ISS ( p < 0.001; ES = 1.56), and IR ( p < 0.001; ES = 3.077).
On the contrary, no significant differences were found in ID, ISS, and IR between subgroups for the following factors: (a) Sex (male and female). (b) Competitive level (professional and amateur). (c) Following a healthy, balanced, and individualized diet. (d) Being subjected to stress due to the pressure received from family members, coaches, friends, or self-imposed.
The association between independent and dependent variables is shown in Table 4 . As for the ID, a significant negative correlation was observed between this variable and the following aspects: (a) Performing specific activities aiming to prevent injuries. (b) Training load adapted to athlete’s ability. (c) The correct execution of sports techniques was supervised by one sports coach. The r values indicate that in all cases, the correlation was weak.
Correlation between independent variables and ID, ISS, and IR.
r: Pearson correlation; p : significance level was set at < 0.05; CI: Confidence Interval; *: significant correlation observed.
The ISS presented a significant negative correlation with the following factors: (a) Carrying out an individualized and sport-specific physical preparation. (b) Performing specific activities aiming to prevent injuries. (c) Performing warm-ups adapted to athletes’ abilities and specific characteristics of the session. (d) Using sports equipment in good condition and frequently inspected. (e) The correct execution of sports techniques was supervised by one sports coach. Moreover, a significant positive correlation was found between ISS and weekly hours of practice. Nevertheless, in all cases, the correlation between the ISS and the injury risk factors was weak.
The IR presented a negative correlation with the following variables: (a) Age. (b) Carrying out an individualized and sport-specific physical preparation. (c) Performing specific activities aiming to prevent injuries. (d) Performing warm-ups adapted to athletes’ abilities and specific characteristics of the session. (e) Using sports equipment in good condition and frequently inspected. (f) The correct execution of sports techniques was supervised by a sports coach. Finally, a significant positive correlation was observed between IR and the following two variables: (a) Weekly hours of practice. (b) Being subjected to stress. The correlation between the IR and the injury risk factors was also weak.
5.1. epidemiological aspects.
One of the present study’s main findings was to verify that 40.4% of the subjects suffered an injury in 2019 (46.4% were professional and 38.8% amateur). The percentage of subjects injured in the present study was lower than the percentage observed by Danes-Daetz et al. [ 3 ] in Chilean University athletes in only six months (48.8%). It was also lower than the percentage registered by Pujals et al. [ 19 ] in Spanish athletes aged between 21 and 38 during one sport season (78.5%), and lower than the percentage observed by Martínez-de-Quel-Pérez et al. [ 21 ], who reported a percentage of 68.7% in secondary-school males, and 47.8% in secondary-school females during one academic year. Therefore, despite the number of injuries is lower than in previous research, we consider that the number of injuries found in the present study is still very high. Hence, it might be reduced in the future with injury prevention programs.
The percentage of subjects who suffered an injury in a previously injured area in the present study was 39% (37.4 in amateur athletes and 43.5% in professional athletes). This finding reveals the importance of complete healing after suffering sports injuries. However, the data can hardly be compared with the rates observed in similar scientific investigations due to the diversity of research protocols used. However, some studies have ascertained that a previous injury is a risk factor for subsequent injury [ 29 , 30 ].
The average injury rate (per 1000 playing and training hours) found in the present study was 2.64 per 1000 h. This figure is considerably lower than the rate observed by Arthur-Banning et al. [ 31 ] in practices in NCAA and club sports among college athletes, which was respectively 3.9 and 3.8. However, in the same study, they reported an injury rate during game competitions of 18.3 in club sports, 13.79 in NCAA, and 10.28 in intramural sports. Similarly, the injury rate found in this study was lower than the average injury rate (training and competition) found by Pujals et al. [ 19 ], which was 4.1.
On analyzing the injury rate by sport, it was observed that soccer presented the highest rate (7.21), followed by judo (4.82) and basketball (4.31). This suggests that contact sports involve an increased risk of injury. As for soccer, Watson [ 7 ] stated that injury rates in youth soccer range between 2.0 and 19.4. Therefore, the present study’s injury rate was relatively low since it was close to the lower limit of the incidence found in previous studies. We understand that the high IR of soccer is due to the following factors: (a) It is a contact sport. (b) It is played outdoors. This exposes soccer players to extreme weather conditions, such as cold in winter, heat in summer, and heavy rain in spring. (c) The characteristics of the soccer field and the use of soccer boots with studs can limit or impair lower limb movements, including rotation. (d) The ball is played mainly with the foot. In addition, very often, tackles are committed on the supporting leg. The injury rate found among judokas in this study is not comparable to the epidemiology data obtained in other studies with judokas since they focus exclusively on competition periods [ 32 ]. Regarding basketball, the current research’s injury rate was lower than the rate reported by Cumps et al. [ 33 ], which amounted to 6.0. The discrepancy between both figures could be due to the study mentioned above was conducted 12 years before the present study, and it is conceivable to think that the strategies to prevent injuries have improved. Furthermore, unlike in the present study, all participants were senior basketball players, which implies a higher volume and hours of practice, and a higher injury risk.
The most common injuries were: Lumbar muscle strains (65 injuries (12.28% of the total)), ankle sprains (63 injuries (11.91% of the total)), and bone fractures (49 injuries (9.31% of the total)). These results are consistent with Hootman et al. [ 34 ] and Trompeter et al. [ 35 ], since they also verify the high incidence of lumbar injuries and ankle sprains. By anatomical region, the three areas that concentrated the highest number of injuries were, respectively, ankles (36.12%), knees (19.32%), and shoulders (6.47%). These results agree with those obtained by Danes-Daetz et al. [ 3 ], who reported that the two most injured anatomical areas were ankles (24.1%) and knees (14.8%). The mentioned authors also observed that 63.0% of the injuries occurred in the lower extremities, 31.5% in the upper extremities, and 5.5% in the trunk. These results are similar to those obtained in the present study, in which 68.33% of the injuries occurred in the lower body, 20.45% in the upper limb, and 11.22% in the trunk. Habelt et al. [ 11 ] also observed a similar incidence (lower extremities 68.71%, upper extremities 25.27%, spine 2.57%, and head 1.99%).
Fifty-nine point twenty-eight percent of the injuries occurred during practices, and 40.72% during competition or peri-competition, reflecting that competition involves a higher injury risk. This matter has also been observed in previous studies [ 8 ]. The most common injury mechanisms observed in this study were no identifiable single events (repetitive transfer of energy, overuse) (30.64% of the cases) and acute non-contact trauma (21.44% of the cases). These results reflect that overuse injuries represent a high percentage of the total number of injuries reported. This finding is consistent with the study conducted by Patel et al. [ 8 ]. They state that overuse injury is often variable with the sport, but this type of injury is on the increase in adolescents due to the increased intensity in youth sports.
A higher injury rate in males than females has frequently been found in the scientific literature [ 36 , 37 ]. Traditionally, the highest injury rate among males has been attributed to the socialization processes. It is assumed that males take more risk and are less protected than females [ 37 ]. However, in the present study, no significant differences were observed between sexes in terms of ID, ISS, and IR. Pujals et al. [ 19 ] also found no sex differences in athletes of 25 sport modalities. Therefore, the impact of the sex factor remains unclear and might be studied in future research.
A significantly higher ID, ISS, and IR were observed in youth between 14 and 17 than those between 18 and 21. This result coincides with Patel et al. [ 8 ], who observed a higher IR among youth between 15 and 18. Sreekaarini et al. [ 38 ], in one study made with athletes, also observed a higher number of injuries in the age 14 years, followed by age 15 years. We consider that adolescents aged between 14 and 17 suffer more injuries due to the replication of adult sports training models in youth. In this respect, Hernán-Guzmán [ 39 ] attributes the increase in acute and subacute injuries in this age group to the increasing practice time and intensity in youth sports.
Although no significant correlation was found between ID, ISS and IR, and BMI, overweight study participants presented an ID and ISS significantly higher than normal-weight individuals. This finding agrees with the study of Richmond et al. [ 40 ]. They observed a greater injury risk in obese than in healthy-weight adolescents. Richmond et al. [ 41 ] also verified an increased risk of suffering a sports injury in obese adolescents. They attributed the increased injury risk to the greater absorption of forces by soft tissues and joints.
5.5. Competitive Level
No significant differences were found in ID, ISS, and IR between amateur and professional athletes in this research. This finding coincides with the results obtained by van Beijsterveldt et al. [ 42 ] in one study conducted with soccer players, where no significant differences were observed between amateur and professional individuals in the total number of injuries. Zurita Ortega et al. [ 43 ] also observed no significant differences in injury severity between professional and amateur athletes. However, they also reported that semi-professional athletes suffer fewer severe injuries.
All these results are surprising since it could be expected that amateur athletes suffer fewer injuries. Nevertheless, Bahr and Krosshaug [ 22 ] understand that the high incidence of sports injuries found in amateur athletes corresponds to an increase in youth sports competitiveness. Another possible explanation would be that the injury prevention strategies used by professional athletes are better than those applied to amateur athletes.
5.6. Weekly Hours of Practice
The present study verified that the number of weekly hours of practice is a decisive factor, since athletes who practiced sports for less than 10 h had a significantly lower ID, ISS, and IR than those who practiced sports for 10 h or more. Furthermore, there was also a significant positive correlation between weekly hours of practice and ISS and IR, further reinforcing this fact. These results seem to be logical. The greater hours of practice, the greater the exposure, and the greater cumulative fatigue. In this respect, Johnston et al. [ 29 ] observed that an increased injury risk in endurance sports was associated with high training distances, training frequency, and low weekly and high monthly training durations. However, they also state a lack of research analyzing the effect of training volume on injury rate.
5.7. Performing an Individualized and Sport-Specific Physical Preparation
As could be expected, this factor has proved to be relevant in the present study to prevent sports injuries. Significant differences were observed between the subjects who carried out an individualized and sport-specific physical preparation and those who did not in ID, ISS, and IR. Likewise, performing an individualized and sport-specific physical preparation presented a significant negative correlation with ISS and IR. However, although one of the main objectives of physical conditioning is to prevent injuries, to our knowledge, the effect of this factor in injury prevention has not been examined in previous studies. Therefore, it should be evaluated in future research.
5.8. Performing Specific Activities Aiming to Prevent Injuries
This factor has proved to be crucial in the present study to prevent sports injuries. The athletes who performed specific activities aiming to prevent injuries presented a significantly lower ID, ISS, and IR than those who did not. Furthermore, performing specific activities to prevent injuries significantly negatively correlated with ID, ISS, and IR. These results are consistent with the study conducted by Hanlon et al. [ 44 ]. They verified that injury prevention programs reduce modifiable intrinsic risk factors in the lower extremities among young athletes. Nevertheless, they also caution that several intrinsic risk factors were not significantly affected or addressed in the mentioned injury prevention programs.
5.9. Performing Warm-Ups Adapted to Athletes’ Abilities and Specific Characteristics of the Upcoming Activity
This factor was also essential to prevent sports injuries, as could have been expected. Subjects who performed appropriate warm-up activities presented significantly lower ID, ISS, and IR than those who did not. Likewise, performing adequate warm-ups had a significant negative correlation with ID, ISS, and IR. This result coincides with similar studies carried out with adolescents [ 45 , 46 , 47 ]. Therefore, based on the current evidence, and considering that one of the warm-up’s main objectives is to prevent sports injuries, it seems clear that warm-up is a crucial aspect in reducing injury risk. Therefore, adequate warm-ups might always be performed before training sessions.
5.10. Sports Equipment in Good Condition and Frequently Inspected
The subjects who used adequate sports equipment presented a significantly lower ID, ISS, and IR. Besides, a significant negative correlation between this factor and ISS was observed. In agreement with this result, Patel et al. [ 8 ] and Hootman et al. [ 34 ] consider that adequate sports equipment effectively minimizes sports injuries. Similarly, Sreekaarini et al. [ 38 ] verified that 28.8% of the sports injuries reported in one study made with adolescents were related to the equipment used.
5.11. Sports Facilities in Good Condition, Free of Obstructions, Well-Lit, Ventilated, and with Adequate Flooring
Although no significant correlation was found between this factor and ID, ISS, and IR, the subjects who used adequate sports facilities presented a significantly lower ID, ISS, and IR than those who did not. Therefore, using appropriate sports facilities can also be essential to prevent sports injuries. Accordingly, Sharma and Parveen [ 48 ] state that sports facilities have a significant role in the prevention of sports injuries, and Sreekaarini et al. [ 38 ] reported that (in the study mentioned in the previous section), 47.6% of the sports injuries were due to the sports surface.
5.12. Training Load
Predictably, this factor has proven to be relevant to prevent sports injuries. Subjects who used a significantly lower training load adapted to athlete’s ability presented a significantly lower ID, ISS, and IR than those who did not. Moreover, using an adapted training load was negatively correlated with ID and IR. This result coincides with numerous studies emphasizing the need to monitor and adapt the training load in youth sports to prevent sports injuries [ 30 ].
5.13. Sports Technique
As expected, this factor proved to be crucial in preventing sports injuries since it presented a significant negative correlation with ID, ISS, and IR. Additionally, the study participants whose sports techniques one sports coach supervised execution had a significantly lower ID, ISS, and IR than those who did not. These results are also consistent with numerous studies indicating that correct technical execution is a crucial factor in sports injury prevention [ 11 ].
5.14. Following a Healthy, Balanced, and Individualized Diet
The present study verified that this factor did not influence ID, ISS, and IR. Actually, the role of nutrition in injury prevention is not entirely clear. Close et al. [ 49 ] point out that nutritional interventions could reduce the onset of acute injuries in track and field athletes. Zurita-Ortega et al. [ 41 ] add that prevention strategies must include nutritional interventions due to injuries’ multifactorial nature. However, randomized controlled studies are needed to verify the role of this factor in injury prevention.
5.15. Being Subjected to Stress Due to the Pressure Received from Family Members, Coaches, Friends, or Self-Imposed
The stress factor did not exert an evident influence on the occurrence of sports injuries. Stress was only positively correlated with IR. Furthermore, there were no significant differences in ID, ISS, and IR between the athletes subjected to stress and those who were not. In this respect, Sreekaarini et al. [ 38 ] verified that stress is a determining injury risk factor in adolescent athletes. Nippert and Smith [ 50 ] also indicated that psychological interventions could potentially reduce the occurrence of injuries. However, we consider more studies are needed to determine the real impact of this factor on ID, ISS, and IR.
5.16. Study Limitations and Future Research Lines
The main limitation of the present study was the difficulty of comparing its findings with other sports-related injury research. This is due to the important differences between studies in key aspects such as the definition of injury, methodological criteria used, target population, data reporting, variety of sports analyzed, and variety of sports practice contexts. Another limitation is that the study was conducted in one of the 17 regions comprising the country. Therefore, the results are not generalizable to the remaining 16 regions.
Future research should continue registering sports injury epidemiological data using standardized methods and measurements, such as the injury rate. The studies might be prospective and randomized, and the recommendations established by the International Olympic Committee Consensus Statement might be followed [ 21 ]. In this way, valid comparisons between studies could be made. Future studies should also examine the effect of certain injury risk factors, particularly those barely studied (training volume and sport-specific physical preparation), and on those whose influence remains unclear (nutrition, stress, and sex).
Forty point four percent of the participants suffered an injury in 2019. Although this figure was lower than in previous recent studies, it is still very high considering the economic and human burden of sports injuries. Thirty-nine percent of the athletes suffered an injury in a previously injured area, reflecting the need for complete injury healing. The average injury found was 2.64 per 1000 h. Three contact sports presented the highest injury rate: soccer (7.21), judo (4.82), and basketball (4.31). The most common injuries were lumbar muscle strains (12.24%), ankle sprains (11.98%), and bone fractures (9.31%). By anatomical region, the three areas that concentrated the highest number of injuries were ankles (36.12%), knees (19.32%), and shoulders (6.47%). Fifty-nine point two eight of the injuries occurred during practices, and 40.72% during competition or peri-competition.
Furthermore, increased IR was associated (in that order) with: (a) Greater number of hours of practice per week. (b) Do not perform warm-ups. (c) Using inadequate sports facilities. (d) Being aged 14–17. (e) Do not perform physical preparation. (f) Inappropriate training load. (g) Do not perform injury-preventive activities. (h) Performing sports technique without the supervision of one sports coach. (i) Inadequate sports equipment. Since many of these factors are modifiable, preventive programs must be designed and implemented to reduce both the number of injuries and the injury rate. In contrast, sex, competitive level (amateur or professional), and following a healthy, balanced, and individualized diet did not influence IR. Moreover, being under stress could increase the IR, and being overweight the ID and ISS.
Since the number of injuries suffered by adolescent athletes and their injury rates still remains high, it is necessary to continue implementing prevention programs to make youth sports practice safe and healthy. Particular attention should be paid to prevent injuries in the following programs: injuries in contact sports, lower-body injuries, and injuries occurred during sports competitions. Preventive programs should also focus on modifiable injury risk factors, such as performing appropriate warm-ups, using adequate sports facilities, performing sports-specific physical preparation, adapting the training load to the athlete’s ability, performing injury-preventive activities, performing sports techniques under the supervision of a sports coach, and exercising with adequate sports equipment.
Conceptualization, P.P.-G.; Methodology, P.P.-G., J.L.M.-C. and J.S.-I.; Software, P.P.-G.; Validation, J.L.M.-C., L.M.F.-G. and A.C.; and S.S.; Investigation, J.L.M.-C., L.M.F.-G. and S.S.; Resources, A.C.; Data Curation, J.S.-I.; Writing—Original Draft Preparation, P.P.-G.; Writing—Review & Editing, A.C.; Supervision, J.S.-I.; Funding Acquisition, P.P.-G. All authors have read and agreed to the published version of the manuscript.
The authors would like to recognize the efforts made by Prince Sultan University in funding the research either with fees, incentives or seed grants.
Institutional Review Board Statement
The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of the Bioethics Committee at Prince Sultan University in Riyadh, Saudi Arabia. (approval no. PSU IRB-2018-010017).
Informed Consent Statement
Informed consent was obtained from all subjects involved in the study.
Conflicts of Interest
The authors declare no conflict of interest.
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Personal and Situational Factors Affecting Psychological Response to Sport Injuries
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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
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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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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Open access funding provided by University of Gothenburg. The Swedish Research Council for Sport Science (CIF) has been funding the FIT project since 2016 through partial funding of a PhD studentship (F2016-0017; FO2021-0016; FO2017-0004; FO2018-0007; FO2020-0005; FO2021-0016) and partial project funding for one year (P2017-0090). The FIT project application was developed for a specific 2014 CIF call for interdisciplinary research on health and performance in child and adolescent sport. CIF funds research in the field of sports, which are defined to include everything from club sports to exercise, physical activity, performance and training for children, young people, adults, and the elderly.
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Department of Food and Nutrition, and Sport Science, University of Gothenburg, Box 300, 405 30, Gothenburg, Sweden
S.E Hausken-Sutter, A Schubring, S Grau, J Jungmalm & N Barker-Ruchti
Department of Sport Science, Malmö University, Malmö, Sweden
K Boije af Gennäs
Institute of Sociology and Gender Studies, German Sport University Cologne, Cologne, Germany
School of Health Sciences, Örebro University, Örebro, Sweden
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NBR initiated and designed the FIT project with SG. SEHS and NBR led the drafting of the manuscript. All authors collected and analysed the data. KBaG, AS, SG, JJ and NBR contributed to the writing of the manuscript. All authors read and revised the manuscript. All authors read and approved the final manuscript.
Correspondence to S.E Hausken-Sutter .
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Ethical approval was obtained from the Central Ethical Review Board in Gothenburg on 18 October 2017 (Dnr 815–17). In accordance with the Swedish Ethics Review Law, participants over the age of 16 gave their own written consent. For participants below 16 years of age, written informed consent was obtained from a parent or a guardian. All methods were carried out in accordance with relevant guidelines and regulations.
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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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DOI : https://doi.org/10.1186/s12874-023-01929-1
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Specialty grand challenge article, great challenges toward sports injury prevention and rehabilitation.
- 1 Inter-university Laboratory of Human Movement Science (LIBM EA 7424), University of Lyon, University Jean Monnet, Saint Etienne, France
- 2 Faculty of Medicine, Department of Clinical and Exercise Physiology, Sports Medicine Unit, University Hospital of Saint-Etienne, Saint-Etienne, France
- 3 Department of Physical Therapy, Congdon School of Health Sciences, High Point University, High Point, NC, United States
While the positive benefits of sport participation are numerous, unfortunately this is balanced by the negative effects of injury ( Engebretsen and Bahr, 2005 ; Merkel, 2013 ; Malm et al., 2019 ). Sports injury prevalence and incidence vary according to sports and population. And unfortunately, short- and long-term negative consequences can impact a variety of different domains (e.g., physical, psychological, sport, professional, financial, or social). Whatever these impacts, there is a need to reduce the occurrence and consequences of sports injury in order to allow a healthy and sustainable sports participation ( Engebretsen and Bahr, 2005 ). This is the important challenge of injury prevention and rehabilitation! This challenge includes primary prevention (i.e., to reduce the occurrence of the first injury event), secondary prevention (i.e., to reduce the occurrence of reinjury after a first injury event) and tertiary prevention (i.e., to reduce the occurrence of sequalae) ( Commission on Chronic Illness, 1957 ).
The popular saying, “prevention is better than cure,” has been known for quite some time. While large efforts have launched to continue to engage in this challenging goal of injury prevention, it still remains a real problem in sports. This could be due to the complex and multifactorial nature of sports injury ( Meeuwisse, 1994 ; Bittencourt et al., 2016 ; Pol et al., 2019 ), which makes its “prevention” / “reduction” difficult. It seems that sports injury is not the result of one unique cause but likely the combination and interactions of several factors (including among others intrinsic and extrinsic risk factors and injury mechanism) ( Meeuwisse, 1994 ; Bahr and Krosshaug, 2005 ; Bittencourt et al., 2016 ).
In order to face this challenging problem of sports injury, there is thus even more of a need to understand sports injury: How to monitor sports injury? What are the risk factors? How these factors interact? What is the healing process injured tissue? How can we optimize the process of healing, functional recovery, and safe return to sports? Then, there is a need to continue to reflect and develop strategies that can help to reduce the occurrence and recurrence of sports injuries: How can we play on/modify these factors to reduce the occurrence and/or recurrence of sports injuries? Which strategy or combination of strategies can reduce the occurrence and/or recurrence of sports injuries? Are these strategies efficient to reduce the occurrence and/or recurrence of sports injuries, in the context of scientific studies and in real life? How can we implement these strategies? How can athletes be compliant with these strategies? To answer these questions and reach this great challenge of injury prevention and rehabilitation, we believe that there is not one way, we believe that approaches should be comprehensive, multidisciplinary and holistic, including contributors from different fields, with communication between them and by embracing new fields.
Prevent or Reduce?
Before going to concrete aspects, there is maybe a need to improve knowledge and accuracy on some conceptual and terminological aspects.
“Prevention” is a widely used term, however, this is likely not the most appropriate or feasible term within sports. This term is well-known and recognized as a banner of work which aims to protect the health of athletes, especially injuries and illnesses, perhaps thanks to the important efforts of the Oslo Sports Trauma Research Center and the IOC toward injury and illness prevention ( Engebretsen and Bahr, 2005 ; Ljungqvist, 2008 ; Engebretsen et al., 2014 ). Although this term could be useful to describe the field (as we use for the name of our section Injury Prevention and Rehabilitation ), it is maybe not the most appropriate when we want to accurately discuss about the concrete goals. Indeed, “prevention” means no occurrence of injuries, which is probably not possible. So, most appropriate terms would probably be “injury control” or “injury risk management” or “injury risk reduction” ( Avery, 1995 ; Webster and Hewett, 2018 ). Other terms are also used on our field that deserve to have clear definitions for proper use, such as for instance “efficacy,” “effectiveness,” “compliance,” “prediction,” “prognostic.” Therefore, we believe that some discussions, researches and/or consensus should clarify these aspects.
In addition, sports injury prevention research is often modeled around the classic four-step sequence presented by van Mechelen et al. (1992) nearly 30 years ago. This model has provided a conceptual framework to monitor progress and effectiveness of decreasing the incidence of a variety of sport injuries ( Edouard et al., 2015 ; Hewett et al., 2016 ). The “sequence of prevention” conceptual framework was extended in 2006 by Finch (2006) to phases related to the implementation of prevention measures and evaluation of real-world impact. Recently, Bolling et al. (2018) revised the four-steps sequence by improving the first step of the sequence extended to exploration of the context of the sports injury. Other frameworks have been developed to detail some steps of the sequence or some specific aspects, for instance, concept of sports injury ( Timpka et al., 2014b ), etiology of sports injury ( Meeuwisse, 1994 ), understanding injury mechanisms ( Bahr and Krosshaug, 2005 ), a biomechanics-focused model ( Hewett and Bates, 2017 ), complex systems approach ( Bittencourt et al., 2016 ; Pol et al., 2019 ), risk factor-based categorization of the prevention ( Jacobsson and Timpka, 2015 ), prevention measure implementation ( Tee et al., 2020 ), and individualized approach ( Roe et al., 2017 ). These conceptual frameworks of sports injury prevention research can continue to benefit from improvements or details to help researchers and/or practitioners.
Primary and Secondary Prevention = Same Fight!
Methodology used in primary prevention could seamlessly assist secondary prevention and vice versa ( Hewett and Bates, 2017 ; Cools et al., 2020 ). In addition, given the high prevalence of sports injury, a large percentage of athletes will participate in sport with history of previous injury. Therefore, the need for secondary prevention is ongoing and increasingly more important as athletes age. However, primary and secondary approaches are sometimes compartmentalized; sports scientists and coaches may be more involved with primary prevention, while health professionals involved with secondary prevention. Consequently, scientific literature may also be compartmentalized. Therefore, we strongly support that all knowledge regarding both primary and secondary prevention should be directly translated to all stakeholders (applied, clinical). In addition, we suggest increased communication and collaboration between professionals and community to reach success in this challenge.
Specificity of Sports Rehabilitation
Secondary prevention can be addressed through rehabilitation ( Hewett and Bates, 2017 ; Cools et al., 2020 ). This particular phase of the sports injury management has some specificities. It aims to orient/guide the injured tissue healing process, restore the function, and help the patient/athlete return to sporting activities while at the same time minimizing the risk of reinjury. This multi-goal management is currently approached mainly through biological/physical aspects (e.g., physiological, biomechanical…). However, psychological, social and contextual factors play a critical role in the recovery of patients/athletes after sports injury, and should be taken into account in this phase of the sports injury management.
Sports rehabilitation should thus be done in a multifactorial biopsychosocial approach, bringing the patient/athlete from injury to return to his desired activity, by taking into account the consequences of the sports injury at these different levels ( Ardern et al., 2016 ; Van Melick et al., 2016 ; Cools et al., 2020 ).
Unity is Strength: Need of Multidisciplinary Teamwork!
To face the problem of sports injury, everyone is needed! Each person has a different experience, expertise, and view of the problem. So, it is important to encourage and act on the input from all parties involved. This implies a multidisciplinary approach, with inputs from several fields (e.g., sports medicine, sports and exercise science, physical conditioning and training, biomechanics, nutrition, physiology, psychology, sociology, data science…). This implies for instance at a field level that health professionals and coaching staffs, who are facing the same problem of sports injury, share their points of view, arguments, proposals of management in order to find the optimal solution for athletes. Likewise, this should be extended to other fields working with athletes in order to create a cohesive multidisciplinary team. This approach should be favored at the field/clinical and research levels.
Such an approach implies communication to go beyond discussions simply within a field and extend to discussions between diverse fields of interest. This also means for athletes' monitoring or research purpose collecting data from different fields, and probably makes choice or compromise given the amount of data this can represent. These discussions or choices are probably not easy because of some conceptual or language barriers, potential for competition, or perceived skepticism. There will maybe a need to structure discussion / choice, and there is a need to clarify the responsibility of each other, especially when coming the decision. But we believe that this is a relevant orientation to overcome the great challenge of sports injury prevention and rehabilitation. We suggest this would be a win-win approach for all stakeholders. The resulting benefits of discussion, exchange, and collaboration would be greater than the sum of each individual input.
Need for a Holistic and Individual Approach
Recent evidence supports that several factors of varying types can play a role in the occurrence of injury or reinjury ( Kerkhoffs et al., 2012 ; Hewett et al., 2016 ; Green et al., 2020 ). In addition, each athlete will respond differently to these factors and combination of factors; each will not have an injury for the same reasons. Hence, patients will respond differently to the injury and its consequences. This is supported in contemporary sports injury management which should utilize a bio-psycho-social approach at an individual level and grounded in evidenced-based practice. Thus, efforts should be made in sports injury research to provide knowledge and evidence in each of these different fields, and if possible, combining all these fields.
Given the complexity of sports injury, the research approach currently simplifies the problem, but there will need to go deeper in complex multifactorial individualized approach to better meet the “reality” of sports injury ( Meeuwisse, 1994 ; Bittencourt et al., 2016 ; Pol et al., 2019 ).
There is thus a need for a more complex approach, a comprehensive holistic and individual approach, as for understanding the determinants of the sports injury as for the development of strategies that aim to reduce the occurrence of injury or reinjury. Examples are proposed through conceptual or perspective articles ( Mendiguchia and Brughelli, 2011 ; Mendiguchia et al., 2017 ; Buckthorpe et al., 2019 ), and there is now a need to provide supporting evidence of the theses approaches.
Improve Methodological and Analytical Approaches
One of the challenges in injury prevention research is to capture the outcome, i.e., sports injury. Efforts have been done to develop and improve methodology for recording and reporting injuries ( Hagglund et al., 2005 ; Fuller et al., 2006 ; Junge et al., 2008 ; Timpka et al., 2014a ; Bahr et al., 2020 ) and should continue to most accurately capture injuries and their complexities.
Alternative analytical approaches of effectiveness of injury prevention measures can use as outcome the consequences of the sports injury at physical, psychological, social or financial levels. Injury prevention is of course useful to reduce the occurrence or reoccurrence of injuries, but also that of sequelae ( Engebretsen and Bahr, 2005 ) or of the financial impact ( Krist et al., 2013 ). Taking into account the economical burden of sports injuries ( Hickey et al., 2014 ; Hespanhol Junior et al., 2017 ) could also be a way to improve stakeholders adherence to prevention and increase means for sports injury prevention and rehabilitation at the practical and research levels.
The multifactorial biopsychosocial approach leads to the need of adding in the measurements, data collection or monitoring, information related to the sports injury and the injured athletes, taking into account their multifactorial and complex nature, as well as about the context including individual, socio-cultural and environmental/policy levels ( Bolling et al., 2018 ).
The multifactorial approach leads to multimodal methodological approaches. Traditionally quantitative analyses are used in sports injury prevention and rehabilitation research. There is thus a need to improve knowledge through qualitative approach ( Bolling et al., 2018 , 2019a , b ). There is also a need for more behavioral approach when it comes to actual sports injury prevention ( Verhagen et al., 2010 ) and when we aim increase compliance to prevention measures.
The multifactorial approach leads to analytical challenges. Indeed, this implies increasing the magnitude and type of data, which is of interest to fit the complex nature of sports injury, but can be difficult to managed by traditional analytical approaches, and for sure imply the collaboration with statistical and data science community ( Casals and Finch, 2018 ; Nielsen et al., 2020b ). To analyse complex interactions between factors and/or between sports injury and factors, there is a need for new analytical advances ( Bittencourt et al., 2016 ; Nielsen et al., 2020b ). As a consequence, other fields of data analyses, such as for instance machine learning, will continually be embraced in the future ( Bittencourt et al., 2016 ; Ruddy et al., 2019 ). These analytical approaches may help analyse complex interactions as well as estimating the risk of sports injury occurrence, with application to understand the sports injury as well as to reduce their occurrence or recurrence ( Bittencourt et al., 2016 ; Ruddy et al., 2019 ).
In addition, there is a need to use appropriate methodologies to analyse the efficacy of each of these strategies. Randomized Controlled Trial is currently the gold standard to analyse the efficacy of an intervention ( Philipps et al., 2009 ), it is the design that should allow the highest level of evidence by minimizing the risk of bias. However, such design may not be the most relevant to reflect the reality of sports given, among others, the risk of low compliance ( Nielsen et al., 2020a ). We could benefit from improvement in methodological design inspired from other research fields. In addition, usual analytical approaches, such as intention-to-treat, per protocol or as treated analyses, can lead to bias, especially in the context of low compliance (Edouard et al., in revision). Therefore, there is a need to explore other analytical approaches, as IV analysis, or other G-estimation, which can address some of the problems that arise from low compliance without losing the value of randomization and can also be helpful in observational studies (Edouard et al., in revision).
Although injury prevention and rehabilitation are not new disciplines, there is still an unmet need to improve knowledge toward theoretical understanding on epidemiology, risk factors, and injury mechanisms, as well as on practical strategies that can reduce the risk of sports injury or reinjury and of sequalae after injuries. Given the complex nature of injury, a holistic multifactorial biopsychosocial approach is needed through comprehensive, multidisciplinary and individualized approach to reach this great challenge. We therefore hope that this new section Injury Prevention and Rehabilitation of the Frontiers in Sports and Active Living can contribute to this improvement of knowledge, but also positively impact the sustainable and safe participation and short and long-term health of athletes.
All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.
This work was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under award number R21AR069873 (to KF).
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Keywords: health protection, sports injury prevention, injury risk, sports rehabilitation, multidisciplinary approach, multifactorial approach
Citation: Edouard P and Ford KR (2020) Great Challenges Toward Sports Injury Prevention and Rehabilitation. Front. Sports Act. Living 2:80. doi: 10.3389/fspor.2020.00080
Received: 26 May 2020; Accepted: 28 May 2020; Published: 03 July 2020.
Edited and reviewed by: Gregoire P. Millet , University of Lausanne, Switzerland
Copyright © 2020 Edouard and Ford. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Pascal Edouard, Pascal.Edouard42@gmail.com ; Kevin R. Ford, email@example.com
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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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