Discussion

This study determined the prevalence, severity, nature and causes of injuries and illnesses in TeamGB athletes during the Sochi 2014 Winter Olympic Games. The main findings are that (1) the prevalence of athlete injury was approximately double that of athlete illness; (2) the lower limb was the most commonly injured body region (46% of all injuries) and (3) respiratory system athlete illness was the most common illness.

The rates of injury and illness in the present study (39% and 18% of TeamGB, respectively) were much higher compared with those in previous studies completed by the IOC at both the Summer and Winter Olympic Games in London 2012 and Vancouver 2010 (injury 11% and illness 7% at both Games).3 ,4 The most likely reasons for this are the size of the study cohort, where small changes in the injury or illness numbers can influence prevalence rates to a larger degree, the slightly longer 25 days data collection period (for TeamGB, this included starting 8 days prior to the official opening ceremony) and more sensitive methods of data recording. For example, a small athlete cohort coupled with nine medical and physiotherapy practitioners (equals 6 athletes per practitioner), covering only 13 of the 22 Olympic sport competition and training venues, would likely enable practitioners to have greater awareness of issues as they occurred. Also, data collection forms including all medical-attention, performance-restriction and time-loss athlete injuries and illnesses would lead to greater reporting of not just acute traumatic injuries and illnesses but also overuse/chronic issues;18 ,22 enabling capture of less ‘serious’ injuries and illnesses, that is, those requiring medical attention only and/or performance restriction, whereby they may often be traditionally missed in reporting in favour of the more obvious severe injuries/illnesses. The current data support this theory, where although the overall rates of injury and illness were high, the majority of these were medical attention/performance restriction, with only 7% of all injuries and 9% of all illnesses resulting in the time loss definition. In contrast, 23% of injuries (with authors suggesting this was an underestimation) and 35% of illnesses were reported to result in time loss at the Vancouver 2010 Winter Olympic Games.3 Limitations to time-loss methodologies have been recognised for several years, and it is known that athletes will continue to train and compete, even at high levels, while experiencing restrictions in their performance as a result of injury and illness. The emergence of a number of recent studies has started to address and propose solutions to this problem.18 ,22 ,23 Hence, the current IIPP methods’ inclusion of a performance-restriction classification provides an important additional layer of information, and better characterisation of injury and illness risk factors, potentially negating an overestimation of the true number of impactful time-loss events, and underestimation of the true impact of some previously (incorrectly) classified medical-attention issues.

Upper respiratory illness (URI) was the most common type of illness with TeamGB, the same as reported in previous Winter Olympic Games studies.3 ,17 Elite athletes are more susceptible to URI than their recreational counterparts,24 and environmental factors such as cold dry air inhalation outside, particularly at the high altitude venues, regular changes in temperature extremes going from inside athlete accommodation and other living quarters to outside, coupled with high respiratory air flow rates during high-intensity exercise, and the stress and intensity of Olympic competition are just some of the factors cited to contribute to this prevalence of URI.24–26 With the relative warmth of the sea-level venues at the Sochi Winter Olympic Games, and 8 of 11 illnesses occurring in athletes from the mountain village venues (ie, skiing, snowboarding and sliding events), this adds weight to the theories proposed. By gender, the rate of female athlete illness in the present study was higher than for their male counterparts. In addition, it appeared that older female athletes may be at greater risk of illness. These findings are in agreement with the results reported from the Vancouver Olympic Games, where female athlete illness rates were also higher than those in male athletes, and with ill female athletes being significantly older than their healthy counterparts. Further analysis on the causation of this phenomenon, and whether it is solely an issue for Winter sports, could help our understanding and begin to unpick this issue. Prior to the Games, TeamGB athletes and support staff received illness awareness information, which included updates on hand-washing techniques, use of antimicrobial hand foam bottles and prophylactic nasal gels. This formed a small part of the overall TeamGB Games preparation work delivered to the athletes. Continued work focusing on athletes participating in events in colder and higher altitude venues, and on older female athletes, in particular those with a previous history of repeated upper respiratory tract illness, may be of benefit.

In the present study, just over half of all TeamGB injuries occurred in snowboarding and freestyle skiing. Relative to competing athletes, overall freestyle skiing followed by skeleton and snowboarding presented the greatest risk for injury, and Alpine skiing, biathlon and curling having the lowest risk, with no injuries reported in these sports. However, data numbers were very low when broken down by sport and results should be interpreted with some caution. Owing to limited injury/illness numbers, some sports remained grouped, that is, snowboarding and freestyle skiing, encompassing all disciplines. Overall, the current study data were broadly consistent with previously reported findings by Engebretsen et al3 where freestyle skiing and snowboarding presented the greatest injury risk, and biathlon and curling the lowest. The location and type of all injuries were also similar to that reported previously from Vancouver, with joint (ligament) sprains and contusions most common, and lower limb injuries predominant, across TeamGB.

Contact with a static object was equally the most common cause of injury alongside recurrent injury within TeamGB. Although relatively common, the severity of recurrent injury was very low, with all resulting in medical attention only. This suggests that athletes were seeking maintenance type treatment for recurring index injuries. While they were not by definition impactful, this does suggest that full and complete rehabilitation of these injuries before returning to training and competition had not been completed, and that athletes were affected in a way that caused them to seek treatment. At the highest level of competition, such as the Olympic Games, where winning margins are small, these may have subtly affected athletes to a greater or lesser degree. Hence, return-to-play decisions should be reviewed by medical staff,27 including the pressure from athletes themselves and/or coaches to return early from injury or illness in the run-up to important events such as the Olympic Games. In contrast to recurrent injury severity, almost half of all contact static object injuries were impactful, resulting in a total of 38 performance-restriction/time-loss days. With 78% of all reported contact with static object injuries (ie, with the ground) occurring in snowboarding and freestyle skiing, this indicates that falls were the predominant cause of the higher risk of injuries observed in these sports at the Sochi 2014 Winter Olympic Games. The most severe of these occurred in freestyle skiing with 33 performance-restriction/time-loss days resulting, with one training related injury forcing an athlete to withdraw completely just prior to competition. Although data numbers are low in the current study, these results are in agreement with previous findings by Flørenes et al,28 where the authors reported a high injury rate, especially for severe injuries in World Cup freestyle skiers.

Snow sports such as snowboarding and freestyle skiing are sports that can be affected by adverse weather and snow conditions, and these were reported to be an issue during the Sochi 2014 Winter Olympic Games, with warm weather contributing to soft snow conditions, and reports of more athletes falling during jumps and landing, as a result.29 Standardised guidelines on the quality of snow, and other variables such as the height and technicality of jumps within snowboarding and freestyle skiing in particular, may need to first be implemented during regular season competitions, and then also during the Olympic Games, to try to alleviate the number of fall-related contact injuries in these sports especially.

The main strengths of the present study were the detailed and sensitive data collection methods used, and where reporting accuracy was high given the practitioner to athlete ratio and smaller number of TeamGB athlete events. This also poses a limitation of the work, where high athlete to practitioner ratios would be less likely to occur for many other National Olympic Committee (NOC) delegations, particularly for larger countries. For these larger delegations with more athletes, competing in all 22 sporting events being more disparate across various competition and training venues, it might be more challenging to have knowledge of all medical issues as they arise, and to discern between the more sensitive levels of injury/illness classification. Other strengths include the prospective nature of data collection in one of the most unique sporting competitive environments, the Olympic Games, which provides a valuable insight into the issues suffered by high performance athletes at the pinnacle competitive event of their sporting careers. While the rate of injury and illness was established during the Olympic Games period, it was not logistically possible to record the amount of time dedicated to training and competition for TeamGB athletes. It is known that greater exposure to the environment of risk can increase the absolute number of injury and illness episodes. Hence, in order to determine the true risk of injuries (in particular), inclusion of an exposure time component, that is, the amount of time spent in training and competition, would help to identify more accurate indices of the rate and therefore risk of injury by sport.