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Abstract
Objective To analyse differences between athletic disciplines in the frequency and characteristics of injuries during international athletics championships.
Methods Study design, injury definition and data collection procedures were similar during the 14 international championships (2007–2018). National medical teams and local organising committee physicians reported all newly incurred injuries daily on a standardised injury report form. Results were presented as number of injuries and number of injuries per 1000 registered athletes, separately for male and female athletes, and for each discipline.
Results From a total of 8925 male and 7614 female registered athletes, 928 injuries were reported in male and 597 in female athletes. The discipline accounting for the highest proportion of injuries was sprints, for both men (24%) and women (26%). The number of injuries per 1000 registered athletes varied between disciplines for men and women: highest in combined events for male athletes (235 (95% CI 189 to 281)) and female athletes (212 (95% CI 166 to 257)), and lowest for male throwers (47 (95% CI 35 to 59)) and female throwers (32 (95% CI 21 to 43)) and for female race walkers (42 (95% CI 19 to 66)). Injury characteristics varied significantly between disciplines for location, type, cause and severity in male and female athletes. Thigh muscle injuries were the main diagnoses in the disciplines sprints, hurdles, jumps, combined events and race walking, lower leg muscle injuries in marathon running, lower leg skin injury in middle and long distance running, and trunk muscle and lower leg muscle injuries in throws.
Conclusions Injury characteristics differed substantially between disciplines during international athletics championships. Strategies for medical service provision (eg, staff, facilities) during athletics championships should be discipline specific and be prepared for targeting the main injuries in each discipline.
- injury prevention
- surveillance
- epidemiology
- athletics
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Introduction
Competing and training in athletics (‘track and field’) carries the risk of injury,1 2 especially in international athletics championships where about 10 injuries per 1000 registered athletes have been reported,3 with a slightly higher risk in male than female athletes and sex related differences in injury characteristics.4
Athletics comprises several disciplines with different physical, mechanical, technical and psychological demands, which can potentially lead to different constraints on the musculoskeletal system.1–4 During international athletics championships lasting 3–9 days, the number of injuries per 1000 registered athletes differed by sex and athletic discipline.3–8 Differences between disciplines in injury location were also observed3 but their potential discipline specific differences between male and female athletes were not reported. Differences in other injury characteristics (eg, type) were not reported. Thus, the specific injury patterns (ie, combinations of the characteristics) in different athletic disciplines have not been described for high level athletes during international championships, although such information is of major interest.3 4
We investigated differences among athletic disciplines in the frequency and characteristics of injuries sustained by male and female athletes during international athletics championships.
Methods
The study used a total population design in which eligible participants were all athletes registered for 14 international athletics championships.
European Outdoor Championships 2012,7 2014, 2016, 2018;
World Indoor Championships 2014; and
European Indoor Championships 2009, 2011,11 2013,8 2015, 2017.
The analyses were based on an injury database comprising data collected using the same study design, injury definition and data collection procedures (previously described in detail3–9 11–13). The database was updated and extended from previous studies.3 4 All injury reports in the database were anonymous—that is, they were not associated with individual athletes. There was no patient or public involvement. The study was reviewed and approved by the Saint-Etienne University Hospital ethics committee (institutional review board: IORG000481).
Newly incurred injuries during the athletics championships were reported daily by the national medical teams (physicians and/or physiotherapists) and/or by the local organising committee physicians. Specifically, the instructions were to report 'all musculoskeletal injuries (traumatic and overuse) and concussion newly incurred during competition or training regardless of the consequences with respect to the athlete’s absence from competition or training'.3 4 9 13 In cases where a single incident resulted in more than one injured body part and/or type of injury, each body part and/or type injury was counted as a separate injury.4 12 We used the classification for location, type, cause, severity, circumstance and discipline (event) described in the consensus statement for epidemiological studies in athletics.13 Location was grouped into head, trunk, upper extremities and were detailed for the lower extremities. Type was grouped according to the type of tissue (ie, muscle, tendon, ligament, articular, bone, skin and other). Cause was grouped into overuse, traumatic and other. Preliminary diagnoses were constructed using the combination of location and type for each injury.
National medical team participation, athletes’ coverage, response rate and data completeness were reported according to Edouard et al.14 The total number of registered athletes was calculated by totalling the athlete registrations at each of the 14 championships using the list of registered athletes provided by the International Association of Athletics Federations or the European Athletics Association for each championship (ie, if an athlete registered for more than one championship they were counted for each championship).4 12 15 We analysed the number of athletes who registered for more than one championship. Athlete days were calculated by multiplying the number of athletes registered for a championship by the number of days of the respective championship.15–17
Results are presented as number of injuries, number of injuries per 1000 registered athletes and number of injuries per 1000 athlete days (with 95% CI)3 4 12 13 for all and time loss injuries during training and competition, separately for male and female athletes,4 and for each discipline, for all championships as well as for outdoor and indoor championships. We thereafter analysed differences in the distribution of injury characteristics (ie, location, type, cause and severity) between the nine disciplines separately for male and female athletes for all championships. Finally, for each discipline, we analysed the distribution of injury characteristics for all recorded injuries between male and female athletes, as well as differences between outdoor and indoor championships for male and female athletes separately. We used χ2 tests or Fisher’s exact test where appropriate, and Cramer’s V method for estimation of effect size (small, medium or large).18 19 Significance was accepted at p<0.05. Bonferroni corrections were made to control for multiple tests.
Results
Study participation and exposures
On average, 86.8% of all national medical teams, covering 81.0% of registered athletes, participated in the injury surveillance project and returned 91.6% of the expected report forms. The completeness of injury data use in the present study averaged 98.2%. No athlete refused to allow their data to be used for scientific research.
A total of 8925 male and 7614 female athlete entries were registered at the 14 championships, comprising a total of 78 days (19 days for the 6 indoor and 59 for the 8 outdoor championships). Most athletes (2339 men and 2090 women) registered for 1 championship, 898 men and 790 women athletes registered for 2 championships, 478 and 372 for 3 championships, 263 and 216 for 4 championships, 139 and 119 for 5 championships, 82 and 65 for 6 championships, 58 and 50 for 7 championships, 27 and 29 for 8 championships, 19 and 20 for 9 championships, 8 and 9 for 10 championships, 15 and 6 for 11 championships, 4 and 2 for 12 championships, and 2 and 2 for 13 championships (information was missing for 5 men and 11 women). The duration differed between indoor (mean 3.2 days, range 3–4) and outdoor (mean 7.4 days, range 5–9) championships. Most athletes were registered for sprints, followed by jumps and throws (table 1).
Number of registered athletes and reported injuries according to type of championships, sex and discipline
Number of injuries
A total of 1530 injuries were reported during the 14 championships, 928 in male and 597 in female athletes (information on sex was missing for 5 injuries). Most of the injuries were sustained in sprints by both male (24.2%) and female (26.1%) athletes, followed by jumps (15.8%) and middle distances (10.8%) for male athletes, and long distances (14.1%) and jumps (11.9%) for female athletes (table 1 and online supplementary tables 1 and 2).
Supplemental material
The number of injuries per 1000 registered athletes and per 1000 athlete days varied between disciplines for male (figure 1, table 2 and online supplementary tables 3 and 5) and female athletes (figure 1, table 2 and online supplementary tables 4 and 5). Overall, the number of injuries per 1000 registered athletes and 1000 athlete days was highest in combined events for male and female athletes, and lowest in male and female throwers and in female race walkers (figure 1, table 2 and online supplementary tables 3 to 5).
Number of reported injuries and time loss injuries per 1000 registered male (blue) and female (red) athletes for each discipline, in (A) all (outdoor and indoor) championships and (B) separately for outdoor and indoor championships and for competition and training. The dot represents the value of the number of reported injuries per 1000 registered athletes, and the size of the ellipsoid form represents the 95% CI.
Number of reported injuries (all injuries) per 1000 registered athletes in male and female athletes according to discipline
Interdiscipline differences in injury characteristics
Regarding all injuries recorded in the outdoor and indoor championships, the distribution of injury characteristics varied between the disciplines in male athletes by location (p<0.001, large), type (p<0.001, large), cause (p<0.001, large) and severity (p<0.001, medium), and in female athletes by location (p<0.001, large), type (p<0.001, large), cause (p<0.001, large) and severity (p=0.04, medium) (figures 2–4 and online supplementary tables 6 and 7).
Distribution of injury characteristics by location (A), type (B), cause (C) and severity (D), according to discipline, in male athletes in all championships (data are percentage of all injuries per discipline).
Distribution of injury characteristics by location (A), type (B), cause (C) and severity (D), according to discipline, in female athletes in all championships (data are percentage of all injuries per disciplines).
Number of reported injuries per 1000 registered athletes (represented by the size of the half disc) in all championships (outdoor and indoor), based on nine athletic disciplines, according to sex (male athletes represented by downward facing half disc and female athletes by upward facing half disc), preliminary diagnoses (location and type) and severity (visualised by a colour scale presenting the mean of the estimated absence in days, no time loss represented by the green colour and important time loss (mean time loss ≥30 days) by the purple colour).
Injury characteristics
Sprints
Most injuries in male sprinters were located in the thigh (52.0%), affected the muscles (67.6%), were caused by overuse (42.7%) or trauma (39.1%), and were expected to lead to no time loss (39.1%), time loss of up to 7 days (24.0%) or time loss of 828 days (22.7%).
Most injuries in female sprinters were located in the thigh (37.8%), the foot (12.8%) or the trunk (11.5%), affected muscles (49.4%) or skin (15.4%), were caused by overuse (50.6%) and were expected to lead to no time loss (50.0%) or time loss of up to 7 days (23.1%).
Sex related differences in the distribution of injury location (p=0.002, large) and injury type (p<0.001, large) were observed but not with regards to injury cause or severity. The injury causes differed between outdoor and indoor championships (p=0.008, medium) for female athletes but not for injury location, type or severity. There were no significant differences in injury characteristics between outdoor and indoor championships for male athletes.
Hurdles
Most injuries in male hurdlers were located in the thigh (37.5%) or hip and groin (12.5%), affected muscles (51.3%) or skin (23.8%), were caused by trauma (51.3%) and were expected to lead to no time loss (40.0%) or time loss of 8–28 days (26.3%).
Most injuries in female hurdlers were located in the thigh (22.0%), knee (18.6%) or upper extremities (16.9%), affected skin (30.5%), muscles (27.1%) or ligaments (23.8%), were caused by trauma (52.5%) and were expected to lead to no time loss (40.7%), time loss of up to 7 days (27.1%) or time loss of 8–28 days (20.3%).
There were no significant differences in injury characteristics between male and female hurdlers, or between outdoor and indoor championships.
Jumps
Most injuries in male jumpers were located in the thigh (24.5%), foot (12.9%), knee (12.2%) or ankle (11.6%), affected muscles (40.1%), tendons (15.0%) or joints (13.6%), were caused by overuse (38.8%) or trauma (38.8%), and were expected to lead to no time loss (43.5%), time loss of up to 7 days (21.3%) time loss of 8–28 days (21.8%).
Most injuries in female jumpers were located in the thigh (19.7%) or trunk (14.1%), affected muscles (35.2%), skin (18.3%) or tendons (15.5%), were caused by trauma (43.7%) and were expected to lead to no time loss (50.7%).
There were no significant differences in injury characteristics between male and female jumpers, or between outdoor and indoor championships.
Throws
Most injuries in male throwers were located in the upper extremities (20.0%), trunk (20.0%) or knee (16.4%), affected muscles (47.3%) or ligaments (21.8%), were caused by overuse (49.1%) and were expected to lead to no time loss (49.1%) or time loss of 8–28 days (27.3%).
Most injuries in female throwers were located in the trunk (28.1%), upper extremities (18.8%) or lower leg (15.6%), affected muscles (31.3%), tendons (18.8%) or ligaments (18.8%), were caused by overuse (53.1%) or trauma (40.6%), and were expected to lead to no time loss (53.1%).
There were no significant differences in injury characteristics between male and female throwers. Comparisons between outdoor and indoor championships were not performed due to the small number of indoor injuries.
Combined events
Most injuries in male athletes in combined events were located in the thigh (19.5%), ankle (15.6%) or knee (14.3%), affected muscles (29.9%), skin (22.1%) or tendons (18.2%), were caused by trauma (42.9%) or overuse (36.4%), and were expected to lead to no time loss (40.3%) or time loss of 8–28 days (20.8%).
Most injuries in female athletes in combined events were mostly located in the thigh (21.5%), knee (16.9%) or trunk (13.8%), affected muscles (38.5%), ligaments (27.7%) or tendons (12.3%), were caused by overuse (40.0%) or trauma (40.0%), and were expected to lead to no time loss (36.9%), time loss of up to 7 days (21.5%) or time loss of 8–28 days (21.5%).
There were no significant differences in injury characteristics between male and female athletes in combined events. Comparisons between outdoor and indoor championships were not performed due to small number of indoor injuries.
Middle distances
Most injuries in male middle distance runners were mostly located in the lower leg (30.0%) or foot (18.0%), affected skin (53.0%) or muscles (19.0%), were caused by trauma (57.0%) and were expected to lead to no time loss (69.0%).
Most injuries in female middle distance runners were located in the lower leg (28.6%) or thigh (20.6%), affected skin (47.6%), muscles (19.0%) or tendons (17.5%), were caused by trauma (47.6%) and were expected to lead to no time loss (58.7%)
There were no significant differences in the distribution of injury characteristics between male and female athletes in middle distances. Comparisons between outdoor and indoor championships were not performed due to the small number of indoor injuries.
Long distances
Most injuries in male long distance runners were located in the lower leg (40.8%), affected skin (48.0%) or muscles (24.5%), were caused by trauma (53.1%) and were expected to lead to no time loss (49.0%) or time loss of up to 7 days (25.5%).
Most injuries in female long distance runners were located in the lower leg (36.9%), affected skin (42.9%) or muscles (29.8%), were caused by trauma (48.8%) and were expected to lead to no time loss (39.3%), time loss of up to 7 days (29.8%) or time loss of 8–28 days (23.8%).
There were no significant differences in injury characteristics between male and female long distance runners. Comparisons between outdoor and indoor championships were not performed due to the small number of indoor injuries.
Marathon
Most injuries in male marathon runners were located in the foot (23.3%), lower leg (22.1%) or thigh (17.4%), affected muscles (50.0%), were caused by overuse (69.8%) and were expected to lead to no time loss (36.0%) or time loss of up to 7 days (30.2%).
Most injuries in female marathon runners were located in the foot (23.6%), lower leg (21.8%) or thigh (14.5%), affected muscles (30.9%), skin (21.8%), ligaments (18.2%) or tendons (16.4%), were caused by overuse (69.1%) and were expected to lead to no time loss (40.0%) or time loss of up to 7 days (27.3%).
There were no significant differences in injury characteristics between male and female marathon runners.
Race walking
Most injuries in male race walkers were located in the thigh (30.0%) or trunk (15.0%), affected muscles (61.7%), were caused by overuse (75.0%) and were expected to lead to no time loss (33.3%) or time loss of up to 7 days (30.0%).
Most injuries in female race walkers were located in the foot (33.3%) or thigh (25.0%), affected skin (50.0%) or muscles (25.0%), were caused by overuse (66.7%) and were expected to lead to no time loss (50.0%) or time loss of 7–28 days (25.0%).
Comparisons between male and female athletes were not performed due to small number of injuries in race walkers.
Discussion
The main finding of the present study, based on data from 14 international athletics championships, was that substantial differences between disciplines were observed in the frequency and characteristics of reported injuries: (1) 25% of injuries were reported in sprints, (2) the highest number of injuries per 1000 registered athletes and per 1000 athlete days were observed in combined events, followed by marathon and long distance running in both male and female athletes, and (3) the specific injury patterns, taking injury location, type, cause, severity and diagnosis into account, differed between the disciplines.
Discipline related differences in the frequency of injuries
The number of injures differed between disciplines, confirming previous studies during one5–8 or several3 4 international athletics championships. During athletics championships, attention should be focused on disciplines with the highest total number of injuries (sprints) and the highest number of injuries per 1000 registered athletes or 1000 athlete days (combined events, and marathon and long distance running). This can be done 1) by detecting athletes with injury complaints during the month before the championships,10 20 and 2) during the whole season, by monitoring athletes and adopting injury prevention strategies targeting the main injuries of the respective discipline, in addition to the performance focus training in order to prepare for the championships.
Although athletes are focused mainly on competition during championships, some training injuries were reported. This could be explained by the fact that athletes did not compete every day but exercised/trained once or twice each day. Training injuries during championships are few but do exist, and therefore require attention. Medical services should be available in the warmup area and training ground during championships in order to provide efficient secondary injury prevention by rapid treatment.
Discipline related differences in the characteristics of injuries
The discipline specific injury characteristics reported in the present study are in agreement with the fact that athletics is composed of several different disciplines, leading to different injuries. Our results on discipline specific injury characteristics illustrate the specific constraints of each discipline. Short distance running disciplines were exposed to thigh muscle injuries while long distance running disciplines were exposed to lower leg muscle injuries. Disciplines involving plyometrics (ie, jumping and landing, in jumps or combined events) were associated with musculoskeletal injuries of different locations and types.
These results are in agreement with previous studies on injuries in athletics during the whole season, reporting discipline related differences in injury characteristics (location and/or diagnosis).21–26 However, these studies provided only descriptive analyses of the injury characteristics according to disciplines, except for one21 which focused on club level running disciplines. In summary, these studies reported that athletes participating in sprints suffered more thigh/hamstring,21–26 Achilles tendon23 26 and/or back injuries22; in hurdles, thigh24 and/or lower leg injuries22; in middle and long distance running, lower leg,22 24–26 foot/ankle/Achilles tendon,21 23 25 26 back/hip,21 hamstring23 and/or knee injuries23–25; in jumps, thigh/hamstring,22 24–26 knee,22 back24 and/or Achilles injuries23 25 26; in throws, back,22 23 25 26 upper extremity,23 ankle22 and/or knee injuries25 26; and in combined events, thigh,24–26 back,24 upper extremity,23 knee25 and/or foot/ankle/Achilles injuries.26 These injury locations are similar to our findings. This could be interpreted as specific disciplines lead to specific constraints and injuries whatever the circumstances (entire season or championships).
Methodological considerations
A strength of the present study was the quality of the methodology, regarding team participation, response rates and completeness of the data.14 Another strength was the large sample size (16 539 registered athletes, 1530 injuries) allowing more representative results, and increasing the opportunities for indepth analyses.
However, we calculated the number of reported injuries, which is different from the number of injury events and injured athletes. Some athletes could have sustained more than one injury during one injury event and more than one injury event during one championship. This implies that the injury numbers should not be interpreted as risk indicators at the level of individual athletes. Due to the structure of the database based on requirements from the research ethics committee, it was not possible to perform clustering (by team or country). Injury severity was assessed by the estimated number of days of absence from sport, which has been reported as having low inter-examiner reliability, suggesting caution in its interpretation.27 Injury cause should also be interpreted with caution, given the low to moderate inter-examiner reliability, and the number of injuries classified as 'others' before the consensus statement on athletics injury epidemiology.13 These results represented 3–9 days of the season in the specific context of international championships and are not representative of the whole season in high level athletes. Our study captured high quality data but only during a small part of the season, and more studies on injuries during the entire season are needed in this population of high level athletes.28 Based on the total population study design, we did not formally calculate a priori sample sizes for the analyses. However, post-hoc analysis found that the sizes of the samples used in the analyses were acceptable as the confidence intervals generated were sufficiently small. We performed multiple comparisons, and thus potential confounding and effect modifying factors across championships could exist, although we applied Bonferroni corrections. Finally, the data may lack generalisability and control for dependent data across athletes included in multiple championships.
Conclusions and practical implications
The characteristics of injuries in international athletics championships differed between disciplines. This should be taken into account when planning medical services, including local organisation and medical teams, in the preparation and during these major sports events. The results also highlight the disciplines and injuries which should be focused on in future studies on risk factors and mechanisms, and on prevention measures (eg, combined events, endurance disciplines, thigh (especially hamstring)12 muscle injuries, and lower leg muscle and skin injuries).
What are the new findings?
Athletic disciplines differed in the frequency of injuries reported during international athletics championships: the discipline with the highest total number of injuries was sprints (25% of all injuries) while the highest number of injuries per 1000 registered athletes were in combined events, and marathon and long distance running, for both male and female athletes.
Injury characteristics differed significantly between disciplines with a specific injury pattern for each discipline.
Thigh muscle injuries were the main diagnoses in sprints, hurdles, jumps, combined events and race walking, lower leg muscle injuries in marathon running, lower leg skin lesions in middle and long distance running, and trunk muscle and lower leg muscle injuries in throws.
How might it impact on clinical practice in the near future?
Strategies for medical service provision, including local organisation, medical teams, supplies, and facilities, in the preparation of and during athletics championships should be discipline specific and be prepared for targeting the main injuries in each discipline as they appear in the programme.
Acknowledgments
The authors thank the medical staff of the national teams and the physicians attached to the competition organising committees who collected the data for this project.
References
Footnotes
Contributors PE: substantial contributions to the conception and design of the study, collection, analysis and interpretation of the data, drafting, writing and revising of the manuscript, and approval of the final version to be published. LN: substantial contributions to the analysis and interpretation of the data, developing the figures, revision of the manuscript, and approval of the final version to be published. PB: substantial contributions to the conception and design of the study, collection and interpretation of the data, revision of the manuscript, and approval of the final version to be published. VG: substantial contributions to the revision of the manuscript, and approval of the final version to be published. TT: substantial contributions to the analysis and interpretation of the data, writing, revision of the manuscript, and approval of the final version to be published. AJ: substantial contributions to the conception and design of the project, analysis and interpretation of the data, writing and revision of the manuscript, and approval of the final version to be published.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval The study was reviewed and approved by the Saint-Etienne University Hospital ethics committee (institutional review board: IORG0004981).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available.