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Original research
Team USA injury and illness incidence at the 2022 Beijing Winter Olympic and Paralympic Games
  1. Travis Anderson1,2,
  2. Malia G Cali3,
  3. Stephanie C Clark4,
  4. Ike Hasley5,
  5. Emily G Larson6,
  6. Kayle E Noble-Taylor7,
  7. David M Robinson7,
  8. Eric Post1,2,
  9. Jonathan T Finnoff1,2,8,
  10. William M Adams1,2,9,10
  1. 1 Department of Sports Medicine, United States Olympic & Paralympic Committee, Colorado Springs, Colorado, USA
  2. 2 United States Coalition for the Prevention of Illness and Injury in Sport, Colorado Springs, Colorado, USA
  3. 3 Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
  4. 4 Family Medicine, Rehabilitation and Performance Medicine Swedish Medical Group, Seattle, Washington, USA
  5. 5 Division of Sports Medicine, Department of Orthopedic Surgery, Mayo Clinic, Minneapolis, Minnesota, USA
  6. 6 Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
  7. 7 Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
  8. 8 Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Denver, CO, USA
  9. 9 Department of Kinesiology, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
  10. 10 School of Sport, Exercise and Health Sciences, Loughborough University, Leicestershire, UK
  1. Correspondence to Dr Travis Anderson, Department of Sports Medicine, United States Olympic & Paralympic Committee, Colorado Springs, Colorado, USA; travis.anderson{at}usopc.org

Abstract

Objective The purpose of this study was to determine the injury and illness incidence from Team USA athletes from the 2022 Beijing Winter Olympic and Paralympic Games and assess any sex-based differences or differences between Olympic and Paralympic athletes.

Methods Team USA Olympic (n=231, 48.5% female) and Team USA Paralympic (n=63, 22.2% female) athletes had medical encounters documented during the Games. Injuries and illnesses were defined according to the 2020 International Olympic Committee Consensus Statement and reviewed for accuracy by a physician. Incidence rates were calculated per 1000 athlete-days and further analysed by sex, sport, anatomical location, type of illness, injury event and injury mechanism, with incident rate ratios (IRRs) used for group comparisons.

Results There were no differences in illness (Olympic illness, IRR=0.99 (95% CI 0.48 to 2.07), p=0.998; Paralympic illness, IRR=1.43 (95% CI 0.41 to 4.97), p=0.572) or injury rates (Olympic injury, IRR=0.63 (95% CI 0.39 to 1.03), p=0.062; Paralympic injury, IRR=1.01 (95% CI 0.43 to 2.35), p=0.988) between male and female (reference group) athletes. However, Olympic athletes had significantly lower illness (IRR=0.41 (95% CI 0.22 to 0.76), p=0.003) and injury (IRR=0.56 (95% CI 0.37 to 0.87), p=0.009) risks compared with Paralympic athletes.

Conclusion No significant sex-related differences in injury or illness were detected in Team USA Olympic or Paralympic participating in the 2022 Beijing Winter Games. However, Paralympic athletes exhibited higher rates of injury and illness compared with their Olympic counterparts. This study highlights delegation-specific epidemiological data which may facilitate more focused approaches for injury and illness prevention.

  • epidemiology

Data availability statement

No data are available.

https://doi.org/10.1136/bjsports-2023-107185

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Injury and illness surveillance is a critical component of injury and illness risk reduction models.

    WHAT THIS STUDY ADDS

    • We demonstrated that Winter Paralympic athletes had a higher illness and injury incidence than Winter Olympic athletes, while there were no sex-based differences.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • Injury and illness risk reduction strategies for Paralympic athletes require a larger focus, including potential modifications to equipment or additional preparations for athletes at high risk of impairment-related injury and illness. Medical staffing for Paralympic athletes should consider a greater potential health burden during the Winter Games.

    Introduction

    Injury and illness surveillance has been considered a critical first step in developing injury and illness prevention programmes since Mechelen et al outlined his four-step model.1 Updates to this model, including the Translating Research into Injury Prevention Practice model, continue to highlight the importance of injury and illness surveillance.2 Capturing injury and illness statistics permits the identification of athletes and associated subpopulations (eg, sport, discipline, sport position) that may be at increased risk for injury or illness and can provide the data necessary to allocate and prioritise resources to reduce future risk of injuries and illnesses. Previous injury and illness surveillance reports have elucidated such vital information at multinational single-sport events such as the Federation Internationale de Football Association (FIFA) World Cup3–5 and Fédération Internationale de Natation (FINA) World Championships,6 7 as well as at previous Summer Olympic8–10 and Paralympic11 12 Games, Winter Olympic13–17 and Paralympic18–20 Games and Youth Winter Games.21 22

    The Norwegian Olympic Committee has been a world leader in injury and illness surveillance programmes.23 Notably, Norway published the only single-delegation Summer and Winter Paralympic longitudinal study, including injuries from 2012 to 2020,24 including observations from training and competition. The researchers found elbow and shoulder injuries to be the most common, while infectious respiratory conditions were the most burdensome illness. Further, health problems were relatively common, with the average prevalence being 37%, with an average of 2–7 days lost across injuries and illnesses. Other single-nation Paralympic data from German25 and Swedish26 athletes have also demonstrated a relatively high incidence of health problems. These studies found that 28% of German Paralympic athletes had some form of injury or illness at any given time,25 while 68% and 77% of Swedish athletes sustained an injury or illness during 1 year of training and competition.26 In addition, previous single-delegation data have suggested that male and female athletes at the Winter Games do not differ by injury rates, but female athletes do have a higher incidence of illness.15 In partial agreement, in Norwegian Paralympic athletes, female athletes were again found to have greater illness incidence but lower injury rates compared with their male counterparts.24 Single-nation analyses can provide illustrative data of injury and illness rates that may be able to be generalised to other nations of similar resources and size and with similar sports, that may be attenuated when aggregating multination data. Further, previous injury and illness incidence reports suggest that single-nation incidence rates (IRs) tend to be greater than the aggregated incidence across the entire Games.15

    To the authors’ knowledge, no studies have used data from a single delegation to directly compare injury and illness incidence between Olympic and Paralympic Games. Although early observations suggested that Paralympic athletes did not have a greater injury incidence,20 more contemporary data suggest that Paralympic athletes do have a greater incidence of health problems. For example, longitudinal data from the Norwegian delegation revealed that Olympic athletes had a health problem incidence of 6.1 cases per athlete per year, compared with 7.5 cases per athlete per year for Paralympic athletes.23 Comparison of separately published Winter Games-wide data also suggests greater incidence in Paralympic athletes compared with Olympic athletes; for instance, at the PyeongChang 2018 Winter Games, the injury and illness incidence in Olympic athletes was 7.4 and 5.5 per 1000 athlete-days, respectively,27 compared with injury and illness incidence of Paralympic athletes from the same Games of 20.928 and 12.829 per 1000 athlete-days, respectively. Despite the magnitude of the difference in these IRs, these potential differences need to be statistically confirmed, including within Winter athletes expressly. The 2022 Beijing Winter Olympic and Paralympic Games provided a unique opportunity to assess injury and illness risk at a large multisport international competition for a single-nation delegation, even when compared with previous Winter Olympic and Paralympic Games. International mass-gathering events present significant public health challenges in general,30 but the 2022 Beijing Games were also conducted with unique considerations around infection policies. Additionally, the Winter Olympic and Paralympic Games tend to have a higher risk for respiratory inflammation or agitation, as athletes typically train in cold air environments.31

    Therefore, this study aimed to determine the incidence of injury and illness among Team USA athletes at the 2022 Beijing Winter Olympic and Paralympic Games and assess any sex-based differences or differences between Olympic and Paralympic athletes.

    Methods

    The present observational study used the United States Olympic and Paralympic Committee’s Injury and Illness Surveillance programme during the 2022 Beijing Olympic and Paralympic Games. The injuries and illnesses were recorded for the Olympics from 24 January to 24 February 2022 (pre-Games: 24 January to 3 February, Games: 4 February to 20 February, post-Games: 21 February to 24 February) and for the Paralympics from 21 February to 16 March 2022 (pre-Games: 21 February to 3 March, Games: 4 March to 13 March, post-Games: 14 March to 16 March). Pre- and post-Games periods were included to account for Games-related travel and potential delays in reporting injuries or illnesses sustained in the Games period. This study was approved by the Institutional Review Board at the University of North Carolina at Greensboro (IRB-FY22-218). Although athletes were not directly engaged in the study’s design, oversight was conducted by the USOPC Research Review Committee. This committee comprises Olympic and Paralympic athlete representatives, sports medicine clinicians, mental health experts, sport physiologists, sport nutritionists, strength and conditioning coaches, representatives from sport national governing bodies, and legal professionals. Their insights were sought and integrated into developing the injury and illness surveillance framework and the study protocol before data collection and analysis. The overarching purpose of the injury and illness surveillance programme is to better serve the athletes and provide comprehensive healthcare.

    Equity, diversity and inclusion statement

    No specific efforts were made to recruit participants explicitly based on participant diversity. However, this study was conducted using all Team USA that competed at the 2022 Beijing Winter Olympic and Paralympic Games and thus constitutes a diverse population of elite athletes (sex: males=51.5%, females=48.5%; self-identified ethnic origin: Asian=4.42%, black/African American (not of Hispanic origin) = 1.70%, white (not of Hispanic origin) = 72.8%, two or more races=1.70%, declined to respond=17.70%, American Indian or Alaska Native=0.34%, Hispanic or Latino=1.02%, Native Hawaiian or other Pacific Islander=0.34%). The research team also comprises a diverse group of clinicians and researchers (44% female, 78% physicians). All athletes were provided access to the medical resources they required regardless of regional geographical differences, education or socioeconomic levels.

    Procedures

    Injuries and illnesses were defined using the 2020 International Olympic Committee (IOC) Consensus Statement for recording and reporting epidemiological data on injury and illness in sports.32 An injury was defined as ‘tissue damage or other derangements of normal physical function due to participation in sports, resulting from the rapid or repetitive transfer of kinetic energy.’ An illness was defined as ‘a complaint or disorder experienced by an athlete, not related to an injury.’ For the purposes of this study, mental health problems and medical diagnoses associated with the SARS-CoV-2 virus were not included in these analyses, although only five total athletes from the USA were diagnosed with COVID-19 during the Olympic (n=4) and Paralympic (n=1) Games (all athletes were tested daily for COVID-19). The methodological decision to a priori exclude COVID-19 cases from the statistical analyses (but retain the athlete number) was underpinned by the explicit aim of maintaining comparability between the case numbers and data from prepandemic and postpandemic Games. All injuries and illnesses were classified using the Orchard Sports Injury and Illness Classification System.33 All infection-based illnesses were classified within the body-system category as infections, and all non-infectious conditions were then classified into the relevant body-system category (eg, dermatological, respiratory, etc).

    Medical providers (Olympics, N=73: physicians=26, athletic trainers=16, physical therapists=18, chiropractors=6, massage therapists=7; Paralympics, N=17: physicians=9, athletic trainers=2, physical therapists=3, chiropractors=1, massage therapists=2) documented all medical encounters (ie, consultations, evaluations, treatments, preventative and recovery services) in the electronic medical record (GE Centricity, General Electric, Fairfield, Connecticut, USA). Following the completion of the 2022 Beijing Paralympic Games, the research team completed a quality control process on the documented medical encounters, where a physician individually reviewed each record to ensure accuracy.

    Data reduction and statistical analysis

    Flight manifest data were used to detail and confirm the arrival and departure of all Team USA athletes competing in the 2022 Beijing Winter Olympic and Paralympic Games. The total number of days each athlete was in Beijing was used to obtain an accurate denominator for the IR (ie, athlete-days). IRs were calculated as injuries or illnesses per 1000 athlete-days. IRs were reported for all injuries and illnesses and were characterised by sex, sport, anatomical location and type of illness. IR 95% CIs and injury proportions were also calculated and reported in each table. Lastly, injury and illness proportions (per 100 athletes) and 95% CI were calculated. Sports with fewer than 10 athletes were combined based on relative similarities to avoid reporting identifiable data.

    Incident rate ratios (IRRs) were used to compare IRs between males and females (reference group=females) and between Olympic and Paralympic athletes (reference group=Paralympic athletes), using the rateratio function in the fsmb R package.34 Due to the number of unclassified responses, comprehensive distinctions pertaining to injury mechanisms, anatomical injury locations or afflictions affecting specific body systems could not be accurately statistically analysed and are thus reported as descriptive summary statistics. The alpha level was set at p<0.05 for all analyses and was completed using R statistical software.35

    Results

    The Team USA Olympic delegation (n=231) consisted of 119 male (51.5%) and 112 female (48.5%) athletes, and the Team USA Paralympic delegation (n=63) comprised 49 male (77.8%) and 14 female (22.2%) athletes. These athletes represented 14 and 5 Olympic and Paralympic sports, respectively. This resulted in an athlete-to-medical provider ratio of 3.04 and 3.31 for the Olympics and Paralympics, respectively. On average, Olympic and Paralympic athletes were 25.9 years old (range 16–40 years) and 31.5 years old (range 17–66 years), respectively.

    Injury and illness by sex

    Olympic athletes had a significantly lower risk of illness (IRR=0.41 (95% CI 0.22 to 0.76), p=0.003) and injury (IRR=0.56 (95% CI 0.37 to 0.87), p=0.009) compared with Paralympic athletes (reference group). However, there were no differences in illness (table 1) and injury (table 2) IR between male and female (reference group) Olympic athletes (illness, IRR=0.99 (95% CI 0.48 to 2.07), p=0.998; injury, IRR=0.63 (95% CI 0.39 to 1.03), p=0.062) or male and female (reference group) Paralympic athletes (illness, IRR=1.43 (95% CI 0.41 to 4.97), p=0.572; injury, IRR=1.01 (95% CI 0.43 to 2.35), p=0.988).

    View this table:
    Table 1

    Incidence of illness by sex for Team USA athletes competing in the Beijing 2022 Winter Olympic and Paralympic Games

    View this table:
    Table 2

    Incidence of injuries by sex for Team USA athletes competing in the Beijing 2022 Winter Olympic and Paralympic Games

    Injury counts by event type and mechanism

    Olympic female athletes had the greatest number of injuries recorded during practice (n=20), although a substantial number also occurred during competition (n=15). Comparatively, Olympic males had the greatest number of injuries during competition (n=9) and slightly fewer during practice (n=7). Although fewer in absolute number, female Paralympic athletes also had the greatest number of injuries occurring during competition (n=4), while male Paralympic athletes had the greatest number of injuries recorded during practice (n=8) (figure 1).

    Figure 1
    Figure 1

    Injury event in female and male Olympic and Paralympic Team USA athletes at the 2022 Beijing Games.

    Most recorded injuries for female and male Olympic athletes resulted from direct contact (figure 2). Female Paralympic athletes, however, had the greatest number of injuries as a result of acute non-contact mechanisms, and male Paralympic athlete injuries were primarily due to either direct contact (n=7), acute non-contact (n=6) or overuse (n=5) mechanisms.

    Figure 2
    Figure 2

    Injury mechanism in female and male Olympic and Paralympic Team USA athletes at the 2022 Beijing Games.

    Injury and illness by body system and anatomical location

    Regarding illness, 11.3% and 22.2% of Olympic and Paralympic athletes were diagnosed with some form of illness, respectively. The greatest number of illnesses in Olympic athletes was classified as infectious, while the most common illness in Paralympic athletes was respiratory (table 3). Seventy injuries were recorded for Olympic athletes, while Paralympic athletes had 30. The highest incidence of injuries in Olympic athletes involved the lower limb, while Paralympic athletes had 10 injuries in each of the upper and lower limbs (table 4).

    View this table:
    Table 3

    Incidence of illness by body system in Team USA athletes competing in the Beijing 2022 Winter Olympic and Paralympic Games

    View this table:
    Table 4

    Incidence of injury by anatomic location for Team USA athletes competing in the Beijing 2022 Winter Olympic and Paralympic Games

    Injury and illness by sport

    Bobsled and skeleton had the highest illness IR among Olympic athletes, while biathlon and Nordic ski had the highest illness IR among Paralympic athletes (table 5). Of the Olympic sports, luge (IR=51.5 injuries/1000 athlete-days (95% CI 13.3 to 89.6)), ski and snowboard (IR=22.6 injuries/1000 athlete-days (95% CI 14.5 to 30.6)) and bobsled and skeleton (IR=17.7 injuries/1000 athlete-days (95% CI 4.6 to 30.8)) had the greatest injury rates (table 6). For Paralympic sports, the greatest injury IRs were observed for alpine skiing (IR=59.6 injuries/1000 athlete-days (95% CI 28.4 to 90.8)), wheelchair curling (IR=58.8 injuries/1000 athlete-days (95% CI 7.3 to 110.4)) and snowboarding (IR=32.1 injuries/1000 athlete-days (95% CI 6.4, 57.8)).

    View this table:
    Table 5

    Incidence of illness by sport for Team USA athletes competing in the Beijing 2022 Winter Olympic and Paralympic Games

    View this table:
    Table 6

    Incidence of injury by sport for Team USA athletes competing in the Beijing 2022 Winter Olympic and Paralympic Games

    Discussion

    In this study, we reported 100 injuries (Olympic n=70; Paralympic n=30) and 46 illnesses (Olympic n=29; Paralympic n=17) among Team USA competing in the 2022 Beijing Winter Olympic and Paralympic Games. Paralympic athletes had a greater risk of injury (1.79 times greater risk) and illness (2.44 times greater risk), but no differences were observed between male and female athletes. Furthermore, the injuries and illnesses were observed across various anatomical locations, body systems and sports. For example, Olympic athletes tended to have lower limb injuries and infection illnesses, while Paralympic athletes had equal injury incidence between the upper and lower limbs, but respiratory illnesses had the highest IR.

    Injuries

    The IR observed in the present analysis (16.5 injuries/1000 athlete-days) was greater than that of Team USA Olympic athletes from the 2018 PyeongChang Winter Olympic Games (IR=2.3 injuries/1000 athlete-days).17 Moreover, our observed IR for Olympic athletes is also greater than the overall IR previously reported for the 2016 Rio de Janeiro Summer Olympic Games (IR=5.7 injuries/1000 athlete-days)9 and 2020 Tokyo Summer Olympic Games (IR=5.4 injuries/1000 athlete-days),36 the Sochi Winter Olympic Games (IR=7.8 injuries/1000 athlete-days)13 and the proportion of injured athletes at the 2008 Beijing Olympic Games (20.8% vs 9.6%).10 Conversely, IR for our Paralympic athletes (IR=29.1 injuries/1000 athlete-days) was similar to the IR previously reported (IR=26.5 injuries/1000 athlete-days) in a multinational analysis of the 2014 Sochi Winter Paralympic Games.18 Despite some general population evidence suggesting females may seek medical attention more than males,37 we observed no statistical difference in injury IR between males and females, in agreement with previous findings from the 2014 Sochi Winter Paralympic Games.18

    To the authors’ knowledge, no comparative data exist for our injury IRR between Olympic and Paralympic athletes. Although Webborn et al 20 have previously suggested no appreciable difference in Paralympic and Olympic Winter athlete injury risk, single-nation studies report Paralympic injury and illness rates to be relatively high,26 especially when compared with IR in Olympic athletes from other studies. In support of these observations, our direct statistical comparison demonstrated a significantly greater injury risk in Team USA Paralympic athletes (IR=16.5 injuries/1000 athlete-days vs 29.1 injuries/1000 athlete-days). (Because Paralympic alpine skiing contributed 46.6% of all Paralympic injuries, we completed a sensitivity analysis by recomputing the IRR with the removal of Paralympic alpine skiing injuries and athlete-days. The removal of Paralympic alpine skiing adjusted the IR to 20.1 injuries/1000 athlete-days, which was no longer statistically significantly different (IRR=0.82 (0.48 to 1.42), p=0.483) from Olympic IR (IR=16.5 injuries/1000 athlete-days).) The explanation for this difference is unknown, but multiple plausible explanations exist. First, Paralympic athletes have underlying impairments that may predispose them to greater injury risk. For example, an individual with impaired motor control or vision may be at increased risk for a crash or collision. Second, the addition of adaptive equipment may increase the risk of injury through equipment failure or poor athlete-adaptive equipment interface. Reasons other than inherent sport and athlete differences may also contribute to the present findings, such as the relatively small number of Paralympic athletes, thus increasing the impact on IRs with only a few additional injuries. Furthermore, the relatively small number of Paralympic athletes slightly increases the provider-to-athlete ratio (3.04 vs 3.31), thus permitting clinicians to more readily observe and thus record injuries that may have otherwise been missed. Sensitivity analyses also suggested Paralympic alpine skiing may be disproportionally contributing to these results, and thus future studies should explore specific risk factors to the sport that could be mitigated.

    For Olympic athletes, the highest injury and illness IR appeared within sliding sports. Although not ubiquitous across Games, sliding sports, including bobsleigh and luge, tend to present a high risk to athletes, as they were among the sports with the most visits to the polyclinic in the 2002 Salt Lake Winter Games.38 Further, sliding sports had among the highest athlete percentages injured, and a luge fatality was recorded at the 2010 Vancouver Winter Olympic Games.14 The high-speed nature of these events will present an inherent injury risk, but efforts can continue to be made to track and/or equipment design and targeted prevention programmes to reduce the health risk to competing athletes.

    Illnesses

    The illness incidence in our sample was greater than the rate reported in a multinational assessment of the 2016 Rio de Janeiro Summer Olympic Games (IR=3.2 illness/1000 athlete-days),9 2018 PyeongChang Winter Olympic Games (IR=2.3 illnesses/1000 athlete-days)27 and the 2020 Tokyo Summer Olympic Games (IR=2.3 illnesses/1000 athlete-days).36 We also observed a greater percentage of Olympic (11.3%) and Paralympic (22.2%) athletes that experienced an illness compared with proportions from the 2014 Sochi Winter Olympic Games (8%),13 the 2014 Sochi Winter Paralympic Games (17.4%)19 and the 2010 Vancouver Winter Olympic Games (6.7%).14 The reason for this discrepancy is speculative; however, the present analysis is of a single-nation delegation and may reflect more attentive or assiduous reporting of even minor illness symptoms by athletes or clinicians compared with the average reporting across all athletes at previous Games, particularly given the heightened awareness of illness symptomology during the 2022 Beijing Winter Games. This speculation is somewhat supported by another single-nation delegation report from TeamGB (Great Britain), who also reported a much greater injury (39%) and illness (18%) proportion at the 2014 Sochi Winter Olympic Games.15 The authors offered several explanations for their findings, including reporting potentially less serious injuries and illnesses.15 As Palmer-Green and Elliot15 also detailed, a smaller cohort is more substantially affected by small changes in the number of injuries and illnesses reported, a factor that likely also impacted the present findings.

    Even so, and in comparison to injury incidence, we reported a slightly lower incidence of illness for Olympic athletes (IR=6.8 illnesses/1000 athlete-days) in the present study compared with Team USA Olympic athletes from the 2018 PyeongChang Winter Olympic Games (IR=7.8 illnesses/1000 athlete-days).17 The vast majority of previously reported illnesses were respiratory in nature,17 and while three respiratory illnesses were diagnosed in the current study in Olympic athletes, other illnesses had a higher incidence, including dermatological (n=5), infections (n=6) and gastrointestinal (n=4). In fact, at the 2018 PyeongChang Winter Olympic Games, 45% of Finnish athletes developed common cold symptoms, most of which were viral respiratory infections.39 This discrepancy may reflect the greater precautions taken in Beijing to mitigate the risk of SARS-CoV-2 spread, including mask requirements and hand sanitising stations; such policies and procedures would conceivably limit the spread of other airborne transmissible diseases and thus limit all respiratory illnesses. Although the restrictive nature of these policies may not be required for future Games, organisers should consider offering similar services (eg, hand sanitising stations in dining halls or other common areas) to limit the spread of infections. The implementation of these policies would conceivably have influenced the limited incidence of SARS-CoV-2 cases in Olympic (n=4) and Paralympic (n=1) athletes during the corresponding Games periods, as observed in Team USA athletes during the Tokyo Games,40 despite the high local incidence in the general population. We excluded these cases from the statistical analysis to facilitate meaningful comparisons to prepandemic and postpandemic Games. This methodological choice likely resulted in under-reporting the true health burden for athletes at the Winter Games under investigation. Future meta-analyses should consider and account for these pertinent factors when interpreting and using the case numbers presently reported herein.

    We also report a greater illness incidence for Paralympic athletes compared with Olympic athletes (IR=16.5 illnesses/1000 athlete-days vs 6.8 illnesses/1000 athlete-days). (Because Paralympic biathlon contributed 47% of all Paralympic illnesses, we completed a sensitivity analysis by recomputing the IRR with the removal of Paralympic biathlon illnesses and athlete-days. The removal of Paralympic biathlon adjusted the IR to 11.3 illnesses/1000 athlete-days, which was no longer statistically significantly (IRR=0.61 (0.29 to 1.28), p=0.18) different from Olympic IR (IR=6.8 illnesses/1000 athlete-days).) As with the injury IR, the potential rationales for this observation remain speculative. However, existing literature suggests that Paralympic athletes, due to the underlying impairments, have a greater prevalence of pre-existing medical conditions (eg, bladder dysfunction, paralysis and insensate regions) that can predispose them to secondary illnesses (eg, urinary tract infections or decubitus ulcers).24 41 Relatedly, some medications athletes use to manage aspects of their disability (eg, adalimumab, baclofen) have side effects (eg, immunosuppression, anticholinergic effects) that predispose to secondary illnesses.

    Further, our sensitivity analysis, which removed Paralympic biathlon illnesses and athlete-days from the analysis, tentatively suggests that the observed Olympic versus Paralympic difference is being largely influenced by the number of illnesses observed in the Paralympic biathlon athletes. It was beyond the scope of this study to investigate the causative factors creating this large illness burden in Paralympic biathlon athletes, specifically. However, we can speculate that factors such as long exposures to cold and dry air increase the risk for upper respiratory tract infections,42 and the endurance nature of the sport could result in some degree of immunosuppression,43 although the ‘open-window’ hypothesis has been credibly challenged.44 45 These factors would also be theoretically applicable to Olympic biathlon athletes, but further exploratory analysis with the removal of Olympic biathlon athletes did not re-establish the difference in illness IR, suggesting this may be specific to biathlon athletes in the Paralympic Games. A small sample size in the Paralympic cohort may also contribute to the observed effect, and thus we recommend future research to confirm this potential effect and explore the underlying mechanisms in more detail.

    Limitations

    The present study permitted a comparison of Olympic and Paralympic athletes from the same national delegation and detailed reporting of the type, body systems, anatomical locations affected by injury and illness, and injury events and mechanisms. However, despite the novelty and uniqueness of analysing these data, some study limitations must be acknowledged. First, this study included athletes from a single, although large, National Olympic and Paralympic Committee instead of a global analysis. Therefore, the athletes in the present study may not be representative of smaller delegations or from nations with different demographics, infrastructures and resource availability. Second, these data relied on accurately reporting injuries and illnesses in the electronic medical record. As a result, some injuries or illnesses may have occurred that were considered too minor for the athlete to report to medical staff or went unreported for alternate reasons. In addition, as can be observed in figures 1 and 2, regrettably, a substantial number of injuries did not have an event or mechanism recorded, which limits our ability to understand this information completely. We unfortunately also did not collect measures of injury severity (eg, time loss). However, efforts have been made to include these as mandatory details in medical notes for future use of the injury and illness surveillance system, and we encourage other National Olympic and Paralympic Committees to do the same. Other data may also be able to provide a more comprehensive understanding of the causes of particular injuries and illnesses, such as environmental conditions, and could also be captured as part of a holistic surveillance system. Third, at the time of the Beijing Games, the electronic medical record system used by clinicians had not yet been updated to the most recent version of the Orchard Sports Injury and Illness Classification System.46 Although future surveillance work will incorporate the most contemporary diagnostic codes, the current study is limited in terms of classifying infectious illnesses as their own body system (‘infections’), whereby more recent versions of the Orchard Sports Injury and Illness Classification System (OSIICS) system would include infection as an aetiology within other body system categories. Lastly, out of concerns regarding athlete privacy and the abstention from delivering formal psychological diagnoses, along with the absence of standardised methods for monitoring mental health conditions among athletes during the data collection phase (the mental health supplement to the IOC surveillance consensus statement was published in July 202347), the sports medicine and psychological services team made the decision not to classify mental health interactions, consequently omitting them from the overarching surveillance programme. As such, a broad aspect of holistic athlete health and well-being remains unaddressed in the current framework, and thus it is imperative that future athlete health surveillance systems take this into account, as has been recently recommended.47

    Conclusions

    We demonstrated a relatively high injury and illness incidence among Team USA Olympic and Paralympic athletes competing in the 2022 Beijing Winter Games in relation to other Games data. No differences were observed between male and female athletes; however, Paralympians had a greater injury and illness incidence than their Olympian peers. Differences in reporting protocols between competing countries may contribute to delegation-specific incidences compared with overall Games statistics. Single-nation and Games-wide injury and illness surveillance programmes should continue to collect and publish their data to assess global and more granular historical trends to develop effective and efficient risk mitigation strategies that can be implemented across and within national delegations. The findings of this study underscore a notable disparity in the health burden faced by Paralympic athletes as compared with their Olympic counterparts during the Winter Games. In light of these results, it is imperative that National Paralympic Committees take into account the health needs of Paralympic athletes when making decisions regarding the allocation and staffing of medical personnel during the Paralympic Games.

    Data availability statement

    No data are available.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study was approved by the Institutional Review Board at the University of North Carolina at Greensboro (IRB-FY22-218).

    Acknowledgments

    This work is the author's own and not that of the United States Olympic & Paralympic Committee or any of its members or affiliates. This study was partly funded by a grant from the International Olympic Committee.

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    Footnotes

    • Twitter @travaldinho, @william_m_adams

    • Contributors The contributions of the authors to the revised manuscript are listed below: TA—data analysis, data visualisation, data interpretation, lead manuscript author. MGC, SCC, IH, EGL, KEN-T and DMR—data cleaning, data interpretation, critical manuscript review, manuscript author. EP—data interpretation, critical manuscript review, manuscript author, responses to reviewers. JTF—data interpretation, critical manuscript review, manuscript author. WMA—data interpretation, critical manuscript review, senior manuscript author. TA is the guarantor.

    • 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 The authors declare there are no conflicts of interest. JTF reports receiving royalties from Demos Publishing and UpToDate. WMA reports receiving royalties from Springer Nature.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.