Article Text

Comprehensive periodic health evaluations of 454 Norwegian Paralympic and Olympic athletes over 8 years: what did we learn?
  1. Kathrin Steffen1,2,
  2. Roald Bahr1,2,
  3. Benjamin Clarsen1,2,
  4. Bjørn Fossan1,
  5. Hilde Fredriksen1,
  6. Hilde Gjelsvik1,
  7. Lars Haugvad1,
  8. Aasne Fenne Hoksrud1,
  9. Erik Iversen1,
  10. Anu Koivisto-Mørk1,
  11. Ellen Moen1,
  12. Vibeke Røstad1,
  13. Tonje Reier-Nilsen1,
  14. Thomas Torgalsen1,
  15. Hilde Moseby Berge1,2
  1. 1Olympiatoppen, The Norwegian Olympic Training Center, Oslo, Norway
  2. 2Oslo Sports Trauma Research Center, Insitute of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
  1. Correspondence to Dr Kathrin Steffen, Institute of Sports Medicine, Norwegian School of Sports Sciences, Oslo Sports Trauma Research Center, Oslo, Norway; kathrin.steffen{at}


Objective A periodic health evaluation (PHE) is a comprehensive and multidisciplinary investigation of athlete health widely used in elite sport, but its contents and benefits can be questioned. This study aimed to determine the prevalence of conditions identified by a PHE among Paralympic and Olympic athletes over four consecutive Games cycles from Rio de Janeiro 2016 to Beijing 2022 and to assess the benefits and potential pitfalls of a comprehensive PHE programme in detecting existing injuries, illnesses and other health issues.

Methods We collected extensive health history and clinical examination data on elite athletes: medical history, ECG, blood pressure, blood samples, spirometry, musculoskeletal health, cognitive function, mental health and compliance with public health programmes.

Results The final cohort included 87 Paralympic and 367 Olympic athletes, representing 565 PHE cycles. Musculoskeletal problems and unspecified pain, infections and allergies were the most frequent health issues. High blood pressure was the most prevalent cardiovascular finding, and vitamin D deficiency the most common laboratory abnormality. Most athletes complied with the public childhood vaccination programmes, but fewer with recommended cancer screening. Follow-up of health issues was variable.

Conclusion Our PHE programme identified musculoskeletal problems, infections, allergies, elevated blood pressure and vitamin D deficiency as common health conditions. Longitudinal follow-up of health conditions identified during screening and improved compliance with public health and cancer screening programmes is needed to determine the true benefits of athlete care prompted by the PHE.

  • health
  • evaluation

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • A periodic health evaluation (PHE) is a comprehensive and multidisciplinary investigation of athlete health, widely used in elite sport.

  • A PHE potentially serves several purposes to protect athlete health, as (1) identifying and evaluating existing health conditions, (2) reviewing medications and supplements to avoid inadvertent doping, (3) strengthening the relationship between the medical team and the athlete, (4) providing a baseline health profile in the event of future injury or illness and (5) meeting the legal requirement of the sports relevant governing body.


  • Based on data from 565 PHEs conducted within the Norwegian Olympic Training Centre (Olympiatoppen) Periodic Health Evaluation Programme, we identified several health conditions suitable for preventive measures or that could benefit from better management.

  • Musculoskeletal problems, infections, allergies and pain were the most common health conditions. High blood pressure was the most prevalent cardiovascular finding. Most athletes complied to the long-term public childhood vaccination programme, but poorly with recommended cancer screening.

  • The conversation between the athlete and medical team provided a unique possibility to clarify the most important health issues, however, the most striking pitfall was the lack of documented follow-up.


  • Clinical teams should plan and optimise their healthcare provision and preventive measures for athletes based on individual health history, examination and other clinical testing profiles using a structured evaluation such as the PHE.

  • Longitudinal follow-up of identified health conditions and risk factors identified during screening is needed, both to maximise and determine the true benefits of the PHE.


A periodic health evaluation (PHE) is a comprehensive and multidisciplinary investigation of athlete health and is widely used, at least in elite sport. The contents are usually adapted to the population being examined and typically include history, a medical examination focused on musculoskeletal health, cardiovascular screening and other non-cardiac medical conditions, and, in some cases, an assessment of performance-related movement capacity.1 In elite sport, health promotion programmes often combine an initial PHE followed by monitoring of both existing and new health problems.2–7

Despite the widespread use of PHEs in elite sports, their effectiveness in detecting health problems and their relevant risk factors is debated.7–9 While predicting future injury risk through specific tests probably is unrealistic,10 a PHE can potentially serve several other purposes, as described in the International Olympic Committee (IOC) consensus statement on PHE of elite athletes: (1) identifying existing health conditions and evaluating the current situation, (2) reviewing medications and dietary supplements to avoid inadvertent doping, (3) strengthening the personal relationship between the medical team and the athlete, (4) providing a baseline health and performance profile in the event of future injury or illness and (5) meeting the legal requirement of the governing body in question.1 7 10

With these objectives in mind, we report on the prevalence of conditions identified among Paralympic and Olympic athletes over four consecutive Games cycles from Rio de Janeiro 2016 to Beijing 2022, to assess the benefits of a comprehensive PHE programme in detecting existing injuries, illnesses and other health issues.


Data collection

The candidate athletes for the Rio de Janeiro 2016 to Beijing 2022 Paralympic and Olympic Games (20–40 Paralympic and approximately 200 Olympic athletes each Games cycle), as well as their respective health teams, were informed about procedures and goals for the Norwegian Olympic Training Centre (Olympiatoppen) Periodic Health Evaluation Programme prior to entry. Between 12 and 24 months before each summer and winter Games, national team coaches of all relevant sports were asked to provide lists of athletes they considered to be candidates to qualify. These were invited to take part by the programme manager. Health data were collected using a multidisciplinary health history questionnaire (part 1), followed by an assessment of their responses and a clinical examination at the Olympiatoppen (part 2) with the involvement of their federation medical team where available. For federations without a medical team, Olympiatoppen Medical Department staff completed the examinations.

For the first three Games cycles (Rio 2016 to Tokyo 2020), the health history questionnaires were distributed to candidate athletes when reporting for their clinical examination at Olympiatoppen to be completed on paper while waiting (V.1 and V.1.1, including slight changes in wording, items and response options added before the Pyeongchang 2018 cycle). Before the Beijing 2022 cycle, the health history questionnaire was revised extensively (V.2), transferred into a digital format and distributed electronically to the athletes approximately 1 week before their clinical examination to be completed prior to their appointment. After the clinical examination, the medical team reviewed all health history data and available clinical test results with the athlete and discussed recommendations on potential health conditions to be followed up.

Expert/user involvement

The health history questionnaire was developed through extensive consultations between the Olympiatoppen Medical, Nutrition and Sports Psychology Departments, based on experience over several previous Paralympic/Olympic Games cycles, as well as through athlete user involvement.

Health history questionnaire: PHE part 1

The health history questionnaire covered background information (training history, education, family, work and funding situation), general medical, cardiovascular and musculoskeletal history, nutrition-related issues, cognitive function, mental health, women’s/men’s health issues and the athletes’ experiences with travelling, including climate/time zone acclimatisation. We obtained information on their use of over the counter and prescription drugs. In addition, we asked about women’s/men’s health issues, including recommended screening for cervical cancer,11 and compliance with the national childhood vaccination programme, as well as the more recently introduced vaccination programme against human papilloma virus (HPV).12

The format of the questionnaires included dichotomous (yes/no), multiple-choice, as well as free-text items. The digital version embedded logic to present items relevant to the athlete and minimise questionnaire burden and took 20–30 min to complete.

Clinical examinations: PHE part 2

General medical: In addition to a general medical examination by a physician (and in some cases, a physiotherapist), according to common practice, two experienced medical secretaries drew venous blood samples for laboratory analyses and measured pulmonary function by maximal expiratory flow-volume curves (Welch Allyn, SpiroPerfect PC-based spirometer, New York, USA), recorded as forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and peak expiratory flow (PEF). They also placed the athlete in a seated position in a quiet room, provided appropriate cuff size and started an automated blood pressure (BP) device (Watch BP office, Microlife) that measured BP three times in both arms simultaneously, in 1 min intervals. BP was calculated as the mean value of the two last measurements and considered high if systolic BP was ≥140 mm Hg and/or diastolic BP was ≥90 mm Hg in one or both arms.1 13 Finally, a standard 12-lead resting ECG (Welch Allyn Cardio Perfect) was taken on all first-visit athletes and on those who had turned 20 years since their previous ECG or if their most recent examination was done >5 years ago. A sports cardiology-trained physician assessed all ECGs according to the International criteria for interpreting ECG in athletes,14 referring to a cardiologist when needed.

Analysis and definition of measures included

This report includes data from the entry PHE prior to four Paralympic and Olympic Games. Only data from the initial PHE within each cycle were included for these analyses, not subsequent tests, for example, for treatment evaluation. For athletes enrolled in >1 cycle, dynamic health history data and data on treatable conditions, such as BP, relevant blood measures, asthma or injury history, were included as two separate measures while stable conditions such as congenital heart failure, diabetes, removed appendix or confirmed mononucleosis were counted only once. As the health history questionnaire is a dynamic tool with thematic and item changes based on feedback from the users, the response rate for each question varied for Paralympic and Olympic athletes through the four PHE cycles, as did the number of clinical measurements.

We defined a health condition as any condition sufficient to require continued treatment or a recommendation for follow-up and reported the proportion as the number of conditions detected per 100 performed PHE. We exported deidentified data from the health questionnaire and clinical examinations to a static Excel file for further descriptive analyses (Microsoft Excel 2010 for Windows, Microsoft Office 365, California, USA). Baseline characteristics (sex, age, training history, sport category, impairment type) and all other data are presented as mean values with SD/range or as frequencies with percentages. Spirometry measures are reported as percentages of predicted values according to the last updated reference values from the Global Lung Function Initiative.15 For blood samples, we followed the reference values from the laboratory,16 as shown in the relevant results tables.

Equity, diversity and inclusion statement

The diverse panel of authors consists of sports medicine physicians, sports physiotherapists, a sports scientist and a dietician. In total, nine female and six male authors were invited based on their active contribution to the development of the programme and data collection. Athletes were neither invited to nor did they contribute to the editing of this paper for readability or accuracy.


The final cohort includes 87 Paralympic and 367 Olympic athletes, represented with 123 and 442 PHE cycles, respectively. Of these, 35 Paralympic (40%) and 75 Olympic athletes (20%) participated in two summer or winter PHE cycles. The characteristics of the two groups, including their training history, are presented in table 1.

Table 1

Characteristics of the Paralympic and Olympic athletes included

Cardiac history and ECG screening

Elevated resting BP was found in 21% of Paralympic and 7% of Olympic athletes, increasing with age. Of these, one-fifth reported previous high BP. As for other cardiovascular diagnoses and perceived cardiac symptoms in the preceding year, heart rate abnormalities and chest pain were the most common symptoms reported (table 2). After assessment, none of the cardiac symptoms alone resulted in a cardiology referral.

Table 2

Cardiac, medical and nutrition-related history and symptoms among Paralympic and Olympic athletes

ECG was interpreted as abnormal in five athletes (1.1%), all because of abnormal T-wave inversions. After a specialist cardiologist referral for appropriate investigations, all five were cleared without restrictions. Family history data on cardiovascular disease data are presented in online supplemental table 1.

Blood sample analyses

Table 3 provides a summary of the laboratory analyses and the prevalence of those above and below reference values. The main abnormalities were related to low vitamin D levels, defined as serum 25-hydroxy-vitamin D (s-25(OH)D) ≤75 ng/mL, with a prevalence of 74% in Paralympic (n=75) and 31% in Olympic (n=120) athletes. For both athlete groups, vitamin D levels fluctuated significantly throughout the year as presented in online supplemental table 2. Self-reported history of vitamin and/or mineral deficiencies and low bone mineral density is presented in online supplemental table 3.

Table 3

Laboratory measures with number and proportions (%) of Paralympic and Olympic athletes below and above reference values

The proportion of cholesterol levels (total and/or LDL) above recommended values was 3.8% for athletes >30 years (n=4) compared with 3.2% for younger athletes (<30 years, n=12). Half of them received further follow-up as required while the other half had total cholesterol/HDL cholesterol ratio <4 and were not assessed to be at any risk. A few other athletes were on lipid-lowering drugs with normal cholesterol levels when tested.

The proportion with positive serology confirming past infection was 52% for Paralympic (53 out of 102) and 65% for Olympic athletes (252 out of 390) for mononucleosis (EBV) and 42% (n=42) and 45% for Paralympic and Olympic athletes (n=175) for CMV infection, respectively.

Online supplemental tables 4 and 5 present normative data on blood profiles of Paralympic and Olympic athletes, respectively.

Medical history, asthma and allergy, pulmonary function

During the preceding year, 16% of Paralympic vs 5% of Olympic athletes had been hospitalised (overnight stay).

A high proportion of both Paralympic and Olympic athletes had experienced an infection during the prior 6 months, of which upper respiratory tract infections were most common (40%–44%) (table 2). One in three Paralympic athletes reported at least one urinary tract infection. As many as 23% of Paralympic athletes felt their training had been affected by infections, compared with 8% of Olympic athletes.

Other health conditions frequently needing clinical follow-up and/or continued treatment were asthma and allergies, with half of the athletes reporting allergies. Twice as many Olympic athletes (24%) as Paralympic athletes (12%) presented with asthma.

The prevalence of abnormal lung function, defined as predicted FEV1<80% or FEV1%<70%, was 8.7% among Paralympic athletes (n=5) and 1.5% among Olympic athletes (n=4). These athletes underwent targeted follow-up examinations; none were subsequently diagnosed with asthma.

Pulmonary function with predicted values for FEV1, PEF and FVC across winter and summer sport athletes and sports categories are presented separately for Paralympic and Olympic athletes in online supplemental table 6.

Cognitive function, mental health, relative energy deficiency in sport

Athlete responses to questions related to cognitive function and mental health are presented in table 4. Paralympic athletes had been assessed for educational and psychological counselling at school 4.5 times more often than Olympic athletes and received adapted education three times more often. Dyslexia was present in both groups. Approximately one-third of all athletes reported to quite often and/or sometimes having symptoms of depression or anxiety. More Paralympic than Olympic athletes experienced sleep disturbances. Every fourth Olympic athlete experienced to quite often/sometimes having negative stress related to social media or gaming, compared with every 10th Paralympic athlete. Over the last 6 months, more than one in three Paralympic and Olympic athletes had been in contact with a sports psychologist for performance reasons, and half of both groups had or wanted follow-up from a sports psychologist for performance reasons.

Table 4

Self-reported cognitive function and mental health experiences among 55 Paralympic and 114 Olympic athletes

Addressing questions related to relative energy deficiency in sport (REDs), one-sixth of the athletes reported not having a relaxed relationship with food intake and body weight (table 2). The prevalence of menstrual disturbances was 38% for Paralympic athletes (14 out of 37, including 1 on oral contraceptives) and 25% for Olympic athletes (44 out of 174, including 9 on oral contraceptives).

Musculoskeletal health and pain

When invited to the PHE, half of the athletes presented with self-reported current or recent (last 6 months) musculoskeletal problems. The shoulder and pelvis/lower back were the most common body locations for current problems in Paralympic athletes while knee and pelvis/lower back problems were most common among Olympic athletes. Also, one in three athletes were currently receiving treatment for musculoskeletal problems (table 5).

Table 5

Injury history among Paralympic and Olympic athletes

Almost half of the Paralympic athletes (46%) and one-fifth of the Olympic athletes (20%) reported current pain (not further specified) (table 2).

Compliance with public health programmes

Three out of five female athletes 25 years or older (n=67, 60.3%), followed the screening programme for cervical cancer, which in Norway was recommended every third year for all women ≥25 years.

With early identification of cancer in mind, across both female cohorts, one in three athletes (34%, n=18) checked their breasts regularly while 13% (n=7) checked sometimes, and 49% (n=26) never checked (n=2, 4% did not know). Among male athletes, 14% (n=16) checked their testicles regularly, 41% (n=47) sometimes and 44% (n=51) never (2% did not know, n=2).

The national childhood vaccination programme was followed by 94% of all athletes. When asked about HPV vaccination, introduced in Norway for grade 7 girls in 2009 and boys in 2018, respectively, 65% of the females had received the vaccine while 33% had not and 2% did not know about the programme. The corresponding proportions were 4%, 22% and 73% for male athletes.


Based on extensive data from nearly 600 PHEs conducted within the Olympiatoppen Periodic Health Evaluation Programme, we identified several health issues suitable for preventive measures or that could benefit from better management. Musculoskeletal problems, infections, allergies and pain were the most burdensome conditions. High BP was the most prevalent cardiovascular finding. Most athletes had completed the national childhood vaccination programme, but compliance with recommended cancer screening and vaccination was poor. Vitamin D deficiency was the most common finding among the many blood sample analyses included in the programme. The PHE uncovered a wealth of information that allowed us to profile each athlete’s health status, plan management and discuss measures to prevent future health problems with each athlete. However, there is little benefit from the programme unless findings are followed up systematically.

Cardiac screening

How to screen for cardiac conditions potentially putting an athlete at increased risk for sudden cardiac arrest is much debated.14 17 18 While Norway does not have national guidelines mandating cardiac screening of athletes, we decided to include a 12-lead ECG as we had the necessary infrastructure and in-house expertise at no extra cost. This compelled follow-up of five athletes with abnormal ECG findings; after further specialist investigations they were cleared without restrictions.

As expected from other studies,19 20 a substantial proportion of athletes reported symptoms, which could be suggestive of cardiac problems; 17% reported palpitations, 16% chest pain during training, 11% syncope or near syncope and 13% difficulty with breathing during the past 12 months (table 2). Syncope or near syncope is considered a serious warning sign of arrhythmia, but according to the medical reports available, the (near) fainting episodes were typically interpreted as vasovagal. In other words, given the extremely low prevalence of cardiac conditions in this population, the specificity of the standard cardiac screening questions is so low as to render them nearly useless.

High BP continues to be the most common cardiovascular finding.21 With hypertension representing a serious medical condition, appropriate follow-up should be ensured. For one-third of the 42 athletes with an elevated BP measurement, no further action was noted. One-fifth had prior high BP measurements, and two-thirds of the athletes, recommended to return for control, did not show up. Four athletes were referred for 24-hour BP recording, of whom two were diagnosed with hypertension. Also, we do not know if left ventricle hypertrophy (LVH) according to the Sokolow-Lyon criteria displayed on ECG in 12 of 30 athletes with simultaneously high BP indicates possible end-organ damage.22 With repeated high BP, they should have been referred to echocardiography to differentiate possible training-related LVH from hypertensive LVH.

Few athletes had elevated total and/or LDL cholesterol (3.8% and 3.2%). Half of them had a total/HDL cholesterol ratio <4 and were deemed not to be at risk while the other half were followed up according to guidelines. A few other athletes were on lipid-lowering drugs with normal values when tested. Based on these data, an initial total cholesterol screen seems warranted and, if elevated, followed up with LDL and HDL cholesterol.

In summary, while effective screening for risk factors associated with sudden cardiac arrest may be unrealistic, elite athletes are not exempt from having risk factors for cardiovascular disease, and treatable conditions like hypertension and hyperlipidaemia should be addressed properly.

Blood sample analyses

Few of the many other blood sample analyses performed were abnormal. As expected, the most common abnormality was low serum vitamin D, affecting three in every four Paralympic athletes and one in three Olympic athletes and with seasonal variations.23–25 The potential role of vitamin D on performance, musculoskeletal health (injury risk, stress fractures), immune function and inflammatory response can justify monitoring vitamin D status, especially in athletes with limited sunlight exposure, dark skin colour or in non-ambulant athletes. Inadequate vitamin D status has frequently been identified in athletes with spinal cord injuries, suggesting a need for proactive preventive measures.24 We do not know if all athletes with insufficiencies received dietary advice or prescriptions, but most reported having taken supplements before. Still, only one in four Paralympic and one in three Olympic athletes had retested to check if their vitamin D status had reached the recommended level (online supplemental table 3).

An adequate iron status is critical for athletes, especially in endurance sports, with haemoglobin and ferritin representing the markers most commonly included in screening programmes.6 9 Notably, very few athletes were clinically iron deficient when compared with population reference values, but as many as one in four female athletes presented with s-ferritin below 30 µmol/L, our recommended level, emphasising the need to monitor iron status in female athletes.26 27 Significant proportions of low values were also seen for vitamin B and magnesium, which can justify routine testing.

Apart from screening for vitamin D, iron status, magnesium and vitamin B, our data do not support a practice of extensive routine blood testing to detect (early) disease. Rather than a predefined panel, analyses should target symptoms, clinical findings and family history, if any. An argument for baseline testing in the IOC consensus statement was that such data may be helpful if symptoms develop, and perhaps even aid return-to-play decisions.1 There may have been cases where baseline values have been helpful, but these few do not countenance the cost.

Asthma and allergy

We identified nine athletes (2.3%) with abnormal FEV1 values, none subsequently diagnosed with asthma. In other words, resting spirometry adds little to no value in detecting lower airway dysfunction other than as a baseline. For athletes at risk of developing asthma through their sporting career, or who report symptoms of airway dysfunction, we recommend targeted testing according to the Global Initiative for Asthma guidelines.15 28–30

Nearly every second athlete self-reported some type of clinical allergy, more than twice that of the general population in Norway31 or that reported by 940 US Olympic and Paralympic athletes using the Allergy Questionnaire for Athletes.32

We assume that treatment for these athletes either is optimised with asthma medication or that their exercise-induced asthma is not detected on resting spirometry, probably a combination of the two. A few of the abnormal pulmonary function tests were from Paralympic athletes with chest deformities but with no asthma confirmed on additional examinations.

Self-reported asthma was twice as common in Olympic (24%) compared with Paralympic athletes (12%). If this difference is due to underdiagnosing of Paralympic athletes, insufficient testing procedures or fewer Paralympic endurance athletes competing in cold conditions, we do not know. However, a three times higher reporting of chest soreness during training and cough/phlegm following competition among Olympic athletes points to a real difference between the two groups.

It has been previously reported that athletes may be negligent in complying with allergy medication or preventive treatment.33 As allergy is closely related to other health conditions affecting quality of life, such as sleep disturbances and upper respiratory disease,34 continued education on best medical treatment, preparing for high allergen seasons, allergen-specific immunotherapy and more focus on reducing allergen exposure, may reduce the burden from allergies.

Mental health and REDs

The increased focus on mental health35–39 and REDs is timely.38 Recently, a Canadian study on collegiate athletes revealed an alarmingly high prevalence of anxiety (30%), depression (26%), sleep disturbances (39%), alcohol misuse (55%) and disordered eating (83%),38 following screening with Sport Mental Health Assessment Tool-1 (SMHAT-1).40 Data from the UK37 and the USA36 Olympic teams confirmed high rates of mental distress among their athletes.

Recent IOC consensus statements have recommended including mental health in NOC screening and monitoring programmes,38 41 and relevant tools such as the SMHAT-1 and a revised form of the OSTRC-H are available for this purpose.38 40 However, the sensitivity and specificity of the SMHAT-1 need to be explored.

A new Norwegian study investigated the relationship between ‘at-risk-scores’ for mental distress on a self-report questionnaire with mental disorders from diagnostic interviews among 378 elite and semi-elite athletes.35 Three-quarters of them presented with ‘at-risk-scores’, and among the third, completing a diagnostic interview, 44% had a mental disorder. Sleep problems (25%) and obsessive–compulsive disorder (OCD) and OCD-related disorders (19%), were most common.35 Based on other NOCs experiences,36 37 we included single questions from multiple tools, authored by our team of professional psychologists and a psychiatrist, with the intention to both educate and optimise health in our population. These non-validated single questions served as entry questions for a more in-depth assessment when indicated.

As another proactive health protection measure, some Norwegian Sports Federations have introduced a health certificate aimed at the early detection of REDs and eating disorders in athlete groups at risk, including guidelines on when to restrict participation.42 This approach can be considered as an additional tailor-made PHE, including relevant blood samples, as proposed in the recent IOC consensus statement on REDs.38 Also, including questions on menstrual disturbances and low mineral density can facilitate the prompt reversal of problematic low energy availability, preventing more severe consequences of REDs.

Musculoskeletal health and pain

When invited to the PHE, shoulder, knee and pelvis/lower back were commonly reported (10%–25%), thereby slightly underestimating our prospective monitoring data, showing that one in five Olympic and one in four Paralympic athletes suffer from an injury at any given time.43 As in line with experiences from Team USA, surveying athletes on previous and current injuries underestimates the true burden.44

The pain reported by athletes is often related to musculoskeletal problems. However, for many of our Paralympic athletes with varying impairments and comorbidities, pain is often multifaceted, and for future PHEs, more specific questions to better differentiate between nociceptive, neuropathic or inflammatory pain could be helpful.

Compliance with public health programmes

The majority of these elite athletes had free and immediate access to health services at Olympiatoppen. The benefit is the low threshold to seek help, but a possible pitfall is that they do not build a relationship with their own general practitioner and, as shown by our data, do not follow national cancer screening programmes. Only two-thirds of female athletes had undergone cervical cancer screening, which is not offered at Olympiatoppen, about the same as in 25–33 years in the general population in Norway.45 That only half checked themselves regularly for lumps in either breasts or testicles and too few had been vaccinated for HPV, indicates that caring for the elite athlete should involve more than just the classic sports medicine issues.

Methodological considerations

The collaborative effort across multiple disciplines at Olympiatoppen improved the overall utility of the PHE process. The health history questionnaire has been revised several times through the four PHE cycles evaluated in this paper, for instance, adding questions to identify mental health issues and learning disabilities. The priority on clinical relevance, rather than running a research programme, has led us to evaluate and change practice continuously. Based on valuable feedback from athletes, questions have also been rephrased to avoid misinterpretation.44

Most importantly, the initial part of the PHE has been transformed from a paper format to secure online questionnaires with input logic and additional pop-up questions. The additional in-person interview and clinical examination have helped strengthen the relationship between the athlete and the health team. The interview also allowed us to capture a more complete and reliable picture of athlete health than questionnaires alone.44

One of the limitations of the PHE data is the cross-sectional design, providing only a snapshot of an athlete’s recent and current health. For example, athletes not qualified as potential Olympic/Paralympic candidates because of severe injury/illness are not included. We acknowledge the complementary value of systematic prospective health monitoring in clinical practice.43 46 47

Lessons learned and future plans

Online questionnaires prior to the physical meeting save consultation time and pinpoint the most important health issues to address while follow-up interviews with clarifying and targeted questions allow us to capture a more complete and reliable picture of athlete health than the questionnaires alone.44

We also asked our Paralympic athletes to complete questions related to impairment-specific health issues, and we highly recommend scheduling sufficient time when examining Paralympic athletes to ensure a proper assessment. Skin health issues, as one example, can otherwise easily be overlooked among prothesis users or in athletes with sensory loss.

While our data document that an extensive PHE programme captures multiple health problems and risk factors, alone, this has limited value. The main purpose is to protect the future health of the athlete by acting on these findings. Another limitation is that the PHE itself requires significant resources and time, and appropriate follow-up demands even more resources. It is important to clearly communicate who is responsible for following up on the various health issues identified from the PHE between the athlete and their medical team. Standardising follow-up of preventable or treatable health conditions recognised by the PHE represents the biggest room for improvement within our programme.


Our extensive PHE programme revealed a wealth of information on each athlete’s health status, with musculoskeletal problems, infections, allergies and pain as common conditions. But the data also emphasise the need to address issues not traditionally targeted in sports medicine, like mental health, REDs, asthma, risk factors for other cardiovascular diseases, cancer screening and vaccination. Also, blood testing should be minimised and targeted. Longitudinal follow-up of health issues identified during screening is needed to determine the true benefits of PHE.

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and the program has been reviewed by the South-Eastern Norwegian Regional Committee for Research Ethics and approved by the Norwegian Data Inspectorate. Informed written consent has been obtained from all athletes included in this report. Participants gave informed consent to participate in the study before taking part.


The authors acknowledge the supportive health personnel, coaches and management at Olympiatoppen, particularly Monica Viker Brekke and Berit Lian Berntzen. We also thank the athletes, team physicians and physiotherapists and others involved in data collection for their vital role in the success of this program, including Margrethe Lund. The Oslo Sports Trauma Research Center has been established at the Norwegian School of Sport Sciences through generous grants from the Royal Norwegian Ministry of Culture, the South-Eastern Norway Regional Health Authority, the International Olympic Committee, the Norwegian Olympic Committee & Confederation of Sport and Norsk Tipping AS.


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • X @RoaldBahr, @benclarsen, @FredriksenHilde, @LarsHaugvad, @koivisto_anu, @ReierTonje, @HildeMBerge

  • Contributors KS, RB, BC and HMB planned and designed the study, and all authors contributed to data collection. KS and HMB analysed the data and drafted the paper with RB. All authors provided critical revisions and contributed to the final manuscript. KS, RB and HMB are the guarantors.

  • Funding The Norwegian Olympic and Paralympic team health monitoring program has been supported by a grant from Olympic Solidarity since 2016. The Norwegian Olympic Training Center (Olympiatoppen) also highly appreciates funding from Stiftelsen VI and the Foundation Dam (grant number 2022/HE1-397971).

  • Competing interests KS is the coeditor of the British Journal of Sports Medicine-Injury Prevention and Health Protection. In the period, these data were collected, the Oslo Sports Trauma Research Center has had a non-financial research partnership with FitStats Technologies (2017 to present).

  • 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.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.