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Original article
Muscle injury is the principal injury type and hamstring muscle injury is the first injury diagnosis during top-level international athletics championships between 2007 and 2015
  1. Pascal Edouard1,2,3,
  2. Pedro Branco4,5,
  3. Juan-Manuel Alonso5,6
  1. 1Inter-university Laboratory on Biology of Motor skills (LIBM EA), University of Lyon, Saint Etienne, France
  2. 2Department of Clinical and Exercise Physiology, Sports Medicine Unity, Faculty of medicine, University Hospital of Saint-Etienne, Saint-Etienne, France
  3. 3Medical Commission, French Athletics Federation (FFA), Paris, France
  4. 4European Athletics Medical & Anti Doping Commission, European Athletics Association (EAA), Lausanne, Switzerland
  5. 5Medical & Anti Doping Commission, International Association of Athletics Federations (IAAF), Monaco
  6. 6Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  1. Correspondence to Dr Pascal Edouard, Department of Clinical and Exercise Physiology, Sports medicine unity, IRMIS, Campus Santé Innovations, University Hospital of Saint-Etienne, Saint-Etienne cedex 2, Saint-Etienne 42055, France; Pascal.Edouard42{at}gmail.com

Abstract

Background During top-level international athletics championships, muscle injuries are frequent.

Objective To analyse the incidence and characteristics of muscle injuries and hamstring muscle injuries (hamstring injuries) occurring during top-level international athletics championships.

Methods During 16 international championships held between 2007 and 2015, national medical team and local organising committee physicians reported daily all injuries on a standardised injury report form. Only muscle injuries (muscle tears and muscle cramps) and hamstring injuries have been analysed.

Results 40.9% of all recorded injuries (n=720) were muscle injuries, with 57.5% of them resulting in time loss. The overall incidence of muscle injuries was higher in male athletes than female athletes (51.9±6.0 vs 30.3±5.0 injuries per 1000 registered athletes, respectively; RR=1.71; 95% CI 1.45 to 2.01). Muscle injuries mainly affected the thigh (52.9%) and lower leg (20.1%), and were mostly caused by overuse with sudden onset (38.2%) and non-contact trauma (24.6%). Muscle injury risk varied according to the event groups. Hamstring injuries represented 17.1% of all injuries, with a higher risk in male compared to female athletes (22.4±3.4 vs 11.5±2.6 injuries per 1000 registered athletes, respectively; RR=1.94; 95% CI 1.42 to 2.66).

Conclusions During international athletics championships, muscle injury is the principal type of injury, and among those, the hamstring is the most commonly affected, with a two times higher risk in male than female athletes. Athletes in explosive power events, male athletes and older male athletes, in specific were more at risk of muscle injuries and hamstring injuries. Injury prevention strategies should be sex-specific.

  • Hamstrings
  • Injury prevention
  • Athletics
  • Epidemiology

https://doi.org/10.1136/bjsports-2015-095559

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    Introduction

    During top-level international athletics championships, muscle injury is the principal type of reported (time-loss) injury, with thigh muscle tear (hamstring muscle tear in particular) as the most common (time-loss) injury diagnosis.1–8 However, there has been no detailed characterisation of muscle injuries and especially hamstring muscle injuries (location, cause, severity, circumstance, event groups and age categories) at this top level of athletics.

    Detailed analyses of muscle injuries can help us better understand the sex-related differences in the incidence of injuries and more specifically to that of muscle injuries.9 Indeed, in athletics, a muscle injury is the most frequent type of injury in male (46.4%) and female (34.6%) athletes, and represents the only sex-different injury type (with the exception of stress fractures which are less common (0.7% in male and 3.0% in female athletes)).9 The susceptibility to muscle injury seems different between male and female athletes, and could explain the overall sex-related difference in injury risk.

    Therefore, we analysed the incidences and characteristics of muscle injuries, and especially hamstring muscle injuries (hamstring injuries), during top-level international athletics championships from 2007 to 2015, to better understand the sex-related differences in injury risk.

    Methods

    The study design, injury definition and data collection procedures were identical for all championships and have been described in detail previously.1–11 All new injuries that occurred during the respective athletics championships (listed below) were reported daily by the national medical teams (physicians and/or physiotherapists) and/or by the local organising committee's physicians (LOC). 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.9 An injury was defined as “all musculoskeletal injuries (traumatic and overuse) newly incurred during competition or training regardless of the consequences with respect to the athlete's absence from competition or training”.1 ,10 ,11

    In this paper, we only analysed reported muscle injuries. ‘Muscle injuries’ were defined as those reported as ‘strain/muscle rupture/tear’ or ‘muscle cramps or spasm’ in the injury type section of the injury report form. In agreement with Ekstrand et al,12 structural-mechanical injuries, such as total and partial muscle ruptures and functional injuries, such as fatigue-induced or neurogenic muscle hardening (hypertonia) or cramps, were included in the ‘muscle injuries’, whereas contusions, haematomas, tendon ruptures and chronic tendinopathies were excluded. ‘Hamstring muscle injuries’ were those whose location was reported as ‘posterior thigh’. The registration of a ‘strain/muscle rupture/tear’, ‘muscle cramps or spasm’ or ‘posterior thigh’ injury was based on clinical examination and/or medical imaging by the national medical teams and/or by LOC physicians; no specific diagnostic criteria were sent out in advance.

    Injuries were recorded during 16 top-level international Athletics championships from 2007 to 2015: the World Outdoor Championships (WOC) 2007,1 2009,2 2011,3 2013;4 the Olympic Games (OG) 2008,13 2012;14 the European Outdoor Championships (EOC) 2010, 2012,5 2014; the World Indoor Championships (WIC) 2008, 2010, 2014; and the European Indoor Championships (EIC) 2009, 2011,6 2013,7 2015 (Country participation: 29.6%; registered athletes’ coverage: 76.9%; expected injury report forms returned: 88.2% (information is missing for OG 2008, OG 2012 and WIC 2010); and muscle injury data completeness: 96.0%).

    For sex-related analyses of muscle injuries, the data from only 12 championships (WOC 2007, WOC 2009, WOC 2011, WOC 2013, OG 2012, EOC 2012, EOC 2014, WIC 2014, EIC 2009, EIC 2011, EIC 2013 and EIC 2015) were included, since the other competition studies had missing data for sex (EOC 2010, WIC 2008 and WIC 2010) or circumstances, event groups and time loss (OG 2008) (Country participation: 33.1%, registered athletes’ coverage: 80.3%, expected injury report forms returned: 89% (information is missing for OG 2012), and muscle injury data completeness: 98.3%).

    For the hamstring injury analyses, data from nine championships (WOC 2009, WOC 2011, WOC 2013, EOC 2012, EOC 2014, WIC 2014, EIC 2011, EIC 2013 and EIC 2015) were included, since the other competition studies did not specifically record hamstring injuries but only thigh injuries (WOC 2007, OG 2008, OG 2012, WIC 2008 and EIC 2009) and/or had missing data for sex (EOC 2010, WIC 2008 and WIC 2010) (Country participation: 33.3%; registered athletes’ coverage: 81.4%; expected injury report forms returned: 92.3% and muscle injury data completeness: 98.7%).

    Incidence of all (time-loss), training and in-competition (time-loss) injuries, muscle injuries and hamstring injuries was calculated as the number of injuries per 1000 registered athletes using a list of athletes provided by the International Association of Athletics Federations (IAAF) or the European Athletics Association (EAA). Muscle injury and hamstring injury data were analysed separately for male and female athletes according to Edouard et al,9 and pooled for outdoor, indoor and all championships. Data were analysed and are presented using frequencies, percentages, cross-tabulations, incidences, relative risks (RR) with 95% confident intervals (95% CI) and magnitude thresholds,15 and with the χ2 test.9 All data were processed using Excel. Significance was accepted at p<0.05.

    Results

    Incidence of muscle injuries

    From the 16 international athletics championships held between 2007 and 2015, a total of 720 muscle injuries of a total of 1762 injuries (40.9%) were recorded. Among the 720 muscle injuries, 57.5% (n=414) led to time loss. The proportion of muscle injuries was significantly higher among time-loss injuries than all injuries (χ2=17.3; p<0.001), as about half of the total time-loss injuries were muscle injuries (n=414 of a total of 836 time-loss injuries; 49.5%).

    From the 12 international athletics championships, 631 muscle injuries were reported of the 1527 injuries (41.3%). The proportion of muscle injuries was significantly higher among male (45.6%) than female athletes (34.7%) (χ2=18.1; p<0.001). For male athletes, the proportion of muscle injuries was significantly higher among time-loss and in-competition time-loss injuries (about 57%) than among all, training and in-competition injuries (about 46%; p<0.05).

    The overall incidence of muscle injuries was significantly higher in male than female athletes (51.9±6.0 vs 30.3±5.0 injuries per 1000 registered athletes, respectively; RR=1.71; 95% CI 1.45 to 2.01, small; table 1). Male athletes suffered significantly more muscle (time-loss) injuries, both during training (except for total championships) and in competition, than did female athletes for outdoor and total championships (p<0.05), while the incidences of muscle injury in indoor championships were similar for both sexes (table 1).

    View this table:
    Table 1

    Incidences of injuries, muscle injuries and hamstring muscle injuries per 1000 registered athletes and relative risks (RR) of injury with lower and upper limits of 95% of CI (±95% CI) in male and female athletes during outdoor (WOC 2007, WOC 2009, WOC 2011, WOC 2013, OG 2012, EOC 2012, EOC 2014) and indoor (WIC 2014, EIC 2009, EIC 2011, EIC 2013, EIC 2015) championships

    Characteristics of muscle injuries

    Type

    Two-third of muscle injuries were diagnosed as muscle tears, and one-third as muscle cramps, without any differences in the distribution between male and female athletes or between outdoor and indoor championships. The risk of muscle injuries was greater for male than female athletes (table 2).

    View this table:
    Table 2

    Percentage of all muscle injuries (%), incidences of all muscle injury per 1000 registered athletes and relative risks of injury with lower and upper limits of 95% of confidence interval (±95% CI) in male and female athletes for type, location, cause, severity, event groups and age categories during outdoor (WOC 2007, WOC 2009, WOC 2011, WOC 2013, OG 2012, EOC 2012 and EOC 2014) and indoor (WIC 2014, EIC 2009, EIC 2011, EIC 2013 and EIC 2015) championships.

    Location

    More than half of all muscle injuries affected the thigh (52.9%), followed by the lower leg (20.1%) and the hip and groin (8.6%). There were no differences in the distribution between males and females and indoor/outdoor championships. Males had a greater risk of injuries to the hip and groin, thigh and lower leg than female athletes (table 2).

    Cause

    Overuse injuries were dominant (51.8%), primarily of sudden onset (38.2%) and to a lesser degree of gradual onset (13.6%), followed by non-contact trauma (24.6%) and others (including contact trauma and recurrence of previous injury; 21.4%; table 2). Male athletes presented more muscle injuries caused by overuse with sudden onset during outdoor championships and higher non-contact trauma injuries during indoor competitions (p<0.05; table 2).

    Severity

    There were no differences in the distribution of muscle injuries either between outdoor and indoor championships or for males and females (table 2). The severity of muscle injury per location is presented in table 3.

    View this table:
    Table 3

    Severity of all muscle injuries per location during outdoor (WOC 2007, WOC 2009, WOC 2011, WOC 2013, OG 2012, EOC 2012, EOC 2014) and indoor (WIC 2014, EIC 2009, EIC 2011, EIC 2013 and EIC 2015) championships

    Event groups

    The muscle injury incidences differed significantly between male and female athletes in the various events (p<0.001; table 2). The three most prevalent events were sprints, jumps and the marathon for male athletes, and sprints, jumps and long distances for female athletes (table 2). For male athletes, muscle injury incidences were higher in the marathon, combined events and race walking than in other events, and for female athletes in combined events, the marathon, long distances and sprints than in other events (table 2). The distribution of muscle injuries per location and event is presented in table 4.

    View this table:
    Table 4

    The distribution of muscle injuries per location and events in percentages and in incidences of all muscle injury per 1000 registered athletes with lower and upper limits of 95% of confidence interval (±95% CI) per location and events, in male and female athletes, during outdoor (WOC 2007, WOC 2009, WOC 2011, WOC 2013, EOC 2012 and EOC 2014) and indoor (WIC 2014, EIC 2009, EIC 2011, EIC 2013 and EIC 2015) championships

    A comparison between explosive power events (sprints, hurdles, jumps, throws and combined events) and endurance events (middle and long distances, the marathon and race walks) revealed differences (p<0.05) for male athletes only in the distribution of (1) injury location (a higher proportion of thigh muscle injuries in explosive power events, and of lower leg muscle injuries in endurance events), (2) injury cause (higher proportion of non-contact trauma muscle injuries in explosive power events), and (3) significant differences in mean time-loss duration (9.4±9.1 vs 6.5±7.7 days, for explosive-power vs endurance events, respectively).

    Age

    There were no differences in the distribution of muscle injuries between males and females or between outdoor and indoor events. Muscle injury incidence increased significantly with age for male athletes (p<0.05; table 2).

    Incidence of hamstring muscle injuries

    Of the 1082 injuries recorded during the 9 international athletics championships, there were 185 hamstring injuries, constituting 17.1% of total injuries. Hamstring injury frequencies were significantly higher in male (19.3%) than female (13.5%) athletes (χ2=6.1; p=0.01); 61.1% (n=113) of these hamstring injuries led to time loss from the sport; a quarter of all time-loss injuries were hamstring injuries (n=113 out of a total of 480 time-loss injuries, 23.5%).

    For male athletes, the proportion of hamstring injuries was significantly higher among time-loss injuries (about 25%) than among all and in-competition injuries (about 19%; p<0.05). For female athletes, the proportion of hamstring injuries was significantly higher among time-loss and in-competition time-loss injuries (about 21%) than among all and in-competition injuries (about 13%; p<0.05).

    Hamstring injuries represented 39.8% of all muscle injuries (41.3% in male and 36.7% in female athletes, without any differences in the distribution between male and female athletes) and 74.6% of all thigh muscle injuries (75.6% in male and 72.4% in female athletes, without any differences in the distribution between male and female athletes).

    The overall incidence of hamstring injuries was significantly higher in males than females (22.4±3.4 vs 11.5±2.6 injuries per 1000 registered athletes, respectively; RR=1.94; 95% CI 1.42 to 2.66, moderate; table 1). Male athletes suffered significantly more hamstring injuries, in-competition hamstring injuries, time-loss hamstring injuries and in-competition time-loss hamstring injuries than female athletes for outdoor and total championships (p<0.05), while the hamstring injury incidence in indoor championships and during training was similar for both sexes (table 1).

    Characteristics of hamstring muscle injuries

    Type, cause and severity

    Three-quarter of hamstring injuries were diagnosed as muscle tears, and one-quarter as muscle cramps, with similar distribution between males and females and between outdoor and indoor championships, although the risk was higher for males (table 5). Overuse with sudden onset was the main cause of hamstring injuries, followed by non-contact trauma; again, no differences are observed between the sexes, without any differences in the distribution between male and female athletes or between outdoor and indoor championships (table 5). Neither were differences in distribution observed for severity (tables 3 and 5).

    View this table:
    Table 5

    Incidences of hamstring muscle injury per 1000 registered athletes and relative risk of injury with lower and upper limits of 95% of confidence interval (±95% CI) in male and female athletes for type, cause, event groups and age categories during outdoor (WOC 2009, WOC 2011, WOC 2013, EOC 2012 and EOC 2014) and indoor (WIC 2014, EIC 2011, EIC 2013 and EIC 2015) championships

    Event groups

    Hamstring injury incidences differed significantly between events for males and females for outdoor and total championships (p<0.001), but not for indoor competitions (table 5). The three prevalent events were sprints, jumps and hurdles for male athletes and sprints, combined events and hurdles for female athletes (table 5). Hamstring injury incidences were higher in combined events, sprints and hurdles than in other events for male athletes, and in combined events, sprints and hurdles than in other events for female athletes (table 5).

    A comparison between explosive power events (sprints, hurdles, jumps, throws and combined events) and endurance events (middle and long distances, marathon and race walks) revealed differences (p<0.05) for male athletes only in the distribution of (1) injury cause (higher proportion of non-contact trauma hamstring injuries in explosive power events), and (2) injury severity (higher proportion of time-loss hamstring injuries in explosive power events).

    Age

    There was no difference in hamstring injury distribution between male and female athletes and between outdoor and indoor championships (table 5).

    Discussion

    The main findings of this study were that muscle injuries represented a high proportion of all injuries incurred during international athletics championships (45.6% in male and 34.7% in female athletes), with a higher risk for males (RR=1.71; 95% CI 1.45 to 2.01). The risk was greatest during competitions and during outdoor championships. Muscle injuries mainly affected the thigh (52.9%), were most commonly caused by overuse with sudden onset (38.2%) and by non-contact trauma (24.6%), and the risk varied between events.

    The most frequent diagnosis was hamstring injuries, accounting for 19.3% in males and 13.5% in females of all injuries incurred during international athletics championships. Males were more at risk than females (RR=1.94; 95% CI 1.42 to 2.66). Athletes were more likely to injure themselves during competitions. Hamstring injuries mainly caused by overuse with sudden onset (44.9%), although the risks varied between the events.

    Muscle injuries and hamstring muscle injuries are the most frequent injuries during international athletics championships

    This is the first study to provide a detailed description of the incidence and characteristics of the principal type and diagnosis of injury during international athletics championships. The large number of championships, and consequently, the number of muscle injuries and hamstring injuries included in this study have allowed us to provide detailed analyses regarding their location, cause, severity, event groups and age categories.

    The present results extend previous smaller studies that reported muscle injury as the principal type of injury and hamstring injuries as the most common diagnosis during international athletics championships,1–9 and during the single-meet event of the Penn Relay Carnival.16

    Studies carried out over the whole athletics season have shown muscle injury to be the second most common type of injury after ligament injury,17 ,18 or after inflammation and pain with gradual onset.19 ,20 Hamstring injuries have been reported as the most (50%)21 or second most common diagnosis (14.2% of all injuries),22 whereas other studies have found hamstring injuries to be the most frequently injured muscle,17 or have found hamstring injuries to be less frequent.18 ,19 ,23

    Substantial consequences for athletes

    In our study, muscle injuries resulting in time loss represented 57.7% and 52.4% of all injuries for male and female athletes, respectively, and time-loss hamstring injuries represented 58.5% and 67.3% of all injuries for male and female athletes, respectively. Almost half of the time-loss muscle injuries and hamstring injuries were moderate, meaning an estimated time loss of 8–28 days.

    Thigh muscle injuries and hamstring injuries cause the greatest time loss for athletes and have the greatest impact on an athlete's subsequent performance. The time to return to sport after hamstring injury can be long, requires a progressive and adapted rehabilitation programme and is associated with a risk of reinjury.24 ,25

    What can be done to prevent this type of injury? Nordic hamstring exercises reduce hamstring injuries in footballers.26 These and other eccentric exercises24 ,27 warrant trialling in athletics.

    More hamstring muscle injuries in explosive power events

    The frequency of muscle injuries was higher in explosive power events such as sprints, jumps and combined events, but the risk of muscle injury was also high in endurance events (long distance and marathon). In explosive power events, a higher proportion of muscle injuries and hamstring injuries were caused by non-contact trauma and their severity was greater. The predominance of muscle injuries has already been reported in explosive power sports such as football12 or rugby.28 In our study, the hamstring injury risk was clearly higher in explosive power events (sprints, hurdles, jumps and combined events). Our findings extend previous results in combined events.29 ,30 Thigh muscle injuries have been reported to be the most common diagnosis in national combined event championships (21.6%),29 and hamstring injuries to be the most frequent diagnosis and cause of dropouts during a decathlon competition.30

    Older male athletes had a higher muscle injury risk

    The incidence of muscle injuries increased with the age of male athletes. Compared with a 20-year-old sprinter, a 26-year-old, 30-year-old and 35-year-old-sprinter had a 1.6, 1.9 and 2.1 times risk of suffering a muscle injury, respectively. This has also been reported in football.12 In athletics, age appears to be the second most important risk factor after male sex.

    Male and female athletes have different risks of muscle and hamstring muscle injury

    The previously reported differences in total injury incidence between male and female athletes9 could be explained by the higher incidence of muscle injuries in males compared to females. If all muscle injuries (not just hamstring injuries) were removed from the total injury count, there would be no difference in injury risk between the sexes.

    This study extends previous findings that male athletes suffered more thigh muscle tears than female athletes, although thigh muscle tear was still the most frequent injury,3 ,9 and added to our understanding of sex-related differences in these injuries.9 Hamstring injury was the most frequent thigh muscle injury (three-quarters of all such injuries), with equivalent proportions among male and female athletes, but a higher risk in males than females (RR=1.94; 95% CI 1.42 to 2.66). Other thigh muscle injuries (including quadriceps injuries) represented 25.4% of all thigh injuries (5.8% of all injuries), without any differences in proportion and injury risk between males and females. In addition, there were no sex-related differences in the distribution of the severity of these hamstring injuries. Thus, thigh muscle injury sex-related differences applied only to hamstring muscle injuries whatever the severity.

    These results also support previous recommendations that epidemiological data from male and female athletes should be analysed separately.9

    Methodological considerations

    This is the first study to concentrate specifically on muscle injuries and hamstring injuries occurring during a large number of international athletics championships, using standardised consensus methods.1 ,10 ,11 Some methodological issues regarding recording systems and data analyses have been discussed previously.3 ,5 ,9 Study results can only be interpreted if complete trust is put in the diagnoses of injury type (muscle) or location (hamstring) made by the physicians or physiotherapists after clinical examination or medical imaging, as has been the case in previous epidemiological studies carried out during championships.1–7 ,13 ,14 To avoid the bias of muscle injury diagnosis and classification, we chose to include all muscle injuries: muscle tears and cramps. Future studies could require a more accurate diagnosis (location, size…) using medical imaging (especially MRI) and/or improve the description of muscle injuries by using one of the new muscle injury classifications.31 ,32 Finally, the cause of injury should be discussed. The mode of onset is easily determined, and is mainly sudden for muscle injuries and hamstring injuries. However, the exact cause of the incident (‘overuse’ or ‘non-contact trauma’) can be difficult to ascertain and should be explored in future studies.

    Summary

    During top-level international athletics championships, muscle injuries are the most common injuries in male (45.6%) and female (34.7%) athletes, although muscle injury risk is almost two times higher in males than in females. Hamstring injury is the most common injury diagnosis (19.3% in male athletes and 13.5% in female athletes), with a twofold higher risk in males than females. Athletes in explosive power events, male athletes and older male athletes seem to be more at risk of muscle and hamstring muscle injuries. Injury prevention strategies should focus on muscle injuries, particularly hamstring injuries and should be sex-specific including screening of athletes at risk, paying particular attention to athletes at risk and to small signs, and adapted physical and strengthening conditioning.

    What are the findings?

    • Muscle injury and hamstring muscle injury are the principal type and diagnosis, respectively, of injury diagnosed during international athletics championships, for both male and female athletes, but with a two times higher risk for male athletes.

    • Muscle injury incidences were higher in the marathon, combined events and race walking for male athletes, and in combined events, the marathon, long distances and sprints for female athletes.

    • Hamstring muscle injury incidences were higher in combined events, sprints and hurdles for male athletes, and in combined events, sprints and hurdles for female athletes.

    • Athletes competing in explosive power events, male athletes and older male athletes seem to be more at risk of muscle and hamstring muscle injuries.

    How might it impact on clinical practice in the future?

    • Injury prevention strategies should focus on muscle and hamstring muscle injuries, be sex-specific and focus on athletes competing in explosive power events, male athletes and older athletes.

    Acknowledgments

    The authors greatly appreciate the cooperation of the team physicians and medical staff of the different championships (WOC, EOC, OG, WIC and EIC) who volunteered their time to collect the data for this project. The authors would like to acknowledge Astrid Junge, Kathrin Steffen and Karim Khan for their help in this project.

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    Footnotes

    • Twitter Follow Pascal Edouard at @PascalEdouard42

    • Contributors PE made substantial contributions to the conception and design of the project, preparation of data files for the championships, analysis and interpretation of all championship data, drafting, writing and revising of the manuscript and final approval of the version to be published. PB made substantial contributions to the data collection, revision of the manuscript and final approval of the version to be published. JMA made substantial contributions to the development of the project and data collection, revision of the manuscript and final approval of the version to be published.

    • Competing interests None declared.

    • Ethics approval The study was approved by the medical research Ethics Committee of the South-Eastern Norway Regional Health Authority, Norway (for athletics championships from 2007 to 2011 and for the Olympic Games) and the Ethics Committee of the Saint-Etienne University Hospital, France (for athletics championships from 2012 to 2015).

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