CONTEMPORARY KNOWLEDGE ON INJURY EPIDEMIOLOGY, RISK FACTORS, AND PREVENTION STRATEGIES
– Written by Pascal Edouard, France, Jenny Jacobsson, Sweden, Robert Mann, UK, Pedro Branco, Switzerland, Juan Manuel Alonso, Qatar, Karsten Hollander, Germany, Toomas Timpka, Sweden
INTRODUCTION
Performance is a key shared goal in athletics (track and field). Injuries, however, often derail performance1-4, and compromise athletes’ short-, middle-, and long-term health5,6. Indeed, the sport of athletics is unfortunately and invariably associated with an increased risk of injury5,7. About two-thirds of athletes experience at least one injury per season8-12. And almost all athletes have experienced at least one injury after a few years of athletics practice13. Most key stakeholders agree, from both a performance and health perspective, on the need to reduce injury risk in athletics14,15.
To reach this goal, we could use the injury prevention sequence16: establishing knowledge on injury epidemiology informs research on mechanisms and risk factors, as well as development of prevention strategies, whilst knowledge on mechanisms and risk factors could enlighten prevention strategies. However, athletics, although one sport, consists of several disciplines, each with its unique physical, mechanical, technical, and psychological demands, and therefore injury profile17. This complexity is a challenge for injury prevention. In addition, the potential efficacy of a prevention strategy, in the context of a scientific study, does not always translate to real-world effectiveness. Indeed, prevention strategies are not always used in practice, raising the challenge of adherence to the suggested measures.
This paper aims to narratively review injury prevention in athletics. We present contemporary knowledge on injury epidemiology, risk factors, and prevention strategies.
INJURY EPIDEMIOLOGY IN ATHLETICS: A STRONG BASIS TO INFORM INJURY PREVENTION STRATEGIES
Several peer reviewed epidemiological studies have spotlighted the extent of the injury problem in athletics in different contexts and populations—during international athletics championships; during the entire season; in different age categories (from youth to adult); and in the different athletics disciplines18.
During an athletics season, about two-thirds of athletes had at least one injury, and the incidence was reported as 3-4 injuries per 1,000 hours of athletics practice8-10,18. During international athletics championships, about 100 injuries per 1,000 registered athletes have been reported, with variation according to sex19 and disciplines17 (Figure 1). In addition, about a third of athletes reported having suffered from an injury during the four weeks before the championships20.
Injury characteristics (location and/or diagnosis) reported in athletics epidemiological studies have been quite consistent, despite different injury definitions and classifications, and being mostly descriptive (no comparison)8-10,21,22. In Table 1, we present a summary of the main injury locations in the different athletics disciplines. These discipline-specific injury characteristics suggest that each discipline has its unique challenges and therefore injuries, irrespective of the circumstances and/or population17.
In different studies with different contexts (e.g., age, level, country), some injury risk factors were associated with higher injury rates8-10,19,20,23-27. Table 2 presents the main reported risk factors. Less than a hand full of epidemiological studies in children’s and youth athletics suggest a possible relationship between injuries and growth24,28. More work is needed in specific athletic populations, taking into account differences between disciplines and the large variety of potential risk factors (e.g. intrinsic, extrinsic, physical, psychological, social)5,29.
Despite this relatively substantial number of epidemiological studies to date, more high-quality studies are needed to better understand injuries in athletics. However, the current evidence-base is likely adequate to inform the development of various injury prevention strategies18.
INJURY PREVENTION STRATEGIES
Current scientific evidence to reduce injury risk in athletics
Unlike other sports31,32, only two randomised controlled trials33,34 (to our knowledge) investigated the efficacy of injury prevention strategies in athletics.
Evaluation of a neuromuscular programme
One cluster randomised controlled trial, called PREVATHLE, was conducted during a 39-week period in a population of 840 athletes aged between 15 to 40 years. Athletes were randomly divided into two groups: (1) a control group who continued their usual training (n = 391), and (2) an intervention group (n = 449) who performed an Athletics Injury Prevention Programme (AIPP). The AIPP included eight exercises, chosen to target the most common athletics injuries: hamstring muscle injuries, Achilles and patellar tendinopathies, low back pain, and ankle sprains. Whilst being time efficient and feasible for the athlete to complete, the eight exercises (addressing: core stability, hamstring, leg and pelvic muscles strengthening and stretching, and balance exercises) were performed in addition to the athletes’ usual training at least twice a week (Figure 2)33. The AIPP was based on available literature on the epidemiology of athletics injuries, injury risk factors, and current evidence on injury prevention strategies33. Exercises used successfully for primary and/or secondary prevention were selected, including: eccentric strengthening to prevent hamstring injuries, Achilles and patellar tendinopathies; strengthening and neuromuscular control to prevent ankle sprains; and core stability to guard against low back pain33. Among the 840 included athletes, only 68 (15.1%) from the intervention group and 100 (25.6%) from the control group provided 100% of the requested information (weekly injury and participation in athletics training and competition) during the follow-up (39 weeks), and were included in the final analyses33. Furthermore, only 8.8% of athletes in the intervention group performed the intervention twice per week or more, as requested33. The proportion of athletes who had at least one injury complaint over the follow-up period was similar in the intervention (64.7%) and control groups (65.0%), with an adjusted odds ratio of 0.81 (95% CI 0.36 to 1.85)33. There were no between-group differences when separately comparing subgroups according to their different intervention compliance. In this randomised controlled trial, an AIPP did not reduce injury complaint risk33. However, the overall low response rate and intervention compliance could have contributed to the negative results. Notedly, a 40-week prospective cohort study (level 2 evidence) on 62 inter-regional and national-level athletes was conducted before the randomised controlled trial, asking the athletes to regularly perform the AIPP35. At 12 weeks follow-up, performing the AIPP was associated with a significantly lower risk of injury complaint, with a hazard ratio of 0.29 (95% CI: 0.12 to 0.73)35. However, after 40 weeks follow-up, there was no significant association35. More work is therefore needed to improve the AIPP itself, and importantly improve implementation and adoption of interventions more generally.
Evaluation of a digital health platform
A cluster randomized controlled trial involving young athletics athletes (aged 12 – 15 years) during a 4-month outdoor season in Sweden34, employed a universal prevention approach. This form of prevention is delivered to large groups without prior screening and aims to reduce injury risk among asymptomatic populations36. The aim of the study was to investigate whether having access to athletics-specific training and health information—delivered through a digital health platform (Figure 3)—could reduce the incidence of injuries34. Digital health platforms—with well-aligned information that supports the development of safe sports practices—could efficiently engage grassroot-level stakeholders in a sport, particularly parents and coaches37. As the organisation of clubs varies considerably in Sweden (such as regarding coaching structure, e.g., employed, parents or older peers; or focusing on elite or youth athletes), the clubs were cluster randomised into intervention or control groups according to club size. Parents and coaches in the intervention group were given password-protected access to the digital health platform (Figure 3) and were encouraged (four times during the 4-month period by e-mail alerts) to read and delve deeper into specific topics of the digital health platform34. The control group continued training according to their routine. Parents in both groups returned training and injury data every 2-weeks during the study period. Included in the analysis were 56 athletes in the intervention group and 79 athletes in the control group34. During the study, 85% of the athletes (together with parents) provided training reports. Compared to the control group, injury incidence was significantly lower (p = 0.049) (HR = 0.62; χ2 = 3.865; p = 0.049) among youth athletes in the intervention group34. This effect was amplified in larger clubs (p = 0.049). The median time to first injury was 16 weeks in the intervention group and 8 weeks in the control group. The authors concluded that an athlete’s environment impacted individual risk of injury. However, as the study did not collect unique log-in data, inference on individual user patterns was not possible. Despite that, adherence with the intervention seems to have been good as the average time spent on the digital health platform was close to 5 minutes per log-in session. This study could inform development and implementation of injury prevention strategies in sports organisations and their grassroot networks (e.g., clubs). These multi-component social systems are dynamic; they interact and change along with the current societal environment38. We need more high-quality studies based on digital platforms to inform universal injury prevention in youth sports.
What else could be done?
Beside these two contemporary examples, we could suggest other prevention strategies; however, they are primarily based on the ideas and hypotheses of the article authors. Notedly, such prevention strategies should be global, multimodal, and multifactorial. They can include5,29,39:
- Physical conditioning of athletes for improvement of sensorimotor control by, for example: stretching-, muscular strengthening- (particularly eccentric), proprioceptive-, and balance exercises; exercises focussing on increased resistance to fatigue; and appropriate and optimal (not too much and not too less) training.
- Improvement of technical movement and biomechanics to avoid specific pathologies associated with a specific movement and/or technical mistakes that may result in injuries.
- Sports equipment and rules, for example: modification of rules to improve safety; changes in competition schedules according to weather conditions and the athletes’ circadian cycle.
- Lifestyle for example, improved recovery, sleep, and/or nutrition, and being vigilant of painful symptoms.
- Psychological approach for example, mental preparation, mental imagery, regular psychological follow-up.
- Coordinated and consistent medical care of athletes for example, medical staff focussing on early and correct care of an injury, and athletes’ health monitoring.
- Education of athletes and their entourages is important to make them actively participate in athlete’s health protection and injury prevention40;
- Systematic and sustained approach by all stakeholders: policy-level advocacy/change; national governing bodies and/or international federations prioritising “duty of care” for youth athletes; the top management of national and international athletics federations prioritising injury prevention and safety promotion initiatives41,42.
The challenge of adherence and implementation
Injury prevention is logical and relevant—a notion shared by key athletics stakeholders14,15. However, injury prevention strategies are seldomly adopted13,33. In a recent online survey, less than one-third of 7,715 athletes self-declared having partially or fully adopted any injury prevention programme during their lifetime13. Furthermore, only 7.5% of athletes who participated in this study had completed an injury prevention programme during their lifetime13. In a randomised controlled trial in athletics33, only 9% (6 of 68 intervention group athletes) declared to have fully complied with the injury risk reduction intervention (i.e., eight exercises two times a week). Although contexts are different (survey on a big sample of athletes with possible interpretation and recall bias, and experimental study), these results could indicate that injury prevention strategies are poorly adopted in athletics33,43,44, similarly to other sports45. Indeed, compliance with injury prevention strategies are suboptimal in the context of scientific studies43. Equally, adherence to injury prevention strategies in applied practice has been disappointing46,47. The ideal to reduce sports injuries might never be realised if end-users do not properly use injury prevention strategies in practice48-50. Therefore, a better understanding of the beliefs and intentions of athletes who adopt or do not adopt an injury prevention strategy is likely to improve the implementation of such strategies. A recent online survey revealed that some athletes’ characteristics could be associated with different levels of compliance with injury prevention strategies13. Characteristics such as competing at the highest level, presenting a larger number of past injuries, and sustaining a most-recent injury during the last or current season were positively associated with injury prevention programme adoption13. Higher scores of socio-cognitive determinants supported adopting an injury prevention programme in these categories of athletes13. Additionally, athletes who adopted an injury prevention programme during their career or the current season showed higher scores of socio-cognitive determinants than those who did not13. In the randomised controlled trial discussed earlier33, no athletes’ characteristics were associated with low compliance with the exercise-based injury prevention programme44. We should therefore continue to explore athlete characteristics that might explain adherence to injury prevention strategies. Such information could inform future strategies to improve injury prevention compliance50.
CONCLUSION
Injury prevention in athletics is complex and challenging. In Figure 4, we present a summary of the contemporary knowledge on injury epidemiology, risk factors, and prevention strategies in athletics. Current knowledge on injury epidemiology and risk factors could inform prevention strategies. However, work should continue in collaboration with end-users (e.g., athletes, coaches, and healthcare professionals). Co-producing injury prevention strategies with end-users is crucial, not only because athletics is a diverse and complex sport, but also to bolster effective and efficient implementation.
Pascal Edouard MD PhD1,2,3
Jenny Jacobsson PT PhD4
Robert Mann PhD5,6
Pedro Branco MD3
Juan Manuel Alonso MD PhD7
Karsten Hollander MD PhD8
Toomas Timpka MD PhD4
- University Jean Monnet, Lyon 1, University Savoie Mont-Blanc, Inter-university Laboratory of Human Movement Biology, EA 7424, Saint-Etienne, France
- Department of Clinical and Exercise Physiology, Sports Medicine Unit, University Hospital of Saint-Etienne, Faculty of Medicine, Saint-Etienne, France
- European Athletics Medical & Anti-Doping Commission, European Athletics Association (EAA), Lausanne, Switzerland
- Athletics Research Center, Linköping University, Linköping, Sweden
- Children's Health and Exercise Research Centre, Department of Public Health and Sport Sciences, University of Exeter, Exeter, Devon, UK
- Podium Analytics, London, UK
- Sports Medicine Department, Aspetar, Qatar Orthopedics and Sports Medicine Hospital, Doha, Qatar
- Institute of Interdisciplinary Exercise Science and Sports Medicine, MSH Medical School Hamburg, Hamburg, Germany
Contact:
Pascal.Edouard@univ-st-etienne.fr
References
1. Raysmith BP, Drew MK (2016) Performance success or failure is influenced by weeks lost to injury and illness in elite Australian track and field athletes: A 5-year prospective study. J Sci Med Sport 19:778–783
2. Edouard P, Richardson A, Navarro L, Gremeaux V, Branco P, Junge A (2019) Relation of Team Size and Success With Injuries and Illnesses During Eight International Outdoor Athletics Championships. Front Sport Act Living 1:8
3. Edouard P, Navarro L, Pruvost J, Branco P, Junge A (2021) In-competition injuries and performance success in combined events during major international athletics championships. J Sci Med Sport 24:152–158
4. Chapon J, Navarro L, Edouard P (2022) Relationships Between Performance and Injury Occurrence in Athletics (Track and Field): A Pilot Study on 8 National-Level Athletes From Sprints, Jumps and Combined Events Followed During at Least Five Consecutive Seasons. Front Sport Act Living 4:852062
5. Edouard P, Alonso JM, Jacobsson J, Depiesse F, Branco P, Timpka T (2019) On your marks, set, Go! We need a fying start to prevent injuries in Athletics. Aspetar Sport Med J 8:210–2013
6. Bull FC, Al-Ansari SS, Biddle S, et al (2020) World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med 54:1451–1462
7. Edouard P, Morel N, Serra JM, Pruvost J, Oullion R, Depiesse F (2011) Prévention des lésions de l’appareil locomoteur liées à la pratique de l’athlétisme sur piste. Revue des données épidémiologiques. Sci Sport 26:307–315
8. D’Souza D (1994) Track and Field athletics injuries -- a one-year survey*. Br J Sports Med 28:197–202
9. Bennell KL, Crossley K (1996) Musculoskeletal injuries in track and field: Incidence, distribution and risk factors. Aust J Sci Med Sport 28:69–75
10. Jacobsson J, Timpka T, Kowalski J, Nilsson S, Ekberg J, Dahlström Ö, Renström PA (2013) Injury patterns in Swedish elite athletics: annual incidence, injury types and risk factors. Br J Sports Med 47:986–991
11. Carragher P, Rankin A, Edouard P (2019) A One-Season Prospective Study of Illnesses, Acute, and Overuse Injuries in Elite Youth and Junior Track and Field Athletes. Front Sport Act Living 1:1–12
12. Martínez-Silván D, Wik EH, Alonso JM, Jeanguyot E, Salcinovic B, Johnson A, Cardinale M (2021) Injury characteristics in male youth athletics: A five-season prospective study in a full-time sports academy. Br J Sports Med 55:954–960
13. Ruffault A, Sorg M, Martin S, Hanon C, Jacquet L, Verhagen E, Edouard P (2022) Determinants of the adoption of injury risk reduction programmes in athletics (track and field): an online survey of 7715 French athletes. Br J Sports Med 56:499–505
14. Edouard P, Ruffault A, Bolling C, Navarro L, Martin S, Depiesse F, Oestergaard Nielsen R, Verhagen E (2022) French Athletics Stakeholders’ Perceptions of Relevance and Expectations on Injury Prevention. Int J Sports Med 43:1052–1060
15. Edouard P, Dandrieux P-E, Tondut J, Chapon J, Navarro L, Ruffault A, Branco P, Zyskowski M, Hollander K (2023) Perceptions and behaviours towards injury risk reduction in athletics (track and field): Survey on elite athletes and stakeholders participating at the Munich 2022 European Championships. Dtsch Z Sport 74:197-204
16. van Mechelen W, Hlobil H, Kemper HCG (1992) Incidence, severity, aetiology and prevention of sports injuries. Sport Med 14:82–99
17. Edouard P, Navarro L, Branco P, Gremeaux V, Timpka T, Junge A (2020) Injury frequency and characteristics (location, type, cause and severity) differed significantly among athletics (' track and field’) disciplines during 14 international championships (2007-2018): Implications for medical service planning. Br J Sports Med 54:159–167
18. Edouard P (2022) The Burden and Epidemiology of Injury in Track and Field. In: Canata GL, D’Hooghe P, Hunt KJ, Kerkhoffs GMMJ, Longo UG (eds) Manag. Track F. Inj. Springer International Publishing, pp 3–12
19. Edouard P, Feddermann-Demont N, Alonso JM, Branco P, Junge A (2015) Sex differences in injury during top-level international athletics championships: Surveillance data from 14 championships between 2007 and 2014. Br J Sports Med 49:472–477
20. Edouard P, Junge A, Alonso JM, Timpka T, Branco P, Hollander K (2022) Having an injury complaint during the four weeks before an international athletics (‘track and field’) championship more than doubles the risk of sustaining an injury during the respective championship: a cohort study on 1095 athletes during 7 international championships. J Sci Med Sport 25:986-994
21. Jacobsson J, Timpka T, Kowalski J, Nilsson S, Ekberg J, Renström P (2012) Prevalence of musculoskeletal injuries in Swedish elite track and field athletes. Am J Sports Med 40:163–169
22. Ahuja A, Ghosh AK (1985) Pre-Asiad ’82 injuries in elite Indian athletes. Br J Sports Med 19:24–26
23. Feddermann-Demont N, Junge A, Edouard P, Branco P, Alonso JM (2014) Injuries in 13 international Athletics championships between 2007-2012. Br J Sports Med 48:513–522
24. Ek A, Kowalski J, Jacobsson J (2022) Training in spikes and number of training hours correlate to injury incidence in youth athletics (track and field): A prospective 52-week study. J Sci Med Sport 25:122–128
25. Edouard P, Branco P, Alonso JM (2016) 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. Br J Sports Med 50:619–630
26. Timpka T, Jacobsson J, Dahlström Ö, Kowalski J, Bargoria V, Ekberg J, Nilsson S, Renström P (2015) The psychological factor “self-blame” predicts overuse injury among top-level Swedish track and field athletes: A 12-month cohort study. Br J Sports Med 49:1472–1477
27. Timpka T, Janson S, Jacobsson J, Dahlström Ö, Spreco A, Kowalski J, Bargoria V, Mountjoy M, Svedin CG (2019) Lifetime history of sexual and physical abuse among competitive athletics (track and field) athletes: Cross sectional study of associations with sports and non-sports injury. Br J Sports Med 53:1412–1417
28. Wik EH, Martínez-Silván D, Farooq A, Cardinale M, Johnson A, Bahr R (2020) Skeletal maturation and growth rates are related to bone and growth plate injuries in adolescent athletics. Scand J Med Sci Sport 30:894–903
29. Edouard P (2022) Injury Prevention in Track and Field. In: Canata GL, D’Hogghe P, Hunt KJ, Kerkhoffs GMMJ, Longo UG (eds) Manag. Track F. Inj. Springer International Publishing, pp 313–318
30. Rebella GS, Edwards JO, Greene JJ, Husen MT, Brousseau DC (2008) A prospective study of injury patterns in high school pole vaulters. Am J Sports Med 36:913–920
31. Lauersen JB, Bertelsen DM, Andersen LB (2014) The effectiveness of exercise interventions to prevent sports injuries: A systematic review and meta-analysis of randomised controlled trials. Br J Sports Med 48:871–877
32. Lauersen JB, Andersen TE, Andersen LB (2018) Strength training as superior, dose-dependent and safe prevention of acute and overuse sports injuries: A systematic review, qualitative analysis and meta-analysis. Br J Sports Med 52:1557–1563
33. Edouard P, Steffen K, Peuriere M, Gardet P, Navarro L, Blanco D (2021) Effect of an unsupervised exercises-based athletics injury prevention programme on injury complaints leading to participation restriction in athletics: A cluster-randomised controlled trial. Int J Environ Res Public Health 18:11334
34. Jacobsson J, Kowalski J, Timpka T, Hansson PO, Spreco A, Dahlstrom O (2023) Universal prevention through a digital health platform reduces injury incidence in youth athletics (track and field): a cluster randomised controlled trial. Br J Sports Med 57:364–370
35. Edouard P, Cugy E, Dolin R, Morel N, Serra JM, Depiesse F, Branco P, Steffen K (2020) The athletics injury prevention programme can help to reduce the occurrence at short term of participation restriction injury complaints in athletics: A prospective cohort study. Sports 8:84
36. Greenberg MT, Abenavoli R (2017) Universal Interventions: Fully Exploring Their Impacts and Potential to Produce Population-Level Impacts. J Res Educ Eff 10:40–67
37. World Health Organization (2016) Monitoring and Evaluating Digital Health Interventions A practical guide to conducting research and assessment.
38. Timpka T, Lindqvist K, Ekstrand J, Karlsson N (2005) Impact of social standing on sports injury prevention in a WHO safe community: Intervention outcome by household employment contract and type of sport. Br J Sports Med 39:453–457
39. Edouard P, Richardson A, Murray A, Duncan J, Glover D, Kiss M, Depiesse F, Branco P (2019) Ten Tips to Hurdle the Injuries and Illnesses During Major Athletics Championships: Practical Recommendations and Resources. Front Sport Act Living 1:12
40. Edouard P, Bolling C, Chapon J, Verhagen E (2022) What does not kill us can make us stronger’: can we use injury experience as an opportunity to help athletes and their teams engage in injury risk reduction? BMJ Open Sport Exerc Med 8:e001359
41. Dahlström O, Jacobsson J, Timpka T (2015) Overcoming the organization-practice barrier in sports injury prevention: A nonhierarchical organizational model. Scand J Med Sci Sport 25:e414–e422
42. Jacobsson J, Bergin D, Timpka T, Nyce JM, Dahlstrom O (2018) Injuries in youth track and field are perceived to have multiple-level causes that call for ecological (holistic-developmental) interventions: A national sporting community perceptions and experiences. Scand J Med Sci Sport 28:348–355
43. Nielsen RO, Bertelsen ML, Ramskov D, Damsted C, Verhagen E, Bredeweg SW, Theisen D, Malisoux L (2020) Randomised controlled trials (RCTs) in sports injury research: authors-please report the compliance with the intervention. Br J Sports Med 54:51–57
44. Edouard P, Blanco D, Steffen K, Nielsen RO, Verhagen E, Ruffault A (2023) Which Athletes Fail Faster to Send Weekly Questionnaires or to Comply with an Injury Risk Reduction Program? Dtsch Z Sportmed 74:24–28
45. van Reijen M, Vriend I, van Mechelen W, Finch CF, Verhagen EA (2016) Compliance with Sport Injury Prevention Interventions in Randomised Controlled Trials: A Systematic Review. Sport Med 46:1125–1139
46. Bahr R, Thorborg K, Ekstrand J (2015) Evidence-based hamstring injury prevention is not adopted by the majority of Champions League or Norwegian Premier League football teams: The Nordic Hamstring survey. Br J Sports Med 49:1466–1471
47. Owoeye OBA, Rauvola RS, Brownson RC (2020) Dissemination and implementation research in sports and exercise medicine and sports physical therapy: Translating evidence to practice and policy. BMJ Open Sport Exerc Med 0:e000974
48. Finch C (2006) A new framework for research leading to sports injury prevention. J Sci Med Sport 9:3–9
49. Donaldson A, Finch CF (2012) Planning for implementation and translation: seek first to understand the end-users’ perspectives. Br J Sports Med 46:306–307
50. Edouard P, Caumeil B, Verhagen E, Guilhem G, Ruffault A (2022) Maximising individualisation of sports injury risk reduction approach to reach success. Brazilian J Phys Ther 26:100394
Header image by Andrea Piacquadio (Cropped)