sports injury essay

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Article Contents

Introduction, literature search, physeal injuries and growth disturbance, residual problems after injury in athletes, outcomes of operative management of common sports injuries, conclusions.

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Sport injuries: a review of outcomes

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Nicola Maffulli, Umile Giuseppe Longo, Nikolaos Gougoulias, Dennis Caine, Vincenzo Denaro, Sport injuries: a review of outcomes, British Medical Bulletin , Volume 97, Issue 1, March 2011, Pages 47–80, https://doi.org/10.1093/bmb/ldq026

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Injuries can counter the beneficial aspects related to sports activities if an athlete is unable to continue to participate because of residual effects of injury. We provide an updated synthesis of existing clinical evidence of long-term follow-up outcome of sports injuries. A systematic computerized literature search was conducted on following databases were accessed: PubMed, Medline, Cochrane, CINAHL and Embase databases. At a young age, injury to the physis can result in limb deformities and leg-length discrepancy. Weight-bearing joints including the hip, knee and ankle are at risk of developing osteoarthritis (OA) in former athletes, after injury or in the presence of malalignment, especially in association with high impact sport. Knee injury is a risk factor for OA. Ankle ligament injuries in athletes result in incomplete recovery (up to 40% at 6 months), and OA in the long term (latency period more than 25 years). Spine pathologies are associated more commonly with certain sports (e.g. wresting, heavy-weight lifting, gymnastics, tennis, soccer). Evolution in arthroscopy allows more accurate assessment of hip, ankle, shoulder, elbow and wrist intra-articular post-traumatic pathologies, and possibly more successful management. Few well-conducted studies are available to establish the long-term follow-up of former athletes. To assess whether benefits from sports participation outweigh the risks, future research should involve questionnaires regarding the health-related quality of life in former athletes, to be compared with the general population.

Participation in sports is widespread all over the world, 1 with well-described physical, psychological and social consequences for involved athletes. 2–5 The benefits associated with physical activity in both youth and elderly are well documented. 2 , 6–8 Regular participation in sports is associated with a better quality of life and reduced risk of several diseases, 1 , 9 allowing people involved to improve cardiovascular health. 10 , 11 Both individual and team sports are associated with favourable physical and physiological changes consisting of decreased percentage of body fat 12 and increased muscular strength, endurance and power. 13 , 14 Moreover, regular participation in high-volume impact-loading and running-based sports (such as basketball, gymnastics, tennis, soccer and distance running) is associated with enhanced whole-body and regional bone mineral content and density, 14 , 15 whereas physical inactivity is associated with obesity and coronary heart disease. 16 Sports are associated with several psychological and emotional benefits. 7 , 17 , 18 First of all, there is a strong relationship between the development of positive self-esteem, due to testing of self in a context of sport competition, 19 reduced stress, anxiety and depression. 20 Physical activities also contribute to social development of athletes, prosocial behaviour, fair play and sportspersonship 21 and personal responsibility. 22

Engaging in sports activities has numerous health benefits, but also carries the risk of injury. 7 , 23 , 24 At every age, competitive and recreational athletes sustain a wide variety of soft tissue, bone, ligament, tendon and nerve injuries, caused by direct trauma or repetitive stress. 25–35 Different sports are associated with different patterns and types of injuries, whereas age, gender and type of activity (e.g. competitive versus practice) influence the prevalence of injuries. 7 , 36 , 37

Injuries in children and adolescents, who often tend to focus on high performance in certain disciplines and sports, 24 include susceptibility to growth plate injury, nonlinearity of growth, limited thermoregulatory capacity and maturity-associated variation. 9 In the immature skeleton, growth plate injury is possible 38 and apophysitis is common. The most common sites are at the knee (Osgood-Schlatter lesion), the heel (Sever's lesion) and the elbow. 39 Certain contact sports, such as rugby, for example, are associated with 5.2 injuries per 1000 total athletic exposures in high school children (usually boys). These were more common during competition compared with training and fractures accounted for 16% of these injuries, whereas concussions (15.8%) and ligament sprains (15.7%) were almost as common. 40

Sports trauma commonly affects joints of the extremities (knee, ankle, hip, shoulder, elbow, wrist) or the spine. Knee injuries are among the most common. Knee trauma can result in meniscal and chondral lesions, sometimes in combination with cruciate ligament injuries. 37 Ankle injuries constitute 21% of all sports injuries. 41 Ankle ligament injuries are more commonly (83%) diagnosed as ligament sprains (incomplete tears), and are common in sports such as basketball and volleyball. Ankle injuries occur usually during competition and in the majority of cases, athletes can return to sports within a week. 42 Hip labral injuries have drawn attention in recent years with the advent of hip arthroscopy. 43 , 44 Upper extremity syndromes caused by a single stress or by repetitive microtrauma occur in a variety of sports. Overhead throwing, long-distance swimming, bowling, golf, gymnastics, basketball, volleyball and field events can repetitively stress the hand, wrist, elbow and shoulder. Shoulder and elbow problems are common in the overhead throwing athlete whereas elbow injuries remain often unrecognized in certain sports. 45 Hand and wrist trauma accounts for 3–9% of all athletic injuries. 46 Wrist trauma can affect the triangular fibrocartilage complex 47 or cause scaphoid fractures, 48 whereas overuse problems (e.g. tenosynovitis) are not uncommon. 49 Spinal problems can range from lumbar disc herniation, 39–42 to fatigue fractures of the pars interarticularis, 50 and ‘catastrophic’ cervical spine injuries. 51

Thus, in addition to the beneficial aspects related to sports activities, injuries can counter these if an athlete is unable to continue to participate because of residual effects of injury. Do injuries in children, adolescents and young adults have long-term consequences? What are the outcomes of the most commonly performed surgical procedures? The aim of this review is to provide an updated synthesis of existing clinical evidence of long-term follow-up outcome of sports injuries.

An initial pilot Pubmed search using the keywords ‘sports’, ‘injury’, ‘injuries’, ‘athletes’, ‘outcome’, ‘long term’, was performed. From 1467 abstracts that were retrieved and scanned we identified the thematic topics (types of injury, management, area of the body involved) of the current review, listed below:

Then a more detailed search of PubMed, Medline, Cochrane, CINAHL and Embase databases followed. We used combinations of the keywords: ‘sport’, ‘sports’, ‘youth sports’, ‘young athletes’, ‘former athletes’, ‘children’, ‘skeletally immature’, ‘adolescent’, ‘paediatric’, ‘pediatric’, ‘physeal’, ‘epiphysis’, ‘epiphyseal injuries’, ‘hip’, ‘knee’, ‘ankle’, ‘spine’, ‘spinal’, ‘shoulder’, ‘elbow’, ‘wrist’, ‘football players’, ‘football’, ‘soccer’, ‘tennis’, ‘swimmers’, ‘swimming’, ‘divers’, ‘wrestlers’, ‘wrestling’, ‘cricket’, ‘gymnastics’, ‘skiers’, ‘baseball’, ‘basketball’, ‘osteoarthritis’, ‘former athletes’, ‘strain’, ‘contusion’, ‘distortion’, ‘injury’, ‘injuries’, ‘trauma’, ‘drop out’, ‘dropping out’, ‘attrition’, ‘young’, ‘ youth’, ‘sprain’, ‘ligament’, ‘ACL’, ‘cruciate ligament’, ‘meniscus’, ‘meniscal’, ‘chondral’, ‘labrum’, ‘labral’, ‘reconstruction’, ‘arthroscopy’, ‘throwing’, ‘overhead’, ‘rotator cuff’, ‘TFCC’, ‘scaphoid’, ‘osteoarthritis’, ‘arthritis’, ‘long term’, ‘follow-up’ and ‘athlete’. The most recent search was performed during the second week of November 2009.

Osteoarthritis (OA) in former athletes

Spine problems in former athletes

Knee injury and OA

Ankle ligament injury and OA

Residual upper limb symptoms in the ‘overhead’ athlete

Meniscectomy and oa, meniscal repair in athletes.

Anterior cruciate ligament (ACL) reconstruction and OA

ACL reconstruction in children

Ankle arthroscopy in athletes, hip arthroscopy in athletes.

Operative management of shoulder injuries in athletes (focusing on surgery for instability and labral tears)

Operative management of wrist injuries in athletes (focusing on triquetral fibrocartilage complex, TFCC, injuries and scaphoid fractures)

Given the different types of sports injuries in terms of location in the body, several searches were carried out. The search was limited to articles published in peer-reviewed journals.

From a total of 2596 abstracts that were scanned, 1247 studies were irrelevant to the subject and were excluded. The remaining studies were categorized in the topics identified earlier. We excluded from our investigation case reports, letter to editors and articles not specifically reporting outcomes, as well as ‘kin’ studies (studies reporting on the same patients' population). The most recent study or the study with the longest follow-up was included. In some topics of particular importance, such as the effect of knee injuries (given their frequency), we included long-term studies reporting not only on athletes, but also on the general population (usually in these studies a very high proportion on sports injuries is included). Regarding knee injuries in adults, we included articles with follow-up more than 10 years.

Given the linguistic capabilities of the research team, we considered publications in English, Italian, French, German, Spanish and Portuguese.

A concern regarding children's participation in sports is that the tolerance limits of the physis may be exceeded by the mechanical stresses of sports such as football and hockey or by the repetitive physical loading required in sports such as baseball, gymnastics and distance running. 52 Unfortunately, what is known about the frequency of acute sport-related physeal injuries is derived primarily from case reports and case series data. In a previous systematic review on the frequency and characteristics of sports-related growth plate injuries affecting children and youth, we found that 38.3% of 2157 acute cases were sport related and among these 14.9% were associated with growth disturbance. 24 These injuries were incurred in a variety of sports, although football is the sport most often reported. 53

There are accumulating reports of stress-related physeal injuries affecting young athletes in a variety of sports, including baseball, basketball, climbing, cricket, distance running, American football, soccer, gymnastics, rugby, swimming, tennis. 24 Although most of these stress-related conditions resolved without growth complication during short-term follow-up, there are several reports of stress-related premature partial or complete distal radius physeal closure of young gymnasts. 25–29 These data indicate that sport training, if of sufficient duration and intensity, may precipitate pathological changes of the growth plate and, in extreme cases, produce growth disturbance. 24 , 32

Disturbed physeal growth as a result of injury can result in length discrepancy, angular deformity or altered joint mechanics and may cause significant long-term disability. 33 However, the incidence of long-term health outcome of physeal injuries in children's and youth sports is largely unknown.

Based on the previously selection criteria, 20 studies 54–73 were retained for analysis (Table  1 ). Injury to the physis can result in limb deformities and leg-length discrepancy, the latter being more common after motor vehicle accidents, rather than sports participation.

Evidence on acute physeal injury with subsequent adverse affects on growth.

OA in former athletes

Two studies investigated former top-level female gymnasts for residual symptoms (back pain) and radiographical changes. 74 , 75 Both studies reported no significant differences in back pain between gymnast and control groups; however, the prevalence of radiographical abnormalities was greater in gymnasts than controls in one study. 74

Lower limb weight-bearing joints such as the hip and the knee are at risk of developing OA after injury or in the presence of malalignment, especially in association with high impact sport. 76 Varus alignment was present in 65 knees (81%) in 81 former professional footballers (age 44–70 years), whereas radiographic OA in 45 (56%). 77 Others showed that prevalence of knee OA in soccer players and weight lifters was 26% (eight athletes) and 31% (nine athletes), respectively, whereas it was only 14% in runners (four athletes). 78 By stepwise logistic regression analysis, the increased risk is explained by knee injuries in soccer players and by high body mass in weight lifters. A survey in English former professional soccer players revealed that 47% retired because of an injury. The knee was most commonly involved (46%), followed by the ankle (21%). Of all respondents, 32% had OA in at least one lower limb joint and 80% reported joint pain. 79 Another study examined the incidence of knee and ankle arthritis in injured and uninjured elite football players. The mean time from injury was 25 years. 80 Arthritis was present in 63% of the injured knees and in 33% of the injured ankles, whereas the incidence of arthritis in uninjured players was 26% in the knee and 18% in the ankle. Obviously, it should be kept in mind that radiographic studies can only ascertain the presence of degenerative joint disease, which is just one of the features of OA. Clinical examination is always necessary to clarify the diagnosis, and formulate a management plan.

Ex-footballers also had high prevalence of hip OA (odds ratio: 10.2), 81 whereas in another study the incidence of hip arthritis was 5.6% among former soccer players (mean age: 55 years) compared with 2.8% in an age-matched control group. In 71 elite players it was higher (14%). Female ex-elite athletes (runners, tennis players) were compared with an age-matched population of women, and were found to have higher rates (2–3 fold increase) of radiographic OA (particularly the presence of osteophytes) of the hip and knee. 82 The risk was similar in ex-elite athletes and in a subgroup from the general population who reported long-term sports activity, suggesting that duration rather than frequency of training is important. An older study 83 is runners associated degenerative changes with genu varum and history of injury. A cohort of 27 Swiss long-distance runners was at increased risk of developing ankle arthritis compared with a control group. 84 Similarly elite tennis players were at risk of developing glenohumeral OA, 85 whereas handball players of developing premature hip OA, 86 and former elite volleyball players had marginally increased risk for ankle OA. 87 Interestingly a study that investigated the health-related quality of life (HRQL) in 284 former professional players in the UK found that medical treatment for football-related injuries was a common feature, as was arthritis, with the knee being most commonly affected. Respondents with arthritis reported poorer outcomes in all aspects of HRQL. 88

In summary, OA is more common among former athletes, compared with the general population. The lower limb joints are commonly affected, in association with high impact and injury.

Evidence from follow-up studies on spine of former athletes

Heavy physical work and activity lead to degenerative changes in the spine. Studies on different athletic disciplines and heavy workers have given variable degenerative changes and abnormalities in the lumbar spine. Even though sporting activity is regarded as an important predisposing factor in the development of spinal pathologies, 89–99 there are few studies on the late spinal sequelae of competitive youth sport. Any comparison in terms of back pain between top athletes and the general population is difficult. Experience of pain may be influenced by factors such as susceptibility, motivation and physical activity. Minor pain may be provoked by vigorous body movements that hamper athletic performance, thereby ascribing the pain a greater impact than in the general population. On the other hand, a well-motivated athlete may ignore even severe pain to maintain or improve his/her athletic performance. Also, varying rate/prevalence of osteophytosis has been reported in players associated with various disciplines of sports.

Efforts should be made to understand the aetiology of injuries to the intervertebral discs during athletic performance and thereby prevent them. 74

Based on the previously selection criteria, seven studies 74 , 89 , 98 , 100–103 were retained for analysis (Table  2 ). In summary, spine pathologies are associated more commonly with certain sports (e.g. wresting, heavy-weight lifting, gymnastics, tennis, soccer). Degenerative changes in the athlete's spine can occur, but they are not necessarily associated with clinically relevant symptoms of OA. Therefore, it cannot be determined whether it threatens the athlete's career, or whether it has a worse impact on athletes compared with the general population.

Evidence from follow-up studies on spine of former athletes.

Knee injury and OA in athletes

A population-based case-control study investigated the risk of knee OA with respect to sports activity and previous knee injuries of 825 athletes competing in different sports. They were matched with 825 controls. After confounding factors were adjusted, the sports-related increase risk of OA was explained by knee injuries. 104 Another study leads to the same conclusion: 23 American football high-school players were compared with 11 age-matched controls, 20 years after high-school competition. No significant increase in OA could be demonstrated clinically or radiographically. However, a significant increase in knee joint OA was found in the subgroup of football players who had sustained a knee injury. 105

A cohort of 286 former soccer players (71 elite, 215 non-elite) with a mean age of 55 years was compared with 572 age-matched controls, regarding the prevalence of radiographic features of knee arthritis. Arthritis in elite players, non-elite players and controls was 15%, 4.2% and 1.6%, respectively. In non-elite players, absence of history of knee injury was associated with arthritis prevalence similar to the controls. 106

An interesting study involved a cohort of 19 high-level athletes of the Olympic program of former East Germany. They sustained an ACL tear between 1963 and 1965. None were reconstructed, and all were able to return to sports within 14 weeks. Subsequent meniscectomies were necessary in 15/19 (79%) athletes at 10 years and 18/19 (95%) at 20 years, when in 18 of the 19 knees, arthroscopy was performed, 13 patients (68%) had a grade four chondral lesion. By year 2000 (more than 35 years after ACL rupture), 10/19 knees required a joint replacement. 107

The incidence of radiographic advanced degeneration (Kellgren–Lawrence grade 2 or higher) was 41% in a cohort of 122 Swedish male soccer players (from a total of 154) who consented to radiographic follow-up, 14 years after an ACL rupture. No difference was found between players treated with or without surgery for their ACL rupture. The prevalence of Kellgren–Lawrence grade 2 or higher knee OA was 4% in the uninjured knees. 108

Similar results were evident among Swedish female soccer players who were injured before the age of 20. The prevalence of radiographic OA was 51%, compared with 8% only in the uninjured knee, 12 years later. The presence of symptoms was documented in 63 of 84 (75%) athletes who answered the questionnaire, and was similar ( P = 0.2) in the two management groups (operative versus non-operative). The presence of symptoms did not necessarily correlate with radiographic OA ( P = 0.4). 109

In summary, knee injury is a recognized risk factor for OA. Injured athletes develop OA more commonly than the general population in the long term. Approximately half of the injured knees could have radiographic changes 10–15 years later. It is not clear whether radiographic changes correspond to presence of symptoms.

Ankle ligament injuries and OA in athletes

Ankle sprains are common sporting injuries generally believed to be benign and self-limiting. However, some studies report a significant proportion of patients with ankle sprains having persistent symptoms for months or even years. Nineteen patients with a mean age of 20 years (range: 13–28), who were referred to a sports medicine clinic after an ankle inversion injury, were followed for 29 months (average), and compared with matched controls. Only five (26%) injured patients had recovered fully, whereas 74% had symptoms 1.5–4 years after the injury. Assessments of quality of life using the short form-36 questionnaires revealed a difference in the general health subscale between the two groups, favouring the controls ( P < 0.05). 110

Similar conclusions were drawn from another study, regarding ankle injuries in a young (age range: 17–24 years) athletic population. 111 There were 104 ankle injuries (96 sprains, 7 fractures and 1 contusion), accounting for 23% of all injuries seen. Of the 96 sprains, 4 were predominately medial injuries, 76 lateral and 16 syndesmosis sprains. Although 95% had returned to sports at 6 weeks, 55% reported pain or loss of function. At 6 months, 40% had not fully recovered, reporting residual symptoms. Syndesmosis injuries were associated with prolonged recovery.

The association between ligamentous ankle injuries has been highlighted in a study that, retrospectively, reviewed data from 30 patients (mean age: 59 years, 33 ankles) with ankle osteoarthritis. 112 They found that 55% had a history of sports injuries (33% from soccer), and 85% had a lateral ankle ligament injury. The mean latency time between injury and OA was 34.3 years. The latency period for acute severe injuries was significantly lower (25.7 years), compared with chronic instability (38 years). Varus malalignment and persistent instability were present in 52% of those patients.

In summary, ankle ligamentous injuries in athletes can result in considerable morbidity, residual symptoms and arthritis 25–30 years later.

Shoulder injuries account for 7% of sports injuries and often limit the athlete in his or her ability to continue with their chosen sport. 113 Repetitive overhead throwing imparts high valgus and extension loads to the athlete's shoulder and elbow, often leading to either acute or chronic injury or progressive structural change and long-term problems in the overhead athlete. 45

Schmitt et al . 102 examined 21 elite javelin throwing athletes at an average of 19 years after the end of their high-performance phase (mean age at follow-up was 50 years). Five athletes (24%) complained about transient shoulder pain and three (16%) about elbow pain in their throwing arm affecting activities of daily living. All dominant elbows had advanced degeneration (osteophytes).

Elbow intra-articular lesions are recognized as consequences of repetitive stress and overuse. Shanmugam and Maffulli 9 reported follow-up (mean 3.6 years) of lesions of the articular surface of the elbow joint in a group of 12 gymnasts (six females and six males). This group showed a high frequency of osteochondritic lesions, intra-articular loose bodies and precocious signs of joint ageing. Residual mild pain in the elbow at full extension occurring after activity was present in 10 patients and all patients showed marked loss of elbow extension compared with their first visit.

Glenoid labral tears require repair, and shoulder instability is currently approached operatively more often. A review article found that conservative management of traumatic shoulder dislocations in adolescents was associated with high rates of recurrent instability (up to 100%). Therefore, surgical shoulder stabilization is recommended. The outcomes of surgical management are presented in the next section.

A distinct clinical entity is the ‘little league shoulder’, which is characterized by progressive upper arm pain with throwing and is more commonly seen in male baseball pitchers between ages 11 and 14 years. It is thought to be Salter-Harris type I stress fracture. Activity modification, education to improve throwing mechanics and core muscle training are recommended. It is not known how this condition behaves in the long term, regarding structural damage and development of degenerative changes.

Overhead athletes are plagued by shoulder and elbow injuries or overuse syndromes that can affect their performance and cause degeneration and pain in the long term.

The association between knee OA and meniscectomy has been well documented. In former athletes 114 – 116 it is associated with OA (Table  3 ). Meniscectomy in children and adolescents 117 – 123 has been associated with unfavourable results and radiographic arthritic changes in the long term (Table  4 ). However, radiographic criteria were not always clearly defined. To assess the long-term outcomes of meniscectomy, we also evaluated studies with a minimum follow-up of 10 years in the adult general population 106 , 124 – 129 (Table  5 ). Many of the ‘older’ studies providing the long-term outcomes represent results of open total meniscectomies. The overall message is that radiographic degeneration is common in meniscectomized knees, and patients are at risk of developing OA. The condition of the articular cartilage is a prognostic factor. However, clinical and radiographic findings do not always correlate. Resection should be limited to the torn part of the meniscus.

Menicectomy and osteoarthritis in athletes.

Menicectomy in children and adolescents.

Meniscectomy in adults / general popaltion—long-term outcomes.

Given the long-term problems associated with meniscectomies, preservation of the substance of the meniscus after injury is currently advocated. Based on this concept, arthroscopic meniscal repair techniques have been developed. 125 In the general population, encouraging clinical results with failure rates of 27–30% at 6–7 years follow-up have been reported. 130–132 One study 133 evaluated 45 meniscal repairs in 42 elite athletes followed for an average of 8.5 years. In 83% of them an ACL reconstruction was performed as well. Return to their sport was possible in 81% at an average of 10 months after surgery. They identified 11 failures (24%), seven of which were associated with a new injury. The medial meniscus re-ruptured more frequently compared with the lateral (36.4 versus 5.6%, respectively).

Mintzer et al . 134 retrospectively reviewed the outcome of meniscal repair in 26 young athletes involved in several sports at an average follow-up of 5 years (range: 2–13.5). No failures were reported, with 85% of patients performing high level of sports activities.

In general, the results of meniscal repairs in the general population, as well as in athletes, are encouraging.

ACL reconstruction and OA

Knee injuries can result in ligament ruptures and/or meniscal tears and are recognized as a risk factor of OA. A systematic review on studies published until 2006 135 reported on the prognosis of conservatively managed ACL injuries showed that there was an average reduction of 21% at the level of activities (Tegner score evaluation). ACL reconstruction is therefore a procedure frequently performed in athletic individuals, as they desire to maintain a high level of activities. However, does ACL reconstruction affect the incidence of knee degeneration and symptoms in the long term? We identified three studies 108 , 109 , 136 comparing operative versus non-operative management of ACL ruptures specifically in athletes, in regard to OA.

Two studies from Sweden investigating the prevalence of OA after ACL rupture in male 108 and female 109 soccer players were discussed earlier. Both found no difference in the incidence of radiographic arthritis between surgically and conservatively treated players, more than 10 years after their injury.

A comparative study 136 on high-level athletes with ACL injury showed no statistical difference between the patients treated conservatively or operatively (patella tendon graft) with respect to OA or meniscal lesions of the knee, as well as activity level, objective and subjective functional outcome. The patients who were treated operatively had a significantly better stability of the knee at examination.

Several studies present outcomes of ACL injuries in the general population. A recent systematic review included 31 studies (seven were prospective) reporting radiographic outcomes regarding OA, with more than 10 years follow-up after ACL injury. 137 The prevalence of OA in the injured knee varied from 1 to 100%, whereas in the contralateral knee it was 0–38%. Isolated ACL tears were associated with low OA incidence between 0 and 13%, whereas in the presence of additional meniscal injury, it was 21–48%. Meniscal injury and meniscectomy were the most frequently reported risk factors for OA. The authors scored the quality of the studies and found that studies scoring high reported low incidence of OA. Data extraction indicated that ACL reconstruction as a single factor did not prevent the development of knee OA. 137

There is lack of evidence to support a protective role of reconstructive surgery of the ACL against OA, both in athletes as well as in the general population.

ACL reconstruction in skeletally immature patients is a relatively new trend. 138 The concern is intra-operative epiphysis damage and growth disturbance, a complication which has been avoided in several studies. 139–143

The earliest published study 144 compared non-operative versus operative management of ACL ruptures in 42 skeletally immature athletes (age range: 4–17 years) followed for a mean of 5.3 years. They used a composite knee score based on clinical examination and a patient questionnaire and found superior results in the operatively treated patients. Age and growth plate maturity did not influence results. They recommended ACL reconstruction for active athletic children.

One of the early reports showed that there were no growth disturbances at a mean of 3.3 years after surgery in 9 children, however, with two re-ruptures. Those children could not return to athletic activities. 139

In a series of 57 ACL reconstructions, 15 patients had reached completion of growth when examined at follow-up, none had signs of growth disturbance, whereas clinical scoring was good or excellent in all patients. 142

Another study compared the outcomes of two management strategies in 56 children with ACL ruptures, namely ligament reconstruction in the presence of open physis, or delayed reconstruction after skeletal maturity. The ‘early’ reconstruction group had evidence of less medial meniscal tears (16 versus 41%), and no evidence of growth disturbances, at 27 months mean follow-up. 140

After 1.5–7.5 years follow-up of 19 ACL reconstructions in 20 athletic teenagers (age range: 11.8–15.6 years), all but one had returned to sports, none had tibiofemoral malalignment or a leg-length discrepancy of more than 1 cm, and the modified Lysholm score was 93 out of 95. 143

Finally, 55 children (ages 8 to 16 years, mean 13 years) were followed for a mean of 3.2 years (range: 1–7.5 years) after ACL reconstruction, with no evidence of growth disturbances. Clinical scores showed normal or almost normal values (higher than 90 out of 100 possible points) and 88% of the patients went back to normal or almost normal sports according to the Tegner score. 141

Overall, the clinical results are encouraging and iatrogenic epiphysis damage does not seem to be a problem, possibly because physeal sparing procedures were used. The study designs, however, are inadequate to answer the question of whether early or delayed ACL reconstruction results in the best possible outcome in skeletally immature patients.

Anterior impingement syndrome is a generally accepted diagnosis for a condition characterized by anterior ankle pain with limited and painful dorsiflexion. The cause can be either soft tissue or bony obstruction. Arthroscopic debridement is currently considered a routine procedure, and chondral lesions are now more frequently identified as causes of ankle pain. Few reports specifically in athletes are available 145–149 (Table  6 ). Short-term outcomes only are available. It is not known whether arthritis is a long-term consequence.

Ankle arthroscopy in athletes.

Only recently has the hip received attention as a recognized site of sports injuries, possibly as a result of the evolution of hip arthroscopy which allowed recognition of intra-articular pathology. 150 Acetabular labrum and chondral lesions can be addressed arthroscopically, and patients' satisfaction rates up to 75% have been reported. 44 One study evaluated the outcome of hip arthroscopy in 15 athletes (mean age: 32 years, range: 14–70) followed for 10 years. Nine were recreational athletes, four high school and two intercollegiate athletes. Diagnoses included cartilage lesion (8), labral tear (7), arthritis (5), avascular necrosis (1), loose body (1) and synovitis (1). The median improvement in the modified Harris hip score was 45 points (from 51 preoperatively to 96, on the 100-point scale), with 13 patients (87%) returning to their sport. All five athletes with arthritis eventually underwent total hip arthroplasty at an average of 6 years. 43 Long-term outcomes regarding progression of joint degeneration after traumatic chondral or labral damage are not available.

Operative management of shoulder injuries in athletes

Labral tears require repair, whereas shoulder instability is currently approached operatively more often. Conservative management of traumatic shoulder dislocations in adolescents is associated with high rates of recurrent instability (up to 100%), whereas recurrent dislocations were reported in up to 12%, at an average of 3 years after arthroscopic stabilization. Shoulder dislocations are particularly common in rugby, the characteristic mechanism of injury being tackling, whereas labral tears are common in the ‘overhead’ athlete'. Published results in athletes 151 – 162 (Table  7 ) show that operative stabilization of the shoulder is initially successful, but instability and pain can recur in the long term. Results of arthroscopic techniques in the management of intra-articular pathologies are promising, but long-term outcomes are unknown (Table  7 ).

RCT, randomized controlled trial; VAS, visual analogue scale.

Operative management of elbow injuries in athletes

Elbow ulnar collateral ligament (UCL) insufficiency is one of the frequently recognized injuries in the overhead athlete, as a result of excessive valgus stress. It constitutes a potentially career threatening injury and requires surgical repair. 163 The use of a muscle-splitting approach, avoiding handling of the ulnar nerve, and the use of the docking technique for stabilization is recommended 164 , 165 (Table  8 ). Recent advantages in arthroscopic surgical techniques and ligament reconstruction in the elbow have improved the prognosis for return to competition for highly motivated athletes. The results of arthroscopic debridement 150 , 166 (Table  7 ) need to be evaluated in the long term.

Operative management of elbow injuries in athletes.

UCL, ulnar collateral ligament.

Operative management of wrist injuries in athletes

A review of the literature shows that 3–9% of all athletic injuries occur in the hand or wrist, and are more common in adolescent athletes than adults. 46 In this article, we focused on TFCC injuries and acute scaphoid fractures in athletes.

TFCC injuries are an increasingly recognized cause of ulnar-sided wrist pain, and can be particularly disabling in the competitive athlete. Advances in wrist arthroscopy made endoscopic debridement and repair of the TFCC possible. McAdams et al . 47 treated arthroscopically TFCC tears in 16 competitive athletes (mean age: 23.4 years). Repair of unstable tears was performed in 11 (69%) and debridement only in 5 (31%). Return to play averaged 3.3 months (range: 3–7 months). The mean duration of follow-up was 2.8 years (range: 2–4.2 years). Clinical scores (mini-DASH and mini-DASH sports module) improved significantly. No long-term outcomes are available.

Operative management of scaphoid fractures in athletes, even if undisplaced, is recommended if early return to sports is desired. One study followed 12 athletes treated operatively for a scaphoid fracture. They were able to return to sports at 6 weeks. At an average follow-up of 2.9 years, 9 of 12 athletes had range of motion equal to the uninjured side, and grip strength was equal to the unaffected side in 10 of 12 athletes. 49

Participation in sports offers potential benefits for individuals of all ages, such as combating obesity and enhancing cardiovascular fitness. 1 On the other hand, negative consequences of musculoskeletal injuries sustained during sports may compromise function in later life, limiting the ability to experience pain-free mobility and engage in fitness-enhancing activity. 167 Increasingly, successful management of sports-related injuries has allowed more athletes to return to participation. The knee is the joint most commonly associated with sports injuries, and therefore is most at risk of developing degenerative changes. It is not clear whether radiographic OA always correlates with symptoms and reduced quality of life. Furthermore, even effective management of meniscal or ACL injury does not reduce the risk of developing subsequent OA. 137 , 168 OA in an injured joint is caused by intra-articular pathogenic processes initiated at the time of injury, combined with long-term changes in dynamic joint loading. Variation in outcomes involves not only the exact type of injury (e.g. ACL rupture with or without meniscal damage), 137 but also additional variables associated with the individual such as age, sex, genetics, obesity, muscle strength, activity and reinjury. A better understanding of these variables may improve future prevention and treatment strategies. 169

In many of the long-term studies (the majority being retrospective case series), several methodological flaws have to be highlighted. A recent systematic review on OA after ACL injuries 137 suggested that some studies may overestimate the prevalence of long-term OA. The authors in several studies mention that a proportion of the index group of injured athletes were available for follow-up or consented for radiographic examination. One can argue that these patients were the ones with symptoms, therefore the prevalence of OA (after ACL rupture for example) may appear higher than it really is. Presentation of outcomes was not always based on robust criteria. Different clinical scores and radiographic classifications have been used, and therefore results between studies are not directly comparable. In the majority of the studies, it was not clarified whether radiographic appearance correlated with symptoms, and how important these were for the quality of life of the patients. Disabling arthritis requiring intervention may actually be delayed for more than 20–30 years. 107 , 112 Furthermore, long-term studies present outcomes of older techniques, not used any more in clinical practice (e.g. primary ACL repair or total meniscectomy). Evolution in surgical or rehabilitation techniques might have improved outcomes of certain injuries. Therefore, currently known ‘long-term outcomes’ may only reflect the results of techniques used in the past and not what we should expect in the future. Increasing awareness of athletes and trainers, new diagnostic and musculoskeletal imaging modalities, improved surgical and rehabilitation methods, but also analysis of injury patterns in different sports and development of injury prevention strategies might be beneficial to minimize the effects of sports injuries in the years to come.

What is the true incidence of arthritis in the long term? Will it be a disabling condition for the former athlete, in the coming decades? Currently, joint preserving procedures (e.g. microfractures, 145 mosaicplaty, 170 autologous chondrocyte implantation, 171 , 172 realignment osteotomies 173 and implant arthroplasties 174 ) have evolved and allow middle aged or older patients to live without pain and maintain an active life style. Meniscal transplantation shows encouraging results. 175 Should therefore an increased risk for developing musculoskeletal problems prevent children and adults from being active in sports? 176 Do the benefits of participating in sports outweigh the risks?

A survey in Sweden showed that 80% of former track and field athletes with an age range of 50–80 years felt they were in good health, compared with 61% of the referents, despite higher prevalence of hip arthritis in former athletes. Low back disorders were similar in the two groups, shoulder and neck problems were lower in former athletes, and knee arthritis was similar in the two groups. 177

No definite answer can be given to the previously addressed questions, based on available evidence. Future research should involve questionnaires assessing the HRQL in former athletes, to be compared with the general population. 27 , 178–181

Physical injury is an inherent risk in sports participation and, to a certain extent, must be considered an inevitable cost of athletic training and competition. Injury may lead to incomplete recovery and residual symptoms, drop out from sports, and can cause joint degeneration in the long term. Few well-conducted studies are available on the long-term follow-up of former athletes, and, in general, we lack studies reporting on the HRQL to be compared with the general population. Advances in arthroscopic techniques allow operative management of most intra-articular post-traumatic pathologies in the lower and upper limb joints, but long-term outcomes are not available yet. It is important to balance the negative effects of sports injuries with the many social, psychological and health benefits that a serious commitment to sport brings. 9

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How to Write a Non-Cliche College Essay About Sports + Examples

What’s covered:, what makes a sports essay cliche.

• How To Make Your Sports Essay Unique

Great Examples of College Essays About Sports

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You’ve been brainstorming essay topics for your college applications, and you think you’ve finally found the right one: an extended metaphor likening your experience on the field with overcoming personal struggles. The problem: many other students have this same thought. 

The purpose of a college essay is to make yourself stand out as a unique individual, but when students write about sports, they often blend in. Because of that, students are usually advised to pick a different topic.

That being said, it is possible to write a non-cliche college essay about sports if you put in a little extra effort. Read along to learn how to make your sports essay different from all the other sports essays.

Sports essays are cliche when they follow a standard trajectory. Some of these trajectories include writing a story about:

• An agonizing defeat
• Forging bonds with teammates
• Overcoming adversity
• Overcoming an injury
• Refusing to quit
• Victory during a big game

Because sports essays have very similar themes and “lessons learned,” it can be difficult to make your story stand out. These trajectories also often focus too much on the sport or storyline, and not enough on the writer’s reflections and personality.

As you write your essay, try to think about what your experience says about you rather than what you learned from your experience. You are more than just one lesson you learned!

(Keep in mind that the sports essay is not the only college essay cliche. Learn about other essay cliches and how to fix them in our complete guide).

How to Make Your Sports Essay Unique

1. focus on a specific moment or reflection..

The college essay is a way for students to humanize themselves to admissions officers. You do not feel human if you are describing yourself as just another player on the field!

One important way to make your essay about you (not just about sports) is by focusing on a specific moment in time and inviting the reader to join you in that moment. Explain to the reader what it would be like to be sitting in that locker room as you questioned the values of the other players on your team. Ask your reader to sit with you on the cot in the trainer’s room as your identity was stripped away from you when they said “your body can’t take this anymore.” Bring your reader to the dinner table and involve them in your family’s conversation about how sports were affecting your mental health and your treatment of those around you.

Intense descriptions of a specific experience will evoke emotions in your reader and allow them to connect with you and feel for you.

When in doubt, avoid anything that can be covered by ESPN. On ESPN, we see the games, we see the benches, we even see the locker rooms and training rooms. Take your reader somewhere different and show them something unique.

2. Use sports to point out broader themes in your life.

The main risk when writing about sports is neglecting to write about yourself. Before you get started, think about the main values that you want to express in your sports essay. Sports are simply your avenue for telling the reader what makes you unique. 

As a test, imagine if you were a pianist. Would you be able to talk about these same values? What if you were a writer? Or a chemist? Articulating your values is the end, and sports should simply be your means.

Some values that you might want to focus on:

• Autonomy (you want to be able to set your mind to anything and achieve it on your own)
• Growth (you seek improvement constantly)
• Curiosity (you are willing to try anything once)
• Vulnerability (you aren’t afraid to fail, as long as you give it your all)
• Community (you value the feedback of others and need camaraderie to succeed)
• Craft (you think that with deliberate care, anything can be perfected)
• Responsibility (you believe that you owe something to those around you and perhaps they also owe something to you)

You can use the ESPN check again to make sure that you are using sports as an avenue to show your depth.

Things ESPN covers: how a player reacts to defeat, how injuries affect a player’s gameplay/attitude, how players who don’t normally work well together are working together on their new team.

Things ESPN doesn’t cover: the conversation that a player had with their mother about fear of death before going into a big surgery (value: family and connection), the ways that the intense pressure to succeed consumed a player to the point they couldn’t be there for the people in their life (value: supporting others and community), the body image issues that weigh on a player’s mind when playing their sport and how they overcame those (value: health and growth).

3. Turn a cliche storyline on its head.

There’s no getting around the fact that sports essays are often cliche. But there is a way to confront the cliche head-on. For example, lots of people write essays about the lessons they learned from an injury, victory, and so on, but fewer students explain how they are embracing those lessons. 

Perhaps you learned that competition is overwhelming for you and you prefer teamwork, so you switched from playing basketball to playing Dungeons & Dragons. Maybe, when your softball career ended abruptly, you had to find a new identity and that’s when you became obsessed with your flower garden and decided to pursue botany. Or maybe, you have stuck with football through it all, but your junior-year mental health struggle showed you that football should be fun and you have since started a nonprofit for local children to healthily engage with sports.

If your story itself is more cliche, try bringing readers to the present moment with you and show why the cliche matters and what it did for you. This requires a fair amount of creativity. Ensure you’re not parroting a frequently used topic by really thinking deeply to find your own unique spin.

Night had robbed the academy of its daytime colors, yet there was comfort in the dim lights that cast shadows of our advances against the bare studio walls. Silhouettes of roundhouse kicks, spin crescent kicks, uppercuts and the occasional butterfly kick danced while we sparred. She approached me, eyes narrowed with the trace of a smirk challenging me. “Ready spar!” Her arm began an upward trajectory targeting my shoulder, a common first move. I sidestepped — only to almost collide with another flying fist. Pivoting my right foot, I snapped my left leg, aiming my heel at her midsection. The center judge raised one finger. 

There was no time to celebrate, not in the traditional sense at least. Master Pollard gave a brief command greeted with a unanimous “Yes, sir” and the thud of 20 hands dropping-down-and-giving-him-30, while the “winners” celebrated their victory with laps as usual. 

Three years ago, seven-thirty in the evening meant I was a warrior. It meant standing up straighter, pushing a little harder, “Yes, sir” and “Yes, ma’am”, celebrating birthdays by breaking boards, never pointing your toes, and familiarity. Three years later, seven-thirty in the morning meant I was nervous. 

The room is uncomfortably large. The sprung floor soaks up the checkerboard of sunlight piercing through the colonial windows. The mirrored walls further illuminate the studio and I feel the light scrutinizing my sorry attempts at a pas de bourrée, while capturing the organic fluidity of the dancers around me. “Chassé en croix, grand battement, pique, pirouette.” I follow the graceful limbs of the woman in front of me, her legs floating ribbons, as she executes what seems to be a perfect ronds de jambes. Each movement remains a negotiation. With admirable patience, Ms. Tan casts me a sympathetic glance.   

There is no time to wallow in the misery that is my right foot. Taekwondo calls for dorsiflexion; pointed toes are synonymous with broken toes. My thoughts drag me into a flashback of the usual response to this painful mistake: “You might as well grab a tutu and head to the ballet studio next door.” Well, here I am Master Pollard, unfortunately still following your orders to never point my toes, but no longer feeling the satisfaction that comes with being a third degree black belt with 5 years of experience quite literally under her belt. It’s like being a white belt again — just in a leotard and ballet slippers. 

But the appetite for new beginnings that brought me here doesn’t falter. It is only reinforced by the classical rendition of “Dancing Queen” that floods the room and the ghost of familiarity that reassures me that this new beginning does not and will not erase the past. After years spent at the top, it’s hard to start over. But surrendering what you are only leads you to what you may become. In Taekwondo, we started each class reciting the tenets: honor, courtesy, integrity, perseverance, self-control, courage, humility, and knowledge, and I have never felt that I embodied those traits more so than when I started ballet. 

The thing about change is that it eventually stops making things so different. After nine different schools, four different countries, three different continents, fluency in Tamil, Norwegian, and English, there are more blurred lines than there are clear fragments. My life has not been a tactfully executed, gold medal-worthy Taekwondo form with each movement defined, nor has it been a series of frappés performed by a prima ballerina with each extension identical and precise, but thankfully it has been like the dynamics of a spinning back kick, fluid, and like my chances of landing a pirouette, unpredictable. 

Why it works:

What’s especially powerful about this essay is that the author uses detailed imagery to convey a picture of what they’re experiencing, so much so that the reader is along for the ride. This works as a sports essay not only because of the language and sensory details, but also because the writer focuses on a specific moment in time, while at the same time exploring why Taekwondo is such an important part of their life.

After the emotional image is created, the student finishes their essay with valuable reflection. With the reflection, they show admissions officers that they are mature and self-aware. Self-awareness comes through with statements like “surrendering what you are only leads you to what you may become” and maturity can be seen through the student’s discussion of values “honor, courtesy, integrity, perseverance, self-control, courage, humility, and knowledge, and I have never felt that I embodied those traits more so than when I started ballet.” These are the kinds of comments that should find their way into a sports essay!

“Advanced females ages 13 to 14 please proceed to staging with your coaches at this time.” Skittering around the room, eyes wide and pleading, I frantically explained my situation to nearby coaches. The seconds ticked away in my head; every polite refusal increased my desperation.

Despair weighed me down. I sank to my knees as a stream of competitors, coaches, and officials flowed around me. My dojang had no coach, and the tournament rules prohibited me from competing without one.

Although I wanted to remain strong, doubts began to cloud my mind. I could not help wondering: what was the point of perfecting my skills if I would never even compete? The other members of my team, who had found coaches minutes earlier, attempted to comfort me, but I barely heard their words. They couldn’t understand my despair at being left on the outside, and I never wanted them to understand.

Since my first lesson 12 years ago, the members of my dojang have become family. I have watched them grow up, finding my own happiness in theirs. Together, we have honed our kicks, blocks, and strikes. We have pushed one another to aim higher and become better martial artists. Although my dojang had searched for a reliable coach for years, we had not found one. When we attended competitions in the past, my teammates and I had always gotten lucky and found a sympathetic coach. Now, I knew this practice was unsustainable. It would devastate me to see the other members of my dojang in my situation, unable to compete and losing hope as a result. My dojang needed a coach, and I decided it was up to me to find one. 

I first approached the adults in the dojang – both instructors and members’ parents. However, these attempts only reacquainted me with polite refusals. Everyone I asked told me they couldn’t devote multiple weekends per year to competitions. I soon realized that I would have become the coach myself.

At first, the inner workings of tournaments were a mystery to me. To prepare myself for success as a coach, I spent the next year as an official and took coaching classes on the side. I learned everything from motivational strategies to technical, behind-the-scenes components of Taekwondo competitions. Though I emerged with new knowledge and confidence in my capabilities, others did not share this faith.

Parents threw me disbelieving looks when they learned that their children’s coach was only a child herself. My self-confidence was my armor, deflecting their surly glances. Every armor is penetrable, however, and as the relentless barrage of doubts pounded my resilience, it began to wear down. I grew unsure of my own abilities.

Despite the attack, I refused to give up. When I saw the shining eyes of the youngest students preparing for their first competition, I knew I couldn’t let them down. To quit would be to set them up to be barred from competing like I was. The knowledge that I could solve my dojang’s longtime problem motivated me to overcome my apprehension.

Now that my dojang flourishes at competitions, the attacks on me have weakened, but not ended. I may never win the approval of every parent; at times, I am still tormented by doubts, but I find solace in the fact that members of my dojang now only worry about competing to the best of their abilities.

Now, as I arrive at a tournament with my students, I close my eyes and remember the past. I visualize the frantic search for a coach and the chaos amongst my teammates as we compete with one another to find coaches before the staging calls for our respective divisions. I open my eyes to the exact opposite scene. Lacking a coach hurt my ability to compete, but I am proud to know that no member of my dojang will have to face that problem again.

In the beginning, you might think this is another cliche sports essay about overcoming adversity. But instead, it becomes a unique statement and coming-of-age tale that reads as a suspenseful narrative. 

The author connects their experience with martial arts to larger themes in their life but manages to do so without riffing off of tried-and-true themes. Through statements like “I knew I couldn’t let them down. To quit would be to set them up to be barred from competing like I was” we learn about the students values and their desire to be there for those who depend on them. 

The student also brings it full circle, demonstrating their true transformation. By using the “Same, but Different” ending technique , the student places themself in the same environment that we saw in the intro, but experiences it differently due to their actions throughout the narrative. This is very compelling!

“1…2…3…4 pirouettes! New record!” My friends cheered as I landed my turns. Pleased with my progress, I gazed down at my worn-out pointe shoes. The sweltering blisters, numbing ice-baths, and draining late-night practices did not seem so bad after all. Next goal: five turns.

For as long as I can remember, ballet, in all its finesse and glamor, had kept me driven day to day. As a child, the lithe ballerinas, donning ethereal costumes as they floated across the stage, were my motivation. While others admired Messi and Adele, I idolized Carlos Acosta, principal dancer of the Royal Ballet. 

As I devoted more time and energy towards my craft, I became obsessed with improving my technique. I would stretch for hours after class, forcing my leg one inch higher in an effort to mirror the Dance Magazine cover girls. I injured my feet and ruined pair after pair of pointe shoes, turning on wood, cement, and even grass to improve my balance as I spun. At competitions, the dancers with the 180-degree leg extensions, endless turns, and soaring leaps—the ones who received “Bravos!” from the roaring audience—further pushed me to refine my skills and perfect my form. I believed that, with enough determination, I would one day attain their level of perfection. Reaching the quadruple-pirouette milestone only intensified my desire to accomplish even more. 

My efforts seemed to have come to fruition two summers ago when I was accepted to dance with Moscow’s Bolshoi Ballet at their renowned New York City summer intensive. I walked into my first session eager to learn from distinguished ballet masters and worldly dancers, already anticipating my improvement. Yet, as I danced alongside the accomplished ballerinas, I felt out of place. Despite their clean technique and professional training, they did not aim for glorious leg extensions or prodigious leaps. When they performed their turn combinations, most of them only executed two turns as I attempted four. 

“Dancers, double-pirouettes only.” 

Taken aback and confused, I wondered why our teacher expected so little from us. The other ballerinas seemed content, gracing the studio with their simple movements. 

As I grew closer with my Moscow roommates, I gradually learned that their training emphasized the history of the art form instead of stylistic tricks. Rather than show off their physical ability, their performances aimed to convey a story, one that embodied the rich culture of ballet and captured both the legacy of the dancers before them and their own artistry. As I observed my friends more intently in repertoire class, I felt the pain of the grief-stricken white swan from Swan Lake, the sass of the flirtatious Kitri from Don Quijote, and I gradually saw what I had overlooked before. My definition of talent had been molded by crowd-pleasing elements—whirring pirouettes, gravity-defying leaps, and mind-blowing leg extensions. This mindset slowly stripped me from the roots of my passion and my personal connection with ballet. 

With the Bolshoi, I learned to step back and explore the meaning behind each step and the people behind the scenes. Ballet carries history in its movements, from the societal values of the era to each choreographer’s unique flair. As I uncovered the messages behind each pirouette, kick, and jump, my appreciation for ballet grew beyond my obsession with raw athleticism and developed into a love for the art form’s emotive abilities in bridging the dancers with the audience. My journey as an artist has allowed me to see how technical execution is only the means to a greater understanding between dancer and spectator, between storyteller and listener. The elegance and complexity of ballet does not revolve around astonishing stunts but rather the evocative strength and artistry manifested in the dancer, in me. It is the combination of sentiments, history, tradition, and passion that has allowed ballet and its lessons of human connection to become my lifestyle both on and off stage.

This essay is about lessons. While the author is a dancer, this narrative isn’t really about ballet, per se — it’s about the author’s personal growth. It is purposefully reflective as the student shows a nice character arc that begins with an eager young ballerina and ends with a reflection on their past. The primary strength of this essay is the honesty and authenticity that the student approaches it with.

In the end, the student turns a cliche on its head as they embrace the idea of overcoming adversity and demonstrate how the adversity, in this case, was their own stereotypes about their art. It’s beautiful!

“Getting beat is one thing – it’s part of competing – but I want no part in losing.” Coach Rob Stark’s motto never fails to remind me of his encouragement on early-morning bus rides to track meets around the state. I’ve always appreciated the phrase, but an experience last June helped me understand its more profound, universal meaning.

Stark, as we affectionately call him, has coached track at my high school for 25 years. His care, dedication, and emphasis on developing good character has left an enduring impact on me and hundreds of other students. Not only did he help me discover my talent and love for running, but he also taught me the importance of commitment and discipline and to approach every endeavor with the passion and intensity that I bring to running. When I learned a neighboring high school had dedicated their track to a longtime coach, I felt that Stark deserved similar honors.

Our school district’s board of education indicated they would only dedicate our track to Stark if I could demonstrate that he was extraordinary. I took charge and mobilized my teammates to distribute petitions, reach out to alumni, and compile statistics on the many team and individual champions Stark had coached over the years. We received astounding support, collecting almost 3,000 signatures and pages of endorsements from across the community. With help from my teammates, I presented this evidence to the board.

They didn’t bite. 

Most members argued that dedicating the track was a low priority. Knowing that we had to act quickly to convince them of its importance, I called a team meeting where we drafted a rebuttal for the next board meeting. To my surprise, they chose me to deliver it. I was far from the best public speaker in the group, and I felt nervous about going before the unsympathetic board again. However, at that second meeting, I discovered that I enjoy articulating and arguing for something that I’m passionate about.

Public speaking resembles a cross country race. Walking to the starting line, you have to trust your training and quell your last minute doubts. When the gun fires, you can’t think too hard about anything; your performance has to be instinctual, natural, even relaxed. At the next board meeting, the podium was my starting line. As I walked up to it, familiar butterflies fluttered in my stomach. Instead of the track stretching out in front of me, I faced the vast audience of teachers, board members, and my teammates. I felt my adrenaline build, and reassured myself: I’ve put in the work, my argument is powerful and sound. As the board president told me to introduce myself, I heard, “runners set” in the back of my mind. She finished speaking, and Bang! The brief silence was the gunshot for me to begin. 

The next few minutes blurred together, but when the dust settled, I knew from the board members’ expressions and the audience’s thunderous approval that I had run quite a race. Unfortunately, it wasn’t enough; the board voted down our proposal. I was disappointed, but proud of myself, my team, and our collaboration off the track. We stood up for a cause we believed in, and I overcame my worries about being a leader. Although I discovered that changing the status quo through an elected body can be a painstakingly difficult process and requires perseverance, I learned that I enjoy the challenges this effort offers. Last month, one of the school board members joked that I had become a “regular” – I now often show up to meetings to advocate for a variety of causes, including better environmental practices in cafeterias and safer equipment for athletes.

Just as Stark taught me, I worked passionately to achieve my goal. I may have been beaten when I appealed to the board, but I certainly didn’t lose, and that would have made Stark proud.

This essay uses the idea of sports to explore a more profound topic—growing through relationships. They really embrace using sports as an avenue to tell the reader about a specific experience that changed the way they approach the world. 

The emphasis on relationships is why this essay works well and doesn’t fall into a cliche. The narrator grows not because of their experience with track but because of their relationship with their coach, who inspired them to evolve and become a leader.

Have a draft of your college essay? We’re here to help you polish it. Students can participate in a free Peer Review, or they can sign up for a paid review by CollegeVine’s experts. Sign up for your free CollegeVine account today to start improving your essay and your chances of acceptance!

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Health Encyclopedia

Preventing sports injuries.

Exercise is good for the body. And with the correct safety steps, sports injuries can often be prevented. The quality of protective equipment—padding, helmets, shoes, mouth guards—has helped to improve safety in sports. But you can still be at risk of injury. Always contact your healthcare provider before starting any type of physical activity. This is especially important for vigorous types of exercises or sports.

Causes of sport injuries may include:

Incorrect or poor training practices

Wearing incorrect sporting gear

Being in poor health

Incorrect warm-up or stretching practices before a sporting event or exercise

Common sports injuries include:

Sprains and strains

Joint injuries (knee, shoulder, ankle)

Muscle injuries

Dislocations

Broken bones (fractures)

Achilles tendon injuries

Pain along the shin bone

How can I prevent a sports injury?

The following are some basic steps to prevent a sports injury:

Create a fitness plan that includes cardiovascular exercise, strength training, and flexibility. This will help decrease your chance of injury.

Alternate exercising different muscle groups and exercise every other day.

Cool down correctly after exercise or sports. It should take 2 times as long as your warm-ups.

Stay hydrated. Drink water to prevent dehydration, heat exhaustion, and heat stroke.

Stretching exercises can improve the ability of muscles to contract and perform. This can reduce the risk for injury. Each stretch should start slowly until you reach a point of muscle tension. Stretching should not be painful. Aim to hold each stretch for up to 20 seconds.

Use the right equipment or gear. Wear shoes that give support and that may correct certain foot problems that can lead to injury.

Learn the right methods to play your sport or do strength training

Rest when tired. Don't exercise when you are tired or in pain.

Always take your time during strength training. Go through the full range of motion with each repetition.

If you do have a sports injury, make sure you get as much rehab (rehabilitation) as needed before restarting a strenuous activity.

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• Volume 49, Issue 17
• Preparticipation injury complaint is a risk factor for injury: a prospective study of the Moscow 2013 IAAF Championships
• Article Text
• Article info
• Citation Tools
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• Juan-Manuel Alonso 1 , 2 ,
• Jenny Jacobsson 3 , 4 ,
• http://orcid.org/0000-0001-6049-5402 Toomas Timpka 3 ,
• Ola Ronsen 1 , 5 ,
• Alma Kajenienne 1 , 6 ,
• Örjan Dahlström 7 ,
• Armin Spreco 3 ,
• Pascal Edouard 8 , 9 , 10
• 1 Medical and Anti-doping Commission , International Association of Athletics Federations (IAAF) , Monaco , Monaco
• 2 Sports Medicine Department , Aspetar, Qatar Orthopedics and Sports Medicine Hospital , Doha , Qatar
• 3 Athletics Research Center, Linköping University , Linköping , Sweden
• 4 Swedish Athletics Association, Stockholm , Sweden
• 5 Aker Solutions , Lysaker , Norway
• 6 Institute of Sport, Lithuanian University of Health Sciences , Kaunas , Lithuania
• 7 Department of Behavioural Sciences and Learning , Linköping University , Linköping , Sweden
• 8 Department of Clinical and Exercise Physiology, Sports Medicine Unity, Faculty of Medicine , University Hospital of Saint-Etienne , Saint-Etienne , France
• 9 Laboratory of Exercise Physiology (LPE EA 4338) , University of Lyon , Saint-Etienne , France
• 10 Medical Commission , French Athletics Federation (FFA) , Paris , France
• Correspondence to Dr Juan-Manuel Alonso, Sports Medicine Department, Aspetar, Qatar Orthopedics and Sports Medicine Hospital, PO Box 29222, Doha, Qatar; juan-manuel.alonso{at}aspetar.com

Objectives To determine the health status of athletes before the start of an international athletics championship and to determine whether preparticipation risk factors predicted in-championship injuries.

Methods At the beginning of the 2013 International Association of Athletics Federations (IAAF) World Championships, all registered athletes (n=1784) were invited to complete a preparticipation health questionnaire (PHQ) on health status during the month preceding the championships. New injuries that occurred at the championships were prospectively recorded.

Results The PHQ was completed by 698 (39%) athletes; 204 (29.2%) reported an injury complaint during the month before the championships. The most common mode of onset of preparticipation injury complaints was gradual (43.6%). Forty-nine athletes in the study reported at least one injury during the championships. Athletes who reported a preparticipation injury complaint were at twofold increased risk for an in-championship injury (OR=2.09; 95% CI 1.16 to 3.77); p=0.014). Those who reported a preparticipation gradual-onset injury complaint were at an almost fourfold increased risk for an in-championship time-loss injury (OR=3.92; 95% CI 1.69 to 9.08); p=0.001). Importantly, the preparticipation injury complaint severity score was associated with the risk of sustaining an in-championship injury (OR=1.14; 95% CI 1.06 to 1.22); p=0.001).

Summary and conclusions About one-third of the athletes participating in the study reported an injury complaint during the month before the championships, which represented a risk factor for sustaining an injury during the championship. This study emphasises the importance of the PHQ as a screening tool to identify athletes at risk of injuries before international championships.

• Epidemiology
• Risk factor

https://doi.org/10.1136/bjsports-2014-094359

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Introduction

During international outdoor athletics championships, the incidence and characteristics of new injuries have been well described. 1–5 To further expand our knowledge, we aimed to identify possible risk factors for injury during the championships.

Athletes participating in championships are assumed to be healthy, that is, free of health problems at the start of a championship; however, this is not always the case. Athletes may have been injured and/or sick during preparation for the championships. In a recent pilot study of 74 athletes, 54% reported at least one health problem (an injury complaint was reported by 24%, an illness complaint by 18% and a pain complaint by only 12%) during the 4 weeks before the 2013 European Athletics Indoor Championships. 6 There have been no studies examining whether carrying injuries into competition predicts injury during competition.

As injury epidemiology has evolved, so have the ways to capture preparticipation health status. 6 When focusing on injuries, we can collect data on several aspects of an athlete's self-reported injury complaints (eg, all complaints, time-loss complaints, gradual-onset/sudden-onset complaints and severity scores). 7 , 8

Therefore, we aimed to determine the health status (injury complaints) of athletes before the start of an international athletics championship. We hypothesised that certain types of preparticipation injury complaints would predict injury during the championship. Our methodological investigation was to investigate the strength of different measures of preparticipation injury complaints (all complaints, time-loss complaints, a complaint severity score) as well as gender, age and event group as predictors of injury during a championship.

Study design and data collection procedures

A total cohort design was used for the study. At the beginning of the International Association of Athletics Federations (IAAF) World Athletics Championships in Moscow in 2013, all registered athletes (n=1784) were invited to complete a preparticipation health questionnaire (PHQ) including individual preparticipation information (personal and training characteristics and health status during the month preceding the championship).

The PHQ was developed by a group of experts consisting of scientists and practitioners (n=6) based on a previously published PHQ. 6 The overall goal was to identify possible risk factors of sustaining injury during the championships by comparing data from the PHQ with those from injury surveillance during the championships. 6 The PHQ was developed to collect information directly from the athletes regarding their personal characteristics (gender, age, country, height, weight, event group, time spent in training) and health status (‘injuries or physical complaints’, which will be called ‘injury complaints’ from this point on, and ‘illnesses’) during the month preceding the championships (online supplementary figure S1). 6

The questions on the functional consequences of the injury complaint were formulated in line with a questionnaire used for monitoring overuse sports injuries. 9 , 10 An injury complaint severity score was calculated using items 3.1, 3.2, 3.3 and 3.4 of the PHQ inspired by the calculation of the Oslo Sports Trauma Research Centre (OSTRC) Overuse Injury Questionnaire severity score from Clarsen et al 9 The response values 0–4 were allocated so that 0 represents no problems and 4 represents the maximum level for each question. An injury complaint severity score of 0 means no problem, and a score of 16 means maximal functional limitation. In the case of more than one injury complaint during the 4-week period, the athletes had to specify the main (worst) injury complaint in the PHQ and then report the additional number of injury complaints. The PHQ was available in a paper format (in English, French, Spanish, Russian), and distributed in the athlete's welcome bag, or by the team physicians or at the antidoping blood sample collection office. Athletes were asked to complete the questionnaire themselves or with the help of team physicians, if needed, and to return it to their team physician or to the designated desk in the warm-up area.

During the period of the championships (10–18 August 2013), newly incurred injuries were recorded by national medical teams (physicians and/or physiotherapists) and/or by physicians on the local organising committee (LOC) using the injury surveillance system (definitions and methods) previously used during international athletics championships. 2–6 , 11 To maintain anonymity and enable linking of the PHQ and injury surveillance data, each participant in the study received a specific identification number.

All the national medical teams and LOC physicians were informed about the study 1 month before the championships by email and on the day before the championships during a medical and antidoping meeting.

Preparticipation injury complaints asked for by self-reporting were defined as “injuries or physical complaints (such as pain, ache, stiffness, swelling, instability/giving way, locking or other symptoms) that athletes had had in the four weeks prior to the championship, even if this had not had major consequences for athlete's participation in normal training and/or competition.” In-championship injury was defined as proposed by the International Olympic Committee consensus 12 and used during the three previous IAAF World Championships. 2–4 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.” 2 , 12 A time-loss injury was defined as one that “leads to the athlete being unable to take full part in athletics training and/or competition the day after the incident occurred.” 12 Similarly, for a preparticipation injury complaint, a reduced participation injury complaint was defined as one that “leads to the athlete being unable to take full part in athletics training and/or competition the day after the incident occurred”; it corresponds to the responses “Yes, reduced participation” and “Yes, I cannot participate” to question 1 of the PHQ and/or “Minor/Moderate/Major/No training” to questions 3.1 and/or 3.2.

Although the PHQ also included items on illness complaints, this study focuses on injuries: preparticipation injury complaints and in-championship injuries. Data on illness complaints were not included in the present analyses.

Confidentiality and ethical approval

The athletes’ gender, date of birth and nationality were used only to avoid duplicate reporting from team and LOC physicians, and to provide descriptive data on athletes’ characteristics. Information about the purpose of the study and the procedure was provided to the athletes in their welcome bags or by medical teams. All athletes were free to refuse the use of their data. All PHQs and injury reports were stored in a locked filing cabinet and were made anonymous after the championships. The confidentiality of all information was ensured so that no individual athlete or national team could be identified. Ethical approval was obtained from the Saint-Etienne University Hospital Ethical Committee (Institutional Review Board Information: IORG0004981).

Data analysis

For the PHQ data, the response rate and completeness of the PHQs were assessed, and the athletes’ characteristics and injury complaints were analysed using descriptive statistics. 6 Analysis of the non-responders was performed by comparing their distribution of home continent, event group, gender and age with the final study group.

For the in-championship injury surveillance, the response rate, coverage, and injury incidence calculations and comparisons were analysed in accordance with previous injury surveillance studies in athletics 4–6 , 11 using a list of athletes provided by the IAAF and the internet database ( http://www.iaaf.org/competitions/iaaf-world-championships/14th-iaaf-world-championships-4873 ).

For the final risk factor analyses, the PHQ data were recoded into the four variables “any injury complaints” (y/n), “reduced participation injury complaints” (y/n), “gradual-onset injury complaints” (y/n) and the injury complaint severity score (0–16). We first performed analyses with simple models (logistic regression analyses with one explanatory variable) and thereafter analyses with multiple models (logistic regression analyses with several explanatory variables) with any in-championship injury (y/n) and in-championship time-loss injury (y/n) as outcomes. The explanatory variables were gender, age, home continent, event group (following event group categories from Timpka et al 13 ) and preparticipation injury complaints. The multiple models were calculated using backward elimination of non-significant variables (ie, variables with p≥0.05 were eliminated stepwise). The Statistical Package for the Social Sciences (SPSS) for Windows V.21.0 was used for the analyses. All statistical tests were two-sided and outcomes with p<0.05 regarded as statistically significant.

Study population

From a total population of 1784 registered athletes, 940 (52.7%) were reached to provide their informed consent to participate in the study; 750 athletes (42% of the total population) accepted. Fifty-two (2.9%) PHQs did not provide sufficient information to classify the athlete (eg, missing date of birth, event); 698 (39.1%) athletes were included in the study ( figure 1 ). Analysis of the non-responders did not show any meaningful differences between the final study group and the non-participant athletes with regard to gender, age category and event groups; differences did exist for continents (slightly increased primary non-participation among Asian, North American and African athletes (p<0.001); online supplementary table S1). The characteristics of the 698 athletes are reported in table 1 . With regard to in-championship injury surveillance, 42 of the 102 national teams (41.2%) that had medical teams took part, covering 588 athletes (84.2%). The response rate for the injury report forms was 91%. None of the participating athletes refused to allow their injury data to be used for scientific research.

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Characteristics of the 698 athletes who agreed to participate in the PHQ

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Flow chart of athlete enrolment and analysis population (PHQ, preparticipation health questionnaire).

Preparticipation injury complaints

Two hundred and four of the 698 athletes (29.2%) reported an injury complaint during the month before the championships; 108 reported having only one injury complaint, 61 reported two injury complaints or more, and 35 did not provide the total number of injury complaints. The characteristics of the main (worst) injury complaints are displayed in table 2 , the distribution and incidence according to the event groups in table 3 and body location in table 4 . One hundred and twenty-six athletes reporting injury complaints (61.8%) reported that the injury complaint problem did not affect their ability to participate in athletics ( table 2 ). The most frequently reported mode of onset was gradual (49.2%), followed by sudden/overuse (36.5%). Only 9.9% of the preparticipation injury complaints were caused by trauma. Almost half of the injury complaints (44.6%) had lasted for more than 4 weeks. There was a tendency for a higher proportion of gradual-onset injury complaints (61.7%) among those lasting for more than 4 weeks, and a higher proportion of sudden-onset injury complaints (50%) among those lasting for less than 2 weeks (p=0.07). At the start of the championship, 134 (65.6%) of the 204 athletes reported no or minor discomfort during training or competition caused by the injury complaint, 14 reported major discomfort and 3 were unable to participate.

Characteristics of preparticipation injury complaints (n=204)

Number of athletes reporting preparticipation injury complaints and number of athletes reporting in-championship injuries, displayed by event groups and severity (n=698); in the case of several preparticipation injury complaints, only the main (worst) complaint is presented and in the case of several in-championship injuries only the first is presented

Body location for the main (worst) preparticipation injury complaint and body location for the first in-championship injury

In-championship injuries

Forty-nine (7%) athletes reported at least one in-championship injury. A total of 64 injuries were recorded, representing an incidence of 91.7 injuries per 1000 registered athletes (95% CI 70.3 to 113.1), including 35 time-loss injuries (54.7%). The most frequent location of injury was the thigh (33.3%), followed by the lower leg (20.6%). Hamstring strain (20.3% of injuries and 25.7% of time-loss injuries) was the most common diagnosis. The most commonly reported cause of injury was overuse (57.1%).

Associations between preparticipation risk factors and in-championship injuries

Using all in-championship injuries as the outcome (ie, any injury; y/n), the simple models showed that all categories for reporting an injury complaint in the month before the championship were associated with an increased injury risk: any injury complaint (OR=2.09; 95% CI 1.16 to 3.77; p=0.014), reduced participation injury complaints (OR=2.53; 95% CI 1.39 to 4.61; p=0.002), gradual-onset injury complaints (OR=2.72; 95% CI 1.38 to 5.36; p=0.004), and the injury complaint severity score (OR=1.14; 95% CI 1.06 to 1.22; p=0.001; table 5 ). In the analyses of the multiple models, only the injury complaint severity score remained associated with in-championship injury (OR 1.14; 95% CI 1.06 to 1.22; p=0.001; table 5 ). Restricting the outcome for the examinations to in-championship time-loss injuries only (ie, time-loss injury; y/n), the analyses using simple models still showed that reporting injury complaints in the month before the championships was associated with increased injury risk, but only for gradual-onset complaints (OR=3.92; 95% CI, 1.69–9.08; P=0.001) and the injury complaint severity score (OR=1.12; 95% CI, 1.02–1.23; P=0.001) ( table 5 ). In the analysis of the multiple models, only the gradual-onset injury complaints category remained with an almost fourfold increased injury risk (OR=3.92; 95% CI, 1.69–9.08; P=0.001) ( table 5 ).

Risk factors for sustaining an in-championship injury or an in-championship time-loss injury presented as ORs (95% CI) calculated by simple and multiple logistic regression analyses (n=698)

The main findings of this study were as follows: (1) about one-third of the athletes involved in this study and participating in an international athletics championship reported an injury complaint during the month before the competition; (2) almost two-thirds of these athletes (61.8%) stated that this injury complaint did not influence their participation; (3) athletes who reported a preparticipation injury complaint had twice the risk of an in-championship injury; (4) those who reported a preparticipation gradual-onset injury complaint had an almost fourfold increased risk of an in-championship time-loss injury; (5) the preparticipation injury complaint severity score was associated with an increased in-championship injury risk.

Competing with injury in athletics

About one-third of the athletes involved in this study and participating in this international championship reported at least one injury complaint during the previous month. This finding extends results from our pilot study at the 2013 European Athletics Indoor Championships during which 54% of the athletes included reported at least one health problem (injury complaint for 24%, illness complaint for 18% and pain complaint for 30%) during the 4 weeks leading up to the championships. 6 This is a relatively high percentage given that athletes aim to peak at a championship. The results also correspond to the findings from a study performed at the 2013 FINA World Championships (Aquatics) where 33% of responding athletes reported a physical complaint in the 4 weeks prior to the championships, 14 and are also in agreement with those from a cohort of Swedish national-level gymnasts, where 58% competed with injury complaints. 15

For the sport of athletics, it is a matter of concern that a high number of athletes seem to live and train with injuries. About half of the athletes reported a preparticipation injury complaint related to overuse and more than half had had their injury complaint for more than 3 weeks. These data are consistent with historical publications where the incidence and prevalence of injuries throughout the athletics season is about 2–3 injuries per athlete per year. 16–20

Jacobsson et al 19 found that 96% of injuries reported by elite Swedish athletes throughout the season were classified as non-traumatic (caused by overuse). Similarly, in a cohort of 142 Olympic and Paralympic candidates from different sports, Clarsen et al 10 reported an average weekly prevalence of overuse injury of 25% at any given point in the season. These results suggest that athletes continue training and compete even though they have injury and/or health problems. To confirm this, prospective whole-season studies must be conducted in athletics to record injuries, including overuse injuries, and examine possible causes and their functional consequences. 13 , 19 , 21

Bringing injuries to the championships increases risk of injury

Having an injury complaint during the month preceding an international athletics championship represented a risk factor for sustaining an in-championship injury. Our results showed that the injury complaint severity score predicted sustaining any injury during the championships according to the multiple model (logistic regression analyses with several explanatory variables), suggesting that having an injury complaint before the championships interferes with preparations and predisposes athletes to an injury during the championships. Injury complaints during the past month may have delayed the athletes’ physical preparation and training and affected their ability to perform optimally at the championships, leaving the athlete more at risk of injury. Therefore, the injury severity score could be a good method for predicting which athletes are at increased risk of sustaining an injury during the championships, but not the severity of that injury.

A gradual-onset injury complaint was strongly associated with the risk for sustaining a time-loss injury at the championships. These measures of preparticipation injury complaints thus seem to have the highest validity with regard to impact and relevance in athletics. These results support the further development of functional consequences assessment of injuries to better define the severity in addition to the duration of time loss. 9 , 22 The duration of time loss may not be an appropriate measure of the severity of an injury for athletes, 20 , 22 because many athletes continue to train and compete despite being injured. 9 , 10 , 15 , 22 The severity score (or functional consequences assessment) may help to better define the magnitude of the functional consequences for athletes. However, more research is needed to identify a cutpoint whereby the severity score denotes a clear injury risk.

Limitations

Several potential limitations should be acknowledged when interpreting the results of this study. First, the percentage of athletes included in the study is low. However, the 60.9% of all registered athletes who did not participate in this study would most probably not change the results, since the study group of 698 athletes is similar to the non-participating athletes on the demographic and in-championship injury characteristics. Considering the methods of preparticipation data collection (circumstances and timing correspond to the last 3 days before and throughout the IAAF World championships), the response rate of 39.1% to our preparticipation questionnaire is acceptable. However, we need to consider how modern technology including tablets and translation mobile applications could help us improve our recruitment of athletes. 23

We faced methodological challenges in reaching out to more than 200 national teams with native languages not covered in our translations of the information and questionnaire. There was also lack of trust in our confidentiality measures which could in part explain the proportion of non-responders. We noted a lower response rate among North American, African and Asian athletes, which indicates that language, social or other cultural disparities were involved to some extent.

Furthermore, some athletes and team medical personnel voiced concerns about filling out forms about personal injuries at a time close to the most important competition of the year. This is hard to circumvent when collecting data during a championship.

Our response rate was lower than that of a previous pilot study (60.6%), 6 but the pilot study was a European indoor championship with a smaller and more homogeneous study population with less language and cultural differences. For future studies, methodological factors must be mastered in order to increase the response rate (improving the information about the study and its interest for athletes, increasing the number of languages, developing informatics support rather than the paper form).

Second, this study combined two different methods for collecting injury data: athletes’ retrospective self-reports and medical attention at the championship. Although a detailed definition of injury complaint was given at the start of the PHQ, athletes could have misunderstood this. 9 Furthermore, self-reported data might provide a limited description of injuries; data on the exact location (including type, severity and cause) and functional consequences should preferably be reported by medical practitioners. In addition, injuries reported at the championships by national and LOC medical teams might not all be new index injuries. On review of the data (not presented in this study), we noted that athletes reported an injury complaint in the PHQ and then the same problem was reported by the medical team as a new injury incurred during the championship.

This observation does not affect the results in this study but indicates an area where the method of reporting needs to be improved to distinguish between, for example, recurrence and exacerbation, because gradual-onset injury complaints were the best predictor of injury. Also, the complete burden of injuries affecting the athletes is not taken into account fully.

Third, the retrospective design of the PHQ could represent a recall bias, although this should have been minimal as we asked the participants only about the 4 weeks immediately before the competition. 6 The content and characteristics of the PHQ should be analysed further and validated in a future study.

Summary and conclusions

What is already known on this topic.

During previous international outdoor athletics championships, injury incidence has been about 100 injuries per 1000 athletes.

The most frequently reported injury has been thigh strain, especially hamstring strain, and overuse has been the predominant cause.

To better understand what causes injuries during a championship, the European Athletics Association and the International Association of Athletics Federations encourage teams to administer a valid athlete self-reporting preparticipation health questionnaire.

What are the new findings?

During the month before the championships, about one-third of athletes involved in this study were troubled by an injury complaint.

Athletes who presented with a preparticipation injury complaint were at twice the risk of sustaining an injury and/or time-loss injury during the championships.

Athletes who reported a preparticipation gradual-onset injury complaint were at an almost fourfold increased risk for an in-championship time-loss injury.

How might it impact clinical practice in the near future?

Up-to-date information on the health status of athletes is important.

National medical teams should obtain health status data during the month before and at the start of the championships.

We recommend a routine preparticipation health questionnaire for athletes and medical teams before the championships in order to screen for athletes at risk of being injured.

Acknowledgments

The authors highly appreciate the cooperation of the team physicians and physiotherapists and the local organising committee of the 2013 IAAF World Championships who volunteered their time to collect the data for this project. The authors would also like to thank Jan Kowalski for his help with the data support, Ben Clarsen, Astrid Junge, Margo Mountjoy and Kathrin Steffen for their help with the development of the preparticipation health questionnaire, and Mathieu Oriol and Vincent Pichot for their contribution to the statistical analyses.

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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.

Files in this Data Supplement:

• Data supplement 1 - Online figure
• Data supplement 2 - Online table

Twitter Follow Juan Manuel Alonso at @DrJuanMAlonso

Contributors J-MA and PE made substantial contributions to the development of the project. J-MA, JJ, OR and PE made substantial contributions to the conception and design of the study. J-MA, JJ, OR, AK and PE were involved in data collection. JJ, TT, OD, AS and PE were involved in the analysis of the data. J-MA, JJ, TT, OR and PE made substantial contributions to data interpretation. PE made a substantial contribution to the drafting and writing of the article. All authors were involved in revising the manuscript and final approval of the version to be published.

Competing interests None.

Provenance and peer review Not commissioned; externally peer reviewed.

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