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Abstract
Background Analysis of injury and illness prevalence in elite sport provides the basis for the development of prevention programmes.
Objectives To analyse the frequency and characteristics of injuries and illnesses occurring during the 13th Federation Internationale de Natation (FINA) World Championships 2009.
Design Prospective recording of newly incurred injuries and illnesses.
Methods The 13th FINA World Championships hosted 2592 athletes from 172 countries in the disciplines of swimming, diving, synchronised swimming water polo and open water swimming. All team physicians or physiotherapists were asked to complete daily a standardised reporting form for all newly incurred injuries and illnesses for their teams. To cover teams without medical staff, the physicians of the Local Organizing Committee also submitted daily report forms.
Results 171 injuries were reported resulting in an incidence of 66.0 per 1000 registered athletes. The most affected body parts were the shoulder (n=25; 14.6%), and head (n=21; 12.3%). Half of the injuries occurred during training. The most common cause of injury was overuse (n=61; 37.5%). 184 illnesses were reported resulting in an incidence of 71.0 per 1000 registered athletes. The respiratory tract was most commonly affected (n=91; 50.3%) and the most frequently classified cause was infection (n=81; 49.2%). The incidence of injuries and illnesses varied substantially among the five disciplines, with the highest incidence of injury in diving and the lowest in swimming.
Conclusions As the risk of injury varied with the discipline, preventive measures should be discipline specific and focused on minimising the potential for overuse. As most of the illnesses were caused by infection of the respiratory and gastrointestinal tract, preventive interventions should focus on eliminating common modes of transmission.
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Introduction
Aquatic sports are enjoyed around the world from the recreational level to the elite level. The Federation Internationale de Natation (FINA), which was founded in 1908, was one of the original sports in the modern Olympic Games with the inclusion of swimming in 1896.1 FINA has global representation with a total of 202 member National Federations. FINA has organised multidisciplinary aquatic World Championships since 1973 which are now held biannually. The 13th FINA World Championships held in Rome in 2009 was the largest aquatic event in the world with 2592 athletes participating from 172 countries.
Injury surveillance during elite events is a duty of care to ensure safety for future athletes.2 3 FINA is increasingly emphasising the protection of the health of the athlete. FINA Medical Rules: Preamble Item 1.0: “FINA, in accomplishing its mission, should take care that sport is practised without danger to the health of the athletes… To that end, it takes the measures necessary to preserve the health of athletes and to minimise the risks of physical injury.”4
Although the aquatic sports enjoy worldwide participation, little is known of the incidence of injury for its participants at the elite level. Injury surveillance studies have been conducted in single sport events including football,5,–,10 rugby,11,–,14 handball,15 athletics,16 karate,17,–,19 ice hockey,20 21 volleyball,22 beach volleyball,23 cycling24 and tennis.25 Injury surveillance studies have occurred in large multi-sport events at the 2004 Athens Olympic Games for team sports and for all sports at the 2008 Beijing Olympic Games.26 27 To the authors' knowledge, no studies have been published on injuries incurred during major events in elite aquatics. One prospective 5 year study on National Collegiate Athletic Association (NCAA) swimmers has been published in the scientific literature on injury incidence.28 Injury prevalence in aquatic sports is published from the 2008 Beijing Olympic Games27 and for water polo in 2004 Athens Olympic Games.26
Although there are a limited number of publications on illness surveillance data at elite multi-sport events,29,–,31 aquatic specific illness incidence does not exist. Based on a previously standardised injury reporting system by the Federation International de Football Association (FIFA) in football,6,–,9 the International Olympic Committee (IOC) implemented an injury surveillance programme during the 2004 Athens Olympic Games for team sports26 and the 2008 Beijing Olympic Games for all sports.27 32 In follow-up of the 2008 Beijing Olympic Games, the IOC decided to add illness surveillance for the 2010 Vancouver Winter Olympic Games. FINA conducted this current study to establish the feasibility of illness surveillance component as a pilot project for the 2010 Vancouver Winter Olympic Games.
The objectives of the current study were to record and analyse injuries and illnesses incurred during the 13th FINA World Championships 2009.
Methods
Implementation
In this study, the IOC Injury Surveillance system32 was implemented with the extension to also survey illness. All five disciplines of the 13th FINA World Championships 2009 (swimming, water polo, diving, synchronised swimming and open water swimming) were included as the study population. In preparation for the study, an information booklet was circulated 1 month in advance to the medical representatives of all participating countries. A site visit occurred 1 month before the event by a member of the study group (MM) to educate the medical team of the Local Organizing Committee (LOC) on the logistics of the study. On-site in Rome, a voluntary information meeting was held for the medical teams of the visiting countries 2 days before the commencement of the Championships. These information sessions included instructions on completion and submission of the reporting forms. Instructional booklets and reporting forms were distributed. The team physicians or, in their absence, a team physiotherapist were asked to report daily on the occurrence (or non-occurrence) of all newly incurred injuries and illnesses. Reporting forms could be submitted at a confidential mailbox adjacent to swimming pools. Reporting forms were also accepted by fax and by electronic submission. Additional reporting forms were completed daily by the LOC medical team from each of the medical stations at the venues. Compliance was encouraged by regular visits to the National Federation and LOC medical staff by members of the FINA Sports Medicine Committee.
Definitions of injury and illness
The definition of injury was the same definition as is used in the IOC Injury Surveillance system,32 thus allowing comparison with previous studies.26 27 An injury was defined as any musculoskeletal complaint and/or concussion newly incurred due to competition and/or training during the 13th FINA World Championships that received medical attention regardless of the consequences with respect to absence from competition and/or training. Pre-existing injuries were not included unless there was an acute exacerbation during the time period of the Championships. Injuries occurring not during training or competition were also excluded.
The definition of an illness was developed based on the injury definition to ensure compatibility with the existing injury protocol and ease of understanding for the participating physicians. An illness was defined as any physical complaint (not related to injury) newly incurred during the 13th FINA World Championships that received medical attention regardless of the consequences with respect to absence from competition or training. Chronic pre-existing illnesses were not included unless there was an exacerbation requiring medical attention during the Championships.
Injury and illness report form
The injury part of the report form was identical in design to the IOC Injury Surveillance System utilised during the 2008 Beijing Olympic Games.27 32 The following information was required for documentation: athlete's accreditation number, sport/event, heat/training, date and time of injury, injured body part/side, type and cause of injury, and estimated duration of the subsequent absence from competition and/or training. The illness part of the report form was located directly below the injury part on the same page. The following information was required for documentation: athlete's accreditation number, sport/event, diagnosis, date, main symptoms, cause of illness, and estimated duration of the subsequent absence from competition and/or training. Definitions of injury and illness parameters were stated on the back of the form. Examples of injuries and illnesses to be included on the report form were illustrated in the instructional booklet. The injury and illness report form was available in five languages (English, French, Spanish, Italian and Russian).
Confidentiality and ethical approval
Completed injury and illness report forms were stored during the Championships in a locked storage cabinet. The accreditation number of the athlete was used to ensure that duplication of reporting was avoided from the team doctor and the LOC physicians, and to facilitate the determination of age and gender of the athlete from the FINA database. After the Championships, the forms were made anonymous to ensure that no individual athlete or National Federation could be identified. Ethical approval was obtained from the Ethical Committee of the Oslo University School of Medicine.
Data analysis
All data were processed using Excel and SPSS. Response rate, coverage and incidences were calculated in accordance with the IOC approach for injury surveillance.32 Statistical methods applied were descriptive statistics, frequencies and cross-tabulations. For incidence rates, 95% confidence intervals (CIs) were calculated as the incidence ± 1.96 times the incidence divided by the square root of the number of injuries.
Results
Response rate and coverage
A total of 2592 athletes from 173 registered countries participated in the 13th FINA World Championships. The medical staff from 73 countries (42.2%) with a total of 1745 athletes (67.3%) participated in the project and returned at least one report form, resulting in a total of 495 report forms. Since some countries did not compete in all five disciplines of the FINA World Championships, response rates were calculated separately (table 1).
Characteristics and team physicians' response rates for the five aquatics disciplines
The response rate and coverage of athletes by team physician's reports were highest for water polo (53.4%) and lowest for swimming (21.8%).
Acute injuries and illnesses were reported daily by the physicians at the medical stations at the different venues. The majority of injuries (140; 82.5%) were reported by the team physicians; 32 (17.5%) injuries were reported by the LOC physicians. Only one injury was reported by both sources. About three quarters of the illnesses (n=133, 72.3%) were reported only by the team physician, one quarter (n=41, 22.3%) only from venues, and 10 (5.4%) by both sources.
Frequency and characteristics of injury
There were 171 newly incurred acute injuries reported during the Championships, equivalent to an injury rate of 65.6/1000 athletes. Female athletes had a higher risk of injury (n=88; 68.4 per 1000 athletes, 95% CI 54.1 to 82.7) than male athletes (n=68; 52.1 per 1000 athletes, 95% CI 39.7 to 64.5). The oldest injured athlete was 37 years old, the youngest 14 (in 57 cases age was missing). Most injuries affected the upper extremity (n=63; 36.8%), followed by the lower extremity (n=47; 27.5%), head/neck (n=33; 19.3%) and trunk (n=28; 16.4%). The most frequently injured body parts were the shoulder (n=25; 14.6%) and head (n=21; 12.3%). The most common types of injury were sprains (n=41; 24.0%) and skin lesions (n=32; 18.7%) (table 2).
Number and diagnosis of all (time loss) injuries in the championship and in the five disciplines
Approximately half of the injuries (n=79; 49.7%) were incurred during training or in competition (n=78; 49.1%), and two injuries during warm-up for competition (in 12 cases the information was missing). On average, 7.2 in-competition injuries per 1000 starting athletes were reported. In most cases, the injury was caused by overuse (n=61; 37.5%). Other frequent causes of injury were non-contact trauma (n=25; 15.3%) and contact with another athlete (n=24; 14.7%).
Only 21 of the reported injuries (13.4%, 14 missing values) resulted in time loss, which is equivalent to an 8.1 time loss injury per 1000 registered athletes or <1% of the registered athletes. The five most severe injuries (estimated absence ≥14 days) were a shoulder sprain, a ligamentous rupture in the thoracic spine, a patellar subluxation, a tendon rupture in the hand, and a broken finger.
The general injury risk was highest for diving (134.1/1000 female athletes) and lowest for swimming (21.8/1000 female athletes); the risk of an in-competition injury was highest in open water swimming (57.7/1000 starts of female athletes) and water polo (23.8/1000 starts of male athletes). There were no time loss injuries incurred in women's open water swimming and women's diving. Injuries expecting a time loss of >14 days occurred in male water polo, swimming and in male open water swimming (table 3). While in swimming, synchronised swimming and diving most injuries were incurred during training, in open water swimming, synchronised swimming and water polo the majority of injuries occurred during competitions.
Injuries and illnesses occurring during training and competition including time-loss from sport at the FINA World Aquatic Championships
Frequency and characteristics of illness
A total of 184 acute illnesses were reported, which is equivalent to 7.1% of the registered athletes suffering an illness during the Championships. About half of the illnesses affected the respiratory system (n=91; 50.3%) and a fifth the gastrointestinal system (n=36; 19.9%). The most commonly reported symptom was pain. The most frequent diagnosis affected the upper respiratory tract including ‘otitis’ (n=31; 16.8%) and ‘tonsillitis’ (n=18; 9.8%). Consequently, the cause was most frequently classified as infection (n=89; 49.2%) or environmental (n=50; 27.6%).
Thirty (16.3%) of the illnesses were expected to result in time loss from sport inferring that only 1.2% of all registered athletes incurred a time loss illness. However, time loss illnesses were only reported from swimmers and male water polo players (table 3). No illness was expected to result in absence from sport longer than a week.
Discussion
The aim of this study was to register and analyse all newly incurred injuries and illnesses in athletes participating in the 13th FINA World Championships 2009. To the authors' knowledge, this is the first injury and illness survey during an international aquatic event. The results indicate that the surveillance system was feasible and accepted by both the team physicians and the local medical staff. In all disciplines (except swimming) over 50% of all athletes were covered by the team physicians' reports. Although medical reports were also received from LOC medical team at the medical stations at each competitive and training venues, the incidence of injuries and illnesses may be underestimated due to the response rate indicated above.
On average, <7% of all registered athletes incurred injuries during the Championships. This injury rate is consistent with the injury incidence in aquatics reported during the 2008 Beijing Olympic Games (4.25%).27 The incidence of acute injury in swimming during the World Championships was substantially lower than in a 5 year longitudinal study in NCAA Division I Colleges in the USA (4/1000 exposures),28 which includes chronic injuries in addition to acute new onset injuries.
Most injuries incurred during the FINA World Aquatic Championships affected the upper extremity followed by the lower extremity, trunk and head/neck. The most frequently injured body regions were the shoulder, low back and head. These findings are consistent with other published data in swimming where the shoulder was the most affected joint.31 33,–,36 These findings differ, however, from the 2008 Olympic Games where about half of the injuries affected the lower extremity,27 and the 2007 International Association of Athletics Federations (IAAF) World Championships where 80% of all injuries affected the lower extremity.16 This discrepancy is not surprising given the obvious differences in biomechanics between swimming and athletic disciplines. The injury location data obtained in this study illustrate the need in aquatic sport to focus injury prevention programmes on the shoulder.
In most cases, overuse injuries were reported as the cause of injury (37.5%). Other causes identified were non-contact trauma (15.3%) and contact with another athlete (14.7%). All five time loss injuries in water polo were caused by contact with another player, while seven time loss injuries in swimming were caused by overuse and the other five by non-contact trauma. Attention to the prevention of overuse injuries should be a focus of aquatic injury prevention programmes.
In the present study the proportion of in-competition injuries (50%) was lower than in team sports during the 2004 Olympic Games (75%),26 in athletics during the 2007 IAAF World Championships (74%),16 and all sports during the 2008 Olympic Games (75%).27 Only 21 injuries (13.4%) reported in the present study were expected to result in time loss from sport. This proportion is substantially lower than that reported from the 2008 Olympic Games (49.6%),27 the 2007 Athletics World Championships (56%),16 and the recent FIFA World Cups (63–67%).8 The data from the present study indicate that, on average, <1% of the registered athletes incurred a time loss injury during the FINA World Championships 2009. Even if this result may be an underestimation due to the moderate response rate, these data would suggest a relative low risk of serious time loss injury in aquatic sports in comparison with other sports.
During the FINA World Championships in Rome 2009 slightly more illnesses than injuries were reported. These data contrast with the findings at the 1996 Olympic Games where more athletes were treated for injury (52%) than for illness (43%).31 The overall rate of illness from the Rome data was 7.1% of registered athletes. Approximately half of the illnesses reported affected the respiratory system. These findings are consistent with prevalence data from other elite sporting events such as the Olympic Games in 1996,31 200029 and 2004.30 Results published from a prospective analysis of upper respiratory tract infections (URI) in athletes during training and in-competition shows that URI are more common in elite athletes than in non-competitive athletes.37 This is thought to be due to the increased risk of infection from such factors as over training induced ‘immunosuppression’ and from crowding at competition venues.38 This is supported by the data from Rome where the highest incidence of illness was reported in swimming, with the highest number of competitors exposed to more crowding in warm-up areas and event call rooms. The most frequent diagnosis of illness was otitis (n=31). Beck38 reports that ear infections are common in aquatic sports relating to exposure to water borne pathogens. No illness was expected to result in absence from sport longer than 1 week. Very few illnesses were related to exercise induced causes or environmental causes. This is in contrast to the data reported in the literature on other elite sporting events such as marathon running.39
At future FINA World Championships, attention to strategies to encourage compliance with reporting will improve the quality of the injury and illness surveillance programme. The institution of injury prevention programmes based on the findings from this study will be implemented and evaluated at future FINA World Championships.
Conclusion
The injury and illness surveillance system was accepted by the majority of the medical personnel at the 13th FINA World Championships, demonstrating its feasibility for any large international multidisciplinary event. Attention to improving compliance in reporting at future FINA World Championships will strengthen the quality of the results. The findings are consistent with studies in other sports using a similar methodology. Less than 7% of the registered athletes were injured during the Championships, with most injuries caused by overuse. The most commonly affected body part was the upper extremity. The incidence and characteristics of injury varied by discipline, with the lowest injury risk in swimming and the highest in water polo and open water swimming. Approximately 7% of all registered athletes suffered an illness during the Championships, with about half affecting the respiratory system. In swimming, prevention studies should focus on overuse injuries with emphasis on the upper extremity. Medical care at future FINA World Championships should institute measures to decrease the incidence of respiratory illnesses.
What is already known on this topic
The Federation Internationale de Natation injury and illness surveillance project is the first study in the scientific literature to address the incidence of injuries and illness during a large international swimming event.
Injury surveillance has occurred in aquatics during the Olympic Games in Beijing 2008 and in water polo during the Olympic Games in Athens in 2004.
Results from these relatively smaller events show that the aquatic sports are at low risk for acute traumatic injuries. Illness surveillance at large international swimming events has not been reported in the scientific literature.
What this study adds
This study reveals the incidence of injury and illness of the five aquatic disciplines during a Federation Internationale de Natation (FINA) World Championships event.
The findings show that the shoulder is the most often injured body region. In most cases, the injury was caused by overuse.
More illnesses were recorded than injuries during the 13th FINA World Championships. The most common reported illness was infection of the respiratory tract.
This study is helpful identifying areas for the development and implementation of both injury and illness prevention projects
Acknowledgments
The authors highly appreciate the cooperation of all team physicians and the medical staff of the FINA World Aquatic Championships 2009 who volunteered their time to collect the data for this project. We gratefully acknowledge the FINA, the IOC and the FIFA for their support and the funding of the study. We thank Ms Agnes Gaillard very much for her valuable assistance in data collection.
References
Footnotes
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Competing interests None.
Patient consent Not required.
Ethics approval This study was conducted with the approval of the University of Oslo.
Provenance and peer review Not commissioned; externally peer reviewed.