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Original article

Injury patterns in Swedish elite athletics: annual

incidence, injury types and risk factors
Jenny Jacobsson,1 Toomas Timpka,1 Jan Kowalski,1 Sverker Nilsson,1
Joakim Ekberg,1,2 Örjan Dahlström,3 Per A Renström4

▸ Additional material is ABSTRACT added from 2009, and since 2008 surveillance has
published online only. To view Objective To estimate the incidence, type and severity also included the corresponding competitions
please visit the journal online
(http://dx.doi.org/10.1136/ of musculoskeletal injuries in youth and adult elite during the Olympic Games.1–4 Data from these
bjsports-2012-091651). athletics athletes and to explore risk factors for championship settings display a cumulative injury
1 sustaining injuries. incidence close to 10% per occasion and the occur-
Department of Medical and
Health Sciences, Linköping Design Prospective cohort study conducted during a rence of injuries is frequently associated with
University, Linköping, Sweden 52-week period. overuse. Older studies on athletics populations
2
University of Skövde, School Setting Male and female youth and adult athletics representing geographic areas have reported an
of Life Sciences, Skövde, athletes ranked in the top 10 in Sweden (n=292). annual injury incidence ranging between 65% and
Sweden
3
Department of Behavioural Results 199 (68%) athletes reported an injury during 75%.5 6 A recent study on Swedish elite athletics
Sciences and Learning, the study season. Ninety-six per cent of the reported analysed retrospectively the prevalence of injury
Linköping University, Linnaeus injuries were non-traumatic (associated with overuse). over 1 year and found that nearly every second
Centre HEAD, Linköping, Most injuries (51%) were severe, causing a period of adult athlete experienced a performance-limiting
Sweden
4 absence from normal training exceeding 3 weeks. Log- musculoskeletal injury primarily of the overuse
Department of Molecular
Medicine and Surgery, rank tests revealed risk differences with regard to athlete type.7
Karolinska Institutet, category ( p=0.046), recent previous injury (>3 weeks Participation in high-level sports carries a sub-
Stockholm, Sweden time-loss; p=0.039) and training load rank index (TLRI; stantial risk of musculoskeletal injuries that not
p=0.019). Cox proportional hazards regression analyses only interfere with scheduled training routines and
Correspondence to
Jenny Jacobsson, showed that athletes in the third (HR 1.79; 95% CI competitions but may also compromise entire
Department of Medical and 1.54 to 2.78) and fourth TLRI quartiles (HR 1.79; 95% careers. The injury problem has grown to an extent
Health Sciences, Linköping CI 1.16 to 2.74) had almost a twofold increased risk of that has raised concerns about the general health
University, Linköping, injury compared with their peers in the first quartile and status of elite athletes.8 It is generally agreed that
SE 58183, Sweden;
interaction effects between athlete category and previous programmes for prevention of sports-related injur-
[email protected]
injury; youth male athletes with a previous serious injury ies ought to be implemented.9 10 Nonetheless,
Accepted 13 February 2013 had more than a fourfold increased risk of injury before designing specific interventions, it is also
Published Online First (HR=4.39; 95% CI 2.20 to 8.77) compared with youth essential to understand the mechanisms and factors
29 March 2013 females with no previous injury. related to the risk of sustaining injuries in real-
Conclusions The injury incidence among both youth world sport settings.11 Athletics encompasses
and adult elite athletics athletes is high. A training load diverse subdisciplines and specific training require-
index combing hours and intensity and a history of ments differ according to the nature of the discip-
severe injury the previous year were predictors for injury. line. In general, the sport is characterised by high
Further studies on measures to quantify training content training demands; adult athletes complete between
and protocols for safe return to athletics are warranted. 20 and 35 h of training per week during prepar-
ation periods (Oscar Gidewall, Sweden Athletics,
personal communication). The literature is ambigu-
INTRODUCTION ous regarding the risk factors associated with injur-
The umbrella term athletics includes race walking, ies in athletics. D0 Souza12 found that unsupervised
cross-country and road running, and the track and training and older age were associated with injury
field disciplines consisting of running, jumping risk. Similarly, Bennell and Crossley6 reported that
and throwing. The sport is governed by the older age was a risk factor for sustaining multiple
International Association of Athletics Federation injuries and showed that higher flexibility was asso-
(IAAF). World Championships are held every ciated with injury. These studies reported no differ-
second year at which almost 2000 athletes repre- ences in risk with regard to gender, menstrual
senting all continents compete (http://www.iaaf. disturbances, event groups or training hours. In
org). Although athletics is such a popular sport and contrast, other studies have reported an association
the largest at the Olympics Games, contributing with training routines.5 13 Previous injury has been
about 20% of all participants (http://www.olympic. shown to be a risk factor in recent studies covering
org), surprisingly few studies have prospectively discipline-specific training14 and in competitions.1 4
reported injury incidence and patterns in athletics In an analyses of data collected in association
athletes at the elite level, and hence limited infor- with the IAAF World Championships, Alonso
mation is available linking risk factors to athlete et al2 4 found a higher injury risk for men relative
To cite: Jacobsson J, categories. to women. However, while data from high-level
Timpka T, Kowalski J, et al. In 2007, the IAAF introduced routine data competitions provide valuable information, they
Br J Sports Med collection on injury incidence during the World cannot contribute sufficient knowledge for under-
2013;47:941–952. Championships. Collection of data on illness was standing the general injury risks across populations

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Original article

of elite athletics athletes. The athletes entering a championship Data categorisation

are presumably relatively healthy and the training performed Before classification, the injury data were verified according to
during the time period close to major competitions is not com- the study protocol and irregularities removed. A matrix adjusted
parable with the training performed during the rest of the year, to athletics injuries was used to categorise the coded injury data
that is, during general preparation and preseason periods. according to injury type (nature of the injury) and anatomic
Published studies of club and elite athletic cohorts have reported location (body region).7 18 Injuries were defined as overuse
that athletics injuries are mostly sustained during training.5 6 12 injuries if caused by repeated microtrauma without a single
Movement towards sport safety in athletics through the intro- identifiable causal event and as a traumatic injury if resulting
duction of preventative strategies requires that the unique injury from a specific identifiable event.19 For one diagnostic group,
profile for the sport is established in typical populations of ath- stress fractures, MRI was required to verify the findings for clas-
letes.11 15 To our knowledge, no routine surveillance of system- sification. A group consisting of one physiotherapist and three
atic injury similar to that used by the IAAF exists at the level of physicians with a background in sports medicine classified each
national federations in athletics. The difficulties in accomplish- self-reported diagnosis into a three-digit diagnostic code accord-
ing longitudinal studies in this sport have been highlighted.16 ing to the International Classification of Diseases, Ninth
The aim of this study was to estimate the incidence of musculo- Revision, Clinical Modification (ICD-9-CM) (see online supple-
skeletal injuries in youth and adult athletics athletes competing mentary appendix table A1). The physiotherapist ( JJ) and one
at national and international levels in track and field events, and physician (SN) assigned a preliminary code independently and
to examine the type, severity and risk factors of the associated any diversity in this classification was a subject for clarification.
injuries sustained. The resulting knowledge is to be used to for- The list was then reviewed by the two remaining physicians
mulate principles for evidence-based injury prevention and (PR, TT).
safety promotion programme in athletics. The weekly training load was quantified by combining training
hours and intensity20 on a relative basis for a 6-week period in
association to the start of the study. A training load rank index
METHODS (TLRI) defining the relative training load was constructed by first
A prospective cohort design covering a 52-week period starting multiplying the reported training intensity (light=2, moder-
in March 2009 was used for the study. The design and the rou- ate=3, hard=5) with minutes of training performed during the
tines for data collection have been reported in detail earlier.17 week. The athletes were thereafter grouped by athlete category
For this study, the concept of elite athlete was defined with and event group and then ranked and separated into quartiles by
regard to the national level, that is, if the athlete was ranked at their training load score into TLRI categories Q1–Q4.
the national top-10 list in one athletics discipline.17 A total of We used time loss from athletics to define the severity of
649 athletes (367 adults and 282 youths) were invited to take the injury,19 21 that is, the number of days the athlete was
part in the study. Postal addresses were obtained from the unable to participate (totally or partially) from the date the
Swedish Athletics Association and from the athlete’s club. athlete reported onset of injury until return to normal training.
Seventy-two per cent (n=461) of the athletes responded to the Injuries were classified as slight (1–3 days missed participation),
invitation, of which 70% (n=321) gave their written consent to minor (4–7 days), moderate (8–20 days) and severe (>21 days).
participate in the study. The final study population included Injuries were defined as recurrent if they occurred in the same
50.2% of the initial selection of athletes (figure 1). location, were of the same type, and within 2 months of a previ-
ous injury. Further injuries occurring after a first injury were
defined as subsequent injuries. In this study, no attempt was
Ethics made to classify recurrent and subsequent injuries in detail.22 23
Ethical approval for the study was obtained from the Ethical
Committee in Linköping in November 2008 (dnr. M-201–08).
Informed written consent was obtained from all participants in Statistical analysis
the study. For those under the age of 18 years, approval was Analyses were performed first at the level of injured and non-
also obtained from their parents. injured athletes. The athletes had to be free of injury to be
eligible for analyses. Accordingly, the injured athletes were cate-
gorised with regard to the first new injury reported during the
Data collection 52-week study period. Injury rates were also calculated per
Data on injury incidence and exposure during athletic training 1000 athletic-hours of training.
and in competition were collected using web-based question- All data were presented using descriptive statistics, that is,
naires (SiteVision V.2.5, Senselogic AB, Örebro, Sweden). The mean, median, SD, minimum and maximum for continuous
data were self-reported by the athletes; assistance from parents data and frequency and proportion (%) for categorical data.
was promoted for athletes under 18 years of age. An injury was Frequency of injuries was presented together with the corre-
defined as any new musculoskeletal pain, soreness or injury that sponding 95% exact CI for a proportion. The statistical analysis
resulted from athletic training or competition and caused were performed on the analysis population which consists of all
changes in normal training/competition to the mode, duration, athletes who did not drop out from the study, that is, 292 sub-
intensity or frequency from the current or subsequent training jects (figure 1). Differences in the proportions of subjects were
and/or competition sessions. Only injuries occurring while par- analysed using the χ2 test. Severity of injury was analysed using
ticipating in athletics, training or competition were included. the χ2 test comparing the order of injury (1, 2, 3, 4, 5 and ≥6)
During the first week of the study, a baseline questionnaire was as well as gender and age category with regard to the severity of
administrated asking for personal sports-specific and sociode- injury (minor, moderate and major).
miographic data. Emails were sent weekly to participants with The primary end point for the injury risk analyses was time
questions about the preceding week, with one reminder to those to injury. Data from the participating athletes were entered into
who did not respond to the first email. the analyses from the first day they were free of injury and in

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Original article

Figure 1 Flow chart of athletes

enrollment and analysis population.

normal training. At baseline, 96 athletes were identified as being All tests were two-sided and p<0.05 was regarded as statistic-
injured,7 and therefore these athletes were left censored until ally significant. All calculations were carried out using SPSS V.18
the week after they reported being back in normal training after or higher (IBM Inc).
injury. Athletes were analysed according to the first injury they
reported during the study period. Time to injury was analysed RESULTS
using the Kaplan-Meier method for presenting data descrip- During the study period, 292 athletes (91% of the enrolled
tively and the log-rank test as a univariate test for differences population; table 1) submitted weekly reports covering 135.0 h
among subgroups with regard to athlete category (combing of exposure to athletics (figure 2). The mean age of adult ath-
gender and age group), event group, injury history, number of letes was 24 years (range 18–37 years) and the age of all youth
training hours per week, number of training sessions per week athletes was 17 years.
and categories of training load per week. Multivariate regression
analyses for examination of time to injury were thereafter Injury incidence
applied using the Cox proportional hazards regression. As previ- A total of 199 (68%) of the athletes (73% of adults and 61% of
ous studies have reported that injury risk is associated with youths) reported at least one injury (table 2). The median time
athlete categories and previous injury, we decided to test for to the first injury was 101 days (95% CI 75 to 127).
interaction between combinations of these factors in the multi- One hundred and twenty-two athletes (42%) reported more
variate analyses. than one injury and 70 athletes (24%) reported more than two

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Table 1 Mean and SD for athlete characteristics of the study population by age group and gender
Adults Youth

Mean (SD)

Female (n=90) Male (n=76) Female (n=71) Male (n=55)

Age (years) 23.4 (4.6) 24.5 (5.0) 17 (0.2) 17 (0.0)

Height (cm)* 170.6 (6.2) 184.8 (7.1) 170.5 (4.4) 182.3 (6.2)
Weight (kg)* 62.6 (12.9) 82.0 (17.1) 60.4 (7.6) 72.0 (10.5)
Main event group (%)
Throw 19 21 18 20
Sprint 22 28 27 31
Middle/long distance 34 34 20 21
Combined events 7 4 8 4
Jump 18 13 27 24
Serious injury in previous year (%)† 44 49 39 25
Training volume
Sessions/week 6.5 (1.9) 6.9 (2.4) 5.1 (2.2) 4.8 (1.4)
Hours/week 11.5 (4.4) 13.3 (5.4) 8.4 (3.8) 8.8 (2.7)
Hours‡ 489 (141) 531 (199) 433 (160) 417 (131)
Training volume includes all training, that is, normal and performed when injured. Values in parentheses are SDs.
*Values missing for 16 athletes (276).
†Values missing for 19 athletes (273).
‡Mean for 52 weeks.

injuries (figure 3). There was a statistically significant difference in a lower extremity (76% among adults and 78% among
with regard to gender and age category in the proportion of ath- youths). The most common locations were the Achilles tendon,
letes who avoided injury ( p=0.043); 16 men (21%), 28 women ankle, foot and toe (28%), followed by the hip, groin and thigh
(31%), 20 boys (36%) and 29 girls (41%) reported no injury (24%), and the knee and lower leg (24%). Ninety-six per cent
during the study period (table 2). Differences between sub- of injuries reported were classified as non-traumatic (caused by
groups of events could not be statistically demonstrated overuse); 55% had gradual onset and 41% had sudden onset.
( p=0.937; figure 4B). For adults, the most common diagnoses were Achilles bursitis
and tendinitis (17%) and sprain or strain of hip or thigh (13%;
Injury locations and types table 3). Youths reported most injuries in the category of sprains
A total of 482 injuries were reported; 199 (41%) primary injur- and strains of hip and thigh (16%), sprains of ankle or foot
ies and 283 (59%) were recurring (22, 8%) or subsequent (261, (14%), and shin splints (13%; table 4).
92%) injuries. The cumulative injury incidence in the study Separating the event subgroups, the most frequent diagnosis
population was 3.57 injuries/1000 h of exposure to athletics in sprinters was hamstring strain (23.5%), calf/shin splits
(men 3.76/1000 h, women 3.62/1000 h, boys 3.89/1000 h and (22.5%) and Achilles tendinitis/bursitis (19.4%) in middle-
girls 3.13/1000 h). Seventy-seven per cent of injuries occurred distance and long-distance runners, lumbago (11.2%) in
throwers, while jumpers mostly had thigh injuries with gradual
onset (11.2%) and hamstring strains (10.2%; table 5).

Injury events
Most injuries (73%) were reported to have occurred during train-
ing; 13% from technique-specific training, 12% from interval
training, another 12% from sprint training, 11% from warm-up
and 10% each from distance running and weight training (data
are missing from 32% of injuries sustained during training).
Eighteen per cent of the injuries were reported to have occurred
during competition; information on the remaining 9% was
missing. For non-traumatic injuries, the athletes reported experi-
encing soreness or pain in the affected area before the injury
event more often for injuries with gradual onset (53%), com-
pared with injuries with sudden onset (34%; p<0.001).
Most reported injuries (51%) led to absence from normal
training for more than 3 weeks (table 6). There were no differ-
ences in the severity of injuries with regard to athlete category
(p=0.916). However, there was a tendency for the severity of
injury to increase with the order of injury (first injury, second
injury, etc; p=0.110). Severe injuries were predominantly
Figure 2 Box-plot for median weekly (dots) training hours by study located according to the injury matrix categories as follows:
week (1 to 52). Boxes represent minimum and maximum. thigh/groin with gradual onset (9%), posterior thigh with

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Table 2 Frequency and proportion of athletes with at least one injury during the 12-month study period by event group, age and gender
Adults Youth
Female Male All Female Male All Total
Event N=90 N=76 N=166 N=71 N=55 N=126 N=292

Throwing (n) 17 16 33 13 11 24 57
Proportion (% (95% CI)) 76 56 67 69 73 71 68 (55 to 80)
Sprints (n) 20 21 41 19 17 36 77
Proportion (% (95% CI)) 60 81 71 58 59 58 65 (53 to 75)
Middle and long distance (n) 31 26 57 14 12 26 83
Proportion (% (95% CI)) 74 81 77 57 58 58 71 (60 to 80)
Jumping (n) 16 10 26 19 13 32 58
Proportion (% (95% CI)) 63 100 77 58 69 63 69 (55 to 80)
Combined (n) 6 3 9 6 2 8 17
Proportion (% (95% CI)) 67 100 78 50 50 50 65 (38 to 86)
Total (n) 90 76 166 71 55 126 292
Proportion (% (95% CI)) 69 (58 to 78) 79 (68 to 87) 73 (66 to 80) 59 (47 to 71) 64 (50 to 76) 61 (52 to 70) 68 (62 to 73)
n, number of athletes; %, percentage of total number of athletes from respective age, gender and event group.

sudden onset (9%), followed by Achilles tendinitis (8%) and The results of the multivariate Cox regression analyses statis-
calf/shin splints (7%). tically demonstrate an interaction between athlete category and
history of serious injury ( p<0.001; table 8). Youth male athletes
Risk factors
Log-rank tests revealed statistically significant variation in the
risk for injury among athlete categories ( p=0.046) with the
highest risk in adult men. There was also an increased risk of
injury for subjects with a serious injury (>3 weeks time loss)
during the previous season ( p=0.039), and increased risk with
rising TLRI ( p=0.019; table 7). No statistically significant dif-
ferences between event groups could be demonstrated
( p=0.879). The median time to injury was 69 person-days
(95% CI 31 to 107) for previously injured athletes and 105
person-days (95% CI 59 to 150) for those with no 3-week
injury the previous year. The median time to injury was 227
person-days (95% CI 1 to 453) for athletes in TLRI category
Q1 and 98 person-days (95% CI 68 to 128) for those in Q4.

Figure 3 Distribution and time of the injury events during the study Figure 4 Kaplan-Meier curve for time to first injury during the study
year displayed by injury order 1–9. season displayed by athlete categories (A) and event groups (B).

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Table 3 Frequency and proportion of all time-loss injuries in 166 adult track and field athletes (females n=90, males n=76) during 1 year by diagnosis and body part
Non-traumatic injury Traumatic injury
Gradual onset injury Sudden onset injury
Open wound/
Inflammation Stress Sprain, strain or Joint contusion
and pain fracture rupture derangement Fracture Dislocation superficial Internal Total (n)
Proportion
Body region F M Tot F M Tot F M Tot F M Tot F M Tot F M Tot F M Tot F M Tot F/M Tot (% (95% CI))

Vertebral column
Head, face 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 2 1/1 2 1 (0 to 2)
Cervical, thoracic 2 1 3 0 0 0 2 6 8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4/7 11 3 (1 to 6)
Lumbar, pelvis, sacrum 16 7 23 1 3 4 5 3 8 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 23/13 36 11 (8 to 16)
Abdomen 0 0 0 0 0 0 1 2 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1/2 3 1 (0 to 3)
Jacobsson J, et al. Br J Sports Med 2013;47:941–952. doi:10.1136/bjsports-2013-092676

Extremities
Upper
Shoulder 0 4 4 0 0 0 0 3 3 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1/8 9 3 (1 to 5)
Upper arm, elbow 3 1 4 0 0 0 0 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3/6 9 3 (1 to 5)
Forearm, wrist, hand 2 0 2 0 0 0 2 2 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4/2 6 2 (1 to 4)
Lower
Hip, groin, thigh 20 13 33 0 0 0 16 25 41 0 1 1 0 0 0 0 0 0 2 0 2 0 0 0 38/39 77 25 (20 to 30)
Knee, lower leg 29 18 47 1 2 3 3 7 10 4 0 4 0 0 0 0 0 0 0 1 1 0 0 0 37/28 65 21 (16 to 26)
Achilles tendon, ankle, foot/toe 29 26 55 3 1 4 12 16 28 0 0 0 0 0 0 1 0 1 1 5 6 0 0 0 46/48 94 30 (25 to 36)
Unclassified by site
Others and unspecified 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0/0 0 (0 to 1)
Total (n) 101 70 171 5 6 11 41 69 110 5 1 6 0 1 1 2 0 2 3 6 9 1 1 2 312
Proportion (% (95% CI)) 55 (49 to 60) 3 (0 to 3) 35 (30 to 41) 2 (1 to 4) 0 (0 to 2) 1 (0 to 2) 3 (1 to 5) 1 (1 to 5)
F, number of females; M, number of males; Tot, total number of injuries.
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Table 4 Frequency and proportion of all time-loss injuries in 126 youth track and field athletes during 1 year (females n=71; males n=55) by diagnosis and body part
Non-traumatic injury Traumatic injury
Gradual onset injury Sudden onset injury
Open wound/
Inflammation Stress Sprain, strain Joint contusion
and pain fracture or rupture derangement Fracture Dislocation superficial Internal Total (n)
Proportion
Body region F M Tot F M Tot F M Tot F M Tot F M Tot F M Tot F M Tot F M Tot F/M Tot (% (95% CI))

Vertebral column
Head, face 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1/0 0 1 (0 to 3)
Cervical, thoracic 1 1 2 0 0 0 1 2 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2/3 1 3 (1 to 7)
Lumbar, pelvis, sacrum 5 0 5 2 0 2 4 6 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11/6 5 10 (6 to 15)
Abdomen 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0/1 0 1 (0 to 3)
Extremities
Upper
Shoulder 0 1 1 0 0 0 1 3 4 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 2/4 6 3 (1 to 8)
Upper arm, elbow 0 1 1 0 0 0 2 2 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2/3 5 3 (1 to 7)
Forearm, wrist, hand 0 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0/2 2 1 (0 to 4)
Lower
Hip, groin, thigh 5 7 12 0 1 1 11 16 27 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 16/24 40 23 (17 to 31)
Knee, lower leg 15 25 40 1 1 2 6 1 7 1 0 1 0 0 0 0 0 0 1 0 1 0 0 0 24/27 51 30 (23 to 37)
Achilles tendon, ankle, foot/toe 9 3 12 5 0 5 13 11 24 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 27/15 42 25 (18 to 32)
Unclassified by site
Others and unspecified 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0/0 0 (0 to 2)
Total (n) 35 40 75 8 2 10 38 42 80 1 0 1 0 0 0 1 0 1 2 1 3 0 0 0 170
Proportion (% (95% CI)) 44 (37 to 52) 6 (3 to 11) 47 (39 to 55) 1 (0 to 3) 0 (0 to 2) 1 (0 to 3) 2 (0 to 5) 0 (0 to 2)
F, number of females; M, number of males; Tot, total number of injuries.

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Table 5 Frequency and proportion of all 1-year prospective time loss injuries among athletics athletes (youth and adult) by event category (columns) and body region (rows)
Throwing Sprints Middle/long distance Jumping Combined Total
N=57 N=77 N=83 N=58 N=17 N=292
Non-traumatic Non-traumatic Non-traumatic Non-traumatic Non-traumatic Non-traumatic
Traumatic Traumatic Traumatic Traumatic Traumatic Traumatic
injuries injuries injuries injuries injuries injuries
injuries injuries injuries injuries injuries injuries Total
Body region G S G S G S G S G S G S (%)

Vertebral column
Head, face 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 3 3 (1)
Cervical, thoracic 2 7 0 2 1 0 0 1 0 1 2 0 0 0 0 5 11 0 16 (3)
Lumbar, pelvis, sacrum 14 8 0 6 7 0 5 1 0 4 3 0 5 0 0 34 19 0 53 (11)
Abdomen 0 1 0 0 0 0 0 1 0 0 1 0 0 1 0 0 4 0 4 (1)
Extremities
Jacobsson J, et al. Br J Sports Med 2013;47:941–952. doi:10.1136/bjsports-2013-092676

Upper
Shoulder 3 1 0 1 1 0 0 0 2 0 4 1 1 1 0 5 7 3 15 (3)
Upper arm, elbow 3 4 0 0 0 0 0 0 0 1 3 0 1 2 0 5 9 0 14 (3)
Forearm, wrist, hand 4 3 0 0 0 0 0 0 0 0 0 0 0 1 0 4 4 0 8 (2)
Lower
Hip, groin, thigh 3 6 1 11 28 0 16 12 1 11 18 0 5 5 0 46 69 2 117 (24)
Knee, lower leg 12 5 0 20 6 0 43 7 1 13 3 1 4 1 0 92 22 2 116 (24)
Achilles tendon, ankle, 3 8 1 20 19 0 32 8 2 14 10 5 7 7 0 76 52 8 136 (28)
foot/toe
Unclassified by site
Others and unspecified 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Total (n) 44 43 2 60 62 0 96 30 9 44 44 7 23 18 0 267 197 18 482
Number of body regions (athletes) 89 (39) 122 (50) 135 (59) 95 (40) 41 (11) 482 (199)
Proportion (% (95% CI)) 68 (55 to 80) 65 (53 to 75) 71 (60 to 80) 69 (55 to 80) 65 (38 to 86) 68 (62 to 73)
G, gradual onset non-traumatic injury; S, sudden onset non-traumatic injury.
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Table 6 Frequency and proportion of injuries by within-athlete order of injuries (1-6) or higher during the 1-year study period
Order of injury
1 2 3 4 5 6 or higher Total
n Per cent n Per cent n Per cent n Per cent n Per cent n Per cent n Per cent

Boys
Minor 10 29 6 25 3 27 0 0 1 50 0 0 20 23
Moderate 10 29 7 29 2 18 3 37 0 0 3 60 25 29
Major 15 42 11 46 6 54 5 62 1 50 2 40 40 47
Total 35 100 24 100 11 100 8 100 2 100 5 100 85 100
Men
Minor 16 27 11 30 4 17 2 12 1 9 0 0 34 22
Moderate 19 32 10 28 6 26 5 31 2 18 2 25 44 29
Major 25 42 15 42 13 56 9 56 8 73 6 75 76 49
Total 60 100 36 100 23 100 16 100 11 100 8 100 154 100
Girls
Minor 11 26 2 9 3 25 0 0 0 0 0 0 16 19
Moderate 13 31 6 29 2 17 0 0.0 1 25 0 0 22 26
Major 18 43 13 62 7 58 4 100 3 75 2 100 47 55
Total 42 100 21 100 12 100 4 100 4 100 2 100 85 100
Women
Minor 16 26 6 15 4 17 4 29 2 20 0 0.0 32 20
Moderate 19 31 9 22 5 21 4 29 3 30 2 29 42 27
Major 27 43 26 63 15 62 6 43 5 50 5 71 84 53
Total 62 100 41 100 24 100 14 100 10 100 7 100 158 100
All athletes
Minor 53 27 25 20 14 20 6 14 4 15 0 0 102 21
Moderate 61 31 32 26 15 21 12 29 6 22 7 32 133 28
Major 85 43 65 53 41 59 24 57 17 63 15 68 247 51
Total 199 100 122 100 70 100 42 100 27 100 22 100 482 100
Results are presented by severity, gender and age (slight and minor injuries are merged into one category).

with a severe injury the previous year had more than a fourfold reported injuries on training and performance in athletics can
increased risk (HR=4.39; 95% CI 2.20 to 8.77) and adult be assumed to be substantial.
males showed more than a twofold risk (HR=2.56; 95% CI
1.44 to 4.58) of sustaining a new injury compared with youth Body location and injury types
female athletes with no previous injury (figure 5). Athletes in There are few studies in athletics on athletes representing all
the third (HR 1.79; 95% CI 1.54 to 2.78) and fourth quartiles event groups for an entire season. The annual injury incidence
(HR 1.79; 95% CI 1.16 to 2.74) had almost a twofold increased of 68% in this study is similar to that described previously in
risk of injury compared with their peers in the first quartile more specific athletics populations. In accordance with previous
(figure 6). studies, we found that most reported injuries were located in
the lower extremities.1 2 5 6 25 26 We also found similar injury
patterns in adults and youths. Girls were most likely to avoid
DISCUSSION injuries, which is in accordance with the findings of a recent
Longitudinal investigations of injury incidence and injury risk in review.27 Most injuries were reported to occur during athletics
youth and adult elite athletics athletes competing at national training. One explanation for this finding could be that compet-
and international levels that allow comparisons across age, ing in athletics demands that the athlete is close to fully physic-
gender and event categories are scarce. This is most apparent at ally fit. Therefore, athletes with vague symptoms may have
the youth elite level.24 To our knowledge, this is the first study chosen to replace competition with training and thereby have
to simultaneously follow two athletics elite cohorts during a sustained an insidious injury during training.
period of 1 year. We found a high incidence of injury and more The most frequently reported diagnoses were in the injury
than every second injury was severe, causing absence from matrix category strains/cramps of the hip/thigh. The exact loca-
normal participation for at least 3 weeks. Subsequent injuries tion and nature of these injuries were not determined in this
accounted for 54% of injury events recorded during the study, because MRI reports were not collected. Muscle injuries,
12-month study period. Only 4% of the reported injuries were especially hamstring strains, is a common diagnosis (14%)
classified as traumatic, which is consistent with previous studies reported from competitions,1 2 4 and similarly, a 12-month
in athletics.1 5 6 13 Severe injury the previous season and a high study showed a 14% incidence of hamstring strain.6 These find-
TLRI score were found to predict the risk for a new injury ings and the high risk of reinjury28 raise urgent concerns about
during the study year. Male adult athletes showed the highest the identification of risk factors for prevention. Stress fractures
injury risk and female youth athletes the lowest; no large differ- are commonly associated with athletics. Bennell et al29 reported
ences were found between event groups. The impact of the a 21% incidence in their cohort; only 4% of MRI-confirmed

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Table 7 Results of log-rank tests for time-to-a new (first) injury Table 8 Results of the Cox proportional hazard multivariate
Injury
regression analysis for time to a new (first) injury, presented using
Log-rank test p Median time to the HR together with its corresponding 95% CI and p value
value injury (days) n Yes No
95% CI
Event group
p Value HR Lower level Upper level
Throw 0.879 69 57 39 18
Sprint 127 77 50 27 Athlete category×previous serious injury
Middle and long 117 83 59 24 Youth female×no injury* 1.000
distance Youth female×injury† 0.351 1.358 0.714 2.585
Combined events 106 17 11 6 Youth male×no injury* 0.464 1.266 0.673 2.383
Jump 67 58 40 18 Youth male×injury† <0.001 4.389 2.198 8.765
Athlete category 0.046 Adult female×no injury* 0.076 1.665 0.948 2.925
Youth female 199 71 42 29 Adult female×injury† 0.062 1.756 0.973 3.167
Youth male 101 55 35 20 Adult male×no injury* 0.052 1.767 0.996 3.133
Adult female 94 90 62 28 Adult male×injury† 0.001 2.563 1.435 4.579
Adult male 69 76 60 16 TLRI
Serious injury previous 0.039 Q1 0–25 1.000
year*
Q2 26–50 0.147 1.390 0.890 2.170
Yes 69 119 89 30
Q3 51–75 0.009 1.792 1.154 2.782
No 105 154 102 52
Q4 76–100 0.008 1.787 1.165 2.741
Average weekly 0.165
training sessions† *No severe injury reported in the 12 months prior to the study.
†Severe injury reported during the 12 months prior to the start of the study.
1–3 125 46 28 18 Factors in the model were athlete category, previous injury and training load rank
4–5 105 89 60 29 index, TLRI.
6–8 90 112 80 32
9+ 83 31 28 3
Average weekly 0.488 rehabilitated from a previous injury. Our findings also highlight,
training hours†
as indicated by Meeuwisse et al33 that even though athletes
0–9 105 136 91 45
report being injured, they may continue participating ( partially)
10–14 90 93 68 25
in athletics training and thereby remain exposed to injury risk.
15–19 88 34 25 9
What the high successive injury rate observed in our study can
20+ 56 15 12 3
be attributed to remains unanswered. However, this study
Training load rank 0.019
index (TLRI)‡
emphasises the need for further investigation to identify athletes
Q1 0–25 227 73 40 33
at increased risk for sustaining multiple injuries, and to examine
Q2 26–50 78 67 46 21
the consequences of these injuries and how these events affect
Q3 51–75 69 69 53 16
overall athletics performance.
Q4 76–100 98 70 57 13
The tests included the athlete category, event group, serious injury the previous year, Design and definition
number of training sessions per week, number of training hours per week and TLRI. Studies on sports epidemiology can differ with regard to the
*Values were missing for 19 athletes.
†Values were missing for 14 athletes. design, definitions and settings, which may affect the reported
‡Values were missing for 13 athletes. incidence of injury. This highlights the need for overall

stress fractures were identified in our study. However, overuse

injuries are generally diagnosed clinically and a stress fracture
can remain undiagnosed for several weeks if radiologic investi-
gations are performed only when symptoms persist.30 This
implies that this specific type of diagnosis may have been under-
reported in our study.

Recurrent and subsequent injuries

The importance of clear specification and categorisation of sub-
sequent injuries, separating them from recurrence injuries, has
lately been emphasised.22 31 We found that successive injuries
accounted for 59% of all injury events recorded. The low pro-
portion of recurrent injuries found in this study (8% of the suc-
cessive injuries) could be explained by the strict definitions used.
In an injury surveillance study covering high-school team sports
and cross-country runners, Rauh et al23 32 found that almost
25% of athletes reported multiple injuries. Why some athletes
seem more prone to sustain numerous injuries has not been Figure 5 Survial curves for time to first non-traumatic injury during
established. Possible causes are that some athletes are more the study season displayed by history of severe injury the previous
exposed to their sport or they may not have been adequately season and athlete categories.

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practitioners may recommend return to athletics training and

competition based on experience from popular but less physic-
ally demanding team sports, such as soccer. In addition, if the
coach and athlete underestimate the injury severity,28 decisions
regarding need for treatment and return to sport may become
systematically biased. It has been observed in other sports that
high-level athletes modify their training while injured, but still
train at high volume and eventually increase load.42 43 However,
this study has identified previous injury as a major risk factor in
athletics, and we interpret that the need to fully understand and
identify current gaps and barriers towards obtaining adequate
rehabilitation for overuse injuries is most urgent.

Age, gender and event groups

Conflicting results have been reported from studies in athletics
regarding how injury incidence rates differ by gender2 6 12 and
little agreement exists in other sports.38 In our study, we found
that male athletes, youth and adult, with a previous severe
injury were at increased risk. The risk for male youth athletes
Figure 6 Survial curves for time to first injury during the study was close to four times higher than female youth athletes
season displayed by the training load rank index (TLRI) quartiles.
without previous injury. Because not much epidemiological
knowledge about youth elite athletes is available, information
about the impact of subsequent injuries among young athletes is
uniformity in structuring, collecting and reporting data in athlet-
also limited.24 44 Moreover, similar to reports from adult elite
ics studies. The definitions used in this study follow earlier con-
athletics competitions,2 adult male athletes in our study had a
sensus statements,34 35 in which time-loss definitions are
higher risk for injury. For further development of preventative
recommended and injuries occurring during training and compe-
safety programmes, understanding of athletes’ perceptions of
tition are included. The data were prospectively collected, self-
injury risks is essential.45 and the literature suggest that these
reported and reflect the individual’s interpretation of the injury.
perceptions may be gender specific.46 Moreover, like Benell and
The injury definition used was also broad in the sense that it
Crossley,6 we found no difference between subgroups of events
included restricted participation defined as partial time loss, that
with regard to injury risk. This indicates the existence of sys-
is, not fully participating in normal scheduled athletics activities.
temic effects from athletics training, for example, the double
One requirement identified for the protocol for surveillance
seasons (indoors and outdoors) and preseason planning.
studies in athletics17 was to formulate an injury definition to suf-
ficiently cover conditions at the borderline between over-reach
Training load
and overuse. It could be argued that some events reported cannot
Almost all injuries identified in this study were non-traumatic.
be regarded as injuries of medical importance with a distinct
This finding emphasises that there are knowledge gaps regarding
pathology and clear tissue damage. However, most of the injuries
the incidence and risk indicators associated with overuse injuries
accounted for in this study were severe, causing more than
in sports.47 Overuse injuries have also drawn little attention
3 weeks loss of full participation in athletics. Only 9% were
when it comes to preventative interventions,48 even though such
slight injuries, implying that the athletes reported an injury when
efforts have shown efficacious long-lasting effects in well-
it notably limited performance. From the viewpoint of the elite
targeted groups of athletes.49 In particular, surprisingly little
athlete, injuries associated with only minor tissue damage (eg,
research has attempted to associate injury profiles with
overuse injuries) might have a substantial negative impact on per-
training-related factors, which in part can be explained by the
sonal achievements.36 Almost every second athlete with a gradual
fact that quantifying training loads is a challenging task.50 Injury
onset of injury reported having felt something in the affected
profiles are known to differ between sports51 and certain sports
body area 1–2 weeks before the onset of the reported injury, sug-
have reported patterns of injuries linked to overuse that are also
gesting that pain and soreness can be used as proxies for early tar-
site specific, for example, climbers with tendinopathies located
geting of these types of overuse-related conditions.37
in the hands and fingers.52 These sports are characterised by
recurrent discipline-specific movements and loads suggesting a
Previous injury connection with workplace routines similar to those seen in set-
Bennell et al6 found that close to 33% of athletics injuries are tings describing work-related overuse injuries.53 54 Elite cricket
associated with a previous injury. A history of previous injury is players have shown an association between a high throwing
a commonly observed risk factor for obtaining a new injury in work load and a risk for upper limb injuries.55 At the elite level
sports.38–41 Why a previous injury is related to a subsequent in athletics, training during the preparation period consists of
injury has not been carefully examined. Little knowledge exists weight training, sprinting, jumping, endurance training and
about the pathways between a primary injury and subsequent other discipline-specific training performed at a high level with
injuries, and about the relationship with treatment and rehabili- relatively long-training sessions and with increasing intensity,
tation. A number of extrinsic factors may contribute to why an especially closer to the competition season.
athletics athlete receives poor clinical treatment and rehabilita- Similar to Benell and Crossley,6 we could not confirm any
tion. For example, the athlete may live in an area where there is association between injury rates and hours or sessions trained,
limited access to clinical professionals specialised in sports medi- even though our results showed a tendency towards increased
cine, such as physicians and physiotherapist, leading to lack of injury risk when sessions per week increased in number.
proper services for diagnosis and rehabilitation. Sports medical However, we noted a significant association between injury and

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relative training load measured as a combination of hours and only one injury, but also multiple injuries during one season. The
intensity. A similar relationship between intensity in practice internet-based system for collection of injury data in athletics was
and overuse injury incidence has been noted previously in elite found generally feasible. An adapted version of the system is
settings.42 43 56 57 Gabbett58 has also reported associations about to be introduced for injury surveillance on a routine basis
between reduction in training loads and fewer injuries. In the in Swedish Athletics. The frequent occurrence of injuries related
study by Benell and Crossley,6 the injured athletes attributed to overuse suggest that most of the injuries observed are prevent-
almost 80% of injuries, particular those related to overuse, to a able by altering the exposure to athletics. This study also identi-
change in training during the month preceding the injury; the fied risk factors for sustaining musculoskeletal injuries that have
most perceived cause was an increase in training intensity. In relevant implications for prevention. In particular, two areas of
rugby, Gabbett58 has reported associations between reduction in concern were identified: a relationship with training intensity
preseason training loads and fewer injuries. The dose–response and athletes with previous injuries. Future studies should focus
relationship, or rather the training–performance relationship in on measures to quantify training content in athletics and the
sports,57 is an area for further research because optimising train- development of protocols for rehabilitation of specific injury
ing without obtaining adverse effects such as injuries is highly types to ensure a safe return to athletics.
warranted in any elite sports setting.

Limitations What are the new findings?

Several considerations have to be taken into account when
drawing conclusions from this study. An overall concern with
self-reported injury data is the reliability and validity of the diag- ▸ This prospective study identified a high incidence of injuries
nosis. In this study, the injury follow-up questionnaire included in youth and adult elite athletics athletes.
a question on whether any medical practitioner had confirmed ▸ The majority of injuries are of the overuse type affecting the
the reported diagnosis by a clinical investigation, and all self- lower extremities, and cause more than a 3-week time loss
reported diagnoses were evaluated by practitioners with long from participation.
experience in clinical sports medicine. However, we do not ▸ Many athletics athletes sustained multiple injuries during the
know to what degree the information reported expressed the study season.
athlete’s own opinion regarding the injury. The injuries recorded ▸ No difference between subgroups of events with regard to
were mainly unilateral, of the overuse type, and affected body injury risk was found. This suggests the existence of systemic
areas in accordance with earlier reports from athletics, for effects from athletics training.
example, back of the thigh, knee and ankle. Another limitation ▸ A training load index combing training hours and intensity
of this study is the notion of new injury. The results suggest that and a history of severe injury the previous year did predict
it may not have been the athlete’s factual first injury that was risk for injury.
recorded as the first injury during the study period, but rather
one in a sequence of interconnected injuries. This indicates that
more investigations on recurrent injuries and the lifetime preva- Contributors JJ TT JK and ÖD contributed in materials/analysis tools. JJ and TT
lence of injuries in athletics are warranted. Almost 50% of the wrote the manuscript. JJ TT JK JE SN and PR participated in conception and design
targeted population consented to participate in this 1-year of the project. JJ TT JK JE SN ÖD and PR participated in revision of manuscript
providing intellectual content. TT is the guarantor of the manuscript content.
individual-level study, which can be considered satisfactory.
Also, the drop-out was not found to be skewed with regard to Funding The study received research grants and research training support for PhD
studies ( JJ) from the Swedish Centre for Sports Research (CIF) (P2012–0138).
age, gender, event group and ranking. A limitation is that elite
athletes affected by season-long injuries the preceding season Competing interests None.
were not included in the top 10 Swedish ranking list. This non- Ethics approval Regional reaearch Ethics Board in Linköping.
healthy worker effect59 may have biased the study population Provenance and peer review Not commissioned; externally peer reviewed.
towards including more healthy athletes. No power calculation
was performed to establish the size of the study population as a REFERENCES
basis for statistical testing, since we aimed to reach the entire 1 Alonso JM, Junge A, Renstrom P, et al. Sports injuries surveillance during the 2007
population defined elite athletic athletes in Sweden. An evident IAAF World Athletics Championships. Clin J Sport Med 2009;19:26–32.
2 Alonso JM, Tscholl PM, Engebretsen L, et al. Occurrence of injuries and illnesses
risk for type 2 errors must thus be accounted for when inter- during the 2009 IAAF World Athletics Championships. Br J Sport Med
preting the results, in particular at the subgroup level. 2010;44:1100–5.
Furthermore, no anthropometrics data were included,17 imply- 3 Junge A, Engebretsen L, Mountjoy ML, et al. Sports injuries during the Summer
ing that some explanatory variables causing injuries might not Olympic Games 2008. Am J Sport Med 2009;37:2165–72.
4 Alonso JM, Edouard P, Fischetto G, et al. Determination of future prevention
have been detected. However, not many studies have reported
strategies in elite track and field: analysis of Daegu 2011 IAAF Championships
an association between injury outcome and anthropometrics. injuries and illnesses surveillance. Br J Sport Med 2012;46:505–14.
The TLRI used in this study should be considered as an explora- 5 Lysholm J, Wiklander J. Injuries in runners. Am J Sport Med 1987;15:168–71.
tive attempt to further quantify training load. For example, the 6 Bennell KL, Crossley K. Musculoskeletal injuries in track and field: incidence,
intensity stated in the weekly reports in our study reflects the distribution and risk factors. Aust J Sci Med Sport 1996;28:69–75.
7 Jacobsson J, Timpka T, Kowalski J, et al. Prevalence of musculoskeletal injuries in
training schedule and is not a subjective measure of perceived Swedish elite track and field athletes. Am J Sport Med 2012;40:163–9.
training-related exertion. 8 Ljungqvist A, Jenoure P, Engebretsen L, et al. The International Olympic Committee
(IOC) Consensus Statement on periodic health evaluation of elite athletes March
CONCLUSIONS 2009. Br J Sport Med 2009;43:631–43.
Musculoskeletal injuries among elite athletes are a common phe- 9 Van Mechelen W, Hlobil H, Kemper HC. Incidence, severity, aetiology and
nomenon and an understanding of the underlying causes is war- prevention of sports injuries. A review of concepts. Sports Med 1992;14:82–99.
10 Finch C. A new framework for research leading to sports injury prevention. J Sci
ranted in every sport. This study showed that both youth and Med Sport 2006;9:3–9.
adult elite athletics athletes are at high risk for sustaining not

12 of 13 Jacobsson J, et al. Br J Sports Med 2013;47:941–952. doi:10.1136/bjsports-2013-092676

 Downloaded from http://bjsm.bmj.com/ on June 30, 2015 - Published by group.bmj.com

Original article

11 Timpka T, Finch CF, Goulet C, et al. Meeting the global demand of sports safety: 35 Fuller CW, Molloy MG, Bagate C, et al. Consensus statement on injury definitions
the intersection of science and policy in sports safety. Sports Med. and data collection procedures for studies of injuries in rugby union. Clin J Sport
2008;38:795–805. Med 2007;17:177–81.
12 D’Souza D. Track and field athletics injuries—a one-year survey. Br J Sport Med 36 Finch CF. An overview of some definitional issues for sports injury surveillance.
1994;28:197–202. Sports Med 1997;24:157–63.
13 Orava S, Puranen J. Exertion injuries in adolescent athletes. Br J Sport Med 37 Bahr R. No injuries, but plenty of pain? On the methodology for recording overuse
1978;12:4–10. symptoms in sports. Br J Sport Med 2009;43:966–72.
14 Rebella GS, Edwards JO, Greene JJ, et al. A prospective study of injury patterns in 38 Murphy DF, Connolly DA, Beynnon BD. Risk factors for lower extremity injury:
high school pole vaulters. Am J Sport Med 2008;36:913–20. a review of the literature. Br J Sport Med 2003;37:13–29.
15 Finch CF. Implementation and dissemination research: the time has come! Br J 39 Emery CA, Meeuwisse WH, Hartmann SE. Evaluation of risk factors for injury in
Sport Med 2011;45:763–4. adolescent soccer: implementation and validation of an injury surveillance system.
16 Edouard P, Morel N. Suivi prospectif des blessures en athlétisme. Étude pilote sur Am J Sport Med 2005;33:1882–91.
deux clubs durant une saison. Sci Sports 2010;25:272–6. 40 Hagglund M, Walden M, Ekstrand J. Previous injury as a risk factor for injury in elite
17 Jacobsson J, Timpka T, Ekberg J, et al. Design of a protocol for large-scale football: a prospective study over two consecutive seasons. Br J Sport Med
epidemiological studies in individual sports: the Swedish Athletics injury study. Br J 2006;40:767–72.
Sport Med 2010;44:1106–11. 41 Hjelm N, Werner S, Renstrom P. Injury risk factors in junior tennis players:
18 Hauret KG, Jones BH, Bullock SH, et al. Musculoskeletal injuries description of an a prospective 2-year study. Scand J Med Sci Sports 2012;22:40–8.
under-recognized injury problem among military personnel. Am J Prev Med 2010;38 42 Wilson F, Gissane C, Gormley J, et al. A 12-month prospective cohort study of
(1 Suppl):S61–70. injury in international rowers. Br J Sport Med 2010;44:207–14.
19 Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and 43 Vleck VE, Bentley DJ, Millet GP, et al. Triathlon event distance specialization:
data collection procedures in studies of football (soccer) injuries. Br J Sport Med training and injury effects. J Strength Cond Res 2010;24:30–6.
2006;40:193–201. 44 Caine D, Maffulli N, Caine C. Epidemiology of injury in child and adolescent sports:
20 Foster C, Florhaug JA, Franklin J, et al. A new approach to monitoring exercise injury rates, risk factors, and prevention. Clin Sports Med 2008;27:19–50, vii.
training. J Strength Cond Res 2001;15:109–15. 45 White PE, Finch CF, Dennis R, et al. Understanding perceptions of injury risk
21 Pluim BM, Fuller CW, Batt ME, et al. Consensus statement on epidemiological associated with playing junior cricket. J Sci Med Sport 2011;14:115–20.
studies of medical conditions in tennis, April 2009. Br J Sport Med 2009; 46 Morrongiello BA, Rennie H. Why do boys engage in more risk taking than girls?
43:893–7. The role of attributions, beliefs, and risk appraisals. J Ped Psychol 1998;23:33–43.
22 Hamilton GM, Meeuwisse WH, Emery CA, et al. Subsequent injury definition, 47 Cook JF, Finch CF. The long-term impact of overuse injuries on life-long
classification, and consequence. Clin J Sport Med 2011;21:508–14. participation in sport and health status. In: Farelli AD,. Sports participation.
23 Rauh MJ, Macera CA, Ji M, et al. Subsequent injury patterns in girls’ high school New York: Nova Science Publishers, Inc, 2011:85–104.
sports. J Athl Train 2007;42:486–94. 48 McBain K, Shrier I, Shultz R, et al. Prevention of sport injury II: a systematic review
24 Steffen K, Engebretsen L. More data needed on injury risk among young elite of clinical science research. Br J Sport Med 2012;46:174–9.
athletes. Br J Sport Med 2010;44:485–9. 49 Holmich P, Nyvold P, Larsen K. Continued significant effect of physical training as
25 Orava S, Saarela J. Exertion injuries to young athletes: a follow-up research of treatment for overuse injury: 8- to 12-year outcome of a randomized clinical trial.
orthopaedic problems of young track and field athletes. Am J Sport Med Am J Sport Med 2011;39:2447–51.
1978;6:68–74. 50 Borresen J, Lambert MI. The quantification of training load, the training response
26 Watson MD, DiMartino PP. Incidence of injuries in high school track and field and the effect on performance. Sports Med 2009;39:779–95.
athletes and its relation to performance ability. Am J Sport Med 1987;15:251–4. 51 Ristolainen L, Heinonen A, Turunen H, et al. Type of sport is related to injury
27 Knowles SB. Is there an injury epidemic in girls’ sports? Br J Sport Med profile: a study on cross country skiers, swimmers, long-distance runners and soccer
2010;44:38–44. players. A retrospective 12-month study. Scand J Med Sci Sports 2010;20:384–93.
28 Malliaropoulos N, Isinkaye T, Tsitas K, et al. Reinjury after acute posterior thigh 52 Backe S, Ericson L, Janson S, et al. Rock climbing injury rates and associated risk
muscle injuries in elite track and field athletes. Am J Sport Med 2011;39:304–10. factors in a general climbing population. Scand J Med Sci Sports 2009;19:850–6.
29 Bennell KL, Malcolm SA, Thomas SA, et al. The incidence and distribution of stress 53 Bradshaw L, Harris-Roberts J, Bowen J, et al. Self-reported work-related symptoms
fractures in competitive track and field athletes. A twelve-month prospective study. in hairdressers. Occup Med (Lond) 2011;61:328–34.
Am J Sport Med 1996;24:211–17. 54 Walker-Bone K, Palmer KT, Reading I, et al. Occupation and epicondylitis: a
30 Major NM, Helms CA. Sacral stress fractures in long-distance runners. AJR Am J population-based study. Rheumatology (Oxford) 2012;51:305–10.
Roentgenol 2000;174:727–9. 55 Saw R, Dennis RJ, Bentley D, et al. Throwing workload and injury risk in elite
31 Fuller CW, Bahr R, Dick RW, et al. A framework for recording recurrences, reinjuries, cricketers. Br J Sport Med 2011;45:805–8.
and exacerbations in injury surveillance. Clin J Sport Med 2007;17:197–200. 56 Dennis R, Farhart P, Goumas C, et al. Bowling workload and the risk of injury in
32 Rauh MJ, Margherita AJ, Rice SG, et al. High school cross country running injuries: elite cricket fast bowlers. J Sci Med Sport 2003;6:359–67.
a longitudinal study. Clin J Sport Med 2000;10:110–16. 57 Gabbett TJ, Ullah S. Relationship between running loads and soft-tissue injury in
33 Meeuwisse WH, Tyreman H, Hagel B, et al. A dynamic model of etiology in sport elite team sport athletes. J Strength Cond Res 2012;26:953–60.
injury: the recursive nature of risk and causation. Clin J Sport Med 58 Gabbett TJ. Reductions in pre-season training loads reduce training injury rates in
2007;17:215–19. rugby league players. Br J Sport Med 2004;38:743–9.
34 Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and 59 Knudsen AK, Hotopf M, Skogen JC, et al. The health status of nonparticipants in a
data collection procedures in studies of football (soccer) injuries. Clin J Sport Med population-based health study: the Hordaland Health Study. Am J Epidemiol
2006;16:97–106. 2010;172:1306–14.

Jacobsson J, et al. Br J Sports Med 2013;47:941–952. doi:10.1136/bjsports-2013-092676 13 of 13

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Injury patterns in Swedish elite athletics:

annual incidence, injury types and risk
factors
Jenny Jacobsson, Toomas Timpka, Jan Kowalski, Sverker Nilsson,
Joakim Ekberg, Örjan Dahlström and Per A Renström

Br J Sports Med 2013 47: 941-952 originally published online March 29,
2013
doi: 10.1136/bjsports-2012-091651

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References This article cites 58 articles, 32 of which you can access for free at:
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