Epidemiology of Injuries in Racquet Sports: a Cross-sectional Study of Specific Injuries Within One Olympic Cycle

doi:10.21203/rs.3.rs-5235000/v1

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Epidemiology of Injuries in Racquet Sports: a Cross-sectional Study of Specific Injuries Within One Olympic Cycle

https://doi.org/10.21203/rs.3.rs-5235000/v1

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Objective

Despite the growing interest in racquet sports, injury prevalence, circumstances and severity as a function of gender, performance level and return to play have not been investigated to date. The aim was therefore to evaluate the occurrence of sport-specific injuries from a quantitative and qualitative perspective in the Olympic discilines Tennis, Badminton and Table Tennis.

Methods

Racquet sport-specific injuries and frequencies were assessed according to gender and performance level in one Olympic cycle (from the Olympic Games in London in 2012 until Rio de Janeiro in 2016). The Injury severity was recorded by time loss and performance reduction. Data was retrospectively collected based on a questionnaire.

Results

A total of 390 (55%) athletes have suffered a serious injury. There were more injuries during training than competition. 78% of the three most common injuries in the various racket sports involved the lower extremities. The longest injury time loss was seen in Tennis for an unspecified injury of the shoulder (16±12 weeks), in Badminton for the foot-ligament injury (13±14 weeks) and the meniscus injury of the knee in table tennis (13±10 weeks). The injuries to the knee accounted for the highest number of athletes with a reduced level of performance (Badminton: Knee - unspecified injury: reduced level = 64%; Table tennis: Knee - meniscus injury: reduced level = 54%)

Conclusion

Although recognized as one entity of racquet sports with some similar trends in terms of injuries, there are some relevant differences in injury type, circumstances and consequences, which should be considered in future sport-specific injury prevention strategies.

Olympic

Elite

Athletes

Extremities

Injuries

Muscle

Cartilage

Ankle

Shoulder

down time

performance reduction

Racquet sports like Tennis, Badminton and Table Tennis are competitive Olympic disciplines and gained increasing popularity since the last decade. Despite growing interest in racquet sport, injury prevalence, injury circumstances and severity with reference to gender, level of performance and return to play have not been epidemiologically investigated, yet. Surprisingly for racquet sports, in which motor skills and visual perception is executed with an emphasis on the upper body part, injuries are predominantly located in the lower extremity¹. Acute accidents occur in the ankle joint, followed by injuries of the upper extremity which tend to be more of a chronic nature ^2–4, as the lateral epicondylitis or known as “tennis elbow” or chronic shoulder instabilities and arthorisis⁵. Further, there are rapid multidirectional acceleration and deceleration movements seen in racket sports, making some anatomic regions, as the knee, more prone to injuries⁶

As with many other sports, the literature presents conflicting data regarding training-related versus competition-related injuries, often due to missing or inconclusive injury data or difficult assessment of overuse injuries. ⁷. Beside overlapping injury pattern with other non-contact sports, there are some unique considerations to Racquet sports, such as the impact of the different court surfaces played on ⁸. Despite a shared preponderance of musculotendinous injuries ⁹ and the biomechanical and kinetic commonalities, there are sport-specific movement characteristics such as repetitive rapid jumps and lunges with an excessive load on lower extremity seen in Badminton¹⁰. Further long-term associations take place in the context of the injured body region and the affected structure, which are associated with consequences such as downtime and delayed regain of performance or permanently reduced performance.

In professional tennis, injuries to the knee and shoulder seem to be the most severe considering time loss from competition ¹¹, often requiring a surgical treatment with the inability to return to previous performance level ¹². Although considered as low risk sports ⁹ table tennis, badminton and tennis were listed among the sports with the longest downtime rates after injury in the London summer Olympic Games 2012 ⁷. Return-to-play is mainly determined by injury severity and level of play with some injuries, mostly acute ones, resulting in withdrawal from competition ⁸.

The aim of this study is to examine the prevalence and consequences of severe injuries among Racket sports disciplines in competitive and recreational athletes with respect to time loss from sport and reduction in sporting performance across genders, level of performance and affected body region. Long term data of 5 year were collected. The results of this study could provide a better understanding for injuries unique to Racquet sports athletes as further tailored prevention programs are needed.

Study design

A survey was designed to retrospectively analyze the self-reported injury prevalence in one Olympic cycle from the Summer Olympic Games in London in 2012 to Rio de Janeiro in 2016. An injury was defined by causing a break in training or competition for > 3 weeks, in accordance with the definition established by Olsen et al.¹³. All injuries were self-documented. To differentiate between the injuries with reference to anatomic, injuries have been clustered in subgroups distinguished by the body region (1) head, (2) upper limb without shoulder (ws), (3) shoulder, (4) front torso, (5) back, (6) lower limb without knee (wk) and (7) knee. They have been also clustered by the damaged structure (ligament rupture, cartilage damage, tendon injury, and bone fracture).

Ethics approval has been received by the Ethical committee of the University of Witten/Herdecke. At the beginning of the questionnaire the athletes were informed about the anonymous use of the data for scientific purposes and asked to confirm their consent. Only Athletes who confirmed their consent were included in the study. The authors used the “Declaration of Helsinki ethical principles for medical research involving human subjects” as standards.

Data collection

Injury characteristics of scientific relevance were assessed by a three section, 139-item questionnaire^14,15. The German Olympic Federation and associated international sports federations published the survey and sent it via e-mail to their members, encouraging athletes to participate.

Section one contained questions on the individual competitive level of athletes clustered into five performance classes: international elite, international, national, regional or recreational, marking the highest level at which athletes had competed in their career ¹⁵.

Section two contained questions about the athletes’ injuries. The athletes were asked to report only major injury that resulted in a time loss of > 3 weeks ¹⁶. In cases of positive answers an athlete specified the injury type, the affected anatomical region and damaged structure. For each injury, the age (years) when the injury occurred, the duration of time loss (weeks) and the level of performance following the return to sport (same or reduced) were assessed ¹⁵.

Section three collected data on anthropometry, age when completing the survey and gender.

Study population

A total of 709 individuals participated in the survey. The exclusion criterion was an incomplete questionnaire. An age <18 years Athletes classified as competing as international or national elite were pooled into the ‘competitive sports’ category. Athletes classified as competing in recreational sports were grouped into the ‘recreational sports’ category.

Only specific injuries with more than three events were analyzed with regard to time loss in sport and reduction of sporting performance. Only injuries or injuryconcerning questions with ten or more responses were included in the analysis.

Statistical analysis

We used SPSS 25.0 (SPSS, Inc, Chicago, Illinois, USA) for the statistical analyses encompassing descriptive statistics and significance tests. To compare injury prevalence throughout the Olympic cycle (2012–2016), we used χ² tests. To analyze the top eight injury diagnoses and the discipline-specific top three diagnoses, between disciplines, gender, competitive or recreational athletes, and whether they occurred during training or competition, as well as the performance after the injury, we calculated χ² tests. Since the duration of sporting time loss in weeks is a non-normal, interval scales variable, we computed Mann-Whitney-U tests (gender and competitive level) or Kruskal-Wallis tests for a comparison of the duration of sporting time loss between the top eight diagnoses.

P-values < 0.05 were considered to be statistically significant.

A total of 390 (55%) athletes reported to have suffered a serious injury in the time period of the Olympic Games in London in 2012 until the Olympic Games in Rio de Janeiro in 2016. In Badminton (62% ; n=203) athletes reported significantly more injuries than in Tennis (50% ; n=91) and Table tennis (47% ; n=96) (p>0.001).

Top 10 ranking of injuries and top three ranking of injuries differentiated by sports

Among all racket sports and genders the ligament injuries of the upper ankle (n=66) and the foot (n=65) showed the highest prevalence. In the top 10 ranking eight of ten injuries occurred in the lower extremities. For the upper extremities, the unspecified shoulder injury (n=57) and the muscle injury of the elbow (n=20) where the only two injuries in the top 10 ranked injuries.

Regarding the top three injuries in the different racket sports discipline seven (78%) of the nine injuries occurred in the lower limb region. Ligament injuries to the foot or the upper ankle joint were ranked in the top three ranking equally for Badminton, Tennis and Table tennis. (Badminton: Upper ankle joint- ligament injury= 14% ; n=45 ; Foot- ligament injury= 13% ; n=44) (Tennis: Foot – ligament injury= 8% ; n=12) (Table tennis: Upper ankle joint- ligament injury= 7% ; n=11) (Table 1).

Prevalence of the top three injuries during training and competition

The occurrence of the top three injuries during training and competition varied between the sports. In Badminton a higher prevalence in training of the top three injuries was reported (Badminton: training injuries: Upper ankle joint- ligament injury= 51% ; n=23 ; Foot- ligament injury= 57% ; n=25 ; Knee- unspecified injury= 73% ; n=8). In Tennis and Table tennis the athletes reported a higher prevalence of injuries during competition (Tennis: competition injuries: Fibula- muscle injury= 58% ; n=11 ; Foot- ligament injury= 58% ; n=7) (Table tennis competition injuries: Knee- meniscus injury= 64% ; n=9). There were no significant differences regarding the genders and the competitive level of athletes (Figure 1).

Duration of sporting time loss

All injuries in the top three ranking showed a time loss of less than 15 weeks. The longest time loss after injury was documented in Tennis for an unspecified injury of the shoulder (16 weeks). The foot-ligament injury accounted for the longest time loss in Badminton (13 weeks) and the meniscus injury of the knee in Table tennis (13 weeks). The injury with the shortest time loss in sporting activity was the fibula- muscle injury in tennis (5 weeks). Comparing the duration of time loss, there were no significant difference regarding the genders and the competitive level of athletes (Figure 2).

Reduction of performance

The injuries to the knee accounted for the highest number of athletes with a reduced level of performance (Badminton: Knee- unspecified injury: reduced level=64%; Table tennis: Knee- meniscus injury: reduced level=54%). Three injuries in top ranking showed numbers of over 70% with the same level of performance after injury (Badminton: Upper ankle joint- ligament injury=78% ; Tennis: Fibula- muscle injury=74% ; Table tennis: Upper ankle joint- ligament injury=70%). There was no significant difference regarding the genders and the competitive level of athletes comparing the reduction of performance after injury (Figure 3).

Olympic cycle, this study provides an important insight into lost time, injury severity and the impact of gender and level of competition, differentiated by racquet sport, with the following key findings.

Top ranking of injuries differentiated by sports

The data in literature is unanimous: most injuries in Racket Sports occur to the lower limb ^4,9,11,17, followed by the upper extremity and the trunk ^2,18. Injuries to the upper ankle joint, as ankle sprains, are considered to be the most common acute injuries ^2,18,19 which is consistent with our findings. In a study analyzing injuries in Hong Kong elite badminton players injuries to the shoulder and knee were the most common types²⁰. ondric found a preponderance of shoulder injuries among top Slovenian racket sports athletes, with the highest incidence in table tennis, where the vulnerability of the shoulder complex is due to short and abrupt multiplanar movements ²¹. With the highest incidence in tennis, Kondric found the ankle and foot to be the second most injured anatomic part in racket sports, which can be explained by a poor local muscle support and stabilization highlighting the need for good footwear²¹. The lower limb biomechanics and the different pattern of footwork generate high plantar and joint forces also in table tennis ²² leading to ankle sprains²³ as well as chronic conditions as plantar fasciitis⁵, the jumper’s knee or knee osteoarthritis ⁶. Also in badminton players repetitive loading to the patellar tendon, as seen in lunges, is associated with high intra-tendinous flow and the onset of the jumper’s knee²⁴.

Duration of sporting time loss

Although underrepresented, injuries to the shoulder result in the longest time loss rates. In the literature, injuries to the upper extremities are often referred to as overuse injuries ^2,4,18. In a study of Young et al., only 25% of professional tennis players came back to their pre-injury level with a mean return to play time of 7 months after a shoulder surgery ¹². Kaldau et al. reported a lasting limitation in 50% of elite badminton players by significant injury with a mean time loss of 90 days²⁵. Thereby, scientific evidence underpins a direct link between match and training load and number of injuries as well as the consequent time loss¹¹

Reduction of performance

Knee injuries in racquet sports are inevitable and are responsible for a significant drop in performance. Inadequate warm-up is recognized as a primary injury factor, and a large number of athletes require surgical intervention in the form of knee arthroscopy, with meniscal injuries being the most common cause ²⁶. Powell et al. described a comparable performance achievement as prior to the injury although knee injuries are most often documented as severe injuries ¹¹. We have observed a remarkable reduction in performance of more than 50% in table tennis players with knee meniscus injuries, which is a cause for concern.

Prevalence of the top three injuries during training and competition

There is evidence that more injuries occur in racket sports during competition than during training. In contrast, our study shows a higher prevalence of training injuries in badminton. This is in line with the findings of Phomsoupha et al ²⁷, mentioning the highest injury frequency at the end of training which could be related to muscle fatigue as a result of repetitive jumps and multidirectional stop-and-go maneuvers. Herbaut and Delannoy found an increased risk of ankle sprains due to fatigue in badminton players ²⁸.

However, contradictory findings exist an refer to more competition-related injuries in their study ²⁹. Considering the US Open Tennis Championships between 1994 and 2009, Sell et al. reported more competition related injuries. However, it is mentioned by the authors that injuries which did not occur during match play were not generally collected by the medical staff and included in the study ¹⁹. McCurdie et al. analyzed the injury data of the Wimbledon tournaments from 2003-2012 pointing out an onset of 61% of injuries prior to the arrival to the Championships shedding light on the importance of injury prevention during a professional tennis season ¹⁷. Other authors described higher training related injuries for tennis ¹⁸ or badminton²⁰. Table tennis presents the lowest injury rates, compared to tennis and badminton³⁰.

Limitations:

As the data in the following study is based on retrospective documentation and self-reporting by athletes, there may be an over- or under-reporting of injuries, which should be considered as one of the main limitations. In addition, discrepancies or misstatements in injury rates may be due to the fact that injuries are reported at a selected point in time and not consecutively among the entire season ¹¹. In our study, no direct distinction was made between acute and overuse injuries, which may be a reasonable distinction based on literature.

Prospect

Assessment of time loss and performance reduction following injury in racquet sports shows discipline-specific injury patterns, with shoulder, knee and foot injuries causing the highest loss of performance and calcium. This study points to the importance of training injuries and emphasizes the need for future research on this topic to adapt training management and improve medical care and rehabilitation in all sports.

Description of Author Contributions

CL, SS, CG and BW were involved in the acquisition of data. CL, RR, NR, DL and MG were involved in the interpretation and analysis of the data and editing of the manuscript. CL, RR, NR, NP, MG, SS, CG, BW and MB drafted the original manuscript. CL and SS conceived and designed the original project. All authors read and approved the final manuscript.

CL and MB share the first authorship.

Funding

Open Access funding enabled and organized by Projekt DEAL. There was no funding for this study.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

Participants provided informed consent, and the study was approved by the Ethics Committee of the University of Witten/Herdecke.

Consent for publication

Participants provided informed consent.

Competing interests

The authors declare that they have no competing interests.

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Table 1 is available in the Supplementary Files section.

No competing interests reported.

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Epidemiology of Injuries in Racquet Sports: a Cross-sectional Study of Specific Injuries Within One Olympic Cycle

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