Injuries in Team Sport Tournaments During
the 2004 Olympic Games
Astrid Junge,*† PhD, Gijs Langevoort,‡ MD, Andrew Pipe,§ MD, Dip Sport Med, FACSM,
||
¶
#
Annie Peytavin, MD, MBA, Fook Wong, MD, Margo Mountjoy, MD, CCFP, FCFP, Dip Sport Med,
††
||
Gianfranco Beltrami,** MD, Robert Terrell, MD, Manfred Holzgraefe, MD, PhD,
‡‡
†‡‡
Richard Charles, and Jiri Dvorak, MD
†
From the Fédération International de Football Association–Medical Assessment and Research
‡
Centre, Zurich, Switzerland, the International Handball Federation, Basle, Switzerland, the
§
International Basketball Federation, Geneva, Switzerland, the ||International Volleyball
¶
Federation, Lausanne, Switzerland, the International Hockey Federation, Lausanne,
#
Switzerland, the Fédération International de Natation, Lausanne, Switzerland, the
††
**International Baseball Federation, Lausanne, Switzerland, the International Softball
‡‡
Federation, Plant City, Florida, the Fédération International de Football Association,
Zurich, Switzerland, and the International Olympic Committee, Lausanne, Switzerland
Background: Several authors have analyzed the incidence of injuries in a given sport, but only a few have examined the
exposure-related incidence of injuries in different types of sports using the same methodology.
Purpose: Analysis of the incidence, circumstances, and characteristics of injuries in different team sports during the 2004
Olympic Games.
Study Design: Cohort study; Level of evidence, 2.
Methods: During the 2004 Olympic Games, injuries in 14 team sport tournaments (men’s and women’s soccer, men’s and
women’s handball, men’s and women’s basketball, men’s and women’s field hockey, baseball, softball, men’s and women’s water
polo, and men’s and women’s volleyball) were analyzed. After each match, the physician of the participating teams or the official
medical representative of the sport completed a standardized injury report form. The mean response rate was 93%.
Results: A total of 377 injuries were reported from 456 matches, an incidence of 0.8 injuries per match (95% confidence interval, 0.75-0.91) or 54 injuries per 1000 player matches (95% confidence interval, 49-60). Half of all injuries affected the lower
extremity; 24% involved the head or neck. The most prevalent diagnoses were head contusion and ankle sprain. On average,
78% of injuries were caused by contact with another player. However, a significantly higher percentage of noncontact (57%) versus contact injuries (37%) was expected to prevent the player from participating in his or her sport. Significantly more injuries in male
players (46%) versus female players (35%) were expected to result in absence from match or training. The incidence, diagnosis, and
causes of injuries differed substantially between the team sports.
Conclusion: The risk of injury in different team sports can be compared using standardized methodology. Even if the incidence
and characteristics of injuries are not identical in all sports, prevention of injury and promotion of fair play are relevant topics for
almost all team sports.
Keywords: team sports; athletic injury; incidence rate; Olympic Games; injury-reporting system
Major sports tournaments, such as the Olympic Games,
are popular events and a source of entertainment for the
spectators. However, they are associated with a certain
risk of injury for the participating players or athletes.
Several authors have analyzed the incidence of injuries in
a given type of sport, but the results of these studies cannot
be compared with one another because of heterogeneous
injury definitions, methods of data collection, observation
*Address correspondence to Astrid Junge, PhD, Schulthess Clinic,
Lengghalde 2, CH-8008 Zurich, Switzerland.
No potential conflict of interest declared.
The American Journal of Sports Medicine, Vol. 34, No. 4
DOI: 10.1177/0363546505281807
© 2006 American Orthopaedic Society for Sports Medicine
565
566
Junge et al
periods, study designs, and sample characteristics.17,26,48 As
long as no consensus on a standardized assessment of sport
injury is approved by the scientific community and the
sports federations, the incidence and characteristics of
injuries in different types of sport can best be compared
within one study. In reviewing the literature on sports
injuries, we found only a few studies in which exposurerelated incidences of injury in different types of sport were
compared using the same methods.5,10,11,25,38,52 Although all of
these studies focus on injuries during a season, Cunningham
and Cunningham9 surveyed the incidence of injuries during
the 1994 Australian University Games, a multisport event
featuring 5106 participants competing in 19 sports. The
great advantages of conducting a comparative study during
a sports tournament are that multiple sports with the players of a comparable skill level can be included and that the
study period is defined by the event. Furthermore, in a topclass international tournament, a high standard of environmental factors, such as the quality of the playing fields and
equipment, is guaranteed.
To the best of our knowledge, no study has ever compared
the exposure-related incidences and characteristics of
injuries of elite athletes in different types of sports during a
major international tournament. Therefore, the aim of the
present study was to analyze and compare the incidence,
characteristics, and causes of injuries in all team sport tournaments (soccer, handball, basketball, field hockey, baseball,
softball, water polo, volleyball, and beach volleyball) during
the 2004 Olympic Games.
The American Journal of Sports Medicine
Federation, the International Basketball Federation, the
International Hockey Federation, the International Baseball
Federation, the International Softball Federation, the
Fédération International de Natation, and the International
Volleyball Federation agreed to participate in the present
study under the leadership of the Medical Assessment and
Research Centre of the Fédération International de Football
Association (F-MARC). The medical representative of each
international team sports federation (IF) informed the physicians of their teams that were participating in the 2004
Olympic Games about the study and instructed them in how
to complete the injury report forms. For each match, the
physicians of both teams were instructed to return the completed form of their team to the medical representative of
their IF. In some team sports in which not all teams had a
team physician, the IF medical representatives (all physicians experienced in sports medicine) were present at all
matches, asked the players about injuries incurred during
the match, examined the injured players, and completed the
injury report forms (basketball, softball, and partly volleyball). The IF medical representatives forwarded the injury
report forms to the study center of F-MARC for analysis.
Confidentiality of all information was ensured.
All team sports, except beach volleyball, followed the
methodology of the study. In beach volleyball, players were
not supported by a team doctor, so the medical representative of the International Volleyball Federation reported
2 injuries and the exact exposure time via e-mail. Because
of the deviating reporting system and the small size of the
teams, beach volleyball was excluded from the analysis.
METHODS
Calculation of Incidence and Statistical Analysis
The injury-reporting system applied in the present study
was developed for the documentation of injuries during
team sport tournaments and has been implemented as a
matter of routine in more than 20 international soccer and
handball tournaments.27-29,53
The injury report form comprised a single page on which
all injuries during a given match or, where applicable, the
nonoccurrence of injury were to be described in tabular form
(see Appendix, available in the online version of this article
at http://ajsm.sagepub.com/cgi/content/full/34/4/565/DC1).28
An injury was defined as any physical complaint incurred
during the match that received medical attention from the
team physician, regardless of the consequences with respect
to absence from the match or training. For all injuries, the
following information was to be documented: shirt number
of the injured player, minutes in the match, injured body
part and type of injury, circumstances (noncontact, contact,
foul play), and consequences of injury (referee’s sanction,
treatment, time-loss in sport). Because follow-up was not
possible, the physicians were asked to state an estimate of
the duration of the player’s likely absence from training
and/or matches as a result of the injury. The injury report
form was identical for all team sports, except for the indication of the relevant sport, and for volleyball, the questions
regarding foul play and referee’s sanction were removed.
During a pretournament instructional meeting, the
medical representatives of the International Handball
The incidence of injury was expressed as (1) number of
injuries per match, (2) number of injuries per 1000 player
matches, and (3) number of injuries per 1000 player hours.
The rates were calculated as follows: (1) number of injuries
divided by number of matches documented, (2) number of
injuries multiplied by 1000 and divided by number of
matches documented and by number of players per match,
and (3) number of injuries multiplied by 1000 and divided
by number of matches documented, number of players per
match, and duration of a match in hours.28
The statistical methods applied were frequencies, crosstabulations, descriptive statistics, and χ2 tests. For incidence
rates, 95% confidence intervals (CI) were calculated according to the following formula: 95% CI = incidence ± 1.96 ×
(incidence/square root [number of incidents]). Significance
was accepted at the 5% level.
Tournaments
All details concerning the number of teams and players
participating in the 2004 Olympic Games in Athens, Greece,
and the most important characteristics of the team sports,
such as number of players, duration of a match, and rules
of the game are available at www.athens2004.com. All
sports are also described in detail on the Web site of the
respective international federations.
Vol. 34, No. 4, 2006
Injuries in 8 team sports (soccer, handball, basketball,
field hockey, baseball, softball, water polo, and volleyball)
were surveyed during the 2004 Olympic Games in Athens.
In most of the team sports, tournaments of male and female
players took place. Baseball was played by male players
only, and softball was played by female players only. The
14 tournaments varied in the number of matches (range,
20-44 matches) and comprised a total of 488 matches,
equivalent to 7476 player matches.
RESULTS
From the 14 tournaments, 911 injury report forms, covering 6953 player matches, were completed and returned to
F-MARC for analysis. The mean response rate was 93%.
The response rate was lowest for field hockey (73%); for
all other tournaments, the response rate ranged between
91% and 100% (Table 1).
A total of 377 injuries were reported from 456 matches,
which is equivalent to an incidence of 0.8 injuries per match
(95% CI, 0.75-0.91) or 54 injuries per 1000 player matches
(95% CI, 49-60). Half of all injuries affected the lower
extremity, and 24% involved the head or neck. Injuries of the
upper extremity (17%) or the trunk (9%) were less numerous. The most frequently injured body part was the head
(n = 78, 21%), followed by the ankle (n = 49, 13%) and the
knee (n = 47, 13%). Almost half of the injuries (n = 171, 46%)
were diagnosed as contusions. Sprains (n = 48, 13%) and
strains/muscle fiber ruptures (n = 35, 10%) were also frequent. Seventeen injuries were diagnosed as fractures;
17 were diagnosed as ligament ruptures; 8, as dislocations;
7, as concussions; and 4, as lesions of the meniscus. The diagnoses of injuries covered a wide spectrum and are described
in more detail in Table 2 and in relation to the different types
of sports (see below). The most frequent diagnoses were contusion of the head (n = 35) and ankle sprain (n = 29). The
majority of injuries (n = 280, 78%) were incurred during contact with another player, and more than half of these injuries
(54%, 134 of 249) were caused by foul play, as rated by the
team physician. However, a significantly (P < .01) higher percentage of noncontact (57%) versus contact injuries (37%)
was expected to result in absence from match or training.
Information in relation to time-loss from sport after
injury was available for 347 (92%) injuries. One hundred
forty-five injuries (42%) were expected to prevent the
player from participating in match or training. The incidence of time-loss injuries was 0.32 per match (95% CI,
0.27-0.37) or 21 per 1000 player matches (95% CI, 17.624.4). Time-loss injuries most frequently affected the ankle
(n = 29, 20%), followed by the knee (n = 19, 13%), thigh
(n = 17, 12%), and head (n = 15, 10%). The most prevalent
diagnoses were sprain (n = 18) or ligament rupture of the
ankle (n = 9) and contusion of the thigh (n = 10). The physicians’ estimate was that 92 injuries (29%) would result in
an absence from sports for up to 1 week and that 27 injuries
(8%) would result in an absence for more than 1 week. The
14 injuries with an anticipated duration of more than
4 weeks absence from sport were 8 fractures, 1 dislocation
of the shoulder, 4 ligament ruptures of the knee, 1 rupture
Team Sport Injuries During the 2004 Olympic Games
567
of the knee meniscus, and 1 ligament rupture of the ankle.
For 26 time-loss injuries, no estimate of the duration of
absence was reported. The most severe diagnoses of these
injuries were fracture (nose [n = 2], elbow [n = 1], and foot
[n = 1]), subluxation of the shoulder (n = 1), ligament rupture of the knee (n = 2), and lesion of the meniscus (n = 2).
The incidence of injuries per 1000 player matches was
only slightly higher in men than in women. But significantly
more injuries of male players than of female players were
expected to result in absence from a match or training (46%
vs 35%, P < .05). Thus, the incidence of time-loss injuries per
1000 player matches was substantially higher in male players (24.7; 95% CI, 19.8-29.6) than in female players (15.9;
95% CI, 11.4-20.4). Overall, location and circumstances of
injuries were similar in men and women. However, the types
of injuries differed significantly (P < .05) between the
groups, with more concussions (4% vs 0.5%) and sprains
(19% vs 9%) and fewer fractures (3% vs 6%) and lacerations (5% vs 11%) in female players than in male players.
Substantial differences in the incidence, characteristics, and
causes of injuries were observed in relation to the different
types of sports.
Soccer
From 52 soccer matches (response rate, 99%), a total of 122
injuries were reported, which is equivalent to an incidence
of 2.4 injuries per match (95% CI, 2.0-2.8) or 108 per 1000
player matches (95% CI, 89-127). The majority of injuries
affected the lower extremity (70%), followed by the head
(14%), upper extremity (8%), and trunk (7%). The most frequent types of injuries were contusion (58%) and sprain
(16%). The most prevalent diagnoses were contusion of
the lower leg (n = 15), of the thigh (n = 11), and of the head
(n = 10). The great majority of injuries (83%) were caused by
contact with another player. More than half of the contact
injuries (59%, 55 of 93) were caused by foul play, as judged
by the team physician. Sixty-four percent (35 of 55) of the
injury situations rated by the team physician as involving
foul play were followed by a corresponding sanction from the
referee. Slightly fewer injuries occurred in the first half
(42%, 44 of 106) than in the second half of the match (58%).
An estimate of the anticipated duration of absence from
match or training after injury was available for 112 (92%)
injuries. More than half of the injuries (56%, 63 of 112) were
not expected to result in absence from match or training.
Forty-one injuries (37%) were expected to result in absence
from soccer for up to 1 week, 5 injuries were expected to
result in an absence of 8 to 28 days, and 3 injuries were
expected to result in an absence of more than 28 days (1 rupture of the knee meniscus and 2 fractures of the clavicle). The
most frequent diagnoses of time-loss injuries were contusion
of the thigh and of the lower leg (each n = 7), followed by
sprain of the ankle (n = 5) and of the knee (n = 4). The incidence of time-loss injuries was 44 per 1000 player matches
(95% CI, 32-56) or 1 per match (95% CI, 0.7-1.3). The incidence and location of injuries were similar in men and
women. However, the type of injuries differed significantly
(P < .01), with fewer contusions and lacerations and more
568
Junge et al
The American Journal of Sports Medicine
TABLE 1
Characteristics of Injuries in Team Sport Tournaments During the 2004 Olympic Gamesa
Tournament
No. of matches
Response rate
Player matches documented
Player hours documented
No. of injuries
Injuries per match
Injuries per 1000 player matches
Injuries per 1000 player hours
Circumstances
Noncontact injuries
Contact injuries
Contact injury caused by foul, as
judged by the team physician
Foul sanctioned by referee
Estimated duration of absence
0d
1-3 d
4-7 d
> 1 wk < 1 mo
> 1 mo
Not specified
Missing
Injuries
Injuries
Injuries
Injuries
with expected time-loss
per match
per 1000 player matches
per 1000 player hours
Tournament
No. of matches
Response rate
Player matches documented
Player hours documented
No. of injuries
Injuries per match
Injuries per 1000 player matches
Injuries per 1000 player hours
Circumstances
Noncontact injuries
Contact injuries
Contact injury caused by foul, as
judged by the team physician
Foul sanctioned by referee
Estimated duration of absence
0d
1-3 d
4-7 d
> 1 wk < 1 mo
> 1 mo
Not specified
Missing
Injuries
Injuries
Injuries
Injuries
with expected time-loss
per match
per 1000 player matches
per 1000 player hours
Men’s
Soccer
Women’s
Soccer
Men’s
Handball
Women’s
Handball
Men’s
Basketball
Women’s
Basketball
32
64 (100)
704
1056
20
39 (98)
429
643.5
44
79 (90)
553
553
33
64 (97)
448
448
42
84 (100)
420
280
42
84 (100)
420
280
77
2.4 (1.9-2.9)
109 (85-133)
73 (57-89)
45
2.3 (1.6-3.0)
105 (74-136)
70 (50-90)
49
1.2 (0.9-1.5)
89 (64-114)
89 (64-114)
65
2.0 (1.5-2.5)
145 (110-180)
145 (110-180)
27
0.6 (0.4-0.9)
64 (40-89)
96 (60-133)
28
0.7 (0.4-0.9)
67 (42-91)
100 (63-137)
11/76 (14)
65/76 (86)
41/61 (67)
9/42 (21)
33/42 (79)
14/32 (44)
4/48 (8)
44/48 (92)
18/36 (50)
12/63 (19)
51/63 (81)
34/44 (77)
6/26 (23)
20/26 (77)
4/20 (20)
11/28 (39)
17/28 (61)
2/16 (13)
27/41 (66)
8/14 (57)
10/16 (63)
25/34 (74)
2/4 (50)
0/2 (0)
41 (77)
7 (13)
3 (6)
0
2 (4)
4
8
15 (79)
1 (5)
0
1 (5)
2 (11)
8
0
18 (95)
0
0
0
1 (5)
9
0
16
0.5 (0.3-0.7)
36 (18-53)
36 (18-53)
12
0.3 (0.1-0.5)
29 (12-45)
43 (19-67)
10
0.2 (0.1-0.4)
24 (9-39)
36 (14-58)
42
23
3
2
2
(58)
(32)
(4)
(3)
(3)
1
4
31
1.0 (0.7-1.3)
44 (29-60)
29 (20-38)
21 (53)
10 (25)
5 (13)
3 (8)
1 (3)
0
5
19
1.0 (0.5-1.4)
44 (24-64)
30 (16-43)
21
16
1
3
1
(50)
(38)
(2)
(7)
(2)
1
6
22
0.6 (0.3-0.8)
40 (23-57)
40 (23-57)
Men’s Field
Hockey
Women’s Field
Hockey
Men’s
Baseball
Men’s
Water Polo
Men’s
Volleyball
42
60 (71)
660
770
29
43 (74)
473
552
32
62 (97)
558
44
82 (93)
574
268
38
76 (100)
456
36
1.2 (0.8-1.6)
55 (37-72)
47 (32-62)
8
0.4 (0.1-0.6)
17 (5-29)
14 (4-24)
16
0.5 (0.3-0.7)
29 (15-43)
17
0.4 (0.2-0.6)
30 (16-44)
63 (33-93)
5
0.1 (0.02-0.2)
11 (1.4-21)
13/34 (38)
21/34 (62)
6/12 (50)
1/7 (14)
6/7 (86)
12/15 (80)
3/15 (20)
1/2 (50)
0/16 (0)
16/16 (100)
11/16 (69)
3/5 (60)
3/10 (30)
16 (52)
10 (32)
4 (13)
0
1 (3)
1
4
6 (75)
2 (25)
0
0
0
0
0
9 (56)
2 (13)
1 (6)
3 (19)
1 (6)
0
0
10 (67)
1 (7)
1 (7)
1 (7)
2 (13)
0
2
16
0.5 (0.3-0.8)
24 (12-36)
21 (11-31)
2
0.1 (0-0.2)
4 (0-10)
4 (0-8.6)
7
0.2 (0.1-0.4)
13 (3.2-22)
5
0.1 (0-0.2)
9 (1.1-16.3)
19 (2.4-35)
2 (100)
2
1
4
0.1 (0-0.2)
9 (0.2-17)
(Continued)
Vol. 34, No. 4, 2006
Team Sport Injuries During the 2004 Olympic Games
569
TABLE 1
(Continued)
Tournament
Men’s
Soccer
Women’s
Soccer
Men’s
Handball
Women’s
Handball
Men’s
Basketball
Women’s
Basketball
Injured body part
Head, neck
Trunk
Shoulder
Arm, upper/lower
Elbow
Hand, including wrist, finger
Hip/groin
Thigh
Knee
Lower leg
Ankle
Foot/toe
Missing
11 (14)
6 (8)
3 (4)
0
1 (1)
1 (1)
4 (5)
13 (17)
12 (16)
14 (18)
9 (12)
3 (4)
0
7 (16)
4 (9)
3 (7)
0
0
0
1 (2)
7 (16)
5 (11)
6 (13)
9 (20)
3 (7)
0
15 (32)
2 (4)
4 (9)
2/— (4)
0
4 (9)
2 (4)
2 (4)
5 (11)
3 (6)
7 (15)
1 (2)
2
23 (35)
12 (18)
2 (3)
1/— (1.5)
2 (3)
2 (3)
1 (1.5)
4 (6)
10 (15)
3 (5)
5 (8)
0
0
4 (15)
0
1 (4)
1/— (4)
5 (19)
5 (19)
1 (4)
3 (11)
1 (4)
1 (4)
4 (15)
1 (4)
0
8 (29)
2 (7)
1 (4)
0
0
2 (7)
1 (4)
2 (7)
6 (21)
1 (4)
4 (14)
1 (4)
0
0
1 (1)
0
1 (1)
2 (4)
1 (2)
2 (4)
0
1 (2)
2 (4)
2 (4)
5 (11)
1 (1.6)
1 (1.6)
1 (1.6)
5 (8)
0
4 (15)
0
1 (4)
0
2 (7)
1 (4)
2 (7)
13 (29)
4 (9)
16 (36)
0
7 (16)
0
3 (7)
2 (4)
25 (54)
1 (2)
5 (11)
3
9 (14)
7 (11)
33 (52)
2 (3)
5 (8)
1
4 (15)
6 (22)
3 (11)
7 (26)
2 (7)
0
5
4
8
3
3
Type of injury
Concussion
Fracture
Dislocation
Tendon/ligament rupture,
meniscal lesion
Sprain
Strain/muscle fiber rupture
Contusion
Laceration/abrasion/blister
Others
Missing
Tournament
Injured body part
Head, neck
Trunk
Shoulder
Arm, upper/lower
Elbow
Hand, including wrist, finger
Hip/groin
Thigh
Knee
Lower leg
Ankle
Foot/toe
Missing
Type of injury
Concussion
Fracture
Dislocation
Tendon/ligament rupture,
meniscal lesion
Sprain
Strain/muscle fiber rupture
Contusion
Laceration/abrasion/blister
Others
Missing
a
7
5
55
3
5
(9)
(6)
(71)
(4)
(6)
0
(18)
(14)
(29)
(11)
(11)
0
Men’s Field
Hockey
Women’s Field
Hockey
Men’s
Baseball
Men’s
Water Polo
Men’s
Volleyball
8 (22)
3 (8)
1 (3)
1/2 (8)
1 (3)
2 (6)
0
3 (8)
8 (22)
1 (3)
5 (14)
1 (3)
0
4 (50)
1 (13)
0
0
0
2 (25)
0
0
0
0
1 (13)
0
0
0
0
1 (6)
4/— (25)
2 (13)
2 (13)
1 (6)
1 (6)
0
3 (19)
1 (6)
1 (6)
0
9 (53)
2 (12)
1 (6)
0
1 (6)
3 (18)
0
0
0
0
0
1 (6)
0
0
0
1 (20)
0
0
0
0
0
1 (20)
0
3 (60)
0
0
0
3 (8)
0
3 (8)
2 (25)
0
0
0
0
0
0
1 (6)
0
2 (12)
1 (6)
0
0
0
1 (20)
3 (60)
4 (11)
3 (8)
15 (42)
7 (19)
1 (3)
0
1 (13)
0
3 (38)
2 (25)
0
0
3
6
3
3
0
(19)
(38)
(19)
(19)
0
0
0
7 (41)
3 (18)
4 (24)
0
1 (20)
0
0
0
0
0
Data are presented as no. (%) or no. (95% confidence interval). Softball, women’s water polo, and women’s volleyball are not presented
because of the small number of injuries.
570
Junge et al
The American Journal of Sports Medicine
TABLE 2
Number and Diagnosis of Injuries in All 14 Team Sport Tournaments and in the
4 Types of Sport With the Highest Number of Injuries Reported
Total No. of Injuries
in All 8 Team Sports
Location and Diagnosis
Head/neck
Concussion
Fracture
Strain
Contusion
Laceration
Others
Not specified
Trunk
Fracture
Strain/muscle fiber rupture
Contusion
Others
Not specified
Shoulder
Fracture
Dislocation
Sprain/strain
Contusion
Arm, including elbow
Fracture
Strain
Contusion
Laceration
Others
Hand, including wrist
Fracture
Dislocation
Sprain/strain
Contusion
Laceration
Others
Hip
Strain
Contusion
Others
Groin
Strain
Contusion
Thigh
Strain/muscle fiber rupture
Contusion
Others
Knee
Ligament rupture
Lesion of meniscus
Sprain
Contusion
Laceration
Others
Not specified
Lower leg
Fracture
Strain/muscle fiber rupture
Contusion
All
90
7
6
4
41
14
16
2
32
2
6
19
4
1
18
2
5
4
7
23
1
1
14
4
3
23
3
2
4
9
2
3
4
1
2
1
8
5
3
35
10
22
3
48
6
4
13
18
5
1
1
33
1
3
21
Time-Loss
a
16
5
3
3a
5
2
1a
0a
9a
2
2a
4
1
0a
11
2
5
2
2
10
1
1
6
0
2
7
2
1
1
1
0
2
1a
0
1a
0
5
4
1
17a
5
10a
2
20a
5a
3
6a
5a
0
1a
0a
13
1
3
8
No. of All Injuries
Soccer
Handball
Basketball
Field Hockey
18
2
0
0
12
1
3
0
10
0
0
9
1
0
6
2
1
1
2
1
0
0
1
0
0
1
0
0
0
0
0
1
2
0
1
1
3
3
0
20
6
11
3
17
0
1
7
9
0
0
0
20
0
0
15
38
2
2
4
20
2
6
2
14
1
2
7
3
1
6
0
2
0
4
5
0
0
5
0
0
6
0
1
2
2
0
1
1
0
1
0
2
0
2
6
2
4
0
15
3
1
4
5
0
1
1
6
0
1
5
12
0
2
0
2
4
4
0
2
0
2
0
0
0
2
0
0
2
0
6
1
1
0
4
0
7
2
1
2
1
1
0
0
0
0
0
2
2
0
5
0
5
0
7
2
1
1
2
1
0
0
2
0
1
1
12
2
2
0
4
4
0
0
4
0
2
2
0
0
1
0
0
0
1
4
0
0
4
0
0
4
1
0
0
2
1
0
0
0
0
0
0
0
0
3
1
2
0
8
1
0
1
2
4
0
0
1
0
0
0
(Continued)
Vol. 34, No. 4, 2006
Team Sport Injuries During the 2004 Olympic Games
571
TABLE 2
(Continued)
Total No. of Injuries
in All 8 Team Sports
No. of All Injuries
Location and Diagnosis
All
Time-Loss
Soccer
Handball
Laceration
Others
Ankle
Dislocation
Sprain/ligament rupture
Contusion
Foot
Fracture
Sprain
Contusion
Others
3
5
49
1
39
9
12
2
2
5
3
0
1
29a
1
27a
1a
5a
1a
0
3
1
1
4
18
1
9
8
6
0
2
3
1
0
0
12
0
11
1
1
0
0
1
0
Basketball
0
0
8
0
8
0
2
1
0
0
1
Field Hockey
0
1
6
0
6
0
1
0
0
1
0
a
Information is missing for at least 1 injury.
sprains and concussions in female players than in male
players (Table 1). The proportion of noncontact injuries was
not statistically different in men and women, but significantly
(P < .05) more contact injuries of men than of women were
attributed by the team physician to foul play (67% vs 44%).
Handball
A total 114 injuries were reported from 72 handball matches
(response rate, 93%). The incidence was 1.6 injuries per
match (95% CI, 1.3-1.9) or 114 per 1000 player matches
(95% CI, 93-135). The majority of injuries affected the lower
extremity (38%) and head (34%), followed by the upper
extremity (15%) and trunk (13%). The most frequent types
of injury were contusions (53%) and sprains (11%). The most
prevalent diagnoses were contusion of the head (n = 16) and
sprain (n = 6) and ligament rupture (n = 5) of the ankle. The
vast majority of injuries (86%, 95 of 111) were caused by contact with another player. In the view of the team physician,
65% of the contact injuries were caused by foul play (52 of
80); 70% of these situations (35 of 50) were followed by a
sanction of the match referee. A similar number of injuries
occurred in the first half (44%) and the second (56%) half.
Thirty-eight injuries (38%) were expected to result in
absence from sport. The incidence of time-loss injuries was
0.53 per match (95% CI, 0.36-0.7) or 38 per 1000 player
matches (95% CI, 26-50). The most frequent diagnosis for
time-loss injuries was a ligament rupture (n = 4) or sprain
(n = 3) of the ankle. Twenty-seven injuries were expected
to result in time-loss of up to 1 week; 3, in time-loss of up
to 2 weeks; and 3, in time-loss of more than 4 weeks (2 ligament ruptures of the knee and 1 fracture of the head). For
5 injuries, an estimate of the duration of absence was not
specified (1 facture of the nose, 1 ligament rupture of the
knee, 1 muscle fiber rupture in the lower leg, 1 contusion
of the knee, and 1 contusion of the thigh). All 3 ligamentous injuries of the knee were incurred by female players.
The incidence of handball injuries was higher in women
than in men, but significantly (P < .05) more injuries of
male players than of female players were expected to result
in absence from sport. Thus, no difference in the incidence
of time-loss injuries was observed between male and female
players. The proportion of contact injuries was similar in
men and women, but significantly (P < .05) more contact
injuries of women than of men were caused by foul play
(77% vs 50%), as rated by the team physician.
Basketball
Fifty-five injuries were reported from the 84 basketball
matches (response rate, 100%), which is equivalent to an
incidence of 0.65 injuries per match (95% CI, 0.48-0.82) or
65 injuries per 1000 player matches (95% CI, 48-82). The
majority of injuries affected the lower extremity (47%), followed by the upper extremity (27%), head (22%), and trunk
(4%). The most frequent types of injuries were contusions
(20%), lacerations (18%), strains (18%), sprains (16%), and
fractures (11%). The predominant diagnoses were ankle
sprain (n = 8) and contusion of the thigh (n = 5). Almost 70%
of the injuries (37 of 54) were caused by contact. The team
physician attributed 6 injuries to foul play. The occurrence
of the injuries was equally distributed among the quarters
of the game.
The majority of injuries (60%) were not expected to result
in absence from match or training; a time-loss injury
occurred in roughly every fourth match. The incidence of
time-loss injuries was 26 per 1000 player matches (95% CI,
15-37). Significantly (P < .01) more noncontact injuries
(71%) than contact injuries (24%) were expected to result in
time-loss from sport. Thus, 57% of time-loss injuries (12 of
21) were incurred without contact. Eight time-loss injuries
(36%) were diagnosed as ankle sprains; 2, as ligament
injuries of the knee (both in women); and 1, as a lesion of
the meniscus. The other time-loss injuries were 6 strains
(2 of the groin and 1 each of back, finger, elbow, and calf)
and 4 fractures (nose, metacarpal bone, metatarsal bone,
and elbow). For the majority of time-loss injuries, an estimate of the duration of absence was not noted. However,
572
Junge et al
2 career-threatening injuries of the knee were identified,
both in female players.
The incidence, type, severity, and causes of injury were
similar in men and women. But the location differed significantly (P < .05), with twice as many head injuries and
substantially fewer injuries of the upper extremity in
female players than in male players (Table 1).
Field Hockey
A total 44 injuries were reported from 52 field hockey
matches (response rate, 73%), which is equivalent to an
incidence of 0.85 injuries per game (95% CI, 0.6-1.1) or
39 injuries per 1000 player matches (95% CI, 27-50). The
majority of injuries affected the lower extremity (47%), followed by the head (27%), upper extremity (20%), and trunk
(9%). The most frequent types of injuries were contusion
(41%), laceration (20%), and sprain (11%). The most prevalent diagnoses were ankle sprain, laceration of the knee
and head, and contusion of the head (each n = 4). Almost
70% of the injuries (29 of 42) were incurred from contact
with another player (including at least 2 injuries from a hit
by a stick). The team physician regarded 8 injuries as
caused by foul play. In both halves of the games, the same
number of injuries was observed.
Eighteen injuries (45%) were expected to result in absence
from match or training. For 4 injuries, this information was
missing (2 contusions of the knee, 1 abdominal muscle strain,
and 1 anterior cruciate ligament injury). Almost all time-loss
injuries (16 of 18) were expected to result in absence from
sport up to 1 week, and only 1 injury (fracture of the thumb)
was expected to result in an absence of more than 1 month.
On average, a time-loss injury was incurred in every third
match. The incidence of time-loss injuries was 16 per 1000
player matches (95% CI, 9-23). The incidence and characteristics of injuries differed substantially between male and
female field hockey players. In the men’s tournament, the
incidence of all injuries, as well as of time-loss injuries, was
approximately 4-fold higher than in the women’s tournament (Table 1). The location of injuries varied considerably
between men and women (twice as many head injuries and
substantially fewer injuries of the lower extremity in female
players than in male players), but the difference reached
no statistical significance because of the small number of
injuries in female players. However, for time-loss injuries, the
difference was significant (P < .05) because both time-loss
injuries of female players affected the head, compared with
only 1 of 16 time-loss injuries in men.
Water Polo
Seventeen injuries from the men’s tournament and 1 (concussion without loss of consciousness) from the women’s
tournament were reported (total response rate, 95%). Thus,
in men’s tournaments, an injury occurred in every 2 to 3
matches. The total incidence was 21 injuries per 1000 player
matches (95% CI, 11-31). The majority of injuries affected
the head (56%), followed by the upper extremity (28%),
trunk (11%), and lower extremity (6%). All injuries were
incurred because of contact with another player. In the
The American Journal of Sports Medicine
view of the team physician, two thirds of the injuries (12 of 18)
were caused by foul play, but only 30% of these (3 of 10) or
19% of all injuries were followed by a sanction of the match
referee. The time in the match was available for 11 injuries.
Four injuries occurred in the first 2 quarters of the match,
whereas almost twice as many (7 of 11) injuries occurred
during minute 15 to minute 28.
Eleven injuries (69%) were not expected to result in
absence from sport (including the one in the women’s tournament). For 2 injuries (1 fracture of the foot and 1 rupture
of the ear membrane), this information was missing. The
5 time-loss injuries were a contusion of the eye (2 days), a
laceration in the face (7 days), a rupture of the eardrum
(4 weeks), a dislocation of the shoulder (30 days), and a fracture of the sternum (more than 30 days). The incidence of
injuries with expected time-loss was approximately 1 in 6 to
8 matches or 8.7 per 1000 player matches (95% CI, 1.1-16.3)
in the men’s tournament.
Baseball
Sixteen injuries were reported from 31 baseball games,
which is equivalent to 1 injury in every second match or
29 injuries per 1000 player matches (95% CI, 15-43). The
injuries affected either the upper (56%) or lower extremity
(44%). The most prevalent diagnosis was contusion of the
upper arm (n = 4). Three injuries (20%) were reported to
result from contact with another player or object. One contusion of the upper arm was caused by a hit by the pitcher
and classified as foul play. The occurrence of the injuries
seems not to be equally distributed during the course of the
game, whereas 7 injuries occurred in the first 10 minutes,
3 occurred in the 60th minute, and 5 occurred between
minute 90 and minute 120.
Seven injuries (44%) or 1 injury in 4 to 5 matches were
expected to result in time-loss. The expected time-loss was
less than 1 week for 3 injuries (soreness of the elbow, abrasion of the big toe, and hematoma at the tip of the middle
finger), 10 to 20 days for 3 injuries (tendinitis in the elbow,
strain of the rotator cuff of the shoulder, and muscle fiber
rupture in the lower leg), and more than 1 month for a ligament rupture with instability in the ankle. All time-loss
injuries were classified as noncontact injuries.
Softball
Only one injury (strain of the hip) was reported from
29 games of the softball tournament (response rate, 91%).
This noncontact injury was not expected to result in
absence from match or training.
Volleyball
Seven volleyball injuries were reported: 5 from the men’s
tournament and 2 from the women’s tournament (total
response rate, 100%). The incidence was approximately
1 injury in 10 matches or 7.7 injuries per 1000 player matches
(95% CI, 2.0-13.4). All injuries, except 1 (subluxation of the
shoulder), affected the lower extremity (86%). Ligamentous
injury of the ankle was the most prevalent diagnosis, stated
Vol. 34, No. 4, 2006
Team Sport Injuries During the 2004 Olympic Games
573
in approximately half of the injuries (4 of 7). Almost all
injuries (83%, 5 of 6) were classified as time-loss injuries.
One ankle sprain was not expected to result in absence from
match or training. For another ankle sprain, the expected
duration of time-loss was not reported, and 2 ligamentous
injuries of the ankle were expected to result in less than
1 week absence from sport. For 2 time-loss injuries (subluxation of the shoulder and suspected lesion of the meniscus),
an estimate of the duration of absence was not provided. A
fracture of the lower leg was expected to result in more than
1 month absence from regular sport activities. The incidence
of time-loss injuries was approximately 1 in 15 matches or
5.5 per 1000 player matches (95% CI, 0.7-10.3).
Comparison of the Team Sports
The number of injuries per match was highest in soccer,
followed by handball, field hockey, basketball, baseball,
water polo, volleyball, and softball. However, the risk of
injury for a player was highest in handball, followed by
soccer, basketball, and field hockey (for other sports, see
Figure 1). When the number of players per team and the
duration of the match were taken into account and when
the incidence was consequently expressed in injuries per
1000 player hours, the sequence changed to handball, basketball, soccer, water polo, and field hockey (for the other
sports, it was not possible to calculate exposure-rated incidences because the duration of the games was not available). The percentage of injuries that were expected to
result in absence from match or training was similar in
most types of sports (31%-45%), except in volleyball (83%).
Thus, the sequence of team sports was the same with
regard to time-loss injuries per match and almost the same
for time-loss injuries per 1000 player matches (Figure 1)
and time-loss injuries per 1000 player hours.
For all team sports, except water polo and baseball, most
injuries affected the lower extremity. In baseball, 44% of
the injuries were located in the lower extremity. The percentage of injuries in the upper extremity was high in
baseball (56%), basketball (27%), and field hockey (20%).
Injuries of the head were frequent in water polo (56%), handball (34%), field hockey (27%), and basketball (22%). In all
team sports, injuries of the trunk were infrequent. Beside
contusions of the head and thigh, ankle sprains were the
most prevalent diagnoses in team sports (except in water
polo, baseball, and softball).
The types of injuries were significantly different (P < .001)
among the team sports, even if only the 4 sports with the
highest incidence of injury (handball, soccer, basketball, and
field hockey) were compared. Severe injuries, such as fracture and ligament ruptures, seem to be more frequent in
handball (9 ligament ruptures) and basketball (6 fractures)
than in the other sports in which a maximum of 3 of these
injuries were observed (Tables 1 and 2).
The causes of injuries also varied substantially between
the team sports. While 75% of baseball injuries occurred
without contact, the majority of injuries in basketball
(68%), field hockey (69%), soccer (83%), handball (86%), and
water polo (100%) occurred because of contact with another
player or an object (P < .001; volleyball and softball were
Figure 1. Number of injuries per 1000 player matches.
excluded from the analysis). Furthermore, the proportion
of contact injuries that were caused by foul play, as judged
by the team physician, ranged from 14% in basketball, 40%
in hockey, and 58% in soccer to two thirds in handball,
baseball, and water polo (P < .001; volleyball and softball
were excluded from the analysis). When time-loss injuries
only were included in the analysis, the results for contact
injuries (baseball, 0%; basketball, 43%; field hockey ,71%;
handball, 79%; soccer, 80%; water polo, 100%; P < .001) and
contact injuries caused by foul play (basketball, 13%; handball, 46%; field hockey, 50%; soccer, 59%; water polo, 80%;
P = .10, not significant) were similar. In some team sports,
the incidence of injury seemed to differ between men and
women, but for field hockey and water polo only, the 95%
CIs did not overlap. Compared with male players, the
injury rate was lower in female field hockey, water polo,
and volleyball players, similar in female soccer and
basketball players, and higher in female handball players.
With respect to time-loss injuries, the results changed only
for handball (to similar incidence in male and female players). Although the proportion of noncontact injuries varied
between men and women, the difference reached no statistical significance for any of the sports included in the
study.
DISCUSSION
The present cohort study was a prospective survey of
injuries in 14 team sport tournaments during the 2004
Olympic Games in Athens. The injury-reporting system,
which has been implemented as matter of routine in many
international soccer and handball tournaments,27-29,53 proved
to be feasible for other team sports. The acceptability of and
compliance with the procedure were excellent, as demonstrated by the response rate of more than 90% in almost all
tournaments. However, slight modifications concerning the
documentation of the causes of injury should be considered
for future projects. For sports in which a player might be
574
Junge et al
injured by an object such as a stick or ball, a differentiation
of contact with a player or object is recommended to have
more insight into the injury mechanism. A follow-up of the
injured players (as for time-loss injuries incurred during
the European Football Championship 2003 in Portugal13)
could improve the validity of the data, but such a procedure was impractical in the present study because some
teams had no associated physician or physical therapist.
Thus, injuries in some sports (basketball, softball, and
partly volleyball) were reported by the medical representative of the IF. Although all IF medical representatives
were physicians experienced in sports medicine and followed exactly the same procedure as the team physicians,
this deviation in the reporting agents might have influenced the results. However, a similar percentage of injuries
with and without expected time-loss in almost all sports
indicates that almost all physicians had the same reporting threshold. The strengths and weaknesses of the
applied methods are discussed in detail by Junge et al.28 In
general, the consistent findings with previous studies28,29
demonstrate the high quality of the data obtained.
The overall injury incidence of the team sport tournaments was almost 1 injury per match, and the most frequently injured body part was the head, followed by the
ankle and knee. When only injuries with expected time-loss
were considered, the incidence decreased to 1 in 3 matches,
and the percentage of head injuries declined from 21% to
10%. The severity of head injuries is not always obvious;
therefore, a careful examination of players with a trauma to
the head is highly recommended, and diagnosis and treatment should follow the recently published guidelines.4,31 The
high risk of ankle injuries, especially ankle sprains, is well
known in most sports, and prevention programs have been
effective in their reduction for different types of sports.22,43,47,50
The most severe types of injuries reported during the 2004
Olympic Games in Athens were 16 fractures, 16 ligament
ruptures, 4 meniscal lesions, and 2 dislocations, which is
equivalent to 1 in 12 matches. Four of 6 injuries of the knee
ligaments were incurred without contact to another player.
The risk of noncontact anterior cruciate ligament injuries
in female athletes participating in pivoting sports is widely
recognized,21,34,37 and effective preventive programs have been
developed for soccer8,30 and handball36 players.
Injuries of male and female players were similar in location and circumstances but differed significantly in the type
of injury. Five of 6 ligament ruptures of the knee reported
were incurred by female (handball and basketball) players.
The higher incidence of ligamentous knee injuries in women
than in men has been previously described for different
team sports.1,21,23,24 In addition, concussions were diagnosed
more frequently in female players than in male players.
Fuller et al19 reported the same for soccer players and
hypothesized that diagnoses were more cautionary in the
women’s games, as far as concussion was concerned, or that
some concussions in the men’s games were missed and/or
were recorded as contusions.
Almost 80% of all injuries were incurred because of contact
with another player, and more than half of these injuries
were caused by foul play, as rated by the team physician. This
finding is in agreement with findings reported previously for
The American Journal of Sports Medicine
soccer18,28 and handball29 tournaments and stresses the
importance of fair play and strict refereeing for the prevention of injury.
Comparison Between the Team Sports
A methodological dilemma arose when we aimed at comparing the incidence of injury in different sports. Looking
at only the total number of injuries in different sports
ignores that the tournaments comprised different numbers
of matches for each sport. The mean number of injuries per
match disregards that the number of players in a match
and the duration of a match vary between the sports. An
exposure-time related incidence (number of injuries per
1000 player hours) seems to be the most accurate reporting method; however, the actual playing time is hard to
determine because in some team sports, such as basketball, the match time stops when the ball is out of bounds,
whereas match time continues in other sports, such as
soccer. Furthermore, for volleyball, baseball, and softball,
the time of a match is not even defined, and the duration
can vary substantially. Based on the consideration that a
match is a defined entity, regardless of the sport, we finally
decided that the player’s individual risk of injury can be
best expressed in injuries per player matches.
The relative risk of a player to be injured was highest in
soccer and handball, followed by basketball, field hockey,
baseball, water polo, and volleyball and was lowest in softball. This finding could be expected from the nature of the
sports and is, in general, in agreement with the literature.5,10,11,42,44 Although the types and causes of injury differed substantially between the sports, it was interesting
to notice that contusions of the head and thigh and ankle
sprains were the most prevalent diagnoses in all team sports
(except water polo, baseball, and softball). In basketball, field
hockey, soccer, handball, and water polo, the majority of
injuries were caused by contact with another player. In all
these sports, except basketball, the team physician attributed a substantial proportion of contact injuries to foul play.
Comparison With Previous Studies
A comparison with previous studies on injuries in team
sports is difficult because of the methodological problems
such as heterogeneous definitions of injury, study populations, methods of assessment, and calculations of incidence. Furthermore, detailed prospective studies on the
incidence, type of injuries, and circumstances of injuries
could not be found for all team sports included in the present study. Most information is available about injuries of
elite male2,14,27,28,53 and female15,16,20,28,41 soccer players, and
these studies are in agreement with the present results.
Handball injuries have also been investigated in several
studies,3,29,39,40,46,51 but the reported incidences and characteristics of injury varied substantially. However, injury
rates similar to the present study have been reported from
other tournaments3,29 and in a retrospective study on selfreport injuries during the season.51 In all 3 prospective
studies on basketball injuries,32-34 including 1 on injuries
Vol. 34, No. 4, 2006
during elite and recreational competitions,32 the rates of
injury were lower than in the present study, probably
because of the lower skill level of the players and/or standards of the tournaments. Nevertheless, the results in
relation to location and diagnosis of injury were in agreement with the present study. Both prospective studies on
volleyball injuries during the season6,49 and an additional
one on injuries during a national tournament45 expressed
the injury rate in relation to exposure hours. This figure is
not available in the present study; therefore, the data cannot be compared. However, similar to the present study,
ankle sprain was reported to be the predominant type of
injury in volleyball. Information on injuries in field hockey
is available from only 2 retrospective studies.12,35 A general
description of injuries in water polo7 was found, but no
study exclusively concerning injuries in baseball or softball
was identified.
CONCLUSION
Using a standardized methodology, the incidence and characteristics of injuries in different team sports can be compared. During the 2004 Olympic Games, the risk of injuries
in some team sports tournaments (eg, handball, soccer, and
basketball) was higher than in others (eg, volleyball, baseball,
and softball). However, prevention of injury and promotion of
fair play are relevant topics for almost all team sports.
ACKNOWLEDGMENT
The authors gratefully acknowledge the Fédération
Internationale de Football Association, and the medical
commissions of the International Handball Federation,
the International Basketball Federation, the Fédération
International de Natation, the International Hockey
Federation, the International Baseball Federation, the
International Softball Federation, the International
Volleyball Federation, and the International Olympic
Committee Medical Commission for their support. We
thank Dr Patrick Schamasch and Professor Per Renström
for the opportunity to conduct the study during the 2004
Olympic Games. We highly appreciate the cooperation of all
team physicians and the medical staff of all Olympic teams
who volunteered their time to collect the data for this project.
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