Injuries in Male and Female Elite Aquatic Sports Athletes: An 8-Year Prospective, Epidemiological Study.

Author:Kim, Hyun Chul


Aquatic sports have been part of the Olympic Games since the 1896 Athens Games (FINA, 2020). In 1908, the International Amateur Swimming Federation was established to provide a much-needed structure to the competitive aquatics program (FINA, 2020).

South Korea as the host of the Gwangju 2019 FINA World Championships (FINA, 2020), the popularity of aquatic sports and the expectations regarding the athletic performance of South Koreans at international aquatic sports competitions have been increasing.

Elite South Korean aquatic sports athletes undergo intensive training involving high-intensity exercise for long durations. Although the increased activity is critical for maximizing athletic performance (McGuine, 2006), it significantly increases the risk of sports injury (Park and Brian, 2017). Aquatic sports athletes are matched according to aquatic style, leading to entirely different styles of play, traits, and tactics (International Olympic Committee, 2020). It is unknown whether this also leads to a difference in the injury rate and nature of sports injuries.

According to epidemiological studies carried out during the Olympics, aquatic sports have been associated with lower injury rates compared to combat sports (Junge et al., 2009; Engebretsen et al., 2012). However, every part of the human body is vulnerable to injury in aquatic sports (Caine et al., 2010). Although several reports on aquatic sports injuries have been published (Annett et al., 2000; Badman and Rectine, 2004; Bak and Fauno, 1997; Capaci et al., 2002), few studies have examined injuries during training or competition for these sports.

Furthermore, most studies involve short-term follow-ups (typically no longer than 1 year) and are focused around special sports events. For example, Engebretsen et al. (2013) only addressed the injury rate of sports damage during the London Olympics. Furthermore, the injury profile for aquatic sports is unclear, and most studies evaluating aquatic sports injuries are retrospective and do not account for exposure when determining injury rates. Therefore, their study showed the highest injury rate of artistic swimming injury (Engebretsen et al. 2013). The Charter of the International Olympic Committee (IOC) aims to develop programs to prevent sports injuries and help enhance the performance of Olympic athletes (International Olympic Committee, 2019). To collect data on the circumstances in which injuries of different severity occur, a prospective surveillance program was initiated at the National Training Center in South Korea, which hosts the training of elite athletes who are expected to represent South Korea at international sporting events.

In this study, we analyzed sports injury data prospectively recorded during the 8-year period following the initiation of the surveillance program. We aimed to analyze the specific patterns (injury rate, body region, site, type, and severity) of injury for each of the main aquatic styles (swimming, diving, water polo, and artistic swimming) and to investigate potential sex-specific differences in aquatic injuries.


Study population

This study included elite aquatic athletes participating in top-level international competitions who trained at the Korea National Training Center between January 2012 and December 2019. The study design was approved by the Korea Training Center, and the study was conducted ethically according to the principles of the Declaration of Helsinki. The requirement for informed for informed consent was waived by the ethics committee.

Annually, the center hosts an average of 42 elite aquatic athletes grouped according to four aquatic styles (swimming: 5 men, 5 women; diving: 5 men, 5 women; water polo: 12 men; artistic swimming: 10 women) (Table 1). All athletes who trained in this facility for a duration ranging from at least one year were included in this study. South Korean aquatic athletes compete for national team selection every year; therefore, only selected athletes train at the National Training Center. During the research period, some athletes were selected for the national team for only 1 year, while others were selected for multiple years. The longest an athlete spent on the national team was 8 years.

Data collection

Training details (aquatic style and date), athlete characteristics (sex and name), and injury characteristics (injury rate, body region, site, type, and severity) were recorded using daily injury report forms issued by the IOC (Bahret al. 2020). During the study, the athletes were assessed by one of four sports medicine doctors who completed the daily injury report forms on-site before referring the athletes to the training center clinic.

Operational definitions

A sports injury was defined as any acute or chronic mus-culoskeletal signs or symptoms occurring due to aquatic activities during training sessions (Goldberg et al., 2007). Multiple injuries in a single athlete were classified according to the affected body region. However, acute and overuse injuries were not distinguished. Bahret al. (2020) Calculated as the number of days of failing to participate in training due to sports injury, the Injury severity was classified as level I (mild injury, requiring 1-3 days of time loss), lever II (moderate injury, requiring 4-7 days of time loss), and lever III (severe injury, requiring [greater than or equal to]8 days of time loss) (Park and Brian, 2017; Park et al., 2019). The injury body location and injury type was classified based on an IOC consensus statement (Bahret al. 2020). We defined affected body regions and type of injury as the head and neck, upper limb (shoulder, upper arms, elbow, forearm, wrist, hand), trunk (chest, thoracic, lumbosacral, abdomen), and lower limb (hip/groin, thigh, knee, lower leg, ankle, foot). Muscle/Tendon, Nervous, Bone, Cartilage/Synovium/Bursa, Ligament/Joint capsule, Superficial tissues/skin, Vessels, Stump, Internal organs and Non-specific (Bahret al. 2020).

Statistical analysis

The examined variables included sex, aquatic style, injury body location (body region and specific site of injury), injury severity and injury rates. Descriptive statistics were used to examine injury patterns. We used chi-square tests to compare injury severity and body location between groups based on aquatic style or sex. Injury rates were expressed as the number of injuries per year, the number of injuries per 1000 hours of training, and the number of injuries per 1000 athlete exposures (AEs). The total number of training hours was calculated based on the total time that athlete spent at the training center. One AE was defined as participation in one training session. The annual hours and AEs were calculated by excluding hours and exposure of not participating in training due to injury. The calculations of the injury rate per 1,000 hours and 1,000 AEs were calculated as follows: (total injury/the total training hours or total AEs of all athletes * 1000). To compare the relative risk of injury between sexes, the injury rate ratio (RR) was determined with 95% confidence intervals (CIs). All statistical analyses were performed using SPSS version 24.0 for Windows (IBM Corp., Armonk, NY, USA), and the significance level was set at p


In total, 241 athletes were included in the study. They trained an average of 4.5 h/day, 5 days/week. For 1 year, the athletes were present at the training center for 9.5 months (41.25 weeks). Swimmers and divers trained 4 h/day, 5 days/week, for 9 months (39 weeks); water polo players and artistic swimmers trained 5 h/day, 5 days/week, for 10 months (43.5 weeks). Overall, athletes participated in nine training sessions for each two-week period (4.5 training sessions per week). In total, 797 injuries (including acute and...

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