Abstract
Background
Our study aims to investigate injury patterns and treatment results in sports-related knee and shoulder injuries among athletes from Haryana, the most prominent state in the contribution of Olympic medals for India.
Material and methods
A cross-sectional prospective observational study was conducted in a tertiary referral centre. Over five years, from May 2018 to June 2023, 920 participants were included in our study.
Result
Most injuries (59.90 %) occurred between the ages of 16 and 20. Men (62.60 %) outnumbered women (37.40 %). On average, the individuals weighed 68.57 ± 13.65 kg, stood 1.57 ± 0.11 m tall, and had a BMI of 25.75 ± 4.81 kg/m2. Kabaddi players, most commonly injured athletes (42.60 %), followed by wrestling (31.30 %). Most athletes were professional, with 35.43 % competing at the national level, while 33.26 % competed at the state level. The average delay in presentation was 14.28 ± 8.12 months. Most injuries occurred during competitive matches (61.30 %), rest during practice. Contact injuries accounted for 31.41 % of cases, while non-contact injuries accounted for 54.02 % of all injuries. Only knee and shoulder injuries were considered, accounting for 77.28 % and 22.72 % of all injuries. Most observed injuries were ACL rupture (60.76 %), followed by meniscal tears (54.45 %) and collateral ligament injuries (26.96 %). 424 patients treated conservatively, whereas 53.9 % cases underwent arthroscopic/open surgical procedures. 74.13 % of athletes returned to competitive sports after their injury of which 38.71 % returned to the previous level of activity. The duration of time lost to injury ranged from 4 to 60 months (average 10.58 ± 4.74). Return to sports was significantly affected by the athletes’ gender, BMI, level of competitiveness, and management modality (p-value <0.01 each).
Conclusion
Limiting the frequency, severity, and amount of time missed in sports while enabling athletes to return virtually to their pre-injury activity level should continue to be the primary goal of injury prevention.
1. Introduction
Sports are vital for both psychological and physical well-being and are significant for socializing, education, and health. In addition to offering vital physical conditioning, it also reduces the risk of chronic diseases including diabetes and cardiovascular conditions.1 However, involvement in competitive sports carries the inherent risk of injury. The most frequent causes of sports injuries are acute trauma, repetitive stress from exertion, inadequate training methods, insufficient equipment, conditioning, and preventive measures, inadequate warm-up, and a lack of information about injury prevention.2 Injury to the shoulder joint and knee joint are fairly common in regular sporting activities and more so in competitive athletes. Injury to the knee joint accounts for 41 % of all sports-related trauma and, injury to the ACL contributes to 20 % of all knee injuries. Meniscal tears, Posterior cruciate ligament (PCL) and collateral ligament injury, and intra-articular cartilage damage complete the spectrum of injury profile to the knee.3
Whilst India has only won 30 individual medals at the Olympic Games, individual sports and athletics are becoming more popular here nearly a century after independence. Some of the most renowned athletes in India have come from the northern state of Haryana, which is home to just 2.09 % of the country's population. Eight of the 24 medals have come from it, and in the last three quadrennial event editions, the state's medal share has increased to as much as 50 %. Boxing, wrestling, weightlifting, athletics, and shooting are the categories in which the commendations have been achieved. There is a dearth of literature on the epidemiological data on sports injury from the most populous country on the planet. The study aimed to assess the epidemiology of sports-related injuries involving the knee and shoulder joints of athletes hailing from the state of Haryana.
2. Material and methods
A cross-sectional observational study was carried out at the Department of Orthopaedics in a tertiary care centre that receives a sizeable number of patients with sports-related injuries. The research was conducted from May 2018 to June 2023. Institutional ethical clearance was obtained for the study (Letter no.: Anaesth/19/746) and informed consent was obtained from all patients enrolled in the research.
2.1. Selection criteria
Athletes of all ages belonging only to Haryana who were involved in competitive sports were included in the study. Only injuries sustained to the knee or shoulder joint during a game or training were considered. The study did not include injuries that an athlete received while participating in non-sporting activities, such as motor vehicle accidents or recreational sports. Athletes with no clear diagnosis (clinical or radiological) and the ones with incomplete data were excluded from the study. The study also eliminated athletes who were not reachable for follow-up after returning to sports.
2.2. Data extraction and analysis
Data was collected from a specialised sports proforma maintained in the Outpatient department since its inception. The athletes were categorised into amateur and professional based on their level of sporting activity. Athletes competing at the intercollegiate level or for recreation were referred to as amateurs, while those competing in a professional club, city, state, or national team were considered professionals.
Quantitative variables were analysed using the student T-test and the qualitative variables were compared using the Chi-square test. A p-value of <0.05 was considered to be statistically significant. The Statistical Package for Social Sciences (SPSS) version 21.0 was used for statistical analysis.
3. Results
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A.
Demographic details
A total of 920 patients from 9 different sports specialties were enrolled in the study. The average age of athletes was 20.19 ± 3.71 years. The majority of patients belonged to the 16–20 year age group (558/59.89 %), which was followed by 25.11 % (231) patients in the 21–25 age range and 78 patients (8.47 %) in the 26–30 age range, and 3.04 % (28) of patients were below the age of 15 (Fig. 1). There were 344 (37.4 %) female patients and 62.6 % (576) male patients, indicating a male preponderance. The mean weight was 68.57 ± 13.65 kg, the mean height was 1.57 ± 0.11 m, and the mean body mass index was 25.75 ± 4.81 kg/m2. There was no specific side dominance, with the left side being involved in 468 (50.86 %) patients and the right side involved in 452 (49.13 %) patients. 471 (51.1 %)were amateur athletes, and 449 (48.9 %) were professional. (p-value 0.347).
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B.
Sports wise distribution
Fig. 1.
The majority of cases were in the 16–20 years age group i.e. 558 (59.89 %) followed by 21–25 years i.e. 231 (25.1 %).
Contact sports contributed to most cases with Kabaddi contributing to 392 (42.60 %) patients, followed by wrestling with 288 (31.3 %) patients, and football with 88 (9.56 %) cases. The remaining sports contributed to 16.54 % of the caseload received during the study period. There was no clear difference between the levels of sports leading to injury, where 326 patients (35.43 %) were injured in national-level games, 306 (33.26 %) players sustained injuries in state-level tournaments, and 288 (31.31 %) athletes were injured in inter-collegiate events. The average delay in presentation to the hospital for the research population was 14.28 ± 8.12 months, with a range of 1–56 months. Most athletes (564/61.3 %) were injured during game time when compared to training sessions (356/38.7 %), which was statistically significant (p < 0.05). Kabaddi contributed to most injuries sustained during a game.
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C.
Mechanism of Injury
The most frequent mechanism of injury was a twisting injury to the knee, which occurred in 477 (51.8 %) cases, followed by collision in 269 (29.5 %) and impact with the ground in 45 (4.89 %) patients. 37 cases (4.02 %) were related to injuries sustained when lifting weights. Shoulder injuries from pushing (36, 3.91 %) and throwing (25, 2.71 %) came after (Fig. 2). Knee joint injuries were more common (711, 77.28 %) than shoulder injuries (209, 22.72 %). Ten patients experienced concomitant shoulder and knee injuries.
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D.
Anatomical distribution
Fig. 2.
In 477 (51.8 %) cases, twisting of the knee was the most common mechanism of injury followed by collision in 269 (29.5 %), weight lifting (n = 37, 4.02 %).
ACL tear was the most encountered lesion seen in 559 (60.76 %) athletes, closely followed by meniscal tears (501, 54.45 %). Associated injuries to the collateral ligaments of the knee were noticed in 248 (26.96 %) patients. Isolated injury to PCL was seen in 32 (3.47 %) athletes and was exclusively associated with direct contact injury to the anterior aspect of the knee. Instability of the shoulder was noticed in 99 (10.76 %) patients, rotator cuff injuries in 37 (4.02 %) athletes, and injury to the acromioclavicular joint was seen in 52 (7.36 %) patients.
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E.
Treatment modality
53.9 % (496) athletes underwent arthroscopic/open surgery to address the pathology, while 46.1 % (424) were treated conservatively with bracing and rehabilitative techniques (p-value 0.390). We found that all amateur or professional athletes had a superior return to sports after surgery, with 219 out of 280 amateur players and 260 out of 305 professional athletes choosing surgical management. (p-value <0.01).
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F.
Return to sports
Return to sports is a significant measure of a person's ability to recover from injury related to sporting activity effectively. There was no significant difference in the rate of return between sports. (p-value 0.52) (Table 1) In our study, 238 (25.87 %) players did not return to any sports activity, whereas 682 players (74.13 %) did return to their original sport. However, out of the 682 patients who were able to return to play, only 264 (38.71 %) were able to return to the previous level of play (p < 0.01). The mean time lost to injury was 10.58 ± 4.74 months, with a range of 4–60 months. The mean BMI was 25.75 ± 4.81 kg/m2. We noticed that athletes with BMI towards the higher side tend to return to play less often when compared to others with BMI in the normal range (P value < 0.01).
Table 1.
Comparison of rejoining status with sports profile.
|
Sports profile |
Rejoining status |
Chi square |
P value |
||
|---|---|---|---|---|---|
| Not rejoined | Rejoined (At any level) | Rejoined (at same level) | |||
| Athletics (n = 32) | 11 | 21 | 12 | 15.03 | 0.52 |
| Badminton (n = 28) | 9 | 19 | 13 | ||
| Basket ball (n = 32) | 8 | 24 | 9 | ||
| Football (n = 88) | 31 | 57 | 29 | ||
| Hockey (n = 8) | 3 | 5 | 4 | ||
| Judo (n = 20) | 7 | 13 | 6 | ||
| Kabaddi (n = 392) | 97 | 295 | 111 | ||
| Tennis (n = 32) | 9 | 23 | 9 | ||
| Wrestling (n = 288) | 63 | 225 | 71 | ||
| Total (n = 920) | 238 | 682 | 264 | ||
With 489 men and 189 women returning to their original sport, women's return to sports was more modest. (p-value <0.001) While just 290 amateur athletes returned to participate, 392 professional athletes made a stronger comeback to the sport. (p-value less than 0.001) The rate of return to sports was significantly higher for athletes who warmed up for at least half an hour before the competition (463 out of 571), got professional assistance from coaches (351 out of 421), and had assistance from a qualified physiotherapist (369/469). (p-value <0.01).
-
G.
Tegner Activity Level
A patient-reported questionnaire dubbed as Tegner Activity Scale gauges an athlete's level of activity both before and following an injury. Before injury, the mean Tegner activity scale4 was 8.39 ± 1.32; following injury, it dropped to 4.67 ± 0.54 (at presentation). The mean Tegner activity scale at the final follow-up was 8.18 ± 1.39 which revealed a significant decrease in level of play post-injury (p < 0.001).
4. Discussion
As participation in competitive sports in India continues to rise, there is an obvious increase in the incidence of sports-related injuries. Sports injuries inflict major physical, psychological, and financial difficulties on athletes. The incidence and distribution of sports-related injuries vary depending on the game, level of participation, gender, and player position.5,6 The aetiology of sports injury varies with country, and the results of the epidemiological study from developed countries do not apply to developing countries. There is very minimal data available on sports injury epidemiology from South East Asia, notably in India.7 John et al. (2015) reported comparable outcomes and return to sports in a similar demographic profile.8
The prevalence of sports injuries is highest in the teenage population, and it peaks in the second and third decades of life when athletes reach the pinnacle of their careers. The male population was significantly more affected than the females. The male-to-female ratio may be explained by the pervasive gender prejudice in Indian sports, particularly in the state of Haryana. As wrestlers and kabaddi players have larger body frames, their mean BMI was higher. The player's return to sports was significantly correlated with their BMI. Individuals with a BMI greater than 25 kg/m2 were less likely to return to sports than those with a normal BMI. Contact sports like kabaddi and wrestling were associated with the greatest number of injuries suffered.
The increased level of competition during a competitive game may be the reason why athletes are more prone to sustain an injury during a game than during practice. Since throwing, grappling, and twisting are all popular kabaddi manoeuvres, 79 % of the injuries in our study were caused by these three actions. The most frequent injury was an ACL rupture, which was followed by lateral and medial meniscus tears. Based on the current study, the most frequent sports-related shoulder injuries were dislocation and instability. Since wrestlers and Kabaddi players are more prone to suffer knee injuries than shoulder injuries, these findings can be explained by the fact that they made up a larger portion of the study group than athletes from badminton, basketball, and tennis. 74.13 % of athletes resumed their sports following an injury but only 38.71 % were able to reach pre-injury performance. A few factors that may have contributed to this include delayed referrals, inadequate on-site assistance, late presentations, local quack treatment, and restricted access to sports-specific physiotherapy. Athletes who received conservative treatment were generally less dedicated to returning to sports.
Injury rates were found to be lower when systematic warm-ups were used before training or competition. Additionally, the rate of return to sports was increased by the presence of a qualified coach and professional rehabilitation assistance. Professional athletes are more motivated than amateur athletes, which may explain why they return to sports more frequently. Furthermore, athletes who had surgery recovered more quickly, which allowed them to resume sports more quickly and effectively. The gender gap in Indian sports and the socioeconomic structure of the Indian population may be the reasons why more men than women returned to sports.
This study highlights the severe consequences that sports-related knee and shoulder injuries have on athletes, as well as the enormous burden they place on their careers. We do, however, recognize this study's shortcomings. Since bias in the study population cannot be ruled out, there are certain unavoidable inherent flaws in the study's design. Furthermore, a gender bias resulted from the clear gender distribution discrepancy. Given the significant disparity in women's sports involvement, particularly outside of metropolitan areas, this was to be expected. To attract more women, future research should attempt to mitigate this bias by incorporating a more multicentric approach. This study was unable to determine the precise on-site incidence rates of distinct injuries in different sports because it was based in a tertiary care hospital, and only athletes who sought out hospital-based treatment were recruited in the study. A multi-centre study or a community-based study would be more suited to cater to a wider data collection and improve the strength of the study. Furthermore, only six of the nine sports modalities in the study had sample sizes larger than ten, making it challenging to do sub-group analysis in these specific categories. This was probably influenced by more athletes participating in financially rewarding and locally popular sports. A more focused recruitment approach in the future to accommodate the under-represented sports could prevent this.
To accurately determine damage incidence and strategies to overcome these limitations, more multicentric, long-term, prospective studies with related exposure data and video footage will be required in the future. Studies like this should preferably be conducted in a variety of professional sports leagues, sports academic institutions, universities, etc. to more accurately determine the incidence rates and individual risk factors of various sports injuries. Based on impromptu observations of injury clusters and a thorough understanding of the repercussions, this will help make well-informed decisions regarding topics like training schedules and game regulations. Sports-related injury rates are successfully reduced by preventive and safety measures.9, 10, 11, 12 We can look forward to formulating policies to prevent and reduce the burden of sports-related injuries in athletes only if we create a sound epidemiological database.
5. Conclusion
Athlete injuries, particularly ACL tears, are a major problem since they may result in a player losing a significant amount of time throughout their career and placing a financial burden on both the athlete's family and the healthcare system. According to the study, injury prevention techniques and the availability of professional assistance are crucial, and they inevitably influence recovery and return to sports.
CRediT authorship contribution statement
Amit Mor: Investigation, Conceptualization, Formal analysis, Resources. Ashish Devgan: Conceptualization, Methodology, Supervision, Project administration. Anurag Bhakhar: Writing – original draft, Writing – review & editing. Umesh Yadav: Data curation, Validation. Nirvin Paul: Conceptualization. Arvind Yadav: Visualization, Software.
Patient consent
Written informed consent has been obtained from the patient or guardian for participation and publication.
Ethical clearance
Anaesth/19/746, 27/03/2019.
Source of funding
None.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
None.
Contributor Information
Amit Mor, Email: amitmor9221@gmail.com.
Ashish Devgan, Email: ashishdevgan@gmail.com.
Anurag Bhakhar, Email: anuragbhakhar@gmail.com.
Umesh Yadav, Email: drumeshyadav735@gmail.com.
Nirvin Paul, Email: drnirvinpaul@gmail.com.
Arvind Yadav, Email: akyadavmdb@gmail.com.
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