Meniscal Injuries in the Olympic and Elite Athletes

Abstract

Introduction

Elite and Olympian athletes are often stretching the upper limits of normal physiology and biomechanics of the musculoskeletal system in their efforts to excel in their sport. For them to get back to their sport at the same level after injury, the management, repair techniques, and rehabilitation protocols should be robust to permit healing of tissues to allow supra-normal loading and performance. The knee and the meniscus are commonly injured in these sports. Yet, the incidence, mechanisms, types of injuries to the meniscus, and their management are not known across different sports in the Olympics.

Methods

We set out to look into the incidence and the trends of publications on meniscal injuries of the knee in Olympic games. A search of the PubMed and Scopus for these injuries using a search strategy gave 79 and 116 articles, respectively.

Results

There were very few publications giving the incidence of meniscal injuries in the Olympics. Football is the sport with the highest rate of meniscal injuries. Different sports are popular in different countries, and depending on the popularity and the country reporting these injuries, incidences differed. There was data available from India and Brazil for Elite athlete from diverse sports, whereas most data from other countries were for football and soccer. Knee was found to be the second most commonly injured part of the body in both Winter and Summer Olympics as well as the Youth Winter Olympics. Data were not available from the Youth Summer Olympics to make any conclusions. The number of publications on this topic is low. We presented the timeline of publications and citations of articles on this topic. The top country, language, journal, university, and author were USA, English, American Journal of Sports Medicine, Hospital of Special Surgery in New York and Brophy RH, respectively. The data on the risk factors for meniscal injuries were analyzed, discussed, and presented for football, as this was the most extensively studied sport.

Conclusions

Even though the knee is one of the commonly injured anatomical locations in elite athletes, there is a lack of literature on meniscal injuries in this subset of population. We looked at possible reasons and made recommendations to improve data collection on these injuries.

Electronic supplementary material

The online version of this article (10.1007/s43465-020-00049-y) contains supplementary material, which is available to authorized users.

Introduction

Olympic Games are, indeed, the most prestigious games that take place on a world stage for the sportspersons. The participation in these games requires a lot of practice and execution of high standards by these individuals. Hence, these people are prone to various sports-related injuries in the body. The knee is a commonly involved joint in sports injuries, and the menisci and ligaments are the most commonly injured structures. Ironically, publications on meniscal injuries in Olympic athletes are very few. The reasons for such few publications are discussed and presented in the Discussion section.

The mechanisms of occurrence, forces involved, management, and results of injuries in Olympic events may differ as there are different environmental, kinetic, and physiological factors operating in Summer, Winter, and Adult and Youth Olympics. Youth Summer Olympics (YSO) was started in the year 2010, the year of winter Olympics. Youth Winter Olympics (YWO) was begun from the year 2012, the year of the Summer Olympics (SO). Age restriction for Youth Olympic events is at 14–18 years. Since the management of some of the injuries differs between the youth and adult age groups, it is imperative that these injuries are studied in detail to educate prospective sportspersons on ways to avoid these injuries.

The aim of this study was to look into the available literature and their scientometrics to identify best sources of information on this topic. Specifically, on the meniscus, we looked at the incidence of meniscal injuries compared to other injuries in sporting events in elite and Olympic athletes, which sport is associated with maximal numbers of these injuries. Focussing on football, we looked to see if there was any difference between Olympic event and World Cup/Premier League events, any effect of injury on the team and the athlete as a whole and his/her life and prognosis, which countries had best data on this problem and where India stands in this and finally if we can device preventive strategies from the available data. Where specific information in meniscus and Olympians was not available, we presented data on knee injuries as they form a surrogate marker of meniscal injuries along with ACL injuries.

Methods

A literature search was done to identify articles on meniscal injuries in professional athletes using the strategy given below on 2/11/2019.

[(knee) AND (((Meniscus) OR meniscal) OR menisci)] AND [(((elite athlete) OR professional athlete) OR Olympic athlete) OR high-performance athlete]. This resulted in 79 articles.

A similar search strategy was employed to search in Scopus on 3/11/2019.

[(knee) AND (((Meniscus) OR meniscal) OR menisci)] AND [(((elite athlete) OR professional athlete) OR Olympic athlete)].

It resulted in 116 documents. Both the outputs were used to compile the results of this study. We have not looked into the Paralympic events, since we only wanted to study injuries in athletes with normal biomechanics and function.

Incidence of meniscal injuries was extracted from the literature from articles reporting injuries in several Summer, Winter, and Youth Olympic games from the past and related articles. The search strategy for incidence was:

[(((injury OR injuries) AND (Epidemiology OR incidence)) AND (Football OR soccer)) AND (Professional OR elite OR experienced)] AND (meniscus OR menisci OR meniscal) done on 9/12/2019. It resulted in an output of 22 articles. Using the same strategy in Scopus search, 25 articles were retrieved. Both the results were synthesised to compile 40 reports on the epidemiology of injuries in football as it was the sport studied in detail among all sports.

The data were stored and analysed using Microsoft Excel 365.

Results

Analysis of PubMed Publications

Yearly publications Yearly publication numbers were similar to those seen in Scopus (Fig. 1). Recent publications have shown an increased publication trend in the year of Summer Olympics, being maximum in the years 2012 and 2016.

Fig. 1.

Chart shows the timeline of number of publications and citations

First author There were a total of 77 first authors who published on this topic. Brophy RH and Jäger A were the most published ones with only two publications each. The smaller numbers indicate that there are not many publications, overall.

Journals in PubMed (Table 3) There were a total of 47 journals publishing on this topic in PubMed. The maximum number of publications was done by the American Journal of Sports Medicine (AJSM) with nine publications followed by Knee Surgery Sports Traumatology and Arthroscopy (KSSTA) with eight.

Table 3.

Journals publishing in Scopus and PubMed

Source title	Scopus	Total Citations	PubMed
American Journal of Sports Medicine	7	313	9
Arthroscopy—Journal of Arthroscopic and Related Surgery	7	246	7
Knee	3	238	3
The American Journal of Sports Medicine	1	193	–
Medicine and Science in Sports and Exercise	1	182	2
Knee Surgery, Sports Traumatology, Arthroscopy	8	148	8
Clinics in Sports Medicine	3	112	3
British Journal of Sports Medicine	3	76	–
Clinical orthopaedics and related research	2	76	2
Investigative radiology	1	48	–
Sportverletz Sportschaden	–	–	3
Cartilage	–	–	2

Languages publishing English was the predominant language with 67 publications followed by German (7), Spanish (2), and 1 each for Swedish, French, and Croatian. No other language had publications indexed on PubMed including Chinese, Russian, or Japanese. It is an irony that there was a dichotomy in the gold medals received by China, Russia, and Japan, and the publications on this topic indexed in PubMed from these countries.

Scopus Analysis

The total number of publications found on Scopus for the search strategy given was 116 and the total number of citations of these publications was 2095.

Journals on Scopus (Table 3) American Journal of Sports Medicine (AJSM) remained the most published journal on this topic with a total number of publications of 10 and a citation count of 551. This table gives AJSM two entries because of the small change in the way which the entries have been made. This has been left uncorrected to highlight this fact and to substantiate that the quality of data entry becomes vital in retrieving high-quality output while analyzing such data.

Timeline number and citations (Fig. 1) Although the number of publications since 2015 has been high, the peak year for citations was 2009 with 472 citations. There is an obvious lag for the number of citations to the peak. Citations peaked in 1991, 2005, and 2009. The years 2005 and 2009 were preceded 1 year earlier by the summer Olympics.

Authors in Scopus (Fig. 2) As in PubMed, Brophy was again the most published followed by Sonnery-Cottet B.

Fig. 2.

Chart shows the top ten published authors

Universities (Scopus) (Fig. 3) The top ten published universities on this topic were from the following countries USA (4), followed by Switzerland (3), and one each from Italy, India, and Germany. The numbers published by each were modest with a maximum of seven publications. With the headquarters of FIFA in Switzerland and football being the most popular sport in that region, it could be the reason for this region having three universities publishing on this topic.

Fig. 3.

Chart shows the top ten most published universities on this topic

Countries (Scopus) (Fig. 4) The USA was the topmost country for publishing on this topic with 38 articles, followed by Germany (12) and the UK (10). Although not listed in the top 10 in Scopus, India has three publications on this list.

Fig. 4.

Chart shows the top ten most published countries on this subject

Incidence

Due to the frequent actions of pivoting and cutting, the menisci are at particular risk of injury, and meniscal tears account for 8% of all injuries sustained over a season in professional soccer [1].

Rugby sustained more injuries to the knee than other sports in one study. The most commonly injured body region for time loss was the knee (21%). The most common type of injury in the knee was ligament sprain (43%, including all joints) and frequently occurred during the competition (71%) [2] as opposed to during rehearsals.

The knee was also the most commonly injured joint in wrestling (24.8% of wrestling injuries occurred in the knee). Other sport in which knee injuries were common was Judo (9.7%) [3].

Seventy six knee injuries among Kabaddi players from India were studied by Dhillon et al. [4]. Within these injuries, almost 54% were professional players. 72% of the injuries occurred by a contact mechanism and 88% happened during competing. Of these, 89% were ACL injuries and meniscal injuries occurred in 68.4%. Medial meniscal tears were seen in 32 knees and lateral meniscal tears were seen in 20 knees.

The total number of injuries in all winter Olympics for which data were available (2010 WO, 2012YWO, 2014WO, 2016YWO, and 2018WO) were 1273 among which knee injuries were 149 with an overall incidence of knee injuries among all injuries of 11.7%.

Incidence of knee injuries in Winter Olympics (Table 1) Table 1 gives an incidence of knee injuries among all athletes as an overall incidence and also percentage knee injuries among all the injuries that were seen during each of the events listed in the table. Knee injuries are the second most common injuries in Winter Olympic events after ankle injuries. They are more common among Alpine and snowboarding events compared to other.

Table 1.

Event and sportwise knee injuries published on Winter Olympics

	2010 WOa	2012 YWOb	2014 WOc	2016 YWOd	2018 WOe
Bob—bob	Knee = 1/314 (0.32%)
Bob—skeleton
Bob—luge
Curling	Knee = 0/100 (0%)	Knee = 0/64 (0%)		Knee = 2/64 (3.13%)
Ice hockey	Knee = 7/444 (2.23%)	Knee = 0/199 (0%)	Knee = 4/466 (1.27%)	Knee = 1/199 (0.5%)
Skating—figure	Knee = 5/432 (1.59%)	Knee = 3/153 (0.96%)
Skating—short track
Skating—speed
Alpine and snowboarding—Alpine	Knee = 24/665 (7.64%)	Knee = 11/222 (3.5%)	Knee = 17/580 (5.41%)	Knee = 14/317 (4.46%)
Alpine and snowboarding—freestyle—cross
Alpine and snowboarding—freestyle—aerial
Alpine and snowboarding—freestyle—moguls
Alpine and snowboarding—snowboard—cross
Alpine and snowboarding—snowboard—Halfpipe
Alpine and snowboarding—snowboard—Slalom
Ice track sports		Knee = 1/134 (0.32%)		Knee = 1/166 (0.6%)
Nordic skiing—Biathlon	Knee = 2/615 (0.64%)	Knee = 0/243 (0%)		Knee = 1/246 (0.41%)
Nordic skiing—cross country
Nordic skiing—ski jumping
Nordic skiing—combined
Overall among all athletes	Knee = 39/2567 (1.52%)	Knee = 15/1015 (1.48%)	Knee = 26/2780 (0.94%)	Knee = 19/1131 (6.05%)	Knee = 53/5914 (0.9%)
Incidence among all injuries	13.59% of all injuries	13.51% of all injuries	5.88% of all injuries	17.6% of all injuries	14.1% of all injuries

WO Winter Olympics, YWO Youth Winter Olympics

^aEngebretsen et al. [5]: Vancouver WO

^bRuedl et al. [6]: Innsbruck YWO

^cSoligard et al. [7]: Sochi WO

^dSteffen et al. [8]: Lillehammer YWO

^eSoligard et al. [9]: PyeongChang WO

While Engebretsen et al. [5] found in 2010 WO that the knee and the head were the most frequent body parts injured among alpine and freestyle skiers, and snowboarders, Ruedl et al. [6] found in 2012 YWO that the most affected part was the knee at 14% of all injuries (111 in number and 4.78% in all competing athletes). 73% occurred during Alpine Skiing and snowboarding and most of these injuries were severe injuries [6]. Steffen et al. in 2016 presented data on 2016 YWO and found 17.6% knee injuries among all injuries during the games.

Incidence of knee injuries in the Summer Olympics (Table 2) Table 2 gives a summary of knee injuries in studies published on Summer Olympics. Among Gymnasts and team sports, ankle injuries appear to be the most common body part injured followed by the knee. However, among all injuries in the Olympic events, knee and thigh injuries were the most common parts injured. There were no data available for YSO from the last three events. A benchmark recording of injuries should be performed to be able to compare with future events to improve on injury incidences.

Table 2.

Publications on injuries in the Summer Olympics

Events vs findings	Total players	Injuries	Summary of findings
2008, 2012, 2016 (knee injuries in 963 Gymnasts)a	963 Gymnasts		Ankle injuries were the most common injuries in all Gymnasts. 2.5% were knee injuries, and 2.5% were meniscal injuries with 3.2% causing time loss due to injury
Team sports injuries in 2004 SO Athensb	6953 Players		The knee is the third most commonly injured part after head and ankle with an incidence rate of 13% of injuries. There were 54 overall injuries per 1000 players. More than half the injuries occurred in the lower limbs. Ligament rupture and meniscal injuries were among the most severe injuries that prevented players from returning to the sport
2004 SO Athensc	10,625 Athletes		71 (14%) of knee injuries seen among all injuries at a physiotherapy clinic in the Olympic Village of the 398 athletes who visited. Of these, 49 (12%) were athletes. Details of injuries not reported. Most commonly injured areas were the thigh followed by the knee
2008 SOd Beijing	10,977 Athletes	1055 total injuries (injuries = 10%)	The knee is the second most commonly injured part (12%) after thigh injuries. No indication is given in this paper as to the most common sport that is likely to cause knee injury specifically
2010 YSO Singapore	3600 Athletes		Not reported
2012 SO Londone,f	10,568 Athletes	1457 MSK encounters (injuries = 12%)	1457 musculoskeletal encounters were seen. Total Injuries incidence = 12%. Peak usage services were found to be 9–10 days after start coinciding with the greatest number of finals for events
2014 YSO, Nanjing	3579 Athletes		Not reported
2016 SO Rio De Janeirog	11,274 Athletes	221 severe injuries (total injuries = 8%)	Most common part injured was knee (130) followed by the thigh. No details of the subclassification of injuries given. Football injury incidence was found similar to FIFA world cups 2004 and 2014 (10–23% among five FIFA world cups)h
2018 YSO, Buenos Aires	3997 Athletes		Not reported

SO summer olympics, YSO youth summer olympics

^aEdouard et al. [10]

^bJunge et al. [11]

^cAthanasopoulos et al. [12]

^dJunge et al. [13]

^eVanhegan et al. [14]

^fEngebretsen et al. [15]

^gSoligard et al. [16]

^hJunge et al. [17]

Incidence of knee injuries in team sports in SO 2004 [11] The data from 377 injuries from 456 matches were presented. There were 48 knee injuries and only four lesions of the meniscus. Team Sports causing meniscal injuries were soccer, handball, and basketball.

Discussion

Standardised recording of injuries of Summer Olympic events started in 2004 (Table 2). Most reports on the injuries in Olympic Games are Epidemiologic studies that do not go into specific details of injuries, for example, which ligament injury or the subclassification of meniscal injuries, but only provide the incidence of injuries. Football, which is the most popular sport in the world, has been extensively studied outside the Olympics. Incidence of injuries in Football was measured in terms of injuries per 1000 h of sport, whereas, in the Olympics, which is less intensive for an individual sport and thought to be less competitive than the corresponding world cup or Premier League, the incidence is given as a percentage of overall injuries.

To get information about subclassifications of meniscal injuries, their treatment and prognosis, one would have to look into publications by specialist knee surgery units who have published on the results of injuries to elite athletes. However, these athletic injuries would not be restricted to just the Olympics, but also other games and training sessions. Hence, details of meniscal injuries, from the data given out by publications reporting on Olympic injuries alone, are not available. Furthermore, the researchers doing Olympic studies may not be specialized knee surgery practitioners. Hence, we have included those search terms in our search strategy.

Winter Olympics involve mostly skiing where lower limb injuries are common, whereas Summer Olympics involve contact sports, racket sports, as well as team events. In the lower limb, knee injuries appear to be commonest injuries in the Summer events, while ankle injuries are commonest in the winter events followed by the knee. While a physical impact with the player in a winter event is dissipated due to minimal friction on the ice, this does not happen in the summer events as the foot is firmly planted on the ground, predisposing to injury to the knee. Another possible reason is contact sports are more in number in the summer events with bigger teams of players. Participant numbers are also higher in summer events compared to the winter and youth events.

The last two WO games (YWO 2016 and WO2018) reported high incidences of knee injuries compared to the previous games (Table 1). Possible reasons could be better reporting of injuries or increased number of participants or increase in the actual incidence or a combination of these. The techniques of athletes and facilities provided should be examined as to why the incidence was higher. The presentation of data changed in recent publications [9] where only percentages were given and data presented in bar charts. Consequently, overall knee injuries numbers alone were presented for that year in Table 1.

There is no record for injuries in the Youth Summer Olympics. Injuries to the meniscus in team events appear to be relatively low [11], but overall in summer Olympic events, knee injury is among the top two common locations of injuries.

Publications vis-à-vis gold medals The number of publications from each country in relation to the number of gold medals from each country is presented in Fig. 5. One major limitation for no publications from the Soviet Union or Russia could be the language. Although Japan and China had a high number of medals, their publication numbers on PubMed were low. Again language could be the main limiting factor with these countries as their main languages are not English.

Fig. 5.

Publications vs gold medals by countries

Incidence of Meniscal Injuries of the Knee Among Indian and Brazilian Athletes

John et al. [18] looked at sports-related injuries to the knee in professional and amateur athletes from India among 363 athletes and found an overwhelming majority of injuries to be ACL injuries (86.5%) followed closely by meniscal injuries (78.2%). The medial meniscal injury was more commonly seen (53.7%) compared to the lateral meniscus (24.5%) which is 2.2 times approximately. The overall incidence of meniscal injuries for the types of sports played in Brazil was 18% (79 injuries in 430 athletes), whereas it was 79% (284 injuries in 363 athletes) for Indian Players. Of the athletes sustaining any knee injury, less than 40% returned to the sport in India and those treated surgically were more likely to return back to the sport than those treated conservatively.

The data on meniscal injuries (medial and lateral menisci) are presented in the supplementary Table 2. Although the number of injuries was less in nine events, the percent of injuries were 100% or more, indicating that athletes from those sports had high chances of meniscal injuries. The numbers are low among these sports in this study. Further studies with larger numbers are required to establish a higher prevalence of injuries in these events (Table 3).

Nicolini et al. [19] looked into knee injuries among 430 athletes in Brazil and reported the highest percentage of meniscal injuries in skating followed by surfing. The type of sport reported by both authors had a different spread of sporting events. While football was the most common sport with the maximum number of injuries in both studies, street run, volleyball, athletics, and basketball were in descending order of occurrence after football in Brazil, whereas, in India, Kabaddi, athletics, cricket, and volleyball were more common in the descending order. The difference in incidence could be related to the type of sports that are popular in these two countries.

None of the individual countries has reported specifically on knee injuries or on meniscal injuries in Olympic or elite sporting activities. There are multiple publications on individual sporting injuries, particularly for football in the world cups and Premier League matches as this is the most popular sport.

Baker et al. [20] reviewed discharge summaries of 1515 meniscectomies over a period of 9 years (1973 to 1982) in the New York area of which 505 were sports-related. The variables related to meniscectomies were studied and compared between general population and sports. They found the ratio of medial vs lateral meniscectomy was 4.9:1 in the general population. In skier's, meniscal injuries in females were higher than males in a ratio of 2.4:1. Right knee meniscus was more frequently injured in basketball players and between the two menisci, the medial meniscus was injured in 75% cases in Football, 75% in basketball, 55% in wrestling, 78% in skiing, and 90% in basketball.

The odds ratio (and confidence intervals) of developing meniscal tears compared to participants who had not played sport for at least 12 months prior to symptoms for different sports were Football 3.58 (1.87, 6.86), rugby 2.84 (1.48, 5.45), running 1.24 (0.74, 2.07), and swimming 1.54 (1.09, 2.17) [21]. Hence, playing the sport regularly reduces the odds of injury.

In an effort to find preventive strategies for meniscal injuries, we studied the risk factors and consequences of meniscal injuries in football and classified the variables involved for the injuries. The findings are summarized in Table 4c.

Table 4.

Risk factors and consequences of meniscal injuries and variables involved in knee injuries in football

(a) Factors that increase risk of Knee/Meniscal Injuries in Football	(b) Consequences of Meniscal Injuries in Football	(c) Variables involved in knee injuries in sport
Condition of the ground	Loss of time in the sport	Environmental
Lack of warm-up period before play	Impaired efficiency of sport	Ground condition
Not performing particular exercises	Early-onset of OA of knee	Hardness
Position of the player in the field (midfielders)	Higher radiological signs of OA in injured	Dryness
Age of player (14–22 yrs)	Higher rates of TKR in injured	Grass cover
Experience < 10 years of players	MRI showed significant findings even in asymptomatic non-injured athletes	Root density
Low nutritional status of players	Injuries shorten sporting careers	Surface/terrain—snow/water/roughness of ground
Contact injuries	Chondral loss following partial meniscectomy	Weather
Unsupervised players	Partial meniscectomy and further arthroscopies	Winter—snowing/cold
The second half of play		Autumn
Lack of ground watering/softening		Summer
Long cleats in shoes of players		Rainy
Previous injuries to the knee		Player related
Competitive games > training games		Nutritional status of the player
Anabolic steroids		Age of player
Absence from sport > 4 weeks		Fatigue factor (first half vs final half)
Danish, Dutch, and English players		Experience of the player in years
Lateral partial meniscectomy poorer prognosis than medial partial M’ectomy		Supervision
Longer recovery periods for goalkeepers		Position in play (forward vs back)
Lack of Injury prevention programmes		Exercise and warm-up before play
		Type of shoe worn (cleats)
		Previous injuries
		Genetics
		Technique of play
		Type of sport
		Football, Rigby, Soccer, Wrestling, Hockey
		Contact Sport
		Speed of the game
		Impact/loading games
		Lower limb intensive vs upper limb intensive games
		Equipment used for play

Meniscal injuries broadly appear to be of three types: primary acute isolated injury to the meniscus, Primary acute combined injury to the ACL and the meniscus and secondary injury to meniscus following ACL injury after a period of instability [22–25].

Gee et al. [26], in their review, classified sporting events based on the level of risk of injury to the meniscus. The high-risk group consisted of football, soccer, basketball, and wrestling in decreasing order of risk. Moderate-risk group consisted of Gymnastics, lacrosse, ice hockey, field hockey, and baseball/softball in decreasing order. The low-risk group consisted of track and field events, swimming and cheerleading in decreasing order.

Reports on knee injuries in elite athletes and football players have been published from different countries including Brazil [19, 27–29], Australia [30], Iceland [31], Sweden [32], South Africa [33], USA [32, 34–39], The Netherlands [40], Germany [41], Kosovo [42], India [4, 18], Bangladesh [43]. Danish, Dutch, and the English players which were found to be more prone for injuries [44].

The knee is the second most common region to be injured after the thigh [45–47] in football and the most common structure to be injured in the knee is the ACL (54%) [19] followed by meniscus. There is no difference in the incidence of injuries between Olympic football injuries compared with FIFA world cup injuries [17]. 34% of ACL injuries have an associated meniscal injury. Cutting, pivoting, and contact injuries are believed to be the reason for an increased incidence of injury of ACL and menisci in football [19].

The following risk factors [43] were associated with risk of knee injuries in football. Condition of the ground, warm-up period before play, performing particular exercise or its lack of, position of the player in the field during play (midfielders suffered more injuries), age of players, and experience. Morgan et al. [48] found no relation of injuries with age or position in the field. Nutritional status of the athlete influenced injuries: only 30% were injured if nutrition was very good as opposed to 64% if the status was good. Contact injuries were higher than non-contact injuries. Unsupervised players sustained more injuries compared to supervised players [19]. Fatigue is another factor reported, since the second half of sporting events found more injuries compared to the first half [45, 47, 49]. Climate did not have an effect on meniscal injuries [50].

Measures that reduce shoe-surface traction were recommended to reduce non-contact injuries. These include ground watering and softening, playing during winter, use of natural grass (ryegrass), and short cleats in shoes of players [50]. Although there is an increased risk of ankle injuries in artificial turf compared to natural turf in football and rugby, there is no difference in knee injuries [51].

Age and previous injuries are risk factors for all injuries in football [31] and having an injury to the knee is the most common cause of time loss in sport [33]. Majority of studies showed lower rates of injury during training compared to that during competitive matches [42]. Anabolic steroids increase the risk of ligament and meniscal injuries [52] and among high school athletes, meniscal injuries varied by gender, sport, and type of exposure and 63% of these injuries required surgery [39].

An absence from the sport of more than 4 weeks increased the risk of injury [44] due to prolonged lack of practice. The efficiency of athletes was impaired following a knee injury [27] and their careers shortened [34]. Players who had an injury previously are at increased risk of similar injury in subsequent seasons [32] by a factor of up to three [53]. At 25 years after an injury, 63% of those injured showed signs of arthritis compared to 26% in uninjured knees [54]. They had higher radiological signs of OA compared to nonelite athletes [55]. Even in asymptomatic athletes, MRIs showed significant findings [31].

One-fourth of the players injured needed to undergo surgery [36] and the most common surgeries on these patients were arthroscopic partial meniscectomies. In retired athletes who had undergone TKR, osteoarthritis was commonly secondary to a meniscal injury [37] compared to non-injured athletes. Non-injured athletes, in turn, had higher rates of TKR compared to the normal population. Lateral partial meniscectomy had a poorer prognosis than medial partial meniscectomy in terms of return to the previous level of play, return to play, increased adverse events post-surgery, longer recovery, and need for further arthroscopy [56].

Side midfielders had the shortest recovery periods, while goalkeepers had the longest [29]. This could reflect on the severity of the injuries sustained in those positions. Female elite players had a substantial meniscal loss and isolated partial meniscectomy increased chondral loss [57] in these subjects. 58% of injuries seen among female soccer players were to a knee ligament or meniscus [58]. The pressure to return early to play after injury also has a high risk of joint degeneration in athletes [59].

While current surveillance systems are able to record broad categories of injuries.

Robust systems are needed to record data in details in Olympic events as they lack depth of information.

Strategies to prevent injuries could include the following:

• Using the experience of players with more than 10 years [43] to guide younger players in preventing injuries.

• Employing training programmes like FIFA11 + which have been shown to reduce injury rates by 30% [60].

• Addressing environmental, personal, and sports-related variables that are involved in causing injuries (Table 4).

• Reducing risk factors for injury to the meniscus (Table 4).

• Further studies on the lines of those done for football to reduce injuries in other sports.

• Knee societies could formulate a format of data collection to gather details in knee injuries.

• Since knee injuries are the commonest in winter and summer Olympics, a focused study on knee injuries by specialist units during the events could improve data accuracy for details on the mechanisms, management, and outcomes of meniscal injuries.

• Since most of these events are televised, mechanisms of these injuries may be studied using clippings from the events, and perhaps, severe injuries may be predicted or identified from these clippings to route them to relevant specialists early.

Conclusions

Alpine skiing and football were associated with the greatest number of knee injuries, in the winter and summer Olympics, respectively. There are very few publications on meniscal injuries in elite sportsmen except in football. No correlation was found between publications or citations with the year of games or country getting the greatest number of medals. AJSM and USA were the journal and country publishing most of these injuries. The number of publications has increased steadily and standardized, since the surveillance of injuries in these games was introduced.

The pattern and details of the injuries in the elite athletes involved in the Olympic Games need to be properly documented and studied in future. It would help the researchers to identify the nature of these injuries and their relationship with the various types of sports. Furthermore, the preventive and management strategies could be devised to protect these top athletes from any long-term disabilities related to these injuries. We recommend that any sportsperson sustaining an injury is properly evaluated by a sports specialist doctor and appropriate investigations, like MRI, done early to diagnose and treat the injury promptly. The current documentation template may be extended to include details of injuries sustained and, perhaps, published by the International Olympic Association in their website for those interested parties to look into details of injuries to identify and device strategies to decrease the incidence of severe, career-altering injuries.

Majority of studies report poor prognosis to the career and the knee following meniscal injury and/or partial meniscectomy compared to non-meniscal injured elite athletes.

More studies are needed to look into meniscal injuries in events other than football. Attention to the risk factors causing knee/meniscal injuries listed could reduce the incidence as most of these are controllable.

There is a high incidence of meniscal injuries among elite Indian athletes. Further studies with higher numbers are required to explore reasons and possible solutions and prevention strategies to reduce this incidence.

Electronic supplementary material

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Author contributions

Concept: RV. Design: RV and SK. Intellectual content: RV, SK, and AV. Literature search: RV and SK. Data acquisition: RV and SK. Data analysis: RV, SK, and AV. Manuscript preparation: RV, SK, and AV. Manuscript editing: RV, SK, and AV. Manuscript critical review: RV, SK, and AV. Approval of manuscript: RV, SK, and AV.

Compliance with Ethical Standards

Conflict of interest

The authors declare no conflict of interests (i.e., personal associations or involvement as a director, officer, or expert witness) in relation to the content published here. Presentation at a meeting: Organisation Nil, Place NIL, and Date Nil.

Ethical standard statement

The manuscript has been read and approved by all the authors. The manuscript represents an honest work by the author. There are no submissions and previous reports regarded as redundant publication of the same or very similar work. I (we) affirm that I (we) have no financial affiliation (including research funding) or involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript

Informed consent

Informed consent is not necessary for this article since no patients were involved in doing this study.