sports-related injuries in athletes with disabilities

Review

Sports-related injuries in athletes with disabilities

K. Fagher1, J. Lexell1,2,3

1Department of Health Sciences, Lund University, Lund, Sweden, 2Department of Rehabilitation Medicine, Skåne University Hospital,Lund, Sweden, 3The Swedish Sports Organization for the Disabled and The Swedish Paralympic Committee, Lund, SwedenCorresponding author: Kristina Fagher, RPT, MSc, Department of Health Sciences, Rehabilitation Medicine Research Group, LundUniversity, PO Box 157, 221 00 Lund, Sweden. Tel: +46 46 222 1991, Fax: +46 46 222 1808, E-mail: [email protected]

Accepted for publication 9 December 2013

The number of athletes with disabilities participating inorganized sports and the popularity of the ParalympicGames is steadily increasing around the world. Despitethis growing interest and the fact that participation insports places the athlete at risk for injury, there are fewstudies concerning injury patterns, risk factors, and pre-vention strategies of injuries in disabled athletes. In thissystematic literature search and critical review, we sum-marize current knowledge of the epidemiology of sports-related injuries in disabled athletes and describe theircharacteristics, incidence, prevalence, and preventionstrategies. The outcomes of interest were any injury,either an acute trauma or an overuse event. PubMed,

EMBASE, CINAHL, and Google Scholar were systemati-cally searched and 25 of 605 identified studies met theinclusion criteria. Lower extremity injuries were morecommon in walking athletes, whereas upper extremityinjuries were more prevalent in wheelchair athletes. Themethodologies and populations varied widely between thestudies. Few studies were sports or disability specific,which makes it difficult to determine specific risk factors,and few studies reported injury severity and preventionof injuries. Further longitudinal, systematic sports anddisability specific studies are needed in order to identifyand prevent injuries in athletes with disabilities.

Exercise is frequently associated with health benefitsand is widely recommended as a proactive behavior toreduce the risk of several diseases such as osteoporosis,cardiovascular diseases, the metabolic syndrome, andcancer (Pedersen & Saltin, 2006). For a disabled person,it is even more important to be physically active toimprove and maintain cardiovascular fitness, self-efficacy, and self-perceived quality of life (Blauwet &Willick, 2012). Participation in organized sports is anatural way for people with disabilities to be physicallyactive, and the opportunities to take part in organizedsports have increased markedly during the last decades.

However, participation in sports also increases the riskof sports-related injuries, either acute trauma or overuseinjury. An injury may lead to morbidity and mortality(Kjaer et al., 2005; Ljungqvist et al., 2009) and the indi-vidual could lose training time and working/school time.Furthermore, sports-related injuries can be a burden for thesociety, with medical treatment, rehabilitation, and reducedwork capacity (Kjaer et al., 2005). For the disabled athlete,an injury could also have more serious consequences com-pared with an able-bodied athlete. For example, an upperextremity muscle strain may influence the throwing in anable-bodied javelin thrower, whereas it will affect bothsports participation and activities of daily living in a dis-abled wheelchair javelin thrower (Vanlandewijck &Thompson, 2011). Despite the growing popularity and

interest in competitive and Paralympic sports, there hasbeen little research on injuries caused by sports participa-tion among disabled athletes.

In a health-care perspective, Paralympic sports posesmany challenges not faced in Olympic sports (Webborn& Van de Vliet, 2012). Existing studies show that theoverall rates of injuries are considerably high andcomparable with injury rates in able-bodied athletes.However, data regarding the epidemiology of injuries,time loss due to injury, injury severity, and sports anddisability specific risk factors are very limited. Further-more, very few studies have assessed injury preventionstrategies. The aim of this systematic literature searchand critical review was therefore to bring togethercurrent knowledge about injury epidemiology with afocus on prevalence, incidence, etiology, risk factors,and prevention strategies of sports-related injuries in ath-letes with disabilities participating in organized sportsand Paralympic sports.

Methods

This review is based on a structured systematic literature search thatwas conducted in the following databases: PubMed, CINAHL,EMBASE, and Google Scholar. The first database search wascompleted before the 25th of April 2013 and updated on 1st of June2013. The literature search employed the following keywords:“sports” AND “Paralympic” OR “disability” AND “wounds and

Scand J Med Sci Sports 2014: ••: ••–••doi: 10.1111/sms.12175

© 2014 John Wiley & Sons A/S.

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injuries” OR “injury” AND “epidemiology” NOT “review”. Thesearch produced 605 results (Fig. 1). In addition, each reference listfrom the identified articles was cross-checked to verify that relevantarticles were not missed. The same eligibility criteria were consid-ered in the screening of titles, abstracts, and full text.

Eligibility criteria and selection process

To be eligible for inclusion, each study needed to be: (a) written inEnglish; (b) published in a peer-reviewed journal between January1985 and June 2013; (c) include disabled athletes participating inorganized sports or Paralympic sports; and (d) present adequatequantitative results. The conditions of interest were sports-relatedinjuries, either acute injury and/or overuse injury. A total of 43 poten-tially relevant studies were found, assessed, and evaluated against theeligibility criteria; 28 studies were not in the area of interest, and 14other studies were identified through other sources. Finally, 29studies were included for detailed evaluation; four were subsequentlyexcluded because they did not meet the eligibility criteria. Thus, 25remaining studies are included in this review (Fig. 1).

ResultsSummary of search results

Of the 25 included studies, 10 studies were prospectiveand 15 retrospective studies. Thirteen studies were olderthan 10 years, and 18 studies had a definition of injury.Ten studies used prevalence as outcome (9–86%), sevenreported incidence rate (IR), and eight of the studiesreported incidence. Fourteen studies separated the inju-ries as acute or nonacute, 12 reported disability-specificinjuries, and 20 reported sports-specific injuries. Nine

studies reported sports and disability specific injuriestogether. Sports that featured most were swimming,wheelchair basketball, and athletics. No studies reportedinjuries in triathlon or canoe. A majority of studiesreported injuries to the musculoskeletal system, i.e.,injuries to the upper or lower extremities, whereas veryfew reported other type of injuries, such as head injuries(concussion) or injuries to the internal organs.

In the following section, we start by summarizingstudies describing overall injury epidemiology, theninjuries specific to wheelchair athletes, injuries specifi-cally reported during winter sports, and finally acute vsnonacute injuries. In Table 1, we present the character-istics of the 25 reviewed studies. In Fig. 2, the injuriesare described by body location in the 18 studies thatincluded these data, and in Table 2, studies reportingsports-specific injuries are presented.

Overall injury epidemiology

In this section, we describe the overall injury epidemiol-ogy of the reviewed studies. Lower extremity injuriesappeared to be more common in walking athletes [ampu-tees, visual impairments (VIs) and cerebral palsy (CP)](Athanasopoulos et al., 2009; Patatoukas et al., 2011;Magno e Silva et al., 2013b, c). During the 1996 SummerParalympic Games in Atlanta, USA, athletes with a uni-lateral amputation from Disabled Sports USA sufferedfrom a higher injury frequency in the ankle region

Fig. 1. Flow chart of the literature search.

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Table 1. Characteristics of studies and type of injuries

Author, (publicationyear), type of study

Population, disability, sports, and follow-upperiod

Injury definition Results Type of injuries

Athanasopouloset al. (2009

Retrospective

n = nrAge: mean 31.4 yearsIPC impairments*Paralympic Sports†

Physiotherapy Service at the ParalympicSummer Village Polyclinic 2004

nr 131 athletesreportedinjury

Acute injuries 64.1%Overuse injuries 22.1%28.2% tendinopathyMost injuries to the upper extremity among

(WA)Most injuries to the lower extremity among

(VI)Bernardi et al.

(2003)Retrospective

n = 227Age: range 12–60 yearsCP, SCI, amputees, “les autres”Swimming, track and field, basketball1 year

Any muscle pain during the past 12months during sport activity atleast 1 day

Prevalence50.7%

56% shoulder injuriesIncreased prevalence rate of sports-related

muscle pain with increased trainingvolume

Burnham et al.(1991)

Retrospective

n = 151Age: nrIPC impairments*Paralympic Sports†

Paralympic Summer Games 1988

nr 84 injuries in151 athletes

Acute injuries 49%Overuse injuries 51%21.4% of all injuries classified as rotator

cuff impingementHigh number of lower extremity injuries in

(VI)Chung et al.

(2012)Prospective

n = 14Age: mean 28.6Wheelchair athletesWheelchair foil fencing3 years

Trauma that occurred during atraining/competition and prohibitedthe athlete from continuing fencingactivity for at least 1 day

Incidence3.9/1000 h

73.8% upper extremity injuries58.9% strainWheelchair fencers had a higher overall

injury incidence rate than abled-bodiedfencers

Curtis and Dillon(1985)

Retrospective

n = 128Age: mean 29SCI, congenital disorders, postpolio,

amputees, neuromuscular disordersWheelchair sports; track, basketball, field,

swimming, road racingnr

nr Prevalence 72% 33% soft tissue injuriesA high number of training hours was related

to a high number of injuries

Curtis and Black(1999)

Retrospective

n = 46Age: mean 33Female wheelchair athletesWheelchair basketballOne tournament

The Wheelchair User’s Shoulder PainIndex

Prevalence 52% 72% reported shoulder pain and 70%reported hand or elbow pain since start ofwheelchair use

Ferrara andDavis (1990)

Retrospective

n = 19Age: mean 29.5Wheelchair athletesWheelchair; track and field, shooting,

swimming, table tennis1 year

Anything the athlete expressedconcern about and caused loss ofparticipation due to injury or illness

50 injuries in 19athletes

Acute injuries 65%Overuse injuries 23%48% strains58% upper extremity injuries32% of the injuries caused a time loss of 22

days or more of participation in sportFerrara et al.

(1992a)Retrospective

n = 426Age: mean 25.7Track, field, weightlifting, swimmingWheelchair users, CP, VINational Competition 1989

Any trauma to the participant thatoccurred during any practice,training, or competition sessionthat caused the athlete to stop,limit, or modify participation for 1day or more

Prevalence 32% Acute injuries 45.9%Overuse injuries 54.1%44.3% upper extremity injuriesThe athletes with disability demonstrated

approximately the same percentage ofinjury as the athlete without a disability insimilar sports activities

Ferrara et al.(1992b)

Retrospective

n = 68Age: mean 29.6Amputees, SCI, VI, spina bifida, MS,

muscular dystrophySkiingSix months

Any trauma to the participant thatoccurred during any practice,training, or competitive session thatresulted in the cessation, limitation,or modification of the athlete’sparticipation for at least 24 h

100 injuries in68 athletes

Acute injuries 40%Overuse injuries 60%51% upper extremity injuries

Ferrara et al.(2000)

Prospective

n = 1360Age: nrWheelchair users, CP, VI, dwarfMultisports5 competitions, 6 years

Any injury/illness that was evaluatedby the U.S. medical staff during thestudy period

1037injuries/1360athletes

Acute injuries 67.9%Overuse injuries 20.6%22.1% sprainsThe most commonly body location was

thorax/spineMagno e Silva

et al. (2013b)Prospective

n = 13Age = nrVIBlind football4 years (5 competitions)

Symptom 1 day or more Incidence 2.7Incidence rate

0.12Prevalence 86%

Acute injuries 80%Overuse injuries 20%31% contusionsMost common with lower extremity injuries

Magno e Silvaet al. (2013c)

Prospective

n = 40Age = nrVITrack and field4 years (5 competitions)

Symptom 1 day or more Incidence 0.93Incidence rate

0.39Prevalence 78%

Acute injuries 18%Overuse injuries 82%26% spasmMost common with lower extremity injuries

Magno e Silvaet al. (2013a)

Prospective

n = 28Age = nrVISwimming4 year (5 competitions)

Any injury that caused an athlete tostop, limit, or modify participationfor 1 or more days.

Incidence 1.5Incidence rate

0.3Prevalence 64%

Acute injuries 20%Overuse injuries 80%36.6% spasmMost common with injuries in the shoulder,

29.3%

Injuries in athletes with disabilities

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Table 1. (continued)

Author, (publicationyear), type of study

Population, disability, sports, and follow-upperiod

Injury definition Results Type of injuries

McCormacket al. (1991)

Retrospective

n = 90Age = mean 28SCI, amputees, CP, spina bifida,neurological and congenital disorders,WA4 competitions, all past injuries recorded

Trauma that incurred while training,practicing, or competing inwheelchair sports

346 injuries/90athletes

24.9% blistersUpper extremity injuries most common

McCormick(1985a)

Retrospective

n = 60Age = mean 32Amputees, postpolio, VIAlpine skiing1 day, all past injuries recorded

nr Incidence2.0/1000 skiers

days23 injuries in 60

athletes

Knee injuries most common, 17.4%Lower injury incidence compared with

able-bodied athletes

McCormick(1985b)

Retrospective

n = 23Age = range 22–54Paraplegia, amputees, brain trauma, MS,

arthrogryposis,vascular diseaseSit skiers1 day, all past injuries recorded

nr Incidence16.1/1000 skiers

day21 injuries in 23

athletes

Most common with shoulder injuries,33.3%

Sit-skiers were eight times more likely tosustain an injury than disabled athletesnot using a sit ski

Nyland et al.(2000)

Prospective

n = 304Age = -nrIPC impairments*Paralympic Sports†

Summer Paralympics 1996

Soft tissue injuries; strain, sprain,tendonitis, bursitis, contusion

254 injuries/304athletes

Acute injuries 67%Overuse injuries 33%20.9% shoulder injuries

Ramirez et al.(2009)

Prospective

n = 210Age = mean 18Autism, emotional disturbance, mental

retardation, learning disability,orthopedic disability, sensory disability

Basketball, field hockey, soccer, andsoftball

4 seasons

Events resulting in immediate removalof the athlete from the session andmedical treatment by school staffor transport to a hospital. Aphysical trauma that was sustainedto the body region of an athleteduring the injury event.

Incidence 2.0injuries/1000sessionsplayed

44.7% lower extremity injuries31.6% abrasionAthletes with autism, a history of seizure,

and emotional disturbance had a higherinjury rate

Reynolds et al.(1994)

Retrospective

n = 203Age = nrIPC impairments*Paralympic Sports†


nr 291 teammembers, 201attended themedical center

Most common with injuries in the upperextremity and the cervical spine

The injury/illness profile was similar tothose in abled-bodied sport

Patatoukas et al.(2011)

Retrospective

n = 139Age: mean 32.8SCI, postpolio, CP, amputees, “les autres”Wheelchair basketball, track and field,

swimming, gym, powerlifting,wheelchair dancing, shooting

1 competition

Any injury that caused an athlete tostop, limit, or modify participationfor 1 day or more, all injuries inathlete’s sport life included

Incidence SCIathletes 1.47,CP 0.97, otherdisabledathletes 1.16

178 injuries in69 athletes

58.9% soft tissue injuriesThe number of fractures significantly higher

in SCI athletes

Sobiecka (2005)Retrospective

n = 114Age: mean 27 women, 30 menVI, amputees, SCI, CP, intellectual disabilityParalympic Sports†


nr 125 injuries/114athletes

Injuries to the motor system

Taylor andWilliams(1995)

Retrospective

n = 53Age: nrWheelchair athletesWheelchair racing1 year

Symptom 1 day or more Prevalence 72% Acute injuries 16%Overuse injuries 52%52% upper extremity injuriesOveruse injuries recurred more often

Webborn et al.(2006)

Prospective

n = 416Age: mean 33.0IPC impairments*Paralympic Sports‡

Winter Paralympics 2002 (20 days)

Any injury during the games Prevalence 9% Acute injuries 77%Overuse injuries 15%32% sprains21% resulted in time lost from participating

in sportWebborn et al.

(2012)Prospective

n = 505Age: range 19–53IPC impairments*Paralympic Sports‡

Winter Paralympics 2010

Any sport-related musculoskeletalcomplaint that caused the athlete toseek medical attention during thestudy period

Incidenceproportion23.8%

Acute injuries 41%Overuse injuries 58%Increase of injuries in Paralympic Winter

games

Willick et al.(2013)

Prospective

n = 3565Age: mean 30IPC impairments*Paralympic Sports†


Any sport-related musculoskeletal orneurological complaint promptingan athlete to seek medical attention,regardless of whether or not thecomplaint resulted in lost time fromtraining or competition

Incidence rate12.7/1000

athlete daysInjury proportion

17.8/100athletes

Acute injuries 51.5Overuse injuries 31.8Acute on chronic 16.7%50.2% upper extremity injuriesHigher injury rates in older athletes

*IPC impairments: impaired muscle power, impaired passive range of movement, limb deficiency, leg length difference, hypertonia, ataxia, athetosis, short stature, visionimpairment, and intellectual impairment.†Paralympic Summer Sports (until 2012): football 5-a-side, powerlifting, goalball, wheelchair fencing, wheelchair rugby, athletics, judo, wheelchair tennis, table tennis,wheelchair basketball, football 7-a-side, seated volleyball, cycling track, equestrian, swimming, archery, boccia, cycling road, sailing, rowing, and shooting.‡Paralympic Winter Sports: alpine skiing, biathlon, cross-country skiing, wheelchair curling, ice sledge hockey.CP, cerebral palsy; MS, multiple sclerosis; nr, not reported; SCI, spinal cord injury; VI, vision impairment; WA, wheelchair athletes.

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compared with other categories of athletes (Nyland et al.,2000). A limitation of this prospective study is that onlysoft tissue injuries were reported (Table 1). Magno e Silvaet al. (2013b) reported an injury prevalence of 84.6% in apopulation of 13 male Brazilian soccer players with VIduring five major competitions; the clinical incidence was2.7 injuries per athlete. The most common injuries werecontusions and sprains, and 80% of the injuries wereacute. The most common injury site was the lower limb(80%), and 29% of the injuries occurred in the knee. Alimitation of this longitudinal study is that injuries wereonly reported during competitions. Similar injury pat-terns were seen in the Union of European Football Asso-ciations (UEFA) injury study in able-bodied soccerplayers, where 87% of the injuries occurred in the lowerextremity and 81% resulted from trauma. On average,each player suffered from 2.0 injuries/season (Ekstrandet al., 2011).

Fig. 2. Injuries presented by body location in the 18 studies thatincluded these data. Data are presented as minimum andmaximum, and range.

Table 2. Studies reporting sports-specific injuries in current Paralympic Summer and Winter sports

Summer sports Studies Winter sports Studies

Archery Reynolds et al. (1994); Willick et al. (2013) Alpine skiing McCormick (1985a, b); McCormack et al.(1991); Webborn et al. 2006; 2012)

Athletics Athanasopoulos et al. (2009); Bernardi et al. (2003);Curtis and Dillon (1985); Ferrara and Davis (1990);Magno e Silva et al. (2013c); McCormack et al. (1991);Patatoukas et al. (2011); Reynolds et al. (1994); Taylorand Williams (1995); Willick et al. (2013)

Biathlon Webborn et al. (2012)Cross-country

skiingWebborn et al. 2006; 2012)

Ice sledge hockey Webborn et al. 2006; 2012)Wheelchair curling Webborn et al. (2012)

Canoe –Cycling Athanasopoulos et al. (2009); Reynolds et al. (1994);

Willick et al. (2013)Equestrian Athanasopoulos et al. (2009); Willick et al. (2013)Football 5-a-side Magno e Silva et al. (2013b); Willick et al. (2013)Football 7-a-side Reynolds et al. (1994); Willick et al. (2013)Goalball Athanasopoulos et al. (2009); Willick et al. (2013)Wheelchair dance

sportPatatoukas et al. (2011)

Judo Athanasopoulos et al. (2009); Reynolds et al. (1994);Willick et al. (2013)

Powerlifting/weightlifting

Athanasopoulos et al. (2009); McCormack et al. (1991);Patatoukas et al. (2011); Reynolds et al. (1994); Willicket al. (2013)

Rowing Willick et al. (2013)Sailing Willick et al. (2013)Shooting Patatoukas et al. (2011); Reynolds et al. (1994); Willick

et al. (2013)Volleyball Athanasopoulos et al. (2009); Reynolds et al. (1994);

Willick et al. (2013)Swimming Athanasopoulos et al. (2009); Bernardi et al. (2003);

Ferrara and Davis (1990); Magno e Silva et al. (2013a);Reynolds et al. (1994); McCormack et al. (1991);Patatoukas et al. (2011); Willick et al. (2013)

Table tennis Athanasopoulos et al. (2009); Reynolds et al. (1994);Willick et al. (2013)

Triathlon –Wheelchair

basketballAthanasopoulos et al. (2009); Bernardi et al. (2003);

Curtis and Dillon (1985); Curtis and Black (1999);McCormack et al. (1991); Patatoukas et al. (2011);Reynolds et al. (1994); Willick et al. (2013)

Wheelchairfencing

Athanasopoulos et al. (2009); Chung et al. (2012);Reynolds et al. (1994); Willick et al. (2013)

Wheelchair rugby McCormack et al. (1991); Willick et al. (2013)Wheelchair tennis Athanasopoulos et al. (2009); Curtis and Dillon (1985),

Reynolds et al. (1994); Willick et al. (2013)


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During the 2012 Summer Paralympic Games inLondon, UK, a prospective injury surveillance system wasused. Football 5-a-side had the highest injury IR with 22.4injuries/1000-athletes days (overall IR 12.7); 54% of theinjuries were acute. Football 7-a-side had a lower IR(11.2); 73% of these injuries were classified as acute(Willick et al., 2013). Goalball had the second highestinjury IR (19.5); 77% of the injuries were classified asacute. Sports specificity, age, gender, and disability classi-fication were included as baseline covariates in the studyfrom the 2012 Paralympic Games, and it is recommendedthat future studies follow a similar approach. Anotherstrength of this study is the reporting of incidence propor-tions and IRs based on exposure. However, disability-specific injuries were not reported (Willick et al., 2013).

In a retrospective survey of 426 competitive disabledathletes in the United States, a high number of the lowerextremity injuries occurred in ambulatory athletes withpolio. In CP athletes, the knee (21%) was the most vul-nerable and injured body part. Also, VI athletes had ahigh percentage of lower extremity injuries (53%), andthe leg/ankle was involved in 26% of all injuries (Ferraraet al., 1992a). Soccer had the highest IR (3.7 injuries per1000 athlete exposure) in a population of 210 athletesparticipating in organized high school sport in the UnitedStates; 44.7% were lower extremity injuries and athleteswith autism, a history of seizure and emotional distur-bance had a higher injury rate. The athletes were fol-lowed during one season (Ramirez et al., 2009).

Magno e Silva et al. (2013c) documented injuries lon-gitudinally during five major competitions in a popula-tion of 40 Brazilian track and field athletes with VI,giving a prevalence of 78% and a clinical incidence of1.93 injuries per athlete. The most frequently reporteddiagnoses were spasms and tendinopathies, and 82%of the injuries occurred in the lower limbs (Magno eSilva et al., 2013c). Also Athanasopoulos et al. (2009)reported a high injury prevalence in track and field ath-letes. Over half (51.2%) of the total number of injuriesthat were admitted to the physiotherapy department ofthe 2004 Summer Paralympic Village Polyclinic inAthens, Greece, occurred among track and field athletes.Most of these injuries (22.1%) occurred in VI athletes.Lower extremity injuries were more common than inju-ries to the upper extremities in athletes with VI, CP, andamputation. The documentation of injuries was based onthe physiotherapy treatment reports, and a limitation ofthe study is that no definition of injury was present.During the 2012 London Paralympic Games, 216 inju-ries were reported in the 977 athletes participating intrack and field. The IR was 15.8 injuries/1000 athletes-days (overall IR 12.7), and 50% of the injuries had anacute onset, whereas 21% were acute on chronic and29% were overuse injuries (Willick et al., 2013). At the1992 Summer Paralympic Games in Barcelona, Spain,80% of the track and field athletes in the Britishteam suffered from an injury (Reynolds et al., 1994).

However, this study has a poor description of methodand injury definition. Patatoukas et al. (2011) showed ina retrospective survey that a population of Greek eliteathletes with locomotor disabilities participating instanding track and field events had the second highestpercentage of injury (23.0%) among nine different sports(41 injuries were reported in 35 athletes). Burnham et al.(1991) showed in a retrospective cohort study that ath-letes involved in stand-up track events, long jump, andhigh jump had a significantly higher frequency of lowerextremity injuries during the 1988 Paralympic Games inSeoul, South Korea, compared with athletes involved insports using predominantly their upper extremity.

Swimming had a lower injury IR (8.7) compared withthe overall injury IR (12.7) during the 2012 LondonParalympic Games; 47% of the injuries were classifiedas acute, whereas 37% were overuse injuries and 16%were acute on chronic injuries (Willick et al., 2013).During the Summer Paralympic Games 1992 in Barce-lona, 69% of the swimmers in the British team reportedan injury during the games (Reynolds et al., 1994).McCormack et al. (1991) reported that wheelchairswimmers had one of the lowest injury frequencies(1.2%) in a population of 90 wheelchair athletes.Patatoukas et al. (2011) reported 34 injuries in 51 swim-mers in their study among Greek elite athletes, andswimming had the third largest injury prevalence(19.1%). Magno e Silva et al. (2013a) reported a preva-lence of 64.3% and a clinical incidence of 1.5 in a pro-spective study among a population of 28 VI swimmers;80% of the injuries were overuse injuries, and the mostaffected body part was the shoulder (29.3%).

Taken together, lower extremity injuries are commonin walking athletes, especially in those with VI and inthose participating in ball sports and track and field, andthe prevalence of injuries in swimming seems to vary.However, it is difficult to compare the results as moststudies have used different rate denominators and defi-nitions of injury.

Wheelchair athletes

Wheelchair sports are specific to disabled athletes, andthe epidemiology of injuries occurring in these types ofsports are also specific to this population of athletes.Taylor and Williams (1995) reported an injury preva-lence of 72% during a 12-month period in a retrospectivestudy among a population of 53 British wheelchairracing athletes, where the most common disability wasspinal cord injury (SCI) (56%). Mostly, upper extremityinjuries were reported; 27% occurred in the hand andwrist followed by 25% in the upper arm and shoulder.Fifty injuries were reported in a population of 19 U.S.elite wheelchair athletes participating in track and field,swimming, table tennis, and shooting (Ferrara & Davis,1990). In this retrospective study, a total of 60% of theinjuries occurred in track and field, and 48% occurred

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during the competitive season. The most common typeof injury was strain (48%), and the most frequentlyinjured area was the shoulder (27.6%). The authors con-cluded that the time loss factor appeared to be higher formajor injuries when compared with athletes without dis-ability. Only time-loss injuries were recorded, and theresults may therefore be biased.

Curtis and Dillon (1985) retrospectively assessed theinjury prevalence of 128 U.S. wheelchair athletes. Themost common disability was SCI, and the largest per-centage of athletes were involved in track and field(79%) followed by basketball and swimming. As manyas 72% of the athletes reported that they had been injuredat some time during their career. Soft tissue injuries inshoulders, elbows, and wrists were the most frequentlyreported injuries. The sports associated with the highestinjury prevalence were track and field (26%) and basket-ball (24%). A significantly high proportion of injurieswere reported in athletes aged 21–30 years. Noteworthyis the low response rate – the questionnaire was distrib-uted to 1200 athletes (response rate just over 10%) – aswell as the possibility of recall bias. Ferrara et al.(1992a), also in a retrospective survey, reported that theupper extremity was involved in injuries twice as oftenas the lower extremity in athletes from the U.S. NationalWheelchair Athletics Association. A limitation of thisstudy is that only traumatic injuries were registered.

During the Summer Paralympic Games 2004 in Athens,the majority of injuries reported to the Paralympic VillagePhysiotherapy Service occurred among wheelchair athletes(51.2%). The most common injury site in the 67 injuredwheelchair athletes was in the shoulder (50.1%) and spine(20.1%) (Athanasopoulos et al., 2009). During the samegames, athletes from the Wheelchair Sports USA had ahigher frequency of elbow, forearm, and wrist injuries thanother categories. However, wheelchair athletes had not ahigher frequency of shoulder injuries compared with othergroups (Nyland et al., 2000).Also, during the 2012 LondonParalympic Games, wheelchair athletes had high injuryrates. Wheelchair rugby (IR 16.3) and wheelchair tennis(IR12.8) had higher injury IRs than the overall injury IR(12.7). Upper extremity injuries were the most commonduring the 2012 London Games (Willick et al., 2013).

McCormack et al. (1991) retrospectively surveyed90 Canadian wheelchair athletes participating in 18different wheelchair sports. In total, 346 injuries werereported. Upper extremity injuries were the mostcommon, and the authors suggested that the high fre-quency of upper extremity injuries were probably due towheelchair propulsion. A limitation of this study is thatjust trauma-related injuries were registered. Curtis andBlack (1999) showed in a retrospective study that 52%of a population of female wheelchair basketball playerssuffered from current shoulder pain during a tournament.A total of 70% of the athletes reported a history of elbowor hand pain after beginning with wheelchair driving,and 72% had a history of shoulder pain. The athletes

participated in sports and leisure activities on average11 h per week. A limitation of this study is that justinjuries to the upper extremity were recorded.

During the 2012 London Summer Paralympic Games,34 injuries were reported in 202 wheelchair basketballathletes (IR 12.0, overall IR 12.7) and 65% of theseinjuries had an acute onset (Willick et al., 2013). Duringthe Summer Paralympics 1992 in Barcelona, Spain, 79%of the British basketball team players suffered from aninjury (Reynolds et al., 1994). McCormack et al. (1991)reported that wheelchair basketball players were the ath-letes with the highest injury frequency (30.9%) in agroup of 90 Canadian wheelchair athletes, and upperextremity injuries were the most common. Also,Patatoukas et al. (2011) showed that wheelchair basket-ball was the sport with the highest percentage of injury(30.9) among a group of Greek elite athletes.

Chung et al. (2012) demonstrated in a prospectivestudy that wheelchair foil fencers had a higher overall IR(3.9/1000 h) compared with able-bodied fencers (2.4/1000 h). Furthermore, wheelchair athletes without activetrunk control were more susceptible to injury (4.9/1000 h) compared with athletes with good trunk control(3.0/1000 h). The most prevalent injuries in the wheel-chair athletes were upper extremity injuries (73.8%),whereas the able-bodied fencers had a higher percentageof lower extremity injuries. Four of the 14 wheelchairfencers were absent from their sport for more than 22days because of a major injury. Willick et al. (2013)reported an injury IR of 18.0 injuries/athletes-days(overall IR 12.7) in wheelchair fencing during the 2012London Paralympic Games; 58% of the injuries wereoveruse injuries. During the Paralympic Games 1992,71% of the fencers suffered from injury in the Britishteam (Reynolds et al., 1994).

In summary, mostly upper extremity injuries, espe-cially in the shoulder, are reported in wheelchair athletes,confirming that these types of injuries are overrepre-sented among these athletes. Once again, different ratedenominators and definitions of injury cause inconsis-tencies in the reported data and comparisons of resultsare therefore difficult.

Winter sports

Five sports – alpine skiing, biathlon, cross-countryskiing, ice sledge hockey, and wheelchair curling – areincluded in the Winter Paralympic Games. During the2002 Winter Paralympic Games in Salt Lake City, USA,the International Paralympic Committee (IPC) startedprospective injury surveillances. Alpine skiers were theathletes that experienced most injuries (62% of allinjuries), and 12.3% of all alpine skiers (n = 194) suf-fered from at least one injury. The most serious injuriesreported were anterior cruciate ligament ruptures, distalradius fractures, and concussions. One of the conclu-sions of the 2002 injury surveillance was that a risk


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factor for injury in alpine skiing may be failure of ski-bindings to release (Webborn et al., 2006). During the2010 Winter Paralympic Games in Vancouver, Canada,alpine skiing had the second highest injury incidenceproportion (21.6%). The sitting class athletes had ahigher injury rate with 1.7 injuries/100 race exposurescompared with 0.7 injuries/100 race exposures in VIathletes and standing class athletes (Webborn et al.,2012). Ferrara et al. (1992b) reported 100 time-loss inju-ries in a retrospective study in 68 skiers prior to theNational Games of Handicapped Sports and Blind Ath-letes in the United States 1989. Upper extremity injurieswere 1.4 times more common than lower extremity inju-ries; 60% of the injuries were classified as chronic. Theshoulder (30%) was the most vulnerable body location,and acute injuries were most prevalent in the thigh andknee (30%). A limitation of this study is that only traumaswere recorded. An IR of two injuries per 1000 skier-dayswas reported in a population of disabled alpine skiers inthe United States; 23 injuries were reported in 60 ath-letes, mostly amputees. The knee (17.4%) was the mostcommonly injured body location, and 21.6% of the inju-ries were fractures (McCormick, 1985a). A higher IR(16.1 injuries per 1000 skier-days) was shown in a similarstudy including 23 disabled sit-skiers. Individuals withSCI at T6 or above had a higher injury frequencycompared with those with paraplegia. Upper extremityinjuries were the most frequently reported injuries(McCormick, 1985b). Both studies were retrospectiveand did not report any definition of injury.

Ice sledge hockey players had the highest rate ofinjury per 100 athletes (14%) during the 2002 WinterParalympic Games. Four of the injuries occurred fromcollisions that resulted in lower limb injuries (Webbornet al., 2006). Also, during the 2010 Winter ParalympicGames, ice sledge hockey had the highest incidence pro-portion (33.9%) of all sports. A total of 40 of 118 athletesrequired medical attention for musculoskeletal prob-lems. Of these, 60% of the injuries were classified asoveruse injuries, 52.5% of the injuries occurred duringcompetition time and 42.9 of these, in turn, were contactinjuries. Upper extremity injuries were most common(47.5%), followed by spine-related injuries (35%)(Webborn et al., 2012).

Very few injuries were reported among the 134 ath-letes competing in the Nordic Skiing during the 2002Paralympic Games. Three injuries were reported, allinvolving the upper limbs (Webborn et al., 2006). A largeincrease in injury prevalence was seen during the WinterParalympic Games 2010; 26 injuries were reported in140 athletes resulting in an injury prevalence of 18.6%.Almost half (46.2%) of the injuries were classified asacute, including serious injuries like concussions, pneu-mothorax, and fractures. VI athletes had a higher IRbased on a new acute injury (two injuries/100 race expo-sures) compared with (1.3 injuries/100 race exposures)for standing class athletes (Webborn et al., 2012).

Interestingly, a remarkable increase in injury incidenceproportion was seen during the 2010 Paralympic WinterGames (IP = 23.8%) compared with the Winter Games2002 (IP = 9.4%), and a noteworthy high prevalence(57.5%) of overuse injuries was reported 2010. The authorssuggested that the high number of overuse injuries might bedue to an increased level of training during the precedingyears (Webborn et al., 2012). In conclusion, the reportedinjury prevalence in Paralympic Winter sports appears tovary. Injuries are reported both to the lower and upperextremities and seem to have both acute and chronic onset.

Acute vs nonacute injuries

Overuse injuries have lately gained increased attention inthe literature of sports injury epidemiology. These inju-ries are frequently seen in sports involving repetitivemovements and could lead to devastating consequencesfor the athlete. The mechanisms of injury are often aresult of repeated micro-trauma to the tissue, with nosingle identifiable incident responsible for injury (Fulleret al., 2006). Clarsen et al. (2013) showed that overuseinjuries represented 49% of all health problems (acuteinjuries 13%) in 116 Norwegian Olympic and 26Paralympic athletes preparing for the 2012 SummerOlympic/Paralympic Games. This study is one of fewprospective studies reporting injuries during normaltraining and not only competition. During the WinterParalympic Games 2010, 57.5% of the injuries wereoveruse injuries (Webborn et al., 2012). Magno e Silvaet al. (2013c) reported that 82% of the injuries, mostly inthe lower extremity, were overuse injuries in their studyof VI track and field athletes. Similar results have beendemonstrated in able-bodied track and field athletes.Jacobsson et al. (2013) reported that 96% of the injurieswere nontraumatic, and 77% of the injuries were relatedto the lower extremity in a population of able-bodiedelite track and field athletes in Sweden. In another studyof VI swimmers, 80% of the injuries were classified asoveruse injuries (Magno e Silva et al., 2013a). Also,Taylor and Williams (1995) reported a high prevalenceof overuse injuries in wheelchair athletes. Overuse inju-ries were more likely to recur within 12 months, espe-cially in those who started their training before the painof the injury had disappeared. In wheelchair racing ath-letes, 43% reported that they restarted training before thepain had disappeared, and 71% of the injuries preventedthe athlete from training (the median time off trainingwas 14 days). The authors suggested that there is a linkbetween overuse injuries, restarting exercise before painhas disappeared and the rate of recurrence of injury.

In a population of 227 Italian athletes with locomotordisability, 51% experienced sports-related muscle pain thatoccurred during sports activity causing discomfort for atleast 1 day. A training volume above 7 h per week [oddsratio 3.8; 95% confidence interval (1.4-10.0)] was associ-ated with pain (Bernardi et al., 2003). It has been suggested

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that there is a risk that the demands of sports activitiestogether with daily wheelchair pushing result in insuffi-cient time for rest and recovery of the musculature inwheelchair athletes (Curtis & Black, 1999; Ferrara et al.,2000). Curtis and Dillon (1985) showed with time expo-sure data that a high number of hours per week spent ontraining were associated with significantly higher injuryprevalence. Athletes who reported most injuries were thoseinvolved in repetitive wheelchair pushing. These resultsmight be related to overuse of soft tissue structures.

Regarding traumatic injuries, Webborn et al. (2006)reported that 77% of all injuries during the WinterParalympic Games 2002, Vancouver, were acute inju-ries. During the 2012 Summer Paralympic Games inLondon, 51.5% of the injuries were classified as trau-matic injuries. Boccia had the highest proportion ofacute traumatic injuries (91%), followed by goalball(77%). Also wheelchair rugby, football 7-a-side, seatedvolleyball, and football 5-a-side had high proportions ofacute injuries (Willick et al., 2013). Ferrara et al. (2000)demonstrated that 65% of the injuries were acute in apopulation of elite wheelchair athletes; 32% of the inju-ries were classified as major (missing 22 days or more).In a longitudinal study following disabled U.S. athletesover five international competitions, including theSummer Paralympic Games 1992 and 1996, the authorsrecorded 1037 injuries in a total of 1360 participants;67.9% of these were classified as acute injuries. Most ofthe injuries occurred during the Summer ParalympicGames 1992 (37.3%) and 1996 (39.2%). Wheelchairathletes had the highest injury prevalence (27.8%) fol-lowed by CP athletes (24.3%). The most commonlyinjured body part was the thorax/spine.

Athanasopoulos et al. (2009) reported that 64.1% ofall registered injuries at the physiotherapy department ofthe Summer Paralympic Games, Athens, 2004, wereclassified as an acute injury. Similar patterns were seenin U.S. Paralympic athletes during the 1996 SummerGames, Atlanta, where 67% (170/254) of all soft tissueinjuries among 304 athletes had an acute onset (Nylandet al., 2000). Chung et al. (2012) showed that the injuryIR was significantly higher during competition thantraining (5.1/1000 h vs 2.0/1000 h) in elite wheelchairfencers. Ferrara et al. (2000) suggested that the nature ofcompetitive events increases the incidence of acute inju-ries, and a limitation of some of the reviewed studiesis that injuries are just reported during competition(Table 1). In the UEFA injury study of soccer injuries inable-bodied athletes, the authors showed that 57% of theinjuries occurred during matches and 43% during train-ing. Overuse injuries were more frequent during the pre-season, and traumatic injuries were more commonduring the competitive season (Ekstrand et al., 2011).

A strength of the study by Clarsen et al. (2013), inwhich a web-based prospective monitoring of illness andinjury in Norwegian elite athletes was performed, is thatinjuries were recorded both during training and competi-

tion. The conclusion of this study is that this method wassensitive and valid for recording injuries in a large group.The authors also suggested that weekly reporting maylead to earlier and more comprehensive interventions ofhealth issues. A limitation of this study is, however, thesmall number of Paralympic athletes surveyed.

In summary, a considerably high prevalence of sports-related overuse injuries has been demonstrated in ath-letes with disabilities. Two studies have shown that ahigh number of hours per week spent on training areassociated with higher injury prevalence. Overuseinjuries may be under-diagnosed, as some studiesjust include events related to trauma and competition intheir injury definitions (Table 1). Several authors havereported a high number of acute injuries during compe-tition, and it seems like athletes participating in ballsports are more prone to acute injuries.

Risk factors and prevention of injuries

In the sport medicine research area, preventative strategieshave gained increased interest over the past years. Waldénet al. (2012) showed that anterior cruciate ligament injuriescould be reduced by 64% when implementing a preventa-tive training program in female soccer players. VanBeijsterveldt et al. (2013), however, reported conflictingevidence for the effectiveness of exercise-based programsto prevent soccer injuries and recommended high-qualitystudies investigating the best type and intensity of exer-cises. A limitation is that very few studies involving clini-cal trials exist within Paralympic sports. Already in 1985,Curtis and Dillon (1985) suggested that preventive strate-gies should be taken to decrease injury risks in disabilitysports. Ferrara and Davis (1990) reported the importanceof designing prevention programs including strength,endurance, and flexibility for disabled athletes, and Curtisand Black (1999) recommended that warm-up strategies,stretching, and strengthening should be included in thetraining. McCormick (1985a) suggested focusing onstrengthening of the legs, improvement of cardiovascularfitness, and adequate equipment to help reduce the injuryrate among disabled skiers. Bernardi et al. (2003) showedthat a high training volume was associated with sports-related muscle pain in disabled athletes, and monitoring oftraining volume was suggested as part of injury prevention.Also, the authors of the injury surveillance study duringthe 2012 Paralympic Games recommended that injury pre-vention interventions should initially target high risk sports(Willick et al., 2013).

According to the model that van Mechelen et al.(1992) presented for prevention of sports injuries, thefirst step is to evaluate the extent of the injury problemthrough injury surveillance. Thereafter, injury riskfactors and injury mechanisms could be established, andon the basis of this information preventive strategies canbe introduced. Risk factors for sports injuries are oftenclassified as intrinsic or extrinsic. Intrinsic risk factors


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are related to the athlete, whereas extrinsic risk factorsare related to the environment.

In disabled athletes, the disability itself could be con-sidered an intrinsic risk factor (Magno e Silva et al.,2013a). For example, during the Paralympic Games1988, 78% of all lower extremity injuries reported in theCanadian team occurred in the blind athletes (Burnhamet al., 1991) and during the Paralympic Games 2010,injuries from falls were more common in VI Nordicskiers (Webborn et al., 2012). Athanasopoulos et al.(2009) suggested that the high incidence of ankle injuriesin VI athletes may be related to poor proprioception, andit has been stated that postural stability is affected byvision (Aydog et al., 2006). Orthopedic deformities in thefoot and knee region are sometimes present in individualswith CP (Horstmann et al., 2009). Patatoukas et al.(2011) showed that CP athletes had a higher percentageof soft tissue injuries compared with other athletes, andthe authors suggested that limited range of motion, spas-ticity, and discoordination might cause additional stressto muscles, joints, and tendons. Athanasopoulos et al.(2009) proposed that the greater number of lower extrem-ity injuries in athletes with CP may be related toincreased tensile forces in the lower extremity as a resultof spasticity and deformities.

Amputee athletes appeared to have a high prevalenceof injury and pain (Nyland et al., 2000; Bernardi et al.,2003; Athanasopoulos et al., 2009), and it has been sug-gested that the high number of injuries might depend onaltered biomechanics in the lower extremity (Bernardiet al., 2003). Athletes with a unilateral amputation mayalso suffer from injuries in the intact lower limb due toasymmetrically higher forces during running (Nylandet al., 2000).

In wheelchair athletes low bone mineral density couldbe considered as a possible intrinsic risk factor for injury.Osteoporosis occurs in almost every person with SCI,which results in an increase in the incidence of lowerextremity fractures (Jiang et al., 2006). McCormacket al. (1991) reported seven fractures among 90 wheel-chair athletes. Patatoukas et al. (2011) showed that SCIathletes had a significantly higher prevalence of fracturescompared with other athletes. Four fractures werereported in ice sledge hockey players during the WinterParalympic Games 2002. A regulation change on protec-tive equipment and sledge height was implementedthereafter, and only one fracture was reported in 2010(Webborn et al., 2012), which should be considered asuccessful prevention work.

Moreover, wheelchair athletes had a high frequency ofupper extremity injuries (Burnham et al., 1991; Dermanet al., 2013), and these athletes often rely on their upperextremities both in their daily life as well as in sports,which could cause a high stress on their tissues. The dis-ability might also be associated with a seated posture, asmaller upper extremity musculature, denervated muscu-lature, flaccidity, muscle spasms, and spasticity (Asayama

et al., 1985; McCormack et al., 1991), which all should beconsidered as intrinsic risk factors. Burnham et al. (1991)suggested that weakness of the external rotators and shoul-der adductor muscles can contribute to shoulder impinge-ment in these athletes. The problem is often exacerbatedbecause the sitting posture in a wheelchair is characterizedby internal rotation of humerus and scapular protraction.Upper extremity injuries were also the most frequentlyreported during the Summer Paralympic Games 2012, andit has been suggested that future research should putemphasis on understanding injury factors and preventionstrategies of these specific anatomical regions (Dermanet al., 2013). Also, the authors of the injury surveillancefrom the Olympic Games 2012 recommend further devel-opment of preventative measures tailored for each specificsport (Engebretsen et al., 2013).

Very few of the studies reviewed have discussedintrinsic or extrinsic risk factors. Ferrara and Davis(1990) recommended physical screening of flexibility,strength, and cardiovascular function of all athletes todetermine any deficiencies that might predispose theathlete for injury. Also, Reynolds et al. (1994) recom-mended pre-event screening of injuries to provide bettermedical support.

Discussion

It is apparent that existing studies within the area havepoor injury definitions. The methodologies, rate denomi-nators, and populations have varied widely between thereviewed studies. Few studies are sports and disabilityspecific, and some studies use cross-disability design,which makes it difficult to determine sports and disabil-ity specific risk factors. Many studies use the termwheelchair athlete. However, there are a variety of dis-abilities and classification systems of wheelchair ath-letes, and each disability group may have differentmovement patterns and performance levels (Patatoukaset al., 2011). Magno e Silva et al. (2013b) stated that tobe able to recognize different risk factors within disabil-ity sports, it is important to report etiology and injuryprevalence by disability and sports. Few studies reportaccurate information on characteristics of the subjects,data collection, and surveys. Only three out of 25 studiesincluded the age range of the athletes studied, and this isa limitation that is suggested to be addressed in futurestudies. Only one of the studies reported that the injurysurvey was validated (Ferrara et al., 1992a). The samplesizes have sometimes been small, and some studies didnot report the specific nature of injury (Table 1). Also,the classification systems of injury have varied betweenstudies. For example, Ferrara and Davis (1990) classifieda minor injury as an injury that caused time loss fromtraining of 7 days or less, whereas one study include ablister as an injury (McCormack et al., 1991).

Few studies report incidence, exposure, and time lossof training due to an injury. In injury epidemiology of

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able-bodied athletes, time loss of training is a commonlyused parameter to describe severity of injury (Kjaeret al., 2005). Variations in the definitions and method-ologies used for studies of injuries in Paralympic sportstoday cause inconsistencies in reported data, and com-parisons of results are difficult. Present studies justprovide information from short-term surveillance duringcompetitions, and most of the definitions used are notadopted for overuse syndromes that develop over time.

In several sports for able-bodied athletes, consensusstatements on definitions and data collection proceduresof sports injuries are available, and it is clear that similarconsensus is needed within Paralympic sports. In thefuture, it is recommended that larger and better designedstudies concerning injury epidemiology are conductedwithin the area of Paralympic medicine. Standardizationof injury definition, nature of injury, and surveys arerecommended. Sports and disability specific studies arepreferred, and risk factors should be evaluated. Very fewstudies present information regarding long-term conse-quences of an injury in disability sports. Therefore, lon-gitudinal studies following disabled athletes over timeare recommended, which would also allow researchersto estimate injury IRs based on athlete exposures. Fur-thermore, it is important to examine the consequences ofan injury upon quality of life.

The injury surveillances conducted by the IPC at theParalympic Games 2002, 2010, and 2012 have been verysuccessful and represent a huge step forward in under-standing injuries in Paralympic athletes during competi-tion. During the Summer Paralympics Games 2012, theinjury incidence proportion was 17.8 injuries/100 athletes(Willick et al., 2013) compared with the injury rate of 12.9injuries/100 athletes during the Summer Olympic Games(Engebretsen et al., 2013). These results suggest that theinjury panoramas today are almost equal in athletes withdisabilities compared with able-bodied athletes.

However, there are still very few studies of injuryincidence in disabled athletes during their normal trainingseason. Further research in this area could include thedevelopment of an international scientific injury surveil-lance system for athletes with disabilities, along the lineswith the system used during the Paralympic Games inLondon 2012. With continuous data over several seasons,it would be possible to observe the development of spe-cific trends over time and to monitor and assess the type of

training, load, and exposure. This information could pos-sibly help coaches, trainers, physicians, and therapists tounderstand and reduce risk factors of injuries and to betterplan training and competition phases. An enhancedknowledge of injury epidemiology could also helpresearchers to better understand injury mechanisms andthereby develop and implement effective injury preven-tion programs. It is therefore recommended that futurestudies also examine the effects of prevention strategies inathletes with disabilities. And, most importantly, knowl-edge in this field could also help athletes to increase theirsports performance and improve their quality of life.

Perspectives

The Paralympic Games is currently the world’s secondlargest sporting event with regard to the number of par-ticipants. Paralympic athletes have become elite in theirsport, and a consequence of this is increased fitnesslevels and training time (Vanlandewijck & Thompson,2011). It is well known that participation in sports, espe-cially at elite levels, places the athlete at risk for muscu-loskeletal injury (Ljungqvist et al., 2009).

Based on the information in this review, it is clear thatthe few existing studies of injuries in Paralympic sportsshow that overall rates seem to be high and comparablewith rates in able-bodied athletes. Epidemiological dataregarding the nature of injuries, and sports and disabilityrisk factors are very limited. Furthermore, few studieshave assessed injury prevention strategies. It is alsoapparent that some of the existing studies have poorinjury definitions and methodologies. In the future, con-sensus statements on sports injury definitions and datacollection procedures of sports injuries are recom-mended within Paralympic sports.

Key words: Disability, epidemiology, paralympic, sports,wounds and injuries.

Acknowledgements

Kristina Fagher, MSc, RPT, is a contracted physiotherapist for theSwedish Paralympic Women’s Goalball Team. Jan Lexell, MD,PhD, is Chief Medical Officer in The Swedish Sports Organizationfor the Disabled and The Swedish Paralympic Committee.

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sports-related injuries in athletes with disabilities

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