Gymnastics injury incidence during the 2008, 2012 and 2016 Olympic Games: Analysis of prospectively collected surveillance data from 963 registered gymnasts during Olympic Games

Abstract

Objective
To determine the incidence and characteristics of injuries in female and male gymnastics disciplines (artistic, rhythmic and trampoline) during three Olympic Games with a view to ultimately improving injury prevention.

Methods
The National Olympic Committee’s head physicians and the medical teams of the Local Organising Committee of the Olympic Games reported daily the occurrence (or non-occurrence) of newly sustained injuries in artistic, rhythmic and trampoline gymnastics on a standardised report form during the 2008, 2012 and 2016 Summer Olympic Games.

Results
During the three Olympic Games, 81 injuries were reported in a total of 963 registered gymnasts, corresponding to an incidence of 84 injuries (95% CI 67 to 102) per 1000 registered gymnasts, with no difference in injury incidence between female and male gymnasts. Thirty-eight per cent of injuries led to time-loss from sport. The most frequent injury location and injury type were the ankle (22%) and sprain (35%), respectively. The most common diagnosis was ankle sprain (14% of all injuries and 23% of time-loss injuries). The injury incidence was highest in female (107±35) and male artistic gymnastics (83±32), followed by female rhythmic gymnastics (73±30), and lower in male (63±69) and female (43±43) trampoline gymnastics.

Conclusions
Research should focus on preventing injuries in artistic gymnastics and of the condition of ankle sprain. Injury surveillance studies should be continued during major championships and throughout the entire competitive season as the Olympic Games provides only a snapshot (although an important one).

Full text

1
EdouardP, etal. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-097972
ABSTRACT
Objective To determine the incidence and
characteristics of injuries in female and male gymnastics
disciplines (artistic, rhythmic and trampoline) during
three Olympic Games with a view to ultimately improving
injury prevention.
Methods The National Olympic Committee’s head
physicians and the medical teams of the Local Organising
Committee of the Olympic Games reported daily the
occurrence (or non-occurrence) of newly sustained
injuries in artistic, rhythmic and trampoline gymnastics
on a standardised report form during the 2008, 2012
and 2016 Summer Olympic Games.
Results During the three Olympic Games, 81 injuries
were reported in a total of 963 registered gymnasts,
corresponding to an incidence of 84 injuries (95% CI 67
to 102) per 1000 registered gymnasts, with no difference
in injury incidence between female and male gymnasts.
Thirty-eight per cent of injuries led to time-loss from
sport. The most frequent injury location and injury type
were the ankle (22%) and sprain (35%), respectively.
The most common diagnosis was ankle sprain (14%
of all injuries and 23% of time-loss injuries). The injury
incidence was highest in female (107±35) and male
artistic gymnastics (83±32), followed by female rhythmic
gymnastics (73±30), and lower in male (63±69) and
female (43±43) trampoline gymnastics.
Conclusions Research should focus on preventing
injuries in artistic gymnastics and of the condition
of ankle sprain. Injury surveillance studies should be
continued during major championships and throughout
the entire competitive season as the Olympic Games
provides only a snapshot (although an important one).
INTRODUCTION
Gymnastics is a popular sport with high participa-
tion rates worldwide.1 The International Gymnas-
tics Federation (FIG, http://www. fig- gymnastics.
com) has 148 affiliated/associated federations, and
it is estimated that worldwide about 50 million
people of all ages regularly perform gymnastics
in a club setting. Among the different gymnastics
disciplines, the current programme at the Olympic
Games includes artistic gymnastics (men’s and
women’s), rhythmic gymnastics (women’s) and
trampoline gymnastics (men’s and women’s),1 2
comprising about 320 gymnasts (≈3% of all regis-
tered athletes) at each Olympic Games.
Gymnastics requires explosive, balance and
artistic skills, and includes movements with high
levels of intensity and difficulty.1 3 Elite gymnasts,
aged from 7 to 18 years, are exposed to high
training loads of up to 21–37 hours per week, for
11–12 months per year according to reports.1 2 4–6
In addition, gymnastics training begins in child-
hood; talent scouting for USA Gymnastics looks
at children aged between 6 and 11 years.2 3 These
gymnasts have immature musculoskeletal systems
and consequently their growth cartilage, articular
cartilage and bones are more susceptible to injury.7
The combination of all these aspects, and others
including low-energy availability, gives rise to the
concern regarding the risk of injury.1 2 6 8
Several studies have provided epidemiological
data on female artistic gymnasts of different ages,
levels and settings.1 2 These studies cover gymnasts
at elite level,4 5 9–11 club level4 6 12 13 and school
activities.14–17 Injury rates range from 1.6 to 4.1
per 1000 hours of training,4–6 9 with the elite-level
gymnasts being exposed to higher rates, more severe
injuries6 9 and higher risk during competitions (2–6
times more than in training conditions).6 15 16 In
comparison, much less is known regarding the
injury risk in men’s artistic,11 12 17 18 women’s
and men’s trampoline,19 and women’s rhythmic
gymnastics.20 21
As a first step towards prevention strategies,22 23
improving knowledge on injury epidemiology in
the three gymnastics disciplines will be relevant. In
addition, given the differences in the nature of these
Olympic disciplines (eg, in physical demands, skills
and rules), it is of interest to determine whether
injury risks and characteristics differ across disci-
plines.1 2 The Olympic Games provide a unique
opportunity to analyse and compare the injury risk
and characteristics in elite-level athletes of different
disciplines under similar conditions (eg, same level
of play, identical environmental conditions). In
addition, given the efforts of the IOC to protect
athletes’ health,24–26 and by the FIG to prevent
gymnastics injuries (http://www. fig- gymnastics.
com), as well as given the changes made by the
FIG to the rules and in the Code of Points,1 2 it is
of interest to analyse the change in injury risk and
characteristics over time.
We aimed to determine the incidence and charac-
teristics of injuries in elite gymnastics, specifically in
the three Olympic disciplines (artistic, rhythmic and
Gymnastics injury incidence during the 2008, 2012
and 2016 Olympic Games: analysis of prospectively
collected surveillance data from 963 registered
gymnasts during OlympicGames
Pascal Edouard,1,2 Kathrin Steffen,3,4 Astrid Junge,5,6 Michel Leglise,7
Torbjørn Soligard,4 Lars Engebretsen3,4,8
Original article
To cite: EdouardP,
SteffenK, JungeA, etal.
Br J Sports Med Published
Online First: [please include
Day Month Year]. doi:10.1136/
bjsports-2017-097972
1Inter-university Laboratory of
Human Movement Science,
University of Lyon, University
Jean Monnet, Saint Etienne,
France
2Department of Clinical and
Exercise Physiology, Sports
Medicine Unit, Faculty of
Medicine, University Hospitalof
Saint-Etienne, Saint-Etienne,
France
3Department of Sports Medicine,
Norwegian School of Sport
Sciences, Oslo Sports Trauma
Research Centre, Oslo, Norway
4Department of Medical
and Scientific, International
Olympic Committee, Lausanne,
Switzerland
5Medical School Hamburg,
Hamburg, Germany
6Swiss Concussion Centre,
Schulthess clinik, Zurich,
Switzerland
7International Gymnastics
Federation (FIG), Lausanne,
Switzerland
8Department of Orthopaedic
Surgery, Faculty of Medicine,
University of Oslo, Oslo, Norway
Correspondence to
Dr Pascal Edouard, Department
of Clinical and Exercise
Physiology, Sports Medicine
unit, IRMIS, Campus Santé
Innovations, University Hospital
of Saint-Etienne, Saint-Etienne
cedex 2, France;
Pascal. Edouard42@ gmail. com
Accepted 18 September 2017
BJSM Online First, published on October 14, 2017 as 10.1136/bjsports-2017-097972
Copyright Article author (or their employer) 2017. Produced by BMJ Publishing Group Ltd under licence.
group.bmj.com on October 14, 2017 - Published by http://bjsm.bmj.com/Downloaded from

2EdouardP, etal. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-097972
Original article
trampoline) during three consecutive Olympic Games (2008,
2012 and 2016) and to evaluate their changes over time.
METHODS
The IOC injury and illness surveillance system for multisport
events24 was used to record the injuries during the last three
summer Olympic Games: the Beijing Olympic Games from 9 to
24 August 2008 (OG 2008),25 the London Olympic Games from
27 July to 12 August 2012 (OG 2012)26 and the Rio Olympics
Games from 5 to 21 August 2016 (OG 2016).
The study design, study implementation, injury definition and
data collection procedures were identical for the three Olympic
Games and have previously been described in detail.24–26 The
National Olympic Committee’s (NOC’s) head physicians and
the medical teams of the Local Organising Committee of the
Olympic Games were asked to report daily the occurrence (or
non-occurrence) of newly sustained injuries on a standardised
paper report form.24–26 An injury was defined as ‘any musculo-
skeletal complaint or concussion newly incurred (exclusion of
pre-existing and not fully rehabilitated injuries) due to compe-
tition and/or training during the Olympic Games that received
medical attention regardless of the consequences with respect to
absence from competition or training’.24 In cases where a single
incident caused multiple injury types or affected multiple body
parts, only the most severe diagnosis was recorded.25 26 Confi-
dentiality of all information was ensured so that no individual
athlete could be identified. Ethical approval for injury and illness
surveillance during these Olympic Games was obtained from the
medical research ethics committee of the South-Eastern Norway
Regional Health Authority, Norway (2011/388-4).
Incidences of injuries were calculated as the number of
injuries per 1000 registered gymnasts using a list of gymnasts
provided by the IOC. Data were analysed and are presented
using numbers, frequencies, percentages, cross-tabulations,
incidences with 95% CIs, relative risks (RR) with 95% CI,
magnitude thresholds27 and with the χ2 test. Comparative anal-
yses between disciplines and individual Olympic Games were
performed only if the number of injuries was statistically suffi-
cient. All data were processed using Excel. Significance was
accepted at p<0.05.
RESULTS
Number and incidence of injuries
A total of 963 gymnasts participated in the three Olympic Games,
competing mainly in artistic and rhythmic gymnastics (90.1%
of all registered gymnasts). These two disciplines accounted for
most of the recorded injuries (93.8%) (table 1).
Eighty-one injuries were reported in gymnasts, corresponding
to an incidence of 84.1±17.5 injuries per 1000 registered
gymnasts. Fifty-four injuries were reported in female (66%) and
27 (33%) in male gymnasts. The injury incidence was similar
between female and male gymnasts (86.4±22.0 vs 79.9±28.9
injuries per 1000 registered gymnasts, respectively; RR=1.08;
95% CI 0.69 to 1.68, trivial) (table 2).
Thirty-one injuries led to time-loss from sport (38.3%),
corresponding to an incidence of 32.2±11.1 injuries per 1000
registered gymnasts, without any significant difference between
female and male gymnasts (27.2±12.8 vs 41.4±21.2 injuries per
1000 registered gymnasts, respectively; RR=0.66; 95% CI 0.33
to 1.32, small) (table 1).
The injury incidence in artistic gymnastics was significantly
higher in 2016 than in 2008. While a similar trend in the same
direction was observed for women’s artistic gymnastics, the
results were not significant for men’s artistic gymnastics (table 3).
Injury characteristics in gymnastics
The affected body parts, types, circumstances and causes are
presented in tables 4 and 5. The lower limb was affected in 62.8%
of injuries, the trunk in 23.1% and the upper limb in 14.1%. The
most frequent injury location was the ankle (21.8%), followed
by the lumbar spine (14.1%) and the foot (12.8%). The most
frequent types of injury were sprains (34.6%), followed by tendi-
nopathy/arthritis/impingements (17.3%), contusions (9.9%) and
Table 1 Number of registered gymnasts and (time-loss) injuries, percentages of (time-loss) injuries and incidences of injuries per 1000 registered
gymnasts in the three Olympics gymnastics disciplines according to sex, during the 2008, 2012 and 2016 Olympic Games
Gymnastics artistic
Gymnastics
rhythmic Gymnastics trampoline
TotalFemale Male Female Male Female
Population
Registered gymnasts (n) 292 290 286 48 47 963
Percentage of all gymnasts (%) 30.3 30.1 29.7 5.0 4.9 100.0
Injuries
Injuries (n) 31 24 21 3 2 81
Percentage of all injuries (%) 38.3 29.6 25.9 3.7 2.5 100.0
Incidence of injuries (per 1000 gymnasts) 106.2 82.8 73.4 62.5 42.6 84.1
Training injuries (n) 15 5 16 2 2 40
Competition injuries (n) 13 16 3 0 0 32
Missing information regarding circumstance (n) 3 3 2 1 0 9
Time-loss injuries
Time-loss injuries (n) 13 14 4 0 0 31
Percentage of all time-loss injuries (%) 41.9 45.2 12.9 0.0 0.0 100.0
Percentage of time-loss injuries among all injuries (%) 41.9 58.3 19.0 0.0 0.0 38.3
Incidence of time-loss injuries (per 1000 gymnasts) 44.5 48.3 14.0 0.0 0.0 32.2
Training time-loss injuries (n) 3 5 1 0 0 9
Competition time-loss injuries (n) 8 9 1 0 0 18
Missing information regarding circumstance (n) 2 0 2 0 0 4
group.bmj.com on October 14, 2017 - Published by http://bjsm.bmj.com/Downloaded from

3
EdouardP, etal. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-097972
Original article
fractures (7.4%). The most common diagnosis was ankle sprain
(13.6%).
More injuries occurred during training (49.4%) compared
with competition (39.5%) (missing information for 11.1%).
Acute trauma injuries were dominant (contact with immobile
objects (23.4%) and non-contact trauma (22.1%)), followed by
overuse injuries (with both sudden (15.6%) and gradual onset
(11.7%)), and recurrence of previous injuries (14.3%).
The most common time-loss injury location was the ankle
(28.6%), and most common time-loss injury type was sprains
(41.9%), the main circumstance was during competition (58.1%),
and the most common causes were contact with immobile object
(33.3%) and non-contact trauma (30.0%) (table 4). The injury
frequency differed significantly between injuries and time-loss
injuries for circumstance (χ2=3.9, p<0.05), but not for location,
type and cause (table 5). The proportion of time-loss injuries was
higher in competition than in training (56.3% vs 22.5%; χ2=8.6,
p=0.003). All eight injuries with >4 weeks absence were sustained
in artistic gymnastics, five during competition, one during training
and two unknown, and were two foot fractures, one ankle fracture
Table 2 Number of registered gymnasts and injuries, incidences of injuries per 1000 registered gymnasts and relative risks (female being the
reference group) with lower and upper limits of 95% CI (±95% CI) and probabilistic inferences about the true standardised magnitude in relative
risks, in male and female gymnasts during the 2008, 2012 and 2016 Olympic Games (OG)
Registered gymnasts Injuries(n)
Injuries per 1000 registered gymnasts
(±95% CI)
Relative risk of female versus
male gymnasts
Total Male Female Total Male Female Total Male Female (±95% CI)
OG
OG 2008 318 112 206 24 7 17 75.5±29.0 62.5±44.8 82.5±37.6 1.32 (0.56 to 3.10) small
OG 2012 323 114 209 24 10 14 74.3±28.6 87.7±51.9 67.0±33.9 0.76 (0.35 to 1.66) small
OG 2016 322 112 210 33 10 23 102.5±33.1 89.3±52.8 109.5±42.2 1.23 (0.61 to 2.49) small
Gymnastic disciplines
Artistic
gymnastics 582 290 292 55 24 31 94.5±23.8 82.8±31.7 106.2±35.3 1.28 (0.77 to 2.13) small
Trampoline
gymnastics 95 48 47 5 3 2 52.6±44.9 62.5±68.5 42.6±42.6 0.68 (0.12 to 3.89) moderate
Rhythmic
gymnastics 286 0 286 21 0 21 73.4±30.2 – 73.4±30.2 – –
Age groups (years)
<18 85 0 85 9 0 9 105.9±65.4 0.0±0.0 105.9±65.4 – –
18–19 121 9 112 16 3 13 132.2±60.4 333.3±308.0 116.1±56.7 0.35 (0.12to1.00) large
20–22 176 50 126 7 3 4 39.8±28.9 60.0±65.8 31.7±30.6 0.53 (0.12to2.28) moderate
23–25 129 74 55 8 4 4 62.0±41.6 54.1±51.5 72.7±68.6 1.34 (0.35to5.14) small
26–29 85 61 24 8 5 3 94.1±62.1 82.0±68.8 125.0±132.3 1.53 (0.39to5.89) small
30–34 38 27 11 0 0 0 0.0±0.0 0.0±0.0 0.0±0.0 – –
>34 6 3 3 1 1 0 166.7±298.2 333.3±533.4 0.0±0.0 – –
Total 963 338 625 81 27 54 84.1±17.5 79.9±28.9 86.4±22.0 1.08 (0.69 to 1.68) trivial
There was a significant difference in the distribution of injuries between the different age groups (χ2=14.3; p=0.03).
Table 3 Changes in injury incidences per 1000 registered gymnasts with 95% CI (±95% CI) from the 2008 to the 2012 and the 2016 Olympic
Games (OG) regarding the gymnastics disciplines
Total Male Female
Incidence±95% CI χ2; pValue Incidence±95% CI χ2; pValue Incidence±95% CI χ2; pValue
Total
OG 2008 75.5±29.0 62.5±44.8 82.5±37.6
OG 2012 74.3±28.6 χ2=0.0; p=0.96 87.7±51.9 χ2=0.8; p=0.35 67.0±33.9 χ2=0.4; p=0.55
OG 2016 102.5±33.1 χ2=1.4; p=0.23 89.3±52.8 χ2=0.6; p=0.45 109.5±42.2 χ2=0.9; p=0.35
Artistic gymnastics
OG 2008 72.5±36.6 62.5±48.4 82.5±54.7
OG 2012 76.9±37.4 χ2=0.0; p=0.87 91.8±57.2 χ2=0.6; p=0.44 61.9±47.9 χ2=0.3; p=0.58
OG 2016 134.0±47.9 χ2=4.0; p=0.05 93.8±58.3 χ2=0.7; p=0.42 173.5±75.0 χ2=3.6; p=0.06
Trampoline gymnastics
OG 2008 64.5±86.5 62.5±118.6 66.7±126.2
OG 2012 62.5±83.9 χ2=0.0; p=0.97 62.5±118.6 χ2=0.0; p=1.00 62.5±118.6 χ2=0.0; p=0.96
OG 2016 31.3±60.3 χ2=0.4; p=0.54 62.5±118.6 χ2=0.0; p=1.00 – –
Rhythmic gymnastics
OG 2008 85.1±56.4 85.1±56.4
OG 2012 72.9±52.0 χ2=0.1; p=0.76 72.9±52.0 χ2=0.1; p=0.76
OG 2016 62.5±48.4 χ2=0.4; p=0.55 62.5±48.4 χ2=0.4; p=0.55
group.bmj.com on October 14, 2017 - Published by http://bjsm.bmj.com/Downloaded from

4EdouardP, etal. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-097972
Original article
and one lower leg fracture, one neck meniscus/cartilage lesion,
one ruptured knee ligament, one groin sprain and one knee lesion.
The mean age of injured gymnasts was 21.1±4.3 years (range
from 16 to 36 years; 32 missing values including 24 from OG
2012), with significant differences between female and male
gymnasts (19.6±3.3 vs 24.1±4.5 years; p<0.001), but without
significant differences in the mean age of uninjured gymnasts
(22.2±4.3 years, range from 16 to 41 years; values were missing
for OG 2012 (n=323); p=0.07). Eighteen per cent of injured
gymnasts were under the age of 18 years and 51% were <20
years, compared with 13% and 31% of uninjured gymnasts,
respectively (χ2=1.2, p=0.3; χ2=8.6, p=0.003, respectively).
Numbers of injured and uninjured gymnasts are presented in
figure 1, and injury incidences per age category are reported in
table 2.
The comparison of the injury characteristics between the three
Olympic Games was not possible due to the small number of
injuries.
Injury incidence and characteristics according to gymnastics
disciplines
Injury incidences were generally higher in women’s and men’s
artistic gymnastics as well as in women’s rhythmic gymnas-
tics, and lower in men’s and women’s trampoline gymnastics,
whereas time-loss injury incidences were higher in men’s and
women’s artistic gymnastics, and lower in women’s rhythmic
gymnastics (tables 1 and 2). Time-loss injuries represent an
important proportion of injuries in men’s artistic gymnastics
(58.5%), without statistical differences with women’s artistic or
rhythmic gymnastics (χ2=3.2; p=0.20).
The characteristics of (time-loss) injuries according to disci-
plines are presented in table 4. Due to the low number of inju-
ries per disciplines, only comparisons between women’s and
men’s artistic gymnastics were performed. The injury frequency
differed significantly between women’s and men’s artistic
gymnastics for circumstance (χ2=4.4, p<0.05), but not for loca-
tion, type and cause (table 4). Compared with males, female
Table 4 Percentage of injuries (and percentage of time-loss injuries) for location, type, circumstance and causes according to the three Olympic
gymnastics disciplines and sex during the 2008, 2012 and 2016 Olympic Games
Artistic gymnastics
Rhythmic
gymnastics Trampoline gymnastics Gymnastics
Female Male Female Male Female Total
Injury location
Face/head/neck 9.7 (23.1) 4.2 (0.0) 33.3 (0.0) 6.2 (9.7)
Trunk 16.1 (7.7) 12.5 (7.1) 19.0 (0.0) 33.3 (0.0) 16.0 (6.5)
Shoulder 3.2 (0.0) 8.3 (7.1) 3.7 (3.2)
Arm/hand except shoulder 9.7 (0.0) 16.7 (14.3) 8.6 (6.5)
Hip/groin 9.7 (15.4) 19.0 (25.0) 50.0 (0.0) 9.9 (9.7)
Thigh 3.2 (0.0) 50.0 (0.0) 2.5 (0.0)
Knee 3.2 (7.7) 16.7 (21.4) 4.8 (0.0) 7.4 (12.9)
Lower leg/Achilles tendon 12.9 (0.0) 8.3 (7.1) 4.8 (0.0) 8.6 (3.2)
Ankle 25.8 (38.5) 16.7 (14.3) 23.8 (25.0) 21.0 (25.8)
Foot 6.5 (7.7) 12.5 (21.4) 19.0 (0.0) 33.3 (0.0) 12.3 (12.9)
Missing values 4.2 (7.1) 9.5 (50.0) 3.7 (9.7)
Injury types
Fracture 3.2 (7.7) 16.7 (28.6) 4.8 (25.0) 7.4 (19.4)
Stress fracture 9.5 (0.0) 2.5 (0.0)
Other bone injury 3.2 (0.0) 4.8 (0.0) 2.5 (0.0)
Sprain/ligamentous rupture/dislocation 48.4 (61.5) 29.2 (28.6) 28.6 (50.0) 66.7 (0.0) 37.0 (45.2)
Lesion of meniscus or cartilage 3.2 (7.7) 8.3 (14.3) 4.8 (0.0) 4.9 (9.7)
Strain/muscle cramps 12.9 (15.4) 9.5 (0.0) 7.4 (6.5)
Contusion 6.5 (0.0) 20.8 (7.1) 50.0 (0.0) 9.9 (3.2)
Tendinopathy/impingement/
arthritis fasciitis
12.9 (0.0) 16.7 (14.3) 23.8 (0.0) 50.0 (0.0) 17.3 (6.5)
Other 9.7 (7.7) 8.3 (7.1) 14.3 (25.0) 33.3 (0.0) 11.1 (9.7)
Missing values
Injury circumstances
Competition 41.9 (61.5) 66.7 (64.3) 14.3 (25.0) 39.5 (58.1)
Training 48.4 (23.1) 20.8 (35.7) 76.2 (25.0) 66.7 (0.0) 100.0 (0.0) 49.4 (29.0)
Missing values 9.7 (15.4) 12.5 (0.0) 9.5 (50.0) 33.3 (0.0) 11.1 (12.9)
Injury causes
Overuse (gradual onset) 6.5 (0.0) 4.2 (7.1) 23.8 (0.0) 33.3 (0.0) 11.1 (3.2)
Overuse (sudden onset) 16.1 (0.0) 8.3 (7.1) 19.0 (25.0) 50.0 (0.0) 14.8 (6.5)
Non-contact trauma 25.8 (38.5) 25.0 (28.6) 9.5 (0.0) 50.0 (0.0) 21.0 (29.0)
Recurrence 9.7 (7.7) 8.3 (7.1) 28.6 (0.0) 13.6 (6.5)
Contact with immobile object 29.0 (38.5) 20.8 (28.6) 9.5 (25.0) 66.7 (0.0) 22.2 (32.3)
Others 9.7 (15.4) 25.0 (21.4) 4.8 (25.0) 12.3 (19.4)
Missing values 3.2 (0.0) 8.3 (0.0) 4.8 (25.0) 4.9 (3.2)
group.bmj.com on October 14, 2017 - Published by http://bjsm.bmj.com/Downloaded from

5
EdouardP, etal. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-097972
Original article
artistic gymnasts sustained significantly more ankle sprains
(27.4±18.7 vs 3.4±6.7 injuries per 1000 registered gymnasts,
respectively; RR=7.95; 95% CI 1.00 to 63.1, very large) and
training injuries (51.4±25.3 vs 17.2±15.0 injuries per 1000
registered gymnasts, respectively; RR=2.98; 95% CI 1.10 to
8.09, moderate), whereas no gender differences were found for
other locations, types, causes or circumstances.
DISCUSSION
The main findings of the present study were that (1) injury inci-
dence was 84±18 injuries per 1000 registered gymnasts during
the three Olympic Games without any difference between female
and male gymnasts, (2) the injury incidence in artistic gymnastics
increased from the 2008 to the 2016 Olympic Games, (3) injury
incidences varied between age groups with higher rates among
the youngest and the oldest gymnasts, (4) ankle sprain was the
most frequent diagnosis (14%), (5) higher injury incidences
were reported in women’s and men’s artistic gymnastics than in
rhythmic and trampoline gymnastics, and (6) about half of the
injuries in artistic gymnastics (58% for male and 42% for female
gymnasts) resulted in time-loss injuries but just 19% in rhythmic
and none in trampoline.
Gymnastic injury risk is moderate
The overall incidence of gymnastic injury during the Olympic
Games was lower than the overall injury incidence in all sports
reported from the 2008 and 2012 Summer Olympic Games.25 26
Artistic, rhythmic and trampoline gymnastics can be considered
as Olympic sports with a lower risk of injury compared with
taekwondo, football, BMX, handball, mountain biking, hockey,
weightlifting, athletics and badminton (all with >150 inju-
ries per 1000 athletes).26 However, the injury risk in the three
gymnastic disciplines combined was higher than in sports with
injury rates <50 injuries per 1000 athletes, for example, archery,
canoeing, track cycling, rowing, shooting and equestrian sports
in the 2012 OG.26
In comparison to other individual sports and data available
from international Championships using a similar injury surveil-
lance system,24 the overall gymnastic injury incidence was also
lower than those during athletics28 or aquatic29 championships.
Comparison of these injury incidences with previous epidemi-
ological studies in gymnastics, especially with prospective studies
collecting injury data during the entire season,4–6 9 11 13 15 16 is
difficult because the injury surveillance systems used were
different particularly with regard to the exposure (per number
of hours of practice or per gymnast per year in comparison to
per number of gymnasts) and consequently the incidences.1 2
Increase of injury rate in artistic gymnastics from the 2008 to
the 2016 Olympic Games
Our analysis showed a significant increase of injury incidence
in artistic gymnastics from 2008 to 2016, and a similar trend
in female artistic gymnastics (table 3). This could be considered
as surprising given the efforts made by the IOC and the FIG to
prevent injuries in elite athletes. However, this result could be
explained by the other changes, such as those in the FIG Code of
Points, increasing the required levels of difficulty.2 This should
encourage all stakeholders around gymnasts to reconsider the
Code of Points with respect to its influence on the injury risk.
This result should be interpreted with caution due to the small
Table 5 Percentage of injuries (and percentage of time-loss injuries) according to the location and types for all the three Olympic gymnastics
disciplines during the 2008, 2012 and 2016 Olympic Games
Injury types/
location Fracture
Stress
fracture
Other
bone
injury
Sprain/
ligamentous rupture/
dislocation
Lesion of
meniscus or
cartilage
Strain/muscle
cramps Contusion
Tendinopathy/
impingement/
arthritis
fasciitis Other Total
Face/head/neck 1.2 (3.2) 1.2 (3.2) 1.2 (3.2) 2.5 (0.0) 6.2 (9.7)
Trunk 4.9 (0.0) 4.9 (3.2) 2.5 (3.2) 3.7 (0.0) 16.0 (6.5)
Shoulder 1.2 (0.0) 3.7 (3.2) 4.9 (3.2)
Arm/hand except
shoulder 2.5 (0.0) 1.2 (3.2) 1.2 (0.0) 3.7 (3.2) 8.6 (6.5)
Hip/groin 3.7 (6.5) 1.2 (3.2) 3.7 (0.0) 8.6 (9.7)
Thigh 2.5 (0.0) 2.5 (0.0)
Knee 2.5 (6.5) 2.5 (3.2) 1.2 (0.0) 1.2 (3.2) 7.4 (12.9)
Lower leg/Achilles
tendon 1.2 (3.2) 1.2 (0.0) 1.2 (0.0) 1.2 (0.0) 1.2 (0.0) 2.5 (0.0) 8.6 (3.2)
Ankle 1.2 (3.2) 1.2 (0.0) 13.6 (22.6) 1.2 (0.0) 3.7 (0.0) 21.0 (25.8)
Foot 2.5 (6.5) 1.2 (0.0) 1.2 (0.0) 6.2 (6.5) 1.2 (0.0) 12.3 (12.9)
Missing values 1.2 (3.2) 2.5 (6.5) 3.7 (9.7)
Total 7.4 (19.4) 2.5 (0.0) 2.5 (0.0) 37.0 (45.2) 4.9 (9.7) 7.4 (6.5) 9.9 (3.2) 17.3 (6.5) 11.1 (9.7) 100 (100)
Figure 1 Number of uninjured and injured male and female gymnasts
in different age groups during the 2008, 2012 and 2016 Olympic Games.
group.bmj.com on October 14, 2017 - Published by http://bjsm.bmj.com/Downloaded from

6EdouardP, etal. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-097972
Original article
number of gymnasts and injuries, and the fact that the overall
injury incidence in the OG increased from 2008 (96 injuries
per 1000 registered athletes25) to 2012 (129 injuries per 1000
athletes26), most probably due to a better compliance of the
NOCs medical teams and their physicians with the surveillance
system. Ongoing injury surveillance during the Olympic Games
and other international gymnastics competitions can help to
determine the impact of proposed injury prevention measures
and/or changes to the Code of Points2 on the gymnasts’ injury
risk.
Ankles and ligaments were most often affected
In the present study, the ankle was the most frequently injured
location, followed by the lumbar spine, foot, hip and groin.
Previous studies in gymnastics also reported such locations as
sustaining the most injuries.1 4–6 9 12–17
An ankle sprain was the most frequent injury diagnosis (14%)
and the primary time-loss injury (22.6%). Although previous
reports have not always found it be the most common diagnosis,
ankle sprains have always been very high on the list of gymnas-
tics injuries especially in artistic gymnastics.1 5 6 9 15 17
The important proportion of ligament (37%) and bone inju-
ries (12%) was consistent with previous studies in gymnas-
tics,1 2 5 6 9 12 13 15 and also similar to findings from other contact
and/or pivot-shift sports (eg, football,30 handball31 or alpine
skiing32).
Although not statistically significant, differences in injury
frequencies were observed between women’s and men’s artistic
gymnastics for location (higher proportion of ankle injuries for
females and knee injuries for males) and type (higher propor-
tion of sprains for females and fractures for males) (table 4). The
sex-related differences in apparatus (female: vault, uneven bars,
beam, floor exercise; and males: floor exercise, pommel horse,
rings, vault table, parallel bars and horizontal bar), and conse-
quently in the biomechanical and physiological constraints could
explain these differences in injury characteristics.
Gymnastics competition leads to a higher risk of time-loss
injuries than training
When analysing injury circumstances, we reported a higher
proportion of time-loss injuries in competition than in
training (table 1). Among the eight injuries requiring
>4 weeks of absence, five were competition injuries (one in
training and two unknown). This is consistent with a previous
study, where a higher rate of severe injury in competitions,
especially in high-level gymnasts, was reported.6 The role
of different equipment and conditions, lack of confidence
or preparation, nerves and time pressures, skill difficulties,
travel and possibly insufficient training have all previously
been discussed as aetiologies or factors of the high injury
rates during competitions.2 6 13
In addition, the incidence of training injuries may be
lower in the context of the Olympic Games because the
conventional wisdom tends to reduce training days during
the Olympic Games, allowing these athletes a moment of
respite between competition days to save energy and thereby
also reducing their risk of injury.
It is also important to note that fortunately no catastrophic
injuries (head and spinal cord injuries1 33) were suffered by
gymnasts either in the present study (only one neck meniscus
or cartilage lesion with an estimated 42 days of absence)
or in any other previous gymnastic injury surveillance
protocol.5 6 8 9 11
Artistic gymnastics is the discipline associated with the
highest injury risk
To our knowledge, data are limited regarding the injury rate
and characteristics in men’s artistic,11 12 17 18 women’s and
men’s trampoline19 and rhythmic gymnastics.20 21 The present
study reports information on the injury rates and characteristics
in these disciplines during three Olympic Games. However, a
significant limitation of the present study is the small number
of registered gymnasts, and consequently of injuries which
restricted statistical comparison between gymnastics disci-
plines. The present study showed that injury incidence varied
between disciplines with artistic gymnastics having the highest
risk. Higher injury incidences were reported in women’s and
men’s artistic gymnastics than in women’s rhythmic gymnastics,
and lower injury incidences in women’s and men’s trampoline
gymnastics. Differences in physical demands, skills and rules
probably influence the injury risk. Comparison with previous
studies is difficult because, to our knowledge, this is the first
study to analyse the injury rates under identical conditions in
these three Olympic disciplines.
Paying attention to young gymnasts!
Gymnastics involves young athletes with immature musculoskel-
etal systems,6 13 and we wanted to analyse the influence of age
on injury risk. Unfortunately, age was missing for 34% of regis-
tered gymnasts and 40% of injured gymnasts, which represents
another significant limitation of the study.
A preliminary analysis showed that the mean age of injured
gymnasts was 21±4 years, without significant differences with
the mean age of uninjured gymnasts (22±4 years). The fact that
this mean age seems lower than that reported for all sports during
the 2008 OG (26±5 years)25 or during international athletics
championships (26±4 years),28 is in favour of our hypothesis
that gymnastics injuries involve young gymnasts.
Injury incidences varied between age groups with higher rates
among the youngest and the oldest gymnasts. This is consistent
with clinical experience since young gymnasts could be more
susceptible to injury due to their immature musculoskeletal
system and lower physical conditioning, and older gymnasts
could have weaker musculoskeletal tissues caused by ageing and
years of gymnastic practice.
Further studies should be done to clearly analyse the influ-
ence of age and maturation on gymnastics injury risk and its
characteristics.
Methodological considerations
Edouard et al34 highlighted the need of clear methodological
parameters to ensure the quality of the injury surveillance system:
medical team participation, coverage of athletes, response rate
and completeness of data. For the present study, these parame-
ters are not specific to gymnastics, but are applicable to all disci-
plines included in the various Olympic Games, and showed good
methodological quality.25 26
To our knowledge, this is the first study to provide data on the
injury risk and characteristics of elite-level gymnasts in a context
of top-level competition using proper surveillance methods. The
Olympic Games clearly represent a unique opportunity to have
a picture of the risk and characteristics of injuries sustained by
elite-level gymnasts during a major international competition.
However, injury surveillance does not allow a clear picture of
overuse injuries,26 which represent an important proportion of
injuries in this sport with high training loads and durations.2 5 6 8 9
group.bmj.com on October 14, 2017 - Published by http://bjsm.bmj.com/Downloaded from

7
EdouardP, etal. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-097972
Original article
This clearly supports the need of further studies over an entire
season.
The exposure used in the present study (per 1000 registered
gymnasts) is the reference for epidemiological studies during
multievent competitions.24–26 However, it does not account
for the potential variance in exposure of participants to risk of
injury (eg, not all gymnasts compete in all events).2 As a result,
the injury rates reported in the present study lack precision and
are difficult to compare meaningfully within and across studies.
The data used in the present study are based on a general data
acquisition form for all Olympic sports24–26 and do not include
a specific questionnaire for gymnastics. Gymnastics includes
different competition formats, a variety of apparatus, specific
rules for each apparatus, as well as specific pathologies for each
apparatus.3 6 16 A more specific surveillance of gymnastics would
require noting the apparatus concerned, the level of the diffi-
culty of the exercise as well as the format of competition.
Suggestions for gymnastics injury prevention
These preliminary results and their limitations support the
value of running injury surveillance studies during international
competitions (gymnastics continental and world championships)
as is done with football,30 athletics28 and aquatics.29 In addition,
pre-participation health questionnaires would be relevant for
such injury surveillance29 35 since 10%–20% gymnasts present
injury complaints at some time during a season,6 and this would
provide vital information regarding any injuries occurring in
the month preceding a championship and so better understand
injury risks during international competitions. In addition, injury
surveillance over an entire season is highly relevant for injury
prevention.6 13 22 This should at least include demographic infor-
mation, longitudinal anthropometric follow-up, information on
the movement during which an injury occurred, monitoring of
impact loads and psychological parameters.6 8 10 13 In addition,
it is also fundamental to collect injury data both during compe-
titions and in-season training as well as exposure data for all
gymnasts to provide accurate evaluations of injury risks.2
Efforts should be focused on artistic gymnastics since this
is the discipline with the highest injury risk and the greatest
number of gymnasts. This can include long-term injury
surveillance monitoring,3 36 optimal medical follow-up of
gymnasts with musculoskeletal screening and/or pre-partic-
ipation physical examination,8 36 optimised physical condi-
tioning,36 37 good mastery of techniques,3 improving the
preparation for gymnastics competition (intensity and skill
difficulty, performance anxiety and competitive stress) and
also a better knowledge of the constraints/stresses/biome-
chanics of artistic gymnastics whether this be the acute
constraints inherent in the movements themselves or chronic
constraints due to the accumulation of training loads.38
Other strategies for injury prevention in artistic gymnastics
have been proposed such as monitoring an gymnast’s growth
and paying attention to the immature musculoskeletal
system, preventing the first injury, improving healing and
the rehabilitation process, improving recovery, follow-up of
nutritional aspects, mental preparation, education, equip-
ment, rules and the Code of Points.3 6 8 36 39 We speculate that
improving these aspects may also allow an improvement in
performance; that would be a win-win performance-preven-
tion strategy.
Given the high percentage of ankle sprains, especially in
female gymnasts, strategies focusing on primary and secondary
ankle sprain prevention should be implemented including
strengthening, postural control and neuromuscular training,
and/or ankle bracing.15 40
Since a third of all injuries are caused by contact with an
immobile object, this raises a question about the equipment;
gymnastic injury prevention can be done by improving the
safety of the equipment.3 8 36
In summary, artistic gymnastics is the discipline with the
highest injury risk, while injury risk in rhythmic gymnastics
and trampoline was low in the years studied. Consequently,
suggestions to prevent injuries should target the group of
artistic gymnasts and their increased risk of sustaining time-
loss injuries and ankle sprains. These efforts will be facili-
tated by regular/constant monitoring of injuries and training
loads.
What are the new findings?
►Injury incidence was 84 injuries (95% CI 67 to 102) per
1000 registered gymnasts during the three Olympic Games,
with no significant riskdifference between female and male
gymnasts.
►Artistic gymnastics was the discipline with the highest injury
risk with 107 (95% CI 71 to 141) and 83 injuries (95% CI 51
to 114) per 1000 registered gymnasts in female and male
gymnasts, respectively.
►Injury incidences varied among age groups with higher rates
among the youngest and the oldest gymnasts.
►An ankle sprain was the most frequent injury diagnosis (14%)
and time-loss injury diagnosis (23%).
►Ligament (37%) and bone injuries (12%) represented the
most frequent injury types of injury.
How might it impact on clinical practice in the future?
►Gymnastic injury prevention should be oriented towards the
discipline of artistic gymnastics, focusing on ankle sprains,
especially in female gymnasts, and on bone and knee injuries
in male gymnasts.
Acknowledgements The authors highly appreciate the cooperation of the medical
staffs of the National Olympic Committee and the medical teams of the medical
staffs Local Organising Committee of the Olympic Games who volunteered their time
to collect the data for this project.
Contributors PE: substantial contributions to the conception and design of
the study, analysis and interpretation of data, drafting, writing and revising of
the manuscript, and final approval of the version to be published. KS: substantial
contributions to the conception and design of the study, collection, analysis
and interpretation of data, drafting, writing and revising of the manuscript, and
final approval of the version to be published. AJ: substantial contributions to
the conception and design of the project, collection and interpretation of data,
revision of the manuscript, and final approval of the version to be published. ML:
substantial contributions to the interpretation of data, revision of the manuscript,
and final approval of the version to be published. TS: substantial contributions to
the collection, analysis and interpretation of data, revision of the manuscript, and
final approval of the version to be published. LE: substantial contributions to the
conception and design of the project, collection and interpretation of data, revision
of the manuscript, and final approval of the version to be published.
Funding The data acquisition was funded by the International Olympic Committee,
which has contributed to planning, developing and executing the injury surveillance
procedure from with the Beijing Games onwards.
Competing interests None declared.
Patient consent Obtained.
Ethics approval The present study is a part of an injury and illness surveillance
study during the Olympic Games, which was reviewed and approved by the medical
group.bmj.com on October 14, 2017 - Published by http://bjsm.bmj.com/Downloaded from

8EdouardP, etal. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-097972
Original article
research ethics committee of the South-Eastern Norway Regional Health Authority,
Norway (2011/388-4).
Provenance and peer review Not commissioned; externally peer reviewed.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2017. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.
RefeRences
1 Kolt GS, Gymnastics CDJ. In: Caine DJ, Harmer PA, Schiff MA, eds. Epidemiology of
Injury in Olympic Sports. Wiley-Blackwell 2010:144–60.
2 Caine DJ, Harringe ML. Epidemiology of injury in gymnastics. In: Caine DJ, Russell K,
Lim L, eds. Gymnastics handbook of sports medicine and science: Wiley-Blackwell,
2013:111–24.
3 Sands WA. Injury prevention in women’s gymnastics. Sports Med 2000;30:359–73.
4 Caine D, Cochrane B, Caine C, et al. An epidemiologic investigation of injuries
affecting young competitive female gymnasts. Am J Sports Med 1989;17:811–20.
5 Kolt GS, Kirkby RJ. Epidemiology of injury in Australian female gymnasts. Sports
Medicine, Training and Rehabilitation 1995;6:223–31.
6 Caine D, Knutzen K, Howe W, et al. A three-year epidemiological study of injuries
affecting young female gymnasts. , 2003:1466, 10–23.
7 Engebretsen L, Steffen K, Bahr R, et al. The International Olympic Committee
Consensus statement on age determination in high-level young athletes. Br J Sports
Med 2010;44:476–84.
8 Bradshaw EJ. Biomechanical approaches to identify and quantify injury mechanisms
and risk factors in women’ s artistic gymnastics Biomechanical approaches to identify
and quantify injury mechanisms. , 2012:11, 324–41.
9 Kolt GS, Kirkby RJ. Epidemiology of injury in elite and subelite female gymnasts: a
comparison of retrospective and prospective findings. Br J Sports Med 1999;33:312–8.
10 Kerr G, Minden H. Psychological Factors Related to the Occurrence of Athletic injuries.
Journal of Sport and Exercise Psychology 1988;10:167–73.
11 Dixon M, Fricker P. Injuries to elite gymnasts over 10 yr. Med Sci Sports Exerc
1993;25:1322–9.
12 Lowry CB, Leveau BF. A retrospective study of gymnastics injuries to competitors and
noncompetitors in private clubs. Am J Sports Med 1982;10:237–9.
13 O’Kane JW, Levy MR, Pietila KE, et al. Survey of injuries in Seattle area levels 4 to 10
female club gymnasts. Clin J Sport Med 2011;21:486–92.
14 Sands WA, Shultz BB, Newman AP. Women’s gymnastics injuries. A 5-year study. Am J
Sports Med 1993;21:271–6.
15 Marshall SW, Covassin T, Dick R, et al. Descriptive epidemiology of collegiate women’s
gymnastics injuries: national collegiate athletic association injury surveillance system,
1988-1989 through 2003-2004. J Athl Train 2007;42:234–40.
16 Kerr ZY, Hayden R, Barr M, et al. Epidemiology of National Collegiate Athletic
Association Women’s Gymnastics Injuries, 2009-2010 Through 2013-2014. J Athl
Train 2015;50:870–8.
17 Westermann RW, Giblin M, Vaske A, et al. Evaluation of men’s and women’s
gymnastics injuries-a 10-year observational study. , 2014:7, 161–5.
18 Kirialanis P, Malliou P, Beneka A, et al. Occurrence of acute lower limb injuries
in artistic gymnasts in relation to event and exercise phase. Br J Sports Med
2003;37:137–9.
19 Grapton X, Lion A, Gauchard GC, et al. Specific injuries induced by the practice of
trampoline, tumbling and acrobatic gymnastics. Knee Surg Sports Traumatol Arthrosc
2013;21:494–9.
20 Cupisti A, D’Alessandro C, Evangelisti I, et al. Injury survey in competitive sub-elite
rhythmic gymnasts: results from a prospective controlled study. J Sports Med Phys
Fitness 2007;47:203–7.
21 Sabeti M, Jeremian L, Graf A, et al. Elite level rhythmic gymnasts have significantly
more and stronger pain than peers of similar age: a prospective study. Wien Klin
Wochenschr 2015;127:31–5.
22 van Mechelen W, Hlobil H, Kemper HC. Incidence, severity, aetiology and prevention of
sports injuries. A review of concepts. Sports Med 1992;14:82–99.
23 Finch C. A new framework for research leading to sports injury prevention. J Sci Med
Sport 2006;9:3–9.
24 Junge A, Engebretsen L, Alonso JM, et al. Injury surveillance in multi-sport events: the
International Olympic Committee approach. Br J Sports Med 2008;42:413–21.
25 Junge A, Engebretsen L, Mountjoy ML, et al. Sports injuries during the Summer
Olympic Games 2008. Am J Sports Med 2009;37:2165–72.
26 Engebretsen L, Soligard T, Steffen K, et al. Sports injuries and illnesses during the
London Summer Olympic Games 2012. Br J Sports Med 2013;47:407–14.
27 Hopkins WG. A New View of Statistics: A Scale of Magnitudes for Effect Statistics.
2002 http://www. sportsci. org/ resource/ stats/ effectmag. html
28 Edouard P, Feddermann-Demont N, Alonso JM, et al. Sex differences in injury
during top-level international athletics championships: surveillance data from 14
championships between 2007 and 2014. Br J Sports Med 2015;49:472–7.
29 Prien A, Mountjoy M, Miller J, et al. Injury and illness in aquatic sport: how high is the
risk? A comparison of results from three FINA World Championships. Br J Sports Med
2017;51:277–82.
30 Junge A, Dvorak J. Injury surveillance in the World Football Tournaments 1998-2012.
Br J Sports Med 2013;47:782–8.
31 Moller M, Attermann J, Myklebust G, et al. Injury risk in Danish youth and
senior elite handball using a new SMS text messages approach. Br J Sports Med
2012;46:531–7.
32 Bere T, Flørenes TW, Nordsletten L, et al. Sex differences in the risk of injury in World
Cup alpine skiers: a 6-year cohort study. Br J Sports Med 2014;48:36–40.
33 Boden BP. Direct catastrophic injury in sports. J Am Acad Orthop Surg
2005;13:445–54.
34 Edouard P, Branco P, Alonso JM, et al. Methodological quality of the injury surveillance
system used in international athletics championships. J Sci Med Sport 2016;19:984–9.
35 Alonso JM, Jacobsson J, Timpka T, et al. Preparticipation injury complaint is a risk
factor for injury: a prospective study of the Moscow 2013 IAAF Championships. Br J
Sports Med 2015;49:1118–24.
36 Harringe ML, Caine DJ. Gymnastics injury prevention. In: Caine DJ, Russell K, Lim
L, eds. Gymnastics handbook of sports medicine and science: Wiley-Blackwell,
2013:170–8.
37 Durall CJ, Udermann BE, Johansen DR, et al. The effects of preseason trunk muscle
training on low-back pain occurrence in women collegiate gymnasts. J Strength Cond
Res 2009;23:86–92.
38 Soligard T, Schwellnus M, Alonso JM, et al. How much is too much? (Part 1)
International Olympic Committee consensus statement on load in sport and risk of
injury. Br J Sports Med 2016;50:1030–41.
39 Daly RM, Bass SL, Finch CF. Balancing the risk of injury to gymnasts: how effective are
the counter measures? Br J Sports Med 2001;35:8–19.
40 Kerkhoffs GM, van den Bekerom M, Elders LAM, et al. Diagnosis, treatment and
prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med
2012;46:854–60.
group.bmj.com on October 14, 2017 - Published by http://bjsm.bmj.com/Downloaded from

Olympic Games
from 963 registered gymnasts during
prospectively collected surveillance data
2012 and 2016 Olympic Games: analysis of
Gymnastics injury incidence during the 2008,
Soligard and Lars Engebretsen
Pascal Edouard, Kathrin Steffen, Astrid Junge, Michel Leglise, Torbjørn
published online October 14, 2017Br J Sports Med
http://bjsm.bmj.com/content/early/2017/10/14/bjsports-2017-097972
Updated information and services can be found at:
These include:
References
#BIBL
http://bjsm.bmj.com/content/early/2017/10/14/bjsports-2017-097972
This article cites 36 articles, 14 of which you can access for free at:
service
Email alerting box at the top right corner of the online article.
Receive free email alerts when new articles cite this article. Sign up in the
Collections
Topic Articles on similar topics can be found in the following collections
(170)Epidemiology
Notes
http://group.bmj.com/group/rights-licensing/permissions
To request permissions go to:
http://journals.bmj.com/cgi/reprintform
To order reprints go to:
http://group.bmj.com/subscribe/
To subscribe to BMJ go to:
group.bmj.com on October 14, 2017 - Published by http://bjsm.bmj.com/Downloaded from