Paralympic Sports Medicine and Science
Descriptive Epidemiology of Paralympic Sports Injuries
Nick Webborn, MB, BS FSEM (UK), Carolyn Emery, PT, PhD
Abstract: Paralympic sports have seen an exponential increase in participation since 16
patients took part in the first Stoke Mandeville Games on the opening day of the 1948
London Olympic Games. More than 4,000 athletes took part in the London 2012 Paralympic Games. Few sporting events have seen such rapid evolution. This rapid pace of
change also has meant challenges for understanding the injury risks of participation, not
only because of the variety of sports, impairment types, the evolution of adapted equipment but also because of the inclusion of additional impairment types and development of
new sports over time. Early studies were limited in scope but patterns of injuries are slowly
emerging within Winter and Summer Paralympic sports. The IPC’s London 2012 study is
the largest to date with a prospective cohort study involving 49,910 athlete-days. The
results identified large differences across sports and highlighted the need for longitudinal
sport specific studies rather than solely games-time studies. This will require collaboration
with international sports federations to examine injury patterns and risk factors for injury
in this population to appropriately inform injury prevention strategies. Further studies will
also need to address the impact of sporting participation, injury, and future health.
PM R 2014;6:S18-S22
INTRODUCTION
Paralympic sports have seen an exponential increase in participation since 16 patients
took part in the first Stoke Mandeville Games on the opening day of the 1948 London
Olympic Games. More than 4000 athletes took part in the London 2012 Paralympic
Games to packed audiences and worldwide television coverage. Few sporting events have
seen such a rapid evolution. This rapid pace of change also has meant challenges for
understanding the injury risks of participation because of inclusion of additional
impairment types and development of new sports. In 1960, the International Stoke
Mandeville Games were held in Rome and since that time, the Games have been held in
the country selected for the Olympic Games where possible, save for financial or political
reasons. In 1976, in Toronto, the Games included visually impaired and amputee athletes
for the first time, and the Games were known as the Olympiad for the Physically Disabled.
In 1980, in Arnhem, athletes with physical disabilities not fitting into the historical
disability groups (Les Autres; fr. “the others”) or with cerebral palsy also were included.
The International Paralympic Committee (IPC) was founded in 1989, and since 1994 the
management of the Paralympic Games has been administered byr the IPC. Although
athletes with intellectual disabilities have participated in some Paralympic Games, they are
not included in this review.
The data for this review were primarily published articles and reports from a literature
search of PubMed and SPORTDiscus; however, information from Congress proceedings
and both published and unpublished articles known to the authors but not identified
through these database sources also were evaluated. English-language articles were used
primarily, but some German texts were incorporated where translation could be performed. Search terms involved permutations and combinations of Paralympic, injury, cerebral palsy, visually impaired, wheelchair, disability, and sport.
A variety of methodologic limitations, which confound the interpretability of the
findings, were evident in the literature, particularly in earlier studies. Factors included a
lack of standard definitions for reportable injury and injury details, short study timeframes,
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1934-1482/14/$36.00
Printed in U.S.A.
N.W. The Centre for Sport and Exercise Science and Medicine (SESAME), University of
Brighton, Eastbourne, UK. Address correspondence to: N.W.; e-mail: nickwebborn@sportswise.org.uk
Disclosure: nothing to disclose
C.E. University of Calgary, Alberta, Canada
Disclosure: nothing to disclose
Submitted for publication January 31, 2014;
accepted June 10, 2014.
ª 2014 by the American Academy of Physical Medicine and Rehabilitation
Vol. 6, S18-S22, August 2014
http://dx.doi.org/10.1016/j.pmrj.2014.06.003
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poor or absent exposure data, use of self-report surveys that
did not include a confirmed medical diagnosis, and small
sample sizes. In addition, the unique grouping of sports by
disability makes obtaining a clear picture of injury risk and
risk factors in Paralympic sport complicated. For example,
when investigating the risk of injury related to a particular
sport, of the 27 Paralympic sports (22 summer [planned in
year 2016] and 5 winter), some are participated in by athletes with different impairments (athletics: spinal cord
injured, visually impaired, amputee, and cerebral palsy),
some are unique to particular disability categories (goalball:
visually impaired; wheelchair rugby: athletes with impairment in all 4 limbs), some are modified by rules (judo) or
equipment (sit-ski; sledge hockey) for particular classes of
athletes, and some involve multiple categories of disability
on the same team (basketball).
Caution also may be required intepreting studies if the
investigation is focused on the risks related to a particular
class of disability across different sports. For example, a
lower limb amputee athlete may compete with a prosthesis
for track athletics or cycling, without a prosthesis for
swimming or high jump, or in a wheelchair for sports such
as basketball and tennis. Athletes with cerebral palsy may be
ambulant or wheelchair users depending upon the degree of
disability. Some more recent studies have used a combination of impairment and sport specificity to limit these confounders but so far have relatively few athlete numbers, and
the results need to be treated with some caution [1-3].
Changes in professionalism and level of participation in
disability sport impose a further difficulty in interpreting the
available data. In the 1970s and 1980s, it was not uncommon for individual athletes to participate in multiple sports,
even at the Paralympic Games. In a survey of 128 athletes
with disabilities, Curtis and Dillon [4] found 79% were
competing in track athletics, 71% in wheelchair basketball,
57% in road racing, and 60% in field events in athletics. This
occurrence would be rare in elite disability sports now.
Technology in the form of lightweight, high tensilestrength
materials and improved designs for wheelchairs and prostheses for different populations of Paralympic athletes have
changed performance parameters and injury risk characteristics during the past 2 decades. In addition, training protocols and access to specialized trainers, coaches, and
medical personnel have changed during the past few decades. As such, comparisons between injury patterns seen
20-30 years ago and those seen currently may not be
appropriate. In addition, findings from older research articles in this area may not reflect the current position in elite
Paralympic sport.
Thus, a broad overview of injury patterns in Paralympic
sports potentially loses sight of risk and risk factor relationships in specific sport/disability interactions, and the
small numbers in any particular combination renders analyses and conclusions unstable. In an attempt to address
some of these issues, the IPC’s Injury Surveillance System
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(ISS) was implemented during the 2002 Salt Lake City
Winter Paralympic Games and has continued at all subsequent Winter Paralympic Games. The first summer games
injury and illness survey was during the London 2012
Paralympic games and was the first study to report on
sport-specific injury incidence rates considering exposure
to risk.
WHO IS AFFECTED BY INJURY?
A comparison of injury rates (IRs) reported in prospective
and retrospective research is summarized in Table 1 [5-17].
As noted previously, some studies involved multiple
disability groups and some covered only individual disability
groups; sports surveyed ranged from the full complement of
summer Paralympic sports to individual sports. Few studies
reported incidence rates because of the omission of exposure
data. Interpretability of the results often is challenging in the
absence of a reportable injury definition or by the variation
of the definition between studies. Invariably, the definition
will influence both the data collected and the risk assessment
of the sports studied. For example, several retrospective
questionnaire studies included minor soft-tissue injuries (eg,
blisters or abrasions for which no medical attention was
sought) whereas other research, which was based on the
organizing committee’s medical services at Paralympic
Games, did not include minor soft-tissue injuries.
Summer Sports
The first study to attempt to quantify exposure data was a
2-year prospective study by Ferrara et al [8] of 319 multidisability athletes in summer Paralympic sports. An
overall IR of 9.3 injuries/1000 participation hours was reported; however, no sport-specific details were provided,
and self-reported symptoms have inherent limitations. The
London 2012 injury survey13 captured data from 3565
athletes (84% compliance by athletes) from 160 delegations
(98% compliance by delegation) during training and
competition in the 20 summer sports. A total of 49,910
athlete-days were monitored during which a total of 633
injuries in 539 athletes were documented. The overall
injury incidence rate was 12.7 injuries/1000 athlete days
(95% confidence interval [95% CI] 11.7-13.7). The overall
incidence proportion was 17.8 injuries/100 athletes (95%
CI 16.5-19.0); however, there were marked variations by
sport, with the greatest injury rates in Football 5-a-side (IR
22.4 injuries/1000 athlete-days), Goalball (IR 19.5 injuries/
1000 athlete-days), Powerlifting (IR 19.3 injuries/1000
athlete-days), wheelchair fencing (IR 18.0 injuries/1000
athlete-days), and wheelchair rugby (IR 16.3 injuries/1000
athlete-days). Sports with the lowest IRs included sailing
(IR 4.1 injuries/1000 athlete-days), rowing (IR 3.9 injuries/
1000 athlete-days), and shooting (IR 2.2 injuries/1000
athlete-days).
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EPIDEMIOLOGY OF PARALYMPIC SPORTS INJURIES
Table 1. Distribution of injury onset: acute vs chronic
Author
Summer sports
Curtis and Dillon [4]*yzx
Ferrara and Davis [5]*
Burnham et al [6]*yzx{
Richter et al [7]z
Ferrara et al [8]*yzx{
Taylor and Williams [9]*
Reeser [10]yx
Ferrara et al [11]*yzx{
Nyland et al [12]*yzx
Magno e Silva et al [1]{
Magno e Silva et al [3]{
Magno e Silva et al [2]{
Willick et al [13]*yzx{
Mean
Winter sports
Ferrara et al [14]*yx
Webborn et al [15]*yzx{
Webborn [16]*yzx{
Webborn et al [17]*yzx{
Sample
Injuries (Frequency)
M:F, %
Type of Sport
Acute, %
Chronic, %
1200
19
151
75
426
53
89
1360
304
13
40
28
3565
128
19
108
27
137
38
41
1037
254
35
77
41
633
79:21
53:47
NR
NR
NR
77:23
All male
NR
NR
All Male
70:30
68:32
66:34
Wheelchair sports
Wheelchair sports
Summer Paralympic
Summer Paralympic
Summer Paralympic
Wheelchair racing
Standing volleyball
Multisport
Summer Paralympic
Football 5-a-side
Track and field athletics
Swimming
Summer Paralympic
40
65
49
73
46
41
60
77
67
80
18
20
68
54
60
35
51
27
54
59
40
23
33
20
82
80
32
46
68
194
134
88
190
112
132
68
24
12
3
23
12
5
118
40
Alpine skiing
Alpine skiing
Ice sledge hockey
Nordic skiing
Alpine skiing
Ice sledge hockey
Nordic skiing
Alpine skiing
Ice sledge hockey
Nordic skiing
Wheelchair curling
50
91
83
50
78
64
80
45
40
40
0
56
50
9
17
50
22
36
20
55
60
60
100
44
Mean
78:22
79:21
79:21
75:25
NR ¼ not reported.
*Spinal cordrelated disability.
y
Amputee.
z
Cerebral palsy.
x
Les Autres.
{
Visually impaired.
A separate study [18] describing injuries in 91 Polish
Paralympians in Beijing (2008) and 100 in London (2012)
reported an incidence rate of 29.8/1000 athlete-days (95%
CI 22.1-37.6) in Beijing and only 15/1000 athlete-days (95%
CI 9.0-21.0) in London. Three studies examining injury in
elite Brazilian visually impaired athletes recorded longitudinal data during the period 2004-2008 in 3 separate sports
but sample size is small and limited to one nation [1,3].
Allen [19] reported an injury prevalence of 6.3% in a
survey of sailors with multiple disability types in the International Foundation for Disabled Sailing World Championship (n ¼ 24 teams). McCormick and Reid [20] reported
the prevalence of injury in basketball (30.9%), track athletics
(30.6%), and road racing (12.1%) in a retrospective study of
wheelchair athletes; however, blisters and abrasions formed
approximately 50% of these injuries, many of which did not
require formal medical treatment.
Winter Sports
Studies examining winter sports also included variation between reports on single events, such as Alpine skiing
compared with all winter Paralympic sports. A multicenter
study describing injuries occurring in recreational skiers with
a disability reported an injury incidence rate of 2 injuries/ 1000
skier days [21]. Webborn [16] reported comparative injury
data by sport from 2 winter Paralympic Games (2002 and
2006) and found similar rates at both Games in each sport;
however, the ISS captured sport injuries in 24% of all athletes
participating in the 2010 Vancouver Winter Paralympic
Games [17]. The injury risk was significantly greater than
during the 2002 (9.4%) and 2006 (8.4%) Winter Paralympic
Games, which may reflect improved injury surveillance
methodology and data capture but also highlights the high risk
of acute injury in alpine skiing and ice sledge hockey in
particular. There were a total of 120 injuries among the 505
athletes (incidence proportion 23.8%, 95% CI 20.1-27.7). In
Alpine skiing, 22% of competitors presented with an injury
compared with 13% and 12% of competitors in 2002 and
2006, respectively. Downhill racing was the most likely cause
of injury, with 4 new acute injuries occurring for every 100
race events. For ice sledge hockey, 34% of competitors presented with injury compared with 14% and 11% of competitors in 2002 and 2006, respectively. Nordic skiing and
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wheelchair curling have significantly lower injury rates at
18.6% and 18%, respectively.
Vol. 6, Iss. 8S, 2014
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WHEN DOES THE INJURY OCCUR?
Injury Onset
WHERE DOES INJURY OCCUR?
Anatomical Location
In studies involving wheelchair athletes, the upper limb,
particularly the shoulder, is the most common site of injury,
with a prevalence for shoulder injury ranging from 19% [20]
across multiple wheelchair sports to 72% in female wheelchair basketball players [22]. However, Webborn and
Turner [23] noted in their report on 244 British athletes seen
during a 4-week period, including the build-up to, and
competition in, a summer Paralympic Games that although
the shoulder was the most common site of pain in wheelchair athletes (30%), the cervical and thoracic spine (59%
and 8%, respectively) were the actual sites of pathology
(resulting in referred pain to the shoulder) compared with
33% of specific shoulder pathology.
In the London 2012 study [13], the distribution of injury
by body part also was greatest in the upper limb irrespective
of impairment type (50.2% of all injuries), with shoulder
injuries being most prominent (17.7% of all). The knee was
the most common injured region of the lower limb (7.9% of
all injuries).
In elite disabled standing volleyball players (including
athletes with upper limb and lower limb impairments
including amputation), Reeser [10] identified the foot and
ankle as the most common site of injury (21%), followed by
the shoulder (18%), wrist and hand (18%), and the knee
(14%). In this study, the distribution of injury locations was
not related to the type of disability. In a 4-year study
examining injury in Brazilian visually impaired (n ¼ 13)
footballers (soccer players) [1], the greatest proportion of
injuries reported were lower limb (80%), head (8.6%), spine
(5.7%), and upper limb injuries (5.7%).
Webborn et al [15] noted that lower limb fractures were
frequent in spinal cord-injured ice sledge hockey athletes
and in standing athletes in Alpine skiing in the 2002 Winter
Games. However, in the 2006 and 2010 Winter Games, only
one lower limb fracture occurred in ice sledge hockey over
both the Games compared with the 4 fractures seen in 2002
before the introduction of the regulation change on protective equipment and sledge height [17]. Athletes in seated
Alpine classes consistently had more upper limb injuries in
all 3 Winter Paralympics studied. Injuries to the head and
neck in ice sledge hockey and Alpine events also were
common. IRs in wheelchair curling appear consistently low
across the 2 Games (2006 and 2010) in which the sport has
been included. There were no recorded injuries in 2006. In
2010 although 9 of 50 (18%) curlers sought medical
attention for musculoskeletal complaints, none of these was
acute injuries, and 5 of the 9 encounters were for pre-Games
nonsport-related symptoms.
Table 1 also presents the percent distribution of acute and
chronic injuries in disability sport. here is approximately a
55:45 ratio of acute to chronic injuries reported in the
literature for most summer and winter Paralympic sports;
however, there is marked variation by sport as one would
expect with differences between contact and endurance
sports for example. This finding also may reflect when the
injury data were collected, with competition surveys
reporting more acute injuries [10,12,24] and longitudinal
surveys reporting more chronic injuries [4,8].
WHAT IS THE OUTCOME?
Injury Type
In Summer Paralympic sports, the authors of a previous
review [25] reported strains (mean ¼ 25.4%; range: 4%60%) and sprains (mean ¼ 22.8%; range: 3.7%-48%) to be
the most common injury types. However, this finding varies
greatly between studies. The use of self-report data in the
majority of the studies raises questions about the validity of
injury classifications in these works. The studies by Burnham
et al [6] and Webborn et al [15], in which physician or
therapist diagnosis was the basis for classification, may be
considered more accurate. Three longitudinal studies [1-3]
in visually impaired athletes in swimming, football 5-a-side,
and track and field athletics reported injuries during a 5-year
period in one national team squad. Two of the studies
describe “muscle spasms” as the most common injury type
but without further explanation as to whether this definition
indicates muscle cramp, fatigue-related, or neurally mediated
spasm. Thus, it remains unclear of the true nature of the
problem and its significance for injury prevention.
In the Winter Sports, contusions, fractures, and concussion
are more prevalent because of the impact potential and speed.
For example, in Ice Sledge Hockey in 2002 fractures comprised
33% of injuries. After modifications in regulations on protective equipment and sledge height, fractures accounted for 7.5%
of all sledge hockey injuries in 2010. Only one of these fractures involved the lower limb. In Nordic and Alpine Skiing,
there were 4 head injuries in the 2010 Winter Games, 3 of
which prevented further participation in competition.
CONCLUSION
There is significant variability in injury definitions, research
designs, data collection methodology, and analytic approaches in the literature examining injury in disabled athletes during the past 2 decades. The IPC has supported the
development of injury surveillance tools to ensure methodological rigor in examining injuries in the Paralympic Games
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Webborn and Emery
that will hopefully lead to evidence informed safety and
prevention practices in future game.
Patterns of injuries are slowly emerging within Winter
and Summer Paralympic sports, which highlights the need
for longitudinal studies rather than solely games-time studies
through collaboration with international sports federations.
To further examine injuries and risk factors for injury in this
population to inform injury prevention strategies, the IPC
plans to continue the ISS during future summer and winter
Paralympic Games while encouraging and supporting longitudinal, sport-specific studies.
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