International Olympic Committee Consensus Statement

Consensus Statement
International Olympic Committee

Consensus Statement
Methods for Recording and Reporting of Epidemiological
Data on Injury and Illness in Sports 2020
(Including the STROBE Extension for Sports
Injury and Illness Surveillance (STROBE-SIIS))
International Olympic Committee Injury and Illness Epidemiology Consensus Group*†
Background: Injury and illness surveillance, and epidemiological studies, are fundamental elements of concerted efforts to protect
the health of the athlete. To encourage consistency in the definitions and methodology used, and to enable data across studies to
be compared, research groups have published 11 sport- or setting-specific consensus statements on sports injury (and, even-
tually, illnesses) epidemiology to date.
Objective: To further strengthen consistency in data collection, injury definitions, and research reporting through an updated set of
recommendations for sports injury and illness studies, including a new Strengthening the Reporting of Observational Studies in
Epidemiology (STROBE) checklist extension.
Study Design: Consensus statement of the International Olympic Committee (IOC).
Methods: The IOC invited a working group of international experts to review relevant literature and provide recommendations. The
procedure included an open online survey, several stages of text drafting and consultation by working groups, and a 3-day
consensus meeting in October 2019.
Results: This statement includes recommendations for data collection and research reporting covering key components: defining
and classifying health problems, severity of health problems, capturing and reporting athlete exposure, expressing risk, burden of
health problems, study population characteristics, and data collection methods. Based on these, we also developed a new
reporting guideline as a STROBE extension—the STROBE Sports Injury and Illness Surveillance (STROBE-SIIS).
Conclusion: The IOC encourages ongoing in- and out-of-competition surveillance programs and studies to describe injury and
illness trends and patterns, understand their causes, and develop measures to protect the health of the athlete. The imple-
mentation of the methods outlined in this statement will advance consistency in data collection and research reporting.
Keywords: injuries; illness; epidemiologic methods; surveillance; STROBE
Injury and illness surveillance, and epidemiological stud- injuries and illnesses? How do injury rates in various
ies, are fundamental elements of concerted efforts to pro- sports compare? Do participant characteristics and factors
tect the health of the athlete. Carefully designed injury within competition and training affect the risk?
surveillance programs, accurate data capture, and careful To encourage consistency in the definitions and methods
analysis of data are building blocks for sports injury/ill- used, and to enable data across studies to be compared,
ness prevention programs. Important questions that research teams have published 11 consensus papers on
sports injury and illness surveillance projects are sports injury (and, eventually, illness) epidemiology. Most
designed to address include: What is the risk of an indi- of them addressed specific sports—cricket,84 football,50
vidual athlete sustaining an acute injury, developing an rugby union,52 rugby league,65 aquatic sports,78 tennis,86
overuse injury, or becoming ill in a given sport? Within a athletics,98 and horse racing.102 Two statements covered
given sport, what is the typical pattern and severity of multisport events64 and mass-participation events (eg,
marathon races).92
The Orthopaedic Journal of Sports Medicine, 8(2), 2325967120902908
We now have more than a decade of experience with the
DOI: 10.1177/2325967120902908 existing recommendations. Sports epidemiology has
ª The Author(s) 2020 advanced, with a new focus on overuse injuries and also
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1
2 IOC Injury and Illness Epidemiology Consensus Group The Orthopaedic Journal of Sports Medicine
on illnesses. Data collection and reporting methods have diverse settings (sports types, age groups, performance
also advanced as data are being collected for routine sur- levels) and with a variety of health problems as outcomes
veillance or predefined observational or intervention stud- (eg, illnesses, not only acute injuries).
ies in diverse settings, ranging from community to elite
sports, from youth sports to the master’s level, in able- 1. Online survey: The survey included 25 questions invit-
bodied and athletes with disabilities, and in team sports ing free-text comments on aspects identified from pre-
and individual sports. In 2005, when the first of these vious consensus statements. The survey link was open
sports injury surveillance consensus statements was devel- to the public and was launched via email and Twitter
oped, there were no agreed on research reporting methods on February 1, 2019, and closed on March 15, 2019. We
(eg, the EQUATOR Network [Enhancing the QUAlity and received comments from 188 respondents, including 19
Transparency Of health Research] was just holding its consensus group members. A report including all
inaugural meeting). Many important research epidemiolog- responses was distributed to the consensus group on
ical issues were not discussed in any of the previous sports- August 31, 2019.
related consensus statements. 2. The consensus group was split into 7 working groups.
In 2019, the International Olympic Committee (IOC) con- Each working group was responsible for a subset of the
vened an expert panel to update recommendations for the sections presented in this final document (eg, “classifying
field of sports epidemiology—this consensus statement. We health problems”). For each section, the group reviewed
the survey responses, examined available relevant liter-
drew on recent methods developments and the experience of
ature (including previous consensus statements), and
scientists working in the field of sports injury and illness
composed draft text with the necessary background and
surveillance. A specific goal was to further encourage con-
proposed definitions and recommendations.
sistency in data collection, injury definitions, and research
3. R.B. created a complete draft that was shared online
reporting (in line, where possible, with the EQUATOR Net-
with the consensus group, asking all members to pro-
work recommendations). Our aim was to provide hands-on
vide written comments/suggestions. Comments were
guidance to researchers on how to plan and conduct data
made online and were visible to all group members.
collection and how to report data. We anticipate that this
4. The working groups revised their sections based on
sports-generic statement will be complemented by subse-
input from other members of the consensus group.
quent sport-specific statements with more detailed recom-
5. At the in-person consensus meeting, attended by all
mendations relevant for the sports and/or setting. We also
consensus group members, the revised draft was dis-
extended the Strengthening the Reporting of Observational
cussed section by section, focusing on recommendations
Studies in Epidemiology (STROBE) checklist 63 —the
and definitions.
STROBE Sports Injury and Illness Surveillance
6. Seven new revision groups made up of those not respon-
(STROBE-SIIS)—to assist users in planning surveillance
sible for drafting the original section under discussion
studies and in writing articles based on injury/illness data.
were responsible for taking notes and revising the text.
If necessary, items were voted on to achieve a majority.
7. The revised draft was edited for consistency and form
METHODS by R.B. and reviewed with the rest of the editorial
group (K.C., B.R., K.M.K.).
This was an 8-stage process: (1) an online survey; (2) work-
8. Finally, the manuscript was distributed to the consen-
ing groups reviewed the survey responses, available litera-
sus group members for final approval.
ture, and drafted text; (3) all consensus group members
reviewed the draft text; (4) the initial working groups
revised their draft text; (5) a 3-day consensus meeting was
held in Lausanne, Switzerland (October 9-11, 2019); (6) DEFINING AND CLASSIFYING
new working groups revised the draft text; (7) an editorial HEALTH PROBLEMS
group (R.B., K.C., B.R., K.M.K.) made final edits; and (8) all
authors reviewed and approved the final draft. Terminology for Health Problems
The IOC Medical and Scientific Department appointed
R.B. to chair the consensus group. He selected a consensus The World Health Organization (WHO) defines health as “a
group that included at least 1 author from previous consen- state of complete physical, mental, and social well-being”
sus statements on sports injury epidemiology. Care was and not merely the absence of a disease or infirmity.114
taken to include experts with research experience from Extending this definition, Clarsen et al 15 defined an
*Address correspondence to Roald Bahr, MD, PhD, Department of Sports Medicine, Oslo Sports Trauma Research Center, Norwegian School of Sport
Sciences, PB 4014 Ullevål Stadion, 0806 Oslo, Norway (email: [email protected]).
†
All authors are listed in the Authors section at the end of this article.
This article has been co-published in the British Journal of Sports Medicine. Minor differences exist between the 2 versions to be consistent with OJSM
editorial style.
Final revision submitted December 30, 2019; accepted January 3, 2020.
One or more of the authors has declared the following potential conflict of interest or source of funding: B.R. receives payment for duties as Editor-in-
Chief of The Orthopaedic Journal of Sports Medicine. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not
conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
The Orthopaedic Journal of Sports Medicine Injury/Illness Surveillance Methods 3
injury, the primary mode involves the transfer of kinetic

energy, but other types of injury, such as sunburn or
drowning, may have a different etiology.
These definitions are meant to be inclusive; they embrace
a broad array of injury- and illness-related health problems
that may affect an athlete. Depending on the goal of the
monitoring activity, data recording may be limited to spe-
cific health problems that constitute a narrower subset of
the above definitions (ie, via an operational definition). If
the surveillance program has a narrow scope (eg, to capture
only concussions in school rugby), data recording can be
limited to the specific injury type of interest.
Relationship to Sports Activity
Health problems may result:

Figure 1. Distribution of health problems by consequences
1. Directly from participation in competition or from train-
(not to scale). Adapted from Clarsen and Bahr.14
ing in the fundamental skills of a sport (eg, players col-
liding in a match, overuse from repetitive training, or
athletic health problem as any condition that reduces an transmission of a skin infection from contact with
athlete’s normal state of full health, irrespective of its con- another player).
sequences on the athlete’s sports participation or perfor- 2. Indirectly from participation in activities related to com-
mance or whether the athlete sought medical attention. petition or training in a sport but not during competition
This constitutes an umbrella term that includes, but is not or a training session (eg, slipping, falling, and sustaining
limited to, injury and illness. an injury when in the Olympic village; developing an
Health problems can have several consequences. A illness after international travel to a competition or an
health problem that results in an athlete receiving medical illness deemed to be related to an increased training load
attention is referred to as a “medical attention” health prob- over a few weeks).
lem, and a health problem that results in a player being 3. From activities that are not at all related to participation in
unable to complete the current or future training session sports, that is, would occur in the absence of participation
or competition is referred to as a “time-loss” health prob- during competition or training in the fundamental skills of
lem.51,52,65,78,84,98 As not all health problems limit an ath- a sport (eg, car crash, sudden cardiac arrest at home).
lete’s ability to participate nor require medical attention,
broader definitions (self-reported, symptom-based, or per- Depending on the purposes of the study, researchers
formance based) will capture more health problems. may want to report health problems in these categories
Figure 1 illustrates these differences. separately.
Defining Injury and Illness Mode of Onset
Previous consensus statements on injury and illness in Traditionally, health problems have been classified into
sports have proposed largely consistent definitions for an those that have a sudden onset and those that have a grad-
injury and illness.‡ Differences in definition stem from the ual onset. Sudden-onset health problems were considered
specific sport or context for which statements were devel- to be those that resulted from a specific identifiable event
oped. For this consensus statement, we define an injury (eg, a collision between an athlete and an object causing a
and illness as follows: fracture). Gradual-onset health problems, on the other
hand, were considered to be those that lack a definable
Injury is tissue damage or other derangement of normal sudden, precipitating event as the onset (eg, a tendinopathy
physical function due to participation in sports, result- induced by repetitive movement).
ing from rapid or repetitive transfer of kinetic energy. The term “overuse injury” is commonly applied to
Illness is a complaint or disorder experienced by an ath- gradual-onset injuries. However, this term is used inconsis-
lete, not related to the injury. Illnesses include health- tently in the literature,80,90 and most injury surveillance
related problems in physical (eg, influenza), mental (eg, systems do not define “overuse injury.”90
depression), or social well-being or removal or loss of Health problems may have elements of both sudden
vital elements (air, water, warmth). onset and gradual onset. For example, a long-distance run-
ner with an intensive training regimen may have insuffi-
We acknowledge that there is not always a clear distinc- cient recovery, resulting in cumulative stress-related
tion between injury and illness. The consensus was that for changes to the bone, but presenting as an acute tibial frac-
ture without prior pain. The dichotomy between sudden
‡
References 51, 52, 64, 78, 83, 84, 86, 92, 98, 102. and gradual onset, which most methods of data capture are
based on, means such important nuances may be missed. TABLE 1

One option to address this problem would be to classify Examples: Assessment of Mode of Onset
health problems based on the underlying pathology,
whether this indicates a single or repetitive pathogenic Mechanism Presentation Example
mechanism, based on imaging studies (eg, magnetic reso- Acute Sudden 1. A sprinter pulls up suddenly in a
nance imaging, ultrasound) or tissue biopsies. However, onset race, stops, and hobbles a few steps
routine capture of such detail in a reliable manner within in obvious pain with a hamstring
a surveillance system is challenging. injury.
Repetitive Sudden 2. A gymnast experiences a frank tibial
onset and fibular fracture on landing from
Mode of Onset—Injury a vault; computed tomography
imaging reveals pre-existing
For injuries, classic epidemiology provides a solution for morphological changes consistent
this issue by viewing health problems as the result of a with bone stress, that is, a stress
series of interactions between agent, host, and environ- fracture.
ment.45,58 Injury epidemiology adapted this model by defin- Repetitive Gradual 3. A swimmer experiences a gradual
ing kinetic energy as the “agent” of injury.56,69,107 onset increase in shoulder pain over the
In this paradigm, following the definition above, course of a season; diagnosed as
injury results from a transfer of kinetic energy (agent) rotator cuff tendinopathy on
that damages tissue. Injury may result from a near- magnetic resonance imaging.
instantaneous exchange of large quantities of kinetic energy
(eg, as in a collision between athletes), from the gradual
accumulation of low-energy transfer over time (as in the acute and repetitive mechanisms. Data collectors should
bone stress injury example), or from a combination of both consider whether a health problem results from a clear acute
mechanisms (repetitive training regimen resulting in ten- mechanism, clear repetitive mechanism, or appears to
don weakness that then manifests itself acutely as a tear include a mix of both elements (Table 1). Examples 1 and 3
from acceleration forces applied during a single jump). This in Table 1 reflect clear acute and repetitive etiology, respec-
model suggests mode of onset for injuries should be concep- tively, whereas example 2 represents a mixed etiology.
tualized as a continuum interplay of energy exposures.
Classifying the Mechanism of Injury
Mode of Onset—Illness Mechanism of onset has typically been defined only in the
context of sudden-onset injuries. Sudden-onset health pro-
Illnesses, like injuries, may be either associated with a spe- blems can result from contact and noncontact mechanisms;
cific precipitating event (eg, a player ingesting a toxin from this classification is discussed below and presented
food and suffering gastrointestinal illness that manifests in Table 2.
within hours of exposure) or may involve a progressive path- Direct contact mechanisms directly lead to the health
way that cannot be linked to a specific precipitating event problem in an immediate and proximal manner. Indirect
(eg, progressive fatigue from increased training load). Simi- contact mechanisms also stem from contact with other ath-
larly, the time scale for sudden-onset illness can be seconds letes or an object. The force is not applied directly to the
or minutes (eg, acute anaphylaxis), develop within hours injured area but contributes to the causal chain, leading to
after exposure to a pathogen or toxin (eg, gastroenteritis), the health problem.13,20,57,82 Noncontact mechanisms are
or even days or weeks (eg, upper respiratory tract infection). those that lead to health problems without any direct or
The mode of onset for illnesses may also be related to a indirect contact from another external source. Gradual-
specific event, with or without some underlying subclinical onset injuries, by their nature, are noncontact.
pathology. For example, myalgic encephalomyelitis will We anticipate that subsequent sport-specific consensus
typically present without a precipitating event, whereas statements will provide more detailed subclassifications to
influenza usually has a point source of exposure (although address specific features of contact mechanisms (eg, subclas-
this may be difficult to trace). As with injuries, many ill- sification of contact with objects, such as ball, bat, net, gate).
nesses reflect both the underlying pathology and a sudden- Future sport-specific statements may also give specific
onset event (eg, an athlete may be predisposed to bronchial recommendations on other categories for classification
hyperreactivity, and this may present acutely as broncho- related to injury causation (eg, rule infringements, particular
constriction when exposed to air pollution at a venue). movements, or other sport-specific features). The Interna-
tional Classification of Diseases (ICD) External Causes chap-
Classifying the Mode of Onset ter111 and the International Classification of External Causes
of Injury112 provide specific codes that might be useful.
We recommend that injury/illness surveillance discontinue
use of sudden onset and gradual onset as a simple dichotomy Multiple Events and Health Problems
and implement methods that capture relevant subtleties.
We encourage researchers to develop and use measures that One of the particular features of sports epidemiology, com-
will help identify injuries and illnesses that involve mixed pared with other settings, is the relatively high chance that
TABLE 2 an athlete will sustain more than 1 health problem over the
Examples: Classification of Contact as a Mechanism for follow-up period. This is illustrated in Figure 2.
Sudden-Onset Injuriesa The relatively common occurrence of multiple health pro-
blems in a single patient poses challenges for the reporting
Injury Type of Contact Example and analysis of sports injury and illness data.44 In particu-
Noncontact lar, note that the number of athletes in a study is unlikely to
None No evidence of disruption ACL tear in a basketball be the same as the number of reported health conditions, and
or perturbation of the player landing with both should be stated. When reporting the frequency (or
player’s movement knee valgus/rotation proportion) of specific diagnoses or other characteristics, it
pattern after a jump, with no is important to state clearly whether this is expressed as the
contact with other proportion of all athletes followed up, the proportion of all
players injured athletes, or the proportion of all reported injuries.
Contact
Indirect Through another athlete ACL tear in a handball
player landing out of Subsequent, Recurrent, and/or Exacerbation of
balance after being
pushed on her shoulder
Health Problems
by an opponent while
in the air
Was a subsequent health problem related to previous
Indirect Through an object Downhill skier suffers a health problems? This is an important question in the field.
concussion from a To know whether health problems follow previous health
crash after being problems requires both sets of problems to be classified
knocked off balance, correctly using consistent terminology. This exercise can
hitting the gate with provide greater insight into the etiological factors that
his knee underpin subsequent health problems.34
Contact Hamilton et al60 provided a useful framework to catego-
Direct With another athlete ACL tear in a football
rize subsequent injuries/illnesses and exacerbations in
player from a direct
tackle to the anterior sport (Figure 3). More recent frameworks incorporate
aspect of the knee, extensive criteria34,100,101 that require judgment by trained
forcing the knee into clinicians, which may be beyond the scope and capacity of
hyperextension many surveillance protocols. When reporting frameworks
Direct With an object Volleyball player being become more complex, there is a greater risk for data
hit in the face by a errors.93 In general, we do not recommend complex frame-
spiked ball, resulting works but they can be considered for sophisticated data
in a concussion
collection and analysis where appropriate expertise and
a
ACL, anterior cruciate ligament. resources exist.
The recommended subsequent injury terminology,
adapted from Hamilton et al,60 includes noting whether
Figure 2. Examples of hypothetical prospectively collected injury/illness data (adapted from Finch and Marshall37). “X” indicates
when a period of surveillance is ended because the athlete left, unrelated to health problems, before the end of the study period;
this is called censoring.
Subsequent injuries to the same location and tissue as

the index injury are recurrences if the index injury was
healed/fully recovered or exacerbations if the index injury
was not yet healed/fully recovered. Subsequent illnesses to
the same system and type as the index illness are recur-
rences if the individual has fully recovered from the index
illness and exacerbations if the patient has not yet recov-
ered from the index illness. Healed/fully recovered from
injury (or illness) is defined as when the athlete is fully
available for training and competition (see “Severity of
Health Problems” section).
To illustrate how to classify a subsequent injury, con-
sider athlete “A” who, following an ACL rupture and surgi-
cal reconstruction, presents late in the rehabilitation period
before returning to play with swelling and pain in the knee
after a slip and fall injury, resulting in a graft tear. This
injury would be classified as an exacerbation of the index
injury. In contrast, athlete “B” rehabilitated successfully
after ACL reconstruction and returned to play; that player
presents with pain and swelling in the same knee. If the
diagnosis is a torn ACL graft, this would be classified as a
recurrent injury. If the diagnosis is a meniscal tear (ACL
graft intact), this is a local subsequent injury.
To illustrate how to classify subsequent illness, consider
athlete “C” who has withdrawn from sports participation
due to an upper respiratory tract infection caused by influ-
enza type A virus, which then progresses to a lower respira-
tory tract infection, resulting in a diagnosis of viral
pneumonia. As athlete “C” is diagnosed with pneumonia
before recovery and return to play, the diagnosis of pneumo-
nia is an exacerbation of a recurrent illness. In contrast,
Figure 3. Classification tree for subsequent health problems athlete “D,” following full recovery from the upper respira-
(adapted from Hamilton et al60). Definitions: (1) index injury tory tract infection and returning to play, is diagnosed with
(illness) is the first recorded injury (illness), and (2) subsequent pneumonia; this illness is a subsequent new illness.
injury (illness) is any injury (illness) occurring after the index Time to recurrence or an exacerbation should be recorded
injury (illness): (a) subsequent injury to a different location than in days (see “Severity of Health Problems” section). A min-
the index injury (subsequent illness involving a different sys- imum list of data items recommended when collecting infor-
tem than the index illness), (b) subsequent injury to the same mation on subsequent injuries or illnesses is shown in
location but of a different tissue type than the index injury Table 3.
(subsequent illness involving the same system but of a differ-
ent type/other diagnosis), or (c) subsequent recurrent injury
(illness) is a subsequent injury to the same site and of the Classifying Sports Injury and Illness Diagnoses
same type as the index injury (subsequent illness involving
the same system and type as the index illness). Third, fourth, Injury and illness classification systems are used in sports
or more health problems should be assessed relative to the medicine to:
initial index health problem and all other previous ones (eg,
Accurately classify and group diagnoses for research or
second and third health problems).
reporting, allowing easy grouping into parent classifica-
tions for summary, so that injury and illness trends can
subsequent injuries (1) affect the same site but other be monitored over time or injury or illness incidence or
tissues (eg, knee but meniscus instead of anterior cruci- prevalence can be compared between groups (eg, differ-
ate ligament [ACL] alone) or (2) affect other sites. Sub- ent teams, leagues, sports, sexes), potentially leading to
sequent illness terminology 60 notes whether the risk factor and preventive studies.
subsequent illnesses is the same system (eg, respiratory) Create databases from which cases can be extracted for
but other diagnosis (eg, bronchospasm as distinct from a research on particular or specific types of injuries and
viral illness) or to other systems. The relevant defini- illnesses.
tions are shown in Figure 3. Note that an injury may
be subsequent to an illness and vice versa (eg, bone In the late 1980s, clinicians and researchers were using
stress injury following diagnosis of an eating disorder, the 9th edition of the ICD.111 The ICD system is an impor-
depression following a lengthy recovery from revision tant international standard, yet even the 11th edition,
ACL reconstruction). released in 2018, lacks some classifications important in
sports injury and illness surveillance. Hamstring strain other researchers to use them free of charge (with acknowl-
and exercise-associated postural hypotension are 2 exam- edgment). These diagnostic coding systems are the Sport
ples.1,27,88 We encourage developers to include more sports Medicine Diagnostic Coding System (SMDCS) and the
medicine diagnoses in future revisions of the ICD. Orchard Sports Injury Classification System (OSICS). Both
In the early 1990s, in Canada and Australia, 2 alternate are based on initial codes to represent the body area and
diagnostic coding systems were developed specifically further codes to represent the injury type or pathology.
for sports medicine, and these have flourished into the One advantage of these coding systems is that they are
most widely used systems in sports injury surveillance less cumbersome to apply than ICD codes, especially when
in the world today. Their “open access” nature has allowed built into electronic systems with drop-down menus, taking
advantage of the body area and tissue/pathology type cate-
gories. The full ICD-11 coding system includes 55,000
TABLE 3 codes, of which the majority are not relevant in sports med-
Recommendations for Key Data Items That Should Be icine, compared with 750 to 1500 codes for versions of the
Collected and Reported on in Surveillance Systems SMDCS and OSICS.
to Enable Multiple and Subsequent Injuries/Illnesses When reporting aggregate injury data, we recommend
to Be Monitoreda using the categories for body area (Table 4) and tissue type
and pathology (Table 5) outlined below. In addition, the
Data Item Why It Is Important
categories for organ system/region (Table 7) and etiology
Unique identifier to link all All participants require a unique (Table 8) are presented below for illnesses.
injuries/illnesses in 1 identifier that covers all When recording injuries or illnesses, the diagnosis
participant seasons/time periods and should be recorded in as much detail as possible given the
should be anonymized to information available and the expertise of the individual
protect privacy and reporting. Acknowledging that some studies will rely on
confidentiality. athlete self-reports or proxy reports by parents, coaches,
Injury/illness time order The exact date (day, month, year) or other nonmedically trained staff, this consensus group
sequence of the onset of each health
also suggests categories to guide reporting of illnesses
problem is essential for the
(Table 9). When injury data are reported by athletes or
sequence to be clear. For
greater precision, time can be nonmedical staff, we recommend that reporting is limited
important if there are multiple to the body area, as their reporting of tissue type and abnor-
events/heats each day (eg, mality is unreliable.53
swimming). To facilitate reporting based on diagnostic codes, a com-
Multiple injury/illness type Multiple injuries and illnesses panion paper has been written with a supplemental Excel
details can be the result of different or (Microsoft) data file that provides a full list of revised
same events or etiology, SMDCS and OSIICS (Orchard Sports Injury and Illness
coincide at the same time, or a Classification System) codes, along with a translation
mixture of both. Injuries/
between both systems and the ICD system.85
illnesses need to be linked to
the specific circumstances/
events that led to them. Date Injuries—Body Area Categories
and time stamping, directly
linked to diagnoses of all Wherever possible, we tried to define body areas anatom-
injuries/illnesses, can inform ically as either joints or segments. However, we made
these relationships. exceptions based on common clinical presentations in
Injury/illness details, including Collect information on the sport where needed. For example, the hip/groin is an area
diagnosis nature, body region/system, that we have defined, which is a combination of a joint and
tissue/organ, laterality, and part of a segment, and therefore not a singular anatomical
diagnosis for all injuries/
region.
illnesses. Sport injury/illness
When 1 injury event results in more than 1 injury, the
diagnostic classification and
coding are optimal. individual diagnoses should be recorded and classified
Details of circumstances and The time elapsed between separately. However, for injury incidence and prevalence
time elapsed between injuries/illnesses will be reporting purposes, this will be counted as 1 injury,
determined by date and time and severity should be reported as the severity of the
stamping. If away from principal (most severe) injury (see below for further
participation in sport, then it is explanations).
important to collect details and
date/time stamps regarding
rest, rehabilitation, treatment,
Injuries—Tissue- and Pathology-Type Categories
training, modified sport
participation, and return to
Using consensus methodology, we compared “injury type”
play. codes from the OSICS and SMDCS to arrive at definitions
of injury types. We constructed this table to be a single table
a
Modified from Finch and Fortington.35 reflecting “injury types” (as per the OSICS) but split 2
TABLE 4 Recommendations: Reporting

Recommended Categories of Body Regions Injury Characteristics
and Areas for Injuriesa
Injury characteristics are often reported in a single table by
Body Region/Area OSIICS SMDCS Note region, injury type, or both. Cross-tabulations depicting
Head and neck
data by region and injury type (ie, combining the 2 into 1
Head H HE Includes face, brain table) often become large and unwieldy. It can leave many
(concussion), eyes, ears, cells empty or with very few cases (which can then compro-
teeth mise confidentiality) unless the dataset is unusually large.
Neck N NE Includes cervical spine, Such tables often also provide insufficient information for
larynx, major vessels research focused on specific areas or sports. For example, in
Upper limb a sport where knee sprains dominate, it may be desirable to
Shoulder S SH Includes clavicle, scapula, report subgroups of these (eg, ACL, medial collateral liga-
rotator cuff, biceps ment) in greater detail.
tendon origin
In many cases, a better reporting option is to combine
Upper arm U AR
Elbow E EL Ligaments, insertional
region and type and diagnosis in 1 table, such as in the
biceps and triceps tendon example shown in Table 6, where some categories have
Forearm R FA Includes nonarticular been collapsed at the level of body region (bold), some
radial and ulnar injuries regions have been split further into injury types (subhea-
Wrist W WR Carpus der), and some even at the level of specific diagnosis (ita-
Hand P HA Includes finger, thumb lics). It is expected that subsequent consensus statements
Trunk on specific sports will provide recommendations on suit-
Chest C CH Sternum, ribs, breast, chest able, standard formats for each sport to facilitate a direct
organs comparison of data on key injury types from studies on the
Thoracic spine D TS Thoracic spine,
same sport.
costovertebral joints
Lumbosacral L LS Includes lumbar spine,
sacroiliac joints, sacrum, Illness—Categories for Organ System and Etiology
coccyx, buttocks
Abdomen O AB Below diaphragm and
Illness consensus categories are presented in Tables 7 and 8.
above inguinal canal,
These are more detailed than the original versions of the
includes abdominal organs
Lower limb SMDCS and OSICS. Our tables diverge from the ICD cate-
Hip/groin G HI Hip and anterior gorization format in which body systems and abnormality
musculoskeletal types are grouped together. We believe that it is important
structures (eg, pubic to recognize that an illness, like an injury, both affects a body
symphysis, proximal system and has a specific pathological type. A respiratory
adductors, iliopsoas)108 infection does not need to be considered either only as a
Thigh T TH Includes femur, hamstring respiratory condition or an infection; it is certainly both. Our
(including ischial recommended illness systems are similar to many of those in
tuberosity), quadriceps,
the ICD, but we have merged some systems, such as the
middistal adductors
upper respiratory system and nose/throat.
Knee K KN Includes patella, patellar
tendon, pes anserinus The professional background of those who report health
Lower leg Q LE Includes nonarticular tibial data will influence the final data quality (see “Data Collec-
and fibular injuries, calf, tion Methods” section).39 When athletes themselves (or non-
Achilles tendon clinical recorders like coaching staff) are asked to capture
Ankle A AN Includes syndesmosis, illness data, they should be encouraged to record symptoms
talocrural and subtalar rather than attempt a diagnosis. Table 9 lists symptom clus-
joints ters that are characteristic of various systems. We caution
Foot F FO Includes toes, calcaneus, that this table requires additional validation and may be
plantar fascia
modified in the future. Mapping symptoms to body systems
Unspecified Z OO
sacrifices some accuracy; however, in circumstances where
Multiple (single X OO
injury crossing expert recorders are unavailable, it is better to have general
2 regions) systems diagnosis data than no data at all.
a
OSIICS, Orchard Sports Injury and Illness Classification Sys-
tem; SMDCS, Sport Medicine Diagnostic Coding System. Recommendations: Reporting
Illness Characteristics
columns into “tissue” (as the broad area) and then As was the case when we discussed reporting of injury data,
“pathology” type more specifically. This reflects the original we recommend against illness data being reported as
approach taken in the SMDCS. cross-tabulations of organ system by type of etiology type.
TABLE 5
Recommended Categories of Tissue and Pathology Types for Injuriesa
Tissue/Pathology Type OSIICS SMDCS Note
Muscle/tendon
Muscle injury M 10.07-10.09 Includes strain, tear, rupture, intramuscular tendon
Muscle contusion H 10.24
Muscle compartment Y 10.36
syndrome
Tendinopathy T 10.28-10.29 Includes paratenon, related bursa, fasciopathy, partial tear, tendon
subluxation (all nonrupture), enthesopathy
Tendon rupture R 10.09 Complete/full-thickness injury; partial tendon injuries considered to be
tendinopathy
Nervous
Brain/spinal cord injury N 20.40 Includes concussion and all forms of brain injuries and spinal cord
Peripheral nerve injury N 20.39, 20.41-20.42 Includes neuroma
Bone
Fracture F 30.13-30.16, 30.19 Traumatic, includes avulsion fracture, teeth
Bone stress injury S 30.18, 30.32 Includes bone marrow edema, stress fracture, periostitis
Bone contusion J 30.24 Acute bony traumatic injury without fracture; osteochondral injuries are
considered “joint cartilage”
Avascular necrosis E 30.35
Physis injury G 30.20 Includes apophysis
Cartilage/synovium/bursa
Cartilage injury C 40.17, 40.21, 40.37 Includes meniscal, labral, articular cartilage, osteochondral injuries
Arthritis A 40.33-40.34 Posttraumatic osteoarthritis
Synovitis/capsulitis Q 40.22, 40.34 Includes joint impingement
Bursitis B 40.31 Includes calcific bursitis, traumatic bursitis
Ligament/joint capsule
Joint sprain (ligament tear or L or D 50.01-50.11 Includes partial and complete tears plus injuries to nonspecific ligaments
acute instability episode) and joint capsule; includes joint dislocations/subluxations
Chronic instability U 50.12
Superficial tissues/skin
Contusion (superficial) V 60.24 Contusion, bruise, vascular damage
Laceration K 60.25
Abrasion I 60.26-60.27
Vessels (vascular trauma) V 70.45
Stump (stump injury) W 91.44 In amputees
Internal organs (organ trauma) O 80.46 Includes trauma to any organ (excluding concussions), drowning, relevant
for all specialized organs not mentioned elsewhere (lungs, abdominal and
pelvic organs, thyroid, breast)
Nonspecific (injury without P or Z 00.00 (also 00.23, No specific tissue/pathology diagnosed
tissue type specified) 00.38, 00.42)
a
OSIICS, Orchard Sports Injury and Illness Classification System; SMDCS, Sport Medicine Diagnostic Coding System.
A better option is to combine system/region and etiology in (called “time loss”), the athlete’s self-reported conse-
1 table, as in the example on injuries shown in Table 6. quences (various patient-rated measures of both health
Depending on the illness pattern of the sport/setting, some and sports performance), the clinical extent of the
region categories may be collapsed and others split further illness/injury, and societal cost (economic evaluation).
into etiology type and even to the level of specific diagnosis When considering which severity criterion to use, investi-
(where available) to highlight the most significant ill- gators should consider the strengths and limitations of
nesses. We expect that subsequent sport-specific consen- each approach related to the objectives of their study or
sus statements will recommend useful standard formats surveillance program.
for each sport.
Time Loss From Training and Competition
SEVERITY OF HEALTH PROBLEMS The most widely used severity measure in sports medicine
is the duration of time loss. It has been recommended in
The severity of health problems in sport can be described previous consensus statements49,52,78,102 and is relatively
using various criteria.33,99,104 These include the duration simple to capture, even when data collectors are nonexperts
of the period for which an athlete is unable to train/play (coaches, parents, or athletes themselves).
TABLE 6
Data on Injury Pattern and Burden of Specific Match Injuries Among Professional Rugby Teams in New Zealanda
Incidence, Injuries/ Time Loss, Burden, Time-Loss Days/

Region/Type/Diagnosis No. of Injuries 1000 h (95% CI) Median (95% CI), d 1000 h (95% CI)
Head 277 12.9 (11.5-14.5) 9 (8-10) 325 (317-333)

Concussion 204 9.5 (8.3-10.9) 10 (9-11) 257 (250-263)
Neck 60 2.8 (2.2-3.6) 8 (6-10) 135 (130-140)
Shoulder 168 7.8 (6.7-9.1) 21 (14-27) 628 (618-639)
Acute dislocation 15 0.7 (0.4-1.1) 209 (27-337) 165 (159-170)
Hematoma 18 0.8 (0.5-1.3) 8 (4-13) 25 (23-27)
Joint sprain 102 4.8 (3.9-5.7) 19 (12-25) 292 (285-300)
Acromioclavicular joint sprain 54 2.5 (1.9-3.3) 14 (10-20) 68 (65-72)
Glenohumeral joint sprain 48 2.2 (1.7-2.9) 30 (14-80) 225 (218-231)
Upper arm 4 0.2 (0.1-0.4) 6 (3-133) 7 (6-8)
Elbow 27 1.3 (0.9-1.8) 9 (5-17) 42 (39-44)
Forearm 10 0.5 (0.2-0.8) 99 (44-131) 65 (61-68)
Wrist and hand 96 4.5 (3.6-5.4) 10 (7-27) 194 (188-200)
Chest 81 3.8 (3.0-4.7) 13 (10-16) 75 (71-79)
Thoracic spine 6 0.3 (0.1-0.6) 5 (3-50) 5 (4-6)
Lumbar spine 32 1.5 (1.0-2.1) 10 (5-21) 66 (63-70)
Pelvis/buttock (excluding groin) 6 0.3 (0.1-0.6) 12 (5-20) 3 (3-4)
Hip/groin 40 1.9 (1.4-2.5) 9 (6-11) 82 (78-86)
Thigh 138 6.4 (5.4-7.6) 14 (11-17) 171 (165-176)
Knee 165 7.7 (6.6-8.9) 31 (23-37) 544 (535-554)
Knee cartilage injury 29 1.4 (0.9-1.9) 43 (29-58) 124 (120-129)
Meniscal cartilage injury 22 1.0 (0.7-1.5) 44 (28-62) 101 (96-105)
Knee ligament injury 125 5.8 (4.9-6.9) 30 (20-37) 390 (382-398)
MCL injury 75 3.5 (2.8-4.4) 33 (24-37) 154 (149-159)
ACL injury 9 0.4 (0.2-0.8) 275 (70-295) 92 (88-96)
PCL injury 6 0.3 (0.1-0.6) 20 (12-218) 23 (21-25)
PLC and LCL injury 8 0.4 (0.2-0.7) 35 (7-132) 55 (52-58)
Lower leg 100 4.0 (3.2-4.9) 17 (14-23) 190 (184-196)
Ankle 147 6.9 (5.8-8.0) 15 (11-21) 320 (313-328)
Ankle sprain 113 5.3 (4.4-6.3) 15 (11-21) 228 (222-235)
Lateral ligament sprain 46 2.1 (1.6-2.8) 15 (9-19) 78 (74-82)
Syndesmosis sprain 34 1.6 (1.1-2.2) 33 (28-43) 108 (104-112)
Foot 40 1.9 (1.4-2.5) 37 (14-57) 84 (80-88)
a
From 2005 to 2018 (unpublished data). See also Figure 5, illustrating the same data set in less detail as a risk matrix as well as the
sections on rates, severity, and burden of health problems for an explanation of these concepts. ACL, anterior cruciate ligament; LCL, lateral
collateral ligament; MCL, medial collateral ligament; PCL, posterior cruciate ligament; PLC, posterolateral corner.
When using this approach, we recommend that investi- When aggregating data across athletes, severity should
gators record severity as the number of days that the ath- be reported as the total number of time-loss days, together
lete is unavailable for training and competition, from the with medians and quartiles. Means and standard devia-
date of onset until the athlete is fully available for training tions should be interpreted with care, given that the distri-
and competition. bution of time-loss days is likely to be right-skewed.
The number of time-loss days should be counted from the When reporting data separately in severity categories,
day after the onset that the athlete is unable to participate we recommend using the following time bins: 0 days, 1 to
(day 1) through the day before the athlete is fully available 7 days, 8 to 28 days, and >28 days.
for training and competition. Therefore, cases in which an If a single injury event results in multiple injuries, injury
athlete does not complete a particular competition or train- severity should be based on the injury leading to the longest
ing session but returns on the same or following day should time loss (eg, if a downhill skier crashes and suffers 2 injuries,
be recorded as 0 days of time loss (see Table 10 for exam- a concussion that takes 10 days to resolve and a tibial fracture
ples). We note that in some cases, time loss does not follow that takes 120 days, the time loss for the event is 120 days).
immediately after the health problem occurred and may be
delayed and/or intermittent (Table 10).
When athletes recover from health problems during per- Health Problems Contracted During Multiday Events
iods with no planned training or competition (eg, during an
end-of-season break), investigators should record the end After athletes have left an event, it may be difficult to
date as when the athlete normally would have been ready obtain accurate follow-up information on their condition
for full training and competition participation. and return to play. For cases that were not closed by a date
TABLE 7 TABLE 8
Recommended Categories of Organ Recommended Categories for Etiology of Illnessesa
System/Region for Illnessesa
Etiology ICD-11 OSIICS SMDCS Note
Organ System/
Region ICD-11 OSIICS SMDCS Note Allergic (22) MxA 71
Environmental (23) MxE 72 Heat illness,
Cardiovascular 11 MC CV (exercise hypothermia,
Dermatological 14 MD DE related) hyponatremia,
Dental (13) MT DT dehydration
Endocrinological 05 MY EN Environmental (22/7) MxS 73 Includes sleep/
Gastrointestinal (13) MG GI (nonexercise) wake, sunburn
Genitourinary 16 MU GU Includes renal, Immunological/ (04) MxY 74
obstetrical, inflammatory
gynecological Infection 01 MxI 75 Viral, bacterial,
Hematological 03 MH BL parasitic
Musculoskeletal 15 MR MS Includes Neoplasm 02 MxB 76
rheumatological Metabolic/ 05 MxN 77
conditions nutritional
Neurological 08 MN NS Thrombotic/ (11/03) MxV 78
Ophthalmological 09 MO OP hemorrhagic
Otological 10 ME OT Ear only Degenerative or — MxC 79 Chronic acquired
Psychiatric/ 06 MS PS chronic conditions
psychological condition
Respiratory 12 MP RE Includes nose and Developmental 20 MxJ 80 Includes congenital
throat anomaly conditions
Thermoregulatory (22) MA TR Drug-related/ 22 MxD 81 Includes
Multiple systems MX MO poisoning pharmaceutical,
Unknown or not MZ UO illicit
specified Multiple MxX 82
Unknown or not MxZ 83
a
ICD-11, International Classification of Diseases–11th Revi- specified
sion; OSIICS, Orchard Sports Injury and Illness Classification Sys-
a
tem; SMDCS, Sport Medicine Diagnostic Coding System. ICD-11, International Classification of Diseases–11th Revi-
sion; OSIICS, Orchard Sports Injury and Illness Classification Sys-
tem; SMDCS, Sport Medicine Diagnostic Coding System.
of return to play at the time of the end of the event, we

recommend that:
1. If the researcher can liaise with team medical staff athletes may be able to participate before an injury or illness
and record the actual date of return to play, this infor- has fully resolved, for example, by adapting their technique,
mation should be captured. Collecting actual dates is accepting a lower performance level, or playing a different
recommended. role on the team (eg, a ballet dancer working at the barre but
2. If this is not possible, then team medical staff should not dancing on the floor or doing any jumps). Participation
be asked to provide an estimate of when the athlete is before an injury or illness is fully resolved would tend to
expected to return to play. In such cases, this infor- underestimate the absolute severity of the injury if one con-
mation should be clearly labeled as an estimated sidered full healing as the gold standard. Conversely, ath-
severity. letes may choose not to resume their “normal” training and
3. If this is not possible, then event medical staff should competition for an extended period after an injury or illness
record the date that the athlete leaves the tourna- has clinically resolved to allow them to regain full fitness (eg,
ment, that is, the last date on which the athlete was a professional football player after ACL reconstruction). This
seen with the unclosed health problem. In such cases, would overestimate the severity of the condition.
the information should clearly be labeled as right- Second, a time loss–based severity measure underesti-
censored injury duration (a statistical term for situa- mates the severity of those health problems that limit a
tions in which only a portion of the time loss can be player’s performance but do not stop the person from play-
observed). ing. Many gradual-onset injuries fit that bill (eg, patellar
tendinopathy). Similarly, when athletes have a recurrent
Limitations of Using Time Loss to Measure Severity or chronic illness, such as asthma or inflammatory arthri-
tis, they may have relatively low time loss (from training or
Time loss generally reflects injury severity but has limita- competition) but may be markedly affected in training con-
tions. First, the demarcation between the end of time loss tent and intensity.3,16,17
and the resumption of “normal training and competition” is Third, time loss is inappropriate to describe the most
not necessarily a clear line in the sand. In some sports, severe types of health problems, such as those leading to
TABLE 9
Recommended Categories of Illness Symptom Clusters for Athlete Self-reports or Nonmedical Data Reporters
System/Region Symptom Cluster
Upper respiratory (nose, throat) Runny nose, congestion, hay fever (allergy), sinus pain, sinus pressure, sore throat, cough,
blocked/plugged nose, sneezing, scratchy throat, hoarseness, head congestion, swollen
neck glands, postnasal drip (mucus running down the back of the nose to the throat)
Lower respiratory Chest congestion, wheezing (whistling sound), chesty cough, chest pain when breathing/
coughing, short of breath, labored breathing
Gastrointestinal Heartburn, nausea, vomiting, loss of appetite, abdominal pain, constipation, weight loss
or gain (>5 kg in the past 3 months), change in bowel habits, diarrhea, blood in the stool
Cardiovascular Shortness of breath, racing heart beats, irregular or abnormal heart beats, chest pain,
chest pain or discomfort with exercise, dizziness, fainting spells, blackouts, collapse
Urogenital/gynecological Burning urination, blood in urine, loin pain, difficulty in passing urine, poor urine stream,
frequent urination, genital sores, loss of normal menstruation, irregular or infrequent
menstruation, menstrual cramps/pain, excessively long periods, excessive bleeding
during periods, vaginal discharge, penile discharge, swollen groin glands
Neurological Headache, fits or convulsions, muscle weakness, nerve tingling, nerve pain, loss of
sensation, chronic fatigue
Psychological Anxiety, nervousness, excessive restlessness, feeling depressed (down), excessive sadness,
not sleeping well, mood swings, feeling excessively stressed
Dermatological Skin rash, dark/light/colored areas on the skin that have changed in size or shape, itchy
skin lesions
Musculoskeletal, rheumatological, and connective Joint pain, joint stiffness, joint swelling, muscle twitching, muscle cramps, muscle pain,
tissue (unrelated to injury) joint redness, warmth in a joint
Dental Toothache, painful gums, bleeding gums, oversensitive teeth, persistent bad breath,
cracked or broken teeth, jaw pain, mouth sores
Otological Ear pain, ear discomfort, loss of hearing (new onset), deafness, discharge from the ear
canal, bleeding from the ear canal, ringing in the ears
Ophthalmological Pain in eye, itching or burning eye, scratchy eye, eye discharge, change in vision including
double vision, blood in eye, excessive tearing, abnormal eye movements, swelling of eye,
blind spot in eye, drooping eye, halo around lights, lightning flashes, swelling of eyelid
Nonspecific illness Feeling feverish, chills, pain, whole body aches, feeling tired
Energy, load management, and nutrition Unexplained underperformance, reduced ability to train and compete, fatigue
(nonbody system)
retirement from sport, permanent disability, or death, questions, researchers can calculate a severity score
because the time-loss data from those injuries are right- ranging from 0 to 100 at specific time points. These can
censored. be aggregated (summed as the area under the curve) to
monitor injury and illness over time (Figure 4). This is
called the cumulative severity score. A limitation of this
Athlete-Reported Symptoms and Consequences method is that the severity score is an arbitrary num-
ber, and it has not been thoroughly validated as a proxy
There are tools to measure injury and illness symptoms
for injury severity.
that directly address the second limitation of time loss
discussed earlier, underestimating the effect of ongoing
pain and symptoms that are below the time-loss thresh- Recording the Severity of Health Problems
old. A tool such as the Oslo Sports Trauma Research Based on Clinical Assessment
Center Questionnaire on Health Problems (OSTRC-H)
complements time-loss measures of severity, as it also Investigators may also report the severity of health pro-
captures symptoms and functional consequences of blems based on clinical outcomes such as the need for hos-
injury and illness. This purpose-built instrument was pitalization or surgery, 33,92 retirement from sport,
devised in 201317 and updated in 202015 and has played permanent disability, or death.43,92
an increasing role in sports injury and illness surveil- Degree and Urgency of Medical Attention. The severity of
lance, especially in sports and settings where overuse an injury or illness can also be recorded based on the degree
injuries and illnesses represent a substantial burden on and urgency of medical attention received by the athlete.
health and performance.71 This approach is best suited to record acute conditions and
The tool (which can be delivered via a mobile applica- is often used in mass-participation events and community
tion) invites athletes to record reduced sports participa- sports settings.33,40,41 An example using this approach is
tion, training modifications, performance reductions, provided by Schwellnus et al 92 in their work on mass
and symptoms. 17 Based on the response to these community-based endurance sports events.
TABLE 10 This does not include injuries resulting in transient

Practical Examples of How to Calculate Time Loss neurological deficits such as burners/stingers, pares-
thesia, transient quadriplegia, or cases of concus-
Time sions in which there is full recovery. The term
Case Loss, d
“catastrophic event” has also been extended to
A collegiate volleyball player is substituted from a match 0 include noninjury events that are life-threatening,
because of an injury but returns to compete in another such as sports-related sudden cardiac arrest and
match later the same day. exertional heat stroke.28 More detailed recommenda-
A cyclist interrupts a training session because of mild 0 tions on this issue are provided in the consensus
diarrhea and resumes normal training the statement on mass community-based endurance
following day. sports events.92
A hockey player strains her hamstring during a training 6 A “fatality” refers to any athlete fatality related to
session on Monday and returns to normal training on
training or competition. When fatalities occur
Monday of the following week.
months or years after the event, researchers should
A recreational-level cricket player injures his shoulder 2
during a match on Saturday. His shoulder is stiff and justify the relationship to training/competition.43,66
painful for 2 days after the match (Sunday and
As such cases often receive media attention, we remind
Monday). The team only trains once per week, every
investigators to consider privacy issues. Special considera-
Thursday, but the player feels that he would have been
able to train normally had training been on Tuesday tions apply to approaching, consenting, and collecting data
instead. from families who have sustained a major loss.
“Delayed” time loss: An athlete suffers an injury on 3
Sunday, a thigh contusion, is able to train on Monday Other Severity Measures
and Tuesday, but is unable to train on Wednesday and
returns on Sunday (time loss starts on Wednesday, Depending on the sport setting and the purpose of data
even though the injury occurred on Sunday). collection, investigators may also quantify severity in other
“Intermittent” time loss: A player with Osgood-Schlatter 2 ways.99 Function, performance, and patient-reported out-
disease that gets reported at the start of a training
come measures may be used to capture severity. Specific
camp on Monday. He may train fully on Monday,
examples include the following:
Tuesday, and Thursday but miss training on
Wednesday and Friday (time loss counted as Functional measures, for example, the International
Wednesday and Friday only).
Classification of Functioning, Disability and Health
(ICF).113
Sports-related performance measures, for example,
balance, strength, and endurance. We include ath-
letes reporting retirement from sports in this
category.
Patient-reported outcome measures, for example, the
ACL Quality of Life Questionnaire (ACL-QOL),75
Knee injury and Osteoarthritis Outcome Score
(KOOS),89 and Sport Concussion Assessment Tool–
5th Edition (SCAT5).23
Figure 4. Example of severity scores being used to track the

severity of 3 “typical” health problems. Each black dot repre-
sents the weekly severity score. The area in orange repre- CAPTURING AND REPORTING
sents a gradual-onset injury (cumulative severity score [sum ATHLETE EXPOSURE
of weekly scores, as the area under the curve] ¼ 1820), the
black area represents a short-duration illness (score ¼ 100), Assessing exposure is fundamental to quantifying injury
and the dark red area represents an acute medial collateral and illness risk in sports.33,46 There are many ways to
ligament injury (score ¼ 362).17 quantify athletic exposure, and no single measure will suit
all surveillance settings and research questions. The choice
of exposure measures is heavily influenced by sport-specific
Permanent Disability and Death. All conditions leading and contextual factors as well as which types of health pro-
to permanent disability or death that occur during the blems are of interest. Therefore, it is often necessary to
period of data collection should be reported separately. record exposure in several ways.
There are some specific definitions accepted in the field:
Tracking Exposure for Injury Analyses
A “catastrophic injury” refers to a confirmed spinal
cord or traumatic brain injury, resulting in perma- For injuries, exposure is generally quantified as the time
nent functional disability (using the American Spinal during which athletes are at risk of injury (eg, minutes
Injury Association scale2 and assessed at 12 months). played), the distance covered, or a count of the number of
specified events (eg, tackles, throws, or jumps). In some obtaining summary data from every team for each day of
sports, exposure is commonly expressed as the number of the tournament (eg, squad numbers). As a minimum stan-
athletic participations (eg, games, races, training sessions), dard, exposure can be estimated for each event by multi-
often referred to as “athletic exposures.” Table A2 in Appen- plying the number of registered athletes by the duration of
dix 1 provides a range of examples of exposure measures the tournament (the number of days of competition). In
used. multisport tournaments, this should be calculated for each
In team sports, we recommend recording exposure for sport. However, this approach assumes that all athletes
each individual within a team rather than merely estimat- have the same exposure and participate every day, which
ing the number of matches that the team plays and match is rarely the case.
duration (team exposure) because the former permits the
researcher to examine individual risk factors. Results of all
the individuals are then summed to provide exposure at the Training Subcategories
sport or team level.
As the injury risk is often markedly different between Different types of training should, if possible, be recorded
training and competition, these exposures should be and reported separately. Training types can be generally
recorded and reported separately. To do this consistently, categorized as follows:
it is necessary to define competition and training and to
consider situations where applying the definition may be Sport-specific training: sessions involving the
challenging. techniques and/or tactics of the sport, usually
We define competition as organized scheduled play supervised by a coach.
between opposing athletes or teams of athletes or as ath- Strength and conditioning: sessions solely composed
lete(s) competing (1) against time and/or (2) to obtain a of resistance training and/or conditioning training.
score (judged or measured). We define training as physical In many cases, training sessions are mixed (sport-
activities performed by the athlete that are aimed at main- specific, but with the addition of some strength and
taining or improving their skills, physical condition, and/or conditioning; eg, plyometrics and endurance). As a
performance in their sport. pragmatic consideration, any session containing
In many sports, it is common to simulate competition as a sport-specific training should be categorized as
part of training. Examples include preseason “friendly such, even if the session includes some strength and
scrimmages” between 2 teams or dividing a single squad conditioning, purely to streamline exposure
into teams that compete against each other. In general, this tracking.
should be counted as training exposure. Additionally, activ- Other training sessions: sessions that include activi-
ities such as warm-up and cool-down should be counted ties other than sport-specific training or strength and
separately and reported as training injuries, even if occur- conditioning. These include recovery sessions (eg,
ring around competition. low-intensity running and stretching), rehabilita-
It is likely that, in some sports, these definitions will not tion, and postrehabilitation transition sessions (after
be fully applicable. In such cases, we encourage sport- return to sport but prior to resuming normal
specific consensus groups to define what constitutes com- training).
petition and training in that sport.
Sport-specific injury surveillance systems may need to
Tracking Exposure for Illness Analyses depart from this guidance if there is a need to address a
specific training concern; however, at a minimum, all train-
Because athletes remain at risk of developing an illness ing exposures that contain sport-specific training should be
even when they are not participating in sports, it is inap- tracked.
propriate to use exposure measures such as playing hours Sport-specific injury surveillance systems are encour-
or movement counts to quantify the illness risk (except for aged to develop specialized procedures for tracking the
the rare cases of transmissible infections that are specific to diversity of training exposures in their particular sport.
participation in a sport; eg, scrum pox). Instead, it is often Training programs vary considerably among sports, and
most appropriate to use exposure measures based on the many coaches intentionally design training programs that
time that athletes are under surveillance (days or years) integrate multidimensional training (eg, plyometric
rather than time engaged in competition and training. stretching, sport-specific training, light running) into a sin-
gle session. In general, investigators should prioritize cap-
Recording Exposure During Multiday Competitions turing specific data on the training activities considered to
present the greatest health risk.
Multiday competitions, such as championships and tourna- Wearable physical activity tracking devices enable inves-
ments, represent an exposure measurement challenge, par- tigators to capture large volumes of competition and train-
ticularly for injury analyses. Ideally, investigators should ing data at the elite level and from community sports
obtain accurate records of every athlete’s individual partic- participants across large sample groups. We encourage the
ipation (eg, training and competition minutes) throughout use of these devices for tracking exposure. However, we
the tournament. However, this is not always feasible. caution that any device needs to be fit for the purpose, and
Acceptable exposure estimates can also be made by researchers should obtain evidence on their validity and
reliability before data collected through these devices are prevalence). Therefore, for such conditions, prevalence (the
used for injury surveillance. proportion of athletes affected) is a more appropriate meas-
ure than incidence (the number of new cases during the
season).
EXPRESSING RISK Because sports and the activities that comprise them are
so diverse, there is no single approach to expressing risk
Rates and Proportions appropriately for all sports injury surveillance projects.70
In general, incidence-based measures that provide a stan-
Rates and proportions of injury and illness in studies of dard time window for the population at risk (injuries per
sports are usually reported as counts of “cases” of the out- hour) are preferable to measures for which the time at risk
come of interest (the “numerator”) divided by a population varies across individuals (injuries per athletic exposure, ie,
at risk of developing the outcome (the “denominator”).18 per training session or match) because time-based mea-
Because research questions such as “How many players sures better facilitate comparison across sports.
have suffered a knee injury?” “What is the risk of getting To provide numbers that are easy to interpret, avoiding
injured in this sport?” and “How does sport A compare with small decimals, these data are typically reported as per
sport B for concussion risk?” are very different, there are 1000 player-hours (eg, the concussion rate in a men’s rugby
various ways of reporting risks related to sports injury and study was reported as 4.7/1000 player-hours rather than
illness. We explain some fundamental terms here. 0.0047 per player-hour).55 Such numbers allow risks to be
Prevalence: How Many? Prevalence is a proportion and compared (eg, how does the concussion risk vary across
refers to the number of existing cases divided by the total contact sport codes?). We expect that subsequent sport-
population at risk at a given point in time (point preva- specific statements will recommend suitable, standard
lence; eg, the proportion [percentage] of players on a volley- incidence-based measures for each sport. Table A2 in
ball team who, today, are suffering from patellar Appendix 1 provides a range of examples of risk measures.
tendinopathy). It is a snapshot at one point in time but can If 1 injury event results in multiple injuries, these should
be repeated to determine changes in prevalence over time only be counted as 1 when calculating overall injury inci-
(eg, weekly). With serial measurements, it is possible to dence (eg, if a downhill skier crashes and suffers 2 injuries,
report, for example, the average prevalence over the course a concussion and a tibial fracture, these are counted as 1
of the season and also to compare different stages of the injury when calculating incidence).
season. Because of the difficulties in accurately measuring expo-
Period prevalence extends the concept of a single point in sure to pathogens (which may be greater when not training
time to a window of time (eg, 1 season, 1 year). It refers to or competing), illness risk should be estimated based on the
the proportion of athletes that has reported the condition of entire period of exposure (eg, the duration of a competition,
interest (eg, patellar tendinopathy) at any time during that a “season of play,” a year), not athletic exposure only. We
given window. Notably, this includes people who already recommend reporting illness risk as either the incidence;
had the condition at the start of the study period as well the number of new cases divided by a period of time (eg,
as those who acquired it during that period. illnesses per 365 athlete-days)91; or as the period preva-
Incidence: How Often (Do New Cases Occur)? Incidence lence of the illness, the proportion of athletes who were ill
is a rate, and as with any rate, time comes into play. Inci- during a defined period.94,95
dence refers to the number of new injuries/illnesses in the Where time-based measurements of exposure are
population that develop during a defined period of time. unavailable but participant numbers are available, crude
The term “incidence rate” is synonymous, but we argue that rates of injury per number of participants per period can be
it is a tautology; “incidence” is a rate. derived. In such cases, we suggest that the incidence that
Note that prevalence is calculated based on the number may be most useful to permit population-level comparisons
of athletes with a health problem, while incidence refers to among sports or studies is “injuries per 365 athlete-days.”
the number of new health problems. Similarly, the proportion of participants with new or
recurring injury or illness (ie, excluding pre-existing cases
Recommendations: Expressing Risk in and exacerbations) during the event has been used to pro-
Sports Injury/Illness Surveillance vide an impression of the risk associated with participation
in each sport in both the summer and winter Olympic
Incidence-based measures usually represent more appro- Games.94,95 However, this approach—period prevalence—
priate outcomes for sudden-onset conditions (eg, ankle can suggest widely different relative risks of activities that
sprains, ACL injuries) and prevalence-based measures for differ substantially in the amount of exposure participants
gradual-onset conditions (eg, asthma, patellar tendinopa- experience.94 For example, exposure differs substantially
thy).3 Overuse injuries and pain problems such as low back between a football player and a sprinter. Period prevalence
pain and patellar tendinopathy are often chronic, with per- describes the absolute risk of participation in the Olympic
iods of remission and exacerbation. For example, in a pro- Games but not the relative risk (the risk of injury during 1
fessional volleyball team, there could be only 1 new case of hour of football play vs 1 hour of marathon running).
patellar tendinopathy (so the incidence will be low), yet 40% Injury rates reported on a per-event (eg, per rugby
of the players (nearly all pre-existing) could be affected by tackle) basis provide information about how likely a partic-
patellar tendinopathy during the season (period ular aspect of play (event) is to result in an injury.
Understanding events that both do5 and do not result in

injury73,74 helps researchers identify injury prevention
opportunities. In the absence of information about how fre-
quently the event occurs within a sport and the average
duration of the sport to which participants are exposed,
rates per event also provide an incomplete view of the over-
all risks that a sport poses. Using time- and event-based
denominators (eg, tackles in football codes) in parallel can
help provide insights into both which event (eg, tackle type)
is most frequently associated with injuries and which event
carries the highest risk when it occurs. To date, there have
been relatively few injury surveillance studies in which
such statistics have been provided together.44 For televised
sports and those using new technology such as activity
trackers, measurement of the duration of playing time and
intensity for each athlete is feasible, and coding of the num-
ber, characteristics, and duration of activities each partic-
ipant engages in (eg, tackles) is routine for some Figure 5. Risk matrix based on the duration of time loss illus-
professional sports (eg, football). We include a real-life illustrating the burden of match injuries among professional rugby
trative case of surveillance methods being used to investi- teams in New Zealand between 2005 and 2018 (unpublished
gate injury risk in rugby in Appendix 1. data). The darker the yellow, the greater the burden. The
curved gray lines represent points with equal burden. The
Communicating the Risk to Stakeholders vertical and horizontal error bars represent 95% CIs. See also
Table 6, illustrating the same dataset in more detail.
From clinical and practical perspectives, it is important
that the end users (the athletes, coaches, and medical staff
members) can make sense of the injury reports and years.79 Burden allows different health problems to be com-
increase the chances of having them participate in risk pared—Does low back pain or diabetes cause more burden
management plans. This can be done by expressing the to society?
injury incidence based on the concerned sport’s specifica- The burden of injuries and illnesses can also be
tions. For instance, if an injury incidence for a specific mus-
expressed using measures that combine their frequency
cle group (eg, hamstring) is expressed as 0.9 injuries per
and consequences.4,21 For example, in football and rugby
1000 hours of exposure, the incidence per player per season
union, injury burden has been reported as the number of
(0.28 injuries/player/season) could be multiplied by the
days of time loss per 1000 hours of player exposure. 8-
average number of athletes per squad for the concerned 12,87,110
This contrasts with incidence (discussed earlier),
sport (eg, 25 in football). This gives 7 hamstring injuries
where the numerator is the number of injuries rather than
per squad per season, a quantity that is more easily inter-
the consequence of those injuries—days of time loss.
preted by end users.
As measures of incidence and consequences vary depend-
Another relevant measure, which is easy to communi-
ing on the purpose and setting of data collection, there is no
cate to managers, coaching staff, and athletes and that is
associated with team performance in football,59 is player single method of calculating burden in sports. To facilitate
availability. Player match availability is calculated as the comparison among sports, investigators should consider
sum of player match opportunities (ie, the number of reporting the number of days of time loss per 365 athlete-
matches multiplied by the full size of the squad) minus the days for each outcome of interest in addition to measures
sum of player match absences due to injury or illness and based on sport-specific exposures. We expect that subse-
can be expressed as the average percentage over the quent sport-specific statements will provide recommenda-
period of interest (eg, 1 season). Training availability can tions on suitable, standard burden measures for each sport.
be calculated in the same way. Burden can also be visualized using a risk matrix in
We encourage sport-specific consensus statements to rec- which the incidence of each health problem of interest is
ommend relevant measures to communicate risk to rele- plotted against its consequences (such as mean time loss, as
vant stakeholders. illustrated in Figure 5). This is an effective way to commu-
nicate the overall burden (and its determinants) for a range
of health problems. However, there are certain limitations
BURDEN OF HEALTH PROBLEMS to interpreting risk matrices, depending on how figures are
designed and how data are structured (see Fuller47 for a
Burden is a collective measure of the overall impact of a detailed review).
health problem in a specified population. In public health, Burden measures that use time loss as a measure of
burden is often expressed by financial cost, mortality, or severity fail to incorporate the most severe health problems
morbidity. One common approach is specific measures such (ie, fatalities and nonfatal catastrophic injuries and ill-
as quality-adjusted life years or disability-adjusted life nesses) and other cases where the athlete fails to return
were grouped. The research problem being addressed

should shape the classification system used rather than
vice versa.
DATA COLLECTION METHODS

The methods underpinning the data collection have great
impact on the outcome of sports injury and illness surveil-
lance studies.33,38,97 A systematic review of ongoing injury
surveillance systems in sport found that data quality
aspects were published for only 7 of the 15 systems and
validation studies for only 4.26 The review concluded that
data quality could be improved through the establishment
of data collection standards.
Given the wide range of settings in which surveillance is
undertaken, data collection methods should be flexible
enough to adapt to the specific context (eg, sport culture,
Figure 6. Risk matrix based on Oslo Sports Trauma Research
level of sport, availability of resources) and to the specific
Center Questionnaire on Health Problems severity scores
research question and objectives of the study.33 These fac-
illustrating the burden of injuries and illnesses affecting elite
tors in combination will determine:
Norwegian endurance athletes (unpublished data). Error bars
represent 95% CIs.
Who should provide the information (eg, athlete, physi-
cian, physical therapist, coach, nonclinical volunteer)
to sport (eg, due to retirement). As previously discussed, What data sources should be used (eg, athlete self-
time loss–based severity measures also underrepresent report, medical records, examinations, video recording)
overuse injuries and chronic illnesses.3,16 In this case, The frequency of data collection and reporting (eg, daily,
mean OSTRC-H severity scores can be used instead of time weekly, monthly)
loss, as illustrated in Figure 6.15 The timing of and window for data collection (eg, day of
injury/illness or of competition/training or following
day, within a week)
STUDY POPULATION CHARACTERISTICS The duration of surveillance (eg, tournament, season,
whole year, playing career)
Depending on the purpose of the study, demographic and
health data may be included in injury and illness surveil- Taking all of these variables into account, it is evident
lance protocols. The demographic information captured that “one size does not fit all.”14,105
should, as a minimum, include age, sex, and level of com- In 2001, the WHO38,62 published guidelines for injury
petition and disability/impairment type in Paralympic surveillance that remain relevant. In particular, some gen-
sport. These can be supplemented with data on other rele- eral aspects about quality of data collection systems (ie,
vant characteristics that could help investigators evaluate objectivity, reliability, validity, practicability, risk of bias,
risk factors. cost-/time-effectiveness, acceptability), quality of imple-
It is important to describe the performance and training mentation (eg, guidance document, communication, com-
level of the study population both because they are often pliance, data check), and some methodological issues (eg,
closely related to health outcomes and to allow appropriate handling of missing values, completeness of reports, cover-
studies to be compared.33 It is beyond the scope of this con- age, response rate) are important.24,36,64 In addition, the
sensus group to provide a universal classification of com- choice of injury definition, exposure measure, and methods
petitive level. For example, the criteria used to define used to express rates influence the results substantially, as
“elite” vary considerably among sports. We encourage discussed in the relevant sections of this document.
sport-specific methodological consensus groups to define The reliability of the system can be improved by tailored
what constitutes “elite,” “subelite,” and “recreational” ath- education, ongoing support for the people who report the
letes in their sport. data, and a detailed process manual62 and should be eval-
uated at least by analysis of interrater reliability of people
Classification of Sport Categories reporting the data.24
Validity and completeness of data reporting can be ana-
There are many ways of classifying and grouping sports. lyzed, comparing with another “gold-standard” data
Any sports classification system used in surveillance source.6,42,53,67,77,81 A recent study showed that research-
should be clearly described in the methods section of involved staff recording the data in a surveillance program
reports. The description should permit other researchers reported a greater number of mild injuries than did
to understand and replicate the process by which sports nonresearchers.109
TABLE 11 athletes, 76,77,81 there are also reports of poor athlete

Implementation Recommendations for engagement,7 and thus demonstrates the importance of
Injury/Illness Surveillance understanding uptake barriers. It is important to use sur-
veillance tools that minimize intrusion into the daily activ-
The implementation of an injury and illness surveillance project ities of the data reporters (athletes, medical teams,
should include the following aspects:
coaches), for example, by limiting the number of questions
Methods based on this consensus statement on definitions and to responders so that only essential data are captured.
data collection procedures Another recommendation is to provide a clear incentive to
Mandatory standards for compliance with defined time scales for athletes and teams to participate in injury surveillance, for
completion for report forms example, by allowing continuous feedback within the data
Guidance document (a quality protocol) shared with all club/ collection system (eg, performance data, load monitoring
national team medical staff (preseason/tournament) data) or sending regular reports back to the teams, ath-
Regular contact between study lead and responsible person at each letes, and other relevant stakeholders.25
club/national team (face-to-face meeting preseason/prior to
Data collection methods must be adapted to the specific
tournament, conference call midseason/tournament)
research question, the sport context, and the skill set of the
All injuries cross-checked with club/team medical records and
followed up with medical staff for missing, incomplete, research team and should follow strict quality standards.
inconsistent, or duplicate entries (regularly during season/ The quality of the surveillance system includes the quality
tournament) of the forms (baseline, health problems, and exposure) as
Data cleaning and final review of dataset with responsible person well as the quality of the data collection procedure, imple-
at each club/team before definitive analysis (end of season/ mentation, data cleansing, and analysis methods.40 The
tournament) quality and usability of the forms and the data collection
Injury reports where individual club/team data are reported, procedures should be examined before implementation. Reli-
analyzed, and compared with the average of all participating ability and validity should be analyzed, and all translations
clubs/teams (midseason and end of season/tournament)
should follow the standards of intercultural adaptation.54,61
Medical meeting (end of season/tournament) where whole
The adherence to the data collection protocol as well as the
surveillance results and translational value are presented to
club/team medical practitioners for discussion completeness and consistency of responses should be moni-
tored on a regular basis during implementation. Collabora-
tion between research groups to share resources and joint
data analytics can help advance the management of sport
An example of specific measures to improve the reliabil- injuries/illnesses. 103 Having data collection forms and
ity of a surveillance project is illustrated in Table 11, based related material available in free-to-access formats makes
on the procedure of the Professional Rugby Injury Surveil- it easier for sports bodies to participate in surveillance activ-
lance Project.29 ities,40 and this consensus statement includes some sample
forms as mentioned in Appendix 2.
From Pen and Paper to Electronic Solutions
Research Ethics and Data Security
Health problems and exposure can be captured using dif-
ferent methods ranging from paper copy data collection Research ethics govern the conduct of medical research and
forms to a comprehensive web-based surveillance system, aim to protect the dignity, rights, and welfare of human
for example, internet platforms, mobile applications, or text participants. They detail principles such as informed con-
messaging.7,31,40,76,77,81,96,117 The traditional pen-and- sent, data confidentiality, the use of research ethics com-
paper approach is often easy to implement,41 as it reduces mittees and risks, burdens, and benefits. Importantly,
the need for specific technical knowledge, equipment, and informed consent is the process in which permission is
related costs.40,72 Data can be verified and cleaned as they granted in full knowledge of the possible consequences
are manually entered.72 (risks and benefits), for example, for their data to be used
Electronic data capture reduces time for the duplication of for research purposes. In some contexts, injury and illness
data entry41 and associated entry errors.72 In terms of costs, surveillance may be regarded as an integral part of data
there is potential long-term cost-effectiveness through the audit and quality control processes and, as long as individ-
elimination of expenses linked to the printing, shipping, manual patient data are fully deidentified, may not require
agement, and storage of physical documents.72 informed consent. It is the duty of all researchers (and all
Web-based solutions allow instant and remote on- other users of the data) to consider, and adhere to where
demand queries of real-time data (including end users such appropriate, internationally recognized guidelines for
as team medical staff) as well as integration with other data research ethics (such as the Declaration of Helsinki115 and
feeds (eg, performance, load, sleep). Web-based solutions the Declaration of Taipei116).
should preferably be prototyped prior to being implemented Data protection governs how data are collected, shared,
in a larger injury surveillance setting. Full integration of used, and conserved and aims to ensure that personal data
surveillance reporting systems within clinical electronic are safe from unforeseen, unintended, or malevolent use.
medical record-keeping systems has been used successfully Particular attention must be directed to the security of data
in a number of professional elite leagues.22 While electronic stored on cloud-based systems and other electronic reposi-
solutions can lead to high response rates among tories. Researchers must adhere to the data protection
regulations applicable to their context (such as the General this checklist to other languages for the benefit of the inter-
Data Protection Regulation in Europe).30 national sports medicine community.
REPORTING GUIDELINES: STROBE SPORTS AUTHORS

INJURY AND ILLNESS SURVEILLANCE
International Olympic Committee Injury and Illness Epide-
The statement on STROBE was published in 2007.106 miology Consensus Group; Roald Bahr, MD, PhD (Oslo
Since then, it has been adapted (extensions) to ensure the Sports Trauma Research Center, Department of Sports
statement is relevant to other areas of interest such as Medicine, Norwegian School of Sport Sciences, Oslo, Nor-
infectious diseases32 and most recently (2018) for pharma- way; Aspetar Orthopaedic and Sports Medicine Hospital,
coepidemiology. 68 These extensions of STROBE have Doha, Qatar); Ben Clarsen, PT, PhD (Oslo Sports Trauma
stressed, like the original, that they only guide on how Research Center, Department of Sports Medicine, Norwe-
to report findings from observational studies rather than gian School of Sport Sciences, Oslo, Norway; Department
guiding study design. However, the two are related, and of Health Promotion, Norwegian Institute of Public Health,
researchers are strongly encouraged to consider the ele- Bergen, Norway); Wayne Derman, MD, PhD (Institute of
ments of the checklists when planning studies; this may Sport and Exercise Medicine, Division of Orthopaedic Sur-
eventually improve study quality and ensure that gery, Faculty of Medicine and Health Sciences, Stellenbosch
researchers are able to report what is needed at the end University, Stellenbosch, South Africa); Jiri Dvorak, MD,
of the study. STROBE has checklists for the 3 most com- PhD (Spine Unit, Swiss Concussion Center and Swiss Golf
mon study types: cohort studies, case-control studies, and Medical Center, Schulthess Clinic, Zurich, Switzerland);
cross-sectional studies. Here, we summarize our consen- Carolyn A. Emery, PT, PhD (Sport Injury Prevention
sus recommendations on the collection and reporting of Research Centre, Faculty of Kinesiology, University of Cal-
SIIS data as an extension to the initial STROBE checklist. gary, Calgary, Alberta, Canada; Pediatrics and Community
These apply regardless of study design. Note that many Health Sciences, Cumming School of Medicine, University of
other study designs common in sports and exercise med- Calgary, Calgary, Alberta, Canada); Caroline F. Finch, PhD
icine research, such as randomized controlled trials, (School of Medical and Health Sciences, Edith Cowan Uni-
should be reported against other reporting standards (like versity, Joondalup, Western Australia, Australia); Martin
CONSORT, which will be refreshed in 2020).19 As most Hägglund, PT, PhD (Department of Medical and Health
sports medicine studies rely on surveillance methods to Sciences, Division of Physiotherapy, Linköping University,
collect injury and illness outcome data, the recommenda- Linköping, Sweden); Astrid Junge, PhD (Medical School
tions in this consensus statement apply widely. Hamburg, Hamburg, Germany; Swiss Concussion Centre,
To guide researchers in the field of sport and exercise Schulthess Clinic, Zurich, Switzerland); Simon Kemp,
medicine, we have adapted (extended) the STROBE check- MBBS, MSc (Rugby Football Union, London, UK; Depart-
list so that it reflects recommendations from this current ment of Epidemiology and Population Health, London
IOC consensus statement on studies of injury and illness School of Hygiene and Tropical Medicine, London, UK);
surveillance in sports. This extension refers to 21 of the Karim M. Khan, MD, PhD (Department of Family Practice,
original items. It includes only items specific to the report- University of British Columbia, Vancouver, British Colum-
ing of injuries and illnesses in sport, as amendments to bia, Canada; British Journal of Sports Medicine, London,
reflect broader epidemiology methodology developments UK); Stephen W. Marshall, PhD (Injury Prevention
should be more appropriately documented by the EQUA- Research Center and Department of Epidemiology at the
TOR Network, which oversees STROBE. Gillings School of Global Public Health, University of North
It is intended that this new checklist, the STROBE-SIIS, Carolina at Chapel Hill, Chapel Hill, North Carolina, USA);
will help researchers design an injury/illness surveillance Willem Meeuwisse, MD, PhD (Sport Injury Prevention
study and plan the study protocol as well as better report Research Centre, University of Calgary, Calgary, Alberta,
their observations (Appendix 3). By consistently using the Canada; National Hockey League, Calgary, Alberta,
STROBE-SIIS, authors ensure that other researchers will Canada); Margo Mountjoy, MD, PhD (Department of Family
be able to more easily replicate, compare, and synthesize Medicine (Sport Medicine), McMaster University, Hamilton,
sport and exercise medicine research studies. Ontario, Canada; FINA Bureau (Sport Medicine), Lausanne,
We also strongly recommend that researchers publish Switzerland); John W. Orchard, MD, PhD (School of Public
their study protocols ahead of study completion, ideally Health, University of Sydney, New South Wales, Sydney,
with an open access formal register, and also report on any Australia); Babette Pluim, MD, PhD, MPH (Department of
changes made to the initial protocol during study conduct, Sports Medicine, Royal Netherlands Lawn Tennis Associa-
together with their rationale for the change, once the study tion, Amstelveen, the Netherlands; Amsterdam Collabora-
has been completed. Details of where protocols and their tion on Health & Safety in Sports (ACHSS), AMC/VUmc
amendments are publicly available should be stated in IOC Research Center of Excellence, Amsterdam, the Nether-
papers submitted for publication. lands); Kenneth L. Quarrie, PhD (New Zealand Rugby, Wel-
Feedback on this checklist is welcome, and we will both lington, New Zealand; Sports Performance Research
monitor and evaluate the impact of its use over time. We Institute New Zealand, AUT University, Auckland, New
welcome researchers with relevant expertise to translate Zealand); Bruce Reider, MD (Department of Orthopaedic
Surgery and Rehabilitation, University of Chicago, Chicago, 8. Brooks JH, Fuller CW. The influence of methodological issues on the
Illinois, USA); Martin Schwellnus, MD, PhD (Sport, Exer- results and conclusions from epidemiological studies of sports inju-
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9. Brooks JH, Fuller CW, Kemp SP, et al. An assessment of training
University of Pretoria, Hatfield, South Africa); Torbjørn Soli-
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APPENDIX 1
Case Study: Tackle Injuries to TABLE A1

Ball Carriers in Rugby Injury Rates to Ball Carriers in Rugby Tacklesa
Data Set Injuries Requiring Player to Be

Removed From Match
A study was conducted in which video records of every
Percentage
tackle that occurred in 434 professional rugby matches Tackles Per Per of Injuries
were coded on a range of dimensions, including the location Tackle per 10,000 10,000 per 10,000
on the body at which the tackler(s) contacted the ball car- Height Match Tackles Player-Hours Player-Hours
rier (“tackle height”).87 The information in the table has
been restricted to that from 43,366 tackles in which a single Head/neck 4±2 43 (23-79) 4 (2-8) 13 (7-23)
tackler tackled a ball carrier (ie, the 100 tackle events per High 37 ± 10 12 (8-17) 11 (8-16) 36 (26-47)
match that met this criteria). For the purposes of the exam- Middle 44 ± 9 9 (6-13) 10 (7-15) 32 (23-43)
ple below, an injury is defined as “any injury sustained by a Low 15 ± 5 16 (9-26) 6 (3-10) 19 (12-29)
ball carrier during a rugby tackle that required them to be a
Rates are expressed via event- and time-based denomina-
removed from the field of play for the remainder of the
tors. Data are shown as mean ± standard deviation or mean
match.” (range).
Different Denominators: Different Perspectives on Risk most common tackles in the game would have the greatest
effect; together, high and middle tackles account for over
Rates of injury have been presented in Table A1 as “per two-thirds of all tackle injuries requiring ball carriers to be
10,000 tackles” and “per 10,000 player-hours.” If data were removed from the pitch. Reducing the numbers of such
reported using only the time-based denominator, as has tackles, or the characteristics of them, would probably
been the case in most studies of sports injury epidemiology, require major changes to the sport of rugby. If, however,
the conclusion drawn would be that “high” and “middle” the overall degree of risk were considered acceptable, then
tackles are those that carry the greatest risk to ball car- focusing on decreasing the number of head and neck tackles
riers. When the relative frequency of the tackles is consid- would have a modest effect on overall injury rates but
ered, and the rates are presented on a “per 10,000 tackles” reduce the occurrence of a particularly risky element of the
basis, head/neck tackles place ball carriers at the greatest sport (note: head/neck tackles are not permitted within the
risk of injuries when they occur. laws of rugby, but sometimes occur).
The different perspectives provided by per-event and The types of exposure measures that can form the basis
per-time denominators can be helpful in identifying injury of risk statistics are presented in Table A2, along with a
prevention priorities. If the overall risk of injuries was con- range of risk measures that have been reported in studies of
sidered unacceptably high by those responsible for manag- team sports injury epidemiology. The examples are taken
ing the risks in the sport, then reducing the numbers of the from the same study discussed above.
TABLE A2
A Range of Exposure and Risk Measures Derived From Injury Surveillance Dataa
Statistic Value Calculation Explanation Comment
Injury statistics
No. of injuries (carrier 53 Nil Count of the number of The “numerator” used for calculating the
injury replacements tackler injuries requiring rate of tackler replacement injuries per
in 434 matches) the injured player to be unit of time or per tackle. Absolute
replaced observed in 434 numbers and costs of injuries are of
matches interest to risk managers, especially
when provided in parallel with rates.
No. of injured players 48 Nil This is the numerator for calculating
(some were injured injury risk.
more than once)
Exposure measures
Player-hours in 434 17,360 30 579 30 players (15 from each This number provides a “time-window”
matches team) multiplied by 579 denominator. Usually, it is assumed
(hours of play in 434 that time lost for yellow and red cards,
matches of 80 minutes’ or time gained for “extra time,” is
duration) negligible and is ignored.
(continued)
Table A2 (continued)
No. of single-tackler 43,366 Nil All tackles in 434 matches This number forms an “event-based”
tackle events in 434 were coded, regardless of denominator.
matches whether they resulted in
injury
No. of players who 1403 Nil This is a count of the size of the cohort
appeared in the 434 across the entire study period. It is used
matches as the denominator for calculating
injury risk.
No. of full player 13,020 30 434 30 players (15 from each This number provides a “per-match”
matches team) multiplied by 434 denominator.
matches
No. of athlete- 17,685 Nil Count of the number of The similarity to the number of player-
exposures (athlete- players who took the field hours is coincidental. There are 40
participations) over 434 matches (players hours of player time per match, and the
can be substituted for average number of athlete-exposures
tactical purposes or per match over this series of matches
replaced due to injury) was 40.8.
Risk measures
Period prevalence 3% (48/1403) 100 Percentage of people who Often reported as the “risk per season” or
(percentage of cohort appeared in matches who “risk per year.” It cannot be easily used
injured) were replaced to compare between activities if the
duration of surveillance varies from
activity to activity. The longer the
surveillance period, the higher the risk
will appear to be for closed cohorts.
Injuries per 1000 3.1 (53/17,360) 1000 Number of injuries is divided The most commonly reported metric of
player-hours by the number of hours of injury rates in studies of rugby injury
player exposure and epidemiology has been the rate of
multiplied by a scaling injuries per 1000 player-hours. This
factor (eg, 1000, 10,000) to convention is endorsed in the consensus
provide a rate that is statement by Fuller et al.52 It is
convenient to work with relatively simple to estimate based on
(eg, numbers in the range the number of matches played.
of 1 to 1000 rather than Comparisons of incidence rates between
numbers <0 or >1000) activities or within activities over time
based on this denominator require the
assumption that the number and
characteristics of energy transfers to
which participants are exposed remain
relatively constant per unit of exposure
time.
Injuries per 1000 122 (53/434) 1000 Rate of tackler replacements Ignores the number of players and match
matches per rugby union match duration and provides an estimate of the
multiplied by 1000; rate number of injuries that an observer
per match multiplied by a would expect to see if they watched 1000
factor that provides a matches. Not useful for comparing
convenient interpretation incidence rates between activities of
(0.12 carrier replacement differing durations or numbers of
injuries per match, 12.2 participants.
per 100 matches, 122 per
1000 matches, etc)
(continued)
Table A2 (continued)
Injuries per 1000 hours 92 (53/579) 1000 Rate per hour is multiplied Ignores number of players and provides an
of play (ignoring by a factor that provides a estimate of the number of injuries an
number of players) convenient interpretation observer would expect to see if they
(0.9 carrier replacement watched 1000 hours of play. Not useful
injuries per hour, 9.2 per for comparing between activities with
100 hours, 92 per 1000 differing numbers of participants
hours, etc) because the sizes of the populations at
risk differ.
Injuries per 1000 3.0 (53/17,685) 1000 Carrier injury replacements Injuries per 1000 athlete-exposures are
athlete-exposures per 1000 athlete-exposures commonly reported in injury
(athlete- surveillance in the United States.
participations) Problematic for comparing between
activities that have different numbers of
typical athlete-exposures per match or
when the average exposure time per
player changes over time.
Injuries per 1000 full 4.1 (53/13,020) 1000 Not commonly used. It ignores the
player matches duration of the match and, as such, has
similar drawbacks to reporting injuries
per athlete-exposure because the time
window of exposure varies between
activities of different durations.
Injuries per 1000 “ball 6.8 (53/7740) 1000 Not commonly used but technically a more
in play” player-hours accurate measure of exposure than
injuries per 1000 player-hours because
players are only exposed to tackles when
the ball is “in play.”
Injuries per 1000 “ball 13.5 (53/3819) 1000 Again, not commonly used but an even
in play and ball closer approximation of the actual time
carrier’s team in exposed to the risk of ball carrier
possession” player- injuries. Players are only tackled when
hours the ball is in play and their team is in
possession.
Injuries per 1000 tackle 1.2 (53/43,366) 1000 Ball carrier injury Provides an accurate assessment of per-
events replacements per 1000 event injury rates but in isolation
times tackled ignores the frequency of occurrence of
the event of interest. Injury rates per
event have sometimes been termed
“injury propensity.”48
Injuries per 1000 24 ([23 þ 17 þ 13] Sometimes provided as a gross estimate of
players per year 1000) / (983 þ the injury risk when participant
589 þ 627) numbers and injury numbers are
available but no measure of exposure for
players is available (eg, data derived
from insurance claims combined with
registers of participants). Of limited use
when exposure varies by subgroup or
across sports.
a
Examples from a study of rugby tackle injuries.87
APPENDIX 2A
Daily Medical Report on Injuries and Illnesses
Country: Date of report:
Form completed by: Name: Contact details:
Please report: (1) All sport injuries and (2) all illnesses of your athletes newly incurred, recurrent or an exacerbation of an
underlying stable injury/illness during the <name of the championship> regardless of the consequences with respect to
absence from competition or training. The information provided will be treated strictly confidential.
1. Injury – Example Definitions and codes (see reverse)

age gender sport and event date of injury competition / training code onset code new code
22 male / female decathlon 21. July sprint competition 2 1 1
injury mechanism code injured body region code injury type code time-loss duration
slipped and fell 5 ankle 17 sprain 10 no / yes 28 days
male / female
no / yes days
male / female
no / yes days
male / female
no / yes days
male / female
no / yes days
2. Illness – Example Definitions and codes (see reverse)

age gender sport and event date of onset organ system / region code
27 male / female athletics, pole vault 24th July respiratory system 13
aetiology code new, recurrent or exacerbation code time-loss duration
Environmental - not exercise related 3 1 no / yes 2 days
male / female
aetiology code new, recurrent or exacerbation code time-loss duration
no / yes days
male / female
aetiology code new , recurrent or exacerbation code time-loss duration
no / yes days
male / female
no / yes days
male / female
no / yes days
If space is not sufficient to report all injuries or illnesses, please use additional forms.
no new injury or illness in any athlete of our team today
(continued)
Definitions and codes

For injuries (defined as tissue damage or other derangement of normal physical function due to participation in
sports, resulting from rapid or repetitive transfer of kinetic energy)
Competition or training
1 competition, please specify event 2 training 3 peri-competition activities
(e.g. warm-up, cool-down)
Mode of onset
1 sudden after acute trauma 2 sudden but no acute trauma 3 gradual 4 mixed
Injury mechanism
1 no identifiable single event 3 direct contact with another athlete 5 direct contact with an object (e.g. ball,
(repetitive transfer of energy, overuse) 4 following contact with another wall, ground, i.e. slipped and fell)
2 acute non-contact trauma athlete (e.g. fall after a push) 6 following contact with an object
Injured body region

1 head / face 7 shoulder 13 hip / groin
2 neck / cervical spine 8 upper arm 14 thigh
3 chest (incl. chest organs) 9 elbow 15 knee
4 thoracic spine / upper back 10 forearm 16 lower leg / Achilles tendon
5 lumbar-sacral spine / buttock 11 wrist 17 ankle
6 abdomen (incl. abdominal organs) 12 hand 18 foot
Injury type
1 concussion / brain injury 10 joint sprain / ligament tear 19 contusion / bruise (superficial)
2 spinal cord injury 11 chronic instability 20 arthritis
3 peripheral nerve injury 12 tendon rupture 21 bursitis
4 bone fracture 13 tendinopathy 22 synovitis
5 bone stress injury 14 muscle strain / rupture / tear 23 vascular damage
6 bone contusion 15 muscle contusion 24 stump injury
7 avascular necrosis 16 muscle compartment syndrome 25 internal organ trauma
8 physis injury 17 laceration 26 unknown, or not specified
9 cartilage injury 18 abrasion
For illnesses (defined as a complaint or disorder not related to injury)

Organ system
1 cardiovascular 6 genitourinary 11 otological
2 dermatological 7 hematologic 12 psychiatric/psychological
3 dental 8 musculoskeletal 13 respiratory system
4 endocrinology 9 neurological 14 thermoregulatory system
5 gastrointestinal 10 ophthalmological 15 unknown, or not specified
Aetiology
1 allergic 5 infection 9 degenerative or chronic condition
2 environmental - exercise-related 6 neoplasm 10 developmental anomaly
3 environmental - non-exercise 7 metabolic/nutritional 11 drug-related/poisoning
4 immunological/inflammatory 8 thrombotic/haemorrhagic 12 unknown, or not specified
For injuries and illnesses

Sport and event
Please report the sport (e.g. athletics) AND specify the event (e.g. pole vault) if applicable.
New, recurrent or exacerbation

1 newly incurred during the championships 3 exacerbation of a stable (not recovered) condition
2 recurrent after full recovery and return-to-sport 4 unknown, or not specified
Time-loss in sport due to injury or illness

no athlete continues to train or compete, even if not at usual level (duration, intensity, performance)
yes athlete did not finish the training or competition when the injury occurred OR could not participate in sport later
Duration of impaired participation/ limited performance in sport due to injury or illness (in days)
Please provide an estimate of the number of days that the athlete will not be able to undertake his/her normal training or
will not be able to compete as usual, counting the day after the onset of the injury/illness as day 1.
If an athlete is not expected to return to sport after the injury or illness, please state the reason: F=fatality, P=permanent
disability, OR=reasons.
APPENDIX 2B
Medical Report of Injury or Illness Date of report: __________
Team: ____________ Athlete identification: ___________ Date of onset: __________
For injury
Competition or training
competition training peri-competition activities
(e.g. warm-up, cool-down)
Mode of onset
sudden after acute trauma sudden but no acute trauma gradual mixed
Injury mechanism (each category might have subcategories based on the purpose of the surveillance)
no identifiable single event direct contact with another athlete direct contact with an object
non-contact trauma following contact with another athlete following contact with an object
Injured body region (each category might have subcategories based on the purpose of the surveillance)
head shoulder hip / groin
neck / cervical spine upper arm thigh
chest (incl. chest organs) elbow knee
thoracic spine / upper back forearm lower leg / Achilles tendon
lumbar-sacral spine / buttock wrist ankle
abdomen (incl. abdominal organs) hand foot
Injury type
concussion / brain injury joint sprain / ligament tear contusion / bruise (superficial)
spinal cord injury chronic instability arthritis
peripheral nerve injury tendon rupture bursitis
bone fracture tendinopathy synovitis
bone stress injury muscle strain / rupture / tear vascular damage
bone contusion muscle contusion stump injury
avascular necrosis muscle compartment syndrome internal organ trauma
physis injury laceration unknown, or not specified
cartilage injury abrasion
For illness
Organ system
cardiovascular genitourinary otological
dermatological hematologic psychiatric / psychological
dental musculoskeletal respiratory system
endocrinology neurological thermoregulatory system
gastrointestinal ophthalmological unknown, or not specified
Aetiology
allergic infectious disease degenerative or chronic condition
environmental - exercise-related neoplasm developmental anomaly
environmental - non-exercise metabolic / nutritional drug-related / poisoning
immunological / inflammatory vascular unknown, or not specified
For injury and illness

New, recurrent or exacerbation
new recurrent after full recovery and return-to-sport unknown, or not specified
exacerbation of a stable (not recovered) condition
Time-loss in sport due to injury / illness

no yes
Date of full return to normal training and competition ______________ (dd/mm/yy)

No return to sport possible: fatality permanent disability other reasons _______________
APPENDIX 3
Strobe-SIIS (Sports Injury and Illness Surveillance) Statement 1.0
Checklist of Items for Reporting Observational Studies on Injury and Illness in Sportsa
Source of Rationale for Item From

Recommendation From Consensus Statement and Where to
Item STROBE Statement STROBE-SIIS Extension Find Further Details
(1) Title and abstract (a) Indicate the study’s design

with a commonly used term in
the title or abstract
(b) Provide in the abstract an SIIS 1.1: Include information on the SIIS 1.1: “Study population
informative and balanced sport, athlete population (sex, characteristics”
summary of what was done age, geographic region), and level SIIS 1.2: “Capturing and reporting
and what was found of competition athlete-exposure”
SIIS 1.2: Include the duration of
observation (eg, 1 season, 1 year,
multiple years)
Introduction
(2) Background/rationale Explain the scientific
background and rationale for
the investigation being
reported
(3) Objectives State specific objectives, SIIS 3.1: State whether study was SIIS 3.1: “Reporting guidelines:
including any prespecified registered. Identify the registration STROBE Sports Injury and
hypotheses number and database used Illness Surveillance (STROBE-
SIIS 3.2: State the specific purpose SIIS)”
of the study (eg, to describe the SIIS 3.2: Throughout consensus
injury burden associated with statement
Olympic-level rowing)
Methods
(4) Study design Present key elements of study SIIS 4.1: Clearly specify which SIIS 4.1: “Defining and classifying
design early in the paper health problems are being health problems”
observed SIIS 4.2: “Data collection methods”
SIIS 4.2: State explicitly which SIIS 4.3: “Classifying sports injury
approach was used to record the and illness diagnoses”
health problem data, including SIIS 4.4: “Study population
all outcome measures or tools characteristics”
SIIS 4.3: State explicitly which
coding system was used to
classify the health problems (eg,
OSIICS, SMDCS, ICD, etc)
SIIS 4.4: Where relevant, clearly
describe how athletes were
categorized. Variables to consider
could include the type of athlete
and/or sport, environment in
which the sport occurs (eg, type of
course or playing area), the
typical duration of the sport, the
degree of physical contact
permitted in the sport, and the
equipment permitted
(5) Setting Describe the setting, locations, SIIS 5.1: Describe the location, level SIIS 5.1: “Study population
and relevant dates, including of play, dates of observation, and characteristics”
periods of recruitment, data collection methods (ie, who, SIIS 5.2: “Capturing and reporting
exposure, follow-up, and data what, where) athlete-exposure”
collection SIIS 5.2: Specify the dates of the SIIS 5.3: “Capturing and reporting
surveillance period and how athlete-exposure” and “Data
the data were handled when collection methods”
the study covered more than 1
season/calendar year
SIIS 5.3: Define whether the health
problem data were collected
prospectively or retrospectively
(continued)
(continued)

(6) Participants (a) Cohort study: give the SIIS 6.1: Define the population of SIIS 6.1: “Data collection methods”
eligibility criteria and the athletes as well as describe how and “Study population
sources and methods of they were selected and recruited characteristics”
selection of participants.
Describe the methods of
follow-up
Case-control study: give the
eligibility criteria and the
sources and methods of case
ascertainment and control
selection. Give the rationale
for the choice of cases and
controls
Cross-sectional study: give the
eligibility criteria and the
sources and methods of
selection of participants
(b) Cohort study: for matched
studies, give matching criteria
and the number of exposed
and unexposed participants
Case-control study: for matched
studies, give matching
criteria and the number of
controls per case
(7) Variables Clearly define all outcomes, SIIS 7.1: Justify why you measured SIIS 7.1: “Defining and classifying
exposures, predictors, your primary and secondary health problems”
potential confounders, and outcomes of interest in the SIIS 7.2: “Defining and classifying
effect modifiers. Give the specific way chosen health problems”
diagnostic criteria, if SIIS 7.2: Describe the method for
applicable identifying the health problem
outcome of interest
(8) Data sources/ For each variable of interest, SIIS 8.1: Specify who collected/ SIIS 8.1: “Classifying sports injury
measurementb give sources of data and reported the data for the study and illness diagnoses” and “Data
details of methods of and their qualifications (eg, collection methods”
assessment (measurement). qualified doctor, data analyst, etc) SIIS 8.2: “Classifying sports injury
Describe comparability of SIIS 8.2: Specify who coded the data and illness diagnoses”
assessment methods if there is for the study and their SIIS 8.3: “Data collection methods”
more than 1 group qualifications (eg, qualified SIIS 8.4: “Relationship to sports
doctor, data analyst, etc; in many activity” and “Capturing and
instances, this will not be the reporting athlete-exposure”
same as in SIIS 8.1) SIIS 8.5: “Relationship to sports
SIIS 8.3: Specify the direct methods activity” and “Capturing and
used to collect the data and the reporting athlete-exposure”
use of physical documents or
electronic tools (if extracting
information from existing
sources, specify the data source)
SIIS 8.4: Specify the timing of and
window for data collection (eg,
day health problem occurred or
following day). Specify the
frequency of data collection (eg,
daily, weekly, monthly)
SIIS 8.5: Report the duration of
surveillance (eg, tournament,
season, whole year, playing
career)
(continued)
(continued)

(9) Bias Describe any efforts to address SIIS 9.1: Clearly report any SIIS 9.1: “Data collection methods”
potential sources of bias validation or reliability SIIS 9.2: “Data collection methods”
assessment of the data collection
tools
SIIS 9.2: Formally acknowledge any
potential biases associated with
the data collection method (eg,
self-report, recall bias, reporting
by nonmedically trained staff, etc)
(10) Study size Explain how the study size was
arrived at
(11) Quantitative variables Explain how quantitative SIIS 11.1: Explain in detail how SIIS 11.1: “Multiple events and
variables were handled in the multiple injuries/illness episodes health problems” and
analyses. If applicable, are handled both in individual “Subsequent, recurrent, and/or
describe which groupings athletes and across athletes/ exacerbation of health problems”
were chosen and why surveillance periods SIIS 11.2: “Severity of health
SIIS 11.2: Specify how injury problems”
severity was calculated
(12) Statistical methods (a) Describe all the statistical SIIS 12.1: Specify how the exposure SIIS 12.1: “Capturing and reporting
methods, including those used to risk has been adjusted for and athlete-exposure”
to control for confounding specify units (eg, per participant, SIIS 12.2: “Expressing risk”
per athlete-exposure, etc) SIIS 12.3: “Burden of health
SIIS 12.2: Specify how relevant risk problems”
measures (incidence, prevalence,
etc) were calculated
SIIS 12.3: When relevant to the study
aim, specify how the injury burden
was calculated and analyzed
(b) Describe any methods used to
examine subgroups and
interactions
(c) Explain how missing data SIIS 12.4: For studies reporting SIIS 12.4: “Multiple health
were addressed multiple health problems, state problems” and “Subsequent,
clearly how these were handled recurrent, and/or exacerbation of
(eg, time to the first injury only, injury/illness”
ignoring subsequent return to SIIS 12.5: “Capturing and reporting
play and reinjuries, or modeling athlete-exposure”
of all injuries)
SIIS 12.5: Explain how/if athletes
not included at outset (eg, those
already injured) were handled in
the analyses
(d) Cohort study: if applicable, SIIS 12.6: In longitudinal studies, it SIIS 12.6: “Capturing and reporting
explain how loss to follow-up is particularly important to athlete-exposure”
was addressed explain how athlete follow-up has
Case-control study: if applicable, been managed. For example, what
explain how matching of cases happened if a player was
and controls was addressed trasferred to another team or has
Cross-sectional study: if been censored (for those no longer
applicable, describe analytical part of the study due to removal
methods taking account of during the observation period).
sampling strategy Censoring can occur when
athletes are removed due to
transfer out of the team/study,
injury/illness, or due to study
design])
(e) Describe any sensitivity
analyses
(continued)
(continued)

Results
(13) Participantsb (a) Report numbers of SIIS 13.1: Clearly state the number SIIS 13.1: “Multiple health
individuals at each stage of of athletes who were followed up, problems”
study (eg, numbers the number (and percentage) of SIIS 13.2: “Multiple health
potentially eligible, examined those with the health problem, problems” and “Expressing risk”
for eligibility, confirmed and the number of problems
eligible, included in the study, reported among them (a median
completing follow-up, and number of problems per affected
analyzed) athlete could be useful)
SIIS 13.2: For studies over multiple
seasons/years, report the total
number of health problems for
each year and number common to
each period
(b) Give the reasons for SIIS 13.3: Report how athletes who SIIS 13.3: Throughout the
nonparticipation at each stage were removed (eg, because of the consensus statement
transfer of teams or timeout due
to an injury or illness) impact the
data at key data collection/
reporting points, ideally with a
flow diagram
(14) Descriptive datab (a) Give the characteristics of SIIS 14.1: Include details on the SIIS 14.1: “Study population
study participants (eg, level of competition being characteristics”
demographic, clinical, social) observed (eg, by age level, skill
and information on exposures level, sex, etc)
and potential confounders
(b) Indicate number of
participants with missing
data for each variable of
interest
(c) Cohort study: summarize
follow-up time (eg, average
and total amount)
(15) Outcome datab Cohort study: report numbers of SIIS 15.1: In observational studies, SIIS 15.1: “Multiple health
outcome events or summary individuals will sustain more problems” and “Subsequent,
measures over time than one health problem over the recurrent, and/or exacerbation of
surveillance period. Take care to injury/illness”
ensure that descriptive data
represent both the number of
health problems and the number
of athletes affected. It is
important to represent effectively
both the analysis and reporting of
correct units for frequency data
(ie, the percentage of affected
athletes or percentage of injuries,
body regions, etc)
Case-control study: report
numbers in each exposure
category or summary
measures of exposure
Cross-sectional study: report
numbers of outcome events or
summary measures
(continued)
(continued)

(16) Main results (a) Give unadjusted estimates SIIS 16.1: Report exposure-adjusted SIIS 16.1: “Expressing risk”
and, if applicable, confounder- incidence or prevalence measures SIIS 16.2: “Relationship to sports
adjusted estimates and their with appropriate confidence activity,” “Mode of onset—
precision (eg, 95% confidence intervals when presenting risk injury,” “Mode of onset—illness,”
interval). Make clear which measures and “Classifying the mechanism
confounders were adjusted for SIIS 16.2: Report details of interest, of injury”
and why they were included such as the mode of onset
(b) Report category boundaries
when continuous variables
were categorized
(c) If relevant, consider
translating estimates of
relative risk into absolute risk
for a meaningful time period
(17) Other analyses Report other analyses done (eg, SIIS 17.1: Report injury diagnosis SIIS 17.1: “Defining and classifying
analyses of subgroups and information, including region and health problems”
interactions and sensitivity tissue type in tabular form
analyses)
Discussion
(18) Key results Summarize key results with
reference to study objectives
(19) Limitations Discuss the limitations of the SIIS 19.1: Discuss limitations in the SIIS 19.1: “Data collection methods”
study, taking into account the data collection and coding and “Expressing risk”
sources of potential bias or procedures adopted, including in
imprecision. Discuss both the relation to any risk measures
direction and magnitude of calculated
any potential bias
(20) Interpretation Give a cautious overall
interpretation of results,
considering objectives,
limitations, multiplicity of
analyses, results from similar
studies, and other relevant
evidence
(21) Generalizability Discuss the generalizability SIIS 21.1: Discuss the SIIS 21.2: “Relationship to sports
(external validity) of the study generalizability of the athlete activity” and “Study population
results study population, and health characteristics”
problem subgroups of interest, to
broader athlete groups
Other information
(22) Funding Give the source of funding and
the role of the funders for the
present study and, if
applicable, for the original
study on which the present
article is based
(23) Ethics SIIS 23.1: Outline how individual SIIS 23.1: “Research ethics and data
athlete data privacy and security”
confidentiality considerations
were addressed, in line with the
Declaration of Helsinki
a
The STROBE-SIIS checklist with additional sports epidemiology annotations should be used in conjunction with the original STROBE
statement (freely available on the websites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at http://www.an-
nals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE initiative is available at www.strobe-statement.org.
The term “health problem” is used to encompass both injury and illness. Where there is a blank cell, there are no specific additional reporting
requirements for sports injury and illness surveillance over what is already covered in the original STROBE checklist.
b
Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort
and cross-sectional studies.

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Consensus Statement

International Olympic Committee

injury, the primary mode involves the transfer of kinetic

Relationship to Sports Activity

Health problems may result:

Defining Injury and Illness Mode of Onset

based on, means such important nuances may be missed. TABLE 1

Subsequent injuries to the same location and tissue as

TABLE 4 Recommendations: Reporting

Tissue/Pathology Type OSIICS SMDCS Note

Incidence, Injuries/ Time Loss, Burden, Time-Loss Days/

Head 277 12.9 (11.5-14.5) 9 (8-10) 325 (317-333)

of return to play at the time of the end of the event, we

System/Region Symptom Cluster

TABLE 10 This does not include injuries resulting in transient

Figure 4. Example of severity scores being used to track the

Understanding events that both do5 and do not result in

were grouped. The research problem being addressed

DATA COLLECTION METHODS

TABLE 11 athletes, 76,77,81 there are also reports of poor athlete

REPORTING GUIDELINES: STROBE SPORTS AUTHORS

Case Study: Tackle Injuries to TABLE A1

Data Set Injuries Requiring Player to Be

Statistic Value Calculation Explanation Comment

Statistic Value Calculation Explanation Comment

Statistic Value Calculation Explanation Comment

Daily Medical Report on Injuries and Illnesses

Country: Date of report:

Form completed by: Name: Contact details:

1. Injury – Example Definitions and codes (see reverse)

2. Illness – Example Definitions and codes (see reverse)

Definitions and codes

Injured body region

For illnesses (defined as a complaint or disorder not related to injury)

For injuries and illnesses

New, recurrent or exacerbation

Time-loss in sport due to injury or illness

Medical Report of Injury or Illness Date of report: __________

Team: ____________ Athlete identification: ___________ Date of onset: __________

For injury and illness

Time-loss in sport due to injury / illness

Date of full return to normal training and competition ______________ (dd/mm/yy)

Strobe-SIIS (Sports Injury and Illness Surveillance) Statement 1.0

Source of Rationale for Item From

(1) Title and abstract (a) Indicate the study’s design

Source of Rationale for Item From

Source of Rationale for Item From

Source of Rationale for Item From

Source of Rationale for Item From

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Team: ______ Athlete identification: _ Date of onset: ______