Exercise and The Risk of Injury

Dr. Lon Kilgore, tenured exercise science professor of Kansas State University, is one of my favorite and most-read authors in the health and wellness industry. I came across one of his pieces this weekend regarding injury and couldn’t agree anymore with it.

 

A concern I hear from many in regards to starting back up exercise relates to injury. I don’t think I can give a better response to this concern than Dr. Kilgore’s. Below is an attachment of  his 2018 publication:

 

Sleep Banned After Mattress Injuries Cause Panic

 

It’s fascinating to read social media, blogs, popular news sites, and the marketing materials within the medical, allied health, and fitness industries when it comes to promoting and criticizing various exercises and exercise systems.

 

How many articles out there are titled something akin to “7 Exercises to Never Do”? How many headlines have you seen arguing against the use of squats, deadlifts or the Olympic lifts? How many have you seen decrying even the consideration of doing CrossFit?

 

Why do so many varied professional groups and individuals try to convince so many members of the general public that exercise—especially progressive, high-intensity exercise—is dangerous and injurious? Given the empirical and scientific evidence that supports the benefits of exercise of all kinds, it almost seems as though many “experts” are playing a high-stakes game of “would you rather?”—with fitness and its correlate health counterpoised against the possibility of training injury.

 

In reality, no one has ever suggested that exercise and the pursuit of fitness is absent risk. Sport and exercise can kill you.

 

Approximately 563 people die during scuba dives each year. That sounds like a lot, but with over 300 million logged dives each year, it is relatively safe (2). A total of 331 of 30,141 climbers died at elevations over 6,000 meters in Nepal’s Himalayas during a 16-year period (17). As much as safety is attended to within these endeavors, these activities take place in hostile environments, and deaths are not unexpected. After all, the north face of the Eiger in the Alps has earned the nickname “Mordwand” or “murder wall.”

 

But what about death rates in more “normal” environments?

 

Even though deaths in the gym or on the sports field do occur, they are uncommon in comparison to deaths in other everyday environments. Consider that the U.S. Department of Transportation reported 37,461 automobile deaths in 2016. Consider also that about 146,571 accidental deaths occurred in the home during 2015. Finally, consider that there were 3,326 deaths from sports, exercise and equipment in 2000. Of course, more people drive and live in homes than exercise, but it’s clear exercise-related deaths are relatively rare.

 

But what if we consider the big picture of training and simple injury? We know that injuries happen, and we are told that lots of them happen in the gym. For alarmists, any injury is catastrophic, and some even consider simple muscle soreness an injury, but for the most part the rest of us consider injuries an acceptable and inevitable risk balanced by great fitness and health rewards. We do what we can to avoid injuries as trainers and as trainees, but they do happen.

 

Isn’t a bout of sore muscles, a strain, a sprain or another minor and transient nuisance far preferable to a lifetime of chronic disease and premature physical decay and debilitation?

 

I suppose I can play “would you rather?” too.

 

All the padding in the world won’t prevent sports injuries—and yet sport has great value. 

 

A Short History of Exercise

 

Exercise science is a relative neophyte discipline, and if we consider the more extensive empirical and historical accounts, we see that exercise was promoted for functional purposes and for its corollary benefits as early as about 200 B.C. in “The Yellow Emperor’s Classic of Internal Medicine” (“Huangdi Neijing”). Favorable sentiment survived in many cultures throughout history. Socrates summed up these beliefs and observations in an oft-quoted passage:

 

“The results of physical fitness are the direct opposites of those that follow from unfitness. The fit are healthy and strong, and many as a consequence save themselves decorously on the battle-field and escape all dangers of war; many help friends and do good to their country and for this they earn gratitude, glory and honor that leads to a better life and provide their children a better means of achieving a livelihood.”

 

Despite the widespread belief of innate benefits for those who exercise, exercise has often been considered harmful in relative modernity. Exercise and physical exertion was noted to increase the severity and lethality of polio in the epidemics that ravaged U.S. cities from its first appearance in 1894 through the 1940s (6). Even the hallowed work of Hans Selye, the originator of general adaptation syndrome (13), considered, in that first paper, exercise a “nocuous” agent—but adaptation to exercise was stated to be beneficial.

 

Again, exercise has long been considered a healthy endeavor, but it has rarely been portrayed or suggested to be without risk.

 

Injury rates have been considered in academic writings for a long time. The earliest accounts of this generally addressed injury rates in sports such as javelin, baseball and football (1,10,16). Since those early publications, injury rates in many sports and exercise activities have been quantified, sometimes from large and robust sources, sometimes from small and non-specific resources.

 

Table 1: Injury rates in various sports as documented in various studies.

 

Sport/ExerciseInjuries Reported——People Studied——% Injured
Track & field event (11)436 48473 0.9
Paralympic sport (3)510 3567 14.3
Youth lacrosse (9)300 1498 20
Running (12)16 47 34
Major tennis event (5)350 998 35.1
Youth sports (15)247 647 38.2
Elite bodybuilding (14)43 71 60.6
Running (7)148 228 64.9
Stand-up paddleboard (4)161 240 67.1
Triathlon (18)155 212 73.1
Break dancing (8)47 64 73.4

 

The above data is from just a small cross section of the many, many publications on the topic, and while it is tempting to suggest one exercise or sport type is safer or more dangerous, the research rarely calculates injury rates in the same manner nor reports data using the same—or even useful—quantitative units.

 

Given that injuries do occur in any sport or exercise, and given the frequent modern penchant for applying bubble wrap to everything, what happens if padding and pillows are actually more dangerous than exercise and exercise equipment? Data suggests just that (see Table 2 and Table 3 below).

 

Where does that leave us in terms of nerfing exercise and exercise equipment?

 

Table 2: Estimated number of injuries annually by leading source for U.S. males. Data from the National Electronic Injury Surveillance System (NEISS).

 

Source of InjuryNumber of Injuries
Stairs, ramps, landings, and floors1,156,350
Basketball393,540
Football350,212
Beds, mattresses, pillows348,390
Bicycles338,057
Exercise and exercise equipment315,405
Chairs, sofas, and sofa beds276,888
Cutlery and knives232,777
Ceilings, walls, and panels214,756
Bathtubs and showers198,018
Tables168,157
Ladders and stools165,680
ATV, mopeds, and mini-bikes157,598
Clothing150,500
Soccer150,199
Non-glass doors144,394
Desks, cabinets, shelves, and racks135,968
Baseball and softball134,277
Cans and other containers134,197
Playground equipment126,832

 

Table 3: Estimated number of injuries annually by leading source for U.S. females. Data from NEISS.

 

Source of InjuryNumber of Injuries
Stairs, ramps, landings, and floors1,891,199
Beds, mattresses, and pillows459,873
Chairs, sofas, and sofa beds341,274
Bathtubs and showers312,025
Exercise and exercise equipment262,258
Clothing225,951
Tables167,990
Ceilings, walls, and panels165,061
Non-glass doors164,927
Desks, cabinets, shelves, and racks164,277
Cutlery and knives154,346
Cans and other containers150,618
Bicycles130,824
Carpets and rugs125,320
Miscellaneous personal use items121,715
Playground equipment115,976
Miscellaneous sports113,271
Swimming, pools, and equipment103,287
Miscellaneous97,517
Basketball90,309

 

The NEISS statistics are incomplete, including only those injuries that are seen within the medical system and excluding incidents in which the injured individual self-treats or the injury is not significant enough to require any treatment. Another limitation: NEISS statistics are derived from only 96 hospital systems across the U.S. and are not comprehensive. As such, the injury data presented in the reports is calculated and extrapolated, not absolute.

 

Still, the data is informative and provides a broad conceptual representation of injury occurrence across a spectrum of normal endeavors.

 

Reclinin’ to the Danger Zone

 

In the face of the frequent and oft-published alarmism regarding the imminent dangers of exercise, it is curious that your sleepy-time mattress poses a larger absolute risk of injury than exercise and exercise equipment—according to NEISS data.

 

That epiphany will surprise most. Sticklers will say that exposure time makes the gym more dangerous, as we sleep about eight hours per night and are in the gym less than eight hours per week, or that we have seven exposures to the bed and three or fewer exposures to the gym each week. But even when calculations produce injuries per hours of exposure, injuries per exposure or any other metric, being relatively immobile and inactive in bed still produces injuries—many of them. In our perceived least dangerous circumstance, sleep, we cannot completely avoid risk. It’s naïve to think that the gym or any system of exercise we use to produce fitness and health can ever be without risk.

 

Research and calculations will continually be produced on all sides of the discussion on exercise and injury. Researchers will supply data on injuries and individuals, and corporations will use that data to demonstrate the superiority of one sport, exercise or exercise system over the other, whether the broader data supports their opinions or not. A single case is frequently used as “proof” of a point of view in the media. If we want to use but a single paper’s data, there is one study of interest from the tables above—the one on youth sports (15).

 

In the researcher’s analysis, it was determined that the relative frequency of self-reported injury was 10.8 injuries per 1,000 hours of recreational sport participation, 12.6 for school sport (physical education) and—very interestingly—21.9 for sedentary youth. While the data is self-reported and therefore squishy, it does seem to suggest that being a couch potato can be riskier, in terms of injury, than participation in sports and exercise. The data seems to say that if you want to be at higher risk of injury, just stay at the house, don’t train and don’t play sports.

 

So how do we proceed with training ourselves or others?

 

First, we acknowledge that injuries will likely occur and that all aspects of our lives present risk of injury—not just the gym. Second, we inform trainees of the possibility that they might be injured when they exercise, with you in your gym or elsewhere. Third, we provide all due care by creating an exercise environment that is as safe as possible without removing the possibility of adequate and effective training stimuli. And finally, we set up a plan of action to follow in the event of an injury, one that allows recognition, action and referral as appropriate for the circumstances.

 

It is important to acknowledge that exercise—every single variation—poses some risk of injury, but it is equally as important to acknowledge that training, especially under the tutelage of a trainer or coach, reduces risk of injury in the gym and elsewhere in life. As those physicians who recently completed CrossFit’s Level 1 Certificate Course would agree, very minor orthopedic risks from exercise are far preferable to the mountain of pathologies and functional issues that accompany a sedentary life.

 

References

  1. Bennett GE. Shoulder and elbow lesions distinctive of baseball players. Annals of Surgery 126(1): 107-10, 1947.
  2. Buzzacott P et al. Epidemiology of morbidity and mortality in U.S. and Canadian recreational scuba diving. Public Health 155: 62-68, 2018.
  3. Derman W et al. High precompetition injury rate dominates the injury profile at the Rio 2016 Summer Paralympic Games: A prospective cohort study of 51198 athlete days. British Journal of Sports Medicine 52(1): 24-31, 2018.
  4. Furness J et al. Epidemiology of injuries in stand-up paddle boarding. Orthopaedic Journal of Sports Medicine 5(6): 2017.
  5. Gescheit DT et al. Injury epidemiology of tennis players at the 2011-2016 Australian Open Grand Slam. British Journal of Sports Medicine 51(17): 1289-1294, 2017.
  6. Hargreaves ER. Poliomyelitis; effect of exertion during the pre-paralytic stage. British Medical Journal 2(4588): 1021-1022, 1948.
  7. Hespanhol LC, van Mechelen W, Verhagen E. Health and Economic Burden of Running-Related Injuries in Dutch Trailrunners: A Prospective Cohort Study. Sports Medicine 47(2): 367–377, 2017.
  8. Joka T et al. Etiology of musculoskeletal injuries in amateur breakdancers. Journal of Sports Medicine and Physical Fitness 55(10): 1174-83, 2015.
  9. Kerr ZY et al. Epidemiology of youth boys’ and girls’ lacrosse injuries in the 2015 to 2016 seasons. Medicine and Science in Sports and Exercise 50(2): 284-291, 2018.
  10. McPhee HR. Football injuries; a ten-year review of football injuries at Princeton University. Lancet 67(7): 267, 1947.
  11. Opar D et al. Acute injuries in track and field athletes: A 3-year observational study at the Penn Relays Carnival with epidemiology and medical coverage implications. American Journal of Sports Medicine 43(4): 816-22, 2015.
  12. Ostermann K, Ridpath L, Hanna JB. Self-reported minimalist running injury incidence and severity: A pilot study. Journal of the American Osteopathic Association 116(8): 512-20, 2016.
  13. Selye H. A syndrome produced by diverse nocuous agents. Nature 138: 32, 1936.
  14. Siewe J et al. Injuries and overuse syndromes in competitive and elite bodybuilding. International Journal of Sports Medicine 35(11): 943-948, 2014.
  15. Silva CE, Fragoso MI, Teles J. Physical activity-related injury profile in children and adolescents according to their age, maturation and level of sports participation. Sports Health 9(2): 118-125, 2017.
  16. Waris W. Elbow injuries of javelin-throwers. Acta Chirurgica Scandinavica 93(6): 563-75, 1946.
  17. Windsor JS et al. Mountain mortality: A review of deaths that occur during recreational activities in the mountains. Postgraduate Medical Journal 85: 316–321, 2009.
  18. Zwingenberger S et al. An epidemiological investigation of training and injury patterns in triathletes. Journal of Sports Science 32(6): 583-90, 2014.
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