From Strain to Gain: Emerging Trends in Sports Injury and Prevention

Opening up about mental health

When cruel headlines and mobs of fans taunted David Beckham after the infamous 1998 World Cup red card, the emotional abuse he received had a lasting impact on the then 23-year-old's state of mind. The football superstar's eponymous Netflix docu-series, released in 2023, shines a light on how the backlash affected his mental health. In it, Beckham confesses, "I wasn't eating, I wasn't sleeping. I was a mess."

With victories and setbacks intertwining, it's crucial for sporting clubs and associations to exercise a duty of care to young players to protect them both mentally and physically. "I watched the Beckham series, and you could just see on his face how affected he was, even now," observes Steve van Leeuwen, National Head of Sport, Gallagher Australia. "There is a lot more awareness today, but player welfare and mental fatigue remain one of our greatest risks."

Back in the 1990s, less attention was paid to the mental health of athletes, and the field of sports psychology was still in its infancy.² Since then, the sector has come to better appreciate the importance of a player's emotional state in helping or hindering their form on and off the pitch. There's a recognition that clubs have an important duty of care to their players' wellbeing, particularly those starting out in their careers.

"When you look at some of the players who are signed at a young age to play at elite levels of football or rugby, there can be a lot of isolation, particularly if they're moving overseas and there are language barriers. And I've seen massive bouts of homesickness," says van Leeuwen.

"Our workplace team conducts workshops with development officers where they communicate with young players aged 15 to 16 years playing at an elite level. In sports, particularly in football, these young players would often be signed to play outside their home country."

Building mental health literacy and improving understanding of the indications of poor mental health among competitors and athletes are focuses at the highest levels of sport. England Rugby announced in November that captain Owen Farrell would be taking an indefinite break from international games to prioritize his mental health.

"Everyone at England Rugby is fully behind Owen's decision," said Head Coach Steve Borthwick.

"The demands on elite athletes are extremely challenging...It's with typical courage that Owen has made this decision to open up in this manner. Together with all of us at England Rugby, I will do everything I can to ensure that he has the support he requires going forward." ³

Other examples include the decision by gymnast Simone Biles to withdraw from the 2021 Tokyo Games to focus on her mental health.⁴ Swimmer Michael Phelps spoke openly about his battle with depression, and tennis champions Naomi Osaka⁵ and Emma Raducanu⁶ withdrew from the French Open and Wimbledon respectively in 2021 due to performance anxiety and poor mental health.

In July 2023, the International Olympic Committee (IOC) released a Mental Health Action Plan. The intention, it explains, is to integrate expert-led support for athletes' wellbeing across multiple IOC programs, working on complementary topics such as gender equality and safeguarding. "Good mental health means much more than the absence of a mental health symptom or disorder," it notes.

Spotlight on women's sports

At present, the frequency of sports injury within women's sports is higher than in men's sports. Research suggests that female athletes are more likely to sustain a concussion, tend to have more severe symptoms and take longer to recover.⁷ Moreover, looser knee ligaments increase the risk of anterior cruciate ligament (ACL) injuries in female football players.⁸

As more women are now taking up contact sports like rugby and soccer, the injury risk is growing. Girls often start their sporting career later in their teenage years than boys, who usually begin playing at a much younger age. To a large degree, this age difference is because women's professional leagues are a relatively new phenomenon.

In the US, for instance, the value of women's professional soccer franchises has increased more than tenfold in recent years.⁹ Sports England figures from November 2022 highlight that the number of women playing rugby has grown from 25,000 to 40,000 over the last five years.¹⁰ Over one third — 2.7 million — of global rugby participants are females.

From equal pay agreements to amazing comeback stories, record audiences and new media deals, women's sports are in the spotlight more than ever. Better yet, that growth no longer depends on quadrennial events, such as the Olympics or FIFA World Cup (with nearly two billion fans watching this year's event in Australia and New Zealand).¹¹

As women's sports continue to take significant strides, injury prevention is all in the science. "A lot of the players in elite women's football teams come from different sporting backgrounds, such as beach sprinting," says van Leeuwen. "It's fantastic the progression they have made, and it shows that if you can tailor the training, you can improve strength and skill and reduce the risk of injury."

Studies show that women who participate a lot in sports at school are three times more likely to be very interested in sports throughout their life. They suggest that young athletes who have good nutrition and participate in different sports — making use of different muscle groups — are likely to build bone and muscle density, protecting them against injuries longer term.

Other important factors for both genders include the using protective equipment such as helmets and shin guards, warming up before exercise and resting adequately between games.

Data, analytics and sports injury prevention

A growing number of professional leagues are using wearable technology and sensor-enabled real-time data input during training sessions to allow for quick coaching modifications, further enhancing performance and reducing mistakes.

In soccer, for example, a group of researchers predicted injuries by fitting a sensor package into the clothing of 26 soccer players on an Italian team. By relying on a category of machine learning models called decision trees, the researchers were able to predict 80% of potential injuries.¹²

In the US, the NFL discovered the importance of "load management" among players through data-based prediction analysis. They limited how many minutes of practice players could have in their first four days of training after a long break. As a result, the NFL reports a 26% year-over-year decrease in injuries during the first two weeks of a new season.¹³

Recognizing rugby as one of the top sports for injuries — with an estimate of 100 injuries per 1,000 hours played — the 2023 Rugby World Cup implemented increased rest periods for all teams. This rule capitalized on the "hugely encouraging" player welfare results after the 2019 World Cup in Japan.

In a bid to prevent serious concussion injuries, World Rugby is moving to adopt smart mouth guard technology. It measures the G-force of every head impact in real time to help make the game safer by ensuring serious head impacts are treated accordingly.¹⁴

Dealing with climate extremes

Climate has a huge impact on sports. Record temperatures in different parts of the world during 2023 showed the impact of heat stress on athletes. During the US Open in September, tennis player Daniil Medvedev warned that a player could "die" due to sweltering conditions and temperatures around 35C (95F) in New York. After the match, he compared the "brutal" heat to conditions he had experienced during the Tokyo Olympics in 2021.¹⁵

Medvedev and his opponent Andrey Rublev were given a 10-minute break between the second and third sets, during which they took cold showers, sat under ice towels and savored the air conditioning units at their seats.

The 2022 Football World Cup in Qatar demonstrated some innovations in handling extreme heat, with air-conditioned stadiums among the offerings. Some professional leagues are trying to mitigate heat stress by scheduling games in the early morning or evening, and encouraging players to spend time acclimatizing to heat ahead of major championships taking place in hot climates.

"A lot of players are used to playing night football, so then when they do play in the afternoon — to satisfy broadcasting because of different time zones, for instance — they need to have rest breaks because of the hot, humid conditions," says van Leeuwen. "You've got to be careful that you avoid dehydration by ensuring adequate drink breaks and taking other measures to keep the players cool."

"The professional football league has just kicked off here in Australia, and players play during the summer — through Christmas and into January — so they will often be playing in conditions upwards of 35C."

The 2023 National Rugby League (NRL) Grand Final was played in Sydney on a day when temperatures reached 36C (97F). With an evening kick off at 7pm, the temperature dropped to 30C (86, but it was still a factor in the match. The NRL matches in Las Vegas in March 2024 are in Las Vegas, another host city where temperature extremes could prove challenging. "Teams are going over there now on scouting missions to find training venues where the players can get accustomed to the climate," explains van Leeuwen.

Smoke, smog and pollution

Pollution can also be a health and safety issue for players. During the 2020 Australian Open, for instance, wildfires caused poor air quality that forced some tennis players to withdraw from the tournament.

More recently, smoke particles from wildfires that raged across Quebec in 2023¹⁶ impacted sporting events across Canada and the US.¹⁷ Major League Baseball (MLB), the Women's National Basketball Association (WNBA) and National Women's Soccer League (NWSL) were forced to reschedule games due to poor air quality in early June.

Pollution has also been an issue during Olympic Games. It's understood the Chinese government spent $10 billion ahead of the 2008 Beijing Olympics, taking half the city's cars off the road each day and shutting down production at chemical and cement factories in an effort to reduce the city's smog levels. During the 2022 Winter Games, the government again took major steps to improve air quality across the Beijing-Tianjin-Hebei region, but emissions fell short of World Health Organization (WHO) recommendations.¹⁸

Athletes taking part in the Winter Olympics faced another challenge. A lack of snow meant the city had to rely almost entirely on fake snow. One study warns that half of the former Winter Olympic host cities could be unable to sponsor winter games by 2050, due to a lack of snow and ice.¹⁹

In climates prone to weather extremes — such a heavy rainfall or drought — sports are increasingly turning to artificial turf to maintain surface durability. However, injuries associated with playing on synthetic surfaces need to be carefully managed, stresses van Leeuwen. "We had a rugby team that stopped off for a game in the US on a trip home from playing in the UK. Out of that game there were three season-ending ACL injuries."

He adds, "Some of the synthetic surfaces I've seen are fantastic, and I've been lucky enough to walk on Old Trafford [the home of Manchester United]. But we don't have that here in Australia, where most teams are used to playing on turf. It's just a different set of conditions, and if you're not prepped for that, it can result in injury."

How are sports associations mitigating injury risk?

Sports associations are taking many steps to reduce the risk of injury for athletes, some of which include:

• Safety equipment. Proper sports gear improves player performance and safety, from customized balls to individualized body protection.
• Injury assessments. Knowledge of concussion protocol and an emergency action plan are essential in contact sports. The NRL, for example, has tailored the game to include head injury assessments (HIA) for each player, so they can make necessary adjustments for player safety.
• Access to medical professionals. Top-notch support staff is necessary for keeping athletes safe and healthy, including medical personnel, physiotherapists, dietitians and trained psychologists.
• On-site automated external defibrillators. When used within two minutes of a sudden cardiac arrest, an AED can save lives. AEDs must be located strategically during sporting events to allow for a quick response.

Within sports at every level, injuries can be debilitating for the individual and a considerable cost and potential reputational issue for other stakeholders. The best outcome is no injury, which is why there continues to be substantial investments in risk mitigation.

Even with best practice health and safety approaches, tragic accidents and injuries do occur. Insurance is there to provide financial relief for clubs and players when the worst happens, with rehabilitation and support the main priority.