Is high performance sport healthy?
Rates of injury and illness in high performance athletes
Alan Couzens, M.Sc. (Sports Science)
May 23rd, 2017
“A ship is safe in harbor but that’s not what ships are for”-William G.T. Shedd
It has been an interesting week. Stu McMillan threw the proverbial cat among the pigeons with this tweet…
Elite sport is not healthy - hopefully, this is not controversial— Stuart McMillan (@StuartMcMillan1) May 16, 2017
What we do pre- & post-career perhaps requires further discussion though pic.twitter.com/bokxQqQPMQ
A tweet like this carries a little more weight when it comes from somebody who spends the bulk of their lives in this elite sport that they’re deeming unhealthy!
And I wasn’t the only one whose mental gearbox was pushed up a gear. Brad Stulberg convened a virtual round table to offer thoughts for a coming Outside magazine piece (which I’m predictably super excited to read given the quality of thoughts that came out of the discussion!). It was a lively discussion & I won’t spoil the surprise here but I did want to expand a little on my own thoughts on the subject.
Maybe surprisingly, one of the toughest things to come out of the discussion was pinning down an appropriate definition for health. Is it longevity? If so, high performance athletes seem to fare pretty well here. Lemez and Baker (2015) did a huge meta-analysis of research to date on the topic and came to the conclusion that elite athletes live as long, and often longer than the Norm, especially in the case of endurance sports (even with the obvious risk of things like careening down a mountain on 2 wheels at 100km/h!). Sanchis-Gomar et al. (2011) in a study of 30+ years worth of Tour De France Cyclists found an increased life expectancy of 8 years when compared to controls!
However, surely longevity only tells a part of the story. If an athlete trashes their joints during their ‘golden training years’ and lives a long while but in constant pain do we consider them healthy? If an athlete lacks the energy to enjoy greater life & is ultimately forced to retire from the sport they love due to chronic fatigue that lasts multiple years, are they healthy? I would argue not & I would argue that there is a lot more to the question of health than longevity....
(Click to tweet)
And so, with my head spinning on the impact of high level athletic training on these key health & quality of life indicators, there is only one thing to do: Crank up the Python shell and start crunching some data! :-) Fortunately, due to my life long obsession with endurance sports, I have a lot of it!
So, the questions running through my head…
* Are high performance athletes more ‘sickly’ than recreational athletes?
* Do high performance athletes spend more of their time injured/compromised than recreational athletes?
My gut would say yes to both, but my gut is sometimes not trustworthy, so we turn to the data…
The mean annual training volume of my entire data set of 94 athletes to date is 576hrs with a standard deviation of 240hrs. Let’s chop off those athletes training at very high levels – greater than 816hrs per year/avg training volume greater than 16hrs/wk (1 SD above the mean) and those athletes training at low levels – less than 336hrs per year/avg training volume less than 7hrs per week. (1 standard deviation below the mean) and see how they compare for frequency of illness and injury.
While 'high performance' is certainly a subjective term, looking at who comprises the high load sample, we have professional triathletes, podium age-groupers, multiple kona qualifiers & 2 Ultraman World Champions, certainly athletes traning at a very high level.
And the recreational group is made up of (often uber-busy) working athletes who often have demanding jobs and use triathlon as a recreational outlet. So let's look at how they compare on a few markers of health...
In a previous post on injury prediction in athletes, I looked at what some machine learning algorithms had to say about the factors that are most predictive of injury. Load was at the top of the list, so it’s little surprise to see that the incidence of injury in the ‘high performance’ sample is significant higher than the ‘recreational’ sample.
This includes all types of injury that affect the training – crashes, overuse injuries etc. Still, it’s a sobering stat. High performance athletes can expect to spend a month a year with an injury that affects the training. Of course, this may not be a month every year, it may be & often is something a little more significant every couple of years – 6 weeks recovering from a bike wreck or a nagging ITB issue or Achilles issue that hangs around longer than it should etc.
Since writing that piece, I’ve further divided injuries along a scale of severity as ‘niggles’ – points of tenderness/irritation that are notable but don’t impact the training vs injuries – maladies that cause us to decrease either the volume or intensity. ‘Niggles’ unsurprisingly occur more frequently (a very good sign as it means, at least some of the time we head them off to the point that they don’t progress to the point of affecting the training).
Particularly at high load, niggles are even more common that injuries, almost twice as frequent. For high load athletes in my sample, for about 1 day in 5, they're starting their warm up with a little specific tightness or point tenderness. However, by definition, it disappears after warm up and doesn't negatively affect the training. It is a warning sign to be heeded during mobility and trigger point work (& potentially during technique work). To me, these warning signs are welcome & the athlete actually noticing them frequently is all the more welcome! The higher I can get my niggle:injury ratio, the happier I’ll be :-) That said, the incidence of these warning signs in high load athletes is a good reminder of the importance of soft tissue health. It is no coincidence that physical therapists & massage therapists are becoming integral to high performance programs. For those high load athletes with less access to these resources due to budgetary constraints, web resources like MobilityWod.com offer incredible value!
Maybe a little surprisingly, and not necessarily in line with the research, the incidence of upper respiratory infections among the high and low load athletes is similar in my sample….
This is somewhat contrary to research in the field e.g. Spence et al., (2007), Nieman (1994) Peters & Bateman (1983) which tend to show significantly greater incidence of URI in elite athletes vs the general pop (by a factor of 2-4). However, these studies tended to focus on the high load competitive and post competitive period (following Marathons, Ultras etc). Perhaps, over the course of a full training year, the immune protective response of more moderate training in the base phase balances out the risk as the above data might suggest? Either way, there is obviously no negative impact in my sample of high load training & in fact, the high load group had slightly less days marked as 'head cold' than the lower volume group. Perhaps this indicates that there are other more important stressors/exposures at play in the lower volume group. the The incidence of more serious (training affecting) systemic bugs (fever, flu etc) is less frequent but similarly patterned…
While it is fairly clear from the data that athletes training at the highest levels risk more frequent occurrence of injury, there are other factors that come into play that can significantly increase or decrease this risk.
The first and most important of these is life stress..
Life stress ratings are a very strong predictor of illness and injury. As the above data shows, the 'high stress' group (athletes with average life stress ratings higher than 4 out of 5) had more than 7x higher incidence of injury over the course of the year than those low stress athletes (whose average rating was at or below 2_ -- 60 days injured vs 8 days injured!
Also interesting is the relationship between stress and frequency of upper respiratory infections. While there was little relationship observed between training volume and U.R.I. risk (in fact, a slightly negative one), the relationship between life stress and incidence of U.R.I. is positive, with high stress athletes reporting twice as many days with an upper respiratory infection as the low stress athletes.
Of course, both these relationships are correlative. Stress may be the result of dealing with long term injury or illness rather than the cause. But, having a little more 'inside knowledge' & knowing some more details on the life situations of some of these athletes & given the magnitude of the effect, these relationships are still worthy of a mental note & maybe even spending a few minutes extra today meditating or taking a walk in nature in my opinion :-)
The practical flipside of this is that during times of high training load, athletes should, in order to minimize risk of injury & illness, actively seek to manage/minimize life stress or, maybe even more practically, should try to plan the highest training loads away from the most stressful times of year.
This is especially relevant to high performance sport because competition is in and of itself a major stressor! For a recreational athlete, competitions are often fun, a celebration of the training. For elite athletes, they are more often filled with pressure to perform, pressure to 'earn points' to qualify for ‘the big meets’, pressure to validate their hard work and that of their team. For professional athletes, esp those in the lower $ sports, these pressures can extend to more simple matters like making enough $ to pay the mortgage, buy groceries and stay on the path of the vocation that they love! These are no small matters and they need to be seriously considered in planning the frequency of competition & the overall ‘stress periodization’ of the training year & the athletic life as a whole.
Additionally, this relationship between stress and injury risk speaks to the danger of "high pressure" programs in elite sport. I have certainly seen the dark side of high performance sport in programs obsessed with winning to the exclusion of all else. Squads where athletes were constantly on edge & at risk of public shaming or expulsion from the program at the first sign of 'weakness'. While the training load is often blamed for the injury rates of these programs, I'd suggest it's only a part & that often the pure stress of the environment is at least equally culpable. Some might think that high performance and high pressure are synonymous. I disagree. Though rare (& less financially profitable), there are high performance programs that focus on athlete support & focus on the long term development process. These are the most globally successful programs over the long term. It's the 'Cobra-Kai' vs 'Miyagi' approaches to (healthy) athlete development and we all know that Miyagi always wins in the end :-)
Of course, even with the purest motives and the best of intentions, the occurence of some life stressors is not always predictable (or convenient wrt the training plan!). However, given what we know about the risk of high load coupled with high stress, in the case of a major stressor ‘cropping up’, athletes and coaches should seriously consider balancing out total stress by bringing down the level of training stress at that time to minimize the overall risk of illness or injury. I’ve discussed previously how we can do this more ‘real time’ by using a simple readiness questionnaire coupled with some basic machine learning algorithms implemented with just a few lines of Python code. to keep a ‘real time’ eye on the probability of illness/injury on a day to day basis for a given athlete. I will be continuing to develop and implement these models in my coaching practice.
Interestingly, the 'goal posts' have moved a bit over the course of the discussion as we've sought to better define what our standard of 'being healthy' is. Stuart posted this as a follow up...
Fit & Unhealthy— Stuart McMillan (@StuartMcMillan1) May 17, 2017
It's not that elite sport participation is less healthy than typical gen pop - it's what can we do to make it 'healthier'? pic.twitter.com/Z2ke53qR0G
Our standard now is: "If the objective of the person was a more balanced health than what we see through the typical athlete (or human's) career progression." In other words, is elite sport optimally healthy? If you wanted to achieve your full health potential, to become one of the healthiest humans on the planet, would you sign up for ~30hrs of hard training each week & the bulk of the year spent internationally travelling from uber competitive race to uber competitive race, where your very income depends on your day to day form along with the day to day form of athletes that you have no control over? Probably not :-) Certainly doesn't sound like the lowest stress environment to me. But...
Is pure 'balanced' health (maybe the type of health sought by the Yogis who remove themself from the world to live in an Ashram?) the objective? This may or may not be a worthy goal depending on your philosophical views of why we're put on this Earth. But, if you are of the mindset that you were put on this Earth to "do something", the pursuit of doing that something, whatever it is, will, by its very nature, result in some imbalance & cause some 'wear and tear'. The trick is not to become so 'out of whack', to let your tool become so blunt with work and stress, that it ultimately limits your ability to do that thing. This is true whether your 'thing' is elite sport or building the next world changing widget empire!
In summary, while longevity and immune health may not take a significant hit with long term high level training (and may even be positively affected, especially if undertaken in an environment that recognizes the impact of & actively seeks to manage non-training stress), the data would suggest that folks who *use* their bodies at a higher level are more prone to injury than those who don’t. No great surprise really, you could say the same thing about a car that is housed in the garage vs one that does 100,000 miles a year, the high volume car is going to need a lot more ‘maintenance’ to keep it in working order. That said, a more philosophical qu might be – what kind of existence is sitting in a garage, ever so gradually fading away? Aren’t we supposed to be ‘out there’ on the proverbial highways of life laying down some mileage, exploring this world while we’re here on it? Or, in the wise words of the opening quote – a ship is safe in harbor but that’s not what ships are for.
Perhaps the take home message is that, as athletes who are committed to moving through this world as strong as we can and as long as we can, we have an even greater responsibility to be mindful of and take good care of these wonderful vehicles that we’ve been given
Live BIG, smart & healthy
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