Sports injuries: population based representative data on
incidence, diagnosis, sequelae, and high risk groups
S Schneider, B Seither, S To¨nges, H Schmitt
See end of article for
Dr Schneider, Department
of Orthopaedic Surgery,
University of Heidelberg,
Br J Sports Med 2006;40:334–339. doi: 10.1136/bjsm.2005.022889
Objective: To generate national representative data on the incidence, diagnosis, severity, and nature of
medically treated sports injuries and to identify high risk groups.
Methods: The first national health survey for the Federal Republic of Germany, conducted in the format of
a standardised, written, cross sectional survey in the period October 1997 to March 1999, gathered data
on the incidence of accident and injury and information on social demographics, injury related disability/
time off work, and injury location/setting. The net sample comprised 7124 people aged 18–79.
Results: 3.1% of adult Germans said they sustained a sports injury during the previous year,
corresponding to an annual injury rate of 5.6% among those engaging in regular recreational physical
activity and ranking sports injuries as the second most common type of accident. About 62% of all sports
injuries result in time taken off work. The period of occupational disability is 14 days or less in around two
thirds of these cases. The occupational disability rate after occupational and traffic accidents is much
higher by comparison. Dislocations, distortions, and/or torn ligaments make up 60% of all sports injuries,
followed by fractures (18%), contusions, surface wounds, or open wounds (12%). Three out of four sports
injury casualties are male. The incidence declines noticeably in higher age groups.
Conclusions: Future injury prevention measures should focus on the high risk group of young male
recreational athletes. The data indicate that the fear of damage to health and injury, believed to be
significant internal psychological barriers to participation in sports, is largely unwarranted for the female
population and/or older age groups. Sporting injuries are a marginal phenomenon among the female
population and mobile seniors actively engaged in sports.
he positive effects of regular recreational physical activity
are uncontested: it can help to prevent numerous
and to lower health related risk factors such
as obesity and hypertension.
Most clinical trials and
epidemiology studies show a dose-response relation between
recreational physical activity and indicators of morbidity and
The positive psychological and social impact of
physical activity is an added benefit.
By the same token,
health economy based cost benefit studies from the United
States, Austria, and Switzerland show that inactive people
generate 30–50% higher direct cost of illness than physically
Sports injuries are a side effect of sporting activity. The
extent to which they undermine the preventive potential of
regular physical activity is largely unknown in Germany
because of a hitherto deficient epidemiological database. For
one thing, German Census Bureau data and Government
issued healthcare bulletins are too unspecific, containing, for
instance, no information on injury type, localisation, and
For another, the few alternative papers on this
topic are based on selective insurance company
data or subsume sports accidents along with other domestic
and recreational accidents.
The purpose of this study is therefore to generate
representative national sports injury incidence rates for
Germany. In addition to injury severity, type, and localisa-
tion, injury statistics for the total adult population are
projected. Incidence rates for separate sectors of the popula-
tion are also generated in order to identify high risk groups.
The importance of such information lies in the fact that
sports injuries are mostly avoidable and theoretically
controllable through the implementation of preventive
measures. In the light of the ongoing heated debate on
removal of certain sports injuries from the list of entities
covered by statutory health insurance benefits, our data may
help to objectify and provide a rational basis for healthcare
STUDY DESIGN AND METHODS
The first national health survey for the Federal Republic of
Germany is a representative epidemiological study of the
German speaking inhabitants of the country. This cross
sectional study was the first since reunification to generate
healthcare data and information on the incidence, nature,
localisation, and consequences of injuries and accidents for
the total post-reunification German population. The survey
was conducted by the Robert Koch Institute on behalf of the
Federal Ministry of Health in the period October 1997 to
March 1999 and comprises a total net sample of 7124 people
Not all survey respondents answered the
sports injury questions. Hence, the subsequent bivariate
analyses are based on a weighted total sample size of 6911
after exclusion of 213 incomplete datasets. The factor
weighting according to age, sex, community size, and federal
state used in the survey enables representative conclusions to
be drawn for the adult population in post-reunification
The national health survey data were provided to
our research group as a public use file as part of a cooperation
agreement with Robert Koch Institute, Berlin. The necessary
recoding and statistical/epidemiological analyses were per-
formed (on the basis of the raw data files) by the first and
second author. The national health survey also permits the
investigation of numerous other epidemiological and medical
issues, as documented on the Robert Koch Institute website
(www.rki.de) under the menu item ‘‘Forschung .
Publikationen’’ (‘‘Research . Publications’’).
During their time spent in the mobile investigational site,
study subjects were asked about the incidence of past injuries
using a standardised written questionnaire on the basis of the
question: ‘‘During the past 12 months, did you experience
any injury or poisoning requiring medical treatment?’’ The
response categories were: ‘‘No’’, ‘‘Yes, to be more precise:
During sports/games’’, ‘‘Yes, to be more precise: At home’’,
‘‘Yes, to be more precise: On the street’’, ‘‘Yes, to be more
precise: On the footpath’’, and ‘‘Yes, to be more precise: At
work/on the way to/from work’’; or ‘‘Yes, in another setting’’.
Information was also elicited on time off work/occupational
disability resulting from injury, and the duration of same
(including non-working days). Finally, the national health
survey also contains information on the diagnosis and site of
injury. To identify high risk groups, the extent of regular
recreational physical activity and demographic variables (sex
and age) are factored into our analyses. The sex of the subject
was dummy coded with 0 = male and 1 = female. The age
is expressed in whole years at the time of the interview and
was divided into 10 year age groups. Time spent exercising
was graded into five categories ‘‘no sporting activity’’, ‘‘less
than 1 hour per week’’, ‘‘regularly, 1–2 hours per week’’,
‘‘regularly, 2–4 hours per week’’ and ‘‘regularly, more than
4 hours per week’’ on the basis of responses to the question:
‘‘How often do you practise a sport?’’ A note explained that
the question related to average behaviour during the three
months before the survey.
In addition, all study subjects underwent a medical check
up involving measurement of blood pressure, a blood test,
urinalysis, and a simple physical examination to determine
basic anthropometric dimensions (height, waist to hip ratio,
etc). This check up was not performed by a doctor but by
trained study personnel. It did not involve differential
diagnostic procedures. Therefore the above information was
not included in our analyses.
Statistical analysis was started by determining the one year
incidence of sports injuries and the types of injury sustained.
Statistically speaking, this method calculated the risk of
injury, also known by the term ‘‘cumulative incidence rate’’.
The study subject, not the event causing the injury, was
defined as the unit of investigation in order to rule out
misinterpretations arising from the inclusion of multiply
injured individuals. Part two of the statistical analysis
investigated the severity of injury and cumulative incidence
rates for defined sectors of the population.
For metric variables, the arithmetic mean (SD) was
calculated. Group differences with regard to the investigated
factors were analysed by x
test. Age specific and sex specific
injury risk was identified by logistic regression analysis, with
the individual sporting activity held constant. All tests were
two tailed at a level of significance of p(0.05. All analyses
were performed using the statistics program SAS for
Windows, version 9.1.3 (SAS Institute Inc, Cary, North
Carolina, USA). The study was performed in accordance with
the ethical standards laid down in the 1964 Declaration of
Helsinki, and necessary approval was secured.
Injury incidence and influencing factors
A sporting injury was sustained by 3.1% of adult Germans
during the preceding year. Sports injuries thus represent the
second most common type of accident after domestic
accidents (3.7%) together with occupational accidents
(3.1%). Traffic accidents and pedestrian accidents are much
rarer, with respective incidence rates of 1.8% and 0.8%. For
the physically active population alone, the annual injury rate
About 62% of all sports injuries result in occupational
disability/time off work. The time taken off work is no more
than one week in one third and no more than two weeks in
another third of the cases. Occupational disability for longer
than 90 days arises in only 3% of these cases.
Sports injuries are less likely than other accidents to result
in occupational disability: 82% of occupational accidents, 71%
of pedestrian accidents, and 67% of road traffic accidents
result in time off work. In contrast, domestic accidents seem
to be less serious: 56% of those in household accidents or
incidents in the domestic environment said that they were
unable to go to work (or perform their usual housework).
Figure 1 shows relative incidences broken down by
accident type and site: six out of 10 sports injuries are
dislocations, distortions, and/or torn ligaments. The ques-
tionnaire used lay terms appropriate to the target populations
as a means of eliciting information on the type of injury—for
example, ‘‘sprain, strain, torn ligament’’. The second most
common type of injury (18%) was fracture (‘‘broken bone’’).
The most common fracture sites involved the lower extre-
mities (fig 1). Articular and ligamentous injuries were the
most common kinds of trauma and seem to be typical of
sports injuries; fig 2 shows that injuries of this kind are less
Minor head injury: 3%
Fracture of the
upper extremity: 4%
thoracic injury: 4%
Hip fracture: 1%
rupture of ligaments: 60%
Fracture of the
lower extremity: 8%
Contusion, open or
superficial wound: 12%
Other fractures: 5% Other sports injuries: 3%
Figure 1 Relative distribution of sports injuries by type and location
(both sexes). German national health survey.
Distortion, dislocation, torn ligament
Open wound, surface wound, contusion
Road traffic accident
Figure 2 Diagnostic breakdown by accident setting/location. German
national health survey.
Sports injuries 335
common in subjects involved in accidents occurring in other
settings. Contusions, open wounds, and surface wounds are
much more common in domestic and occupational accidents
(fig 2). More extensive analysis of the findings collated under
the residual category ‘‘Other injuries’’ shows that head
injuries—for example, concussions—are significantly more
common in other accident settings, especially pedestrian
accidents, than in association with sporting activity.
To identify high risk groups, let us take a look at
demographic distribution in terms of injury incidence.
Three quarters of recreational sports casualties in Germany
are male (table 1; p,0.001). The one year incidence declines
significantly in association with increasing age. Whereas one
in 14 (6.9%) of the 18–29 population sustains a sports injury
during the space of a year, the risk among the over 60
population is less than 1% (0.4%; table 1). However, an
exclusively bivariate analysis does not take into account the
fact that the risk of injury correlates closely with the extent of
individual sporting activity (‘‘time spent exercising’’). Finally,
as our data indicate, the incidence rates rise approximately in
proportion to the extent of recreational physical activity
(table 1). Factoring in sex and age specific sporting activity
produces the same picture. After adjustment within logistic
regression analysis for participation and time spent exercis-
ing, as called for by Uitenbroek, Jones et al and Taimela et al
for injury studies of this kind, the risk pattern (presented as
odds ratios in table 1) remains largely unchanged: young
men represent by far the most significant risk group for
sports injuries. It is also evident on the basis of the odds
ratios of 4.38 to 17.97 that the risk of sports injury increases
with the extent of sporting activity (‘‘time spent exercising’’).
This can also be seen from fig 3, which summarises one year
incidences for 16 subpopulations.
In conclusion, our data form a reliable basis for
estimates on the incidence of injury in the German
population aged 18–79 (table 2), yielding an annual
incidence of 88 000 injuries in the over 60 population
(including 27 000 in the over 70s). The total annual incidence
of sports injuries estimated on the basis of national health
survey data is about 2 million.
Particularities of the methodology and limitations of
The primary end point of this study is medically treated
sports injuries sustained during the 12 months preceding
Table 1 Incidence and risk of sports injuries as a function of sex, age, and time spent exercising (German national health
Odds ratio with no
adjustment for other
p Value and
sample size for
Odds ratio adjusted
for sex, age and time
p Value and sample
size for total
p Value and
Sex Female 1.5% p,0.001 0.29 (0.21 to 0.40) p,0.001 0.37 (0.27 to 0.51) p,0.001
Male 4.8% 1.00
n = 6.954 n = 6.911
Age (in years) 70 to 79 0.4% p,0.001 0.06 (0.02 to 0.19) p,0.001 0.15 (0.04 to 0.48) p = 0.002
60 to 69 0.6% 0.08 (0.03 to 0.18) p,0.001 0.13 (0.06 to 0.30) p,0.001
50 to 59 2.7% 0.37 (0.25 to 0.56) p,0.001 0.58 (0.38 to 0.90) p = 0.014
40 to 49 2.9% 0.41 (0.28 to 0.61) p,0.001 0.57 (0.38 to 0.86) p = 0.007
30 to 39 3.4% 0.45 (0.32 to 0.65) p,0.001 0.58 (0.40 to 0.84) p = 0.004
Under 30 6.9% 1.00 1.00
n = 6.954 n = 6.911
p,0.001 28.14 (16.44 to 48.15)
15.28 (8.89 to 26.27)
17.97 (10.38 to 31.13)
11.36 (6.57 to 19.63)
1–2 h/week 2.8% 5.28 (2.95 to 9.47) p,0.001 4.44 (2.47 to 8.00) p,0.001
Less than 1 h/week 2.9% 5.66 (3.14 to 10.21) p,0.001 4.38 (2.42 to 7.94) p,0.001
No sport 0.5% 1.00 1.00
n = 6.911 n = 6.911
Values in parentheses are 95% confidence intervals.
Age 50 and over
Male athletes (at least 1 h of recreational
physical activity per week)
Female athletes (at least 1 h of recreational
physical activity per week)
Male non-athletes (no sports or less than 1 h
of recreational physical activity per week)
Female non-athletes (no sports or less than 1 h
of recreational physical activity per week)
Figure 3 One year incidence of sports injuries by age, sex, and activity
status. German national health survey.
Table 2 Estimation of total annual sports
injuries by sex and age for the Federal Republic
of Germany (German national health survey)
70 to 79 0.0
60 to 69 0.1
50 to 59 0.3
40 to 49 0.4
30 to 39 0.4
Under 30 0.8
Basis: total population aged 18–79 of the Federal Republic
of Germany as on 31 December 2003 (64 028 469).
336 Schneider, Seither, To¨nges, et al
the study. This procedure follows standard international
We believe that the retro-
spective time window of one year in conjunction with the
18 month survey period effectively offsets seasonal varia-
tions with implications in terms of injury patterns and
Only 0.25% of the respondents (n = 17) said that they had
both sustained a sports injury during the preceding year and
not participated in sport during the preceding three months.
It is possible in these 17 cases that the injury itself was the
reason for the reported physical inactivity during the
preceding three months. However, our occupational disability
analyses indicate that sports injuries are rarely that severe.
These in depth analyses provide good grounds to interpret the
extent of physical activity as a causal factor contributing to
the risk of injury in the vast majority of cases.
The national health survey elicited information on injuries
sustained ‘‘during sports/games’’ (to quote the wording). We
believe that it is legitimate to assume that injuries sustained
by adults ‘‘during games’’ will in most cases refer to games or
playful situations occurring during physical activity—for
example, playing football in a park, Frisbee by the pool, etc;
as such, the (probably) fairly low percentage of such cases
can also be legitimately classified as sports injuries. As the
base population comprises adults only, we believe that
playtime accidents typically occurring in children—for
example, in the playground or while playing about with
objects—are insignificant for the purposes of our analysis.
Nevertheless, this terminological indistinctness should not go
unmentioned at this point.
The survey does not cover untreated or fatal sports injuries.
Limiting the survey to treated cases on the one hand results
in an over-representation of comparatively severe injuries, as
On the other hand, this procedure reduces
the likelihood of recall bias, as people are more likely to
remember medical consultations than minor injuries requir-
ing no treatment—scrapes, for example.
. The German
Census Bureau statistics lists 187 deaths in association with
sports and games incidents for the year 2003, 154 of these
accidents having occurred in the over 15 population.
EHLASS, the European Home and Leisure Accidents
Surveillance System, and official German statistics indicate
that fatal sports accidents throughout the EU and Germany
account for only 1% of all fatalities, whereas the correspond-
ing rate for domestic and other leisure time accidents is 50–
Confirmation of national and international findings
and new information
The unique characteristic of this paper is that it generates
population based data on the basis of a nationwide German
population sample with an exclusive focus on sports injuries.
Federal health bulletins and representative data presented
elsewhere either subsume sports injuries under the category
‘‘Domestic and leisure accidents’’
or analyse sports
injuries only in a marginal fashion with no differentiation
according to diagnosis, localisation, and severity.
Our analyses reveal what German insurance company and
hospital statistics have long indicated
: a sex ratio of 3:1
and a clear age gradient, with the highest incidence in the
under 30 population. National German health studies in the
past have shown that the high risk group of young men
presented in fig 3 typically engages in ball sports—44% of all
19–26 year old active sport club members play soccer—
whereas 25% of female sport club members of the same age
This agrees with data from other statistical
analyses indicating that 46% of all sports injuries in Germany
are soccer related. Another male dominated sport, handball,
ranks a poor second (15% of all sports injuries). Gymnastics
injuries account for only 3%.
The figures clearly show that,
as might be expected, the sex typical choice of a particular
sport plays a decisive role in determining injury patterns.
As might be expected, the risk of injury also increases with
the time spent exercising and hence presents a ‘‘function of
opportunity’’ (among other factors). Our literature search
disclosed another two studies showing a similar use of the
extent of sporting activity as a predictor of injury risk.
From the point of view of sports medicine, it can be assumed
that injuries caused by other people (as a result of foul play,
violent contact, or physical combat) would be more likely to
follow the identified ‘‘function of opportunity’’ than other
sports injuries. For these other sports injuries, the relative
risk—that is, per unit of training—might be expected to
decrease as a function of increasing physical fitness and more
extensive training and competitive experience. For future
studies, a more detailed investigation of duration, intensity,
and extent would be desirable.
This typical age, sex, and participation specific pattern for
sporting accidents agrees with data from Canada, the United
States, Australia, and New Zealand.
5 25 28 31 33 34 39–41
Comparison of the types of injury shows, however, that data
from hospital populations seem to be subject to selection
processes. For instance, Steinbru¨ck’s presentation of hospital
data from Stuttgart/Bad Cannstatt
reports more distortions
(67%, suspected torn ligaments and menisci), muscle and
tendon injuries, and fewer fractures (11% plus some of the
deformities, a category with a reported incidence of 9%) than
are indicated by our data. A probable explanation is that
those who suffer a sports injury tend to seek treatment at this
kind of sports hospital later and more selectively after
capsular-ligamentous lesions than after sustaining fractures;
our experience suggests that fractures are usually treated
immediately after the trauma event in a surgical outpatients
department or by a readily accessible community based
accident surgeon. Our results in terms of type of injury and
the body region involved are congruent with the results of
descriptive studies from other countries.
ent preferences in terms of the sports performed, the
observation that the lower extremities are affected two to
What is already known on this topic
Univariate and bivariate representative data on sports
injury incidence are available from a number of
western industrialised countries
However, descriptive only data do not provide a basis
for calculating the actual injury risk among individual
sectors of the population, as data of this kind do not
address age related and sex related differences in the
extent of physical activity performed
What this study adds
This study is the first to provide representative data on
the incidence, type, site, and extent of sports injuries
and their implications in terms of occupational
disability/time off work in the Federal Republic of
These incidence rates are set in relation to actual
sporting activity, and young men present the main high
Sports injuries 337
three times more often than the upper extremities seems to
apply across societies and cultures. We can only suppose that
this relation also applies to other sports injuries (ligamentous
injuries, for instance), as the national health survey
provides injury site information only with regard to
Our representative data correspond to insurance company
and statistical data also in terms of the injury incidence of
5.6% determined by us in relation to the physically active
population. Germany’s most extensive database to date on
sports injuries puts the injury incidence at 5.1% for those
participating in sport in a club and 5.9% for physically active
people who are not organised in a sports club.
accident event number estimated on the basis of the national
health survey—just below 2 million sports injury victims a
year—is higher than the number generated by the Federal
Work Safety and Occupational Medicine Agency in a
nationwide survey of households (1.3 million). This phenom-
enon is already known from publications on recreational and
road traffic accidents, which are also based on the national
In conclusion, the national health survey provided a basis
for presenting representative nationwide data on the inci-
dence, type, and risk structure of sports injuries, data that
had not previously been available in such analytical depth.
Firstly, earlier, non-representative calculations from—in
most cases—selective cohorts and populations have now
been objectified and validated. Secondly, the data also show
that sports injuries are a major cause of accidents but are
fairly harmless in terms of severity and occupational
disability in comparison with other types of accident.
Typical injuries are distortions and other injuries of the
capsular-ligamentous apparatus. Thirdly, these investigations
reveal that young men actively engaged in sports are by far
the main risk group. In contrast, sports injuries among
seniors, even those who are mobile and do sport, are a
We believe that future measures and interventions to
prevent injury should focus primarily on the high risk group
of active young men. Studies on sports participation and
adherence show that psychological factors, in particular fear
of injury, are significant internal barriers to an active
Our findings provide arguments against this view
by showing that this fear is largely unfounded, especially in
the senior population which is so important in terms of
The exclusion of high risk sports from the standard of
care provided by the German Statutory Health Insurance
system is currently a subject of heated debate. Statutory
health insurance organisations, business associations, and
healthcare institutes with industry affiliations argue that
those engaging in (selected) sports should take out
special insurance or pay an additional premium.
clubs respond by arguing that excluding sports injuries would
counteract efforts to implement and promote preventive
healthcare programmes that are based on encouraging
people to exercise more.
The (former) Chancellor of
Germany pointed out in a government statement that a
separate insurance obligation for sports accidents would
impede, and increase the cost of, sports for children and
adolescents, and would have the same effect on ‘‘sports for
all’’ programmes that are so important in terms of helping to
In view of the injury incidences
identified, the cost-benefit ratio presented at the start of
the paper, and the in any case fairly low levels of sporting
participation among lower socioeconomic groups,
believe that excluding high risk sports such as soccer from
standard healthcare insurance benefits would be a move in
the wrong direction.
This paper received financial support from the independent research
fund of Heidelberg Orthopaedics Foundation at the University of
Heidelberg and arose out of research project F05-0007 ‘‘Sports and
orthopaedic symptoms’’ as an interdisciplinary cooperation between
Heidelberg University Hospital Orthopaedic Foundation and the
Robert Koch Institute (RKI) of Berlin. The sponsor did not influence
the study or this paper in any way. We wish to thank Dr Heribert
Stolzenberg, RKI, for providing access to the dataset and for
immeasurable methodological support and fruitful discussions.
Likewise, this paper would not have been possible without the
Department (Internal Medicine VII: Sports Medicine) at Heidelberg
S Schneider, S To¨nges, H Schmitt, Department of Orthopaedic Surgery,
University of Heidelberg, Heidelberg, Germany
B Seither, Ludwig Maximilians University of Munich, Munich, Germany
Competing interests: none declared
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The positive effects of sport on physical and mental health are
undisputed. Unwanted side effects of recreational physical
activity are sports injuries, but most of them are avoidable
and theoretically controllable through the implementation of
preventive measures. To weigh the sports positive against
negative effects on men and women at different ages, it is
important to know the injury frequency and diagnosis. After
identification of groups with frequent occurrences of sports
injuries, preventive measures could be used specifically to
avoid sports injuries in those high risk groups. This paper
gives information on the incidence of injury in the German
population aged 18–79 and identifies groups at high risk.
Institute of Medical Sociology and Social Medicine, Medical School and
University Hospital, University of Marburg, Marburg, Germany;
Sports injuries 339