Single season re-injury risk after concussion and lower extremity injury among male,collision sport,high school athletes

ObjectivesResearch suggests that a recent concussion increases subsequent lower extremity injury risk; however, data in high school athletes is limited. This study evaluates the association between concussion and subsequent injury risk among male, collision sport, high school athletes over a single season.DesignRetrospective cohort study.MethodsData were obtained from 2005/06–2014/15 in the High School Reporting Information Online database. A two stage, multi-method matching process was used to identify athletes who suffered multiple injuries over a single athletic season. Demographics and injury characteristics were compared with Chi square and Student's t-tests. Multiple Cox Proportional Hazards regression analysis was used to test whether index injury type was associated with hazard of subsequent injury following return to play from index injury.ResultsOverall 1364 HS athletes sustained 2 injuries over a single athletic season (subsequent injury within 45 days of the index injury). Index injuries included 686 (50.2%) lower extremity injuries, 417 (30.6%) upper extremity injuries, and 261 (19.1%) concussions. Hazard of subsequent concussion was increased in the index concussion group relative to the index lower extremity injury group [hazard ratio (HR): 1.60, 95% CI: 1.15–2.23, p = 0.0052]. Hazard of a subsequent lower extremity injury was not significantly different for the index lower extremity injury group relative to the index concussion group [HR: 1.27, 95% CI: 0.98–1.65, p = 0.0728].ConclusionsHistory of recent concussion or recent lower extremity injury are both risk factors for subsequent lower extremity injury in male, collision sport, high school athletes.     

Reliability of a field-based drop vertical jump screening test for ACL injury risk assessment

Objectives: There is an epidemic of anterior cruciate ligament (ACL) injuries in youth athletes. Poor neuromuscular control is an easily modifiable risk factor for ACL injury, and can be screened for by observing dynamic knee valgus on landing in a drop vertical jump test. This study aims to validate a simple, clinically useful population-based screening test to identify at-risk athletes prior to participation in organized sports. We hypothesized that both physicians and allied health professionals would be accurate in subjectively assessing injury risk in real-time field and office conditions without motion analysis data and would be in agreement with each other. Methods: We evaluated the inter-rater reliability of risk assessment by various observer groups, including physicians and allied health professionals, commonly involved in the care of youth athletes. Fifteen athletes age 11–17 were filmed performing a drop vertical jump test. These videos were viewed by 242 observers including orthopaedic surgeons, orthopaedic residents/fellows, coaches, athletic trainers (ATCs), and physical therapists (PTs), with the observer asked to subjectively estimate the risk level of each jumper. Objective injury risk was calculated using normalized knee separation distance (measured using Dartfish, Alpharetta, GA), based on previously published studies. Risk assessments by observers were compared to each other to determine inter-rater reliability, and to the objectively calculated risk level to determine sensitivity and specificity. Seventy one observers repeated the test at a minimum of 6 weeks later to determine intra-rater reliability. Results: Between groups, the inter-rater reliability was high, κ = 0.92 (95% CI 0.829–0.969, p < 0.05), indicating that no single group gave better (or worse) assessments, including comparisons between physicians and allied health professionals. With a screening cutoff isolated to subjects identified by observers as “high risk”, the sensitivity was 63.06% and specificity 82.81%. Reducing the screening cutoff to also include jumpers identified as “medium risk” increased sensitivity to 95.04% and decreased the specificity to 46.07%. Intra-rater reliability was moderate, κ = 0.55 (95% CI 0.49–0.61, p < 0.05), indicating that individual observers made reproducible risk assessments. Conclusions: This study supports the use of a simple, field-based observational drop vertical jump screening test to identify athletes at risk for ACL injury. Our study shows good inter- and intra-rater reliability and high sensitivity and suggests that screening can be performed without significant training by physicians as well as allied health professionals, including: coaches, athletic trainers and physical therapists. Identification of these high-risk athletes may play a role in enrollment in appropriate preventative neuromuscular training programs, which have been shown to decrease the incidence of ACL injuries in this population.     

Epidemiology and moderators of injury in Gaelic football: A systematic review and meta-analysis

ObjectivesTo quantify the incidence, location and severity of injuries in Gaelic football and to identify potential moderators of those injuries.DesignSystematic review and meta-analysis.MethodsA comprehensive search strategy of six electronic databases was undertaken independently by two researchers in March 2020. Studies must have prospectively investigated injuries sustained by Gaelic footballers over a minimum duration of six months. The Newcastle-Ottawa Scale was used to assess risk of bias. Studies were combined in a pooled analysis using an inverse variance method.ResultsTwelve prospective cohort studies were eligible. The total injury incidence was 10.7 injuries/1000 h of exposure. Match incidence (55.9 injuries/1000 h) was much higher than training (4.6 injuries/1000 h). The lower limb accounted for over 70% of all injuries, with hamstring injuries ranging from 22 to 24% of all injuries. Non-contact injuries were the most common injury mechanism. Players aged >30 were at greatest risk of injury with incidence risk ratios ranging from 1.2 to 2.3. High aerobic fitness and chronic workloads were associated with reduced risk of injury in elite Gaelic footballers.ConclusionsElite Gaelic football athletes are twelve times more likely to get injured during match play compared to training. The lower limb is the most affected body region, and most injuries occur by non-contact mechanisms. Athlete age of greater than 30, poor aerobic fitness and sudden increments in training workload all increase the likelihood of injury. By understanding the incidence and nature of injuries in Gaelic football, targeted injury prevention strategies can be developed and implemented.     

Monitoring of sport participation and injury risk in young athletes

ObjectivesCareful modulation of training characteristics in high-level sports optimizes performance and avoids inappropriate workloads and associated sports injury risk. The aims of this study were to compare sport participation characteristics in different youth sport categories and to investigate their relationship with injury.DesignProspective cohort follow-up.MethodsYoung (12–19 years) high-level athletes (n = 154) from a regional sport school were followed during 41 weeks regarding sport participation characteristics and traumatic and overuse sports injuries (time-loss definition). All data were self-recorded by the athletes in an electronic system “TIPPS” (Training and Injury Prevention Platform for Sports) and subject to a systematic data quality control. Volume and intensity (self-rated perceived exertion) of each sport session were used to compute weekly load, monotony and strain. Sport categories were defined as team, racket, and individual sports.ResultsAll sport participation characteristics were dependent on sport category (p < 0.05). Weekly intensity, load and strain were dependent on age (p < 0.05). Racket and individual sports were associated with lower injury risk (HR = 0.37 and 0.34, p = 0.001 and p < 0.001, respectively) compared to team sports. Average sport participation characteristics were not related to injury according to the survival analysis. However, intensity during the week prior to injury was significantly higher (p < 0.01) compared to that of the 4 preceding weeks.ConclusionsThis study investigated for the first time the relationship between sport participation pattern and injury risk in young athletes. The monitoring method was sensitive to variations according to pertinent variables and might help identify athletes with increased sports injury risk.     

Training and match volume and injury in adolescents playing multiple contact team sports: A prospective cohort study

Training and competition loads have emerged as valuable injury risk factors but very few studies have explored injury outcomes in adolescent athletes. The aims of this study were to describe injuries and to explore the relationship between training and match load volumes and injury in adolescent athletes participating in multiple contact team sports. One hundred and three male youth rugby athletes aged 14‐16 years from 8 rugby union teams were prospectively monitored during a season for weekly training and match volumes and injuries. The relationship between volume and injury was explored by comparing the weekly volume in the week prior to an injury vs weeks without injury. There were 83 time‐loss injuries in 58 athletes (62%). Overall injury incidence was 18.5 per 1000 player‐hours. Mean weekly injury prevalence was 27% (95% CI 25‐30). Average weekly volume was 5.4 (2.2) hours comprising 1.4 (1) match hours and 4 (2.6) training hours. Compared with weeks without injury, weeks prior to an injury had higher match volumes (110 [57] min vs 83 [59] min, P < 0.001). Poisson regression demonstrated that match volume was a predictor of injury with an odds ratio of 1.41 (P = 0.001). The contribution of match volumes to injury risk and the relatively high injury burden in these athletes may be profound. Very high match volumes are unlikely to be in the best interests of young athletes and could be avoided with a systematic approach to load management and athlete development.     

Health professionals' perceptions of musculoskeletal injury and injury risk factors in Australian triathletes: A factor analysis

ObjectiveThis study investigated health professional perceptions of triathlon-related injury risk factors and injury prevention strategies, to inform prospective cohort studies investigating injury in triathletes.DesignExploratory factor analysis.MethodsA questionnaire was developed and distributed to Australian sports medicine health professionals (n = 504). Information was collected about their perceptions of factors contributing to injury and injury prevention strategies relating to Sprint/Olympic (S/O) and Ironman/Long Course (I/LC) athletes. Factor analysis was performed to identify the number and nature of the constructs (factors) underlying the responses to the questions, and to ascertain whether these factors were similar for S/O and I/LC athletes.ResultsThe response rate was 22.4% (n = 113). Five factors were extracted for injury risk accounting for 53% (S/O) and 56% (I/LC) of the variance. The factors were common across S/O and I/LC groups; biomechanics and technique, training factors, demographics, injury prevention and personal factors. Three common factors accounted for 54% (S/O) and 55% (I/LC) of the variance for injury prevention strategies; designated training regimes, health and medical monitoring and preparation of the triathlete.ConclusionsThese results indicate that future studies into triathlon injuries should include, at a minimum, detailed training load and demographic factors to test their impact as injury risk factors in triathlete populations.     

Injury risk is different in team and individual youth sport

ObjectivesThis study compared sports injury incidence in young high-level athletes from various team and individual sports and investigated if sport participation patterns are linked to injuries.DesignProspective cohort follow-up.MethodsPupils from a public sports school (12–19 years) were recruited over two separate school years (2008–2009: 42 weeks, n = 199 athletes; 2009–2010: 40 weeks, n = 89 athletes). Training and competition volume and intensity were recorded via a personal sports diary. Sports injuries (time-loss definition) were registered by medical staff members using a standardized questionnaire.ResultsInjury incidence was significantly higher in team compared with individual sports (6.16 versus 2.88 injuries/1000 h, respectively), as a result of a higher incidence of both traumatic (RR = 2.17; CI95% = 1.75–2.70; p < 0.001), and overuse injuries (RR = 2.06; CI95% = 1.46–2.91; p < 0.001). A Cox proportional hazards regression revealed that team sports participation had a hazard ratio of 2.00 (CI95% = 1.49–2.68; p < 0.001) compared to individual sports, with additionally previous injury being a risk and age a protective factor. The number of competitions per 100 days was significantly higher in team sports, whereas the number of intense training sessions per 100 days was significantly lower. In team sports, the number of competitions per 100 days was positively associated with injuries (HR = 1.072; CI95% [1.033; 1.113]; p < 0.001), while in individual sports the number of competitions per 100 days had a protective effect (HR = 0.940; CI95% [0.893; 0.989]; p = 0.017).ConclusionsTeam sports participation entailed a higher injury risk, whatever the injury category. Further research should elucidate the role of characteristics related to sport participation in injury causation.     

The effect of hypermobility on the incidence of injury in professional football: A multi-site cohort study

BackgroundA recent study demonstrated joint hypermobility increased the incidence of injury in an elite football team utilising a univariate statistical model.ObjectivesTo compare injury incidence between hypermobile and non-hypermobile elite football players incorporating a multi-site design and multivariate inferential statistics.Methods80 players comprising 3 English Championship football teams were followed prospectively during the 2012–2013 season. Joint hypermobility was assessed according to the 9-point Beighton Criteria at the start of the study period. A cut-off score of ≥4 categorised a participant as hypermobile. Player exposure and time-loss injuries were recorded throughout.ResultsMean ± standard deviation incidence of injuries was 9.2 ± 10.8 injuries/1000 h. The prevalence of hypermobility was 8.8%. Hypermobiles had a tendency for higher injury incidence (mean [95% confidence interval] difference, 5.2 [0.9–2.7] injuries/1000 h; p = 0.06). Cox regression analyses found training exposure to be highly significant in terms of injury risk (p < 0.001) for all participants. Non-hypermobiles had a lower injury risk (p = 0.11), according to the Cox model, which is suggestive but not conclusive that hypermobility predisposes injury risk.ConclusionsHypermobility showed a trend towards increased risk of injury. Training exposure is a significant injury risk factor in elite football.     

Prolonged restricted training,fixture congestion and player rotation: What the COVID-19 pandemic taught us about injury risk in professional collision sport

ObjectivesThe COVID19-induced suspension of the 2019-20 professional England rugby union season resulted in players being exposed to an extended restricted training period, coupled with a congested match schedule once competition resumed. We assessed the impact of these changes on match and training injuries in the final 20-weeks of the season following competition resumption.DesignEpidemiological study.MethodsThe 2019-20 season was compared to the previous three seasons (2016-19).ResultsThere was no significant difference in the mean incidence, severity and burden of training and match injuries in 2019-20 compared to 2016-19 period mean. The 2019-20 post-suspension mean match injury rate [77/1000 h (95%CIs [confidence intervals]: 67-89)] was comparable to the 2019-20 pre-suspension [93/1000 h (95%CIs: 85-101)] and significantly lower than the 2016-19 equivalent post-suspension period [97/1000 h (95CIs: 90-104) IRR [incidence rate ratio] 0.8 p=0.002]. In the 2019-20 season, there was a significantly higher rate of training injury post-suspension in comparison to pre-suspension [3.8/1000 h (95CIs: 3.3-4.4) vs 2.7/1000 h (95% CIs: 2.5-3.1) IRR 1.4 p=0.005]. There was no significant difference in the overall incidence, severity or burden of injuries sustained in fixtures with shorter (<6 days) turnarounds but there was a significantly higher burden of soft tissue injuries.ConclusionsThis is the first study to assess the effect of restricted training on injury risk in collision sports. Players were at an increased risk of training injury when returning from the suspension, but 10-weeks of preparatory training meant the incidence of match injury was not higher when competition resumed.     

Concussion reporting and perceived knowledge of professional fighters

Objective: For concussions to be effectively managed in sports, they need to be correctly identified and reported. The extent to which professional athletes correctly recognize concussions, and their willingness to report symptoms, is not yet well understood. Given the risk of head injuries leading to concussions across combat sports, insight into professional fighters’ knowledge and reporting of concussive symptoms is essential to improve concussion management.

Methods: To investigate understanding and reporting patterns of concussions sustained while training or competing, 257 fighters completed a self-report questionnaire assessing self-perception of concussion knowledge, trust of ringside medical providers, and reported number of previous head injuries. Fighting history, including number of knockouts, was obtained from self-report (amateur) and published (professional) records.

Results: Significant gaps in fighters’ perceived knowledge of concussion symptoms and long-term effects of multiple concussions emerged. Approximately 40% of fighters reported returning to training or competition the same day a head injury was sustained, while 21% of fighters endorsed concealing symptoms of head injury from medical providers and coaches.

Conclusions: Confusion surrounding terms used to describe head injuries amongst fighters (e.g., concussions, knockouts), coupled with limited understanding of concussive symptoms and a desire to return to competition, likely contributes to significant underreporting of symptoms.     

A qualitative study on overuse injuries: The beliefs of athletes and coaches

ObjectivesPreventive approaches for overuse injuries in sports will be more successful when synchronised with athletes’ and coaches’ beliefs. We interviewed athletes and coaches in order to better characterize their beliefs about the definition of an overuse injury, as well as the intrinsic and extrinsic risk factors that underlie overuse injuries.DesignQualitative study using in-depth interviews in athletes and coaches of different sports.MethodsAthletes who had experienced overuse injuries and coaches who trained athletes who had sustained overuse injuries from sports clubs were invited to participate through interview. We explored each participant's individual definition of an overuse injury and the beliefs concerning the intrinsic and extrinsic risk factors concerning overuse injuries were explored.ResultsAfter nine athletes and nine coaches, sample size saturation was confirmed. Athletes and coaches integrate somatic as well as psychological and sociological factors into the definition of and risk factors for overuse injuries. Intrinsic factors for an overuse injury were related to physical factors, technique, psychological factors and heredity. The extrinsic factors were related to situational, social and training factors, as well as the individual coach.ConclusionsAthletes and coaches have a holistic view on the definition of overuse injuries, and the intrinsic and extrinsic risk factors for overuse injuries. If preventive approaches for overuse injuries are developed and implemented, they should incorporate physical factors, as well as incorporate psychological and social factors. Based on the input of coaches and athletes, the latter are important risk factors for overuse injuries.     

Knieverletzungen bei männlichen und weiblichen adoleszenten Fußballspielern

BackgroundAim of the study was analyze knee injuries in male and female youth soccer players.Materials and MethodsWith a web-based survey data of 1110 male and female players aged 12 to 19 years of all German youth leagues were collected.ResultsA total of 285 knee injuries in male and 83 knee injuries in female players occurred. The most common injury types were injuries of joint & ligament (32.4%). Strikers (40.2%) showed the highest rates. The confounders gender, level, age and weekly training load showed no influence whereby increasing training experience increased the injury rate.ConclusionsIn order to reduce or prevent risk of knee injuries further univariate and multivariate testing is needed.Level of evidenceLevel IV.     

Effectiveness of shoulder injury prevention programs in an overhead athletic population: A systematic review

ObjectiveTo analyze the effectiveness of shoulder injury prevention programs in overhead athletes.DesignSystematic Review.MethodsCINAHL, Embase, PubMed, and SPORTDiscus electronic databases were searched from database inception through December 2020 for randomized controlled or prospective cohort studies that implemented shoulder injury prevention programs in overhead athletes and reported shoulder injury incidence rates.ResultsSeven studies fulfilled the inclusion criteria. Two studies reported on odds ratios (OR) that resulted in a reduction of shoulder injuries in overhead athletes following shoulder strengthening and flexibility exercises (OR, 0.72; 95% CI; 0.52, 0.98; OR, 0.22; 95% CI; 0.06, 0.75). One study reported on hazard ratio (HR) that resulted in a reduction of shoulder injuries following stretching of the posterior capsule (HR, 0.36; 95% CI; 0.13, 0.95).ConclusionThere is limited research surrounding the effectiveness of shoulder injury prevention programs in overhead athletes specific to injury reduction. Only three studies reported a favorable effect in terms of injury prevention, with only one study at low risk of bias. At present, no conclusions can be made regarding the effectiveness of shoulder injury prevention programs in the overhead athlete.     

Incidence,burden, and pattern of injuries in Spanish male youth soccer players: A prospective cohort study

ObjectivesTo explore the incidence, burden, and pattern of injuries in Spanish male youth soccer players during a 9-month competitive season (from September to May–June).DesignProspective cohort study.Participants314 young (10–19 years) soccer players.Main outcome measuresIncidence, burden, location, type, severity, mechanism, and circumstance of injuries, as well as potential differences by tactical position, month of the year, age group, and maturity status.ResultsA total of 146 time-loss injuries were sustained by 101 different players. This resulted in an overall injury incidence of 3.1 injuries per 1000 h, a training injury incidence of 1.8 injuries per 1000 h, and a match injury incidence of 11.2 injuries per 1000 h. The probability of injury over the season was 34%. Most of the injuries affected the lower extremity and were classified as muscle/tendon injuries, with hamstring muscle injuries representing the most burdensome diagnosis. The incidence of injuries increased with age and maturation, but a heightened risk of overuse injuries during periods around peak height velocity was also identified.ConclusionsThese findings suggest a need for implementing specific injury prevention measures. Due to the high burden shown, these measures should mainly focus on reducing the number and severity of hamstring muscle injuries.     

Assessing parents,youth athletes and coaches subjective health literacy: A cross-sectional study

ObjectivesThe aim was to describe levels of subjective Health Literacy (HL), and to examine possible differences in prevalence proportions between sexes, age groups and level of educations among youth athletes and their mentors (coaches, parents/caregivers) in Swedish Athletics.DesignCross-sectional.MethodsData on subjective HL were collected using the Swedish Communicative and Critical Health Literacy (S-CCHL) instrument for mentors and for youth the School-Aged Children (HLSAC) instrument. Questions assessing mentors’ literacy on sports injury and return to play were also included.ResultsThe surveys were completed by 159 (91%) mentors and 143 youth athletes (87%). The level of S-CCHL was sufficient in 53% of the mentors. Of youth athletes, 28% reported a high level of HL and the item with least perceived high HL (21%) was critical thinking. Ninety-four percent of the mentors believed that it is quite possible to prevent injuries in athletics and 53% perceived having a very good knowledge about how to prevent injuries. Forty-six percent of the mentors perceived having a very good knowledge of return to sport criteria.ConclusionsThe level of health literacy was low with about half of the mentors and one out of three youth athletes having adequate HL levels. Only half of the mentors stated having a good knowledge of various injury prevention strategies. To reduce health consequences in youth sport and enable talent development more work is needed to understand the facilitators and barriers for the uptake of various health promotion and injury prevention strategies.     

The epidemiology of back injuries in elite Gaelic football athletes: An 8-year prospective study

ObjectivesTo describe the epidemiology of back injury in elite male Gaelic football athletes between 2008 and 2016.DesignProspective cohort study.SettingInjury data from the National GAA Injury Surveillance Database.ParticipantsElite male Gaelic football athletes.Main outcome measuresIncidence of injury as a rate per 1000 h of exposure.Results38 datasets were analysed. Out of a total of 1606 time-loss injuries, 76 were back injuries (4.73%, 95% CI 3.80%–5.88%). The incidence of back injuries in match play was 1.72 (CI 95% 1.21 to 2.45) and in training was 0.2 (CI 95% 0.14 to 0.28) injuries per 1000 h of exposure. The majority of back injuries (63.16%, CI 95% 51.93–73.12) were new, as opposed to recurrent (35.53% CI 95% 25.7–46.74). Most back injuries were acute (51.32%, CI 95% 40.29–62.22), compared to chronic (31.58%, CI 95% 22.23–42.7) or overuse (11.84%, CI 95% 6.36–21.00). The majority of back injuries occurred during non-contact player activities (n = 60, 78.94% CI 95% 68.50–86.60).ConclusionsBack injury rates in Gaelic football are similar to soccer and Australian football but less than rugby union. Further research is needed to understand the factors leading to the onset and recurrence of back injury in Gaelic football athletes.     

Comparison of incidence,prevalence, severity and profile of health problems between male and female elite youth judokas: A 30-week prospective cohort study of 154 athletes

ObjectivesTo describe and compare the incidence, prevalence, severity, and profile of injuries (acute and overuse) and illness between female and male youth elite judokas during 30 weeks of a sports season.DesignProspective cohort study.MethodsA total of 154 elite youth judokas (83 males and 71 females) were assessed from January to August 2019 in a training period organized by the Brazilian Judo Confederation. We conducted a prospective 30-week follow-up study on acute and overuse injuries and illness among youth female and male judokas through the Oslo Sports Trauma Research Center questionnaire on health problems (OSTRC-H). Every week, the OSTRC-H was sent to all youth judokas electronically, starting in the first week of preseason. The incidence rate, prevalence, and severity of illnesses and acute and overuse injuries were compared between sexes using an independent t-test (variables with normal distribution) or Mann Whitney U test (variables with non-normal distribution) with α set a 0.05.ResultsFemale and male judokas showed 16.96 and 16.57 injuries per 1000 athletic exposures, respectively (p = 0.383). Female judokas showed a higher average weekly prevalence of health problems (38.8%) than male judokas (29.0%). In addition, females had a greater prevalence of substantial health problems (p < 0.001), injuries (p < 0.001), and overuse injuries (p < 0.001) than males.ConclusionThere were no differences in the incidence rate of injuries between sexes. Youth female judokas showed a higher prevalence of all health problems than youth male judokas. For both sexes, the knee and shoulder were the most affected joints for acute and overuse injuries, respectively.     

Multiple factors explain injury risk in adolescent elite athletes: Applying a biopsychosocial perspective

Many risk factors for injury are presented in the literature, few of those are however consistent and the majority is associated with adult and not adolescent elite athletes. The aim was to identify risk factors for injury in adolescent elite athletes, by applying a biopsychosocial approach. A total of 496 adolescent elite athletes (age range 15‐19), participating in 16 different sports, were monitored repeatedly over 52 weeks using a valid questionnaire about injuries, training exposure, sleep, stress, nutrition, and competence‐based self‐esteem. Univariate and multiple Cox regression analyses were used to calculate hazard ratios (HR) for risk factors for first reported injury. The main finding was that an increase in training load, training intensity, and at the same time decreasing the sleep volume resulted in a higher risk for injury compared to no change in these variables (HR 2.25, 95% CI, 1.46‐3.45, P<.01), which was the strongest risk factor identified. In addition, an increase by one score of competence‐based self‐esteem increased the hazard for injury with 1.02 (HR 95% CI, 1.00‐1.04, P=.01). Based on the multiple Cox regression analysis, an athlete having the identified risk factors (Risk Index, competence‐based self‐esteem), with an average competence‐based self‐esteem score, had more than a threefold increased risk for injury (HR 3.35), compared to an athlete with a low competence‐based self‐esteem and no change in sleep or training volume. Our findings confirm injury occurrence as a result of multiple risk factors interacting in complex ways.