Winning at all costs: a review of risk-taking behaviour and sporting injury from an occupational safety and health perspective

In an article about concussion in professional rugby union, ex-Scotland representative player Rory Lamont comments that “a flagrant disregard for your own welfare almost seems a prerequisite for achieving success at the highest level” [1]. The pressure of sports competitiveness inspires elite athletes to “win at all costs” [2] and may lead them to neglect injuries and continue playing with pain [3‐6], resulting in a higher occupational risk acceptance [5]. Sporting injuries limit an athlete’s preparation and subsequent performances, which can have both short-term [6] and long-term health impacts [7]. According to statistics reported in the UK, the overall injury risk in professional soccer is 1000 times higher compared to other high-risk occupations such as construction and mining [8, 9]. One potential reason for this is that non-sporting workplaces have adopted OSH management practices to reduce the risk to as low as reasonably practicable (ALARP) [10]. OSH management practices have been embedded into organisational management in international and national health and safety legislation [11‐13] but not completely adopted in elite sport organisations [14]. The incorporation in elite sport of OSH practices to reduce risky behaviours could minimise the health impacts of inevitable sporting injuries in the long-term [15]. If injury awareness were given a similar weighting in elite sport as in any other highly physical occupation, the potential benefits to elite athletes and their long-term health and wellbeing could be highly significant.

To date, researchers have studied sporting injury from different perspectives. For example, of the studies reviewed, many focus on elite athletes’ injury-related knowledge or certain types of injury prevention techniques, such as ankle sprain prevention [16] and knee injury prevention [17]. While some studies focus on the relationship between injury risk and individual factors such as personality traits [18, 19] and BMI [20], other studies assess injury risk in elite sport from a general health and safety perspective [8, 14, 21]. By reviewing existing studies across the disciplines of both OSH and sporting injury, this narrative review provides an OSH insight into elite sport to (1) summarise elite athletes’ attitudes towards important OSH practices, including injury reporting, medicine usage and personal protective equipment (PPE) usage, and (2) explore factors that may influence elite athletes’ injury awareness from three safety management perspectives: organisational, societal and individual. This review contributes to a better understanding of how to build a positive OSH culture in sport, one that could reduce injury rate and improve elite athletes’ long-term wellbeing.

This paper adopts a narrative review method to transmit knowledge and information across the two disciplines [22]. The databases searched were PubMed, Scopus and Web of Science. The Boolean operators AND, OR and NOT were used to narrow or broaden the literature search. The combination of key terms searched are (“elite athletes” OR “professional players” OR “professional athletes” OR “elite players” OR “professional sports” OR “elite sports”) AND (“occupational safety” OR “occupational health” OR “occupational risk” OR “occupational health and safety”) AND (awareness OR perception). Because, considered occupational health terms in sports may not have been commonly used, articles identified by manual journal search were also included for a more comprehensive coverage. Since each database provides different facilities for paper screening, papers were generally screened by limiting publication date (2008–2018), article type (original research), English written, publication status (fully publicised) and text availability (full-paper available) in the searched databases. Explicitly, 47 books, 3 book series, 3 conference proceedings, 27 review papers, 1 conference paper, 1 short survey and 7 articles written in a language other than English (i.e. French, Spanish, German, Portuguese, Croatian, and Polish) were excluded. After limiting the publication date from 2008 to 2018, 163 documents were identified. Following a manual search, 36 papers were identified. One hundred ninety-six articles were identified after removing duplication. The first author reviewed and assessed all the 196 articles retrieved against criteria agreed by the other two authors to determine their inclusion in the final sample. On a case-by-case basis, we excluded a further 157 articles which met the key word criteria but following a review of the title and abstract, were not relevant to this study. In the first instance, we excluded 79 articles which focused on a non-sport setting (e.g. military). Furthermore, studies on dancing were not included in this review. In the second instance, we excluded 20 articles in which the health awareness of sport supporting staff is examined rather than that of athletes (e.g. coaches’ burnout, physiotherapists’ burnout or Paralympic leaders’ stress). Subsequently, 44 studies not focused on health awareness were also excluded (e.g. studies focused on the association between training load and sleep quality, studies focused on associations between common mental disorder symptoms and potential stressors or studies focused on associations between athlete burnout, insomnia, and polysomnographic indices among athletes). The abstract of the studies were reviewed if the information the study title provided was insufficient for screening. For example, studies such as Mental and psychosocial health among current and former professional footballers were excluded after reviewing the abstract, in which the association between the prevalence of mental health complaints and the psychosocial problems was examined rather than how players are aware of their mental health. In addition, 13 studies that did not meet the study type were excluded. We also excluded another one paper, the full text of which could not be located. Finally, 39 studies meeting the inclusion criteria were included. Figure 1 flowchart diagram indicates the overall search process. Table 1 presents the study information of the final included 39 papers after the inclusion and exclusion criteria screening process conducted. The study population of athletes was categorised as professional, elite, high-performance amateur, student athletes and mixed population as presented in Table 1.

After reviewing the papers included, the three most frequent themes were injury reporting, medicine usage and PPE usage. The results of the remaining studies on other health and safety issues have also been included in the table, though not discussed within the three themes.

In the studies reviewed, of seven studies on concussion symptom awareness, five studies reported on inadequate concussion symptom knowledge or awareness; of six studies examined injury consequence awareness, four papers reported inadequate concussion consequence awareness; and of seven studies on papers PPE, three studies reported inadequate mouthguard use. Since most of the included studies on sporting injury focused on concussion, the main discussion was based on concussion evidence, a topic which requires future research. Because OSH is a relative alien term in the sport literature the core purpose of this narrative review is to bridge the gap between the academic fields of OSH and sport.

The studies reviewed revealed that most elite athletes’ injury awareness does not meet the basic requirements of OSH standards. Existing injury prevention programmes focus more on techniques rather than consistently raising awareness. From an OSH perspective, risk communication practices should be improved in the sport context by establishing a proactive injury prevention culture, identifying clear-cut responsibilities between athletes and staff. In addition, factors influencing elite athletes’ OSH awareness have not been quantitatively measured since no such instrument has so far been devised. Arguably the development of an instrument or research toolkit linked to a conceptual framework is required to elicit the identification of the principal factors that could influence elite athletes from reaching appropriate levels of OSH awareness. Subsequently, OSH or welfare remedial programmes could be devised with the intention of improving awareness, enhancing involvement, increasing reporting and developing a safer sporting environment overall for the long-term wellbeing of athletes during and post-elite career.