Sports injury is a collective name for all types of injury that can occur in relation to physical activity, and it is defined as any damage of the tissues of the body that occurs as a result of sport or exercise. Saudi Arabia is opening to all types of sports activities, and residents have ready access to a variety of sporting facilities. This has also brought a number of injuries sustained during exercise/sporting activities, including (weightlifting, stretching, swimming, football, volleyball, jogging, squash, and basketball). There are several risk factors associated with sports injury. These factors may be divided into intrinsic risks factors such as: (sex, age, injury history and biomechanics) and extrinsic risk factors such as: (sports rules, sports equipment and environment). As a best practice, it is recommended to do warm-up before the actual exercise or sport. Warm-up is intended to perform two major functions improve the muscles dynamics so that it is less inclined to injury and prepare and raise body and muscles temperature for demands of exercise. Warm-up has many types such as stretching and increase range of motion. Warm-ups are intended to increase the body temperature, thus making it more energetic and prepared for doing the exercise.
World over, the prevalence of sports injury ranges from 56% in Israel to 51% in Australia to as low as 32% in Switzerland. Studies from the Western countries have contradictory results pertaining to warm-up and sports injury, with some supporting the association, whereas few concluding that warm-up has psychological effect. A review from Australia evaluated five high-quality studies investigating whether or not undertaking a warm-up before physical activity reduced the risk of injuries in humans. All of the studies focused on warm-up behaviors in isolation, and no other concurrent safety practices. Three of the studies found that performing a warm-up before physical activity significantly reduced the risk of injury, while the remaining two studies found that the warm-up was not effective in reducing the number of injuries. Due to the heterogeneity of the studies reviewed, no meta-analysis was undertaken. Interventions in the three studies which found that warm-up significantly reduced the risk of injury had a greater focus on exercise to increase body temperature than the remaining two studies.
A review on sports injury in the Arab world has included studies from 1985 to 2015 have reported varying figures for sports-related injuries reaching as high as 70%. They have recommended that due to the increasing popularity of sports in the Arab region, further prospective and interventional studies are needed. Past studies are available on sports injury from Saudi Arabia, few conducted on professional athletes, and some among college going or high school students. Studies have found that football injuries are common among sports players and the role of environmental factors cannot be ruled out. In a study done in 2018 in Saudi high school male students in Riyadh, Saudi Arabia. The prevalence of ankle injuries of 399 participants at the study time, last month, last 6 months, last 12 months, and high school time were 14%, 21.1%, 30.3%, 31.7%, and 34.7%, respectively. The other study was to identify the prevalence of knee injuries among male college students in Riyadh, Saudi Arabia. The overall prevalence of knee injury was 23.2%. Recent study from Jeddah city included athletes and people playing sports, ranging from 10 to 60 years, reported 50% of injuries occurring due to cocker playing followed by basketball. Around 79% of injuries occurred due to sports-related to recreational activities. Most of them injured during sport activities, especially soccer and 68.7% involved in a noncontact mechanism of injury.
To promote physical activity, a large number of fitness centers/gymnastic clubs have opened up all over Saudi Arabia, especially in major cities like Riyadh. A significant number of young adults visit the fitness centers and gymnastic clubs to promote physical activity and reduce the high burden of obesity. However, no study is available from fitness centers or the gymnastic clubs focusing on injuries. The objective of this study was to measure the prevalence of sports injuries and its association with warm-up in males visiting fitness centers in Riyadh city, Saudi Arabia.
MATERIALS AND METHODS
A cross-sectional study was conducted on 521 males aged 16–50 years living in Riyadh city while they were visiting a fitness center of the famous Fitness Time gym chain. There are more than 50 health club facilities in Riyadh, and 34 branches were selected by the random number generator. We made sure each administrative area of the city is included; hence 13 from the north, 8 from the east, 5 from the west, and 8 from the south were included in the study. The initial plan was to approach the participants in the common lounge of the health club; however, permission was declined at the last moment; hence, participants were approached in the designated parking area of the fitness/sports club.
Males aged <16 and >50 years, suffering from disability or having injury resulting from nonsport causes were excluded. The data were collected by using the electronic questionnaire administered by using computer tablets. The questions on sports referred to sports played as leisure games and not from professional athletes. The questionnaire was developed in Arabic and comprised questions on sociodemographic information, current or past history of injury while playing sports games including football, volleyball, basketball, and squash, injury caused during exercise that included weight lifting, treadmill, swimming or Swedish exercise, details about warm-up exercise and its type and duration and included running/jogging, stretching, bicycling, light weight lifting, walking, the current and past medical history and smoking status, height, and weight of the participants. All participants were asked to read, understand and sign the consent form. Each participant took 10–15 min to answer the questions. Response rates were >95% and participants were cooperative. Few participants refused mainly because of cold weather in the parking area making it difficult for them to wait. Data collection continued for 2 weeks, with 35–50 questionnaires per day. The study protocol was reviewed and approved by the Institutional Review Board, King Saud Medical City (project No. E-19-4429).
Data were analyzed using the Statistical package for the Social Science (IBM, SPSS 24.0 version statistical software, USA). Proportions for categorical and mean with standard deviation for continuous variables were calculated under descriptive information. To explore the association between the sports injury (dependent variable) and the warm-up exercise, body mass index (BMI), diet, age, education, occupation, and other potential (independent variables), we carried out bivariate and multivariate statistical analysis by logistic regression analysis. The adjusted and unadjusted odds ratio with 95% confidence interval (CI) was calculated. BMI was divided into following categories; normal >18.5–24.9 kg/m2, overweight ≥25–29.9 kg/m2, and obese ≥30 kg/m2. The factors identified to have a significant association with sports injury, and those with biological plausibility (potential confounders) or causing a 10% change in the estimates were retained in the final model. Plausible interactions were checked before developing the final model. A value of P < 0.05 was used to report the statistical significance. The model fit was assessed using the Hosmer–Lemeshow goodness-of-fit test.
The mean age and BMI of the participants was 24.0 (±6.7) years and 25.8 (±5.8) kg/m2, respectively. More than one-third of the participants (43.5%, n = 228) mentioned that they had a positive history for sports or exercise-related injury during the last one year. The sports-related injuries were more frequent than exercise-related injuries (68.8% vs. 31.2%). The most common sport played was football (68.5%), followed by volleyball (18.2%). Sports are quite common among males, however majority were playing for 1–3 days per week and only 2% were playing on a daily basis. Similar trend was observed for the exercises as well. Majority reported that they do exercise for >1 h [Table 1]. Performing regular exercise was reported by 63% (n = 330) of the participants. Exercise-related injuries found that torsions (16%) was the most common type of injury, followed by tendinopathy (10.5%) and back injury (9.3%). The most common reason for sports-related injury was football playing. The injury rate due to football playing was 43.6% (157/360 × 100).
Regular warm-up before sports was reported by 45% (n = 236) of the participants, whereas 40% (n = 210) said sometimes and remaining 15% (n = 79) said they do not do warm-ups. Stretching was the most common type of warm-up (49%) and majority (around 83%) mentioned doing warm-up for <10 min [Table 1]. Majority of the participants reported satisfaction with the gymnasium quality of floor, machines and lighting, except for the availability of the coach.
The mean age of the participants with a positive history for injury was 24.76 (±6.46) years and it was not significantly different from those without a history of sports injury (24.08 [±6.12], (P = 0.22). Similarly, no significant difference was found in the BMI between the two groups (26.18 [±6.67] and 25.57 [±5.07], P = 0.23), respectively. However, there was significant difference in BMI between those following a diet plan versus no diet plan (28.23 [±4.68] vs. 24.75 [±5.97], P < 0.001).
[Tables 2 and 3] show unadjusted odds ratio and 95% CI between various factors and sports injury. Except for the age category 31–50 years, remaining age groups did not show significant association. The average household income found that those reporting income < 5000 SAR were showing higher odds for injury [Table 2]. Univariate analysis between warm-up and sports/exercise injury did not show any significant association between warm-up and sports injury. Interestingly, the lifestyle pattern with those following a diet plan also showed increase in the odds of reporting sports/exercise injury [Table 3]. The remaining lifestyle and gymnasium-related factors did not show any significant association with the reported sports/exercise injury [Tables 2 and 3].
The factors identified on univariate analysis were also significant after conducting multivariate logistic regression analysis and adjusting for the potential confounders such as BMI, warm-up exercise, chronic diseases, and taking any dietary supplements. The age category 31–50 years had 2.06 (95% CI: 1.15–3.69) times higher odds for the injury versus younger ages (16–25 years). Low income group (reporting <5000 SAR) had odds of 2.04 (95% CI: 1.28–3.24) versus >10,000 SAR. The participants following the diet plan also showed higher odds (1.61 [95% CI: 1.06–2.43]) for reporting sports injury versus those without diet plan. We adjusted for warm-up and the BMI, and they were not statistically significantly associated with the sports injury [Table 4]. Similarly, no association was found with the environmental factors of the gym.
The sports injury prevalence reported by our study are comparable to those from Scotland, United Kingdom (43.4% vs. 42%), however, the prevalence in Riyadh was low in comparison to the study from Jeddah that found 72% prevalence for the sports injuries. This difference may be attributed to the difference in the age group and the data collection site. The study collected data from young adults visiting fitness clubs in Riyadh city, whereas the Jeddah study had participants as young as 10 years and included official government clubs and private centers. Saudi Arabia has lately started its focus on sports, especially the health club exercise programs, and fortunately, the injury rates are lower than reported from other regional countries. According to one of the regional studies conducted in Kuwait among male athletes aged 15 years and older found that the overall 12-month and lifetime prevalence of sports injuries was 73.8 and 89.8%, respectively.
We found that injuries were almost twice in number while playing sports (football, volleyball basketball) than performing indoor gym exercises (weightlifting, jogging, and swimming). Exercise is defined as a structured and repetitive type of activity perform to improve health or fitness. Exercise injuries can be because of a combination of factors such as high speed and aggressive contact between players with the lack of protective equipment, the types of field or turf, ground rules, and education about how to avoid injures in sports. A study shows that the risk of ankle sprain was increased in matches on artificial turf compared with grass. Similar to our study, sprains and strains have been reported as the most common type of injury. It may be caused by imbalance due to excessive exercise and not allowing the body to recover from the exercise, and it could be due to a lack of awareness of the importance of wearing proper footwear and protective joint braces. Similar to other local studies from Saudi Arabia, we found that football is the most commonly and regularly played sport in Riyadh, followed by volleyball, basketball and squash.
Treadmill and weightlifting were the most used type of exercise; followed by swimming, and Swedish exercises. Usually, individuals who attend the fitness centers have access to all sort of weight lifting dumbbells and equipment. This not only makes the weight lifting interesting but probably bestows a sense of achievement. This can explain why weightlifting is a very common exercise. Jogging is an easy way to achieve your daily required physical activity, so the treadmill is preferred by a lot of people as it helps them in completing the target in terms of calories burnt and time assigned. Most of the participants perform these exercises 4–6 days a week, which is considered adequate and helps in preventing several chronic diseases. It actually differs from one person to another according to the goal and needs. However, experts and professional trainers prefer setting a time limit between 45 and 60 min. This will help to prevent unnecessary exercise injury or wasting the time.
Nutrition and diet play an important role in an athlete's health. Key nutrients are utilized daily to assist muscle growth, as well as ongoing recovery and repair. The data presented in this study suggest that participants who have reported following caloric-deficit diet to reduce their weight have a higher risk of injury than others. This was supported by the fact that people with diet plan had higher BMI. It may be that people with high BMI have more risk of injury than others; however, despite the increasing trend, the association between injury and BMI was not statistically significant. This may be because we verbally inquired about the height and weight and did not conduct actual measurements. Our results are supported by another study that showed a clear association between BMI and the probability of sustaining an injury. The incidence of injuries, including those related to falls, sprains/strains, lower extremity fractures, and joint dislocations are likely to increase as the prevalence of obesity increases. Hydration is also related to good nutrition, especially during the warmer months. In Riyadh, we have high humidity in the summer, then its even more important. The cartilage is made of collagen, proteins, cells, synovial fluid, and water, up to 80% water. This water and synovial fluid cushions your bones when they bear weight or pressure, so, being well hydrated is crucial to preventing injury. However, we are limited on commenting on this as we do not have the required information from our study.
We found that age plays a significant role in sports injury because according to this study, participants 31–50 years had twice the higher odds for sports injury in comparison to younger participants. There may be several explanations for this association. First, this age group may be slightly overconfident as they are experienced hence at higher chance of negligence. Second, it may be due to deficiency of certain bone vitamins, like Vitamin D. A study showed that correcting hypovitaminosis D by screening for Vitamin D status and providing Vitamin D3 supplements will reduce the incidence of stress fractures. Other study had similar results, which showed that injury risk rate increases positively with age. They divided the age into three groups, the oldest group (over 28 years) had the highest injury risk rate, which was about 9.1%. Another study showed that there was a positive relationship between aging and proneness to injury. Furthermore, injuries are progressively increasing, beginning with high income to low income, this can be explained based on the lack of the capability to provide necessary care such as proper shoes, visiting doctors, and buying supplements. Our study included participants irrespective of the social class they belonged to; hence, the facilities within the gym were equally available to all.
Our results are in contradiction with studies that have found an association between an association between warm-ups and sports injury. There are previously published studies that have shown that warming up was not effective in significantly reducing the number of injuries. Others have shown that, based on the results, no neuromuscular warm-up program was able to reduce lower limb injury risk significantly. There may be unexplored factors that may have contributed to the results, for example, the time limitation for warming up. Most warm-up sessions last between 20 min and half an hour; this given the body plenty of time to gradually get ready for physical activity and gives the player time to prepare themselves mentally, the intensity and duration of warm-up must be individualized to the particular level of fitness of the athlete, the environmental conditions, and to the expected performance of the anticipated physical task. We recommend large scale studies in future to explore the association between the two.
Our study has some limitation as it was a cross-sectional study, we cannot establish causality. Our selection was from one chain of fitness centers belonging to urban areas; hence the results may be different from government clubs and those from rural areas. Recall bias/information bias pertaining to height; weight cannot be ruled out. Cold weather may have acted as a barrier since we used the outside parking lot as a location to conduct the interviews.
CONCLUSIONS AND RECOMMENDATION
We conclude that there is high prevalence of sports/exercise related injuries among people visiting fitness centers in Saudi Arabia. Our cross-sectional study found lack of association between warm-up and injury hence it is important to consider other factors like age, weight and lifestyle. All sports centers should have programs on the awareness about sports injuries and how to avoid them. We recommend that large scale prospective national level studies be conducted to measure the true prevalence and factors associated with sports injury. This will strengthen the national physical activity programs, improve the quality of life and also decrease the burden on health facilities.
Financial support and sponsorship
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. We are thankful to the Deanship of Scientific Research, King Saud University for their support and co-operation in conducting this study.
Conflicts of interest
There are no conflicts of interest.
Our deepest thanks to everyone who gave us their time and participate in this study.
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