Sports injury and illness incidence among South Korean elite athletes in the 2018 Asian Games: a single-physician prospective study of 782 athletes

Abstract

Objective

The increasing incidence of sports injury among athletes calls for systemic surveillance of injuries and illnesses in this field to develop preventive measures. The patterns of injuries and illnesses that occurred among Korean athletes during the 2018 Asian Games held in Indonesia were studied.

Methods

We recorded the occurrence of all injuries and illnesses reported to the chief medical officer, coordinated with the help of an instant social messaging application in real time.

Results

A total of 782 elite athletes participated in 46 sporting events. A total of 141 (18.03%) injuries were recorded, with 121 (15.47%) athletes suffering at least one injury. Out of 141 injuries 80 (56.74%) were in male athletes and 61 (43.26%) were in female athletes. The highest number of injuries was seen among sport climbing athletes (n=10, 71.43%), followed by sepak takraw. A total of 16 (11.35%) injuries were expected to prevent athletes from participation in competition/training. Most of the injuries occurred during training (46.10%), with lower lumbar spine being the most common part injured. A total of 209 (26.72%) illnesses were reported, with at least one illness in 170 (21.73%) athletes. The incidence among female athletes (26.90%) was comparable with that of male athletes (26.90%). Maximum illness rate was reported in table tennis (100%). The most common system involved was gastrointestinal (n=93, 44.49%), followed by respiratory (n=53, 25.36%). Environmental factors were causative in 111 athletes (53.11%) and infection in 79 (37.79%). Illnesses resulted in loss of at least 1 day among 30 (14.35%) athletes.

Conclusion

Overall 15.47% of athletes suffered at least one injury and 21.73% suffered at least one illness; the incidence of injury and illness varied depending on the type of sports.

Correspondence to Dr Sang-Hoon Lhee; [email protected]

Summary

• Injury and illness patterns among the Korean athletes who participated in the Asian Games were studied by a single physician using electronic media in real time and thus uniformity in reporting can be expected.

• We recorded an overall injury rate of 18 per 100 athletes, with male athletes at slightly higher risk of getting injured than female athletes.

• The rate of injury was higher compared with previous Olympics reports.

• Our statistics may reveal the actual risk of injury to athletes since it is based on a single-physician report.

• Training injuries were more common, implying the necessity of strict enforcement of adequate training rather than very little or too aggressive training sessions.

• Injury rates among sepak takraw and sport climbing athletes were very high, and it may be noted that these injury-prone games are included only in Asian Games; thus, we may suggest alterations in the game floor and use of more protective equipment.

• Regarding illnesses, the overall rate of illness was higher compared with earlier Olympics reports.

• Gastrointestinal problems were more frequent in contrast to other reports where respiratory issues were more common; in our report, respiratory issues stood next to gastrointestinal issues.

Introduction

Participation in sporting activities is important for all age groups to maintain health and for many other reasons, such as pleasure, socialisation and competition. Regular involvement in physical activity is well known to reduce the risk of coronary heart disease, hypertension, obesity and diabetes mellitus. However, sports injuries and illnesses among athletes have also led to temporary or permanent morbidity.^{1 2} Standardised monitoring and evaluation of sports injury has been developed to provide not only epidemiological information on how injury occurs but also knowledge for its preventive measures. van Mechelen et al described these measures as the ‘sequence of prevention’.^3–5 The first step in the sequence of prevention is identification of the extent of injury, second the factors causing this injury, and third the measures to be taken to prevent injury. FIFA started injury surveillance in 1998,⁵ which was then followed by other major events.^6–9 The Korean Olympic Committee, formed in 1946, became a member of the IOC in 1947 and made their first appearance in London Olympic Games in 1948.¹⁰

The injury surveillance system developed by Junge et al¹¹ convened by IOC was first successfully applied to multisport event during the 2008 Olympic Games,¹² which later was extended to include injury as well as illness during the 2010 Vancouver Olympics¹³ and the subsequent Olympics.^14–16

Although injury among athletes has been a main area of concern, the effects of illnesses cannot be overlooked. There is conclusive evidence that athletes in training are more susceptible to viral illnesses when compared with the normal population.¹⁷ Illnesses not only affect athletes’ performance, but a transmittable illness could also affect sports competitors, trainers and even the audience.^{18 19} Moreover, the desire of athletes to train through illness to minimise lay-off time conflicts with the need to minimise stress during acute illness.¹⁷

Various studies have reported injury and illness patterns in Korean athletes over time.^20–25 Most of these studies were performed over a long period of training in different sports. The aim of the present study is to study the injury and illness patterns among elite Korean athletes who participated in the 2018 Asian Games held in Jakarta and Palembang, Indonesia.

Methods

Study design and implementation

We employed the IOC surveillance system to record injuries and illnesses sustained by South Korean athletes during the 2018 Asian Games in this prospective cohort study. Three weeks prior to the games, the study objectives were explained to South Korean team physiotherapists, trainers and team coaches. All injuries and illnesses which occurred during training or competition were reported to the chief medical officer (CMO) in real time using a South Korean free instant messaging client called ‘Kakao Talk’ and the reported athletes were examined and treated by the CMO.

Injuries and illnesses were recorded in a standardised injury and illness form adopted from IOC.⁷ Anonymity and confidentiality were assured to all participants. Athletes’ accreditation number was used to eliminate duplicate entries.

Definition of injury and illness

An injury is defined as any musculoskeletal complaint, concussion or other medical conditions newly incurred due to competition and/or training that received medical attention regardless of the consequences with respect to absence from competition and/or training.¹¹ This excluded pre-existing and not fully rehabilitated injuries, but included all injuries that required medical attention and fully rehabilitated injuries that occurred during training and games.

An illness is defined as any physical complaint (not related to injury) newly incurred during games that received medical attention regardless of the consequences with respect to absence from competition and/or training.¹¹ This excluded pre-existing and chronic illnesses, but included all illnesses that required medical attention and acute exacerbations of chronic illness.

Data analysis

Injury and illness incidence rates were calculated using the formula I=n/e, where n is the total number of injury and illness and e is the total number of exposed athletes. The 95% CI for each rate was based on the Poisson distributed variable. The incidence of injury and illness was expressed per 100 athletes. Comparisons of categorical variables were done using χ² test or Fisher’s exact test for small numbers. Incidence rates between the two groups were presented as rate ratio (RR). We considered p≤0.05 as significant. All data were evaluated using Microsoft Excel and SPSS V.14.0.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

Results

A total of 782 Korean athletes took part in the 2018 Asian Games held in Jakarta and Palembang in Indonesia from 18 August 2018 to 2 September 2018 (16 days), of whom 440 (56.26%) were male and 342 (43.73%) were female athletes.

Incidence and distribution of injury

We observed a total of 141 injuries, giving an injury rate of 18.03 per 100 athletes, out of which 121 (15.47%) suffered at least one injury, 18 (2.30%) suffered two injuries each and one athlete suffered triple injury. Out of 141 injuries 80 (56.74%) were in male and 61 (43.26%) were in female athletes. The risk of an athlete being injured was highest in sepak takraw (n=17, 62.96%), followed by sport climbing (n=8, 57.14%). The risk of injury was high in basketball, bowling, fencing, field hockey, handball, jet ski, ju-jitsu, kabaddi, roller sports, rowing, squash, triathlon, weightlifting and wushu (20%–50% of registered athletes were affected in each sport). No injuries were reported in archery, badminton, diving, equestrian, golf, gymnastics, karate, kurash, modern pentathlon, paragliding and water polo (table 1 and figure 1).

Figure 1. Graphical representation of the incidence of injuries and illnesses in different sport events.

Table 1

Summary of the incidence of total injuries and illnesses with distribution of time loss due to injury

Sport	Athletes who participated			Injuries								Illness
				Distribution				Severity				Male	Female	Total	Incidence (%)
	Male	Female	Total	Total	Incidence (%)	Male	Female	No time loss	1–6 days	>7 days	Early return
Archery	8	8	16	0	0.00	0	0	0	0	0	0	3	2	5	31.25
Artistic swimming	0	10	10	1	10.00	0	1	0	1	0	0	0	0	0	0.00
Athletics	22	18	40	7	17.50	4	3	7	0	0	0	1	0	1	2.50
Badminton	10	10	20	0	0.00	0	0	0	0	0	0	3	2	5	25.00
Baseball	24	0	24	3	12.50	3	0	3	0	0	0	10	0	10	41.67
Basketball	16	4	20	7	35.00	5	2	7	0	0	0	4	2	6	30.00
Bowling	6	6	12	4	33.33	2	2	4	0	0	0	0	3	3	25.00
Boxing	7	3	10	1	10.00	1	0	1	0	0	0	1	0	1	10.00
Canoeing	21	13	34	5	14.70	1	4	5	0	0	0	6	5	11	32.35
Cycling	18	9	27	1	3.70	1	0	1	0	0	0	1	2	3	11.11
Diving	2	4	6	0	0.00	0	0	0	0	0	0	0	0	0	0.00
Equestrian	11	0	11	0	0.00	0	0	0	0	0	0	5	0	5	45.45
Fencing	12	12	24	7	29.17	3	4	6	1	0	0	4	5	9	37.50
Field hockey	18	18	36	11	30.56	10	1	11	0	0	0	7	7	14	38.89
Football	20	20	40	2	5.00	0	2	1	1	0	0	0	9	9	22.50
Golf	4	3	7	0	0.00	0	0	0	0	0	0	0	0	0	0.00
Gymnastics	5	9	14	0	0.00	0	0	0	0	0	0	4	0	4	28.57
Handball	16	16	32	12	37.50	6	6	7	5	0	0	2	10	12	37.50
Jet ski	6	0	6	3	50.00	3	0	3	0	0	0	1	0	1	16.67
Ju-jitsu	1	1	2	1	50.00	0	1	1	0	0	0	0	0	0	0.00
Judo	9	10	19	2	10.53	0	2	2	0	0	0	0	1	1	5.26
Kabaddi	12	11	23	5	21.74	4	1	4	1	0	0	2	1	3	13.04
Karate	4	4	8	0	0.00	0	0	0	0	0	0	1	0	1	12.50
Kurash	1	1	2	0	0.00	0	0	0	0	0	0	0	0	0	0.00
Modern pentathlon	2	2	4	0	0.00	0	0	0	0	0	0	0	0	0	0.00
Paragliding	5	3	8	0	0.00	0	0	0	0	0	0	0	0	0	0.00
Roller sports	6	2	8	2	25.00	2	0	2	0	0	0	3	1	4	50.00
Rowing	10	8	18	5	27.78	3	2	5	0	0	0	10	6	16	88.89
Rugby sevens	12	12	24	2	8.33	2	0	2	0	0	0	0	1	1	4.17
Sailing	8	3	11	1	9.09	1	0	1	0	0	0	5	0	5	45.45
Sepak takraw	15	12	27	17	62.96	7	10	16	0	0	1	7	5	12	44.44
Shooting	18	10	28	4	14.29	2	2	4	0	0	0	5	4	9	32.14
Soft tennis	5	5	10	1	10.00	1	0	1	0	0	0	0	3	3	30.00
Softball	0	17	17	3	17.65	0	3	3	0	0	0	0	0	0	0.00
Sport climbing	7	7	14	8	57.14	7	1	8	0	0	0	3	2	5	35.71
Squash	4	4	8	2	25.00	1	1	2	0	0	0	3	1	4	50.00
Swimming	14	13	27	3	11.11	1	2	3	0	0	0	6	9	15	55.56
Table tennis	5	5	10	1	10.00	1	0	1	0	0	0	5	5	10	100.00
Taekwondo	9	9	18	3	16.67	0	3	3	0	0	0	0	1	1	5.56
Tennis	6	6	12	1	8.33	1	0	0	1	0	0	3	2	5	41.67
Triathlon	2	3	5	1	20.00	0	1	0	0	0	1	2	0	2	40.00
Volleyball	16	16	32	3	9.38	0	3	3	0	0	0	2	1	3	9.38
Water polo	13	0	13	0	0.00	0	0	0	0	0	0	1	0	1	7.69
Weightlifting	8	7	15	6	40.00	6	0	5	1	0	0	2	1	3	20.00
Wrestling	12	6	18	3	16.67	0	3	1	2	0	0	3	1	4	22.22
Wushu	10	2	12	3	25.00	2	1	2	1	0	0	2	0	2	16.67
Total	440	342	782	141	18.03	80	61	125	14	0	2	117	92	209	26.72

Statistics

The rate of injury in male (18.18 per 100 athletes, 95% CI 11.44 to 28.45) and female (17.84 per 100 athletes, 95% CI 10.67 to 27.22) athletes was similar. There was no statistical difference between the two groups (RR=1.01, p=0.901). However, male athletes were at significantly increased risk of injury in field hockey (p=0.003), sport climbing (p=0.005) and weightlifting (p=0.007), whereas female athletes were at higher risk of injury in wrestling (p=0.025).

Severity

Majority (125, 88.65%) of the athletes returned to their sports with no time loss, while 14 (9.93%) athletes lost less than 7 days and 2 female (1.42%) athletes had to return to their home country before their event. Both the two female athletes who returned earlier suffered ligament rupture, knee in one and ankle in the other, due to non-contact trauma.

Circumstances

Most of the injuries (65 of 141, 46.10%) occurred during the time of training, followed by 28 (19.86%) injuries during the time of competition. Only one (0.71%) injury occurred during warm-up.

Location, cause and diagnosis of injury

Lower lumbar spine was injured in 25 (16.67%) cases, followed by knee in 23 cases (15.33%) and ankle in 16 cases (10.67%). The abdomen, upper arm and hip were not injured.

The more frequently observed cause was overuse (sudden onset) in 57 cases (40.42%), followed by non-contact trauma in 25 cases (17.70%) (figure 2). The least reported causes were violation of rules (obstruction, pushing), field of play conditions, weather conditions and equipment failure, with no cases in each.

Figure 2. Cause of injury.

The most common diagnosis of muscle strain/rupture/tear was made in 42 cases (28.77%), followed by ligament sprain in 30 cases (20.55%) (figure 3). Tendon rupture, joint dislocation, joint subluxation, arthritis, synovitis, bursitis, dental injury, neurological injury, spinal injury and others were not found to be causative in our series.

Figure 3. Diagnoses.

Incidence and distribution of illness

Among a total of 782 athletes, 209 (26.72%) illnesses were reported; at least one illness was reported in 170 (21.73%) athletes and double illness in 39 (4.98%) athletes. Out of 209 illnesses 117 (26.59%) were in male and 92 (26.90%) were in female athletes. The maximum incidence of illness was reported in table tennis (100%), followed by rowing (94.44%). The risk of illness was also high in archery, baseball, basketball, canoeing, equestrian, fencing, field hockey, handball, tennis, sailing, shooting, squash and swimming (30%–60% of registered athletes in each sport) (table 1). No illness was reported in artistic swimming, diving, golf, jet ski, ju-jitsu, kurash, modern pentathlon, paragliding, softball and water polo. The maximum number of illnesses was reported on the fourth day of event (n=22, 10.52%).

Statistics

The rate of illness among female athletes (26.90 per 100 female athletes, 95% CI 17.79 to 38.10) was comparable with the rate of illness in male athletes (26.59 per 100 male athletes, 95% CI 17.79 to 38.09). There was no statistical difference between the two groups (RR=0.98, p=0.923). Female athletes in football were at significantly higher risk of falling ill (p=0.001).

Affected system, symptom and cause of illness

The most common system involved was gastrointestinal (n=93, 44.49%), followed by respiratory (n=53, 25.36%). Out of 93 athletes complaining of gastrointestinal problems, 37 (39.78%) were male and 56 (60.21%) were female athletes; 83 of them reported gastrointestinal problems associated with diarrhoea/vomiting, 16 athletes had gastrointestinal problems associated with fever, and 42 athletes had associated pain in the abdomen (table 2). When gastrointestinal problem was plotted against the day of arrival, it was found that 32.25% of athletes complained of gastrointestinal problems on the fourth and fifth day of their arrival at the venue (figure 4). Change of environment was attributed to be the cause of gastrointestinal problem in 67 athletes (72.04%) and infection in 24 (25.80%).

Figure 4. Distribution of gastrointestinal (GI) illness with respect to the nth day of their arrival at the venue.

Table 2

Distribution of presenting symptoms and causes of illness in two most affected systems (respiratory and gastrointestinal)

Affected system	Respiratory	Gastrointestinal	Total
Sex
Male	23	37	60
Female	30	56	86
Total	53	93	146
Main symptom
Fever	15	16	31
Pain	46	42	88
Diarrhoea, vomiting	0	83	83
Dyspnoea, cough	13	0	13
Other	0	2	2
Total	74	143	217
Cause of illness
Infection	50	24	74
Exercise-induced	0	1	1
Environmental	2	67	69
Other	1	1	2
Total	53	93	146

The second most common system involved was respiratory (n=53, 25.36%). Among 53 athletes with respiratory symptoms, 46, 15 and 13 presented with throat pain, fever and dyspnoea, respectively. Infection was attributed to be the cause in 50 (94.33%) athletes. The maximum incidence of respiratory illness (16.98%) was reported on the fifth day of event, whereas the maximum incidence of total illness was reported on the fourth day of event. Other systems involved were gynaecological in 4, cardio vascular system in 1, allergic/immunological in 5, neurological in 8, dermatological in 25 and musculoskeletal in 12.

Of all illnesses, pain was the most common symptom (n=113, 54.06%). Environmental factors were causative in 111 athletes (53.11%) and infection in 79 (37.79%). Illnesses resulted in loss of at least 1 day among 30 (14.35%) athletes.

Discussion

Injury patterns during the 2018 Asian Games

A total of 141 athletes were injured out of 782 athletes, giving an incidence of 18.03 athletes per 100 registered athletes. This incidence is higher when compared with the incidence in previous Olympic Games, Beijing 2008 (9.61%),¹² Vancouver 2010 (11.18%),¹³ London 2012 (12.88%),¹⁴ Sochi 2014 (14%)¹⁵ and Rio 2016 (9.80%),¹⁶ but lower compared with the Malaysian team in the 2014 Asian Games (30%).²⁶ Earlier reports from the Olympic Games relied on voluntary reporting of injuries and illnesses by the athletes and submission by the medical officers of each country, which might not have uniformity and can have some bias based on individual perceptions of severity. This study is based on a single-physician (CMO) report. Each injury and illness was brought to notice irrespective of severity. Only the CMO decided whether the injury/illness must be reported or not.

In our study the rate of injury was higher in sepak takraw (62.96%) and sport climbing (57.14%). The higher incidence may be due to smaller study population when compared with previous Olympic reports. The higher rate of injury in our study can also be explained by our finding of higher rates of injury in sport climbing and sepak takraw; these injury-prone games are restricted to Asian Games only and are not included in the Olympics. Since the very nature of sepak takraw^{27 28} and sport climbing^29–32 is injury-prone, we therefore suggest better padded floorings and protective equipment for these games. With more than half of the players getting injured, we may suggest omission of such sports from Asian Games owing to the expenditure involved in taking care of them. However, such drastic conclusions cannot be made from few studies^27–32 involving smaller groups of athletes and hence larger studies are required.

Severity

Out of the total injuries, majority (n=125, 88.65%) of the encounters did not result in any loss of days. The percentages of injuries which did not result in loss of days from sports were, respectively, 50.40%, 65%, 61% and 60% in Summer Olympics 2008,¹² London Olympics 2012,¹⁴ Sochi 2014 Winter Olympics¹⁵ and Rio De Janeiro 2016 Olympics.¹⁶ Injury data from the Malaysian team in Asian Games reveal a closer injury severity with no time loss injuries of 68.70%.²⁷

The higher incidence and more injuries with no time loss in our study population could be due to increased awareness among athletes to report even minor incidents and due to the cultural nature of perseverance to continue sports despite minor ailments. This also explains better rapport and compliance between athletes and medical personnel, more comprehensive and accurate reporting, and minimal or zero loss of injury coverage and data, which are vital in order not to miss any injury that can further harm the athletes and may prevent them from participating in sports.

Since the number of athletes injured with no loss of days is very high in our report, we therefore compared the athletes with severe injuries with the total number of athletes who participated rather than the number of athletes injured. In our study 2 out of 782 (0.26 per 100 or 2.6 per 1000) athletes had to return early due to severe injuries (one female athlete had ligament rupture in the knee and the other had ligament rupture in the ankle). We compared these data with athletes whose injuries cost them more than 28 days’ time loss (considering them as severe injuries) to the total number of athletes who participated in the previous studies. Agreeably, this was, respectively, 3.70, 6.50, 14.02 and 10.20 per 1000 registered athletes in Summer Olympics 2008,¹² London Olympics 2012,¹⁴ Sochi 2014 Winter Olympics¹⁵ and Rio 2016 Olympics.¹⁶

Circumstances

More injuries occurred during training (46.10%). This is almost closer to the injury circumstances (ie, during training) of the Malaysian team in 2014 Asian Games (57%)²⁶ and Sochi 2014 Winter Olympics (63%),¹⁵ whereas the majority of the injuries (72.60%) occurred during competition in Summer Olympics 2008,¹² 55% during competition in London Olympics 2012¹⁴ and 59% during competition in Rio 2016 Olympics.¹⁶ We are not sure of this gross variation in injury circumstances.

There is adequate evidence in the literature that both undertraining and overtraining can lead to increased injuries to the athletes.^{33 34} However adequate hard training actually improves physique, which protects from injuries.³⁵ We also firmly believe that injuries during training can be reduced to a greater extent by balancing the intensity of training to appropriate levels³⁶ just before the events and not to be overenthusiastic.

Location, type and cause of injuries

Lower lumbar spine was injured in 25 (16.67%) cases, followed by knee in 23 (15.33%) cases and ankle in 16 (10.67%) cases. The most frequently observed type was muscle injuries, which occurred in 42 (28.77%) cases, followed by sprains in 30 (20.55%) cases. In Rio 2016 Olympics¹⁶ ligament injuries (16.98%) and muscle injuries (15.26%) were frequent, in agreement with our study.

The more frequently observed cause was overuse (sudden onset) in 57 (40.40%) cases, followed by non-contact trauma in 25 (17.70%) cases and contact with another athlete in 20 (14.20%) cases. Overuse was causative in 25% in London 2012,¹⁴ 14% in Sochi 2014,¹⁵ 19% among the Malaysian team in Asian Games²⁶ and 19% in Rio 2016.¹⁶ Non-contact trauma was causative in 20% in London 2012,¹⁴ 13% in Sochi 2014¹⁵ and 21% in Rio 2016.¹⁶ Thus overuse and non-contact trauma were more frequently causative in other reports as well.

Illness risk during the 2018 Asian Games

The overall rate of illness in our report was higher (26.72%) when compared with previous reports, that is, in London 2012 (7%),¹⁴ Vancouver 2010 (7%),¹³ Sochi 2014 (8%)¹⁵ and Rio 2016 (5%).¹⁶ Higher illness incidence was reported by the Malaysian athletic team (23.2%)²⁶ during the 2014 Asian Games, the Korean Olympic team in Rio (35.8%)³⁷ and during the 2009 International Association of Athletics Federations World Athletics Championship (68.2%).³⁸ Like previous reports illness was slightly more common among female athletes as compared with male athletes (26.90 vs 26.59 per 100 athletes).

Gastrointestinal was the most common system involved (44.49%) in contrast to previous events which reported respiratory as the most common system involved. Out of 93 athletes with gastrointestinal problems, 83 presented with diarrhoea or vomiting. Runner’s diarrhoea³⁹ (runners trots) is a well-known complaint in athletes. Stuempfle et al³⁹ in their study reported gastrointestinal distress in as high as 96% of endurance athletes. Although the exact mechanism is unknown, proposed theories are shunting of blood from the gut to the musculoskeletal system during exercise leading to disruption of the gastric barrier and diarrhoea,⁴⁰ increased jostling of abdominal contents during exercise causing altered transit time in small and large bowels,^{41 42} decreased adaptability to changes in the environment, increased training stress, temperature changes during and after training, increased crowd in athletic village, and change in food types and water in a different country. Almost all cases of diarrhoea and vomiting responded to oral fluids and antimotility agents; 16 of them presented with fever and 42 with abdominal pain requiring medication, but none lasted for more than 48–72 hours.

Respiratory complaints were present in 25.36% of athletes, which was lower compared with 62.8% in Vancouver, 64% in Sochi, 47% in Rio, 51% in Malaysian athletes in the 2014 Asian Games and 75.9% in Korean Olympics team in Rio Olympics. Respiratory illness has always been on the higher side among athletes participating in multisport events.^43–49 This increased incidence of respiratory illness has been attributed to increased inhalation of airborne pollutants and irritants during increased ventilatory exercises, dehydration of airway, immunosuppression following stress and performance pressure.⁵⁰ Studies have anticipated that athletes travelling intercountry or intercontinental are at higher risk of contracting an illness.⁵¹

Treatment and prevention

Adequate oral fluids and antimotility agents such as loperamide relieve diarrhoea, and for athletes complaining of abdominal pain or haematochezia all non-steroidal anti-inflammatory drugs should be stopped and supplemented with H2 blockers.^{41 52}

For prevention all athletes should be evaluated with adequate history of irritable bowel disease or any gastrointestinal-related conditions; although prewarming increases the performance of athletes, excessive body heat can cause decreased performance.⁵³ de Oliveira et al⁴² in their study recommended fluid intake with multiple transportable carbohydrates such as glucose and fructose rather than hydration with only glucose. Another nutritional preventive measure proposed by Lis et al⁵⁴ is to avoid fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs). FODMAPs increase water and fermentable substrate within the colon.⁵⁵

Strengths and limitations

The strength of this study is the comprehensive and 100% reporting of injuries and illnesses. Since the data collection and reporting was through a single physician, there was no bias in reporting of severity of injury and illness and even the trivial ones were notified to the CMO. Formation and use of social media-based group for communication was a new approach to this type of study which helped to prevent loss of data.

The smaller study population was a limitation of this study, which led to higher incidence of injuries and illnesses as compared with previous Olympic Games. Another limitation was that we did not report risk of injury and illness as a measure of time exposed owing to the fact that large numbers of participants had variable exposed days; thus, our method assumes that all participants were equally exposed to length and frequency of risks.

Time loss for injured athletes who had to return home early was based on how long he or she could not participate in training or competition. A follow-up of these athletes on how long it takes for them to recover and the percentage of recovery achieved could improve the validity of the data. Another suggestion is video analysis of all injuries for better understanding of the mechanism of injuries.

Conclusion

The incidence of injuries and illnesses among South Korean athletes in the 2018 Asian Games was 18.03 and 27.28 per 100 athletes, respectively. The rate of injuries and illnesses was affected by specific types of sports and gender. Most of the injuries and illnesses were minor, with no loss of participation. The highest number of injuries was recorded in sport climbing and sepak takraw, while the highest number of illnesses was reported in table tennis and rowing.

Data availability statement

Data are available upon reasonable request.

Footnote

Contributors S-HL conceived the idea of the study and design of the work, assisted by SK, MB and JY with data collection. RJ and MMS helped in the analysis of the collected data and in drafting of the manuscript. DYL made critical revision to the manuscript. All authors made approval of the final manuscript as submitted.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

References

¹ Bahr R, Holme I. Risk factors for sports injuries--a methodological approach. Br J Sports Med 2003; 37: 384–92. doi:10.1136/bjsm.37.5.384 http://www.ncbi.nlm.nih.gov/pubmed/14514527

² Fuller CW, Junge A, Dvorak J. A six year prospective study of the incidence and causes of head and neck injuries in international football. Br J Sports Med 2005; 39 Suppl 1: i3–9. doi:10.1136/bjsm.2005.018937 http://www.ncbi.nlm.nih.gov/pubmed/16046353

³ Meeuwisse WH, Love EJ. Athletic injury reporting. Sports Medicine 1997; 24: 184–204. doi:10.2165/00007256-199724030-00008

⁴ van Mechelen W, Hlobil H, Kemper HC. Incidence, severity, aetiology and prevention of sports injuries. A review of concepts. Sports Med 1992; 14: 82–99. doi:10.2165/00007256-199214020-00002 http://www.ncbi.nlm.nih.gov/pubmed/1509229

⁵ Junge A, Dvorak J, Graf-Baumann T, et al. Football injuries during FIFA tournaments and the Olympic Games, 1998-2001: development and implementation of an injury-reporting system. Am J Sports Med 2004; 32: 80–9. doi:10.1177/0363546503261245 http://www.ncbi.nlm.nih.gov/pubmed/14754863

⁶ Bahr R, Reeser JC, Fédération Internationale de Volleyball. Injuries among world-class professional beach volleyball players. The Fédération Internationale de Volleyball beach volleyball injury study. Am J Sports Med 2003; 31: 119–25. doi:10.1177/03635465030310010401 http://www.ncbi.nlm.nih.gov/pubmed/12531768

⁷ Fuller CW, Laborde F, Leather RJ, et al. International rugby board rugby world cup 2007 injury surveillance study. Br J Sports Med 2008; 42: 452–9. doi:10.1136/bjsm.2008.047035 http://www.ncbi.nlm.nih.gov/pubmed/18539659

⁸ Hägglund M, Waldén M, Bahr R, et al. Methods for epidemiological study of injuries to professional football players: developing the UEFA model. Br J Sports Med 2005; 39: 340–6. doi:10.1136/bjsm.2005.018267 http://www.ncbi.nlm.nih.gov/pubmed/15911603

⁹ Webborn N, Willick S, Reeser JC. Injuries among disabled athletes during the 2002 winter Paralympic Games. Med Sci Sports Exerc 2006; 38: 811–5. doi:10.1249/01.mss.0000218120.05244.da http://www.ncbi.nlm.nih.gov/pubmed/16672831

¹⁰ Korea Sports. Korea Sports & Olympic Committee. Available: https://www.sports.or.kr

¹¹ Junge A, Engebretsen L, Alonso JM, et al. Injury surveillance in multi-sport events: the International Olympic Committee approach. Br J Sports Med 2008; 42: 413–21. doi:10.1136/bjsm.2008.046631 http://www.ncbi.nlm.nih.gov/pubmed/18390916

¹² Junge A, Engebretsen L, Mountjoy ML, et al. Sports injuries during the summer Olympic Games 2008. Am J Sports Med 2009; 37: 2165–72. doi:10.1177/0363546509339357 http://www.ncbi.nlm.nih.gov/pubmed/19783812

¹³ Engebretsen L, Steffen K, Alonso JM, et al. Sports injuries and illnesses during the winter Olympic Games 2010. Br J Sports Med 2010; 44: 772–80. doi:10.1136/bjsm.2010.076992 http://www.ncbi.nlm.nih.gov/pubmed/20820057

¹⁴ Engebretsen L, Soligard T, Steffen K, et al. Sports injuries and illnesses during the London summer Olympic Games 2012. Br J Sports Med 2013; 47: 407–14. doi:10.1136/bjsports-2013-092380 http://www.ncbi.nlm.nih.gov/pubmed/23515712

¹⁵ Soligard T, Steffen K, Palmer-Green D, et al. Sports injuries and illnesses in the Sochi 2014 Olympic winter games. Br J Sports Med 2015; 49: 441–7. doi:10.1136/bjsports-2014-094538 http://www.ncbi.nlm.nih.gov/pubmed/25631542

¹⁶ Soligard T, Steffen K, Palmer D, et al. Sports injury and illness incidence in the Rio de Janeiro 2016 Olympic summer games: a prospective study of 11274 athletes from 207 countries. Br J Sports Med 2017; 51: 1265–71. doi:10.1136/bjsports-2017-097956 http://www.ncbi.nlm.nih.gov/pubmed/28756389

¹⁷ Roberts JA. Viral illnesses and sports performance. Sports Med 1986; 3: 296–303. doi:10.2165/00007256-198603040-00006 http://www.ncbi.nlm.nih.gov/pubmed/3526508

¹⁸ Ahmadinejad Z, Alijani N, Mansori S, et al. Common sports-related infections: a review on clinical pictures, management and time to return to sports. Asian J Sports Med 2014; 5: 1–9. doi:10.5812/asjsm.34174 http://www.ncbi.nlm.nih.gov/pubmed/24868426

¹⁹ Roberts JA, Wilson JA, Clements GB. Virus infections and sports performance--a prospective study. Br J Sports Med 1988; 22: 161–2. doi:10.1136/bjsm.22.4.161 http://www.ncbi.nlm.nih.gov/pubmed/2852528

²⁰ Yang YJ, Lee JH, LEe MJ. Injuries and illnesses of Korean athletes during 2002 Busan Asian games. Korean J Sports Med 2004; 22: 135–43.

²¹ Kim E, Kim T, Park W. Injuries at the summer Asian games 2010: a prospective epidemiologic study in national athletes. Int SportMed J 2014; 15: 62–76.

²² Lee CY. The sport injuries of Korean national male and female ice hockey players. Korean J Phys Educ 2007; 46: 473–84.

²³ Park KJ, Brian Byung S, Byung SB. Injuries in elite Korean fencers: an epidemiological study. Br J Sports Med 2017; 51: 220–5. doi:10.1136/bjsports-2016-096754 http://www.ncbi.nlm.nih.gov/pubmed/28148511

²⁴ Son BA, Jeong HS, Kong ID, et al. Epidemiological study of taekwondo injuries: 1-year prospective study. Br J Sports Med 2017; 51: 391 doi:10.1136/bjsports-2016-097372.273

²⁵ Cho YJ, Na YM, Jung HS, et al. One-Year follow-up prospective epidemiological study of injury types in the Korea ladies professional golfers, 2015 season. Br J Sports Med 2017; 51: 307 doi:10.1136/bjsports-2016-097372.61

²⁶ AHamid MS, Puji A, Salleh Z. Patterns of injuries and illness among Malaysian athletes during the XVII Asian games 2014. Sains Malaysiana 2016; 45: 1531–153.

²⁷ Jalayondeja W, Vatchalathiti R, Neraphong K. Injuries in Thai male national Sepaktakraw team: 13th Asian games tournament. Hong Kong, China: International symposium in biomechanics in sports, 2000.

²⁸ Kerdsomnuk P, Limroongreungrat W, Chaunchaiyakul R. Ground reaction force and loading rate during sepaktakraw spike landings. J Sports Sci 2015; 15.

²⁹ Grønhaug G, Norberg M. First overview on chronic injuries in sport climbing: proposal for a change in reporting of injuries in climbing. BMJ Open Sport Exerc Med 2016; 2: e000083. doi:10.1136/bmjsem-2015-000083 http://www.ncbi.nlm.nih.gov/pubmed/27900162

³⁰ Grønhaug G. Self-Reported chronic injuries in climbing: who gets injured when? BMJ Open Sport Exerc Med 2018; 4: e000406. doi:10.1136/bmjsem-2018-000406 http://www.ncbi.nlm.nih.gov/pubmed/30057779

³¹ Woollings KY, McKay CD, Emery CA. Risk factors for injury in sport climbing and bouldering: a systematic review of the literature. Br J Sports Med 2015; 49: 1094–9. doi:10.1136/bjsports-2014-094372 http://www.ncbi.nlm.nih.gov/pubmed/26009554

³² Paige TE, Fiore DC, Houston JD. Injury in traditional and sport rock climbing. Wilderness Environ Med 1998; 9: 2–7. doi:10.1580/1080-6032(1998)009%5B0002:IITASR%5D2.3.CO;2 http://www.ncbi.nlm.nih.gov/pubmed/11990177

³³ Orchard J. Who is to blame for all the football injuries? Br J sports Med, 2012. Available: http://blogs.bmj.com/bjsm/2012/06/20/who-is-to-blame-for-all-thefootball-injuries/

³⁴ Soligard T, Schwellnus M, Alonso J-M, et al. How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. Br J Sports Med 2016; 50: 1030–41. doi:10.1136/bjsports-2016-096581 http://www.ncbi.nlm.nih.gov/pubmed/27535989

³⁵ Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med 2016; 50: 273–80. doi:10.1136/bjsports-2015-095788 http://www.ncbi.nlm.nih.gov/pubmed/26758673

³⁶ Morton RH. Modeling training and overtraining. J Sports Sci 1997; 15: 335–40. doi:10.1080/026404197367344 http://www.ncbi.nlm.nih.gov/pubmed/9232559

³⁷ Yoon J, Bae M, Kang H, et al. Descriptive epidemiology of sports injury and illness during the Rio 2016 Olympic games: a prospective cohort study for Korean team. Int J Sports Sci Coach 2018; 13: 939–46. doi:10.1177/1747954118768686

³⁸ Alonso J-M, Tscholl PM, Engebretsen L, et al. Occurrence of injuries and illnesses during the 2009 IAAF world athletics Championships. Br J Sports Med 2010; 44: 1100–5. doi:10.1136/bjsm.2010.078030 http://www.ncbi.nlm.nih.gov/pubmed/21106775

³⁹ Stuempfle KJ, Hoffman MD. Gastrointestinal distress is common during a 161-km ultramarathon. J Sports Sci 2015; 33: 1814–21. doi:10.1080/02640414.2015.1012104 http://www.ncbi.nlm.nih.gov/pubmed/25716739

⁴⁰ de Oliveira EP. Runner's diarrhea: what is it, what causes it, and how can it be prevented? Curr Opin Gastroenterol 2017; 33: 41–6. doi:10.1097/MOG.0000000000000322 http://www.ncbi.nlm.nih.gov/pubmed/27798441

⁴¹ Moses FM. The effect of exercise on the gastrointestinal tract. Sports Med 1990; 9: 159–72. doi:10.2165/00007256-199009030-00004 http://www.ncbi.nlm.nih.gov/pubmed/2180030

⁴² de Oliveira EP, Burini RC, Jeukendrup A. Gastrointestinal complaints during exercise: prevalence, etiology, and nutritional recommendations. Sports Med 2014; 44 Suppl 1: 79–85. doi:10.1007/s40279-014-0153-2 http://www.ncbi.nlm.nih.gov/pubmed/24791919

⁴³ Schwellnus M, Derman W, Jordaan E, et al. Factors associated with illness in athletes participating in the London 2012 Paralympic games: a prospective cohort study involving 49,910 athlete-days. Br J Sports Med 2013; 47: 433–40. doi:10.1136/bjsports-2013-092371 http://www.ncbi.nlm.nih.gov/pubmed/23525473

⁴⁴ Derman W, Schwellnus M, Jordaan E, et al. Illness and injury in athletes during the competition period at the London 2012 Paralympic games: development and implementation of a web-based surveillance system (WEB-IISS) for team medical staff. Br J Sports Med 2013; 47: 420–5. doi:10.1136/bjsports-2013-092375 http://www.ncbi.nlm.nih.gov/pubmed/23537560

⁴⁵ Dvorak J, Junge A, Derman W, et al. Injuries and illnesses of football players during the 2010 FIFA World cup. Br J Sports Med 2011; 45: 626–30. doi:10.1136/bjsm.2010.079905 http://www.ncbi.nlm.nih.gov/pubmed/21257668

⁴⁶ Alonso J-M, Edouard P, Fischetto G, et al. Determination of future prevention strategies in elite track and field: analysis of Daegu 2011 IAAF Championships injuries and illnesses surveillance. Br J Sports Med 2012; 46: 505–14. doi:10.1136/bjsports-2012-091008 http://www.ncbi.nlm.nih.gov/pubmed/22522588

⁴⁷ Sell K, Hainline B, Yorio M, et al. Illness data from the US open tennis Championships from 1994 to 2009. Clin J Sport Med 2013; 23: 25–32. doi:10.1097/JSM.0b013e31826b7e52 http://www.ncbi.nlm.nih.gov/pubmed/23011554

⁴⁸ Al-Shaqsi S, Al-Kashmiri A, Al-Risi A, et al. Sports injuries and illnesses during the second Asian beach games. Br J Sports Med 2012; 46: 780–7. doi:10.1136/bjsports-2011-090852 http://www.ncbi.nlm.nih.gov/pubmed/22611140

⁴⁹ Theron N, Schwellnus M, Derman W, et al. Illness and injuries in elite football players--a prospective cohort study during the FIFA Confederations Cup 2009. Clin J Sport Med 2013; 23: 379–83. doi:10.1097/JSM.0b013e31828b0a10 http://www.ncbi.nlm.nih.gov/pubmed/23657119

⁵⁰ Kippelen P, Fitch KD, Anderson SD, et al. Respiratory health of elite athletes - preventing airway injury: a critical review. Br J Sports Med 2012; 46: 471–6. doi:10.1136/bjsports-2012-091056 http://www.ncbi.nlm.nih.gov/pubmed/22522585

⁵¹ Schwellnus MP, Derman WE, Jordaan E, et al. Elite athletes travelling to international destinations >5 time zone differences from their home country have a 2-3-fold increased risk of illness. Br J Sports Med 2012; 46: 816–21. doi:10.1136/bjsports-2012-091395 http://www.ncbi.nlm.nih.gov/pubmed/22875910

⁵² Cooper BT, Douglas SA, Firth LA, et al. Erosive gastritis and gastrointestinal bleeding in a female runner. prevention of the bleeding and healing of the gastritis with H2-receptor antagonists. Gastroenterology 1987; 92: 2019–23. doi:10.1016/0016-5085(87)90638-x http://www.ncbi.nlm.nih.gov/pubmed/2883068

⁵³ Koon G, Atay O, Lapsia S. Gastrointestinal considerations related to youth sports and the young athlete. Transl Pediatr 2017; 6: 129–36. doi:10.21037/tp.2017.03.10 http://www.ncbi.nlm.nih.gov/pubmed/28795002

⁵⁴ Lis D, Ahuja KDK, Stellingwerff T, et al. Food avoidance in athletes: FODMAP foods on the list. Appl Physiol Nutr Metab 2016; 41: 1002–4. doi:10.1139/apnm-2015-0428 http://www.ncbi.nlm.nih.gov/pubmed/27507006

⁵⁵ Barrett JS, Gearry RB, Muir JG. Dietary poorly absorbed, short-chain carbohydrates increase delivery of water and fermentable substrates to the proximal colon. Aliment Pharmacol Ther 2010; 31: 874–82. doi:10.1111/j.1365-2036.2010.04237.x http://www.ncbi.nlm.nih.gov/pubmed/20102355