{"paper_id":"22e0ae40-e543-4e68-93ad-3432747c7955","body_text":"Patterns of musculoskeletal injury onset and injured body regions among competitive swimmers attending a single medical institution: a retrospective descriptive epidemiological study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Patterns of musculoskeletal injury onset and injured body regions among competitive swimmers attending a single medical institution: a retrospective descriptive epidemiological study Akira Hirosawa, Koji Natori, Wataru Machida, Takato Ogata, Yosuke Mitomi, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9528841/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background : Competitive swimming is characterised by repetitive movements and is associated with a substantial burden of musculoskeletal injuries. However, descriptive epidemiological studies organising injuries according to both onset pattern and injured body region, including regions other than the shoulder, remain limited. This study aimed to describe the distribution of injury onset patterns and injured body regions among competitive swimmers seeking medical care. Methods : This retrospective descriptive study included competitive swimmers who visited a single medical institution between 2019 and 2024. Data on age, sex, competition level, diagnosis, injury onset pattern, and injured body region were extracted from electronic medical records. Injury onset patterns were classified as acute–sudden, repetitive–sudden, or repetitive–gradual. Injured body regions were categorised as follows: the trunk as head/face, neck, chest, thoracic spine/upper back, lumbosacral spine/buttocks, and abdomen; the upper extremity as shoulder, upper arm, elbow, forearm, wrist, hand, and fingers; and the lower extremity as hip/groin, thigh, knee, lower leg/Achilles tendon, ankle, and foot. The number and proportion of injury events with 95% confidence intervals were calculated, and the associations between injury onset patterns and injured body regions were explored using the chi-square test. Results : Overall, 615 injury events from 360 swimmers were analysed (mean age, 19.4 ± 6.5 years). Repetitive gradual-onset injuries were most frequently observed in the shoulder and lumbosacral spine/buttocks, whereas acute sudden-onset injuries were more commonly distributed in the lower extremity (χ² = 27.7, df = 4，p < 0.001), particularly at the ankle. Conclusions : Distinct distributions of injury onset patterns and injured body regions were observed in competitive swimmers seeking medical care, potentially providing baseline data that support future hypotheses and injury prevention strategies. Swimming Overuse injury Acute injury Descriptive epidemiology BACKGROUND Competitive swimming is characterised by repetitive movements and associated with a high incidence of overuse-related musculoskeletal injuries. 1 , 2 Shoulder disorders, commonly referred to as swimmer’s shoulder, are well recognised as representative conditions in this population. 3 – 5 Additionally, elite competitive swimmers have a significantly higher prevalence of intervertebral disc degeneration compared to recreational-level swimmers, 6 and 73% of breaststrokers have a history of knee pain. 7 Consequently, musculoskeletal injuries involving the shoulder, lumbar region, and knee are widely recognised in competitive swimmers. Injury surveillance studies conducted in international competitions have demonstrated that a large proportion of injuries among competitive swimmers are attributable to overuse. An injury surveillance study at the 2009 Fédération Internationale de Natation (FINA) World Championships reported 171 injuries during the championship period, corresponding to an incidence rate of 65.6 injuries per 1,000 registered athletes; 61 (35.7%) of the injuries were attributed to overuse. 8 Furthermore, a questionnaire-based survey conducted by FINA in 2015 reported that 68.1% of injuries sustained during the championship period were caused by overuse, with the shoulder, knee, lumbar region, and hip/groin being the most commonly affected sites. Across the three most recent FINA World Championships, shoulder injuries were the most frequent, and overuse was identified as the primary cause of injury. 9 In contrast, the authors previously focused on lower extremity injuries in competitive swimmers and reported that, among swimmers who sought medical care, lower extremity injuries were frequently associated with non-swimming-related mechanisms. 10 Other studies have reported that the knee and ankle are particularly vulnerable to injuries in competitive swimmers 1 and that many foot injuries occur during land-based resistance training or warm-up activities. 11 Therefore, injury onset patterns may differ by injured body region, particularly for lower extremity injuries such as those involving the ankle, compared with overuse-related injuries of the shoulder, lumbar region, and knee. However, the detailed epidemiological characteristics of these differences remain unclear. Additional methodological challenges have been noted, including reliance on self-reported questionnaire data; the limited number of epidemiological studies estimating injury incidence and risk factors in swimming; and the predominant focus on elite swimmers, which limits generalisability to developing and youth athletes. 12 Injuries that interrupt training hinder athletic development, regardless of the injured body region or injury onset pattern. Therefore, accurate characterisation of injury patterns is an essential first step in developing effective injury prevention strategies. Specifically, studies based on physician-diagnosed cases among swimmers may provide more objective and clinically relevant insights than questionnaire-based surveys that rely on self-reports. Accordingly, this study aimed to descriptively examine injury onset patterns and injured body regions among competitive swimmers, including athletes at a wide range of competition levels. Using physician-diagnosed medical records, this study sought to provide a comprehensive descriptive epidemiological overview of musculoskeletal injuries in competitive swimmers, encompassing shoulder, trunk, and lower extremity injuries, including overuse and acute sudden injuries. METHODS Patient and public involvement The patients and/or the public were not involved in the design, conduct, reporting, or dissemination of the study. Study design and participants This retrospective, descriptive study included competitive swimmers diagnosed with musculoskeletal injuries who visited the Department of Orthopaedic Surgery at a single general hospital between January 2019 and December 2024. The study reporting followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. 13 For swimmers with multiple visits, consultations were considered duplicate events when the interval between visits was in less than 1 year and the diagnoses were identical. Conversely, visits with an interval of 1 year or more for the same diagnosis, as well as visits involving different diagnoses, were treated as new injury events. A 1-year interval was applied as an operational definition to distinguish recurrent consultations from newly occurring injuries, with reference to previous studies. 14 – 16 This interval was selected to reflect typical seasonal training cycles and competition schedules in competitive swimmers and to help minimise the potential overcounting of prolonged or recurrent symptoms attributable to a single underlying condition. The exclusion criteria comprised para-athletes and those in whom the injury onset pattern was unclear in their medical records. The following variables were extracted from the electronic medical records: age, sex, competition level, diagnosis, injury onset pattern, and injured body region. The unit of analysis was the injury event. Basic characteristics (age, sex, competition level, and number of injury events) were summarised at the athletic level, whereas injury characteristics (injury onset pattern and injured body region) were summarised at the injury event level. Classification of competition level Competition level was determined using the official results database published by the Japan Swimming Federation. 17 Competition participation records were reviewed, and two physical therapists independently classified swimmers into three levels: international, national, and regional. The international level was defined as swimmers who had represented Japan in international competitions within 1 year prior to the injury date. The national level was defined as swimmers who participated in one or more of the following competitions: the All-Japan Junior Olympic Cup, the All-Japan Junior High School Swimming Championships, the All-Japan High School Swimming Championships, the Japan Intercollegiate Swimming Championships, the Japan Swimming Championships, the National Sports Festival of Japan, and the Japan Open. The regional level was defined as participation in competitions not classified as national-level events. Competition-level classification was concordant between the two evaluators in all cases. Classification of injury onset patterns Injury onset patterns were classified according to predefined operational rules based on information documented in medical records, including the chief complaint, history of present injuries, injury mechanism, symptom progression, and physician diagnosis. Following previous studies, 14 injury onset patterns were categorised into three types. Acute–sudden onset was defined as symptoms appearing immediately or if any symptoms appear on the same day following a single identifiable event (e.g., a fall, contact, or twisting). Repetitive onset was described as the sudden appearance of symptoms without a clearly identifiable single external event occurring against a background of accumulated repetitive load, with a definable onset date (e.g., sudden pain during training). Repetitive–gradual onset was defined as symptoms developing gradually due to accumulated repetitive load, with no clearly identifiable onset date (e.g., symptom progression over several weeks or months). When medical record descriptions permitted multiple interpretations, classification priority followed this order: (1) presence or absence of a single external event, (2) ability to identify the onset date, and (3) symptom progression (sudden vs. gradual). Cases that remained difficult to classify using these criteria were excluded due to unclear documentation. Injury onset patterns were independently classified by two physical therapists according to predefined rules. For discordant classifications, the evaluators reviewed the medical records and reached consensus through a discussion; when consensus could not be achieved, an orthopaedic surgeon made the final determination based on the medical records and clinical findings. As this was a retrospective study and final classifications were determined through a consensus process, inter-rater reliability indices (e.g., Cohen’s kappa) were not calculated. To minimise potential classification bias, independent assessments and a stepwise consensus procedure were implemented. Initial agreement was achieved in 557 of 615 injury events (90.6%), whereas the remaining 58 events (9.4%) were finalised through consensus, including 46 resolved by agreement between the physical therapists and 12 adjudicated by an orthopaedic surgeon. Classification of injured body regions Injured body regions were classified according to previous studies. 14 , 18 , 19 Classification was based on physician diagnoses, and the two physical therapists confirmed the appropriateness of the categorisation. The injured body regions were categorised into three upper-level categories: trunk, upper extremity, and lower extremity. The subcategories were as follows: trunk (head/face, neck, chest, thoracic spine/upper back, lumbosacral spine/buttocks, and abdomen), upper extremities (shoulder, upper arm, elbow, forearm, wrist, hand, and fingers), and lower extremities (hip/groin, thigh, knee, lower leg/Achilles tendon, ankle, and foot). When multiple diagnoses were recorded, the injured body region was determined by the primary diagnosis most closely related to the chief complaint. Statistical analysis Statistical analyses were primarily descriptive. This study primarily aimed to describe the distribution of injury characteristics; therefore, statistical tests were conducted solely to support the interpretation of distributional patterns rather than for inferential purposes. Continuous variables were presented as mean ± standard deviation and categorical variables as counts and proportions (n [%]). For the distribution of the upper-level injured body region categories by injury onset pattern and subcategory distributions, we calculated the proportions within each onset pattern and their 95% confidence intervals (CIs). Because some subcategories included small cell counts, 95% CIs were calculated using the Wilson score method based on a binomial distribution. Exploratory analyses of the distributional structure of the injured body regions were conducted using a chi-square test based on a 3 × 3 contingency table (degrees of freedom = 4). To identify the cells contributing to the overall association, adjusted standardised residuals were calculated. Because the unit of analysis was the injury event, multiple events from the same swimmer were included, and event independence could not be fully assured. Therefore, the distribution of the number of injury events per swimmer was summarised at the athlete level. For diagnoses and injured body regions corresponding to acute–sudden-onset injuries, counts and proportions (n [%]) were calculated for descriptive purposes. All analyses were performed using IBM SPSS Statistics (version 30.0; IBM Corp., Armonk, NY). RESULTS Overall, 370 swimmers and 632 injury events were initially identified. Data from four para-athletes (nine injury events) and six swimmers (eight injury events) with unclear documentation of injury onset patterns were excluded. Ultimately, 615 injury events from 360 swimmers were analysed. The mean participant age was 19.4 ± 6.5 years. There were 204 (56.7%) and 156 (43.3%) male and female swimmers, respectively. Regarding competition level, 22 (6.1%), 258 (71.7%), and 80 (22.2%) swimmers were classified as international, national, and regional, respectively (Table 1 ). Additionally, 238 swimmers (66.1%) sustained a single injury, whereas 122 swimmers (33.9%) experienced two or more injuries (Table 2 ). Table 1 Demographic characteristics of swimmers included in the study (n = 360) Variable Total (n = 360) Age, years 19.4 ± 6.5 Sex Male 204 (56.7%) Female 156 (43.3%) Competition level International 22 (6.1%) National 258 (71.7%) Regional 80 (22.2%) Values are presented as mean ± SD or n (%). Table 2 Distribution of the number of injury events per swimmer (n = 360) No. of injury events n % 1 238 66.1 2 72 20 3 21 5.8 4 12 3.3 ≥ 5 17 4.7 The distribution of the number of injury events per swimmer is presented in aggregated categories for clarity, as higher frequencies were observed in only a small number of swimmers. The following analyses describe the distributional tendencies and should be interpreted as exploratory findings. Characteristic distributional patterns were observed between injury onset patterns and upper-level injured body regions (χ² = 27.7, df = 4, p < 0.001); however, the effect size was small to moderate (Cramér’s V = 0.15) [Table 3 ]. Residual analysis demonstrated that lower extremity injuries occurred significantly more frequently than expected for acute–sudden-onset injuries. Conversely, trunk injuries occurred significantly more frequently than expected for repetitive–gradual-onset injuries (Table 4). Table 3 Distribution of injured body regions across injury onset patterns (n = 615) Injured body region Acute–sudden (n = 121) 95% CI Repetitive–sudden (n = 82) 95% CI Repetitive–gradual (n = 412) 95% CI Trunk (n = 185) 17 (14.1%) 9.0–21.4 32 (39.0%) 29.2–49.8 136 (33.0%) 28.6–37.7 Upper extremity (n = 214) 42 (34.7%) 26.8–43.5 21 (25.6%) 17.4–36.0 151 (36.7%) 32.1–41.4 Lower extremity (n = 216) 62 (51.2%) 42.4–60.0 29 (35.4%) 25.9–46.2 125 (30.3%) 26.1–34.9 Chi-square test: χ² = 27.7, df = 4, p < 0.001 Effect size: Cramer’s V = 0.15 Values are presented as n (%) with 95% confidence intervals (CIs). Percentages were calculated within each injury onset pattern. Ninety-five percent CIs were calculated using the Wilson score method for binomial proportions. Data are presented per injury event (n = 615). Table 4. Adjusted standardised residuals for the association between injury onset pattern and injured body region (n = 615) Injured body region Acute–sudden Repetitive–sudden Repetitive–gradual Trunk -4.29* + 1.90 + 2.26* Upper extremity -0.02 -1.88 + 1.37 Lower extremity + 4.14* + 0.05 -3.54* Values represent adjusted standardized residuals. Positive values indicate cells with observed frequencies higher than expected, whereas negative values indicate lower-than-expected frequencies. Cells with |adjusted standardized residuals| ≥ 1.96 are considered statistically significant (*p < 0.05). The distribution of injured body region subcategories is displayed in Table 5 . Regarding acute–sudden-onset injuries, the ankle was the most frequently affected site (32 injuries, 26.4%), followed by the fingers (16 injuries, 13.2%) and knee (12 injuries each, 9.9%). For repetitive–sudden-onset injuries, the lumbosacral spine/buttocks were most frequently affected (27 injuries, 32.9%), followed by the shoulder (15 injuries, 18.3%) and knee (nine injuries, 11.0%). Regarding repetitive–gradual-onset injuries, the shoulder was the most frequently affected site (130 injuries, 31.6%), followed by the lumbosacral spine/buttocks (101 injuries, 24.5%) and knee (42 injuries, 10.2%). Table 5 Distribution of injuries across anatomical subregions according to injury onset pattern Major body region Anatomical subregion Acute–sudden (n = 121) 95% CI Repetitive–sudden (n = 82) 95% CI Repetitive–gradual (n = 412) 95% CI Trunk (n = 185) Head/Face 0 0.0–3.1 0 0.0–4.5 0 0.0–0.9 Neck/Cervical spine 1 (0.8%) 0.1–4.5 2 (2.4%) 0.7–8.5 17 (4.1%) 2.6–6.5 Chest (including thoracic organs) 4 (3.3%) 1.3–8.2 1 (1.2%) 0.2–6.6 6 (1.5%) 0.7–3.1 Thoracic spine/Upper back 2 (1.7%) 0.5–5.8 2 (2.4%) 0.7–8.5 11 (2.7%) 1.5–4.7 Lumbosacral spine/Buttocks 10 (8.3%) 4.6–14.5 27 (32.9%) 23.7–43.7 101 (24.5%) 20.6–28.9 Abdomen (including abdominal organs) 0 0.0–3.1 0 0.0–4.5 1 (0.2%) 0.0–1.4 Upper extremity (n = 214) Shoulder 6 (5.0%) 2.3–10.4 15 (18.3%) 11.4–28.0 130 (31.6%) 27.3–36.2 Upper arm 0 0.0–3.1 0 0.0–4.5 2 (0.5%) 0.1–1.8 Elbow 11 (9.1%) 5.2–15.5 4 (4.9%) 1.9– 11.9 12 (2.9%) 1.7–5.0 Forearm 2 (1.7%) 0.5–5.8 0 0.0–4.5 2 (0.5%) 0.1–1.8 Wrist 3 (2.5%) 0.8–7.0 1 (1.2%) 0.2–6.6 1 (0.2%) 0.0–1.4 Hand 4 (3.3%) 1.3–8.2 1 (1.2%) 0.2–6.6 4 (1.0%) 0.4–2.5 Finger 16 (13.2%) 8.3–20.4 0 0.0–4.5 0 0.0–0.9 Lower extremity (n = 216) Hip/Groin 1 (0.8%) 0.1–4.5 7 (8.5%) 4.2–16.6 10 (2.4%) 1.3–4.4 Thigh 2 (1.7%) 0.5–5.8 3 (3.7%) 1.3–10.2 12 (2.9%) 1.7–5.0 Knee 12 (9.9%) 5.8–16.5 9 (11.0%) 5.9–19.6 42 (10.2%) 7.6–13.5 Lower leg/Achilles tendon 4 (3.3%) 1.3–8.2 1 (1.2%) 0.2–6.6 8 (1.9%) 1.0–3.8 Ankle 32 (26.4%) 19.4–34.9 5 (6.1%) 2.6–13.5 35 (8.5%) 6.2–11.6 Foot 11 (9.1%) 5.2–15.5 4 (4.9%) 1.9–11.9 18 (4.4%) 2.8–6.8 Values are presented as n (%) with 95% confidence intervals (CIs). Percentages were calculated within each injury onset pattern. CIs were calculated using the Wilson score method for binomial proportions. Subcategories represent anatomical subregions within each major body region. [insert Table 5 here] The distribution of diagnoses for the 121 injuries classified as acute–sudden-onset is presented in Additional file 1. Anterior talofibular ligament injury was the most common diagnosis (28 injuries, 23.1%), followed by lumbar sprain (five injuries, 4.1%) and ulnar collateral ligament injury of the elbow (four injuries, 3.3%). DISCUSSION The principal finding of this study was that injury onset patterns among competitive swimmers differed based on injured body region. When injury onset patterns were examined by body region, gradual-onset injuries associated with repetitive loading were predominant in the shoulder and lumbar regions. Conversely, sudden–acute-onset injuries were more frequently observed in the lower extremities, particularly at the ankle. Regarding injured body regions, repetitive–gradual-onset injuries were characterised by a significantly higher expected frequency of trunk injuries, with lumbosacral spine/buttock injuries accounting for 24.5% of all injuries. Thus, sustained mechanical loading on the lumbar region during swimming may contribute to overuse-related injury onset patterns, and lumbar injuries constitute a substantial proportion of trunk injuries in competitive swimmers. Previous studies have reported high prevalence of intervertebral disc degeneration and lumbar injuries among elite swimmers, 6,20–23 and the present findings are consistent with these observations. Shoulder injuries accounted for a high proportion of repetitive–gradual-onset injuries. Epidemiological studies of international competitions and systematic reviews have consistently reported that the shoulder is the most frequently injured body region during competitive swimming, 9,12 and a similar pattern was observed in the present study. Furthermore, knee injuries were frequently associated with overuse-related onset patterns, second to injuries in the shoulder and lumbar region. This distribution aligns with swimming-specific overuse injuries, such as breaststroker knee. 7 , 24 , 25 Nevertheless, a notable proportion of knee injuries were classified as acute–sudden-onset, including anterior cruciate ligament injuries, medial collateral ligament injuries, and contusions. Therefore, knee injury prevention strategies in competitive swimmers should address both swimming-related overuse mechanisms and acute traumatic injuries associated with non-swimming activities. Conversely, lower extremity injuries were significantly overrepresented among acute–sudden-onset injuries, with ankle injuries accounting for 26.4% of all acute–sudden-onset injuries. Among acute–sudden-onset injuries, anterior talofibular ligament injury was the most common diagnosis, representing 23.1% of cases. Lower extremity injuries in competitive swimmers frequently occur during non-swimming activities; 10 a previous study reported approximately 38% of injuries during strength training or team activities outside of swimming. 11 Therefore, the present findings may reflect patterns previously reported in the literature regarding non-swimming and land-based activities. Furthermore, given the previously reported ankle characteristics in competitive swimmers 26 – 28 and evidence that foot and ankle injuries commonly occur during land-based training, 11 the present results may reflect sport-specific demands and athlete-specific physical characteristics. Because taping and ankle bracing are restricted during swimming competitions, ankle-focused injury prevention strategies should extend beyond water training and include land-based training and daily activities. Collectively, injury onset patterns in competitive swimmers may differ substantially by injured body region. Accordingly, preventive strategies focusing on managing cumulative loading during swimming may be particularly important for shoulder and lumbar injuries. In contrast, more comprehensive approaches that address acute traumatic injuries during non-swimming activities may be required for knee and ankle injuries. Although this was a single-institution study, it provides clinically derived, physician-diagnosed data across a wide range of competition levels and offers distinct descriptive insights into the combination of injury onset patterns and injured body regions, including non-shoulder sites. Clinical Implications This retrospective descriptive study conducted at a single medical institution provided a comprehensive overview of injury onset patterns and injured body regions among competitive swimmers. The use of long-term medical record data collected within a consistent clinical setting ensured uniform diagnostic criteria and evaluation practices, enabling detailed characterisation of injury patterns. By examining distributional relationships between injury onset patterns and injured body regions, this study provides baseline descriptive evidence that may inform future injury prevention strategies and hypothesis-driven research. These findings suggest that shoulder and lumbosacral problems may warrant monitoring of cumulative swimming load, whereas knee and ankle problems may require broader prevention strategies that also address land-based training and daily activities. Limitations This study had some limitations. First, this was a retrospective, single-centre study based on medical records from swimmers who sought medical care. Therefore, selection bias related to healthcare-seeking behaviours and institutional characteristics cannot be excluded. In addition, because the sample was drawn from a single geographical region, the findings may not be representative of all competitive swimmers in Japan, and generalisability should be interpreted with caution. Second, reliance on medical record data may have introduced information bias or misclassification bias in injury mechanisms and onset patterns. Detailed contextual factors, such as training volume, training intensity, and specific training content, could not be adequately assessed, and residual confounding by unmeasured variables was possible. Furthermore, because the unit of analysis was an injury event, multiple events from the same swimmer were included, and the assumption of statistical independence may not have been fully satisfied. Accordingly, the results should be interpreted as descriptive findings, and statistical analyses using chi-square tests should be regarded as exploratory to supplement the description of distributional patterns. Future studies with multicentre designs and prospective data collection are warranted to test the hypotheses generated from our findings. CONCLUSIONS In this retrospective descriptive study, competitive swimmers who sought medical care, injury onset patterns, and injured body regions were systematically characterised. Injury onset patterns differed according to the injured body region, with gradual onset associated with repetitive loading predominating in the shoulder and lumbar region and acute–sudden-onset injuries occurring more frequently in the lower extremities, particularly at the ankle. Therefore, injury prevention strategies in competitive swimming should be interpreted as baseline descriptive evidence for future prevention planning. Abbreviations CI Confidence interval CIs Confidence intervals FINA Fédération Internationale de Natation IOC International Olympic Committee SD Standard deviation STROBE Strengthening the Reporting of Observational Studies in Epidemiology STROBE-SIIS Strengthening the Reporting of Observational Studies in Epidemiology Extension for Sport Injury and Illness Surveillance Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of IMS group Takashimadaira Chuo General Hospital (approval number: 202307). Given the retrospective nature of the study and the use of anonymized medical records, the requirement for informed consent was waived by the Institutional Review Board. Information regarding the study purpose, use of data, protection of personal information, and the right to opt out was publicly disclosed on notice boards within the hospital. Eligible participants were given the opportunity to opt out at any time. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to ethical restrictions and the potential risk of participant identification but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The article processing charge for this publication was supported by the 2026 Collaborative Research Grant of Bunkyo Gakuin University. Authors’ contributions Conceptualization: AH, SM. Methodology: AH, KN, YM, SM. Formal analysis: AH, KN. Investigation: AH, KN, WM, TO. Data curation: AH, KN. Resources: SM. Writing – original draft: AH. Writing – review & editing: AH, KN, WM, TO, YM, TI, SM. 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Sports Health. 2024;16:971-81. doi:10.1177/19417381231225213. Matsuura Y, Hangai M, Koizumi K, Ueno K, Hirai N, Akuzawa H, et al. Injury trend analysis in the Japan national swim team from 2002 to 2016: effect of the lumbar injury prevention project. BMJ Open Sport Exerc Med. 2019;5:e000615. doi:10.1136/bmjsem-2019-000615. Knobloch K, Yoon U, Kraemer R, Vogt PM. Die 200- bis 400 m-Brustlage dominiert bei Knieüberlastungsschäden im Schwimmsport [200-400 m breaststroke event dominate among knee overuse injuries in elite swimming athletes]. Sportverletz Sportschaden. 2008;22:213-9. German. doi:10.1055/s-2008-1027987. Johnson JE, Sim FH, Scott SG. Musculoskeletal injuries in competitive swimmers. Mayo Clin Proc. 1987;62:289-304. doi:10.1016/S0025-6196(12)61906-5. Hsu C, Schon J, Genovese T, McInnis K. Ankle laxity and instability in collegiate swimmers. J Sports Med Phys Fitness. 2025;65:1194-200. doi:10.23736/S0022-4707.25.16570-5. Kaneda K, Maeda N, Ikuta Y, Tashiro T, Tsutsumi S, Arima S, et al. The features of foot morphology and intrinsic foot muscle property in adolescent swimmers: an ultrasound-based study. J Hum Kinet. 2023;87:95-103. doi:10.5114/jhk/163148. Kobayashi T, Takabayashi T, Kudo S, Edama M. The prevalence of chronic ankle instability and its relationship to foot arch characteristics in female collegiate athletes. Phys Ther Sport. 2020;46:162-8. doi:10.1016/j.ptsp.2020.09.002. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.xlsx Additional file 1 Format: Excel spreadsheet (.xlsx) Title of data: List of diagnoses and injured body regions among acute–sudden-onset injuries Description of data: This Excel file provides the diagnoses and injured body regions for acute–sudden-onset musculoskeletal injuries among competitive swimmers. Each row presents the diagnosis, anatomical subregion, number of injury events, and percentage of the total acute–sudden-onset injuries. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 18 May, 2026 Reviewers agreed at journal 06 May, 2026 Reviewers agreed at journal 02 May, 2026 Reviewers invited by journal 02 May, 2026 Editor invited by journal 30 Apr, 2026 Editor assigned by journal 27 Apr, 2026 Submission checks completed at journal 27 Apr, 2026 First submitted to journal 25 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-9528841\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":633475812,\"identity\":\"ea64ed68-e722-4594-81a6-a799b6632625\",\"order_by\":0,\"name\":\"Akira Hirosawa\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYDACCcYGCIO9ByZ0gFgtPGeI1gJn5BDpLv7ZzW0fPvyxS+yf+fbwax4GO3kGxrP4rZG4c7B55sy25MQZt/PSrHkYkg0bGM4l4LfmRmIzM28Dc27D7RwzYx4GZqDyMwZ4dciDtPD8qc+df/MMSEs9YS0GYC1sh3M33OAxfszDcJiwFkOgFsaZbcfrN57JS2OcY3DcsI2QX+RupD9m+PCn2lju+NnDH95UVMvzSxAIMWTAJsFgACLPEFYKA8wfwBR/DwF1o2AUjIJRMNIAACOXSL2FD1RoAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"Bunkyo Gakuin University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Akira\",\"middleName\":\"\",\"lastName\":\"Hirosawa\",\"suffix\":\"\"},{\"id\":633475813,\"identity\":\"33f2b593-935a-4420-94e0-ad2fff238f0d\",\"order_by\":1,\"name\":\"Koji Natori\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Takashimadaira Chuo General Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Koji\",\"middleName\":\"\",\"lastName\":\"Natori\",\"suffix\":\"\"},{\"id\":633475814,\"identity\":\"f4238b63-b8a4-445a-9168-96a63b1526ad\",\"order_by\":2,\"name\":\"Wataru Machida\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Takashimadaira Chuo General Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Wataru\",\"middleName\":\"\",\"lastName\":\"Machida\",\"suffix\":\"\"},{\"id\":633475815,\"identity\":\"a81655b3-2a1c-41eb-8591-c2f9c5163bb2\",\"order_by\":3,\"name\":\"Takato Ogata\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Takashimadaira Chuo General Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Takato\",\"middleName\":\"\",\"lastName\":\"Ogata\",\"suffix\":\"\"},{\"id\":633475818,\"identity\":\"7109ac08-69e0-474b-8da1-cfd0b0ab257a\",\"order_by\":4,\"name\":\"Yosuke Mitomi\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Komatsu Ltd.\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Yosuke\",\"middleName\":\"\",\"lastName\":\"Mitomi\",\"suffix\":\"\"},{\"id\":633475819,\"identity\":\"71c7b08a-42fd-482e-b87b-962913b80579\",\"order_by\":5,\"name\":\"Tatsuya Igarashi\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Bunkyo Gakuin University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Tatsuya\",\"middleName\":\"\",\"lastName\":\"Igarashi\",\"suffix\":\"\"},{\"id\":633475820,\"identity\":\"d1ab96ed-5348-475e-8a0b-2cac2d2e6054\",\"order_by\":6,\"name\":\"Sayaka Motojima\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Takashimadaira Chuo General Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Sayaka\",\"middleName\":\"\",\"lastName\":\"Motojima\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-04-26 02:08:25\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-9528841/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-9528841/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":108493390,\"identity\":\"1a8ca0a5-3191-4f5e-a6b5-bf218e1f6d0f\",\"added_by\":\"auto\",\"created_at\":\"2026-05-05 10:00:10\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":362861,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9528841/v1/2f572d72-9300-4793-82fd-3d38ef571126.pdf\"},{\"id\":108411383,\"identity\":\"bd3e5e78-ac64-4013-bc42-85f9b7f20532\",\"added_by\":\"auto\",\"created_at\":\"2026-05-04 10:21:26\",\"extension\":\"xlsx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":19489,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eAdditional file 1\\u003c/p\\u003e\\n\\u003cp\\u003eFormat: Excel spreadsheet (.xlsx)\\u003c/p\\u003e\\n\\u003cp\\u003eTitle of data: List of diagnoses and injured body regions among acute–sudden-onset injuries\\u003c/p\\u003e\\n\\u003cp\\u003eDescription of data: This Excel file provides the diagnoses and injured body regions for acute–sudden-onset musculoskeletal injuries among competitive swimmers. Each row presents the diagnosis, anatomical subregion, number of injury events, and percentage of the total acute–sudden-onset injuries.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Additionalfile1.xlsx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9528841/v1/9a9a0d0f2f45d8307e7b9fa2.xlsx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Patterns of musculoskeletal injury onset and injured body regions among competitive swimmers attending a single medical institution: a retrospective descriptive epidemiological study\",\"fulltext\":[{\"header\":\"BACKGROUND\",\"content\":\"\\u003cp\\u003eCompetitive swimming is characterised by repetitive movements and associated with a high incidence of overuse-related musculoskeletal injuries.\\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e\\u003c/sup\\u003e Shoulder disorders, commonly referred to as swimmer\\u0026rsquo;s shoulder, are well recognised as representative conditions in this population.\\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR4\\\" citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u003c/sup\\u003e Additionally, elite competitive swimmers have a significantly higher prevalence of intervertebral disc degeneration compared to recreational-level swimmers,\\u003csup\\u003e6\\u003c/sup\\u003e and 73% of breaststrokers have a history of knee pain.\\u003csup\\u003e\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u003c/sup\\u003e Consequently, musculoskeletal injuries involving the shoulder, lumbar region, and knee are widely recognised in competitive swimmers.\\u003c/p\\u003e \\u003cp\\u003eInjury surveillance studies conducted in international competitions have demonstrated that a large proportion of injuries among competitive swimmers are attributable to overuse. An injury surveillance study at the 2009 F\\u0026eacute;d\\u0026eacute;ration Internationale de Natation (FINA) World Championships reported 171 injuries during the championship period, corresponding to an incidence rate of 65.6 injuries per 1,000 registered athletes; 61 (35.7%) of the injuries were attributed to overuse.\\u003csup\\u003e\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e\\u003c/sup\\u003e Furthermore, a questionnaire-based survey conducted by FINA in 2015 reported that 68.1% of injuries sustained during the championship period were caused by overuse, with the shoulder, knee, lumbar region, and hip/groin being the most commonly affected sites. Across the three most recent FINA World Championships, shoulder injuries were the most frequent, and overuse was identified as the primary cause of injury.\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eIn contrast, the authors previously focused on lower extremity injuries in competitive swimmers and reported that, among swimmers who sought medical care, lower extremity injuries were frequently associated with non-swimming-related mechanisms.\\u003csup\\u003e\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u003c/sup\\u003e Other studies have reported that the knee and ankle are particularly vulnerable to injuries in competitive swimmers\\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u003c/sup\\u003e and that many foot injuries occur during land-based resistance training or warm-up activities.\\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u003c/sup\\u003e Therefore, injury onset patterns may differ by injured body region, particularly for lower extremity injuries such as those involving the ankle, compared with overuse-related injuries of the shoulder, lumbar region, and knee. However, the detailed epidemiological characteristics of these differences remain unclear.\\u003c/p\\u003e \\u003cp\\u003eAdditional methodological challenges have been noted, including reliance on self-reported questionnaire data; the limited number of epidemiological studies estimating injury incidence and risk factors in swimming; and the predominant focus on elite swimmers, which limits generalisability to developing and youth athletes.\\u003csup\\u003e\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eInjuries that interrupt training hinder athletic development, regardless of the injured body region or injury onset pattern. Therefore, accurate characterisation of injury patterns is an essential first step in developing effective injury prevention strategies. Specifically, studies based on physician-diagnosed cases among swimmers may provide more objective and clinically relevant insights than questionnaire-based surveys that rely on self-reports.\\u003c/p\\u003e \\u003cp\\u003eAccordingly, this study aimed to descriptively examine injury onset patterns and injured body regions among competitive swimmers, including athletes at a wide range of competition levels. Using physician-diagnosed medical records, this study sought to provide a comprehensive descriptive epidemiological overview of musculoskeletal injuries in competitive swimmers, encompassing shoulder, trunk, and lower extremity injuries, including overuse and acute sudden injuries.\\u003c/p\\u003e\"},{\"header\":\"METHODS\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePatient and public involvement\\u003c/h2\\u003e \\u003cp\\u003eThe patients and/or the public were not involved in the design, conduct, reporting, or dissemination of the study.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eStudy design and participants\\u003c/h3\\u003e\\n\\u003cp\\u003eThis retrospective, descriptive study included competitive swimmers diagnosed with musculoskeletal injuries who visited the Department of Orthopaedic Surgery at a single general hospital between January 2019 and December 2024. The study reporting followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.\\u003csup\\u003e\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eFor swimmers with multiple visits, consultations were considered duplicate events when the interval between visits was in less than 1 year and the diagnoses were identical. Conversely, visits with an interval of 1 year or more for the same diagnosis, as well as visits involving different diagnoses, were treated as new injury events. A 1-year interval was applied as an operational definition to distinguish recurrent consultations from newly occurring injuries, with reference to previous studies.\\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR15\\\" citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u003c/sup\\u003e This interval was selected to reflect typical seasonal training cycles and competition schedules in competitive swimmers and to help minimise the potential overcounting of prolonged or recurrent symptoms attributable to a single underlying condition.\\u003c/p\\u003e \\u003cp\\u003eThe exclusion criteria comprised para-athletes and those in whom the injury onset pattern was unclear in their medical records. The following variables were extracted from the electronic medical records: age, sex, competition level, diagnosis, injury onset pattern, and injured body region.\\u003c/p\\u003e \\u003cp\\u003eThe unit of analysis was the injury event. Basic characteristics (age, sex, competition level, and number of injury events) were summarised at the athletic level, whereas injury characteristics (injury onset pattern and injured body region) were summarised at the injury event level.\\u003c/p\\u003e\\n\\u003ch3\\u003eClassification of competition level\\u003c/h3\\u003e\\n\\u003cp\\u003eCompetition level was determined using the official results database published by the Japan Swimming Federation.\\u003csup\\u003e\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e\\u003c/sup\\u003e Competition participation records were reviewed, and two physical therapists independently classified swimmers into three levels: international, national, and regional.\\u003c/p\\u003e \\u003cp\\u003eThe international level was defined as swimmers who had represented Japan in international competitions within 1 year prior to the injury date. The national level was defined as swimmers who participated in one or more of the following competitions: the All-Japan Junior Olympic Cup, the All-Japan Junior High School Swimming Championships, the All-Japan High School Swimming Championships, the Japan Intercollegiate Swimming Championships, the Japan Swimming Championships, the National Sports Festival of Japan, and the Japan Open. The regional level was defined as participation in competitions not classified as national-level events. Competition-level classification was concordant between the two evaluators in all cases.\\u003c/p\\u003e\\n\\u003ch3\\u003eClassification of injury onset patterns\\u003c/h3\\u003e\\n\\u003cp\\u003eInjury onset patterns were classified according to predefined operational rules based on information documented in medical records, including the chief complaint, history of present injuries, injury mechanism, symptom progression, and physician diagnosis. Following previous studies,\\u003csup\\u003e14\\u003c/sup\\u003e injury onset patterns were categorised into three types.\\u003c/p\\u003e \\u003cp\\u003eAcute\\u0026ndash;sudden onset was defined as symptoms appearing immediately or if any symptoms appear on the same day following a single identifiable event (e.g., a fall, contact, or twisting).\\u003c/p\\u003e \\u003cp\\u003eRepetitive onset was described as the sudden appearance of symptoms without a clearly identifiable single external event occurring against a background of accumulated repetitive load, with a definable onset date (e.g., sudden pain during training).\\u003c/p\\u003e \\u003cp\\u003eRepetitive\\u0026ndash;gradual onset was defined as symptoms developing gradually due to accumulated repetitive load, with no clearly identifiable onset date (e.g., symptom progression over several weeks or months).\\u003c/p\\u003e \\u003cp\\u003eWhen medical record descriptions permitted multiple interpretations, classification priority followed this order: (1) presence or absence of a single external event, (2) ability to identify the onset date, and (3) symptom progression (sudden vs. gradual). Cases that remained difficult to classify using these criteria were excluded due to unclear documentation.\\u003c/p\\u003e \\u003cp\\u003eInjury onset patterns were independently classified by two physical therapists according to predefined rules. For discordant classifications, the evaluators reviewed the medical records and reached consensus through a discussion; when consensus could not be achieved, an orthopaedic surgeon made the final determination based on the medical records and clinical findings. As this was a retrospective study and final classifications were determined through a consensus process, inter-rater reliability indices (e.g., Cohen\\u0026rsquo;s kappa) were not calculated. To minimise potential classification bias, independent assessments and a stepwise consensus procedure were implemented. Initial agreement was achieved in 557 of 615 injury events (90.6%), whereas the remaining 58 events (9.4%) were finalised through consensus, including 46 resolved by agreement between the physical therapists and 12 adjudicated by an orthopaedic surgeon.\\u003c/p\\u003e\\n\\u003ch3\\u003eClassification of injured body regions\\u003c/h3\\u003e\\n\\u003cp\\u003eInjured body regions were classified according to previous studies.\\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u003c/sup\\u003e Classification was based on physician diagnoses, and the two physical therapists confirmed the appropriateness of the categorisation. The injured body regions were categorised into three upper-level categories: trunk, upper extremity, and lower extremity.\\u003c/p\\u003e \\u003cp\\u003eThe subcategories were as follows: trunk (head/face, neck, chest, thoracic spine/upper back, lumbosacral spine/buttocks, and abdomen), upper extremities (shoulder, upper arm, elbow, forearm, wrist, hand, and fingers), and lower extremities (hip/groin, thigh, knee, lower leg/Achilles tendon, ankle, and foot). When multiple diagnoses were recorded, the injured body region was determined by the primary diagnosis most closely related to the chief complaint.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStatistical analysis\\u003c/h2\\u003e \\u003cp\\u003eStatistical analyses were primarily descriptive. This study primarily aimed to describe the distribution of injury characteristics; therefore, statistical tests were conducted solely to support the interpretation of distributional patterns rather than for inferential purposes. Continuous variables were presented as mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;standard deviation and categorical variables as counts and proportions (n [%]).\\u003c/p\\u003e \\u003cp\\u003eFor the distribution of the upper-level injured body region categories by injury onset pattern and subcategory distributions, we calculated the proportions within each onset pattern and their 95% confidence intervals (CIs). Because some subcategories included small cell counts, 95% CIs were calculated using the Wilson score method based on a binomial distribution.\\u003c/p\\u003e \\u003cp\\u003eExploratory analyses of the distributional structure of the injured body regions were conducted using a chi-square test based on a 3 \\u0026times; 3 contingency table (degrees of freedom\\u0026thinsp;=\\u0026thinsp;4). To identify the cells contributing to the overall association, adjusted standardised residuals were calculated. Because the unit of analysis was the injury event, multiple events from the same swimmer were included, and event independence could not be fully assured. Therefore, the distribution of the number of injury events per swimmer was summarised at the athlete level.\\u003c/p\\u003e \\u003cp\\u003eFor diagnoses and injured body regions corresponding to acute\\u0026ndash;sudden-onset injuries, counts and proportions (n [%]) were calculated for descriptive purposes. All analyses were performed using IBM SPSS Statistics (version 30.0; IBM Corp., Armonk, NY).\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"RESULTS\",\"content\":\"\\u003cp\\u003eOverall, 370 swimmers and 632 injury events were initially identified. Data from four para-athletes (nine injury events) and six swimmers (eight injury events) with unclear documentation of injury onset patterns were excluded. Ultimately, 615 injury events from 360 swimmers were analysed.\\u003c/p\\u003e\\n\\u003cp\\u003eThe mean participant age was 19.4\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;6.5 years. There were 204 (56.7%) and 156 (43.3%) male and female swimmers, respectively. Regarding competition level, 22 (6.1%), 258 (71.7%), and 80 (22.2%) swimmers were classified as international, national, and regional, respectively (Table \\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Additionally, 238 swimmers (66.1%) sustained a single injury, whereas 122 swimmers (33.9%) experienced two or more injuries (Table \\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u0026nbsp;\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eDemographic characteristics of swimmers included in the study (n\\u0026thinsp;=\\u0026thinsp;360)\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003ccolgroup cols=\\\"3\\\"\\u003e\\u003c/colgroup\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eVariable\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eTotal (n\\u0026thinsp;=\\u0026thinsp;360)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eAge, years\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e19.4\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;6.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eSex\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e204 (56.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e156 (43.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eCompetition level\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eInternational\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e22 (6.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eNational\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e258 (71.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eRegional\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e80 (22.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c3\\\" namest=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eValues are presented as mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD or n (%).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003cbr\\u003e\\u003c/div\\u003e\\u0026nbsp;\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eDistribution of the number of injury events per swimmer (n\\u0026thinsp;=\\u0026thinsp;360)\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003ccolgroup cols=\\\"4\\\"\\u003e\\u003c/colgroup\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eNo. of injury events\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003en\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e%\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colspan=\\\"1\\\" nameend=\\\"c4\\\" namest=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e238\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e66.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\" nameend=\\\"c4\\\" namest=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003e2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e72\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e20\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\" nameend=\\\"c4\\\" namest=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e21\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e5.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\" nameend=\\\"c4\\\" namest=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003e4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e3.3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\" nameend=\\\"c4\\\" namest=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003e\\u0026ge;\\u0026thinsp;5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e17\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e4.7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\" nameend=\\\"c4\\\" namest=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003eThe distribution of the number of injury events per swimmer is presented in aggregated categories for clarity, as higher frequencies were observed in only a small number of swimmers.\\u003c/p\\u003e\\n\\u003cp\\u003eThe following analyses describe the distributional tendencies and should be interpreted as exploratory findings. Characteristic distributional patterns were observed between injury onset patterns and upper-level injured body regions (\\u0026chi;\\u0026sup2; = 27.7, df\\u0026thinsp;=\\u0026thinsp;4, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001); however, the effect size was small to moderate (Cram\\u0026eacute;r\\u0026rsquo;s V\\u0026thinsp;=\\u0026thinsp;0.15) [Table \\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e]. Residual analysis demonstrated that lower extremity injuries occurred significantly more frequently than expected for acute\\u0026ndash;sudden-onset injuries. Conversely, trunk injuries occurred significantly more frequently than expected for repetitive\\u0026ndash;gradual-onset injuries (Table 4).\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u0026nbsp;\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eDistribution of injured body regions across injury onset patterns (n\\u0026thinsp;=\\u0026thinsp;615)\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003ccolgroup cols=\\\"7\\\"\\u003e\\u003c/colgroup\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eInjured body region\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eAcute\\u0026ndash;sudden\\u003c/p\\u003e\\n \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;121)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e95% CI\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003eRepetitive\\u0026ndash;sudden\\u003c/p\\u003e\\n \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;82)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e95% CI\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003eRepetitive\\u0026ndash;gradual\\u003c/p\\u003e\\n \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;412)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e95% CI\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eTrunk (n\\u0026thinsp;=\\u0026thinsp;185)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e17 (14.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e9.0\\u0026ndash;21.4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e32 (39.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e29.2\\u0026ndash;49.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e136 (33.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e28.6\\u0026ndash;37.7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eUpper extremity (n\\u0026thinsp;=\\u0026thinsp;214)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e42 (34.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e26.8\\u0026ndash;43.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e21 (25.6%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e17.4\\u0026ndash;36.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e151 (36.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e32.1\\u0026ndash;41.4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eLower extremity (n\\u0026thinsp;=\\u0026thinsp;216)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e62 (51.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e42.4\\u0026ndash;60.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e29 (35.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e25.9\\u0026ndash;46.2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e125 (30.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e26.1\\u0026ndash;34.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003ctfoot\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"7\\\"\\u003eChi-square test: \\u0026chi;\\u0026sup2; = 27.7, df\\u0026thinsp;=\\u0026thinsp;4, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"7\\\"\\u003eEffect size: Cramer\\u0026rsquo;s V\\u0026thinsp;=\\u0026thinsp;0.15\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tfoot\\u003e\\n \\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003eValues are presented as n (%) with 95% confidence intervals (CIs).\\u003c/p\\u003e\\n\\u003cp\\u003ePercentages were calculated within each injury onset pattern.\\u003c/p\\u003e\\n\\u003cp\\u003eNinety-five percent CIs were calculated using the Wilson score method for binomial proportions.\\u003c/p\\u003e\\n\\u003cp\\u003eData are presented per injury event (n\\u0026thinsp;=\\u0026thinsp;615).\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003cbr\\u003e\\u003c/div\\u003e\\u0026nbsp;\\u003ctable float=\\\"No\\\" id=\\\"Taba\\\" border=\\\"1\\\"\\u003e\\n \\u003ccolgroup cols=\\\"7\\\"\\u003e\\u003c/colgroup\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\" colspan=\\\"5\\\" nameend=\\\"c5\\\" namest=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eTable\\u0026nbsp;4. Adjusted standardised residuals for the association between injury onset pattern and injured body region (n\\u0026thinsp;=\\u0026thinsp;615)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eInjured body region\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eAcute\\u0026ndash;sudden\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003eRepetitive\\u0026ndash;sudden\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003eRepetitive\\u0026ndash;gradual\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c7\\\" namest=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eTrunk\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e-4.29*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e+\\u0026thinsp;1.90\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e+\\u0026thinsp;2.26*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c7\\\" namest=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eUpper extremity\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e-0.02\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e-1.88\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e+\\u0026thinsp;1.37\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c7\\\" namest=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eLower extremity\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003e+\\u0026thinsp;4.14*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e+\\u0026thinsp;0.05\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e-3.54*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c7\\\" namest=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003eValues represent adjusted standardized residuals.\\u003c/p\\u003e\\n\\u003cp\\u003ePositive values indicate cells with observed frequencies higher than expected, whereas negative values indicate lower-than-expected frequencies.\\u003c/p\\u003e\\n\\u003cp\\u003eCells with |adjusted standardized residuals| \\u0026ge; 1.96 are considered statistically significant (*p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05).\\u003c/p\\u003e\\n\\u003cp\\u003eThe distribution of injured body region subcategories is displayed in Table \\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e5\\u003c/span\\u003e. Regarding acute\\u0026ndash;sudden-onset injuries, the ankle was the most frequently affected site (32 injuries, 26.4%), followed by the fingers (16 injuries, 13.2%) and knee (12 injuries each, 9.9%). For repetitive\\u0026ndash;sudden-onset injuries, the lumbosacral spine/buttocks were most frequently affected (27 injuries, 32.9%), followed by the shoulder (15 injuries, 18.3%) and knee (nine injuries, 11.0%). Regarding repetitive\\u0026ndash;gradual-onset injuries, the shoulder was the most frequently affected site (130 injuries, 31.6%), followed by the lumbosacral spine/buttocks (101 injuries, 24.5%) and knee (42 injuries, 10.2%).\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u0026nbsp;\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 5\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eDistribution of injuries across anatomical subregions according to injury onset pattern\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003ccolgroup cols=\\\"8\\\"\\u003e\\u003c/colgroup\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eMajor body region\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eAnatomical subregion\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003eAcute\\u0026ndash;sudden\\u003c/p\\u003e\\n \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;121)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e95% CI\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003eRepetitive\\u0026ndash;sudden\\u003c/p\\u003e\\n \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;82)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e95% CI\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003eRepetitive\\u0026ndash;gradual\\u003c/p\\u003e\\n \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;412)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e95% CI\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eTrunk (n\\u0026thinsp;=\\u0026thinsp;185)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eHead/Face\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e0.0\\u0026ndash;3.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e0.0\\u0026ndash;4.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e0.0\\u0026ndash;0.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eNeck/Cervical spine\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e1 (0.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e0.1\\u0026ndash;4.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e2 (2.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e0.7\\u0026ndash;8.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e17 (4.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e2.6\\u0026ndash;6.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eChest (including thoracic organs)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e4 (3.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e1.3\\u0026ndash;8.2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e1 (1.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e0.2\\u0026ndash;6.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e6 (1.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e0.7\\u0026ndash;3.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eThoracic spine/Upper back\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e2 (1.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e0.5\\u0026ndash;5.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e2 (2.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e0.7\\u0026ndash;8.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e11 (2.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e1.5\\u0026ndash;4.7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eLumbosacral spine/Buttocks\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e10 (8.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e4.6\\u0026ndash;14.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e27 (32.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e23.7\\u0026ndash;43.7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e101 (24.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e20.6\\u0026ndash;28.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eAbdomen (including abdominal organs)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e0.0\\u0026ndash;3.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e0.0\\u0026ndash;4.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e1 (0.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e0.0\\u0026ndash;1.4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eUpper extremity (n\\u0026thinsp;=\\u0026thinsp;214)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eShoulder\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e6 (5.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e2.3\\u0026ndash;10.4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e15 (18.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e11.4\\u0026ndash;28.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e130 (31.6%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e27.3\\u0026ndash;36.2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eUpper arm\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e0.0\\u0026ndash;3.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e0.0\\u0026ndash;4.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e2 (0.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e0.1\\u0026ndash;1.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eElbow\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e11 (9.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e5.2\\u0026ndash;15.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e4 (4.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e1.9\\u0026ndash; 11.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e12 (2.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e1.7\\u0026ndash;5.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eForearm\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e2 (1.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e0.5\\u0026ndash;5.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e0.0\\u0026ndash;4.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e2 (0.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e0.1\\u0026ndash;1.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eWrist\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e3 (2.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e0.8\\u0026ndash;7.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e1 (1.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e0.2\\u0026ndash;6.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e1 (0.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e0.0\\u0026ndash;1.4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eHand\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e4 (3.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e1.3\\u0026ndash;8.2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e1 (1.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e0.2\\u0026ndash;6.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e4 (1.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e0.4\\u0026ndash;2.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eFinger\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e16 (13.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e8.3\\u0026ndash;20.4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e0.0\\u0026ndash;4.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e0.0\\u0026ndash;0.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eLower extremity (n\\u0026thinsp;=\\u0026thinsp;216)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eHip/Groin\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e1 (0.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e0.1\\u0026ndash;4.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e7 (8.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e4.2\\u0026ndash;16.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e10 (2.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e1.3\\u0026ndash;4.4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eThigh\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e2 (1.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e0.5\\u0026ndash;5.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e3 (3.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e1.3\\u0026ndash;10.2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e12 (2.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e1.7\\u0026ndash;5.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eKnee\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e12 (9.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e5.8\\u0026ndash;16.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e9 (11.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e5.9\\u0026ndash;19.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e42 (10.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e7.6\\u0026ndash;13.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eLower leg/Achilles tendon\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e4 (3.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e1.3\\u0026ndash;8.2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e1 (1.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e0.2\\u0026ndash;6.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e8 (1.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e1.0\\u0026ndash;3.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eAnkle\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e32 (26.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e19.4\\u0026ndash;34.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e5 (6.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e2.6\\u0026ndash;13.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e35 (8.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e6.2\\u0026ndash;11.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\n \\u003cp\\u003eFoot\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\n \\u003cp\\u003e11 (9.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\n \\u003cp\\u003e5.2\\u0026ndash;15.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\n \\u003cp\\u003e4 (4.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\n \\u003cp\\u003e1.9\\u0026ndash;11.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\n \\u003cp\\u003e18 (4.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\n \\u003cp\\u003e2.8\\u0026ndash;6.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"8\\\" nameend=\\\"c8\\\" namest=\\\"c1\\\"\\u003e\\n \\u003cp\\u003eValues are presented as n (%) with 95% confidence intervals (CIs). Percentages were calculated within each injury onset pattern. CIs were calculated using the Wilson score method for binomial proportions. Subcategories represent anatomical subregions within each major body region.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003e[insert Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e5\\u003c/span\\u003e here]\\u003c/p\\u003e\\n\\u003cp\\u003eThe distribution of diagnoses for the 121 injuries classified as acute\\u0026ndash;sudden-onset is presented in Additional file 1. Anterior talofibular ligament injury was the most common diagnosis (28 injuries, 23.1%), followed by lumbar sprain (five injuries, 4.1%) and ulnar collateral ligament injury of the elbow (four injuries, 3.3%).\\u003c/p\\u003e\"},{\"header\":\"DISCUSSION\",\"content\":\"\\u003cp\\u003eThe principal finding of this study was that injury onset patterns among competitive swimmers differed based on injured body region. When injury onset patterns were examined by body region, gradual-onset injuries associated with repetitive loading were predominant in the shoulder and lumbar regions. Conversely, sudden\\u0026ndash;acute-onset injuries were more frequently observed in the lower extremities, particularly at the ankle.\\u003c/p\\u003e \\u003cp\\u003eRegarding injured body regions, repetitive\\u0026ndash;gradual-onset injuries were characterised by a significantly higher expected frequency of trunk injuries, with lumbosacral spine/buttock injuries accounting for 24.5% of all injuries. Thus, sustained mechanical loading on the lumbar region during swimming may contribute to overuse-related injury onset patterns, and lumbar injuries constitute a substantial proportion of trunk injuries in competitive swimmers. Previous studies have reported high prevalence of intervertebral disc degeneration and lumbar injuries among elite swimmers,\\u003csup\\u003e6,20\\u0026ndash;23\\u003c/sup\\u003e and the present findings are consistent with these observations.\\u003c/p\\u003e \\u003cp\\u003eShoulder injuries accounted for a high proportion of repetitive\\u0026ndash;gradual-onset injuries. Epidemiological studies of international competitions and systematic reviews have consistently reported that the shoulder is the most frequently injured body region during competitive swimming,\\u003csup\\u003e9,12\\u003c/sup\\u003e and a similar pattern was observed in the present study.\\u003c/p\\u003e \\u003cp\\u003eFurthermore, knee injuries were frequently associated with overuse-related onset patterns, second to injuries in the shoulder and lumbar region. This distribution aligns with swimming-specific overuse injuries, such as breaststroker knee.\\u003csup\\u003e\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e\\u003c/sup\\u003e Nevertheless, a notable proportion of knee injuries were classified as acute\\u0026ndash;sudden-onset, including anterior cruciate ligament injuries, medial collateral ligament injuries, and contusions. Therefore, knee injury prevention strategies in competitive swimmers should address both swimming-related overuse mechanisms and acute traumatic injuries associated with non-swimming activities.\\u003c/p\\u003e \\u003cp\\u003eConversely, lower extremity injuries were significantly overrepresented among acute\\u0026ndash;sudden-onset injuries, with ankle injuries accounting for 26.4% of all acute\\u0026ndash;sudden-onset injuries. Among acute\\u0026ndash;sudden-onset injuries, anterior talofibular ligament injury was the most common diagnosis, representing 23.1% of cases. Lower extremity injuries in competitive swimmers frequently occur during non-swimming activities;\\u003csup\\u003e10\\u003c/sup\\u003e a previous study reported approximately 38% of injuries during strength training or team activities outside of swimming.\\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u003c/sup\\u003e Therefore, the present findings may reflect patterns previously reported in the literature regarding non-swimming and land-based activities. Furthermore, given the previously reported ankle characteristics in competitive swimmers\\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR27\\\" citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e\\u003c/sup\\u003e and evidence that foot and ankle injuries commonly occur during land-based training,\\u003csup\\u003e11\\u003c/sup\\u003e the present results may reflect sport-specific demands and athlete-specific physical characteristics. Because taping and ankle bracing are restricted during swimming competitions, ankle-focused injury prevention strategies should extend beyond water training and include land-based training and daily activities.\\u003c/p\\u003e \\u003cp\\u003eCollectively, injury onset patterns in competitive swimmers may differ substantially by injured body region. Accordingly, preventive strategies focusing on managing cumulative loading during swimming may be particularly important for shoulder and lumbar injuries. In contrast, more comprehensive approaches that address acute traumatic injuries during non-swimming activities may be required for knee and ankle injuries.\\u003c/p\\u003e \\u003cp\\u003eAlthough this was a single-institution study, it provides clinically derived, physician-diagnosed data across a wide range of competition levels and offers distinct descriptive insights into the combination of injury onset patterns and injured body regions, including non-shoulder sites.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eClinical Implications\\u003c/h2\\u003e \\u003cp\\u003eThis retrospective descriptive study conducted at a single medical institution provided a comprehensive overview of injury onset patterns and injured body regions among competitive swimmers. The use of long-term medical record data collected within a consistent clinical setting ensured uniform diagnostic criteria and evaluation practices, enabling detailed characterisation of injury patterns. By examining distributional relationships between injury onset patterns and injured body regions, this study provides baseline descriptive evidence that may inform future injury prevention strategies and hypothesis-driven research. These findings suggest that shoulder and lumbosacral problems may warrant monitoring of cumulative swimming load, whereas knee and ankle problems may require broader prevention strategies that also address land-based training and daily activities.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eLimitations\\u003c/h2\\u003e \\u003cp\\u003eThis study had some limitations. First, this was a retrospective, single-centre study based on medical records from swimmers who sought medical care. Therefore, selection bias related to healthcare-seeking behaviours and institutional characteristics cannot be excluded. In addition, because the sample was drawn from a single geographical region, the findings may not be representative of all competitive swimmers in Japan, and generalisability should be interpreted with caution. Second, reliance on medical record data may have introduced information bias or misclassification bias in injury mechanisms and onset patterns. Detailed contextual factors, such as training volume, training intensity, and specific training content, could not be adequately assessed, and residual confounding by unmeasured variables was possible. Furthermore, because the unit of analysis was an injury event, multiple events from the same swimmer were included, and the assumption of statistical independence may not have been fully satisfied. Accordingly, the results should be interpreted as descriptive findings, and statistical analyses using chi-square tests should be regarded as exploratory to supplement the description of distributional patterns. Future studies with multicentre designs and prospective data collection are warranted to test the hypotheses generated from our findings.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"CONCLUSIONS\",\"content\":\"\\u003cp\\u003eIn this retrospective descriptive study, competitive swimmers who sought medical care, injury onset patterns, and injured body regions were systematically characterised. Injury onset patterns differed according to the injured body region, with gradual onset associated with repetitive loading predominating in the shoulder and lumbar region and acute\\u0026ndash;sudden-onset injuries occurring more frequently in the lower extremities, particularly at the ankle. Therefore, injury prevention strategies in competitive swimming should be interpreted as baseline descriptive evidence for future prevention planning.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eCI\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eConfidence interval\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eCIs\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eConfidence intervals\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eFINA\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eF\\u0026eacute;d\\u0026eacute;ration Internationale de Natation\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eIOC\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eInternational Olympic Committee\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eSD\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eStandard deviation\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eSTROBE\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eStrengthening the Reporting of Observational Studies in Epidemiology\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eSTROBE-SIIS\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eStrengthening the Reporting of Observational Studies in Epidemiology Extension for Sport Injury and Illness Surveillance\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of IMS group Takashimadaira Chuo General Hospital (approval number: 202307). Given the retrospective nature of the study and the use of anonymized medical records, the requirement for informed consent was waived by the Institutional Review Board. Information regarding the study purpose, use of data, protection of personal information, and the right to opt out was publicly disclosed on notice boards within the hospital. Eligible participants were given the opportunity to opt out at any time.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets generated and/or analysed during the current study are not publicly available due to ethical restrictions and the potential risk of participant identification but are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The article processing charge for this publication was supported by the 2026 Collaborative Research Grant of Bunkyo Gakuin University.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors’ contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eConceptualization: AH, SM. Methodology: AH, KN, YM, SM. Formal analysis: AH, KN. Investigation: AH, KN, WM, TO. Data curation: AH, KN. Resources: SM. Writing – original draft: AH. Writing – review \\u0026amp; editing: AH, KN, WM, TO, YM, TI, SM. Visualization: AH, KN. Supervision: SM. Project administration: SM. All authors read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors would like to thank Editage for English language editing.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n \\u003cli\\u003eTrinidad A, Gonz\\u0026aacute;lez-Garcia H, L\\u0026oacute;pez-Valenciano A. An updated review of the epidemiology of swimming injuries. PM R. 2021;13:1005-20. doi:10.1002/pmrj.12503.\\u003c/li\\u003e\\n \\u003cli\\u003eHill L, Mountjoy M, Miller J. Non-shoulder injuries in swimming: a systematic review. Clin J Sport Med. 2022;32:256-64. doi:10.1097/JSM.0000000000000903.\\u003c/li\\u003e\\n \\u003cli\\u003eStruyf F, Tate A, Kuppens K, Feijen S, Michener LA. Musculoskeletal dysfunctions associated with swimmers\\u0026apos; shoulder. Br J Sports Med. 2017;51:775-80. doi:10.1136/bjsports-2016-096847.\\u003c/li\\u003e\\n \\u003cli\\u003eWeldon EJ 3rd, Richardson AB. Upper extremity overuse injuries in swimming. A discussion of swimmer\\u0026apos;s shoulder. Clin Sports Med. 2001;20:423-38. doi:10.1016/S0278-5919(05)70260-X.\\u003c/li\\u003e\\n \\u003cli\\u003eSein ML, Walton J, Linklater J, Appleyard R, Kirkbride B, Kuah D, et al. Shoulder pain in elite swimmers: primarily due to swim-volume-induced supraspinatus tendinopathy. Br J Sports Med. 2010;44:105-13. doi:10.1136/bjsm.2008.047282.\\u003c/li\\u003e\\n \\u003cli\\u003eKaneoka K, Shimizu K, Hangai M, Okuwaki T, Mamizuka N, Sakane M, et al. Lumbar intervertebral disk degeneration in elite competitive swimmers: a case control study. Am J Sports Med. 2007;35:1341-5. doi:10.1177/0363546507300259.\\u003c/li\\u003e\\n \\u003cli\\u003eVizsolyi P, Taunton JE, Robertson DG, Filsinger L, Shannon HS, Whittingham D, et al. Breaststroker\\u0026apos;s knee. An analysis of epidemiological and biomechanical factors. Am J Sports Med. 1987;15:63-71. doi:10.1177/036354658701500109.\\u003c/li\\u003e\\n \\u003cli\\u003eMountjoy M, Junge A, Alonso JM, Engebretsen L, Dragan I, Gerrard D, et al. Sports injuries and illnesses in the 2009 FINA World Championships (Aquatics). Br J Sports Med. 2010;44:522-7. doi:10.1136/bjsm.2010.071720.\\u003c/li\\u003e\\n \\u003cli\\u003ePrien A, Mountjoy M, Miller J, Boyd K, van den Hoogenband C, Gerrard D, et al. Injury and illness in aquatic sport: how high is the risk? A comparison of results from three FINA World Championships. Br J Sports Med. 2017;51:277-82. doi:10.1136/bjsports-2016-096075.\\u003c/li\\u003e\\n \\u003cli\\u003eHirosawa A, Natori K, Mitomi Y, Kachi Y, Motojima S. Correlation between musculoskeletal disorders and injury factors in competitive swimmers. Jpn J Clin Sports Med. 2025;33:433-8. doi:10.57474/jjcsm.33.3_433.\\u003c/li\\u003e\\n \\u003cli\\u003eWolf BR, Ebinger AE, Lawler MP, Britton CL. Injury patterns in Division I collegiate swimming. Am J Sports Med. 2009;37:2037-42. doi:10.1177/0363546509339364.\\u003c/li\\u003e\\n \\u003cli\\u003eFern\\u0026aacute;ndez-Galv\\u0026aacute;n LM, Alcain Sein J, L\\u0026oacute;pez-Nuevo C, S\\u0026aacute;nchez-Sierra A, Ladri\\u0026aacute;n-Maestro A, S\\u0026aacute;nchez-Infante J. Injury patterns and frequency in swimming: a systematic review. Appl Sci. 2025;15:1643. doi:10.3390/app15031643.\\u003c/li\\u003e\\n \\u003cli\\u003evon Elm E, Altman DG, Egger M, Pocock SJ, G\\u0026oslash;tzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61:344-9. doi:10.1016/j.jclinepi.2007.11.008.\\u003c/li\\u003e\\n \\u003cli\\u003eBahr R, Clarsen B, Derman W, Dvorak J, Emery CA, Finch CF, et al. International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance [STROBE-SIIS]). Br J Sports Med. 2020;54:372-89. doi:10.1136/bjsports-2019-101969.\\u003c/li\\u003e\\n \\u003cli\\u003eClarsen B, Bahr R, Heymans MW, Myklebust G. The prevalence and impact of overuse injuries in five Norwegian sports: application of a new surveillance method. Scand J Med Sci Sports. 2015;25:323-30. doi:10.1111/sms.12223.\\u003c/li\\u003e\\n \\u003cli\\u003eFuller CW, Ekstrand J, Junge A, Andersen TE, Bahr R, Dvorak J, et al. Consensus statement on injury definitions and data collection procedures in studies of football (soccer) injuries. Br J Sports Med. 2006;40:193-201. doi:10.1136/bjsm.2005.025270.\\u003c/li\\u003e\\n \\u003cli\\u003eJapan Swimming Federation. Results of Japan Swimming [Internet]. [cited 2025 Nov 18]. Available from:\\u0026nbsp;\\u003ca href=\\\"https://www.swim.or.jp/\\\"\\u003ehttps://www.swim.or.jp/\\u003c/a\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003eJunge A, Engebretsen L, Alonso JM, Renstr\\u0026ouml;m P, Mountjoy M, Aubry M, 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.\\u003c/li\\u003e\\n \\u003cli\\u003eMountjoy M, Junge A, Alonso JM, Clarsen B, Pluim BM, Shrier I, et al. Consensus statement on the methodology of injury and illness surveillance in FINA (aquatic sports). Br J Sports Med. 2016;50:590-6. doi:10.1136/bjsports-2015-095686.\\u003c/li\\u003e\\n \\u003cli\\u003eWanivenhaus F, Fox AJS, Chaudhury S, Rodeo SA. Epidemiology of injuries and prevention strategies in competitive swimmers. Sports Health. 2012;4:246-51. doi:10.1177/1941738112442132.\\u003c/li\\u003e\\n \\u003cli\\u003eNyska M, Constantini N, Cal\\u0026eacute;-Benzoor M, Back Z, Kahn G, Mann G. Spondylolysis as a cause of low back pain in swimmers. Int J Sports Med. 2000;21:375-9. doi:10.1055/s-2000-3780.\\u003c/li\\u003e\\n \\u003cli\\u003eHsu C, Krabak B, Cunningham B, Borg-Stein J. Swimming anatomy and lower back injuries in competitive swimmers: a narrative review. Sports Health. 2024;16:971-81. doi:10.1177/19417381231225213.\\u003c/li\\u003e\\n \\u003cli\\u003eMatsuura Y, Hangai M, Koizumi K, Ueno K, Hirai N, Akuzawa H, et al. Injury trend analysis in the Japan national swim team from 2002 to 2016: effect of the lumbar injury prevention project. BMJ Open Sport Exerc Med. 2019;5:e000615. doi:10.1136/bmjsem-2019-000615.\\u003c/li\\u003e\\n \\u003cli\\u003eKnobloch K, Yoon U, Kraemer R, Vogt PM. Die 200- bis 400 m-Brustlage dominiert bei Knie\\u0026uuml;berlastungssch\\u0026auml;den im Schwimmsport [200-400 m breaststroke event dominate among knee overuse injuries in elite swimming athletes]. Sportverletz Sportschaden. 2008;22:213-9. German. doi:10.1055/s-2008-1027987.\\u003c/li\\u003e\\n \\u003cli\\u003eJohnson JE, Sim FH, Scott SG. Musculoskeletal injuries in competitive swimmers. Mayo Clin Proc. 1987;62:289-304. doi:10.1016/S0025-6196(12)61906-5.\\u003c/li\\u003e\\n \\u003cli\\u003eHsu C, Schon J, Genovese T, McInnis K. Ankle laxity and instability in collegiate swimmers. J Sports Med Phys Fitness. 2025;65:1194-200. doi:10.23736/S0022-4707.25.16570-5.\\u003c/li\\u003e\\n \\u003cli\\u003eKaneda K, Maeda N, Ikuta Y, Tashiro T, Tsutsumi S, Arima S, et al. The features of foot morphology and intrinsic foot muscle property in adolescent swimmers: an ultrasound-based study. J Hum Kinet. 2023;87:95-103. doi:10.5114/jhk/163148.\\u003c/li\\u003e\\n \\u003cli\\u003eKobayashi T, Takabayashi T, Kudo S, Edama M. The prevalence of chronic ankle instability and its relationship to foot arch characteristics in female collegiate athletes. Phys Ther Sport. 2020;46:162-8. doi:10.1016/j.ptsp.2020.09.002.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-sports-science-medicine-and-rehabilitation\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"ssmr\",\"sideBox\":\"Learn more about [BMC Sports Science, Medicine and Rehabilitation](http://bmcsportsscimedrehabil.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/ssmr/default.aspx\",\"title\":\"BMC Sports Science, Medicine and Rehabilitation\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Swimming, Overuse injury, Acute injury, Descriptive epidemiology\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-9528841/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-9528841/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground\\u003c/strong\\u003e: Competitive swimming is characterised by repetitive movements and is associated with a substantial burden of musculoskeletal injuries. However, descriptive epidemiological studies organising injuries according to both onset pattern and injured body region, including regions other than the shoulder, remain limited. This study aimed to describe the distribution of injury onset patterns and injured body regions among competitive swimmers seeking medical care.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods\\u003c/strong\\u003e: This retrospective descriptive study included competitive swimmers who visited a single medical institution between 2019 and 2024. Data on age, sex, competition level, diagnosis, injury onset pattern, and injured body region were extracted from electronic medical records. Injury onset patterns were classified as acute–sudden, repetitive–sudden, or repetitive–gradual. Injured body regions were categorised as follows: the trunk as head/face, neck, chest, thoracic spine/upper back, lumbosacral spine/buttocks, and abdomen; the upper extremity as shoulder, upper arm, elbow, forearm, wrist, hand, and fingers; and the lower extremity as hip/groin, thigh, knee, lower leg/Achilles tendon, ankle, and foot. The number and proportion of injury events with 95% confidence intervals were calculated, and the associations between injury onset patterns and injured body regions were explored using the chi-square test.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e: Overall, 615 injury events from 360 swimmers were analysed (mean age, 19.4 ± 6.5 years). Repetitive gradual-onset injuries were most frequently observed in the shoulder and lumbosacral spine/buttocks, whereas acute sudden-onset injuries were more commonly distributed in the lower extremity (χ² = 27.7, df = 4，p \\u0026lt; 0.001), particularly at the ankle.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions\\u003c/strong\\u003e: Distinct distributions of injury onset patterns and injured body regions were observed in competitive swimmers seeking medical care, potentially providing baseline data that support future hypotheses and injury prevention strategies.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Patterns of musculoskeletal injury onset and injured body regions among competitive swimmers attending a single medical institution: a retrospective descriptive epidemiological study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-05-04 10:21:22\",\"doi\":\"10.21203/rs.3.rs-9528841/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-05-18T08:30:03+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"227702437536135832873350715979697284603\",\"date\":\"2026-05-06T06:05:21+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"129723059585307505707461495595917808445\",\"date\":\"2026-05-02T23:33:24+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-05-02T18:52:42+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2026-04-30T07:16:05+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-04-27T14:10:26+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-04-27T14:10:23+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Sports Science, Medicine and Rehabilitation\",\"date\":\"2026-04-26T01:50:57+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-sports-science-medicine-and-rehabilitation\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"ssmr\",\"sideBox\":\"Learn more about [BMC Sports Science, Medicine and Rehabilitation](http://bmcsportsscimedrehabil.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/ssmr/default.aspx\",\"title\":\"BMC Sports Science, Medicine and Rehabilitation\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"c0e5ee8c-a77d-429f-aead-c130533fb401\",\"owner\":[],\"postedDate\":\"May 4th, 2026\",\"published\":true,\"recentEditorialEvents\":[{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-05-18T08:30:03+00:00\",\"index\":51,\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"227702437536135832873350715979697284603\",\"date\":\"2026-05-06T06:05:21+00:00\",\"index\":49,\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"129723059585307505707461495595917808445\",\"date\":\"2026-05-02T23:33:24+00:00\",\"index\":44,\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"18\",\"date\":\"2026-05-02T18:52:42+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2026-04-30T07:16:05+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-05-04T10:21:22+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-05-04 10:21:22\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-9528841\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-9528841\",\"identity\":\"rs-9528841\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}