Influence of Time of Day, Breaks, and Physical Activity on Injuries in Recreational Alpine Skiers

Influence of Time of Day, Breaks, and Physical Activity on Injuries in Recreational Alpine Skiers | 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 Influence of Time of Day, Breaks, and Physical Activity on Injuries in Recreational Alpine Skiers Dinko Kolarić, Ana Kolarić, Domagoj Sirovec, Lana Ružić This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5752047/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives: This study aims to identify significant risk factors contributing to injuries in recreational alpine skiers using a validated questionnaire. Design: Retrospective cohort study. Methods: Participants were categorized into two groups: the injured group (N = 212) and the uninjured group (N = 206). The injured skiers completed a questionnaire that identified potential risk factors, while the control group answered the same questionnaire, excluding injury-related questions. General questions were used to assess the likelihood of injury and additional questions for the injured group helped evaluate injury severity using the Injury Severity Score (ISS). Results: The analysis revealed several key risk factors. Skiers aged over 40 years were identified as a higher-risk group. Women were found to experience more severe injuries and had a higher incidence of knee injuries. The highest risk of injury was observed on the third day of skiing, with injuries most likely occurring between noon and 2 p.m. Additionally, injuries were more frequent after three hours of skiing. An increase in the average duration of breaks was associated with a 14% reduction in the likelihood of injury for every additional 10 minutes of break time. Body mass index (BMI), regular physical training throughout the year, regardless of the duration or intensity of the training, and warming up before skiing did not significantly reduce injury risk or affect injury severity. Conclusions: Gender, age, time of day, skiing duration, and break duration are identified as significant potential risk factors for injuries in recreational alpine skiing. snow skiing accidental injuries risk factors Figures Figure 1 1. INTRODUCTION Despite having only approximately 30 kilometers of ski slopes, alpine skiing is a highly popular activity in Croatia, with an estimated 300,000 individuals participating annually. Most skiers belong to the working-age population or younger age groups. Among these, between 500 and 1,000 skiers sustain injuries each year that require hospitalization [ 1 ]. Defining a skiing injury poses significant challenges, as it may range from minor scratches to severe physical trauma. For the purposes of this study, a skiing injury is classified as any injury that prevents the skier from continuing to ski for at least one day. Over the past four decades, the incidence of skiing-related injuries has declined significantly, primarily due to advancements in equipment quality [ 2 ]. The risk factors for alpine skiing injuries are well-documented in the literature [ 3 ] and are broadly categorized into internal and external factors [ 4 ]. However, certain factors, such as the duration of rest periods and the role of habitual exercise (HE), remain poorly understood and inadequately defined. Previous studies indicate that children, adolescents, and individuals over the age of 50 are the most vulnerable age groups [ 5 , 6 ]. Gender has also been identified as an internal risk factor, with male skiers exhibiting a higher overall risk of injury [ 7 ], while female skiers are more predisposed to knee injuries [ 8 ]. Knee injuries represent the most common type of injury in skiing, accounting for 24–59% of all reported cases [ 2 , 3 , 9 ]. Among these, anterior cruciate ligament (ACL) injuries constitute nearly 50% of all severe knee injuries [ 9 ]. The role of physical fitness, habitual exercise, and warm-ups in preventing skiing injuries remains a contentious issue. Habitual exercise refers to any physical activity involving the large muscle groups of the musculoskeletal system, such as walking, running, cycling, or even passive activities like gardening. While many studies have explored the relationship between physical training and safer skiing practices [ 10 , 11 ], no conclusive evidence exists to support the notion that higher levels of habitual exercise reduce injury risk in recreational skiers [ 12 ]. Similarly, while body mass index (BMI) is a well-established risk factor in many sports [ 13 ], its influence on injuries in recreational skiing has not been substantiated. Number and duration of breaks were analysed in a large study on the impact of fatigue on injuries. The study concluded that breaks have no effect [ 14 ] especially in women [ 14 , 15 ]. Conversely, another study have reported that rest intervals significantly reduce injury risk [ 16 , 17 ], identifying fatigue as a key contributing factor [ 5 ]. Temporal patterns in skiing injuries reveal that the majority occur on the third day and the final days (sixth and seventh) of skiing, likely due to cumulative fatigue [ 17 ]. Regarding the time of day, some studies suggest that injuries predominantly occur in the afternoon or just before lunch, accounting for up to 81% of cases [ 18 ]. However, one British researcher has reported no significant association between the time of day and injury risk [ 19 ]. Additionally, the duration of skiing prior to injury has been identified as an important factor. One study found that up to 80% of injuries occur after three hours of skiing [ 20 ]. Both internal and external factors appear to partially influence the incidence of injuries among recreational skiers in Croatia, consistent with global trends. The present study aims to analyze comprehensive data on injured recreational skiers, emphasizing the roles of these factors by comparing observed and control groups. Ultimately, this research seeks to provide evidence-based behavioral recommendations for both recreational skiers and ski trainers to enhance safety during skiing activities. 2. METHODS This research was conducted as a retrospective, questionnaire-based study spanning five winter seasons (2013–2018). Data were collected from injured recreational skiers of all ages and genders who were treated at five Croatian rehabilitation hospitals. The study exclusively included skiers injured at ski resorts in Austria and Slovenia. The study followed ethical guidelines approved by the Ethics Committee of the Faculty of Kinesiology, University of Zagreb, at its meeting on April 23, 2013. All participants were informed of the study's purpose and provided informed consent prior to completing the questionnaire. Data for the control group of uninjured skiers were obtained through random recruitment of Croatian skiers at the same ski resorts after a full day of skiing. Recruitment occurred at the end of the day, at the base of ski slopes, throughout five winter seasons. Control group participants skied for a minimum of six hours per day, and all ski resorts examined included 40–120 kilometers of slopes. The target sample size comprised 200 injured skiers and 200 uninjured skiers. The sample size was calculated using G*Power software (Heinrich-Heine-University Düsseldorf, Germany) to achieve a statistical significance level of 0.05, a statistical power of 0.95, and a moderate effect size (d = 0.5). While not all participants fully completed the questionnaire, the sample size was deemed sufficient for reliable analysis. Both the injured and uninjured groups completed a validated questionnaire. Test-retest reliability of the questionnaire was assessed in a subsample of 20 participants who completed the questionnaire a second time, yielding a satisfactory reliability coefficient (r = 0.857, p < 0.001). Participants were queried on a range of variables, including injury location, injury type, gender, age, weight, height, habitual exercise (type, duration, and intensity), pre-ski warm-up routines, number of ski days prior to injury, time of injury, total ski hours (including breaks and lift wait times) prior to injury, and the frequency and duration of breaks. The injured cohort completed the full version of the questionnaire, while the control group completed a modified version that excluded injury-specific questions (e.g., time of injury, ski days prior to injury, and total ski hours until injury). Skiing proficiency and alcohol consumption were excluded as variables from this study. Not all participants (n = 175–212) provided responses to every question, but the planned sample size was deemed sufficient for reliable statistical analysis. The intensity of habitual exercise was categorized based on the Compendium of Physical Activities [ 21 ] as mild (1–4 metabolic equivalents of task [MET]), moderate (5–8 MET), and vigorous (> 8 MET). The number of activity days per year was estimated by multiplying the reported frequency of activity per week by the corresponding number of weeks or months in a year for both groups. Warm-up was assessed via the question: “ Did you perform a worm up that lasted over two minutes immidiately before skiing day?” (Yes/No). For injured participants, the severity of injuries was analyzed based on the Injury Severity Score (ISS): mild (1–8), moderate (9–11), and severe (> 15) [ 22 ]. Descriptive statistics, including tabular and graphical presentations, were used to summarize data distributions. Categorical variables were presented as frequencies and proportions, while quantitative variables were expressed as means and standard deviations or medians and interquartile ranges, depending on distribution normality assessed via the Shapiro-Wilk test. To compare distributions between injured and uninjured groups, chi-square tests, Fisher’s exact tests, and Mann-Whitney U tests were used. Logistic regression was used to calculate the likelihood of injury. The Kruskal-Wallis test was applied to examine factors influencing injury severity across multiple ISS categories. Statistical analyses were conducted using the Statistical Analysis System (SAS Institute Inc., North Carolina, USA), with p-values < 0.05 considered statistically significant. 3. RESULTS A total of 418 surveys were collected, comprising responses from injured skiers (212 surveys; 51%) and uninjured skiers (206 surveys; 49%), achieving an approximately equal representation of both groups. The Injury Severity Score (ISS) was transformed from a numerical to a categorical variable with three severity levels, as informed by observed values and prior research (Table 1). Injury Location and Type: Knee injuries were the most common, accounting for 58.5% of cases, followed by lower leg injuries (10.9%) and shoulder injuries (9.0%). Among knee injuries, anterior cruciate ligament (ACL) injuries were the most prevalent, representing 18.9% of cases. Regarding the type of injury, joint soft tissue injuries were the most frequently reported (Graph 1). Demographics: Participants ranged in age from 10 to 76 years, with a median age of 29 years (interquartile range: 18 years). Injured skiers were slightly older compared to their uninjured counterparts (Table 2). A chi-square test revealed a statistically significant association between injury and age group, divided by decade, with the highest incidence observed in skiers aged over 40 years. Skiers under 20 years old accounted for 34% of injuries, with this proportion increasing progressively in older age groups, peaking at 61% among skiers aged over 40 years. Skiers with minor injuries were slightly younger, but this difference was not statistically significant (Table 3). Gender: The gender distribution was nearly equal between groups, but females experienced more severe injuries compared to males (Table 3). Women had a 20% higher incidence of ACL injuries and a 50% higher rate of knee soft tissue injuries compared to men. Body Mass Index (BMI): The median BMI was identical between injured and uninjured skiers at 23.5, with interquartile ranges of 4.8 and 4.7, respectively. No statistically significant association was found between BMI and injury probability (Table 2) or between BMI and injury severity (Spearman correlation coefficient = -0.028; p = 0.682). Break Duration: Skiers took an average of 2.1 breaks per day (SD = 1.30), with an average break duration of 29.7 minutes (SD = 18.48). While the number of breaks showed no significant relationship with injury occurrence, differences were observed in the distribution of average break duration and total break duration (Table 2). Uninjured skiers tended to take longer breaks. Logistic regression analysis demonstrated that each additional 10 minutes of break time was associated with a 14% reduction in injury probability (OR = 0.986; CI = 0.973–0.999). However, neither the number nor the duration of breaks significantly influenced injury severity (Table 3). Habitual Exercise (HE): HE duration averaged 8.3 months (SD = 4.79) or 105.2 days (SD = 89.25) per year, with no statistically significant differences between injured and uninjured skiers in terms of HE duration (Table 2). Additionally, no significant relationship was found between HE intensity or warm-up practices and the likelihood of injury (Table 2). The distribution of the duration of HE, measured in months (KWT; p = 0.662), and the estimated number of days of HE (KWT; p = 0.953), did not exhibit statistically significant differences across groups of skiers with varying injury levels. Similarly, HE intensity and pre-ski warm-up showed no association with injury severity (Table 3). Timing of Injuries: Most injuries occurred between 12:00 and 14:00, after approximately three hours of skiing, and predominantly on the third day of skiing. While injury severity was not associated with the time of day (KWT; p = 0.761) or ski hours per day (KWT; p = 0.759), the number of ski days before the injury differed. Severe and moderate injuries tended to occur earlier in the trip, with a median of two days, compared to minor injuries, which occurred after a median of three days. 4. DISCUSSION The primary finding of this study indicates that risk factors, such as age and break duration, significantly influence injury patterns among recreational skiers. Existing literature highlights that men ski more frequently than women (although exact proportions are often unspecified), while women are reported to have a higher likelihood of injury [ 23 ]. In this study, however, gender distribution was similar between injured and uninjured groups. Notably, female skiers exhibited higher mean and median Injury Severity Scores (ISS), suggesting more severe injuries in this group, possibly attributable to physiological differences such as reduced muscle strength and increased ligament elasticity [ 24 ]. Previous studies have identified the age group at highest risk of injury as 13 to 16 years [ 5 , 25 ]. Furthermore, injury severity, rather than likelihood, has been shown to increase in individuals aged 18–29 years and 60–69 years [ 7 ]. In contrast, this study observed a slightly older average age among injured participants. The youngest skiers (under 20 years) had the lowest injury rates, while injury prevalence increased in older age groups. These discrepancies could be explained by the study's inclusion criteria, which focused on injuries resulting in at least one day of missed skiing, thereby excluding minor injuries such as sprains and bruises, which are more common in younger skiers. The findings of this study corroborate previous reports indicating that height, weight, and BMI do not significantly influence injury likelihood or severity in skiing, in contrast to many other sports [ 13 , 26 ]. This phenomenon may reflect skiers self-awareness of their physical limitations, such as body weight. However, as BMI does not differentiate between fat and muscle mass, future analyses could benefit from utilizing body fat percentage as a more precise measure. Knee injuries were the most frequently observed type of injury, particularly ACL injuries [ 9 ]. Unlike other studies [ 3 ], this study reported a high incidence of knee injuries, likely due to its inclusion of participants requiring rehabilitation. ACL injuries were found to be three times more prevalent in women, while overall knee injuries occurred twice as often in women [ 8 , 9 ]. This study supports these findings to a degree, showing a 20% higher incidence of isolated ACL injuries and a 50% higher rate of soft tissue injuries in the knee among women compared to men (43 cases in men versus 64 in women). Break duration and fatigue also emerged as important factors. Although one study concluded that break duration did not significantly reduce injury risk in women [ 15 ], fatigue is widely recognized as a critical factor for injuries in both adolescents [ 16 ] and the general population [ 7 , 27 ]. In this study, while the total number of breaks was similar between injured and uninjured groups, the average duration of breaks was longer in the uninjured group. Each additional 10 minutes of break time reduced injury likelihood by 14%, likely due to improved recovery and preparation for subsequent skiing activity. Although the control group skied throughout the entire day and the injured group skied only until the moment of injury, the number of breaks taken by skiers did not differ significantly. This observation underscores the significance of the data regarding the average duration of breaks. One of the most paradoxical findings concerns the influence of habitual exercise (HE) throughout the year on injury outcomes. While numerous countries and ski clubs provide guidelines on ski preparation, and literature exists on injury prevention through fitness enhancement [ 28 ], several studies have demonstrated that neither the intensity nor the duration of exercise has a proven effect on injury likelihood or severity [ 12 , 29 ]. These findings align with the results of this study, which examined both the intensity and duration of HE. The duration of HE was categorized into four groups: no preparation, 1–6 months of preparation, 7–11 months of preparation, and year-round preparation. Across these groups, no statistically significant association was observed between the duration of HE and the likelihood of injury. Similarly, when HE intensity was stratified into three levels (low, moderate, high), no statistically significant relationship with injury was identified. Thus, the results indicate that habitual exercise does not have a significant effect on either injury likelihood or severity. A possible explanation for this apparent discrepancy could be the skiers’ ability to self-regulate by avoiding excessive demands, such as high speeds or challenging slopes. Warming up during skiing, a variable that has not been extensively studied [ 30 ], also demonstrated no significant influence on injury likelihood or severity in this study. Since warming up can be viewed as a component of physical preparation for skiing, these results further suggest that other factors may play a more substantial role in influencing injury outcomes. Analysis of the number of days spent on the ski slope before injury revealed that the highest incidence of injuries occurred on the second and third days of skiing, typically after approximately three hours of skiing. Furthermore, moderate and severe injuries were more frequently observed earlier in the skiing session compared to mild injuries. These findings are consistent with previous research, which has shown that up to 50% of injuries occur on the second and third days of skiing [ 15 ]. This pattern may be attributed to a false sense of security or relaxation often experienced on the second or third day. Notably, other studies did not gather data regarding the severity of injuries based on the day or time of day. In terms of timing, contrary to common expectations, the peak injury period was not observed during the late afternoon, typically between 3 and 4 p.m. Instead, only approximately 10% of all injuries occurred during this time. The majority of injuries were recorded between 12:00 p.m. and 2:00 p.m., with the median injury time for mild and moderate injuries being 1:00 p.m., and for severe injuries, 12:30 p.m. One potential explanation for this timing is that various factors, beyond carelessness or risk-taking, may contribute to injury risk. For instance, the period between 12:00 p.m. and 1:00 p.m. typically corresponds with the first major break, during which skiers often have lunch. Hunger and dehydration, in addition to fatigue, could therefore serve as risk factors for injury during this time window. 5. CONCLUSION Although awareness of risk factors has improved, many remain significant in recreational alpine skiing. To the best of our knowledge, this study is the first to investigate specific risk factors, including the precise time of injury, habitual exercise intensity, and break duration, in comparison to a control group. In summary, the findings suggest that skiers should prioritize taking breaks at the onset of fatigue, as the majority of injuries occur after approximately 2.5 hours of skiing (including time spent waiting for lifts), with a peak around 12:30 PM. Breaks should last a minimum of 30 minutes to allow for adequate recovery. Additionally, arriving at the slopes well-rested appears to be more critical than extensive physical preparation or a warm-up immediately prior to skiing. The findings presented in this study have practical implications for injury prevention among recreational alpine skiers. Disseminating these results in areas frequented by skiers, alongside guidance provided by ski instructors, could enhance adherence to these recommendations. Future research should explore additional factors, such as self-reported causes of injury, to expand upon these findings and refine preventative strategies. Declarations Conflicts of Interest : The authors declare no conflict of interest. Funding: This research received no external funding. Author Contribution Conceptualisation- all authors; methodology, D.K., D.S., L.R., formal analysis, D.K., A.K., L.R.; investigation, D.K., L.R.; writing-original draft preparation, D.K., A.K. D.S.; writing-review and editing: all authors. Acknowledgements: Conceptualisation- all authors; methodology, D.K., D.S., L.R., formal analysis, D.K., A.K., L.R.; investigation, D.K., L.R.; writing-original draft preparation, D.K., A.K. D.S. ; writing-review and editing: all authors. References Babić M (2017) Prevention of injuries in alpine skiing [in Croatian]. Final Thesis, University of Zagreb School of Medicine. Available at: https://urn.nsk.hr/urn:nbn:hr:105:755366 . Accessed 24 July 2022 St-Onge N, Chevalier Y, Hagemeister N et al (2004) Effect of ski binding parameters on knee biomechanics: a three-dimensional computational study. Med Sci Sports Exerc 36(7):1218–25. https://doi.org/10.1249/01.mss.0000132375.00721.7a Davey A, Endres NK, Johnson RJ et al (2019) Alpine skiing injuries. Sports Health 11(1):18–26. https://doi.org/10.1177/1941738118813051 Deibert MC, Aronsson DD, Johnson RJ et al (1998) Skiing injuries in children, adolescents, and adults. J Bone Joint Surg Am 80(1):25–32 Koehle MS, Lloyd-Smith R, Taunton JE (2002) Alpine ski injuries and their prevention. Sports Med 32(12):785–93. https://doi.org/10.2165/00007256-200232120-00003 Porter ED, Goldwag JL, Wilcox AR et al (2021) Geriatric skiers: active but still at risk, a National Trauma Data Bank study. J Surg Res 259:121–129. https://doi.org/10.1016/j.jss.2020.11.013 Basques BA, Gardner EC, Samuel AM et al (2018) Injury patterns and risk factors for orthopaedic trauma from snowboarding and skiing: a national perspective. Knee Surg Sports Traumatol Arthrosc 26(7):1916–1926. https://doi.org/10.1007/s00167-016-4137-7 Ammerman B, Richards M, Davie R, Pahapill N, Sutton K (2024) Difference in Injury Risk between Male and Female Alpine Skiers: Review of the Literature Posch M, Schranz A, Lener M et al (2021) In recreational alpine skiing, the ACL is predominantly injured in all knee injuries needing hospitalisation. Knee Surg Sports Traumatol Arthrosc 29(6):1790–1796. https://doi.org/10.1007/s00167-020-06221-z Song Y, Li L, Dai B (2022) Trunk neuromuscular function and anterior cruciate ligament injuries: a narrative review of trunk strength, endurance, and dynamic control. Strength and Conditioning Journal. https://doi.org/10.1519/SSC.0000000000000727 Bhatt AM, Inclan PM, Pearle AD (2024) Mechanisms and Prevention Strategies of Anterior Cruciate Ligament Injuries in Alpine Skiers: A Review. JBJS Journal of Orthopaedics for Physician Assistants 12(4):e24 Hébert-Losier K, Holmberg HC (2013) What are the exercise-based injury prevention recommendations for recreational alpine skiing and snowboarding? A systematic review. Sports Med 43(5):355–66. https://doi.org/10.1007/s40279-013-0032-2 Bahr R, Krosshaug T (2005) Understanding injury mechanisms: a key component of preventing injuries in sport. Br J Sports Med 39(6):324–9. https://doi.org/10.1136/bjsm.2005.018341 Hermann A, Christl V, Hastreiter V, Carqueville P, Ellenberger L, Senner V (2023) Muscular fatigue and quadriceps-to-hamstring ratio in alpine skiing in women over 40 years. Int J Environ Res Public Health 20(8):5486 Ruedl G, Helle K, Tecklenburg K et al (2015) Impact of self-reported fatigue on ACL injuries in alpine skiing: a sex comparison [Article in German]. Multicenter Study Sportverletz Sportschaden 29(4):226–30. https://doi.org/10.1055/s-0041-106948 Gao B, Dwivedi S, Milewski MD et al (2019) Lack of sleep and sports injuries in adolescents: a systematic review and meta-analysis. J Pediatr Orthop 39(5):e324-e333. https://doi.org/10.1097/BPO.0000000000001306 Uppstrom TJ, Hawryluk CJ, MBS PJM, Insights I (2024) Safe Slopes: Preventing Winter Sports Injuries. Sports Medicine Greier K (2011) Skiing injuries in school sport and possibilities to prevent them [Article in German]. Sportverletz Sportschaden 25(4):216–21. https://doi.org/10.1055/s-0031-1281816 Harlow T (1996) Factors predisposing to skiing injuries in Britons. Injury 27(10):691–3. https://doi.org/10.1016/s0020-1383(96)00135-0 Burtscher M, Pühringer R, Werner I et al (2009) Predictors of falls in downhill skiing and snowboarding. In: Müller E, Lindinger S, Stöggl T (eds) Science and Skiing IV. Aachen: Meyer & Meyer, pp 183–187 Ainsworth BE, Haskell WL, Herrmann SD et al (2011) 2011 Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc 43(8):1575–81. https://doi.org/10.1249/MSS.0b013e31821ece12 Stevenson M, Segui-Gomez M, Lescohier I et al (2001) An overview of the injury severity score and the new injury severity score. Inj Prev 7(1):10–3. https://doi.org/10.1136/ip.7.1.10 Hunter RE (1999) Skiing injuries. Am J Sports Med 27(3):381–9. https://doi.org/10.1177/03635465990270032101 Burt E (2019) The science of skiing: the effect of terrain, gender and orthotics on quadriceps load. Available at: https://csfjournal.com/volume-1-issue-3/2019/5/23/the-science-of-skiing-the-effect-of-terrain-gender-and-orthotics-on-quadriceps-load . Accessed 24 January 2021 Hagel B (2005) Skiing and snowboarding injuries. Med Sport Sci 48:74–119. https://doi.org/10.1159/000084284 Ruedl G, Ploner P, Linortner I et al (2011) Interaction of potential intrinsic and extrinsic risk factors in ACL injured recreational female skiers. Int J Sports Med 32(8):618–22. https://doi.org/10.1055/s-0031-1275355 Zorko M, Hirsch K, Šarabon N et al (2020) The influence of ski waist-width and fatigue on knee-joint stability and skier’s balance. Applied Sciences 10(21):7766. https://doi.org/10.3390/app10217766 Matković B, Ferenčak S, Žvan M et al (2004) Let's ski together [in Croatian]. Europaperss holding: Ferbos inženjering Fan Z, Min L, He W, Yang Y, Ma W, Yao J (2024) Effectiveness of Multi-Component Interventions on Injury Risk Among Ice and Snow Sports Participants—A Systematic Review and Meta-Analysis Hasler RM, Dubler S, Benneker LM et al (2009) Are there risk factors in alpine skiing? A controlled multicentre survey of 1278 skiers. Br J Sports Med 43(13):1020–5. https://doi.org/10.1136/bjsm.2009.064741 Tables Table 1: Distribution of categorized ISS indicators ISS kat N (%) Minor injury 70 (33,2) Moderate injury 47 (22,2) Severe injury 94 (44,6) Total 211 (100) Table 2 Injury probability Injured (n=212) Uninjured (n=206) p-value Gender (%) 0.836* Male 52 51 Female 48 49 Age (median) 32 27 0.002* Body Mass Index (mean) 23.5 23.5 0.637** Number of breaks (n-median (1 st q- 3 rd q)) 2(1-2) 2(1-3) 0.252** Duration of every break (min-median (1 st q- 3 rd q)) 20 (15-30) 30 (20-30) 0.016** Total duration of breaks (min-median (1 st q- 3 rd q)) 40 (20-60) 60 (30-80) 0.001** Habitual exercise Number of days (mean) 102.5 105.2 0.204** Number of months (mean) 8.1 8.4 0.065** Intensity (%) 0.557*** Low 1.2 0.0 Moderate 34.5 37.2 High 64.3 62.8 Worm up (%) 0.969* Yes 47.9 47.8 No 52.1 52.2 q-quartil. *p-value of chi-square test. **p-value of Mann-Whitney U test. ***p-value of Fischer’s test. Table 3 Injury severity minor moderate severe p-value Gender (%) 0.034** Female 25 24 51 Male 41 20 39 Age (median) 29 31 35 0.178* Number of breaks (median) 2 2 2 0.485* Duration of every break (median-minutes) 30 20 20 0.744* Total duration of breaks (median-minutes) 45 45 40 0.411* Habitual exercise intensity (%) 0.711** Low 1.8 2.7 0.0 Moderate 32.7 35.1 36.0 High 65.5 62.2 64.0 Warm-up 0.865*** Yes 50.7 46.7 46.8 No 49.3 53.3 53.2 *p-value of KWT. **p-value of chi-square test. ***p-value of Fischer’s test. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-5752047","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":397886074,"identity":"75e8f266-2a93-4054-8ddf-387e0a06d4ac","order_by":0,"name":"Dinko Kolarić","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIie3PoQ6CQBzH8f/tNiwIFYvPgONxLDI2LF6/oI6ERTvB6StoIR/7b1hwPoBFi5mIzZM5pwHB5uZ9w2+E++w4AJXqF0OgcgdgyBXA5VIaNCNaSbI7ITVEvBAgYbmfibFro52D39Va+7O4riZ9cyZJweNK0kHDcyMYOZo+tJNFvGMRkoDMs2MlsVF3UAfuhuADkjhlgSSUhE2IeZFkmbJ1E+LpMHJD635LMGabOtKRpBfZvqNZF0jmqWBbSZJPbzEOmWPl3Ouapk/zYjxlqwMmp4JXk8fvPb+wXFFz/q3pN4dVKpXqT7oBp85XRJzDLekAAAAASUVORK5CYII=","orcid":"","institution":"Special Hospital for Medical Rehabilitation Daruvarske toplice","correspondingAuthor":true,"prefix":"","firstName":"Dinko","middleName":"","lastName":"Kolarić","suffix":""},{"id":397886075,"identity":"26236866-e053-4b38-8371-778a166542de","order_by":1,"name":"Ana Kolarić","email":"","orcid":"","institution":"Special Hospital for Medical Rehabilitation Daruvarske toplice","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"","lastName":"Kolarić","suffix":""},{"id":397886076,"identity":"c94b1647-698d-4f01-a805-87fd04ad6a0b","order_by":2,"name":"Domagoj Sirovec","email":"","orcid":"","institution":"Special Hospital for Medical Rehabilitation Daruvarske toplice","correspondingAuthor":false,"prefix":"","firstName":"Domagoj","middleName":"","lastName":"Sirovec","suffix":""},{"id":397886077,"identity":"0e65e130-9380-4340-af95-2a533745ca0e","order_by":3,"name":"Lana Ružić","email":"","orcid":"","institution":"University of Zagreb","correspondingAuthor":false,"prefix":"","firstName":"Lana","middleName":"","lastName":"Ružić","suffix":""}],"badges":[],"createdAt":"2025-01-02 13:23:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5752047/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5752047/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73049593,"identity":"55375eb6-f1cc-4520-9838-573389b026ce","added_by":"auto","created_at":"2025-01-06 09:18:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":55354,"visible":true,"origin":"","legend":"\u003cp\u003eGraph 1: Type of injury\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5752047/v1/f80943a044f8afd0212dd00b.png"},{"id":89922265,"identity":"af0c91ee-717d-413d-86d5-448b47ea98d0","added_by":"auto","created_at":"2025-08-26 12:54:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":539442,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5752047/v1/23cf5503-b3ec-4418-b007-1daa2a7f976d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Influence of Time of Day, Breaks, and Physical Activity on Injuries in Recreational Alpine Skiers","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eDespite having only approximately 30 kilometers of ski slopes, alpine skiing is a highly popular activity in Croatia, with an estimated 300,000 individuals participating annually. Most skiers belong to the working-age population or younger age groups. Among these, between 500 and 1,000 skiers sustain injuries each year that require hospitalization [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDefining a skiing injury poses significant challenges, as it may range from minor scratches to severe physical trauma. For the purposes of this study, a skiing injury is classified as any injury that prevents the skier from continuing to ski for at least one day. Over the past four decades, the incidence of skiing-related injuries has declined significantly, primarily due to advancements in equipment quality [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe risk factors for alpine skiing injuries are well-documented in the literature [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and are broadly categorized into internal and external factors [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, certain factors, such as the duration of rest periods and the role of habitual exercise (HE), remain poorly understood and inadequately defined.\u003c/p\u003e \u003cp\u003ePrevious studies indicate that children, adolescents, and individuals over the age of 50 are the most vulnerable age groups [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Gender has also been identified as an internal risk factor, with male skiers exhibiting a higher overall risk of injury [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], while female skiers are more predisposed to knee injuries [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Knee injuries represent the most common type of injury in skiing, accounting for 24\u0026ndash;59% of all reported cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Among these, anterior cruciate ligament (ACL) injuries constitute nearly 50% of all severe knee injuries [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe role of physical fitness, habitual exercise, and warm-ups in preventing skiing injuries remains a contentious issue. Habitual exercise refers to any physical activity involving the large muscle groups of the musculoskeletal system, such as walking, running, cycling, or even passive activities like gardening. While many studies have explored the relationship between physical training and safer skiing practices [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], no conclusive evidence exists to support the notion that higher levels of habitual exercise reduce injury risk in recreational skiers [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Similarly, while body mass index (BMI) is a well-established risk factor in many sports [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], its influence on injuries in recreational skiing has not been substantiated.\u003c/p\u003e \u003cp\u003eNumber and duration of breaks were analysed in a large study on the impact of fatigue on injuries. The study concluded that breaks have no effect [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] especially in women [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Conversely, another study have reported that rest intervals significantly reduce injury risk [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], identifying fatigue as a key contributing factor [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTemporal patterns in skiing injuries reveal that the majority occur on the third day and the final days (sixth and seventh) of skiing, likely due to cumulative fatigue [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Regarding the time of day, some studies suggest that injuries predominantly occur in the afternoon or just before lunch, accounting for up to 81% of cases [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, one British researcher has reported no significant association between the time of day and injury risk [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdditionally, the duration of skiing prior to injury has been identified as an important factor. One study found that up to 80% of injuries occur after three hours of skiing [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBoth internal and external factors appear to partially influence the incidence of injuries among recreational skiers in Croatia, consistent with global trends. The present study aims to analyze comprehensive data on injured recreational skiers, emphasizing the roles of these factors by comparing observed and control groups. Ultimately, this research seeks to provide evidence-based behavioral recommendations for both recreational skiers and ski trainers to enhance safety during skiing activities.\u003c/p\u003e"},{"header":"2. METHODS","content":"\u003cp\u003eThis research was conducted as a retrospective, questionnaire-based study spanning five winter seasons (2013\u0026ndash;2018). Data were collected from injured recreational skiers of all ages and genders who were treated at five Croatian rehabilitation hospitals. The study exclusively included skiers injured at ski resorts in Austria and Slovenia.\u003c/p\u003e \u003cp\u003e The study followed ethical guidelines approved by the Ethics Committee of the Faculty of Kinesiology, University of Zagreb, at its meeting on April 23, 2013. All participants were informed of the study's purpose and provided informed consent prior to completing the questionnaire. Data for the control group of uninjured skiers were obtained through random recruitment of Croatian skiers at the same ski resorts after a full day of skiing. Recruitment occurred at the end of the day, at the base of ski slopes, throughout five winter seasons. Control group participants skied for a minimum of six hours per day, and all ski resorts examined included 40\u0026ndash;120 kilometers of slopes.\u003c/p\u003e \u003cp\u003eThe target sample size comprised 200 injured skiers and 200 uninjured skiers. The sample size was calculated using G*Power software (Heinrich-Heine-University D\u0026uuml;sseldorf, Germany) to achieve a statistical significance level of 0.05, a statistical power of 0.95, and a moderate effect size (d\u0026thinsp;=\u0026thinsp;0.5). While not all participants fully completed the questionnaire, the sample size was deemed sufficient for reliable analysis.\u003c/p\u003e \u003cp\u003eBoth the injured and uninjured groups completed a validated questionnaire. Test-retest reliability of the questionnaire was assessed in a subsample of 20 participants who completed the questionnaire a second time, yielding a satisfactory reliability coefficient (r\u0026thinsp;=\u0026thinsp;0.857, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Participants were queried on a range of variables, including injury location, injury type, gender, age, weight, height, habitual exercise (type, duration, and intensity), pre-ski warm-up routines, number of ski days prior to injury, time of injury, total ski hours (including breaks and lift wait times) prior to injury, and the frequency and duration of breaks. The injured cohort completed the full version of the questionnaire, while the control group completed a modified version that excluded injury-specific questions (e.g., time of injury, ski days prior to injury, and total ski hours until injury). Skiing proficiency and alcohol consumption were excluded as variables from this study.\u003c/p\u003e \u003cp\u003eNot all participants (n\u0026thinsp;=\u0026thinsp;175\u0026ndash;212) provided responses to every question, but the planned sample size was deemed sufficient for reliable statistical analysis. The intensity of habitual exercise was categorized based on the Compendium of Physical Activities [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] as mild (1\u0026ndash;4 metabolic equivalents of task [MET]), moderate (5\u0026ndash;8 MET), and vigorous (\u0026gt;\u0026thinsp;8 MET). The number of activity days per year was estimated by multiplying the reported frequency of activity per week by the corresponding number of weeks or months in a year for both groups.\u003c/p\u003e \u003cp\u003eWarm-up was assessed via the question: \u003cem\u003e\u0026ldquo; Did you perform a worm up that lasted over two minutes immidiately before skiing day?\u0026rdquo;\u003c/em\u003e (Yes/No).\u003c/p\u003e \u003cp\u003eFor injured participants, the severity of injuries was analyzed based on the Injury Severity Score (ISS): mild (1\u0026ndash;8), moderate (9\u0026ndash;11), and severe (\u0026gt;\u0026thinsp;15) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Descriptive statistics, including tabular and graphical presentations, were used to summarize data distributions.\u003c/p\u003e \u003cp\u003eCategorical variables were presented as frequencies and proportions, while quantitative variables were expressed as means and standard deviations or medians and interquartile ranges, depending on distribution normality assessed via the Shapiro-Wilk test.\u003c/p\u003e \u003cp\u003eTo compare distributions between injured and uninjured groups, chi-square tests, Fisher\u0026rsquo;s exact tests, and Mann-Whitney U tests were used. Logistic regression was used to calculate the likelihood of injury. The Kruskal-Wallis test was applied to examine factors influencing injury severity across multiple ISS categories. Statistical analyses were conducted using the Statistical Analysis System (SAS Institute Inc., North Carolina, USA), with p-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered statistically significant.\u003c/p\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003eA total of 418 surveys were collected, comprising responses from injured skiers (212 surveys; 51%) and uninjured skiers (206 surveys; 49%), achieving an approximately equal representation of both groups.\u003c/p\u003e\n\u003cp\u003eThe Injury Severity Score (ISS) was transformed from a numerical to a categorical variable with three severity levels, as informed by observed values and prior research (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInjury Location and Type:\u003c/strong\u003e Knee injuries were the most common, accounting for 58.5% of cases, followed by lower leg injuries (10.9%) and shoulder injuries (9.0%). Among knee injuries, anterior cruciate ligament (ACL) injuries were the most prevalent, representing 18.9% of cases. Regarding the type of injury, joint soft tissue injuries were the most frequently reported (Graph 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics:\u003c/strong\u003e Participants ranged in age from 10 to 76 years, with a median age of 29 years (interquartile range: 18 years). Injured skiers were slightly older compared to their uninjured counterparts (Table 2). A chi-square test revealed a statistically significant association between injury and age group, divided by decade, with the highest incidence observed in skiers aged over 40 years. Skiers under 20 years old accounted for 34% of injuries, with this proportion increasing progressively in older age groups, peaking at 61% among skiers aged over 40 years. Skiers with minor injuries were slightly younger, but this difference was not statistically significant (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGender:\u003c/strong\u003e The gender distribution was nearly equal between groups, but females experienced more severe injuries compared to males (Table 3). Women had a 20% higher incidence of ACL injuries and a 50% higher rate of knee soft tissue injuries compared to men.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBody Mass Index (BMI):\u003c/strong\u003e The median BMI was identical between injured and uninjured skiers at 23.5, with interquartile ranges of 4.8 and 4.7, respectively. No statistically significant association was found between BMI and injury probability (Table 2) or between BMI and injury severity (Spearman correlation coefficient = -0.028; p = 0.682).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBreak Duration:\u003c/strong\u003e Skiers took an average of 2.1 breaks per day (SD = 1.30), with an average break duration of 29.7 minutes (SD = 18.48). While the number of breaks showed no significant relationship with injury occurrence, differences were observed in the distribution of average break duration and total break duration (Table 2). Uninjured skiers tended to take longer breaks. Logistic regression analysis demonstrated that each additional 10 minutes of break time was associated with a 14% reduction in injury probability (OR = 0.986; CI = 0.973\u0026ndash;0.999). However, neither the number nor the duration of breaks significantly influenced injury severity (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHabitual Exercise (HE):\u003c/strong\u003e HE duration averaged 8.3 months (SD = 4.79) or 105.2 days (SD = 89.25) per year, with no statistically significant differences between injured and uninjured skiers in terms of HE duration (Table 2). Additionally, no significant relationship was found between HE intensity or warm-up practices and the likelihood of injury (Table 2). The distribution of the duration of HE, measured in months (KWT; p = 0.662), and the estimated number of days of HE (KWT; p = 0.953), did not exhibit statistically significant differences across groups of skiers with varying injury levels. Similarly, HE intensity and pre-ski warm-up showed no association with injury severity (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTiming of Injuries:\u003c/strong\u003e Most injuries occurred between 12:00 and 14:00, after approximately three hours of skiing, and predominantly on the third day of skiing. While injury severity was not associated with the time of day (KWT; p = 0.761) or ski hours per day (KWT; p = 0.759), the number of ski days before the injury differed. Severe and moderate injuries tended to occur earlier in the trip, with a median of two days, compared to minor injuries, which occurred after a median of three days.\u003c/p\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eThe primary finding of this study indicates that risk factors, such as age and break duration, significantly influence injury patterns among recreational skiers. Existing literature highlights that men ski more frequently than women (although exact proportions are often unspecified), while women are reported to have a higher likelihood of injury [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In this study, however, gender distribution was similar between injured and uninjured groups. Notably, female skiers exhibited higher mean and median Injury Severity Scores (ISS), suggesting more severe injuries in this group, possibly attributable to physiological differences such as reduced muscle strength and increased ligament elasticity [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious studies have identified the age group at highest risk of injury as 13 to 16 years [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Furthermore, injury severity, rather than likelihood, has been shown to increase in individuals aged 18\u0026ndash;29 years and 60\u0026ndash;69 years [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In contrast, this study observed a slightly older average age among injured participants. The youngest skiers (under 20 years) had the lowest injury rates, while injury prevalence increased in older age groups. These discrepancies could be explained by the study's inclusion criteria, which focused on injuries resulting in at least one day of missed skiing, thereby excluding minor injuries such as sprains and bruises, which are more common in younger skiers.\u003c/p\u003e \u003cp\u003eThe findings of this study corroborate previous reports indicating that height, weight, and BMI do not significantly influence injury likelihood or severity in skiing, in contrast to many other sports [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This phenomenon may reflect skiers self-awareness of their physical limitations, such as body weight. However, as BMI does not differentiate between fat and muscle mass, future analyses could benefit from utilizing body fat percentage as a more precise measure.\u003c/p\u003e \u003cp\u003eKnee injuries were the most frequently observed type of injury, particularly ACL injuries [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Unlike other studies [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], this study reported a high incidence of knee injuries, likely due to its inclusion of participants requiring rehabilitation. ACL injuries were found to be three times more prevalent in women, while overall knee injuries occurred twice as often in women [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This study supports these findings to a degree, showing a 20% higher incidence of isolated ACL injuries and a 50% higher rate of soft tissue injuries in the knee among women compared to men (43 cases in men versus 64 in women).\u003c/p\u003e \u003cp\u003eBreak duration and fatigue also emerged as important factors. Although one study concluded that break duration did not significantly reduce injury risk in women [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], fatigue is widely recognized as a critical factor for injuries in both adolescents [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and the general population [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In this study, while the total number of breaks was similar between injured and uninjured groups, the average duration of breaks was longer in the uninjured group. Each additional 10 minutes of break time reduced injury likelihood by 14%, likely due to improved recovery and preparation for subsequent skiing activity.\u003c/p\u003e \u003cp\u003eAlthough the control group skied throughout the entire day and the injured group skied only until the moment of injury, the number of breaks taken by skiers did not differ significantly. This observation underscores the significance of the data regarding the average duration of breaks.\u003c/p\u003e \u003cp\u003eOne of the most paradoxical findings concerns the influence of habitual exercise (HE) throughout the year on injury outcomes. While numerous countries and ski clubs provide guidelines on ski preparation, and literature exists on injury prevention through fitness enhancement [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], several studies have demonstrated that neither the intensity nor the duration of exercise has a proven effect on injury likelihood or severity [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. These findings align with the results of this study, which examined both the intensity and duration of HE.\u003c/p\u003e \u003cp\u003eThe duration of HE was categorized into four groups: no preparation, 1\u0026ndash;6 months of preparation, 7\u0026ndash;11 months of preparation, and year-round preparation. Across these groups, no statistically significant association was observed between the duration of HE and the likelihood of injury. Similarly, when HE intensity was stratified into three levels (low, moderate, high), no statistically significant relationship with injury was identified. Thus, the results indicate that habitual exercise does not have a significant effect on either injury likelihood or severity.\u003c/p\u003e \u003cp\u003eA possible explanation for this apparent discrepancy could be the skiers\u0026rsquo; ability to self-regulate by avoiding excessive demands, such as high speeds or challenging slopes.\u003c/p\u003e \u003cp\u003eWarming up during skiing, a variable that has not been extensively studied [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], also demonstrated no significant influence on injury likelihood or severity in this study. Since warming up can be viewed as a component of physical preparation for skiing, these results further suggest that other factors may play a more substantial role in influencing injury outcomes.\u003c/p\u003e \u003cp\u003eAnalysis of the number of days spent on the ski slope before injury revealed that the highest incidence of injuries occurred on the second and third days of skiing, typically after approximately three hours of skiing. Furthermore, moderate and severe injuries were more frequently observed earlier in the skiing session compared to mild injuries.\u003c/p\u003e \u003cp\u003eThese findings are consistent with previous research, which has shown that up to 50% of injuries occur on the second and third days of skiing [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This pattern may be attributed to a false sense of security or relaxation often experienced on the second or third day. Notably, other studies did not gather data regarding the severity of injuries based on the day or time of day.\u003c/p\u003e \u003cp\u003eIn terms of timing, contrary to common expectations, the peak injury period was not observed during the late afternoon, typically between 3 and 4 p.m. Instead, only approximately 10% of all injuries occurred during this time. The majority of injuries were recorded between 12:00 p.m. and 2:00 p.m., with the median injury time for mild and moderate injuries being 1:00 p.m., and for severe injuries, 12:30 p.m. One potential explanation for this timing is that various factors, beyond carelessness or risk-taking, may contribute to injury risk. For instance, the period between 12:00 p.m. and 1:00 p.m. typically corresponds with the first major break, during which skiers often have lunch. Hunger and dehydration, in addition to fatigue, could therefore serve as risk factors for injury during this time window.\u003c/p\u003e"},{"header":"5. CONCLUSION","content":"\u003cp\u003eAlthough awareness of risk factors has improved, many remain significant in recreational alpine skiing. To the best of our knowledge, this study is the first to investigate specific risk factors, including the precise time of injury, habitual exercise intensity, and break duration, in comparison to a control group.\u003c/p\u003e \u003cp\u003eIn summary, the findings suggest that skiers should prioritize taking breaks at the onset of fatigue, as the majority of injuries occur after approximately 2.5 hours of skiing (including time spent waiting for lifts), with a peak around 12:30 PM. Breaks should last a minimum of 30 minutes to allow for adequate recovery. Additionally, arriving at the slopes well-rested appears to be more critical than extensive physical preparation or a warm-up immediately prior to skiing.\u003c/p\u003e \u003cp\u003eThe findings presented in this study have practical implications for injury prevention among recreational alpine skiers. Disseminating these results in areas frequented by skiers, alongside guidance provided by ski instructors, could enhance adherence to these recommendations. Future research should explore additional factors, such as self-reported causes of injury, to expand upon these findings and refine preventative strategies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003e \u003cb\u003eConflicts of Interest\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualisation- all authors; methodology, D.K., D.S., L.R., formal analysis, D.K., A.K., L.R.; investigation, D.K., L.R.; writing-original draft preparation, D.K., A.K. D.S.; writing-review and editing: all authors.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eConceptualisation- all authors; methodology, D.K., D.S., L.R., formal analysis, D.K., A.K., L.R.; investigation, D.K., L.R.; writing-original draft preparation, D.K., A.K. D.S. ; writing-review and editing: all authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBabić M (2017) Prevention of injuries in alpine skiing [in Croatian]. Final Thesis, University of Zagreb School of Medicine. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://urn.nsk.hr/urn:nbn:hr:105:755366\u003c/span\u003e\u003cspan address=\"https://urn.nsk.hr/urn:nbn:hr:105:755366\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 24 July 2022\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSt-Onge N, Chevalier Y, Hagemeister N et al (2004) Effect of ski binding parameters on knee biomechanics: a three-dimensional computational study. Med Sci Sports Exerc 36(7):1218\u0026ndash;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1249/01.mss.0000132375.00721.7a\u003c/span\u003e\u003cspan address=\"10.1249/01.mss.0000132375.00721.7a\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavey A, Endres NK, Johnson RJ et al (2019) Alpine skiing injuries. Sports Health 11(1):18\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1941738118813051\u003c/span\u003e\u003cspan address=\"10.1177/1941738118813051\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeibert MC, Aronsson DD, Johnson RJ et al (1998) Skiing injuries in children, adolescents, and adults. J Bone Joint Surg Am 80(1):25\u0026ndash;32\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoehle MS, Lloyd-Smith R, Taunton JE (2002) Alpine ski injuries and their prevention. Sports Med 32(12):785\u0026ndash;93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2165/00007256-200232120-00003\u003c/span\u003e\u003cspan address=\"10.2165/00007256-200232120-00003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePorter ED, Goldwag JL, Wilcox AR et al (2021) Geriatric skiers: active but still at risk, a National Trauma Data Bank study. J Surg Res 259:121\u0026ndash;129. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jss.2020.11.013\u003c/span\u003e\u003cspan address=\"10.1016/j.jss.2020.11.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBasques BA, Gardner EC, Samuel AM et al (2018) Injury patterns and risk factors for orthopaedic trauma from snowboarding and skiing: a national perspective. Knee Surg Sports Traumatol Arthrosc 26(7):1916\u0026ndash;1926. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00167-016-4137-7\u003c/span\u003e\u003cspan address=\"10.1007/s00167-016-4137-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmmerman B, Richards M, Davie R, Pahapill N, Sutton K (2024) Difference in Injury Risk between Male and Female Alpine Skiers: Review of the Literature\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePosch M, Schranz A, Lener M et al (2021) In recreational alpine skiing, the ACL is predominantly injured in all knee injuries needing hospitalisation. Knee Surg Sports Traumatol Arthrosc 29(6):1790\u0026ndash;1796. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00167-020-06221-z\u003c/span\u003e\u003cspan address=\"10.1007/s00167-020-06221-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSong Y, Li L, Dai B (2022) Trunk neuromuscular function and anterior cruciate ligament injuries: a narrative review of trunk strength, endurance, and dynamic control. Strength and Conditioning Journal. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1519/SSC.0000000000000727\u003c/span\u003e\u003cspan address=\"10.1519/SSC.0000000000000727\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhatt AM, Inclan PM, Pearle AD (2024) Mechanisms and Prevention Strategies of Anterior Cruciate Ligament Injuries in Alpine Skiers: A Review. JBJS Journal of Orthopaedics for Physician Assistants 12(4):e24\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026eacute;bert-Losier K, Holmberg HC (2013) What are the exercise-based injury prevention recommendations for recreational alpine skiing and snowboarding? A systematic review. Sports Med 43(5):355\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s40279-013-0032-2\u003c/span\u003e\u003cspan address=\"10.1007/s40279-013-0032-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahr R, Krosshaug T (2005) Understanding injury mechanisms: a key component of preventing injuries in sport. Br J Sports Med 39(6):324\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bjsm.2005.018341\u003c/span\u003e\u003cspan address=\"10.1136/bjsm.2005.018341\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHermann A, Christl V, Hastreiter V, Carqueville P, Ellenberger L, Senner V (2023) Muscular fatigue and quadriceps-to-hamstring ratio in alpine skiing in women over 40 years. Int J Environ Res Public Health 20(8):5486\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuedl G, Helle K, Tecklenburg K et al (2015) Impact of self-reported fatigue on ACL injuries in alpine skiing: a sex comparison [Article in German]. Multicenter Study Sportverletz Sportschaden 29(4):226\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/s-0041-106948\u003c/span\u003e\u003cspan address=\"10.1055/s-0041-106948\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGao B, Dwivedi S, Milewski MD et al (2019) Lack of sleep and sports injuries in adolescents: a systematic review and meta-analysis. J Pediatr Orthop 39(5):e324-e333. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/BPO.0000000000001306\u003c/span\u003e\u003cspan address=\"10.1097/BPO.0000000000001306\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUppstrom TJ, Hawryluk CJ, MBS PJM, Insights I (2024) Safe Slopes: Preventing Winter Sports Injuries. Sports Medicine\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreier K (2011) Skiing injuries in school sport and possibilities to prevent them [Article in German]. Sportverletz Sportschaden 25(4):216\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/s-0031-1281816\u003c/span\u003e\u003cspan address=\"10.1055/s-0031-1281816\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarlow T (1996) Factors predisposing to skiing injuries in Britons. Injury 27(10):691\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0020-1383(96)00135-0\u003c/span\u003e\u003cspan address=\"10.1016/s0020-1383(96)00135-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurtscher M, P\u0026uuml;hringer R, Werner I et al (2009) Predictors of falls in downhill skiing and snowboarding. In: M\u0026uuml;ller E, Lindinger S, St\u0026ouml;ggl T (eds) Science and Skiing IV. Aachen: Meyer \u0026amp; Meyer, pp 183\u0026ndash;187\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAinsworth BE, Haskell WL, Herrmann SD et al (2011) 2011 Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc 43(8):1575\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1249/MSS.0b013e31821ece12\u003c/span\u003e\u003cspan address=\"10.1249/MSS.0b013e31821ece12\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStevenson M, Segui-Gomez M, Lescohier I et al (2001) An overview of the injury severity score and the new injury severity score. Inj Prev 7(1):10\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/ip.7.1.10\u003c/span\u003e\u003cspan address=\"10.1136/ip.7.1.10\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHunter RE (1999) Skiing injuries. Am J Sports Med 27(3):381\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/03635465990270032101\u003c/span\u003e\u003cspan address=\"10.1177/03635465990270032101\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurt E (2019) The science of skiing: the effect of terrain, gender and orthotics on quadriceps load. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://csfjournal.com/volume-1-issue-3/2019/5/23/the-science-of-skiing-the-effect-of-terrain-gender-and-orthotics-on-quadriceps-load\u003c/span\u003e\u003cspan address=\"https://csfjournal.com/volume-1-issue-3/2019/5/23/the-science-of-skiing-the-effect-of-terrain-gender-and-orthotics-on-quadriceps-load\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 24 January 2021\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHagel B (2005) Skiing and snowboarding injuries. Med Sport Sci 48:74\u0026ndash;119. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1159/000084284\u003c/span\u003e\u003cspan address=\"10.1159/000084284\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuedl G, Ploner P, Linortner I et al (2011) Interaction of potential intrinsic and extrinsic risk factors in ACL injured recreational female skiers. Int J Sports Med 32(8):618\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/s-0031-1275355\u003c/span\u003e\u003cspan address=\"10.1055/s-0031-1275355\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZorko M, Hirsch K, Šarabon N et al (2020) The influence of ski waist-width and fatigue on knee-joint stability and skier\u0026rsquo;s balance. Applied Sciences 10(21):7766. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/app10217766\u003c/span\u003e\u003cspan address=\"10.3390/app10217766\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatković B, Ferenčak S, Žvan M et al (2004) Let's ski together [in Croatian]. Europaperss holding: Ferbos inženjering\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFan Z, Min L, He W, Yang Y, Ma W, Yao J (2024) Effectiveness of Multi-Component Interventions on Injury Risk Among Ice and Snow Sports Participants\u0026mdash;A Systematic Review and Meta-Analysis\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHasler RM, Dubler S, Benneker LM et al (2009) Are there risk factors in alpine skiing? A controlled multicentre survey of 1278 skiers. Br J Sports Med 43(13):1020\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bjsm.2009.064741\u003c/span\u003e\u003cspan address=\"10.1136/bjsm.2009.064741\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1:\u003c/p\u003e\n\u003cp\u003eDistribution of categorized ISS indicators\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"228\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003eISS\u003csub\u003ekat\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003eMinor injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e70 (33,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003eModerate injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e47 (22,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003eSevere injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e94 (44,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e211 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 2\u003c/p\u003e\n\u003cp\u003eInjury probability\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"612\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003eInjured (n=212)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eUninjured (n=206)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eGender (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.836*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eAge (median)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eBody Mass Index (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e23.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e23.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.637**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eNumber of breaks (n-median (1\u003csup\u003est\u003c/sup\u003e q- 3\u003csup\u003erd\u003c/sup\u003e q))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e2(1-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e2(1-3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.252**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eDuration of every break (min-median (1\u003csup\u003est\u003c/sup\u003e q- 3\u003csup\u003erd\u003c/sup\u003e q))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e20 (15-30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e30 (20-30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.016**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eTotal duration of breaks (min-median (1\u003csup\u003est\u003c/sup\u003e q- 3\u003csup\u003erd\u003c/sup\u003e q))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e40 (20-60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e60 (30-80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eHabitual exercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eNumber of days (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e102.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e105.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.204**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eNumber of months (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.065**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eIntensity (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.557***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e34.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e37.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e64.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e62.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eWorm up (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.969*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e47.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e47.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e52.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e52.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eq-quartil.\u003c/p\u003e\n\u003cp\u003e*p-value of chi-square test.\u003c/p\u003e\n\u003cp\u003e**p-value of Mann-Whitney U test.\u003c/p\u003e\n\u003cp\u003e***p-value of Fischer\u0026rsquo;s test.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3\u003c/p\u003e\n\u003cp\u003eInjury severity\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"619\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eminor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003emoderate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003esevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eGender (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e0.034**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eAge (median)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e0.178*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eNumber of breaks (median)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e0.485*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eDuration of every break (median-minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e0.744*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eTotal duration of breaks (median-minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e0.411*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eHabitual exercise intensity (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e0.711**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e32.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e35.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e36.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e65.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e62.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e64.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eWarm-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e0.865***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e50.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e46.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e49.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e53.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e53.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p-value of KWT.\u003c/p\u003e\n\u003cp\u003e**p-value of chi-square test.\u003c/p\u003e\n\u003cp\u003e***p-value of Fischer\u0026rsquo;s test.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"snow skiing, accidental injuries, risk factors","lastPublishedDoi":"10.21203/rs.3.rs-5752047/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5752047/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjectives: This study aims to identify significant risk factors contributing to injuries in recreational alpine skiers using a validated questionnaire.\u003c/p\u003e\n\u003cp\u003eDesign: Retrospective cohort study.\u003c/p\u003e\n\u003cp\u003eMethods: Participants were categorized into two groups: the injured group (N = 212) and the uninjured group (N = 206). The injured skiers completed a questionnaire that identified potential risk factors, while the control group answered the same questionnaire, excluding injury-related questions. General questions were used to assess the likelihood of injury and additional questions for the injured group helped evaluate injury severity using the Injury Severity Score (ISS).\u003c/p\u003e\n\u003cp\u003eResults: The analysis revealed several key risk factors. Skiers aged over 40 years were identified as a higher-risk group. Women were found to experience more severe injuries and had a higher incidence of knee injuries. The highest risk of injury was observed on the third day of skiing, with injuries most likely occurring between noon and 2 p.m. Additionally, injuries were more frequent after three hours of skiing. An increase in the average duration of breaks was associated with a 14% reduction in the likelihood of injury for every additional 10 minutes of break time. Body mass index (BMI), regular physical training throughout the year, regardless of the duration or intensity of the training, and warming up before skiing did not significantly reduce injury risk or affect injury severity.\u003c/p\u003e\n\u003cp\u003eConclusions: Gender, age, time of day, skiing duration, and break duration are identified as significant potential risk factors for injuries in recreational alpine skiing.\u003c/p\u003e","manuscriptTitle":"Influence of Time of Day, Breaks, and Physical Activity on Injuries in Recreational Alpine Skiers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-06 09:18:54","doi":"10.21203/rs.3.rs-5752047/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"acbcb2f5-3b7e-43eb-b4e5-72c8273ffeb9","owner":[],"postedDate":"January 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-26T12:54:07+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-06 09:18:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5752047","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5752047","identity":"rs-5752047","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}