Physical Activity-Related Injuries and Their Risk Factors Among Adolescents in Selected Schools - Cross-Sectional Survey

INTRODUCTION

Physical activity (PA) is defined by actions of varying intensity occurring as part of one's daily habits, owing to the contraction-relaxation cycle of skeletal muscle fibres, accompanied by energy consumption.^[1] The World Health Organization (WHO) proposes that children and adolescents devote at least 1 hour on a routine basis to moderate to vigorous physical activity (MVPA), which is vital for bone density and muscle integrity, thus promoting physical development and motor skills.^[2,3]

Wear and tear are natural processes that hinder PA participation due to bouts of spasms or pain from overtraining or as a result of joint loading.^[4] Literature suggests that injuries affecting the growth plates, cartilage, etc., may be primarily observed in adolescents on account of their still-developing maturity, risk-taking nature, and decreased endurance due to growing skeletal tissue.^[5] Traumatic incidents of injury have therefore been a subject of concern as they are more likely to have a long-term impact, impairing physical welfare, and instigating a cognitive decline affecting academic and athletic performance.^[6] These may further cause a financial burden on family members for medical care.^[7] Often, adolescents have been observed to take part in organized and recreational sports even during extreme weather and environmental hazards without the use of proper sports safety equipment.^[8] Additionally, unhealthy lifestyle choices, insufficient nutritional intake, peer pressure, and substance use make adolescents more vulnerable to unintentional injuries.^[9,10] Presently, body weight and image issues push adolescents towards overtraining, which, along with strict dietary restrictions, could lead to burnout and have a detrimental effect on their physical and mental health.^[11]

Alternatively, WHO’s recent survey determined that 81% of adolescents are physically inactive, with females exhibiting greater inactivity compared to males, which made the implementation of the Global Action Plan on Physical Activity 2018-2030 (GAPPA) policy essential, particularly after the COVID-19 pandemic.^[12] Prospective studies showed that prepubertal children were more prone to injuries like fractures owing to their sedentary nature.^[13] A study indicated a higher likelihood of injury in obese individuals due to high mechanical stress.^[14] Growing evidence for the rise of physical inactivity may be attributed to high academic workload, prioritization of tuition after school, and the use of electronic devices.^[15]

Therefore, this study aimed to determine the prevalence and risk factors of physical activity-related injuries (PARI), as well as a sex-wise comparison of injuries in adolescents in Mangaluru, India.

MATERIAL AND METHODS

RESULTS

A total of 400 adolescents (males: 84, females: 316) with a mean age of 12.7 years (SD:1.22) took part in this study, out of which 179 students, consisting of 52% (44/84) males and 43% (135/316) females reported at least one injury that occurred in 12 months with an overall risk of 0.71 injuries/student/year. About 23% (92/400) of the students reported that they were part of sports teams/clubs and practiced their sport at least once a week. Table 1 represents the sociodemographic and lifestyle factors where significant differences were observed in BMI, father’s occupation, sports team involvement, and partaking in MVPA between the injured and non-injured groups (p < 0.05).

A major proportion of injuries took place at school (46%), while 36% and 17% occurred at home and other public places, respectively. Recreational activities such as skating, dancing, yoga, jogging, etc., accounted for over half the injuries (54%), followed by 24% during high-impact sports events such as basketball, football, kickboxing, wrestling, etc., that required rapid movements and physical contact, and 21% were accidental injuries during physical activities involving transportation, household chores, extreme weather, etc. The most common injuries were bruises and wounds like abrasions, lacerations, and contusions (64%); thereafter, 29% were due to joint and ligament sprains. About 7% of injuries were fractures, dislocations, and concussions. Minor injuries were more commonly seen during recreational activities. In contrast, major injuries occurred during high-impact sports events, as in Figure 1. 72% affected the limbs, whereas 28% affected the head, neck, and torso, shown in Figure 2. The highest number of injuries occurred in the lower limbs (53%). 44% of the injuries resulted in instantaneous withdrawal from physical activity, and 32% in absence from school. First aid was administered for 57% of the injury episodes, and 10% required hospitalization.

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Figure 1:

Distribution of injuries during accidental, recreational, and high-impact sports activities.

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Figure 2:

Areas affected by physical activity-related injuries in adolescents.

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On comparing injuries between males and females, as presented in Table 2, significant differences with p < 0.05 were observed in injury severity, withdrawal from physical activity, and absence from school following injury, with a greater proportion of males suffering from more severe injuries (45% vs. 22%) and higher school absence after injury (45% vs. 26%). However, immediate withdrawal from activity following injury was more common in females (29% vs. 48%).

The univariate regression analysis [Table 3] showed that father’s occupation of being seasonally employed (adjusted OR: 3.159 with p =0.0001), participation in MVPA for >120 mins/day (adjusted OR: 3.987, p = 0.0005), participation in high impact sports (adjusted OR: 2.103, p = 0.0037), sleeping for less than 8 hours per day (adjusted OR: 1.515, p = 0.054), climbing walls/trees (adjusted OR: 2.271, p = 0.0097), lack of pre-activity warmups (adjusted OR: 1.589, p = 0.023), playing in extreme weather (adjusted OR: 1.732, P = 0.03), unavailability of playgrounds (adjusted OR:1.574, p = 0.025), and playing on uneven surfaces (adjusted OR: 2.917, p = 0.0007) significantly increased the odds of injury. However, the multivariate regression analysis revealed that father’s occupation of being seasonally employed (adjusted OR: 4.009 with p < 0.0001), participation in MVPA for >120 mins/day (adjusted OR: 3.699, p = 0.0027), participation in high impact sports (adjusted OR: 2.003, p = 0.027), screen-based sedentary behaviour for greater than 2 hours (adjusted OR: 1.714, p = 0.0206), lack of pre-activity warmups (adjusted OR: 1.61, p = 0.0397) and playing on uneven surfaces (adjusted OR: 2.382, p = 0.0316) were significantly associated with PARI. This model showed good fit, with a Hosmer-Lemeshow statistic of 5.374 (p = 0.717), and an acceptable area under the ROC curve of 0.73 (p value <0.0001).

DISCUSSION

This study aimed to find the prevalence of physical activity-related injuries among adolescents in Mangaluru, India. The main findings included an overall injury rate of 44.7% in 12 months, with males suffering from more severe injuries and absence from school. Most injuries were sustained at school, during leisure activities, with the primary site of injury being the lower limbs. PARI risk increased significantly with paternal seasonal employment, high intensity of MVPA (>120 mins/day), participation in high-impact sports, screen-based sedentary behavior, lack of pre-activity warm-ups, and playing on wet/uneven surfaces.

Incidents of injury could lead to medical complications and financial burdens as well as impact mental health, preventing individuals from being physically active, thus elevating the risk of obesity and other non-communicable diseases.^[19] The prevalence of injury varies worldwide, with reports of 68.1% among teens in the United States, 22.7% among University students in China, 45% in Polynesian countries, and 32% among school students in Hong Kong.^[17,20-21] A study in Chandigarh, India, had an incidence of 0.02% among students between 11-12 years and about 1.57% among 17-18-year-olds, whereas in a south Indian state, Puducherry, there was a 23% prevalence.^[22,23] This is one of the few studies that attempt to determine the prevalence of PARI encountered by adolescents in Mangaluru City. A study in Mangaluru comprising adolescent athletes found an injury prevalence of 65%, with limb injuries being the most common.^[24] Our study showed a similar trend with a high prevalence of lower limb injuries, with almost 60% injury prevalence among sports team members within 12 months.

The number of injuries in males was profound compared to females, along with an increased Scholl absence of 45%, which may be attributed to activity levels of more than 120 minutes per day (63% in males vs. 34% in females in this study), participation in high-impact sports, a greater risk-taking nature, and overtraining to attain the ideal body type which may explain their reluctance in immediate withdrawal after injury.^[25,26] Further specific anatomical features of the pelvis and shoulders, prominent during adolescence, make males more vulnerable to overuse injuries, especially affecting the anterior cruciate ligament (ACL).^[27,28] Studies have also indicated that female adolescents in India are less likely to engage in sports and have limited mobility due to cultural and safety issues.^[29]

The most frequent injuries experienced in this study were wounds and sprains, most of which affected the limbs. These injuries may be explained by constant falls when playing on uneven ground, due to the dearth of footpaths and playgrounds in residential areas, as reported by 49% and 31% of participants, respectively.^[30] A significant number of studies report comparable findings, primarily in those involving high-impact sports.^[30] About 95% of the participants perceived the use of protective gear during sports activities as not required, and 8% were unaware of first aid kits in school, which aligns with a study in South India, highlighting the lack of safety awareness among children.^[31] Lack of pre-activity warm-ups intensified the severity of injuries, especially when the training load was increased without gradual progression in high-impact sports or in cases of previous injuries, which was corroborated by other studies involving adolescents.^[32,33]

In contrast, over half the injuries occurred during leisure time, which is possibly because 77% of the participants were not part of sports teams with lower daily PA levels and had not developed a similar level of strength as compared to those in sports teams, elevating their exposure to unintentional injury.^[34] Further, significantly higher BMI in injured participants may be attributed to prolonged sedentary behavior, which poses a health risk and increases the likelihood of injury, which coincides with other studies.^[35] This study suggests the role of paternal occupation in increasing the odds of injury, which may reflect the consequences of social and socioeconomic circumstances on adolescent behaviour concerning unintentional as well as intentional injury, as highlighted by Engström et al.^[36] Moreover, research emphasizes the role of educators in children’s lifestyle choices and even shows that when parents of athletes are educated about safety practices and communicate with children, it could help decrease the occurrence of sports-related injuries.^[37]

CONCLUSION

This study focuses on the prevalence and nature of PARI among adolescents in Mangaluru city. The injuries mainly occurred at school, specifically during non-organized sports activities. Increased intensity of physical activity and sports participation, parental occupation, lack of pre-activity warm-ups, and playing on uneven surfaces contributed significantly to injury risk. Therefore, this study emphasizes the need for a safe environment during training, proper techniques, and protective equipment during daily participation in PA to maximize its benefits and develop endurance to mitigate the risk of injury. Creating awareness among educators and parents about safety methods that can be instilled in children during training may aid in reducing the frequency of injuries.