Injuries in elite orienteers

CHRISTER JOHANSSON,* MD

From the Department of Orthopedic Surgery, University of Umeå, Sweden

ABSTRACT An elite competition in a men’s elite course is about 15

km (on a map) through rough terrain, with almost no tracks
A prospective studyof injuries in 89 elite orienteers and great variances in altitude, with about 20 controls
showed total incidence of three injuries per 1,000
a
marked on the map to find in the terrain. The winner’s time
training hours, with no difference between the sexes. usually is about 90 minutes, a time that reflects the high
Mean absence from training per year due to injury was demands of the terrain. For elite women the course is about
20 days for men and 19 days for women. Most injuries 11 km (on a map) and a winner’s time is about 65 minutes.
(80.3%) occurred during training, while the remaining To win an elite course the orienteer must be an excellent
injuries occurred during competition. The lower extrem- runner and have a very good technique in map reading and
ities were affected in 93.6% of the male injuries and in
strategy, as the closest way on the map might not be the
all of the female injuries. The majority of injuries (60.6%) fastest way to run. In running, the best national orienteers
were moderate, while 19.7% were minor and 19.7%
can easily compete with the best long-distance runners in
were major injuries. Overuse injuries accounted for track events and cross country running.
57%; 43% of the injuries were due to trauma. Overuse In Sweden there are four orienteering colleges, where the
injuries predominated in the preseason period, while best national younger (age 17 to 19 years) orienteers can
the incidence was equal between overuse and trau- combine studies and elite training, supervised by an athletic
matic injuries over the rest of the year. Of a total number teacher. Injuries, affecting training and competition results,
of 38 overuse injuries, 60.5% occurred during running are common practical problems for elite orienteers.
on tracks or roads. Thirteen injuries (19.7%) were ma-
The purpose of this study was to analyze incidence, type,
jor; the majority (84.6%) of these injuries were due to and major mechanisms of orienteering injuries, and to see
overuse, affecting the knee in eight cases (61.5%). Of how absences due to injury affect training. The main purpose
the major injuries, 76.5% occurred during the period for the future is to try to make training more successful by
December to May. Of a total number of 28 traumatic
preventing unnecessary injuries.
injuries, 78.6% occurred while running on uneven
ground, mainly in forests. Among the traumatic injuries, MATERIALS AND METHODS
ankle sprains accounted for 57.1 %, equally distributed
between the sexes. The majority of these sprains
Eighty-nine elite orienteers, 33 women and 56 men (aged
(81.2%) were moderate. This paper will discuss injury 17.5 ± 1.5 years), participated in this prospective study. All
mechanisms and possibilities of prevention. were students at four Swedish orienteering colleges at the
time of investigation (July 1, 1983 to June 30, 1984). All
subjects were healthy and had no injuries at the start of the
Orienteering is a sport in which athletes must find their way study. This was verified by a thorough history and clinical
through unknown country, mainly in forests, with the help examination performed by the author.
of a map and a compass, and running as fast as possible. In Supervised by their athletic teacher, subjects made
Sweden there are about 80,000 orienteers ranging in age monthly reports on training and injuries on special cards.
from 10 to 80 years. Elite orienteering has spread all over All orienteers also kept their own training diary, where
the world. In the last world championships in Australia training and absence from training was registered daily.
(1985), there were participants from 22 countries. In May When injured, the orienteers were instructed to seek medical
1986, the first World Cup competition in the United States advice for diagnosis and treatment. All injuries were de-
took place in Hudson Valley, New York. scribed thoroughly on the injury cards, and major injuries
were further analyzed by personal interviews with the au-
*
Address correspondence and repnnt requests to Chnster Johansson, MD, thor.
Department of Orthopedic Surgery, University of Umea, S-10185, Sweden An injury was defined as an occurrence at training or

410
 411

competition, causing at least 1 day of absence from ordinary Incidence of injury over the year
training. Injuries were classified in three categories accord-
The incidence of injury over the year is shown in Figure 1.
ing to duration of absence from training: (1) minor injury-
absence from training for less than a week; (2) moderate Male incidence was highest in April, May, and September,
injury-absence from training for more than a week but less while female incidence was highest in December and March.
than a month; and (3) major injury-absence from training Overuse injuries dominated in the period December to May,
for more than a month. while traumatic and overuse injuries occurred equally over
Data was analyzed with ordinary statistics.’ A retrospec- the rest of the year.
tive investigation with comparison of data from training
diaries and injury cards was performed at the end of the Diagnosis and treatment
study.
Forty-seven injuries (71.2%) were primarily examined by a
doctor, with no difference found between the sexes. Exclud-
RESULTS ing advice to rest, specific treatment or training advice was
given in 33.3% of the male group and in 50% of the female
The orienteers (N 89) reported 66 injuries, 13 (19.7%)
=
group. All major injuries (N 13) were examined by doctors,
=

being minor, 40 (60.6%) moderate, and 13 (19.7%) major. in most cases (N 12) orthopaedic surgeons.
=

No difference in incidence was found between the sexes. No

one reported more than one injury. The remaining orienteers
Localization and type of injury
(N =
23) reported no injury.
The lower extremities were affected in 93.6% of the male
Retrospective investigation injuries and in all female injuries (Table 1). Distribution of
injuries between the sexes, and severity of injuries are shown
When comparing data on injury cards with data from train- in Tables 2 and 3. Overuse injuries dominated in both sexes
ing diaries, we found 25 injuries that were not registered on and accounted for 57% of all injuries. The majority of
injury cards. Of these injuries, 14 were due to trauma and overuse injuries were moderate (55.3%) and localized in or
11 were due to overuse. None of these injuries were major below the knee. Of the major injuries (N 13), 11 (84.6%)
=

and none required a visit to a doctor. Most (N 15) were

=
were due to overuse. These (61.5%) were also localized in or
minor, the rest (N 10)
=
being moderate injuries. No injury near the knee (Table 4).
caused more than 3 weeks of absence from training. All Only men sustained stress fractures (N 2) and Achilles
=

injuries affected those who reported another injury. The tendinitis (N 6). The stress fractures were localized to the
=

reasons for not reporting the injuries were, in most cases, distal part of the tibia in one case and to the neck of the
that the orienteer had forgotten to report the injury while femur in the other case. Among the traumatic injuries, ankle
on holidays and unsupervised by his or her athletic teacher. sprains accounted for 52.9% of the male injuries and 63.6%
These injuries have not been analyzed further and are, of the female injuries. A total of 60.7% of the traumatic
therefore, not included in the results of the prospective injuries affected the ankle. The majority of these injuries
study. were moderate. Two traumatic injuries were major; one was

Figure 1. Relative incidence of injury over the year in 66 elite orienteers.

412

TABLE 1 Mechanism of injury

Localization of injuries’

Twenty-five male injuries (59.5%) and 13 female injuries

(54.2%) had gradually increasing symptoms and were de-
fined as overuse injuries. Local pain on provocation or when
loading was the single most common symptom. The other
28 injuries (42.4% ) occurred as traumatic injuries, with
mechanisms described in Table 5. The most common mech-
anism, which resulted in ankle sprain, occurred when run-
ning in terrain with uneven ground where the foot suddenly
&dquo;gave way&dquo; when loading the extremity.
° Numbers within parentheses show percent of total number of
injuries. Activity and surroundings
TABLE 2 The
Type of mjury and sex’ majority of injuries (93.9%) occurred during running.
The remaining injuries (N 4) occurred when skiing (N
= =

1) or at indoor activities such as gymnastics (N 3), and

=

were defined as overuse injuries. Most injuries (80.3%) oc-

curred during training, while the rest of the injuries (N =

13) occurred during competition, with no differences be-

tween the sexes.
The ground was uneven (in forest) in 53.2% of the running
injuries. Of those injuries occurring on uneven ground, 66.6%
were traumatic, while the rest (N =
11) were due to overuse.
The ground was dry in 71 %, wet in 11 % and slippery (snow/
ice) in 18% of the traumatic running injuries. Of a total of
28 traumatic running injuries, 22 (78.6%) occurred on un-
even ground, while the remaining injuries (N =
6) occurred
when running on tracks or roads.
Nearly half (46.7%) of the running injuries occurred while
°
running on tracks or roads. Of these injuries, 79.3% were
Numbers within parentheses show percent of total number of due to overuse, with no difference in incidence between the
injuries. sexes. Of a total number of 38 overuse injuries, 60.5%
occurred when running on tracks or roads, while the remain-
TABLE 3
ing injuries (N 15) occurred when running on uneven
=

Type and severityof injuriesa

ground (N 11), at indoor activities (N 3), or when skiing
= =

(N =
1).

Major injuries
Thirteen injuries, 2 traumatic and 11 overuse, caused more
than a month of absence from training (range, 41 to 150
days). These injuries are detailed in Table 4. Of the major
injuries, 76.5% occurred during the period from December
to May. The knee was affected in eight cases (61.5%). All
major injuries were examined by doctors, in most cases
orthopaedic surgeons.
Eight of the major injuries (61.5% ) were treated only with
the advice to rest. In four cases some form of antiinflam-
matory treatment was used. In one case (stress fracture at
°
Numbers within parentheses show percent of total number of neck of femur) hospital care was necessary. Arthroscopy was
injuries. used for diagnosis in three cases, and in two of these cases
no exact diagnosis was made. In one case the arthroscopy
an uncomplicated fracture of the fibula and another a hy- was performed in the case of a differential diagnosis, with

perextension injury of the ankle joint. Contusions (N =

5) the clinical diagnosis of patellar tendinitis. This tendinitis
affected men only, four of them involving the knee. was later surgically repaired.
 413

TABLE 4
Diagnosis and treatment of major injuries

~~ ~ ~

° 0 in this column refers to clinical examination only.

b 0 in this column refers to no treatment, only rest.

TABLE 5 TABLE 7
Mechanism of traumatic injuries’ -
Training differences between injured and uninjured groups

a Numbers within parentheses show percent of total number of

injuries.

TABLE 6
Total effective training time and absence from training due to ° Male injured trained significantly more than male uninjured.
injuries b Female injured trained significantly less than female uninjured.

DISCUSSION

Due to the individual training of the elite orienteer (trainers

* Denotes significant differences between men and women. do not always supervise), there are methodologic problems
** Denotes nonsignificant differences in epidemiologic studies of this nature that do not exist in
studies of team sports. The students in our study attend
Training and absence from training due to injuries school, where training is supervised by an athletic teacher
during weekdays, and on weekends and during holidays their
Men (N =
56) trained significantly more hours than the training is unsupervised and spread all over the country.
women (N 33). This is shown in Table 6. Absences from
=
Incidence of injury can be affected by unreported injuries,
training, however, were equal between the sexes. The mean an occurrence shown in the retrospective investigation. Def-
number of absences per year from training was 20 days for inition of injury can also vary in different studies.
males and 19 days for females. The total incidence of injury The purpose of this study was to analyze incidence, type
was calculated to three injuries per 1,000 training hours. and major mechanism of orienteering injuries, and to see
The male-injured group (N 42) trained significantly
=
how injuries affect training absence. For the elite orienteer,
more than the male-uninjured group (N 14). The female-
=
absence from training due to injuries is a threat to compe-
injured group (N 24) trained significantly less than the
=
tition result and the elite career.
female-uninjured group (N 9) (Table 7). Of the traumatic
=
Orienteering is not a dangerous sport. No injury registered
injuries 78.6%, and 47.4% of the overuse injuries caused an was graded more than AIS 2 in the abbreviated injury scale
absence from training for less than 2 weeks. Of the overuse (moderate injury-fracture of fibulae, distortion of knee
injuries, 28.9% were major. joint).&dquo; When using our definition of severity of injury, 80%
414

were minor or moderate. Twenty percent of the injuries, extremities, in agreement with other reports.4,5,11 Stress
however, were major. A prolonged absence from training can fractures are described with a 10% incidence in athletes, 15
severely affect the elite career. while in this study only two stress fractures (3%) occurred.
Most of the overuse injuries occurred during preseason One male orienteer had a stress fracture of the tibia, an
training, which is in agreement with the findings of Orava injury not rare in runners. 7,11,15,18 He had been ill for a few
and Puranen.l4 In general, an alteration in the type of weeks and was trying to catch up for spring competition by
training and a rapidly increased training quantity could be training more than he was used to. His fracture was localized
responsible for some overuse injuries.6. 7,14 During October at the proximal insertion of the medialis tibialis posterior.
and November, overuse injuries were rare, due to a break in The second stress fracture in this study occurred in a male
training and a lowered intensity of training after the com- orienteer who also trained for ski competitions in winter.
petition season. During autumn he trained with roller skis. Using the skating
Injuries may be more likely when orienteers begin training technique (pushing off with one leg with the hip joint out-
to prepare for the next competition season. A too rapid
wardly rotated while standing on the other leg for balance)
increase in training in December probably explains the high he probably stressed the hip of the &dquo;push-off’ leg too much.
incidence of overuse injuries in women. This injury mecha- He fractured the neck of his femur, a fairly common site of
nism is described in another study of elite orienteers, where stress fractured Different mechanisms can lead to stress
a rapid increase in the relative amount of quality running
fractured 11, ~5° ls A varied, well-planned training and a good
(intervals, high intensity running, uphill sprints, and com- technique can probably prevent some of these injuries.
petitions) is shown parallel with a high incidence of overuse Achilles tendinitis affected six men in this study. Clement
injuries from February through May. et al.’ described overtraining, overpronation, and gastrocne-
The majority of overuse injuries occurred during running
mius/soleus insufficiency as mechanisms for Achilles ten-
training. This seems reasonable, as running is the major dinitis. None of the men in our study had overpronation.
training exercise for orienteers. Running as training in the The fact that no women were affected might be due to a
investigated group accounted for 150 to 450 hours, while lower amount of training.
competitions accounted for 20 to 50 hours during the year. Shin splints 17 affected seven orienteers, equally between
The intensity and type of training is not known, nor is the
the sexes. This is a common injury in runners. 13,16.17
amount to which orienteers trained before entering the
Slocum17 described overuse in early season training, a change
study. It seems reasonable to suggest that the individual in footwear, or a change to a hard surface as mechanisms
relative increase in training, concerning all types, is a more
for shin splints. Tight heel cords and improper conditioning
important injury risk factor than the training amount itself. are also suggested as mechanism. In this study, three of
Students attending an orienteering college can have a too
the female injured athletes received orthotic devices to cor-
rapid increase in training although the total amount of rect overpronation. No surgery&dquo; was necessary. All shin
training may be low. This might explain why, although
training for less than 1 hour per day, orienteers may sustain splints as well as tendinitis were moderate injuries.
The knee was the most common localization of major
overuse injuries. A good orienteering technique can compen-
overuse injuries. Three of the major knee overuse injuries in
sate for a low running capacity in elite competitions to some
this study required arthroscopic examination. In two cases
extent, especially on the junior level. The top international
no exact diagnosis was confirmed. In one case patellar
orienteers, however, are extremely good runners and train
in most cases more extensively than the orienteers in this tendinitis was surgically repaired. Of the traumatic injuries,
78.6% occurred when running on uneven ground in forests,
study.
Another major mechanism of overuse injuries during the during competition, or in training. This reflects the de-
training (noncompetition period) period is the necessity of manding running technique in orienteering, with uphill,
running on tracks or roads (snow precludes running in downhill, and forest running.
forests) where the eccentric loading on the lower extremities Injuries to the knee are also described as common injuries
in running is greater than in forests. Training also, surpris- in runners in other reports.4, 5, 14 Clement et al.~ discussed
ingly, consists mostly of low intensity and long distance microtrauma produced by eccentric loading of fatigued mus-
running, despite the fact that competitions demand high cle as a factor causing Achilles tendinitis. This mechanism
intensity running in rough terrain. could also be responsible for some of the knee injuries. If so,
In my opinion, training errors such as overly rapid in- a sufficient muscle strength in the muscles supporting the

creases or changes in training type, intensity, or running knee joint, a variation of running surface, proper shoes, and
surface could be prevented by an individual training plan a training plan could prevent some of these injuries.

for the orienteer. Furthermore, to avoid a prolonged absence When running in forests, orienteers use special shoes
from training due to overuse injuries, immediate analysis of which are somewhat different from ordinary training shoes.
injury mechanism and correction of training should be car- They must be able to withstand water, snow, rough ground,
ried out when overuse symptoms occur. Treatment of over- sharp edges, sticks, and slippery ground. They cannot be so
use injuries should start with prevention. 14 high as to risk ankle distortions. These shoes are neither
In this study, almost all overuse injuries affected the lower comfortable nor stable and should be further developed.
 415

Ordinary training shoes, however, are not sufficient due to and competition results. Overuse injuries are common, even
the special demands. though in this study there was a low amount of training.
The most common traumatic injury was sprain of the Training and injury mechanisms must be further analyzed
ankle. Most of the sprains (81.2%) were moderate injuries. and defined. Individually planned training programs are
Since these injuries give residual disability in one-third of suggested. Competition injuries, which are mostly traumatic,
the cases,’ mostly as giving way feelings9 and redistortion,19 need further analysis as they are rarely investigated.’
it is very important to prevent new injuries and reinjuries.
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=
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