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Balancing Sport Risk and Health Benefits


A substantial part of our work as physicians involves treating sport- and exercise-related injuries. We also recommend exercise, knowing that it will result in a certain number of acute and overuse injuries. As team physicians, we attend competitive events despite awareness that participants in certain sports run a high risk of significant harm. So then, where do we stand in relation to the Hippocratic Oath: "First do no harm"?

As physicians intent on giving the best possible advice to our patients, we must reconcile this seeming paradox. On one hand, exercise and sports improve fitness and quality of life and lower all-cause mortality rates. On the other, exercise and sports cause injuries, with their morbidity and economic costs. When we're recommending treatment that presents a potential for injury, how do we balance the relative risks?

In a now-classic study, Siscovick et al (1) showed that while the risk of dying from an MI during exercise is slightly greater than succumbing at rest, this risk is more than offset by the reduced mortality in those who exercised regularly. Given the effectiveness of exercise in reducing cardiovascular risk and the immense toll of cardiovascular disease on public health, this particular balance point appears clear.

What about other perspectives? Children and adolescents are increasingly obese and decreasingly fit—they clearly need exercise. But we also know that sports injuries in children and adolescents are common: 4.4 million injuries per year in the US, 1.4 million of them serious (2). In another representative statistic, just three surgical procedures (arthroscopy, meniscectomy, ligamentous repair), limited to one joint (the knee) represented 5% of all surgical procedures done in outpatient clinics in the US in 1995 (3).

Could some of these injuries be prevented? Should physicians be recommending different activities? For example, should we stop promoting sports—or certain sports—in favor of other physical activity that can be maintained throughout life: exercise?

When 1 in 4 US adults has cardiovascular disease (4), and 9.8% of ambulatory care visits relate to musculoskeletal symptoms (5), these are important questions in every physician's office. It is therefore essential that we learn more about relative risks and about injury prevention, and that we urgently seek to define the risk-benefit ratio, even if just to make informed recommendations.

This is an epidemiologic science still in its infancy. We are still establishing injury surveillance systems that allow us to evaluate interventions (6). We do know, though, that such study can lead to changes that make a difference (7). Lives have been saved and serious injury prevented by simple measures such as banning spearing in football, requiring deeper pools for dive starts, and using breakaway bases and bicycle helmets.

At The Physician and Sportsmedicine, we present factors on both sides of the scale this month. Discussions of elbow injury in youth baseball (page 87) and glenohumeral ligament lesions (page 73) are counterweighted by others on exercise benefits in metabolic syndrome (page 40) and immunity (page 47).

There is no real paradox here, only a lack of knowledge. We know that we must emphasize physical activity as a principal determinant of health and quality of life. But we must also balance this stance by embracing programs of intervention and prevention. We can begin by not blindly endorsing all aspects of sport, but instead critically evaluating and speaking out about the dangers. This is a matter of debate and conscience that will no doubt occupy us for a long time to come.

Gordon O. Matheson, MD, PhD


  1. Siscovick DS, Weiss NS, Fletcher RH, et al: The incidence of primary cardiac arrest during vigorous exercise. N Engl J Med 1984;311(14):874-877
  2. Bijur PE, Trumble A, Harel Y, et al: Sports and recreation injuries in US children and adolescents. Arch Pediatr Adolesc Med 1995;149(9):1009-1016
  3. Kozak LJ, Owings MF: Ambulatory and inpatient procedures in the United States, 1995. National Center for Health Statistics. Vital Health Stat March 1998;13(135);Hyattsville, Maryland; DHHS pub no. (PHS) 98-1795
  4. National Center for Chronic Disease Prevention and Health Promotion: Major chronic diseases: cardiovascular disease. Available at: Accessed May 11, 1999
  5. Schappert SM: Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1996. National Center for Health Statistics. Vital Health Stat Feb 1998;13(134);Hyattsville, Maryland; DHHS pub no. (PHS) 98-1795
  6. van Mechelen W: Sports injury surveillance systems: 'one size fits all?' Sports Med 1997;24(3):164-168
  7. Ytterstad B: The Harstad injury prevention study: the epidemiology of sports injuries: an 8 year study. Br J Sports Med 1996;30(1):64-68