Injuries in French High-Level and National-Level Women Artistic Gymnastics: One-Year Prevalence and Associated Factors

: Objective: The aims of this study were (1) to determine the one-year prevalence of injuries and their characteristics and (2) to analyze potential injury risk factors in high-level/national-level women artistic gymnasts. Methods: Competitive women artistic gymnasts training more than 10 h per week in a national training center and a TOP 12 club in France were invited to participate in a retrospective study through an online questionnaire about their self-reported injuries and potential injury risk factors (e.g., previous injuries, diseases, weight modiﬁcation) during the 2020/2021 season. Results: A total of 88 gymnasts between 9 and 23 years old, who trained on average 22.0 ± 6.2 h per week, answered the questionnaire. Ninety-ﬁve injuries were reported by 62 (70.5%) of the 88 gymnasts. The one-year injury prevalence was 70.5% (95% CI 60.9 to 80.0%). Gymnasts had, on average, 1.1 ± 1.0 injuries per year. The most common reported injury location was the knee (25.3%), and the most common reported injury type was the ligament (26.3%). Having an injury during the previous season (OR = 9.06; CI 95% 2.66 to 36.73; p = 0.0007) and using a prevention program (OR = 3.97; CI 95% 1.46 to 11.15; p = 0.007) were associated with a higher risk of injury in the multivariate analysis. Conclusions: More than 70% of French high-level/national-level gymnasts had at least one injury during the 2020/2021 season. This high injury rate supports the need to promote injury prevention. However, in the present study, using a prevention program was associated with a higher risk of injury. There is thus a need to improve injury prevention strategies to counter the high injury risk and its potential consequences.


Introduction
Women's Artistic Gymnastics (WAG) is an Olympic sport requiring numerous hours of training from a very young age [1].Becoming a high-level gymnast requires training for more than 30 h per week for about 46 weeks per year, starting at 11 years old [1].In France, WAG activity generally leads to injury risk [2][3][4][5][6][7][8].A gymnast can have between 2.5 and 3.6 injuries per year [2].The injury incidence was higher during competition and preseason than during training periods [4].The prevalence of injuries increased with the number of training hours [6,8].Most injuries involved the lower limb [2,4], and sprains and strains were the most common injury types [5,7].This knowledge on WAG injuries mainly comes from studies performed in National College Athletics Association (NCAA) gymnastics [4][5][6].This practice differs from high-level/national-level gymnasts, who are often younger and train more than NCAA gymnasts but have fewer competitions during the season and different sporting and governing body organizations [4][5][6][7][8][9].Since injury epidemiology represents the first step of the injury prevention sequence [10], there is a need to extend injury epidemiological knowledge to this specific population of highlevel/national-level (i.e., national training centers and TOP 12 clubs in France).
In addition, van Mechelen et al. [10] suggested developing injury risk reduction measures based on an understanding of internal (e.g., physical defect, physical fitness, age, sex, previous injuries, psychological factors, and physical build) and external (e.g., sports-related factors, venue equipment, weather conditions, and trainer) injury risk factors [10,11].Through a systematic review, Campbell et al. [2] found that a higher competition level, an older age, a greater body mass, and increased life stress were determinants of injuries.An injury during the previous season was also reported as a risk factor for an injury in gymnastics [6], as were the number of training hours, age, and sports experience [12].The proportion of injuries was higher in the floor apparatus (39%) and especially during the landings (76%) [2,13].However, only a few injury risk factors have been explored and analyzed in gymnastics.It justifies the need to continue their understanding by extending this research to other risk factors, such as lifestyle (e.g., sleep, nutrition, school, and daily organization) and mental health, which can play a role on injuries [14][15][16].Indeed, injuries can impact mental health and quality of life and could have long-term effects physically as well as psychologically and vice versa [15,[17][18][19].Palmer et al. [20] reported that the prevalence of depression reached 6.6% in Olympic athletes during their careers.Thus, a be er understanding of mental health status and its potential impact on injuries in high-level/national-level gymnasts is needed.
In this context, the aims of this study were (1) to determine the one-year prevalence of injuries and their characteristics and (2) to analyse potential injury risk factors in highlevel/national-level women artistic gymnasts.

Study Design and Overall Procedures
We conducted an observational retrospective study with data collection using an online questionnaire sent at the end of the 2020/2021 season to the French women artistic gymnasts from the national training center and TOP 12 clubs in France.The present study was approved by the Saint-Etienne University Hospital Ethics Commi ee (IRB32N232016/CHUSTE).
For the recruitment, the primary investigator (SC) contacted each coach from each national training center or TOP 12's club by phone or email to present the study objective.When coaches/structures accepted to participate in the study, they were asked to send the list of eligible gymnasts to the investigator (SC), including name, first name, and email.
The questionnaire was then sent directly by the main investigator (SC) by email to the eligible gymnasts.A wri en information le er about the study objective and modality was included at the beginning of the questionnaire for the gymnasts and their parents (especially for the under 18 years old gymnasts).
Inclusion criteria were being competitive in women's artistic gymnastics, training in a national training center or in a TOP 12 club, training more than 10 h per week, and replying to the online questionnaire.There were no exclusion criteria.

Definitions and Data Collection
In this study, we defined injury as "all discomfort or physical pain impacting the training during seven days or more (interruption or limitation of the practice)" [21].The injury definition was presented to the gymnasts in the questionnaire.
Data were collected using an online questionnaire developed on Google Forms.This questionnaire aimed to determine the most encountered injuries in the targeted population of WAG and their potential risk factors.Thus, we asked gymnasts about their injuries during the 2020-2021 season, as well as general information, social life, health status, characteristics of training, performance level, diseases, mental health, and nutrition during the previous season (the questionnaire is in Supplementary Material).The questionnaire was elaborated based on the questionnaire from Jederström et al. [14].The questionnaire was created by the first author (a former elite gymnast, resident in general medicine and sports medicine) and co-investigators of the research (a professor in physiology and sports medicine physician, physiotherapist, Ph.D. student in sports performance engineering, and research assistant), and also checked twice by the national federal physician (PB).Before sending the questionnaire to the gymnasts, it was tested twice on three gymnasts of the targeted population (once in Word format and once in Google Forms format) in order to check its understanding and feasibility.The gymnasts had to fill out the questionnaire themselves; no supervision was asked, but parents were allowed to help, especially for young gymnasts.
The questionnaire was composed of 52 questions and was divided into several parts:  General information: anthropometric data, puberty, chronic disease, previous injuries, number of hours of training, number of years of gymnastics practice, and competition's level;  Lifestyle (school, school adaptation (i.e., flexible schedule (yes/no)), transport, living place…);  Sleep (quantity and quality [22]);  Injuries during the last season (2019/2020), corresponding to the primary outcome;  Mental health [16];  Eating habits [14,16,22].
The topics of the questions are presented in Table 1, and the details are in Supplementary Material.
Table 1.Characteristics of the 88 participating gymnasts and univariate and multivariable analyses.For the univariate analysis, there is no model adjustment (each variable was analysed alone with the dependent variable).In the multivariable analysis, we kept only significant variables (p < 0.05) from the univariate analysis and they were all included in the model of the multivariable analysis.OR: odds ratio; CI: confidence interval.
The questions were related to the 2020/2021 gymnastic season, from the 1 September 2020 to the 31 August 2021.The questionnaire was opened for three months, between November 2021 and February 2022.

Data Analysis
First, we performed a descriptive analysis using frequency and percentages for categorical data and means and standard deviations (SD) for continuous variables, and we calculated the one-year prevalence of injured gymnasts by dividing the number of gymnasts having had at least one injury during the season 2020-2021 by the total number of participating gymnasts.
Second, in order to identify potential injury risk factors, we conducted an univariate analysis using a logistic regression with injury during the season 2020-2021 (yes/no) as dependent variable and as independent variables: age, menstruations, chronic disease, injury in the previous season, years of practice, number of hours of training before the season 2020-2021, level during the season 2019-2020, school level, school adaptation, number of hours of school, number of hours in transport, sedentary time, type of residence, number of hours of sleep, sleep quality, number of hours of training during the season, competition participation, number of competition, level of performance during the season, feeling empty following a prevention program, having a disease, being infected with COVID, being vaccinated against COVID, stress, anxiety, sadness, frustration, disgust, low morale, training apprehension, eating disorders, irritability, feeling of inferiority, regular or irregular menstrual cycles, snacking, being worried about her weight, and being forced or compelled to gain or lose weight.Then, we performed a multivariable analysis by including only variables that were significant (p < 0.05) in the univariate analysis.The unity of analysis was a gymnast.Odds ratios (OR) were calculated for univariate and multivariable analyses and presented with a 95% confidence interval (CI 95%).

Population
From the total of 17 eligible structures in France (5 national training centers and 12 TOP 12 clubs), we obtained answers and approval from 12: 5 national training centers and 7 TOP 12 clubs (Figure 1).These 12 structures represented a total of 127 eligible competitive gymnasts.Among them, a total of 88 gymnasts (69.3%) completed the questionnaire and were thus included in the present study (Figure 1).

Figure 1.
Flow chart of the included population ("?" means that the total number of gymnasts is not known).
The participating gymnasts were between 9 and 23 years old ((mean ± SD) 14.1 ± 2.5 years) at the beginning of the 2020/2021 season (Table 1).The gymnasts practiced WAG for 9.7 ± 2.9 years (Table 1).The mean of number of training hours per week before the 2020/2021 season was 21.2 ± 6.6 h a week for a range between 11 and 35 h, and 22.0 ± 6.2 h a week during the season 2020/2021 (Table 1).
Gymnasts were sedentary (sedentary times counted as soon as there were 30 min consecutives spent si ing or lying) on average 4.7 ± 1.9 h a day (Table 1).

Menstruation
Forty-two gymnasts (47.7%) had their menstrual cycle at the beginning of the season (Figure 2).The mean age of the first menstrual cycle was 14.1 ± 2.5 years old (between 10 and 18 years old) (Figure 2).At the end of the season, 44 gymnasts had their menstrual cycle (50.0%).Among these 44 gymnasts, 26 (29.5%) had regular cycles, 13 (14.8%)had irregular cycles, and 5 (5.7%) had an interruption of their menstrual cycle for more than 3 months.

Injuries during the 2020-2021 Season
Seventy-four (84.1%) gymnasts had an injury before the season 2020-2021.During the season 2020-2021, 62 (70.5%) participating gymnasts reported 95 injuries.The one-year injury prevalence was 70.5% (95% CI 60.9 to 80.0%) injury per year.Twenty-three (26.1%) gymnasts had two injuries, six (6.8%) had three injuries, two (2.3%) had four injuries, and two (2.3%) gymnasts had five or more injuries.Gymnasts had an average of 1.1  1.0 injuries during the season.The number of gymnasts with and without injuries is presented according to the gymnasts' age in Figure 3.The most frequently reported injury locations were the knee (25.3%), the ankle (14.7%), and the foot (13.7%) (Table 2).The most frequently reported injury types were the ligament (26.3%) and the bone injuries (22.0%); it is also important to note that the type was not reported for 14 injuries (14.7%).Ankle sprains (11.6%), foot bone injuries (10.5%), and knee sprains (9.5%) were the most common injuries reported during the 2020/2021 gymnastics season.

Injury risk Factors
Univariate analysis found that having an injury during the previous season (OR = 9.06; CI 95% 2.66 to 36.73; p = 0.0007) and using a prevention program (OR = 3.97; CI 95% 1.46 to 11.15; p = 0.007) were associated with an increased risk of sustaining an injury during the 2020/2021 season (Table 1).
In the multivariable analysis, having an injury during the previous season (OR = 10.87;CI 95% 2.60 to 59.50; p = 0.002), using a prevention program (OR = 3.74; CI 95% 1.13 to 12.86; p = 0.031) and having a disease (OR = 7.58; CI 95% 1.46 to 63.1; p = 0.032) were associated with an increased risk of sustaining an injury during the 2020/2021 season, while being asked to gain weight was associated with a reduced risk of sustaining an injury during the 2020/2021 season (OR = 0.04; 95% CI 0.00 to 0.61; 0.032) (Table 1).

Discussion
The main findings of the present study were that (1) in high-level/national-level women artistic gymnasts, the one-year injury prevalence was 70.5% (95% CI 60.9 to 80.0%), the most frequently reported injury location was the knee (25.3%) and injury type was the ligament (26.3%), and (2) having an injury during the previous season, using a prevention program, and having a disease were associated with an increased injury risk during the season, while were asked to gain weight being associated with a reduced injury risk.

Injury Prevalence
The one-year injury prevalence of 70.5% in the present study was lower than in previous studies [6,8].Similarly, the number of injuries per gymnast during a season (1.1) was also lower than in the previous studies (2.5 in NCAA gymnasts [5] or 2.4 in elite and nonelite Australian gymnasts [7]).These differences between our study and previous studies could be explained by the difference in the population and the methodological differences (e.g., injury definition, data collection).Indeed, many studies define injury as "any gymnasticsrelated incident that resulted in the gymnast missing any portion of a practice or competitive event, beginning on the day of injury" [5,6,21], which corresponds to a time-loss injury definition [23].However, many gymnasts are training with pain or injury (83%, according to Marini et al. [24]).Consequently, a time-loss injury definition could underestimate the extent of the injury problem in WAG.Therefore, we collected injuries that led to the adaptation of gymnastics in addition to the interruption of the gymnastics activity [21].The recall bias could have also been responsible for the differences in values between the studies.Indeed, the questionnaire was sent 3 to 6 months after the end of the season 2020-2021.So, a gymnast could have forgo en minor injuries that may impact the injury prevalence.However, we think that our definition (i.e., "all discomfort or physical pain impacting the training during seven days or more (interruption or limitation of the practice)" [21]), targeting injuries that had a long-duration impact, could have decreased the risk of recall bias.

Injury Characteristics
The knee (25.3%) and the ankle (14.7%) were the locations most concerned by injuries in our present study (Table 1), in agreement with previously published results [4,6,7].Caine et al. [6] found that the knee corresponds to 10.9% of all injuries and 12.0% for the ankle.Kolt et al. [7] reported that knee injuries represented 14.6% of all injuries and ankle injuries 31.8%.Kerr et al. [4] reported that knee injuries represented 10.3% of all injuries and ankle injuries 17.9%.The most common injury type was the ligament (26.3%), in agreement with previous results (20.3% [4], 29.6% [7], and 19% [5]).In our study, ankle sprains were the most common injury (11.6%), in agreement with previous studies [2,6].These results regarding the injury location and type were consistent with the sport of gymnastics involving the lower limbs and with several rotations or pivots [1].

Injury Risk Factors
As Campbell et al. [2] described in their systematic review, we also reported that an injury during the previous season was associated with increased injury risk during the season.Previous studies [8,12,25] reported that injury prevalence increases with the number of hours of training, but in our study, we did not observe any association between injury and the training load.Marini et al. [24] reported that a preventive program could help reduce pain syndrome and injuries.However, our results showed that using a prevention program was associated with an increased injury risk.This can be explained by the fact that (i) the gymnasts who used a prevention program were already injured or trained despite the injury, (ii) the injury prevention program was inappropriate or not performed according to the prescribed instructions due to the lack of close supervision, and/or (iii) some confounding factors (e.g., training load) were not included in the analysis (i.e., multivariable analysis).The majority of gymnasts who followed a prevention program were in the national training centers (97.4% of national training center gymnasts followed a prevention program), and/or they had a higher number of hours of training.Readers should interpret these results with caution.We also recommend that coaches and athletes focus their a ention on the current injury prevention program by managing their injuries closely and pu ing in effort to improve the rehabilitation program.We think that the epidemiological results and the injury prevalence should encourage developing and/or improving injury risk reduction programs specifically targeting high/national-level women artistic gymnasts.
Otherwise, our results confirmed that mental suffering is prevalent in gymnastics; 90.9% of participating gymnasts declared being stressed, and more than 50% described symptoms like sadness and anxiety.Consequently, it is essential to screen gymnasts for mental health and manage them appropriately, as well as to prevent mental health problems in WAG [16,18,19].

Strengths and Limitations
This is the first study to evaluate injuries and their related i n ju ry risk factors in France, and this study focused on almost all of the high-level/national-level WAG in the country (national training centers and TOP 12 clubs), with a high response rate to the questionnaire (69.3%).The questionnaire evaluated different fields through numerous questions, including two hot topics of mental health and nutrition.
As limitations, despite the high response rate from the gymnasts, 5 TOP 12 clubs did not provide us their list of gymnasts.So, we could not send the questionnaire to all of the targeted population.This study was a retrospective study and could suffer from recall bias.The self-reported questionnaire can also have been responsible for recall bias.The injury type was not reported for all injuries.For some questions (e.g., about sleep quality), the responses could have varied according to the interpretation of the participants.Some of the participants are young, and it is admi ed that they might encounter some difficulty understanding the questions of the survey.The evaluation of mental health with an objective score could have been useful in order to quantify and compare the status between gymnasts suffering from mental symptoms and those who are not.

Perspectives and Practical Implications
The high injury rate and the potential negative consequences of these injuries support the need to continue improving knowledge on injuries, as well as to improve injury risk reduction measures and strategies in WAG.This is even more important in high-level and national-level WAG since the epidemiological knowledge in these populations is lower than in the population of NCAA gymnasts.
In addition, there were changes in the apparatus in the last decades to protect the gymnasts (e.g., softer and thicker mats, enlarging the horse for the vault, vault board protection for Yurchenkos's vault, use of handguards on the uneven bars apparatus).However, these changes also allowed the gymnasts' performance level to increase, consequently to increasing their injury risks.The gymnastics scoring system also encourages the gymnasts to take more and more risks, pushing human bounds.Floor apparatus seems to be the apparatus with the highest injury risk, followed by uneven bars apparatus [4,6], since during take-offs and landings gymnasts endure up to 17 times their bodyweight [1,4,6].A cumulative exposure to these massive impacts could be responsible for overuse and acute injuries.Therefore, it would be of interest to be er understand the injury epidemiology relative to apparatus in order to orient injury prevention approach.
Despite the association found between the use of a prevention program and higher injury risk, there is a need to include an injury prevention approach in WAG.Therefore, a be er understanding of what is currently done on field se ing and to co-construct with end-useres injury prevention programs seems like a relevant, if not fundamental, perspective.

Conclusions
In French WAG, about three quarters (70.5%) of high-level/national level gymnasts had at least one injury during a season.This result supports the need to improve the injury prevention approach in WAG through, for instance, a close collaboration between gymnasts, coaches, and medical staff.It seems even more critical since we found that having a previous injury could increase the risk of a new injury.
Author Contributions: S.C. and P.E.conceived the study; S.C. performed the data collection; S.C. performed the data extraction; S.C. and P.E.performed data analyses; S.C. and P.E.drafted the manuscript; and all co-authors contributed substantially to interpreting the results, provided important revisions, and approved the manuscript.All authors understand that they are accountable for all aspects of the work and ensure the accuracy or integrity of this manuscript.All authors have read and agreed to the published version of the manuscript.

Figure 2 .
Figure 2. Number of gymnasts with and without their menstrual cycles at the beginning of the season per age.

Figure 3 .
Figure 3. Number of gymnasts with and without injuries per ages.
intensive training could be done by high-level gymnasts trained within national training centers (Pôles France).These structures are recognized by the French Sport Ministry //www.ffgym.fr/Equipe_de_France/Faire_du_Haut_Niveau/Les_poles(accessed on 19 September 2023)".Other gymnasts not involved in national training centers can have similar intensive training and compete at the national level by training within the TOP 12 clubs, representing the first division of the French team championship. this

Table 2 .
Characteristics of the 95 injuries reported during the season 2020-2021 according to location and type (n (%)).