The process of risk management can be implemented as part of a best practiceAbstract management system within the sport and leisure sector. The process enables risk factors that might lead to injuries to be identified and the levels of risk associated with activities to be estimated and evaluated. This information can be utilised proactively by sports governing bodies and participants to identify preventive and therapeutic interventions in order to reduce the frequency of occurrence and/or severity of injuries within their sports. The acceptability of risk within specific sports, however, is dependent on the perceptions of the participants involved.

1. Introduction to Risk Management ciples of risk management, it is necessary to define the terms used. A ‘hazard’ or ‘risk factor’ is a condition, object or situation that may be a potentialMost sports activities will always involve a cer- source of harm to people, and ‘risk’ is the probabili-tain level of risk, even when reasonable precautions ty or likelihood that a hazard will have an impact onhave been implemented. It is essential, therefore, for these people. ‘Risk assessment’ involves the identi-governing bodies to demonstrate that they have fication, estimation and evaluation of these risks.identified the potential risks within their sports and ‘Risk estimation’ involves identification of the poss-implemented adequate measures to control them. ible consequences from risk factors and an estima-This is normally achieved through the process of tion of the magnitude and probability of occurrencerisk management. Although risk assessment is ac- of these consequences. ‘Risk evaluation’ involvescepted as an important element of best-practice risk determining the significance and acceptability of themanagement systems in many sectors,[1-3] its appli- risks to all stakeholders. ‘Risk mitigation’ is thecation has not achieved wide recognition within the process of identifying and implementing measuressport and leisure sectors.[4-6] While the process of to control the level of exposure to and/or the conse-risk assessment can be used to identify high-risk quences from risks. The application of risk assess-activities, it does not on its own lead to reductions in ment is, however, confounded by issues of riskthe level of injury; this can be achieved only through perception, risk communication and participant be-the identification and application of appropriate risk haviour. The aims of this paper are to discuss issuesmitigation measures. It is important, therefore, to related to the risk assessment process in the contextunderstand the role of risk assessment and to place of sport within the conceptual framework presentedits contribution within the broader context of risk in figure 1.management (figure 1).

‘Risk management’ is the overall process of as- 2. Risk Assessment sessing and controlling risks within an organisation- al setting and includes the subprocesses of risk as- The first stage of risk assessment is identification sessment and risk mitigation. In discussing the prin- of the risk factors associated with the sport and

350 Fuller & Drawer

Sports facilities, equipment and activities

Risk assessment

Situational risks

Stakeholders

Risk factors

Risk estimation

Preventive interventions

Risk mitigation

Risk perception

Unacceptable risk

Acceptable risk

Standards

Communicate results to sports community

Epidemiological studies

Event-based risks

Risk evaluation

Risk communication

Therapeutic interventions

Risk management

Fig. 1. A framework for risk management in sport.

determination of how these may impinge on stake- and the public. The present discussion is focused on holders. Participants normally represent the major the risks to participants. Risk factors can arise from stakeholder in most sports but other stakeholders the facilities required to play the sport, such as include, for example, officials, spectators, the media stadiums, public roads and waterways; the equip-

Risk Management in Sport 351

ment, such as goal posts, hockey sticks and hurdles; 3. Risk Mitigation and the physical activity itself, such as running, cycling and swimming. These risks can be cat- One of several approaches to risk mitigation egorised as situational or event-based risks. Situa- could be adopted by governing bodies in sport. They tional risks exist permanently within the sport’s could identify the worst-case scenario, in terms of environment and arise from issues such as the facili- participants’ knowledge, skill, experience, etc., and ties and equipment. Event-based risks exist only at insist that control measures were implemented that specific points in time and occur because of a partic- would cope with the risks in this extreme case. This

approach would create a very rigidly controlledular set of circumstances, such as the way in which framework within which the sport could operate butone player tackles another player. The next stage is which would ensure that the risks to all participantsto consider how each of the identified risk factors were controlled to an acceptable standard. Gov-might affect individual participants. This is partic- erning bodies could, however, adopt the principle ofularly important where the impact may vary from an average participant, who has a reasonable level ofone group of participants to another, for example, knowledge, skill and experience, and implementmale/female, youth/veteran and able/disabled ath- control measures to manage the risks to this hypo-letes. Risk factors can be categorised as intrinsic if thetical person. However, in this case, some partici-the factors are specific to individual participants, pants would be exposed to significantly higher riskssuch as age, joint stability and muscle strength, and than others, and some would be exposed to signifi-

extrinsic if the factors arise from external sources, cantly lower risks. The compromise approach,

such as the laws of the game, protective equipment which is adopted within many sports, is to recognise

and pitch conditions. Both types of risk factor can that there are definable groups of participants, such

modify the likelihood of a participant receiving an as male/female, youth/veteran, able/disabled, who injury and/or the severity of the injury received. may need specific control measures under certain

The final stages of risk assessment are the estima- circumstances. In this case, general measures would tion and evaluation of the level of risk for each be introduced by the governing bodies to control the

majority of risks within the sport but there would begroup of participants. This process can be as simple specific measures required to control the uniqueas categorising the risk qualitatively as, for example, risks associated with vulnerable groups of athletes‘high, medium or low’ or quantitatively for speci- and specific events. This approach provides greaterfied outcomes and circumstances through the use of flexibility in the way in which a sport is operatedprobability or incidence values, such as the number and addresses the specific needs of different groupsof lost-time injuries per 1000 hours of competition. of participants.Merely quantifying the level of risk, however, does

There are fundamentally two control optionsnot define whether a risk is acceptable or unaccept- available for risk mitigation: namely, risk accept-able to participants. This judgement can be reached ance and risk reduction. Risk acceptance impliesonly by comparing the risk estimates obtained with that an informed decision has been made to acceptdefined standards and then ascertaining whether the consequences and/or likelihood of an injury.

participants will accept this level of risk. These risks are mitigated through the use of insur-

It can be seen that the process of risk assessment ance in order to cover the cost of any losses incurred. merely determines what the risk factors are within a This approach, which allows participants to carry on sport, who is affected by the risks, what the levels of with their sports activities in the knowledge that if risk are and how these levels compare with accepted they suffer injury their insurance company will pro- standards of risk. Completing the process of risk vide compensation, provides little incentive for par- assessment does not in itself, therefore, lead to a ticipants to significantly reduce the levels of risk to reduction in the level of risk or injury to participants. themselves or others associated with their sport. In order to achieve this, it is necessary to consider Risk reduction, on the other hand, involves the and implement risk mitigation measures. application of appropriate control measures to modi-

352 Fuller & Drawer

Prevention strategies

Injury causation factors

Time

Pre-event

Event

Post-event

Physical

Condition of playing surface

Shoe design

Neck brace

Management

Training programme

Competition rules

Surgery

Human

Playing tactics

Tackle mechanism

Rehabilitation programme

Fig. 2. An example of a Haddon Matrix for identifying injury causation and prevention, and therapeutic measures in sport.

fy the risk factors such that they reduce the an injured athlete. Therapeutic interventions can only reduce the consequences of an injury becauseprobability of occurrence and/or reduce the conse- the injury has already occurred. These interventionsquences of injury. In this approach, therefore, it is may, however, have an indirect effect on thenecessary to identify the causal factors associated probability of future injuries occurring, as previouswith injuries in order to focus risk reduction strate- injuries are often a major risk factor.[7] The successgies in the most effective areas. The identification or otherwise of preventive and therapeutic interven-and analysis of causal factors can be carried out tions should always be assessed and confirmed byusing quantitative or qualitative methods. Quanti- appropriate epidemiological studies.fied fault tree analysis, for example, can be used to

analyse the sequence of events and causal factors, 4. Epidemiological Studiessuch as physical, management and human issues,

leading to an injury. However, a simpler descriptive Epidemiological studies provide the information approach based on the Haddon Matrix provides a that allows evidence-based decisions to be made more appropriate qualitative method of identifying about risk levels and the efficacy of preventive and causal factors and hence preventive and/or therapeu- therapeutic interventions. Prospective epidemiologi- tic intervention strategies in sport. An example of a cal studies have been found to provide more reliable matrix that retains the timing sequence of pre-event, data than retrospective studies, owing to the poor event and post-event adopted in the Haddon Matrix memory recall of injured players.[8] Issues involved but utilises the concept of physical, management in conducting sports epidemiological studies have and human causal factors in injuries is presented in been reviewed[9,10] and the general conclusions figure 2. reached were that published injury reports were

In sport, mitigation through risk reduction can often difficult to interpret and compare because of also be categorised as injury prevention (preventive the differences in the data collection and analysis intervention) and/or injury treatment and rehabilita- methodologies used by different researchers. A ma- tion (therapeutic intervention). Preventive interven- jor problem associated with epidemiological studies tions, which attempt to minimise the effects of in- in sport is the difficulty of agreeing a universally trinsic and extrinsic risk factors on participants, are acceptable definition of a sports injury because what applied prior to injury and involve providing infor- may be regarded as an injury in one sport may not be mation to participants on, for example, match prepa- regarded as such in another sport. Epidemiological ration, nutrition and protective equipment. Preven- studies have used a variety of injury definitions, tive interventions are used to reduce the likelihood such as incidents resulting in lost-time from compe- of an injury occurring and/or the consequences of an tition and/or training,[11] insurance claims[12] and injury. Therapeutic interventions are applied after hospital treatment.[13] Each of these definitions has injury and involve providing, for example, appropri- disadvantages: lost-time injuries are sport-specific, ate medical support services and facilities in order to as an injured hand, for example, may prevent partic- facilitate the injury treatment and rehabilitation of ipation in tennis but may not affect participation in

Risk Management in Sport 353

football; insurance claims relate only to injuries to 5. Risk Perception people who have insurance cover; and hospital treat- ments are biased towards more severe injuries. The consequences of exposure to most risk fac-

tors can be quantified objectively, in terms of, forSome authors have recommended that injuries example, the frequency of occurrence and the sever-should be excluded from epidemiological studies ity of injury or financial loss suffered. However, riskunless they involve more than just ice and bandag- assessment is not only concerned with objective oring;[14] however, this approach would exclude minor statistical levels of risk but also with the subjectiveinjuries and this could hide the causes and onset of or perceived levels of risk and this is determined bychronic injuries such as osteoarthritis.[15] In addition, the individual characteristics of the participants in-participants often continue to train and/or compete volved. An individual’s overall perception of risk iseven though their performance is impaired by injury made up of two components: namely, physical per-and this can have long-term effects on an injured ception, which relates to the factual informationparticipant’s physical and mental well-being.[16] The received through the sensory system, and cognitiveadvantage of categorising all player complaints that perception, which relates to the mental processes

require medical attention and result from participa- that determine how an individual reacts to the infor-

tion in sport as an injury is that it provides a defini- mation received. Physical perception of situations is

tion that can be applied across all sports. It also normally rapid and this enables athletes to respond

enables the impact of the whole range of injuries, quickly to changing circumstances during sports

from minor contusions to fractures, to be assessed. activities. Cognitive perceptions, on the other hand, Associated with the difficulty of defining injury are formed over time and change with the partici-

is the problem of defining injury severity. Descrip- pant’s knowledge and experience. tive phrases, such as ‘minor’, ‘moderate’ and ‘ma- Theories of risk perception have been based on a jor’ have been used but these could be misleading range of issues, such as an individual’s knowledge, because some ‘minor’ injuries, measured in terms of personality, economics and culture. ‘Knowledge

theories’ imply that participants would perceivetime lost, can involve significant tissue damage. sports facilities, equipment or activities to be dan-Therefore, it may be preferable to define injury gerous if they knew (or thought they knew) that theyseverity by the consequences of an injury rather than were dangerous. ‘Personality theories’ would takethe injury per se. For professional sportspeople, this into account participants’ personality traits as thesecould be defined as time lost from training and/or would determine whether they were risk-averse orcompetition, whereas for amateur sportspeople it risk-taking in their activities. ‘Economic theories’would be more appropriate to use a wider definition indicate that participants would be prepared to takethat includes the time lost from competition/training greater risks as the rewards for success becameand/or the time lost from their normal occupation. greater. ‘Cultural theories’ indicate that participants’

Meeuwisse[17] emphasised the importance of perceptions of risk would be determined by their identifying causal relationships between risk factors social environment and behaviours. A complicating and injuries and highlighted the need to account for factor in mitigating against risk is that many individ- exposure to risk factors through the use of injury uals have a level of risk to which they wish to be incidence. In this context, the number and percent- exposed. In these cases, no matter how safe an age distributions of injury diagnoses and locations activity is made, these individuals will seek other have limited application in risk assessment, as re- sports that will expose them to the desired level of sults presented in this format do not define risk risk; this phenomenon is referred to as risk homeo- levels. For quantified risk assessment purposes, it is stasis. Hence the popularity of extreme sports essential, therefore, to collect epidemiological data among individuals who seek exposure to high levels that define the probability of an injury event occur- of risk. ring together with the severity of the resultant inju- One important issue related to risk assessment is ries as functions of the risk factors involved. whether the athletic situation or the individual’s

354 Fuller & Drawer

personality characteristics affect a participant’s risk dangerous than rolling starts in motor racing, specta- of injury more. This is also closely related to the tors preferred to see the more dangerous standing discussion over whether some athletes are more starts in competition rather than the safer rolling injury prone than others. Junge[18] reviewed the liter- starts. These results presented a view that spectators ature regarding possible relationships between psy- in motor racing wanted to be associated with a chological factors and sports injuries across a range dangerous sport but preferred to experience the risks of sports and developed a stress theory model based vicariously through the participants. on the work of Andersen and Williams[19] to explain the published results. The main conclusion was that 6. Acceptable Levels of Risk competitive anxiety by participants was the only factor that consistently showed an association with While the risks associated with most occupation- injury. Whether an athlete was injured during an al activities are normally assessed against specified activity was, however, affected by the way in which values for acceptable levels of risk,[25] there are no the athlete reacted to the specific situation and this in defined acceptable risk levels within sport. In fact, turn was influenced by the participant’s exposure to acceptable levels of risk in amateur sport are deter- stressful life-events, such as job loss, marriage or the mined more by the risk perceptions of the partici- death of a relative or friend. The review led to the pants than by quantified measurements and evalua- conclusion that personality traits had no effect on tions of risk. Frey[26] claimed that with familiar the risk of injury and that there was no apparent activities such as sport, people minimised the nega- personality profile for athletes with higher injury tive outcomes and, because they felt they were in rates, although there was evidence that injured ath- control of the risks, would mentally assign a zero letes were more likely to exhibit risk-taking beha- level of risk to the activity. Table I, however, illus- viour. Uitenbroek[20] argued that accident proneness trates the relatively high levels of risk in terms of among athletes could be accounted for simply by injuries per 1000 hours of exposure observed during probability because statistically there would always competition in four major team sports for men; this be a certain number of people within a population range of values illustrates the difficulty of defining who would not suffer an injury and others who an acceptable level of risk across all sports. would suffer one, two or more injuries. Drawer and Fuller[30] assessed the incidence of

injury in professional football against the risk crite-The assessment of risk in certain sports is further ria adopted within UK industry and commerce andconfounded by the desire of some participants to concluded that the levels of risk accepted withinperpetuate the image of tough athletes together with football were around 1000 times higher than thosethe paradox of coaches who are responsible for the found in what are more traditionally regarded ashealth of athletes yet express admiration for athletes high-risk occupations, such as agriculture and con-who continue to compete while injured.[21] A pro- struction. Although participants may appear to ac-cess referred to as cognitive dissonance can also cept the levels of risk associated with a sport, this isaffect participants’ perceptions of risk, as they will often a result of ignorance of the actual levels of riskoften disregard factual information about levels of involved. This is an important issue because it isrisk when it conflicts with their preferred choice;[22] clearly difficult for a participant to accept risksa particularly important issue among participants in about which they have little or no knowledge. Invery high-risk sports. In some activities, stakehold-

ers’ perceptions of risk are changed through a pro- cess referred to as affiliation bias, which is created through familiarity with the risks involved.[23] In a study of risk perception in motor racing, Fuller and Myerscough[24] found that spectators exhibited an affiliation bias effect by rating risks associated with motor racing higher than other stakeholders. In addi- tion, while believing that standing starts were more

Table I. Relative injury risks during competition in major team sports (men)

Sport Incidence of injury (per Reference 1000h exposure)

Cricket 2 27

Football 28 11

Ice hockey 53 28

Rugby 69 29

Risk Management in Sport 355

these cases, governing bodies have a major respon- relations and multidisciplinary. The technical ap- sibility for identifying and managing the risks asso- proach relies solely on the presentation of factual ciated with the sport and then communicating the information about the issues, and the public rela- information to participants. Current levels of risk in tions approach concentrates on getting the message many sports are clearly too high and there have been across rather than trying to justify the information examples of litigation as a result of severe and fatal presented. The multidisciplinary approach attempts injuries. However, defining an acceptable level of to take the positive aspects of the technical and risk to which individuals voluntarily expose them- public relations approaches by presenting the infor- selves is a complex issue. Even so, it is an issue that mation in a favourable way but supporting the mes- must be addressed because of the financial impact of sage with technical information. sports injuries on the health services in many coun- An important issue in risk communication and tries. one that is used in sport is referred to as the framing

effect. This involves presenting information in a 7. Risk Communication way that influences the recipients’ views of the risks

– more recently referred to as ‘putting a positiveThe purpose of risk communication is to change spin’ on the information. A common framing effector consolidate the views or concerns of the recipi- is the domain effect in which the communicatorents of the information. Stakeholder concerns about concentrates on the positive aspects (benefits) ratherrisk generally revolve around the fear of injury and/ than the negative aspects (costs) associated with aor the emotive impact of the risks. Therefore, when risk.[31] For example, sport and exercise can be pre-communicating information about risk, it is impor- sented positively as having important health benefitstant to understand which of these two concerns is for individuals, as they decrease the risk of coronarydominant. Fear usually occurs as a result of concerns heart disease and osteoporosis, rather than identify-over personal injury and ill-health but, because of ing the actual level of injury and ill-health asso-the lack of information communicated about the ciated with the sport.levels of injury and ill-health, participants rarely

appreciate the actual level of risk to which they are 8. Conclusionexposed. The emotive impact on participants is not

usually related to the actual levels of harm that may This paper has attempted to outline the key issues arise from an activity but is more closely related to involved in risk management. It has highlighted the the individual’s perception of how the risk might fact that risk assessment is not a simple process affect them. For example, a footballer may not be as because, although it can be defined objectively in concerned about information that stated that the terms of the probability and severity of injuries, the incidence of acute injuries during competition was subjective nature of risk plays an important role. To 28 injuries per 1000 playing hours[11] as they would quantify levels of risk and to identify cost-effective be if they were told that 32% of retired footballers risk mitigation strategies, it is essential to link epide- were diagnosed with osteoarthritis in at least one of miological studies of sports injuries to the related their lower limb joints.[15] In the case of the acute risk factors. Governing bodies have a responsibility injury, the player might perceive that the injury to identify and assess risks within individual sports would be easily treatable, whereas in the latter case and to control the risks at acceptable levels through the injury might be perceived to be non-treatable. the application of appropriate evidence-based miti- When information may affect people’s level of fear, gation measures. it is more important to address issues such as who will be affected and how the risks will affect them; if Acknowledgements the concerns are related more to emotive issues, it is

No sources of funding were used to assist in the prepara-more appropriate to discuss risk mitigation mea- tion of this review. The authors have no conflicts of interest

sures and explain how these address the risks. that are directly relevant to the content of this review. The There are three general approaches adopted for views expressed are those of the authors and not necessarily

communicating risk information: technical, public those of UK Sport.

356 Fuller & Drawer

17. Meeuwisse WH. Predictability of sports injuries: what is theReferences epidemiological evidence? Sports Med 1991; 12 (1): 8-15

1. Health and Safety Executive. Successful health and safety man- 18. Junge A. The influence of psychological factors on sports inju-agement. Sudbury: HSE Books, 1993

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19. Andersen MB, Williams JM. A model of stress and athleticStrathfield: Standards Association of Australia, 1999 injury: prediction and prevention. J Sport Exerc Psychol 1988;

3. International Labour Organisation. Guidelines on occupational 10: 294-306 safety and health management systems. Geneva: International

20. Uitenbroek DG. The mathematical relationship between theLabour Organisation, 2001 number of events in which people are injured and the number

4. Fuller CW. Implications of health and safety legislation for the of people injured. Br J Sports Med 1995; 29: 126-8 professional sportsperson. Br J Sports Med 1995; 29 (1): 5-9

21. Nixon HL. Accepting the risk of pain and injury in sport: 5. Fuller CW, Hawkins RD. Assessment of football grounds for mediated cultural influences on playing hurt. Sociol Sport J

player safety. Safety Sci 1997; 27 (2/3): 115-28 1993; 10: 183-96 6. SportSafe Australia. A national sports safety framework. Can- 22. Ball JD. Comparing the magnitudes of risks and benefits. Sports

berra: Australian Sports Commission, 1997 Exerc Injury 1998; 4: 174-82 7. van Mechelen W, Twisk J, Molendijk A, et al. Subject related 23. Slovic P. Perceptions of risk: reflections on the psychometric

risk factors for sports injuries: a 1-year prospective study in paradigm. In: Krimsky S, Golding D, editors. Social theories young adults. Med Sci Sports Exerc 1996; 28 (9): 1171-9 of risk. London: Praeger, 1992: 117-52

8. Junge A, Dvorak J. Influence of definition and data collection 24. Fuller CW, Myerscough FE. Stakeholder perceptions of risk in

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28: S40-6 25. Health and Safety Executive. The tolerability of risks from9. Finch CF. An overview of some definitional issues for sports

nuclear power stations. Sudbury: HSE Books, 1988injury surveillance. Sports Med 1997; 24: 157-63 26. Frey JH. Social risk and the meaning of sport. Sociol Sport J10. van Mechelen W. Sports injury surveillance systems. Sports

1991; 8: 136-45Med 1997; 24: 164-8 27. Orchard J, James T, Alcott E, et al. Injuries in Australian cricket11. Hawkins RD, Fuller CW. A prospective epidemiological study

at first class level 1995/1996 to 2000/2001. Br J Sports Medof injuries in four English professional football clubs. Br J 2002; 36: 270-4Sports Med 1999; 33: 196-203

28. Tegner Y, Lorentzon R. Ice hockey injuries: incidence, nature12. de Loes M. Epidemiology of sports injuries in the Swiss organi- and causes. Br J Sports Med 1991; 25: 87-9zation ‘Youth and Sports’ 1987-1989: injuries, exposure and

risks of main diagnoses. Int J Sports Med 1995; 16: 134-8 29. Bathgate A, Best JP, Craig G, et al. A prospective study of injuries to elite Australian rugby union players. Br J Sports13. Hoy K, Lindblad BE, Terkelsen CJ, et al. European soccer Med 2002; 36: 265-9injuries: a prospective epidemiologic and socio-economic

study. Am J Sports Med 1992; 20: 318-22 30. Drawer S, Fuller CW. Evaluating the level of injury in English professional football using a risk based assessment process. Br14. Noyes FR, Lindenfeld TN, Marshall MT. What determines an J Sports Med 2002; 36 (1): 446-51athletic injury (definition)? : who determines an injury (occur-

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Correspondence and offprints: Dr Colin Fuller, University16. Luthje P, Nurmi I, Kataja M, et al. Epidemiology and trau- of Leicester, 154 Upper New Walk, Leicester, LE1 7QA, UK.matology of injuries in elite soccer: a prospective study in

Finland. Scand J Med Sci Sports 1996; 6: 180-5 E-mail: [email protected]

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