South African para-athletes, who have consistently punched above their weight on the global stage, face a significant burden from sports-related injuries that can sideline their impressive performances. A groundbreaking study from the University of the Witwatersrand has for the first time mapped out the injury landscape for these athletes, revealing patterns, prevalence rates, and modifiable risk factors that could transform training protocols and support systems nationwide.

This research comes at a pivotal moment for para-sports in South Africa, where athletes have secured notable successes, including six medals at the Paris 2024 Paralympics and a peak of 21 gold medals at Beijing 2008. Yet, limited resources and high injury rates threaten to undermine these achievements, making evidence-based interventions more crucial than ever.

Background on Para-Sports in South Africa

Para-sports in South Africa have evolved dramatically since the country's return to the Paralympic movement in 1992 after apartheid-era exclusion. The South African Sports Confederation and Olympic Committee (SASCOC) oversees high-performance programs, but challenges persist, including inconsistent funding for development pathways and specialized medical support. Para-athletes often train in resource-constrained environments, balancing elite competition with disabilities ranging from limb deficiencies to visual impairments.

Globally, para-athletes experience injury rates 1.4 to 1.8 times higher than Olympic counterparts, with musculoskeletal issues predominant. In South Africa, anecdotal evidence suggested similar trends, but until now, no comprehensive local data existed to guide prevention efforts. The study fills this gap, led by physiotherapist Siyabonga H. Kunene from Wits University's Faculty of Health Sciences.

Study Design and Methodology

Conducted as a cross-sectional survey, the research targeted high-level South African para-athletes affiliated with national programs. Researchers distributed a self-developed questionnaire to 116 athletes, achieving a robust response rate of 74.14%, with 86 complete responses analyzed.

The questionnaire captured detailed demographics, impairment types, sporting history (experience, training volume, competition frequency), injury history over the past 12 months, and potential risk factors like warm-up routines, environmental adaptations, and equipment quality. Data underwent descriptive statistical analysis and logistic regression to identify associations, adjusting for confounders in multivariable models.

Ethical approval came from Wits' Human Research Ethics Committee, ensuring participant confidentiality and informed consent, reflecting rigorous academic standards at the institution.

Athlete Demographics and Participation Patterns

Participants had a median age of 27 years (interquartile range [IQR] 23–32), nearly evenly split by sex (52% men, 48% women), with Black athletes comprising 45.4%. Limb deficiency emerged as the dominant impairment at 50%, followed by visual impairment and other types like cerebral palsy.

Athletics dominated as the primary sport (44.2%), followed by swimming (23.3%) and cerebral palsy football (12.8%). Training intensity was high: median 5.3 sessions per week lasting 60 minutes each, with 76.7% incorporating rest days. Competition averaged 3.4 days per month. Men were more likely to train in adapted environments (67% vs. 33% for women, p=0.015), highlighting sex-based differences in access.

Cross-training (40.7%) and strength training (38.4%) were common, while 71% used sport-specific equipment, though only 46.5% replaced it promptly.

Injury Prevalence and Characteristics

The study uncovered a median of three injuries per athlete over the previous 12 months (IQR 2–3), with no significant sex disparity (men: 3 [IQR 2–4]; women: 2 [IQR 2–3]; p=0.279). This translates to a substantial burden, as nearly all respondents reported at least one incident.

Injuries predominantly affected the lower body quadrant (74%, including back, hip, thigh, knee, leg, ankle, foot; p=0.617), underscoring vulnerabilities in propulsion-dependent sports. Upper body involvement was 26% (head, neck, shoulder, arm, wrist, hand).

Common types included muscle strains (34%), ligament sprains (24%), fractures (8.1%), joint dislocations (7%), joint pain (10.5%), bruises (10.5%), and concussions (5.8%), with no sex differences (p=0.313). Most occurred during training (78% lower body), though competition saw higher upper body rates (87%). Only 45.4% sought medical or rehabilitation treatment, and 40.7% had prior injury prevention education.

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Key Risk and Protective Factors

Logistic regression pinpointed actionable insights. Skipping warm-ups during training tripled injury odds (OR=3.2, 95% CI 1.3–7.9, p=0.011). More competition days per month heightened risk (OR=2.7, 95% CI 1.1–6.8, p=0.036), as did skipping cool-downs (OR=8.2, 95% CI 1.2–54.1, p=0.029).

Protective elements were striking: swimming (OR=0.05, p=0.010) and strength training (OR=0.05, p=0.002) slashed risk dramatically. Well-maintained equipment (OR=0.1, p=0.030) and challenges in extreme weather (hot: OR=0.002, p=0.031; cold moderate: OR=0.1, p=0.023) also buffered against injuries.

These findings emphasize modifiable behaviors like consistent warm-ups and diversified training, particularly swimming and strength work, to bolster resilience.

Implications for Training and Rehabilitation

The data calls for paradigm shifts in para-sport preparation. Coaches should mandate warm-ups and cool-downs, integrating swimming and strength routines to mitigate risks. Equipment maintenance protocols are essential, given the protective effect of quality gear.

Rehabilitation access remains a bottleneck; only half sought professional care, pointing to needs for subsidized services and on-site physio at training facilities. Injury prevention education reached just 41%, suggesting workshops tailored to impairment types and sports could yield dividends. The full study urges multidisciplinary teams involving physiotherapists like those at Wits.

Wits University's Pivotal Role

Hosted at the University of the Witwatersrand's Faculty of Health Sciences, this research exemplifies Wits' commitment to sports medicine through its Wits Sports and Health (WiSH) initiative. WiSH integrates clinical practice, training facilities, and research to support athletes, positioning Wits as a hub for para-sport science in Africa.

Kunene's work builds on prior Wits-led Paralympic surveillance, contributing to global databases like those from London 2012 and Rio 2016, where SA para-athletes showed elevated injury rates. This study advances local evidence, aiding SASCOC and federations in policy-making amid funding strains.

Global Comparisons and Broader Context

SA's median three injuries per year aligns with global para-athlete trends, where musculoskeletal prevalence hits 40.8% annually and incidence 14.3 per 1,000 athlete-days. Lower limb dominance mirrors Paralympic data, with pre-competition spikes noted in Rio 2016.

Unlike resource-rich nations, SA faces amplified risks from suboptimal environments and limited rehab. Funding shortfalls plague SASCOC para-programs, curtailing development. Yet, SA's Paralympic medal hauls—42 across recent Games—demonstrate potential when supported.

Stakeholder Perspectives and Actionable Insights

SASCOC officials highlight funding as a barrier to injury prevention infrastructure. Coaches advocate strength-swim hybrids; athletes stress equipment upgrades. Policymakers could leverage this for targeted DSAC allocations, echoing calls for R100 million boosts.

• Prioritize warm-up compliance in national guidelines.
• Subsidize strength training access via university partnerships like Wits WiSH.
• Enhance rehab networks for lower limb focus.
• Monitor weather impacts for adaptive strategies.

These steps could elevate SA para-athletes, mirroring successes in athletics where smart training yields medals.

Photo by DIANA HAUAN on Unsplash

Future Outlook and Research Directions

This Wits-led study sets a benchmark, calling for longitudinal surveillance akin to IPC standards. Future probes should dissect sport-specific risks (e.g., athletics' lower limb strain) and intervention efficacy, like mandatory strength programs.

With Paris 2024's six medals fueling momentum, integrating findings into SASCOC strategies could propel LA 2028 performances. Universities like Wits must lead, fostering collaborations for resilient para-athletes.

In a nation where para-sports inspire inclusion, curbing injuries ensures sustained excellence and equity.