Mortality in former Olympic athletes: retrospective cohort analysisBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e7456 (Published 13 December 2012) Cite this as: BMJ 2012;345:e7456
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A recent study published in BMJ identified higher mortality rates in athletes from disciplines with high physical contact (hazard ratio 1.13, 95% confidence intervals 1.06 to 1.21), and no indication of cardiovascular intensity as a significant mortality predictor1. We performed an extension of this idea on to the football players, aiming to compare how a position within a team might be associated with all-causes mortality. For this purpose we collected information on professional players of football club Hajduk from Split, Croatia. We included all players who were born since 1894 onwards, with a total of 644 analysed players. Among them, there were 192 cases of deaths that were sufficiently informative to be included in the analysis, based on the club registry data and publicly available information, with a total number of 45 goal keepers. The initial comparison of goal keepers vs. all other positions in the team indicated that they had on average lived longer (76.3±14.3 vs. 65.2±16.6 years; P=0.031). A multivariate proportional Cox analysis suggested that the hazard ratios for all-causes mortality were insignificant for national representation vs. non-representation players, a proxy of the overall player quality and performance (0.88, 0.54 to 1.41), number of appearances in the field, as a proxy of the career length (0.99, 0.98 to 1.01), while the position of the goal keeper was associated with the decreased hazard ratios (0.37, 0.19 to 0.72). Notably, this model is an oversimplification of a very complex matrix of possible effects, which nevertheless seemed to yield significant result even in a rather small sample size.
Previous studies have suggested higher neurodegenerative mortality among players in speed positions compared to players in nonspeed positions2, increased risk of sudden death in athletes exposed to blunt trauma3 and excess cardiovascular mortality in defensive linemen compared to the offensive ones4. It would therefore seem that the best position to play football is that of a goal keeper, at least in terms of the reduced mortality risk.
Director, Medical Department, Football team Hajduk, Split, Croatia
Department of Public Health, Medical School, University of Split, Croatia
1. Zwiers R, Zantvoord FW, Engelaer FM, van Bodegom D, van der Ouderaa FJ, Westendorp RG. Mortality in former Olympic athletes: retrospective cohort analysis. BMJ. 2012;345:e7456.
2. Lehman EJ, Hein MJ, Baron SL, Gersic CM. Neurodegenerative causes of death among retired National Football League players. Neurology. 2012;79:1970-4.
3. Thomas M, Haas TS, Doerer JJ, Hodges JS, Aicher BO, Garberich RF, Mueller FO, Cantu RC, Maron BJ. Epidemiology of sudden death in young, competitive athletes due to blunt trauma. Pediatrics. 2011;128:e1-8.
4. Baron SL, Hein MJ, Lehman E, Gersic CM. Body mass index, playing position, race, and the cardiovascular mortality of retired professional football players. Am J Cardiol. 2012;109:889-96.
Competing interests: No competing interests
We read with interest the recent paper by Zwiers et al (1). Rugby was alluded to as one of the disciplines which appear to predispose top athletes to a higher mortality due to repeated body collisions and high physical contact. Recent developments in rugby have seen augmented player size, shuddering hits and a corresponding increase in injury rate (2, 3).
We have recently completed a study exploring the physical characteristics of 95 modern-day professional rugby union and rugby league players (age 25.9±4.3 years) of the highest standard in the UK. These sportsmen have physiques unlike any other. At first glance, body mass index (29.5±2.9 kg.m-2) would suggest overweight or obesity, but on examination of DXA reports, these men have low levels of body fat (%BF: 17.7±4.1), substantial lean mass (78.1±8.1 kg), and their bones are far denser than average (total body Z-score: 3.6±1.2). The question we ask is why would these men be at risk of greater mortality due to repeated collisions? Doesn’t the musculoskeletal system respond and adapt to the loads it is exposed to? This is all highly documented in Frost’s Mechanostat seminal model (4) and has formed the basis of countless exercise intervention studies. Perhaps rugby-related trauma regularly exceeds the operational strain threshold of the body and adverse effects on biological and physiological systems have not yet been identified. Could aging be accelerated? Cervical spine degeneration and osteoarthritis is frequently reported in professional rugby players (5, 6).
Zwiers and colleagues’ important findings should provide the impetus for research into the hidden risk factors for increased mortality risk in this unique population. As the group rightly points out, professionalism in sport has resulted in a substantially greater physicality than the early 1900’s. This is particularly true for both codes of rugby, with professional players often referred to as ‘superhuman’, and a media emphasis increasingly placed on the size of the players and the impacts of the ‘hits’. Whilst gladiatorial and entertaining to watch, these athletes are not machines, nor are superhuman. The risk factors for their apparent high mortality risk warrant timely investigation.
1. Zwiers R, Zantvoord FWA, Engelaer FM, et al. Mortality in former Olympic athletes: retrospective cohort analysis. BMJ 2012. 345:e7456 doi: 10.1136/bmj.e7456
2. Kaplan KM, Goodwillie A, Strauss EJ, Rosen JE. Rugby injuries: A review of concepts and current literature. Bull NYU Hosp Joint Dis 2008. 66:2:86-93
3. English rugby premiership training and injury audit steering group. England rugby premiership training and injury audit 2010-2011 Rugby Football Union 2011
4. Frost HM. Bone ‘mass’ and the ‘mechanostat’: A proposal. The Anatom Rec 219:1:1-9
5. Castinel BH, Adam P, Milburn PD et al. Epidemiology of cervical spine abnormalities in asymptomatic adult professional rugby union players using static and dynamic MRI protocols 2002-2006. BJSM 2010. 44:194-199
6. Molloy MG, Molloy CB. Contact sport and osteoarthritis. BJSM 2011. 45:275-277
Competing interests: No competing interests