Background: Professional athlete’s often risk sports injuries during their career in the hope of achieving better results. Because of the rising expectations as regards competitive sports, the number of sports injuries and sports accidents is increasing together with the number of injuries involving permanent damage. A significant proportion of such injuries could be prevented by providing appropriate information, with professional competence and with caution, and the consequences of lasting damage to athlete’s health could be reduced significantly.

Hungary is a successful nation in sports, and it is amongst the world leaders in the field of professional sports. Among further possibilities of developing sports, legislative regulation is one of the paths to follow. In Hungarian sport, in the future an even greater emphasis should be laid on making sure that responsible specialists with appropriate skills supervise high-risk sports and professional athletes. These ambitions should be supported with a legislative background.

Methods and Results: The Ministry of State for Sport carried out a study about the internal regulations of the National Associations of Olympic Sports, with special regard to regulations concerning sports medicine and the prevention of sports injuries. We followed a case based approach, where we created case studies about successful Hungarian Olympic Sports and Team Sports. From the 16 strategic Olympic Sports and 5 spectacle Team Sports we created 12 cases. Cases were based on a semi-structured case interview and the submission of semi-structured questionnaire. In this paper we introduce these cases and the analysis based on them. According to the cases we could identify the gap of the ideal prevention based legal protection and the actual Hungarian legislation and the practice of Hungarian National Sport Associations Conclusion After evaluating these results, the Hungarian Ministry of State for Sport and the Hungarian Government decided that in the amendment of the Sports Act entering into force on 1 January 2017 it shall include a legal obligation for national associations to prepare ethical and child protection regulations, as well as sports medicine regulations protecting and advocating sport athlete’s interests, within 45 days after the amendment enters into force.

Introduction

Van Mechelen et al (1992) states that “in general sports injury is a collective name for all types of damage that can occur in relation to sporting activity” [1]. Sports injuries and accidents occur increasingly more frequently due to rising expectations as regards competitive sports [2]. A significant proportion of such injuries could be prevented by providing appropriate information, with professional competence and with caution, and the consequences of lasting damage to sport athlete’s health could be reduced significantly [3]. In the first part of my series of articles concerning the rights of injured athlete’s I presented the regulations adopted in connection with head injuries and concussions suffered in American football [4], as well as US laws and legislation [5]. These laws do not simply deal with injuries suffered by professional athletes, but they all cover juvenile athlete, and they also include regulations relating to sports at high schools, colleges and universities./p>

The Legal Aspects of Injuries Resulting in Concussion, US laws

As American football is characterized by a high number of collisions and body-to-body contacts, concussions occur more frequently than in any other sport, as a result of which in recent years American football received outstanding attention among doctors and lawyers [6]. One of the first regulations was the Zackery Lystedt Law passed by the state of Washington. It was named after a young American football player who returned to play after sustaining a concussion and suffered brain injury [7]. The Law orders that players showing signs of a concussion must not be allowed to play or train, and it bans players from competition until a licensed health care provider trained to assess and treat concussions (this clause also includes appropriately skilled trainers) allows them to return to play [8]. The law also establishes that trainers, sportspeople and their parents/guardians should receive appropriate training in connection with head injuries, which may include further training courses for trainers as well as information materials distributed among students and parents [9]. Furthermore, every year before the season starts, sportspeople and their parents must sign an information sheet dealing with concussion and head injuries. This document is a significant step forward as compared to other general consent forms to be signed before starting any sporting activity, which, however, usually cover the risk of injuries in one or two short sentences and do not provide any detail about the lasting effects of injuries or about the most common injuries [10]. By November 2014 nearly all federal states of the USA had introduced legislation relating specifically to concussions occurring in youth sport [11].

Regulations of Hungarian Olympic Sports Associations

Hungary is a successful nation in sports, and it is amongst the world leaders in the field of professional sports. Among further possibilities of developing sports, legislative regulation is one of the paths to follow. The Ministry of Human Capacities, Ministry of State for Sport, which is the state organization controlling Hungarian sports, regards it as its outstanding task to create the backgrounds for safe Hungarian sports. For this reason it carried out a study of the internal regulations of the National Associations of Olympic sports, with special regard to regulations concerning sports medicine and the prevention of sports injuries. As part of the study, the Ministry of State for Sport asked the different sports associations to submit in writing a description and occurrence of relevant sports injuries, the possibilities of prevention, and the relating provisions and their wording included in the national and international regulations concerning the given sports. The Ministry of State for Sport asked 16 successful Olympic sports and 5 team sports to participate in the study.

Materials and Methods

In 2016 there were 5 spectacle team sports in Hungary (football, handball, basketball, ice-hockey and water polo) and there were 16 strategic Olympic sports (table tennis, athletics, wrestling, volleyball, canoeing and kayaking, cycling, skating, boxing, pentathlon, tennis, swimming, fencing, judo, gymnastics, rowing and shooting). We followed the case-based approach for the research, creating in-depth cases from the spectacle team sports and strategic Olympic sports. Semi-structured case interviews were conducted with focus on injuries, prevention and legal protection of athletes and national associations submitted their answers for a semi-structured questionnaire as well. From the overall 21 sports we could create comprehensive cases for 12 sports. From these 12 cases generalizable results can be drawn to the Hungarian spectacle team sports and strategic Olympic sports as well.

Results

Four of the National Associations did not provide any information at all concerning this issue, and 3 Associations gave only simple conventional answers in a few lines, without any substantial content. Two Associations submitted answers dealing exclusively with health issues contained in the international regulations relating to the given sport, and they did not provide any information about their own ideas or rules. A total number of 12 meaningful answers were submitted, with contents suiting the aims of the study. A summary of these answers and their main aspects are presented below.

Table tennis

Table tennis is a sport moving all parts of the body from top to toe. Today’s professional table tennis players do special strengthening exercises since their early childhood, and they prepare for competitions in an increasingly more body- and health-conscious manner, reducing by this the risk of sports injuries during their career. Hungarian table tennis players are significantly behind the top players of the world in the field of injuries and their prevention. This sport has no directives or regulations, which could provide guidance for trainers and ultimately for players in the field of prevention. Among injuries specific to this sport, shoulder joint and hip joint injuries are the most significant. Several Hungarian table tennis athletes were qualified for the Olympic Games in the last decade. For the Beijing Olympic Games 3 women and 1 man qualified, 2 women and 2 men qualified for the London Olympic Games and 2 women and 1 man for the Rio Olympic Games.

Athletics

This is a complex sport involving sporting activities that require different forms of exercise. This sport is characterized by overtraining syndromes and injuries. They try to prevent injuries first of all by providing appropriate education for trainers and athletes and by integrating preventive movement therapy in the training plans. They also pay special attention to avoiding random accidents. The International Association of Athletics Federations has a highly detailed medical guide, in which all medical knowledge specific to athletics is summarized in a precise and accurate manner. The Hungarian association does not have its own guide. Several Hungarian athletes were qualified for the Olympic Games in athletics in the last decade. For the Beijing Olympic Games 11 women and 9 men qualified and won one 4th places, 8 women and 10 men qualified for the London Olympic Games and won one gold medal (Krisztian Pars – hummer throw). For the Rio Olympic Games 10 women and 9 men qualified and won one bronze medal.

Wrestling

Since 2011 the Hungarian association has had a separate working group dealing with injuries specific to this sport, the causes of such injuries, their conservative and surgical treatment and the possibilities of prevention. Numerous scientific publications, lectures and theses have been issued concerning this topic, on the basis of which the practice of proprioceptive functional training specific to wrestling has been integrated in the national preparation system. At the request of the International Wrestling Association the national working group prepared a guide containing medical knowledge specific to wrestling, which also contains a description of securing competitions. This sport is extremely complex, as both anaerobic and aerobic fitness is needed during a match or contest, and technical, conditional and tactical preparedness is also required. In the case of wrestlers, special attention should be paid to exercises stabilizing the spine. The specialists of the association are open to cooperation and elaborating regulations. Several Hungarian athletes were qualified for the Olympic Games in wrestling in the last decade. For the Beijing Olympic Games 1 woman and 8 men qualified and won one silver medal, 1 woman and 6 men qualified for the London Olympic Games and won one silver medal and two bronze medals. For the Rio Olympic Games 2 women and 6 men qualified and did not score any Olympic points.

Canoeing and Kayaking

Due to the nature of this sport, it is characterized by overtraining injuries. During the foundation period, other injuries also occur when involved in supplementary sports (running, ball games). Special training courses are available for prevention, focusing on the tools of physiotherapy. This sports association does not have regulations elaborated for specific injuries and long-term consequences, but they would like to join forward-looking initiatives, which they would welcome. Several Hungarian athletes were qualified for the Olympic Games in canoeing and kayaking in the last decade. For the Beijing Olympic Games 5 women and 13 men qualified and won two gold medals, one silver medal and one bronze medal. For the London Olympic Games 5 women and 8 men qualified and won three gold medals, two silver medals and one bronze medal. For the Rio Olympic Games 5 women and 10 men qualified and won three gold medals (Danuta Kozák – five times Olympic champion).

Cycling

Sports injuries are injuries characteristic of one or more sports, resulting in tissue damage on certain areas. Sports accidents occur as a result of a single and sudden macro trauma. If treated appropriately, they are reversible both structurally and functionally (bruise, strain, fracture, rupture, dislocation). Reoccurring micro traumas may cumulate as a result of overtraining or wrong training. Medical histories include increased stress during several years of regular sporting activity. Generally they are specific to certain sports and are especially dangerous, because in the lack of appropriate treatment they may become irreversible (permanent health damage). If these injuries are not recognized or are treated badly, they may result in chronic damage and prolonged inflammation. In the case of cyclists, external fixture is recommended for a period as short as possible in order to prevent muscle wasting; consequently early rehabilitation is of fundamental importance. Several Hungarian athletes were qualified for the Olympic Games in cycling in the last decade. For the Beijing Olympic Games 1 woman and 4 men qualified. For the London Olympic Games 1 woman and 2 men qualified. For the Rio Olympic Games 1 man qualified.

Skating

Figure skating is characterized by a unique combination of athleticism, strength, fastness, perseverance, beauty and art. The realization of jumps, lifts and throw jumps involves an increased risk of injury, and cut injuries are also specific to this sport. At least half of the injuries occurring in this sport could be prevented. The number of injuries could be reduced through the appropriate construction and selection of skates. Muscle strengthening, stretching and proprioceptive training are also important elements of prevention. Most commonly, skaters have waist complaints, as skating is asymmetrical and rather static, and in basic position skaters lean forward. In skating they lay an increasingly greater emphasis on preventing injuries, but there is no injury register, and regulations supporting prevention have not been prepared yet. Several Hungarian athletes were qualified for the Olympic Games in cycling in the last decade. For the Vancouver Olympic Games 6 women and 3 men qualified. For the Sochi Olympic Games 5 women and 4 men qualified and won a sixth place.

Football

The incidence rate of injuries has risen in this sport due to the high number of active players and the increasing physical requirements in the past years. In the scope of its Medical and Research Centre (F-MARC) programme, FIFA focuses on preventing non-contact injuries. The international organization elaborated a series of football-specific structured warm-up exercises. In the programme it is emphasized that warm-up and prevention exercises are the most effective, if they form part of the youth training structure. In the case of football players the most common injuries include muscle strains in the thighs, and ankle and knee joint injuries, and a greater proportion of players are injured on their non-dominant side, which also proves the importance of preventing asymmetries. Studies carried out in this sport have demonstrated that if a player suffers a sports injury, his chances of suffering another injury in the next season are three times higher. Regeneration as an injury prevention procedure must be noted in particular, because due to increasing physical requirements and popular competition systems, the process of regeneration has become an efficient and widely applied segment in the methodology of prevention (appropriate diet, hydration, taking antioxidants, diving in cold water, wearing compression tights, shorts and other accessories). Besides scientific research, screening programmes and prevention procedures, it is also essential to document and record occurring injuries and set up an injury register within the given sports. The Hungarian Football Association has recognized the practical benefits and necessity of an injury register and launched its own football injury register. The national team of Hungary did not participate in any Olympic Games or World Championships in the last decade.

Boxing

The effects of the significant modifications to the rules introduced in 2013 (banning the use of head guards in competitions, increasing the total duration of the rounds, a change in the attitude of the evaluators towards tolerating and appreciating more aggressive boxing) on the incidence rate of injuries cannot be assessed yet. Among the injuries characteristic of this dynamic fighting sport involving direct contact, injuries caused by collisions and blows to the head are the most common. It is first of all the referee’s task to prevent serious brain injuries. The incidence of tear injuries on the face or scalp increased by about 10% after banning the use of head guards, but injuries to the eyes, limbs and abdomen caused by direct blows also occur. Numerous scientific articles with a medical approach and medical associations demand the termination of this sport, and this is one of the reasons why very detailed health regulations have been elaborated for boxing. The most important health prescriptions regulate medical examinations, which are compulsory every year, medical examinations before and after competitions, which are compulsory in certain cases, they clarify the referee’s and the doctor’s role during the matches, and they also contain prescriptions relating to compulsory resting periods following K.O. or concussion and to the conditions of returning to play. Several Hungarian athletes were qualified for the Olympic Games in boxing in the last decade. For the Beijing Olympic Games 5 men qualified and won one fifth place. For the London Olympic Games 3 men qualified and won one fifth place. For the Rio Olympic Games 2 men qualified, but they could not get any Olympic points.

Modern Pentathlon

Due to the complex nature of modern pentathlon consisting of five different sports, athletes are exposed to the risks of all five sports. Among these sports, injuries are the most likely to occur during horse-riding and fencing. The most important steps of handling injuries involve the joint work of sports surgeons, sports doctors, physiotherapists and masseurs in the interest of treating injuries appropriately. Rehabilitation and the careful follow-up of the injuries form organic parts of the process of recovery. The perfect acquisition of the movements characteristic of this sport and the development of general motor skills may significantly contribute to preventing injuries, avoiding the development of permanent damage and avoiding reoccurrence in the case of already existing complaints. Due to the complex nature of this sport it would be important to have detailed and comprehensive internal regulations, but currently there are no such regulations in respect of this sport. Several Hungarian athletes were qualified for the Olympic Games in modern pentathlon in the last decade. For the Beijing Olympic Games 2 women and 2 men qualified. For the London Olympic Games 2 women and 2 men qualified and won one bronze medal. For the Rio Olympic Games 2 women and 2 men qualified.

Tennis

Injuries in tennis can be classed in two categories: overtraining injuries caused by excessive training, and acute or traumatic injuries caused by sudden or strong impacts. Overtraining injuries are reoccurring micro traumas, which exceed the ability of the tissues to adapt or heal. They may depend on internal factors (sudden overstretching, muscle balance disorders) or on external factors (hits, tennis elbow, jumper’s knee, and bad environmental conditions). Both types of injuries are characterized by that the wrong assessment of the severity of the primary injury, wrong rehabilitation or returning to the sporting activity too early may result in further injuries. From the aspect of sports medicine, the most common complaints in tennis involve shoulder, elbow, back, and ankle and Achilles tendon complaints. Each time before starting to play, and even before doing warm-up exercises, it is recommended to thoroughly stretch the muscles around the shoulders. There are no regulations relating to specific injuries in this sport. Several Hungarian athletes were qualified for the Olympic Games in tennis in the last decade. For the Beijing Olympic Games 2 women qualified. For the London Olympic Games 2 women qualified. For the Rio Olympic Games 2 women qualified.

Swimming

A special feature of swimming is that due to buoyancy in water it stresses the muscles without bearing the body weight, in the form of repetitive, power and fitness training. As a result of the stress, the most commonly occurring musculoskeletal injuries affect first of all the shoulders, the knees and the spine. In order to prevent injuries, it is very important to acquire the right stretching technique and to strengthen specifically muscles participating in the dynamic stabilization of the joints, already from childhood. In 2015, in the framework of the programme entitled “Champions of the Future”, the Hungarian Swimming Association launched a programme aimed at preventing shoulder injuries. In the scope of this programme, following a complex examination of the shoulder joints, physiotherapists teach children a series of exercises to promote the appropriate stretching and stabilization of shoulder joints. Developing a correct swimming technique (with the help of camera systems and specialists analyzing movements), acquiring appropriate stretching techniques and special strengthening exercises for stabilizing joints, facilitating regeneration, and rehabilitation with the help of physiotherapists all play an important role in the prevention and rehabilitation of injuries specific to swimming. Several Hungarian athletes were qualified for the Olympic Games in swimming. For the Beijing Olympic Games 14 women and 14 men qualified and won three silver medals. For the London Olympic Games 11 women and 14 men qualified and won two gold medals and one bronze medal (Dániel Gyurta 200m breaststroke, Éva Risztov 10km). For the Rio Olympic Games 12 women and 19 men qualified and won three gold, two silver and two bronze medals (three gold medals for Katinka Hosszú 200IM, 400IM, 100 backstrokes).

Fencing

Despite appearances, fencing is not a dangerous sport in theory. Obviously, injuries may occur, but serious injuries are unlikely. Problems may result from a failure to do warm-up exercises, unpreparedness or overtraining. Sport-specific injuries develop as a result of doing a given sport for a long time, and such injuries are mostly very typical. These injuries are associated with the techniques and equipment characteristic of the sport, and most often they are caused by a sudden disruption in the harmonious operation of muscles and joints. Sports injuries may also occur as a result of a sudden and unexpected external impact, which interrupts the dynamic process of movement. This is called a macro trauma. Due to the protective equipment used, such type of acute injuries hardly occur in fencing. Micro traumatic sports injuries resulting from overtraining are much more common. Injuries to the knee joints, or the wearing of the knee joints, or sometimes knee tendon injuries may also occur. Fencers often overstress their hands holding their weapon, or their wrist joints. In most cases these processes are reversible, if appropriate treatment is given and resting is ensured, but in the lack of treatment irreversible damage may occur. The Hungarian Fencing Association does not keep statistics on injuries, in its regulations there are no provisions relating to the prevention of injuries, but the training methodology regulations contain guidance relating to warm-up and prevention exercises. Several Hungarian athletes were qualified for the Olympic Games in fencing in the last decade. For the Beijing Olympic Games 7 women and 8 men qualified and won one bronze medal. For the London Olympic Games 2 women and 2 men qualified and won one gold medal. For the Rio Olympic Games 4 women and 6 men qualified and won two gold, one silver and one bronze medals (one gold medal for Emese Szász, and two gold medals for Áron Szilágyi).

Discussion

Professional athletes often risk sports injuries during their career in the hope of achieving better results. In pursuit of success and results, the number of sports injuries and sports accidents is increasing together with the number of injuries involving permanent damage [12]. Providing appropriate information, professional competence and caution are essential for preventing injuries to professional athletes and young sportsmen, and for protecting their health [13].

A very important aspect is that competent specialists sharing a unified view on the prevention, treatment and rehabilitation of sports injuries should be there to help all sport athletes in all sports. The medical profession itself does not have a unified view. They do not make a distinction between an injured person and an injured sportsmen. They have different aims and walk different ways to reach their aims: while an ordinary injured person just wants to recover as soon as possible, a sports man wants to return to play and compete again as soon as possible. Other external factors include trainers, teams and families, who all want to reach this aim in different ways. Consequently it is important that the sportsmen, the medical profession and the trainer or senior adviser form a close unit and cooperate in the interest of speedy recovery [11].

Hungary is a successful nation in sports, and it is amongst the world leaders in the field of professional sports. Among further possibilities of developing sports, legislative regulation is one of the paths to follow. In Hungarian sport, in the future an even greater emphasis should be laid on making sure that responsible specialists with appropriate skills supervise high-risk sports and professional sportsmen these ambitions should be supported with a legislative background. For this reason the Ministry of State for Sport decided that in the amendment of the Sports Act entering into force on 1 January 2017 it shall include a legal obligation for associations to prepare sports medicine regulations protecting and advocating sports athlete’s interests.

Prior to this, the Ministry of State for Sport carried out a survey in order to prepare a comprehensive study material and publication aimed at identifying, summarizing and classifying the injuries specific to the different Olympic sports in Hungary, and providing information to parents with a view to prevention. As expected, the survey was not very successful, only a few associations were able to give adequate, forward-looking answers to the questions asked. Only 12 sports Associations actually addressed these issues, and 7 of them reported that they regularly discussed these problems and were already using prevention exercises both in training theory and in practice, such as muscle strengthening, stretching and proprioceptive training. These sports have no regulations relating to the prevention of specific injuries, and the international regulations do not contain detailed instructions either in respect of the prevention of sport-specific injuries. Three sports – athletics, swimming and boxing – have a detailed international medical guide, in which all medical knowledge specific to the given sports is summarized in a precise and accurate manner. The regulations relating to boxing are especially highly detailed, health prescriptions regulate medical examinations, which are compulsory every year, medical examinations before and after competitions, which are compulsory in certain cases, they clarify the referee’s and the doctor’s role, and the rules aimed at the prevention of injuries. Two sports take the lead in taking steps in the interest of preventing injuries to sports athlete. The Hungarian Boxing Association set up a separate working group within its medical committee, the task of which is to study injuries occurring in the sport and their prevention, to hold lectures and issue scientific publications on the research results. As a result of this, the international association asked the national working group to prepare a guide containing medical knowledge relating to boxing. The so-called F-MARC programme is already operating in football, focusing on the prevention of non-contact injuries, and the international organization has elaborated a series of football-specific structured warm-up exercises. These exercises can also be seen on television when players do warm-up exercises before the matches. The programme emphasizes that it is compulsory to integrate warm-up and prevention exercises in the youth training structure, as well as regeneration as a process for preventing injuries. The Hungarian Football Association has also recognized the practical benefits and necessity of this programme, and it has successfully launched its own prevention programme and a football injury register.

Legislative Regulation in Hungary

After evaluating the experience and the deficiencies identified in this field, the Ministry of State for Sport decided that in the interest of consciously preventing injuries to sportspeople it is necessary to elaborate appropriate legislative regulations, by amending or supplementing the relating provisions of the Sports Act, as appropriate, and to provide information for those participating in sports with a view to prevention. The primary aim of the amendment is that in Hungarian sports, associations should lay an even greater emphasis in the future on making sure that responsible specialists with appropriate skills supervise high-risk sports and professional sportsmen. The new Sports Act created prescribes for the different sports associations to prepare ethical and child protection regulations, as well as sports medicine regulations advocating athlete’s interests, within 45 days after the amendment enters into force. The regulations should be elaborated taking into consideration the following aspects:

• In the introductory part of the regulations, the most common injuries specific to the given sport must be described together with the causes and mechanisms leading to them.

• Sports doctors working in the given sports must elaborate a series of specific structured warm-up exercises, a short description of which must be included in the regulations (or as an appendix), and the practical use of which must be recommended in the regulations for all trainers. In the programme it must be emphasised that warm-up and prevention exercises are the most effective, if they form part of the youth training structure.

• One of the first and most important steps in the prevention of sports injuries must be to set up a system of physical screening examinations suiting the training programmes.

• The specific screening, prevention and rehabilitation programmes relating to the given sports must be described, and the possibilities of examining motor skills controlled with performance tests must be presented.

• Besides scientific research, screening programmes and prevention procedures, it is also essential to document and record occurring injuries and set up an injury register within the given sports.

• In the case of the most dangerous team sports and fighting sports the regulations must contain the most important health prescriptions regulating medical examinations, which are compulsory every year, medical examinations before and after competitions, which are compulsory in certain cases, they must clarify the referee’s and the doctor’s role during the matches, and they must also contain prescriptions relating to compulsory resting periods following K.O. or concussion and to the conditions of returning to play.

• A list of specialists sharing a unified view, who work in the given sports and can be contacted by everybody (doctors, psychiatrists, masseurs, physiotherapists) must be appended to the regulations, and opportunities for consulting them must be provided for specialists working in the given sports.

Conclusions

Among further possibilities of developing sports, legislative regulation is one of the paths to follow. For this reason, the Hungarian Government and the Ministry of State for Sport must lay an even greater emphasis on making sure that responsible specialists with appropriate skills supervise high-risk sports and professional sportsmen. These ambitions should be supported with a legislative background. The Hungarian Government has taken the first step, the legislative regulation has been created, and the Ministry of State for Sport has issued guidelines for the sports associations on elaborating appropriate health regulations specific to the given sports. Now it is up to the National Sports Associations to realize these ambitions in practice, taking further steps in the interest of protecting young sports athlete’s health and preventing sports injuries to them.

National Sports Associations and clubs also take decisive steps in the field of providing information and prevention; they elaborate sport-specific rules, integrate the necessary guidelines in their operation and provide adequate information for children and their parents. Furthermore, they undertake to prepare information materials for children and parents, which contain the characteristics of injuries specific to the given sports, the possibilities of prevention, and describe the possibilities available for preventing the long-term consequences of injuries, and provide information on where young sportspeople suffering injuries can turn for help.

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