Changes in Sleep,Stress,and Fatigue Were Not Prospectively Associated With Running-Related Injuries Among High School Cross Country Runners

Abstract

Background:

Running-related injuries (RRI) are common among adolescent runners; however, our understanding of RRI risk factors in this population is limited. Sleep, stress, and fatigue are risk factors in other youth sports but have not been studied in high school runners. This study prospectively assessed the effect of changes in sleep duration and quality, stress, and fatigue on RRI among high school cross country runners.

Hypothesis:

Less and poorer quality sleep and greater stress and fatigue, compared with the previous week, would be associated with RRI.

Study Design:

Prospective, observational study.

Level of Evidence:

Level 2b.

Methods:

Runners completed a preseason demographics and injury history survey and daily surveys regarding sleep duration and quality, stress, fatigue, and current RRI. Values were summed within each week, and change scores were calculated relative to the previous week. Runners completing ≥75% of daily surveys were analyzed; sensitivity analyses for those completing ≥50% and ≥90% were also conducted. Generalized estimating equations assessed the association between change in each predictor, including its interaction with sex, and RRI, controlling for year in school, previous RRI, and repeated observations.

Results:

A total of 434 runners enrolled in the study; 161 (37%) completed ≥75% of daily surveys. No associations between change in sleep duration, sleep quality, or fatigue and RRI were observed (P values ≥0.24). A significant change in stress × sex interaction with RRI was observed (P < 0.01). Associations among boys (P = 0.06) and girls (P = 0.07) were marginally significant. Sensitivity results were similar.

Conclusion:

Short-term changes in sleep duration, quality, and fatigue were not associated with RRI, but a significant interaction between change in stress and sex suggests that stress may influence RRI risk in high school cross country runners.

Clinical Relevance:

Large changes in stress levels should be monitored throughout the season, as these changes may precede RRI occurrence in this population.

Keywords

adolescent female athlete injury well-being

Participation in high school cross country running has grown considerably over the last several decades.^1,2 Unfortunately, a corresponding increase in running-related injuries (RRI) has also been observed, with nearly 200,000 high school cross country runners likely to experience RRI each year.^1,15 The consequences of these RRI range from a few days of altered training to increased risk of future RRI,^4,12,15,16 which can have longer-term health implications for these athletes. Therefore, identification of RRI risk factors in youth runners has become an important area of research, and a recent consensus statement on youth running further emphasized the need for prospective cohort studies, which are necessary to inform the development of RRI risk reduction programs.¹¹

Perhaps the most widely studied variables related to RRI are a runner’s sex and RRI history, but there is growing evidence that behavioral and psychosocial measures such as sleep, stress, and fatigue may also influence injury risk in a variety of youth sports. Regarding the influence of sex on subsequent RRI, female runners typically have greater RRI risk than male runners,¹¹ although this can vary by the specific type or location of the RRI.^3,18 Having a history of RRI is also known to be a strong predictor of future RRI risk.^10,11,19 Unfortunately, a runner’s sex and history of RRI are nonmodifiable, and, although measuring the effect of these nonmodifiable risk factors remains important, there is a need to determine modifiable risk factors for RRI.

Sleep, stress, and fatigue are modifiable characteristics and all have been studied as risk factors for musculoskeletal injury. Sleeping fewer hours per night was associated with increased injury risk among male collegiate basketball players and female youth soccer players.^21,22 In a sample of adolescent athletes in several sports, sleeping for ≤8 hours per night was associated with a 70% increase in the likelihood of injury.¹³ Similarly, poorer sleep quality, regardless of duration, has been associated with increased odds of injury among collegiate runners and youth floorball athletes.^6,17 As sleep duration and quality have not yet been evaluated in adolescent runners but have been related to injury in other athlete populations, assessing sleep in this population is warranted.

Increased psychological stress in a given week has also been associated with increased injury risk during the subsequent week in youth athletes.¹⁷ Similarly, soccer athletes who went on to sustain an injury were identified as being more susceptible to stress based on a preseason survey.⁷ Further supporting the importance of stress as a risk factor for injury, a randomized control trial assessing a stress reduction intervention in soccer athletes found a reduced number of injuries after the intervention compared with the control group.¹⁴ The association of fatigue with injury risk, however, is less clear. Increased fatigue was associated with a 70% increase in injuries among professional soccer players within the subsequent month, and fatigue was worse on the day before an injury occurred in collegiate volleyball players.⁵ In contrast, increased fatigue was associated with fewer injuries during training and competition among rugby players,^8,9 suggesting the need for additional investigations to clarify the relationship between fatigue and injury.

Given the lack of research into risk factors for injury in youth athletes in general, and even less research on youth runners specifically, the aim of this study was to prospectively assess the influence of week-to-week changes in sleep duration and quality, stress, and fatigue on RRI among high school cross country runners. It was hypothesized that less sleep, poorer sleep quality, and increased levels of stress and fatigue compared with the previous week would be associated with RRI in this population.

Methods

Cross country runners from 24 high schools in Wisconsin were recruited from June to August 2021 to participate in this study. Runners were informed about the study at preseason team meetings and training sessions. Parental consent and athlete assent were obtained for runners <18 years old at the start of the season. The University of Wisconsin-Madison Health Sciences Institutional Review Board approved all study procedures.

Runners received an electronic preseason survey that included demographic information such as sex, age, and year in school, as well as injury history. This survey was completed once and became available 2 weeks before the start of the season and remained open through 2 weeks after the start of the season. In addition, beginning on the first day of the season through the last day that the runner participated with their high school team, runners received a daily text message or email prompting completion of a short survey. The daily survey asked about the previous day’s sleep duration and quality, stress level, and fatigue level (Appendix Table A1, available in the online version of this article). Sleep was reported in 0.5 hour increments, while sleep quality, stress, and fatigue were reported on a 5-point Likert scale with higher scores indicating better sleep quality, increased (worse) stress, and increased (worse) fatigue. Runners were permitted to complete up to 2 previous day’s surveys; eg, on a Thursday, a runner could also complete the surveys for Tuesday and Wednesday if they were not previously completed.

The daily survey also asked runners to self-report current pain brought on by or occurring immediately after running, and whether that pain caused them to modify their training. Team athletic trainers also entered details including dates of onset, modification to training, and dates of resolution for any injuries they evaluated or treated. The daily injury surveys completed by the runners were compared with athletic trainer logs to confirm dates of diagnosis and injury duration. Injuries were matched between the runner self-report and the athletic trainer report based on dates of onset, body part, and diagnosis. The earliest date reported by either the runner or athletic trainer was used as the date of onset, while the latest date reported from either report was recorded as the date of injury resolution. RRI were specifically defined as lower extremity (below the waist) injuries resulting from running and causing at least 7 consecutive days of pain with modified participation.²³

Data Processing

Daily survey completion rates were calculated for each runner as the number of surveys completed/total days enrolled in the study. Those who completed the preseason survey and ≥75% of their daily surveys were included in the primary analysis. Two additional datasets were created for sensitivity analysis, 1 including runners who completed ≥50% of their eligible daily surveys and 1 including runners completing ≥90% of their eligible daily surveys, to determine the influence of including athletes who were less compliant and those who were highly compliant on the association between sleep, stress, fatigue, and RRI.

For each dataset, the weeks in which the runner completed all 7 days of surveys were included in the analysis. Days with available and missing data are shown for each athlete in Online Appendix Figure A1. Hours of sleep and the Likert rating for sleep quality, stress, and fatigue were summed across all 7 days for a given week, creating a total value for that week. Change scores were then calculated as follows: (current week total - previous week total)/previous week total, such that positive change scores indicated the current week demonstrated greater values (eg, more hours of sleep, better sleep quality, more stress and fatigue) compared with the previous week and vice versa.

Statistical Analysis

Demographic data were summarized for each survey completion group by N (%) or means and standard deviations for categorical and continuous variables, respectively. Demographic variables for survey completion group were also compared with those who completed <50% of their surveys using chi-square and independent t tests for categorical and continuous variables, respectively. Mean (and standard deviation) hours of sleep and median (with interquartile range [IQR]) quality of sleep, fatigue, and stress on both weekdays (Sunday to Thursday) and weekends (Friday to Saturday) were calculated separately for runners on the boys and girls teams. Separate generalized estimating equations with a binomial distribution and logit link were used to determine the effect of change in each of the predictors of interest on the odds of RRI occurring in the subsequent 1 week and also in the subsequent 2 weeks, controlling for sex, year in school, and history of RRI. An interaction between sex and each predictor of interest was considered, and the interaction term was removed from the model if nonsignificant. An a posteriori association between total weekly hours of sleep and RRI in the subsequent week was also assessed. The covariance structure of all models also accounted for repeated observations across runners and correlation between runners within each school. Significance for all analyses was set a priori at α ≤ 0.05 and all analyses were performed in R Version 4.1.1 (R Core Team).

Results

A total of 434 runners enrolled in the study. After calculating completion rates, data from 161 (37%) runners who completed ≥75% of their daily surveys were included in the primary analysis, while 228 (53%) runners completed ≥50% of their surveys and 91 (21%) completed ≥90% (Table 1). Demographic data for each of the survey completion groups are summarized in Table 1, including those who completed <50% of their daily surveys and were excluded from all subsequent analyses. The ≥75% completion group had a greater proportion of runners who went on to sustain an RRI (P = 0.04) compared with the <50% completion group (Online Appendix Table A2); otherwise, no significant group differences were observed (P ≥ 0.19).

Table 1.

Participant demographics for runners who completed at least 50%, 75%, and 90% of the daily surveys^a

	<50% Survey Completion	≥50% Survey Completion	≥75% Survey Completion	≥90% Survey Completion
N	206	228	161	91
Boys	137 (50)	105 (46)	71 (44)	36 (40)
Girls	136 (50)	123 (54)	90 (56)	55 (60)
Age	15.6 ± 1.2	15.4 ± 1.2	15.4 ± 1.1	15.4 ± 1.2
Grade
9	75 (27)	64 (28)	43 (27)	24 (26)
10	62 (23)	62 (27)	51 (32)	33 (36)
11	67 (25)	51 (22)	31 (19)	14 (15)
12	69 (25)	51 (22)	36 (22)	20 (22)
History of RRI	106 (39)	92 (40)	70 (44)	40 (44)
RRI sustained
Total RRI	52	49	45	34
Unique runners	46 (17)	41 (18)	37 (23)	27 (30)

RRI, running-related injury.

Values represent mean ± SD or N (%).

After reconciling the runner self-reported injuries with the athletic trainer logs, there were no instances where an athletic trainer reported an injury without a clear, corresponding injury in the athlete report. Among runners who completed ≥75% of their daily surveys, 37 (23%) runners experienced at least 1 RRI during the season, with 13 of 37 RRI (22%) being corroborated by an athletic trainer report. In addition, 41 (18%) and 27 (30%) of the runners completing ≥50% and ≥90% of their daily surveys, respectively, sustained at least 1 RRI (Table 1).

Hours and quality of sleep, stress, and fatigue were comparable on weekdays and weekends for both sexes (Table 2). Boys and girls both reported an average of approximately 8 (SD = 1.2) hours of sleep per night with a median sleep quality rating of 4 [IQR, 3, 5], indicating “good” sleep quality. On weekdays, boys reported median stress and fatigue ratings of 2 [IQR, 1, 3], corresponding to “low stress, but a busy day” and “good energy level,” respectively, whereas on weekends the median stress rating for boys increased to a rating of 3 [IQR 2, 4]. Girls reported consistent median stress and fatigue ratings of 3 [IQR, 2, 4] on weekdays and weekends, which corresponded to “average stress, typical day,” and “average energy level,” respectively.

Table 2.

Daily sleep, stress, and fatigue characteristics summarized by sex and weekdays (Sunday to Thursday) and weekend days (Friday to Saturday)^a

Measure		Boys	Girls
Hours of sleep	Weekday	8.0 ± 1.2	7.9 ± 1.2
Hours of sleep	Weekend	7.9 ± 1.2	7.8 ± 1.3
Quality of sleep	Weekday	4 [3, 5]	4 [3, 5]
Quality of sleep	Weekend	4 [3, 5]	4 [3, 5]
Stress	Weekday	2 [1, 3]	3 [2, 4]
Stress	Weekend	3 [2, 4]	3 [2, 4]
Fatigue	Weekday	2 [1, 3]	3 [2, 4]
Fatigue	Weekend	2 [1, 3]	3 [2, 4]

Values represent mean ± SD or median [25%, 75%] and were calculated from data provided by athletes who completed at least 75% of their daily surveys.

Among runners who completed ≥75% of their surveys, there was not a significant interaction between sex and change in sleep duration, quality of sleep, or fatigue (P ≥ 0.24, Table 3); therefore, the interaction term was removed from the model. No significant association was identified between change in sleep duration (odds ratio [OR], confidence interval [CI] 0.71 [0.32, 1.58]; P = 0.41), quality of sleep (OR, 0.92 [CI, 0.52, 1.62]; P = 0.78), or fatigue (OR, 1.01 [CI, 0.72, 1.40]; P = 0.98) and RRI in the subsequent week (Table 3). Moreover, no significant interaction between sex and total weekly hours of sleep was detected (P = 0.70) and no significant association between total weekly hours of sleep and RRI was observed (OR, 0.98 [CI, 0.92, 1.02]) (Table 4). A significant interaction between sex and change in stress was observed (P < 0.01) and the predicted probability of RRI for a given change in stress level for boys and girls are presented in Figure 1.

Table 3.

Model results for the change in sleep duration, sleep quality, stress, and fatigue compared with the previous week and RRI in the subsequent week

Model	Change Variable	Sex	Unit of Change	≥50% Survey Completion		≥75% Survey Completion		≥90% Survey Completion
Model	Change Variable	Sex	Unit of Change	OR (95% CI)^a	P value	OR (95% CI)^a	P value	OR (95% CI)^a	P value
1	Hours of sleep		20%	0.77 (0.37, 1.61)	0.49	0.71 (0.32, 1.58)	0.41	0.88 (0.37, 2.07)	0.77
2	Quality of sleep		20%	0.92 (0.54, 1.57)	0.75	0.92 (0.52, 1.62)	0.78	0.88 (0.47, 1.64)	0.69
3	Fatigue		20%	0.99 (0.72, 1.36)	0.93	1.01 (0.72, 1.40)	0.98	1.07 (0.80, 1.44)	0.64
4^b	Stress	Boys	20%	0.62 (0.39, 1.00)	0.05	0.61 (0.37, 1.02)	0.06	0.58 (0.31, 1.10)	0.09
4^b	Stress	Girls		1.38(1.00, 1.90)	0.05	1.37(0.97, 1.94)	0.07	1.40(0.91, 2.16)	0.12

OR, odds ratio; RRI, running-related injury

All models are adjusted for sex, history of RRI, and year in school. Models also accounted for repeated observations within-athlete and correlation between athletes within each school.

Model 4 demonstrated a significant interaction between change in stress and sex. No significant interactions with sex in models 1 to 3 (P ≥ 0.24) were identified; therefore, only the main effects of the change score of interest are reported.

Table 4.

Model results for association between total weekly hours of sleep and RRI occurrence in the subsequent week

Variable	≥50% Survey Completion		≥75% Survey Completion		≥90% Survey Completion
Variable	OR (95% CI)^a	P value	OR (95% CI)^a	P value	OR (95% CI)^a	P value
Total hours of sleep^b	0.97(0.92, 1.02)	0.19	0.97(0.92, 1.02)	0.18	0.97(0.91, 1.03)	0.32

OR, odds ratio; RRI, running-related injury

Model was adjusted for sex, history of RRI, and year in school. Model also accounted for repeated observations within-athlete and correlation between athletes within each school.

No significant interaction with sex was identified (P ≥ 0.70); therefore, the main effect of total weekly hours of sleep is reported.

Figure 1.

The probability of sustaining an RRI among boys (blue/dashed line) and girls (red, solid line) experiencing various levels of change in stress compared with the previous week, among runners who completed ≥75% of their daily surveys. Shaded regions around each line represent 95% CI. There was a significant interaction between change in stress and sex (P < 0.01), though the associations between change in stress and RRI were not significant among boys (P = 0.06) and girls (P = 0.07) who experienced a 20% increase in stress compared with the previous week. Predicted probabilities were calculated given year in school = 10, week = 4 of 11 total weeks in the season, and no history of RRI. RRI, running-related injury.

Among boys, the odds of RRI decreased by 39% for every 20% increase in stress compared with the previous week (OR, 0.61 [CI, 0.37, 1.02]; P = 0.06), while the odds of RRI increased by 37% for a similar change in stress among girls (OR, 1.37 [CI, 0.97, 1.94]; P = 0.07) (Table 3). The model assessing the relationship between change in the predictors of interest and RRI occurring within the subsequent 2 weeks detected no significant interactions with sex (P ≥ 0.16, Online Appendix Table A2) and no associations between change in sleep duration, quality of sleep, or fatigue and RRI (P ≥ 0.23, Online Appendix Table A2).

Sensitivity Analysis

The demographic characteristics of those who completed ≥50% and ≥90% of their daily surveys were not significantly different from those who completed <50%, with the exception of a greater proportion of runners sustaining an RRI observed in the ≥90% completion group (P = 0.01, Online Appendix Table A2). The results among those who completed ≥50% and ≥90% of their daily surveys were comparable with those who completed ≥75% (Table 3). No interactions were observed between sex and change in sleep duration, quality of sleep, or fatigue (P ≥ 0.14) nor were any significant main effects observed for those variables on RRI within the subsequent week (P ≥ 0.49) (Table 3). When considering the potential effect of total weekly hours of sleep on RRI in the subsequent week, no interactions between sex and total weekly hours of sleep were detected (P ≥ 0.80), nor were any significant main effects of total weekly hours of sleep observed (P ≥ 0.19) (Table 4). Similar to the results among those who completed ≥75% of their daily surveys, models assessing RRI occurring within the subsequent 2 weeks instead of the subsequent 1 week identified no significant interactions with sex (P ≥ 0.12, Online Appendix Table A3) and no associations between change in sleep duration, quality of sleep, fatigue, or stress and RRI (P ≥ 0.23, Online Appendix Table A3).

Discussion

Our study aimed to determine whether week-to-week changes in sleep duration and quality and levels of stress and fatigue were associated with RRI in a sample of high school cross country runners. A significant interaction between change in stress and sex on odds of RRI was observed, with girls experiencing a greater odds of RRI than boys, given a 20% change in stress compared with the previous week. No statistically significant associations were observed between total sleep duration or change in sleep duration, sleep quality, or fatigue and RRI. This study is the first, to the authors’ knowledge, to describe these associations in this population of adolescent distance runners.

Although we observed an overall significant interaction between change in stress and sex on odds of RRI, with girls demonstrating an overall greater odds of RRI than boys at a given change in stress, the relationship between change in stress and RRI within each sex was only marginally significant. Among girls, a 37% increase in the odds of RRI was observed with a 20% increase in stress compared with the previous week (P = 0.07), whereas boys demonstrated a 39% decrease in the odds of RRI with a 20% increase in stress (P = 0.06). Although our findings among boys were unexpected, increased stress compared with the previous week being associated with an increased odds of RRI among girls is consistent with earlier work in youth athletes.^7,17 Boys experienced relatively few RRI compared with girls overall which contributed to large variability in the probability of RRI among boys (Figure 1), particularly when stress levels decreased by a large amount (eg, >10%). In addition, it is possible that factors we were unable to account for, given the limited number of RRI observed and number of variables already included in our models, could also influence changes in stress. Consideration of additional factors related to training, other sport participation, and other psychosocial characteristics may clarify the interaction between sex and stress that we observed in this study, and larger studies assessing these variables in youth runners are certainly warranted.

Previous research has identified an association between sleep habits and injury in a variety of sports, but our findings did not corroborate these results in adolescent runners. We also did not detect an association between change in levels of fatigue and RRI. Our study utilized prospective, daily surveys, while previous work finding worse sleep quality being associated with injury utilized postseason surveys or surveyed on a weekly basis.^6,17 Further, the definition of stress and fatigue, and how and when they are measured, is highly variable and may contribute to the mixed findings of previous research. For example, both 0 to 10 scales and 5-point Likert scales have been utilized, and stress and fatigue have been measured at preseason only or at weekly intervals,^7,17 whereas our study measured stress and fatigue daily and then aggregated it to a weekly total. Future work should aim to standardize the measure(s) and frequency of assessments used to quantify stress and fatigue, as well as sleep, to clarify the importance of these variables on subsequent injury risk.

As our findings were consistent across all survey completion groups (≥50%, ≥75%, and ≥90%), the relationships we observed were unlikely to be biased by intrinsic factors that may be associated with persons who demonstrated low or high completion rates. The lack of statistically significant associations between the predictors of interest, particularly change in stress, and RRI within the subsequent 2 weeks, as compared with the current week, suggests that the influence of a large change in stress may result in the runner having an altered risk of RRI only for a relatively short period (eg, 1 week).

As mentioned previously, there may be interactions between sleep, stress and fatigue, and other aspects of a runner’s training and lifestyle. For example, in a large sample of elite adolescent athletes from several sports, it was found that decreasing sleep duration while training load was increasing resulted in a greater risk of injury.²⁰ Sleep duration has also been shown to modify the independent associations between sleep quality, stress, fatigue, and injury in collegiate volleyball players.⁵ These findings highlight the multifactorial cause of injuries, and consideration of training and biopsychosocial data simultaneously is an important next step in this area of research.

Our study required runners to complete surveys on a daily basis, providing high precision for calculating week-to-week changes. However, this also increases the burden on the runners and created more opportunities for missing data. Several previous studies have utilized weekly, monthly, or 1-time surveys, with varying consistency of findings across studies. Therefore, determining whether daily surveys do, in fact, improve data quality or whether less frequent surveys provide similar data quality while improving daily availability is an important consideration for future prospective studies. In addition, RRI are typically defined by the onset of pain and not by seeking medical attention, which is why we relied primarily on runner self-report for RRI occurrence; as a result, it is possible RRI were underreported in this study, particularly for those in the ≥50% completion group. We also utilized a more stringent RRI definition of ≥7 days of pain or modified participation, in accordance with an RRI consensus statement,²³ which also may have resulted in a lower incidence of RRI observed in the present study compared with other studies.

While the present study is one of the first to assess the influence of sleep, stress, and fatigue on RRI in adolescent runners, some limitations should be noted. Only 37% of the runners completed over 75% of the daily surveys, which reduced the data available for our analyses. However, the runners included in the primary analysis were not significantly different from those who were excluded from all analyses (those completing <50% of the daily surveys), with the exception of proportion of runners sustaining an RRI, suggesting that our results are likely to represent the effects of sleep, stress, and fatigue on RRI in the entire sample. It is likely that fewer than expected RRI were observed in the <50% completion group due to underreporting of RRI resulting from missing daily surveys. Multiple imputation was considered as an alternative approach to the sensitivity analysis; however, utilizing multiple imputation with these data did not result in improved precision of the estimates than the current sensitivity analysis. This study also did not incorporate training metrics, which likely influence RRI risk and may interact with the variables assessed in the present study. Finally, our study was performed among high school runners in a single geographical region, and generalizations to runners of other ages or in other areas may not be appropriate.

Conclusion

Among high school cross country runners, the association between change in stress and odds of RRI differed depending on the runner’s sex; however, sex-specific associations were only marginally significant, with boys demonstrating decreased probabilities and girls demonstrating greater probabilities of RRI with greater increases in stress, respectively. These findings indicate that monitoring stress may be an important consideration when evaluating RRI risk in youth runners, but additional work is needed to clarify how boys and girls may respond to increased stress throughout a season. Further, we did not observe an association between sleep duration, quality, and fatigue, but our study is the first to assess these measures in youth runners. Continued evaluation of these variables as they relate to injury in high school runners would be beneficial.

Supplemental Material

sj-pdf-1-sph-10.1177_19417381231217347 – Supplemental material for Changes in Sleep, Stress, and Fatigue Were Not Prospectively Associated With Running-Related Injuries Among High School Cross Country Runners

Supplemental material, sj-pdf-1-sph-10.1177_19417381231217347 for Changes in Sleep, Stress, and Fatigue Were Not Prospectively Associated With Running-Related Injuries Among High School Cross Country Runners by Mikel R. Joachim, Bryan C. Heiderscheit and Stephanie A. Kliethermes in Sports Health

Footnotes

The authors report no potential conflicts of interest in the development and publication of this article.

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: UW-Madison Department of Orthopedics and Rehabilitation Freedom of Movement Fund; Virginia Horne Henry Fund for Women’s Physical Education; American Academy of Sports Physical Therapy Young Investigator Award.

ORCID iD

Mikel R. Joachim

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Supplementary Material

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