BREAST IMPLANT INJURIES AND BACK TO COMPETITIVE STANDARD

Breast implant injuries and back to a competitive standard

BLUF

With  the  increasing  number  of  females  with  breast  implants  participating  in advanced  competitive  sports,  this  pilot  study  determined  that  secondary  breast trauma injuries where more problematic due to lengthier recovery and rehabilitation times when compared to the primary injury.

ABSTRACT

The injury epidemiology of competitive female athletes with breast implants was examined as a pilot study to provide a basis for injury recovery, rehabilitation and return to a competitive standard initiative in semi-professional, professional and elite athletes. Retrospective injury data from a statistical survey and selected biographical and training information were obtained via a one-page survey. Five female athletes (three self reporting and two reported by athletic staff) participated; these athletes were competing at various levels (semi-professional to elite level) of varying ages and sports. Injury was defined as any physical damage to the breast implant that caused the athlete to miss a competition or miss or modify one or more training session. Of note, most injuries occurred during training (80%) rather than competition (20%), with the most commonly reported injury sites including the pectoral muscles (40%), ribs (40%) and rotator cuff (20%). A total of 10 injuries (breast implant plus any secondary injuries) where reported. This equated to 2.0 1.0 secondary injuries per athlete per breast implant injury. The reported return to competitive standard time were 28.6 13.7 weeks, respectively. The nature of the secondary breast trauma injuries were more problematical due to the duration in recovery and rehabilitation, as compared to the primary injury. These findings offer vital information regarding the design of improved recovery and training strategies for female athletes with breast implants. Such strategies may include greater attention to the training program variables (e.g. warm-up procedures, training volume and intensity) and/or focusing on upper body musculature and range of motion imbalances. Alternately, performing functional movement screens to ascertain and/or identify compensatory movement patterns indicative of increased injury risk and inefficient movement thus reducing performance may also be beneficial.

Introduction

The number of females participating at semi-professional, professional and elite level sports (individual and team sports) is increasing, as is various athletes’ desire to look more aesthetically pleasing. Thus, issues concerning breast implant injuries must be addressed to ascertain the types of injuries, recovery time and rehabilitation time required for the athlete to return back to a competitive standard. This pilot study will investigate the type of breast injury and time negated from the athletes training and competition schedule. This specific project will provide input from athletes as well as athletic and medical staff. Given the popularity of social media playing a significant role in advertising, female athletes are often portrayed in sexualized poses, dressed in revealing clothing or pictured in clothing outside of their uniform (1). For these reasons athletes are strongly exposed to sport and sociocultural pressure regarding their weight and body shape (2). These factors are also promoted by the media as important for an athlete to have an attractive appearance and ideal body shape (3). As a result, breast augmentation of submammary and submuscular procedures among female athletes at a competitive level are becoming increasingly popular as can be seen on social media platforms such as Facebook and Instagram.

Submammary vs Submuscular

However, it is apparent that a number of gaps still exist within literature that addresses breast augmentation and associated injuries among female athletes. Gaps identified in the data/literature include: the onset of injury; how long the athlete has had the breast implant; minor injuries that affect training due to the breast augmentation; the rehabilitation approach used by athletes to recover from breast implant injuries; and intrinsic factors affecting the injury epidemiology of the athlete.  Accordingly, helpful data would also include type of breast implant, required recovery and rehabilitation, duration of injury, the sport played, time required to resume a competitive standard, total number of breast implant injuries the athletes has sustained, and if any protective equipment was worn.

 

Although retrospective surveys have some limitations for injury epidemiology research (4, 5), the present study sought to mitigate these effects.  First, it is argued that support staff such as strength and conditioning coaches often meticulously record their athletes daily training sessions in a training diary such as an excel spread sheet.  These diaries would allow better recall, in a retrospective manner, of information relevant to a study of injury epidemiology than compared to other athletes completing a lower level who likely do not record their training sessions.  Nevertheless, it has been shown that the validity of determining the injury type (e.g. sprain, strain, etc.) in retrospective injury surveys is not high even when the injury was assessed by trained medical personnel (5).  Concerns regarding the validity of injury type data in retrospective injury surveys for resistance training have also been expressed (6).  Accordingly, questions were asked regarding how the injury was sustained (i.e. training, tackled, landed wrong) and what, if any, additional injuries were sustained.

 

There are limited published studies investigating breast implant injuries that occur among female athletes at semi-professional, professional and elite levels.  Furthermore, no studies have investigated the effects of the breast implant rehabilitation, recovery and time to return to a competitive level. Therefore, the aim of this study was gather and examine statistical data with the purpose of protecting against injuries or limit the time from recovery to competitive standard for athletes who underwent cosmetic procedures, particularly breast augmentation, while participating in their respective sports at advanced levels.

METHODS

Approach to the Problem:

The present study used a retrospective injury survey involving categorical and open-ended multiple-choice questions to further examine the injury profile of competitive athletes’ breast implant injuries.  In particular, this study sought to examine how four factors, namely, the incidence of any breast implant injuries reported by athletes or staff, severity of breast injury, reported time of recovery, and how reported time in rehabilitation and total competing time lost affected the athlete’s ability to return to a competitive standard (7). 

Subjects:

The majority of the subjects (65%) for this study were recruited by posting notices on social media and web-based forums associated with weightlifting and sports, which were redirected to the participation information fact sheet and survey link. A small number (30%) of athletic/medical/coaching staff also participated in the survey. A small number (< 5%) of subjects were recruited/approached at various state and national sports competitions held in Australia.  Of the athletes approached at these competitions, only one was eligible to participate. As a result of these recruitment strategies, three female and two athletic/medical/coaching staff participated in the survey.  To be eligible for participation, the female athlete must have a current or previous breast augmentation implant injury caused by sporting competition, in training, or must be athletic or medical staff working with a female athlete with a breast augmentation injury who competes at an elite, professional or semi-professional level. A participant Information sheet was cited prior to completing the survey (see Figure 2). All procedures used in this study complied within the guidelines of Mayhem Fitness PTY LTD.

Participation Fact Sheet

Procedures:

For the purposes of this study, an injury was defined as any physical damage to the body that caused the athlete to miss one or more training sessions or miss a competition (4,7-9). Breast implant was defined as constructive surgery to increase breast size cosmetically (10).  Which sport was the athlete involved in (e.g. equestrian, powerlifting, Olympic lifting, sprinting), information on the incidence of any breast implant injuries reported by athletes or staff (e.g. role, athlete, coach, doctor, physiotherapist, other), reporting time of injury recovery (e.g. time in weeks), additional injuries sustained (e.g. rotator cuff, shoulder dislocation, pectoral minor), reporting time in rehabilitation and total training and/or competing time lost (e.g. time in weeks). It was also deemed necessary to ascertain the type of implant (e.g. saline, silicon, unknown), mechanism of injury (training, tackled, landed wrong), if protective equipment was worn (e.g. supportive bra, chest plate), how many breast augmentation injuries has the individual completing the survey been involved in (e.g. number) and any other information that may be relevant was also obtained when possible (e.g. pain and program/exercise modification).

The effect of the injury on the athlete’s training was quantified in how the training program had to be modified or discontinued, and by the exercises that were modified and/or discontinued.  A mild effect meant that the athlete had to modify their execution of an exercise; a moderate effect meant that the athlete had to stop performing an exercise; and a major effect meant that the athlete had to cancel all training sessions for at least one week. Regardless of mild, moderate or major effects they all came under the injury profile.  A somewhat similar approach was recently used to assess injury severity in the prevention of sports injuries among children (11). Recovery options include: no treatment (rest), self-treatment (e.g. ice, strapping, supportive bra and massage), and medical treatment (e.g. general practitioner and plastic surgeon). Rehabilitation options include: no treatment (rest), self-treatment (e.g. ice, strapping, massage), medical treatment (e.g. physician, physiotherapist or chiropractor), and work with coaches (strength and conditioning coaches, personal trainers, other programs).

 

Data Analyses

Means and standard deviations (SD) were calculated for the subject characteristics of recovery rate, injury rate and total time from injury to resuming competition. Recovery and injury rates were quantified in two ways: the total time in weeks per recovery period per athlete with a breast augmentation; and the number of weeks injured per secondary injury site. For all other dependent variables, the number and percentage of total values were calculated. 

Results were calculated for the entire sample, as well as for the various sub-groups of breast implant injuries, how the injury was sustained (training, competition), if any additional sub-injury was sustained, the role played by supporting staff, how many other breast augmentation injuries the athlete has endured and if the athlete wore any protective equipment due to the nature of the sport played or to reduce breast implant movement during competition (12-13).

Statistical Analyses

An analysis of data from a series of five case studies were used to determine if any significant differences existed in the demographics or injury epidemiology of the athletes as a function of recovery, rehabilitation and competitive standard or sport.  Statistical significance was set at p < 0.05 (14). All analyses were performed using Microsoft Excel.

 

Results

The results of this study are presented in Tables 1 and 2.  Each Table includes data for the entire sample of five female athletes as well as for the sport involved, how the injury was sustained, additional injuries, protective equipment worn and previous breast implant injury sub-groups.

 

Table 1.  Athlete information

 

 

 

 

Role / Reported by

 

                   Implant type

 

 

 

 

 

Athletes    (n = 3)

 

 

Athletic staff

(n = 2)

 

Coach

(n = 0)

 

 

Doctor

(n = 0)

 

Physio

 (n = 0)

 

Saline

(n = 0)

 

Silicone

(n = 5)

 

Unknown

(n = 0)

 

 

 

 

Sport Involved

 

 

 

 

 

 

 

 

 

 

 

 

Weight lifting

1 (20.0%)

1 (20.0%)

  0 (0.0%)

   0 (0.0%)

  0 (0.0%)

  0 (0.0%)

1 (100.0%)

  0 (0.0%)

 

 

 

Sprinting

1 (20.0%)

0 (0.0%)

  0 (0.0%)

   0 (0.0%)

  0 (0.0%)

  0 (0.0%)

1 (100.0%)

  0 (0.0%)

 

 

 

 

 

 

How injury was sustained

Equestrian

Body Building

0 (0.0%)

1 (20.0%)

1 (20.0%)

0 (0.0%)

 

  0 (0.0%)

  0 (0.0%)

0 (0.0%)

0 (0.0%)

  0 (0.0%)

  0 (0.0%)

  0 (0.0%)

  0 (0.0%)

1 (100.0%)

1 (100.0%)

  0 (0.0%)

  0 (0.0%)

 

 

 

Over-use

0 (0.0%)

1 (20.0%)

  0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

1 (100.0%)

0 (0.0%)

 

 

 

In Training

3 (60.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

3 (100.0%)

0 (0.0%)

 

 

 

Comp

0 (0.0%)

1 (20.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

1 (100.0%)

0 (0.0%)

 

 

Additional Injuries

 

 

 

 

 

 

 

 

 

 

 

 

Rotatory Cuff

1(14.3%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

1 (100.0%)

0 (0.0%)

 

 

 

Pectoral Major/Minor

1(14.3%)

1(14.3%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

2 (100.0%)

0 (0.0%)

 

 

 

Rib

1(14.3%)

1(14.3%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

2 (100.0%)

0 (0.0%)

 

 

 

None

1(14.3%)

1(14.3%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

2 (100.0%)

0 (0.0%)

 

 

 

 

Protective equipment worn

 

 

 

 

 

 

 

 

 

 

 

 

Yes

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

 

 

 

 

No

3 (100.0%)

2 (100.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

 

 

 

Previous Breast implant injury

 

 

 

 

 

 

 

 

 

 

 

 

Yes

2 (66.6%)

2 (100.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

 

 

 

 

No

1 (33.3%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

0 (0.0%)

 

 

 

Athlete injury data and the time in weeks in which the athlete was at each stage (recovery, rehabilitation and competitive standard), and what type of breast implant the athlete had are presented in Table 2.  Table 2 indicated that the athlete takes a mean average of 9.5 weeks in the recovery zone, rehabilitation zone mean average of 9 weeks and a mean average of 26.6 weeks back to a competitive standard. The most frequently injured body regions when a breast implant injury occurred during training or competition were the pectoral and rib regions. All breast implant injuries sustained where of a silicon compound nature. Of note, silicone implants are the most common implant of 2019 as outlined in a study by the United States Food and Drug Administration Large Postapproval (LPAS).  Of the 99,993 patients included in this study, 56% of implants were listed as silicone for primary augmentation (15).

Table 2. Recovery, rehabilitation and back to competitive time of the athlete.

 

 

 

Reported time (in weeks)

 

   Implant type

 

 

 

Recovery    (n = 5)

 

 

Rehab

(n = 5)

 

Back to Competitive Standard

(n = 5)

 

 

 

 

Saline

(n = 0)

 

Silicone

(n = 5)

 

Unknown

(n = 0)

 

 

 

 

 

Injury time

9.5 2.2

9 

28.6 37

 

0

5 0.0

0

 

 

Participant 1

8 (21.6%)

8 (21.6%)

21 (56.8%)

 

0 (0.0%)

1 (100%)

0 (0.0%)

 

 

Participant 2

12 (16.7%)

10 (13.9%)

50 (69.4%)

 

0 (0.0%)

1 (100%)

0 (0.0%)

 

 

Participant 3

12 (22.6%)

6 (11.3%)

35 (66.1%)

 

0 (0.0%)

1 (100%)

0 (0.0%)

 

 

Participant 4

7.5 (20.0%)

11 (29.3%)

19 (50.7%)

 

0 (0.0%)

1 (100%)

0 (0.0%)

 

 

Participant 5

8 (22.2%)

10 (27.8%)

18 (50.0%)

 

0 (0.0%)

1 (100%)

0 (0.0%)

 

 

Injury times are presented as mean standard deviation (SD).  All other results are presented as number in weeks and percentage (in parentheses) of occurrences.

 

Discussion

Breast implants are placed either above or below the pectoral muscle, according to the patient’s lifestyle, aesthetic goals, and other factors. Sub-muscular placement requires an incision in the skin and separation of a portion of the pectoral muscle to place the implant. This is often the recommended placement for females who desire the most natural-looking results. Breast augmentation is an aesthetic procedure that in most cases does not enhance the athleticism or increase an athletes potential to win in a sport. However, the importance of the aesthetic look does enhance the athlete’s potential to obtain endorsements from companies due to increased sex appeal of the athlete (17-20). Therefore, some members of the public, sporting, medical and scientific communities may believe that breast augmentation is an approach that an athlete can take to be more confident within their sport. However, as previous and ongoing studies have not provided any long-term data regarding the link between breast augmentation and obtaining endorsements for the athlete, nor were any studies cited for which specific sports are more likely to have breast augmentations, future research is needed to investigate ths hypothesis.

 

Entire Sample:

The incidence of injury, recovery, rehabilitation and return to competitive standard observed in the present study appears relatively consistent with the majority of the breast augmentation literature that was cited in regard to breast implantation and sports (6,7,15,16,24,31).

 

As well as quantifying the breast implant injury, it was also considered important to determine which muscle groups were associated with a breast implant injury in relation to a secondary injury profile.  This information may also assist a rehabilitation team better determine the presence of a performance detriment, the initial breast implant injury or if a more significant secondary injury occurred.  The results revealed that three common associated injuries of pectorals (40%), ribs (40%), and rotator cuff (20%) all had a greater likelihood of a lengthier recovery then that of the breast implant injury alone. Previous studies show that a pectorals tendon repair can take up to 16 weeks for the return of full range of motion (RoM) (21), up to 4 weeks for rib injuries (22), and a rotator cuff full thickness tear can require up to 12 weeks for functional recovery and 52+ weeks for stabilisation (23). Rehabilitation is required to minimise the severity of injury, thus allowing the athlete to resume training and competition as soon as possible.  The athletes in the present study appeared to be relatively diligent with their injury treatment and used qualified health professionals when required.

 

Effect of Breast Implant Age in collation to injury occurrence:

Rupture and/or deflation rates of 3% to 5% and 7% to 10% have been reported at 3 and 10 years after insertion of saline breast implants, respectively (24). Studies regarding the lifespan of saline implants have shown that rupture occurs in 10% of these implants during the first 10 years after insertion (24).

Breast Implant vs. Ruptured Implant

A previous study noted that saline implants have a short life span, but ruptures are easier and safer to diagnose thus leading to fewer complications. Rupture of previous-generation silicone implants are often overt, and may lead to health problems at any time, including an increased risk of cancer. For older silicone implants, close follow-up is required to detect deterioration before rupture occurs. Consideration should be given to replace these older silicone implants to a cohesive gel silicone implant. Cohesive breast implants appear to offer major advantages over their predecessors, but they have been in use for less than 10 years, so further studies are required to evaluate their long-term effects. For silicone implants, ruptures were identified at a mean of 12 years after insertion, which was substantially longer than the time for saline implants. This is likely to be related to the silicone shell being thicker than the saline implant’s shell, and the silicone shell’s lower likelihood of being damaged during implantation (25-26).

 

Effects of recovery 

Initially it appears that recovery in athletes who experience breast implant injuries that require implant replacement during the recovery phase have a duration

 

significantly longer than those reported in other literature (27-28). With athletes showing a mean average of 9.5 weeks  (9.5 2.2) to have a significant influence on the injury profile of recovery, where as other literature shows a return to physical activity over a course of three weeks (27).  Therefore, athletes may participate in non-evasive day-to-day duties with minimized physical activity after breast implant surgery of three to seven days (mean average time absent from work is 6.6 days) (28).  The recovery methods may include: compression garment, bandage/wrapping, supportive bra (no underwire), and massaging the breast area in a downward motion while using the opposite hand to massage the opposite breast, thus maintaining a larger space within the scar capsule than the diameter of the implant (27). It is recommended that athletes who compete at a semi-professional, professional or elite level take into account that due to the nature of their training it will likely take 9.5 weeks (9.5 2.2) to complete their recovery. However, more studies are needed to ascertain the difference between semi-professional, professional and elite athletes and general fitness enthusiast to better understand the needs of these different athletes.

Supportive bra no underwire
Compression garment
Massage

Effect of Rehabilitation

Initially it appears that the rehabilitation duration of a breast implant injury with implant replacement is 9 weeks (9 ), which also has a significant influence on the injury profile of the rehabilitation phase. After a lengthy rehabilitation process, existing literature shows that athletes are concerned about re-injuring themselves while returning from the initial injury (29). They also worry that they may not be able to perform at the same standard post injury as pre-injury. During the injury epidemiology the survey found that three common associated injuries that were also addressed during the rehabilitation process were injuries of the pectorals (40%), ribs (40%), and rotator cuff (20%). As a consequence of the breast implant injury chest injuries, rib injuries and shoulder injury rehabilitation (21-23) have an increased rehabilitation time as compared to initial injury of the breast implant replacement. These associated injuries also have a direct effect on the athlete’s training performance.  No other study has assessed athletes with breast implant injuries at a semi-professional, professional and elite levels to determine what is more important for rehabilitation of the initial breast implant replacement or the secondary injury. Therefore, further extensive studies need to be conducted to ascertain injury epidemiology and to the effect of these associated injuries on their training.

Effect of Competitive standard  

Initially it appears that the rehabilitation of a breast implant requiring implant replacement has a duration of 28.6 weeks (28.6 37). For replacement to significantly influence the competitive standard and back to competitive standard, data reveals it will take a mean average of 28.6 weeks for an athlete to again be competitive within their sport.  Other studies have evaluated the effect of injury epidemiology rate across multiple spots (30), however no studies were citied for competitive standard of injury epidemiology. As the athlete is attempting to resume competition it is important to note that 60% of the injury profiles suggested that the previous breast implant injury occurred during training with an additional 20% from overuse. Irrespective of competitive standard, the chest, ribs and shoulders were the three most frequently injured sites. For these reasons, in regard to getting an athlete back to being competitive, the athlete may need to pay more attention to the training program variables (e.g. warm-up procedures, training volume and intensity) and/or address upper body muscular and RoM imbalances.  Alternately, performing functional movement screens (FMS) to ascertain and/or identify compensatory movement patterns indicative of increased injury risk and inefficient movement resulting in reduced performance may also be beneficial. Further research regarding breast implant injury epidemiology should use a prospective cohort or case-controlled design to examine the effect of these and/or other intrinsic factors (e.g. anthropometric profile, muscle in-balance, flexibility, etc.) on injury profile as well as assess the effect that various interventions may have on a physiological injury profile.

Breast implant type and protective equipment worn

The study has shown that the most common breast implant type is silicone, which aligns with other studies such as the LPAS (15). The use of chest protection in female sports is rare and the efficacy and use of such protection should further be explored.  This study revealed that 100% of female athletes were not wearing any type of protection beyond their normal sports bra. It has been determined in other studies that among premenarchal females, breast trauma can potentially lead to future breast asymmetries during development (31).  For this reason, chest protection is needed at all levels of female sports, including adolescent athletes, thus ensuring early education of female athletes regarding the importance of breast protection.

Practical Applications

Consistent with the literature, the present pilot study found that the majority of breast implant injuries, have a secondary injury that affected the shoulder, ribs and/or pectoral muscles (both pectoral major and minor). Nevertheless, this pilot study has shown that breast implant injuries in athletes who require surgery indicated that the initial breast implant injury has a faster recovery and back to competitive standard then the secondary injuries that where presented.

  • Recovery method of self-treatment (g. ice, strapping, supportive bra and massage) are not seen as sports specific recovery methods, although they appear to be the most effective training method to transition the athlete into a quicker rehabilitation phase.
  • The main emphasis of rehabilitation of a breast implant injury is to address the secondary injury or the injury with the lengthiest time of recovery and rehabilitation. Pectoral muscle, shoulder muscle and rib injuries have a lengthier and more intensive rehabilitation duration then that of the initial breast injury. It is also important RoM testing, FMS or flexibility testing are performed to ensure the athlete is appropriately progressing through rehabilitation. Emphasis should be placed on pectoral muscle length, shoulder mobility and a pain free rib cage with movement to ensure the athlete can transition to a more complex training stage in preparation for resuming competition.
  • Returning to a competitive standard at a semi-professional, professional and elite level can only be achieved once the recovery and rehabilitation phase is fully complete. For an athlete to resume competing correct functional training and movements must be tailored in a sports specific manner to achieve a positive outcome. During the competitive phase the athlete can return to full training under load. (E.g. strength, conditioning and sports related movement).
  • The findings from this pilot study may help answer question regarding the key focus for a breast implant injury for practitioners and also a major step prior to the design and implementation of specific recovery and rehabilitation programs.

It is also important for athletic staff to know that medication such as Nonsteroidal anti-inflammatory drugs (NSAIDs) maybe be prescribed however it is advised to check https://www.asada.gov.au to ensure such prescriptions do not violate the anti-doping policy for the athlete’s chosen sport.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest or bias opinions with respect to the breast implant procedures, research, authorship, and/or publication of this article.

 

 

Acknowledgements

No external sources of funding were provided during this research. The authors would like to thank the athletes and support staff that took part in this study. The author(s) would also like to thank the team at National Academies Press for the use of their copyright (figures 1 and 3).

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