Introduction

Fencing is a combat sport characterized by rapid acceleration and decelerations, repetitive unilateral upper extremity movements, and asymmetrical lower extremity loading. These biomechanical demands create a unique injury profile that includes both acute traumatic injuries and chronic overuse conditions. As participation in competitive fencing spans a wide age range and often extends over decades, understanding how cumulative exposure related to injury burden is particularly important.

Prior studies of fencing injuries have largely focused on elite competition settings, emergency department presentations, or clinic-based cohorts which may overrepresent acute or medically attended injuries while under capturing training related and overuse conditions [1–6]. Emergency department surveillance studies, such as that by Stanicki et al. [7], have characterized acute injuries requiring urgent medical care, while clinical series have provided insight into injuries presenting for specialty evaluation. More recently, Cross et al. [8] reported a predominance of lower extremity injuries and a clear vulnerability of the dominant side in a clinical population. Similarly, a retrospective analysis of French elite fencers by Gondouin et al. [9] demonstrated a high overall injury burden with a predominance of lower extremity injuries, while also showing that nearly all upper extremity injuries involved the dominant weapon arm, highlighting the role of repetitive, asymmetric loading in this sport. Systematic reviews have likewise identified the ankle and knee as the most commonly reported sites of fencing-related injury [10].

Several studies focusing on competition-related injuries have similarly identified strains and sprains of the knee and ankle as the most common injury types [1,11]. An informal survey conducted by American Fencing magazine in 1992 likewise reported the knee and ankle as the most frequently injured body parts [12]. Although these studies contributed to early characterization of fencing injury patterns, they were largely limited to competition-based or clinical populations. Consequently, large-scale, population-based data capturing injuries sustained during both practice and competition and detailing injury mechanisms, anatomic distribution, and injury burden, particularly with respect to dominant versus non-dominant side involvement, remain limited. In addition, medically attended injury datasets may not capture chronic or recurrent conditions that do not prompt clinical evaluations, limiting insight into cumulative injury burden among long-term participants.

Reports of upper-extremity injuries in fencing, especially overuse conditions affecting the dominant weapon arm, have varied across study designs and populations. The highly unilateral nature of fencing, requiring repeated weapon handling, grip force, wrist extension, and forearm rotation, suggests that dominant-side upper-extremity injuries may be an important, but under characterized, component of fencing-related injury patterns. However, population-based data describing injury type, anatomical distribution, laterality, and mechanism across training and competition settings remain limited.

Understanding how training- related exposures contribute to injury burden presents additional challenges. Prior work suggests that greater training volume, longer participation history, and higher competitive level may be associated with increased injury risk, yet the form of these relationships is not well defined. Many studies have relied on categorization of continuous exposure variables, which may obscure a nonlinear dose-response patterns and limit interpretability. Analytic approaches that allow for flexible modeling of exposure-injury relations are needed to better characterize how cumulative and intensity related factors contribute to recurrent injury.

Accordingly, the objectives of this study were to: (1) describe the prevalence, mechanism and anatomic distribution, and laterality of fencing related injuries in a population based cohort of competitive fencers and (2) examine associations between training related exposures and reported injury burden. We hypothesize that greater cumulative exposure, reflected by training volume and years of fencing experience, would be associated with higher injury burden. To address potential nonlinear relationships, we modeled continuous exposure variables using restricted cubic splines within a multivariable framework.

Methods

Results

Participant characteristics and injury burden

Of 303 survey respondents, 270 (89.1%) reported at least one fencing-related injury and were included in descriptive analyses. Injury burden was categorized as no injuries, one to two injuries, or three or more injuries. Demographic characteristics were generally similar across injury burden groups (Table 1), with no significant differences in age or sex distribution.

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Table 1. Characteristics of study sample by injury burden (n = 303).

https://doi.org/10.1371/journal.pone.0344263.t001

In contrast, several indicators of cumulative exposure differed significantly by injury burden. Fencers with three or more injuries reported greater years of fencing experience, higher weekly training volume, greater competition participation, and higher competitive level compared with those reporting fewer or no injuries (Table 1).

Injury patterns, location, side and mechanism

Across the 571 reported injuries, overuse conditions, particularly tendonitis/tenosynovitis (26.4%), were the most frequent injury types (Table 2). Injuries most frequently involved the knee (18.2%) and ankle (11.7%), as well as the upper extremity, with a predominance of dominant-side involvement for upper-limb injuries. Non-contact and gradual-onset mechanisms accounted for the majority of injuries, and most injuries occurred during training rather than competition.

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Table 2. Most common injuries and body part affected, side of injury, and mechanism (N = 571).

https://doi.org/10.1371/journal.pone.0344263.t002

Upper-extremity injuries were significantly more likely to involve the dominant side compared to non-upper extremity injuries (χ² = 54.3, p < 0.001) whereas lower-extremity and trunk injuries were more evenly distributed. Detailed distributions of injury type, anatomical location, laterality, and mechanism are presented in Table 2.

Associations between exposure variables and injury count

Spearman correlation analyses demonstrated positive associations between injury count and cumulative exposure measures, including years of fencing (ρ = 0.30, p < 0.001) and weekly training hours (ρ = 0.13, p = 0.03; see Table 3). These bivariate relationships informed the multivariable modeling strategy.

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Table 3. Spearman correlation between training factors and injury (N = 303).

https://doi.org/10.1371/journal.pone.0344263.t003

Multivariable analyses of injury burden

Among injured fencers, multivariable logistic regression modeling the odds of experiencing three or more injuries demonstrated a statistically significant improvement in fit compared with an intercept-only model (see Table 4). Years of fencing experience showed a significant non-linear association with injury burden (overall Wald p = 0.002), with increasing odds of multiple injuries across the observed range. Weekly training volume demonstrated a non-linear association that approached statistical significance (overall Wald p = 0.06), with higher injury burden observed at moderate-to-high training levels and no further increase at the highest volumes. Age at starting fencing, number of competitions, and gender were not independently associated with higher injury burden after adjustment.

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Table 4. Multivariable logistic regression modeling the odds of experiencing three or more injuries (N = 263).

https://doi.org/10.1371/journal.pone.0344263.t004

As a sensitivity analysis, Poisson regression models using categorized predictors and injury count as the outcome yielded qualitatively similar findings. Years of fencing remained the most consistent predictor of injury outcomes, while associations with training volume were attenuated in the count-based models. Results of these categorical logistic and Poisson analyses are provided in Supplementary Materials S2 and S3 in S1 File.

Predicted probabilities of injury burden

To aid interpretation of the nonlinear models, predicted probabilities of experiencing three or more injuries were plotted across the observed ranges of weekly training hours and years of fencing (Fig 1). The predicted probability of higher injury burden increased steadily with years of fencing, consistent with cumulative exposure. In contrast, training volume demonstrated a nonlinear pattern, with highest predicted probabilities observed at moderate-to-high volumes and no further increase at the highest reported volumes.

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Fig 1. Predicted probability of experiencing three or more injuries by training exposure.

(A) Adjusted predicted probability of experiencing three or more injuries across total training hours. (B) Adjusted predicted probability of experiencing three or more injuries across years of fencing. Predictions were estimated from multivariable logistic regression models using restricted cubic splines. Curves are shown separately by gender (coded 0 and 1), with all other covariates held at their median values. The smooth curves illustrate non-linear associations between cumulative training exposure and injury burden.

https://doi.org/10.1371/journal.pone.0344263.g001

Discussion

In this cross-sectional survey of competitive fencers, injury burden was most strongly associated with cumulative training exposure, particularly years of fencing experience, with additional contribution from weekly training volume. Across analytic approaches, including bivariate correlations, spline-based regression, and Poisson regression sensitivity analysis, years of fencing consistently emerged as the most robust covariate of higher injury burden. This pattern supports an interpretation centered on cumulative exposure accumulates over time, rather than demographic characteristics or competition participation alone.

Descriptive analyses of 571 reported injuries provide important clinical context for these associations. Overuse injuries, particularly tendonitis and tenosynovitis, were the most common injury types, and injuries most frequently involved the knee, ankle, and dominant upper extremity. The predominance of gradual-onset and non-contact mechanisms highlights the contribution of repetitive loading rather than acute trauma. These findings align with the mechanical demands of fencing, which combine repeated unilateral upper-extremity actions with high- frequency lower-extremity loading during footwork and lunging.

The pronounced asymmetry observed in upper-extremity injuries, with a strong predominance on the dominant side, is clinically and biomechanically plausible. These findings both align with and extend prior clinic- and competition-based studies of fencing injuries. Similar to the clinical cohort reported by Cross et al. [8], we observed a predominance of lower extremity injuries, with the knee being the most frequently affected joint, along with clear dominance-side vulnerability. However, important differences emerge due to study design and population. Cross et al. examined injuries presenting to sports medicine and orthopedic clinics, capturing clinically evaluated cases that likely represent more acute or medically attended injuries. In contrast, the present population-based survey captured reported injuries occurring during both practice and competition, including overuse conditions such as tendonitis and tenosynovitis that may not prompt formal medical evaluation. Accordingly, we observed a higher proportion of dominant-side upper extremity overuse injuries, particularly involving the elbow, shoulder, and finger, which are likely underrepresented in clinic-based cohorts.

These findings are further supported by recent studies in elite fencing populations. A retrospective analysis of French elite fencers by Gondouin et al. [9] demonstrated a high overall injury burden with a predominance of lower extremity injuries, while also showing that nearly all upper extremity injuries involved the dominant weapon arm. Similarly, Thompson et al. [13], examining injuries among U.S. National Team and Olympic fencers, reported frequent lower extremity injuries, particularly involving the knee, along with marked laterality consistent with fencing’s asymmetric loading patterns. Together, these studies reinforce the biological plausibility of our observed injury distribution while highlighting that population-based surveys capture a broader spectrum of cumulative and overuse injuries beyond those presenting for clinical care.

The anatomical distribution of injuries observed in the present study reflects the asymmetrical biomechanical demands of fencing. Lower extremity injuries were most common at the knee and ankle, likely related to repetitive lunging, deceleration, and rapid directional changes intrinsic to fencing footwork. In contrast, upper extremity injuries clustered at the elbow, finger, and shoulder, consistent with repetitive weapon handling, gripping, and striking motions. The strong predominance of dominant-side upper extremity injuries further underscores the role of unilateral loading and repetitive stress in injury development. While lower extremity injuries were common, they were more bilaterally distributed, consistent with alternating propulsion, lunging, and recovery movements inherent to fencing footwork.

Compared with emergency department–based surveillance, such as the NEISS analysis by Stanicki et al. [7], our findings provide complementary insight into chronic and cumulative injury patterns across a wider range of fencing participation contexts. While Stanicki et al. similarly reported lower extremity injuries as most common, emergency-based surveillance inherently excludes overuse injuries and training-related conditions that do not result in emergency care. Likewise, the systematic review by Swatowska et al. [10] identified ankle sprains and lower-limb strains as the most frequently reported fencing injuries across heterogeneous study designs, while emphasizing substantial variability in injury definitions, settings, and athlete populations. Our findings build on this literature by characterizing reported injury burden across both training and competition settings and by explicitly examining cumulative exposure as a key determinant of recurrent injury.

The nonlinear association between training volume and injury burden observed in spline-based models further underscores the importance of flexible analytic approaches. Injury burden increased with training volume at lower to moderate levels, but did not rise uniformly at the highest training volumes. This pattern may reflect a combination of training adaptation, selective retention of more resilient athletes at higher levels of exposure or exposure modification following injury. Such dynamics could be obscured by linear or categorical models and highlight the value of spline-based methods for examining dose response relationships in sports injury research.

Notably, competition frequency was not independently associated with higher injury burden after adjustment, despite showing a positive bivariate correlation with injury count. This finding suggests that training exposure may contribute more substantially to cumulative injury burden than competition exposure alone, particularly for overuse conditions. Similarly, age at starting fencing and gender were not independently associated with higher injury burden in multivariable analyses indicating that exposure related factors outweigh demographic characteristics once participation history is accounted for.

With respect to generalizability, the sex and weapon distribution of the study sample appears broadly representative of adult competitive fencing in the United States. Epee was the most commonly represented weapon, followed by foil and saber, and male fencers comprised approximately two-thirds of participants across weapons, consistent with available USA fencing membership summaries (provided to the authors). Although the median age of respondents was relatively high, multivariable analyses indicated that cumulative fencing exposure rather than chronological age was most strongly associated with injury burden. Accordingly, these findings are most applicable to adult competitive fencers with extended participation histories and may not directly generalize to youth or early-career athletes.

Limitations

Several limitations should be considered. First, the response rate was low (2%), introducing a substantial risk of selection bias and limiting external validity. Although this response rate is comparable to that reported in other USA Fencing surveys [14], it does not mitigate the possibility of non-response bias. Respondents may differ systematically from non-respondents, particularly with respect to injury history, engagement with the sport, and training exposure. The low response rate also limits external validity and generalizability. As a result, absolute injury prevalence and injury counts in this sample are likely overestimated relative to the broader competitive fencing population. However, the primary aim of this study was to characterize injury patterns and examine associations between cumulative exposure and injury burden rather than to generate precise prevalence estimates. While selection bias may distort absolute injury frequencies, the observed relationships between training exposure and injury are internally consistent, biologically plausible, and aligned with prior clinical and epidemiologic studies of fencing. Accordingly, the results should be viewed as exploratory and hypothesis-generating, intended to inform future prospective surveillance rather than definitive risk estimates.

Additional limitations include the cross-sectional design, which precludes causal inference, and injury histories were self-reported and limited to the five most severe injuries, resulting in truncated counts. This constraint likely contributed to underdispersion in count-based models and motivated the use of injury burden as clinically meaningful outcome. Exposure measures were also self-reported and may be subject to recall bias. Despite these limitations, the consistency of findings across descriptive analyses, correlation analyses, spline-based logistic regression and Poisson sensitivity models support the robustness of the observed associations.

Taken together, these findings emphasize the clinical relevance of cumulative exposure and asymmetrical loading in fencing-related injuries. Monitoring training volume, promoting balanced strength and conditioning, and incorporating recovery strategies may be particularly important for mitigating recurrent injury burden among long-term participants. Future prospective studies incorporating longitudinal exposure tracking and standardized injury surveillance are needed to better define temporal relationships and inform targeted, evidence-based injury prevention strategies in fencing.

Conclusion

In this cohort of adult competitive fencers, higher injury burden was most strongly associated with cumulative training exposure, particularly years of fencing experience with additional contribution from weekly training volume. Descriptive analyses demonstrated that overuse injuries predominated and most frequently involved the knee, ankle, and dominant upper extremity, with pronounced asymmetry favoring dominant-side upper-limb injuries. Together, these findings suggest the recurrent fencing related injury reflects sustained, asymmetrical mechanical loading accumulated over time rather than isolated acute events.

The nonlinear relationships observed between training exposure and injury burden highlight the importance of monitoring cumulative load and considering adaptation and recovery in long-term participants. These results emphasize the potential value in training loan management, balance strength, conditioning, and recovery strategies in mitigating recurrent injury burden among adult competitive fencers. Future prospective studies incorporating longitudinal exposure tracking and injury surveillance are needed to better define temporal relationships and inform targeted injury prevention strategies.

Supporting information