Sleep Apnea in Athletes: Fit Does Not Mean Immune
Ten of twenty-two professional rugby league players had sleep apnea on a home sleep study. The risk factors that drive it in the general population are the ones collision sports deliberately build.
Sleep apnea is filed mentally under middle-aged and overweight, which makes it easy to dismiss if you are neither. The problem is that the two strongest anthropometric predictors are body mass and neck circumference — and some sports deliberately maximise both.
The rugby data
An observational study of 22 professional rugby league athletes put each of them through a night of home polysomnography.
Seven had mild sleep apnea and three had moderate. Ten of twenty-two — in a group of elite professional athletes.
The distribution within the squad is the interesting part. Of the seven with mild apnea, six were forwards. Of the three with moderate apnea, two were forwards. Forwards are the heavier, thicker-necked positional group, and the pattern follows body composition rather than fitness.
Higher BMI was associated with a moderate increase in AHI (r=0.38, p=0.04). There was also an ethnicity signal, with a difference in REM-AHI between Polynesian and European-Australian players (effect size 0.90, p=0.02) — worth noting because Polynesian players are heavily represented in forward positions, so body composition and ethnicity are entangled here rather than cleanly separable.
It is a small study. Twenty-two players, one night each, exploratory by the authors' own description. Treat the 45% figure as a signal that the prevalence is non-trivial in this population, not as a precise rate.
What the wider review says
A 2026 review of eleven studies published between 2015 and 2025 found a substantial prevalence of sleep apnea in athletes, particularly in collision sports such as rugby and American football, with higher BMI and increased neck circumference consistently associated with increased risk.
It also lists what the apnea costs: reduced sleep quality, hormonal disruption, excessive daytime sleepiness, and slower reaction times.
For an athlete, that list is the whole argument. Sleep is where adaptation happens — if your nights are fragmented, your training load is not being converted into gains at the rate your programme assumes. Slower reaction times are a performance problem and, in a collision sport, a safety one.
Evidence tier 2. Prevalence in collision-sport athletes is consistently reported across small studies, and the anthropometric association is strong and mechanistically obvious. The performance and recovery consequences are plausible and less rigorously quantified.
Why fitness is not protection
Because the mechanism is anatomical, not aerobic.
Obstructive apnea happens when the upper airway collapses during sleep. Soft tissue around the pharynx, tongue volume, and the mass of the neck pressing in all make that collapse more likely. A large neck narrows the airway whether the tissue underneath is fat or muscle. Cardiovascular fitness does not hold the airway open at three in the morning.
This is why a 110 kg forward with 10% body fat and a 45 cm neck can have a genuinely obstructive airway, and why "but I'm in good shape" is not a reason to discount the symptoms. Why neck circumference beats the scale.
There is a second loop worth knowing about: apnea suppresses testosterone, and lower testosterone works against the training adaptation athletes are chasing. Snoring, apnea and testosterone.
What to do about it
Get tested rather than reasoning about it. A home sleep study is straightforward and the alternative is guessing. The symptoms to act on are witnessed breathing pauses, gasping or choking arousals, waking unrefreshed after adequate hours, and daytime sleepiness that more sleep does not fix. What testing involves.
Be alert to the symptoms that get misattributed. In an athlete, persistent fatigue, poor recovery, irritability and flat training performance get blamed on load, nutrition or overtraining. A fragmented airway produces all of them, and it is the explanation nobody checks.
Do not accept "you're too fit for that." You may need to push for assessment. The anthropometric profile that makes a good forward is the same profile the screening questionnaires flag.
Treatment is the same as for anyone else, and CPAP works regardless of your training history. An oral appliance is a reasonable alternative where apnea is mild to moderate — there is even a study of mandibular advancement devices specifically in rugby athletes with poor sleep quality. CPAP alternatives, ranked.
And weight is a complicated lever here. Advising an athlete to lose mass they built deliberately for their position is not straightforward, which makes the non-weight treatments disproportionately useful in this group. How weight relates to the airway.