Introduction
Over the past few years, there have been significant advances in the field of injury prevention across several sports. Yet there is ongoing debate about our ability to truly and confidently prevent harm. The ultimate global goal is to minimize the risk of injury. This can be done by identifying factors that may increase risk. The aim, then, is to try and reduce the individual’s propensity for injury.
Larger studies have shown positive outcomes for physical activity-based prevention programs but there are still gaps between research findings and the application of these findings to real-world settings. Physical therapists tend to follow long-term, modifiable habits such as dynamic strength proprioception and movement awareness. By influencing these factors, risk can be modified and therefore an individual’s propensity to be injured can be reduced.
Read more on Musculoskeletal Injury Risk Assessment.
Modifiable Risk Factors
- Proprioception
- Strength
- Range of movement
- Movement skill
Evidence for Proprioception (Stability Training) for Injury Prevention
There is a link between poor static balance and ankle and knee ligament injuries and static balance training has been found to reduce the incidence of ankle and knee injuries.
- Trojian and McKeag[1] found an association between pre-season performance on a single-leg balance test and ankle weakness throughout the season.
- Oshima et al.[2] indicated that poor static balance is an additional risk factor for ACL injury and that proprioceptive training may be effective and clinically relevant in ACL prevention.
- Rivera et al.[3] concluded that proprioceptive training programs are effective in reducing the incidence of ankle sprains in a group of athletes including those with and without a history of ankle sprains.
There is a correlation between strength imbalance and injury. The dynamic balance test is the Star Excursion Balance Test (SEBT). If you are unfamiliar with this test, then watch the video below.
The available evidence for the SEBT is:
- Anterior reach on SEBT
- Low performance on the SEBT anterior reaching direction (ANT) may increase the risk of ankle ligament injury.[4]
- Stiffler et al.[5] reported that assessing bilateral asymmetry along the anterior axis of the SEBT may identify individuals prone to knee and ankle injuries without intervention.
- Ko and others.[6] investigated dynamic balance as a risk factor for ankle injury in adolescent soccer players and found that the chances of ankle injury were increased in individuals with low SEBT – ANT scores (<64%) four times.
- Bliekendaal et al. [7]reported that lower scores on the standardized SEBT – ANT as a measure of dynamic balance were associated with an increased risk for subsequent ankle injury. However in this study this was significant only in male participants and not in females.
- Postero-medial reach in SEBT
- Attenborough et al.[8] investigated the risk factors for ankle sprains in netball players and found that a low posterior-medial distance of reach was associated with ankle sprains (sloping less than or equal to 77.5% of leg length); are in relationship.
- Ruffe et al.[9] reported an increased incidence of hip/hip/knee running-related fractures in runners with a postero-medial reach difference > 4cm.
- Postero-lateral reach in SEBT
- Impaired function in the posterior-lateral (PL) motion of the SEBT is a risk factor for ankle ligament injury in active individuals.[10]
- Johanson et al.[11] reported a significant difference in scores on the SEBT-PL in individuals with femoroacetabular impingement (FAI) compared with individuals without FAI. Individuals with FAI reported significantly lower scores on the SEBT-PL and increased risk of pain and symptoms. This testing is a valid test for pain and other symptoms in individuals with FAI.
Improving static and dynamic balance can reduce the risk of ankle and knee injuries.
Evidence for Range of Movement
- Poor hamstring flexibility is not associated with an increased risk of hamstring injury. Green et al.[12] reported that no factors related to flexibility and range of motion were clearly associated with risk of lower extremity injury. Common tests include: passive knee extension active knee extension passive straight leg raise and slump test.[12]
- A limited hip abduction range of motion does not increase the risk of hip flexor injury. Whittaker et al[13] systematic review of risk factors for hip injuries in sport confirmed that there is little evidence of an association between hip range of motion and hip in between injuries.[13] Current the systematic review did find decreased hip abductor range of motion as a risk factor for groin/hip injury in field-based sports. However, a number of sports were considered in this study and both hip and thigh injuries were analyzed.[14]
- Quadriceps weakness (as determined by the modified Thomas test) was reported as an independent risk factor for hip injury in Australian rules football players; players with greater flexibility were 70% less likely to sustain a hip injury.[15]
- Limited ankle dorsiflexion range is not a risk factor for calf muscle injury.[16]
- Ankle dorsiflexion range did not predict stress fractures of the tibia or foot in military recruits.[17] [18] .
- Dorsiflexion range and knee injury
- Fong et al.[19] reported that increased dorsiflexion range of motion was associated with greater knee flexion and smaller forces acting on the ground during landing – ie. landing position with decreased risk of anterior cruciate ligament (ACL).
- There is strong evidence for an association between reduced/limited ankle dorsiflexion and active knee valgus. It is therefore recommended that ankle dorsiflexion range of movement assessments be included in clinical practice because limitations in range may cause individuals to perform them lower motor organ injury.[20]
Improving ankle dorsiflexion range of movement may be beneficial in injury prevention but improving jaw muscle flexibility will not prevent hamstring injury.
Evidence for Strength
- Hip abduction weakness in single-leg balance tasks is related to poor postural control. Failure to maintain posture and balance may increase the risk of ankle fracture.[21]
- Hip abduction strength and knee valgus angle are significantly correlated in single-leg ballistic tasks[22] but the correlation with injury is limited and further research is needed.[23]
- Gnee valgus angle and duration of landing work influence gluteal muscle strength. Impact rates vary across tasks such as single leg landing and landing tasks as well as between genders.[24]
- Decreased isometric hip abductor strength can predispose individuals to noncontact posterior fractures.[25]
- Trunk and hip muscle performance and motor control are significant contributors to ACL injury risk.[26] Khayambashi et al.[27] showed that initial hip abduction strength <35% of body weight (BW) allows athletes to develop a future ACL without involvement.
- Bilateral isometric hip abduction was assessed with a hand-held ergometer. The athlete lies on their side and uses a strap (located proximal to the iliac crest and secured around the treatment table) to stabilize the pelvis. Hip abduction to 30° and placement of dynamometer pads 10 cm proximal to the lateral femoral condyle. Athletes abduct their hips onto the ergometer pad for 5 seconds against manual resistance with a maximal effort. [27]
- Decreased trunk lateral flexion measured by the side bridge test was associated with increased knee abduction angle during the single-leg squat. The side bridge test combines lateral flexion strength of the trunk with hip abductor strength. Weakness of this musculature can lead to Increased trunk instability and increased knee abduction, which may predispose athletes to injury. [twenty three]
- Bilateral squat strength was related to hip abduction and knee valgus at landing. [28]
- Weaker lower extremity muscle strength levels, as assessed by single-rep maximum (1RM) barbell squats, may be an important and modifiable predisposition to traumatic knee injuries in young female athletes. [29]
Injuries may be mitigated by increasing triple extension or squat strength and improving hip abductor strength.
Evidence for Movement Skill
- Female athletes with increased knee valgus and trunk lateral motion during the single-leg drop vertical jump test may be at increased risk for noncontact knee injuries. [30]
- Increased knee valgus during single-leg squats increases the risk of lower extremity injury. [31] Raisanen et al. [32] showed that athletes with a high frontal face knee joint projection angle (FPKPA) during single-leg squats were 2.7 times more likely to suffer lower extremity injuries than others, and the likelihood of lower extremity injuries was 2.4 times that of others. Sustain the ankle injury.
- Adolescent girls (13 years) with knee abduction moments or loads >15 Nm were more likely (6.8%) to develop patellofemoral pain (PFP). 16-year-old girls with landing scores >25Nm were at increased risk of PFP and ACL injury. [33]
- [34] showed that for every 1° of pelvic descent during running, the odds of being classified as an injury increased by 80%.
Improving landing and running mechanics by reducing trunk tilt, hip adduction and knee valgus may reduce injury risk.
Multi-modal Interventions
Interventions with multiple modalities are designed to incorporate modifiable tendencies such as motor proprioception and the intensity range of motor skills. These programs are usually introduced as part of an extended warm-up program. There is evidence that these types of injury prevention The program successfully reduced the risk of injury. [35][36] More research is needed to better understand adherence and maintenance of these programs. It is clear that compliance is key to successful harm reduction. [37] also suggested that these multimodal interventions The plan should be implemented throughout the season, not just for a short period of time, i.e. only during the pre-season. [38]
Read more about sports injury prevention here: Sports Injury Prevention
Examples of Interventions
- The KNEE Program – Netball Australia
- Kinesiology: A Warm Up for Injury Prevention and Performance
- FIFA 11+
- World Rugby: Launching an Injury Prevention Exercise Program
- Can a 15-Minute Warm-Up Program Prevent ACL Injury? Research results
- Jump Higher and Prevent Injury
- Copenhagen Adductor Strengthening Program [39]
- Aspetar Hamstring Protocol
Implementing Injury Prevention
Approaches to successfully implementing injury prevention [40]:
- Gain support from all key decision makers
- Develop an interdisciplinary team
- Identify barriers and solutions
- Design a context-specific programme
- Coach the coaches
- Enhance fidelity
- Develop an exit strategy
Learn more about these steps here: Implement injury prevention[41]
Key Considerations for Prehabilitation
- Identify the need for intervention
- Identify potentially modifiable physical attributes
- Assess whether these physical qualities are problematic
- Involve athletes and coaches in planning [37]
- Minimise time and maximise impact[42]
- Make it progressive and sustained[43]
- Consider using mesocirculation and microdosing
- Periodic training works on the principles of overload and flexibility. There are three types of periodisation cycles:
- Macrocycle = whole season
- Mesocycle = a specific training block during the period designed to accomplish a specific goal such as stable endurance strength or movement skills typically 4 – 6 weeks in length
- Microcycle = a smaller unit of the mesocycle – usually a week of training
- Microdosing = requires low intensity but repeated training.[44]
- Periodic training works on the principles of overload and flexibility. There are three types of periodisation cycles:
References
- ↑ Trojian TH, McKeag DB. Single leg balance test to identify the risk of ankle sprains. British journal of sports medicine. 2006 Jul 1;40(7):610-3.
- ↑ Oshima T, Nakase J, Kitaoka K, Shima Y, Numata H, Takata Y, Tsuchiya H. Poor static balance is a risk factor for non-contact anterior cruciate ligament injury. Archives of Orthopaedic and Trauma Surgery. 2018;138:1713-8.
- ↑ Rivera MJ, Winkelmann ZK, Powden CJ, Games KE. Proprioceptive training for the prevention of ankle sprains: an evidence-based review. Journal of athletic training. 2017 Nov;52(11):1065-7.
- ↑ Gribble PA, Terada M, Beard MQ, Kosik KB, Lepley AS, McCann RS, Pietrosimone BG, Thomas AC. Prediction of lateral ankle sprains in football players based on clinical tests and body mass index. The American journal of sports medicine. 2016 Feb;44(2):460-7.
- ↑ Stiffler MR, Bell DR, Sanfilippo JL, Hetzel SJ, Pickett KA, Heiderscheit BC. Star excursion balance test anterior asymmetry is associated with injury status in division I collegiate athletes. journal of orthopaedic & sports physical therapy. 2017 May;47(5):339-46.
- ↑ Ko J, Rosen AB, Brown CN. Functional performance tests identify lateral ankle sprain risk: a prospective pilot study in adolescent soccer players. Scandinavian journal of medicine & science in sports. 2018 Dec;28(12):2611-6.
- ↑ Bliekendaal S, Stubbe J, Verhagen E. Dynamic balance and ankle injury odds: a prospective study in 196 Dutch physical education teacher education students. BMJ open. 2019 Dec 1;9(12):e032155.
- ↑ Attenborough AS, Sinclair PJ, Sharp T, Greene A, Stuelcken M, Smith RM, Hiller CE. The identification of risk factors for ankle sprains sustained during netball participation. Physical Therapy in Sport. 2017 Jan 1;23:31-6.
- ↑ Ruffe NJ, Sorce SR, Rosenthal MD, Rauh MJ. Lower quarter-and upper quarter Y balance tests as predictors of running-related injuries in high school cross-country runners. International journal of sports physical therapy. 2019 Sep;14(5):695.
- ↑ De Noronha M, França LC, Haupenthal A, Nunes GS. Intrinsic predictive factors for ankle sprain in active university students: a prospective study. Scandinavian journal of medicine & science in sports. 2013 Oct;23(5):541-7.
- ↑ Johansson AC, Karlsson H. The star excursion balance test: Criterion and divergent validity on patients with femoral acetabular impingement. Manual therapy. 2016 Dec 1;26:104-9.
- ↑ Jump up to:12.0 12.1 Green B, Bourne MN, van Dyk N, Pizzari T. Recalibrating the risk of hamstring strain injury (HSI): A 2020 systematic review and meta-analysis of risk factors for index and recurrent hamstring strain injury in sport. British Journal of Sports Medicine. 2020 Sep 1;54(18):1081-8.
- ↑ Jump up to:13.0 13.1 Whittaker JL, Small C, Maffey L, Emery CA. Risk factors for groin injury in sport: an updated systematic review. British journal of sports medicine. 2015 Jun 1;49(12):803-9.
- ↑ Ryan J, DeBurca N, Mc Creesh K. Risk factors for groin/hip injuries in field-based sports: a systematic review. British journal of sports medicine. 2014 Jul 1;48(14):1089-96.
- ↑ Gabbe BJ, Finch CF, Bennell KL, Wajswelner H. Risk factors for hamstring injuries in community-level Australian football. British journal of sports medicine. 2005 Feb 1;39(2):106-10.
- ↑ Green B, Pizzari T. Calf muscle strain injuries in sport: a systematic review of risk factors for injury. British journal of sports medicine. 2017 Aug 1;51(16):1189-94.
- ↑ Dixon S, Nunns M, House C, Rice H, Mostazir M, Stiles V, Davey T, Fallowfield J, Allsopp A. Prospective study of biomechanical risk factors for second and third metatarsal stress fractures in military recruits. Journal of science and medicine in sport. 2019 Feb 1;22(2):135-9.
- ↑ Nunns M, House C, Rice H, Mostazir M, Davey T, Stiles V, Fallowfield J, Allsopp A, Dixon S. Four biomechanical and anthropometric measures predict tibial stress fracture: a prospective study of 1065 Royal Marines. British journal of sports medicine. 2016 Oct 1;50(19):1206-10.
- ↑ Fong CM, Blackburn JT, Norcross MF, McGrath M, Padua DA. Ankle-dorsiflexion range of motion and landing biomechanics. Journal of athletic training. 2011 Jan;46(1):5-10.
- ↑ Lima YL, Ferreira VM, de Paula Lima PO, Bezerra MA, de Oliveira RR, Almeida GP. The association of ankle dorsiflexion and dynamic knee valgus: A systematic review and meta-analysis. Physical Therapy in Sport. 2018 Jan 1;29:61-9.
- ↑ Gafner SC, Hoevel V, Punt IM, Schmid S, Armand S, Allet L. Hip-abductor fatigue influences sagittal plane ankle kinematics and shank muscle activity during a single-leg forward jump. Journal of Electromyography and Kinesiology. 2018 Dec 1;43:75-81
- ↑ Dix J, Marsh S, Dingenen B, Malliaras P. The relationship between hip muscle strength and dynamic knee valgus in asymptomatic females: A systematic review. Physical Therapy in Sport. 2019 May 1;37:197-209.
- ↑ Jump up to:23.0 23.1 Cronström A, Creaby MW, Nae J, Ageberg E. Modifiable factors associated with knee abduction during weight-bearing activities: a systematic review and meta-analysis. Sports Medicine. 2016 Nov;46(11):1647-62.
- ↑ Neamatallah Z, Herrington L, Jones R. An investigation into the role of gluteal muscle strength and EMG activity in controlling HIP and knee motion during landing tasks. Physical Therapy in Sport. 2020 May 1;43:230-5.
- ↑ Powers CM, Ghoddosi N, Straub RK, Khayambashi K. Hip strength as a predictor of ankle sprains in male soccer players: a prospective study. Journal of athletic training. 2017 Nov;52(11):1048-55.
- ↑ Lucas KC, Kline PW, Ireland ML, Noehren B. Hip and trunk muscle dysfunction: implications for anterior cruciate ligament injury prevention. Ann Joint. 2017 May 1;2:18.
- ↑ Jump up to:27.0 27.1 Khayambashi K, Ghoddosi N, Straub RK, Powers CM. Hip muscle strength predicts noncontact anterior cruciate ligament injury in male and female athletes: a prospective study. The American journal of sports medicine. 2016 Feb;44(2):355-61.
- ↑ McCurdy K, Walker J, Armstrong R, Langford G. Relationship between selected measures of strength and hip and knee excursion during unilateral and bilateral landings in women. The Journal of Strength & Conditioning Research. 2014 Sep 1;28(9):2429-36.
- ↑ Augustsson SR, Ageberg E. Weaker lower extremity muscle strength predicts traumatic knee injury in youth female but not male athletes. BMJ open sport & exercise medicine. 2017 Apr 1;3(1):e000222.
- ↑ Dingenen B, Malfait B, Nijs S, Peers KH, Vereecken S, Verschueren SM, Staes FF. Can two-dimensional video analysis during single-leg drop vertical jumps help identify non-contact knee injury risk? A one-year prospective study. Clinical biomechanics. 2015 Oct 1;30(8):781-fro7.
- ↑ Eckard T, Padua D, Mauntel T, Frank B, Pietrosimone L, Begalle R, Goto S, Clark M, Kucera K. Association between double-leg squat and single-leg squat performance and injury incidence among incoming NCAA Division I athletes: A prospective cohort study. Physical Therapy in Sport. 2018 Nov 1;34:192-200.
- ↑ Räisänen AM, Pasanen K, Krosshaug T, Vasankari T, Kannus P, Heinonen A, Kujala UM, Avela J, Perttunen J, Parkkari J. Association between frontal plane knee control and lower extremity injuries: a prospective study on young team sport athletes. BMJ open sport & exercise medicine. 2018 Jan 1;4(1):e000311.
- ↑ Myer GD, Ford KR, Di Stasi SL, Foss KD, Micheli LJ, Hewett TE. High knee abduction moments are common risk factors for patellofemoral pain (PFP) and anterior cruciate ligament (ACL) injury in girls: is PFP itself a predictor for subsequent ACL injury?. British journal of sports medicine. 2015 Jan 1;49(2):118-22.
- ↑ Bramah C, Preece SJ, Gill N, Herrington L. Is there a pathological gait associated with common soft tissue running injuries?. The American journal of sports medicine. 2018 Oct;46(12):3023-31.
- ↑ Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R. Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial. Bmj. 2005 Feb 24;330(7489):449
- ↑ Silvers-Granelli HJ, Bizzini M, Arundale A, Mandelbaum BR, Snyder-Mackler L. Does the FIFA 11+ injury prevention program reduce the incidence of ACL injury in male soccer players?. Clinical Orthopaedics and Related Research®. 2017 Oct;475(10):2447-55
- ↑ Jump up to:37.0 37.1 Sugimoto D, Myer GD, Micheli LJ, Hewett TE. ABCs of evidence-based anterior cruciate ligament injury prevention strategies in female athletes. Current physical medicine and rehabilitation reports. 2015 Mar;3(1):43-9.
- ↑ Petushek EJ, Sugimoto D, Stoolmiller M, Smith G, Myer GD. Evidence-based best-practice guidelines for preventing anterior cruciate ligament injuries in young female athletes: a systematic review and meta-analysis. The American journal of sports medicine. 2019 Jun;47(7):1744-53
- ↑ Harøy J, Clarsen B, Wiger EG, Øyen MG, Serner A, Thorborg K, Hölmich P, Andersen TE, Bahr R. The adductor strengthening programme prevents groin problems among male football players: a cluster-randomised controlled trial. British journal of sports medicine. 2019 Feb 1;53(3):150-7
- ↑ Padua DA, Frank B, Donaldson A, de la Motte S, Cameron KL, Beutler AI, DiStefano LJ, Marshall SW. Seven Steps for Developing and Implementing a Preventive Training Program: Lessons Learned from JUMP ACL and Beyond. Clinics in sports medicine. 2014 Oct;33(4):615.
- ↑ O’Brien J, Hägglund M, Bizzini M. Implementing injury prevention: the rocky road from RCT to real world injury reduction. Aspetar Sports Med J. 2018:70-6.
- ↑ Dargo L, Robinson KJ, Games KE. Prevention of knee and anterior cruciate ligament injuries through the use of neuromuscular and proprioceptive training: an evidence-based review. Journal of athletic training. 2017 Dec;52(12):1171-2
- ↑ Sugimoto D, Myer GD, Foss KD, Hewett TE. Dosage effects of neuromuscular training intervention to reduce anterior cruciate ligament injuries in female athletes: meta-and sub-group analyses. Sports Medicine. 2014 Apr;44(4):551-62
- ↑ Read PJ, Oliver JL, Lloyd RS. Seven Pillars of Prevention: Effective Strategies for Strength and Conditioning Coaches to Reduce Injury Risk and Improve Performance in Young Athletes. Strength & Conditioning Journal. 2020 Dec 1;42(6):120-8
- ↑ E3 Rehab. Fifa 11+ Injury Prevention Program (Plus Free Handouts). Available from https://www.youtube.com/watch?v=X5YyunLZzBc. [last accessed 13/09/2021]
- ↑ Aspetar. Aspetar Hamstring Protocol Full video. Available from https://www.youtube.com/watch?v=Fzex_zG1JtA&t=1s. [last accessed 13/09/2021]