Evaluation is a valuable practice for athletes and is common in many major sports. One of the most common areas of periodic medical examination of athletes is a musculoskeletal examination or examination. For years, physical therapists have examined athletes with the goal of identifying them athletes at risk of injury so that injury prevention programs can then be implemented for these athletes. Recently, however, the focus has shifted from using research to predict injury to using research to identify potential injury risk factors.
Reasons for Regular Physical Exams for Athletes
The primary reason for regular medical evaluations of athletes is to maintain athletic participation, but there are many other added benefits, including:
- Identify medical conditions that prohibit participation in sports
- Assess known injuries and illnesses
- Review current medications and supplements
- Athlete education
- Baseline testing
- Developing rapport with the athlete
- Specific screening
- Cardiac screening
- Screening for unknown illnesses
- Screening for risk factors for future injury
Read more: Sports Screening and Pre-Game Screening
Why Screen for Injury Risk?
Despite the specialization of sports science and the increasing use of sports medicine support teams, the rate of injuries in sports is still on the rise. Although physical activity is encouraged as part of a healthy lifestyle, the burden of exercise-related injuries is high. 
Consequences of Injuries in Sport
- Financial implications for the club
- Player injury costs to sports leagues and organizations fall into two main categories: direct medical costs and the opportunity cost of time-loss injuries and shortened careers. This led to professional teams offering player contracts based on medical evaluation – players Short-term contracts with a high risk of injury may then be offered. 
- Team performance
- Significant relationships between injury rates and time lost and performance have been reported in elite team sports. 
- Financial Impact on the Healthcare System
- Finch et al.  investigated the trends and burden of hospitalization for sports injuries in Australia and estimated the direct cost of sports-related injuries to be A$265 million over 7 years. 
- Financial costs for the individual
- The inability to perform has a significant impact on an athlete’s earnings. Secrist et al.  showed that NFL players with ACL injuries earned an average of $2,070,521 less than a salary-matched control group over the 4 years following injury.
- Implications for long term health
- Injury to the knee joint (such as ACL or meniscal injury) has been shown to increase the chance of subsequent knee OA 
- Career progression in sports
- Larukain et al.  demonstrated a negative relationship between injuries and player improvement in elite football academies, with players progressing to the next level having a lower injury burden and higher game availability than players who did not improve. 
Can we predict harm? In literature there is the problem of prediction or association. Most of the available literature looks at retrospective studies in which the association between a physical agent and injury is seen as opposed to using a physical agent in a retrospective manner Investigate whether it can actually predict injury. 
In recent years, much of the literature on screening tests has shown that these tests cannot predict which athletes will get injured, so clinicians are abandoning the idea.  However, this does not mean that screening should not be done, as screening is still essential in our lives Work hard to protect the health of athletes.  The following video explains injury risk and screening very well.
An infographic explaining sports injury prediction and association can be found here.
Related factors of injury
Multiple factors play a role in the risk of injury occurring and these factors can interact with each other:
- Training-related factors
- Training volume, load, intensity
- Type of training
- Training and competition schedule
- Motor control factors
- Movement patterns
- Muscle tone
- Sport specific movements
- Psychological factors
- Coping strategies
- Emotional state (stress depression anxiety)
- Health-related factors
- General health
- Sleep patterns
- Non-modifiable factors
- Maturation stage
- Body type
- Previous injuries
- Environmental factors
- Training/competition surface
- Conditioning factors
- Muscle length
- Joint range of motion
- Chronic capacity
- Additional demands
- Other factors
- Sport specific skill level
- Ranking and status
- Athlete Goals – Short and Long Term
When considering injury screening, it is important to consider the various factors that may affect the occurrence of an injury. Furthermore, it is unlikely that these will be reduced to a single factor that could cause harm.  Factors commonly used to screen for musculoskeletal injury risk Filters are:
- Strength and conditioning
- Movement quality
It is evident from the map of Bolling et al.  that these factors are only a few of the many factors that may contribute to the occurrence of injury. 
A multilevel system map of factors strategies and stakeholders related to injuries and their prevention. Start from the center of the map (i.e. the athletes) and move outward; (A) include artist-related internal injury factors; (2) present external injury factors; (C) describe the main Prevention strategies driven by factors from both inner circles (e.g. load management security and preparedness); (D) Represent stakeholders in the system and how they connect to strategies and factors at multiple levels. 
Predisposition to Injuries
Rather than attempting to predict the occurrence of injury, it may be more appropriate to identify susceptible athletes and, where possible, modify susceptibility.
- Non-modifiable predispositions include:
- Previous injury
- Environmental factors
- Modifiable predispositions include:
- Is the athlete’s condition tired or stressed?
This flowchart created by Dr. Lee Herrington illustrates how susceptibility and load exposure contribute to vulnerability in athletes and how, in combination with stimulating events, lead to injury mechanisms and events.
Considerations for Identifying Susceptible Athletes
- Understand the nature of the sport and the injuries that occur
- Common vs Catastrophic Injuries (e.g. Hamstring vs ACL Injured Football)
- Determine which injury needs to be targeted, as this will determine what type of screening test will be used
- Are there modifiable factors for these specific injuries?
- Is there a well-defined physical quality associated with the injury? Can these modifiable factors be clearly defined in terms of certain physical qualities?
- Are these physical qualities identifiable by reliable screening tests?
- Are these physical qualities affected or altered? (Example – blue eyes may be a predisposing factor for a certain type of injury, which can be easily and reliably screened for, but cannot alter or affect eye color.)
- Trauma in sports – How much do screening and training affect injury?
Screening for neuromuscular control of movement
Neuromuscular control refers to the ability to perform movements optimally to minimize loading stress or maximize the distribution of loading stress on the relevant tissues.  An important part of “motor screening” is to identify high-risk motor tasks and determine If these tasks can be broken down into closed skills. Closed skills are performed in a controlled environment, with the athlete focusing only on that specific skill (such as a single-leg squat or single-leg touchdown).  Open-ended skills are performed in very chaotic and random environments (e.g. landing on one leg in an athletic environment such as a game or competition). The environment in which these sports are played will have an impact on performance and risk of injury. For example, an athlete may have passed a closed skill test/task such as landing on one leg Preseason screened but still injured from landing on one leg in an athletic setting such as a game (i.e. ACL injury).
Selecting a Screening Test/Task
Factors to consider when selecting a screening test or task include:
- the nature of the activity performed in a particular sport
- Nature of major injuries in specific sport (are these related to specific sport or activity?)
- Athlete’s injury history (was the previous injury related to a particular movement or activity?)
Factors Affecting Neuromuscular Control of Motor Movement
Various factors can affect an athlete’s ability to perform a particular screening test or task. These include:
- Joint range of motion
- Muscle Length – Flexibility
- proprioception – sense of joint position
- Movement dissociation
- Sport specific skill
Establishing an Injury Risk Screening Paradigm
- Consider susceptibility and injury prediction
- Screening tests cannot predict whether an athlete will be injured, but we can screen and look for susceptible athletes. Remember that being vulnerable to a certain injury doesn’t mean an athlete will get injured. Furthermore, if the athlete is not prone to injury, it is not Make sure the players are not injured. When athletes are exposed to stressful and stimulating events, they are vulnerable to injury (see flowchart above).
- Determining whether force production force absorption or motor skill is a predisposition issue
- Identify susceptible motor tasks
- Break down identified motor tasks into closed skills that can be reliably measured
- If an athlete fails a test/task, identify the reason for the failure
- Establish methods for improving skills in controlled environments as well as in training and competition settings
Examples of Screening Tests
- Lower quadrant tests
- Single-leg squat
- Single-leg landing
- Drop jump Test
- Star Excursion Balance Test
- Hop for distance tests
- Upper quadrant tests
- Glenohumeral internal rotation defect (GIRD)
- Closed chain upper limb test
- Functional Movement Screen (FMS)
- USTA High Performance Profile
- Nine Test Screening Battery
- Athletic Ability Assessment
- Boksmart player selection before the competition
- The site has various documents available for download, such as musculoskeletal assessment forms and protocols and various other assessment documents.
- The video below shows an example of the musculoskeletal screening process.
- ↑ Targett S, Clarsen B. Periodic medical assessment of athletes. In: Brukner P, Clarsen B, Cook J, Cools A, Crossley K, Hutchinson M, McCroy P, Bahr R, Khan K. Brukner and Khan’s Clinical Sports Medicine: Injuries, Volume 1, 5e. Sydney: McGraw Hill Education. 2017
- ↑ Emery CA, Pasanen K. Current trends in sport injury prevention. Best Practice & Research Clinical Rheumatology. 2019 Feb 1;33(1):3-15.
- ↑ Walia B, Boudreaux CJ. The cost of players’ injuries to professional sports leagues and other sports organizations. Managerial Finance. 2020 Jul 31.
- ↑ Hägglund M, Waldén M, Magnusson H, Kristenson K, Bengtsson H, Ekstrand J. Injuries affect team performance negatively in professional football: an 11-year follow-up of the UEFA Champions League injury study. British journal of sports medicine. 2013 Aug 1;47(12):738-42.
- ↑ Jump up to:5.0 5.1 Finch CF, Kemp JL, Clapperton AJ. The incidence and burden of hospital-treated sports-related injury in people aged 15+ years in Victoria, Australia, 2004–2010: a future epidemic of osteoarthritis?. Osteoarthritis and cartilage. 2015 Jul 1;23(7):1138-43.
- ↑ Secrist ES, Bhat SB, Dodson CC. The financial and professional impact of anterior cruciate ligament injuries in National Football League athletes. Orthopaedic journal of sports medicine. 2016 Aug 30;4(8):2325967116663921.
- ↑ Poulsen E, Goncalves GH, Bricca A, Roos EM, Thorlund JB, Juhl CB. Knee osteoarthritis risk is increased 4-6 fold after knee injury–a systematic review and meta-analysis. British journal of sports medicine. 2019 Dec 1;53(23):1454-63.
- ↑ Jump up to:8.0 8.1 Larruskain J, Lekue JA, Martin-Garetxana I, Barrio I, McCall A, Gil SM. Injuries are negatively associated with player progression in an elite football academy. Science and Medicine in Football. 2021 Jun 16(just-accepted)
- ↑ McCall A, Fanchini M, Coutts AJ. Prediction: the modern-day sport-science and sports-medicine “quest for the holy grail”. International journal of sports physiology and performance. 2017 May 1;12(5):704-6.
- ↑ Bahr R. Why screening tests to predict injury do not work—and probably never will…: a critical review. British journal of sports medicine. 2016 Jul 1;50(13):776-80.
- ↑ Verhagen E, van Dyk N, Clark N, Shrier I. Do not throw the baby out with the bathwater; screening can identify meaningful risk factors for sports injuries. British journal of sports medicine. 2018;52(19):1223-4.
- ↑ Clinical Athlete. Injury risk and screening. Available from https://www.youtube.com/watch?v=lvP_KtQf3Xc [last accessed 25/8/2021]
- ↑ Jump up to:13.0 13.1 13.2 13.3 13.4 13.5 Herrington LC, Munro AG, Jones PA. Assessment of factors associated with injury risk. In: Performance Assessment in Strength and Conditioning 2018 Oct 9 (pp. 53-95). Routledge.
- ↑ Jump up to:14.0 14.1 14.2 Bolling C, Mellette J, Pasman HR, Van Mechelen W, Verhagen E. From the safety net to the injury prevention web: applying systems thinking to unravel injury prevention challenges and opportunities in Cirque du Soleil. BMJ open sport & exercise medicine. 2019 Feb 1;5(1):e000492.
- ↑ Flodström F, Heijne A, Batt ME, Frohm A. The nine test screening battery-normative values on a group of recreational athletes. International journal of sports physical therapy. 2016 Dec;11(6):936.
- ↑ McKeown I, Taylor‐McKeown K, Woods C, Ball N. Athletic ability assessment: a movement assessment protocol for athletes. International journal of sports physical therapy. 2014 Dec;9(7):862.
- ↑ AFL Community. Musculoskeletal Screening Process. Available from u0DnAjMj3fU [last accessed 19/5/2022]
- ↑ Aspetar. Why screening to predict injury doesn’t work and probably never will. Available from https://www.youtube.com/watch?v=y0HroNZWmT8 [last accessed 19/5/2022]
- ↑ Aspetar. From athlete screening to injury risk management -Prof Roald Bahr. Available from https://www.youtube.com/watch?v=jXWWc3wML3o&t=3s [last accessed 19/5/2022]