How I Approach Injury Prevention

Hello Everybody,

Today’s SOAP Note is going to be about injury rates in sports. The field of athletic training is generally moving towards more injury prevention instead of a reaction approach to injuries. The first step in injury prevention is to identify how they happen. I’ve had some recent thoughts I want to share on how and why injuries occur (in a general sense, not a specific mechanism of injury) and my role as an athletic trainer in their prevention.

Anytime injury rates are discussed, football always dominates the conversation. Football, ice hockey, lacrosse, soccer, basketball, rugby, these are all high contact sports. When it comes to athlete-athlete collisions, injuries are near impossible to prevent. You can build the perfect athlete with no compensation patterns, ideal muscle balances, incredible strength-to-weight ratio, etc. and as soon as that athlete is hit by another those measurables go out the door. A “perfect athlete” may be able to withstand more forces, but eventually there will come an awkward collision with somebody at a bad angle and that perfect athlete will break somehow, somewhere. Think about all the professional athletes that get hurt in a given year. They have hundreds of thousands of dollars to spend on injury prevention science and yet some still get hurt. Gray Cook talks about the two purposes of the body; locomotion and manipulation. Withstanding collisions is not something we are built for. Preventing contact injuries is a matter of trying to build that "perfect athlete" and crossing your fingers it all works out. It is that reason why I believe injury prevention has the greatest influence on non-contact injuries.

There are only three animals on this earth that get stress fractures; race horses, race dogs, and humans. The common factor? These animals get pushed to their limits time and time again. The overload and SAID principles more or less dictate that for athletes to get stronger, they must constantly push their physical limitations. So there is no getting around this aspect of sports. When training protocols are introduced properly and progressed appropriately the athlete will adapt to the controlled stress of training and get stronger. If the athlete is not coached on correct form, that stress becomes uncontrolled (look back on my article “Theories on Movement” for more discussion on controlled vs uncontrolled stress). Uncontrolled stress in the body will find its way to unintended structures and result in injury. Therefore correct form and appropriate progressions during training can be used as a method of injury prevention. In the words of Gray Cook, “quality of movement before quantity”. I think sometimes the pressure to perform leads us to skip on training quality of movement for our athletes. In the collegiate setting, there is a finite amount of time allotted in the offseason for training and the competition is getting stronger every day. This makes it hard to truly improve movement efficiency while also taking full advantage of the offseason period to train.

Movement inefficiency does not just effect athletes in the weight room. Imagine a 100m sprinter who pulls up with a hamstring strain. There are multiple possibilities to explain why the injury occurred. The glutes weren’t firing so the hamstrings had to work both knee flexion and hip extension and they got caught. There was a neurological misfire and the hamstrings didn’t shut off when the quads took over, and the quads will always win (they should anyways, 4 > 3). However you want to break it down, the sprinter likely strained his hamstring due to a neurological-based movement inefficiency.

Another possibility for that hamstring strain results because in a race setting the athlete will get adrenaline flowing and push himself/herself more than ever before. Attempting to run faster might put the hips into a more extreme range of motion than s/he is used to. This is a common occurrence, as playing sports will put the body through some extreme motion. Think back to the equation I provided in my “Theories on Movement” article. In this scenario, that equation would be manipulated to read: flexibility + stress = injury. It’s simple, but I removed “strength” because we are talking about an extreme range of motion where the athlete lacks control (aka strength). This doesn’t just apply to the outer limits of a normal range. Going back to the 100m sprinter, let’s now assume their glutes weren’t firing optimally for hip extension. The hamstrings can’t extend the hip as much as the glutes, so if the athlete is in a compensation pattern around the glutes their range of motion at the hip is restricted compared to normal. Not to mention if the glutes aren’t firing, the psoas will be down-regulated and thus hip flexion may also be restricted. Let’s put some numbers on this scenario. We will assume the athlete has 110 degrees of hip flexion normally and 20 degrees of hip extension. In a compensation pattern like the one I described, the controllable range within their motion might be restricted to something like 85 degrees of hip flexion and 5 degrees of hip extension. For this athlete, “extreme” range of motion is now 10 degrees of hip extension instead of 20 and 90 degrees of hip flexion instead of above 110. Not to mention a joint with decreased ROM will provide decreased neural signal to the brain and thus effect proprioception and control of the joint/limb. I tried to make a graphic that would represent what I am describing, hopefully it isn’t any more confusing.

 

If this athlete is running as fast as they can and the get into the "lost ROM", they are at a high risk for injury, all because of a movement inefficiency. It’s easy to see how so many non-contact injuries occur when you start to combine two or three movement inefficiencies on one athlete. The last factor I believe to play a role in these non-contact injuries is athlete fatigue. It shouldn’t be a surprise that athlete fatigue contributes to injury, but fatigue is really just another road that leads to movement inefficiency. Notice the theme here? I started this article talking about trying provide more and better injury prevention methods. I think the first step is to educate and train athletes for optimal movement. Essentially it begins with the bottom of the two pyramids in my article on “Internal vs. External cues”. In an ideal setting, if I were working with a team full of athletes who had been trained to not compensate and to be as efficient as possible my job would be like the bumpers in a bowling alley. I just need to keep them from drifting too far into the gutter of movement inefficiencies/injuries instead of reactively fishing them out all the time.

I’d love to hear your thoughts on non-contact injuries! Do you agree with the ideas I presented? Maybe some additional thoughts? How do you approach injury prevention?

More next time,

Mark D.

@MarkDomATC