Injury Reduction: A case to rethink the term "injury prevention”

What is injury prevention and what do we have backwards about it?

An unavoidable fact is that injuries happen. Pickleball has been getting more public attention for both it’s growing popularity and injury risk. A recent CNN article reports that pickleball injuries may cost Americans nearly $400 million in health care costs. If you want to argue about some of those injuries being preexisting injuries that playing pickleball exacerbated, fine we can do that. Let’s say half of the costs are true acute injuries from playing pickleball and the other half are injuries that were already there. If that’s true, that still costs $200 million in added health care costs. That’s a lot of money.

Professional and amateur sports are no different. Sports fans commonly will hear about a fan-favorite player injuring their ankle, ACL, hamstring, Achilles, or UCL to name a few notable, common sports injuries. Both athletes and parents I’ve worked with have also expressed concern for the risk of some of those injuries from playing sports. The specific injuries I just mentioned aren’t the only injuries that can happen from sports or general physical activity. This article isn’t a comprehensive analysis of the literature either, so if you were looking for that I’ll save you some time and tell you that you won’t find that here.

I mention those injuries because they carry high incidence of reinjury, high short and long-term health care costs, and can also predispose people to other injuries. A common example you may know an athlete who tore their ACL, got surgery, rehabilitated their knee, and returned to their sport, only to tear their ACL on the opposite side. Other burdens of orthopedic injury include decreased quality of life, decreased performance, an increased risk for other further orthopedic issues like osteoarthritis, and even some mental health challenges.

So, why is this important? 

As the proverb goes: “an ounce of prevention is worth a pound of cure.” The idea of injury prevention is not new, but it does get a lot of attention in the sports and sports medicine world. Go online and you’ll likely be able to find an injury prevention protocol for anything. There’s inherent risk in life, playing sports, and enjoying oneself; injuries happen. But, if we can reduce the likelihood of an injury occurring, we theoretically could reduce future health care costs.

Here lies an important terminology issue: prevention vs. reduction. Complete prevention of injuries is nearly impossible. The human body is very resilient, but not invincible. Even the most physically prepared athlete, one who’s exceptionally strong, fast, moves excellently, can still get injured under certain conditions; physics always will have a say. With that in mind, adopting the phrase ‘injury reduction’ vs ‘injury prevention’ is important because we can reduce injury, but not totally prevent it.

While I can’t make a definitive statement about the efficacy of every “injury prevention” protocol, I would like to point out some common themes across protocols. Regardless of the study design, patient population, injury type and/or body part, most protocols have similar components: a combination of range of motion interventions (stretching), a warmup, motor control drills, targeted strengthening, plyometric exercises, and possibly balance training. Some protocols have a measurable, direct influence on reducing injuries, other protocols can affect some form of performance (landing technique, physical literacy, strength, etc), which can be linked to injury reduction with other data sets. Interventions vary in length and complexity, but generally can be expected to take 5-30 minutes in length per session.

Many factors influence risk of injury in playing sports. In general, these factors include strength imbalances between muscle groups, poor neuromuscular control, lack of core stability, weakness, overtraining, environmental factors, and previous orthopedic injury. That is very oversimplified list of injury etiology, but it is worth listing them.  

Kaminski et al. found that “strength deficits of leg muscles, specifically the plantar flexors,70,124evertors,71,114 and invertors,65,71 have been reported in patients with ankle instability. Further, hip- extensor and -abductor strength deficits have been shown.70,168 Strength deficits and imbalances may play a role in vulnerable positioning of the foot relative to the center of mass during movement, adding to the risk of ankle injury.”

Those risk factors are not mutually exclusive to the ankle too, as lack of body control has been linked with many lower extremity injuries across multiple joints. It is important to what can lead to injury, so we can ideally reduce the likelihood of an injury happening. Hewett et al. found that “core body control and lower extremity proprioception are modifiable risk factors and are important for attenuating and adapting to perturbations during sports tasks.” They also wrote that “Integrated neuromuscular training programs (bio-mechanical, neuromuscular control, and strength training techniques) have effectively improved performance and decreased risk for ACL injury.” Decreasing ACL injury risk also may decrease the risk of other injuries within the knee. That statement isn’t scientifically backed, but it does have some common sense behind it.

It’s also worth noting that Kaminski et al’s article and Hewett et. al. both identify similar risk factors for injury for the knee and the ankle. They also had similar interventions to address these risk factors. Kaminksi et al. found that “interventions … included single-legged–stance balance training, balance training with additional perturbation, balance training with upper extremity movements or tasks, and dynamic jumping activities with a balance component. Other injury-prevention programs focusing on balance training have also shown a reduction in ankle-injury incidence especially in athletes with a history of ankle injury.67–69 McKeon and Hertel41 reported a relative risk reduction of 20% to 60% based on these controlled trials.” Petushek et al. similarly found that “Overall, the most effective ACL injury prevention programs included trained or informed personnel (eg, coaches, trainers), targeted younger athletes, exposed athletes to NMT throughout the sport season, and included lower body strengthening and landing stabilization exercises.” Most interestingly they found that interventions done throughout the playing season had a positive effect of reducing injury risk. It also is worth noting that these specific findings support a trained professional coach administering these activities.

In short, targeted interventions that focus on strengthening, unilateral strength, balancing, landing mechanics, and core control can reduce the incidence of injury. This does beg the question: if these targeted ‘injury prevention’ programs work, why aren’t they more popular? The more glaring question to me is: why isn’t everyone doing this all the time? The idea that there’s a specific time to work on injury prevention that’s separate from time to work on physical preparation, like strength training, is foolish.

Mike Boyle posed the question: is injury prevention training just good training? The obvious answer is yes. My hope here was to help quantify this question with some of the literature on injury prevention. We need to focus on intelligent training practices because we want to be a part of the injury reduction movement. “Injury prevention” is a false idea, while injury reduction is more likely what we are doing. By incorporating some of these concepts into programming, we effectively can reduce the need to spend time and resources on targeted injury prevention programming, because we’re doing it all the time.

Train smart, train hard, facilitate recovery. It really is that simple, however that doesn’t mean that it is easy.

References:

1. Hewett, T.E., Myer, G.D., Ford, K.R., Paterno, M.V. and Quatman, C.E. (2016), Mechanisms, prediction, and prevention of ACL injuries: Cut risk with three sharpened and validated tools. J. Orthop. Res., 34: 1843-1855. https://doi.org/10.1002/jor.23414

2. Kaminski TW, Hertel J, Amendola N, Docherty CL, Dolan MG, Hopkins JT, Nussbaum E, Poppy W, Richie D; National Athletic Trainers' Association. National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013 Jul-Aug;48(4):528-45. doi: 10.4085/1062-6050-48.4.02. PMID: 23855363; PMCID: PMC3718356.

3. Liaghat B, Pedersen JR, Husted RS, Pedersen LL, Thorborg K, Juhl CB. Diagnosis, prevention and treatment of common shoulder injuries in sport: grading the evidence - a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF). Br J Sports Med. 2023 Apr;57(7):408-416. doi: 10.1136/bjsports-2022-105674. Epub 2022 Oct 19. PMID: 36261251; PMCID: PMC10086287.

4. 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. Am J Sports Med. 2019 Jun;47(7):1744-1753. doi: 10.1177/0363546518782460. Epub 2018 Jul 12. PMID: 30001501; PMCID: PMC6592422.

5. Foss KDB, Thomas S, Khoury JC, Myer GD, Hewett TE. A School-Based Neuromuscular Training Program and Sport-Related Injury Incidence: A Prospective Randomized Controlled Clinical Trial. J Athl Train. 2018 Jan;53(1):20-28. doi: 10.4085/1062-6050-173-16. Epub 2018 Jan 13. PMID: 29332470; PMCID: PMC5800723.

6. Jayanthi NA, Post EG, Laury TC, Fabricant PD. Health Consequences of Youth Sport Specialization. J Athl Train. 2019 Oct;54(10):1040-1049. doi: 10.4085/1062-6050-380-18. PMID: 31633420; PMCID: PMC6805065.