Musculoskeletal Injury Risk Screening

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Reasons for the Periodic Medical Assessment of Athletes

The main reason for the periodic medical assessment of athletes is to safeguard sports participation, but there are many more beneficial reasons as well. Some of the reasons include:

• Identification of medical conditions that contraindicate sports participation
• Assessment of known injuries and illnesses
• Review of current medications and supplements
• Athlete education
• Baseline testing
• Development of athlete rapport
• Specific Screening
  • Cardiac screening
  • Screening for unknown illnesses
  • Screening for risk factors for future injury

Why Screen for Injury Risk?

Injury rates in sports are increasing despite the increased professionalism of sports science and sports medicine support teams. Although participation in sport is encouraged as part of a healthy lifestyle, the sport-related injury burden is high.

Consequences of Injuries in Sport

• Financial implications for the club
  • The cost of player injuries on sports leagues and organisations mainly fall into two categories: the direct medical costs and the opportunity cost of time loss injuries and shortened careers. This has led to professional teams offering players contracts contingent upon medical evaluations and players with high injury risk being offered short-term contracts.

• Team performance
  • A significant relationship of injury rates and time loss with performance in elite team sports is reported.

• Financial implications for the healthcare system
  • Finch et al investigated the trends and burdens of hospital-treated sports injuries in Australia and estimated the direct cost of sport-related injury over 7 years to be $265 million Australian dollars.

• Financial costs for the individual
  • The inability to perform has significant impact on an athlete’s earnings. Secrist et al showed that players in the National Football League with an ACL injury earned on average $2,070,521 less than salary-matched controls over the 4 years after the injury.
• Implications for long term health
  • It has been shown that knee injuries such as ACL or meniscal injury increases the odds of subsequent knee OA development

• Career progression in sports
  • Larukain et al demonstrated a negative association between injuries and player progression in an elite football academy with players that progressed to the next level having a lower injury burden and higher match availability compared to players that did not progress.

Injury Prediction

Can we predict injuries

Association vs prediction articles

Factors Involved in the Development of Injuries

There are various factors that play a role in the risk of injury occurrence, and these factors can interact with each other:

• Training-related factors
  • Training volume, load, intensity
  • Type of training
  • Training and competition schedule
  • Rest

• Motor control factors
  • Posture
  • Movement patterns
  • Muscle tone
  • Technique
  • Sport specific movements

• Psychological factors
  • Beliefs
  • Fears
  • Coping strategies
  • Self-efficacy
  • Catastrophising
  • Emotional status (stress, depression, anxiety)

• Health-related factors
  • Diet
  • Medication
  • General health
  • Fatigue
  • Sleep patterns

• Non-modifiable factors
  • Gender
  • Age
  • Maturation stage
  • Body type
  • Genetics
  • Previous injuries

• Environmental factors
  • Training/competition surface
  • Equipment
  • Clothing
  • Weather
  • Coaching

• Conditioning factors
  • Strength
  • Endurance
  • Muscle length
  • Joint range of motion
  • Chronic capacity

• Additional demands
  • Home
  • Work
  • Family
  • Social
  • Leadership
  • Media
  • Sponsors

• Other factors
  • Sport specific skill level
  • Ranking and status
  • Goals of athlete – short and long term

When considering injury screening it is important to consider this myriad of factors that can influence injury occurrence. Furthermore, it is unlikely that these can be reduced to a single factor that may lead to injury occurrence. Factors that are commonly screened for in musculoskeletal injury risk screening are:

• strength and conditioning
• movement quality
• stability/alignment

From the map by Bolling et al it is evident that these factors are just a few of numerous factors that can be involved in injury occurrence.

A multilevel system map with factors, strategies and stakeholders in relation to injury and their prevention. Starting at the centre of the map (ie, the athlete) and moving distally; (A) entails artists-related intrinsic injury factors; (B) presents external injury factors; (C) describes the main preventive strategies (eg, load management, safety and preparation) which are driven by the factors from the inner two circles; (D) represents the stakeholders in the system as well as how they connect to the strategies and factors across the multiple levels.

Predisposition to Injuries

Instead of trying to predict injury occurrence, it may be more appropriate to identify athletes who are predisposed and where possible modify the predisposition.

• Non-modifiable predispositions include:
  • Anatomy
  • Genetics
  • Previous injury
  • Environmental factors

• Modifiable predispositions include:
  • Strength
  • Movement
  • Skill
  • Flexibility
  • State of the athlete eg. tired or stressed?

This flow diagram created by Dr Lee Herrington illustrates how predispositions and exposure to load can lead to vulnerability in an athlete and in combination with an inciting event this can lead to injury mechanisms and occurrences.

Injury predisposition

Considerations in Identifying Predisposed Athletes

• Understand the nature of the sport and the injuries occurring
  • Common injuries vs Catastrophic injuries (for example hamstring injuries vs ACL injuries soccer)

• Identify which injury needs to be targeted as this will determine what types of screening tests will be used
• Do these specific injuries have modifiable factors?
• Are there clearly definable physical qualities related to the injury? ? Can these modifiable factors be clearly defined in terms of certain physical qualities?
• Can these physical qualities be identified with reliable screening tests?
• Can these physical qualities be influenced, modified or changed? (For example – blue eyes may be a predisposing factor to a certain type of injury and can easily and reliably be screened for, but eye colour can not be changed, modified or influenced.)
• Traumatic injuries in the sport – how influenceable are traumatic injuries through screening and training?

Screening for Neuromuscular Control of Movement

Neuromuscular control is the ability to perform a movement in the best possible way to minimise loading stress or maximise the distribution of loading stresses on the tissue involved. An important part of “movement screening” is to identify the high-risk movement tasks and can these tasks be broken down into closed skills.  A closed skill is undertaken in a controlled environment where the athlete only focuses on that specific skill (e.g. single leg squat or single-leg landing). An open skill is undertaken in a very chaotic and random environment (e.g. single-leg landing in the middle of a sporting environment such as competition or match). The context in which these movements take pace will have an influence on performance as well as the risk for injury. For example, an athlete may pass a closed skill test/task such as single-leg landing at the pre-season screening, but still get injured (i.e. ACL injury) as a result of a single-leg landing in a sporting environment such as a competition.

Selecting a Screening Test/Task

Factors to consider when selecting a screening test or task include:

• Nature of activities undertaken in the specific sport
• Nature of the major injuries in the specific sport (are these linked to specific movements or activities?)
• Athlete’s injury history (can the previous injuries be linked to specific movements or activities?)

Factors Influencing Neuromuscular Control of Movement

Various factors can have an impact on an athlete's ability to perform a specific screening test or task. These include:

• Strength
• Joint range of motion
• Muscle length – flexibility
• Proprioception – joint position sense
• Movement dissociation
• Sport specific skill

Building a Paradigm for Injury Risk Screening

• Consider Predisposition vs Prediction of injuries
  • Screening tests can’t predict if an athlete will get injured, but we can screen and look for predisposed athletes. Remember that being predisposed to a certain injury does not mean that the athlete will get injured. Also, if an athlete does not have a predisposition to an injury, this is not a guarantee that the athlete won’t be injured. Athletes become vulnerable to injury when they are exposed to load and inciting events. (see flow diagram)

• Identify if force generation, force absorption or movement skill is an issue in predisposition
• Identify the predisposing movement task/s
• Break down the identified movement task into close skills that can be measured reliably
• If the athlete fails the test/task, identify the reasons for failure
• Build ways to improve the skill in a controlled environment but then also in training and competition environments

Examples of Screening Tests

Functional Movement Screen (FMS)

United States Tennis Association High Performance Profile

Nine Test Screening Battery

Lower Quadrant Tests

Single-leg squat

Single-leg landing

Drop Jump Test

Star Excursion Balance Test

Hop for distance tests

Upper Quadrant Tests

GIRD

Closed chain upper limb test

Resources

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