Musculoskeletal Injury Risk Screening

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Introduction

Reasons for the periodic medical assessment of athletes

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

Types of 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 (Emery, 2019)

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 for example. (Walia B, Boudreaux CJ. The cost of players’ injuries to professional sports leagues and other sports organizations. Managerial Finance. 2020 Jul 31.)

Team performance

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

Financial implications for the healthcare system –

Finch et alestimated the direct cost of sport-related injury over seven years to be $265 million Australian dollars (Finch, Emery ref)

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. (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.)

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 (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.)

Career progression in sports

Larukain et al demonstrated a negative association between injuries and player progression in an elite football academy. (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).

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 and 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. – download Bolling image and edit and upload

Predispose vs Predict

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

Anatomy

Genetics

Previous injury

Environmental factors

Modifiable predispositions

Long-term

Strength

Movement

Skill

Flexibility

Short term

State of the athlete

How does the athlete feel?

Tired?

Stressed?

This flow diagram 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

Exposure = load applied through training, match-time

Vulnerability = predisposed athlete exposed through load applied eg playing a game

Add image of flow diagram

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 ie modified and changed? (Example – blue eyes are predisposing to a certain type of injury: one can easily and reliably screen for it, 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. (Herrington book chapter). 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.

Factors to consider when selecting a task/screening test

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

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

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

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