Musculoskeletal Injury Prevention

Original Editor - Wanda van Niekerk based on the course by Lee Herrington

Top Contributors - Wanda van Niekerk  

Introduction[edit | edit source]

During the last couple of years significant progress has been made in the field of injury prevention in multiple sports, but there is always an ongoing debate on our ability to truly and confidently prevent injuries. The global aim is to try and reduce the risk of injury as much as possible. This can be achieved by identifying factors that could increase risk and then the aim would be to try and reduce the predisposition. Large scale research studies have shown the positive results of exercise-based prevention programmes, but there still remains a gap between research findings and implementing these findings into real-world scenarios. Physiotherapists are often involved in addressing the more long-term modifiable predispositions such as strength, stability, proprioception and movement skill. By influencing these factors, the risk factor may be modified and therefor the predisposition to injury may be reduced.

Read more on Musculoskeletal Injury Risk Screening

Modifiable Risk Factors[edit | edit source]

Evidence for Proprioception (Stability Training) to Prevent Injuries[edit | edit source]

There is an association between poor static balance and ankle and knee ligament injuries, and it has been shown that static balance training reduces the incidence of ankle and knee injuries.

  • Trojian and McKeag[1] found an association between preseason performance on a single-leg balance test and ankle sprains throughout the season.
  • Oshima et al[2] showed that poor static balance is a novel risk factor for ACL injuries and that proprioceptive training may be effective and clinically relevant in ACL prevention.
  • Rivera et al[3] concluded that proprioceptive training programmes were effective in reducing the incidence of ankle sprains in an athletic population, including those with and those without a history of ankle sprains.

An association between poor dynamic balance and injury exists. A test used to assess dynamic balance is the Star Excursion Balance Test (SEBT). Available evidence for this test:

  • Anterior reach on SEBT
    • Low performance on the SEBT -ANT may increase the risk of an ankle ligament injury.[4]
    • Stiffler et al[5] reported that assessing side to side reach asymmetry in the anterior direction of the SEBY may identify predisposed individuals at risk of sustaining non-contact injuries to the knee and ankle.
    • Ko et al[6] investigated dynamic balance as a risk factor for ankle injuries in adolescent soccer players and found a four-fold increased odds for ankle injuries in individuals with lower SEBT – ANT scores (<64%).
    • Bliekendaal et al [7]reported that lower scores on the normalised SEBT -ANT, as a measure of dynamic balance, are associated with an increased odds for subsequent ankle injury. However, in this study this was only significant in male participants and not females.
  • Postero-medial reach in SEBT
    • Attenborough et al[8] investigated risk factors for ankle sprains in netball players and found that a lower posterior-medial reach distance is associated with ankle sprains. (a reach of less or equal to 77.5% of leg length).
    • Ruffe et al[9] reported that runners with an postero-medial reach difference of > 4cm had an increased likelihood of hip/thigh/knee running-related injuries.
  • Postero-lateral reach in SEBT
    • A weak performance on the postero-lateral reach of the SEBT is a predisposing factor for ankle ligament injuries in an active population.[10]
    • Johanson et al[11] determined that lower scores on the SEBT – PL increases the risk of femoral acetabular impingement (FAI) injuries.

Improving static and dynamic balance could mitigate the risk of ankle and knee injuries.

Evidence for Range of Movement[edit | edit source]

  • Poor hamstring flexibility does not relate to hamstring injury risk. Green et al[12] reported no factor related to flexibility, mobility and range of motion showed a clear relationship with the risk of hamstring injury. Common tests investigated included: passive knee extension, active knee extension, passive straight leg raise and slump.[12]
  • Limited hip abduction range of movement does not increase the risk of a groin muscle injury. Whittaker et al[13] did a systematic review on risk factors for groin injury in sport and highlighted that there is limited evidence of an association between hip range of motion and groin injury.[13] Another systematic review did find reduced hip abductor range of movement as a risk factor for groin/hip injury in field-based sports. However, there was a limited scope of sports considered in this review and both hip and groin injuries were investigated.[14]
  • Quadriceps flexibility (as determined by the modified Thomas test), was reported as an independent risk factor for hamstring injury occurrence in Australian rules football players; players with greater flexibility were 70% less likely to suffer a hamstring injury.[15]
  • Limited ankle dorsiflexion range is not a risk factor for calf muscle injuries.[16]
  • Ankle dorsiflexion range did not predict stress fractures of the tibia or foot in military recruits.[17] [18]
  • Dorsiflexion range and knee injury
    • Fong et al reported that increased dorsiflexion range of motion was associated with greater knee flexion and smaller ground reaction forces during landing, thus a landing posture that is related to reduced anterior cruciate ligament (ACL) risk.[19]
    • There is compelling evidence for an association between reduced/limited ankle dorsiflexion and dynamic knee valgus. It is therefor recommended to include ankle dorsiflexion range of movement assessments in clinical practice as it may be a predisposition to harmful lower limb movement patterns.[20]

Improving ankle dorsiflexion range of movement may be beneficial in preventing injuries, but improving hamstring flexibility will not prevent hamstring injuries.

Evidence for Strength[edit | edit source]

  • Hip abduction weakness on single-leg balance tasks relates to impaired postural control. Deficits in postural control and balance may lead to an increased risk of ankle sprains.[21]
  • Hip abduction strength correlates to knee valgus angle, especially in single leg ballistic tasks[22], but association to injury is limited and further research is necessary.[23]
  • Knee valgus angle and moment on landing tasks are influenced by gluteal muscle strength. The level of influence varies across different tasks such as single leg squatting and landing tasks as well as between genders.[24]
  • Reduced isometric hip abductor strength can be a predisposition to non-contact lateral ankle sprains.[25]
  • Trunk and hip muscle performance and motor control are significant contributors to ACL injury risk.[26] Khayambashi et al[27] indicated that baseline hip abduction strength <35% of body weight (BW) predisposes athletes to future non-contact ACL injuries.
  • Reduced trunk lateral flexion strength, measured with a side-bridge test, was associated with increased knee abduction angle during a single-leg squat. The side-bridge test incorporates lateral flexion strength of the trunk as well as hip abductor strength, therefore a weakness in this musculature may lead to increased trunk instability and increased knee abduction and together this may predispose an athlete to injury.[23]
  • Bilateral squat strength was associated with hip abduction and knee valgus on landing.[28]
  • Weaker levels of lower extremity muscle strength (assessed with the one repetition maximum (1RM) barbell squat) may be an important and modifiable predisposition for sustaining a traumatic knee injury in youth female athletes.[29]

Injuries are likely to be mitigated by increasing triple extension or squat strength and by improving hip abductor muscle strength.

Evidence for Movement Skill[edit | edit source]

  • Female athletes with a combination of increased knee valgus and lateral trunk motion in the direction of the stance limb during the single leg drop vertical jump test may have an increased risk for non-contact knee injuries.[30]
  • Increased knee valgus on single leg squat increases lower limb injury risk.[31] Raisanen et al[32] showed that athletes with a high frontal plane knee projection angle (FPKPA) during a single-leg squat were 2.7 times more likely to sustain a lower extremity injury and 2.4 times more likely to sustain an ankle injury.
  • Adolescents girls (13 years) with a knee abduction moment or load of >15 Nm associated with a greater likelihood (6.8%) of developing patellafemoral pain (PFPS). Girls aged 16 with a landing score of >25Nm have an increased risk for both PFP and ACL injury.[33]
  • Bramah et al[34] showed that for every 1° increase in pelvic drop during running, there was a 80% increase in the odds of being classified as injured.

Improving landing and running mechanics through mainly reducing trunk lean, hip adduction and knee valgus it is likely to mitigate injury risk.

Multi-modal Interventions[edit | edit source]

There are multi-modal interventions that aim to incorporate the modifiable predispositions such as strength, range of movement, proprioception and movement skill. These programmes are usually introduced as part of an extended warm-up programme. There is evidence that these types of injury prevention programmes are successful in reducing injury risk.[35][36] More research is needed to gain a further understanding of the adherence to and the maintenance of these programmes. It is clear, though, that compliance is key to a successful reduction in injury.[37] It is also recommended to implement these multi-modal intervention programmes throughout the season and not just for a short period of time i.e. only during pre-season.[38]

Read more about Injury Prevention in sport here: Injury Prevention in Sport

Examples of Interventions[edit | edit source]

Implementing Injury Prevention[edit | edit source]

Ways to successfully implement an injury prevention[40]:

  1. Secure buy-in from all key decision makers
  2. Develop an interdisciplinary team
  3. Identify barriers and solutions
  4. Design a context-specific programme
  5. Coach the coaches
  6. Enhance fidelity
  7. Develop an exit strategy

Read more detail about these steps here: Implementing Injury Prevention

Key Considerations for Prehabilitation[edit | edit source]

  • Identify the need for intervention
  • Identify potential modifiable physical qualities
  • Assess if these physical qualities are an issue
  • Engage athletes and coaches in programme[37]
  • Minimise time and maximise impact[41]
  • Make it progressive and sustained[42]
  • Consider making use of mesocycles and micro-dosing
    • Perodisation of training works on the principles of overload and adaptation. There are three types of periodisation cycles:
      • Macrocycle = whole season
      • Mesocycle = specific training block within the season designed to accomplish a particular goal such as endurance, strength, stability or movement skill, usually between 4 – 6 weeks in length
      • Microcycle = smallest unit within the mesocycle – usually a week of training
    • Microdosing = involves performing high intensity, low volumes of training but with a higher frequency.[43]

Resources[edit | edit source]

References[edit | edit source]

  1. Trojian TH, McKeag DB. Single leg balance test to identify risk of ankle sprains. British journal of sports medicine. 2006 Jul 1;40(7):610-3
  2. Oshima T, Nakase J, Kitaoka K, Shima Y, Numata H, Takata Y, Tsuchiya H. Poor static balance is a risk factor for non-contact anterior cruciate ligament injury. Archives of Orthopaedic and Trauma Surgery. 2018;138:1713-8.
  3. Rivera MJ, Winkelmann ZK, Powden CJ, Games KE. Proprioceptive training for the prevention of ankle sprains: an evidence-based review. Journal of athletic training. 2017 Nov;52(11):1065-7
  4. Gribble PA, Terada M, Beard MQ, Kosik KB, Lepley AS, McCann RS, Pietrosimone BG, Thomas AC. Prediction of lateral ankle sprains in football players based on clinical tests and body mass index. The American journal of sports medicine. 2016 Feb;44(2):460-7
  5. Stiffler MR, Bell DR, Sanfilippo JL, Hetzel SJ, Pickett KA, Heiderscheit BC. Star excursion balance test anterior asymmetry is associated with injury status in division I collegiate athletes. journal of orthopaedic & sports physical therapy. 2017 May;47(5):339-46
  6. Ko J, Rosen AB, Brown CN. Functional performance tests identify lateral ankle sprain risk: a prospective pilot study in adolescent soccer players. Scandinavian journal of medicine & science in sports. 2018 Dec;28(12):2611-6
  7. Bliekendaal S, Stubbe J, Verhagen E. Dynamic balance and ankle injury odds: a prospective study in 196 Dutch physical education teacher education students. BMJ open. 2019 Dec 1;9(12):e032155
  8. Attenborough AS, Sinclair PJ, Sharp T, Greene A, Stuelcken M, Smith RM, Hiller CE. The identification of risk factors for ankle sprains sustained during netball participation. Physical Therapy in Sport. 2017 Jan 1;23:31-6
  9. Ruffe NJ, Sorce SR, Rosenthal MD, Rauh MJ. Lower quarter-and upper quarter Y balance tests as predictors of running-related injuries in high school cross-country runners. International journal of sports physical therapy. 2019 Sep;14(5):695
  10. De Noronha M, França LC, Haupenthal A, Nunes GS. Intrinsic predictive factors for ankle sprain in active university students: a prospective study. Scandinavian journal of medicine & science in sports. 2013 Oct;23(5):541-7
  11. Johansson AC, Karlsson H. The star excursion balance test: Criterion and divergent validity on patients with femoral acetabular impingement. Manual therapy. 2016 Dec 1;26:104-9
  12. 12.0 12.1 Green B, Bourne MN, van Dyk N, Pizzari T. Recalibrating the risk of hamstring strain injury (HSI): A 2020 systematic review and meta-analysis of risk factors for index and recurrent hamstring strain injury in sport. British Journal of Sports Medicine. 2020 Sep 1;54(18):1081-8
  13. 13.0 13.1 Whittaker JL, Small C, Maffey L, Emery CA. Risk factors for groin injury in sport: an updated systematic review. British journal of sports medicine. 2015 Jun 1;49(12):803-9
  14. Ryan J, DeBurca N, Mc Creesh K. Risk factors for groin/hip injuries in field-based sports: a systematic review. British journal of sports medicine. 2014 Jul 1;48(14):1089-96
  15. Gabbe BJ, Finch CF, Bennell KL, Wajswelner H. Risk factors for hamstring injuries in community level Australian football. British journal of sports medicine. 2005 Feb 1;39(2):106-10
  16. Green B, Pizzari T. Calf muscle strain injuries in sport: a systematic review of risk factors for injury. British journal of sports medicine. 2017 Aug 1;51(16):1189-94
  17. Dixon S, Nunns M, House C, Rice H, Mostazir M, Stiles V, Davey T, Fallowfield J, Allsopp A. Prospective study of biomechanical risk factors for second and third metatarsal stress fractures in military recruits. Journal of science and medicine in sport. 2019 Feb 1;22(2):135-9
  18. Nunns M, House C, Rice H, Mostazir M, Davey T, Stiles V, Fallowfield J, Allsopp A, Dixon S. Four biomechanical and anthropometric measures predict tibial stress fracture: a prospective study of 1065 Royal Marines. British journal of sports medicine. 2016 Oct 1;50(19):1206-10
  19. Fong CM, Blackburn JT, Norcross MF, McGrath M, Padua DA. Ankle-dorsiflexion range of motion and landing biomechanics. Journal of athletic training. 2011 Jan;46(1):5-10
  20. Lima YL, Ferreira VM, de Paula Lima PO, Bezerra MA, de Oliveira RR, Almeida GP. The association of ankle dorsiflexion and dynamic knee valgus: A systematic review and meta-analysis. Physical Therapy in Sport. 2018 Jan 1;29:61-9
  21. Gafner SC, Hoevel V, Punt IM, Schmid S, Armand S, Allet L. Hip-abductor fatigue influences sagittal plane ankle kinematics and shank muscle activity during a single-leg forward jump. Journal of Electromyography and Kinesiology. 2018 Dec 1;43:75-81
  22. Dix J, Marsh S, Dingenen B, Malliaras P. The relationship between hip muscle strength and dynamic knee valgus in asymptomatic females: A systematic review. Physical Therapy in Sport. 2019 May 1;37:197-209
  23. 23.0 23.1 Cronström A, Creaby MW, Nae J, Ageberg E. Modifiable factors associated with knee abduction during weight-bearing activities: a systematic review and meta-analysis. Sports Medicine. 2016 Nov;46(11):1647-62
  24. Neamatallah Z, Herrington L, Jones R. An investigation into the role of gluteal muscle strength and EMG activity in controlling HIP and knee motion during landing tasks. Physical Therapy in Sport. 2020 May 1;43:230-5
  25. Powers CM, Ghoddosi N, Straub RK, Khayambashi K. Hip strength as a predictor of ankle sprains in male soccer players: a prospective study. Journal of athletic training. 2017 Nov;52(11):1048-55
  26. Lucas KC, Kline PW, Ireland ML, Noehren B. Hip and trunk muscle dysfunction: implications for anterior cruciate ligament injury prevention. Ann Joint. 2017 May 1;2:18
  27. Khayambashi K, Ghoddosi N, Straub RK, Powers CM. Hip muscle strength predicts noncontact anterior cruciate ligament injury in male and female athletes: a prospective study. The American journal of sports medicine. 2016 Feb;44(2):355-61.
  28. McCurdy K, Walker J, Armstrong R, Langford G. Relationship between selected measures of strength and hip and knee excursion during unilateral and bilateral landings in women. The Journal of Strength & Conditioning Research. 2014 Sep 1;28(9):2429-36
  29. Augustsson SR, Ageberg E. Weaker lower extremity muscle strength predicts traumatic knee injury in youth female but not male athletes. BMJ open sport & exercise medicine. 2017 Apr 1;3(1):e000222
  30. Dingenen B, Malfait B, Nijs S, Peers KH, Vereecken S, Verschueren SM, Staes FF. Can two-dimensional video analysis during single-leg drop vertical jumps help identify non-contact knee injury risk? A one-year prospective study. Clinical biomechanics. 2015 Oct 1;30(8):781-fro7
  31. Eckard T, Padua D, Mauntel T, Frank B, Pietrosimone L, Begalle R, Goto S, Clark M, Kucera K. Association between double-leg squat and single-leg squat performance and injury incidence among incoming NCAA Division I athletes: A prospective cohort study. Physical Therapy in Sport. 2018 Nov 1;34:192-200
  32. Räisänen AM, Pasanen K, Krosshaug T, Vasankari T, Kannus P, Heinonen A, Kujala UM, Avela J, Perttunen J, Parkkari J. Association between frontal plane knee control and lower extremity injuries: a prospective study on young team sport athletes. BMJ open sport & exercise medicine. 2018 Jan 1;4(1):e000311
  33. Myer GD, Ford KR, Di Stasi SL, Foss KD, Micheli LJ, Hewett TE. High knee abduction moments are common risk factors for patellofemoral pain (PFP) and anterior cruciate ligament (ACL) injury in girls: is PFP itself a predictor for subsequent ACL injury?. British journal of sports medicine. 2015 Jan 1;49(2):118-22
  34. Bramah C, Preece SJ, Gill N, Herrington L. Is there a pathological gait associated with common soft tissue running injuries?. The American journal of sports medicine. 2018 Oct;46(12):3023-31
  35. Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R. Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial. Bmj. 2005 Feb 24;330(7489):449
  36. Silvers-Granelli HJ, Bizzini M, Arundale A, Mandelbaum BR, Snyder-Mackler L. Does the FIFA 11+ injury prevention program reduce the incidence of ACL injury in male soccer players?. Clinical Orthopaedics and Related Research®. 2017 Oct;475(10):2447-55
  37. 37.0 37.1 Sugimoto D, Myer GD, Micheli LJ, Hewett TE. ABCs of evidence-based anterior cruciate ligament injury prevention strategies in female athletes. Current physical medicine and rehabilitation reports. 2015 Mar;3(1):43-9
  38. 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. The American journal of sports medicine. 2019 Jun;47(7):1744-53
  39. Harøy J, Clarsen B, Wiger EG, Øyen MG, Serner A, Thorborg K, Hölmich P, Andersen TE, Bahr R. The adductor strengthening programme prevents groin problems among male football players: a cluster-randomised controlled trial. British journal of sports medicine. 2019 Feb 1;53(3):150-7
  40. Padua DA, Frank B, Donaldson A, de la Motte S, Cameron KL, Beutler AI, DiStefano LJ, Marshall SW. Seven Steps for Developing and Implementing a Preventive Training Program: Lessons Learned from JUMP ACL and Beyond. Clinics in sports medicine. 2014 Oct;33(4):615
  41. Dargo L, Robinson KJ, Games KE. Prevention of knee and anterior cruciate ligament injuries through the use of neuromuscular and proprioceptive training: an evidence-based review. Journal of athletic training. 2017 Dec;52(12):1171-2
  42. Sugimoto D, Myer GD, Foss KD, Hewett TE. Dosage effects of neuromuscular training intervention to reduce anterior cruciate ligament injuries in female athletes: meta-and sub-group analyses. Sports Medicine. 2014 Apr;44(4):551-62
  43. Read PJ, Oliver JL, Lloyd RS. Seven Pillars of Prevention: Effective Strategies for Strength and Conditioning Coaches to Reduce Injury Risk and Improve Performance in Young Athletes. Strength & Conditioning Journal. 2020 Dec 1;42(6):120-8
  44. E3 Rehab. Fifa 11+ Injury Prevention Program (Plus Free Handouts). Available from https://www.youtube.com/watch?v=X5YyunLZzBc. [last accessed 13/09/2021]
  45. Aspetar. Aspetar Hamstring Protocol Full video. Available from https://www.youtube.com/watch?v=Fzex_zG1JtA&t=1s. [last accessed 13/09/2021]