Musculoskeletal Injury Prevention

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

Top Contributors - Wanda van Niekerk, Jess Bell, Tarina van der Stockt, Kim Jackson, Lucinda hampton and Merinda Rodseth  

Introduction[edit | edit source]

Injury prevention.jpeg

During the last couple of years, significant progress has been made in the field of injury prevention in multiple sports. However, there is an ongoing debate on our ability to truly and confidently prevent injuries. Ultimately, the global aim is to try to reduce the risk of injury as much as possible. This can be achieved by identifying factors that can increase risk. The aim is then to try to reduce an individual's predisposition to injury.

Large scale research studies have shown positive results for exercise-based prevention programmes, but there is still a gap between research findings and implementing these findings into real-world scenarios. Physiotherapists often address the more long-term modifiable predispositions such as strength, stability, proprioception and movement skill. By influencing these factors, the risk may be modified and, therefore, an individual's 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 found that static balance training reduces the incidence of ankle[1] and knee injuries.[2]

  • Trojian and McKeag[3] found an association between pre-season performance on a single leg balance test and ankle sprains throughout the season.
  • Oshima et al.[4] 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.[5] 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). If you are unfamiliar with this test then watch the video below.

The available evidence for the SEBT is:

  • Anterior reach on SEBT
    • Low performance on the SEBT anterior reaching direction (ANT) may increase the risk of an ankle ligament injury.[6]
    • Stiffler et al.[7] reported that assessing side to side reach asymmetry in the anterior direction of the SEBT may identify predisposed individuals at risk of sustaining non-contact injuries to the knee and ankle.
    • Ko et al.[8] 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. [9]reported that lower scores on the normalised SEBT - ANT, as a measure of dynamic balance, are associated with an increased risk for a 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.[10] investigated risk factors for ankle sprains in netball players and found that a lower postero-medial reach distance is associated with ankle sprains (a reach of less or equal to 77.5% of leg length).
    • Ruffe et al.[11] reported that runners with a postero-medial reach difference of > 4cm had an increased likelihood of hip/thigh/knee running-related injuries.
  • Postero-lateral reach in SEBT
    • Weak performance on the postero-lateral (PL) reach of the SEBT is a predisposing factor for ankle ligament injuries in an active population.[12]
    • Johanson et al.[13] reported a significant difference between scores on the SEBT-PL in individuals with femoroacetabular impingement (FAI) compared to individuals without FAI. Individuals with FAI score significantly lower on the SEBT-PL and an increased risk of pain and symptoms was reported. This test is a valid test to assess pain and other symptoms in individuals with FAI.

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.[14] reported that no factors related to flexibility, mobility and range of motion had a clear relationship with the risk of a hamstring injury. Common tests investigated included: passive knee extension, active knee extension, passive straight leg raise and the slump test.[14]
  • Limited hip abduction range of movement does not increase the risk of a groin muscle injury. Whittaker et al.'s[15] systematic review on risk factors for groin injury in sport highlighted that there is limited evidence of an association between hip range of motion and groin injury.[15] Another systematic review did find reduced hip abductor range of movement as a risk factor for groin/hip injury in field-based sports. However, a limited number of sports were considered in this review and both hip and groin injuries were investigated.[16]
  • 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.[17]
  • Limited ankle dorsiflexion range is not a risk factor for calf muscle injuries.[18]
  • Ankle dorsiflexion range did not predict stress fractures of the tibia or foot in military recruits.[19] [20]
  • Dorsiflexion range and knee injury
    • Fong et al.[21] reported that increased dorsiflexion range of motion was associated with greater knee flexion and smaller ground reaction forces during landing - i.e. a landing posture that is related to reduced anterior cruciate ligament (ACL) risk.
    • There is compelling evidence that there is an association between reduced/limited ankle dorsiflexion and dynamic knee valgus. It is, therefore, recommended that ankle dorsiflexion range of movement assessments be included in clinical practice as limitations in range may predispose individuals to harmful lower limb movement patterns.[22]

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.[23]
  • Hip abduction strength correlates to knee valgus angle, especially in single-leg ballistic tasks,[24] but the association to injury is limited and further research is necessary.[25]
  • 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.[26]
  • Reduced isometric hip abductor strength can predispose individuals to non-contact lateral ankle sprains.[27]
  • Trunk and hip muscle performance and motor control are significant contributors to ACL injury risk.[28] Khayambashi et al.[29] indicated that baseline hip abduction strength <35% of body weight (BW) predisposes athletes to future non-contact ACL injuries.
    • Bilateral isometric hip abduction was assessed with a handheld dynamometer. The athletes were in side-lying and a strap (positioned proximal to the iliac crest and secured around the treatment table) was used to stabilise the pelvis. The hip was abducted to 30°, and the dynamometer pad placed 10cm proximal to the lateral femoral condyle. The athletes abducted their hip with maximum effort into the dynamometer pad for 5 seconds against manual resistance.[29]
  • 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. Weakness in this musculature may lead to increased trunk instability and increased knee abduction, which may predispose an athlete to injury.[25]
  • Bilateral squat strength was associated with hip abduction and knee valgus on landing.[30]
  • 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 young female athletes.[31]

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 who have 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.[32]
  • Increased knee valgus on single leg squat increases lower limb injury risk.[33] Raisanen et al.[34] 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 have a greater likelihood (6.8%) of developing patellofemoral pain (PFP). Girls aged 16 with a landing score of >25Nm have an increased risk for both PFP and ACL injury.[35]
  • Bramah et al.[36] showed that for every 1° increase in pelvic drop during running, there was an 80% increase in the odds of being classified as injured.

Improving landing and running mechanics by reducing trunk lean, hip adduction and knee valgus will likely mitigate injury risk.

Multi-modal Interventions[edit | edit source]

There are multi-modal interventions that aim to incorporate 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.[37][38] More research is needed to better understand adherence to and the maintenance of these programmes. It is clear, though, that compliance is key to a successful reduction in injury.[39] It is also recommended that these multi-modal intervention programmes should be implemented throughout the season and not just for a short period of time i.e. only during pre-season.[40]

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 injury prevention[42]:

  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 about these steps here: Implementing Injury Prevention[43]

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 the programme[39][44]
  • Minimise time and maximise impact[45]
  • Make it progressive and sustained[46]
  • Consider making use of mesocycles and micro-dosing[47]
    • Periodisation 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.[48]

Resources[edit | edit source]

References[edit | edit source]

  1. Al Attar WS, Khaledi EH, Bakhsh JM, Faude O, Ghulam H, Sanders RH. Injury prevention programs that include balance training exercises reduce ankle injury rates among soccer players: a systematic review. Journal of physiotherapy. 2022 Jun 23.
  2. Olivares-Jabalera J, Fílter-Ruger A, Dos’ Santos T, Afonso J, Della Villa F, Morente-Sánchez J, Soto-Hermoso VM, Requena B. Exercise-based training strategies to reduce the incidence or mitigate the risk factors of anterior cruciate ligament injury in adult football (soccer) players: a systematic review. International journal of environmental research and public health. 2021 Dec 18;18(24):13351.
  3. Trojian TH, McKeag DB. Single leg balance test to identify the risk of ankle sprains. British journal of sports medicine. 2006 Jul 1;40(7):610-3.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
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  18. 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.
  19. 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.
  20. 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.
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  23. 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
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