Primary vs. secondary prevention. Page 1. Risk factors for Sports Injuries. Which is more important?

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1 Sports Medicine Association of Serbia and Montenegro Prevention of Sports Injuries Prof Martin Schwellnus UCT/MRC Research Unit for Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town Risk factors for Sports Injuries. Intrinsic (inherent to the athlete) Not modifiable (age, gender, ethnicity - genetics) Modifiable (biomechanics, muscle strength, flexibility). Extrinsic - factors not inherent to athlete (training, nutrition, equipment, environment and others) vs. secondary : Prevention of first injury Which is more important : or secondary Prevention of a recurrent injury What are the risk factors for injury in recreational athletes 58 men, 85 women 35 recreational athletes 3 Subjects were measured for 5 aerobic fitness, height, and body weight during the baseline athletes are: 5 examination. They reported past injury 5 detailed information about not their weight lifting >/week physical activity levels and injury experiences on the follow-up not stretching >/week survey (986) training > /week (increased frequency of load) An injury was defined as any self-reported soft tissue or bone injury that occurred within the previous months % male subjects with any injury The risk factors for injury in recreational Past injury Weight lifting > /week /week Physically active / week Present Absent Hootman JM, Macera CA, Ainsworth BE, Addy CL, Martin M, Blair SN, Med Sci Sports Exerc, ; 3(5): 838 to 8 Risk ratio What are the risk factors for acute muscle injury in sport A past history of muscle injury is is the single most important risk factor for a muscle injury (6-6 X greater risk) Past hx (< 8 weeks) Past hx (> 8 weeks) Age > 3 years Other past muscle injury Ham s tring Quadriceps Calf What is the best predictor of a hamstring strain or a groin strain in soccer rugby players Prospective cohort study 36 football players Pre-season assessment history, fitness parameters, muscle strength, muscle flexibility, and history of past hamstring injury Followed for season and incidence of injuries was documented Odds Ratio for injury 8 6 No previous injury Players with a past history of a hamstring or groin injury were respectively.6 and 7.3 times more likely to sustain a second Hamstring strain injury Previous injury Groin strain Orchard JW: Am J Sports Med ; 9(3): 3-33 Arnason A, Sigurdson SB, et al, Am J Sports Med (Suppl) 3 () Page

2 What is the best predictor of an acute hamstring strain in club rugby players Prospective cohort study Club rugby players Pre-season muscle strength (isokinetic), muscle flexibility, and history of past hamstring injury documented Followed for season and incidence of hamstring injuries was documented Hamstring Injuries % Players with a past history of a hamstring injury are 8.3 times more likely to sustain a hamstring injury (despite normal muscle Past Injury No Past Injury strength and flexibility) Odds ratio 8.3 p<. In, a past history In injury, of an injury (muscle, ligament) secondary is the single is most important one of risk the most factor for important another challenges injury Lombard R, Schwellnus M,. Adequate warm-up. Regular effective stretching 3. Normal muscle strength and balance. Correct sports equipment 5. Adequate and correct training 6. Correct biomechanics 7. Correct use of strapping and bracing 8. Optimum nutrition 9. Normal psychological status. / habits. Adequate warm-up. Regular effective stretching 3. Normal muscle strength and balance. Correct sports equipment 5. Adequate and correct training 6. Correct biomechanics 7. Correct use of strapping and bracing 8. Optimum nutrition 9. Normal psychological status. / habits of sports injuries. Warm up Increase muscle temperature by o C General vs. local Active vs. specific Decreased risk of injuries Animal studies Epidemiological studies Effect on performance Page

3 Force (N) Does warm-up influence the mechanical properties of the muscle Passive warm-up Increases peak stretch but decreases peak force Stretch (mm) Force (N) Active warm-up Increases peak stretch and peak force Stretch (mm) Does keeping the muscle warm by wearing thermal pants decrease the risk of recurrent hamstring muscle injuries Injury rate (Injuries/hrs play) (p<.5) Thermal pants No thermal pants Upton P et al, Br J Sports Med, 3, 996 of sports injuries. Does stretching decrease the risk of injuries Flexibility and injury risk: The effects of the stretch protocol Relative risk of injury.5.5 Andrish (97) No details 5 X 3 sec Hartig (999) 3 X sec X sec X sec Pope (998) Pope () v Mechelen (993) Adapted from: Yeung et al, Br J Sports Med (35) Does increased flexibility reduce the risk of muscle strain injuries (Specific injuries) 9 healthy military recruits randomly allocated to stretching (n=58) or no stretching (n=383) before and after each physical training session Stretches consisted of 3 sec hold ( repetitions) Injury rate reported (overall, monthly) for specific injuries (bony, muscle/tendon, ligament, joint, spine) Prospective randomized controlled trial Injury rate (% recruits) All injuries Control Amako M, Oda T, Masouka K, Yokoi H, Campisi P: Mil Med, 3; 68(6): -6 Bony Muscle tendon Ligament Joint Spine Page 3

4 Does decreased flexibility increase the risk of muscle strain injuries in soccer players with no previous injury ( ) Prospective cohort study 6 male soccer players with no history of muscle injury in the lower extremities in the previous years Flexibility of specific muscles (hamstring, quadriceps, adductor, calf) of the subjects was measured before the start of the season Players were monitored for specific muscle injuries (hamstring, quadriceps, adductor, calf). Pre-season ROM in the injured and non-injured groups Pre season ROM (deg) Witvrouw E, Danneels L, Asselman P, D Have T, Cambier D, Am J Sports Med, 3; 3(): Non-injured Hamstring Injured Quadriceps Summary: and sports injury. Using the correct dose of stretching reduces the risk of specific injuries (muscle/tendon). Data from studies on specific injuries (muscle and tendon) show reduction in injury risk with flexibility training 3. Flexibility and injury risk may be joint specific: possibly inherently stable joints greater flexibility will reduce injury risk. Inflexibility may be a more important independent risk in primary, but not secondary of injury of sports injuries 3. Normal muscle strength and balance Muscle strength (Isokinetic dynamometry) Muscle imbalances Muscle activation or recruitment patterns Peak torque (Nm/kg) Does decreased pre-season hamstring muscle concentric and eccentric peak torque increase risk of hamstring injury () Injured Non-injured : (p=.) Orchard J, Am J Sports Med, 5() 997 Peak torque (Nm) Injured : (p<.5) Non-injured Ecc 3 Ecc 8 Ecc 3 Jonhagen et al, AmJ Sports Med, () 99 Seasonal injury rates (%) Does reduced hamstring eccentric / quadriceps concentric ratios reduce the risk of hamstring injury () 5 3 Ratio <.9 (n=8) >.9 (n=8) Du Randt J, Scales N (unpublished data), 999 Page

5 Does pre-season hamstring muscle strength predict recurrent hamstring injury risk ().5 Prospective cohort study Club rugby players Pre-season muscle 3.5 strength (isokinetic), 3 muscle flexibility, and.5 history of past hamstring injury documented.5 Followed for season and incidence of hamstring.5 injuries was documented Hamstring Injuries % Con Quad Ecc Quad Con Ham Injured Ecc Ham Non-injured Con Ratio Ecc Ratio Lombard R, Schwellnus M, Ecc/Con of sports injuries. Correct Sports equipment Do shock absorbing insoles reduce the risk of injuries during training () Footwear Socks Shorts / Tops Underwear Racquets Randomized controlled clinical trial week training Incidence of overuse injuries documented Injuries/hrs All Stress # Tibial bone stress Schwellnus et al Am J Sports Med 6(), 99 Does a soft shock absorbing insert decrease the risk of bone stress injuries of the lower leg Odds Ratio of lower leg bone stress injury Control Insoles Gillespie WJ, Grant I. Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults (Cochrane Review). In: The Cochrane Library, Issue, 3 of sports injuries Page 5

6 5. Adequate and correct training Does pre-season strength (S) and endurance (E) training reduce the risk of injury in Rugby () Frequency Duration Type (Strength, endurance) Intensity Progression Periodization Risk ratio 5 5 No S or E Mainly S Mainly E S and E Randomized trial provincial rugby teams over one season Pre season strength (S) and endurance (E) training Calculate risk ratio of all injuries Upton P, MSc thesis, Univ. Of Cape Town Does pre-season training reduce the injury risk in soccer () of sports injuries 3 female soccer players (ages -8 years) Studied over a -year period players (TR group) were randomly selected to participate in a 7- week training program before the season Control, CON=8 % injuries in players 3 All CON TR ACL Heidt et al, Am J Sports Med ; 8(5) 6. Correct biomechanics Pelvic control and stability Knee alignment Patellar anatomy Quadriceps angle Lower leg alignment Rearfoot Forefoot Does the pattern of knee movement in the down stroke of cycling increase the risk of knee injuries () Linear (Normal) Oval Figure-of-eight Schwellnus MP, Milligan J, et al: MSSE 995; 7(Suppl), 5 Page 6

7 Frequency (%) Knee injury (n=) No knee injury (n=) : p<. 5 3 Oval Figure 8 Linear Schwellnus MP, Milligan J, et al: MSSE 995; 7(Suppl), 5 of sports injuries 7. Correct use of strapping and bracing Do ankle orthoses reduce the risk of ankle sprains ( Prevention) Seasonal incidence (%) Soccer (Tropp 985) Incidence/ hrs 5 5 Orthoses Controls Soccer (Surve 99) Orthoses Controls Incidence/ hrs Basketball, Sitler 99 6 Orthoses Controls There is only weak evidence that ankle orthoses decrease the incidence of primary lateral ankle ligament sprains Seasonal incidence (%) Incidence/ hrs Do ankle orthoses reduce the risk of recurrent ankle sprains ( ) Soccer (Tropp 985) 3 Orthoses Controls Soccer (Surve 99).5.5 There is stronger evidence that ankle orthoses decrease the incidence of secondary lateral ankle ligament sprains of sports injuries Little evidence Orthoses Controls Page 7

8 of sports injuries No evidence What does the future hold Is there a genetic risk for sports injuries Is there a genetic predisposition to chronic Achilles tendinopathy 8 53 Caucasian subjects diagnosed with chronic Achilles tendinopathy 6 p=.5 (AT) using clinical criteria and 5 non-injured Caucasian control subjects (CON) the development of chronic Achilles Subjects were genotyped for the tendinopathy A A A3 BstUI restriction fragment length polymorphism (RLFPs) within the COL5A RFLP BstUI Allele COL5A gene Control Achilles tendinopathy There appears to be a genetic predisposition to % subjetcs Thank you for your attention Mokone GG, Gajjar M, September A, Schwellnus MP, Greenberg J, Noakes TD, Collins M, ACSM 3 Page 8

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