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Fit for play. Injury prevention and Management Chris McNicholl

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1 Fit for play. Injury prevention and Management Chris McNicholl
Fit for play. Injury prevention and Management Chris McNicholl.Chartered Physiotherapist. Mid Ulster Physiotherapy Clinic.

2 Fit for play. Set the scene re injury. Injury occurrence.
Injury management. Injury prevention.

3 Dynamic, multifactorial model of sports injury etiology Meeuwisse, ‘94
Internal Risk Factors Age Gender Body composition Health Physical fitness Anatomy Skill level Previous injury Motor Abilities Psychological profile Motivation Risk taking Stress coping INJURY Predisposed Athlete Susceptible Athlete Exposure to external risk factors: Human factors (team Mates, opponents, ref) Training Exposure Protective equipment Sports Equipment Environment Inciting event: Joint motion (Kinematics, jt forces and moments) Playing situation (Skill performed) Training programme Match schedule Risk factors can be divided into modifiable and non-modifiable factors. Although non-modifiable factors such as gender and age may be of interest, as a minimum it is NB to study factors which are potentially modifiable through physical training or behavioural approaches, such as strength, balance or flexibility. However, merely to establish the int and ext risk factors for sports injuries is not enough. To establish a complete understanding of the causes, the mechanisms by which they occur must also be identified. In other words, sports injuries result from complex interaction of multiple risk factors and events of which only a fraction have been identified. Roald Bahr, I. Holme – ’03 Dynamic model required – that accounts for the multifactorial nature of sports injuries, and, in addition, takes the sequence of events eventually leading to an injury into account. E.g. Meeuwisse model. BASEM Congress 2004

4 Recurrent Injuries First Injury
Croisier, 2004 Modifications From initial strain Questionable Options in treatment Extrinsic Factors Intrinsic Factors Recurrent Injuries First Injury Factors associated with recurrent hamstring injuries Jean-Louis Croisier Sports Medicine 2004:34(10): Persistence of mistakes or abnormalities in action represent a component contributing to the re-injury cycle. Additional factors leading to the chronicity can come from the first injury per se through modifications in the muscle tissue and possible adaptive changes in biomechanics and motor patterns of sporting movements. We emphasise the role of questionable approaches to the diagnosis process, drug treatment or rehabilitation design. BASEM Congress 2004

5 Age Age Age Nature Activity Cause Location Time Severity Other

6 Results

7 Occurrence of Injury

8 Location of Injury

9 Location of Injury Shoulder 7% Groin 9% Quads 8% Knee 14%
Hamstrings 22% Ankle 13%

10 Hurling Injuries Muscle injuries 24% (hamstrings 12%) Contusions 16.3%
sprains 15.6% 41% were attributed to foul play! Watson 1996 Am.J.Sp.Med

11 Location of injury Hamstring 12% Head 9% Fingers 13% Knee and ankle 9%
Watson. A 1996 Am. J.Sp.Med

12 Figure 1 Site of injury, with 95% CI.
Wilson, F et al. Br J Sports Med 2007;41: Copyright ©2007 BMJ Publishing Group Ltd.

13 Figure 2 Type of injury, with 95% CI.
Wilson, F et al. Br J Sports Med 2007;41: Copyright ©2007 BMJ Publishing Group Ltd.

14 Figure 3 Mechanism of injury, with 95% CI.
Wilson, F et al. Br J Sports Med 2007;41: Copyright ©2007 BMJ Publishing Group Ltd.

15 Figure 4 Injury rate by position, with 95% CI.
Wilson, F et al. Br J Sports Med 2007;41: Copyright ©2007 BMJ Publishing Group Ltd.

16 Comparisons Gaelic football 13.5/1000 hrs Wilson et al 2006
Soccer /1000 hrs Hawkins. Aus Rules /1000 hrs Seral et al Rugby League 139/1000 hrs Seral et al Rugby Union /1000 hrs Bird et al

17 My practice. 296 attendances in 2004. 33% Muscular 22.6% Ligament
23.9% Overuse 9.5% Tendon 6.5% Contusion 4.5% Fracture,Dislocation, derangement.

18 Audit of Gaelic footballers and hurlers attending from clubs in Tyrone, Derry and Antrim over 2004.
1 3

19 Injury management. Acute Stage (Hours and days)
Bleeding and onset of inflammation. Protection. Rest. Ice. Compression. Elevation.

20 Regeneration. Involves the production of scar (collagen) material. Begins 24-48hrs post injury and can peak up to 2-3 weeks post injury. Therapeutic modalities. Soft tissue mobilisation. Return to non- “harmful” activities.

21 Repair and remodelling.
The production of a high quality functional scar. 4 weeks to 6 months. Graduated exposure to stress. Return to full range of movement and strength. Full sport specific rehabilitation. Address any biomechanical weaknesses.

22 Inadequate rehab. Watson demonstrated in Irish Soccer/Gaelic/hurling that time lost through injury in the previous year was largest predictor of new injury. 82% of County players in one study had been injured in previous 6 months. 35% of these injuries were recurring. 46% Continued to play, 93% of whom believed their performance had been affected. Cromwell et al Br J.Sp Med. Injured muscle retains sufficient muscle strength to allow early limited functional rehab Injured muscle at risk for complete rupture if muscle subjected to high tensile forces Use of techniques designed to rapidly return the athlete to competition may magnify this risk for rupture Taylor et al, ’93

23 Injury prevention

24 Injury prevention. Ensure previous injuries are fully healed and player fully rehabilitated. Use professionals. Set yourself /team a rule that going into league players returning from injury must be back in training for 2 weeks before game.

25 “Recovery that’s the name of the game… Whoever recovers the fastest does the best”.

26 Principles of training
Adaptation. Adaptation only happens if the body is worked harder than normal. This is called OVERLOAD. If the body is overloaded regularly it will adapt to try and tolerate the stress. This is the point of training. If the overload is too great the body may breakdown and cause an injury. Therefore the overload needs to be PROGRESSIVE

27 Consequences of exercise
Training and competition create an overload to stress the body, which in turn produces fatigue –followed by improved performance. Normal recovery Training Accelerated recovery The Principle of Recovery

28 Muscle DOMS. Increase in muscle stiffness. Lactic.
Calcium and fatigue.

29 Neurological Sympathetic nervous system. Aerobic metabolism.
Fast and slow components. With adequate recovery this returns to normal levels. However if a high training volume or intensity is repeatedly performed without necessary rest sympathetic nervous system activity will become increasingly high. This leads to an increase in resting heart rate and is a sign of overreaching and overtraining when symptoms are not detected.Hahn 1994

30 Key Aspects to Fatigue Psychological Physiological Nutritional
Neurological Environmental

31 Recovery Recovery is one of the basic principles of training methodology.Rushall and Pyke 1990. It refers to the period of time after training when the body recovers from the demands placed upon it during intense exercise. Many athletes train extremely hard without giving their body time to recover. This can lead to over reaching, burn out, or poor performance.Mackinnon and Hooper 1991 “The team” (athlete, coach, trainer, Physio, Doctor Masseur) need to continually monitor for signs and symptoms of poor adaptation to training and stress. Need to implement strategies to minimize residual fatigue.

32 Adequate Recovery Fitness Level Session 2 Session 3 Session 1 Days

33 Inadequate Recovery Fitness Level Days Session 3 Session 2 Session 4

34 Overtraining Fitness Level Days Session 2 Session 3 Session 4

35 Direct Body Communication Language
Signs and symptoms of incomplete recovery (Adapted from Angela Calder: Recovery Strategies for Sports Performance) Direct Communication Body Language Facial Expression Facial Colour Posture Signs of frustration Athlete says he has: Heavy legs Doesn’t feel good Legs are sore Feels tired

36 Performance Psychological
Signs and symptoms of incomplete recovery (Adapted from Angela Calder Recovery Strategies for Sports Performance) Poor skill execution Slow acceleration off the mark Heavy feet Poor decision making Slow response time Low motivation Low concentration Aggressiveness No self confidence Poor eating/diet Poor sleep pattern Performance Psychological

37 Case Study 20yr old footballer Poor kyphotic posture
History of right ankle sprains History of right hip pathology History of right shoulder pain Currently complaining of left thigh pain Poor balance and proprioception Significantly reduced hamstring length Unstable right shoulder Continued to play throughout injury- still feels sore (2 years later) Constantly feels stiff and sore Trains 5 times per week Regularly plays 3 games per week Case Study

38 Advantages of good recovery.
Minimise the effects of residual training fatigue. Help prevent overtraining- injury- illness. Allow you to get the most out of your trainings Overall improve performances

39 Hydration and Nutrition
Restore fluid balance as quickly as possible 1.5 litres fluid for every 1 kg weight loss Rehydration solutions helps retain fluid and prevents big losses Consume CHO immediately to promote refuelling 1 g / kg body weight immediately Eat / Drink protein Follow with a high CHO meal within 2-3 hours Sodium replacement will help to maximise retention of ingested fluid

40 Passive Recovery (Rest is Best!)
A good 7-9 hrs provides invaluable time for an adult to adapt to the Physical - Immunological - Emotional – Stressors experienced During that day Napping helps recovery ? ½ hr during day

41 Hydrotherapy The Theory Accelerates recovery by increasing peripheral circulation, removing metabolic wastes and stimulating the central nervous system.Calder 2001. Hot and cold baths accelerated lactate recovery in elite female hockey players. Sanders 1996 Jet pressurised water spa immersion in Judo fighters demonstrated an improvement in recovery. Gieremek 1990. Contrast baths (hot and cold) Spas Showers Ice baths ? Cryotherapy chambers

42 Hydrotherapy “Despite the popularity..little research has been conducted….they all need to be thoroughly investigated before it can be claimed as an accelerant for aiding recovery” Cochrane J Alternating hot and cold water immersion for athlete recovery:a review. Physical Therapy in Sport. Ice baths “Its absolute agony, and I dread it, but it allows my body to recover so much more quickly” Paula Radcliffe Reduces inflammation but is this always desirable?

43 Massage Improved recovery and maintenance of performance during pre season female volley ball. Mancellini et al 2006 It does promote relaxation in the muscles Calder Improved mood states and feelings of well being have been shown in several studies. Hamer 1999

44 Psychological Recovery
Healing rates are slower when in a state of stress.Marucha et al 1998 Higher levels of depression and anxiety had a statistically significant association with slower healing.Cole-King 2001 Debriefing Emotional Recovery/Contingency plans Mental Toughness Skills e.g. positive self talk, positive body language Relaxation techniques egg meditation, music, breathing

45 Compression Garments Garments-leggings,short pants or tops
Apply a graded compression to the body.

46 N.Gill investigated 4 different recovery strategies following competitive rugby matches by measuring Creatine Kinase concentration. Players were measured post match and at 24 hrs and 72 hrs. active recovery hot and cold baths passive recovery 4 skins

47 Periodisation This is the term used for planning and organising training , competition and rest over a given period of time e.g. 1 season with the aim of “peaking” at various times. Period should be divided into blocks or cycles of training. There should always be several consistent phases to the training plan.

48 Planning your season. Dec Jan Feb Mar Apr May Jun July Aug Sep Oct Nov
Off season. Rest, recovery, holiday, turkey. Injuries sorted. Screening. Pre-season. Set a base. Developmental phase. Advance and develop key components of fitness Power phase. Power, speed and explosive fitness. Competition Phase. Maintain strength etc.

49 Example 2 months training consisting of 2x 4week cycles
F= Field, C=Circuit, P=Pool Intensity: L= Low, M=Medium, H=High

50 Planning your session. Ensure players are punctual and hydrated.
Warm up 15mins- 20mins Match /Training 60 mins+/- Warm down.10-15max Recovery strategies.

51 Warm up Gradual increase in intensity jog- ½ ¾ pace.
Increase blood flow, get the nervous system “tuned in” and decrease muscle stiffness (passive). Facilitate motor unit recruitment before full out activity. Introduce skills and change of direction. Introduce dynamic movements/stretches. Get our full active flexibility. Introduce full pace and end range body movements necessary for that sport.

52 Specificity It is advised that training should be sport specific.
Gaelic football and hurling are multisprint sports. Sprints are rarely any more than 40 metres, with the majority less than 20 metres. They are rarely linear. Training should include lots of directional change at pace to include decceleration as well as acceleration.

53 Fatigue Remember alterations in calcium ion content in muscle affects contractibility. Muscles less able to absorb high forces Decreased viscoelasticity. Avoid sprints when fatiqued.(ie end of session).

54 Australian Rules Verral et al 2005 British Journal of Sports Medicine.
Pre season intervention to decrease. hamstring injuries. Changed focus from long endurance runs to acceleration training and high intensity sports specific drills. Stretched when fatigued. Strength training. Bodyweight only to first timers, weights to those with experience. Hamstring injuries went from 4.7/1000 playing hours to 1.3/1000.

55 Active Recovery (Cool Down)
The Theory: Light activity during the post exercise period has been shown to increase lactate clearance rates E.g. Walk/jog/cycle/swim Gupta et al 1996 Needs to be at least 5 mins Bonen A 1976 Dodds.s demonstrated greatest recovery at 35% VO2 max. Advice is to work for approx mins as any longer causes glycogen depletion. Improves psychological recovery Suzuki 2001 The following day mins of light activity (eg low intensity pool session.) Reduces DOMs Hasson et al 1989 ? stretch

56 Active Recovery (Cool Down)
In Practice: Desirable after training and games Where possible use “off feet” strategies ie bike/rower or pool : eg easy spinning 5 mins /row 5 mins then walking and general limb movements in water. Sports requiring repeated bouts of high intensity work will benefit from active recovery in between efforts. Next day where possible short low intensity session.

57 Flexibility. Is described as a component of fitness.
Relationship with performance. Relationship with injury controversial. No correlation between flexibility and injury in Irish soccer/gaelic/hurlers. Watson 2001 Flexibility of a joint is determined by the geometry (shape) of the articular structures, the muscles, tendons,ligaments and joint capsule laxity. The nervous system can also affect flexibility. One would presume that individuals who have greater flexibility would be at less risk of injury than those with less. However the evidence here is controversial.

58 Stretching: Definitions
We need to separate stretching from flexibility /range of movement. Static vs Dynamic Ballistic PNF. Effects? There are those who have excellent flexibility and don't stretch and those who have terrible flexibility and stretch all the time.

59 When..? Where...? How..? Sports involving bouncing and jumping activities with a high intensity of stretch-shortening cycles (SSCs) [e.g. hurling and football] require a muscle-tendon unit that is compliant enough to store and release the high amount of elastic energy that benefits performance in such sports. Sports involving SSC movements Require a compliant muscle-tendon unit Store/release high amounts of elastic energy Stretching may be important as an injury prevention measure No, or low SSC movements Compliant muscle-tendon unit offers no advantage Additional stretching exercises to improve compliance may have no beneficial effect Witvrouw et al, ‘04

60 Static Stretching Therefore the advice must be at present to stretch throughout the week as an intervention to maintain compliance within the musculotendinous unit.

61 Screening General health. Musculoskeletal profiling. Functional tests
Pitch tests.

62 Musculoskeletal profiling
Identify predisposing factors to injury. Detect potential “weak” links that affect performance. Identify injuries Posture Range of movement Muscle Strength Stability. Balance.

63 Screening in Gaelic Football Sports Institute for Northern Ireland
As a group the Gaelic footballers had Tight hip flexors and poor core stability. Poor posture associated with Thoracic and Lumbar stiffness. Proprioceptive deficits. (Balance deficits) 8/18 “sway back” posture 14/18 had comments regarding postural problems 8/18 Tight hip flexors 9/18 Poor pelvic stability

64 So what? It is generally believed that poor control of stability around the pelvis and CORE are responsible for causing a lot of pain and injury. L.Hennessy 1993 in a study looking at possible causes of hamstring injuries in gaelic footballers found that poor lower back posture was an increased risk factor. Poor posture was the second best predictor of injury in irish field sports after previous injury. In runners poor pelvic control was demonstrated as a risk factor.

65 Core Stability???? Where is your core?
What does a stable core consist of? What is an unstable core like? Demonstrate imbalance. How do we improve core stability? A) Low load postural exercises B) Low load Stability exercises C) High load Stability exercises D) High load mobility exercises. Explain Neutral posture and muscle function in Mid range.

66 Interventions Postural alignment and dynamic balance are the foundation for all training. Focus on perfect technique. Fundamental movement skills before sports specific skills Stop when technique fails. Emphasis on powerful, safe and efficient movement.

67 Train movements not muscles.
CNS uses pre-programmed motor/movement patterns. If form is correct muscles will adapt. If technique/form is incorrect then faulty movement patterns will be rehearsed.

68 Some “core” strengthening with good technique.
Squat. Lunge. Single leg squat. Plank. Side bridge. Press up.

69 Balance Balance work using wobble boards and other apparatus has been shown to reduce the risk of knee and ankle injuries. Include some of these ex`s in your circuits or warm up/ warm down.

70 Jumping and landing practice.
Practice jumping and landing technique. Reduces risk of ACL injury. Think of form and landing softly. And eventually!

71 Strength and Conditioning.
Increased fitness levels= increased resistance to fatigue. Better strength improves ability to sprint and change direction. More muscle to absorb impact forces. Stronger bones, cartilage, tendons and ligaments.

72 Load? McBride et al compared athletes jump squatting at 80% and 30% of 1RM max. Measured sprint times, agility times and agility runs, squat strength and squat jump 80 % had decreased sprint times, increased strength force and power. 30% had increases sprint, strength force and power.

73 Improving power. We want to train muscle elastic components.
During many functional movements the muscles actually experience minimal lengthening due to joint movement and tendon lengthening. Eccentric training, plyometrics and flexibility can affect this positively. Enhances ability for elastic energy storage. Injury prevention.

74 Equipment Footwear. Helmet. Hurling glove. Mouth guard.

75 To sum up. Injury surveillance a must to make accurate interventions.
Avoid high intensity work when fatiqued. Allow for recovery. Full functional rehab after injury Sports specific training. Strength and conditioning. Some balance training if time is available .


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