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Jun 6, 2017

An Ounce Of Prevention Is Worth A Pound Of Cure


This is a medical adage that applies to Sports Medicine and predates modern movement screens, dynamic warm-ups, ankle taping, and electrolyte beverages. When I look back at my career that started as a freshmen Athletic Training Student to where I stand today, I look at the amount of time I’ve spent surrounding injuries and the vast majority has been spent caring for injuries and waiting for them to happen. Of course there has been plenty of time spent on organizing and executing PPEs, counseling and directing nutritional programs, coordinating care with medical providers, and counseling athletes and coaches on return to play procedures. Yet a large majority of time has been spent between pre-practice time therapy and taping, practice or games rehabbing and watching players for signs of injuries, and post-practice evaluating, communicating, and cleaning.

Posted by: KSherry

An Ounce Of Prevention Is Worth A Pound Of Cure

 

This is a medical adage that applies to Sports Medicine and predates modern movement screens, dynamic warm-ups, ankle taping, and electrolyte beverages. When I look back at my career that started as a freshmen Athletic Training Student to where I stand today, I look at the amount of time I’ve spent surrounding injuries and the vast majority has been spent caring for injuries and waiting for them to happen. Of course there has been plenty of time spent on organizing and executing PPEs, counseling and directing nutritional programs, coordinating care with medical providers, and counseling athletes and coaches on return to play procedures. Yet a large majority of time has been spent between pre-practice time therapy and taping, practice or games rehabbing and watching players for signs of injuries, and post-practice evaluating, communicating, and cleaning.

I believe Athletic Trainers will read this and echo the same whether student or certified, young or old, and Assistant or Head. If the age-old adage at the start of this article is true, as most things that stand the test of time are, there must be a better way that we can spend our time, in the already long days, with long trips, in long seasons. To provide even more “care” through keeping our rooms as empty as possible BEFORE they will fill up.

When starting at the foundation of the injuries we treat, there exists the basic concept of stress and strain, where a specific tissue has had a stress applied to it that it is either able to cope or not. Most of us learned this in Physics class as pre-requisite for our Athletic Training courses. If a specific tissue is able to tolerate the stress, then there is no injury, if it is not able to there is an injury with a severity in direct positive correlation to the severity of the stress beyond the tissue’s threshold. Whether a mild lateral ankle sprain, moderate hamstring strain, or complete fracture, each injury results from more stress than the tissue can absorb applied to it and subsequently has a resulting strain.

When combining this concept with the adage I started with, if we want to be effective and efficient with our efforts and care for our athletes, we must examine, which frequently occurring injuries we can prevent.  Contact injuries such as bruises and fractures certainly can be somewhat prevented with padding such as shin guards and helmets, though we can’t wrap everyone in foam padding and ensure everyone takes that levels of Calcium and Vitamin D they need outside of the meals the team serves.  Non contact injuries, such as ankle sprains can also be somewhat prevented by taping, though likely just lessened, and proprioceptive programs, but we all should know if you jump up for rebound or header and land on the outer half of someone’s foot, unless your muscles and proprioceptive nerves are ready for that stress, which is unlikely in an absolute sense, you will get an ankle sprain.

For muscle injuries, such as the prevalent Hamstrings strain or any other large lower extremity injury, many have seen the sniper scenario of an athlete moving at full speed and with a maximal stress contraction and an injury to the target tissue takes them down as if being shot.  Strain injuries to the major lower extremity muscle groups (calf, Quadriceps, and Hamstrings) accounted for 60% of all injury incidences in Major League Soccer last season, which when we know muscles have a volume of work they are capable to before fatiguing and the can be accounted for as stress, there must be a way to manage that stress to limit the likelihood of strain.

Modern Sports Medicine has all looked at strength, flexibility, and imbalances in a kinetic chain as reasons that can and should be applied to why to muscle is stressed beyond its limit, but when we go back to Physics class in the classic example of a bridge, we know the strength, elasticity, load balance of the materials is important, but we cannot forget about the fatigue factor over time. Every structure has a fatigue point. As an Athletic Trainer, we have measured fatigue in duration of practices, frequency, and the looks of athlete’s faces or comments while chatting the Athletic Training room pre or post practice. However now the era of big data is upon us and we must use more advanced methods of information gathering to understand fatigue that I believe is the most important factor in why injuries occur.

Let me pause here and ensure that this is not another message regarding injury prevention that is putting forth that we can focus all of our efforts on prevention, because our experience and Murphy’s law exists enough to know that injuries will happen. The important question is less about will injures happen, but rather more about how, why, and when will they occur.

The era of using data has brought forth great research with the advent of GPS technology to understand the stresses on the body, help quantify fatigue, and subsequently identify risk of strain for injuries. Currently one of the pre-eminent researchers is Tim Gabbett from Australia, whose research has focused on the stresses that are strongest correlated to soft tissue injuries and their fatigue points, through looking at the amount of work that athletes have done in the past 4 weeks and comparing it to the past week. Through doing this, he generates a ratio that gives a reflection on the chronic stresses that the body has experienced and is acute stresses is recently experienced. The chronic load provides a fitness level of what the body has been prepared to do and the acute load reflects a fatigue level from what the body has recently been stressed to do. We know from the stress and strain concept that failure and strain is a result of simply being asked to do more that being prepared to do, so applying the acute to chronic loading concept we can have a greater glimpse into what current demands are relative to the preparation for them.

If you have the opportunity to meet Tim Gabbett in person or hear him speak, he will use an example that many can relate to that adds even more understanding to the acute to chronic concept. Should a person drink 6 beers a day normally, when a night out with friends that entails 8 beers, that person will be relatively well prepared for what the body will feel like the next day. Conversely, should the same person be not drink at all in weeks leading up to that same night out, there will be a significant reaction from the body due not being prepared for the night before. The same concept applies to the bodies of our athletes and when we start looking at what they are prepared to do and what they are currently doing, we have a greater insight into if a strain in both senses of the word is more likely.

In the article, “Has the athlete done enough training to RTP safely?” Gabbett and his colleague Peter Blanch found that a ratio of acute to chronic workload maintained between 0.8 and 1.3 for volume and high intensity running significantly decreases the risk of injury. As both a sport performance professional and academic researcher, Gabbett’s studies take data into the applied setting to help practitioners prevent injuries. This concept has proven true in research across a range of sports from upper extremity injuries in Cricket to lower extremity injuries in Australian Rules football, Rugby, and Soccer.

We have applied the following main findings of his research with the San Jose Earthquakes with the data that we collect.

First, maintaining volume and high intensity workloads within the recommended ratios of acute to chronic workloads can reduce the relative risk of soft tissue injuries. When looking back at injuries that had occurred to our players, we found that we were able to point to workload ratios that exceeded those brought forward in research had an increased frequency and risk of injury.

Second, chronic load when increased gradually has a protective effect against injury. We’ve all seen the out of shape player or new player that isn’t prepared for the stresses at the start of a season, struggle through issues of significant soreness and fatigue to actual injury that applies that concept. You cannot ignore that everyone has a biomechanical, physiological, ceiling of work, but the more prepared a person is for high loads, the better they will cope with the slight increased stress without strain. For this we made pre-season workloads goals with the recommended ranges and monitored physiological responses for indicators of tolerance for increased workloads.

Third and possibly one of my favorites as it is very useful return to play decisions, Gabbett and Blanch researched the relative injury risk for athletes returning from injury to ensure they are adequately prepared for the return to sport. It is easy to say that someone is healed from injury, but often difficult to determine readiness to return to full team participation workloads. Through measuring workloads in rehabilitation and comparing to normal acute and chronic levels, the research provides relative injury risk probabilities. This guides determining how ready an athlete is so that they don’t end up re-injured because they haven’t prepared their body for the workloads necessary and they can be ramped up appropriately to safely confirm when they will be completely ready.

Using these concepts, we monitor the most important characteristics of workloads for our athletes and work to maintain players on the field. This can be done complexly to the fullest extent with GPS units and dedicated sports scientists and simply on Microsoft Excel with Ratings of Perceived Exertion (RPE) and duration. In our retroactive analysis of GPS data on injury incidence of our players, we found the recommended range of acute to chronic workload for sprint distance to be protective from hamstring injuries as research indicates.  Even when comparing our players within same positions groups they have the most similar physical demands, we found the acute to chronic ratio to be effective for identifying injury. Players that sustained injuries were almost always beyond the ranges, due to uncontrollable game demands most frequently, while those in the same group were in recommended range and did not sustain an injury. By not recognizing the abnormal physical demands, the fatigue that causes failure and injury was increased and players were much more likely to sustain an injury

We’ve taken the research and information on our players to push into the greatest extent of injury prevention by correlating these factors to workload (i.e. training session) design. We know from the start of our education that that the best injury prevention is proper training, so through applying what we know of aspects of training session exercises, we are striving for players workloads to be managed individually and collectively so athlete’s can be kept healthier and maintain preparation for physical workloads to complete. This is collaborative process with our Head, Assistant, and Strength & Conditioning coaches and Data Analysts to design a workload that is the safest to prevent soft tissue injuries, within the tactical and technical needs of training session design.

We combine this information, with data on injury history, biomechanical screenings, and strength assessments to manage the workloads of our athletes and limit the exposure to workloads that are beyond strain thresholds, which have greater risk injury. The work in this area has been engaging, created more work, and a long and ongoing process, but we are certain that we will yield a greater effect on health of our team.

I firmly believe we should all be thinking like the sport scientists that we have been trained through our Kinesiology degrees by collecting workload information to prevent as many injuries as possible. If you can find the right information for your organization, Athletic Trainers can keep their bridges from fatiguing beyond a breaking point and you can measure the amount of time treating preventable injuries in ounces rather than pounds.  The data can start integrate Athletic Trainer into program design and expose the value of Athletic Trainers in numbers that are hard to ignore as healthy teams consistently win more by maximize their player availability.

 

Ron Shinault, MS, ATC

PSATS President

Head Athletic Trainer

San Jose Earthquakes

rshinault@sjearthquakes.com

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