Best Guess Principles to Prevent Injury and Reinjury in Athletes

Our best guess to prevent injuries and rehab after an injury in general. We will try to provide principles, that are evidence based, rather than describing a recipe for a single condition.

2 models:

Return to play -> Return to sports -> return to competition

Return to practice -> return to sports -> return to performance

Most importantly, you need to figure out the individual demands of the sports. This will help you decide which capacities need to be tested and tracked in order to make RTS as safe as we can.

2 things need to be considered: time and function. For some injuries, time can play a major role for preventing reinjuries (muscle strains). For others, function is more important (ACLR).

Load and risk management need sport specific tracking methods (number of throws done for baseball pitchers vs kilometers run for an endurance athlete). These underpin primary and secondary injury prevention efforts.

7 key principles for RTS of the Upper extemity https://www.jospt.org/doi/epdf/10.2519/jospt.2022.10952

1. Let Irritability GuideRehabilitation Progression (not the pathoanatomic diagnosis)
2. Address Clinically Relevant Glenohumeral ROM Deficits Using Active Exercise Therapy
3. Do Address theScapula in Rehabilitation but Do NotScreen for Dyskinesis
4. Select the Appropri-ate Exercise (Open Chain Versus ClosedChain)
5. Include Plyometrics Ear-ly in a Rehabilitation Program
6. Train the Brain

Simultaneous neurocognitive elements -> test for cognitive motor interference (treat with “cognitive-motor dual-task training intervention”) (“This could involve adding visual stimuli to a high-impact task, such as hopping or running, in which the athlete's perception of the visual stimuli is required to guide the motor action, while they concurrently perform a working memory task”)

7. Sport-Specific Exercises

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include regular testing of:

1. "Handheld dynamometer for measur-ing strength
2. 2. Inclinometer or goniometer for mea-suring ROM
3. 3. Questionnaires or patient-reportedoutcome measures"

6 Domains to consider for shoulder RTS:

1. Pain (Overhead/throwing athletes canreturn to participation with pain,but should be pain free when at-tempting to return to performance ; Contact-sport athletes can returnto participation with pain, in acontrolled environment, but shouldbe pain free before RTS or return toperformance is attempted)
2. Active Shoulder Joint ROM (Overhead/throwing athletes do notneed full ROM prior to return toparticipation, but full ROM shouldbe restored before RTS; There is no expectation to achievefull ROM at any stage of theRTS continuum in contact-sportathletes)
3. Strength, Power, and Endurance (The ER/IR strength ratios are impor-tant for athletes in overhead/throw-ing sports, but should not be used inisolation. Absolute strength valuesalso need to be considered to de-termine functional shoulder capacity.)
4. Kinetic Chain (Identifying inadequate movementstrategies wherever they occur alongthe length of the kinetic chain, and ad-dressing them, is central to qualityrehabilitation.)
5. Psychological Readiness (Before RTS andreturn to performance, no apprehensionduring contact with opponents and lowfear of reinjury may support psychologi-cal readiness to RTS)
6. Sport Specific (Knowing the demands ofthe athlete’s sport is crucial to support-ing successful RTS; compare to theathlete’s preinjury values for the key de-mands of the sport)

A framework on how you can think about rehab and injury prevention:

• Injury prevention has always been thought of as a very complicated area. And it is. It is likely impossible to predict injury with accuracy. But still, there are things we can do and measure, although limited. We can manage loads and make sure that weekly loading is progressed slowly (along the ACUTE:CHRONIC workload ratio) and we can measure risk factors and try to change the modifiable ones by adding preventive exercises (include some exercises for the most common injury type of your athletes sport, and the more unmodifiable risk factors present, the more focus we should lay on prevention).
  This is a sound and uncomplicated best guess on how to tackle prevention in your sport.
  Even if you try to track load management as good as possible it is impossible to know how much is too much for the team. Especially if internal stressors come up in a few people, due to (for us) uncontrollable circumstances, they can impact they loading capacity and predispose them to injury (which makes readiness questionaires a good option to fill out every other week or more of then in elite athletes).

Prevention exercises:

Look up the most common injuries (if you enter a new sport) and make sure you find ways to objectively track risk factors that are associated with that and measures that will be of importance in the RTS decision making if they get injured. Think it out in advance.

• which type of exercise is likely best fitted for prevention? should it mimic the sports? yes, but with load for example banded abduction with ER for throwers + plyometrics + CKC
• should be performed twice weekly

Workload:

measure the worklaod an athlete or atheltes are exposed to thorughout training sessions, to know their current capacity.

E.g. for the shoulder: measures should include thenumber of repetitions (eg, throws),the magnitude of load applied perrepetition (eg, throwing velocity),and the distribution of load overtissue structures applied per rep-etition (eg, type of throw)

do this on a weekly basis

Rehab exercise progression:

General principles require your athletes to develop strength (power, RFD, hypertrophy) and endurance. Coordination will likely come back naturally, no wasting your time on specific technique work is probably not worth it. Unless things are really obvious and has been already prior to injury. But most of the time you did not know how the athlete moved prior to injury, therefore you do not need to act as if you knew how "optimal movement" should look like for them now.

PROMS:

Sport specific ones and general (tampa scale of kinesiophobia...)

Performance tests:

"Experts at the in-person meetingagreed that clinicians supporting athletespost shoulder injury should aim to1. Improve sport-specific biomechanics/technique2. Increase rehabilitation intensity tochallenge athletes at the limit of theircapacity3. Build resilience: increase capacity toload from physiological and psycho-logical perspectives"

According to the 2016 bern consensus statement on RTS, you should always look at:

1. Timing - when can the athlete be safely returned to play, regarding tissue healing times and type of injury?
2. Testing - have the athlete undergo a battery of tests to track and measure performance
3. Workload - a huge factor to progress safely as it might be connected to reinjury risk
4. Psychology - make sure the athlete is psychologically ready for RTS and nor fearful of reinjury

The tests that make up the protocol should investigate some aspects:

► Clinical (pain, swelling, range of motion).► Functional (maximum and explosive strength, both specific to the joint and global measures, muscular endurance strength, body composition).► Biomechanical (movement analysis testing).► Psychological (fear of reinjury, psychological attitudes).► Sport specific (ability to support volumes and work intensities in training, sport-specific physiological screening).

(Buckthorpe, Frizziero, et al., 2019)

If you check all of the above boxes, you are likely doing far more than you realise for your athletes. As it is sadly rare to find therapists who make the effort to do so.