222 Orthopedics and Clinical Science
Sports Injuries Related to Flexibility, Posture, Acceleration,
Clinical Defects, and Previous Injury, in High-Level Players
of Body Contact Sports
A. W. S. Watson
Sports Injuries Research Centre, University of Limerick, Limerick, Ireland
Watson AWS. Sports-Injuries Related to Flexibility, Posture, Ac-
celeration, Clinical Defects, and Previous Injury, in High-Level
Players of Body Contact Sports. Int J Sports Med 2001; 22:
222 ± 225
Accepted after revision: July 15, 2000
nnnn One-hundred-and-two high-level players of the field-
games soccer, Gaelic football and hurling began a two-year in-
vestigation into the intrinsic causes of sports-injuries; 86 com-
pleted the study. During the first year all injuries, and the time
affected by injury, were recorded. The subjects then underwent
flexibility tests, an accurate photogrammetric assessment of
posture, measures of speed and acceleration, and a clinical as-
sessment of anatomical and physiological factors thought to be
associated with the risk of sports injury. Time affected by injury
was then recorded for a further 12-month period. Stepwise mul-
tiple-regression analysis revealed that the number of days of in-
jury during the second 12-month period could be predicted from
(1) the days of injury during the first 12-month period, (2) pos-
ture, (3) acceleration over 10 m from a standing start, and (4)
the number of musculo-skeletal clinical defects. Flexibility
scores were not found to be significant predictors of injury. It is
suggested that injury prevention programmes should concen-
trate on improving posture and the rehabilitation from previous
injury rather than flexibility; and that research should be under-
taken into the effectiveness of such interventions.
n Key words: Football, hurling, soccer, pre-participation medi-
cal examination, clinical examination, physiological examina-
tion, injury risk factors.
Introduction
A number of intrinsic factors have been associated with sports
injuries. Poor flexibility was found to increase the risk in a pro-
spective study of soccer players [3], imbalance in the strength
of the knee flexors and extensors has been identified as a risk
Int J Sports Med 2001; 22: 222 ± 225
 Georg Thieme Verlag Stuttgart ´ New York
ISSN 0172-4622
factor in American football [1]. Several studies, reviewed by
Knappick et al. [7], have found that other types of muscle im-
balance increase the risk of injury. A number of studies, all pro-
spective in design, have demonstrated a link between injuries
and posture defects: Cowan et al. in a study on male infantry
trainees [2], Powers et al. on athletes with patello-femoral pain
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[11], Shambaugh et al. in basketball players [14], and Watson
in footballers [22]. A prospective study of soccer players has
identified weakness due to previous injury as a risk factor for
further injury [4]. Other factors such as poor development of
the muscles that stabilize the knee joint [4, 21] and running
speed [8] have also been suggested in studies on runners and
in literature reviews. Injury prevention programmes are often
based upon the assumption that improvements in the above
factors will result in a reduction in the incidence of sports-in-
juries [12,13]. Despite the wide adoption of such injury-pre-
vention practices, few prospective studies have been undertak-
en on the relationship of intrinsic risk factors to the indidence
of injury. The present paper describes such a study.
Material and Methods
The subjects were all involved in one of the field games: ± soc-
cer, Gaelic football or hurling at county or good club level, and
gave their informed consent to take part in a two-year investi-
gation into sports-injuries. Gaelic football and hurling are tra-
ditional Irish games and are played by teams of 15 players. In
both games the goal posts have uprights (as in rugby), and 3
points are scored for placing the ball into the opponents goal
below the upright; 1 point if it goes above the upright. The ball
used for Gaelic football is similar to a soccer ball but unlike
soccer, in Gaelic it is possible to punch the ball with hand or
run with it for short distances. Hurling is played with sticks
and a small ball, but unlike the game of hockey most of the
play occurs in the air. Both games are free from an off-side rule
and other restrictive rules. Heavy contact is allowed during
tackles, and both games involve a considerable amount of
physical contact between players.
During the first 12-months of the study the injuries sustained
at any of the above sports were recorded. Each subject then
undertook a fitness assessment that included 1) measurement
of flexibility, 2) assessment of posture, 3) measurement of run-
ning speed and acceleration from a standing start over distan-
ces of 5, 10, 15, and 20 m, 4) a clinical examination concentrat-
ing on the musculo-skeletal system. The above measurements
Intrinsic Factors Related to Sports Injury
and observations were made in the rest period at the end of
season-one. At this stage nine subjects who were suffering
from injuries were excluded from the 102 who began the
study. Sports injuries were then recorded for a further 12
months. A further 7 subjects left the study during year 2. Thus
data is reported for the remaining 86 subjects who completed
all stages of the investigation.
All injuries were treated by physiotherapists or physicians who
made a diagnosis of each injury and recommendations of
when each player should return to sport. The analysis in the
present paper uses the number of days on which the subjects
were affected by injury during the second 12-month period as
the dependent variable. The definition of injury used was
based upon those of McLennan and McLennan [9] and Watson
[19], ªa mishap occurring during training or a match that
resulted in the inability to train or compete normallyº. The
number of days of hospitalisation, off sport, and of restricted
activity were summed to obtain the total days of injury.
Six aspects of flexibility were measured as described by Wat-
son [20]. The subjects wore only swimming trunks for the as-
sessment, and every precaution necessary was taken to ensure
the highest precision of measurement [20]. The 95 % confi-
dence limits for all six measurements were within  10 % of
the mean scores.
Posture was assessed from direct observation and from analy-
sis of 250 ” 100 mm prints on which a grid had been superim-
posed. Subjects were assessed wearing briefs, or if a spinal
asymmetry or lumbar lordosis was suspected, in the nude. This
procedure has been described previously [22]; 95 % of repeat
assessments were found to be within  1 unit of measurement
and 71 % were within  0.5 units. The following aspects of pos-
ture were assigned a score of 5 (normal posture), 3 (moderate
deviation), or 1 (major deviation): forward head, kyphosis,
shoulder symmetry, back symmetry, scapulae abduction, sco-
liosis, rib hump, chest mechanics, sway-back, lumbar lordosis,
knee interspace, knee hyper extension, tibial torsion, ankle
posture, foot arch.
All clinical examinations were carried out by the same experi-
enced assessor (the author). The following were assessed. Gen-
eral: blood pressure, full blood count, urine, cardiovascular
system, respiratory system, visual acuity, ears, hearing, nose,
throat, nervous system, reflexes, lymphatics, abdomen, hernia,
skin. Musculo-skeletal: ankle anatomy, lower limb, knee bur-
sae, knee ligaments, patella function, other joints, develop-
ment of the muscles crossing the knee joint, signs of tender-
ness at the origin or insertion of major muscle groups, signs
of previous injury, muscle development and balance. Ankle
proprioception was assessed using the Romberg test: the sub-
ject balanced on one foot with his arms crossed in front of his
chest and his eyes closed. A score of less than 60 seconds was
considered abnormal. The selection of these variables was
based upon previous experience of working with this type of
subject and in order to investigate whether general medical
examinations ± common as pre-participation assessments in
this country ± were of value in the prediction of injury risk. A
clinical deficiency was recorded when any result was outside
the normal range for the variable, as recorded in our labora-
tory. In order to determine reliability, 10 subjects were re-ex-
Int J Sports Med 2001; 22 223
amined after a period of between 3 and 7 days. In all cases the
subjects re-test score was found to be within  2 units.
Data analysis
The relationship between individual clinical deficiencies and
the number of days of injury in the second 12-month period
was investigated using t-tests for independent samples with
the application of the Bonfiori correction for multiple t-tests
[17]. When it became apparent that there were no relation-
ships between individual general or musculo-skeletal deficien-
cies and the number of days of injury, the number of each kind
of clinical deficiency for each subject was summed and used as
independent variables in the multiple regression analysis.
Since it has been suggested that the incidence of sports injury
may be increased if flexibility is either markedly below aver-
age or above average [7], the following function was computed
for each individual for each of the six measures of flexibility, X1
to X6.
Flexibility Functions (X)1 ¼¼ 6 = abs (X ± meanX)
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These functions approach zero for scores close to the mean for
the group, but take on positive values when flexibility scores
are either high or low in relation to the mean. A composite
flexibility score was computed as the mean of the above func-
tion for the six measures of flexibility.
The relationship between days of injury during the second 12-
month period and the other variables was investigated using
stepwise-inclusion, multiple-regression analysis. Days of in-
jury during the second 12-month period was used as the de-
pendent variable, and the other variables were entered as
independent variables. This experimental design was selected
because the objective of the study was to examine factors in-
fluencing ªDays of injuryº. Since this is an ªinterval levelº vari-
able, regression analysis is an appropriate method of data
analysis.
The SPSS for Windows statistical analysis package was used for
all data analysis.
Results
Descriptive statistics for the study are shown in Table 1. Days
of injury during the first and second years of the study were
58.5  18.9 and 55.6  23.5 days, respectively. These results are
typical of those for the players of field games in Ireland [19].
A zero-order correlation matrix for the variables is presented
in Table 2. Days-of-injury during the second year of the study
was found to be significantly related to: (1) days of injury dur-
ing year 1, (2) posture, (3) number of musculo-skeletal clinical
defects, (4) acceleration between zero and 10 m.
None of the flexibility measurements or their functions were
selected for inclusion in the regression analysis. Thus in subse-
quent analyses individual flexibility scores were replaced by
the overall flexibility function. The following variables were
then selected for inclusion in the regression equation with sta-
tistically significant regression coefficients (p < 0.01): accel-
eration (A), posture score (P), number of musculo-skeletal clin-
224 Int J Sports Med 2001; 22 Watson AWS

Table 1 Descriptive statistics for the 86 subjects who completed the
study
Variable
Age of subjects (years)
Height (mm)
Weight (kg)
Days of injury during first 12 months
Days of injury during second 12 months
Posture Score
Clinical deficiencies (number)
Flexibility (spinal flexion) cm
(hip abduction) degrees
(hip flexion) degrees
(ankle dorsi-flexion) degrees
(hip hyper extension) degrees
(shoulder hyper extension) degrees
Flexibility (composite score)
Acceleration 0 to 10 metres (m ´ s±2)
clinical examination, days-of-injury during the first 12-month
period. In contrast, none of the six measures of flexibility or
their functions were predictors of injury. These results fail to
Mean  SD support the frequently made suggestion that high-levels of
flexibility help to protect from sports injury. Although this
24.34  3.71
relationship is widely assumed, there is in fact very little em-
1 831  68 pirical evidence to support it [7]. The only prospective study
80.1  6.6 that appears to indicate that poor flexibility is a factor predis-
58.5  18.85 posing to injury in field games is due to Ekstrand and Gillquist
55.6  23.48 [3]. Other studies fail to support these findings [5,14 ± 16].
62.7  4.6
Knappick et al. [7] suggest that the relationship between flex-
5.0  2.3
ibility and injury may be ªUº shaped: athletes with either very
3.5  4.2 low or very high levels of flexibility being at increased risk of
52.4  6.1 sustaining a sports injury. This proposition was tested in the
73.3  7.9 present study but no evidence to support it was found. Studies
34.8  4.5 on other sports have also failed to demonstrate that stretching
19.9  7.8
and high levels of flexibility protect from sports injury [5,14 ±
16]. Taken in combination with other research, the present
24.3  6.8
study suggests that flexibility is not an important factor in the
50.0  28.3 prediction of injury in field games and that it may be more
2.066  0.191 fruitful to look at other intrinsic risk factors.

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ical defects (C), days-of-injury during the first 12-month peri-
od (D). This result indicates that these four variables were
statistically significant predictors of the number of days-of-in-
jury during the second 12-month period. The regression equa-
tion was:
Days of injury = 8.64 A ± 1.14 P + 2.76 P + 0.364 D + 39.98
Studies by Shambaugh et al. [14], Power et al. [11], Watson [22],
and Cowan [2] all indicate that defects of posture are important
predictors of specific types of sports injury and are in agree-
ment with the present study. All four used carefully validated,
quantitative precedures for the evaluation of posture. Thus the
results further suggest that posture evaluation must be quanti-
tative, precise, and carefully carried out if they are to be of value
in the prediction of sports injury: it is necessary to base the as-
sessment on high quality photographs of the subject.

R2 = 0.633, adjusted R2 = 0.589, n = 86
A = acceleration between zero and 10 m
P = posture score
C = clinical deficiencies ± number detected
D = days of injury over the first 12 month period
All regression coefficients were significantly different from
zero (p < 0.01).
Discussion
The following variables were found to be significant predictors
of injury: acceleration over 10 m from a standing start, posture
score, number of musculo-skeletal deficiencies noted during a
The incidence of injury was not found to be related to the num-
ber of general clinical defects detected during a clinical exam-
ination. Thus the present study fails to support the value of
general medical examinations for injury prevention in high
level sport. This result is important because such examinations
are common ± at least in this country. In contrast, the results
do suggest that a clinical examination that concentrates on
the detection of musculo-skeletal defects is likely to be useful
in the prediction of future injuries. Pre-participation physical
assessments should emphasize the detection musculo-skele-
tal defects such as: muscle imbalances, weakness of the mus-
cle groups that protect and stabilize joints, joint function, and
signs of lack of full recovery from previous injury.

Table 2 Zero order correlation matrix of the variables

Posture & Body Days of Injury General Clinical Musculo Skeletal Flexibility Acceleration Days of Injury
Mechanics during Year 1 Deficiencies Deficiencies in Year 2

Posture & Body Mechanics 1

Days of Injury during Year 1 ± 0.414* 1
General Clinical Deficiencies ± 0.196 0.326 1
Musculo-skeletal Deficiencies ± 0.446* 0.543* 0.180 1
Flexibility ± 0.084 ± 0.205 0.171 ± 0.178 1
Acceleration ± 0.420* 0.333 0.313 0.330 0.047 1
Days of Injury during Year 2 ± 0.576 0.627* 0.257 0.647* ± 0.047 0.569* 1

*significantly different from zero (p < 0.01)

Intrinsic Factors Related to Sports Injury Int J Sports Med 2001; 22 225

Injury was also found to be associated with acceleration over a
distance of 10 m. Acceleration is directly proportional to the
force developed by the athlete: presumably this equates with
greater stress on the athletes tissues and thus an increased
risk of injury. The ability to accelerate is highly desirable in
field games which are often known as ªmultiple sprintº activ-
ities. A high level of acceleration should be encouraged: but
athletes who possess it will need to take steps to minimize
the effects of all other injury risk factors. Posture and clinical
assessments should be particularly thorough in such individ-
uals. It has previously been noted that sprinters are at a greater
risk of sports injury than other types of runners [8].
Previous injury was found to be a predictor of future injury.
This result is consistent with those of a number of studies car-
ried out in other sports [3, 4,10,15,18]. It is not known whether
re-injury was due to insufficient treatment or rehabilitation of
the original injury or whether it is due to inherent characteris-
tics of the subject. More research is needed into the recurrence
of sports injuries.
The present research suggests that injury prevention pro-
grammes should concentrate on the following intrinsic risk
15
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Van Mechelen W. Injuries in running. In: Renstom PAFH (ed).
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Vincent WJ. Statistics in Kinesiology. Champaign III: Human Ki-
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Walter SD, Hart LE, McIntosh JM, Sutton JR. The Ontario cohort
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Watson AWS. Sports Injuries in Ireland: an analysis of four differ-
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20
Watson AWS. Development and evaluation of procedures for val-
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21
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factors: 1) the elimination of posture defects, 2) the detection Corresponding Author:
and correction of musculo-skeletal clinical deficiencies, and 3)
ensuring full recovery and rehabilitation from previous injury. A. W. S. Watson
Further research should be undertaken into the effectiveness 51 Church Road
of such interventions. Wimbotsham
Kings Lynn
Norfolk
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