  15 MINUTES SPORTS COACHING DIPLOMA

Module 15: Sports Injury Prevention and

Rehabilitation

Injury Prevention
Injuries occur as a consequence of fatigue, previous trauma, lack of physical preparation and occasionally, bad
luck. The strength and conditioning (S&C) coach not only has the knowledge and insight to physically prepare
athletes for competition but also has the unique position within an interdisciplinary team (IDT) to characterise the
stress of training and an athlete’s response to it.

Injuries cannot be totally prevented, but the risk of injuries occurring can certainly be reduced. Musculoskeletal
trauma occurs as a consequence of tissue being placed under greater stress than it can tolerate. Subsequently,
the purpose of injury prevention is to:

Find methods of reducing the acute or chronic stress placed through a tissue; and/or
Increase the stress a tissue can tolerate prior to failure.

It is clear that certain tissues are more plastic in nature than others and can adapt to stress placed through them.
For example, ligaments are far less plastic than muscle tissue. To reduce the risk of injury to a ligament, one must
reduce the stress placed through it. Equally, to reduce the risk of injury to a muscle, coaches should seek to
increase the stress it could tolerate by increasing it’s cross-sectional area and force production/absorption
qualities.

Reducing Biomechanical Stress on Non-Plastic Structures

There are two methods of reducing the stress placed through the musculoskeletal system. The rst is to ensure
that the movement patterns that the athlete is undertaking do not place excessive force through structures that
cannot tolerate it or are not particularly plastic in nature. In order to achieve this, the S&C coach must have a
thorough understanding of both functional anatomy and clinical biomechanics. Whilst these two topics are not
typical of the education of an S&C coach; they can certainly seek this knowledge from the medical team
supporting the athlete. For example, anterior cruciate ligament (ACL) injuries occur as a consequence of
excessive or rapid knee valgus. In order to reduce the risk of ACL injuries, the S&C coach must prioritise exercises
that reduce frontal or transverse plane forces through the knee joint. Examples include sti -leg kettlebell swings
and single-leg landing drills with no frontal or transverse plane motion of the pelvis, knee or foot.

Fatigue Management

The second method of reducing stress in the musculoskeletal system is to manage the fatigue an athlete is
experiencing. Fatigue can reduce a muscle’s capacity to generate large, rapid forces and reduce reaction times,
concentration and joint proprioception. All of these factors can reduce an athlete’s capacity to tolerate stress
through speci c structures in the musculoskeletal system. Subsequently, managing fatigue is a vital component
of reducing injury risk.

As the S&C coach has the knowledge, insight and position within an IDT to modulate and prescribe training
volume and intensity, they are the best-placed person to undertake this vital role. Planned variation of training
load on a daily, weekly and monthly basis reduces the monotony of training, which reduces the risk of injury and
illness in athletes.

Increasing Tolerance

Whilst reducing stress going through the Musculoskeletal system is one approach to injury risk reduction, it is
important to realise that too great a reduction will result in insu cient adaptive stress and decreased
opportunity for technical improvement. As a consequence, a coach should look to couple this approach with
strategies to increase tissue tolerance. Tissue failure occurs when the stress/strain placed through the structure
exceeds its plastic region (exceeds its capacity to adapt).

It is possible to alter the amount of stress/strain a structure can tolerate by changing the length of the tissue or
its capacity to generate force. The nature of the change required is determined by the most likely mechanism of
injury.

Identifying Risk Factors

In order to identify risk factors, the mechanisms of injury must be fully understood. anterior cruciate ligament
sprains occur as a consequence of the magnitude and rate of knee valgus whilst landing or turning. Posterior
shoulder impingements occur as a consequence of a decreased capacity to decelerate the internal rotation of the
humeral head whilst throwing or pushing. Lateral ankle sprains occur due to the magnitude and rate of inversion
during landing and turning.

To understand the risk of injury, the strength and conditioning coach must understand the mechanism. Once the
mechanism is understood, the risk can be identi ed. To reduce knee valgus during landing or cutting activities,
the medial hamstrings are required to rapidly and forcefully contract. To decelerate the internal rotation of the
humeral head whilst throwing, the external rotators of the shoulder must rapidly and forcefully contract. To
prevent the ankle inverting whilst landing or turning, the ankle evertors must rapidly and forcefully contract at
the appropriate time.

Muscle Injuries
Muscle injuries occur frequently in all sports and at every level of participation. As athletes continue to strive for
greater athletic performance and their competition schedule continues to expand, it is perhaps understandable
that the muscles may fail to tolerate the intensity, volume or frequency of the e orts. Re-injury rates are also
common, in part due to the pressure to return the athletes to the sport as soon as possible and also perhaps due
to the limited understanding of modi able risk factors and rehabilitation. To compound this, re-injury recovery
time will often be signi cantly longer than for a rst-time injury. 

Whilst pressures in sport will always remain, and the use of a risk management approach to returning an athlete
will frequently be adopted, as a profession, coaches must continue to aspire to a better understanding of both
the prevention and reconditioning of soft-tissue injury.
Managing Muscle Injuries

Successful rehabilitation of all injuries requires a carefully blended mix of science and art. The focus of coaches is
on the science of muscle strain rehabilitation. The art component of rehabilitation is less tangible, as it rests
heavily on practitioner experience and factors, including the relationship with the athlete and knowledge of the
sport. It certainly should not be discounted or devalued as a less important consideration, however. Intuition,
communication and empathy are highly valuable skills in rehabilitation.

Rehabilitation is sub-divided into three broad and commonly used phases:

Acute rehabilitation
Progressive loading
Return to performance.

Prevention of Re-injury: Current Concepts

It is widely accepted that athletes will return to sport successfully before their injuries have resolved
radiologically, operating with a diminishing but elevated risk of re-injury for a sustained period. Even in cases
where isolated tissue characteristics and functional measures of athletic performance have demonstrably
returned to normal, re-injuries still occur, and ongoing prevention should be considered an essential component
of rehabilitation. Recent work has demonstrated ongoing electromyographical delays in e erent ring long after
functional restoration of muscle strength has been achieved. 

In terms of basic ongoing prevention, we should consider several key areas, namely:

Range of motion restoration/maintenance

Adequate tissue preparation for sport
Eccentrically biased strength development
Synergist assessment and development
Sport-relevant movement conditioning.

Muscle injuries continue to account for a signi cant proportion for all injuries reported across all sports. E ective
rehabilitation requires a clear understanding of the target muscles’ architecture and speci c functional
characteristics to best inform exercise prescription. It requires a bias towards eccentric strengthening and clear
and well-reasoned exit criteria. Crucially, reconditioning does not nish once the athlete has returned to sports
but must continue for an extended period to minimise future injury risk.
Bone Injuries
Bone is the most resilient tissue in the human body, and under normal conditions remains highly resistant to
injury. It is extremely adaptable to athletic loads, and with an understanding of how it adapts, and the mechanical
underpinnings of how loading magnitude and frequency a ects it, athletes and coaches can begin to understand
the mechanisms of bone injury and rehabilitation.

Bone tissue is continuously being broken down and renewed, and when the delicate balance of bone breakdown
and bone synthesis is upset, it can start to fail under a seemingly normal load. This type of bone failure is in
contrast to those that result from acute high-load impacts.

Management of Bone Stress Injuries in Athletes

Bone cells respond to high-magnitude loads, applied rapidly and in di erent loading distribution from that to
which the bone is accustomed. The number of loading cycles required to stimulate osteogenesis is also an
important determinant of the adaptive process. The fact that the osteogenic response to loading becomes
saturated after relatively few loading cycles have led to the notion that bone cells become desensitised to
prolonged mechanical stimulation. However, bone cell mechanosensitivity returns following a period of no
loading, and short periods of rest may re-sensitise bone cells to the next bout of loading. 

Accordingly, the application of loading to enhance osteogenesis should be done in short bouts separated by rest
intervals and may begin with low loads, e.g. low box jumps with 10-second test intervals, progressing to higher
loads up to 90 cycles within a bout, but with at least four hours rest between training bouts. In a football training
camp situation, this may translate to a concept of two shorter sessions of jumping and landing drills separated by
rest, rather than one long session followed by a game.

Low-risk stress fractures can be successfully treated with activity restriction and a carefully graduated return to
sport. A detailed management plan should be mapped out in consultation with the athlete, coaching team and
other members of the interdisciplinary support team. Management should seek to address all the modi able risk
factors present, and a two-phase protocol should be used to manage most low-risk stress fractures.

Phase 1 is pain control with relative rest, ice and oral analgesics. Anti-in ammatory medications should be
avoided due to potential delayed bone healing. For lower-body stress fractures, weight-bearing, as tolerated, is
allowed for daily activities, but participation in sports will be limited (depending on the sport). Walking boots
should be used to allow pain-free ambulation. For upper-body stress fractures, the management is along similar
lines: no high-impact or heavy-resisted loads through the arms or upper body. Low-impact cardiovascular
exercise, such as pool running, elliptical trainers and cycling, are options for tness maintenance in this phase.

Phase 2 can begin when the athlete has been pain-free for 10–14 days. One week after the localised bony
tenderness has eased, loading should be resumed at half the usual intensity. For a runner, this will be a slow easy
run; for a rower, this will be an easy session in a single scull or rowing ergometer. Antigravity treadmills are an
emerging approach to the management of bone stress injuries in athletes.

Antigravity treadmills provide adjustable body weight support and may help to maintain tness during the
recovery from bone stress, as well as providing a controlled loading environment. Initially, athletes with a healing
stress fracture should not increase their load every day but allow the healing bone time to recover between these
early sessions. Increments of 25 per cent should be used to gradually increase training loads to the pre-injury
level over three to six weeks under strict supervision according to the pain response.

High-risk stress fractures require more complex management, and referral to a sports physician, orthopaedic
surgeon and other specialists is often required. Grades 1 and 2 usually resolve with conservative management,
including strict restriction of weight-bearing and/or immobilisation until healing has occurred on repeat imaging.
To prevent progression to full fracture and associated complications, complete healing must be con rmed
before the athlete returns to sport.