Injury Prevention And Safety

Injury Prevention And Safety

Measuring Success (Programmatic Evaluation)

Injury Prevention And Safety | Measuring the success of an injury prevention program or prevention initiative is imperative. There are many injury prevention programs in the community that appear to be effective. However, without adequate evaluation of the efforts, there is no way to verify if a program is actually achieving the goal of injury mitigation.

The most important aspect of evaluation is an adequate measurement of the problem conducted before, during, and after the intervention. The evaluation process should be dynamic. Assessment is started early, immediately after a program idea is conceived, and should continue through the intervention phase until the program is complete, when one determines whether the program has met its overall goal. In some cases, evaluation may continue for years after the intervention is complete to assess the durability of the desired outcome.

Evaluation is also critical to prove to funding agencies that their support is making a difference. A successful evaluation can also be used to strengthen funding proposals and to continue or replicate the program in other areas. A program that has rigorous, scientifically proven success is much more likely to receive continued funding. The same standards are necessary to publish the work in professional journals and disseminate prevention ideas to professionals in other communities.

Evaluation has four essential stages that are intertwined throughout the planning and intervention phase of a program. These stages are formative, process, impact, and outcome evaluation. A well-designed formative evaluation will give the program a better chance at success, along with elucidating areas of improvement. In the formative stage, a targeted issue is identified (e.g., bicycle helmet use to lessen head injury) and may include an assessment of existing resources and deficiencies. During this stage, it is important to identify barriers to success (e.g., age, access to target population, education). Inclusion of community stakeholders at this stage increases the likelihood of long-term success.

Through process evaluation, the second stage, a plan is formulated to measure whether or not the program is reaching the desired audience. This stage typically requires documentation of the number of people reached during the educational or interventional program, for instance, the number of bicycle helmets distributed or the number of students taught bicycle safety. Such data will provide the foundation for sound assessment of the program.

Impact evaluation is a measure of how well the program is progressing toward its goals. It is a measurement of knowledge, attitudes, and beliefs. This assessment may be through direct observation of a particular behavior, or perhaps though survey or questionnaire. Preintervention and postintervention data collection (e.g., observed bicycle helmet use) will provide insight regarding the success of a program.

The final phase, outcome evaluation, measures whether or not the program met its goal of decreasing incidence of injury, morbidity, and/or mortality. Demonstrating long-term success (beyond the intervention stages) is ideal, but such study can be time consuming and resource intensive. However, demonstration of sustained injury reduction is likely to lead to dissemination of practices and ongoing funding.

Table 17-5.

The complete reference list is available online at .

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Sports equipment

Mike Bundy MBBS MRCGP DipSportsMed(Bath) FFSEM(UK), Andy Leaver BSc(Hons) MCSP SRP, in A Guide to Sports and Injury Management, 2010


Stretching has been one of the most commonly discussed and debated topics among sports medics and conditioners in recent times. The debate has raged about the differences between static and dynamic stretching and where and when they should be incorporated into a sportsperson’s training programme.

They are both in fact very important and therefore need to be included in every sportsperson’s training programme. The differences will be discussed here and a suggested programme with examples will also be proposed.

Static stretching

Static stretching is simply where a muscle is taken to its fully lengthened position and held for a period of time. It has been the mainstay of warm-ups for many years, although there is now a trend away from using it. This is due to the fact that there has been much debate as to whether the use of static stretching is in fact detrimental to performance when used as part of a warm-up. Some studies have concluded that the use of static stretching before sprinting and jumping produces a negative effect on performance and therefore should no longer be used. However, the majority of these studies have compared static stretching to dynamic stretching in a warm-up and found that dynamic stretching simply produces a better performance outcome than a purely static stretch warm-up. When you look further into the research, however, there have been very few studies that have fully investigated a combined approach where both static and dynamic stretching are used. To counter this, there have in fact been other studies which have found no significant difference between the approaches, so this is an area which will be discussed further in the warm-up section.

Static stretching remains an important component in injury prevention, as studies have shown that players with reduced muscle length (commonly this has been the hamstrings) are more likely to sustain a muscle strain.

Muscle tightness can also cause load to be transferred elsewhere in the body, with injuries occurring there instead and this is common in the lumbar spine. Players with tight hamstrings or hip flexors will often transfer load and strain to their lumbar spine where excessive compensatory movements then take place and subsequent dysfunctions occur.

Therefore, when taking into account these two factors, it is important that a player’s muscle length is screened regularly and that they are given programmes to address any reductions in muscle length.

Static stretching has been shown to be more effective than dynamic stretching in improving muscle length and should therefore be used to elicit these changes.

Duration of static stretching


Again, there has been a widely debated topic as to the time it actually takes for adaptations to occur and muscle length to change.

For significant changes to occur to a muscle’s length, the stretch must be sustained for between 20 and 30 seconds, repeated a number of times and then continued over a period of weeks.

It would therefore be our suggestion that a stretching programme involves each stretch lasting 30 s, being repeated 5 times, and that it is carried out at least twice a day over a month-long period for significant changes to be noticed.


As tendons have a far greater percentage of collagen and hence are a more rigid structure, it will take significantly longer for differences to occur here. This is an important consideration when tendons have been injured, such as after an Achilles rupture or ankle injury, where a period of immobilisation has occurred and the tendon has become shortened.

Stretches here must be sustained for at least 2 min with 3 repetitions and carried out at least twice a day for a ‘creep’ effect to occur on the collagenous tissue. This again may take a significant number of weeks for an effect to be noticed.

Some good examples of static stretches are detailed below:

Hold–relax stretch technique

This is a technique which can be very beneficial to increase muscle length and, consequently, the range of movement.

The athlete requires a partner to achieve this technique as it requires a purely passive stretch to occur after the hold or activation component. The muscle is initially taken passively to its end of range or stretched position and then it is activated against the resistance of the stretching partner, although the activation of the muscle should not actually cause any movement at the joint in which the muscle acts over. This active movement should be held for 7 s before the athlete’s stretch partner takes the joint, and hence the muscle, further into its available range. The passive stretch component still needs to be held for 20–30 s before the activation occurs again. This technique can be repeated 3–5 times with excellent increase in range possible.

Dynamic stretching

Dynamic stretching has become the warm-up technique of choice over the past few years, with conditioners teaching and athletes hence using the techniques to prepare themselves for their sport.

Simply, dynamic stretching is where the muscles and the joints that they act over are taken actively through their available range without holding the position for any length of time.

Studies have shown that dynamic stretching allows athletes to improve their performance in athletic tasks such as sprinting and jumping when they have prepared using these techniques. It is thought that the dynamic movements help prepare a muscle for activity by replicating the functional movement patterns which are to be carried out in the sport, together with having a neuromuscular effect of stimulating the stretch reflex of the muscle–tendon units.

Dynamic stretching exercises have, however, been shown to be less beneficial in providing long-term changes in actual muscle length, so their inclusion in training programmes should be restricted to the warm-up components of athletes’ training.


The dynamic stretch should start gently and then be repeated a number of times with a gradual increase in the range of movement each time until the athlete is moving through the full available range.

Ageing and older people

Dawn A Skelton, Susann M Dinan-Young, in Exercise Physiology in Special Populations, 2008

Injury prevention

Carroll et al 1992, Pollock et al 1991, 1997). The risk of an event, an accident or an exacerbation of an existing joint condition can be controlled by ensuring biomechanically sound positions, cautious training loads and by introducing exercises one by one around affected joint(s). All activities must avoid undue spinal stress or disc compression (e.g. sit ups or other exercises that cause spinal loading in flexion (Dinan 2001, Sinaki 1982)); moves with high falls risk (turns of more than 90° or exercises involving lateral movement of one leg across the other (Skelton & Dinan 1999)); and uncontrolled isometric contraction (Bell 2001). Older people with muscular weakness, particularly those with a history of joint, muscular or connective tissue damage caused by overuse injury or disease, should use an especially conservative training load initially with predominantly controlled isometric work at first and then progression to light isotonic work loads (Ettinger et al 1997). Wearing hip protectors during exercise reduces the risk of a hip fracture if a fall does occur and improves both self-efficacy in the participant and confidence in the instructor (Skelton & Dinan 1999). Balance training should be progressed cautiously in frailer older adults, first by increasing the number of repetitions, then decreasing the support (e.g. chair support to no support, bipedal to unipedal base of support, increasing the difficulty of the surface etc.) (Rose 2003, Skelton & Dinan 1999), whilst being aware of potential hazards of asymmetry in lower limb strength and power (Skelton et al 2002) (Table 6.5). Particular care during transitions between exercises and components, particularly floor work transfers, is also necessary.

The senior athlete


Improper or inconsistent stretching techniques, for example, ballistic techniques, can cause muscle strains and soreness, especially in the aging athlete whose flexibility is decreasing. Although it may not be harmful, statically stretching a cold muscle is not as efficient as stretching a warm muscle. There is some evidence for the necessity of holding a static stretch for 60 seconds in older persons as compared with 30 seconds in younger persons


In the opinion of the authors, there is no substitute for an adequate warm-up by senior athletes before exercise. Athletes who have always avoided this aspect of training find it increasingly essential as they age. The best warm-up for a specific activity is 10 to 15 minutes of low-intensity engagement in that activity in order to increase intramuscular temperature of the requisite muscles., For example, if tennis is the activity, then the players should begin by total body movements for warm-up, progress to hitting balls across the net, slowly at first and then with increased velocity and movement. If running is the activity, the runner should begin the few minutes walking and progressing to an easy jog, gradually picking up speed. This rule is easily generalized to other sports.

Injury Prevention And Safety

Warm-up is often confused with stretching. Although stretching may be a component of the warm-up for some athletes, stretching can be as much of a problem as it can help, and outcomes of the research exploring the effects of preparticipation stretching are mixed. Muscle can be adequately warmed by the previously mentioned warm-up techniques, and the authors suggest that older athletes engage in more global activities to warm the muscles before stretching or, even better, to incorporate stretching into their cool-down routine. As a rule of thumb, athletes who have always stretched before exercise should not be discouraged from doing so. In general, low-velocity, nonballistic stretching is best for the muscles and soft tissues of the aging athlete. Stretching in functional patterns and with low-velocity sport-specific movements may be helpful to prepare for athletic activity. It seems logical to suggest stretching as a remedy for the flexibility changes that occur with aging. However, it should be noted that the reason for the loss of flexibility or range of motion with aging may be less a result of soft tissue tightness and more a result of joint changes. Some changes include joint surface deterioration, breakdown of the collagen fibers, and a decrease in the viscosity of synovial fluid. In these cases, stretching may not be particularly helpful.

First contact management

Injury prevention

Injury prevention should perhaps be the most important topic within the field of sports medicine. The term ‘prevention’ is normally used in the context of sports injuries to refer to any measure which can stop an injury occurring. But the processes of prevention also play an important role in arresting the exacerbation of a current injury, and ensuring that the same injury does not recur.

Injury Prevention And Safety

The causes of sports injuries are many and varied. Items such as technique failure, faulty sports equipment, poor physical fitness, inadequate warm-up and psychological factors can all act as co-factors. Taimela, Kujala and Osterman (1990) divided injury risk factors into intrinsic and extrinsic groups as shown in Table 6.1.

Some factors will clearly affect athletes differently, and certain elements are more important in one sport than another. However, in general, the more risk factors an athlete shows, the more likely he or she is to be injured. Consequently, the aim of the coach or practitioner should be to reduce these risk factors to a minimum.


Injury Prevention And Safety

Joints, muscles and other soft tissues should be extended through their full physiological range before competition, using maintenance stretching. However, it is important that developmental stretching be separate to, and follow, a warm-up.


Maintenance stretching may form part of a warm-up. Developmental stretching must be preceded by a warm-up.

It is also important that vigorous exercise does not end abruptly, but slows gradually during a cool-down period. This period allows the cardiopulmonary system to return to resting levels without placing undue stress on the body. In addition, delayed onset muscle soreness (DOMS) may be reduced by flushing fresh blood into the muscles previously worked during exercise, and removing waste products. To achieve an increase in muscle perfusion, the activity must involve rhythmic muscle pumping actions of low intensity.

Injury Prevention And Safety


All the components of fitness are required for injury prevention, and importantly, a balance should exist between each. For example, increased flexibility without a similar increase in strength may leave a joint hypermobile or unstable and increase the risk of injury. Similarly, strength and muscle bulk increases without adequate flexibility and skill can leave an athlete ‘muscle bound’ and lacking agility.

Symmetry of muscle development and range of motion is also important. Athletes who exercise unilaterally, for example throwers, must take care that they redress the imbalance caused by their sport with a suitable strength-training programme. Unequal muscle development across a single joint or series of joints may alter specific body segment alignment and general posture. Similarly, unequal training within an antagonistic pair of muscles will cause imbalance.

It is also important that training accurately reflects the physical demands of a sport, and exercise is specific to the physiological adaptations that the sport requires (SAID principle). Sports requiring speed and power, for example, will suffer if only strength is included in training. The ‘strong’ athlete who has trained exclusively with heavy weight training is open to injury when rapid explosive actions are used in sport. This is because the skills involved in the two actions are very different.


Physical training must aim to give a balanced overall development.

Psychological factors

A variety of psychological factors may predispose an athlete to injury. Personality tests (Cattell 16PF) performed on footballers have shown that tender-minded players were more likely to be injured, and those who were reserved/detached or apprehensive to suffer more severe injuries (Jackson et al., 1978). Anxiety, and the unconscious attempt to cope with it, can cause abnormal behaviour in the athlete (Sanderson, 1981) and may also increase the likelihood of injury. Coping mechanisms for tension or anxiety can in some instances create a distortion of reality. An example is the overly tense athlete who simply denies that he/she is anxious, yet loses composure easily and in some cases actually becomes violent. Individuals of this type may harbour a sense of guilt which they try to reduce by self-punishment. A number of visible characteristics are displayed by the injury-prone athlete.

Injury Prevention And Safety

Stressful events in a player’s life can also be a factor in injury. These can be measured as life change units (Table 6.3), and injured players tend to have significantly more of these in the period preceding injury (Kerr and Minden, 1988). One of the reasons for this increased risk is that the athlete’s attention may be affected, with life events hindering concentration. To perform well, an athlete must ‘let go’ and allow automatic or grooved motor actions to ‘flow’ freely. Stressful life events could lead to worry about performance which may prevent an athlete from letting go. In a study of gymnasts, those who had experienced recent stressful life events were four times more likely to be injured and the severity of injury was 4.5 times greater. The subjects in this study reported ‘lack of concentration’ and ‘thinking of other things’ as the major causes of their injuries.

Injury Prevention And Safety

Stressful life events may ultimately lead to mental fatigue, which may present as apathy where an athlete is ‘not interested’ and ‘lacks concentration’. Remedial action could involve a period of attention training from a sport psychologist, to enable the athlete to focus on a task or shift attention between different tasks rapidly. Coaches and therapists must recognize that an athlete is vulnerable to injury after a stressful life event. Training should be modified by reducing its intensity and concentrating on basic skills rather than introducing new ones.


Athletes are more vulnerable to injury after a stressful life event. Training must be adapted to take this into account.

Equipment and environment

All athletes are under pressure to buy particular sportswear. Professional athletes may receive sponsorship, and amateur athletes (particularly children) will respond to changing fashions. It is important to emphasize to the athlete that sports equipment should be comfortable and functional. If a particular shoe or item of clothing does not fit correctly, another should be tried, the fit being more important than the type.

The field of play should also be the focus of attention, particularly in amateur sport. Before training, both the environment and equipment should be inspected by the coach. If, for example, a child falls on a broken bottle that no one realized was there, part of the responsibility lies with the coach for not checking the area beforehand.

Injury Prevention And Safety

Another aspect of ‘environment’ that warrants attention is the other players. Variability of young athletes grouped by chronological age rather than biological (physiological) age may be tremendous. This is especially true at the onset of puberty, where a relatively narrow age range of 2 years in a grouping of 9–11-year-olds will give a large size variation. It was these variations (at the time within the child labour market) which gave rise to the use of physiological age groupings based on pubic hair development.

Injury Prevention And Safety

Table 6.4 shows the difference between age, size and a selection of performance variables in small and large youth ice hockey players in the same league. It is clearly a risk to have a 37 kg athlete able to produce an impact force of just over 1000 N competing against a 74 kg athlete capable of producing an (almost double) impact force of 1700 N.

Self-assessment of maturity can be made using secondary sex characteristics, including external genitalia and pubic hair in males, and breasts, pubic hair and menarche in females (Malina and Beunen, 1996).

There is obviously a potential problem of under- and overestimation (by the athlete or others) to remain with peers or to gain a competitive advantage, but the possibility of random testing by medical staff should control this.


Children in sport should be matched for biological age, body build and skill level.

Rather than chronological age alone.


In professional sport, rule changes have had a dramatic effect, particularly with head injuries.

However, the local youth club under-12 team must also have a firm policy of sports regulation.

Where children are involved, it is important to lay down firm rules concerning safety and equipment.

The coach who tries to be popular by allowing a ‘free for all’ is really being irresponsible and is likely to be the cause of injury.

Injury Prevention And Safety

Alteration of rules in sport has been shown to have a positive effect on injury rate and intensity.

Changes in the rules in ice hockey.

Making the wearing of helmets compulsory, significantly reduced the number of head and eye injuries .

In American football, the banning of ‘spear tackles’.

Hitting an opponent with the vertex of the head.

Has reduced the number of head and neck injuries .

In hockey, banning high sticking (lifting the stick above shoulder level) has reduced eye injuries.

And in karate, banning round-house kicks in competition (a rapid kick aimed at the side of the head) has prevented injury .

Allowing free substitution (permitting injured players to be substituted immediately) in soccer has been shown to reduce injury (Jorgensen, 1989).

Injury Prevention And Safety


The subject of physical screening of youngsters in sport is one which attracts much discussion.

A variety of anatomical abnormalities may develop largely unnoticed to the layperson.

However, these can often be readily identified by the sports medicine practitioner.

With a series of annual screening tests.

Injury Prevention And Safety

Posture, flexibility and strength can all be measured using fairly simple field tests.

These can be incorporated into a training session.

And educational period for youngsters, at the beginning of a season.

Pre-season screening may involve tests of a number of measures .

Tests should be performed 6–8 weeks prior to competition to allow for the effects of training to take place.

In addition, pre-event screening should be performed to assess a player’s suitability to compete.

What Is the Optimal Treatment for Thoracolumbar Burst Fractures?

Burst fractures of the thoracolumbar spine account for approximately 45% of all thoracolumbar trauma cases.

And half of these patients remain neurologically intact after injury.

The 1990s and 2000s have brought significant technologic advancements.

Specifically the widespread use of pedicle screw fixation in the thoracic spine.

The design of stiffer and more rigid instrumentation.

Injury Prevention And Safety

The ability to reconstruct the anterior spinal column with expandable cages and biologics.

And less invasive spinal surgical approaches.

The treatment of thoracolumbar trauma.

However, and specifically that of burst fractures.

Continues to be one of the most controversial areas in spine trauma care.

Despite the high incidence of these injuries and extensive published research.

Injury Prevention And Safety

Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

Neuromuscular Training

Well-designed injury prevention programs reduce the risk of ACL injuries for athletes, particularly females.

These programs attempt to alter dynamic loading of the tibiofemoral joint through neuromuscular.

And proprioceptive training.

They emphasize proper landing and cutting techniques.

This includes landing softly on the forefoot and rolling back to the rearfoot, engaging knee and hip flexion.

And, whenever possible, landing on two feet.

Players are also trained to avoid excessive dynamic valgus of the knee and to focus on the “knee-over-toe position” when cutting.

Preventive programs should be implemented during ACL rehabilitation, followed by a maintenance program.

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