Transcript Injury Prevention - CLG Uladh – Ulster GAA

Fit for play.
Injury prevention and Management
Chris McNicholl.Chartered Physiotherapist.
Mid Ulster Physiotherapy Clinic.
Fit for play.
Set the scene re injury.
Injury occurrence.
Injury management.
Injury prevention.
Dynamic, multifactorial model of sports
injury etiology
Meeuwisse, ‘94
Internal Risk Factors
•Age
•Gender
•Body composition
•Health
•Physical fitness
•Anatomy
•Skill level
•Previous injury
•Motor Abilities
•Psychological profile
- Motivation
- Risk taking
- Stress coping
BASEM Congress 2004
Predisposed
Athlete
Susceptible
Athlete
Exposure to external
risk factors:
•Human factors (team
Mates, opponents, ref)
•Training
•Exposure
•Protective equipment
•Sports Equipment
•Environment
INJURY
Inciting event:
•Joint motion
(Kinematics, jt forces
and moments)
•Playing situation
(Skill performed)
•Training programme
•Match schedule
Croisier, 2004
Extrinsic
Factors
First Injury
BASEM Congress 2004
Intrinsic
Factors
Modifications
From
initial strain
Questionable
Options in
treatment
Recurrent Injuries
Age
Age
Age
Nature
Activity
Time
Location
Cause
Severity
Other
Results
Training
41%
Game
59%
Occurrence of Injury
60
% of Injury
50
40
Training
30
Game
20
10
0
1st
2nd
3rd
4th
0
THIGH
Training
TOE
SHOULDER
RIB
QUADS
OTHER
LOWER LEG
KNEE
HIP
HAMSTRING
GROIN
FOOT
FINGER
FACIAL
CALF
BACK
ARM
ANKLE
ACHILLES
ABDOMINAL
% of Injury
Location of Injury
Game
30
25
20
15
10
5
Location of Injury
Groin 9%
Quads 8%
Ankle 13%
Shoulder 7%
Knee 14%
Hamstrings 22%
Hurling Injuries
Muscle injuries 24% (hamstrings
12%)
Contusions 16.3%
sprains 15.6%
41% were attributed to foul play!
Watson 1996
Am.J.Sp.Med
Location of injury
Head 9%
Hamstring
12%
Fingers 13%
Knee and ankle 9%
Watson. A 1996 Am. J.Sp.Med
Figure 1 Site of injury, with 95% CI.
Wilson, F et al. Br J Sports Med 2007;41:317-321
Copyright ©2007 BMJ Publishing Group Ltd.
Figure 2 Type of injury, with 95% CI.
Wilson, F et al. Br J Sports Med 2007;41:317-321
Copyright ©2007 BMJ Publishing Group Ltd.
Figure 3 Mechanism of injury, with 95% CI.
Wilson, F et al. Br J Sports Med 2007;41:317-321
Copyright ©2007 BMJ Publishing Group Ltd.
Figure 4 Injury rate by position, with 95% CI.
Wilson, F et al. Br J Sports Med 2007;41:317-321
Copyright ©2007 BMJ Publishing Group Ltd.
Comparisons
Gaelic football
al 2006
Soccer
Aus Rules
13.5/1000 hrs Wilson et
8.5/1000 hrs Hawkins.
62/1000 hrs Seral et al
Rugby League 139/1000 hrs Seral et al
Rugby Union
72/1000 hrs Bird et al
My practice.
296 attendances in 2004.
33% Muscular
22.6% Ligament
23.9% Overuse
9.5% Tendon
6.5% Contusion
4.5% Fracture,Dislocation,
derangement.
Audit of Gaelic footballers and hurlers attending from
clubs in Tyrone, Derry and Antrim over 2004.
ankle 47
foot
hand
8neck
4 8
shoulder 15
back 53
shin 4
calf 14
hip 18
knee 57
groin
quad 20
hamstring
48
Injury management.
Acute Stage (Hours and days)
Bleeding and onset of inflammation.
Protection.
Rest.
Ice.
Compression.
Elevation.
Regeneration.
Involves the
production of scar
(collagen) material.
Begins 24-48hrs post
injury and can peak
up to 2-3 weeks post
injury.
Therapeutic
modalities.
Soft tissue
mobilisation.
Return to non“harmful” activities.
Repair and remodelling.
The production of a high quality
functional scar. 4 weeks to 6 months.
Graduated exposure to stress.
Return to full range of movement
and strength.
Full sport specific rehabilitation.
Address any biomechanical
weaknesses.
Inadequate
rehab.
Watson demonstrated in Irish Soccer/Gaelic/hurling that
time lost through injury in the previous year was largest
predictor of new injury.
82% of County players in one study had been injured in
previous 6 months.
35% of these injuries were recurring.
46% Continued to play, 93% of whom believed their
performance had been affected. Cromwell et al 2000. Br
J.Sp Med.
Injured muscle retains sufficient muscle strength to allow
early limited functional rehab
Injured muscle at risk for complete rupture if muscle
subjected to high tensile forces
Use of techniques designed to rapidly return the athlete to
competition may magnify this risk for rupture
Taylor et al, ’93
Injury prevention
Injury prevention.
Ensure previous
injuries are fully healed
and player fully
rehabilitated.
Use professionals.
Set yourself /team a
rule that going into
league players
returning from injury
must be back in
training for 2 weeks
before game.
“Recovery that’s the
name of the game…
Whoever recovers the
fastest does the best”.
Principles of training
Adaptation.
Adaptation only happens if the body is worked
harder than normal. This is called OVERLOAD.
If the body is overloaded regularly it will adapt
to try and tolerate the stress. This is the point
of training.
If the overload is too great the body may
breakdown and cause an injury.
Therefore the overload needs to be
PROGRESSIVE
Consequences of exercise
Training and competition create an
overload to stress the body, which
in turn produces fatigue –followed
by improved performance.
The Principle of Recovery
Muscle
DOMS.
Increase in muscle
stiffness.
Lactic.
Calcium and
fatigue.
Neurological
Sympathetic nervous system.
Aerobic metabolism.
Fast and slow components.
With adequate recovery this
returns to normal levels.
However if a high training volume or
intensity is repeatedly performed
without necessary rest sympathetic
nervous system activity will become
increasingly high.
This leads to an increase in resting
heart rate and is a sign of
overreaching and overtraining
when symptoms are not
detected.Hahn 1994
Key Aspects to Fatigue
Recovery
Recovery is one of the basic principles of
training methodology.Rushall and Pyke 1990.
It refers to the period of time after
training when the body recovers from the
demands placed upon it during intense
exercise.
Many athletes train extremely hard without
giving their body time to recover.
This can lead to over reaching, burn out,
or poor performance.Mackinnon and Hooper 1991
“The team” (athlete, coach, trainer, Physio,
Doctor Masseur) need to continually monitor
for signs and symptoms of poor adaptation to
training and stress.
Need to implement strategies to minimize
Fitness Level
Adequate Recovery
Session 1
Session 2
Session 3
Days
Fitness Level
Inadequate Recovery
Session 1
Session 2
Session 3
Days
Session 4
Fitness Level
Overtraining
Session 1
Session 2
Session 3
Days
Session 4
Session 5
Signs and symptoms of incomplete recovery
(Adapted from Angela Calder:
Recovery Strategies for Sports Performance)
Facial
Expression
Facial
Colour
Posture
Signs
of frustration
Athlete says he has:
Heavy legs
Doesn’t feel good
Legs are sore
Feels tired
Signs and symptoms of incomplete recovery
(Adapted from Angela Calder Recovery Strategies for Sports Performance)
Poor skill execution
Slow acceleration
off the mark
Heavy feet
Poor decision
making
Slow response time
Low motivation
Low concentration
Aggressiveness
No self confidence
Poor eating/diet
Poor sleep pattern
20yr old footballer
Case Study
Poor kyphotic posture
History of right ankle sprains
History of right hip pathology
History of right shoulder pain
Currently complaining of left thigh pain
Poor balance and proprioception
Significantly reduced hamstring length
Unstable right shoulder
Continued to play throughout injury- still
feels sore (2 years later)
Constantly feels stiff and sore
Trains 5 times per week
Regularly plays 3 games per week
Advantages of good recovery.
Minimise the effects of residual training
fatigue.
Help prevent overtraining- injury- illness.
Allow you to get the most out of your
trainings
Overall improve performances
Hydration and Nutrition
 Restore fluid balance as quickly as
possible
 1.5 litres fluid for every 1 kg weight loss
 Rehydration solutions helps retain fluid and
prevents big losses
 Consume CHO immediately to promote refuelling
 1 g / kg body weight immediately
 Eat / Drink protein
 Follow with a high CHO meal within 2-3
hours
 Sodium replacement will help to maximise
retention of ingested fluid
Passive Recovery (Rest is Best!)
A good 7-9 hrs provides invaluable time for an adult to adapt to the
Physical Immunological Emotional –
Stressors experienced During that day
Napping helps recovery ? ½ hr during day
Hydrotherapy
The Theory
Accelerates recovery
by increasing
peripheral circulation,
removing metabolic
wastes and
stimulating the central
nervous system.Calder 2001.
Contrast
baths (hot and cold)
Spas
Showers
Ice
?
baths
Cryotherapy chambers
Hot and cold baths
accelerated lactate
recovery in elite female
hockey players. Sanders 1996
Jet pressurised water spa
immersion in Judo fighters
demonstrated an
improvement in recovery.
Gieremek 1990.
Hydrotherapy
“Despite the popularity..little research has been
conducted….they all need to be thoroughly
investigated before it can be claimed as an
accelerant for aiding recovery”
Cochrane J 2004 .Alternating hot and cold water immersion for
athlete recovery:a review. Physical Therapy in Sport.
Ice baths
“Its absolute agony, and I dread it, but it allows my
body to recover so much more quickly”
Paula Radcliffe
Reduces inflammation but is this always desirable?
Massage
Improved recovery
and maintenance of
performance during
pre season female
volley ball. Mancellini et al 2006
It does promote
relaxation in the
muscles Calder
Improved mood states
and feelings of well
being have been
shown in several
studies. Hamer 1999
Psychological Recovery
Healing rates are slower when in a state
of stress.Marucha et al 1998
Higher levels of depression and anxiety
had a statistically significant association
with slower healing.Cole-King 2001
Debriefing
Emotional Recovery/Contingency plans
Mental Toughness Skills e.g. positive self
talk, positive body language
Relaxation techniques egg meditation,
music, breathing
Compression
Garments
•Garments-leggings,short
pants or tops
•Apply a graded compression
to the body.
N.Gill investigated 4 different recovery
strategies following competitive rugby
matches by measuring Creatine Kinase
concentration.
Players were measured post match and at 24 hrs
2500
and 72 hrs.
2000
1
active recovery
2
1000
hot and cold baths
3
passive recovery
Active Recove
Skins
Hot and cold
Passive
1500
500
0
4
skins
Post game
24 hrs
72 hrs
Periodisation
•This is the term used for planning
and organising training , competition
and rest over a given period of time
e.g. 1 season with the aim of
“peaking” at various times.
•Period should be divided into blocks
or cycles of training.
•There should always be several
consistent phases to the training plan.
Planning your season.
Dec Jan Feb Mar Apr Ma Jun Jul
y
y
Au
g
Se
p
Oct No
v
Off season. Rest, recovery, holiday, turkey. Injuries sorted. Screening.
Pre-season. Set a base.
Developmental phase. Advance and develop key components of fitness
Power phase. Power, speed and explosive fitness.
Competition Phase. Maintain strength etc.

Example 2 months training consisting of 2x
4week cycles
F C F F C F C P F C F C P F C P
L
M M
M
H
H
L
C F C F F C F C F P F C F C F P
H
H M
H
M
F= Field, C=Circuit, P=Pool
Intensity: L= Low, M=Medium, H=High
H
H
L
Planning your session.
Ensure players are punctual and
hydrated.
Warm up 15mins- 20mins
Match /Training 60 mins+/Warm down.10-15max
Recovery strategies.
Warm up
Gradual increase in intensity jog- ½ ¾ pace.
Increase blood flow, get the nervous system
“tuned in” and decrease muscle stiffness
(passive).
Facilitate motor unit recruitment before full out
activity.
Introduce skills and change of direction.
Introduce dynamic movements/stretches.
Get our full active flexibility.
Introduce full pace and end range body
movements necessary for that sport.
Specificity
It is advised that training should be sport
specific.
Gaelic football and hurling are multisprint
sports.
Sprints are rarely any more than 40
metres, with the majority less than 20
metres.
They are rarely linear.
Training should include lots of directional
change at pace to include decceleration as
well as acceleration.
Fatigue
Remember alterations in calcium ion
content in muscle affects
contractibility.
Muscles less able to absorb high
forces
Decreased viscoelasticity.
Avoid sprints when fatiqued.(ie end of
session).
Australian Rules
Verral et al 2005 British Journal of Sports
Medicine.
Pre season intervention to decrease.
hamstring injuries.
Changed focus from long endurance runs
to acceleration training and high intensity
sports specific drills. Stretched when
fatigued.
Strength training. Bodyweight only to first
timers, weights to those with experience.
Hamstring injuries went from 4.7/1000
playing hours to 1.3/1000.
Active Recovery (Cool Down)
The Theory:
Light activity during the post exercise period has been
shown to increase lactate clearance rates.
E.g.
Walk/jog/cycle/swim
Gupta et al 1996
Needs to be at least 5 mins.
Bonen A 1976
Dodds.s demonstrated greatest recovery at 35% VO2 max.
Advice is to work for approx 10-15 mins as any
longer causes glycogen depletion.
Improves psychological recovery.
Suzuki 2001
The following day 15-20 mins of light activity (eg low
intensity pool session.) Reduces DOMs.
Hasson et al
1989
? stretch
Active Recovery (Cool Down)
In Practice:
Desirable after training and games
Where possible use “off feet” strategies ie
bike/rower or pool :
eg easy spinning 5 mins /row 5 mins then
walking and general limb movements in water.
Sports requiring repeated bouts of high
intensity work will benefit from active recovery
in between efforts.
Next day where possible short low intensity
session.
Flexibility.
Is described as a component of fitness.
Relationship with performance.
Relationship with injury controversial.
No correlation between flexibility and injury in Irish
soccer/gaelic/hurlers. Watson 2001
Stretching: Definitions
We need to separate stretching from
flexibility /range of movement.
Static vs Dynamic
Ballistic
PNF.
Effects?
When..? Where...? How..?
Sports involving bouncing and jumping activities with a high
intensity of stretch-shortening cycles (SSCs) [e.g. hurling and
football] require a muscle-tendon unit that is compliant enough to
store and release the high amount of elastic energy that benefits
performance in such sports.
Sports involving SSC movements
– Require a compliant muscle-tendon unit
Store/release high amounts of elastic energy
Stretching may be important as an injury prevention measure
No, or low SSC movements
– Compliant muscle-tendon unit offers no advantage
– Additional stretching exercises to improve compliance may have no
beneficial effect
Witvrouw et al, ‘04
Static Stretching
Therefore the advice
must be at present to
stretch throughout the
week as an
intervention to
maintain compliance
within the
musculotendinous
unit.
Screening
General health.
Musculoskeletal profiling.
Functional tests
Pitch tests.
Musculoskeletal profiling
Identify predisposing factors to injury.
Detect potential “weak” links that affect
performance.
Identify injuries
Posture
Range of movement
Muscle Strength
Stability.
Balance.
Screening in Gaelic Football
Sports Institute for Northern Ireland
As a group the Gaelic
footballers had
Tight hip flexors and
poor core stability.
Poor posture
associated with
Thoracic and Lumbar
stiffness.
Proprioceptive deficits.
(Balance deficits)
8/18 “sway back”
posture
14/18 had
comments
regarding postural
problems
8/18 Tight hip
flexors
9/18 Poor pelvic
stability
So what?
It is generally believed that poor control of
stability around the pelvis and CORE are
responsible for causing a lot of pain and injury.
L.Hennessy 1993 in a study looking at possible
causes of hamstring injuries in gaelic footballers
found that poor lower back posture was an
increased risk factor.
Poor posture was the second best predictor of
injury in irish field sports after previous injury.
In runners poor pelvic control was demonstrated
as a risk factor.
Core Stability????
Where is your core?
What does a stable core consist of?
What is an unstable core like?
Demonstrate imbalance.
How do we improve core stability?
A) Low load postural exercises
B) Low load Stability exercises
C) High load Stability exercises
D) High load mobility exercises.
Interventions
Postural alignment and dynamic
balance are the foundation for all
training.
Focus on perfect technique.
Fundamental movement skills before
sports specific skills
Stop when technique fails.
Emphasis on powerful, safe and
efficient movement.
Train movements not muscles.
CNS uses pre-programmed
motor/movement patterns.
If form is correct muscles will adapt.
If technique/form is incorrect then
faulty movement patterns will be
rehearsed.
Some “core” strengthening with
good technique.
Squat.
Lunge.
Single leg squat.
Plank.
Side bridge.
Press up.
Balance
Balance work using
wobble boards and
other apparatus
has been shown to
reduce the risk of
knee and ankle
injuries.
Include some of
these ex`s in your
circuits or warm
up/ warm down.
Jumping and landing practice.
Practice jumping
and landing
technique.
Reduces risk of
ACL injury.
Think of form and
landing softly.
Strength and Conditioning.
Increased fitness levels= increased
resistance to fatigue.
Better strength improves ability to sprint
and change direction.
More muscle to absorb impact forces.
Stronger bones, cartilage, tendons and
ligaments.
Load?
McBride et al compared athletes
jump squatting at 80% and 30% of
1RM max.
Measured sprint times, agility times
and agility runs, squat strength and
squat jump
80 % had decreased sprint times,
increased strength force and power.
30% had increases sprint, strength
force and power.
Improving power.
We want to train muscle elastic
components.
During many functional movements the
muscles actually experience minimal
lengthening due to joint movement and
tendon lengthening.
Eccentric training, plyometrics and
flexibility can affect this positively.
Enhances ability for elastic energy
storage.
Injury prevention.
Equipment
Footwear.
Helmet.
Hurling glove.
Mouth guard.
To sum up.
Injury surveillance a must to make
accurate interventions.
Avoid high intensity work when fatiqued.
Allow for recovery.
Full functional rehab after injury
Sports specific training.
Strength and conditioning.
Some balance training if time is available .