We are all, I hope, aware of the benefits of an active lifestyle, however there are also risks associated with participation. Female & young athletes are at the highest risk. Sports injuries are the leading cause of adolescent visits to emergency rooms. Injuries delay or even derail athletic progress & may impact on other areas of the athlete's life. Some injuries including brain damage & osteoarthritis may only manifest years later. While it is impossible to completely avoid injury a large percentage can be predicted & prevented. The US CDC claims that over 50% of sports injuries in children & adolescents are preventable. In order to develop strategies to prevent the injuries we first need to understand the causes & look at the special cases of female & young athletes.
Causes of Injury
Overtraining Syndrome & Overuse Injuries
Overtraining is, simplistically, an imbalance between training & recovery & is often caused by 'hyper-motivation'. Extreme training programmes seldom produce optimal results. It is all too easy to push too far, too fast. Typical symptoms include being tired, sluggish & sore. It is often responsible for a star athlete 'choking' in an event after performing well in training. More astute observers sometimes refer to it as peaking too soon. At its worst it becomes a viscous cycle: the athlete's performance deteriorates due to overtraining so the athlete trains harder only to see their performance deteriorate even more...It has been demonstrated that overtraining is at least partially due to glycogen depletion. As previously discussed, it is vital that athletes refuel correctly immediately after exercise. Without sufficient carbohydrate intake post exercise & in the diet as a whole there will be insufficient fuel to maintain performance. As a rule of thumb: anyone involved in training should have a minimum of 60% of their energy intake from carbohydrates to optimise muscle & liver stores of glycogen.A simple test for overtraining is to take your resting heart rate (RHR) every morning (simple yes but it requires some commitment). Your RHR is your pulse at absolute rest, some people sleep with their heart rate monitor & take the lowest point. It is easier to take your pulse just after you have woken up & are completely relaxed (& you've gotten over the shock of the alarm). Track this number, it should be quite stable with a decline to a point as your fitness increases. If there is a sudden significant increase there is a good chance you are overtrained. Rest & refuelling are recommended until your RHR drops back to normal, usually a day or 2. Failure to spot it early & remedy it can lead to declines in performance & health & will increase the probability of overuse injuries.Overuse injuries occur when a body is pushed past its tolerance to absorb repetitive strain. Typical injuries include: shin splints; sore Achilles & tennis elbow. Incorrect technique or dysfunctional movement caused by limited mobility / stability & fatigue are key contributors. As these are often injuries of hyper-motivation, patience during rehabilitation is key.In terms of prevention, technique can be practised, mobility / stability issues can be addressed & programmes can be properly planned & (self) control can be exercised. These injuries are very preventable.
These injuries are as a result of an imbalance in the power / flexibility of the myofascia in one aspect of the body relative to another. This could be because of postural issues or highly specific training e.g. soccer players often have very powerful quads relative to their hamstrings / glutes & this contributes to knee injuries. Back pain can also often be attributed to an imbalance in the core muscles. Fatigue is often a key contributing factor. Balancing flexibility & strength endurance across antagonist muscle groups can prevent this type of injury.
Impact / Accidental Injuries
Accidents happen, but even so many are avoidable. Correct technique & equipment along with obeying the rules goes a long way...
There is one particular impact injury that needs to be delved into, head injuries. We will take a more detailed look at concussions in a future post.
The unfortunate reality is that most female athletes train or are trained in exactly the same way as their male counterparts. No account is taken of the intrinsic anatomical & bio-mechanical differences. This is exacerbated by hormonal influences on neuromuscular control & ligament laxity.Female athletes, largely due to societal influences, are also prone to the 'female athlete triad'; a group of interrelated conditions related to too low energy consumption. The low energy intake is often in an attempt to remain 'feminine'.
Anterior Crucial Ligament (ACL)
Female athletes are significantly more prone to particular injuries than their male counterparts. Teenage girls for example are 6 times more likely to injure their ACL than boys. The majority of theses injuries occur during deceleration i.e. while landing, stopping, cutting or dodging. On average female athletes show poor flexion of the hips & knees during these motions. Video analysis shows that when these injuries occur the knee is at or near full extension & the hip is adducted & rotated internally while the tibia is rotated externally i.e. the knee is valgus.The literature shows that building:
- core strength & stability,
- strength / power in the muscle groups across the hips & knees (specifically with plyometrics),
- strong hamstrings help to prevent knee hyper-extension and anterior tibial translation
- strong gluteal muscles help reduce hip adduction and internal rotation.
- improving flexibility, balance, proprioception & agility
- combined with feedback driven technique (movement) correction
is effective in preventing this injury. In essence this is a subset of the rules for injury prevention listed below.
Shoulder / Rotator Cuff
This is another area where female athletes are more vulnerable. Less research has been done on this injury & set protocols, like those for ACL injury prevention, have not been developed yet. However applying the same principals is expected to yield similar results.
Female Athlete Triad
The female athlete triad was first described by the American College of Sports Medicine's Women's Task Force in 1992 (updated in 1997 & 2007). The International Olympic Committee (IOC) & the International Federation of Sports Medicine (FIMS) have both issued position statements on the triad. The 3 inter-related issues are serious on their own but potentially lethal when combined.
Eating disorders are psychiatric in nature & include distorted body image & nutritional / medical complications. Female athletes are far more susceptible to eating disorders than non-athletes. Those most susceptible are endurance athletes as well as those where aesthetics are important (e.g. gymnastics & figure skating) & where there are weight classifications. These disorders often have origins in attempts by young athletes trying to prevent the change in body composition that occurs during puberty.The disorders lead to a deficit in energy as the athlete is not consuming enough to match the output. Initially this leads to overtraining syndrome & as it becomes more extreme leads to severe nutritional deficiencies & medical complications.Since many eating disorders arise in childhood, it is important that parents along with coaches & other role models educate & implement healthy eating habits.
Amenorrhea & Other Menstrual Disorders
Energy deficiencies arise during training through an increase in training or low intake or a combination. If these imbalances are prolonged / severe, as with eating disorders, they can lead to hormonal imbalances. Estrogen in particular is lowered. This may lead to irregular menstruation (oligomenorrhea) or the cessation of menstruation (amenorrhea).Missed periods are common, in particular up to the age of 19-21, so a missed period here & there should not be interpreted as a symptom of the triad. Menarche, the start of menstruation, may be delayed in young female athletes. This is usually not a cause for concern, but it is advised that medical advice be sought if delayed beyond the age of 15.
Bone Mineral Health (Density)
A history of menstrual disorders is a strong indicator of reduced bone density, largely due to the reduced estrogen levels. When the cause is an eating disorder the problem is compounded as a low energy intake is often associated with a low calcium intake. Athletes suffering from menstrual disorders are 2 - 4x more likely to suffer stress fractures.The key to preventing the triad is sound nutrition, however the psychological & societal issues need to be addressed too.
Young athletes are particularly susceptible to overuse injuries, at over 50% of youth sports injuries. Often this is due to the incorrect emphasis being placed by parents & coaches. An emphasis on winning too early on, leads to overtraining & increased risk of injury. In extreme cases it may lead to athletes competing while injured or even 'sacrificing' themselves for the 'greater good' of the team.
The Canadian Sports For Life's (CS4L) Long Term Athletic Development (LTAD) model prescribes a focus for each stage of development. The focus is only shifted to winning in early adulthood.
Stage 1: Active Start (0-6 years)Stage 2: FUNdamental (girls 6-8, boys 6-9)Stage 3: Learn to Train (girls 8-11, boys 9-12)Stage 4: Train to Train (girls 11-15, boys 12-16)Stage 5: Train to Compete (girls 15-21, boys 16-23)Stage 6: Train to Win (girls 18+, boys 19+)Stage 7: Active for Life (any age participant)
This framework offers essential guidance to coaches, parents & athletes.
Rules for Injury Prevention
Be Fit for Your Sport
Sport specific fitness requires a combination of:
- mobility, flexibility & stability (including core stability & anti-rotation)
- integration, co-ordination, balance & agility
- strength & strength endurance (strengthen movements not muscles) combined with
- reactions & speed / quickness to produce
- power & power endurance
- cardiovascular, pulmonary & oxygen transportation capacity
- metabolic & cellular endurance
- cognitive, psychological & emotional fitness
Practice & Perfect Movements & Technique
Focusing on perfecting movement has benefits beyond preventing injuries. Posture, leverage & timing alone can produce great power. Efficient movement also conserves energy.
Warm-Up & Cool Down
An effective warm-up will not only raise the heart rate, warm up & increase the flexibility of the myofacia, it will also raise the level of neuromuscular control & proprioception. The additional control includes a reduction in the likelihood of overextension & other 'error'. Mobility exercises are good for warming up, while stretching is best left for the cool down as it may reduce performance.Cooling down is the first step in the recovery process & active recovery is in effect a prolonged cool down. The body is brought back to its resting state with decreasing activity. Along with stretching this reduces muscle tension which equates to less pain & quicker healing.
Recover & Nourish
Recovery is more than just the absence of training. It is the re-establishment of performance abilities in time for the next session / competition. It is also more than purely physiological; it also includes the psychological & social aspects (particularly in team sports). The psychological component is intuitive but social preferences are very important too. While some athletes might find group activities relaxing, spending extra time with team mates (or simply in a group) may be stressful to others. In this way team building activities can at times be counter productive.The simplest strategy is passive, rest & refuelling & these should form the foundation of any strategy. It is during sleep that the body repairs & recoups, so a good night's sleep should be high on the list of priorities. In terms of refuelling carbohydrate, fluid & protein replacement are critical for a fast recovery. Refuelling should ideally commence within 30min of finishing the activity. We will look at recovery strategies in more detail in another post.
Do Not Train / Compete While Injured
If you answer no to any of the following questions you should not train that joint other than with prescribed corrective exercises:
- Do you have more than 90% mobility / stability?
- Do you have more than 90% strength?
- Are you more than 90% pain free?
Use Correct, Functioning Equipment & Obey the Rules
It seems obvious that there is a large risk in using damaged, broken or incorrect equipment, yet it happens all the time. The risk is not always only to you but others as well.Rules ensure fair play & are often centered on safety. There are certain specific examples where rules are misguided & not supported by science, however if you agree to compete you agree to obey the rules. There is no harm in petitioning etc. to have the rules altered too.