Updated: Jan 4, 2020
This blog is directed predominantly at the patient and will explore why the idea of ‘injury prevention’ may not be quite what you think. One book that has greatly shaped my thoughts on this topic is Nassim Taleb’s Black Swan. A book about the human condition; a book which demonstrates we actively create environments of order, which only serves to increase the likelihood and severity of random events (a Black Swan) - events that we are trying to avoid in the first place.
We demand order and we love stories
Of all of the topics in the sporting medicine realm, none is more sexy, more lucrative, more researched than injury prevention. A quick Google Scholar search of ‘sports injury prevention AND systematic review’ reveals some 350,000 citations. There are some perennial best-sellers in the reviews of Lauersen et al (2013) - here - and Hubscher et al (2011) - here. Two reviews, which came to some pretty clear conclusions on which kinds of interventions have an impact on injury rates (more on that later), in a landscape that is crammed with an amazing amount of studies, that make it impossible to draw any strong conclusions. One of the main problems with this data-copia is most studies are observational in nature, and studies that control for a host of other issues are rare as hen’s teeth. We love to gather data about injuries and project into the future; in high performance sport it is an incredibly lucrative area.
The problem with all of this data is that we have an innate need, as humans, to create links and draw ‘stories’ into what is essentially inert information. The problem isn’t gathering data, it is simply the meaning we ascribe to it that is the problem. Nassim Taleb describes this as Platonicity, and it can explain a lot of the weird and wonderful fads that you might see marketed as ‘injury prevention’ nowadays. You see, we can’t stand randomness; to put it another way it always makes perfect sense to us that if we work on our reduced ankle range before squatting we are going to avoid any knee pain. That link makes sense to us intuitively, and is easy; the problem is that some ankle restriction may be linked to our knee pain, but in the unlikely event that it is, it will be a weak link and probably meaningless in the grand scheme of things.
Health professionals provide this information, and unfortunately, it is almost always to the detriment of your understanding of the complexity of pain and injury. We crave for stories, and these inert data points (your ankle range of motion) become easy to reach narratives to tell yourself about injury. We demand order and crave stories amongst the randomness; platonicity in action makes you think you are preventing injuries when you may not be.
So what are we doing when we are doing our ‘injury prevention’?
In short, it depends. There are (from the reviews above) a couple of clear conclusions from the mountains of data we have so far:
People that are stronger have less injuries (Lauersen et al (2013)).
People that do ‘neuromuscular training’ - essentially learning to land, balance and be better at the complex tasks that sport involves - have less injuries (Hubscher et al (2011)).
There is no such benefit from things like static stretching, foam rolling or any of the other fads that may be popular. Which means that unless it involves one of the above things, you may actually just be entertaining yourself with a spiky implement for a few minutes while you get ready to squat, deadlift or run. There may be benefits of these activities for other reasons, like a psychological readiness or relaxation, but these once again haven’t been shown to be strongly linked to injury rates. I would be the first to admit that we don’t know enough about the pscyhological data points that may link to injury, but it would be certainly a complex and hard-to-predict relationship. So when you are aiming for injury prevention practices, there are probably two main rules to follow:
Make it strength based.
Make it like the activity or skill you want to perform on the field or in the gym.
I am not saying don’t do the other things, just understand you probably aren’t preventing injury when you do them; in a simplistic way they may just be making you feel better.
So should we try to prevent injuries at all?
When you begin to exercise, or if you train at a consistent level, a key consideration is that you have automatically increased your level of injury risk. Just by partaking in more movement, you are increasing your risk of injury. Now importantly, I am not suggesting that more movement equates to more pain, because that is ultimately an incomplete relationship; to understand further let’s look at a couple of examples. A rock doesn’t get injured and it doesn’t feel pain; this is because it is not conscious. But if you were to never move again; you would still feel pain and this is because pain is a conscious, human experience based on a lot more things than the way your body moves. So more movement simply adds in many more variables and data into the mix and this is like taking out an extra bank loan - it simply adds to your overall risk. So when you are getting into some exercise program, changing your training or simply continuing to train hard then some injuries just happen. It is the nature of randomness and the natural world - an increased level of risk equates to an increased level of incidence. So, at the risk of sounding hyper-critical, some injuries just happen.
If we remember the two clear conclusions that the injury prevention literature has come up with (so far) - people that are stronger have less injuries and people that train their body to be better at the skill they want to perform have less injuries - we can be certain that there are simple things you can do to reduce your risk of injury.
And that is what I think we should be doing; considering any injury prevention as simply injury risk reduction.
We shouldn’t be disbanding the field of research or forgetting about the eternal search for ‘the bulletproof athlete’, but I think we need to understand that our goalposts might have to shift from time to time. The most integral point to all of this is that whether or not you are playing with increased risk, and whether or not injuries just happen to you, it is the attitude towards and the behaviour after an injury that probably matters most. This reaction can include things that we know have no bearing on injury risk reduction or you can utilise the two simple principles listed above. So maybe what we should be doing is ‘injury risk reduction’ and simply to have the understanding that there will be injuries (Black Swans) is useful. But always remember your reaction can either reduce your risk of future injuries or make you more susceptible.
In the long run
The most damaging aspect of some of our 'injury prevention' practices (like self myofascial release, prophylactic massage etc.) from my perspective is that it gives patients a narrative of being fragile.
The entire point of ‘injury risk reduction’ is to encourage the opposite; reduction in risk with the ability to react quickly and return to full capacity is probably what we should aim for instead of the abolition of all injuries.
The meaningful impact of more movement and activity on your body far outweighs the risk of minor injuries in the long run. So thinking of injuries as part of the process of getting better is a useful mindset shift, a subtle difference in what you might think of as injury prevention. Transitioning your thinking to long term durability instead of short term prevention is the key to less injuries; now only if we can get the politicians onto this as well.