Injury prevention programs: facts and figures for decision-makers

Jason Tee provides an evidence-based insight into how clinicians, athletes and coaches can quantify an injury prevention program’s value.

Injuries cost athletes and sports teams both time and money. Yet, investment in injury prevention remains the ultimate grudge purchase in the sporting world. Team managers view injury prevention as unexciting, time-consuming, and undependable. However, it is something of a taboo to forsake injury prevention efforts altogether. As a result, many athletes and organizations go through the motions of injury prevention fairly aimlessly. They lack clear expectations regarding an appropriate investment and what sort of return to expect on that investment.

Individual athletes

The Center for Disease Control (CDC) estimates that 8.6 million sports and recreation-related injuries occur in the United States each year. Of these, approximately half require medical treatment⁽¹⁾. The cost of treatment is high, with emergency department visits estimated at $439 per visit and hospital admission costing $6,039 per visit⁽²⁾. Once the loss of earnings during a period of injury is factored in (due to an inability to work - estimated at $1,500), and reduced quality of life as a result of injury (approximately $8,000)⁽³⁾, the personal cost of sports injuries are substantial. Professional athletes, who are part of a professional organization, share some of these costs with the team. However, it is worth considering what actions can mitigate this risk for amateur athletes and avoid the physical and financial toll.

In addition to injury costs, there is also the persistent effect on performance. Athletes can’t perform while injured, but healed injuries can continue to impact performance outcomes adversely. Researcher estimate that for every training week affected by injury within a season, the chances of reaching that season’s performance goals are reduced by 25%⁽⁴⁾.

Research indicates that the most effective way to reduce sports injury risk is with regular strength training. This conditioning approach reduced the risk of all injury types by a third, and halved the risk of overuse injury (see figure 1)⁽⁵⁾. Stretching alone was ineffective at staving off injuries⁽⁵⁾. While other interventions, like proprioceptive training programs and programs that combined strength, stretching, and proprioception, did reduce injury, strength training alone was the most effective at mitigating risk⁽⁵⁾.

Figure 1: Effectiveness of exercise interventions to reduce sport injury rates

Graphic adapted from Yann le Meur: ylmsportscience.com/2014/11/29/prevention-best-exercise-interventions-to-prevent-sports-injuries-the-answer-in-bjsm_bmj-by-ylmsportscience/

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Team performance and injury

There are numerous anecdotal accounts of how teams substantially reduce injury rates, which results in unprecedented performance success. Possibly, the most famous of these is the legendary account of how the Leicester City Football Club won the English Premier League in 2016. In the 2015/2016 season, Leicester dominated the competition with an exciting brand of counter-attacking football. However, critical to their effectiveness was the ability to keep their best players available for selection – ie, injury-free – throughout the season (see figure 2). Likewise, the New South Wales Waratahs dominated Australian Super Rugby in 2014 by selecting the same 13 players in their starting 15 for every match. These stories are inspirational for injury prevention champions, but decision-makers need more than anecdotes to prompt investment.

Figure 2: Number of injuries per English Premier League team during the 2015/2016 season*

Data from thestatzone.com: www.thestatszone.com/archive/the-premier-league-physio-room-13994

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Without a doubt, injuries hurt team performance. An 11-year study on European professional soccer teams showed that teams with lower injury rates achieved higher league table positions⁽⁶⁾. The relationship is the same in professional rugby union; researchers showed that over seven seasons, every additional 42 days lost to injury cost the team three league points⁽⁷⁾. NBA basketball teams are subject to the same trend, where fewer team injuries result in more games won⁽⁸⁾. Moreover, a systematic review study looking at soccer, basketball, taekwondo, rugby league, rugby union, track and field, ice hockey, and Australian Rules Football confirmed the relationship between lower injury rate and higher league table positions⁽⁹⁾.

The cost-benefit ratio of team injury prevention

The data above confirms that preventing injuries improves performance, but what are the most effective ways to achieve this? One way to assess the return on investment for injury-prevention programs is to consider how much time teams need to invest in a plan to gain additional time on the field⁽¹⁰⁾. For example, a soccer team committed to performing the FIFA 11+ at every training session might invest 20 minutes per session for three sessions per week – ie, one hour per week per player. If the squad has 25 players and the season length is 46 weeks, this will require 1,150 player-hours per season.

Now, if a soccer player trains three hours per day, this investment needs 1,150÷3 = 383 training days. Therefore, to break even on this investment, the team should reduce their injury burden by this amount. The FIFA 11+ reportedly reduces injuries by about 30% on average. If the team’s historical injury burden is 1,400 days per season, they could expect to reduce this by 420 days (30%). This outcome represents a reasonable return on investment: 383 days spent incorporating injury prevention training to gain 420 healthy player days. On the other hand, if the team’s historical burden is only 700 days, they would only reduce this by 210 days, and the investment in terms of time spent would not be as worthwhile.

Interestingly, the author of this investment-minded approach calculated that specific exercises did not present good returns. For example, a training using Nordic hamstring exercises, Copenhagen adductor exercises, and an ACL injury prevention protocol did not deliver good returns because the average football squad does not suffer sufficient injuries to make these interventions worthwhile⁽¹⁰⁾.

Being more effective, not doing more

This cost-benefit analysis example is enlightening. If a team were to do all of the FIFA 11+ (20 minutes), additional Nordic’s (10 minutes), and Copenhagen’s (7 minutes), and the ACL program (20 mins), they would add 57 minutes to their training time. This approach isn’t practical! Of course, many of these exercises could be integrated during other training components, such as the strength and conditioning sessions. Thus, designing an effective injury prevention program may not be about adding more features, but understanding where and how to integrate various components, while knowing what to leave out.

As an illustration of this concept, a recent study demonstrated that the FIFA 11+ was no more effective at preventing lower extremity injuries than the training provided by a qualified athletic trainer⁽¹¹⁾. In this study, compliance with the FIFA 11+, which was an addition to the participants’ baseline program, was low. On the other hand, the athletic trainers were qualified professionals who understood injury prevention in their environment. The FIFA 11+ wasn’t ineffective in this study; it just wasn’t any more effective than qualified professionals doing their job!

Injury prevention is more than the application of  scientifically-validated prevention programs. Factors like, ensuring that training is specific to the sport’s demands, selecting appropriate training loads (neither too high nor too low), and preparing athletes for high-risk maneuvers required by their sport contribute to reducing risk. Professional coaches and trainers with high levels of expertise can do this in ways that one-size-fits-all injury prevention programs can’t. Professional coaches don’t just implement injury prevention programs. They tailor them to their specific athletes’ needs and style of play to maximize the prevention strategy.

In professional sport, the amounts spent on wages lost when players are unavailable for selection justify employing a whole army of injury prevention experts! As an example, an average team in the English Premier League pays an estimated £9 million in wages to players who are unavailable for selection due to injury over the course of one season⁽¹²⁾. In addition, the resulting loss of league points contributes another £36 million in lost potential income⁽¹²⁾. Similar results are evident across other professional sports leagues (see figure 3). While injuries in amateur sport do not result in wasted salary payments, personal cost can be high. An organization sponsoring multiple teams (schools, universities, clubs) could provide tangible benefits to their members if they employed a sports injury prevention professional.

Figure 3: Financial losses due to injury

Estimations of the wages paid to injured players and effects on team performance across major North American sports leagues. (data from Kitman labs - info.kitmanlabs.com/i3-2017)

The bottom line

• Sports injuries affect performance and may come at significant personal cost.
• While it’s worthwhile investing in reducing injury risk, consider where to place the investment for maximum impact.
• Experts who understand the demands of the sport, training specificity, training load management, neuromuscular performance preparation, and team playing style produce similar or better outcomes than cookie-cutter programs.
• Expertise comes at a price, so calculate the cost-benefit ratio of employing an injury prevention expert.

References

1. National Health Statistics Reports. 2016 Nov;99:1-10 www.cdc.gov/nchs/data/nhsr/nhsr099.pdf
2. BMJ Open Sport & Exercise Medicine 2019;5: doi:10.1136/bmjsem-2018-000491
3. Inj Prev. 2007 Dec; 13(6): 416–421.doi: 1136/ip.2006.014720
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5. Br J Sports Med. 2014 May;48(11):871-877
6. Br J Sports Med. 2013 Aug;47(12):738-42. doi: 10.1136/bjsports-2013-092215
7. Br J Sports Med. 2016 Jun;50(11):651-6. doi: 10.1136/bjsports-2015-094798
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10. Sports Med. 2019 Apr;49(4):621-629. doi: 10.1007/s40279-019-01083-z
11. Am J Sports Med. 2019 Oct;47(12):2844-2852
12. BMJ Open Sport Exerc Med. 2020 May 20;6(1):e000675. doi: 10.1136/bmjsem-2019-000675