How to prevent subsequent injuries and keep playing for longer

So you want to prevent subsequent injuries, who doesn’t?

Let’s pretend that you’ve ruptured your ACL and decided to have surgery. It was pretty tough at the time, and you hated sitting on the side line, but you’ve nearly got through it. You did all the rehab and now 12 months later you’re preparing for your first game back. You’re excited to be back, but also nervous. You start off the game okay, but then halfway through, your worst fears are realised. You’ve ruptured your ACL… again.

This is not an unfamiliar story. Chances are you know someone who has been through something similar, or perhaps it was you. This is an experience that is not just limited to ACL injuries either. Many people will return to sport only to re-injure themselves, or to injure something different.

Within a sporting team, it is often the case that the majority of injuries that occur are done by a minority of players. These are the people who spend more time in the physio than they do on the field. Some athletes just seem to be more prone to subsequent injury. But why is that? And what can we do to prevent injury in these players? If this sounds like you or someone you know, then read on about how to prevent subsequent injuries.

I recently listened to a great lecture by Liam Toohey who has done lots of research around subsequent injury and injury prevention. I’ve summarised some of the ideas and studies he discussed below.

What is a subsequent injury?

A subsequent injury is any injury following an initial injury. It doesn’t necessarily need to be the same injury, or even related to the first injury.

What impact do injuries have?

Injuries have a negative impact on everyone. It is no fun for the individual who has to sit out, and they can also have a big impact on the success of a team. Injuries often mean time missed from trainings and games. And studies have shown that individuals are seven times more likely to reach their performance goals when they are able to attend 80% of trainings. As you can imagine, that has a big flow on effect for team success as well.

Research in rugby 7s demonstrated a trend where the time between each subsequent injury was reduced. So each time there was an injury, there was less time where to athlete was back playing before they got injured again. They also found that the total time that the player was out for increased with each subsequent injury.

When is the risk of injury the highest?

Studies in AFL showed that the risk for subsequent injury was highest when players were first returning to sport. This risk was higher for time loss injuries (injuries where the athlete had to miss games as a result of their injury). But the risk was still relatively high for non time loss injuries (where the athlete did not miss any games but was able to play with an injury). While most of us would expect the risk might be higher coming back from an injury where you were out for an extended period of time, it is important to also consider the increased risk that comes from non time loss injuries. A massive 68% of time loss injuries were preceded by a non time loss complaint. What does this mean? Don’t ignore your niggles! In most cases, niggles will lead to more severe injuries, with a longer recovery time.

What is a recurrent injury?

A recurrent injury is an injury of the same type and at the same site of the original injury. It is a risk factor for future injury. The most commonly known one is ACL injuries. This comes back to our example above. You probably know someone who has done their ACL more than once. And based on the statistics, it’s not surprising.

Once you have ruptured your ACL and have it repaired, you’re 4.4 times more likely to re-injure it. Even worse, if you injure your ACL more than 3 times (and have it repaired), that risk skyrockets to 25.8 times more likely. On top of all that, 11.8% of people will then go and rupture their ACL on the other side.

If you follow AFL, you may know Alex Johnson, who played for the Sydney Swans. He managed a whopping seven ACL reconstructions throughout his career (5 on the left, 2 on the right).

It’s a similar story for hamstring re-injuries. Following a hamstring strain you are 2.7 times more likely to strain your hamstring again, and 4.8 times more likely to strain it when coming back in the same season. More than 50% of hamstring re-injuries occur within 25 days after return to sport. Just emphasising again, that the risk of injury is highest when initially returning to sport after an injury.

Calf injuries have even worse stats – you are 9 times more likely to re-injure your calf. Re-injuries were most common during training and generally took longer to recover the second time around. What’s more, 70% of re-injuries occurred in players who did not attend at least 80% of pre-season.

So if you’re considering skipping pre-season, I would reconsider! Especially if you’ve had a previous calf strain. There is a reason your coach makes you do all that running.

Is there a link between subsequent injuries?

So clearly there is a link between previous injury, and re-injury. But have you ever thought about whether there is any relationship between different types of injuries?

Well, there is! A few different pairs of injuries have been studied to see if there are any connections. One such study demonstrated a relationship between ACL injuries and subsequent hamstring strains. Rupturing your ACL doubled your risk of hamstring injury. And that’s not all, there are links between a number of different injuries:

So what does this all tell us? So far it’s just sounding like bad news for anyone who’s every had an injury and is playing sport. It’s not as though you can change the fact that you’ve had an injury. You can’t prevent what has already happened. What you can do is take this information and consider your risk for future injury, and how to minimise that.

Considering training load to prevent subsequent injuries

Training load is an important factor to consider when talking about injury prevention. The likelihood of injury can become high with both over and under loading. There is a sweet spot in the middle that will reduce injury risk. This is important to consider in general, but also important to think about when looking to return to sport after an injury.

If you’ve been sitting out of competition for 6 weeks with an ankle sprain, you haven’t been loading anywhere near what you might have been doing if you were still playing. And if you are then jumping straight back into competition because your ankle feels better, you are increasing your load dramatically, causing a huge increase in injury risk.

It is important to make sure you’ve loaded all your tissue structures sufficiently before returning to sport, which usually requires a more gradual progression.

As alluded to above, your first game back is when your injury risk is the highest. In fact, the injury rate for the first game back from injury, is 87% higher than any other seasonal game.

This rate drops by 7% for every full training session attended before returning to play. So the more trainings you can go to before you start playing, the better.

The other important thing to do is make sure you are exposing yourself to everything you might need to do during a game while you are training. For example, if you are playing a sport that requires you to do lots of sprinting, it is important to actually train sprinting.

One study demonstrated that by attaining high sprint distances (being able to sprint for 400-700m) could protect against subsequent injury. The types of things you need to expose yourself to will vary depending on your sport, but examples of things to consider include contact, agility and repeat efforts. Make sure the first time you do these things again is not in a game.

Return to sport does not equal return to performance

The other thing to remember is that just because you got through your first game back okay, it doesn’t mean you’re out of the woods. Remember, the highest risk of injury was in those first few weeks after return to sport. You’re also not going to be back at your best straight away.

You will likely be less confident and carry some baggage into your first few games back. There is still work to be done, so don’t just drop your physio exercises yet. Keep loading and doing your training until you’re back to your best, and even then, I wouldn’t be so quick to put them away.

You can’t change the fact that you have a previous injury, so that increased risk of subsequent injury will always be there.

Summary

So to prevent subsequent injuries, know this:

Success is reduced with subsequent injuries
Subsequent injury is more than just recurrence: you also have an increased risk of a different injury
Consider training load principles to protect against injury
Be sure to expose yourself to everything you might need to do in a game during training first (e.g. sprinting, contact etc.)
The risk of injury is highest at the first game back from injury, and that risk reduces by 7% with each full training session you attend.
You’re not out of the woods once you return to sport! Aim for return to performance instead.