Injury Prevention: Fact or Fiction?
Injuries are an unfortunate aspect of sports and physical activity, both as a participate and as a fan. We’ve made lots of advances from a rehab perspective, but what if we could prevent injuries from happening to begin with? “Bulletproofing” body parts seems to be the buzzword when referring to the use of exercise for preventing injuries. But can we actually prevent injury? No, maybe AND yes.
Let’s start with no. We cannot prevent injuries from ever occurring. Injuries are multifactorial, many out of our control, and there can be many moving parts that influence whether we get injured. It’s also hard to quantify any of these factors to try and reduce their influence. We would never be able quantify forces at the time of injury to know for sure those were the factors that lead to injury to say “this is what caused it.” Plus, sometimes sh*t happens. You’re out running, you hit a divot and you sprain your ankle. Or you’re playing soccer and someone slide tackles you.
Maybe we need to adjust our terms and use the words “decrease risk” instead of “prevent”; we’re decreasing our risk or chance of injury, or mitigating injury (make less severe, serious or painful). In theory, exercise should be able to help. Exercise can help increase our threshold or tolerance for load such that we have increased capacity for stress on our body. A well designed exercise program that exposes us to a progressive overload that we can adapt to adequately with proper recovery should help decrease the chance of overtraining or chronic injuries, and make us more resilient to acute injury. However that exercise program may not factor in you getting stressed out at work and not eating and sleeping well, which could lower your capacity and increase your risk of injury.
Interestingly, getting stronger may not be the exact mechanism by which resistance training and exercise could mitigate injuries. Patients don’t need to see increases in their strength in order to see improvements in their pain or function (they often do, but not always). Some other mechanism might be at play. Maybe through resistance training and loading our muscles, they become more accustomed to load/stress without necessarily getting stronger.
We're learning that exercise can prevent injuries at a population level though, and we need look no further than soccer and the FIFA 11+ protocol. The 11+ is a series of running, strength, plyometric and balance exercises completed as a warm-up. One study from the British Medical Journal in 2008 (Soligard et al) showed that female teams that performed the 11+ at least twice a week had a statistically significant reduction in all injuries. There was a reduction in lower extremity, knee, ankle and acute injuries in the group that performed the 11+ versus the control group performing their usual warm-up, though these were not statistically significant. Injuries in games and in training were also lower in the 11+ group, but again not statistically significant. There was a statistically significant reduction in overuse and severe injuries the 11+ group. Another study showed that those with high compliance to the 11+ had a 35% lower risk of all injuries compared to those with intermediate compliance (Soligard et al 2010). Other studies have shown similar results (see below for references).
Even with the FIFA 11+ program showing a statistically significant reduction in all injuries, that number is still not 0, meaning some people who performed the 11+ still got injured.
BUT! If there were 1.3 knee injuries per 1000 hours of soccer in the standard warm-up group and 0.7 knee injuries per 1000 hours in the 11+ group, weren’t 0.6 knee injuries per 1000 hours prevented?
To summarize, can we prevent injuries? Yes, but actually no. We see some data that exercise programs, at least at a population level, can prevent injuries. But prevention might be the wrong word. Exercise and resistance training can mitigate and decrease our risk or chance of injury to a certain degree, but we’ll ever be able to 100% prevent injuries, if only because sh*t happens. Injuries are complex and rarely due to one factor, but that also means there are many avenues we can take to try and decrease our risk of injury.
Barengo NC et al. The impact of the FIFA 11+ training program on injury prevention in football players: a systematic review. Int J Environ Res Public Health. 2014; 11 (11): 11986-12000.
Nuhu A, Jelsma J, Dunleavy K, Burgess T. Effect of the FIFA 11+ soccer specific warm up programme on the incidence of injuries: a cluster-randomized controlled trial. PLoS One. 2021; 16 (5).
Owoeye OB, Akimbo SR, Tella BA, Olawale OA. Efficacy of the FIFA 11+ warm-up programme in male youth football: a cluster randomized controlled trial. J Sports Sci Med. 2014; 13 (2): 321-328.
Sadigursky D et al. The FIFA 11+ injury prevention program for soccer players: a systematic review. BMC Sports Sci Med Rehabil. 2017; 9 (18).
Silvers-Granelli H, et al. Efficacy of the FIFA 11+ injury prevention program in the collegiate male soccer player. Am J Sports Med. 2015; 43 (11): 2628-2637