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Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 76-80

5.2 Physical and rehabilitation medicine in health care systems: Prevention and prehabilitation in physical and rehabilitation medicine – The example of musculoskeletal and sports injuries

Department of Physical Medicine, Rehabilitation and Sports Medicine, School of Medicine, University of Puerto Rico, San Juan, PR, USA

Date of Web Publication11-Jun-2019

Correspondence Address:
Prof. William Micheo
Department of Physical Medicine, Rehabilitation and Sports Medicine, School of Medicine, University of Puerto Rico, San Juan, PR
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisprm.jisprm_18_19

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How to cite this article:
Micheo W. 5.2 Physical and rehabilitation medicine in health care systems: Prevention and prehabilitation in physical and rehabilitation medicine – The example of musculoskeletal and sports injuries. J Int Soc Phys Rehabil Med 2019;2, Suppl S1:76-80

How to cite this URL:
Micheo W. 5.2 Physical and rehabilitation medicine in health care systems: Prevention and prehabilitation in physical and rehabilitation medicine – The example of musculoskeletal and sports injuries. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2019 Aug 20];2, Suppl S1:76-80. Available from: http://www.jisprm.org/text.asp?2019/2/2/76/259344

  Introduction Top

Musculoskeletal and sports injuries can result in significant morbidity, pain, limitation in the ability to participate in work, recreational, and sports activities. Prior injury, high volume of activity, and abnormal biomechanics have been found to have an impact in return to physical and sports activity, function, and the development of long-term consequences such as knee osteoarthritis (OA) and reduced quality of life.[1] Approximately 50% of individuals who suffer an anterior cruciate ligament (ACL) injury will develop OA 10–12 years following the injury irrespective of conservative or surgical treatment.[2] High volume of throwing, poor biomechanics, and abnormalities in the kinetic chain are associated with shoulder pain. There is strong evidence that when pitching more months per year, more innings per game, higher volume of pitches per game, and per year the frequency of shoulder injury increases.[3]

Prevention of injury associated with participation in occupational, recreational, and sports activities is one of the roles of the Physical and Rehabilitation Medicine Physician. Development of musculoskeletal and sports medicine preventive programs to reduce the risk of injury is a complex process. Components of preventive strategies include an understanding of injury epidemiology and mechanics, identification of risk factors, timing of implementation, and specific components of the program and evaluation of the results of the intervention.[4] However, it is not clear how many injuries are preventable in daily life and sports, but many have the potential to be preventable with appropriate strategies that may include rule changes, education, protective equipment, and preseason as well as in season exercise programs.[5]

The incidence of musculoskeletal and sports injury can be influenced by the specific risk factors which may be divided into those that are intrinsic and extrinsic to the individual and those that are modifiable and nonmodifiable. Intrinsic risk factors may be genetic, anatomical, and biomechanical. Extrinsic factors are usually related to inherent demands of activity, playing surface, equipment, and environmental conditions.[6]

Prevention strategies can be classified as primary, secondary, or tertiary based on the goal of the intervention. Primary prevention has the goal of reducing the risk of an initial injury, secondary prevention deals with the reduction of risk of recurrence of an established injury and tertiary prevention strategies address the reduction of long-term consequences of injury.[7] Using injury-related knee OA as an example; primary prevention reduces the initial risk by limiting the exposure to high-risk activities, emphasizing weight loss in at-risk individuals and recommending regular exercise starting at a young age, secondary prevention targets muscle weakness, and neuromuscular deficits that result from a previous injury as well as correction of abnormal sports-specific technique and tertiary prevention utilizes rehabilitation to prevent deficits in activities of daily living as well is in sports performance that leads to chronic pain, loss of motion, and ultimately a restriction in participation.[8]

In this chapter, we will address important aspects of prevention of musculoskeletal and sports injuries including identification of risk factors, the components of a prevention program and the evaluation of the outcome of these interventions. We will present examples of specific injuries and which preventive strategies are effective in reducing long-term consequences of these conditions.

  Identification of Risk Factors Top

Musculoskeletal and athletic injury can be caused by extrinsic and intrinsic factors classified as modifiable and nonmodifiable [Table 1]. Modifiable extrinsic factors include high volume or a sudden increase in activity, inappropriate equipment, and surfaces in which training and competition occur. Poor load management which includes rapid changes in training and competition load, congestion of competitive calendar, and frequent travel has been found to be a major risk for injury in athletes.[9]
Table 1: Sports and musculoskeletal injury risk factors

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Intrinsic factors can be modifiable (poor flexibility, muscle weakness, and body mass index) or nonmodifiable (sex, height, ligamentous laxity, and joint malalignment). Young athletes with muscle and tendon injury can present with reduced flexibility and poor neuromuscular control associated with rapid growth.[10] Female athletes with ligamentous laxity, core muscle weakness, and abnormal landing biomechanics are at risk of ACL injuries.[1] Older athletes with muscle weakness or imbalance often present with Achilles tendinopathy associated with sports participation.[11] Psychologic stressors have also been found to be associated with increased risk of injury. Negative life events, sports-related stress, trait anxiety, maladaptive coping strategies, and type A personality influence injury risk and are associated with attentional and somatic changes, muscle fatigue, and reduced coordination.[9]

  Classification of Injury Top

Understanding the incidence, classification, and severity of musculoskeletal and sports injury is key in developing appropriate prevention strategies. A sports or musculoskeletal injury can be defined as impairment associated with pain and functional limitations and participation restriction with the inability to compete as a result of acute trauma or chronic overuse. If not managed appropriately within the health system, the individual or the athlete may present with recurrent or residual symptoms, physical impairment, participation restriction, and sports-related disability.[12] Sports injuries are usually divided into two basic types: those that result from trauma and those associated with overuse. In traumatic injuries, there is a clear inciting event, and in overuse injury, repetitive exposure to activity results in a failure of normal homeostasis and an inability of tissue to recover from athletic-related trauma. A more complete description and understanding of the injury mechanism is required if the object is to prevent injury. This includes understanding the epidemiology of the injury, the events leading to the injury (playing situation, player behavior) as well as a description of body position and joint biomechanics at the time of injury.[13]

Acute injury can be defined as one that occurred within 2 weeks of the evaluation, the sub-acute injury is associated to with symptoms of 2–6 week's duration, and in chronic injury, symptoms persists after 6 weeks. The severity of the injury can be classified as mild if participation is restricted <7 days, moderate if symptoms persist between 7 and 21 days and severe if the inability to participate last >21 days.[14]

  Patient Evaluation Top

A clinical evaluation which includes a history and physical examination is very important in evaluating the individuals at risk for an injury or following a lesion. Preparticipation examinations may be used to evaluate individuals at risk for initial or recurrent injury. Following an injury, pertinent information that should be obtained from the history includes the type of activity that led to symptoms, the mechanism of injury, the severity of the injury, and prior treatment strategies. In addition, information regarding age, stage of growth and development, menstrual history, previous history of similar or related injuries, and associated medical problems should be obtained. Psychological issues that should be investigated include the history of anxiety, stress associated with competition, abnormal attitude toward eating and fear of recurrent injury.

The physical examination should identify postural asymmetry, lack of flexibility, muscle weakness and imbalance, neurologic as well as proprioceptive deficits, and ligamentous laxity. It is also important to evaluate core, trunk, and hip muscle strength, dynamic flexibility, and sports specific techniques such as landing and pivoting.

Complete diagnosis of musculoskeletal and athletic injury can be established using a modification of the musculoskeletal injury complex model.[15] This model identifies the clinical symptoms, the anatomic location of injury and the functional deficits. Understanding not only individual symptoms but also the cause of the injury and abnormalities in the kinetic chain of the physical activity or sport allow for appropriate planning of a prevention program.

The clinical symptoms complex addresses the main complaints of the injured individual. Symptoms such as pain, swelling, instability, numbness, weakness, or change in performance should be identified to be appropriately treated. The anatomic alterations complex identifies the site of the primary injury causing the patients symptoms and the associated areas of tissue overload that contribute to the clinical presentation. The functional alterations complex addresses the biomechanical deficits that result from injury, the adaptations used by the patient to try to continue to participate in daily activities and sports and the changes in sports and exercise performance.[15]

  Rehabilitation and Return to Play Top

Following acute or surgical management of a musculoskeletal or sports injury an appropriate rehabilitation program should be established to address the symptoms, neuromuscular abnormalities, and functional deficits. A rehabilitation program should be divided into acute, recovery and functional phases, each with goals and criteria for progression and followed by a return to participation protocol.[16] The acute phase has goals of reducing patient symptoms and protecting injured tissue. The recovery phase works on achieving normal motion, flexibility, strength, and neuromuscular control with progression to functional activities. The functional phase emphasizes dynamic flexibility, strength, and power training and progression to sports specific training.

Defined return to activity or sports criteria should be established and include being free of symptoms at rest and with activity, normal flexibility, strength and balance, and psychologic readiness. In addition, objective tests such as isokinetic dynamometry and functional testing that could include the performance of horizontal, vertical, and lateral jumps or supervised progressive throwing programs, should be part of the established protocol. Completion of a structured rehabilitation program and return to play protocol has been shown to result in injury reduction in individuals at risk of or following an ACL injury.[17]

  Components of a Prevention Program Top

Prevention programs should include strategies for individuals susceptible to injury because of activity-specific demands and abnormal biomechanics as well as for injured athletes who return to practice and competition. The focus is on understanding injury mechanisms, etiology, risk factors, correction of modifiable risk factors and evaluation of outcomes of the interventions[4],[6],[14] [Figure 1].
Figure 1: Sequence of prevention of sports injuries modified from van Mechelen 1992

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Preventive programs have multiple components that address modifiable intrinsic risk factors and include strengthening, stretching, aerobic conditioning, proprioceptive and balance training, education about the injury, feedback regarding body mechanics and landing techniques as well as coaching to correct technical errors. A preseason injury prevention program starting 6 weeks before the competitive season combined with in-season maintenance exercise which can be integrated with traditional warm-up is preferred.[2] In young athletes participating in competitive sports prevention programs should be implemented early in the developmental process. A preventive program for soccer injuries the FIFA'11 + For Kids' makes partner-based exercises more play oriented, improves motor control, balance and agility and can reduce football-related lower extremity lower extremity injuries.[18]

Strengthening exercises are known to reduce the risk of injury. Eccentric exercise, in particular, has been found to reduce the risk of hamstring strains in elite athletes and should be included as part of the training and prevention program for the running athlete. Core strengthening and balance training have been shown to reduce knee and ankle injuries.[19],[20] Balance training, learning how to fall from a jump, modifying cutting techniques, and plyometric exercises that activate the hamstrings have been found to reduce the risk of ACL injuries and should be integrated into injury prevention programs.[21]

Modification of extrinsic factors for injury should also be incorporated into the prevention program. Playing on indoor wooden floors and natural grass, using shorter cleats or shoes that reduce shear with the playing surface are strategies that can be used to reduce injury risk.[2] The use of appropriate protective equipment is also a component of preventive programs. Prescription of ankle braces to reduce ankle sprain recurrence, mouth-guards to reduce dental injuries in combat sports, protective eyewear to reduce ocular injuries in Lacrosse and shin guards to reduce fractures of the Tibia in soccer players should be considered.[6]

  Evaluation of Outcomes Top

The primary goal of a prevention program is the reduction in the incidence of initial or recurrent injuries. Structured prevention programs with the components previously discussed have been shown to reduce knee and ankle injuries in adult and adolescent athletes.[13] ACL injury prevention programs are ones of the most widely evaluated, with multiple scientific publications showing a reduction of the risk of injury in female and male athletes. A recent systematic review concluded that ACL prevention programs reduce the risk of injury 52% in females and 85% in males.[22] Ankle sprains are one of the most common traumatic injuries associated with sports participation. Exercise programs that train balance and coordination and ankle taping or bracing have been shown to reduce the recurrence of ankle sprains. The effect on primary prevention of ankle sprain is not that clear.[6],[23]

Other musculoskeletal and sports conditions in which preventive strategies have been shown to be effective in reducing initial or recurrent injury and associated morbidity include injury-related OA, falls, and concussions.[8],[24],[25]

Individuals participating in ACL prevention programs may also exhibit improvement in athletic performance as a positive outcome of the intervention.[2],[4]

  Clinical Correlation Top

The following brief examples illustrate some of the concepts discussed above including sports medicine and general rehabilitation clinical cases.

Ankle sprains

Ankle sprains are very common in sports and daily life. They are associated with an inversion injury usually upon landing in sports such as basketball and volleyball. Injury risk factors include fibular muscle weakness, loss of ankle dorsiflexion, reduced proprioception, and poor dynamic balance. Previous injury and incomplete rehabilitation are also risk factors. Interventions that have been shown to be effective in preventing recurrence of injury include strengthening, flexibility and balance exercises, taping or the use of ankle bracing. The role of these interventions in primary prevention of injury is not that clear. There appears to be no protective effect of shoes of different heights in ankle sprain incidence.[6],[23]

Anterior cruciate ligament injury

ACL injuries are common in athletes that participate in sports such as soccer, basketball, and American football and lead to long-term consequences such as knee OA. They affect young athletes, in particular females, are associated with noncontact injury mechanisms in the majority of cases and are treated with surgery in young individuals and elite athletes. Modifiable risk factors for injury include the trunk, hip and thigh muscle weakness, and abnormal sports mechanics which include landing with hip and knee in extension and knee in abduction, poor dynamic balance, fatigue, type of sport, and level of competition, with the injury occurring more frequently in games than in practice. Intervention strategies that have been shown to be effective in preventing injury include strengthening, balance and proprioceptive training, aerobic conditioning, plyometric exercises, education, and feedback about body mechanics as well as landing technique. Identification of modifiable extrinsic factors such as playing on artificial turf and wearing shoes with long cleats have also shown benefit in injury prevention.[1],[2],[4],[6]


Falls are a major health issue and the major cause of accidents that affect older individuals living in the community. Risk factors for falls include muscle weakness, poor balance, poor vision, and household barriers. Interventions that have been found to be effective in reducing the risk of falling include Tai-Chi, group, and home-based exercise programs and modification of the home environment. Multifactorial assessment and interventions reduce the rate of falling.[24]

  Concussion Top

Mild traumatic brain injury and sports-related concussion have a significant impact on the health and quality of life of individuals who suffer these conditions. Increased awareness of these conditions and an earlier diagnosis has led to more standardized treatment strategies, but prolonged symptoms persist in a significant number of individuals who suffer concussion. Young individuals and females seem to be at risk for the injury, and other risk factors for concussion include prior concussion history, number, and the severity of concussion and participation in contact sports. Intervention strategies that have shown to be effective in preventing concussion include education about the signs and symptoms of concussion, removal of the athlete with concussion from competition, establishing a return to play protocol and modification of rules in sports to limit head contact. The use of helmets and mouth-guards has not shown to be effective in reducing the incidence of concussion.[6],[25]


The development of injury prevention strategies is one of the roles of the physical and rehabilitation medicine specialist. The sequence of injury prevention includes an understanding of injury, establishing the etiology and mechanism, identifying risk factors, introducing preventive strategies, and evaluating the outcomes of the intervention. The various components of prevention programs include exercise, education, and correction of abnormal biomechanics and sports specific technique, evaluation of the playing environment, and the use of protective equipment. Preventive programs have been shown to be effective in reducing knee and ankle injuries in adolescent and adult athletes falls in older individuals and sports-related concussions.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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